ISSN: 0269-9052 (print), 1362-301X (electronic) Brain Inj, 2014; 28(5–6): 517–878 ! 2014 Informa UK Ltd. DOI: 10.3109/02699052.2014.892379



Comparison between the Montreal Cognitive Assessment and the Mini-Mental State Examination in patients with traumatic brain injury

Mild TBI causes sleep disturbances which are mitigated by dietary therapy

Elaine de Guise1, Joanne LeBlanc1, Marie-Claude Champoux1, Ce´line Couturier1, Abdulrahman Yaqub Alturki1, Julie Lamoureux2, Monique Desjardins1, Judith Marcoux1, Mohammed Maleki1, & Mitra Feyz1 McGill University Health Center, Montreal, Canada, 2University of Montreal, Montreal, Canada

Miranda Lim1, Jaclynn Elkind2, Guoxing Xiong2, Julianna Rodin3, Ray Galante3, Jingxu Zhu3, Lin Zhang3, Jie Lian3, Nicholas Kuzma3, Allan Pack3, & Akiva Cohen2 1

Portland Veterans Affairs Medical Center, Portland, OR, USA, Children’s Hospital of Philadelphia, Philadelphia, PA, USA, 3 University of Pennsylvania, Philadelphia, PA, USA 2


The Montreal Cognitive Assessment (MoCA) is a brief measure of global cognitive function originally developed to detect mild cognitive impairment (MCI). Compared to the Mini-Mental State Examination (MMSE), the MoCA has been shown to be sensitive to subtle cognitive deficits in a variety of populations. More specifically, the latter was shown to be more sensitive to early detection of cognitive impairments in persons with cerebrovascular conditions, with dementia and with Parkinson’s disease. The objective of the present study was to find the best validated, efficient and brief tool that could be used with TBI patients in an acute care context. To do so, results on the MoCA were compared to those on the MMSE in patients with TBI and this study looked at how both scores predicted outcome at discharge from the acute care setting. It was hypothesized that the MoCA would be a better predictor of acute outcome than the MMSE in this population. Both tests were administered to 214 patients with TBI during their hospitalization in a Level I trauma centre. Outcome was measured with the Disability Rating Scale (DRS). The medical charts of all patients were reviewed to gather data on the following predictive factors: age, education, GCS scores (TBI severity) and initial CT scan results. A linear regression determined that the MoCA, the MMSE, TBI severity, education level and presence of diffuse injuries predicted 57% of the total variability of the DRS scores. The model without the MMSE had a R2 of 53.7% and the model without the MoCA had a R2 of 55.0%. The models without the MMSE or the MoCA had a R2 of 24.9%. This indicated, firstly, that the MoCA and the MMSE function as similar predictors of the DRS at discharge and, secondly, that the MMSE and MoCA scores were correlated because removing one or the other from the original model only reduced the R2 by a small percentage. The results also showed that the MMSE had a slightly better ability to predict outcome because of the small difference in the R2, but this was probably not statistically significant. In conclusion, the MoCA compared to the MMSE was not a better predictor of outcome as assessed with the DRS. Perhaps at a later time in the recovery process, that is after the acute stage and when cognitive deficits of patients with TBI are more subtle, the MoCA would show greater outcome prediction. Further studies on the MoCA are, therefore, needed in the later stages of recovery post-TBI.

Objectives: Sleep disorders are highly prevalent in patients with traumatic brain injury (TBI) and can significantly impair cognitive rehabilitation. No proven therapies exist to mitigate the neurocognitive consequences of TBI. This study established a mouse model of mild brain injury using lateral fluid percussion injury which recapitulates the chronic sleep–wake disturbances seen in the human condition. It also identified a dietary intervention, composed of branched chain amino acids (BCAA: precursors to glutamate synthesis in the brain), which improves wakefulness after TBI. Methods: Mice were randomized to receive either mild grade fluid percussion brain injury or sham surgery, and a dietary BCAA supplement in the drinking water. They were then implanted with intracranial fronto-parietal EEG and neck surface EMG electrodes for chronic in vivo recording. Amplified polysomnographic EEG/EMG recordings, which occurred exactly 14 days after surgery, were digitized at 256 samples per second and scored for behavioural state (i.e. non-rapid-eye movement (NREM) sleep, rapid-eye-movement (REM) sleep and wakefulness (W)) across a 24-hour baseline period (i.e. light from 7am to 7 pm). EEG power density was calculated using Fast Fourier transformation. Statistical significance was assessed using one-way ANOVA followed by post-hoc Dunnett’s tests (p50.05). Results: Chronic EEG/EMG recordings in freely behaving mice revealed that brain-injured mice showed a persistent inability to maintain wakefulness compared to sham control mice. Brain-injured mice also had a significant shift in EEG power spectra to slower peak theta frequencies. To examine mechanisms underlying wake disturbances, this study examined orexin (hypocretin) neuron activation, and found that brain-injured mice show significantly less activation of orexin neurons in response to sustained wakefulness. BCAA dietary therapy reinstated activation of orexin neurons after TBI and, more significantly, BCAA intervention restored wake deficits after injury. Conclusions: The data establish a mouse model of persistent sleep– wake disturbances in mild TBI, including the persistent inability to maintain wakefulness. EEG power spectral shifts to slower theta peak frequencies have been implicated in early dementia and other cognitive disorders. Orexin (hypocretin) is a critical neuropeptide that regulates sleep and wakefulness and has been implicated in narcolepsy, and appears to be affected in the mouse model of mild TBI. Dietary BCAA intervention acts in part through activation of

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Abstracts 2013

518 orexin neurons to normalize wake deficits. Therefore, BCAA supplementation is a promising therapy for the treatment of wakefulness and cognitive deficits after mild TBI.


Youth offending and ABI – a practical approach Lisa Turan, & Louise Wilkinson

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Child Brain Injury Trust, London, UK Due to the cognitive, behavioural, psychological and emotional manifestations of childhood acquired brain injury (ABI), it is possible that some young people affected by ABI have a higher likelihood of entering the criminal justice system; 24–32% from the general public and 65–72% from young offenders institutions; and, once there, their neurological needs are frequently poor or indeed appropriately supported. By providing better and appropriate support, earlier in life, there is the potential to reduce the offender population. It is the authors’ argument that this must start to take place within the education environment and with the full support of educators. The Child Brain Injury Trust (CBIT), a lead provider of family support in the UK following childhood ABI, understand not only the difficulties families face following injury, but also the complexities of associated brain injury on adolescent behaviour and how it can change over time. Generally it has been found that educators, health professionals and other associated practitioners such as social workers often do not have the time or necessary expertise to manage individuals with ABI and, as such, many of these professionals find themselves facing a different person than they knew before the brain injury who now may have issues with concentration, fatigue, social interaction, behaviour or memory, for example, and find themselves on a road that they were not expected to travel. In the authors’ experience this can also cause a significant and detrimental pressure on the young person with the ABI and their family. According to the Independent Commission on Youth Crime & Antisocial Behaviour (2010) the cost of youth Crime and antisocial behaviour in 2008/9 was in excess of £4Billion and is generally linked to a breakdown in communities, lack of family support and/or lack of resources. It is suggested that it is equally important to acknowledge causal factors such as ABI in understanding criminal behaviour. Children and young people with ABI are frequently misunderstood by authority figures, peers, families and friends. Their often disinhibited behaviour can mean that they are more likely to take risks, get in with the wrong crowd and have particular difficulties with social competence including problemsolving, making sound judgement and understanding consequences. This, coupled with other common issues associated with brain injury, sets the scene for an uneasy future for these individuals.


Developing and implementing a UK-wide intervention programme for families affected by childhood acquired brain injury Lisa Turan Child Brain Injury Trust, London, UK The Child Brain Injury Trust has developed a UK-wide intervention programme supporting families in the community following childhood acquired brain injury. A ‘key-worker’ model established with

Brain Inj, 2014; 28(5–6): 517–878

local partners from Health, social care and education. Honouree contracts are secured for Child & Family Support Coordinators with regional trauma centres to enable the child to have a smooth transition from hospital to home. Co-ordination of support services, access to information and training and opportunities for families to learn more about brain injury are offered throughout the partnership. The presentation will illustrate the steps taken in order to establish and implement a national programme across the UK. It will cover lessons learnt, sustainability and self-management outcomes; from raising £1.5 million to recruiting appropriate key workers to provide a new and challenging way of working. Results indicate that families have better outcomes, children feel better about their future and educational outcomes improve:  Reduced isolation,  Reduced stress levels in the family,  Improved self-esteem,  Improved social skills, and  Reduction in state support Specifically the model provides: Practical support, emotional support, information, social support, training, youth work and CPD opportunities.


Does what we measure matter? Quality-of-life defined by adolescent brain injury survivors Ashley Di Battista1, Cheryl Soo1, Cathy Catroppa1, Celia Godfrey1, & Vicki Anderson1 1 2

Murdoch Childrens Research Institute, Melbourne, Victoria, Australia, University of Melbourne, Melbourne, Victoria, Australia

Objectives: The PedsQL (Varni, 1998–2000) is the most commonly used paediatric quality-of-life (QoL) assessment tool in traumatic brain injury (TBI), but available data using this tool relies almost exclusively on parent proxy reports, despite very poor concordance rates between teen self-reported and parent proxy reported data. The aims of this study were to (1) assess how adolescent TBI survivors quantify their QoL; (2) determine what domains are considered important to the adolescents’ interpretation of QoL post-TBI; and (3) compare the data between adolescents and parent-proxies. Methods: A mixed methods approach was used. Adolescent QoL was assessed via the PedsQL and semi-structured interview created by the lead author. Adolescent self-report (PedsQL) was compared to adolescent self-report on the semi-structured interview. Adolescent self-report on the PedsQL was compared with parent proxy report on the PedsQL. Results: Eleven adolescents and 10 parents were assessed. Parent and self-reported PedsQL were not correlated. Adolescent narratives endorsed changes post-injury on the PedsQL, but the adolescents attributed the changes to a sense of age-appropriate maturation, not to the TBI. The adolescents reported that the functional changes identified on the PedsQL were not important and did not impact on their sense of QoL. All of the respondents, regardless of injury severity, reported a good QoL. Conclusions: The PedsQL is able to determine change in functional areas after TBI, but does not capture either (1) the reason for this change or (2) if these functional changes matter to the adolescent or their concept of their QoL post-injury. These results also support growing evidence that there is disconnect between parent and view of QoL, especially on the PedsQL. Although these findings need to be confirmed using larger samples, the data suggests that the PedsQL provides an oblique view of the adolescent QoL experience, which may be putting teens at risk of misrepresentation about their wellbeing after a TBI.


DOI: 10.3109/02699052.2014.892379


Microglia modulatory pathway is involved in the protective effect of ginseng against traumatic head injury induced neuroinflammation and cognitive deficits in rats Anil Kumar, Puneet Rinwa, & Hitesh Dhar

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Panjab University, Chandigarh, India Introduction: Traumatic brain injury significantly causes behavioural alterations, oxidative stress, neuroinflammation and apoptosis. Therefore, the present study has been designed to explore the possible role of ginseng and its possible microglial modulatory pathway against experimental brain trauma-induced behavioural, biochemical and molecular alterations. Materials and methods: Wistar rats were exposed to brain traumatic injury using weight-drop method. Following injury and a post-injury rehabilitation period of 2 weeks, animals were administered vehicle/ drugs for another 2 weeks. Various behavioural (Morris water maze, locomotor activity), biochemical parameters (Lipid peroxidation,nitrite level, reduced glutathione and catalase), acetylcholinestrase activity and neuroinflammatory markers (TNF-alpha) were assessed in discrete areas of the brain. Results: Traumatic brain injury caused significant memory impairment in the Morris water maze task, as evident from delayed escape latency and increased total distance travelled to reach the hidden platform. Time spent in the target quadrant and frequency of appearance in the target quadrant were also significantly decreased in head trauma rats. Further, there was a significant oxidative stress (elevated malondialdehyde, nitrite concentration and decreased reduced glutathione, superoxide dismutase and catalase levels), neuroinflammation (TNF- and IL-6) and raised acetylcholinesterase levels in both cortex and hippocampal regions of traumatized rat brain. Ginseng (100 and 200 mg kg1) and minocycline (50 mg kg1) treatment for 2 weeks significantly attenuated all these behavioural, biochemical and molecular alterations as compared to control. Further, combination of sub-effective doses of ginseng (50 and 100 mg kg1) and minocycline (25 mg kg1) potentiated their protective effects, which was significant as compared to their effects alone. Conclusion: The present study suggests that microglial inhibitory mechanism might be involved in the protective effect of ginseng against head trauma-induced cognitive impairment and neuroinflammation in rats.


Genetic association for prolonged recovery from athletic concussion: A novel study 1


of ions through protein channels. Extracellular glutamate binds with cell membrane proteins (e.g. NR2A), which exacerbates the Ca2+ ion influx and prolongs neuron dysfunction. Genetic variation may be a factor in regulating glutamate binding and, therefore, cell recovery time. The NR2A sub-unit of NMDA contains a variable (GT)n nucleotide tandem repeat (VNTR) within the GRIN2A promoter region. This VNTR has been shown to regulate transcription levels in a length-dependent manner, where longer repeat decreases transcription of the NR2A sub-unit. The purpose of this study was to determine the association of the GRIN2A VNTR and recovery (days) as well as concussion severity scores within concussed athletes. Methods: The independent variable was VNTR (long allele vs short allele). The primary dependent variable, recovery time, was defined as injury date to return-to-play (RTP) clearance date as determined by the physician. Participant RTP time was categorized as normal (520 days) or prolonged (420 days). Secondary dependent variables were assessed at the initial evaluation and included vestibular ocular score, Balance Error Scoring System (BESS) score and Immediate PostConcussion and Cognitive Testing (ImPACT) module scores. All 51 participants were athletes, comprised of 38 males and 13 females with a mean age of 18.69 ± 6.65. Participants were evaluated at a university concussion centre. The standardized concussion evaluation consisted of vestibular ocular tests, balance (Balance Error Scoring System) and neurocognitive (ImPACT) testing. Each participant was genotyped via saliva sample for the GRIN2A (GT)n repeat polymorphism (rs3219790). Results: Data analysis consisted of descriptive and inferential statistics. Chi-squares were used to assess the association between VNTR (long allele vs short allele) and concussion recovery (prolonged vs normal). Regression analyses were used to estimate the extent to which nongenetic factors and genotype contributed to concussion recovery group assignment. Conclusions: There were no differences between demographic or health history within the VNTR or recovery groups. There was a significant association (2 ¼ 4.01, p ¼ 0.045) between the VNTR group (recessive model: LL vs SS + LS) and recovery, where the chance of prolonged recovery was 4.3-times greater for carriers of the homozygous long allele. There were no differences in concussion severity scores between VNTR groups. This was the first study to investigate the association of the (GT)n VNTR within GRIN2A. The current study established a DNA collection, estimation and genotyping protocol of the (GT)n VNTR for the samples and demonstrated accuracy of this genotyping method. Clinically, athletes carrying the long allele genotype may be pre-disposed to prolonged recovery following a concussive injury.


Meeting the need for ecologically valid and innovative instrument development: Structured functional cognitive assessment! for individuals with acquired brain injury Marianne H. Mortera


Jane McDevitt , Ryan Tierney , Joesph Torg , & Evgeny Krynetskiy3 1

Temple University, Philadelphia, PA, USA, 2Temple University School of Medicine, Department of Orthopedic Surgery, Philadelphia, PA, USA, 3Temple University School of Pharmacy, Philadelphia, PA, USA

Objectives: During a concussion, mechanical forces cause neuron cell strain that initiates dysfunction through the indiscriminate movement

Columbia University, New York, NY, USA Objectives: This presentation details the need for ecologically valid cognitive assessments as occupational therapists are responsible for the development and testing of cognitive assessments germane to establishing goals and interventions in adult brain injury rehabilitation. Developing ecologically valid cognitive assessments that aid in the structured observation and documentation of cognitive deficits manifested during activities of daily living (ADL) performance is

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critical for reimbursement of rehabilitation services. This presentation delineates the method to create a Structured Functional Cognitive Assessment! (SFCA) for use with specific ADL tasks that provides an objective assessment to determine the impact of cognitive deficits on functional performance and establish appropriate burden of care. Details include (a) who is appropriate for developing a SFCA, (b) the methods required to develop a SFCA, (c) implications related to reimbursement of OT services and (d) beginning test development for examining content validity and inter-rater reliability. Methods: The following steps drawn from basic instrument development procedures are tailored for occupational therapists and for designing a SFCA and include (a) a review of the literature on ecological validity and criteria for establishing the need for functionbased assessment, (b) comparing the purpose of contrived or paper and pencil testing to function-based assessment, (c) delineating conceptual and operational definitions based on a review of the literature for cognitive processes to assess, (d) creating a table of specifications detailing the activity analysis of selected ADL tasks and cognitive processes of interest, (e) developing an objective scale to measure cognitive deficits manifested during function-based performance and (f) outlining the beginning and necessary steps for testing content validity and inter-rater reliability of the SFCA. Results: The SFCA method was used to develop and initially test the following: The Mortera Cognitive Screening Measure (M-CSM) for individuals who have sustained an acquired brain injury was tested where content validity and inter-rater reliability analyses were performed on the M-CSM. The screen was shown to demonstrate adequate content validity and an intra-class correlation coefficient (ICC) of 0.93. The Cognitive Screen for Grooming (CSG) was initially tested with patients post-stroke for inter-rater rater reliability, with resultant intra-class correlation coefficients (ICC) of 0.713–0.995. Conclusions: It is critical that occupational therapists use rigorous instrument development procedures to develop and test ecologically valid cognitive assessments and demonstrate adequate validity and reliability in order to provide best practice for individuals needing brain injury rehabilitation. Using the SFCA method can provide the means to meet this critical need via the ability to objectively record cognitive deficits during ADL and subsequently allow for the establishment of appropriate burden of care and adequate reimbursement of rehabilitation services.

between PVS and MCS is a difference in quality. If a novel technique reveals consciousness in a PVS patient, this means that the patient was not in PVS but simply misdiagnosed. According to non-unitary approaches (e.g. Damasio), there are different grades or levels of consciousness. Then, MCS patients may be assumed to have a different kind (e.g. a lower level) of consciousness as compared with fully conscious individuals. A still lower level of consciousness might characterize some PVS patients. From this point of view, therefore, the difference between PVS and MCS is gradual rather than qualitative. Detecting consciousness in a PVS patient does not necessary imply a misdiagnosis, because the patient’s level of consciousness might be so low that it remains undetectable by any traditional method. Some empirical data obtained with functional MRI (e.g. PVS and MCS patients’ brain responses to nociceptive and highly emotional stimuli) may indicate a really decreased level of awareness, beyond the temporal fluctuations of consciousness. Each set of data has, however, its own limitations; thus, the issue cannot be regarded as resolved at present. Conclusions: Two completely different notions of minimal consciousness, related to two basic approaches to the structure and function of consciousness, must be distinguished. The inability to this distinction can lead to severe misunderstandings, resulting in serious errors in both diagnostics and rehabilitative interventions.


Hockey is and will remain a central part of Canadian culture. Hockey players subject themselves to head injuries frequently, as 20% of hockey players receive concussions annually. TBI is shown to increase the risk for subsequent development of psychiatric disorders, yet hockey players do not seek psychiatric help after experiencing TBI. This present project examines the reasons behind this phenomenon. Forty various individuals who are involved in the culture of hockey were interviewed, including current and past professional and/or recreational hockey players, junior and professional hockey league coaches, medical professionals in the field of TBI and members of the public. The interviews were then qualitatively analysed and several major themes were found behind the barrier to accessing care. First, ex-hockey players openly talked about the masculine culture of hockey which pressured them to appear physical invincible in the past, sometimes with help from alcohol and other substances, but current hockey players do not. Secondly, both ex and current hockey players remarked on pressure to play through injuries and not seek psychiatric help because of their fear of being replaced by other players. Thirdly, the role of the enforcer, a person who inflicts many TBIs of other hockey players on purpose, is accepted and promoted in professional hockey and is influencing the recruitment of junior team members. Fourthly, neither the general public nor professional hockey players have adequate information about traumatic brain injury’s psychiatric sequellae, the role of a psychiatrist vs psychologist and where to seek psychiatric help. Lastly, there still is a great stigma to talk about psychiatric issues in Canada, especially in the realm of hockey athletes.

Two approaches to the notion of minimal consciousness in patients with severe brain injury Boris Kotchoubey University of Tu¨bingen, Tu¨bingen, Germany Objectives: Conceptual analysis of the notion of ‘minimal consciousness’ in patients with severe brain injury with the diagnoses Persistent Vegetative State (PVS) and Minimally Conscious State (MCS). Methods: Two principally different models of consciousness, both well known in the philosophical and neurological literature, are analysed. Each of them corresponds to a particular concept of what can be regarded as ‘minimal consciousness’. Results: According to a unitary approach (e.g. Baars), any act of information processing in the brain can be either conscious or not, but nothing in between. If this is true, then consciousness in patients diagnosed as MCS is not minimal, but the same as in any other (conscious) patients. It is, however, characterized by strong temporal fluctuations, making its behavioural manifestations unstable. PVS patients, in contrast, are simply unconscious. Therefore, the difference


Why won’t Sydney Crosby show up at your door? An examination of barriers to accessing psychiatric care post-TBI in ice hockey players Carrol Zhou, Shree Bhalerao, Yuri Markarov, & Michael Cusimano University of Toronto, Toronto, Ontario, Canada


DOI: 10.3109/02699052.2014.892379


Neuroprotection from traumatic brain injury by targeting intracellular neuronal signal transduction mechanisms James Bibb1, Ryan Turner2, Aric Logsdon2, Adan Hernande´z1, Chunfeng Tan1, Tanvir Singh1, Deena Sajitharan2, Jason Huber3, Florian Plattner1, Charles L. Rosen2, & James A. Bibb1 1

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Department of Psychiatry, The University of Texas Southwestern Medical Center, Dallas TX, USA, 2Department of Neurosurgery, West Virginia University School of Medicine, Morgantown, WV, USA, 3 Center for Neuroscience, Morgantown, WV, USA TBI is a major health problem associated with poor prognosis, acute and latent effects and long-term disability. Severity varies across a broad spectrum. Mild TBI is under-diagnosed, with many episodes going unreported. Severe TBI with or without cranial penetration is better documented and includes neuronal injury in response to blast exposure, particularly in the military combat setting. Immediate brain damage involves massive neuronal depolarization and influx of ions. In response to activation of voltage-gated Ca2+ channels, extremely high levels of the excitatory neurotransmitter glutamate are released, triggering excitotoxicity. Cerebral oedema and metabolic disturbances quickly follow. Swelling of neurons, oxidative stress and free radical production all contribute acutely to neuronal death. Following initial trauma, a delayed and spreading process of injury occurs. White matter fibre degenerates as axonal damage results from axolemmmal or cytoskeletal destabilization and collapse. Injured brains also exhibit increased sensitivity to secondary ischaemic insult, changes in cerebral blood flow and persistent excitotoxicity. Neuroinflammation may also contribute to lesion spread. To better understand the mechanisms mediating TBI, this study assessed the histopathological, neurophysiological, biochemical and behavioural effects of both cortical controlled impact (CCI) and blast-induced traumatic brain injury in rodent models. It was found that the deleterious effects of injury closely correlate with excitotoxic activation of calpain, aberrant activation of the neuronal protein kinase, Cdk5, and hyperphosphorylation of the microtubule associated protein tau. Conditional knockout of Cdk5 in adult mice dramatically reduced in vivo imaged TBI lesions and deleterious neurophysiological, histopathological and behavioural effects. These results implicate aberrant Cdk5 activity as a critical contributor to excitotoxic TBI and suggest that acute therapies targeting its acute activation or the mechanisms by which it causes neuronal injury and death may serve as effective therapies to mitigate TBI and improve recovery.


Early inflammatory biomarkers indicators of neonatal hypoxicischaemic encephalopathy Adnan Amin Alsulaimani, & Abdelaziz S. A. Abuelsaad Taif University, Taif, Saudi Arabia Background: Hypoxic-ischaemic encephalopathy (HIE) after perinatal asphyxia is a condition in which serum concentrations of brainspecific biochemical markers may be elevated. There is no gold

standard test for HIE-foetal distress, academia. Apgar score and other clinical markers of possible intra-partum injury have low positive predictive value. The present study was aimed to evaluate some biochemical and inflammatory markers that played an increasingly relevant role in the assessment of neonatal asphyxia neuroprotective interventions in asphyxiated newborns require early indicators of brain damage to initiate therapy. Patients and methods: A total of 48 cases of full-term infants born were classified into two groups. The first was normal healthy infants (eight males and 21 females). The second group consisted of infants with hypoxic-ischaemic encephalopathy (five males and 14 females). Blood gases, electrolytes, liver and renal function and some inflammatory cytokines were evaluated. Results: Normal healthy control newborns with average cordial pH level at birth 7.16 ± 0.24; body weights 3.41 ± 0.36 g and Apgar score 9.28 ± 0.65 at 5 minutes; while the hypoxic infants recorded an average cordial pH level 6.83 ± 0.12; B. wt. 2.76 ± 0.54 g; and Apgar score 5.47 ± 1.07 at 5 minutes. By applying stepwise multiple regression to select the more effective biomarkers; pH level was more affected by BE at birth and 72 hours, while many biomarkers, e.g. lactic acid, total protein, PCO2, Mg, PO2, BE and TNF-a were more effected at 24 hours. On the other hand, pooled data showed that pH is more affected by PCO2, BE, nRBC, PO2 and IL-1. The equations illustrating these relationships were represented and discussed. Conclusion: Based on some mathematical equations, the present data unveiled some vital biochemical and immunological factors that were most affected when there was a lack of blood pH in a newborn baby. Such situation is easily map forecasting or predicting treatment for overcome the severe side-effects arise in case of hypoxic-ischaemic encephalopathy. Also, there are some biomarkers with chemical and physiological effects correlated with injury cerebral. So, the study predicted early diagnosis and necessary treatment in a timely manner to avoid any ominous complications.


Traumatic brain injury in older adults: Special context of glutamate homeostasis Rajaneesh Gupta, Madhusudan Kanungo, & Sukla Prasad Banaras Hindu University, Varanasi, UP, India Objectives: Traumatic brain injury (TBI) can occur in individuals, regardless of age, and leads to brain dysfunction with varying degrees of recovery. However, the mechanism of otherwise effects of injury on the brain function, recovery and the mortality rate is unknown. TBI effects have been reported to be age-dependent. The recovery has been reported to be worse in age-matched older people than in younger people with similar injury. Glutamate homeostasis is one of the important phenomena that are subject to abnormal alteration in TBI, which in turn leads to prolonged neuronal depolarization, ionic imbalance, enhanced calcium influx, ATP depletion, etc. Heavy buildup of glutamate in synapse leads to a secondary wave of excitotoxicity and an exacerbation of post-traumatic cerebral oedema. The excitatory amino-acid transporter, EAAT-2/GLT-1, is responsible for clearance of the glutamate from neuronal synapses in the brain. Impaired glutamate uptake by EAAT-2 can result in cell death from excessive levels of glutamate and over-stimulation of glutamate receptors. Glutamate toxicity has been implicated in TBI, ageing and a wide variety of neurodegenerative disorders. Therefore, expression and regulation of the EAAT-2 gene in adult and old brain was studied in the induced TBI mouse model. Methods: Electrophoretic mobility shift assay (EMSA), RT-PCR and immunoblotting were carried out to study the interactions of NF-kB

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522 and N-myc transcription factors to their cognate sequences of EAAT-2 gene promoter and expression of EAAT-2 gene in the ipsi- and contralateral cortex of injured or SHAM adult mice in the adult (20-week) and old age (70-week) mice after severe TBI. Results: The results suggest that the interaction of NF-kB and N-myc to their binding sequences (583, 272, 251 and 163 bp upstream to transcription start site) is significantly increased after 4, 24 and 72 hours of TBI in the ipsi-lateral pericontusional cortex of the adult TBI mice compared with either the respective contralateral cortex or the adult sham-operated control. However, in oldmice, their interaction with their cognate sequences is significantly increased after 1, 4, 24 and 72 hours after TBI in the ipsi-lateral pericontusional cortex of the old TBI mice compared with the respective contra-lateral cortex and sham-operated old mice. The binding pattern of NF-kB and N-myc was further correlated with EAAT-2 protein and transcript levels. It was noted that higher NF-kB and N-myc interaction was associated with lower EAAT-2 mRNA and protein expression. Conclusion: The data provides a novel mechanism for regulation of EAAT-2 expression and, thence, glutamate homeostasis in the brain after TBI as an age-dependent manner that may align with more pronounced glutamate excitotoxicity in old TBI mice as compared to that in the adult TBI mice. Thus, TBI may challenge the brain function in a worse way in old age as compared to adult age.


Behaviour improvement and neural protection by long-term nasal delivering of bone marrow stromal cells after brain injury caused by ischaemia reperfusion in rats

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Outcomes of traumatic brain injury in Hong Kong: Validation with TRISS, CRASH and IMPACT models George Kwok Chu Wong, Janice Yeung, Wai Sang Poon, & Timothy Rainer Chinese University of Hong Kong, Hong Kong, PR China Objective: This study aimed to test prognostic models (TRISS, IMPACT and CRASH models) for 14-day mortality, 6-month mortality and 6-month unfavourable outcome in a cohort of trauma patients with TBI in Hong Kong. Methods: This study analysed 661 patients with significant TBI treated in a regional trauma centre in Hong Kong over a 3-year period. Discriminatory power of the models was assessed as the area under the receiver operating characteristics curve. One-sample t-tests were used to compare actual outcomes in the cohort against predicted outcomes. Results: All three prognostic models were shown to have good discriminatory power and no significant systemically over-estimation or under-estimation. For the 153 mild TBI patients, 14-day mortality was 12% (16/133) and 6-month unfavourable outcome was 18% (24/133). Fourteen-day mortality did not differ from the CRASH prediction (difference: 2%, 95% CI ¼ 5% to 1%, p ¼ 0.297), but the CRASH-predicted the 6-month unfavourable outcome rate was higher than the actual rate in this patient cohort (difference: 11%, 95% CI ¼ 7–15%, p50.001). Conclusions: All three predictive models are applicable to the respective eligible TBI patients in Hong Kong. These predictive models can be utilized to audit TBI management outcome for trauma service development in the future. The impact of healthcare delivery models for mild head injury should be further investigated.

Xianzhi Zeng, Huijuan Shen, & Yang Wang Jiaxing University, Jiaxing/Zhejiang, PR China Objectives: To explore the feasibility of treating brain injury caused by ischaemia reperfusion by long-term nasal delivering bone marrow stromal cells (BMSCs). Methods: MSCs were sorted from rat whole bone marrow by adherent culture. Brain ischaemia reperfusion rats were made by 15-minute occlusion of bilateral common carotid artery and then reperfusion, Model rats were randomly divided into experimental or control groups and the normal group were kept intact. MSCs in PBS or phosphate buffer saline (PBS) were dropped into the nasal cavity of the experimental group and control group, respectively, from the next day after brain ischaemia reperfusion once every 2 days for 4 weeks and the normal group were not treated with anything. Behaviour was assessed once a week. Brain pathological examination was done after the last behaviour assessment. Results: Compared with the control group, the modified neurological severity score and Morris Water Maze Test showed that the behaviour of the experimental group was gradually improved at 2 weeks after treatment and lasted until 4 weeks (p50.05, p50.01). Corresponding to behaviour improvement, ischaemia reperfusion resulted in 66% cell loss in CA1 in the hippocampus in the control group; however, in the experimental group, the cell loss in CA1 was significantly lower than the control group and only resulted in 25% cell loss in the same area. Conclusions: The data indicated that long-term intra-nasal delivering BMSCs could improve the function and decreasing cell loss after brain injury caused by ischaemia reperfusion.


Anaesthetics influence closed head injury induced blood–brain barrier disruption, cerebral blood flow, brain oedema and brain pathology Aruna Sharma1, Dafin Fior Muresanu2, Ranjana Patnaik3, Vannemreaddy Prasad1, & Hari Shanker Sharma1 1 Uppsala University Hospital, Uppsala, Sweden, 2University of Medicine & Pharmacy, Cluj-Napoca, Romania, 3Banaras Hindu University, Varanasi, India

Closed head injury (CHI) induced death or severe neurological disability in the US could account for 2000 per million populations per year and result in 400 000 new cases every year leading to longterm disabilities. However, the effect of anaesthetics on neurological outcome in CHI patients and the potential benefits of systemic vs volatile gas anaesthesia are still not well known. This investigation is undertaken to study brain pathology and functional outcome following a well-established model of rat closed head injury (CHI) under intravenous or volatile anaesthetics. Previous works from this


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laboratory showed a profound rise of plasma and brain serotonin levels in CHI associated with bran pathology. Thus, the effects of anaesthetics on plasma and brain serotonin level in relation to changes in blood–brain barrier (BBB) permeability, brain oedema development, alteration in cerebral blood flow (CBF) and brain pathology was also evaluated. The CHI was produced by an impact of 0.224 N on the right parietal bone under volatile ether anaesthesia or systemic ketamine, pentobarbital or Equithesin administered intraperitoneally. The CHI was inflicted by dropping a weight of 114.6 g on the skull from a height of 20 cm through a guide tube. This concussive brain injury resulted in profound leakage of Evans blue and radioiodine tracers in both the hemispheres and underlying subcortical tissues and induced brain oedema formation at 5 hours after the CHI. These changes were most pronounced in the contralateral cerebral hemisphere. At this time a marked decrease in the regional CBF was seen that was most marked in the contralateral side. The plasma and brain serotonin showed a pronounced increase and exhibited a good correlation with the oedema formation. Profound cell damage is seen in many parts of the brain that are most marked in the left uninjured hemisphere. These pathophysiological changes were most marked when the CHI was produced under ether anaesthesia compared to systemic anaesthesia. Mild but significantly less pathological changes are seen when the injury was made under ketamine as compared to pentobarbital anaesthesia. The Equithesin anaesthesia showed moderate brain pathology quite comparable to pentobarbital anaesthesia. Interestingly, the plasma and brain serotonin levels were highly correlated with the development of brain oedema in animals subjected to CHI under various anaesthetics. This suggests that anaesthetic stress plays important roles in inducing serotonin levels in the brain and plasma following trauma that could be detrimental in brain pathology. The functional outcome using Rota rod performances or Grid walking following CHI was most adversely affected under ether anaesthesia followed by pentobarbital, Equithesin and ketamine. This indicates that those anaesthetics markedly influence the functional and pathological outcome of CHI.

with bilateral horizontal nystagmus, nuchal rigidity and right-sided hypermyotonia were noted and Babinski sign was positive bilaterally. Brain MRI showed severe brain oedema and extensive symmetric white matter lesions (Figure). The blood concentration of potassium was 2.76 mmol L1 and that of glucose was 22.47 mmol L1. The white blood cell (WBC) count in the blood is 24.14  109 L1 and the platelet count is 24  109 L1. The blood coagulation routine was abnormal. Amylase in both serum and urine was elevated. TnT was 5.4 ng ml1. Her blood urea nitrogen was also increased (7.67 mmol L1). Heat stroke and multiple organ dysfunction syndrome were diagnosed and intensive symptomatic treatment was initiated immediately. Ice saline infusion and physical cooling was applied to cool down the patient. Mannitol was used to relieve intracranial oedema and supportive therapies were used to keep the vital signs stable. Two hours after admission, the patient suffered from generalized epilepsy twice presented as extending of the limbs and bilateral mydriasis. Epilepsy could be controlled with injection of 200 mg luminal; however, the patient fell into a deep coma and disseminated intravascular coagulopathy and rhabdomyolysis were noted. Despite intensive care, the patient remained comatose with respiratory and circulatory system abnormality which did not improve during the following days. Her family refused any further diagnostic and therapeutic procedures and she was discharged.


Diplopia and ptosis as the initial manifestations of acquired hepatocerebral degeneration Hongliang Zhang, Xiujuan Wu, Jiang Wu, & Chunkui Zhou The First Hospital of Jilin University, Changchun, PR China


Unusual heat stroke caused by herbal therapy of traditional Chinese medicine Hongliang Zhang, Jie Cao, Jiang Wu, & Hui Deng The First Hospital of Jilin University, Changchun, PR China Traditional Chinese medicine (TCM) comprises a range of traditional medical practices that originated in China, including herbal medicine as a major therapy. Heat stroke is a severely life-threatening heatrelated illness that is most commonly seen during summer heat waves and high environmental temperatures. Intake of medications or toxins is considered one of the risk factors leading to heat stroke, as they may affect the body thermoregulation. A 49-year-old woman presented to the department with acute-onset unconsciousness. The patient had been diagnosed as right-sided idiopathic facial palsy and had received herbal therapy from a local TCM practitioner after a non-effective 20-day acupuncture treatment. Covered with a thick quilt, she lay down on a heated kang (brick bed) so as to induce diaphoresis. Meanwhile, she held ginger (Zingiber officinale) homogenates in hands. After 1-hour of treatment, the patient complained of numbness in her face and bilateral upper limbs. Three hours later, she suddenly fell unconscious, with high fever and urinary and faecal incontinence. Hypokalemia, hyponatremia and hyperglycaemia developed and brain computed tomography (CT) in the local hospital was unremarkable. The patient was then transferred to the intensive care unit (ICU) in the hospital. At admission, she was deliriant and incooperative; her body temperature was 41.2 C and her blood pressure was 90/60 mmHg. Right-sided facial palsy together

Acquired hepatocerebral degeneration is a rare neurologic disorder of cirrhotic patients, characterized by extrapyramidal signs and cognitive impairment. A 62-year-old cirrhotic woman presented with an 18-day history of diplopia and right-sided ptosis. Neurologic examination showed right-sided ptosis, anisocoria (left ¼ 3.0 mm and right ¼ 3.5 mm), upward gaze diplopia and bilaterally positive Babinski sign. T1-weighted images (T1WI) of magnetic resonance imaging (MRI) showed hyperintensity, primarily in the bilateral globus pallidus and cerebral peduncle. The results of contrast-enhanced MRI, magnetic resonance spectroscopy and cerebrospinal fluid examination were unremarkable. The blood level of ammonia was 177 mmol L1, albumin 22.3 g L1 and cholinesterase 1926 U L1. Abdominal ultrasound revealed ascites. Albumin, vitamins B, reduced glutathione and diammonium glycyrrhizinate did not improve the symptoms. Acquired hepatocerebral degeneration was diagnosed. T1WI hyperintensity found in globus pallidus is due to accumulation of manganese. Diplopia and ptosis as the initial manifestations of acquired hepatocerebral degeneration have not been reported in the literature.


Acute necrotizing encephalopathy secondary to sepsis Hongliang Zhang, Jie Cao, Limin Wu, Chunkui Zhou, & Jiang Wu The First Hospital of Jilin University, Changchun, PR China

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524 A 46-year-old man was admitted for a sudden onset of generalized tonic-clonic seizure and convulsion as well as deteriorating unconsciousness for 14 hours. He was treated with antibiotics during the preceding 2 weeks for high fever and upper respiratory tract infection. Upon admission, his body temperature was 40.3 C, blood pressure was 86/50 mmHg and the Glasgow Coma Scale score was 5/15. Nuchal rigidity was noted. Kernig sign and Babinski sign were positive bilaterally. Other systemic physical examinations were unremarkable. Blood routine test showed increased WBC (17.47  109 L1; neutrophils 86%) and decreased platelet (37  109 L1); and coagulant dysfunction (FDP 122.9 mg mL1, D-dimer 6283 mg L1, PT 25 s, APTT 44.1 s) was observed. Acidosis and elevated serum liver enzymes (AST 7222 IU L1, ALT 5126 IU L1), creatinine (142 mmol L1) and amylase (705 IU L1) were found. Blood samples were collected for blood cultivation, whereas no pathogen was identified. Serum viral studies (HBV, HCV, HIV) and syphilis serology tests were all negative. Cerebrospinal fluid (CSF) test revealed a slightly elevated protein level (0.87 g L1), elevated IgG level (107 mg L1) and normal glucose level without pleiocytosis. CSF IgG and IgM for HSV, CMV, EBV, Rubella, Rubeola and HHV were all negative. CSF RPR for syphilis was negative. Electroencephalography examination demonstrated diffuse generalized and slow background activity. Pulmonary CT showed mild pneumonia and abdominal CT showed abnormal signal intensity in the right lobe of the liver. Brain CT showed symmetric hypointensity on the thalamus and brain MRI showed symmetric concentric thalamic lesions. Sepsis and acute necrotizing encephalopathy (ANE) were diagnosed by ruling out viral encephalitis, acute disseminated encephalomyelities, cerebral vasculitis and metabolic encephalopathy, according to laboratory tests and imaging features. Intensive antiseptic as well as supportive treatment was initiated and the patient turned conscious 2 days later.


Traumatic brain injury induced blood–brain barrier disruption, brain oedema formation and brain pathologies are reduced by cerebrolysin in a dose-dependent manner. An experimental study in the rat using biochemical and morphological approaches Hari Shanker Sharma1, Dafin Fior Muresanu2, Ranjana Patnaik3, Herbert Moessler4, & Aruna Sharma1

Brain Inj, 2014; 28(5–6): 517–878

brain injury (OBI) on blood–brain barrier (BBB) disruption, brain oedema formation and cerebrla blood flow (CBF) changes in different areas of the brain and spinal cord. Furthermore, the sensory motor functions were evaluated in these traumatized animals using a RotaRod treadmill, inclined plane angle (IPA) and walking on a mesh-grid following varying doses of the cerebrolysin treatment. At the end of the experiments, the specific areas of the brain and spinal cord tissues were removed after in situ perfusion with 4% buffered paraformaldehyde for further analyses of nerve cell injury by Nissl staining and glial reaction and myelin damage using immunohistochemistry of glial fibrillary acidic protein (GFAP) and myelin basic protein (MBP) immunoreactivity. The results showed that cerebrolysin up to a certain extent (2.5, 5 and 10 ml kg1 equivalent doses) induced a dose-dependent neuroprotection on BBB, brain oedema and alterations in CBF and attenuated behavioural dysfunction following brain injuries in these models. However, with further escalation of the dose ca. 10 ml kg1 to 15 ml kg1 (equivalent doses) no greater effects were observed. This suggests that cerebrolysin in a dose of 10 ml kg1 appears to be maximum effective in attenuating traumatic brain injuries induced brain pathology. Interestingly, when these escalated doses are given 30 minutes to 4 hours after brain injury the beneficial effect was still observed on pathology and sensory motor function up to 12 hours after trauma. Moreover, when repeated doses of cerebrolysin were administered starting from 4 hours to 12 hours after injury (at 3-hour intervals), the beneficial effects are seen until 24 hours of survival. These beneficial effects on brain and behavioural dysfunction also exhibited a tight correlation with the rescuing of neuronal, glial and myelin damage using immunohistochemical and histopathological techniques. To the authors’ knowledge, these observations are the first to demonstrate that cerebrolysin has a dose–response effects and repeated administration after injury is beneficial as the drug is able to thwart both the brain pathology and the behavioural dysfunctions after trauma.


Cold and hot environment exacerbates brain pathology following concussive brain injury Hari Shanker Sharma1, Dafin Fior Muresanu2, Prasad Vannemreddy1, Ranjana Patnaik3, & Aruna Sharma1 1

Uppsala University Hospital, Anesthesiology & Intensive Care Medicine, Uppsala University, Uppsala, Sweden, 2Department of Clinical Neurosciences, University of Medicine & Pharmacy, Cluj-Napoca, Romania, 3School of Biomedical Engineering, Indian Institute of Technology, Banaras Hindu University, Varanasi, India


Uppsala University Hospital, Anesthesiology & Intensive Care Medicine, Uppsala, Sweden, 2Department of Clinical Neurosciences, University of Medicine & Pharmacy, Cluj-Napoca, Romania, 3School of Biomedical Engineering, Indian Institute of Technology, Banaras Hindu University, Varanasi, India, 4Ever Neuro Pharma, Oberburgau, Austria Traumatic brain injuries are life-threatening events and induce longterm disability to the survivor. This imposes a huge financial burden on society. Thus, exploration of novel therapeutic agents to enhance quality-of-life of these victims in a well-balanced manner is highly needed. Recently, Cerebrolysin (Ever Neuro Pharma), a well-balanced composition of several neurotrophic factors and active peptide fragments (2.5 or 5 ml kg1, i.v.), showed profound neuroprotective effects in rat models of brain or spinal cord injuries. However, a dose response of cerebrolysin in brain injuries has not been investigated so far. This investigation examined the effects of cerebrolysin in escalating doses on closed head injury (CHI) as well as in open

Our soldiers are often engaged in combat operations or peacekeeping activities across the World either in extreme cold weather in Afghanistan or in excessive hot climates in Middle East countries. Under such situations, they are often exposed to blast injuries by explosive devices, roadside landmines or grenade injuries. In such situations, often the soldiers show mild-to-severe concussive brain injuries that lead to severe disability or even death. Thus, efforts should be needed to find out whether brain injury in extreme weather conditions is somehow associated with the adverse brain pathology as compared to the normal room temperature. This laboratory has initiated a series of investigations in which various environmental factors like cold and heat on the pathophysiology of penetrating or blunt head trauma are being examined in detail. This investigation examined the effects of cold and hot environment on concussive brain injury as compared to trauma inflicted at a thermoneutral temperature zone in a rat model. Adult rats were either reared to cold (+5 ± 1 C), hot (+33 ± 1 C) or thermoneutral (+23 ± 1 C) environments in climatic chambers beginning from


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the age 5–7 weeks for 5 weeks in a Columbus Instruments Comprehensive Lab Animal Monitoring System (CLAMS) (Columbus, OH). After 5 weeks of acclimatization at each temperature zone, the rats were anaesthetized with Equithesin and subjected to closed head injury (CHI) using standard protocol. In this model a weight of 114.6 g was dropped over the right parietal skull over a 20 cm height inflicting an impact of 0.224 N on the surface. After injury the animals were replaced in their respective cages for 5 h. At the end of the experiment, the blood–brain barrier disruption, brain oedema formation and neuronal injuries were determined in each group. These results showed that animals reared ina cold environment showed a 3–6-fold higher leakage of the BBB to Evans blue, a 5–8-fold increase in brain oedema formation and a 3–4-fold greater neuronal injuries as compared to the animals injured at the thermoneutral temperature zone. Likewise, CHI in animals reared in a hot environment also showed 3–4-fold higher BBB leakage, 4–6-fold more brain swelling and 2–3-fold higher neuronal injuries as compared to animals injured in the thermoneutral temperature zone. These observations are the first to demonstrate that ambient temperature significantly influence brain pathology after concussive brain injury. It is interesting to see further whether the effects of neuroprotective drugs could also be altered in these conditions, a feature that is currently being investigated in this laboratory.


Engineered nanoparticles from metals aggravate spinal cord injury induced neuropathic pain syndrome and exacerbate blood– spinal cord barrier breakdown, astrocytic activation and neural injury: Neuroprotective effects of cerebrolysin Lianyuan Feng1, Aruna Sharma2, Dafin Fior Muresanu3, Herbert Moessler4, & Hari Shanker Sharma2 1

Department of Neurology, Bethune International Peace Hospital, Shijiazhuang, Hebei Province, PR China, 2Department of Surgical Sciences, Anesthesiology & Intensive Care Medicine, University Hospital, Uppsala University, Uppsala, Sweden, 3Department of Clinical Neurosciences, University Hospital, University of Medicine & Pharmacy, Cluj-Napoca, Romania, 4Ever Neuro Pharma, Oberburgau, Austria Post-traumatic injury to the spinal cord is well known to induce neuropathic pain syndrome that includes sensitivity to touch and pain perception including phantom pain. However, it is not well known if nanoparticles (NPs) intoxication could influence neuropathic pain after spinal cord injury (SCI). Animal models of chronic neuropathic pain simulating some of the clinical symptoms can be introduced by constriction, ligation or transection of sensory and/or motor spinal nerves. The present investigation combined the effects of a SCI with nerve ligation and examined the effects of NPs on the development of spinal cord pathology. Previous experiments in this laboratory showed that the magnitude and intensity of brain or spinal cord injury are altered by nanoparticles intoxications. However, effects of nanoparticles in modifying neuropathic pain syndrome in combination with SCI are still unknown. The present investigation examined the role of engineered NPs from metals on development of neuropathic pain with SCI on the BSCB dysfunction, astrocytic reactivity and neural injury in the rat. SCI was performed on the T9–10 segments by making a

longitudinal incision of the dorsal horn and, in these animals, spinal nerve ligation at L-4 and L-5 was also performed surgically. In a group of SCI and nerve lesioned rats Cu, Ag or Al NPs (50 to 60 nm; 50 mg kg1, i.p.) were given once daily for 10 days. Morphological examination of the cord including albumin immunoreactivity for BSCB dysfunction, GFAP reactivity for astrocytic activation and Nissl staining for neural injuries were examined after 2, 4, 8 and 10 weeks after nerve ligation with SCI. NPs treated rats exhibited prolonged hypersensitivity to external stimulation (fur touching) up to 8 weeks. Leakage of albumin and activation of astrocytes in the spinal cord segments T10, T12 and L5 were exacerbated by 120% at 4 weeks; 250% at 8 weeks and 300% at 10 weeks after SCI and ligation in the NPs treated group. This effect was most marked in Cu and Ag treated animals. Neuronal injury closely corresponded to albumin leakage in the spinal cord. Cerebrolysin in high doses (5 ml kg1) if co-administered with NPs daily was able to reduce morphological changes in the cord effectively. However, cerebrolysin (10 ml kg1 but not 5 ml dose) if given after 4–6 days of NPs administration was also able to induce sufficient neuroprotection. The drug also reduced hyperalgesia only if given as a pre-treatment. These observations are the first to show that NPs potentiate duration of hyperalgesia of neuropathic pain following SCI and exacerbate disturbances in a spinal cord microfluid environment. Furthermore, cerebrolysin in high doses is able to thwart these changes, indicating a potential role of this drug in pain management and SCI, not reported earlier.


Neurophysiotherapy Treatment of a schizophrenic patient after recovering from pinealoma – Case report Katarina Persˇic´1,2 1

Psychiatric Hospital, Rab, Croatia, 2Croatian Council of Physiotherapist, Zagreb, Croatia Objectives: This case report outlines a six months long longitudinal study applied on a forthy years old schizophrenic patient after his recovering from epiphiseal neoplasm pinealoma and being operated twice. Pinealoma is the cause of the motorical and psychological disorders in patient, and after the last operation patient has got left-side hemyparesis with consequent postural balance disorders, occasional vertigo and deteriorating eyesight. Patient also has great difficulties in coping with everyday activities and social interactions. The goal of this study was to investigate the influence of combined techniques on gait stability, normalization of muscular tone and quality of patient’s life. Methods: Patient passed an intensive individual and specific neurorehabilitation programe during six months in a Psychiatric Hospital Rab, which was based on Pilates exercises with a ball, Cawthorne-Cooksey rehabituative exercises for reducing vertigo, balance exercises in standing position and mobilization-stretching techniques applied on hemiparetic left foot. Patient exercised four times a week, forty five minutes twice daily. Results: Patient’s evaluation included range of motion of dorsal and plantar flexion in left ankle joint, flexion and extension in left big toe, Ashworth scale, Timed Up and Go Test, Foot-tapping test, FIM measure, EORTC QLQ-C30 life quality inventory and Dizziness Handicap Inventory.Statistics collected during study were analysed by Pearson’s multiple correlation and also presented with diagrams. Results in Timed Up and Go Test indicated that skilfulness and gait velocity raised from 23 seconds to 8,5. The frequency of foot tapping raised from 22 to 58 in rehabilitation period, simultaneously dizziness decreased from 96 to 38 scores on DHI inventory. Pearson correlation for Timed Up and Go and Foot-tapping Test was – 0,979. Pearson correlation for Foot-tapping Test and DHI inventory

526 was – 0,991, consequently foot frequency increased while dizziness decreased. Pearson correlation for Timed Up and Go Test and DHI inventory was 0,994. Muscular tone condition in hemiplegic muscles was improved from mark 3 to mark 1, through Ashworth scale. From maximum 91 scores of physical/ motorical domaine of FIM measure, the initial result was 47 and at the end was 70. From maximum 35 scores of cognitive domaine of FIM measure, initial result was 19 and at the end 27. Analysing qalitiy of patient’s life, the highest scores were achieved in social and emotional functioning (from score 0 till 100).From symptomatic scale factors, fatigue, insomnia and constipation were successfully decreased from score 100 till 33. Conclusion: Application of combined techniques described in this study is recommended also for similar specific pathology, but results don’t allow generalization on population.

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Species diversity of nNOS gene in spinal cord in response to nerve roots avulsion

Brain Inj, 2014; 28(5–6): 517–878 1

New College of Florida, Sarasota, FL, USA, 2Mind Research Network, Albuquerque, NM, USA Mild traumatic brain injury (mTBI) is a silent but costly epidemic, affecting millions of people worldwide every year. The inability for traditional medical imaging technologies to detect some types of damage that occur in mTBI has prevented the injury from receiving appropriate attention in research and clinical settings for decades. A continually growing body of research establishes diffusion tensor imaging (DTI) as an imaging modality sensitive to the subtle sequelae of diffuse axonal injury (DAI), common in mTBI. With the development of better imaging and analysis techniques for DTI and the establishment of certain imaging biomarkers for identifying mTBI, a shift is occurring in the medical standards and practices for how one recognizes and treats mTBI. Using T1-weighted MRI (sMRI) and DTI data obtained from the Mind Research Network (MRN), voxel-based analysis is performed to determine the relative merits of these data types in identifying mTBI and producing predictive biomarkers. These results demonstrate that diffusion tensor imaging (DTI) may be used to discriminate mTBI pathophysiology more effectively than standard imaging modalities such as T1-weighted magnetic resonance imaging (sMRI). A case is made for adopting DTI as part of the standard clinical protocol in the diagnostic evaluations of head injury.

LiHua Zhou, YanLi Feng, JiaChuan Wang, & Ying Tang Zhongshan Medical School of Sun Yat-sen University, Guangzhou, Guangdong, PR China Objectives: In order to study the mechanism of the spinal root-avulsioninduced spinal motoneurons death, the diversity of the nNOS gene expression and the response to the root-avulsion injury of the spinal motoneurons were compared among different laboratory rodents. Methods: Sprague-Dawly rats, Hamsters and BALb/c mice were chosen as the experimental animals. All of the right C5, C6, C7, C8 and T1 spinal roots of the brachial plexus were avulsed. After surviving for 3 and 14 days, the spinal cords of all the animals were taken and prepared for RT-PCR, Western blot of nNOS genes and NADPH histochemistry plus neutral red staining. Results: Following avulsion injury, the levels of the nNOS mRNA in ipsilateral spinal cords decreased in hamsters and mice, while increasing in rats. The nNOS mRNA levels were more in the ipsilateral than that in the contralateral spinal cords in all studied species; however, this difference disappeared for mice at 14 days post-injury. The levels of the nNOS proteins in the ipsilateral spinal cords were dramatically increased for rats and hamsters but declined for mice following avulsion. The nNOS protein levels were higher in the ipsilateral than in the contralateral spinal cords in the rats and hamsters but not in mice at 14 days. Avulsion induced obvious positive NADPH reactions inside the spinal motoneurons both in rats and hamsters at 14 days but not in mice. Avulsion-induced ipsilateral spinal motoneurons died in all species. At 14 days post-injury the number of surviving motoneurons at the ipsilateral C7 spinal segments was only 35.64% in mice, 53.29% in hamsters and 79.57% in rats. Conclusions: The present data showed the evidence of the species diversity of nNOS gene expressions in the spinal cords in laboratory rodents in response to the root avulsion injury. It suggests that the nNOS gene might be essential for spinal motoneurons to survive the root-avulsion injury.


Neuroimaging of mild traumatic brain injury: A voxel-based analysis of sMRI And DTI data Graham Robart1,2


The role of the orbitofrontal cortex in behaviour and cognition Frank Jonker, Cees Jonker, & Eric Scherder VU University, Amsterdam, The Netherlands The orbitofrontal cortex plays a crucial role in behaviour and is a common site for damage due to different types of injuries; e.g. closed head injuries, cerebrovascular accidents, tumours and neurosurgical interventions. Despite the (severe) behavioural changes following orbitofrontal cortex lesions, persons with damage to the orbitofrontal cortex appear to be cognitively intact, i.e. at least when assessed by means of standard neuropsychological tests. Based on an elaborate review, Zald and Andreotti suggest that there are at least three cognitive functions that seem to be related to orbitofrontal cortex damage; they also recommend tasks to test that specific cognitive function; (1) Learning and adapting to changing reinforcement contingencies. The reversal learning task measures the ability to utilize cues in the environment to predict future rewarding or aversive events. A task that show components of reversal learning is the Wisconsin Card Sorting Test (WCST), in particular completing fewer sorting categories’; (2) Decision-making tasks. The Iowa Gambling Task (IGT) measures the ability to regulate behavioural responses in the context of changing reinforcement contingencies, based on rewards and punishment; and (3) Social processing and theory of mind. Theory of Mind (ToM), the ability to attribute mental states and intentions to oneself and others, as well as the recognition of expressed emotion, are the two core components of social processing and essential for human non-verbal communication. The ‘faux pas test’ requires the capacity to judge inappropriate behaviour in social situations. The test for recognition of expressed emotion is a computerized task designed to assess an individual’s ability to recognize social emotions. The goal of this review is to examine studies that investigated behavioural changes in daily life following lesions in the orbitofrontal cortex in relationship to the recently-introduced cognitive functions in order to find a neurocognitive basis for behaviour. In six studies a relationship was found between orbitofrontal cortex damage and disinhibited behaviour. Six studies found a relationship between orbitofrontal cortex damage and obsessive compulsive behaviour. Three studies found a positive relationship between orbitofrontal cortex damage and a type of


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social inappropriate behaviour. Complex higher order cognitive functions of the orbitofrontal cortex cannot be measured by traditional neuropsychological functions. Based on this review, it was found that ‘disinhibition’ as a behavioural disorder has been related to deficits in Reversal Learning Tasks and that ‘rigid or antisocial behaviour’ has been related to deficits in Recognition Expressed Emotions. Neuropsychologically obsessive compulsive behaviour is seen as a deficit in set shifting, It explains why the WCST is the most used test to assess obsessive compulsive behaviour. No relationship is found. These results are consistent with the view of a separate (neuro)cognitive system underlying profound emotional and social behavioural changes following orbitofrontal cortex lesions.

symptoms of mTBI/post-concussion syndrome. The rapid improvement in these cases suggests that brain stimulation techniques deserve more study in patients suffering from persistent sequelae of mTBI.


Pamela Weatherbee1, Ryan Todd2, & Shree Bhalerao2

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The use of non-invasive brain stimulation in mTBI treatment: A case series George Kukurin Private Practice, Avondale, AZ, USA Objectives: To describe the response of mTBI cases to non-invasive brain stimulation techniques. Mild traumatic brain injury (mTBI) and Persistent Post-Concussion Syndrome, the long-term consequence of mTBI are emerging as serious public health concerns. Major advances in the diagnosis of mTBI sequelae are being made, but effective treatment options are lacking. The field of neuromodulation has led to a number of non-invasive techniques of brain stimulation that may find clinical application in the treatment of persistent post-concussion symptoms. This paper describes the use of several types of noninvasive neuromodulation techniques in cases of mTBI that failed to respond to traditional methods of neural rehabilitation. Techniques employed include Cranial Nerve Non-Invasive Neuromodulation (PoNsTM), Transcranial Direct Current Brain Stimulation (tDC) and Galvanic Vestibular Stimulation (GVS). Methods and results: Cases were recruited from a private chiropractic neurology practice. Patients (BE, BA, JM, DG) were all females, aged 19, 25, 42 and 58, respectively, who suffered from persistent postconcussion symptoms as a result of mTBIs associated with motor vehicle accidents. A major clinical feature common to all four cases was balance dysfunction and disequilibrium. Each of these cases had at least one and in the case of BA and JM multiple trials of vestibular rehabilitation without improvement prior to non-invasive neuromodulation. BA had significant cognitive and motor impairment that failed to respond to 18 months of speech and occupational therapy. BE developed vertigo and syncope. All complained of chronic headaches and brain fog. JM had significant anxiety symptoms. Before treatment none of these cases could drive due to disequilibrium and related symptoms. BA and BE had third party formal neurocognitive testing. All had been or were under the care of multiple specialists prior to non-invasive neuromodulation. BA and JM were unable to work due to their ongoing signs and symptoms. All were previously diagnosed with mTBI by appropriate neurological specialists. Patient BA was treated using the PoNS device and neural rehabilitation techniques. Patients BE, DG and JM were treated with GVS (anode on left mastoid, cathode on right mastoid and or tDC anode over the DLPFC. Results: BA demonstrated dramatic cognitive and overall improvement. She was able to return to work as an attorney after more than 2 years of mTBI-related total disability. In all cases vestibular signs and symptoms were completely resolved. Headache and other associated symptoms were dramatically improved or completely resolved with the addition of non-invasive brain stimulation to traditional neural rehabilitation. Conclusions: Non-invasive brain stimulation techniques were used as an add-on treatment in a group of patients suffering from intractable


Upper body injury: A literature review on the psychiatric outcomes of hockey concussion 1

University of Calgary, Department of Psychiatry, Calgary, Alberta, Canada, 2University of Toronto, Department of Psychiatry, Toronto, Ontario, Canada Objectives: Recent suicides and overdose deaths of professional athletes in the National Hockey League (NHL) have highlighted the need for further research into the possible long-term psychiatric effects of concussion. This study sets out to uncover the literature surrounding concussions in hockey and psychiatric effects of concussion. Methods: A literature search was executed utilizing MEDLINE, EMBASE and PsychINFO initially looking at research specifically connected to ice hockey, concussion and psychiatric outcomes, including depression, anxiety, substance abuse and dependence and Post-Concussive Syndrome (PCS). In addition, a more broadly defined search was conducted looking at athletes, concussions or mild traumatic brain injury (mTBI) and psychiatric outcomes including those aforementioned between 2000 to current. Results: Hockey has the highest rates of concussion in both high school and professional level athletics compared to other contact sports. One report found that 25% of high school ice hockey players suffer at least one concussion per season. In terms of psychiatric sequelae from head injury, depression has been recognized as the most cited psychological disturbance after any type of traumatic brain injury. Studies have demonstrated prevalence of depression as a result of all cause traumatic brain injury to range from 18.5–61%. One study found that 33% of patients were diagnosed with Major Depressive Disorder (MDD) according to DSM-IV criteria within the first year of the brain injury occurring, specifically 46.7% in those that suffered a mild TBI (Glasgow Coma Scale 13–15 at time of injury). The relationship between suicide and traumatic brain injury is well documented. Teasdale and Engberg completed a retrospective population study; those with a mild cognitive brain injury had an increased relative incidence of 3.0-times comparatively to the general population. Currently, there is no literature regarding screening tools for psychiatric manifestations of concussion and this is not included in the standard screening tools; the Balance Error Scoring System (BESS), the Sensory Organization Test (SOT) and neuropsychological testing, which focuses mainly on cognitive processing, memory performance and reaction time. Finally, there is no literature that directly examines hockey concussion and psychiatric outcomes. Conclusions: Ice hockey has one of the highest rates of concussion compared to other amateur contact sports. Moreover, there is strong data to support negative psychiatric outcomes from concussion, most prominently depression and suicide. Despite this, research in the field of psychiatric outcomes of concussion in ice hockey is non-existent. It is critical that research be directed towards ice hockey, at all skill levels, ages and sexes in an effort to prevent and attempt to reduce the potentially devastating effects of concussion.



ADHD: An integration with paediatric traumatic brain injury Robert Eme Illinois School of Professional Psychology, Schaumburg, IL, USA

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This review examines the long-standing finding that ADHD is a common sequela of paediatric traumatic brain injury (PTBI) in light of the current conceptualization of ADHD as a dimensional, neuropsychologically heterogeneous disorder. The review contends that this conceptualization established the basis for concluding that frequently occurring symptoms caused by PTBI, such as slow processing speed, emotional dysregulation and disinhibition, are indicative of ADHD. Consequently, it concludes that ADHD following PTBI is even more common than the 30% rate the current literature suggests. It provides recommendations for the assessment and treatment of ADHD associated with PTBI.


Music therapy in post-acute rehabilitation following brain injury Rick Soshensky State University of New York at New Paltz, New Paltz, NY, USA The most common post-injury emotional reactions have been found to be negative affect states such as depression, boredom, worthlessness and loneliness. Once acute injury and life-threatening conditions have been stabilized, the next phase of rehabilitation involves addressing areas of functional and social behaviour involving arousal, attention, relationship management, executive function, emotional management, physical control, communication and motivation such that the patient can achieve meaningful quality-of-life and community integration. Brain imaging technology has shown significantly broad and comprehensive neurological response to music therapy in comparison with verbally and cognitively oriented therapies. Through the presentation of case studies illuminated by the most current theoretical information, the study will demonstrate how music therapy can assist in improved outcomes in psychosocial rehabilitation involving progress in essential areas of well-being such as engagement, self-expression, affiliation, self-efficacy and enjoyment, all of which can have a significantly positive impact on the patient’s quality-of-life.


Acute care evaluation of conversational discourse skills post-traumatic brain injury Joanne LeBlanc1, Elaine de Guise2, Marie-Claude Champoux1, Celine Couturier1, Julie Lamoureux2, Judith Marcoux1, Mohammed Maleki1, & Mitra Feyz1 1

McGill University Health Centre, Montreal, Quebec, Canada, 2 Universite´ de Montre´al, Montreal, Quebec, Canada

Brain Inj, 2014; 28(5–6): 517–878

Objectives: Following traumatic brain injury (TBI), deficits in communication skills are common. These are generally related to impairment in cognitive processes sub-serving language and communication functions. Among these difficulties, impaired discourse has been considered as the hallmark of post-TBI cognitive-communication disorders. It is known that persistent problems in conversational discourse can have a significant impact on social, community and vocational reintegration. However, analysis of such skills tends to be time-consuming and difficult to carry out in the clinical setting, particularly in acute care. Moreover, little information is available regarding communication and conversational discourse proficiency post-TBI in the acute care phase. The goal of this study was to explore the validity of a brief and easily administered tool, the conversational discourse checklist of the Protocole Montre´al d’e´valuation de la communication (D-MEC) to assess conversational discourse post-TBI in acute care and to explore how demographic variables, pre-morbid characteristics and injury severity variables predict conversational discourse performance. Methods: Data on demographics (age, education, employment status), pre-morbid characteristics (cognitive limitations, learning and attention deficit disorders, psychiatric diagnosis, substance abuse history, neurological insult history) and injury related variables (mechanism of injury, TBI severity as measured with the Glasgow Coma Scale (GCS)) were gathered through retrospective chart review or from the TBI program database as well as through interviews with relatives. The D-MEC was administered to 195 patients in a tertiary care trauma centre within 3 weeks post-mild, moderate and severe TBI. Results on the D-MEC were compared to performance on the following cognitive and language measures: the Digit Span of the Wechsler Memory Scale-III (working memory), the Trail Making Test (visual attention and mental flexibility), the Hopkins Verbal Learning Test (verbal learning), the short form of the Boston Naming Test (confrontation naming), the verbal absurdities sub-test of the Detroit Test of Learning Aptitude (comprehension of illogical content) and verbal fluency measures. Results: The items of the D-MEC which were most frequently rated as problematic included inappropriate/unexpected comments (35.89%), imprecise expression of ideas (30.78%), speech rate too slow/too fast (26.67%), word-finding/incorrect word choice (26.66%), repetitiveness (18.98%), lack of verbal initiative (15.9%) and inappropriate topic switches (11%). Patients with severe TBI performed significantly worse than mild and moderate groups (2KW2df ¼ 24.435, p ¼ 0.0001). The total D-MEC score correlated significantly with all cognitive and language measures (p50.05). A stepwise linear model showed that age, GCS score and history of neurological problems together explained 30% of the variability of the total D-MEC score. Conclusion: The D-MEC identified conversational discourse impairment in patients post-acute TBI. As such, it is a useful clinical tool to screen early conversational discourse skills in this stage of recovery.


Can outcome be predicted by conversational discourse abilities post-traumatic brain injury? Joanne LeBlanc1, Elaine de Guise2, Marie-Claude Champoux1, Celine Couturier1, Julie Lamoureux2, Judith Marcoux1, Mohammed Maleki1, & Mitra Feyz1 1 2

McGill University Health Centre, Montreal, Quebec, Canada, Universite´ de Montre´al, Montreal, Quebec, Canada

Objective: Following a traumatic brain injury (TBI), individuals frequently present with communication deficits related to cognitive impairment. Among the cognitive-communication problems that have been described, impaired conversational discourse is a well-


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DOI: 10.3109/02699052.2014.892379

established consequence. Persistent problems in conversational discourse can lead to difficulty with social, community and vocational reintegration. In fact, several studies have shown that competence in discourse can predict long-term vocational and social integration as well as quality-of-life in patients with TBI. These studies were mainly carried out several months or years post-injury. Very little information is available regarding communication and conversational discourse proficiency in the acute recovery phase, that is a few weeks postinjury. Given the significant impact of conversational discourse impairment on long-term outcome in TBI, it would be important to gain a better understanding of how problems in this domain influence acute outcome so that appropriate early rehabilitation services can be enabled. The main goal of this study was to examine how conversational discourse impairment following TBI predicts early outcome. Methods: The conversational discourse checklist of the Protocole Montre´al d’e´valuation de la communication (D-MEC) was presented as part of an acute care screening battery in a tertiary care trauma centre to 195 patients within 3 weeks post-TBI. This brief and easily administered tool, originally developed for individuals post (R) hemisphere stroke assesses items which characterize discourse deficits of individuals with neurogenic language and communication problems, including those with TBI. Outcome was measured with the Disability Rating Scale (DRS), the Extended Glasgow Outcome Scale (GOS-E) and included discharge destinations. Results: Linear regression results showed that the D-MEC total score, age and initial Glasgow Coma Scale (GCS) score accounted for 50% of the variation of the DRS scores. The DRS score was lower, signifying better outcome, when the total D-MEC score was higher, the subject was younger and when the initial GCS score was higher. Moreover, D-MEC performance significantly predicted the moderate and severe disability categories of the GOS-E and the probability of requiring rehabilitation (p50.05). The more severely impaired was conversational discourse, the worse was the level of disability and the level of global outcome while the greater was the chance of needing rehabilitation. Conclusion: Outcome was related to conversational discourse skills of patients assessed in acute care with the D-MEC post-TBI. These results provide additional information to guide clinicians in predicting overall outcome acutely post-TBI. This information can in turn help the rehabilitation team and stakeholders plan for adequate allocation of resources in acute care and for required discharge services post-acute care hospitalization to target communication deficits.


Walk in my shoes—A survivor’s survival story and what can be learned by health professionals Valerie Bergeron Manitoba Brain Injury Association, Winnipeg, Manitoba, Canada Objective: To enlighten doctors on what it is like to live through a brain injury from a survivors viewpoint. What works and why you need to look at the ‘whole’ person— physically and spiritually in rehabilitation. How do you get the most ‘bang for your buck’ when helping someone get back to being the best person they can be after brain injury? Methods: Sometimes the best way to help a patient is to try and ‘put yourself in their shoes’. Brain injury is not new. Surviving brain injury is—when you consider that the technologies used today to help people survive really are relatively new. What happens to a brain injury patient after they are released from hospital? What are the aspects of ‘living again’ that sometimes get overlooked when all that is concentrated on is the physical instead of physical/emotional/and spiritual well-being? Can this approach save money?

Results: What works for survivors? How can doctors support the brain injury survivor and that person’s family to achieve an outcome that everyone can live with? These will be discussed. Conclusions: When doctors/therapists/the brain injured person and their family members work and are allowed to work as a team—well sometimes recovery can be better than expected for all the people involved. What can one learn from one person’s survival story?— LOTS—about what it takes to move a patient through the effects of brain injury to a point in their life where they can be happy with life again.


Model of participation determinants of participation among children and youth with acquired brain injury: A systematic review Arend de Kloet1, Rianne Gijzen2, Thea Vliet Vlieland3, & Lucia Braga4 1

Sophia Rehabilitation, The Hague, The Netherlands, 2Vilans, Knowledge Center for Chronic Care, Utrecht, The Netherlands, 3 Leiden University Medical Center, Leiden, The Netherlands, 4 Sarah Network of Rehabilitation Hospitals, Rio de Janeiro, Brazil, 5 The Hague University of Applied Sciences, The Hague, The Netherlands Objectives: A number of studies have shown that participation is considerably restricted in children and youth with acquired brain injury (ABI) in comparison with their peers without disabilities. Aim: Description of factors associated with worse or better participation of children and youth with acquired brain injury (ABI). Implementation of results in a ‘participation model’, based on the ICF-CY model. Methods: Systematic review of literature from 2001–2012. Results: The search of the electronic databases yielded 1842 records. After excluding 704 records which appeared in multiple databases, 1138 unique records were evaluated based on title and abstract. Subsequently 1050 records were excluded because they did not meet the inclusion criteria and 88 full text papers were retrieved. Of these, 22 met the inclusion criteria, with a methodological quality varying from high (n ¼ 5) to moderate (n ¼ 11) and low (n ¼ 6). Results show a variety of factors associated with participation of youth after ABI, covering all ICF domains: health category, body structure and functions, activities, environmental and personal factors. The ‘participation model’ enables one to (a) describe the complex and dynamic reality of participation, visually organized in a meaningful, inter-related and accessible way for professionals, parents and youth; (b) communicate about dissimilar points of view, beliefs, expectations regarding patient’s needs and goals, e.g. to increase adherence, control and commitment of patient and family; (c) find possibilities instead of disabilities and problems, showing a multi-perspective approach with multiple interactions: strengths-based perspective, acknowledges the importance of personal competences, supportive relationships and environments; (d) analyse and outline relationships between factors, causal pathways, facilitating a quick overview and broad perspective (in clinical practice, healthcare policy, innovation, research). Conclusion: Youth with acquired brain injury are at risk of participation problems. Nature and predictors of participation (problems) of youth with ABI are specific. Evidence was found for a wide diversity of factors associated with participation after paediatric ABI. Results were implemented in a ‘participation model’, meant to facilitate

530 comprehension and further improvement of the conceptual framework of participation (description), understanding of participation problems at individual, group or population level (analysis; measurement) and the effective support, therapy and policy (intervention), focused on youth with ABI.


Robot-assisted exercise for hemiparesis: Characterizing the dosage response Denise Gobert, Kristin Dugan, Melissa Kaplan, & Andrea Walker

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Texas State University, San Marcos, TX, USA Background: This study proposed to characterize patient response to robot-assisted therapy according to dosage of assisted activity. Although the American Heart Association and Department of Veteran Affairs promote robot-assisted therapy as the ‘standard of care’ for patients with hemiparesis, standardized treatment protocols have yet to be developed. Participants: A retrospective chart review included 10 male patients with UE hemiparesis (right/left ¼ 6/4) treated at a university clinic during 2012–2013. Mean age ¼ 57.521 (±23.935) years, hemiparesis ¼ 69.669 (±64.625) months. Methods: Physical therapy supervised, robot-assisted therapy sessions were twice weekly, progressing in duration (session length), dosage (games per session) and intensity (adaptive/non-adaptive) according to patient tolerance. Primary outcomes included: Number of completed sessions and Adaptive Hand/Shoulder assisted sessions, dynamometer Grip Strength (GRIP- kg/psi), Motor Activity Log Scores for ‘How Well’ (MAL_W) and ‘How Much’ (MAL_A) and Box & Blocks Test (BBX) measured during initial evaluation and discharge. Data analysis: Descriptive statistics were conducted using SPSS (v. 21), with an alpha level of 0.05. Due to the small sample size, the Wilcoxon Signed Rank Test analysis was used to compare pre- and post-treatment differences while the Spearman’s Rho Coefficient explored significant relationships between outcomes. Results: Completed sessions totalled 21.100 (±16.690) including 2.905 (±0.857) games per session. Session time averaged 32.797 ± 9.205 minutes with 29.200 ± 27.740% adaptive-shoulder and 17.200 ± 28.220% adaptive-hand assisted activities. Preliminary results indicate significantly improved MAL_W and MAL_A scores (p ¼ 0.042). GRIP significantly improved by 38.89% (p ¼ 0.028), while BBX scores improved by 89.99% (p ¼ 0.017). There was a significant positive relationship between number of games per session and GRIP scores (r ¼ 0.943, p ¼ 0.005) and average Adaptive Shoulder percentage and BBX scores (r ¼ 0.804, p ¼ 0.019). GRIP was significantly related to BBX scores (r ¼ 0.941, p ¼ 0.005) but negatively related to MAL_A scores (r ¼ 0.900, p ¼ 0.037). Conclusion/clinical relevance: This study characterized UE recovery in response to robot-assisted therapy. To the authors’ knowledge, this is the first of its kind that explores customized patient treatment and, in terms of duration, dosage and intensity of specific robotassisted therapy. Results can be used to improve rehabilitation protocols to help customize robot-assisted therapy for specific patient populations.


Does age matter when a child suffers a brain injury? Lisa Letzkus, & Peter Patrick

Brain Inj, 2014; 28(5–6): 517–878

University of Virginia Health Systems, Charlottesville, VA, USA Background/objective: Brain injury is the leading cause of death and disability in children in the US. Most children will awaken and regain spontaneous arousal and awareness; however, others will not and will be diagnosed with a Disorder of Consciousness (DOC). The objective was to determine the effect of age related to paediatric brain injury on hospital length of stay and cognitive function using a clinically established dataset of variables from children (n ¼ 83) that have been diagnosed with a DOC and admitted to UVA Children’s Rehabilitation Centre from 1998–2012. Methods: The retrospective secondary analysis used a dataset of clinical variables of children who have suffered a brain injury and diagnosed with a DOC prior to admission to KCRC. SPSS v. 20 was used to analyse the data. Frequencies and percentages were calculated for categorical variables (gender, the presence of storming, type of injury and transition to rehabilitation) based on age groups (55, 5–10, 410 years of age). Means and standard deviations for continuous variables [total length of stay and discharge Rancho Los Amigos Scale (RLA)] were calculated based on age groups. Chi-square test was used to determine if there was a difference between gender, diagnosis of storming and transition of rehabilitation depending on age group. Analysis of Variance (ANOVA) was used to determine the differences in total length of stay and discharge RLA between age groups. Results: Children that were younger than 5 years of age were less likely to transition to rehabilitation (p50.001). In addition, children less than 5 years of age had a shorter total length of stay (days) compared to children aged 5–10 years (p ¼ 0.033) and aged greater than 10 years (p ¼ 0.001). The younger age group also had a lower Discharge Rancho Los Amigos Score (a tool used to assess cognitive function following brain injury) compared to those aged 5–10 years (p ¼ 0.015) and aged greater than 10 years (p50.001). The lower score correlates with worse cognitive function at time of discharge. Conclusion: Based on the finding of this study, age should be taken into consideration when a child has suffered a severe paediatric brain injury. This study suggests that younger age contributes to the inability to transition to rehabilitation, shorter length of stay and lower Rancho Los Amigos Score at time of discharge.


Comparison of antibody positive levels against clamydophila pneumonia in two groups of brain ischaemic stroke and control that refer to Rajaee and Imam Sajad hospitals in 2010–2011 Mahdieh Molla, Melodi Omarani Nava, & Reza Ebrahimi Rad Medicine Faculty, Tonekabon, Iran Introduction: Recent studies explained that chlamydophila pneumonia has been associated with atherosclerosis and ischaemic stroke. If there is a positive association demonstrated, it can lead to a good effect on health of society with correct treatment. So, this study detected infection with chlamydophila pneumonia with ELISA method in ischaemic stroke patients admitted in Rajaee and Emam Sajad hospitals in 1389–1390. Method: This case-control studies method was an analytic study and used from 30 serum samples of patients with demonstrated brain ischaemic stroke with physical exams and brain CT scan and 30 patients that were the control group and selected from the surgery


DOI: 10.3109/02699052.2014.892379

ward that conformed to age and sex. Then the serological test was performed with ELISA (IBL, Germany). Result: In this study, after omission of doubtful cases, there were 23 men (44.2%) and 29 women (55.8%). The control group had 23 subjects (48.1%) and the patient group had 27 subjects (51.9%). Measurement of positive IgG in the patient group was 74.1% and in the control group was 52% (p ¼ 0.15) and measurement of positive IgA in the patient group was 14.8% and in the control group was 20% (p ¼ 0.722). Conclusion: This study could not find an association between positive level of IgG and IgA against chlamydophila pneumonia and ischaemic stroke, just a positive association between IgG Ab and different ages in the ischaemic stroke group (p50.029).

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Recommendations from the 2013 Galveston Brain Injury Conference for implementation of a chronic care model in brain injury Flora Hammond1,2, & James Malec1 1

Indiana University School of Medicine, Indianapolis, IN, USA, 2 Rehabilitation Hospital of Indiana, Indianapolis, IN, USA The 2013 Galveston Brain Injury Conference (GBIC) convened 50 experts including consumer representatives in brain injury (BI) clinical practice, research and policy to focus on the topic of ‘Brain Injury as a Chronic Condition’. This concept was originally introduced by Masel and DeWitt, who underscored the importance of extending the focus of BI care beyond the acute setting to the lifelong needs of individuals with BI for ongoing medical treatment, prevention of secondary complications and co-morbidities, psychosocial and vocational support and services to achieve community re-integration. The Chronic Care Model (CCM) described by Wagner and colleagues depicts long-term management of chronic medical conditions as a highly dynamic process in which health systems and community resources interact at system and provider levels to support patient self-management. To achieve improved outcomes through the model, these interactions are orchestrated to create a strong and sustained working relationship between an informed, activated patient and a prepared, pro-active provider team. Following the Wagner CCM model, GBIC participants developed concrete recommendations for changes in (1) the healthcare system and clinical practice, (2) self-management support and (3) integration of community and medical supports and services. The group split into four task forces. The Guideline Development Task Force focused on identifying priority areas in which care guidelines were needed. The High Priority Implementation Task Force identified high priority recommendations for more immediate practice changes. The Self-management Support Task Force focused on developing recommendations for self-management and provider support of self-management and the Health Care and Community Systems Integration Task Force focused specifically on community-medical systems integration. This presentation will describe recommendations and their rationales emanating from these deliberations. Task Force recommendations emphasized the importance of the development of clinical guidelines and surveillance technologies, improved specialist– primary care–community provider communications, patient–provider collaboration, use of existing educational resources and risk-stratified self-management support and case management. While seeking to outline the path toward optimal long-term care of individuals with BI, each task force was clearly conscious of the cost of recommended initiatives both in financial and personnel resources. Hence, a series of recommendations were outlined that range from those that

minimize new costs by leveraging existing resources to more costly initiatives, such as lifelong case management and resource facilitation. Nonetheless, even the cost of these more complex and sustained initiatives have the potential to be offset in the long-term by reduction of health and social problems among those living with BI that carry a high price in dollars and in human suffering. While GBIC recommendations are certainly not exhaustive, progressive implementation is very likely to have a favourable impact on outcomes of individuals with BI by reducing long-term complications and enhancing access to appropriate care.


Neuromodulation (cervical spinal cord stimulation, cSCS) on a comatose patient due to traumatic brain injury—One case report Xiaodong Zhang, Hehong Chen, & Enhe Liang Huanhu Hospital, Tianjin, PR China Objective: To study the effect of high cervical spinal cord stimulation (cSCS) on persistent comatose patients with traumatic brain injury. Methods: To observe consciousness improvement of 3 months comatose with brain trauma after cSCS. Result: After 2 months of cSCS treatment, the patient emerged from coma and evoked potential latency improved. Conclusions: These results indicate that cervical cSCS may induce cerebral vasodilation and that this effect may be involved in direct effects on vasomotor centres in the brainstem as well as an alteration in sympathetic tone.


Effects of decompressive craniectomy on patients with acute post-traumatic brain swelling Qiu Wusi1, Wang Weiming1, Shen Hong2, Jiang Qizhou1, & Guo Chenchen0 1

Hangzhou Second Hospital, College of Medicine, Hangzhou Normal University, Hangzhou, PR China, 2College of Medicine, Zhejiang University, Hangzhou, PR China Introduction: Acute post-traumatic brain swelling (BS) is one of the pathological forms that need emergent treatment following traumatic brain injury. There is controversy about the effects of craniotomy on acute post-traumatic BS. The aim of the present clinical study was to assess the efficacy of unilateral decompressive craniectomy (DC) or unilateral routine temporoparietal craniectomy on patients with unilateral acute post-traumatic BS. Methods: Seventy-four patients of unilateral acute post-traumatic BS with midline shifting of more than 5 mm were divided randomly into two groups: the unilateral DC group (n ¼ 37) and the unilateral routine temporoparietal craniectomy group (control group, n ¼ 37). The vital signs, the intracranial pressure (ICP), the Glasgow outcome scale (GOS), the mortality rate and the complications were prospectively analysed.

532 Results: The mean ICP values of patients in the unilateral DC group at hour 24, hour 48, hour 72 and hour 96 after injury were much lower than those of the control group (15.19 ± 2.18 mmHg, 16.53 ± 1.53 mmHg, 15.98 ± 2.24 mmHg and 13.518 ± 2.33 mmHg vs 19.95 ± 2.24 mmHg, 18.32 ± 1.77 mmHg, 21.05 ± 2.23 mmHg and 17.68 ± 1.40 mmHg, respectively). The mortality rates at 1 month after treatment were 27% in the unilateral DC group and 57% in the control group (p ¼ 0.010). Good neurological outcome (GOS score of 4–5) rates 1 year after injury for the groups were 56.8% and 32.4%, respectively (p ¼ 0.035). The incidences of delayed intracranial haematoma and subdural effusion were 21.6% and 10.8% vs 5.4% and 0, respectively (p ¼ 0.041 and 0.040). Conclusions: The data suggest that unilateral DC has superiority in lowering ICP, reducing the mortality rate and improving neurological outcomes over unilateral routine temporoparietal craniectomy. However, it increases the incidence of delayed intracranial haematomas and subdural effusion, some of which need secondary surgical intervention. These results provide information important for further large and multi-centre clinical trials on the effects of DC in patients with acute post-traumatic BS.

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Top-down attentional processing in disorders of consciousness: An event-related potentials study Caroline Schnakers1, Joseph Giacino2, Marianne Løvstad3, Dina Habbal4, Melanie Boly4, Steve Majerus4, & Steven Laureys4 1

University of California, Los Angeles, CA, USA, 2Hospital and Harvard Medical School, Boston, MA, USA, 3Sunnaas Rehabilitation Hospital, Nesoddtangen, Norway, 4University & University Hospital of Lie`ge, Lie`ge, Belgium Objective: Despite recent evidence suggesting that some severely brain-injured patients retain capacity for top-down attentional processing, the degree of sparing is unknown. In order to better understand such processing, it was decided to assess top-down attentional processing in patients in minimally conscious (MCS) and vegetative states (VS) using an active event-related potential (ERP) paradigm. Methods: Twenty-eight patients were included in this prospective cross-sectional study (nine traumatic, 21 patients41 year post-onset). In the MCS group, eight patients followed commands (MCS+) whereas nine failed to do so (MCS). Eleven patients in VS were also included in this study. The ERP paradigm included: (1) a ‘passive’ condition wherein the subject’s own name was repeated 100 times and (2) an ‘active’ condition wherein the subject was instructed to voluntarily focus attention on his/her own name. Results: In both MCS+ and MCS patients, an enhanced P3 amplitude was observed in the active vs passive condition. Unlike MCS+ patients who showed a sustained response widely distributed over frontoparietal areas, MCS patients showed a frontally isolated and rapidly extinguished response suggesting a transient top-down attentional processing. No reliable P3 signal was observed in VS patients, except for one patient who showed similar responses to MCS+ patients. Conclusion: Volitional top-down attention appears to differ among severely brain-injured patients. Further investigation is needed to better understand top-down cognitive functioning in patients who respond to active paradigms as this may refine BCI-based communication strategies in this population.


Impact of aphasia on consciousness assessment

Brain Inj, 2014; 28(5–6): 517–878

Caroline Schnakers1, Helene Bessou2, Ilona Rubi-Fessen3, Alexander Hartmann3, Gereon Fink4, Ingo Meister4, Joseph Giacino5, Steven Laureys2, & Steve Majerus2 1

University of California, Los Angeles, CA, USA, 2University of Lie`ge, Lie`ge, Belgium, 3Rehanova Neurorehabilitation Center, Cologne, Germany, 4University Hospital of Cologne, Cologne, Germany, 5 Spaulding Rehabilitation Hospital and Harvard Medical School, Boston, MA, USA Objective: Previous findings suggest that language disorders may occur in severely brain injured patients and could interfere with behavioural assessments of consciousness. However, no study investigated to what extent language impairment could affect patients’ behavioural responses. To estimate the impact of receptive and/or productive language impairments on consciousness assessment. Methods: Twenty-four acute and sub-acute stroke patients with different types of aphasia (global, n ¼ 11; Broca, n ¼ 4; Wernicke, n ¼ 3; anomic, n ¼ 4; mixed, n ¼ 2) were recruited in neurology and neurosurgery units as well as in rehabilitation centres. The Coma Recovery Scale-Revised (CRS-R) was administered. Results: It was observed that 25% (six out of 24) of brain-injured patients with a diagnosis of aphasia and 54% (six out of 11) of patients with a diagnosis of global aphasia did not reach the maximal CRS-R total score of 23. An under-estimation of the consciousness level was observed in three patients with global aphasia as they could have been misdiagnosed as being in a minimally conscious state, even in the absence of any documented period of coma. More precisely, lower sub-scores were observed on the communication, motor, oromotor and arousal sub-scales. Conclusion: Consciousness assessment may be complicated by the co-occurrence of severe language deficits. This stresses the importance to develop new tools or to identify items in existing scales allowing the detection of language impairment in severely braininjured patients.


Do sensory stimulation programmes have an impact on consciousness recovery? Lijuan Cheng1, Maria Daniela Cortese2, Steve Majerus3, Martin Monti4, Fuyan Wang1, Francesco Riganello2, Xiaohua Hu1, Francesco Arcuri2, Yunzhi Nie1, Federica Guglielmino2, Dan Yu1, Steven Laureys3, Giuliano Dolce2, Haibo Di1, & Caroline Schnakers4 1

Hangzhou Normal University, Hangzhou, PR China, 2S.Anna Institute and Research in Advanced Neurorehabilitation, Crotone, Italy, 3 University of Lie`ge, Lie`ge, Belgium, 4University of California, Los Angeles, CA, USA Objective: Sensory stimulation programmes were introduced in 1978 as a potential treatment for severely brain injured patients. Until now, no study succeeded in showing the efficacy of such treatment. Using behavioural and neuroimaging approaches, it was decided to objectify whether the changes observed are related to the treatment rather than spontaneous recovery. Methods: An ABAB design was applied. Both phases A constituted the baseline. During both phases B, a programme including auditory, visual, tactile, olfactory and gustatory stimulation was administered 3 days a week. The Coma Recovery Scale-Revised (CRS-R) was also


DOI: 10.3109/02699052.2014.892379

administered once a week by a blinded rater during all the phases. Each phase lasted 4 weeks. In a sub-set of patients, resting state fMRI data were collected at the end of each phase. Results: Twenty-nine patients (48 ± 19 years old; 15 traumatic; 2141 year post-onset; 11 VS) were included in the analyses. Higher behavioural responses were obtained in the end of the sensory stimulation programme. In parallel, higher CRS-R scores were observed in the presence of treatment than in its absence. In three patients who underwent a MRI scan at each phase, the group ALFF analyses revealed higher activation during treatment in brain areas related to consciousness (i.e. middle frontal and superior temporal gyri and ventro-anterior thalamic nucleus). Conclusion: This study objectified treatment-related changes at a behavioural as well as at a neuronal level, indicating that using a sensory stimulation programme as treatment has an impact on the consciousness recovery of severely brain injured patients.

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A study of the reliability and the diagnostic sensitivity of the Nociception Coma Scale Francesco Riganello1, Maria Daniela Cortese1, Francesco Arcuri1, Antonio Candelieri1, Federica Guglielmino1, Giuliano Dolce1, Walter Sannita2, & Caroline Schnakers4 1

S. Anna Institute and RAN (Research in Advanced Neurorehabilitation), Crotone, Italy, 2University of Genova, Genova, Italy, 3University of Liege, Liege, Belgium, 4University of California, Los Angeles, CA, USA Objective: The Nociception Coma Scale has recently been developed to assess nociception in non-communicative severely brain-injured patients. This study further explored the psychometric properties of this scale and, more exactly, its reliability and its diagnostic sensitivity. Design: The Nociception Coma Scale has been administered by two experts on two consecutive weeks to measure the interrater agreement and the test–re-test reliability. The ability of the scale to differentiate the vegetative state (i.e. absence of consciousness) from the minimally conscious state (i.e. fluctuating consciousness) has also been compared to two other pain scales developed for non-communicative patients such as newborns and elderly. Results: This study performed a total of 176 assessments in 44 patients diagnosed as being in a vegetative state (n ¼ 26) or in a minimally conscious state (n ¼ 18). The inter-rater agreement was moderate for the total scores (k ¼ 0.57) and fair to substantial for the sub-scores (0.33  k  0.62), on week 2. The test–re-test reliability was substantial for the total scores (k ¼ 0.66) and moderate to almost perfect for the sub-scores (0.53  k  0.96), in rater A. Both measures were weaker on week 1 and in the least experienced rater (rater B), respectively. Finally, the Nociception Coma Scale showed a higher diagnostic sensitivity (91%) compared to the Pain Assessment In Advanced Dementia Scale (63%) or the Neonatal Infant Pain Scale (44%). Conclusions: This study provides further evidence of the psychometric qualities of the Nociception Coma Scale. Future studies should, nevertheless, assess the impact of training and experience on administering and scoring the scale.


Volitional electromyographic responses in disorders of consciousness

Dina Habbal1, Olivia Gosseries1, Quentin Noirhomme1, Jerome Renaux1, Damien Lesenfants1, Tristan Bekinschtein2, Steve Majerus1, Steven Laureys1, & Caroline Schnakers3 1

University Hospital of Lie`ge, Lie`ge, Belgium, 2Cognition and Brain Sciences Unit, Medical Research Council, Cambridge, UK, 3University of California, Los Angeles, CA, USA Objective: The aim of the study was to validate the use of electromyography (EMG) for detecting responses to command in patients in vegetative state/unresponsive wakefulness syndrome (VS/UWS) or in minimally conscious state (MCS). Methods: Thirty-eight patients were included in the study (23 traumatic, 25 patients41 year post-onset), 10 diagnosed as being in VS/UWS, eight in MCS (no response to command) and 20 in MCS+ (response to command). Eighteen age-matched controls participated in the experiment. The paradigm consisted of three commands (i.e. ‘Move your hands’, ‘Move your legs’ and ‘Clench your teeth’) and one control sentence (i.e. ‘It is a sunny day’) presented in random order. Each auditory stimulus was repeated four times within one block with a stimulus-onset asynchrony of 30 seconds. Results: Post-hoc analyses with Bonferroni correction revealed that EMG activity was higher solely for the target command in one patient in permanent VS/UWS and in three patients in MCS+. Conclusion: The use of EMG could help clinicians to detect conscious patients who do not show any volitional response during standard behavioural assessments. However, further investigations should determine the sensitivity of EMG as compared to neuroimaging and electrophysiological assessments.


Retrospective pre-injury personality as the predictor of persistent post-concussion symptoms Kit-Man Yuen1, Sheng-Jean Huang2, Sheng-Huang Hsiao3, Yi-Hsin Tsai5, Wei-Chi Lin1, & Chi-Cheng Yang1 1

Division of Clinical Psychology, Master of Behavioral Science, Department of Occupational Therapy, College of Medicine, Chang-Gung University, Taoyuan, Taiwan, 2National Taiwan University Hospital, Jin-Shan Branch, New Taipei City, Taiwan, 3 Department of Neurosurgery, Taipei City Hospital, Taipei, Taiwan, 4 Department of Surgery, National Yang-Ming University, Taipei, Taiwan, 5Department of Neurosurgery, Far Eastern Memorial Hospital, New Taipei City, Taiwan Objectives: Post-concussion symptoms (PCS) are not uncommon following mild traumatic brain injury (mTBI). Even though patients with PCS usually recovered within 3 months post-injury, a number of patients who suffered from the persistent post-concussion symptoms (PPCS) still continued to complain about these symptoms several months after traumas. In fact, pre-injury personality trait has been evidenced as one of the most influencing factors to contribute to the presence of PPCS. Unfortunately, studies of the association between pre-injury personality trait and the PPCS were still limited in scope. The purpose of this study, thus, aims to directly examine the relationship between the retrospectively-evaluated pre-injury personality and the PPCS in patients with mTBI.

534 Methods: This is a prospective study with 53 mTBI patients and 53 healthy adults. Participants completed the selective neuropsychological tests, which mainly include memory, executive function and information processing ability. PCS was examined by the Checklist of Post-Concussion Symptoms (CPCS) and the Health, Personality & Habit Scale (HPH) was used to evaluate the personality traits. All participants were evaluated at 1 month, 3 months and 6 months post-injury. Results: The results showed that mTBI patients would under-estimate their pre-injury PCS, consistent with ‘good old days bias’. In addition, it also showed a significant positive association between the PCS and the pre-injury personality. Patients whose pre-injury personality was depressive, major depression, anxiety-related and borderline personality would more easily develop to PPCS. Conclusions: This might be the first prospective follow-up study which directly demonstrates that the specific pre-injury personality traits are closely linked to PPCS in patients with mTBI. Clinicians, thus, should be aware of the personality trait of patients with mTBI to prevent them from the presence of the PPCS.

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The profile of head injuries and traumatic brain injury deaths in Kashmir S. A. Tabish, & G. H. Yattoo SKIMS, Srinagar (J&K), India

This study was conducted on patients with head injury admitted through the Accident & Emergency Department of Sher-i-Kashmir Institute of Medical Sciences during the year 2004 to determine the number of head injury patients, nature of head injuries, condition at presentation, treatment given in hospital and the outcome of intervention. Traumatic brain injury (TBI) deaths were also studied retrospectively for a period of 8 years (1996–2003). The TBI deaths showed a steady increase in number from year 1996 to 2003, except for 1999 that showed a decline in TBI deaths. TBI deaths were highest in the age group of 21–30 years (18.8%), followed by the 11–20 years age group (17.8%) and 31–40 years (14.3%). The TBI death was more common in males. Maximum number of TBI deaths was from rural areas as compared to urban areas. To minimize the morbidity and mortality resulting from head injury there is a need for better maintenance of roads, improvement of road visibility and lighting, proper mechanical maintenance of automobile and other vehicles, rigid enforcement of traffic rules, compulsory wearing of crash helmets by motor cyclists and scooterists and shoulder belts in cars and imparting compulsory road safety education to school children from a primary education level. Moreover, appropriate medical care facilities (including trauma centres) need to be established at district level, sub-divisional and block levels to provide prompt and quality care to head injury patients.


Out in public: Brad Pitt and Congresswoman Gabby Giffords share a neuro-behavioural mismatch. Evidence shows that both are wired opposite to their avowed handedness

Brain Inj, 2014; 28(5–6): 517–878

Iraj Derakhshan Private Practice, Charleston, WV, USA Objective: I present credible pictorial evidence that Brad Pitt, who writes with his right hand is in fact wired as a left hander, i.e. he is right hemispheric in his laterality motor and sensory control. The evidence for this comes from video clips from the 2008 movie ‘Burn after Reading’ in a scene showing Pitt swinging both his arms to his sides in the air repeatedly while sitting behind the wheel. Method: As he swing his arms simultaneously to his left side the left fist is measured to be farther away from the right than is the case when he subsequently swings them to the right, indicating faster speed of the left hand than the right. According to 1-way callosal traffic theory, the faster speed of the dominant side results from the fact that that side is directly connected to the command centre, whereas the non-dominant side is connected to the command centre via the corpus callosum. In the case of Congresswoman Giffords (one of the victims of a tragic shooting event in January 2011 which decimated her left hemisphere, leaving the hemiplegic on the right), the evidence is in from of photographs and videos taken by her husband Captain Mark Kelley in the acute stage of her illness. The photos show the eyes deviated to the left, i.e. the damaged hemisphere. This conjugate deviation of the eyes is a laterality indexed finding known as the Pre’vost sign, occurring only when the damaged hemisphere is the non-dominant hemisphere. Similarly, the video aired by ABC News in November 2011 shows absence of apraxia in the left hand and an intact ability to comprehend language on the part of the patient. Both of these findings indicate that, despite the Congresswoman’s claim to right handedness, she was in fact wired as a left hander, with the intact right hemisphere handling her linguistic abilities and motor control. Results and conclusion: Cases such as these, showing a neurobehavioural mismatch, are not rare, constituting 10–15% of the population. The most accurate documentation of these cases in the normal population is the bimanual simultaneous drawing test in which the hand contralateral to the major hemisphere draws the longer and straighter line, as it receives a more pristine version of the command, compared to the other hand which is connected to the command centre via the corpus callosum. Dedication: I dedicate this abstract to the loving memory of my sister Farkhondeh.


A prospective randomized study of use of drain vs no drain after burr hole evacuation of chronic subdural haematoma Amit Kumar Singh, S. Bhaskar, Ajay Choudhary, & L. N. Gupta PGIMER & Dr R M L Hospital, New Delhi, India Objective: Chronic subdural haematoma (CSDH) recurs after surgical evacuation in 5–30% of patients. Inserting a subdural drain might reduce the recurrence rate, but is not commonly practiced. There are few prospective studies to evaluate the effect of subdural drains. The aim was to investigate the effect of subdural drains on recurrence rates and clinical outcomes following burr hole drainage (BHD) of CSDH. Methods: This was a prospective randomized study at PGIMER & DR R M L Hospital, New Delhi from January 2011 to June 2012. Two hundred and forty-six patients with CSDH were assessed for eligibility.


DOI: 10.3109/02699052.2014.892379

Among 200 patients fulfilling the eligibility criteria, 100 each were assigned to the ‘Drain Group’ (drain inserted into the subdural space following BHD) and the ‘Without Drain Group’ (subdural drain was not inserted following BHD) by Random allocation software. The primary end-point was recurrence needing re-drainage up to a period of 6 months from surgery. Results: Recurrence occurred in nine of 100 patients with a drain and 26 of 100 patients without a drain (p value ¼ 0.002). The mortality was five of 100 in patients with a drain and four of 100 in patients without a drain (p value ¼ 0.744). The medical and surgical complications were comparable between the two study groups. Conclusion: Use of a subdural drain after burr hole evacuation of a CSDH reduces the recurrence rate and is not associated with increased complications.


Therapeutic landscape theory: Identifying health detracting and health enhancing aspects of neurorehabilitation Pia Kontos1, Karen-Lee Miller1, Angela Colantonio2, & Cheryl Cott2 1

Toronto Rehabilitation Institute-University Health Network, Toronto, Ontario, Canada, 2University of Toronto, Toronto, Ontario, Canada


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Specific work integration programme with a patient with TBI: Case report Maria Agostina Ciampa, Julieta Camino, Ana Ines Vivanco, & Alicia Lischinsky INECO (Neuro Cognitive Institute), Buenos Aires, Argentina Introduction: Traumatic brain injury (TBI) is one of the principal causes of disability among young adults. It can lead to physical, behavioural and cognitive impairments that affect their functional performance, interpersonal relationships, social participation and work reintegration. Return-to-work is one of the main concerns within patients with TBI. It depends on several aspects due to the complexity of the skills involved; and their interaction with the client’s impairment. Objective: To report the case of a Specific Work Integration Programme in a patient with TBI. Methods: Mr J, a 30 year-old patient, suffered a TBI in a car accident. The Specific Work Training Programme carried out consisted of different stages: assessment, interview and training. Specific questionnaires were designed, including visoanalogic scales and structured questionnaires (work samples) according to the patient’s skills and work requirements. Based on the data collected, particular goals were established and intervention strategies were developed in order to improve work performance. Results: Through work samples, it was possible to identify achievements in the following items: Supervision Acceptance, Security, Tools Identification, Decision-Making and Pace. Furthermore, a progressive improvement was observed in the amount of tasks performed. At the beginning, the client work routine consisted of only three activities; at the end of the programme, he was able to perform six different tasks. Conclusions: The development of a Specific Programme that involves an objective assessment of the workstation, as well as structured questionnaires, enables one to identify real limitations at the workplace. Therefore, occupational therapists can design the best strategies and appropriate interventions in order to fulfil the patient’s needs, working towards successful integrations. Further research needs to be done within the assessments used in Work Rehabilitation, in patients with cognitive impairments.

Objectives: Traditional neurorehabilitation research focuses on the built (e.g. hospital design) or social (e.g. socialization to disability status) aspects of rehabilitation. Often overlooked is the inter-play between place, body and emotion in the experience of receiving and providing care. Therapeutic landscape theory provides a novel lens through which to examine this inter-play and may be used to identify health detracting and health enhancing aspects of neurorehabilitation care that impact patients and practitioners. Methods: Qualitative interviews (n ¼ 38) were conducted with staff (nursing; allied health; psychology; chaplaincy) of two in-patient neurorehabilitation units in Ontario, Canada during a 3-year intervention study. Results: A focus on the inter-play between place, physical and socialized bodies and emotion enabled the identification of health detracting and enhancing aspects of neurorehabilitation care. First, the neurorehabilitation units strove to imitate real-life situations by providing simulated kitchens, yet a lack of authenticity in replication of home space and consequent unfamiliarity was implicated in clients’ poor performance on assessments and also impaired their comprehension of deficits. Poor patient responses to dissimilarities in scale and layout between simulated bathrooms and hospital rooms further precipitated interventions that led to nursing injuries and interprofessional tensions. Next, despite the profound emotional impact of TBI, patients had little access to publicly-financed psychological services. Patients were also actively inhibited from expressing grief and loss due to staff’s focus on physical functioning and their corresponding use of quantifiable outcomes to support treatment decisions and satisfy third-party payers. Patients’ therapeutic engagement was significantly hampered by unexpressed emotional concerns. Practitioners’ use of client’s self-identity to individually tailor therapy was health-enhancing. Patient motivation was facilitated by their increased influence in goal-setting and the therapeutic utilization of items associated with their ordinary, everyday routines or habits. Emphasis on self-identity ensured therapeutic goals were congruent with patients’ life worlds, including considerations of homelessness and illiteracy. The motivation clients derived from tasks associated with self-identity led to observable clinical improvements. Conclusions: Viewing existing TBI practices through the lens of therapeutic landscape theory identified health-enhancing and healthdetracting aspects of care. Patient wellbeing was improved through positive place–body interactions such as the tailoring of therapy to clients’ social locations, and resulted in therapeutic gains. Yet, place– body interactions such as the impact of neurorehabilitation design and ideology on functional assessments and care practices and place– emotion interactions involving institutional practices that suppressed clients’ emotions detracted from patient and nurse well-being. These negative impacts suggest the need for better environmental semblance among rehabilitation units to more accurately relay clients’ abilities, reduce nursing injuries and improve inter-professional collaboration. They also suggest the importance of recognizing and addressing psychological needs of patients that includes facilitating emotional expression to improve treatment engagement.



Only about half of the supratentorial cortex in humans can generate seizures: Laterality of motor control and onsethemisphere of epilepsy always coincide Iraj Derakhshan1,2 Private Practice, Charleston, WV, USA, 2Case Western Reserve University, Cleveland, OH, USA

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According to a review published recently (see references), the incidence of epilepsy in lesions that are equality distributed between the two hemispheres is always below the 50% mark. Thus, it may be said that less than half of the cerebral cortex in humans is capable of generating seizures (epileptogenic). This article answers the question raised above by recounting the overwhelming data in favour of the proposition that the directionality of traffic between the two hemispheres (corpus callosum and anterior commissure) is one-way and that the signals travelling between two hemispheres are excitatory in nature (not inhibitory, as it is currently believed). If correct, the above arrangement indicates that only the controlling hemisphere (i.e. the dominant hemisphere) is the epileptogenic hemisphere as the minor hemisphere has no motor capability of its own, depending instead on the signals arising from the major hemisphere for those movements occurring on the non-dominant side of the body at its behest. The results of the bimanual simultaneous drawing test confirm the abovementioned scheme. In every instance, there is an asymmetry between the performance of one hand and the other, with the hand closer to the dominant hemisphere, as defined above, drawing the longer and straighter lines compared to the other, which is farther from the command centre by an inter-hemispheric transfer time (IHTT). This inter-hemispheric distance, together with the additional synapses involved, make those commands destined for the minor hemisphere less pristine (more noisy), imposing waviness to the lines or shapes drawn by the non-dominant hand in addition to the shortness of the line caused by that same delay. Thus, according to the data provided in this report, the reason of the incidence of epilepsy falling below the 50% mark is the variability of the epileptogenicity of different regions of the dominant hemisphere, with the occipital lobe region being least epileptogenic.


Utilization of a removable mandibular neuroprosthesis for the reduction of post-traumatic stress disorder (PTSD) and TBI/ PTSD (traumatic brain injury) associated nightmares, headaches and sleep interruptions: A large case series Donald Moeller1,2 1

Moeller Oral Surgery, Columbus Georgia, USA, 2University of Alabama, Birmingham, AL, USA

Brain Inj, 2014; 28(5–6): 517–878

Objectives: To evaluate the ability of a soft removable mandibular stabilization splint (neuroprosthesis) to attenuate the frequency, duration and intensity of co-morbid headaches, nightmares and sleep disruptions in PTSD and PTSD/TBI patients in a military veteran and civilian population who presented with clinically detectable trigger-points in the intra-oral and extra-oral muscles of mastication. Methods: This large case series of 150 patients (130 military and 20 civilian) between the ages of 24–73 required that participants had their PTSD or PTSD/TBI diagnosis established by either the US Army or the Veterans Administration and that they had this condition for a minimum of 3 years. Participants also needed to have a minimum of (a) three nightmares a week, (b) three headaches a week, (c) three sleep interruptions a week and (d) three clinically detectable triggerpoints in the intra-oral or extra-oral muscles of mastication. Patients were administered the PCL-M for DSM IV (Military checklist, Weathers, F.W.) and the Defense and Veterans Pain Rating Scale (Cleeeland, C.S. Pain Assessment: Global use of the Brief Pain Inventory) and evaluated by a single clinician for the documentation of the location and severity (sensitivity to palpation) of the trigger-points in the muscles of mastication. A standard algormeter with an extension was used to quantitate pressure needed to activate trigger-points. Alginate impressions were made of the mandibular arch and a modified soft mandibular stabilization splint (neuroprosthesis) was fabricated for each participant. Intra-arch distance was increased to eliminate anterior overbite and separate the maxillary and mandibular arch by at least 5 millimetres. Effectiveness of treatment was determined by a telephone interview using self-scoring questions with respect to reduction in duration, frequency and severity of symptoms. Although the duration of the study was 3 months, a significant number of patients have been followed for up to a year. All patients received a standard dental mandibular stabilization splint (neuroprosthesis) to treat their bruxing. The changes which occurred in their PTSD co-morbidities, i.e. nightmares, headaches and sleep interruptions were retrospectively analysed through a chart review. Results: Ninety-four per cent of participants responded positively to this device. Reductions between 40–90% were obtained with respect to severity, duration or frequency of headaches or nightmares or sleep interruptions measured individually or as a group. No patient had any untoward clinical response or had their symptoms worsened by this treatment. Conclusions: The intra-oral mandibular stabilization splint (modified as a neuroprosthesis) is an effective device for the reduction of the PTSD and PTSD/TBI associated co-morbid headaches, nightmares and sleep interruptions.


Development of a culturally acceptable toolkit for assessing ABI with indigenous Australians India Bohanna, Anne Stephens, Deborah Graham, Juliette Catherall, Rachael Wargent, Alyssa Harlow, & Alan Clough James Cook University, Queensland, Australia Objectives: Indigenous Australians, like other Indigenous groups worldwide, suffer higher rates of all risk factors for acquired brain injury compared to their non-Indigenous counterparts. Despite this, there is a global paucity of culturally acceptable, scientifically validated instruments for the assessing cognitive and psychosocial function in these populations. This project aimed to determine the optimal characteristics of instruments for use with Aboriginal and Torres Strait Islander Australians with acquired brain injury aged 18–45 and to develop and pilot a toolkit of culturally acceptable instruments.


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DOI: 10.3109/02699052.2014.892379

Methods: Interviews or focus groups were conducted with 75 participants involved in assessment, rehabilitation or care, from a variety of clinical, allied health, advocacy and community backgrounds, from across Australia (40% Indigenous). An evaluation framework of key characteristics of culturally acceptable assessments (instruments and process) was derived from these interviews, incorporating multiple perspectives from the clinic to community. The evaluation framework was used to rate existing assessments and to develop a toolkit of culturally acceptable assessment instruments that rated highly. Pilot studies of this toolkit have been undertaken across clinical and community sites in the Northern Territory, Queensland and Western Australia. Results: Professionals involved in assessment of Indigenous Australians with acquired brain injury typically relied on informal assessment approaches and instruments not designed or validated for the target population. Mainstream instruments generally performed poorly against the evaluation framework. Results of survey feedback from clinicians at five initial pilot sites using the culturally acceptable toolkit suggests the instruments are culturally acceptable, easy to use and effective for assessing the cognitive and psychosocial impacts of acquired brain injury in Indigenous Australians. Conclusions: Developing a culturally acceptable toolkit for assessing acquired brain injury with Indigenous populations is critical to ensure equitable access to reliable and accurate assessment. This study represents a significant step toward this goal. Pilot studies are ongoing and validation studies will be discussed. Implications for assessing acquired brain injury in Indigenous populations across Canada, the US, Australia and New Zealand will be discussed.


Educate, train, treat, track: Bringing state-of-the-art care to our military with TBI Stephanie Maxfield-Panker1, Sarah Goldman2, Tara Cozzarelli1, Lynne Lowe3, Karen McCulloch4, Mary Radomski5, & Michael Russel1 1

US Army Office of The Surgeon General, Falls Church, VA, USA, Research Program, Fort Detrick, MD, USA, 3Oak Ridge institute for Science and Education, Bellcamp, MD, USA, 4University of North Carolina at Chapel Hill, Chapel Hill, NC, USA, 5Sister Kenny Research Center, Minneapolis, MN, USA


An expert will discuss the US. Army traumatic brain injury (TBI) programme within the context of rehabilitation clinical and research initiatives as well as programmatic outcomes. Presentation will discuss progress from the US Army TBI Task Force and delineate existing rehabilitation gaps within the system. Additional topics include rehabilitation capabilities and services in the deployed and garrison environments within the context of Department of Defense (DoD) policy for TBI care including specific algorithms for recurrent concussion. Policy discussions include the evolution of and current policies and clinical algorithms in the deployed and garrison environments as well as DoD clinical recommendations related to rehabilitation from TBI. Briefly discuss the Neurocognitive Assessment Tool and role of neurocognitive assessment in return-to-duty decision-making. Share Department of Defense TBI coding procedures and discuss challenges in analysing coded data. Share Army TBI education and training strategies to educating a widely-dispersed population of medical providers. Present specific rehabilitation tools and resources developed to support the TBI mission to include patient education handouts, educational videos and slide decks, the TBI Rehabilitation ToolKit and the Graded Return-to-Activity clinical recommendation. Share Army TBI research initiatives related to TBI rehabilitation.


The therapeutic impact of thalidomide analogue, 3,60 dithiothalidomide, on recovery from minimal traumatic brain injury Renana Baratz-Goldstein1, Vardit Rubovitch1, David Tweedie2, Shaul Schreiber3, Nigel H. Greig2, & Chaim G. Pick1 1

Department of Anatomy and Anthropology, Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel, 2Drug Design and Development Section, IRP/NIA/NIH, Baltimore, MD, USA, 3Department of Psychiatry, Tel Aviv Sourasky Medical Center, & Tel Aviv University Sackler Faculty of Medicine, Tel Aviv, Israel

Introduction: Traumatic brain injury (TBI) is a leading cause of death and lifelong disability in individuals under the age of 50. The main reasons for TBI are car accidents, attacks and falling. mTBI (mild traumatic brain injury) accounts for 80–90% of total brain injuries. mTBI may lead to short- and long-term cognitive, emotional and behavioural deficits. As yet, there is no effective treatment or cure for patients with mTBI. Tumour necrosis factor-alpha (TNF-a) is a cytokine that is fundamental in the systemic inflammatory process. TNF-a levels are alternated post-TBI and can lead to secondary damage to the brain tissue and instigate an apoptotic cascade in susceptible neurons leading to dysfunction or death. 3,60 -dithiothalidomide has been synthesized to reduce TNF-R mRNA stability via its 30 -UTR, both the cytosolic and the transmembrane TNF-a. Previous experiments from this laboratory have shown that mTBI may lead to cognitive impairments. These impairments were reversed in mice that were treated with 3,60 -dithiothalidomide after the injury. Methods and results: The present study investigated changes in neuronal loss, apoptosis and astrocyte number after treatment with 3,60 -dithiothalidomide. 30 6-dithiothalidomide was injected 1 hour post-closed head weight drop injury. Brains were removed 72 hours post-injury. Increased neuronal loss (NeuN), astrocyte number (GFAP) and apoptotic death (Bid) were found post-mTBI in the Dentate Gyrus and in the cortex. 3,60 -dithiothalidomide reduced this elevation and there were no differences between mice that received the treatment and the sham group. Conclusions: These findings may suggest a new therapeutic strategy to treat damages induced by mTBI. The current study may also shed new light on the mechanisms that underlie 3,60 -dithiothalidomide action.


Necessity of monitoring after negative head CT in patients with an acute head injury Harri Isokuortti1,2, Teemu M. Luoto3, Anneli Kataja4, Jari Siironen5, Suvi Liimatainen3, Grant L. Iverson6,7, Aarne Ylinen1,2, & Juha O¨hman3 1

Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland, 2University of Helsinki, Helsinki, Finland, 3 Department of Neurosciences and Rehabilitation, 4Medical Imaging Centre, Department of Radiology, Tampere University Hospital, Tampere, Finland, 5Department of Neurosurgery, Helsinki University


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Central Hospital, Helsinki, Finland, 6Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, USA, 7 Red Sox Foundation and Massachusetts General Hospital Home Base Program, Boston, MA, USA Objectives: The main objective of the study was to evaluate how many of the patients with a normal (i.e. negative) computed tomography (CT) scan after an acute head injury (HI) suffer aserious delayed intracranial complication (death, delayed haemorrhage and/or oedema) related to the primary injury within the first 72 hours post-CT. Secondarily, the study aimed to characterize the patients with complications in order to predict which patients would need hospital observation after a CT-negative HI. Methods: All consecutive patients who underwent head CT due to acute HI (n ¼ 3023) at the Emergency Department (ED) of Tampere University Hospital between August 2010 and July 2012 were included. Data collection consisted of socio-demographics, injuryrelated data and clinical information from the ED. In the ED, an emergency non-contrast head CT scan was performed for all patients with a 64-row scanner. Patients with a normal acute head CT were identified (n ¼ 2445, 80.9%). Patient records of these subjects were reviewed to identify patients with a serious intracranial complication related to the primary HI. The time window considered was the following72 hours after the primary head CT. A repeated head CT in the hospital ward, death or return to the ED was indicative of a possible complication. A detailed retrospective data collection was performed on those patients. Results: In the total sample, the age distribution was skewed (n ¼ 3023, median ¼ 55years, IQR ¼ 34–76) and the majority of the patients (56.4%) were men. Of the patients with normal acute head CT (n ¼ 2445), 54.4% were men. The most common mechanism of injury was ground-level falls (50.8%, n ¼ 1241). The majority (n ¼ 1811, 74.1%) of the patients with a negative head CT were discharged home from the ED and 1.1% (n ¼ 27) of these patients returned to the ED within the first 72 hours post-CT. A repeated head CT was performed to 12 (44.4%) of the returned patients and none of the scans revealed an acute lesion. Of the 633 (25.9%) CT-negative patients admitted to the hospital ward from the ED, a head CT was repeated in 46 (7.3%) patients within the first 72 hours. Only two (0.3%) patients had developed an acute intracranial lesion related to the primary HI. One of the patients with an intracranial complication died. Among patients with a CT-negative acute HI, the overall complication rate within the first 72 hours after the primary head CT was 0.08%. The very small number of subjects with complications was insufficient to characterize, clinically/statistically, to predict the need for hospitalization. Conclusions: The likelihood of developing a life-threatening delayed intracranial complication after an acute HI with a normal head CT is minor, although not totally negligible. The vast majority of patients with an acute HI can be safely discharged home after a normal head CT.


Reducing the need for restraint and seclusion: Changing the treatment culture on an inpatient neurobehavioural rehabilitation unit Rolf Gainer1, & Matt Maxey2 1

Brookhaven Hospital, Tulsa OK, USA, 2Neurologic Rehabilitation Institute of Ontario, Etobicoke, ON, Canada Objectives: In 2011 a project was initiated to reduce the need for seclusion and restraint on a 28-bed inpatient neurobehavioural

Brain Inj, 2014; 28(5–6): 517–878

rehabilitation unit serving adults with traumatic and acquired brain injury and a concurrent neurobehavioural syndrome. Methods: The project has three components: establishing an understanding of the incidence and duration of restraint and seclusion events including a review of individuals who were ‘high consumers’; re-designing the crisis response training curriculum to focus on the application of alternative strategies and developing specific crisis response teams who were consistently available to respond to behavioural events. The project was conducted within the scope of the hospital’s Performance Improvement Committee and the findings were reported to the Professional Staff Committee and governance structure. Results: At the 2-year anniversary, the project had reduced the restraint and seclusion events frequency from over 100 events per month to an average of 11. The 2-year project review provided opportunities to examine the outcome in terms of the persons served by the programme and the support of behavioural alternatives made available to them to avoid the application of restrictive practices. Additionally, the project included an opportunity to evaluate and revise the training curriculum. Coincidental to the review process, changes in the treatment culture became evident. As the restraint and seclusion events decreased in both frequency and duration, patient participation increased in treatment and pro-social activities on the unit. Additionally, the reduction in restraint and seclusion supported staff members engaging in more productive activities with patients. Overall, the project to reduce the use of restraint and seclusion enhanced the programme by creating new roles for both patients and staff members. Conclusions: Individuals with a brain injury and concurrent neurobehavioural syndrome are confronted with an environment based on external control. In addition to reducing the reliance on restraint and seclusion, the project initiative created an opportunity to introduce and support alternative responses to patient behaviour by staff members and allowed patients greater access to replacement behaviours. Reducing physical violence and the concomitant controlling responses patients have benefitted from increased access to choices and staff members have been able to forge more productive therapeutic relationships with the persons served to assist them in achieving transferrable rehabilitation outcomes.


Effects of neuropsychological rehabilitation in a left-handed patient with brain injury Yulia Solovieva, Luis Quintanar, Emelia La´zaro, & Grecia Paz Puebla Autonomous University, Puebla, Mexico Traffic accidents are responsible for 70% of the brain damage suffered by the young adult population. The frequency of such types of accidents has increased in Latin American countries, consequently generating a great impact in the health systems economy and family structure. Such patients always need not only medical attention, but also concrete proposals of cognitive rehabilitation in order to achieve better conditions in their day-to-day life. Creation and application of programmes of neuropsychological rehabilitation is one of urgent necessities in Latin America. The objective of this work is to present a study case of a Mexican young female left handed patient who suffered bilateral brain injury. The programme was created and assessed by specialists in neuropsychology. Qualitative neuropsychological assessment fulfilled on A.R. Luria’s background has detected dynamic aphasia syndrome accompanied by severe spatial difficulties. A programme for rehabilitation was designed and applied during a 4-month period. The programme included training of specific speech disorders and gradual formation of spatial orientation. Different


DOI: 10.3109/02699052.2014.892379

original tasks on material, perceptive and verbal level of presentation and execution were used. The poster presents the content of tasks with examples. The guided activities used during the work on the rehabilitation programme divided between patient and the therapist. Relevant examples of the patient executions before and after the neuropsychological intervention are presented. Speech production of independent phrases was achieved, writing by copy and evocation of words as well. Drawing by copy of geometric figures and images of simple objects became also possible after rehabilitation. The results pointed out essential changes in speech production of the patient together with successful execution of tasks for spatial functions. Positive changes were noticed in the emotional sphere of the patient. High possibilities of neuropsychological rehabilitation together with neuroplasticity should be considered in cases of brain injury. Specific consequences of brain injury in left handed patients as a probability is also discussed. It is concluded that neuropsychological rehabilitation created on solid theoretical bases may improve significantly the level of life and social activity of young adults with brain damage.

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A head-to-head comparison of the Sport Concussion Assessment Tool 2 (SCAT2) and the Military Assessment of Concussion Evaluation (MACE) Teemu M. Luoto1, Grant L. Iverson2,3,4, Noah D. Silverberg5,6, Anneli Kataja7, Antti Brander7, Olli Tenovuo8,9, & Juha O¨hman1

was created by summing the number of symptoms endorsed on the symptom scale. Results: The SAC discriminated patients with MTBI from controls [area under the curve (AUC) ¼ 0.76, p50.001], was associated with acute traumatic lesions on MRI (odds ¼ 1.64, 95% CI ¼ 1.06–2.54, p ¼ 0.025), improved over 1 month post-injury (W ¼ 549.5, p ¼ 0.001) and predicted RTW (odds ¼ 1.528, 95% CI ¼ 1.03–2.26, p ¼ 0.033). The SCAT2 Symptom Scores differentiated patients with MTBI from controls (AUC ¼ 0.84, p50.001) and elevated initial SCAT2 Symptom Scores in patients with MTBI were associated with a greater risk of PCS diagnosis at 1 month follow-up (odds ¼ 0.882, 95% CI ¼ 0.79–0.99, p ¼ 0.035). The combination of the SCAT2 Symptom Score and SAC achieved better classification accuracy between the patients and the controls than either one of the components individually. Patients and controls did not differ on the M-BESS. The discriminability of the MACE Symptom Score between patients with MTBI and controls was poor (AUC ¼ 0.646, p ¼ 0.029). The MACE Symptom Score predicted PCS diagnosis (odds ¼ 1.55, 95% CI ¼ 1.08–2.22, p ¼ 0.018), but not RTW (odds ¼ 0.99, 95% CI ¼ 0.66–1.51, p ¼ 0.99). The MACE Symptom Score did not improve classification when used jointly with the SAC. Conclusion: The SCAT2 was superior to the MACE. Most notably, the more detailed 22-item Symptom Scale component of SCAT2 provided clinically useful information over and above the SAC, whereas the MACE’s Symptom Scale was unhelpful. The SCAT2 appears useful for detecting acute MTBI-related symptoms and cognitive impairment, refining prognosis and monitoring recovery.


Presentation and outcome of traumatic subarachnoid haemorrhage in relationship to the mechanism of injury


Department of Neurosciences and Rehabilitation, Tampere University Hospital, Tampere, Finland, 2Department of Physical Medicine and Rehabilitation, Harvard Medical School, Harvard, MA, USA, 3Red Sox Foundation and Massachusetts General Hospital Home Base Program, MA, USA, 4Defense and Veterans Brain Injury Center, Charlestown, MA, USA, 5Division of Physical Medicine & Rehabilitation, University of British Columbia, BC, Canada, 6GF Strong Rehab Centre, Vancouver, BC, Canada, 7Medical Imaging Centre, Department of Radiology, Tampere University Hospital, Tampere, Finland, 8Department of Neurology, University of Turku, Turku, Finland, 9Turku University Central Hospital, Turku, Finland Objectives: To evaluate the clinical usefulness of the Sport Concussion Assessment Tool-Second Edition (SCAT2), in comparison to the Military Acute Concussion Evaluation (MACE), in patients with acute mild traumatic brain injuries (MTBI). It is hypothesized that the SCAT2 would be more sensitive to the acute effects of MTBI than the MACE. Methods: In a prospective case-control study, patients (n ¼ 49) between the ages of 18–60 years who met the World Health Organization criteria for MTBI (and had no pre-morbid medical or psychiatric conditions) were enrolled from an emergency department. Trauma controls (n ¼ 33) were recruited using the same study criteria when applicable. All patients with MTBI were evaluated within 5 days post-injury. Socio-demographics and injury-related data were collected and included age, gender, years of education and Injury Severity Scores. Main measures consisted of the SCAT2, MACE, MTBI severity markers including neuroimaging [CT and conventional MRI (3 Tesla)] and 1 month clinical outcomes [post-concussion syndrome diagnosis (PCS, ICD-10 criteria) and return-to-work status (RTW)]. The SCAT2 includes five scoreable components: (i) Symptom Score, (ii) Symptom Severity, (iii) Standardized Assessment of Concussion (SAC), (iv) Co-ordination Score and (v) Modified Balance Error Scoring System (M-BESS). The MACE consists of a symptom scale (nine symptoms, coded present or absent) and also the SAC. A MACE Symptom Score

Ayman El-Menyar, Ashok Parchani, Hassan Al-Thani, Ahmad Zarour, Husham Abdulrahman, Mohammad Asim, Ahmed El-Faramawy, Ruben Peralta, & Rifat Latifi Trauma Surgery, Hamad General Hospital, HMC, Doha, Qatar Objectives: Worldwide, it is difficult to estimate the real incidence of traumatic subarachnoid haemorrhage (TSAH) after sustaining traumatic brain injury (TBI). The present study aimed to study the pattern of TSAH based on the mechanism of injury (MOI), either motor vehicle crash (MVC) or fall from height (FFH). Methods: Data were collected retrospectively from a prospectively created database registry in the section of Trauma Surgery at Hamad General Hospital. All patients presented with head trauma and TSAH between January 2008 and July 2012 were enrolled. Patient data included age, gender, nationality, MOI, injury severity score (ISS), types of head injuries and associated injuries. Ventilator days, ICU length of stay, pneumonia and mortality were also studied. Results: A total of 1665 TBI patients were identified, of them 403 had TSAH with a mean age of 35 ± 15 years. Of them 93% were males and 86% were expatriates. MVC (53%) and FFH (35%) were the major MOI. The overall mean ISS and head AIS were 19 ± 10.6 and 3.4 ± 0.96, respectively. Patients in the MVC group sustained severe TSAH with significantly greater head AIS (3.5 ± 0.9 vs 3.2 ± 0.9; p ¼ 0.009) and ISS (21.6 ± 10.6 vs 15.9 ± 9.5; p ¼ 0.001) and lower scene GCS (10.8 ± 4.8 vs 13.2 ± 3.4; p ¼ 0.001) compared to the FFH group. Moreover, the MVC group represented more intraventricular haemorrhage (4.7 vs 0.7; p ¼ 0.001) and diffuse axonal injury (4.2 vs 2.9; p ¼ 0.001). In contrast, extradural haemorrhage (14.3% vs 11.6%; p ¼ 0.008) was higher in the FFH group. Lower extremities (14% vs 4.3%; p ¼ 0.004) injury was mainly associated with the MVC group. The overall mortality was 19% among TSAH patients. The mortality rate was higher in the MVC

540 group when compared to the FFH group (24% vs 10%; p ¼ 0.001). In both groups, ISS and GCS at the scene were independent predictors of mortality. Conclusion: Patients with TSAH have high mortality rate. In this group of population, MVCs are associated with a 3-fold increased risk of mortality. Therefore, prevention of MVC and fall can reduce the rate and severity of TBI.

Brain Inj, 2014; 28(5–6): 517–878

but did not show a significant difference between both groups. Many people of both groups had needs for rehabilitation. These were re-evaluation of the neuropsychological impairment, re-setting of the rehabilitation plan the support for social participation and support for working maintenance. Conclusions: The psychosocial problem influenced strongly the cognition disorder of chronic phase TBI. Chronic stage rehabilitative intervention for TBI was important.

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Relation of participation limitation and rehabilitation needs of mild-to-moderate traumatic brain injured (TBI) persons discharged from the advanced critical emergency centre: A qualitative study


Hironobu Sashika1, Naohisa Kikuchi2, & Kaokuko Takada2

Objectives: The purpose of this research was to determine a relationship between employment outcomes and communication skills in persons with traumatic brain injury (TBI). Methods: Thirty-one participants with TBI participated in this study. Participants ranged in age from 25–64 (M ¼ 47.73, SD ¼ 10.92), had an average time-post-onset of 11.5 years (range ¼ 1.2–30.2) and a duration of post-traumatic amnesia (PTA) of 34.4 days (range ¼ 1–168). Participants with TBI were employed in mid-level jobs requiring 2 years of training (defined by the US Department of Labor as ‘Job Zone 3’ occupations) before their injury and attempted to return to Job Zone 3 occupations after their injury. All participants reported being cleared for return-to-work by a physician or neuropsychologist. Participants were divided into stable employment and unstable employment groups. There were no statistical differences for age, sex, PTA or education. Stable employment was defined as maintaining employment for greater than 1 year, while unstable employment was defined as unable to maintain employment for 12 consecutive months. Qualitative interviews of persons without neurological involvement in Job Zone 3 occupations were conducted to select communication measures relevant to functional workplace communication. Measures were: (1) Woodcock-Johnson III Tests of Achievement (WJ-III)– Understanding Directions, (2) The SCAN–3A, (3) The Wechsler Memory Scales III–Logical Memory, (4) The Nelson-Denney Reading Test (NDRT), (5) The Functional Assessment of Verbal Reasoning and Executive Strategies (FAVRES), (6) The Modified Six Elements Test, (7) The Video Social Inference Test (VSIT) and (8) A voicemail message task (VMT) used to assess verbal pragmatic expression. Logistic regression was used to determine if measures were associated with employment outcomes. Results: Communication measures correctly classified 86% of participant group membership. The model was able to correctly classify 12 of 15 SE participants (80% sensitivity) and 12 of 14 UE participants (86% specificity). A model of four communication measures (WJ-III, FAVRES, VSIT and NDRT) explained 53% of the variance with measures of verbal reasoning speed and social cognition being significant. A model of five measures (WJ, FAVRES, VMT, VSIT, NDRT) explained 63% of the variance, with no communication measures being independently predictive. Conclusions: Communication measures were positively associated with stable employment in mid-level jobs after TBI. Communication skills of specific interest include verbal reasoning speed and social cognition. These measures are associated with employment stability, thus communication may be implicated with workplace separation decision in persons with TBI. Prospective studies demonstrating a predictive value of communication skills on employment outcomes in persons with TBI is necessary to demonstrate a causal relationship. Communication measures of interest will be reviewed and implications for assessment and treatment will be discussed.


Yokohama City University, Medical Center, Yokohama, Japan, Yokohama City University, School of Medicine, Yokohama, Japan


Objectives: Assessment and rehabilitation programmes for cognitive disorders of traumatic brain injured persons (TBIs) have been insufficient in the advanced critical care and emergency centre (ACEC). Although a participation limitation of TBIs may increase in the case of the insufficient rehabilitation service, the co-operation of the ACEC rehabilitation intervention with convalescent rehabilitation hospitals and/or chronic stage welfare facilities was difficult. The purpose of this study was to clarify qualitatively the relation of the participation limitation and the rehabilitation needs of chronic phase TBIs discharged from the ACEC. Methods: Data about neuropsychological assessment (WAIS-III, WMSR, RBMT, BADS, etc.) were reviewed. Zung depression scale (SDS), Sydney Psychosocial Reintegration Score (SPRS) and SF-36 were evaluated. Qualitative data of psycho-behavioural problems, participation limitation and rehabilitation needs were assessed by semistructured interviews. Subjects: Inclusion criteria was (1) TBIs treated by rehabilitation therapy in the ACEC from 2007–2011, (2) 18–75 years old at the injured time, and (3) modified Rankin Scale 0–3. Eighty-three TBIs from 110 candidates in all 228 TBIs were mailed the purpose and 39 TBIs replied. Finally, 27 TBIs who provided informed consent were registered to this study. Median age was 36.9 years old (19.0–62.9: Male/female: 14/13). All cases were brain contusion or diffuse axonal injury. The discharge destination from the ACEC was 14 went home, three went to general hospital and 10 went to rehabilitation special hospital. Twelve TBIs had received the chronic phase outpatient cognitive rehabilitation. Results: The period from TBI to interview was 50.7 months (median ¼ 14.4–81.7). The Social participation group (SP-G) was 13 were working, one was a student and two were housewives. The non-social participation group (nSP-G) was one in a sheltered workshop, two in a welfare workshop, one in prolonged hospitalization to psychiatry hospital and seven were jobless. The main problems were neuropsychological disorder in 16 subjects, psycho-behavioural disorder in four and no trouble in seven subjects. Many TBIs showed mild-tomoderate neuropsychological disorder (lower FIQ of WAIS-III, WMS-R, RBMT and BADS), regardless of having psycho-behavioural problems or not. The nSP-G showed larger psychosocial problems (SPRS, Rolesocial component summary of SF-36) than the SP-G. In cases of inappropriate psycho-behavioural disorder, SPRS deteriorated more than the normal score. SF-36 (Mental and role-social component summary) of the significant others deteriorated. The SDS was high,

Communication skill and employment stability in competitive jobs after TBI Peter Meulenbroek1, & Lyn Turkstra2 1

Northwestern University, Chicago, IL, USA, 2University of Wisconsin-Madison, Madison, WI, USA


DOI: 10.3109/02699052.2014.892379


Influence of the severity and location of bodily injuries on symptom reporting following military-related concurrent mild TBI and polytrauma Louis French1, Rael Lange2, Katherine Marshall2, Olga Prokhorenko2, Tracey Brickell2, Jason Bailie3, Sarah Asmussen4, Brian Ivins2, Doug Cooper2, & Jan Kennedy5 1

Walter Reed National Military Medical Center, Bethesda, MD, USA, Defense and Veterans Brain Injury Center, Bethesda, MD, USA, 3 San Diego Naval Medical Center, San Diego, CA, USA, 4Marine Corps Base Camp Pendleton, San Diego, CA, USA, 5San Antonio Military Medical Center, San Antonio, TX, USA

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Objectives: Traumatic brain injuries (TBI) sustained by US military service members in Iraq and Afghanistan frequently co-occur with significant bodily injuries. Intuitively, more extensive combat-related physical injuries might be associated with increased symptom reporting. Counter intuitively, however, French et al. recently demonstrated an inverse linear relation between bodily injury severity and symptom reporting. That is, as bodily injury severity increases, symptom reporting decreases. The purpose of this study is to expand on the work by French and colleagues by examining the influence of the location and severity of bodily injuries on symptom reporting following mild TBI. Methods: Participants were 579 US military service members (Age: M ¼ 26.7 years, SD ¼ 6.8; Male ¼ 100%) who sustained a mild TBI and who were evaluated at Walter Reed Army Medical Center (n ¼ 220) or San Antonio Military Medical Center (n ¼ 359) following injuries sustained in combat while deployed to Operation Iraqi Freedom and Operation Enduring Freedom. All had sustained an uncomplicated mild TBI and had concurrent bodily injuries. Severity of bodily injuries was quantified using a modified Injury Severity Score that excluded intracranial injuries (ISSmod). Participants were classified into four ISSmod groups: Minor (n ¼ 73), Moderate (n ¼ 278), Serious (n ¼ 148), Severe/Critical (n ¼ 80). Participants completed the Neurobehavioural Symptom Inventory (NSI) and the Post-traumatic Stress Disorder Checklist (PCL-C), on average, 2.5 months post-injury (M ¼ 72.8 days, SD ¼ 89.5, Range ¼ 1–364). Results: There was a significant negative association between ISSmod scores and the NSI (r ¼ 0.267, p50.001) and PCL-C (r ¼ 0.273, p50.001) total scores. There were significant main effects across the four groups for the NSI and PCL-C (Kruskal Wallis H test: both p50.001). Pairwise comparisons revealed that the highest NSI and PCL-C total scores were consistently found in the ISSmod Minor group, followed by the Moderate, Serious and Severe/Critical groups (i.e. Minor & Moderate 4 Serious & Severe/Critical; all p50.05). Using linear regression to examine the relation between symptom reporting and injury severity across the six ISS body regions (Head/Neck/ Cervical Spine, Face, Thorax/Thoracic Spine, Abdomen/Lumbar Spine, Extremities, External/Burns), three of the six ISS body regions were significant predictors of the NSI total score (Face; p50.001; Abdomen; p ¼ 0.003; Extremities; p50.001) and accounted for 9.3% of the variance (p50.001). For the PCL-C, two of the six ISS body regions were significant predictors of the PCL-C total score (Face; p50.001; Extremities; p50.001) and accounted for 10.5% of the variance (p50.001). Conclusions: Consistent with recent work by French and colleagues, there was an inverse relation between bodily injury severity and symptom reporting in this sample. This inverse relationship was mostly influenced by bodily injuries to the face, abdomen and

extremities; although this relationship was moderate at best. Hypothesized explanations include under-reporting of symptoms, increased peer support, disruption of fear conditioning due to acute morphine use or delayed expression of symptoms.


Female service members and post-concussion symptom reporting following militaryrelated mild traumatic brain injury Tracey Brickell1, Rael Lange2, Jan Kennedy3, Jason Bailie4, Sarah Asmussen5, & Louis French2 1

Defense and Veterans Brain Injury Center, Bethesda, MD, USA, Walter Reed National Military Medical Center, Bethesda, MD, USA, 3 San Antonio Military Medical Center, San Antonio, TX, USA, 4 San Diego Naval Medical Center, San Diego, CA, USA, 5Marine Corps Base Camp Pendleton, San Diego, CA, USA 2

Objectives: More female US service members (SM) have been deployed to Operations Iraqi Freedom and Enduring Freedom (OIF/ OEF) than all previous military conflicts. Female SMs are often exposed to combat and are at similar risk for combat-related injuries as males. Mild traumatic brain injury (MTBI) is a common injury sustained during OIF/OEF. A substantial body of research has examined outcome from military-related MTBI. However, researchers will often exclude females from MTBI studies due to the low prevalence of females in the military. The purpose of this study was to focus specifically on outcome from MTBI in female SMs. Methods: Participants were 3184 US military SMs (155 female, 3029 male) evaluated at one of six military medical centres following a TBI sustained during deployment or non-deployment. A sub-sample of 172 participants (86 female, 86 male) were selected from the larger sample that had sustained a MTBI and were evaluated within 24 months of injury (Age: M ¼ 28.9, SD ¼ 8.1). Eighty-six females were matched to 86 males on nine key variables: TBI severity, mechanism of injury, bodily injury severity, days post-injury, age, number of deployments, theatre where wounded, branch of service and rank. Participants in the matched sub-sample had completed the Neurobehavioural Symptom Inventory (NSI) and the Post-traumatic Stress Disorder Checklist (PCL-C). Results: In the entire sample, the prevalence of female SMs who had sustained a TBI was 4.9%. There were no meaningful gender differences across the vast majority of demographic or injury-related variables (p40.05). In the matched MTBI sub-sample, females reported a significant (p50.05) and meaningfully (d40.30) higher number of PCL-C symptoms, but only when they sustained a (a) nonblast TBI (d ¼ 0.39), (b) moderate-serious bodily injury (d ¼ 0.52) or (c) ‘equivocal’ MTBI (d ¼ 0.63). For the NSI, females reported a significant and meaningfully higher number of NSI symptoms, but only when they sustained a (a) non-blast TBI (d ¼ 0.56), (b) minor (d ¼ 0.33) or moderate-serious bodily injury (d ¼ 0.66) or (c) ‘equivocal’ (d ¼ 0.62) or uncomplicated MTBI (d ¼ 0.35). Across the entire sample, PTSD symptoms mediated the effect of gender on the NSI. Controlling for the influence of PTSD, the majority of gender effects across NSI symptoms disappeared; except for non-blast TBI (ANCOVA; p50.05). However, for those who did not have PTSD, controlling for PTSD symptoms did not impact gender differences across NSI symptoms (d ¼ 0.69, medium–large effect size). Conclusions: Post-concussion symptoms were influenced by gender. These effects were strongest in the absence of PTSD, less severe MTBI, non-blast related injuries and moderate–severe bodily injury. The

542 relation between PTSD and post-concussion symptoms was very strong and likely accounts for some gender differences, but certainly not all. As females become more active in combat-related deployments, it is critical that future studies place more emphasis on this important military population.


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Factors influencing postconcussion and post-traumatic stress symptom reporting following military-related concurrent polytrauma and traumatic brain injury Rael Lange1, Tracey Brickell2, Jan Kennedy3, Jason Bailie4, Cheryl Sills2, Sarah Asmussen5, Ricardo Amador2, Angelica Dilay2, Brian Ivins2, & Louis French1 1

Walter Reed National Military Medical Center, Bethesda, MD, USA, Defense and Veterans Brain Injury Center, Bethesda, MD, USA, 3 San Antonio Military Medical Center, San Antonio, TX, USA, 4 San Diego Naval Medical Center, San Diego, CA, USA, 5Marine Corps Base Camp Pendleton, San Diego, CA, USA

Brain Inj, 2014; 28(5–6): 517–878

factors were statistically and meaningfully associated with clinically elevated post-traumatic stress symptoms: (a) decreased bodily injury severity, (b) increased depression symptoms, (c) a longer time evaluated post-injury, (d) military operation where wounded and (e) current auditory deficits (p50.001; 65.6% variance accounted for). Depression alone accounted for the vast majority of unique variance (60.0%) and was strongly associated with, and predictive of, clinically elevated post-traumatic stress symptoms (OR ¼ 38.78; RR ¼ 4.63). Conclusions: There was a very clear, strong and clinically meaningful association between depression, post-traumatic stress and postconcussion symptoms in this sample. Brain injury severity in this mild– moderate sample, however, was not associated with symptom reporting.


Mild traumatic brain injury and pyruvate treatment on mitochondrial functions in different parts of the brain Pushpa Sharma, Guoqiang Xing, & Brandi Benford


Objectives: Identification and diagnosis of traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD) following military-related injuries can be challenging. Early detection of patients who are at risk of poor long-term outcome can potentially result in early treatment and the opportunity to minimize poor outcome. To date, many researchers have examined a single or a small number of risk factors that can influence symptom reporting following TBI (e.g. depression, ‘good old days’ bias). However, few studies have examined a large number of variables concurrently to identify those factors that provide the most unique contribution to post-injury symptom reporting. The purpose of this study was to identify factors that are predictive of, or associated with, endorsement of postconcussion and PTSD symptoms in a large sample of US military service members. Methods: Participants were 1600 US military service members (Age: M ¼ 27.1, SD ¼ 7.1; 95.4% male), diagnosed with a mild or moderate TBI, who had been evaluated by the Defense and Veterans Brain Injury Center at one of six military medical centres within 2 years of sustaining a deployment-related or nondeployment-related injury. A total of 22 factors were examined that related to (a) demographic variables (gender, military rank, branch of military service, reserve status), (b) injury circumstances (mechanism of injury, deployment number when wounded, military operation when wounded, type of military operation when wounded, number of prior blast exposures), (c) injury severity (duration of loss of consciousness, post-traumatic amnesia, TBI severity classification, intracranial abnormality, amputations, bodily injury severity), (d) treatment/evaluation factors (CT ordered after injury, planned disposition for return-to-duty, number of days evaluated postinjury) and (e) psychological/physical symptoms (immediate auditory deficits, current auditory deficits, traumatic stress symptoms, depression). Results: Four factors were statistically and meaningfully associated with increased post-concussion symptoms; (a) less severe bodily injuries, (b) mild post-traumatic stress symptoms, (c) higher depression symptoms and (d) military operation where wounded (p50.001, 43.2% variance). Depression and post-traumatic stress symptoms accounted for the vast majority of unique variance (41.5%) and were strongly associated with, and predictive of, clinically elevated postconcussion symptoms (range: OR ¼ 4.24–7.75; RR ¼ 2.28–2.51). Five

Uniformed Services University of the Health Sciences, Bethesda, MD, USA Introduction: Mitochondrial damage resulting in increased oxidative stress and neuronal cell death in response to traumatic brain injury (TBI) is widely accepted as one of the key contributing factors to the outcome of TBI recovery. The brain is a complex structure and cognitive impairments after TBI may be due to the severity of injury in different parts of the brain. Energetically active cells such as neurons require a more efficient ATP supply, which can only be provided by the pyruvate metabolism through the mitochondrial enzyme pyruvate dehydrogenase complex (PDH), and mitochondrial oxidative phosphorylation through its electron transport chain (ETC). However, the severity of mitochondrial damage in different parts of the brain following TBI is not known. The objective of this study is to identify, delineate and prevent the mitochondrial damage in the injured brain of rats treated with sodium pyruvate. Methods: Sprague-Dawley rats were divided into (1) naı¨ve control, (2) mTBI-lateral fluid percussion brain injury (2–2.5 atm ¼ mild TBI), (3) TBI + pyruvate-sodium pyruvate in sterile distilled water (1 g kg1) was given orally every 24 hours for the rest of the experiment. Animals were sacrificed on the 7th day post-TBI/naı¨ve. The brain was harvested and dissected into various parts, stored at 80 C for further use. Expression of brain complex I–V and pyruvate dehydrogenase (PDHE1alpha) were determined by Western blotting. Results: The pre-frontal cortex (PFC) mTBI has no effect on PFC ETC; Pyruvate reduced CV protein level in the TBI brain. Cerebellum mTBI has no effect on cerebellar ETC level but decreased PDHE1a1 level; Pyruvate increased CI & CIII protein level in the TBI brain. Hippocampus mTBI decreased hippocampal CII and CV proteins. Pyruvate decreased CII and CV in Naives but increased CI, CIII and CIV in the uninjured sides of the mTBI brain. Cortex mTBI decreased cortical CIV and PDHE1a1 proteins in the injured hemisphere but not in the uninjured side. Pyruvate treatment increased CIII and CIV in the Naives and CI and CIII in the injured cortex, but decreased CIV and CIV in the uninjured sides of the mTBI brain. Conclusions: In response to TBI, mitochondrial complex I–V expression is dysregulated in different brain regions. Pyruvate treatment has a confounding influence on mTBI-induced complex I–V expression.


DOI: 10.3109/02699052.2014.892379


Delayed increases in microvascular pathology following experimental traumatic brain injury are associated with prolonged inflammation, blood– brain barrier disruption and progressive white matter damage Olena Glushakova, Danny Johnson, & Ronald Hayes

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Banyan Biomarkers, Inc., Alachua, FL, USA Background: Traumatic brain injury (TBI) is a significant risk factor for many neurological and neurodegenerative disorders including Chronic Traumatic Encephalopathy (CTE), post-traumatic epilepsy and Alzheimer’s and Parkinson’s disease (AD and PD). Cerebral microbleeds, focal inflammation and white matter damage are associated with these and many other neurological and neurodegenerative disorders. Nevertheless, the aetiology of microbleeds as well as their involvement in neuropathological consequences of diseases is not understood. This study correlated microvascular pathologies with inflammatory markers at acute and chronic stages following TBI in rats and examined pathological pathways associated with these abnormalities. Methods: TBI in adult rats was induced by controlled cortical impact (CCI) of two magnitudes using unilateral CCI (uCCI) and bilateral CCI (bCCI) configurations. The progression of brain pathologies was accessed in the corpus callosum using immunohistochemistry (IHC) starting from 24 hours and up to 3 months following injury. Results: TBI resulted in focal microbleeds that were related to the magnitude of injury. At the lower magnitude of injury, microbleeds gradually increased over the 3 month duration of the study. IHC revealed TBI-induced focal abnormalities including blood–brain barrier (BBB) damage (IgG), endothelial damage [Intercellular Adhesion Molecule 1 (ICAM-1)], activation of reactive microglia [Ionized calcium binding adaptor molecule 1 (Iba1)], gliosis [Glial Fibrillary Acidic Protein (GFAP)] and macrophage mediated inflammation [Cluster of Differentiation 68 (CD68)], all showing different temporal profiles. At chronic stages (up to 3 months), apparent myelin loss (Luxol fast blue) and scattered deposition of microbleeds were observed. Microbleeds were surrounded by glial scars and co-localized with CD68 and IgG puncta stainings, suggesting localized BBB breakdown and inflammation were associated with vascular damage. Conclusion: These studies provide the first systematic examination of the delayed onset of inflammation and white matter damage following TBI. Although historically most studies of TBI have focused on acute pathology and therapeutic interventions, the data suggest that significant post-TBI pathology occurs at far later periods. These results indicate that evolving white matter degeneration following experimental TBI is associated with significantly delayed microvascular damage and focal microbleeds that are temporally and regionally associated with development of punctuate BBB breakdown and progressive inflammatory responses. Increased understanding of the biochemical mechanisms of delayed microvascular damage and inflammation could provide novel insights into chronic pathological responses to TBI and reveal potential common mechanisms underlying brain pathologies in TBI and neurodegenerative diseases. In addition, these findings could potentially provide novel targets for development of more personalized therapies to treat chronic post-traumatic neurodegenerative conditions.


Reconsidering paediatric TBI rehabilitation. A Maori intervention Hinemoa Elder Te Whare Wananga o Awanuiarangi, Whakatane, New Zealand Objectives: The paediatric TBI rehabilitation literature is clear that a family approach is necessary. However, what this means in practice varies. In addition, ethic cultural aspects of the family are well recognized as having an impact on how the family consider their role, the meaning of the TBI itself as well as services responses. Despite this knowledge, culturally-determined TBI rehabilitation interventions are not in common usage. This research aimed to develop a Ma¯ori cultural response to paediatric TBI. Methods: Participants at 18 marae wa¯nanga (culture-specific fora in traditional meeting houses), held in urban, rural and remote locations, were asked to tell stories from their wha¯nau (extended family) about injury to the brain. A form of member checking was used to confirm identified core themes. Data was analysed using Rangahau Kaupapa Ma¯ori (Ma¯ori indigenous research methods). Results: An intervention called Te Waka Oranga was developed. This is a practical tool which brings wha¯nau and professionals together to improve outcomes. Early results of field testing the intervention will be presented. Conclusions: Te Waka Oranga, an alternative to mainstream paediatric TBI rehabiltiation, has been developed and is in the early stages of field testing with wha¯nau. This approach may also have application in other fields dealing with insult to the brain such as mental health and addiction services and for other ethnic cultures.


Theory of mind in discourse of adults with traumatic brain injury Lindsey Byom, & Lyn Turkstra University of Wisconsin-Madison, Madison, WI, USA Objectives: Social communication deficits after TBI are associated with long-term negative social outcomes. While social communication deficits have been well documented in the TBI literature, the underlying mechanisms of these impairments and their consequences for social interaction remain unclear. The objectives of this study were to (1) investigate the relationship between one cognitive process commonly impaired after TBI, theory of mind (ToM) and social communication performance and (2) investigate how social communication of individuals with TBI was perceived by potential communication partners. It was hypothesized that participants with TBI would demonstrate poorer social communication performance on a discourse task, especially when ToM demand was high. It was also hypothesized that social communication performance of the TBI group in a high-ToM condition would be associated with social judgements. Methods: Participants were 22 adults with moderate-to-severe TBI and 22 comparison participants (CP), matched for age and sex. Participants completed a discourse task in which ToM demand was manipulated and changes in social communication were measured. The outcome variable was the rate of words used that reflect ToM, i.e. mental state terms (MST). It was hypothesized that the TBI group would not increase their MST use in response to increased ToM demand to the same degree as the

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544 CP group. Fifty-one undergraduate students rated the TBI group’s transcripts from high-ToM condition for appropriateness and acceptability on a 4-point likert scale (1 ¼ very appropriate/ acceptable, 4 ¼ very appropriate). It was hypothesized that more frequent MST use would be associated with more positive social judgements. All participants gave informed consent and all procedures were approved by the Social and Behavioural Institutional Review Board. Results: Results indicated that the TBI group used MSTs less frequently than the CP group in both the low-ToM (t ¼ 1.92, p ¼ 0.03) and high-ToM (t ¼ 3.16, p ¼ 0.002) conditions. The groups did not differ in how MST rate was affected by increased ToM demand (t ¼ 1.20, p ¼ 0.12), as measured by the change in MST rate across conditions (high-ToM demand – low-ToM). Analysis of perceptual ratings indicated that MST rate in the TBI group was significantly correlated with perceptual ratings of both appropriateness (r ¼ 0.63, p ¼ 0.01) and acceptability (r ¼ 0.66, p ¼ 0.01) such that more frequent MST use was associated with more positive (lower ratings) perceptual judgements. Conclusions: Results suggest that adults with TBI may have deficits in ToM that are evident in their discourse, even when ToM demand is low. Further, results indicate that the ability to appropriately use words reflective of ToM may influence how others judge discourse samples of adults with TBI.


Chronic radiological abnormalities in patients with mild traumatic brain injury

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Groups A and B, respectively. Brain abnormalities were revealed in four (7.8%) and six (14.6%) on FDG-PET, four (7.8%) and two (4.9%) on ECD-SPECT, six (11.8%) and one (2.4%) on tractography and eight (15.7%) and three (7.3%) on FA-SPM imaging in Groups B-1 and B2, respectively. Conclusions: Even in patients without intracranial abnormalities on conventional CT and/or MRI in an acute stage of injury, chronic radiological abnormalities could be seen on both morphological and metabolic brain imaging in a certain number of patients, although the number is significantly small compared to patients with intracranial abnormalities on conventional CT and/or MRI in an acute stage of injury. Additionally, in mTBI patients without intracranial abnormalities on conventional CT and/or MRI in an acute stage of injury, there was a tendency that more frequent chronic radiological abnormalities could be seen on metabolic imaging in patients who had suffered direct head injury compared to patients who had suffered only whiplash injury. There was, however, no difference in the frequency of chronic radiological abnormalities on morphological imaging between these patient groups.


Obstructive sleep apnea affects functional and cognitive status after stroke Justine Aaronson1, Coen van Bennekom1, Winni Hofman2, & Ben Schmand2 1

Jun Shinoda, Yoshitaka Asano, Kazuhiro Miwa, Shinoga Yonezawa, Yu-ichi Nomura, & Kei-ichi Itou Chubu Medical Center for Prolonged Traumatic Brain Dysfunction, Kizawa Memorial Hospital and Department of Clinical Brain Sciences, Gifu University Graduate School of Medicine, Minokamo, Gifu, Japan Objectives: It is generally difficult to detect chronic radiological brain lesions in patients with mild traumatic brain injury (mTBI). This study assessed the frequency of radiological abnormalities on morphological and metabolic neuroimaging in patients with mTBI in a chronic stage. Methods: Between January 2012 and February 2013, 97 patients (44 males, mean age ¼ 46 years, range ¼ 19–77 years) with mTBI who had been having neuropsychiatric dysfunction after injury were referred to the hospital as outpatients to examine their brain damage. The mean interval between the injury and consultation was 54 months (7–245 months) and the causes of injury were traffic accident in 94 patients, falling in two and assault in one. Intracranial abnormalities on a conventional CT and/or MRI in the acute stage of injury were seen in five patients (5.2%) (Group A) and they included traumatic subarachnoid haemorrhage, intracerebral haemorrhage and acute subdural haematoma. The remaining 92 patients were grouped as Group B. Patients of Group B were divided into Group B-1 (51 patients who suffered direct head injury) and Group B-2 (41 patients who suffered only whiplash injury). Imaging exams including MRI (T2*WI, SWI and DWI), FDG-PET and ECD-SPECT were performed. Brain abnormalities on FDG-PET and ECD-SPECT were defined as significant regional hypometabolism in the cingulum, medial prefrontal, frontal base and thalamus typical of diffuse brain injury compared to age-matched normal control. Results: Brain abnormalities were revealed in three (60%) and zero (0%) patients on T2*WI/SWI, four (80%) and 10 (10.9%) on FDG-PET, three (60%) and six (6.5%) on ECD-SPECT, two (40%) and seven (7.6%) on tractography and four (80%) and 11 (12%) on FA-SPM imaging in

Heliomare R&D, Wijk aan Zee, The Netherlands, 2University of Amsterdam, Amsterdam, The Netherlands Objective: Obstructive sleep apnea (OSA) is a highly prevalent sleep disorder in stroke patients and is known to lengthen hospitalization after stroke and increase the risk of recurrent stroke and post-stroke mortality. To date, the effect of OSA on the functional and cognitive outcome following stroke is not well established. The aim of the study was to compare the functional and cognitive status of stroke patients with OSA with non-OSA stroke patients upon admission to the rehabilitation centre. Methods: A total of 114 patients underwent sleep examination for diagnosis of OSA. This study performed a neurological and cognitive assessment and rated the activities of daily living (ADL) of the patients. It also administered questionnaires on fatigue, sleepiness and mood. Results: Thirty-six per cent of the stroke patients had OSA (n ¼ 41). The majority of patients were middle-aged and male. Patients with OSA had a significantly higher BMI than non-OSA patients. No difference in stroke severity was objectified. As regards to functional status, OSApatients showed worse ADL than non-OSA patients (p ¼ 0.03), while no differences in pure neurological status were found. As for cognitive functioning, OSA patients performed worse in attention (p ¼ 0.019) and in problem-solving (p ¼ 0.006) than patients without OSA. In the cognitive domains of vigilance, memory and executive functioning no difference was seen. Also, the reported levels of fatigue, sleepiness and depressive symptoms did not differ between patients with and without OSA. Conclusions: Stroke patients with OSA have more difficulties in ADL and show a decrease in attention and problem-solving as compared to non-OSA patients. Thus, it is concluded that OSA negatively affects the functional and cognitive outcome of stroke patients.


DOI: 10.3109/02699052.2014.892379


Cognitive function after cardiorespiratory fitness training in a patient recovering from traumatic brain injury Kurt Mossberg1, Anna deJoya2, & Jennifer Hale3 1

University of Texas Medical Branch, Galveston, TX, USA, TIRR/Memorial Hermann, Houston, TX, USA, 3Texas State University, San Marcos, TX, USA

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Objectives: There is an abundance of literature supporting the positive effects of long-term cardiorespiratory fitness training on neuropsychological status in a variety of patient populations. Little attention has been given to patients recovering from traumatic brain injury (TBI). The purpose of this case report was to assess the effects of cardiorespiratory fitness training on cognitive function in a patient recovering from a moderate TBI. Methods: The subject was a 41 year old male involved in a sportsrelated accident resulting in an initial Glasgow Coma Scale (GCS) score of 10. Observation and treatment began 3 months post-injury after admission to an out-patient post-acute day treatment programme. Baseline measures included (1) verbal memory (Hopkins Verbal Learning Test-R), (2) visual tracking and scanning (Symbol Digits Written and Oral), (3) selective attention (Ruff 2&7) and (4) sustained attention and reaction time (Conner’s Continuous Performance Test-II). These measures were repeated after 13 weeks of optimal aerobic conditioning. The frequency of cardiorespiratory fitness training was 3-times per week with an intensity of 50–70% of age-predicted maximal heart rate for 20–30 minutes on an elliptical training device. Results: Depending on the specific sub-test of each of the cognitive measures, improvements were observed in most but not all. Verbal memory increased 20–50%; visual tracking and scanning improved 30–50%; selective attention increased 20–60%; sustained attention and reaction time improved 50% and 7%, respectively. Conclusions: The observations made on this subject suggest that cognitive function has the potential to favourably change in response to long-term cardiorespiratory fitness training. Limitations of the study include the fact that this is a single individual studied in a relatively short period of time after injury. Consequently, one cannot rule out the possibility that the changes would have taken place spontaneously. However, given the known benefits of cardiorespiratory fitness training on overall physical and mental health, more rigorous investigations are recommended in patients with TBI.


Randomized controlled trial on impact of two training packages on the knowledge and care practices of the family care givers of operated neurosurgery patients admitted in a tertiary care hospital in North India Madhanraj Kalyanasundaram1, Sukhpal Kaur2, Manoj Tewari2, & Amarjeet Singh2

1 2

Pondicherry Institute of Medical Sciences, Pondicherry, India, PGIMER, Chandigarh, India

Objectives: To compare the impact of two training packages on knowledge and practices of family caregivers of operated neurosurgery patients. Methods: A Randomized Controlled Trial was done among the operated neurosurgery patients and their caregiver dyads (n ¼ 90). They were randomly allocated to receive either training package 1 (TP1 ¼ self-instruction manual and one-to-one training) or training package 2 (TP2 ¼ self-instruction manual only). Block randomization (block size ¼ 4) method was used. Sequentially numbered sealed envelope was used for allocation concealment. Monthly follow-up was done for 3 months. Informed written consent was obtained from all the participants. Primary outcome measure was knowledge gain of the caregivers. Variety of secondary outcome measures was also assessed in 3-monthly follow-ups. Results: The Attrition rate was 15.5%. Intention to treat analysis was followed. Caregivers in the TP1 group had significant knowledge gain (95% CI of mean difference ¼ 9.4–14.5, Bonferroni corrected p value50.05). The number of caregivers who followed correct care-giving practices were significantly more in the TP1 group. The number of patients with bedsores was significantly low in the TP1 group. Life satisfaction of the caregivers in the TP1 group improved significantly. This study could not find any significant difference in the improvement in the degree of patients’ disability and in the caregivers’ strain between the groups. Conclusions: Training of caregivers by providing information along with one-to-one training is an effective strategy for improving the knowledge and skills of caregivers regarding care provision of the operated neurosurgery patients.


In search of ecological validity in the assessment of executive functioning Leslie Birkett1, & Deidre Sperry2 1

McMaster University, Hamilton, Ontario, Canada, 2Private Practice, Hamilton, Ontario, Canada Objective: The assessment of Executive Functioning has become a topic of vibrant debate. It is widely known that assessment tools that use novel, complex tasks that challenge a number of executive processes are best able to estimate a person’s real world functioning. Yet, clinicians continue to use traditional means of assessment. Typically, this involves pencil and paper tasks that follow a set format, are assessor driven and occur in the quiet confines of an office. Therefore, the ecological validity of traditional assessment methods is being challenged. It is accepted that assessment methods, settings and materials used to assess executive functioning must change in order to reflect a person’s proficiency as they function in their real world. The evolving direction of the evaluation of executive function includes the use of real world performance-based tools. The I CAN was developed as a means to bring ecological validity to the assessment of executive functions. It provides an individualized and hierarchical method to systematically analyse a person’s ability to utilize executive functions necessary to navigate complex environments. The objective of this project was to review the literature regarding assessment of executive function to determine if the I CAN is following best practices. This presentation will provide the outcome of this literature review and will demonstrate how the I CAN is currently being used to provide valuable information regarding an individual’s executive functioning in real world environments. Method: A systematic review of literature regarding the evolution of the assessment of executive functioning was completed.

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546 The conclusion identified that functional analysis is an important adjunct to the assessment of executive function. Following this, a retrospective analysis of I CAN assessments was completed to determine if these assessments provided this important clinically relevant information. Results: When used in conjunction with traditional assessment methods, the I CAN provides clinically valuable information. As the I CAN examines a broad range of executive functions simultaneously, it more closely resembles daily functioning. It is because I CAN assessments occur in real world contexts that the findings are more likely to predict behaviour and performance. Additionally, it is due to the functional nature of the assessment tasks that clients and families more easily understand the results of the assessment. The I CAN requires further work to define the rating scale to address issues of inter-rater reliability. Training modules and an assessment manual are also identified as areas requiring attention. Conclusions: The I CAN is following best practices as a valuable means to evaluate executive functioning. Because I CAN assessments observe dynamic functioning, the link to treatment directions is clear. Therefore, the I CAN provides information necessary to develop meaningful and dynamic treatment programmes that focus on participation in life roles.


Brain injury: Voices of a silent epidemic Cindy Daniel, Andrew Palumbo, & Patrick Morrissey BRAVE Publications, Springfield, VA, USA Objectives: Long-term outcomes from brain injury are difficult to predict and more challenging to fully understand. Athletes who have been concussed, soldiers coming back from war with brain injuries, even political figures who have sustained brain injuries through assault have all lived to tell their stories. Even though traumatic brain injuries now receive unprecedented attention in popular media, the common perception of recovery still tends to gloss over the longerterm struggles that many face. What can one do to help others really understand what they are going through and to encourage successful reintegration? Methods: This video was designed to help laypersons understand the impairments and changes in abilities that occur following brain injury. Viewers are guided through primary functions of the brain by active professionals in the field, supported by personal testimonials from survivors of brain injury regarding daily challenges and successes they face. Results: Individuals who view this video gain a better understanding and perspective regarding what individuals with brain injury experience by seeing and feeling their brain injuries through their personal experiences. The professional narration assures clear scientific and clinical grounding, something that is often absent from such intimate examinations. The video has also been recognized for its potential to teach a number of professions, such as clinicians, caregivers, attorneys and policymakers. Conclusions: Many survivors of brain injury can appear to be completely uninjured in their day-to-day lives, but the fact remains that altered brains often result in persistent hidden challenges that can have adverse and dramatic daily effects. Just as advances in neurology have improved the survival rate of those who sustain a brain injury, increased awareness and understanding of these injuries by laypersons and professionals will help improved recovery and reintegration of brain injury survivors. By exploring the cases presented in this video and tying them back to today’s understanding of the brain, this silent epidemic is given a new voice that can speak to people unfamiliar to brain injury.

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Racial/ethnic disparities in mental health over the first 2 years after traumatic brain injury: A NIDRR model systems study Paul Perrin1, Denise Krch2, Megan Sutter1, Daniel Snipes1, Juan Carlos Arango-Lasprilla3, Stephanie Kolakowsky-Hayner4, Jerry Wright4, & Anthony Lequerica2 1

Virginia Commonwealth University, Richmond, VA, USA, Kessler Foundation, West Orange, NJ, USA, 3University of Deusto, IKERBASQUE Basque Foundation for Science, Bilbao, Spain, 4 Santa Clara Valley Medical Center, San Jose, CA, USA 2

Objectives: People with traumatic brain injury (TBI) experience high rates of mental health problems, but racial/ethnic differences in depression, anxiety and satisfaction with life (SWL) in this population have not been examined over time. The purpose of this study was to determine whether racial/ethnic disparities in depression, anxiety and SWL occur 1 and 2 years post-discharge. Methods: This study was a prospective, longitudinal, multi-centre study of individuals with TBI participating in the National Institute on Disability and Rehabilitation Research (NIDRR) TBI Model Systems (TBIMS) study. Medical, demographic and outcome data were obtained from the TBIMS database at baseline, as well as 1 and 2 years postdischarge from 16 TBIMS hospitals in the US. Individuals were recruited with moderate or severe TBI (n ¼ 1662) aged 16 or over who had been consecutively discharged between January 2008 and June 2011 from acute care and comprehensive inpatient rehabilitation at a TBIMS hospital. Variables included the Patient Health Questionnaire-9, Generalized Anxiety Disorder-7 and Satisfaction with Life Scale which assessed depression, anxiety and SWL at 1 and 2-year follow-ups. Results: After controlling for all possible covariates, hierarchal linear models found that African Americans had elevated depression across the two time points relative to White Americans (b ¼ 1.24, p ¼ 0.023). Asian Americans’ depression increased over time in comparison to the decreasing depression in Hispanic Americans (b ¼ 3.53, p ¼ 0.023), which was a greater decrease than White Americans (b ¼ 2.07, p ¼ 0.027). African Americans had lower SWL in comparison to White (b ¼ 2.49, p ¼ 0.001) and Hispanic Americans (b ¼ 3.50, p ¼ 0.005), but only marginally greater anxiety over time than White Americans (b ¼ 1.16, p ¼ 0.059_; and similar levels of anxiety to Asian (b ¼ 2.10, p ¼ 0.267) and Hispanic Americans (b ¼ 1.13, p ¼ 0.291). Conclusions: Mental health trajectories of individuals with TBI differed as a function of race/ethnicity across the first 2 years post-discharge, providing the first longitudinal evidence of racial/ethnic disparities in mental health after TBI during this time period. Further research will be required to understand the complex factors underlying these differences.


Case report: Complete functional recovery of severely brain-injured children Li Wang, & Qi Minshuang Enyu Child Brain Development Research Center, Beijing, PR China The prognosis of the newborns suffering from severe brain-injury is grim if left untreated or not treated in a timely fashion. A number


DOI: 10.3109/02699052.2014.892379

of multidisciplinary approaches have been applied for the treatment of brain-injured children, which generally show mixed outcomes. While improvement in physical and mental capacities can be achieved, complete functional recovery is rare. This study shows that three severely brain-injured patients have been fully recovered both physically and mentally, after early and extensive intervention involving individualized design and execution of integrated nutritional, physiological, physical and intellectual programmes. One of the patients suffered from severe cerebral malacia involving approximately one-third of the left cerebrum. Interestingly, the structural changes in her brain remained, despite a full functional recovery that had led to a normal life for the patient in the past 19 years. The patient is currently a second-year college student majoring in accounting. These results suggested that the human brain is a very delicate organ prone to permanent injury and yet highly plastic, which allows functional compensation by the undamaged tissues after proper training and management.

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Statistical models for prediction of outcomes after traumatic brain injury based on patients admission characteristics Vineet Kumar Kamal, Deepak Agrawal, & R. M. Pandey All India Institute of Medical Sciences (AIIMS), New Delhi, India Background: Traumatic brain injury is the leading cause of disability and death all over the Globe. An early estimation of outcome after TBI is of great importance for several reasons. The aim is to develop and validate prognostic models using admission characteristics for mortality at 30 days and unfavourable outcome according to Glasgow Outcome Scale at 6-months post-trauma in patients with moderate and severe head injury. Methods: This study used the Trauma database (n ¼ 1466 patients) for severe and moderate head injury patients from this centre, to develop and validate prognostic models. Seventy per cent data were utilized for models development and the remaining 30% were utilized for validation of the models. For each outcome, three different models were developed based on admission characteristics using logistic regression analysis and on the basis of these models; this study also developed score charts in a user-friendly manner to estimate probability. The performance of the models was assessed in terms of discrimination and calibration. Discriminative and celebrative ability were assessed with the area under the receiver operating characteristic curve (AUC) and Hosmer-Lomeshow test (H-L test), respectively. This study validated these models with split sample method. Results: For mortality, model-1 included age, motor score, papillary reactivity, limb movement as independent predictors for mortality, but for unfavourable outcome, model-1 included age, gender, motor score, papillary reactivity and limb movement as independent predictors. For each outcome, model-2 included CT features (Midline shift, SDH, EDH, Basal cistern effaced, tSAH/IVH) as independent predictors in addition to independent predictors of model-1. Similarly, model-3 included laboratory variables (Levels of haemoglobin, glucose, sodium and creatnine) as independent predictors in addition to independent predictors of model-2 for each outcome. The discriminative ability of the three prognostic models for mortality and unfavourable outcome was excellent in the development data set (AUC ¼ 0.845–0.905). The split sample validation method in the validation data set confirmed the discriminative ability of these three models (AUC ¼ 0.836–0.880) for each outcome. Calibration in validation data set for model-2 was good for both outcomes (H-L test p value40.05) but, for model-1 and model-3 it was poor (H-L test p value50.05). Score chart was used for clinical usefulness.

Conclusion: This study is the first to show limb movement and creatnine level as independent predictors of mortality at 30 days and unfavourable outcome at 6-months post-trauma in TBI patients. This models performance is good and these models are generalizable for predicting outcomes in new patients. It is recommended for the use of these models in predicting outcomes for severe and moderate TBI patients in low- and middle-income countries.


Application of lateral pedicled temporalis fascial-osteoperiosteal flap in reconstruction of anterior skull base Yilu Gao, Jianhong Shen, Yaohua Yan, Liu Yang, Yu Zhang, & Huasong Gao Department of Neurosurgery, Affiliated Hospital of Nantong University, Nantong, PR China Objective: To introduce a novel application of lateral pedicled temporalis fascial-osteoperiosteal flap in repairing anterior skull base defect, which results from traumatic cerebrospinal rhinorrhea or after anterior skull base tumour resection. Methods: A coronal subgaleal incision was made within the frontal hairline and extended to the bilateral superciliary arch. Then, the unaffected side periost was cut 3  5 cm beyond midline while the affected side and temporalis fascia was dissected to form a 10  15 cm  5  6 cm muscle-fascial-osteoperiosteal flap with a stem in temple the lower edge of bone window was taken near the skull base as much as possible and a bone hole, 2.5 cm in diameter, was made behind the sylvian point as a tunnel for the pedicle flap. The dura was separated and the skull base defect and the size of dural leakage were checked epidurally. The defect was repaired as follows: First, pad the bone leak with free temporalis and EC glue. Then, spread the lateral pedicled fascial-osteoperiosteal flap on the anterior skull base through a pre-prepared bone tunnel and suture it to cerebral flax. Lastly, stick the flap to the skull base with EC glue. After operation, the patients should rest in bed for at least 1 week. Twentysix cases were completed with this method. Result: Sixteen cases of fracture of the anterior skull base accompanied by CSF rhinorrhea and 10 cases of anterior skull defect after tumour resection were repaired using a lateral pedicled temporalis fascial-osteoperiosteal flap. There was no recurrence or infection after operation in 5-months to 10-years follow-up. Conclusion: The lateral pedicled temporalis fascial-osteoperiosteal flap is rich in blood supply and owns a high rate of transplant survival. It can be fastened by both sewing and glue, forming a permanent barrier to prevent any relapse of rhinorrhea. Besides, compared with the fronto ascial flap, it is longer in length and width and easier to tile the anterior skull base.


Development of Guillain-Barre´ syndrome in patients receiving ganglioside treatment Xiujuan Wu, Kangding Liu, Jiang Wu, & Hongliang Zhang The First Hospital of Jilin University, Changchun, PR China Cases of Guillain-Barre´ syndrome (GBS) associated with exogenous ganglioside have been scarcely reported in several European countries.


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The exact pathogenesis of GBS after treatment with ganglioside, however, remains unclear. High titres of anti-GM1 antibodies were found in some of the patients who developed GBS after exogenous ganglioside injection. However, many observational studies on the relationship between incidence of GBS and intravenous ganglioside failed to reveal a positive correlation. As a result, the relationship between exogenous ganglioside and GBS remains controversial. The acute motor axonal neuropathy (AMAN) model has been successfully established by sensitizing Japanese white rabbits with a bovine brain ganglioside mixture including GM1. The pathological findings in the peripheral nerves of the immunized rabbits were similar to pathological changes in patients with AMAN. This study presents five patients who developed GBS after reviving ganglioside treatment. All of them presented with acute or progressively flaccid paralysis without antecedent infection or other identified causes. The cervical MRI scan was normal in all five patients, which ruled out acute paralysis of the limbs caused by acute cervical myelopathy. The cerebrospinal fluid examination showed an increase in protein level, with cell count within the normal range. The diagnosis of GBS was further confirmed by electrophysiological examinations.


Sexual changes following traumatic brain injury Jennie Ponsford1, Rene Stolwyk1, & Marina Downing2 1

School of Psychology and Psychiatry, Monash University, Clayton, Victoria, Australia, 2Monash-Epworth Rehabilitation Research Centre, Epworth Hospital, Richmond, Victoria, Australia Objectives: Limited research has focused on sexuality following Traumatic Brain Injury (TBI). This study aimed to examine selfreported changes in sexuality following TBI and explore the factors associated with these changes. Methods: Participants included 865 people with TBI (PTA days M ¼ 27.6, SD ¼ 30.6) and 142 healthy controls. Participants completed the Brain Injury Questionnaire of Sexuality (BIQS), Hospital and Anxiety and Depression Scale and Rosenberg Self-Esteem Scale. Results: Relative to controls, participants with TBI reported significantly more negative changes in Sexual Function, Relationships and Self-Esteem and Mood on the BIQS, with more than half reporting a decline in these aspects of sexuality post-injury. These sexual changes were attributed to various causes, most commonly fatigue, low confidence, pain, decreased mobility and feeling unattractive. Being depressed, older in age, at shorter time post-injury and less independent in ADL significantly predicted poorer overall BIQS Sexuality scores, as well as the Sexual Functioning sub-scale score. Poorer Relationship Quality and Self-Esteem scores on the BIQS were predicted by older age at injury, shorter time post-injury, higher depression and lower self-esteem. Lower Mood was associated with shorter PTA duration, younger age, higher depression, lower self-esteem and being on antidepressants. Conclusions: Therapeutic interventions for sexuality need to focus on depression and self-esteem and address specific barriers to social participation and opportunities for sexual contact in individuals who are less independent in daily activities.


Mortality from head injury in 1974–2012 in Scotland Victoria Hamill, Sarah Barrie, Thomas McMillan, & Graham Teasdale University of Glasgow, Scotland, UK

Brain Inj, 2014; 28(5–6): 517–878

Objectives: There are few reports of how national mortality from head injury has behaved over extended time periods. Information uniquely available in Scotland has been studied to investigate the patterns in annual mortality since 1974. Methods: The General Register Office in Scotland provided populationbased data of all deaths ascribed to a head injury within a year of the event in consecutive years 1974–2012. Information on annual numbers, demographics and causes were analysed. The total numbers of deaths were modelled over time using a regression model and binomial regression models were fitted to assess the impacts of age, gender and causation on head injury death rates, adjusting for population counts. The potential influences of the introduction of specific safety measures were assessed. Odds ratios were calculated for the effect of a 1-year increase in time on the incidence rate of nontransport- and transport-related head injury deaths, separately for males and females and different age groups. Results: There were 15 470 deaths from head injury from 1974–2012. The average annual rate fell from 9.8 per 100 000 in the 1970s to 6.7 in the 1980s and fluctuated thereafter. The total number of young people dying from head injury fell over time (1974–1980: average incidence rates/100 000: 10–19 year old ¼ 75.6; 2011–2012: rate ¼ 13.0) and that of older people rose (1974–1980: 79 year old rate ¼ 28.3; 2011–2012: rate ¼ 96.0). There were consistently more males who died than females, but the number of males dropped more over time, narrowing the gender gap slightly (1974: females ¼ 161, males ¼ 443; 2012: females ¼ 117, males ¼ 226). Deaths related to transport accidents dropped progressively with significant decreases in rates in all males and the majority of age groups in females. Deaths from causes unrelated to transport fell initially but then rose after the mid-1980s. Rates increased significantly for older age groups: males475 years and females 480 years. In contrast, rates decreased significantly in 5–19 year old males. Conclusions: Changes in an overall national pattern of deaths from a head injury reflect complex interactions between the age and sex of victims and the cause of injury. In Scotland death rates fell by a third in the decade and a half after 1974. This resulted from falling numbers of transport-related deaths. These continue to decline but are counter-balanced by a rise in injuries from other causes, especially in older females, and there is need to intensify preventative measures targeted at this group.


Specific acupuncture stroke treatment: Fundamentals about gallbladder points connected with the ‘Sea of Marrows’ Adria´n A´ngel Inchauspe1–7 1

Scientific Department, Argentina Acupuncture Society, Capital Federal, Argentina, 2Argentina Resuscitation Council, Capital Federal, Argentina, 3Investigation Department, HINEA y C. ‘Dr. Alejandro Korn’, La Plata, Argentina, 4Medical Sciences Faculty of La Plata University, La Plata, Argentina, 5World Journal of Critical Care Medicine, Beijing, PR China, 6Frontiers of Clinical Pharmacology Research and Outcomes Journal, Basilea, Switzerland, 7 Investigation Department Chronic and Acute Care Neuropsychiatric Hospital Interzonal ‘Dr. Alejandro Korn’, La Plata, Argentina Being invited to the 9th Brain Injury World Congress in Edinburgh in March 2012, I presented K-1 Yongquan’s effectiveness as a brain protector. Other acupuncturists attending this Congress


DOI: 10.3109/02699052.2014.892379

demonstrated classical treatments as complementary therapy in neurological rehabilitation for these patients. Beyond their valuable contributions towards a multidisciplinary approach in such recoveries, technical presentations only devoted to energy stabilization, promoting in this way a patient’s holistic return to normal status. However, it’s appropriate to insist that Acupuncture’s treatment can also contribute with specific points directly related not only to the Central Nervous System, but based upon the underlying disease that caused these conditions. In Traditional Chinese Medicine, hemiplegia is diagnosed as ‘Overflowing of Liver’s Internal Wind’. For this reason, it is reasonable to include gallbladder points’ detailed analysis in stroke’s treatment and rehabilitation, thus allowing balance of the liver’s plenitude, especially in those conditions that generate the Chinese diagnosis of ‘Wind-Heat’.

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Health-related quality-of-life in children and youth with acquired brain injury: Two years after injury Esther C. Ilmer1, Suzanne A. M. Lambregts2, Monique A. M. Berger3, Arend J. de Kloet3, Sander R. Hilberink4, & Marij E. Roebroeck4 1

Rijndam Rehabilitation Center, Rotterdam, The Netherlands, Revant Rehabilitation Center, Breda, The Netherlands, 3 The Hague University (for applied sciences), The Hague, The Netherlands, 4Erasmus MC University Medical Center, Department of Rehabilitation Medicine and Physical Therapy, Rotterdam, The Netherlands, 5Sophia Rehabilitation, The Hague, The Netherlands 2

Objectives: To determine health-related quality-of-life (HRQoL) of children and youth with acquired brain injury (ABI) 2 years post-injury and to explore associated factors. Methods: Children and youth (n ¼ 72; aged 6–22 years), hospital diagnosed with ABI in 2008 and 2009, were assessed 2-years postinjury in a cross-sectional study. Self-reported and parent-reported HRQoL was assessed with the Paediatric Quality of Life Inventory (PedsQL 4.0) and compared with reference values of Dutch peers of the same age. The PedsQL 4.0 is a recommended outcome measure in long-term follow-up after paediatric ABI. Spearman correlation coefficients (Rs) were used to explore determinants of HRQoL, investigating sociodemographic and ABI characteristics, severity of impairments and developmental problems. Results: Severity of brain injury was mild in 78% (n ¼ 56), moderate in 10% (n ¼ 7) and severe in 13% (n ¼ 9). Children and youth with ABI had similar self-reported HRQoL, compared with the general population. They self-reported very good physical health. However, as reported by their parents, children aged 6–7 years with ABI seemed to have a poorer HRQoL, especially in the sub-domain psychosocial health. Also youth aged 13–18 years had, according to their parents, a poorer HRQoL regarding psychosocial health, specifically emotional functioning. In this cohort, post-injury developmental problems of the child, addressing cognitive or learning problems, behavioural problems and social problems, were moderately associated with poorer HRQoL, especially in psychosocial health (Rs  0.40). Conclusion: Two years post-injury, children and youth with ABI report similar HRQoL compared to the general population, except for children younger than 8 years. Post-injury cognitive or learning problems, behavioural problems and social problems require specific attention during long-term follow-up. The present results support the relevance of the PedsQL 4.0 as an outcome measure in long-term follow-up of children and youth with ABI.


Traumatic brain injury and women: A review of the literature on depression and hope Tolu Oyesanya, Eileen Porter, & Earlise Ward University of Wisconsin-Madison, Madison, WI, USA Purpose: The purpose of this review is to examine the current literature focusing on women who have had a traumatic brain injury (TBI), co-morbid with depression and hope. Research implications are presented. Background/significance: Traumatic brain injury (TBI) is a significant injury that affects more than 333 000 women in the US each year. Yet, there is insufficient literature on women who have had a TBI, including literature on female veterans who have had a TBI. In particular, current literature does not adequately capture the issues this population faces during rehabilitation. Methods: A literature review on women who have had a TBI, depression and hope was conducted. The literature search was carried out using PubMed, CINAHL Plus and Google Scholar. Peerreviewed studies published between 1992–2012 were included. The chosen studies varied by design, population, aims and findings. Results: Ten studies fulfilled the inclusion criteria. The literature review suggests that men and women affected by TBI have a different experience after injury. Many women who have had a TBI face issues with adaptation, emotional functioning and depression, while men often face issues with controlling their anger. Depression among women with TBI is of particular concern as it influences the rehabilitation process, treatment adherence and outcomes. Based on studies of persons who did not have a TBI, the degree of hope is also a concern as it affects process, treatment adherence and outcomes. Yet, no research could be located that has explored the impact of hope and depression on the rehabilitation process for women who have had a TBI or on female veterans who have had a TBI. Conclusions and implications for practice: More research needs to be conducted on women who have had a TBI and female veterans who have had a TBI, as current literature does not sufficiently describe issues that they face, particularly during the rehabilitation process. New knowledge is needed to determine the healthcare needs of this population during the rehabilitation process, including the adequacy of current interventions, treatments and resources.


Exendin-4, a candidate treatment for the clinical management of traumatic brain injury David Tweedie1, Lital Rachmany2, Vardit Rubovitch2, Barry Hoffer3, Chaim Pick2, & Nigel Greig1 1

National Institute on Aging, National Institutes of Health, Baltimore, MD, USA, 2Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel, 3Case Western Reserve University School of Medicine, Cleveland, OH, USA Objectives: Traumatic brain injury (TBI) is a widespread health concern that afflicts individuals of all age groups and genders. Typical causes are motorcar accidents, falls, sports injuries and acts of violence. In civilians, TBI events are typically concussive in nature, as exemplified by motorcar accidents and full contact sport injuries (i.e. boxing

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Brain Inj, 2014; 28(5–6): 517–878

and football). TBI is associated with secondary neuronal changes that induce cognitive deficits that develop over time and may associate with dementia. Presently there are no outstanding medicines of choice for the management of secondary pathological changes in victims of TBI, thus the ensuing cognitive deficits impose huge burdens on family members and healthcare providers alike. The objective was to evaluate a defined neuroprotective agent for use in mild TBI. Methods: This study utilized a mouse model that represents the more common form of concussive TBI: a closed head weight drop model. Subsequent to TBI (a 30 g weight dropped from 80 cm above the head impacting between the eye and ear), this study examined the following behaviours: novel object recognition and Y-maze. An agent currently used clinically for the management of type 2 diabetes mellitus (T2DM) was assessed; the glucagon-like peptide-1 analogue exendin-4 (Ex-4). In prior studies involving a series of neurodegenerative disorders Ex-4 was found to possess neuroprotective and antiapoptotic properties. As apoptosis is a pathological process known to be relevant to human TBI, it was hypothesized that this agent may translate favourably to rodent models of TBI and hopefully to clinical TBI. Ex-4 was administered as a clinically relevant dose via ALZET mini pumps implanted subcutaneously either prior to (48 hours) or immediately after the induction of TBI. Results: Significant, long-lasting TBI-induced behavioural deficits were observed from 7 days post-injury. Ex-4 treatment induced marked benefits in animal behaviours when administered prior to and after the induction of TBI. In a cohort of Ex-4 pre-treated TBI animals, hippocampal gene expression profiles were examined at 14 days post-injury, a time point after the development of behavioural deficits. Marked changes in gene expressions were observed as a result of TBI; pre-treatment with Ex-4 effectively reversed the traumainduced changes in many molecular pathways, several of which were related to Alzheimer’s disease. Conclusions: These studies provide insight into molecular changes associated with TBI-induced cognitive impairments that may relate to the development of neurodegenerative disorders or dementia later in life. Additionally they support the rapid implementation of Ex-4, an agent in safe and effective clinical use for the management of T2DM for investigation in the clinical setting of human, concussive TBI. Ongoing studies are investigating possible benefits of Ex-4 treatment in a blast shockwave model of TBI-induced changes in behaviour and hippocampal gene expressions; a model with relevance to the battlefield.


TBI in infancy and early childhood—Findings from the ICTBI research project Jonas Halldorsson1, Gudmundur Arnkelsson2, Kristinn Tomasson3, Kjell Flekkoy4, Hulda Magnadottir5, & Eirikur Arnarson1 1


Landspitali University Hospital, Reykjavik, Iceland, University of Iceland, Reykjavik, Iceland, 3Administration of Occupational Safety and Health, Reykjavik, Iceland, 4University of Oslo, Oslo, Norway, 5 Upper Valley Neurology and Neurosurgery, Lebanon, NH, USA Objectives: The main objectives of the Icelandic research project on early traumatic brain injury (TBI), the ICTBI research project, were (1) to estimate the nationwide incidence and prevalence of early TBI and TBI-related long-term consequences; (2) to assess the prognostic value of injury-related and non-injury-related factors for late outcome; and (3) to serve as a foundation for the development of goal-oriented prevention and intervention in Iceland. Methods: Participants were all children and adolescents 0–19 years old diagnosed with TBI (ICD-9 850–854) in Iceland from 15 April 1992 to

14 April 1993 (the ICTBI study group (SG)) (n ¼ 550) and a control group (CG) (n ¼ 1232) selected from the Icelandic National Registry in 2008, using a stratified random sampling method. Demographic and injury data were collected in 1992–1993. Follow-up of the SG took place 4 years and 16 years post-injury. Participants responded to questionnaires and clinical outcome scales. In the present context the emphasis is on findings on TBI in the youngest age group, 0–4 years old. Results: The youngest age group was at greatest risk of sustaining mild TBI treated at emergency departments. The youngest children seemed to be at greatest risk of not being brought to medical attention or included in medical records in rural areas. The incidence rates of hospitalized mild, moderate and severe TBI in the youngest age group was comparable to the corresponding incidence rates in the older age groups. Parents of children in the youngest age group were least likely to report symptoms attributed to TBI 4 years post-injury. Four years post-injury six young children in the SG had been diagnosed with developmental disabilities, without reference to the early TBI. In the study group, the youngest participants were most likely not to report to have sustained TBI. Not reporting the medically confirmed TBI was not related to better cognitive outcome on clinical scales 16 years post-injury. Only 1% of participants reporting TBI-related disability in the youngest age group had been evaluated for or awarded compensation. Absence of evaluation was not associated with better outcome on clinical scales. Age at injury did not predict late outcome. Conclusions: The findings of the ICTBI research project suggest that there is still a tendency to minimize early TBI. TBI appears under-reported, under-diagnosed or under-recorded, under-treated and its consequences under-estimated. This may be especially so in the youngest age group. Challenges as regards accurate estimates of TBI severity in infancy and early childhood are acknowledged. However, alertness to possible long-term consequences, continued follow-up and appropriate intervention in the case of emerging developmental problems with age may help reach optimal outcome.


Incidence, prevalence and prognostic factors—Findings from the ICTBI research project Jonas Halldorsson1, Gudmundur Arnkelsson2, Kristinn Tomasson3, Kjell Flekkoy4, Hulda Magnadottir5, & Eirikur Arnarson1 1

Landspitali University Hospital, Reykjavik, Iceland, 2University of Iceland, Reykjavik, Iceland, 3Administration of Occupational Safety and Health, Reykjavik, Iceland, 4University of Oslo, Oslo, Norway, 5 Upper Valley Neurology and Neurosurgery, Lebanon, NH, USA Aims: The main objectives of the Icelandic research project on early traumatic brain injury (TBI), the ICTBI research project, were (1) to estimate the nationwide incidence and prevalence of early TBI and TBI-related long-term consequences; (2) to assess the prognostic value of injury-related and non-injury-related factors for late outcome; and (3) to serve as a foundation for the development of goal-oriented prevention and intervention in Iceland. Methods: Participants were all children and adolescents 0–19 years old diagnosed with TBI (ICD-9 850–854) in Iceland from 15 April 1992 to 14 April 1993 (the ICTBI study group (SG)) (n ¼ 550) and a control group (CG) (n ¼ 1232) selected from the Icelandic National Registry in 2008, using a stratified random sampling method. The CG was in the same age range as the SG in 2008, 15–35 years old. Demographic and injury data were collected in 1992–1993. Follow-up of the SG took place 4 years and 16 years post-injury. Participants responded to questionnaires and clinical outcome scales.


DOI: 10.3109/02699052.2014.892379

Results: The incidence rates of paediatric TBI in Iceland was comparable to corresponding incidence rates in the neighbouring countries. The incidence of mild TBI treated at emergency departments was higher in the Reykjavik area than in rural areas. The prevalence of TBI in the 15–35 year old CG (49.5%) was higher than previously reported in general population samples and so was the prevalence of TBI-related moderate disability (7.0%). Force of impact to the head and more than one TBI sustained had greatest prognostic value as regards reports of late symptoms. Reports of late symptoms were reflected in worse outcome on clinical outcome scales assessing cognition, mental health, adjustment and behaviour. Conclusions: The ICTBI research project highlights the benefits of long-term follow-up studies and nationwide samples.

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Using person-oriented methods for investigating the individual context within large groups with paediatric TBI Catherine Aaro Jonsson1, Vicki Anderson2, Cathy Catroppa2, Celia Godfrey2, & Ann Charlotte Smedler3 1

¨ stersunds Hospital, O ¨ stersund, Child and Youth Rehabilitation, O 2 Sweden, Murdoch Childrens Research Institute, Melbourne, Australia, 3 Department of Psychology, Stockholm University, Stockholm, Sweden Most research on cognitive outcome after paediatric TBI describe outcome of groups, providing an important overview of the field. However, individual variation of outcome is large, even within groups based on severity, and several variables are found to influence outcome. Individual patterns of co-working variables can instead be studied with person-oriented methods. One of those is Cluster analysis, linking similar individual profiles of chosen variables into clusters, studying the individual context, still in large groups. Two longitudinal studies using Cluster-analysis rendered both new and similar results as research on groups with TBI. One interesting result suggests that long-term developmental change takes place on a continuum, where plasticity of the young brain at one end of the continuum is connected to good recovery after TBI, whereas vulnerability at the other extreme is associated with elevated risk of poor recovery. The usefulness of Cluster analysis as a method in those studies will be discussed.


The effect of attrition on postconcussion syndrome incidence: Initial findings from a metaregression of mild traumatic brain injury cohort studies

Objectives: How frequently post-concussion syndrome (PCS) follows mild traumatic brain injury (MTBI) is controversial and the factors that account for wide discrepancies in incidence rates are unclear. Follow-up data points that are Missing Not At Random (MNAR) may be one important source of bias. That is, if participants who drop out of prospective longitudinal MTBI studies systematically have better or worse outcomes than participants who complete a study, PCS incidence rates may be inaccurately high or low, respectively. Methods: An electronic literature search with data extraction and meta-regression was conducted. Cohort studies and randomized controlled trials recruiting participants consecutively from an Emergency Department and following them prospectively for at least 1 month were included. For studies with multiple follow-up assessments, only the last one was included. For randomized controlled trials, intervention and control arms were collapsed. The primary outcome was the PCS event rate, using study-specific operational definitions of PCS; these were coded on a 3-point ordinal scale for stringency, where the mid-point was 3+ post-concussion symptoms of any severity. Studies defining PCS more laxly (one or two symptoms endorsed) were dummy coded as 1 and those with a higher threshold for PCS diagnosis (e.g. 4+ symptoms or 3+ symptoms with functional impairment) were dummy coded as +1. Results: Thirty-six studies involving 8922 participants with MTBIs met eligibility criteria. Attrition rates ranged from 0–68% (M ¼ 23.9, SD ¼ 16.8). Estimates of the incidence of PCS varied from 5–82% (M ¼ 37.0, SD ¼ 17.7) at a median of 6 months post-injury. The Pearson correlation between attrition and PCS was 0.46 (p ¼ 0.005). Controlling for PCS case definition stringency and time post-injury in a weighted least squares regression model, higher attrition rate was related to higher PCS incidence rates (B ¼ 0.437, t ¼ 3.01, p ¼ 0.005). For every 10% of cases lost to follow-up, the PCS incidence rate rose by 4.4%. Restricting the definition of PCS to a constellation of symptoms (i.e. dummy codes of 0 or +1) and setting attrition to 0 gave a hypothetical PCS incidence rate of 17–28% across 3–12 months post-injury in this aggregated ED cohort. Conclusion: Attrition in MTBI inception cohort studies appears to contribute to an over-estimation of PCS, suggesting that asymptomatic participants are more likely to drop out. Ignoring the bias introduced by attrition will contribute to a more negative view of prognosis following this injury. A systematic review (PROSPERO registration #CRD42013003623) is now underway to obtain a more comprehensive set of cohort studies and refine the effect of attrition and other methodological factors on PCS incidence.


Sexual quality-of-life, sexual satisfaction and relationship satisfaction in partnered individuals with traumatic brain injury Jhon Alexander Moreno1, Silvia Leonor Olivera2, Edgar Ricardo Valdivia2, Nataly Gonza´lez2, Lilian Stevens3, Paul B. Perrin4, & Juan Carlos Arango-Lasprilla5 1

Noah Silverberg1, Andrew Gardner2, Scott Millis3, & Grant Iverson4 1

University of British Columbia, Vancouver, BC, Canada, 2University of Newcastle, NSW Australia, Australia, 3Wayne State University School of Medicine, Detroit, MI, USA, 4Harvard Medical School, Boston, MA, USA

Center for Interdisciplinary Research in Rehabilitation-Centre de Re´adaptation Lucie-Bruneau, Montreal, Quebec, Canada, 2 Universidad Surcolombiana, Grupo de Investigacio´n Carlos Finlay, Neiva, Huila, Colombia, 3Hunter Holmes McGuire Department of Veterans Affairs Medical Center, Richmond, VA, USA, 4Virginia Commonwealth University, Richmond, VA, USA, 5Ikerbasque, Basque Foundation for Science, Bilbao, Basque Country, Spain

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552 Objective: The physical, emotional, social, personality and neuropsychological changes after traumatic brain injury (TBI) have a negative impact on survivors and family members. Following TBI, couples can experience relationship strain, communication difficulties, role changes, loss of intimacy and sexual problems. Consequently, all these changes can lead to marital breakdown, separation and divorce. The objective of this study was to compare sexual qualityof-life, as well as sexual and relationship satisfaction in individuals with TBI to healthy controls. Methods: A total of 28 individuals with mild-to-severe TBI and 27 healthy controls were recruited from one city in Colombia, South America. Individuals with TBI were recruited at a University Hospital and healthy controls were recruited from the general community. Healthy controls had no prior history of depression, anxiety, psychiatric disorders or sexual difficulties. The TBI sample consisted of 19 men (67.9%) and nine women (32.1%), with an average age of 38.43 years (SD ¼ 11.07) and 8.9 years of education (SD ¼ 3.4). Participants had been in a heterosexual relationship for an average of 11 years (SD ¼ 7), had a Glasgow Coma Scale (GCS) at admission of 8.18 (SD ¼ 3.7) and were 21.3 months post-injury (SD ¼ 12.5). The healthy controls consisted of 19 men (70.4%) and eight women (29.6%), with an average age of 39.7 years (SD ¼ 11.46) and 8.93 years of education (SD ¼ 3.1). Controls had been in a heterosexual relationship for an average of 11.48 years (SD ¼ 10.7). Groups were comparable in terms of gender, age, education and time in a relationship (all p’s40.05). Sexual quality-of-life was assessed with the 18-item self-report Sexual Quality of Life Questionnaire (SQoL), sexual dissatisfaction with the 25-item Index of Sexual Satisfaction (ISS) and global relationship satisfaction with the 7-item Relationship Assessment Scale (RAS). Results: A MANOVA comparing individuals with TBI and healthy controls on the SQoL, ISS and RAS was significant (p50.0001). Individuals with TBI scored significantly lower than healthy controls on the SQoL (p50.0001) and RAS (p50.0001) and had higher scores in the ISS (p50.0001). In addition, Pearson correlations showed that, in individuals with TBI, SQoL, ISS and RAS scores did not significantly correlate with GCS scores, months after the injury or duration of the relationship (all p’s40.05). Conclusions: Compared to healthy controls, individuals with TBI showed diminished sexual quality-of-life, greater sexual dissatisfaction and lower relationship satisfaction. These difficulties were not related to injury severity, time since injury or the duration of the relationship. Sexual and relationship changes after TBI need to be addressed using a biopsychosocial perspective including medical and physical issues, neuropsychological and psychological difficulties and relationship factors. TBI rehabilitation should include sexual rehabilitation and couples therapy as part of the strategies to treat these problems that have been usually overlooked or underestimated.

Brain Inj, 2014; 28(5–6): 517–878

explore the widely proclaimed therapeutic effect of employment on psychological wellbeing (PWB) and quality-of-life (QoL) relative to perceived sense of purpose in life (PIL). An additional aim was to examine the influence of factors involving cognitive function, injury severity, age at time of injury, gender and pre-injury education on survivors’ work ability and return-to-work (RTW). A mixed methods design was used for an in-depth and comprehensive understanding about adjustment in life post-TBI. Method: Participants (n ¼ 40; 10–18 months post-TBI) were grouped according to age: 18–39 years (younger group), 40–55 years (older group) and injury severity (Glasgow Coma Scale scores): mild TBI (n ¼ 25), moderate–severe TBI (n ¼ 15). Quantitative component: Neuropsychological testing and questionnaire surveys were performed to evaluate participants’ cognitive function, levels of perceived work gainfulness, PIL, PWB and QoL. Data was analysed using bivariate and multivariate analyses of variance, aided by SPSS computer software. Qualitative component: Twelve participants (six from each severity group) were randomly selected for digitally recorded semi-structured interviews, predominantly concerning the impact of work and life meaningfulness on adjustment process. Interviews were analysed using grounded theory methodology, aided by the NVivo 10 computer package. Results and discussion: PIL, in comparison to employment, cognitive function and injury severity, made the strongest unique contribution in explaining PWB and QoL (p50.001). Employment potential was largely affected by memory and injury severity, with increased memory deficits (p50.01) and injury severity (p50.05), respectively, associated with deteriorated employment potential. Main conclusion: Having a strong sense of life as purposeful, notwithstanding employment, cognitive function and injury severity, encourages survivors to focus on their lives and important life goals and to ultimately achieve a promising life with healthy wellbeing.


Department of Veterans Affairs smart home 2: Extending smart home technology for cognitivelyimpaired veterans to delay institutionalization Christina Dillahunt-Aspillaga1, Deborah Rugs1, & Kristina Martinez2 1


Adjustment in life after traumatic brain injury: The impact of cognition, employment and perceived sense of purpose in life Phoebe Kho1, Vicki Anderson1, Cathy Catroppa1, Gavin Davis2, & Wendy Castle3 1

Child Neuropsychology, Murdoch Childrens Research Institute, Royal Children’s Hospital, Melbourne, Victoria, Australia, 2Neurosurgery, Cabrini Hospital, Melbourne, Victoria, Australia, 3Royal Talbot Rehabilitation Centre, Austin Health, Melbourne, Victoria, Australia Background: Traumatic brain injury (TBI) affects the most wideranging domains of survivors’ lives, markedly reducing emotional health and quality-of-life. The primary objective of this study was to

Center of Innovation on Disability & Rehabilitation Research (CIDRR8), James A. Haley Veterans Hospital, Tampa, FL, USA, 2 Defense and Veterans Brain Injury Center, Tampa, FL, Defense and Veterans Brain Injury Center (DVBIC) through the US Army Medical Research and Materiel Command under Contract No. W81XWH-09-C-0026, Tampa, FL, USA Objectives: The Smart Home (SH) technology developed at the Tampa James A. Haley Veteran’s Hospital’s Polytrauma Transitional Rehabilitation Programme (PTRP) uses a precise indoor tracking technology to monitor Veterans’ activities. SH technology provides time- and location-dependent Activities of Daily Living (ADL) prompting [1]. The use of SH technology has been expanded to individual Veterans’ homes in the Tampa Bay area to support ADL’s, maintain independence and reduce caregiver burden and the likelihood of institutionalization. Methods: Veteran participants with mild-to-moderate cognitive impairments were selected based upon eligibility criteria. Systematic home and Veteran assessments were conducted to determine technology needs of Veterans and their caregivers. Based on the assessments, in-home technologies were installed to maximize


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DOI: 10.3109/02699052.2014.892379

freedom, promote independence and increase safety for Veterans. The Ultra Wide Band (UWB) Real-time Location System (RTLS) assigned a unique identifier to each Veteran and caregiver. The technology continuously and objectively monitored and documented Veterans’ behaviours in their environments. Results: Outcome measures collected by the in-home SH technology include: (a) frequency and context of memory cuing, navigational assistance and environmental safety cues, (b) frequency, location and duration of caregiver and therapeutic interactions, (c) frequency of safety risk encounters and (d) progress in achieving individual rehabilitation goals. Data reports were generated for Veterans and caregivers to assist them in recognizing achievements and identifying goals for further improvement. Clinician reports provided documentation for assessing and charting progress of the Veteran. Changes in caregiver burden were measured using the Perceived Change Index tool. Caregiver and Veteran satisfaction with Technology was measured through a modified Technology Acceptance Model (TAMs) instrument. Conclusions: Smart Home technology is an integral tool for supporting the transition of Veterans with cognitive impairments to their homes and into the community. Extending the successful PTRP SH to a home-based population, where a current gap in services exists, aligns with the goals of (Patient Aligned Care Teams) PACT model of team-based, patient-centred care for enhanced access to care, through cutting-edge technology. Immediate integration of SH technology will reinforce the use of compensatory strategies early in recovery, aiding in the success of the rehabilitation process. The material presented herein is based upon work supported by the Department of Veterans Affairs, Veterans Health Administration, Office of Patient Centred Care and Cultural Transformation T-21 Innovation grant awarded to Steven Scott and Jan Jasiewicz in 2010 and the Office of Geriatric and Extended Care Non-Institutional Long Term Care (NILTC) T-21 grant awarded to Jan M. Jasiewicz in 2011–2013.


Evaluating the use of a computerized writing log for assessing the writing process in individuals with acquired brain injury Alexander Ledbetter, McKay Moore Sohlberg, & Stephen Fickas University of Oregon, Eugene, OR, USA Virtually nothing is known about the writing profiles of individuals with acquired brain injury. A limitation to this research is the lack of validated measurements. This study reports the results of an investigation evaluating the use of a computerized writing log (CWL) for assessing the writing process of 20 individuals aged 16–25 with acquired brain injury. Data is gathered on participants’ essay writing through analysis of permanent written product and composing process during an initial baseline session plus three sessions and a post-test session using CWL. This study obtained time-stamped responses to a directed retrospection task (DRT) using CWL presented at 90-second intervals (±15 seconds) during the composing process, while writers compose expository essays using the word processing function. For the DRT, participants were trained to respond each time the log presents on the computer screen by selecting responses from 15 items across four categories representing cognitive processes involved in writing (planning, translating, reviewing) and another category intended to sample unrelated activity (stretching, daydreaming). Process data obtained includes time-stamped responses to each

log presentation, time delay in response to log presentation and keystroke playback. Product data obtained includes number of main ideas, number of supporting sentences, number of transition words and total words. Trained raters score quality using the Oregon Department of Education Writing Scoring Guide. Analyses describe allocation of time to each writing process and the amount of time spent on unrelated activities, time delay in response to log presentation, as well as quantitative and qualitative characteristics of essays.


Predictors of behavioural health service use and associated costs: Individuals with TBI in Florida Christina Dillahunt-Aspillaga, & Marion Becker University of South Florida, Tampa, FL, USA Objectives: Traumatic brain injury (TBI) is a major public health concern. Such injuries often results in a dramatic change in the individual’s life-course due to the complex myriad of complex co-morbidities that follow TBI. Limited research exists on the costs and frequency of use of behavioural healthcare services by individuals with TBI post-injury. This study examined the predictors of behavioural service use, incarceration and associated costs of individuals with traumatic brain injury (TBI) in Pinellas County Florida in fiscal year (FY) 2005. Methods: Emergency Medical Services and AHCA Medicaid Claims data were used to identify all individuals diagnosed with a TBI (ICD-9 diagnosis codes) in Pinellas County Florida in FY 2005. Medicaid and service use data from 2005–2008 were used to determine the number of individuals with TBI who used behavioural health services including mental health and substance abuse services. A total of 10 Florida statewide and local Pinellas County Administrative data sets from 2005–2008 were used. Data were extracted on demographic characteristics, mental health and substance abuse service use and criminal justice encounters of individuals with TBI in Pinellas County. Average annual costs and penetration rates of mental health, substance abuse and criminal justice services over a 3-year period were determined. Results: In FY 2005, a total of 1005 individuals diagnosed with TBI were identified in Pinellas County Florida through ICD9 codes (800.00–854.10 & 959.01) in EMS and Medicaid claims files. Of these, 910 individuals met inclusion criteria and were included in this retrospective data analysis. Data on use of community services were used to identify treatment episodes in behavioural healthcare settings (inpatient and outpatient mental health and substance abuse) and encounters with the criminal justice system. Individuals diagnosed with a TBI were grouped into high and low behavioural health costs groups over a period of 3 years. Of these, those in the high cost group were more likely to be male, white and were likely to have received mental health services. Approximately 23% of individuals had an encounter with the criminal justice system. Inpatient and outpatient behavioural health and criminal justice expenditures over a 3-year period of time ranged from $47 041–$4 428 823 per person, with total costs estimates of $23 934 845 over 3 years. Conclusions: This study contributes to knowledge of predictors of and associated costs of co-occurring mental health substance abuse patterns of individuals with TBI within Medicaid users. Additionally, it provides new information about service use costs and expenditures for this unique population.



The Sport Concussion Assessment Tool 3 (SCAT3)—Baseline values for professional ice hockey players Timo Ha¨nninen1, Markku Tuominen2, Matti Vartiainen3, Jari Parkkari1, Juha O¨hman4, Grant L. Iverson5,6, & Teemu M. Luoto4

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Tampere Research Centre of Sports Medicine, UKK Institute for Health Promotion Research, Tampere, Finland, 2Medisport Inc., Tampere, Finland, 3Institute of Behavioural Sciences, University of Helsinki, Helsinki, Finland, 4Department of Neurosciences and Rehabilitation, Tampere University Hospital, Tampere, Finland, 5 Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, USA, 6Red Sox Foundation and Massachusetts General Hospital Home Base Program, Boston, MA, USA Objectives: To determine baseline scores for the scoreable components [Symptom Score and Severity, Standardized Assessment of Concussion (SAC), Co-ordination Score, Modified Balance Error Scoring System (M-BESS) and Tandem gait] of the Sport Concussion Assessment Tool–3rd Edition (SCAT3) using a large sample of professional male ice hockey players. Methods: The SCAT3 was administered as a pre-season baseline test to 206 professional male ice hockey players from 10 teams in Finland. Background health history was obtained at the time of testing. The SCAT3 was administered individually to every player before or after team practice (at least 10 minutes after physical exertion). The testing was conducted by the team physiotherapist and/or physician. Results: The mean age of the players was 25.6 years (SD ¼ 5.2). Most of the players (88.8%) were Finnish, all players were Caucasian. Their mean education was 12.4 (SD ¼ 1.9) years. The average number of concussions sustained prior to testing was 1.2 [SD ¼ 1.5, interquartile range (IQR) ¼ 0-2.0, range ¼ 0–12] and the mean time of recovery after the last concussion was 16.7 days (SD ¼ 31.3, IQR ¼ 7.0–14.0, range ¼ 0–308). A minority of players (12.6%) had been hospitalized or medically imaged following head trauma. A small percentage reported a history of learning disability (2.4%) or psychiatric problems (1.5%). The means, SDs, medians (md), IQRs and ranges of the SCAT3 components were distributed as follows: (i) Symptom Score (n ¼ 205), mean ¼ 1.52, SD ¼ 2.5, md ¼ 1.0, IQR ¼ 0–2.0, range ¼ 0–21; (ii) Symptom Severity (n ¼ 205), mean ¼ 2.2, SD ¼ 3.8, md ¼ 1.0, IQR ¼ 0–3.0, range ¼ 0–27; (iii) SAC (n ¼ 204), mean ¼ 26.8, SD ¼ 1.7, md ¼ 27.0, IQR ¼ 26.0–28.0, range ¼ 19–30; (iv) Co-ordination Score (n ¼ 194), mean ¼ 1.0, SD ¼ 0.1, md ¼ 1.0, IQR ¼ 1.0–1.0, range ¼ 0– 1.0; (v) M-BESS (n ¼ 197), mean ¼ 1.9, SD ¼ 2.4, md ¼ 1.0, IQR ¼ 0–3.0, range ¼ 0–20.0; (vi) Tandem gait (n ¼ 75), mean ¼ 10.9, SD ¼ 1.8, md ¼ 11.0, IQR ¼ 9.6–12.3, range ¼ 6.7–14.3. The sub-scores of the four SAC components were distributed as follows: (i) Orientation (n ¼ 205), mean ¼ 4.9, SD ¼ 0.4, md ¼ 5.0, IQR ¼ 5.0-5.0, range ¼ 3.0– 5.0; (ii) Immediate memory (n ¼ 206), mean ¼ 14.5, SD ¼ 1.0, md ¼ 15.0, IQR ¼ 14.0–15.0, range ¼ 5.0–15.0; (iii) Concentration (n ¼ 206), mean ¼ 3.8, SD ¼ 0.8, md ¼ 4.0, IQR ¼ 3.0–4.0, range ¼ 2.0– 5.0; and (iv) Delayed recall (n ¼ 206), mean ¼ 3.7, SD ¼ 1.1, md ¼ 4.0, IQR ¼ 3.0–4.0, range ¼ 0–5.0. The most commonly endorsed symptoms on the Symptom Scale were (i) neck pain (n ¼ 52, 25.4%), (ii) fatigue (n ¼ 48, 23.4%), (iii) trouble falling asleep (n ¼ 35, 17.1%) and (iv) drowsiness (n ¼ 32, 15.1%). On the SAC, the most difficult components were concentration and delayed recall. Only 43 (20.9%) and 50 (24.3%) performed flawlessly on these components, respectively. Spearman’s correlation between the M-BESS and Tandem gait was non-significant (r ¼ 0.015, p ¼ 0.9).

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Conclusion: This large-scale study of the SCAT3 provides important information regarding the clinical application and interpretation of the test.


Microembolic signals detected with transcranial Doppler sonography differ between symptomatic and asymptomatic middle cerebral artery stenoses in northeast China Xiujuan Wu, Hongliang Zhang, Yingqi Xing, & Kangding Liu The First Hospital of Jilin University, Changchun, PR China Objectives: Although microembolus monitoring has been widely used for ischaemic cerebrovascular disease, especially in the patients with cerebral artery stenosis, the clinical significance of microembolic signals (MES) in asymptomatic middle cerebral artery (MCA) stenosis, which is more common in China, remains unclear. This study aimed to investigate the frequency of MES and the value of MES in predicting ischaemic stroke secondary to asymptomatic MCA stenosis. Methods: From June 2011 to December 2012, subjects who visited the Ultrasound Laboratory of the First Hospital of Jilin University with a diagnosis of asymptomatic or symptomatic MCA stenosis were enrolled in the study. All the recruited subjects received paired examination with transcranial Doppler sonography (TCD) and carotid duplex. All of them had a sufficient transtemporal bone window and consented to participate. The subjects who had ipsilateral carotid stenosis, potential cardiogenic emboli, bloodborne emboli as well as other artery-borne emboli were excluded from the study. Results: A total of 15 019 out of 49 109 subjects received paired TCD and carotid duplex examination, among whom MCA stenosis with or without other cerebral artery stenosis was identified in 2399 subjects. Finally, 209 subjects who met the inclusion criteria were enrolled and performed microembolus monitoring, including 83 asymptomatic subjects with 108 stenosed MCA and 126 symptomatic subjects with the same number of stenosed MCA. By comparing the demographics and risk factors between the symptomatic and asymptomatic subjects, it was found that the ratio of male sexuality and smoking history differed (101/126 vs 43/83 and 88/126 vs 38/83, respectively, p50.01). The frequency of MES was significantly higher in the symptomatic group than in the asymptomatic group (49/126 vs 2/108, p50.01). Specifically, the frequency of MES in the symptomatic and asymptomatic groups with mild stenosis, moderate stenosis, severe stenosis and occlusion groups were 4/18 (22.22%) vs 0/30 (0), 13/31 (41.94%) vs 1/28 (3.57%), 30/62 (48.39%) vs 1/39 (2.65) and 2/15 (13.33%) vs 0/11 (0), respectively. Except for the occlusive group, the frequency of MES is correlated with stenosis degree and symptom. Two patients in the asymptomatic group were found positive for MES and the MES number was 1 for both. During the 1-year follow-up, neither of them developed ischaemic stroke. Conclusions: MES detected with TCD differ between symptomatic and asymptomatic MCA stenoses. Due to the low frequency, the value of MES as a predictor of subsequent ischaemic stroke in patients with asymptomatic MCA stenosis might be limited.


DOI: 10.3109/02699052.2014.892379


Feasibility and satisfaction with the VETeranS Compensate, Adapt, REintegrate (VETS-CARE) intervention

treatment effects, small effect sizes were found for the PHQ-9 (d ¼ 0.004), CIQ (d ¼ 0.008) and SSQ (d ¼ 0.027). Conclusions: Mobile applications may be a practical modality to deliver novel interventions specific to Veterans who have sustained a mTBI and experience challenges across multiple domains as they reintegrate. Mobile apps can be tailored and accessible to Veterans in diverse settings.

0114 Virginia Daggett1, Tamilyn Bakas2, Laura Murray3, Heather Woodward-Hagg1, Jennifer Gleason Williams4, Kyle Maddox1, Andrew Allen5, Scott Russell5, & Richard Darin Ellis6

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Department of Veterans Affairs, VISN 11VA-Center for Applied Systems Engineering (VA-CASE), Indianapolis, IN, USA, 2Indiana University School of Nursing, Indianpolis, IN, USA, 3Indiana University, Department of Speech and Hearing Sciences, Bloomington, IN, USA, 4Department of Veterans Affairs, Richard L. Roudebush VAMC, HSR&D Center Of Excellence, Indianapolis, IN, USA, 5 Department of Veterans Affairs, Richard L. Roudebush VAMC, HSR&D Center of Excellence Human Computer Interaction Simulation Lab, Indianapolis, IN, USA, 6Wayne State University, Department of Industrial & Systems Engineering, Detroit, MI, USA Objectives: This study was conducted to determine the feasibility and satisfaction of the theoretically-based VETS-CARE intervention with Veterans who sustained a mild traumatic brain injury (mTBI). The VETS-CARE intervention was designed to assist Veterans in selfmanagement skills across six domains: cognitive impairments, physical symptoms, emotions and behaviours, instrumental activities of daily living, interpersonal interactions, community reintegration. Effect sizes for the Patient Health Questionnaire-9 (PHQ-9), Community Integration Questionnaire (CIQ) and Social Support Questionnaire (SSQ) were also estimated. Methods: The VETS-CARE intervention was implemented as an Apple (iOS) mobile application (app). Co-investigators, who were experts in usability testing and human computer interaction, applied iOSoriented usability heuristics and guided the app development. Veterans were recruited from the Polytrauma Unit at one Midwest VA Medical Centre and block-randomized to either the VETS-CARE intervention group or to an attention control (education) group. In Phase I, six Veterans with mTBI were randomized. Veteran feedback was utilized to revise the app. In Phase II, 42 additional Veterans with mTBI were recruited and randomized. Each participant had one study visit that was conducted in a VA research human–computer interaction simulation laboratory. Veterans completed a demographic survey, feasibility and satisfaction questionnaire, PHQ-9, CIQ and SSQ during the visit and the outcome measures were repeated 2 weeks later via telephone interview. Data were analysed using descriptive statistics, independent sample t-tests and Cohen’s d to estimate effect sizes. Comments from the Veterans were categorized using a predetermined code list that addressed the five feasibility and satisfaction domains: usefulness (content), ease of use, affective aspects, control and efficiency, typical task for mobile device. Results: Forty-eight Afghanistan/Iraq Veterans were recruited; 25 Veterans were randomized to the intervention group and 23 Veterans to the attention control group. The Veterans were 33.7 years old, male (91.7%) and their post-concussive symptoms included: PTSD (83.3%), depression (70.8%), chronic pain (77.1%), balance impairments (60.4%), headache (95.8%), fatigue (64.6%), insomnia (81.3%), tinnitus (81.3%), hearing impairment (60.4%) and vision impairment (20.8%). On a scale of 1.0–5.0, with 5.0 being strongly agree, Veterans provided moderately high evidence of feasibility and satisfaction for the VETSCARE intervention iOS app (usefulness 4.19, ease of use 4.39, affective aspects 4.03, control and efficiency 4.17, typical task for mobile device 4.19), with the average overall rating of 4.19. Given that insufficient statistical power and the need for more time with the app moderated

Can we use protective mechanical ventilation in the early stages of neurocritical patients? Effects of PEEP on intracranial pressure and brain oxygenation Santiago Lubillo, Jesus Martin, Ismael Molina, Francisco Clemente, Felipe Belmonte, & Da´cil Parrilla Hospital Universitario NS Candelaria, Santa Cruz de Tenerife, Canary Islands, Spain Objective: Ventilator-induced lung injury (VILI) and, in particular, protective mechanical ventilation have not been studied in the neurocritical population, primarily due to concerns about increased intracranial pressure (ICP) and the requirements for mild hypocapnia established in the Brain Trauma Foundation Guidelines. To clarify the so-called ‘lung–brain dilemma’, the authors are conducting a pilot study in the Neurotrauma ICU using a multi-modal neuro, respiratory and haemodynamic monitoring system to investigate the influence of positive end expiratory pressure (PEEP) on ICP, cerebral perfusion pressure (CPP), PtiO2, lung over-distention and haemodynamic impairment in patients without acute lung injury in the early stages of a neurological insult. Methods: Nine patients (traumatic brain injury ¼ 5, aneurysmatic subarachnoid haemorrhage ¼ 2, spontaneous cerebral haemorrhage ¼ 1, stroke ¼ 1) were studied in the first 48 hours from ICU admission on mechanical ventilation with a PaO2/FiO24300 mmHg and apparently normal chest X-ray. Gas exchange, respiratory mechanics and cerebral and systemic haemodynamics were continuously monitored. All patients were normovolemic and normotensive during the study period. PEEP was applied in increments of 5–20 cm H2O during 30 minutes after 5 minutes of stabilization. The influence of different levels of PEEP on ICP, mean systemic blood pressure (MAP), CPP, PtiO2, PaCO2, Dif (PaCO2ETCO2), respiratory system compliance and cerebrovascular autoregulation was analysed by means of Pearson correlation between MAP and ICP (Prx) and MAP with PtiO2 (POx). Analysis of covariance was performed with ICP, MAP, CPP and PaCO2 as covariates and PEEP as factor level to detect if the increase in ICP for the PEEP was due to the increase of the PaCO2 or was modelled by MAP only. Results: Up to 10 cmH2O of PEEP, there were not significant changes in ICP, even CPP improved. When the PEEP was raised to 15 cm H2O the ICP increased from 11 ± 5.5 to 16.2 mmHg (p50.05). MAP and CPP decreased from 83.8 ± 14 to 79 ± 13 mmHg (p50.05) and 72.2 ± 11 to 63.9 ± 14 (p50.02), respectively, along with an elevation of PaCO2 from 37.2 to 39.4 (p50.04) without changes in the Dif (PaCO2-ETCO2). The rest of the parameters did not change significantly even at PEEP of 20 cm H2O. The negative effects of PEEP on ICP increase and CPP decrease was solely dependent on changes of MAP. After administration of noradrenaline for normalizing the optimum MAP based on best PRx and POx, the ICP returned to previous levels without significant changes in PaCO2 at a PEEP level of 20 cm H2O. Conclusions: The data suggest that the use of moderated to high PEEP may be appropriate in neurocritical patients for prevention of VILI, provided that MAP is maintained and close attention given to ICP, CPP, pulmonary over-distension and cerebrovascular autoregulation.



Filling a void: A day programme for persons living with moderate-to-severe acquired brain injury Judith Gargaro, & Gary Gerber

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with stroke sustained 3 years after? The longitudinal follow-up of a randomized controlled trial Birgitta Langhammer1, Birgitta Lindmark2, & Johan Stanghelle3 1

Oslo and Akershus University College, Oslo, Norway, Uppsala University, Uppsala, Sweden, 3Sunnaas Rehabilitation Hospital, Nesoddtangen, Norway


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Westpark Healthcare Centre, Toronto, ON, Canada Objective: Persons who have sustained an acquired brain injury (ABI) may experience social isolation and may place significant burden on family members due to physical and cognitive impairments and challenging behaviours that prevent them from living independent lives. This study offers a day programme for ABI survivors with moderate-to-severe injury that focuses on skill-building, recreation and community outings and provides community case management, respite and physiatry consultation. The hypothesis that participation in the day programme would increase community integration and decrease challenging behaviours, family burden and health service utilization was tested. Methods: Participants attend a day programme 2–3 days per week for a 6-month period and engage in social and educational activities, skill training and community outings developed in consultation with participants. Fifty-four clients and family members completed standardized measures of community integration, challenging behaviours and family burden at the start and the end of the 6-month attendance. Family members and clients also completed a satisfaction with service measure. Health utilization data was collected for the 12-month period prior to and for the 6-month period of attendance. Results: The mean age of participants is 44.39 years and mean time since injury is 7.60 years. The sample is a mix of traumatic and nontraumatic ABI survivors, some of whom exhibit challenging behaviours. Participants’ injury severity included persons with mild (1%), moderate (9%), moderate-to-severe (80%) and severe injury (10%). There was a significant increase in community integration (p ¼ 0.000), a significant decrease in family burden (p ¼ 0.018) and a decrease in challenging behaviours. Despite these changes, participants’ community integration remained low and family burden continued to be considerable. Family members and participants were very satisfied with the programme. Clients and families commented that a longer period of attendance and more access to respite services are needed. Typically, healthcare utilization during attendance was for planned follow-up medical appointments. Conclusions: A day programme for ABI survivors that provides social, recreational and skill-building activities, case management, respite care and psychiatry consultation produced measurable improvements in community integration, challenging behaviours and decreased family burden. ABI day programmes help fill the void left after other rehabilitation services end and provide survivors with opportunities to engage in a variety of social, skill building and recreational activities. ABI survivors, especially persons who exhibit challenging behaviours following injury may have life-long needs for specialized community programmes. This study highlights the need for services for persons living with ABI after completing formal rehabilitation services. Rehabilitation providers are encouraged to identify day programmes for clients to attend following discharge and to collaborate with community providers to develop relevant day programmes that will provide long-term social, educational and community opportunities and reduce their experience of isolation.


Are effects of a 1-year long-term intervention period in persons

Objective: To observe if physical function, personal-, instrumental activities of daily living (PADL, IADL) and health-related quality-of-life was maintained 3 years post-stroke. Methods: A longitudinal randomized controlled trial. Intervention: Patients allocated to an intensive exercise group were scheduled to have a minimal amount of 80 hours physiotherapy the first year post-stroke. A regular exercise group was in charge of their own exercise. Tests were performed at baseline, 3, 6, 12 and 36 months post-stroke. Results: Of 75 persons with stroke at baseline, 37 were eligible for follow-up tests 3 years post-stroke, 19 (54.3%) in the intensive exercise group and 18 (45%) in the regular exercise group. All were active doing exercises, either in a community setting with an individual coach, in an exercise group or by themselves doing home exercises. Motor function improved up to 6 months and stabilized and was maintained on the same level up to 3 years poststroke in both groups. The same tendency was presented in scores of Timed Up and Go, Bergs Balance Scale, Barthel Index, grip strength bilaterally, walking distance and health-related quality-of-life. Both groups reported a higher extent of activity in all items of Instrumental Activities of Daily Living Test at 3, 6, 12 and 36 months post-stroke. However, there were significant differences in several items at 12 and 36 months in favour of the regular training group. Approximately 40% in both groups were independent, while 60% relied on help from relatives or community-based services 3 months up to 3 years post-stroke. Conclusion: Persons with stroke regain and maintain motor performance, balance, mobility, PADL, IADL, walking capacity and grip strength with regular physical training in a 3-year post-stroke perspective. No adverse effects or increased tone was reported. Maintenance training appears to be reinforced by individuals in charge of their own progress and enhanced through motivational test.


Brain network dysfunction in young athletes with persistent post-concussion syndrome Marjorie Villien1, Brian Edlow1, Elissa McIntosh1, Maulik Purohit2, Andre´ Van der Kouwe1, Janet Sherman1, David Greer3, Ross Zafonte2, & Ona Wu1 1

Massachusetts General Hospital, Boston, MA, USA, 2Spaulding Rehabilitation Hospital, Boston, MA, USA, 3Yale School of Medicine, New Haven, CT, USA Objectives: Approximately 75% of TBI patients with mild TBI (mTBI) experience a broad spectrum of neuropsychological impairments related to attention, executive function and memory. The majority of mTBI patients recover within a few months, but for up to 20% symptoms persist and lead to a devastating impact on interpersonal relationships and potentially to long-term disability named as persistent post-concussion syndrome (PPCS). The poor sensitivity


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DOI: 10.3109/02699052.2014.892379

of conventional neuroimaging not only limits diagnosis but also prevents clinicians from identifying the sub-set of mTBI patients at risk of long-term neurological sequelae. Recently, the analysis of spontaneous fluctuations in resting brain activity has led to the concept of resting state networks. In this resting state functional MRI (rs-fMRI) study, multiple resting state networks in the brains of mTBI patients with PPCS were compared with those from healthy control subjects to determine whether the functional connectivity within these networks differed significantly. Methods: Ten mTBI patients (17.6 ± 1.6 years, four females) presenting with PPCS for at least 3 months post-injury and 10 healthy volunteers (20.4 ± 1.9 years, six females) were enrolled with written informed consent. MRI data were acquired on a Siemens TIM Trio 3T scanner using a 32-channel head-only receive coil. Anatomical images were acquired using a 3D T1-weighted sequence (MPRAGE) at 1  1  1 mm3 resolution. Functional images were acquired axially using a single-shot EPI sequence with TR/TE ¼ 3000/23 ms at 3  3  3 mm3 resolution and 35 slices. Data from 120 time-points were analysed. Functional data were pre-processed using motion correction and in-plane smoothing and co-registered to the MNI-152 T1 template. Functional connectivity maps were obtained using independent component analysis (ICA) and dual regression against a 20component template (fCON 1000). Motion parameters were regressed out. The following five networks were analysed: default mode (DMN), executive control, temporo-parietal memory, attention and salience networks. Results: The most commonly affected brain regions in mTBI patients were the inferior and superior parietal lobules, one of which was affected in all of the networks except for the temporo-parietal memory network. The DMN also showed a large region of voxels with negative Z-statistics in the occipital cortex in mTBI patients compared to controls. In contrast, mTBI subjects showed regions with significantly less negative Z-statistics in the fornix and in the callosal body in the temporo-parietal memory network compared to the controls. Conclusions: This prospective rs-fMRI cohort study demonstrates that multiple resting brain networks are altered in young athletes with PPCS compared to healthy controls. These brain network alterations may provide a pathophysiological basis for the neurocognitive dysfunction experienced by young athletes after mTBI. Furthermore, these results suggest that the inferior and superior parietal lobules are functionally important grey matter nodes within multiple brain networks that are implicated in the pathogenesis of PPCS.

integration of brain injury survivors in their country, in their city or town, in their community. Each survivor has unique needs based on their injury and each survivor wants to thrive in their community. Like that special piece of art, this study will discuss and learn ways to look outside the box, mixing and bringing together people, place, and strategies to make that magic moment happen. That moment occurs when a case manager sees it all starting to come together, resulting in the survivor being able to be less dependent on the system, more self-sufficient and fully engaged in their community. How is this done? Attendees will learn the following crucial pieces of this model: (1) Building relationships: a building block leading to needed resources for successful community integration of brain injury survivors. (2) ‘Switching It Up’: thinking outside the box to find usable natural resources in a community to move toward integration. (3) Creating measurable goals: improving your ability to demonstrate success through goal achievement. (4) Utilizing a Telephonic Community Treatment Collaboration Model (CTC): decreasing service fragmentation and increasing cost savings, to achieve efficient and effective treatment intervention in the community. Human service professionals are under pressure to cut costs, produce outcomes and demonstrate results to substantiate continued funding. This can be achieved by implementing the Community Based Model of Case Management utilizing the four concepts mentioned above. The result is intervention which is long-term, effective and lower cost.


Brain power: Functioning after traumatic brain injury (TBI) in children: A comparison between TBI, orthopaedic injuries and healthy peers in The Netherlands Frederike van Markus-Doornbosch1, Els Peeters2, & Thea Vliet Vlieland3 1

Sophia Rehabilitation Center, The Hague, The Netherlands, 2Medical Center Haaglanden, The Hague, The Netherlands, 3Leiden University Medical Center, Leiden, The Netherlands


The community-based case management model for brain injury survivors producing successful community integration Joyce Cohen Brain Injury Services, Springfield, VA, USA Please note: This is a practice based abstract. Brain Injury Case Management cannot be accomplished by one individual alone or from an office setting. Seeking success by utilizing this approach or seeking to find the one and only treatment to help a brain injury survivor will not produce the most effective outcome. Partnering with neighbouring professionals and agencies, working from a team approach and working in the community is a much stronger indicator for successful integration with that survivor. Applying a communitybased model is like creating a piece of art; integrating all of the different colours, textures and materials to create the whole piece. It is what makes that piece unique and whole, despite the vast complexity. This is Brain Injury Case Management as a ‘best practice’ and the focus of this presentation. This study will cover some of the moving parts that one can utilize to help with successful community

Objective: To establish the incidence and consequences (impairments of body functions, limitations in participation) of traumatic brain injury in children and youth in a region of The Netherlands as well as the incidence of the same symptoms in a group of children and youth with an orthopaedic injury and a group of healthy peers. Special attention will be paid to fatigue, sleep disorders, physical activity, depression and anxiety in these groups. In The Netherlands there is a large group of young adults with undiagnosed symptoms and limitations in participation (school, sport) that need to be addressed. Study design: Cross-sectional, multi-centre study. Study population: All consecutive patients aged 12–24 years registered with the diagnosis traumatic brain injury and trauma capitas between 6–18 months post-injury (March 2012–March 2013) in one of two hospitals in The Hague. In the same period a cohort of 100 orthopaedic patients as well as 200 healthy peers will be used as the control group. Main study parameters/end-points: The main study parameters are questionnaires assessing body functions (fatigue: Checklist Individual Strength; headaches, depression and anxiety: YSR/ASR; sleep disturbances: Pittsburgh Sleep Quality Index; level of physical activity: SQUASH); overall quality-of-life: TAAQOL/TACQOL and a general questionnaire. The questionnaires have been transformed into one internet questionnaire. Results: The data was collected in the Fall of 2013. Three hundred and twenty-five TBI patients and 330 orthopaedic patients were approached to participate in the study. Data was collected through November 2013. The use of an internet questionnaire facilitates the

558 data collection with direct import into SPSS. Characteristics of responders was analysed using descriptive statistics. Comparisons among groups were made using unpaired t-tests, Mann-Whitney U-tests, analysis of co-variance (ANCOVA) or Chi-square tests, where appropriate. The association between potential determinants and the primary outcome measures are examined by means of regression analysis. Conclusions: Conclusions were made after analysis of the data. The main parameters, fatigue, sleep quality, depression, anxiety and physical fitness were analysed first. The presentation in San Francisco will entail these parameters for the TBI group in comparison to orthopaedic injuries and healthy peers. It is hypothesized that the TBI group has more fatigue, sleep disorders and a lower level of PA than the other two groups. An intervention addressing these symptoms is in development and will be tested and implemented in a later phase.

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Utilizing functional skills to enhance community re-integration Erica Guardascione, Mary Morris, & Katrina Torres Kessler Institute for Rehabilitation, Saddle Brook, NJ, USA As research in traumatic brain injury indicates, generalization of cognitive skills from in clinic to the community is essential. Use of functionally-based tasks has demonstrated most significant carry-over of strategies and skills gained through education within cognitive rehabilitation programmes. Kessler Institute for Rehabilitation’s functional skills group is an individually tailored component of its Cognitive Rehabilitation Programme utilizing an interdisplinary approach consisting of speech language pathology, occupational therapy and vocational rehabilitation. The aim of ‘functional skills’ is to provide clients with an opportunity to practice learned strategies to support attention, memory and executive functioning skills within the context of functional tasks that reflect everyday life situations and activities. As all individuals with brain injury are different, client’s personalized goals are prioritized; whether their goal is return-to-work, volunteer or pre-morbid community re-integration (hobbies, classes, clubs, religious affiliations). Once a client’s discharge goal is established, cognitive components of tasks that clients engage in within their home, community and work settings are identified. In-clinic tasks are then developed to target these cognitive components as well as a client’s personal community reintegration goals. As clients become more familiar with the group format, they are encouraged to identify tasks and activities of importance and relevance to them; these tasks/activities are then reviewed with the clinicians to assess planning and accuracy of task execution. Examples of tasks and activities provided in functional skills include: completing work trials, assembling objects, scheduling, community resourcing, managing finances, meal planning and preparation, constructing medication management charts, following written or video directions to learn a new skill and role-playing problematic situations that someone may face in everyday life. Opportunities are provided from multiple departments within the hospital (nursing, reception, nutrition, shipping/receiving) to provide a realistic environment to test out strategies learned and potential transferrable job skills for return-to-work/volunteer. The functional skills group also provides opportunities for increased awarenessbuilding. For clients with limited awareness and for which a ‘hands-on approach’ is preferred over an ‘academic-like’ setting, the format allows for clients to obtain concrete and direct feedback on their performance of tasks that most closely simulate tasks engaged in prior to injury. Clients are responsible for time and information management throughout their 4 hour ‘work’ day. Using an executively-based approach, each session begins with a morning review

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and concludes with ‘wrap-up’, where clients are encouraged to predict performance prior to task engagement and to review results following task completion for improved awareness and selfmonitoring.


Intravenous mesenchymal cells therapy in the acute phase after traumatic brain injury improves neurological recovery Esther Pe´rez-Sua´rez1, Ignacio Mastro-Martı´nez2, Fernando Casco3, A´frica Gonza´lez-Murillo4, Gustavo Melen4, Marı´a Gutie´rrez-Ferna´ndez5, Ana Serrano1, Esuperio Dı´ez-Tejedor5, Juan Casado-Flores1, & Manuel Ramı´rez4 1

Pediatric Intensive Care Service, Nin˜o Jesu´s University Hospital, Madrid, Spain, 2Pediatric Department , Jime´nez Dı´az Hospital, Madrid, Spain, 3Histiocitomed Institute, Madrid, Spain, 4 Oncohematology Research Laboratory, Nin˜o Jesu´s Hospital, Madrid, Spain, 5Neuroscience and Cerebrovascular Research Laboratory, La Paz University Hospital, Idi Paz, Madrid, Spain Objective: The aim of this study was to evaluate the effects of intravenously (IV) administered allogeneic mesenchymal stem cells (MSC), in the acute period after a traumatic brain injury (TBI), in improving short-term functional recovery. Methods: MSCs were isolated from peritoneal fat of healthy rats, expanded in vitro and labelled with a fluorescent protein GFP. Groups of six Sprague-Dawley rats received physiological saline, a single dose of 2 million MSCs or three dosis of 2 million MSCs, respectively, within the first 24–72 hours after receiving a moderate, unilateral, controlled cortical impact. Histological examination and immunohistochemistry were used to identify cell distribution. Motor and cognitive behavioural testing (Rota rod, stickytape and modified Roger’s test) were performed to evaluate functional recovery. Results: No adverse effects were observed during or after the administration of MSCs. MSCs were found in the perilesional area 24 hours and 14 days after the IV infusion. There was higher punctuation of all three cognitive behavioural tests in the multidoses treatment group compared to the single dose group and to placebo. These differences were statistically significant in the Roger’s test. Conclusions: IV infusions of multi-doses of MSCs immediately after a TBI were well tolerated. The multi-doses treatment resulted in better recovery of motor and cognitive functions compared to single dose. This cellular therapy might be considered for patients suffering TBI.


Sodium selenate treatment reduces hyperphosphorylated tau and improves outcome in experimental brain injury models Ping Zheng, Xin Lin Tan, David Wright, Terence O’Brien, & Sandy Shultz Department of Medicine (RMH), University of Melbourne, Parkville, Australia


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DOI: 10.3109/02699052.2014.892379

Objectives: Traumatic brain injury (TBI) is a progressive neurodegenerative condition. Brain concussion accounts for the majority of TBIs and repetitive concussions can result in cumulative damage, neurodegeneration and chronic neurological abnormalities. Hyperphosphorylated tau has been implicated in the pathogenesis of TBI and repeated concussion. This study investigated whether treatment with sodium selenate, a drug that reduces the pathological hyperphosphorylation of tau by increasing PP2A activity, would reduce neurodegeneration, post-traumatic epilepsy and functional impairments in rat models of both severe TBI and repeated concussion. Methods: Young-adult male Long-Evans rats were administered either a severe fluid percussion injury, repeated mild fluid percussion injuries or appropriate sham-injuries. Rats were then given either continuous sodium selenate treatment (1 mg kg1 day1) or vehicle control, administered via subcutaneous osmotic mini-pump, for a period of 3 months. Cognitive, motor and emotional impairments were assessed at 3 months post-injury. Serial anatomical magnetic resonance imaging and diffusion weighted imaging were used to assess progressive structural damage and axonal injury at 1 week, 1 month and 3 months post-injury. Rats were then implanted with extradural recording electrodes for a continuous 2-week video EEG analysis for post-traumatic seizures. Immunohistochemical and western-blot analyses were used to assess levels of hyperphosphorylated tau and related pathologies. Results: The results demonstrated that continuous sodium selenate treatment reduced hyperphosphorylated tau, neurodegeneration, seizure frequency and behavioural impairments after severe TBI and repeated concussions in the rat. Conclusions: These data indicate that sodium selenate has neuroprotective effects in a rat model of TBI. These results are consistent with other recent findings from the laboratory that sodium selenate treatment has neuroprotective properties in rat models of neurodegenerative disease. Taken together, these studies implicate hyperphosphoryalted tau in the degenertive effects in a number of brain injury models and suggest that sodium selenate is a novel approach to treat these conditions.


Structural and functional changes in the brain following sportsrelated mTBI in adolescent athletes Naznin Virji-Babul, Michael Borich, Nadia Makan, Aliya-Nur Babul, Po Hsiang Yuan, & Lara Boyd University of British Columbia, Vancouver, BC, Canada Objectives: Sports-related mTBI in adolescents is a major public health issue; however, little is known about the underlying structural and functional changes in the developing brain following injury. The objectives were: (1) To establish the short-term changes in white matter integrity and (2) To evaluate the changes in connectivity of resting state brain networks in adolescents following sportsrelated mTBI, in comparison with a group of healthy adolescent athletes. Methods: Twelve adolescents with a clinical diagnosis of sub-acute mTBI and 10 healthy, physically active adolescents matched for age, gender and physical activity level participated in this study. Adolescents with other focal neurologic deficits, pathology and/or those on prescription medications for neurological or psychiatric conditions were excluded. Trained examiners tested all participants using the Sport Concussion Assessment Tool 2 (SCAT2). Resting state functional magnetic resonance imaging (fMRI) and diffusion tensor

imaging (DTI) data were acquired on a Philips Achieva 3.0T MRI scanner (Phillips Healthcare, Andover, MD). Functional connectivity in resting state networks was compared between the two groups using independent component analysis followed by dual regression. DTI data were analysed using whole-brain tractography using a deterministic streamline approach. Results: No statistically significant group differences were observed in SCAT2 scores. White matter integrity was significantly different between groups (Wilks’ l ¼ 0.847, F(2,39) ¼ 3.53, p ¼ 0.039). Whole brain fractional anisotropy (FA) values were significantly increased (F(1,40) ¼ 6.29, p ¼ 0.010) and mean diffusivity (MD) values decreased (F(1,40) ¼ 4.75, p ¼ 0.036) in concussed athletes compared with control participants. In addition, altered functional connectivity was found within three resting state networks in adolescents with concussion. Specifically, alterations were noted within the default mode network, increased connectivity in the right frontal pole in the executive function network and increased activity in the left frontal operculum cortex associated with the ventral attention network. Conclusions: To the authors’ knowledge, these data show for the first time that sport-related mTBI in adolescents is associated with widespread changes in white matter microstructural integrity and alterations in whole brain functional connectivity in networks related to cognition and attention, up to 2 months post-injury. These data suggest that the trajectory of adolescent recovery may be more prolonged than in adults. Changes in resting state functional connectivity and white matter integrity may be sensitive to changes in cognitive function following mTBI. Increased knowledge of these changes may lead to improvements in clinical management and help to develop evidence-based return-to-play/ learn protocols.


Can demyelinative lesion in the brain cause behavioural changes? Arezou Hajhashemi, Masoud Etemadifar, Hossein Vaziripour, & Ali Hekmatnia Clinic & Research Center of Multiple Sclerosis, Isfahan, Iran Background: Multiple Sclerosis (MS) is one of the most prevalent demyelinating diseases of the central nervous system. MS is an inflammatory and demyelinating disease, resulting in dmyelinative plaques in different parts of the brain. Since different parts of the brain are responsible for different behavioural symptoms and/or personality, this investigation was intended to study the association between behavioural symptoms and location of plaques in the Limbic System, Prefrontal, Temporal, Cingulate Gyrus and Basal Ganglia of the brains of patients with MS. Materials and methods: The sample was selected consecutively from patients with MS, who are registered with Isfahan MS Society. Brain System Test (BST) was administered to the participants and their brain Magnetic Resonance Imaging (MRI) scans were analysed by a radiologist in order to identify the number of plaques in the Limbic System, Prefrontal, Temporal, Cingulate Gyrus and Basal Ganglia. The results of BST and the location of plaques were analysed for any association. Results: The chi-square analysis showed that there were significant relationships between MS plaques in cingulated and pre-frontal areas and behavioural symptom (p ¼ 0.001 and p ¼ 0.007); however, there were no significant relationship between MS plaques and behavioural symptoms in limbic, temporal and basal ganglia areas (p50.05). Conclusion: The results of this study suggest that the location of demyelinative plaques in prefrontal and cyngulate gyrus areas are associated with behavioural symptoms of MS patients.



Functional improvement in patients with post-traumatic hydrocephalus after acquired brain injury Marina Motin1, Tamara Cherkassky1, & Yaron Sacher1,2 Loewenstein Rehabiltation Hospital, Raanana, Israel, 2Tel-Aviv University, Tel-Aviv, Israel

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Objectives: Brain injury resulting either from traumatic or no traumatic injuries is an important cause of disability in the modern societies. Ventricular enlargement is a frequent finding after severe head injury, as a consequence of either post-traumatic hydrocephalus or posttraumatic atrophy. This study was intended to evaluate the setiology, the need for anti-epileptic treatment and the functional improvement after VP insertion. Methods: A retrospective evaluation of the charts of severe brain injured patients after implantation of ventriculo-peritoneal shunt for post-traumatic hydrocephalus. Results: Fourteen patients were included, suffering from posttraumatic hydrocephalus after traumatic brain injury (TBI) or nontraumatic brain injury (ruptured aneurysm). All of the patients suffered severe brain injury according to their GCS score or duration of unconsciousness. Twelve patients had TBI (seven patients after road accident, three after fall injury and two patients after assault), two patients were after rupture of an aneurysm. All of them were diagnosed with post-traumatic hydrocephalus and had a shunt inserted. The timing of shunt placement was between 2 days and 5 years post-injury. Three of the patients had only subdural haemorrhages (SDH), eight patients had only subarachnoid haemorrhages (SAH) and three patients suffered from more than one type of haemorrhage. Eleven patients had an EEG study, in 10 of them abnormalities were identified. Only in one patient the EEG examination was normal. Ten patients were treated with anti-epileptic drugs. The given anti-epileptic treatment was not based on the EEG results and no patient suffered seizures after the insertion. The length of stay in the rehabilitation department was between 1.5–9 months. Ten patients achieved major improvement according to their FIM score after shunt insertion in their cognitive and motor functions. The remainder had no change (or a minimal one) in their functional status. Conclusion: Post-traumatic hydrocephalus has a detrimental effect on the functional level with varying onset and clinical presentations. Hydrocephalus might appear even in the absence of SAH and, therefore, clinical and radiological follow-up is warranted in ABI patients presenting with other types of intracranial vascular pathologies as well. Even though the incidence of shunt insertion after brain injury is not high, the significant benefit from the procedure requires the physician in charge to evaluate the functional status of the patient and refer him/her to insertion of VP shunt as soon as possible.


Risk factors associated with haemorrhagic progression of a contusion in operated patients with severe traumatic brain injury Anton Kordonskiy, Yulia Puras, & Vladimir Krylov Sklifosovsky Emergency Care Institute, Moscow, Russia

Brain Inj, 2014; 28(5–6): 517–878

Introduction: A phenomenon termed haemorrhagic progression of a contusion (HPC) is the progression lesion during the first several hours or days after impact by means of either expanding or developing new, non-contiguous haemorrhagic lesions. HPC results in irrevocable loss of brain tissue that was ostensibly intact immediately following the primary injury. HPC causes uncontrollable intracranial hypertension, descending transtentorial herniation and is associated with a worse clinical course and higher rates of mortality. It is known that the surgery for removing intracranial haematomas is one of the switch triggers to HPC. Aim: To identify the factors encouraging to HPC in operated patients with traumatic brain injury (TBI). Materials and methods: The retrospective analysis was conducted in 719 patients who had undergone surgery in The Sklifosovsky Emergency Care Institute from 2005–2012. On the initial CT scan all patients had small haemorrhagic lesions which did not require surgery. All patients were operated on for large traumatic intracranial haematomas (epidural, subdural and intracerebral). Surgery was performed within the first 6 hours after injury. Small contusions were not removed following their non-surgical volume. HPC was noted in 183 patients out of 719 (25.4%). This study compared two groups of patients (with and without HPC) between each other and analysed statistically different variables in these groups in order to find possible risk factors associated with HPC in operated patients with TBI. Results: Among patients with HPC the progression of lesions within 24 hours after injury was found in 30% cases, from 24–72 hours in 56% and more than 72 hours in 14%. The average time of contusions progression was 41 ± 15 hours. There were three patterns of haemorrhagic progression: expansion (50.3%), merger (37.7%) and appearance (12%). The risk factors of HPC were: aged up to 40 years, injury mechanism with a high intensity of force application (traffic accidents and falling down from a great height), combination of small haemorrhagic lesion and large evacuated subdural haematoma, traumatic subarachnoid haemorrhage, low initial Glasgow Coma Scale (12 or less), initial haemorrhagic contusions volume 17 ml or larger, decompressive craniectomy as a type of surgery (p50.05). The progressive contusions were located mainly on the decompressed side. Multiple small lesions located within the same cerebral lobe also had a trend to progression. This study has not received a causative relationship between coagulopathy and HPC. On admission and for a further 5 days all coagulation parameters were within the reference range. Conclusion: Patients with risk factors of HPC require particular attention. They must be subjected to dynamical CT on the 1st, 2nd and 3rd days post-operatively in order to not be passed over.


Development of minimal clinical pathway for TBI rehabilitation programme in Saudi Arabia Jiri Pazdirek, Sadia Misbach, Abdulaziz Al Hraibat, Mona Bakhet, Martin Muriuki, Daniel Ruhiu, Rozliza Mudarshah, Sze Ling Chai, & M. Tahar Si Larbi Prince Sultan Bin Abdulaziz Humanitarian City, Riyadh, Saudi Arabia Objectives: Development of clinical pathways is becoming increasingly important as it might be a useful tool for co-ordination and standardization of therapeutic efforts across multidisciplinary teams. Clinical pathways in TBI rehabilitation are not yet widely documented and available for clinical practice and rarely found on the Web. Methods: Prince Sultan Bin Abdulaziz Hospital is a new, unique and dynamically developing 450 beds Rehabilitation Hospital in Saudi


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DOI: 10.3109/02699052.2014.892379

Arabia aspiring to be a Centre of excellence and a model for other facilities in the Middle East. The therapy team members have come to work here from 27 countries and communicate in different versions of English in an Arabic-speaking environment. Facing some communication challenges related to different cultural and educational backgrounds, this study made an attempt to develop a Clinical Pathway for TBI rehabilitation adjusted to this special situation to facilitate precise mutual understanding and standardization of evaluation and therapy. The authors are aspiring to present this approach to the development of minimal TBI rehabilitation pathway adjusted to special conditions of growing rehabilitation infrastructure and multinational therapy team. The main goal was to achieve simplicity in description of even such a complex task as is rehabilitation of patients with brain injury. This TBI rehabilitation programme is unique in the region and the TBI case mix being treated is largely heterogeneous regarding functional impairment and time passed from the injury. Clinical course of TBI rehabilitation in time is predictable only in general and with large inter-individual variations regarding progress of functional recovery. Results: Proposed solutions to the above-mentioned challenges were defined as: Case groups related to the time passed from the injury and severity of impairment; Specific problem-oriented evaluation of patients impairments with continuous feedback; Individual inpatient rehabilitation therapy plan with assignment of therapeutic resources appropriate to a particular situation; and Common general long-term rehabilitation plan. A TBI Rehabilitation Evaluation and Intervention Form and TBI Rehabilitation Admission Tracks were developed as a tool for evaluation, interventions and long-term therapy programme planning in the environment with limited resources. Conclusions: With further continuing adjustment to local conditions in developing countries it can become a useful instrument for organization of rehabilitation of TBI patients in an environment with growing rehabilitation infrastructure.


Predictors for walking capacity after stroke: Sitting, standing static or dynamic balance? Birgitta Langhammer1, Birgitta Langhammer2, & Birgitta Lindmark3 1

Oslo and Akershus University College, Oslo, Norway, 2Sunnaas Rehabilitation Hospital, Nesoddtangen, Norway, 3Uppsala University, Uppsala, Sweden Introduction: Postural control and balance, dynamic and static, is a pre-requisite for physical function and independence in activities in human beings. For people with a neurological condition such as stroke, reduced postural control is one of the most disabling problems, closely related to falls. The prevalence of reduced sitting balance in an acute population of stroke (n ¼ 75) was present in 19 persons with stroke (24%), reduced standing balance in 37 (46%) and reduced dynamic standing balance in 41 (51%). A total of 49 persons (65%) were identified as potential fallers with Berg Balance Scale total score 545. Walking capacity varied day 3 after stroke: 28 persons walked 0–10 metres, five walked 30–90 metres and 42 walked between 124–700 metres in 6 minutes. Objective: To examine the influence of postural control on walking capacity at 6 months, 1 year and 3 years post-stroke. Is there an association and, if so, what is most influential: static or dynamic balance in sitting or standing? Methods: A hierarchical multiple regression analysis was performed with 6 Minutes’ Walk Test (6MWT) 6 months, 1 and 3 years post-stroke as a dependent variable and Motor Assessment Scale (MAS) item 3

(sitting balance/dynamic), Berg Balance Scale (BBS) item 12 (standing without support stepping reciprocally 4-times on a step/dynamic) and item 14 (one leg standing/ static) as independent variables using baseline scores. The analyses were performed on an intention-to-treat analysis where the last observation carried forward was practiced (LOCF). Significance was set to p50.05. Results: A total of 75 persons with stroke, 32 women and 43 men, were analysed. Persons with a right/left sided hemiparesis were n ¼ 38/37. The items MAS 3, BBS items 12 and 14 showed an adjusted R2 of 0.82, 0.77 and 0.77 at 6 months, 1 and 3 year post-stroke, respectively. MAS 3 R change value was 0.59, 0.48 and 0.44, BBS item 12: 0.08, 0.07 and 0.12 and item 14: 0.002, 0.04 and 0.02 in the same time periods. Conclusion: Walking capacity at 6 months, 1 and 3 years post-stroke is significantly associated with baseline sitting balance (MAS 3), dynamic (BBS 12) and static balance (BBS 14). The balance items explained 77–82% of walking capacity at 6 months, 3 years poststroke. Sitting balance was the strongest predictor, explaining 40–60% of 6MWT at 3 years post-stroke.


Implementing a communication partner training programme in a brain injury community re-entry programme Nathan Zasler, Beth Ann Norvell, Bridgette Gutzmer, & Mark Bender Tree of Life Services, Richmond, VA, USA Background: Aphasia in acquired brain injury (ABI) has had a reported incidence of 2–50%. There is also a well-documented decrease in social interaction/community participation in people with aphasia. Working in a specialized community re-entry programme for persons with ABI, where the ultimate goal is for the person to be optimally reintegrated into society, can be particularly challenging when there is a communication deficit present. There have been recent encouraging results with training programmes for the caregivers of people with aphasia aimed at increasing caregiver’s understanding of aphasia, as well as training them to assist in the communication process. Objective: This phase 1 study will report the results of implementing a caregiver training programme designed to increase knowledge about aphasia. Phase 2 will include training on strategies to improve communication with clients with aphasia. Methods: All professional and non-professional staff at Tree of Life Services (TOLS), a community re-entry programme, will be randomized into an experimental and a control group. Both groups will take preand post-tests of the Aphasia Quiz published by the National Aphasia Association (NAA). The Control group will undergo the standard staff orientation for employment at TOLS and have access to a speech therapist and neurophysiatrist if they have questions regarding aphasia or specific clients as related to the same. The Experimental group will undergo the standard staff orientation for employment at TOLS, have access to a speech therapist and neurophysiatrist and then view a video presentation regarding aphasia. Results: The authors are currently in the recruiting phase for subjects. This study will include data on demographics of participants including age, race, sex, educational level and length of time in a rehabilitation related field. It will analyse pre-test/post-test data with a paired t-test for overall scores and each individual question. Conclusions: This study will present the results of the pilot programme with the study hypothesis being that aphasia-specific training will result in an increased understanding of this post-ABI impairment, as well as increased staff sensitivity and empathy to the same.



The effectiveness of a brain and spinal cord injury prevention programme in school-aged children Eva Knifed, Adam MacLellan, Paul Freund, Augene Seong, & Wai Ng

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University of Western Ontario, London, Ontario, Canada Objective: CNS injury is a great cause of morbidity and mortality amongst Canadian youth. It is well known that prevention is the best treatment for devastating childhood CNS injuries. The aim of this study was to determine whether educating young children about injury prevention can result in sustained knowledge transfer and effect positive behavioural and attitudinal changes regarding injury prevention practices. Methods: Grade 4–5 students were surveyed three times in their classrooms: before, after and 6 months after a 2.5-hour presentation about brain and spinal cord injury prevention. The presentation was segmented into Anatomy, Smell and Taste, Vision, Hearing and Somatosensation sections. All sections were interspersed with hands-on activities. Injury prevention messages and strategies were re-iterated in each section. Results: Ninety-seven students of 111 completed all three questionnaires. There was a sustained increase in overall knowledge about central nervous system injury and safe play behaviours. Students showed an understanding of the fact that CNS injuries do not recover and, thus, an appreciation that CNS injuries can alter their lives. The acquired knowledge was also translated into a positive intention in asking peers to wear bicycle helmets. Despite the expressed intention to wear helmets immediately after the injury prevention presentation, there was no sustained increase in reported helmet use 6 months later, although other injury prevention behaviours, such as avoidance of diving into shallow water, showed positive changes. Conclusion: An injury prevention presentation is effective in facilitating knowledge transfer and behavioural intention in young children, although self-reported injury prevention behaviour changes were not always evident at 6 months follow-up. Further study into behaviour change post-presentation is encouraged with consideration of socio-economic barriers to implementing change.


Influence of functional magnetic stimulation on swallowing function. Ryo Momosaki, Masahiro Abo, Shu Watanabe, Wataru Kakuda, Naoki Yamada, & Kenjiro Mochio Jikei University School of Medicine, Tokyo, Japan Objectives: Recently the usefulness of neuromuscular electrical stimulation and repetitive transcranial magnetic stimulation for post-stroke dysphagia has been reported. However, there is no report that describes the effectiveness of functional magnetic stimulation (FMS) for dysphagia. Compared with electrical stimulation, FMS is capable of stimulating deep tissue without pain. The purpose of this study is to clarify the safety and feasibility of a 6-day protocol of FMS for post-stroke dysphagia.

Brain Inj, 2014; 28(5–6): 517–878

Methods: The subjects were four male patients who had dysphagia due to a chronic cerebral infarction. The age at the time of intervention ranged from 61–78 years; the time between onset of stroke symptoms and treatment ranged from 13–42 months. The type and location of the strokes were diagnosed by MRI: all patients had multiple cerebral infarctions. This study excluded patients with contraindications to magnetic stimulation and with general health problems. The stimulation device used for the study was the MagVenture MagProR30; the magnetic stimulation coil was the parabolic coil. The coil was parabolic in shape to provide powerful and focused stimulation and it was suitable for stimulation of the jaw and neck regions. The inner diameter of the transducer head was 25 mm, the outer diameter was 87 mm and the winding height was 11 mm. The active pulse width was 280 ms (biphasic). The suprahyoid muscle group above, at the mid-point of the hyoid bone and the chin, was chosen as the stimulation site and the stimulation strength was set at 90% of the minimal intensity at which the patient subjectively feels local pain. One train of stimulation comprised 30 Hz for 2 seconds followed by 28 seconds of rest. In one session, 20 trains of stimulation were repeated, lasting 10 minutes. Over 6 consecutive days, each patient received 10 sessions of FMS twice daily every morning and afternoon. To evaluate swallowing function upon admission and discharge, a videofluoroscopic swallowing study was performed. Patients were scored using the Penetration Aspiration Scale and laryngeal elevation delay time, Modified Mann Assessment of Swallowing Ability and Swallowing Quality-of-Life. The study was approved by the Ethical Committee of the Jikei University School of Medicine. Results: All patients completed the 6-day treatment protocol and none showed any adverse effects throughout the treatment. At the end of treatment, improvements in the penetration aspiration scale, quality-of-life and swallowing speed were found in all patients. Conclusions: The proposed protocol of treatment seems to be safe and feasible for post-stroke dysphagic patients. Improvement of swallowing function is suggested by this finding, although the efficacy of the protocol needs to be confirmed in a large number of patients.


Family impact of acquired brain injury in children and youth Arend de Kloet1, Monique Berger2, Suzanne Lambregts3, Ron Wolterbeek4, & Thea Vliet Vlieland4 1

Sophia Rehabilitation, The Hague, The Netherlands, 2The Hague University (of applied sciences), The Hague, The Netherlands, 3 Rehabilitation Breda, Breda, The Netherlands, 4Leiden University Medical Center, Leiden, The Netherlands Objectives: Many studies underpin the impact of paediatric TBI on families, also after mild or moderate TBI and the importance to measure and monitor family impact. Long-term child outcome is related to family and environmental factors. Studies were not found about either family impact of paediatric TBI/NTBI in the Netherlands or measures actually used in Dutch paediatric ABI care. The Paediatric Quality-of-Life Inventory Family Impact Module (PedsQL FIM), a reliable and valid, multi-dimensional measure of the impact of paediatric chronic health conditions, has not been used in ABI research yet. Aim: To determine the impact of paediatric TBI and NTBI on families in the Netherlands, 24–30 months after diagnosis, using the PedsQL FIM as a specific outcome measure. A secondary aim was to determine associations between family impact and sociodemographic characteristics, ABI characteristics and current physical and mental functioning.


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DOI: 10.3109/02699052.2014.892379

Methods: This follow-up study was part of a larger, multi-centre, hospital-based study on the incidence of ABI in The Netherlands. A sample of parents of children and youth, with a hospital-based diagnosis of ABI made in 2008 or 2009, family impact and functioning were measured with the PedsQL FIM. Additional assessments included the PedsQL General Core and Multiple Fatigue scales, the Paediatric Stroke Outcome Measure (PSOM) and the Child & Family Follow-up Survey (CFFS). Results were analysed using descriptive statistics. Correlations among the three sub-scales of the FIM were computed using Spearman Rank Correlation Coefficients. To explore the association between the FIM and measures of the patients’ and parents’ health status, this study computed the FIM scores for sub-groups of patients for each variable. Independent variables were explored as factors associated with the primary outcome measure using linear regression models with the FIM as dependent variable. Results: Parents of 108 patients participated. Age of the patients was 6–22 years old, with 60 (56%) male and 84 (78%) with mild and 24 (22%) with moderate/severe ABI, with a traumatic cause (TBI) in 75%. The mean total FIM-scores were 81.8 (95% CI) and 75.6 (95% CI), in the mild and moderate/severe groups, respectively. In a multivariable regression analysis, female gender, non-traumatic type of injury, more fatigue, a lower educational level of the parents and pre-injury health problems were associated with lower FIM scores (more family impact). Conclusion: Two years after ABI, the impact on the family as measured by the PedsQL FIM was considerable, measured in a hospital-based cohort. Determinants of higher family impact were found in categories in all components of the International Classification of Functioning, Disability and Health (ICF) model.

Results: A total of 56 patients met the inclusion criteria during the period of investigation. All patients could be adequately examined with determination of target variables. PI measurements were normally distributed. The mean PI value awake was 0.82 (2, SD ¼ 0.32) and PI-anaesthetized was 0.89 (2, SD ¼ 0.42). There was a statistically significant difference (p ¼ 0.045) between the groups with a mean difference of 0.069. There was no difference between men and women (awake p ¼ 0.34 and anaesthesia p ¼ 0.16), nor between adults and children (awake p ¼ 0.81 and anaesthesia p ¼ 0.93). Conclusion: This study presents preliminary data on reference values for PI in healthy adults in children in both awake and anaesthetized states. Although PI was higher in anaesthetized patients, the absolute difference was small and without clinical or practical relevance. More patients are presently being enrolled.


Scandinavian guidelines for initial management of minimal, mild and moderate head injuries in adults Johan Unden1, Tor Ingebrigtsen2, & Bertil Romner3 1 3

Clinical Science, Lund, Sweden, 2Clinical Medicine, Tromso¨, Norway, Neurosurgery, Copenhagen, Denmark


Intracranial pressure monitoring (ICP) with transcranial Doppler (TCD)—Reference values in awake and anaesthetized patients Ma˚ns Nilsson1, Johan Unde´n2, & Peter Reistrup3 1

Department of Anesthesiology and Intensive Care Halmstad, Halmstad, Sweden, 2Departement of Intensive Care, Malmø, Ska˚nes Universitetssjukhus, Malmø, Sweden, 3Lund Univeristy, Lund, Sweden Introduction: Current methods for determining the pressure inside the skull (intracranial pressure, ICP) are invasive, costly, associated with potentially life-threatening complications and can only be performed by a neurosurgeon. Transcranial Doppler (TCD) determination of pulsative index (PI) has been shown to estimate ICP with high precision and safety, but has defaulted on practical grounds. Recent technological advances have made this method more suitable in clinical situations. In order to fully understand the implications of TCD in patients with intracranial disease, it is necessary to first establish reliable reference values in clinically relevant states. Methods: Healthy (American Society of Anaesthesiology, ASA, grade 1) patients of all ages, subjected to minor surgery (such as tonsillectomy, hernia and simple orthopaedic surgery), were prospectively included after informed consent. TCD was performed with a Philips CX 50 and PI was determined through a prespecified algorithm. This study used non-parametric tests. For the difference between PI awake/anaesthetized, this study used Wilcoxon Signed Rank Test and between the groups, male/female and adults/children it used the Mann-Whitney Test. Values were calculated as means with two standard deviations at two significant figures.

Background: The management of minimal, mild and moderate head injuries is still controversial. In 2000, the Scandinavian Neurotrauma Committee (SNC) presented evidence-based guidelines for initial management of these injuries. Since then, considerable new evidence has emerged. Methods: General methodology according to the AGREE II framework and the GRADE system. Systematic evidence-based review according to PRISMA methodology, based upon relevant clinical questions with respect to patient-important outcomes, including QUADAS and CEBM quality ratings. Based upon the results, GRADE recommendations, a guideline and discharge instructions were drafted. A modified Delphi approach was used for consensus and relevant clinical stakeholders were consulted. Results: This study presents the updated SNC guidelines for initial management of minimal, mild and moderate head injury in adults including criteria for CT selection, admission and discharge with suggestions for monitoring routines and discharge advice for patients. The guidelines are designed to primarily detect neurosurgical intervention with traumatic CT findings as a secondary goal. For elements lacking good evidence, such as in-hospital monitoring, routines were largely based on consensus. It is suggested that external validation of the guidelines before widespread clinical use is recommended.


Mental health and health-related quality-of-life in caregivers of individuals with traumatic brain injury from Colombia Laiene Olabarrieta1, Carlos Jose De los Reyes Arago´n2, Alfonso Caracuel3, Diego Rivera1, Paul B. Perrin4, & Juan Carlos Arango-Lasprilla5

564 University of Deusto, Bilbao, Bizkaia, Spain, 2Universidad del Norte, Barranquilla, Atla´ntico, Colombia, 3University of Granada, Granada, Andalucı´a, Spain, 4Virginia Commonwealth University, Richmond, Virginia, USA, 5IKERBASQUE, Basque Foundation for Science, Bilbao, Bizkaia, Spain

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Objective: To determine the system of connections between mental health and health-related quality-of-life (HRQoL) in caregivers of individuals with traumatic brain injury (TBI) from Barranquilla, Colombia. Participants: Fifty caregivers of individuals with TBI completed the Satisfaction with Life Scale, PHQ-9 (depression), Zarit Burden Interview, Rosenberg Self-Esteem Scale, State-Trait Anxiety Inventory and the SF-36, a self-report HRQoL measure composed of eight component areas: physical health problems, pain, role limitations due to physical problems or due to emotional problems, emotional well-being, social functioning, energy/fatigue and general health. Only the six domains primarily associated with physical (rather than emotional) health were examined. Results: A canonical correlation analysis revealed that the better caregivers’ HRQoL, the better their mental health was, with the effect reaching a large-sized effect. A pattern emerged linking caregivers’ higher energy levels and better social functioning to greater burden. A series of linear regressions showed that the model with six areas of HRQoL significantly predicted caregiver burden, satisfaction with life and anxiety. These analyses also revealed that the most robust independent HRQoL predictors of caregiver mental health were vitality, social functioning and role limitations due to physical problems. Conclusions: These findings suggest a need for rehabilitation health professionals to develop and implement culturallyappropriate interventions to improve both caregiver HRQoL and mental health and, perhaps as a result, informal care for individuals with TBI.

Brain Inj, 2014; 28(5–6): 517–878

years; all caregivers completed the Spanish version of the 40-item FNQ. Results: The original FNQ total score had a Cronbach’s alpha of 0.53, indicating low internal consistency. A confirmatory factor analysis (CFA) suggested that the original FNQ six-factor/six-subscale solution did not fit the data well (RMSEA ¼ 0.104). An exploratory factor analysis (EFA) without a specified number of factors resulted in nine factors. A second EFA with a specified sixfactor structure explained 59% of the variance, but the item grouping did not coincide with identified sub-scales. Finally, an EFA that used a Four-factor solution with 32 items showed that the structure explained 52.3% and had sufficiently high internal consistency at the total score ( ¼ 0.92) and sub-scale score levels (40.80). Conclusion: The FNQ with a four-factor 32-item model is an appropriate measure to assess the needs of Spanish-speaking family caregivers of individuals with TBI.


Mice with genetic deficiency for complement receptor type 2 (CR2) show neuroprotection after experimental closed head injury Miriam Neher1, Megan Rich1, Chesleigh Keene1, Sebastian Weckbach1, Ashley Bolden1, Justin Losacco1, Michael Holers2, & Philip Stahel1 1

Denver Health Medical Center, Denver, CO, USA, 2University of Colorado, School of Medicine, Aurora, CO, USA


Factor structure and reliability of the Spanish family needs questionnaire (FNQ) in a Colombian, Mexican and Spanish sample Diego Rivera1, Alfonso Caracuel2, Laiene Olabarrieta Landa1, Paul Perrin3, Maria Quijano4, Dulce Diaz5, Irma Espinosa6, & Juan Arango-Lasprilla7 1

University of Deusto, Bilbao, Bizkaia, Spain, 2University of Granada, Granada, Andalucia, Spain, 3Virginia Commonwealth University, Richmond, Virginia, USA, 4Javeriana University, Santiago de Cali, Colombia, 5Universidad de Londres, Ciudad de Me´xico, Distrito federal, Mexico, 6Instituto Nacional de Rehabilitacio´n de Me´xico, Ciudad de Me´xico, Distrito federal, Mexico, 7IKERBASQUE, Basque Foundation for Science, Bilbao, Bizkaia, Spain Objective: To investigate the psychometric properties of a Spanish version of the Family Needs Questionnaire (FNQ), a measure assessing perceptions of needs of family caregivers of individuals with traumatic brain injury (TBI). Participants: The sample consisted of 143 caregivers of patients with TBI from Colombia, Mexico and Spain; the majority of the sample were women (76.9%) and the average age was 47.8 ± 14.5 years. The average length of education was 11.3 ± 4.5

Objectives: The pathophysiology of traumatic brain injury is characterized by complement activation, leading to neuroinflammation and delayed neuronal cell death. Complement receptor type 2 (CR2) has recently been identified as a ‘key player’ in orchestrating complement-mediated immune responses. The present study hypothesized that mice deficient in the CR2 gene (Cr2/) would be protected from complement-mediated secondary neuropathology after closed head injury. Methods: Adult C57BL/6 male Cr2/ mice (n ¼ 98) and wild-type littermates (n ¼ 157) were subjected to focal closed head injury, using a standardized weight-drop device. Sham-operated mice served as internal controls. Outcome parameters consisted of neurological scoring, quantification of inflammatory mediators in brain tissue and serum by Western blots and ELISA, assessment of glial activation and complement deposition in injured tissue by immunohistochemistry and detection of neuronal cell death by TUNEL histochemistry. Results: Head-injured Cr2/ mice showed a significantly improved neurological outcome for up to 72 hours after trauma, compared to wild-type mice. While the post-injury release of pro- and antiinflammatory cytokines was in a similar range between both groups, complement C3 deposition was markedly reduced in injured brain hemispheres of Cr2/ mice. In addition, the activation of GFAPpositive astrocytes and CD11b-positive microglia was attenuated in head-injured Cr2/ mice, compared to wild-type littermates. Cr2/ mice also showed a decreased extent of neuronal cell death at 7 days post-trauma by TUNEL histochemistry. Conclusions: These data emphasize a central role of CR2 in promoting complement deposition, glial activation, delayed neurodegeneration and adverse neurological outcome after closed head injury. Targeting complement activation on the level of CR2 may represent a promising future approach for therapeutic immunomodulation after closed head injury.


DOI: 10.3109/02699052.2014.892379


Frontal lobes and TBI: Assessment and training of integrative higher-order cognition Asha Vas, Molly Keebler, & Lori Cook

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Center for BrainHealth, Univeristy of Texas at Dallas, Dallas, TX, USA Objective: There is an urgent need to study the effects of cognitive training among individuals who experience persistent higher-order cognitive impairments as the result of a traumatic brain injury (TBI). Due to the developmental trajectory of frontal functions, a TBI can disrupt many aspects of daily-life functioning, particularly for those injured as youth. Based on use-dependent neuroplasticity evidence that brain networks can be changed and cognitive function improved given intensive stimulation, this gap warrants attention. The current proposal discusses (1) Frontal lobe development and impact of TBI on frontal functions, (2) A functionally relevant Test of Strategic Learning measure to assess higher-order frontal function of abstracting meanings from complex information, referred to as gist reasoning, and (3) Empirical evidence from adolescents (two studies) and adults with TBI of the benefits of a dynamic high-level cognitive training programme labelled Strategic Memory Advanced Reasoning Training (SMART) at chronic stages post-TBI across severity levels. The SMART programme targets integrative frontal lobe function of gist reasoning vs specific cognitive processes such as attention or memory. Specifically, SMART teaches top-down modulation of information to improve gist reasoning using strategies that facilitate strategic attention, complex reasoning, innovative thinking and real life application. Participants and procedures: Adolescent TBI study 1: Twenty participants with mild-to-severe TBI, aged 12–20 years (M ¼ 15.30, SD ¼ 2.25), were randomized into either a SMART training group (n ¼ 10) or a memory strategy training group (n ¼ 10), each completing eight in-person, one-on-one 45-minute sessions. Adolescent TBI study 2: Nine participants with mild-to-severe TBI, aged 15–19 (M ¼ 17.34, SD ¼ 1.34) completed eight one-on-one 45minute SMART sessions via Skype (videoconferencing). Adult study: Seven college students with moderate-to-severe TBI, aged 20–46 (M ¼ 32.5, SD ¼ 10.5) completed 18 hours of SMART in an in-person group format. Measures: The primary outcome measure in all three studies was gist reasoning (i.e. the ability to abstract meanings from information). Secondary outcome measures included frontal measures of working memory, inhibition, switching and fluency. Immediate and delayed recall was also examined. Measures also included self and/or parental reports on daily life activities. Results: Overall results from both adolescent and adult studies demonstrate improved performance on the trained domain of higherorder gist reasoning (p50.05). Generalized benefits were also found on frontal mediated executive functions (e.g. working memory, inhibition) and daily function (p50.05). Results also indicated improved recall ability (p50.05). Long-term follow-up of SMART benefits are underway. Conclusion: Improved frontal mediated higher-order cognitive skills could positively influence participation in home, work and community-related tasks. Knowledge gained from this study could help better inform researchers, educators and policy-makers regarding the paths to determine promising solutions and field-test gains from strategy-based intensive cognitive training in students with TBI in secondary schools and colleges.


Characterization of acute diffusion MRI abnormalities following concussion using a joint distribution free-water imaging normative atlas Ofer Pasternak1, Sylvain Bouix1, Yogesh Rathi1, Craig Branch2, Carl-Fredrik Westin1, Martha Shenton1,3, & Michael Lipton2 1

Harvard Medical School, Boston, MA, USA, 2Albert Einstein College of Medicine, Bronx, NY, USA, 3VA Boston Healthcare System, Brockton, MA, USA Objectives: Diffusion MRI can identify microstructural alterations caused by traumatic axonal injury (TAI) following a concussion. However, this is challenging because the location of TAI pathology is likely heterogeneous across patients and conventional group analyses obscure these individual differences, which are characteristic of brain injury. Comparing individual patients with normative atlases, thereby detecting individual ‘out-of-the-normal’ features, circumvents the heterogeneity problem. This study enhances normative atlases by applying free-water imaging, which identifies changes that occur in the extracellular space vs those that occur near tissue membranes. By comparing joint distributions of free-water measures one can better characterize the underlying pathology. Methods: Twenty-five patients within the first 14 days following a concussion, and 31 matched controls received diffusion MRI scans (3T, 2  2  2 mm3, 32 directions, b ¼ 800 s mm2). Free-water maps (FW) and free-water corrected maps of fractional anisotropy (FAt), Radial diffusivity (RDt) and Axial diffusivity (ADt) were computed. All maps were projected onto a common white matter skeleton using TBSS software (FSL, Oxford). Atlases were constructed by calculating mean and standard deviation over the normal controls, with age, gender and motion as covariates. Individual subjects were compared to an atlas using a z-score (leave-one out approach). The z-score distributions of a measure or the joint distributions of two independent measures were compared between groups (t-test) using 100 bins in the range 85z58 of each axis. Statistical significance was adjusted for number of bins (false discovery rate). TBSS was also used to perform conventional group comparisons. Results: TBSS did not identify significant differences between groups. Comparing the distribution of FAt, however, this study found decreased FAt (p50.05; 6.95z51.9), as well as increased FAt (p50.05; 1.85z55.1) in the concussed group. This group also evinced increased FW (p50.05; 2.85z56.6) compared with controls. Joint distributions of FAt and FW revealed that increased FAt cooccurs with increased FW. The joint distribution of ADt and RDt revealed two clusters, one with combinations of decreased ADt or increased RDt (i.e. increased FAt) and the second with co-occurring increased ADt and decreased RDt (i.e. decreased FAt). Conclusions: Using a normative atlas identifies at least two types of subtle abnormalities following a concussion, which are not identified using conventional group comparisons. The decreased FAt range that was observed is consistent with axonal damage, whereas the increased FAt range might be associated with an immune system response that involves the extracellular space, such as inflammation or neuroglial proliferation. This additional information might prove important for the prognosis of concussed subjects and in the development of targets for treatment discovery and proxy end-points in clinical trials.



Therapeutic effect of familiar auditory sensory training for acute severe traumatic brain injury from a placebo-controlled trial Theresa Pape1, Joshua Rosenow2, Monica Steiner1, Todd Parrish2, Ann Guernon3, Brett Harton1, Shane McNamee4, Vijaya Patil1, Matthew Walker5, Kathleen Froelich6, Catherine Burress6, Cheryl Odle1, Xue Wang2, Amy Herrold1, Weihan Zhao7, Domenic Reda1, Mark Coneely8, & Alexander Nemeth9 1

US Department of Veterans Affairs, Hines VA, Hines, IL, USA, Northwestern University Feinberg School of Medicine, Chicago, IL, USA, 3Marianjoy Rehabilitation Hospital, Wheaton, IL, USA, 4US Department of Veterans Affairs, Hunter Holmes McGuire VAMC, Richmond, VA, USA, 5Northshore University Health Systems, Evanston, IL, USA, 6The Rehabilitation Institute of Chicago, Chicago, IL, USA, 7University of IL at Chicago, Chicago, IL, USA, 8Captain James A Lovell VAMC, North Chicago, IL, USA, 9Northwestern Memorial Hospital, Chicago, IL, USA, 10Loyola University Chicago, Stritch School of Medicine, Maywood, IL, USA

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Objective: Rehabilitation for persons in states of seriously impaired consciousness (SIC) includes provision of sensory stimulation, but evidence regarding the therapeutic benefit is unclear. To address the need for clear evidence, thist study conducted a double blind randomized clinical trial to examine the neurobehavioural effect of Familiar Auditory Sensory Training (FAST) relative to placebo. The objective of this presentation is to present trial findings. Methods: Patients in states of SIC up to 12 months after traumatic brain injury (TBI) were recruited from two inpatient rehabilitation programmes and from an urban community. Subjects were randomized to either Placebo Silence or Experimental FAST. The FAST is context-dependent stimulation and consists of a familiar voice calling the subject’s name aloud followed by the same familiar voice telling a story about a familiar past event. FAST and Placebo interventions were provided 4-times daily, in 10 minute sessions, for 6 weeks. Neurobehavioural recovery was measured 2-times per week with the Coma-Near-Coma (CNC) scale. Functional Magnetic Resonance Imaging (fMRI) was used to measure neural activation in response to vocal, non-vocal, familiar and non-familiar auditory stimuli. Results: The FAST group (n ¼ 8), relative to Placebo (n ¼ 7), had significantly (p ¼ 0.0022) more neurobehavioural functioning each week (CNC slope difference ¼ 0.63 points; Mean Effect ¼ 1.884; Confidence Interval: 0.77, 3.0) and at end-point (6.2 CNC points). The FAST group, relative to placebo, also had significantly (p50.05) more neural activation at end-point within Wernicke’s region (mFAST ¼ 4.67 ± 1.5 voxels, mPlacebo ¼ 0.0 ± 0.0 voxels; p ¼ 0.034) and voxels, within the whole brain (mFAST ¼ 3431.3 ± 1277.2 mPlacebo ¼ 1039 ± 1422.1 voxels; p ¼ 0.034) in response to a non-familiar person telling a short story. The FAST group also had significantly greater activation at end-point to a familiar person calling the subject’s name aloud within the whole brain (mFAST ¼ 1338.3 ± 698.2, mPlacebo ¼ 206.6 ± 172.3; CI: 49.1, 1,885.6; t ¼ 3.1653df ; p ¼ 0.045). Conclusions: As hypothesized, the FAST protocol provided for at least 28 days improves neurobehavioural functioning for persons remaining in states of SIC for 50–80 days after severe TBI. The FAST group’s neurobehavioural gains are associated with enhanced neural responsivity within language dominant brain regions and within the whole brain to non-familiar and familiar auditory stimulation.

Brain Inj, 2014; 28(5–6): 517–878


Whose head hurts in Alaska? TBI trends and disparities Hillary Strayer1,2, & Mary Paige Lucas1,2 1 2

Alaska Native Tribal Health Consortium, Anchorage, Alaska, USA, Alaska Brain Injury Network, Anchorage, Alaska, USA

Introduction: According to the Centers for Disease Control and Prevention, the Alaska Native/American Indian (AN/AI) population has one of the highest rates of traumatic brain injury (TBI) in the US. People who acquire a TBI can experience severe or long-term life changes. Understanding how best to use limited funding for prevention and care is critical. This project determined the magnitude of TBI occurrence in Alaska and how it changed over time. It identified disparities based on demographic characteristics, activity at the time of injury and alcohol involvement. Method: The State of Alaska Trauma Registry provided data on all injury hospitalizations in Alaska from 1992–2011. For the time trend, rates were calculated in 4-year intervals from 1992–2011. For other rates, the most recent 5 years (2007–2011) were examined. Results: From 2007–2011, there were 3353 hospitalizations in Alaska for TBI out of a total of 22 669 injury hospitalizations (15%). AN/AI had 2.3-times the risk of TBI as non-Natives (176 vs 76 per 100 000, respectively). Regional rates ranged from the Aleutian Pribilof Islands (40 per 100 000) to the Northwest Arctic (269 per 100 000). The age groups with the highest rates were ages 20–29 for AN/AI (247 per 100 000) and age 70 and older for both AN/AI and non-Native (307 and 309 per 100 000, respectively). Over the full 20-year period examined (1992–2011), only non-Native males showed a significant decrease in the rate of TBI hospitalizations (p50.05).


Association between lowest prehospital systolic blood pressure and mortality in major traumatic brain injury: Is there a ‘hypotension’ threshold? Daniel Spaite1, Uwe Stolz1, Bentley Bobrow2, Vatsal Chikani2, Duane Sherrill3, Michael Sotelo1, Bruce Barnhart1, Joshua Gaither1, David Adelson4, Chad Viscusi1, Terry Mullins2, Will Humble2, & Kurt Denninghoff1 1

Arizona Emergency Medicine Research Center, College of Medicine, The University of Arizona, Tucson, AZ, USA, 2Arizona Department of Health Services, Phoenix, AZ, USA, 3College of Public Health, The University of Arizona, Tucson, AZ, USA, 4Barrow Neurological Institute at Phoenix Children’s Hospital and Department of Child Health/ Neurosurgery, College of Medicine, The University of Arizona, Phoenix, AZ, USA Purpose/background: The current pre-hospital traumatic brain injury (TBI) guidelines utilize an SBP threshold of 590 mmHg for treating hypotension in patients 10 years. This is supported by literature showing higher mortality when cohorts of patients with SBP 590 mmHg vs 90 mmHg are compared. However, the use of this threshold is limited by: (1) the studies nearly always dichotomized SBP (rather than assessing it as a continuous variable), (2) the thresholds


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DOI: 10.3109/02699052.2014.892379

evaluated in the literature ranged from 79–100 mmHg and any ‘cut-point’ in this range showed higher mortality in the ‘hypotensive’ cohort and (3) the recognition within the published guidelines that the threshold was primarily developed from statistical, rather than physiological, perspectives. Hypothesis: In a statewide, multi-system evaluation of major TBI, no statistically-supportable SBP vs mortality cut-point or threshold will emerge from the data when evaluated a priori and without reference to any given definition for ‘hypotension’. Methods: All moderate/severe TBI cases (CDC Barell Matrix Type-1) in the Excellence in Pre-hospital Injury Care (EPIC) TBI Study (NIH/NINDS: 1R01NS071049; from 1 January 2008–31 December 2011 were evaluated [exclusions: age 510, transfers, pre-hospital death, missing EMS SBP (3.0%)]. The sub-set of patients with SBP between 40–130 mmHg (study population) were assessed using fractional polynomials and logistic regression (LR) to determine the relationship between SBP and mortality. The adjusted odds ratio (aOR) for death across this range of SBP was analysed by controlling for important independent risk factors and confounders. Results: In total, 3950 patients met inclusion criteria. SBP was linearly associated with the log odds (logit) of death and no statistical transformation improved the model fit compared to the un-transformed (linear) values of SBP. LR showed that each 5-point increase of SBP decreased the odds of death by 14.8% (OR ¼ 0.852, 95% CI ¼ 0.828–0.877) across the range of SBP from 40–130 mmHg. After controlling for ISS, AIS-Head, pre-hospital airway management, age, sex and payor, this linear relationship held up with an aOR for death of 0.936 (0.903–0.970) for each 5 mmHg increase in SBP (e.g. a patient with SBP ¼ 110 has an aOR for death of 0.892 compared to a patient with SBP ¼ 100 and so on throughout the entire range). Conclusion: In major TBI, a linear relationship was found between lowest pre-hospital SBP and severity-adjusted probability of mortality across an exceptionally wide range. This suggests that: (1) the concept that 90 mmHg represents a unique or important ‘cut-point’ may not be true and (2) for the injured brain, clinically meaningful ‘hypotension’ may not be as low as current guidelines suggest. The fact that the adjusted odds of death increase as much for a 10-point drop in SBP from 110 to 100 mmHg as for 100 to 90, suggests that the optimal treatment threshold may be higher than 90 mmHg. Specific trials comparing various BP treatment thresholds are needed.


The relationship between erectile dysfunction, dysexecutive impairment and mental health in men with traumatic brain injury

controls did not report any history of depression, anxiety, psychiatric disorders or sexual difficulties. The TBI sample consisted of men with an average age of 37.2 years (SD ¼ 10), 10 years of education (SD ¼ 3) and an average Glasgow Coma Scale (GCS) at admission of 8.42 (SD ¼ 3.9). The men were on average 25.13 months post-injury (SD ¼ 17.9). The healthy controls were men with an average age of 38.3 years (SD ¼ 10.8) and 10 years of education (SD ¼ 2.8). Groups were comparable in terms of age, t(60) ¼ 0.390, p ¼ 0.698, and education, t(60) ¼ 0.086, p ¼ 0.932. Erectile dysfunction was assessed with the 5-item self-report Sexual Health Inventory for Men (SHIM), symptoms of dysexecutive impairment with the 20-item Dysexecutive Questionnaire (DEX), anxiety symptoms with 7-item Generalized Anxiety Disorder Scale (GAD-7) and depressive symptoms with the 9-item Patient Health Questionnaire (PHQ-9). Results: A MANOVA comparing individuals with TBI and healthy controls on the SHIM, DEX, GAD and PHQ-9 was significant (p50.01). Compared to healthy controls, men with TBI reported more erectile dysfunction (p50.01), greater dysexecutive impairment (p50.01), higher anxiety (p50.01) and more symptoms of depression (p50.01). In addition, Pearson correlations showed that, in men with TBI, greater erectile dysfunction was significantly associated with higher overall dysexecutive impairment (r ¼ 0.487, p50.01), higher behavioural dysexecutive impairment (r ¼ 0.494, p50.01), higher emotional dysexecutive impairment (r ¼ 0.603, p50.01), higher anxiety (r ¼ 0.600, p50.01), more symptoms of depression (r ¼ 0.44, p50.05) and higher injury severity at admission (r ¼ 0.37, p50.05), but not with the number of months after the injury (r ¼ 0.030, p ¼ 0.81) or cognitive dysexecutive problems (r ¼ 0.030, p ¼ 0.059). Conclusions: Compared to healthy controls, men with TBI showed diminished erectile function, more dysexecutive impairment and worse mental health. In addition, men with TBI showing higher erectile dysfunction had higher injury severity, more behavioural/emotional dysexecutive symptoms and more anxiety/ depression. Future studies should further investigate the directionality of the associations between erectile function, mental health and dysexecutive impairment in order to establish effective treatment plans.


Mortality as a function of prehospital systolic blood pressure in major traumatic brain injury: What is the optimum pressure for survival?

Silvia Leonor Olivera Plaza , Edgar Ricardo Valdivia Tagarife1, Jhon Alexander Moreno2, Nataly Gonza´lez Gonza´lez1, Lillian Flores Stevens3, Paul B. Perrin4, & Juan Carlos Arango-Lasprilla5

Daniel Spaite1, Uwe Stolz1, Bentley Bobrow2, Joshua Gaither1, Vatsal Chikani2, Duane Sherrill3, Michael Sotelo1, Bruce Barnhart1, P. David Adelson4, Chad Viscusi1, Terry Mullins2, Will Humble2, & Kurt Denninghoff1


Universidad Surcolombiana, Neiva, Huila, Colombia, 2Centre de Re´adaptation Lucie-Bruneau, Montre´al, Que´bec, Canada, 3Hunter Holmes McGuire Department of Veterans Affairs Medical Center, Richmond, VA, USA, 4Virginia Commonwealth University, Richmond, VA, USA, 5IKERBASQUE, Basque Foundation for Science, Bilbao, Bizkaia, Spain


Arizona Emergency Medicine Research Center, University of Arizona, Tucson, AZ, USA, 2Arizona Department of Health Services, Phoenix, AZ, USA, 3College of Public Health, University of Arizona, Tucson, AZ, USA, 4Barrow Neurological Institute at Phoenix Children’s Hospital and Department of Child Health/Neurosurgery, College of Medicine, University of Arizona, Phoenix, AZ, USA

Objective: To explore the relationship between erectile dysfunction, mental health and dysexecutive impairment in men with TBI and healthy controls. Methods: Thirty-one men with mild-to-severe TBI and 31 healthy controls were recruited from one city in Colombia, South America. Individuals with TBI were recruited from a University Hospital and healthy controls were recruited from the general community. Healthy

Purpose/background: Hypotension is known to significantly increase mortality in traumatic brain injury (TBI). The EMS TBI guidelines recommend treating SBP590 in patients 10 years old. However, these published guidelines forthrightly state that the treatment thresholds were developed primarily from statistical analyses of normal adult and paediatric populations and that little is known about the optimal level of SBP in the setting of TBI. Since most clinical


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568 studies evaluating the association between SBP and mortality have focused nearly exclusively on hypotension, relatively little is known about the SBP range associated with optimal survival. This study evaluated mortality across the entire range of presenting SBP in major TBI patients. Methods: All moderate/severe TBI cases (CDC Barell Matrix Type-1) in the Excellence in Pre-hospital Injury Care (EPIC) Study cohort of the Arizona State Trauma Registry (NIH/NINDS: 1R01NS071049; from 1 January 2008 to 31 December 2011 were evaluated [exclusions: age 510, transfers, death before ED arrival, SBP 540 mmHg or 4300 mmHg, missing EMS SBP (3.0%)]. Fractional polynomials (FP) and logistic regression (LR) were used to determine the optimal transformation for SBP across the entire range of physiologically-plausible observed values (40–300 mmHg) and to identify the range of SBP associated with maximum probability of survival (both unadjusted and adjusted for ISS, AIS-Head, age, sex, payor source). Results: Among 8805 included patients, 2-power FP transformation was performed for the lowest pre-hospital value of SBP of 0.5, 0.5 (SBP1/2 + [SBP1/2  ln(SBP)]). This transformation produced a linear relationship between SBP and mortality in the logit scale and significantly improving model fit compared to no transformation (single order analysis). An unadjusted LR model with transformed SBP shows a pre-hospital SBP of 136 mmHg to be associated with the lowest probability of death (8.3%; 95% CI ¼ 7.7–8.9%). A plot of this model shows an approximately U-shaped curve with tight 95% CIs when probability of mortality is plotted vs SBP across its entire range (40–300 mmHg). The adjusted LR analysis shows that a pre-hospital SBP of 144 mmHg is associated with the lowest probability of death (9.7%; 95% CI ¼ 9.0–10.3%). Conclusions: In this multi-system analysis of major TBI patients, an SBP between 130–150 mmHg was associated with the highest probability of survival. This was true even after controlling for injury severity and several other key confounders. In the risk-adjusted LR model, the optimal SBP value, associated with the lowest probability of death, was 144 mmHg. The U-shaped curve that results when SBP is plotted against probability of survival in this study suggests that the optimal range of SBP may be relatively narrow and that it may be significantly higher than previously thought. Further study is needed to confirm these findings and identify their potential therapeutic implications.


Rehabilitation needs of acquired brain injury survivors: Results from the TBI registry in Bangalore, India Gopalkrishna Gururaj, K. V. R. Shastri, B. A. Chandramouli, D. K. Subbakrishna, & Jess Kraus National Institute of Mental Health and Neuro Sciences, Bangalore, India Introduction: Traumatic brain injury is a leading cause if mortality, morbidity, disability and socioeconomic losses in India and many Low and Middle Income Countries, primarily due to increasing numbers of Road Traffic Injuries. The problem is likely to increase in the coming years due to growing motorization and infrastructure expansion amidst the absence of safety policies and programmes. However, information on the burden, pattern and impact of disabilities is not known to formulate Neurotrauma policies and programmes that include prevention, care and rehabilitation.

Brain Inj, 2014; 28(5–6): 517–878

Objectives: The objectives of the present study were to identify the nature and pattern of disabilities, socioeconomic impact and qualityof-life among survivors of neurotrauma in the rapidly motorizing city of Bangalore, India. Methods: A Neurotrauma registry was established at NIMHANS with the initial enrolment of 6900 first contact brain injured persons. Based on chosen criteria, 698 and 209 subjects were interviewed at home at 1 and 2 year post-discharge, respectively, by trained research officers using modified Barthel’s Index, Glasgow Outcome Scale (extended version) and WHO quality-of-life questionnaire to assess disability status, socioeconomic impact and quality-of-life after neurotrauma. Results: Post-discharge, 14% died at home or in other hospitals and 63% were continuing care. Whole significant numbers of those with mild injuries had recovered, nearly 35% had problems in health, social and economic dimensions at 1 year follow-up and 50% of them continued with problems at the second year also. Difficulties in activities of daily living (8%), memory impairment (14%), communication problems (7%), post-traumatic headache (19%) and behavioural problems (17%) were the common health problems. Nearly 20% of subjects had difficulties in day-to-day life. With regard to work status, 5% had shifted to part-time jobs, 3% were unemployed and 14% had changed to other jobs compared to pre-injury status. Moderate-to-severe levels of economic decline were experienced by 58% and 33% of families and the majority had to lose their savings or take extra loans. The quality-of-life was poor and unsatisfactory in 30% and 18% of subjects at 1 and 2 years after discharge from hospital. Conclusions: Traumatic brain injury survivors face extreme difficulties after trauma due to combined events. Integrated rehabilitation services along with developing skilled human resources and augmenting financial and social support are essential to meet the needs of tBI survivors. Undoubtedly, prevention of neurotrauma should receive greater importance in India and all low- and middleincome countries.


Objective assessment of upper extremity function in neurorehabilitation Kee Hao Leo1, Effie Chew2, & Wei Tech Ang3 1

Singapore Polytechnic, Singapore, 2National University Hospital, Singapore, 3Nanyang Technological University, Singapore Objective: To develop a criterion-referenced approach to objectively assess upper extremity (UE) functions in neurorehabilitation. Background: Clinical assessment of upper extremity function often lacks sensitivity, objectivity or attention to the quality of movement, while instrumented assessments are often time-consuming to perform and require skill to interpret. The reach-to-grasp task is an important functional movement in rehabilitation and is commonly assessed. It consists of three inter-dependent movement components, (i) orientation, (ii) transport and (iii) grasp. It is proposed that a finite number of motor strategies exist to co-ordinate these components. Hand transport tangential velocity (TVel) during reaching has previously been shown to be a sensitive marker of upper limb motor recovery. This study aims to define the criteria of a normal reach-to-grasp movement by establishing normative hand transport TVel curve for a reachto-grasp task and to assess its utility in assessing performance in stroke patients. Method: Sixteen healthy male subjects (48.7 ± 18.3 years) performed a horizontal reach-to-grasp task with a cylindrical object (7.5 cm diameter) located 30 cm medially from the dominant hand. Motion


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DOI: 10.3109/02699052.2014.892379

capture was performed using a Qualisys Oqus 8-camera system. Each movement trial was analysed by (i) max TVel, (ii) proportion time of max TVel, (iii) mean of proportion times of hand aperture closure initiation and max closing velocity and (iv) mean of proportion times of supination max acceleration and max velocity using k-means and silhouette statistics to identify the motor strategies employed by healthy individuals. A pilot trial was conducted with three hemiparetic stroke patients with differing degrees of motor impairment, to assess the utility of these motor strategies as a marker of motor recovery. Results: A total of 159 trials were analysed. Each trial was linearly time normalized by its movement duration. Significant amplitude and temporal variances were observed in the TVel curves. A group ensemble mean TVel (EM_TVel) was constructed using the pointby-point averaging method and a prediction interval (PI) was constructed assuming a t-distribution at each time point. The highest level of PI that does not contain negative values was 70%. Using k-means and silhouette statistics, this study identified three clusters of normative hand transport EM_TVel, suggesting three different motor strategies. The PI increased to 90% and successfully detected pathological movement in the three patients. Conclusion: Data analysis suggests that there are three motor strategies for normal reach-to-grasp movement characterized by three clusters of normative hand transport EM_TVel and this may be used as a criterion to assess pathological movement. This evaluation is quick and simple to perform and evaluates co-ordination of movement at the arm, forearm and hand simultaneously with great sensitivity. Such an evaluation is important in determining the efficacy of therapy. Larger studies are required to assess the validity of the identified motor strategies.


Verbal working memory deficits after paediatric brain tumour Jean-Michel Saury1, & Ingrid Emanuelson2 1

Queen Silvia Children’s Hospital, Go¨teborg, Sweden, The Sahlgrenska Academy at the University of Gothenburg, Go¨teborg, Sweden


Objectives: One of the most important activities in school-aged children is learning. A pre-requisite for learning is to maintain information in the working memory. After a brain tumour, children undergo treatment, which has a detrimental effect on neurocognitive functions. The purpose of the study is to investigate the verbal working memory of children treated for brain tumour in the posterior fossa compared to supratentorial tumours. Method: Twenty-one children (10 boys and 11 girls) with tumours in the posterior fossa (PF) were selected together with 19 children (seven boys and 12 girls) with supratentorial tumours (ST). They were evaluated with five measures of working memory: Digit Span Forward (DSF), Digit Span Backward (DSB) and Working Memory Index (WMI) from the age-relevant Wechsler Intelligence Scale, as well as the first trial (TRIAL1) and the interference list (TRIALB) from the Rey Auditory Verbal Learning Test. In the PF-group, the mean age at diagnosis was 7.56 years, all the children underwent surgery, 13 radiation, 14 chemotherapy and 11 of them had increased intracranial pressure (ICP) at diagnosis. In the ST-group, the mean age at diagnosis was 8.46 years, 18 children underwent surgery, 13 radiation, 11 chemotherapy and five children had high ICP at diagnosis. Results: Both groups of children treated for brain tumour demonstrated significant impairments on the five variables of working memory (DSF: p50.005; DSB: p50.05; TRIAL1: p50.001; TRIALB: p50.002; WMI: p50.002), with no significant difference between the two groups. High ICP at diagnosis was associated with significant decreases in performance for DSB in children with ST tumours

(p50.005) and in all children (p50.05) and showed a trend for low WMI in all children (p ¼ 0.097). When evaluating the effect of radiation, significant decreases were found in DSB in children with ST tumours (p50.05) and in all children (p50.02) on TRIALB in all children (p50.02) and as a trend on the WMI in children with PF tumours (p ¼ 0.051) and in all children (p ¼ 0.069). Treatment with chemotherapy had a significant negative effect on the performance of children with PF tumours (p50.02) and all children (p50.05) on the TRIALB and showed a trend in all children on the DSB (p ¼ 0.088). Conclusions: Paediatric brain tumour survivors demonstrate significant impairments in verbal working memory independently of tumour location. High intracranial pressure at diagnosis, as well as treatment with radiation and/or chemotherapy were found to impact the performance on working memory measures adversely, especially digit span backward, interference list and working memory index. The implications of these findings for rehabilitation are discussed.


Goal management training in patients with acquired brain injury—Preliminary results Sveinung Torna˚s1, Marianne Løvstad1, Anne-Kristin Solbakk2, Katja Høst3, Anne-Kristine Schanke1, & Jan Stubberud1 1

Sunnaas Rehabilitation Hospital, Nesodden, Norway, Oslo University Hospital, Department of Neurosurgery, Oslo, Norway, 3University of Oslo, Oslo, Norway Objectives: Goal Management TrainingTM (GMT) is a standardized compensatory cognitive rehabilitation intervention that relies on verbally mediated, metacognitive strategies for improving attention and problem-solving. This randomized controlled trial explored the efficacy of group-based GMT, compared to an alternative active control condition, Brain Health Workshop (BHW), in patients with MRIverified acquired brain injury. Both groups received ‘content free’ cuing between sessions. The aim of the study was to determine the efficacy of GMT, hypothesizing that GMT would reduce dysexecutive problems in everyday living. Methods: Preliminary results for 29 patients pre (T1) and post (T2) treatment are presented. All subjects underwent 16 hours of intervention, delivered in eight modules dispersed over 4 days of intervention, with 2 weeks between intervention days. Executive functioning in everyday living and emotional functioning was assessed with the Behaviour Rating Inventory of Executive Function (BRIEF-A) and the Symptom Checklist-90 Revised (SCL-90-R), respectively. IQ was obtained using the Wechsler Abbreviated Scale of Intelligence. Pairwise T-tests were employed to examine changes between T1 and T2. Significance level was set to p  0.05. Results: There were no significant group differences (GMT; n ¼ 19; BHW; n ¼ 13) with regard to age (GMT: 41.8 (SD ¼ 13.4); BHW: 31.1 (SD ¼ 13.2)), sex (GMT: 63% female; BHW: 31% female), level of education (GMT: 14.3 (SD ¼ 3.7); BHW: 13.4 (SD ¼ 2.9)) and IQ (GMT: 107.1 (SD ¼ 14.4); BHW: 101.8 (SD ¼ 12.8)). Only the GMT group demonstrated a significant treatment-related reduction in selfreported symptoms of executive dysfunction in everyday living, with lower scores on all three main indexes of the BRIEF-A; the Global Executive Composite, the Behavioural Regulation Index and the Metacognition Index. No significant changes were detected on the SCL-90-R post-intervention in either treatment group. Conclusions: Preliminary data from the first 29 patients receiving either GMT or an unspecific psychoeducational service delivered in group sessions indicated that GMT resulted in a specific effect on subjectively experienced executive functioning in everyday life. Similar findings were not observed in the BHW group. As SCL-90-R 2

570 scores were stable, a general improvement in emotional functioning did not seem to account for the observed treatment-related improvement of self-reported executive functioning.


Organization of rehabilitation and outcome after severe traumatic brain injury in the Scandinavian countries Cecilie Røe1, Alison Godbolt2, Catharina Nygren Deboussard2, Lars P. Kammersgaard3, Jørgen F. Nielsen4, Jørgen Borg2, & Nada Andelic1

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Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway, 2Department of Clinical Sciences, Karolinska Institute and University Department of Rehabilitation Medicine Stockholm, Danderyd Hospital, Stockholm, Sweden, 3Department of Neurorehabilitation/Traumatic Brain Injury Unit, Copenhagen University Hospital, Copenhagen, Denmark, 4Hammel Neurorehabilitation and Research Center, Aarhus University, Hammel, Denmark Objectives: The aims of this study were to assess differences in organization of rehabilitation and 1-year outcome of severe traumatic brain injury (TBI) in the Scandinavian countries. Methods: A prospective study of severe TBI based on the Danish TBI register and patients admitted to the Regional trauma centres in Sweden and Norway. Patients injured in 2010 with the diagnosis S06.1–S06.9, aged 18–65 years, Glasgow Coma Scale Score (GCS)  8 and in need of neurointensive care for at least 5 days were included. The study outcome as evaluated by GOSE was assessed at 1-year follow-up. Mann-Whitney U-tests were applied for comparison between countries. Ordinal regression analysis was used to evaluate global outcome with country as predictor and controlling for age, gender and GCS score. GOSE was categorized in dead/vegetative state, severe disability, moderate disability and good recovery for this analysis. Results: Of the 180 patients included, 18 were lost to follow-up at 12 months, leaving 162 subjects (56 from Denmark, 54 from Norway and 52 from Sweden), 80% men, with a median age of 38 (IQR ¼ 23–51) years. The subjects admitted to rehabilitation in Denmark had more severe TBI as evaluated by GCS (3.5, IQR ¼ 3–6) compared to the other Scandinavian countries (6.0, IQR ¼ 3–7 in Norway and 5, IQR ¼ 4–7 in Sweden) (p ¼ 0.003). Despite the higher severity levels, they were transferred to rehabilitation within 24 (IQR ¼ 7–36) days, compared to 20 (IQR ¼ 12–38) in Norway (p ¼ 0.005) and 30 (IQR ¼ 21–51) days in Sweden (p ¼ 0.01). The duration of rehabilitation was 90 (IQR ¼ 56– 147) days in Denmark compared to 60 (IQR ¼ 35–91) days in Norway (p ¼ 0.02) and 69 (IQR ¼ 34–113) days in Sweden (p ¼ 0.02). The total length of stay in hospital during the first year was longer in Denmark, at 114 (IQR ¼ 80–172) days compared to Norway, at 83 (IQR ¼ 57–139) days (p ¼ 0.02), whereas the length of stay was similar to Sweden, at 117 (IQR ¼ 69–189) days (p ¼ 0.53). The global outcome level evaluated by GOSE in Denmark (GOSE 5; IQR ¼ 3–5) was lower than in Norway (GOSE 6; IQR ¼ 5–7) (p ¼ 0.001) and quite similar to Sweden (GOSE 5; IQR ¼ 3–7). Global outcome remained different between countries after controlling for age, gender and brain injury severity (p50.001). Conclusion: Injury severity, as well as initiation of rehabilitation and length of in-patient rehabilitation after severe TBI varied between the Scandinavian countries, at least as recorded in the data registers. These differences are a major challenge when comparing treatment and outcome in the Scandinavian countries.

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The fibrotic scar is a major impediment for axonal regeneration after traumatic brain injury Hitoshi Kawano1, Junko Kimura-Kuroda1, Yukari Komuta1, Hong-Peng Li2, & Kosei Takeuchi3 1

Department of Brain Development and Neural Regeneration, Tokyo Metropolitan Institute of Medical Science, Tokyo, Japan, 2Department of Human Anatomy, College of Basic Medical Sciences, China Medical University, Shenyang, PR China, 3Department of Molecular Biology and Biochemistry, School of Medicine, Niigata University, Niigata, Japan

In the central nervous system (CNS) of adult mammals, transected axons display almost no regenerative capacity following traumatic injury. Various kinds of factors which occur around the lesion site, such as glial scar and chorndoitin sulphate proteoglycans, have been postulated to prevent the re-growth of severed axons. A fibrotic scar containing deposition of type IV collagen (Col IV) is also considered as an impediment for axonal regeneration. After traumatic injury, meningeal fibroblasts migrate in the lesion site, proliferate and secrete Col IV to form the fibrotic scar. This study has demonstrated that suppression of the fibrotic scar formation is required for axonal regeneration in the damaged CNS in a variety of animal models, such as (1) suppression of Col IV synthesis, (2) newborn mouse, (3) the mouse hypothalamic arcuate nucleus, (4) degradation of glycoaminoglycan side chains of chondroitin sulphate proteoglycans with chondroitinase ABC, (5) transplantation of olfactory ensheathing cells and (6) suppression of transforming growth factor- (TGF-) function. Addition of TGF-1 to the co-culture of meningeal fibroblasts and cerebral astrocytes induced a fibrotic scar-like cell cluster which repels neurites of cerebellar neurons. The fibrotic scar and TGF-1-induced cell cluster intensely expressed both dermatan sulphate (DS) and condroitin sulphate (CS). Administration of enzymes specifically degrading DS or CS in injured brains and in cell culture demonstrated that DS is involved in the fibrotic scar formation and CS inhibits axonal regeneration. This study proposes that the elimination of the fibrotic scar would be a reliable strategy to promote axonal regeneration in the damaged CNS.


Biopsychosocial elements in posttraumatic headache: Emotional distress and family functioning Moran Bar-Hen1, Motti Ratmansky2, Nathan D. Zasler3,4, Avraham Schweiger1, & Yaron Sacher2 1

Academic College of Tel Aviv, Tel Aviv, Israel, 2Loewenstein Rehabilitation Hospital, Raanana, Israel, 3Concussion Care Centre of Virginia, Richmond, VA, USA, 4VCU Department of Physical Medicine and Rehabilitation, Richmond, VA, USA Introduction: According to a biopsychosocial model of pain, posttraumatic headache (PTH) is not merely a psychosomatic or


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DOI: 10.3109/02699052.2014.892379

physiological phenomenon, but rather it is affected by social and cultural factors, which play a major role in the aetiology and maintenance of this pain condition. The aim of this study was to identify the biopsychosocial contributors to PTH. Preliminary findings are reported here. Method: Thirty-seven TBI patients hospitalized at Loewenstein Hospital in Israel completed four questionnaires regarding headaches, general psychological distress (BSI), coping strategies with pain (CSQ) and family functioning (FF). All participants completed also a standardized effort measure (TOMM). For each participant, one family member also completed the Family Functioning Questionnaire. Three patients were excluded due to poor effort on testing. Results: The results suggest a relationship between elevated psychological distress and prevalence of PTH: Multivariate ANOVA was performed using the BSI’s Indexes in order to compare the two groups (headaches/no headaches). This analysis did not yield an overall significant difference between the groups (Lambda ¼ 0.707, p ¼ 0.69). However, further exploration using univariate analyses showed that patients who reported headaches, scored significantly higher on the somatization, depression and anxiety indexes. In order to test the different coping strategies, a Multivariate ANOVA was performed, using the CSQ Index to compare the two groups (headache/no headache). This analysis did not yield a significant difference (Lambda ¼ 2.236, p ¼ 0.07). However, the univariate analyses showed that patients who did not report headaches used coping strategies (such as Diverting attention, Ignoring pain, Self-statements coping, Increasing behaviour activity, Increasing pain behaviour, Reinterpreting pain sensation) significantly more frequently than patients who reported headaches. To test the perception of family functioning (FF) by patients vs their family members, the difference between the family member and the patients was calculated and Multivariate ANOVA test was performed to compare the two groups. This analysis did not yield a significant difference (Lambda ¼ 1.34, p ¼ 0.29). Stepwise Logistic Regression was performed to examine the relations between psychological distress and coping strategies, to the presence of headaches revealed overall classification accuracy of 85.7% for the two groups, using ‘somatization’ (OR ¼ 1.433, CI ¼ 1.06–2.02, p ¼ 0.04) and ‘coping selfstatements’ variables (OR ¼ 0.811, CI ¼ 0.654–1.006, p ¼ 0.057). Discussion: The results of the present study suggest that psychological distress and utilization coping strategies in the presence of pain are related to the reports of headaches among patients with TBI. In contrast, the difference between patients’ and their family members’ perception of family functioning was not related to the presence of headaches. The authors are presently exploring the effect of perceived family functioning per se on the presence and severity headaches.

healthcare in EU countries. It has been developing since 1977 and originates from special education teacher Andreas Frohlich from Germany. BS conception is to perceive the patient overall. The loss of the ability to move and lack of stimulation from the surrounding environment leads to sensomotoric deprivation and afterwards to an insufficient neuron network. BS makes individual structured care based on biographical anamnesis which is taken from patients close family or friends. This concept respects and supports a patient’s abilities of communication, perception and locomotion that stayed intact. The technique of BS concept is to set up realistic goals and a proper therapeutic plan after receiving proper autobiographic anamnesis, to follow with continuous evaluations of patient’s reactions on applied stimulation and integration. Patient’s response would be feeling of the own life and body, experiencing motion, realizing a change of position or discovering the inside with the help of different kinds of stimulation or positioning; experiencing security and building trust, developing the own rhythm, experience the outside world, establishing relationships and arranging interactions, responsibility. Methods: Basic techniques of BS are somatic stimulation (special massage, positioning, breathing stimulation), vestibular stimulation (head position), vibrational stimulation (use of tuning fork, vibrators). Advanced techniques of BS are optical stimulation (watching), audio stimulation (listening), tactile-haptic stimulation (sense of touch, pressure, tension, cold and warm, etc.), olfactory stimulation (sense of smell) and oral stimulation (sense of taste). Conclusion: BS is s concept that stimulates development of the basic level of human perception and communication. Continuous stimulation of sense organs facilitate formation of new dendritic connections in the brain and new neuronal establishment in certain regions of the brain. This leads to reproduction of memory imprints inside the brain. BS reduces stress.


Roles of chondroitin sulphate and dermatan sulphate in the scar formation and axonal regeneration after traumatic brain injury Hong-Peng Li, Hitoshi Kawano, Yong-Xin Sun, & Xiao-Hong Wang China Medical University, Shenyang, PR China


Basal (basic) stimulation in physiotherapy Barbora Kalousova Security Forces Hospital, Riyadh, Saudi Arabia Objectives: Basal stimulation is communication, interaction and progress supporting stimulation concept that focus on all aspects of human needs. BS care is adjusted according to the age and condition of the patient. This concept has great value in care, ranging from neonatal intensive care up to adults; people who are unconscious, disoriented, somnolent or have artificial respiration applied to them. They suffer from craniocerebral trauma, hypoxic brain damage, Alzheimer’s disease or a hemiplegic, apalic or comatose syndrome. BS is one of the most popular concepts in

After traumatic brain injury, various kinds of chondroitin sulphate (CS) proteoglycans are up-regulated around the lesion site. Dermatan sulphate (DS) is synthesized from CS by epimerization of glucuronic acid of CS to yield iduronic acid. This study examined the roles of CS and DS in the scar formation and axonal regeneration in an injured brain and in cell culture. In in vivo experiments, the mice received transection of nigrostriatal dopaminergic pathway followed by injection of glycosaminoglycan degrading enzymes into the lesion site. Two weeks after injury, fibrotic and glial scars were formed around the lesion and transected axons did not regenerate beyond the fibrotic scar. Injection of chondroitinase ABC (ChABC) which degrades both CS and DS completely suppressed the fibrotic scar formation, reduced the glial scar and promoted the regeneration of dopaminergic axons. Injection of the DS-degrading enzyme chondroitinase B (ChB) also yielded similar results. In contrast, injection of chondroitinase AC (ChAC), a CS-degrading enzyme, did not suppress the fibrotic and glial scar formation, but reduced CS immunoreactivity and promoted the axonal regeneration. In cell culture experiments, addition of transforming growth factor-1 (TGF-1) to a co-culture of

572 meningeal fibroblasts and cerebral astrocytes induces a fibrotic scarlike cell cluster. The effect of TGF-1 on cluster formation was suppressed by treatment with ChABC or ChB, but not by ChAC. TGF1-induced cell cluster repelled neurites of neonatal cerebellar neurons and addition of ChABC or ChAC suppressed the inhibitory property of clusters on neurite outgrowth. The present study is the first to demonstrate that DS and CS play different roles after traumatic brain injury: DS is involved in the lesion scar formation and CS inhibits axonal regeneration.


Assessment executive function in pre-school age: BRIEF-P and ECI scales Esperanza Bausela Herreras

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UNIR, Madrid, Spain Introduction: There are several instruments by means of which parents and/or professors can evaluate the executive function (diverse dimensions of the same) of a boy along a period of time, generally not very long, assigning values to the items that compose the listing or checklist or in a format of scale type Likert. Aim: This paper analyses diverse instruments of assessment of the executive function considering the contributions of diverse informants, parents and teachers, in two of them: BRIEF-P and ECI scales. Of all the instruments, perhaps the most known in English speech are the Behaviour Rating Inventory of Executive Function (BRIEF), being in its pre-school version the object of this project, that allows one to surpass limitations and lagunas identified in this field (BRIEF-P). It is composed of two versions, one for parents and another for professors, designed to assess the executive function in the home and in the school. It is configured by 63 items, that organize around five scales (Inhibition, Shift, Emotional Control, Memory of Work, Planning/Organization), three clinical indexes (Inhibitory Self-supervision, Flexibility and Emergent Metacognition) and a Compound Index Global Executive; it has, besides, two scales: Inconsistency and Negativity. The Scales of Childish Behaviour (ECI-Professors and ECI-Parents) have been adapted for a Spanish population. They are scales of qualification (‘rating scales’) that allow one to differentiate between boys with deficits in attention (not necessarily hyperactivity) and boys with hyperactivity (not necessarily with attention deficits). It is configured by 37 items that group around four scales: school interest, attention, activity and learning. This study analyses the concurrent validity between parents and teachers obtained in the instruments ECI and BRIEF-P in the samples used in the process of normalization.


Cost of traumatic brain injury from biking accidents with or without helmet use Jehane H. Dagher, Camille Costa, Elaine de Guise, & Mitra Feyz Montreal General Hospital, Montreal, Quebec, Canada Rationale: Considering the Canadian context of publicly-funded healthcare and the recent cutbacks in healthcare funding, determining societal costs of disease may help better allocate funding to

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effective preventative measures. Furthermore, with the relatively recent increase of interest and uptake of cycling amongst Quebecers, this study evaluating traumatic brain injury (TBI) outcomes and costs in helmet and non-helmet wearers comes at an opportune time. The setting of Montreal is ideal to evaluate the effects of helmet wearing among cyclists, since there are no helmet laws in the province of Quebec. Objective: The goals of this project are to determine whether there is a difference or not in health outcomes and societal financial burden from TBIs in patients who wear helmets compared to those who do not. Methods: This was a retrospective observational study of all patients (143) admitted to the Montreal General Hospital (MGH) following a TBI that occurred while cycling between 1 April 2007 and 31 March 2011. Information was collected from the trauma database and all charts were manually evaluated for added completeness. The independent variables collected were socio-demographic, helmet status, clinical, medical and neurological patient information. The dependent variables evaluated were length of stay in days (total and in ICU), Extended Glasgow Outcome Scale collected at discharge from hospital, ISS, discharge destination, death, direct medical costs and societal costs. Results: Pending. Conclusion: Persons who sustain a TBI undergo an abrupt transformation from living in a healthy state to surviving a life-threatening situation to eventually coping with a state of chronic illness. The physical, cognitive and psychosocial functioning impairments associated with TBI can be far reaching and can result in a significant change in the afflicted person’s life-course, an extreme loss of income or earning potential and a profound disruption to the family unit, which may lead to tertiary costs such as the reduction of employment for family members in order to care for a disabled relative and treatment of caregiver burnout. Helmet use while cycling is one prevention method that can be used to decrease the burden of TBI on patients, their families and society.


Mental fatigue scale and its relation to cognitive, social and emotional functioning after a TBI or stroke Birgitta Johansson, & Lars Ro¨nnba¨ck Department of Clinical Neuroscience and Rehabilitation, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden Objectives: After a traumatic brain injury (TBI) or stroke, long-term mental fatigue may occur. It takes more energy to deal with cognitive and emotional issues with significant impact on work and social interactions. A more in-depth assessment of mental fatigue is required and it is necessary to increase the knowledge of factors which are relevant to mental fatigue. The purpose here is to present a validation of the Mental Fatigue Scale (MFS) and how the scale is related to cognitive and emotional functioning. Scholars have been using the MFS since 2008 in research. The amount of information that has been collected has increased research knowledge of the scale. With the use of these data, the purpose has been to validate the MFS and its connection to cognitive and emotional functioning Methods: Healthy controls and well-rehabilitated subjects suffering from long-term mental fatigue after a TBI or stroke, between 19–69 years of age, were included in the study. For validation of the MFS, self-assessment scales were used measuring fatigue (MFS), depression, anxiety (Comprehensive Psychopathological Rating Scale), executive functioning (Behaviour Rating Inventory of Executive


DOI: 10.3109/02699052.2014.892379

Function–Adult version) and social activities (Frenchay activity index). Neuropsychological tests measuring information processing speed (digit symbol coding, WAIS-III), attention (Trail Making Test (TMT) A and B) and working memory (digit span, WAIS-III) were also used. Results: The results showed MFS to be invariant to age, gender and education. A cut-off score of 10.5 is proposed and the cut-off score significantly distinguishes healthy controls from mental fatigue subjects. Information processing speed was a significant predictor for the rating on MFS. Conclusions: A more in-depth assessment of mental fatigue is required and it is necessary to increase the knowledge of the various factors which are relevant to mental fatigue. It has been shown in this study that the MFS is linked to cognitive functioning and that depression and mental fatigue must be treated as separate constructs.

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Evaluation effects of methylphenidate on posttraumatic brain injury symptoms with focus on mental fatigue and pain Birgitta Johansson1, Anna-Pia Wentzel2, Paulin Andre´ll2, Clas Mannheimer2, & Lars Ro¨nnba¨ck1 1

Department of Clinical Neuroscience and Rehabilitation, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden, 2Department of Molecular and Clinical Medicine/Multidisciplinary Pain Center, Sahlgrenska University Hospital, Institute of Medicine, Gothenburg University, Gothenburg, Sweden Objectives: Fatigue after traumatic brain injury (TBI) is common, but often overlooked. However, for people fighting their fatigue after brain injury day after day, fatigue is a major problem. This post-injury mental fatigue is characterized by limited energy reserves to accomplish ordinary daily activities. A normal, well-functioning, brain performs mental activities simultaneously throughout the day, but, after a brain injury, it takes greater energy levels to deal with cognitive and emotional situations. The neurobehavioural symptoms and pain following traumatic brain injury (TBI) can be long-lasting. The condition impairs the persons’ ability to function in their work, studies and gatherings with family and friends. The aim of this study was to investigate dosage, safety and effects of methylphenidate on mental fatigue, pain and cognitive function. Methods: Fifty-four physically well-rehabilitated TBI victims, most with a mild TBI and also with pain in the neck, shoulders and head were included. Methylphenidate was tested in each patient using three treatment strategies: no medication, low dose (5 mg  3) and normal dose (20 mg  3) for 4 weeks using a randomized cross-over design. All the participants were suffering from mental fatigue at least 1 year after a brain injury. Results: Forty-four patients completed the three treatment periods. Methylphenidate significantly decreased mental fatigue as evaluated by the Mental Fatigue Scale (p50.001) and the effects on mental fatigue were dose-dependent. No effect on pain was detected. Methylphenidate also improved information processing speed significantly (p ¼ 0.038). Ten withdraw due to adverse effects. These subjects did not experience positive effects of any significance and, among those, nine females also reported high blood pressure, increased heart rate, depressive mood and anxiety. Conclusions: Methylphenidate decreased mental fatigue and improved processing speed for subjects suffering a TBI. The treatment is considered to be safe. Pain was rated high by most of the subjects

in this study, but no changes were reported. However, it is important to note that pain can hide post-traumatic brain injury symptoms which are not always connected to the pain itself.


Evaluation of an advanced mindfulness programme following a mindfulness-based stress reduction programme for participants suffering from mental fatigue after acquired brain injury Birgitta Johansson, Helena Bjuhr, & Lars Ro¨nnba¨ck Department of Clinical Neuroscience and Rehabilitation, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden Objectives: Mental fatigue is, for many, a very distressing and longterm problem after a traumatic brain injury (TBI) or stroke. This will make it more difficult for the individual to return-to-work and resume social activities and it can take several years to find the right balance between rest and activity in daily life, to find strategies and to accept the new situation. The aim of this study was to evaluate the effect of an advanced mindfulness programme following an 8 week MBSR programme, designed for subjects suffering from long-term mental fatigue after a brain injury. The advanced programme was based on The Brahma Viharas, meditative practices known for cultivating four mental states; compassion, metta (metta is often translated into English as loving–kindness but this does not capture the full sense of the word), appreciative joy and equanimity. Methods: Fourteen participants followed an 8-month programme with monthly group meetings (2.5 hours) and the programme concluded with an all-day retreat. Eight participants had suffered a stroke (five females, three males) and six participants a TBI (four females, two males, including one TBI and five mild TBI). The mean age was 58. All the participants were suffering from mental fatigue at least 1 year after a brain injury following a stroke or a TBI. Results: All participants completed the advanced programme. The assessments after the advanced programme showed a significant and sustained positive effect on mental fatigue and on tests measuring information processing speed and attention. The comments after the advanced programme indicated a deepening of their understanding of mindfulness practice. They also learned how this had become a natural part of their every-day lives. The insight dialogue helped participants to develop new ways of talking and listening which they experienced with a sense of relief and they found this to be less demanding on energy levels. Metta and compassion meditation were imbedded in the whole programme. It was noticeable that the participants expressed more of the positive feelings and the feelings of joy after practicing compassion and metta meditation in the class. A growing overall attitude of acceptance of oneself and others was reported, especially during the final sessions. More joy, happiness and satisfaction with life were reported. Conclusions: The results of this work and a previous MBSR study demonstrate that mindfulness practice may be a therapeutic method well-suited to subjects suffering from mental fatigue after a brain injury. Despite the problem of ensuring that participants stay awake, which is one of the fundamental aspects of practicing meditation, it was possible to adjust mindfulness to suit the needs of mental fatigue subjects and to improve their wakefulness as well as reducing their mental fatigue levels.



Use the app—Measure mental fatigue—Take control Birgitta Johansson1, Jan-Olof Karlsson2, & Lars Ro¨nnba¨ck1 1

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Department of Clinical Neuroscience and Rehabilitation, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden, 2University West, Department of Economy and Informatics, Trollha¨ttan, Sweden Objectives: Fatigue after an acquired brain injury is common and is characterized by limited energy reserves to accomplish ordinary daily activities. A typical characteristic of mental fatigue is that the mental exhaustion becomes pronounced during sensory stimulation or when cognitive tasks are performed for extended periods without breaks. There is a drain of mental energy upon mental activity in situations in which there is an invasion of the senses with an overload of impressions and in noisy and hectic environments. Another typical feature is a disproportionally long recovery time needed to restore the mental energy levels after being mentally exhausted. The mental fatigue is also dependent on the total activity level as well as the nature of the demands of daily activities. For many people, there is an increased risk of doing too much and becoming even more fatigued. Methods: The authors have developed an application for Windows Phone for assessment of mental fatigue. The Mental Fatigue Scale is used. The MFS is a multidimensional questionnaire containing 15 questions. The questions included in the MFS are based on symptoms described following longitudinal studies of patients with TBI, brain tumours, infections or inflammations in the nervous system, vascular brain diseases and other brain disorders. The app also includes information about mental fatigue. Results: This application can help people determine the level of mental fatigue and it can also serve to provide an overall picture of the severity of the condition and detect changes in mental fatigue over time. The scores will be added up and the results will be presented in the form of a rating scale and a diagram. People can then see their results for 1 week ago, 1 month ago or a whole year ago. Today, the most important recommendations are to adapt to the energy available by doing one thing at a time, resting regularly and not overdoing things. However, this is challenging for most people and it may take a long time, even years, to adapt to a sustainable level. It may also be difficult for the person to learn by himself/herself and it can take several years of considerable struggle, frustration, despair and depression to find the right balance between rest and activity. This app can help people to be aware of mental fatigue. If they connect the results to daily activities, the app may also help them to be more aware about what may alleviate and what may make mental fatigue worse. Conclusions: With regular assessment of mental fatigue, this app may give feedback and support in order to achieve an enduring balance between activities and rest. The application can be downloaded without cost: mental-fatigue/87d4cb88-c9b5-4ac9-9a92-b63a5d8f4d82

Brain Inj, 2014; 28(5–6): 517–878

Michael Boivin1, Bruno Giordani2, Paul Bangirana3, Alla Sikorskii1, Noeline Nakasujja3, Brian Winn1, Bryan Novak1, & Robert Opoka3 1

Michigan State University, East Lansing, MI, USA, 2University of Michigan, Ann Arbor, MI, USA, 3Makerere University, Kampala, Uganda

Objectives: The study population was school-age children infected with HIV in an impoverished rural district in south-central Uganda. The purpose of this study was to compare the neuropsychological benefit of 24 training sessions of Captain’s Log computerized cognitive rehabilitation training (CCRT) compared to an active control (limited Captain’s Log locked at the simplest levels of training) and passive control (no intervention) group over a 2-month period (24 sessions over 8 weeks) and at 3-month follow-up post-training. Methods: School-aged children (9–12 years of age) were randomly assigned to receive either CCRT intervention delivered via Captain’s Log ( or a limited, non-adaptive version of Captain’s log (active control). The third group was a passive control group receiving no computer training between baseline and 2-month neuropsychology assessment. All children were assessed at intake, 2 months (immediately post-intervention) and at 5 months after enrolment. The neuropsychological battery consisted of the Kaufman Assessment Battery for Children, 2nd ed. (KABC-2), the CogState computerized cognitive evaluation (, the computerized Tests of Variables of Attention (TOVA;, the Behaviour Rating Inventory of Executive Function (BRIEF) and the Achenbach Child Behaviour Checklist (CBCL). Results: At present, 144 children have completed the intake assessment (72 girls, 72 boys) and 106 completed the 5-month follow-up. Treatment arms were compared on all assessment outcomes using an ANCOVA analysis with baseline age, caregiver relationship to the child, quality of home environment, socioeconomic status, HAART treatment status at baseline and viral load and CD8 activation at 2 and 5 months as time-varying covariates. The full CCRT group had significantly greater gains compared to passive controls on overall KABC-II performance (p ¼ 0.02), Learning (p ¼ 0.04) and Planning/Reasoning (p ¼ 0.08). They also had significantly greater gains on CogState maze learning (p50.001) and working memory (p ¼ 0.04). Performance gains for the limited Captain’s Log (active control) were similar to the full CCRT group. Also, differences between limited Captain’s Log active and passive controls were similar to the differences between Captain’s Log full CCRT and passive controls, but smaller in magnitude. Conclusions: Twenty-four sessions of Captain’s Log CCRT can enhance higher-order learning performance and executive function in HIVinfected children in a low-resource setting. The authors are now in the process of field testing an African village version of CCRT (Brain Powered Games; BPG) developed at Michigan State University. BPG is being implemented with the passive control group (n ¼ 50) and significant CogState working memory and TOVA attention gains are being seen. BPG has the advantage in that it has been coded for scaling to a mobile network platform, found throughout the developing world. BPG will be used for both cognitive assessment and rehabilitative training in resource-poor global settings.

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Computerized cognitive rehabilitation training can improve neuropsychological outcomes in rural school-age Ugandan children with HIV

Brain plasticity after implanted drop foot stimulator in chronic stroke Aurore Thibaut1, Olivia Gosseries1, Paul Filipetti2, Fre´de´ric Chantraine2, Florent Moissinet2, Ce´line Schreiber2, & Steven Laureys1


DOI: 10.3109/02699052.2014.892379 1

University of Lie`ge, Coma Science Group, Lie`ge, Belgium, Rehazenter, Luxembourg, Luxembourg

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Objective: This study assessed regional changes in cerebral metabolism using positron emission tomography (PET) 1 year after an implanted drop foot stimulator system in chronic stroke patients. Methods: [18F]-fluorodeoxyglucose-PET was prospectively acquired in four stroke patients with drop foot before and 1 year after the activation of a 4-channel stimulator ActiGait, which selectively and directly stimulates the fibular nerve (mean age: 43 ± 18 years, three men, time since injury: 32 ± 5 months, two left and two right median cerebral artery stroke). Data were pre-processed and analysed by means of statistical parametric mapping (SPM8), with PET images of right-sided stroke patients being flipped. Results: The implanted drop foot stimulator system improved gait speed, walking endurance and the physiology of ankle joint kinematics. Prior to treatment, FDG-PET showed a significant decrease in metabolism in pre-motor and supplementary motor cortices and left thalamus, contralateral to the paralysed side. After 1 year of implanted fibular nerve stimulation, regional metabolism increased in pre-motor and supplementary motor cortices. Conclusion: Clinical improvement of gait after unilateral fibular nerve stimulation in chronic drop foot is paralleled by metabolic changes in the contralateral motor network.


In-vivo two-photon imaging of impaired balance between neuronal excitation/inhibition and acute vascular trauma in somatosensory cortex correlates with growth of microinfarcts following CCI injury in mice

microinfarct after TBI and sham surgery in acute and chronic TBI. In addition, the loss or disruption of functionally evoked neuronal population activity in the core of the microinfarct was assessed by imaging in the relatively large hindlimb region of the primary somatosensory cortex, where peripheral electrical stimulation could reliably activate a large number of neurons. To address the last question, in order to control for the impact of vascular injury on neuronal activity, this study monitored vascular changes caused by damage to the integrity of the BBB with dye specific for blood vessels/ arteries with simultaneous recordings of Ca2+ transients in E/I neurons. Furthermore, by using SCALE reagent transparent brains, the authors have constructed the neuro-vasculature 3D map of circuit disruption in mice post-hoc used for 2-photon imaging. Result: In-vivo 2-photon Ca2+ imaging revealed a decrease in overall spontaneous activity within the neuronal population of TBI mice, due to a higher number of hypoactive excitatory/inhibitory layer 2/3 neurons within microinfarcts of the injury epicentre. At the same time preliminary experiments revealed both excitatory and inhibitory neurons from TBI mice displayed an unexpected increase in their frequency of spontaneous Ca2+ transients in comparison to sham littermates. The number of excitatory neurons responsive to hindlimb stimulation appears to decrease precipitously in the injured postinjury. Conclusions: Overall, the results suggest re-organization of cortical population activity, traumatized vasculature and impaired balance between E/I excitatory and inhibitory sensory circuits, with vascular defects exacerbating neuronal activities.


Olfactory identification and its relationship to executive functioning and functional outcome 1 year after severe traumatic brain injury

Manoj K. Jaiswal , Fritz W. Lischka , & Zygmunt Galdzicki1,2

Solrun Sigurdardottir1, Eike Wehling2, Nada Andelic3, Toril Skandsen4,8, Audny Anke5, Cecilie Roe6, Oyvor Oistensen Holthe3,8, Anne-Kristine Schanke7





Center for Neuroscience and Regenerative Medicine, Bethesda, MD, USA, 2Department of Anatomy, Physiology and Genetics, USUHS, School of Medicine, Bethesda, MD, USA Objective: The adult brain is soft-wired and must undergo plasticity to support long-term adaptation to an altered environment or injury. In response to sensory deprivation caused by TBI, the functional topography of the neocortex is altered such that cortical areas or ‘maps’ of deprived sensory inputs shrink, while maps of the remaining spared inputs expand. However, it is not known how sensory-driven activity in individual L2/3 neurons changes over time after brain injury and how these changes differentially occur within local excitatory/ inhibitory (E/I) neuronal populations in response to alterations in plasticity after injury. It is hypothesized that TBI impacts the balance of E/I sensory circuits and with trauma-induced vascular defects exacerbate neuronal recovery. Methods: There are three central unanswered questions relating to alterations in plasticity after injury. First: What is the time window for the onset of neuronal deficits? Second: How do sensory and motor circuit remodelling change over the course of the recovery period? Third: To what extent does neuronal injury cause additional vasculature disruption and vice versa? To address the first two questions, this study has proposed using in vivo imaging of neuronal [Ca2+] by two-photon microscopy to monitor the activity of E/I neurons in GAD67-GFP knock-in mice and assess the loss/gain of spontaneously evoked neuronal activity in the core of the

Institute of Health and Society, Research Centre for Habilitation and Rehabilitation Models and Services (CHARM), Faculty of Medicine, University of Oslo, Oslo, Norway, 2Department of Physical Medicine and Rehabilitation, Haukeland University Hospital, Bergen, Norway, 3 Division of Surgery and Clinical Neuroscience, Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway, 4Department of Physical Medicine and Rehabilitation, St. Olavs Hospital, Trondheim, Norway, 5Department of Rehabilitation, University Hospital of North Norway, Tromso, Norway, 6Faculty of Medicine, University of Oslo, Oslo, Norway, 7Sunnaas Rehabilitation Hospital, Nesoddtangen, Norway, 8Department of Neuroscience, Faculty of Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway, 9Department of Psychology, Faculty of Social Sciences, University of Oslo, Oslo, Norway Objectives: Olfactory dysfunction and executive functioning deficits are common effects of severe traumatic brain injury (TBI), but how they are related remains unclear. This study investigated the frequency of olfactory function (anosmia, microsmia, normosmia) and its relationship to executive functioning 1-year post-injury. It was hypothesized that individuals with anosmia would show greater deficits on tasks of executive functioning and more frequent problems of executive deficits compared with those with normosmia and microsmia. Methods: A population-based multi-centre study was carried out in four regional Trauma Referral Centres in Norway from January 2009 to

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Brain Inj, 2014; 28(5–6): 517–878

January 2012. Adults with Glasgow Coma Scale (GCS) scores 3–8 were included. One-hundred and forty-eight patients participated and underwent neuropsychological assessment 1-year post-injury, 112 (76%) males and 36 (24%) females. Olfactory function was evaluated with the University of Pennsylvania Smell Identification Test (UPSIT) or the Brief Smell Identification Test (B-SIT). Executive functioning deficits were identified with the Verbal Fluency Test (VFT), Trail Making Test (TMT) and Colour-Word Interference Test (CWIT) of the Delis-Kaplan Executive Function System. The Behaviour Rating Inventory of Executive Functions (BRIEF-A) was completed by the patient (BRIEF-A-Self-report) and by a close relative (BRIEF-AInformant) to assess nine areas of executive functions. The Glasgow Outcome Scale Extended (GOSE) was rated by a physician to assess functional outcome. Results: The final sample included 132 patients (102 males and 30 females) aged 16–85 years (mean age 38.3 ± 17.4) who completed the smell tests. Three individuals were excluded for possible malingering (UPSIT score56 and B-SIT52). Eighty-eight relatives completed the BRIEF-A. The UPSIT and B-SIT scores classified patients into three subgroups: 40% normosmic (n ¼ 52), 33% microsmic (n ¼ 42) and 27% anosmic (n ¼ 35). Data were analysed with Students t-tests. Relative to the normosmic/microsmic groups, scores on the CWIT inhibition/ switching (p50.05), VFT category fluency (p50.05) and VFT verbal fluency/switching (p50.001) were significantly lower in the anosmic group. In addition, the anosmic group had significantly more errors on the CWIT (p50.05). Families’ ratings of the BRIEF-A Plan/Organize and the Working Memory sub-scales (T-scores) were significantly higher (more symptoms) in the anosmic group (p50.05). Conversely, self-ratings of the BRIEF-A sub-scales did not differ between the groups. Individuals identified as anosmics had significantly lower scores on the GOSE and GCS (p50.05) compared to normosmic/ microsmic individuals. Conclusions: This study suggests that anosmia may provide a marker for poorer outcome. Individuals with anosmia were found to have greater executive functioning deficits, in particular on set shifting tasks and worse functional outcome. Furthermore, anosmia was found to relate to more frequent problems with planning, organizing and working memory. It is important to identify individuals with anosmia who might benefit from early cognitive interventions to improve executive functioning.


Computerized cognitive rehabilitation training can improve neuropsychological outcomes in school-age Ugandan children surviving severe malaria 1



Deep brain stimulation for moderate and severe disability due to traumatic brain injury John D. Corrigan, & Ali Rezai


Michael Boivin , Bruno Giordani , Paul Bangirana , Alla Sikorski1, Robert Opoka3, Chandy John4, & Noeline Nakasujja3 1

Methods: Thus far, 163 children 5–12 years of age have been enrolled (56 in cognitive rehabilitation, 55 in active control, 52 passive control). These are comprised of 106 CNS malaria survivors and 57 non-malaria children recruited from their households (Kampala, Uganda), who do not have a history of severe malaria or other known brain injury. Both the CNS (2-years after illness) and non-malaria children were randomly distributed among the three treatment arms (Captain’s Log CCRT, Captains Log locked at the simplest levels (active control) and no computer intervention (passive control)). The Kaufman Assessment Battery for Children, 2nd ed. (KABC-2), visual and auditory Tests of Variables of Attention (TOVA), CogState computerized neuropsychological screening test, The Behaviour Rating Inventory for Executive Function (BRIEF) and the Achenbach Child Behaviour Checklist (CBCL) were all used. These tests have been administered before and after the 8-week training period. Captain’s Log has an internal evaluator feature which will help monitor the specific training tasks to which the children best respond. Results: An analysis of covariance comparison adjusted for age, gender, WAZ and socio-economic score. Neuropsychological (KABC, TOVA, CogState) and behavioural (BRIEF, CBCL) gains over the 8-week training period were compared for the three treatment arms (CCRT, active control, passive control) for the CNS and non-malaria children. CNS malaria survivors receiving CCRT showed significant improvements (compared to passive controls) on KABC-II Learning, KABC-II Conceptual Reasoning, CogState working memory, BRIEF Behaviour Regulation Inventory and Achenbach CBCL psychiatric symptoms. They also showed marginally significant improvements on the TOVA overall performance index (ADHD score). Non-malaria children receiving CCRT (compared to control groups) showed significantly greater improvement on KABC-II Story Completion, TOVA simple Response Time (an attentional measure) and CogState maze chase (visual-motor tracking/attention) and CogState maze learning. The non-malaria CCRT children also had marginally significant improvements on the BRIEF Behaviour Regulation Index. Both CCRT and active controls had similar levels of improvement across the 24 training sessions using the Captain’s Log internal evaluator outcomes, indicating comparable fidelity of training for the two computer intervention groups. Conclusions: CCRT has proven effective and sustainable in rehabilitation for severe malaria. Comparable gains were observed for both the full Captain’s Log CCRT and limited Captain’s Log (active control). CCRT and computerized cognitive tests are viable for treating braininjured children in resource-poor settings.


Michigan State University, East Lansing, MI, USA, University of Michigan, Ann Arbor, MI, USA, 3Makerere University, Kampala, Uganda, 4University of Minnesota, Minneapolis, MN, USA

Objectives: In Uganda, one out of four school-age survivors of cerebral malaria (CM) has persisting attention, memory or learning impairment 2 years after illness. No viable treatment presently exists to prevent these disabilities and hundreds of thousands of children are affected each year in sub-Sahara Africa. Principal study aim: To evaluate the effectiveness of CCRT in improving neuropsychological performance and psychiatric outcomes in Ugandan children who survive severe malaria, 2 years after illness.

Ohio State University, Columbus, OH, USA Deep brain stimulation (DBS) delivers electrical current to the deep structures of the brain to treat a number of movement disorders including Parkinson’s disease, tremor, and dystonia (Oluigbo, Salma & Rezai, 2012). DBS has been approved as a humanitarian device exemption for refractory obsessive-compulsive disorders. Research is being conducted on its use with epilepsy, depression, Alzheimer’s Disease, anorexia, obesity, addiction, multiple sclerosis, post-traumatic stress disorder and chronic pain syndromes (Oluigbo, Salma & Rezai, 2012; Taghva, Corrigan & Rezai, 2012; Taghva et al., 2013). DBS has been used in traumatic brain injury (TBI) for persons in the Persistent Vegetative State or Minimally Conscious State (Schiff, et al., 2007; Giacino et al., 2012), though results have been mixed. The study presented here used a different target for DBS of persons with TBI who had recovered beyond the Minimally Conscious State but still


DOI: 10.3109/02699052.2014.892379

experienced severe disability due to poor regulation of executive functions. This FDA approved, open label study was intended to test the feasibility of using DBS to restore self-regulation and ameliorate disability resulting from damage to frontal systems of the brain. This was an open label design to test the feasibility of using DBS for persons with moderate and severe disability (defined by the Glasgow Outcome Scale-Extended) due to TBI that was at least 2 years prior. Four (4) individuals who ranged from 30–45 years in age, and were from 6–21 years post-injury underwent bilateral placement of DBS electrodes in the anterior internal capsule. Assessments consisting of multiple cognitive, functional and imaging protocols were conducted at baseline, post-surgically and up to 1-year post-initiation of stimulation.

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Assessment and treatment of deficits in social perception, apecifically lying and sarcasm interpretation, following TBI Michael J. Bamdad, Mandi Woods, Samantha Shepard, & Carla Traub The George Washington University, Washington, DC, USA Objectives: Following a taumatic brain injury (TBI), patients often experience breakdowns in social functioning. Only recently has there been recognition of emotion perception deficits and how they may contribute to the pragmatic difficulties faced by TBI patients. The Awareness of Social Inference Test (TASIT) is comprised of video vignettes and includes three sub-tests assessing the ability to recognize spontaneous emotional expressions, comprehend and identify sincerity vs sarcasm and differentiate lies vs sarcasm. The Assessment of Interpersonal Problem-Solving Skills (AIPSS) is a test used to evaluate social problem-solving skills in individuals with schizophrenia, which uses similar video vignettes of everyday situations to assess the individual’s ability to identify, describe and provide a solution to a problem, as well as enact a solution through role-play. Through the use of the TASIT, AIPSS and observer ratings this research will examine social cognitive deficits following TBI, specifically with lying and sarcasm, in order to determine the effectiveness of these two assessment tools and to initially explore specific treatment approaches. Methods: Four adult subjects with a history of moderate-to-severe TBI participated in 6 hours of group treatment with pre- and postassessment via the TASIT and the AIPSS. Treatment was comprised of training of strategies to identify accurate social perception, drilling learned techniques and role-playing activities to engage the use of learned approaches. Twenty volunteers rated pre- and post-therapy video clips of the subjects during clinician and client communicative interactions using a 7-point Likert scale to evaluate communication performance in seven language-related categories. Results: A paired sample t-test was used to compare observer’s rating of appropriateness pre- and post-therapy, per individual scale category. The p value was controlled using the Bonferroni Adjustment, to allow for multiple comparisons (0.05/7) noting significant (p ¼ 0.0158) change in patients’ ability to respond to emotions in communication exchange. Conclusions: The TASIT and AIPSS highlighted areas of social perception deficits that clinicians would expect to see in this population, while also matching patient challenges with self and family reports. Performance gains were noted in the areas of determining sarcasm vs sincerity and demonstrating solutions during social interactions, according to the assessment tools. Clinical changes were noted among participants, as indicated by

carryover of strategies introduced during therapy. Observers, blind to pre/post labels, consistently rated patients lower on post-treatment videos, suggesting that these four patients did present differently after treatment. It is possible that the lower post-rating scores are the result of the patients having learned the strategies to a degree and, in an attempt to incorporate these strategies, they appeared more socially awkward to the observers. This could further suggest that intervention presented may require additional treatment time in order to determine patient benefit.


‘What am I supposed to do? Cartwheels down the passageway?’ Perspectives on the rehabilitation journey from people with ABI Annalise O’Callaghan, Beverley McNamara, & Errol Cocks Curtin University, Perth, Western Australia, Australia Objectives: Acquired brain injury (ABI) is a complex condition that affects at least 432 700 Australians. There is a lack of qualitative research into the lived experience of people with ABI and their families in Australia. The purpose of this study is to document the journey taken by people with ABI through the transition from rehabilitation to living independently. The study aims to identify barriers and enablers to engagement in meaningful occupations for people with ABI throughout their rehabilitation journey and identify the roles of the family members and health professionals in supporting the person. Methods: A qualitative approach using two in-depth interviews with 11 people with ABI who received services from a slow stream rehabilitation service were conducted to explore their lived experiences. Purposive sampling was used to include people who resided in a rehabilitation service and were preparing to live independently; people who resided in transitional accommodation services; and people who had returned to living independently. Each participant was interviewed on two occasions at 3-monthly intervals. In addition, a nominated family member was interviewed once and a focus group of health professionals involved in the participants care was completed. Thematic analysis was used to document the experience of participants from time of injury to time of interview. Results: Eight males and three females between the ages of 23–65 years were interviewed. Each participant nominated a family member to be interviewed. The family members included three wives, three mothers, a niece, son and sister. All family members had provided support to the participant from the time of injury and were continuing to provide support at the time of interview. This support included assistance with daily activities (ADLs and IADLs), financial assistance, social support and emotional support. The themes identified from the interviews and focus group included: the need for ongoing and consistent support following discharge from rehabilitation services; a lack of service options to support the emotional needs of family members experiencing significant changes in their productive and leisure occupations; a poor understanding of the role of different health professionals; a lack of direction in relation to appropriate interventions at each stage of the rehabilitation journey; and the need for individualized approaches to rehabilitation. Conclusions: The journey through rehabilitation for people with ABI and their families requires an individualized and consistent approach to ensure their long-term needs are met. An improved understanding of the needs of people with ABI and their family members at each stage of the journey through rehabilitation will

578 assist in ensuring people with ABI are not having to do ‘cartwheels down the passageway’ in order to secure adequate and appropriate support.


Minor brain trauma affects theta and alpha frequency activity during a working memory task: A longitudinal magnetoencephalography imaging study Sarah Midgley1, Aziz Asghar2, Laura Cowley3, Gary Green4, & William Townend3 Brain Inj Downloaded from by RMIT University on 09/02/14 For personal use only.


Royal Derby Hospital, Derby, Derbyshire, UK, 2Hull York Medical School, Hull, East Yorkshire, UK, 3Hull Royal Infirmary, Hull, East Yorkshire, UK, 4York Neuroimaging Centre, York, North Yorkshire, UK Objectives: Previous magnetoencephalography (MEG) scanning revealed that mild traumatic brain injury (MTBI) affects resting state activity. No published work has reported the effects of MTBI on neuronal activity identified by MEG as a working memory task is completed, although many MTBI patients report difficulties with such tasks and functional magnetic resonance imaging (fMRI) has revealed differences between controls and MTBI participants. Theta and alpha frequency activity are reported to have a role in working memory task completion. This study investigated the effects of MTBIs on neuromagnetic activity when participants completed the n-back task. Methods: Participants were recruited from two Emergency Departments after admission following an MTBI. Data was collected from eight participants 2–3 weeks post-injury and seven were reviewed 6 months later. All received training in the n-back task (0-back, 1-back and 2-back) before entering the MEG scanner. Beamforming analysis located the sources of neuromagnetic activity in the theta (4–8 Hz) and alpha (8–13 Hz) frequency bands. Changes in neuronal activity within the active time period (50–550 milliseconds after stimulus presentation) were assessed and activity in the 1-back task was compared with that in the 0-back task. Results: There were noticeable differences between the two different MTBI groups and the control group in the alpha and theta frequency bands. In the theta frequency band there were widespread significant (p50.05) power decreases in both MTBI groups, with the most significant voxels being in the left frontal lobe in the 2-week group and in the right insular cortex in the 6-month group. In the control group significant theta frequency power decreases were limited to the right frontal and occipital regions. In the alpha frequency band there were no significant power decreases in the control group. The 2-week MTBI group showed a power decrease (p50.05) in several locations including the right lateral occipital cortex and the left paracingulate gyrus. In the 6-month group power decreases (p50.05) were again widespread. The differences between the groups occurred despite similar levels of accuracy on the n-back task. Conclusions: After MTBI there are alterations in brain function as measured by activity in the theta and alpha frequency bands when the 1-back and 0-back tasks are compared. Differences between the control and MTBI groups may underlie difficulties reported by some MTBI patients post-injury as it appears the brain functions in a different manner to achieve the same result. Activity after MTBI is not the same as the control group even 6 months post-injury, indicating that a minor brain trauma may have longer lasting impact on brain function.

Brain Inj, 2014; 28(5–6): 517–878


Investigating brain injury after minor head trauma: A longitudinal fMRI study of working memory Sarah Midgley1, Aziz Asghar2, Laura Cowley3, Gary Green4, & William Townend3 1

Royal Derby Hospital, Derby, Derbyshire, UK, 2Hull York Medical School, Hull, East Yorkshire, UK, 3Hull Royal Infirmary, Hull, East Yorkshire, UK, 4York Neuroimaging Centre, York, North Yorkshire, UK Objectives: Controversy exists as to whether ongoing symptoms and disability after mild traumatic brain injury (MTBI) relate to brain injury or factors such as personality or PTSD. Previous fMRI studies have revealed BOLD (blood oxygen level-dependent) signal alterations during working memory tasks after MTBI, but these studies generally assess the participants at one time-point only. Little is known about how changes in BOLD signal evolve with time, so this study investigates the longitudinal impact of MTBI on the BOLD signal. Methods: Participants admitted to the Emergency Department observation ward following MTBI were recruited. Ten underwent fMRI scanning at 2–3 weeks after injury and seven of these were re-assessed at 6–9 months. During fMRI the participants completed the 0-, 1- and 2-back n-back tasks. A whole brain fMRI analysis was performed and the MTBI groups were compared using subtraction analysis using FSL FEAT Version 5.63. Clusters with a z-score of greater than 2.3 were identified using this method. Results: The two MTBI groups had similar levels of BOLD signal in the less challenging n-back tasks, with clusters being seen in different cortical regions. In the 0-back and 1-back tasks activity was in areas known to be associated with working memory, but in the 2-week group the BOLD clusters were in the left hemisphere and in the 6-month group activity was seen in the right hemisphere. When the 2-back task was completed the 6-month group had significantly greater activity than the 2-week group. Clusters of BOLD signal were found in the right lateral occipital cortex, the superior temporal gyrus and frontal medial cortex during the 2-back task in only the 6-month group. The n-back task was performed more accurately at all levels by the 6-month group. Conclusions: As time progresses following the brain injury BOLD signal activity changes. At all levels of the n-back task activity in the 6-month group has become right lateralized. Right-sided BOLD signal has been reported by other studies as a consequence of MTBI and is thought to reflect damaged working memory networks. Shortly after the brain injury it is possible that working memory networks have not been able to re-organize, resulting in poorer task performance and left lateralized activity. Increasing BOLD signal to complete a task with greater accuracy has also been reported and in this study only the 6month group were able to do this. This may also reflect damage and subsequent repair to working memory networks following MTBI. Further work using diffusion tensor imaging may be indicated to examine the integrity of fibre tracts within the brain.


A review: What can one do to those suffering from bipolar disorder? Sudha Kharade, & Sheetalkumar Patil Ashokrao Mane College of Pharmacy, Kolhapur, Maharastra, India


DOI: 10.3109/02699052.2014.892379

Bipolar disorder involves cycles of mania and depression and often a chronic, recurring condition with varying degree of mood swings. In the depressive cycle, the person can experience any or all of the symptoms of depressive disorder and in the manic phase the patient experiences the symptoms of mania which often affect thinking, judgements and social behaviour. The cyclic attacks of mania have many symptoms of paranoid schizophrenia like grandiosity, bellicosity, paranoid thoughts and over-activity. The present study focuses on some educational treatment recommendations for continued treatment and crisis intervention as needed for bipolar disorder and also focuses on symptom changes with situation, aetiology and brain injury. People who have mood disorders can more readily achieve wellness when they recognize the symptoms and understand the issues related to this spectrum of conditions. The aim was to review educational materials which help people with diagnoses and their loved ones to know what mood disorders are and what can be done for treatment and management.

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Understanding the effect of acquired head injury on high speed communication skills in children and adolescents ˚ sa Fyrberg1,2, & Go¨ran Horneman3 A 1

Sahlgrenska University Hospital, Gothenburg, Sweden, SCCIIL Center for Cognitive Science, Gothenburg, Sweden, 3 University of Gothenburg, Gothenburg, Sweden 2

Objectives: Children and adolescents with acquired brain injury (ABI) are often left with life-long cognitive impairments, severely affecting communicative functions in real life situations. Outcome measures seldom include procedures to identify everyday communication skills that may co-exist with a good speech and language performance on batteries of standardized tests. This study evaluated a common interactive situation in real life with high demands on communication speed: ‘Being part of a conversation when it is fast and there are a number of people involved’. The aim was to further explore how impaired cognitive functions influence communication in real life. Methods: Thirty youths, 19 males and 11 females, with cognitive and communicative impairments after ABI were included. Mean age at assessment was 14.2 years (range ¼ 8.6–17.8). Mean age at ABI was 12.7 years (range ¼ 2.6–17.5). Traditional psychometric assessments were applied during a clinical assessment period. In addition, the subjects’ everyday communication skills were estimated by proxies, using a qualitative rating scale, The Communicative Effectiveness Index (The CETI). In the CETI, 16 communicative situations are measured on a VAS-scale and 87% of the items have been found to be consistent with communicative participation. One CETI item in particular was analysed; ‘Being part of a conversation when it is fast and there are a number of people involved’. Baseline data were collected at a mean of 14 months post-injury with follow-up at a mean of 11 months post-baseline. Results: Clinical data showed un-even cognitive profiles typically associated with ABI. In 63% of the subjects, intellectual capacity was impaired. Verbal functions were assessed as impaired in 50%. Visual memory functions were assessed as impaired in 70%. The speechlanguage tests revealed that word comprehension was impaired in 12%, grammar comprehension in 32% and naming ability in 26% of the subjects. However, the CETI-data showed that 85% of the subjects had explicit difficulties when it came to high speed communication in every-day life. Only five out of 30 subjects had an adequate ability to participate in fast conversations with several people involved. One out of 30 subjects showed a significantly improved function at followup. The number of active speakers in dialogues, the subject’s ability to take initiative, the ability to take turns and the comprehension

abilities were found to be crucial factors in high speed communication for subjects with ABI. Conclusions: Multiple factors seem to influence the ability to participate in high speed communication. It is hypothesized that impairment of auditory and visual functions, in combination with limited language comprehension, attention and memory, contribute to difficulties in high speed dialogues. These impairments seem to persist over time.


Family needs in the chronic phase after severe brain injury in Denmark Karoline Doser1,2, & Anne Norup1 1

Research Unit on Brain Injury Rehabilitation, Copenhagen (RUBRIC) Department of Neurorehabilitation, Traumatic Brain Injury Unit, Copenhagen University Hospital, Glostrup, Denmark, 2Catholic University of Applied Sciences, Freiburg, Germany Objectives: The study aimed at investigating (1) changes in demographics in family members following severe brain injury and (2) needs within the family in the chronic phase after severe brain injury. Methods: The sample comprised 42 relatives (76% female, mean age ¼ 53 years) of patients with severe brain injury, who had received intensive sub-acute rehabilitation at the Traumatic Brain Injury Unit, Glostrup University Hospital, Copenhagen. The relatives were contacted in the chronic phase after brain injury (Mean ¼ 65 months; range ¼ 45–93 months) and asked to participate in a follow-up study, where demographic data, e.g. relationship, marital and cohabitant status, was collected. The relatives also completed questions about time spent taking care and supervising the patient since injury. The relatives completed the revised version of the FNQ (Family Needs Questionnaire), a questionnaire consisting of 37 items related to different types of needs following brain injury. Each need was rated in terms of importance on a Likert-scale from 1–4 and whether the need has been met, partly met or not met. Results: Significant changes were found in relation to full time employment, as 91% of the relatives were full-time employed at time of injury and at follow-up merely 62% were (z ¼ 3.464, p ¼ 0.001). In relation to co-habitant status, 67% shared accommodation at time of injury and this number was reduced to 41% in the chronic phase (z ¼ 3.317, p ¼ 0.001). A non-significant decrease was seen in the number of married couples from 74% to 69% (z ¼ 1.000, p ¼ 0.317). The sub-scale ‘Health Information’ (Mean ¼ 3.50, SD ¼ 0.73) had the highest mean importance rating, whereas the sub-scale ‘Emotional support’ (Mean ¼ 3.07, SD ¼ 0.79) had the lowest rating. Ensuing, the importance for each item was rated by the family member, three of the most important needs identified were from the sub-scale ‘Health Information’. The sub-scale ‘Health Information’ (Mean ¼ 2.46, SD ¼ 0.44) had the highest met need rating, whereas the sub-scale ‘Professional Support’ (Mean ¼ 2.03, SD ¼ 0.59) had the lowest met need rating, implicating that these needs were most likely unmet. When combining importance and met ratings, it was found that the five most important needs were only met in 41–50% of the total sample. Conclusions: These findings show how family members’ co-habiting and employment status changed after the brain injury. This study also found that these family members reported important needs related to both health information as well as professional support several years after injury. Even more striking is the finding that less than half of the sample reported that these needs were actually met. Future research should employ a mixed-method design in order to gain knowledge about family members reporting unmet needs. Additionally, semi-structured interviews should be conducted to obtain more detailed information about these issues.



The use of an activity monitoring system to provide motivational feedback to increase walking in a wheelchair user Sara da Silva Ramos, Michael Oddy, & Megan Eve

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Brain Injury Rehabilitation Trust, Horsham, UK Objectives: To evaluate the usefulness of a remote activity monitoring system to provide motivational feedback aimed at increasing walking in a wheelchair user in the context of a transitional living rehabilitation service for acquired brain injury (ABI). Methods: Commercially available remote activity monitoring technology was used in a single-case ABB’ design. The objective was to provide adequate levels of feedback to support the goal of increasing walking for a service user (JTR) who was living alone in a transitional living flat adjacent to a residential rehabilitation unit. The main aim for installing the system was to monitor time spent in a wheelchair and time spent walking, without having staff in the flat at all times. To achieve this, Just Checking, a system of movement sensors that generates an online chart of daily living activity, was installed in the flat. Some of the sensors were placed upside down so that they would only be triggered when JTR was walking. Through an internet connection, the information captured by the sensors was collated on a webpage. In the intervention phase, clinicians used this information to prepare a walking record chart with JTR. A second intervention phase required JTR to prepare the charts on his own and send them by e-mail to a member of the clinical team who would then e-mail back with encouraging feedback. Results: At the end of the intervention it was observed that both personal and e-mail feedback resulted in increased time spent walking, as measured by movement sensors. Although personal feedback was more effective, the technology was invaluable to allow unobtrusive behaviour monitoring in all phases of the study. Conclusions: Remote activity monitoring systems are widely available commercially, but have mostly been used in the context of long-term care of individuals with dementia. This paper demonstrates an innovative use of such a system to promote rehabilitation after an ABI. Moving to transitional living accommodation is an important step towards achieving greater independence. However, in this context the degree of supervision available is lower and this can inhibit the achievement of specific rehabilitation goals. The present findings suggest that off-the-shelf monitoring and telecare technology can be used creatively within an ABI rehabilitation setting to promote intervention-targeted behaviours. Remote activity monitoring systems are a good alternative for situations where staff are not available or where having staff on site interferes with other rehabilitation goals.


The BIRT Neuro-Behavioural Scales (BNBS): New measures of impulsivity, disinhibition, emotion regulation, social perception and motivation after acquired brain injury (ABI) Sara da Silva Ramos1, Charlotte Cattran2, & Michael Oddy1

Brain Inj, 2014; 28(5–6): 517–878 1 2

Brain Injury Rehabilitation Trust (BIRT), Horsham, UK, Active Assistance Group, Sevenoaks, UK

Objectives: To describe five new measures of non-cognitive neurobehavioural change after acquired brain injury (impulsivity, disinhibition, emotion regulation, social perception and motivation) and to evaluate their criterion validity with reference to a group of healthy individuals. Methods: This study used a cross-sectional mixed design. The BNBS were administered to a non-clinical sample of the general adult population (n ¼ 128) and proxy data was collected for 26% of this sample. The BNBS were also administered to a sample of individuals with acquired brain injury (ABI) (n ¼ 84) with 88% providing proxy data. Results: Mean scores of the non-clinical sample were compared with the ABI group who scored significantly higher. Furthermore, individuals from the non-clinical group scored themselves higher than their relatives on the social perception scale, but no significant differences were found between self- and proxy-reports in the ABI group. Receiver Operating Characteristic (ROC) analyses revealed that most scales could discriminate those with an ABI from a non-clinical sample reliably, with Area Under the Curve values ranging between 0.65–0.84. While both self- and proxy-ratings revealed good degrees of sensitivity (0.80–0.84), the proxy-ratings were more specific (0.30–0.70) than the self-ratings (0.27–0.56), particularly for the motivation and emotion regulation scales. Conclusions: The present findings establish differences in reports on the BNBS between healthy individuals and individuals with an ABI and, thus, provide further validation for the use of these scales within the ABI population. These results should also aid the interpretation of the BNBS scores observed in clinical practice and strengthen the utility of these measures as tools for screening non-cognitive problems arising from an ABI and for guiding rehabilitation strategies and measuring outcomes.


Psychological functioning and quality-of-life in caregivers of individuals with traumatic brain injury Melissa Alejandra Rodrı´guez Dı´az1, Carlos Jose´ De los Reyes Arago´n1, Laiene Olabarrieta Landa2, Paul B. Perrin3, & Juan Carlos Arango-Lasprilla4 1

Universidad del Norte, Colombia, 2University of Deusto, Bilbao, Spain, 3Virginia Commonwealth University, Richmond, Virginia, USA, 4 IKERBASQUE, Basque Foundation for Science. University of Deusto, Bilbao, Spain Objective: To examine the levels of psychological functioning and health-related quality-of-life (HRQoL) in caregivers of individuals with traumatic brain injury (TBI) from Barranquilla, Colombia. Participants: Thirty TBI caregivers and 44 healthy controls completed the PHQ-9 (depression), Zarit Burden Interview, Satisfaction with Life Scale and the SF-36, a self-report HRQoL measure composed of eight component areas: physical health problems, pain, role limitations due to physical problems or due to emotional problems, emotional well-being, social functioning, energy/fatigue and general health perceptions. The samples were statistically similar with respect to age and different with respect to gender, education and socioeconomic status (SES). Results: Seventy-three per cent of caregivers reported some symptoms of depression and 30% indicated some dissatisfaction with their lives; 60% had some level (mild–severe) of burden. Compared to healthy controls, TBI caregivers had significantly


DOI: 10.3109/02699052.2014.892379

higher means on depression (p50.05) and lower means on qualityof-life (p50.05), after adjusting for gender, education and SES. Specifically, TBI caregivers had lower adjusted means on Physical Functioning (p50.05), Role-Physical (p50.005), Role-Emotional (p50.005), Emotional Well-Being (p50.001), Social Functioning (p50.001), Energy and Fatigue (p50.005) and General Health (p50.005). Conclusions: These findings suggest the need for rehabilitation professionals to develop and implement culturally-appropriate interventions to improve quality-of-life, depression, and burden in Colombian caregivers of individuals with TBI.


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Duloxetine as a treatment of mood instability after acquired brain injury Jeff Suykerbuyk1, & Maud Demeester1,2 1

JKS/Miander, Antwerpen, Gent, Belgium, 2Amares, Goes, The Netherlands


Virginia Commonwealth University, Richmond, USA, 5IKERBASQUE, Basque Foundation for Science. University of Deusto, Bilbao, Spain Objective: To determine the system of connections between traumatic brain injury (TBI) symptoms and caregiver mental health in Barranquilla, Colombia. Participants: Fifty TBI caregivers completed the Satisfaction with Life Scale, PHQ-9 (depression), Zarit Burden Interview, Rosenberg SelfEsteem Scale, State-Trait Anxiety Inventory and a 22-item TBI symptoms inventory composed of four component areas: cognitive, neurobehavioural, physical and social symptoms. Results: A canonical correlation analysis revealed that the greater the symptoms, the worse caregivers’ mental health was, with the effect reaching a large-sized effect. A pattern emerged linking greater neurobehavioural symptoms to higher caregiver burden and depression, as well as to lower self-esteem. A series of linear regressions similarly showed that the model with four groups of symptoms predicted caregivers’ depression, burden and self-esteem, but none of the symptom domains was an independent predictor. Conclusions: These findings suggest the need for rehabilitation health professionals to develop and implement culturally-appropriate interventions to reduce neurobehavioural symptoms in people with TBI, as well as interventions to improve self-esteem and reduce depression symptoms and burden in Colombian caregivers of individuals with TBI.

0187 Objectives: Emotional lability frequently occurs following acquired brain injury and has an important negative influence on the qualityof-life of patients and their families. At present there is still no satisfactory treatment for this condition. Best current evidence suggests that emotional lability in patients with acquired brain injury characterizes often depressed mood, more than sadness and tearfulness do. Methods: This study describes an open trial using duloxetine, an antidepressant with a serotonergic and noradrenergic action, in the treatment of emotional lability due to acquired brain injury. Twenty-one subjects, 12 men and nine women, attending an outpatient psychiatric setting were included (16 cases were anoxic brain injury due to cardiac problems, five cases were non-invasive brain tumours). Response to treatment was measured using the Lability Affect Scale-Short Form described by Oliver and Simons after 1 week, 1, 2 and 3 months of treatment. Results: All subjects showed a marked improvement within the first week after starting duloxetine 60 mg. The drug was well tolerated, with two subjects reporting nausea during the first day. After 1, 2 and 3 months of treatment there was still an ongoing improvement. Conclusions: The speed of onset and the degree of improvement, even after 3 months, suggest that duloxetine can be useful in the treatment of mood instability after acquired brain injury. More observations and investigations are needed to evaluate the mechanism of duloxetine in the treatment of mood instability after acquired brain injury


TBI symptoms and caregiver mental health in Colombia, South America Carlos Jose´ De los Reyes Arago´n1, Laiene Olabarrieta Landa2, Alfonso Caracuel3, Paul B. Perrin4, & Juan Carlos Arango-Lasprilla5 1

Universidad del Norte, Barranquilla, Colombia, 2University of Deusto, Bilbao, Spain, 3University of Granada, Granada, Spain,

Returning children and youth to activity and to school after MTBI/ concussion: A conservative approach with new evidencebased guidelines Carol DeMatteo1,2, Kathy Stazyk1, William Mahoney1, Lucy Giglia1, Sheila Singh1, Robert Hollenberg1, & Cheryl Missiuna1 1

McMaster University, Hamilton, Ontario, Canada, 2McMaster Children’s Hospital, Hamilton Ontario, Canada Background: The decision regarding return-to-activity following MTBI/ concussion is one of the most difficult and controversial areas in concussion management for adults and even more complicated for children and youth. Objectives: (i) To challenge the existing paradigm and clinical practice that uses adult Return-to-Play (RTP) guidelines with children/youth who have sustained a sport-related concussion. (ii) To introduce new child/youth-specific, evidence-based guidelines for return-to-activity and return-to-school for children and adolescents after mild traumatic brain injury/concussion. Methods: These guidelines were developed as part of a Canadian Institute for Health Research Knowledge Translation study aimed at educating physicians about concussion management in children. Three main approaches were used, influenced by the National Institute for Health and Care Excellence (NICE) recommendations for service guideline development: (i) a scoping review, (ii) focus groups with expert clinicians and (iii) pilot testing of proposed guidelines. Results: There is no level A evidence for any concussion management in children. The following three themes emerged from the scoping review and focus groups: (1) Existing consensus-based adult guidelines are not appropriate for children. (2) More conservative guidelines were needed for children. The research team concluded that child-specific guidelines needed to be developed. The resulting Guidelines for Return-to-Activity and Return-to-School are presented here. The evaluation of implementation reveals that these guidelines

582 have been enthusiastically accepted and implemented by 194 Family Health Teams and allied health; 292 emergency, hospital physicians and nurses; educators and public health departments with distribution to over 1000 parents, teachers, coaches in Ontario and other pockets of Canada and the US. In addition there have been over 40 000 downloads of the guidelines from the CanChild website. Conclusions: There is consensus that children require a more conservative approach to management post-concussion in order to prevent repeat injuries closely following initial injury; and to prevent a prolonged recovery. These are the first guidelines developed specifically for children and youth based on evidence. They appear to be meeting a need for guidance regarding concussion management in children. The next steps must be to evaluate them to determine if they do result in better outcomes post-concussion.

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Gender and the effects of TBI/ polytrauma: Comparative analysis of female TBI/polytrauma cohort characteristics and outcomes

Brain Inj, 2014; 28(5–6): 517–878

with: depression (78.3%), PTSD (86.7%), anxiety disorders (33.3%), substance abuse (26.7%), cognitive disorder NOS (38.3%), clinically significant cognitive impairments (70%), and two or more co-morbid mental health disorders (73.3%). Conclusions: Because females represent such small numbers in the TBI/Polytrauma cohort, most available published literature might not wholly represent or characterize this sub-population. This research provides augmentative data by identifying outcomes specific to a female cohort that have sustained a TBI. Several diagnostic as well as demographic differences emerged as significantly different to the predominantly male Polytrauma cohort. Female-specific data can serve as an aid in directing current and future VA healthcare services for female veterans who have been impacted by TBI/Polytrauma.


Changes in functional brain networks following sports-related mTBI in adolescents

David Horton1, Joyce Chung2, Jennifer Zahm3, Carmelinda Mann1, & Odette Harris4

Po Hsiang Yuan1, Nadia Makan1, Aiping Lee1, Aliya-Nur Babul2, Chris Franks3, Jane Wang1, Naznin Virji-Babul1, Courtney Hilderman1, & Jenna Smith1



Defense and Veterans Brain Injury Center, Palo Alto, CA, USA, 2VA Palo Alto Health Care System, Palo Alto, CA, USA, 3Palo Alto University, Pacific Graduate School of Psychology, Palo Alto, CA, USA, 4 Stanford University School of Medicine, Stanford, CA, USA Background: Polytrauma, defined as multiple systemic injuries including traumatic brain injury (TBI), most frequently secondary to blast, emerged during the military conflicts in Iraq and Afghanistan. The Polytrauma population has been extensively studied, with significant data utilized to drive management and policy related to this population. The resulting data is often characterized by the larger cohort of active duty service members, which is comprised of an almost entirely male population (95%). Given that females represent a small number being treated for TBI/Polytrauma, there is concern that characteristics and outcomes specific to females could easily be overlooked, when included as part of the larger Polytrauma cohort, vs evaluated specifically. Objective: The goals of this study were: (1) to better characterize the female TBI/Polytrauma cohort in terms of demographics, injury and severity and to compare these data to the larger, predominantly male TBI/Polytrauma cohort and (2) to determine immediate and long-term outcomes in the female cohort. Methods: The authors conducted a retrospective cohort study of female veterans who sustained a TBI and were treated in the VA Palo Alto Health Care System, Polytrauma System of Care (VAPAHCS PSC). Data on the female cohort were collected with regards to demographics, injury, substance use, post-concussive/ neurobehavioural symptoms, psychiatric diagnoses and quality-of-life. These parameters were compared to the prevalence rates found in the Polytrauma published literature. Results: Female patients represent 6% of Polytrauma patients seen at the VAPAHCS (August 2006–May 2012). At the time of evaluation, female mean age was 27; 80% were Veterans; 27% had a high school degree; 28% were working or in school; 42% were unemployed; 10% were homeless. Of the 60 female patients in the initial cohort, 93% received a mild TBI (mTBI) diagnosis, 5% moderately severe and 1.7% severe. Approximately 77% of the injuries occurred in theatre. The female TBI cohort were diagnosed significantly more often

University of British Columbia, Vancouver, BC, Canada, 2University of Toronto, Toronto, Ontario, Canada, 3Whitecaps Residency Program, Vancouver, BC, Canada Objective: It has previously been shown that sports-related mild traumatic brain injury (mTBI) in adolescents is associated with changes in whole brain properties of white matter pathways. This study now evaluates the changes in functional brain connectivity following sports-related mTBI in adolescents, using high density electroencephalograph (EEG). Graph theory analysis was applied to resting state EEG data to evaluate changes in brain networks. Graph theory characterizes brain networks in terms of nodes, representing distinct brain regions and edges, delineating pathways connecting the regions. The objective was to evaluate changes in brain network measures derived from graph theory in adolescent athletes following sports-related mTBI. Methods: Thirty-three healthy adolescent athletes affiliated with a local soccer league completed a resting state EEG scan at the beginning of the soccer season. All players also took part in the ImPACT assessment at the start of the season. During the season, players who sustained a mTBI (as diagnosed by the team physical therapist) as well as athletes from other sports who sustained a concussion completed a resting state EEG scan within 1 week of their injury. The ImPACT assessment was repeated at this time. Results: No statistically significant group differences were observed in ImPACT scores between the control and concussed groups. Graph theory analysis showed that the groups were similar in terms of the properties of global brain networks with the exception of global efficiency. The concussed group showed statistically significant increased global efficiency (p50.005) in comparison with the control group. Conclusions: These data show that sport-related mTBI in adolescents is associated with alterations in resting state networks. Overall increased global efficiency may reflect a shift to a more random brain network organization following mTBI. Resting state EEG combined with graph theory approaches may be a promising low-cost tool that is sensitive to the subtle changes in brain connectivity following brain injury.


DOI: 10.3109/02699052.2014.892379


Tonic stretch reflex threshold: A new standard in spasticity measurement

Lost to follow-up after mild traumatic brain injury—Does it matter?

Mindy F. Levin1, Aditi Mullick1, & Andreanne Blanchette2

Eirik Vikane1, Torgeir Hellstrøm2, Cecilie Røe3, Erik Bautz-Holter3, Jo¨rg Assmus4, & Jan Sture Skouen5


McGill University & Centre for Interdisciplinary Research in Rehabilitation, Montreal, Canada, 2Universite Laval, Quebec, Canada

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Objectives: A number of systematic reviews have questioned the validity of evaluation tools traditionally used to measure spasticity in the clinical setting. As an example, the most widely used clinical measure; the Modified Ashworth Scale measures the total muscular resistance to passive movement rather than stretch reflex excitability per se. Although the presence or absence of spasticity may be identified using current clinical scales, the accuracy of determination of spasticity severity and the relationship between severity level and deficits of voluntary movements remain elusive. The objective of the study was to demonstrate the validity and reliability of a new measure of spasticity: the stretch reflex threshold, using a portable measurement device. Methods: An alternative approach to the measurement of spasticity is the evaluation of the excitability of motoneurons (tonic stretch reflex threshold; TSRT) resulting from both descending and segmental influences. It is well established that, in healthy subjects, the regulation of TSRTs may be a major mechanism underlying the control of posture and movement. Previous studies have shown that spasticity and disordered muscle activation in persons with central nervous system lesions are related to deficits in the regulation of TSRTs throughout the biomechanical joint range. The TSRT measure identifies where, in the joint range, problems in modulation of muscle activity begin. According to the SRT measure, a higher value indicates a higher threshold and, therefore, a lower level of spasticity and vice versa. This study investigated the intra- and inter-evaluator reliability of TSRT measurement in different muscle groups to quantify spasticity in patients with chronic stroke-related spasticity using a portable device and the Modified Ashworth Scale (MAS). Intraevaluator reliability was examined by comparing data collected on 2 days, while data collected by two or more evaluators on the same day were used to determine inter-evaluator reliability. For each evaluation, EMG signals and joint angular position were recorded during 20 stretches of the spastic muscle applied at different velocities. Results: Velocity-dependent dynamic stretch reflex thresholds (angular position at which the muscle is activated for a given stretch velocity) were recorded. These values were used to compute TSRTs which reflects the excitability of motoneurons at 0 s1. Intra- and inter-evaluator reliability of TSRT measurement was moderately good for evaluating elbow flexor spasticity, especially for subjects with moderate-to-high spasticity (intra-evaluator: ICC ¼ 0.46–0.68 and inter-evaluator: ICC ¼ 0.53–0.68). For the plantarflexors, inter-evaluator reliability was very good (ICC ¼ 0.85). The TSRT measure did not correlate with resistance to stretch (MAS). Conclusions: The TSRT measure overcomes most of the limitations posed by currently available clinical measures of spasticity. As the TSRT relates spasticity to deficits in voluntary movement and is also sensitive to subtle changes in spasticity, it may guide clinical decisionmaking.


Department of Physical Medicine and Rehabilitation, Haukeland University Hospital, Bergen, Norway, 2Department of Physical Medicine and Rehabilitation, Oslo University Hospital HF, Oslo, Norway, 3Faculty of Medicine, University of Oslo, Oslo, Norway, 4 Centre for Clinical Research, Haukeland University Hospital, Bergen, Norway, 5Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway Objectives: It is a challenge to assess outcome for patients who are lost to follow-up after a mild traumatic brain injury (MTBI). Patients with MTBI are often young people and return-to-work (RTW) has been stated to be a good indicator of the patients overall adaptation after suffering from TBI. By using data from a national register about sick leave this study was able to evaluate the outcome for patients who failed to follow-up. Hence, the aim of this study was to identify clinical characteristics for patients in the group who attended (AG) at 2 months follow-up and for those who did not attend (NAG). Further, if clinical characteristics from the emergency admittance and attendance 2 months after injury could be related to RTW 1 year later. Methods: Three hundred and forty-three patients of 16–55 years admitted consecutively to the Neurosurgery Department from January 2009 to July 2011 with MTBI defined as Glasgow Coma scale (GCS) 13–15 and unconsciousness less than 30 minutes were recruited. Exclusion criteria were other significant diseases, substance abuse, unemployed in the last 6 months or lack of Norwegian language skills. Demographic and clinical data were obtained from the hospital files and data about sick leave from The Norwegian Labour and Welfare Service through a third accredited agency Statistics Norway. Patients were categorized in two groups according to attendance or not. Results: Of the included patients, 161 (67%) patients attended (AG) and 80 (33%) did not attend (NAG) to their appointments. In the AG 19% had intracranial pathology and 9% had multiple lesions on CT scan compared to 5% and 1% in the NAG (p ¼ 0.012). 39% had consumed alcohol in the AG compared to 62% in the NAG (p ¼ 0.001). AG were older, median age 31 years compared to 25 years (p ¼ 0.022). There were no significant differences between the groups concerning GCS, sex, education, cause of injury or sick leave before injury. Logistic regression analysis showed that follow-up attendance (OR ¼ 16.89) and sick listed the last year before injury (OR ¼ 9.70) predict unfavourable RTW at 12 months. It was a trend that patients with multiple lesions on CT had an unfavourable outcome concerning RTW after MTBI. Skull fracture, fracture in face or neck and cause of injury had no influence of the outcome. Conclusions: Lost to follow-up indicates a favourable outcome after MBTI and patients who do not attend have probably less need for further follow-ups for their brain injury.



Negotiated order: The intraprofessional and interprofessional practices of neurorehabilitation nurses Karen-Lee Miller, Pia Kontos, & Romeo Colobong

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Toronto Rehabilitation Institute-University Health Network, Toronto, Canada

Objectives: Negotiated order theory emphasizes that negotiation involves professionals continually working together to determine who is to do what, how and with whom during patient care. Negotiations among healthcare practitioners are largely shaped by the structural and social conditions under which they are made and settings where they occur, such as disciplinary silos and the nursingmedical hierarchy. To date, nurses’ engagements with one another and with allied healthcare practitioners have not been examined using negotiated order theory, despite that these comprise the majority of nurses’ daily interactions in hospitals. The purpose of this study was to examine intra-professional (nurse–nurse) and interprofessional (nurse–allied health practitioner) negotiative practices. Methods: Qualitative semi-structured interviews (n ¼ 35) were conducted with 15 nurses and 20 allied health practitioners in the neurorehabilitation units of two hospitals in central Canada. Twohundred and thirty hours of non-participant observations of structured (e.g. nursing reports, inter-professional rounds) and unstructured activities (e.g. information sharing) were also conducted. Results: For neurorehabilitation nurses, negotiation took place in a practice context characterized by heavy workload, high patient acuity and historically poor relations with AHPs. This practice context was negotiated through two strategies. First, nurses engaged in intraprofessional collegialism, accomplished with positive and problematic practices such as co-operation, coercion and conflict avoidance. Nurses often privileged agreeability with one another over clinical problem-solving. Second, nurses vied for an autonomous essential nursing role in inter-professional practice. They did so by claiming unique nursing knowledge based on around-the-clock nursing proximity, expanding the division of professional labour with allied health practitioners and modifying rehabilitation care plans. Conclusions: Understanding nursing negotiation practices has important implications for improving patient safety and inter-professional practice interventions. Identifying the negative aspects of nursing collegialism is novel and is suggestive that agreeability may compromise patient safety and hinder professional development. Further, nurses’ desire for an autonomous professional role challenges the central tenets of inter-professional practice and should be addressed in initiatives to improve nurse–allied health practitioner collaboration.


Acute assessment of mild traumatic brain injury with the King-Devick test in an emergency department sample Noah D. Silverberg1,2, Teemu M. Luoto3, Juha O¨hman3, & Grant L. Iverson4,5

Brain Inj, 2014; 28(5–6): 517–878 1

Division of Physical Medicine & Rehabilitation, University of British Columbia, BC, Canada, 2GF Strong Rehab Centre, Vancouver, BC, Canada, 3Department of Neurosciences and Rehabilitation, Tampere University Hospital, Tampere, Finland, 4Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, USA, 5Red Sox Foundation and Massachusetts General Hospital Home Base Program, Boston, MA, USA Objectives: The King-Devick Test (K-D) is a brief measure of cognitive processing speed and rapid gaze shifting that appears sensitive to the acute effects of sport-related concussion. The present study evaluated its diagnostic and incremental validity in civilian trauma patients with mild traumatic brain injury (MTBI). Methods: Participants with MTBI (n ¼ 26) and trauma controls with non-head injuries (n ¼ 33) were prospectively recruited from the Emergency Department of Tampere University Hospital between August 2010 and July 2012. MTBI diagnosis was operationalized by World Health Organization Neurotrauma Task Force criteria. Stringent exclusion criteria were used to rule out pre-existing medical conditions or other confounding factors. All participants underwent a clinical evaluation that included the K-D test and the Sport Concussion Assessment Tool-Second Edition (SCAT2). The SCAT2 includes a symptom scale and the Standardized Assessment of Concussion (SAC; a cognitive screening test). The MTBI group was assessed an average of 31 hours post-injury (range ¼ 4–72 hours). Magnetic resonance imaging (3 Tesla) was also conducted within 10 days following hospital discharge. Results: The MTBI and control groups had comparable demographic profiles except that the MTBI group had somewhat more men (73.1% vs 51.5%); chi-square ¼ 3.71, p ¼ 0.054. Gender was not associated with K-D test performance. Patients with MTBI differed from controls on the SCAT2 Symptom Scale (p50.001, Cohen’s d ¼ 1.02–1.15, large effect) and Standardized Assessment of Concussion (p ¼ 0.004, d ¼ 0.81, large effect), but not the K-D test (p ¼ 0.148, Cohen’s d ¼ 0.40, medium effect). In a logistic regression analysis, the K-D did not contribute over and above the other two measures in predicting group membership (MTBI vs trauma control), p ¼ 0.191. Only 15.4% (n ¼ 4) of the MTBI group obtained low K-D scores, defined as 51 standard deviation below controls. Three of these participants had normal Sport Concussion Assessment Tool scores and none had a loss of consciousness or traumatic abnormalities on magnetic resonance imaging, suggesting that these cases may have been false positives. Conclusions: The present findings do not support the K-D test for the assessment of civilian trauma MTBI in an Emergency Department setting. Its utility may depend on the availability of pre-injury baseline testing and more rapid (51 hour) post-injury testing.


Cost-efficiency of in-patient rehabilitation following acquired brain injury: A multi-centre analysis from the UK Rehabilitation Outcomes Collaborative (UKROC) dataset Lynne Turner-Stokes1, Alan Bill2, Heather Williams2, & Keith Sephton2 1

King’s College London, London, UK, 2Northwick Park Hospital, London, UK Objectives: To evaluate the cost efficiency of inpatient rehabilitation in patients with acquired brain injury (ABI) at different levels of


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DOI: 10.3109/02699052.2014.892379

dependency and to compare findings with estimates of ‘FIM Efficiency’. Methods: The UKROC database collates prospectively-collected inpatient episode data for all specialist rehabilitation units in England. Data were extracted for all patients with ABI admitted to Level 1 and 2 services from April 2010 to September 2013, who had both Northwick Park Dependency Scores (NPDS) and Functional Independence Measure (FIM) scores recorded on admission and discharge. Patients were divided into three groups of dependency, based on admission NPDS scores: ‘High’ (NPDS424) requiring assistance of two carers for most self-care tasks; ‘Medium’ (NPDS ¼ 10–24), requiring assistance of one carer; and ‘Low’ (NPDS510) largely independent. The NPDS also computes an estimate of weekly care costs in the community. Estimated life-time cost savings were computed individually with reference to the formulation by Shavelle, based on FIM scores for ‘Eating’ and ‘Walking’ at discharge. Results: In total, 1696 eligible case episodes were identified from a total of 48 centres: mean age (±SD) ¼ 51.5(±17.1) years; M:F ratio ¼ 61:39; aetiology ¼ 48% stroke, 27% trauma, 8% anoxia, 7% tumour and 10% other. Mean (±SD) FIM scores were 60 (±31) on admission and 83 (±34) on discharge. Mean length of stay (LOS) was 91 (±112) days. Distribution of patients across the three dependency groups was as follows: High: n ¼ 1037 (61%); Medium: n ¼ 482 (28%); Low: n ¼ 177 (10%). Respectively, across the three groups: (1) Mean (±SD) LOS were 106 (±75), 72 (±174) and 53 (±44), giving total episode costs of £48 577 (±39 053), £32 922 (±92 992) and £23 546 (±18 952). (2) Mean (±SD) reduction in ongoing care costs/week were £607 (±480), £399 (±597) and £95 (±480). (3) Based on the mean weekly savings in cost of care, the estimated times to offset the initial costs of rehabilitation were 20, 21 and 62 months. (4) Assuming steady state in dependency after discharge, the mean estimated life time savings were £662 853, £580 928 and £163 931. Calculated FIM efficiency (FIM gain/length of stay) was 0.23, 0.32 and 0.24. Conclusions: This large multi-centre analysis confirms the findings from a single-centre study that, although high dependency patients have longer lengths of stay, the higher initial costs of initial rehabilitation are more rapidly offset by greater savings in the cost of ongoing care. When gains are extrapolated as potential life-time savings, the high-dependency group is the most cost-efficient to treat. In contrast, FIM efficiency appears to be highest in the medium dependency group, which probably reflects the floor and ceiling effects of the FIM, limiting its use as a proxy for cost-efficiency in patients with complex disability following ABI.


The relationship between self and team reports of rehabilitation outcomes in traumatic brain injury Jami Halpern, Kyle Haggerty, Karen Lindgren, & Cynthia Boyer Bancroft Brain Injury Services, Cherry Hill, NJ, USA Background: In long-term post-acute rehabilitation settings, improvement in quality-of-life (QoL) is a major goal. Self-report measures, such as the World Health Organization Quality-of-Life QuestionnaireBREF (WHOQoL-BREF), are often used to assess this construct. Research suggests that self-report measures may not accurately assess individuals who have sustained severe traumatic brain injuries (TBI) due to cognitive changes and decreased self-awareness. Also, it is unclear what factors contribute to reporting high quality-of-life; for instance it may be a reflection of mood rather than participation.

The Mayo-Portland Adaptability Inventory (MPAI-4) assesses rehabilitation outcomes in post-acute settings and consists of the following indices: Abilities (e.g. mobility, verbal communication and memory), Adjustment (e.g. depression, pain and headache and fatigue) and Participation (e.g. initiation, self-care and employment). The MPAI-4 was completed by professional consensus (i.e. interdisciplinary teams). The Adjustment and Participation indices assess many of the same domains as the WHOQoL-BREF measure, but can utilize clinical consensus rather than self-report. The current study aimed to explore the relationship between the Adjustment and Participation sub-scales of the MPAI-4 and the WHOQoL-BREF, to examine whether a self-report measure of QoL correlated with clinical observation in persons with severe TBI. Hypothesis: It was hypothesized that the Adjustment and Participation sub-scales of the MPAI-4 would be significantly associated with responses on the WHOQoL-BREF. Design: Data from 65 participants (mean age ¼ 44.8, SD ¼ 11.41; 70% male) was collected from a post-acute long-term brain injury rehabilitation programme, using a cross-sectional design. Age and gender were examined as potential covariates. Results: Linear regressions examined the relationship between WHQoL-BREF and MPAI-4 Adjustment and Participation. Preliminary results revealed a significant association between MPAI Adjustment and WHQoL-BREF. However, no relationship was found between MPAI Participation and WHQoL-BREF. Discussion: These findings highlight the key research and treatment issues. First, discrepancies exist regarding how individuals with TBI and their clinical team perceive functioning. Rehabilitation research needs to consider these discrepancies in order to accurately measure outcome. In addition, psychological factors appeared to predict quality-of-life to a greater degree than community participation. Rehabilitation treatment focused on improving quality-of-life must consider psychological treatment. Future research should focus on developing measures of quality-of-life that more accurately reflect the experience of individuals who have sustained TBI.


Is current brain injury rehabilitation enhancing the biopsychosocial model? A 2-year post injury follow-up study Chalotte Glintborg, Tia Hansen, & Ane Sondergaard Thomsen Aalborg University, Aalborg, Denmark Objectives: The long-term psychosocial consequences following acquired brain injury (ABI) have received little attention in rehabilitation research as well as in rehabilitation practice, compared to the physical problems, but is becoming a major challenge in current rehabilitation. This paper describes a Mixed Methods design and some preliminary results regarding adults with ABI (n ¼ 37) 2-years post-injury. This study investigates the bio-psychosocial rehabilitation outcome and looks for predictors of this outcome seen from a patient perspective. The theoretical framework is the bio-psychosocial model represented by International Classification of Functioning (ICF). Methods: A mixed methods design using concurrent testing, interview and observations. Descriptive statistics on five rehabilitation outcomes: Functional Independence Measure (FIM), Impact on Participation and Autonomy (IPAQ-DK), Quality-of-life (WHOQoLBREF), Major Depression Inventory (MDI) and Return-to-Work. These measures are correlated with coded field notes from interviews with adults with ABI. Results: Preliminary results indicate that Return-to-Work, Personal factors (e.g. independence and personal drive) and Psychological

586 rehabilitation (supporting the transition phase from disabled to well) may be among the important predictors of rehabilitation outcome. A model of all analysed predictors will be ready for presentation at the conference. Conclusions: Outcome measures and perspectives from adults with ABI provide input to a model of predictors of rehabilitation outcome. By depicting influences that are likely to increase or decrease the outcome, this model could have practical impact for people suffering from ABI as well as economic benefits for both hospital and the municipality that provide these services. An evaluation of rehabilitation outcome predictors might also assists administrators in making programme-level decisions.


Post-traumatic Parkinsonism Rita Formisano1, & Nathan Zasler2

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Santa Lucia Foundation, Rome, Italy, 2Concussion Care Centre of Virginia, Glen Allen, USA Amantadine hydrochloride is one of the most commonly used drugs in the pharmacotherapeutic treatment of disorders of consciousness (DOC) following traumatic brain injury (TBI). Indeed, its actions as a pro-dopaminergic drug and as an N-methyl-D-aspartate antagonist makes amantadine an interesting candidate to improve consciousness and responsiveness in individuals with DOC including vegetative state (VS) and minimally conscious state (MCS). Giacino et al. recently reported that amantadine was able to accelerate the functional recovery course of subjects after TBI with DOC during a 4-week treatment period. Some patients with DOC following severe TBI, especially when there is significant traumatic axonal injury, have been reported to have Parkinsonian symptoms. Severe traumatic brain injury and post-traumatic Parkinsonism may share a common midbrain network dysfunction. In fact, VS, MCS, akinetic mutism and Parkinsonism might represent a recovery continuum following severe TBI. Responsiveness to pro-dopaminergic agents, like L-Dopa or amantadine, in some patients and to deep brain stimulation (DBS) in others might depend, respectively, on the integrity, or lack thereof, of the dopaminergic post-synaptic receptors. The authors are of the strong opinion that more attention should be given to Parkinsonian findings in persons with DOC after severe TBI and would advocate for multi-centre, randomized, controlled trials to assess risk factors for Parkinsonism following severe TBI (including patient stratification and clinical features), as well as responsiveness to therapeutic interventions with pro-dopaminergic agents (and potentially neuromodulatory techniques).


Wii challenges you? Monique Berger1, Karen van Stein Callenfels1, & Arend de Kloet2

Brain Inj, 2014; 28(5–6): 517–878

rehabilitation patients spend playing with the Wii; and (3) How experience therapists the use of Wii games in rehabilitation treatment. Methods: In a period of 10 months, the Nintendo Wii was placed in three rehabilitation centres in the Netherlands. Patients could pre-select from the following skills they would like to improve using the Wii: gross and fine motor skills, perception, cognition, communication skills and participation in social situations. The patients were asked to fill in a profile (including questions about gaming experience and treatment goals). During the intervention (gaming) period gamers were asked to fill in a log, at least once a week. After completion of the therapy, or when gamers stopped gaming, a final questionnaire had to be filled in by the patient and therapist. Results: A total of 42 players (21 men, 21 women (6–52 years, mean ¼ 21 years) used the Wii during the study period. The medical diagnosis of gamers is very diverse (including traumatic brain injury, stroke, CP, Duchenne muscular dystrophy, spina bifida and spinal cord injury). In the category gross motor skills patients want to improve endurance, balance and strength, in the category fine motor skills, eye–hand co-ordination and timing, in cognitive skills concentration and memory. During the period of participation (mean 12 weeks), patients filled the log on average 7-times (range ¼ 2–39 times), so less than once per week. The playing time was mostly less than half an hour (54%). In 89.6% of the logs the training with Wii games was evaluated as very nice. Only 21 patients filled in the final questionnaire, however 12 of them reported to have achieved one or more personal training goals. These patients gamed more intensely (on average 15 logs were filled). Thirty-three therapists filled in the final questionnaire; 85% of the therapists described strong enthusiasm and motivation for training with the Wii in addition to regular therapy, the other 15% scored moderate. Therapists address gaming as a potential, additional means to regular therapy. Intensity and motivation for therapy are improved by gaming, as well as the opportunity for practicing at home. The transfer of skills to the ‘real world’ is marked as important; 90% of the therapists think the Wii is challenging for patients.


Combination treatment of lowfrequency repetitive transcranial magnetic stimulation and intensive occupational therapy for upper limb hemiparesis after stroke: Clinical results in more than a thousand patients Wataru Kakuda1, Masahiro Abo1, Masato Shimizu1, Junichi Sasanuma1, Takatsugu Okamoto1, Hiroyoshi Hara1, Tomoyuki Kimura1, & Mitsuo Takei1 1


The Hague University (of applied sciences), The Hague, The Netherlands, 2Sophia Rehabilitation, The Hague, The Netherlands

Objectives: Gaming, especially commercial ‘off the shelf’ consoles, are more and more acknowledged to be promising in therapeutic intervention. Gaming appeals on skills in social-emotional, physical and cognitive areas. ‘Wii challenges you’ is an explorative study to provide insight into the usefulness of the Nintendo Wii to train specific skills of patients within the context of a rehabilitation treatment. The following questions are addressed: (1) Which skills will rehabilitation patients, together with their therapists, choose to improve using the Wii; (2) How much time will

Jikei University School of Medicine, Tokyo, Japan, 2Shimizu Hospital, Tottori, Japan, 3Tokyo General Hospital, Tokyo, Japan, 4 Nishi-Hiroshima Rehabilitation Hospital, Hiroshima, Japan, 5 Aizawa Hospital, Nagano, Japan, 6Kimura Hospital, Fukui, Japan Objectives: Application of repetitive transcranial magnetic stimulation (rTMS) influences neural excitability of selected brain areas noninvasively. Low-frequency rTMS suppresses local neural activity while high-frequency rTMS increases the activity. Low-frequency rTMS applied to the non-lesional hemisphere has proved to improve motor function of the paretic upper limb after stroke, with the reduction of inter-hemispheric inhibition towards the lesional hemisphere. On the other hand, some clinical studies have confirmed the beneficial effect


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DOI: 10.3109/02699052.2014.892379

of intensive occupational therapy (OT) for upper limb hemiparesis after stroke. Therefore, this study originally developed a combined protocol of these two interventions, expecting that motor recovery would be facilitated. The purpose of this study was to clarify the safety, feasibility and efficacy of the combined protocol for poststroke patients with upper limb hemiparesis. Furthermore, this study investigated the influence of age at the intervention on the extent of motor recovery with the protocol using linear regression analysis. Methods: The study subjects were 1008 post-stroke patients with upper limb hemiparesis (mean age ¼ 61.1 ± 12.4 years, mean time after stroke onset ¼ 81.5 ± 88.5 months) from eight institutions in Japan. Prior to the intervention, medical doctors and occupational therapists from each institution received a training programme for standardizing the protocol. During 15-day hospitalization, each patient was scheduled to receive 22 treatment sessions of 20-minutes low-frequency rTMS followed by 120-minutes of intensive OT daily. Low-frequency pulses of 1 Hz were applied to the motor cortex of the non-lesional hemisphere. The intensity of the stimulation was set at 90% of resting motor threshold of the first dorsal interosseous muscle of the unaffected upper limb. The programme of intensive OT is composed of one-to-one training and self-exercise. In oneto-one training, shaping and repetitive task practice techniques were mainly involved. Fugl-Meyer Assessment (FMA), log performance time of Wolf Motor Function Test (WMFT) and Functional Ability Score (FAS) of WMFT were evaluated on the days of admission and discharge. Results: The protocol was completed by all patients without any adverse effects. The FMA score significantly increased from 45.3 ± 12.1 to 49.7 ± 10.4 points (p50.001). Similarly, log performance time of WMFT significantly decreased from 2.78 ± 1.07 to 2.43 ± 1.22 (p50.001). In addition, the intervention significantly increased FAS of WMFT from 45.6 ± 13.8 to 49.7 ± 14.1 points (p50.001). Linear regression analysis indicated that the response to the treatment was significantly influenced by severity and side of hemiparesis. However, the age at the intervention did not influence the response. The extent of motor recovery did not differ between patients aged 70 years or over and those aged under 70 years. Conclusions: The proposed combination treatment is safe and feasible. The treatment seems to improve motor function of the paretic upper limb after stroke, although the efficacy of the treatment needs to be confirmed in a further study.


Treatment of severe cranialcerebral traumas in traffic accident victims Kirill Poshataev, Dmitrii Frolov, Von Gi Kim, & Mikhail Kosmachev Regonal Hospital N2, Khabarovsk, Russia Goal: To work out treatment tactics of traffic accidents victims (TAV) diagnosed with a severe cranial-cerebral trauma (CCT). Materials and methods: This study has analysed the results of treatment of patients with cranial-cerebral traumas after traffic accidents who were hospitalized to the neurosurgery department of the Regional hospital N2 in Khabarovsk. In 2011, 632 patients, traffic accidents victims, were hospitalized. Out of them 415 (55.5%) had CCTs; in 2012, 810 were admitted to the hospital, 415 (51.2%) had CCTs. All the victims underwent panoramic X-ray of the skull, ECHO-EG, SCT or MRI of the brain. Results: In 2011, out of the total number of hospitalized patients with cranial-cerebral trauma, 57 (16%) were operated on, in 2012 it was 84 (20.2%). Mortality rate comprised 6.2% and 3.3%, respectively; post-operative mortality was 26% and 17.8%. Indications from the operative treatment were: volume of intracranial haematoma,

over 40 cm3, confused consciousness up to 11 or less, presence of stem and dislocation symptoms, shift of the middle structures more than 5 mm and/or marked deformation of basal cisterns, concussion focus volume over 60 cm3, and highly dense part over 50 cm3. If a haematoma was located in a medial cranial fossa zone, an absolute indication for an operation was the volume 20 ml, compression of the fourth ventricle with occlusion hydrocephaly development. Indications for a conservative therapy were: haematoma volume up to 30 cm3, consciousness level 14–15, absence of stem and dislocation symptoms, shift of medial structures less than 5 mm, intact basal cisterns, a total volume of a pathological focus not more than 45 cm3, high density part not more than 30 cm3. A mandatory condition for a conservative therapy was a 24-hour observation by a neurosurgeon having an access to CT/MRI and intracranial pressure control. Observation tactics was used if: haematoma volume was 31–39 cm3, consciousness level 12–13 points, absence of dislocation symptoms, medial structures shift up to 5 mm, intact basal cisterns, a total volume of a pathological focus less than 60 cm3, a highdensity part less than 50 cm3. Priorities in the treatment of these patients are: on-time adequate brain compression removal, hypoxemia (blood saturation with O2 over 90%), maintenance of systemic blood pressure not lower than 90 mm Hg, control of central perfusion pressure (not lower than 50 mm Hg, target parameter ¼ 50–70), intracranial pressure control (up to 20–25 mm Hg), prevention of thrombi and thromboembolic complications, infection diseases complications prophylaxis, adequate nutritional support, fluid-electrolyte impairment control. A strict following of the worked out and approved algorithm of treatment of patients with severe cranial-cerebral traumas has dramatically improved the outcomes of treatment.


Periodic changes of the pulsatility index of the cerebral artery by transcranial Doppler sonography as a clue for leptomeningeal carcinoma: A report of two cases Xiujuan Wu, Kangding Liu, Hongliang Zhang, & Yingqi Xing The First Hospital of Jilin University, Changchun, PR China Leptomeningeal carcinomatosis (LC) results from the diffuse infiltration of leptomeninges by malignant cells originating from an extrameningeal primary tumour site. It has been reported that the incidence of LC was 4–15% in patients with solid carcinomatosis and the common causes of LC are breast cancer, lung cancer and malignant melanoma. Patients with LC can present with various neurological symptoms and signs depending on the site of leptomeningeal invasion. The diagnosis of LC, however, can sometimes be difficult and challenging. It typically requires the demonstration of malignant cells in cerebrospinal fluid (CSF) which may require several lumbar punctures. MRI, especially gadolinium-enhanced MRI, may play an important role in supporting the diagnosis of LC in patients with negative cytology in CSF. However, to the authors’ knowledge, there have been no reports on the periodic changes of the pulsatility index (PI) of the cerebral artery by transcranial Doppler sonography (TCD) in patients with LC. This study reports two cases of patients who complained of headache without positive neurological signs and who visited the outpatient department. The MRIs showed no positive results. Both of them were found to have a periodically changing PI of the cerebral artery which disappeared after intravenous mannitol, detected by TCD monitoring, which indirectly reflects periodic

588 intracranial pressure change. This prompted the authors to perform a lumbar puncture for each patient. As a result, LC from lung cancer was found, as demonstrated by CSF cytology and chest CT. Unfortunately, neither of them performed gadolinium-enhanced MRI which, in the authors’ opinion, may help to explain the periodic changing PI of the cerebral artery. From the communication, it was speculated that TCD monitoring may be helpful in LC diagnoses in the future, but still needs further research.

Brain Inj, 2014; 28(5–6): 517–878

Monique Berger1, Karen van Stein Callenfels1, Inge Verhoeven2, Klaasjan van Haastrecht3, Joep Janssen4, & Arend de Kloet3 1

The Hague University (of applied sciences), The Hague, The Netherlands, 2Technical University Delft, Delft, The Netherlands, 3 Sophia Rehabilitation, The Hague, The Netherlands, 4Rehabilitation Center de Hoogstraat, Utrecht, The Netherlands


Efficacy of trauma centre organization in the Khabarovsk region, the subject of the Russian Federation

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Vladimir Korolev1, Kirill Poshataev1, & Vladimir Korablev2 1

Regional Hospital N2, Khabarovsk, Russia, 2Far Eastern State Medical University, Khabarovsk, Russia Goal: To work out measures to improve effectiveness of treatment of the victims with multiple traumas at the Russian Federation District level. Materials and methods: In the Khabarovsk Region in the period from 2006–2012, an unsteady tendency to traffic traumatism has been observed. The number of traffic accidents (TA) decreased by 16.3%, the amount of those who died showed a 28% decrease and the amount wounded decreased by 17.6%. Nevertheless, from 2011 to 2012 a 15.9% increase was noted in the TA number, while the amount of those who died remained the same and the number of wounded was 17.8% higher than previously registered. To make the situation with traffic traumatism better in the Khabarovsk Region according to the federal programme ‘Improvement of traffic safety in the period 2006–2012’, a three-level net of trauma centres was set up throughout 2009–2010. The centres were equipped according to the standards, medical personnel were trained to provide aid to traffic accidents victims including neurosurgeons, surgeons specializing in multiple traumas, intensive care experts and traumatologists. Universal standards of medical aid provision to traffic accidents victims have been implemented. A system of indicators and criteria for the assessment of medical interventions quality evaluation in the case of traffic accidents has been created. A constant monitoring of trauma centres activities is being conducted. All the medical measures are supported scientifically. In all rural municipal organizations of the Khabarovsk region healthcare departments together with trauma centres specialists performed organizational measures among the population and medical personnel working at out- and in-patient departments as well as central district hospitals. Results: Due to the conducted measures the number of those who died at the pre-hospital stage had a 35.7% decrease in the Khabarovsk Region. There was 40% diminishing of the people who died during ambulance transportation. The number of people who died in the medical institutions of the Region was 34.0% less. There was a 66.7% increase for operations performed for multiple trauma at the first level trauma centre. There is a 1.4% time decrease of total mortality rate, from 6.6% to 4.8%. Thus, all the measures carried out to set up trauma centres of different levels, resources and technological maintenance have helped to raise the efficacy of medical services provided to the victims with multiple traumas.


Explorative study: Effects of gaming on youth with acquired brain injury

Objectives: Gaming, especially commercial ‘off the shelf’ consoles, are gaining interest for use in therapeutic settings. The rapidly ongoing development may offer an attractive enrichment for application in therapy of children, youth (and adults) with ABI. The Nintendo Wii can be used as therapeutic intervention, e.g. to improve learning and performance of motor skills in patients with ABI. This pilot study wants to challenge, convince and facilitate rehabilitation therapists to start gaming during therapy and encourage patients with ABI to apply gaming for several activities/therapy goals. Goal: To discover and describe the possibilities and effects of gaming (Wii) as a therapy supplement for patients with ABI (12–25 years). Methods: A multi-centre, observational proof-of-concept study. Fifty participants were included in the study. The intervention consists of 12 weeks of gaming with Nintendo Wii with help of a ‘Game menu’, personalized (patient–therapist) to self-chosen therapy goals. Outcome assessments were done at baseline and after 12 weeks and included: cognitive functioning measured with sub-scales of the ANT (Amsterdam Neuropsychological Tasks), average number of minutes per week of recreational physical activity, self-reported results and satisfaction on individual treatment goals (Goal Attainment Scaling, GAS) . Results: Forty-five participants completed the study. Neuropsychological tasks showed significant improvement of speed of information processing: in reaction time, figure identification, shifting attention, visual motor co-ordination and in response inhibition. However, no significant changes were found regarding accuracy. The average number of minutes per week of physical activity increased significantly from 30–60 minutes at baseline to 1–2 hours. Nineteen participants chose gross motor activities as the first treatment goal, in which endurance training and balance was most chosen. Fifteen of them experienced improvement (GAS); 18 participants chose information processing as a first goal, in which concentration and memory were most chosen; eight of these reported improvement (GAS). Conclusions: This study underlines the expected benefits of gaming in rehabilitation. Gaming, in addition to therapy, is a promising tool for therapists and patients (, Research on the effect of gaming on physical and mental functioning should be further explored.


The effect of computerized brain training on cognitive impairments and quality-of-life after stroke: A RCT Manon Wentink1, Arend de Kloet1, Monique Berger2, Klaasjan van Haastrecht1, Inge Verhoeven1, Monique Jakobs3, Thea Vliet-Vlieland4, Guido Band4, Jorit Meesters1, Paulien Goossens3, Anne Marie Ter Steeg1 1

Sophia Rehabilitation, The Hague, The Netherlands, 2The Hague University of Applied Sciences, The Hague, The Netherlands,


DOI: 10.3109/02699052.2014.892379

Rijnlands Rehabilitation Center, Leiden, The Netherlands, 4Leiden University Medical Center, Leiden, The Netherlands

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Objectives: Computers are more and more used as an intervention tool to improve cognitive functions in patients with cognitive impairments after stroke. Recently, a meta-analysis showed that computer-based cognitive rehabilitation is effective in improving attention and visual perception in patients with stroke. However, results for other cognitive functions such as memory, executive functions and orientation are still unknown. Moreover, studies mainly focused on cognitive functions and there is no insight into effects on quality-of-life. The aim of this study is to determine the effect of computerized brain training on cognitive functions (attention, memory, speed, flexibility) and quality-of-life compared with no intervention in stroke patients with cognitive impairments 12–36 months after stroke. Methods: This study had a randomized controlled design (RCT) and took place between January 2013 and September 2013. Participants were recruited from two participating rehabilitation centres, had a stroke (12–36 months ago), were between the age of 45–75 years, had self-perceived cognitive impairments and access to and were able to use a computer with Internet connection. The intervention consisted of computer gaming during a period of 8 weeks, 5 days per week, at least 15–20 minutes per day. The training aimed at four cognitive domains: attention, memory, speed and flexibility. The control group received general information about the brain once a week during 8 weeks. Assessments were done before the intervention (t0), 8 weeks after baseline (t1) and 16 weeks after baseline (t2). At all times the assessments consisted of the Cognitive Failures Questionnaire (CFQ), the Stroke Specific Quality-of-Life Questionnaire (SSQoL) and four neuropsychological tests: Trail Making Test A and B, Eriksen Flanker Test, Corsi Block-Tapping Task, Digit Span Test. In addition, socio-demographic and stroke characteristics were registered at baseline. Baseline characteristics and changes over time will be compared between the intervention and control groups by means of Mann-Whitney U or Chi Square tests or analysis of (co)variance, where appropriate. Results: In total, 889 patients were invited, of whom 115 met the inclusion criteria and were willing to participate. Directly after randomization, five patients refused further participation, so that 110 patients were finally included. Of these, 107 participants (97%) completed the study, 50 (47%) in the treatment group and 57 (53%) in the control group. Further results are not yet available. Data-analysis will start in November 2013.

Objectives: To examine communicative and adaptive skills postMM-TBI and their impact on the occupational and social adaptation. Methods: This study included 28 adults patients, at least 3 months after MM-TBI, with an initial Glasgow coma scale score ranging from 9–15: nine women and 19 men, mild TBI in six and moderate TBI in 22, 41 years on average (21–62), mean time since TBI of 7.3 years (3 months to 31.4 years). Validated French tests of language and communication (the Subtle Language Test (SLT), Lille Communication Test (TLC) and Participation to Communication Questionnaire (QLPC)) and the Daily Life Problems Resolution Test (DLPRT) were used to objectively address adaptive social skills. Social and occupational adaptation (leisure, occupation, family activity) was apprehended with items of the European Brain Injury Society (EBIS) document and the QLPC. Quality-of-life (with QOLIBRI questionnaire), a reflection of social adjustment, was also examined. Patient performance was compared to norms obtained in normal control subjects. Statistical analyses use the SPSS software (p50.05). Results: Pathological scores were found in 14.3% of cases in the SLT, in 14.3% of cases for verbal communication (especially at the ideational and pragmatic levels) and 25% for non-verbal communication (especially at the pragmatic levels) in the TLC and in 28.6% of cases in the QLPC. Only 3.6% obtained abnormal scores on the DLPRT. Conversely, 64% had interrupted or adapted leisure activities, 43% had interrupted or adapted work activities and 32% reported deterioration in conjugal relationships. The total QOLIBRI score and the recovery of professional and leisure activities showed definite relationships with the TLC and STL total scores, and with the QLPC’s communication satisfaction sub-tests. Conclusions: This study showed that MM-TBI patients can present with subtle language (SLT) and communication (TLC) difficulties, especially at the ideational and pragmatic level. Those difficulties can clearly participate in quality-of-life reduction (QOLIBRI), and impair work and leisure recovery. Difficulties in problem-solving (DLPRT) were less frequent and showed less consequence on quality-of-life.


Exploring meaning structures among adolescents with traumatic brain injury (TBI)—Why is that significant? Eli Marie Killi


Social skills post-mild or moderate traumatic brain injury evaluation: Communication trouble’s influence on social and professional adaptation Odile Kozlowski1,4, Maud Le Gall2, Laetitia Wittmann-Stephann2, Paula Dei Cas2, & Marc Rousseaux3 1 Reseau TC AVC 59/62, Lille, France, 2Institut d’orthophonie, Lille, France, 3CHRU, Lille, France, 4Service AUPRES TC, La Bassee, France

Introduction: Traumatic brain injury (TBI) is a public health problem and 90% of TBI are mild or moderate (MM-TBI). MM-TBIs consequences on communicative and adaptive skills are still poorly investigated. Some patients have difficulties in familial and social relationships and communication.

Aarhus University, Copenhagen, Denmark Objective: This paper examines potentials for transcending marginal positions and expanding agency in school. Students’ perspectives after TBI are seldom included in research studies. Mealings et al. have performed a systematic review of the literature published in English from 1998–2010, exploring students’ experiences of their educational experiences following TBI, and only eight articles met the criteria out of 400 articles. Method: This paper is based on an explorative multi-case study inspired by ethnographic fieldwork including eight young people, their parents and two significant professionals in their schools. The inclusion criteria were: aged between 13–17 years old, the participants had to have incurred a mild or moderate TBI, absence of previous psychiatric diagnoses and oral communication skills. The study combines participation observations, semi-structured interviews and documents: neuropsychological reports, Individual Education Plans (IEPs) and half-year evaluation reports. The study includes interviews with the young people (8), their parents (11) and teachers (15) and assistants (3). There were 47 interviews conducted in total and 12 weeks of observation in a total of nine schools. The analysis relies on a conditioning discourse from an external standpoint that is neuropsychology and a reason discourse from the standpoint of the subject that is critical psychology (CP).

590 Results: ‘Not to dare’ was central to the adolescents and their reasons to act. However, this seemed to change when they felt confident and felt part of a ‘we’, together with their peers. This need for recognition and belonging is not unique for students after TBI. Nevertheless, to help students transcend learning barriers and expand agency after TBI, one has to come to an understanding of both conditioning aspects and the action reasons and the standpoints of the students. Conclusion: Agency is produced in a close dialectical relation with the contexts and communities in which the adolescents participate. Expanding agency relies on particular kinds of contexts in relation to which it is possible to make up necessary and sufficient personal pre-conditions for participation and, hence, transcend marginal positions in and out of school.

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Employment probability trajectories and employment stability at 1, 2 and 5 years after moderate-to-severe traumatic brain injury Marit V. Forslund1, Juan C. Arango-Lasprilla2, Cecilie Roe1,5, Paul B. Perrin3, Solrun Sigurdardottir4,6, & Nada Andelic4

Brain Inj, 2014; 28(5–6): 517–878

Results: The employment rates dropped from 81% pre-injury to 51% and 44% at 1-year and 2-year follow-ups, respectively. At the 5-year follow-up, the employment rate increased to 55%. The rates of stably employed individuals were 39%, unstable employed 44% and unemployed 17%. Being single, unemployment prior to injury, blue collar occupation and lower GCS score and greater length of PTA at hospital admission were significantly associated with being unemployed at 1, 2 and 5 years post-injury. Further, younger age, lower GCS, greater length of PTA and greater length of hospital stay were negatively associated with employment stability. Conclusion: The main considerations relate to target patient populations with these demographic and injury characteristics for more extensive follow-ups and vocational rehabilitation to help improve employment outcomes following injury. Intervening with these at-risk populations, especially when these risk factors appear in combination, could represent a maximal use of rehabilitation resources.


Coping with communication breakdown: Applying single case experimental design to evaluate a new treatment Jacinta Douglas, Lucy Knox, Carren Mitchell, & Helen Bridge


Oslo University Hospital, Department of Physical Medicine and Rehabilitation, Oslo, Norway, 2University of Deusto, IKERBASQUE (Basque Foundation for Science), Bilbao, Spain, 3Virginia Commonwealth University, Richmond, VA, USA, 4University of Oslo, Faculty of Medicine, Institute of Health and Society, CHARM (Research Centre for Habilitation and Rehabilitation Models and Services), Oslo, Norway, 5University of Oslo, Faculty of Medicine, Oslo, Norway, 6Sunnaas Rehabilitation Hospital Trust, Nesoddtangen, Norway Objectives: To describe the proportion of individuals with TBI who were employed as well as the stability of their employment at 1, 2 and 5 years after injury and to assess whether demographic and injury characteristics significantly predicted employment probability trajectories and employment stability across 1, 2 and 5 years after injury. Methods: A longitudinal cohort study was conducted with 105 individuals (mean age ¼ 30.9 years [SD ¼ 11.2], 78% male) with moderate-to-severe TBI (i.e. Glasgow Coma Scale score, GCS 3–12), who had been admitted to the Trauma Referral Centre for the Southeast region of Norway during a 2-year period (2005–2007). Patients were followed up at 1, 2 and 5 years after the injury. One hundred individuals participated at the 2-year follow-up and 94 individuals at the 5-year follow-up. No statistically significant differences were found in demographics and injury characteristics between individuals lost to 5-year follow-up and those assessed at that time point. Multi-level modelling and multinomial logistic regressions were used to examine trajectories of employment probability and stability over the first 5 years post-TBI. Sex, age, relationship status at admission, guardianship of dependent children, education, employment status prior to admission, occupation prior to admission, acute GCS score, cause of injury, days of post-traumatic amnesia (PTA) and days spent in acute care and sub-acute rehabilitation were all entered simultaneously as fixed effects into the multi-level model. Employment status (employed vs unemployed) at each of the three time points was entered as the dependent variable. In addition, a series of multinomial logistic regressions were then run to examine associations between the same patient characteristics and job stability across the four data collection points.

La Trobe University, Melbourne, Victoria, Australia Objectives: Impaired communication is a well-established consequence of traumatic brain injury (TBI). As a result, people with TBI frequently experience communication breakdown. Typically, communication-specific coping strategies are used in situations characterized by communication breakdown. Productive strategies enhance message transfer and facilitate participation. In contrast, non-productive strategies do little to resolve problems and are likely to increase social isolation. This research aimed to evaluate the effectiveness of a new intervention, specifically designed to target coping in the context of communication breakdown. Methods: Single case experimental design (baseline, treatment, withdrawal and follow-up at 1 and 3 months post-treatment) with replication was used. Participants were two adults: RJA, a 30-year old woman who sustained very severe TBI in a motor vehicle accident when she was 22 years old and ABR, a 34 year old man who sustained a very severe TBI 6 years ago. The intervention is a 6-week structured programme which targets personally-relevant productive coping strategies identified collaboratively with the client. It incorporates the procedures and principles utilized in cognitive behavioural therapy and context-sensitive social communication therapy. The programme required 22 hours: pre-treatment assessment (4 hours), intervention phase (12 hours), post-treatment assessment (2 hours) and two follow-up assessments (4 hours). The intervention phase was delivered at a rate of two sessions/week over 6 weeks. Data analysis involved independent assessment of video-recordings during baseline sessions, intervention sessions 3, 5, 7, 9, 10 and 11 and follow-up sessions at 1 week, 1 month and 3 months. Inter-rater reliability was evaluated through intra-class correlation coefficients (ICC) (two-way random effects model): average of two raters (ICC ¼ 0.995). Data was analysed using the percentage of non-overlapping corrected data (PNCD) procedure. PNCD involves a data-correction to remove baseline trend from the data series prior to calculating the change produced as a result of intervention. Results: A large treatment effect was demonstrated in both participants (PNCD: end of treatment RJA ¼ 100%, ABR ¼ 100%, 3month follow-up RJA ¼ 92%, ABR ¼ 100%). These results are consistent with highly effective treatment based on Scruggs and


DOI: 10.3109/02699052.2014.892379

Mastropieri’s guideline for assessing the significance of results between phases of the single case trial. Conclusions: The programme elicited clinically significant improvements which were maintained up to 3 months post-treatment in participants with chronic and severe disability. Qualitative feedback from clients and close others highlighted important strengths of the intervention, including its focus on strategy development, use of video feedback and community practice. The study provides sound phase 1 evidence for the effectiveness of the intervention.



Cecilia Jonsson1, & Elisabeth Elgmark Andersson2

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Clinical and cost outcomes of using smart home technology in a transitional living service for individuals with acquired brain injury (ABI) Sara da Silva Ramos, & Michael Oddy Brain Injury Rehabilitation Trust, Horsham, UK Objectives: To describe the process of prescribing and evaluating the usefulness of smart home technology for individuals with acquired brain injury and to assess its effect on psychological and functional outcomes and on costs with long-term care. Methods: This study describes the use of a person-centred, multidisciplinary approach to assess needs, establish goals and prescribe smart home technology to support independent living in the community of two individuals with severe ABI. Clinical outcomes were evaluated using the Mayo-Portland Adaptability InventoryVersion 4 (MPAI-4), the BIRT Independent Living Scales (BILS) and the Hospital Anxiety and Depression Scales (HADS). Changes in long-term care costs were calculated on the basis of hours of support required per week. The effects of using the technology on other aspects of the service users’ psychological wellbeing, including self-efficacy, mood, locus of control and self-esteem were also assessed with self-report questionnaires. Results: On discharge from the transitional living environment, the two service users’ needs in an unstructured independent living setting were established. Technology was recommended to meet some of the needs identified. However, there were areas of complex need for which technology solutions were not suitable or available. Scores on clinical outcome measures showed reductions in impairments and improvements in adjustment and participation. Results revealed that providing technology could reduce the long-term costs of support. The measures of service users’ wellbeing also demonstrated additional benefits of living in an independent transitional living environment. Conclusions: The present findings demonstrate the usefulness of a smart home system in assessing and supporting independent living skills. There were associated economic and psychological benefits of promoting independence. However, this study also highlighted important limitations of current technological solutions to support those living with the cognitive and behavioural consequences of ABI.

Mild traumatic brain injury: A description of how children and youths between 16 and 18 years of age perform leisure activities after 1 year 1

Work For You, Jo¨nko¨ping, Sweden, 2Department of Rehabilitation Medicine, School of Health Sciences, Jo¨nko¨ping, Sweden Objectives: The aim is to describe how children and youths perform leisure activities, 1 year after a mild traumatic brain injury (MTBI). Methods: The basis is to compile previously collected material; patients were extracted from a prospective randomized controlled trial of MTBI. A retrospective analysis was conducted among 73 children and youths between 16–18 years of age. The entire group administrated the Interest Checklist at baseline and at 1-year follow-up. Results: Statistically significant differences were found in 31 of 50 different activities. The result showed that children and youths did not return to perform leisure activities. Fewer returned in the intervention group than in the control group. Conclusions: An occupational therapist can help children and youths to have balance in their life and continue a functional life after a MTBI. Continued research is needed, how to prevent MTBI and how to support children and youths to continue with leisure activities.


Self and near relative ratings of functional level 1 year after traumatic brain injury Maria Sandhaug1, Nada Andelic2, Svein A. Berntsen3, Stephen Seiler4, & Aase Mygland5 1

Oslo and Akershus University College of Applied Sciences, Faculty of Health Sciences, Department of Physiotherapy, Oslo, Norway, 2Oslo University Hospital, Ulleval, Department of Physical Medicine and Rehabilitation, Oslo, Norway, 3Sørlandet Hospital, Department of Physical Medicine and Rehabilitation, Kristiansand, Norway, 4Agder University, Faculty of Health and Sports, Kristiansand, Norway, 5Sørlandet Hospital, Department of Habilitation and Department of Neurology, Kristiansand, Norway Purpose: To quantify traumatic brain injury (TBI), patients’ perceptions of own function by the Patient Competency Rating Scale (PCRS) 12 months after injury and to examine self-awareness of functional deficits by comparing PCRS ratings from patients (PCRS-P) and near relatives (PCRS-R) and to identify predictors of awareness deficits. Method: A cohort of 50 severe (n ¼ 33) and moderate (n ¼ 17) TBI patients. Awareness of deficits was investigated by subtracting PCRS relative ratings from PCRS patient ratings. Predictors of PCRS ratings and differences were assessed by stepwise multiple regression analyses.

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Brain Inj, 2014; 28(5–6): 517–878

Results: The average patient PCRS sum score was 122/150 (95% CI ¼ 115; 129) as compared to a sum score of 117/150 (95% CI ¼ 110; 125) given by their relatives (p ¼ 0.93). The patients scored themselves slightly higher than their relatives in the domains of ADL and cognitive function (p50.001, p50.001). Regression analyses showed that GCS at admission to rehabilitation was the strongest predictor of patient PCRS (B ¼ 3.314, p ¼ 0.008). The strongest predictor of differences between patient and relative PCRS was GCS acute (B ¼ 3.530, p ¼ 0.001). Conclusions: TBI patients demonstrated a slight ‘awareness gap’ in ADL and cognitive function (p50.001, p50.001). Low GCS in the acute phase and high age were the strongest predictors of self-awareness deficits.

their brain injuries and to state that they did not receive the medical and rehabilitative services that they needed. This effect was not found among family respondents. Increased satisfaction with services was found to be correlated with decreased time since injury (r ¼ 0.165, p ¼ 0.049). Qualitative analysis of comments made revealed key themes including the telling of personal stories and specific comments about the care received, the giving of prognosis information and the adequacy of discharge planning and available resources. Results of this survey indicate that both survivors of brain injury and their family members report not having enough information about brain injury. Interesting questions emerge as to why females and especially females with mild brain injuries appear to be over-represented in terms of survey completion.



Individuals with TBI and their significant others’ perceptions of information given about the nature and possible consequences of brain injury: Analysis of a national survey

Altered structural organization of the uncinate fasciculus and impulsive behaviour correlates in retired professional athletes with a history of concussions

David Krych1, Rosette Biester2,4, Devan Parrott3, M. J. Schmidt1, & Mary Pat Murphy1

Ruma Goswami1, Maria C. Tartaglia2,3, Robin Green2,4,5, Charles H. Tator2,6, Richard Wennberg2,5,7, Lili-Naz Hazrati2,3, & Karen D. Davis1,2



ReMed Recovery Care Centers, Paoli, PA, USA, 2Philadelphia VA Medical Center, Philadelphia, PA, USA, 3Rehabilitation Hospital of Indiana, Indianapolis, IN, USA, 4University of Pennsylvania, Philadelphia, PA, USA A 42-item survey (including 20 demographic questions and comments) was developed to assess how well both individuals with brain injuries and their significant others (family members, partners or friends) felt they were informed about the nature of brain injury and the possible consequences of their injuries. The survey was constructed based on input regarding traumatic brain injury from task force members, prior research and then reviewed by members of an advisory panel comprised of both adults with brain injuries and significant others. Feedback to improve question construction, length and face validity was utilized to develop the final instrument which was reviewed and approved by an IRB in 2011. The survey was administered online through Surveymonkey, with links to the survey provided through state brain injury associations, rehabilitation hospitals and providers across the US and was available for online completion for 1 year (June 2012 to June 2013). In total, 117 significant others completed the survey. They were primarily female (84.6%), white (94.9%) and welleducated (35.9% some college, 24.8% bachelor’s, 20.5% masters+). More than half of these respondents indicated that they were not provided enough information about TBI (53.5%); with just under half indicating that they did not have enough information about the course of recovery of their family member (46.5%). There were no significant differences between their responses when asked about three specific types of clinical information provided (medical/ rehabilitation; cognitive; emotional/personality). In total, 149 individuals with brain injuries completed the survey and again were primarily female (63.8%), white (88.2%) and well-educated (35.9% some college, 23.5% bachelor’s, 23.5% masters+). More than 38% reported their injury as a mild TBI and the largest survivor cohort were females with mild brain injuries. Again, more than half of the respondents felt that they were not provided enough information about TBI (53.8%) and nearly 43% reported not being satisfied with services provided. Further analysis of the data revealed that female survivors and those with mild brain injuries were significantly more likely to feel they were not provided enough information about

Toronto Western Research Institute, University Health Network, Toronto, Ontario, Canada, 2Canadian Sports Concussion Project at Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada, 3Tanz Centre for Research in Neurodegenerative Disease, University of Toronto, Toronto, Ontario, Canada, 4Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada, 5University of Toronto, Toronto, Ontario, Canada, 6Division of Neurosurgery at Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada, 7Division of Neurology at Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada Objectives: Concussions can result in impaired cognitive processes, such as impulsivity and disinhibition, often manifesting decades after the injuries were sustained. Damage to brain connectivity may be implicated in such sequelae. The uncinate fasciculus (UF) is vulnerable to damage from traumatic forces and connects regions in the orbitofrontal and temporal areas that are involved in impulsivity. Therefore, the objective of this study was to assess UF white matter and neuropsychological correlates related to impulsivity and inhibitory control in former professional athletes who had sustained concussions. Methods: This study acquired 3T MRI diffusion tensor imaging (DTI) data from 15 retired professional athletes (13 former Canadian Football League players and two former hockey players, mean age ¼ 47 ± 10 years) and from 15 healthy controls (mean age ¼ 47 ± 10 years) with no history of concussions who were case-matched to the athletes for sex, age and years of education. Region-of-interest (ROI) analyses of the UF were based on ROIs drawn on each subject’s diffusion space maps. Probabilistic tractography was performed (FSL) and DTI metrics of fractional anisotropy (FA), axial diffusivity (AD), radial diffusivity (RD) and mean diffusivity (MD) were derived from each subject’s tract mask. Increased errors and decreased reaction time (RT) on a go/no-go (sustained attention to response, SART) task were used as measures of impulsivity and inhibitory control. Results: In the SART test, athletes had faster RTs than controls (315 ± 57 vs 384 ± 91 milliseconds, p50.05) and made more errors (15 ± 6 vs 10 ± 5, of a possible 25, p50.05). DTI indicated that athletes had significantly greater RD and MD in the left UF compared to


DOI: 10.3109/02699052.2014.892379

controls (RD: 0.000 742 ± 0.000 081 7 vs 0.000 707 ± 0.000 056 5 mm2 s  1, p50.05; MD: 0.000 904 ± 0.000 067 4 vs 0.000 866 ± 0.000 043 0 mm2 s1, p50.05). No statistically significant group differences were observed in FA or AD or right UF DTI metrics. However, left UF FA and AD were significantly correlated with RTs (FA: r ¼ 0.608; AD: r ¼ 0.635; p50.05) and AD in the left UF was also negatively correlated with the number of errors in the task trials (r ¼ 0.837, p50.05). There were no statistically significant correlations between DTI metrics and RT or error rate in control subjects. Conclusions: These data reveal altered white matter properties of the orbitofrontal-temporal connections in athletes in contact sports with previous concussions. These types of abnormalities may reflect demyelination and/or neuroinflammation (RD and MD). Furthermore, a disruption of UF FA and AD was related with impulsive/disinhibitory behaviours, suggesting that impaired brain connectivity impacts some cognitive changes in this population. Further research is needed to determine whether UF changes are secondary to the cumulative effects of multiple concussions and/or a neurodegenerative process.

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Severe traumatic brain injury patients in Northern Sweden computed tomography and clinical outcomes Maud Stenberg1, Lars-Owe Koskinen2, Richard Levi1, Per Jonasson3, & Britt-Marie Sta˚lnacke1 1

Department of Community Medicine and Rehabilitation, Rehabilitation Medicine, 2Department of Pharmacology and Clinical Neuroscience, Division of Neurosurgery, 3Department of Radiation Sciences, Diagnostic Radiology, Umea˚ University, Umea˚, Sweden Objectives: Following severe traumatic brain injury (sTBI), computed tomography (CT) is the most frequently used neuroimaging method for assessment of the severity of the injury and a criterion for further treatment. Patients with sTBI are an heterogeneous group with varying complexity and prognosis. It is, therefore, of importance to find instruments that could be used early after the injury to identify the individual’s need of rehabilitation. The aim of this study was to investigate the associations between early CT scan and key clinical outcomes at 3 months and 1 year after injury. Methods: This is a prospective, cohort study conducted at the Neurotrauma Centre (NC), at the Umea˚ University Hospital, Sweden from January 2010 to December 2011. Consecutive patients with acute sTBI, aged 17–65 years, lowest non-sedated Glasgow Coma Scale (GCS) score of 3–8 within 24 hours post-trauma were included. Patients were treated according to an intracranial pressure (ICP)oriented protocol based on the Lund concept. The first available CT scans (CT1) and follow-up scans nearest to 24 hours (CT24) were evaluated using the Marshall and Rotterdam classifications. Patients were assessed at 3 months and 1 year after injury with the Rancho Los Amigos Cognitive Scale Revised (RLAS-R) and Glasgow Outcome Scale Extended (GOS-E). Results: A total of 37 patients were included. Mean age was 41.3 years. Median lowest unsedated GCS was 5 (range ¼ 3–8). Post-traumatic amnesia (PTA) was very severe (47 days) in 36 (97%) patients and severe (1–7 days) in one (3%) patient. Median stay at intensive care was 17 days (range ¼ 2–54). Hospital deaths during the first year occurred in six patients (16%). The RLAS-R and the GOS-E scores were significantly improved from 3 months to 1 year after the injury (RLAS-R: 8.00 ± 2.4 vs 8.9 ± 1.9, p ¼ 0.003; GOS-E 4.4 ± 2.3 vs 5.5 ± 2.7, p ¼ 0.003, Wilcoxon’s signed-ranks-test). There were significant correlations at 3 months between Marshall CT1 and CT24 and RLAS-R (CT1: p ¼ 0.044, r ¼ 0.364; CT24: p ¼ 0.024, r ¼ 0.425,

Spearman’s correlation coefficient). The Rotterdam CT24 was significantly correlated to GOS-E at 3 months (p ¼ 0.015, r ¼ 0.421, Spearman’s correlation coefficient). The CT1 and the CT24 Marshall and Rotterdam classifications did not significantly correlate to the GOS-E and RLAS-R scores at 1 year. Conclusion: Clinical outcome assessed as GOS-E and RLAS-R improved during the first year after sTBI. The CT classifications were only associated with the GOS-E and RLAS-R scores at 3 months. Thus, the results in this specific patient cohort indicate that the CT classification systems used is not valid enough to judge the need for rehabilitation. As the patients clearly improve with time, the authors recommend an appropriate rehabilitation of sTBI patients in spite of initial severe symptoms.


Examination of a treatment to help improve couples’ relationships after brain injury Samantha Backhaus1, Dawn Neumann1, Devan Parrot1, Claire Brownson1, Amy Crane1, James Malec1, & Flora Hammond2 1

Rehabilitation Hospital of Indiana, Indianapolis, IN, USA, 2Indiana University, Department of Physical Medicine and Rehabilitation, Indianapolis, IN, USA

Objectives: Relationship problems are common after brain injury (BI) and there is a strong need for evidence-based treatments to address these issues. The purpose of this study was to determine the feasibility and efficacy of a group treatment aimed at improving couples’ relationships following a BI. Methods: Couples were recruited from a post-acute BI rehabilitation centre to participate in a group where one individual in each dyad had a traumatic brain injury (TBI) or acquired BI. Nine dyads participated in the study, four in one group and five in another; both groups received treatment during the same time period. The treatment, called Couples CARE (Caring and Relating with Empathy)–10 Ways to Care for your Partner after a Brain Injury, is a 16-week, manualized group therapy programme facilitated by two BI clinicians. Sessions met once weekly for 2 hours. Main outcome measures included the Dyadic Adjustment Scale (DAS), Quality of Marriage Index (QMI) and Marital Attitude Scale (MAS). Results: Paired samples t-tests showed significant improvements from baseline to post-test on the DAS Total Score (t ¼ 3.265, p ¼ 0.003) and the DAS sub-scales, including Consensus (t ¼ 2.90, p ¼ 0.008), Affectional Expression (t ¼ 2.18, p ¼ 0.040), Satisfaction (t ¼ 3.16, p ¼ 0.004) and Cohesion (t ¼ 2.28, p ¼ 0.033). Paired samples t-tests also revealed significant improvements from baseline to post-test on the QMI (t ¼ 2.54; p ¼ 0.018). Finally, significant improvements were found on the MAS total from baseline to posttest (t ¼ 3.744; p ¼ 0.001) and MAS sub-scales Own Behaviour (t ¼ 3.45, p ¼ 0.002), Partner’s Behaviour (t ¼ 2.44, p ¼ 0.023) and Partner’s Personality (t ¼ 2.96, p ¼ 0.007). They did not show significant improvements from baseline to post-test on the subscales Lack of Love (t ¼ 3.02, p ¼ 0.756), Malicious Intent (t ¼ 0.693, p ¼ 0.495) and Own Personality (t ¼ 1.40, p ¼ 0.174). Conclusion: This study showed that when couples, in which one person experienced a BI, learned more adaptive methods of communication, coping, problem-solving, emotional expression and positive interactions, they report greater quality, overall adjustment and greater satisfaction with the relationship. They also report improvements in their own and their partner’s behaviours. Results from this small sample study suggest that small group treatment for relationship skills may help improve a couple’s relationship following a brain injury. This is the first study that the authors are aware of

594 studying the efficacy of a manualized couple’s relationship programme following a BI. Further clinical implications and limitations and plans for more rigorous evaluation of this programme will be discussed.


Using social stories to assess emotional inferencing of people with traumatic brain injury (TBI)

Comparison of a cognitivebehavioural coping skills group to a peer support group in improving self-efficacy and neurobehavioural functions after brain injury

Barbra Zupan1, Dawn Neumann2, Duncan Babbage3, & Barry Willer4

Samantha Backhaus, Summer Ibarra, Devan Parrot, & James Malec



Brock University, St. Catharines, ON, Canada, 2Indiana University School of Medicine, Indianapolis, IN, USA, 3Auckland University of Technology, Auckland, New Zealand, 4State University of New York at Buffalo, Buffalo, NY, USA Brain Inj Downloaded from by RMIT University on 09/02/14 For personal use only.

Brain Inj, 2014; 28(5–6): 517–878

Objectives: It has been well documented that people with moderateto-severe TBI have difficulty interpreting the intended meaning of a message, even when language comprehension remains relatively intact. Although some measures exist to assess social inferencing, none solely assess the ability of people with TBI to make inferences about the emotional state of others using only contextual cues. When additional social cues such as facial or vocal expressions, gestures or postures are provided with social context, it does not allow a clear understanding of the role that social context plays on its own in generating accurate inferences about the thoughts, feelings and intentions of others. The purpose of the current study was to assess emotional inferencing in people with TBI using social stories that provide only contextual cues. The secondary aim was to begin development of a tool to assess emotional inferencing in people with TBI. Method: Phase I: Twenty-five stories were presented to a group of 40 typically-developing young adults. This data was used to select stories for two separate emotional inferencing tasks (EIST-1; EIST-2), each consisting of 12 stories. Phase II: Two groups of participants with moderate-to-severe TBI participated in the main study. Group one (n ¼ 77) completed EIST-1 and group two (n ¼ 126) completed EIST-2. Stories were presented simultaneously in auditory and written format. Participants were only included if they passed a discourse comprehension test. Participants also completed a test of facial affect recognition. Results: Phase I: The resulting normative mean score for EIST-1 was 11.75 and 11.28 for EIST-2. Phase II: No significant between-group differences were found for demographic variables or in facial affect recognition performance. Participants who completed EIST-1 scored significantly higher (mean ¼ 8.49) than participants who completed EIST-2 (mean ¼ 6.98), F(1,200) ¼ 20.67, p50.001, indicating that EIST-2 was a more difficult task. Individual scores were compared to the normative means for EIST-1 and EIST-2. Seventy-seven per cent of participants in Group 1 scored 2 standard deviations below the normative mean for EIST-1 and 93% of participants in Group 2 scored 2 standard deviations below the normative mean for EIST-2. Facial affect performance was significantly correlated with scores of the EIST-1, r ¼ 0.50, p50.001 and EIST-2, r ¼ 0.31, p50.001, lending support to the concurrent validity of the tasks designed. Moreover, participants identified as having facial affect recognition impairment were found to score significantly lower than participants without facial affect impairment for both EIST-1 and EIST-2. Conclusions: This study was the first step in creating a task for people with TBI that would identify difficulties in emotional inferencing using only social and contextual information. With further reliability and validity testing, it appears that these tasks may be useful for identifying emotional inferencing difficulties in people with TBI.

Rehabilitation Hospital of Indiana, Indianapolis, IN, USA Objectives: To determine if manualized group cognitive-behavioural treatment (CBT) is better than self-directed (SD) support group treatment in improving neurobehavioural functions and perceived self-efficacy (SE) in survivors of brain injury (BI) and caregivers. Methods: This study was a randomized controlled treatment with measurements at baseline, post-intervention, 3 - and 6-month followups, completed in a post-acute rehabilitation centre. Subjects (n ¼ 38) included individuals with TBI or acquired brain injury. The CBT group (n ¼ 18) was a once weekly, 12-session, manualized programme that provided (1) psychoeducation on effects of brain injury; (2) group psychotherapy; and (3) CBT coping skills training. Topics included Effects of Brain injury, Recovery, Importance of Family/ Caregivers, Managing Challenging Situations, Signs of Depression and the 5 R’s of Stress Management. Two clinicians trained in BI rehabilitation facilitated the CBT group. In the SD group (n ¼ 20), participants also met once weekly for 12 weeks, but held group independently and discussed whatever they wanted in a support group fashion. A clinician was present in the room, but did not have any formal facilitation. Main outcome measures included the Brain Injury Coping Skills Questionnaire (BICS-Q measure of PSE) and Frontal Rating Systems of Behavioural and Executive Functions (FrSBe). Results: ANCOVA revealed no significant differences on PSE between groups longitudinally, but independent samples t-tests revealed that the CBT group was significantly better than the SD group at 3 (t ¼ 2.33; p ¼ 0.025) and 6 months (t ¼ 2.19; p ¼ 0.035). The two groups did not start equal on the FrSBe, with the treatment group scoring higher on the Total scale (t ¼ 2.35, p ¼ 0.024) and, specifically, the Executive Dysfunction sub-scale (t ¼ 2.94, p ¼ 0.006). Using baseline scores as a co-variate, the Total FrSBe score showed a significant group effect at 3-month follow-up (F ¼ 4.34, p ¼ 0.045) using ANCOVA. Analysis of Covariance also showed a significant group effect at 3 - (F ¼ 5.33, p ¼ 0.028) and 6-month follow-ups (F ¼ 5.24, p ¼ 0.029) on the Disinhibition sub-scale on the FrSBe. The Apathy sub-scale on the FrSBe did not show significant differences between groups at any time point, but, at baseline, the treatment group again trended higher than the controls (p ¼ 0.075) and, at posttest, the control group trended higher than the treatment group (p ¼ 0.067). Conclusions: This study suggests that individuals who participate in a manualized CBT group intervention report significantly better PSE in their ability to manage brain injury-related challenges at long-term follow-ups (even after group treatment is complete) when compared to those who meet in support groups alone. Similarly, individuals seeking strategies to manage emotional dysregulation, impulsivity and anger dyscontrol may benefit more from participating in a CBT-based programme rather than merely participating in a support group alone without formal intervention. Clinical implications and limitations to study will be discussed.


DOI: 10.3109/02699052.2014.892379


ICP and mean square deviation of ICP in prognosis of outcomes in severe TBI of children Janna Semenova, Valeriy Lukjanov, Semen Mescherjakov, Olga Karaseva, & Leonid Roshal

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Clinical and Research Institute of Emergency Children’s Surgery and Trauma, Moscow, Russia Nowadays there are a number of recommendations and standards for the treatment of severe TBI are based on principles of the basedevidence medicine. This refers to indications for using invasive and non-invasive methods of diagnostic and monitoring as well as surgical approaches. Recommendations for optimal range of treatment in children are not specified. According to literature there are no sufficient researchers that could develop the standard approaches for surgical treatment and intensive care. Since 2003 the principles of treatment strategies for children with severe head trauma based on contemporary recommendations have been developed in the Clinical and Research Institute of Emergency Children’s Surgery and Trauma. The aim was to evaluate the importance of ICP-monitoring in prognosis for outcomes of severe TBI. The study included 129 patients with severe TBI (2005–2012). GCS was 6 ± 1.5. The total mortality was 27.9%. Firstly, a classification matrix was constructed where as a predictor values of ICP was used, and as a grouping variable GOS was considered. The prognosis was possible only within favourable and unfavourable. The probability of the correct classification was  50%. Hypothesis: If the other things being equal where the average value of ICP statistically doesn’t differ, predicatively the mean square deviation of ICP characterizing dynamics of process can be a significant factor. According to the aim, this study entered one more indicator—variability of process—which consists of the sum of a square of average value of ICP and a square of dispersion of process, i.e. a mean square deviation. Retrospective discriminative analysis of the ICP data demonstrated significant dependence (72.2%) of negative influence of the index E2 (E2 ¼ m2 + 2), where m is mean ICP and  is dispersion of the daily monitoring. According to the results, a fundamental importance to maintain the ‘physiological corridor’ is revealed, wherein ICP-monitoring must be used as the main criteria to the indication for conservative or surgical strategy of medical treatment.


Patterns of mental recovery in children with severe traumatic brain injury in the early stage of neurorehabilitation Ekaterina Fufaeva, Janna Semenova, Valeriy Lukyanov, & Svetlana Valiullina Clinical and Research Institute of Emergency Children’s Surgery and Trauma, Moscow, Russia Background and aims: In recent years, Russia has been going through a continuing rise in the level of paediatric traumatism, 30–50% of which is comprised of traumatic brain injury. Lately the development of high technologies and the progress in neurointensive care and neuroimaging has decreased the mortality rates among patients with neurotrauma. It has also led to a sharp increase in the number of

children with severe disabilities. In paediatric trauma in the developing brain outcomes and quality-of-life after severe traumatic brain injury (sTBI) are the most important parameters. One of the key roles in evaluating the brain injury outcomes is recovery of cognitive functions in injured children. According to modern concepts of neurorehabilitation, early intervention can improve cognitive outcomes. The aim of this study was to follow-up patterns of recovery in children (6–17 years) with severe TBI from the early stage of consciousness recovery. Objectives: (1) Identify specific cognitive impairments and compare them to the MRI data; (2) Follow the patterns of cognitive functions recovery in children (6–17 years) who had had sTBI at different ages; and (3) Follow the patterns of consciousness recovery in children with sTBI. Methods: Eighty-two children with sTBI (GCS  8) were evaluated with the Luria Neuropsychological Battery test within the first 6 months after sTBI. Twenty-eight of them were re-evaluated 48 months after their trauma. Also 17 children were evaluated with Coma Recovery Scale-R at the early stage of consciousness recovery. Six children remained in a minimally conscious state (MCS) and were tested by the adapted procedure of neuropsychological assessment during the first 4 months. Four children have not recovered and they were not evaluated with the Luria Neuropsychological Battery test. Results and conclusions: (1) Cortical contusions of the frontal lobes and diffuse axonal injuries were the most frequent lesions. Children with the frontal (fronto-temporal areas) cortex damage had slow dynamics of consciousness comparing to children with posterior (parietaloccipital areas) cortex damage. (2) The most destroying functions at the early recovery period were the processing speed (neurodynamics of metal activity), executive functions and memory functions (modalnon-specific memory). (3) During the period of consciousness recovery in children after sTBI the key role played parameters: the time when behavioural changes appeared, character of the dynamics in consciousness recovery and velocity of changes in behaviour. Children who had demonstrated a slower dynamics of consciousness recovery had severe primary damages of visual gnosis, speech and executive functions according to neuropsychological examination. The factor of voluntary regulation plays a key role at the early stage in consciousness recovery.


Comparative analysis of Boston and Puebla-Sevilla test for assessment of aphasia in Spanishspeaking patients Luis Quintanar, Emelia La´zaro, & Yulia Solovieva Puebla Autonomous University, Puebla, Mexico One of the most commonly used tests in Latin America within clinical neuropsychology of patients with aphasia is the ‘Test of Boston for the diagnosis of Aphasias’ (TBDA). However, the items of this test are not suitable for Spanish-speaking patients. It is necessary not only to translate or adapt assessment tests, but also to create specific instruments which consider proper linguistic features of Spanish language. An example of such a test is ‘The clinical-neuropsychological assessment of the aphasia Puebla-Sevilla’ (P-S), which was recently created by Quintanar et al. An aim of this instrument is to obtain clinical characterization of patients with different types of aphasia. Clinical characterization is based on Luria’s classification of types of aphasia according to identification of the central mechanism underlying neuropsychological difficulties. The objective of the study is to compare the contributions of the Boston and Puebla-Sevilla Test for the analysis of the clinical picture in Spanish-speaking patients with aphasia. The sample of the study includes 10 patients


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who suffered a cerebral vascular event or traumatic brain injury. Both instruments were applied to all patients in separate sessions. The results showed an absence of total correspondence between the types of aphasia identified by both tests. For example, according to TBDA, patient 1 presented motor-transcortical aphasia, but, according to P-S, the same patient presented dynamic aphasia. Patient 7 showed no apparent alteration by TBDA, but with P-S showed a mild case of amnestic aphasia. Similar situations happened with the other cases. The results are discussed according to consideration of clinic possibilities of each instrument and types of classification used by a neuropsychologist. It is concluded that both instruments help to establish some type of aphasia according to used classification and psychological processes. The Boston test determines the diagnosis from isolated symptoms of speech comprehension or production. The Puebla-Sevilla Test permits one to establish the central mechanism of speech difficulties involving both comprehension and production. In this case it is more useful for proposals of integral rehabilitation for each patient with aphasia. Emphasis is placed on the needs to continue the creation and clinical application of Tests for Aphasia for Spanish-speaking populations in different social contexts.


Gait patterns of children with traumatic brain injury (TBI) as compared with cerebral palsy (CP) and with typically developed (TD) Ofer Keren1, Michal Katz-Leurer2, & Hemda Rotem3 1

Rehabilitation Department, Sheba Medical Center, Tel Hashomer, Israel, 2Sackler Faculty of Medicine Tel-Aviv University, Tel Aviv, Israel, 3 Alyn Rehabilitation Center, Jerusalem, Israel Objective: To investigate the differences of gait patterns between children with traumatic brain injury (TBI), with cerebral palsy (CP) and typically developed (TD). Methods: Participants were (1) 60 TD children, matched for age (7–13 years) and sex (1:2 F/M); (2) 20 children with CP [Gross Motor Function Classification System (GMFCS 1 or 2)]; and (3) 30 children post TBI (initial GCS  8) with independent ambulation, 41 year post-trauma. Tests and measurements used were: (1) Balance control: Timed Up and Go (TUG), The Functional Reach Test (FRT); (2) Walking velocity: Two minute walk; and (3) Endurance of Mobility: The Energy Expenditure Index (EEI) was used as a relative estimate of metabolic energy expenditure. Results: Significant differences were found in walking parameters between the groups (e.g. 2-minute walk test: TBI 109 ± 31 compared to TD 168 ± 19 metres). Post-TBI children had a significantly greater variability in step time and step length in comparison to TD controls (step length variability: TBI 16.3 ± 13.6 compared to TD 4.9 ± 2.0). The 2minute-walk test correlated inversely with the step time and length variability only among children post-TBI, while muscle strength values correlated positively with the 2-minute-walk test only in TD children. Significant differences were found between step variability, muscle strength and functional walking performance (e.g. 2-minute walk test: TBI 109 ± 31 compared to TD 168 ± 19 metres). The 2-minute-walk test correlated inversely with the step time and length variability only among children post-TBI, while muscle strength values correlated positively with the 2-minute-walk test only in TD children. Conclusion: Step-to-step variability was significantly increased in the non-typically developed children compared to typically developed children.

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Post-traumatic hydrocephalus: Clinical characteristics and rehabilitation outcomes Alan Weintraub, Don Gerber, & Ken Gerhart Craig Hospital, Englewood, CO, USA Objectives: Post-traumatic hydrocephalus (PTH) resulting from an acquired brain injury (ABI) is a potentially significant complication that may limit rehabilitation progress and impact outcomes. The incidence of clinically relevant PTH during inpatient rehabilitation has been estimated to be as high as 45%. In this sample, 11% underwent CSF diversion—ventricular shunting. In a retrospective study of 48 individuals with severe ABI, who were diagnosed with PTH and underwent ventricular shunting, 52% showed improvement on the Glasgow Outcome Scale. This study reported a seizure complication rate of 64.5%. Acutely, complications arising from shunting procedures including infection, seizures or shunt malfunction are estimated from 20–64%. However, longer term serious complications usually do not exceed 5–8% of shunted patients and most are related to shunt malfunctions. There remains a significant need for relevant research to guide clinicians about distinguishing ‘ventriculomegaly’ due to cerebral atrophyexvacuo dilatation from abnormalities in CSF flow dynamics secondary to CSF malabsorption, obstruction and about patient selection criteria for ventricular shunting within the context of risk/ benefit considerations. This retrospective study will describe incidence, clinical characteristics, complications and outcomes of patients diagnosed with clinically significant PTH who underwent ventricular shunting and while participating in a categorical inpatient ABI programme. Methods: A retrospective chart review of consecutive ABI patients who were undergoing inpatient rehabilitation was conducted from 2003–2013. Individuals with hydrocephalus were identified by ICD-9 codes: 331.3 and 331.4. Those who underwent a shunt procedure were identified by CPT code: V45.2. Demographic variables were abstracted to characterize the sample. Injury characteristics included: primary diagnosis, admission FIM, neurobehavioural presentation, neuroimaging findings, communicating or non-communicating hydrocephalus diagnosis, type of shunt procedure, complications and discharge FIM. Results: The retrospective chart review identified 1105 ABI inpatients, of which 202 (18.2%) were diagnosed with hydrocephalus. Of the 202 diagnosed with hydrocephalus, 177 (87.6%) underwent neurosurgical shunting. The demographics, clinical characteristics, neurodiagnostic findings, complications and outcomes of those who underwent the shunting procedure are currently being analysed and will be presented. Conclusions: This retrospective study of PTH in individuals with ABI found an 18.2% incidence rate, of which the majority exhibited malabsorptive PTH and underwent shunting. PTH, a known treatable complication of ABI, may present confounding challenges during rehabilitation related to consciousness, initiation of behavioural motor output such as speech, swallowing, motor tone and functional outcome. Careful selection for ventricular shunt placement must be based on appraisal of risk/ benefit ratios and the potential for improvement in outcomes. Favourable outcomes should consider the timing of intervention, types of shunts, risk of seizures, synergistic rehabilitation and longer-term follow-up.


DOI: 10.3109/02699052.2014.892379


Comparison of G-ratio in the repaired rat nerves with nerve conduits of different size Yan Wo1, Satya Mallu2, Wenjing Wang1, Hao Zhu1, & Wenlong Ding1 1

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Department of Anatomy, Shanghai Jiao Tong University School of Medicine, Shanghai, PR China, 2Division of Hand Surgery, Department of Orthopaedic Surgery, Virginia Commonwealth University Medical Center, Richmond, VA, USA Objectives: The nerve conduit ‘fit’ around the repaired rat sciatic nerve is an important but previously unrecognized variable. In this study there are four experimental groups (Reverse autograft, 3 mm, 2 mm and 1 mm diameter nerve tube). Methods: For Axon counts and G-ratio measurements, the nerve tissue is stained with Toludine Blue and ImagePro software is used for quantitative analysis. Results: The percentage of axons, having the range of G-ratio as 0.50– 0.68, has been compared among these groups and the results show that there is a significant difference compared to the Control group (55.89 ± 10.18%) with all experimental groups: reverse autograft (47.30 ± 8.50%); 3 mm nerve tube diameter (31.54 ± 10.26%); 2 mm nerve tube diameter (39.93 ± 8.93%) and 1.5 mm nerve tube diameter (39.11 ± 8.50%). The percentage of axons having the range of Axon caliber as 3–5.99 mm was higher in the control group (63.83 ± 11.37%), followed by reverse autograft (59.96 ± 12.92%), 1.5 mm diameter (56.25 ± 8.04%), 2 mm nerve tube diameter (53.26 ± 9.77%) and 3 mm nerve tube diameter (48.48 ± 6.02%) and there is a significant difference between control group and 3 mm nerve tube diameter group. The percentage of axon counts which meet the variables of G Ratio with the range between 0.5–0.68 and Axon caliber with the range between 3–5.99 mm was the most abundant in reverse autograft group (60.28 ± 6.65%), followed by 1.5 mm nerve tube diameter (55.31 ± 5.83%), 2 mm nerve tube diameter (52.38 ± 8.45%) and 3 mm nerve tube diameter (40.61 ± 14.85%) and there is a significant difference between the reverse autograft group and 3 mm nerve tube diameter group. Conclusions: As the rat sciatic nerve diameter is 1.52 mm, the fitting size of the nerve conduit is very important in nerve repair, as shown by G-ratio and Caliber measurements and a size discrepancy between the diameter of the nerve tube and the injured nerve related outcome may further be useful to nerve surgeons in clinical scenarios.


Functional level during the first 2 years after moderate and severe traumatic brain injury Maria Sandhaug1, Nada Andelic2, Birgitta Langhammer1, & Aase Mygland3 1

Oslo and Akershus University of Applied Sciences, Faculty of Health Sciences, Department of Physiotherapy, Oslo, Norway, 2Oslo University Hospital, Ulleval, Department of Physical Medicine and Rehabilitation, Oslo, Norway, 3Sørlandet Hospital, Department of Habilitation and Department of Neurology, Kristiansand, Norway Background: Long-term outcomes after TBI are examined in a large extent, but longitudinal studies with more than 1-year follow-up time after injury have been fewer in number. The course of recovery may

vary due to a number of factors and it is still somewhat unclear which factors are contributing to the course of functional recovery in a longterm perspective. Aim: The aim of this study was to describe the functional level at four time points up to 24 months after traumatic brain injury (TBI) and to evaluate the predictive impact of pre-injury and injury-related factors. Design: A cohort study. Setting: Outpatient. Population: Sixty-five patients with moderate (n ¼ 21) or severe (n ¼ 44) TBI. Methods: The TBI patients were examined with Functional Independence Measure (FIM) and Glasgow Outcome Scale Extended (GOSE) at 3 months, 12 months and 24 months after injury. Possible predictors were analysed in a regression model using FIM total score at 24 months as the outcome measure. Results: FIM scores improved significantly from rehabilitation unit discharge to 24 months after injury, with peak levels at 3 and 24 months after injury (p50.001), for the whole TBI group and the group with severe TBI. The moderate TBI group did not show significant FIM score improvement during this time period. GOSE scores for the whole group and the moderate group improved significantly over time, but the severe group did not. FIM at admission to the rehabilitation unit and GCS score at admission to the rehabilitation unit were closest to being significant predictors of FIM total scores 24 months after injury (B ¼ 0.265 and 2.883, R2 ¼ 0.39, p ¼ 0.073, p ¼ 0.081). Conclusion: FIM levels improved during the period from rehabilitation unit discharge to 3 months follow-up; thereafter, there was a ‘plateauing’ of recovery. In contrast, GOSE ‘plateauing’ of recovery was at 12 months. The study results may indicate that two of the most used outcome measures in TBI research are more relevant for assessment of the functional recovery in a sub-acute phase than in later stages of TBI recovery.


Acupuncture treatment increases motor evoked potentials induced by using transcranial magnetic stimulation in patients with chronic disorder of consciousness following severe traumatic brain injury Jun Matsumoto-Miyazaki, Shingo Yonezawa, Norio Nishiyama, Ryuji Okumura, Seisuke Fukuyama, Yukari kanematsu, Yuichi Nomura, Yoshitaka Asano, & Jun Shinoda Chubu Medical Center for Prolonged Traumatic Brain Dysfunction, Kizawa Memorial Hospital, and Department of Clinical Brain Science, Gifu University Graduate School of Medicine, Minokamo, Japan Objective: The aim of this study was to evaluate the immediate effect of acupuncture on activity of the cortico spinal tract (CST) in patients with chronic disorder of consciousness (CDC) following traumatic brain injury (TBI) by measuring motor-evoked potentials (MEPs). Methods: Ten patients (aged 36 ± 16 years; eight males, two females) with quadriplegia accompanying CDC following severe TBI, who were admitted to Chubu Medical Centre for Prolonged Brain Dysfunction, were enrolled in this study. A self-controlled design was used for the acupuncture trial: the control trial consisted of a resting state without acupuncture. In the acupuncture trial, acupuncture needles were inserted in patients at six points including GV26, Ex-HN3, bilateral LI4

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598 and ST36 and were left without manipulation for 10 minutes. MEPs induced by transcranial magnetic stimulation (TMS) on a primary motor area were recorded from the abducter pollicis brevis (APB) muscle of each patient. MEP recordings were performed before acupuncture (phase 0), 10 minutes after acupuncture needle insertion (phase 1) and 10 minutes after acupuncture needle removal (phase 2). As a control, the same procedure without acupuncture was performed three times every 10 minutes at rest in each patient on a separate day. Ten MEPs were obtained at each session and the mean MEP amplitude and mean MEP latency were calculated. Changes from phase 0 in MEP amplitude and latency at phase 1 and phase 2 in the acupuncture trial were compared to the control trial. Results: MEP amplitude at phase 0, phase 1 and phase 2 in the acupuncture trial were 0.870 [0.194, 1.477] mV, 1.230 [0.179, 1.712] mV and 0.710 [0.183, 1.787] mV, respectively, whereas those of the control trial were 0.895 [0.280, 1.764] mV, 0.290 [0.057, 1.747] mV and 0.370 [0.063, 1.612] mV (median [first quartile, third quartile]). There were significant differences between control and acupuncture trials in the MEP amplitude at phase 1 (0.116 [0.357, 0.018] mV vs 0.170 [0.004, 0.401] mV, p ¼ 0.002) and phase 2 (0.124 [0.673, 0.003] mV vs 0.038 [0.018, 0.387] mV, p ¼ 0.002). MEP latency at phase 0, phase 1 and phase 2 in the acupuncture trial were 24.8 [4.3] milliseconds, 23.8 [3.8] milliseconds and 23.7 [3.9] milliseconds, respectively, whereas those of the control trial were 23.3 [4.2] milliseconds, 24.0 [3.8] milliseconds and 23.5 [4.2] milliseconds (mean [SD]). There were significant differences between control and acupuncture trials in changes of MEP amplitude at phase 1 (0.2 [0.4, 1.1] vs 1.16 [1.5, 0.4] milliseconds, p ¼ 0.004). Conclusions: Increasing MEPs amplitude and reducing MEPs latency indicate that CST activity increased. Acupuncture treatment increases CST activity and acupuncture treatment might be a beneficial treatment for motor disturbance of CDC patients following severe TBI.


Community integration 2 years after moderate and severe traumatic brain injury Maria Sandhaug1, Nada Andelic2, Birgitta Langhammer1, & Aase Mygland3 1

Oslo and Akershus University College of Applied Sciences, Faculty of Health Sciences, Department of Physiotherapy, Oslo, Norway, 2Oslo University Hospital, Ulleval, Department of Physical Medicine and Rehabilitation, Oslo, Norway, 3Sørlandet Hospital, Department of Habilitation and Department of Neurology, Kristiansand, Norway Objective: To evaluate Community Integration Questionnaire (CIQ) scores 1 to 2 years after moderate and severe TBI. First, is there a significant difference in CIQ outcomes in-between each groups of moderately and severely injured 1–2 years after TBI? Secondly, is there a significant difference in CIQ outcomes between moderately and severely injured 1–2 years after TBI? Methods: A cohort of 65 patients with moderate (n ¼ 21) or severe (n ¼ 44) TBI were examined 1–2 years post-injury with the Community Integration Questionnaire (CIQ). Results: Lower home integration among moderately injured from 1–2 years (8 vs 6, p ¼ 0.002). Higher productivity in moderately compared to the severely injured 2 years after TBI (5 vs 3, p ¼ 0.003).

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Conclusion: Home integration may be lower after 2 years among moderately injured as more move out from institutions, but require help services at home instead. Higher scores in productivity 2 years after TBI may reflect a moderate level of injury severity and better return-to-work. Still, CIQ group outcomes cannot only be attributed to functional recovery, as individual factors are important to examine when assessing change.


Physical activity through homebased exercise-gaming after childhood brain tumour treatment—A method to improve motor and process function Ingrid Emanuelson1, Magnus Sabel2, Daniel Arvidsson3, Jurgen Broeren1, Jonas Gillenstrand2, Jean-Michel Saury2, Charlotte Simmons2, Anette Sjo¨lund2, Klas Blomgren4, & Birgitta Lannering1 1

University of Gothenburg, Gothenburg, Sweden, 2The Queen Silvia Children Hospital, Gothenburg, Sweden, 3Center for Primary Health Care Research (CPF), Lund, Sweden, 4Karolinska Institute, Stockholm, Sweden Objectives: Childhood brain tumour treatment carries a substantial risk of impaired intellectual development. Physical activity appears to have a positive effect on cognitive function in humans and on neurogenesis in animal models. The aim was to investigate if homebased exercise-gaming could achieve improved motor and process function if supported by a web-based coach. Methods: Children of 7–17 years of age who underwent treatment including radiotherapy for a malignant brain tumour 1–5 years earlier were randomized to either an intervention or a waiting-list group. After 10 weeks the groups shifted in a cross-over fashion. A motion controlled video console (Nintendo Wii) was used for physical exercise, for a minimum of 30 minutes a day, 5 days a week, for 10 weeks. In order to sustain compliance a coach had weekly web-sessions over the Internet with the child. All children were tested with cognitive and motor tests (BOT2) as well as execution of daily activities, using the Assessment of Motor and process Skills (AMPS), before and after each period. Test scores before and after the intervention period were compared for the whole group and a parallel group comparison was also performed. Results: All children (six boys and seven girls) who were involved in the study (n ¼ 13) completed the programme. Their mean age was 12.5 years (range ¼ 7.2–16.4). After the intervention period there was a significant improvement compared to base-line, in body coordination in BOT2 (p ¼ 0.02) and in the motor (p ¼ 0.012) and process (p ¼ 0.002) parts of AMPS. In the parallel group analysis there was an improvement in the intervention group compared to controls, in the process part of AMPS (p ¼ 0.029), but not to a statistically significant change in the motor part of AMPS (p ¼ 0.058) or BOT2 body co-ordination (p ¼ 0.27). Conclusion: Exercise-gaming used as an enjoyable home-based intervention for childhood brain tumour survivors improved body co-ordination and motor and process skills in daily activities after 10 weeks.


DOI: 10.3109/02699052.2014.892379


Utilization of healthcare and social resources after the acute stage in patients with severe TBI: Which patient profiles for which services? Results from the PariS-TBI study


Fatigue after paediatric brain injury: What predicts fatigue at 6 weeks after injury? Ali Crichton1, Vicki Anderson2, Franz Babl2, & Ed Oakley2 1

University of Melbourne, Melbourne, Victoria, Australia, Murdoch Children’s Research Institute, Melbourne, Victoria, Australia, 3Victorian Paediatric Rehabilitation Service, Melbourne, Victoria, Australia 2

Claire Jourdan1, Eleonore Bayen1, Emmanuelle Darnoux2, Philippe Aegerter3, Idir Gout3, Sylvie Azerad3, Pascale Pradat-Diehl4, Jean-Jacques Weiss2, Claire Vallat-Azouvi1, & Philippe Azouvi3

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AP-HP, hopital Raymond Poincare, Garches, France, 2CRFTC, Paris, France, 3University of Versailles Saint Quentin, Garches, France, 4APHP, hopital Pitie-Salpe´trie`re, Paris, France Objectives: To describe post-acute therapies, medical care, social and community re-entry services and to outline which patient profiles determine care utilization. Methods: Prospective 4-year follow-up of a cohort of 504 adults with severe TBI recruited from 2005–2007 in the Parisian area (PariS-TBI study). Socio-demographic, geographical and severity variables were collected. Among 245 survivors, 147 (mean age ¼ 33 years, 80% men) were evaluated in a face-to-face interview with a neuropsychologist. Motor and cognitive disabilities, global outcome and activity limitations were measured. Provision of several services after acute care discharge was recorded and statistical associations with patient characteristics were analysed. Results: Patients’ outcome was severe disability in 31%, moderate disability in 39% and good recovery in 27%. They had received physiotherapy for 78%, speech and cognitive therapy for 68%, psychotherapy for 50% and occupational therapy for 42%. Specialized medical follow-up was provided to 63%, community re-entry programmes to 21% and 59% had applied for state socio-financial support. Disability upon acute care discharge was the main predictor of services utilization in univariate and multivariate analyses. Physiotherapy, speech and cognitive therapy and psychotherapy were more frequent for patients with, respectively, motor, speech/ swallowing and mood impairments. Care provision was not significantly associated with cognitive impairments, nor with most instrumental activity limitations. Patients who received a community re-entry programme were younger, less disabled in daily living activities and had predominantly intermediate GOSE scores. Sociofinancial support application was strongly related to all deficiencies and activity limitations and to a lower educational level. Geographical variables had no influence on care utilization and socio-demographic variables had a limited influence. Conclusions: Services oriented towards community re-entry were insufficient compared to therapies. Provision of care was related to need factors and specific deficiencies, but not to cognitive impairments.

Objectives: The objectives are: (1) to assess levels of subjective fatigue in children who sustain a traumatic brain injury (TBI) at 6-weeks after injury; (2) to use a psychometrically sound multidimensional measure of fatigue post-injury that captures both parent and child ratings of fatigue symptoms; and (3) to explore the relationship between the severity of post-brain injury fatigue with other common co-morbidities of sleep disturbance, mood and pain. This research forms the first part of a 12-month longitudinal study that describes the recovery from fatigue symptoms over time following TBI in children. Methods: This study recruited 48 children with mild, moderate or severe TBI, admitted to the Royal Children’s Hospital (RCH) in Melbourne. Inclusion criteria: (1) aged between 8–17 years and (2) with a mild, moderate or severe TBI within last 24 hours. Exclusion criteria: (1) non-English speaking and (2) previous TBI, neurological disorder or developmental disorder. Participants were identified in the Emergency Department and Intensive Care Unit at RCH. Data on injury severity and pre-injury mental health (SDQ) were collected at baseline. Fatigue was measured by the PedsQL Multidimensional Fatigue Scale (PedsQLFatigue), parent and child report at 6 weeks post-injury. Results: Overall ratings of fatigue, by both parent and child, indicated significantly more fatigue symptoms than for published controls (p  0.05). Analysis indicated fatigue symptoms were significant for general fatigue, sleep–rest fatigue and cognitive fatigue dimensions (p  0.05). Regression analysis indicated parent ratings of the child’s overall fatigue were significantly associated with 6-week levels of parent-reported child depressive symptoms (b ¼ 1.79, t(21) ¼ 3.24, p ¼ 0.003). Of the fatigue dimensions, parent ratings of general fatigue and cognitive fatigue were significantly related to their ratings of child depression, but sleep–rest fatigue was not. Child ratings of overall fatigue were significantly associated with 6-week depressive symptoms (b ¼ 2.55, t(21) ¼ 3.78, p ¼ 0.001). Pre-injury mental health, injury severity and other symptoms (anxiety, sleep disturbance and pain) were not statistically significant in the explanation of fatigue experienced at 6 weeks post-injury. Overall, the model explained a significant proportion of variance in parent-rated fatigue scores, R2 ¼ 0.38, F(4, 24) ¼ 5.29, p ¼ 0.003, and in child self-report of fatigue scores, R2 ¼ 0.44, F(5, 21) ¼ 5.11, p ¼ 0.003. Conclusions: These results suggest that clinically significant levels of fatigue symptoms are commonly reported by both children and their parents at 6 weeks after brain injury. These fatigue symptoms are most strongly related to co-morbid levels of depressive symptoms. Providing follow-up data on these children will be important to identifying how fatigue symptoms and depressive symptoms present over time. This will be important to identifying longitudinal change and natural recovery of fatigue symptoms and to better understand the different dimensions of fatigue being assessed.



Executive dysfunctions and outcome 4 years after a severe TBI. Results from the PariS-TBI study Philippe Azouvi1, Claire Vallat-Azouvi2, Claire Jourdan3, Emmanuelle Darnoux4, Idir Ghout5, Sylvie Azerad5, Philippe Aegerter6, Eleonore Bayen6, Pascale Pradat-Diehl6, & Jean-Jacques Weiss7 1

University of Versailles Saint Quentin, Garches, France, UGECAMIDF, Garches, France, 3hopital Raymond Poincare, Garches, France, 4CRFTC, Paris, France, 5URC Paris Ouest, Boulogne, France, 6 hopital Pitie-Salpe´triere, Paris, France

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Objectives: To assess the impact of executive dysfunctions, as assessed with the Dysexecutive Questionnaire (DEX), on outcome 4 years after a severe traumatic brain injury (TBI). Methods: Prospective 4-year follow-up of a cohort of 504 adults with severe TBI recruited from 2005–2007 in the Parisian area (PariS-TBI study). Socio-demographic and severity variables were collected. Among 245 survivors, 147 (mean age ¼ 33 years, 80% men) were evaluated in a face-to-face interview with a neuropsychologist. A global assessment of cognitive impairments was conducted with the Neurobehavioural Rating Scale-revised (NRS-R). Mood disorders were assessed with the Hospital Anxiety and Depression scale (HAD). Executive dysfunctions in everyday life were assessed with the DEX (self-rated version), which is a 20-item questionnaire using a 5-level Likert-type rating scale. Results: The DEX showed a good internal consistency in this sample. A factorial analysis showed only one single underlying factor. The total DEX score was significantly and inversely correlated with years of education. No injury severity variable was significantly related with the DEX total score. The DEX was, however, significantly and positively related with cognitive deficits as assessed with the NRS-R, with mood disorders, with dependency in elementary and extended activities of daily living and with non-return to work. In multivariate analyses, only cognitive and mood impairments were significantly and independently related with the total DEX score. Conclusions: The DEX (self-rated version) is a reliable and sensitive questionnaire to assess executive dysfunctions in patients with severe TBI at a chronic stage. The total DEX score was significantly related with social and vocational outcome. Cognitive deficits and mood impairments seem to both independently contribute to the total DEX score. This finding emphasizes the complex interaction between cognition and mood in patients with severe TBI.


The process of returning to work and other occupations after traumatic brain injury. A focus group study Helene L. Soberg1, Unni Sveen1, & Sigrid Ostensjo2 1

Oslo University Hospital, Oslo, Norway, 2Oslo and Akershus University, College of Applied Sciences, Oslo, Norway Objectives: Typical challenges experienced by people with mild TBI (mTBI) are a lack of energy and impaired concentration and memory

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affecting daily life and work. There is a lack of comprehensive descriptions of the experiences of living with mTBI in an occupational perspective. The objective was to describe how persons with mTBI experience the process of resuming work life and everyday life occupations in general. Methods: Focus group interviews with 12 women and eight men, 18– 61 years, who had sustained mTBI were conducted. Exclusion criteria were pre-injury psychiatric disorder or substance abuse. All were employed or studying pre-injury and at the interview 50% had to some extent returned to work/school. The interviews were transcribed verbatim and a qualitative content analysis was applied involving the following stages: The interviews were discussed to create a sense of wholeness and of meanings; the text was read, focusing on meaning units reflecting the aim; and meaning units were extracted and condensed into initial codes which were compared and refined into categories drawing on the concept of biographical disruption. Results: Two main aspects appeared: How the impairments are linked to their consequences for daily life and work activities and participation and the implications they have on the respondents’ personal, social and work life. The following themes emerged: (1) The meaning of impairments. The impairments were experienced both physiologically and in an occupational context. The burden of cognitive and sensory impairments and their complexity was described. Overwhelming mental fatigue was typically addressed like: ‘The head takes all the capacity’. (2) Conception of self. ‘Not being the same person as before’. (3) Coping and self-efficacy in the biographical reconstruction. Strategies related to striving for occupational balance, such as taking frequent breaks at work, reducing social activity and explaining to friends about the need for rest and less exposure to social events. (4) The perception of time. Time as a healing parameter in the process as in comparing ‘myself’ shortly after the injury, after some time and the ‘here and now’ situation of daily life. Or the contrary, as in time as a source for frustration, ‘healing takes such a long time’. (5) The burden of sickness absence and of returning to work. A feeling of failure when returning too early and the anxiety of failing again. Using all capacity at work and longer working hours to produce like before the injury. Frustration of not managing obligations and sadness of not managing the work situation. Conclusion: Resuming daily life and work is a contextualized process where impairments are linked to their consequences for daily life and work activities and participation. The uncertainty of the healing process and anxiety of failure represents an emotional strain on persons with mTBI.


Training of attention in the early phase after brain injury Aniko Bartfai1, Gabriela Markovic1, Mattias Elgh2, & Marie-Louise Schult1 1 Karolinska Institutet, Stockholm, Sweden, 2Linko¨ping University, Linko¨ping, Sweden

Objectives: Experiential factors are among the major driving forces in cortical re-organization after acquired brain injury (ABI). The implications of findings in animal studies on restoration and compensation of function are of major importance, emphasizing the need for targeted goal-driven rehabilitation in the early phase. There is a scientific and clinical gap of knowledge of how to evaluate and streamline the process of cognitive rehabilitation at the early stage after ABI due to variability of individual recovery. Statistical Process Control (SPC) to describe patterns of recovery and restitution on a group level in early brain injury rehabilitation programmes has, to the authors’ knowledge, not been applied. Statistical Process Control is used for its susceptibility to variations in a process and might give a closer


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DOI: 10.3109/02699052.2014.892379

indication of the variability in the recovery process after ABI. Attention, i.e. the allocation of processing resources, has been found to be successfully improved through systematic training after ABI and the Attention Process Training (APT) was found to be one of the evidence-based restorative methods in the chronic phase. The aim of the present study was, within the framework of an RCD design, to investigate the effects of targeted goal-driven rehabilitation in the early phase after ABI and evaluate the effects both with a process method (SPC) and with end-point measures. Methods: Sixty consecutive patients (aged 18–60 years) were included within 4 months (starting on 7.08 ± 3.7 weeks post-injury) after ABI following brain trauma or stroke. Patients, fulfilling inclusion and exclusion criteria, received 20 hours of attention training; either intensive area-specific with APT or general activitybased training of attention within traditional interdisciplinary rehabilitation. Training effects were assessed both with pre- and post- measures by a battery of neuropsychological tests and serially with the Paced Auditory Serial Addition Test (PASAT) continuously during the intervention programme. Results: Serial data were analysed by SPC control charts, to explore statistical control limits and variability in improvement. Line graphs on a personal level showed patterns of improvement and variability between measuring points in time. Intensive area-specific training showed steady improvement on PASAT. General activity-based training showed improvement, although more variability. SPC methodology enabled correction for inter-group differences, allowing for a more transparent comparison of progress data, including the influence of external factors. Differences between pre- and postmeasures were analysed by analyses of variance with repeated measures. Differences in the results obtained by serial vs pre- and post- data are analysed. Conclusions: This clinical trial is part of an effort to intensify research on evidence-based cognitive rehabilitation in the early stage after ABI. SPC allows a closer insight in the intervention process enabling a more calibrated individual rehabilitation programme and aiming at healthcare quality improvement.


Decreased apparent diffusion coefficient in pituitary and correlated with hypopituitarism in patients with traumatic brain injury Ping Zheng, Bin He, & Wusong Tong Pudong New area People’s Hospital, Shanghai, PR China Objectives: The relationship between microstructural abnormality in patients with traumatic brain injury (TBI) and hormonesecreting status remains unknown. This study aimed to identify the role of the apparent diffusion coefficient (ADC) using a diffusionweighted imaging (DWI) technique and to evaluate the association of such changes with hypopituitarism (HPT) in TBI patients. Methods: Diffusion weighted images were performed in 164 consecutive patients with TBI within 2 weeks after onset to generate the pituitary ADC as a measure of microstructural change. Patients with TBI were further grouped with or without HPT based on the secretion status of pituitary hormones at 1 month post-injury. MRI data and laboratory findings were analysed blindly. Thirty healthy controls were enrolled. Mean ADC values were compared among the control, TBI with and without hypopituitarism group and correlational studies were also performed. The neurological outcome was assessed by the Glasgow outcome scale (GOS) scores at 6 months post-injury.

Results: This study included 84 TBI patients with HPT and 80 TBI patients with normal pituitary function. The pituitary ADC in TBI patients was significantly less compared to controls (1.83 ± 0.16 vs 4.13 ± 0.33, p50.01). Furthermore, the mean ADC was much less in TBI patients with pituitary dysfunction compared to those without HPT (1.32 ± 0.09 vs 2.28 ± 0.17, p50.05). There was also a significant difference in ADC value between patients with Hyperprolactinemia (HPRL) and normal prolactin (PRL) level (p50.05). In addition, the ADC value was positively correlated with the neurological outcome at 6 months following TBI (r ¼ 0.602, p50.05). Conclusions: Using the DWI technique, this study confirms that the ADC in pituitary is correlated with the hormone-secreting status in TBI patients. It also demonstrates that the pituitary ADC may become a novel biomarker to assess the pituitary function in patients with TBI.


Computerized working memory training at home for people with acquired brain injury Ulrike Andersson1, Kerstin Ohlsson1, & Christina Broga˚rdh2 1

Department of Rehabilitation Medicine, Ska˚ne University Hospital, Lund, Sweden, 2Department of Health Sciences, Lund University, Lund, Sweden Background: Reduced memory is one of the most common impairments in people with acquired brain injury, which leads to activity limitations and difficulties to reintegrate into normal living. One way to train the working memory is by computerized tasks. A study in people with acquired brain injury showed that intensive computer-based training in a clinical setting improved working memory, both subjectively and objectively. This study examined whether computerized training can be performed at home with support from a coach. Objective: To evaluate (i) if computerized training (by Cogmed) is feasible to perform at home by persons experiencing memory difficulties after their acquired brain injury and (ii) if the training leads to improved working memory and less perceived memory difficulties in everyday life. Method: Twelve persons with mild-to-moderate impairments after brain injury participated in the study. Two dropped-out due to increased mental fatigue. The mean age (±SD) of the 10 participants was 42 ± 12.5 years and the mean time since onset of brain injuries was 38 months (range ¼ 6–90 months). All participants were independent in P-ADL. Each participant performed a total of 25 training sessions with Cogmed. The first training session was conducted in the clinic. Thereafter, the participants planned and performed the training on their own at home with access to coach support by phone or mail. After completed training, the participants visited the clinic for an evaluation. The working memory training was evaluated by the Cogmed programme, i.e. by training index (TI) and by CPI (Cogmed Progress Indicator). In addition, the participants rated how they experienced the training and memory problems in everyday life by using the Goal Attainment Scale (GAS), ranging from 2 to +2. Results: All participants reported that they could plan the training on their own and that they were positive to the home training. The TI increased on average 26.5 and the CPI increased on average 32% for ‘working memory’, 27% for ‘follow instructions’ and 13% for ‘mental arithmetic’. Two people perceived that they had less energy than expected for other activities during the day (1 on the GAS). All but one person experienced that it was easier than expected to concentrate and remember information in everyday life (+1 or +2 on the GAS).

602 Conclusion: This pilot study suggests that computer-based working memory training at home with support from a coach may be feasible for persons with acquired brain injuries. Most of the participants perceived the training to be positive, but energy-demanding. The working memory improved after training and participants experienced less memory difficulties in everyday life. By offering computerbased working memory training at home the training can be more cost-effective.


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Coping, complaints and early work resumption after mildto-moderate traumatic brain injury. Preliminary results of the Upfront-study M. E. Scheenen1, M. E. de Koning1, H. J. van der Horn1, G. Roks2, T. Yilmaz2, J. M. Spikman1, & J. van der Naalt1 1

University Medical Center Groningen, Groningen, The Netherlands, Tilburg St. Elisabeth Hospital, Tilburg, The Netherlands


Objectives: To investigate the nature and severity of complaints 2 weeks post-trauma in a cohort of mild-to-moderate traumatic brain injury (TBI) patients and to determine the relation with return-to-work (RTW). Furthermore, it was explored whether an active vs a passive coping style is related to the severity of perceived complaints and the rate of RTW. Methods: Design/setting: Multi-centre prospective longitudinal cohort study of mild-to-moderate TBI patients admitted to the Emergency Departments. Brain injury severity was determined using the Glasgow Coma Scale (GCS) on admission. Patients received a questionnaire 2 weeks post-trauma covering complaints (Dutch-modified Rivermead Post-concussion Questionnaire), return-to-work and coping styles (Utrecht Coping List). Results: The questionnaire was completed by 217 patients, with a mean age of 45.3 years (SD ¼ 19.6, range ¼ 16–91) and GCS scores ranging from 9–15 with 95% classified as mild TBI (GCS 13–15). Two weeks post-injury 83% of all patients reported complaints. On average, patients reported six complaints, most frequently headache, dizziness, increased fatigability and sleepiness. Of those patients who were employed or following an education at the time of the injury, 52% partly or completely resumed their occupational activities or studies. The participants that resumed their work or studies reported a significantly lower amount of complaints compared to the nonresumers (4 vs 8, t(147) ¼ 5.49, p5.001). Of the resumers, almost half (46%) reported two or more complaints. Concerning the pre-morbid coping profiles, the passive coping style was associated with a higher number of perceived complaints (r ¼ 0.187, p50.001). A relation between an active coping style and the rate of RTW 2 weeks postinjury was not found. Conclusions: Two weeks following mTBI the majority of the patients experiences complaints. Pre-morbid coping styles were associated with perceived complaints: patients with a passive coping style reported a higher number of complaints. In this relatively acute phase, more than half of the patients have resumed their previous activities. This implies that, despite complaints, almost half of these early resumers are continuing their work or studies while not being fully recovered. Follow-up of these patients is necessary to assess if this early RTW pattern is predictive of long-term work sustainability.

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Cortical and subcortical brain morphology, white matter microstructure and functional impairment following mild traumatic brain injury Torgeir Hellstrom1, Lars T. Westlye2, Andres Server Alonso3, & Nada Andelic4 1

Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway, 2KG Jebsen Centre for Psychosis Research/ Norwegian Centre for Mental Disorder Research (NORMENT), Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway, 3Department of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway, 4CHARM Research Centre for Habilitation and Rehabilitation Models & Services, Oslo, Norway Objectives: To investigate global and regional brain volumetric, morphometric and microstructural properties in patients 8 weeks after mild traumatic brain injury (MTBI) and to assess associations with post-traumatic clinical and self-reported symptoms and global outcome. Methods: A prospective study of individuals (n ¼ 172) with MTBI defined as hospitalization with GCS between 13–15 and loss of consciousness less than 30 minutes, aged 16–65 years, admitted to the Department of Neurosurgery at Oslo University Hospital during a 2-year period (2011–2013). This study excluded those with severe substance abuse, prior brain injury, psychiatric disease and progressive neurological disease. Baseline data include clinical information based on medical records and brain imaging (CT) in the acute phase. Both symptomatic and asymptomatic individuals were followed-up at 8 weeks with clinical evaluation and MRI. MRI data was obtained on a 3T whole-body MRI system (Signa HDxt, GE Medical Systems). The protocol included a 3D FSPGR T1-weighted sequence used for morphometric assessments and diffusion tensor imaging (DTI) was performed in the axial plane by using a single-shot spin-echo echoplanar imaging sequence with diffusion gradient encoding in 30 directions; b ¼ 0 and 1000 s mm2. All patients’ MRI data were evaluated with regards to gross pathologies and lesions by an expert in neuroradiology. Volumetric and morphometric analyses were performed using T1-weighted data by means of FreeSurfer (http://, allowing for automated estimation of sub-cortical and cortical volumes and cortical morphometric properties including cortical thickness and a realization across the brain surface. DTI analysis was performed using Tract-Based Spatial Statistics (FSL), part of FSL (, allowing for cross-subject voxel-wise analysis of DTI indices of white matter microstructure, including fractional anisotropy (FA) and mean diffusivity (MD). Post-traumatic clinical symptoms included anxiety, depression and post-concussion symptoms as assessed by the Hospital Anxiety and Depression scale (HAD), Rivermead postconcussion symptom questionnaire (RPQ) and global outcome evaluated by Glasgow Outcome Scale Extended (GOSE). Results: The mean age of the individuals was 39.9 years (SD ¼ 14.3), 65.4% were men. Relevant pathologic findings were observed in 72 patients (42%). Relevant pathology comprised extra axial haematomas in 54 (31%), skull fractures in 44 (26%) and contusions in 28 (16%) patients. A GCS of 15 was reported for 72% of patients. At 8 weeks follow-up, the mean HAD anxiety and depression scores were 4.99 (SD ¼ 4.06) and 2.91 (SD ¼ 3.28), respectively. The mean sum of the RPQ was 12.43 (SD ¼ 13.00). The majority of patients showed favourable functional outcome measured by GOSE (mean ¼ 6.74, SD ¼ 0.92). The authors are currently analysing the imaging data and clinical associations with MRI phenotypes will be presented at the congress.


DOI: 10.3109/02699052.2014.892379

Conclusions: In combination with clinical assessment, MRI techniques used in this study may provide important information on the structural brain abnormalities and functional consequences of MTBI.


Diffuse axonal injury on early MRI is associated with executive problems and emotional and behavioural symptoms 3–5 years after traumatic brain injury

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Torun G. Finnanger1, Alexander Olsen2, Toril Skandsen3, Stian Lydersen1, Anne Vik4, Kari-Anne Indredavik Evensen5, Asta Ha˚berg2, Stein Andersson6, & Marit S. Indredavik1 1

Regional Centre for Child and Youth Mental Health and Child Welfare, 2MI Lab and Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway, 3Department of Physical Medicine and Rehabilitation, St. Olavs Hospital Trondheim University Hospital, Trondheim, Norway, 4Department of Neuroscience, Faculty of Medicine, 5Department of Public Health and General Practice, Department of Laboratory Medicine, Children and Women’s Health, Norwegian University of Science and Technology, Trondheim, Norway, 6Department of Psychology, University of Oslo, Oslo, Norway Objective: To evaluate how early indicators of injury severity such as Glasgow Coma Scale score (GCS), post-traumatic amnesia (PTA) and diffuse axonal injury (DAI) affects executive, emotional and behavioural function 3–5 years after traumatic brain injury (TBI). Materials and methods: Sixty-seven patients, 15–65 years, with moderate and severe TBI, underwent MR imaging (1.5 Tesla) at median 10 days (range ¼ 1–120) post-injury. The scan protocol included T1- and T2-weighted sequences, a T2*-weighted gradient echo sequence, fluid-attenuated inversion recovery (FLAIR) sequences and diffusion-weighted imaging. PTA was registered as less or more than 1 week. At a mean of 2.9 years (SD ¼ 0.95) after injury the patients reported subjectively perceived symptoms of executive dysfunction assessed with the Behavioural Rating Inventory of Executive Function–Adult form (BRIEF-A). Emotional and behavioural problems were assessed with the Adult Self-Report form (ASR). Results: Presence of DAI on MRI in the early phase predicted more problems on two of the main indexes of the BRIEF; Global Executive Composite (GEC;  ¼ 14.61, 95% CI ¼ 0.67–28.55, p value ¼ 0.04) and Behavioural Regulation Index (BRI;  ¼ 6.78, CI ¼ 0.76–12.79, p value ¼ 0.028). However, this association reached only borderline significance when adjusted for age and length of education. Shorter length of education predicted more problems on GEC ( ¼ 2.99, CI ¼ 5.91 to 0.07, p value ¼ 0.045) and BRI ( ¼ 1.29, r2 ¼ 0.06, CI ¼ 2.53 to 0.04, p value ¼ 0.043). Further, DAI predicted more problems on two of the main composite scales on the ASR; total problems ( ¼ 16.09, CI ¼ 1.82–30.34, p value ¼ 0.028) and internalizing problems ( ¼ 5.99, CI ¼ 0.67–11.30, p value ¼ 0.028). The latter association also held when adjusted for age and education ( ¼ 5.54, CI ¼ 0.06–11.04, p value ¼ 0.048). Younger age at injury predicted more total problems ( ¼ 0.64, CI ¼ 1.08 to 0.20, p value ¼ 0.005) and more externalizing problems ( ¼ 0.22, CI ¼ 0.37 to 0.08, p value ¼ 0.003). GCS score and duration of PTA were not associated with any of the scales on either BRIEF-A or ASR. Conclusion: In this study, DAI was related to later executive, emotional and behavioural problems for years after TBI. Neither length nor of

PTA and GCS score were associated with any of the problems. Shorter education was associated with more executive problems, in particular emotional and behavioural regulation. Also, younger age predicted more emotional and behavioural problems, especially externalizing problems such as aggression. These findings illustrate that detection of DAI in the early phase could contribute to identifying individuals at risk of developing cognitive, emotional and behavioural problems in the years following TBI.


Prognosis analysis and risk factors related to hypopituitarism in patients with traumatic brain injury Ping Zheng, Wusong Tong, & Bin He Shanghai Pudong New area People’s Hospital, Shanghai, PR China

Background: Since hypopituitarism (HPT) was introduced in traumatic brain injury (TBI) literatures, several studies have been performed to show the relationship between HPT and an increased risk of cognitive dysfunction following TBI and worse neurological outcome as well. So, early detection and prediction of HPT is practically important in a clinical situation. Objectives: To investigate the risk factors related to HPT in patients with TBI and analyse their clinical significances. Methods: Patients with TBI were grouped with or without HPT based on the secretion status of pituitary hormones at 1 month post-injury. Data compared included patients’ gender, age, mechanism of injury, Glasgow Coma Scale (GCS) score at admission, timing from injury to the first CT and the signs of the initial CT scan. Logistic regression analysis was used to explore the risk factors related to HPT. Results: A cohort of 169 patients with TBI was evaluated and there were 87 (51.48%) patients who suffered from HPT at 1 month after injury. The differences between HPTs and non-HPTs were significant in GCS score at admission, the signs of the initial CT scan (basal fracture, subarachnoid haemorrhage, multiple haematoma and diffuse axonal injury) (p 5 0.001). Logistic regression analysis was used to identify that CT scans (basal fracture, diffuse axonal injury) and initial GCS scores as the most important predictors of HPT (p50.001). Conclusions: For patients with the initial CT scan showing basal fracture and diffuse axonal injury with lower GCS scores, they are more likely to develop the hypopituitarism following TBI. Therefore, dynamic laboratory tests should be performed for the detection of HPT as early as possible and the medical intervention would be enforced in time.


Endocrine dysfunction after traumatic brain injury in children and adolescents (a single centre prospective and rerospective study) Darina Aleksijevic, David Krahulik, Vladimir Mihal, Kamila Michalkova, Eva Klaskova, Petra Venhacova, & Zapletalova Jirina


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University Hospital, Palacky University, Department of Paediatrics, Department of Radiology and Department of Neurosurgery, Olomouc, Czech Republic Introduction: Neuroendocrine dysfunction in 23–60% of adults and 15–21% of children following brain injury is described in retrospective studies. Background: To discover the prevalence of hypothalamo-hypophyseal dysfunction in children after brain injury (TBI) due to retrospective and prospective surveillance. In the retrospective phase all children after TBI were re-examined 3–10 years after trauma. In the prospective phase, children were observed during a 12-month period after TBI. This study evaluated the dependence on the type of injury and the course of acute post-traumatic phase. Patients and methods: A group of retrospective patients comprised 30 children (18 boys) and a group of prospective patients comprised 58 children (21 girls) after TBI (GCS 3–12). In both groups physical development (growth, pubertal development and skeletal maturity) was evaluated and they underwent standard endocrine tests—TSH, fT4, IGF 1, PRL, morning cortisol, FSH, LH, testosterone (in boys), estradiol (in girls) in the early post-traumatic period (2–14 days, T0) and at 3, 6 and 12 months after the injury (T3, T6 and T12) in the prospective group. In the retrospective group a standard endocrine test was made a few years after the TBI (depending on the time of study, all more than 3 years after the TBI). Results: Retrospective group: The study results showed hormonal disorder for at least one hormone axis in 16.7% of subjects (which is consistent with the majority of published works). They all had been tested more than 1 year after accident. Pathological findings in the CNS at the time of injury were found in 4/6 (80%). Only one patient had a GCS of less than 8. Prospective group: Twenty-three patients had a GCS58/15. During the first year after TBI, a hormonal disorder was detected in 15.5% of patients (diabetes insipidus, syndrome of inappropriate antidiuretic hormone secretion, central hypothyroidism, hypogonadotropic hypogonadism, growth hormone deficiency). Patients with GCS  8 had hormonal dysfunction more often (6/23) compared to those with a medium trauma (3/35). The occurrence of early endocrine dysfunction significantly correlated with severity of injury (p  0.05), but did not serve as an indicator of development of late hormonal dysfunction (p ¼ 0.5). Conclusion: Hormonal disorder occurred in 15.5% of patients within a year after an injury and in 16.7% of patients more than 3 years after head trauma. Neuroendocrine dysfunction as a late consequence of craniocerebral trauma is not as frequent in children as in adults. Risk factors influencing its development include severity of injury, abnormalities in the brain-imaging techniques and DI, SIADH or CSWS in the acute post-traumatic phase.


Exertion Testing in Youth with Mild Traumatic Brain Injury/ Concussion: does it contribute to return to activity decisions? Carol DeMatteo, & Brian Timmons McMaster University, Hamilton, Ontario, Canada Background: The decision regarding return-to-activity following MTBI/ concussion is one of the most difficult and controversial areas in concussion management for adults and even more complicated for children and youth. Post-concussion symptoms are often exacerbated by exertion. Determining an individual child’s response to exertion may be an important component of safe return to activity decisions. Objectives: (i) To present the results of a study testing exertion in youth with concussion and it’s effect on post-concussive symptoms.

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(ii) To discuss the contribution of standardized exertion testing in youth, to decision-making for safe return-to-play and activity. Methods: Youth, 7–18 years, who had sustained a concussion, completed an Exertional Fitness Test in the Children’s Exercise & Nutrition Centre (CENC) at McMaster Children’s Hospital (MCH). The exertion testing was completed during a regular ABI clinic visit. Exertion testing consisted of an incremental test, lasting up to 12 minutes, on a cycle ergometer. Heart rate (HR) was monitored throughout and the child was asked to rate their perceived exertion using Borg’s 6-20 categorical scale. Symptoms were assessed using the Post-Concussion Symptom Inventory (PCSI). PCSI were recorded at (i) 30 minutes before exertion, (ii) during exertion, (iii) 5 minutes after exertion, (iv) 30 minutes after exertion and (v) 24 hours after exertion by email survey. Results: Fifty four youth, 32 males and 22 females, with concussion participated, mean age ¼ 15 (10–17 years). Sixty-three per cent had multiple concussions, 33% of these having more than three. Sixtythree per cent had symptoms during exertion, but overall there was a statistically significant improvement over 24 hours in symptoms and symptoms worsened in only seven youth. In comparing youth who got worse vs those whose symptoms improved, Logistic Regression Analysis showed that the number of previous concussions, gender and cause of injury did not significantly impact the results between groups. The time from most recent injury had a significant impact on the symptom score. The more recent the injury the higher symptom scores. Youth who were symptomatic were the same with perceived exertion/actual exertion as non-symptomatic youth. Conclusions: Exertion fitness testing has an important role in the evaluation of symptoms and readiness to return-to-activity. It contributes to more objective- and evidenced-based decisionmaking for families and clinicians. Controlled exertion overall seemed to lesson symptoms for most youth; what isn’t known is if this effect was physiological or psychological or both. The children with multiple injuries had more symptoms with exertion, as did youth who were closer to time of injury.


S-Nitrosylation ameliorates neuroinflammatory traumatic brain injury by reducing peroxynitrite levels in a rat model of controlled cortical impact Mushfiquddin Khan, Tajinder Singh, Fumiyo Matsuda, Inderjit Singh, & Avtar Singh Medical University of South Carolina, Charleston, SC, USA Objective: Endothelial dysfunction due to oxidative and inflammatory components in traumatic brain injury (TBI) causes blood–brain barrier (BBB) disruption and oedema, leading to sustained cell death and functional deficits. S-nitrosylation has been shown to protect the integrity of the BBB and the potent oxidizing agent peroxynitrite is reported to be causative in endothelial dysfunction. This study tested the hypothesis that exogenous treatment with the S-nitrosylating agent S-nitrosoglutathione (GSNO) ameliorates TBI and aids functional recovery by reducing peroxynitrite levels in the neurovascular unit. Methods: TBI was induced by controlled cortical impact (CCI) in rats. GSNO, the peroxynitrite-decomposing catalyst FeTPPS and the peroxynitrite-forming agent 3-morpholino-sydnonimine (SIN-1) were administered orally at 2 hours after CCI. The treatment was repeated daily until experiment end-points. Neurobehavioural function was evaluated at several time points through the rotarod task and adhesive tape test. The following markers and mediators were evaluated for neurovascular protection: peroxynitrite (as 3-NT), nitric


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DOI: 10.3109/02699052.2014.892379

oxide, BBB leakage (Evan’s blue extravasation), mRNA expression of ICAM-1 and MMP-9, oedema and altered redox (levels of glutathione and reactive lipid aldehydes). Results: Treatment with GSNO or FeTPPS after TBI reduced peroxynitrite levels, inhibited BBB leakage and reduced oedema. The treatment with GSNO also increased the levels of glutathione and the expression of both occludin and Zonula occludens-1 (ZO-1) while reducing the levels of reactive lipid aldehydes and the expression of MMP-9 and ICAM-1 in the neurovascular unit. Furthermore, a 2-week treatment of TBI with GSNO improved motor and sensory functions. In contrast, treatment with SIN-1 increased BBB leakage and oedema while decreasing the expression of occludin and ZO-1 following TBI. Conclusions: Attenuation of neuroinflammatory injury, reduction of peroxynitrite levels and improvement of neurobehavioural function by GSNO following TBI show that S-nitrosylation confers neurovascular protection. An increase of BBB leakage and oedema in SIN-1treated and decrease in the same outcomes in FeTPPS-treated rats supports the involvement of peroxynitrite and its metabolites in the TBI disease process. GSNO is a natural molecule in the human brain and body and its exogenous administration has not shown any evidence of toxicity or side-effects in humans. Therefore, this novel S-nitrosylation-based therapy has potential and clinical implications for TBI therapy.


Cranial nerve non-invasive neuromodulation (CN-NINM) for symptomatic treatment of mild and moderate traumatic brain injury Kurt Kaczmarek, Mitchell Tyler, Kimberly Skinner, Yakov Verbny, & Yuri Danilov University of Wisconsin, Madison, WI, USA Objectives: The objective of this study was to investigate the efficacy of cranial nerve non-invasive neuromodulation (CN-NINM) intervention using a portable neurostimulator (PoNSTM) device to treat symptoms of chronic mild-to-moderate traumatic brain injury (mTBI), especially functional deficits in balance, gait, cognition and mood. It has been demonstrated that regular application of superficial electrical stimulation to two major cranial nerves: lingual branch of the trigeminal nerve and lingual branch of the facial nerve, innervating the anterior 2/3rd of the dorsal surface human tongue induces activity in the brainstem (dorsal pons varolli, superior medulla) and ventrolateral cerebellum. It is postulated that systematic application of CN-NINM induces processes of neuroplasticity that lead to improved and sustained functional behaviour regulated by these structures, specifically balance, gait and eye-movement control. Methods: A single-arm pilot study involving four subjects with chronic (5.4 years) symptoms of mTBI were tested immediately before and after 2 weeks of CN-NINM intervention using standardized measures: (1) Dynamic Gait Index (DGI), a test of eight facets of gait including modulating speed, turning the head during gait, stepping around and over obstacles, and the ability to climb stairs. (2) NeuroComTM Computerized Dynamic Posturography Sensory Organization Test (SOT), standing balance performed under six sensory conditions to quantitatively evaluate the relative use of visual, vestibular and proprioceptive inputs in dynamic balance control. All subjects had previously completed therapeutic interventions for balance and gait dysfunction, had reached a plateau and been declared clinically disabled. Subjects completed twice-daily training sessions for 2 weeks (5 days/week). Each session involved 20-minutes each of a maximalchallenge balance and treadmill-based gait with concurrent CN-NINM stimulation.

Results: DGI: Subjects exhibited improvements in scores of 13.5, 14, 10 and 21.5 points, respectively, on a 24-point scale. A 3-point change is considered clinically and statistically significant. SOT: Subjects exhibited improvements in scores of 62, 10, 22 and 47 points, respectively, on an age and height normalized scale. A 10-point change is considered clinically and statistically significant. Additionally, TBI subjects C and D were tested for changes in cognitive function, memory, attention and mood. Their scores on the Brief Repeatable Battery of Neuropsychological Tests (BRBNT) exhibited improvements in all seven categories of test for declarative and spatial memory, attention, arithmetic capacity and mood. Conclusion: The CN-NINM intervention was efficacious in treating symptoms of balance and gait deficit in four subjects with chronic traumatic brain injury. While dramatic, the results are consistent with earlier research in subjects with heterogeneous balance disorders that evidenced changes in metabolic activity of the neural structures involved in balance, posture and gait regulation. These results have led to randomized controlled trials in blast and sport concussive injuries, mild and moderate TBI and stroke.


Prevalence, characteristics and treatment limitations of institutionalized patients in a vegetative state/unresponsive wakefulness syndrome Willemijn van Erp1, Jan Lavrijsen1, Pieter Vos2, Hans Bor1, Steven Laureys3, & Raymond Koopmans1 1

Radboud UMC, Nijmegen, The Netherlands, 2Slingeland Ziekenhuis, Doetinchem, The Netherlands, 3University of Lie`ge, Lie`ge, Belgium Objectives: To map the Dutch population of institutionalized patients in a vegetative state/unresponsive wakefulness syndrome (VS/UWS). Main outcomes were the prevalence of institutionalized VS/UWS patients/100 000 inhabitants (verified/unverified); clinical characteristics of these patients and treatment limitations; and the number of patients who turned out to be in a minimally conscious state (MCS) or to have emerged from MCS. Methods: Cross-sectional, nationwide prevalence study involving all hospitals, nursing homes, rehabilitation centres and hospices in the Netherlands and the members of the Dutch association of physicians for people with intellectual disability, carried out on 1 May 2012. This study included patients in VS/UWS at least 1 month following acute brain injury, i.e. excluding degenerative, congenital, genetic or otherwise non-acute causes. Diagnoses were verified by means of the Coma Recovery Scale-revised. Treating physicians provided information regarding the patients’ clinical characteristics and treatment limitations. Results: This study identified 33 patients, in 24 of whom the diagnosis of VS/UWS was verified within a median of 20 days from the study date. Patients were on average 51 years old with a mean duration of VS/UWS of 5 years. Anoxic brain injury, sustained during outof-hospital cardiac arrest, accounted for the largest proportion of cases. Over 50% of patients in long-term care facilities had been denied rehabilitation. The majority of patients in VS/UWS received life-sustaining treatment beyond internationally accepted prognostic boundaries regarding recovery of consciousness. Seventeen out of 41 patients (41%) presumed to be in VS/UWS were found to be at least minimally conscious when examined by means of the CRS-r. Conclusions: Results translate to a nationwide prevalence of 0.1–0.2 institutionalized VS/UWS patients per 100 000 members of the general Dutch population, comparable to the figure found by Lavrijsen et al. in 2003. The Netherlands have the lowest documented prevalence of VS/UWS. This may be related to the legal option to


Brain Inj, 2014; 28(5–6): 517–878

withhold or withdraw life-sustaining treatment, including artificial nutrition and hydration. On the other hand, this study shows that in certain cases physicians do continue life-prolonging treatment, even when chances of recovery of consciousness have become negligible. In the light of poor access to rehabilitation and a significant risk of misdiagnosis, this apparent paradox calls for more research aimed at the factors influencing end-of-life decisions in VS/UWS.


Post-concussive syndrome does not alter the relationship between depression and alcohol use after mild TBI

Conclusions: PCS does not alter the known association between depression and alcohol misuse. Clinical care should be based on established protocols for depression and alcohol misuse after mTBI.


Return to physical activity following concussion affects recovery in balance control during dual-task walking David Howell, Louis Osternig, & Li-Shan Chou University of Oregon, Eugene, OR, USA




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Steven L. West , Carolyn W. Graham , David X. Cifu , William C. Walker1, & Brett B. Hart2 1

Virginia Commonwealth University, Richmond, VA, USA, United States Navy, 4Naval Medicine Operational Training Center, Pensacola, FL, USA


Objectives: Nearly 250 000 US military personnel have incurred deployment-related mild traumatic brain injury (mTBI) during the Global War on Terrorism. Many of these individuals have subsequent post-concussion syndrome (PCS). Occurrence of blast-induced mTBI is common in this population and this mechanism has been hypothesized to alter the risk of PCS and presentation of individual symptoms as compared to blunt mTBI, particularly when repetitive. These individuals also present with co-morbid conditions including depression, PTSD and increased risk of alcohol misuse. Of these, alcohol problems have received attention in the literature due to their significant frequency. There is debate on treatment algorithms for other co-occurring conditions in patients with PCS concerning whether to focus on PCS as the primary point of treatment or vice versa. Currently, empirical support is sparse on the impact of PCS on known corollaries of mTBI such as alcohol misuse and it is unclear if PCS modifies the relationships between known symptomology post-mTBI. The goal was to determine if PCS modifies the known relationships between depression, PTSD and alcohol misuse. Methods: Data were obtained from a larger study examining hyperbaric oxygen therapy as a potential treatment for PCS. Time-1 data obtained prior to the intervention phase of the original study were utilized. The sample was 60 active duty service members. Analysis revealed no group differences with respect to age, pay grade, marital status or race/ethnicity. All had physician confirmed diagnosis of blast-related mTBI. Measurement data were PCS as indicated by Rivermead Post-Concussive Symptom Questionnaire, depressive symptomology from the Center for Epidemiologic Studies Depression Scale, PTSD as measured by the PTSD Checklist and alcohol misuse as indicated by Alcohol Use Disorders Identification Test. Data were analysed to determine if PCS mediated or moderated the association between (1) depression and alcohol misuse and (2) PTSD and alcohol use. Results: Only depression predicted drinking, with those having greater depressive symptoms drinking more than those who were not depressed [t(58) ¼ 2.362, p ¼ 0.022, 95% CI ¼ 3.151, 0.260, d ¼ 0.609]. PTSD did not predict drinking in this sample [t(58) ¼ 1.464, p ¼ 0.149, 95% CI ¼ 2.723, 0.423]. Regression-based path analyses tested potential moderating and mediating effects of PCS on the relationship between depression and alcohol use. No moderating [F(3, 56) ¼ 2.3358, p ¼ 0.0835] or mediating [F(1, 58) ¼ 1.0619, p ¼ 0.3071] effects were found. Although the overall model was significant [F(1, 58) ¼ 26.6913, p ¼ 0.00001], only direct effects for depression were found (p ¼ 0.00001), with depression explaining 31.52% of the variance in alcohol use.

Objectives: Recent work identified deficits in dual-task gait balance control for up to 2 months following adolescent concussion, however how resumption of pre-injury physical activities affects recovery is unknown. Due to the vulnerability to a second concussion following a first, a premature return to activity may increase the risk of re-injury or prolong recovery. Thus, the purpose of this study was to observe how return-to-activity affects recovery from concussion by observing adolescents with concussion prior to and after returning to preinjury activity on measures of cognition, single-task and dual-task walking. Methods: Nineteen adolescents with concussion who returned to preinjury activity within 2 months following injury (mean age ¼ 15.4 ± 1.3 years) and 19 uninjured, matched controls (mean age ¼ 15.6 ± 1.1 years) completed a dual-task gait analysis and computerized cognitive testing. Concussion subjects were assessed within 72 hours, 1 week, 2 weeks, 1 month and 2 months post-injury. Returnto-activity was documented as the day after injury which physical activity participation was allowed. Concussion management decisions were made by attending physicians using conventional methods and independent of study-related data. The effect of returning to physical activity was assessed by examining data collected two sessions prior to (pre-return-2), the session directly prior to (pre-return-1) and the session directly after (post-return-1) each subject’s return-to-activity day. Control subjects were assessed at the same time points as their matched concussion counterparts. Data were analysed by two-way mixed effects ANOVAs. Results: Four concussion subjects returned to pre-injury activities between 1–2 weeks, nine concussion subjects returned between 2 weeks and 1 month and six concussion subjects returned between 1–2 months post-injury. During dual-task walking, concussion subjects displayed similar centre of mass (COM) medial/lateral displacement as controls at pre-return-2 and pre-return-1, but exhibited significantly greater displacement at post-return-1 (group*time interaction, p ¼ 0.016). Concussion subjects also significantly increased peak COM medial/lateral velocity from pre-return-1 to postreturn-1, while control subjects demonstrated no changes (group*time interaction, p ¼ 0.035). Main effects of time indicated improvement for both groups on dual-task peak COM anterior velocity (p ¼ 0.001), conflict resolution ability, (p ¼ 0.013) and task switching ability (p ¼ 0.008). Conclusions: After returning to physical activities, subjects with concussion displayed increased medial/lateral displacement and velocity during dual-task walking, which could indicate a regression of recovery in gait balance control. However, measurements of singletask walking, COM forward velocity and cognition indicated continuous improvement or no change in performance for both groups. Thus, the frontal plane COM motion suggests possible impairments to recovery for concussion subjects which were not detectable through sagittal plane movement or cognitive assessments. Resumption of physical activities may interfere with recovery of motor function, indicating that post-concussion evaluations beyond the point of return to activity may be warranted.


DOI: 10.3109/02699052.2014.892379


Lightning injuries: A review of the literature concerning the pathophysiology and clinical manifestations of neurologic damage Maria Mironidou, & Anastasios Mitsakos

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Aristotle University of Thessaloniki, Medical School, Thessaloniki, Greece Until the last few years, lightning injuries have been the second most common cause of storm-related death in the US, behind flash floods. Injuries have a wide range of clinical manifestations, from tiny static electricity-like exposures to cardiac arrest. However, lightning strikes are primarily a neurologic injury, that affects all three components of the nervous system: central, peripheral and autonomic. In addition, cardiologic complications should be taken into consideration, especially in severe cases where primary cardiac arrest and fatal arrhythmias can occur, deteriorating the patient’s existing respiratory depression due to medullary paralysis. Complications from other organ systems include mostly superficial burns with characteristic Lichtenberg figures, musculoskeletal manifestations (e.g. rhabdomyolysis) and otologic long-term problems such as tinnitus and tympanic membrane rupture. Diagnosis can be quite easy if witnesses report finding the patient on wet ground or under trees during a thunderstorm. However, the patient’s history may be confusing in the absence of witnesses due to the commonly reported retrograde amnesia following lightning injuries. Clinical suspicion, along with signs of diffuse vasomotor instability because of dysfunction of the autonomic nervous system can guide the physician to the correct differential diagnosis. Cerebral oedema with brainstem herniation is a rare but very dangerous acute complication that should be managed properly. Nerve damage can also occur secondarily to mechanical trauma, in the case of bone fractures or development of compartment syndrome. The threshold for imaging a patient with clouded mentation should be low, because it is often difficult to distinguish coma resulting from electrical shock from intracranial haematoma until lateralizing signs develop. Non-contrast computed tomography (CT) scan or magnetic resonance imaging (MRI) scan are commonly used for this reason. Typically, all lightning strike victims who do not experience cardiac or respiratory arrest survive. However, immediate attention should be directed to the resuscitation of those patients in respiratory or cardiac arrest. Non-steroidal anti-inflammatory drugs (NSAIDs) as well as narcotics are used in the treatment of acute pain. Chronic management of neuropathic pain can also include tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs) or other pain control measures, as indicated by the patient’s symptoms. In addition, vitamins C and E are hypothesized—but not proven—to be neuroprotective and helpful in nerve injuries, due to their action as free radical scavengers. Predicting the possibility or severity of any given lightning strike is impossible. Altering the course of injury, once set in motion, is also difficult. Therefore, preventive measures and education for individuals at risk are the most effective methods of minimizing lightning-related mortality and morbidity.


Neurobiological mechanisms associated with facial affect recognition deficits after traumatic brain injury Dawn Neumann, Yang Wang, Brenna McDonald, Michelle Keiski, John West, Dori Smith, & Andrew Saykin Indiana University, Indianapolis, IN, USA Objectives: People with traumatic brain injury (TBI) often have impaired facial affect recognition. The objective of this preliminary study was to use functional neuroimaging to elucidate mechanisms related to facial affect processing impairments after TBI by comparing brain activations in participants with TBI who have impaired facial affect recognition (TBI-I); TBI with normal facial affect recognition (TBIN); and Healthy Controls (HC). Methods: To date 22 participants have been recruited (TBI-I ¼ 6; TBIN ¼ 9; and HC ¼ 7). All TBI participants had a moderate-to-severe injury (PTA424 hours and LOC430 minutes) and were an average of 13 years post-injury (range ¼ 2–36). A facial affect recognition screening assessment (DANVA Faces) was used to classify TBI participants as impaired or unimpaired; HCs only qualified if scores were within the standardized normal range. Eligible participants were later presented with a facial emotion identification task during 3T functional magnetic resonance imaging (fMRI). A fixation point centred in a scrambled face served as a baseline control. Using this baseline, blood oxygenation level-dependent changes were contrasted for the overall emotion task and for emotional categories: Happy, Sad, Angry and Fearful. Results: Average age was 42; 46% were males. The three groups did not significantly differ for age or years of education; the HC group had more females than both TBI groups. The two TBI groups did not differ in injury severity, years post-injury or gender. On the DANVA Faces, TBI-I had more errors than TBI-N (p ¼ 0.025) and HC (p ¼ 0.033); no significant differences were found between TBI-N and HCs (p ¼ 0.978). On the neuroimaging face emotion identification task (all emotions vs baseline), HC had significantly more activation in the right fusiform gyrus and left precuneus compared to TBI-I and more activation in the declive of the right cerebellum compared to TBI-N. In contrast, TBI-I participants had significantly more activation in the right superior parietal lobule compared to HC. Compared to TBI-I, TBI-N participants had significantly more activation in the fusiform gyrus, bilaterally. Significant activation differences between HC and TBI-I were also found for individual emotions. Conclusions: The perception of faces and facial expressions has been reliably associated with greater activity in the fusiform gyrus, an area characteristically associated with global processing. In contrast, activation in the superior parietal lobule has been associated with processing features separately. As such, the preliminary findings suggest that, compared to their unimpaired counterparts, the TBI-I participants may be processing facial expressions one feature at a time, rather than as a single unit. These findings are similar to neuroimaging studies in children with autism. Future studies with a larger sample size should be conducted. If replicated, these findings suggest affect recognition treatments should focus on teaching patients to process facial expressions more holistically, rather than scanning features separately.



Brain strain following mild traumatic brain injury: A neuroimaging investigation of dual-task performance in youth athletes Katia J. Sinopoli1, Jen-Kai Chen2, Greg Wells3, Alain Ptito2, Tim Taha4, & Michelle Keightley5,6

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The Hospital for Sick Children, Department of Psychology, Division of Neurology, Toronto, Ontario, Canada, 2Montreal Neurological Institute, Montreal, Quebec, Canada, 3The Hospital for Sick Children, Physiology and Experimental Medicine, Toronto, Ontario, Canada, 4 University of Toronto, Faculty of Kinesiology & Physical Education, Toronto, Ontario, Canada, 5Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada, 6 University of Toronto, Department of Occupational Science and Occupational Therapy, Graduate Department of Rehabilitation Science & Psychology, Toronto, Ontario, Canada Objectives: Mild traumatic brain injury (mTBI) is a common cause of injury in youth athletes. Much of what is known about the sequelae of mTBI has been yielded from adult participants, with the majority of studies reporting ongoing behavioural and neuroimaging abnormalities in those with persistent symptoms. There is a dearth of data that focuses specifically on paediatric populations, especially where neuroimaging outcomes are concerned. A major question to be addressed is whether or not the administration of cognitively challenging tasks for youth will uncover mTBI-related abnormalities in those without ongoing symptoms or functional impairments. Methods: To explore this question, male athletes aged 9–15 years with and without a history of mTBI 3–6 months prior to testing completed a working memory task both in isolation (single-task) and while completing a concurrent motor (dual-task). Neuroimaging correlates were recorded using functional magnetic resonance imaging. Results: Although participants performed similarly during the singletask condition, youth with mTBI displayed abnormal activation in key working memory areas including the dorsolateral prefrontal cortex and parietal cortices. During the dual-task condition, youth with mTBI slowed their rate of responding to ensure accuracy. These participants also exhibited abnormal recruitment of brain structures involved in both working memory and dual-tasking. Conclusions: Overall, the data shows that the dual-task paradigm can uncover functional impairments in youth with mTBI who are not highly symptomatic and do not exhibit neuropsychological dysfunction. Moreover, neural recruitment abnormalities were noted in both the single- and dual-task condition, which it is argued suggests mTBI-related disruptions in efficient cognitive control and allocation of processing resources.


Decompressive craniectomy is an efficient treatment option for traumatic brain injury: Our experience Gorazd Bunc1, Janez Ravnik1, Robert Klobucar2, & Tomaz Velnar1

Brain Inj, 2014; 28(5–6): 517–878 1

University Medical Centre Maribor, Maribor, Slovenia, 2Brighton and Sussex Medical School, Brighton, UK

Objectives: In 10–15% of patients after severe traumatic brain injury (STBI), the intracranial pressure rises significantly and does not react to conservative treatment or to external ventricular drainage. Patients with intracranial pressure (ICP) higher than 20 mmHg, not responding to intensive care measurements, show higher morbidity and mortality. In such cases, decompressive craniectomy (DC) may be employed for lowering the elevated ICP. This reduction of ICP after DC is thought to improve recovery. Experience with DC is presented. Methods: In the retrospective study, 27 patients with STBI were included (GCS rated from 3–8) in whom DC was performed due to a rise in ICP that was not responsive to conservative measurements. A classical, mostly unilateral DC of 10–15 cm in diameter was performed. The influence of patient age, initial GCS score, time of surgery, pupillary light reflex, associated injuries, concomitant intracranial procedures and treatment outcomes were studied. For every patient, the effect of treatment was scored by GOSE score (Glasgow Outcome Scale Extended) at discharge and during followup. Student’s t-test was used for statistical evaluation. Results: From 2005–2010, 243 patients with severe brain injury were treated at the centre. DC was employed in 27 patients. A favourable treatment outcome was achieved in 38% of patients, 44% died, 12% remained in persistent vegetative state and 6% were severely disabled. Rated by GOSE score (GOSE 1–4), poor treatment outcome was observed in 63% (average GOSE ¼ 1.4) and favourable in 37% (average GOSE ¼ 6.5). Before and after DC, the average ICP has fallen from 48 ± 19 mmHg to 16 ± 12 mmHg, respectively (p ¼ 0.003). Patients younger than 50 years, those treated by DC later than 24 hours after injury and those with GCS rated from 6–8 (p ¼ 0.0038) had a better treatment outcome. Conclusions: DC effectively reduces the rise in ICP following STBI. Patients with less significant neurological dysfunction as well as patients younger than 50 years of age benefit the most. These results are, thus, comparable to those reported in other retrospective studies, although a straightforward comparison among DC studies is not possible due to the various parameters they considered. However, they all demonstrated a successful treatment outcome on patients’ survival after DC, ranging from 16–69%.


The predictive value of early CT frontal abnormalities for longterm behavioural changes in moderate-to-severe TBI Jacoba M. Spikman, & Joukje van der Naalt University of Groningen, University Medical Center Groningen, Groningen, The Netherlands Objectives: Moderate-to-severe TBI can lead to physical, cognitive and behavioural impairments. Of these three areas of deficit the behavioural changes have the most negative consequences on successful social and vocational rehabilitation. However, it is still difficult to predict in the acute stage which patients will develop chronic behavioural problems. In a previous study, frontal lesions on MRI were found to be predictive for 1-year outcome. Although MRI is more sensitive, the primary and most commonly used imaging technique in the acute phase of TBI is CT. The present study aimed to investigate whether the presence of frontal abnormalities on CT on admission would have predictive value for the presence of behavioural changes in the long-term. Methods: Data of all patients with moderate-to-severe TBI who were admitted between 2000–2010 to the UMC Groningen, the


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DOI: 10.3109/02699052.2014.892379

Netherlands, a level one trauma centre, were prospectively collected. Five-to-ten years later, all patients (n ¼ 361) were sent an after care questionnaire. This questionnaire comprised seven questions, asking for behavioural and/or affective changes (apathy, childishness, emotional indifference, anger, depression, sadness, anxiety), to be filled in by the patients themselves as well as by a close other. One hundred and ninety patients returned the questionnaire; these patients did not differ from the non-responders with respect to mean GCS score or age. Results: A principal components analysis on the proxy answers to the questions revealed two factors, representing behavioural and affective changes. A single item: ‘getting angry more often’ ’loaded equally on both factors and was analysed separately. Three measures were created, representing Behaviour, Affect and Anger, with both a self and a proxy rating. Patients were divided into two groups, based on whether CT scan had revealed frontal abnormalities (n ¼ 80) or not (n ¼ 110). These two groups did not differ with respect to mean GCS score or age. Non-parametric testing revealed no difference between the frontal and non-frontal group with respect to the self and proxy rated Affect scores. However, the frontal group was significantly more often Angry and had significantly higher Behavioural scores than the non-frontal group, both according to self as well as proxy ratings. Correlations between self and proxy ratings were significant for all three measures (Affect ¼ 0.74, Anger ¼ 0.65, Behaviour ¼ 0.68). Conclusions: Early CT has predictive value for the long-term. Patients with frontal abnormalities on early CT had significantly more behavioural problems 5–10 years later, both according to self as well as to proxy ratings, than patients with no frontal abnormalities. Affective problems were equally present in both groups. The significant correlations between self and proxy ratings suggest that these patients with chronic TBI have acquired some self-awareness of problems.


Deficits in children and youth with acquired brain injury, two years after injury Suzanne Lambregts1, Frederike van Markus2, Coriene Catsman3, Arend de Kloet2, Sander Hilberink3, Marij Roebroeck1, & Monique Berger2 1

Revant Rehabilitation Center, Breda, The Netherlands, 2University Applied Sciences, The Hague, The Netherlands, 3Erasmus MC University Center, Rotterdam, The Netherlands Objectives: Acquired brain injury (ABI) is a leading cause of morbidity and mortality in children and youth in first-world nations. This study is performed to determine deficits in children and youth with ABI 2 years post-injury and to explore associated factors. This study is part of a larger retrospective cohort study to determine incidence, causes, outcome, care needs and participation. Methods: Children and youth (n ¼ 114; aged 6–22 years) were assessed 2-years post-injury in a cross-sectional study. The assessment consisted of a neurological examination, based on the Paediatric Stroke Outcome Measure (PSOM) and prior to the screening parents were questioned about medical history of their child and to indicate presence of pre-morbid developmental problems. Spearman correlation coefficients were used to explore the relationship between these determinants, patient characteristics and outcome by using the Deficit Severity Score (DSS) of the PSOM. The PSOM assess five spheres of functioning: right sensorimotor, left sensorimotor, language production, language comprehension, cognitive and behavioural. Results: The mean age was 13.2 years and 57% were boys; 76.3% of the participants have undergone a traumatic brain injury. Severity of

brain injury was mild in 78.1%, moderate in 11.4% and severe in 9.6%. Bilateral sensorimotor deficits were diagnosed in 14.0% and unilateral sensorimotor deficits in 7.9%. Language production deficits were found in 5.2% and language comprehension deficits in 4.4%. Cognitive deficits were found in 24.6% and behavioural deficits in 16.7%. The DSS was normal in 51.8%, mild in 24.6%, moderate in 14.0% and severe in 9.6%. In traumatic brain injury there was a significantly poorer outcome for younger age and lower SES. Severity of brain injury was not significant for poorer outcome. Pre-morbid problems, especially in gross motor function, communication and social function had a negative impact on outcome. Conclusion: There was a good outcome in most of the survivors of an acquired brain injury 2 years post-injury, based on neurological examination. In a quarter of the patients a poor outcome was found, especially in younger age and lower SES.


Cost-effectiveness analysis (CEA) of continuous chain of rehabilitation after severe traumatic brain injury Nada Andelic1, Jiajia Ye2, Sveinung Tornas3, Cecilie Roe4, Juan Lu5, Erik Bautz-Holter4, Tron Moger2, Solrun Sigurdardottir1, Anne-Kristine Schanke3, & Eline Aas2 1

Institute of Health and Society, Research Centre for Habilitation and Rehabilitation Models and Services (CHARM), Faculty of Medicine, 2 Institute of Health and Society, Department of Health Management and Health Economics, University of Oslo, Oslo Norway, Oslo, Norway, 3Sunnaas Rehabilitation Hospital Trust, Nesoddtangen, Norway, 4Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway, 5Department of Family medicine and Population Health, Division of Epidemiology, Virginia Commonwealth University, Richmond, USA Objectives: To estimate the long-term cost-effectiveness of continuous chain of rehabilitation after severe traumatic brain injury (sTBI) compared with a broken chain of rehabilitation. Methods: The authors developed a decision tree model to represent two rehabilitation trajectories after sTBI and compared the incremental cost-effectiveness ratio (ICER) of continuous vs broken chain of rehabilitation by measuring the hospitalization costs (acute hospitalizations and inpatient rehabilitation) and health effect for both trajectories. The costs were estimated by means of average costs per diagnosis-related group (DRG) and based on point estimates from the Disability Rating Scale (DRS); the health effect was measured by means of area under the curve (AUC). Thus, the incremental health benefit was estimated as the difference in area for the AUC for continuous chain vs AUC for broken chain of rehabilitation. Due to the DRS scale, the smaller AUC, the better is the health effect. The modelled population was a cohort of 59 patients with sTBI, admitted to the Trauma Referral Centre for the Southeast region of Norway in the time period 2005–2007. Inclusion criteria were aged 16–55 years, Glasgow Coma Scale (GCS) score  8, need of neurointensive care (i.e. neuromonitoring to optimize conditions for neuronal survival) for at least 5 days and survival 5 years post-injury. As the ethical justification for randomizing patients seemed untenable for researching acute TBI care, a quasi-experimental study design was used for inclusion of patients in the acute phase. In general, the capacity (i.e. available bed principle) in the Intensive Care Unit (ICU) determined the assignment to a continuous chain of rehabilitation (i.e. direct transfer from the ICU to specialized brain injury rehabilitation entities, n ¼ 30) or to a broken chain of treatment (i.e. discharge to local hospitals and

610 delayed admission to brain injury rehabilitation, n ¼ 29). Patients were followed-up at 6-weeks, 1-year and 5-years post-injury. Results: Regarding the DRS estimates, the 5-year AUCs were 19.40 and 23.46 for the continuous and broken chain of rehabilitation, respectively. The mean 5-year length of hospital stays in continuous and broken chains of rehabilitation was 113 and 137 days, respectively. The average 5-year costs (SD) per patient for continuous treatment and broken chain were $207 780 (77 266) and $213 659 (127 658), respectively. In a 5-year perspective, the continuous chain of rehabilitation trajectory had lower costs and better health effects. By replacing the broken chain with a continuous chain of rehabilitation, $13 606 could be saved and 4.06 DRS points gained. By means of the probabilistic sensitivity analysis, the majority of incremental cost-effectiveness estimates (67% of the Monte Carlo simulations) indicated that the continuous chain of rehabilitation was less costly and more effective. Conclusion: Findings indicate that the continuous chain of rehabilitation represents a dominant strategy in that it reduces costs and improves outcomes.

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Craniocerebral trauma as a result of a compressor tube explosion: A case report Tomaz Velnar, & Rado Pregelj University Medical Centre Ljubljana, Ljubljana, Slovenia Objectives: Traumatic brain injury is frequently encountered in neurosurgical practice. Although penetrating trauma is less common than closed injuries, it is more often lethal. Cavitation effect, vascular and neuronal damage, secondary brain injury and infection are the main causes of poor outcome. Methods: Clinical presentation of a 35-year old patient is described, who suffered explosion head injury. During the explosion of a construction machine, a foreign body (a part of a high-pressure compressor air tube, 6 cm in length, made of steel wires and plastic mantle) penetrated the basal parts of the frontal lobes through maxilla, medial orbit and ethmoid. It was embedded in the vessels of the anterior communicating complex, elevating it to the lower falx. At admission, GCS was rated at 14. No paresis was evident. Results: Through the inter-hemispheric approach, the foreign body was removed, debridement and reconstruction were done and all vessels were spared. The initial recovery was good and sedation was gradually discontinued. However, the patient’s clinical condition deteriorated after 1 week due to vasospasm-induced brain infarction and meningitis and he died weeks later of infection and multi-organ failure. Conclusions: Penetrating injury to the brain has a poor prognosis and high disability among the survivors. Minimizing secondary insults to the brain tissue, strict adherence to the brain trauma guidelines and infection prevention are imperative. The deterioration may appear also late in the treatment course, after initial promising recovery.


College students and bicycle helmets: Who wears them and why? Miriam Krause1, Kathryn Miller1, Sabiha Parveen2, Hanna Peeples1, Stephanie Richards3, & Faith Yingling1

Brain Inj, 2014; 28(5–6): 517–878 1

Bowling Green State University, Bowling Green, OH, USA, Oklahoma State University, Tulsa, OK, USA, 3Central Michigan University, Mount Pleasant, MI, USA


Objectives: The purpose of this study was to conduct a mixedmethods analysis of the self-reported use of bicycle helmets among undergraduate college students and their stated reasons for wearing or not wearing helmets. Methods: In this mixed-methods study, 82 undergraduate students were interviewed about their use of bicycles and bicycle helmets. Fifty-four (27 males, 27 females) reported that they did ride bicycles at least occasionally and data from these 54 participants are discussed here. Interviews were conducted verbally and included basic demographic information and questions about participants’ frequency of bicycle and helmet use. Participants were also asked about their primary reasons for either wearing or not wearing helmets. Results: Of the 54 participants who reported riding bicycles, 49 reported how often they wore helmets: 14 of these (29%) stated that they wore helmets at least half the time (open-ended responses included comments such as ‘likely’, ‘about half the time’ and ‘of course’). Thirty-five of the respondents (71%) indicated that they rarely or never wore helmets (responses included ‘not likely’, ‘almost never’ and ‘barely ever’). Participants offered a range of responses regarding their reasons for and against helmet use. Chi-square analysis showed an interaction between gender and helmet use, such that fewer respondents wore helmets among both males and females, but the proportion of males reporting they never or almost never wore helmets (78%) was significantly higher than it was for females (52%), p50.05. Based on a thematic analysis of the interview responses, the most frequent reason cited for those who did wear helmets regularly was safety, with several participants additionally reporting that they wore helmets because they had personally experienced an accident. Reasons for not wearing helmets varied more widely; the three most frequently cited reasons were simply not owning a helmet, finding helmets inconvenient and believing them to be unnecessary. Examining the responses of men and women separately provided interesting insights in this analysis as well, in that women had a much higher proportion of ‘don’t own’ reasons, while men were more likely to respond with ‘inconvenient’ or ‘unnecessary’ themes. Conclusions: Very few college students interviewed for the study regularly wore helmets when riding bicycles, but the patterns and reasons for this behaviour differed between male and female respondents. This suggests that future efforts to promote helmet use among college-age adults should incorporate a variety of strategies and could benefit from using different approaches when targeting men and women.


Classification of gait disorders following traumatic brain injury Gavin Williams1, Daniel Lai2, Anthony Schache3, & Meg Morris4 1

Epworth Healthcare, Melbourne, Australia, 2Victoria University, Melbourne, Australia, 3University of Melbourne, Melbourne, Australia, 4 LaTrobe University, Melbourne, Australia Objective: To develop a classification system for people with gait disorders resulting from traumatic brain injury (TBI). Method: Cross-sectional cohort study comprising people with TBI receiving physiotherapy for mobility limitations. Participants: One hundred and two people with TBI. The taxonomic framework for gait disorders following TBI was devised based on a framework previously developed for people with cerebral palsy.


DOI: 10.3109/02699052.2014.892379

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Participants with TBI who were receiving therapy for mobility problems were assessed using three-dimensional gait analysis. Pelvis and bilateral lower-limb kinematic data were recorded using a VICON motion analysis system while each participant walked at a self-selected speed. Five trials of data were collected for each participant. Multi-class support vector machine (SVM) models were developed to systematically and automatically ascertain the clinical classification. Results: The statistical features derived from the major joint angles from unaffected limbs contributed to the best classification accuracy of 82.35% (84 out of the 102 subjects). Features from the affected limb resulted in a classification accuracy of 76.47% (78 out of 102 subjects). Conclusions: Despite considerable variability in gait disorders following TBI, this study was able to generate a valid and sensitive clinical classification system based on six distinct sub-groups of gait deviations. Statistical features related to the motion of the pelvis, hip, knee and ankle on the less-affected leg were able to accurately classify 82% of people with TBI-related gait disorders using a multiclass SVM framework.


Strength training for walking in neurological rehabilitation is not task-specific: A focused review Gavin Williams1, Michelle Kahn2, & Alana Randall3 1

University of Melbourne, Melbourne, Australia, 2Epworth Healthcare, Melbourne, Australia, 3Northern Health, Melbourne, Australia Objective: Muscle weakness is prevalent and often the primary impairment for many people with neurological conditions. The last 10–15 years has seen a proliferation in studies investigating the efficacy of strength training to improve walking. Despite many studies demonstrating that strength training is safe and efficacious for improving muscle weakness, few studies have reported improved walking outcomes as a result of greater leg strength. The primary question for this systematic review was to investigate whether strength training programmes for walking in neurological rehabilitation are task-specific? Method: Systematic review with data synthesized in a narrative format. Ten electronic databases were searched from conception to October 2012 for randomized controlled trials (RCT) which used strength training to improve walking in adult neurological populations. Results: The search identified 25 randomized controlled trials which investigated the efficacy of strength training to improve walking in people with a variety of neurological conditions. Results revealed that, despite significant strength gains, many studies failed to show a significant improvement in walking capacity. Most studies did not include exercises relating to all three main power events important for walking. Strength testing and strengthening exercises were prioritized for the knee extensors and flexors, despite their relatively minor role in human walking. Conclusion: Strengthening exercises performed in the neurological population are not specific to the main muscle groups responsible for the power generation required for walking. There is a predisposition for strength testing and strengthening exercises to focus on the knee flexors and extensors, despite their relatively minor role during walking. Further consideration of the specificity of strength training may provide greater translation of strength gains to improved walking outcomes.


Does cyclosporine-A improve neurorecovery in patients with diffuse axonal injury after traumatic brain injury? Bahram Aminmansour1, Salman Abbasi Fard1, Payam Moein1, Rasoul Norouzi1, & Morteza Naderan2 1

Neurosurgery and Neurology Departments, Al-Zahra Hospital, Isfahana University of Medical Sciences, Isfahan, Iran, 2 Farzan Institute of Clinical Research, Tehran, Iran Objectives: Cyclosporine-A (CsA), a calcineurin inhibitor, has shown neuroprotective properties in some recent studies. It has reduced neural cytoskeletal and calcium-induced mitochondrial damage involved in the secondary axotomy of brain tissues affected by stretch axonal injury. Human studies, however, report heterogeneous results about CsA efficacy on improving the outcome of patients with diffuse axonal injury (DAI). Methods: This randomized double-blind placebo-controlled study evaluated the effect of CsA on the outcome of patients with DAI. Eighty-five patients with moderate-to-severe traumatic brain injury and a Glasgow coma scale (GCS)  10 with clinical and radiological evidence of DAI were randomized into intervention (group A, n ¼ 50) or control (group B, n ¼ 50) groups. CsA (5 mg kg1 per 24 hours via 250 ml dextrose water 5% solution (DW 5%)) was administered to group A during the first 8 hours after trauma. Group B received only DW 5% in the same course. The Glasgow outcome scale-extended (GOSE) and mini-mental state examination (MMSE) were performed 3 and 6 months after the trauma to compare outcome between the groups. The GOSE scores were categorized into lower (1–4) and upper (5–8) recovery. The MMSE scores were grouped into normal cognitive function (MMSE ¼ 25–30), mild impairment (MMSE ¼ 20– 24), moderate impairment (MMSE ¼ 10–19) and severe impairment (MMSE ¼ 0–9). Results: The baseline GCS and GOSE scores were statistically similar. The 3rd month GOSE results were 23 lower/27 upper in group A and 18 lower/22 upper in group B (p ¼ 0.208). The 6th month GOSE scores were 29 lower/21 upper in group A and 22 lower/28 upper in group B (p ¼ 0.115). Regarding MMSE, the following results were achieved: MMSE after 3 months: 24 moderate/26 severe disability in group A and 29 moderate/21 severe disability in group B (p ¼ 0.212). MMSE after 6 months: 19 moderate/31 severe disability in group A and 22 moderate/28 severe disability in group B (p ¼ 0.342). The risk of infection, mortality rate and serum biomarker derangements were not different between the groups except for a higher BUN level in the cyclosporine-treated group at 48 hours after admission which was still in the normal range. The CBC results showed only a significantly higher white blood cell count 12 hours after admission in group A (p ¼ 0.001). Conclusion: Although CsA caused no serious adverse event, it did not improve the neurorecovery of DAI patients in this study.


Does intervention using virtual reality improve upper limb function in children with neurological impairment? Jane Galvin1, Cathy Catroppa1, Rachael McDonald2, & Vicki Anderson1

612 Murdoch Children’s Research Institute, Victoria, Australia, 2Monash University, Victoria, Australia

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Background: Virtual reality (VR) is an emerging area of clinical and research practice. Most research has been conducted on adults with neurological impairments. Current evidence for VR to improve hand and arm skills in children is emerging; however, further research is required to investigate the ability to maintain gains made in VR and to determine whether these gains transfer to real life tasks and activities. This study aimed to investigate whether involvement in a 6-week block of VR therapy results in improved upper limb function and performance of functional tasks compared to standard care and whether any gains are maintained over time. Objectives: (1) To present outcome data from an intervention trial of motor-based therapy using VR to improve upper limb motor outcomes for children following traumatic brain injury. (2) To discuss the outcomes in relation to clinical decision-making regarding the use of VR to improve motor function and performance. (3) To identify directions for future research. Methods: This study used a repeated measures design to determine whether 6 weeks of VR-based interventions resulted in improved motor performance compared to standard therapy. Participants were recruited through paediatric rehabilitation services. All measures were completed at baseline, upon completion of the 6-week intervention phase and then again 3 months post-intervention. Children completed measures of motor performance, as well as measures of functional hand use. The IREX Virtual Reality system was used to provide the intervention. The IREX uses video capture technology and has 12 games that provide differing challenges. Variables such as speed and range of movement can be altered to accommodate movement challenges of individual children. Children in the intervention group attended two sessions of VR-based therapy for 6 weeks, while the comparison group attended standard therapy Results: Children in the intervention group showed greater gains than those attending standard therapy. Children with the greatest motor deficits at baseline showed the greatest gains in motor skills; however, those with the least deficits showed greater gains in goalrelated activity. Conclusions: VR provides an opportunity for intensive practice of motor skills. Rehabilitation-specific VR platforms allow children with more severe motor deficits to engage in motor activities at greater intensity than might otherwise be possible and appear to provide opportunities to improve motor skills. Differences in outcome based on motor abilities at baseline provide evidence to support clinical decision-making about VR system choices. Further research is required to determine optimum intensity and duration of intervention to maximize functional changes, particularly in those with more severe motor deficits.


The Swedish version of the Brain Injury Family Intervention programme for Adolescents (BIFI-A) Ingrid van’t Hooft, & Annika Lindahl-Norberg Astrid Lindgren Children’s Hospital, Karolinska University Hospital/ Karolinska Institutet, Stockholm, Sweden Primary objective: To test the feasibility of a Swedish version of the Brain Injury Family Intervention for adolescents (BIFI-A) with acquired brain injury (ABI) developed in Toronto/Canada. Methods and procedures: The BIFI-A, including a 12-session manual based curriculum, focusing on education, skill building and emotional support for the whole family, will be tested on three families with an

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adolescence suffering from acquired brain injuries. Descriptive/ exploratory self-administered questionnaires and semi-structured interviews will be used. The presentation will focus on the theoretical background of the BIFI-A, earlier evaluations of the method, the protocol and the plan for a pilot and a collaborative effect study.


Rehabilitation in a sparsely populated area Catherine Aaro Jonsson ¨ stersunds Hospital, O ¨ stersunds, Child and Youth Rehabilitation, O Sweden Options for rehabilitation in sparsely populated areas meet special challenges. The more severely injured paediatric ABI group is often small and diverse. Patient-needs differ due to the specific type of brain injury, the age of the child, time passed after the injury and the conditions of the specific child, family and network. A way of providing family-based paediatric rehabilitation within these circumstances in Sweden will be presented, with a focus on the TBI group. These team-based interventions aim to help the parents and the child to handle the early changes followed by the injury, to promote recovery during the first 1.5 year after injury and to support long-term development and coping with enduring injury-related problems. Co-operation with the school and other parts of the child’s network is important. This work can start at the initial stage at the local hospital and continues up to the age of 18 years old, if needed.


Age-related atrophy of white matter tracts in veterans Maheen Adamson1, Keith Main1, Jennifer Kong1, Arthur Noda2, Beatriz Hernandez2, Joy Taylor1, Laura Lazzeroni2, John Ashford1, & Peter Bayley1 1

VA Palo Alto Health Care System, Palo Alto, CA, USA, 2Stanford Medical School, Stanford, CA, USA

Objectives: Diffusion Tensor Imaging (DTI) fibre tractography has been used to assess the relationship between age and microstructural changes in white matter tracts (WMT). Such studies typically include healthy adults and report common indexes of DTI including Fractional Anisotropy (FA) and Mean Diffusivity (MD). The objective was to investigate WMT changes in a veteran population with multiple health complaints including mild-to-moderate traumatic brain injury (TBI) (68%) and/or post-traumatic stress disorder (PTSD) (78%). Methods: Participants were recruited at the War Related Illness and Injury Study Center, California (WRIISC CA). Forty-seven participants (40 males, mean age ± SD ¼ 47.19 ± 12.3 years (range ¼ 23–77 years); mean education ± SD ¼ 14.06 ± 2.7 years) were given a high-resolution T1 anatomical scan and a 30 direction DTI scan (3T GE MRI). Participants also completed a battery of neuropsychological tests. DTI data were analysed with custom software for the creation of tensor maps and white matter tractography that provided common DTI indices of FA and MD for twenty fibres of interest. Results: Correlation analyses revealed a linear decrease in FA with age in most fibre tracts examined except the right cingulum and bilateral uncinate, where the linear correlation was almost zero (right cingulum r ¼ 0.18, p40.1; left uncinate, r ¼ 0.0047, p40.1; right uncinate, r ¼ 0.23, p40.1). Similarly, a significant linear increase in MD was found in most fibres except the bilateral uncinate, bilateral


DOI: 10.3109/02699052.2014.892379

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corticospinal tract and the left cingulum, where the correlations were not statistically significant (all p’s40.05). As expected, performance on neuropsychological tests correlated negatively with age: attention (r ¼ 0.57, p50.0001) and executive function (r ¼ 0.35, p50.02). Conclusions: These results are consistent with previous reports in finding significant negative correlations between FA and age in the majority of WM tracts. Of note, contrary to previous research, this study did not find a negative correlation between FA and age in the right cingulum and bilateral uncinate. These differences in results may reflect differences between populations of healthy adults and the veteran population used here. For example, a decrease in WM FA values has previously been reported in the cingulum and uncinate in clinically depressed populations. Reduced FA values have also been reported in the cingulum in individuals who have experienced physical and/or emotional trauma and Generalized Anxiety Disorder. These conditions are common in the Veteran population from which this sample was drawn. Therefore, microstructural changes in the uncinate and cingulum in this sample may have overridden the age-related changes in FA that have been found in these structures.


activity, depressive troubles, suicide and attempts. Standardized and well-validated assessment tools were reviewed. Guidelines for treatment and management were drawn. Non-drug therapy included cognitive-behaviour, systemic and holistic types of psychotherapy, psychoanalysis and advices for care teams and relatives. Special attention was paid to bursts of anger, violence and aggressive behaviour. Drug therapy included -blockers, anxiolytics, neuroleptics (clozapin), antidepressant (serotoninergic) and antiepileptic drugs. Separated guidelines were drawn for chronic impairments and for crisis and emergency situations. Conclusions: The group claimed for forthcoming, well-designed and controlled studies on this critical concern. They will discuss French guidelines compared to guidelines of other countries.


Clinical profile and outcome of childhood traumatic brain injury in a Nigerian tertiary health institution

Management of behavioural disorders after traumatic brain injury: SOFMER guidelines for daily practice

Ayodeji Salman Yusuf, Nurudeen Abiola Adeleke, Moshood Folorunsho Adeyemi, Timothy Olugbenga Odebode, & Olusegun Adeola Kolade

Laurent Wiart1, Jacques Luaute´2, David Plantier2, Angelique Stephan3, Julia Hamonet2, Jean Michel Mazaux4, Jean Franc¸ois Mathe´1, & the Sofmer Group4

Background: Traumatic brain injury (TBI) is a leading cause of injuryrelated morbidity and mortality among the paediatric population all over the world. It makes a significant impact on the child and the family, often putting a strain on the family economy and emotional well-being. Objective: This study was designed to determine the causes, clinical characteristics and hospital course of children with accidental traumatic head injury in a tertiary referral centre of a developing country. Methods: A prospective study of consecutive children aged 15 years and below with traumatic brain injury managed from 2011–2013. Information on demography, mechanism of injury, clinical presentation, computerized tomography (CT) scan and treatment modality were entered into a pre-designed proforma. Outcome was measured at discharge and 6 months post-injury using the Glasgow outcome scale. Results: One hundred and one children with TBI were managed during the study period. Their age ranged from a few months to 15 years with a median age of 6 years and a male-to-female ratio of 2:1. Most injuries occur outside the home, 85 (84%), with road traffic crash accounting for 62.4% of cases and it is more common among children between the age of 6–10 years. Children were involved as pedestrians in 44 (71%) cases of road crashes. Children less than 5 years suffered TBI more commonly from a fall, 69% of cases. Loss of consciousness and seizures were the commonest presenting symptoms. Most TBI were mild (46.5%), 18 (17.8%) cases were severe. Skull fractures occurred in 19 (19%) patients, while 31 (31%) patients suffered intracranial haematoma. Faciomaxillary injury (41%) and extremities (20%) fractures were the commonest associated injury. Neurosurgical operations were carried out for 21 patients. Seventy eight (77%) patients had good recovery and six patients died (mortality rate 5.9%). Conclusion: Most childhood TBI result from preventable causes outside the home; strict adherence to road safety measures and better supervision for the children may result in significant reduction of TBI. Although most cases are mild and most children have good clinical recovery, the long-term effect of TBI on the cognitive function of these children may be worse than predicted by immediate clinical outcome.


Department of Physical Medicine and Rehabilitation, Pellegrin University Hospital, Bordeaux, France, 2Department of Physical Medicine and Rehabilitation, University Hospital, Lyon, France, 3 Department of Physical Medicine and Rehabilitation, University Hospital, Nantes, France, 4Sofmer, Paris, France, Objectives: Neurobehavioural disorders (ND) are a major consequence of traumatic brain injury (TBI) and a cause of severe stress and burden on relatives and caregivers. Treatments and management of ND remain difficult, controversial and some times of low efficacy. This study reports here the conclusions of a task force undertaken by the French Rehabilitation Medicine Society (SOFMER) along with the French Health Ministry (FHM). The framework involved six questions about ND: symptoms, assessment, non-drug therapy, drug therapy, organization and strategy of care and follow-up. Method: During 2011, a SOFMER group redacted general questions about ND after TBI and asked French specialists and the French Health Ministry to build a work group. During 2012, a first group of four readers made a review of the literature from 1990–2012 and classified studies from grade A (high level of proof) to grade C (low level of proof). A second group of 23 members representing various domains of TBI (PMR doctors, psychiatrists, neurologists, psychologists, families, associations, lawyers, ...) redacted guidelines. During 2013 a third group of 32 senior specialists reviewed and corrected guidelines before final agreement by the FHM. Results: More than 500 articles were reviewed, 18% of which were classified level B and 82% level C. None was classified level A. A total of 131 guidelines were redacted, summarized in 32 main guidelines to be published by the SOFMER and the FHM. Neurobehavioural impairments were classified into four broad categories: over-arousal and high activity, lower-arousal and low

University of Ilorin/University of Ilorin Teaching Hospital, Ilorin, Kwara State, Nigeria



Cross-sector and interdisciplinary co-operation in brain injury rehabilitation Ane Søndergaard Thomsen, & Tia Hansen

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Aalborg University, Aalborg, Denmark Objectives: The co-ordination of efforts across sectors, disciplines and administrative units is a necessity for coherent rehabilitation but by no means easy. In a recent review-based report, the Danish National Board of Health strongly recommended improvement of co-ordination in brain injury rehabilitation. The analysis recommended a more formalized structure for collaboration between administrative levels and units in order to ensure co-ordination and integration of services across disciplines and areas. This requires early communication between the parties involved and relevant transfer of knowledge. It may be achievable by further development of current means of co-ordination such as co-ordination committees and health contracts between municipalities and their administrative region. The main recommendations from the Danish Board of Health are: (1) Interdisciplinary collaboration between professionals, in collaboration with the person with acquired brain injury (ABI) and his or her relatives; (2) In the municipality, establish a co-ordination function of brain injury rehabilitation in order to co-ordinate efforts in relation to the individual person with ABI; and (3) Differentiated rehabilitation services in both hospitals and at the municipal level, with gradual transfer of knowledge and services to ensure that people with ABI receive the level and kind of services that are appropriate to their individual need. Because rehabilitation of people with ABI was given priority, some development projects were funded by the Danish Government. This study reports from the KORE/REKO project of Aalborg Municipality/Northern Jutland and this presentation focuses on: (1) establishing new ways of working together across disciplines and sectors from doctors and neuropsychologists to home healthcare workers and (2) joint rehabilitation plans. Methods: Procedures for co-ordination were constructed through dialogue and workshops that mobilized representatives of all stakeholders. The authors are developing and testing an organizational education approach that adapts tools from organizational psychology and cognitive therapy. The aim is to help the organization develop and explicit a conceptual framework that links rehabilitation activities to projected outcomes (‘articulated logic’) and which enhances insights and shared goals across the organizations in all phases of the project. Results: A co-ordination centre to strengthen coordination within the municipal level has been established. Interdisciplinary co-ordination of processes across primary and secondary sectors to ensure differentiated rehabilitation services and gradual transfer has been established. There is agreement on united efforts (joint rehabilitation plans and tests). There is agreement on a collaboration accord (new ways of working together). Conclusions: The articulated logic of the rehabilitation programme has been created and the halfway evaluation shows successful implementation.

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Pros and cons of using Addenbrooke’s Cognitive Examination in the early phase of rehabilitation after acquired brain injury (ABI) Trine Ryttersgaard1,2 1

Aalborg University Hospital, Aalborg, Denmark, 2Brønderslev Neurorehabilitation Center, Brønderslev, Denmark Objectives: Recent health technology assessment in Brain Injury Rehabilitation made by the Danish National Board of Health describes factors that affect a coherent rehabilitation intervention across sectors. One of the barriers described is that patients with ABI are discharged without being properly examined by a neuropsychologist. In everyday practice not all rehabilitation units have access to a neuropsychologist or the resources do not match the number of patients. Gaber investigated whether the Addenbrooke’s Cognitive Examination (ACE) could be used in brain injury rehabilitation, although the test is developed for dementia screening. Gaber concluded that ACE-R can play an important role in screening and evaluation of brain injury patients. Methods: To investigate whether, by using a short screening, one could describe the cognitive disabilities and thereby improve the cross-sectorial co-operation, this study started screening with ACE and Symbol Digit Modalities Test (SDMT) 1–2 weeks after admission. The screening is made by a neuropsychologist who evaluates the test results and together with the multidisciplinary team makes a plan of rehabilitation. The literature has already shown the possibilities using SDMT, why this test is used to supplement ACE and, on that basis, thiss tudy will only focus on ACE. The aim is to repeat the screening 1 year after the first screening. Conclusions: Preliminary experiences with ACE have shown that the ACE-score cannot help to plan the rehabilitation process or improve the cross-sectorial co-operation. However, the neuropsychological evaluation of every part of the test seems valuable and contributes to the rehabilitation process and cross-sectorial co-operation. At the same time ACE have limitations to which cognitive functions it investigates. The oral presentation will focus on case-reports to illustrate the pros and cons of using ACE as neuropsychological screening in the early phase of rehabilitation after ABI. Especially in the case of mild cognitive impairment, aphasia, visuoperceptive disabilities and the importance of habitual cognitive function.


Opening the brain injury blackbox—Functional and social re-integration outcomes data from an acute rehabilitation care clinical pathway in Singapore Geoffrey Samuel, Annie Jane Nalanga, Chek Wai Bok, Cheng Kiang Lee, & Yang Bin Singapore General Hospital, Singapore Introduction: There is a growing amount of data with regards to functional outcomes in brain injury patients. However, there is a


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DOI: 10.3109/02699052.2014.892379

relative dearth of outcomes data with regards to community reintegration and quality-of-life in the post-discharge period. Locale and health system specific differences in availability, quality and accessibility of brain injury rehabilitation services in the community setting equates to difficulty with interpretation of existing data in the international literature. This mandates the need for countries with nascent brain injury rehabilitation services such as Singapore to study and understand such outcomes within their own context. This study presents preliminary data obtained from a brain injury rehabilitation clinical pathway established as collaboration between the departments of Rehabilitation Medicine and Neurosurgery within an acute care hospital in Singapore. Methods: This study identified 150 patients seen in the clinical pathway between November 2010 and October 2011. These patients were admitted through the department of Neurosurgery with diagnosis of traumatic brain injury (TBI) and reviewed by the rehabilitation team within 72 hours. At 18–24 months post-discharge 26 patients consented to an interview, corresponding to a response rate of 23.8% from 109 contactable responders. The World Health Organization Quality-of-Life Survey (WHOQoL-BREF) and the Community Integration Questionnaire (CIQ) were administered. The Care-giver Strain Index questionnaire was administered as applicable. Functional Independence Measure (FIM) scores were recorded. Results: Mean age was 59.1 years with a male-female ratio of 1:1. The majority (84.6%, n ¼ 22) had mild TBI. The mean FIM follow-up score of 117.3 ± 16.6 vs mean admission score 87.5 ± 28.6 suggests that most patients continued to achieve functional independence. The WHOQoL-BREF data show that patients were generally satisfied with their quality-of-life. The CIQ domain scores for home integration and social integration were good. The score for productivity was not high as many of the patients had retired due to age prior to TBI. Eleven of the respondents were employed prior to injury. All except one person returned to work at follow-up. Nine caregivers were interviewed but only one reported experiencing significant stress. Common concerns included having to make work adjustments to accommodate patient care, financial strain and limited access to care services. Access to caregiver education, respite care services and support groups were high on the suggestion list of post-discharge services for caregivers. Conclusion: While the numbers polled were small, the follow-up data is insightful. Overall patients with TBI tended to cope well after discharge and most patients improved in terms of functional ability up to 2 years post-discharge from initial TBI. The caregiver interviews illustrate the current shortfall and demand for community-based services targeting brain injury patients and their caregivers in Singapore.


Resilience predicts quality-of-life at 1 year follow-up after mild traumatic brain injury Heidi Losoi1, Eija Rosti-Otaja¨rvi1, Minna Wa¨ljas1, Senni Turunen1, Mika Helminen2, Antti Brander3, Teemu M. Luoto1, Juhani Julkunen4, & Juha O¨hman1 1

Tampere University Hospital, Department of Neurosciences and Rehabilitation, Tampere, Finland, 2Pirkanmaa Hospital District, Science Center and University of Tampere, School of Health Sciences, Tampere, Finland, 3Tampere University Hospital, Medical Imaging Center, Department of Radiology, Tampere, Finland, 4University of Helsinki, Institute of Behavioural Sciences, Helsinki, Finland Objectives: The aim was to study the association between post-injury resilience and long-term quality-of-life (QoL) after mild traumatic brain injury (MTBI).

Methods: In a prospective 1 year follow-up study, patients (n ¼ 57) between the ages of 18 and 60 years who met the World Health Organization criteria for MTBI were enrolled from an emergency department. Nine exclusion criteria were used to rule out pre-existing medical conditions or other confounding factors possibly influencing outcome. Conventional magnetic resonance imaging (MRI) of the head was performed within 2 weeks after injury. At 1-month postinjury, the patients were assessed for resilience [Resilience Scale (RS)], post-traumatic stress [PTSD-Checklist-Civilian Version (PCL-C)], depressive [Beck Depression Inventory (BDI-II)], fatigue [Barrow Neurological Institute Fatigue Scale (BNI-FS)], insomnia [Insomnia Severity Index (ISI)], pain [Pain Scale of the Ruff Neurobehavioral Inventory (RNBI)] and post-concussion symptoms [Rivermead PostConcussion Symptoms Questionnaire (RPCSQ)]. To predict the QoL [Quality of Life after Brain Injury (QOLIBRI)] at 1 year follow-up with the factors assessed 1-month post-injury, a multiple stepwise linear regression analysis was conducted. The model was adjusted for demographic variables, the severity of physical injuries (Injury Severity Score) and head MRI findings. Results: The mean age of the patients was 37.5 years (SD ¼ 12.4). The study group consisted of 34 men (59.6%) and 23 women (40.4%). The 1-month variables were distributed as follows: (i) RS, M ¼ 139.6, SD ¼ 14.6; (ii) PCL-C, M ¼ 25.1, SD ¼ 8.5; (iii) BDI-II, M ¼ 5.2, SD ¼ 5.7; (iv) BNI-FS, M ¼ 14.5, SD ¼ 14.5; (v) ISI, M ¼ 5.3, SD ¼ 5.2; (vi) RNBI Pain Scale, M ¼ 8.0, SD ¼ 2.0; (vii) RPCSQ, M ¼ 10.1, SD ¼ 9.4. The mean QoL score 1 year after MTBI was 159.1 (SD ¼ 19.4). Age, gender, education, physical injuries or traumatic lesions on MRI did not predict QoL 1 year after MTBI (adjusted R2 ¼ 0.012, significance of R2 change ¼ 0.509). Adding post-traumatic stress, depressive, fatigue, insomnia, pain and post-concussion symptoms simultaneously to the model produced a significant change (p ¼ 0.002) and together these variables were significant predictors of QoL (explaining 25.9% of the variance; p ¼ 0.008). After controlling for the aforementioned variables, resilience contributed significantly (p  0.005) to the regression model. The final step of the regression model explained 51.8% of the variance and predicted significantly the QoL 1 year after MTBI (p  0.005). Conclusions: In a multivariable model, resilience was a significant independent predictor of QoL 1 year after MTBI. Resilience seems to be a relevant factor to consider in the long-term management of MTBI.


What SLP need to know about post-traumatic post-intubation persistent trachea oesophageal fistula leading to gastric pullup—An unusual case report Premalatha Bachalli Subbarao, & Anjum Zahra Naqvi Dr S R Chandrasekhar Institute of Speech and Hearing, Bangalore, Karnataka, India Introduction: Laryngo-pharyngo-oesophagectomy and gastric transposition is very common following malignant lesions of the oesophagus and/or hypopharyngeal cancer. Gastric pull-up surgery for the non-malignant site of tracheo-oesophageal fistula (TOF) is very rare. About 80% of the acquired trachea-oesophageal fistulae are malignant and the remaining 20% non-malignant fistulae occur due to various causes. Causes of TEF include internal trauma due to cuffed endotracheal tube or nasogastric tubes or a combination of both or external trauma may be from penetrating foreign bodies, open or closed aero digestive tract injuries. Treatment options for TEF may be conservative or surgical depending upon the severity.

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616 Objective: An extensive literature review indicated that there is a dearth of studies regarding the management of persistent tracheaoesophageal fistula due to prolonged intubation by surgical method such as laryngo-pharygno-oesophagectomy with gastric pull up. The current study reports a case that has undergone such surgical intervention following prolonged intubation, persistent tracheaoesophageal fistula after road traffic accident. Materials and method: A 43 year old male was referred for voice management following major surgery to the larynx. Medical history revealed that after a road traffic accident in September 2009, he was diagnosed with right front temporal specks of contusions, right parietal SDH with right hemispheric oedema and a fractured left clavicle and underwent Right Fronto-Temporo-Parietal Craniotomy and Duroplasty. Due to prolonged intubation, although a tracheostomy was planned it could not be done as he developed DIC and bilious aspiration. Tracheostomy was done after correcting DIC to relieve respiratory distress. Later, he developed a 7 cm long tracheaoesophageal fistula for which a repair was attempted but was not successful. Respiratory distress, aspiration, dysphagia and pneumonia were the complications noted with the diagnosis as post-traumatic post-intubation persistent trachea-oesophageal fistula with postcraniectomy status. T tube was introduced, but not helpful. In order to relieve from persistent fistula and aspiration, total laryngopharyngo-oesophagectomy with a gastric pull-up was done. Gastric speech and artificial larynx instrument was advised as a rehabilitative method after assessment of language performance in different domains. Results: There was no impairment seen in language performance. An artificial larynx was used by him for verbal communication. Conclusion: As speech languages professionals, the authors often come across cases with communication difficulties after a trauma such as stroke. The present case was unusual because the communication difficulty seen was due to complications of prolonged intubation and the development of a TEF. Speech language pathologist need to be aware of such instances where communication difficulty occurs not as a result of the condition but as sequelae to treatment complications, as seen in the present study.

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provided to a sample of Irish children who have returned to school following TBI. The survey also provides feedback on the general knowledge of teachers from across the Irish educational system in relation to TBI. Those students whose experience is explored are 34 from a cohort of children who attended hospital school during in-patient treatment of TBI between January 2009 and June 2011. As this study investigated both processes and outcomes, the mixed methods design allows for a more comprehensive investigation of this complex subject area. The quantitative elements of the survey provides measurable data on processes and supports during school re-entry, while the qualitative approach provides a richer account of the experiences of the small sample group. Results: This study was based on 125 teacher participants and seven parent participants. Examination of the quantitative and qualitative results revealed that many misconceptions and misperceptions of TBI-related issues exist among these teachers. Themes emerged which relate to successful school re-entry including; consequences of TBI, identity, communication and teacher training needs. While these experiences echoed the broad research themes from international studies, this study provided a uniquely Irish perspective. Conclusion: This research study provides a ‘snapshot’ of Irish teachers’ experience and knowledge of the issues pertinent to supporting children with TBI in their school re-entry. The findings highlight that these teachers have had little or no formal training in TBI at preservice level. The knowledge levels of the teachers within the sample suggest that many of the common misperceptions and misconceptions associated with TBI exist among Irish teachers.


Significant risk of misreading when using intra-parenchymal pressure monitors—Three case reports


Supporting school re-entry for students following traumatic brain injury—An Irish perspective Avril Carey Hibernia College, Dublin, Ireland Background: This research was carried out as part of a Master’s Thesis in 2012. The researcher is an Irish hospital school teacher working in a school based in the acute neurosurgical setting. Objective: The purpose of this study is to present findings of an investigation into current practices in supporting school re-entry for students with TBI in Ireland. Specifically, it sets out to examine: (i) Current school re-entry processes experienced by a cohort of students identified with TBI from both a parent and teacher perspective. This includes an exploration of parents’ perceptions of school re-entry success following discharge from rehabilitation and the experience of their teachers in supporting that re-entry; (ii) The levels of teacher knowledge of the educational ramifications of TBI; (iii) Levels of teacher confidence in delivering appropriate support to students with TBI; and (iv) To identify any significant areas for TBI education and professional development for educators. Methods: This study uses mixed methods survey instruments to examine teacher and parent perception of school re-entry supports

David Cederberg, & Peter Reinstrup Department of Neurosurgery, Lund, Sweden Introduction: Two different methods for measuring ICP are used today. The intraventricular method of continuous ICP measurement and drainage is considered gold standard. The intraparenchymal method of measuring ICP, using an electronic device based on either fibre-optics or electrical impedance has been used since the early 1990s. Recently, a micro-sensor, based on electrical impedance, but with an air duct between the micro-sensor at the tip and the connecting piece to the scope, enabling for continuous calibration with the surrounding atmospheric pressure, has been introduced and used in the department (Neurovent, Raumedic, 95205 Mu¨nchberg, Germany). The system was found easy to use and the common perception was that it was reliable. However, three cases are hereby reported using this monitoring device questioning its reliability. Method: Three patients were fitted with a Raumedic neurovent intraparenchymal pressure monitoring device and an intra-ventricular pressure monitor. Both ICP values were recorded during a total of 240 hours. The accuracy of the intra-ventricular monitors were checked regularly using a column of fluid, to avoid zero drift. All intraparenchymal catheters were bench tested after removal from the patient. Results: In all three cases, ICP measured by the intraparenchymal pressure monitor differed from that of the intraventricular catheter by an average of 11.5–11.8 mm Hg. Bench testing


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showed that the air canal of one catheter may have been blocked by blood. The other two catheters worked properly, without any zero drift. Conclusions: In all three reported cases there was a significant difference in ICP measured by the different catheters. ICP measured by the intra-parenchymal device was critically high (above 25 mm Hg) at suspended periods of time. If this device would have been the only ICP measuring device, the increased ICP readings would lead to immediate ICP lowering manoeuvres. The patients would most likely receive intensified medical treatment and perhaps decompressive surgery. It is concluded that intra-ventricular pressure monitoring systems are the most reliable and should probably be the system of choice. If, however, intra-parenchymal pressure monitoring devices are used, it is probably safer to use a system with a known risk of zero drift, but without the ability to recalibrate during patient use. The Raumedic neurovent catheter has the potential risk of electronic zero drift, but also the risk of a greater drift, probably due to the collapse of the air canal in the catheter by which the device re-calibrates itself continuously. The latter being very difficult to verify during patient use. Bench testing the catheters after removal from the patient will show that compression of the tubing, especially at temperatures close to body temperature, will lead to faulty ICP values. However, this is not normally done when bench testing a catheter for zero drift.


Impact of litigation procedure upon patients and caregivers: Results from the Paris-TBI study

In addition, 15 other victims received mensual indemnities from the French social security in relation with their work accident. Patients in the TBI-LP group were more severe initially (length of post-traumatic amnesia score) and (not surprisingly) more severe 4 years after the accident (GOS-E, DEX, NRS-r, HAD) than patients in the TBI-with-noLP group (with no other significant difference found between both groups for age, socio-cultural level, Glasgow coma score and length of coma variables). A significant difference was found between both groups (TBI-LP vs TBI-with-noLP) in terms of patient sub-HADdepression score and informal caregivers burden (mean ZBI-LP ¼ 26 vs mean ZBI-noLP ¼ 15). In multivariate analyses, both outcome measures sub-HAD-depression and ZBI were significantly and positively associated with more cognitive disorders (NRS-r) and with LP involvement after adjusting for the GOS-E level and length of posttraumatic amnesia variables. Conclusion: In France, the so-called Badinter law (1985) has improved the injury payment process for road traffic accident victims. Nevertheless, legal proceedings remain long, in part due to a necessary sufficient hindsight of several years for assessing stabilized neuropsychological sequelae appropriately. These results might suggest that LP might increase reported depression symptoms in patients and perceived burden in caregivers after adjusting for patient’s global handicap and patients initial severity. If so, this pejorative side-effect of the LP itself should be taken into account first during legal forensic accounting and second in order to deliver appropriate psychological support.


Relationship between cognitive and motor performance in physically well-recovered men with traumatic brain injury

Eleonore Bayen1, Claire Jourdan2, Pascale Pradat-Diehl1, Emmanuelle Darnoux3, Sylvie Azerad4, Jean-Jacques Weiss3, Claire Vallat-Azouvi2, Philippe Aegerter4, Idir Ghout4, Marie-Eve Joel5, & Philippe Azouvi2

Jaana Sarajuuri1, Matti Pasanen2, Marjo Rinne2, Matti Vartiainen2, Tommi Lehto2, & Hannu Alaranta2



Objectives: To assess patient’s and informal caregiver’s 4-year outcomes in cases of a TBI litigation procedure. Methods: This was a multi-centre prospective inception cohort study in the Parisian area (France) including initially 504 patients with severe TBI (Glasgow Coma Scale score  8). Among the 257 survivors (51%) at discharge from acute care, 147 were followed-up 4 years after their accident. Patient’s injury severity and outcome measures (Glasgow Outcome Scale-Extended (GOS-E), DysExecutive Questionnaire (DEX), Neurobehavioural Rating Scale-revised (NRS-r), Hamilton Anxiety and Depression Scale (HAD)); primary caregiver’s burden score (Zarit Burden Inventory) and litigation process were the main processes scored. Results: Among the 147 patients followed 4 years after the TBI, 50 declared being involved in a litigation procedure (LP). Mechanisms of TBI-LP were road traffic accident (n ¼ 46), physical attack (n ¼ 2) and fall during professional activity (n ¼ 2). In the case of RTA (n ¼ 46), victims transportation means were: motorbike (n ¼ 13), pedestrian (n ¼ 10), car (n ¼ 6), passenger (n ¼ 4), bicycle (n ¼ 4) andunknown (n ¼ 9). In 89% of the cases (33/37), the victim had experienced a collision with a vehicle from a superior size category (e.g. motorbike against a car). Among these TBI litigations, 24 (50%) were work accidents (two during their professional activity, 22 during their professional commute). Mean financial compensation (capital) amounted to 203 761 euros (min ¼ 0, max ¼ 500 000) for 29 patients.

Objective: To explore the relationship between cognitive and motor performance in physically well-recovered men with traumatic brain injury. Methods: Cross-sectional explorative study in a national neurorehabilitation centre. Subjects were men with post-acute traumatic brain injury (n ¼ 34; aged 19–55 years) who had recovered well physically. Cognitive performance (attention, information processing, cognitive flexibility, motor regulation, praxis of the upper limbs) and motor performance (postural balance, agility, rhythm-co-ordination) were assessed. Partial rank correlation coefficients and analyses of covariance were used to assess the associations between these tests. Results: Associations were found between the time taken in both Trail Making tests and performance time in the agility test (r ¼ 0.57). The score on the Digit Symbol test correlated with time in the agility test (r ¼ 0.52). Patients with normal performance in verbal fluency performed the tests of dynamic balance and agility 26% more quickly than those with abnormal performance. Moreover, patients with normal performance in the reproduction of rhythmic structures were 20% faster in the dynamic balance test. Motor functions of the hands associated with all the motor-performance test results. Conclusion: Measures of information processing, attention and executive functioning may be associated with motor performance. Apart from the theoretical relevance, the finding of an association between cognitive and motor performance may have clinical relevance with regard to rehabilitation.

Hoˆpital Pitie´-Salpeˆtrie`re, Paris, France, 2Hoˆpital RPoincare´, Garches, France, 3CRFTC, Paris, France, 4URC APare´, Boulogne, France, 5 Universite´ Paris-Dauphine, Paris, France

Ka¨pyla¨ Rehabilitation Centre, Helsinki, Finland, 2UKK Institute for Health Promotion Research, Tampere, Finland



Effect of concomitant administration of progesterone and erythropoietin on neurological outcomes after traumatic brain injury Zahra Nourzad1, Tahere Ghadiri2, Fariba Karimzade2, Hadi Aligholi2, Arezou Eshaghabadi1, Mostafa Modarres Mousavi1, Homayoun Khazali3, & Ali Gorji4

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Shefa Neuroscience Research Center, Tehran, Iran, 2School of Advanced Technologies in Medicine, Tehran University of Medical Sciences, Tehran, Iran, 3College of Biological Science, GC, Shahid Beheshti University, Tehran, Iran, 4Epilepsy Research Center, Westfa¨lische Wilhelms-Universita¨t Mu¨nster, Mu¨nster, Germany Objectives: Traumatic brain injury (TBI) is one of the most common neurological diseases with no definite treatment. Erythropoietin (Epo) and progesterone (Prog) have been shown to have neuroprotective effects in different types of experimental brain injury models. This study was designed to determine the effect of Epo, Prog and combination of Epo/Prog on neurological outcome after traumatic brain injury. Methods: Fifty-four male Wistar rats were divided into five groups including; intact (n ¼ 6), TBI (n ¼ 12), TBI + 16 mg kg1 Prog (n ¼ 12), TBI + 5000 U kg1 Epo (n ¼ 12), TBI + 16 mg kg1 Pro + 5000 U kg1 Epo (n ¼ 12). Neurological evaluation was performed using modified Neurological Severity Score on days 1, 2, 7 and 14 post-TBI. Results: The results revealed that Prog and Epo individually ameliorated neurological deficit following TBI while the combination of Prog and Epo exacerbated the neurological dysfunction. Conclusions: In conclusion, this study indicates that the combination of Prog and Epo does not improve neurologic outcome after TBI.


Psychological health following goal management training in adults with spina bifida Jan Stubberud1, Donna Langenbahn2, Brian Levine3, Johan Stanghelle1, & Anne-Kristine Schanke1 1

Sunnaas Rehabilitation Hospital, Nesoddtangen, Akershus, Norway, Rusk Institute of Rehabilitation Medicine, New York University School of Medicine, New York, NY, USA, 3Rotman Research Institute, Baycrest Centre, Toronto, ON, Canada


Objectives: Executive function (EF) impairments are common following spina bifida (SB) and exert a detrimental effect on psychological health. Goal Management Trainingä (GMT) is a cognitive rehabilitation intervention that targets disorganized behaviour resulting from executive dysfunction and has received empirical support in studies of other patient groups. The purpose of this study was to determine the impact of GMT on aspects of perceived psychological health in individuals with SB. Post-intervention changes in scores are hypothesized to reflect perceived improved psychological health. Methods: Thirty-eight subjects with SB (58% female, aged 32 ± 8 years) were included in this randomized controlled trial. Inclusion was based

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upon the presence of EF complaints. Experimental subjects (n ¼ 24) received 21 hours of GMT, with efficacy of GMT being compared to results of subjects in a wait-list (WL) condition (n ¼ 14). Assessment of behavioural changes related to psychological health at pre- and postintervention and at 6 months follow-up included two self-rating measures; Hopkins Symptom Checklist 25 (HSCL-25) and Dysexecutive Questionnaire (DEX). Data were analysed using a 2  3 mixed-design ANOVA that treated Group (GMT, WL) as a betweensubjects factor and Time (baseline, post-intervention, follow-up) as a within-subjects variable. T-tests were used to explore change scores (baseline to post-intervention and baseline to follow-up) between the two groups. Significance level was set to p  0.05. Results: Preliminary data showed significant GMT-related treatment effects on HSCL-25 and DEX. There was a significant Group  Time interaction for total score (HSCL-25), (F(2, 34) ¼ 5.29, p ¼ 0.010), due to a reduction in the presence and intensity of total anxiety and depression symptoms across time for the GMT group, F(2, 34) ¼ 9.76, p50.001, but not the WL group. Of note, within the GMT group there were statistically significant improvements on both HCSL-25 subscales (i.e. Anxiety and Depression) following training, where the GMT group’s change from baseline to post-intervention (p50.001) held at follow-up (p50.001). Also, results of t-tests showed that the GMT group reported significantly less problems with positive and negative affects (DEX) at post-training, t(23) ¼ 2.52, p ¼ 0.019, and follow-up, t(23) ¼ 3.31, p ¼ 0.003, compared to baseline. Similar findings were not observed in the WL group. Conclusions: Preliminary findings indicated superior effects of GMT on measures of psychological health. Overall, these findings indicate that, by employing a structured group-based compensatory intervention to manage executive problems, effective and lasting benefits can be achieved with regard to several aspects of perceived psychological health. The results of this current study may have implications for psychological treatment not only in individuals with SB, but in patients with other neurodevelopmental disorders as well.


Post-hospital brain injury rehabilitation: Comparison of neurobehavioural intensity and neurorehabilitation outcomes Frank Lewis, & Gordon Horn NeuroRestorative, Boston, MA, USA Objectives: This study investigated outcome differences in two posthospital rehabilitation programme types (Neurorehabilitation [NR] and Neurobehavioural [NB]). Criteria were established for group affiliation using the Mayo Portland Adaptability Inventory (MPAI-4) which assesses the level of functional disability reduction in posthospital rehabilitation. The study objectives were: (1) determine differences between groups using the MPAI-4; (2) determine effectiveness of programming to reduce symptoms of behavioural dyscontrol among NB individuals; and (3) identify outcome predictors of independent functioning for each group. Methods: A total sample of 289 brain injured adults met inclusion criteria. NB participants (n ¼ 70) were identified by (1) obtaining moderate or severe ratings on MPAI-4 variables (Irritability-AngerAggression, Novel Problem-Solving, Inappropriate Social Interaction and Impaired Self-Awareness); and (2) onset to admission greater than 8 months duration. Most (n ¼ 219) met criteria for the NR group including (1) MPAI-4 Irritability score no greater than mild and (2) onset-to-admission58 months duration. The average onset of injury to admission length was 99.6 months (8.3 years) for NB and 3.1 months for NR. Diagnoses for both groups were predominately TBI (NB ¼ 83% and NR ¼ 60%). The MPAI-4 was completed within 30 days


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of admission and at discharge for comparison. Scores were converted to T-scores for direct comparisons. Results: Repeated Measures Multivariate Analysis of Variance revealed a significant group main effect [F(1,286) ¼ 97.29, p ¼ 0.0001]. The NR group demonstrated lower scores than the NB group on the Ability, Adjustment and Participation Indices. This analysis also revealed significant within-subjects effects [F(2,286) ¼ 98.66, p ¼ 0.0001]. A follow-up Wilcoxon Z-test for the NB group demonstrated statistical differences from admission to discharge for each of the four variables defining behavioural dyscontrol (p50.0001). Lastly, a stepwise multiple regression analysis using the MPAI-4 variables for each group revealed that Initiation and Novel Problem-Solving significantly predicted Participation T-scores for the NB group [F(1,69) ¼ 20.42, p50.0001; Adjusted R2 ¼ 0.33]. Initiation, Length of Onset to Admission, Fund of Information and Memory significantly predicted Participation T-scores for the NR group [F(4,213) ¼ 22.86, p50.0001; Adjusted R2 ¼ 0.29]. Conclusions: Participation in the comprehensive post-hospital rehabilitation programmes led to significant reduction in disability for both groups. Significant disability reduction was demonstrated within the NB group, which is remarkable since this group is chronically impaired, averaging 8.3 years post-injury at the time of study inclusion, with behavioural dyscontrol. The improvements noted in the NB group were not attributed to time or natural healing. Prior research demonstrated that time significantly impacts recovery during the initial 3–6 months of care only. Finally, the MPAI-4 provided different predictor variables for each group. The Initiation variable demonstrated the strongest predictor of independent functioning for both groups.


Quality-of-life after traumatic brain injury: Finnish experience of the QOLIBRI in residential rehabilitation Sini-Tuuli Siponkoski1, Lindsay Wilson2, Nicole von Steinbuechel3, Jaana Sarajuuri1, & Sanna Koskinen1 1

Ka¨pyla¨ Rehabilitation Centre, Helsinki, Finland, 2University of Stirling, Stirling, UK, 3Department of Medical Psychology and Medical Sociology, Georg-August-University, Goettingen, Germany

Objective: To evaluate health-related quality-of-life of traumatic brain injury patients who have received intensive multidisciplinary residential rehabilitation. To examine the psychometric characteristics of the Finnish Quality-of-Life after Brain Injury (QOLIBRI) questionnaire. Methods: Subjects were 157 adults with TBI, up to 15 years post-injury, who had been treated in the Ka¨pyla¨ Rehabilitation Centre, Helsinki, Finland. Functional status was assessed using the Extended Glasgow Outcome Scale. Emotional state was evaluated using the Hospital Anxiety and Depression Scale. Health-related quality-of-life was measured using a generic measure (Short Form-36) and the QOLIBRI. Results: Quality-of-life was related to depression, amount of help needed, anxiety, education level and age at injury. Quality-of-life was not associated with time since injury, but a paradoxical relationship was found with injury severity. Internal consistency (alpha ¼ 0.79– 0.95) and test–re-test reliability (rtt ¼ 0.75–0.87) of the Finnish QOLIBRI met standard psychometric criteria. Conclusion: Quality-of-life remained relatively stable in the longterm. Milder injuries were associated with lower life satisfaction and careful follow-up is recommended to target patients in special need. This study confirms the reliability and validity of the Finnish QOLIBRI.


PET imaging in traumatic brain injury: Novel tracers for understanding the response to and recovery from TBI William Trigg, Paul Jones, Alexander Jackson, Ella Hirani, Mark Battle, & Vladimir Reiser GE Healthcare Ltd, Amersham, UK Traumatic brain injury is an extremely heterogeneous condition with a broad range of injury types ranging from mild single events, through repetitive events and severe trauma. The brain’s response to the injury and the outcome for patients is also heterogeneous and new tools are required to understand how the brain is responding to enhance scientific understanding of the processes involved and eventually guide intervention to improve patient outcome. GE Healthcare is committed to develop tools and technologies which will aid in the diagnosis, prognosis and monitoring of patients with TBI. The authors are currently developing a series on novel [18F]labelled PET tracers which will have potential utility in TBI, each of which is targeted to a specific protein or receptor which is involved or believed to be involved in the pathological processes which occur post-injury. GE-180 is a novel TSPO targeted tracer for imaging neuroinflammation by targeting activated microglial cells (and infiltrating immune cells). Microglial cells are the brain’s resident immune cells which respond to injury and insult to the brain and understanding the progression of inflammation could be a key prognostic indicator. GE-179 is a tracer targeted at activated NMDA receptors which could aid understanding of glutamate-based neurotoxicity as well as understanding brain re-modelling and plasticity post-injury. Abnormal activation of NMDA receptors may be an indication of the generation of an epileptic focus which is a common outcome for TBI patients. GE-194 is tracer targeting GABAA receptors which can be used to understand the extent of inhibitory neuronal loss in the brain post-injury. GE-194 imaging could be used to identify areas of the brain where damage has occurred and again indicate areas of epileptogenic potential. As TBI and the brain’s response to TBI is complex and not well understood, it is expected that a combination of these tracers with other biomarkers and imaging modalities will be required to enable further understanding of the pathology of TBI. One or more of the tracers may also become part of the clinical work-up of TBI patients. This paper will describe the radiotracers and the radiosynthesis platform used and present some initial data from pre-clinical studies using the tracers.


Evaluation of the implementation of an early vocational rehabilitation intervention for people with acquired brain injury Judith van Velzen2, Coen van Bennekom2, Max van Dormolen2, Judith Sluiter1, & Monique Frings-Dresen1 1

Academic Medical Center, University of Amsterdam, Department: Coronel Institute of Occupational Health, Amsterdam, The Netherlands, 2Department of Research and Development and

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Institute of Vocational Assessment and Education, Heliomare Rehabilitation Centre, Wijk aan Zee, The Netherlands

Mu¨nster, Germany, 3Epilepsy Research Center, Westfa¨lische Wilhelms-Universita¨t Mu¨nster, Mu¨nster, Germany

Objectives: The Early Vocational Rehabilitation (EVR) protocol is a process guideline to facilitate the interdisciplinary rehabilitation team to systematically focus on return-to-work during an early stage of (inpatient or outpatient) rehabilitation of people with acquired brain injury (ABI). Before being able to evaluate the effects of EVR, the usability in practice of the protocol has to be tested. Therefore, the aim of the study was to evaluate the usability of the EVR intervention in the standard rehabilitation process. Methods: The evaluation was performed in an ABI unit of a rehabilitation centre in the Netherlands. Caregivers of this unit, patients who were included for treatment according EVR between 1 June 2009 and 1 June 2010 and the patients’ employers and occupational physicians were asked to participate. The usability of the protocol was studied (1) on a process level by meeting goals that were defined for each of the 13 steps by the ABI rehabilitation department management team, (2) through the fulfilment of expectations of the caregivers and (3) through the fulfilment of the expectation of the patients, employers and occupational physicians. On a process level, the percentage of patients receiving the initiatives described in the steps, and the percentage of patients for whom the actions were performed at the appropriate time were computed from existing forms and registrations. To investigate the extent to which the goals were met, these percentages were compared to the minimum percentage of patients for whom a given step should be executed. The expectations and the frequency at which the expectations were fulfilled were investigated with self-designed questionnaires. Results: Informed consent was signed by 23 patients, resulting in data of 23 patients available for process evaluation. However, not all actors returned the questionnaires: data about expectations were available for nine caregivers, 10 patients, nine employers and six occupational physicians. On a process level, two-thirds of the steps were performed as planned while the planned protocol timing was followed in one-fourth of the steps. This was according to the expectations of the caregivers. All caregivers noted that the EVR protocol provides structure for the role of vocational rehabilitation within standard rehabilitation. Seven patients, five employers and one occupational physician reported that their expectations about the outcome of EVR for the patient were fulfilled. One patient, two employers and two occupational physicians reported that their expectations were not fulfilled. Two patients reported that their expectations were not yet totally fulfilled. Two employers and three occupational physicians expressed no expectations concerning EVR. Conclusions: The EVR protocol is a usable protocol to focus on return-to-work during rehabilitation of people with ABI. It was implemented successfully and is suitable, with minor adaptations, for implementation in other rehabilitation settings.

Objectives: Post-traumatic epileptic seizure is one of the common neurological disorders after military injuries. This study evaluated clinical characteristics of post-traumatic epilepsy in 163 patients injured during the Iraq–Iran war. Methods: The medical records of patients who were admitted by the Epilepsy Department of the Shefa Neuroscience Center between 2005–2009 were retrospectively reviewed. The mean follow-up period after developing epilepsy was 17.2 years. Results: The time interval between the trauma and the first seizure was shorter and the seizure frequency was higher in epileptic patients suffering from penetrating head trauma while there was no difference in seizure type between patients injured by blunt or penetrating trauma. Patients with seizure frequency of more than 30 per month mostly had simple partial seizure. Frontal and parietal semiologies were observed more frequently in patients with penetrating trauma, whereas patients with blunt trauma showed a higher temporal semiology. The most common brain lesion observed by CT scan was encephalomalacia followed by porencephaly and focal atrophy. There was no association between intracerebral retained fragments and different characteristic features of epilepsy. Conclusions: There is a high risk of intractable post-traumatic epilepsy in patients suffering from military brain injury. Consequently, these patients require a long-term medical follow-up.


Intractable epilepsy and craniocerebral trauma: Analysis of 163 patients with blunt and penetrating head injuries sustained in war Hadi Kazemi1, Sayed Mostafa Modarres Mousavi1, Peir Hossein Kolivand1, Stjepana Kovac2, & Ali Gorji3 1

Shefa Neuroscience Research Center, Tehran, Iran, 2Klinik und Poliklinik fu¨r Neurologie, Universita¨tsklinikum Mu¨nster,


Consecutive application of continuous theta burst stimulation combined with intensive occupational therapy for upper limb hemiparesis after stroke: A preliminary study Naoki Yamada1, Wataru Kakuda1, Takahiro Kondo2, Masato Shimizu2, Sugao Mitani2, & Masahiro Abo1 1

Department of Rehabilitation Medicine, Jikei University School of Medicine, Minato-Ku, Tokyo, Japan, 2Shimizu Hospital, Kurayoshi-City, Tottori, Japan Objectives: Theta burst stimulation (TBS) is a novel modality of transcranial magnetic stimulation (TMS) for neuromodulation. It has been reported that continuous TBS produces more potent and longer suppressive effect on local neural activity, compared to conventional low-frequency rTMS. For recent several years, this department has therapeutically applied low-frequency rTMS over the non-lesional hemisphere with intensive occupational therapy (OT) for post-stroke patients with upper limb hemioparesis. The results of the pilot study suggested that low-frequency rTMS plus intensive OT can significantly improve motor function of the affected upper limb after stroke. However, so far, no researcher has therapeutically applied cTBS with intensive OT for such a patient population. It is expected that the application of continuous TBS, instead of low-frequency rTMS, can facilitate motor functional recovery of the affected upper limb. Therefore, a new protocol was developed featuring cTBS and intensive OT for post-stroke patients with upper limb hemiparesis. The purpose of this preliminary study is to provide an initial evaluation of safety, feasibility and efficacy of this therapeutic approach. Methods: Ten post-stroke patients with upper limb hemiparesis (age at intervention: 62.0 ± 11.1 years, time after stroke onset: 95.7 ± 70.2


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months) were studied. The patients consisted of two patients with intra-cerebral haemorrhage and eight with cerebral infarction. During 15-days of hospitalization, each patient consecutively received 13 sessions of cTBS applied to the non-lesional primary motor cortex combined with intensive OT. The stimulating pattern of cTBS is comprised of bursts of three pulses at 50 Hz, which were repeated at 200 ms intervals (i.e. at 5 Hz). In one session of cTBS, 800 bursts of the pulses were delivered, lasting 160 seconds. The intensity of stimulation was set at 80% of resting motor threshold of FDI muscle of the unaffected upper limb. Intensive OT consisted of 120minutes of one-to-one training and 120-minutes of self-training. The motor function of the affected upper limb was evaluated by FuglMeyer Assessment (FMA) and Wolf Motor Function Test (WMFT) on the days of admission and discharge. For WMFT performance time, the natural logarithm of the mean performance time of 15 timed tasks was calculated. Results: All patients completed the 15-day protocol without any adverse effects. No neurological deterioration was found in any patient. The treatment significantly increased the FMA score from 46.6 ± 8.7 to 51.6 ± 8.2 points (p50.01). In addition, the natural logarithm of WMFT performance time WMFT significantly decreased from 2.5 ± 1.1 to 2.2 ± 1.2 seconds (p50.01). Conclusions: The proposed protocol featuring cTBS and intensive OT is safe and feasible for post-stroke patients with upper limb hemiparesis. The protocol seems to have a potential to improve motor function of the paretic upper limb after stroke, although the efficacy of the protocol should be confirmed in a larger number of patients.


Outcomes of brain injury family intervention training for professionals Caron Gan1, & Jeffrey Kreutzer2 1

Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada, 2Virginia Commonwealth University, Richmond, VA, USA Objectives: (1) Provide an overview of two empiricallybased interventions for families after adult and paediatric brain injury; (2) Present an overview of a research-informed brain injury family intervention training programme for professionals; and (3) Identify key components of professional training and its evaluation. Background: Developed by researchers at Virginia Commonwealth University, the Brain Injury Family Intervention (BIFI) is an empiricallybased whole-family intervention designed to promote effective family coping after acquired brain injury (ABI). The adolescent version, BIFI-A (developed by researchers at Holland Bloorview Kids Rehabilitation Hospital), targets adolescents (13–19 years) with ABI and their families. Founded on cognitive behavioural, strengthbased and family systems theories, BIFI and BIFI-A are manualized and incorporate a broad curriculum, comprised of multiple components: education about brain injury, emotional support and skill building. Methods: As part of its knowledge translation activities, key members of the BIFI and BIFI-A research team developed a 2-day Brain Injury Family Intervention Training programme. Goals of the training programme were to help professionals learn skills in family assessment, family engagement and research-informed clinical practice. Through a combination of discussion, video-tapes, role plays and vignettes, participants were taught implementation of the BIFI or BIFI-A protocol. Participants completed self-evaluations preand post-training related to the following: (1) Knowledge around impact of ABI on families; (2) Familiarity with theoretical models of post-ABI family intervention; (3) Self-confidence in assessment and

intervention skills; (4) Possession of tools to work effectively with families after ABI; and (5) Confidence in skills required to address complex family situations. Five training sessions were held between 2009–2011 and data was collected from 219 professionals who completed the 2-day training. Results: Descriptive statistics were used to summarize responses and t-tests were used for comparison of pre–post mean scores across five areas: knowledge, familiarity, confidence, tools and skills. Results showed statistically significant improvements in participants’ subjective ratings across all five areas. Qualitative findings from participants underscore the practical utility and quality of the training programme. Conclusions: There are few empirically-based family intervention programmes that target the entire family system after brain injury. More importantly, there are fewer formal evaluations of knowledge translation activities and training effectiveness with these programmes. This training programme is unique in that it bridges the research to practice gap to foster research-informed practice. Over 200 professionals from Sweden, Brazil, the US and Canada learned about implementation of BIFI or BIFI-A and ways of enhancing their family intervention skills. Evaluation of the 2-day training showed statistically significant improvements in participants’ subjective ratings of knowledge, confidence and skills in working effectively with families after brain injury. These workshops exemplify the integration of research, education and knowledge translation activities to enhance clinical care for clients with ABI and their families.


Barriers to recovery after concussion Teena Shetty1, Kelianne Cummings2, Christine Villegas3, Erin Manning1, Niesha Voigt4, Maxwell Singer5, & Joseph Nguyen1 1

Hospital for Special Surgery, New York, NY, USA, 2New York University, New York, NY, USA, 3NJ Medical School, Newark, NJ, USA, 4 Brown University, Providence, RI, USA, 5Princeton University, Princeton, NJ, USA Objectives: To determine factors which influence recovery from a concussion and to investigate the correlation between duration and quality of prescribed rest and recovery time. Concussion is a complex pathophysiologic process induced by traumatic biomechanical forces which then cause a disturbance of brain function. The prescribed treatment for a concussion is physical and cognitive rest. Both physicians and patients struggle with defining the prescription of ‘rest’ and also understanding the consequences of compliance with this prescription. Few other studies have been done to determine the optimal amount and type of prescribed rest necessary to influence recovery. There is little current published evidence evaluating the effect of rest following a sports-related concussion. One study attempted to determine whether recommending cognitive rest to sport-related concussion patients had any effect on the duration recovery and was unable to identify any independent associations between the recommendations of cognitive rest and duration of concussive symptoms. Methods: Any patient between the ages of 10–50 years that came in for a concussion was asked to complete a questionnaire regarding their activity during their recovery period. A total of 170 patients were asked to participate between November 2011 and September 2013 and 34 had completed it by this time. Results: Football (29%) was the most common sport played, followed by baseball (13%) and soccer (13%). On average, females had a longer recovery time compared to males (125 vs 86 days, respectively) and all females had recovery periods of 14 days or longer. Mechanism of injury was also associated with longer


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recovery period. Those who hit their head on stationary or moving objects were more likely to have recovery periods 14 days or longer compared to those collision injuries (p ¼ 0.015 and 0.004, respectively). While many activities were associated with longer average recovery times, only reading (p ¼ 0.024) and listening to audio books, talk radio or podcasts (p ¼ 0.003) were statistically significant. Patients who had previous concussions had a recovery length nearly 4-times longer than first time concussion patients (p ¼ 0.011). Conclusions: Gender, mechanism of injury, pastimes during recovery and concussion history all have a significant impact on concussion recovery time. Females have a more difficult time recovering than males and suffer symptoms for greater lengths of time. The mechanism of injury influences the duration of symptoms following the event, possibly related to the degree of rotational acceleration the brain is subject to. Simple activities, such as reading or listening to music, may in fact impede recovery. Patients who have had a previous concussion face greater challenges recovering than those who experienced their first concussion, suggesting that cumulative injury from concussions is of concern.


Experimental study of new nano-condui repairing nerve defect in rat Wenlong Ding, Hao Zhu, Wenjin Wang, Ting Gui, & Yueming Wang Department of Anatomy, Shanghai Jiao Tong University School of Medicine, Shanghai, PR China The use of nerve autografts is the clinical ‘gold standard’ for repair of a peripheral nerve defect. However, the application of the nerve autograft is limited by availability of donor sites, additional surgery, size mismatch and donor site morbidity. Therefore, the use of conduits in bridging nerve defects has become one of the most promising alternatives. These tubular constructs are made out of absorbable, non-absorbable, synthetic and natural materials. Biodegradable conduits, including poly-lactic-co-glycolic acid (PLGA), prevent compression of the regenerating nerve through continuous absorption. Electrospinning is a well-established method for fabricating fibres with diameters ranging from nanometres to microns. A previous study showed that PLGA with chemical modification might be a promising candidate material for nerve tissue engineering applications. This study made fully synthetic, bioactive and degradable extracellular matrix-mimetic conduits by electrospinning, using PLGA with chemical modification as the matrix polymer and investigated its suitability in 1 cm Sprague-Dawley (SD) rat sciatic nerve defect for nerve gap bridging. The thermal nociceptive responses in hind paw, axon regeneration and Schwann cell migrating in proximal and distal conduits, end plate and sensory nerve ending formation were examined in this study. The results indicated that axons could regenerate from the proximal stump to the distal end through the conduit, considerable Schwann cells migrated from severed nerve stumps and formed longitudinally aligned strands (bands of Bu00 ngner) that guide axonal regeneration, the reformations of end plate and sensory nerve ending were detected and pain thresholds were partly recovered. The conduits using PLGA with chemical modification as the matrix polymer by electrospinning are suitable for bridging periphery nerve defects.

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Screening for traumatic brain injury and cognitive impairments amongst homeless and at-risk youth Jane Topolovec-Vranic1, Isabelle Dobronyi1, Jade Ryan2, Katie Uram2, Naomi Ennis1, Michael D. Cusimano1, & Angela Colantonio2,3 1

St. Michael’s Hospital, Toronto, Ontario, Canada, 2University of Toronto, Toronto, Ontario, Canada, 3Toronto Rehabilitation InstituteUniversity Health Network, Toronto, Ontario, Canada Objective: Recent research suggests that the rates of traumatic brain injury (TBI) are elevated amongst individuals who are homeless as compared to community-based samples. Cognitive impairments from a TBI coupled with homelessness can be detrimental to the functional and health-related status of the individual. Youth are currently the fastest growing age group amongst the homeless population, yet there is limited research exploring the prevalence of TBI or cognitive impairment in this group. Methods: A cross-sectional observational study was conducted of a sample of youth attending an urban drop-in centre. History of TBI was assessed with the Brain Injury Screening Questionnaire (BISQ). Cognitive function was assessed with the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). Results: Sixty youth (68.3% male) aged 18–24 years (mean [SD] age ¼ 21.6 [1.8] years) participated in the study. Only 3.3% (n ¼ 2) of the participants had a negative screen for TBI as per the BISQ assessment: 26.7% (n ¼ 16), 55.0% (n ¼ 33) and 15.0% (n ¼ 9) had low, moderate and high probability BISQ screens, respectively. Of those with a positive TBI screen (n ¼ 58), the severity of the worse TBI reported was mild for 39.7% (n ¼ 23), moderate for 43.1% (n ¼ 25), severe for 8.6% (n ¼ 5) and negative/unknown for 8.6% (n ¼ 5) of the cases. There were no significant differences between those with negative/low probability vs moderate/high probability TBI screens on any demographic variables, duration of homelessness, presence of mental illness, learning disabilities or attention deficit hyperactivity disorder or use of illicit substances. The median percentile score on the RBANS was generally low across the sample (median ¼ 4.0; range ¼ 0.1–58.0). There were significant differences between the low, moderate and high probability TBI screen groups for: RBANS Overall percentile rank (H(2) ¼ 6.896, p ¼ 0.032), with a mean rank of 36.81 for low, 26.48 for moderate and 19.94 for high probability groups; and RBANS Attention domain (H(2) ¼ 6.621, p ¼ 0.037), with a mean rank of 37.06 for low, 25.91 for moderate and 21.75 for high probability groups. Conclusions: In a sample of homeless and at-risk youth, nearly all respondents screened positive for a history of TBI as per the BISQ and a history of TBI was associated with poorer overall cognitive functioning and the attention sub-domain of the RBANS. These findings highlight the importance of assessing for a past TBI as well as an opportunity for cognitive rehabilitation as a potential intervention for this vulnerable population. Additional research is needed to examine the temporal relationship between TBIs, cognitive impairment and homelessness and to evaluate potential interventions upon functional and health-related outcomes of homeless and at-risk youth.


DOI: 10.3109/02699052.2014.892379


Autologous half–half in situ nerve graft repairing peripheral nerve defect Wenjin Wang, Hao Zhu, Yueming Wang, Ting Gui, & Wenlong Ding

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Department of Anatomy, Shanghai Jiao Tong University, School of Medicine, Shanghai, PR China Peripheral nerve repair across large gaps represents a common but challenging clinical problem. Clinically, current repairing strategies prefer either autologous grafting or with commercialized nerve conduit. Yet autologous graft inevitably results in second injury in the donor skin due to deteriorated nutrient supply. Also, an empty or bioengineered nerve conduit is not able to provide sufficient neural trophic support, especially in the middle of the conduit. Thus, a half– half in situ autologous nerve transplantation model is proposed, in which the autologous distal nerves were harvested from the distal nerve and divided into two halves longitudinally and rearranged in an end-to-end manner to bridge the old and new defect. The autologous half–half in situ model was compared with the mere autologous graft model, empty nerve conduit model and autologous half–half in situ graft plus conduit model to repair a 5 mm nerve defect. Cell account in the transverse section in the middle of the graft (2.5 mm to the proximal suture) was most abundant in the autologous nerve by 4 weeks and was constricted by dense in the autologous half–half in situ graft plus conduit model, which has a cell count comparable to that of the empty conduit by less than the half–half in situ autologous graft model, suggesting a relatively less accommodating microenvironment in the conduit. Nerve regeneration 12 weeks after the repair in the half–half in situ autologous model was found to be comparable to that of the empty conduit or conduit with half–half autologous nerve with regard to the nerve thickness, g ratio and axon counts. Mere autologous nerve graft model, as the gold standard, was optimal among all the groups. In conclusion, the half–half in situ autologous graft performed just as well as the conduit model in repairing of a 5 mm defect. Also, surprisingly, the conduit with half– half autologous graft model was no better than the empty conduit model. Thus, this study suggests that in the case of nerve defect a half–half in situ autologous graft could be an alternative strategy of repair other than conduit or sacrifice of any other donor nerves.


Predictors of community rehabilitation outcome using the BICRO-39 scale—A service evaluation for rehab without walls Lisa Marie Gruenwald1, Neil Brooks2, Melanie Bristow2, & Andrew Cooper1 1


Goldsmiths, University of London, London, UK, Rehab Without Walls, Milton Keynes, UK Aims: The aim of this study was to assess community rehabilitation outcome after brain injury, as part of a Service Evaluation for Rehab Without Walls, a community-based rehabilitation provider. Possible predictors of outcome of community rehabilitation were assessed.

Method: Forty-five clients receiving case management at Rehab Without Walls were studied at 6 and 12 month follow-up. Injury severity was categorized using the Mayo Classification, on which 85% were classified as suffering from moderate–severe TBI, largely due to road traffic accidents. Functioning in the community was assessed using the BICRO (Brain Injury Community Rehabilitation Outcome Measure)-39 Scale at 6 and 12 month follow-up, as well as the Risk Factor Checklist. The Risk Factor Checklist was developed by Rehab Without Walls and identifies potential risk factors for community living such as substance abuse, mental health symptomatology, drug or alcohol abuse and self-neglect. Differences in rehabilitation outcome were assessed. Results: Results showed small improvements in client’s overall performance between 6 and 12 month follow-ups. Given the clinical heterogeneity of the client group, small differences were not unexpected. However, closer analysis revealed significant variability in BICRO scores, which demanded closer analysis. Clients with more severe BICRO scores at the beginning of treatment showed the greatest improvements. On the other hand, clients scoring low (better performance) on the BICRO at 6 months follow-up showed a small decrease in performance at 12 months follow-up. This appeared to be unrelated to initial injury severity. In addition, the Risk Factor Checklist scores were significantly related to BICRO scores and the strength of the association between risk and BICRO increased from 6 to 12 months, suggesting an increasing role of risk factors in predicting community outcome, as time progressed. Recommendations: Research is needed to explore the relationship between the Risk Factor Checklist and the items it includes and rehabilitation outcome, as measured by the BICRO. It illustrates how pre-morbid factors influence outcome not only directly, but also indirectly by affecting outcome on the BICRO-39 scale. Furthermore, the difference in client profiles requires attention. The data suggests that rehabilitation may be qualitatively different for individuals already showing a high level of independence at the start of the treatment process, than individuals who are low on independence, as measured by the BICRO. Future research is needed to explore this relationship, potentially by including other measures, which may capture the difference in outcome.


Traumatic brain injury in UK armed forces serving in Iraq and Afghanistan: Injury characteristics and severity measures predictive of survival Carol Hawley1, Robert Russell2, H. Thomas de Burgh3, & Andrew Mead4 1

Warwick Medical School, Coventry, West Midlands, UK, 2Academic Department of Military Emergency Medicine & Royal Centre for Defence Medicine, Birmingham, West Midlands, UK, 3Army Medical Directorate & Ministry of Defence Hospital Unit, Peterborough, UK, 4 School of Life Sciences, University of Warwick, Coventry, West Midlands, UK Objectives: The UK Joint Theatre Trauma Registry (UK-JTTR) is a UK Ministry of Defence resource maintained continuously since 2003 by the Academic Department of Military Emergency Medicine (ADMEM) at the Royal Centre for Defence Medicine (RCDM). UK-JTTR records comprehensive data for all military personnel on active duty who are either killed or injured and subject to a trauma call. Several studies have shown that a significant proportion of US military personnel returning from Afghanistan and Iraq with combat injuries also have traumatic brain injury (TBI). However, the numbers of UK service personnel sustaining TBI are currently unknown. The aims of

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624 this study were to use UK-JTTR to (1) identify service personnel sustaining TBI in Afghanistan and Iraq, (2) examine injury characteristics and outcomes and (3) identify severity measures predictive of survival. Methods: UK-JTTR was retrospectively analysed to identify those who sustained TBI. The Mayo system was used to define TBI as either mild (probable) TBI or moderate/severe (definite) TBI. The six injury severity measures routinely collected in UK-JTTR were used to predict survival: Glasgow Coma Scale (GCS), Injury Severity Score (ISS), New Injury Severity Score (NISS), Trauma Injury Severity Score (TRISS), Abbreviated Injury Scale (AIS) and A Severity Characterization of Trauma (ASCOT). Results: UK-JTTR recorded 2440 UK casualties in Afghanistan and Iraq between 2003–2011. Of these, 464 (19%) sustained TBI. Most had moderate/severe TBI (402, 87%). 98% of those with TBI were male and 82% were from the Army. The average age of TBI casualties was 26 years (range ¼ 18–53) There were 181 (39%) survivors. Most TBIs (87%) were the result of hostile action. Two-thirds of injuries were caused by blast (improvised explosive devices (IEDs) or other explosives). IEDs accounted for 55% of Afghanistan and 31% of Iraq TBIs. All injury severity scores were highly correlated with survival. Logistic regression analyses were performed using the 412 cases (149 survivors; 263 fatalities) with scores on all six severity measures. The best fitting model was based on TRISS. A TRISS scor e411.13 indicates a 495% probability of survival. Conclusion: Almost one in five UK service personnel recorded in UKJTTR had TBI, most were moderate/severe. However, mild TBI is likely to be under-represented as inclusion in UK-JTTR requires a trauma team response or evacuation to RCDM for in-patient care. This may account for the lower rates of mild TBI than those reported for US armed forces. TRISS was the best predictor of survivors, but all routinely collected severity scores were good predictors of fatalities. These findings may be used to plan future rehabilitation provision for survivors.


Modulation of the default-mode network and the attentional network by self-referential processes in patients with disorder of consciousness Vero´nica Ma¨ki-Marttunen1, Lisandro Olmos2, Ramo´n Leiguarda2, & Mirta Villarreal1 1

CONICET, Buenos Aires, Argentina, 2FLENI, Buenos Aires, Argentina

Objectives: The present work studies patients with disorder of consciousness (DOC) secondary to severe traumatic brain injury. Consciousness is defined as the awareness of the environment and the self. This study focuses on the latter aspect and investigates the presence of modulation of the brain networks associated to selfreferential processing, caused by external stimuli that induced a selfreflection state. Methods: Sixteen controls and nine patients were measured in the DOC state (assessed by the Revised Coma Recovery Scale) using functional magnetic resonance imaging (fMRI), during an auditory task paradigm requiring yes-or-no mental decision. During an experimental session blocks of questions related to knowledge and reflection on the own abilities, traits and attitudes (SELF condition) and blocks of questions requiring a basic level of semantic knowledge (GENERAL condition) were delivered. The patients were studied in two instances: first soon after the traumatic lesion and second after 4–6 months of the first scan, thus capturing possible changes associated to recovery in those patients that show

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some increase in the level of consciousness during the inter-scans period. Results: Controls showed a pattern of activation related to the SELF condition involving medial frontal gyrus (MedFG), precuneus and bilateral inferior parietal lobules/middle temporal gyrus, areas comprising the Default Mode Network (DMN). Activation of a mainly left-lateralized network involving pre-central area (PA), inferior frontal gyrus and inferior parietal lobe, comprising the so-called Attentional Network (AN) was observed in the GENERAL condition. In contrast, patients showed incomplete or segregated patterns. In order to further study the modulation induced by the paradigm in the activity of these areas, the correlation of their mean BOLD activity with the experimental design was calculated. Interestingly, it was found that in controls the areas within networks showed different patterns of modulation. Moreover, the modulation on the MedFG positively correlated with the level of consciousness of the patients (CRS-R score), while the modulation on the PA presented negative correlation with this level. In addition, this study assessed the coherence in the temporal activity of the regions of interest (functional connectivity, FC). It was found that the FC is not homogeneous between the areas in and across networks and that the FC between MedFG and precuneus positively correlates with the level of consciousness of the patients. Conclusions: The results suggest that, despite all the areas in the DMN showing an involvement in the processing of the self, MedFG is the only one whose contribution can be linked to an increasing level of consciousness. The results support the role of the frontal lobe in the sustainment of the ‘self’ and the importance of anterior–posterior connectivity for conscious processing.


Internet-based cognitive training enhances attention and functional outcomes in OEF/OIF/ OND veterans Regina McGlinchey1, Andrew Rosenblatt2, Roger Mercado3, Michael Esterman1, & Joseph DeGutis1 1

VA Boston Healthcare System, Boston, MA, USA, 2University of Houston, Houston, TX, USA, 3Temple University, Philadelphia, PA, USA Objectives: Mild traumatic brain injury (mTBI) is highly prevalent amongst OEF/OIF veterans and most individuals (90%) diagnosed with mTBI have co-occurring post-traumatic stress disorder (PTSD) and other comorbidities (depression, substance abuse, pain, etc.). Attentional problems, including sustaining attention and inhibitory control, are prevalent in this cohort and likely contribute to problems in everyday functioning. This pilot study aimed to determine whether an at-home, computer-based training programme could enhance attentional function and, if so, if these improvements would be associated with improved functional outcome. Methods: Twenty-eight OEF/OIF veterans from the VA RR&D TRACTS Center of Excellence at the VA Boston Healthcare System with diagnosed mTBI and/or PTSD were randomly assigned to one of two groups who: (1) received a computer-based cognitive training program, Tonic And Phasic Attention Training (TAPAT) or (2) were assigned to a test–re-test control condition. Intervention: 6 hours of TAPAT at home via the web over 2 weeks (36 minutes per day for 10 days). Participants responded to frequent non-target images (90% of trials) and withheld their response to rare target images (10% of trials). Near transfer was assessed using a measure of sustained attention and inhibitory control (gradual onset continuous performance task, gradCPT) and selective attention (attentional blink);


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DOI: 10.3109/02699052.2014.892379

far transfer was assessed using a measure of short-term (digit span) and verbal memory (Hopkins Verbal Learning Test). Functional outcome was assessed using self-report measures of PTSD severity (PTSD checklist-civilian; PCL-C), sleep (Pittsburgh Sleep Quality Index; PSQI) and dissociative symptoms (Multiscale Dissociation inventory, MDI). Results: Protocol compliance was excellent (10% attrition rate). Repeated measures multivariate analyses of variance (MANOVAs) revealed a significant group (control/TAPAT)  assessment (pre/ post) interaction for near transfer tasks (gradCPT/attentional blink) but not for far transfer tasks (memory), suggesting that TAPAT improved attentional performance. Notably, MANOVA also revealed a significant group  assessment interaction on functional outcome measures, indicating that TAPAT improved sleep quality and quantity and reduced dissociative symptoms. Post-hoc analysis revealed that participants with more severe PTSD symptoms (435 on PCL-C) had the greatest initial impairments in sustained attention and inhibitory control (grad CPT) and most dissociative symptoms (MDI), but they also showed greater improvement following TAPAT in these measures relative to those with less severe PTSD symptoms. Conclusions: Veterans exposed to 2 weeks of TAPAT had less attentional dysfunction compared to veterans in a control group. Improvements were found to generalize to measures of functional outcome, especially in those veterans with more severe symptoms of PTSD. Generalized benefits in sleep quantity and quality and reductions in dissociative symptoms may prove to have reciprocal benefits to cognitive function.


A portrait of existing services to address mental health issues following traumatic brain injury: Strengths, weaknesses, opportunities and threats Bonnie Swaine1, Yvonne Richard1, Debbie Feldman1, Marie-Christine Ouellet2, Elaine de Guise3, Ste´phane Gagnier4, Monique Desjardins5, Annie Bourgouin6, & Fre´de´ric Banville7 1

Universite´ de Montreal - CRIR, Montreal, Que´bec, Canada, Universite´ Laval - Centre de Recherche en Re´adaptation et Inte´gration Sociale (CIRRIS), Quebec city, Que´bec, Canada, 3Universite´ de Montreal - Department of Psychology, Montreal, Que´bec, Canada, 4 Institut de Re´adaptation Gingras-Lindsay de Montre´al, Montreal, Que´bec, Canada, 5Centre Universitaire de Sante´ McGill (CUSM), Montreal, Que´bec, Canada, 6Institut de Re´adaptation en De´ficience Physique de Que´bec, Quebec city, Que´bec, Canada, 7Universite´ du Que´bec a` Rimouski, Rimouski, Que´bec, Canada

Methods: Managers from all 28 TBI rehabilitation programmes in the province were mailed a questionnaire asking them to provide a general overview of their existing services for MH issues. Two 3-hour focus groups, structured around a SWOT analysis, were held with 13 service providers from varying disciplines. Transcribed verbatim was analysed using NVivo software to identify principle themes and recommendations. Results: Twenty-three programmes (82%) responded. Seventeen (74%) of them reported lacking a systematic screening process for MH problems. Only about one half of the clinical teams felt well or relatively well equipped to diagnose (48%) and to treat (57%) MH problems. The most common reported approach used was cognitive behavioural therapy (70%), but varying approaches appear to be used. Seventy per cent of clinical teams include a psychiatrist and all centres make referrals outside of their programme, but only seven centres (30%) have formal partnerships or agreements. Sixty per cent have no mechanism to allow people to obtain access to services once discharged. Perceived strengths were local inter-institutional referral agreements and overall good quality of care while weaknesses included under-developed partnerships with other health centres and community services, unequal access to medical specialists and potentially long waiting times. Opportunities included using existing regional steering committees to facilitate joint action between stakeholders. Ageing of the population and the privatization and partitioning of services were perceived as threats. Conclusions: This research presents the first overview of the situation of MH services for TBI survivors in the province of Quebec, Canada, and suggests significant progress is needed to optimize MH following TBI. Major recommendations (to be presented and discussed at a province-wide dissemination forum in February 2014) include a need for systematic early screening and mechanisms to access specialists for MH problems, a need to train all service providers as well as those working in the community about TBI and about mental health problems.


The changing face of behaviour referrals: The trauma lens applied to behavioural treatment Judith Gargaro, Kelley Anstey, Struan Cardoso, & Gary Gerber West Park Healthcare Centre, Toronto, ON, Canada


Introduction: Traumatic brain injury (TBI) can have serious mental health (MH) sequelae, yet it is unclear whether TBI rehabilitation programmes can adequately face the challenges related to MH problems suffered by TBI survivors. Objectives: The objectives of this research were to (1) document current aspects of organizational structure and process within 28 TBI clinical programmes (trauma care, rehabilitation and community integration) across Que´bec, Canada, (2) document service providers’ perceptions of the strengths, weaknesses, opportunities and threats (SWOT) of the present care system and (3) provide recommendations for optimal care and an action plan for the health ministry to address this issue.

Objective: Trauma can be defined as experience(s) that overwhelm(s) an individual’s capacity to cope. Persons who have sustained an acquired brain injury (ABI) often experience the lasting effects of trauma that can provide the context for life after brain injury. Without understanding behaviour in the context of this trauma, service providers run the risk that clients with ABI will not engage in treatment and not achieve their potential for rehabilitation and effective adjustment after injury. Trauma-informed care is an approach into engaging people with histories of trauma that recognizes the presence of trauma symptoms and acknowledges the role that trauma-related to ABI has played in their lives. This talk will review the theory of trauma-informed behavioural strategies used in the ABI Behaviour Services Program at West Park Healthcare Centre in Toronto, ON, Canada. Case studies will be used to illustrate the need for such treatment and the outcomes possible with such an approach. Methods: Trauma-informed care has been conceptualized as hinging on the three main concepts of understanding, commitment and practices. ‘Understanding’ involves a holistic strengths-based focus; ‘Commitment’ indicates organizational support; and ‘Practices’ focuses on empowerment vs management and control. At ABI Behaviour Services adults, who have sustained an ABI, referred for outpatient behavioural services are assessed using a trauma-informed

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626 lens. The focus is on developing resilience and supporting survivors of ABI and family members. During assessment a complete history is obtained that allows for an understanding of how history, including trauma, may influence current behaviour. Results: Survivors are referred for a range of issues including aggression, anger, irritability, deficits in self-care skills and community integration and post-injury eating disorders. The focus of the service is on behavioural solutions to behavioural problems. In developing these solutions therapists have found it useful to assist survivors to create new meaning of their ABI trauma history in the context of current experiences. Interventions involve focus on treatment engagement using a variety of strategies, survivor and family strengths and practical goals and outcomes of behaviour change. Case examples will be discussed that review the approach and detail the gains that can be made. Conclusions: One of the strengths of this behavioural approach is it allows for detailed assessment of individual client histories and current behavioural needs. The reasons for referral to this programme have changed over the last decade and it is important to adopt a trauma-informed lens to the treatment of behaviours that may be exhibited in response to the trauma of the brain injury itself and/or circumstances following the brain injury. Brain injury is a chronic condition that is complex and requires service providers to be flexible in their approach and address trauma-related issues to effect lasting change.


Level of observation outcomes tool: A measure of need for supervision for persons with acquired brain injury—Revised edition pilot validity/reliability study Cynthia Bailey, & Andrea Johnson Touchstone NeuroRecovery Center, Conroe, TX, USA In working with clients in a Residential Facility a measure of need for supervision is essential. It was found that the current assessment tool was insufficient at both ends of measurement, i.e. sometimes residents required more than one person 24 hours a day and sometimes it would be helpful to know if a resident could be safely left alone for greater than 1 hour. This study modified the current assessment tool to reflect those concerns and had the same raters rate residents on both tools. Initial results indicate that the expanded LOOT is a much more sensitive and helpful measure.


Elaboration and implementation of a profile form of complexity indicators influencing post-TBI outcome Josianne Creˆte1, Genevie`ve Le´veille´2, Anne Simard2, Marie-Reine Jutras2, & Mariama Toure´2 1

University of Montreal, Montreal, Quebec, Canada, 2Lucie-Bruneau Rehabilitation Centre, Montreal, Quebec, Canada

Brain Inj, 2014; 28(5–6): 517–878

Objectives: The purpose of the project is to develop an analysis profile form enabling the fast and precise identification of the prognosis of social participation after a TBI. Methods: To achieve this goal, a documentary analysis was performed between 2010–2013 to review 100 articles. These articles were chosen using key words referring to post-TBI outcomes. The evidences found in these articles permitted the identification and operationalization of five complexity indicators that were than organized, through an iterative process, into a profile form. To help with the completion and application of the form, it is accompanied by a descriptive guide. The implementation in clinical practice is currently ongoing at the TBI programme of Lucie-Bruneau rehabilitation centre in Montreal. Results: The findings are summed up in the profile form and its accompanying guide. As such, five complexity indicators were identified as having significant influence on social participation outcome at the end of the rehabilitation process. These indicators are (1) the pre-TBI profile, (2) the peri-accidental medical elements, (3) the severity of the neurological deficits and co-morbid factors, (4) the environmental resources and (5) the use of adaptive resources. All five indicators are divided in sub-categories, detailed in the accompanying guide in a table format where the elements are split between the factors of good prognosis and those of bad prognosis. Conclusions: The profile form and its accompanying guide will enable the clinical teams to rapidly and precisely predict what the social participation profile of its clientele will be at the end of their interventions. Not only will that permit more accurate and realistic rehabilitation goal-setting, but these more realistic goals can than motivate the client to more fully invest him-/herself in the rehabilitation programme. This project, thus, enables a better prediction of the social participation outcome of the clientele by the end of the rehabilitation program, through the rapid and accurate identification of the client’s detailed profile (pre-, peri- and post-TBI). It also facilitates the interdisciplinary and systematic observation of the characteristics of the clientele that are related to the complexity indicators. Lastly, it is important to note the profile form elaborated and presently being implemented will be the basis for documenting the profiles of the clientele and its outcome at the end of the rehabilitation programme, furthering the understanding of the link between the complexity indicators and the outcomes.


Pragmatic language skills in young children with TBI Julie Haarbauer-Krupa1, Justin Wise2, Tricia King3, Cassandra Hendrix3, & Roberta DePompei4 1

Children’s Healthcare of Atlanta, Atlanta, GA, USA, 2Oglethorpe University, Atlanta, GA, USA, 3Georgia State University, Atlanta, GA, USA, 4University of Akron, Akron, Ohio, USA, 5Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA Objectives: A traumatic brain injury (TBI) in children before age 5 can impact language development that contributes to pragmatic skills or social language use. Impaired pragmatic ability has been identified following TBI, with a significant contribution of executive functions in adults with severe TBI. Differences in pragmatic language skills are also reported in children with language impairments. The purpose of this study was to examine the pragmatic language skills in young children with TBI compared to an orthopaedic control group. Methods: Participants were 54 children between the ages of 6–10 years at the time of their initial study visit who sustained a TBI (n ¼ 27) or orthopaedic injury (OI; n ¼ 27) before age 6 years. Time since their injury was at least 1 year (TBI M ¼ 4.81 years, SD ¼ 1.5; OI M ¼ 3.99 years, SD ¼ 1.33). TBI severity ranged from mild (GSC 13–15; 55.6%), moderate (GSC 9–12; 18.5%) and severe (GSC48; 14.8%). The pragmatic language and grammaticality sub-tests of the Comprehensive Assessment of Spoken Language (CASL), the


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DOI: 10.3109/02699052.2014.892379

Peabody Picture Vocabulary Test (PPVT) and the Expressive One Word Picture Vocabulary (EOWPVT) tests were administered as part of a child test battery. Parents completed the Behavior Rating Inventory of Executive Function (BRIEF). Results: A one-way analysis of variance (ANOVA) was calculated to compare the TBI and OI groups on language and executive function measures. Significant group differences occurred for the PPVT (TBI M ¼ 102.81, SD ¼ 15.88; OI M ¼ 112.24, SD ¼ 12.10), F(1,50) ¼ 5.72, p ¼ 0.02, h2p ¼ 0.10, EOWPVT (TBI M ¼ 99.19, SD ¼ 20.29; OI M ¼ 109.6, SD ¼ 12.63), F(1,50) ¼ 4.67, p ¼ 0.04, h2p ¼ 0.09, and Pragmatic Judgement (TBI M ¼ 99.69, SD ¼ 11.83; OI M ¼ 111.83, SD ¼ 8.26), F(1,34) ¼ 13.08, p ¼ 0.001, h2p ¼ 0.29. Group scores were not significantly different for the BRIEF Global Composite Score (TBI M ¼ 52.23, SD ¼ 11.21; OI M ¼ 47.26, SD ¼ 8.51), F(1,34) ¼ 3.33, p ¼ 0.07, h2p ¼ 0.06, or CASL grammaticality (TBI M ¼ 104.62, SD ¼ 11.39; OI M ¼ 111.96, SD ¼ 15.68), F(1,34) ¼ 2.18, p ¼ 0.15, h2p ¼ 0.06. Conclusions: Significant differences in pragmatic language skills are observed in children aged 6–10 years with TBI, who scored lower when compared to an orthopaedic control group. In adults with TBI, executive skills are significant contributors to pragmatic language skills. In this study, executive function skills measured by the BRIEF were not significantly different at this young age. Based on literature in children with language disorders, other factors, such as language capacity, may play more of a role in predicting pragmatic skills in children. Further investigation is needed to understand the contribution of language and cognitive skills to pragmatic language and how these skills contribute to social language outcomes for children with TBI.


Beneficial role of cerebrolysin in management of traumatic brain injuries: Our experience Ishwar dayal Chaurasia, Mahim Koshariya, & Vikram Watti Gandhi Medical College and Associated Hamidia Hospital, Bhopal, MP, India Background: Traumatic brain Injury is one of the major causes of mortality and morbidity all over the world. Cerebrolysin, a neuropeptide synthetic preparation produced by enzymatic breakdown of lipid having neurotropic and neuroprotective role, being successfully used in the treatment of Alzheimer’s disease, in acute cerebrovascular strokes with proven efficacy. Although it has been used successfully in traumatic brain injuries, only limited studies are reported. Objectives: This study evaluated the efficacy and safety of cerebrolysin in the treatment of traumatic brain injury. Methods: The present study was conducted at the Surgical Unit of Medical College Hospital to evaluate the effect of cerebrolysin on functional and cognitive outcome in patients with moderate and severe TBI. One hundred and twenty patients were divided into two groups. Group I received cerebrolysin for 14–20 days and Group II received only conventional therapy as a control group. Both groups were subjected to GCS and CT brains on admission and were compared with the degree of improvement on 14, 20 days and subsequently from the day of admission. Results: The cerebrolysin-treated group was compared to the conventional therapy (controlled) group. There was a statistically significant difference (p value ¼ 0.001) seen in improvement of GCS and in terms of cognitive and functional outcome in patients treated with cerebrolysin therapy as compared with the conventional therapy control group. Conclusions: Patients with cerebrolysin treatment showed a significant improvement and outcome in GCS as compared with conventional therapy. The results suggest that patients with traumatic brain injuries

when treated with cerebrolysin benefited with regards to functional and cognitive outcome and it can be safely used.


Enhanced attention capture by emotional stimuli in MTBI Vero´nica Ma¨ki-Marttunen1, Venla Kuusinen1, Markus Polvivaara1, Maarja Brause1, O¨hman Juha2, & Kaisa Hartikainen1 1

Behavioral Neurology Research Unit of Tampere University Hospital, Tampere, Finland, 2Department of Neurology and Rehabilitation of Tampere University Hospital, Tampere, Finland Background: Mild traumatic brain injury (MTBI) may be associated with compromised executive functioning and altered emotional reactivity. Despite frequent affective and cognitive symptoms in MTBI, objective evidence of brain dysfunction is often lacking. Previously compromised performance has been reported in symptomatic MTBI patients in an Executive-Reaction Time (RT) test, a computer-based RT test engaging several executive functions. This study investigated whether attention allocation to emotional stimuli and emotionexecutive function interaction are altered in MTBI. Objectives: Cognitive control processes were investigated in MTBI in the context of threat-related stimuli. Behavioural measures and eventrelated potentials (ERP) are used to investigate attentional capture by task-relevant and task-irrelevant emotional stimuli during a task requiring cognitive control. Methods: Patients admitted to Tampere University Hospital emergency room due to MTBI (n ¼ 23) or ankle injury (controls, n ¼ 17) were recruited. The groups were matched in age, sex and level of education. Over 6-months post-injury EEG was recorded while patients performed a computer-based Go-NoGo visual discrimination task with threat-related and emotionally neutral stimuli, a modified Executive RT-test. Threat-related stimuli were line drawings of spiders while neutral control images were constructed from the same linecomponents resembling a flower. Emotional and neutral images served either as task-relevant Go or NoGo signal or as a task-irrelevant distractor. N2-P3 ERP amplitude was used as a measure of attention allocation. Repeated Measures Analysis of Variance was performed for reaction times (RT), different error types and Go and NoGo N2-P3 ERP amplitude with Emotion (threat, neutral) and Task-relevance (relevant, non-relevant) as within-subject factors and Group as a betweensubjects factor (MTBI, Control). Significant interaction effects were decomposed by additional ANOVAs. Results: Threat-related stimuli were associated with faster RTs (p50.001) and increased N2-P3 (p50.05) amplitudes in both Go and NoGo situations. There were no main effects of group at the main level of analysis. However, there were interaction effects of Emotion by Group for commission errors and for NoGo N2-P3 amplitudes. The MTBI group made fewer commission errors and evoked greater N2-P3 amplitude when faced with threat-related NoGo signal in comparison to neutral. Threat-related Go signal was associated with greater N2-P3 Go amplitudes in comparison to neutral in MTBI (p50.05). Conclusions: MTBI may be associated with enhanced allocation of attentional resources to threat-related stimuli. Along with behavioural evidence for improved inhibitory control in the context of task-relevant threat stimuli, enhanced brain responses due to threat were observed in MTBI. Enhanced attention capture by threat-related emotional stimuli may reflect sensitization to threat and might contribute to affective symptoms in MTBI. This study highlights the need for further studies on emotion–attention interaction in MTBI. Further, this study introduces a way to objectively assess emotional reactivity as reflected in behaviour and brain physiology in MTBI.



The role of brain injury and PTSD on post-concussive symptom reporting in a military population Jan Kennedy1, Matthew Reid1, Douglas Cooper1, David Tate1,7, Lou French2, Jason Bailie3, Sarah Asmussen4, Tracey Brickell5, Katherine Marshall5, Ricardo Amador1, Cheryl Sills1, & Rael Lange5 1

San Antonio Military Medical Center, Ft Sam Houston, TX, USA, Walter Reed National Military Medical Center, Bethesda, MD, USA, 3 San Diego Naval Medical Center, San Diego, CA, USA, 4Marine Corps Base Camp Pendleton, Camp Pendleton, CA, USA, 5Defense and Veterans Brain Injury Center, Silver Spring, MD, USA, 6Uniformed Services University of the Health Sciences, Bethesda, MD, USA, 7 Center for Neuroscience and Regenerative Medicine, Bethesda, MD, USA, 8University of British Columbia, Vancouver, BC, Canada, 9Marine Corps Base Twenty Nine Palms, Twentynine Palms, CA, USA Objectives: Post concussive symptoms (PCS), although common following traumatic brain injury (TBI), can arise from factors other than brain injury itself. In a recent study, PCS, measured by the Neurobehavioural Symptom Inventory (NSI), differentiated military veterans with and without TBI. However, PCS also strongly correlated with co-occurring post-traumatic stress, as measured by the Posttraumatic Checklist (PCL). The current study evaluates the extent to which these findings generalize to an active duty military sample evaluated more acutely following injury. Methods: Participants included 1184 active duty military service members in three TBI groups: Moderate (n ¼ 79), Mild (n ¼ 682), Equivocal (n ¼ 372); and a Control group (n ¼ 51). Moderate and mild TBI groups were classified according to DoD criteria. Participants in the equivocal group sustained a mild TBI with alteration (but no loss) of consciousness. Controls were active duty service members who sustained bodily injury without TBI. The participants who sustained TBI were evaluated by The Defense and Veterans Brain Injury Center at a major military medical centre from 1–24 months after injury. PCS symptoms were measured with the NSI and PTSD symptoms were measured with the PCL. Results: NSI scores ranked from lowest to highest across Controls, Equivocal, Mild and Moderate groups. The mean total NSI score for the combined TBI group (29.7; 95% CI ¼ 28.6–30.7) was significantly higher than for Controls (20.0; 95% CI ¼ 15.4–24.7; p50.01). Pair-wise comparisons of the NSI total for the four groups revealed significant differences (p50.05) for all comparisons except Mild vs Equivocal TBI groups (p ¼ 0.26). Negligible-to-small effect sizes were associated with NSI comparisons between the three TBI groups (d ¼ 0.07–0.31). NSI comparisons of the three TBI groups to Controls yielded medium effect sizes for Equivocal (d ¼ 0.49) and Mild (d ¼ 0.55) and large effect sizes for Moderate (d ¼ 0.79) TBI. When PCL score was included in between-groups analysis on the NSI, the residual group effect (TBI vs Controls) was insignificant (partial eta2 ¼ 0.001). Conclusions: Although limited by sample size inequalities and a relatively broad range of time post-injury, results confirm the expected elevation of PCS among service members with TBI. PCS differed between TBI and controls, whereas negligible-to-small differences were found between TBI severity groups. However, when PCL score was included as a covariate, the effect of severity was no longer significant. Results suggest that, in a military population, both NSI and PCL reflect common variance derived from level of distress, encompassing affective, physical and cognitive domains. Further research needs to examine the extent to which this commonality between self-rating measures relates to clinically diagnosed PTSD following TBI. To be maximally effective, evaluation and treatment plans for service members as well as veterans with PCS

Brain Inj, 2014; 28(5–6): 517–878

following mild–moderate TBI need to address co-existing clinical sources of ongoing distress.


Resilience, adjustment and psychological functioning after traumatic brain injury Herman Lukow II, Jennifer Marwitz, Ana Mills, Stephanie Lichiello, & Elizabeth Coalter

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Virginia Commonwealth University, Richmond, VA, USA Objective: Resilience has been defined as positive adaptation in the face of a traumatic event. The exploration of resilience began with the study of individuals who emerged from traumatic situations unharmed and even strengthened. Studies have noted the positive benefit of a patient’s sense of resilience on outcomes after traumatic injury. However, there is little information about resilience after traumatic brain injury (TBI). The present investigation examined the relationship between resilience, psychological distress, adjustment and community participation after TBI. Methods: The sample consisted of 56 adult survivors of mild-tosevere TBI participating in an ongoing intervention to promote resilience and adjustment funded by the NIDRR TBI Model Systems. Resilience was measured using the Connor-Davidson Resilience Scale (CD-RISC-10 Item Version), with higher scores indicating greater resilience. The Brief Symptom Inventory (BSI-18) was used to characterize psychological distress (lower scores indicate better functioning). The BSI-18 also yields a cut-off measure for clinically significant levels of emotional distress (‘caseness’). Additionally, the Mayo-Portland Adaptability Inventory (MPAI) Ability, Adjustment and Participation sub-scales were examined (lower scores indicate better functioning). All participants were assessed prior to initiating the intervention. Results: The sample was predominantly male (n ¼ 31), Caucasian (n ¼ 42), with at least a high school education (n ¼ 42), mean age of 41 years (SD ¼ 13.1), moderate–severe injury severity (n ¼ 30) and mean time post-injury of 4.9 years (SD ¼ 7.0). Eighteen participants (15%) received psychological services prior to participation. Correlational analysis indicated significant (p50.001) negative relationships between resilience scores on the CD-RISC and all global and sub-scales scores on the MPAI and BSI-18, indicating that those with greater resilience had fewer psychosocial difficulties. Pearson’s correlations between resilience and the MPAI Ability, Adjustment and Participation Indices ranged from 0.45 to 0.62. Pearson’s correlations between resilience and the BSI-18 Somatization, Depression and Anxiety Scales ranged from 0.47 to 0.56. Significant differences in resilience scores (p50.001) were found when comparing individuals meeting caseness criteria for psychological distress (n ¼ 27) on the BSI-18 and those not meeting criteria (n ¼ 28), with lower scores on resilience associated with higher levels of caseness. No significant relationships were found between resilience and age, injury severity, time post-injury, gender, education, minority status or prior use of psychological services. Conclusion: This study highlights the significant relationship between resilience and psychological functioning for adult survivors of TBI engaged in post-acute rehabilitation efforts. Individuals with lower resilience skills would be considered at risk for psychological distress and psychosocial maladjustment. These findings support the key premise of the ongoing intervention, which targets the development of resilience skills as a means to foster adjustment and improve psychosocial functioning post-injury.


DOI: 10.3109/02699052.2014.892379


The necessity of considering visual changes after acquired brain injury Ma¨rta Berthold-Lindstedt, Eric Lindstro¨m, Lena Hamelius, Maria Jabocsson, & Miriam Engstro¨m

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Karolinska Insitutet, Stockholm, Sweden Objectives: More than 50% of cerebral activities are related to vision. Consequently, visual disorders are common after acquired brain injury and should have high priority in brain rehabilitation. Visual disorders are, however, commonly overlooked. There are few reports available about the degree, amount and rehabilitation of visual disorders. The most common visual disturbances are vision field disorder, double vision and different forms of binocular problems. Visual deficits bring headache, fatigue, dizziness, eye pain or strain, reading problems and difficulties to move. An ‘Interview Questionnaire’ for capturing visual disorders appeared in 1990, was translated to Norwegian in 1995 and to Swedish in 2010. The authors have, during the last 2 years, used this questionnaire, here slightly modified and referred to as the ‘Visual Interview’, as a screening method in the Out-patient Brain Injury Programme (for medium-tosevere acquired brain injury, ages 18–65), This was done in order to find out the occurrence of visual disorders in the group and if the ‘Visual Interview’ could be a tool for better assessments and rehabilitation plans. Methods: One hundred and ninety-six individuals, mostly stroke patients, enrolled in the out-door brain injury rehabilitation unit during the period 1 September 2010–30 June 2012. Twenty-six patients dropped out and 170 patients, mean age 47 years, participated. The ‘Visual-interview’holds 18 questions. Ninety-eight patients, in addition to the ‘Visual Interview’, were assessed with regard to the self-reported scales of depression, anxiety and fatigue in order to see if there were any connections between these common brain injury symptoms and visual changes Results: The ‘Visual Interview’ showed that 54% of the patients had noticed a change in their vision. The most important symptoms were: double vision (19%), visual field disturbances (29%), glare (35%), blurred vision (35%) and reading problems (53%). This study found a strong significant connection (Mann-Whitney Test) between depression, anxiety and fatigue and the noted visual changes, blurred vision, glare and reading problems, but no such connection for visual field defects and double vision. Conclusion: A varied collection of visual disorders are to be expected in any Out-patient Brain Injury Programme. Rehabilitation directed to blurred vision, glare and reading problems should, in the authors’ opinion, be tried in order to alleviate depression, anxiety and fatigue. The ‘Visual Interview’ seems to be an informative tool to highlight visual changes.


Developing a full day cognitive programme in a residential setting Cynthia Bailey, Coby Nirider, & Tom Owens Touchstone Neurorecovery Center, Conroe TX, USA Objectives: To develop a client-centred residential cognitive programme which utilizes licensed therapeutic staff and assistants (OT/

PT/SLP/psych), trained direct care staff and vocational resources to provide a therapeutic day in which residents remain constantly active, every member of the staff reinforces appropriate techniques (swallowing, transfers, behaviour). At the same time the residents must slowly gain increased independence and control while feeling that their goals are being addressed. Methods: Discuss evaluation/treatment planning and scheduling issues, as well as techniques to increase staff’s awareness of protocols to reinforce. Results: This study has developed four main tracks for residents and the programme has an effective combination of structure and flexibility. Outcome measures and patient satisfaction have both shown improvement. Conclusions: While it can be difficult and resource heavy to develop an effective therapeutic day, it results in improved outcomes and improved client attitude.


Can depressive symptoms and global function in the first year after traumatic brain injury predict executive problems and emotional and behavioural symptoms 2–5 years post-injury? Torun G. Finnanger1, Alexander Olsen2, Toril Skandsen3, Stian Lydersen1, Anne Vik4, Kari-Anne Indredavik Evensen5, Stein Andersson6, & Marit S. Indredavik1 1

Regional Centre for Child and Youth Mental Health and Child Welfare – Central Norway, Faculty of Medicine, 2MI Lab and Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway, 3 Department of Physical Medicine and Rehabilitation, St. Olavs Hospital Trondheim University Hospital, Trondheim, Norway, 4 Department of Neuroscience, Faculty of Medicine, 5Department of Public Health and General Practice, Department of Laboratory Medicine, Children and Women’s Health, Norwegian University of Science and Technology, Trondheim, Norway, 6Department of Psychology, University of Oslo, Oslo, Norway Objective: To evaluate how symptoms of depression and global outcome within the first year after traumatic brain injury (TBI) could predict executive, emotional and behavioural function 3–5 years postinjury. Materials/methods: Sixty-seven patients, 15–65 years, with moderate and severe TBI were assessed with Beck Depression Inventory at 3 and 12 months post-injury and with Glasgow Outcome Scale Extended (GOSE) 12 months post-injury. At mean 2.9 years after TBI (SD ¼ 346 days) the patients reported subjectively perceived symptoms of executive dysfunction assessed with Behavioural Rating Inventory of Executive Function–Adult form (BRIEF-A). In addition, emotional and behavioural problems were assessed with Adult Self-Report form (ASR). Results: More symptoms of depression at 3 months post-injury predicted more problems on all of the main composite scores on the ASR; total problems ( ¼ 2.87, CI ¼ 1.38–4.36, p value ¼ 0.001), internalizing problems ( ¼ 0.80, CI ¼ 0.11–1.50, p value ¼ 0.024) and externalizing problems ( ¼ 0.93, CI ¼ 0.49–1.38, p value50.001). More symptoms of depression at 12 months post-injury predicted more problems on all of the main composite scores on the ASR; total problems ( ¼ 2.52, CI ¼ 1.48–3.55, p value50.001),

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630 internalizing problems ( ¼ 0.89, CI ¼ 0.44–1.34, p value50.001) and externalizing problems ( ¼ 0.72, CI ¼ 0.43–1.01, p value50.001). Further, symptoms of depression 12 months post-injury also predicted more problems on all the main indexes on BRIEF; Global Executive Composite (GEC;  ¼ 2.07, CI ¼ 0.92–3.21, p value 50.001), Behavioural Regulation Index (BRI;  ¼ 0.98, CI ¼ 0.51–1.45, p value50.001) and Metacognitive Index (MI;  ¼ 1.02, CI ¼ 0.31–1.74, p value ¼ 0.006). Also, lower GOSE score 12 months postinjury predicted more problems on GEC ( ¼ 9.34, CI ¼ 15.10 to 3.58, p value ¼ 0.002), BRI ( ¼ 4.05, CI ¼ 6.55 to 1.55, p value ¼ 0.002) and MI ( ¼ 5.19, CI ¼ 8.80 to 1.58, p value ¼ 0.006). All associations were adjusted for age and length of education. Conclusion: Symptoms of depression within the first year after TBI predicted later emotional and behavioural problems as long as up to 5 years after injury. In particular, symptoms of depression 12 months post-injury seemed to affect both executive function and perceived emotional and behavioural problems. Global outcome at 12 months post-injury affected later executive function, but not emotional and behavioural problems. The results indicate a need to monitor the patients’ psychological health throughout the first year after TBI to identify individuals at risk of developing later emotional and behavioural problems.


Exploratory analysis of the dimensionalization of the Benton visual retention test with the three-factor solution of the WAISR in patients with traumatic brain injury Emma Shapiro, Supria Gill, & James Moses VA Palo Alto Health Care System, Palo Alto, CA, USA Objectives: This study aimed to increase the scope of understanding the dimensional categories of the Benton Visual Retention Test (BVRT) within a traumatic brain injury (TBI) population. The goal was to develop a model of understanding the adaptive ability of the WAIS-R (verbal, non-verbal and working memory components) and how it interacts with demographic variables (age and education) to determine pattern of performance of visual memory, assessed with the BVRT in patients with TBI. Methods: Analyses were completed utilizing archival data of 64 veterans with a primary diagnosis of TBI from the VA Palo Alto Health Care System. Patients were primarily male (95%) and Caucasian (84%) with 12 years of education (M ¼ 12.72) and a mean age of 49 years. Inclusion criteria were a primary diagnosis of a TBI and completion of the BVRT and the WAIS-R. Principal component analysis was used to determine the interactions among the two-factor structure of the BVRT (early items, 1–4, and late items, 5–10), demographic variables and the three-factor solution of the WAIS-R including the Verbal Comprehension (VC), Perceptual Organization (PO) and the Freedom from Distractibility factors (FFD). Results: Results of principal component analysis demonstrated strong loadings of late items on the BVRT with respect to age (0.673) and WAIS-R PO (0.936) on factor one. Strong loadings of the early items on the BVRT were also noted with respect to level of education (0.803) and WAIS-R VC (0.875) on factor two. The WAIS-R FFD showed a strong loading on a third factor (0.951) and did not show a strong relationship with either early or late items, but indicated an indirect relationship with late items. Extraction of these three factors accounted for 83% of the variance.

Brain Inj, 2014; 28(5–6): 517–878

Conclusions: In a veteran sample with TBI, performance on more complex items of a visual memory test decreased with age and was strongly related to non-verbal reasoning, abstraction and fluid intelligence. Performance on more familiar and less complex items improved with higher levels of education and was strongly related to verbal reasoning ability, comprehension and long-term memory for crystallized knowledge. The current study examined level of performance crossed with a pattern of performance in measures of cognitive functioning. Clinically, the findings suggest that when brainstorming compensatory strategies in a treatment setting, older adults with TBI or those who have fewer years of education may require more verbal mediation in facilitating treatment goals. This is an exploratory study with preliminary data, which offers promising implications for understanding how TBI impacts the interpretation of visual memory testing.


Taxonomy of combat-related mild TBI: NSI and PCL-C symptom profiles following combat-related mild traumatic brain injury Jason Bailie1, Rael Lange1, Tracey Brickell1, Sarah Asmussen1, Louis French2, Felicia Qashu1, Matthew Reid1, Katie Marshall1, Angelica Dilay1, & Jan Kennedy1 1 2

Defense and Veterans Brain Injury Center, Silver Spring, MD, USA, Walter Reed National Military Medical Center, Bethesda, MD, USA

Objectives: Combat-related mild traumatic brain injury (mTBI) has been a cardinal injury in modern warfare. Patients with mTBI report a wide array of symptoms reflecting cognitive, somatic and emotional processes. Treatment guidelines for mTBI have emphasized the need for symptom-specific intervention arguing against a one-size fits all approach to mTBI management. To date, a comprehensive evaluation of the taxonomy of combat-related mTBI has not been conducted to determine if sub-types of combat-related mTBI can be identified based on prominent symptom clusters. The objective of this study was to explore potential symptom profiles (i.e. sub-types) of combatrelated mTBI. Method: The sample included 1341 male military personnel who experienced a combat-related mTBI within the past 2 years (Age: M ¼ 26.90, SD ¼ 6.94). Measures included the Neurobehavioural Symptom Inventory (NSI) and the PTSD Checklist (PCL-C). A factor analysis, followed by a two-step cluster analysis procedure (i.e. hierarchical and k-means analyses) was used to identify common symptom profiles in the sample. Results: Factor analysis of the NSI and PCL-C items revealed a four factor solution to the 39 symptoms inventoried by the NSI and PCLC. Cluster analysis identified four primary sub-types of combatrelated mTBI: a primarily ‘PTSD’ group, a ‘Cognitive’ group, a ‘Mixed Cognitive/PTSD’ symptom group and a ‘Good Recovery’ group. The ‘PTSD’ cluster included 21.9% of the sample and was characterized by symptoms of hyperarousal and depression with relatively few cognitive or neurological complaints. The ‘Cognitive’ group composed 21.5% of the sample and reported only cognitive complaints. The ‘Mixed Cognitive/PTSD’ cluster included 18.6% of the sample and had relatively high endorsement of both cognitive and emotional symptoms. The largest cluster (37.8%) had the lowest symptom profile and was labelled the ‘Good Recovery’ group. None of the pattern profiles had notable elevations on motor/sensory symptoms. Examination of external variables revealed the ‘Good Recovery’ group was more likely to be in the sub-acute phase of recovery and had sustained injuries later in the OEF/OIF conflicts (2008–2011). The ‘Cognition’ group had the highest rate of central


DOI: 10.3109/02699052.2014.892379

nervous system dysfunction. The ‘Mixed Cognitive/PTSD’ group had the highest return to duty rate, lowest rate of injury to the CNS (0.8%) and, along with the ‘PTSD’ group, the highest use of antidepressant medications. Conclusion: The results support a unique taxonomy for combatrelated mTBI. Four cluster profiles representing (a) few cognitive/ emotional complaints, (b) primarily PTSD symptoms, (c) primarily cognitive complaints and (d) both cognitive and emotional symptoms were identified. The taxonomy provided preliminary evidence for focused treatment programmes. Only a small segment (18.6%) had a symptom profile that would require a comprehensive treatment for both cognitive and emotional complaints. The vast majority either had relatively few post-concussive symptoms or had specific problems related to cognition or emotional health.

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A numerical study of the underwash phenomenon of the helmeted-human-head under blast waves Hesam Sarvghad-Moghaddam, Asghar Rezaei, Mehdi Salimi Jazi, Ghodrat Karami, & Marisuz Ziejewski North Dakota State University, Fargo, ND, USA Upon the interaction with a high-pressure fluid flow, such as blast waves, a helmeted head might experience an intensified pressure region beneath the helmet, compared to an unprotected head. This is contrary to the expectation that the pressure should drop as the blast flow propagates with time and spreads over the helmet and head. This usually happens due to the altered flow behaviour inside the head-helmet gap on the opposite side of the incoming flow. This study presents an investigation on this phenomenon, known as underwash effect of the incoming flow. The underwash effect is observed through an increase in pressure due to the geometrical constraints along the path of the head–helmet gap. Simulation of a high-pressure fluid flow, representing a blast scenario in an interaction with the unprotected and helmeted head, is conducted using computational fluid dynamic (CFD) methods. A simplified rigid head–neck model is exposed to the high-pressure supersonic air flow in frontal, backward, upward and downward orientations. An advanced combat helmet (ACH) geometry is assembled on the model to represent a helmeted head. The simulations and computations are carried out using ANSYS-CFX. Based on the direction of incoming flow, different velocity fields and pressure distributions are observed which might result in creating an underwash effect under special circumstances. As expected, the direction of the flow has a dominant influence on the creation of such a phenomenon. Due to the curvature of the head–helmet gap and the interaction of the incoming flow from all sides, with the ongoing flow over the surface of the helmet, the momentum change is believed to be the main reason for this effect to happen.


Patients with the most severe traumatic brain injury benefit from rehabilitation Ingrid Poulsen, Anne Norup, Annette Liebach, Lars Westergaard, Karin Spangsberg Kristensen, Tina Haren, & Lars Peter Kammersgaard Department for Neurorehabilitation, TBI Unit, Copenhagen University, Glostrup Hospital., Hvidovre, Denmark Objectives: During the last couple of years, studies have indicated that even patients with the most severe traumatic brain injuries (TBI) benefit from rehabilitation despite what initially appears to be dismal prognosis. In Denmark, all patients with severe TBI have had an opportunity for specialized and centralized rehabilitation for the last 12 years. The objective of this study was to describe changes in level of consciousness and functioning in patients with very severe TBI during sub-acute rehabilitation. Methods: A total of 461 adult patients with severe TBI admitted to sub-acute inpatient rehabilitation during a 12-year period followed an intensive interdisciplinary rehabilitation programme. Severity of injury was defined by Glasgow Coma Scale (GCS) score on rehabilitation admission and duration of post-traumatic amnesia (PTA). Patients were routinely measured with neuropsychological and functional assessment scales from admission to discharge. Results: Data from 461 patients was collected, 17 patients died during hospital stay. Mean age was 45 years (SD ¼ 18), 77% were male. GCS on admission to the rehabilitation unit was 11 (IQR ¼ 9–14). Duration of PTA days was 53 (median) (IQR ¼ 32–120). Almost half of the patients (45%) were vegetative/unresponsive or minimally conscious on admission, whereas at discharge only 4% remained in these states. More than half of the sample (54%) had a FIMTM total-score of 18 points on admission, while only 10% were discharged with a score of 18 poins. Thirty-nine per cent were discharged home; 46% to further rehabilitation; 1.5% to acute treatment; and 9% to nursing homes. Conclusions: In this relatively large sample, comprising all patients with severe TBI in the Eastern part of Denmark, nearly all patients improved in both level of consciousness and function. These results emphasize that the prognosis after the most severe TBI is not uniformly dismal. Centralized specialized interdisciplinary inpatient rehabilitation of these patients directly after acute care may to some extent explain these results. These findings may suggest that all patients, even patients with the most severe injuries, should be considered for sub-acute specialized rehabilitation.


A case of 3D motion analysis for quantitative evaluation of dysmetria Wanho Kim, So Yeon Ahn, Doo Young Kim Kim, Bo Ra Kim, & Hye Sun Li National Rehabilitation Center, Seoul, Republic of Korea Quantitative analysis of ataxic disorder is a pre-requisite for measuring clinical severity of disease. So far, scales such as the International cooperative ataxia rating scale (ICARS) or the Scale for the assessment and rating of ataxia (SARA) are in use for the quantification of motor


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deficit of ataxic disorder. 3D motion analysis (three-dimensional kinematic analysis) has been mainly used to analyse limb and joint motion and gait through quantitative and qualitative assessment. This study tried to assess the ataxic movement of upper limb motion by using an optical motion capture system (VICON system; Oxford’s Metrics, Oxford, UK) and eight infrared cameras. A 24-year-old Asian woman who presented with ataxic movement to the department, was assessed with the upper limb ataxic movement by the 3D motion analysis in 2-week interval. This case is reported because the result was satisfied objectively. The curvilinearity ratio (CR) and tangential velocity (TV) of the upper limb motion in six directions were calculated. The CR represents the ratio between a straight line and the actual displacement from start to target at the finger marker of a moving arm. CR values close to 1 indicate that the line drawn between starting and target points is close to a straight line. In this CR values were all improved except direction 1. The TV profile in a normal person is continuous, smooth and bell shaped. Ataxic movements are demonstrated as oscillatory velocity profiles with multiple peaks. In this case later (post) analysis was shown to be more continuous and smooth shaped. In conclusion, 3D motion analysis for quantitative evaluation of ataxic disorder can be used for objective measurement.


Use of individual cognitive therapy with professionals in aviation Alissa Carver Touchstone Neurorecovery Center, Conroe, TX, USA Touchstone Neurorecovery Center provides a variety of services to residents with acquired brain injury. Cognitive services are provided in group and individual settings and are available to clients participating in Touchstone’s day programme. Day programmers come from a variety of backgrounds, including aviation. Pilots and other professionals in aviation present with specific areas of need and anticipated outcomes, due to the nature of their profession. A small group of pilots engaged in individual cognitive therapy sessions and were administered activities in order to address deficits in sustained attention, visual/spatial processing and impulse control when in stressful situations. Each pilot participated in 8 weeks of individual cognitive therapy sessions and received similar visual/spatial activities that were modified according to each pilot’s areas of need, such as length of activity, enforcing time restrictions, number of variables and extent of variety within session. Each pilot developed individualized compensatory strategies and protocols unique to their areas of need within the first three sessions and followed their protocols consistently throughout the duration of individual cognitive therapy treatment. These strategies were utilized regardless of added stressors such as time limitations, additional workload or auditory distractors during activities. The need for a pilot to engage in compensatory strategies and maintain protocol of action when under duress is not only effective within individual therapy, but may be generalized for managing stressful situations upon discharge. Each pilot reported in follow-up communication personal examples of using compensatory strategies developed within sessions for maintaining focused attention and impulse control when engaging in stressful activities within the community. However, a limited number of participants and testing administered by differing individuals may lead to type 1 errors or confounding variables. Future research is needed in order to determine extent of efficacy of individual cognitive therapy when used with professionals in aviation.

Brain Inj, 2014; 28(5–6): 517–878


Music therapy and its potential for addressing cognitive needs for clients with brain injury Alissa Carver Touchstone Neurorecovery Center, Conroe, TX, USA Music in the health arts and sciences has an extensive history, from shamans utilizing music in healing rituals, to music and accompanying dances administered to treat ailments, to songs facilitating production of speech in speech therapy. However, music therapy as a health profession began after World War I within the VA hospital setting. Music therapy is currently defined by the American Music Therapy Association as ‘the clinical and evidence-based use of music interventions to accomplish individualized goals within a therapeutic relationship by a credited professional who has completed an approved music therapy programme’. Music therapy provides support for clients with a wide scope of needs and within a variety of settings. Traditionally, music therapy is used as a specialized service reinforcing therapeutic goals of primary therapy services such as speech, occupational or physical therapy. However, the potential for using music therapy to address cognitive deficits is under-utilized, both by music therapists and professionals in related fields. Clients with deficits in communication and cognition resulting from brain injury are in greater need for alternative means of addressing cognitive limitations. Specifically, sustaining focused and divided attention, working memory, cuts in field of vision, impulsivity and speed of processing may be addressed with non-verbal means within music therapy sessions. This can be accomplished in several ways, including the use of adaptive instruments, song as mnemonic device or task analysis, multisensory stimulation, clinical improvisation or coding musical sequences. Although the therapeutic alliances and structure of clinical interventions may appear wide in scope and difficult to standardize, the therapeutic intent, documentation of therapeutic gains in session and means of monitoring progress are easily quantifiable. Measuring fixed data such as tempo, pitch, proximity of instruments to clients and ability to manage differing number of variables within sessions may indicate cognitive gains achieved by the client. In order for healthcare professionals to determine the extent of music in session appropriate for their own scope of practice and when a board-certified music therapist is clinically appropriate, it is imperative that they familiarize themselves with music techniques, levels of music therapy practice, the selection process of music within session and clinical contraindications. Clinicians with this knowledge base may address needs of clients holistically, both within their sessions and within interdisciplinary treatment teams.


DOI: 10.3109/02699052.2014.892379


A novel 3D 2-photon imaging of unsectioned transparent mouse brain to assess neuronal injury, vascular disruption, microglial activation and tissue-axon degeneration and regeneration using morphology preserving optical clearing agent for circuit reconstruction at an unprecedented depth Brain Inj Downloaded from by RMIT University on 09/02/14 For personal use only.

Manoj K Jaiswal1, & Zygmunt Galdzicki1,2 1

Center for Neuroscience and Regenerative Medicine, Bethesda, MD, USA, 2Department of Anatomy, Physiology and Genetics, USUHS, School of Medicine, Bethesda, MD, USA

Objective: Studying traumatic brain injury (TBI) in the central nervous system (CNS) is hampered by current physiological, histological and imaging techniques because they provide no three-dimensional (3D) information about vasculature disruptions, only partial information about a role of neurons and astrocytes in the neurovasculature coupling and axonal and glial reactions. For existing TBI models, these approaches yield incomplete spatiotemporal information and are, therefore, prone to misinterpretation. In particular, there are varying reports about the effectiveness of one-dimensional experimental intervention that produces degeneration and regeneration in the mild and severely injured mice. To overcome these limitations, a Urea- and Fructose based clearing procedure was developed that makes the unsectioned adult whole brain tissue transparent and fully penetrable for deep tissue fluorescence imaging. Methods: In the transgenic GAD67-GFP/CX3CR1 mouse whole intact brain, this study imaged fluorescently labelled cortical and deep brain region vasculature using tail vein injection and intrinsically labelled GFP neurons and microglia cells by two-photon microscopy without the need for histological sectioning. Simultaneously, this study performed ex-vivo 3D reconstruction of vasculature using fluorescent dyes injected into the tail vein. Results: Intact-tissue imaging of long-range projections, local circuit wiring, cellular relationships and subcellular structures in mouse models of TBI are shown. It was found that, through 2 weeks after TBI, vascular disruption and capillary diameters increases and the area of dying tissue widens. Depending on the TBI model, vascular deformities directly correlate with area of injury and impact depth and are accompanied by neuronal and glial loss and tissue deformation as well as massive microglial activation. It was found that, more than a year after injury, growth-competent axons regenerated abundantly through the injury site whereas blood vessels and artery disruption is extended to deeper layers of the brain. Moreover, this study accurately determined quantitative changes of activated microglial cells after mild TBI in CCI and repetitive close head injury model. Thus, the procedures of clearing whole brain tissue enables an unambiguous evaluation of TBIinduced vasculature disruption, neuro-glial-vasculature coupling impairment, axon regeneration and glial reactions. Both clearing procedures also render other organs transparent, which makes this approach useful for a large number of pre-clinical paradigms. The results suggest that visualizing cells in unsectioned CNS tissue holds promise for assessing experimental therapies in mild TBI and other neurological disorders.

Conclusions: In summary, the proposed approach could provide multimodal characteristics and, therefore, invaluable information for a variety of pre-clinical TBI models to assess tissue damage and neuroastrocytic activity and then efficacy of pharmaceutical interventions. This simple and technologically driven efficient method is very useful for imaging intact morphological architecture of different brain areas at large scales in both the adult and young mouse brains and is very useful for determining phenotypic changes that appear during the early and late stages of TBI.


Early treatment of neurostimulants is helpful to improve cognition in hypoglycaemic encephalopathy Jae Hyeok Chang, Yong Beom Shin, & Jin A. Yoon Pusan National University Hospital, Busan, Republic of Korea Introduction: Transient hypoglycaemic episodes are common and usually not life-threatening. Severe persistent hypoglycaemic states, however, may cause long-lasting coma, seizure and neurologic deficits that are symptom of hypoxic encephalopathy. Hypoglycaemic encephalopathy has no better prognosis than hypoxic encephalopathy, but shows a different course depending on the duration of hypoglycaemia. The case about a neurorestorative effect of neurostimulant in hypoglycaemic encephalopathy not been reported. This study reports a case that showed good cognitive prognosis by early and intensive administration of neurostimulant. Case report: A 31-year-old woman had treatment for laceration on the left hand a few days ago. The dressing and intravenous -lactam antibiotics were administered to her. Just after injection, she complained of nausea. A day later, her father found a change of awareness at dawn. She was admitted to the emergency room and turned to semi-coma with tonic seizure. Her blood pressure was noted as 80/40 mmHg, heart rate 104 beats min1, body temperature 36 C and blood glucose 18 mmol L1. There was no evidence for suspecting systemic infection. Dextrose saline 500 ml was infused to her immediately. Laboratory investigation, EEG, brain MRI and ECG were checked to find out the cause of decreased mentality. MR diffusion showed high signal intensity at the splenium and both parital-occipital lobes. MR ADC showed reduced diffusion at the splenium. EEG was suggestive of diffuse cerebral dysfunction. ECG showed decreased systolic function with an ejection fraction of 20%. She was diagnosed with hypoglycaemic encephalopathy secondary to hypoglycaemic shock and transferred to the ICU. Fifteen days after ICU care, her Glasgow Coma Scale score was 10, but MMSE was not tested due to her stupor mental state. She was administered amantadine 100 mg day1 as a starting dose and the dose was increased to 300 mg day1 rapidly during 5 days. The next day, methylphenidate 20 mg day1 was added as a starting dose while continuing to administer a high dose of the neurostimulant to her. After 5 days, rapid recovery of her cognition was observed and she responded to a 3-step verbal command properly. Her MMSE score was 14, after 1 month it increased to 22. Discussion: It is known that severe hypoglycaemia results in decreased synthesis of the neurotransmitter such as dopamine (DA) and norepinephrine (NE). Methylpenidate, one of the neurostimulants, increases the level of DA and NE by regulating the re-uptake. Early treatment with a neurostimulant appears to decrease oxidative neuronal damage and improve cognitive recovery. It may be controversial whether her cognitive recovery is a result of spontaneous course or the beneficial effect of the neurostimulant. Considering her rapid cognitive recovery after increasing the dose of the medication, however, one could think that early treatment with a maximal dose of brain stimulant has a benefit on cognitive recovery.



PEG-induced necrotizing fasciitis in the TBI patient Jae Hyeok Chang, Yong Beom Shin, Sung Hwa Ko, & Soo Kuon Kim

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Pusan National University Hospital, Busan, Republic of Korea Introduction: Percutaneous endoscopic gastrostomy (PEG) has become the modality of choice for providing enteral access to patients who require long-term enteral nutrition. Although generally considered safe, infections associated with PEG have been reported in 4–32% of patients and otherwise necrotizing fasciitis after PEG replacement have been reported not infrequently. This study reports a case that managed the necrotizing fasciitis around PEG insertion site and spared the PEG tube without any surgical intervention. Case report: A 64-year-old man was transferred to the rehabilitation clinic, after surgical procedure for traumatic SDH, SAH and multiple skull fracture. He underwent PEG because of a swallowing difficulty and recurrent gastrointestinal tract bleeding caused by the nasogastric tube insertion for 6 months. From that day, daily dressing was done and a 3rd cephalosporin was administered to him intravenously. Two days after operation, there were no abnormal findings such as erythema on the skin around the PEG site and pus squeezed from the PEG site. On the 3rd post-operation day, his body temperature was noted to be 38.7 C with elevated WBC (21040 ul1), ESR (67 mm h1), CRP level (14.39 mg dl1). Erythema was found on the left lower quadrant abdominal region on physical examination. Because of no evidence for suspecting urinary tract infection, pneumonia and other infectious condition, the abdomen CT was requested and showed subcutaneous emphysema spreading from the PEG site to the left lower abdominal wall and inguinal area. After realizing that it is the necrotizing fasciitis that originated from the PEG site, blood and pus were sampled for cultures and piperacillin/tazobactam and metronidazole administered to the patient. After 8 days, a follow-up abdomen CT showed abscess-like lesions, so a pigtail catheter insertion was done to drain pus. After 7 days, K.pneumoniae, E.cloacae were isolated from pus and CRP, WBC were checked within the normal range. After 10 days, the pigtail catheter was removed after confirming resolved abscess by ultrasonography and he started to be fed through a PEG tube. Discussion: This report represents one of the attempts to control necrotizing fasciitis by conservative therapy instead of removing the PEG tube and surgical debriment. The tube was not removed because reinsertion of the PEG tube is a very burdensome procedure to the patient and there was no severe infectious sign around the PEG insertion site. Remission of the disease was achieved by applying daily dressing, antibiotics administration and catheter insertion for draining the pus. Occurring in any region of the body, necrotizing fasciitis most commonly involves the abdominal wall, perineum. one has to keep in mind that a physical examination is needed on the whole abdomen to check abnormal findings such as erythema, oedema and bullae, because it is not always around the PEG insertion site where the first infectious sign emerges from.


Beneficial effect of music on the coma recovery scale-revised score in minimally conscious state patients Fabien Perrin1, Julie Verger2, Sabine Ruiz2, Manel Ben Romdhane2, Me´laine De Quelen2,

Brain Inj, 2014; 28(5–6): 517–878

Maı¨te´ Castro1, Laurence Tell2, Barbara Tillmann1, & Jacques Luaute´2 1´

Equipe Cognition Auditive et Pyschoacoustique, Centre de Recherche en Neurosciences de Lyon, Universite´ Lyon 1, CNRS UMR5292, INSERM U1028, Lyon, France, 2Service de Me´decine Physique et de Re´adaptation, CHU de Lyon, Lyon, France Objectives: Several studies have shown that music can boost cognitive functions in normal and brain-damaged subjects. Only a few singlecase studies have investigated a potential effect of music on perceptual and cognitive processes in patients with a disorder of consciousness. In addition, it is difficult to draw firm conclusions from these studies as they did not use quantified measures and control condition/group. The aim of the present study was to compare the effect of music to that of a continuous sound on the relational behaviour of patients in a minimally conscious state Methods: Behavioural responses of six chronic minimally conscious state patients were evaluated using items from the Coma Recovery Scale-Revised (CRS-R). Weekly evaluation sessions were carried out, over 4 weeks and under two conditions: following the presentation of either the patient’s preferred music or following a continuous sound (control condition). Results: Qualitative and quantitative analyses showed that the obtained item score on the CRS-R was greater in the music condition than in the control condition in 66.6% of the sessions. When analysing only the first 2 weeks, 90% of the sessions were in favour of the music condition. Conclusions: This new protocol suggests that preferred music has a beneficial effect on the cognitive and communication abilities of minimally conscious state patients. The results further suggest that cerebral plasticity may be enhanced, even at a chronic stage, in autobiographical (emotional and familiar) contexts. These findings will now be further extended with an increased number of patients to further validate the hypothesis of the beneficial effect of music on cognitive recovery.


Temporal and spatial gait parameters in patients dependent on walking assistance after stroke: Reliability and agreement between simple and advanced methods of assessment Ellen Høyer1, Arve Opheim2, Liv Inger Strand1, & Rolf Moe-Nilssen1 1

University of Bergen, Bergen, Norway, 2Sunnaas Rehabilitation Hospital, Oslo, Norway Objective: Gait abnormalities after severe stroke may be characterized by reduced walking speed and asymmetric gait function. Until the last decade, patients in need of assistance for walking were neither commonly assessed by simple timed walking tests over ground, nor by instrumented tests in gait laboratories. Laboratory equipment has in later years become available in hospitals for research and clinical purposes, thus allowing for detailed analysis of gait impairments after stroke. Uncertainty remained, however, regarding test–re-test reliability of both simple and advanced methods for gait assessment in stroke patients dependent on assistance for walking. Accordingly, the aims of the present study were (1) To investigate whether gait parameters can be reliably measured in patients dependent on walking assistance after stroke, both when using a simple method (10


Brain Inj Downloaded from by RMIT University on 09/02/14 For personal use only.

DOI: 10.3109/02699052.2014.892379

metre walk test) in a corridor and an advanced 3D camera method in a gait laboratory and (2) To investigate the agreement between the simple and advanced methods regarding walking speed, cadence and step length. Methods: Twenty-one patients with severe stroke were recruited from a larger randomized controlled trial. All patients underwent testing of over-ground gait function both in a corridor and in a gait laboratory, before and after 11 weeks of rehabilitation. A 10 metre walk test was conducted in the corridor. A model with three retro-reflexive markers on each foot was used in the laboratory. A test–re-test design was used to examine the reliability of repeated trials at the same session for each method. A cross-sectional design was used to examine the agreement between gait speed, cadence and step length, obtained with the two methods at both test points. Test– re-test reliability was examined using Intra-class correlation (ICC1.1) and measurement error was reported by within-subject standard deviation (Sw). The agreement between different methods for measuring walking speed, cadence and step length was explored by Bland-Altman plots. Results: All patients completed the test procedures. Highto-excellent test–re-test reliability was found between trials, both when assessed in the corridor (ICC ¼ 0.93–0.99) and in the laboratory (ICC ¼ 0.88–0.99). Agreement between methods was high at baseline and was slightly higher after the rehabilitation period. Agreement was found to be slightly better at lower walking speeds and for shorter step lengths at baseline than after the rehabilitation period. Conclusions: The results of this study suggest that the most commonly used gait parameters; walking speed, cadence and step length, may be reliably measured with both a simple test in a corridor and with an advanced 3D camera method in patients dependent of walking assistance after stroke. The laboratory method is preferable when more in-depth analysis is needed, as it provides parameters for the left and right leg separately, thus the possibility to assess gait asymmetry.

Data extraction: Eligible studies were critically appraised using a modification of the Scottish Intercollegiate Guidelines Network (SIGN) criteria. Two reviewers independently reviewed and extracted data from accepted studies into evidence tables. Data synthesis: Evidence was synthesized qualitatively according to modified SIGN criteria and prioritized according to design as exploratory or confirmatory. After 77 911 records were screened; 299 articles were eligible and reviewed, 101 (34%) of these with a low risk of bias were accepted as scientifically admissible and four of these had RTW or employment outcomes. This evidence is preliminary and suggests that most workers RTW within 3–6 months after MTBI; MTBI is not a significant risk factor for long-term work disability; and predictors of delayed RTW include a lower level of education (511 years of formal education), nausea or vomiting on hospital admission, extra-cranial injuries, severe head/bodily pain early after injury and limited job independence and decision-making latitude. Conclusions: These findings are based on preliminary evidence with varied patient characteristics and MTBI definitions, thus limiting firm conclusions. More well-designed studies are required to understand RTW and sustained employment after MTBI in the longer term (2 years post-MTBI).


Resolution of frontal release signs corresponds with cognitive improvement following severe traumatic brain injury Mark Slatyer1, & Warren Jennings-Bell2 1

University of Tasmania, Hobart, Australia, 2Calvary Health Care Tasmania, Hobart, Australia


A systematic review of return-towork after mild traumatic brain injury: Results of the International Collaboration on MTBI Prognosis (ICoMP) Carol Cancelliere1, Vicki Kristman2, J. David Cassidy3, Cesar Hincapie1, Pierre Cote4, Eleanor Boyle3, Linda Carroll5, Britt-Marie Stalnacke6, Catharina Nygren-de Boussard7, & Jorgen Borg7 1

University of Toronto, Toronto, Ontario, Canada, 2Lakehead University, Thunder Bay, Ontario, Canada, 3University of Southern Denmark, Odense, Denmark, 4University of the Ontario Institute of Technology, Oshawa, Ontario, Canada, 5University of Alberta, Edmonton, Alberta, Canada, 6Umea University, Umea, Sweden, 7 Karolinska Institutet, Stockholm, Sweden Objective: To synthesize the best available evidence on return-to-work (RTW) after mild traumatic brain injury (MTBI). Data sources: MEDLINE and other databases were searched (2001– 2012) with terms including ‘craniocerebral trauma’ and ‘employment’. Reference lists of eligible articles were also searched. Study selection: Controlled trials and cohort and case-control studies were selected according to pre-defined criteria. Studies had to assess RTW or employment outcomes in at least 30 MTBI cases.

Objectives: (1) To describe the natural history of frontal release signs (FRS) in severe traumatic brain injury (TBI). (2) To demonstrate the utility of FRS to the clinician in tracking outcome in severe TBI. Methods: It is well documented that the severity of TBI corresponds with the severity of cognitive impairment. Following a severe TBI, neuropsychological evaluation and cognitive assessment is often an unfruitful process due to the patient’s inability to meaningfully participate. Frequently it results in disingenuous results and is, therefore, impractical. Corresponding with this stage of recovery the clinician may be able to elicit frontal release signs, including the palmo-mental, suck, snout and grasp reflexes. These signs are indicative of frontal lobe dysfunction for which there are numerous causes, particularly TBI. This study presents a series of 12 patients with TBI, followed from acute admission to a tertiary referral hospital through to the inpatient and outpatient rehabilitation phases. Each patient satisfied GCS criteria for a severe TBI and computed tomography scans confirmed frontal lobe injury. All patients were in a coma or a minimally responsive state when the initial neurological examination was performed. Results: It was found that all of the previously mentioned frontal release signs were present. Moreover, it was noted over time that, as cognition improved, particularly communication, fewer frontal release signs were able to be elicited. In some cases there was complete resolution of frontal release signs. Conclusions: This association leads one to believe that the gradual resolution of frontal release signs following severe TBI could potentially act as an indication of when neuropsychological assessment may be beneficial. Given the importance of neuropsychological evaluation in assisting with identification of genuine cognitive impairments, further emphasis on clinically monitoring frontal release signs is an important clinical bedside tool for the care of those with severe TBI.




Post-stroke shoulder pain and its association with upper extremity sensorimotor function, daily hand activities, perceived participation and life satisfaction

Biocompatibility evaluation of PLGA with chemical modification with peripheral neural cells in vitro

Christina Broga˚rdh, & Ingrid Lindgren Department of Health Sciences, Lund University, Lund, Sweden

Brain Inj Downloaded from by RMIT University on 09/02/14 For personal use only.

Brain Inj, 2014; 28(5–6): 517–878

Background: Post-stroke shoulder pain (PSSP) is a common type of pain after stroke, especially in those with reduced arm and hand function. Even if PSSP is common after stroke, it is unclear how it impacts on the individual’s life situation. This knowledge could assist clinicians in the selection of appropriate rehabilitation interventions. Objectives: To assess the differences in upper extremity sensorimotor function, daily hand activities, perceived participation and life satisfaction between individuals with and without PSSP and to determine how PSSP is associated with these variables. Methods: Forty-nine individuals (mean age 64 ± 9 years), 24 with PSSP and 25 without (non-PSSP) with mild-to-moderate impairments in upper extremity were assessed on average 15 ± 8 months after stroke. The following upper extremity sensorimotor functions were assessed: (i) passive range of motion in abduction and external rotation of the upper arm; (ii) motor function in the arm and hand by the Modified Motor Assessment Scale; (iii) resistance to passive movements in the elbow by the Modified Ashworth Scale; (iv) light touch; and (v) proprioception. Self-reported daily hand activities were assessed by the ABILHAND Questionnaire, perceived participation by the Stroke Impact Scale (domain 8) and life satisfaction by the LiSat-11 checklist. Demographics were described and shoulder pain characteristics recorded in the PSSP group. Between-group differences and regression analyses were conducted. Results: The PSSP group had significantly decreased passive shoulder abduction (p50.001) and upper extremity motor function (p ¼ 0.04) in comparison to the non-PSSP group, but there were no significant differences between the groups in daily hand activities, perceived participation or life satisfaction. The univariate regression analyses revealed that shoulder pain was associated with upper extremity motor function (p ¼ 0.03, OR ¼ 3.82, 95% CI ¼ 1.13–12.87), but did not explain the variance in daily hand activities and only 3% in perceived participation. In the multivariate analyses passive shoulder abduction was associated with upper extremity motor function (p ¼ 0.02, OR ¼ 1.03, 95% CI ¼ 1.00–1.05), whereas perceived participation was associated with life satisfaction (p50.001, OR ¼ 1.08, 95% CI ¼ 1.03–1.13). Passive shoulder abduction, resistance to passive movements and proprioception explained 44% of daily hand activities, while daily hand activities, sex and vocational situation explained 41% of perceived participation. Conclusions: PSSP is associated with upper extremity motor function, but has a much weaker association with daily hand activities, perceived participation and life satisfaction in persons with mild-tomoderate upper extremity impairments after stroke. PSSP is commonly described as a severely disabling condition, but these results imply that it may not have such a great impact on the individual’s life situation.

Hao Zhu, Wenjin Wang, Ting Gui, Yueming Wang, & Wenlong Ding Department of Anatomy, Shanghai Jiao Tong University, School of Medicine, Shanghai, PR China Peripheral nerve repair across large gaps represents a common but challenging clinical problem. Scaffold design plays a pivotal role in nerve tissue engineering. Advanced biomaterials and scaffolds for tissue engineering place high demands on materials. Recently, Grafahrend et al. constructed new nanofibres using poly-lactic-coglycolic acid (PLGA) with chemical modification as the matrix polymer by the electrospinning, which had a biocompatibility. However, it is necessary to evaluate the biocompatibility of this new material with neural cells when it will be used in nerve tissue engineering in the future. So the evaluations were performed by MTT test, western blotting, RT-PCR and morphology assay. The results of MTT test, light microscopy showed that Schwann cells from rat sciatic nerves and neurons of dorsal root ganglia (DRG) cultured in the material extract fluid showed no significant difference in their morphology, cell viability. Furthermore, no significant difference was found in expression of the factors secreted by Schwann cells and neurons, such as nerve growth factor (NGF), brain-derived neurotrophic factor (BDNF) between in the material extraction fluid and in medium by RTPCR and Western analysis. In addition, DRG neurons were cultured on the substrate made up of the material fibres and observed the neurite outgrowth by using light and confocal microscopy coupled with immunocytochemistry. A great quantity of neurons grew on the material fibres and axons grew in parallel along the fibres. In conclusion, these data indicate that PLGA with chemical modification is beneficial to the survival of Schwann cells and neurons without exerting any significant cytotoxic effects and has good biocompatibility with peripheral neural cells. Thus, the present study provided an experimental foundation for the development of PLGA with chemical modification as a candidate material for nerve tissue engineering applications.


A systematic review of prognosis and return-to-play after sport concussion: Results of the International Collaboration on MTBI Prognosis (ICoMP) Carol Cancelliere1, Cesar Hincapie1, Michelle Keightley2, Alison Godbolt3, Pierre Cote4, Vicki Kristman5, Britt-Marie Stalnacke6, Linda Carroll7, Ryan Hung8, Jorgen Borg3, Catharina Nygren-de Boussard3, Victor Coronado9, James Donovan1, & J. David Cassidy10 1

University of Toronto, Toronto, Ontario, Canada, 2Bloorview Research Institute, Toronto, Ontario, Canada, 3Karolinska Institutet,


DOI: 10.3109/02699052.2014.892379

Brain Inj Downloaded from by RMIT University on 09/02/14 For personal use only.

Stockholm, Sweden, 4University of the Institute of Technology, Oshawa, Ontario, Canada, 5Lakehead University, Thunder Bay, Ontario, Canada, 6Umea University, Umea, Sweden, 7University of Alberta, Edmonton, Alberta, Canada, 8Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada, 9Centers for Disease Control and Prevention, Atlanta, GA, USA, 10University of Southern Denmark, Odense, Denmark Objective: To synthesize the best available evidence on prognosis after sport concussion. Data sources: MEDLINE and other databases were searched (2001– 2012) with terms including ‘craniocerebral trauma’ and ‘sports’. Reference lists of eligible articles were also searched. Study selection: Randomized controlled trials and cohort and casecontrol studies were selected according to pre-defined criteria. Studies had to have a minimum of 30 concussion cases. Data extraction: Eligible studies were critically appraised using a modification of the Scottish Intercollegiate Guidelines Network (SIGN) criteria. Two reviewers independently reviewed and extracted data from accepted studies into evidence tables. Data synthesis: Evidence was synthesized qualitatively according to modified SIGN criteria and studies were categorized as exploratory or confirmatory based on the strength of their design and evidence. After 77 911 records were screened, 48 articles were eligible for this review and 24 articles (representing 19 studies) with a low risk of bias were accepted. The findings are based on exploratory studies of predominantly male football players at the high school, collegiate and professional levels. Most athletes recover within days to a few weeks and American and Australian professional football players return-to-play quickly after MTBI. Delayed recovery appears more likely in high-school athletes, in those with a history of previous concussion and in those with a higher number and duration of post-concussion symptoms. Conclusions: The evidence concerning sports concussion course and prognosis is very preliminary and there is no evidence on the effect of return-to-play guidelines on prognosis. These findings have implications for further research. Well-designed, confirmatory studies are urgently needed to understand the consequences of sport concussion, including repeat concussion, across different athletic populations and sports.


The bilateral bispectral index (BIS) for the detection of pain in critically ill patients with a traumatic brain injury and alterations in level of consciousness: An exploratory study Caroline Arbour1, Ce´line Ge´linas1, Manon Choinie`re2, Jane Topolovec-Vranic3, Carmen G. Loiselle1, & Patricia Bourgault4 1

McGill University, Ingram School of Nursing, Montreal, Quebec, Canada, 2Universite´ de Montre´al, Centre de Recherche de Centre Hospitalier de l’Universite´ de Montre´al, Montreal, Quebec, Canada, 3 St. Michael’s Hospital, Trauma and Neurosurgery Program and Keenan Research Center of the Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada, 4Universite´ de Sherbrooke, Faculte´ de Me´decine et des Sciences de la Sante´, Sherbrooke, Quebec, Canada

Objectives: Many patients with a traumatic brain injury (TBI) cannot self-report their pain in the intensive care unit (ICU) due to alterations in level of consciousness (LOC). While observation of pain behaviours (e.g. frowning) is recommended for pain assessment in non-verbal populations, they are suppressed in TBI patients receiving neuroblocking agents or high doses of sedatives. Although vital signs are easily available in the ICU, previous findings do not support their use for pain assessment. The present study explores the potential utility of the bilateral bispectral index (BIS)—a processed EEG parameter— for pain detection in critically ill TBI adults with alterations in LOC. Specifically, this study described/compared bilateral BIS values recorded in critically ill TBI patients during a non-nociceptive and a nociceptive procedure and examined the association between fluctuations in bilateral BIS and the frequency of pain behaviours documented during the nociceptive procedure. Methods: Using a repeated measure within-subject design, TBI participants (n ¼ 25) were observed for 1 minute before (baseline), during and 15-minutes after two procedures: (1) non-invasive blood pressure: NIBP (non-nociceptive) and (2) turning (nociceptive)—for a total of six assessments. At each assessment, BIS index (from 0–100) of the right (R) and left (L) hemispheres were recorded simultaneously using the new BIS VISTATM monitor (Aspect Medical Systems, Newton, USA). Pain behaviours were also documented using a pre-tested 50item behavioural checklist inspired from two behavioural pain assessment tools developed for critically ill adults [i.e. Pain Behavioural Assessment Tool (PBAT) and Critical-Care Pain Observation Tool (CPOT)]. Frontal electromyogram (fEMG) activity and signal quality index (SQI) were recorded to assess for artefacts in BIS signal. Results: Compared to baseline, significant increases (p ¼ 0.05) in BIS-R (+4.93%), BIS-L (+8.43%) and in the frequency of pain behaviours (+3.00) were observed during turning, but not during NIBP. Interestingly, increases in BIS-R were significantly more pronounced in participants with left-sided TBI (+17.23%, p ¼ 0.021) than those with right-sided TBI (+3.01%). BIS-R fluctuations in participants with leftsided TBI were also positively correlated (rs ¼ 0.986, p ¼ 0.001) with the frequency of pain behaviours observed during turning. In contrast, no correlation between BIS-L and pain behaviours was found. Average values of fEMG (35.7 dB) and SQI (85.7%) showed good signal quality. Conclusions: Overall, only increases in BIS-R were correlated with participants’ pain behaviours and in those with left-sided TBI exclusively. While further research is needed, these findings suggest that the bilateral BIS could potentially be useful for pain detection in non-verbal patients with left-sided TBI in the instance where they cannot respond behaviourally to pain. Studies using electro-cortical mapping are also underway to further correlate the findings about hemispheric dominancy to nociceptive stimulation after TBI with possible underlying mechanisms.


Brain injury in battered women and its relationship to microstructural white matter alterations: A diffusion tensor imaging study Eve Valera1, Alan Francis1, Nikos Makris1, Zhi Li1, Ezra Wegbreit2, & Margaret O’Connor3 1

Harvard Medical School/Massachusetts General Hospital, MA, USA, Brown University Medical School Department of Psychiatry/Bradley Hospital, RI, USA, 3Harvard Medical School/Beth Israel Deaconess Medical Center, MA, USA 2

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638 Objectives: It is estimated that 2–4 million women are severely assaulted by partners each year. These women report a wide range of abusive acts that can cause mild traumatic brain injuries (mTBIs), that often result in the shearing and straining of axonal fibres, referred to as diffuse axonal injury (DAI). Surprisingly, almost no research exists on the effects of partner-related brain injury. In an exception, previous work demonstrated that nearly 75% of battered women sustained partner-related brain injuries and 50% sustained multiple partnerrelated brain injuries, the severity of which were associated with partner-abuse severity, cognitive functioning and psychopathology. Building on these results, diffusion tensor imaging (DTI) was used to examine the relationship between partner-related brain injuries, abnormalities in white matter integrity (possibly resulting from DAI) and cognitive functioning. Methods: Twenty-two women with a history of being in a physically abusive relationship underwent DTI imaging, a semi-structured brain injury severity interview and cognitive and psychological assessments. For each woman, FSL-TBSS was used to calculate fractional anisotropy (FA) maps and to create alignment-invariant tract representations of the white matter. FA values were compared between women with a limited number of mTBIs (Group ‘BW1’, n ¼ 11) and women with an extensive number of mTBIs (Group ‘BW2’, n ¼ 11). FA values were also correlated with a brain injury severity score as well as scores from standardized tests of executive functioning, attention, memory and learning. Results: DTI analysis demonstrated significantly decreased FA in the BW2 in comparison with the BW1 group in the splenium, right posterior corona radiata, right superior corona radiata and right cortico-spinal tract (p ¼ 0.05; corrected for multiple comparisons), including the superior longitudinal fascicle II (SLF II) within these areas. FA of the callosal body (r ¼ 0.50, p ¼ 0.02) and right corticospinal tract (r ¼ 0.41, p ¼ 0.06, trend) negatively correlated with a brain injury severity score. FA in the right superior corona radiata (including SLF II) correlated positively with scores of memory and learning on the California Verbal Learning Test (r’s ¼ 0.49 and 0.45, p’s ¼ 0.02 and 0.04) and negatively with inattention and impulsivity measures on a Continuous Performance Test (r’s ¼ 0.51 and 0.43, p’s ¼ 0.02 and 0.04). Conclusions: To the authors’ knowledge, this is the first study to use neuroimaging to examine brain injuries in battered women. Associations were found between partner-related mTBIs, measures of white matter integrity and cognitive functioning in these women. The effects of such brain injuries could contribute to the attention and concentration difficulties many battered women report. The implications of these findings on personal, social, legal and treatment issues will be discussed.


The incidence of traumatic brain injury in Tasmania during 2000– 2001 to 2010–2011 Mark Slatyer1, Jenny Langley1, Kevin Ratcliffe2, & Clive Skilbeck1 1

University of Tasmania, Hobart, Australia, 2Department of Health & Human Services, Hobart, Australia Objectives: (1) To establish to incidence of traumatic brain injury within a discrete population. (2) To analyse demographic and other associations with this rate of injury burden to the community. The incidence of traumatic brain injury (TBI) varies greatly among and within countries and even within methodologies. The World Health Organization estimates of TBI vary from 100–300/100 000 population, with higher rates in poorer less developed countries (although within the US rates vary significantly). The authors presented an earlier series in the 2005 IBIA Congress. Tasmania, the island state of Australia, has

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a population of 512 400 persons and a relatively large geographical area of 68 401 km2. Methods: A systematic sample of all TBI separations, using the ICD-10AM codes range S00–S05, S07–T75, T79 provided that S06 appears as an additional diagnosis code. This sample was collected from 2000– 2001 to 2010–2011 from all three main public hospitals within the state. Results: There was a gradual increase in the incidence of TBI admissions from 181/100 000 in 2000–2001 to a high of 316/100 000 in 2008–2009 and falling to 210/100 000 in 2010–2011. The mode for admission was 1 day and the range of length of stay up to 127 days. The majority of subjects were male (at 66%). Analysis of mortality rates and exploration of associations of demographic data, with incidence, will be made. Conclusions: The rate of TBI in Tasmania is higher than other western societies and also compared to the other six states and territories of Australia. However, more recently, rates as high as 618/100 000 have been recorded in North America and 453/100 000 in Europe. What is needed are prevalence studies which have been rarely done. Separation data is incomplete and does not include presentations of mild TBI, which do not present to health providers, general practitioners and other primary care providers.


Cranial nerve deficits in mild traumatic brain injury Mark Slatyer1, Clive Skilbeck1, & Warren Jennings-Bell2 1

University of Tasmania, Hobart, Australia, 2Calvary Health Care Tasmania, Hobart, Australia Objectives: (1) To establish the incidence of cranial nerve deficits in a mild traumatic brain injury (TBI) population. (2) To analyse associations among other clinical data to enable a better understanding of these neurological deficits. Methods: A systematic sample was made of 502 patients with mild TBI who were examined neurologically as well as other data such as demographic data, education, post-traumatic amnesia (PTA), Galveston Orientation Assessment Tool (GOAT), Mini-Mental Status Examination (MMSE), Rivermead Post-Concussional Scale (RPCS) and Hospital Anxiety & Depression Scale (HADS). Cranial nerve (CN) examination was performed in accordance with the technique outlined by Bickerstaff and Spillane. The sharpened Romberg’s Test has been validated by a number of investigators. Data was collected at 1, 3, 6 and 12 months. t-tests were performed to detect any association between deficits. Results: Olfactory deficits were 20% and fell to 4% by 12 months. Other CN deficits were comparable to other studies. The was a relationship for balance and age where there was an association between age and the likelihood of poor balance. A relationship existed with years of education and Olfactory deficit (p50.05). There was also a strong association between RPCS and Olfactory dysfunction (p50.001). The HADS anxiety scale (p50.05) and HADS depression scale (p50.01) both showed an association. The Sharpened Romberg’s also showed a strong association with RPCS (p50.01). Relationships were found with initial deficits with PTA, GOAT, RPCS, age and education. Initial CN deficits and RPCS showed a relationship at 3 and 6 months. Conclusions: CN deficits are relatively common in mild TBI and should be looked for in any physical examination. In particular, Olfaction in a high yield along with Balance. There are numerous and strong relationships between a significant number of demographic and outcome variables as shown. This outlines the importance of physical examination as well as history in the medical management of mild TBI.


DOI: 10.3109/02699052.2014.892379


Sleep dysfunction and disability outcomes after head injury among Ontario workers: Sex differences Tatyana Mollayeva1, Shirin Mollayeva2, Colin M. Shapiro3, David J. Cassidy4, & Angela Colantonio5 University of Toronto, Toronto, ON, Canada, 2Acquired Brain Injury Research Laboratory, Toronto, ON, Canada, 3Toronto Western Hospital-UHN, Toronto, ON, Canada, 4University of Southern Denmark, Odense M, DK-5230, Denmark, 5Toronto Rehabilitation Institute-UHN, Toronto, ON, Canada Brain Inj Downloaded from by RMIT University on 09/02/14 For personal use only.


Objectives: Although sex differences have been documented with respect to perceived sleep quality, to date no study has examined sex differences in sleep dysfunction after brain injury. This study investigated sex differences in sleep dysfunction and associations with disability outcomes with respect to work, social and family life among workers with head injury. Methods: This was a cross-sectional study of outpatients assessed for work-related mild-to-moderate traumatic brain injury. Sleep functioning was assessed by standardized scales, in accordance with the International Classification of Sleep Disorders (ICSD); insomnia by the Insomnia Severity Index (ISI), daytime sleepiness by the Epworth Sleepiness Scale (ESS). Disability was evaluated by the Sheehan Disability Scale and its sub-scales. Results: Eighty-four Ontario workers (52 males, 32 females; shift workers; 57% males, 31% females) with head injury: mean age 45 ± 10.5; median time since injury 531 days. Sixty-eight per cent of males and 72% of females reported moderate-to-severe insomnia interfering with their daytime performance. One or more sleep disorders were found in every worker: irregular sleep phase in 67%, restless legs in 50%, sleep apnea in 68% and excessive daytime sleepiness in 44% of this population. In males, a significant association was found between outcome of interest insomnia total score and all sub-scales of the Sheehan Disability Scale total scores for work, social life and family life (r ¼ 0.52, p50.0001; r ¼ 0.51, p ¼ 0.0002; r ¼ 0.49, p ¼ 0.0002; r ¼ 0.51, p ¼ 0.0001). In females, the associations between insomnia and Sheehan Disability Scale scores were as follows: r ¼ 0.51, p ¼ 0.003; r ¼ 0.49, p ¼ 0.001; r ¼ 0.48, p ¼ 0.005; and r ¼ 0.17, p ¼ 0.35, respectively. Conclusions: Insomnia in Ontario workers with head injury is associated with poor outcomes. Men are more prone to the negative association of insomnia symptoms with all aspects of disability. In females, insomnia was associated with lower scores in work and social life but was not associated with disability in relation to family life. These results suggest that differential sensitivity to negative effects of insomnia, particularly family responsibilities, could underlie sex-specific disability patterns.


Fatigue in workers with traumatic brain injury: An occupational performance modelling approach Tatyana Mollayeva1, David J. Cassidy2, Colin M. Shapiro3, & Angela Colantonio4


University of Toronto, Toronto, ON, Canada, 2University of Southern Denmark, Odense M, DK-5230, Denmark, 3Toronto Western Hospital, Toronto, ON, Canada, 4Toronto Rehabilitation Institute, Toronto, ON, Canada Background: Fatigue is one of the most frequently reported symptoms after traumatic brain injury (TBI), interfering with functioning and resulting in degraded performance and inability to perform occupational duties. While most physiology-based models of fatigue and performance list Sleep among the components accepted as critical in the modulation of performance, this is yet to be studied in the brain injury population. The aim of this study was to test a three-process model—Sleep, Fatigue and Activity participation in Ontario workers with TBI. Methods: A cross-sectional study of a population with mildto-moderate TBI and persistent symptoms, seen for assessment at the Toronto Rehabilitation Institute’s Worker’s Safety and Insurance Board Clinic between May 2012 and October 2013. Eighty-four Ontario workers (62% males, 38% females) completed the Fatigue Severity Scale (FSS), Patient’s Health Questionnaire (PHQ-9), Hospital Anxiety and Depression Scale (HADS), Insomnia Severity Scale (ISS), Epworth Sleepiness Scale (ESS) and the Toronto Hospital Alertness Test (THAT). Activity participation was evaluated by the Sheehan Disability Scale and its sub-scales. Workers also reported on premorbid shift work and the number of work-related injuries occurring in the past 5 years. Frequency distribution and Pearson correlation were used for data analysis. Results: Thirty-three per cent of workers named fatigue as one of their three most disabling symptoms. Forty-eight per cent of the sample performed shift work (80% rotating shifts, 20% night shift) at the time of their injury. Fatigue requiring further evaluation based on self-report (FSS total) was found in 79%, depression in 98%, anxiety in 70%, excessive daytime sleepiness in 44% and impaired alertness in 68% of these participants. Clinical insomnia based on ISS was found in 85% of workers. A strong association was found between outcome of interest (FSS total score) and insomnia (r ¼ 0.43, p50.0001), depression (r ¼ 0.55, p50.0001), anxiety (r ¼ 0.48, p ¼ 0.015) and alertness (r ¼ 0.60, p50.0001) total scores. Weak correlation was found between fatigue total score and the number of work-related injuries occurring in the past 5 years (r ¼ 0.29, p ¼ 0.007); moderate with daytime sleepiness (r ¼ 0.32, p ¼ 0.003). A strong positive relationship was observed between fatigue and disability total score (r ¼ 0.55, p50.0001) and work disability sub-scale total score (r ¼ 0.40, p ¼ 0.0004). Conclusions: This model demonstrates the general relationship between Sleep, Fatigue and the potential impact on performance. Fatigue was strongly associated with depression, insomnia, anxiety and disability total and work disability. A strong negative association between fatigue and alertness may suggest workers’ inability to return to duties that require sustained attention. Future research on the effect of circadian displacement due to shift work as a determinant of post-morbid fatigue, alertness and performance is warranted.


Examining the under-reporting of traumatic brain injuries amongst professional and amateur martial artists Amy Hao, Brian Im, Annika Ginsberg, Teresa Ashman, & Aaron Beattie Rusk Institute of Rehabilitation Medicine, New York, NY, USA

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640 Objectives: The goal of this study was to investigate the incidence of training and competition-related concussions amongst practitioners of various martial arts. Concussions in sports such as professional football and collegiate level contact sports have been a focus of media attention recently due to both the immediate and long-term consequences of concussive injuries. However, little research has been done in the realm of martial arts, particularly outside of Western boxing. It is believed that concussions are common in the practice of martial arts and are both under-reported and under-treated. Methods: This study involved the administration of an anonymous online survey to martial artists of all training levels. Data collected in this surgery included basic demographic data as well as information on types of martial arts practiced, details of training (level of training, length and intensity of training), incidence of head injuries and symptoms, treatment received and persistence of symptoms and its impact on quality-of-life. Results: Eighty-four completed surveys were obtained. Seventy-four subjects reported that they had suffered training or competition related blows to the head. Of these, 10 were subsequently diagnosed with a concussion. An additional 40 people (48% of total subjects, 54% of those who had experienced a martial arts related blow to the head) reported symptoms consistent with a concussion following a blow to the head. Amongst these 40 subjects who likely suffered a mild brain injury without being diagnosed, only eight reported their symptoms and only five sought treatment. Conclusions: The data shows that a large percentage of martial arts practitioners surveyed have experienced symptoms and likely suffered from a mild brain injury related to their training/competition without proper diagnosis and treatment. In the vast majority of these cases, subjects neither reported nor sought medical treatment for their symptoms. It is important to identify these populations at risk for brain injury so that one can improve education and screening in these communities.


Head impact accelerations for brain strain-related responses in contact sports: A model-based investigation Songbai Ji1, Wei Zhao1, Zhigang Li1, Richard Greenwald2, Jonathan Beckwith2, Richard Bolander2, & Thomas McAllister3 1

Dartmouth College, Hanover, NH, USA, 2Simbex, Lebanon, NH, USA, Indiana University, Indianapolis, IN, USA


Objectives: The biomechanical mechanisms of sports-related concussion remain elusive. Both linear (alin) and rotational (arot) accelerations contribute to head impact kinematics on the field; however, they are often isolated in injury studies. It is critical, therefore, to evaluate the feasibility of estimating brain responses using isolated accelerations instead of full degrees-of-freedom (DOFs) impacts. This study investigated the relative sensitivities of regional brain strain-related responses to resultant alin and arot as well as the relative contributions of these acceleration components to the responses. These efforts were based on two finite element (FE) models of the human head (Dartmouth Head Injury Model (DHIM) and Simulated Injury Monitor (SIMon)) independently established and validated. Methods: Triangulated head impact accelerations (n ¼ 100) were randomly and independently generated to serve as model inputs. The ranges of peak alin and arot magnitudes and impulse durations were based on on-field data (17–96 g, 1534–7812 rad s2 and 7–13 ms, respectively), while their directions were random and unrestricted. Peak values of maximum principal strain ("p), strain

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rate ("^p), and von Mises stress (p) accumulated from each simulation (40 ms) were obtained. Linear regressions were performed to analyse the relative sensitivities of strain-related responses to the peak magnitudes and impulse durations of alin and arot. Responses from alin- or arot-only were further compared with their counterparts from full DOFs to quantify their relative contributions. Results: Volume-weighted "p, "^p, and p in the whole-brain, cerebrum and cerebellum significantly correlated to the product of the magnitude and duration of a_rot (instead of independently to either of them) or effectively, the rotational velocity, but not to a_lin. However, the correlations in the brainstem were not consistent. Strain-related responses from a_lin-only were nearly zero, while those from a_rot-only were virtually identical to the full-DOFs ‘ground-truth’ for the majority of the brain, especially for the cerebrum (e.g. volume fractions of element-wise differences diminished at a difference percentage level of 10% and 5% when normalized by the ‘groundtruth’ counterparts for each element and injury-causing thresholds from in vivo animal or real-world injury studies, respectively) for both head FE models. Conclusions: The results suggest that it is necessary to include both rotational impact magnitude and duration into kinematics-based metrics to assess regional brain strain levels and consequently, the risk of strain-induced injury. In addition, "p, "^p and p estimated from arot-only were comparable to the full-DOFs counterparts for the majority of the brain, suggesting the feasibility of using strain-related responses from isolated arot for analyses of strain-induced injury in contact sports without significant loss of accuracy, especially for the cerebrum. These findings consistently found from two head FE models provide important new insights on the biomechanical basis of sports-related concussion.


Mean girls: Sex differences in the juvenile play behaviour of rats following a mild traumatic brain injury Richelle Mychasiuk, Harleen Hehar, Allyson Farran, Irene Ma, & Michael Esser University of Calgary, Calgary, Alberta, Canada Clinical studies indicate that children who experience a traumatic brain injury (TBI) are often the victim of peer rejection, have very few mutual friends and are at risk for long-term behavioural and social impairments. As peer play is critical for healthy development, it is possible that the long-term impairments are associated not only with the TBI, but also with altered play during this critical period of brain development. This study was designed to determine if social dynamics and juvenile play are altered in rats following a mild TBI (mTBI) early in life. Young male and female Sprague Dawley rats were given a mTBI using a modified weight drop technique or a sham injury at post-natal day 30. The rats remained with the cage-mates they were housed with from the time of weaning, but the study was designed to allow for mixed cages (2 mTBI + 2 sham) or homogenous cages (4 mTBI or 4 sham). As rats tend to only play with rats they are familiar with, this permitted play analysis of the greatest range of play partners. One week post-injury, rats were recorded for 10-minute play behaviour sessions that were later scored by two blinded observers. Play was scored for the number of play initiations or attacks, i.e. one rat using his snout to ‘attack’ the others nape and for their defensive manoeuvres which include; evasions (swerving, leaping or running away), complete rotations (rolling over into a supine position which leads to the rat being ‘pinned’), partial rotations (rolling onto their side) and horizontal rotations (both rats stand on their hind legs and ‘fight’ with their fore paws). If a rat does not want to play with the


DOI: 10.3109/02699052.2014.892379

other rat, it can also ignore the play initiation with a non-response. The study found that the presence of a mTBI altered the play fighting relationship, an effect that was dependent on sex and injury status of the pairs. Sham rats were significantly less likely to initiate play with a mTBI rat and were more likely to respond to a play initiation from a mTBI rat with an avoidant strategy. This effect was significantly more pronounced in female rats, as female rats with mTBI were particularly rejected and most often excluded from play experiences. Male rats with mTBI learned normal play strategies from their sham peers (when housed in mixed cages), whereas female rats with mTBI show heightened impairment when in mixed cages. These results suggest possible mTBI-induced alterations in the fronto-temporo-limbic circuits involved in normal social development and that perhaps play therapy should be incorporated into treatment strategies for children with TBI.

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Exploring the King’s outcome scale for childhood head injury in children attending a rehabilitation hospital Peter Rumney1, Ryan Hung1, Laura McAdam1, Arthur Ameis2, Michel Lacerte3, Pierre Cote4, David Cassidy5, Eleanor Boyle5, & Dayna Greenspoon1 1

Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada, 2Universite de Montreal, Montreal, Quebec, Canada, 3 Western University, London, Ontario, Canada, 4University of Ontario Institute of Technology, Oshawa, Ontario, Canada, 5University Health Network, Toronto, Ontario, Canada Objective: Few tools exist to assess and monitor impairment and disability in children with acquired brain injury. The King’s Outcome Scale for Childhood Head Injury (KOSCHI) was developed as an alternative to the Glasgow Outcome Scale. However, limited information is available to support its reliability, validity and responsiveness. A pilot study was designed to (1) develop a KOSCHI data collection form; and (2) determine the feasibility of studying its intra-rater and inter-rater reliability in children with acquired brain injury. Methods: A KOSCHI data collection form was developed after reviewing the literature. Two paediatricians and one paediatric neurologist tested its use in a clinical setting and the form was modified. As a pilot study, a rehabilitation paediatrician then assessed 10 children (aged 5–18 years) with acquired brain injuries (six traumatic, four non-traumatic) and completed a KOSCHI data collection form and assigned a KOSCHI score. After joint training, three additional physicians (one pediatrician, two community physiatrists) independently reviewed the completed KOSCHI data collection form and assigned a KOSCHI score. Each physician was blinded to each other’s scores. A reiterative process was undertaken to discuss the scoring process and revise the KOSCHI data collection form. Results: The percentage agreement within and between examiners was 60% and 70%, respectively. The primary scoring discrepancies concerned KOSCHI 4a vs 4b (low vs high moderate disability) and 4b vs 5a (moderate disability vs good recovery). Conclusions: Initial pilot evaluation suggests moderate agreement at best within and between raters. These findings suggest: (1) better training is needed to improve rater agreement and (2) revisions to the KOSCHI data collection form are necessary to enhance clarity of the collected information and reduce rater disagreement over assigning a KOSCHI score at the moderate disability and good recovery levels. Previous studies used patient charts to assign KOSCHI scores. Clinicians vary in their note-taking when conducting a history and

this could have resulted in the moderate agreement levels found in past literature. It is believed that the use of a KOSCHI data collection form as an interview guide will increase level of agreement, as it will enable clinicians to record all the issues that are needed to assign a KOSCHI score. The revised KOSCHI data collection form will undergo additional pilot testing. These pilots are part of a larger prospective cohort study that examines KOSCHI intra-rater and inter-rater reliability, whether the different levels of the KOSCHI correlate with other outcome measures of overall health status and whether the KOSCHI can detect changes in outcome over time. It is expected that these research projects will expand the use of the KOSCHI and maximize its clinical reliability.


Interpreting non-verbal communication cues following TBI: Understanding relationship intentions of others Kelli Evans, & David Evans University of South Alabama, Mobile, AL, USA Background: This study examines a key element of social communication: how adults with TBI interpret the non-verbal cues of new conversational partners to form impressions of relationship closeness during face-to-face dialogue. Methods: Participants included 12 male adults with moderate-tosevere TBI and 10 typical comparison peers. Groups were matched for age, gender and education. Stimuli consisted of the Relationship Closeness Induction Task (RCIT)—a 29-item questionnaire for inducing relationship closeness through reciprocal self-disclosure during conversation. Participants completed the RCIT three separate times in counterbalanced orders. Conversational partners for the RCIT were three actresses trained to convey similar verbal answers to the RCIT questions, but to produce different non-verbal cues: solicitation (i.e. flirting), neutral and rejecting. Following each conversation, the participants filled out a 10-item Likert-type questionnaire about the experience. Participants also selected, from a list, personality traits for each actress. Results: Likert statements: The Shaprio-Wilk test of normality showed non-normal distribution of scores; therefore, non-parametric statistics were used. The Friedman test was performed for each statement to determine within-group significant differences across conditions (p50.05). Post-hoc pairwise comparisons used the Wilcoxon signedrank with a Bonferroni correction (p50.0166). Both groups consistently showed the same pattern of response, rating the rejecting condition significantly lower than the neutral or solicitation condition. In addition, solicitation was rated significantly higher than neutral in response to four questions (e.g. How much did this person like you?, How likely is it that this person could be your friend?, Did she enjoy talking with you?). A Mann-Whitney test revealed no significant differences (p50.05) between groups on any Likert question. Personality traits: Descriptive statistics were calculated for selection of 10 engaging personality traits (e.g. friendly, warm, flirty) and nonengaging personality traits (e.g. unfriendly, cold, distracted). For the flirting condition, both participant groups reported 100% engaging traits. For the neutral condition, 87.9% of the responses from the TBI group were engaging traits compared to 78.1% from the comparison group. The TBI group showed more variability in selection of traits for the neutral condition, with 37.5% of the response consisting of the words boring, unfriendly and sad; in contrast, the control group only selected the words shy, quiet and nervous. For the rejecting condition, 35.7% of responses from the TBI group were engaging traits compared with 27.3% from the comparison group. Conclusions: Participants with TBI were similar to the typical comparison group in rating relationship closeness resulting from

642 conversations with unfamiliar females who produced neutral, rejecting and solicitation non-verbal cues. They rated the rejecting actress as less close than either the neutral or solicitation actress. These results suggest males with TBI are able to correctly interpret non-verbal cues in real-time conversations with unfamiliar partners.


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Promoting employment success through workplace accommodations following traumatic brain injury and electrical injury Mary Stergiou-Kita1, Elizabeth Mansfield1, Angela Colantonio1, David Cassidy2, Joel Moody3, Oshin Vartanian4, Manuel Gomez5, Bonnie Kirsh6, Marc Jeschke5, Mark Bailey1, & Vicki Kristman7 1

Toronto Rehabilitation Institute, Toronto, Canada, 2University of Southern Denmark, Odense, Denmark, 3Electrical Safety Authority, Toronto, Canada, 4Defence Research and Development Canada, Toronto, Canada, 5Sunnybrook Research Institute, Toronto, Canada, 6 University of Toronto, Toronto, Canada, 7Lakehead University, Thunder Bay, Canada Objectives: Returning to work following a workplace brain or electrical injury can be challenging due to the confluence of physical, cognitive and emotional impairments that may arise. Workplace accommodations assist injured workers to successfully return-to-work and are legally mandated through human rights legislations. However, very little is understood about the types of workplace accommodations that are relevant following a brain or electrical injury and how factors within the worker (e.g. injury severity), occupation (type, demands, flexibility) and workplace (e.g. supports, safety culture) interact to facilitate positive outcomes. The aim of this presentation is to understand the process of workplace accommodations following brain and electrical injuries, from both injured worker and employer representative perspectives. Methods: Thirty-seven semi-structured telephone interviews were conducted—13 with electrical injured workers, 12 with workers who sustained a brain injury and 12 with employer representatives in the electrical sector in Ontario, Canada. Thematic analysis was employed to identify themes related to the return-to-work process, the request and provision of workplace accommodations. Thematic analysis involves the following steps: (1) becoming familiar with the data; (2) generating initial codes from the data; (3) categorizing codes into initial themes; (4) identifying the key themes related to the research objective and questions; (5) defining and naming the key themes; and (6) producing a scholarly report of the analysis. Results: Accommodations were narrowly defined in relation to physical work restrictions and graduated return to duties. Issues that challenged the accommodations process include: (i) communication difficulties; (ii) issues with perceived injury severity and legitimacy; (iii) workplace culture issues; and (iv) issues related to ‘paying lip’ service to accommodations with inadequate follow through. The individual, injury, workplace and institutional elements that workers’ perceived to most directly impact their return-to-work experiences included: (1) their own personal resources; (2) their job characteristics; (3) the workplace setting; (4) their injury elements; (5) the workers’’ compensation context in which they operated; and (6) the supports and advocacy they were provided. Process elements that facilitate the effective provision of workplace accommodations included: (i) finding a ‘just right’ fit between workers’ abilities and assigned tasks and duties; (ii) effective communication between

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relevant stakeholders; (iii) prompt response to needs and making changes to accommodations as required; and (iv) having a knowledgeable individual in a position of power to advocate on the worker’s behalf. Conclusions: Further education regarding workplace accommodations is required to broaden employers’ and workers’ understanding of accommodations. Clinicians must consider a number of factors that can influence the return-to-work process. These include the legitimacy of the injuries and resulting impairments, knowledge regarding accommodation legislations, institutional structures such as workers’ compensation systems, social relations at work (with employers and co-workers) and broader economic imperatives.


Increased connectivity between the sensorimotor cortex and dorsal attention network in children after mild-to-moderate traumatic brain injury Sarah Risen1,2, Anita Barber1, Stewart Mostofsky1, & Stacy Suskauer1 1

Kennedy Krieger Institute, Baltimore, MD, USA, 2Johns Hopkins University School of Medicine, Baltimore, MD, USA Objectives: Children with mild–moderate traumatic brain injury (TBI) experience a broad range of short-term functional deficits. In adults, resting state fMRI (rs-fMRI) has revealed altered functional connectivity within the default mode network (DMN) after mild and moderate TBI, with strength of connectivity correlated with neurocognitive task performance. The purpose of this study was to first evaluate resting state connectivity of the DMN and the anti-correlated dorsal attention network (DAN) in children in the sub-acute phase of mild–moderate TBI and then to explore the relationship between strength of connectivity and measures of neurological function. Methods: Rs-fMRI was completed in 14 children aged 11–17 years with mild-to-moderate TBI 2 months post-injury and compared to rs-fMRI data from 14 age- and gender-matched typically-developing controls (TDC). Functional connectivity was evaluated, separately for DMN and DAN, by examining whole brain connectivity with three seeds in each network and then averaging the three seed maps to develop one DMN and one DAN map per subject. Between-group contrasts were used to identify differences in connectivity with the DMN or DAN. Brain–behaviour relationships involving areas of between-group differences in connectivity were further examined within the TBI group; correlations were sought between strength of connectivity and performance on relevant functional measures completed outside of the scanner on the same day as imaging. Results: Compared to TDC, children with TBI showed significantly greater connectivity between the DAN and bilateral primary sensorimotor cortex (SM1) and significantly lesser connectivity between the DMN and right SM1 and caudate. In children with TBI, connectivity between the DAN and left SM1 negatively correlated with measures of motor control: Physical and Neurological Examination of Subtle Signs (PANESS) scores for dysrhythmia with timed motor movements (r ¼ 0.62, p ¼ 0.018), total overflow movements (r ¼ 0.59, p ¼ 0.027) and total score (r ¼ 0.54, p ¼ 0.045), in all cases indicating that more left SM1 connectivity was associated with better performance. Connectivity between the DAN and right SM1 negatively correlated with Lafayette Grooved Pegboard z-scores (dominant hand, r ¼ 0.62, p ¼ 0.02), demonstrating that more right SM1 connectivity was associated with slower performance. Conclusions: Using rs-fMRI, children with mild–moderate TBI demonstrate robustly increased connectivity between the dorsal attention


DOI: 10.3109/02699052.2014.892379

network and bilateral SM1 in the sub-acute phase after injury. Correlations with sensorimotor performance data suggest that this altered connectivity has implications for motor function after even mild childhood TBI. Similar to task-based fMRI studies in adolescents and adults with TBI indicating compensatory increased neural activation to achieve task performance similar to controls, connectivity between the dorsal attention network and left SM1 may reflect a need to recruit the DAN to facilitate external attention for more effective motor performance.



Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada

Subject-specific evaluation of mTBI with diffusion MRI: Statistical considerations

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Sylvain Bouix1, Phoebe Cai1, Ofer Pasternak1, Ross Zafonte2,3, & Martha Shenton1,4 1

Brigham & Women’s Hospital, Boston, MA, USA, 2Spaulding Rehabilitation Hospital, Boston, MA, USA, 3Massachusetts General Hospital, Boston, MA, USA, 4Veterans Affairs Boston Healthcare System, Boston, MA, USA Objectives: For many patients who suffer from persistent postconcussive symptoms (PPCS) following a mild traumatic brain injury (mTBI), conventional imaging does not detect brain abnormalities. This research focuses on improving a recently developed, more powerful procedure that employs diffusion tensor imaging (DTI) to create a normative brain atlas of the fractional anisotropy (FA) of each of 145 regions of interest in the brain. The existing method assumes that the distribution of FA values in each region over a population of healthy individuals is normally distributed. The work presented here shows that applying a power transform to the data to better fit a normal distribution can increase the power of the method. Methods: Previous work uses a set of 45 healthy individuals to estimate ‘reference’ distributions of FA values in 145 regions. Eleven subjects with PPCS were tested against this atlas by computing the zscore of the FA against the mean and standard deviation of the healthy subjects in each region. Eleven matched controls were also tested against this atlas to assess its specificity and sensitivity. The DTI data was acquired on a 3T GE MRI scanner. The proposed improvement consisted of applying a Box-Cox power transformation procedure so that the FA values in each ROI better fitted the normal distribution. This transformation was applied to all subjects and the normative atlas was estimated following the method described above. A Lilliefors test was applied to each ROI in the original and transformed data to check for normality. Finally, the highest absolute z-score (across all ROIs) of each of 11 mTBI subjects and their 11 matched controls was used as the metric for evaluating the Area under the Curve (AUC) for both the original and transformed data. Results: When testing for normality of the distribution of FA over the 45 controls in each ROI, the Lilliefors procedure flagged 10 ROIs as non-normally distributed in the raw data, but only oneROI when using Box Cox transformed data. When using the absolute largest z-score to classify PPCS from Healthy, the original atlas produced an AUC of 0.76 (sensitivity ¼ 0.64, specificity ¼ 0.82), whereas transformed data gave an AUC of 0.93 (sensitivity ¼ 0.73, specificity ¼ 1). Conclusions: Although DTI is sensitive to changes in the brain resulting from mTBI, using raw FA values to form a normative atlas may not be an optimal method for detecting abnormalities in PPCS subjects. Indeed, applying a Box-Cox transformation to the data improves the sensitivity and specificity of the method for detecting abnormalities in more PPCS subjects and returning fewer false positive results in normal subjects.

Long-term functional and psychological outcomes after hypoxic-ischaemic brain injury Nora Cullen, & Meredith Harbinson

Objectives: To assess the differences in long-term functional outcomes between case-matched hypoxic-ischaemic brain injury (HIBI) and traumatic brain injury (TBI) cohorts 4–11 years after inpatient rehabilitation. Secondly, to determine long-term functional and psychosocial outcomes in the HIBI population. Methods: Eleven patients with HIBI and 11 patients with TBI that attended the same inpatient neurorehabilitation programme were matched on age, admission Functional Independence Measure (FIM) score and acute care length of stay (ALOS). Data from the time of rehabilitation admission and discharge were leveraged from an existing ABI database at this facility. Participants were contacted by telephone and completed assessments evaluating long-term functional and psychosocial outcomes. Long-term functional outcomes were assessed using the FIM, Disability Rating Scale (DRS), Personal Health Questionnaire (PHQ-9) and the Mayo-Portland Adaptability Inventory (MPAI-4). Results: At telephone follow-up 4–11 years after rehabilitation, patients with HIBI performed worse on all measures of functional outcome compared to patients with TBI. Patients with HIBI had significantly lower FIM motor and cognitive scores than patients with TBI (motor FIM mean 75.3 ± 20.6 vs 88.1 ± 4.78; p50.01; cognitive FIM mean 25.5 ± 5.80 vs 32.7 ± 2.54; p50.01). Patients with HIBI also had significantly worse scores on the DRS, PHQ-9 and MPAI-4 at follow-up (p ¼ 0.01, p ¼ 0.04, p ¼ 0.01, respectively). There was no significant difference in FIM motor, FIM cognitive or DRS gains made from rehabilitation discharge to follow-up between the groups (p ¼ 0.09, p ¼ 0.11, p ¼ 0.66, respectively), although there was a trend towards smaller gains in the HIBI population. Conclusions: Results show that patients with HIBI have worse longterm functional outcomes than patients with TBI after controlling for age and injury severity. These findings suggest that functional recovery including cognitive, motor, psychosocial and behavioural factors is less complete for patients with HIBI compared to patients with TBI. Further reserch is needed to assess why these differences occur and determine how rehabilitation can be targeted to each population to maximize rehabilitation gains and functional outcomes.


The continuum of care: How working ourselves out of a job benefits everyone Geoff Sing The Cridge Centre for the Family, Victoria, BC, Canada Until a 100% foolproof method to preventing brain injuries is developed, there will always be new survivors of a brain injury who will need rehabilitation and lifeskills support on their road to recovery. In British Columbia there is a critical need to have survivors of a brain injury, who are supported by taxpayer-funded rehabilitation programmes, become independent as quickly as possible. The financial pressures for the overall healthcare system are becoming unbearable for BC tax revenues. In time, if the funds are not used more efficiently,

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644 the system will not be able to support the new survivors that will always be encountered. For the majority of survivors of a brain injury, lifelong care after brain injury is an unrealistic, unsustainable expectation. However, the majority of survivors will, in fact, need support. It is in everyone’s best interest that programmes are developed to fit within these budgetary constraints while ensuring the survivor receives the necessary services and supports to aid them in becoming productive, contributing citizens in their community. Ironically, there are other reasons to work ourselves out of a job. It is recognized that brain injury has a lifelong impact to a survivor. However, the impact does not need to be a detriment. Survivors of a brain injury can and do live well post-injury. When critical supports are available, albeit for a limited time, service providers must ensure the rehabilitation is goal-specific, time-specific and has realistic and measurable outcomes. In doing so, one is able to move the survivor forward in life and stay within limited budgets. When the survivor has attained the goals within their care plan, carers have worked ourselves themselves of a job and can now provide services for another. The scenario above is relevant to nations around the world. This presentation will address: the Continuum of Care of support for survivors of a brain injury, the organization’s goal to work ourselves out of a job for the survivors supported and the steps taken in developing appropriate housing, teamed with meaningful community involvement for survivors of a brain injury to prepare survivors to live independently with success. Housing options include: 24/7 residential care, independent apartment living with support, community living with support and a programme for survivors who are completely independent but may be in isolation. Finally, there will be discussion with regard to brain injury and homelessness and the need to appropriately house survivors now or there will be a greater detrimental cost to society later.


Disrupted structural connectome predicts cognitive performance in people with diffuse traumatic brain injury: A graph theoretical analysis Junghoon Kim1, Drew Parker2, John Whyte1, Tessa Hart1, John Pluta3, Madhura Ingalhalikar2, H. Branch Coslett3, & Ragini Verma2 1

Moss Rehabilitation Research Institute, Elkins Park, PA, USA, Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA, 3Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA


Objectives: Graph theoretical network analysis that quantifies structural connectivity at the whole-brain level may show promise in facilitating research on the relationship of white matter pathology to neuropsychological deficits in traumatic brain injury (TBI), for several reasons. The neuropathology of TBI is known to involve multiple neural circuits to display large heterogeneity among individuals. In addition, the higher-level cognitive processes known to be affected by TBI are also known to be dependent on widely distributed neural networks. By conducting graph theoretical analysis on a diffusion tensor imaging (DTI) based structural connectome, the present study aimed to characterize local and global network measures in people with diffuse TBI and relate them to neuropsychological dysfunction. Methods: Twenty-two people with moderate-to-severe TBI with mostly diffuse pathology and 18 demographically matched healthy controls underwent DTI and neuropsychological assessment. Three cognitive domains were assessed: executive function, verbal learning and processing speed. The structural connectome was created by

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conducting probabilistic tractography on 68 cortical regions and 27 sub-cortical structures. Connection strength between each node was compared between people with TBI and controls. In addition, global network measures including density, shortest path length, modularity and transitivity were calculated to quantify the whole-brain level connectivity. Results: Participants with TBI were significantly impaired relative to controls in all three cognitive domains. Local edge-wise analysis demonstrated that participants with TBI showed disproportionately reduced structural connectivity arising from sub-cortical areas including thalamus, caudate and hippocampus. Global network analysis revealed that the shortest path length in the brains affected by TBI was longer compared to controls while other network measures did not show group differences. Shortest path length was also correlated with performance in executive function (rho ¼ 0.502; p ¼ 0.017) and verbal learning (rho ¼ 0.573; p ¼ 0.005) in people with TBI but, somewhat surprisingly, not with processing speed. Conclusions: The finding of weakened connection strength from subcortical areas is in line with previous neuropathologic, morphometric and simulation studies that reported disproportionate vulnerability of deep grey matter structures in diffuse TBI. The increased shortest path length metric in people with TBI may mean that the injured brain requires longer pathways to maintain connectivity between the same regions compared to the uninjured brain. This could lead to reduced efficiency in the brains affected by TBI, which may in turn help to explain poor performance on some cognitive tasks.


Prognostic value of the head abbreviated injury score, injury severity score and Glasgow coma scale in patients with traumatic brain injury Hassan Al-Thani1, Ayman El-Menyar2, Ahmad Zarour1, & Husham AbdulRahman1 1

Hamad General Hospital, Doha, Qatar, 2Weill Cornell Medical School, Doha, Qatar Background: Traumatic brain injury (TBI) poses worse outcomes worldwide. This study aimed to analyse the prognostic value of the three scoring tools including head abbreviated injury score (AIS), the injury severity score (ISS) and the Glasgow Coma Scale (GCS) after TBI. Methods: Data were retrospectively collected from patients with TBI at the level 1 trauma centre in Qatar. Patients’ demographics, mechanism of injury, head AIS, ISS and GCS were documented at admission. The primary end-points were in-hospital mortality and hospital length of stay (LOS). Student t-test, correlation and multivariate analyses were performed. Results: A total of 1665 patients with TBI were admitted over 4 years (2008–2011) with a mean age of 28 ± 16 and 93% of them were males. The common mechanism of injury was motor vehicle crashes (MVCs) and falls from height (51% and 35%, respectively). The mortality rate was 11.7% among TBI patients. The mean ISS, GCS and Head AIS were 33 ± 10 vs 16 ± 9, 5 ± 4 vs 13 ± 4 and 4.4 ± 1 vs 3 ± 1, respectively, in those who died during hospital course vs survived cases, p ¼ 0.001 for all. The best independent predictors for mortality were head AIS (adjusted OR ¼ 1.93) followed by GCS (aOR ¼ 0.81), ISS (aOR ¼ 1.10) and age (aOR ¼ 1.03), p ¼ 0.001 for all. LOS was correlated significantly but with various strength with GCS (r ¼ 0.25), followed by ISS (r ¼ 0.25), head AIS (r ¼ 0.17), age (r ¼ 0.08), p ¼ 0.001 for all. Conclusion: TBI has a serious impact in young age, particularly after MVCs. There are needs for aggressive prevention measures to reduce mortality and LOS in this sub-set of the population. Further studies are required to validate the best scoring tool for risk stratifications after TBI.


DOI: 10.3109/02699052.2014.892379


Hearing screening in young children with traumatic brain injury Julie Haarbauer-Krupa1, Colleen O’Rourke2, Akilah Heggs Davis2, Brian Herrmann1, Jill Maddox1, & Lisa Matesevac1 Children’s Healthcare of Atlanta, Atlanta, GA, USA, 2Georgia State University, Atlanta, GA, USA

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Objective: Children aged 5 years and younger have the highest rate of emergency room visits for traumatic brain injury (TBI). Previous reports on the rate of hearing loss following TBI in children ranges from 23–64%. This presentation will report the rate of hearing screen failure in elementary school-aged children enrolled in a longitudinal study investigating outcomes related to language and academic performance. Methods: Children between the ages of 6–10 years with a history of TBI or orthopaedic injury at or before age 5, recruited from a trauma registry and community outreach, were enrolled in a longitudinal study comparing performance on cognitive, language, reading and adaptive behaviour. At the initial study visit, children were screened for hearing loss following guidelines established by the ASHA and the American Academy of Audiology (2011) and reviewed by an audiologist. Hearing screening failure was defined as failure to respond to speech frequencies (1000 Hz, 2000 Hz and 4000 Hz) at 20 dB HTL after three attempts. These children were referred to their paediatrician for further assessment. Parent report of follow-up services accessed including hearing assessment was collected. Results: Participants were 54 children between the ages of 6–10 years old (mean age ¼ 8.12 years) at the time of their initial study visit who sustained a TBI (n ¼ 27) or orthopaedic injury (n ¼ 27). Time since their injury was at least 1 year (mean ¼ 4.39 years). TBI severity ranged from mild (GSC 13–15; 55.6%) to moderate (GSC 9–12; 18.5%) and severe (GSC48; 14.8%). The primary injury mechanism was falls (55.6%) followed by motor vehicle accidents (14.8%), hit by object (7.4%), other (7.4%) and MV–pedestrian accidents (3.7%). The rate of hearing screening failure for the TBI group was 18% compared to a rate in the OI control group of 11%. Caregivers reported inconsistent hearing assessment and screening efforts following their child’s TBI and did not identify that their child had a hearing loss. One child referred for further assessment from the study was fitted with hearing aids. Conclusions: Hearing loss is a known consequence in children with TBI. Early detection and intervention can improve a child’s functioning at school. Children in the current study received their care in the emergency department and the majority sustained a mild TBI. Caregiver identification of hearing loss or report of hearing assessment shows inconsistent approaches for hearing loss identification in a childhood TBI population. Findings indicate the importance of establishing hearing screening procedures in a population at risk for hearing loss that can be undetected and influence outcome.


The impact of traumatic brain injury (TBI) on the survivor’s spouse/partner using an existential paradigm Elva Hoxie Saybrook University, San Francisco, CA, USA

Objectives: The purpose of this study was to examine the experience of the non-injured spouse/partner using an existential phenomenological paradigm. The objective was to gain a better understanding of the experiences of the traumatic brain injury (TBI) survivors’ spouse/partner to develop supportive interventions. A critical review of the literature on TBI shows the complexity of brain function and illustrates how damage negatively affects the survivor. Trauma to the brain frequently causes pervasive cognitive dysfunction and a variety of personality changes, including impulsivity, unpredictability, anger, lack of critical thinking, lack of empathy and lack of awareness about one’s own impairments. These problematic issues have a negative impact on the marital/couple relationship, family dynamics and relationships in general. Yet, meaningful and supportive relationships can contribute to the TBI-survivor’s coping and rehabilitation process from TBI-related life changes and psychological trauma. Methods: The research for this study was based on a combination of the following three nursing methods; concept analysis, concept advancement and integrative review. The main tenet and value of these theoretical designs are 2-fold: (1) the methods are based on health research; and (2) the conclusions promote practical utilization. A synthesis of published narratives on the experiences of spouses whose partner suffered from TBI and the researcher’s personal experiences were used to gather data. Results: The resulting information from the study contributes an additional guide for directing healthcare professionals and practitioners in developing care plans and supportive mental health interventions. The concept of processing changes and adapting to a new life post-tragedy was referred to as transcending existential shattering. This was exemplified by the human impact of TBI on the victim and the family members. The process was illustrated by a visual model based on Peirce’s diagrammatic reasoning. Visual/diagram was used for the purpose of clarifying ambiguities and broadening the understanding of concepts. The existential perspective emphasized the individualistic interpretation of experiencing catastrophic events. The diagram illustrates the existential themes of perception and recreating meaning in one’s life as an on-going process. Conclusion: This research adds to the growing body of literature on TBI by addressing the phenomenological experiences of TBI survivor’s spouse/partner from an existential perspective. The study presents how the changes, challenges and skills for adaptation in the aftermath of TBI can be processed from an existential perspective. Raising the existential consciousness provides the opportunity to recreate, rebuild and reframe one’s foundational worldview. The existential themes address the potentials for exercising one’s innate abilities for adapting to challenging changes. The aim is to help facilitate the process of learning to live with challenges and transcend the psychological pain into existential meaning.


Ethical and cultural considerations in the management of individuals with brain injury Sabahat Asim Wasti Berlin Medical and Neurological Rehabilitation, Abu Dhabi, United Arab Emirates In the last couple of decades better emergency and acute care of an individual with brain injury has resulted in better outcomes. However, the net result of this improved survival is that many patients are surviving with permanent impairments leading to disabilities. These disabilities can range from subtly mild to severe. Those caring for patients with brain injury have to be alert to the fact that any one of

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646 their clients, including those with so called mild injury, may be sufficiently impaired, so as to place him or herself at risk of being exploited or violated. It is, therefore, a key role of brain injury teams to support and protect their clientele from harm that may come to them directly because of impaired cognition or physical impairments. However, in undertaking this duty the teams must not become overbearing and refrain from altering the basic and normal dynamics of a client’s pre-morbid role. It is imperative that all professionals engaged in providing care educate themselves in basic ethical and cultural aspects of each individual case and formulate all management plans in the light of this knowledge. In doing so the principles of case-based ethics or casuistry must be understood and adhered to. Casuists claim that ethics is primarily a matter of attention to details or circumstances of a case. In order to launch and maintain the process of case-based ethics, brain injury teams must manage each case within an ethical framework. All teams should acknowledge that each case has some ethical issues and in every case the emphasis and considerations should be placed on longer-term outlook and final outcome and judgements should be made in the context of several months or even years. In this presentation basic principles of ethics will be introduced and topics such as consent in the context of cognitive and consciousness disturbance, decision-making capacity, surrogate decision-making and matters related to disturbance of consciousness, including passive and active euthanasia will be discussed. On the cultural aspect of caring for individuals with brain injury this study will be introducing the construct of culture and cultural awareness. It will argue for the need for each member of the brain injury team to achieve an acceptable level of cultural competency. This study will also be giving a list of measures that can help to keep the personal bias and prejudices outside the clinical practice. With increasing burden of health and social care that is assigned to brain injury, there is a danger of professionals focusing on health economics and ignoring the importance of ethical and cultural aspects of care. This presentation aims to highlight the vital importance of these issues.


Pharmacological treatment of interictal psychoses in patients with epilepsy, a systematic review Mebeline Boon, & Bert ter Mors GGZ Oost Brabant, Boekel, The Netherlands Objectives: Emil Kraepelin already pointed out the association between epilepsy and psychosis 100 years ago. Current research states that the lifelong prevalence of all psychotic disorders in patients with epilepsy ranges from 2–7%, of which 10–30% are interictal. These patients display classical schizophrenia-like psychotic symptoms with hallucinations and paranoid delusions. Typical and atypical anti-psychotic drugs are widely used by psychiatrists to treat psychotic disorders resulting from psychiatric or neurologic causes. The combination with epilepsy, drug-interaction and the effect of anti-psychotic medication on the seizure threshold are complicating factors. Evidence for the efficacy of pharmacological treatment is lacking, therefore a systematic review was performed of the literature to provide evidence for the guideline for the treatment of interictal psychosis in epilepsy for Kempenhaeghe, a categorical epilepsy treatment centre in Heeze, the Netherlands. The goal of this review is to establish the current evidence state on the subject. The research question is: Which anti-psychotic medication is effective and safe in the treatment of interictal psychosis? Methods: This study performed a systematic literature search in the electronic databases: Medline, Embase, Psychinfo and the Cochrane database. Two independent reviewers made a first selection on the basis of the inclusion criteria, based on the information in the titles

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and abstracts of the articles that were the result of the search strategies. If necessary the selection was made with the full text version of the article. If these two reviewers did not agree a third reviewer decided. References in the articles found were checked for further inclusion. Data extraction: (a) Study characteristics; (b) Patient characteristics; and (c) Intervention characteristics. Quality assessment: Cohort studies and Case control studies were assessed with the appropriate CASP (Critical Appraisal Skills Program) assessment tools. Results: The search yielded 206 articles. After application of the inclusion- and quality criteria in the final selection, six articles remained; three prospective cohort studies, one case series and two case reports. Conclusions: The literature provides an indication that anti-psychotic medication can be effective in interictal psychosis in epilepsy (grade 3). Possibly the dose needed in interictal psychosis in epilepsy can be lower than in the treatment of schizophrenic psychosis (grade 3). Possibly clozapine lowers the seizure threshold, but the literature is contradictory (grade 3). There is no evidence that other antipsychotic medications lower the seizure threshold (grade 4). There is not one anti-psychotic medication especially effective in interictal psychosis in epilepsy (grade 4). The literature does not provide evidence about the duration of treatment with anti-psychotic medications. Based on this evidence the taskforce defined recommendations for the guideline. The review and the guideline will be presented.


Exploring the relationship between cognitive flexibility and psychological flexibility after acquired brain injury Diane Whiting1, Frank Deane2, Joseph Ciarrochi3, Hamish McLeod4, & Grahame Simpson5,6 1

Liverpool Brain Injury Rehabilitation Unit, Liverpool Hospital, Sydney, NSW, Australia, 2School of Psychology, University of Wollongong, Wollongong, NSW, Australia, 3School of Social Sciences and Psychology, University of Western Sydney, Milperra, NSW, Australia, 4Institute of Health and Wellbeing, University of Glasgow, Scotland, UK, 5Rehabiliation Studies Unit, University of Sydney, Sydney, NSW, Australia, 6Ingham Institue of Applied Medical Research, Liverpool, NSW, Australia Objectives: Psychological inflexibility has been linked to a wide range of mental health problems and is a primary target for change in Acceptance and Commitment Therapy (ACT). It has been proposed that a component of psychological flexibility is cognitive flexibility but this has not been empirically established. Any link between psychological and cognitive flexibility becomes particularly pertinent when implementing ACT with people who have impaired cognitive flexibility such as individuals with an acquired brain injury (ABI). This study measured psychological and cognitive flexibility in individuals with an acquired brain injury to determine whether cognitive flexibility is a pre-requisite of psychological flexibility. Methods: Seventy-five participants with an ABI were recruited from a specialist brain injury rehabilitation unit and given self-report measures of mood (Depression Anxiety Stress Scale-21, Positive and Negative Affect Scale), psychological flexibility (generic and braininjury specific forms of the acceptance and action questionnaire; AAQ-II & AAQ-ABI), avoidance (Appraisal of Threat and Avoidance Questionnaire) and neuropsychological measures of cognitive flexibility (Wisconsin Card Sort Test, Stroop Test and Controlled Oral Word Association Test). Participation occurred an average of 21 months (range ¼ 1–136) after the index injury.


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DOI: 10.3109/02699052.2014.892379

Results: The measures of psychological flexibility correlated with measures of psychological distress in the predicted direction, with higher levels of psychological flexibility significantly associated with lower levels of psychological distress (DASS-21, Depression, rs ¼ 0.67) and avoidance (ATAQ-Threat, rs ¼ 0.66 and ATAQAvoidance, rs ¼ 0.72). Functional measures of cognitive flexibility that assess the ‘ability to shift’ were not related to psychological flexibility or distress. Broader measures of cognitive flexibility that capture additional cognitive processes, such as the ability to suppress habitual responses, were correlated with psychological flexibility. This relationship became non-significant when general intelligence was controlled in most measures of cognitive flexibility with the exception of verbal generativity (COWAT, rs ¼ 0.39, p50.01) and verbal inhibition (Stroop, rs ¼ 0.35, p50.05). Conclusions: Components of cognitive flexibility, namely verbal generativity and verbal inhibition, are significantly related to psychological flexibility, even after controlling for general intelligence in individuals with an ABI. This suggests an overlap between the constructs of cognitive flexibility and psychological flexibility within this population. How impaired cognitive flexibility impacts on achieving treatment-induced gains in psychological flexibility in those with an ABI warrants further exploration. The data suggest that cognitive flexibility may not be a pre-requisite in order to achieve psychological flexibility, but it probably helps.


A case of cerebral herniation from cerebral hypotension early after decompressive craniectomy associated with cerebral hypoxemia (PbrO2) Francis Bernard1,2, Ve´ronique Brunette1, Paul J. Khoueir1, Yoan Lamarche1, & Mathieu Laroche1 1

Hoˆpital du Sacre´-Coeur de Montre´al, Montre´al, Que´bec, Canada, University of Montre´al, Montre´al, Que´bec, Canada


This study reports the case of a young patient who developed cerebral hypotension while still in the first week of treatment for elevated intracranial pressure (ICP), with the brain still herniating through a decompressive craniectomy (DC). To the authors’ knowledge, this is also the first case of the so-called ‘sinking skin flap syndrome’ occurring this early after DC and being associated with cerebral hypoxemia. The patient ultimately recovered to go back home. The patient’s initial GCS was 8, with skull fractures, cerebral contusions and a midline shift of 7 mm. He was managed medically for 24 hours before a right DC was successfully performed. Medical therapy was weaned and sedation was stopped on day 7. The next day, both pupils progressively became dilated over 2 hours while the ICP dropped from 10 to 2 mmHg and PbrO2 from 25 to 6 mmHg. The monitors were changed to confirm accurate measurements. A scan showed herniation of both temporal lobes, absent basal cisterns, cerebral oedema and herniation through the craniectomy. Treatment was initially resumed for elevated ICP. A diagnosis of cerebral hypotension was made 24 hours later and the patient put in a supine position. The PbrO2 returned to the normal range within minutes while the ICP increased to 21 mmHg. The pupils progressively became reactive over 48 hours when another scan showed re-opening of

the basal cisterns. Subsequently, an intermittent CSF leak became apparent though a base of skull fracture. Until the leak resolved, the patient could not be semi-recumbent without the PbrO2 dropping and the pupils becoming less reactive. The GOSE at 3 months is 6. The diagnosis of cerebral hypotension can be challenging, particularly during the acute phase of TBI, while brain still herniates though the craniectomy. This is compounded by the fact that a CSF leak can be occult. The loss of CSF combined with the absence of skull allows the brain to ‘sink’ and herniate, causing brainstem compression. The management of this condition is counter-intuitive during the first week of elevated ICP management. The fact that cerebral hypoxemia accompanies this condition makes it critical. It highlights the limitation of usual neurocritical care monitoring and the potentially unrecognized adverse effects of DC. DC is still being performed routinely to treat refractory ICP, although the DECRA trial showed no benefit of it. It is possible that clinical judgement about the perceived benefit of DC is adequate, while a randomized controlled trial failed to routinely look for complication of DC that negatively affect outcome. Careful and meticulous care should be provided after DC, even though elevated ICP has resolved.


Developmental and gender influences on executive function following concussion in youth hockey players Ilyse Lax1, Melissa Paniccia1, Sabrina Agnihotri2, Nick Reed2, Evan Garmaise3, Mahdis Azadbakhsh3, Justin Ng3, & Michelle Keightley2 1

Department of Occupational Science and Occupational Therapy (University of Toronto), Toronto, Ontario, Canada, 2Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada, 3Graduate Department of Mathematics and Statistics (York University), Toronto, Ontario, Canada Background: Concussion is the most common athletic injury in youth. As the developing brain is more vulnerable to concussive injury, a greater understanding of how concussion affects executive functioning (EF) in youth athletes is needed. Objectives: (1) What are athlete-specific normative data for measures of EF? (2) What are the effects of age, gender and concussion history on EF in youth hockey players? Methods: This 3-year cross-sectional and longitudinal multiple cohort study examined data obtained from 211 hockey players between 8–15 years of age. Data was analysed using a mixed-effects modelling approach. Results: Normative analyses revealed significant age and gender effects on measures of EF. Multiple effects of concussion history on measures of cognitive flexibility (F ¼ 2.48, p ¼ 0.03) and psychomotor speed (F ¼ 2.59, p ¼ 0.04) were also found. Conclusion: Age, gender and concussion history have profound effects on EF in youth athletes. These factors must be considered in the clinical management of concussion. Relevance: This study provides rehabilitation professionals with foundational knowledge to better manage cognitive sequelae following sports-related concussion and ultimately enable returnto-play.


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Recovery from brain injury after prolonged disorders of consciousness: Outcome of patients admitted to rehabilitation with 1–8 year follow-up

Factors underlying the physical and mental health of veterans with chronic multi-symptom illnesses

Douglas Katz1, Meg Polyak2, Daniel Coughlan2, Emily Goff2, & Meline Nichols2 1


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Boston University School of Medicine, Boston, MA, USA, Braintree Rehabilitation Hospital, Braintree, MA, USA

Objectives: To characterize course of recovery, long-term outcome and prognostication for patients with prolonged disorders of consciousness (DOC) after brain injury. Methods: Design: Retrospective review. Setting: DOC brain injury programme in an inpatient rehabilitation facility. Participants: Consecutive series, 64 patients with traumatic (TBI) and non-traumatic brain injury (non-TBI) in a vegetative state (VS) or minimally conscious state (MCS) on rehabilitation admission. Intervention: 1–8 year followup of time to resolve VS, MCS and confusional state/post-traumatic amnesia (CS/PTA), based on serial Coma Recovery Scale–Revised (CRS-R) and Galveston Orientation Amnesia Test (GOAT) scores. Main outcome measures: Proportion who resolve VS, MCS, CS/PTA stages, who achieve household independence, return-to-school or -work and DRS scores at 1–8 years post-injury. Results: The majority (72%) emerged from MCS (TBI 79%) and half resolved CS/PTA by latest follow-up (TBI 59%), taking longer for patients admitted in VS than in MCS to reach both milestones. Almost all who failed to resolve CS/PTA by latest follow-up were patients with non-TBI or VS48 weeks. Of those followed41 year, 42% (TBI ¼ 50%) achieved recovery to safe, daytime household independence, 25% were employable by DRS criteria (TBI 29%) and 17% actually returned to work or school, 11% at or near pre-injury levels of functioning. DRS outcomes: 29% severe–extremely severe, 40% moderate–moderate/ severe, 31% partial to no disability. Significant predictors of better long-term outcome (1–8 years) were: shorter lag time from injury to rehabilitation admission, admission level of consciousness (MCS better than VS), higher FIM at discharge from inpatient rehabilitation, shorter time to resolve MCS and CS/PTA. Patients with slower MCS resolution 480 days or CS/PTA resolution 4100 days had a poor chance of better outcomes at latest follow-up, such as DRS54 (partial or no disability), ability to be independent at home or return to some productive activity (work or school). The mean change in CRS-R scores over the first 3 weeks was a significant predictor of resolution of MCS or CS/PTA and of DRS scores (1 year and latest scores). Conclusions: (1) Patients who recover to the MCS level of recovery, especially 58 weeks post-onset, have more favourable prospects to recover to higher levels of cognitive functioning, nearly half to household independence and a substantial proportion to productive pursuits. (2) The chance of recovery to household independence or productive pursuits is poor in those who take longer than 80 days to emerge from MCS or more than 100 days to clear CS/PTA. (3) Improvement in CRS-R scores early in rehabilitation predicts progress in recovery and quality of outcome. (4) Recovery continues well beyond 2 years post-injury, is better for TBI than non-TBI and faster for those admitted in MCS than VS.

Tong Sheng, Jennifer Kong, Peter Bayley, Keith Main, Wes Ashford, & Maheen Adamson VA Palo Alto Health Care System, Palo Alto, CA, USA Objectives: Multiple diagnoses are common in Veteran populations. For example, veterans seen at the War Related Illness and Injury Study Center California (WRIISC CA) are frequently diagnosed with a combination of disorders that includes traumatic brain injury (TBI), post-traumatic stress disorder (PTSD), musculoskeletal pain, gastrointestinal issues, sleep problems, depression and fatigue. These and other factors potentially interact with each other to further impact the quality-of-life of the Veteran. This study examined the extent to which these seven disorders, together with demographic variables, predicted Veterans’ physical and mental health as stated in self-report health questionnaires during their evaluation at WRIISC CA. Methods: Results from 68 Veterans were analysed (62 males; mean age (years ± SD) ¼ 47.9 ± 11.7; education (years ± SD) ¼ 14.3 ± 2.4). Physical and mental health complaints were quantified using the 7.2 and 7.8 components of the SF-36, respectively. PTSD Check List (PCL-M) was used to assess PTSD symptoms (mean score ¼ 36.5 ± 16.2). TBI severity was characterized using Loss of Consciousness scores as rated by a neurologist. Other diagnoses, such as musculoskeletal pain, gastrointestinal, sleep and fatigue, were also recorded during their physical health exam. Results: Forty-seven (69%) of the veterans met criteria for either mild or moderate TBI. Physical health scores were predicted by PCL scores, TBI severity along with, age, sex and education (adj-R2 ¼ 0.14; F ¼ 3.74, p ¼ 0.0085). The strongest predictor was PCL scores. Post-hoc stepwise regression models with fatigue and gastrointestinal diagnoses as additional predictors performed negligibly better (adjR2 ¼ 0.16). Physical health scores were best predicted by PCL score and age, with education and gastrointestinal issues contributing marginally. Mental health scores were predicted most strongly by PCL scores, TBI severity and demographic variables (adj-R2 ¼ 0.30, F ¼ 8.48, p ¼ 0.000 015). PCL score, again, was the strongest predictor. Post-hoc stepwise regression models with fatigue and sleep problems as additional predictors performed marginally better (adj-R2 ¼ 0.33). In this model, PCL score remained the strongest predictor, with TBI severity contributing marginally. Conclusions: Veterans seen at the centre have multiple health complaints that potentially interact. A statistical approach was adopted that combines the trauma-related factors of PTSD and TBI with common health complaints and demographic variables to predict mental and physical health complaints. Our results suggest that although PTSD symptoms were the strongest predictors of both mental and physical health, other medical history and demographic factors also play a role. These results may be especially relevant when choosing factors for longitudinal follow-up assessments.


DOI: 10.3109/02699052.2014.892379



Influence of robotic-assisted treadmill therapy on walkingtests performance in chronic phase (>1 year) after traumatic rain injury

‘I would never regret getting run over’: Understanding children and young people following a traumatic brain injury

Klemen Grabljevec1, Tatjana Krizmanic1, Crt Marincek1, & Calogero Foti2 National University Rehabilitation Institute, Ljubljana, Slovenia, 2Tor Vergata University - Advanced Sciences in Rehabilitation Medicine and Sports, Rome, Italy

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Objectives: Injury to the central and peripheral nervous system is an important aetiologic factor for gait abnormalities in patients after traumatic brain injury (TBI). Consequences of severe TBI include motor, cognitive, behavioural and emotional dysfunction. The key biomechanical abnormalities of gait after TBI are yet to be determined. Independent gait is one of the priorities in rehabilitation after TBI. Adverse effects associated with gait abnormalities include falls, reduced aerobic fitness and limited community access. Because falls are a major cause of TBI and people with TBI are at a greater risk of re-injury, there is a pressing need to ensure optimal therapy outcomes. Very limited data is available about the influence of robotic-assisted treadmill therapy on walking and standing performance in the adult TBI population. The aim of the study was to determine the effect of robotic-assisted treadmill therapy on walking performance in adult subjects long-term after moderate and severe TBI. Methods: Eighteen adult ambulatory subjects (14 M; 4 F) with gait abnormalities after moderate and severe (GCS513) TBI in chronic phase (41 year after injury, average 6.6, range 1–16 years) were included in the study. Each subject received 10 sessions of 30 minutes of robotic-assisted treadmill training on Lokomat (Hocoma-CH) as single therapy. Four standardized assessments were performed before and after the therapy: 10-Metre Walking Test (10MWT), 6Minutes Walking Test (6minWT), Get Up and Go Test (GUGT) and OneFloor Stair-Climbing Test (1FSCT). The data were analysed as the ratio between the value of the second and the first assessment for all tests except the 6minWT, where the inverse ratio was calculated (hence, the more a ratio was above 1, the larger the improvement for all four walking tests). One-sample t-test and Wilcoxon signed-rank test were used to test the null hypothesis that the average value of ratio equalled 1. Results: On average, the patients improved in all the performed tests. The results of the 10MWT improved from a mean of 31.0 seconds (range ¼ 7.5–95.1; SD ¼ 29.1; n ¼ 18) to 28.1 seconds (range ¼ 6.9– 103.0; SD ¼ 28.7; n ¼ 18; p ¼ 0.010 and p ¼ 0.009 for t-test and Wilcoxon test, respectively); results of 6minWT improved from 184.1 metres (range ¼ 31–460; SD ¼ 134.6; n ¼ 18) to 220.1 metres (range ¼ 38.0–520.0; SD ¼ 145.4; n ¼ 18; p ¼ 0.001 and p ¼ 0.002); results of GUGT improved from 50.0 seconds (range ¼ 6.6–301.0; SD ¼ 72.2; n ¼ 17) to 31.2 seconds (range ¼ 6.4–102; SD ¼ 30.4; n ¼ 17; p ¼ 0.010 and p50.001); results of 1FSCT improved from 42.4 seconds (range ¼ 16.1–100.3; SD ¼ 25.9; n ¼ 15) to 34.8 seconds (range ¼ 15.2– 97.3; SD ¼ 23.1; n ¼ 15; p ¼ 0.002 and p ¼ 0.003). No statistically significant correlation between the length of the post-injury period and improvement in walking performance was found. Conclusions: Robotic-assisted treadmill therapy seems to improve walking tests performance in adult brain injury subjects in the chronic (41 year post-injury) period. Comparison studies with other methods are needed.

Lorna Wales1, & Carol Hawley2 1

The Children’s Trust, Tadworth, UK, 2University of Warwick, Coventry, UK Introduction: Rehabilitation following a brain injury in childhood is challenging for all concerned—the children and young people, their families and their clinicians. At the forefront of any respectful collaborative venture should be understanding of the others’ perspective. The therapeutic relationship is shaped by an understanding of typical development. In early years the acquisition of physical skills dominates. With increasing age the focus changes towards the social and peer concerns of adolescence. Additionally, children develop from a concrete and physical focus to an abstract understanding of psychological and social themes. This developmental approach needs integrating with the unique personal perspective of children and young people having experienced an interruption to development at various ages. Objective: To improve collaborative participation through understanding the personal impact of a brain injury in childhood. Methods: Fifteen subjects, 10 boys, five girls, with moderate–severe traumatic brain injury (TBI), aged 9–19 years, 1–5 years post-injury were administered the self-understanding interview and a2nd interview at 6 months (n ¼ 12). Results: Key themes: Aspirations, ‘I want to become an RSPCA officer’; Beliefs, ‘Well you get better jobs, earn a better salary, have a better life when you’re older’; Being different, ‘I’m different from everybody and how I was’; Brain injury, ‘It’s really hard to think about the future because of what happened to me’, ‘I’ll still have a brain injury . . . the future will tell’, ‘I’m older . . . I’ve got a brain injury . . . and everything is different now’; Characteristics, ‘I’m a girl . . . I’ve got brown hair’; Participation, ‘I like coming home and having a nice bath’; Social, ‘well everybody gets on with me’; Relationships, ‘I’ve got true friends and I can trust my family and my friends’. Three children reported positive adjustment, ‘I would never regret getting run over right cos I’ve met some great people’, and three children negative adjustment to brain injury, ‘it’s been nearly 3 years now and if I can’t get over it now, I doubt I’ll ever be able to’. Sixteen out of 20 children who made reference to the accident were over 12 years old and 14/20 children who made reference to the accident were in the first 2 years postinjury. Children of all ages describe themself in present and future in physical and material domains. Conclusion: Children and young people who have a TBI have similar self-perceptions compared to their typically-developing peers. Unsurprisingly, these data support a supplementary theme relating to brain injury. Many of the children articulate their brain injury as an ongoing concern in the first 2 years post-injury, especially those who sustain their injury in adolescence. Understanding children and young people within a developmental context will enable professionals to maximize their therapeutic relationship and consequently improve participation in goal-orientated rehabilitation.



Assessing balance in children after a mild traumatic brain injury (mTBI): Choosing the right assessment Krithika Sambasivan1, Lisa Grilli2, & Isabelle Gagnon1 McGill University, Montreal, Canada, 2Montreal Children’s Hospital, Montreal, Canada

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Objective: Research has shown that balance deficits can outlast post-concussion symptoms and be identified even 3 months after an mTBI in children, while using high technology tools to measure balance. Despite this, children are often returned to physical activities primarily based on symptom resolution. The objective of this study is to compare the ability of selected static and dynamic balance measures to detect differences between children who are deemed clinically recovered from mTBI and healthy controls, in order to provide clinicians with more sensitive clinical balance measures to improve decision-making for readiness to return to physical activities. Methodology: Twenty-seven children with mTBI aged 8–17 (13.15 ± 2.20 years) considered clinically recovered (symptom free for 7 days at rest measured using a Post-Concussion Symptom Scale and cleared for graded step-wise return to play guidelines) were recruited at the Montreal Children’s Hospital and matched to 22 (13.59 ± 2.56 years) controls, on age, gender and levels of pre-injury physical activities. A cross-sectional design was used, assessing both groups using clinical balance measures, namely: Bruininks Osteresky Test for Motor Proficiency, Second Edition–Balance sub-test; Balance Error Scoring System; Community Balance and Mobility Scale; and three gait paradigms (self-selected pace, tandem, obstacle crossing) using the GAITRite Walkway (CIR Systems, USA). Differences between the groups on these balance measures were analysed using independent sample t-tests with a significance level of 0.05 with Bonferonni corrections. Results: There was no difference found in the age, gender, levels of physical activities and symptom reporting (p ¼ 0.10) between the groups. The control group performed better than the mTBI group on all clinical balance measures (p50.05). Gait was significantly better in the healthy controls across the three tasks evaluated on the GAITRite walkway (p50.05). The mTBI group had a wider stride width during self-selected pace walking, had a longer distance of the lead lower extremity from the obstacle and the time spent on single support on the trail foot was longer during obstacle crossing. The velocity during tandem walking was decreased in the mTBI children and the percentage of time spent in double support was greater compared to that of the controls. Conclusion: Findings from this study provide further evidence that balance deficits could outlast post-concussion symptoms in the paediatric and adolescent population and that assessment of balance skills could enhance clinical decision-making upon return to physical activities. Furthermore, it emphasizes the fact that balance assessments may need to include both static and dynamic paradigms to capture performance difficulties and prevent premature return to sports and physical activities.

Brain Inj, 2014; 28(5–6): 517–878


Significance of regional strain measures and mesh topology and density on simulated brain responses following rotational accelerations Wei Zhao, & Songbai Ji Thayer School of Engineering, Dartmouth College, Hanover, NH, USA Objectives: The biomechanical mechanisms of traumatic brain injury are still poorly understood. Finite element (FE) models of the human head are increasingly employed to bridge the gap between macroand micro-scale injury studies. However, important inconsistencies (e.g. strain measures) and disparities in models (e.g. meshes) exist among studies without consensus to date. This study investigates the significance of different regional strain measures as well as mesh topology and density on brain responses through a parametric study. Methods: Four FE models of an identical sphere with a radius of 7.5 cm were meshed with two different mesh topologies (single- vs multiblock or models with vs without severe mesh distortions) and two levels of density (coarse vs fine) to simulate the brain. An additional layer of elements and a rigid shell surface were created to simulate the cerebral-spinal fluid and skull. The models were subjected to an identical set of rotational impulses with five unique peak magnitudes (range ¼ 1534–7812 rad s2) and a duration of 10 milliseconds drawn from on-field data in contact sports. Using the maximum principal strain (") values at each FE element from the simulations, three regional brain strain measures were obtained: (1) the maximum " regardless of the location or time of occurrence ("m); (2) peak strain from volume-weighted averages for each temporal frame ("VWA); and (3) volume-weighted average strain based on element-wise peak " accumulated from the entire simulation duration, regardless of the time of occurrence ("PVWA ). Results: The brain responses differed substantially when different strain measures were employed (e.g. regional strain responses varied from 0.15 (for "VWA) to 0.48 (for "m) using the highest peak acceleration magnitude). All strain measures were highly sensitive to mesh density (responses increased by 12.3–49.1% when using a fine mesh). Regardless of mesh density, "m and "VWA were highly sensitive to mesh topology as well (responses decreased by 7.5– 22.1% when using a multi-block topology). With fine meshes, however, "PVWA was insensitive to mesh topology (responses differed by 1.3% with different mesh topologies). Conclusions: The results clearly demonstrate that brain responses could vary substantially when different strain measures, mesh topologies and mesh densities are used. However, "PVWA based on element-wise peak " accumulated from the simulation was able to consistently represent brain responses when the model was meshed with sufficient density, regardless of the mesh topology. In contrast, "m and "VWA were dependent on both mesh topology and density. Therefore, "PVWA with sufficient mesh density is recommended for a reliable and consistent characterization of regional brain responses which is immune to mesh distortion. These findings provide important support for a possible unified response variable for future model-based brain injury analyses in order to facilitate exchange of model simulation results among studies.


DOI: 10.3109/02699052.2014.892379


The evolving discussion of concussion in the US national football league Catharine F. Kennedy, & Mary Connor Thomas Jefferson Hospital, Philadelphia, PA, USA


Walking to ameliorate perceived stress and depressive symptoms after TBI Kimberly Bellon1, Stephanie Kolakowsky-Hayner1, Jerry Wright1, Henry Huie1, Ketra Toda1, Tamara Bushnik2, & Jeffrey Englander1 1

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Objectives: This poster will examine the evolving concussion awareness in the National Football League (NFL) and its ramifications on public perception of football in youth. This poster will examine the financial implications of concussion and football. Methods: Literature review Results and conclusions: If less youth play football there will be an eventual dramatic impact of financial implications for the NFL.


Unintentional injuries after TBI: Triggers, impacts and prevention Stephanie Kolakowsky-Hayner, & Kimberly Bellon Santa Clara Valley Medical Center, San Jose, CA, USA According to the National Center for Health Statistics at the CDC, unintentional injuries continue to be the fifth leading cause of death overall and the leading cause of death for those under 35 years of age in the US. The top three causes of fatal unintentional injuries include motor vehicle crashes, poisoning and falls. Two of those aetiologies also happen to be the leading causes of TBI in the US: motor vehicle crashes and falls. TBI is itself a serious public health problem in the US. Each year, at least 1.7 million TBIs occur, contributing to a substantial number of deaths and cases of permanent disability. While TBI has been classified as an unintentional injury, reduced cognitive functioning, poor decision-making, increased risk taking, disinhibition, diminished safety skills and substance use, place individuals with TBI at an increased risk for subsequent unintentional injuries. The caregiving, psychological, social and financial burden of initial injuries is enormous. Unintentional injuries post-TBI add to that burden significantly. Many unintentional injuries and emergencies can be prevented with simple education and environment and lifestyle changes. Injury prevention requires collaboration among many stakeholders including individuals with brain injuries, family members, caregivers, healthcare providers, public health workers, safety professionals, educators, policy-makers and many others. Information will be shared regarding potential triggers or causes of unintentional injuries after TBI; providing examples for multiple stakeholders to identify potential issues. The many impacts of these injuries will be reviewed from various stakeholders’ perspectives. Best practices in prevention will be presented and tips for developing new or augmenting existing prevention programmes will be provided. Interactive discussion will encourage sharing of existing resources and identifying gaps.

Santa Clara Valley Medical Center, San Jose, CA, USA, 2Rusk Institute for Rehabilitation, New York, NY, USA Objective: To determine whether a 12-week home-based walking programme can decrease perceived stress and depressive symptoms in persons with a traumatic brain injury (TBI). Setting: Community- and home-based. Participants: Sixty-nine participants with a TBI. Design: Each participant completed a 12-week walking intervention and a nutrition education module, assisted by a coach who provided guidance and support throughout the duration of the study. The walking intervention utilized pedometers to track the amount of steps each participant walked daily. With the assistance of an assigned coach, weekly goals were given with the intent of increasing the amount of walking that the participant was initially completing. The nutrition control group was created to offset the impact of the coaching calls. Main measures: Measurement of perceived stress and depressive symptoms was completed through the use of the Perceived Stress Scale (PSS) and Center for Epidemiological Studies-Depression (CESD). These measures were collected at three time points: baseline and following each 12-week intervention. Results: Results indicated that both perceived stress and depression symptoms significantly improved following the walking intervention. Conclusions: While limitations existed with this study, it is evident that walking can be used as an efficient and cost-effective tool to manage perceived stress and depressive symptoms in persons who have sustained a TBI.


A randomized control trial of walking to ameliorate brain injury fatigue Stephanie Kolakowsky-Hayner1, Jerry Wright1, Kimberly Bellon1, Ketra Toda1, Tamara Bushnik2, & Jeffrey Englander1 1

Santa Clara Valley Medical Center, San Jose, CA, USA, 2Rusk Institute for Rehabilitation, New York, NY, USA Objective: To evaluate the impact of a graduated physical activity programme on fatigue after traumatic brain injury. Secondarily to examine the impact of a graduated physical activity programme on related factors of depression, sleep quality/daytime drowsiness, cognitive function and general health measures. The authors

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652 hypothesized that participants in the physical activity intervention group will exhibit greater decreases in fatigue and other related conditions and more improvements in physical and mental wellbeing than controls, regardless of cross-over order. Design: Prospective randomized single-blind cross-over study with follow-up at 12, 24 and 36 weeks after enrolment. Setting: Rehabilitation Hospital and general community. Participants: One hundred and twenty-three individuals who had sustained a TBI at least 6 months prior that required medical attention, were over the age of 18, able to ambulate unassisted by another person, not participating in an individual physical therapy programme at the time of recruitment and able to speak and understand either English or Spanish. Interventions: A home-based walking programme utilizing a pedometer to track daily number of steps at increasing increments accompanied by tapered coaching calls over a 12-week period. Main outcome measure(s): The Global Fatigue Index (GFI), the Barrow Neurological Institute (BNI), Fatigue Scale Overall Severity Index Score and the Multidimensional Fatigue Inventory (MFI). Results: Step counts improved over time regardless of group assignment. The walking intervention led to a decrease in GFI, BNI Total and MFI General. Participants reported less fatigue at the end of the active part of the intervention (24 weeks) and after a wash-out period (36 weeks) as measured by the BNI Overall. Conclusions: Walking can be used as an efficient and cost-effective tool to improve fatigue in persons who have sustained a TBI.


Model-based sensitivity analysis of brain strain responses to rotational acceleration pulse shapes Wei Zhao, & Songbai Ji Thayer School of Engineering, Dartmouth College, Hanover, NH, USA Objectives: Head impact rotational accelerations (arot) generally consist of varying acceleration- followed by deceleration-time histories. However, the severity of head impact is often characterized by the peak acceleration magnitude alone. It is important, therefore, to assess the sensitivity of regional brain responses to the arot pulse shapes in order to evaluate whether the response level can be solely characterized by peak arot magnitude alone. This study employed two finite element (FE) models of the human head to compare brain strain responses generated from different acceleration–deceleration load traces to investigate the significance of pulse shapes on regional brain strain responses. Methods: Two independently established and validated FE models, the Dartmouth Head Injury Model (DHIM) and Simulated Injury Monitor (SIMon), were utilized to simulate brain responses subjected to rotational accelerations in the coronal plane about the head centre of gravity. Rotational impacts consisted of monophasic accelerationonly (peak magnitude and duration of 7.8 krad s2 and 4.5 ms, respectively) or biphasic acceleration followed by deceleration (peak magnitude and duration of 1.4 krad s2 and 20 ms, respectively, with a separation time of 0–25 ms). Using the maximum principal strain (") values at each FE element, volume-weighted regional average strains based on element-wise peak " accumulated from the simulation regardless of the time of occurrence ("PVWA ) were obtained. Results: For the whole brain, cerebrum, cerebellum and brainstem, "PVWA obtained from the mono or biphasic accelerations were mostly

Brain Inj, 2014; 28(5–6): 517–878

comparable (difference ranged 0.01–7.2%), regardless of the separation time. For DHIM, however, the central part of the brain (i.e. corpus callosum) had elevated "PVWA when biphasic accelerations were used compared to the monophasic counterpart (e.g. increased by 17.6% (31.4%) with a separation time of 0 (5) milliseconds). In addition, volume fractions of element-wise differences between the responses from the mono and biphasic impacts in DHIM were up to 1.6 (81.2) times higher than their SIMon counterparts at a percentage level of 10% with a separation time of 0 (20) milliseconds. Conclusions: The results suggest that global "PVWA responses are less sensitive to the deceleration phase; however, the sensitivity in the central part of the brain is model-dependent (responses from DHIM substantially more sensitive than the SIMon counterparts). This model- and region-dependency of "PVWA to pulse shapes could lead to inconsistent findings of whether peak arot magnitude alone is sufficient to characterize the level of brain strain responses. These findings highlight the poor understanding of the model-based regional strain responses in head impact and, thus, warrant further investigation on the FE model parameters that are important to regional brain responses in order to improve understanding of the biomechanical mechanisms of traumatic brain injury.


Vitamin D status in stroke and TBI inpatient rehabilitation Thao Duong1, Stephanie Kolakowsky-Hayner1, Daniela Mehech2, & Jerry Wright1 1

Santa Clara Valley Medical Center, San Jose, CA, USA, 2Case Western Reserve University, School of Medicine, Cleveland, OH, USA

Objective: To characterize the prevalence of vitamin D deficiency in an acute inpatient brain injury rehabilitation unit and to identify any associations between vitamin D level, patient demographics and time since injury. Design: Retrospective case series. Setting: Brain injury inpatient rehabilitation unit. Participants: A convenience sample of 169 patients with stroke and traumatic brain injury (TBI), admitted to inpatient rehabilitation between July 2012 and May 2013, who had 25-hydroxyvitamin D level measured after admission to rehabilitation. Methods: Patients’ gender, age, race, injury type, date of injury, date of vitamin D test and initial vitamin D level were pulled from medical charts. Main outcome measure: 25-hydroxyvitamin D. Results: Of the patients with brain injury sampled, 22.6% (n ¼ 38) were sufficient in vitamin D (30 ng mL1), 42.3% (n ¼ 71) were insufficient (29–20 ng mL1), 28.0% (n ¼ 47) were moderately deficient (19– 10 ng mL1) and 7.1% (n ¼ 12) were severely deficient (9 ng mL1). The mean 25-hydroxyvitamin D level was 23.1 ng mL1 ± 9.8 ng mL1 and the mean age was 50.1 ± 19.8 years. Vitamin D levels were significantly lower in patients with stroke than TBI (p50.001). Vitamin D levels varied significantly between different age groups (p ¼ 0.022), race groups (p50.001) and time in hospital at time of measurement (p ¼ 0.014). Conclusion: Clinicians should consider measuring 25-hydroxyvitamin D levels in brain injury inpatient rehabilitation settings because of high prevalence of vitamin D insufficiency and deficiency. Prospective and interventional studies are needed to determine specific factors influencing insufficiency and deficiency and if vitamin D supplementation improves outcome or facilitates recovery.


DOI: 10.3109/02699052.2014.892379 1


Impact of concomitant brain injury in individuals with spinal cord injury Kathleen Castillo, Stephanie Kolakowsky-Hayner, Kazuko Shem, & Kimberly Bellon

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Santa Clara Valley Medical Center, San Jose, CA, USA

Diagnosing and managing individuals with spinal cord injuries (SCI) who also sustain concomitant traumatic brain injury (TBI) present unique challenges to healthcare providers involved in the care of these individuals. Many individuals with SCI sustain injuries due to motor vehicle crashes, falls, diving into shallow water or assaults and the mechanism of injuries involved in such accidents is an abrupt impact at a high velocity. Any mechanical injury severe enough to cause spinal cord damage is also likely to cause insult to the brain via such mechanisms as contusion, diffuse axonal injury or concussion. Many patients with SCI who sustain concussion or mild TBI may go undiagnosed and untreated, because most individuals with SCI may also have mood changes or other symptoms of head injury, such as headaches, dizziness, fatigue and sleep dysfunction. These symptoms may be treated in an isolated manner or as secondary complications to SCI as opposed to manifestations of concussion or mild TBI. SCI is also a more obvious injury than mild TBI. There are potential a priori difficulties of diagnosing mild TBI and the difficulty is compounded in individuals with SCI since paralysis from SCI may be a barrier in completing a cognitive test requiring motor function. Despite these aforementioned diagnostic challenges, there are studies in the literature reporting a relatively high incidence of concomitant TBI of 50–75% in individuals with traumatic SCI; with mild TBI being the most common TBI severity. A prospective cohort study with a control group was conducted to assess the consequences and the impact of TBI on quality-of-life and community reintegration in individuals with spinal cord injury. Starting with a quantitative characterization of TBI in the SCI population, this study investigated the long-term impact of such injuries on the QoL and community reintegration of these individuals. It was speculated that mild TBI would be found to be a significant barrier against return-to-home and community reintegration, a barrier that with greater awareness and understanding will benefit from targeted intervention. Data will be shared regarding the incidence of mild TBI in traumatic SCI. Implications of pre-morbid conditions, characteristics of clinical presentation and associated patterns of cognitive deficits will be presented. Given that the presence of mild cognitive deficits post-SCI are a risk factor and/or barrier to health, QoL and community re-integration and re-employment of these individuals, information regarding outcome measures at 6 months after the initial study enrolment will be summarized. Comparison will be made among the individuals who did and did not have brain injury and among those who did and did not sustain traumatic SCI to reveal factors that may influence QoL and community integration the most. Multi-disciplinary treatment strategies will be presented.


Compensation and long-term mortality after traumatic brain injury Thomas Gates1, Ian Baguley1, Hannah Barden1, Grahame Simpson2, & Melissa Nott3

Westmead Brain Injury Rehabilitation Service, Westmead, NSW, Australia, 2Liverpool Brain Injury Unit, Liverpool, NSW, Australia, 3 Charles Sturt University, Albury, NSW, Australia Objective: To determine whether financial compensation modifies long-term mortality following severe traumatic brain injury. Methods: Data from consecutive adult discharges from three metropolitan, inpatient brain injury rehabilitation services of the New South Wales Brain Injury Rehabilitation Programme for firstepisode TBI were analysed with respect to the impact of compensation status on long-term mortality. Results: Overall, subjects had a 4:1 male:female ratio with a mean age of 35 years. All cases for whom data were available experienced severe, very severe or extremely severe injuries using standardized PTA assessment. The median length of rehabilitation stay was 37 days and 74% of participants returned home following rehabilitation. While the mean discharge FIM score was 104, 32% of people required moderate or maximal assistance with activities of daily living. Compensation data were available for 1851 (73%) of the 2545 participants eligible for the study. Eight hundred and twenty-six (45%) people within this cohort received financial compensation in addition to universal healthcare (Australian Medicare). Univariate Cox regression analysis suggested that compensation following TBI provided a significant protective factor against late mortality (HR ¼ 0.66, 95% CI ¼ 0.51–0.87). Hazard ratios and 95% CIs were undertaken for three multivariate Cox regression models, examining (1) all variables known to influence late mortality, (2) non-modifiable factors such as demographic and injury related factors and (3) rehabilitation service variables that were potentially modifiable through compensation. Of these models, receipt of compensation showed a protective trend with rehabilitation service variables that approached statistical significance (HR ¼ 0.75; 95% CI ¼ 0.55–1.03). Functional dependence (based on discharge FIM) and discharge to a care facility remained significant risk factors for late mortality in this model. Conclusions: At the time of discharge from rehabilitation, receipt of compensation was associated with reduced mortality risk, with functional dependence and discharge to a care facility remaining significant risk factors for late mortality.


Establishing consensus on paroxysmal sympathetic hyperactivity after acquired brain injury Ian Baguley1, Iain Perkes2, Juan-Francisco Fernandez-Ortega3, Alejandro Rabinstein4, Giuliano Dolce5, & Henk Hendricks6 1

Westmead Brain Injury Rehabilitation Service, Westmead, NSW, Australia, 2Royal Prince Alfred Hospital, Sydney, NSW, Australia, 3 Hospital Regional Universitario Carlos Haya, Malaga, Spain, 4 Mayo Clinic, Rochester, MI, USA, 5S. Anna Institute, Crotone, Italy, 6 Rehabilitation Centre Groot Klimmendaal, Arnhem, The Netherlands Objective: A syndrome of paroxysmal, episodic sympathetic hyperactivity following acquired brain injury has been identified for almost 60 years. While research has increased, the field remains hampered by confused nomenclature (at least 31 eponyms in the literature) and with nine overlapping sets of diagnostic criteria. Methods: A steering committee developed a questionnaire based on a systematic review of the literature. The resulting definition, nomenclature and a set of 16 diagnostic criteria were forwarded to a widely representative, international expert group utilizing a Delphi approach. Diagnostic criteria were dropped if group consensus failed to agree

654 on their relative importance. The simplified construct was analysed using Cronbach’s Alpha with a goal of reaching 0.8 (suitable for research purposes). The criteria were then combined into an assessment measure for use in clinical and research settings. Results: The consensus group recommended that ‘paroxysmal sympathetic hyperactivity’ replace previous terms to describe the ‘syndrome, recognized in a sub-group of survivors of severe acquired brain injury, of simultaneous, paroxysmal transient increases in sympathetic [elevated heart rate, blood pressure, respiratory rate, temperature, sweating] and motor [posturing] activity’. Agreement was reached on an 11-point probabilistic diagnostic scale developed from the original 16 criteria, yielding an acceptable Cronbach’s Alpha of 0.8. These items were combined with a symptom severity index to produce a diagnostic tool for use with adults (the paroxysmal sympathetic hyperactivity assessment measure (PSH-AM)). Conclusions: It is hoped that the consensus position will represent an important foundation from which to standardize PSH research and management.

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The Wessex Head Injury Matrix (WHIM)—Re-ordering the hierarchy in patients with vegetative and minimally conscious states Lynne Turner-Stokes1, Natalie Campbell1, Mary Robertson2, Alison Knight2, & Hilary Rose2 1

King’s College London, London, UK, 2Northwick Park Hospital, London, UK Background: Following severe brain injury, many patients progress through stages of coma, vegetative (VS) and minimally conscious state (MCS). Some will emerge to full awareness, others will remain in VS or MCS. The Wessex Head Injury Matrix (WHIM) is a 62-item hierarchical scale, which provides a sequential framework of responses to monitor an individual’s level of interaction as this changes over time. Originally designed to monitor patients recovering from post-traumatic amnesia, WHIM has potential for application as a tool to monitor emergence from VS/MCS, but the hierarchical order of items may need adjusting for use in this context. This study describes the serial application of WHIM assessments in a consecutive series of patients in VS/MCS to determine whether the items are ordered correctly for this patient group and if not to inform a more appropriate order. Methods: A cohort analysis of prospectively-collected serial WHIM data in consecutive patients in VS or MCS (n ¼ 59) admitted to a tertiary specialist neurorehabilitation unit for evaluation of responsiveness over a 10-year period (2003–2013). Primary diagnostic categorization of patients was by detailed multidisciplinary evaluation in accordance with published diagnostic criteria for VS or MCS. Emergence was defined according to the Aspen criteria. Results: The male:female ratio was 38:21; with a mean age of 38.4 (SD ¼ 14.6) years. The aetiology was traumatic 37 (63%); hypoxic 10 (17%); vascular 11 (19%); infective 1 (2%). Mean time from onset to admission was 16.4 (SD ¼ 16.1) weeks. Mean length of stay was 130 (SD ¼ 70) days. On admission, 28 (48%) were in VS and 31 (52%) in MCS. On discharge, 12 (20%) remained in VS, 25 (43%) were in MCS and 22 (37%) had emerged. A total of 1521 WHIM assessments were recorded: 371 in patients who were in VS at the time of assessment; 1116 in MCS; and 34 in patients who had emerged into consciousness. Mean number of assessments patient was 26 (SD ¼ 17): Median duration of assessment was 30 minutes (IQR ¼ 20–40). In the 11 patients who remained in VS throughout

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their stay, only 16 of the WHIM items were observed in 1% of the 251 assessments. These were items 1–9, 11, 14–16, 21, 24 and 26. In the 25 patients remaining in MCS, a further 28 items (12–29, 31–36, 38, 39, 41 and 43) were observed in 5% of 689 assessments and seven additional items (10, 30, 41, 45, 46 and 53) in 2–4%. Seven items were only observed after patients had emerged (37, 42, 48, 51, 55, 59 and 61). Items 49, 54, 48 and 60 were not observed at all and may, therefore, be redundant in this population. Conclusions: Serial recording of the WHIM can be useful to separate patients in VS and MCS, but the current hierarchy requires adjustment. Re-ordering to group items into those compatible with VS, then MCS, then emergence, may assist interpretation of WHIM scores in this context.


Can the Wessex Head Injury Matrix (WHIM) be used as a diagnostic tool in vegetative states? Lynne Turner-Stokes1, Natalie Campbell1, Mary Robertson2, Alison Knight2, & Hilary Rose2 1

King’s College London, London, UK, 2Northwick Park Hospital, London, UK Background: The Wessex Head Injury Matrix (WHIM) is commonly used for assessment and monitoring of patients in vegetative and minimally conscious states (VS and MCS) in the UK. It is a 62-item hierarchical scale, which provides a sequential framework of responses to record an individual’s level of interaction as this changes over time. Although not originally designed as a diagnostic tool for VS, systematic serial recording of the WHIM has potential to contribute to the diagnosis, if it consistently fails to demonstrate any actions above the level of reflex or spontaneous behaviour over a prolonged period of repeated observation. This study describes the serial application of the WHIM in a consecutive series of patients in VS, to address the following questions: (a) Which behaviours within the WHIM are compatible with a diagnosis of VS? (b) Are the WHIM items in the correct hierarchical order? (c) If not, what order would be more appropriate? Methods: In a cohort analysis of prospectively-collected serial WHIM data in consecutive patients (n ¼ 59) with VS or MCS admitted to a tertiary specialist neurorehabilitation unit for evaluation over a 10-year period (2003–2013), 12 patients remained in VS throughout their stay and were categorized as ‘Continuing’ or ‘Permanent’ VS on discharge. Primary diagnostic categorization of patients was by detailed multi-disciplinary evaluation in accordance with published diagnostic criteria for VS or MCS, supported in seven cases by SMART (Sensory Modality Assessment and Rehabilitation Technique) tests. Results: The male:female ratio was 7:5 with a mean age of 38.4 (SD ¼ 15.4) years. The aetiology was six traumatic (50%) and six hypoxic (50%). Mean time from onset to admission was 21.8 (SD ¼ 31.3) weeks. Mean length of stay was 103 (SD ¼ 44) days. A total of 267 WHIM assessments were recorded. The mean number of assessments per patient was 23 (SD ¼ 14). The median duration of assessment was 30 minutes (IQR ¼ 20–40). Only 10 items (1–5, 7, 8, 14, 24 and 26) were observed 10 times (4%). A further six items (6, 9, 11, 15, 16 and 21) were seen 2–5-times (1–3%) and three items (18, 22 and 36) were seen only once, possibly due to chance. In this series the order of frequency for observation of items was (from highest to lowest): 1, 2, 3, 7, 14, 26, 4, 5, 8, 24 (6, 15, 9, 11, 16, 21). Conclusions: Whilst diagnosis of VS/MCS should not rely solely on any one assessment tool, the findings suggest that serial recording of the WHIM has potential value in the diagnosis of VS. The current hierarchy


DOI: 10.3109/02699052.2014.892379

requires adjustment, however, and an alternative order is proposed for use with patients in vegetative states. Further multi-centre research is now required to confirm or refute these findings.


Vestibular rehabilitation (VR) after traumatic brain injury—A case report Ingerid Kleffelgaard1, Helene Lundgaard Søberg1, Anne-Lise Tamber2, Kari-Anette Bruusgaard2, Cecilie Roe1, & Birgitta Langhammer2 Oslo University Hospital, Oslo, Norway, 2Oslo and Akershus University College, Oslo, Norway

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Objectives: There has been an increasing focus on vestibular rehabilitation (VR) after TBI in recent years, but the description of and responses to VR for patients with TBI are sparse. This case report describes the responses of four TBI patients with dizziness and balance problems to a group-based VR intervention that includes eye–head co-ordination exercises, habituation exercises, balance training and group-counselling. Methods: Two female and two male (aged 24–45) patients with mild TBI (Glasgow Coma Scale Score 14–15) participated in an 8-week long intervention which consisted of group training twice weekly, group counselling once weekly and a home exercise programme. Self-report outcome measures used were the Dizziness Handicap Inventory (DHI), with smallest detectable change (SDC) of 20 points and minimally important change (MIC) of 11 points, the Vertigo Symptom Scale-SF (VSS-SF) with a clinically significant change of 43 points, Quality-oflife after brain injury (Qolibri), where a 10-point improvement was considered clinical important, and the Hospital Anxiety and Depression Scale (HADS), where a sum score above 15 is the recommenced cut-off point indicating psychological distress. Performance-based measures were the Balance Error Scoring System (BESS) where improvement of one category was considered clinically important (categories: very poor, poor, below average, broadly normal, above average and superior) and the High Level Mobility Assessment Tool for TBI (HiMAT), with a minimal detectable change of 4-points. Results: Three out of four patients improved 20 points in selfperceived disability associated with dizziness measured by DHI. The same patients improved 43 points on the frequency and severity of dizziness symptoms measured by the VVS-SF. Qolibri scores improved by over 10 points in three out of four patients. HADS improved in three patients from a score above 15 points to a score below 15 points. On the performance-based measures all participants improved at least one category on standing balance on the BESS from ‘poor’ and ‘very poor’ scores prior to the intervention. Two patients improved to ‘broadly normal’, one improved to ‘below average’ and one was still poor but had improved from very poor. Only one patient had an improvement over 4-points in balance and mobility on the HiMAT. One patient did not improve on any outcome measures except from the Qolibri. Conclusion: Results from this case report of VR after TBI seem promising as three out of four patients experienced improvements in dizziness, balance, psychological distress and health-related qualityof-life. The results are consistent with other studies and reports of VR after TBI. Future randomized controlled trials are warranted to evaluate efficacy and long-term effects.


Specialist rehabilitation in a major trauma centre: It’s not just about saving lives Trudi Massey, Samantha Smith, Clive Bezzina, & Alex Ball North Staffordshire Rehabilitation Centre, Haywood Hospital, Stoke-on-Trent, UK Background: It has been estimated that, by improving the organization of trauma care, an additional 450–600 lives could be saved in English NHS hospitals. After detailed planning, a new system of regional trauma networks went live across England in 2012. Rehabilitation, including specialized rehabilitation for complex injuries, is a critical component of the Trauma Care Pathway, without which the Major Trauma networks will inevitably fail. Objectives: To illustrate how the Rehabilitation Team is integral to the Major Trauma Pathway facilitating recovery, re-ablement, rehabilitation and repatriation. To demonstrate use of the Rehabilitation Prescription to improve outcome for patients surviving head trauma through a more structured approach. Methods: An audit of all head injury admissions to a Major Trauma Centre (MTC) between March 2012 and March 2013 was undertaken. Patients and outcomes were identified from an electronic database that was specifically created to record all rehabilitation activity within the MTC. Results: Between March 2012 and April 2013, 190 patients were admitted to The University Hospital of North Staffordshire, MTC, with a traumatic, moderate/severe head injury. Of the 190 admitted, 181 (95.2%) were seen within 72 hours of admission by a Consultant in Rehabilitation Medicine or Senior Rehabilitation Co-ordinator. One hundred and sixty-three (85.8%) were issued with a Rehabilitation Prescription which was used to detail needs and expedite rehabilitation. Fifty-nine patients (31%) were referred to specialist community rehabilitation services prior to discharge from the MTC and 14 (7%) were transferred to a regional specialized inpatient rehabilitation unit. Thirty patients (16%) were transferred to general rehabilitation facilities and a further 23 (12%) were transferred back to their local hospitals for on-going care closer to home. Delays in discharge from the MTC were minimal, with 90% of patients transferred to the appropriate setting within 48 hours. Prior to the introduction of a structured trauma rehabilitation pathway, many patients were discharged without assessment of their rehabilitation need or faced lengthy delays in accessing appropriate specialist facilities. Conclusion: Early rehabilitation assessment in the MTC has improved access to specialist rehabilitation services, known to maximize functional recovery following injury. Prompt rehabilitation interventions prevent complications and can enhance quality-of-life for many patients. Further study is recommended to evaluate levels of functioning and participation 12 months post-injury. Communication across and between teams is improved through use of the Rehabilitation Prescription. Rehabilitation is now embedded in the Major Trauma service, showing a significant culture change and a greater awareness that quality-of-life, not just saving lives, is fundamental to trauma care.



Correlation between functional, structural and metabolic changes after mild traumatic brain injury and it’s relationship with persistent PCS and cognitive performance Philip Dean1, Joao Sato2, Gilson Vieira3, Adam McNamara1, & Annette Sterr1

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School of Psychology, University of Surrey, Guildford, UK, 2Center of Mathematics, Computation and Cognition, Universidade Federal do ABC, Sa˜o Paulo, Brazil, 3NIF/LIM44, Departamento de Radiologia da Faculdade de Medicina da Universidade de Sa˜o Paulo, Sa˜o Paulo, Brazil Objectives: Mild traumatic brain injury (mTBI) is a heterogeneous injury and it is difficult to predict those that will go on to experience sustained post-concussion syndrome (PCS, 43 months). As such, data from a wide variety of sources would be useful in investigating longterm outcome, preferably within the same population. This study explored the interplay between functional, structural and metabolic changes after mTBI and their relationship with persistent PCS and cognitive performance. Methods: fMRI, DTI and MRS data were acquired from participants with chronic (41 year) mTBI and persistent PCS (n ¼ 8), participants with mTBI but no on-going PCS (n ¼ 8) and non-head injured controls (n ¼ 9). Functional data was acquired whilst participants undertook an n-Back and Paced Serial Visual Addition Task (PVSAT). Conventional analysis was undertaken to investigate areas of difference in BOLD response and fractional anisotropy (FA) between groups. These regions of interest were then used to extract individual BOLD contrast values or FA for each participant. MRS acquired from right DLPFC was analysed. Metabolites which differed between groups were used in further analysis. The relationship between functional, structural and metabolic indices was investigated using partial correlation, controlling the effect of age. Results: Participants with mTBI and PCS displayed less of an increase in BOLD response in prefrontal (left inferior/middle frontal gyrus; PVSAT) and temporal (right medial/inferior temporal lobe; n-Back) areas when performing the most difficult task compared to controls, despite similar task performance in both groups. Greater post-concussion symptom report correlated with reduced temporal (right medial/ inferior temporal; n-Back) and posterior cingulate/precuneus (PVSAT) BOLD response, as well as increased anterior cingulate (n-Back) BOLD response. Correlations revealed that reduced BOLD response in the left inferior/middle frontal gyrus also was associated with reduced FA in posterior corpus callosum (r ¼ 0.4, p50.05) and reduced creatine concentration in rDLPFC (r ¼ 0.5 p50.05) across all participants. This correlation approached significance when only mTBI participants were included in the analysis (FA: p ¼ 0.08; Creatine: p ¼ 0.06). Conclusions: Participants who sustained an mTBI a year previously and have persistent PCS did not exhibit increased activity in working memory related areas (prefrontal/temporal) with task difficulty to the same extent as controls, but did show an increase in an area related to attention and error monitoring (anterior cingulate). This suggests that increased attention in this group is compensating for reduced working memory capacity in the task to achieve the same level of performance. Furthermore, the functional differences in prefrontal cortex correlate with both structural changes indicative of impaired white matter tract integrity and metabolic changes indicative of an

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ongoing energy crisis. The symptoms experienced by these participants seem to be caused by an interaction of these modalities and it is likely that each brain injury will result in a different pattern of change.


A novel method for acquiring cognitive data after brain injury and during follow-up: The use of mobile technology in a visuospatial working memory task Philip Dean, Lucie Perkins, Adam McNamara, Paul Sauseng, & Annette Sterr School of Psychology, University of Surrey, Guildford, UK Objectives: To investigate the utility of mobile touch-screen technology in the assessment of cognitive function in everyday contexts. A novel visuo-spatial working memory (VSWM) task was chosen here to (a) test the technology in the field and (b) examine VSWM performance of participants with mTBI under everyday conditions. Methods: A VSWM task was administered using PsyApp software ( on a 10" tablet computer to participants with a previous mTBI (n ¼ 15) and those without (n ¼ 15). mTBI was diagnosed using ICD-10 criteria and post-concussion symptoms were recorded using the Rivermead Post-Concussion Questionnaire (RPQ). Participants were tested in a busy cafe and were shown an arrangement of 3, 4, 5, 6, 7 or 8 dots for 500 milliseconds (encoding), followed by a blank screen for 2 seconds (retention), then asked to press the touch-screen in the spatial positions occupied by the dots in the encoding phase. The distance between the actual and recalled dot locations was calculated as a measure of precision. The task was presented in two sessions of six blocks (one of each condition, lasting 30 minutes) with a 30-minute rest between sessions. Fatigue measures were calculated using the Piper Fatigue Scale at the start of each session and at the end of the experiment. Results: As expected, precision was lower in the harder tasks (p50.001; 3 Dot: 9.2 mm to 8 Dot: 13.1 mm) and participants were more accurate in the second session compared to the first (p50.001; e.g. 3 Dot: 9.5 to 8.8 mm). However, there was no difference in performance between the groups (mTBI: 11.15 mm; Control: 11.20 mm). A correlation was seen between higher RPQ score and lower precision in the 3 dot condition in participants with mTBI for both sessions (both p50.05, r40.6). There was also a correlation between higher overall fatigue (Total PFS score, p50.05, r ¼ 0.4) and lower precision in the second session of the 6 dot condition across participants. Conclusions: Touch-screen technology enabled the acquisition of a novel measure of precision in a VSWM task in an everyday context. Precision decreased with difficulty level, suggesting that the protocol and measure are valid. This technology can be further adapted to gain more in-depth and regular data acquisition in a variety of realworld situations. However, there was no significant difference in performance between groups, despite interesting correlations with post-concussion symptoms, fatigue. Previous VSWM studies report differences in mTBI populations, but use a delayed prompt and match to sample, rather than the recollection of object positions. In addition, this was a small sample of very mild TBI and the task might not have been taxing enough to show a group difference. This interpretation is supported by the finding that the difference between actual and recalled dots was relatively small.


DOI: 10.3109/02699052.2014.892379


Severe sleep–wake disturbances in acute and post-acute traumatic brain injury: A case report Catherine Duclos1, Marie Dumont1, He´le`ne Blais1, Jean Paquet1, Marie-Julie Potvin1, David K Menon2, Francis Bernard3, & Nadia Gosselin1 1

Center for Advanced Research in Sleep Medicine, Hoˆpital du Sacre´Coeur de Montre´al, Montre´al, Que´bec, Canada, 2Division of Anaesthesia, University of Cambridge, Cambridge, UK, 3 Traumatology program, Hoˆpital du Sacre´-Coeur de Montre´al, Montre´al, Que´bec, Canada


Haemodynamic adjustment optimization with sympathomimetic agents in patients after severe traumatic brain injury (sTBI) Alexander Sychev, Ivan Savin, Alexander Goryachev, Konstantin Popugaev, Andrey Oshorov, Alexander Polupan, Valeria Tenedieva, Evgenia Alexandrova, Anton Gavrilov, & Alexander Potapov

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Institute of Neurosurgery. NN Burdenko, Moscow, Russia Objectives: Sleep–wake cycle disturbances arise in the days following traumatic brain injury (TBI) and can impede early rehabilitation. This study reports the case of LC, a 43-year-old man with severe TBI who suffered important sleep–wake disturbances while hospitalized in the acute phase post-injury. Methods: LC was admitted with a Glasgow coma scale score of 3 and spent 27 days in the intensive care unit (ICU). A cerebral scan revealed diffuse subarachnoid haemorrhage in the left hemisphere; left parieto-occipital subdural haematoma; right temporal intraparenchymal haematoma (3 cm); intrapedoncular, intrapontine and left temporal petechiae; and left frontal and right parieto-occipital contusions. He experienced persistent neuropsychological and cognitive deficits and was still in post-traumatic amnesia at hospital discharge, 9 days after actigraphy recording had ceased. Five days post-discharge, LC was re-admitted for paranoid delusions and a psychotic disorder. LC also suffered retrograde and anterograde memory deficits, spatiotemporal disorientation, verbal disinhibition and anosognosia. LC wore an actigraph starting in the ICU when continuous sedation was discontinued and he had reached medical stability. Activity counts were summed for daytime (7:00–21:59) and nighttime periods (22:00–6:59). An individual rest period was defined as 5 or more consecutive minutes scored as rest by the actigraph’s software (Actiware 5.0). Results: First hospitalization (15 days of actigraphy, days 31–45 postinjury): There was an absence of rest–activity cycle, with activity counts almost equally distributed over the 24-hour period and daytime activity representing 67.8 ± 9.8% of 24-hours activity. Little rest was observed: LC had 4.2 ± 1.2 rest hours per 24-hour period, the average duration of rest periods was 13.4 ± 9.1 minutes and the longest rest period was 53 minutes. Mean daytime and nighttime rest periods were 11.3 ± 6.5 and 15.05 ± 10.4 minutes, respectively. Second hospitalization (7 days of actigraphy, days 68–74 post-injury): Daytime activity represented 96.2 ± 1.0% of 24-hour activity, which represented a significant improvement compared to the first hospital stay (t(20) ¼ 7.5; p50.001). More rest was also observed (9.2 ± 4.0 hours of rest per 24-hours, t(20) ¼ 15.6; p50.001), with a significant increase in the duration of each rest period (29.7 ± 38.5 minutes, t(426) ¼ 6.5; p50.001). Mean daytime and nighttime rest periods were 13.9 ± 13.2 and 57.1 ± 51.0 minutes, respectively, representing a significant improvement of nighttime rest periods compared to the first hospitalization (t(210) ¼ 9.8, p50.001). Conclusions: This case report is the first to extensively document sleep–wake disturbances during acute hospitalization following severe TBI. Actigraphy results showed an absence of rest–activity circadian cycle and few rest periods during the first hospitalization, but a significant improvement was shown during the second hospitalization. Globally, this case study suggests that the hospital environment cannot entirely account for sleep restriction and sleep disturbances occurring in patients with TBI and that other factors, such as brain recovery, may influence the quality or quantity of sleep and wake periods.

Objectives: Sympathomimetics are the first agents for rapid correction of haemodynamics in patients with acute sTBI demanding optimal cerebral perfusion pressure maintenance. This work was done to personalize the sympathomimetic application according to haemodynamic derangements guided by transpulmonary thermodilution (PiCCO) in patients with sTBI. Methods: Fifty-eight patients with sTBI (GCS58) were enrolled in this study. All patients received norepinephrine, dopamine, phenylephrine or a combination of two agents for haemodynamics adjustment according to PiCCO monitoring measurements. Haemodynamic variables before and after sympathomimetic administration were estimated for therapy modification. Results: Some of the patients (31%) had low arterial blood pressure and high heart rate due to systemic vascular resistance decrease. In this case the most effective was -adrenergic agent administration (phenylephrine). Haemodynamic profile in 15% of patients was characterized by low cardiac output and heart rate. In these patients -adrenergic agent (dopamine) provided the most appropriate correction of haemodynamics. Forty per cent of patients had mixed haemodynamic profile, which required both - and -adrenergic agents administration (norepinephrine). If norepinephrine was ineffective for heart rate, systemic vascular resistance and cardiac output correction used a combination of two drugs: dopamine + phenylephrine (9%) or norepinephrine + phenylephrine (5%). Conclusion: Advanced haemodynamic monitoring with PiCCO provides a reasonable and personalized selection of sympathomimetic agents in patients with acute sTBI.


Melatonin secretion and the rest– activity cycle in the acute phase of moderate–severe traumatic brain injury Catherine Duclos1, Marie Dumont1, He´le`ne Blais1, Jean Paquet1, Marie-Jose´e Quinn1, David K. Menon2, Francis Bernard3, & Nadia Gosselin1 1

Center for Advanced Research in Sleep Medicine, Hoˆpital du Sacre´-Coeur de Montre´al, Montre´al, Que´bec, Canada, 2Division of Anaesthesia, University of Cambridge, Cambridge, UK, 3 Traumatology program, Hoˆpital du Sacre´-Coeur de Montre´a, Montre´al, Que´bec, Canada Objectives: Sleep–wake disturbances are among the most common and persistent sequelea following traumatic brain injury (TBI). These

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658 disturbances can have severe consequences by slowing processes of physical recovery and exacerbating cognitive and neurobehavioural impairments. Sleep–wake disturbances could arise as early as a few days post-injury and could point to circadian disturbances. The first objective was to measure 24-hour melatonin secretion, assessed by urinary 6-sulphatoxymelatonin excretion, in acute moderate–severe TBI patients and to determine whether melatonin secretion increased during the night. The second objective was to evaluate the association between the 24-hour melatonin secretion and the rest– activity cycle, as measured by actigraphy. Methods: For each patient, all urine excreted for 24 hours was collected by hourly collection from the urinary catheter during hospitalization in the intensive care unit, when continuous sedation had been ceased for at least 24 hours and they had reached medical stability. During this 24-hour period, patients also wore a wrist actigraph to measure the rest–activity cycle. Activity counts were summed for daytime (7:00–21:59) and nighttime periods (22:00–6:59). A ratio of daytime period activity to total 24-hour activity higher than 80% was used to denote the presence of rest–activity cycle consolidation during the day of urine collection. Melatonin production was estimated by dosing the concentration of 6-sulfatoxymelatonin (aMT6s), melatonin’s principal metabolite, in each sample. Peak aMT6s concentration and mean daytime and nighttime excretion were calculated. Student t-tests were carried out to measure the difference between daytime and nighttime aMT6s excretion. Pearson correlations were carried out to assess the association between the daytime activity ratio of actigraphy and melatonin variables. Results: Nine patients (six men, 36.3 ± 16.2 years old) admitted with a Glasgow Coma Scale score of 6.7 ± 2.5 (range ¼ 4–11) were included in this study. Urine collection and actigraphy began 20.2 ± 15.8 days post-injury, when patients had a Rancho Los Amigos score of IV. During the data collection period, daytime activity represented 70.8 ± 11.4% of total activity and only two of the nine patients had a consolidated rest–activity cycle. Peak hourly aMT6s concentration was 25.9 ± 21.3 ng ml1 and was highly variable among patients (range ¼ 2.37–80 ng ml1). Overall, patients showed increased nighttime averaged hourly aMT6s concentration (13.0 ± 17.9 ng ml1) compared to daytime averaged hourly concentration (3.0 ± 5.2 ng/ml; t(16) ¼ 2.3, p50.05). No association was found between melatonin variables and rest–activity cycle consolidation. Conclusions: Nocturnal melatonin secretion is present in moderate– severe TBI patients. Therefore, the preliminary data suggest that the lack of consolidation of the rest–activity cycle might not be a direct consequence of an abnormal circadian rhythm of melatonin secretion. However, the sample size still needs to be expanded and results will be compared to those obtained from other patients hospitalized in a similar environment, without TBI.


Behavioural deficits in stroke rehabilitation Marcela Lippert-Gru¨ner1, & Yvona Angerova2 1

Universoity of Cologne, Ko¨ln, Germany, 2Charles University, Prague, Czech Republic Objectives: For a good quality-of-life and a successful social and occupational reintegration first of all the dimension of neuropsychological disturbances and behavioural disorders after brain damage is of major responsibility. Methods: In a retrospective study 61 patients 0–6 months after haemorrhagic or ischaemic stroke were included. Examination of daily behaviour was made with the Marburger Kompetenz Skala (MKS). Results: Results of the MKS-score of daily behaviour showed most of all limits in recreational activities, physical work and mobility (driving a car, using public transport)—this as well as in self-assessment and in foreign assessment.

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Conclusion: Behavioural deficits are of essential importance for sucessful reintegration. Therefore, they should have earned special consideration even in the early phase of rehabilitation. Early comprehension of individually customized neuropsychological and behavioural therapy, accompanied by therapeutic care of the social and familiar environment, could be expected as an important factor for improvement of reintegration of these patients.


Emotion recognition in context in adults with traumatic brain injury Lyn Turkstra1, Kristina Visscher2, & Sara Vandenheuvel3 1

University of Wisconsin-Madison, Madison, WI, USA, 2University of Alabama at Birmingham, Birmingham, AL, USA, 3American SpeechLanguage-Hearing Association, Rockville, MD, USA Objective: To test the hypothesis that emotion recognition errors by adults with ABI may be due in part to not looking at all relevant aspects of the visual stimulus. The hypothesis was motivated by evidence of impaired selective attention and atypical gaze patterns in adults with ABI. Methods: Four adults with ABI were asked to name what people were feeling in a series of 50 black-and-white Life magazine photographs of complex scenes. Photographs were emotionally evocative, captured people in real-life scenarios, had visual contexts that would influence interpretation of affective displays and represented basic emotions (e.g. anger, happiness) and social emotions (e.g. contentment, desperation). Each photograph was presented in one of two formats, randomly assigned: as a full photograph in its original form, with a 1’’  1’’ box drawn around the face to be labelled (face-in-box items) and a cropped image of only the face. To identify correct responses, the photographs were first presented via computer to 202 undergraduate students, who were asked to name the emotion shown by the target person in each photograph. Fifty photographs had more than 80% agreement across students and were used for the study. Eye position was measured using an infrared, desk-mounted eyetracking system while photographs were presented. Participants were four adults with moderate–severe TBI (two males and two females), who viewed the 50 photographs in random order and were asked to state what the person was feeling in each photograph. Photographs were presented for 500 milliseconds each and the experimenter advanced stimuli manually after the participant had labelled the emotion for each photograph. Answers were correct if valence agreed with data from students. Results: Valence agreement for the two female participants was 65% and 81% correct and the two male participants had 46% and 69% correct. For face-in-box items, three of four participants looked outside the box (i.e. at the context) longer for correct than incorrect answers. Conclusions: Results replicated earlier findings of impaired affect recognition in adults with ABI and suggest that examination of gaze patterns might yield useful information about affect recognition and avenues for intervention.


Perceived self-efficacy and coping in acquired brain injury: Relations with quality-of-life and social participation after 1 year Ingrid Brands1, Sebastian Ko¨hler2, Sven Stapert3, Derick Wade4, & Caroline van Heugten2


DOI: 10.3109/02699052.2014.892379 1

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Department of Neurorehabilitation, Libra Rehabilitation Medicine & Audiology, Eindhoven, The Netherlands, 2School for Mental Health and Neuroscience, Faculty of Health, Medicine and Life Sciences, 3 Department of Neuropsychology and Psychopharmacology, Faculty of Psychology and Neuroscience, 4Department of Rehabilitation Medicine, School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands Objective: To investigate the effect of perceived self-efficacy for the management of brain injury-related symptoms and coping style on long-term quality-of-life (QoL) and social participation and to explore the interaction between self-efficacy and coping. Methods: One hundred and forty-eight patients with newly acquired brain injury (ABI) were assessed at baseline (start of outpatient rehabilitation/discharge from hospital or inpatient rehabilitation; mean time since injury ¼ 15 weeks) and 1 year later (mean time since injury ¼ 67 weeks). Whether self-efficacy (TBI Self-efficacy Questionnaire, SEsx) and basic coping styles (task-oriented (T), emotion-oriented (E) and avoidance (A) coping scales of the Coping Inventory for Stressful Situations, CISS) predicted 1-year follow-up scores of the modified Frenchay Activities Index (Modi-FAI), EQ-5D (EQ-5D index and EQ VAS) and Life Satisfaction Questionnaire (LiSat-9) was tested in hierarchical regressions adjusted for age, gender, education and baseline scores of outcomes variables. Results: Higher EQ-5D index scores at follow-up were predicted by an increase in SEsx score from baseline to follow-up ( ¼ 0.30, p50 .001), which accounted for 8.5% of the total 43.5% variance explained. Higher EQ VAS scores were predicted by an increase in SEsx scores ( ¼ 0.49, p50.001) and lower CISS-E ( ¼ 0.23, p ¼ 0.002), jointly accounting for 23.1% of the total 51.5% variance explained. Higher LiSat-9 scores at follow-up were predicted by higher SEsx scores at baseline ( ¼ 0.40, p50.001) and an increase in SEsx scores from baseline to follow-up ( ¼ 0.44, p50.001), jointly accounting for 16.4% of the total 58% variance explained. Higher Modi-FAI scores were predicted by higher baseline SEsx ( ¼ 0.19, p ¼ 0.006) and CISST scores ( ¼ 0.14, p ¼ 0.027), but they accounted for only 5.1% of the total 48.9% variance explained. At baseline, SEsx (p50.001) completely mediated the relation between CISS-E and EQ VAS; and CISS-E and LiSat-9. In the relation between CISS-E and EQ-5D index, effect moderation (SEsx x CISS-E, p ¼ 0.003) by SEsx occurred. Conclusions: Patients who are able to increase their level of selfefficacy over time have better health-related and general QoL. Additionally, patients with higher initial self-efficacy display better long-term general QoL, while those with high initial emotion-oriented coping have worse long-term general health. In contrast, self-efficacy and coping styles appear to be less important in explaining differences in long-term levels of social participation. Furthermore, higher self-efficacy protects against the negative effect of emotionoriented coping on quality-of-life. Enhancing self-efficacy and adaptive coping in an early stage after ABI may, thus, have beneficial long-term effects.


Effect of initial ramp rate in the performance of quasi-linear viscoelastic theory on brain tissue characterization Asghar Rezaei, Ghodrat Karami, & Mariusz Ziejewski North Dakota State University, Fargo, ND, USA Determination of mechanical properties of the brain tissue as a nonlinear viscoelastic material is an important and challenging issue in modelling the response of the brain under different loading conditions. In principal, one of the effective tools in prior studies

has been the employment of the quasi-linear viscoelastic (QLV) model even in a large deformation scheme. In this research, the mechanical properties of the swine brain are quantitatively examined by implementing the QLV method. Several samples from different swine brains are harvested and prepared to perform tensile stress relaxation tests at a 5% strain level. The focus of the study is on the effect of initial ramp rate on the application of the QLV so the stress relaxation tests in tension are carried out at ramp rates of 10, 20 and 50 mm s1. The mechanical properties of the tissue samples are characterized using a non-linear regression procedure to determine the constants of the equation. The non-linear elastic relationships, as well as the reduced relaxation functions, will be obtained and compared to determine short-term and long-term moduli, as well as the decay times of the tissue. The performance of the model under these situations will be challenged and optimized.


The relationship between mental health and sexual functioning in individuals with traumatic brain injury (TBI) Laiene Olabarrieta Landa1, Silvia Leonor Olivera Plaza2, Edgar Ricardo Valdivia Tagarife2, Iva´n Andre´s Soto Rodrı´guez2, Lillian Flores Stevens3, Paul B. Perrin4, & Juan Carlos Arango-Lasprilla5 1

University of Deusto, Bilbao, Bizkaia, Spain, 2Universidad Surcolombiana, Neiva, Huila, Colombia, 3Hunter Holmes McGuire Department of Veterans Affairs Medical Center, Richmond, VA, USA, 4 Virginia Commonwealth University, Richmond, VA, USA, 5 IKERBASQUE, Basque Foundation for Science, Bilbao, Bizkaia, Spain Objective: To explore the relationship between mental health and sexual functioning in individuals with traumatic brain injury (TBI) from Neiva, Colombia. Methods: Fifty individuals with mild-to-severe TBI from Neiva, Colombia completed measures of mental health (anxiety and depression) and sexual functioning (sexual desire and dissatisfaction). Anxiety and depressive symptoms were measured with the Generalized Anxiety Disorder Scale (GAD-7) and the Patient Health Questionnaire (PHQ-9). Sexual desire and dissatisfaction were measured using the Sexual Desire Inventory (SDI-2) and Index of Sexual Satisfaction (ISS). Results: A canonical correlation analysis between the mental health variables and sexual functioning variables revealed that the two sets of constructs were significantly related, r ¼ 0.56 (30.8% overlapping variance), l ¼ 0.62, 2(4) ¼ 11.30, p ¼ 0.023, a large-sized effect. The standardized canonical coefficients for the mental health variables showed that anxiety loaded most highly (1.36) followed by depression (0.46). Although both mental health variables loaded above the conventional cut-off of 0.40, depression loaded in the opposite direction as what would be expected. The high correlation between depression and anxiety (r ¼ 0.84) suggested that depression’s loading was likely due to multicollinearity among the two variables and, therefore, due to error. The standardized canonical coefficients for the sexuality variables showed that both sexual desire (0.57) and dissatisfaction (0.59) loaded above the cut-off of 0.40. This pattern of shared variance suggests that individuals with TBI who had high anxiety also tended to have low sexual desire and high dissatisfaction. Conclusions: Mental health intervention programmes for individuals with TBI in Latin America should include cognitive and behavioural techniques to reduce anxiety symptoms which significantly improve patients’ sexual functioning in the domains of sexual desire and satisfaction.



Effects of a support intervention for long-term family problems after paediatric acquired brain injury Eric Hermans1,2 Brain Project, Sittard, The Netherlands, 2Vilans, Utrecht, The Netherlands

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Objectives: It is well documented that an acquired brain injury (ABI) in a child can have negative effects on other family members and on families as a whole and that the burden for families is high. In The Netherlands only few families with a child with ABI receive family support. Furthermore, support that is actually given is not tailored to meet the specific family needs that may emerge after paediatric ABI. This study developed a paediatric ABI-specific family support intervention (PAFS) and conducted a study to investigate parental satisfaction and effects of PAFS. Methods: The intervention consisted of one or two weekly family visits for as long as needed for a minimum of 6 months by an ABI-educated family support worker and psychologist. Evaluation of the intervention took place on average 60 weeks after the start of the intervention (range ¼ 30–94 weeks). To measure family burden the Family Burden of Injury Interview (FBII) was administered at the start of the intervention (T1) and on evaluation (T2). Parental satisfaction was measured using a home-made 5-point scale. Findings: The number of families included in the study was 35. Mean age of children was 11.7 years (range ¼ 3–22).Twenty-two (63%) were boys. Eighteen (51%) had suffered a non-traumatic brain injury and 17 had had a traumatic brain injury. Children acquired their brain injury on average 7.4 years before the start of PAFS. The nature of problems the families wanted support for varied; most prevalent were behavioural problems of the brain injured child severely disturbing normal family life and the need for information on paediatric ABI and its possible future consequences. Parental satisfaction with the intervention was high. No statistically significant decrease was found in total FBII scores on T2 compared to T1, but significant decreases were found in worries parents had on six FBII items: (1) the child’s behaviour; (2) possible consequences of the brain injury in the future; (3) care for other children; (4) daily household chores; (5) emotional acception of the brain injury and its consequences; and (6) finding time to do things with partner. Conclusions: As long as 7 years after paediatric brain injury, families still suffer from related problems. PAFS is highly appreciated by parents and may help to reduce family stress after paediatric brain injury.


Factors affecting cost of care and case management in a UK community sample of persons with traumatic brain injury Jo Clark-Wilson1, & Gordon Muir Giles2,3 1

Head First, Hawkhurst, UK, 2Samuel Merritt University, Oakland, CA, USA, 3Crestwood Treatment Center, Fremont, CA, USA

Primary objective: To examine the relationship between traumatic brain injury (TBI) related impairments and disabilities and utilization of

Brain Inj, 2014; 28(5–6): 517–878

independent case management and care/support hours in two UK community samples. Methods: Case managers from a single UK case management company and a convenience sample of UK case managers contributed client profiles via a web portal to comprise two independent data samples. Demographic, case management and care/support hours and ratings of activities of daily living (ADL), cognitive and behavioural status and community skills were entered using a computerized version of the Adaptive Behaviour and Community Competency Scale (ABCCS). Samples were compared on injury and demographic variables and correlations between areas of impairment or disability and case management and care/support utilization were computed. Results: Deficits in ADL were associated with care/support hours, but not with case management hours. Behaviour disorder items were related to case management hours and showed some limited correlations to care/support hours. A group of ABCCS items related to executive functions (impulsivity, predictability and response to direction) were related to case management hours but not to care/ support hours. Insight was related to both case management and care/support hours. Conclusions: In the two UK community samples the need for C/S is related to ADL deficits and the need for case management is related to impaired self-regulatory skills including insight.


Psychometric evaluation of the UK FIM + FAM in stroke patients from a multi-centre database Meenakshi Nayar1, & Lynee Turner-Stokes2 1

Regional Rehabilitation Unit, Northwick Park Hospital, London, UK, King’s College London, Department of Palliative Care, Policy and Rehabilitation, London, UK


Objectives: The UK FIM + FAM is a 30-item, ordinal measure of functional independence after brain injury. This study reports the first psychometric examination of it with left and right hemisphere stroke patients. Methods: Data were gathered from 77 specialist rehabilitation units (Levels 1 and 2) across England collated through the UK Rehabilitation Outcomes Collaborative (UKROC) database over a 3year period (2010–2013). Admission data for 1434 UKROC stroke patients (739 L, 695 R) from rehabilitation units across the UK were analysed. Psychometric analyses included principal components analysis with Varimax rotation, corrected item-total correlations and Cronbach’s  for the factorial sub-scales identified. Left and right strokes were then compared on these sub-scales. Results: The sample comprised 414 haemorrhagic (28.9%), 762 infarcts (53.1%), 156 sub-arachnoid (10.9%) and 102 ‘other’ strokes (7.1%). This included 820 males (57%) and 614 females (43%) with a mean age of 59 years (SD ¼ 16) and a mean length of stay of 79 days (SD ¼ 58). Factor analysis showed a strong general factor. The first principal component accounted for 48% of total variance. All 30 items loaded above 0.40 on this component and had an item-total correlation greater than 0.50. Two and three-factor solutions were compared based on inspection of the scree test and parallel analysis. A twofactor solution identified a Motor ( ¼ 0.96) and a Cognitive sub-scale ( ¼ 0.94). The three-factor solution identified Motor ( ¼ 0.97), Communication ( ¼ 0.89) and Psychosocial ( ¼ 0.92) sub-scales. Comparing left and right strokes on the Motor and Cognitive subscales showed that right hemisphere strokes were more physically disabled (mean difference ¼ 3.22, p50.05, CI ¼ 0.41–6.03) and left hemisphere strokes were more cognitively disabled (mean difference ¼ 9.66, p50.01, CI ¼ 10.08 to 2.08). A comparison on the Communication and Psychosocial sub-scales demonstrated that left


DOI: 10.3109/02699052.2014.892379

hemisphere strokes were notably more disabled in terms of Communication (mean difference ¼ 6.79, p50.01, CI ¼ 7.67 to 5.91) and slightly more disabled in Psychosocial terms (mean difference ¼ 2.87, p50.01, CI ¼ 4.35 to 1.38). Conclusions: In the first psychometric evaluation of the UK FIM + FAM with a sample of stroke patients, two primary dimensions were found, similar to those previously reported in mixed brain injury samples. A clear two-factor structure (Motor and Cognitive) is observable and the Cognitive items also split neatly into Communication and Psychosocial sub-scales when three factors are extracted. Internal consistency was very high for all these sub-scales. Comparison of left and right hemisphere strokes on these sub-scales was consistent with the pattern of disability seen clinically.


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Psychiatric disorders in children and adolescents 24 months after mild traumatic brain injury Jeffrey Max1, Keren Friedman1, Elisabeth Wilde2, Erin Bigler3, Gerri Hanten2, Russell Schachar4, Ann Saunders5, Maureen Dennis4, Linda Ewing-Cobbs5, Sandra Chapman6, Tony Yang7, & Harvey Levin2 1

University of California, San Diego, San Diego, CA, USA, 2Baylor College of Medicine, Houston, TX, USA, 3Brigham Young University, Provo, UT, USA, 4Sick Children’s Hospital, Toronto, Ontario, Canada, 5 University of Texas Health Science Center, Houston, TX, USA, 6 University of Texas, Dallas, TX, USA, 7University of California, San Francisco, CA, USA

Objectives: To better understand the occurrence of novel psychiatric disorders (NPD) in children with mild traumatic brain injury (mTBI) in relation to pre-injury variables, injury-related variables and concurrent neurocognitive outcome. Methods: Eighty-seven children between the ages of 5–14 years who had experienced mTBI were studied from consecutive hospital admissions with semi-structured psychiatric interviews soon after injury (baseline). Fifty-four children were re-assessed 24 months postinjury. Standardized instruments were used to evaluate injury severity, lesion characteristics, pre-injury variables (lifetime psychiatric disorder, family psychiatric history, family function, socioeconomic status (SES), psychosocial adversity, adaptive function, academic function) and, finally, post-injury neurocognitive and adaptive function. Results: At 24-months post-injury NPD had occurred in 17/54 (31%) participants. NPD at 24 months was related to frontal white matter lesions and associated with estimated pre-injury reading, pre-injury adaptive function and concurrent deficits in reading, processing speed and adaptive function. Conclusions: These findings extend earlier reports from this group that the psychiatric morbidity following mTBI in children is more common than previously thought and, moreover, that it is linked to pre-injury individual variables, injury characteristics and associated with postinjury adaptive and neurocognitive functioning.


Decreased cerebral blood flow in chronic paediatric mild traumatic brain injury: An MRI perfusion study

Yang Wang1, John West1, Jessica Bailey1, Daniel Westfall1, Hui Xiao1, Todd Arnold2, Patrick Kersey2, Andrew Saykin1, & Brenna McDonald1 1 2

Indiana University School of Medicine, Indianapolis, IN, USA, St. Vincent Sports Performance, Carmel, IN, USA

Objectives: It becomes increasingly clear that cerebrovascular alterations play a significant role in the evolution of traumatic brain injury (TBI) sequelae as well as in the recovery process. Measurement of cerebral blood flow (CBF) in vivo can, thus, enhance the understanding of neurovascular mechanisms underpinning the paediatric brain’s functional recovery from TBI and how such injury in adolescence may result in altered neuronal functioning, possibly leading to persistent changes in brain activity and neurobehavioural status. Arterial spin labelling (ASL) is an advanced MRI technique capable of measuring CBF non-invasively by using magnetically labelled arterial blood water as an endogenous contrast tracer. This study aimed to characterize regional CBF in chronic paediatric mild TBI (mTBI) patients compared with healthy controls (HC). Methods: To date, 34 adolescents (mTBI ¼ 17; HC ¼ 17) have been studied. Post-injury period ranged from 3–12 months (mean 7.2 ± 2.3). While mTBI patients were slightly older (14.7 ± 1.5 vs 12.9 ± 2.5), there was no significant group difference in gender or maternal education. Mechanism of injury was sports- or activity-related for 14 participants. For the other participants injuries were sustained in bicycle (n ¼ 1) or ATV (n ¼ 2) accidents. All participants underwent comprehensive cognitive and clinical assessments. MRI perfusion was performed on 3T (Siemens Tim Trio) using the Q2TIPS pulsed ASL (PASL) sequence. An additional T1-weighted MPRAGE was acquired for anatomical reference. Individual quantitative CBF maps were generated from PASL images using updated versions of previously published methods. The general linear model including age and sex as covariates was utilized in SPM8 for voxel-wise group analysis. Results: Group comparison showed significantly lower CBF in the mTBI group relative to the HC group in the posterior frontal lobe, insula and medial temporal lobe, predominantly on the left side (p50.01). No region showed significantly greater CBF in mTBI adolescents compared to controls. In addition, no significant difference was found in neuropsychological measures between groups. Conclusions: While the injury and recovery processes in the immature brain may differ from the adult brain, delayed recovery of cognitive function and other self-report symptoms have been found in paediatric mTBI. Extending previous findings from very limited existing ASL reports in adults with chronic moderate and severe TBI, the results also suggest that ASL MRI may serve as an important tool to assess underlying functional abnormality in adolescents with chronic mTBI.


fMRI correlates of emotional dysregulation in US soldiers with post-concussion syndrome Jeffery Katz1, Thomas Daniel1, Alex Goodman1, Thomas Denney1, Gopikrishna Deshpande1, Stephanie Traynham2, Grant Iverson3,4, & Michael Dretsch5 1

Auburn University MRI Research Center, Auburn University, Auburn, AL, USA, 2US Army Aeromedical Research Laboratory, Fort Rucker, AL, USA, 3Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, USA, 4Red Sox Foundation and Massachusetts General Hospital Home Base Program, Boston, MA,


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USA, 5Comprehensive Soldier and Family Fitness; G-1, HDQA, Arlington, VA, USA Objective: The purpose of this study was to determine if soldiers with post-concussion syndrome (PCS) have problems with emotional regulation and whether differences in emotional regulation can be visualized through functional magnetic resonance imaging (fMRI). Method: This study compared performance on an affect regulation task and brain-related activity using blood-oxygen-level-dependent fMRI in 38 soldiers suffering from combat-related PCS compared to 38 healthy soldiers. In addition, whole blood and plasma were collected for proteomic, lipidomic and genetic assays and participants were administered a neurocognitive battery (ANAM and CNS-Vital Signs) and self-report measures. The affect regulation task was performed in a 3T Siemens Verio MR scanner with a 32 channel head coil and differences in functional activation of various neural regions of interest were examined (MRI data was set at 16 slices every 600 milliseconds). The affect regulation task required participants to view picture stimuli from the Military Affective Picture System (MAPS). The MAPS is a stimuli set of neutral, positive and negative valence pictures from military combat environments in Iraq and Afghanistan and military training environments. Three regulation instructions for the pictures were presented in a random manner: maintain, enhance and suppress. After each attempt to regulate or maintain their emotions toward a picture, they were instructed to report their success on a 4-point scale using a button box. Results: The PCS group reported more difficulty during the maintain condition compared to controls, suggesting less success with viewing the pictures without an increase in the magnitude of emotions. On fMRI, the PCS group showed significantly greater activation in the medial frontal gyrus in the suppress condition compared to controls; greater activation in the inferior frontal gyrus in the enhance condition; and greater activation in the superior frontal gyrus and less activation in the anterior cingulate cortex when viewing negative vs neutral images. There was also increased activation of the emotion network (insula, inferior parietal, limbic system, temporal pole) compared to controls. Conclusion: The findings suggest that soldiers with PCS have compromised efficiency for emotional regulation. However, it remains unclear if the findings reflect pre-morbid vulnerability to PCS, residual combat-related traumatic stress, mTBI-related neurobiological changes or a combination of factors. Moreover, the degree to which differences in emotional regulation contribute to the maintenance of PCS is unknown.

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attack that affected blood flow due to strangulation as well as repeated facial trauma. Her main symptom was chronic debilitating headaches unresponsive to rest, medication or other interventions. Prior to being seen at this office was under the care of a neurologist and taking various prescription medications which caused her extreme side-effects yet did not relieve her headaches. Methods: She has been under care for 3 years, which consisted of chiropractic sacro occipital technique (SOT) and cranial treatment. Within the past year laboratory tests were instituted to monitor neurotransmitter balance of the HPA axis and used to help direct nutritional supplementation. The patient is seen once per week for chiropractic care and laboratory test, while usually performed every 4 months, in this case was performed annually. This was due to the patient not performing the laboratory test in a timely manner, believed due to her profile which included inability to cognitively function in scheduling situations. Results: Overall all her symptoms improved which included headaches which are less frequent and less debilitating. The headaches went from daily constant chronic to 2–3 times per a week with significantly less intensity and debilitation, allowing her to function in her activities of daily living. Prior to care she could not function when she had a headache. While she was making good progress with the chiropractic care during the first 2 years when nutritional supplementation based on laboratory analysis for neurotransmitter balance headaches and function improved, including not needing to sleep during the day and mental clarity. Conclusion: Treatment of brain trauma is a very individualized process and what may help one patient may not help another. It is unclear with case reports whether effective treatment for one patient can be generalized to the brain trauma population at large. However, it is worthy of consideration when a patient is not responsive or has an adverse reaction to medications and is non-responsive to traditional approaches that a chiropractor trained in SOT and cranial care might be considered for collaborative care. Greater research is needed in interdisciplinary settings to determine how this sub-set of patients may be best served.


Chiropractic care and its effects on a patient with a moderate traumatic brain injury (TBI) Ryan Pollard, Charles Blum, & Esther Remeta


Chiropractic sacro occipital technique (SOT) and cranial treatment model for traumatic brain injury along with monitoring and supplementing for neurotransmitter balance: A case report Esther Remeta, & Charles Blum Sacro O