Abstracts 2014. [corrected].

http://informahealthcare.com/bij 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

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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

1

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.

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


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.

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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.

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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.

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DOI: 10.3109/02699052.2014.892379

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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


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.

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

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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.

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

2

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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Brain Inj, 2014; 28(5–6): 517–878

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.

0014

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

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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

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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


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.

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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.

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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


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.

0019

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

Brain Inj, 2014; 28(5–6): 517–878

0020

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.

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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.

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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

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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.

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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


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.

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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.

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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

1

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.

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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.

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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.

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

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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.

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Pamela Weatherbee1, Ryan Todd2, & Shree Bhalerao2


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

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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.

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


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.

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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.

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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 Montreál, 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 Montreál 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.

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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 Montreál, 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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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 Montreál 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.

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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.

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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.

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


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.

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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.

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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

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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.

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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.

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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.

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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.

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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

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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.

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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.

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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.

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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.

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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.

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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.

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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

0062


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.

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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


1

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.

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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.

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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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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.

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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

2

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.

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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.

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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.

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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.

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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

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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.

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

1

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

0075

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.

1

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

2

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

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DOI: 10.3109/02699052.2014.892379

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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


2

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.

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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.

0078


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.

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

2

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.

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DOI: 10.3109/02699052.2014.892379

0080

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


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.

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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.

0083

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


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.

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Chronic radiological abnormalities in patients with mild traumatic brain injury

Brain Inj, 2014; 28(5–6): 517–878

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.

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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.

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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


2

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.

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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.

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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.


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.

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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.

Brain Inj, 2014; 28(5–6): 517–878

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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.

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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

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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.

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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.

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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.

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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.

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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.

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Specific acupuncture stroke treatment: Fundamentals about gallbladder points connected with the ‘Sea of Marrows’ Adriań Ańgel 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

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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.

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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.

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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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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.

0102

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

2

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.

0103

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.

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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.


0104

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.

0105

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.

0106

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 Reádaptation Lucie-Bruneau, Montreal, Quebec, Canada, 2 Universidad Surcolombiana, Grupo de Investigacioń 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


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.

0108

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

0107

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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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.

0109

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.

0110

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.

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0111

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


1

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).

Brain Inj, 2014; 28(5–6): 517–878

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

0112

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.

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0113

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


1

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, & Daćil 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.

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

Brain Inj, 2014; 28(5–6): 517–878

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

2


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.

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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.

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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.

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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

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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

Brain Inj, 2014; 28(5–6): 517–878

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.

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Intravenous mesenchymal cells therapy in the acute phase after traumatic brain injury improves neurological recovery Esther Pe´rez-Sua´rez1, Ignacio Mastro-Martıńez2, Fernando Casco3, A´frica Gonza´lez-Murillo4, Gustavo Melen4, Marıá Gutie´rrez-Fernańdez5, Ana Serrano1, Esuperio Dıéz-Tejedor5, Juan Casado-Flores1, & Manuel Ramı´rez4 1

Pediatric Intensive Care Service, Ninõ Jesu´s University Hospital, Madrid, Spain, 2Pediatric Department , Jimeńez Dıáz Hospital, Madrid, Spain, 3Histiocitomed Institute, Madrid, Spain, 4 Oncohematology Research Laboratory, Ninõ 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.

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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.

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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.

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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.

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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


1

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.

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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.

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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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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.

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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.

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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.

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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


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.

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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.

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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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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.

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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

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Intracranial pressure monitoring (ICP) with transcranial Doppler (TCD)—Reference values in awake and anaesthetized patients Ma˚ns Nilsson1, Johan Undeń2, & 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.

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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 Aragoń2, Alfonso Caracuel3, Diego Rivera1, Paul B. Perrin4, & Juan Carlos Arango-Lasprilla5

564 University of Deusto, Bilbao, Bizkaia, Spain, 2Universidad del Norte, Barranquilla, Atlańtico, Colombia, 3University of Granada, Granada, Andalucıá, Spain, 4Virginia Commonwealth University, Richmond, Virginia, USA, 5IKERBASQUE, Basque Foundation for Science, Bilbao, Bizkaia, Spain


1

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.

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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

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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 Rehabilitacioń 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.

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


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.

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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.

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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


2

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

0145

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).

0146

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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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; ClinicalTrials.gov-#NCT01339702) 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.

0147

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.

0148

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

1

Universidad Surcolombiana, Neiva, Huila, Colombia, 2Centre de Reádaptation Lucie-Bruneau, Montreál, 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

1

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

1


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; ClinicalTrials.gov-#NCT01339702) 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.

0149

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.

0150

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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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.

0151

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

2

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.

0152

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.

0154

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


1

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.

Brain Inj, 2014; 28(5–6): 517–878

0155

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.

0156

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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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.

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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

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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.

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


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.

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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

Brain Inj, 2014; 28(5–6): 517–878

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.

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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

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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.

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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.

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


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: http://www.windowsphone.com/en-us/store/app/ 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 (http://www.braintrain.com/captainslogmentalgym/) 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 (www.cogstate.com), the computerized Tests of Variables of Attention (TOVA; www.tovatest.com), 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

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


2

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.

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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.

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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

1

1

1

1

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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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.

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

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

3

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.

2

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

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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.

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‘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.

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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 informahealthcare.com by RMIT University on 09/02/14 For personal use only.

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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

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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.

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

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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.

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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.

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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


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.

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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.

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Psychological functioning and quality-of-life in caregivers of individuals with traumatic brain injury Melissa Alejandra Rodrı´guez Dıáz1, Carlos Jose´ De los Reyes Aragoń1, 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

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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

4

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

0186

TBI symptoms and caregiver mental health in Colombia, South America Carlos Jose´ De los Reyes Aragoń1, 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.


0189

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.

0190

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

1

1

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.

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DOI: 10.3109/02699052.2014.892379

0191

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

1

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


0192

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.

1

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.

584

0194

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


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.

0195

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.

0196

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

585


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.

0197

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.

0200

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.

0202

Post-traumatic Parkinsonism Rita Formisano1, & Nathan Zasler2


1

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).

0203

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.

0204

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

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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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.

0205

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.

0206

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

0207

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


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.

0208

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 (www.TherapWii.nl), Research on the effect of gaming on physical and mental functioning should be further explored.

0209

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,

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


3

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.

0213

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

0212

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.


0214

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.

0215

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

1

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

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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.

0217

0216

Cecilia Jonsson1, & Elisabeth Elgmark Andersson2


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.

0218

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.

0219

0220

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

1

1

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

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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.


0222

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.

0223

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.

0225

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

0224

1

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 informahealthcare.com 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.

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0226

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


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.

0227

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.

0228

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.

0229

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.

Brain Inj, 2014; 28(5–6): 517–878

0231

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.

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0233

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


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.

0234

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.

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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


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.

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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).

Brain Inj, 2014; 28(5–6): 517–878

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.

0237

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.

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0238

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

0239

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


1

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.

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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


2

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.

0241

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

Brain Inj, 2014; 28(5–6): 517–878

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.

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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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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 postmeasures 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.

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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.

0245

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

2

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.

Brain Inj, 2014; 28(5–6): 517–878

0247

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:// surfer.nmr.mgh.harvard.edu), 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 (http://fsl.fmrib.ox.ac.uk/fsl/fslwiki), 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.

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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.

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


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.

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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.

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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.

0252

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.

Brain Inj, 2014; 28(5–6): 517–878

(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.

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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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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.

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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.

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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

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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.

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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.

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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

1

1

1


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

2

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.

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


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.

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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.

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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


1

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.

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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%.

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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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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.

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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.

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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.

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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

2

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.

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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.

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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.

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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.

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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.

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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


1

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.

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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

Brain Inj, 2014; 28(5–6): 517–878

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.

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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.

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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

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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.

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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.

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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 François 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.

1

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

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


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.

Brain Inj, 2014; 28(5–6): 517–878

0281

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.

0282

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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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.

0283

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.

0284

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.


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.

Brain Inj, 2014; 28(5–6): 517–878

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.

0286

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

0285

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.

0287

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.

0288

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

1

1

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

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0289

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


1

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.

0290

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

2

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

Brain Inj, 2014; 28(5–6): 517–878

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.

0291

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.

0292

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.

0293

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.

0294

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.

0295

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,

0296

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.

0297

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.

0298

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.

0299

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.

Brain Inj, 2014; 28(5–6): 517–878

0300

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.

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0301

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

0302

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

2

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.

0303

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


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.

0304

Modulation of the default-mode network and the attentional network by self-referential processes in patients with disorder of consciousness Verońica Ma¨ki-Marttunen1, Lisandro Olmos2, Ramoń 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

Brain Inj, 2014; 28(5–6): 517–878

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.

0305

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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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.

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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 Reádaptation et Inte´gration Sociale (CIRRIS), Quebec city, Que´bec, Canada, 3Universite´ de Montreal - Department of Psychology, Montreal, Que´bec, Canada, 4 Institut de Reádaptation Gingras-Lindsay de Montreál, Montreal, Que´bec, Canada, 5Centre Universitaire de Sante´ McGill (CUSM), Montreal, Que´bec, Canada, 6Institut de Reádaptation 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.

0307

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

2

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


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.

0308

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.

0309

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.

0310

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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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.

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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.

0312

Enhanced attention capture by emotional stimuli in MTBI Verońica 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.

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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.

0314

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


2

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.

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0315

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


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.

0316

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.

0317

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),


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.

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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.

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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

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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.

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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.

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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.

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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

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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.

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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 informahealthcare.com 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.

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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.

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


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.

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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 Reádaptation, 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.

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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

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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).

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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

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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.

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0336

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, 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.

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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,

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DOI: 10.3109/02699052.2014.892379


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.

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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 Montreál, Centre de Recherche de Centre Hospitalier de l’Universite´ de Montreál, 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.

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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


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.

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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

Brain Inj, 2014; 28(5–6): 517–878

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.

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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.

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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 informahealthcare.com by RMIT University on 09/02/14 For personal use only.

1

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.

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

1

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.

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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


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.

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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

3

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

Brain Inj, 2014; 28(5–6): 517–878

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.

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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

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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.


0348

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.

0349

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.

0350


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

Brain Inj, 2014; 28(5–6): 517–878

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.

0351

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

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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.

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0352

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

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


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.

0354

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,


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.

0355

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

2

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

Brain Inj, 2014; 28(5–6): 517–878

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.

0357

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.

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0358

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


1

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.

0359

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.

0361

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


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.

0362

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

Brain Inj, 2014; 28(5–6): 517–878

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.

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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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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.

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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 Montreál, Montreál, Que´bec, Canada, University of Montreál, Montreál, Que´bec, Canada

2

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.

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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

2


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.

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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


1

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.

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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


1

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

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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.

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The evolving discussion of concussion in the US national football league Catharine F. Kennedy, & Mary Connor Thomas Jefferson Hospital, Philadelphia, PA, USA

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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


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.

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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.

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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


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.

0376

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.

0377

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.

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DOI: 10.3109/02699052.2014.892379 1

0378

Impact of concomitant brain injury in individuals with spinal cord injury Kathleen Castillo, Stephanie Kolakowsky-Hayner, Kazuko Shem, & Kimberly Bellon


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.

0379

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.

0380

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.


0381

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

Brain Inj, 2014; 28(5–6): 517–878

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.

0382

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

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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.

0383

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


1

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.

0384

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.

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0385

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


1

School of Psychology, University of Surrey, Guildford, UK, 2Center of Mathematics, Computation and Cognition, Universidade Federal do ABC, Saõ Paulo, Brazil, 3NIF/LIM44, Departamento de Radiologia da Faculdade de Medicina da Universidade de Saõ Paulo, Saõ 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

Brain Inj, 2014; 28(5–6): 517–878

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.

0386

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 (www.psyapp.co.uk) 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.

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0388

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 SacreĆoeur de Montreál, Montreál, Que´bec, Canada, 2Division of Anaesthesia, University of Cambridge, Cambridge, UK, 3 Traumatology program, Hoˆpital du Sacre´-Coeur de Montreál, Montreál, Que´bec, Canada

0389

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


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.

0390

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-Joseé Quinn1, David K. Menon2, Francis Bernard3, & Nadia Gosselin1 1

Center for Advanced Research in Sleep Medicine, Hoˆpital du Sacre´-Coeur de Montreál, Montreál, Que´bec, Canada, 2Division of Anaesthesia, University of Cambridge, Cambridge, UK, 3 Traumatology program, Hoˆpital du Sacre´-Coeur de Montreá, Montreál, Que´bec, Canada Objectives: Sleep–wake disturbances are among the most common and persistent sequelea following traumatic brain injury (TBI). These


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.

0391

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.

Brain Inj, 2014; 28(5–6): 517–878

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.

0392

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.

0393

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

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DOI: 10.3109/02699052.2014.892379 1


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.

0394

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.

0395

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, Ivań 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.

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0397

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


1

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.

0399

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.

0400

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

2

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

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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.

0401


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.

0402

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.

0403

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.

Brain Inj, 2014; 28(5–6): 517–878

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.

0405

Chiropractic care and its effects on a patient with a moderate traumatic brain injury (TBI) Ryan Pollard, Charles Blum, & Esther Remeta

0404

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 Occipital Technique Organization - USA, Sparta, NC, USA Objectives: The purpose of this paper is to present a novel treatment model incorporating Sanesco Laboratories to evaluate patient neurotransmitter balance and chiropractic cranial care for the treatment of a patient with traumatic brain injury. The patient is a 33-year old female presenting at this office for care secondary to an

Sacro Occipital Technique Organization - USA, Sparta, NC, USA Objective: Emerging evidence suggests that chiropractic care may play a role in treatment of TBI. Current research suggests that neurological damage from a TBI may evolve following the initial trauma. A patient was injured at work when struck twice in the head by a plank of wood, with the second blow rendering him unconscious. Following the injury he gradually had worsening symptoms consistent with a TBI. The chiropractic technique used in this case was Sacro-Occipital Technique (SOT). The purpose of this paper is to discuss how conservative chiropractic care may help a patient suffering from longterm effects of TBI. Methods: An MRI following the urgent care visit found a 2 2 1 centimetre mass in the right cerebellar peduncle and noted a subacute hsemorrhage and calcification suggestive of an injury to the skull. SOT evaluation noted hypertonicity on the left of his body which appeared to affect his neck, left shoulder, scapula, rib cage, pelvis and hip. These presentations were consistent with a person exhibiting a possible upper motor lesion along with a lack of balance, disorientation and intermittent muscle fasciculations. A thorough SOT cranial assessment was performed determining some cranial dural and CSF pulsation imbalance as well as temporomandibular joint dysfunction (TMD).

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Results: The initial goal of his treatment was to maintain as much balance as possible in the myofascia until such a time as his nervous system could recover greater inhibitory function. The therapy appears to reduce his pain and neurological imbalance for periods of time, sometimes lasting for a few weeks aiding his balance, walking and general flexibility. Following care the patient finds it easier to sleep and perform activities around his home. Currently the care is considered supportive with its focus to prevent worsening of his condition and maintaining his quality-of-life and increasing his level of independence. Conclusions: This case report discusses the care of a patient who suffered TBI with subsequent neurological-related complications. The chiropractic supportive care has as its focus supporting his activities of daily living, preventing worsening of his symptoms and asymmetry and continually working toward the possibility of improvement. With challenging TBI cases low-risk interdisciplinary care may hopefully represent future healthcare options for these patients. Further research should study whether supportive care represents an important strategy for TBI patients to help sustain their ability to function, having a good quality-of-life and not becoming an increased burden to society.

0406

Music boosts cognition in patients with disorders of consciousness Maı¨te´ Castro1, Barbara Tillmann1, Jacques Luaute´2, Alexandra Corneyllie1, Fre´de´ric Dailler3, Nathalie Andre´-Obadia4, & Fabien Perrin1 1

Auditory Cognition and Psychoacoustics Team, Lyon Neuroscience Research Center, Lyon, France, 2Department of Physical Medicine and Rehabilitation, Henry Gabrielle Hospital, Lyon, France, 3Department of Intensive Care, 4Clinical Neurophysiology Unit, Neurological Hospital, Lyon, France Objectives: Some studies in patients with disorders of consciousness (DOC) have shown that the use of pertinent and emotional stimuli increases the probability to observe a cerebral response. One of the most emotional and alerting stimulus for many is probably music. Furthermore, many studies have demonstrated that music listening conveys beneficial effects on cognitive processes as well as both normal and pathologic cerebral functioning. However, only a few studies have evaluated the potential effect of music on cognition in patients with DOC. The present study aimed to evaluate, in comatose and post-comatose patients, whether exposure to the patient’s preferred music could enhance cognition to a highly significant stimulus, the patient’s own name, as compared to a control condition. Methods: This study recorded event-related potentials to the patient’s first name and to unfamiliar first names in 13 patients with DOC. These names were presented after either an excerpt of the patient’s preferred music (music condition) or a continuous sound (control condition). Individual t-tests were performed on ERP amplitudes. Significance thresholds were defined by a triple criterion: p50.01 on a minimum of 20 milliseconds and two electrodes. Results: Seven of the 13 patients showed a significant discriminative response (N2 and/or P3) to the patient’s own name (in comparison to the other first names) in the music condition. Only one of these seven patients also showed a significant discriminative response in the control condition. Furthermore, the presence of a discriminative response in the music condition was predictive of awakening or partial recovery after 1 month. Its absence was also associated with a bad recovery (death or poor evolution after 6 months). Conclusions: This study showed that exposure to the patient’s preferred music increased the probability to observe the N2 or/and P3 to the patient’s own name. The results thus suggest that music has

a beneficial effect on cognitive processes of patients with DOC. This finding could be explained by an emotional effect and increased arousal induced by music. Finally, thanks to the use of emotional and personally relevant stimuli, this new test could become a very sensitive clinical tool to predict patients’ recovery.

0407

Factors that influence concussion knowledge and self-reported attitudes in high school athletes Brad G. Kurowski, Wendy J. Pomerantz, Courtney Schaiper, & Michael A. Gittelman Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA

Objectives: Many organizations and healthcare providers support educating high school (HS) athletes about concussions to improve their attitudes and behaviours about reporting. The objectives of this study are to determine if prior education, sport played, age and/or gender are associated with better knowledge about concussion and to determine if more knowledge is associated with improved selfreported attitudes toward reporting concussions among a large sample of HS athletes. Methods: Participants included 496 athletes aged 13–18 years from two large, urban high schools. Players were recruited from fall and winter and men and women’s sports considered higher risk for concussion. During pre-season, each participant was given a survey, developed by study investigators, which asked about their previous education, current knowledge and self-reported attitudes and behaviours about reporting concussions. Bivariate and multivariate linear regression were used to evaluate the association of age, gender, sport and prior concussion education with knowledge about concussions and self-reported attitudes and behaviours about reporting. Results: Older age (p ¼ 0.002), female gender (p ¼ 0.05), basketball (p ¼ 0.002), soccer (p ¼ 0.03) and prior concussion education (p ¼ 0.03) were associated with improved knowledge and younger age (p ¼ 0.004), female gender (p 0.0001) and soccer participation (p ¼ 0.0003) were associated with improved self-reported behaviours in bivariate regression. Better knowledge was not associated with better self-reported behaviours (p ¼ 0.63). Multivariate models that included age, gender, sport, prior concussion education and history of concussion demonstrated that older age (p ¼ 0.01) and female gender (p ¼ 0.03) were associated with better knowledge and younger age (p ¼ 0.01), female gender (p ¼ 0.0002) and soccer participation (p ¼ 0.02) were associated with better self-reported behaviours. Conclusions: Findings suggest that prior education on concussion is less predictive of knowledge when controlling for other factors such as sport and gender. Older age, female gender and soccer participation were more likely to be associated with better selfreported behaviours. Future studies need to focus on development of beneficial interventions to not only improve concussion-specific knowledge, but also improve behaviours.

0408

Neurobehavioural rehabilitation—A case study: Successful progression through a continuum of care Tonia Wells, & Melissa Hopkins

664 Commonwealth of Kenucky, Frankfor, KY, USA

Brain Inj, 2014; 28(5–6): 517–878 3


4

Objective: Brain injury studies have shown that the first 18–20 months after brain injury presents the optimal window for neurorehabilitative recovery. However, this case study involving Steven R. illustrates successful progression through a neurobehavioural rehabilitative continuum of care 30 + years post-injury. Steven R. sustained frontotemporal brain injury secondary to a 10–15 feet fall at the age of 7, resulting in chronic behavioural dysregulation, including physical aggression, Anxiety Disorder and Seizure Disorder. Steven R. received no rehabilitation intervention. In 1999, Steven R. ceased all prescribed medications, marking the beginning of a critical decline in Steven R.’s mental health status. The results were estrangement from his family, homelessness and significant legal troubles. Steven R. was arrested multiple times, incarcerated/probated and, on numerous occasions, hospitalized involuntarily into psychiatric facilities. In 2008, Steven R. was arrested and charged with criminal mischief, two counts of criminal trespassing, terroristic threatening, violation of emergency protective order and Persistent Felony Offender after he threatened the lives of his parents, attempting to set fire to their home while his parents were inside. After intense psychological testing, Steven R. was found incompetent to stand trial and placed under guardianship of the Commonwealth of Kentucky. Steven R. was court ordered to secure neurorehabilitative treatment. Unfortunately there were no providers of brain injury treatment in Kentucky that could offer the secure neurorehabilitation programming Steven R. needed. He remained incarcerated until an appropriate provider was located. In 2009, Steven R. was admitted to Nexus Health Systems, Touchstone Neurorecovery Center in Conroe, TX. Methods: Touchstone Neurorecovery Center’s treatment model is a post-acute continuum of care designed to be patient-centred; meeting the individual’s needs and providing for freedom of choice. This treatment model provides tailored services including Neuromedical Management, Rehabilitation Services including therapeutic and behavioural programming, Independent Living Services, Vocational/Educational Services and Structured Day Programming. Residential Services are provided through a series of cottages that provide a homelike setting with varying levels of support ranging from high levels of supervision to supported independent living. Results: Upon admission, Steven R. exhibited cognitive deficits, pressured speech, poor concentration, perseveration, poor reasoning, judgement, problem-solving and decision-making skills, poor understanding of cause/effect, poor impulse control and physical aggression. Although independent in all basic Activities of Daily Living, he required maximum assistance with Instrumental Activities of Daily Living. Despite the lack of early rehabilitative intervention, Steven R. successfully progressed through the treatment model continuum of care at Touchstone, from secure neurobehavioural residential treatment targeting stabilization, constraints to learning, coping skill development and maladaptive behaviours, to eventual community living focusing on independent living skills, self-regulation and vocational training and productivity. Conclusion: Neurobehavioural rehabiliation is a successful intervention regardless of date of injury when designed by person-centred principles.

0409

Eye tracking measures differentiate fatigue from concussion and recovery Jianliang Tong1, Jun Maruta1, Kristin Heaton2, Alexis Maule2, Nana Asiedu1, & Jamshid Ghajar1 1

Brain Trauma Foundation, New York, NY, USA, 2United States Army Research Institute of Environmental Medicine, Natick, NA, USA,

Boston University School of Public Health, Boston, MA, USA, Weill Cormell Medical College, New York, NY, USA

Objectives: Attention can be impaired by sleep deprivation or mild traumatic brain injury (mTBI), conditions that are prevalent with military populations. Eye movement is known to activate the same brain regions that are observed during attention-dependent tasks and oculomotor assessment may provide objective measures of subtle attention changes. Since fatigue and mTBI require different approaches to management, identification of specific alterations in attention associated with each condition is important. Methods: This study characterized binocular co-ordination and gazetarget synchronization dynamics during predictive visual tracking, an attention-dependent task, in 59 healthy subjects who were fatigued by sleep-deprivation and in 10 patients with acute mTBI. Eye movements were recorded while the subject visually tracked a circularly moving target. In the sleep-deprivation portion of the study, testing was conducted before and after one night of total sleep deprivation. In the mTBI portion of the study, the patients were initially tested following recruitment within 2 weeks of injury and were re-tested 1 month post-injury. The dynamics of binocular coordination were quantified with the standard deviation of the difference between the left and right eye positions. The dynamics of gaze-target synchronization were quantified with the standard deviation of the difference between gaze and target positions in the direction parallel to the target motion. Performance changes during sleep deprivation and in acute mTBI patients were tested using a repeated measures approach. Results: Both binocular co-ordination and gaze-target synchronization were deteriorated during sleep deprivation, with binocular co-ordination showing a more significant disruption in this condition. The mTBI patients showed improvements in both binocular co-ordination and gaze-target synchronization over time; however, gaze-target synchronization showed better improvement than binocular co-ordination. Conclusions: The indices of binocular co-ordination and gaze–target synchronization showed different sensitivities in sleep deprivation and mTBI, suggesting that correlates to specific alterations in attention associated with each condition can be identified. These indices may also be used differentially for monitoring fatigue induced by sleep deprivation and recovery from mTBI.

0411

Traumatic brain fungus Shameem Ahmed, Binoy Kr Singh, & Zakir Hussain Gauhati Medical College and Hospital, Guwahati, Assam, India Introduction: Brain fungus means protrusion of brain tissue through a defect in its covering, i.e. scalp, skull and meninges. The formation of brain fungus at the site of a traumatic wound of the head is not infrequent. This study was undertaken to evaluate the pattern of causation, clinico-radiological presentation and the treatment outcome of brain fungus at the centre. Materials and method: All patients with fungus cerebri were analysed retro-prospectively during the period from January 2007 to December 2012, admitted at the centre. Clinical and radiological data and outcome were evaluated. Results: In total, five patients were enrolled, four had sustained compound head injuries, while one patient had penetrating head injury. Mean age was 36 years, four of them were male, road traffic accident was the commonest mode of injury. At admission, mean GCS (Glasgow coma score) was 12/15 and 60% (n ¼ 3) sustained moderate head injury (GCS 9–13). The average duration was 3 days post-trauma. All patients were subjected to CT scan of the head and CT cerebral angiography was done in one patient. All the patients were surgically managed; artificial dura or fascia lata was used for dural closure. Bone flap was discarded in two patients in view of gross contamination.

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One patient had post-operative meningitis and one had wound infection. There was no mortality in this series. At follow-up, three patients had good functional outcome with mean Glasgow outcome score (GOS) of 4 and the remaing two had poor functional outcome (mean GOS of 2.5). Conclusions: Management of brain fungus requires a variety of surgical and technical skills. This study shows that aggressive management is feasible in brain fungation. This study recommends a database to which all head injury must be reported in order to assess the magnitude of the problem, as well as funding of research in injury control and management as well as complication avoidance.

0413

0412

1

Cerebral malaria retinopathy severity during acute illness and its prediction of persisting neuropsychological problems at follow-up Michael Boivin1, Maclean Vokhiwa2, Alla Sikorskii1, & Jed Magen1 1

Michigan State University, East Lansing, MI, USA, 2Blantyre Malaria Project, Blantyre, Malawi Objectives: Neuropsychological sequelae from paediatric cerebral malaria (CM) have been well documented. Although malaria-specific retinopathy during acute illness has become a defining criterion for CM, its relationship to neuropsychological sequelae has not been documented. This relationship is important if malaria-specific retinopathy reflects the possible brain neuropathogenesis leading to longterm neurocognitive deficits. The principal aim of the present study was to evaluate the extent to which retinopathy severity during acute CM illness predicted persisting neuropsychological impariment over subsequent years. Methods: Several years following illness, 52 Malawian children of 6 years of age and older surviving retinopathy-positive cerebral malaria (CM-R) were evaluated for neuropsychological problems with the Kaufman Assessment Battery for Children, 2nd edition (KABC-II), the Tests of Variables of Attention (TOVA) and the school-age CBCL. These test outcomes were correlated with CM clinical and retinopathy measures gathered previously during acute illness. Results: Composite retinopathy severity (p ¼ 0.044) and coma duration (p ¼ 0.025) predicted poorer overall KABC-II cognitive performance. Coma duration also predicted greater impulsivity on the TOVA attention (p ¼ 0.005). The more severe retinopathy sub-group consistently did more poor poorly on the KABC-II. This was the case when the CM group was dichotomized for number of microhemorrhages (p ¼ 0.016), hyperanemia (p ¼ 0.041), right eye papilloedema (p ¼ 0.006) and foveal central whitening (p ¼ 0.029). Right-eye papilloedema was also predictive of TOVA D prime overall attention performance (p ¼ 0.014). Conclusions: This study is the first to report the relationship between severity of malaria-specific retinopathy during acute illness in CM survivors and persisting neurocognitive and attention problems. These findings confirm earlier studies documenting that severity of retinopathy during acute illness is prognostic in CM surviving children. These findings are rextended to include neuropsychological outcomes.

Nerve cell organelle degeneration in severe and complicated human traumatic brain oedema. An electron microscopic study Orlando Castejoń1,2 Biological Research Institute, Faculty of Medecine, Zulia University, Maracaibo, Venezuela, 2Fundadesarrollo, LUZ, Maracaibo, Venezuela

Objectives: To postulate cell nerve orgenelle degeneration as markers of lethal nerve cell injury. Method: Transmission electron microscopy study of glutaraldehydeosmium fixed ultrathin sections of cortical biopsies from patients with severe and complicated brain injuries taken during neurosurgical treatment. Results: Three injured mitochondrial morphological patterns are found in the human oedematous cerebral cortex of 30 patients with complicated brain trauma associated to subdural or epidural haematoma. Swollen clear (SCM), swollen dense (SDM) and dark degenerated (DDM) mitochondria are described. SCM exhibit low electron dense mitochondrial matrix, enlarged intracristal space and continuity of outer and inner mitochondrial membranes. SDM show high electron dense matrix and swollen intact or fragmented cristae. DDM display overall high electron density of matrix and mitochondrial membranes. Disruption of the Golgi apparatus with displacement of fragmented Golgi endoplasmatic sacs and presence of small, medium and large clear and dense Golgi vesicles. Fragmentation of the stacked Golgi cisternae, increased secretory activity in the transGolgi compartment and morphological signs of increased number of Golgi and clathrin-coated vesicles with augmented intracytoplasmic vesicular traffic is observed. In addition, an increased formation of Golgi and coated vesicles is observed in the cis- and trans-Golgi regions. Most Golgi and clathrin-coated vesicles are observed throughout the cytoplasm, suggesting an increased vesicular intracytoplasmic transport. Vacuolized and hyperthrophic Golgi complex is observed with increased formation of Golgi and clathrincoated vesicles. The ischaemia and anoxia associated to the vasogenic and cytotoxic brain oedema induce enlargement and fragmentation of stacked Golgi cisternae. The Golgi apparatus also is considered an early marker of nerve cell injury, degeneration and cell death. Lysosomes show fragmentation of their limiting membranes and a matrix coarse dense granulation. Areas of cytoplasmic focal necrosis are observed surrounding the lysosomes, suggesting the release of lysosomal enzymes. Lysosomes co-existing with an increased amount of lipofuscin granules are observed in young and adult patients. The role of released and activated lysosomal enzymes is discussed in relation with the cytoplasmic focal necrosis of nerve cells. Conclusions: Nerve cell organelles, such as mitochondria, Golgi apparatus and lisosomes showed sub-microscopic changes of nerve cell degeneration leading to nerve cell death. The role of anoxicischaemic conditions of brain parenchyma, calcium overload, lipid peroxidation and reactive oxygen species, glutamate and haemoglobin excitotoxicity, cytochrome C release and nitric oxide are discussed in relation with mitochondrial dysfunction, Golgi apparatus fragmentation, lysosomal damage and nerve cell death. The injured mitochondrial patterns and Golgi apparatus fragmentation are considered markers of lethal nerve cell injury.

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0414

Evaluation of pituitary-target gland functions in the acute phase of traumatic brain injury Godwin Ojieh1, & Osaretin Ebuehi2 Ambrose Alli University, Ekpoma, Edo State, Nigeria, 2University of Lagos, Lagos, Nigeria


1

Background: Screening for endocrine deficiency is not performed routinely in the acute post-injury period and these abnormalities often go undiagnosed and untreated in persons with traumatic brain injury (TBI). In light of the potentially adverse effects of hormonal deficits on the rate and extent of both physical and cognitive recovery, the effect of the acute phase of TBI on pituitary-target gland functions with respect to testosterone and cortisol were investigated. Objective: To determine the plasma testosterone and cortisol showing their variation in the early response to TBI and probable beneficial effects of hormones replacement strategy. Study location: This study was carried out at Irrua Specialist Teaching Hospital, Irrua, Edo State, Nigeria. Method: One hundred and twenty-four patients, all adults without history of any chronic ailment, were enrolled in the study. Ninety-six of them were men and the remaining 28 were women. In each case, blood was collected within 24 hours and then after 1 week of trauma on admission. The blood samples were collected by standard venopuncture in heparinized bottles and centrifuged. Plasma was extracted for testosterone and cortisol measurement, stored frozen at 200 C until the samples were analysed consecutively in the chemical laboratory of the hospital by ELISA method. The results obtained were compared with reference values of normal healthy adults. Results: Eighty-five men with moderate-to-severe TBI had low testosterone level of 3.7 nmol l1 with two of them that had burns reaching a nadir of 1.2 nmol l1. The testosterone levels were even more abysmally low 1 week after admission. The remaining men with mild TBI and all the women had less lowering of testosterone levels. Most of the subjects studied showed early decrease in cortisol levels followed by increase in 1 week of study. Conclusion: It is obvious that TBI may cause pituitary dysfunction. Testosterone and cortisol are regulated by the pituitary gland. Identification and treatment of testosterone deficiency may be particularly relevant to the management of TBI. Testosterone could mitigate against the effects of injury, improve cognition, neurobehavioural functions and particularly motivation, muscle mass and lean body mass, thereby facilitating recovery. Cortisol is an anti-stress or post-injury hormone and helps to maintain blood pressure and fight infection. Therefore, cortisol deficiency due to disturbances anywhere along the hypothalamic-pituitary-adrenal axis may be life-threatening and may contribute to the morbidity and mortality from TBI.

0415

Active and affiliative identities: A mediation model investigating relationships between identity, social support and psychological well-being amongst survivors of brain injury and the general population

Brain Inj, 2014; 28(5–6): 517–878

R. Stephen Walsh1, Donal G. Fortune1, Orla T. Muldoon2, & Stephen Gallagher2 1

Acquired Brain Injury Ireland, Mid-West South, Ireland, 2University of Limerick, Limerick, Ireland Objectives: Research indicates that identity exerts a protective effect in the context of extreme stress because it offers individuals a basis to give and receive social support. Acquired brain injury (ABI) is understood to be a chronic stressor. The aim of this study was to investigate whether identity provides a protective effect in the context of ABI. A second focus was whether different types of identity relate differently to social support. To this end the study introduced and applied the concepts of active and affiliative identities to an investigation of relationships between social identity, social support and psychological well-being. Methods: Active and affiliative identity strength was measured using Leach et al.’s hierarchical (multi-component) model of in-group identification. Path analysis was employed to investigate the relationships between active and affiliative identities, social support and psychological well-being amongst a cohort of people with ABI in receipt of post-acute neurorehabilitation. A second study replicated these investigations amongst a cohort recruited from the general population for comparison purposes. Results: Consistent with predictions, in the first study, active and affiliative identities were found to operate differently amongst survivors of ABI. Active identities were correlated with both anxiety and depression (r ¼ 0.32; r ¼ 0.38). Path analysis revealed significant indirect relationships between social identity, social support and psychological well-being. Evidence supports an ‘upward spiral’ between social identity and social support whereby affiliative identity is driving social support and social support is driving active identity. In contrast to the direct relationships between active identity, anxiety and depression, affiliative identity was found to have a significant, positive, indirect effect on psychological well-being via social support and active identity (B ¼ 0.29; SE ¼ 0.10; 95%CI ¼ 0.12, 0.49). Study two provided evidence that, amongst a convenience sample drawn from the general population, active and affiliative identities are not significantly related to social support or psychological well-being. Conclusion: This research highlights the utility of distinguishing between identity types and emphasizes the importance of identity characteristics and perceived social support to psychological wellbeing for survivors of ABI.

0416

Different identities, different correlates: Stigmatized identity, survivor identity, anxiety and depression following acquired brain injury R. Stephen Walsh1, Donal G. Fortune1, Stephen Gallagher2, & Orla T. Muldoon2 1

ABI Ireland, Mid-West South, Ireland, 2University of Limerick, Limerick, Ireland Objectives: Affective disorders are a common consequence of acquired brain injury (ABI) and identity processes are understood to play a key role in the psychological well-being of ABI survivors. The purpose of the present study was to investigate how different dimensions of personal identity, specifically survivor identity and

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stigmatized identity relate to social support and outcomes within the diagnostic classes of anxiety and depression amongst survivors of ABI. Methods: A cross-sectional study was conducted to investigate the relationships between anxiety, depression, social support and survivor/stigmatized identities. The Hospital Anxiety and Depression Scale (HADS) was used to measure anxiety and depression. The Medical Outcomes Study (MOS) social support survey was utilized to measure perceived social support. Survivor and stigmatized identities were measured on the basis of valid and reliable items sourced from Jones et al. and Phelan et al. Results: Investigations revealed that survivor identities were related only to depression (r ¼ 0.38). In contrast, stigmatized identities were significantly correlated with social support and anxiety (r ¼ 0.30 and 0.45, respectively). Regression analysis suggests that in terms of affective well-being survivor identity and stigmatized identity were more significant predictors of anxiety and depression than perceived social support. Results also indicate that survivor identities offer specificity with regard to depression and stigmatized identities offer specificity with regard to anxiety. Conclusion: This study suggests the clinical utility of attending to individual identities and also of distinguishing between anxiety and depression in the context of neuropsychological rehabilitation following ABI.

0417

Concussion history in adolescent and young adult athletes with attention-deficit hyperactivity disorder Grant Iverson1, Joseph Atkins2, Ross Zafonte1, & Paul Berkner2 1

Harvard Medical School, Boston, MA, USA, 2Colby College, Waterville, ME, USA

Objectives: Attention-Deficit Hyperactivity Disorder (ADHD) is characterized, in part, by inattention and impulsivity which could place children and adolescents at increased risk for accidental injury. Very little is known, however, about the rate of concussions in adolescents with ADHD. It was hypothesized that high school athletes with ADHD would report a greater history of concussion compared to students without ADHD. Methods: Participants were 6529 adolescent and young adult student athletes from Maine, USA, between the ages of 13–19 (M ¼ 15.9, SD ¼ 1.3 years), who completed baseline pre-season testing with ImPACTÕ in 2010. There were 3736 (57.2%) males and 2793 (42.8%) females who completed a demographics and history questionnaire embedded in the ImPACTÕ programme. All information in this study is retrospective and based on self-report. Results: In the total sample, 17.7% reported a history of one or more concussions and 5.7% reported two or more injuries. Stratified by gender, 20.5% of males and 14.0% of females reported one or more past concussions and 7.0% of males and 4.0% of females reported two or more past injuries. In the total sample, 6.3% self-reported a diagnosis of ADHD, representing 8.0% of the males and 3.9% of the females. Of those with ADHD, 26.1% reported a history of one or more concussions compared to 17.1% of those without ADHD [X2 (1, 6529) ¼ 21.05, p50.00001; OR ¼ 1.71, 95% CI ¼ 1.35–2.15]. Stratified by gender, 27.0% of males with ADHD reported a history of one or more concussions compared to 20.0% of males without ADHD [X2 (1, 3736) ¼ 8.37, p50.004; OR ¼ 1.48, 95% CI ¼ 1.13–1.94] and 23.6% of females with ADHD reported a history of one or more concussions compared to 13.6% of females without ADHD [X2 (1, 2793) ¼ 8.92, p50.003;

OR ¼ 1.97, 95% CI ¼ 1.25–3.10]. Of those with ADHD, 9.8% reported a history of two or more concussions compared to 5.5% of those without ADHD [X2 (1, 6529) ¼ 13.14, p50.0003; OR ¼ 1.87, 95% CI ¼ 1.33–2.64]. Stratified by gender, 10.0% of males with ADHD reported a history of two or more concussions compared to 6.7% of males without ADHD [X2 (1, 3736) ¼ 4.56, p50.033; OR ¼ 1.54, 95% CI ¼ 1.03–2.30] and 9.1% of females with ADHD reported a history of two or more concussions compared to 3.8% of females without ADHD [X2 (1, 2793) ¼ 7.51, p50.006; OR ¼ 2.51, 95% CI ¼ 1.27–4.94]. Conclusions: In this large-scale, retrospective survey study, males and females with ADHD were significantly more likely to report a history of one or more and two or more concussions than those who do not have ADHD. Additional research is needed to determine if students with ADHD are more susceptible to injury (i.e. have a lower threshold) or have different recovery trajectories.

0418

Factors influencing postconcussion-like symptom reporting in adolescent athletes Grant Iverson1, Joseph Atkins2, Ross Zafonte1, & Paul Berkner2 1

Harvard Medical School, Boston, MA, USA, 2Colby College, Waterville, ME, USA

Objectives: The medical assessment and monitoring of sport-related concussion relies heavily on subjective symptom reporting. This study examined factors related to symptom reporting in uninjured adolescent student athletes. Methods: Participants in this cross-sectional, descriptive, cohort study were 6625 adolescent student athletes from Maine, USA, between the ages of 13–18 (M ¼ 15.8, SD ¼ 1.3 years), who completed baseline pre-season testing with ImPACTÕ in 2010. There were 3772 males (56.9%) and 2853 females (43.1%) who completed a demographics and history questionnaire embedded in the ImPACTÕ programme. The information is retrospective and based on self-report. No athlete with a history of concussion within the past 6 months was included. Mann Whitney U-tests were used for two group comparisons. Results: Adolescent females (M ¼ 6.7, SD ¼ 9.8) report more baseline symptoms than males (M ¼ 4.6, SD ¼ 8.0, p50.0001, Cohen’s d ¼ 0.24). Females with ADHD (p50.001, d ¼ 0.79), learning disabilities (p50.001, d ¼ 0.51) or a history of medical treatment for headaches (p50.001, d ¼ 0.65), migraine (p50.001, d ¼ 0.48) or psychiatric problems (p50.001, d ¼ 1.1) reported significantly more symptoms than those who did not have these conditions. Similarly, males with ADHD (p50.001, d ¼ 0.35), learning disabilities (p50.001, d ¼ 0.44), those who received special education services (p50.001, d ¼ 0.51) or those with a history of medical treatment for headaches (p50.001, d ¼ 0.71), migraine (p50.001, d ¼ 0.64) or psychiatric problems (p50.001, d ¼ 1.0) reported significantly more symptoms. There was an overall main effect of concussion history on symptom reporting in males [KW (3, 3546) ¼ 34.8; p50.001] and females [KW (3, 2696) ¼ 13.3; p50.005]. For males, but not females, there was a linear trend in that those with 1, 2 or 3 or more past concussions had increasingly greater symptom total scores. In males and females, fewer hours of sleep the night before was associated with greater symptom reporting. Unusually high symptom scores were reported by a substantial minority of males with (a) ADHD (20.7%) or learning disabilities (22.6%); (b) a history of medical treatment for headaches (27.1%), migraine (28.3%) or psychiatric problems (33.8%); (c) a past history of two (21.7%) or three or more concussions (26.6%); or (d) those who slept 3–4 hours (35.8%) or 5 hours (32.6%) the night before. Unusually high symptom scores were reported by a

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substantial minority of females with (a) ADHD (24.5%) or learning disabilities (22.1%); (b) a history of medical treatment for headaches (20.1%) or psychiatric problems (31.7%); or (c) those who slept 3–4 hours (43.6%) or 5 hours (25.6%) the night before. Conclusion: Higher baseline symptom reporting is expected in athletes with developmental conditions (e.g. ADHD or learning disabilities), a history of treatment for headaches or mental health problems and in those who 5 or fewer hours of sleep the night before. Concussion history was more strongly associated with baseline symptom reporting in boys than in girls.

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Outcome from complicated vs uncomplicated mild traumatic brain injury

DTI. This study illustrates that macrostructural neuroimaging changes following MTBI were associated with measurable DTI signal, but the division of MTBI into complicated and uncomplicated sub-types did not predict worse clinical outcome at 6 weeks post-injury.

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Hyperbaric oxygen for blast related post-concussion syndrome: 3-month outcomes William Walker1, David Cifu1, Steven West1, Brett Hart2, Laura Manning Franke3, Adam Sima1, Carolyn Graham1, & William Carne3 1


1

2

1

William Panenka , Rael Lange , Jason Shewchuk , Manraj Heran1, Jeffrey Brubacher1, Sylvain Bouix3, Ryan Eckbo3, Martha Shenton3, & Grant Iverson3 1

University of British Columbia, Vancouver, BC, Canada, 2Walter Reed National Military Medical Center, Bethesda, MD, USA, 3Harvard Medical School, Boston, MA, USA Objectives: A substantial minority of patients who sustain a mild traumatic brain injury (MTBI) will show trauma-related intracranial abnormalities, such as haemorrhages, contusions or skull fractures, on day-of-injury computed tomography (CT) or follow-up magnetic resonance imaging (MRI). This study examined whether neuroimaging abnormalities, as evidenced by CT or MRI (i.e. those with ‘complicated’ MTBIs), were associated with worse outcome as measured by cognitive testing, symptom ratings and diffusion tensor imaging (DTI). It was hypothesized that (i) as a group, subjects with complicated MTBIs would report greater symptoms and have worse neurocognitive outcomes than those with uncomplicated MTBIs and (ii) the complicated MTBI group would show a decrease in white matter integrity on DTI, most noticeably in the region of the corpus callosum. Methods: Adults with MTBIs (31 complicated and 31 uncomplicated) who presented to Vancouver General Hospital, Canada, were included in this study. The participants completed neurocognitive testing, symptom ratings and DTI on a 3T MRI scanner at 6–8 weeks postinjury (M ¼ 47.1 days, SD ¼ 5.6). Tract-based spatial statistics (TBSS) were used to analyse the DTI data. Results: There were no statistically significant differences between groups on a broad range of neuropsychological tests. A greater percentage of those in the complicated group had three or more neuropsychological test scores below the 10th percentile (25.8%) than the uncomplicated group (12.9%), but this finding was not significant (in part due to small sample sizes). The two groups did not differ in their reporting of post-concussion symptoms (Cohen’s d ¼ 0.23), anxiety (d ¼ 0.03) or depression (d ¼ 0.10). When comparing the groups on DTI, no significant difference was found for axial diffusivity (AD) or mean diffusivity (MD). Several brain regions were different on measures of fractional anisotropy (FA) and radial diffusivity (RD). More specifically, FA was significantly decreased in the genu and body of the corpus callosum and left frontal corona radiata in the complicated group. In addition, the complicated group showed a significantly increased RD signal in the genu of the corpus callosum and the left frontal corona radiata at the p50.05 level. Conclusions: The complicated MTBI group performed no worse than the uncomplicated MTBI group on a broad range of neurocognitive tests and they reported no greater burden of post-concussion or mood symptoms. The complicated group was, however, significantly more likely to show changes consistent with a decrease in white matter integrity in the corpus callosum and frontal white matter on

Virginia Commonwealth University, Richmond, VA, USA, Navy Medicine Operational Training Center, Pensacola, FL, USA, 3 McGuire Veterans Administration Medical Center, Richmond, VA, USA 2

Objective: Mild traumatic brain injury (mTBI) and residual postconcussion syndrome (PCS), while prevalent in the general population, are especially common among military combatants of Operations Enduring Freedom, Iraqi Freedom and New Dawn (OIF/ OEF/OND). Hyperbaric oxygen (HBO2) is a proposed innovative treatment for these conditions that has garnered much attention but it has not been rigorously studied. The primary objective of this study was 2-fold: (1) to determine the effects by 3-months post-intervention of HBO2 delivered at two commonly employed dosing levels to treat PCS after combat-related mTBI; and (2) to determine how co-morbid conditions such as post-traumatic stress disorder (PTSD) interacted with any effects found. Secondarily and only if no overall benefit was found, this study planned to examine for efficacy within pre-defined sub-groups. Methods: In this randomized, double-blind, sham controlled trial of HBO2, 61 male Marines with a history of combat-related, blastinduced mTBI and persistent PCS received the experimental intervention at hyperbaric chambers located in Naval Air Station, Pensacola, FL. All participants received a series of 40, once daily, chamber compressions at 2.0 atmospheres absolute (ATA) for 60 minutes at one of three randomly pre-assigned oxygen fractions (10.5%, 75% or 100%), resulting in respective blinded groups with an oxygen breathing exposure equivalent to (1) surface air (sham), (2) 100% oxygen at 1.5 ATA or (3) 100% oxygen at 2.0 ATA. The primary outcome measure was the Rivermead Post-Concussion Questionnaire (RPQ-16) collected before (Pre), immediately after (Post-1) and 3 months after (Post-2) compression. Multiple secondary outcomes were also pre-specified. All outcomes were analysed using a linear mixed-effects model to assess change over time and interaction effects of multiple potential explanatory variables. Results: The efficacy hypothesis test, interaction of time (Pre, Post-1, Post-2) by intervention group (sham equivalent, 1.5 ATA equivalent, 2.0 ATA), was not significant for symptomatic improvement on the RPQ-16. Nor was there evidence of intervention efficacy on the RPQ-16 for any specific sub-group, defined with three-way interactions (p40.05). Similarly, no significant timeby-intervention interaction was found for any of the secondary outcome measures, despite analysis of numerous symptom, functional, cognitive and psychomotor measures at an unadjusted 0.05 significance level. Conclusions: Using a rigorous randomized control trial design and analysis including a well-disguised sham, these results show no evidence of efficacy by 3 months after HBO2 intervention to treat the symptom, cognitive or behavioural sequelae of PCS after combatrelated mTBI.

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How much is enough? Is there a critical duration of neurorehabilitation for maximal change in outcomes in acquired brain injury: Prospective cohort study R. Stephen Walsh, Donal G. Fortune, Brian Waldron, Caroline McGrath, Sarah Casey, & Brian McClean


Acquired Brain Injury Ireland, Mid-West South, Ireland Objective: To examine where and when most gains occur across time on indices of Community Integration, Quality of life, Mental Health and NeuroDisability for people with ABI undergoing post-acute neurorehabilitation. Method: Prospective cohort study. Participants with ABI entered a rolling recruitment assessment process on induction to service and were assessed at a number of timepoints on the Mayo Portland Adaptability Index (MPAI), Community Integration Questionnaire (CIQ), Hospital Anxiety and Depression Scale (HADS) and World Health Organization Quality-of-Life measure (WHOQoL-Bref). Results: At 6 months following the beginning of neurorehabilitation, significant pre–post differences were found on the MPAI Abilities (p ¼ 0.005), Adjustment (p ¼ 0.02) and total scale score (p ¼ 0.001); on HADS anxiety (p ¼ 0.001) and depression (p ¼ 0.001) and on Home and Social integration as assessed by the CIQ (p ¼ 0.01). In contrast, there was no effect at 6 months on any of the Quality-of-life indices, on the CIQ’s Productivity sub-scale or the Participation Index of the MPAI. One year follow-up showed continuation of the significant positive effects with the addition of Whoqol physical health (p ¼ 0.001) and Psychological health (p ¼ 0.001) and MPAI participation index (p ¼ 0.001) at this later time point. Age or type of injury did not significantly influence change scores. Conclusion: Results suggest that different constructs may respond to post-acute neurorehabilitation at different time points in the rehabilitative milieu, that may not be significantly related to type of injury or age of the client.

primary constructs measured and comprehensiveness of financial management items. Methods: As recommended in the Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN), two reviewers searched five databases (Embase, CINAHL, Medline, PsycINFO, Scopus) using 47 population terms (e.g. brain injury), nine instrument construct terms (e.g. finance) and 38 measurement quality terms (e.g. validity) to identify assessments that had financial management items. Due to limitations in how databases electronically search at title, abstract and keyword level and the fact that all items of an assessment are not always outlined until the full article level, reviewers completed a second search of the same five databases, systematically identifying reviews of everyday living assessments to identify a larger breadth of potentially applicable assessments. Everyday living terms (e.g. activities of daily living) were used in this search as examination of the financial management assessment literature found this was often the primary measurement construct in assessments that had financial management skill items. The second search used a combination of population (n ¼ 47), instrument construct (n ¼ 8) and measurement terms (n ¼ 4) to identify relevant reviews. Results: Eighty-eight discrete assessments were identified through the search process; 42 assessments in search one and 65 in search two (20 were duplicates). Identified assessments were first categorized based on tool type. Of the 88 found, 44 were categorized as including observation or performance based items; 10 as self-report only; 17 as proxy-report only; and 17 as a combination of self- and proxy-reports. Performance/observationbased assessments were then classified based on populations, primary construct and comprehensiveness of financial management skill items, based on nine nominal categories of financial management tasks. Of the 44 performance-based assessments, eight had been developed for brain injury and/or stroke populations, while 24 had been developed for ageing and dementia populations; 11 had financial management as a primary construct, while 21 had everyday living; only seven assessments had items spanning six or more financial management task areas. Of these seven comprehensive, performance-based assessments, only one, the Financial Capacity Instrument, has been identified in the literature for use with brain injury populations. Conclusions: This is the first systematic review of financial management skills assessments. Of the assessments that used performance observation, few were comprehensive in financial management items and not many had been developed for use in brain injury and/or stroke populations. This review provides fundamental information to clinicians and researchers that will assist them in selecting assessments in this area.

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A systematic review of financial management skills assessments: Do any show promise for use in brain injury populations? Lisa Engel1, Yael Bar2, Dorcas Beaton3, Robin Green4, & Deirdre Dawson2 1

University of Toronto, Toronto, Ontario, Canada, 2Baycrest/Rotman Research Institute, Toronto, Ontario, Canada, 3St. Michael’s Hospital, Toronto, Ontario, Canada, 4University Health Network/Toronto Rehabilitation Institute, Toronto, Ontario, Canada Objectives: The objectives of this systematic review of financial management skill assessments are (1) to identify all assessments in the published literature that have been used with adults who have acquired cognitive impairments (e.g. brain injury populations); and (2) to categorize the assessments based on tool type, populations,

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How participatory research supports writing of ‘Acquired brain injury: Rehabilitation services and assisted living project—A business case to drive a model of care for the town of Sioux Lookout and the 31 remote first nations communities it serves. Phase I: Stakeholder consultation and engagement’ Michelle Keightley, Angela Colantonio, Bruce Minore, Mae Katt, Alice Bellavance, Anita Cameron,

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Claudine Longboat-White, Randy White, & Marshalina Reader


Brain Injury Services of Northern Ontario, Thunder Bay, Ontario, Canada Background: Aboriginal Canadians experience disproportionately higher rates of acquired brain injury than the general Canadian population. Cultural ideas impact the perception of rehabilitation needs and the ability to access rehabilitation services. Purpose: The objective of this pilot study was to explore the lived experiences of treating and healing brain injury from Aboriginal Elders and traditional healers in the communities served by WassayGezhig-Na-Nahn-Dah-We-Igamig (Kenora Area Health Access Centre or KAHAC). Methods: A focus group was held using a participatory action approach. A framework analysis method was used and findings were member-checked prior to dissemination. Findings: Four themes arose from the data: pervasiveness of spirituality, ‘fixing’ illness or injury vs living with wellness, working together in treating brain injury and financial support needed for traditional healing. Implications: Findings will help guide more culturally-relevant rehabilitation services for Aboriginal individuals with brain injury. Future research could explore multiple perspectives on healing and traditional teachings from Aboriginal Elders and traditional healers. Recommendations supported more investigation to determine the number impacted by brain injury, types of services and supports that would engage participation. Subsequent proposals for more research were not funded, however Brain Injury Services of Northern Ontario (BISNO) is working with many First Nations communities and many have identified desperate need prevention, early intervention and ongoing supports and services for their members. Thus, the writing of Acquired Brain Injury: Rehabilitation Services and Assisted Living Project - A Business Case to Drive a Model of Care for the Town of Sioux Lookout and the 31 Remote First Nations Communities it Serves - Phase I: Stakeholder Consultation & Engagement. This also includes a Needs Assessment as recommended in the Research Project. It will assist in determining the scale and type of services required.

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Challenges to long-term community viability after moderate-to-severe traumatic brain injury Kathleen Kortte1, David Williamson2, & Gary Goldberg3 1

The Johns Hopkins University School of Medicine, Baltimore, MD, USA, 2Walter Reed National Military Medical Center, Bethesda, MD, USA, 3McGuire VA Medical Center, Richmond, VA, USA Over the past few decades, advances in casualty triage, trauma medicine and neurosurgery have significantly increased survival rates after severe TBI. The majority of TBI survivors in both the civilian and military populations are in their late teens through mid-20 s at the time of injury, generating a large cohort of individuals who will survive for decades with residual impairments and derivative challenges in community re-integration. The symposium panel will compare and contrast evolving approaches to community re-entry and longer-term support for patients within the civilian and Department of Defense–Veterans Administration (DODVA) healthcare systems for patients with moderate and severe TBI. The Center for Disease Control (CDC) epidemiologic surveillance data indicates that

Brain Inj, 2014; 28(5–6): 517–878

5.3 million people in the US are living with TBI-related disability. As a derivative of the Global War on Terror, there have been over 200 000 service members who have sustained TBI. Although the majority of civilians and military personnel suffer TBI of mild severity and recover fully within a relatively short period of time post-injury, 25% of TBIs are moderate-to-severe injuries that result in persistent problems. Long-term sequelae include increased rates of mental health morbidity (i.e. depression, psychosis), persistent cognitive disorders, aggression, seizures, headaches, sleep disturbance and fatigue. According to the CDC 2010 statistics, TBI costs Americans 76.5 billion dollars in medical care, rehabilitation and loss of work every year. Despite knowledge of the economic impact, there have been very few studies that have investigated the impact of moderate-to-severe TBI on the ability of the individual to reintegrate into the community and be socially and economically viable in the long-term. A handful of studies in civilian and military personnel suggest that moderateto-severe TBI is associated with post-injury unemployment, diminished social relationships and increased rates of criminal behaviour and misconduct. Many survivors don’t return to independent living. There is evidence to suggest that reduced social competency related to behavioural control issues, increased affective reactivity and cognitive impairments all likely play a key role in these adverse outcomes. However, there has been little attention to the development and evaluation of strategies to improve community viability and economic self-sufficiency for individuals with TBI trying to reintegrate into everyday life. Using a case example format, this study will highlight the challenges in each of these systems (DOD-VA and civilian) and the successful cases to note potential ingredients of care that facilitate successful reintegration. It will review current strategies and resources and provide recommendations on where the TBI field and these healthcare systems might go from here to address the long-term needs of these individuals to achieve success.

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Three-month test–re-test reliability of the brain injury screening questionnaire with men attending an urban homeless shelter Jane Topolovec-Vranic1, Connor Avery-Cooper2, Naomi Ennis1, & Michael Cusimano1 1

St. Michael’s Hospital, Toronto, Ontario, Canada, 2University of Toronto, Toronto, Ontario, Canada

Objective: Although evidence suggests the traumatic brain injury (TBI) is prevalent amongst the homeless population, there are no widely used or validated tools for screening for TBI amongst this population. The Brain Injury Screening Questionnaire is a comprehensive, structured, self-reported screening measure based on the Center for Disease Control criteria for TBI. Based on reported TBI event histories (events resulting in loss of or alterations of consciousness) and the presence of symptoms indicative of TBI, the BISQ provides a negative screen or low, moderate or high likelihood of the respondent having sustained a TBI in the past. The objective of the study was to assess the 3-month test–re-test reliability of the BISQ in a sample of men attending a large urban homeless shelter. Methods: Participants were recruited from the harm reduction and long-term care programmes of a shelter for homeless men in Toronto, Canada. Participants completed the BISQ and detailed demographic, mental health and substance use histories were collected (Time 1). The interview was repeated at 3 months post-enrolment into the study (Time 2). Response agreements at Times 1 and 2 were calculated using the Kappa statistic.

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Results: Sixty-five men were included in the study, of which 77% (n ¼ 50) were re-tested at the 3-month follow-up. Data from six participants were excluded due to concerns about their capacity to participate at Time 2 (e.g. intoxication). Five of the remaining 44 (11%) had sustained a new TBI in the 3-month interval. For the remaining participants (n ¼ 39), exact agreement on the BISQ score (i.e. same result for negative, low, moderate or high probability) was observed in 59% (n ¼ 23) of the cases (Kappa ¼ 0.407, p50.001). For 18% (n ¼ 7) a greater likelihood of TBI was reported at Time 2 than Time 1. The most common discrepancy (15%, n ¼ 6 of the cases) was in the classification of a moderate likelihood of TBI at Time 1, to a low likelihood of TBI at Time 2. There were no differences between those for whom agreement was or was not observed in age, mental health of substance abuse histories, number of reported blows to the head or the longest period of loss or alteration of consciousness. When comparing the BISQ scores between Times 1 and 2 for negative TBI screen vs any likelihood of TBI collapsed, the agreement was 87% (n ¼ 34; Kappa ¼ 0.624, p50.001). Conclusions: Fair-to-good agreement results were found for test– re-test reliability of the BISQ scores among a sample of men attending an urban homeless shelter. The BISQ may be a valuable tool for careproviders working in such settings to screen for TBI. Further research should validate the BISQ against more objective markers of TBI, such as neuroimaging.

therapists may comment on a client’s need for supervision, ability to comprehend and communicate information, the degree of limitation in daily functions due to impaired cognition, anger outbursts and the effect of fatigue on the ability to complete daily tasks. This presentation will provide specific case studies of how the OT Situational Assessment applies to the Catastrophic determination process in clients who have sustained a head injury.

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Cognitive recovery after traumatic brain injury in very early childhood: Outcomes at 4 and 8 years of age Louise Crowe1, Cathy Catroppa1, Franz Babl2, & Vicki Anderson1 1 2

Murdoch Childrens Research Institute, Parkville, Victoria, Australia, Royal Children’s Hospital, Parkville, Victoria, Australia

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Occupational therapy situational assessment as part of catastrophic determination assessment for mental and behaviour impairments Galit Liffshiz, & Kathryn Decker Galit Liffshiz and Associates, Toronto, Ontario, Canada When it comes to catastrophic determination in Ontario, occupational therapists have been accepted as part of the assessors team, as it has been recognized that the clinical findings by an occupational therapist are integral to the process of the evaluation. OTs are experienced in analysing function from the physical, cognitive and mental perspective. They are trained to observe the client’s performance in activities of daily living and to rate the severity of functional impairments. During an OT Situational Assessment, the OT will spend several days with the client in his or her own environment. It is a comprehensive observational assessment of the client’s ability to participate in a variety of activities both in home and community settings. The OTs observation of a client’s social interactions and adaptation to a variety of settings are central to the evaluation of the depth and degree of mental or behavioural impairments. Given that several criterions in the application for catastrophic designation in Ontario (OCF 19) consider the individual’s level of performance in daily functions as it relates to his or her mental and behavioural status, the OT Situational Assessment is particularly appropriate. There are several chapters in the AMA Guides that refer the assessor to observe the client’s ability to perform Activities of Daily Living (ADL). When it comes to a head injury these include: Chapter #4: When analysing the neurological system in a case of a head injury the assessor must consider communication problems such as in aphasia, sleep and arousal disorders and the degree to which fatigue interferes with the person’s day-to-day activities and mental and behaviour problems; and Chapter #14: When assessing mental and behavioural functioning, the mental impairment must be evaluated in accordance with each of four categories: (1) Activities of daily living; (2) Social functioning; (3) Concentration, persistence and pace; and (4) Adaptation to work or work-like settings. Through participation in a Situational Assessment, occupational

Objectives: Traumatic brain injury (TBI) occurs frequently in young children. In fact, some research suggests that children under 3 years are at the greatest risk of sustaining a TBI. Further, in the first few years of life the brain is developing and acquiring skills rapidly. It is possible that disruption to the brain in this period will have long-term consequences. Despite this, long-term follow-up of children injured in this age range is limited. The purpose of this study was to provide detailed information on the long-term cognitive recovery of children who sustained a TBI at an early age by following them up at two time points. Method: Children who sustained a TBI from birth to 3 years were followed-up and assessed cognitively at the age of 4 years (3 years after TBI) and then again at 8 years (7 years after TBI). Children were divided by injury severity with a mild and moderate–severe TBI group. A group of injured comparison children matched for socioeconomic status and gender were also assessed at the same time points. Results: The findings on the IQ and executive function assessments will be discussed. Further, at age 8 years additional executive function assessments were administered and these results will be presented. Children’s performance on the tasks at 4 years and 8 years will be compared. Conclusion: TBI is common in young children and this study significantly adds to the knowledge on the long-term outcomes of TBI. This is one of the first studies available that has assessed this group over time and, therefore, is able to discuss the cognitive recovery from TBI.

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Children from disadvantaged families are more likely to benefit from family-centred treatment for TBI Shari Wade1, Gerry Taylor2, Terry Stancin3, Michael Kirkwood4, Tanya Maines5, & Amy Cassedy1 1

Cincinnati Children’s Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, OH, USA, 2University Hospitals of Cleveland and Case University, Cleveland, OH, USA, 3 MetroHealth Medical Center and Case University, Cleveland, OH,

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USA, 4Children’s Hospital of Colorado and the University of Denver Medical Center, Denver, CO, USA, 5Mayo Clinic, Rochester, MN, USA Background: Psychosocial recovery following paediatric TBI is influenced by a variety of factors including socioeconomic status, demographic characteristics/ethnicity and family functioning with social disadvantage contributing to poorer short- and long-term outcomes. These same psychosocial risk factors are associated with less access to care and poorer adherence to treatment recommendations. Given the importance of family characteristics in recovery, this study sought to examine whether they moderated treatment response to online, family-centred interventions. Method: This study examined income and parental education as moderators of treatment efficacy across three randomized trials of online family problem-solving therapy (FPST, total n across studies ¼ 212) and one trial of online parent-skills training (n ¼ 37) with children with complicated mild-to-severe TBI. Participants were randomly assigned to either online FPST/parent skills training or an internet resource comparison group (IRC) and outcomes were assessed pre- and post-treatment and at 6- and 12-month follow-up assessments in the largest of the four studies. Multiple regression analyses and linear mixed models analyses were used to examine moderation effects on child behaviour as assessed by the Child Behaviour Checklist (CBCL) and global functioning as assessed by the Child and Adolescent Functional Assessment Scale (CAFAS). Results: Support for the hypothesis that income or parental education moderated treatment efficacy was found in each study. Specifically, children from families with lower income (5$30 000) or lower parental education (high school or less) were rated as having greater behavioural recovery from pre- to post-treatment in the FPST and parenting skills training than in IRC comparison group. In the largest RCT (n ¼ 132), parental education moderated improvements in child functioning over time, with adolescents in the FPST group with less educated parents demonstrating the greatest improvements in interviewer ratings of functioning on the CAFAS at 12-months posttreatment completion. Conclusion: Taken together these findings suggest that evidencebased treatments such as FPST and parent-skills training may serve to buffer the deleterious effects of family adversity on child behavioural functioning post-TBI, despite poorer adherence in this sub-sample. However, the challenge of how to effectively engage and retain disadvantaged families in treatment remains. Future research and clinical efforts must seek to identify strategies to further reduce barriers to care in at-risk populations.

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Cognitive functioning in the acute phase after aneurysmal subarachnoidal haemorrhage Tonje Haug Nordenmark1, Tanja Karic1, & Angelika Sorteberg2 1

Department of Physical Medicine and Rehabilitation, 2Department of Neurosurgery, Oslo University Hospital, Oslo, Norway Objectives: Cognitive dysfunction is one of the most common forms of neurological impairments after an aneurysmal subarachnoidal haemorrhage (aSAH). Studies have found cognitive impairments in as much as 65% of patients after aSAH and it is well known that even patients without neurological deficits have a mild-to-moderate cognitive deficit. Few studies have looked at the cognitive deficits in the acute phase after aSAH. The objective of this study was, therefore, to describe cognitive functioning in the acute phase after aSAH.

Brain Inj, 2014; 28(5–6): 517–878

Methods: One hundred and thirty-seven patients with aSAH were admitted to Oslo University Hospital in 2012. Ninety-eight patients were included in this study, 15 died, 18 were discharged directly from the ICU and six were excluded due to previous SAH. Out of the remaining 98 patients, 51 could complete the neuropsychological test battery at the time of discharge (median ¼ 11 days). The neuropsychological test battery included general orientation questions (GOAT), as well as tests of visual memory (Brief Visual Memory Test, BVMT), motor functioning (Grooved pegboard), executive function (Colour– word interference test, D-KEFS), attention (Digit span, WAIS-IV) and psychomotor function (Digit symbol, WAIS-IV). Results: Out of the 51 patients who completed the neuropsychological test battery, 29 were women and 22 were men, with a median age of 51 years (range ¼ 26–77). The orientation questions on GOAT showed that 41% were fully oriented at discharge. On the neuropsychological tests, a moderate cognitive deficit was found, with all tests being significantly lower (p50.001) than the norm data for age-matched healthy controls published for each test. Test of psychomotor functioning was the least affected, with mean score falling 0.75 SD below the expected mean. The remaining tests fell between 1.50–2.00 SD below the expected mean. When compared to aneurysm localization, no significant differences were found. Conclusions: aSAH patients were to a large extent oriented about personal information, time and place at the time of discharge, but they exhibited a moderate global cognitive deficit. The fact that all cognitive functions tested were equally reduced and no differences were found based on aneurysm localization gives support to previous research arguing that an aSAH causes a global cognitive deficit caused by factors associated with the bleed per se, rather than a localized damage at the aneurysm site.

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Factors affecting caregiver burden 1 year after severe traumatic brain injury: A prospective nationwide multi-centre study Unn Sollid Manskow1, Solrun Sigurdardottir2, Nada Andelic3, Elin Damsga˚rd4, So¨lve Elmsta˚hl5, & Audny Anke1 1

University Hospital of North Norway, Department of Rehabilitation, Tromso, Norway, 2Research Centre for Habilitation and Rehabilitation Models and Services (CHARM), Faculty of Medicine, University of Oslo, Oslo, Norway, 3Oslo University Hospital, Department of Physical Medicine and Rehabilitation, Oslo, Norway, 4 University of Tromso, Faculty of Health Sciences, Tromso, Norway, 5 Lund University, Department of Health Sciences, Division of Geriatric Medicine, Lund, Sweden Objectives: The aim of this study was to assess the caregiver burden in caregivers of patients with severe traumatic brain injury (TBI) 1 year post-injury. Caregiver burden was investigated in relation to caregiver’s demographic data and social network and to patient’s demographic data, injury severity and functional status. Methods: A population-based prospective multi-centre study in Norway including primary caregivers of patients 16 years with severe TBI. Ninety-two caregivers completed a questionnaire 1 year post-injury, containing demographic data, Caregiver Burden Scale (CBS), relation to the patient, time spent with the patient and social network. Patient data (n ¼ 92) from the acute stage and at 1 year follow-up were collected from the national cohort on patients with severe TBI. Inclusion rate on caregivers and patients was 56.4% of the total 163 patients at 1-year follow-up. Seventy-five per cent of the

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caregivers were females and 87% of the patients were males. Caregiver burden was assessed by the Caregiver Burden Scale (CBS). The CBS comprises 22 items, with index scores from 1–4, with higher scores indicating more burden. CBS is divided into five sub-scales representing general strain, isolation, disappointment, emotional involvement and environment. Patient’s functional status was assessed by the Glascow Outcome Scale Extended (GOSE). Results: Sixteen per cent of the caregivers reported a high burden, 34% a moderate and 50% reported low burden. The total CBS score indicated a moderate level of burden (mean index score ¼ 2.12, SD ¼ 0.77). General strain represented the highest burden (mean ¼ 2.33, SD ¼ 0.89), followed by disappointment (mean ¼ 2.21, SD ¼ 0.86) and isolation (mean ¼ 2.05, SD ¼ 0.88). Univariate analysis revealed that poor quality of the social network, lack of friends and seldom meeting friends were predictors of higher caregiver burden (p50.05), together with feelings of loneliness (p50.05). Higher scores on four sub-scales of CBS were also found among caregivers whose relative had a low functional level (p50.05). Linear regression analysis showed that caregivers feelings of loneliness and low patient functional status at 1 year follow-up were independent significant predictors for higher caregiver burden for all the sub-scales of CBS. Conclusions: This study highlights different dimensions of burden like general strain, disappointment and isolation experienced by primary caregivers of adults with severe TBI. Lack of social network, feelings of loneliness and the patient’s functional status were significant predictors related to higher caregiver burden. It is important to identify areas in which caregiver burden is high in order to understand the challenges that caregivers are facing and to develop interventions that will ease their burden.

0432

Children first and head-injured second: Assessing self-awareness developmentally

discrepancy, norms in scholastic competence and social acceptance; Over-rates athletic competence compared to teacher (William); SUI, physical abilities (17.8%); physical characteristics (8.99%). No ageexpected expressions of psychological and social themes (Rachel). SDQ, self ratings ‘slightly raised’ compared to norm, 3/6 domains; Rates self lower than mother in 4/6 domains. Self rating ‘slightly raised’ compared to mother ‘very high’ for overall stress (Lee). Executive function map, self rating before 6.5/10; Self rating after 8/10; Researcher rating 3/10. Anticipated physical difficulties only. Researcher prompted throughout task, no self-reported thinking difficulties. KIC, Awareness Discrepancy Index 8/12 (William). Conclusions: These data demonstrate that existing measures can be utilized to provide clinicians with a profile of children’s level of selfawareness across domains. Tools are available from a developmental framework or specifically for children with TBI. Each measure provides a report from different sources, i.e. parents, therapists, teachers and young people. From a research perspective this range of measures gives a deeper understanding of the complex phenomenon of self-awareness. However, the combined profile also benefits multidisciplinary teams involved in goal-setting. Professionals in the team could administer different assessment tools and discuss the findings, ensuring a complete picture of the child’s ability across the range of domains. Joint working would ensure collaborative rehabilitation goal-setting at a developmentallyappropriate level.

0434

Atomoxetine for attention deficits following traumatic brain injury: Results from a randomized controlled trial

Lorna Wales1, & Carol Hawley2

David Ripley1, Don Gerber2, Cynthia Harrison-Felix2, Lisa Brenner3, Clare Morey2, Christopher Pretz2, & Keith Wesnes4

1

1

Introduction: Traumatic brain injury (TBI) in childhood differs from adults, not least that children have an injury against a backdrop of ongoing development. Impaired self-awareness is frequently cited in the adult literature as a factor interfering with engagement in rehabilitation and affecting long-term outcomes. However, there is currently no guidance for assessing self-awareness from a developmental perspective. Objective: To evaluate the role of existing measures to understand self-awareness in children following TBI. Methods: This was a multiple case study with mixed methods. It included 15 subjects (10 boys, five girls), aged 9–19 years. Age at injury ranged from 5 years 11 months to 17 years 1 month. Time since injury ranged from 1 year 2 months to 4 years 4 months. GCS was moderate–severe. Measures must provide discrepancy scores comparing self-rating with others; teachers, therapists, parents, across developmental domains. Results: There were five measures of discrepancy data: Self Perception Scale for Children/Adolescents; Self Understanding Interview; Strengths and Difficulties Questionnaire; Knowledge Interview for Children; and Executive function map. Three were developed for typical children (SPSC/A, SUI, SDQ), two were developed for children with brain injury (KIC, Executive function map) and three were norm referenced (SSPSC/A, SUI, SDQ). Both SDQ and KIC were self/parent ratings; Harter scales were self/teacher ratings; and Harter scales and Executive function map were self/therapist ratings. Time taken to administer was 5–20 minutes each. Examples from case studies were: SPSC, self rating was below the norm in 5/6 domains; Greatest

Objective: To determine if atomoxetine will improve attention impairment following traumatic brain injury (TBI). Setting: Outpatients from a free-standing, private, not-for-profit rehabilitation hospital. Population: Fifty-five adult participants with a history of a single moderate-to-severe TBI, who were at least 1 year from injury and with self-reported complaints of attention difficulties. Intervention: Atomoxetine, a selective norepinephrine re-uptake inhibitor with a primary indication for attention dosed at 40 mg twice a day for 2 weeks, compared to placebo. Design: Randomized double-blind placebo controlled trial, cross-over design with placebo run-in. Measures: Cognitive Drug Research (CDR) Computerized Cognitive Assessment System, Stroop Color and Word Test, Adult ADHD SelfReport Scale (ASRS-v1.1), Neurobehavioural Functioning Inventory (NFI). Results: Atomoxetine was well-tolerated by the subject sample. The use of atomoxetine by individuals with reported attention difficulty following TBI did not significantly improve scores on measures of attention, the CDR Power of Attention domain or the Stroop Interference score. In addition, no significant relationship was found between atomoxetine use and self-reported symptoms of attention or depression. Conclusion: Atomoxetine did not significantly improve performance on measures of attention among individuals post-TBI with difficulties with attention. This study follows a trend of other pharmacological

The Chidrens Trust, Tadworth, Surrey, UK, 2University of Warwick, Coventry, UK

Rehabilitation Institute of Chicago, Chicago, IL, USA, 2Craig Hospital, Denver, CO, USA, 3University of Colorado, Denver, CO, USA, 4 Swinburne University of Technology, Melbourne, Australia

674 studies not demonstrating significant results among those with a history of TBI.

0435

Longitudinal changes in brain volume following remote repetitive TBI: Evidence from retired professional and semiprofessional hockey players Carrie Esopenko, Melissa Pangelinan, Aggie Bacopulos, Tiffany Chow, Anthony McIntosh, Toma´sˇ Paus, Stephen Strother, & Brian Levine


Rotman Research Institute, Baycrest, Toronto, Ontario, Canada Objective: There is substantial evidence that a history of traumatic brain injury (TBI) has effects on the development of neurodegenerative disease, with even seemingly mild TBIs sustained in sport being associated with accelerated cognitive impairments during ageing and the earlier onset of dementia, including Alzheimer’s disease and chronic traumatic encephalopathy (CTE). Studies examining the effects of mild TBI in athletes have shown white matter abnormalities and changes in cortical thickness, as well as abnormal brain changes in athletes diagnosed with CTE at autopsy. Considering the highincidence of sports-related TBI, this has significant public health implications. Given that many athletes experience TBI during their careers and that their TBI characteristics are well documented, they provide an excellent model for this line of research. As such, the goal of this work was to determine whether athletes with a history of repetitive TBI in sport show abnormal brain changes not typical of healthy ageing. Methods: Twenty retired professional and semi-professional hockey players and age-matched control participants with no significant history of TBI were assessed using high-resolution structural magnetic resonance imaging, which included susceptibility weighted imaging (SWI), gradient echo (GRE), fluid attenuated inversion recovery (FLAIR), diffusion tensor imaging (DTI) and T2- and T1-weighted images. To evaluate TBI effects specifically, this study focused on the T1weighted images, which were acquired on a 3.0T Siemens MAGNETOM Trio TIM Syngo scanner using the 3D Magnetization Prepared Rapid Gradient Echo [MPRAGE] sequence. The Minc Tool Kit was used for the structural analysis pipeline to derive lobar estimates of brain volume (grey and white matter volumes; values were normalized to total brain volume). A detailed TBI interview was used to determine the frequency and severity of TBI throughout the playing careers of the sample of hockey players, the protective equipment used and other sports-related injuries. It was hypothesized that there would be a negative relationship between ageing and brain volume in individuals with a history of TBI and that volume loss would be greater than that seen in healthy ageing. Results: In this sample of retired professional and semi-professional hockey players, robust negative correlations were found between grey matter volumes and age. While ageing alone is associated with volume loss, these correlations were larger than what has been shown in prior studies on healthy ageing. Moreover, consistent with prior research on the extent of TBI effects on brain volume, the relationships were found in the frontal, parietal, temporal and occipital regions, whereas normal ageing effects are accentuated in frontal regions. Conclusion: Taken together, the data suggests that athletes with a history of repetitive mild TBI show decreases in brain volume above that seen in normal healthy ageing and that these changes may be more widespread than what would typically be expected.

Brain Inj, 2014; 28(5–6): 517–878

0436

The lived experience of enacting agency in everyday life after a stroke Aileen Bergstro¨m1, Gunilla Eriksson1, Eric Asaba1, Anette Erikson1, & Kerstin Tham1 1

Karolinska Institutet, Stockholm, Sweden, 2Uppsala University, Uppsala, Sweden Objective: To present findings from a study which explored six persons with stroke lived experience of enacting agency in everyday life, which is defined in this study as making things happen by one’s own actions. Persons with stroke often experience everyday life as challenging and rehabilitation specialists have the possibility of supporting persons regarding these challenges. Unfortunately, little is known about how persons experience themselves as an agent in everyday life during the year after their stroke. A better understanding of how persons with stroke experience the phenomenon of agency could help inform rehabilitation specialists and support them in their quest to facilitate participation in everyday life among clients with stroke. Methods: This qualitative, longitudinal, descriptive study followed three men and three women, aged 64–89 and with mild or moderate degrees of stroke severity, during the year after their stroke. They were interviewed on four separate occasions, 2 weeks after the start of their rehabilitation period, 2 weeks after their rehabilitation period ended and at 6 and 12 months post-stroke. The interview data was analysed with a phenomenological method, which is appropriate to study complex phenomenon such as agency. Results: The participants experienced making things happen in their everyday lives as complex negotiations, i.e. dealing with different aspects over a span of time, a range of difficulty and in a number of activities. These different aspects made up the four characteristics that described agency in this study. The first characteristic illuminated how the participants experienced negotiating their damaged bodies. The second characteristic described how the participants took into account the past and envisioned the future and the third how they dealt with the world outside themselves (which included navigating barriers and doing things through and involving others). The fourth characteristic described how the participants negotiated through their internal dialogues, for example regarding their goals and fears, in their quest to enact agency in their everyday lives. Conclusions: These findings, of how persons experienced enacting agency through complex negotiations, elucidate a new dimension as to how persons make things happen in their everyday lives during the year after a stroke and adds to understanding of agency. These findings can be understood and will be presented with help of a transactional theoretical framework, i.e. the constant interplay of the person and environment in the constant change of situations. These findings help contribute to clinicians’ understanding of individuals’ enactment of agency after stroke and suggest the need to facilitate the negotiations that are necessary to enable participation in everyday life.

0437

Patient navigation for traumatic brain injury Emily Rosario, Laura Espinoza, & Bonnie Scudder Casa Colina Centers for Rehabilitation, Pomona, CA, USA

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DOI: 10.3109/02699052.2014.892379

Objectives: Individuals who suffer a traumatic brain injury (TBI) can experience a range of significant functional impairments including physical, emotional, behavioural, cognitive and social deficits. Outcomes such as quality-of-life and transitioning back into the community are often negatively impacted due to these deficits, as well as other health-related and financial issues. Patient navigation has been used in other medical conditions to help identify barriers to quality and timely healthcare in addition to providing support for a patient through a healthcare episode. The aim was to investigate the effectiveness of patient navigation in post-acute rehabilitation for TBI. Methods: The navigation programme is focused on identifying and addressing barriers to care and support, co-ordination of care among providers, facilitating communication among the family and healthcare providers, psychosocial support, adherence to treatment, providing education, linking families with community resources and assisting with financial issues such as insurance. Evaluation of the Navigation programme includes longitudinal assessment of outcomes in both navigation participants and controls not involved who have a TBI with the goal to better understand the cognitive, physical, psychosocial and physiological needs of people with TBI over the course of their adaptation to community re-integration. Results: With a study population of 15/group, this study has observed promising results supporting the effectiveness of navigation. Initial findings for overall global outcomes using the disability rating scale and the Glasgow outcome scale extended show good recovery in the navigation participants. Similarly, using the Neurobehavioural Symptom Inventory (NSI), shows that the navigation participants report far less symptoms and issues such as vision problems, headaches, dizziness, hearing problems and seizures. Of particular importance, this study has found a significant reduction between navigation participants and the baseline participants previously discharged from Casa Colina in terms of re-hospitalizations and falls. Conclusions: Current data show very promising results for the effectiveness of a Navigation programme for individuals with a TBI. The significant reduction in falls and re-hospitalizations appears to be supported by the decrease in neurobehavioural symptoms and overall improved recovery. This study has identified a strong need for behavioural, social and emotional support for both the participant and their family. This highlights the key role of the social worker and neuropsychologist in this intervention. Future research with a larger sample will continue to help refine this programme and determine its sustainability.

on admission to discharge by a designated nurse. Those included accessed a period of inpatient neurorehabilitation from 2007 to the present: ranging from 21–622 days. Age range ¼ 11 months to 17.5 years. Boys (n ¼ 46)/Girls (n ¼ 38). Results: A reduction in the mean value in nursing dependency was seen in 16 out of the 17 areas of ‘basic nursing care needs’. ‘Urinary incontinence’ and ‘faecal incontinence’saw the greatest reduction (49.1% and 48.7%, respectively), with ‘transfers’ seeing a 38.9% reduction. A reduction in the number of children requiring ‘special nursing needs’ was seen in six out of the seven areas; 69.1% (58/84) of children scored lower in the total NPDS from Admission to Discharge; 16.7% (14/84) of children scored the same in the total NPDS from Admission to Discharge; and 14.3% (12/84) of children scored higher in the total NPDS from Admission to Discharge. Conclusions: A reduction in nursing dependency for children who have accessed inpatient paediatric neuro-rehabilitation is demonstrated using the NPDS from admission to discharge. Recommendations from the study include development of a paediatric-specific nursing dependency score to explore how these results can influence developing a nursing discharge tool to facilitate discharge and to explore how this data can influence the development of a training package for nurses and carers within paediatric neuro-rehabilitation. Further work will seek to explore measuring actual nursing care given compared to NPDS data.

0438

IRCCS Santa Lucia Foundation, Rome, Italy

Demonstrating the reduction of nursing dependency for children who have accessed inpatient paediatric neuro-rehabilitation Lisa Kliem, Tim Grove, & Lorna Wales The Children’s Trust, Tadworth, Surrey, UK Objectives: The Children’s Trust is the UKs largest centre providing inpatient paediatric acquired brain injury rehabilitation. Research into the nurses’ role within paediatric neuro-rehabilitation is limited due to the specialized nature of this clinical area. This study explores nursing care in paediatric neuro-rehabilitation setting using the Northwick Park Dependency Scale (NPDS) and uses this data to demonstrate the reduction in nursing dependency for children who have accessed inpatient paediatric neuro-rehabilitation. The NPDS is an ordinal scale with 17 areas incorporating activities of daily living, safety awareness, behavioural management and communication. Methods: The Northwick Park Dependency Scale (NPDS) is an ordinal scale with 17 areas incorporating activities of daily living including safety awareness, behavioural management and communication. NPDS data were collected for 84 children with acquired brain injury

0439

Perspective taking disorders after severe traumatic brain injury Rita Formisano, Umberto Bivona, Sara Laurentiis, Maria Rita Di Cosimo, Natascia Accetta, Roberta Massicci, Paola Ciurli, Eva Azicnuda, Daniela Silvestro, Umberto Sabatini, Chiara Falletta Caravasso, Giovanni Augusto Carlesimo, Carlo Caltagirone, & Alberto Costa

Objectives: To investigate perspective taking (PT) deficits in individuals with severe traumatic brain injury (TBI) and normal self-awareness level (SA) and the association with psychopathological variables. The relationship between PT abilities and quality-of-life of the patients and their caregivers was also investigated. Methods: Twenty TBI individuals with adequate SA, assessed computing the discrepancy scores between Patient Competency Rating Scale and the caregiver, and 20 healthy controls (HCs) were recruited. PT abilities were examined by administering the Interpersonal Reactivity Index (IRI), Faux-pas tasks and Social Perception sub-tests of the NEPSY-II. Neuropsychological and psychopathological assessments were executed to investigate executive functioning, episodic and short-term memory, visual–spatial perception, psychotic symptoms, depression, anxiety, apathy and alexithymia. The Disability Rating Scale, Levels of Cognitive Functioning scale, Glasgow Outcome Scale were also used to assess functional capacities. All participants were also submitted to a neuroimaging evaluation (CT, MRI) in order to identify the presence of focal lesion and/or diffuse axonal injury (DAI). The imaging study allowed one to classify patients in three groups: (1) DAI patients; (2) focal lesions patients; and (3) mixed lesion pattern (DAI + focal). Results: PT performance: TBI patients were significantly less accurate than HCs on both faux-pass and Social Perception tasks (p50.05). They also achieved, in respect to HCs, lower scores than on Perspective Taking and Fantasy IRI sub-scales (p50.05). Neuropsychological disorders: TBI patients were significantly less


676 accurate than HCs on the Wisconsin Card Sorting Test, the Prose Memory Test and the Figures Completion sub-test of the Wechsler Adult Intelligence Scale (in al cases p50.05). There wasa relationship between PT performance, neuropsychological variables and qualityof-life. A significant correlation was found between performance on the Social Perception tasks and on executive and visual-spatial tasks (p50.05). However, IRI and Faux-pas scores did not correlate with any of the cognitive tests (all p consistently40.10). Faux-pas scores were, instead, significantly correlated with the distress perception score of the patients’ caregiver (p50.05) and tended to be correlated with self-perceived quality-of-life of the patients (p ¼ 0.06). Finally, the neuroimaging evaluation showed in the three groups a higher number of patients with lesions (focal and DAI) located in the frontal lobe (19); less in the temporal (16) and parietal (12) lobes. Conclusions: These results show that PT may be impaired in individuals with severe TBI also with adequate levels of SA. The same data suggest that some components of PT abilities may be impaired independently from the involvement of other specific cognitive and psychopathological domains and that PT disorders are associated to poor quality-of-life in the persons with severe TBI and their family. Findings of this study could, thus, give some important clues for the clinical management of TBI patients and the rehabilitation of their interpersonal difficulties.

0440

On ERPs detection in disorders of consciousness rehabilitation Monica Risetti1, Rita Formisano2, Jlenia Toppi3, Lucia Rita Quitadamo4, Luigi Bianchi5, Laura Astolfi3, Febo Cincotti1, & Donatella Mattia1 1

Neuroelectrical Imaging and BCI Laboratory, 2Post-Coma Unit, Santa Lucia Foundation, Rome, Italy, 3Department of Computer, Control, and Management Engineering, Sapienza University, Rome, Italy, 4Department of Electronic Engineering, Tor Vergata, Rome, Italy, 5Department of Civil Engineering and Computer Science Engineering, Tor Vergata University, Rome, Israel Objectives: Disorders of Consciousness (DOC) like Vegetative State (VS) and Minimally Conscious State (MCS) are clinical conditions characterized by the absence or intermittent behavioural responsiveness. A neurophysiological monitoring of parameters like Event-Related Potentials (ERPs) could be a first step to follow-up the clinical evolution of these patients during their rehabilitation phase. Methods: Eleven patients diagnosed as VS (n ¼ 8) and MCS (n ¼ 3) by means of the JFK Coma Recovery Scale Revised (CRS-R) underwent scalp EEG recordings during the delivery of a 3-stimuli auditory oddball paradigm, which included standard, deviant tones and the subject’s own name (SON) presented as a novel stimulus, administered under passive and active conditions. Four patients who showed a change in their clinical status as detected by means of the CRS-R (i.e. moved from VS to MCS) were subjected to a second EEG recording session. Results: All patients, but one (anoxic aetiology), showed ERP components such as mismatch negativity (MMN) and novelty P300 (nP3) under passive condition. When patients were asked to count the novel stimuli (active condition), the nP3 component displayed a significant increase in amplitude (p ¼ 0.009) and a wider topographical distribution with respect to the passive listening, only in MCS. In two out of the four patients who underwent a second recording session consistently with their transition from VS to MCS, the nP3 component elicited by passive listening of SON stimuli revealed a significant amplitude increment (p50.05). Conclusions: Most relevant, the amplitude of the nP3 component in the active condition, acquired in each patient and in all recording

Brain Inj, 2014; 28(5–6): 517–878

sessions, displayed a significant positive correlation with the total scores (p ¼ 0.004) and with the auditory sub-scores (p50.000 01) of the CRS-R administered before each EEG recording. As such, the present findings corroborate the value of ERPs monitoring in DOC patients to investigate residual unconscious and conscious cognitive function.

0441

Acute modulatory effects of low frequency repetitive transcranial magnetic stimulation on the frontoparietal network Guangqing Xu, Yue Lan, Qun Zhang, & Xiaofei He Department of Rehabilitation Medicine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, PR China Lesion and neuroimaging studies in humans have suggested that the frontoparietal networks including the posterior parietal cortex (PPC) and dorsolateral prefrontal cortex (DLPFC) regions were involved in visuospatial attention. Healthy subjects were studied with the Attention Network Test following the repetitive transcranial magnetic stimulation (rTMS) of left or right frontoparietal networks. During this task, the efficiencies of alerting and resolving conflict were deficits in participants after right DLPFC rTMS, however, increased after left DLPFC. In addition, participants after right PPC rTMS showed deficits in the alerting and orienting networks, but not left PPC. The findings of this study not only supported the model of inter-hemispheric rivalry for visuospatial attention, but also indicated inter-regional competition between the areas of FPN. In addition, the visuospatial attention bias might be selectively modulated through rTMS.

0442

The use of accelerometer in rehabilitation of brain damage patients with upper arm paresis Olga Svestkova1, Petra Sladkova1, Pavlina Oborna1, Marketa Janatova1, Marie Ticha1, Yvona Angerova1, Adam Bohuncak2, & Igor Bodlak3 1

Department of Rehabilitation Medicine, the 1st Medical Faculty, Charles University, Prague, Czech Republic, 2Faculty of Biomedical Engineering Czech Technical University, Prague, Czech Republic, 3 Princip, Prague, Czech Republic The rehabilitation of patients with brain damage is an interprofessional, complex, intensive, long-lasting and individuallyoriented process. One frequent consequence of brain damage is hemiparesis, which also causes a disorder of the upper extremity movement pattern. Movement ability of the upper extremity is essential for an individual’s self-sufficiency, the performance of normal daily activities and, thus, for an independent life in a family setting. Special therapeutic rehabilitation approaches should involve the training of new activities, including the motor learning mechanism that activates brain plasticity. A functional re-organization of the motor cortex occurs concurrently with the activation of reserve neurons and the replacement of damaged synapses. One of the aims of this work was to demonstrate that the monitoring of motor functions in patients after brain damage (using the accelerometer) leads to improved motivation for exercise, thereby improving motor

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functions. This study developed HW and SW of the initial sensor (accelerometer) for monitoring movement of upper arm paresis. The second aim was to demonstrate, using objective function methods, the possibility of influencing the movement patterns of a paretic upper extremity by means of intensive inter-professional rehabilitation even several years after brain damage. A study was conducted among 55 selected patients after having suffered brain damage with central hemiparesis who participated in a 4-week stay in a rehabilitation day care centre. Two groups of patients were studied—one group with an accelerometer (30 patients, Group A) and one group without an accelerometer (25 patients, Group B). The parameter studied with the accelerometer was a day-long physical activity of the upper extremities, paretic extremity and non-paretic extremity. Two functional tests were used to clarify the efficacy of rehabilitation: FIM test (Functional Independence Measure) and JT test (Jebson-Taylor test). The tests were used in both groups A and B, at onset and after 4 weeks of rehabilitation during the final tests. Movement therapy was indicated in the same quality and quantity for all patients involved in the study. The results confirmed that an accelerometer is a suitable instrument for detecting the changes of upper arm movement activity, increasing motivation for exercise and making it possible to use bio feedback with the goal of increasing motoric patterns of paretic upper arms. It is possible to use the accelerometer for patients in intensive inter-professional neuro-rehabilitation intervention even several years after brain damage.

0443

A predictive model of the visual pursuit response in the disorder of consciousness Francesco Riganello1, Maria Daniela Cortese1, Giuliano Dolce2, & Walter G. Sannita3 1

S.Anna Institute, Crotone, Italy, 2University of Genova, Department of Neuroscience, Ophthalmology and Genetics, Genova, Italy, 3 State University of New York, Department of Psychiatry, Stony Brook, NY, USA Objective: The visual pursuit response predicts better outcome in the vegetative state (VS/UWS) and is a key marker of evolution into the minimally conscious state (MCS). It is reportedly observed in 20–30% of VS/UWS subjects, but its incidence proved variable during the day. We tested by Heart Rate Variability (HRV) methodologies whether the occurrence of the visual pursuit response is correlated to and can be predicted/modelled based on measures of sympathetic/parasympathetic balance. Methods: Fourteen subjects in VS/UWS and 16 in MCS for more than 1 year were studied. A mirror was used to evoke a pursuit response for a total 231 useful trials. HRV parameters known to reflect responsiveness in the VS/UWS (nuLF, peakLF) were recorded and processed by descriptive statistics and advanced Support Vector Machine (SVM). Results: A pursuit response was observed in 33% and 78.2% of subjects in VS/UWS or MCS, respectively. The incidence of visual pursuit response was higher at HRV nuLF values in the 20–60 range and peakLF values at 0.06–0.12 Hz (76.6%) and at nuLF values in the 10–60 range and peakLF values at 0.05–0.10 Hz (80.7%) in the VS/UWS and MCS subjects. The SVM generated model confirmed the results in the training leave one out and 10-fold cross-validation tests (81% and 81.4%). Conclusion: The pursuit response incidence depends to a relevant extent on the sympathetic/parasympathetic balance and autonomic functional state. Extensive monitoring appears advisable.

0444

Development of internet-based cognitive behavioural therapy for persistent post-concussional symptoms Kirsten Smith1, Sebastian Potter1, Michael Dilly1, Richard G. Brown2, & Rona Moss-Morris2 1 2

South London and Maudsley NHS Foundation Trust, London, UK, Institute of Psychiatry, King’s College London, London, UK

Objectives: Cognitive-behavioural therapy (CBT) may offer a method to reduce symptoms and improve quality-of-life for individuals with persistent post-concussional symptoms (PCS). A degree of expertise in offering this therapy may be preferred due to the heterogeneity of symptoms and relative lack of symptom specificity, overlap with other diagnoses and debate about the role of mild TBI in the evolution and maintenance of persistent PCS. However, access to specialist resources may be geographically limited. Nonetheless, there is a growing evidence base for the effectiveness of CBT in other clinical conditions for remotely-accessed therapy (e.g. via the telephone or internet), with different degrees and levels of therapist involvement. This study will discuss the development of an internet-based but therapist-supported programme of CBT for persistent PCS after a mild–moderate TBI. Methods: Weekly interactive treatment modules will be based on a model of cognitive behavioural therapy for persistent post-concussional symptoms, with evidence of its effectiveness from a previous randomized control trial of face-to-face CBT. Qualitative data from service users will be used to develop and pilot the programme, to gain feedback regarding the structure and content of online modules, different options of remote (e.g. phone/online) therapist contact and the perceived advantages and disadvantages of this format compared with more traditional face-to-face therapy sessions. Results: It is anticipated that patient priorities highlighted in the development may include a number of issues including the experience of developing a therapeutic alliance through ‘virtual’ contact with a therapist, as well as any challenges to feeling understood when communicating via email or instant messaging rather than in person. Development issues and user feedback will also be discussed regarding the use of symptom-specific modules vs a more general transdiagnostic approach; integrating therapist contact with online materials; and offering a tailored intervention reflecting individual concerns vs a ‘one-size-fits-all’ approach. Conclusion: Study findings will be discussed in the context of clinical relevance and future studies.

0445

The effects of erythropoietin on cognitive and motor functions in adult rats after experimental brain injury Michaela Hralova1, Eva Plananska1, Yvona Angerova2,3, Andrea Jadwiszczokova1, Jana Bortelova1, Marcela Lippert-Gruener4, Olga Svestkova2,3, & Dana Maresova1 1

Institute of Physiology, 2Department of Rehabilitation Medicine, First Faculty of Medicine, Charles University, Prague, Czech Republic,

678 3

General University Hospital in Prague, Prague, Czech Republic, Medical Faculty, University of Cologne, Cologne, Germany


4

Objectives: Erythropoietin (EPO) has been shown to be neuroprotective in the brain subjected to a variety of injuries. The aim of this study was to reveal the influence of EPO on motor and cognitive functions following experimental focal ischaemic injury (ischaemic stroke) in adult rats. Methods: Thirty-six 3-month-old male albino Wistar rats were used as subjects for induced focal ischaemia resulting in cognitive and motor impairment. Endothelin-1 (ET-1) was delivered to the cortical area of a. cerebri media of all subjects. One half of the group (the experimental one) was injected with erythropoietin, while the second one (the control group) received saline. The experimental group was administered intraperitoneal (i.p.) injection of EPO (NeoRecormon - Epoetinum beta, Roche, 5000 IU ml1, UK) at a dose of 5000 IU kg1 body weight 10 minutes before the experimentally-induced stroke. Motor and cognitive functions were assessed prior to, immediately after stroke and then at periodic intervals. Motor functions assessment included spontaneous and provoked motor activity, as well as changes in behaviour and eating. Cognitive functions were assessed using a Morris water maze. The learning ability was evaluated mainly in two aspects: escape latency (in seconds) and path length (in metres). The movements of rats were recorded by a video camera connected to a computer running the program ANY MAZE. Results: The group of rats receiving EPO exhibited significantly better motor and cognitive responses as well as in general status following the stroke than the group with saline. Rats treatad with EPO had significantly higher behavioural scores than rats that received only saline (p50.05 or 0.01). They found the target much faster and remembered the position of the hidden island statistically significantly better (even better than before stroke) than the rats administrated only saline. The rats treated with EPO eventually exhibited better motor outcomes, but not until after the 1st day after stroke (acute effect of EPO). Conclusions: The outcomes of this study suggest that EPO could be used in the development of new treatment strategies for neural injury in human medicine. Pre-clinical studies testing efficacy of those substances in animal brain damage models are essential to prepare clinical trials.

Brain Inj, 2014; 28(5–6): 517–878

World Health Organization Neurotrauma Task Force criteria. Stringent exclusion criteria were used to rule out pre-existing medical conditions or other confounding factors. All underwent an acute clinical evaluation that included MTBI severity markers including neuroimaging [computed tomography and 3 T magnetic resonance imaging (MRI)] and Injury Severity Score (ISS). The patients filled out the Rivermead Post-concussion Symptoms Questionnaire (RPQ) at 1, 6 and 12 months following injury. Post-concussion syndrome (PCS) diagnosis was determined using the ICD-10 criteria. Time to returnto-work was assessed. Venous whole blood was drawn for DNA analysis 1 month post-MTBI. Genomic DNA was extracted from peripheral blood leukocytes using the QIAampDNA Blood Minikit and automated biorobot M48 extraction (Qiagen, Hilden, Germany). Genotyping was performed using TaqMan SNP Genotyping Assays (rs429358 assay C 3084793_20; rs7412 assay C_904973_10) and the ABI Prism 7900HT Sequence Detection System (Applied Biosystems, Foster City, CA). Results: The mean age of the patients was 37.2 years (SD ¼ 12.0) and 60% were men. Loss of consciousness occurred in 37.3% (n ¼ 28; mean duration ¼ 0.9 minutes, SD ¼ 2.2) and post-traumatic amnesia occurred in 92.0% (n ¼ 69; mean duration ¼ 2.7 hours, SD ¼ 1.5). Six (8.0%) patients had a Glasgow Coma Scale (GCS) score of 14; the rest had a score of 15. Traumatic intracranial lesions were found in 15 (20.0%) patients. ApoE genotypes were distributed as follows: (i) "2e"3 ¼ 6.8% (n ¼ 5), (ii) "3"3 ¼ 62.2% (n ¼ 46), (iii) "3"4 ¼ 27.0% (n ¼ 20) and (iv) "4"4 ¼ 4.1% (n ¼ 3). Genotypes "2"2 and "2"4 were not represented. The mean time between injury and return-to-work was 55.0 days (SD ¼ 139.1, median ¼ 15.0, IQR ¼ 5.0–43.0) and 68.0% had returned to work at the 1-month follow-up. The rates of PCS diagnoses at 1, 6 and 12 months after injury were 30.7% (n ¼ 23), 22.7% (n ¼ 17) and 21.3% (n ¼ 16), respectively. ApoE-"4 genotype was not associated with PCS diagnosis at 1, 6 or 12 months. Those with ApoE-"4 genotype took longer to return-to-work than other ApoE genotypes (mean ¼ 71.1 days vs 48.8, Mann-Whitney U ¼ 411.0, p ¼ 0.04). Binary logistic regression analysis was used to identify predictors of 1-month RTW. The model covariates were: age, LOC (yes/no), ISS, traumatic lesion on MRI (yes/no) and ApoE-"4 genotype (yes/no). ISS (p50.0001, OR ¼ 1.46, 95% CI ¼ 1.19–1.78) and ApoE-"4 genotype (p ¼ 0.045, OR ¼ 3.72, 95% CI ¼ 1.03–13.39) were significant predictors of RTW. Conclusion: ApoE-"4 genotype was not related to post-concussion symptomology 1, 6 or 12 months following MTBI. However, the "4 genotype was an independent predictor of time to RTW.

0446

A prospective study of the ApoE gene as a predictor of mild traumatic brain injury outcome Teemu M. Luoto1, Grant L. Iverson2,3,4, Heidi Losoi1, Terho Lehtima¨ki5,6, & Juha O¨hman1

0447

Insomnia 1 year after traumatic brain injury: Frequency, psychosocial correlates and risk factors

1

Department of Neurosciences and Rehabilitation, Tampere University Hospital, Tampere, Finland, 2Department of Physical Medicine and Rehabilitation, Harvard Medical School, Charlestown, MA, USA, 3Red Sox Foundation and Massachusetts General Hospital Home Base Program, Boston, MA, USA, 4Defense and Vet, Boston, MA, & Bethesda, MD, USA, 5Department of Clinical Chemistry, Fimlab Laboratories, Pirkanmaa Hospital District, 6School of Medicine, University of Tampere, Tampere, Finland Objectives: To evaluate the predictive value of ApoE gene in outcome from mild traumatic brain injury (MTBI). It was hypothesized that ApoE-"4 genotype would be associated with greater time off work (RTW) and prolonged post-concussion symptoms. Methods: Participants with MTBI (n ¼ 75) were prospectively recruited from the Emergency Department of Tampere University Hospital (August 2010–July 2012). MTBI diagnosis was operationalized by

Simon Beaulieu-Bonneau, Myriam Giguere, & Marie-Christine Ouellet Centre interdisciplinaire de recherche en readaptation et integration sociale, Quebec, QC, Canada Objectives: (1) To document the frequency of insomnia symptoms 12 months following traumatic brain injury (TBI). (2) To compare participants with and without insomnia 12 months post-TBI on premorbid, injury and 4-month-post-TBI characteristics. (3) To explore which of these variables are significant predictors of 12-month insomnia status. Methods: This abstract reports preliminary data from a longitudinal study on mental health following TBI, with assessments taking place 4, 8 and 12 months post-injury. Participants were 116 adults with TBI who were admitted to a Level I trauma centre in Que´bec, QC, Canada,

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and who completed the 12-month assessment (mean age ¼ 42.3 ± 15.6 years; 23.3% women; 44.8% mild, 31.9% moderate, 23.3% severe TBI). Presence of insomnia at 12 months was defined as a score 8 on the Insomnia Severity Index. Participants with and without insomnia at 12 months were compared using Chi-Square tests and t-tests on pre-morbid psychiatric history, sociodemographic characteristics, TBI severity and psychological and physical functioning at 4 months postinjury. A direct binary logistic regression was then performed (dependent variable: presence/absence of insomnia at 12 months; potential predictors: variables on which participants with and without insomnia significantly differed). Results: Insomnia symptoms were present in 52.7% of participants 12 months after TBI. Compared to those without insomnia, participants with insomnia at 12 months were more likely to present a past psychiatric history (53.6% vs 34.0%; p ¼ 0.04), and, at 4 months postTBI, displayed higher levels of anxiety, depression, irritability, cognitive difficulties and pain and a greater number of stressful life events (p’s50.01). Groups did not significantly differ on age, sex, employment, marital status, TBI severity or social support or alcohol/ drug use at 4 months. Results of the logistic regression revealed a significant model (X2 (8, n ¼ 76) ¼ 38.69; p50.01; R2 ¼ 0.54), with two variables predicting the presence of insomnia at 12 months: irritability (OR ¼ 1.65; p50.01) and the number of stressful life events (OR ¼ 1.64; p ¼ 0.01), both assessed 4 months post-TBI. Conclusions: Insomnia is a very prevalent issue 1 year following TBI, with more than half the sample reporting sleep difficulties. Among the several psychosocial correlates of insomnia, it appears that a higher level of irritability and a greater number of stressful life events experienced at 4 months post-TBI are the strongest predictors of insomnia 8 months later. As such, clinical attention should be devoted to alleviate manifestations of irritability and attenuate the impact of stressful circumstances early on after TBI in order to reduce the likelihood for patients to present insomnia in the long-run. This would in turn promote good psychological and physical wellbeing.

0448

Prolonged alterations of visuallydriven balance control in children following a mild traumatic brain injury: A virtual reality study Selma Greffou1, Michelle McKerral1, Isabelle Gagnon2, Robert Forget1, & Jocelyn Faubert1 1

University of Montreal, Montreal, Canada, 2McGill University, Montreal, Canada Introduction: Traumatic brain injury (TBI) is a leading cause of disability in children. Information about the way that a mild TBI affects balance in children is scarce, notably that concerning the visual contribution to these difficulties and their post-injury evolution across time. Objectives: This study assessed the visual and vestibular components involved in postural control of children (9–18 years-old) having sustained mTBI as a function of symptomatology and time post-injury. Methods: Postural reactivity (Postural Perturbations, PP and Body Sway, BS) was measured for moderately-symptomatic mTBI (MS-mTBI; n ¼ 18), low-symptomatic mTBI (LS-mTBI; n ¼ 19) and control (n ¼ 36) groups in response to a virtual tunnel oscillating at three different frequencies at three distinct time intervals: 2 weeks (n ¼ 73), 12 weeks (n ¼ 67) and 12 months post-injury (n ¼ 48; preliminary data). Results: It was found that, 2 weeks post-injury, the MS-mTBI group exhibited significantly more PP than the control group, whether the tunnel was static or dynamic, notably at the slowest stimulation frequency. Moreover, at 12 weeks post-injury, the MS-mTBI group showed significantly more PP than the control group when the tunnel was dynamic, but not when it was static; interestingly, only 11% of

the participants in the MS-mTBI group were still moderately symptomatic at that time. Preliminary data suggests that the increased visually-induced postural instability observed in the MS-mTBI group at 2 and 12 weeks post-injury is no longer observed 12 months post-injury. No significant differences were found between groups for the BS measure. Conclusions: Taken together, these results suggest that children, having sustained mTBI and who are initially moderately symptomatic, generally show increased postural instability when exposed to optic flow stimuli up to 12 weeks post-injury, even when an elevated total score of symptoms is no longer self-reported; this instability appears to resorb within 12 months post-injury. This indicates that the balance difficulties reported following mTBI may be, at least partly, related to altered processing of dynamic visual information and do not appear to be solely predicted by the magnitude of the total score on a post-concussion symptoms scale (PCS-R).

0449

Clinical and brain imaging changes after upper-limb rehabilitation with a virtual reality tabletop system: A case study Roberto Lloreńs1, Carolina Colomer2, Amparo Baldovı´-Felici2, & Ignacio Verdecho2 1

Instituto Interuniversitario de Investigacioń en Bioingenierıá y Tecnologıá Orientada al Ser Humano (Universitat Polite`cnica de Vale`ncia), Valencia, Spain, 2Servicio de Neurorrehabilitacioń y Danõ Cerebral de los Hospitales NISA, Fundacioń Hospitales NISA, Valencia, Spain

Objectives: This case study describes the clinical improvements, measured with standard tests and supported by neuroimaging studies, observed after an upper limb rehabilitation protocol using a Virtual Reality (VR) system that provides enriched sensorimotor feedback to conventional physical therapy exercises. Methods: The hardware components of the tabletop system consist of a table, a standard computer, a projector and a depth sensor (KinectTM). The projector and the sensor are fixed in an upper plane of the table oriented to its surface. This way, the projector displays the virtual environment on the table and the patients interact within it through movements of their own extremities. A set of exercises taking into account the brain plasticity and motor learning principles were designed to promote locomotor recovery of the upper extremities of individuals with ABI. The exercises covered movements that were likely to belong to the motor repertory of the patients previously to the injury and aim to maximize the correlation of the virtual tasks with the real tasks of the ADL (to dial a telephone number, to cook, to knock a door, etc.). This case study presents the data from a chronic 62-year-old gentleman with left hemiparesis secondary to an intracerebral haemorrhage stroke (38 months post-stroke) who took part in 30 1-hour sessions with the system. Clinical assessment was performed 1 month before the treatment (T1), 1 day before the treatment (T2), the day after the treatment (T3) and 1 month after the treatment (T4). Clinical measures included the Wolf Motor Function Test (WMFT), the Nine-hole Pegboard (9HP) and the Box & Block Test (BBT). Activity-induced neural re-organization was examined using functional magnetic resonance imaging (fMRI) and diffusion tensor tractography, before (T2) and after the treatment (T3). Usability and motivation were assessed at the end of the treatment with the System Usability Scale (SUS) and the ‘interest and enjoyment’ and the ‘value and usefulness’ sub-scales of the Intrinsic Motivation Inventory (IMI). Results: Improvement was observed in all clinical scales (WMFT ¼ 3; 9HPT ¼ 19.24; BBT ¼ 7) after the treatment (T3–T2 scores). One-month after therapy (T4–T2 scores), clinical improvements were still evident

680 (WMFT ¼ 1.5; 9HT ¼ 12.8; BBT ¼ 7). The participant considered that the system was easy to use, easy to learn, robust and consistent (SUS ¼ 95). He found the system enjoyable (IMI ¼ 4.1) and defined it as a ‘useful system to improve their deficits’ (IMI ¼ 5.4). fMRI during a sequential elbow movement revealed distinct therapy-related changes with a tendency to a reduction of the contralesional motor lateralization during movement. Conclusions: The results suggest that VR therapy can induce functional recovery in chronic hemiparetic stroke patients. Results were supported by cortical re-organization, which evidenced an increase in the ipsilateral and a decrease in contralateral activity in the sensorimotor cortex.


0450

Does multi-dose progesterone modify seizure susceptibility following traumatic brain injury in rat? Tahereh Ghadiri Garjan1, Mohammad Sharifzadeh2, Sayed Mostafa Modarres Mousavi1, & Ali Gorji3 1

Shefa Neuroscience Research Center, Tehran, Iran, 2School of Advanced Technologies in Medicine, Tehran University of Medical Sciences, Tehran, Iran, 3Epilepsy Research Center , Westfa¨lische Wilhelms-Universita¨t Mu¨nster, Mu¨nster, Germany Objectives: Traumatic brain injury is one of the most common brain injuries that result in post-traumatic epilepsy. Following TBI and other insults, a normal brain by the process of epileptogenesis develops epilepsy. Nonetheless, the prevention and treatment of PTE are not well understood. The present study was designed to determine probably anti-post-traumatic seizure (PTS) activity of progesterone as a potent new emerged treatment for TBI. Methods: Twenty-six male wistar rat were divided into four groups including; Sham (n ¼ 6), TBI (n ¼ 6), TBI-veh (n ¼ 6) and TBI-prog 16 mg kg1 (n ¼ 6). First of all, focal traumatic brain injury was induced by a novel modified weight drop device. Then, the animals of this experiment, depending on the type of group, during a critical time window (during 2 weeks after trauma) were treated by peanut oil or progesterone 16 mg kg1 in 1 or 6 hours and daily for 2 weeks after TBI in veh and prog groups, respectively. Finally, the seizure susceptibility of rats following (i.p) injection of sub-convulsant dose of PTZ was evaluated according to Racine’s scale within 60 minutes. Results: Based on the result of this study, all animals of TBI, veh and prog groups behave excited during latency of seizure compared to other groups. Moreover, progesterone had no effect on reducing seizure score compared to the TBI group (5/5 vs 5/5). Also, latency and duration of the seizure in the prog treated rats were not significantly different from the TBI groups. Conclusions: According to behavioural seizure evaluation the data showed that progesterone in the dose of 16 mg kg1, 15 times 1 and 6 hours and then daily until the 14th day after TBI did not reduce seizure behaviour.

0451

Relationship between estimated pre-morbid IQ and neuropsychological measures of brain injured individuals in an acute rehabilitation setting

Brain Inj, 2014; 28(5–6): 517–878

Mark Herceg, Kristen Bonistall, & Joanna Spencer Burke Rehabilitation Hospital, White Plains, NY, USA Objectives: Cognitive reserve theories have been used in an attempt to explain differences in performance and outcome after neurological injury or illness. Theories suggest that higher education and IQ scores may preserve functional abilities after acquired brain injury. Greater cognitive reserve may buffer the effects of injury, regardless of severity. The Wechsler Test of Adult Reading (WTAR) has been utilized to provide a measure of intellectual functioning prior to the onset of illness, injury or disease. The objective of this study was to analyee IQ scores of brain injured individuals obtained on admission to acute rehabilitation and evaluate if they correlate to scores on brief neuropsychological measures. Methods: A retrospective cohort analysis of TBI patients admitted to an acute rehabilitation brain injury programme were administered the WTAR during the initial neuropsychological evaluation on admission. Testing was conducted within 3 days of admission. Patients were also adminstered the Montreal Cognitive Assessment (MOCA) and Mini Mental Status Examination-2 EV. Multivariate analysis was used to determine if individuals with higher IQ scores also had higher scores on the MOCA and MMSE-2EV. An analysis was also conducted to determine if a higher WTAR IQ correlated to MOCA gain on discharge. Results: A database of 1378 patients who were discharged between 3 January 2012 and 25 May 2013 was examined. Of these patients, 760 were given the MMSE-2EV on admission; 327 were given the MOCA; and 82 had an initial WTAR. One hundred and fifty-eight patients had both initial and dischage MOCA. Patients with higher WTAR IQ scores correlated with higher scores on both intial MOCA (r ¼ 0.498, p50.01) and initial MMSE-2EV (r ¼ 0.529, p50.01). There was no significance in MOCA gain from initial to discharge (r ¼ 0.272). Conclusions: Pre-morbid estimated IQ appears to be good predictor of outcome on neuropsychological measures and appears to back up the theory of cognitive reserve. This may help understand functional outcome and return to a better quality-of-life.

0452

Stroke rehabilitation through the Kinectä: Reality beyond the revolution. A comparison among different tracking systems and populations Roberto Lloreńs1, Enrique Noe´2, Valery Naranjo1, & Beleń Moliner2 1

Instituto Interuniversitario de Investigacioń en Bioingenierıá y Tecnologıá Orientada al Ser Humano (Universitat Polite`cnica de Vale`ncia), Valencia, Spain, 2Servicio de Neurorrehabilitacioń y Danõ Cerebral de los Hospitales NISA, Fundacioń Hospitales NISA, Valencia, Spain Objectives: Motion tracking systems are commonly used in virtual reality-based interventions to detect movements in the real world and transfer them to the virtual environment. There are different tracking solutions based on different physical principles, a fact that mainly defines their performance parameters. However, when virtual reality is used in rehabilitation, special requirements have to be considered. The particular requirements of the patients, the needs of the therapists and the limitations of the physical therapy units can affect the use of the tracking systems beyond their objective performance. This paper studies and compares the performance of three different tracking solutions (optical, electromagnetic and

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skeleton tracking) in a practical scenario and analyses the subjective responses of healthy and stroke individuals to the virtual experience, and also their implications for therapists. Methods: The accuracy and jitter of three tracking systems in an area of 1.5 1.5 metres in a physical therapy unit was analysed. In addition, 22 individuals with stroke, 19 healthy subjects and 14 physical therapists provided their subjective perceptions after using the three systems. Healthy and stroke groups interacted with the VRHB system for a total of 45 minutes divided into 15-minute sessions with each technology. After each session the participants filled out a questionnaire, which consisted of eight items that assessed (1) fixation speed of the sensors/markers, (2) ease of the calibration, (3) accuracy of the represented movements, (4) robustness, (5) comfort, (6) perceived success, (7) agreement with the results and (8) order of preference. The therapists group supervised and guided the virtual training of individuals with stroke during 45 sessions, 15 sessions with each system. After the 45 sessions, the therapists filled out a questionnaire consisting of 12 items that assessed (1) fixation speed, (2) ease of the calibration, (3) accuracy, (4) robustness, (5) ease of fixation, (6) insensibility to changes in the clinical setting, (7) ease of assistance, (8) maintenance, (9) working range, (10) integration in the clinical setting, (11) value for money and (12) order of preference. Results: The optical tracking system provided the best accuracy (1.074 ± 0.417 cm), while the electromagnetic device provided the most inaccurate results (11.027 ± 2.364 cm). However, this tracking solution provided the best jitter values (0.324 ± 0.093 cm), in contrast to the skeleton tracking, which had the worst results in terms of jitter (1.522 ± 0.858 cm). Subjective perceptions varied among groups. By and large, healthy individuals and professionals preferred the skeleton tracking solution rather than the optical and electromagnetic solution (in that order). Individuals with stroke chose the optical solution over the other options. Conclusions: The results show that subjective perceptions and preferences are from being constant among different populations, thus suggesting that these considerations, together with the performance parameters, should also be taken into account when designing a rehabilitation system.

Vegetative State/Unresponsive Wakefulness Syndrome (VS/UWS), the other was in MCS. Differences in the clinical course were demonstrated. Contrary to VS/UWS, the patient in MCS showed new behavioural reactions, like speaking words 4 months after brain injury and beyond a year after injury visual tracking with fixation and emotional reactions to family members were seen. Interviews with family and caregivers showed differences in perception of the situation of VS/UWS and MCS. The family of the MCS patient experienced movement of the head and mouth in response to a kiss. Family and caregivers experienced no emotional reactions from the VS/UWS patient. These results support the importance to distinguish MCS from VS/UWS in long-term care, in particular regarding diagnosis, prognosis, long-term course, care and perception of families and caregivers. To improve adequate diagnosis of MCS in long-term care the aim was to explore the current diagnostic guideline and to establish a diagnostic guideline suitable for the daily practice in long-term care. This exploration was done through a literature review on the diagnostics of MCS. After the literature review, the diagnostic guideline for long-term care will be discussed with experts. This guideline is the basis for identifying the population MCS patients in the long-term care. For the first time this will be conducted in the Netherlands, following earlier prevalence studies of VS/UWS and Locked-in syndrome. Particularly the Dutch long-term care, with its own medical specialty and academic networks, provides an optimal infrastructure for this research. The results from the case study and from the literature review will be presented on the congress.

0454

Randomized controlled trials in adult traumatic brain injury: Compliance to the CONSORT statement Juan Lu, Al Copolillo, & Kelli Gary

0453

The minimally conscious state: To shed a light on the importance of diagnosis in longterm care Berno Overbeek, Jan Lavrijsen, & Henk Eilander Radboud University Medical Centre, Nijmegen, The Netherlands The minimally conscious state (MCS) is a condition of severely altered consciousness in which minimal but definite behavioural evidence of self or environmental awareness is demonstrated. In long-term care in the Netherlands, knowledge is scarce about patients in MCS. Most of these patients live in nursing homes or institutions for mentally disabled patients and probably a significant proportion lives at home. A central registration for MCS is lacking and the care for these patients is fragmented. Therefore, data like prevalence, characteristics, long-term course and prognosis are unknown. There also is a need for further research into the long-term outcome of therapeutic interventions and medical-ethical issues. To make that research possible, the population of MCS patients in long-term care facilities has to be identified. It is known that diagnosing MCS is difficult, shown by rates of misdiagnosis of 40%. To emphasize the importance of an accurate diagnosis of the state of consciousness in long-term care, this study described the clinical course of two nursing home patients after non-traumatic brain injury. One patient was in

Virginia Commonwealth University, Richmond, VA, USA Objectives: To examine the extent that reports of RCTs in the adult traumatic brain injury (TBI) population adheres to Consolidated Standards of Reporting Trials (CONSORT) Statement and assess whether quality of reports has improved between periods of 1997– 2001 and 2002–June 2011. Methods: MedLine, PsycINFO and CINAHL databases were searched to identify all primary reports of RCTs in an adult TBI population through 29 June 2011. The search terms and methods were published in a previous report. In the previous report, there were 100 eligible studies, including 93 primary RCT reports and seven studies with unpublished results. This review only consisted of those 93 published reports. Results: Of the 93 trials reviewed, 23 were published before and up to the publication of the initial CONSORT Statement in 1996, 14 before and up to the publication of the CONSORT revision in 2001 and 56 after the revision in 2001. Overall, 38.7% (36/93) of the trials investigated drugs as the primary intervention of interest, 4.3% (4/93) assessed surgical procedures, 34.4% (32/93) assessed rehabilitation-related interventions and 22.6% (21/93) studied other types of treatment. Among the methodological aspects, 76.3% (71/93) of all reports defined the primary outcome; 36.6% (34/93) stated that a sample size calculation had been undertaken; 43.0% (40/93) reported the method used to generate the randomization sequence; 47.3% (44/93) reported the allocation concealment method; 59.1% (55/93) reported whether there was any blinding; 87.1% (81/93) reported any loss to follow-up for each study group or reported no loss to followup; and 82.8% (77/93) reported intention to treat analysis was applied. Additionally, there was a significant improvement in the proportion of reports that provided methods of allocation concealment from 2002–June 2011 compared with the proportion of reports

682 from 1997–2001 (RR ¼ 4.33, 95% CI ¼ 1.18–15.88). The improvement between the two periods was also observed in other areas but did not reach statistical significance. These included the proportions of reports for sample size calculation (RR ¼ 1.50, 95% CI ¼ 0.62–3.62); methods of random sequence generation (RR ¼ 2.00, 95% CI ¼ 0.85– 4.72); any blinding (RR ¼ 1.20, 95% CI ¼ 0.72–2.01); reasons for loss to follow-up (RR ¼ 1.44, 95% CI ¼ 0.97–2.15) and intention to treat analysis (RR ¼ 1.31, 95% CI ¼ 0.87–1.96). Conclusion: Reporting of several important methodological aspects of RCTs conducted in an adult TBI population improved between the periods of 1997–2001 and 2002–June 2011; however, quality of reporting remains below an acceptable level. This review calls for further improvement in reporting of RCTs in TBI research and full adherence of the CONSORT Statement.


0455

Initial evaluation of a virtual reality executive function assessment tool in individuals with traumatic brain injury Denise Krch1, Denise Vazquez1, Sebastian Koenig2, Albert Rizzo2, & Nancy Chiaravalloti1

Brain Inj, 2014; 28(5–6): 517–878

neuropsychological tests of EF may be explained by increased sensitivity of a VR-based EF evaluation. VR allows for presentation of complex stimuli that more closely reflects spatial and temporal demands of real life scenarios. Qualitative feedback from subjects suggests carrying out tasks in the face of distractors in the virtual environment negatively impacted their performance. These preliminary results suggest that VR assessment tools may allow for increased validity in EF evaluations, providing a more accurate reflection of how individuals perform in the real world. However, further studies are warranted to test this hypothesis.

0456

Virtual reality-based telerehabilitation programme for balance recovery. A pilot study in hemiparetic individuals with acquired brain injury Roberto Lloreńs1, Enrique Noe´2, Joan Ferri2, & Mariano Alcan˜iz1 1

1

Instituto Interuniversitario de Investigacioń en Bioingenierıá y Tecnologıá Orientada al Ser Humano (Universitat Polite`cnica de Vale`ncia), Valencia, Spain, 2Servicio de Neurorrehabilitacioń y Danõ Cerebral de los Hospitales NISA, Fundacioń Hospitales NISA, Valencia, Spain

Objectives: Executive function (EF) impairments are a key problem following TBI. Deficits in EF have been shown to impact multiple areas of the lives of persons with disabilities, including societal and family functioning and employment. Developing effective tools to evaluate EF impairments are instrumental in treatment planning. EFs are complex and dynamic in nature, making it a challenging domain to assess. The current study used a novel, virtual reality (VR)-based tool, the Assessim Office (AO), to evaluate EF performance in individuals with TBI. Performance on the AO was compared to performance on standard neuropsychological measures. Methods: Subjects included seven healthy controls (HCs; aged 38.4 ± 13.6 years, 13.5 ± 1.6 years of education) and 18 individuals with moderate-to-severe TBI (aged 31.1 ± 14.1 years, 16.0 ± 1.2 years of education). All subjects were administered the AO, in which complex problem-solving, divided attention and selective attention were assessed. Individuals with TBI also completed the following EF measures: Symbol Digit Modalities Test (SDMT), Letter Comparison (LC), Pattern Comparison (PC), Delis-Kaplan Executive Function System (D-KEFS) Trail Making Test, D-KEFS Color-Word Test sub-test, Wechsler Abbreviated Scale of Intelligence (WASI), Matrix Reasoning (MxR) and Similarities (Sim) sub-tests and the Paced Auditory Serial Addition Test (PASAT). Results: Independent sample t-tests demonstrated that the TBI sample was significantly more impaired on the AO complex problem-solving task (p ¼ 0.002) relative to HCs, whereas effect sizes of all AO tasks (i.e. complex problem-solving, divided attention, selected attention) exceeded moderate-to-large effect sizes (all r’s40.28; Cohen). The TBI sample demonstrated impaired performance on SDMT and PASAT, with low average-to-average performance on the remaining neuropsychological tests of EF. The AO complex problem-solving task correlated significantly with all standard neuropsychological tasks, whereas inconsistent relationships between remaining AO tasks and performance on neuropsychological tests were found. Conclusions: Results show that individuals with TBI performed at lower levels than HCs on EF evaluated in the AO. Individuals with TBI were less consistently impaired on standard neuropsychological tests of EF. The relationship between performance on AO tasks and standard neuropsychological tests were inconsistent. The presence of consistent EF impairment in the TBI sample in the AO and few deficits on

Objectives: The increasing number of studies reporting the use of specific virtual reality (VR) applications for the rehabilitation of motor impairments after acquired brain injury (ABI) together with the progressive decrease of the costs are facilitating the introduction of new tools not only in the clinical setting but also in the home setting. A VR-based system for balance rehabilitation was integrated in the physical therapy programme of the neurorehabilitation unit 5 years ago. Patients were being included in the programme according to their particular condition and expected clinical benefits. Previous results showed that the system is effective for the recovery of balance in hemiparetic individuals with ABI. The off-the-shelf KinectTM meant a technological breakthrough that allowed some individuals to interact with custom-made VR applications without wearable devices and with affordable costs. The objective of this study is to analyse the clinical effectiveness of a telerehabilitation programme using this VR system in the home setting of individuals with chronic ABI. Methods: A sample of eight participants with a mean score in the Berg Balance Scale of 47.6 ± 3.8 were considered in the study. A complete setting of the VR system consisting of a laptop and a KinectTM was provided to each participant. A therapist guided them in the home installation, set-up and common usage of the system. The programme consisted of 20 45-minute sessions with a stepping exercise, which difficulty was previously estimated by experienced clinical therapists, 3–5 times a week. The programme was monitored by the clinical team from the neurorehabilitation unit. Participants were assessed before and after the treatment with a battery of motor scales that included the Berg Balance Scale (BBS) and the Tinetti Performance-Oriented Mobility Assessment (POMA) and also a posturography test. In addition, the subjective experiences of the participants after the programme were registered by two questionnaires: the SUS and the Intrinsic Motivatory Inventory (IMI). Results: Statistical analyses showed that the participants had a significant improvement in the BBS (p50.01), the POMA (p50.05) and in the posturography tests that assessed the rhythmic weight shift (p50.05) and the vestibular index (p50.05). Scores of the SUS and IMI show high satisfaction and a good usability perception of the telerehabilitation system.

Kessler Foundation, West Orange, NJ, USA, 2University of Southern California Institute for Creative Technologies, Playa Vista, CA, USA

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DOI: 10.3109/02699052.2014.892379

Conclusions: The results of the clinical scales and the posturography test support that the training with the telerehabilitation programme provided clinical benefits to individuals with ABI. The high chronicity of the sample highlight the clinical improvement, suggesting that these programmes can provide benefits, even a long time after the injury. Scores to the questionnaires reported that the experience was very positive, even though the training was performed in their places, instead of in the neurorehabilitation unit.

alternative therapies did not reduce or eliminate their chronic headaches and migraines and other symptoms. Determination of the precise hue and density of the various wavelengths of light must be individually determined in order to eliminate headaches, migraines and other symptoms and improve the ability to function.

0458 0457

Precision-tinted coloured filters: A successful intervention for medically resistant headaches and migraines after brain injury 1

1

2

Sandra Tosta , Helen Irlen , Jeffrey Lewine , & Joseph Annibali3

The efficacy of early treatment with sertraline for preventing mood and anxiety disorders in the aftermath of TBI Ricardo Jorge1, Acion Laura2, Robinson Robert2, & Marielle Meurice2


1 1

2

Irlen Institute, Long Beach, CA, USA, The University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA, 3Amen Clinics DC, Washington, DC, USA Background: Since March 2011, Irlen has been investigating the use of Irlen Spectral Filters with military personnel experiencing chronic light senstivity, headaches and migraines as a result of brain or head trauma that has not been successfully remediated through other interventions, including migraine medications, acupuncture, chiropractic treatments, healing touch, yoga, meditation, vestibular therapy, Botox injections, hyperbaric and Neurofeedback. Methods: A sample of 134 Military personnel diagnosed with medically resistant headaches and migraines and chronic light sensitvity as a result of combat-related brain or head trauma were seen at the Irlen Institute for treatment. A preliminary questionnaire determined the severity and frequency of headaches and migraines experienced and difficulties related to 28 areas of functioning. The individualized, precision-tinted Irlen Spectral Filter was determined and given to each individual to wear in the form of glasses. After 4–12 weeks, a follow-up survey was conducted to assess reduction of light sensitivity, headaches and migraines and a variety of other areas. Amount and severity of difficulties experienced were reported on a 0–5 scale (0 means ‘no problem’ and 5 means ‘considerable problem’). Results: Results confirmed a nearly 100% reduction in headaches and migraines, 98% reduction in light sensitivity, 80% reduction in weekly/monthly migraine medication use, 99% reduction in weekly/ monthly OTC medication use, 88–95% reduction in other physical symptoms (eye strain, dizziness, nausea), 93–97% reduction in academic difficulties (reading, math computation, copying, paperpencil tasks, computer, job performance), 75–98% reduction in physical difficulties (co-ordination, balance, depth perception, general perception, tracking moving objects, marksmanship) and 54–64% reduction in emotional symptoms not related to PTSD (anxiety, irritability/agitation, anger, depression). Paired samples t-tests confirmed all improvements were significant at p50.05. Conclusions: For individuals who have suffered head trauma resulting in light sensitivity and chronic headaches and migraines that fail to respond to other standard interventions, Irlen Spectral Filters provide dramatic and immediate relief and improvements. These improvements extend beyond headaches and migraines to impact other areas of life and daily functioning that are crucial to both their ability to remain in active duty and to achieve success after retiring from the Marine Corps. Irlen Spectral Filters are able to eliminate the pain and discomfort that no other intervention or medication has been able to eliminate, provide stability and clarity in the visual field (both on the printed page and in the environment) and improve functioning in more than 26 areas. Sunglasses, tinted lenses, transition lenses, medications and

Baylor College of Medicine, Houston, TX, USA, 2University of Iowa, Iowa City, IA, USA Objectives: Mood and anxiety disorders are the most frequent psychiatric complications of TBI and have a large impact on family functioning, interpersonal relationships and return-to-work or school. Furthermore, a significant proportion of these disorders will progress to more chronic and treatment refractory forms. This study examined the efficacy of sertraline to prevent the onset of mood and anxiety disorders during the first 6 months after TBI. Methods: A group of 94 patients with closed TBI were recruited after resolution of post-traumatic amnesia and randomized to receive 6 months of double-blind treatment with sertraline (n ¼ 48) or placebo (n ¼ 46). Primary outcome measures included onset of DSMIV-defined mood and anxiety disorders and psychosocial outcome measured by Community Integration Questionnaire (CIQ) scores. Magnetic resonance imaging structural analysis and diffusion tensor imaging were used to examine neurobiological correlates of mood and anxiety disorders as well as biological predictors of treatment response and community reintegration. Results: While 10 (21.7%) patients receiving placebo had a mood or anxiety disorder 6 months following TBI, only three (6.3%) patients receiving sertraline had a mood or anxiety disorder in the same period (Fisher’s Exact test p value ¼ 0.038). Conclusions: Sertraline is effective to prevent the onset of mood and anxiety disorders during the first 6 months after TBI.

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Services and supports for students with TBI: Survey of US educational agencies Ann Glang1, Debbie Ettel1, Bonnie Todis1, Wayne Gordon2, Jennifer Oswald2, Susan Vaughn3, Susan Connors3, & Margaret Brown3 1

University of Oregon, Eugene, OR, USA, 2Brain Injury Research Center at Icahn School of Medicine at Mount Sinai, New York, NY, USA, 3 Brain Injury Association of America, Vienna, VA, USA Objectives: The National Institute on Disability and Rehabilitation Research funded two research centres that collaborated in investigating current approaches to service provision for children and youth with brain injury/concussion. The goals of this effort were: (1) To update and expand knowledge about efforts within each state to


684 identify and provide appropriate educational and support services to children with brain injury and (2) To identify effective practices in these areas that can be shared with State and Local Education Agencies. Methods: Representatives from 43 state education agencies (SEAs) completed an on-line survey on services for students with TBI. A follow-up interview was conducted with each representative and with 45 state brain injury consumer organizations. Results: Fifty-five per cent of respondents report that the TBI count in their state is inaccurate. Eligibility categories reported to provide services to students with TBI include: TBI (40%), Other Health Impaired (12%), Specific Learning Disability (9%), Emotional Disturbance (6%), Intellectual Disability and Multiple Disabilities (5% each). Factors identified by respondents as contributing to children with TBI not being identified were: (a) lack of awareness about TBI as a disability, (b) lack of communication between hospital and school, (c) identification of students with TBI under different eligibility categories, (d) under-reporting of injuries by parents and (e) a narrow definition of TBI that excludes other forms of acquired brain injury. A few state representatives asserted that category accuracy was not as important as providing services to the student. Many students with TBI are not assessed, often because they have not been identified as needing formalized school supports. There is a lack of information among educators about how best to provide educational services to students with TBI. While SEAs recommend evidence-based practices to local districts for educating all children, respondents did not know of any specific practices that meet this criterion in teaching children with TBI. Half of surveyed states have dedicated TBI personnel at the State Department of Education. Thirtyone states (70%) reported providing on-going, sustained professional development in brain injury. States endorsed the following professional development approaches as most effective: on-line training, workshops and webinars. Conclusions: To effect systemic change will require a collaborative effort by school systems, educators, parents, hospitals, physicians, policy-makers and advocates to enact solutions in five areas: (1) better screening, identification and assessment practices; (2) identification of a comprehensive research agenda regarding educational supports for students with brain injury; (3) expanded pre-service and professional development for school staff; (4) increased efforts to train and support parents as advocates; and (5) directed funding to support the implementation of each of these recommendations.

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Brain Inj, 2014; 28(5–6): 517–878

Methods and results: Sprague Dawley rats received a single intravenous injection of MK-886 (6 mg kg1) or vehicle either before or after fluid percussion injury (FPI) using a 20 millisecond pulse of pressurized saline delivered to an intact dura. MK-886, given before or after injury, significantly blocked injury-related brain leukotriene synthesis, measured by reverse-phase liquid chromatography coupled to tandem mass spectrometry, and brain oedema, measured by T2weighted magnetic resonance imaging. MK-886 also significantly attenuated blood–brain barrier (BBB) disruption in the CA1 hippocampal region, detected by fluorescence microscopy of Evans blue extravasation. To examine the functional integrity of the hippocampus after FPI, long-term potentiation (LTP) was measured in hippocampal slices by recording field excitatory post-synaptic potentials (fEPSPs) from CA1 neurons in response to electrical stimulation of the Schaffer collaterals. There was no difference in fEPSP input–output curves or paired pulse ratio measurements between sham and FPI-injured animals, indicating similar levels of basal synaptic transmission for these groups. On the other hand, hippocampal slices from sham animals exhibited robust LTP in response to high frequency stimulation whereas FPI-injured animals failed to express LTP. Rats that received either an injection of MK-886 before or after FPI demonstrated normal LTP. To verify that injuryinduced deficits in LTP reflect impairments in hippocampal-dependent spatial learning and memory, sham and FPI-injured animals treated with drug or vehicle were tested in a six arm radial arms water maze (RAWM) after FPI. FPI-injured rats showed marked deficits in the reversal task compared to sham rats and MK-886 given after injury significantly attenuated these cognitive impairments. Conclusions: The results indicate that leukotrienes contribute significantly to secondary injury and subsequent cognitive deficits after TBI. As FLAP inhibitors like MK-886 have proven to be safe in human clinical trials of asthma, there is a high translational potential for the use of FLAP inhibitors in human TBI patients. The authors have recently developed a proprietary FLAP inhibitor that has nanomolar potency and improved brain bioavailability compared to MK-886. They are exploring the efficacy of intra-nasal delivery of this compound. Intra-nasal FLAP inhibitors represent a novel anti-inflammatory approach for treating human TBI that is feasible for mitigating or preventing secondary brain injury following head trauma.

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Strength training associated with task-oriented training to enhance upper limb motor function in people with chronic ctroke

A novel anti-inflammatory approach to attenuate secondary injury and cognitive deficits after experimental TBI

Aline Pagnussat, Paulo Silva, Fabiane Antunes, Patrıćia Graef, & Fernanda Cechetti

Chelsea Corser-Jensen, Dayton Goodell, Ronald Freund, Predrag Serbedzija, & Kim Heidenreich

Universidade Federal de Cieˆncias de Sau´de de Porto Alegre, Porto Alegre, Brazil

University of Colorado Anschutz Medical Campus, Aurora, CO, USA

Objective To verify the effects of load exercises associated with a taskoriented training (TOT) programme in the recovery of upper limb function in individuals with chronic hemiparesis after stroke. Methods: A single-blind, randomized controlled study was conducted. Patients were included into two TOT groups: one that performed the task-oriented therapy without load (TOT group) and another that performed task-oriented therapy with personalized load resistance (TOT_ST group) over 6 weeks, in a total of 12 sessions. Main measures included The Upper Extremity Performance Test (TEMPA), shoulder flexor and handgrip strength, shoulder active range of motion (ROM), motor impairment (Fugl-Meyer scale) and muscle tone. Results: The TOT_ST group showed greater variation in scores relating to the total score of unilateral tasks and in the quality aspects of bilateral movements (p ¼ 0.04). The highest muscle force gain was reached by the TOT_ST group in shoulder flexors (p ¼ 0.001) and

Objectives: Neuroinflammation is a component of secondary injury following traumatic brain injury (TBI) that may persist beyond the acute phase. Leukotrienes are a family of potent inflammatory mediators produced by the oxidation of arachidonic acid. In the uninjured brain, leukotrienes are undetectable, but after trauma they are rapidly synthesized by a transcellular mechanism involving infiltrating neutrophils and endogenous brain cells. The goal of this project was to investigate the efficacy of MK-886, an inhibitor of 5lipoxygenase activating protein (FLAP), in blocking leukotriene production, secondary brain damage, synaptic dysfunction and cognitive impairments after TBI.

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handgrip muscles (p ¼ 0.05). Similarly, the active ROM (p ¼ 0.01) and Fugl-Meyer scores (p ¼ 0.001) were higher in the TOT_ST group than in the TOT group. Both groups showed improvement after training. Conclusion: Strength training was able to intensify the upper limb rehabilitation, as demonstrated by the superior scores achieved by the TOT_ST group in most of the evaluated parameters. Muscle strength training might be a pivotal element of the task-oriented rehabilitation programme of chronic patients with mild impairment after stroke.

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The effect of empathy and individual dispositions on resiliency among mothers of traumatic brain injury patients Brain Inj Downloaded from informahealthcare.com by RMIT University on 09/02/14 For personal use only.

Ezequiel Gleichgerrcht, & Alicia Lischinsky Institute of Cognitive Neurology (INECO), Buenos Aires, Argentina Introduction and objectives: An episode of traumatic brain injury (TBI) can alter a family’s wellbeing in many ways, from their finances to their dynamic and structure. Mothers of patients with TBI tend to take on a fundamental role in caring for their son/daughter, being essential for the success of patients’ rehabilitation. What makes, however, some mothers prone to being able to favourable overcome such profound adversities, while others experience marked deleterious effects on their health and wellbeing? The present study examined this question by looking at the effect of individual dispositions, including empathy, on resiliency capabilities of mothers of patients with TBI. Methods: This study surveyed 25 mothers of patients who had suffered TBI with measures of resiliency. It classified them into high (HR) and low (LR) resiliency groups according to whether their scores were above or below the group’s average, respectively. It then compared measures tapping on financial status, emotional and cognitive empathy, coping mechanisms, social cohesion, patient’s symptoms, caregiver burden, personality traits and mood symptoms. Results: HR and LR participants were comparable across most variables, but a specific effect of empathy was found on resiliency, such that HR had significantly higher cognitive empathy (p50.01) and empathic concern (p50.01) than LR mothers. Contrary to this, it was found that LR participants had significantly poorer skills (p50.01) in being able to regulate the self-oriented emotions derived from the affective experience of others (personal distress) and reported higher scores on mood symptoms (BDI-II, p50.001). Conclusions: Specific empathy sub-domains relating to the ability to put oneself in someone else’s mind (cognitive empathy) and to share their emotional experience (other-oriented emotional empathy) favour resiliency among mothers of patients with TBI. These abilities seem to protect mothers against depression. Research of this caliber has the potential to contribute to better, more specific, evidencebased programmes to grant families of patients with TBI with the cognitive tools to deal with dramatic acute contexts, thus leading to diminished stress and caregiver burnout.

0463

Coma recovery scale–revised: Within-day variability Maria Daniela Cortese1,3, Francesco Riganello1, Francesco Arcuri1, Maria Elena Pugliese1, Giuliano Dolce1, & Walter G. Sannita2

1

S.Anna Institute, Crotone, Italy, 2University of Genova, Department of Neuroscience, Ophthalmology and Genetics, Genova, Italy, 3 State University of New York, Department of Psychiatry, Stony Brook, NY, USA Objective: The diagnostic error between the Vegetative State (VS, also known as the Unresponsive Wakefulness Syndrome or UWS) and MCS reportedly still hovers up to 25–45%. Multiple testing in VS/UWS and MCS subjects has documented within-subject spontaneous fluctuations in the response incidence during the day. The purpose of this study was to analyse the spontaneous fluctuation of the CRS-r scores in VS/UWS and MCS subjects. Method: The CRS-r was administered 342 times (18 times per subject) to seven VS/UWS and in 12 MCS subjects for at least 1 year, undergoing intensive rehabilitation in 2-week periods intervalled by resting periods (1-week) over a total of 13 weeks. The CRS-r global and sub-scales scores at the morning and afternoon ratings and at the beginning and end of treatment were compared by means of the Wilcoxon’s test. The risk of misclassification of VS/UWS and MCS subjects to the other condition when relying only on a single (morning or afternoon) assessment was tested by the Odds Ratio and Risk Ratio in both subjects’ sub-groups and in the rehabilitation and resting conditions separately. Results: The CRS-r global, visual and auditory scores were higher in the morning than in the afternoon, with no sizeable differences between the treatment and resting periods or between sub-groups. The estimated overall risk for a VS subject of being misclassified as being in MCS at least once during the 13 weeks observation was 33% and 9.5% at the morning and afternoon assessments, respectively. Conclusion: Multiple CRS-r assessments at different times of the day and accurate monitoring over time are advisable. Diagnostic criteria taking also the individual variability into proper account could help reduce misdiagnosis of the patients.

0464

Socio-affective processing of negative facial expressions is impaired in juvenile delinquents with traumatic brain injury Miriam Cohen, & Huw Williams Exeter University, Devon, UK Objectives: To investigate the impact of traumatic brain injury (TBI) on expression recognition in delinquent adolescents. This study examined the effect of TBI dosage on overall accuracy, individual expressions, biases in incorrect selections and relation to criminal history. Methods: A between-group, cross-sectional design. Participants were 27 community-based vulnerable and delinquent adolescents, an average age of 16 years (18 male). They were grouped according to whether they incurred a substantial lifetime ‘dosage’ of TBI. Sixtythree per cent of all participants had had a history of TBI, whilst 41% of the TBI participants had had a history of severe injury (LOC greater than 60 minutes). Nine had two or more injuries. They were tested for facial expression recognition, had self-report measures of TBI, postconcussion symptoms (PCS) and screened for neuropsychological deficits. Criminal history also recorded. Results: There was a significant impairment in expression recognition accuracy in those with highest TBI dosage (41% of the sample) compared to mild and non-injured. These effects were not attributable to processing speed, concentration or IQ. Impairment was exaggerated for negative affect expressions and suggestive of perceptual bias towards fear. PCS symptoms were associated with dosage of TBI. Greater degree of injury (mild, moderate to severe) was associated with greater symptoms. Gender did not moderate effects.

686 Conclusions: This study provides evidence for socio-emotional impairment in delinquents with TBI. Such deficits may lead to problems in social-functioning in daily life. This study proposes a range of remedial strategies that may be offered to this group. This includes innovative technological methods for neurorehabilitation using face processing systems. Such initiatives may reduce offending behaviour.

0465

Sports-related concussion and diffusion tensor imaging findings in rugby players Stephanie Baker1, Huw Williams2, Dave Sharp3, Andrew Gardner4, Adrian Harris2, Adam Zeman2, & Jonathan Fulford2


1

Cardiff University, Cardiff, UK, 2Exeter University, Exeter, UK, Imperial College, London, UK, 4University of Newcastle, NSW, Australia

Brain Inj, 2014; 28(5–6): 517–878

Methods: A sample of male young offenders from a Young Offender Institute (n ¼ 98) were assessed for TBI, PCS (Rivermead PCS Scale), Aggression (Reactive–Proactive Scale) and Criminal histories. TBI reported by 73.5%, with 61.1% reporting a ‘knock out’. Results: Frequency of TBI was associated with significantly higher PCS scores. Loss of Consciousness (LOC) also linked to higher PCS symptoms. Examination of covariates—drug and alcohol use—did not modify these relationships. Frequency of TBIs was significantly related with all variables except pro-active aggression. Reactive aggression and PCS symptoms were highly significantly correlated. Conclusion: TBI leading to PCS is an important predictor of reactive aggression. This highlights the need for screening for TBI and ongoing symptoms in juvenile delinquents. Such issues may compromise functions and lead to greater aggression.

0467

Mild traumatic brain injury in the Go¨ttingen minipig using two unique injury devices

3

Objective: Diffusion tensor imaging (DTI) has been utilized as a method for identifying white matter structural abnormalities caused by mild traumatic brain injuries (mTBI) such as sports-related concussion (SRC). DTI abnormalities have been correlated with cognitive impairments. This study collected data from detailed injury records in elite contact sportsmen and undertook neurocognitive testing and DTI. This study aimed to identify changes in brain systems and cognition, linked to SRC history. Participants and methods: Eighteen elite rugby players were tested pre-season on a neuro-cognitive battery and computerized assessment of attention, memory, problem-solving and executive control. Retrospective data was collected on history of SRC including frequency (53 or 44) and severity (loss of consciousness). Participants underwent DTI scanning, collecting fractional anisotropy (FA) measures of the structural integrity of 34 white matter structures. Results: There was a significant relationship between SRC frequency and DTI FA in the right uncinate fasciculus, corpus callosum genu and left thalamus to superior frontal gyrus. Analysis found these areas did not correlate post-correction with the neuro-cognitive measures. Conclusions: A link with areas highlighted in inhibition networks and vulnerable to mTBI may support the notion that SRC has a role in impacting on inhibition networks. Future research would benefit from longitudinal analysis and inclusion of more subtle neuro-cognitive assessments. Use of DTI as a means of monitoring change in cumulative SRC is supported.

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Post-concussion symptoms after traumatic brain injury associated with reactive aggression in encarcerated youth who offend Hannah Meadham, Avril Mewse, Huw Williams, & Cris Burgess University of Exeter, Devon, UK Objectives: Young people with traumatic brain injury (TBI) are at risk of crime. This study aimed to explore the relationships between TBI, post-concussive symptoms, aggression and offending.

Elizabeth M. Fievisohn, Sujith V. Sajja, Pamela J. VandeVord, & Warren N. Hardy Virginia Tech-Wake Forest University, Center for Injury Biomechanics, Blacksburg, VA, USA Objectives: This study developed two new injury devices to study impact-induced traumatic brain injury (TBI) to gain a greater understanding of the underlying injury mechanisms. The injuries generated using these devices are being characterized for up to 24 hours post-injury using magnetic resonance spectroscopy (MRS) and immunohistochemistry (IHC) in an in vivo Go¨ttingen minipig model. Methods: Two repeatable injury devices are used to generate TBI. A rotational injury device induces injury similar to real-world scenarios (combined rotational and translational acceleration), while a translational injury device isolates the impact to one plane with minimal rotational motion. Both devices use gravity to impart energy to the minipig head, the skull of which is rigidly fixed to a platform on each device, while the rest of the body is tightly restrained. The animal/ platform complex undergoes a controlled/guided drop from various heights and is rapidly decelerated after contacting brass bumpers. Young adult female Go¨ttingen minipigs were chosen due to the gyrencephalic nature of their brains. Sham animals (n ¼ 2), rotational injury device animals (n ¼ 8) and translational injury device animals (n ¼ 6) were tested. MRS scans were taken prior to injury and 24 hours post-injury, at which point the brains were perfused and harvested for IHC. MRS quantifies metabolites within a 216 mm3 voxel placed in the genu of the corpus callosum. Metabolites of interest included glutamate (Glu), N-acetylaspartate (NAA), N-acetylaspartylglutamate (NAAG), glutamine (Gln) and the combination of Glu + Gln. IHC was performed on the genu using four antibodies; light neurofilament (LNF), heavy neurofilament (HNF), glial fibrillary acid protein (GFAP) and cleaved caspase-3. ImageJ was used to calculate integrated density for comparison between groups. Paired Student’s t-tests were used to compare baseline and 24-hour injury metabolite values and two-tailed Student’s t-tests were used to compare sham and 24 hour injury IHC integrated densities. Results: For the rotational injury device (930–3770 rad s2; 7–11 rad s1), there were significant increases in Glu + Gln, Glu/Gln, Glu/NAAG and Glu + Gln/NAAG 24 hours post-injury (p50.05) compared to baseline. There were significant increases in LNF and HNF (p50.05) between sham and injury animals. GFAP and cleaved caspase-3 were not significant between sham and injury animals. For the translational injury device (30–67 G), there were significant increases in glutamine 24 hours post-injury (p50.05). IHC analysis is pending, but trends suggest an increase in LNF and HNF post-injury. Conclusions: This study developed new injury devices to examine TBI mechanisms in a higher-order animal. The IHC and MRS data showed

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axonal and metabolic disruptions in the brain. Correlation of these data will facilitate interval MRS scanning during a subsequent longitudinal study of TBI development. Finally, preliminary data suggested different metabolic changes due to the separate injuries while displaying similar underlying axonal disruption.

0468

Use of donepezil as a memory enhancer for traumatic brain injury during acute neurological recovery Eduardo Lopez1, Ammar Abbasi2, Jaime Levine3, & Keith Cicerone4


1

Metropolitan Hospital Center, NewYork, NY, USA, 2Alliance Medical Group, Hazleton, PA, USA, 3NYU-Langone Medical Center, New York, NY, USA, 4JFK-Johnson Rehabilitation Institute, Edison ,NJ, USA

Objectives: To identify whether donepezil, an acetylocholinesterase inhibitor, improves cognitive function, as measured by the Functional Independence Measure (FIM) instrument, during the acute inpatient rehabilitation phase in the traumatic brain injury (TBI) population. Method: Retrospective chart review perfomed on 77 subjects admitted to an acute inpatient neurorehabilitation unit with a diagnosis of moderate-to-severe TBI. Patients underwent a structured acute inpatient physical and cogntive therapy programme of 4 week length of stay (LOS). Treatment preferences of the attending physiatrist dictated patients who initiated treatment with donepezil 5 milligrams daily (n ¼ 39) and were compared with a second group that did not receive donepezil treatment (n ¼ 38). Average treatment time was 13 days. Motor and cognitive function was evaluated on admission and on discharge using the FIM instrument. Results: There were no statistically significant differences between experimental and control groups with respect to discharge FIM motor scores (control ¼ 50.79, experimental ¼ 57.87): gain in FIM motor scores (control ¼ 27.08, experimental ¼ 32.41); discharge FIM cognitive scores (control ¼ 20.37, experimental ¼ 20.79); and gain in FIM cognitive scores (control ¼ 9.55, experimental ¼ 10.38). Conclusions: Use of donepezil in conjunction with formal functional and cognitive therapies, in an acute neurorehablitation setting, did not result in appreciable increases in cognitive or motor FIM scores when compared to formal therapies alone. It is the belief of the authors that the five items related to cognition in the FIM are not sufficient and do not have the inherent sensitivity to detect subtle improvement in memory which is the indication for using donepezil. The small sample size as well as the short duration of treatment on low dose donepezil may also have obscured any benefits from its use. Future controlled studies are needed to assess the effectiveness of donepezil as a pharmacological treatment for improving memory deficits during the acute phase of recovery after a TBI. Other measures of detecting subtle memory changes as well as neuropsychological assessment may enhance selection of patients with greater potential for memory improvements on donepezil during the early recovery process.

0469

Default mode network functional connectivity plasticity in severe acquired brain injury patients after recovery: A functional MRI study at rest Francesco de Pasquale, Chiara Falletta Caravasso, Paola Ciurli, Sheila Catani, Rita Formisano, & Umberto Sabatini IRCCS Santa Lucia Foundation, Rome, Italy Objective: In this work, the plasticity of Resting State Networks is investigated on a sample of 15 severe brain injury patients (GCS score 8) with fMRI in the post-acute stage. Methods: The sample group included 10 males and five females with a mean age of 33 years. At the time of evaluation the mean interval that had elapsed since injury was 6 months. Two separate MRI scans were acquired for every patient: one after admission to the post-acute rehabilitation ward, one after 3 months. Different connectivity measures were obtained over time and these were correlated with a set of neurological and neuropsychological clinical scores classified into three cognitive domains: short- and long-term memory, attentional and executive functions. In this way, connectivity measures could be related to the clinical recovery of the patients. Based on previous findings, this study performed seed-based functional connectivity focusing on two central hubs: the posterior cingulate cortex and the supplementary motor area belonging to the default mode and motor networks, respectively. Results: Interestingly, it was found that the default mode network (DMN) showed an increased strength of internal coupling. In particular, the intensity of local connections between the posterior cingulated cortex and left/right angular gyrus significantly increased. In addition, an important plasticity was observed in the spatial topography of the default mode network. In fact, while from the first scan the medial prefrontal regions were not significantly connected to the seed, at subsequent times (3 months) both the ventro and dorso/medial prefrontal cortex nodes enriched the network topography. This effect was specific for these nodes and such plasticity supports the hypothesis that the default mode network connectivity can be linked to the clinical recovery in severe acquired brain injury patients. In fact, the clinical outcomes revealed a significant improvement in the long-term memory and executive functions domains. Interestingly, at rest, the motor network topography showed increased internal connectivity, but the topography did not change over time. Conclusion: These results supports the central role played by the default mode network which is functionally associated to internal cognition and can be decomposed into distinct and functionally separated sub-systems such as the dorsal medial prefrontal cortex and the medial temporal lobe systems. In this study these subsystems show specific changes over time. Moreover, these results showing a link between the patient performance and the default mode connectivity support the hypothesized central role of this network for the cross-network integration at rest. In fact, since the default pays a central role of integration among different networks, an improvement within this network is directly reflected in an improvement of performance of tasks typically involving different systems underlying motor and attentional functions.

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0470

0471

Static and dynamic intrinsic connectivity following mild traumatic brain injury

Review of concussion guidelines for children and youth

1,2

1

1

Andrew Mayer , Josef Ling , Elena Allen , & Stefan Klimaj1 1

National Center for Injury Prevention and Control, CDC, Atlanta, USA

2

The Mind Research Network, Albuquerque, NM, USA, The University of New Mexico, Albuquerque, NM, USA


Juliet Haarbauer-Krupa, Michael Lionbarger, & Lisa McGuire

Introduction: Researchers are increasingly turning to measures of functional connectivity (fcMRI) to examine neuronal health following mild traumatic brain injury (mTBI). fcMRI is based on intrinsic neuronal activity that aliases to low-frequency fluctuations in the blood oxygen level dependent response. Work in healthy controls convincingly demonstrates that intrinsic connectivity networks (ICN) mirror the functional activation evoked across a variety of cognitive and sensorimotor tasks. Several recent studies have examined static fcMRI in semi-acute and chronically injured mTBI, primarily focusing on the default-mode network (DMN). Studies examining how dynamic connectivity (i.e. the shifting between various states) is affected by mTBI have yet to be conducted. Methods: Resting state data (5 minutes, eyes open and fixating on cross) were collected on 48 semi-acutely injured mTBI patients and matched controls (3T scanner). Patients met standard mTBI inclusion criteria and were scanned within 21 days of injury (14.0 days ± 5.3). A high-dimensional (n ¼ 100) independent component analysis (ICA) with rigorous post-processing examined how various metrics of static fcMRI (spatial maps, static connectivity and the ratio of low frequency to high frequency power) were affected by mTBI for DMN and subcortical ICN (16 ICN in total). A sliding window approach quantified fluctuations in identical networks over shorter scan intervals (dynamic fcMRI). Results: Patients reported more cognitive (p50.001), somatic (p50.001) and emotional (p50.001) complaints relative to HC. A significant difference between patients and HC on estimates of pre-morbid intelligence (p ¼ 0.005) also existed, despite educational matching. No other significant (p40.10) group differences were observed on a battery of neuropsychological tests. Eight patients were identified as likely exhibiting trauma-induced pathology on CT (4/36 mTBI patients) or anatomical (T1, T2 or SWI images) MRI (4/48 patients) scans. There were no differences in the degree of head motion across the two groups. However, estimates of frame-wise displacement and pre-morbid intelligence were used as covariates in static and dynamic fcMRI analyses. Preliminary results indicated no differences on spatial maps (DMN and sub-cortical) between HC and mTBI with appropriate false positive correction. Similarly, no differences in pair-wise static fcMRI or for low/high frequency power were observed. Finally, dynamic connectivity results were also negative for the DMN and sub-cortical ICN. However, several ICN showed fcMRI abnormalities at uncorrected levels (p50.005). The authors are currently determining whether these abnormalities are partially driven by clinical correlates (i.e. post-concussive symptoms). Discussion: Preliminary results do not suggest any abnormalities in static or dynamic fcMRI during semi-acute mTBI within the DMN and sub-cortical ICN when strict corrections for false positives are employed. Methodological differences (lower-dimensional ICA) and/ or differential clinical symptoms may explain discrepancies between current and previous results with static fcMRI.

Objectives: Identification and management of youth who sustain concussion in sports is rapidly evolving both in the US and international communities. In the US, legislation addressing identification and management of concussions among school-aged athletes has passed in 49 US states. As a result, many school systems and clinical programmes are devising practices for concussion identification and management. Many protocols are currently available; however, not all are evidenced-based, making it difficult to identify best practices. This presentation will describe the epidemiology of sports and recreation head injuries in the US, components of existing concussion legislation and a review of available guidelines related to concussion identification, management and post-injury effects for children and youth. Methods: A search was conducted in PubMED for concussion guidelines, review of clinical management practices and position or consensus statements published in English. Articles were reviewed for concussion definition, incidence, signs and symptoms, identification, types of assessment, removal from play, return-to-play, returnto-school and post-injury factors. Results: There is consistency across guidelines in their focus on concussion symptoms, removal from play for youth athletes with a suspected concussion and management by a healthcare professional. International Consensus Guidelines, such as those of McCrory et al., have been distributed to high school athletic groups, but little is known about the scope of dissemination and adherence to specific return-to-play or school protocols for younger children. Symptombased reporting measures, such as the Acute Concussion Evaluation (ACE), have been described in studies, but have not been validated across sites, in children or used in paediatric guidelines. Assessment measures such as computerized neurocognitive assessment or balance testing have also not been validated for children or consistently included in guidelines. Although study data on outcomes for children with traumatic brain injury (TBI), such as age and delayed effects of the injury, could inform recommendations, little information from such studies is considered in guidelines for return-to-play or school. Conclusion: Concussion identification, management and returnto-play and school are an evolving part of clinical practice for youth sports. Results from a review of existing guidelines indicate areas of consensus as well as gaps where consensus does not exist. Findings from outcome research about TBI in children provide information on injury effects at a young age that can inform guideline development. Further research to inform clinical practice for concussion management in youth sports is indicated. Findings can be used to inform research in the US and International Communities.

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DOI: 10.3109/02699052.2014.892379

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Is the Nociception Coma ScaleRevised a useful clinical tool for managing pain in patients with disorders of consciousness? Camille Chatelle1, Marie-Daniele De Val2, Antonio Catano3, Cristo Chaskis4, Pierrette Seeldrayers5, Steven Laureys6, Patrick Biston2, & Caroline Schnakers3


1

Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MD, USA, 2 Department of Intensive Care, 3Department of Rehabilitation, 4 Department of Neurosurgery, 5Department of Neurology, University Hospital of Charleroi, Charleroi, Belgium, 6Coma Science Group, Cyclotron Research Centre, University of Lie`ge, Lie`ge, Belgium, 7 Department of Psychology and Department of Neurosurgery, UCLA, Los Angeles, CA, USA Objectives: The Nociception Coma Scale-Revised (NCS-R) has recently been developed and validated for assessing nociception in patients with disorders of consciousness (DOC). However, this scale was validated using noxious experimental stimuli and has not yet been tested in a clinical setting. In this study, the objective was to assess the clinical interest of the NCS-R in the pain management of patients with DOC. Methods: Thirty-four patients with documented painful areas (e.g. due to fractures, decubitus ulcers or spasticity) were assessed during nursing care before and after the administration of an analgesic treatment of the best analgesic treatment according to each patient’s clinical status. In addition to the NCS-R, the Glasgow Coma Scale (GCS) was used before and during treatment in order to observe fluctuations in consciousness. Eleven patients were in a vegetative state or unresponsive wakefulness syndrome (VS/UWS; seven males; median age ¼ 63 years; range ¼ 22–90 years; 0–108 days post-injury (median ¼ 11 days); eight non-traumatic) and 23 were in a minimally conscious state (MCS; 16 males; median age ¼ 61 years, range ¼ 21– 93 years; 0–34 days post-injury (median ¼ 12 days), 14 non-traumatic). Eighteen of them had no analgesic treatment prior to the assessment, whereas the analgesic treatment has been revised in the other 15 patients. Results: An ANOVA was performed with repeated measures on the treatment (before vs during) and on the scales (NCS-R vs GCS) and with the level of consciousness (VS/UWS vs MCS) and the aetiology (traumatic vs non-traumatic) as covariates. A main effect of the treatment (F ¼ 16.7; p50.0001) as well as an interaction between the treatment and the scales (F ¼ 21.7; p50.0001) have been found. This study found no significant difference according to the level of consciousness or the aetiology. Post-hoc analyses using Wilcoxon signed-rank tests revealed that NCS-R total scores were statistically lower during treatment when compared to the scores obtained before treatment (p50.0001). On the contrary, no difference was found between the GCS total scores obtained before vs during treatment. Using Wilcoxon signed-rank tests, this study found that the motor sub-scores (p corr ¼ 0.006) and the facial expression subs-cores (p corr50.001) were lower during treatment than before treatment. Verbal sub-scores did not differ significantly before vs during treatment (p corr ¼ 0.08). Conclusion: According to these results, the NCS-R total scores but not the GCS total scores decreased during analgesic treatment in severely brain-injured patients with documented painful areas. The results suggest that the NCS-R is an interesting clinical tool in pain management when a balance is needed between reduced nociception/pain and preserved level of consciousness in patients with DOC.

0473

The influence of penetrating vs closed type of traumatic brain injury on long-term global outcome William Walker1, Jennifer Marwitz1, Stephanie Kolakowsky-Hayner2, & Tamara Bushnik3 1

Virginia Commonwealth University, Richmond, VA, USA, 2Santa Clara Valley Medical Center, San Jose, CA, USA, 3Rusk Rehabilitation, NYU Langone School of Medicine, New York, NY, USA

Objectives: Well-validated predictors of poor global outcome after TBI include advanced age, low education, unemployment, long duration of post-traumatic amnesia (PTA) or coma (LOC) and longer hospitalization. Type of TBI, penetrating vs closed, is also believed important. Higher rates of early mortality, medical and neurologic complications are reported after penetrating TBI as are worse headache density and high seizure rates. However, information is lacking on the effect TBI type has on global long-term outcome. A recent review determined that nearly all studies of prognostic factors within civilian samples either exclude or under-represent patients with penetrating injuries. This study sought to understand the influence of injury type on TBI outcome within the NIDDR-funded TBI Model Systems (TBIMS) whose very large cohort size facilitates examining low frequency conditions. It was hypothesized that penetrating TBI increases the risk of poorer long-term global outcome when adjusting for known risk factors. Methods: Study design was a prospective multi-centre cohort study with retrospective data abstraction. All participants: (1) presented to the TBIMS acute care hospital within 72 hours of injury; (2) received both acute medical and acute rehabilitation care; (3) sustained TBI with at least admission Glasgow Coma Scale (GCS) score513, LOC430 minutes, PTA424 hours or trauma-related intracranial abnormality on neuroimaging; and (4) age415 years. Penetrating TBI was defined by either gun-shot wound injury mechanism and/or skull fragments on imaging. The final sample with complete data sets was 4982 patients. Outcome measure was the Glasgow Outcome Scale (GOS) 2 years post-injury. Dead and vegetative categories due to very low counts were collapsed into severe disability. A multiple cumulative logistic regression model was built using significant predictors identified on preliminary bivariate analyses. Manual backwards selection (p50.05) was used to reduce the model and identify a parsimonious set of predictors for GOS. All two-way interactions were also considered. Results: Penetrating type TBI was 8.1% of the cohort. The final model identified the following predictors: injury type, age, sex, race/ ethnicity, pre-injury education level and employment, LOS and PTA duration. Injury type also had significant secondary interactions with employment and age. The odds of lower (worse) 2-year GOS were greater for individuals with penetrating TBI who were younger (45 or less) and employed pre-injury. A 20 year old individual employed preinjury is 2-times (95% CI ¼ 1.5, 2.8) more likely to have a lower GOS category; a 30 year old employed individual is 1.8-times (95% CI ¼ 1.4, 2.2) more likely. Conclusions: Global outcome 2 years after TBI is worse for penetrating compared to closed type, with the largest effect for younger persons employed pre-injury. Prognostication models and counselling should consider differing outcomes for type of TBI.

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Neurosensory sequelae of mild traumatic brain injury: The military experience Michael Hoffer1, Carey Balaban2, Colleen Perez1, Christopher Johnson1, Sara Murphy1, & Kim Gottshall1 Spatial Orientation Center, San Diego, CA, USA, 2University of Pittsburgh, Pittsburgh, PA, USA


1

Background: Mild traumatic brain injury (mTBI) has been called the signature injury of modern warfare. It is estimated that as many as 19% of all indivduals who have deployed to Southwest Asia have suffered mTBI. Moreover, mTBI associatd with blast exposure accounts for over 80% of all battlefield injuries. This centre has been studying the neurosensory effects of mTBI secondary to blast and blunt exposure for over 10 years. Objective: This presentation will describe the neurosensory sequelae of blast and blunt mTBI as a function of time since injury, intensity and type of injury mechanism and treatment received. In addition, it will examine the optimal diagnostic and best treatment strategies in this group of patients. Methods: To develop this data, a retrospective review of the patient population was combined with a series of prospective studies undertaken over time. Results: Neurosensory symptoms of mTBI including dizziness, hearing loss, cognitive difficulties, sleep distrubance and headache change as a funciton of time. Dizziness is the most common symptom at all time points in those without orthopeadic injuries. In those who suffered significant upper extremity or lower extremity injuries, hearing loss was the most common neurosensory sequela and a disproportionate reduction in other neurosensroy effects were obseverd. Standard treatment modalities were effective but significant modification had to be implemented to account for the number of injuries and unique patterns of deficits. Conclusioins: Neurosensory deficits are common after mTBI and may provide excellent objective markers of this disorder. Neurosensory disorders do not routingly normalize over time and must be treated. Understanding the symptom complex as a function of time, injury intesity and treatment effects is critical to understanding mTBI as a disorder and to treating and studying this important health risk.

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Mindfulness-based group therapy vs healthy living intervention: A pilot RCT intervention Esther Bay1, Roxanne Chan2, & Janet Larson1 University of Michigan, Ann Arbor MI, USA, 2Michigan State University, Lansing MI, USA

Brain Inj, 2014; 28(5–6): 517–878

psychosocial functioning after TBI and in persons with other neurological disorders. The overall objective of this pilot intervention study is to determine whether persons who sustained a mildto-moderate TBI between 3–24 months of enrolment, as identified by a treating neuropsychologist, and who are participating in outpatient rehabilitation therapies will benefit from a mindfulness-based meditation group or active complementary control programme by lowering chronic stress and depressive symptoms or improving psychosocial functioning. Methods: This two-arm randomized control pilot study will establish the difference in effectiveness of the two interventions, the acceptability of the group interventions and home practice, and begin to examine and determine whether the effects achieved at 8 weeks persist at 12 weeks from the initial training. It will use in-person and telephone-guided training led by experts over the 8 week group interventions and examine main study variable responses in relation to the intervention with linear mixed modelling for repeated measures. All outcomes measures (depressive symptoms, chronic stress and psychological functioning) will be collected at baseline, following the 8-week intervention and at 12 weeks (to determine beginning sustainability). In addition to randomization, each group will be stratified for brain injury symptoms, depressive symptoms and risk factors for poor recovery. Results: Forty-six persons were screened from two outpatient clinics. Twenty-four patients agreed to participate in the 8-week intervention, while 17 persons completed the study. Two persons never began the intervention because of health issues, two persons withdrew at week 3 for personal issues and three persons participated in active intervention but passively withdrew from the telephone follow-up portion and, therefore, did not complete T2 and T3 surveys (reasons were ‘too busy’, family death, illness). Preliminary data analysis indicates that patients were highly satisfied with both the healthy control class and the mindfulness class, but preferred ‘ive classes’ over telephone. Linear mixed modelling over time revealed that the mindfulness intervention group had greater improvement in scores on depression, stress and psychological functioning. Effect sizes look promising. Conclusion: An additional control and mindful group is planned for a final sample of 30. Acceptability of both interventions was present; attendance for live classes was good until stressful life events occurred (hospitalization, death, loss of job).

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Mild brain injury and repeated anaesthesia increase BDNF density in the rat hippocampus Jennifer Schrandt1, Alexander Alexandrovitch2, Jasbeer Dhawan1, Marta Nawrocky1, Esther Shohami2, Victoria Trembovelr2, & Anat Biegon1 1

Stony Brook University, Stony Brook, NY, USA, 2Hebrew University, Jerusalem, Israel

1

Problem: This study and the work of others have shown that TBIrelated stress is strongly associated with post-TBI depressive symptoms and that chronic stress mediates the relationship between depressive symptoms and post-injury psychosocial functioning. Further poor psychosocial functioning negatively impacts families and return-to-work and promotes disability. Research suggests that improving one’s psychosocial functioning and ability to interact emotionally and interpersonally is likely to reduce stress and depressive symptoms after TBI. Mindfulness-based group therapies have demonstrated the potential to effect stress, depression and

Approximately 75% of traumatic brain injuries in the US are classified as mild traumatic brain injuries (mTBIs) or concussions and yet the only diagnostic tool for mTBI is symptom-based, with memory deficits among the most commonly reported. The severity and persistence of mTBI symptoms appear to increase following repeated injuries. Unlike moderate and severe traumatic brain injury, mTBI does not cause gross morphological changes of the brain and cannot be detected by standard CT or MRI scans. Brain-derived neurotrophic factor (BDNF) is a secreted protein involved in neurogenesis, synaptogenesis and memory formation, which has been shown to increase in the aftermath of ischaemic brain injury. Using a rat model of mild TBI, this study sets out to examine the effect of single or multiple mTBIs on BDNF levels in the hippocampus. Thirty rats were randomized

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DOI: 10.3109/02699052.2014.892379

into four treatment groups: (1) Isoflurane anaesthesia followed by closed head injury (sCHI, aministered by weight drop onto the left anterior intact skull, n ¼ 10). (2) Anaesthesia and CHI repeated 3times within 1 week (mCHI, n ¼ 10). (3) Animals exposed to a single anaesthesia session (sSHam, n ¼ 5). (4) Rats exposed to anaesthesia 3-times at the same intervals as the mCHI group (mSham, n ¼ 5). Neurological function was scored 1 hour after each injury; when the neurological severity score is at its highest, and periodically over a 4week follow-up, during which time neurological symptom in individual rats declined in severity or disappeared completely. Rats were euthanized and their brains were sectioned for immunohistochemistry of BDNF. Signal density over the CA1, CA3 and dentate gyrus fields of the hippocampus was measured using ImageJ and results analysed by 2-way ANOVA. Pearson’s r was used to assess the correlation between BDNF levels and neurological score. BDNF staining intensity (inverted grey levels) was significantly increased after sCHI relative to sSHam throughout the hippocampus (mean ± SD: 156.6 ± 19.8 and 129.9 ± 10.1, respectively; p50.05). BDNF levels after mCHI (168.0 ± 28.9) were higher than after sCHI (p50.05) but not significantly different from the matched multiple anaesthesia controls (mSham, 166.3 ± 17.4), which were, however, significantly higher than sSham (p50.005). BDNF levels in the hippocampus of rats in all treatment groups were significantly and positively correlated with the neurological severity score 1 hour after the final injury (R ¼ 0.54, p ¼ 0.005). There was no correlation between BDNF density and the last neurological severity score measured before decapitation. A previously reported loss of BDNF in animals subjected to moderate/severe injury (weight drop from a height of 10 cm) was associated with neuronal loss and persistent neurological deficits. The present results suggest that mild CHI and multiple exposures to anaesthesia invoke an adaptive increase in BDNF levels, which is important for recovery of neurological function over time.

0477

Evaluating change in virtual reality adoption for brain injury rehabilitation: A knowledge translation study Stephanie Glegg1, Liisa Holsti2, Sue Stanton2, Steven Hanna3, Diana Velikonja3, Barbara Ansley4, Denise Sartor4, & Christine Brum4 1

Sunny Hill Health Centre for Children, Vancouver, BC, Canada, University of British Columbia, Vancouver, BC, Canada, 3McMaster University, Hamilton, ON, Canada, 4Hamilton Health Sciences, Hamilton, ON, Canada

2

Objectives: An estimated 1.4 million Canadians live with acquired brain injury. Moderate-to-severe injuries typically result in a range of functional impairments requiring rehabilitation. Virtual reality (VR) is a relatively new treatment approach being used increasingly for this purpose. A lack of research documents the barriers, facilitators and support needs of therapists expected to adopt the technology. The objectives of this research were (1) to apply theory to examine systematically the factors influencing therapists’ adoption of VR for brain injury rehabilitation and (2) to evaluate the impact of a multifaceted knowledge translation (KT) intervention at mediating these factors. The study hypotheses were that provision of the KT intervention would be associated with improvements in therapists’ perceived ease of use and self-efficacy in using the technology and an associated increase in their intentions to use VR. Methods: A single group pre-test–post-test design was used to evaluate changes in the determinants of VR adoption as proposed by an extended Theory of Planned Behaviour, following the KT

intervention. The intervention included interactive education, the provision of clinical protocols and technical and clinical support. Topics included an evidence synthesis, assessing virtual rehabilitation readiness, equipment set-up, selecting games, grading activities, goalsetting and measuring client outcomes. Thirty-seven physical, occupational and rehabilitation therapists recruited from one adult and one paediatric health centre completed the ADOPT-VR outcome measure. Related-samples Wilcoxon signed ranks tests were used to evaluate pre-test–post-test changes in the hypothesis variables. Descriptive statistics were used to analyse nominal data. Content analysis was used to interpret qualitative data, which included perceptions of barriers and facilitators of VR use, as well as feedback about the KT intervention. Results: Overall, therapists had positive attitudes and intentions to use VR. Increases in perceived ease of use and self-efficacy, but not in behavioural intention, were observed following KT. Among the perceived barriers identified at pre-test, a statistically significant decrease was observed for time to learn the technology, access to evidence and lack of education; these factors were targeted by the KT intervention. The most significant barriers to VR use were time and client factors, while a statistically significant reduction in lack of knowledge was reported by post-test. Primary facilitators consisted of peer influence and organizational-level supports. Additional support needs included identifying appropriate clients, goal-setting, treating complex clients, linking activity grading and outcome measurement to client goals, choosing between competing technologies and technical troubleshooting. Conclusions: This was the first study to quantitatively examine the social, personal, external and technology-specific barriers to VR use from the perspective of brain injury therapists. Barriers and facilitators identified can be targeted by management to support VR implementation. Therapist-identified knowledge and support needs have informed the refinement of KT strategies employed in ongoing research.

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The contribution of social cognition in the prediction of social participation difficulties following moderate-to-severe TBI in adolescents and young adults Katia Sirois1, Beátrice Tousignant2, Miriam H. Beauchamp3, Ame´lie M. Achim2, Gary Bedell4, Normand Boucher5, Elsa Massicotte2, Evelyn Vera2, & Philip L. Jackson2 1

Institut de Reádaptation en de´ficience Physique de Que´bec, Que´bec, Canada, 2Laval University, Que´bec, Canada, 3Montreal University, Montreal, Canada, 4Tufts University, Medford, MA, USA, 5Centre Interdisciplinaire de recherche en Reádaptation et inte´gration sociale, Que´bec, Canada Objectives: Research shows that moderate-to-severe TBI can lead to a decline in social function and social skills. In rehabilitation, one of the primary goals is to create intervention plans that optimize social participation (i.e. interactions between the patient and his environment, including school, home and community). Those plans are based, among other things, on results of standard cognitive assessments. However, a recent integrative framework for the development of social function highlights the role of social cognition, which refers to the mental functions through which social cues are processed during social interactions. Social cognition is rarely included in standard assessments and very few studies have directly assessed the link between social cognition and social participation in


692 TBI. The aim of the current study was, thus, to clarify the impact of TBI on social participation in adolescents and young adults by determining the contribution of social cognition components vs non-social cognitive functions in the prediction of reported social participation. Methods: Twenty-two adolescents and young adults who had sustained moderate-to-severe TBI (aged 12–21 years, M age ¼ 16.82, SD ¼ 2.28 years, 13 males) were compared to a matched group of 22 typically-developing peers (M age ¼ 16.77, SD ¼ 2.28 years, 11 males). Social participation was assessed using the Child and Adolescent Scale of Participation (CASP), which investigates participation in home, school and community activities. A social cognition test battery, an empathy questionnaire, a social comparison scale (SCS, measures almost self-esteem) and non-social cognitive tests (attention, working memory, executive functions, brief IQ) were also administered. Results: Wilcoxon test revealed that the TBI group had a significantly lower level of social participation compared to controls (p ¼ 0.003). Within TBI, group analysis revealed a significant relationship between CASP and social/non-social cognition predictors (p50.001), the multiple regression model accounting for 75% of variance (R2 ¼ 0.746) of social participation. Significant contributions were found for three predictors: 2nd order mentalizing, social comparison and planning/problem-solving abilities, whereas other social and nonsocial components were not significant. Semi-partial correlations revealed that planning/problem-solving abilities had the greatest contribution to CASP variation (32%), followed by mentalizing (24.6%) and by social comparison (12.6%). Conclusions: The results confirm the impact of TBI on social participation and suggest that, in addition to executive abilities, the ability to infer the mental states of others in a given situation can predict a large part of social participation. Comparing themselves to others in a negative way, negative social comparisons to others seem to predict social difficulties in TBI participants. Social cognition and comparison should be more systemically considered in neuropsychological assessments, because it might better target those individuals who are at most risk of encountering social participation difficulties.

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Influence of APOE genotype and APOE promoters A-491T and G-219T in the rehabilitation of patients with TBI after emergence from post-traumatic amnesia Angel Martıńez Nogueras, Raquel Balmaseda, Myrtha O’Valle, Ana Villalba, Gracia Martıńez Crespo, Maria Dolores Navarro, Carmen Garcıá-Bla´zquez, Desiree Amoros, Enrique Noe, & Joan Ferri Hospital NISA Sevilla Aljarafe, Sevilla, Spain Introduction: The possession of an APOE e4 allele could negatively influence the trajectory of recovery after traumatic brain injury (TBI) . Moreover, it could influence both APOE "4 qualitative and quantitative aspects. Objective: To determine if the APOE genotype and the A-491T and G-219T polymorphisms from APOE’s promoting area influence the trajectory of recovery from moderate–severe TBI patients participating in a multidisciplinary rehabilitation programme. Participants and methods: Seventy-two TBI patients, 21 carriers of the APOE "4 ("4+) and 51 non-carriers ("4). The Differential Outcome Scale (DOS) and US FIM + FAM were used as measuring instruments, both applied at three different times, after emergence from PTA

Brain Inj, 2014; 28(5–6): 517–878

(post-traumatic amnesia), 6 months and 1 year after emergence from PTA. Results: An ANOVA of repeated measures revealed a significant time effect in all the measures made in the comparisons with DOS scale (p50.01) and FIM + FAM (p50.01). A significant group effect was revealed with "4+ vs "4- groups in DOS’ total score (p50.05) and in its Cognitive (p50.01) and Behavioural sub-scales (p50.01) and FIM + FAM (p50.05). When including promoters, using APOE "4/ A-491T haplotype a significant group effect in DOS Cognitive sub-scale (p50.05) was found, a post-hoc comparison by Bonferroni, among the group factor’s levels, showed that the greatest differences of A-491T promoter occur within the group 491AA+, among carriers and non-carriers of "4 allele in a DOS Cognitive measure (p50.05). With APOE "4/G-219T haplotype, a significant group effect was found in the DOS total score (p50.01) and Neurological (p50.05), Cognitive (p50.05) and Behavioural sub-scales (p50.05) and FIM + FAM (p50.05), a post-hoc comparison by Bonferroni, among the group factor’s levels showed that the maximum difference for G-219T promoter occurs within the group 219TT + among carriers and noncarriers of allele "4 DOS Neurological (p50.05), DOS Cognitive (p50.05), DOS Behavioural (p ¼ 0.06), DOS TOTAL (p50.01) and FIM + FAM (p ¼ 0.07). No significant group-by-time interaction was detected for any of the measures. Conclusions: Both groups improve with the treatment in a similar way. Although APOE "4 carriers begin rehabilitation at a more impaired level, they are able to benefit from the treatment as non-carriers do. Furthermore, 491AA and 219TT promoters are a significant factor of influence, but only when associated with "4, not independently.

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Predicting cognitive function in veterans with TBI and multiple health complaints Jennifer Kong1, Tong Sheng1,2, Keith Main1, Lisa Kinoshita1, Jennifer Kaci Fairchild1, John Wesson Ashford1, Peter Bayley1, Linda Isaac1, & Maheen Adamson1 1

War Related Illness & Injury Study Center, VA Palo Alto Health Care System, Palo Alto, CA, USA, 2Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA Objectives: Patients with traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD) show cognitive impairments. Veterans with TBI and PTSD evaluated at the War Related Illness and Injury Study Center, California (WRIISC CA) are also frequently diagnosed with multiple health complaints, including gastrointestinal (GI) and pulmonary disorders that may also have an impact on cognition. This study assessed the extent to which health factors related to trauma and somatic problems predicted cognitive performance. Methods: Sixty-seven Veterans (61 males, mean age (years ± SD) ¼ 48.1 ± 11.6; WTAR IQ (IQ ± SD) ¼ 104.9 ± 9.7) were evaluated. PTSD was assessed using the Clinician-Administered PTSD Scale. TBI severity was diagnosed by a neurologist using self-reported Loss of Consciousness scores (mild TBI, n ¼ 38 (57%), moderate TBI, n ¼ 8 (12%)). Other health complaints, including gastrointestinal (GI) and pulmonary problems, were obtained from comprehensive physical health exams. A battery of cognitive tests was used: pre-morbid functioning (WTAR); attention and concentration (WAIS IV Digit Span Forward); working memory (WAIS IV Digit Span Backward and Sequencing); and executive function (Trail Making B). Two multiple regression models (trauma and somatic) were analysed separately to predict cognitive performance.

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DOI: 10.3109/02699052.2014.892379

Results: The trauma model (TBI, PTSD, age, WTAR IQ) predicted working memory performance (adj-R2 ¼ 0.126, F ¼ 3.382, p50.01), with WTAR IQ being the strongest predictor. The somatic model (GI, pulmonary problems, WTAR IQ) also predicted working memory performance (adj-R2 ¼ 0.149, F ¼ 3.907, p50.01), with WTAR IQ as the strongest predictor. This somatic model also predicted performance in attention and concentration (adj-R2 ¼ 0.137, F ¼ 3.625, p50.01), with WTAR IQ and GI complaints as the best predictors. Neither models predicted executive functioning as measured by Trail Making B. Conclusions: Both the trauma and somatic models predicted working memory performance, while only the somatic model predicted performance in attention and concentration. However, WTAR IQ was the strongest predictor of working memory and attention and concentration, while mental and physical health factors had little influence. These findings suggest (1) pre-morbid intelligence may function as a protective factor against injury-/illness-related deficits in attention and concentration and working memory and (2) traumarelated factors might be related to other cognitive components that were not assessed in the current investigation (e.g. affect regulation, decision-making). Taken together, these findings shed light on the robustness of pre-morbid intelligence in predicting cognitive performance, even in the presence of complex health problems. These findings have important implications for evaluation of cognitive performance in Veterans with multiple health complaints.

employed. Additional variables influencing risk of death included calendar year of injury, injury aetiology, discharge disposition, discharge Functional Independence (FIM) motor scale score and discharge Disability Rating Scale (DRS) score. Risk of death was increased 19% for each advancing calendar year of injury; 36% for individuals injured from falls as compared to those with motor vehicle accidents; 18% for those discharged to an institution as compared to home; and 7% for every one point increase in DRS score. Risk of death was lowered 1% for every 1 point increase in FIM motor score. Individuals with TBI were 50-times more likely to die of seizures; 10-times more likely to die of accidental poisoning, 9-times more likely to die of sepsis; 6-times more likely to die of aspiration pneumonia, 5-times more likely to die of a fall or homicide, 4-times more likely to die of pneumonia or all external causes of injury combined, 3-times more likely to die of a vehicular crash, 2-times more likely to die of suicide, all respiratory conditions combined, mental/behavioural conditions or nervous system conditions and 1.4-times more likely to die of circulatory conditions, compared to individuals in the general population of similar age, gender and race. Conclusion: There is an increased risk of death after TBI requiring inpatient rehabilitation, with risk factors and causes of death that may be amenable to intervention.

0482 0481

Life expectancy following inpatient rehabilitation for traumatic brain injury in the US Cynthia Harrison-Felix1, Christopher Pretz1, Flora M. Hammond2, Jeffrey Cuthbert1, Jeneita Bell3, John Corrigan4, A. Cate Miller5, & Juliet Haarbauer-Krupa3 1

2

Craig Hospital, Englewood, CO, USA, Indiana University School of Medicine, Indianapolis, IN, USA, 3Centers for Disease Control, National Center for Injury Prevention and Control, Atlanta, GA, USA, 4 Ohio State University, Columbus, OH, USA, 5National Institute on Disability and Rehabilitation Research, US Department of Education, Washington DC, USA Objectives: To characterize life expectancy, causes and risk factors of mortality after traumatic brain injury (TBI). Methods: The TBI Model Systems (MS) National Database (NDB) was weighted to represent individuals aged 16 years and older completing inpatient rehabilitation with TBI in the US between 2001–2010. Analyses included Standardized Mortality Ratios (SMRs), Cox regression and life expectancy. The US mortality rates by cause of death, age, sex and race for 2005 (for SMRs) and 2010 (for life expectancy) were used for comparison purposes. Results: In total, 1325 deaths occurred in the weighted cohort of 6913 individuals during the study period. Individuals with TBI were 2.23times more likely to die as individuals of comparable age, sex and race in the general population, with a reduced average life expectancy of 9 years. Socio-demographic variables that influenced risk of death included age, sex, marital status and education. The risk of death was increased 3% for each year of advancing age at injury and 27% for those divorced, widowed or separated compared to those married. The risk of death was lowered 53% for females as compared to males; 24% for those with a bachelor’s degree as compared to less than high school education; and also for those competitively employed as compared to those not competitively

Utilizing serial neuropsychological assessment to evaluate recovery from TBI: Acute to 2 years post-injury John DenBoer The Nicholls Group, Scottsdale, AZ, USA Objective: The purpose of this study was to evaluate the effectiveness of utilizing serial neuropsychological evaluations to help assess and inform patient’s recovery from TBI. It was hypothesized that the inclusion of neuropsychological evaluation at important time points in the patient’s recovery (i.e. 10 days postinjury, 1 month, 3 months, 6 months, 1 year and 2 years post-injury) would greatly aid clinical-decision making (particularly in the area of prognosis). Methods: Participants were 264 patients with diagnosed TBI. Patients were administered a fixed battery of standard neuropsychological test measures at the following uniform time points: 10 days post-injury, 1 month, 3 months, 6 months, 1 year and 2 years postinjury. Recovery from TBI was measured using reliable change index (RCI) analysis. Neuropsychological evaluation results were combined with neuroimaging results at multiple time points, whenever available. Results: Researchers found that the use of neuropsychological assessment measures at important time points in TBI recovery greatly aided diagnostic decision-making. Neuropsychological evaluation was a significant and positive factor in guiding treatment interventions (e.g. speech therapy). Although a positive neuropsychological trajectory was found throughout the 2-year period for the majority of patients, the most significant clinical change was found to be between 10 days and 1 month and 1 month and 3 months. Conclusions: The results of this study provide the first comprehensive depiction of assessment of longitudinal TBI recovery utilizing serial neuropsychological evaluation. Results underscore the utility of neuropsychological assessment during TBI recovery and emphasize the need for earlier neuropsychological intervention during recovery from TBI.

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Detecting lesions following traumatic brain injury using susceptibility weighted imaging: A comparison with FLAIR and correlation with clinical outcome Gershon Spitz1, Jerome Maller1, Amanda Ng2, Richard O’Sullivan3, Nicholas Ferris2, & Jennie Ponsford4 School of Psychology and Psychiatry, 2Monash Biomedical Imaging, Monash University, Melbourne, Victoria, Australia, 3Healthcare Imaging Services, Epworth Hospital, Melbourne, Victoria, Australia, 4 Central Clinical School, Monash University, Melbourne, Victoria, Australia Brain Inj Downloaded from informahealthcare.com by RMIT University on 09/02/14 For personal use only.

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Objectives: The development and utilization of newer neuroimaging modalities provides the capability to more accurately detect the extent of pathology following TBI. The current study examined the ability of susceptibility-weighted imaging (SWI) to detect lesions following TBI and the relationship to subsequent clinical outcome. The performance of SWI was compared to that of fluid-attenuated inversion recovery (FLAIR). Methods: This study comprised 79 individuals with mild-to-severe TBI, 38 of whom completed neuropsychological tests of attention, working memory, processing speed, memory and executive functions. Results: SWI was found to quantify a greater lesion volume over the entire brain, specifically in frontal, central, limbic, subcortical grey and parietal brain regions, than did FLAIR. Moreover, SWI was able to identify TBI-related lesions in almost a third of patients for whom FLAIR was unable to detect any lesions. Greater overall SWI volume, as well as frontal SWI volume, was found to relate to the severity of TBI. Conversely, no association was found between FLAIR lesion volume and injury severity. In addition, there was some evidence that higher lesion volume, for both SWI and FLAIR, were associated with poorer memory and processing speed impairment. Conclusions: This study suggests that SWI may provide additional sensitivity in the detection of lesions following TBI. Consequently, this imaging sequence may provide a more accurate representation of the severity of individuals’ injuries and their subsequent neuropsychological outcomes.

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Prediction of long-term mortality in adults with traumatic brain injury (TBI) using age, sex, walking and feeding skills Jordan Brooks1, David Strauss1, Robert Shavelle1, Flora Hammond2, & Cynthia Harrison-Felix3 Life Expectancy Project, San Francisco, CA, USA, 2Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Indianapolis, IN, USA, 3Craig Hospital & Department of Physical Medicine and Rehabilitation, University of Colorado at Denver, Denver, CO, USA

Brain Inj, 2014; 28(5–6): 517–878

Objectives: To assess the validity of prognostic models for long-term mortality in adults with TBI using two independent study populations and to investigate whether mortality rates and ratios have changed over the last two decades. Methods: Two cohorts of long-term survivors of TBI were considered. The first comprised participants in the US National Institute on Disability and Rehabilitation Research TBI Model Systems (TBIMS) national database who were injured in the years 1988–2010, had been discharged from inpatient rehabilitation and who provided follow-up information 1 year or later after injury. Walking and feeding skills were classified using the Functional Independence Measure. The second cohort included clients of the California Department of Developmental Services (CADDS) during years 1988–2010, who had an indication of TBI (ICD-9 codes 800–804 or 850–854) or were involved in a motor vehicle accident that led to significant cognitive disabilities. For these individuals, walking and feeding skills were classified using the Client Development Evaluation Report. Regression models for survival data with time-dependent covariates were fit on each database independently. Covariates included age, sex, walking and feeding skills and calendar year. Predictive accuracy was assessed using two-sample cross-validation. The model fitted to the CADDS data was used to predict mortality for persons in the TBIMS; and vice versa. This study computed the ratio of the observed number of deaths to the number of deaths expected under each model. Statistical inference was based on the assumption that the observed death counts followed a Poisson distribution. Results: The CADDS cohort included 5352 persons, of whom 602 died during the study period. These individuals contributed 55 621 personyears of follow-up. The TBIMS cohort comprised 7228 persons, of whom 537 died. These individuals contributed 32 505 person-years of follow-up. Current age, sex, walking and feeding skills were significant predictors of long-term mortality rates (all p50.0001 both databases). Calendar year was not significantly associated with mortality rates (p40.05 both databases). The mortality ratio between persons with TBI and the US general population increased over the study period (p50.05 both databases). The CADDS-fitted model predicted 534 deaths for persons in the TBIMS database, for an observed-toexpected ratio of 1.01 (95% CI ¼ 0.92–1.10). The TBIMS-fitted model predicted a total of 575 deaths for persons in the CADDS database, for an observed-to-expected ratio of 1.05 (95% CI ¼ 0.96–1.13). Conclusions: The close agreement between predicted and observed mortality suggests that these models may be generally applicable to persons from other populations with moderate-to-severe TBI. Because there have been no significant time trends in long-term mortality rates, the prognostic models may remain valid over the next several decades. The increase in the mortality ratio contradicts speculation that life expectancy in TBI has improved along with that of the general population.

0485

Fatigue and sleep disturbances following paediatric traumatic brain injury: A systematic review of the literature Charlotte Gagner1, France Laine´1, & Miriam H. Beauchamp1,2 1

University of Montreal, Montreal, Canada, 2Sainte-Justine Hospital Research Center, Montreal, Canada

1

Objectives: Sleep problems following traumatic brain injury (TBI) is a commonly reported symptom and can persist several years postinjury. The adult literature covering this topic is exhaustive; numerous robust studies using objective measures of sleep and advanced methodologies support the presence of sleep disturbances post-TBI.

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DOI: 10.3109/02699052.2014.892379

However, despite being the leading cause of morbidity and mortality in children and adolescents, relatively few studies exist investigating sleep problems after paediatric TBI and methodologies differ substantially between studies. The aim of the present project was to provide a systematic review of the literature concerning fatigue and sleep disturbances following paediatric TBI. Methods: A systematic literature search in the PsycINFO, Medline, CINAHL and Web of science databases was performed. Terms and keywords pertaining to TBI, children/adolescents and sleep were included in the search. Of the 361 articles identified by the search, 49 studies met the inclusion criteria, which included all severity levels of closed head injury. Results: According to the results of the literature search, sleep disorders and fatigue are common symptoms following paediatric TBI, regardless of the severity of the injury. However, in mild TBI, sleep disorders seem less prevalent in children and adolescents than in adults. The methodologies used in the studies reported varied widely and were less robust than in the adult literature, which could explain the divergence in the conclusions reported. The most commonly used methods for assessing sleep disturbances in the paediatric TBI population are semi-structured interviews and questionnaires completed by parents. These methods are subjective and can lead to several biases, especially when parents are the primary responders and have concerns about the medical condition of their child. The use of objective methods such as actigraphy and polysomnography was relatively rare. Conclusions: The results of the studies analysed were mostly consistent with the presence of sleep disorders and fatigue after paediatric TBI. The instruments used to measure sleep varied widely across studies and were mostly subjective. The results are discussed in the broader context of outcomes after childhood TBI. The use of more objective measures such as polysomnography and actigraphy could allow for a better understanding of the impacts of TBI on the quality of children’s sleep.

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Exploring the role of potential mediators in the association between concussions and laterlife depression in retired professional rugby union players John Sullivan1, Danielle Salmon2, Andrew Gray3, Phil Handcock2, & Paul McCrory4 1

Centre for Health, Activity and Rehabilitation Research, 2School of Physical Education, Sports and Exercise Sciences, 3Department of Preventive and Social Medicine, University of Otago, Dunedin, New Zealand, 4The Florey Institure of Neuroscience and Mental Health, University of Melbourne, Melbourne, Australia Introduction: There is an emerging literature describing the association between sportspersons with a history of concussions and their behavioural, cognitive and psychiatric health in the years following their retirement. Studies have generally focused on retired American football players. Rugby union is a collision sport played in over 100 countries. Participation often results in concussions, but little is known about the consequences of these concussions. The purpose of this study was to document the players’ concussion history, current health status and various lifestyle factors with the goal of exploring the role of lifestyle factors in mediating the association between concussion and depression in later-life. Methods: Data on their playing career, concussion experiences, physical and mental health and socio-demographics were collected via an on-line survey sent to rugby player associations of major

rugby union playing countries including; New Zealand, Australia, England and Ireland, with 255 players responding and 184 meeting the study criteria. Unadjusted logistic regression was used to model associations between reporting depression and potential confounders (age, country), potential exposures (including ever being concussed, number of concussions, multiple concussions and being ‘knocked-out’) and potential mediators (current pain, stiffness (a measure of joint health), quality-of-life, comorbidities, employment and current activity). Potential mediators, associated with both the exposure and outcome, were explored to see how they might affect any associations between concussion and depression. Results: The mean (SD) age of the male respondents was 37.5 (5.2), years played 8.7 (3.7) and current BMI 29.6 (2.8). Depression had been experienced by over a third (n ¼ 57, 37%), with 14 diagnosed (9%), 17 treated (11%) and 10 currently depressed (6%). Most (n ¼ 159, 90%) had experienced at least one concussion during their playing career. A large percentage (n ¼ 134, 85%) had continued to play despite being concussed and over a quarter (n ¼ 43, 27%) played or practiced with symptoms present. Close to half (n ¼ 71, 41%) reported having experienced multiple concussions in a single season. Nearly twothirds reported that the longest duration of symptoms exceeded a day (n ¼ 100, 63%). Results from logistic regression models showed associations between the number of concussions, multiple concussions and symptom duration and depression. Of potential mediators, only stiffness measures were associated with both exposure and outcome. Only multiple concussions remained statistically significantly associated with depression when adjusting for age and association and including worst stiffness as a non-statistically significant mediator (OR slightly attenuated from 2.45, p ¼ 0.012– 2.05, p ¼ 0.050). Discussion: Concussion is common among high-level rugby players and rates of players continuing to play and returning to play with symptoms were worryingly high. There was no evidence that any of the effects of concussion were mediated by lifestyle or current health variables, suggesting that effects of concussion on depression may be directly neurological.

0487

Clinical and electroencephalographic markers of dopaminergic and cholinergic deficiency in patients after severe TBI Helen V. Sharova1, Marina V. Chelyapina1, & Oleg S. Zaytsev2 1

Institute of Higher Nervous Activity and Neurophysiology of the Russian Academy of Science, Moscow, Russia, 2Institute of Neurosurgery, n.a Burdenko N.N. of Russian Academy of Medicine, Moscow, Russia Background: Neurochemical systems suffer defeat as the direct anatomical structures containing cholinergic and dopaminergic neurons and in the course of secondary oedema and hypoxia—due to the high sensitivity of these neurons to hypoxia after TBI. The authors show the relationship status of these systems with clinical outcome and TBI. Objectives: The objectives of the study were to: (1) identify patients with clinical signs of dopaminergic and cholinergic deficiency in the sample observations after TBI; (2) an analysis of the dynamics of clinical symptoms identified in the ruling consciousness after TBI; and (3) study of the peculiarities of EEG and its dynamics in groups with clinical observations signs of dopaminergic and cholinergic deficiency.


696 Materials and methods: Ninety-eight patients were studied (60 men, 38 women) after TBI. The observation period was from 30–495 days. In 35 of the clinical signs of dopaminergic deficiency (DD) in the form of increased muscular tone of extrapyramidal type, resting tremor, hypersalivation, greasiness of the skin. Seventeen patients from this group, along with the standard therapy, received dofaminomimetic therapy. In 37 people were clinical signs of cholinergic deficiency (ChD) in the form of reduced muscle tone, dryness of skin, tachycardia, disorders of eye movement. Among them, 18 patients in the course of treatment received cholinomimetic therapy. A dynamic assessment of the state of consciousness and neurological status was spent with specialized scales. EEG study included a 19-channel recording, visual and spectral-coherent analysis. Results: It is shown that the syndrome is more common in DD for the early stages of mental recovery and ChD syndrome—for higher levels of mental recovery. Clinical manifestations of the syndrome DD accompany changes in the EEG in the form of increasing the severity of the synchronized beta frequency of 13–14 Hz activity was significantly enhanced in the frontal and anterior temporal areas, as well as the abnormal increase right hemisphere of coherence of theta and beta activity. DD regression syndrome is accompanied by increased frequency of beta-EEG activity (13–16 Hz), but the persistent abnormal enhancement of right-hemisphere of coherence, especially in the occipital-temporal areas. ChD syndrome accompanied by slowing and asymmetry of EEG alpha activity. ChD regression syndrome accompanied by an increase of regularity, capacity and frequency of alpha activity (from 7–8 to 9–10 Hz), but along with persistent pathological increase of coherence in the left hemisphere.

0488

The Northwick Park Therapy Dependency Assessment (NPTDA) scale: A psychometric analysis from a large multicentre dataset Lynne Turner-Stokes1, Roxana Alexandrescu1, Keith Sephton2, Heather Williams2, & Richard J. Siegert3 1

School of Medicine, King’s College London, London, UK, 2Northwick Park Hospital, Middlesex, UK, 3School of Public Health & Psychosocial Studies and School of Rehabilitation & Occupational Studies, University of Technology, Auckland, New Zealand Objectives: The NPTDA is a measure of therapy intervention that is designed to record the amount and type of therapy inputs delivered by a multidisciplinary team in specialist neurorehabilitation settings. This study examined the internal reliability, construct validity and responsiveness of the scale. Methods: A cohort of 2505 neurorehabilitation inpatients submitted to the UK Rehabilitation Outcomes Collaborative database. Coefficient Cronbach’s Alpha was used to assess internal reliability. This study randomly split the sample in two equal parts for exploratory and confirmatory factor analysis (FA) to assess construct validity. NPTDA scores at admission and discharge were then compared to examine responsiveness within each factor. The authors did not necessarily expect large changes in the overall level of therapy inputs, but hypothesized that there may be differences in the type of therapy activities as the programme progressed from admission to discharge Results: For the full 22-item NPTDA scale the Cronbach’s Alpha was 0.74. Based on the Gorsuch’s criterion, the exploratory FA resulted in a

Brain Inj, 2014; 28(5–6): 517–878

model of four latent factors (‘physical’, ‘psychosocial’, ‘discharge planning’ and ‘activities’) that accounted for 43% of variance. More than half of the item loadings were 0.5 and above. The model was further confirmed by the confirmatory FA. The final model had a good fit: root-mean-square error of approximation of 0.069, comparative fit index/Tucker-Lewis index of 0.739/0.701 and the goodness of fit index of 0.909. There was a small change in NPTDA total score between admission and discharge which was statistically, but not necessarily clinically significant. However, differential changes within the four domains demonstrated a change in the type of therapy activities as the programme progressed. The scores for the first three fell during the admission—the mean change (95% CI, p value) was 2.73 (2.99, 2.46, 50.0001) for ‘physical’, 0.18 (0.34, 0.02, 0.028) for ‘psychosocial’ and 0.22 (0.35, 0.09, 0.001) for ‘activities’, whilst the score for ‘discharge planning’ rose towards the end of the programme to 2.54 (2.35, 2.72, 50.0001). Conclusions: The NPTDA has acceptable internal reliability and good construct validity for measuring multidisciplinary therapy interventions in neurorehabilitation. It is responsive to change during neurorehabilitation between admission and discharge, reflecting an expected increase in therapy dependency needs in the domain of ‘discharge planning’ and a decrease in the other domains of direct patient care, which resonate with clinical experience. Further studies should explore the potential of the scale to assess therapy interventions within different rehabilitation populations.

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Validation of mechanism-based MRI classification of traumatic brainstem injury John Scotter, Hani Marcus, & Mark Wilson The Traumatic Brain Injury Centre, Department of Neurotrauma, St. Mary’s Hospital, Imperial College, London, UK Objectives: Although CT remains the gold standard investigation for acute head injury, it is less effective at determining posterior fossa injuries. Recently, a mechanism-based MRI classification of traumatic brainstem injuries has been described and potential associations with outcomes reported. The aim of this study was to validate this classification. Methods: A retrospective case note review was performed of all patients admitted to a major trauma centre over the last 2 years. This study included all patients who underwent an MRI scan within 2 weeks of admission that demonstrated brainstem injury. Brainstem injury was classified independently by two raters (HJM and MW) into three patterns: (1) Secondary to supratentorial herniation, (2) Severe diffuse brain injury and (3) Isolated brainstem injury. Outcome was assessed at 6 months using the Glasgow Outcome Scale (GOS). Results: In all, nine patients were included in the study. The median age was 41 years (range ¼ 17–68 years), the male:female ratio 4:5 and the median GCS on presentation was 4 (range ¼ 3–9). The median time from admission to MRI scan was 7 days (range ¼ 1–15 days). Cohen’s kappa coefficient was 0.231. At follow-up six patients had died and two patients were severely disabled. One patient was lost to follow-up. Conclusions: Poor inter-rater agreement may limit the use of this classification of traumatic brainstem injury. Nonetheless, brainstem injury either secondary to supratentorial herniation or severe diffuse brain injury was associated with a poor outcome, supporting the use of MRI for prognostication.

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DOI: 10.3109/02699052.2014.892379

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The relationship between subjective quality-of-life measures with an objective assessment of functional competencies and an objective outcome rating scale in persons with traumatic brain injury Mark Holloway1,2 Head First, Kent, UK, 2Sussex University, Brighton, UK


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Primary objective: To ascertain correlations between objectively-rated functional competency, an objectively-rated outcome measure and subjective quality-of-life ratings. Methods: A convenience sample of persons with severe TBI were administered the Glasgow Outcome Score Extended (GOSE), the Quality-of-Life after Brain Injury (QOLIBRI) and the Adaptive Behaviour and Community Competency Scale (ABCCS). Data obtained were entered into the SPSS (19) statistical package. Pearson’s correlational analyses were performed between the QOLIBRI scores and the ABCCS and are due to be performed with the GOSE data shortly. Qualitative information was also sought from both the interviewer and respondent regarding the completion of the QOLIBRI. Results: Results so far indicate a negative correlation is reported between subjective quality-of-life (QOLIBRI) and the objective measure of reduced insight (ABCCS). This correlation is not found to be evenly distributed across the domains identified by the QOLIBRI. In particular, the negative correlation is noted to be found (and found more powerfully) in the domains/questions that are of a more abstract nature and those that ask the respondents to selfrate their executive skills. Conversely, the negative correlation is not found to be present in the domains/questions that are more concrete and where respondents have greater opportunity to use actual functional performance feedback to self-rate satisfaction. Qualitative results identified several themes of interest. In general the professionals involved raised issues about the validity of the answers, in particular with the more abstract questions. It was suggested that answers would be different if asked on a different day or by a different person (this was also noted by the more insightful respondents too). There also appeared to be a significant gap between the positive responses given, in particular by those with lower levels of insight, with the real lived experience. The desire or need to answer the same question with more than one answer was also regularly commented upon. Conclusions: The previously noted connection between reduced levels of insight and subjectively perceived quality-of-life are also found in this cohort. Analysis and interpretation of results leads towards the conclusion that the self-rating of quality-of-life of those who have reduced insight is subject to increased variance from their more insightful peers when the tool used to ascertain this rating is abstract or demands the ability to assess and rate executive skills. The complexity of seeking information from people with an acquired brain injury is noted, as is the personal nature of what constitutes a good quality-of-life.

0491 JEF!:

A new ecologically-valid assessment of executive functions

Ashok Jansari1, Charlotte Sosson2, & Dana Samson2 1

University of East London, London, UK, 2University Catholic of Louvain-la-Neuve, Louvain-la-Neuve, Belgium

Objectives: Acquired brain injury (ABI) can lead to a constellation of higher-order executive problems, which can significantly impact everyday behaviour. Although some neuropsychological assessments are able to objectively assess these impairments, increasingly, clinicians are finding that a sub-set of their patients pass these tests whilst still exhibiting difficulties in day-to-day living. Calls have, therefore, been made to develop assessments that are more sensitive and that are more ecologically-valid. Virtual Reality (VR) technology offers an opportunity to address some of the limitations of the traditional tests. The Jansari assessment of Executive Functions (JEF!) is a new tool developed to address these issues through a series of experiments in the ‘real world’ and then VR. Methods: JEF! is a role-playing task set within a standard business office which mimics aspects of the Multiple Errands Task (MET). Performance is evaluated on sub-tasks designed to test eight constructs central to executive function: Planning, Prioritization, Selective-Thinking, Creative-Thinking, Adaptive-Thinking, ActionBased Prospective Memory (PM), Event-Based PM and Time-Based PM. Three experiments are reported. In Experiment 1, participants performed their tasks in the ‘real-world’ moving between two rooms of a university building. In Experiment 2, JEF! was reproduced in a non-immersive VR environment, the resulting task looking like a standard computer game. In Experiment 3, JEF! was translated into French to assess cross-cultural applicability. In all experiments, participants with ABI who performed in the ‘unimpaired’ range on two standard tests (the BADS and/or BrixtonHayling) were compared to age- and IQ-matched healthy controls. Results: Experiment 1 found a significant difference in the real-life version of JEF! between the ABI group and the matched controls (U ¼ 31.5, n ¼ 12, p ¼ 0.03). This difference was maintained in the virtual version in Experiment 2 (F(10,36) ¼ 21.3, p50.001). Finally, in Experiment 3, the French patients were significantly impaired relative to matched controls (F(9,32) ¼ 7.48, p50.001). The ABI groups, therefore, performed poorly on this new task despite showing unimpaired profiles on standard clinical instruments. Conclusions: JEF! is a safe ecologically-valid task that shows great potential for becoming a standard assessment of executive functions. Due to performance being evaluated across eight constructs, it also offers a post-assessment tool for targeting specific vocational rehabilitation. Further, it can be used for evaluating theoretical models of executive functions. Currently, clinicians in Australia, New Zealand and India are using it in their clinical investigations while clinicians in Brazil, Finland, Sweden, Italy, Holland and Israel are using JEF! in their local languages to explore appropriateness for their cultures. Finally, a children’s version, JEF-C! has been developed to use with children with ABI as well as developmental disorders such as ASD and ADHD.

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Feasibility of acceptance and commitment therapy for treating emotional distress in persons with traumatic brain injury Angelle M. Sander1, Kacey L. Maestas1, David Arciniegas1, Allison Clark1, & Mark Sherer2 Baylor College of Medicine, Houston, TX, USA, 2TIRR Memorial Hermann, Houston, TX, USA


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Emotional distress, including depression and anxiety, is common following traumatic brain injury (TBI) and is associated with negative outcome, including reduced functioning, independence, participation and overall quality-of-life. In spite of this, there has been minimal research to evaluate treatment for emotional distress following TBI. To date, most studies of psychotherapeutic treatments targeting depression after TBI have used cognitive-behavioural therapy (CBT). While there is an extensive body of empirical work supporting the effectiveness of CBT for depression and anxiety in a wide range of populations, the application of CBT for persons with TBI has been questioned. Cognitive impairments common in persons with TBI can be an obstacle to understanding, recalling and implementing the primary treatment ingredient in CBT (identifying and evaluating maladaptive thought patterns). Persons with TBI have been shown to have difficulty understanding and applying CBT concepts. Furthermore, the concept of labelling negative thoughts as irrational can be difficult to apply to persons with TBI who are realistically assessing injury-related limitations in functioning. For these reasons, some researchers have recommended that alternative psychotherapeutic interventions be considered for persons with TBI. One such therapy is Acceptance and Commitment Therapy (ACT). While traditional cognitive-behaviour therapy focuses on altering of maladaptive or irrational thinking, ACT focuses on helping clients simply experience their thoughts, without judging or assigning value to them. The goal of ACT is to change the context within which thoughts are experienced rather than to alter the thoughts themselves. In parallel, ACT focuses on guiding clients in identifying their values and setting activity goals that are consistent with these values. ACT has demonstrated effectiveness in treating a variety of problems, ranging from work-related stress to psychosis. A large body of research has emerged in support of ACT’s effectiveness for treating a variety of emotional difficulties and problem behaviours, including depression, anxiety and combined anxiety and depression, with effect sizes ranging from 0.53–2.97 immediately following intervention and from 0.47–2.34 at follow-up periods ranging from 8–36 weeks. There is also evidence for the underlying mediating processes of ACT. Taken together, all studies including mediational analyses for the process components showed significance at p ¼ 0.10 or better. This evidence provides a firm basis on which to evaluate the effectiveness of ACT for treating emotional distress in persons with TBI. The current presentation will describe ACT and how it is being applied to treat emotional distress in persons with TBI in the context of a pilot for a randomized controlled trial. Adaptations to compensate for the impact of cognitive deficits on treatment will be described. A case study will be presented to illustrate concepts.

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Neuro-rehabilitation suggestions for public policy and advocacy Pradeepa Gunasena

Brain Inj, 2014; 28(5–6): 517–878

Brain Injury Association, Charlottetown, Canada

Objective: Provision of holistic, person-centred, uniquely tailored, standadized, efficient, persistent, multidiciplinary neuro-rehabilitation services in order to achieve maximum independence with greater intergration into the mainstream of education and employment, reducing hosptal stays through cost-effective, affordable and transparent services. Background information: The progress of neurorehabiltation is stagnant despite the alarming rise of neurotrauma morbidity due to lack of a solid frame. These policies are based upon two important concepts identified in the neuroscience. (1) Cascade effect; Neurons thrive on activity and stimulation; when a group of neuron dies, the neighbouring neurons become excommunicated, less active and degenerated due to lack of stimulation. (2)Neuroplasticity; experience-based adaptability of neurons through persistent stimulation. These two important concepts explain how important it is to start early provision and persistence of care without having a period of gaps of the service. Typically families are suddenley pushed to the caregiving role with litttle knowledge, training or familiarity of what exactly neurorehabilitation can mean for them. There is no manual that tells them exactly how to care, what to do or not to do. Historically these services developed in an ad-hoc manner, mostly as a volunteer service which cannot address the complex needs of these individuals. This effort is a suggestion for the development of an internatonal framework for neurorehabilitation and is a result of years of experiences and studying of various reference materials written on neurorehabilitation together with dedication and perseverence to develop an effective neurorehabilitiation service system on behalf of this cohort of people in every corner of the world. As the premier neurotrauma organization in the world, the Internatonal Brain Injury association must be the leading advocate of neurotrauma rehabilitaton in order to establish an effective service for the people with disabilities. Key suggestions: (1) The purpose and vision of neurorehabilitation policies and strategies; (2) The importance of the development of international policy to govern, guide and determine by networking these services around the globe and establishment of a statutory body that govern and advocate an international model of neurorehabilitation services in collaboration with world health organization; (3) Mapping of available neurorehabilitation services at a national level and intergrating them at an international level; (4) Advocating to supply feedback to the statutory body after analysing and studying of quality and effectiveness of available services at a national level and establishing an effective reconfigured service delivery framework according to the international standards; (5) To develop a feedback system that reports every individual’s progress of independence and desired level of activity based on their diagnosis in order to intervene in the case of delay in the progress; (6) Advocating governments and political leaders to increase funding for researches and to enhance services; (7) Implementaton of an effective solid framework for the provision of future neuro-rehabilitaton services at international and national levels.

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Use of brain electrical activity for the identification of haematomas in traumatic brain injury patients presenting with low suspicion of abnormality Leslie Prichep1, Andrew Mould2, Rosanne Naunheim3, & Daniel Hanley4

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DOI: 10.3109/02699052.2014.892379 1

New York University School of Medicine, New York, NY, USA, Johns Hopkins University, Baltimore, MD, USA, 3Washington Univerisity Medical Center, St. Louis, MO, USA, 4Johns Hopkins University School of Medicine, Baltimore, MD, USA


2

Objectives: This study investigates the potential clinical utility of the BrainScope TBI-index of brain electrical activity for identification of intracranial haematomas in the acute setting in mild head injured patients presenting clinically with low suspicion of brain injury. Further, the relationship of this Index to the blood volume of the haematoma and the distance from recording electrodes was studied. Methods: Five-to-ten minutes of EEG was recorded from a limited frontal (forehead) montage in 38 adult patients with traumatic haematomas (CT positive, CT+) and 38 mild head injured controls (CT negative, CT) in the Emergency Department. All CT+ patients had GCS 13, were able to give written consent and were capable of participation in brief neurocognitive evaluations. Thirty-seven per cent of these CT+ patients had Standard Assessment of Concussion (SAC) scores 25 (normal), further supporting the mild clinical presentation of this population. Linear and non-linear features of brain electrical activity (including measures of EEG power, connectivity and complexity) were extracted, transformed for Gaussianity and age regressed and a selected sub-set were submitted to a discriminant classification algorithm. This algorithm was independently previously developed to identify the probability of a CT+ traumatic event in an acute mTBI population. Independently, using a published method for quantitative measurement of blood volume, CT images were evaluated blind to the EEG findings. Results: Using the TBI-Index, sensitivity to haematomas was 100%, positive predictive value (PPV) was 74.5% and positive likelihood ratio (PLR) was 2.92. A significant correlation was found with blood volume, where the larger the volume the higher the score. There was no significant relationship found with type of haematoma or distance of the bleed from recording electrodes. Conclusions: The TBI-index demonstrated high accuracy for identification of traumatic haematomas in a population presenting as mild TBI. Further, there was a significant relationship between the TBI-index and the volume of blood present. Accuracy was not related to the distance of the haematoma to the recording electrode, despite all electrodes being on the forehead. This study suggests the potential importance of such a tool in the acute evaluation of head injuries considered to be mild at presentation.

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Improving the individual diagnostics of TBI—The international TBIcare project Olli Tenovuo1, David Menon2, Mark van Gils3, Daniel Rueckert4, Ari Katila1, Jonathan Coles2, Jussi Mattila3, Christian Ledig4, Janek Frantzeń1, Joanne Outtrim2, Jyrki Lo¨tjo¨nen3, & Harri Siitari3 1

Turku University Hospital, Turku, Finland, 2University of Cambridge, Cambridge, UK, 3VTT Technical Research Centre, Tampere, Finland, 4 Imperial College London, London, UK Objectives: To approach personalized medicine in the diagnostic decision-making and treatment decisions in subjects with acute TBI of all severities. Methods: Statistical analysis and data-mining of large existing databases (the IMPACT-database, existing databases from the participating centres) and detailed prospective data collection of an unselected population of adult subjects with acute TBI attending emergency care (n ¼ 392).

Results: During the last 3 years this EU-funded international effort has created a software tool for the clinical care of subjects with TBI, by combining all available information from clinical data (pre-injury factors, injury data, treatment data, outcome), imaging and biochemical markers to a modelling system based on a fingerprint technique. This work has produced a software solution where the individual information from new cases will be compared to the existing databases, thus allowing accurate profiling and outcome prediction which can be used also as a basis for individualized treatment decisions. Conclusions: The properties of the TBIcare software tool will be presented, comprising of injury timeline, fingerprint modelling of injury variables and outcome prediction. Although based on a large number of TBI cases, this tool will need further development in forthcoming efforts such as the InTBIR in order to give improved accuracy and reliability in individual profiling, especially in cases with rare injury mechanisms.

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Pharmacological and nonpharmacological management of organic hyperphagia following brain injury: Systematic review of evidence Rajendra Shah, & Rafey A. Faruqui St Andrew’s Academic Centre, Kings College London Institute of Psychiatry, Northampton, UK Objective: Persistent hyperphagia is a potentially life threatening complication in the post-acute rehabilitation phase following acquired brain injury. Management of hyperphagia remains a challenging task for healthcare professionals due to the often severe and persistent nature of the symptom complex. There is a dearth of medical literature on treatment strategies and this systematic review looks at the current available evidence to assess its quality to guide management. Method: Systematic search of Medline, Embase, PsychInfo, Cochrane Database of Systematic Reviews and Cochrane Clinical Trials Register using terms: ‘Eating Disorder’, ‘Organic Eating Disorder’, ‘Hyperphagia’ and ‘Brain Injury’. Follow-up search of references of retrieved articles was also conducted. Articles providing evidence for levels 1–4 of Evidenced Based Medicine Framework were considered for inclusion. Single case reports were excluded. Results: Electronic search identified 80 articles. These articles were screened and only four were relevant to the study question. This review did not identify any level 1–3 studies, i.e. Randomized control trials, systematic reviews of effectiveness, cohort or case-controlled studies. Two of the identified studies were pharmacological case series of specific medication, one case series provided information on pharmacological strategies for individual patients and the last article was an observational case study incorporating examples of multiple cases and holistic approach to care. The topiramate case series (17 patients) reports effectiveness in attenuation of binges and normalization of Body Mass Index. Topiramate was less effective in those with mood disorders and not effective where weight gain was a sideeffect of other medications. The naltrexone case series (three patients) reported improvement in pathologic impulses, weight loss and persistent feelings of hunger. In one case, withdrawal of the naltrexone resulted in recurrence of binge eating and associated behaviours such as aggression and stealing food; however, on restarting the medication these behaviours were reported to disappear. The case series (four patients) reported ineffectiveness of appetite increasing anti-psychotics and antidepressants and also the unsuccessful use of fluoxetine and topiramate in hyperphagia. They further

700 noted that neurobehavioural techniques including positive reinforcement, extinction and time out also did not result in improvement. The observational case study combined key observations from clinical case management providing an operational definition of morbid hunger or hyperphagia and also highlighted management principles including weight management and health promotion, self-esteem and psychological well-being, environmental control and risk management and further specialist treatment including medication use and specialist referrals such as endocrinology. Conclusions: The evidence base for hyperphagia management following acquired brain injury remains limited. This review is the first report of systematically evaluating the current evidence identifying helpful intervention strategies that require further research examination.


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Traumatic brain injury and common comorbidities associated with prevalence and persistence post-deployment headaches among US veterans of Afghanistan and Iraq wars Carlos Jaramillo1, Blessen Eapen1, Jedediah Robinson2, Megan Amuan1,4, Cindy McGeary3, Don McGeary3, & Mary Jo Pugh1

Brain Inj, 2014; 28(5–6): 517–878

Results: Among all OEF/OIF veterans, 38 426 received their first year of care within the VA in 2008 and 13.7% (n ¼ 5264) of these also received a diagnosis of headache during 2008. Veterans with a headache diagnosis in 2008 were also more likely to have a diagnosis of TBI (OR ¼ 6.75; CI ¼ 5.80–7.86), PTSD (OR ¼ 2.22; CI ¼ 2.03–2.44) and/or depression (OR ¼ 1.742; CI ¼ 1.533–1.978) and combinations of these conditions. Headache persistence was more likely for women (OR ¼ 1.41; CI ¼ 1.19–1.68) and those aged 31–40 (OR ¼ 1.45; CI ¼ 1.25–1.70) and 41–50 (OR ¼ 1.31; CI ¼ 1.07–1.60) compared to those 17–30 years old. Among post-deployment symptoms, conditions and comorbidities, only tinnitus/hyperacussis (OR ¼ 1.21; CI ¼ 1.02–1.45), insomnia (OR ¼ 1.19; CI ¼ 1.02–1.39) and vestibular/ dizziness (OR ¼ 1.83; CI ¼ 1.30–2.57) at baseline were associated with persistent headache. Conclusions: Headaches among OEF/OIF veterans were associated with TBI, PTSD and depression during the first year of care. Persistent headaches were predicted by certain first year symptoms (tinnitus/ hyperacussis, insomnia, vestibular/dizziness), but not with first year diagnosis of TBI, PTSD or depression. These results are the first to describe, in OEF/OIF veterans, the baseline characteristics, comorbidities and conditions that are associated with requiring continued care for headaches after entry into the VA.

0499

SES, racial minority status and functional outcome from TBI: Implications for the utility of FIMä scores for predicting TBI outcomes

1

South Texas Veterans Health Care System, San Antonio, TX, USA, Department of Rehabilitation Medicien, University of Texas Health Science Center San Antonio, San Antonio, TX, USA, 3Department of Psychiatry, University of Texas Health Science Center San Antonio, San Antonio, TX, USA, 4Center for Health Quality, Outcomes and Economic Research, Edith Nourse Rogers Memorial VA Hospital, Bedford, MA, USA

2

Objectives: Headaches are one of the most common symptoms experienced after concussion and among those with post-concussion and post-deployment syndrome. The association of persistent headaches with common comorbidities among Afghanistan and Iraq (OEF/ OIF) veterans has not been well described. The purposes of this study were to: (1) Describe the prevalence of headache and relevant postdeployment symptoms/comorbidities in an inception cohort of OEF/ OIF veterans; (2) Identify the extent to which headaches persist among those diagnosed with headache in their first year of VA care; and (3) Identify baseline characteristics that predict persistent headache in this cohort. Methods: This longitudinal retrospective database analysis gathered data from the national VA inpatient and outpatient data repository for OEF/OIF veterans who first received VA care in 2008. It further selected those who also received care in 2009, 2010 and 2011. It identified those who were diagnosed with headache (ICD9-CM; 339, 346, 784) in the first year of care (2008). It also used algorithms validated for use with ICD-9-CM codes to identify comorbidities common to OEF/OIF veterans (TBI, PTSD and depression) and symptoms and post-deployment conditions associated with headaches (depression, anxiety, memory/attention/cognition, neck pain, tinnitus/hyperacussis, photosensitivity/photo blurring, insomnia, malaise/fatigue, vestibular/dizziness). This study first identified the presence of headache diagnosis each year (2008–2011) and used multivariable logistic regression analysis (LR) to determine baseline characteristics associated with headache in 2008. It then identified individuals with headache diagnosed each year of care (persistent headache) and used multivariable LR to identify baseline characteristics associated with persistent headache.

Hannah McDermott, David Gordon, Heather Glubo, Aaron Beattie, Brian Im, & Tamara Bushnik New York University, New York, NY, USA Low socioeconomic (SES) and racial minority status have been found to predict decreased functional outcomes following a traumatic brain injury (TBI). FIMTM is the functional assessment measure most widely used in rehabilitation settings to measure patient progress, predict burden of care and establish reimbursement. The objective of this study was to examine cognitive outcomes after TBI as measured by the FIM cognitive sub-scale at admission and discharge from two hospitals with significant demographic differences. It was hypothesized that patients from low socioeconomic status (low-SES) and/or racial minority groups would have lower cognitive FIM scores at discharge and smaller cognitive FIM change through their inpatient stay. Data was collected through a retrospective chart review of Uniform Data System data at Rusk Rehabilitation TBI Model System’s two participating hospitals, 565 patients from H1 and 269 patients from H2. The results indicated demographic differences between the two hospitals, with a greater percentage of minorities at H1 (74.6%) than H2 (20%). H1 patients were less likely to have insurance (70.5%) than H2 patients (100%). Of those insured, H1 patients were more likely to be covered by Medicaid than H2 patients (27.6% vs 7.6%, respectively). Despite these differences, a stepwise regression found that racial minority status did not predict cognitive FIM change over the course of inpatient rehabilitation (p ¼ 0.728). A one-way ANOVA demonstrated no significant differences in FIM cognition scores at admission (p ¼ 0.26) or FIM cognition change (p ¼ 0.32) across primary payor conditions. These findings suggest that either low-SES and minority status did not predict cognitive outcomes or that the FIM cognitive sub-scale is not appropriately capturing these outcomes. To further illustrate which of these hypotheses the data may support, this study analysed the difference in cognitive FIM change between patients under 65 years old and patients 65 and older. Despite evidence from the literature that supports a meaningful relationship

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between increased age and decreased cognitive improvement through inpatient rehabilitation, this analysis found that the difference in cognitive FIM change between these two groups, although statistically significant, did not reach the level of minimal clinical significance commonly accepted as a difference of 3-points (under 65 mean ¼ 7.27 [SD ¼ 6.3]; over 65 mean ¼ 4.79 [SD ¼ 5.3]). While the FIM cognitive sub-scale is in widespread use across most rehabilitation settings and has been endorsed by the NINDS TBI Common Data Elements effort, this study highlights its limitations and supports the need to develop alternate measures of cognitive function in TBI.

Cluster 7 was characterized by hearing loss, tinnitus, pain and no memory complaints. The association between clusters 2, 3 and 7 and TBI (AOR 2.2 [2.1–2.2], 1.3 [1.3–1.4], 4.8 [4.7–4.9], respectively) was significantly higher than Cluster 1, but significantly lower than Clusters 4, 5 and 6 (see above). Conclusions: This study identified seven distinct clusters of OEF/OIF Veterans with unique patterns of PD symptoms. Moreover, TBI diagnosis was meaningfully associated with these clusters. These patterns suggest that targeted interventions matching the symptomatic clusters might improve patient outcomes, quality-of-life and efficiency of healthcare among these Veterans with TBI.

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Post-deployment symptom clusters and associations with traumatic brain injury in US veterans of the Afghanistan and Iraq wars

Evaluating access to appropriate concussion care in Ontario

Carlos Jaramillo1, Blessen Eapen1, David Tate2, Gerry York2, Megan Amuan3, Chen-Pin Wang1, & Mary Jo Pugh1 1

South Texas Veterans Health Care System, San Antonio, TX, USA, Defense and Veterans Brain Injury Center, San Antonio, TX, USA, 3 Center for Health Quality, Outcomes and Economic Research, Edith Nourse Rogers Memorial VA Hospital, Bedford, MA, USA 2

Objective: Much debate has centred on the symptoms experienced after combat-related TBI, with studies identifying a strong interaction between PTSD, depression and post-concussion symptoms (PCS). The purpose of this study was to determine how diagnoses linked with persistent PCS cluster and how these diagnostic clusters are associated with TBI, PTSD and depression. This study sought to identify underlying sub-groups within the population of Afghanistan and Iraq Veterans (OEF/OIF) that experience a spectrum of postdeployment (PD) symptoms and determine their associations with TBI. Methods: This cross-sectional observational study used national inpatient and outpatient data of OEF/OIF Veterans who received care in the US Veterans Health Administration in 2010–2011. It used algorithms developed for use with ICD-9-CM codes to identify patients who were diagnosed with symptoms associated with TBI exposure: memory/cognitive problems, blindness, blurred vision, vertigo, tinnitus, hearing loss, anxiety, substance use disorders, insomnia, fatigue, headache (HA), neck pain and other pain. Latent class analysis was used to identify unobservable sub-groups and patterns of PD symptoms within the OEF/OIF cohort based on the distribution of binary diagnosis outcomes. Each latent class represents a ‘cluster’ of symptoms that occur most commonly in a sub-group of the population. Logistic regression (LR) was used to identify clusters more or less likely to have TBI controlling for co-morbid PTSD and depression. Results: In this cohort of 303 716 OEF/OIF Veterans who received inpatient and outpatient care in the VA in 2010–2011, seven PD symptom clusters were found. The seven sub-groups were distinct in their composition of PD symptoms. Forty-eight fell into the relatively healthy sub-group (Cluster 1), which had low probability of having any symptoms and were also less likely to have TBI, PTSD or depression. Clusters 4, 5 and 6 were characterized by a high probability of HA and memory complaints. LR analyses found that Clusters 4, 5 and 6 were also more likely to have TBI (adjusted odds ratios [AOR] 4.4 [4.2–4.6], 7.1 [6.8–7.5] and 12.7 [12.0–13.40], respectively) than individuals in Cluster 1. Cluster 2 had 100% probability of pain and moderate probability of insomnia, Cluster 3 was characterized primarily by mental health-related symptoms and

Charissa Levy1, Laura Langer2, & Mark Bayley Bayley2 1

Toronto ABI Network, Toronto, Canada, 2University Health Network, Toronto, Canada Objectives: Concussion/mild traumatic brain injury (mTBI) is very common and can result from motor vehicle crashes, falls, assaults, sports and recreational injuries and other causes and affects people of any age. Although most individuals recover, some experience ongoing and persistent symptoms affecting physical, cognitive and psychosocial function. There is evidence of inconsistency in management of concussion across Ontario and access to specialized concussion care is variable. Methods: A multimodal design was utilized and determined geographical location of clinics that treat concussions, what resources these clinics offered and compared the incidence of concussion and referral trends of the surrounding areas. Twenty-five clinics were interviewed and, although they had individual areas of expertise, none had what was considered the ideal multidisciplinary concussions clinic. Results: Between 2001 and 2008 almost one million residents of Ontario were diagnosed with a concussion. Most (80%) were diagnosed in the Emergency Department. The average incidence of concussion in Ontario for this time period was greater than 1800/100 000 people. Paediatric incidences were the highest of all the age groups. Wait times for a specialist appointment were 7 months from first index case for adult populations and over 9 months for paediatrics; sex did not affect wait time. There was a weak negative correlation between incidence and number of clinics in a given region and between an area’s incidence. Conclusions: More people are recognizing that concussions require appropriate medical treatment and increases in public awareness; however, specialized clinics are not located in areas of higher incidence. There are areas for improvement in treating concussions in Ontario.

0502

Development of a traumatic brain injury clinical database (TBIRD) for surveillance of symptoms, determinants of health and quality-of-life in an outpatient clinic population Donna Ouchterlony, Andrew Baker, Michael Cusimano, Alicja Michalak, Cindy Hunt, & Jane Topolovec-Vranic

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St. Michael’s Hospital, Toronto, Ontario, Canada Objectives: As a leading cause of death and disability, traumatic brain injury (TBI) requires ongoing surveillance. Further research is needed to understand factors associated with pr versus healthier outcomes following TBI to enable the most effective treatments to be developed and delivered. As a provincial trauma centre, St. Michael’s Hospital specializes in the acute care of patients who have sustained TBI. Moreover, the outpatient Head Injury Clinic (HIC) manages 800 new patients (over 2000 patient visits) with TBI per year. This study developed the clinical database in order to (a) standardize the approach to care of patients with TBI at the clinic, (b) enhance efficiency of care by eliminating duplication of efforts made by staff, clinicians and patients, (c) enable the assessment of who is using the services and (d) provide a quality platform for future research. Methods: The overarching socio-ecological framework in the HIC guided selection of clinician and patient reported variables which were largely derived from the National Institute of Neurological Disorders and Stroke (NINDS) TBI Common Data Elements (CDEs), TBI Models Systems, the Consensus statement on concussion in sport and the Ontario Neurotrauma Foundation (ONF)-Guidelines for Concussion/Mild Traumatic Brain Injury & Persistent Symptoms (2nd Edition). Injury characteristics are collected via a clinical interview (nurse or physician) including the CDEs of geographic location of patient residence, mechanism of injury, loss of consciousness, retrograde and anterograde amnesia. A self-report patient questionnaire captures the CDEs of personal and family history, associated injuries and immediate post-injury care. Symptoms measures are obtained from the Rivermead Post-Concussion Symptom Questionnaire as recommended by NINDS and the ONF guidelines. Determinants of health include education, occupation, from the NINDS-CDEs, while country of origin, cultural background and language spoken are questions from the Canadian Community Health Survey. Type of dwelling, living arrangements and income originate from the TBI Model Systems questionnaire, as does substance use prior to injury (tobacco, drugs and alcohol). This team added the Adverse Childhood Event to the patient’s first HIC visit. The quality-of-life measure is the Euro Qol EQ-5D, NINDS recommended. Results: Building templates on core and clinically relevant data elements has been challenging, mainly in the quest to seek to collect too many variables. This study has managed to limit the collection of data elements by planning a programme of research. For patients who return to the clinic, the authors continue to track changes to symptoms, determinants of health and qualityof-life. Conclusions: Lessons learned will provide guidance as one broadens surveillance of TBI in a wider hospital community (such as in the emergency department and family practice clinics).

0503

Moderate-to-severe TBI impacts on social cognition in adolescents and young adults and contribution of non-social cognitive functions Beatrice Tousignant1, Philip L. Jackson1, Miriam H. Beauchamp2, Amelie M. Achim1, Gary Bedell3, Normand Boucher4, Elsa Massicotte1, Evelyn Vera2, & Katia Sirois5

Brain Inj, 2014; 28(5–6): 517–878

interdisciplinaire de recherche en reádaptation et inte´gration sociale, Quebec, QC, Canada, 5Institut de reádaptation en de´ficience physique de Que´bec, Quebec, QC, Canada Objectives: People who suffer from moderate-to-severe TBI often show changes in social behaviour and psychosocial adjustment that can persist or worsen over time. TBI frequently involves damage to structures of the neural network supporting social cognition. Therefore, the possible contribution of social cognition in the cause of socially maladaptive impacts of TBI has been suggested. Social cognition refers to the mental functions through which social cues are processed during social interactions. Some lines of evidence suggest that those functions are different, but related to, non-social cognition. Disruption of social cognition has been documented in adults and children with TBI, but has not been covered much for TBI sustained in adolescence and young adulthood, periods of life when peer relationships increase in importance and complexity. The aim of the current study was, thus, to examine the impact of a moderateto-severe TBI in adolescents and young adults on multiple facets of social cognition and to examine these effects when controlling for non-social cognitive variables. Methods: Twenty-two adolescents and young adults who had sustained moderate-to-severe TBI (age 12–21 years, M ¼ 16.82, SD ¼ 2.28 years, 13 males) were compared to a matched group of 22 typically-developing peers (M age ¼ 16.77, SD ¼ 2.28 years, 11 males). A social cognition battery (including tests of mentalizing, social knowledge, emotion recognition) and a self-report empathy questionnaire were administered, along with non-social cognitive tests (attention, working memory, executive functions, brief IQ). Results: A MANOVA revealed that the combination of all social cognition variables was significantly affected by group (p ¼ 0.001). Discriminant analysis revealed that levels of perspective-taking, empathic concern (two sub-scales of the empathy questionnaire) and mentalizing maximized differences amongst groups, with TBI adolescents and young adults showing lower scores than controls. However, when controlling for working memory, selective attention and mental flexibility, only the main group effects of perspectivetaking and empathic concern remained significant, with strong (d ¼ 1.48) and moderate (d ¼ 0.6) effect sizes, respectively. Conclusions: The findings suggest that social cognition is affected by TBI in adolescents and young adults. It is not surprising that higher order non-social cognitive abilities, often altered following TBI, explained a certain amount of variation in social cognition performances. Interestingly, even after taking into account those non-social cognitive variables, the TBI group reported a significantly lower ability than controls to adopt the cognitive viewpoint of others and to feel compassion for others. This suggests that cognitive and affective empathy may well contribute to the social skills difficulties frequently noted in this population and represent an interesting target with regards to remediation. Social cognition should, therefore, be more systemically considered in neuropsychological assessments of adolescents and young adults with TBI.

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A conceptual approach to align symptom assessment tools for traumatic brain injury patients in a specialized out-patient head injury clinic Donna Ouchterlony, Alicja Michalak, & Cindy Hunt St. Michael’s Hospital, Toronto,Ontario, Canada

1

Laval University, Quebec, QC, Canada, 2University of Montreal, Montreal, QC, Canada, 3Tufts University, Medford, MA, USA, 4Centre

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DOI: 10.3109/02699052.2014.892379

Objective: Traumatic brain injury (TBI) often has a wide variety of longterm consequences. One needs to consistently measure the effects of TBI over time so one can understand if what is done can help put brain-injury survivors on a better life trajectory. However, selecting the right symptom assessment tool at the right time can be a challenge. This study proposes starting with the Rivermead PostConcussion Symptom Questionnaire (RPQ) and then based on the RPQ score move to a kick out pattern of item-specific symptom measures. By providing an orderly approach to symptom assessment, improvement was anticipated in symptom tracking prospectively and enhanced ability to detect symptom changes as the patient’s response to treatment was monitored. Methods: On the initial visit to the Head Injury/Concussion Urgent Care Clinic a patient completes the RPQ as part of the baseline assessment. If they identify a moderate (score of 3) or severe problem (score of 4) on specific items, then a patient is asked to complete a more in depth symptom-specific measurement tool(s). These include the Sleep and Concussion Questionnaire (RPQ ‘sleep disturbance’ item), the Barrow Neurological Institute Fatigue Scale (RPQ ‘fatigue tiring more easily’), the Generalized Anxiety Score (RPQ ‘irritable, easily angered or feeling frustrated or impatient or restlessness’), the Patient Health Questionnaire-9 (RPQ ‘feeling depressed or tearful’). The choice of symptom assessment kick out tools has been guided by the National Institute of Neurological Disorders and Stroke (NINDS) common data elements for TBI and the Ontario Neurotrauma Foundation, Guidelines for Concussion/Mild Traumatic Brain Injury & Persistent Symptoms, Second Edition. Results: This conceptual approach has provided clarity and consistency in facilitating the clinical team’s decision-making surrounding the utilization of symptom assessment measures across the clinic population. The patients have reported the tools have been brief, easy to complete and helped them gain insight into their symptoms. Conclusions: The authors plan to validate this conceptual approach to align symptom tools by exploring the relationship of the RPQ itemspecific score with the aligned kick out tool score. They also plan to investigate additional measures for the remaining 11 symptoms in the RPQ to enhance the kick out protocol.

(FSS) and Patient Health Questionnaire-9 (PHQ-9) were also collected. Participants who endorsed having headaches on the RPQ also completed a headache specific history and the Migraine Disability Assessment Tool (MIDAS). Descriptive statistics were calculated. Results: Ninety-one patients were recruited to the study (46% [n ¼ 42] male, 54% [n ¼ 49] female; mean age 43 years [range ¼ 18–65]). Patients were on average 33 months post-TBI (range ¼ 6 months–18 years). Based on the RPQ, 77% (n ¼ 70) indicated headaches to be a mild, moderate or severe problem and 78% (n ¼ 71) scored 36 on the FSS (suggesting the presence of fatigue). Patients with headaches were more likely to have a PHQ-9 score 12 (indicative of major depression in this population; 2(1, n ¼ 85) ¼ 7.16, p ¼ 0.007). The majority (70% [n ¼ 49]) did not suffer from headaches during their childhood or teenage years; those who did (10% [n ¼ 7]) were mostly female (n ¼ 6). Thirty per cent (n ¼ 21) of patients indicated moderate headaches with medication and 33% (n ¼ 23) indicated severe headaches without medication. During moderate-to-severe headaches, 93% (n ¼ 65) of patients indicated their ability to function was severely decreased or they were completely bedridden. Headache pain was often felt on the forehead (60% [n ¼ 42]), temples (41% [n ¼ 29]), behind eye(s) (61% [n ¼ 43]) and on the back of the neck (51% [n ¼ 36]). FSS scores were moderately correlated with headache (r(68) ¼ 0.351, p ¼ 0.003). Sixty-two patients (68%) reported fatigue as one of their three most disabling symptoms. Patients suffering from fatigue reported frequent problems sustaining motivation (79% [n ¼ 73]) and physical functioning (68% [n ¼ 61]). Seventy-five per cent (n ¼ 68) of patients reported that fatigue frequently interfered with their work, family and social life, as well as with carrying out duties and responsibilities (77% [n ¼ 69]). Conclusions: The majority of patients with mild-to-moderate TBI who presented to an outpatient TBI clinic report symptoms of headache and fatigue impacting quality-of-life and mental health. A better understanding of factors (e.g. demographics, injury characteristics, medication compliance) leading to persisting headache and fatigue is warranted.

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A prospective study of posttraumatic headaches and fatigue following mild or moderate traumatic brain injury Donna Ouchterlony1, Patricia Johnson1, Alicja Michalak1, Cheryl Masanic1, Johnathan Gladstone2, Chantal Vaidyanath1, Shree Bhalerao1, Kristin Smith1, Monica Pisotta1, Tian Renton1, & Jane Topolovec-Vranic1,2 1

St. Michael’s Hospital, Toronto, Ontario, Canada, 2Sunnybrook Health Sciences Center, Toronto, Ontario, Canada Objectives: Headache and fatigue are two of the most common complaints in patients following mild or moderate traumatic brain injury (TBI). Although some patients with TBI recover to their previous level of functioning, others suffer from long-term debilitating symptoms. The purpose of this study was to investigate the incidence and characteristics of headache and fatigue in patients who had sustained a mild or moderate TBI and their association with mental health and quality-of-life status. Methods: A convenience sample of patients who were at least 6months post-TBI, attending a tertiary outpatient head injury clinic in Toronto, Ontario, were recruited. Participants’ demographic, injury and general health information were collected. The Rivermead Post Concussion Symptoms Questionnaire (RPQ), Fatigue Severity Scale

Predictive value of hyperthermia and intracranial hypertension on neurological outcomes in patients with severe traumatic brain injury Brandon Bonds, Peter Hu, Yao Li, Shiming Yang, Katie Colton, Thomas Grissom, Raymond Fang, & Deborah M. Stein R Adams Cowley Shock Trauma Center, Baltimore, MD, USA Objectives: Intracranial hypertension (ICH) and hyperthermia have been shown to be common findings following traumatic brain injury (TBI) and are aggressively monitored and managed in the intensive care (ICU) setting. TBI management protocols often advocate maintenance of normothermia and avoidance of ICH based on evidence that these factors are associated with worse short and longterm outcomes. This study sets out to determine the combined power of temperature and intracranial pressure (ICP) in the ICU setting for predicting mortality, intensive care length of stay (ICU-LOS) and neurologic outcomes in patients with severe TBI. Methods: High resolution (every 6 seconds) temperature and ICP data were collected in 191 adults with severe TBI from 2009–2010 at a level 1 trauma centre. Body temperatures were plotted against concurrent ICP and divided into nine sections based on breakpoints of temperature (536, 36–38.5, 438.5 C) and ICP (520, 20–30 or 430 mm Hg). These data were then compared to the following


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outcomes: mortality, ICU-LOS 47 days and short-term (56 months) vs long-term (46 months) dichotomized neurologic outcomes determined by a blinded evaluator. The percentage of time spent in each section, as well as several pooled unfavourable conditions (hyperthermia ± ICH), were then evaluated for predictive value by examining the area under the receiver operating characteristic (AUC) curve with a p value50.05 considered to be statistically significant. Results: Patients with at least 50% collection of high resolution temperature and ICP data with clinical follow-up were included for analysis. This sub-set of adults (n ¼ 38, age 41.39, 18–83) were 2:1 male with severe TBI (head AIS ¼ 4.14, GCS ¼ 7.15, ISS ¼ 28), primarily as a result of blunt trauma. Evaluation of the AUC revealed that significant periods of high fever and high ICP (530 mmHg) over the course of 4 days were shown to have a strong association with poor long-term neurological outcomes. This predictive value became significant at day 3 (AUC ¼ 0.7143, p ¼ 0.035) and peaked at day 4 (AUC ¼ 0.7387, p ¼ 0.02) for poor long-term outcome. Early fever with ICP520 mm Hg interestingly showed an association with poor longterm outcome when seen on day 1 (AUC ¼ 0.7257, p ¼ 0.057). ICU LOS47 days was expectantly increased when hyperthermia and/or ICH was uncontrolled by day 5 (AUC ¼ 0.8162, p ¼ 0.018). However, there was no significant predictive value seen for in-hospital mortality by fever or ICH. Summary: Increased occurrences of hyperthermia combined with intracranial hypertension showed to be significant prognostic indicators of future poor neurologic outcomes in patients with severe traumatic brain injury. The strongest predictive value occurred when these conditions were uncontrolled for 43 days despite multiple interventions.

Results: The TBIMS-NDB was found to be largely representative of the national population of late-teens and adults receiving inpatient rehabilitation for a primary diagnosis of TBI. Age accounted for the largest difference between the datasets, with the TBIMS-NDB having a lower proportion of individuals 65 and older. Distributional differences between the datasets were not robust and did not prohibit accurate weighting of the TBIMS-NDB, with raking able to converge within a few iterations. Once weighted, the TBIMS-NDB was used to assess total population estimates and age-related trends within the decade. TBIs were predominantly found to result from falls (49.8%) and motor vehicle crashes (40.8%); however, TBIs to younger individuals were primarily from motor vehicle crashes with decreasing rates as age increased, while TBIs from falls rose as age increased, with those oldest most likely to incur TBIs from falls. Pre-injury alcohol misuse and substance use were found to occur in 22.9% and 12.2% of the total population, respectively; although age distributions demonstrated higher pre-injury use among individuals younger than 50 with decreasing misuse as age increased. With regards to vocational status, 49.2% were retired, 31.1% employed, 14.1% not working and 5.6% were students. Trends by age showed that younger individuals were more likely to be students or employed, with paid employment peaking for those aged 30–39 years and declining to the oldest age group. Conclusions: The TBIMS-NDB was predominantly representative of the national population of late-teens and adults completing inpatient rehabilitation in the US for a primary diagnosis of TBI between 2001– 2010. Using raking and weight-trimming, this extensive dataset can be weighted to mirror the characteristics of the national population and utilized for population-based research.

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0508

US population characteristics and age-related trends of late teens and adults receiving inpatient rehabilitation for a primary diagnosis of TBI between 2001 and 2010

Factors that predict self-reported duration of coma for persons with traumatic brain injury

Jeffrey Cuthbert1, Cynthia Harrison-Felix1, Gale Whiteneck1, Chris Pretz1, Jeneita Bell2, Juliet Haarbauer-Krupa2, & John Corrigan3 1

Craig Hospital, Englewood, CO, USA, 2National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, USA, 3Department of Physical Medicine and Rehabilitation, Ohio State University, Columbus, OH, USA Objectives: To describe the methods used to determine the representativeness of the TBI Model Systems National Database (TBIMS-NDB) and demonstrate how these findings were applied to calculate population characteristics and age-related trends for all lateteens and adults in the US who completed inpatient rehabilitation for a primary diagnosis of TBI between 2001–2010. Methods: Using combined data from the Uniform Data System for Medical Rehabilitation and eRehabdata data repositories, 12 population characteristics of patients receiving inpatient rehabilitation in the US for a primary diagnosis of TBI between 2001–2010 were determined. Categorical distributions of these data were compared with the TBIMS-NDB to assess the representativeness of the TBIMSNDB. The TBIMS-NDB was then weighted using raking, which is an iterative proportional weighting procedure that repeated until the distributions of the TBIMS-NDB matched the distributions of the national population across all characteristics simultaneously. Weights were assessed for extreme values using weight-trimming and were then applied to determine population characteristics and prevalence estimates using the extensive data included within the TBIMS-NDB.

Mark Sherer1, Kacey Maestas2, Angelle Sander2, & Todd Nick3 1

TIRR Memorial Hermann, Houston, TX, USA, 2Baylor College of Medicine, Houston, TX, USA, 3University of Arkansas for Medical Sciences, Little Rock, AR, USA Objectives: Investigators and clinicians confront situations in which it is known that an individual has sustained traumatic brain injury (TBI), but there are no medical records documenting injury severity. In such circumstances, one may attempt to determine injury severity based on patient report of duration of coma (SRComa). This study investigated factors that affect SRComa. Methods: Participants were a convenience sample of persons with medically documented TBI. For all participants, medical records documenting length of coma (MRComa) as indicated by the interval from injury until the person with injury recovered the ability to follow commands were available. Participants were brought to a research centre to be interviewed and administered tests and questionnaires including measures of cognitive functioning, symptom validity and depression symptomatology. Participants were asked if they were unconscious after the injury that caused their TBI and, if so, how long they were unconscious. It was explained to participants that to be unconscious means one is not able to talk or to respond to others. Results: There were 242 study participants. Of these, 74% were male, 72% were white and 70% were non-Hispanic. Age (median [lower quartile, upper quartile]) was 32 (25, 46) years, years of education were 13 (12, 14) and time since injury was 1.9 (0.6, 4.0) years. Candidate predictors for SRComa were age, sex, years of injury, time from injury to interview, average T-score on a battery of neuropsychological tests, significant depressive symptoms (yes/no), valid effort on testing (yes/no),and MRComa. These predictors were analysed

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using a full model multiple linear regression. Time since injury, average neuropsych T-score and MRComa made unique contributions to prediction of SR Coma. Persons who were at the 75th percentile of time since injury had 7 more days of SRComa than those at the 25th percentile. Persons at the 75th percentile on neuropsych tests (less impaired) had 3.6 fewer days of SRComa than persons at the 25th percentile (more impaired). Finally, for all lengths of MRComa, patients had 10 more days of SRComa. So that persons with no MRComa reported an average of 10.2 days of coma, persons documented as having 20 days of MRComa had 30.9 days of SRComa and so forth. Conclusions: Results suggest that clinicians and researchers should be cautious in accepting patient self-report for length of coma. It is striking that persons with no MRComa reported an average of 10.2 days of coma. This could result in persons with mild or moderate TBI being classified as having severe TBI. The relationship of neuropsych testing to SRComa was in the correct direction, although modest in strength. The meaning of the association of time since injury to SRComa is unclear.

Objectives: The objective of this preliminary cohort study is to describe alcohol craving in a convenience sample of Iraq and Afghanistan Veterans (n ¼ 48), including those exposed to traumatic events and experiencing active symptoms. Methods: Veterans completed weekly telephone interviews which included the Alcohol Use Disorder Identification Test, consumption questions (Audit-C; Week 1) and the Penn Alcohol Craving Scale (PACS; Weeks 1–6). Results: Sixty per cent of the sample screened positive on the Audit-C for probable AUD [Audit-C(+)]. For these Veterans, the person separation reliability of the PACS was strong (0.87). Higher PACS scores were reported among Audit-C(+) vs Audit-C() Veterans (mixed effects analysis, p50.0001). PACS scores were higher among Audit-C(+) Veterans with MHDs with and without mTBI (MHD ± mTBI) vs Audit-C(+) combat comparison Veterans (pair-wise comparison, p50.0001). Conclusions: Rates of hazardous alcohol use are high among Iraq and Afghanistan conflict Veterans and suggest that alcohol craving is elevated among those with MHD ± mTBI.

0509

0510

Alcohol craving among veterans with mental health disorders with and without mild traumatic brain injury

Anxiety in the first year after traumatic brain injury: Evolution and risk factors

Amy Herrold1, Neil Jordan2, Walter High3, Judi Babcock-Parziale4, R. Andrew Chambers5, Bridget Smith6, Charlesnika Evans7, Xue Li8, Trudy Mallinson9, Shonna Jenkins10, & Theresa Pape11

Valerie Laviolette1, Marie-Christine Ouellet2, Simon Beaulieu-Bonneau2, & Myriam Giguere2 1

Laval University, Quebec, Quebec, Canada, 2Centre for Interdisciplinary Research in Rehabilitation and Social Integration, Quebec, Quebec, Canada

1

The Department of Veterans Affairs (VA), Center for Innovation for Complex Chronic Healthcare, Edward Hines Jr., VA Hospital, Hines, IL, USA, 2Department of Psychiatry & Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA, 3Lexington VAMC, Lexington, KY, USA, 4Southern AZ VA Health Care System, Tucson, AZ, USA, 5Department of Psychiatry and Institute of Psychiatric Research, Laboratory for Translational Neuroscience of Dual Diagnosis & Development, Indiana University School of Medicine, Indianapolis, IN, USA, 6The Department of Veterans Affairs (VA), Spinal Cord Injury QUERI, Edward Hines Jr. VA Hospital, Hines, IL, USA, 7Center for Healthcare Studies, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA, 8Cooperative Studies Program Coordinating Center , Edward Hines Jr., VA Hospital, Hines, IL, USA, 9Department of Clinical Research and Leadership, The George Washington University, Washington, DC, USA, 10University of Kentucky College of Medicine, Departments of Physical Medicine and Rehabilitation, Lexington, KY, USA, 11Loyola University Chicago, Stritch School of Medicine, Program in Health Services Research, Maywood, IL, USA, 12Cardinal Hill Rehabilitation Hospital, Lexington, KY, USA, 13University of Kentucky College of Medicine, Departments of Neurosurger, Lexington, KY, USA, 14University of Kentucky College of Medicine, Department of Psychology, Lexington, KY, USA, 15Edward Hines Jr. VA Hospital Research Service, Hines, IL, USA, 16Northwestern University Feinberg School of Medicine, Department of Physical Medicine and Rehabilitation, Chicago, IL, USA Background: Mental health disorders (MHDs), mild traumatic brain injury (mTBI) and alcohol use disorder (AUD) are endemic among recent Veterans, resulting in a population with heterogeneous, cooccurring conditions. While alcohol craving negatively impacts rehabilitation and leads to relapse, no studies have examined alcohol craving among Veterans with co-occurring MHDs and mTBI.

Objectives: This study aimed at (1) Examining the evolution of anxiety symptoms at 4, 8 and 12 months post-TBI; and (2) Evaluating how post-TBI anxiety is related to pre-morbid history of anxiety disorders, TBI severity and sex. Method: Preliminary data on a large prospective cohort study on postTBI depression and anxiety are presented. Participants hospitalized for mild-to-severe TBI were recruited at a Level I trauma centre in Quebec City, Canada. Participants completed comprehensive psychological interviews and questionnaire evaluations at 4, 8 and 12 months postTBI including a structured clinical interview, the Mini International Neuropsychiatric Interview for DSM-IV (MINI) and the Hospital Anxiety and Depression Scale (HADS). The MINI was used for diagnosing psychiatric problems before TBI (lifetime) and in the first year after TBI. On the anxiety sub-scale of the HADS, scores 8 are usually indicative of clinically significant symptoms. One hundred and two participants have completed all three psychological interviews (Mean age 41.9 years ± 15.4; 74.7% men; 50.5% mild TBI, 31.3% moderate TBI, 18.2% severe TBI) and 94 all three questionnaires. Results: In the global sample, mean scores on the HADS anxiety subscale did not vary significantly over time: 5.65 ± 4.00 at 4 months, 5.65 ± 4.30 at 8 months and 5.91 ± 4.56 at 12 months (p ¼ 0.693). At 4, 8 and 12 months, respectively, 29.9%, 29.2% and 30.8% of participants presented clinically significant anxious symptoms (scores 8). Generalized estimating equations (GEE) showed that participants with a positive pre-morbid history of anxiety disorders had greater anxiety on the HADS compared to those with a negative pre-morbid anxiety history (p ¼ 0.006). There was also a significant interaction (p ¼ 0.026) between pre-morbid history of anxiety disorders and time; post-hoc comparisons (with Bonferroni correction) showed that 8month HADS scores of participants with pre-morbid history of anxiety disorders were significantly greater than 4-, 8- and 12-month scores of participants without pre-morbid anxiety history (p ¼ 0.034; p ¼ 0.013; p ¼ 0.014). GEEs did not reveal a significant main effect or interaction with time for either TBI severity or sex (ps40.07) although the interaction between severity and time almost reached significance

706 (p ¼ 0.073), suggesting that anxiety increases in the moderate/severe group and decreases in the mild group at 12 months. Conclusion: Results suggest that a high proportion of participants suffer from significant levels of anxiety during the first year post-TBI, regardless of TBI severity and sex. These symptoms seem to persist over time. Furthermore, lifetime psychiatric history of anxiety seems to be associated with more post-TBI anxiety, particularly at 8 months. More severely injured individuals may develop anxiety later in the first year, but this needs to be investigated further. These results show the importance of evaluating psychiatric history and post-TBI anxiety and to intervene before 8 months post-injury to prevent the emergence of full-blown anxiety disorders.

0511


Evaluating case management needs and impact for adults with chronic TBI Jeffrey Cuthbert1, Jennifer Anderson2, Christen Mason2, Stephen Block2, Kathy Martin2, Judy Dettmer3, Alan Weintraub1, & Cynthia Harrison-Felix1 Craig Hospital, Engelwood, CO, USA, 2Rocky Mountain Human Services, Denver, CO, USA, 3Division of Vocational Rehabilitation, Colorado Department of Human Services, Denver, CO, USA

Brain Inj, 2014; 28(5–6): 517–878

Conclusions: This research demonstrated that assessment of casemanagement intensity could be effectively completed using a brief data-driven intake assessment. Using this refined assessment has enabled the TBIS team to reduce time needed to complete casemanagement evaluations and devote more resources to service provision. Early analyses of longitudinal data collected using this assessment suggests that case management may improve community integration for individuals with chronic TBI.

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US population-based 2- and 5-year employment, health and social outcomes for individuals receiving inpatient rehabilitation for a primary diagnosis of TBI between 2001–2010 Jeffrey Cuthbert1, John Corrigan2, Cynthia Harrison-Felix1, Jeneita Bell3, Christopher Pretz1, Juliet Haarbauer-Krupa3, Gale Whiteneck1, & Cate Miller4

1

Objectives: (1) To describe the methods used to improve the evaluation process for determining intensity of case-management needs for adults with chronic TBI who applied for services through the Traumatic Brain Injury Support (TBIS) programme at Rocky Mountain Human Services (RMHS) funded by the Colorado Traumatic Brain Injury Trust Fund (CO-TBITF); (2) To illustrate the assessment developed from these analyses; and (3) To discuss longitudinal changes for individuals receiving case management services between enrolment and 8 months post-enrolment. Methods: A three-stage approach was utilized to evaluate and enhance the TBIS process for determining case-management intensity. (1) The TBIS team was surveyed to determine themes considered most relevant to making a case-management intensity determination. (2) Retrospective analyses of TBIS assessment data, including data from the Mayo Portland Adaptability Inventory-4 and an RMHS-developed case-management intake assessment, were conducted using logistic regression to determine the items most predictive of case-management intensity assigned by case-managers. (3) Logistic regressions of data from 100 assessments prospectively collected by blinded evaluators were calculated to determine the stability of the assessment items and establish case management intensity guidelines. Once finalized, the case-management evaluation was collected from all new TBI survivors seeking support through the TBIS programme at enrolment and at 8-month follow-up intervals. Results: Themes endorsed for case management need by the TBIS team were housing crises, weak social support networks, need for benefit application assistance and untreated mental-health conditions. Analyses of retrospective data suggested 19 items were predictive of case-management intensity, many of which were highly associated with the identified themes, demonstrating good face validity. Prediction of case-management intensity using logistic regression of the selected items resulted in a Nagelkerke of 0.72. Analyses of the prospectively collected data demonstrated adequate stability of the items identified by during retrospective analyses and prediction of case-management intensity using these data produced a Nagelkerke of 0.65. Initial analyses of longitudinal data collected using the refined assessment suggests an increase in community functioning for individuals with chronic TBI following the receipt of case-management services.

1

Research Department, Craig Hospital, Englewood, CO, USA, Department of Physical Medicine and Rehabilitation, Ohio State University, Columbus, OH, USA, 3National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, USA, 4National Institute on Disability and Rehabilitation Research, Department of Education, Washington, DC, USA

2

Objectives: To describe (1) the incidence and characteristics associated with unemployment 2-years post-injury and (2) the incidence and age-related trends of health and social outcomes at 5-years postinjury for all late teens and adults completing inpatient rehabilitation in the US for a primary diagnosis of TBI by using weighted applications of the Traumatic Brain Injury Model Systems (TBIMS) National Database (NDB). Methods: The TBIMS-NDB was weighted to represent the national population of late teens and adults completing inpatient rehabilitation for a primary diagnosis of TBI using two different schemes to produce the desired population estimates. For 2-year unemployment outcomes, a cohort from the TBIMS-NDB including cases collected between 2001–2010 that were aged 16 and 59 and not retired at injury and alive at 2 years post-injury was weighted to determine unemployment incidence. Once selected and weighted, risk factors associated with unemployment were evaluated using a multivariate modified Poisson regression with a robust error variance. Covariates were added in sequential blocks (demographic, socioeconomic, injury severity, functional and substance use) until the model AIC value failed to reduce by 0.005. For 5-year health and social outcomes, a cohort from the TBIMS-NDB that included cases collected between 2001–2007 was weighted to determine population characteristics. Age-related trends for this cohort were examined for individuals who were not expired by 5-years post-injury. Results: The incidence of unemployment at 2-years post-injury was 60.4%. Sequential modelling of unemployment was ceased following the addition of the functional covariates. The final model of unemployment was robust, with increased risk associated with age group, race, gender, marital status, primary inpatient rehabilitation payment source, education, pre-injury vocational status, length of stay and disability rating scale score. Analyses of health and social outcomes found 20% of the cohort expired by 5-years post-injury. Among those alive at 5-years, 12% were institutionalized and 50% had been re-hospitalized at least once. One third needed assistance or supervision in at least one activity of daily living and one third

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required supervision overnight at minimum. Dissatisfaction with life occurred in 29% and 8% reported marked depressed mood. Age-related trends showed worse medical, functional and participation outcomes for those of older age, while younger age groups had worse mental and emotional outcomes. Conclusions: Unemployment at 2-years post-injury was shown to be a substantial issue for individuals receiving inpatient rehabilitation for a primary diagnosis of TBI, with several factors strongly increasing risk for this outcome. Analyses of 5-year outcomes showed a high rate of expiration (20%), with additional high rates of poor physical, social and emotional outcomes among those alive. Additional investigations of these long-term outcomes that include factors that promote more positive outcomes are warranted.


0515

Case report: The effects of 12 months of therapeutic exercise and horseback riding on strength, endurance, postural control and cognitive function in one veteran with anoxic brain injury Louisa Summers, & Maria Sebastiani Eastern Kentucky University, Richmond, KY, USA Background: For some individuals with brain injury, a common pathway after physical and occupation therapy discharge is community-based exercise and adapted recreation. Yet, the functional effects of these services are largely unknown. Objectives: To examine the effects of 12 months of therapeutic exercise and horseback riding on the muscular strength, endurance, postural control and cognitive function in one veteran with anoxic brain injury. Methods: One male participant, aged 28, 3 years post-injury, enrolled in a therapeutic exercise programme for adults with chronic conditions. In addition, the participant had been and continued to participate in weekly therapeutic horseback riding sessions. Muscular strength, endurance and postural control were measured on the horse via level of support and total time; and unsupported sitting time on a mat table. Anthropometric measures were taken in the forearm, arm and leg. Lastly, cognitive function was measured quarterly using the Mini Mental State Exam. Therapeutic exercise was twice per week for 60–90 minutes. Functional exercises were designed to improve the muscular strength and endurance of the abdomen, back, upper and lower extremities. Each session, 5–12 repetitions of 6–10 exercises were performed. Exercises included: shoulder abduction, flexion, extension, mini-squats, chair raises, reverse crunches and hip flexion. The cumulative number of repetitions at the beginning of the intervention was 80–90 repetitions and increased to 200–210 per session. Horseback riding occurred weekly for 1 hour. Results: In October 2012, the participant rode 40–45 minutes with moderate support on both sides. After 6 months of therapeutic exercise and horseback riding, the participant was able to sit up straight on the horse and ride for over 60 minutes. Most importantly, the participant needed only one hand on the right side for support. Anthropometric measures indicated that upper arm, forearm and upper thigh girth increased by 0.5–1.0 centimetres in diameter. After 9 months of exercise, the participant could sit unsupported on a mat table for 2 minutes; after 12 months, sitting lasted over 16 minutes. However, three quarterly examinations of the Mini Mental State Exam remained at 14.0 per session. Conclusions: The study indicates the therapeutic exercise and horseback riding programmes substantially increased the muscular

strength, endurance and postural control of a veteran with anoxic brain injury. Long-term community-based adapted physical activity programmes were able to increase function 4 years post-anoxic brain injury.

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The role of vocational rehabilitation within the neurocontinuum of care: The connection to the community for persons with acquired brain injury Thomas Owens, &Anna Coburn Touchstone Neurorecovery Center, Conroe, TX, USA Objectives: Participants will: (1) Recognize the value of formal vocational rehabilitation (VR) as a critical component of a comprehensive neuro-rehabilitation programme; (2) Differentiate traditional VR programmes from a non-traditional approach (neurointegrative) where the VR programme is imbedded within a neurocontinuum team; and (3) Compare and contrast the efficacy of the trial and error method of traditional VR vs the outcomes of incorporating more evidence-based practices into neurointegrative vocational plans for employment. Methods: A verbal and audio-visual presentation to descriptively discuss previously published research and professional experiences, including: (1) Disadvantages associated with referring patients near or at Maximum Medical Improvement to VR; (2) Barriers to persons with acquired brain injury (ABI) assimilating into the community and workforce; (3) Lack of research to formally evaluate the Return-toWork (RTW) outcomes of patients discharging from a comprehensive post-acute programme; (4) Lack of screening tools to maximize patients’ potential for RTW; (5) Lack of integration of traditional VR with comprehensive therapies; (6) Lack of support services assisting patients with the transition from the controlled settings into environmental, community and on-the-job settings; (7) Advantages of neurointegrative VR collaborating with a neuro-continuum team; (8) Advantages of incorporating evidenced-based situational assessments and job trials with medical treatment plans; (9) Advantages of the patient-centred VR approach for transitioning into the community and competitive employment; (10) Strategies used by the neuro-continuum team for a successful transition into the working world; and (11) Approaches to finding comparable services within the community as substitutes for a one-stop comprehensive programme. Results: Traditional VR is not as effective for patients with brain injury because it does not consider the diverse set of needs and barriers required for the re-entry into the community and workplace. Working within the neuro-continuum of care and utilizing the aspects of the evidenced-based supportive employment model improves chances of successfully returning to work. Neurointegrated VR is more productive because it pro-actively identifies and eliminates the barriers keeping patients from obtaining and, more importantly, maintaining employment. Conclusions: There seems to be a lack of understanding the rewards of using individualized neurointegrative VR methods to returning patients with ABI to work. An individualized collaborative effort with VR, therapeutic and medical interventions increases the probability of returning these patients to work. Identifying and implementing postdischarge compensatory strategies are critical in maintaining the positive worker traits. Post-employment support services are paramount for countering deficits and barriers to maintaining employment and successfully becoming a productive member of the community.

708 Additional research is needed to compare the effectiveness of different VR approaches in returning patients to work. This knowledge will benefit all rehabilitation practitioners committed to improving the overall quality-of-life for a patient with ABI.

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TMS related changes in functional connectivity of default mode network and associated neurobehavioural gains for subjects in vegetative state after traumatic brain injury Theresa Pape1, Joshua Rosenow2, Vijaya Patil1, Monica Steiner1, Brett Harton1, Xue Wang2, Todd Parrish2, Dulal Bhaumik3, Mark Conneely4, Alexander Nemeth2, Ann Guernon5, Weihan Zhao3, Amy Herrold1, & Sandra Kletzel1 US Department of Veterans Affairs, Hines, IL, USA, 2Northwestern University Feinberg School of Medicine, Chicago, IL, USA, 3University of Illinois at Chicago, Chicago, IL, USA, 4Federal Health Care Center, North Chicago, IL, USA, 5Marianjoy Rehabiitation Hospital, Wheaton, IL, USA

Brain Inj, 2014; 28(5–6): 517–878

subjects did not have changes in DMN functional connectivity. Collectively, evidence suggests that rTMS related CNC gains are related to enhanced functional connectivity within the DMN.

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Rate of disorders of consciousness in a prospective population-based study of adults with traumatic brain injury Marianne Løvstad1, Nada Andelic2, Rein Knoph3, Tone Jerstad2, Audny Anke4, Toril Skandsen5, Solveig L. Hauger1, Joseph T. Giacino6, Cecilie Røe2, & Anne-Kristine Schanke1 1

Sunnaas Rehabilitation Hospital, Nesoddtangen, Norway, 2Oslo University Hospital, Oslo, Norway, 3Sørlandet Hospital, Kristiansand, Norway, 4Faculty of Health Science, Tromsø, Norway, 5Trondheim University Hospital, Trondheim, Norway, 6Spaulding Rehabilitation Hospital, Boston, MA, USA

1

Objective: To characterize effects of repetitive transcranial magnetic stimulation (rTMS) on resting state functional connectivity (fcMRI) within the default mode network (DMN) for two non-randomized groups of subjects remaining in states of seriously impaired consciousness after traumatic brain injury (TBI) and for a group of healthy controls (HC). Methods: Subjects receiving rTMS (n ¼ 2) were in the vegetative state (VS) at study enrolment, which occurred 7 and 8 months after TBI. Subjects in the comparison group (CG) (n ¼ 3) were in the minimally conscious state (MCS) at enrolment, which occurred after acute rehabilitation an average of 104 ± 27.7 days after TBI. HC subjects (n ¼ 7) were age- and gender-matched to TBI subjects. For HC, rTMS and CG subjects, this study obtained fcMRI, at baseline and 6 weeks later. For rTMS and CG subjects, neurobehavioral measures were also obtained using the Coma–Near-Coma (CNC) scale where lower scores indicate more function. rTMS subjects received 30 rTMS sessions, over 6 weeks, to stimulate the Right Dorsal-Lateral-Prefrontal Cortex. Each session included 300 trains of paired-pulses provided at 110% of each subject’s motor threshold. CG subjects received a placebo intervention where compact discs comprised of silence were played through headphones four times per day for 6 weeks. HC subjects did not receive any intervention. fcMRI seed analyses using Fisher’s Z transformation was applied to correlations. Mean Z-values and 95% confidence intervals (CI), were computed. A significant change (p50.05) occurs when a mean-Z falls outside of CI limits. Results: CG’s mean baseline CNC (20.0 ± 3.5; CI ¼ 16.0, 24.0) did not significantly change 6 weeks later (16.7 ± 3.1; CI ¼ 13.2, 20.2) remaining within CNC level 1. CGs and HCs mean DMN-Zs (CG ¼ 0.46 ± 0.21; CI ¼ 0.35, 0.56) (HC ¼ 0.44 ± 0.12; CI ¼ 0.35, 0.53) also did not change between baseline and 6 weeks (CG ¼ 0.43 ± 0.12; CI ¼ 0.36, 0.49) (HC ¼ 0.48 ± 0.06; CI ¼ 0.44, 0.53). rTMS # 1s baseline CNC of 36 improved to 28 after 30th rTMS session progressing from CNC Level 4 to 2. After 30th rTMS his mean DMN-Z increased from 0.11 ± 0.11 to 0.18 ± 0.21. rTMS # 2s CNC score progressed from 34 to 24 after 30th rTMS progressing from CNC Level 3 to 2. After 30th rTMS, his mean DMN-Z increased from 0.17 ± 0.21 to 0.23 ± 0.23. Conclusions: During provision of rTMS, rTMS subjects made CNC gains and DMN functional connectivity increased. During placebo intervention, CG subjects did not make significant CNC gains. HC and CG

Objectives: A minority of patients with severe traumatic brain injury (sTBI) sustain prolonged disorders of consciousness (DOC); vegetative (VS) or minimally conscious states (MCS). Over the past decade there has been agreement on diagnostic criteria for both VS and MCS, allowing increased research efforts. However, given that there is no uniform system of care and marked cultural, economic and health policy differences in the approach to and care for patients with DOC, it is challenging to establish incidence rates. The current study aimed at establishing the occurrence of DOC 3 months after sTBI and to describe the course of recovery of these patients, as well as to explore epidemiological, medical and treatment-related factors that might distinguish patients with DOC from the sTBI population at large. Methods: This study forms part of a prospective multi-centre cohort study on severe TBI (sTBI) during 2009 and 2010, including adults (16 years) residing in Norway that were admitted within 72 hours following sTBI to one of the four university hospital Level I Trauma centres in the four geographically determined health regions, ensuring coverage of the total sTBI population. sTBI was defined as Glasgow Coma Scale (GCS) score 8 within the first 24 hours after injury. Three months post-injury, it was registered how many study participants had not regained normal consciousness, defined by a Disability Rating Scale score 411, in combination with inconsistent command following. Diagnosis of VS and/or MCS was established with the Coma Recovery Scale Revised. Patients with DOC at 3 months follow-up, were reassessed at 12 months and between 2–3 years post-injury. Results: Three months post-injury, 2% of the sTBI population remained in VS or MCS, reduced by half after 1 year, corresponding to average annual age-adjusted incidence rates of DOC of 0.09/100 000. At 3 and 12 months, the VS incidence was 0.06 and 0.01/100 000 and 0.03 and 0.04/100 000 for MCS. Diagnostic categorization was stable between 12 and 24–36 months, although clinically relevant improvements were observed in MCS patients. The DOC group had lower GCS than the sTBI group, both at the site of injury and during the first 24 hours after injury, indicating more severe head injuries from injury onset. All DOC-patients but one displayed sub-cortical grey matter lesions as well as diffuse axonal injury (DAI). Conclusions: The findings represent unique epidemiological data on DOC following sTBI, indicating low incidence of prolonged posttraumatic DOC in Norway. Patients with prolonged DOC sustained more severe injuries from the time of injury than patients with sTBI without prolonged DOC and they were characterized by DAI and subcortical grey matter lesions. The findings indicate lower incidence of DOC than previously published reports.

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Substance use and brain injury: Helping families get the information they need

traumatic brain injury and mental health disorders Amy Herrold1,8, Brett Harton2, Neil Jordan3,9, R. Andrew Chambers4, Todd Parrish5, Xue Wang5, Kush Kapur6, & Theresa Pape7

Judith Gargaro, & Carolyn Lemsky 1


Community Head Injury Resources Services, Toronto, ON, Canada

Background: Brain injury, substance use and serious mental illness create inestimable challenges for survivors and their loved ones. Family education and intervention offers the promise of reducing distress and suffering in family members and improving outcomes for brain injury survivors who are better supported during the course of intervention. Unfortunately, there are few resources designed to meet the needs of families and people living with these co-morbid conditions. Addiction-based resources do not include discussion about how cognitive impairments may impact the process of treatment nor deal specifically with matters of consent and capacity. Brain injury resources do not provide information about how to support a loved one who is using substances in a harmful way, modes of treatment or the impact of these disorders. Objective: To develop educational resources that would be available to family members and survivors living in a variety of geographic locations. Method: Existing resources were reviewed, highlighting existing research findings and noting strengths and weaknesses. Information was collated regarding content, structure and access. Focus groups and presentations were conducted to solicit feedback from both family members and service providers about the proposed content and structure of the new resource and the proposed implementation strategy. After this feedback the resource was developed and distributed to a group of interested family member and support provider volunteers for further feedback. Once the resource was finalized it was pilot-tested on a small group of families. Results: The existing resources reviewed were the Brain Injury Family Intervention (BIFI); the Substance Use and Brain Injury Bridging project materials (SUBI), A Family Guide to concurrent disorders (Center for Addictions and Mental Health) and Community Reinforcement and Family Therapy. Initial focus groups endorsed the need for the manual resource and requested that the manual be suitable for self-study and group intervention. A main theme was that substance use issues often appeared after most acute rehabilitation services had ended. Family members then found themselves trying to cope with addictions or mental health systems ill-prepared to manage the brain injury survivor’s needs. Having a single reference to use for both information and advocacy was valued. They endorsed the need to address the following topics: Basic information about brain injury, substance use and mental illness; What is normal?; Role of Family; Communication; Coping; Taking care of self; and System navigation. This study developed Tip Sheets where information is presented in a clear and accessible way entitled: Brain injury and substance use don’t mix; What to do if there is use; Managing crises; Stages of change; Determining capacity; and Taking care of yourself. Discussion: This presentation will provide an overview of the content of the Family resource as well as findings from the follow-up focus groups.

0521

Case series examining the neural responeses to alcohol cues among veterans with mild

The Department of Veterans Affairs (VA), Center for Innovation for Complex Chronic Healthcare, Edward Hines Jr. VA Hospital, Hines, IL, USA, 2Chicago Association for Research and Education in Science, Hines, IL, USA, 3Department of Psychiatry & Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA, 4Department of Psychiatry and Institute of Psychiatric Research, Laboratory for Translational Neuroscience of Dual Diagnosis & Development, Indiana University School of Medicine, Indianapolis, IN, USA, 5Department of Radiology, Northwestern University, Chicago, IL, USA, 6Clinical Research Center, Boston Children’s Hospital, Department of Neurology, Harvard Medical School, Boston, MA, USA, 7 Edward Hines Jr. VA Hospital, Research Service, Hines, IL, USA, 8 Northwestern University Center for Healthcare Studies, Feinberg School of Medicine, Chicago, IL, USA, 9Northwestern University Feinberg School of Medicine, Department of Physical Medicine and Rehabilitation, Chicago, IL, USA Objective: Mild traumatic brain injury (mTBI), mental health disorders (MHDs) and alcohol use disorder (AUD) are prevalent among Veterans. The neural response to alcohol cues has been characterized for people with AUD alone. Little is known about the effect of cooccurring AUD, mTBI and MHDs (AUD + mTBI + MHDs) on the neural response to alcohol cues or network connectivity. The study objective is to compare neural activation and connectivity among individuals with these conditions. Methods: Case series of three adult males including a civilian with AUD only, a Veteran with mTBI and MHDs and a Veteran with AUD + mTBI + MHDs. Participants completed the Alcohol Use Disorder Identification Test, comsumption questions to assess alcohol use and screen for probable AUD and the Penn Alcohol Craving Scale to assess alcohol craving. fMRI data were acquired in the presence of alcohol cues and at rest (resting state functional connectivity). Results: The Veteran with AUD + mTBI + MHD had the greatest brain activation in response to alcohol cues. Functional activation and connectivity findings suggest different brain states for all three cases. Conclusions: Larger studies of the neural signatures of alcohol craving in populations with various combinations of AUD, MHD and mTBI are needed to understand how these disorders interact and synergize.

0522

Is it possible to develop a sharedcare model of service provision with an ACT team and a community-based ABI service provider? Judith Gargaro1, Carolyn Lemsky1, Mohamed Badsha2, Lucy O’Brien2, & Stephanie Wolfert2 1 2

Community Head Injury Resource Services, Toronto, ON, Canada, Reconnect Mental Health Services, Toronto, ON, Canada


710 Objective: Care models that increase access to community-based services for clients with complex needs, including ABI, within existing resources are in high demand. Decades of research have demonstrated that Assertive Community Treatment (ACT) is acceptable to clients and results in functional improvement. Unfortunately, Canadian ACT criteria exclude individuals with a known diagnosis of ABI. ABI providers often exclude individuals with diagnoses of serious mental illness (SMI). This pilot study assessed a model of shared-care between an ACT team and an ABI provider. The goals were to assess the feasibility of caring for individuals with ABI by an existing ACT team with support from an ABI provider and propose a model of shared-care. Methods: Individuals with SMI who were heavy-users of psychiatric services and who had a history of moderate-to-severe ABI were served. The ACT and ABI teams participated in formal cross-training. Training topics included stigma and information related to both comorbidities, along with practical case management information. Clinical consultation services were provided to the ACT team by a neuropsychologist, occupational therapist and behaviour therapist from the ABI provider. The impact of shared-care on ACT team fidelity was measured using the Dartmouth ACT Scale. The impact of crosstraining was measured by satisfaction and attitude-change surveys conducted before the partnership initiation and after the pilot concluded. Client outcomes were measured by Goal Attainment Scaling, the Mayo-Portland Adaptability Inventory-4 and the Neurobehavioural Functioning Index. Family outcomes were measured using the Burden Assessment Scale and days in hospital and psychiatric visits were tracked. Results: Each of the study participants had very complex unique needs and required a flexible and creative approach. Twenty-seven staff members completed pre- and post-training questionnaires. Each team started with low expectations of its ability to manage this challenging population and described the unfamiliar clientele as more dangerous and unpredictable than its typical clientele. Postpilot they reported satisfaction with the training and an increased awareness of the needs of this complex population. They valued having access to a team with the other expertise and were more willing to accept complex individuals into their caseloads. ACT Team fidelity was not adversely affected by shared-care. Clients showed improvement in outcomes and goal achievement. This experience highlighted the similarities among both clienteles. A model of service delivery has been developed that maximizes existing infrastructure. Conclusions: Clients with co-morbid ABI and SMI are falling through the cracks. The shared-care model is feasible and seems to lead to improvements in service and function. While having both teams involved with clients requiring more hours of direct support and supervision is helpful, it is proposed that, for most, a joint-triage model may increase efficiency and service capacity without duplicating resources. It is suggested that this model is scalable.

0523

Practical strategies for problematic substance use after brain injury: Tales from the frontline Carolyn Lemsky1, Judith Gargaro1, Roby Miller1, Jennifer Marsan1, & Jodi Wolff2 Community Head Iunjury Resources, Toronto, ON, Canada, 2Centre for Addiction and Mental Health, Toronto, ON, Canada

Brain Inj, 2014; 28(5–6): 517–878

designed to facilitate the implementation of psycho-educational and case management interventions in brain injury settings. This study will present outcomes of a Canadian intervention pilot based on the SUBI materials using standardized outcome measures. Practical issues, such as format of the groups, case management and outcome assessment, will be discussed. Methods: Psycho-educational groups, based upon the SUBI materials, lasting for 16 weeks were implemented with a small group of survivors of acquired brain injury. All participants met the DSM-V criteria for substance use disorder. The content of sessions included information about the particular harms associated with substance use and brain injury and an emphasis on cognitive-behavioural strategies for recognizing and coping with triggers for substance use. Individualized support with problem-solving was also provided. Client outcomes were measured by Goal Attainment Scaling, the Mayo-Portland Adaptability Inventory-4, the Behavioural and Symptom Identification Scale-32 (BASIS-32), TBI Quality-of-Life (PROMIS) and the Neurobehavioural Functioning Index (NFI). Results: All group members improved with respect to depressed mood as measured by the NFI. Trends for improvement with respect to positive affect, quality-of-life and symptoms as measured by the BASIS-32 were also observed. The majority of group members reported reduction or cessation of their substance use, as measured by self-report, with retention of substance use changes at 3- and 6month follow-up. Group members identified that engagement in meaningful activities and the development of coping strategies such as mindfulness were the most effective aspects of the programme. Goal achievement was assessed at 6 months and 12 months and clients achieved average T-scores of 57.00 and 60.51, respectively. A Tscore of 50 reflects an expected level of achievement, so the study participants achieved at a better than expected level that seems to improve over time. Discussion: Psycho-educational groups are feasible for implementation in community-based settings specializing in care for people living with brain injury. They appear to be effective in reducing harms associated with substance use and, in a majority of cases, reducing substance use. While psycho-educational groups may become a recommended intervention, it is found that they are not sufficient to encourage long-term abstinence. Case management is generally required to encourage engagement in meaningful activity which competes with substance use. Practical issues, such as encouraging group attendance, coping with multiple co-morbid conditions, including pain and psychiatric disorders, alternatives to competitive employment for meaningful engagement will be discussed. Examples of the integration of neurobehavioural techniques along with common substance use interventions will be provided.

0524

Are mental health providers treating brain injury survivors? Results of a large-scale screening project Carolyn Lemsky1, Judith Gargaro1, Tim Godden2, Lucy O’Brien3, Mohamed Badsha3, & Peter Selby2 1

Community Head Injury Resource Services, Toronto, ON, Canada, Centre for Addiction and Mental Health, Toronto, ON, Canada, 3 Reconnect Mental Health Services, Toronto, ON, Canada 2

1

Background: Problematic substance use after brain injury affects as many as one in five survivors, yet only a handful of studies have examined the practicality and efficacy of intervention. The Substance Use and Brain Injury Bridging Project (SUBI) has developed materials

Background: Thirty-to-70% of people presenting for addiction treatment have a history of traumatic brain injury (TBI). This in turn is a predictor of cognitive impairment and concurrent psychiatric symptoms. Unfortunately, history of TBI is infrequently considered in the development of addictions and mental health programming.

711


DOI: 10.3109/02699052.2014.892379

Objective: The goal of this screening project was to explore the relationship between TBI and client characteristics in two settings: a specialized and academic addiction treatment hospital (CAMH: Centre for Addiction and Mental Health) in downtown Toronto and a community-based mental health services provider (Reconnect: Reconnect Mental Health Services) also in Toronto. Method: The Ohio TBI identification method was completed with all adults seeking addiction treatment at the main CAMH campus and being supported by Reconnect. Findings from clinical assessment measures were available from the CAMH participants and included the Addiction Severity Index-Lite, the Behavioural and Symptom Identification Scale-32 (BASIS-32) and other standardized measures. In addition demographic, diagnosis and treatment engagement data were collected for all screened participants. Results: Of the 1131 CAMH clients screened during a 16-month period, 38% reported at least one TBI. Of these, 65% reported at least one injury with loss of consciousness. Of the 160 Reconnect clients screened during a 6-month period, 54% reported at least one TBI. Of these, 58% reported at least one injury with loss of consciousness. The age range was from 18–80 years with the average age of 41 years. Approximately 50% of the combined sample sustained their most serious brain injury prior to age 15 years. Almost 10% of the combined sample sustained a severe brain injury. The most common causes of injury were assault (29%), motor vehicle collision (27%) and falls (25%) and the most common causes of multiple mild injury were sports and abuse. Preliminary analyses indicated that those with a history of TBI with loss of consciousness were at risk for repeated episodes of care and psychiatric symptoms including psychosis, aggression and self-harm. History of childhood TBI and repeated mild TBI were also associated with greater symptom complexity. Discussion: Approximately 25% of the overall sample presented with a history of TBI involving loss of consciousness and elevated risk for neurocognitive and psychiatric symptoms and poorer treatment outcomes. These data clearly underscore the need to raise awareness in addiction and mental healthcare settings regarding the need for screening for ABI and the development of adapted services. Emphasis will be given to recommendations for clinicians and programmes regarding how these data may be used to raise awareness of brain injury in addictions treatment settings and advocate for timely and appropriate care. Implications for programme development and policy will also be discussed. Limitations: Causality cannot be determined in this study.

0525

The impact of tablet use on motivation and language outcomes in the inpatient rehabilitation setting: A case study Brittany Davis, & Anna Holzbach Sheltering Arms, Mechanicsville, VA, USA Objectives: This study examined the impact of tablet device (iPadÕ ) use on motivation and language outcomes during inpatient rehabilitation speech-language treatment for a female CVA patient with expressive aphasia. The aphasia was most consistent with anomic aphasia, status post-left anterior communicating artery (ACA) embolic CVA. Assessment of communication and motivation was conducted at initial evaluation (prior to implementation of Speech Language Pathology (SLP) treatment) and at discharge from inpatient rehabilitation. Traditionally, motivation, feedback and goal-setting have been viewed as fixed components in the rehabilitation story: clinicians may view motivation as a patient-owned and directed

characteristic, whereas feedback and goal-setting are clinician-owned and directed. Those elements, however, are highly variable and should demonstrate change with each individual treatment plan. Although research has been conducted in the areas of neural plasticity, feedback and motivation, it is uncommon for these concepts to be fully integrated when completing a patient’s therapy plan of care. The use of table devices may assist with that integration. Method: Throughout the participant’s stay, an iPad was utilized within structured treatment sessions and was provided to her with a pre-arranged homework programme to be utilized ‘after-hours’ as a supplement to treatment tasks. Results: Results indicated improvement in motivation levels and functional communication levels as measured by the Situational Motivation Scale and the Adaptive Behavior Assessment SystemÕ – Second Edition. Conclusion: The findings of this case study provide support for tablet device use in speech-language treatment to aid in enhancing motivational levels and functional outcomes in the intensive rehabilitation setting.

0526

Novel, high-tech walking recovery programme improves motor recovery Matthew Wilks, Melissa Banta, & Amber Devers Sheltering Arms, Mechanicsville, VA, USA Introduction: Although there are a number of studies investigating walking recovery after stroke, most focus on one intervention or piece of equipment in order to achieve a controlled experimental environment. Such studies have yet to produce a comprehensive clinical practice guideline (CPG) for gait training. To fill this void, the authors implemented a clinical programme for walking recovery, iWalkä, using a variety of advanced technologies as well as evidence-based CPG to assist in making assessment and intervention decisions. This study compares outcomes of patients treated using a traditional therapy programme to those treated with the iWalk programme. Hypothesis: The systematic application of an evidence-based CPG for walking recovery will result in superior motor performance when compared to traditional therapy with post-stroke patients. Methods: This study included all stroke survivors admitted to a rehabilitation facility during a 24-month period, with the cohort split into two groups. The control group received traditional rehabilitation (n ¼ 152) and the experimental group received the iWalk protocol (n ¼ 165). Since full implementation of the protocol could not be assigned a specific date, a buffer group (n ¼ 50) between the two groups was excluded from this analysis. This buffer allowed for time for skill acquisition, practice and full adoption of the CPG into clinical practice. Results: Functional Independence Measure (FIM): An interaction between age and treatment programme was detected (p50.001). Motor FIM scores showed greater improvement for younger patients in iWalk than in the traditional therapy programme. Length of Stay: When examining LOS as an outcome, an interaction between treatment group and total FIM score was detected (p ¼ 0.073). Patients who were lower functioning on admission were more likely to be discharged home if they were in the iWalk programme. Examining LOS as a predictor, the difference in timedup-and-go (TUG) scores between the treatment groups reveals that iWalk seems to be better for a LOS 3 weeks, but is not significant (p40.05). Conclusions: This study demonstrates outcome differences that favour the CPG-based iWalk interventions. Additionally, there may be a LOS range which optimizes motor recovery. It is unclear whether

712 a patient’s LOS is a reflection of the improvement of clinical variables or practical reasons (such as discharge disposition), necessitating additional study.


0527

Brain Inj, 2014; 28(5–6): 517–878

0528

Validating the presence of highsensitivity and high-specificity of mild traumatic brain injury (mTBI) through diffusion tensor imaging (DTI)

Screening and identification of individuals with brain injury (BI) seeking services through the area agency on ageing in rural Nebraska

Tsukasa Tanaka, Nina Butingan, Kirk Shin, Alan Tsai, Eric Chang, Pauline Phan, Vivian To, Angela Wei, & Joseph Wu

Miechelle McKelvey, & Erin Bush

UC Irivine, Irvine, CA, USA

University of Nebraska Kearney, Kearney, NE, USA

Traumatic brain injury (TBI) is one of the leading causes of disability worldwide and it affects 1.7 million people in the US alone. However, damage after TBI does not have to be severe to exhibit post-injury symptoms. Most secondary brain injury is a consequence of mild TBI (mTBI). Medical imaging techniques have greatly enhanced the detection of such injuries. In a previous study, four raters used diffusion tensor imaging (DTI) Z-maps and blindly categorized 28 controls and 18 patient fractional anisotropy (FA) Z-map images and found highly accurate categorization with high-sensitivity (95.7%) and high-specificity (98.2%) in detecting mTBI. This study has analysed a new cohort of 20 traumatic brain injured patients at least 6 months post-mTBI against 42 controls (from the Functional Bioinformatics Research Network (FBIRN)) using a p-value of 0.01 and voxel threshold of 30. Positive and negative contrasts were created to construct the z-maps. Five raters were trained in identifying mTBI z-maps using the previous study findings and blindly categorized the FA Z-maps of the new TBI cohort and the larger control group of 42 into TBI or control patterns. The categorizations were then judged to be either a true positive, true negative, false positive or false negative depending on whether the rater accurately assigned the Z-map to the correct group. The average sensitivity was reported as 94.09% + 0.06% and specificity was 87.98% + 0.06%. This indicatess that FA Z-maps through DTI provide an accurate and robust method for discriminating mTBI from normal controls.

Objectives: The researchers aimed to: (1) Provide education about brain injury to service co-ordinators using a pre- and post-survey; (2) Train the service co-ordinators to administer a specific brain injury screening tool; (3) Interview the service co-ordinators about screening tool use and their feelings of preparedness when administering the screening tool; (4) Acquire data regarding the number of positive brain injury screens attained by the service co-ordinators; and (5) Conduct a follow-up interview with service co-ordinators 3 months after the training. Methods: The current project focused on the need for routine brain injury screenings for the elderly, aged 65 years and over. This population is at great risk for brain injury due to the common cooccurrence of other neurological conditions as well as the frequency with which they experience falls and motor vehicle accidents. This research project involved gathering data from two different sources. The first source is service co-ordinators employed by the Area Agency on Ageing (Group A). The second source is a de-identified database of clients from the same agency (Group B). Participation for Group A (n ¼ 6) consisted of seven tasks: (1) completion of a demographic questionnaire; (2) completion of a pre/post survey about common misconceptions about brain injury; (3) attendance of a brain injury education; (4) completion of a training session regarding accurate administration and scoring of the screening tool; (5) participation in a focus group interview regarding their perceived preparedness for screening clients with possible brain injury; (6) screened of all their current clients and new referrals (n ¼ 83) over a period of 3 months; and lastly (7) completion of a follow-up interview 3 months posttraining. Results: Analysis of the pre/post surveys indicated that participants increased their knowledge of brain injury (i.e. recovery process, BI sequelae and disorders of consciousness). During the posttraining interviews, participants stated the tool would be helpful in identifying individuals with brain injury but were concerned about administration time and ease of scoring. Eighty-three individuals were screened. Of those, 34% were identified as having a possible BI. Ninety-nine incidences of potential brain injury were reported because many individuals reported multiple injuries. Of the individuals that had a positive BI screen, 10 had a loss of consciousness; 14 reported symptoms following the injury (i.e. feeling dazed, confused and a gap in their memory). This indicates that 50% of the individuals screened reported symptoms without a loss of consciousness. Conclusions: These findings support the need to screen elderly individuals for brain injury given the number that tested positive for possible BI on the screening tool. Secondly, data from the screening tool also supports the premise that individuals who sustain a BI do not have to have a loss of consciousness to be symptomatic.

0529

Chronic inflammation is correlated with long-term behavioural impairment following blast exposure Sujith Sajja, William Hubbard, & Pamela VandeVord Virginia Tech University, Blacksburg, VA, USA Objectives: Psychiatric and psychological issues are commonly associated with people suffering from blast induced neurotrauma (BINT). Both clinical and animal models have shown declined cognition following blast exposure. Limited studies have evaluated the chronic effects of blast on cognitive deficits in animals. Issues with specific behavioural type (e.g. short-term memory or long-term memory, etc.) have not been defined in literature so far. In order to understand the long-term effect of blast on memory and anxiety, this study evaluated short-term memory and anxiety paradigms at 1 and 3 months following blast exposure in an established rodent model of BINT. The hypothesis is that impaired cognition is

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DOI: 10.3109/02699052.2014.892379

associated with chronic inflammation following blast over-pressure exposure. Methods: Male Sprague Dawley rats (n ¼ 12) anaesthetized with 3% isoflurane were exposed to calibrated blast over-pressure (17 psi/119 KPa), while control animals (n ¼ 12) received only anaesthesia. Animals underwent a novel object recognition test for short-term memory and light and dark box test for anxiety. Animals were euthanized at 1 month or 3 months following exposure. Brains were collected, sectioned and stained using immunohistochemistry for apoptotic cell death (cleaved caspase-3), neuronal population (NeuN) glial activation (Iba and glial fibrillary acidic protein, GFAP), tau protein aggregation, in the prefrontal cortex (PFC), amygdala (AMY), nucleus accumbens (NAC) and hippocampus (HIPP). Results: Impairment in short-term memory (p50.005) and anxiety-like behaviour was observed at 1 and 3 month time points in the blast group. A significant increase in levels of GFAP and Iba1 was observed in HIPP, PFC and AMY; NAC has increased Iba1 but not GFAP at 1 and 3 months post-blast. Only PFC showed increased cleaved caspase-3 levels; decreased NeuN was found in HIPP, NAC, PFC and AMY at 1 and 3 months. In addition, increased tau protein aggregation was observed in PFC and HIPP at 3 months post-blast, but not in AMY and NAC (p50.05). A significant positive correlation was observed between microglial expression and anxiety; astroglial expression and behavioural impairment at 3 months following blast overpressure exposure. Conclusion: The data demonstrated that exposure to blast caused significant impairment in short-term memory and anxiety-like behaviour in 1 and 3 month time points. Immunohistochemistry data demonstrated elevated levels of activated glia in addition to neurodegeneration. Overall, the evidence suggests that glial cells are highly susceptible to blast injury. Overall, in accordance to the hypothesis, the data indicated elevated levels of inflammation (glial activation) and neurodegeneration at 1 and 3 months following blast over-pressure exposure. In addition, inflammation is correlated with behavioural impairment at 3 months following blast over-pressure. Collectively, increased tau protein aggregation and impaired shortterm memory showed the tendency of dementia-associated symptoms and pathology following blast exposure.

0530

A case study of participatory design that supports metacognition after TBI: Collaborating with low and high technology Katy O’Brien, & Mary Kennedy University of Minnesota Twin Cities, Minneapolis, MN, USA Objectives: For individuals with traumatic brain injury (TBI) who live with severe memory impairments, therapy typically focuses on teaching compensatory, external memory devices. In participatory design (PD), specifications of external memory aids are determined through dialogue with the client so that their preferences, needs and abilities can be incorporated, resulting in an implicit understanding and manipulation by the client. Objectives of this case report are to: (1) Describe the initial use of PD to create low tech memory aids; and (2) Demonstrate how metacognitive and self-regulatory processes are fostered during PD and eventually resulted in instantiated complex routines used in college. Methods: A PD process was initiated with a 19-year-old male with chronic severe declarative memory impairments returning to college after TBI. Guided questioning probed his memory needs and resulted in a list of necessary features for an assignment planner.

Initial layout of planner was provided by the clinician. Revisions followed. A mixed methods design examined performance and metacognitive targets. Quantitative measures included iterations to final version and items suggested and retained by the clinician vs student. Qualitative outcomes described student-initiated revisions, analysis of discontinued use of features, amount of reported assistance and reports of family and educational stress. The student was followed 1.5 hours weekly for 2 academic years and 1.5 hours biweekly for one semester. Results: At onset, the student had two commercially available planners for school and personal use, but was dependent on parents for management of both. PD planner went through four major re-designs across three sessions. The student suggested an equal number of features as the clinician for the initial draft (12); however, 91.7% of student’s suggestions were retained to final draft, as opposed to 58.3% of clinician features. After 3 weeks, the student required minimal assistance only. Other classmates also began asking the student to clarify homework assignments for them. The student maintained use across four semesters, eventually transitioning to a reminder application on his iPhone 4S. The student used his planner as a script to enter assignments into his phone for one semester before fading. Conclusions: In this case study, PD supported a student’s ability to recall and complete homework assignments, while also enhancing self-regulation of his learning and strategy use. Almost all features identified by the student for the planner were retained in the final version, while just slightly more than half of the clinician’s features were held over, suggesting the student had access to idiosyncratic knowledge of his learning processes that would likely have been missed had he not been involved directly in planner design. Engaging the student in a dialogic PD process allowed the student to access and reflect on his memory needs, leading to instantiation of a complex organizational memory routine.

0531

Concussion awareness of athletic school professionals in rural Nebraska: A response to concussion legislation (LB260) Erin Bush, Miechelle McKelvey, & Catherine Paulsen University of Nebraska Kearney, Kearney, NE, USA Objectives: (1) Determine level of knowledge regarding concussion and concussion legislation professionals working with student athletes have; (2) Determine current practices regarding student athlete concussions and recent changes in practices; (3) Determine whether respondents feel their practices are effective; and (4) Determine if respondents feel they need more support and/or education in addressing student athlete concussions. Methods: The researchers sent out a survey to all athletic directors, members of the Nebraska State Interscholastic Athletic Administrators Association (NSIAA), who were then directed to send it to their coaching staff. The respondents were 31 non-coaches and the 201 coaches. Seventeen (55%) of the non-coach participants and 173 (86%) of the coach participants data was kept for analysis. Participants were eliminated if they did not fill out at least 85% of the survey or if they labelled their district as urban. Results: There were 190 participants. One hundred and fifty respondents (79%) had high knowledge of concussion, 16 (8%) had moderate knowledge of concussion, while 24 (13%) had low knowledge. One hundred and seventy-eight participants (94%) were aware of the Concussion Legislation (LB260), that was passed in July 2012. One hundred and fifty-eight (83%) reported that their district had made changes to their practices since the passing of LB260. One hundred and

714


sixty-three participants (86%) reported that their school used computerized neurocognitive testing. Of those that did use neurocognitive testing, 50% used ImPACT. The other 50% reported they didn’t know the name of the test, they referred the student to a doctor or hospital or they did not answer the question. Ninety-eight per cent of those who used neurocognitive testing obtained a baseline, 97% performed the testing after every student concussion and 74% conducted baseline testing annually on all student athletes. Regarding computerized neurocognitive testing, 136 (88%) of respondents (n ¼ 154) reported that they were confident in the interpretation of the results. One hundred and fifteen respondents (61%) reported that they would like further training about concussion (50% of these respondents would prefer to have further training at the school district level; 40% a local conference; and 10% a national conference). Conclusions: To prevent youth athletes from concussions and the life altering side-effects, educators working with school-age athletes have both a moral and legal obligation to enforce their state concussion laws. In order to do this effectively, school professionals must have adequate knowledge of concussion symptoms, sequelae and concussion management. New legislation and/or policies are often challenging to implement into well-established programmes, but necessary for the safety and well-being of student athletes.

0532

In-hospital and 1-year outcome of 1281 severe TBI patients from India Deepak Agrawal, Vineet K. Kamal, & R. M. Pandey All India Institute of Medical Sciences, New Delhi, India Background: Although developing countries like India bear the maximum load of TBI, there is insufficient data on outcome of these patients in these countries. Aims and objectives: To assess the in-hospital mortality and 6 month outcome of patients with severe TBI managed at a single institution in India. Materials and methods: This prospective study was carried out at a level I trauma centre in New Delhi over a 26-month period (May 2010–July 2012). Clinical and radiological records of consecutive patients of severe TBI (GCS 8) were analysed. Outcome assessment was done by assessing in-hospital mortality. Twelve-month outcome was assessed using GOS. A GOS of 1–3 was considered as ‘unfavourable’ outcome and GOS 4–5 was considered as ‘favourable’ outcome. Observations: A total of 1281 patients were enrolled in the study. There were 1114 (87%) males and 167 (13%) females with the mean age of 31.96 ± 16.42 years (range ¼ 1–90 years). The overall mortality was 38.56% (n ¼ 494). Of the 523 patients with motor score of 5, 81 (14.65%) expired. The mortality was 29.38% (n ¼ 57) in patients with motor score of 4; 39.05% (n ¼ 41) in patients with motor score of 3; 63.53% (n ¼ 169) in patients with motor score of 2 and 91.19% (145) in patients with motor score of 1. Overall, 71.54% (n ¼ 646) had unfavourable outcome at 6 months. Unfavourable outcomes were 39.94% (n ¼ 125) in patients with a motor score of 5, 71.43% (n ¼ 95) in patients with a motor score of 4, 85.71% (n ¼ 60) in patients with a motor score of 3, 93.45% (n ¼ 214) in patients with a motor score of 2 and 96.79% (n ¼ 151) in patients with a motor score of 1. Conclusions: This is the largest single centre study of its kind from the Indian sub-continent and shows that large number of severe TBI (28.45% in this study) had favourable outcome at 12 months. This study also shows that a significant number of patients with poor GCS may have good outcome and, therefore, aggressive management should be done for all severe TBI patients.

Brain Inj, 2014; 28(5–6): 517–878

0533

Therapy intensity level (TiL): Establishing a promising prognosis marker in TBI patients Charles Overbeek1, E´rik Therrien1, Marie-Julie Potvin2, Virginie Williams2, Jean-François Gigue`re2, Nadia Goselin2, & Francis Bernard2 1

University of Montreál, Montreál, Que´bec, Canada, 2Hoˆpital du Sacre´-Coeur de Montreál, Montreál, Que´bec, Canada

The aim of neurocritical care is to prevent secondary brain injuries in order to improve outcome of traumatic brain injury (TBI) patients. All TBI patients may not require the same therapeutic interventions in order to achieve this goal. This might reflect disease severity and could be used as a prognostic marker. Alternatively, if therapies are efficacious, aggressiveness of care should not be negatively related to survival or long-term outcome. The Therapy intensity Level (TiL) and the ISS and APACHE II score can be used to describe intensity of care and burden of disease, respectively. The goal of this study is to determine if TiL, ISS and APACHE II differ between survivors and nonsurvivors of TBI. This study retrospectively calculated daily TiL throughout neurocritical care stay and admission APACHE II score of 89 TBI patients, admitted between April 2011 and March 2012, at a level one trauma centre in Montreal, Canada. Mean age was 46 years old, 24 patients were female and 52 had a motor vehicle accident. Twenty patients died before hospital discharge. In survivors, this study administered the EXACT, a new test designed to assess the global cognitive functioning of TBI patients. EXACT is given at hospital discharge and is related to outcome at 1 year. This study also performed the Glasgow Outcome Scale Extended (GOSE) and the Disability Rating Scale (DRS) at 1 year. Mean admission GCS were 7.2 vs 5.1 (p50.02), age 41 vs 64 (p50.001) and ISS score 25 vs 28 (ns), respectively, for survivors and non-survivors. Significant differences were noted between survivors and non-survivors, respectively, for mean daily TiL (3.5 vs 7.0; p50.001), TiL max score (6.7 vs 10.4; p ¼ 0.008) and APACHE II score (18 vs 26; p ¼ 0.001). Average ICU stay was longer in survivors (12.3 vs 7.7; p ¼ 0.03). The area under the curve (AUC) for TiL did not show significant difference between groups, although a trend for higher AUC in non-survivors was observed in the first 10 days (33.9 vs 42.9, NS). Among survivors, none of the TiL variables correlated with EXACT, GOSE or DRS. In multiple regression analysis, mean TiL and APACHE correlated with outcome. In conclusion, admission GCS, age, mean TiL, TiL max and APACHE II score showed significant differences between survivors and nonsurvivors. Whether TiL is a marker of disease severity and could be used as a prognostic factor needs to be confirmed in a larger cohort. TiL should probably be incorporated as a routine baseline characteristic to compare study groups. Therapy intensity does not seem to negatively affect long-term outcome among survivors.

0535

STAT1 negatively regulates spatial memory formation and mediates the memory-impairing effect of amyloid-beta Wei-Lun Hsu1, Yun-Li Ma1, Ding-You Hsieh2, Yen-Chen Liu1, & Eminy Lee1

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DOI: 10.3109/02699052.2014.892379 1

Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan, Institute of Neuroscience, National Cheng-chi University, Taipei, Taiwan


2

Objectives: The signal transducer and activator of transcription-1 (STAT1) plays an important role in inflammation and the innate immune response, but its role in the central nervous system is less well understood. This study examined the role of STAT1 in spatial learning and memory and studied the involvement of STAT1 in mediating the memory-impairing effect of amyloid-beta. Methods: Adult Sprague-Dawley male rats, Stat1 knockout mice, drug infusion, plasmid DNA construction, plasmid and siRNA transfection, immunoprecipitation, promoter luciferase assay, quantitative realtime PCR, western blot, immunohistochemistry, DAB staining, Morris water maze learning. Results: It was found that water maze training down-regulated STAT1 expression in the rat hippocampal CA1 area and that spatial learning and memory function were enhanced in Stat1 knockout mice. Conversely, over-expression of STAT1 impaired water maze performance. STAT1 strongly up-regulated the expression of the extracellular matrix protein laminin-beta (LB1) and a previous study found that LB1 also markedly impaired water maze performance in rats. Furthermore, amyloid-beta dose-dependently impaired spatial learning and memory in association with a dose-dependent increase in STAT1 and LB1 expression, but knockdown of STAT1 and LB1 by RNA interference both reversed the memory-impairing effect of amyloid-beta. This amyloid-beta-induced increase in STAT1 and LB1 expression was also associated with a decrease in the expression of the N-methyl-Daspartate receptor (NMDAR) sub-units, NR1, NR2A and NR2B, with NR1 and NR2B showing a more significant effect. Over-expression of NR1 or NR2B or exogenous application of NMDA reversed amyloid-betainduced learning and memory deficits as well as amyloid-beta-induced STAT1 and LB1 expression. A separate set of experiments found that amyloid-beta treatment also decreased the expression of the alphaamino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptor sub-unit GluR1 and knockdown of GluR1 expression by GluR1 siRNA interference also increased STAT1 expression. Moreover, cAMPresponsive element binding protein (CREB) is known to play an important role in long-term memory formation. Here it was found that transfection of STAT1 siRNA did not affect CREB expression. Likewise, transfection of CREB siRNA did not affect STAT1 expression either. Conclusions: These results provide the first evidence that STAT1 negatively regulates spatial learning and memory formation and STAT1 impairs learning and memory through transcriptional regulation of LB1 expression. This study also identified a novel mechanism for amyloid-beta pathogenesis through STAT1 induction. Notably, impairment of spatial learning and memory by this STAT1-mediated mechanism is independent of CREB signalling.

0536

Exploring the use of a psychoeducational group for people living with acquired brain injury and substance abuse in Essex, England Steven Shears Headway Essex, Colchester, UK Objectives: The incidence of substance abuse in people who are living with acquired brain injury is significant however there have not been many studies into effective interventions with this group. The author used the Substance Abuse and Brain Injury Project (SUBI) workbook (Lemsky) and other materials within a psycho-educational group for

this service user group in England. The author will present outcomes and observations following the use of these materials with this group and discuss the practical issues around the complexity of this service user group’s needs. Methods: The group was a psycho-educational group of 12 week duration for 5 survivors of brain injury. All the group members either had current issues with substances or had done so in the past. The group made use of materials drawn from the SUBI Manual and the Substance Abuse and Traumatic Brain Injury Toolbox. The materials were cognitive behavioural and also used elements of Motivational Interviewing in parts. The overall aim was educational about the harm associated with substance abuse and acquired brain injury and the prevention of further harms by considering the pros and cons of further use, exploring the triggers for substance use and developing alternative coping mechanisms to using. Results: This was a disparate group in terms of their usage of substances and all had or currently experience co-morbid mental health problems. During the group 2/5 reported cessation or reduction of substances. Another member contemplated change (and after the group once managed a relapse in mental health status without recourse to alcohol). Another didn’t report any change and the final member had already ceased usage prior to the group. All filled in a simple exit outcome scale about their gains from the group such as attitudes towards substances and alcohol. A three month follow-up showed maintenance of gains in 2/5 of the group by self-report. Conclusions: This form of group would seem to have utility as an intervention in the community with people who face brain injury, substance misuse and mental health issues. They appear to be useful as part of a strategy of harm reduction and helping to prevent future risky behaviours. However, in itself this type of psycho-educational group is probably not enough to address the complexity of issues faced by this service user group or help them stay in abstinence or reduction. Active case management is needed to help them maintain their gains and will be discussed as will dealing in a group setting with multiple co-morbid conditions by the use of a holistic and integrative approach of therapies.

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Traumatic brain injury with minimally conscious state. Integral rehabilitation approach Ma Carmen Martinez-Garre, Laura Cuni-Dominguez, Xavier Buxo´-Masip, Susana Rodriguez-Gonza´lez, Inma Bori de Fortuny, & Isabel Martıń-Silva Hospital Vall d’Hebron, Barcelona, Spain Objective: Interdisciplinary therapies/integral rehabilitation: physiotherapy; occupational therapy, speech therapy, botulin toxin (BT) use and surgery can be applied throughout the rehabilitative process. The main goal was to demonstrate the effectiveness of integral treatment in a patient with traumatic brain injury with minimally conscious state. Methods: Male, 27 years old, who after traffic accident suffered left predominantly spastic tetraparesis secondary to severe TBI (Diffuse Axonal Injury). During his admission he evolved from vegetative state to minimally conscious state (MCS). After 5 months, he was admitted in the Rehabilitation Unit to be included in the integral rehabilitation treatment plan. He was fed by gastrostomy. He presented mutism. He had no head control and he had spasticity in both upper extremities and the left leg (Modified Ashworth Scale (AMS) 4/4) with left clubfoot. The patient typically showed severe dysfunction, needed assistance with activities of daily living and he was not able to walk independently. The treatment consisted of daily physiotherapy, occupational therapy, speech therapy and periodic injections with BT (XeominÕ ) in left clubfoot. At 2 years and 4 months post-TBI he had clubfoot corrective surgery (Full Rancho).

716 Results: Currently the patient is fed orally. Gastrostomy was retired. He has improved his understanding, he emits words and he use the computer writing to communicate. He has improved his behaviour, showing less aggressiveness. The right upper extremity spasticity disappeared and the left upper extremity spasticity decreased. All this improvement facilitated the ADL, especially the use of two canes for gait training. After surgery, the brace was removed and he was able to walk supervised with two canes. Conclusions: The patient in this case report showed significant improvements and functional gains during the course of comprehensive rehabilitation therapy: physical, occupational and speech therapy, infiltration with BT and surgery. It is believed that if this study could have started the holistic rehabilitation and infiltration with BT earlier, the patient could have avoided the surgery.


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Utility of diffusion tensor imaging of moderate-to-severe traumatic brain injury for detecting white matter injury Ana M. Castanõ-Leon, Marta Cicuendez, Rafael Martinez-Perez, Pablo M. Munarriz, Ana Ramos, Pedro A. Gomez, & Alfonso Lagares Hospital Universitario 12de Octubre, Madrid, Spain Objectives: Diffuse axonal injury (DAI) is presumed to play an important role in the neurologic outcome of patients after head trauma. Computed tomography (CT) or conventional magnetic resonance imaging (MRI) are poor at characterizing DAI and most times only indirect signs can be determined with these methods. The advaced MRI sequence Diffusion tensor imaging (DTI) allows identification of DAI by quantification of the degree and directionality of tissue water diffusion. The most commonly used scalar variant is fractional anisotropy (FA) that reflects the degree of alignment of fibre tracts and their integrity. FA can take values between 0 (completely isotropic) and 1 (highly anisotropic, the perfect situation in which water molecules can diffuse in just one direction of space). The main objective is to look for the correlation between FA values in different WM tracts and patient neurologic outcome after moderate and severe head trauma. Methods: Eighty patients (21 females and 59 males, mean age 35) admitted to the institution after suffering moderate TBI (30) and severe TBI (50), on the basis of GCS score at pre-hospital evaluation, were included. DTI were acquired on a 1.5-T scanner, with 25 diffusion gradient directions, in a mean interval of 24 days after the incident. This study used the method of Region Of Interest (ROI) to obtain the mean FA value of the following WM tracts: Corpus Callosum (genu gCC, body bCC and splenium sCC), Internal Capsule (anterior (ALIC) and posterior limbs (PLIC)), External Capsule (EC), Forceps Major (FM), Forceps Minor (Fm), Cingulum (Cing), Superior Longitudinal Fasciculus (SLF), Inferior Fronto-Occipital Fasciculus (IFO), Inferior Longitudinal Fasciculus (ILF), anterior, posterior and superior portions of Corona Radiata (aCR, pCR and sCR) and both cerebral peduncles (CP). Next, this study calculated Pearson correlation coefficient between FA values and patient outcome determined by Glasgow Outcome Score (GOS) at patient hospital discharge and extended Glasgow Outcome Score (GOS-E) 6-months after head trauma. It also tryed to find which portion of CC can best discriminate patient outcome by determining the proportion of patients correctly classified as good or poor outcome using FA values as a predictor by means of the area under the ROC curve (AUC). Results: The WM tracts in which low FA values showed significantly correlation with poor outcome were: all portions of CC, right sCR, left SLF, left ALIC, both PLIC, both EC and both CP. Pearson correlation coefficient showed a range of values between 0.283–0.514. The genu

Brain Inj, 2014; 28(5–6): 517–878

of the CC is the WM tract showing the highest correlation with outcome and the portion of the CC that best discriminates patient outcome. Conclusions: DTI abnormalities determined as low FA values in some WM fibre tracts are associated with poor outcome at hospital discharge and 6 months post-injury.

0539

Epidemiology of head injury in older adults attending the emergency department Sarah Scapinello1, Carol Hawley1, Harald Bjorndalen2, Helga Magnusson2, & Magdy Sakr2 1

Warwick Medical School, Coventry, Warwickshire, UK, 2University Hospital Coventry and Warwickshire, Coventry, Warwickshire, UK

Objectives and background: In 2011–2012 over 15% of UK emergency department attendances were by patients aged 65 and over. In view of the steadily increasing ageing population this number is likely to rise. Head injury is a major cause of presentation to hospital in this age group. The current UK epidemiological data available for head injuries in the elderly population is limited. This study was, therefore, designed to collect and analyse epidemiological data on head injuries in the 65 and over age group. Methods: Data was collected from Emergency Department (ED) casualty cards at a UK trauma centre in the Midlands. The study period covered a 12-month period from 1 October 2012 to 30 September 2013. All patients aged 65 and over with a head injury were included and data on demographics, mode of arrival, mechanism of injury, other injuries, co-morbidities, Glasgow Coma Scale (GCS), anticoagulation status, loss of consciousness and diagnostic imaging were collected and analysed. Results: Preliminary results show that during the study period 390 patients between the ages of 65–101 years old attended the ED with a head injury. Out of these patients, 222 were female (57%) and 168 male (43%). In the majority of cases (85%), the head injury had been caused by a fall; 4.9% of patients reported loss of consciousness secondary to the head injury; 25% of patients received a CT scan to exclude intracranial haemorrhage. Overall, only six patients out of 390 were admitted to hospital. Preliminary trends reveal that the majority of incidents are occurring in the home. The relationship between elderly head injury and social deprivation will be explored. Conclusion: Head injury is a common cause of attendance to the emergency department in the over 65 age group; however in 97.7% the head injury was minor and did not require hospital admission. This study, hence, shows that the majority of hospital resources spent on elderly patients presenting with head injuries are spent in the ED. Interestingly, most head injuries are secondary to preventable causes such as falls. These results could provide valuable information for emergency department service planning, as well as for primary care services looking into fall prevention and rehabilitation for elderly patients.

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Severe head trauma in older adults: Five years of data from one UK trauma centre Carol Hawley1, Magdy Sakr2, Sarah Scapinello1, Jesse Salvo2, & Paul Wrenn2

717

DOI: 10.3109/02699052.2014.892379 1

Warwick Medical School, Coventry, Warwickshire, UK, University Hospital Coventry and Warwickshire, Coventry, Warwickshire, UK


2

Objectives and background: Traumatic brain injury (TBI) is an important cause of hospital admission for older adults. Previous research has shown that mortality resulting from TBI increases with age, rising from 71% in 65–70 year-old patients to 87% for patients 480 years. There are currently 3 million people aged 65 and over in the UK, representing 17% of the population. This is estimated to rise to 25% by 2041. Consequently, numbers of older adults presenting with TBI will also rise. The purpose of this study was to examine the incidence of TBI among older adults admitted to one Midlands Trauma Centre over a 5-year period and to investigate the relationship between clinical presentation and outcome. Methods: Data were collected from patient notes and Trauma and Audit Research Network (TARN) documentation over a 5-year period from 2008–2013. TARN is a research network dedicated to the collection and assessment of data on trauma and outcomes in the UK. Patients of any age with brain or skull injuries are recorded in TARN if their length of stay is 72 hours or they are admitted to a high dependency area or die following trauma. For this study, only patients aged over 65 years were included. Data were collected on injury cause, details of brain imaging, treatment and outcomes. Results: During the 5-year period, 846 trauma patients aged over 65 years were recorded on TARN. Of these, 399 had brain or skull injuries, representing 47.2% of all serious trauma injuries. The mean and median age was 79 years (SD ¼ 8.53), with a range of 66–99 years. Just over half were male (211, 53%). The most common causes were falls (85%), predominantly low level falls of 52 metres (243 patients, 61%), followed by falls of 42 metres (97 patients, 24%). Fifty-seven patients were injured in road traffic accidents (52, 13%). The mean length of hospital stay was 23 days (SD ¼ 29.07). The majority survived (307, 77%) and most were treated conservatively without any surgical intervention (297, 74%). Over half the survivors were deemed to have made a good recovery on the Glasgow Outcome Scale (221, 55%). Further analysis will examine the relationships between clinical presentation, age and outcomes. Conclusion: TBI is an important cause of admission for older adults, representing almost half of patients with serious trauma. These figures are likely to rise with an ageing demographic. Falls are the most common cause of injury, therefore education on falls prevention is needed for this age group. When data analysis is complete, further information will be provided on treatment outcomes and recommendations for clinical practice.

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Early interdisciplinary rehabilitation in patients with acute aneurysmal subarachnoidal haemorrhage Tanja Karic1, Angelika Sorteberg2,4, Tonje Haug Nordenmark1, Frank Becker3, & Cecilie Røe1

care. The aim of this study was to describe the content and feasibility of early interdisciplinary rehabilitation (EIR) adapted to aSAH patients and to quantify the rehabilitation needs. Methods: Prospective, observational study including aSAH patients admitted between August and December 2012 to the neurointensive ward (NIW) after securing of the ruptured aneurysm. The EIR team consisted of a rehabilitation physician, a neurosurgeon, a physical therapist, an occupational therapist and nurses. For analysis purposes the EIR content was divided into 10 categories: positioning, passive exercises, guidance in ADL, assistance in eating, mobilization, activation, balance training, pulmonary rehabilitation, reality orientation and information. A mobilizing algorithm with six mobilizations steps was developed. World Federation of Neurological Surgeons (WFNS) score was used in the assessment of the patients’ clinical status. Clinical and radiological parameters were collected from patients records. In order to describe and quantify EIR, this study registered the time (in minutes) used on each EIR component daily, for each patient. In order to describe progress in mobilization, it registered the point of time of change in mobilization steps for each patient for the whole stay. For analysis patients were dichotomized into those in good grade (WFNS 1 and 2) and those in poor grade status (WFNS 3, 4 and 5). Results: Thirty-seven patients (26 women and 11 men), aged 35–74 years (median ¼ 58 years) were included. Age, gender and time to securing of the aneurysm were similar in the two groups. Poor grade patients (n ¼ 12) received more rehabilitation (median ¼ 412 minutes) vs good grade patients (median ¼ 240 minutes). The most timeconsuming component in both groups was activation followed by time used on mobilization. Positioning (p ¼ 0.018), passive exercises (p ¼ 0.01), assistance in eating (p ¼ 0.002) and guidance in ADL (p ¼ 0.07) were much more time-consuming in poor grade patients. In good grade patients mobilizing to 60 of head elevation started from the first day after securing of the aneurysm and mobilizing out of bed was possible from the third day. Mobilization in poor grade patients started after 2 days and these patients were out of bed from day 7. At discharge 67% of poor grade patients and 78% of good grade patients were mobilized to walking. Most rehabilitation efforts were required during the first 7 days. No adverse effects from EIR were observed. Conclusions: EIR in aSAH patients is feasible from the first day after securing of the aneurysm. The rehabilitation content varied according to the patient’s clinical status and poor grade patients needed more rehabilitation and had slower progress in the mobilization.

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Pilot use of the physical and neurological examination for soft signs (PANESS) in children and adolescents with mild-tomoderate TBI Stacy Suskauer, Kelly Clark, Cynthia Salorio, & Stewart Mostofsky Kennedy Krieger Institute, Baltimore, MD, USA

1

Oslo University Hospital, Ullevaal, Department of Physical Medicine and Rehabilitation, Oslo, Norway, 2Oslo University Hospital, Rikshospitalet Department of Neurosurgery, Oslo, Norway, 3Sunnaas Rehabilitation Hospital, Nesoddtangen, Norway, 4University of Oslo, Institute of Clinical Medicine, Oslo, Norway Objectives: Currently, there are no international guidelines regarding early rehabilitation for individuals that have undergone aneurysmal subarachnoidal haemorrhage (aSAH) and only a few studies investigated the effect of integrating rehabilitation in acute SAH

Objectives: Abnormalities in motor speed and balance are reported after mild-to-moderate traumatic brain injury (TBI) in children and adolescents, but commonly used measures do not capture subtle motor signs identified on physical examination. Furthermore, it is not known how early motor signs relate to the real-world cognitive and behavioural dysfunction which is commonly the greatest concern after injury. The purpose of this study was to pilot use of the Physical and Neurological Examination for Soft Signs (PANESS) in a cohort of children and adolescents with mild-to-moderate TBI in order to evaluate sensitivity to the presence of and change in motor


718 dysfunction over the first year after injury and to explore the relationship between motor findings and real-world behavioural function. Methods: Eleven children (aged 11–17 years, mean ¼ 14.6 years at first evaluation) with mild-to-moderate TBI were evaluated twice, once 1–2 months post-injury and again 12 months post-injury. Motor function was examined using the PANESS, a reliable measure of balance, timed motor movements and subtle signs such as overflow movements which was designed for use in children. PANESS scores examined were Timed Total (TT) and Gaits and Stations (GS) sub-scores and Total score (TS). Real-world function was assessed with parent report on the Behaviour Rating Inventory of Executive Function (BRIEF) at the same time points as PANESS evaluation; t-scores for Metacognition Index (MI), Behavioural Regulation Index (BRI) and Global Executive Composite (GEC) were examined. Descriptive statistics were used to summarize PANESS performance. Paired t-tests were used to evaluate change in PANESS scores between visits. Spearman’s correlations were used to evaluate association of age with PANESS scores and between PANESS and BRIEF scores. Linear regression was used to evaluate the predictive nature of PANESS scores at 2 months for BRIEF scores at 12 months. Results: PANESS scores were elevated at 2 months post-injury compared to age-based expectations. There was significant improvement in PANESS TT scores and a trend toward improvement in TS between 2 and 12 months post-injury. Age was not correlated with PANESS scores at either time point. At 2 months post-injury, PANESS GS and TS correlated with BRIEF MI and GS correlated with GEC. At 12 months PANESS was not correlated with BRIEF. There was a trend towards PANESS GS and TS at 2 months predicting BRIEF MI at 12 months. Conclusions: These preliminary data suggest that the PANESS is sensitive to the presence of and change in motor findings in children and adolescents with mild-to-moderate TBI. PANESS scores obtained early after injury may serve as an important marker for child’s current and future real-world function. Further investigation of the utility of the PANESS in this population is warranted.

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Conceptual approaches to reconstructive and minimally invasive surgery for head injury sequelae Leonid Likhterman, Alexander Potapov, Alexander Kravchuk, Vladimir Okhlopkov, & Boleslav Lichterman The Burdenko Neurosurgery Institute, Moscow, Russia Objectives: The aim of this study is to improve results of restorative surgical treatment of head injury sequelae which present an important public health problem. Methods: The material includes 3852 cases of head injury sequelae. There were 1315 cases of post-traumatic arterio-venous fistulae (AVF), 427 cases of chronic subdural haematomas (CSH), 186 cases of posttraumatic hydrocephalus, 248 cases of post-traumatic CSF leakage and 1523 cases of post-traumatic skull defects. Clinical and neuroimaging data and tactics of restorative neurosurgical treatment were analysed. Results: Conceptual approaches for surgical treatment of head injury sequelae have been developed. In cases of post-traumatic AVF the concept of reconstructive surgery was implemented in order (1) to eliminate allegation of arterial and venous blood and (2) to restore anatomical integrity of damaged vessels. This study used an endovascular approach and performed plasty of damaged vessels

Brain Inj, 2014; 28(5–6): 517–878

with balloons, coils or stents. The results were good in 82.1% of cases, satisfactory in 13.2%. Complication rate was 4.3% and mortality rate 0.4%. The concept of reconstructive surgery was also used for treatment of post-traumatic CSF-leakage and skull defects. In CSF-leakage this meant restoration of a closed circuit of CSF circulation and plasty of CSF fistula. It was mostly performed with an endoscopic technique and use of autologous tissues. The intracranial approach was seldom used. This study also practiced temporary adaptive tunnel external lumbar draining. The results were good in 84.7% of cases, with relapses in 15.3%. In skull defects, cranial integrity was restored in order to protect the brain from external impacts and individual configuration of the scalp and craniofacial structures were restored with the help of computer modelling and laser stereo lithography of a damaged skull and an implant; subcutaneous expanders were used. The results were good in 93.8% of cases. There was a 6.2% complication rate. In CSH, a concept of minimally invasive surgery was introduced which includes (1) change of environment inside CSH and (2) managed internal decompression. CSH is evacuated via a twist-drill burr hole followed by short-term external closed draining of the haematoma cavity. The results were good in 91.6% of cases and satisfactory in 3.2% of cases. Re-operations were performed in 4.1% of cases,and there was a 1.1% mortality rate. The concept of minimally invasive surgery was also followed in cases of post-traumatic hydrocephalus. This included CSF drainage outside of the craniovertebral space and use of extracerebral fields for CSF resorption (ventriculo-peritoneal and lumbo-peritoneal shunting). The results were good in 52.2% of cases and satisfactory in 22.9% of cases. There was a 21.2% complication rate and 3.7% mortality. Conclusions: Conceptual approaches to surgery for head injury sequelae facilitate neurorehabilitation. Such approaches are philosophical because they are holistic and take into consideration all pathophysiological mechanisms.

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Neurological syndromes associated with glutamatergic, cholinergic and dopaminergic systems dysfunction after severe brain trauma Evgenia Alexandrova, Oleg Zaitsev, Valeria Tenedieva, Yuriy Vorobiov, Alexander Sychev, Natalia Zakharova, & Alexander Potapov Burdenko Neurosurgery Institute, Moscow, Russia Background: Brain functions are provided by different neurotransmitter systems, which help to maintain consciousness, movement activity, muscular tone and reflex regulation. Functional interaction between intact structures of the brain, balance between glutamate/ GABA axis and dopamine/acetylcholine axis play a pivotal role in post-traumatic recovery processes. However, neurotransmitter disorder is not a studied enough problem in recent neurotraumatology, the most researches are experimental, non-systemic and require further synthesis, re-thinking and validation in clinical settings. Taking into account brain trauma mechanisms, the most susceptible to damage are the glutamatergic and GABAergic neurotransmitter systems, damage of dopaminergic and cholinergic systems are less frequent. Serotoninergic and norepinephrinergic structures damage is even less common due to its deep brainstem location. It has been shown that different groups of neuromodulators (dopaminergic, anti-glutamatergic and cholinergic) can be fairly effective for posttraumatic consciousness recovery; however, the guidelines for its choosing are still absent. In this regard the clinical correlates of

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DOI: 10.3109/02699052.2014.892379

neurotransmitter dysfunction revealing at different recovery stages after severe traumatic brain injury (sTBI) is the most important aspect. Objective: To figure out typical clinical manifestations of the most vulnerable brain neurotransmitter systems dysfunction and to evaluate its prognostic and therapeutic value. Patients and methods: Eighty-eight patients with sTBI (GCS58) entered into this study in the acute period (1–15 days) and 70 patients in the sub-acute period (18–70 days after trauma). Brain damage was verified by 1.5–3T MRI (T1, T2, FLAIR, SWI, DWI) in 79 patients. Plasma catecholamine and glutamate levels were measured in dynamics by HPLC. Results: Based on the theoretical concepts this study has identified putative clinical signs, which can indicate the preferential dysfunction of one of the main brain neurotransmitter systems: Glutamatergic Insufficiency (GIS) and Redundancy (GRS) Syndromes, Cholinergic Insufficiency Syndrome (CIS), Dopaminergic Insufficiency (DIS) and Redundancy (DRS) Syndromes. The first three syndromes had equal frequency in the acute period of sTBI. In the sub-acute period the most frequent was GRS and the less frequent CIS. Revealed syndromes are functional and are changed in time, probably reflecting neurotransmitter system re-organization in the process of consciousness and neurological functions recovery after sTBI. Plasma glutamate level was the highest in patients with GRS and the lowest in patients with GIS. The most unfavourable outcome was noticed in patients with CIS, the most favourable outcome in patients with GRS. Directed pharmacological treatment (cholinergic agents for CIS, antiglutamatargic agents for GRS, dopaminomimetics for DIS) was much more effective (74%) for consciousness recovery then non-directed one (34%). Conclusion: It is well known that post-traumatic recovery often depends on regular choice of neuromodulators like glutamatergic, GABAergic, dopaminergic and cholinergic agents. Revealed clinical syndromes can be the basis for selecting a specific directed pharmacotherapy for brain functions recovery after sTBI.

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A simple web-based calculator for long-term survival prognosis in adults with moderate-to-severe traumatic brain injury (TBI) Jordan Brooks1, David Strauss1, Robert Shavelle1, Flora Hammond2, & Cynthia Harrison-Felix3 1

Life Expectancy Project, San Francisco, CA, USA, 2Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Indianapolis, IN,USA, 3Craig Hospital & Department of Physical Medicine and Rehabilitation, University of Colorado at Denver, Denver, CO, USA Objectives: To construct a simple evidence-based tool to assist in long-term survival prognosis for adults with moderate-tosevere TBI. Methods: The study population comprised participants in the US National Institute on Disability and Rehabilitation Research TBI Model Systems national database who were injured in the years 1988–2010, had been discharged from inpatient rehabilitation and contributed at least one follow-up assessment 1 year or more after injury. Long-term disability was classified using both the Functional Independence Measure (FIM) and Disability Rating Scale (DRS). A simple 4-level classification of care needs was constructed based on the single DRS item for ‘level of functioning’. The levels were: (1) largely independent, minimal assistance at most; (2) requires mechanical aids or assistance with some activities; (3) requires assistance with all activities, 24-hour home care; and (4) total dependence, requires 24-hour nursing care. These classifications

may be readily made in the clinic, via phone interview or through record review. Regression models for survival data were used to relate age, sex and severity of disability to long-term survival. Predictive performance of the models was assessed with the Akaike’s Information Criterion (AIC) and the C-index for rightcensored survival data. Results: There were 7228 individuals in the US Model Systems national database who contributed 32 505 person-years of follow-up and 537 deaths. Age and sex were significantly associated with mortality rates in all survival regression models (p50.0001). Separate models in which long-term disability was classified using the FIM and DRS had comparable predictive performance (C-index 0.80 vs 0.80, AIC 11 005 vs 11 015). The simple care needs model had a C-index of 0.80 and AIC of 11 040. Under this model, persons with the most intensive care needs, i.e. 24-hour nursing care, had mortality rates that were 8.2-times higher than those of persons who were largely independent or required minimal assistance at most (p50.0001). Survival prognosis probabilities based on this simple model were incorporated into a web-based calculator available at: http://www.LifeExpectancy.org/ tbims.shtml. Conclusions: The extent of an individual’s care needs is a simple but effective predictor of long-term survival in adults with moderate-tosevere TBI. The simple model has comparable statistical performance to alternative models that incorporate the full DRS and FIM scales. A web-based calculator is available for use by those (regardless of clinical expertise) involved in long-term care or planning for adults with TBI.

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Evaluation of electrical aversion therapy (EAT) for aggressive behaviour after acquired brain injury: A naturalistic single case design study Bert Ter Mors GGZ Oost Brabant, Boekel, The Netherlands Objectives: Aggressive behaviour after acquired brain injury can be pervasive and difficult to treat and has a negative impact on patients and caregivers. Evidence for effective treatment is not available yet. Electrical Aversion Therapy (EAT) is a behavioural therapeutic option used in severe behavioural disorders in persons with intellectual disabilities, which might be suitable for brain-injured individuals. The effect of EAT in brain injury has not been investigated previously. This study investigated the effect of EAT on aggression after brain injury. It aimed at demonstrating EAT to be an option when all else failed. Methods: A naturalistic Single Case AB Design was used. This study evaluated the use of EAT in a 41 year old male with a history of brain injury due to subarachnoid haemorrhage and therapy-resistant aggressive behaviour interfering with his basic care needs. To guarantee safety restraints and sedation were necessary. In an AB design (baseline phase, treatment phase) the frequency of the target behaviour (i.e. aggressive behaviour) was measured daily over time and the restraints needed were taken into account. Results: There was a significant and clinically relevant reduction of the target behaviour. This reduction remained stable over time. No sideeffects were reported. Conclusions: It is concluded that EAT was effective in this patient with aggressive behaviour due to severe brain injury. EAT can, therefore, be considered in severe and therapy resistant aggressive behaviour in brain injured patients. The ethics of EAT need to be considered carefully.

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0548

Volumetric computed tomography analysis for the assessment of moderate and severe traumatic head injury

Changes in functional independence in children with traumatic and non-traumatic brain injury

Ana M. Castanõ, Rafael Martinez-Perez, Pablo M. Munarriz, Santiago Cepeda, Pedro A. Gomez, & Alfonso Lagares

Julia Coyne1, Heather Ferreri2, Michael Dribbon2, & John DeLuca1 1

Kessler Foundation Research Center, West Orange, NJ, USA, Children’s Specialized Hospital, New Brunswick, NJ, USA, 3 Rutger’s University/New Jersey Medical School, Newark, NJ, USA 2


Hospital Universitario 12de Octubre, Madrid, Spain Objectives: The objectives of this study are to evaluate the feasibility and reliability of volumetric Computed Tomography scan (CT scan) for the initial assessment of traumatic brain injury and to determine its prognostic value in relation to other commonly used prognostic factors. Methods: A prospective series of 210 patients suffering, according to Glasgow Coma Score (GCS), of moderate-to-severe traumatic brain injury consecutively admitted to Hospital 12 de Octubre between January 2010 to May 2012 were included in this study. Patients were admitted in the Intensive Care Unit and were managed according to standard protocols consistent with international brain trauma guidelines. All demographic and clinical variables (pupil reactivity, initial motor response, hypoxia and hypotension) related to prognosis were recorded at admission, as well as the development of raised intracranial pressure and the need for surgical treatment. Outcome was determined 6 months after injury using the Glasgow Outcome Scale (GOS). Initial and control CT scans were classified by the Traumatic Coma Data Bank (TCDB) classification and evaluated by the use of Analyze software and the volume of the different haemorrhagic lesions (epidural, subdural and intracerebral haematoma, subarachnoid and intraventricular haemorrhage) were calculated using region of interest volume (ROI). Also midline shift displacement was assessed, as well as cisternal effacement. The first CT scans were evaluated by two independent observers in a blinded fashion in order to assess inter-observer variability. For appraising the inter-rater reliability of volumetric measurements of the different lesions evaluated as well as the total haemorrhagic volume inter-class correlation coefficients (ICC) were used as well as the methodology proposed by Bland and Altman. The relation of individual haemorrhagic lesions and different prognostic factors as well as the total volume of haemorrhagic lesions in the worst CT scan with outcome was determined by means of Mann-Whitney U-tests. Logistic regression analysis was used for predicting outcome using quantitative CT data adjusted by other prognostic factor. Results: Inter-observer reliability was high for the different traumatic haemorrhagic lesions except from traumatic subarachnoid haemorrhage (ICC ¼ 0.6). Subarachnoid haemorrhage, subdural haematoma, intracerebral haematoma and total haemorrhagic volumes were significantly related to a worse prognosis in the univariate analysis. Total haemorrhagic volume had a higher discriminatory capacity then TCDB classification of injury after adjusting for other prognostic factors in the multivariate analysis. Conclusions: Quantitative CT is a novel approach for assessing lesional burden in different cerebral pathologies. Its application in head injury patients is feasible, reliable and could improve outcome prediction.

Objective: The current study examined potential improvements in functional independence scores in children with traumatic (TBI) and non-traumatic (NTBI) brain injury following acute inpatient rehabilitation using the Wee Functional Independence Measure for Children (WeeFIM). The WeeFIM is a standardized assessment that measures a child’s overall global functioning in activities of daily living. Each patient’s functional level is measured at admission and discharge by clinical staff, trained specifically in WeeFIM administration and scoring (e.g. ‘WeeFIM certified’ practitioner) who assigns a numeric value to the amount of assistance that a child requires in the essential areas of the functional activities of cognition, mobility and self-care. Total scores range from 18–126, with higher scores indicating an increase in independent functioning. Method: WeeFIM scores served as the main outcome measure of progress over time. From a single paediatric hospital, data from 2157 patients receiving treatment between 2001–2012 with various diagnostic codes as defined by WeeFIM were extracted from the Uniform Data System for Medical Rehabilitation (UDSMR). From this extraction, 612 patients were coded as having a ‘brain dysfunction’. The category was further sub-coded into two groups: Traumatic Brain Injury (TBI; n ¼ 341), and non-Traumatic Brain Injury (NTBI; n ¼ 271). According to the WeeFIM diagnostic coding system used by physicians to classify patients, the TBI group consisted of patients with brain disorders secondary to open (n ¼ 27) or closed (n ¼ 314) brain injury. The NTBI group included aetiologies such as neoplasms (n ¼ 64), anoxia (n ¼ 23), anoxic/hypoxic encephalitis (n ¼ 22), intracranial abcess (n ¼ 6); other categories consisted of metabolic toxicity, degeneration, meningitis, parasitic disease and developmental/ psychiatric causes, haemangioblastomas (n ¼ 120), and 36 cases were designated as only NTBI with no aetiology listed. There were no significant differences between groups on age at admission [NTBI M ¼ 11 (SD ¼ 5); TBI M ¼ 14 (SD ¼ 5)], length of inpatient stay [nTBI M ¼ 14 (SD ¼ 42); TBI, M ¼ 44 (SD ¼ 50)], ethnicity, language and mean Total WeeFIM scores at admission and discharge. Gender was significant (p50.05). Results: The TBI group showed significantly greater improvement on the WeeFIM scales of Cognition (F(1,609) ¼ 49.351, p50.05), Mobility (F(1,609) ¼ 41.022 p50.05), Self-Care (F(1,609) ¼ 38.599, p50.05) as well as the WeeFIM Total score (F(2,609) ¼ 25.759, p50.05) between admission and discharge when compared with the NTBI group. Conclusions: Recovery in children with brain injury is evident during acute inpatient rehabilitation across the areas of functioning measured by the WeeFIM. The TBI group made greater functional improvements during inpatient rehabilitation in the areas of cognition, mobility and self care than the NTBI group, potentially demonstrating a significantly greater beneficial response to acute inpatient rehabilitation.

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School quality-of-life, disability services and achievement outcomes in children after traumatic brain injury: A population study

Who cares? The long-term care for patients with severe brain injury

1

1

1

Peter Hendrickson , Nancy Temkin , Jin Wang , Andrea Dorsch2, & Frederick Rivara1 University of Washington, Seattle, WA, USA, 2Mary Bridge Children’s Hospital and Health Center, Tacoma, WA, USA


1

Objective: Traumatic brain injury (TBI) is a major cause of death and disability among school children. It is not well known how TBI impacts school functioning, disability services and academic achievement. The aim was to examine those areas in children and adolescents following TBI, across the spectrum of severity. Methods: An IRB-approved prospective cohort study was conducted of children less than 18 treated for a TBI (n ¼ 609) and for an uncomplicated arm injury (n ¼ 186) between 1 March 2007 and 30 September 2008. Subjects were children treated for TBI in King County, WA and Philadelphia, PA emergency departments. Main outcome measures were Paediatric quality-of-life scale (PedsQL) 3, 12, 24 and 36 months after injury compared to pre-injury functioning; Grade Point Average (GPA); and state reading and mathematics achievement tests (WASL, MSP, HSPE in Washington and PSSA in Pennsylvania) 1, 2 and 3 years after injury compared to 1, 2 and 3 years pre-injury. Severity of injury was classified as Mild 1 (without CT abnormality), 2 (with skull fracture) or 3 (with brain CT abnormality), moderate or severe. Results: A companion study established an estimated incidence of 304 TBI cases per 100 000 child years, highest for pre-school-aged children and lowest for children aged 5–8 years. Mild TBI injuries impacted 70%, moderate 7%, severe 1% and arm 23% of the study children. As with adult TBI studies, incidence rates were higher for boys than girls. PedsQL (school and cognitive sub-scores): Children with a mild, moderate or severe TBI showed significant declines in PedsQL scores at 3 months compared to arm controls. Only moderate and severe showed significant declines at 12, 24 and 36 months post-injury. Disability services: In comparing injury severity, including arm, postinjury programme enrolment (IEP or other services) at 3 months was significantly related to injury severity. At year 1, 2% of arm had new disability services compared to 4% mild 1 + 2, 14% mild 3 and 24% moderate + severe. At year 2, 4% of arm had new services compared to 6% mild1 + 2, 11% mild 3, and 25% moderate + severe. Academic Achievement: GPA and State Test data showed little relation to severity, but missing data made interpretation problematic. In a separate population analysis of spring 2012 Washington state test scores, TBI classified students (mostly moderate and severe) consistently under-performed general education students when controlling for poverty and race/ethnicity. Conclusion: Children suffering a mild TBI may need continued support in school beyond the several months recovery period. Other studies suggest their numbers may be under-reported. Obstacles to collecting achievement data included parent permission, transfer to new schools, incomplete school records, gaps in longitudinal test administration and confounding accommodations.

Jan Lavrijsen Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands Objectives: In contrast with the high attention for survival in the acute phase and rehabilitation in the post-acute phase, the long-term care for patients with severe brain injury seems to be a black void. Little is known about the number and characteristics of patients involved, the clinical course after years and the problems and dilemmas patients, families and caregivers have to deal with. In the Netherlands, a research group found their mission in investigating the long-term course and care for patients in vegetative state/unresponsive wakefulness syndrome (VS/UWS), minimally conscious state (MCS) and locked-in syndrome (LIS). In this presentation, the results of recent and earlier studies are compared, focusing on the relation between prevalence, ethical dilemmas and end-of life decisions. The results are discussed in the context of a country lacking possibilities for neurorehabilitation, while legal and professional options to withhold or withdraw medical treatment, including artificial nutrition and hydration (ANH), have been in place for 20 years. The objective is an overview of the lessons learned in the last decades and what one wants to know in years to come: to shed light on the fate of these patients in long-term care and to make the right decisions at the right time by those who care. Methods: The methods are cross-sectional surveys, case studies and ethical debates in the multidisciplinary teams, particularly regarding patients in VS/UWS. A comparison of values and ethics in the Netherlands and Austria was conducted to put the results in an international perspective. Results: The results show a low prevalence of LIS and a stabilized low prevalence of VS/UWS (presented in detail elsewhere). In several case studies about VS/UWS it was seen that the attitude of physicians changed from a reactive approach to a more pro-active approach, in which an evaluation of the treatment as a whole, including ANH, became the starting point. The families received intensive guidance in ‘growing’ towards key decisions and their attitude was found to be a crucial factor in the ultimate decision of physicians. Despite legal and professional frameworks for withdrawing ANH, that may be the reason that life-prolonging treatment is still continued in a substantial number of patients in long-term care. In some cases, this has led to dilemmas and conflicts about treatment, which were analysed by ethical debates with the multidisciplinary team. Conclusion: With current lessons from the long-term care, a model is presented for decision-making in the total course of VS/UWS, answering the question of who should really care at the right time. At the end it is shown how these lessons can cross bridges between professionals, institutions and even countries, in choosing the best option for each individual patient.

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Course of development of consciousness compromise in severe paediatric brain injured patients Monica Ferrea, Flavia Dorrego, Julia Gilardi, & Silvia Intruvini FLENI, Escobar, Argentina


722 Introduction: The level of consciousness recovery in patients who have suffered severe brain injury and who present disorders of consciousness is poor. Even when it is not clear to state which factors are associated with better outcomes, there are variables such as aetiology, the age of the injury or the time course before entering a rehabilitation programme that can be considered. Objective: To compare the development of consciousness compromise among children who suffered traumatic acquired severe brain injury vs non-traumatic acquired brain injury, after receiving intensive rehabilitation treatment (physical therapy, occupational therapy, neuropsycology and speech therapy) in sub-acute stage under a sensory stimulation programme within a stimulus protected environment. Materials and methods: A retrospective descriptive study of clinical records revision of patients who entered the rehabilitation programme with consciousness compromise, Rancho Los Amigos II or III secondary to severe brain injury from 2005–2013. Outcomes: Fifty-three patients were admitted, 22 female and 31 male, age range 13 months–17 years old. Group 1 had a traumatic cause (42%) and group 2 a non-traumatic cause (58%); 82% of group 1 and 97% of group 2 were in level II according to Rancho Los Amigos Scale. There was a significant difference between the groups in the time of entering the rehabilitation post-injury (p50.014), the non-traumatic injury group being the one that was admitted later. Also, consciousness recovery of the traumatic injuries group (59%) was significantly higher (p50.0062) than in the non-traumatic injury group (23%). Within group 2, hypoxic ischaemic encephalopathy (HIE) was associated with poorer results. The comparison between the group that remain in a minimum state of consciousness and the one that recovered consciousness showed a significant correlation among the consciousness recovery and the minor admission time to rehabilitation (p50.02) and the Western Neuro Sensory Stimulation Profile (WNSSP) scores at the admission time (p50.0171). The communication domain of the WNSSP (p50.0095) in particular was the domain that evidenced more difference at enrolment between both groups. There was no significant recovery difference between the various age groups (group A: 1–4 years old, group B: 5–10 years old, group C: 11 years old) among the traumatic injury patients (p50.6) and nontraumatic (p50.07). However, in the non-traumatic injuries group, group B presented a higher percentage (45%) of recovery, associating group A with the lowest percentage; this is related to the injury aetiology in the different groups. Conclusion: This study confirmed in this series that non-traumatic aetiology and lower age at the time of injury were associated with lower percentage recovery, coincidentally with the literature. Early admission to a rehabilitation plan and the initial WNSSP scores, particularly the communication domain, are associated with better prognosis.

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Early intensive rehabilitation improves IQ and school re-integration of children with severe TBI Flavia Dorrego, Monica Ferrea, Nicolas Cataldo, & Silvia Intruvini FLENI, Escobar, Argentina Introduction: It is generally accepted that rehabilitation is effective for patients with traumatic brain injury (TBI), yet to date in the literature there are few studies that explore the cognitive efficacy of early intensive rehabilitation in children with TBI. Objective: To evaluate the effects of an early intensive rehabilitation programme (EIRP) compared with that of conventional clinical care

Brain Inj, 2014; 28(5–6): 517–878

and unstandardized rehabilitation (CCUR) on the cognitive outcomes for children with severe TBI. Design and methods: Retrospective analysis of existing records of patients with severe TBI that had been assessed with the WISC III-R, WISC IV or WAIS IQ evaluation was carried out. A total of 20 patients met the inclusion criteria (10 patients under the EIRP modality and 10 patients under the CCR modality). No significant differences were found in gender, age at lesion or time in assisted ventilation. Results: Significant differences were found in IQ (p50.04), Visual Reasoning Index (p50.02), Working Memory Index (p50.02) and school reintegration (p50.01) between children who had received this EIRP vs the CCUR programme in the general care system. Conclusion: The findings support the proposition that early intensive rehabilitation along with a comprehensive neuropsychologically oriented rehabilitation programme may improve the cognitive outcome as well as the school reintegration of children with severe TBI. Further studies must be done to confirm these preliminary findings taking into account socioeconomic status, type, localization and severity of lesions and other important variables.

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School re-integration in patients with acquired brain injury after a prolonged hospitalization Cecilia Agost Carrenõ, Paula Uhrig, Monica Ferrea, & Silvia Intruvini FLENI, Escobar, Argentina Introduction: School re-integration is a priority goal in the intervention approaches with patients suffering from long-term hospitalizations. Objectives: (1) To determine the percentage of school re-integration, describing the type of support needed in the classroom; and (2) To analyse the supports and accommodations required by patients with TBI, stroke and encephalopathy to re-enter school. Methods: A retrospective study of 55 patients who received rehabilitation in the inpatient programme, who were assessed by school psychologysts. Results: Eighty per cent of the patients went back to regular schools, 14% received home schooling and 2% started attending a special education school. Ninety-eight per cent returned to school with their previous peer group. The diagnoses were TBI (24), encephalopathy (12), stroke (11) and others (7). In terms of the total group, 40% was able to attend school without support, while the 38% required a ‘shadow’ and 22% needed the help of an aide to help them in physical tasks. The most common accommodations were done in terms of curriculum and learning methods in the three groups. The 47% of the TEC group could attend class alone (40%), while the majority of patients with stroke and brain diseases required greater support from a ‘shadow’. Conclusions: Brain injury that occurs during normal development has an impact in cognitive functions. A successful school re-integration can be achieved with an individualized plan of accommodations

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Word and sentence production deficits in patients with temporal lobe epilepsy Mayumi Hirozane1, Daichi Sone2, Yoshiko Murata2, Taichi Mogi2, Go Taniguchi2, Mitsutoshi Okazaki2, & Masako Watanabe2

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DOI: 10.3109/02699052.2014.892379 1

Teikyo Heisei University, Tokyo, Japan, 2National Center of Neurology and Psychiatry, Tokyo, Japan

1

The University of Sydney, Sydney, NSW, Australia, 2University of NSW, Sydney, NSW, Australia, 3University of Wisconsin-Madison, Madison, WI, USA, 4Carnegie Mellon University, Pittsburgh, PA, USA

Objectives: Despite significant literature showing impaired naming difficulty in patients with temporal lobe epilepsy (TLE), there is very limited research in sentence production ability, which might affect daily conversations. Therefore, it is still unknown whether TLE patients present both naming difficulty and sentence production deficits. This study reviewed the language production abilities of TLE patients and the factors that influence language-production abilities. Methods: Fifteen TLE patients (eight male, seven female; 19–69 years old; left lobe 1, right lobe 4; duration since first seizure: 1–51 years; 9–16 years’ education) participated in this study. The Western Aphasia Battery (WAB) (20 words); Test of Lexical Processing in Aphasia (TLPA), which involves naming 100 high-familiarity words (HFW) and 100 lowfamiliarity words (LFW); and the Sentence Production Test (SPT), which requires composing sentences using two presented nouns, verbs, conjunctions, etc., were used. The examinations were used that indicated normal data to set the cut-off points in this study. The cutoff points of each examination were set at scores below the mean scores of the normal group—two standard deviations. Cognitive measures included the Raven Couloured Progressive Matrix (RCPM) and the Wechsler Memory Scale Revised (WMS-R). Although intelligence and cognitive functions are independent in patients with epilepsy, the former might modify the latter. Statistical analysis was performed using partial correlation analysis, controlling nonverbal IQ measured by RCPM. Results: WAB scores were not used for naming-difficulty analysis due to a ceiling effect. According to the results of other language examinations, the patients were divided into four groups: four patients with no impairments, four without naming deficits but with sentence-production deficits, three with naming deficits but without sentence-production deficits and four with both naming and sentence-production deficits. Two patients were judged as HFWand LFW-impaired and five as LFW-impaired only. Eight patients demonstrated sentence deficits. The results of partial correlation analysis revealed a significant correlation between the HFW and LFW scores (r ¼ 0.9420, p50.001), but no significant correlation among TLPA, SPT, age, duration after first seizure, RCPM, or five kinds of memories at WMS-R. Concerning sentence production, significant correlations were shown between sentence-production ability and verbal memory (r ¼ 0.6572, p50.05), and between sentenceproduction ability and general memory (r ¼ 0.6490, p50.05), but not among the others. Conclusions: The results showed that some TLE patients demonstrated naming deficits and sentence-production deficits and that naming and sentence-production ability might be independent. Significant correlations among sentence-production ability, verbal memory and general memory suggest that these cognitive functions use the same brain functions or that examinations such as TLP and WMS-R might detect the same cognitive functions from different perspectives.

Background: Discourse assessment for people with traumatic brain injury (TBI) is frequently dismissed clinically due to the timeconsuming nature of the analysis and the paucity of standardized assessment protocols. As a result, clinicians rarely assess the discourse of people with severe TBI in the early stages following injury. Objectives: This paper will describe the clinical utility of a new webbased resource called TBI Bank, which offers help to address these issues. TBI Bank is a web-based archival repository of spoken discourse of people with TBI. It consists of a standardized assessment protocol, which investigates word, sentence and discourse level language and a compendium of freely accessible computerized language tools, which enable quick evaluation of spoken discourse samples. Specifically, this paper aims to evaluate the feasibility of conducting the TBI Bank protocol at 3 and 6 months post-injury with TBI participants. It will also describe the type of computerized linguistic analyses currently available on the TBI Bank website to evaluate monologic discourse samples. The theoretical background to the TBI Bank system will be discussed with reference to current best practice for the assessment of cognitive communication deficits following TBI. Method: Forty-eight participants with severe TBI were assessed using the TBI Bank protocol at 3 months post-injury and 53 participants were assessed 6 months post-injury as part of a longitudinal communication recovery study. Results: Forty-five participants fully completed the full protocol, while three partially completed the protocol at 3 months. At 6 months, 51 fully completed the assessment and two partially completed the protocol. Participants were less likely to complete the AphasiaBank Repetition Test and describing an important event, while all completed the Cinderella story, their recovery narrative and a procedural discourse task (making a cheese and Vegemite sandwich). Conclusions: Evaluating discourse early post-injury is frequently not conducted due to the time-consuming nature of analysis and a lack of direction regarding the best assessments to use. TBI Bank provides resources, which address both these issues including a detailed assessment protocol and computerized on-line discourse analysis programmes. This paper will describe the use of the TBI Bank protocol with severely injured TBI participants and demonstrate the computerized analyses available on the TBI Bank website. TBI Bank offers clinicians, students and researchers an exciting online collaborative tool for the assessment and analysis of communication following acquired brain injury.

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TBI bank is a feasible assessment protocol to evaluate the cognitive communication skills of people with severe TBI during the subacute stage of recovery

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Training everyday communication partners is efficacious in improving the communication of people with severe TBI: Findings from a single-blind multi-centre clinical trial Leanne Togher1, Skye McDonald2, Robyn Tate1, Emma Power1, & Rachael Rietdijk1 1

1

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Leanne Togher , Elise Elbourn , Belinda Kenny , Emma Power1, Skye McDonald2, Robyn Tate1, Lyn Turkstra3, Audrey Holland4, Davida Fromm4, Margie Forbes4, & Brian MacWhinney4

The University of Sydney, Sydney, NSW, Australia, 2The University of NSW, Sydney, NSW, Australia Background: Communication problems following TBI can contribute to socially inappropriate behaviour causing social isolation. Two


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treatments are effective: (i) conversation training for the TBI individual (which has been termed TBI SOLO) and (ii) training communication partners (JOINT condition). However, no research has compared these approaches. Objectives: This controlled group comparison study asked: (1) Is any combination of treatment (TBI SOLO vs JOINT) more efficacious than no training (CONTROL) alone? (2) Is the combined training for both the person with TBI and the everyday communication partner (JOINT) more effective than the individual treatment (TBI SOLO)? Methods: Forty-four participants with severe TBI and their everyday communication partners (ECP) were allocated to one of three groups: the TBI SOLO group, the JOINT group or a CONTROL delayed treatment condition. The TBI SOLO and JOINT groups received individual and group training in strategies to maximize communicative effectiveness. Outcome measures were collected at initial assessment, 1–3 weeks after the intervention and at 6 months follow-up. Two discourse samples were collected: (1) casual conversation (CC) and (2) purposeful conversation (PC). The primary outcome measure, called the Adapted Measure of Participation in Conversation (MPC), evaluated the person with TBI’s level of participation in conversation in terms of his/her ability to interact (Interaction scale) and transact information (Transaction scale). Two blind trained raters scored 5-minute videotapes of social interactions between the person with TBI and their ECP. Results: At baseline there were no statistically significant differences between the three groups on the variables of age, sex and education, severity of injury and on MPC ratings. A significant treatment effect for conversational skill was found on the MPC Interaction scale in both the CC (F(2, 38) ¼ 3.78, p ¼ 0.03, h2p ¼ 0.17) and PC (F(2, 38) ¼ 4.01, p ¼ 0.03, h2p ¼ 0.17) conditions, i.e. the JOINT group improved relative to the other two. A significant treatment effect was also found on the MPC Transaction Scale in both CC (F(2, 38) ¼ 5.64, p ¼ 0.007, h2p ¼ 0.23) and PC (F(2, 38) ¼ 5.44, p ¼ 0.008, h2p ¼ 0.22) conditions. Conclusions: Training ECPs was more efficacious in improving the everyday interactions of people with TBI than training the person with TBI alone. This study provides a new treatment approach to improve social communication skills of people with severe TBI.

osmolality which was predominately determined by the serum sodium level is another important parameter to be maintained in patients with acute cerebral oedema. Hyponatremia or hypoosmolality is known to be harmful to head injured patients and the management has been towards maintaining serum osmolality and serum sodium level within normal level or even slight hypernatremia or hyperosmolar state. Objectives: It is hypothesized that those neurosurgeons that preferred mannitol alone as their choice of anti-oedema in neurotrauma will prefer normal serum sodium level than a higher targeted serum sodium, compared to those that preferred hypertonic saline alone or in combination. Methods: A questionnaire was conducted among neurosurgeons around the world during a recently concluded international neurosurgical meeting. The null hypothesis was there were no differences in the desired serum sodium level between those that preferred mannitol alone, compared to those that preferred hypertonic saline alone or in combination. There were 72 respondents, whereby 15 were from European countries, 33 from Asian countries and the remaining 24 respondents from other continents. There were 34 consultant neurosurgeons, 15 neurosurgical registrars and the remaining 23 respondents did not state their seniority in neurosurgical practices. Results: For question on desired serum sodium level during acute cerebral oedema in moderate and severe head injury, 51 respondents (70.8%) preferred to maintain serum sodium within the normal range (between 135–145 mmol l1), while 18 respondents (25%) preferred to maintain serum sodium at a higher level (between 145–155 mmol l1). Only three respondents (4.2%) did not have any preferred serum sodium level. Out of 69 respondents with preferred serum sodium level, 39 respondents (82.1%) have targeted a normal serum level while only nine respondents (18.8%) have targeted higher serum sodum level among respondents that preferred mannitol. While 12 respondents (57.1%) have targeted normal sodium level and nine respondents (42.9%) have targeted higher serum sodium level among respondents that preferred hypertonic saline alone or in combination, these differences were statistically significant (p ¼ 0.036). Conclusions: The desire to maintain a higher serum sodium level among neurosurgeons that preferred hypertonic saline alone or in combination was significantly higher than among those who preferred the use of mannitol as the only anti-oedema therapy.

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The relationship between the usage of mannitol and hypertonic saline with targeted serum sodium level in neurotrauma: From the neurosurgeons’ perspective

The prevalence and characteristics of patients with classic locked-in syndrome in Dutch nursing homes

Liew Boon Seng1, Mohammad Jaweed2, Gee Teak Sheng1, Azmin Kass Rosman1, & Johari Siregar Adnan3

Radboud Medical Centre University Nijmegen, Nijmegen, The Netherlands

1

Department of Neurosurgery, Hospital Sungai Buloh, Sungai Buloh, Selangor, Malaysia, 2Taylors University Clinical School, Sungai Buloh, Selangor, Malaysia, 3Department of Neurosurgery, Hospital Sultanah Aminah, Johor Bahru, Johor, Malaysia Introduction: Hyperosmolar therapy is known to be effective in the treatment of cerebral oedema in neurotrauma. The preferred hyperosmolar solution, mannitol has been used by neurosurgeons worldwide for many decades and still is very much preferred in this era. For the past years, hypertonic saline has been gaining much attention and is used in the management of cerebral oedema, in isolation or in combination with the use of mannitol. Serum

Roy Kohnen, Jan Lavrijsen, Hans Bor, & Raymond Koopmans

Objective: Establishing the point prevalence and characteristics of patients with the classic form of Locked-in Syndrome (LIS) in Dutch nursing homes. Methods: A cross-sectional survey of Dutch nursing homes. The classic form of LIS was defined according to the criteria of the American Congress of Rehabilitation Medicine. Elderly Care Physicians of all Dutch long-term care organizations (n ¼ 187) were asked if they had any patients with classic LIS as of 5 December 2011. The treating Elderly Care Physicians were then contacted to provide patient characteristics through a questionnaire. Results: Of all organizations, 91.4% responded and 11 organizations reported a total of 12 patients. After analysing the questionnaires, it

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was determined that 10 patients had LIS and two patients were characterized with vegetative state. Only two patients met the criteria for classic LIS. Causes were ischaemic stroke and vertebral dissection with secondary basilar thrombosis. Six patients showed partial LIS. One of these patients was admitted to the nursing home after 5 December 2011 and was, therefore, excluded. LIS without accompanying pontine lesion was observed in the remaining two patients. Conclusions: For the first time, the prevalence of classic LIS has been established at 0.7/10 000 somatic nursing home beds in all Dutch long-term care organizations. Possible explanations for this low prevalence could be the Dutch provision of home care or the influence of end-of-life decisions, such as euthanasia and withholding or withdrawing all medical treatment, including artificial nutrition and hydration. These alternate outcomes should be explored in further studies.


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Neuropsychiatric differences in patients with predominant damage of the right and left hemisphere Oleg Zaitsev Burdenko Neurosurgical Institute, Moscow, Russia Objectives: To reveal correlations between the side of the predominant brain damage and clinical features of traumatic brain injuries (TBI). Methods: One hundred and thirty-seven patients with severe TBI were studied. All of them had coma (with initial GCS58). Seventy-two patients had clinical and MRI/CT signs of predominant damage to the left hemisphere and 65 patients to the right one. All patients were examined clinically with a total registration of psychopathological symptoms from the acute phase to follow-up which was continued to 0.5–12 years after TBI. Results: Differences between groups with predominant right and left hemisphere damage were evident from the moment of contact with the patient. In the group with predominant right hemisphere damage compared to the left one, the most frequent clinical features were: (1) amnestic type of confusion; (2) typical variant of Korsacoff’s syndrome; (3) confabulations; (4) left-sided form of unilateral neglect; (5) memory loss for current events; (6) prolonged (41 month) period of post-traumatic amnesia; (7) disturbed perception of time and space; (8) marked emotional and personality disorders; (9) low level of insight; (10) hypersensitivity; and (11) varied epileptic seizures. In the group with the predominant left hemisphere damage compared to the right one more frequent signs were as follows: (1) confusion with speech and motor disintegration; (2) disorders of verbal memory; (3) cognitive disorders related to speech processes; and (4) prolonged neurotic disorders (including hypochondriac ones). Causes of nonobservance of revealed regularities were sinistrality and developing of intracranial infections complications and hydrocephalus. There were no marked differences in social assessment of outcomes between groups. However, due to differences in psychopathology it was necessary to modify rehabilitation approaches, including psychopharmacology. Conclusions: The predominant brain damage side must be taken into consideration not only for assessing clinical conditions, but also developing a special programme for mental recovery after TBI.

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Novel neuromuscular electrical stimulation system for the upper limbs in sub-acute stroke patients: A pilot randomized controlled trial Tomokazu Noma1, Shuji Matsumoto2, Megumi Shimodozono2, & Kazumi Kawahira2 1

Department of Rehabilitation, Kirishima Rehabilitation Center of Kagoshima University Hospital, Kirishima City, Japan, 2Department of Rehabilitation and Physical Medicine, Graduate School of Medical and Dental Sciences, Kagoshima University, Kirishima City, Japan Objective: Neuromuscular electrical stimulation (NMES) has recently received considerable attention as a therapeutic intervention option for stroke rehabilitation. However, previous studies on NMES focused on the distal arm or proximal arm, but not both. To address the shortcomings of the classical NMES approach and increase the potential for better outcome measures, this pilot study investigated a novel NMES system, targeting a couple of muscles controlling the shoulder and elbow and individual muscles controlling wrist or finger extensions. The primary study aim was to assess the feasibility of applying this NMES system and method for improving motor control of the hemiplegic upper limbs in sub-acute stroke patients. Methods: Thirty sub-acute stroke patients (16 men and 14 women; 22 with right and eight with left hemiplegia; aged 60.0 ± 13.5 years) were randomly allocated to the ‘control group’ (n ¼ 14) or ‘NMES group’ (n ¼ 16). A control group received conventional manual therapy (repetitive exercises for proximal and distal muscles of the hemiplegic upper limbs without NMES) and task-specific training for 60 minutes/ day. The NMES group underwent upper limb training using both a shoulder-and-elbow stimulation device and a wrist-and-finger stimulation device developed by the study investigators for 60 minutes/ day. Both groups trained for 6 days/week for 4 weeks. Outcome measures were assessed in a blinded manner with the upper extremity component of the Fugle-Meyer Assessment (UE-FMA) and modified Ashworth scale (MAS) scores at pre- and post-treatment. The UE-FMA scores were divided into two sub-portions based on the limb segments tested, a wrist–hand score and a shoulder–elbow score including co-ordination. Results: The control group and NMES group had comparable baseline characteristics and motor impairment. The UE-FMA scores improved for both groups over time (p50.01). Non-parametric statistical analyses revealed significantly greater gains in UE-FMA scores for the NMES group after treatment over the control group (9.1 ± 4.9 vs 4.4 ± 4.0; p50.05). The distal sub-portions of the UE-FMA scores demonstrated a significant difference (p50.01), but the proximal sub-portions of the UE-FMA scores did not demonstrate significant difference. There were no significant differences in both groups at MAS score gains for the biceps brachii and wrist flexor muscles. Conclusions: This pilot study demonstrated that 4 weeks of training using the novel NMES system, targeting a couple of muscles controlling the shoulder, elbow, wrist and individual fingers, can improve volitional motor control of the hemiplegic upper limb in subacute stroke patients. The training protocol appears to provide greater improvement in the distal sub-portions of the UE-FMA scores than in the proximal sub-portions of the UE-FMA scores. Development of a proximal segment training protocol using the shoulder-and-elbow stimulation device may be needed. The positive effects observed in this study suggest that further development of this novel NMES system is warranted.

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Neurosurgical management of indirect brain injury in penetrating trauma: A stab in the right direction Susan Hendrickson, John Scotter, & Mark H. Wilson


The Traumatic Brain Injury Centre, Department of Neurotrauma, St. Mary’s Hospital, Imperial College London, London, UK Introduction: Penetrating trauma is traditionally the domain of the vascular/general surgeon; however, focal ischaemic neurological consequences are amenable to neurosurgical intervention. This study presents two patients (one knife wound victim, one gunshot victim) who required emergency decompressive craniectomies for malignant middle cerebral artery infarcts following penetrating trauma not involving the head, brain or spine. Both cases describe unique injury patterns and are supported by novel radiological findings. Case description: The first patient was a 22-year old Caucasian male who received a single stab wound to the precordium, necessitating an emergency thoracotomy, release of cardiac tamponade and repair of myocardial lacerations. Two days post-operatively the patient was noted to have a left hemiparesis. A Computed Tomography (CT) scan revealed a large right middle cerebral artery (MCA) territory infarct, probably resulting from embolic left ventricular thrombus. He underwent an urgent decompressive craniectomy. The patient made an excellent recovery and returned to part time work 3 months post-injury. The second patient was a 56-year old male who received a shotgun wound to the right side of his neck. He was noted to have a dense left hemiplegia on admission. A CT scan subsequently demonstrated migration of one shotgun pellet into the MCA via the internal carotid, which resulted in a large right MCA territory infarct and radiological evidence of raised intracranial pressure. Similarly, this patient underwent an emergency decompressive craniectomy. The patient made a limited neurological recovery with a persistent left hemiplegia 4 months post-injury. Discussion: The benefits of decompressive craniectomy have been clearly demonstrated for malignant middle cerebral artery territory infarcts; however, there is limited literature on infarcts resulting from trauma. These cases demonstrate that the role of neurosurgery in a major trauma centre extends beyond the management of direct traumatic brain injury and that early intervention in embolic infarction secondary to trauma can improve outcome.

0566

Who are the patients in states of severely altered consciousness in general internal medicine? Yee Sien Ng1, Chunzhen Tan2, Hay Mar Saw1, & Annie Jane Araneta Nalanga1 1

Singapore General Hospital, Singapore, 2Duke-NUS Graduate Medical School, Singapore Objectives: Admissions to general Internal Medicine (IM) comprises the largest patient cohort in hospitals nationally. However, clinical data on patients in states of severely altered consciousness (SSAC), including those in vegetative or minimally responsive states, is scarce compared to specific cohorts undergoing rehabilitation post-

Brain Inj, 2014; 28(5–6): 517–878

brain injury. This study aims to profile the demographics and clinical characteristics of patients in SSAC in IM and compare them to IM patients not in SSAC. Methods: In this prospective study, all patients (n ¼ 516) randomly admitted under a single IM team over 5 years were included. This team accepted patients for a month every year in this period. Demographics, diagnoses, disease, laboratory and social characteristics were recorded. The main outcome measures included the Charlson Comorbidity Index (CCI), the JFK coma recovery scale, the Disability Rating Scale (DRS), length of stay (LOS) and discharge destination. Results: Fifty of 516 (9.7%) patients were in SSAC in the Internal Medicine Cohort and 64% were male. The most common aetiology for SSAC was dementia (34%), stroke (14%), epilepsy (14%), TBI (12%), various encephalopathies (12%) and Parkinson’s disease (10%). The most frequent admission causes were pneumonia (30%), undifferentiated sepsis (28%), UTI (8%) and trauma/falls (8%). In the SSAC group, the mean (SD) JFK and DRS scores were 10.8 (6.2) and 21.5 (5.1), respectively. Compared to IM patients not in SSAC, SSAC patients were older (75.0 years vs 67.0 years, p50.01), had longer lengths of stay (25.8 days vs 9.5 days, p ¼ 0.01) and more comorbidities reflected in the CCI (2.96 vs 2.50, p50.01). On admission, SSAC patients also had significantly lower albumin levels (26.2 vs 32.0, p50.01), although their haemoglobin (p ¼ 0.64) and creatinine (p ¼ 0.70) were similar. In the two groups, there were no differences in the proportion of patients with ischaemic heart disease (p ¼ 0.65), hypertension (p ¼ 0.54) or diabetes mellitus (p ¼ 0.37). The SSAC patients had similar proportions of married patients (36.0% vs 45.3%, p ¼ 0.23) as IM patients without SSAC, but they had higher rate of discharge to a nursing home (54.0% vs 23.0%. p50.01) and had significantly more carer and discharge issues (48.0% vs 33.3%, p ¼ 0.04). Conclusions: Patients in SSAC are not uncommon in general IM, with varied aetiologies and a predominance of non-traumatic causes. The majority of admissions were for infection-related causes. The clinical demographics of the SSAC vs non-SSAC patients in IM reflect a more elderly and medically complex cohort requiring significantly more hospital and medico-social resources in management. This data is important in triaging and allocating scarce medical resources nationally and an SSAC status should be considered together with diagnoses-related groups (DRGs) in heathcare casemix funding. Further research will include rehabilitation and ethical issues in this challenging patient cohort.

0567

Treatment of buccal hypertrophic granulation tissue due to bruxism and bite reflex in anoxic encephalopathy: A case report Natasha Warnick, & Cindy Ivanhoe Baylor College of Medicine-University of Texas PM&R Alliance, Houston, TX, USA Objectives: A 60-year-old previously healthy male presented for inpatient rehabilitation unit 20 days after a severe anoxic brain injury. The patient displayed hypertonicity in all four extremities and face and neck, with an area of heaped up granulation tissues on the inside of his lower lip. A large soft tissue lesion stretched from the inner lining of his lower lip to lie between the patients upper and lower teeth and was frequently aggravated by bruxism. His bite reflex was worsened by the noxious stimulus of ongoing pain and biting of the granulation tissue. His primary source of nutrition was through a gastrostomy tube. The objective was to heal his mouth, thereby decreasing pain.

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Methods: Mouth guards are often prescribed in this scenario, but it was chewed through, posing a threat of aspiration. A family member fabricated a simple device utilizing the end of a suction tube, hooked around the patient’s lower lip and secured with an elastic strap. This created a space between the teeth and gums. Ongoing speech therapy included Beckman oral motor therapy. Two weeks later the patient was also injected with OnabotulinumtoxinA to bilateral masseter muscles to decrease the intensity of his bruxism. Results: After 9 days of oral motor exercises and use of the family fabricated ‘splint’, the patient’s buccal tissue was healing and alertness and swallow improved to tolerate pureed foods. By day 11, he tolerated ground foods without signs of aspiration. OnabotulinumtoxinA injections occurred on day 15 and the patient advanced to tolerate thin liquids and chewable solids by day 23. The patient now tolerates a regular diet with assistance by family for use of utensils. With healing of his buccal mucosa, the patient continued to show significant improvement. One month following the above interventions, the patient’s inner lip had healed and he was tolerating regular food. Discussion: A simple oral splint was key in allowing the healing of a massive lesion that resulted in a reflexive bite reflex. Because it was anterior to the teeth, it did not pose a threat to the patient’s airway. Yet, it was sufficient to decrease the bruxism that led to the manual speech therapy and chemodenervation complemented the treatment approach. Ultimately, advancement of an oral diet was possible, as the lesion healed and the patient was less distracted by pain from his lip. Chemodenervation of appropriate musculature aided in the patient’s rehabilitation by decreasing hypertonic components interfering with oral motor exercises. Use of an appropriate mouth splint allowed protection of soft tissue structures might also be necessary. Creativity in fabricating something specific for the patient’s needs proved valuable.

ultimately were assessed and found to have FNDs. The cases will be presented in the context of increasing understanding of the clinical presentations of patients with ‘conversional’ signs and symptoms and the general treatment approaches for the same. The focus of this brief presentation will be to improve clinical bedside assessment of patients after TBI and increase sensitivity to both historical elements, as well as clinical exam findings that are suggestive of FNDs. Results: A brief lecture format review (with slides) focusing on FND clinical presentation and assessment followed by three video case vignettes will provide the basis of the oral presentation content. At this conclusion of the presentation, some brief comments on treatment approaches will also be provided. Conclusions: FNDs, although uncommon in clinical practice, do occur and must be differentiated from actual TBI-related impairment as the treatment strategies across these impairments are dramatically different, as are the implied prognoses for the same. This presentation will assist clinician attendees in increasing their awareness of this class of impairments and the factors that should be considered when assessing their patients to not miss such diagnoses.

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Anne Mette Berget1, Iris Charlotte Brunner2, Tiina Ader1, Marianne Løvstad3, & Eike Ines Wehling1

Functional neurological disorders after claimed traumatic brain injury Nathan Zasler Concussion Care Centre of Virginia, Ld., Richmond, VA, USA Objectives: This oral presentation will provide attendees with a brief overview focusing on the clinical presentation of patients following presumptive traumatic brain injury (TBI) with conversion disorders, now more commonly referred to as functional neurological disorders (FNDs), focusing on clinical presentation and assessment. The term FNDs provides an umbrella nomenclature for a variety of symptoms of apparent neurological origin but which current models struggle to explain psychologically or organically. Their clinical presentation may be similar to a wide range of neurological impairments seen following TBI from sensorimotor impairments to movement disorders, as well as speech alterations. Functional neurological deficits may be observed after any claimed severity TBI with an array of possible findings including: limb paralysis, impaired hearing or vision, sensory impairment such as a hemianesthesia, speech disorders (i.e. dysarthria, foreign accent syndrome), fixed dystonia (as well as other movement disorders like tremor and myoclonus), among other possible presentations. Given the occurrence of these medically unexplained symptoms in patients with organic brain injury due to trauma and following trauma without evidence of traumatically induced brain injury, clinicians working with these patients are encouraged to be familiar with this unique class of post-traumatic conditions. Methods: This descriptive presentation will provide attendees with a brief lecture and three case examples of FNDs that were previously diagnosed as having a neurological basis due to TBI, but that

0569

Effect of position on responsivity on the coma recovery scale– revised in patients with severe traumatic brain injury: Three case reports

1

Department of Physical Medicine and Rehabilitation, Haukeland University Hospital, Bergen, Norway, 2Physiotherapy Research Group, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway, 3Sunnaas Rehabilitation Hospital, Nesodden, Norway Objectives: Misdiagnosis of patients with disorders of consciousness after TBI is common. The Coma Recovery Scale–Revised (CRS-R) is the assessment scale with the best diagnostic validity. However, little is known regarding the effect of patients’ position on responsivity. To explore this is the aim of this study. Methods: Three patients with TBI admitted to Haukeland University Hospital are included in the study which is done in accordance with the Helsinki Declarations. Two men and one woman (aged 23, 47 and 48), all involved in road traffic accidents, were included 179, 180 and 544 days after injury. Using a balanced design regarding time of day, the patients were assessed twice daily using the CRS-R 16-times (eight sitting/eight standing) over a period of 4 weeks. Additionally, patients’ postural control was clinically evaluated. Descriptive statistics are used to describe the results. Results: Patient 1 had achieved independent sitting and head control and was classified as being in a Minimally Conscious State (MCS) on all assessments, but reached the highest possible scores more often while standing (26%) compared to sitting (15%). The patient showed evidence of emergence from MCS (functional object use) in 33% of standing assessments compared to 28% sitting. Patients 2 and 3 had not achieved independent sitting or head control, both performed at MCS level, with one exception each. Due to extensive motor deficits both patients scored in the lowest range on the motor sub-scale, with more variation on the visual and auditory sub-scales. Based on the latter, patients 2 and 3 performed at MCS level 63% and 75%, respectively, while sitting, compared to 38% and 69% while standing. In patient 2 no difference was found on the visual sub-scale, performing on MCS level 63% of assessments. On the auditory sub-

728 scale patient 2 performed at MCS level 25% while standing and 50% while sitting. Patient 3 performed at an unresponsive wakefulness syndrome (UWS) level once on the visual scale while sitting and 3-times while standing. On the auditory sub-scale, patient 3 was classified to be at UWS level 3-times while sitting and 2-times standing. Conclusion: This study did not find a uniform effect of posture on CRSR performance. For patient 1 a standing position had a positive effect on responsivity, revealing signs of emergence from MCS. This is insofar highly important as decisions regarding further rehabilitation may depend on this. The better performance while sitting in patients 2 and 3 may be explained by their reduced postural control, as maintaining a standing position may have placed high demands on available cognitive resources. The findings indicate that patients in MCS and UWS should be evaluated under varied conditions in order to establish their best possible level of performance.


0570

Tullio’s phenomena after concussion: Case report and review

Brain Inj, 2014; 28(5–6): 517–878

Post-operative VEMP demonstrated marked normalization (from abnormally decreased right-sided threshold and increased amplitude pre-operatively) (nearly 40% increased amplitude pre-operation compared with only 15% post-opeation). The left continued to demonstrate no abnormalities on audiogram, tympanogram or VEMP. Conclusions: Tullio’s phenomenon should be considered in any posttrauma patient with sound-induced vertigo and/or imbalance. Changes to the functioning and/or the morphology of the labyrinth should be assessed including decreased thresholds for the acoustically-evoked vestibular potentials, semicircular canal dehiscence, traumatic lesions of the labyrinth and ligamentous laxity. This is the first known report of symptoms presenting contralateral to the side of the perilymph fistula and represents a window of understanding to vestibular physiology. The cause of this unique finding may rest in the failure of commissural inhibition following labyrinth dysfunction. Clinicians should maintain heightened awareness for the possibility of inner ear dysfunction contralateral to symptoms.

0572

Bilateral fixed dilated pupils in trauma—To operate or not to operate?

Nathan Zasler1, Daniel Coelho2, & Michael Hermann2 1

Concussion Care Centre of Virginia, LTD., Richmond, VA, USA, 2 Department of Otolaryngology, Head and Neck Surgery, Virginia Commonwealth University, Richmond VA, USA Objectives: First reported case of contralateral Tullio’s phenomenon after cranial impact injury and concussion. The presentation will address possible pathophysiological mechanisms of this atypical presentation, as well as provide information on this uncommon condition which should be familiar to all clinicians treating persons with brain injury and head trauma. Methods: The patient was a 20 year old female who presented with an 8-month history of symptoms of left-sided Tullio phenomenon after a motor vehicle collision in which she sustained a cranial impact injury and concussion. She described vertigo as counterclockwise and improved with eye closing. Events were triggered by sound and vibration to the left ear but not the right. She also reported symptoms consistent with left-sided phonosensitivity. On initial neurophysiatric assessment the patient presented with a negative vestibular testing but with a positive Tullio’s phenomena on stimulation of the left ear and left mastoid process with loud sound or vibratory stimulus with associated phonosensitivity. Testing by ENT suggested a right perilymphatic fistula. The Tullio phenomenon refers to sound-induced disequilibrium (vertigo and/or imbalance. Symptoms may also include auditory and visual symptoms/signs, decreased postural control, and cognitive-behavioural symptoms. Superior semicircular canal dehiscence, among other conditions, must be considered in the differential diagnosis for this phenomena. Results: Intervention(s): Bedrest and a right perilymphatic fistula repair after work-up revealed the audiogram to be normal without suprathreshold bone conduction; a CT without evidence of SCCD or stapes subluxation or fracture; VEMP: left within normal limits, right with increased amplitude and decreased threshold; and videonystagmogram (VNG) with calorics within normal limits. Main outcome measure(s): Cervical vestibular evoked myogenic potentials (cVEMPs), audiometry, patient symptoms. Post-operatively the patient’s symptoms of left-sided Tullio’s phenomenon abruptly abated and she reported no activity limitations as well as improvement in her anxiety and cognition. Vertigo and phonosensitivity could not be reproduced.

Susan Hendrickson, John Scotter, Hani J. Marcus, Murtuza Sikander, Fiona Arnold, & Mark H. Wilson The Traumatic Brain Injury Centre, Department of Neurotrauma, St. Mary’s Hospital, Imperial College London, London, UK Objectives: Bilateral fixed dilated pupils (BFDP) in patients with traumatic intracranial haematomas are widely recognized as an ominous sign suggestive of herniation and brainstem injury. A recent retrospective cohort analysis, for example, reported a mortality rate of 82.0% in patients with BFDP. Given such a dismal prognosis many patients with BFDP are currently managed conservatively. The aim of this study was to determine which patients, if any, might benefit from aggressive surgical evacuation of their haematoma. Methods: A retrospective cohort study design was adopted. All patients admitted to a Major Trauma Centre from 1 January 2011 to 30 June 2013 were reviewed. This study included adult patients with head injury that presented with BFDP and also had radiological evidence of a traumatic haematoma resulting in significant mass effect. Patient demographics, clinical presentation, radiological findings, operative procedures and outcomes were recorded. Results: In all, 2146 admissions were reviewed, of which 47 patients had BFDP and 20 also had a traumatic haematoma (19 with acute subdural haematoma and one with an acute extradural haematoma). The mean age was 50 years (range ¼ 17–86 years), the male:female ratio was 16:5 and the median Glasgow Coma Score (GCS) on presentation was 3 (range ¼ 3–6). All six patients that were not operated on died. Of the 14 patients that underwent surgical evacuation of their traumatic haematoma, six died (42.9%), and one patient had a favourable outcome (7.1%). Notably, the patient that made a good recovery was 30 years of age and underwent surgical evacuation within 30 minutes of his pupils becoming dilated and unreactive. Conclusions: Patients with head injury presenting with BFDP are likely to have suffered devastating brain damage, but a good outcome is possible in very selected cases. These findings support those of the existing neurotrauma literature and suggest that patients that are young and those that undergo rapid surgical evacuation may be more likely to benefit from aggressive therapy.

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0573

A systematic review of the prognosis after mild traumatic brain injury in adults: Cognitive, psychiatric and mortality outcomes. Results of the International Collaboration on MTBI Prognosis (ICoMP)


Linda Carroll1, J. David Cassidy2, Carol Cancelliere3, Pierre Cote4, Cesar Hincapie3, Vicki Kristman5, Lena Holm6, Jorgen Borg6, Catharina Nygren-de Boussard6, & Jan Hartvigsen2 1

University of Alberta, Edmonton, Alberta, Canada, 2University of Southern Denmark, Odense, Denmark, 3University of Toronto, Toronto, Ontario, Canada, 4University of the Institute of Technology, Oshawa, Ontario, Canada, 5Lakehead University, Thunder Bay, Ontario, Canada, 6Karolinska Institutet, Stockholm, Sweden Objective: To synthesize the best available evidence on objective outcomes after adult mild traumatic brain injury (MTBI). Data sources: MEDLINE and other databases were searched (2001– 2012) for studies related to MTBI. Inclusion criteria included published, peer-reviewed reports in English and other languages. References were also identified from the bibliographies of eligible articles. 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 MTBI cases and assess objective outcomes in adults. Data extraction: Eligible studies were critically appraised using a modification of the Scottish Intercollegiate Guidelines Network (SIGN) criteria. Two reviewers independently reviewed each study and extracted data from accepted papers 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 77 914 records were screened, 299 were relevant and critically reviewed and 101 were deemed scientifically admissible. Of these, 21 studies related to objective outcomes and formed the basis of this review. Most evidence indicates the presence of cognitive deficits in the first 2 weeks post-MTBI and some evidence suggests that complete recovery may take 6 months or a year. A small number of studies indicate that MTBI increases the risk of psychiatric illnesses and suicide. Conclusions: Early cognitive deficits are common and complete recovery may be prolonged. Conclusions about mortality post-MTBI are limited. This review has implications for expected recovery after MTBI and MTBI-related health sequelae. Well-designed confirmatory studies are needed to understand the medium- to long-term consequences of MTBI and to further evaluate the effect of prior MTBI and injury severity on recovery.

0574

A systematic review of the risk of dementia and chronic cognitive impairment after mild traumatic brain injury. Results of the

International Collaboration on MTBI Prognosis (ICoMP) Alison Godbolt1, Carol Cancelliere2, Cesar Hincapie2, Connie Marras2, Eleanor Boyle3, Vicki Kristman4, Victor Coronado5, & J. David Cassidy3 1

Karolinska Institutet, Stockholm, Sweden, 2University of Toronto, Toronto, Ontario, Canada, 3University of Southern Denmark, Odense, Denmark, 4Lakehead University, Thunder Bay, Ontario, Canada, 5Centers for Disease Control and Injury Prevention, Atlanta, GA, USA Objective: To synthesize the best available evidence regarding the risk of dementia and chronic cognitive impairment (CCI), following mild traumatic brain injury (MTBI). Data sources: MEDLINE and other databases were searched (2001– 2012), using a previously published search strategy and pre-defined criteria. Peer-reviewed reports in six languages were considered. Study selection: Systematic reviews, meta-analyses, randomized controlled trials (RCTs), cohorts and case-control studies, with a minimum of 30 MTBI cases in subjects of any age, assessing the risk of dementia or CCI after MTBI were selected. Data extraction: Eligible studies were critically appraised using a modification of the Scottish Intercollegiate Guidelines Network (SIGN) criteria. Two reviewers independently reviewed each study and extracted data from accepted articles (i.e. with a low risk of bias) into evidence tables. Data synthesis: Evidence from accepted studies was synthesized qualitatively according to modified SIGN criteria and prognostic information was prioritized as exploratory or confirmatory, according to design. Of 77 914 records screened, 304 articles were eligible and reviewed. Methodological quality was acceptable for 101 (33%), of which one considered dementia and seven CCI. The study examining the risk of dementia after MTBI did not find an association. One RCT found that being informed about possible cognitive dysfunction after MTBI was associated with worse cognitive performance on standard tests. Children with MTBI and intracranial pathology (‘complicated’ MTBI) performed worse than children without intracranial pathology. Children showed higher rates of cognitive symptoms 1 year after MTBI than a control group. Conclusions: There is a lack of evidence of increased risk of dementia after MTBI. In children, objective evidence of CCI exists only for complicated MTBI. More definitive studies are needed to inform clinical decisions, assessment of prognosis and public health policy.

0575

Non-surgical interventions after mild traumatic brain injury: A systematic review. Results of the International Collaboration on MTBI Prognosis (ICoMP) Catharina Nygren-de Boussard1, Lena Holm1, Carol Cancelliere2, Alison Godbolt1, Eleanor Boyle3, Britt-Marie Stalnacke4, Cesar Hincapie2, J. David Cassidy3, & Jorgen Borg1 1

Karolinska Institutet, Stockholm, Sweden, 2University of Toronto, Toronto, Ontario, Canada, 3University of Southern Denmark, Odense, Denmark, 4Umea University, Umea, Sweden


730 Objective: To synthesize the best available evidence regarding the impact of non-surgical interventions on persistent symptoms after mild traumatic brain injury (MTBI). Data sources: MEDLINE and other databases were searched (2001– 2012) with terms including ‘rehabilitation’. Inclusion criteria were original, peer-reviewed research published in English and other languages. References were also identified from the bibliographies of eligible articles. Study selection: Controlled trials and cohort and case-control studies were selected according to pre-defined criteria. Studies had to have a minimum of 30 MTBI cases and assess non-surgical interventions using clinically-relevant outcomes such as self-rated recovery. Data extraction: Eligible studies were critically appraised using a modification of the Scottish Intercollegiate Guidelines Network (SIGN) criteria. Two reviewers independently reviewed each study and extracted data from the admissible studies into evidence tables. Data synthesis: The evidence was synthesized qualitatively according to the modified SIGN criteria. Recommendations were linked to the evidence tables using a best evidence synthesis. After 77 914 records were screened, only two of seven studies related to non-surgical interventions were found to have a low risk of bias. One studied the effect of a scheduled telephone intervention offering counselling and education on outcome and found a significantly better outcome for symptoms (6.6 differences in adjusted mean symptom score, 95% confidence interval (CI) ¼ 1.2–12.0), but no difference in general health outcome 6 months. The other was a RCT of the effectiveness of 6 days of bed rest on post-traumatic complaints 6 months post-injury, compared to no bed rest, and found no effect. Conclusions: Some evidence suggests that early reassuring educational information is beneficial after MTBI. Well-designed intervention studies are required in order to develop effective treatments and improve outcomes for adults and children at risk for persistent symptoms after MTBI.

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Associations between caregiver report of driving performance on the American Academy of Neurology Family Questionnaire and frontal systems behavioural dysfunction Janessa Carvalho1, & Jennifer Davis2 1

Bridgewater State University, Bridgewater, MA, USA, 2Alpert Medical School of Brown University, Providence, RI, USA Objectives: The American Academy of Neurology (AAN) practice parameters in the evaluation of driving risk in dementia evaluates four elements associated with decreased driving ability in dementia patients: history of crashes/citations, informant-reported concerns, reduced mileage and aggressive driving. The Frontal Systems Behaviour Scale (FrSBe) is an informant measure of behaviours associated with frontal-subcortical circuits, particularly apathy (anterior cingulate cortex), disinhibition (orbitofrontal cortex) and executive dysfunction (dorsolateral prefrontal cortex). Frontal systems behaviours measured by the FrSBe putatively are crucial in safe driving, although these associations have not directly been explored. The current study explored associations between informant-reported AAN Caregiver Driving Safety Questionnaire and frontally-mediated behavioural dysfunction on the FrSBe. Methods: Participants were 80 caregivers of patients diagnosed with Mild Cognitive Impairment (n ¼ 46) or early Alzheimer’s disease (n ¼ 34) who completed an outpatient neuropsychological evaluation (caregiver M age ¼ 62.57, SD ¼ 14.88, M education ¼ 14.40, SD ¼ 2.30).

Brain Inj, 2014; 28(5–6): 517–878

Results: Significant, strong associations were observed between AAN and FrSBe total score (r ¼ 0.59, p50.001). Specifically, associations were found between caregiver concerns about patient safety and FrSBe Apathy (r ¼ 0.30, p ¼ 0.01), Disinhibition (r ¼ 0.42, p50.001) and Executive Dysfunction (r ¼ 0.63, p50.001). Similarly, reports of decreased miles driven was associated with Disinhibition (r ¼ 0.39, p ¼ 0.001) and Executive Dysfunction (r ¼ 0.38, p ¼ 0.001). Aggressive driving was associated with Apathy (r ¼ 0.30, p ¼ 0.01), Disinhibition (r ¼ 0.48, p50.001) and Executive Dysfunction (r ¼ 0.41, p ¼ 0.001). Controlling for the effects of age did not change the outcome. Conclusions: Significant associations were found between caregiver concerns about driving safety and reported Apathy, Executive Dysfunction and Disinhibition. While associations between driving abilities and performance on cognitive tests of executive dysfunction are documented, less is known about associations between driving safety concerns and reported behavioural dysfunction. Personality and behavioural characteristics of apathy and agitation were associated with decreased driving in dementia patients using the brief Neuropsychiatric Inventory; however, the current study is the first thorough evaluation of frontal systems behaviours and driving ability. The finding of moderate associations between reported concerns about driving and behavioural dysfunction highlights the importance of a thorough evaluation of dementia patient behaviours as part of a determination of driving safety. Further, neurorehabilitation programmes may focus treatment on frontal systems behaviours in patients at risk for driving difficulties.

0577

Prognostication following traumatic brain injury: Can we do better? Amit Dhanda, Christine Wade, Cara Diaz, Jennifer Massetti, & Deborah Stein R Adams Cowley Shock Trauma Center, Baltimore, MD, USA Objectives: Prognostication following traumatic brain injury (TBI) is an important part of the care of these patients. Accurate prognostication not only affects aggressiveness of intervention and therapeutic decision-making, but also clinicians’ recommendations with respect to withdrawal of care. It was hypothesized that experienced clinicians would do as well or better than available predictive models in predicting both mortality and functional outcome patients with TBI. Methods: Patients admitted to a state-designated neurotrauma centre were enrolled over a 6-month period. Inclusion criteria were 14 years old, admission Glasgow Coma Score (GCS) 12 and a head abbreviated injury scale (AIS) score 3. Three groups of care providers—resuscitation/critical care RN (RN), trauma/critical care MD (MD), neurosurgery MD or CRNP (NS)—were surveyed at three time points from injury—admission, day #3 and day #7—asking what did the care provider think the patient’s functional status would be at 6 months following injury using an 8-point scale equivalent to the Glascow Outcome Scale–Extended (GOSE). Outcome was dichotomized by GOSE, when available (poor 1–4 vs good outcome 5–8) or a blinded provider’s judgement at 46 months following injury. Results: Eighty-six patients in whom 6-month outcome was available were enrolled. Mean age was 41.0 (±20.1); 82.6% were male. Mean Injury Severity Score was 33.1 (±12.6), with a median head AIS of 4 (IQR ¼ 4–5). Median admission GCS was 7 (3–10) and Marshall score was 2 (2–4.75). Sixteen patients (18.6%) died. Good functional outcome at 6 months was found in 65 patients (75.6%). Accuracy of prediction of mortality at the three time points was 85%, 87% and 90% (n ¼ 81, 70, 49) for RN, 84%, 82% and 92% (n ¼ 74, 57, 38) for MD and 88%, 85% and 83% (n ¼ 56, 39, 18) for NS (p ¼ ns). Accuracy for prediction of functional outcome was 84%, 77% and 76% for RN, 74%, 77% and 78% for MD and 77%, 74% and 72% for NS (p ¼ ns). Using the CRASH and IMPACT models, accuracies for prediction of mortality

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ranged from 84–88%, with a 450% threshold and 84–87% with a 475% threshold. Functional outcome was accurate 74–80% and 80–87% of the time with 450% and 475% thresholds. Conclusions: Predicting both mortality and functional outcome following TBI remains elusive. In as many as 15% of patients, predicting mortality from TBI is inaccurate even using well-validated models. Using only provider judgement, inaccuracies are similar. Prognosis regarding functional outcome is inaccurate in up to 25% of patients with validated models. Clinician judgement was no better at predicting outcome, even as far as 7 days following injury. The ‘best we can ever do’ at prognostication is grossly inadequate and needs to be improved so that communication regarding prognosis can be more helpful in instructing goals of care.


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A systematic review of prognosis after mild traumatic brain injury in the military. Results of the International Collaboration on MTBI Prognosis (ICoMP) Eleanor Boyle1, Carol Cancelliere2, Jan Hartvigsen1, Linda Carroll3, Lena Holm4, & J. David Cassidy1 1

University of Southern Denmark, Odense, Denmark, 2University of Toronto, Toronto, Ontario, Canada, 3University of Alberta, Edmonton, Alberta, Canada, 4Karolinska Institutet, Stockholm, Sweden

Objective: The WHO Collaborating Centre Task Force on mild traumatic brain injury (MTBI) published their findings on prognosis of MTBI in 2004. This is an update of that review with a focus on deployed military personnel. Data sources: Relevant literature published between January 2001 and February 2012 listed in MEDLINE and four other databases. Study selection: Controlled trials and cohort and case-control studies were selected according to pre-defined criteria. After 77 914 titles and abstracts were screened, 13 articles were rated eligible for this review and three (23%) with a low risk of bias were accepted. Two independent reviewers critically appraised eligible studies using a modification of the Scottish Intercollegiate Guidelines Network (SIGN) criteria. Data extraction: The reviewers independently extracted data from eligible studies and produced evidence tables. Data synthesis: The evidence was synthesized qualitatively and presented in evidence tables. Results: The findings are based on three studies of US military personnel who were deployed in Iraq or Afghanistan. It was found that military personnel with MTBI report PTSD and post-concussive symptoms. In addition, reporting of post-concussive symptoms differed based on the levels of combat stress the individuals experienced. The evidence suggests a slight decline in neurocognitive function post-MTBI, but this decline was in the normal range of brain functioning. Conclusions: This study found limited evidence that combat stress, PTSD and post-concussive symptoms affect recovery and prognosis of MTBI in military personnel. Additional high quality research is needed to fully assess the prognosis of MTBI in military personnel.

Shari Wade1, H. Gerry Taylor2, Terry Stancin3, Amy Cassedy1, Nicolay Walz1, & Keith Yeates4 1

Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA, University Hospitals, Cleveland, OH, USA, 3MetroHealth Medical Center, Cleveland, OH, USA, 4Nationwide Children’s Hospital, Columbus, OH, USA, 5University of Cincinnati, Cincinnati, OH, USA, 6 Case University, Cleveland, OH, USA, 7The Ohio State University, Columbus, OH, USA 2

Objective: Evidence suggests that, contrary to predictions from neural plasticity models, early TBI is associated with an increased risk of poor cognitive outcomes. Some evidence suggests that deficits associated with early TBI may not become apparent until years later when more complex cognitive and executive function skills are required. This study sought to examine the hypotheses that earlier age at injury and greater time since injury would be associated with more pronounced neurocognitive deficits following early TBI. Method: Children who were hospitalized overnight for mild-to-severe TBI between the ages of 3–7 were recruited between the years of 2002–2006. A comparison cohort of children hospitalized for orthopaedic injuries (OI) not involving the head or face was also recruited. A total of 103 children with TBI and 117 children with OI were enrolled within the initial 3 months post-injury. Children from the original cohort were re-assessed in middle school (ages 10–14) when demands for complex cognitive skills were escalating. To date, 63 children with TBI (62%) and 72 children with OI (62%) have completed neuropsychological assessments an average of 6.5 years post-injury. The Wechsler Abbreviated Scale of Intelligence (WASI) vocabulary and matrix reasoning sub-tests were used to assess global verbal and non-verbal intelligence, the Wechsler Intelligence Scale for Children (WISC) processing speed index was used to assess processing speed and the Woodcock Johnson was used to assess academic achievement. Regression analyses were used to examine whether age at injury or time since injury moderated the effects of injury type/severity on global intelligence and academic achievement. Results: WASI vocabulary scores did not differ among the injury groups. However, children with severe TBI (M ¼ 41.06) had lower matrix reasoning scores than children with complicated mild/ moderate TBI (50.66) or OI (51.30). Significant interactions between group and time since injury were found for WISC Processing Speed, with children with severe TBI who were injured longest ago exhibiting the poorest performance. Children with severe TBI (M ¼ 92.30) or complicated mild/moderate TBI (M ¼ 97.64) had significantly poorer performance than children with OI (M ¼ 104.17) on the Woodcock Johnson calculation scale. The injury groups did not differ on the writing fluency or letter-word sub-tests. Conclusions: Only limited support was found for the hypothesis that age at injury and time since injury moderated long-term cognitive and achievement outcomes. Greater effects on processing speed among children with severe TBI injured longer ago provide tentative support for the hypothesis that some deficits may emerge over time. Moreover, the long-term effects of TBI seem to be greatest on nonverbal and math skills, with minimal effects on verbal intelligence or reading skills.

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Head injury among young offenders in the English Midlands Carol Hawley, & Sally Martin Warwick Medical School, Coventry, Warwickshire, UK

0579

Long-term effects of early TBI on IQ and achievement

Objectives and background: Adolescence is a particular risk period for traumatic brain injury (TBI) and for offending behaviour. Of the 85 000 prisoners in the UK, over 2800 are aged between 10–17 years—


732 classed as ‘young offenders’. Previous research has identified a link between TBI and offending in adults and adolescents. The aims of this study were to identify the number of young people entering the criminal justice system with a head injury and to examine patterns of offending behaviour after head or brain injury. Method: A screening questionnaire was developed to identify young offenders who had suffered a head or brain injury. All young people newly referred to the Warwickshire Youth Justice Service (WYJS) during a 6-month period were screened by case workers. Those with a positive screen and aged 16 or over were invited to take part in a structured interview to examine behaviours such as offending, drink or drug use and anti-social behaviours, educational achievement, truancy from school, family and social relationships. Results: To date, 45 young people aged 11–18 years old have been screened for head injury. Of these there were 23 positive screens, indicating that just over half (51%) of the young people had a history of head injury. Sixteen of these young people reported more than one head injury. Offences committed were principally arson, violence or burglary. Interviews identified a lack of specific professional help after head injury. All interviewees reported disrupted education and all changed secondary schools for various reasons, including explusion for behavioural problems. The family structure was usually problematic, with some interviewees based in local authority care homes or placed with foster parents. Conclusions: This study coincided with a fall in the number of referrals to the WYJS, consequently numbers of referrals were lower than expected. However, the finding that half of young offenders had a history of head injury is consistent with previous work with adult offenders. Routine screening for head injury with a simple one page questionnaire will help Youth Justice staff to identify young people with a history of head injury, so that their needs are better met. It is recommended that young offenders with head injury are diverted from custodial sentences and instead receive community-based orders.

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A preliminary study into the sensitivity of different combinations of physical and cognitive demands on mobility to detect mild TBI Isabelle Cossette, Marie-Christine Ouellet, & Bradford McFadyen CIRRIS-Laval Univeristy, Quebec City, Quebec, Canada Objectives: Mild traumatic brain injuries (mTBI) represent 80–90% of all TBIs. However, they are frequently under-diagnosed and their impact is often under-estimated or not fully appreciated. Although people who have sustained an mTBI show executive dysfunction, standard isolated cognitive or motor clinical tests are often not sensitive enough to detect such problems which may put persons at risk for further injury or altered function. It is suggested that revealing the impact of mTBI lies in innovatively evaluating activities of everyday life that naturally integrate cognitive and sensorimotor domains. Dual-task paradigms during gait appear to offer such functional challenges following mTBI, but specific tasks vary widely across protocols. Therefore, the purpose of this study was to begin to explore the level of sensitivity for different combinations of physical and cognitive demands within a locomotor navigational context for differentiating persons with mild traumatic brain injury from control subjects without mTBI. Methods: Seven subjects with a mTBI and seven control subjects were recruited. Subjects were asked to walk in 12 different environmental contexts combining three physical conditions

Brain Inj, 2014; 28(5–6): 517–878

(unobstructed walking, stepping over a 15 centimetre high obstacle and stepping down from 15 centimetres) with fouur cognitive conditions (no dual task, Stroop task (St), verbal fluency task (VFt) and arithmetic task (At)). Three-dimensional motion analyses were obtained using a Vicon system (100 Hz). Gait speed, stride length and cadence were analysed. A generalized linear ANOVA was used to compare groups and conditions, with post-hoc analyses using T-tests. Results: There were no main effects for group for any variable. However, there were significant interactions between groups and cognitive tasks as well as between groups, cognitive and physical tasks for gait speed (p ¼ 0.013 and p50.001, respectively) and cadence (p ¼ 0.034 and p50.001, respectively). Specifically, the mTBI group walked slower and had lower cadences than control subjects in the dual-task conditions. All cognitive tasks appeared to be particularly sensitive for affecting gait speed during approach when planning for the physical environment is greatest. Post-hoc analyses showed significant differences in gait speed, specifically when stepping over an obstacle combined with a cognitive task, regardless of the task (St, p ¼ 0.011; VFt, 0.014; At, 0.037). Further analyses are underway. Conclusions: These preliminary results suggest that the combination of stepping over an obstacle with a simultaneous cognitive task better discriminates executive function deficits in persons with mTBI compared to control subjects. Gait speed and cadence specifically appear to be good clinical measures to assess such executive dysfunction in these ecological tasks following mTBI and could provide important information to diagnose and make decisions about return-to-play or function.

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Is the pattern of change in activity performance similar to cognitive and DTI outcomes during the first year after traumatic brain injury (TBI) and suspected traumatic axonal injury (TAI)? Ann Bjo¨rkdahl1, Eva Esbjo¨rnsson2, Johan Ljungqvist2, Thomas Skoglund2, & Katharina Stibrant Sunnerhagen2 1

Ersta Sko¨ndal University College, campus Bra¨cke, Gothenburg, Sweden, 2Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden Introduction and objective: This is a longitudinal descriptive study of which alterations and patterns in abilities in daily life, cognitive status and Diffusion Tension Imaging (DTI) of the corpus callosum could be seen after suspected Traumatic Axonal Injury (TAI). To increase the knowledge of the outcome after TAI the aim of this study was to explore the pattern of change in activity during the first year after injury with changes in cognitive status and DTI. Methods: Twelve patients who had sustained TBI and where suspicion of TAI was initiated due to affected consciousness and/or focal neurological symptoms without an obvious explanation on the CT brain scan were included. Besides demographic data these persons had complete records of performance of the Assessment of Motor and Process Skills (AMPS), cognition (Barrow Neurological Screen for Higher Cerebral Functions, BNIS) and DTI (FA-value and trace). Analyses were made to describe performance level acute (A1), at 6 (A2) and 12 months (A3) after injury as well as the patterns of

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alterations on the AMPS motor and process skills, the BNIS and DTI between the follow-ups. Results: Four participants were not testable on the BNIS and the AMPS in the acute phase. The level of performance ranged widely, from persons highly dependent (AMPS motor52, process51) to independent and able; AMPS (A1): motor 0.49–3.51, process 0.51–2.52 and (A3): motor 1.53–3.77, process 0.81–2.74. The pattern of change from A1–A2, on all instruments, showed a positive trend indicating an improvement. However, between A2 and A3 there were diverging results both between the patients and the instruments. In four cases the AMPS motor skill deteriorated. For AMPS process skill this was found in another four cases, thus not the same persons. The BNIS deteriorated in six cases of which the four cases in AMPS process skill corresponded with a deterioration or status quo on the BNIS. Correlations of the change from 6 to 12 months showed medium correlations between DTI FA-value and AMPS process skill (r ¼ 0.44), respectively BNIS (r ¼ 0.43). Only small relations were found between DTI trace and AMPS motor (r ¼ 0.16), process (r ¼ 0.16) and BNIS (r ¼ 0.19). Conclusion: The ability to perform activities of daily life, after TAI, varied a lot in this sample from substantial need of assistance (A1, n ¼ 6) to independence (A1, n ¼ 6) and managing work (A3, n ¼ 4). The pattern of alterations were from acute to 6 months straightforward with better outcomes on all measures, but divergent between 6–12 months, with some measures showing deteriorating results in one or more of the assessments.

0583

Participation after traumatic brain injury related to sick-leave Jerry Larsson1, Ann Bjorkdahl2, Eva Esbjornsson1, & Katharina Stibrant Sunnerhagen1 1

Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden, Ersta Sko¨ndal University College, Gothenburg, Sweden

2

Introduction: Traumatic brain injury (TBI) is one of the main causes of death and handicap. Several studies have shown problems with return-to-work (RTW) and a lower level of activity and participation in society after TBI. In Sweden, social insurance and sickness benefit are central to people’s welfare after all illness. The authors have not so far found any studies looking at the consequences of being on sick-leave and how it affects participation in society. The aim of this study was to explore if sick-leave after TBI affects the degree of participation. Method: The study was carried out in Sweden and data were collected from the Sahlgrenska University Hospital in Gothenburg. The cohort was made up of all patients aged between 18–65 admitted to the emergency room during a 2-year period (1999–2000) with a traumatic brain injury classified as S06.2 and S06.3 (ICD 10). The sick-leave pattern was followed during the first 4 years after the trauma. At the 4-year follow-up the patients were asked to reply to the IPA questionnaire (Impact on Participation and Autonomy), the EQ5D (EuroQol), which is a health-related quality-of-life questionnaire, and a questionnaire for descriptive data. Results: In all of the nine aspects of IPA more than 40% of the sample reported lack of participation and autonomy. The greatest extent of problems with participation were experienced in the aspects ‘Activities in and around the house’ (54%), ‘social life and relationships’ (60%) and ‘paid or voluntary work’ (64%). On the EQ5D, 20% reported impaired ‘mobility’, ‘self-care’ and ‘activities’ and 50% reported problems in ‘pain/discomfort’ and ‘anxiety or depression’. In a comparison between the persons on sick-leave and those not on sick-leave, significant differences were found for all of the general questions of IPA covering nine different aspects of participation (p ¼ 0.005–0.048). Similarly, significant differences were found in self-care (p ¼ 0.044) and activity (p ¼ 0.0013) between the groups on EQ5D. There were no difference between the groups on

sick-leave or not on sick-leave concerning age, sex or GCS at time for injury. Conclusions: In this sample of TBI a large proportion reported problems in health outcome according to the EQ5D. In this study the IPA results reveal that lack of participation in society is an even greater problem after a head injury. The findings also show a significant difference between being on sick-leave or not, with less participation and a lower level of quality-of-life in the group on sickleave 4 years after trauma. The results support the hypothesis that if you are on sick-leave and not in work you feel a lower degree of participation in society.

0584

Getting children with ABI back on track at school Peter de Koning, Carla Hendriks, & Liesbeth Bosma Heliomare Rehabilitation Center, Wijk aan Zee, The Netherlands Objectives: Children with acquired brain injury (ABI), their parents and teachers, often are confronted with several problems after a child returns to school. Unexpected problems may occur and sustain in behaviour, in cognition or in physical complaints. Even after several years these sequelae of the ABI can result in under-achievement at, or even dropping out from school. It is a challenge to find resources and develop interventions to prevent this. Three years ago the authors started an outpatient programme, which aims to get children back on track at their own school or find an appropriate alternative. A multidisciplinary team that works interdisciplinary together provides the programme. This study presents a description of the included children and their discharge destination. It describes the programme and presents the evaluation of the interdisciplinary way of working. Critical factors in developing and maintaining the programme are discussed. Methods: Children aged 6–20 years with ABI are included. The programme is carried out in a school class setting for a period of 2 to a maximum of 10 months. In four phases the child’s cognitive level, academic skills and social skills are assessed, optimized and put into practice before the transition to the former school is made. Physical rehabilitation is integrated in the programme, when needed. Every 6 weeks individual goals are set and evaluated by the team and the parents. The team consists of a teacher, an assistant-teacher, neuropsychologist, speech-language pathologist, occupational therapist, physical therapist, social worker, family therapist and a paediatric rehabilitation physician. The way of interdisciplinary working was evaluated using the PATH-method. Results: Twenty-six children (age range ¼ 6–18 years) with ABI entered the programme. All had significant school failures, due to sequelae of the injury. Eleven suffered from traumatic brain injury, 15 from nontraumatic brain injury (tumour: 7, stroke: 4, other: 4). Time after injury ranged from 3–82 months (412 months: n ¼ 14). Duration of the programme ranged from 8–40 weeks. Of the 20 children who completed the programme so far, 12 returned successfully to their old school and eight switched to a school for children with special needs. Evaluation of this way of working resulted in a plan concerning giving each other better feedback, achieving more efficacy during team meetings, allocating reasonable workload and creating moments for alignment. Conclusion: After ABI, children can have a successful school career. A realistic perspective, given the child’s competences, is needed. A welltrained team, working interdisciplinary together, can provide this. Family participation and participation of the former school are essential to success. Finding resources to achieve this asks for strong management commitment.

734

0585

Evaluation of postural function with abnormal cerebellar blood flow in patients with chronic mild brain injury Shin-Tsu Chang1 1


Department of Rehabilitation, Taichung Veterans General Hospital, Taichung, Taiwan, 2Department of Physical Medicine and Rehabilitation, School of Medicine, National Defense Medical Center, Taipei, Taiwan

Objectives: Brain injury has been demonstrated to affect the cerebellum in representing reduced metabolism and decreased regional blood flow. The phenomenon of contralateral cerebellar diaschisis (CCD), one of cerebellar blood flow abnormalities, is related with postural control due to the well-known balance function that the cerebellum plays. The development of CCD has been found to be related to volume of depressed perfusion but not to the severity of decreased blood flow. To study the relationship between postural function and the cerebellar dysmetabolism, patients with chronic brain injury were investigated by using upright posture. Methods: A consecutive patients group with brain injury duration 6–36 months was collected in the study. Based the images of SPECT, this study allocated patients with CCD as Group 1, and those without CCD as Group 2. Comparison of the upright posture of the two groups was obtained from the postural sway parameters. The Biodex Balance System (Biodex Medical Systems, Inc., New York, NY) was used for balance testing, which includes a movable circular platform and changeable resistance level of the foot platform. A multidirectional tilting platform was connected to a computer with software to enable the device to serve as an objective assessment of balance. The balance level indicated the steadiness of the foot platform, with level 12 being the most stable and level 1 the most unstable. The stability settings of 12 through 1 allowed the foot platform a full 20 of deflection from level in any direction. Bilateral stance was assessed using a total of seven levels: six dynamic (12, 8, 4, 3, 2, 1) and one static level (0). Balance function, including postural stability testing (PST) and limits of stability (LOS), was obtained to evaluate the posture function. Those who showed obvious imbalance during testing were removed from the study. Results: After adjusting for age, gender and duration, PST was found to be associated with group, gender and static/dynamic testings, respectively. The relationship between PST and groups was found to vary. Comparing the PST, the group differences ranged from 11.28 to 56.16 (compared 12, 8, 4, 3, 2, 1 to 0, all p50.0001, respectively). LOS was associated with group, gender and static/dynamic testing, respectively. The relationship between LOS and groups was found to vary, where the group differences ranged from 17.14 to 52.36 (compared 12, 8, 4, 3, 2, 1 to 0, all p50.0001, respectively). Conclusions: This study elucidates the postural function with abnormal cerebellar blood flow in patients with chronic mild brain injury.

0586

Rehabilitation in the treatment of cerebral amyloid angiopathy after stroke Andre Cassell, Chiedozie Uwandu, & Ning Cao

Brain Inj, 2014; 28(5–6): 517–878

Johns Hopkins University, Baltimore, MD, USA Objectives: CAA-related inflammation (CAA-I) is a rare disease, defined by the deposition of amyloid proteins within the leptomeningeal and cortical arteries associated with vasculitis or perivasculitis. CAA-I has a characteristic combination of clinical and radiological features. Definite diagnosis requires brain and leptomeningeal biopsy. A favourable response to immunosuppressive therapy is common and treatment without brain biopsy may be considered in selected patients. This case study is to examine the effect of multidisciplinary rehabilitations on cognitive and functional improvement of a patient with probable CAA-1 in addition to the steroid therapy. Methods: A 77-year old female with history of atrial fibrillation and hypertension was transferred from University hospital to inpatient rehabilitation with slurred speech, left-sided hemiparesis, hemianopsia and repaidly-progressive dementia. Her comprehensive neuroimaging and clinical condition support the diagnosis of presumed cerebral amyloid angiopathy, a probable inflammatory variant of CAA. She received a course of IV methylprednsione, then was maintained on a high dose of prednisone in rehabilitation. On arrival, her score on the Repeatable Battery for the Assessment of Neruopsychological status (RBANDS) was 56 (0.2%). She received comprehensive rehabilitation 3–4 hours a day including speech, occupational, physical and neuropsychology therapy focusing on the orientation, cognitive therapy with external memory aid, balance and visual spatial scanning training. Results: She exhibited improvements in many functional domains assessed after 6 days of training. Her RBANS assessment improved in all areas, most notably in visuospatial processing (from 66 points to 87 points) and delayed memory (from 44 points to 68 points), overall RBANDS improved 13 points. Her balance, as rated by the berg scale improved 11 points. She was able to complete transfers, food preparation and gather items with supervision. She was able to be independent with mobility within her house and was ambulating with supervision within the community. Conclusions: There is no definitive treatment for cerebral amyloid angiopathy. When co-existing vasculitis is present, patients can be treated with long-term steroids and immunomodulants such as cyclophosphamide. The long-term treatment of CAA, inflammatory-type, rehabilitation has been shown to increase patient functionality after acute cerebrovascular incident. Such interventions should be maintained in the context of traditional mainstay therapies, including steroids, anti-convulsants and antihypertensives.

0587

Systematic review of selfreported prognosis in adults after mild traumatic brain injury: Results of the International Collaboration on MTBI Prognosis (ICoMP) J. David Cassidy1, Carol Cancelliere2, Linda J. Carroll3, Pierre Coˆte´4, Cesar A. Hincapie´2, Lena W. Holm5, Jan Hartvigsen1, James Donovan2, Catharina Nygren-de Boussard5, Vicki Kristman6, & Jo¨rgen Borg5 1

University of Southern Denmark, Odense, Denmark, 2University of Toronto, Toronto, ON, Canada, 3University of Alberta, Edmonton, AB, Canada, 4University of Ontario Institute of Technology, Oshawa, ON, Canada, 5Karolinska Institutet, Stockholm, Sweden, 6Lakehead University, Thunder Bay, ON, Canada

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DOI: 10.3109/02699052.2014.892379

Objective: To update the MTBI prognosis review published by the WHO Task Force in 2004. Data sources: MEDLINE, PsycINFO, Embase, CINAHL and SPORTDiscus were searched from 2001–2012. This study included published, peerreviewed studies with more than 30 adult cases. Study selection: Controlled trials, cohort and case-control studies were selected according to pre-defined criteria. Studies had to assess subjective, self-reported outcomes. After 77 914 titles and abstracts were screened, 299 articles were eligible and reviewed for scientific quality. This includes three original ICoMP research studies. Data extraction: Eligible studies were critically appraised using the Scottish Intercollegiate Guidelines Network (SIGN) criteria. Two reviewers independently reviewed each study and tabled data from accepted articles. A third reviewer was consulted for disagreements. Data synthesis: Evidence from accepted studies was synthesized qualitatively into key findings and prognostic information was prioritized according to design as exploratory or confirmatory. Of 299 reviewed studies, 101 (34%) were accepted and form the evidence base of prognostic studies. Of these, 23 addressed selfreported outcomes in adults, including two of the three original ICoMP research studies. These studies show that common postconcussion symptoms are not specific to MTBI/concussion and occur after other injuries as well. Poor recovery after MTBI is associated with poorer pre-morbid mental and physical health status and with more injury-related stress. Most recover over 1 year, but persistent symptoms are more likely in those with more acute symptoms and more emotional stress. Conclusions: Common subjective symptoms after MTBI are not necessarily caused by brain injury per se, but they can be persistent in some patients. Those with more initial complaints and psychological distress recover slower. More high-quality research is needed on these issues.

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Self-efficacy related to physical activities in adolescents after a mild traumatic nrain injury (mTBI) Krithika Sambasivan1, Lisa Grilli2, & Isabelle Gagnon1 1

McGill University, Montreal, Canada, 2Montreal Children’s Hospital, Montreal, Canada Objectives: There is preliminary evidence that self-efficacy related to physical activities is negatively affected after an mTBI in adolescents, thus may play a significant role in how successful they are upon return to their physical activities. The objectives of this study were: to explore the evolution of self-efficacy related to physical activities before and after complete return to physical activities in adolescents who are clinically recovered after an mTBI and to explore the contribution of balance in the construction of self-efficacy beliefs. Methodology: A prospective study was conducted to assess selfefficacy in 29 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) who were recruited from the Montreal Children’s Hospital Concussion Clinic. Children with mTBI were matched to 22 controls, on age (13.59 ± 2.56 years), sex and levels of pre-injury physical activities. Perceived self-efficacy related to physical activities was measured at two times: T1, when children were considered clinically recovered and given step-wise guidelines to return to activity, and T2, 2 weeks later, at which time children should have completely returned to physical activities. Selfefficacy was measured using an 18-item questionnaire designed for children with mTBI (eight items were mTBI related, 10 items were

athletic skills related). In addition, balance skills were measured at T1 using three clinical balance measures: Bruininks-Osteresky Test for Motor Proficiency, Second Edition–Balance sub-test; Balance Error Scoring System; and Community Balance and Mobility Scale as well as three gait paradigms (Self-selected pace, tandem, obstacle crossing) using the GAITRite Walkway (CIR Systems, USA). Change in perceived self-efficacy was analysed using repeated measures ANOVA. The relationship between balance at T1 and self-efficacy at T2 was determined using Spearman Rank Order correlations. Results: There was no difference found in age, gender, levels of physical activities and post-concussion symptom levels between the groups. There was a significant interaction between the groups over time. Self-efficacy related to mTBI problems was found to be significantly lower at T1 vs T2 in the mTBI group (p50.05). It was also found that the mTBI group had lower scores compared to the controls at T1 (p50.05). There was no significant correlation found between balance and self-efficacy in either group. Conclusion: The above results suggest that perceived self-efficacy improves with time and after returning to complete physical activities following mTBI. A lack of association with balance skills may indicate that self-efficacy could be constructed based on the psychological and physical states of the individual. Once adolescents return to physical activity, self-efficacy beliefs rely more on performance, encouragement from others as well as observation of others.

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Theory of mind deficits following traumatic brain injury in preschool children Jenny Bellerose1, Annie Bernier2, Cindy Beaudoin3, Jocelyn Gravel3, & Miriam H. Beauchamp1 1

Ste-Justine Hospital Research Center & University of Montreal, Montreal, Quebec, Canada, 2Psychology Department, University of Montreal, Montreal, Quebec, Canada, 3Ste-Justine Hospital Research Center, Montreal, Quebec, Canada Objective: Given the importance of adequate social skills to the establishment of satisfying friendships and relationships in childhood, there is growing interest in documenting the impact of traumatic brain injury (TBI) on the socio-cognitive functions that underlie social competence. However, to date, limited validated and reliable tools have been available to evaluate social cognition during the preschool period. Walz and colleagues are amongst the few to have reported theory of mind deficits in the post-acute phase following pre-school TBI. Most of the research on the topic has been conducted in older age groups. In adolescent and adult populations, TBI can be associated with anti-social behaviours and criminality and social difficulties are amongst the most persistent sequelae reported. A more comprehensive understanding of pre-school children’s sociocognitive functioning after TBI is necessary to design appropriate interventions and to ensure adequate lifelong psychosocial integration. The aim of the current study was, therefore, to examine social cognition, specifically, theory of mind (ToM), in pre-school children who sustain TBI. Method: As part of a longitudinal study examining the cognitive and social repercussions of pre-school TBI, 31 children (2–5 years) with accidental mild, moderate or severe TBI were recruited at an urban paediatric tertiary care Emergency Department using the definition reported by Osmond et al. They were administered a battery of sociocognitive tests including either the Discrepant Desires Task (2–3 years old) or the Desires Task (3–5 years old), as well as a false-belief task, and their performance was compared to that of 32 typicallydeveloping children (TDC). Results: Children with TBI performed significantly worse on the Desires task compared to TDC (t(61) ¼ 1.70; one-tailed, p50.05). Group

736 performances were not significantly different for the false belief task (t(59) ¼ 0.48; one-tailed, p ¼ 0.32). Further analyses of false belief demonstrate a trend towards significance for false belief towards self (t(57.57) ¼ 1.438; one-tailed, p ¼ 0.08), but not for false belief directed towards others (t(59) ¼ 0.73; one-tailed, p ¼ 0.23). Conclusion: Given that ToM emerges during the pre-school period, it is possible that TBI sustained at this time may have a deleterious effect on ToM abilities that are developing at the moment of the injury, whereas ToM abilities that have already been acquired may be more resistant to injury. Further analyses will be conducted on a larger group to examine specific age differences at 6- and 12-months postinjury to document the impact of TBI on ToM and social functioning during the pre-school years.

Brain Inj, 2014; 28(5–6): 517–878

amplitude. The P300 was of a longer temporal duration and had higher frontal amplitude in the active counting condition than in the passive listening task. However, the control group did not present with a clear P300 in the passive listening task, indicating a deficient task differentiation in the patient. Conclusions: Preliminary results from the first patient included in this prognostic ERP study validate that reliable electrophysiological indicators of attentional processing can be demonstrated in a functional imaging task with working memory load in a TBI patient admitted to NICU, who behaviourally displayed inconsistent command following. The highly preliminary results indicate that the design is suitable for investigation of residual cognition in severely brain injured patients still receiving intensive care treatment and that electrophysiological data adds information not conveyed by behavioural methods.


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Repeated acute and sub-acute event-related potentials as predictor of post-acute outcome: Presentation of a study design and single case data Solveig Lægreid Hauger1, Kjell Olafsen2, Nada Andelic3, Cecilie Røe3, Stein Andersson4, Anne-Kristine Schanke1, Frank Becker1, Caroline Schnakers5, & Marianne Løvstad1

0591

Risks for later peer victimization following early childhood traumatic brain injury Anna Hung1, Shari Wade1, Amy Cassedy1, Keith Yeates2, Terry Stancin3, & H. Gerry Taylor4 1

1

Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA, Nationwide Children’s Hospital, Columbus, OH, USA, 3MetroHealth Medical Center, Cleveland, OH, USA, 4Rainbow Babies and Children’s Hospital, Cleveland, OH, USA

Objectives: Predicting outcome following severe TBI remains challenging. Electroencephalography-based Event Related Potentials (ERPs) recorded in the sub-acute phase have potential predictive value. It is, however, unknown whether the rate of ERP normalization can provide predictive information for post-acute outcome. This study describes a prospective study design investigating the prognostic value of repeated sub-acute ERPs in predicting post-acute functional outcome. Data collection started in October 2013 and acute ERP data from the first included patient are presented. Methods: Inclusion criteria for patients recruited from the neurointensive care unit (NICU) at the largest Norwegian Trauma Referral Centre are (1) ICD-10 diagnosis of intracranial injury (S06.1–S06.9), (2) severe TBI (GCS 8) in the first 24 hours after injury, (3) in need of more than 5 days of intensive care and (4) withdrawn infused sedation (4 days). ERPs will be recorded at three time-points, using an auditory design with repeated exposure to the patient’s own name (SON) or an unfamiliar name (UN), with tasks varying from passive listening to requirement of volitional cognition (counting the number of SON). Data are collected bed-side using a 32 electrodes cap and a portable NuAmp EEG-amplifier. Acute medical data will be registered and behavioural function assessed with Glasgow Coma Scale (GCS) and Coma Recovery Scale Revised (CRS-R). Outcome at 6 months will be assessed with standardized questionnaires and neuropsychological measures. Results: The ERPs of the first patient included were recorded 28 days post-injury in a minimally conscious female still admitted to the NICU (aged 53). ERP-data were compared to nine healthy subjects (six males, mean age ¼ 35). GCS and CRS-R total score at the day of recordings was 12 and 16, respectively, displaying intermittant but not consistent command following. The patient displayed an identifiable N1-P2 complex and, more importantly, a parietal P300 component, indicating attentional processing. Compared to the control group, the patient’s P300 was delayed and had reduced

Objectives: Traumatic brain injury (TBI) is the leading cause of acquired disability in children, affecting about half a million children in the US annually. Common sequalae of TBI, including cognitive, behavioural and socio-emotional processing impairments, may lead to increased bullying (i.e. victimization) by peers. To test the hypothesis that early TBI is associated with victimization/bullying in middle school, this study compared children with severe and mild complicated to moderate TBI to children with orthopaedic injuries (OI) on rates of self-reported victimization. Method: Participants sustained TBI or OI between ages 3–7 years (M ¼ 5.13; SD ¼ 1.09) and were followed to ages 10–14 years. The sample was comprised of 15 children with severe TBI, 49 with complicated mild/moderate TBI and 69 with OI. To assess bullying, participants completed the Schwartz Victimization Scale ( ¼ 0.93), which includes questions about frequency of verbal, physical and relational types of bullying. Victimization was classified as either frequent (4 times/year) or infrequent (52–3 times/year). Results: Chi-square analysis revealed significant differences between groups (2 ¼ 6.3, p ¼ 0.043), with children with severe TBI (36%) reporting frequent bullying more often than children with mild complicated/moderate TBI (29%) and OI (13%). Logistic regression analysis, controlling for race and parental education, revealed significant main effects of complicated mild/moderate TBI (b ¼ 1.01, SE ¼ 0.53, Wald ¼ 4.1, p ¼ 0.043, OR ¼ 2.9) and parent education (b ¼ 2.32, SE ¼ 0.55, Wald ¼ 17.9, p ¼ 0.000, OR ¼ 10.2) as predictors of victimization. Conclusions: These findings suggest that having a TBI or a parent with no more than a high school education increases a child’s likelihood of being bullied. Severe TBI may not have been a significant predictor in the logistic regression, despite being associated with the highest rate of self-reported bullying, due to limited statistical power. Increased rates of victimization in the severe TBI group are consistent with findings in other studies of school-age children. Alternatively, youth with severe TBI may be less aware of bullying as emerging research shows that children with severe TBI have greater social processing deficits and they display greater discrepancies from peer reports of victimization than children with less severe TBI or OI. Future research is needed to examine whether child cognitive and behavioural

Sunnaas Rehabilitation Hospital, Nesodden, Norway, 2Department of Neurointensive Care, 3Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway, 4Department of Psychology, University of Oslo, Oslo, Norway, 5Cyclotron Research Centre, University of Lie`ge, Lie`ge, Belgium

2

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deficits mediate the association between TBI and elevated rates of bullying. Because victimization among youth with TBI may exacerbate the adverse effects of these injuries, additional study of bullying in this population is warranted.

psychological treatment for hopelessness among US veterans with traumatic brain injury (TBI)

0592

Long-term outcome after traumatic brain injuries in Northern Sweden: changes between 6–15 and 12–21 years post-injury Lars Jacobsson1, & Jan Lexell2


1

Department of Health Sciences, Lund University/Department of General Medicine, Kalix Hospital, Lund/Kalix, Sweden, 2Department of Health Sciences, Lund University/Department of Rehabilitation Medicine, Ska˚ne University Hospital, Lund/Lund, Sweden Objectives: Studies of long-term outcome after a traumatic brain injury (TBI) have increased during recent years. However, knowledge of changes over time, many years post-injury, is still incomplete. The objective of this study was to compare long-term outcome, assessed in 2007 (on average 10 years post-injury), with data on the same individuals obtained in 2013 (on average 16 years post-injury). The sample comprised individuals in northern Sweden that had been transferred for neurosurgical care following a TBI from 1992–2001. Method: A total of 88 individuals (aged 18–65 years of age) were assessed in 2007, 6–15 years after their TBI, and the assessments were repeated in 2013, 12–21 years post-injury. The following instruments were used in 2007 and 2013: the Swedish versions of the MayoPortland Adaptability Inventory (MPAI-4), the Functional Independence Measure (FIM) and the Disability Rating Scale (DRS). Results: Eight of the 88 individuals had decreased. To date, data for 26 individuals have been collected. The mean age of the 23 men and the three women is 54 (range ¼ 33–70) years. Fourteen individuals had a mild TBI and were significantly (p ¼ 0.001) older than the 12 with a moderate-to-severe TBI. Five of those with mild and none of those with moderate-to-severe TBI were retired. Sixteen individuals were working in 2007 and 10 were still in full-time or part-time work in 2013. For the whole group, the motor and cognitive FIM were 89 and 33 in 2007 and 88 and 32 in 2013; this difference was significant (p50.05) for both measures. The total DRS was 2 in 2007 and 2 also in 2013. There were no significant changes for either the total DRS or any of the DRS sub-scales (Physical, Cognitive and Social). The total MPAI-4 was 20 in 2007 and 23 in 2013, with no significant change over time. There was a small and significant (p50.05) difference for the sub-scale Ability over time (from 8 in 2007 to 9 in 2013), but no other significant changes for the sub-scales Adjustment (10 in 2007 and 11 in 2013) and Participation (7 in 2007 and 12 in 2013). There was no apparent differences over time for those with a mild TBI (n ¼ 14) compared to those with a moderate-to-severe TBI (n ¼ 12). Conclusions: The results so far indicate that many people with a TBI, regardless of injury severity, can achieve and maintain a fairly high level of functioning many years post-injury and that outcome is also fairly stable over time. The significant changes are all small but may imply a trend that some variables in the participants’ life situations tend to be worsened many years post-injury.

0593

Window to hope: Preliminary results from a randomized controlled trial (RCT) of a

Lisa Brenner1, Grahame Simpson2, Jeri Forster1, Gina Signoracci1, Bridget Matarazzo1, Tracy Clemans1, & Adam Hoffberg1 1

VISN 19MIRECC, Denver, CO, USA, 2Liverpool Brain Injury Rehabilitation Unit, Liverpool Hospital, Sydney, Australia

Objectives: Individuals seeking care within the Veterans Health Administration (VHA) with moderate-to-severe TBI have higher rates of suicide than those without this injury history. Window to Hope (WtoH) is a suicide prevention cognitive behavioural-based intervention to treat hopelessness that has been adapted for US Veterans with a history of moderate-to-severe TBI. The objectives of this Phase II randomized controlled trial (RCT) are to: (1) demonstrate successful implementation of the WtoH intervention at a Veterans Affairs Medical Centre (VAMC) in the domains of acceptability, feasibility and fidelity; and (2) demonstrate post-treatment reductions in hopelessness, suicide ideation and depression. Methods: Up to 90 veteran participants with moderate-to-severe TBI are being recruited into a waitlist, cross-over RCT design. The WtoH intervention is delivered in small groups (2–3 participants) during a 2hour block over a 10-week period. Implementation outcomes include attendance records, the Client Satisfaction Questionnaire-8 (CSQ-8) and the Narrative Evaluation of Intervention Interview (NEII). Primary (hopelessness) and secondary outcomes (depression and suicidal ideation) are being measured with the Beck Hopelessness Scale (BHS), the Beck Depression Inventory-Revised (BDI-II) and the Beck Scale for Suicide Ideation (BSI). Results: Of the 24 participants randomized to date, 11 recorded at least 80% attendance, five recorded 50–70% attendance, two recorded 550% attendance, four did not attend any sessions and two are still in treatment. Preliminary quantitative implementation outcomes data, as well as qualitative findings will be presented. In addition, preliminary findings regarding hopelessness, depression and suicidal ideation will also be discussed. Conclusions: Findings regarding attendance suggest that the intervention can be successfully implemented at a VAMC. Further qualitative and quantitative implementation data will be presented. It is also hoped that preliminary primary and secondary outcomes support larger trials of the intervention.

0595

Executive dysfunction and suicide in veterans with and without a history of traumatic brain injury Lisa Brenner, Nazanin Bahraini, Beeta Homaifar, Jeri Forster, Lindsey Monteith, & Brooke Dorsey-Holliman VISN 19MIRECC, Denver, CO, USA Objectives: Individuals with a history of traumatic brain injury (TBI) are at increased risk for suicidal behaviour. Researchers have also found suicidal behaviour to be associated with executive dysfunction as measured by indices of poor decision-making, laboratory-measured impulsivity and aggression; however, such studies were not focused on individuals with histories of moderate or severe neurologic disease or damage.


738 Methods: This 2 2 factorial design observational study of veterans is examining various components of executive functioning (decisionmaking, impulsivity, aggression, concept formation) in the context of an interaction between suicidal behaviour and a history of moderate/ severe TBI. Participants are Veterans recruited from outpatient and inpatient settings at a Mountain state metropolitan Veterans Affairs (VA) Medical Center. Inclusion criteria are as follows: aged 18–65, ability to provide adequate effort, positive or negative history of moderate or severe TBI, positive or negative history of suicidal behaviour and ability to adequately respond to questions regarding the informed consent procedure. Main outcome measures include the Iowa Gambling Test (IGT), Immediate and Delayed Memory Test (IMT/ DMT), State Trait Anger Expression Inventory-2 (STAXI-2) and Wisconsin Card Sorting Task (WCST). To date, 109 participants have completed the study. Results: It is expected that final study results will be available to present at the conference. To date, over 1000 potential participants have been screened and nearly 200 have been enrolled. Conclusions: It is hoped that findings from this study will contribute to clinicians’ ability to identify veterans with TBI who are at risk for suicidal behaviour, as well as create a foundation on which to base further research regarding the relationships between cognition, emotional distress and suicidal thoughts and behaviours among TBI survivors. Highlighting potential vulnerabilities would also allow for the design of evaluation tools and interventions aimed at addressing the needs of VA clinicians and veterans with a history of TBI.

0596

A comparative study of duloxetine and paroxetine in Japanese patients with poststroke depression Shuji Matsumoto1, Megumi Shimodozono1, Tomokazu Noma2, & Kazumi Kawahira1 1

Kagoshima University, Kirishima City, Japan, 2Kagoshima University Hospital, Kirishima City, Japan Objective: Duloxetine is an antidepressant that inhibits the re-uptake of serotonin and norepinephrine and is, thus, classified as a serotoninnorepinephrine re-uptake inhibitor. In Japan, the usefulness of duloxetine as an antidepressant has been demonstrated in clinical studies, the antidepressant effect and tolerability have been shown to be comparable or superior to comparators, such as selective serotonin re-uptake inhibitors (fluoxetine, fluvoxamine, paroxetine) and tricyclic antidepressants (amitriptyline, imipramine). However, no study has been conducted in Japan, with the aim of confirming the non-inferiority of duloxetine to previously introduced drugs in Japanese patients with post-stroke depression. It is considered that it is important to verify the antidepressant effect of duloxetine using a fixed-dose design and a double-blind, controlled study was conducted to determine the non-inferiority of duloxetine in patients with post-stroke depressive disorders against the selective serotonin reuptake inhibitor, paroxetine, which is the most extensively used antidepressant in Japan. Methods: A double-blind, parallel-group, controlled study was performed to investigate if duloxetine was superior to paroxetine in terms of improvement in symptoms of depression and pain in Japanese patients with post-stroke depression in a fixed-dose design.

Brain Inj, 2014; 28(5–6): 517–878

The efficacy and safety of duloxetine 60 mg day1 were also assessed in comparison with those at the standard dose of 40 mg day1. Results: Changes in 17-item Hamilton depression rating scale (HAM-D) total score (mean ± standard deviation) for group D1 (duloxetine 40 mg day1), group D2 (duloxetine 60 mg day1) and group PX (paroxetine 20 mg day1) were 14.9 ± 5.6, 15.6 ± 6.4 and 11.4 ± 6.2, respectively, and the estimated differences in total score for group PX (Dunnett’s 95% simultaneous confidence interval) were 3.8 (3.2–4.4) for group D1 and 4.2 (3.6–4.8) for group D2. The superiority of groups D1 and D2 to group PX was thus confirmed, because the upper confidence limit of differences between groups D1 and PX and between groups D2 and PX was more than 3.2. The groups D1 and D2 presented a reduction in the pain, which was not observed in the group PX. The incidence of treatment-related adverse events was 21% for group D1, 28% for group D2 and 30% for group PX, indicating no significant difference between the three groups. Conclusions: In conclusion, the non-inferiority of duloxetine to paroxetine has been confirmed in the present double-blind, controlled study of Japanese patients with post-stroke depressive disorder. The present study is the first to verify the non-inferiority of duloxetine to a standard antidepressant using a fixed-dose scheme. These results also show that the antidepressant effect of duloxetine 40 mg day1 and that of duloxetine 60 mg day1 were essentially comparable with each other and with the antidepressant effect of paroxetine.

0597

Epidemiology of work-related traumatic brain injury: A review Vicky Chang, & Angela Colantonio University of Toronto, Toronto, Ontario, Canada Objectives: Although occupational traumatic brain injury (TBI) is considered among the most serious of workplace injuries, to date there has not been a comprehensive review of the literature on the epidemiology of TBI occurring at work. This study aimed to examine the burden, risk factors and outcomes of work-related TBI (wrTBI) based on a synthesis of the literature. Methods: A search was conducted in Medline, Embase, PsycINFO and CINAHL using a combination of keywords relating to TBI and occupational injury. In addition to studies focusing on the epidemiology of wrTBI alone, those examining occupational injuries or TBIs in general were included if the number or percentage of wrTBI cases were reported. Results: A total of 52 studies were included in this review, 23 of which specifically examined wrTBI. The annual incidence ranged from 6.2– 49.4 per 100 000 workers, and wrTBI comprised 11–49% of occupational injuries and 2–24% of TBIs overall. Male sex and younger and older age were associated with greater risk of wrTBI. The construction industry ranked among the top in terms of the number of cases, while primary industries experienced the highest rates of severe/fatal wrTBI. In general, falls were identified as the leading cause of wrTBI, followed by either motor vehicle crashes or being struck by/against objects. Depending on the data sources used, injury severity and outcome measures varied widely across studies. Conclusions: This work highlights workers most at risk for wrTBI. Methodological variations contributed to differences in epidemiologic findings across studies. Future research should aim to improve study design and bridge knowledge gaps in order to advance prevention efforts.

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0598

Examining the epidemiology of work-related traumatic brain injury through a sex/gender lens: analysis of workers’ compensation claims in Victoria, Australia Vicky Chang1, Rasa Ruseckaite2, Alex Collie2, & Angela Colantonio1 University of Toronto, Toronto, Ontario, Canada, 2Institute for Safety, Compensation and Recovery Research, Melbourne, Victoria, Australia


1

Objectives: Work-related traumatic brain injury (wrTBI) is among the most serious occupational injuries in North America. To date, no study has examined the epidemiology of wrTBI in the Australian context. There is also a paucity of research focusing on sex/gender differences in risk factors and outcomes of wrTBI. The objective of this study was to provide an overview of the epidemiology of wrTBI in the state of Victoria, Australia and to compare incidence, demographic, injury characteristics and impacts of wrTBI by sex. Methods: This cross-sectional study involved secondary analysis of administrative workers’ compensation claims data obtained from the Victorian WorkCover Authority for the period 2004–2011. Cases of wrTBI were ascertained using codes in the Australian Standard Type of Occurrence Classification System. Trends in rates were assessed using Poisson regression. Descriptive analysis of all variables was conducted for each sex and means and proportions were compared using t-tests and chi-square tests, respectively. Results: A total of 4234 claims for wrTBI were identified, 64% of which involved males. The annual incidence rate of wrTBI was estimated at 20.0 per 100 000 workers, with a non-significant decline from 19.5 to 18.7 per 100 000 over the 8-year period. The rate for males was 1.43 (95% CI ¼ 1.35–1.53) times that for females, but the gap between the two sexes appeared to have narrowed over time. Compared to males, females were older at time of injury, had lower pre-injury income and were more likely to have been working for larger companies or the government. The greatest proportion of wrTBIs occurred in the manufacturing industry for males (17%) and the education and training industry for females (28%). Males had higher wrTBI rates than females across most industry sectors, particularly in the construction industry (RR ¼ 4.49, 95% CI ¼ 2.39–8.42). For both sexes, the arts and recreation industry experienced the highest rates of wrTBI. The most common mechanism of injury was being struck by/against (53%), followed by falls (24%), assaults and violence (13%) and motor vehicle crashes (7%), with the first two being more common in females. WrTBIs among males were associated with significantly longer duration of work disability and higher claim costs compared to females. Conclusions: This study provides the first epidemiologic profile of wrTBI in Australia. Sex-/gender-based analysis revealed significant differences between males and females in terms of demographics, injury characteristics and outcomes of wrTBI. Recognition of these differences is essential for developing tailored approaches to injury prevention and reducing work disability and economic burdens on the workforce and society.

0599

‘Even when I say we, it was a decision that I made’: The

experiences of adults with severe TBI and their partners in making decisions about life after injury Lucy Knox, Jacinta Douglas, & Christine Bigby La Trobe University, Melbourne, VIC, Australia Objectives: There is growing recognition of the inherent right of all individuals to participate in making decisions in all aspects of their lives. Individuals with severe TBI are likely to require support to exercise this right and, for individuals with TBI who are in spousal relationships, decision-making support is likely to be provided by their partner. Although it is well documented that TBI may result in significant changes to the spousal relationship, there has been limited exploration of the process of decision-making within these relationships and the way that decision-making is experienced by both partners. This study aimed to build an understanding of the experiences of individuals with severe TBI and their spouses about making decisions about their lives after injury. Methods: This study utilized a constructivist grounded theory approach informed by a symbolic interactionist perspective. Data included 21 individual interviews with members of four dyads (consisting of individuals with severe TBI and their partners). Indepth interviews were conducted with participants over a 12-month period. Data was analysed through an iterative process of open and focused coding, identification of emergent categories and exploration of the relationships between categories. Results: Multiple examples of types of decisions emerged from the data. Decisions occurred across a number of continua, reflecting perceptions about the size, origin and urgency of the decision and its predicted consequences. Interview data also revealed a complex conceptualization of decision-making within partner relationships. Decision-making played out as a multi-stage process, largely driven by non-injured partners. The nature and quality of the spousal relationship shaped and was shaped by the experience of decisionmaking. Several factors emerged that determined the extent to which decision-making involved one or both partners, such as the level of input required to support involvement and whether the decision could be proceduralized. Conclusions: This study provides in-depth qualitative evidence of the complex nature of decision-making within partner relationships after severe TBI. It emphasizes that decision-making impairments should be considered in the relationships within which they occur. The framework revealed in this qualitative inquiry informs intervention provided by rehabilitation practitioners working with individuals and their partners when making decisions about life after injury. It also highlights the challenges faced by clinicians in balancing the needs of individuals and their relationships and strategies that may be utilized in this process.

0601

A practical magnetic resonance imaging (MRI)-based approach for evaluating diffuse axonal injury Anthony Asemota1, Atul Kalanuria2, Richard Leigh1, & Robert Stevens1 1

Department of Neurology and Neurosurgery, Johns Hopkins School of Medicine, Baltimore, MD, USA, 2Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA


740 Objective: Diffuse axonal injury (DAI) is prevalent in traumatic brain injury of all severities and has been associated with prognosis; however, a practical methodology to rate DAI is lacking. This study evaluates a simple and anatomical MRI-based rating system for DAI in a convenience sample of patients hospitalized with TBI. Methods: Consecutive patients hospitalized with TBI of any severity underwent MRI scanning using a standardized acquisition protocol. DAI was defined as any white matter lesion (WML)51 centimetre detectable on Fluid Attenuated Inversion Recovery, DiffusionWeighted or Susceptibility-Weighted Image sequences. WMLs were classified in three anatomical regions: (1) brainstem and cerebellar peduncles (CP), (2) internal capsule and corona radiata and (3) corpus callosum. Injury severity was assessed clinically using the initial Glasgow Coma Score (GCS) and categorized into mild (GCS 13–15), moderate (GCS 9–12) and severe (GCS 3–8) and clinical outcome at discharge evaluated with the Glasgow Outcome Scale dichotomized into favourable (good and moderate disability) and unfavourable (severe disability, persistent vegetative state and death). Odds ratios (OR) for discharge outcome were computed at p50.05 significance level. Results: MRI scans were obtained in 165 patients, median age was 47 years (Interquartile range (IQR) ¼ 31), median GCS at admission (12, IQR ¼ 8), with males representing 76.97% of cases. The median duration from injury to MRI was 2 days (IQR ¼ 5). Mild TBI was diagnosed in 49.69% of patients, moderate in 18.18% and severe TBI in 32.11%. Twenty-seven patients (16.36%) had unfavourable outcome at discharge. WMLs consistent with DAI were demonstrated in 40.61% of patients and were more likely to be found in moderate and severe than in mild TBI patients (OR ¼ 3.45, p50.01). The distribution of lesions was as follows: region 1 in 16.97% of patients, region 2 in 27.88% and region 3 in 27.27%. Concurrent lesions in more than one region were identified as follows: regions 1 and 2 (2.42% of patients), regions 1 and 3 (1.82%), regions 2 and 3 (10.30%) and regions 1, 2 and 3 (8.48%). Propensity score modelling and analysis matching for age, gender and GCS demonstrated the following associations with the likelihood of unfavourable outcome: presence of WML in any region (OR ¼ 9.09, p50.01), region 1 only (OR ¼ 10.69, p ¼ 0.02), region 2 only (OR ¼ 1.29, p ¼ 0.83), region 3 only (OR ¼ 2.79, p ¼ 0.27), regions 1 and 2 (OR ¼ 12.34, p ¼ 0.03), regions 1 and 3 (OR ¼ 5.37, p ¼ 0.22), regions 2 and 3 (OR ¼ 4.71, p ¼ 0.04), and regions 1, 2 and 3 (OR ¼ 19.63, p50.01). Conclusion: This study has implemented a practical MRI-based anatomical rating for DAI which was independently associated with outcome at discharge. WMLs in brainstem/CP occurring either alone or in combination with supratentorial lesions were independently associated with a higher risk of unfavourable outcome. This approach warrants validation in a larger prospective cohort.

0602

The immediate effects of rhythmic auditory stimulation (RAS) on gait parameters and resulting synchronization capability of adults with severe traumatic brain injury Erin Wegener1, Ed Roth2, & Jeralyn Hunter1 1

Spectrum Health NeuroRehab Services, Grand Rapids, MI, USA, Western Michigan University, Kalamazoo, MI, USA

2

Objectives: Gait parameters and synchronization capabilities were examined following a 1-day experimental implementation of Rhythmic Auditory Stimulation (RAS) for adults with severe traumatic

Brain Inj, 2014; 28(5–6): 517–878

brain injury (TBI). RAS is a neurologic music therapy intervention which uses rhythmic cues to entrain and facilitate movement which is intrinsically and biologically rhythmic. Methods: Eight individuals (n ¼ 8) who had experienced severe TBI and were living in a 24-hour residential care facility participated in this study. Participants ambulated four 10-yard trials across a plastic runner along a flat surface with paint applied to their shoes (via the footprint analysis gait assessment). Trials were timed to measure cadence and velocity, while stride, step lengths and symmetry of step lengths were calculated using the footprint analysis. Trials were videotaped to provide a qualitative analysis. All participants ambulated under the following conditions: baseline with no music, RAS at resonant frequency, RAS with a 10% frequency modulation and removal of RAS. Music used during the RAS condition was recorded on a midi keyboard device embedded with metronome and presented to subjects via headphones. Results: Quantitative data was reported through raw scores as well as percentage change between trials. Results of quantitative and qualitative analysis revealed that at least seven out of eight participants showed capacity to synchronize to an external rhythmic auditory cue for portions of a trial, respond to the frequency modulation and/or reproduce a given frequency cue once rhythm was removed. Gait kinematics appeared optimal for most participants within the RAS resonant frequency pass (trial 2), especially including decreases in asymmetry. From pre–post RAS trials, six out of eight participants showed increases in velocity and cadence, five improved stride length and four improved symmetry. Conclusions: Individuals who have sustained a severe TBI may retain the capability to synchronize and modulate gait to an external rhythmic stimulus. This study suggests training with the rhythmic frequency matched to individual’s baseline cadence may be optimal for improving gait kinematics, especially symmetry, after severe TBI.

0603

Assessing pain in critically ill patients with traumatic brain injury at altered levels of consciousness: Do the practice guidelines fit? Ce´line Ge´linas1, Jane Topolovec-Vranic2, Caroline Arbour1, Darina Tsoller1, Melody Ross1, Andrew Baker2, Michael Cusimano2, & Manon Choinie`re3 1

McGill University, Montreál, Que´bec, Canada, 2St. Michael’s Hospital, Toronto, Ontario, Canada, 3Universite´ de Montreál, Montreál, Que´bec, Canada Objectives: This study described and compared behaviours of critically ill patients with a traumatic brain injury (TBI) at different levels of consciousness (LOC) when exposed to different procedures in the intensive care unit (ICU). Methods: A prospective repeated-measure within-subject design was used. Adults admitted to the ICU for less than 4 weeks following TBI with intact motor function and not receiving neuromuscular blocking agents were eligible. Patients were observed for behavioural responses using a pre-tested checklist of 50 behaviours and video recorded for 1-minute periods at rest before (baseline), during and 15 minutes after (recovery) for the following types of procedures: (a) non-nociceptive: gentle touch of the patient’s arm, (b) nociceptive: turning in bed. Video recordings were reviewed to modify or add any behaviours that may have been missed during assessments initially done at the ICU bedside with the behavioural checklist. Information about patients’ LOC (measured with the Glasgow Coma Scale, GCS), mechanism and severity of brain injury and the administration of

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opioids and sedatives in the 4 hours prior to data collection were also collected. Results: Eighty-four patients with TBI (mostly men, 76.2%) with a mean age of 54 years (SD ¼ 22.7) participated. The majority were mechanically ventilated (66.7%), and suffered from a moderate (33.8%) or severe (42.5%) TBI of the frontal region (51.8%) mainly caused by a fall (51.2%). More than half of them were not receiving any analgesics or sedatives (51.2%), 39.3% were receiving both and 9.5% were receiving either one. Thirty-five participants were conscious (GCS413), 35 had a reduced LOC (GCS 9–12) and 14 were unconscious (GCS58) at the time of data collection. Repeatedmeasures ANOVA showed significant differences in means of behaviours between types of procedures and across assessment periods (p50.001). Participants exhibited more behaviours suggestive of pain during turning (mean ¼ 4.4, SD ¼ 2.9) when compared to baseline (mean ¼ 1.7, SD ¼ 2.2) and to gentle touch (mean ¼ 2.7, SD ¼ 2.4) (post-hoc tests, p50.001). The most common behaviours observed during turning included sudden eye opening (36.9%), frowning (39.3%), mouth opening (21.4%) and movements of the limbs (21.4%). Grimacing, which is considered a typical facial expression of pain, was observed in only 10 conscious participants and threee with reduced LOC. Also, although muscle rigidity is generally considered a common reaction to pain, it was mainly absent in TBI participants (84.5%). Conscious TBI participants exhibited more behaviours during turning (mean ¼ 5.8, SD ¼ 3.0) compared to those with a reduced LOC (mean ¼ 4.0, SD ¼ 2.6) or unconscious (mean ¼ 2.0, SD ¼ 1.4; F-test, p50.001). Conclusions: Critically ill TBI patients at altered LOC present atypical behaviours which are not considered in the behavioural pain scales suggested for clinical use in current practice guidelines. The content of these scales should be adapted to allow for appropriate detection and treatment of pain in this highly vulnerable group.

0604

Increased frontal activation during working memory processing after paediatric concussion: Persistent effects up to 1-year post-injury Daniel Westfall1, Jessica Bailey1, Lindsey Stickans1, Kimberly Campbell1, John West1, Todd Arnold2, Patrick Kersey2, Andrew Saykin1, & Brenna McDonald1 1

Indiana University School of Medicine, Indianapolis, IN, USA, St. Vincent Sports Performance, Indianapolis, IN, USA

2

Objectives: Concussion or mild traumatic brain injury (mTBI) has become a significant public health concern, with recent media attention to paediatric concussion in particular. The nature of persistent post-concussive symptoms following the initial injury period remains poorly elucidated and an area of controversy. While some previous work has shown reduced cognitive performance in the longer-term after paediatric concussion, other data suggest no persistent effects. Executive functions such as working memory (WM) are often found to be affected after TBI of any severity. Limited functional magnetic resonance imaging (fMRI) data has shown altered brain activation during WM processing in the sub-acute period after paediatric concussion, but has generally not examined children further out from injury. The purpose of this study was to examine adolescents 3–12 months post-concussion to assess whether residual differences were detectable via neuropsychological (NP) tests or a WM fMRI task after recovery from injury would typically be expected. Methods: Participants were 19 adolescents (mean age ¼ 14.7 years, six female) who had a concussion 3–12 months prior to study

participation (mean ¼ 7.5 months) and 21 healthy control (HC) subjects (mean age ¼ 12.8 years, 13 female). Mechanism of injury was sports-related for 16 subjects (one bicycle, two ATV accidents). All participants completed NP testing and an fMRI auditory-verbal n-back WM task. Data were analysed using SPM8 and SPSS version 21. Results: No significant between-group differences were apparent for NP testing or n-back task performance, although the expected decrease in performance as task difficulty increased was apparent across subjects. However, the mTBI group showed greater brain activation than HC during the most difficult WM task (2-back40-back) in the left inferior frontal and superior temporal gyri. Conclusions: This study found greater left frontal and temporal WM task-related activation in adolescents up to 1 year post-concussion relative to HC, potentially reflecting compensatory activation to support task performance. As 12 of 19 mTBI subjects had experienced multiple concussions, repeat injury may be a risk factor for persistent effects of injury. Prior related literature has shown brain activation in the sub-acute period to correlate with post-concussive symptomatology. One study of patients 9 months post-injury after resolution of symptoms found no differences in activation compared to HC. In this study, the presence of differences in fMRI activation in the mTBI group so long after injury suggests that these alterations in brain function may have clinical implications. Further investigation is needed to clarify the relationship of these changes to functional and symptom status and examine potential risk factors for persistent post-concussive changes in brain function.

0605

The relationship between exerciseinduced elevations in middle cerebral artery velocity and headache in concussed athletes Katelyn R. Marsden, Nicole C. Strachan, Brad Monteleone, Philip Ainslie, & Paul van Donkelaar University of British Columbia, Kelowna, BC, Canada Background: Exercise frequently results in exacerbation of concussion symptoms, especially headache. However, the mechanisms behind this phenomenon have yet to be determined. Alterations in cerebral blood flow (CBF) regulation have been reported to contribute to headache pathology, although this has not been examined in the context of concussion. Thus, it is possible that an inability to appropriately regulate CBF in concussion leads to over-perfusion and the subsequent exacerbation of headache during exercise. This study, therefore, examined the hypothesis that elevations in CBF during exercise would be partly related to headache exacerbation in those with recent sport-related concussion. Methods: Subjects included six sport-related concussions (five males and one female; aged 17.5 ± 2 years, BMI ¼ 24 ± 1 kg m2) and six sexand activity-matched control subjects (aged 20 ± 2 years, BMI ¼ 22 ± 2 kg m2) who had not suffered a concussion within 12 months of testing. Concussed subjects were tested at the same time of day on days 4, 8, 17 and 29 following injury. Controls were tested at analogous time points. Blood velocities were monitored using transcranial Doppler in both the middle and posterior cerebral artery (MCAv and PCAv). Heart rate, blood pressure and end-tidal carbon dioxide and oxygen were also continuously monitored throughout the testing protocol. Exercise was performed on a stationary bike at 30% and 70% predicted heart rate reserve (HRR) for 2–3 minutes. Relative change in MCA and PCA velocities were calculated for both 30% and 70% HRR compared to baseline values. Symptom exacerbation (calculated as the total score of all 22 symptoms on SCAT2), including a sub-set analysis with headache, was evaluated pre- and post-exercise using a 7-point Likert scale.

742 Results: Across all testing days, headache was the most commonly reported symptom presented at rest and during exercise in symptomatic concussed athletes. Headache was exacerbated on average by 54% during exercise in symptomatic concussed athletes across all testing days. Although MCAv and PCAv were elevated by 20–40% during light and moderate exercise there were no significant differences between concussed and control subjects. Nevertheless, the elevation in MCAv during exercise in the concussed subjects was related to general symptoms exacerbation (r2 ¼ 0.35, p50.01). Interestingly, when the change score of headache severity was run alone against the relative changes in MCAv at 70% HRR, the relationship was more marked (r2 ¼ 0.60, p50.001). Conclusion: In early sports-related concussion, exercise-induced elevations in CBF seem to be a trigger for symptoms exacerbation, especially headache. The predictive merit and mechanisms of action of this relationship requires further investigation.


0606

Validation of an equation to predict peak aerobic capacity in adults with traumatic brain injury Leanne Hassett1, Alison Harmer1, Anne Moseley1, & Hidde van der Ploeg2 1

The University of Sydney, Sydney, NSW, Australia, 2EMGO Institute for Health and Care Research, VU Medical Center, Amsterdam, The Netherlands

Background: Reduced aerobic capacity is a common sequelae of traumatic brain injury (TBI) and impacts on the person’s ability to return to pre-injury work and leisure activities. In the clinical setting it is important to be able to measure peak aerobic capacity (VO2peak) to determine the person’s physical ability to return to pre-injury activities. It also enables accurate evaluation of changes in VO2peak with the prescription of an exercise programme. The modified shuttle test is a simple field test of fitness that has been validated in people with TBI in a previous study by the authors. Within that study, a predictive equation was developed to determine VO2peak from the modified shuttle test (VO2peak ml kg1 min1 ¼ 4.12 speed 0.19). Objective: The objective of this current study was to validate this equation in an independent sample. Methods: A descriptive prospective study recruited a convenience sample of 20 ambulant community-dwelling adults with severe TBI. Participants attended the facility for a familiarization session. One week later they returned to complete the modified shuttle test while wearing a portable gas analysis system. The modified shuttle test was externally-paced and commenced at a speed of 2.4 km h1, which increased every minute until volitional fatigue. Paired t-test was used to compare measured VO2peak to predicted VO2peak. Results: Participants were predominantly males (55%) in their early 30s,3 years post-injury. One participant’s data was excluded due to extraneous values. Measured VO2peak was 32.58 ml kg1 min1, indicating below normal fitness levels compared to age-matched normative data. The predictive equation significantly over-estimated the measured VO2peak on the modified shuttle test (36.66 vs 32.58 ml kg1 min1, respectively; p ¼ 0.001), indicating that the equation was not valid in this sample. However, when the samples from both studies were reviewed, it was observed that there were a greater percentage of females in the current study compared to the original study (45% vs 8%, respectively). When males and females were considered separately, the predicted VO2peak and measured VO2peak did not differ significantly for males (38.26 vs 35.70 ml kg1 min1, respectively; p ¼ 0.148), but the equation still significantly over-estimated for females (34.88 vs 29.13 ml kg1 min1; p ¼ 0.001). Conclusion: The current predictive equation for the modified shuttle test is valid to use for males, however it over-estimates VO2peak for

Brain Inj, 2014; 28(5–6): 517–878

females. A preliminary equation for females has been developed and will be presented.

0607

Supporting students with brain tumours in obtaining school intervention services: The clinician’s role from an educator’s perspective Sharon Grandinette California State University Dominguez Hills, Carson, CA, USA With an increase in the number of paediatric patients surviving the diagnosis and treatment of brain tumours, many children are returning to school with an alteration in their physical, cognitive and social-emotional functioning and, thus, requiring school intervention or services. Physicians and clinicians in hospital and rehabilitation settings serving this population can play a key role in communicating the medical and functional needs these children present as a result of diagnosis and treatment as they transition to an educational setting. Medical and allied health personnel can best support successful school transition when they are aware of the information schools require in order to open the door for students to easily access the interventions, supports and services available through 504 Accommodation Plans and special education supports and services under the Individuals with Disabilities Education Act. Clear communication between medical and school personnel is vital in improving educational, social and vocational outcomes for students with brain tumours. A streamlined approach to accomplish this task is offered for consideration.

0608

Amyloid plaque among patients with mild cognitive impairment following traumatic brain injury detected by [18F]florbetapir Amane Tateno1, Takeshi Sakayori1, Akira Senzaki2, & Yoshiro Okubo1 1

Nippon Medical School, Bunkyo-ku, Tokyo, Japan, 2Tokyo University of Social Welfare, Toshima Ward, Tokyo, Japan Objectives: It has been suggested that mild cognitive impairment (MCI) following traumatic brain injury (TBI) is a risk factor of conversion to AD. However, the role of TBI in the development and progression of AD pathology has not been clearly understood. This study examined young patients with MCI following TBI by amyloid positron emission tomography (PET) imaging to examine the prevalence of AD pathology following TBI. Methods: Ten patients with MCI (39.4 ± 8.2 years old, mean ± SD, range ¼ 30–52; seven males and three females) with a history of TBI participated in the study. Their cognitive function was evaluated by Mini-Mental State Examination (MMSE). The amount of betaamyloid deposit was evaluated by [18F]florbetapir PET for standard uptake value ratios (SUVRs). A region-of-interest (ROI) analysis was performed on individual PET images. Mean cortical ROI templates contained six regions: medial orbital frontal, temporal, anterior and posterior cingulate, parietal lobe and precuneus. Mean cortical and

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whole-cerebellar ROI templates were applied to all PET scans to calculate mean regional cerebral-to-cerebellar SUVRs and the cutoff SUVR value of 1.099 for positive beta-amyloid. Results: The causation of brain injury was as follows: traffic accident (n ¼ 8), fall (n ¼ 1), assault (n ¼ 1). All of them had episodes of posttraumatic amnesia. None of them had physical disabilities at the time of examination. Average time since brain injury was 11.2 ± 10.8 years. Average MMSE score at PET scan was 25.9 ± 1.4. Average SUVR was 1.00 ± 0.15. Using the cut-off point of SUVR41.099, two of 10 patients (20.0%) showed positive beta-amyloid deposit. Conclusions: This is the first study to examine young patients with MCI following single TBI by amyloid PET imaging using [18F]florbetapir to determine the prevalence of AD pathology following TBI. The results revealed that the rate of beta-amyloid pathology was higher among patients with MCI following TBI than those of normal ageing. Thus, the results revealed that MCI after TBI was a risk factor of conversion to AD, which is mainly indicated by the epidemiological study of AD.


0609

Update to translating research into policy: Towards a comprehensive strategy to address concussion in Canada Sandhya Mylabathula, & Swapna Mylabathula University of Toronto, Toronto, ON, Canada In Canada and around the world, concussions resulting from accidents at home, play and work, as well as auto collisions involving animals and/or vehicles and infant and senior falls are receiving increasing attention. Concussions can elicit affective, neuropsychological, psychological and physiological symptoms, social effects and often have substantial economic impacts due to absence from work and for treatment and management. For many people living with the effects of this serious brain injury, the impacts are devastating. Each individual’s recovery is unique; return-to-play, school or work may take minutes to months to even years. Unfortunately, many research questions regarding concussions remain unanswered, reducing one’s ability to recognize, diagnose, treat, manage and even prevent concussions. Regardless, Canadians suffering from concussions, their families and their caregivers deserve increased support. This Private Member’s Bill proposal aims to translate current concussion research into a practical, comprehensive strategy to address this acquired brain injury in Canada in order to improve recovery, as well as the qualityof-life for those living with acquired brain injuries such as concussions. Specifically, this bill proposal outlines and details three essential components that make several recommendations: a National Concussion Awareness Week; a National Strategy to Address Concussion in Canada focusing on awareness, prevention, diagnosis, management and a government-initiated board; as well as a Centre for Excellence in Concussion Research. Overall, the ultimate goal for this Private Member’s Bill proposal is to improve prevention, awareness, management and diagnosis for a broad range of target populations, including sport and occupational, as well as adult and paediatric populations, in order to help all Canadians who suffer from concussions, their families and caregivers. This presentation will also provide an update regarding the progress of the Private Member’s Bill proposal to date.

0610

The impact of group cognitive behavioural therapy on individuals with an acquired/ traumatic brain injury Diana Velikonja1, Christine Brum1, & Selena Scott1 1

The Acquired Brain Injury Program of Hamilton Health Sciences, Hamilton, Ontario, Canada, 2McMaster University, Hamilton, Ontario, Canada Objectives: A substantial proportion of individuals who suffer with an acquired/traumatic brain injury (ABI/TBI) have clinically significant (34%) as well as mild (64%) affective sequelae. Early identification and intervention can reduce symptoms, improve recovery, as well as increase community integration. Research suggests that group Cognitive Behavioural Therapy (CBT), modified for ABI/TBI patients, improves emotional well-being; however, mixed results have been found for the effectiveness of this treatment on community integration. Previous studies have demonstrated strong efficacy for group treatment compared to an educational control group for emotional well-being but did not demonstrate positive results for community integration. A 6-month follow-up of the treatment group alone demonstrated improvement in emotional well-being and community integration. The current study was designed to address some of these methodological differences to examine the efficacy and long-term benefits of this therapy. The primary objective of the current study was to examine the impact of group CBT on emotional well-being, coping skills and community integration with a group of ABI/TBI participants in comparison to a waitlist control group. The secondary objective was to assess whether possible benefits of this treatment were retained, with the first evaluation period being at 6 weeks post-treatment and subsequently at 6 months post-treatment. Method: Participants were recruited from the outpatient clinic of the Hamilton Health Sciences, Acquired Brain Injury Programme, who were on a waitlist for treatment of emotionally-based symptoms. Participants were contacted from the list based upon presenting problems, including anxiety. Individuals participated in an 11-week group CBT programme using modified strategies to develop skills in anxiety management. The control group was comprised of similar participants, from the waitlist, who were contacted and administered the same measures given to the treatment group at similar time periods. Results: Comparisons are planned for within- and between-groups to determine the impact of group CBT on emotional well-being, coping skills and social integration compared to a participants not receiving treatment. Preliminary review of the data indicates that group CBT demonstrates benefits in the identified areas relative to the waitlist group. Further analysis for both groups, regarding the long-term benefits of relative improvements related to treatment, will also be analysed. Conclusions: Preliminary analysis would indicate that group CBT will be effective in decreasing affective symptoms, improving coping skills and increasing social integration which is a unique finding for this population. Analysis of possible improvements will be retained and compared to a matched control group. Evaluation and comparison of treatment and control groups of this nature have yet to be completed, as indicated by current literature.

744

Brain Inj, 2014; 28(5–6): 517–878

0611

A set of traumatic brain injury (TBI) outcome measures for clinical research: Systematic review and critical examination of outcome measures Pearl Chung1, & Fary Khan1 Royal Melbourne Hospital, Melbourne, Victoria, Australia, 2University of Melbourne, Melbourne, Victoria, Australia


1

Objectives: Research evidence in traumatic brain injury (TBI) is ultimately stated in terms of the outcome measures used. Currently, outcomes of TBI research are measured using a widely heterogeneous set of instruments. Previous recommendations for outcome measures to use in TBI research were based on a consensus approach or narrative reviews. The advantage of a systematic review to indentify outcome measures in current use is that the results can be compared with any existing data from previous research. Therefore, the aims of this study were (1) to identify TBI outcome measures in current use; (2) to examine the multidimensional properties of the identified TBI outcome measures; and (3) to recommend a set of TBI outcome measures for use in clinical research based on their multidimensional properties. Methods: A comprehensive search of the literature was performed to identify outcome measures used in acute and sub-acute TBI research in the last 10 years. Two independent reviewers examined the identified abstracts based on the inclusion and exclusion criteria and a consensus process identified TBI outcome measures used in the studies. Outcome measures which were used on 10 or more occasions were included for further examination. The multidimensional and psychometric properties of the identified TBI outcome measures were examined using the criteria set out by Scientific Advisory Committee and Terwee et al. (content validity, internal consistency, criterion validity, construct validity, agreement, reliability, responsiveness, floor or ceiling effect, interpretability, practical burden and cultural adaptation) criteria. Based on this, a final set of TBI outcome measures was recommended for routine use in clinical research among persons with TBI as the minimum dataset for TBI research. Results: The results are currently being analysed.

0612

Attenuation of brain injury induced cognitive dysfunction and hyperlocomotion: Chronic administration enhanced the effects of adenosine A2A receptor antagonist

Objectives: After traumatic brain injury (TBI) and other brain insults, increased concentration of extracellular adenosine is considered as one of the role playing factors in the secondary brain damages. In this laboratory administration of a selective adenosine A2A receptor antagonist SCH58261 attenuated cognitive dysfunction and hyperlocomotion induced by traumatic brain injury has been found. Then it was examined if chronic administration of the selective adenosine A2A receptor antagonist can enhance that ameliorating effect. Methods: Mongolian Gerbils of 23–37 weeks of age weighing 60–100 grams were included in the study. Moderate fluid percussion brain injury was induced at a pressure of 26–32 PSI on the right parietal lobe through the intact dura via craniotomy. Medication groups received injection of selective adenosine A2A receptor antagonist SCH58261 for different durations. TBI group received saline. Saline and drug were also given to sham animals. Open-field locomotion test, T-maze test and grabbing test were conducted before and 1, 3, 5, 7 and 9 days after injury. Open field test was carried out by placing the animals individually in an open field apparatus. A video tracking system recorded the movement. The total distance (centimetres in 10 minutes) moved by each animal was analysed by a software. T-maze test was tested by placing the animal in a T-shaped maze where the animals had a free choice for selecting the right or left arm. Sspontaneous alteration rate was calculated. The animals were also tested for their grabbing tendency by forelimbs. Gerbils were allowed to grab a net weighing 40 grams and the time they lift it freely was recorded. After the behaviour evaluation animals were sacrificed, brains were collected and cooled down rapidly. Frozen sections were used for 3 H-ZM241385 in vitro autoradiography. Results: Moderate TBI increased the total distance of movement, reduced spontaneous alteration rate (SAR) and prolonged grabbing time at all time points compared to sham groups. Administration of SCH58261 significantly blocked hyperlocomotion that was observed after TBI. The medication group also showed improved spontaneous alteration rate and reduced grabbing time. Single administration of the antagonist showed a significant effect up to the 5th post-trauma day, after which its effect wore off. Continuous administration of the drug for 5 or 9 days effectively ameliorated the TBI induced hyperactivity and cognitive dysfunction for the whole duration of the observation period. In autoradiography, no significant difference was seen in A2A receptor density in the cortex and striatum among the groups. Conclusions: The attenuating effect of SCH58261, an adenosine A2A antagonist, in suppressing TBI induced hyperlocomotion and cognitive dysfunction, was enhanced by chronic administration of the drug. SCH58261 presumably played its role in secondary brain damage by blocking the adenosine A2A receptors without regulating the receptor density.

0613

Traumatic brain injury (TBI) diagnosis and treatment: A systematic review and update Pearl Chung1, & Fary Khan0 1

1

2

3

Saad Mullah , Jahanara Urmy , Motoki Inaji , Tadashi Nariai3, Satoru Ishibashi4, & Kikuo Ohno3 1

NeuroTrauma Department, Naval Medical Research Center, Silver Spring, USA, 2Dhaka Medical College, Dhaka, Bangladesh, 3 Department of Neurosurgery, Tokyo Medical and Dental University Graduate School of Medicine, Tokyo, Japan, 4Department of Neurology, Tokyo Medical and Dental University Graduate School of Medicine, Tokyo, Japan

Royal Melbourne Hospital, Melbourne, Australia, 2University of Melbourne, Melbourne, Australia Objectives: To provide an overview of literature on the diagnosis and rehabilitation of adults following traumatic brain injury (TBI). Method: A comprehensive systematic search and screening process identified current literature in TBI diagnosis and rehabilitation. Included studies were examined to identify current standards in the diagnostic criteria for TBI in clinical and research contexts and to present evidence basis for treatment and rehabilitation in TBI. A GRADE approach was used to examine the evidence for treatment in TBI.

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DOI: 10.3109/02699052.2014.892379

Results: Strong agreement exists for a diagnosis of TBI in the presence of PTA following head trauma; and that Glasgow Coma Score (GCS) of 9–12 is moderate TBI and GCS of 3–8 is severe TBI. There is no agreement for whether GCS of 13 should be mild or moderate TBI; which GCS to use to grade TBI severity; which clinical feature (aside from PTA) indicates a diagnosis of mild TBI; and whether imaging findings should be incorporated into diagnostic criteria for TBI and for severity grading. Nomenclature for TBI type in the literature remains disorganized. This is a major problem for TBI care and research in TBI. From the search of literature for treatment in TBI, only seven studies showed moderate-to-strong evidence of benefit (Level 1 evidence) in relation to cognitive behavioural therapy, attention training, meta cognitive strategy, hyperbaric oxygen therapy, therapeutic hypothermia and nutritional support. Conclusion: Clear diagnostic criteria for TBI could improve TBI care, data collection and the quality of future clinical trials for specific targeted therapies according to the diagnosis, the severity and the type of TBI. Improved study designs and intervention to improve TBI outcomes are needed.


0614

Neurologic deterioration after decompressive craniectomy: Case report Akshay Garg1, Lauren Terranova1, & Kirk Lercher1 1

Mount Sinai Medical Center, New York, NY, USA, 2Elmhurst Medical Center, New York, NY, USA Introduction: Decompressive craniectomy is a common neurosurgical procedure performed on patients who has sustained traumatic brain injury and stroke. The Syndrome of the Trephined, also known as Sinking Skin Flap Syndrome, is described as neurological deterioration following such a procedure, with improvement in symptoms after cranioplasty. This study describes the case of a 62 year old male found to have subdural haemorrhage requiring hemi-craniectomy, followed by decline in his neurologic status. Hospital course was notable for hemiparesis, decrease in cognitive function and worsening arousability. Diagnostic evaluation, imaging, pathophysiology, medical and rehabilitation management and current literature review are discussed. Case description: A 62 year old adult male was received by the emergency room with a history of being found at the bottom of a stairwell unconscious. Head CT scan showed frontal lobe contusion, with subdural haemorrhage with mass effect and midline shift. The patient underwent subsequent right hemi-craniectomy and was transferred to the acute rehabilitation centre afterwards. During the patient’s rehabilitation course, the patient continued to have waxing and waning mental status. He was started on neurostimulant medication, including modafinil, venlafaxine and amantadine, with little improvement. Patient’s arousal continued to decline with an inability to participate in therapy sessions. Repeat head CT showed significant sinking of the hemicranial flap, with increased midline shift and new non-communicating hydrocephalus. The patient was then transferred to neurosurgery for emergent cranioplasty for concern of Syndrome of the Triphenid. Post-operatively, patient’s mental status improved, with new ability to follow simple commands and improvement in his hemiparesis. Discussion: This case exhibits worsening neurologic signs and symptoms after a patient underwent a decompressive hemi-craniectomy. A clear differentiation of symptoms was present when comparing those of the initial brain injury and those arising post-operatively. It is important to consider Syndrome of the Triphenid when clinical deterioration is present after such surgical procedures. This syndrome further exemplifies the importance of not delaying a cranioplasty, as it sometimes may take weeks to months for these signs and symptoms to develop. Awareness of the presentation, diagnostic evaluations, as well as management recommendations is necessary, especially in the setting of traumatic brain injury rehabilitation.

0615

Heart rate variability in concussed varsity athletes: From injury to return-to-play Arrani Senthinathan, & Lynda Mainwaring University of Toronto, Toronto, Canada Background: In traumatic brain injured patients, decreases in Heart Rate Variability (HRV) suggest an uncoupling of the autonomic and cardiovascular systems. HRV, a non-invasive measure of neuroautonomic cardiovascular regulation, may be a useful physiologic marker of recovery in sports concussion. Previous research suggests exercise post-concussion influences neuroanatomic regulation. Objective: The aim of this study was to assess HRV in recently concussed athletes from within 72 hours of injury through recovery to post return-to-play (RTP). Method: A group of concussed varsity athletes (11) and their matched controls (11) were assessed in a repeated measures design. Athletes were assessed three times following the diagnosis of concussion: (1) 72–96 hours post-injury; (2) when asymptomatic and they began an exercise progression protocol; and (3) 1-week after medical clearance to return-to-play. Healthy matched control teammates were assessed with the same testing schedule. At each assessment, HRV data were collected over a period of 20–25 minutes using both seated and standing positions. The frequency domain of HRV was analysed for (1) sitting, (2) standing and (3) the absolute difference between sitting and standing. Correlations were conducted between Low Frequency (LF) (n.u.) and High Frequency (HF) (n.u.) and number of days required to RTP. Results: A 2 (Group) 3 (Phase) repeated measures ANOVA revealed significant interactions for sitting HF (n.u.) (p ¼ 0.041), sitting LF (n.u.) (p ¼ 0.041), absolute difference between sitting and standing HF (n.u) (p ¼ 0.021) and absolute difference between sitting and standing LF (n.u.) (p ¼ 0.035). During the acute phase of injury, concussed athletes displayed increased LF (n.u.) and decreased HF (n.u.) while sitting compared to controls suggestive of increased sympathetic and decreased parasympathetic activation. Concussed athletes displayed a smaller change in their HF and LF (n.u.) measures between sitting and standing indicating the autonomic response to the change was diminished. Although not significant, correlations revealed a trend between acute phase HF (n.u.) (r ¼ 0.518; p ¼ 0.103) and LF (n.u.) (r ¼ 0.519; p ¼ 0.102) and number of days required to RTP. Conclusions: Findings suggest that concussed athletes may have neuroautonomic dysfunction following injury and HRV may be an indicator of recovery. Findings warrant further investigation of HRV measures in concussed athletes during recovery and after medical and exercise clearance.

0616

Investigating traumatic brain injury: Correlating external pressure distributions to internal injury Ben Schwartz, Camilla Yanushevsky, Hallie Green, Billy Ani, Mike Reilly, Andrew Shapiro, Katie Kennedy, Jon Henricks, Judy Beaudoin, Julie Peluso, & Sam Jones University of Maryland, College Park, MD, USA Objectives: The use of Improvised Explosive Devices (IEDs) in guerilla warfare-style tactics has led to a dramatic increase in blast-


746 related traumatic brain injury (bTBI). Because of this increase, bTBI has garnered much attention from the medical and scientific communities in recent years with an emphasis on understanding the mechanism of brain tissue damage. This study will expand upon the current methods of blast-induced TBI detection. It uses a physical model with helmet-mounted sensors as well as a twodimensional finite element model to simulate bTBI. It is hypothesized that there exists a correlation between the blast wave induced dynamic pressure measured over the surface of the skull and the responses of brain tissue to the blast event. This presentation will focus on achieving a better understanding of blast-related traumatic brain injury. It will address the relationship found between the pressure measurements over the surface of the skull and the pressure, strain rate and acceleration of brain tissue in a blast wave injury. It will also address the relationship found between direction and magnitude of the blast and the pressure measurements over the surface of the skull. A discussion of the implications of this research for the scientific and medical community will follow. Methods: This study used scaled physical simulations of blast waves to observe the pressure distribution over the surface of a head form. Using a two-dimensional finite element model, it determined the material responses of brain tissue during the simulated blast events. The pressure waveforms outside and inside the helmet were correlated to the interior pressure, strain rate and acceleration to determine time delays and correlation coefficients. The correlations from nodes inside the helmet are compared to those outside the helmet for significant differences in the correlations. Results and conxlusions: The authors are in the process of gathering and analysing data. This will be finished by December. After both are complete, they will begin writing their thesis.

0618

Delayed traumatic intracranial haemorrhage in therapeutic anticoagulation: A case report Pearl Chung1 1

Royal Melbourne Hospital, Melbourne, Victoria, Australia, 2University of Melbourne, Melbourne, Victoria, Australia Case report: This is a case report of a previously well 74 year old Lebanese gentleman on Warfarin, who sustained an unwitnessed head trauma following a fall from a ladder height of 2 metres. He complained of headache only and Glasgow Coma Scale (GCS) remained at 15–14 throughout observation in the Emergency Department over the next 24 hours. INR was 4.2 and initial computerized tomography (CT) of the brain was unremarkable. He underwent a ‘routine’ repeat CT of the brain at 24 hours, which showed a right parietal (3 3.1 4.6 cm) intracerebral haemorrhage with subarachnoid and subdural extension. At 2 months from TBI, he had ongoing cognitive impairment and left hemifield neglect, requiring supervision for community and unable to return to driving. Discussion: Incidences of delayed traumatic intracranial haemorrhage with Warfarin therapy in the literature range from 0.87–6%. Recent Scandanavian guidelines for management of minimal-to-moderate head injury incorporate personal risk factors in early management of TBI. In this evidence review and consensus-based update, persons with mild TBI (defined as GCS 14–15) with risk factors of shunt-treated hydrocephalus, therapeutic anticoagulation or coagulation disorders should be treated as high-risk mild TBI. For such persons, CT scanning and observation of424 hours are indicated for high and medium-risk, respectively. However, this is not widely accepted and the costeffectiveness of 24-hour monitoring and/or routine repeat CT scanning is not well demonstrated.

Brain Inj, 2014; 28(5–6): 517–878

0619

An exploration of salivary cortisol, mood and perceived stress as non-invasive stress measures in concussion recovery assessment Lynda Mainwaring, Arrani Senthinathan, & Michael Hutchison University of Toronto, Toronto, Canada Background: Following concussion, the body is in a state of stress while metabolic and chemical pathways are restored. Elevated stress can be manifested both physiologically and psychologically in various ways, including cortisol cycling, increased mood disturbance and increased perceived stress. During this time, injury susceptibility is increased while recovery is impaired. Ascertaining the stress levels of concussed athletes through recovery can be informative for returnto-play. Objectives: The aim of this study was to examine the utility of three non-invasive stress measures in assessing and monitoring concussion recovery. Method: Following a physician-diagnosed concussion, 11 university varsity level athletes completed two self-report measures: the Profile of Mood States (POMS) questionnaire and the Perceived Stress Scale (PSS). Additionally, morning and afternoon saliva samples were obtained to measure cortisol, a biochemical marker of stress. The data were collected at three time points: (1) 72–96 hours post-injury; (2) when asymptomatic and cleared to start exercise progression; and (3) 1 week after medical clearance to return-to-play. The same protocol was completed by 11 non-injured athletes, who formed a matched-control group. Results: A 2 (Group) 3 (Phase) repeated measures ANOVA revealed significant interactions for Total Mood Disturbance (p ¼ 0.001), Depression (p ¼ 0.003), Anger (p ¼ 0.014) and Confusion (p ¼ 0.001) for concussed athletes during the acute phase of injury. Pairwise comparisons revealed a significant change over time from phase 1 to phase 3 of recovery in Total Mood Disturbance (p ¼ 0.001), Depression (p ¼ 0.004), Anger (p ¼ 0.021), Confusion (p ¼ 0.003) Fatigue (p ¼ 0.006), Vigour (p ¼ 0.034) and Tension (p ¼ 0.020) scores in the concussed group. T-tests revealed a significant difference between the two groups for morning Cortisol levels at phase 3 (p ¼ 0.019). For PSS, there was an increased trend in the acute phase of injury and a decreased trend post-return-to-play compared to controls. Conclusions: During the acute phase of injury, concussed athletes displayed more negative mood states and a trend toward higher perceived stress levels. Cortisol data were individualized and variable with demonstrated differences between groups after return-to-play: Morning cortisol was lower for the concussed group. Study results provide a foundation for further investigation of these and other non-invasive markers of stress in concussed athletes.

0620

Predicting low cognitive function in professional fighters Charles Bernick1, Sarah Banks1, & Nancy Obuchowski2 1

Cleveland Clinic, Las Vegas, NV, USA, 2Cleveland Clinic, Cleveland, OH, USA

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DOI: 10.3109/02699052.2014.892379

Objective: Individuals participating in sports involving repetitive head trauma are at increased risk of developing chronic neurological deficits. There currently is a lack of instruments that can indicate a person’s likelihood of harbouring cognitive impairment. This study aims to develop a prediction model that could be used to identify individuals participating in professional combat sports who may have lower cognitive function. Methods: Active professional fighters (boxing and mixed martial arts) enrolled in the Professional Fighters Brain Health Study were included for analysis. Subjects underwent computerized cognitive testing, with the results categorized into verbal memory, psychomotor speed and processing time. Scores that were 1.5 SD below age-matched controls in a domain were considered below normal. A multiple logistic regression model was built based on the following potential predictors: age, race, education, years of fighting (amateur and professional), number of total fights and fights per year, number of professional fights and fights per year, number of recorded knockouts, number of self-reported concussions. The c-index was used to identify the best discriminating model. Results: The 217 fighters in the study had a mean age of 28.0 years, with a mean of 11.1 professional fights and 4.1 years of professional fighting. Seventy-four subjects scored below normal in at least one cognitive domain. A model that included age, education, number of professional fights, number of professional fights per year and number of reported concussions most strongly predicted low cognitive scores, with a c-index of 0.927. Conclusion: It is possible to create a composite index that incorporates several indicators of exposure to head trauma as well as other easily obtainable information that can predict lower cognitive performance in professional fighters. This composite index may be of use to regulatory agencies to identify athletes that require closer surveillance.

0621

Excess risk of insulin resistance, cardiovascular disease, suicide and all-cause mortality in traumatic brain injury with posttraumatic stress disorder as compared to traumatic brain injury alone Naser Ahmadi, & Nutan Vaidya Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA Background: It was recently reported that traumatic brain injuries (TBI) as well as post-traumatic stress disorder (PTSD) are independent predictors of sub-clinical atherosclerosis measured by coronary artery calcium and major adverse cardiovascular events. This study investigated the relation of TBI with and without PTSD to insulin resistance (IR), Framingham risk score (FRS) of premature cardiovascular disease, suicide and all-cause mortality. Methods: This retrospective matched case control study is inclusive of 564 subjects (208 with TBI, 21 TBI and PTSD and 335 matched controls) with median follow up of 4-years. The relative risk of insulin resistance, FRS, suicide and all-cause mortality across TBI, TBI and PTSD as compared against those without TBI and PTSD were measured using multivariable Cox regression analyses. Medical information was obtained from electronic medical records. Insulin resistance was defined as the ratio of triglyceride over HDL-c43.8. Results: There was no significant differences in age, gender, body mass index, diabetes mellitus, hypertension and hyperlipidemia

between groups (p40.05). At 4-year follow-up, the incidence of insulin resistance increased from 12.2% in a matched group to 24.6% in TBI alone to 29.9% in TBI and PTSD (p ¼ 0.01). Similarly, FRS increased substantially from the matched group to subjects with TBI (p50.05). The rate of completed suicide increased from 0.9% in the matched group to 6.7% in TBI alone to 9.5% in TBI and PTSD (p ¼ 0.001). The mortality rate increased from 4.8% in the matched group to 12.8% in TBI alone to 18.9% in TBI and PTSD (p ¼ 0.001). After adjustment of risk factors, incidence rate of insulin resistance was 39% higher in TBI and 85% in TBI and PTSD as compared to the matched group. Similarly, the risk of 10% increase in FRS was 47% in TBI and 68% in TBI and PTSD as compared to matched subjects (p50.05). The relative risk of suicide was 7.51 (95% CI ¼ 2.09–21.78, p ¼ 0.0001) in TBI alone and 10.63 (95% CI ¼ 8.88–62.83, p ¼ 0.01) in TBI and PTSD, as compared to matched control subjects (p ¼ 0.001). After adjustment for risk factors, the relative risk of death increased from 2.54 (95% CI ¼ 1.18–5.51, p ¼ 0.0008) in TBI to 2.76 (95% CI ¼ 1.44–5.29, p ¼ 0.001) in TBI and PTSD to 2.99 (95% CI ¼ 1.76–5.09, p ¼ 0.0001) in TBI and PTSD and insulin resistance as compared to matched controls (p ¼ 0.001). Conclusion: TBI with and without PTSD is an independent risk factor of insulin resistance, coronary atherosclerosis, suicide and mortality. Furthermore, TBI with PTSD is associated with excess risk of insulin resistance, coronary atherosclerosis, suicide and mortality as compared to TBI alone.

0622

Physiologic and psychologic markers of concussion recovery: A female varsity athlete case study Arrani Senthinathan, Lynda Mainwaring, & Michael Hutchison University of Toronto, Toronto, Canada Background: Sport-related concussions are now recognized as a major public health concern. The majority of the research has focused on neuropsychological assessment and recovery. Recent research has identified the need to examine other psychological variables and physiologic markers of concussion and recovery. Objective: In this varsity athlete case, studied over a single athletic season, two psychological and two physiological variables were assessed across two situations: (1) A healthy (uninjured) physically active period with multiple baseline assessments; and (2) Following concussion through to return-to-play. Method: An 18 year old female varsity hockey player completed two psychological self-report measures: the short version Profile of Mood States (POMS) and the Perceived Stress (PSS) questionnaire. At the same time, salivary cortisol and heart rate variability (HRV) were obtained to capture physiological stress. In the first situation—over a 1-month period while healthy and physically active—the four measures were obtained at three time points. In the second situation—during recovery from concussion—with the addition of the Rivermead Post-Concussion Symptoms Questionnaire, the same protocol was used at 72 hours post-injury while symptomatic, at the beginning of exercise progression when asymptomatic and finally 1-week following medical clearance to return-to-play. Reliable change indices were calculated for all variables using an alpha level of p50.05. Results: At 72 hours post-injury, the athlete had significant elevations in Depression, Confusion and HR while symptomatic: Vigour was decreased significantly. For HRV, there was an increase in LF (n.u.) (sympathetic activation) and decrease in HF (n.u.) (parasympathetic activation) at 72 hours post-injury. On assessment at the beginning of exercise progression when asymptomatic, HR was elevated significantly. Mean RR (ms), STD RR (ms), NN50 (count) and pNN50 (%) were

748 decreased at 72 hours post-injury and at the beginning of exercise progression. Vigour showed a significant increase at exercise progression and 1 week after return-to-play. PSS scores and cortisol levels did not demonstrate significant change during the recovery process compared to control sessions. Conclusions: Post-injury depression, confusion and vigour and HRV changed relative to the athlete’s baseline data. HRV displayed a deviation from the participant’s pre-injury data at 72 hours post-injury while symptomatic and at the beginning of exercise progression when asymptomatic. This suggests that the athlete, despite reporting an absence of symptoms post-injury, may continue to be in a state of stress. Psychologic and physiologic post-injury assessment tools appear to be promising for monitoring recovery from concussion.


0623

Variant of treatment approach between adult and paediatric populations following traumatic brain injury (TBI)—A questionnaire survey Mohammad Jaweed1, Boon Seng Liew2, Teak Sheng Gee2, Azmin Kass Rosman2, & Saiful Azli2 1

School of Medicine Taylors University, Lakeside Campus No.1Jalan Taylor’s, 47500 Subang, Kulalumpur, Malaysia, 2Department of Neurosurgery, Hospital Sungai Buloh, Selangor, Malaysia

Objective: The aim of this study was to assess the views of neurosurgeons from all five continents for treatment of traumatic brain injury (TBI) in adult and paediatric populations. Methods: This was a 3-year cross-sectional descriptive study. A structured questionnaire was administered to neurosurgeons during the 8th Asian congress of neurological surgeon (ACNS) 22–24 November 2010 in Kuala Lumpur, Malaysia, followed by the 9th Asian Congress of Neurological Surgeons in Istanbul, Turkey 02September-2012 and the 15th WFNS World Congress of Neurosurgery, 8–13 September 2013, Coex Convention Center, Seoul, Korea. This questionnaire was prepared related to controversies in management of severely head injured paediatric and adult patients who are ventilated in the ICU. All participants were asked to fill in the questionnaire and return before ending of the congress. Those who were previously participated in questionnaire at 8th and 9th ACNS, congress were excluded from the survey. Results: The response was received from 243 neurosurgeons among 29 countries, 171 for an adult population and 72 for a paediatric population, at consultants and registrar level. In regards to routinely insertion of an intracranial pressure monitoring device (ICP) catheter or external ventricular drainage in severely head injured patient, for adult population 90 out of 171 respondents (53%) agreed on insertion of ICP. In the paediatric population, 23 out of 72 respondents (31%) agreed to the mentioned intervention. This difference is statistically significant (p ¼ 0.002). In severe head injured patients with raised ICP, 75 out of 84 respondents (89%) were in favour of decompressive crainiectomy for adult patients. On the other hand 16 out of 72 respondents (22%) were in favour of medical therapy for thepaediatric group. This difference is statistically significant (p ¼ 0.041). Conclusions: The above findings suggested that, despite the ICP device insertion (for the purpose of monitoring in severely head injured patients) gaining popularity in Europe, America and some of the Asian countries but still a majority of practicing neurosurgeons not in favour of ICP monitoring device insertion in a paediatric population. In both adult and paediatric severe head injured patients with raised ICP, despite most practicing neurosurgeons being in favour of decompressive craniectomy, however in the paediatric

Brain Inj, 2014; 28(5–6): 517–878

population a significant number of practicing neurosurgeons still prefer conservative medical treatment over surgical intervention. Through this study it was found out that the ICP device cost was an additional key influence on the lack of consensus among treating neurosurgeons upon routinely insertion of ICP for paediatric as well as adult TBI patients across the contents.

0624

Neurocognitive function and white matter microstructure in persistent post-concussive syndrome James Hedges1, Yushi Wang1, Brett Yarusi1, Daniel Graham2, Julia Owen2, Jun Maruta1, Lisa Spielman1, Pratik Mukherjee2, & Jamshid Ghajar1 1

Brain Trauma Foundation, New York, NY, USA, 2University of California, San Francisco, CA, USA Some people who sustain a concussion continue to experience symptoms, including headache, dizziness and fatigue, long after their injury. These symptoms define persistent post-concussive syndrome (PPCS), the aetiology and manifestations of which remain unclear. Varied and undefined impairments in neurocognitive function, including in memory and attention, may coincide with PPCS. These impairments can overlap with those seen in fatigue, depression and post-traumatic stress disorder (PTSD) and may suggest shared causal mechanisms. Heterogeneity in the mechanism of injury likely contributes to these complexities. This study applied neurocognitive testing and diffusion tensor imaging (DTI) in 30 PPCS patients and 140 healthy controls to address a number of related questions. Which neurocognitive domains are impaired in PPCS patients and are those impairments systematically related to depression and PTSD symptomatology? In which white matter tracts is microstructural integrity correlated with measures of impaired neurocognitive function and is the integrity of those tracts lower in PPCS patients? PPCS patients were narrowly impaired in visual tracking. They had greater variability in gaze position error in a visual tracking task. This was true for a repeat condition that immediately followed an intensive attentionrelated task and may reflect greater fatigability. They were not impaired in predictive timing. PPCS patients were somewhat impaired in visual attention. They had slower responses and reduced accuracy in the Attention Network Task. PPCS patients were broadly impaired in response timing. They took longer to complete tasks at normal performance levels across a variety of tasks. Symptomatology for PTSD and depression was related to this slowing effect and was unrelated to the eye tracking effect. Microstructural integrity of tracts in anterior and posterior brain regions was associated with a sub-set of the reaction time measures. These regions were generally bilateral and included the anterior corona radiata, the superior longitudinal fasciculus and the posterior thalamic radiation. Of the tracts that showed significant associations between microstructural integrity and measures of function, only the right posterior thalamic radiation was different between the groups. The results suggest that PPCS is associated with impairments in visual tracking, attention and response timing that are differentially related to fatigue and to depression and PTSD symptomatology. These impairments may be part of a sub-set of impairments that fail to recover within a short period of time following a concussion. Associations with symptomatology for co-morbid conditions may reflect overlapping mechanisms, although reductions in microstructural integrity seem to be insufficient to account for all of the neurocognitive effects that overlap with PPCS. Additional research is needed to further establish the relationships between these elements and to define how they relate to changes brought about by therapeutic interventions.

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DOI: 10.3109/02699052.2014.892379

0625

Brian injury survivors deserve a second chance for a happy and fulfilling life Mary Anne Ostapovitch, & Ana Gollega


Association for the Rehabilitation of the Brain Injured, Calgary, Alberta, Canada

Objectives: The Association for the Rehabilitation of the Brain Injured (ARBI) is the only community-based, non-profit service provider in Canada providing intensive, long-term rehabilitation for survivors of the most severe traumatic and anoxic brain injuries. Survivors have an initial Glasgow Coma Scale (GCS)58 and require 24-hour care on admission to ARBI. Survivors receive 15 hours of weekly rehabilitation with an average length of stay of 2.4 years. This study aims to demonstrate that severe brain injury survivors can have successful outcomes through describing one of many ARBI case studies. Methods: In a recent Canadian critical care review of six hospitals, decisions regarding end-of-life are made often within the first 3 days of injury. ARBI has witnessed a significant decrease in the number of severe traumatic and anoxic brain injury referrals. In 2000, ARBI’s clientele consisted of 75% traumatic brain injury (TBI) and 25% anoxic brain injury (ABI). Currently, ARBI’s clientele consists of 18% TBI, 5% ABI and 77% strokes. Over the past 5 years, 80% of ARBI TBI or ABI family members reported being strongly advised by critical care physicians to withdraw lifesaving measures for their family member. This case report followed and documented one of the recent severe TBI survivors throughout her recovery. Results: Case report: Jessica sustained a severe TBI following MVA at age 17. Her initial GCS was 3. The ICU physician strongly advised her family to remove life support 5 days post-injury. Her parents were devastated by this recommendation. ‘It was a nightmare that no parents should have to go through’, commented Jessica’s mother. Against medical advice the family decided to continue treatment. Jessica received 13 months of in-patient rehabilitation and an additional 19 months at ARBI. Clinical outcomes: Rappaport Disability Rating Scale: 3/30; Berg Balance Scale: 50/56 (walks independently); Chedoke McMaster Activity Inventory: 100/100; Rancho Los Amigos Levels of Cognitive Functioning: 8; Leisure Competency Measure: 46.5/56; and Weekly Community Participation: 9. Jessica’s accomplishments: Living independently in her own apartment; Working part-time in an animal shelter; Works out regularly at her local fitness centre; Visits often with family and friends; and Plans to complete Grade 12 diploma. Jessica’s comments on surviving brain injury: ‘Don’t give up. Keep on smiling and work hard. You can do it. You deserve all you’e dreamt for!’. Conclusions: With 35 years of experience providing intensive, longterm rehabilitation for survivors of the most severe brain injury, ARBI has witnessed many positive outcomes. This case report is just one of many stories that demonstrate positive outcomes following severe TBI. ARBI strongly believes that brain injury survivors deserve a second chance to live a happy and fulfilling life.

0626

Hinokitiol, a natural tropolone derivative offers neuroprotection from thromboembolic stroke in rats Ting-Lin Yen, & Joen-Rong Sheu

Taipei Medical University, Taipei, Taiwan Objective: Hinokitiol (-thujaplicin), a tropolone-related compound found in the heartwood cupressaceous plants, is widely used in hair tonics, tooth pastes, cosmetics and food as an antimicrobial agent. Increasing evidence has confirmed that hinokitiol exhibits anti-cancer activity in a variety of cancers through inhibition of cell proliferation. The present study investigated the neuroprotective effect and mechanisms of hinokitiol in rats against middle cerebral artery occlusion (MCAO)-induced thromboembolic stroke. Methods: Hinokitiol at 0.2 and 0.5 mg kg1 doses was given by intraperitoneal injections to rats after 24 hours of middle cerebral artery (MCA) occlusion, followed by reperfusion. Animals were assessed for behavioural deficit scores after 1 and 24 hours of ischaemia. Subsequently, the rats were sacrificed for evaluation of infarct volumes. Western blot assay was used to detect the expressions of hypoxia-inducible factor (HIF)-1, inducible nitric oxide synthase (iNOS), tumour necrosis factor (TNF)- and active caspase-3 in ischaemic regions. Results: Hinokitiol ameliorated the ischaemia-induced neurological functional deficits and the infarct volume measured after 1 and 24 hours of ischaemia. Western blot analysis demonstrated that the expression of HIF-1, iNOS, TNF- and active caspase-3 were increased after the insult and antagonized by treatment with hinokitiol. Conclusions: Hinokitiol possesses potent neuroprotective activity via inhibiting of inflammatory responses (i.e. HIF-1, iNOS expression), apoptosis (i.e. TNF-, active caspase-3), resulting in a reduction of infarct volume and improvement in neurobehaviour in rats with cerebral ischaemia.

0627

Preliminary inter-rater reliability for a novel dual-task and multitask assessment battery guiding return-to-duty in concussed service members Margaret Weightman1, Karen McCulloch2, Leslie Freeman Davidson3, Matthew Scherer4, Laurel Smith5, Marsha Finkelstein1, & Mary Vining Radomski1 1

Courage Kenny Research Center, Allina Health, Minneapolis, MN, USA, 2Division of Physical Therapy, Department of Allied Health Sciences, School of Medicine, University of North Carolina, Chapel Hill, NC, USA, 3Shenandoah University, Winchester, VA, USA, 4Andrew Rader US Army Health Clinic, Joint Base Myer-Henderson Hall, Fort Myer, VA, USA, 5United States Army Research Institute of Environmental Medicine, Natick, MA, USA Objectives: The Assessment of Military Multitasking Performance (AMMP) is a battery of military-related functional dual-tasks and multi-tasks that target known sensorimotor, cognitive and exertional vulnerabilities after concussion/mild traumatic brain injury (mTBI). Once validated, the AMMP is intended for use in combination with other metrics to inform duty-readiness decisions in active duty service members following concussion. The assessment of inter-rater reliability (IRR) provided data regarding IRR of individual AMMP tasks and informed training requirements needed for reliable scoring of the battery. Preliminary IRR findings highlight the challenges and successes in development of performance-based assessments designed to identify subtle deficits in highly trained personnel. Methods: Six AMMP test tasks were individually evaluated for IRR by three person rater teams comprised of physical and occupational therapists who were the task developers, with at least one rater who was initially unfamiliar with the task. Initial IRR evaluation for four


750 tasks was completed on 20 healthy soldiers (HC) and for two tasks on 12 HC. Scoring discrepancies identified by the statistical analysis using Krippendorf Alpha resulted in further clarifications of scoring rules and scorer training requirements. Tasks were again tested by three raters on 11–13 soldiers undergoing rehabilitation following concussion/mTBI. Results: Reliability findings frequently differed in HC vs concussed groups. For example, ICCs for task completion time were 0.96–0.99 in HC and 0.77–0.99 in subjects with concussion. Cognitive components for each of the three dual-tasks, such as responding to key words in recorded radio chatter or recalling grid co-ordinates, demonstrated ICCs between 0.64–0.99. Multi-task metrics demonstrated variable ICCs. For example, task completion and number of transits during a ‘Charge of Quarters’ multi-task demonstrated excellent IRR (ICCs of 0.90–0.98). IRR calculations were highly sensitive to the range of possible values with metrics that involve restricted ranges such as number of errors, cues or rule breaks, demonstrating variable and often lower ICCs (ICC range ¼ 0.13–0.85). Subjects with concussion typically demonstrated greater number and range of errors than were seen in testing of the healthy control soldiers. Conclusions: Preliminary IRR testing informed modifications in test instruction, structure and scoring to enhance IRR. Development of measures that meet military stakeholder requirements for face validity and functional relevance contribute to the complexity of development of a reliable AMMP battery. The consistency of scores across raters is fundamental to the ability to use the findings of the AMMP to make substantive recommendations regarding readiness to return to duty following concussion/mTBI.

0628

Eight year recovery from TBI— Blueprint and protocols for functional recovery Federico Gonzalez, & Karen Gonzalez Olathe Medical Center, Olathe, KS, USA Introduction: Despite the fact that an estimated 1.7 million Americans sustain traumatic brain injuries (TBIs) each year, there exists no standard protocol for recovery from TBI. Reasons for this deficiency in medical care include the wide variability of brain injuries, low expectations for recovery of TBI patients, lack of interest and research in TBIs, lack of testing modalities and monitoring parameters for brain injury, length of time and intensity of therapy to achieve meaningful recovery, dearth of adequately trained professionals for TBIs and inadequate understanding of brain neurophysiology and biochemistry. The case of a TBI patient with 8 years of recovery is presented to illustrate the potential for recovery from TBIs and propose protocols for treatment. Case study: An 18 year-old female without a helmet was thrown from a motorcycle sustaining occipital trauma, a frontal lobe contra-coup injury and brain stem shearing. Exhibiting both decorticate and decerebrate posturing, a Glasgow Coma score of 3 and a marked midline shift on MRI; she underwent subdural haematoma evacuation and placement of an ICP monitor. After a month, comatose in the ICU, the family transported the patient to a well-organized, aggressive neuro-rehabilitation inpatient centre in Miami. Daily physical therapy, occupational therapy, neuro-pharmacology and psychological therapy were instituted; and medications were prescribed to stimulate brain activity. Although, after 10 weeks of inpatient rehabilitation, she could not independently walk or talk; the tone, pattern, orientation and intensity for her recovery had been set. This was followed by 6 months of outpatient, full day rehabilitation and in-home therapy. She continues to improve 8 years later, constantly challenged daily with physical and mental work within a framework of a very

Brain Inj, 2014; 28(5–6): 517–878

organized schedule. She graduated with an associate degree from a junior college with a 3.5 GPA, utilizing an assistant for executive decision-making and focus. Her present schedule consists of working with a transitional living specialist several days a week, a cognitive therapist twice a week, neurofeedback at the University of Kansas twice a week, hypnotherapy, and she delivers mail in a hospital once a week. Conclusions: Despite prevailing attitudes that TBI recovery prognosis is generally poor, it is believed that, with appropriate care and treatment protocols, many more can be returned to functional lives. Maximal TBI recovery requires improved treatment in all phases of recovery: inpatient, outpatient rehabilitation and transition to functional life. Information about brain plasticity and neural pathway regrowth indicates that TBI rehabilitation can continue for many years with appropriate stimulation and treatment. A non-defeatist attitude, the use of pharmacological agents, unconventional modalities, stimulation of specific brain areas, skilled innovative therapists and no ‘limited window of recovery’, many more TBI patients can become productive members of society rather than burdens on society.

0629

Drag-reducing polymers as a novel treatment for intracranial hypertension and ischaemia in traumatized brain Denis E. Bragin1, Olga Bragina1, Gloria Statom1, Susan Thomson1, Marina V. Kameneva2, & Edwin M. Nemoto1 1

University of New Mexico School of Medicine, Albuquerque, NM, USA, 2McGowan Institute for Regenerative Medicine University of Pittsburgh, Pittsburgh, PA, USA, 3BRaIN Imaging Center, Albuquerque, NM, USA Objectives: High intracranial pressure (ICP) is a frequent complication of traumatic brain injury (TBI). It was shoen that post-traumatic increase in ICP caused a stagnation of capillary (CAP) flow and increase in non-nutritive microvascular shunt (MVS) flow resulting in ischaemia, oedema and blood–brain barrier (BBB) damage. Current treatments of TBI have not focused on improving microvascular perfusion. Recently, it was demonstrated that drag-reducing polymers (DRP) enhanced haemodynamics and tissue oxygenation in a healthy rat brain. The effects of DRPs (polyethylene glycol) on microcirculation in traumatized rat brain with intracranial hypertension were examined here. Methods: Using in vivo 2-photon laser scanning microscopy over the parietal cortex, the effect of DRP was studied on microvascular topography, blood flow velocity and volume, tissue oxygenation (NADH) and BBB permeability after TBI. Doppler cortical flux, rectal and cranial temperatures, intracranial and arterial pressures, blood gases and electrolytes were monitored. TBI was induced after baseline imaging by a lateral fluid-percussion transient pulse (1.5 ATA, 100 ms) with a custom built gas-driven device on the left hemisphere through a 5 mm craniotomy. After imaging of the traumatized brain, DRP (2 mg ml1 blood) was injected and brain was imaged for 4 hours after TBI. Results: TBI resulted in a sustained increase in ICP to 30.8 ± 4.7 mmHg above the pre-injury level of 10.4 ± 3.6 mmHg (n ¼ 8, p50.05). The rise in ICP was associated with a progressive decrease in the number of perfused capillaries and an increase in the number of MVS, reflected by the MVS/CAP ratio of 0.43 ± 0.09 before injury and 0.92 ± 0.25, 0.96 ± 0.21, 1.18 ± 0.26, 1.32 ± 0.20 and 1.39 ± 0.23 at 0, 1, 2, 3 and 4 hours after injury, respectively (p50.01). The increase in the MVS/CAP ratio was associated with an increase in NADH by 59.32 ± 9.2% of baseline (p50.01), reflecting reduced oxygenation; and with dye

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DOI: 10.3109/02699052.2014.892379

transcapillary extravasation, reflecting BBB damage. DRP reduced ICP to 24.6 ± 5.6 mmHg, partially restored flow in collapsed capillaries and decreased MVS/CAP ratio to 0.67 ± 0.22 (p50.05). Enhanced perfusion improved tissue oxygenation, as reflected by NADH decrease by 14.8 ± 3.1% (p50.05) and reduced progression of BBB degradation. Conclusions: In the traumatized rat brain DRP injection reduced ICP, restored capillary flow and decreased MVS flow leading to increased tissue oxygenation and reduced BBB permeability. DRP are linear, long-chain, blood soluble non-toxic macromolecules, which increase near-wall blood flow velocity in the vasculature by eliminating flow separations at vessel bifurcations and reducing near wall cell-free layer leading to increased blood volume perfused through the vessel. The result is a decrease in the pressure gradient through arterioles, thereby increasing the pre-capillary pressure and number of perfused capillaries, countering the effects of capillary stasis. This study suggests that DRP could be effective in improving microvascular flow and an effective treatment for ischaemia caused by high ICP after TBI.


0630

Anosmia and olfactory outcomes following paediatric traumatic brain injury Kathleen Bakker1, Cathy Catroppa2, & Vicki Anderson2 1

Victorian Paediatric Rehabilitation Service, Royal Children’s Hospital, Melbourne, Australia, 2Murdoch Childrens Research Institute, Melbourne, Australia, 3Department of Paediatrics, University of Melbourne, Melbourne, Australia, 4Psychology Department, Royal Children’s Hospital, Melbourne, Australia, 5School of Psychological Sciences, University of Melbourne, Melbourne, Australia Background and aims: Post-traumatic anosmia was first described in the scientific literature 150 years ago. Despite its early identification, understanding of olfactory dysfunction (OD) following paediatric traumatic brain injury (TBI) remains limited. This is despite the significant implications for health, safety and quality-of-life that are known to be associated with OD. The current study aimed to investigate the frequency of OD following paediatric TBI and examine the relationship between OD and injury indices such as severity, neuropathology, site of impact, injury cause and other injury related variables. In line with previous literature it was hypothesized that those with moderate/severe TBI would demonstrate greater OD than those with mild TBI. Method: Thirty-seven children with TBI, with a mean age of 12.4 years (SD ¼ 1.96), were assessed on average 1.58 months (SD ¼ 0.63) postinjury. Olfactory function was assessed using the University of Pennsylvania Smell Identification Test (UPSIT). Demographic and injury variables were collected. Results: Almost 19% of participants demonstrated impaired olfaction (with criteria of performance 55% on UPSIT) with 8% of participants demonstrating frank anosmia. No significant difference in olfactory function was found between the mild and moderate/severe TBI group, however there was a trend towards the moderate/severe TBI group being more likely to exhibit impaired olfaction (OD). Investigation of the relationship between injury variables and OD indicated that, in line with previous literature those with impaired olfaction had significantly longer periods of post-traumatic amnesia (PTA) and lower Glasgow Coma Scale (GCS) score than the unimpaired group—indicating that severity of injury does appear to be a factor in post-traumatic OD. The relationship between OD and other injury variables was inconclusive. Conclusions: A significant proportion of children with TBI exhibit OD. Impaired olfaction was related to injury indices such as longer PTA and lower GCS. These findings are discussed in terms of their implications for clinical practice and future research.

0631

Role of proteinase 3 on cell death in rat primary cortical neuron Sung Min Yang1, Eun Joo Lee2, Ha Na Seung1, Mee Jung Ko1, Edson Luck Gonzales1, Kyu Suk Cho1, Chang Soon Choi1, Ji Woon Kim1, Hyun Myoung Ko1, Jin Hee Park1, Seol-Heui Han2, Kyoung Ja Kwon2, & Chan Young Shin1 1

Department of Pharmacology, 2Department of Neurology, Center for Neuroscience Research, Institute of Biomedical Science and Technology, Konkuk University School of Medicine, Seoul, Republic of Korea Background and aims: The recruitment of neutrophils into the cerebral microcirculation occurs, especially, in acute brain diseases like a focal cerebral ischaemia and plays important role in pathological processes. Proteinases 3 is one of the three major proteinases expressed in neutrophils but no reports are available as to whether proteinase 3 can modulate neuronal survival. Methods and results: In this study, treatment of cultured rat primary cortical neuron with proteinase 3 induced overt reactive oxygen species production and decreased total glutathione contents as well as disruption of mitochondrial transmembrane potential. Proteinase 3 induced neuronal cell death as evidenced by MTT analysis as well as propidium iodide staining, which was prevented by pre-treatment with an antioxidant, N-acetyl cysteine. Proteinase 3 increased activation of procaspase-3 and altered expression level of apoptotic regulator proteins, such as Bcl-2, Bax and Bcl-xL. Similar to in vitro data, a direct microinjection of proteinase 3 into the striatum of rat brain induced neuronal death, which was mediated by reactive oxygen species. Conclusions: This study, for the first time, investigated the role of PR3 in ROS generation and neuronal cell death in cultured rat primary neuron. These results suggest that proteinase 3 is a new essential regulator of the neuronal cell death pathway in a condition of excess neutrophil encounter in neuroinflammatory conditions.

0633

Implementation and efficacy of parenting interventions in a clinical paediatric rehabilitation setting Kathleen Bakker1, Melinda Barker1, Debbie Houston1, Natasha Dean1, Jacqueline Irlam1, & Ali Crichton1 1

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

Background and aims: Emotional and behavioural difficulties are common in children presenting to rehabilitation services. Parent training interventions are gaining increasing popularity for remediation of behavioural difficulties in these settings. A recent systematic review identified growing, although limited, evidence for the efficacy of such programmes. The aims of this project were: (1) to report on the feasibility of implementing the ‘Signposts for building better behaviour’ parent training intervention within a clinical paediatric rehabilitation setting and (2) to evaluate the efficacy of the intervention through questionnaire report of child behaviour, parental sense of competence and parental psychological symptoms.

752


Method: Sixteen parents of 15 children (aged 5–11) attending the Victorian Paediatric Rehabilitation Service (Melbourne, Australia) completed the 6-week programme. Parent training intervention was administered by trained facilitators in accordance with programme guidelines. Pre- and post-intervention measures included parental report of child behaviour and psychosocial strengths and difficulties and parent ratings of parental stress, depression, anxiety and parenting competency. Results: Significant improvements in parental sense of competence (increased satisfaction in the parenting role) were observed at completion of the programme. No immediate post-intervention effects were observed for parental sense of efficacy, stress, anxiety or depression or on ratings of child behaviour and psychosocial strengths and difficulties. Follow-up data at 6 months post-intervention are also presented. Conclusions: Limited evidence was found for the efficacy of a parenting training intervention in the paediatric rehabilitation setting, with a significant improvement only in parental satisfaction evident post-intervention. The efficacy of parent interventions and the challenges of implementation and evaluation in a clinical setting are discussed.

0634

WakeUp: A medical product that would revolutionize brain injury prevention and treatment Tasos Smeros ETH, Zu¨rich, Switzerland ‘Brain injury is not an event or an outcome. It is the start of a misdiagnosed, misunderstood, neurological disease’ (American Association of Brain Injury). This study looks at brain injury as a condition that originates either from an accident (e.g. disorders of consciousness) or genetic/ageing causes (e.g. permanent disorders—Down Syndrome, Alzheimer’s, Parkinson’s). Medical errors within brain disorders in Europe for the last decade are really high, at 40%. This costs Europe 1 trillion euros per year. Worldwide statistics look very similar. The authors are developing a product (WakeUp) that invents new methods for diagnosis, therapy/ rehabilitation and prevention and improving the quality-of-life for all people affected by brain injury. A market leader in the area of replicating a human brain in a mobile device. WakeUp is using innovative and non-invasive methods to enable a person to use her/his brain as a medium to communicate with the world and/or to control real things in the surrounding environment and, secondly, for the first time ever to translate this interaction to individual deep brain knowledge about neuro-stimulation, neuroplasticity and molecular genetics. Also to send non-invasive signals to the brain to stimulate production of brain cells. A private first version 1.0 has been achieved and the plan is to introduce this Spring 2013 a KIT v1.0 of WakeUp that doctors and scientists could get and make their own experiments.

0635

Selective inhibitors of nuclear export (SINE) exert robust therapeutic benefits in traumatic brain injury models Naoki Tajiri1, Sandra Acosta1, Mibel Pabon1, Yuji Kaneko1, Sharon Shacham2, Sharon Tamir2,

Brain Inj, 2014; 28(5–6): 517–878

Yosef Landesman2, Dilara McCauley2, & Cesar Borlongan1 1

University of South Florida Morsani College of Medicine, Tampa, FL, USA, 2Karyopharm Therapeutics Inc, Natick, MA, USA

Objectives: Exportin 1 (XPO1/CRM1) plays prominent roles in the regulation of nuclear protein export and was recently shown to be over-expressed in CNS lesion in rats following traumatic brain injury (TBI) and to regulate neuronal apoptosis following brain injury. Selective Inhibitors of Nuclear Export (SINE) are small molecule orally bioavailable, drug-like inhibitors of XPO1. SINE possess potent anti-cancer properties in animal models and are currently being tested in clinic trials for cancer patients. TBI is associated with a progressive secondary cell death characterized by a massive neuroinflammatory response apparently regulated by nuclear receptors. SINE restore and increase nuclear localization of anti-inflammatory and neuroprotective proteins including IkB and Nrf2. The present study was designed to assess whether SINE similarly restrained TBI-induced neuroinflammation within the nucleus, which should reduce disease pathological symptoms. Methods: In vitro and in vivo models of TBI were employed. Cultured primary rat neuronal cells were initially incubated in SINE (10 mM KPT350 or 10 mM KPT-335) or control treatments, exposed over 48 hours in the inflammatory toxin TNF- (20 ng ml1), then processed for cell viability, cellular enzymatic activity and inflammation- and nuclearbased immunocytochemistry. In parallel, adult Sprague-Dawley rats underwent the controlled cortical impact injury model of TBI or sham surgery, 2 hours later and once a day thereafter over the next 4 days received SINE (5 mg kg1 or 7 mg kg1 KPT350 via oral gavage) or vehicle and subsequently assessed for TBI-induced behavioural and histological deficits. Resulrs: SINE (with a trend of better benefits with KPT-350 than KPT-335) significantly preserved cell viability and cellular enzymatic activity by at least 0.5-fold and 1-fold, respectively, against TNF--induced neurotoxicity compared to non-treated primary rat neuronal cells (p’s50.05). SINE also increased XPO1, AKT and FOXP1 nuclear expression and relegated NF-kB expression within the nuclei. TBI animals treated with SINE exhibited significantly better motor co-ordination and balance in the rotorod test and motor asymmetry test by 1- to 2-fold improvements as early as 4 hours after initial SINE injection and sustained during subsequent SINE injections in both doses and throughout the 18-day post-TBI study period compared to vehicle treatment (p’s50.05). Preliminary data also show reduction of cell death in the peri-impact cortical areas in SINE-treated animals compared to vehicle treatment. Conclusions: SINE reduced TNF--induced neuroinflammation in primary neuronal cells with evidence of robust sequestration of secondary cell death within the nucleus. Oral delivery of SINE at postinjury period effectively ameliorated behavioural and histological deficits in TBI animals. Altogether, these novel findings advance SINEs regulation of cell death within the nucleus as an efficacious treatment of neuroinflammation in TBI.

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Long-term disorders of consciousness: A patient population with unique challenges Ann-Marie Morrissey, & Agnes Shiel National University of Ireland Galway, Galway, Ireland

753


DOI: 10.3109/02699052.2014.892379

Objectives: More and more people are surviving severe brain injury with a disorder of consciousness (DoC) in the form of Vegetative State and Minimally Consciousness State. With advancements in medicine and medical technology these survivors are also living longer post-ictus. While knowledge of assessment and management of DoC increases, little is known about the long-term survivors of these conditions. People living for many years with DoC face challenges not encountered during the acute phase such as the challenge of reassessment and changing of diagnosis ‘label’, long-term management, increased secondary complications and potential therapeutic nihilism. Methods: Following a nationwide survey of medical consultants and all registered care settings exploring the care and location of people living with a DoC, case studies exploring long-term survivors in greater detail were undertaken. These case studies explored the daily routine, assessment and management needs for this patient population in a variety of long-term care settings. A review of the literature surrounding long-term DoC was also undertaken. Results: People with longer onset DoC were found to receive limited rehabilitative services and were less likely to receive timely re-assessment of consciousness, thus living with their initial diagnosis ‘label’. Their ability to demonstrate awareness and consciousness was hindered by a number of factors including physical complications. They are also unique in that they can be found to take on the role of ‘observer’ if they have not been engaged with appropriately and regularly over time. This can have a huge impact on standardized assessment. The survey also revealed that they are found in a variety of care settings and the aetiologies of all long-term survivors was explored. Conclusion: This is a unique population with specific challenges. The assessment and management of long-term DoC is complex owing to limited services, limited streamlined care and protocol for re-assessment and long-term physical complications. This paper will explore this population’s needs following a nationwide survey, individual case studies and a review of the literature.

0637

A randomized controlled trial of a modified group cognitivebehavioural intervention for depressed mood following traumatic brain injury Allison Clark1 1

Baylor College of Medicine, Houston, TX, USA, 2TIRR Memorial Hermann, Houston, TX, USA Objective: To investigate the effectiveness of a modified, group cognitive-behavioural intervention (CBT) for depressed mood in persons with traumatic brain injury (TBI). Methods: Persons with medically-documented complicated mild, moderate or severe TBI, recruited from rehabilitation hospitals, were screened for depression. Persons who endorsed clinically significant depressive symptoms were randomized to participate in a modified, 6-session group CBT or to a 6-session support group. Groups met weekly for 90 minutes; there were no more than five persons in each group. The CBT group was led by a neuropsychologist and the content was modified for use with persons with cognitive deficits post-TBI. The support group was facilitated by a TBI survivor and content was modelled after community-based support groups. Measures of emotional functioning, participation and cognition were administered within 2 weeks prior to Session 1. Measures of emotional functioning and participation were re-administered within 2 weeks following session 6 and again 3 months later. All measures were administered by a research assistant blinded to group assignment.

Results: One hundred and thirty-eight persons were consented and screened for depression. Ninety-six persons (69.6%) endorsed clinically significant depressive symptoms. The first five participants who endorsed significant depressive symptoms participated in the pilot phase of the intervention; thus, 91 persons met initial eligibility for participation in the randomized controlled trial. Sixty-nine persons completed baseline measures, but only 56 persons attended one or more group sessions. All 56 persons who attended at least one group session completed discharge measures and 55 completed follow-up measures. There was no significant interaction between group and time on measures of depression and perceived stress. There was a significant main effect for time, with both groups showing improvements in depressive symptoms (Wilks’ Lambda ¼ 0.695, F ¼ 11.21, p50.01) and perceived stress (Wilks Lambda ¼ 0.855, F ¼ 4.25, p ¼ 0.02) across time. Conclusions: Both intervention and control groups showed improvements in depressive symptoms across time. It is hypothesized that both intervention and control conditions possessed components that are important for treating depressive symptoms following TBI: social support and behavioural activation, even though the latter was rather informal and not labelled as such in the control condition. These factors may be important ingredients of interventions for depression following TBI. CBT techniques hold promise as components of psychological interventions for persons with TBI. Further investigation of the active ingredients of the intervention and of patient factors that may impact response to treatment is warranted.

0638

High dose of andrographolide from andrographis paniculata deteriorated ischaemia/ reperfusion-induced brain injury via inducing apoptosis of cerebral endothelial cells Ting-Lin Yen1, Wan-Jung Lu1, & Kuan-Hung Lin2 1

Taipei Medical University, Taipei, Taiwan, 2Shin-Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan Background: Andrographolide extracted from the leaves of Andrographis paniculata is a labdane diterpene lactone. It was widely reported to possess anti-inflammatory and anti-tumourigenic activities. However, no data are available concerning the effects of andrographolide on cerebral endothelial cells (CECs), which play a crucial role in supporting the integrity and the function of the blood– brain barrier (BBB). Objectives: This study investigated the effect of andrographolide on CECs and cerebral ischaemia/reperfusion-induced brain injury. Methods: Cell survival rate and cytotoxicity were tested by MTT assay and lactate dehydrogenase test, respectively. Caspase-3 expression was detected by western blotting. Analysis of cell cycle and apoptosis using PI staining and Annexin V-FITC/PI labelling, respectively, was performed by flow cytometry. This study also determined the effect of andrographolide on middle cerebral artery occlusion (MCAO)/ reperfusion-induced brain injury in a rat model. Results: The present study found that andrographolide markedly caused CEC death. The data revealed that andrographolide induced caspase-3 activation, CEC apoptosis and cell cycle arrest at the G0/G1 phase. In addition, high dose of andrographolide (5 mg kg1) caused deterioration of MCAO/reperfusion-induced brain injury in a rat model. Conclusions: These data suggest that andrographolide may disrupt BBB integrity, thereby deteriorating MCAO/reperfusion-induced brain injury through the induction of cell cycle arrest and apoptosis of CECs.

754

0639

Returning to working life after acquired brain injury—The rehabilitation-process, possibilities and hindrance for participation Thomas Strandberg1, & Marie Mate´rne2 1¨


Orebro University, School of Law, Psychology and social work, The ¨ rebro ¨ rebro, Sweden, 2O Swedish Institute for Disability Research, O University Hospital, Centre for Rehabilitation Research, The Swedish ¨ rebro, Sweden Institute for Disability Research, O Objectives: The overall purpose of this study is to investigate the rehabilitation process facilitating return to working life after acquired brain injury (ABI). Two main themes are in focus: (I) experiences of the rehabilitation process—possibilities and challenges, and (II) long-term perspective—factors that facilitate a sustainable working life. The study was undertaken within a disability research paradigm, which is an interdisciplinary approach that includes medical, technical, behavioural and socio-cultural perspectives. Specifically, this study was derived from a social perspective in studying outcomes in working life after aquired brain injury. Methodology: Persons who acquired a brain injury as adults were interviewed using an interview guide focusing on the experiences of the rehabilitation process. The informants (five females and five males) had participated in a work rehabilitation programme and successfully returned to work. Importantly, at least 50% maintained employment for a minimum period of 1 year. The interviews were qualitative, in-depth and are being conducted longitudinally. Data will be structured and analysed by latent content analysis with a hermeneutic approach and analysed within a social science theory. Results: The findings are in this stage preliminary. Many of those who as adults acquired a brain injury are already established in the labour market. Accordingly, return-to-work could be seen as easier for the ABI group than for other unemployed groups of disabled. Despite this, many of the cases with ABI have difficulties in returning to work after injury concerning different circumstances. Relating to that it is important to identify such circumstances, especially possibilities. An important aim for the rehabilitation process is a long-term perspective in maintaining a job after injury. Some factors of importance for the rehabilitation outcomes can be summarized as: support at the working place, social treatment and individual motivation. Conclusions: Such knowledge is of great importance for the rehabilitation practitioner when meeting clients’ in the stage of work rehabilitation. The implications of this study can be useful in both rehabilitation medicines as well as for social workers in supporting people with ABI who have vocational goals. The common aim is to develop a programme for work rehabilitation for people with ABI.

0640

Management of retropharyngeal pseudomeningocele and pseudoaneurysm in traumatic atlantooccipital dislocation presenting with locked-in syndrome

Brain Inj, 2014; 28(5–6): 517–878

Nazdar Ghafouri1, Sandro Rossitti2, Peter Zsigmond2, Johan Richter2, & Wolfram Antepohl1 1

Rehabilitation Medicine, Department of Medicine and Health Sciences, Linkoping, Sweden, 2Department of Clinical and Experimental Medicine, Linko¨ping University, Linkoping, Sweden

Introduction: Traumatic atlanto-occipital dislocation (AOD) is a ligamentous injury with a wide spectrum of clinical pictures varying from minor neurological deficit to tetraplegia and death. In survivors development of a retropharyngeal pseudomeningocele is a potential complication which can cause dysphagia and airway obstruction. Both conservative approach and decompression by shunting procedures have been reported for management with various outcomes. To the authors’ knowledge, there are no reports of direct closure of retropharyngeal pseudomeningoceles caused by traumatic AOD. Case report: A 20 year old male suffered a high speed motor vehicle accident resulting in AOD, severe bulbar-medullar injury, cardiac arrest, internal injuries and multiple fractures. After initial medical management, he underwent occipitocervical stabilization. Clinical examination revealed severe neurological deficits in line with lockedin syndrome. Once medically stable, the patient was transferred from the ICU unit to the rehabilitation department. A gradual improvement in eye movements and initiation of lip movements was seen. However, he communicated a feeling of pharyngeal irritation, pain, difficulty in performing oral motor therapy and respiratory distress despite ventilator therapy. Magnetic resonance imaging showed a retropharyngeal pseudomeningocele completely obstructing the upper airways and oesophagus and a pseudoaneurysm in the left posterior inferior cerebellar artery (PICA). Surgical closure of the pseudomeningocele was performed successfully by means of obliteration of the CSF fistula with adipose tissue and partial removal of the cele sac as well as suturing at the fistula opening. The intervention resulted in relief of pharyngeal irritation and pain and in free passage of air from the trachea to the mouth when the patient’s tracheal canule was uncuffed. An endovascular approach was used for successful treatment of the pseudoaneurysm. Discussion: AOD with high cervical spinal cord injury as seen in this case is associated with a high mortality risk. Reports on management of neurological and vascular complications, as well as rehabilitation of these patients, are few. Diagnosis and management of the lifethreatening pseudoaneurysm in the left PICA were crucial. Since the patient was on mechanical ventilation, the retropharyngeal pseudomeningocele was not life-threatening, although obstructing the upper airways. However, the cele caused a feeling of distress and was interfering with oral motor therapy and potential improvements in bulbar deficits. In view of the patient’s severe neurologic injury, his improvements were important and might, in a longer perspective, facilitate rehabilitation of orofacial and respiratory function and lead to better quality-of-life.

0642

Assessing the effects of two breakfasts (high-carbohydrate vs high-protein) on cognitive function, mood and satiety status of 9–11 year-old primary school children with a new technology in Iran Fatemehsadat Amiri1, Reza Amani1, Nahid Khajemogahi1, Bahram Rashidkhani2, Brian Saxby3, & Keith Wesnes4

755

DOI: 10.3109/02699052.2014.892379 1

Ahvaz Jondishapur University of Medical Sciences, Tehran, Iran, Shahid beheshti University of Medical Sciences, Tehran, Iran, 3 Institute for Ageing and Health, Newcastle University, Newcastle, UK, 4 Centre for Human Psychopharmacology, Swinburne University, Melbourne, Australia


2

Objectives: Studies generally show that breakfast consumption is beneficial and helps maintain cognition during the morning, but less is known about the relationship between breakfast composition and cognitive performance. This study compared the acute effects of two common Iranian breakfasts and no breakfast on cognition, mood and satiety status of elementary schoolchildren. Methods: Using a randomized cross-over design, once a week for 3 weeks, 51 well-nourished schoolchildren (27 female, 9–11 years) consumed one of the two fixed breakfasts or no breakfast. Children with any learning disorders or having an IQ over 120 were excluded from the study. The two breakfasts were high carbohydrate and high protein which were matched for energy and fat. Cognition (attention, working memory and episodic secondary memory) were assessed pre-, 30 and 120-minutes post-breakfast, using a selection of automated tests from the CDR System. The tasks were presented in the order: Picture Presentation, Simple Reaction Time, Digit Vigilance, Choice Reaction Time, Spatial Working memory, Numeric Working Memory and Picture Recognition. Mood and hunger-satiety were assessed 105-minutes post breakfast using bipolar rating scale. All subjects performed a training session on the CDR System tests and questionnaires to familiarize them with the procedures involved. During the training session the administrator interacted with the children whenever necessary to ensure that the tests were performed correctly. This served the purpose of familiarizing participants with the tests and helped to overcome training effects. Results: The general pattern was for a decline in simple reaction time, choice reaction time and power of attention among girls if they received high-carbohydrate breakfast. Choice reaction time was impaired among boys in the fasted state more than in the other two conditions. There were significant differences in alertness between breakfast and no breakfast conditions among girls and significant differences in satiety ratings between these conditions in both sexes. Conclusions: Computerized tests from the CDR system, which were used for the first time in Iran, seems to be applicable technology for assessing cognitive performance in this target group. High carbohydrate breakfast identified a negative effect on attention in girls and no benefits on attention or memory were seen due to consuming breakfast in either sex. Breakfast consumption had a positive effect on mood in girls and hunger-satiety in both sexes. One important issue is that both quality and quantity of breakfast can affect the relationship between breakfast and cognitive function or mood. The energy delivery of the experimental breakfasts was determined according to the recommended dietary allowance of energy in children. However, the children reported that the quantity of experimental breakfasts was higher than their usually consumed breakfast. This could be an explanation of why no improvement in cognition after breakfast was identified.

0644

Inhibitory role of andrographolide in vascular smooth muscle cell proliferation and cerebral endothelial cell inflammation Wan-Jung Lu, Shih-Yi Huang, & Joen-Rong Sheu Taipei Medical University, Taipei, Taiwan

Objectives: Aberrant vascular smooth muscle cell (VSMC) proliferation and cerebral endothelial cell (CEC) dysfunction contributes significantly in the pathogenesis of cardiovascular diseases. Therefore, inhibition of these cellular events would be candidate agents for treating these diseases. In the present study, the mechanism of antiproliferative and anti-inflammatory effects of andrographolides (andro), a novel nuclear factor-kappaB (NF-kappaB) inhibitor, was investigated in VSMC and CEC cells. Methods: VSMCs and CECs were isolated from rat artery and mouse brain, respectively, and cultured before experimentation. The effect of andro on platelet-derived growth factor-BB (PDGF-BB) induced VSMC cell proliferation was evaluated by cell number, MTT assay. The expression of extracellular signal regulated kinase 1/2 (ERK1/2), proliferating cell nuclear antigen (PCNA) and the effects on lipopolysaccharide (LPS)-induced inducible nitric oxide synthase (iNOS) and cyclooxygenase-2 (COX2) were detected by Western blotting. Results: Andro significantly inhibited PDGF-BB (10 ng ml1) induced cell proliferation in a concentration (20–100 mM) dependent manner, which may be due to reducing the expression of ERK1/2 and by inhibiting the expression of PCNA. Andro also remarkably diminished LPS-induced iNOS and COX2 expression. Conclusions: The results of this study suggest that the effects of andro against VSMCs proliferation and CECs dysfunction may represent an attractive approach for the treatment of vascular diseases.

0645

Relationship between age of first exposure to tackle football and later-life mood, behaviour and cognition Alexandra Bourlas1, Julie Stamm1, Christine Baugh1, Daniel Daneshvar1, Alan Breaud2, Clifford Robbins1, David Riley1, Brett Martin2, Michael McClean2, Rhoda Au1, Gerard Gioia3, Alexander Ozonoff4, Ann McKee1, Chris Nowinski1, Robert Cantu1, Yorghos Tripodis2, & Robert Stern1 1

Boston University School of Medicine, Boston, MA, USA, 2Boston University School of Public Health, Boston, MA, USA, 3Children’s National Medical Center, Washington DC, USA, 4Children’s Hospital Boston, Boston, MA, USA Objectives: With millions of youth athletes participating in contact sports each year, sports-related brain trauma in this population presents an important public health concern. Recent research suggests that repetitive brain trauma (RBT), including concussions and subconcussive impacts, may have long-term neurological consequences in some athletes. However, the age of first exposure (AFE) to RBT and its impact on later-life mood, behaviour and cognitive consequences is unclear. The objective of this study was to examine the relationship between AFE to RBT from tackle football and later-life mood, behaviour and cognition. It was hypothesized that subjects who started playing football prior to age 12 would demonstrate greater later-life impairments in mood, behaviour and cognition, compared with subjects who began playing at age 12 or older. The groups were divided based on neurodevelopment research, indicating that critical aspects of brain development, including peak amygdalar volumes, regional peak cortical thickness, peak myelination rates and peak cerebral blood flow, occur between ages 10–12. Methods: The study population included 92 participants (age 25–82 [M ¼ 52.4, SD ¼ 14.5], AFE512 group n ¼ 40, AFE 12 n ¼ 52) from the Longitudinal Examination to Gather Evidence of Neurodegenerative Disease (LEGEND) study. All participants were male former football players with no history of participation in other contact sports. The LEGEND study uses online questionnaires and telephone interviews to


756 obtain extensive participant histories, including demographics, athletic history, concussion history and self-report measures of mood, behaviour and cognition. Outcome measures used in this study included: Apathy Evaluation Scale (AES); Center for Epidemiologic Studies Depression Scale (CES-D); Behaviour Rating Inventory of Executive Function-Adult Version (BRIEF-A); and Brief Test of Adult Cognition by Telephone (BTACT), which contains the Rey AuditoryVerbal Learning Test (RAVLT) Immediate and Delayed. Results: Compared to the group of subjects who began tackle football aged 12, the subjects who started 512 had significantly higher mean scores for AES (p ¼ 0.02) and BRIEF-A Global Executive Composite (p ¼ 0.03), Behaviour Regulation Index (p ¼ 0.03) and three clinical sub-scales (Inhibit, p ¼ 0.03; Working Memory, p ¼ 0.03; Plan/ Organize, p ¼ 0.03) and had a larger proportion of subjects with elevated scores on the CES-D (p ¼ 0.03) and GEC (p ¼ 0.03). Bootstrapped adjusted odds ratios for the relationship between age of first exposure to football groups and outcome variables indicated a 3.4-fold increase in clinically significant CES-D scores in the group that started playing tackle football younger than age 12. Conclusions: This is the first study to identify initial age of exposure to RBT as a significant risk factor for later life mood, behaviour and cognitive dysfunction. The data suggest that RBT from youth football prior to key neurodevelopmental milestones may put athletes at increased risk for later-life impairments. Additional longitudinal prospective studies are necessary to determine implications for safety recommendations for youth sports.

0646

The pattern of psychological distress in the first 2 years after a severe traumatic brain injury Diane Randall1, Diane Whiting2, & Matthew Thomas1 1

School of Psychology, Charles Sturt University, Bathurst, NSW, Australia, 2Liverpool Brain Injury Rehabilitation Unit, Liverpool Hospital, Sydney, NSW, Australia Objectives: Psychological distress is widespread after a severe traumatic brain injury (TBI). Depression tends to be the predominant presentation, with prevalence rates as high as 53% in the first year. The pattern and course of this distress is less clear and it is important to identify critical time periods for the development of psychological disorders following TBI in order to provide treatment as early as possible. It has been suggested that emotional distress rises with increases in awareness of impairment at 1 year and 2–3 year followups. This study will look at the pattern of depression in a crosssectional study in the first 2 years after a TBI. Method: Archival data was collected from the client files of a specialist brain rehabilitation unit, providing a participant group of 504 (80.4% males, 19.4% females) with an average age of 33.1 years (range ¼ 16– 71 years). Participants had experienced a severe TBI, with an average post-traumatic amnesia period of 26.8 days (range ¼ 1–183). Archival tests had been administered after participants had emerged from PTA. Additional data collected included a measure of the psychological distress (Depression Anxiety and Stress Scale-21: DASS-21) and demographic data such as time since injury and cultural background. Data was then analysed specifically with relation to changes over time. A smaller sample of participants (n ¼ 98) were re-tested with the DASS-21 between 10–26 weeks post-injury. Results: Psychological distress demonstrated significant changes at different time periods where it decreased between months 1 and 2, then gradually increased during the first year with a slight dip at the 2-year mark (2 range of 24.8–46.7, p ¼ 000). Paired sample t-test demonstrated participants (n ¼ 98) showed a significant increase in depression between two different time points (range ¼ 10–26 weeks) (t ¼ 2.62, p50.01) and, although an increase was evident on both stress and anxiety, it was not significant.

Brain Inj, 2014; 28(5–6): 517–878

Conclusions: Psychological distress appears to increase over the first 12 months after a severe TBI with a slight dip at the 2-year time point. This suggests that early intervention for psychological distress, after emergence from PTA, maybe helpful for individuals after a TBI. Assessing awareness of impairments may further optimize the ideal time for treatment.

0647

Early supported discharge service after stroke—How is the service implemented in clinical practice? Malin Tistad1, & Lena von Koch1 1

Karolinska Institutet, Stockholm, Sweden, 2Dalarna University, Falun, Sweden Background: Early supported discharge (ESD) service after stroke was developed in order to reduce length of hospital stay (LOHS) and to provide continuity in rehabilitation in the community. The purpose of the study was to describe to what extent ESD-service has been implemented in clinical practice and to describe resource use and outcome during the first year. Method: Patients were recruited at the stroke units at the Karolinska University hospital, 2006–2007. The ESD criteria were: Barthel Index 50 within the first week and remaining needs for rehabilitation at discharge. Follow-up using the BI were conducted at 12 months. Data regarding use of healthcare services was collected from the Stockholm County Councils computerized register. Comparisons between those who received (1) ESD-service (the ESD-group), (2) in-patient rehabilitation and ESD-service (the IPR-ESD-group) and (3) other rehabilitation (the noESD-group) were performed using Kruskal Wallis and post-hoc tests. Result: Of the 349 patients included, 183 met the criteria for ESD service: the ESD-group 24 patients (13%), the ESD-IPR-group 22 patients (12%) and the noESD-group 137 patients (75%). The ESD-IPRgroup had a lower score on the BI (median 80) at inclusion compared to the ESD-group (median 95, p ¼ 0.003) and the noESD-group (median 90, p ¼ 0.02). No difference was found at 12 months. The ESD-group had a shorter LOHS (median 5 days) compared to the ESD-IR-group (29.5 days, p50.001) and the noESD-group (16 days, p50.001). The ESD-group and the ESD-IPR-group had more outpatient rehabilitation contacts (median 18 and 28 contacts, respectively) compared to the noESD-group (three contacts, p ¼ 0.001 and p50.001, respectively). ESD service constituted 82–83% of the outpatient rehabilitation contacts for the ESD groups. Conclusion: ESD-service has only to a limited extent been implemented in clinical practice. Patients who received ESD-service at discharge from the stroke unit appear to have shorter LOHS but more outpatient rehabilitation contacts.

0648

Restoring cortical connectivity directionality and synchronization is essential to treating disorder of consciousness Umberto Leoń-Dominguez1, Jose´ Leoń-Carrioń2, James Halper3, Luca Pollonini4, George Zouridakis5, & Maria del Rosario Domıńguez-Morales6

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DOI: 10.3109/02699052.2014.892379 1


Brain Injury Rehabilitation & Diagnostic Systems Lab (Neurobirds), Seville, Spain, 2Human Neuropsychology Laboratory, School of Psychology, Department of Experimental Psychology, Seville, Spain, 3 International Brain Research Foundation, NJ, USA, 4Department of Engineering Technology, 5Departments of Computer Science and Electrical & Computer Engineering, University of Houston, Houston, TX, USA, 6Center for Brain Injury Rehabilitation (CRECER), Seville, Spain, 7Department of Psychiatry, School of Medicine, Autonomous University of Madrid, Madrid, Spain, 8Department of Psychiatry, NYU School of Medicine, NY, USA The design of neurorehabilitation therapy to treat subjects with altered consciousness provides opportunities and challenges to professionals involved with the care for these severely ill patients. While there is an increased interest in determining methods to restore consciousness in these patients, the process is complex and challenging, due in part to the diverse aetiology of these states of consciousness and also to the intricate cerebral connectivity involved in their treatment. This study presents the CRECER Combined Method Therapy (CCMT), used in a case study of a patient who showed signs of emergence from the vegetative state after neurorehabilitation. Neurorehabilitation therapy was applied simultaneously with pharmacological treatment, stimulation and neuroimaging techniques to help adjust drug dosage. The results of this study suggest that this combined approach to treatment promoted connectivity among posterior and anterior cortical regions aiding emergence from the vegetative state.

0649

The sooner patients begin neurorehabilitation, the better their functional outcome Jose´ Leoń-Carrioń1, Fernando Machuca-Murga1, Ignacio Solı´s-Marcos1, Umberto Leoń-Domıńguez2, & Maria del Rosario Domıńguez-Morales2 1

Human Neuropsychology Laboratory, School of Psychology, Department of Experimental Psychology, Seville, Spain, 2Center for Brain Injury Rehabilitation (CRECER), Seville, Spain Objectives: The aim of this work is to determine whether early neurorehabilitation improves a patient’s functional recovery. Methods: This study carried out a retrospective study on patients with severe traumatic brain injury (TBI) who had received a minimum of 4 months of integral multidisciplinary neurorehabilitation. Fifty-eight patients with severe TBI were assessed at admission and discharge from rehabilitation using the FIM + FAM scale. Subjects were divided into two groups based on the time elapsed from brain injury to commencing rehabilitation. The early treatment group (ET) was made up of patients who had begun rehabilitation within the first 9 months post-trauma; the late treatment group (LT) had started rehabilitation after the 9-month cut-off date. Intra- and between-group analyses of FIM + FAM scores were carried out at admission and discharge. Multiple linear regressions were used to determine the best predictors for functional rehabilitation. Results: All subjects showed significant improvement in cognitive, motor, communication and psychosocial functioning after rehabilitation. The ET group showed better global functional outcome at discharge than LT patients. The best predictors for successful functional neurorehabilitation were the grouping of months since injury, age, GCS score and months of treatment. Conclusions: It is concluded that the sooner patients begin neurorehabilitation, the better their functional outcome.

0650

Post-concussion syndrome and the lived experience of participation in valued life roles: An interpretative phenomenological analysis Nicholas Best Coventry University, Coventry, UK Aims: Literature suggests that post-concussion syndrome (PCS) following mild traumatic brain injury (mTBI) can negatively affect individuals’ ability to participate in valued life roles, an effect mediated in part by environmental influences. This study aimed to explore the lived experience of this client group, with a focus on participation and the environment. Method: Five participants resident in the UK were recruited purposively through a website used by this client group. Interviews and data analysis were carried out according to the principles of Interpretative Phenomenological Analysis (IPA). Results: Participants’ experiences gave rise to four master themes; ‘PCS changed my life’; ‘the need for understanding’; ‘criticisms of healthcare systems’; and ‘positivity as a strategy’. Overall, participants experienced significant difficulties participating in a range of valued life roles. These difficulties had profound negative effects on qualityof-life, practical role fulfilment and self-image. Participants expressed a deep need for understanding from others, were distressed by misattribution of their symptoms to depression or laziness and the quality of their relationships became largely dependent on a shared understanding of their condition. Healthcare services were generally experienced as uncaring, unhelpful, unwilling to intervene in the social sphere and delegitimizing of participants’ experiences. Misattribution of symptoms by health professionals was viewed as a particular threat due to their perceived authority and influence. Participants adopted a deliberate strategy of positive thinking. Conclusion: These findings have implications for the clinical care of this client group, primarily surrounding their need for information, legitimization and interventions in the social sphere. All participants suggested a range of beneficial psychosocial interventions which could have been provided by healthcare services, but felt that few if any of these had been available to them. There are also implications for the treatment within OT theory of ‘participation’, ‘the self’ and environmental influences.

0651

Living without frontal lobes after TBI Jose´ Leoń-Carrioń1, Umberto Leoń-Dominguez2, Luca Pollonini3, Meng-Hung Wu4, Richard E. Frye4, Maria Rosario Dominguez-Morales2, & George Zouridakis3 1

Human Neuropsychology Laboratory, School of Psychology, Department of Experimental Psychology, Seville, Spain, 2Center for Brain Injury Rehabilitation (C.RE.CER.), Seville, Spain, 3Biomedical Imaging Lab, University of Houston, Houston, TX, USA, 4University of Texas Health Science Center, Houston, TX, USA

758


Objectives: Breakdowns in cortical connectivity often lead to disorders of consciousness in survivors of traumatic brain injury (TBI). This presentation analyses cortical connectivity in patients with severe neurocognitive disorder (SND) and in the minimally conscious state (MCS). Methods: Two synchronized networks were observed to subserve consciousness, one retrolandic (cognitive network) and the other frontal (executive control network). Results: The synchronization between these networks is severely impaired in patients in the MCS when compared to patients with SND, who show better levels of consciousness and a preserved state of alertness. The executive control network could facilitate the synchronization and coherence of large populations of distant cortical neurons using high frequency oscillations on a precise temporal scale. If synchrony and coherence are lost, consciousness is altered or disappears. Conclusions: Synchronization between anterior and posterior brain regions is critical to awareness, while a functioning frontal lobe may serve as a surrogate marker for preserved consciousness. The objective of neurorehabilitation programmes is to restore this cortical circuitry.

0652

Cognitive reserve effects of preinjury educational attainment on outcome following post-acute neurorehabilitation R. Stephen Walsh, Donal G. Fortune, Caroline McGrath, Sarah Casey, Brian McClean, & Brian Waldron ABI Ireland, Mid-West South, Ireland Objective: The cognitive reserve hypothesis has been proposed to account for the mismatch between brain pathology and its clinical expression. The objective of the current research was to explore in a longitudinal neurorehabilitation data set, the effects of level of education prior to brain injury (cognitive reserve) and clinical factors on level of rehabilitation-induced changes in neurodisability and community integration. Method: Participants in receipt of post-acute neurorehabilitation following acquired brain injury were assessed at induction to the service and again at 1.5 years follow-up on changes in neurodisability (Mayo Portland Adaptability Indeces of Abilities, Adjustment and Participation) and community integration (Community Integration Questionnaire). Clinical factors were type of injury (e.g. TBI, CVA), age at onset of injury and duration since injury. Results: Controlling for type of injury, age at onset of injury and duration of time since injury, patients with higher educational attainment prior to injury showed larger changes on MPAI indices of adjustment (R2 change ¼ 0.19; F ¼ 8.81, p ¼ 0.005) and participation (R2 change ¼ 0.13; F ¼ 6.27, p ¼ 0.02), but not on MPAI Abilities or on Community Integration following post-acute rehabilitation. Conclusion: Level of education would appear to be an important element of cognitive reserve in brain injury that serves to aid response to post-acute neurorehabilitation in terms of person’s adjustment to neurodisability and their participation.

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Light therapy may improve sleep and facilitate recovery from mild traumatic brain injury

Brain Inj, 2014; 28(5–6): 517–878

Mareen Weber1, David M. Penetar1, George H. Trksak1, Maia Kipman1, Olga Tkachenko1, John S. Bark1, Allison L. Jorgensen2, Scott L. Rauch1, & William D. S. Killgore1 1 2

McLean Hospital, Harvard Medical School, Belmont, MA, USA, Tufts University, Medford, MA, USA

Objectives: Sleep disturbance is one of the most frequently reported and persisting symptoms following mild traumatic brain injury (TBI). Indeed, mild TBI may disrupt the circadian rhythm of alertness and sleep–wake patterns. Although sleep is critical to neuroplasticity and, therefore, recovery from the injury, there is a dearth of effective, nonpharmacological treatments that both improve sleep following mild TBI and lack adverse side-effects. Because of its regulating effects on the production of sleep-promoting melatonin, morning exposure to short wavelength light may effectively improve sleep via reentrainment of the circadian rhythm. Methods: This study presents preliminary data from 18 individuals with mild TBI aged 18–45 (50% female) who were randomized to either active or placebo light treatment using light therapy devices fitted with light-emitting diodes (LEDs). The active treatment devices were fitted with blue LEDs (469 nm) and the placebo devices were fitted with amber LEDs (578 nm). Participants used the devices for 30 minutes each day, within 2 hours of awakening and before 11:00 am each morning for 6 weeks. All participants underwent comprehensive neuroimaging (including structural and functional magnetic resonance imaging and diffusion-weighted imaging), psychiatric and neurobehavioural assessment, actigraphy and Multiple Sleep Latency Tests before and after the intervention. Results: The treatment group showed significant reductions in daytime sleepiness, accompanied by improvements in overall sleep quality, sleep quantity and cognitive measures of attention. More importantly, neuroimaging showed brain functional changes in regions involved in sleep–wake regulation such as thalamus and prefrontal cortex in the treatment, but not the placebo group. Conclusions: Short wavelength light therapy might be a potentially effective non-pharmacological approach with no known adverse sideeffects to improve sleep and to facilitate recovery from mild TBI. These data are preliminary and need to be confirmed using the full data set (n ¼ 30). Future analyses will also determine whether and how brain functional changes relate to changes in white matter microarchitecture.

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Who should we believe?: Differential parental perspectives of post-TBI behaviour in pre-school children Jenny Bellerose1, Catherine Landry-Roy1, Annie Bernier2, Cindy Beaudoin3, Jocelyn Gravel3, & Miriam H. Beauchamp1 1

Ste-Justine Hospital Research Center & University of Montreal, Montreal, Quebec, Canada, 2Psychology Department, University of Montreal, Montreal, Quebec, Canada, 3Ste-Justine Hospital Research Center, Montreal, Quebec, Canada Objectives: Several studies have demonstrated that paediatric traumatic brain injury (TBI) significantly increases the risk of developing or exacerbating pre-injury behavioural, socio-emotional and psychiatric problems such as anxiety, aggression and disobediance. Despite the fact that less TBI research has been conducted during the pre-school

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period, a few studies have put forth the presence of such difficulties following early TBI. Established assessment guidelines in paediatric (TBI) research recommend that objective evaluation of behaviour be complemented with questionnaires completed by primary caregivers in order to obtain a global understanding of children’s functioning post-TBI (Common Data Elements for TBI research). Therefore, as part of a longitudinal project evaluating the cognitive and social repercussions of early TBI, the current study aimed to examine the behavioural profiles reported by parents of pre-school children 6 months after sustaining a TBI. Method: The parents of 32 children (2–5.5 years) with accidental mild, moderate or severe TBI were recruited at an urban paediatric tertiary care Emergency Department using the definition reported by Osmond et al.. They completed the Child Behavior Checklist and the behavioural profiles of the children with TBI were compared to those of 32 typically-developing children (TDC). Results: Primary caregivers of children with TBI, defined as the parent who is the most involved in the study, reported significantly more difficulties (Total Problem Score; t(62) ¼ 2.41; one-tailed, p ¼ 0.01) in both the Global Internalizing (t(62) ¼ 2.01; one-tailed, p50.05) and Externalizing scales (t(62) ¼ 2.46; one-tailed, p50.01) compared to the primary caregivers of TDC. In particular, more withdrawal symptoms (t(54.16) ¼ 3.03; one-tailed, p50.01), attention difficulties (t(54.25) ¼ 2.50; one-tailed, p50.01) and aggressive behaviours (t(54.25) ¼ 2.50; one-tailed, p50.01) were noted. However, no differences were found between the behavioural ratings of the two groups when the second parent completed the questionnaire. Mothers were typically the primary caregivers (TBI ¼ 93.7%, TDC ¼ 81.3%), whereas fathers were most often the second source of information (TBI ¼ 96%, TDC ¼ 82.6%). Conclusions: The present study suggests an incongruency between primary and secondary parental reports, a finding that could be partly explained by the parents’ gender. Previous research suggests several contributing factors that could explain the mother–father discrepancies regarding child behaviour ratings, such as parental psychological symptoms, parent–child relationships and family stress and distress. Further analyses need to be conducted to clarify the specific contribution of parent gender on child behaviour ratings, both as primary caregiver and secondary respondant, in the context of paediatric TBI.

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Pathway to employment—The successful vocational rehabilitation process Timothy Hoste, & Sue Ellen Jurcak Unique Options, LLC, Warren, MI, USA Objectives: To provide a productive quality-of-life for individuals with traumatic brain injuries through successful, long-term, post-injury employment. Methods: Successful vocational rehabilitation involves a hybrid blend of vocational counselling, occupational therapy and behavioural counselling, coupled with real work in a supported environment. The programme must be individualized for each client to ensure that they have every opportunity to achieve their long-term vocational goal. All aspects of the process must work together seamlessly to allow the client to become proficient with whatever job they work. Real work is imperative. Successful vVocational rehabilitation cannot be achieved in a setting where arts and crafts and ‘busy work’ are the main focus. When clients work on real jobs that have deadlines, quality standards and customer expectations, it creates an environment where the clients deficits can be quickly recognized, allowing the staff to direct their focus to these issues immediately. A close staff-to-client ratio (1:3) is critical to maximize the staff’s ability to meet the client’s needs.

The sooner the client’s deficits can be addressed, the quicker the counsellors, therapists and Job Coaches can work with the clients and provide them with solutions that lead to successful employment. This real work approach also creates an environment where the client can earn a paycheck while going through the vocational rehabilitation process. Real work also allows for clients to earn at least minimum wage and eliminates pay based on either piece rate or a deviated wage scale. Results: By creating a ‘real job’ environment for the client, it causes them to be more committed to the process. They quickly start viewing vocational rehabilitation as a stepping stone for long-term success and not just another appointment they have to attend. This allows the client to become more aware of their deficits, which makes them open to feedback and assistance from the staff. Shortly after starting this style of vocational rehabilitation, clients often want to increase their time and involvement in the programme, which results in their ability to quickly reach their -erm vocational goals of either community employment or long-term success in a supported community training and placement workshop programme. Conclusion: For the past 9 years, the authors have operated a programme that utilizes this vocational rehabilitation approach. During this time the programme has not only grown expedientially, but has proven that successful, long-term employment is possible for all individuals with traumatic brain injury.

0658

Profiling allied health practice in forensic mental health settings for individuals with and without acquired brain injuries Adora Chui1, Danielle Fry1, Sara Maraj1, Chantal Tacchino1, Deirdre Dawson2, & Justine Bertrand3 1

McMaster University, Hamilton, Ontario, Canada, 2University of Toronto, Toronto, Ontario, Canada, 3Northern Ontario School of Medicine, Thunder Bay, Ontario, Canada Objectives: The purpose of this study was to explore the clinical practices of Canadian occupational therapists (OTs) in forensic mental health for adults with and without acquired brain injuries (ABI). The specific objectives were to characterize practice context, factors guiding professional practice, client goals and opportunities for role development. Although evidence suggests a positive correlation between brain injury, mental health and criminal behaviour, there is a paucity of information on how allied health professionals support these individuals in managing their health and functional needs. Methods: Purposive and snowball sampling were used for this pilot study, firstly via the Canadian Association of Occupational Therapists followed by colleague referral. An online survey was designed according to the Canadian Practice Process Framework, a document guiding occupational therapy service delivery. Summative content analysis was used for responses to open-ended questions. Responses were pooled and analysed using descriptive statistics. Results: Twenty-seven OTs (56.3%) practicing in forensic mental health responded to the survey. Respondents had been practicing in this area for an average of 4.4 years. Seventy-six per cent worked in secure units in hospitals and 32% in correctional settings. When asked to identify the top three client diagnoses, 80% of clinicians identified schizophrenia, as expected in a mental health setting, but 16% identified ABI and 32% identified concurrent disorders (including comorbid ABI with mental health diagnoses). Clients having diagnoses other than mental health disorders comprised an average of 62% of the caseload for 78% of respondents. When asked to report theoretical frameworks and/or approaches that guided their interventions, therapists identified those widely used in mental health,

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including cognitive behavioural theory and the recovery philosophy. Yet, when asked to identify commonly used assessments, 96% reported using cognitive assessments such as the Montreal Cognitive Assessment and 33% reported using neurological assessments. The three most typical client goals related to vocational activities, instrumental and basic activities of daily living and community housing. Clinicians also reported that existing community and vocational services for people discharged from forensic mental health services were lacking and that two critical areas for attention were increased therapist-to-client staffing ratios and opportunities to advocate for client access to community services. Conclusions: ABI was among the top 10 reported client diagnoses, the majority of which were psychiatric conditions. However, current forensic OT practice does not include assessments or outcome measures specific to the brain injury group. The practice of OTs in forensic mental health settings primarily involved functional assessment and facilitating the goals of individuals with and without brain injury to re-integrate into the community. Future research could examine the apparent under-reporting of brain injury in the forensic population, the functional implications on community reintegration and its correlation with recidivism rates.

0659

Acute and long-term neurorehabilitation: A comprehensive (follow-up) programme for children and young adults with ABI of all severities Riikka Lovio, Pernilla Bergman, Malin Lo¨nnerblad, Elisabet Skalin, Eli Gunnarson, & Ingrid Hagberg-Van’t Hooft Astrid Lindgren Children’s Hospital, Karolinska University Hospital, Stockholm, Sweden Objectives: To evaluate a comprehensive long-term child-, family- and school-oriented neurorehabilitation and psycho-educational programme for patients with ABI. Methods: In the Stockholm region of Sweden, children with acquired brain injuries (ABI) are enrolled in a long-term rehabilitation programme which contains three integrated multi-disciplinary teams according to the severity of injury and stage of recovery: The hospital rehabilitation team provides multi-sensory therapy in the acute phase to children with moderate-to-severe ABI, as well as emotional and practical support to their families. These patients are in the sub-acute phase transferred to day care therapy where intensive multidisciplinary rehabilitation is provided. The patient’s neurological and functional progress is assessed and recommendations are given to the patient, family and surrounding network. The school rehabilitation team offers then continued rehabilitation in a schoollike environment outside the hospital. This team is responsible for the implementation of interventions and the planning of the children’s return to their regular, or alternative, schools. Children suffering predominantly from mild or minor ABI with cognitive impairments are assessed by The outreach rehabilitation team in order to evaluate the need for rehabilitative interventions and to give adequate advice to home and school. To further develop a long-term continuation of the neurorehabilitation services after the sub-acute phase, two new teams outside the hospital have recently been established: The Center for Children with ABI (age 4–18) and The Center for Young Adults with ABI (age 18–25). These teams provide neurorehabilitation, psycho-social and educational support to the patients, their families and schools and preparation for future studies and work

Brain Inj, 2014; 28(5–6): 517–878

Conclusions: It is suggested that this comprehensive programme leads to discharge from the hospital at an earlier stage of recovery, enables the child to return to school with adequate support and minimizes secondary neurological, psychological and social consequences of the ABI. Furthermore, it gives extra support in the phase of young adulthood preparing for independence in life. The programme offers support on a regular basis throughout childhood until young adulthood. The authors are now planning to perform a systematic evaluation of the outcome of patients receiving rehabilitation in this programme.

0660

Susceptibility weighted imaging and long-term outcome after childhood traumatic brain injury Miriam Beauchamp1, Richard Beare2, Michael Ditchfield3, Lee Coleman4, Franz Babl2, Michael Kean2, Louise Crossley2, Cathy Catroppa2, Keith Yeates5, & Vicki Anderson2 1

University of Montreal, Montreal, Quebec, Canada, 2Murdoch Childrens Research Institute, Melbourne, Victoria, Australia, 3Monash Medical Center, Melbourne, Victoria, Australia, 4Royal Children’s Hospital, Melbourne, Victoria, Australia, 5Center for Biobehavioral Health, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio, USA Introduction: Susceptibility weighted imaging (SWI) is a high-resolution structural MRI technique that exploits the magnetic susceptibility differences between tissues by using a sequence that is sensitive to iron and blood products in the brain, making it particularly useful for detecting TBI-related haemorrhage. Studies in childhood TBI have reported its value in detecting lesions characteristic of axonal injury, its superior sensitivity compared to conventional scanning techniques and its value in predicting clinical and cognitive outcome in the shortterm in children with TBI. However, its association with long-term outcomes has not been investigated. In this study, the relationship between lesions identified on SWI and outcome was investigated 2 years after childhood TBI. Methods: Participants (n ¼ 106, 5–14 years) with varying levels of TBI severity (mild, mild complicated, moderate, severe) underwent SWI on a 3T Siemens scanner 1 month post-injury and completed follow-up assessments 6- and 24-months post-injury including clinical, cognitive, behavioural and quality-of-life measures (e.g. WASI, Test of Language Competence–Making inferences, Child Behavior Checklist, PedsQL-fatigue scale). Lesions visible on SWI were coded, segmented, counted and correlated with outcomes. Results: Number and volume of SWI lesions were significantly correlated with clinical variables including Glasgow Coma Score, surgical intervention, length of hospital stay and intubation (r’s ¼ 0.33–0.43, p50.001), as well as with IQ (r ¼ 0.23, p ¼ 0.03) and the ability to understand and make abstract and executive language inferences (r ¼ 0.31, p ¼ 0.02) at 6-months post-injury. Together, SWI and Glasgow Coma Score (GCS) accounted for a significant, although small, proportion (6.5%) of the variance in IQ. At 24-months post-injury SWI lesions present acutely continued to be correlated with IQ (volume: r ¼ 0.23, p ¼ 0.04, count: r ¼ 0.29, p ¼ 0.01), inferences (volume: r ¼ 0.21, p ¼ 0.07, count: r ¼ 0.26, p ¼ 0.02), as well as with the presence of fatigue symptoms (volume and count: r ¼ 0.32, p ¼ 0.05). At 24-months post-injury, SWI and GCS again accounted for a significant proportion of the variance in IQ (10%), but only SWI was a significant independent predictor (beta ¼ 0.24, p ¼ 0.04) of long-term intellectual functioning after TBI. Conclusions: SWI is a sensitive technique for detecting brain lesions at all TBI severity levels and shows promise in contributing to prediction

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of clinical and cognitive outcomes in the initial stages post-injury after childhood TBI. The current findings also indicate for the first time that the presence and extent of lesions detected on SWI acutely are associated with long-term cognitive outcomes and that they may be a better predictor of long-term outcome than standard clinical measures, such as the GCS. As a whole, the findings support the sensitivity and utility of SWI for detecting TBI lesions, as well as its potential role in establishing prognosis after childhood TBI.

0662

Characteristics of head injury patients in emergency air medical services (EAMS) in Taiwan Shin-Han Tsai1, Wan-Lin Chen2, Yung-Hsiao Chiang3, & Wen-Ta Chiu4 Brain Inj Downloaded from informahealthcare.com by RMIT University on 09/02/14 For personal use only.

1

School of Public Health and Nutrition, Department of Emergency Medicine, College of Medicine, Shuang Ho Hospital and Taipei Medical University, Taipei, Taiwan, 2Institute of Injury Prevention and Control, School of Public Health and Nutrition, Taipei Medical University, Taipei, Taiwan, 3Department of Neurosurgery, Taipei Medical University Hospital, Taipei Medical University, Taipei, Taiwan, 4Ministry of Health and Welfare, Taiwan, Taiwan

Objective: Emergency air medical services (EAMS) have become a major part of the modern trauma care system and are frequently used to transport patients from remote islands to a tertiary centre. The purpose of this study was to determine the characteristics of patients transported by helicopter who had head injuries. Methods: Data of all patients with traumatic brain injury who underwent EAMS were retrospectively retrieved from the National Aeromedical Approval Center (NAAC). Patient data were analysed by using the following parameters: age, gender, injury of severity score and outcome within 3 days after air transport. Results: Between 1 October 2002 to 31 December 2012, there were 3195 EAMS requests. Among them, 2839 were approved (approval rate ¼ 87.98%). Among the 2839 patients, 362 sustained head injury. Male predominates in the head injury patient populations. Mean age of patients was 41.8 years, which is younger than all patients air-lifted. Patients between 16–30 years old comprised 31.5%. Moderateto-severe injured patients comprised 66.7%. Thirteen patients expired within 3 days after air medical transport (mortality rate ¼ 3.6%). Conclusions: This study provides characteristics of head injury patients who underwent EAMS and mortality rate. There is no patient safety and no flight safety issue owing to NAAC gate-keeping and consultation mechanism. The present study also demonstrates that traumatic brain injury patients remain a unique category in airlifted patient group. Meticulous pre-flight management and timely transfer are key factors for patient outcome. The results can be used as a reference for appropriate utilization of EAMS, improving medical quality-of-care and transport efficacy under the National Health Insurance programme.

0663

Vision restoration after optic neuropathy using non-invasive alternating current stimulation Bernhard Sabel Otto-von-Guericke University, Magdeburg, Germany

Non-invasive electrical stimulation is known to induce cortical plasticity in normal subjects. The aim now is to learn if non-invasive, repetitive transorbital alternating current stimulation (rtACS) may also improve visual functions in patients with optic nerve damage. In two prospective, randomized, sham-controlled clinical trials, patients that suffered optic nerve damage were studied, including glaucoma cases. Patients were assigned to a group receiving rtACS or sham treatment with sub-clinical stimulation. rtACS was carried out for 10 consecutive days (20–40 minutes daily) using non-invasive AC-current bursts with amplitudes 51000 mA at 10–50 Hz. The primary outcome measures were detection performance in visual field testing and acuity. In addition, patient-reported vision-related quality-of-life was measured with the NEI-VFQ questionnaire and EEG recordings were collected. Analysing the post-treatment minus baseline differences, significant increases were observed in the primary outcome measures (perimetric stimulus detection rates) and several secondary measures, where rtACS significantly improved compared to sham in visual fields, reaction time and visual acuity. The increase of stimulus detection performance and acuity improvement remained constant at a 2-months follow-up in most but not all patients and it was associated with improved vision-related quality-of-life. Physiological EEG changes were also noticed: increased alpha-power in both occipital and frontal brain areas. It is proposed that non-invasive electrical stimulation can improve visual fields in patients with visual field defects that are clinically relevant. Because of the EEG changes it is proposed that the treatment enhanced neuroplasticity in the brain, activating residual visual capacities by increased neuronal synchronization in higher visual (and non-visual) areas. The results are compatible with the view that alternating current stimulation induces LTP-like strengthening of synaptic transmission in residual tissue, thus restoring some of the lost vision in many (but not all) patients. These findings confirm prior observations that vision loss after optic nerve or brain damage must not be viewed as irreversible, but that there is some room for optimism of vision improvement through mechanisms of brain plasticity.

0664

Think fast! A processing speed intervention in TBI Helen M. Genova1, & Nancy Chiaravalloti0 1 2

Kessler Foundation Research Center, West Orange, NJ, USA, Rutgers, the State University of New Jersey, Newark, NJ, USA

Objectives: Speed of information processing is often impaired in individuals with TBI and leads to significant deficits in the ability to perform activities of daily living. Although processing speed training protocols have been utilized in ageing individuals, there is a lack of research testing processing speed training in individuals with TBI. The current study presents pilot data from a randomized clinical trial testing the efficacy of a behavioural intervention for processing speed in TBI, Speed of Processing Training (SPT). Methods: Seven participants with moderate-to-severe TBI were randomized to a treatment group or a no-treatment control group. This study examined SPT treatment effects on tasks of neuropsychological functioning, as well as brain activation patterns using fMRI. Results: Even with this small sample, a significant effect of treatment was noted on a neuropsychological test of processing speed (Letter Comparison t(4) ¼ 2.18, p50.05, one tailed, which demonstrates a large effect size for the intervention (Cohen’s d ¼ 1.37). A significant treatment effect was also noted on a test of everyday processing speed abilities (Timed Instrumental Activities of Daily Living; t(3) ¼ 2.03, p50.05, one-tailed), again demonstrating a large effect size (Cohen’s d ¼ 1.38). Additionally, brain activation patterns were examined before and after SPT treatment in a sub-sample of a larger study. At baseline, there was no difference between controls (n ¼ 3) and the treatment group (n ¼ 3). However, following SPT treatment, the individuals in the treatment group have significantly more BOLD

762 activation than the control group in several regions including: cuneus, insula and pre/post central gyrus. Conclusions: These findings indicate that: (1) SPT is an effective intervention for improving processing speed in individuals with TBI and (2) SPT treatment is associated with changes both behaviourally and at the level of the brain.

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Predictors of major depression in the year following traumatic brain injury: Interim analysis of a prospective cohort study Marie-Christine Ouellet1, Simon Beaulieu-Bonneau1, Myriam Gigue`re1, Lynne Moore2, Joseé Savard2, Marie-Joseé Sirois2, Bonnie Swaine3, & Alexis Turgeon2

Brain Inj, 2014; 28(5–6): 517–878

the injury, controlling anxiety and irritability and working on an adaptive perception of stress or control. Although it is well known that persons with a history of MDE are particularly at risk, preventive interventions should probably be implemented at large.

0666

Functional connectivity network breakdown and restoration in blindness Michal Bola1, Carolin Gall1, Christian Moewes2, Anton Fedorov1, Hermann Hinrichs3, & Bernhard Sabel1 1

Otto-von-Guericke University, Institute of Medical Psychology, Magdeburg, Germany, 2Otto-von-Guericke University of Magdeburg, Department of Computer Science, Magdeburg, Germany, 3 Otto-von-Guericke University of Magdeburg, University Clinic, Department of Neurology, Magdeburg, Germany

1

Centre Interdisciplinaire de Recherche en Reádaptation et Inte´gration Sociale, Que´bec, Canada, 2Centre de recherche du CHU, Que´bec, Canada, 3Centre de recherche interdisciplinaire en reádaptation du Montreál Me´tropolotain, Montreál, Que´bec, Canada Objectives: (1) To compare individuals with TBI who do and do not develop major depressive episodes (MDE) between 4–12 months post-injury on pre-injury characteristics and psychosocial variables measured at 4 months post-injury; (2) To develop a predictive model of depression to identify potential early intervention targets. Method: Participants were 125 individuals hospitalized for TBI (mildto-severe) at a Level I trauma centre prospectively followed-up with comprehensive interviews and questionnaires at 4, 8 and 12 months. The evaluation included a structured clinical interview evaluating preand post-injury mental disorders (Mini International Neuropsychiatric Interview for DSM-IV (MINI)) and measures of anxiety, insomnia, fatigue, irritability, perceived cognitive functioning, social support, substance use and pain. Participants were categorized into two subgroups: those who did or did not develop a MDE between 4–12 months post-TBI as evaluated by the MINI. After comparisons on pre- and post-injury characteristics, a predictive model of depression was derived using direct binary logistic regression. Results: Preliminary data of this prospective cohort study indicate that 30.4% of participants developed at last one MDE between 4–12 months post-injury. There were no differences between groups with respect to age, sex, education or injury severity, however those who developed a MDE more often reported a pre-injury history of MDE (p50.01). At 4 months post-injury, persons who developed a MDE were significantly more anxious, depressed, irritable, fatigued and had more perceived cognitive problems and perceived stress (p50.05). The groups were similar in terms of social support, pain or alcohol consumption. The logistic predictive model was significant (2 ¼ 38.57, p50.0001) and had good predictive validity (R2 Nagelkerke ¼ 0.61; area under receiver operating characteristic curve ¼ 0.93; 95% CI ¼ 0.87, 0.99). Four variables were found to be significantly associated with the presence of MDE between 4–12 months (p50.05): a positive pre-injury history of MDE (Odds Ratio (OR) ¼ 9.23, p ¼ 0.032), presence of either a minor or a major depressive episode in the first 4 months post-injury (OR ¼ 41.13, p ¼ 0.007), anxiety symptoms as measured at 4 months (OR ¼ 1.34, p ¼ 0.047) and perceived stress measured at 4 months (OR ¼ 0.67, p ¼ 0.01). Irritability at 4 months almost reached significance (p ¼ 0.05). Conclusion: With the high frequency of major depression following TBI, regardless of injury severity, there is a pressing need to identify preventive measures to preserve psychological health. These results pinpoint specific modifiable factors which can become targets for early preventive interventions: preventing depression very early after

Background: Loss of vision after brain damage is thought to be caused mainly by the primary tissue loss. Little is known how the damage affects interactions in widely distributed brain networks and how this, in turn, contributes to vision loss. Objective: This study now studied functional connectivity in the brain of partially blind subjects to delineate the role of wide range neuronal networks in blindness. Methods: Resting state eyes-closed EEG activity was recorded in patients with partial optic nerve damage (n ¼ 15) and uninjured controls (n ¼ 13). Power density and functional connectivity (coherence, Granger Causality) were analysed, the latter as (i) between-areal coupling strength and (ii) individually thresholded binary graphs. Functional connectivity was then modulated by non-invasive repetitive transorbital alternating current stimulation for 10-days (rtACS for 40 minutes daily; n ¼ 7; sham, n ¼ 8) to study how this would affect connectivity networks and perception. Results: Blind patients had lower EEG spectral power (p ¼ 0.005) and decreased short- (p ¼ 0.015) and long-range (p ¼ 0.033) coherence in the high-alpha EEG band (11–14 Hz) and less densely clustered coherence networks (p ¼ 0.025). rtACS strengthened short- and long-range coherence again which correlated with recovery of detection ability (r ¼ 0.57, p ¼ 0.035) and processing speed (r ¼ 0.56, p ¼ 0.049). Conclusion: Vision loss in the blind is not only caused by primary tissue damage but also by a synchronization breakdown of short- and long-range connections in brain networks. Because re-synchronization of alpha band coherence is associated with visual field improvements, brain connectivity is a key component in restoration of vision in partial blindness.

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Cumulative effects of blast exposure on symptom reporting after MTBI in a military sample Jan E. Kennedy1, David F. Tate1, Matthew W. Reed1, Kelly J. Miller2, Douglas B. Cooper1, Rael T. Lange3, Jason Bailie4, Sarah Asmussen5, Tracey A. Brickell3, Ricardo R. Amador6, Cheryl L. Sills6, & Louis M. French7 1 2

San Antonio Military Medical Center, Ft Sam Houston, TX, USA, Defense and Veterans Brain Injury Center, Silver Spring, MD, USA,

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University of British Columbia, Vancouver, BC, Canada, 4San Diego Naval Medical Center, San Diego, CA, USA, 5Marine Corps Base Camp Pendleton, Camp Pendleton, CA, USA, 6Defense and Veterans Brain Injury Center, Ft Sam Houston, TX, USA, 7Walter Reed National Military Medical Center, Bethesda, MD, USA, 8Uniformed Services University of the Heath Sciences, Bethesda, MD, USA, 9Center for Neuroscience and Regenerative Medicine, Bethesda, MD, USA


3

Objectives: In a combat context, exposure to blast is the primary cause of traumatic brain injury (TBI) among service members (SM) and it is not uncommon for SMs to experience multiple blasts across a number of deployments. The purpose of this study is to examine the effects of multiple blast exposure on symptom reporting of SMs who have sustained a mild TBI (MTBI). Methods: Participants included 573 male active duty military SMs, who sustained MTBI, grouped into five categories: (1) No-blast exposure (n ¼ 68), (2) 1-blast exposure (n ¼ 123), (3) 2-blast exposures (n ¼ 178), (4) 3-blast exposures (n ¼ 106) and (5) 4–10-blast exposures (n ¼ 98). The number of blasts that characterize each group reflects the number of prior blast exposures plus the current mechanism of injury subjectively reported by the SM. Blast was the mechanism of injury/ cause of MTBI in all groups except group 1. Blast exposure was operationalized as any blast that knocked the SM off his feet or resulted in injury. MTBI was classified according to DoD criteria. Participants were evaluated by the Defense and Veterans Brain Injury Centre at one of six military medical centres from 1–24 months postinjury. Post-concussive symptoms were measured with the 22-item Neurobehavioural Symptom Inventory (NSI) and PTSD symptoms with the Post-traumatic Checklist-Military version (PCL-M). Results: After controlling for age, time since injury and number of deployments, a main effect of group (F ¼ 10.5, p50.001) was found for total NSI score. Scores among blast exposed SMs increased as the number of blast exposures increased. Group 1 (MTBI due to a nonblast mechanism, no reported previous blast exposures) had scores that fell between groups 3 and 4. Post-hoc analysis revealed significantly higher scores in the 4–10-blast group (mean ¼ 36.0) than the 1- (mean ¼ 23.3, d ¼ 0.76) and 2-blast (mean ¼ 27.4, d ¼ 0.50) groups (p50.001) and significantly higher scores in the 3-blast group (mean ¼ 32.8) than the 1- and 2-blast groups (p50.001, d ¼ 0.56 and p ¼ 0.038, d ¼ 0.31, respectively). Scores from the No-blast group (mean ¼ 29.4) were significantly lower than the 4–10 blast group (p ¼ 0.023, d ¼ 0.37). Controlling for PCL-M scores, significant differences remained on total NSI scores between the 4–10-blast group and the 1- and 2-blast groups (p ¼ 0.001, d ¼ 0.35 and p ¼ 0.020, d ¼ 0.24, respectively). Additional analyses of NSI sub-scale scores while controlling for PCL-M scores revealed that affective symptoms were least affected by number of blasts. Conclusions: In this large sample of US service members, the severity of post-concussive symptom reporting increased as a function of the number of blast exposures. Future research is needed to determine whether these cumulative effects on subjective symptom reporting correlate with neuropathological changes from repeated blast exposures.

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The second face of blindness: Processing speed deficits in the intact visual field after pre- and post-chiasmatic lesions Michal Bola, Carolin Gall, & Bernhard Sabel Otto-von-Guericke University, Institute of Medical Psychology, Magdeburg, Germany

Background: Damage along the visual pathway results in a visual field defect (scotoma) retinotopically corresponding to the damaged tissue. However, other parts of the visual field, processed by the uninjured tissue and believed to be intact, suffer from perceptual deficits as well. Objective: Features of the visual field and scotoma in patients were studied to elucidate factors predicting intact field deficits. Methods: Patients with pre- (n ¼ 53) or post-chiasmatic lesions (n ¼ 98) were tested with high resolution perimetry—a method used to map visual fields with supra-threshold light stimuli. Reaction time (RT) of detections in the intact visual field was then analysed as an indicator of processing speed and correlated with features of the visual field defect. Results: Patients from both groups exhibited processing speed deficits in their presumably ‘intact’ field when compared to a normative sample (p50.001). Further, processing speed was found to be a function of two factors. First, a spatially restricted (retinotopic) influence of the scotoma was seen in longer RT when stimuli were presented in intact field sectors close to the defect. Secondly, patients with larger scotomata had on average longer RT in their intact field, indicating a more general (non-retinotopic) influence of the scotoma. Conclusions: Visual system lesions have more widespread consequences on perception than previously thought. Because dysfunctions of the seeing field are expected to contribute to subjective vision, including visual tests of the presumed ‘intact’ field may help to better understand vision loss and to improve methods of vision rehabilitation.

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Ten-to-twelve years after early intensive neurorehabilitation of young patients with severe disorders of consciousness: Research and a documentary Viona J. M. Wijnen1, Henk J. Eilander1, Wendy W. H. M. Wijnen2, Evert J. Schouten2, & Jan C. M. Lavrijsen1 1

Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands, 2Libra Rehabilitation Medicine and Audiology, Tilburg, The Netherlands Objective: The aim of the current study was to explore the long-term outcome of severe brain injury with a prolonged period of unconsciousness in children and young patients, having received a specialized rehabilitation treatment, The Early Intensive Neurorehabilitation Programme (EINP). Methods: In October 2012 a follow-up study was executed in order to investigate the level of consciousness, the independency in daily care, mobility and communication and the living situation of a cohort of 44 young patients (aged between 1.6–25.5 years at time of injury), who had been submitted to EINP between January 2001 and September 2003 in a Vegetative State/Unresponsive Wakefulness Syndrome (VS/ UWS, n ¼ 32) or a Minimally Conscious State (MCS, n ¼ 12). Patients and their families were asked to fill in a questionnaire about their situation. Also some open-end questions were asked, about their involvement in EINP and what happened in between the period after EINP discharge and October 2012. Data were compared to the earlier study on the outcome and clinical course of these patients during and after participating EINP. Three of the participants were interviewed and filmed and a documentary was developed. Results: Of 34 of the 44 patients data could be collected. Eleven patients were deceased, one patient was in VS/UWS. Three patients were in a MCS and 19 patients were conscious. According to the relatives, four patients had shown some recovery in the level of consciousness: two evolved from VS/UWS into MCS, another two

764 evolved from MCS into consciousness. Of the 19 conscious patients, seven recovered to total independency, 11 patients were able to walk independently, 14 patients could speak oriented, six patients lived totally independent and another six lived independent with guidance. One conscious patient lived in a nursing home. The four patients who did not recover to consciousness were all living with their relatives. Conclusion: It appeared that young patients suffering from prolonged disorders of consciousness (1–6 months) who recovered to consciousness during EINP had good opportunities to further recovery into an independent living situation. Patients who did not recover to consciousness have ample opportunities to further recovery. Most of them died within 10 years after EINP. Additionally, young patients in prolonged VS/UWS or MCS appeared to live at home instead of in an institution. Future research could focus more on quality-of-life of the surviving patients and their relatives.


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REVIS-network: Restoration of vision after stroke with noninvasive alternating current stimulation to improve visual impairment Bernhard A. Sabel1, Doreen Bro¨sel1, Franziska Krohn1, Christiane Schlaug1, Paolo Maria Rossini2, Turgut Tatlisumak3, & Carolin Gall1 1

Otto-von-Guericke University, Institute of Medical Psychology, Magdeburg, Germany, 2Catholic University of Rome and IRCCS, Department of Neurology, Rome, Italy, 3Helsinki University Central Hospital (HUCH), Department of Neurology, Helsinki, Finland

Non-invasive brain stimulation using alternating current stimulation (ACS) has recently been shown to improve vision after optic nerve damage. It is assumed that transorbital ACS induces neuronal networks to propagate synchronous firing, probably activating partially damaged areas surviving the injury. The aim of the ‘Restoration of Vision after Stroke’ (REVIS) ERA-Net is to determine if transorbital ACS may also have a positive impact on vision restoration in patients with post-chiasmatic visual pathway lesions. The REVIS study group now addresses the potential of non-invasive ACS in ameliorating vision impairment following stroke (hemianopia). This study now presents results of a first randomized, controlled, blinded clinical trial including patients with post-chiasmatic lesions. Ten days of either ACS (n ¼ 15) or sham-stimulation (n ¼ 14) were applied. During the treatment course a progressive improvement of perimetric thresholds within areas of residual vision was observed only in the ACS-group. After intervention performance in central 5 visual field was improved and defect depths in 30 -threshold perimetry was significantly reduced only after ACS. An increase in subjectively perceived visual functioning (composite score of National Eye Institute Visual Function Questionnaire 39) was reported by rtACStreated patients while there was no significant change in the shamgroup. The health-related quality-of-life (Short Form Health Survey SF-12) did not significantly change after the treatment in either group. Non-invasive rtACS did not improve absolutely impaired areas of the visual field defect. Therefore, careful selection of patients according to their residual vision is crucial since absolute hemianopic defects are unlikely to improve by brain stimulation techniques. Together with changes of EEG coherence measures this finding indicates that residual vision activation is associated with plastic alterations in neuronal brain networks and that rtACS is a promising approach to partially restore vision loss in unilateral stroke. Understanding how to modulate the balance between synchronized and desynchronized states within cortical networks, in the human

Brain Inj, 2014; 28(5–6): 517–878

brain, may enable tACS to become a potential therapy in the treatment of stroke-related vision deficits.

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Model of traumatic brain injury using imaging physiological and psychosocial parameters: Pilot study Irma Molina, Michelaldemar Santiago-Sanchez, Ivan Velez, Keryl Motta, Isabel Borras, Jeanette Figueroa, Gerty Jones, Magaly Freytes, Jose Mendez-Villarubia, Kathia Jusino, Veronica Faris, Carlos Quijano, & Amilcar Matos VA Caribbean Healthcare System, San Juan, Puerto Rico Objectives: Recovery of function from traumatic brain injury (TBI) is of great value for rehabilitation intervention, yet the mechanism of brain injury and recovery remain poorly characterized. The purpose of this study was to measure the size and location of TBI lesions creating perfusion and metabolic statistical parametric maps using Tc99m ECD SPECT/CT and F-18 FDG PET/CT in veteran patients with TBI, while assessing neurophysiologic parameters using Somatosensory Evoked Potentials. Another goal was to estimate the magnitude of the association between brain perfusion defects, brain metabolism impairment and brain electrical disturbances vs quality-of-life measured by functional status, activities in daily living and depression. Additionally, providing a description of the psychosocial experiences of veterans with TBI and modelling the relationship between the neuro-imaging and neurophysiologic characteristics in veterans TBI patient’s population was a further goal of this study. Methods: This was a cross-sectional, pilot study to obtain preliminary data to characterize the brain injuries of OIF/OEF veterans, group them based on these characteristics and describe the psychosocial experiences of veterans with TBI. Standard imaging procedures were used to obtain neurological data related to brain impairments. The study also used qualitative, quantitative and triangulation methods to obtain data to develop psychosocial profiles for different types of brain impairments classified using the brain imaging data. The study population included male and female returning soldiers older than 18 years of age who were diagnosed with TBI and had not received rehabilitation. Ten study subjects with TBI were selected to participate. The participants underwent a SPECT/CT and PET/CT scan within 2 weeks of TBI diagnosis confirmation. The subjects completed a neurological exam and Evoked Potential tests. Qualitative data on the daily lives and experiences of selected veterans were obtained using a semi-structured interview methodology. Results: Six patients were enrolled in the study and two were screening failure. Perfusion and metabolic findings were detected in the presence of negative CT. A mismatch between perfusion defect findings and metabolic defects were observed, suggesting the possibility of up-regulation of receptors to compensate for diminished perfusion. Additionally, the increased severity and number of perfusion defects compared to metabolic defects suggests the aetiology of the TBI may be in part related to a vasomotor response or endothelial dysfunction and not solely due to the trauma itself. Somatosensory Evoked Potential test was analysed and the results were that patients had an Abnormal Central Time from cervical to cortical response. Conclusions: SPECT CT and PET CT could have an add-value in the diagnosis of patients with mild and moderate TBI. However, a large descriptive study is required to extend those observations with the goal of developing predictive models and designing an algorithm to target rehabilitation interventions.

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DOI: 10.3109/02699052.2014.892379

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Blast induced neurotrauma leads to changes in the epigenome Zachary Bailey, Sajja Sujith, Hubbard William, Evon Ereifej, & Pamela VandeVord


Virginia Tech University, Blacksburg, VA, USA

Objectives: Blast-induced neurotrauma (BINT) leads to behavioural and cognitive deficiencies and neurochemical changes in both clinical and animal models. Changes in the epigenome, including histone modifications and DNA methylation, are known to be involved in learning and memory. Histone deacetylation, facilitated by histone deacetylase enzymes (HDACs), is a prevalent modification that affects chromatin structure and gene regulation. Histone deacetylase 2 (HDAC2) and 6 (HDAC6), along with sirtuin 1 (SIRT1), are responsible for deacetylation of histone proteins. DNA cytosine-5-methyltransferase 1 (DNMT 1) facilitates the methylation of DNA at specific sites resulting in gene regulation. Changes in the expression levels of these genes have been linked to Alzheimer’s disease (AD). To elucidate blast-induced epigenetic changes, this study focused on a time course analysis of relative gene expression levels for the enzymes HDAC2, HDAC6, SIRT1 and DNMT1. It is hypothesized that blast exposure will lead to significant changes in gene expression of these epigenetic markers which may be linked to the negative functional outcomes following blast exposure. Methods: An established rodent model of BINT was utilized to examine changes in gene expression. Male Sprague Dawley rats (250 grams) anaesthetized with 3% isoflurane were exposed to a controlled blast with an average blast peak pressure of 19.7 psi (n ¼ 9). An additional group of animals (n ¼ 9) underwent sham procedures to be used as controls. Animals were euthanized 24 hours or 72 hours after blast exposure. Brains were collected and the hippocampus was isolated. Real time polymerase chain reaction was used to elucidate changes in the epigenetic gene expression within the hippocampus. Changes were determined via comparison with sham animals. Results: All animals survived the blast exposure and brains were collected and processed at the appropriate time points. At the 72 hour time point, there was a significant increase in the levels of HDAC2 and HDAC6 when compared to sham. Trending differences were observed between the 24 and 72 hour time points for HDAC2, HDAC6 and DNMT1. Both HDAC expression levels increased while DNMT1 expression levels decreased from the 24 hour to 72 hour time points. Conclusions: The preliminary data suggest that blast causes significant acute changes in the epigenome, specifically with HDAC gene expression. While the data is limited by the sample size, the resulting changes in HDAC2 and HDAC6 gene expression are consistent with reports of gene expression changes in the brains of AD patients. Future studies will be conducted to thoroughly examine the temporal response changes in the epigenome which occur following blast.

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Mild traumatic brain injury in veterans modifies risk for associated co-morbidities: Defining the deployment trauma cluster

Regina McGlinchey, Sara Lippa, Jennifer Fonda, Catherine Fortier, Melissa Amick, Alexandra Kenna, & William Milberg VA Boston Healthcare System, Boston, MA, USA

Objectives: Veterans and Service Members (SMs) of OEF/OIF/OND have high rates of mild traumatic brain injury (mTBI), post-traumatic stress disorder (PTSD) and other co-occurring medical and psychiatric problems. The primary objective of this study was to characterize behavioural and psychiatric co-morbidities in a large cohort of veterans and SMs and to develop predictive models of how these disorders affect functional status collectively. Methods: Participants were 255 OEF/OIF/OND veterans and SMs consecutively enrolled in the VA TBI Center of Excellence, Translational Research Center for TBI and Stress Disorders (TRACTS). All underwent a comprehensive assessment of lifetime TBI (Boston Assessment of TBI-Lifetime), PTSD (Clinician Administered PTSD Scale), Axis I disorders (Structure Clinical Interview for DSM-IV), and deployment intensity (Deployment Risk and Resilience Inventory). The battery also assessed sleep (Pittsburgh Sleep Quality Index), pain (Short Form McGill Pain Questionnaire), and functional status (World Health Organization Disability Assessment Schedule 2.0). A clinical psychologist accomplished testing and a consensus panel of psychologists/psychiatrists made all diagnoses. Results: Approximately 91% of the sample was diagnosed with a current psychiatric condition and/or a current issue with pain and/or sleep. Unadjusted odds ratios comparing those with and without history of military mTBI showed that mTBI increases the likelihood of being diagnosed with PTSD by more than 300% (OR ¼ 4.06; p50.0001) and being diagnosed with a mood disorder (OR ¼ 2.63; p ¼ 0.0005), pain (OR ¼ 2.54; p ¼ 0.0034) or impaired sleep (OR ¼ 2.40; p ¼ 0.0105) by at least 140%. Cluster analysis revealed four clusters of diagnosed conditions (1) ‘Deployment Trauma Cluster’ (DTC; composed of mTBI, PTSD, MDD; containing 16% of the overall sample); (2) ‘Pain & Sleep Cluster’ (50% of the sample) (3) ‘Substance Abuse Cluster’ (alcohol and other substance abuse/dependence; 15% of the sample); and (4) ‘Anxiety Cluster’ (anxiety disorders not associated with PTSD; 19% of the sample). Regression analysis revealed that the DTC (p50.0001) and the Pain and Sleep Cluster (p50.0001) were highly predictive of WHODASS-2.0 score and accounted for 55% of total variance. The DTC contained 40% of individuals determined to be severely disabled (WHODAS-2.0 45) and 72% of those in the entire sample determined to be severely disabled (n ¼ 22) were in the DTC. The constituents of the DTC were not individually predictive of severe disability. Conclusions: mTBI alone is not predictive of functional disability. mTBI does increase the odds of being diagnosed with PTSD, mood disorder, pain and sleep disturbance. The DTC may represent a syndromic-like condition in OEF/OIF/OND veterans that uniquely and severely impacts overall functional status.

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Factors associated with living setting at discharge from inpatient rehabilitation after acquired brain injury in Ontario, Canada Amy Chen1, Vincy Chan1, Brandon Zagorski2, Daria Parsons3, & Angela Colantonio1

766 1

Toronto Rehabilitation Institute, UHN, Toronto, Ontario, Canada, University of Toronto, Toronto, Ontario, Canada, 3Ontario Neurotrauma Foundation, Toronto, Ontario, Canada


2

Objectives: This study examined factors associated with living setting of patients with acquired brain injury at discharge from inpatient rehabilitation in a publicly insured population. Methods: A retrospective cohort design was used. The cohort of patients included those first identified in acute care with a diagnostic code of traumatic (TBI) or non-traumatic brain injury (nTBI) who also subsequently received inpatient rehabilitation in Ontario, Canada, for fiscal years 2003/2004 to 2005/2006. Logistic regression was used to examine pre-disposing, need and enabling factors that are associated with living setting at discharge from inpatient rehabilitation (home/other vs residential care). Acute care and inpatient rehabilitation data were used and were obtained from the Discharge Abstract Database and National Rehabilitation Reporting System, respectively. Results: The majority of patients (83%) were discharged home after inpatient rehabilitation. Discharge to residential care was associated with longer lengths of stay (OR ¼ 3.21 for TBI and OR ¼ 2.04 for nTBI patients), living alone (OR ¼ 3.02 for TBI and OR ¼ 4.63 for nTBI) or living in non-home settings at admission (OR ¼ 4.55 for TBI and OR ¼ 9.43 for nTBI). Patients with higher total function scores from the FIMTM Instrument (OR ¼ 0.97 for TBI and nTBI) and those receiving informal support at discharge (OR ¼ 0.40 for TBI and OR ¼ 0.64 for nTBI) were significantly less likely to be living in a residential care setting at discharge. Conclusions: The findings suggest that informal support influences service utilization and provides evidence for its importance at discharge with respect to living in the community. Prior living arrangement and functional status at discharge significantly predicted discharge destination. Improving physical function and providing needed supports at discharge may be factors important to reduce the demand for residential care facilities.

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Defining traumatic brain injury in children and youth using International Classification of Disease Version 10 codes: A systematic review Vincy Chan1, Pravheen Thurairajah2, & Angela Colantonio1 1

Toronto Rehabilitation Institute, UHN, Toronto, Ontario, Canada, University of Toronto, Toronto, Ontario, Canada

2

Objective: To systematically review the literature to explore the range of International Classification of Disease Version 10 (ICD-10) codes that are used to define traumatic brain injury (TBI) among children and youth aged 19 years and under. Methods: The databases MEDLINE, MEDLINE In-Process, Embase, PsychINFO, CINAHL, SPORTDiscus and Cochrane Database of Systematic Reviews were systematically searched. Grey literature was searched using Grey Matters and Google. Reference lists of included articles were also searched for relevant studies. All titles and abstracts were first screened using pre-defined inclusion and exclusion criteria. A full text screen was conducted on articles that met the first screen inclusion criteria. All full text articles that met the pre-defined inclusion criteria were included for analysis in this systematic review. Two reviewers independently assessed all papers for fulfillment of pre-determined eligibility criteria in the study selection process. An expert in the field of TBI research using

Brain Inj, 2014; 28(5–6): 517–878

administrative data was consulted to ensure no additional studies were missed with the search strategy. Two independent reviewers assessed all eligible papers and data were abstracted into tables and synthesized for analyses. Results: A total of 1256 articles were identified through the predetermined search strategy and 32 articles/reports met all eligibility criteria to be included in this review. Five articles specifically examined children and youth aged 19 years and under with TBI, two of which examined TBI-related deaths and three explored incidence and trends. ICD-10 case definitions ranged from the broad injuries to the head codes (ICD-10 codes S00–S09) to concussion only (S06.0). There was overwhelming consensus on the inclusion of ICD-10 code S06, intracranial injury, while codes S00 (superficial injury to the head), S03 (dislocation, sprain and strain of joints and ligaments of head) and S05 (injury of eye and orbit) were only included by articles that examined head injury, none of which specifically examined children and youth. Expert consultation and additional literature search revealed retinal haemorrhage to be common in inflicted TBI among infants and children; however, this code was never used in identified ICD case definitions of this review. Conclusions: The identification of the range of ICD-10 codes to define this population in administrative data is crucial, as it has implications for policy, resource allocation, planning of healthcare services and prevention. It also allows for comparison across countries and studies. This review identified the range and most common ICD-10 codes used to conduct surveillance for TBI in children and youth. This is an important first step in reaching an appropriate definition using ICD-10 codes and can inform future work on reaching consensus on the codes to define TBI for this vulnerable population.

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Is repeat CT necessary in mild traumatic brain injury in the elderly? Zach IIGiovine, Damien Campbell, Mellisa Whitmill, Ronald Markert, & Jonathan Saxe Wright State University, Dayton, OH, USA Objectives: Mild traumatic brain injury in elderly patients has increased markedly over the last decade. The current protocol at this hospital requires that all elderly patients with any traumatic brain injury (TBI) are admitted to a critical care unit for observation with serial GCS, receive platelet transfusion if on aspirin or Plavix and obtain a second CT scan in 8–12 hours. It was observed that most of the patients did not have any change in GCS or change in CT and were discharged with no other intervention. The purpose of this study was to study the current protocol to determine if repeat CT is necessary in patients who’s GCS remains unchanged. Methods: This was a retrospective review of the trauma registry of the Level One, American College of Surgeons Trauma Center. It identified 2009 patients with TBI admitted over a 2-year period. Mild TBI (GCS 12–15) was identified in 1561 patients. Data obtained included: Age, Sex, ISS, AIS, BP, serial GCS, Injury Type, CT scan results, operative interventions, outcomes and were evaluated for levels of significance. Results: The average age was 80.3 years with women slightly more commonly injured 54% although not statistically significant. The average ISS was 9, indicating a single system injury in 95% of the patients in the study group. The GCS changed in only 2.6% of the patients. CT scanning showed a change in 4.3% of the patients. None of the patients whose GCS remained unchanged required any intervention. Conclusion: This study supports the notion that CT scanning in patients admitted with mild TBI and unchanged GCS does not appear to contribute to the care of these patients.

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DOI: 10.3109/02699052.2014.892379

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A population-based perspective of hospitalized patients with brain tumours: Who receives occupational therapy services after discharge?

Sex differences in acquired brain injury profiles and outcomes in a national rehabilitation sample Vincy Chan, & Angela Colantonio Toronto Rehabilitation Institute, UHN, Toronto, Ontario, Canada

1

2

1

Vincy Chan , Chen Xiong , & Angela Colantonio 1



2

Objective: Survival rates of persons with brain tumours have increased steadily over the years. Survivors often have residual disability that may be amenable to rehabilitation, yet there is a dearth of research on these services in this clinical population. The aim of this study was to examine the characteristics of patients with benign, malignant and unspecified brain tumours that received occupational therapy (OT) services after discharge from acute care in a publicly insured population. Methods: The cohort of patients included those first identified in acute care with a diagnostic code of brain tumours who also subsequently received OT services in Ontario, Canada, for fiscal years 2004/2005 to 2008/2009. Acute care data were obtained from the Discharge Abstract Database and data on access to OT services were obtained from the Home Care Reporting System. Results: From 2004/2005 to 2008/2009, 3199 patients with brain tumours received OT services after discharge from acute care. OT service visits comprised 2.9% of 538 845 home care visits during this time period. Overall, 12.4% had benign brain tumours, 78.2% had malignant brain tumours and 9.4% had unspecified brain tumours. Patients with benign brain tumours were older (mean ¼ 63.3 years, SD ¼ 17.6 years) than patients with unspecified brain tumours (mean ¼ 60.2 years, SD ¼ 20.9 years) and malignant brain tumours (mean ¼ 59.0 years, SD ¼ 16.4 years). The majority of patients with benign brain tumours that received OT services were females (65.1%) compared to 51.4% of malignant brain tumours and 47.8% of unspecified brain tumours. Patients with benign brain tumours had longer lengths of stay in acute care (17.2 days, SD ¼ 34.5 days) compared to those with malignant brain tumours (mean ¼ 11.2 days, SD ¼ 13.1 days) and unspecified brain tumours (mean ¼ 8.8 days, SD ¼ 10.7 days). Almost 20% of patients with benign brain tumours had alternate level of care days in acute care (days in acute care without needing that level of care) compared to 5% of patients with malignant brain tumours. Discharge destinations from acute care also differed among the three brain tumour groups, in which 13.1% of patients with benign brain tumours that received OT services were discharged to inpatient rehabilitation while only 2.4% with malignant brain tumours were discharged to this destination. Conclusions: Patients with malignant, benign and unspecified brain tumours that received OT services after discharge from acute care have distinct characteristics and, in particular, differences in sex distribution and discharge destinations. Persons with benign tumours, although a smaller group, are more likely to receive inpatient rehabilitation and OT services after discharge, potentially reflecting a lower mortality rate and greater rehabilitation potential. Given that age is associated with benign tumours, this represents a potential area of future practice and research.

Objective: To determine sex differences in the characteristics and outcomes of patients with acquired brain injury (ABI) in a national rehabilitation sample in Ontario, Canada. Methods: Data on inpatient rehabilitation were obtained from the National Rehabilitation Reporting System. A cohort of patients with a brain dysfunction diagnostic code (which includes traumatic and non-traumatic brain injury) in the NRS from fiscal years 2004/2005 to 2009/2010 was identified. Results: From fiscal years 2004/2005 to 2009/2010, there were 5216 patients with an ABI diagnostic code in inpatient rehabilitation in Ontario, Canada. Almost 50% had traumatic brain injury (TBI), 44% had non-traumatic brain injury (nTBI) and 6% had other types of brain injury. The majority of females had nTBI (54.9%), while the majority of males had TBI (57.8%). The mean age of females with ABI (59.1 years, SD ¼ 19.3 years) was significantly higher (p50.001) than males (53.7 years, SD ¼ 19.7 years). The total function score from the FIMTM Instrument among males (82.5, SD ¼ 27.1) was significantly higher (p50.001) than the score among females at admission (78.6, SD ¼ 25.5). Similarly, the total function score among males at discharge (102.4, SD ¼ 24.6) was also significantly higher (p5.001) than the score among females (99.8, SD ¼ 24.6). However, their average length of stay (males ¼ 44.2 days; females ¼ 46.8 days) in inpatient rehabilitation was not significantly different (p40.05). Approximately 60% of female and 55.7% of male patients had a co-morbid health condition at admission, while 12.1% of female and 9.5% of male patients developed a health condition after admission and during the rehabilitation stay. Conclusions: Sex differences exist in the profiles and outcomes of patients with ABI in inpatient rehabilitation. It is important to understand how sex differences affect rehabilitation outcomes in order to inform the planning of healthcare services and the preparation of community support and services for this population at discharge, especially as the rehabilitation population ages.

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Characteristics of hospitalized children and youth with traumatic brain injury: A population-based perspective Vincy Chan, & Angela Colantonio Toronto Rehabilitation Institute, UHN, Toronto, Ontario, Canada Objective: To determine the profile and trajectory of children and youth with traumatic brain injury (TBI) in a publicly insured population. Methods: The Discharge Abstract Database was used for data on acute care admissions. The cohort of patients aged 19 years and under with a TBI diagnostic code in the acute care between fiscal years 2004/2005 and 2009/2010 was identified. Results: From 2004/2005 to 2009/2010, 8837 children and youth aged 19 years and under were admitted to acute care with a TBI diagnostic


768 code, of which 31% were between the ages of 0–4 (infants), 16% were between 5–9 years (children), 19% were between 10–14 years (youth) and 34% were between 15–19 years (older adolescents). During this period, the number of TBI patients admitted to acute care decreased from 1714 patients in fiscal year 2004/2005 to 1322 patients in 2009/ 2010. The majority of patients admitted to acute care were males; however, almost 75% of older adolescents were males compared to 57.7% of infants. Older adolescents had a higher percentage with psychiatric comorbidities (10.2%), length of stay of 12 days or longer in acute care (15.5%), delayed discharge from acute care (9.1%) and special care days (31.3%) compared to other age groups. Overall, 85.4% of patients were discharged home, 4.7% were discharged home with support services, 2.1% to inpatient rehabilitation and 5.3% were transferred to other centres; however, age differences were also observed. While 5.5% of older adolescents were discharged to inpatient rehabilitation, less than 1% of all other age groups were discharged to this destination. Conclusions: This study provided evidence that children and youth with TBI are not an homogenous population and planning and preparation of healthcare services for this population should take into account age differences. Moreover, efforts to decrease delayed discharges from acute care is encouraged, as well as an increase of inpatient rehabilitation services for this population. Future research should examine the significance of these differences to determine their influence on access to healthcare services for this vulnerable population.

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Characteristics of hospitalized children and youth with brain tumours: A population-based perspective Vincy Chan1, & Angela Colantonio2 1


2

Objective: To determine the profile and trajectory of children and youth with malignant, benign and unspecified brain tumours in Ontario, Canada. Methods: The Discharge Abstract Database was used for data on acute care admissions. The cohort of patients with malignant, benign and unspecified brain tumours aged 19 years and under admitted to acute care between fiscal years 2004/2005 and 2009/2010 was identified. Results: From 2004/2005 to 2009/2010, 745 children and youth were admitted to acute care with a brain tumour diagnostic code; 11.7% had benign brain tumours, 65.8% had malignant brain tumours and 22.6% had unspecified brain tumours. The majority of patients with benign brain tumours were between 15–19 years of age (older adolescents; 51.7%), however, the age distributions of patients with malignant and unspecified brain tumours were approximately equal. The number of males and females with benign brain tumours were similar, whereas 54.5% of patients with malignant brain tumours and 59.5% of patients with unspecified brain tumours were males. Overall, approximately half of the patients with brain tumours had at least one special care day and the percentage differed between different brain tumours types (benign ¼ 56.3%; malignant ¼ 55.5%; unspecified ¼ 28.0%). A higher percentage of patients with malignant brain tumours stayed in acute care for 12 days or longer (38.0%) compared to patients with unspecified brain tumours (11.9%) and benign brain tumours (21.8%). Discharge destinations also varied by brain tumour types—among patients with benign brain tumours, 82.8% were discharged home and 10.3% were discharged home with support services. Among patients with malignant brain tumours, 61.6% were discharged home and 23.7% were discharged home with support services. Among patients with

Brain Inj, 2014; 28(5–6): 517–878

unspecified brain tumours, 67.3% were discharged home, 4.2% were discharged home with support services and 25.0% were transferred to other facilities, which included another inpatient hospital care setting and long-term care facility. Conclusions: The profile and outcome of children and youth with benign, malignant and unspecified brain tumours differ; however, there is currently no active surveillance of benign brain tumours in Ontario, Canada. Research on children and youth with brain tumours should differentiate between the brain tumour types so healthcare services for this group of patients can be planned accordingly.

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Traumatic brain injury and falls in Ontario, Canada: When, where and how do they happen? Vincy Chan1, Meera Kugadas2, Brandon Zagorski2, Daria Parsons3, & Angela Colantonio2 1

Toronto Rehabilitation Institute, UHN, Toronto, Canada, 2University of Toronto, Toronto, Canada, 3Ontario Neurotrauma Foundation, Toronto, Canada Objectives: To examine the rate of TBI due to falls in the emergency department (ED) and acute care by age groups, falls sub-types and geographic region in the province of Ontario in Canada. Rates of falls from TBI and ‘head injury’ diagnostic codes were also compared. Methods: ED and acute care data were obtained from the National Ambulatory Care Reporting System and the Discharge Abstract Database, respectively. Rates of ‘head injury’ diagnostic codes were obtained from the Ontario Injury Data Report. Results: From fiscal years 2007/2008 to 2009/2010, there were 24 402 episodes (62.9 per 100 000) and 10 370 episodes (26.7 per 100 000) with a TBI diagnostic code, respectively, due to falls. The highest rates were in South East Ontario (104 per 100 000) for ED visits and North West Ontario (38.0 per 100 000) for acute care admissions. The most common specified falls were slip and trip on the same level and on stairs and steps across all geographic regions in Ontario. The rate of falls using head injury diagnostic codes was 4.2–27.2-times higher than the rate of falls using TBI diagnostic codes with high specificity among children, youth and older adults. Conclusions: Rates and types of falls vary by geographic region and age groups. The disparity in the rates of head injury and TBI with high specificity suggests that current rates of TBI are likely under-estimates for the youngest and oldest age groups. Inclusion of head injury diagnostic codes in research using administrative data for purposes of planning prevention programmes is recommended.

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Hospitalized children and youth with non-traumatic brain injury: Who are they and where do they ho? Vincy Chan1, & Angela Colantonio2 1 2


Objective: To determine the profile and trajectory of children and youth with non-traumatic brain injury (nTBI) in a publicly insured population.

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Methods: The Discharge Abstract Database was used for data on acute care admissions. The cohort of patients aged 19 years and under with a nTBI diagnostic code in the acute care between fiscal years 2004/ 2005 and 2009/2010 was identified. Results: From 2004/2005 to 2009/2010, 6627 children and youth aged 19 years and under were admitted to acute care with a nTBI diagnostic code, of which 45.0% were between the ages of 0–4 (infants), 13.2% were between 5–9 years (children), 16.1% were between 10–14 years (youth) and 25.7% were between 15–19 years (older adolescents). During this period, the number of TBI patients admitted to acute care decreased from 1180 patients in fiscal years 2004/2005 to 1068 patients in 2009/2010. The majority of patients admitted to acute care were males; however, almost 60% of children were males compared to 51% of older adolescents. Age differences were observed for many clinical characteristics—40.3% of infants stayed in acute care for 12 days or longer compared to 16.4% of older adolescents; 36.0% of older adolescents had at least one special care day compared to 27.3% of youth; and 22.3% of children had a Charlson Comorbidity Index Score of 2 or higher compared to 6.3% of infants. Overall, 67.7% of patients were discharged home, 9.2% were discharged home with support services, 15.2% were transferred to other facilities, including another inpatient hospital, 0.8% was discharged to inpatient rehabilitation and 5.9% died in acute care; however, age differences were also observed. More than a fifth of infants were transferred to another facility, 62.1% were discharged home and 9% were discharged home with support while 7.9% were transferred to another facility, 75.3% were discharged home and 11.1% were discharged home with support services. Conclusions: This study presented evidence that the characteristics and discharge destinations of children and youth with nTBI differ by age groups. It also provided healthcare professionals with a profile of the nTBI patients they can expect to see in the acute care setting. Further research into differences by types of nTBI can provide more specific information that can inform planning of services for this population.

mapped onto a high-resolution T1 and co-registered with the freewater maps by non-linear registration. Gray-matter, white-matter and cerebrospinal fluid volumes were extracted and used in addition to unsuppressed water signal from the same ROI to calculate concentrations of individual brain metabolites, using a linear combination model analysis. Correlation tests between the average free-water measures and the metabolite concentrations were carried using Pearson correlation controlling for motion. Results: N-acetylaspartate (NAA) was negatively correlated both with the FW measure (R ¼ 0.42, p ¼ 0.0063) and the RDt measure (R ¼ 0.47, p ¼ 0.0018). Using the NAA measure as a covariate showed that FW was correlated with Glutamate (Glu; R ¼ 0.46, p ¼ 0.0024) and that RDt was correlated with myo-inositol (Ins; R ¼ 0.42, p ¼ 0.0077). Conclusions: The NAA metabolite is a putative marker of neuronal density. Therefore, the correlation of FW and NAA associates FW with white-matter atrophy, reflective of neuronal loss and excessive extracellular space, which are part of a neurodegenerative process. At the same time, the correlation of RDt with NAA suggests that changes in neuronal density also affect the microstructural domain, increasing the overall diffusivity. Importantly, when controlling for the effects of NAA, more subtle microstructural alterations are revealed: The correlation of FW with Glu suggests sensitivity to excitotoxicity, which in turn changes the volume of the extracellular space. Neuroinflammation is a by-product of excitotoxicity through the activation of microglia via pro-inflammatory cytokines. This relation is further supported by the correlation of RDt with Ins indicative of gliosis, i.e. microglia and astrocyte activation and proliferation. Taken together, the new approach described here provides a novel in vivo and non-invasive multimodal way of identifying three important pathologies: atrophy, excitotoxicity and gliosis, which are expected to occur in CTE subjects and link CTE to neurodegeneration and neuroinflammation.

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Identification of atrophy, excitotoxicity and gliosis in the white matter of retired NFL players Ofer Pasternak1, Robert A. Stern2, Michelle Y. Giwerc1, Charles Yergatian1, Sai Merugumala1, Huijun Liao1, Christine M. Baugh2, Carl-Fredrik Westin1, Martha E. Shenton1, & Alexander P. Lin1 1

Harvard Medical School, Boston, MA, USA, 2Boston University, Boston, MA, USA Objectives: Magnetic resonance imaging (MRI) and spectroscopy (MRS) can potentially identify pathologies that appear in chronic traumatic encephalopathy (CTE), a progressive tauopathy that occurs as a consequence of repetitive mild traumatic brain injury. Diffusion MRI (dMRI) methods such as free-water imaging, are sensitive to microstructural alterations that might occur in CTE, but lack the specificity of biochemical changes measured by MRS. However, MRS has poor spatial resolution and coverage. This study combines the two modalities, with the aim to increase the specificity of dMRI and MRS to CTE pathologies. Methods: Forty-nine retired National Football League (NFL) players at high risk for having CTE received multimodal 3T-MRI scans. Shortecho single-voxel MRS was acquired from a region of interest (ROI) defined in the parietal white-matter (PWM). Free-water maps (FW) and free-water-corrected maps of radial diffusivity (RDt) were computed, following eddy currents and motion correction. The MRS ROI was

Do all elderly patients with mild traumatic brain injury require admission? Zach IIGiovine, Damien Campbell, Mellissa Whitmill, Ronald Markert, & Jonathan Saxe Wright State University, Dayton, OH, USA Introduction: Mild traumatic brain injury in elderly patients has increased markedly over the last decade. The current protocol at this hospital requires that all elderly patients with any traumatic brain injury (TBI) are admitted to a critical care unit for observation with serial GCS, receive platelet transfusion if on aspirin or Plavix and obtain a second CT scan in 8–12 hours. It was observed that most of the patients did not have any change in GCS or change in CT and were discharged with no other intervention. The purpose of this study was to study the current protocol to determine if admission is necessary for patients who’s GCS remains unchanged for over 6 hours of observation. Methods: This was a retrospective review of the trauma registry of this Level One, American College of Surgeons Trauma Center. It identified 2009 patients with TBI admitted over a 2-year period. Mild TBI (GCS 12–15) was identified in 1561 patients. Data obtained included: Age, Sex, ISS, AIS, BP, serial GCS, Injury Type, CT scan results, operative interventions, outcomes and were evaluated for levels of significance. Results: The average age was 80.3 years, with women slightly more commonly injured, 54%, although not statistically significant. The average ISS was 9, indicating a single system injury in 95% of the patients in the study group. The GCS changed in only 2.6% of the patients. CT scanning showed a change in 4.3% of the patients. None of the patients whose GCS remained unchanged required any

770 intervention. Most of the patients were discharged to their prior living conditions. Conclusion: This study supports the opinion that admission is not required with mild TBI and unchanged GCS over a 6-hour period.

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Implementation of objective sleep monitoring during acute neurorehabilitation: Feasibility and clinical findings Risa Nakase-Richardson1, Daniel Schwartz1, Mo Modarres1, Jamie Zeitzer2, William Anderson1, & Melanie Midkiff


1

James A Haley Veteran’s Hospital, Tampa, FL, USA, 2Stanford University, Palo Alto, CA, USA, 3Malcom Randall Veterans Hospital, Gainesville, FL, USA, 4University of South Florida, Tampa, FL, USA

Objective: The purpose of this study is to describe feasibility and clinical findings of objective sleep monitoring with consecutive TBI Model System admissions to a rehabilitation unit at a major Polytrauma Rehabilitation Centre within the Veterans Health Care system. Persons with TBI demonstrate a greater prevalence of sleep disorders relative to the general population. Animal and human studies have shown that sleep–wake cycle disturbances may alter neurotransmitters and receptor systems, neuronal activation and related signalling molecules, as well as physical functioning, mood, cognition and behaviour. Sleep is critical for neural repair in early stages of recovery and disordered sleep may play a role in early cognitive decline after TBI. Although sleep disturbances are prevalent, few studies have attempted to characterize the nature of sleep disorders in TBI populations to help direct targeted treatments. For example, recent meta-analysis of post-TBI sleep disturbances highlighted sleep apnea was 12-times higher than large community-based non-TBI studies. The American Academy of sleep medicine has established C-PAP intervention as a standard of care for sleep apnea; however, only one study has attempted to characterize prevalence of sleep apnea during acute neurorehabilitation. This is particularly important because sleep apnea represents a disorder with symptoms (e.g. hypersomnolence, fatigue, cognitive dysfunction) commonly observed in post-TBI sequelae. The nocturnal hypoxemia of untreated apnea is a secondary neurologic insult that may influence acute TBI recovery and potentially contribute to earlier cognitive decline in chronic TBI. Methods: Limb-placed actigraphy and polysomnography (Level 1–2). Results: Since programme inception, 135 persons with brain injury have undergone actigraphy monitoring and 30 participants with acute moderate–severe TBI have undergone Level 1 or 2 polysomnography during acute neurorehabilitation. Conclusions: The relative merits and shortcomings of different objective assessment technologies (e.g. polysomnography and actigraphy) in acute rehabilitation clinical settings will be discussed along with prevalence of sleep disorders with specific empiricallybased treatments established in the sleep medicine literature. Implications for clinical and research work focusing on acute TBI sleep disturbances will be discussed.

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Enhancing clinical decisionmaking in the recovery of consciousness by using the

Brain Inj, 2014; 28(5–6): 517–878

disorders of consciousness scale (DOCS) keyform Ann Guernon1, Trudy Mallinson2, & Theresa Pape3 1

Marianjoy Rehabilitation Hospital, Wheaton, IL, USA, 2George Washington University, School of Medicine and Health Sciences, Washington DC, USA, 3Hines VA Hospital, Research Service, Hines, IL, USA Objective: To demonstrate how the DOCS Keyform enhances clinical knowledge of individual patient’s neurobehavioural functioning by sensory domains and then using that patient-specific information to develop evidence-based rehabilitation and education goals targeted to individual patient’s strengths. Methods: To illustrate enhanced clinical decision-making, four patients will be presented. The four patients are abstracted from a sample of 174 patients with severe brain injury enrolled into a prospective measurement study 180 days after injury. Each participant was evaluated with the DOCS weekly up to six times. The DOCS is a measure of neurobehavioural function (NBF) based on clinician-rating of patient responses elicited via provision of 25 sensory stimuli. Ratings are based on a 3-point scale (no response, generalized response or localized response). Data was analysed using Rasch Analysis applying a partial credit model and adjusting for rater severity/leniency. DOCS items were calibrated to form a hierarchy of NBF. These item calibrations were used to develop the DOCS Keyform, a 2-dimensional, graphical display that reflects indicators of full consciousness and enables simultaneous scoring and measurement of NBF across four sensory domains (gustation/ olfaction, somatosensory, auditory-language and visual). Results: The four cases presented illustrate how using raw scores influences clinical interpretation of a patient’s ability to respond to sensory stimulation. These cases highlight patients with similar total DOCS raw scores, but when best modality scores are plotted on the DOCS Keyform each patient’s NBF across sensory domains identifies variation in NBF across modalities that is not reflected in the total DOCS score. DOCS total score for Case 1 and Case 2 was 16, but keyform plotting for Case 1 indicates he had higher NBF within the gustation/olfaction and somatosensory domains. In contrast, Case 2 demonstrated highest NBF in the somatosensory and auditorylanguage domains. Comparing total DOCS scores of 23 and 22, respectively, for Cases 3 and 4 with Keyform plotting indicates that Case 3 has higher NBF gains in the auditory-language domain and Case 4 has greater recovery within the visual domain. Conclusions: Accurate presentation of NBF for persons in states of seriously impaired consciousness is essential for developing targeted rehabilitatin goals and education. Patient performance over time represented visually according to established item hierarchies for sensory modalities provides a clinically meaningful representation of a patient’s ability and better informs clinicians in goal development and targeting of neurobehavioural responses during therapy. The four cases also demonstrate how similar total DOCS scores do not represent the same level of NBF across sensory domains. Utilization of the DOCS Keyform informs clinical decision-making. The Keyform also offers a meaningful, visual representation of patient ability that can be utilized for education of families.

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Children and youth with traumatic brain injury: A comparison of case definitions Vincy Chan1, & Angela Colantonio2

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DOI: 10.3109/02699052.2014.892379 1



2

Objective: To compare the number of episodes and characteristics of children and youth aged 19 years and under with traumatic brain injury (TBI) by International Classification of Disease Version 10 (ICD10) case definitions in a publicly insured population. Methods: The National Ambulatory Care Reporting System and the Discharge Abstract Database were used for data on emergency department (ED) visits and acute care admissions, respectively. A conservative definition with high specificity, the Centre for Disease Control and Prevention (CDC) and the ICD-10 head injury block of codes (case definitions with higher sensitivity) were used to identify TBI-related ED and acute care episodes between fiscal years 2003/2004 and 2009/2010 among patients aged 19 years and under. The number of patients whose first admissions occurred between 2004/2005 and 2009/2010 were identified to determine their characteristics and rates of TBI-related ED visits and hospitalizations per 100 000 (calculated as number of patients divided by the total population aged 19 years and under in Ontario, Canada between 2004/2005 and 2009/2010). Results: The conservative case definition identified 51 953 TBI-related ED episodes (182.7 per 100 000) and 7352 TBI-related hospitalization episodes (30.5 per 100 000). The CDC case definition identified 580 254 TBI-related ED episodes (2165.4 per 100 000) and 11 152 TBI related hospitalization episodes (47.2 per 100 000) and the ICD-10 head injury case definition identified 596 845 TBI-related ED episodes (2225.5 per 100 000) and 12 107 TBI-related hospitalization episodes (52.9 per 100 000). In the ED, the conservative definition showed that the highest percentage of cases were among older adolescents (41%); however, using the other definitions, the highest percentage of cases were among infants (39%). Also, the conservative definition showed a higher percentage of patients admitted to the acute care from the ED (7%) compared to 1% of patients using the other two case definitions. In the acute care setting, the conservative definition showed that a higher percentage of patients stayed in acute care for 12 days or longer (12% vs 8–9%) and had at least one special care day (25% vs 19%); however, a lower percentage were discharged home (80% vs 86%). Conclusion: The number of episodes and characteristics of children and youth with TBI differed by case definitions. Findings from this study suggested that case definitions should be chosen based on the purpose of the surveillance system, such that a case definition with high sensitivity is preferred for prevention strategies where near misses are of interest. Conversely, a case definition with high specificity may be preferred for cases needed for more inpatient services. A range of definitions should be considered for the planning of prevention and post-injury care for TBI.

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Prevalence, types and correlates of sleep problems in head injury patients during the rehabilitation period? Maria Gardani1, Eleni Morfiri1, Thomas McMillan1, Allan Thomson1, & Brian O’Neill2 1

Institute of Mental Health and Wellbeing, University of Glasgow, Glasgow, UK, 2Brain Injury Rehabilitation Trust, Glasgow, UK

Objectives: The prevalence of sleep difficulties is high after head injury (HI). Previous research suggests that HI patients with sleep problems require longer stays in rehabilitation units and that disturbance of arousal disrupts engagement in rehabilitation activities. The present study explored the prevalence and types of

sleep disorders in patients with severe HI undergoing inpatient rehabilitation and whether the presence of sleep problems affects their rehabilitation. Methods: Twenty-three (n ¼ 23) severe HI patients responded to a semi-structured clinical screening interview about their sleep–wake patterns and wore an actiwatch (an activity monitor that is associated with sleep and wakefulness) for 7 days. Participants also completed self-report measures on sleep, mood, fatigue, pain and daytime sleepiness. Information on rehabilitation variables, including frequency of aggressive behaviour, engagement in rehabilitation and level of disability was collected retrospectively from staff and rehabilitation notes. Results: Fifteen participants (65.2%) had sleep problems. Of these, 10 (43.8%) met formal diagnostic criteria for a sleep disorder and in five (21.7%) no underlying cause for sleep problems was identified. Diagnosed sleep disorders in the sample comprised insomnia (21.7%), post-traumatic hypersomnia (8.7%), circadian rhythm disorder (8.7%), sleep apnoea (4.3%), periodic limb movement disorder (4.3%) and rhythmic movement disorder (4.3%). Senior rehabilitation therapists estimated sleep disturbance as interfering with the rehabilitation process in 26% of the overall research sample (n ¼ 23). Sleep quality, assessed by self-report measures (Pittsburgh Sleep Quality Index; PSQI) was not significantly associated with rehabilitation variables (Hopkins Rehabilitation Engagement Rating Scale). Poor sleep quality (PSQI) was associated with greater anxiety (r ¼ 0.611), fatigue (r ¼ 0.683) and daytime sleepiness (r ¼ 0.529). Conclusions: Consistent with previous studies, sleep disorder and disturbed sleep was common in HI patients undergoing rehabilitation and was associated with anxiety, fatigue and daytime sleepiness. These findings highlight the importance of assessing and treating sleep problems in HI patients undergoing rehabilitation.

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Early calcium response in astrocytes to controlled shear stimuli Mohammad Mehdi Maneshi, Frederick Sachs, & Susan Z. Hua SUNY-Buffalo, Buffalo, NY, USA Traumatic brain injury (TBI) is brain damage resulting from an external mechanical force, such as blast or crashes. The current understanding of TBI is derived mainly from in vivo studies that show measurable biological effects on cells sampled after TBI. Little is known about the primary mechanical responses in brain cells during damaging stimuli and how the forces are transduced into cellular and molecular events involved in TBI. This work aims to identify the stimulus properties that are most critical to cell injury and to determine the stimulus thresholds beyond which the stimulus produces irreversible damage. This study has used tissue cultured adult astrocytes in a microfluidic chamber driven by a fast pressure servo to generate welldefined fluid shear. Using fluorescent beads in the chamber, this study characterized the shear forces in the chamber. It is shown that the pressure servo is capable of producing blast-like pulsatile force with a rise time of 2 milliseconds at 20 dyn cm2 in the microfluidic chamber. To determine the key stimulus properties that might lead to TBI, this study has applied shear pulses with various amplitudes, rise times, durations and pulse trains of various frequency and examined the time-dependent Ca2+ response in astrocytes. Results show that shear forces causes a transient increase in intracellular Ca2+ in astrocytes. While the intensity of the intracellular Ca2+ changes strongly depends on the magnitude and the duration of shear force, the stimulus waveform plays an important role. Pulsed shear force with 2 millisecond rise time cause transient increases in intracellular Ca2+, while this response is drastically reduced when the rise time is

772 extended to 20 milliseconds while keeping the same magnitude. The threshold for cell response established a complex matrix, depending on the magnitude, duration and rise time of stimulation. The Ca2+ response was inhibited by Gd3+, suggesting the mechanosensitive ion channels are responsible for Ca2+ entry. These global Ca2+ responses are further compared with the cytoskeletal deformation under the same stimuli. The results predict the features of the stimulus most effective in eliciting long-term damage, providing guidance for clinical exploration research and the therapeutic treatment.

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EEG power spectrum changes induced by transcranial magnetic stimulation in two vegetative patients Brett Harton1, Xue Wang2, Theresa Pape1, & Todd Parrish2 1

Edward Hines, Jr. VA Hospital, Hines, IL, USA, 2Northwestern University, Chicago, IL, USA

Brain Inj, 2014; 28(5–6): 517–878

Conclusions: Both subjects’ CNC scores improved during rTMS. EEG power spectrum findings suggest that these CNC improvements are related to immediate increases in alpha and theta power, which may have contributed to cognitive readiness and attention, respectively. Sustained rTMS effects were not found in either subject. In both subjects, immediate EEG power changes were seen in areas remote from the stimulation site, indicating that remote effects influenced CNC improvements. Findings suggest that EEG power spectrum analysis could be used to detect neural changes in persons in VS after TBI.

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Effect of IL-6-174 G/C polymorphism in predicting disability and functional outcome in patients with severe traumatic brain injury (STBI) Sumit Sinha, Naseem Mansoori, Neha Samson, A. K. Mukhopadhyay, & B. S. Sharma All India Institute of medical Sciences, New Delhi, India

Objective: To examine the potential of EEG power spectrum analysis for assessing immediate and sustained effects of repetitive transcranial magnetic stimulation (rTMS) for persons in the vegetative state (VS) after traumatic brain injury (TBI). Methods: Two subjects in VS, 287 and 188 days after TBI, were provided with 30 rTMS sessions over 6-weeks to the right dorsolateral prefrontal cortex at 110% of each subject’s motor threshold. The Coma-Near-Coma Scale (CNC) was collected weekly as a neurobehavioural measure. Before and after each rTMS session, resting EEG data was acquired from 18 electrodes. A 60 Hz notch filter, 0.1–70 Hz bandpass filter and a 1 Hz high-pass finite impulse response filter were applied, the data were divided into 1-second epochs and independent component analysis was conducted to remove muscle and eye movement artifact. EEG power was integrated between alpha (8–12 Hz) and theta (4–8 Hz) frequencies and normalized by the total power between 4–40 Hz over all electrodes. For each subject, 27 EEG data sets were included in analyses. A paired two-tailed t-test was conducted to determine immediate (pre-TMS vs post-TMS) and sustained (Week 1 vs Week 6) rTMS effects. Data were corrected for multiple comparisons using a false discovery rate of 0.05. Results: At study completion, CNC scores improved for Subject #1 and #2 by 8 and 10 points, respectively, and each subject progressed to MCS. Significant effects were not found following FDR-correction, but significant uncorrected p values are insightful. During Week 5, Subject 1’s alpha power increased at channels FT8 (p50.03), TP8 (p50.001), CP4 (p50.046) and TP7 (p50.043) and approached significance at FC4 (p50.063). Theta power increased at FT8 (p50.005) and TP8 (p50.02) and approached significance at FC4 (p50.065), CP4 (p50.076) and CP3 (p50.063). During Week 1, Subject 2’s alpha power increased at FC4 (p50.01), FT8 (p50.05), CP4 (p50.05) and TP8 (p50.04) and theta power increased at TP8 (p50.04), FC4 (p50.05) and FT7 (p50.003) and approached significance at FCz (p50.07). During Week 4, theta power increased at CP3 (p50.05). During Week 5 alpha power increased again at CP4 (p50.04) and PO4 (p50.04) and approached significance at PO3 (p50.06). Theta power increased at CP3 (p50.022), PO3 (p50.042), PO8 (p50.01) and approached significance at CPz (p50.08).

Introduction: The outcome after severe traumatic brain injury (STBI) is a multifactorial process and depends on the interaction between environmental and genetic factors. The present study has analysed the role of IL-6-174 G/C polymorphism in predicting the functional outcome as measured by Functional Independence Measure (FIM) and Glasgow Outcome Score (GOS) after STBI. Methods: In this cross-sectional study, all the patients of STBI (Glasgow Coma Scale (GCS) score 4–8), between 18–65 years of age, were included. The polymorphisms of IL-6–174 G/C genes were assessed using PCR-RFLP. Serum IL-6 level was measured by ELISA. The neurologic outcome, GOS and FIM score were evaluated at 1 month and 6 months after injury. Results: A total of 45 subjects (40 male and five female) were studied. The mean age was 32.7 ± 10.5 years. Serum IL-6 level did not show any statistically significant difference between patients with presence or absence of variant allele. Out of 45 subjects; 13 have GC genotype, one has CC and 31 have GG genotype. After the first month of injury the patient having variant C allele showed better outcome as compared to patients having wild G allele. However, this difference was not statistically significant (GOS: p ¼ 0.085 and FIM: p ¼ 0.076). This difference was statistically significant after 6 months of injury (GOS: p ¼ 0.024 and FIM: p ¼ 0.030). The patient having variant C allele showed a6.4-fold better outcome in terms of GOS as compared to those having wild allele. The percentage increase of FIM at 6 months from baseline was found to be higher in variant allele (150.9) than wild allele (103.5) and was not statistically significant (p ¼ 0.30). It was also observed that, in patients having wild allele, the FIM score is low as compared to variant allele. Conclusion: In conclusion, a statistically significant association was found of IL-6-174 G/C polymorphism with the clinical outcome of STBI. This study reveals for the first time that the C allele increased the odds of good clinical outcome 4.4-fold after 1 month and 6.4-fold after 6 months of injury. In addition, patients with wild G allele showed statistically more drop in FIM score. The preliminary data of ongoing study suggest that IL-6-174 G/C polymorphism plays an important role in the clinical outcome of STBI.

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Development and implementation of a clinical practice guideline for the rehabilitation of adults with moderate-to-severe traumatic brain injury in Quebec and Ontario Catherine Truchon1, Corinne Kagan2, Bonnie Swaine3, Marie-Eve Lamontagne4, Mark Bayley5, Shawn Marshall6, Anne-Sophie Allaire4, & Ailene Kua5 1

INESSS, Que´bec, Canada, 2ONF, Toronto, Ontario, Canada, CRIR, Montreal, Que´bec, Canada, 4CIRRIS, Que´bec, Canada, 5Toronto Rehabilitation Institute, Toronto, Ontario, Canada, 6Ottawa Hospital, Ottawa, Ontario, Canada


3

Background: There has been a growing interest in the development of Clinical Practice Guidelines (CPGs) to bridge the gap between research and clinical practice in order to improve healthcare. CPGs are promising tools for aligning services and assisting healthcare professionals in making clinical decisions based on the best available evidence. This study aims to structure and facilitate the adaptation and implementation of a CPG intended for clinicians and administrators providing rehabilitation services to adults having sustained a moderate-to-severe traumatic brain injury (MS-TBI) in Que´bec and Ontario (Canada). Method: A partnership between the Institut national d’excellence en sante´ et en services sociaux (INESSS) and the Ontario Neurotrauma Foundation (ONF) provides the overarching structure to co-ordinate the joint production and implementation of a CPG intended to support the rehabilitation of adults with MS-TBI in facilities offering inpatient and outpatient rehabilitation services, as well as in acute settings offering early rehabilitation services. A scientific committee composed of researchers and clinical experts from both provinces co-ordinate the six main phases of the planned 3-year period: (1) scoping review and evaluation of existing CPGs, (2) formal validation of the end-users’ needs and expectations, (3) synthesis of all existing information (GPCs, literature review, survey), (4) co-ordination of a consensus process amongst experts, (5) adaptation of the recommendations and production of the guideline, and (6) implementation of the CPG in clinical settings. Results: Project phases 1 and 2 provide rich and complementary information to inform the development process of the CPG so as to best address the needs and priorities of the target users, while considering the strengths and limits of the scientific evidence. These preliminary steps further play a key role in preparing the clinical settings for the upcoming strategic implementation phase. Conclusion: INESSS and ONF share a common interest in promoting the improvement of rehabilitation practices by providing their respective provincial networks with a locally relevant, evidenceinformed CPG. They also have significant interest in fostering the capacity for the implementation of the CPG through the development of indicators to inform process and outcome measurement of the recommended practices. The collaboration of several key stakeholders, policy-makers, clinical and research experts speaking English and French brings a unique and stimulating perspective to the project and the process.

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Therapists’ and patients’ experiences and perceptions of sleep difficulties after head injury Maria Gardani, Thomas McMillan, & Liam Gibbons Institute of Mental Health and Wellbeing, Glasgow, UK Objectives: Head injury (HI) patients report frequent problems with memory, concentration, fatigue, irritability, temper, dizziness and headaches. Sleep problems are reported in up to 70% of patients after head injury and insomnia symptoms can be found in up to 30% of HI patients; these rates are significantly higher than those found in the general population. This study has conducted the first qualitative analysis on the impact of sleep difficulties in the quality-of-life of HI patients. Methods: Two groups of therapists (n ¼ 16) participated in focus group discussions. The groups included speech therapists, neuropsychologists, assistant psychologist, nurses and support workers that have been working in two local rehabilitation centres for at least 6 months prior to the study. Community patients were recruited from a local HI supporting network (Headway) and were invited to participate in the study. Three groups of community patients (n ¼ 4 per group) with severe HI were facilitated to discuss their sleep problems after the injury in a group setting. Group discussions lasted 45–60 minutes per group until saturation was achieved. Thematic analysis was used to qualitatively explore the beliefs, experiences and expectations associated with sleep disturbances following head injury. Results: Therapists and support staff reported that sleep difficulties are common in HI patients and that in most cases sleep disturbance is related not only to the HI itself but also to mental health or environmental factors. Staff felt that little attention is routinely paid to these problems during rehabilitation unless specifically linked to challenging behaviour. Fatigue was thought to be highly relevant and to have a negative effect on engagement and participation in rehabilitation. Patients thought that sleep problems became persistent after injury and the areas that emerged as being more affected were: mood, cognition, everyday functioning, physical health, concentration and cognition. Most patients reported severe insomnia symptoms associated with worry about life and family during the night. Conclusions: To provide better management and improve their rehabilitation it is essential to understand the therapists’ and patients’ expectations and perceptions of sleep difficulties after head injury. Qualitative analysis shows that sleep difficulties have a significant impact on the cognitive, affective and behavioural difficulties that many patients experience following a head injury.

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Perceptual learning improves visual functions in TBI patients Maria Lev1, Anna Sterkin1, Ravid Doron1, Moshe Fried1, Yossi Mandel2, Ruth Huna-Baron3, & Uri Polat1 1

Tel-Aviv University, Tel-Aviv, Israel, 2Bar-Ilan University, Ramat-Gan, Israel, 3Sheba Medical Center, Ramat-Gan, Israel Different traumatic brain injuries are associated with visual dysfunction. Accumulating evidence suggests that the adult visual cortex retains significant potential for experience-dependent plasticity.


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A primary mechanism proposed to regulate adult plasticity is the ratio between inhibition and excitation in the cortex. This study developed a psychophysical (behavioural) non-invasive paradigm that triggers plasticity by changing the balance towards excitations. Neuronal interactions in visual processing were robustly affected by changes in the balance between excitations and inhibitions. This paradigm was applied, which induces visual improvement in amblyopia (lazy eye) and presbyopia (ageing eye), an effect that is highly applicable for patients with visual dysfunction associated with TBI. This study reports on results obtained from TBI patients that were trained on contrast detection of Gabor targets under spatial and temporal masking conditions, targeting the improvement of collinear facilitation and temporal processing. They were trained on the fovea and periphery. The patients were trained on a PC computer from a distance of 1.5 metres, once or twice a week. Training improved lateral interactions (increased facilitation and diminished the lateral suppression when it existed) and improved visual functions such as contrast sensitivity, visual acuity, crowding, reaction time, vernier acuity and reading. There was also improvement in the pattern of eye movements and fixation. Although the previously reliable visual field was not measurable, after training, the pattern of fixation enabled measurement of a reliable visual field. Thus, the visual improvements are not due to development of eye movement or a fixation strategy to overcome the visual deficiencies, rather they are due to real improvement of the neural network involved in visual processing in the brain.

following TBI is recommended. Even though there is no conclusive evidence, four anticonvulsants, Phenytoin, Levetiracetam, Carbamazepine and Valproate, were suggested for use during early PTE. Conclusion: Based on this study of the current literature, a known prevention and treatment methodology for PTE does not exist and further research is necessary.

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Objective: While individual professions implementation of clinical practice guidelines has been studied, there is little investigation of how teams implement practice changes. This pilot project explored the processes teams engage in when evaluating individuals’ abilities to return-to-work following a mild-to-moderate traumatic brain injury (TBI). The objective was to understand how knowledge gets translated into practice in team contexts, when varied professionals collaborate in the evaluation process. Data collected for this project will help define current practices and establish baselines against which to measure practice changes following the implementation of the Inter-professional Guideline for Vocational Evaluation Following Traumatic Brain Injury. Methods: A qualitative research approach was employed and three methods were used to collect data: (1) Semi-structured, in-depth interviews (n ¼ 13) were completed with healthcare professionals (i.e. occupational, physical and rehabilitation therapists, neurologist, intake physician, neuropsychologist, service and return-to-work coordinators), who provide vocational assessment and/or rehabilitation services, to gain an understanding of how they and their rehabilitation teams evaluate individuals’ work abilities following a TBI and make return-to-work recommendations; (2) Observations were made of team discussions during clinical meetings (n ¼ 3) to understand which professional(s) is/are involved in various elements of the evaluation, how discrepancies and inconsistencies are addressed and how teams establish recommendations; (3) Workers’ compensation and auto insurance policies from Ontario, Canada were reviewed to understand how larger insurance and fiscal policies influence practices. Interviews were digitally recorded and transcribed verbatim. Field notes of key discussion points during team meetings were also transcribed into a textual document. Data were stored using Atlas Ti (qualitative data management programme) and analysed using thematic analysis. Thematic analysis involves an initial phase of becoming familiar with the data, followed by identification of key concepts or themes in each interview and concludes with the identification and definition of themes across the group of interviews. Evidence from policies was triangulated with discussions in the interview data to determine how compensation policies may affect vocational evaluation practices. Results: Preliminary analysis reveals that evaluation processes are guided by insurers’ requests to confirm diagnoses, prognosis and client’s ability to return to pre-injury duties. Participants describe distinct roles in the evaluation process, a focus on verification of symptoms and findings from individual assessments in order to determine the legitimacy of the injury and a need to determine the

Prevention of post-traumatic epilepsy Maliheh Mohamadpour Sarah Jane Brain Foundation, New York, NY, USA Introduction: Epilepsy is one of the most common neurological disorders, occurring in 0.5% of the world population. Post-traumatic epilepsy (PTE) accounts for 5% of all cases of epilepsy. The incidence increases with the severity of brain damage, ranging from 5% in ‘mild’ injuries to 50% in severe penetrating injuries. Early studies suggested prophylactic administration of anti-epileptic drugs would prevent epileptogenesis; however, controlled studies have failed to support the initial hypothesis. The purpose of this review is to understand the different pathways of the epileptogenesis after the brain injury, investigate what has been studied to prevent and treat PTE and instigate additional research interest in this critical area of medicine. Method: A systematic review of the literature from 1959–2013 focusing on prevention and treatment interventions for posttraumatic seizures after TBI was used for this analysis. Results: There are many different mechanisms of PTE including genetic propensity, cellular mechanisms, structural changes, physiologic changes, biochemical changes, oxidative stress mechanisms and anatomical changes. There are different potential prevention and treatment drugs which have been considered and researched including anticonvulsant prophylaxis, antioxidants, adenosine, melatonin, calcium channel blockers, transresveratrol, glucocorticoids, progesterone, hyaluronic acid and amino acid. There is no evidence to prove the efficacy of classic anti-epileptic drugs (Phenobarbital, Phenytoin, Carbamazepine, Valproate Acid) as a prophylactic treatment for PTE. There are new therapeutic investigations with a strong experimental basis into prophylactic treatment of PTE including lipid peroxidation inhibitors, neuroprotectors (especially antioxidants), glutamic receptor blockers, NMDA receptor blockers and drugs that modulate apoptosis via caspasas inhibition. The most recent Brain Trauma Foundation (BTF) guidelines do not recommend prophylactic use of phenytoin or valproate for prevention of late PTE. According to these BTF guidelines, Pharmacoprophylaxis against early seizures

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Inter-professional approaches to vocational evaluation following traumatic brain injury Mary Stergiou-Kita1, Carolina Bottari2, Deirdre Dawson3, Debbie Hebert4, & Alisa Grigorovich4 1

University of Toronto, Toronto, Ontario, Canada, 2Faculty of Medicine, School of Rehabilitation, Universite´ de Montreál, Montreal, Quebec, Canada, 3Rotman Research Institute, Baycrest, Toronto, Ontario, Canada, 4Toronto Rehabilitation Institute, Toronto, Ontario, Canada, 5Center for Interdisciplinary Research in Rehabilitation of Greater Montreal, Montreal, Quebec, Canada

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effect of symptoms on work performance. Challenges to the evaluation process include: inadequacy of tools to diagnosis mild TBI, limited involvement of employers and access to workplace data and a lack of formal follow-up from insurers to determine if recommendations are implemented. Conclusions: Findings will be discussed in relation to best practice recommendations included in the Guideline for Vocational Evaluation Following TBI.

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Mortality late after mild traumatic brain injury: A prospective population study


Tom McMillan1, Jessica Wainman-Lefley1, & Christopher Weir2 1

University of Glasgow, Scotland, UK, 2University of Edinburgh, Scotland, UK Objective: To investigate mortality rates and associated factors in a population of people with mild traumatic brain injury (MTBI) 15 years after admission to hospital. Methods: A prospective case control, record linkage study in hospitals in Glasgow, Scotland. Over a period of 1 year in 1995–1996 a total of 2428 adults with MTBI (Glasgow Coma Scale Score 13–15) were admitted to hospitals in Glasgow, Scotland. Each case was record linked to a community control (CC) and an ‘other injury’ control (OIC). Controls were case-matched for age, gender and social deprivation and had no history of TBI. OIC were admitted with an injury not involving the head and were in addition matched for duration of hospital stay. Death and cause of death was investigated using the General Register for Scotland database. History of inpatient or day attendance at hospital for 15 years pre- and post-injury was obtained for all groups via the Scottish Morbidity Records. Results: Mortality per 1000 per year after MTBI (24.49; 95% CI ¼ 23.21, 25.79) was higher than in CC (13.34; 95% CI ¼ 12.29, 14.44; p50.0001) or OIC groups (19.63; 95% CI ¼ 18.43, 20.87; p50.0001). Younger adults (15–54 years) with MTBI had a 4.2-fold greater risk of death than community controls. For older adults the risk was less, 1.4-times higher. Gender and social deprivation were not risk factors for death after MTBI compared to controls. Hospital admissions with systemic disease in MTBI and OIC groups were more common in CC pre-injury and increased significantly post-injury. Prospective data that is only available for the MTBI group suggests an association between preinjury lifestyle and mortality. Repeat head injury was more frequent post-injury in MTBI than in controls. Death after MTBI was from the same major causes as in the general population. Conclusions: Adults who were hospitalized with a MTBI had a greater risk of death in the following 15 years than matched controls. Risk was particularly high in younger adults with MTBI. Higher frequencies of admission with systemic disease and associations between lifestyle and death have implications for management interventions.

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Ramelteon improves sleep and functional outcomes in poststroke patients with insomnia Shuji Matsumoto1, Megumi Shimodozono1, Tomokazu Noma2, & Kazumi Kawahira1

1

Kagoshima University, Kirishima City, Japan, 2Kagoshima University Hospital, Kirishima City, Japan

Objective: The complaints of poor sleep quality and insomnia should be given priority assessment during clinical diagnosis of sleep disorders post-stroke. Insomnia is associated with poor outcomes following stroke onset and is considered to worsen life prognosis in elderly patients with stroke. Guidelines for the treatment of sleep disorder recommend a combination of clonazepam and melatonin as a level B treatment. However, in Japan, melatonin may not be used for treatment in clinical practice. Recently, the melatonin receptor agonist ramelteon was approved for the treatment of insomnia in Japan. This study examined whether the ramelteon improved sleep, cognitive and functional outcomes in post-stroke patients. Methods: A total of 28 patients (mean age ¼ 74.2 years; 16 female, 12 male) were studied. The research design was an open treatment trial with pre-treatment and post-treatment evaluations. After screening, the patients were administered ramelteon (8 mg day1) once daily. For each patient, the sleep values, as well as the rehabilitationoutcome measurements at 12 weeks of treatment, were compared with those observed during the screening period (baseline). The clinical characteristics, total sleep time, wake after sleep onset, number of awakenings, the stage REM (%), cognitive status (MiniMental State Examination [MMSE] score) as a measure of cognition. functional status (Barthel Index [BI]) as an assessment tool for activities of daily living and the Brunnstrom stage as a measure of hemiplegia were measured. Written informed consent for participation was obtained from all enrolled patients after they had been given a comprehensive explanation of the protocol. Results: The average ± SD total sleep time increased by 25.3% (from 246.5 ± 44.8 to 308.8 ± 56.1 min; p50.01) with decreased number of awakenings, while the percentage of the stage REM was not unchanged. There were significant improvements in MMSE and BI scores during the study period (p50.01). The Brunnstrom stage of recovery from hemiplegia in the upper limb significantly improved from 3.5 (2–6) to 4.5 (3–6) after 12 weeks of treatment with ramelteon (p50.01); the corresponding values for the hand also showed a significant improvement (from 3.0 [1–5] to 4.0 [2–6]; p50.01), as did those for the lower limb (from 4.0 [2–6] to 5.0 [3–6]; p50.01). Conclusions: This study shows initial evidence for the clinical benefits (longer total sleep time, decreased number of awakenings and functional gains) of incorporating ramelteon as part of a multicomponent insomnia management programme. The inclusion of ramelteon in anti-insomnia regimens could have advantageous effects on rehabilitation in post-stroke patients with insomnia.

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The promise of progress: Co-ordinating interdisciplinary neuro-restorative care transitions Audrey Winograd, Trevor Squirrell, & Barbara Winters Brain Injury Association of Vermont, Waterbury, VT, USA Despite the advances in neuro-rehabilitation, all too many survivors of brain injury slip through the cracks of a fragmented healthcare system. Often they re-surface in another system, with a trail of troubles in their wake. Hospital re-admission is but one negative outcome of poor transitions that concern providers, payers and patients alike. Broken families, lost careers, financial ruin, substance abuse and criminal engagement are not necessary outcomes of a brain injury; their frequent occurrence is troubling. The implications for social welfare and healthcare costs are significant. The impact on the lives of survivors and their families are immeasurable. This is a global problem with local solutions, supported by national initiatives.


776 Facilitators can and must help. In an attempt to bridge the divide, the Brain Injury Association of Vermont (BIAVT) established the Care Transition Project to uncover gaps and monitor care from one healthcare setting to another and from post-acute in-patient rehabilitation to home and community-based services and supports. This is literally mapping out the state healthcare system and figuratively building bridges through relationships with clinicians, hospitals, area agencies on ageing, centres for independent living and the like. The Neuro-Resource Facilitators provide meaningful information and referral at key moments in the neuro-restorative process. Facilitators work in collaboration with their clients, increasingly engaging them in their own development while monitoring the transitions that can derail the process and the person. Together, facilitators develop personal plans with assigned tasks, communicate and visit regularly to assure progress. Alliances of local, state and federal governments, NGOs, non-profit and profit rehabilitation providers are essential to improved health outcomes and meaningful lives post-injury. BIAVT is an integral part of Vermont’s Ageing & Disability Resource Connection (ADRC), a pilot project using evidencebased models to co-ordinate care from hospital to home. The No Wrong Door approach calls on all providers to welcome and assist individuals. BIAVT is in the hospital, a part of the discharge planning team assuring smooth transitions and follow-up care. The clients are among others at high risk for re-admission, compliance complications and co-occurring conditions, yet these may not surface for months or years. Mild-to-moderate brain injury is often off the hospital charts, secondary to highly visible conditions. Education, outreach and a long-term commitment are indispensable. When ready to move from rehabilitation to restorative living, trained Options Counsellors present alternatives geared to the individual’s unique recovery process, financial need and self-directed goals. Most importantly, these programmes keep survivors connected to trusted advisors at critical junctures along the rehabilitative path. Along with the ADRC partners, the authors are adapting evidence-based models to specific needs of the individual, empowering the survivor and the family toward optimum outcomes.

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Syndrome of irreversible lithiumeffectuated neurotoxicity (SILENT) in a woman with epilepsy Deena Hassaballa, Simge Yonter, & Kevin Jiang Loyola University Medical Center Department of Orthopedic Surgery and Rehabilitation, Maywood, IL, USA Objective: To demonstrate the increased risk of Lithium neurotoxicity in patients with pre-morbid seizure disorder. Case report: A 35 year old female with history of bipolar disorder and seizure disorder presented to the emergency department with presumed suicide attempt. She was found confused in her stool and urine with a Glasgow coma scale score of 15, dysarthric speech, choreoathetoid movements, temperature of 103.1 and lithium level of 1.5 mmol l1 (borderline normal). Repeat lithium level 4 hours after presentation was 1.0 mmol l1. She received emergent haemodialysis 24 hours after admission. The family reported that the patient had an upper respiratory infection 3 days prior. Neurology was consulted. Lumbar puncture and MRI of the brain were negative. Electroencephalogram (EEG) on day 5 of admission revealed mild generalized encephalopathy without focal abnormalities or epileptiform activity. After a thorough workup, the diagnosis was made clinically as SILENT syndrome. The patient presented to acute inpatient rehabilitation for neurorehabilitation. Physical examination revealed severe dysmetria and limb ataxia bilaterally with finger to nose and heel to shin testing. Other positive findings were

Brain Inj, 2014; 28(5–6): 517–878

dysdiadochokinesia, dysarthric speech, nystagmus, positive Romberg and moderate cognitive impairment. Muscle strength and sensation were intact, with normal deep tendon reflexes. She presented with a FIM score of 1 for gait and transfers. After a month of rehabilitation she had a FIM score of 2 for ADLs and a FIM score of 1 for her gait at maximum assistance with an ataxic scissoring gait. Her rehabilitation progress was slow and the severe limb and truncal ataxia persisted with no improvement. Conclusions: SILENT syndrome has been reported in cases of lithium neurotoxicity. Past reports have demonstrated patient’s with cerebellar dysfunction, dysarthric speech and other neurologic sequelae. Adityanjee et al. proposed that prior neurologic illnesses or CNS insults of any kind increases the vulnerability to neurotoxicity of lithium and the occurrence of neurotoxicity does not correlate with serum lithium levels. Lithium levels may be borderline normal and still potentially cause devastating sequelae. Finally, patient’s on lithium are potentially at risk of SILENT if infection or fever are present as it is hypothesized that ‘fever may induce a rise in blood–brain-barrier permeability and in increase in the uptake of lithium by cerebellar cells’. This patient had a past history of seizure disorder and questionable infection prior to the events and a borderline normal lithium level. It is suggested that lithium should be very cautiously used in patients with epilepsy. Further research is needed in order to help prevent such destructive outcomes for generations to come.

0701

Game play following traumatic brain injury: Applying an activitybased model for using games during neurorehabilitation Julie Hengst1, Kathleen Kortte2, Jean Neils-Strunjas3, Allison Clark4, Kacey Maestas4, Diane Paul5, & Raksha Mudar1 1

University of Illinois, Champaign, IL, USA, 2Johns Hopkins University School of Medicine, Baltimore, MD, USA, 3Armstrong Atlantic State University, Savannah, GA, USA, 4TIRR Memorial Hermann’s Brain Injury Research Center, Houston, TX, USA, 5American SpeechLanguage-Hearing Association, Rockville, MD, USA, 6Baylor College of Medicine, Houston, TX, USA Computer games are compelling and clients often want to play or already are involved in playing computer and video games. Indeed, the Entertainment Software Rating Board (ESRB) estimates that 67% of US households play video games and that the average gamer spends 8 hours a week playing. Advances in digital technologies have led to computerized versions of traditional games (e.g. Web Sudoku, Words with Friends), powerful gaming platforms (e.g. Wii, PlayStation, Xbox) and virtual game worlds and communities (e.g. World of Warcraft). This symposium, offered by the Joint Committee on Interprofessional Relations Between the American Speech-Language-Hearing Association (ASHA) and Division 40 (Clinical Neuropsychology) of the American Psychological Association, will provide a critical interdisciplinary discussion of the role of game play by and with clients during rehabilitation for traumatic brain injury (TBI). To frame the panel discussion, the symposium will begin with a presentation of James Paul Gee’s activity-based model of game play, which is grounded in situated learning theory. Broadly, the model describes two core dimensions for analysing game play: (1) the elements of game design (e.g. the ‘pieces’ of the game, game rules and the range of skills expected of players) and (2) the social networks and practices that support and surround game play (e.g. fan websites and magazines). The presentation will outline critical learning principles that Gee has

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hypothesized as key components of ‘good’ games and ‘good’ game play, applications of these learning principles to the TBI population and patient-specific attributes that may impact participation in game play. The panel will then present a critical review of literature on the use of computer games as cognitive retraining tasks, highlighting specifically: (1) evidence of improved performance on specific skills or tasks (e.g. attention; behavioural and emotional control; working memory; temporal processing), but little evidence of generalization to other domains; (2) suggestions that the role of motivational factors typical of game play may make brain training an effective intervention for clinical populations; and (3) suggestions that long-term use and application of brain training activities may produce lasting results. Finally, drawing on the literature review, the panel will discuss the pros and cons of game play for engaging patients in the therapeutic process and for leveraging clients’ everyday game play activities to address rehabilitation goals. Overall, the symposium argues that an improved understanding of the role of game design and game play within and outside of clinical settings will enable clinicians from multiple disciplines to collaborate and integrate traditional cognitive rehabilitation techniques with real-world, patient-centred activities.

0702

Injury profiles, demographic features and outcomes in 200 unselected consecutive adults with acute TBI attending a regional emergency care unit Janek Frantzeń1, Ari Katila1, Riikka Takala1, Henna Ala-Seppa¨la¨2, Anna Kyllo¨nen2, Henna-Riikka Maanpaä¨2, Jussi Posti1, Jussi Tallus2, & Olli Tenovuo1 1

Turku University Hospital, Turku, Finland, 2University of Turku, Turku, Finland Objectives: To describe the causes of injury, pathophysiological profiles, demographic features and outcomes in a largely unselected consecutive sample of adults with acute TBI attending a regional emergency care unit. Methods: The study population comprised of 200 consecutive primarily non-selected adult patients with acute TBI attending the Emergency Department of the Turku University Hospital, Turku, Finland between December 2011 and September 2013. The selection depended to some extent on logistics and consent. Basic information from all attendants with suspected TBI was also recorded. The data was collected using a patient record integrated software solution NeuroX (BCB Medical, Turku, Finland). NeuroX is an electronic recording tool including the Common Data Elements for TBI and in some respects even more detailed information. Results: The mean age of the patients was 49.3 years (SD ± 19.9), with male-to-female predominance (143/57). The injury mechanism was ground level fall in 34%, motor vehicle accident 17%, fall from height 13%, bicycle accident 13%, fall on stairs 9%, assault 9%, unclear circumstances 3% and other causes 2%. Outcome was assessed 6–12 months from the injury and all outcome measures will be collected by the end of April 2014. Preliminary data on the outcome from 140 patients was analysed, using the extended Glasgow Outcome Scale (GOSE), Qolibri quality-of-life measure and Rivermead Post-concussion Symptom Questionnaire (RPQ). When stratifying according to severity, a good correlation was found to GOSE, Qolibri and RPQ. In the very mild injuries the outcome at 6 months was GOSE 8, Qolibri 76 (SD ± 2.4) and RPQ 0. In mild injuries GOSE was 6.8 (SD ± 1.4), Qolibri

79.0 (SD ± 16.4) and RPQ 7.3 (SD ± 6.3). In the moderate and severe injuries the corresponding values were GOSE 5.9 (SD ± 1.6) and 5.7 (SD ± 0.8), Qolibri 54.7 (SD ± 16.1) and 50.1 (SD ± 14.1) and RPQ 25.3 (SD ± 3.7) and 35.7 (SD ± 3.8), respectively. For the very severe injuries GOSE was 4.2 (SD ± 1.4), Qolibri 33.2 (SD ± 14.1) and RPQ 52.3 (SD ± 8.1). The mortality was 13% with a male predominance (79%). Conclusions: This study describes in detail the causes of injury, demographic features and outcomes in a largely unselected consecutive sample of adults with acute TBI attending a regional emergency care unit. The initial severity correlates strongly with the outcome measures GOSE, Qolibri and PRQ in this study. Ground level falls were clearly the most common injury mechanism and the fairly advanced mean age was notable in this study population.

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The evolution of psychological distress in caregivers of patients with prolonged disorders of consciousness during in-hospital rehabilitation Pasquale Moretta1, Anna Estraneo1, Lucia De Lucia1, Vincenzo Loreto1, & Luigi Trojano2 1

Salvatore Maugeri Foundation, IRCCS, Telese Terme, Campania, Italy, 2Neuropsychology Laboratory, Department of Psychology, Second University of Naples, Caserta, Campania, Italy Objectives: The present 8-month longitudinal study was aimed to follow-up psychological distress in primary caregivers whose relatives are affected by prolonged disorders of consciousness during the inhospital rehabilitative phase in the Neurorehabilitation Unit of Salvatore Maugeri Foundation Institute. Methods: This study assessed 24 caregivers (15 female; mean age ¼ 47.4; range ¼ 33–62) of 22 patients (11 females; mean age ¼ 52.4 years, range ¼ 21–77) affected by prolonged disorders of consciousness (nine in minimally conscious state and 13 in vegetative state/unresponsive wakefulness syndrome) duo to severe brain injury (five traumatic; nine anoxic; eight haemorrhagic). All participants completed self-reported questionnaires for assessment of depressive symptoms, state and trait anxiety, psychophysiological disturbances, prolonged grief disorder, psychological coping strategies, quality of perceived needs, perceived social support and caregiver burden at admission and after 4 and 8 months. Results: At admission depressive symptoms were found in 20/24 caregivers, high level of anxiety in 16 and relevant psychophysiological disturbances in 10 participants; eight caregivers (32%) met criteria for prolonged grief disorder. The scores on questionnaires did not differ as a function of relatives’ diagnosis (vegetative state vs minimally conscious state). The longitudinal study (n ¼ 18) showed a progressive and statistically significant increase of ‘emotional burden’ during the hospital stay, whereas the remaining variables did not change significantly. Conclusions: Data confirmed the presence of severe psychological problems in caregivers of patients with chronic disorders of consciousness. The levels of psychological distress tend to be constant over time, while the emotional burden increases, suggesting a marked difficulty in psychological elaboration of the ‘bereavement’ related to caregiving of such patients. The present study underlines the need for psychological support for caregivers of patients with chronic disorders of consciousness.

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‘Good old days’ . . . or were they? Melinda Loveless, Kathleen Bell, Jeanne Hoffman, Nancy Temkin, Sureyya Dikmen, & Jason Barber


University of Washington, Seattle, WA, USA Objectives: To compare pre-injury symptom reporting in patients with mild traumatic brain injury at the time of injury and at 6 months postinjury. Additionally, to determine if there are demographic or injury factors correlated with a shift in recall of pre-injury symptoms. Methods: This study was a secondary analysis of a randomized controlled trial of telephone follow-up vs usual care to reduce MTBI symptoms and improve function. Data was collected by in-person interview in the emergency department at time of injury and then at 6 months post-injury by phone interview. Three hundred and sixty-six subjects were enrolled and 312 completed the 6-month follow-up. Information collected included demographics, circumstances of injury, pre-injury and current symptoms at both baseline and 6 months, litigation status and questions regarding mental health. A paired t-test was used for the overall difference between baseline and outcome pre-injury symptoms. Differences in the number of reported symptoms within demographic and baseline variables were assessed with Mann-Whitney tests for categorical variables and Spearman correlations for continuous variables. Results: At the time of injury patients reported an average of 2.2 ± 2.6 pre-injury symptoms compared to 1.4 ± 1.9 at 6 months (p ¼ 0.000). Age, gender, injury circumstances, education level, litigation status and history of concussion were unrelated to recall of pre-injury symptoms from baseline to 6 months (p40.05). History of significant emotional problems (including anxiety, depression, bipolar disorder, obsessive compulsive disorder, post-traumatic stress disorder, schizophrenia and seasonal affective disorder) was correlated with a reduction in pre-injury symptom reporting at 6 months (p ¼ 0.003). Additionally, high pre-injury stress level (p ¼ 0.000), high pre-injury worry level (p ¼ 0.000), high pre-injury fatigue level (p ¼ 0.031), low pre-injury happiness level (p ¼ 0.016) and outcome PHQ-9 score 10 (p ¼ 0.026) were correlated with a significant reduction in recall of pre-injury symptoms at 6 months. Conclusions: Overall, fewer pre-injury symptoms were recalled at 6 months post-injury compared to immediately after injury. This supports previous reports of the ‘good old days’ bias following concussion in which patients misremember themselves as healthier prior to their injury. Factors that were associated with a reduction in recall of pre-injury symptoms at 6 months included history of significant emotional problems, higher pre-injury stress rating, higher pre-injury worry rating, lower pre-injury happiness rating and, to a lesser degree, lower pre-injury energy level. Litigation status, injury circumstances and demographic factors were not associated with a change in pre-injury symptom recall.

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Psychiatric disorders and cognitive consequences in neurological patients Antje Buettner-Teleaga1 1

Albert-Ludwigs-University, Marburg, Germany, 2University WittenHerdecke, Witten-Herdecke, Germany Introduction: Apart from a multitude of physical complaints, neurological disorders can also lead to various kinds of psychiatric

Brain Inj, 2014; 28(5–6): 517–878

and cognitive disorders like mental and cognitive changes or reduced Quality-of-Life (QoL). In such cases, mental health, mood, attention, vigilance and/or memory may be affected as well as the actual mental and/or cognitive processes themselves. Important factors in this can be the severity of the disorder on one hand and the duration of prior therapy on the other hand. Methods: The study was carried out involving two groups of randomly selected persons, neurology patients and healthy participants. All patients were selected according to their clinical diagnosis (ICD10). So far, data have been gathered for more than 50 healthy persons (42 male; nine female) and around 150 neurological patients (101 male; 47 female) (with various neurological clinical pictures) using different tests to research the psychiatric/mental and cognitive status as well as the QoL. Findings: Testing of psychiatric, cognitive and QoL achievements revealed highly significant differences between healthy persons and neurological patients (all parameters: p50.001). Analysis of the degree of severity showed for neurology patients no significant differences between mild and severe status (p40.050). Discussion: The study revealed that patients with neurological diseases (strokes, cerebrovascular diseases, brain traumas, brain tumours, etc.) show problems, deficits and disorders concerning in different areas of psychiatric/mental and cognitive achievements as well as in multidimensional QoL. In contrast, the degree of severity of the disorders (neurology patients) was not relevant.

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Palmitoylethanolamide chronic treatment reduces the sensorian and cognitive disfunction associated with mild traumatic brain injury Livio Luongo, Vito de Novellis, Francesco Rossi, & Sabatino Maione Second University of Naples, Naples, Italy Background: Traumatic brain injury (TBI) represents a major public health problem, with41.7 million new cases annually in the US alone, accounting for 60% of all emergency department admissions and 50% of all trauma deaths. Traumatic brain injury (TBI) initiates a neuroinflammatory cascade that contributes to neuronal damage and behavioural impairment. Cannabinoids of all classes have the ability to protect neurons from a variety of insults that are believed to underlie delayed neuronal death after traumatic brain injury (TBI), including excitotoxicity, calcium influx, free radical formation and neuroinflammation. Objectives: This study investigated the anti-neuroinflammatory properties of a new class of endocannabinoid-like compound, the N-acylethanolamines. In particular, this study used the Palmitoylethanolamide (PEA), a commercially available compound with a pleiotropic mechanism of action. Methods and results: A model was applied of mild TBI that develops sensorial and cognitive disfunctions. In particular, mice developed abnormal pain sensation (allodynia) and depression associated to repetitive, obsessive-compulsive behaviours. According to the literature, it was found that TBI increased the number of pro-inflammatory/ hypertrophic microglial cells as well as the astrocytes. Moreover, the number of infiltrating CD4 positive T-lymphocytes was also importantly increased near the areas of trauma, suggesting a possible neuro-immune cross-talk in this brain pathology. It was observed that PEA chronic treatment (10 mg kg1 i.p.) significantly ameliorate the mechanical allodynia associated with TBI. Moreover, cognitive impairment associated with TBI depressive and obsessive compulsive behaviours were reduced by PEA treatment. In particular, this study

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measured the immobility time in sham, TBI and TBI treated animals in the tail suspension test and the results revealed that, while TBI animals showed an increased immobility time, PEA chronic treatment determined a reduction of depressive. behaviour. Similarly, the TBI animals showed altered obsessive-compulsive behaviour, measured through marble-burying test, which was attenuated by PEA repeated administration. In addition, it was found that PEA significantly reduced the number of infiltrating monocytes as well as restored the phenotype of resident microglia which were, in turn, highly hypertrophic and proliferative. Finally, it was found that PEA, through a genomic mechanism PPAR--mediated, increased the expression level of CB2 cannabinoid receptor and, hence, switch the phenotype of microglia and infiltrating T-cells from pro to an anti-inflammatory/ neuroprotective one. Conclusions: These results show a possible use of natural compounds such as PEA together with the already used drugs for the treatment of severe brain injury. Moreover, the discovery of new mechanisms in endogenous lipid compound could represent a new pharmacological tool to develop new molecules for the treatment of chronic neurological disorders.

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Blood metabolic patterns correlate with the severity of traumatic brain injury

significant differences between the severe TBI patients and controls, with similar metabolites as in samples obtained at presentation. A statistical model comprising two serum metabolites was developed which predicted patient outcomes based on metabolomic data at the time of presentation (GOSe 4 vs GOSe44), with AUC ¼ 0.88, 95% CI ¼ 0.78, 0.96. Conclusions: Serum metabolic profiles between cases and controls, as well as between severe, moderate and mild TBIs, showed substantial differences. These results show that metabolic patterns could provide an objective means of estimating TBI severity, based on the host metabolic response to injury. In addition, these metabolic biomarkers also scaled with outcome. The metabolic patterns observed were unique to TBI and showed no strong correlations with extracranial injuries.

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The neuropathology of blast traumatic brain injury in a porcine polytrauma model Hong-Ting Kwok1, David Baxter2, John DeFelice1, Pete Hellyer3, Emrys Kirkman4, Sarah Watts4, Mark Midwinter2, Steve Gentleman1, & David Sharp3 1

1

2

2

Jussi Posti , Tuulia Hyo¨tylaïnen , Sirkku Ja¨ntti , Henna Ala-Seppa¨la¨3, Jonathan Coles4, Ari Katila1, Anna Kyllo¨nen3, Henna-Riikka Maanpaä¨3, David Menon4, Joanne Outtrim4, Peter Hutchinson4, Keri Carpenter4, Jussi Tallus3, Marko Sysi-Aho2, Riikka Takala1, Matej Oresic2, Harri Siitari2, & Olli Tenovuo1 1

Turku University Hospital, Turku, Finland, 2VTT Technical Research Centre of Finland, Espoo, Finland, 3University of Turku, Turku, Finland, 4University of Cambridge, Cambridge, UK Objectives: To identify blood metabolic biomarkers associated with TBI. Methods: The study population comprised of 256 non-selected adults with acute TBI and 36 patients with acute orthopaedic trauma without any brain disorders (¼controls). The blood samples were taken at presentation and at 1, 2, 3 and 7 days after the injury. Plasma samples were analysed with two-dimensional gas chromatography coupled to time-of-flight mass spectrometry. A total of 851 metabolites were measured. Univariate and multivariate approaches were applied to investigate correlations between metabolic patterns and TBI severity, clinical descriptors of TBI and extracranial injury. In order to investigate the origin of the metabolites, metabolic patterns in brain microdialysates (BMD) were analysed from selected TBI patients and the metabolites were searched from human CSF samples. In addition, the metabolic profiles were utilized for the prediction of outcomes (GOSe scale). Results: At presentation, 43 metabolites showed significant differences between the patients with TBI and controls. These included small fatty acids, a few amino acids and several sugars and sugar derivatives. The differences were most prominent for patients with severe TBI and much smaller in patients with mild or moderate TBI. Several metabolites that were detected in high concentrations in CSF and BMD were significantly upregulated in the arrival samples of the severe TBI patients, suggesting disruption of the blood–brain-barrier. These included short-chain fatty acids, several sugar derivatives, phenolic compounds and hydroxy acids. Similar patterns, although less significant, were observed in the moderate and mild TBI cases. The samples taken the day after the injury showed persistent

Neuropathology unit, Department of Medicine, Imperial College London, London, UK, 2Royal Centre for Defence Medicine, Academic Department of Military Surgery and Trauma, Birmingham, UK, 3 Computational, Cognitive and Clinical Neuroimaging Laboratory, Imperial College London, London, UK, 4Defence Science and Technology Laboratory, Porton Down, UK Objectives: Recent conflicts in Iraq and Afghanistan have seen an increase in use of improvised explosive devices. While better body armour has improved survival rates of soldiers affected by military blasts, cognitive impairments from blast traumatic brain injury (bTBI) are often seen, the underlying neuropathology of which is currently unknown. The overarching objective of this study was to assess the pathological changes suffered in the acute phase (56 hours) following blast and to investigate neuroimaging correlates for these changes. Since blast injury is usually a complex interaction of haemorrhage, peripheral tissue injury and bTBI, a polytrauma porcine model of injury was used. Methods: The study was conducted in accordance with the Animals (Scientific Procedures) Act 1986. Terminally anaesthetised female large white pigs were exposed to either controlled blast (n ¼ 6) or sham (n ¼ 4) treatment followed by musculo-skeletal injury, controlled haemorrhage and fluid resuscitation. Pigs were protected from secondary effects of blast injury while the effects of tertiary injury were minimized. The animals were euthanized within 6 hours of blast or sham exposure. Following extraction and fixation of the brains, a programmed sequence of MR scans, including high resolution T1, susceptibility weighted imaging (SWI) and diffusion tensor imaging (DTI) were performed on a 4.7T MR scanner. Histopathology was performed to investigate structural, vascular, axonal and glial responses, visualized by standard H&E staining, and fibrinogen, amyloid precursor protein (APP) and Iba1 immunoreactivities, respectively. Results: (1) Histopathology: Oedematous stripping of the ventricle ependyma was observed only for blasted animals (four of six), with concurrent microglial activation in the subependyma. There are also implications that the dorsal hippocampus may be particularly susceptible to blast injury, denoted by structural oedematous changes. The internal capsule and thalamus were susceptible to axonal injury, particularly following blast exposure, as observed with APP immunostaining. Damage was also found to the vasculature following both blast and sham exposure, likely due to controlled haemorrhage with fluid resuscitation. (2) Imaging: Although T1 and

780 SWI neuroimaging did not show clear evidence of structural differences in any of the animals, DTI analysis revealed a significant global difference in the fractional anisotropy (FA) between the blast and sham pigs, indicating diffuse axonal injury. This was consistent with the histopathological findings and further confirmed with region of interest (ROI) analysis of the internal capsule. Conclusions: The results show that DTI neuroimaging is more sensitive to white matter damage than standard structural imaging and SWI in the acute phase following blast and polytrauma. The ependyma, the internal capsule and hippocampus appear most vulnerable to damage in this model. Further research should be performed to substantiate the current findings.

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Addressing recognition, diagnosis and management of concussion/mild traumatic brain injury in Ontario, Canada

Brain Inj, 2014; 28(5–6): 517–878

access and services. A review of prognostic factors for good and poor recovery has identified several areas for further research and will guide practice and policy. Return-to-work and school are being addressed through development of practice guides. The 3rd Summit assessed the state of knowledge and resulted in priorities for implementation. Conclusions: Concussions are a serious public health issue and current access to care in Ontario is variable. Current concussion care does not reflect the ideal concussion care and there are areas for improvement in the recognition, diagnosis and management of concussion/mTBI. The strategy aims to ensure that children, youth and adults that are diagnosed with a concussion are able to access appropriate treatment and fully reintegrate back into the community.

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Evaluation of balance disorders in children with posterior cranial fossa tumour

Mark Bayley1, Corinne Kagan2, Shawn Marshall3, Roger Zemek4, Bev Solomon5, Charles Tator6, Ruth Wilcock7, Donna Ouchterlony8, & Charissa Levy1

Enrico Castelli1, Daniela Chieffo1, Susanna Staccioli1, Angela Mastronuzzi2, Carlo Marras3, Franco Locatelli2, Paolo Cappa4, & Maurizio Petrarca1

1

1

Objectives: Concussions/mild traumatic brain injury (mTBI) can occur in many settings and across the age spectrum and many sectors are involved. The objective of the concussion/mTBI strategy is to improve recognition, diagnosis and management of this injury. The specific aims are: increased education and awareness; standardized practice for diagnosis and management of mTBI; improved outcomes for people who have persistent symptoms of mTBI; and to enact change and improve efficiencies within Ontario based upon current research. Methods: The Ontario Neurotrauma Foundation leads the Strategy, working with over 70 stakeholder organizations and provincial experts. Five working groups were created to address priority themes in a co-ordinated manner: (1) Recognition and Awareness, (2) Diagnosis and Early Education, (3) Evaluation of Access to Care, (4) Management of Persistent Symptoms and (5) Psychosocial and Reintegration. Three annual Summits (2011–2013) have been held to update on progress, share results and prioritize next steps. Results: A framework was created to integrate the elements of concussion/mTBI care from point of injury to successful return-toactivity and to identify gaps and flow challenges. Collaboration is occurring with Ontario Ministries of Health, Education and Sports to improve concussion management in schools. A tool was created to assist coaches, teachers, parents, students and athletic therapists/trainers regarding concussion in school and return-to-learn and play. Adult guidelines were updated and released in 2013 and paediatric guidelines for management of persistent symptoms are being developed for 2014. Surveys on clinician knowledge and practice regarding concussion diagnosis and management provide guidance for implementing best practice and standards of care. Research on incidence has identified over 200 000 individuals with concussions per year in Ontario. This information, along with referrals and availability of concussion clinics is guiding work on

Objective: Primary tumours of the CNS are the most common solid tumours in children, with 80% of 5-year survival in low-grade histological types. However, survival is associated with complex deficits and rehabilitation is essential to achieve the maximum functional recovery. More than half of brain tumours arise in the posterior fossa involving the cerebellum and consequently producing impaired balance and ataxia. The objective of this study is the clinical objective characterization of balance disorders in the standing position in children with posterior fossa tumour, in order to define rehabilitation protocols aimed at improving ADL autonomy and quality-of-life. Methods: Balance assessment was performed using the platform RotoBiT3D, a robot with 3 DOF whose mobile base is able to rotate around a fixed point. This study recorded the trajectories of the Centre of Pressure (CoP) during standing position, with the eyes open and closed, both in static and dynamic conditions. Each condition was repeated 3-times. The movements of the CoP were recorded using the force sensors of the platform RotoBiT3D and a matrix of Matscan pressure in direct contact with the feet. Statistical analysis was performed by comparing the evidence with uni-variate ANOVA and the Bonferroni post-hoc test. Results: Thirty-three patients with posterior fossa tumour (18 males and 15 females, mean age ¼ 10.2 SD ¼ 5.1 years) were selected. In this group, histological diagnosis was: 27% medulloblastoma, 43 % astrocytoma, ependymoma 15%, 15% others. The results of the study on balance in these subjects were compared with those obtained with a group of nine control subjects (four males and five females, mean age ¼ 12.1 SD ¼ 3.9 years). Analysing the average distance of the CoP, obtained in static and dynamic tests in the two populations, a statistically significant increase was observed in the results obtained in the children with tumour. In particular, the average distance crossed by the CoP oscillation increases in a statistically significant manner during the dynamic tests. Another interesting result is the trend to a higher oscillation in medio-lateral direction compared to the anterior-posterior direction. The values in

Toronto Rehabilitation Institute, Toronto, Ontario, Canada, 2Ontario Neurotrauma Foundation, Toronto, Ontario, Canada, 3The Ottawa Hospital, Ottawa, Ontario, Canada, 4Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada, 5Holland Bloorview Kids Rehab, Toronto, Ontario, Canada, 6Toronto Western Hospital, Toronto, Ontario, Canada, 7Ontario Brain Injury Association, St. Catharines, Ontario, Canada, 8St. Michael’s Hospital, Toronto, Ontario, Canada

Pediatric Neurorehabilitation Department, 2Department of Hematology-Oncology, 3Department of Neurosurgery, Bambino Gesu` Children’s Hospital, Rome, Italy, 4Department of Mechanics, Sapienza University, Rome, Italy

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DOI: 10.3109/02699052.2014.892379

anterior-posterior direction of this test can be considered as indexes of maturity in the balance control while standing, in particular the more minor are the values the more mature is the control. Conclusions: The characteristics of balance control, recorded in patients with posterior cranial fossa tumour by the robotized platform RotoBiT3D, are an objective reference point for the follow-up of patients and form the basis for a specific training.

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High doses of a new botulinum toxin type A (NT-201) for the treatment of severe spasticity in adult subjects following brain injury Brain Inj Downloaded from informahealthcare.com by RMIT University on 09/02/14 For personal use only.

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2

Domenico Intiso , Valentina Simone , Filomena Di Rienzo1, Andrea Iarossi1, Mario Russo1, Giuseppe Maruzzi1, Luigi Pazienza1, Maurizio Tolfa1, & Mario Basciani1 1

Scientific Institute ‘Casa Sollievo della Sofferenza’, San Giovanni Rotondo (FG), Italy, 2Foundation Rehabilitation ‘Gli Angeli di P.Pio’, San Giovanni Rotondo (FG), Italy Background: Spasticity can be a severe disabling disorder requiring BoNT-A high dose injections treatment due to several reasons including spastic muscular patterns, severity of spasticity, posture and hygiene improvement. Moreover, multi-level muscles can be involved at the same time needing of BoNT-A treatment in subjects with severe focal spasticity. Efficacy and safety of high BoNT-A doses in treating adult subjects with multi-level spasticity due to brain injury were investigated. Pain and functional outcome were also assessed. Method: Multi-level high doses up 800 IU of incobotulinum toxin (Xeomin) were injected in multi-level spastic muscles of upper and lower limbs of adult brain injury (BI). Modified Ashworth Scale, Visual Analogue scale (VAS), Glasgow Outcome Scale (GOS), Frenchay arm test (FAT) and Barthel Scale (BS) were employed to assess spasticity, pain and functional outcome at baseline, 4 and 16 weeks after BoNTA injection. Repeated measures ANOVA models and Friedman were carried out for statistical analysis. Results: Sixteen (10 male, six female; mean age 41.8 ± 13.3) subjects were enrolled. Neurological pictures were hemiparesis (87.5%) and paraparesis. All subjects with hemiparesis received neurotoxin injections in both the upper and lower limbs in the same session. The BoNT-A doses ranged from 770–840 IU. Elbow, wrist, fingers and ankle muscles showed significant spasticity reduction after BoNT-A injections. VAS score significantly improved: 7.4 ± 1.5, 3.9 ± 0.9 and 4 ± 0.9 at baseline, 4 and 16 weeks, respectively (Friedman test, p50.05), but no functional benefit was observed after treatment. Mean GOS and BS scores were: 2.8 ± 0.3, 2.9 ± 0.4 and 2.8 ± 0.5; 40.5 ± 7, 41 ± 8.8 and 42.7 ± 7.1, respectively at baseline, 4 and 16 weeks. The mean FAT score improved (0.3 ± 0.4, 0.5 ± 0.7, 0.5 ± 0.5 at baseline, 4 and 16 weeks, respectively), but not significantly. Two (12.5%) patients complained of mild adverse events consisting of injection site haematoma and of weakness and reduction of active motility of the injected arm lasting 2 weeks. Conclusion: The injections of BoNT-A (Xeomin) up to 840 IU resulted as effective and safe in reducing the spasticity of subjects with brain injury. The treatment produced significant benefit in pain reduction. Despite the improvement of the upper limb ability, the result was not significant. No benefit was observed in global functionality.

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Meta-analysis of the effects of acetylcholinesterase inhibitors on verbal memory deficits among persons with traumatic brain injury David Arciniegas1, Todd Nick2, Angelle Sander1, & Mark Sherer1 1

TIRR Memorial Hermann, Houston, TX, USA, 2University of Arkansas for Medical Sciences, Little Rock, AR, USA Objective: Verbal memory deficits are among the most common chronic and functionally important consequences of traumatic brain injury (TBI). Basic and clinical research studies suggest that persistent deficits in verbal memory are associated with chronically reduced levels of acetylcholine in the brain. Multiple studies demonstrated improvements in memory and other cognitive functions during treatment with acetylcholinesterase inhibitors (AChEI), a class of medicines that increases cerebral levels of acetylcholine. None of these studies individually provides the level of evidence required to establish AChEI as a practice standard for the treatment of posttraumatic verbal memory impairments. However, they are suggestive of a possible benefit of this class of medicines on this clinical problem. This study performed a systematic review and fixed effects model meta-analysis in order to derive a preliminary estimate of the size of the effect of AChEI on post-traumatic verbal memory impairments. Methods: The systematic review entailed a PubMed search anchored to the MeSH Major Topic ‘brain injuries’ (encompassing all related MeSH terms) combined with ‘cholinesterase inhibitors’, ‘physostigmine’, ‘donepezil’, ‘rivastigmine’ or ‘galantamine’. The initial abstract review identified and excluded review articles, pre-clinical (i.e. nonhuman) studies and studies focused on or including conditions other than TBI. All remaining articles were reviewed and accepted for inclusion if they met the following criteria: (1) unequivocal TBI diagnoses; (2) TBI-related verbal memory impairments were present at study entry; (3) an AChEI was used to treat verbal memory impairments; (4) valid and reliable verbal memory measures were employed prior to and at the end of AChEI treatment; (5) placebotreated comparison subjects and/or active-treatment comparators were included; and (6) results reported enabled effect size estimations. Effect sizes were calculated for each study, weighted according to the proportion of total observations each contributed and summed to create an average effect size. The 95% confidence interval (CI) around was calculated using the ‘MBESS’ Open Source R software package. Results: Five articles (four positive studies, one negative study), representing 229 drug–comparator observations, met criteria for inclusion in this meta-analysis. As statistical methods varied between studies (i.e. tests for differences between means vs tests for proportions), Cohen’s d was the only consistently calculable measure of effect size. Weighted mean Cohen’s d ¼ 0.83 (95% CI ¼ 0.56–1.10). Conclusion: This meta-analysis reveals a relatively large effect of AChEI on verbal memory impairments among persons with TBI in the subacute or chronic recovery periods. This finding suggests that this class of medication has potential to benefit persons with post-traumatic verbal memory problems and it will guide sample size determinations in randomized, controlled clinical trials of this treatment approach.

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Diffusion tensor imaging for outcome prediction in complicated and uncomplicated mild traumatic brain injury: A TRACK-TBI study Esther Yuh1, Shelly Cooper1, Pratik Mukherjee1, John Yue1, Hester Lingsma2, Wayne Gordon3, Alex Valadka4, David Okonkwo5, David Schnyer6, Mary Vassar1, Andrew Maas7, Scott Casey1, Maxwell Cheong1, Kristen Dams-O’Connor3, Allison Hricik5, Tomoo Inoue1, David Menon8, Jennifer Pacheco6, Ava Puccio5, & Geoffrey Manley1

Brain Inj, 2014; 28(5–6): 517–878

Conclusions: This is the first study to compare DTI features in individual MTBI patients to conventional MRI, CT, clinical, demographic and socioeconomic features for the prediction of 3- and 6-month outcome in individual patients. It is shown that conventional MRI and DTI are useful, complementary imaging biomarkers for prediction of 3- and 6-month outcome in MTBI.

0715

Effects of external ventricular drain usage in the management of severe head injury at a major trauma centre Deepti Bhargava, Andrew Alalade, Habib Ellamushi, John Yeh, & Roger Hunter Royal London Hospital, London, UK


1

University of California at San Francisco, San Francisco, CA, USA, 2 Erasmus Medical Center, Rotterdam, The Netherlands, 3Mount Sinai School of Medicine, New York, NY, USA, 4Seton Brain and Spine Institute, Austin, TX, USA, 5University of Pittsburgh Medical Center, Pittsburgh, PA, USA, 6University of Texas at Austin, Austin, TX, USA, 7 Antwerp University Hospital, Edegem, Belgium, 8University of Cambridge, Cambridge, UK Objectives: There is growing recognition that current classification schemes for mild traumatic brain injury (MTBI) based solely on Glasgow Coma Scale and duration of post-traumatic amnesia and loss of consciousness are very limited, with small mean effect sizes in long-term impairment obscuring differences among diverse subgroups of MTBI patients with very different prognoses. Diffusion tensor imaging (DTI) is a promising technique for identification of microstructural white matter damage after traumatic brain injury. Although group differences in DTI parameters between MTBI patients and controls have been demonstrated, there has been little exploration of the practical use of acute/sub-acute DTI data for outcome prediction in the individual patient after controlling for demographic, clinical and CT and conventional MRI predictors. Methods: This study evaluated DTI at 3 Tesla for evidence of white matter injury in 37 adult MTBI patients at the semi-acute stage (10.9 ± 3.6 days) after injury, employing both whole-brain voxelwise analysis and a complementary region-of-interest (ROI) approach. Because whole-brain voxelwise approaches may have limited sensitivity due to the heterogeneity of spatial distribution of white matter injury in MTBI, while the ROI approach may be limited by failure to interrogate less common areas of white matter injury, both methods were employed as complementary approaches in the current study. Results: Complicated MTBI, defined as presence of any acute traumatic intracranial lesion and/or depressed skull fracture on day-of-admission CT or semi-acute 3-Tesla MRI, was associated with significantly reduced fractional anisotropy (FA) in the internal and external capsules, uncinate fasciculi, genu of corpus callosum and corona radiata compared to 50 control subjects. In contrast, no significant group differences were found in FA between uncomplicated MTBI and control subjects, using either whole-brain voxelwise or ROI methods. To determine the clinical relevance of DTI findings to outcome, this study assessed for correlations between 3- and 6-month outcome measures and DTI, CT and MRI findings and demographic, socioeconomic and clinical predictors. MRI features, including DTI parameters, surpassed other variables for prediction of 3- and 6-month outcome. The best predictors of 3-month Extended Glasgow Outcome Scale (GOS-E) were DTI evidence of one or more ROIs with severely reduced FA (univariate odds ratio 8.0 per unit decrease in 3-month GOS-E, p ¼ 0.008) and MRI evidence for contusion (univariate odds ratio 12.6, p ¼ 0.02). The only statistically significant predictor of 6month GOS-E was combined conventional MRI and DTI evidence of any traumatic intracranial lesion (odds ratio 4.8, p ¼ 0.03).

Introduction: Severe head injury continues to be a major cause of death and disability in young patients. ICP (Intracranial Pressure) control remains the core principle of management of these patients. Initial measures to lower ICP include positioning, hypothermia, CO2 control, sedation and hyperosmolar therapy. Measures like barbiturate coma and decompressive craniectomy are used for refractory rise in ICP. The drainage of CSF (cerebrospinal fluid) through external ventricular drain or lumbar drainage has been variably employed to lower ICP; however, the scope of this intervention has not been fully understood. With a view to explore the role of EVD in severe head injury, this study retrospectively audited management and outcome of these patients admitted to a level 1 trauma centre in the UK for a period of 1 year. Methods: Cases were identified from the ICU booking register. Case notes, radiology and laboratory records were reviewed to collect data. Statistical tests were carried out using SPSS 15. Results: A total of 139 patients were coded as having severe head injury. Twenty-six died within the initial 48 hours with no ICP driven surgical interventions. Sixty-eight needed only ICP monitoring (with/ without evacuation of haematoma). In 12 patients primary decompression was done at the time of haematoma evacuation as the brain was too swollen at the closure. Of the remaining 33 patients who had secondary elevation of ICP, 15 patients had EVD and 17 were randomized in the RescueICP trial. Of these, nine had decompressive craniectomy and eight were treated with barbiturate coma. Subsequently, two patients with primary decompression had further ICP elevation and needed EVD. Two patients with EVD had raised ICP—one underwent decompression, the other was treated with barbiturate coma. One patient with EVD developed infection which was successfully treated. Conclusions: EVD was a safe and less invasive procedure and achieved sustained control of ICP in this patient group. Patients treated with EVD had a lower risk of needing definitive treatment for ICP control, i.e. decompressive craniotomy or barbiturate coma (Odds Ratio ¼ 13.33:1). This also had a positive cost impact for the institution.

0716

Interthalamic distances are related to structural damage in patients with disorders of consciousness Darwin Martıńez1, Quentin Noirhomme2, Audrey Vanhaudenhuyse3, Marie-Aure´lie Bruno2,

783

DOI: 10.3109/02699052.2014.892379

Olivia Gosseries2, Luaba Tshibanda2, Andrea Soddu4, Hugo Franco1, Natasha Lepore5, Tiberio Hernańdez6, Steven Laureys2, & Francisco Go´mez1

Kendra Jorgensen-Wagers, & Susannah Magruder Landstuhl Regional Medical Center, Military Treatment Facility, Germany

1


Complexus Group, Computer Science Department, Universidad Central de Colombia, Bogota´, Colombia, 2Coma Science Group, Cyclotron Research Centre, University of Lie`ge, Lie`ge, Belgium, 3 Department of Algology–Palliative Care, University Hospital of Lie`ge, Lie`ge, Belgium, 4The Brain and Mind Institute, Department of Physics & Astronomy, Western University, London Ontario, Canada, 5 Department of Radiology & Department of Biomedical Engineering, Children’s Hospital, Los Angeles, University of Southern California, Los Angeles, CA, USA, 6Imagine Group, Computer Science Department, Universidad de los Andes, Bogota´, Colombia

Objectives: Disorders of consciousness (DOC) remain among the most poorly understood brain injury conditions of modern neurology. It has been proposed from post-mortem studies that brain structural preservation may be associated to the level of consciousness under these conditions. Recently, in-vivo evidence from diffusion tensor imaging suggests that severe structural damage in the thalamus can be related to impaired consciousness states. These characterizations do not consider possible changes in the spatial relationships among brain anatomical structures. Nevertheless, these variations are a natural consequence of physiological deterioration induced by the underlying aetiology. It is hypothesized that measurements of the spatial relationships, in particular between thalami (left and right), can be used as a marker of the structural damage related to DOC conditions. Methods: T1 structural magnetic resonance images (3T Siemens, matrix size ¼ 256 240 120 and voxels size ¼ 1 1 1.2 mm3) for 50 DOC chronic patients (20 Vegetative State/Unresponsive Wakefulness–VS and 30 Minimally Conscious State–MCS, average age 45 years (SD ¼ 18),42 months after injury) and 17 healthy control subjects (average age 47 years (SD ¼ 16)) were acquired. From this initial group, 23 DOC patients and three control subjects were excluded by visual inspection. Exclusion criteria included poor data quality, movement artifacts, large bleeding regions or extensive brain damage (450%). Patient thalami were segmented using FSL-FIRST and corrected using the FAST method. The Euclidean distance between every voxel in the left thalamus and every voxel in the right thalamus was computed. The minimum, maximum and average of these distances were used to represent the spatial relationship between the thalami. Possible differences between controls and DOC patients in these spatial relationships were assessed. Results: The minimum, average and maximum distances between thalami for controls were 1 mm (SD ¼ 0), 22.6 mm (SD ¼ 2.5) and 46.2 mm (SD ¼ 2.9), respectively. The same measurements for DOC subjects yield 7.1 mm (SD ¼ 2.8), 29.3 mm (SD ¼ 2.8) and 49.8 mm (SD ¼ 5.0). Significant differences in the spatial relationships minimum and average distance were observed when comparing controls and DOC patients (p50.05, Bonferroni corrected). Conclusions: The results indicate that interthalamic distances can be used as a suitable marker to characterize structural damage related with DOC conditions. Overall, DOC patients presented higher distance values between thalami compared to controls. This may be related to the structural deterioration usually observed in post-mortem studies.

0717

Retrospective descriptive demographics on military concussed servicemembers from Landstuhl regional medical center 2008–2010

Objective: To describe the constellation of symptoms of soldiers who are screened for concussion through Landstuhl Regional Medical Center’s military concussion screening protocol. This is a retrospective review of medically evacuated patients to Landstuhl Regional Medical Center from June 2008 to July 2010 using baseline characteristics, self-report of symptoms and process for assignment of TBI diagnosis. Methods: To explain the screening process and documentation for assessment of symptoms and triage of care for soldiers identified as symptomatic/asymptomatic from concussion. Presents the historical context of concussion screening and triage as well as problems with diagnostic labelling and identification of concussion where a concussion screen was interpreted to be a diagnosis. Results: Illustrates the historical evolution of screening mechanisms and the concussion evaluation process within the military and highlights the development of clinical practice guidelines for screening as well as the best practice improvements in a military treatment facility for the care and rehabilitation of servicemembers diagnosed with concussion. Conclusion: Early triage, identification and systematic assessment procedures to identify the presence of symptoms as the result of a concussion event has significantly improved over the past 4 years. Descriptive statistics highlight the positive trajectory of recovery from concussion for service members because of the early screening and support to triage care within the military treatment network. Landstuhl is the facility where all medically evacuated soldiers from the theatre are sent to for care co-ordination prior to return to CONUS. Therefore, the screening at Landstuhl significantly informs care and recovery and has a profound impact on the health and medical readiness for these service members because it initiates support within the recovery care network as needed.

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Multimodal magnetic resonance imaging quantification using an automated system (QuantaVita) in acquired brain injury patients Umberto Sabatini, Chiara Falletta Caravasso, & Rita Formisano IRCCS Fondazione S.Lucia, Rome, Italy The main objective of neuroimaging in the acquired brain injury (ABI) patients, is to perform a correct diagnosis and to support the clinicians in designing specific surgical, medical and rehabilitation therapies. Recently, the introduction of high field (3T) magnetic resonance imaging (MRI) scanners in routine clinical practice, characterized by an increased spatial contrast and spectral and temporal resolution, has largely improved the capacities of this technique, able to acquire in the same study session both conventional and advanced sequences, in a multimodal approach. Multimodal MRI (mMRI) has been developed to measure morphological, structural, metabolic, haemodynamic and functional changes of the brain induced by ABI. Using mMRI, a qualitative and quantitative approach can be used in the imaging evaluation, both in a single case and in a population of ABI patients. This study has applied an automated system (QuantaVita) of brain images analyses able to produce several morphometric measures, compared with a normative range (range normal values in a health population (1200 unit) corrected for age and sex), helping the physicians in the diagnostic process in ABI patients. Using QuantaVita, macroscopic (grey and


784 white matter volumetry) and microscopic (mean diffusivity, MD, fractional anisotropy, FA, T2* estimation) tissue parameters in brain areas in ABI patients were quantified in sub-acute and chronic phases of the disease. This method allows for image quantification of relevant tissue characteristics in apparently normal tissues, in macroscopic lesions and in diffuse axonal injury and can help clinicians in the global and regional damage evaluation, in comparing longitudinally brain changes, in a single ABI patient, during the recovery phase of the disease. QuantaVita workflow is composed by: (1) Automatic analysis; (2) Co-registration of different image modalities; (3) Delineation of tissues (grey and white matter, cerebral spinal fluid, lesions); (4) Region segmentation; and (5) Measurement of volumetric values and mean values of different parameters (MD, FA, T2*). This study reported data obtained by QuantaVita in single ABI patients. Global brain volume, grey matter volume, white matter volume, right and left hippocampus volume, corpus callosum volume and MD, FA and T2* values, in all these anatomical structures, have been calculated. Data obtained by the QuantaVita system has shown a significant decrease in global brain grey and white matter volume, in all the patients; a regional increase of MD, a decrease in FA and an increase in T2* have also been reported. QuantaVita is a sensitive automated system to quantify MRI tissue changes in ABI patients.

0719

Biological ageing processes and outcome after head injury Maria Gardani1, Thomas McMillan1, Paul G. Shiels2, Liane McGlynn2, Alan MacIntyre2, Michal Masˇ´ın2, & Vladimira Moulisova2 1

Institute of Mental Health and Wellbeing, 2Institute of Cancer Sciences, University of Glasgow, Glasgow, UK Objectives: Findings show that, for at least 13 years after injury, death rate after hospitalization for head injury (HI) patients was twice as high (40%) as in controls. These findings are not explained by demographic factors or injury severity and risk of death after HI was higher in younger adults. One possible explanation for this centres on inter-individual variation in biological, as opposed to chronological age. The present study aimed to explore the relationship between markers of biological ageing after head injury in young adults compared to controls as a contributory factor. Methods: A prospective cross-sectional design study, including adults (18–64 years old) who were admitted to hospital with severe HI (n ¼ 20) and controls (n ¼ 18) matched closely for chronological age, gender and socioeconomic characteristics. The Glasgow Outcome Scale-Extended (GOSE) was the main disability outcome measure. RNA was extracted from patient and control blood samples. QRT-PCR was performed to measure the expression levels of markers linked with ageing processes (CDKN2A) or telomere biology (TERC). Results: Groups were closely matched for chronological age (HI ¼ 33.7 and Controls ¼ 33.5). Based on their GOSE the HI group was found to present with 40% severe disability, 25% moderate disability and 35% good recovery. The head injured group scored more highly on selfreport measures of stress (p50.001) and depression (p50.05). Correlational analysis was carried out between disability outcome and biomarkers associated with ageing processes (e.g. CDKN2A) or that correlate with telomere biology (TERC). TERC gene expression (r ¼ 0.712, p50.05) and CDKN2A expression significantly correlated (r ¼ 0.901, p50.01) with disability outcome at 6-month follow-up in the HI group and not in the control group (p40.05) and not at the time of injury (p40.05). Conclusions: Pre-dispositional differences in cellular background at the time of injury do not account for the higher rates of mortality found in head injury sufferers. The findings indicate associations

Brain Inj, 2014; 28(5–6): 517–878

between changes at cellular level, such as in TERC and CDKN2A expression with disability and stress in head injury patients compared to controls.

0720

Abusive head trauma in young children: Descriptive factors and outcomes Juliet Haarbauer-Krupa, & Sharyn Parks National Center for Injury Prevention and Control, CDC, Atlanta, GA, USA Objectives: Abusive head trauma (AHT) is a form of child maltreatment and the leading cause of serious traumatic brain injury (TBI) and death in children aged 2 years and younger. Compared to survivors of other mechanisms of TBI, sivivors of AHT have a greater risk of persistent and severe physical, cognitive or behavioural disabilities. The Centers for Disease Control and Prevention (CDC) developed recommended definitions for paediatric AHT public health surveillance and research. Studies on long-term outcomes for AHT compared to other types of TBI mechanisms highlight the importance of public health surveilance and research to inform clinical follow-up for young children in the US. The purpose of this presentation is to present guidelines for identification of AHT cases and describe independently conducted research on outcomes for children with AHT injuries. Methods/approach: The presentation will describe the CDC recommended definition for paediatric AHT for public health surveillance and research. Immediate and long-term cognitive and behavioural outcomes related to school readiness and elementary school performance reported in the literature for survivors of TBI sustained at age 5 or younger will be described. Results: Findings from outcome research for children with TBI before age 5 indicates they have greater risk for post-injury effects in cognition and behaviour that may not be observed until they are enrolled in school. These effects can impact new learning and skill acquisition. Further, there is not a single point of community service entry to track developmental progress. Conclusion: Improving identification of markers and risk factors for AHT is important to ensure accurate classification at the time of the injury as well as adequate follow-up. Enhanced surveillance and research through the use of a standardized definition is critical in advancing knowledge of AHT risk factors and characteristics at the population level. The CDC recommended definition of AHT is a resource for the international community to improve AHT surveillance data for public health research and practice which can ultimately result in better identification, treatment and outcomes.

0722

Repeated botulinum toxin type A injections in the severe upper limb hemiparesis Masahiro Abo, Wataru Kakuda, Naoki Yamada, & Ryo Momozaki The Jikei University School of Medicine, Minato-ku, Tokyo, Japan Objectives: Spasticity after a stroke can lead to abnormal limb posturing that interferes with active and passive function. Although many patients with stroke regain the ability to walk with gait aids and

785


DOI: 10.3109/02699052.2014.892379

orthoses, stroke is a major cause of disability involving the arm in as many as 69% of the survivors. Although the botulinum toxin type A (BoNT-A) injection has proved effective in spasticity management, little information is available with regard to the effects of repeated injections over time. Methods: Of the 64 patients who received four repeated BoNT-A injections, 52 patients with spastic upper limb hemiparesis were studied. Fifty-two patients were divided into two groups. Group A; 27 patients of finger and upper limb Brunnstrom stage (Brs) 3 at baseline (before first BoNT-A and therapy). Group B; 25 patients of finger Brs 3 and upper limb Brs 4 at baseline. They received injections of BoNT-A in upper limb muscles and detailed one-to-one instructions for homebased functional training. At baseline and 4 months after injections, Fugl-Meyer assessments (FMA) were used to assess active motor function. Results: In both groups, the total score for upper limb and scores of categories A and B of the FMA had improved with a significant difference compared with baseline values. The FMA score for category C in Group A increased to significantly different compared with baseline values. However, category C in Group B had no significant difference. Conclusions: This study is relevant clinically because repeated BoNT-A injections show unchanging effectiveness in the management of focal spasticity after stroke. It is considered that motor function mainly in the proximal part of the upper limb should improve after BoNT-A and that a rehabilitation programme should be offered to improve the reduced motor function of fingers.

0723

Hair cortisol: A potential biomarker of emotional distress among persons with traumatic brain injuries David Arciniegas, Angelle Sander, Kacey Maestas, Allison Clark, & Mark Sherer TIRR Memorial Hermann, Houston, TX, USA Objective: Chronic emotional stress is accompanied by chronic overactivation of the body’s stress-response system. Cortisol is a component of that stress response system, the levels of which are increased during periods of high stress. Although short-term increases in cortisol can help the body manage illness or injury effectively, longterm increases in cortisol levels are associated with a broad range of adverse health effects that compromise physical and emotional wellbeing and function. In the context of traumatic brain injury (TBI), chronic emotional distress-related increases in serum cortisol levels may, quite literally, add insult to injury. Cortisol circulating in the bloodstream passes via hair follicles into newly produced hair, which grows at the scalp vertex at a rate of 1 centimetre per month. Once incorporated into hair, cortisol remains embedded therein. Measuring the amount of cortisol in the 1 centimetre segment of hair proximate to the scalp vertex allows estimation of the average daily levels of serum cortisol during the month over which that segment of hair was produced. Accordingly, hair cortisol levels in the 1 centimetre segment proximal to the scale vertex may serve as a biomarker of emotional distress among persons with TBI. The development of this biomarker is a component of a study of emotional distress and its treatment after TBI funded by the National Institute on Disability and Rehabilitation Research and in progress at the institution. Method: The study is evaluating the correlation between hair cortisol levels among persons with TBI and scores on the Brief Symptom Inventory 18 (BSI 18). The BSI 18 is a short, self-report assessment of depressive, anxious and physical symptoms that are common among persons experiencing emotional distress, including persons with TBI. The BSI 18 asks participants to report on the levels of symptoms they

experienced over the last 7 days. This measure has been adapted to assess self-reported symptoms of emotional distress over the month preceding hair cortisol sampling. Results: If the anticipated correlation between BSI 18 scores and hair cortisol is observed, then this study will have demonstrated a potential biomarker of emotional distress among persons with TBI. Conclusions: The current study provides an opportunity to assess the biological effects of emotional distress experienced by persons with TBI and to derive a quantifiable estimate of the level of activity of the immune system associated with emotional health/distress. It also may yield a biomarker with which to evaluate the effects of psychological and pharmacologic treatments on the body’s stress-response system. The conceptual background, methods developments, early findings and clinical implications of this line of investigation are the focus of this presentation.

0724

Do comorbid mild traumatic brain injury and chronic pain contribute to greater attention dysfunction? Dmitry Meyerson, Francis Sparadeo, Michael Meyerson, Chantele Petrocelli, & Brittany Colwell Sparadeo & Associates, W. Warwick, RI, USA Mild traumatic brain injury (mTBI) and chronic pain (CP) can be co-occurring problems following injuries often associated with cognitive complaints and considerable interest has been given to this problem. Previous work has sufficiently established the presence of widespread attention weaknesses in mTBI sufferers. Recent work has also begun to emerge pointing to the presence of attention dysfunction in sufferers of CP. In fact it has been suggested that individuals with CP and mTBI exhibit similar levels of severity of attention deficits relative to normative data. Additionally, some work has indicated that no significant differences between the mTBI and CP groups exist in post-concussive symptoms and attention complaints. However, attention functioning in individuals with co-morbid mTBI and CP has not been extensively investigated and issues with differential diagnosis can exist. The current study sought to extend previously reported findings of similarities in attention deficits in CP and mTBI groups by exploring attention performance in a third clinical group comprised of individuals who had suffered a mTBI and co-morbid CP resulting from physical injuries sustained during the mTBI. The study compared Group 1 (mTBI; n ¼ 55), Group 2 (CP; n ¼ 32) and Group 3 (mTBI &CP; n ¼ 21) on a comprehensive continuous performance test (IVA + Plus CPT) that assesses attention performance. All participants in three groups were gathered as part of a clinical evaluation. Subjects in the co-morbid group (Group 3) had a history of mild brain injury as well as co-occurring chronic pain resulting from trauma sustained in an accident. The study also sought to explore whether the psychological symptoms in individuals with co-morbid mTBI and CP are associated with attention functioning. The results supported earlier findings that no differences in attention deficits exist between the CP and mTBI groups; however, the results did indicate that participants in Group 3 performed significantly worse (p50.05) relative to Groups 1 and 2 on some components of attention, suggesting that individuals with co-morbid mTBI and CP are likely to experience greater attention deficits over and above individuals with a single condition (consisting of either mTBI or CP). Implications of these findings are discussed.

786

0725

Elevated cell-free DNA level as an independent predictor of mortality in patients with severe traumatic brain injury Edison Rodrigues Filho1, Daniel Simon2, Nilo Ikuta2, Rita Iara do Nascimento2, Fernando Augusto Dannebrock1, Carla de Oliveira1, & Andrea Regner2 1

Laborato´rio de Biomarcadores do Trauma, 2Programa de Po´sGraduaçaõ em Biologia Celular e Molecular Aplicada a` Sau´de, Universidade Luterana do Brasil, Canoas/RS, Brazil

Brain Inj, 2014; 28(5–6): 517–878

Appropriate statistical analysis was performed and a p value of 50.05 was considered significant. Results: There were 146 male and 30 female patients (range ¼ 2–78 years; mean ¼ 34.4 years, SD ¼ 16.4 years). Mild HI occurred in 30.7% of patients, moderate HI was in 33% and 36.4% had severe HI. Hypoglycaemia [RBG53.5 mmol l1] occurred in 1.2% of the patients, 45.4% had RBG of 3.5–6.1 mmol l1, 50.9% had RBG of 6.2–11.1 mmol l1 and 2.5% had hyperglycaemia at admission. Death occurred in 25% of the patients, moderate disability occurred in 30.1% and good outcome occurred in 35.8%. Hyperglycaemia occurred in one patient with mild head injury; two patients with moderate head injury and one patient with severe head injury. All the patients with hyperglycaemia had favourable outcome. Conclusion: Random blood glucose of 11.1 mmol l1 is not common at admission in head injured patients in this centre and the value is not associated with severe injury or poor outcome.


0727 Objectives: Trauma is the leading cause of death under 45 years worldwide and up to 50% of trauma fatalities are due to brain injury. Prediction of outcome is one of the major problems associated with severe TBI and research efforts have focused on the investigation of biomarkers with prognostic value following TBI. Therefore, the aim was to investigate whether cell-free DNA concentrations correlated to short-term primary outcome (survivor or death) and GCS scores following severe TBI. Methods: A total of 188 victims of severe TBI were enrolled in this prospective study, outcome variables comprised: survival and neurological assessment using the GCS at ICU discharge. Control blood samples were obtained from 14 healthy volunteers. Peripheral venous blood was collected at admission in the ICU. Plasma DNA was measured using a real-time quantitative PCR assay for the -globin gene. Results: There was correlation between higher DNA levels and both fatal outcome and lower GCS scores. Plasma DNA concentrations at the chosen cut-off point (171 381 kilogenomes-equivalents L1) predicted mortality with a specificity of 90% and a sensitivity of 43%. Logistic regression analysis showed that elevated plasma DNA levels were independently associated with death (p50.001). Conclusion: Elevated cell-free DNA concentration was a predictor of short-term mortality following severe TBI and correlated with GCS scores at hospital admission.

0726

Relationships between random blood sugar, injury severity and management outcome in Nigerian patients with head injury A. A. Adeolu, T. B. Rabiiu, I. O. Orhorhoro, A. O. Malomo, & M. T. Shokunbi UCH, Ibadan, Nigeria Objective: A recent study of head injury patients in Nigeria found that the levels of Random Blood Glucose (RBG) in the cohort were not related to severity of the injury and outcome of management unlike the findings in other parts of world. This study set out to ascertain these findings in patients with head injury (HI). Methods: RBG was obtained from patients with HI at admission, 24 hours as well as 72 hours after admission. Severity of injury was graded using Glasgow Coma Scale (GCS). Outcome of management was determined by Glasgow Outcome Score at discharge. Serum glucose level of 11.1 mmol l1 was taken as hyperglycaemia.

Traumatic brain injury and mortality in 1500 homeless people Tom McMillan1, Jessica Wainman-Lefley1, Michael Oddy2, & Elaine Stewart1 1

University of Glasgow, Scotland, UK, 2Disabilities Trust, Surrey, UK

Objective: To determine the prevalence of traumatic brain injury (TBI) and associated demographic and injury factors in homeless people. Methods: Between 2004–2010, forty general practitioner (family doctor) practices in Glasgow completed a brief form for any homeless person that was registered with them. This was a part of a UK strategy to improve health services for homeless people. The Information Services Division record linked the data to Scottish Morbidity Records01 (electronic health records of inpatient attendances, including diagnoses) and to the General Register of Scotland (providing date and cause of death information) using each person’s unique National Health Service Community Health Index number; data were included from 1980–2011. Date, duration of admission and diagnoses of traumatic brain injury as classified by the WHO International Classification of Diseases system in use at that time (ICD-9 or ICD10) were obtained from SMR-01. The prevalence of TBI recorded in Scottish Morbidity Records from this data was compared to the prevalence in the Glasgow population during the same time period and by categories of age, gender and by deprivation quintiles. Deprivation was ranked via postcode area according to the Scottish Index of Multiple Deprivation (2006). Results: A total of 1590 homeless people were recorded in the GP returns between 2004–2010. Of these 214 different people (135 per 1000; 95% CI ¼ 118, 151) were admitted to hospital with a total of 442 TBIs between 1980 and 2011. TBI was more common in males in both the homeless and in the general population and more common in the 35–69 age range. Overall, the rate of TBI in the homeless (135 per 1000) is 5.4-times higher than in the Glasgow population during this time (25 per 1000). Of the 214 homeless people with TBI, 33.6% died during the study period. This compares with 13.9% of the non-TBI and homeless (p50.0001). The rate of death in the general population was much lower (2.5%). Cause of death was similar in the homeless groups with and without TBI. Conclusions: The rate of death in homeless people with head injury is very high and is 2.4-times higher than in homeless without a history of hospitalized TBI.

787

DOI: 10.3109/02699052.2014.892379

0728

Serum ferritin correlates with GCS scores and fatal outcome after severe traumatic brain injury Josi Mara Botome Nicol1, Sabrina Sabino da Silva2, Patricia Corso Silveira2, Adilson Boes1, Daniel Simon1, Nilo Ikuta1, & Andrea Regner1 1


Programa de Po´s-Graduaçaõ em Biologia Celular e Molecular Aplicada a` Sau´de, 2Laborato´rio de Biomarcadores do Trauma, Universidade Luterana do Brasil, Canoas/RS, Brazil Objectives: Severe traumatic brain injury (TBI) is associated with a 30–70% mortality rate. Nevertheless, in clinical practice there are no effective biomarkers for the prediction of fatal outcome following severe TBI. Therefore, the aim was to determine whether ferritin serum levels are associated with primary short-term outcome (death or Intensive Care Unit discharge) in patients with severe TBI. Methods: This prospective study enrolled 69 male patients who suffered severe TBI (GCS 3–8 at emergency room admission). The serum ferritin protein level was determined at ICU admission (mean 5.6 ± 2.5 hours after emergency room admission). Results: Severe TBI was associated with a 39% mortality rate. Higher serum ferritin concentrations were significantly associated with lower hospital admission GCS scores (Linear regression, p ¼ 0.049). Further, there was a significant association between higher ferritin concentrations and fatal outcome (289.5 ± 27.1 mg L1 for survivors and 376.5 ± 31.5 mg L1 for non-survivors, respectively, mean ± SEM, Spearman, p ¼ 0.032). Conclusions: Increased serum ferritin levels were associated to lower hospital admission GCS scores and predicted short-term fatal outcome following severe TBI.

0729

Identification of sentence emotional content in individuals with traumatic brain injury Lauren Schwartz, Thomas Marquardt, & Natalie Czimskey University of Texas, Austin, TX, USA Backgroud: A lexical emotion recognition test was administered via written stimuli to 10 (eight male and two female) participants with a history of traumatic brain injury (TBI) and 30 non-brain injured (NBI) adults. Statistical analyses found significantly more errors for the participants with brain injury, particularly for the emotions of anger and fear. Objective: The objective of the study was to investigate the sensitivity of emotional assessment stimuli developed by Ben David et al. to identify sequelae of mild traumatic brain injury (TBI). Methods: Ten individuals with TBI and 29 non-brain injured individuals participated in the study. Participants with TBI were at least 6 months post-onset of injury (mean ¼ 13 years). Individuals in the unimpaired group consisted of 13 males and 16 females without brain injury ranging in age from 19–57 years (mean ¼ 25 years). Stimuli were 50 lexical sentences, developed by Ben-David et al., that were considered strongly associated with an emotion or were neutral. The sentences were assigned to five affective categories (Anger, Fear, Happiness, Sadness and Neutral) each containing 10 sentences. The stimuli were matched on frequency of usage in the English language and on

phonological neighbourhood density. The 50 sentences were randomized and presented for 10 seconds in the centre of a computer screen. The participants were required to read each sentence and point to a pictogram corresponding to the emotion encoded in the sentence. If the participant could not identify a facial expression after 5 seconds, the administrator advised the participant that only 5 seconds remained. A correct response was defined as the selection of a pictogram that reflected the linguistically coded affect of the stimulus sentence. Results: Total mean scores reflected minimal errors for the NBI participants (mean correct ¼ 48.13) in contrast to increased errors for the participants with TBI (40.70). Comparisons of conditions for the TBI participants found significant differences between happy and neutral sentences and angry and neutral sentences. There was a significant interaction resulting from better performance on the happy and neutral sentences compared to the angry sentences for the TBI but not the NBI participants. Additional analysis showed that both groups were significantly more accurate in recognizing sentences associated with a positive affect than sentences with a negative affect. Conclusions: Results from this study highlight the need for direct teaching of affective linguistic stimuli during treatment for individuals with TBI. These findings can benefit clinicians in determining which emotions to target during treatment. Future research should examine participants with a broader range of cognitive/communication levels and educational backgrounds to develop a more complete synopsis of how these variables interact.

0730

Seizures and epilepsy after traumatic brain injury (TBI)— Moscow study Alla Guekht1, Eugene Gusev2, Igor Kaimovsky3, Raisat Mutaeva3, & Alexander Yakovlev4 1

Moscow Research and Clinical Center for Neuropsychiatry, Moscow, Russia, 2Russain National Research Medical University, Moscow, Russia, 3Moscow City Hospital # 12, Moscow, Russia, 4Institute for Higher Nervous Activity and Neurophysiology, Moscow, Russia Objectives: Traumatic brain injury is the major cause of acquired epilepsy. Epidemiological studies demonstrated that TBI was the main identified cause of epilepsy in Russia; compared to other European studies, there was higher proportion of patients with epilepsy after brain injury. However, no prospective studies of epilepsy and seizures after TBI have been performed in the country. The purpose of the study was to evaluate incidence and risk factors for early and late seizures, as well as epilepsy after TBI in the prospective study of the consecutive cohort of patients in Moscow. Methods: The prospective study of a consecutive cohort of patients (18 years and older) hospitalized with TBI, in two centres in Moscow. Patients were followed from admission (within 24 hours after trauma) to 1 year. After discharge, evaluations (visits or structured telephone interview) were scheduled for 1, 3, 6 and 12 months. Results: Two hundred and thirty-four patients (175 men, 57 women) were included. Fifty-four patients (23%) underwent surgery. Incidence of early seizures was 16.6%, late seizures was 6.8%. The majority (85%) of early seizures occurred on the first day of trauma. Thirty-six per cent of late seizures occurred within 3 months, 53% were from the 3rd until the 6th month after trauma. On multivariate analysis, early seizures were significant risk factor for late seizures: OR ¼ 10 (95% CI ¼ 3–35), p ¼ 0.0003. Surgery was a significant risk factor for early seizures (OR ¼ 7.4; 95% CI ¼ 3–19; p ¼ 0.0001) and late seizures (OR ¼ 5.6; 95% CI ¼ 2–16; p ¼ 0.03). Late seizures were associated with low Glasgow Coma Scale (GCS) score (p ¼ 0.02). Twenty-four out of 234 patients (10.2%) died, including 15 out of 39 patients (38.4%)

788 with early seizures. On multivariate analysis, predictors of mortality were early seizures (p ¼ 0.001), surgery and GCS. Conclusions: Seizures are frequent in patients with TBI. Early seizures are significant predictors of late seizures and are associated with increased risk of mortality. Surgery is the important risk factor for seizures after TBI.

Brain Inj, 2014; 28(5–6): 517–878

highlights the seriousness of TBI as a public health problem and the importance of all severities of TBI, no matter where, or if, the TBI is treated, in estimating the prevalence and associated disability with these injuries.

0732 0731


Over twice as many people report activity limitations co-occurring with non-hospitalized traumatic brain injury than hospitalized traumatic brain injury: A statewide population-based survey Gale Whiteneck1, Jeff Cuthbert1, John Corrigan2, & Jennifer Bogner2 1

Craig Hospital, Englewood, CO, USA, 2Ohio State University, Columbus, OH, USA Objective: Estimates of the prevalence of disability after traumatic brain injury (TBI) (3.2 million in the US) are currently based on hospitalized cases, but non-hospitalized cases are more frequent and can also have negative outcomes. The objective of this study was to investigate the prevalence and associated activity limitations from all severities of TBI, treated in all settings or not treated at all. Methods: A statewide random-digit dialled population-based survey of 2704 adult community-dwelling Coloradoans was administered between 2008–2010 and assessed the lifetime history of TBI using a modified computer assisted telephone interview based on the Ohio State University TBI Identification Method. The activity limitation question from the Behavioural Risk Factor Surveillance System was also asked. Results: Data weighted to the Colorado 2010 census age 18 and over indicated 19.8% reported no injury in their lifetime and 37.7% reported an injury but no TBI, while 42.5% reported having a lifetime history of TBI. Mild TBI was predominate, with 18.1% reporting their most severe TBI as mild without LOC and 18.4% reporting mild TBI with LOC; moderate-to-severe TBI accounted for 6.0%. Of those reporting a TBI, 23.1% were hospitalized for their most severe TBI, 38.5% were treated in an emergency department, 9.8% were seen in a physician’s office and 27.5% did not seek medical care. A clear gradient of activity limitations was seen, with the highest rates occurring in people reporting moderate-to-severe TBI; however, even those reporting mild TBI reported greater rates of activity limitations than those reporting injuries but no TBI and those not reporting injuries in their lives. Among the 3 803 587 adult Coloradoans, an estimated 300 506 reported activity limitations because of physical, mental or emotional problems and 70% also reported a lifetime history of TBI. Among the 208 969 reporting both past TBI and current activity limitations, 73% reported only mild TBI and an estimated 63 660 reported being hospitalized for their worst TBI, while 145 309 reported no hospitalization for their TBI(s). Conclusions: The fact that over twice as many people reported activity limitations co-occurring with non-hospitalized TBI than hospitalized TBI suggests that current estimates of people living with disability after TBI may be low, since they are only based on hospitalized TBI. While the study methodology cannot attribute causation of activity limitations to TBI, the concentration of activity limitations among people experiencing TBI, particularly non-hospitalized TBI, demonstrates that the association of these two factors defines a clear population in need of services and interventions. This investigation

Factors affecting management outcome of head injury in the intensive care unit of a Nigerian tertiary hospital A. A. Adeolu, T. A. Adigun, M. D. Dairo, M. T. Shokunbi, A. O. Malomo, & J. O. Adeolu UCH, Ibadan, Nigeria Objective: Patients with head injury are often admitted to the intensive care unit for optimum monitoring and ventilatory support. There is dearth of information on these and factors affecting outcome of such management are lacking in the environment despite high burden of head injury. This study was, thus, designed to determine the factors affecting management outcome of patients with head injury in the intensive care unit. Method: Prospective data was obtained for all patients with head injury admitted into the intensive care units over the study period. Date were obtained on age, sex, duration of injury before presentation, mean arterial pressure, pulse rate, admission blood glucose, severity of injury using Glasgow Coma Score (GCS) and Injury Severity Score (ISS), intubation period and assisted ventilation. The primary outcome measure was the Glasgow Outcome Score (GOS) at discharge from Hospital. The latter was further dichotomized to favourable (good; GOS ¼ 4–5) and unfavourable (poor; GOS ¼ 1–3) outcome. The variables were analysed for their impact on the outcome and level of significance was set at p 0.05. Results: Seventy-eight patients (male:female ratio of 5:1) were included in the study. Eighty-five per cent were in the third to sixth decades of life. Motorcycle crashes occurred in 52% of patients. Severe head injury occurred in 62.8%, moderate head injury in 24.4% and mild head injury in 12.8%. Unfavourable outcome occurred in 53.8% and 46.2% had favourable outcome. Patients with severe head injury (p ¼ 0.005) and those who had prolonged intubation beyond 1 week (p ¼ 0.037) had poorer outcome. The outcome was not significantly related statistically to age and sex, admission glucose, aetiology of injury, ISS, cranial computerized tomography findings, surgical intervention and mean arterial pressure. Conclusion: Patients with severe head injury and prolonged intubation beyond 1 week were more likely to have poor outcome following management in the intensive care unit in the centre.

0733

Intersentential cohesion influences microlinguistic processing in the discourse of speakers with traumatic brain injury Richard Peach1, & Carl Coehlo0 1

Rush University Medical Center, Chicago, IL, USA, 2University of Connecticut, Storrs, CT, USA

789


DOI: 10.3109/02699052.2014.892379

Objectives: Discourse production requires an effortful interaction between macrolinguistic (between sentences) and microlinguistic (within sentence) processes. However, few studies exist that attempt to establish the connections between these different levels of language. As a result, there is little information available to describe how specific changes at either level may influence the processing of discourse. This study investigated the influence of macrolinguistic processes concerned with establishing intersentential cohesion on microlinguistic impairments in discourse produced by speakers with severe traumatic brain injury (TBI). Methods: Samples of monologic discourse (picture descriptions) were obtained from 15 speakers with severe TBI. Online (increased pause time) and offline (number of mazes, grammatical errors) measures of microlinguistic impairment were identified within each sample. The number of cohesive ties produced by the speakers were also identified and judged for their adequacy (correct, errorful). Instances of co-occurrence between multiple measures of microlinguistic impairment were tallied and analysed with regard to the position of the microlinguistic failure and the cohesive tie (before, after) and the relative frequency of microlinguistic failures associated with correct vs errorful ties. Results: The mean cohesive adequacy of the discourse samples was 69% (range ¼ 0–100%). Seventy-five per cent of the cohesive ties were correct and 25% were in error (p ¼ 0.002). All but one of the speakers produced at least one error tie. Thirty per cent of the total number of cohesive ties was associated with at least one instance of grammatical impairment. When analysed according to the adequacy of the ties, there were significantly more instances of grammatical impairment associated with correct ties (32%) than with error ties (25%) (p ¼ 0.007). Eleven of the 15 speakers demonstrated at least one instance of grammatical impairment associated with the production of correct ties. This impairment occurred after the tie 60% of the time and before the tie 36% of the time. Two instances of a correct tie were observed within a maze. For error ties, only six of the 15 speakers demonstrated grammatical impairment associated with the tie. Grammatical impairment occurred after the tie 45% of the time and before the tie 55% of the time. No instances of an error tie were observed within a maze. The differences between the positions in which these impairments appeared were not significant for either type of cohesive tie. Conclusions: Utilization of processing resources required for establishing adequate cohesion in discourse following TBI appear to negatively affect microlinguistic processing necessary for grammatical sentence production. These findings are consistent with recent work that microlinguistic deficits following TBI are due to the way that these individuals recruit and control attention for discourse planning.

0734

Symptomatic recovery and return-to-work following mild traumatic brain injury: An exploratory study Rosalind Lee1, Noah Silverberg1, & Rael Lange2 1

Vancouver Coastal Health, Vancouver, British Columbia, Canada, University of British Columbia, Vancouver, British Columbia, Canada

2

Objectives: To characterize patients with mild traumatic brain injury (mTBI) who promptly return to work or school. Method: A retrospective cross-sectional of adults (n ¼ 94) with mTBI (mean age ¼ 36.3 years, 50.5% male, 26.9% without loss of consciousness, 14.7% with an abnormal day-of-injury computed tomography scan) from two outpatient concussion clinics. A healthy control group (n ¼ 91) was also included for comparison. The main outcome measures used were a return-to-work questionnaire, the British Columbia Post-concussion Symptom Inventory (BC-PSI) and

the British Columbia Major Depression Inventory–Second Edition (BC-MDI). Results: Almost half (44.7%) of patients with mTBI had resumed work/ school by the initial clinic visit (median ¼ 32 days post-injury). As a group, these patients rated themselves as being far less than 100% recovered in their physical (67.8%), cognitive (59.9%) and psychological (62.1%) capacities. Their post-concussion symptom severity was somewhat lower than mTBI patients who had not returned to work (Cohen’s d ¼ 0.46, p ¼ 0.032), but much higher than healthy controls (Cohen’s d ¼ 1.81, p50.001). The prevalence of sample meeting ICD-10 Category C criteria for post-concussional syndrome (based on the BC-PSI) were comparable among mTBI patients who did (71.1%) or did not return to work (76.3%, p ¼ ns for contrast). The prevalence of depression (based on the BC-MDI-II) was also similar between groups (20.8% vs 22.0%, p ¼ ns). Conclusions: Patients with mTBI often return to work/school before their symptoms resolve. Return-to-work rates may under-estimate the clinical needs and economic burden of mTBI.

0735

Development of regulatory and mediating functions of language through the method of analysis and interpretation in bilingual pre-school story (NahuatlSpanish) Arturo Lopez1, Yulia Solovieva1, Maria Victoria Bartolome´2, & Valentina Ladera2 1

Autonomous University of Puebla, Puebla, Mexico, 2University of Salamanca, Salamanca, Spain

This paper describes the effects of a psychoeducational intervention programme based on the method of analysis of stories in a population of 31 children (as) bilingual (Nahuatl—Spanish) pre-school third party originating from Tlaxcala, Mexico. The authors worked with a research design with a pre-test–post-test control group (n ¼ 31) and an experimental group (n ¼ 31). In the experimental group, a programme was implemented of training from the methodology of analysis and interpretation of story to the development of regulatory and mediating functions of language from the perspective of Historical– Cultural and Activity Theory, both methods applied the teaching– learning process. The results were subjected to Kruskal-Wallis statistical analysis showing significant differences in executions in favour of the experimental group, with a significance level of p50.05 in the various types of tasks evaluated. The results showed that the number of sentences, words and sentences co-ordinated significantly increased, allowing the emergence of dialogues both spontaneously deployed as a slogan also showed a higher level in the organization of behaviour (voluntary), leading out a structured dialogue (regulator of their conduct) and greater inclusion of vocabulary as productive and coherent sentences when communicating with adults.

0736

The role of resilience in predicting depression, anxiety and participation in persons with traumatic brain injury Kacey Maestas1, Mark Sherer2, Angelle Sander1, David Tulsky3, & Todd Nick4

790 Baylor College of Medicine, Houston, TX, USA, 2TIRR Memorial Hermann, Houston, TX, USA, 3Rusk Institute/New York University Langone Medical Center, New York, NY, USA, 4University of Arkansas for Medical Sciences, Little Rock, AR, USA


1

Objectives: Given the heightened risk of depression, anxiety and reduced participation following traumatic brain injury (TBI), it is important to identify modifiable factors that are associated with these unfortunate outcomes. Psychological resilience, which has received increased research attention in other physical and mental health populations, is potentially protective against poor emotional functioning and participation outcomes following TBI. This prospective study of persons with TBI sought to determine whether resilience was a unique predictor of depression, anxiety, the ability to participate in social roles and activities and satisfaction with level of participation. Methods: Participants were 196 adults with medically documented mild, moderate and severe TBI who were living in the community an average of 5.04 years post-TBI. Participants completed baseline and 6month follow-up assessments. Injury characteristics were obtained from medical records. Estimates of resilience and outcomes were obtained as T-scores (mean ¼ 50; standard deviation ¼ 10) on the following computer adaptive tests: resilience (TBI-QoL Resilience), depression (TBI-QoL Depression), anxiety (TBI-QoL Anxiety), ability to participate in social roles and activities (Neuro-QoL Bank v1.0-Ability to Part. in SRA) and satisfaction with level of participation (Neuro-QoL Bank v1.0-Satisfaction). Results: Multivariable linear regression models were fit to determine if baseline resilience made significant, unique contributions to the prediction of follow-up depression, anxiety, ability to participate in social roles and activities and satisfaction with level of participation, after accounting for demographic variables (age, gender, education, race), injury characteristics (time since injury, time to follow commands) and the baseline level of the associated outcome. After controlling for all other factors, resilience was a unique predictor in explaining anxiety at follow-up (p ¼ 0.01), with anxiety T-scores 2.64 points (95% CI ¼ 0.65–4.63) higher for individuals at the 25th as compared to the 75th percentile of resilience. Resilience was also a unique predictor in explaining the ability to participate in social roles and activities at follow-up (p ¼ 0.01), with the ability to participate Tscores 1.58 points (95% CI ¼ 0.01–3.16) higher for individuals at the 75th as compared to the 25th percentile of resilience. Lastly, resilience was also a unique predictor in explaining satisfaction with level of participation at follow-up (p ¼ 0.05), with satisfaction T-scores 1.96 points (95% CI ¼ 0.42–3.50) higher for individuals at the 75th as compared to the 25th percentile of resilience. Conclusions: Persons with TBI with higher levels of resilience at baseline assessment showed lower anxiety, greater ability to participate in social roles and activities and increased satisfaction with level of participation at follow-up. As a potentially modifiable factor, it appears worthwhile to address resilience in future trials of interventions that are aimed at improving anxiety and participation outcomes following TBI. The finding that resilience was not associated with follow-up depression was unexpected.

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Objectives: To present the details and experience of a paediatric healthcare outcomes registry focusing on the mechanism of injury and presenting symptoms of the young child up to 10 years of age. Methods: Details are provided on the data content collected, the methodology of data collection, population descriptions and comparisons. Specifically, this study compares and contrasts patients 0–10 years of age presenting to a major regional paediatric hospital concussion programme. Results: Data was available on 54 patients with ages 3–10 years. There were 16 females/38 males. The median time from injury to first clinic visit was 12 days and ranged from 2–456 days. Sports (43%) and falls (28%) were the most common aetiologies of injury across the entire population. Football (43.5%) was the most common sport-related injury, followed by snow skiing and soccer (13% each). Motor vehicle accidents, recreational vehicle accidents, violence and a variety of other mechanisms were represented. This data was stratified by patient’s age. In the 3–6 year olds, falls were the primary mechanism of injury (54.5%), ages 7–9 years falls and sports were equally represented (34.7% each), whereas patients 10 years of age were injured primarily via sports (70%). A variety of pre-morbid diagnoses were reported (males ¼ females), with learning/dyslexia, sleep, vision, hearing and anxiety being the most commonly identified in that order. Somatic complaints were the most common presenting symptom (92.3%) followed by behavioural (36%) and cognitive (23%). Headaches were the most common somatic complaint reported in 72% of patients. CT imaging was obtained on 41% of all patients (22/54); 39% had positive findings with non-depressed skull fractures predominating. MR imaging was performed on 33% of patients with positive findings in only 18% where no specific trend in findings was identified. Conclusions: Limited data is available for the post-concussion patient 10 years of age or younger. These data suggest that mechanism of injury is largely age-dependent, likely reflecting levels of maturity required for participation in sports. Older children in this population tended to experience primarily sports-related injuries while the most common mechanism of injury in the younger child is still falls. Presenting symptoms cluster in the somatic domain, with headaches being the most common symptom. Neuroimaging findings were present in a relatively large portion of the population, with skull fracture being most common. Continued development and enrolment in the Children’s Hospital Colorado concussion registry will provide the means necessary to begin to make more generalizable conclusions and enable comparisons with the older adolescent population. Future collaboration with other clinic sites is being investigated.

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A linear dose-response relationship between selfreported concussions and laterlife neurobehavioural functioning in former football players

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Paediatric concussion: Injuries, care and outcomes in the prepubertal patient Gerald Clayton1, Pamela Wilson1, Julie Stevenson1, & Jacqueline Murray1 1

Children’s Hospital Colorado, Aurora, CO, USA, 2University of Colorado Denver, Aurora, CO, USA

Philip Montenigro1, Yorghos Tripodis2, Daniel Daneshvar1, Daniel Seichepine1, Christine Baugh1, Clifford Robbins1, David Riley1, Nathan Fritts1, Brett Martin2, Christopher Nowinski1, Ann Mckee1, Robert Cantu1, Michael McClean2, & Robert Stern1 1

Boston University School of Medicine, Boston, MA, USA, 2Boston University School of Public Health, Boston, MA, USA Objectives: The long-term effects of sports-related concussions on neurobehavioural function are uncertain. It was hypothesized that

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there would be a linear dose-response relationship between later-life neurobehavioural functioning and self-reported concussions in former football players. Methods: Two hundred former youth, high-school, college, semiprofessional and professional football players from the Longitudinal Examination to Gather Evidence of Neurodegenerative Disease study completed the Behaviour Rating Inventory of Executive Function (BRIEF-A), a standardized self-report measure of executive functioning. Raw scores were converted into age-appropriate T-scores that yield an overall composite score (Global Executive Composite [GEC]), two index scores (Behavioral Regulation Index [BRI] and Metacognition Index [MI]) and nine clinical scales. Participants selfreported four estimates of concussion exposure: (1) a spontaneous estimate of total concussions; (2) a second estimate after being read a comprehensive definition of concussion based on current medical literature (post-definition); (3) an estimate of concussions with associated loss of consciousness (LOC); and (4) an estimate of concussions subjectively self-reported as major. Each estimate was evaluated for recall bias heteroscedasticity, an increase in memory bias as a result of an increase in the number of concussions experienced by the participant, using the Breusch-Pagan test. Estimates of concussions were modelled as independent variables on four linear regressions of dependent BRIEF-A outcomes. For linear regressions, alpha was set a priori to 0.0125 after Bonferroni’s correction. Results: The post-definition number significantly regressed with the GEC (B ¼ 2.55, SE ¼ 0.52, p50.0125), MI (B ¼ 2.20, SE ¼ 0.62, p50.0125), BRI (B ¼ 2.62, SE ¼ 0.58, p50.0125), and seven of the nine clinical scales. Major concussions significantly regressed with the GEC (B ¼ 3.72, SE ¼ 1.33, p50.0125), MI (B ¼ 4.01, SE ¼ 1.38, p50.0125) and three of the nine clinical scales. Only the postdefinition number significantly regressed with BRI, which is a measure of emotional and behavioural regulation. Memory recall heteroscedasticity significantly affected spontaneous concussion number (p ¼ 0.046) and LOC concussion number (p ¼ 0.013). Spontaneous and LOC concussion numbers were not linearly associated with BRIEFA outcomes. Conclusions: After providing participants with a definition of concussion, the number of reported concussions was linearly related to self-reported problems with executive functioning. In contrast, this dose–response relation was weaker or non-existent when nodefinition was given or when concussion was defined as having LOC or described as ‘major’. The small standard error of the estimated beta-coefficients and the lack of recall heteroscedasticity highlight the validity of concussion estimates made with a definition. In contrast, spontaneous estimates were heteroscedastic and not associated with executive functioning. These findings support the utility in educating athletes to improve retrospective concussion reports. Moreover, this approach should enhance future research that examines the relationship between exposure and later-life functioning.

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Cefaly neuromodulation for posttraumatic neuralgic headache

cervical plexus. The forehead is innervated by branches of the V1 division, specifically the supraorbital and supratrochlear nerves. The vertex and lateral region of the scalp receives its nerve supply from the V2 and V3 divisions (zygomaticotemporal and temporomandibular and auriculotemporal nerves, respectively). The posterior scalp sensation is supplied by the greater auricular and occipital nerves. Results: Patient MH is a 58 year old, Caucasian, male with diagnoses of: concussion in vehicular collision, post-traumatic headache, cervicalgia (myofascial), left supra-orbital and occipital neuralgia, left auriculotemporal scalp neuralgic pain secondary to impact injury (in association with allodynia and hyperalgesia) and left post-traumatic optic neuropathy. After his injury, the patient’s daily PTH was managed with medications, physical therapy and left temporal area local anaesthetic/steroid blocks. After 2 years of varying headache pain levels, neuromodulation was tried using a Cefaly device in combination with manual/myofascial therapy (the latter as previously conducted). The patient reported substantive improvement in his headache intensity and frequency with concurrent ability to decrease use of prescription pain medication. Conclusions: New studies are emerging that show efficacy of transcutaneous neurostimulation/neuromodulation in treating migraine headaches. This case study demonstrates improvement in controlling post-traumatic neuralgic headaches in a patient status post-concussion with addition of supraorbital and supratrochlear neuromodulation using a new device, the Cephaly unit. It is theorized that the improvements were mediated via (1) direct stimulation of the affected left supra-orbital nerve with resultant modulation of neuralgic symptoms; (2) endogenous opioid release occurred as seen with high and low frequency TENS; and (3) increased activation of inhibitory pathways through increased release of serotonin as seen especially in high frequency TENS; and/or, alternatively, central modulation via suppression of activity in pain processing circuits (i.e. down-regulation of central sensitization), as well as potential activation of descending pain control and modulation systems.

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Between resting state network connectivity distinguish between vegetative state/unresponsive wakefulness and minimally conscious state patients Francisco Go´mez1, Athena Demertzi2, Quentin Noirhomme2, Enrico Amico2, Audrey Vanhaudenhuyse3, Marie-Aure´lie Bruno2, Olivia Gosseries2, Andrea Soddu4, Steven Laureys2, & Luaba Tshibanda2 1

Concussion Care Centre of Virginia, LTD, Richmond, VA, USA

Complexus Group, Computer Science Department, Universidad Central de Colombia, Bogota´, Colombia, 2Coma Science Group, Cyclotron Research Centre, University of Lie`ge, Lie`ge, Belgium, 3 Department of Algology - Palliative Care, University Hospital of Lie`ge, Lie`ge, Belgium, 4The Brain and Mind Institute, Department of Physics & Astronomy, Western University, London, Ontario, Canada

Methods: Cefaly is a relatively new durable medical device that was developed in Europe and recently approved for use of treatment of migraines in Canada. It is still pending FDA approval in the US. A literature search revealed no prior published cases where transcutaneous neuromodulation has been used to treat post-traumatic headache (PTH). This study describes the results of supraorbital/ supratrochlear neuromodulation for neuralgic PTH in a patient status post-concussion with mixed headache generators. Nerve supply of the scalp comes from the fifth cranial nerve (trigeminal), as well as the

Objectives: Ten resting state networks (RSNs) of functional significance can be consistently identified in healthy subjects. Disruption in functional connectivity of some of these networks has been associated to impaired levels of consciousness in disorder of consciousness (DOC) patients, when comparing healthy controls and patients. Nevertheless, quantification of within RSN connectivity is not sufficiently sensitive to highly possible differences between more subtle DOC diagnostic categories, such as vegetative state/ unresponsive wakefulness (VS/UWS) and minimally conscious state

Sara Etheredge, & Nathan Zasler


792 (MCS). It is hypothesized that between RSN connectivity may also reflect fundamental changes of functional connectivity related to the loss of consciousness. Materials: Three hundred fMRI resting state scans (3 T scanner, TR ¼ 2 seconds) were obtained in 49 DOC patients (24 MCS, 25 VS/UWS; age ¼ 47 ± 16 years) and 27 controls (age ¼ 47 ± 16 years). Data preprocessing included re-alignment, adjustment for motion-related effects, normalization of functional data into MNI space and spatial smoothing (kernel size ¼ 8 mm). Data was decomposed into 30 independent components (ICs) at the single-subject level using the infomax algorithm (GIFT http://icatb.sourceforge.net/). Ten RSNs (auditory, cerebellum, sensory, saliency, default mode, executive control left and right and three visuals) were identified at individual level by selecting the set of unique couples (RSN binary template-IC) that maximize a global goodness-of-fit similarity measure. Each RSN component underwent a support vector machine ‘neuronality test’ to determine the ICs that followed a well-structured low frequency pattern. A band pass filter (0.008–0.05 Hz) was applied on each RSN time-course for noise removal. RSNs connectivity between all pairwise RSN time-courses was computed as the maximum of the Pearson correlation calculated for different time lags (±6 seconds). Only pairs of ICs labelled as ‘neuronal’ were included in the analysis. Results: For controls, MCS and VS/UWS a total of 36, 24 and 23 out of 45 (10*9/2) possible connections showed significant values (p50.01). When all connections were considered independently of the RSNs connected, significant differences in connectivity between VS/UWS (0.52 ± 0.27) and controls (0.43 ± 0.22) and VS/UWS compared to MCS (0.44 ± 0.23) were observed (p50.05). When individual connections between RSNs were examined, a significant increase in the connection between left and right external control networks was observed when comparing VS/UWS (0.84 ± 0.04) and MCS (0.51 ± 0.18) (p50.05, Bonferroni corrected). Conclusions: These results indicate that between RSN connectivity may help to differentiate DOC patients. High values of the connectivity were linked to impaired states of consciousness. Severe loss of consciousness was related to increases of between RSN connectivity of high level cognitive RSNs.

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Cerebellar white matter integrity and depression in chronic brain injury Patrick Glang1, Michelle Pennington2, & Deborah Little3 1

Baylor Scott and White Healthcare and University of Oregon, Eugene, OR, USA, 2Baylor Scott and White Healthcare, Waco TX, USA, 3 Texas A&M University Health Science Center and Baylor Scott & White Healthcare, Temple, TX, USA Objectives: Across all severities of traumatic brain injury (TBI), deficits in mood and emotion regulation are commonly reported. In moderate-to-severe brain injury, the incidence of depression has been found to be as high as 77%. However, although lower than moderate-to-severe injury, even milder TBI show increased rates of depression and self-reported cognitive problems. It is unknown whether this increased incidence is due to alterations in metabolic function, structural damage to key regions in the brain or other factors. Due to the structure and location of the cerebellum and the functional role of the cerebellum in depression and affect regulation, it was hypothesized that TBI is associated with shear and strain damage in the cerebellum and that this damage would be associated with severity of depressive symptoms. The objective of the current study was to assess whether damage to major white matter tracts in the cerebellum, which have been associated with depression in other populations, are associated with depressive symptoms in chronic TBI.

Brain Inj, 2014; 28(5–6): 517–878

The present study focuses on structural integrity of the pontine crossing tracts, middle and superior cerebellar peduncles, portions of the cortico-spinal tract and medial lemniscus. Methods: High resolution diffusion tensor imaging (DTI) was carried out in patients with a history of a single closed-head injury (n ¼ 24 mild TBI and 24 moderate-to-severe TBI) and 24 healthy uninjured controls. The patients were at least 12 months from injury and demographically matched to the controls. Fractional anisotropy (FA) and both radial and axial diffusivity was extracted from regions of interest in the pontine cross tracts, middle and superior cerebellar peduncles, portions of the cortico-spinal tract and medial lemniscus (bilaterally when appropriate). For each, a total of three regions of interest were placed on each tract. Regions were drawn independently by two raters and exceeded reliability of 0.91. Results: All patients with a history of moderate-to-severe TBI showed reduced FA in all regions of interest compared to healthy controls. The mild TBI differed (decreased FA) from controls in the medial lemniscus, pontine crossing tracts and in the most inferior region in the cortico-spinal tract. Depressive symptoms (as determined by the Beck Depression Inventory II) were not associated with FA for controls for any region of interest (p ¼ 0.09). For the mild TBI, FA of the medial lemniscus was correlated with total BDI score (p ¼ 0.006). For the moderate-to-severe TBI, there were correlations between depressive symptoms and FA in the pontine fibres (p ¼ 0.04), cortico-spinal tract (p ¼ 0.02) and superior cerebellar peduncles (p ¼ 0.04). Conclusions: This study provides preliminary evidence to suggest that structural alterations in the cerebellum are associated with increased depressive symptoms in TBI.

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Study of pseudobulbar affect symptoms in veterans with mild traumatic brain injury Regina McGlinchey1, Jennifer Fonda1, William Milberg1, James Rudolph1, Phillip Hunt2, Matthew Reynolds2, & Charles Yonan3 1

VA Boston Healthcare System, Boston, MA, USA, 2Evidera, Lexington, MA, USA, 3Avanir Pharmaceuticals, Inc., Aliso Viejo, CA, USA Objectives: To characterize the prevalence of pseudobulbar affect (PBA) symptoms in a sample of OEF/OIF/OND veterans who screened positive for traumatic brain injury (TBI) using the VA four-item screen. Methods: The design was a cross-sectional survey, with patient level linkage to VA clinical data. Information from the VA four-item TBI screen and the Comprehensive TBI Evaluation, as well as other clinical measures and healthcare utilization, were extracted from the VA medical datasets. Roughly 4400 Veterans in the New England region (VISN-1) screened positive for TBI and met inclusion criteria. Veterans were mailed a questionnaire consisting of an initial question asking if the veteran has ever experienced ‘involuntary episodes of crying and/ or laughing that were exaggerated or even contrary to how they felt at the time’, as well as the seven-item Center for Neurologic StudyLability Scale (CNS-LS). The EQ-5D questionnaire, an international, standardized, general measure of health status, was also included to evaluate health-related quality-of-life (HRQoL). The presence of PBA symptoms will be determined based on positive response to the ‘involuntary episodes’ question and a CNS-LS score 13. Demographic and clinical characteristics of respondents, as well as HRQoL scores will be compared between those with and without PBA symptoms Results: The 4400 veterans mailed surveys are predominantly male (95%); mean (SD) age 34 (8.8) years. Exposure to blast/explosion is the primary mechanism of injury (84%). Common co-morbidities

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recorded in the VA database include: PTSD (47%), pain (31%), major depression (26%), headaches/migraine (17%) and anxiety disorders (17%). Anti-depressants have been prescribed for 37% and sedatives/hypnotics for 16%. To date, 16% (n ¼ 700) of the sample has responded to the survey. Early results suggest a surprisingly high prevalence of PBA symptoms, with 60% of respondents answering ‘yes’ to the screening question and 64% having a CNSLS 13. Mean scores for involuntary crying-related questions on the CNS-LS are higher than for involuntary laughing-related questions. Respondents with (vs without) PBA symptoms report poorer HRQoL in all five functional domains of the EQ-5D. Higher mean scores and greater between-group differences are seen for anxiety/depression, pain/discomfort and usual activity domains. EQ-5D Visual Analogue Scale (VAS) scores also indicated poorer HRQoL in respondents with a CNS-LS 13. Conclusions: This is the first study to explore PBA symptom presence in VA health system veterans with a history of TBI. Preliminary findings based on early responses show a high presence of PBA symptoms and these symptoms appear to be associated with lower HRQoL scores. This population provides a rich data source to increase the understanding, characteristics and functional impact of PBA in persons with TBI. Results can aid in developing targeted clinical screens for PBA-susceptible patients. As such, these findings have important implications for identification and treatment of PBA.

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Association between allostatic load and outcome following head injury Jessica Wainman-Lefley, Tom McMillan, Jill Pell, & Jonathan Cavanagh University of Glasgow, Glasgow, UK Objectives: Head injury is associated with an increased risk of death over 13 years follow-up, independent of age, gender and social deprivation. Late outcomes after head injury are only partly explained by the severity of the injury and demographic factors. The allostatic load (AL) model conceptualizes how stressors can chronically elevate physiological activity and impact on health. Evidence is growing that AL can predict psychosocial functioning, morbidity and mortality, but there is a paucity of research on head injury. This study explores the extent to which outcome after head injury is associated with AL at the time of injury. Methods: Data were collected from hospitalized patients with severe HI. AL is quantified using a composite measure of: immune, cardiovascular, metabolic and neuroendocrine system functioning. This study examined the association between physiological markers of AL and outcome at discharge measured by the Glasgow Outcome at Discharge Scale (GODS), a global scale of functional outcome after head injury at the time of discharge. Results: Data were available on 18 severe HI patients including anthropometric, cardiovascular and respiratory biomarkers of AL (blood pressure, heart rate, forced expiratory volume, body-mass index, waist-to-hip ratio). Biomarkers from blood samples are currently being analysed. Preliminary analyses of the physiological markers revealed no significant associations between AL and outcome at discharge (Spearman, p40.05). Conclusions: Preliminary analyses of physiological markers of AL do not support the hypothesis that heterogeneity of outcome after head injury at the time of hospital discharge is explained by acccumulation of lifetime stress. Further results will be presented from blood biomarkers of AL, total AL index scores, comparisons with community controls and from preliminary follow-up data 6 months after injury.

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Pathophysiology of sport-related concussion injuries: Interrelationships between physiology, neurocognitive and subjective symptom changes Tanis Burnett1, Scott Bishop2, Colin Wallace1, Sandy Wright1, Patrick Neary2, Philip Ainslie1, & Paul van Donkelaar1 1 2

University of British Columbia–Okanagan, Kelowna, BC, Canada, University of Regina, Regina, SK, Canada

Background: Concussion or mild traumatic brain injury (mTBI) is a common sports injury classified as a complex pathophysiological process that affects brain functioning. Following an mTBI there is a rapid onset of neurological impairments, possibly due to physiological and structural disruption that usually resolve spontaneously. The current subjective methods in mTBI assessment are often masked by inaccurate reporting, lack of baseline standards or issues with testing reliability. Standardized objective assessment of initial diagnosis and recovery of an injury has yet to be achieved. Several physiological mechanisms are thought to be altered after a concussion injury, one of which is cerebral blood flow (CBF) regulation. Two major regulating processes were examined in the current study; cerebrovascular reactivity to CO2 (CVR) and neurovascular coupling (NVC). Quantifying and identifying cerebrovascular function following a concussion injury may provide a novel objective tool to assess recovery and return-to-play for athletes at all levels of contact sport. Objectives: The aim of this study was to compare changes in cerebral haemodynamics, neurocognitive changes in an executive function task and subjective symptom reporting in contact sport athletes, from baseline to concussion injury and throughout recovery. Methods: Participants were fitted with one 2 MHz transcranial Dopper ultrasound probe to measure cerebral blood flow velocity (CBFv) in the right middle cerebral artery (MCA). In addition, end-tidal CO2 (PCO2), heart rate (HR) and mean arterial pressure (MAP) were also monitored. Measurements were made under four conditions: (i) rest; (ii) 20-second breath hold challenge (BH) followed by normal breathing for 40-seconds, repeated 5-times; (iii) neurovascular coupling (NVC) test with a neurocognitive task; and (iv) squat-stand (SS) manoeuvre at 0.05 Hz, for 5 consecutive minutes. Participating athletes were baseline tested during pre-season and again if a concussion was sustained. Concussion testings were done within days 1–3 post-injury and again on days 3–5, 7–10 and 14–21 of recovery. Results: Results showed changes in MCA velocity during BH, NVC and SS following an injury. There were differences in the recovery timeline between neurocognitive function and BH, NVC and SS conditions. Furthermore, there were disparities between subjective symptom reporting severity and BH, NVC and SS changes across the recovery process. Despite the return to baseline values in neurocognitive function and symptomology, the physiological changes after the injury do not show a full recovery. Conclusions: These results demonstrate the significance of the physiologic changes that occur with a concussion injury and that a standardized objective measurement is necessary to ensure a full recovery has been achieved.

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The Glasgow outcome at discharge scale as a measure of outcome at discharge from hospital following a severe head injury Jessica Wainman-Lefley, & Tom McMillan


University of Glasgow, Glasgow, UK Objectives: The Glasgow Outcome Scale (GOS) is the most widely cited measure of disability outcome after head injury. It cannot be used in hospitalized patients, however. The Glasgow Outcome at Discharge Scale (GODS) was developed from the GOS for use in hospitals and can be used in conjunction with the GOS at discharge from hospital. The objective of this study was to provide further data on the validity of the GODS, early after severe head injury in comparison to the Disability Rating Scale (DRS). Methods: Data were collected from medically stable, hospitalized adult patients with severe head injury (n ¼ 18) soon before discharge. In addition to the GODS and DRS, the minimum Glasgow Coma Scale (GCS), length of post-traumatic amnesia (PTA), loss of consciousness, positive or negative CT scan results and incidence of major neurosurgical procedures was noted. Results: Outcome on the GODS ranged from lower severe disability (50%) to upper good recovery (11%). The GODS significantly correlated with the DRS (rs(0.89), p50.001). Both the GODS (rs(0.66), p50.005) and DRS (rs(0.63), p ¼ 0.005) correlated significantly with the minimum GCS score. In addition, the GODS was significantly associated with duration of PTA (rs(0.57), p50.05) and the DRS was not (rs(0.45), p ¼ 0.06). There was no significant relationship between GODS (good vs poor recovery) and early indices of severity of injury such as the occurrence of major neurosurgical procedures (p ¼ 0.1; Fisher’s Exact Test, FET), the presence of loss of consciousness (p ¼ 0.49, FET) or a positive CT scan result (p ¼ 0.28, FET). Conclusions: Results demonstrate a high correlation between GODS and the DRS. The GODS is significantly associated with PTA and minimum GCS, two indicators of head injury severity. These findings support the use of GODS as a measure of outcome after severe head injury at discharge from hospital.

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AMPing it up: Preliminary evidence for the use of aggressive mobilization protocols in disorders of consciousness during acute rehabilitation Cynthia Beaulieu, Jennifer Schinke, & Jennifer Walworth Brooks Rehabilitation Hospital, Jacksonville, FL, USA Objective: Investigative research into treatments for DOC has largely been focused on the effectiveness of medications on improving awareness and consciousness and eventual emergence from the minimally conscious state (MCS). Far less research has focused on the behavioural rehabilitation interventions that may contribute to

Brain Inj, 2014; 28(5–6): 517–878

effecting improvements in the clinical presentations of patients with DOC during acute rehabilitation. Generalized weakness, debility and learned disuse are conditions long identified in the literature as significant consequences resulting from extended critical care stays, especially following neurological disorders such as brain injuries, strokes, spinal cord injuries and major multiple trauma injuries. The benefits of early activation through mobilization protocols are well documented as methods for attenuating or reversing the negative impact of immobility on recovery and for reducing secondary complications. The benefits of aggressive mobilization for patients with DOC, however, have yet to be investigated. Patients with prolonged DOC by their very nature have experienced extended lengths of stay in critical care units. Furthermore, all aspects of DOC diagnosis are dependent upon the observation of patient behaviours (i.e. motor output), particularly to accurately demarcate the transition from MCS to emergence from MCS. Enhancing motor output and reducing the negative impact of the consequences of long-term immobility would be advantageous for patients with DOC. The objective of this study is to present preliminary evidence for the potential benefit of implementing aggressive mobilization protocols (AMP) for patients with DOC. Methods: A total of 30 records were retrospectively identified with patients diagnosed with a DOC following acute rehabilitation admission between September 2011 and August 2013. Variables collected during record review included: Admission Date, Discharge Date, Interrupted Stays and Re-admission date(s), DOB, Sex, DOC diagnosis following admission assessment, Emergence from DOC prior to discharge, Aetiology of diagnosis, type of facilitated mobilization, duration and frequency of mobilization and level of engagement. Calculated variables included: Admission Age and Total Length of Stay (LOS). Results: Of the 30 patients admitted, 11 received one of four types of facilitated mobilization. Of the 11 patients who received facilitated mobilization, seven patients emerged either prior to discharge (n ¼ 4) or shortly after discharge to home (n ¼ 3) and were subsequently re-admitted for acute rehabilitation. Of the 19 patients who did not receive any facilitated mobilization only three emerged prior to discharge. Conclusions: AMP should be formally investigated as a potential valuable addition to care plans for patients with DOC. AMP may assist patients with DOC to overcome severe weakness, debility or learned disuse that may be negatively impacting their ability to respond to external stimuli. AMP may also facilitate recovery of arousal and awareness in low-level clinical profiles.

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Identification of mild traumatic brain injury in the multi-system trauma patient Jane Topolovec-Vranic1, Yangmei Li1, Marlene Santos1, Matthew Hui1, Julia Czyzo2, Anousha Jackson3, Angela Colantonio4, Katie Churchill1, & Andrew Baker1 1 St. Michael’s Hospital, Toronto, ON, Canada, 2Sunnybrook Health Sciences Center, Toronto, ON, Canada, 3Vancouver Coastal Health, Vancouver, ON, Canada, 4University of Toronto, Toronto, ON, Canada

Objective: Mild traumatic brain injury (mTBI) can result in long-term functional deficits, yet is difficult to detect and often goes undiagnosed in the acute stage following multi-system trauma as symptoms can be overshadowed by injuries to other body systems. Early identification of mTBI is critical for the delivery of appropriate clinical and rehabilitation services to improve long-term functional outcome. This study aimed to examine the association between

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cognitive functioning in the acute phase of injury for the multi-system trauma patient and persisting post-concussive symptoms at 3-months post-injury. Methods: Participants were recruited from an adult trauma and neurosurgical ward at a tertiary trauma centre in Toronto, Canada. Patients with traumatic injuries to two or more body systems and a Glasgow Coma Scale (GCS) score of 13–15 at the time of admission to the hospital were included. Those with confirmed isolated head injuries, spinal cord injuries, history of chronic substance use, known pre-morbid psychiatric disorder and/or neurological disorders were excluded. Participants were assessed in-hospital with the Montreal Cognitive Assessment (MoCA) and the Post-Concussion Symptom Scale (PCSS) which were re-assessed at 3 months post-injury. Results: Sixty-nine participants were enrolled into the study (72.5% [n ¼ 50] male; mean age ¼ 41.0 years, range ¼ 18–64 years). The median GCS score post-injury was 15 (range ¼ 13–15). Sixty-two patients had a head computed tomography (CT) scan on which 14 (22.6%) demonstrated lesions (CT+) and 48 (77.4%) had no CT findings (CT). At baseline, the mean MoCA score was 24.8 (SD ¼ 4.3; range ¼ 8–30) and PCSS score was 30.5 (SD ¼ 22.7; range ¼ 1–91). MoCA and PCSS scores were comparable across CT+, CT and no CT groups at baseline. For individuals who had a MoCA score526 (suggestive of cognitive impairment) at baseline, the PCSS score remained elevated at 3 months post-injury (baseline mean ¼ 28.1 [SD ¼ 24.6]; follow-up mean ¼ 32.4 [SD ¼ 34.8]; p ¼ 0.60), whereas those with a MoCA score 26 had significantly decreased PCSS scores (baseline mean ¼ 36.8 [SD ¼ 23.2]; follow-up mean ¼ 22.5 [SD ¼ 18.1]; p ¼ 0.002) suggesting symptom improvement in this latter group, but not in those who had cognitive deficits in the acute phase of injury. MoCA scores were slightly decreased (i.e. worsened) at 3 months post-injury for those with a MoCA score 26 at baseline (baseline mean ¼ 27.6 [SD ¼ 1.5]; follow-up mean ¼ 26.7 [SD ¼ 2.2]; p ¼ 0.036), whereas they were significantly improved for those with a MoCA score526 at baseline (baseline mean ¼ 21.9 [SD ¼ 4.0]; follow-up mean ¼ 24.8 [SD ¼ 3.6]; p ¼ 0.038). Conclusions: This study suggests that, regardless of findings on CT scans, multi-system trauma patients with cognitive deficits in the acute phase of injury report higher post-concussive symptoms at 3 months post-injury than those without cognitive deficits. Whether this association is related to unidentified mTBI, rather than preexisting or other co-morbid factors requires further exploration.

0748

Longitudinal changes in brain health in professional fighters Sarah Banks1, Wanyong Shin2, Nancy Obuchowski2, Mark Lowe2, Michael Modic2, & Charles Bernick1 1

Cleveland Clinic, Las Vegas, NV, USA, 2Cleveland Clinic, Cleveland, OH, USA Objective: The professional fighters’ brain health study (PFBHS) involves collecting cognitive, MRI and exposure data on a large cohort of boxers and mixed martial arts fighters at annual intervals. To date there are 300 fighters’ enrolled, 70 of whom have returned for a second visit. This report describes changes in their cognitive and neuroimaging scores, as a function of exposure to professional fights in the last year. Background: Professional fighting involves repetitive traumatic brain injury, which in some fighters is associated with later development of a clinical neurodegenerative syndrome and some argue the development of a specific tauopathy, chronic traumatic encephalopathy. There have been very few prospective studies of brain health in active contact sports players, so little is known of the trajectory of change. Cross-sectional data from this study points to associations between structural brain volumes (e.g. caudate, thalamus) and exposure and also reductions in white matter integrity in fighters with more

exposure. The current study uses the regions derived from earlier cross-sectional findings to assess whether or not there are changes with exposure within fighters after a year of fighting. Design/methods: Fighters undergo detailed interviews regarding demographics and exposure, professional records check, cognitive testing, blood draw and structural and functional MRI. This study reports initial findings of functional connectivity results and cognitive and diffusion tensor imaging results will be further discussed. Assessment of resting state functional connectivity used a seed based in the right insular. Results: The average age of the study cohort was 28 years, with an average exposure of 11 professional fights and 4 years of fighting. Changes in functional connectivity between the right insular and dorsolateral frontal lobes were identified for the group from baseline to year 1 scans (p ¼ 0.0005). Underlying structural changes in DTI will be further assessed in addition to any changes in cognition. Correlations with level of interim exposure will be discussed Conclusions: These preliminary data suggest some measurable impact of 1 year of fight history on functional connectivity. These findings will be discussed in the context of available multimodal imaging and cognitive findings.

0749

Legal challenges facing the brain injured Robert Mandell, & Laurence Mandell The Mandell Law Firm, Los Angeles, CA, USA While the mechanisms of traumatic brain injury (TBI) vary widely, the legal challenges and financial hurdles facing victims of TBI through the negligence or other wrongdoing of others share common ground. This study examines the legal experiences of six individuals who sustained varying levels of TBI—mild, moderate and severe—from car accidents, defective products and medical negligence. Although the study is somewhat anecdotal, broader conclusions can be drawn as to how TBI and its catastrophic consequences are sometimes misunderstood by insurance professionals as well as lay people who serve on civil juries. For instance, the two individuals with mild TBI were victims of very different car accidents. One was a common ‘rear-ender’ with a very subtle mechanism of injury and the other an auto vs pedestrian accident where the aetiology of TBI was clear. In both cases, longterm effects were disputed by the adverse parties and their insurers. Both of the mild TBI victims were high-level professionals with impaired executive functioning; however, each presented as ‘normal’ to the untrained eye. Their shared legal challenge was presenting persuasive expert evaluations that gave a vivid portrayal of how impaired executive functioning can be devastating to those who have historically relied on higher critical skills. In contrast, the individuals with moderate brain injury faced very distinct challenges to liability. One was a difficult products liability case which ultimately prevailed and provided adequate resources for the victim to manage his life. However, the other was a roadway design case against a public entity where the driver of the car in which the victim was a passenger was highly inebriated. The jury could not get past this latter fact and found no liability against the public entity, effectively leaving this individual to fend for himself and utilize public resources to manage his disability. Finally, the two individuals with severe brain injury faced very different legal and financial challenges. One was a strict products liability case where the offending manufacturer had limited insurance and assets, thus forcing his family and legal team to make difficult pragmatic choices. The final case involved a surgical centre that allowed an anesthesiologist to ‘float’ between sedated patients, leading to anoxic brain injury when one such patient stopped breathing. After a long and expensive legal battle, a jury awarded disappointing damages for future care, revealing a misunderstanding of what resources are really available to severe TBI victims and their families. From these experiences, the authors conclude that still

796 broader public education on the financial fallout of TBI is warranted. TBI victims must be prepared to avail themselves of all resources, public and private, as the legal system can be an unpredictable and unreliable provider.

0750

Classification of self-reported history of head trauma of university students as predicted by psychosocial, emotional and physical health indices Julie Baker, Angela Dzyundzyak, & Dawn Good

Brain Inj, 2014; 28(5–6): 517–878

0751

Cervico-vestibular physiotherapy in the treatment of individuals with persistent symptoms following sport-related concussion: A randomized controlled trial Kathryn Schneider1, Willem Meeuwisse1, Alberto Nettel-Aguirre1, Karen Barlow1, Lara Boyd2, Jian Kang1, & Carolyn Emery1 1


Brock University, St. Catharines, Ontario, Canada Objectives: This study examined psychosocial, emotional and physical health indices of university students (n ¼ 230) that may differentiate group membership of self-reported history of mild head injury (e.g. MHI; sufficient to produce an ‘altered state of consciousness’). Methods: Participants completed health survey packages at the local university. Self-report measures included clinical indices of emotional and physical health status, behavioural measures (e.g. impulsivity, risk-taking behaviour, etc.), post-concussive symptom (PCS) reports and social problem-solving skills. Participants were categorized into four groups: no MHI, ‘minor’ MHI (no loss of consciousness [LOC] or experience symptoms 20 minutes), ‘complicated’ MHI (LOC530 minutes and/or symptoms for 20 minutes) or ‘moderate’ head injury (LOC for 430 minutes and symptoms 20 minutes). Results: Overall, 42% (n ¼ 96) of university students reported a history of head trauma. The majority of reported head injuries were ‘mild’ (29.2% ‘minor’; 67.7% ‘complicated’; and 3.1% were considered more moderate injuries). Sports-related activities and falls were the most frequent causes of head trauma. Discriminant function analyses (DFA) were conducted to examine variables that differentiate among groups with and without history of head trauma (i.e. no MHI; MHI; various severity groups). Two primary models were examined and included reports of PCS (frequency, intensity and duration of the symptoms), impulsivity (i.e. disinhibition, thrill seeking), socially undesirable behaviours (i.e. erratic lifestyle, antisocial tendencies), social problem-solving skills and emotional experience (i.e. state anxiety, experience of life stressors) to predict group membership (Model 1 groups: no MHI vs MHI; Model 2 groups: no MHI, minor MHI, complicated MHI, moderate head injury). The discriminant function (DF) for model 1 accounted for 18.57% of the between-group variability (for MHI vs noMHI) and the second model the variance discriminated by the DFs among the four groups was 15.44%; all predictors were significant in both models (with the exception of state anxiety and social problem-solving skill variables). In general, the distributions of the DF scores were overlapping. The group classification of cases with a history of head trauma was differentiated from cases with no reported head injury in both models (i.e. 69.5% of dichotomous grouping [MHI vs no MHI]; 63.2% for all four groups); however, persons with head trauma were frequently misclassified into the no MHI group in both models. Additional analyses were conducted to examine possible improvement of the model’s group classification (i.e. time since injury) and will be discussed. Conclusions: Although measures of emotional experiences (i.e. stressors), PCS, impulsivity and behavioural challenges (i.e. erratic lifestyle) distinguished those with a history of head trauma from those with no reported injury, the former were frequently misclassified in the models. These findings illustrate the challenges of discriminating the ‘miserable minority’ from those whose symptoms may be transient.

University of Calgary, Calgary, Alberta, Canada, 2University of British Columbia, Vancouver, British Columbia, Canada

Objectives: The objective of this study was to determine if a combination of vestibular rehabilitation and orthopaedic physiotherapy decreased the time until medical clearance to return-to-play in individuals with prolonged post-concussion symptoms of dizziness, neck pain and/or headaches when compared with a control group of rest, education and graded exertion. Methods: Thirty-one participants (12–30 years) who attended the University of Calgary Sport Medicine Centre who had persistent symptoms of dizziness, neck pain and/or headaches following a sportrelated concussion were included in this study. Participants were randomly allocated to a treatment group (i.e. multimodal physiotherapy including vestibular rehabilitation, manual therapy, neuromotor and sensorimotor retraining exercises) or a control group (i.e. rest followed by gradual exertion). Participants in both groups were seen by the study treating physiotherapist once weekly for 8 weeks or until the time of medical clearance. The primary outcome of interest was time of medical clearance to return-to-sport. A sport medicine physician who was blinded to treatment group determined time to medical clearance. A physiotherapist who was blinded to treatment group assessed all secondary outcome measures. Results: One of 14 subjects (7.1%) in the control group and 11 of 15 subjects (73.3%) in the treatment group were medically cleared to return-to-sport at 8 weeks. The participants in the treatment group were 10.27 (95% CI ¼ 1.51, 69.55) times more likely to be medically cleared to return-to-sport before 8 weeks than the participants in the control group (p50.001). Conclusions: Participants who received multimodal physiotherapy treatment were more likely to achieve medical clearance before 8 weeks when compared with rest in individuals with persistent symptoms following a sport-related concussion.

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Differential effects of rotational acceleration magnitude and duration on behavioural outcomes in rats following traumatic brain injury Brian Stemper1, Frank Pintar2, Alok Shah1, Michael McCrea1, Shekar Kurpad1, William Cullinan3, Christopher Olsen1, Danny Thomas1, & Matthew Budde1

797

DOI: 10.3109/02699052.2014.892379

Medical College of Wisconsin, Milwaukee, WI, USA, 2Zablocki VA Medical Center, Milwaukee, WI, USA, 3Marquette University, Milwaukee, WI, USA


1

Determination of a mild traumatic brain injury (mTBI) threshold in terms of quantifiable biomechanics is necessary to improve the safety of automotive, military and sporting environments. However, mTBI threshold quantification is complicated by the wide range of cognitive and emotional symptoms, time-dependent manifestation of pathology and behavioural changes and a limited number of biomechanically-accurate injury models. The present study represents a first step in the determination of mTBI thresholds by quantifying the independent effects of rotational acceleration magnitude and duration on mTBI behavioural outcomes. The MCW Rotational Injury Model was used to induce mTBI in anaesthetized Sprague-Dawley rats through pure coronal plane rotational acceleration. A total of 93 rats were used. Magnitude and duration were independently controlled, resulting in four groups with differing combinations of magnitude (M1: 215 ± 25 krad s2; M2: 350 ± 34 krad s2) and duration (D1: 1.6 ± 0.4 milliseconds; D2: 3.4 ± 0.4 milliseconds). An additional shaminjury group was subjected to the experimental protocol without head rotational acceleration. Behavioural assessments were conducted during the week following rotational acceleration exposure. All experimental rats survived exposure to rotational acceleration without skull fracture or cervical spine injury. Unconsciousness times (UCT) were determined as the time from removal of anaesthesia prior to head rotational acceleration exposure until return of the righting reflex and were significantly different between groups (p50.05). High-magnitude groups (M2D1 and M2D2) had the longest UCT, with the other two exposure groups (M1D1 and M1D2) similar to shams. Changes in emotionality, assessed using the Elevated Plus Maze, were largely dependent on rotational acceleration duration, with increasing magnitude having essentially no effect. The number of arm changes and open area entries was significantly greater (p50.05) for long duration groups (M1D2 and M2D2) than the other three groups. Assessments of emotionality in the Open Field Test, including centre time and centre entries, significantly increased (p50.05) only for the M2D2 group. This study for the first time demonstrated independent effects of rotational acceleration magnitude and duration on behavioural outcomes following mTBI. Length of unconsciousness, a common metric to determine injury severity in humans, significantly increased with rotational acceleration magnitude. This is generally consistent with human outcomes as higher magnitude rotational accelerations are associated with higher severity injuries. However, rotational acceleration duration also had an independent effect on measures of emotionality, with longer duration insults associated with greater levels of risk-taking behaviour. Those behaviours were also previously associated with a rodent model of depression, another common outcome following mTBI. These findings form the foundation for continued investigation into injury tolerance for mTBI in terms of rotational acceleration metrics. These biomechanics can be scaled from the rodent to the human using previously validated mass-based ratios and will be particularly impactful and timely given the incorporation of acceleration sensors in sporting and military helmets.

0754

Influence of hyperthermia on the parameters of MAP, CPP and Prx in patients with severe TBI Andrey Oshorov, Ivan Savin, Konstantin Popugaev, & Alexander Potapov Burdenko Neurosurgery, Moscow, Russia Objectives: Evaluate the influence of hyperthermia on the parameters MAP, CPP, ICP and Prx in patients with severe TBI.

Methods: MAP, CPP, ICP, Prx and rCBF, CBFx were measured in five patients with severe TBI. This study analysed 18 episodes of hyperthermia during which all parameters were registered. A ‘Hemedex’ Monitor was used for measurement of rCBF and cerebral temperature. Prx and CBFx were calculated by soft ICM Plus (Cambridge, UK). ICP was measured by intraparenchymal sensor by ‘Codman’ (USA). ABP was measured via radial arterial catheter. Results: MAP increased in 61% of hyperthermia’s episodes. In 11% of cases it remains the same. At the same time, in 28% of cases the indicator was decreased. ICP: In 89% of cases it was increased. In 5.5% it was constant. In 5% it decreased. CPP: Increase was detected in 27.5% of cases. In 17% it remained the same and decreased in 55.5% of cases. rCBF: An increase was monitored in 55.5% of cases. In 5.5% it was constant. A decrease was measured in 39% of cases. Prx: The indicator failed in 55.5% of cases. In 39% it was restored. In 5.5% it remained the same. CBFx: Impairment was detected in 28% of cases. In 62% it was restored. Conclusions: Hyperthermia is one of the important factors of secondary cerebral insult. It can lead mostly to ICP increase and cerebral autoregulation failure.

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Peaceful habits: A suite of meditation exercises tailored to individuals with a history of brain injury or stroke Jude Theriot Touchstone Neurorecovery Center, Houston, TX, USA A formal meditation practice is beyond the reach of virtually every person treated by the author. Because of the injuries they’ve sustained, the patients are either too confused, too forgetful or too distractible to meditate. A formal meditation practice is too cognitively complex. They need something simpler. Five years ago, the author started a weekly group at a residential rehabilitation centre. The aim was to see if the idea of meditation could be stretched to make it more accessible to the people being treatied. Drawing from the sacred traditions of Asia and from the clinical literature on mindfulness, a suite of exercises were developed with brain-injured people in mind. The seven exercises are simple and tangible on purpose: (1) breathe mindfully; (2) relax the body; (3) enjoy tea mindfully; (4) hear peaceful music; (5) walk mindfully; (6) be with wild birds; an (7) meditate. Think of these exercises as elementary stress management or relaxation techniques, coping strategies for anxiety and irritability which complement treatment with medication. Unlike traditional meditation, these practical exercises are less about sitting on a cushion and more about plugging into the everyday world. It’s a learning-by-doing approach which draws on the procedural learning so crucial to neurorehabilitation. These are not exotic exercises. They require no special equipment. And they’re easy to grasp, which makes them useful for anyone, with or without a history of brain injury, children and the elderly alike. The goal is to inspire each of the patients to begin a daily practice of their own, to set aside some time every day, even if it’s only a minute or two, to devote to the cultivation of peacefulness. In the weekly group, the exercises are done together. Then they are told to practice, practice, practice. Of course, inspiration isn’t enough. Building new habits is hard and people need practical tools, so an electronic prescription was designed in the form of a smartphone app, which allows one to prescribe the exercises as easily as one can prescribe medications. The app features instructions for each of the seven exercises and a daily alarm may be set to sound at a particular time every day. A user opens the app and selects an exercise and a duration from two drop-down menus, establishing a daily practice goal and, when the timer runs out, an animated cartoon serves as

798 positive reinforcement. Progress is recorded by means of a daily tracking system.

0756

Improving quality-of-life and emotional well-being for caregivers of persons with traumatic brain injury: A randomized controlled trial Janet Powell, Robert Fraser, Jo Ann Brockway, Nancy Temkin, & Kathleen Bell

Brain Inj, 2014; 28(5–6): 517–878

0757

What is effective occupational therapy in inpatient traumatic brain injury? Results from traumatic brain injury–practicebased evidence (TBI-PBE) project Clare Giuffrida1, James Young1, Janet M. Powell2, Susan D. Horn3, Ryan S. Barrett3, Teri Sommerfeld1, & Christopher Reddin4 1


University of Washington, Seattle, WA, USA Objectives: With current healthcare trends, survivors of traumatic brain injury (TBI) spend less time in intensive rehabilitation and are discharged home with more deficits, imposing a heavy care burden on family caregivers. While some family/friend caregivers report positive aspects to caring for the TBI survivor, many report depression, anxiety, social isolation, somatic symptoms and marital stress. To date, most intervention studies have focused on facilitating adjustment and recovery for TBI survivors and little is known about the best way to support caregivers. The primary objective of this study was to evaluate the effectiveness of a telephone-based, individualized mentored problem-solving and education intervention on the quality-of-life and emotional well-being of caregivers of persons with TBI at 6 months post-injury. Methods: This study was a randomized controlled trial with blinded outcome assessment. Caregivers of persons with moderate-to-severe TBI who had received acute and/or rehabilitation care at a Level I trauma centre were randomly assigned to the study intervention or standard follow-up at the time the TBI survivor was discharged to the community. The intervention group received 7–10 calls delivered every 2 weeks. During each call, participants were mentored by a trained interventionist in a rational problem-solving approach aimed at addressing the caregiver’s primary concern at the time of that call. Problem-solving included issue definition, goal-setting, solution generation, solution evaluation and determination of an appropriate action plan. Caregivers were also directed to the appropriate educational module from a set of 12 modules developed for the study through a survey/focus group approach. Subsequent calls included review of the prior educational module and discussion of progress towards previously identified goal(s) including barriers to goal attainment. This was followed by mentored problem-solving for the current primary concern as well as for any non-attained goals of continued relevance to the caregiver. The primary outcome was a composite of the Bakas Caregiving Outcomes Scale (BCOS) and the Brief Symptom Inventory (BSI) on an intent-to-treat basis. Secondary measures included the Brief Cope. Results: One hundred and fifty-three caregivers (mean age ¼ 49.7, 82% female) were enrolled and randomized. Thirty-nine per cent of caregivers were spouses, 35% parents and 15% non-married significant others. Participants receiving the intervention endorsed significantly better quality-of-life and emotional well-being as measured by the BCOS and the BSI composite score (p ¼ 0.032). They also reported significantly more active coping (p ¼ 0.020) and significantly less venting (p ¼ 0.028) in managing caregiving’s challenges. Conclusions: An individualized mentored problem-solving and education approach delivered via telephone in the first few months following discharge of the TBI survivor to the community resulted in better quality-of-life and emotional well-being for caregivers. Consideration should be given to using this approach to supplement the support typically offered caregivers of TBI survivors.

Rush University Medical Center, Chicago, IL, USA, 2University of Washington, Seattle, WA, USA, 3Institute for Clinical Outcomes Research, Salt Lake City, UT, USA, 4United States Department of Navy, San Diego, CA, USA Objectives: Inpatient rehabilitation for TBI has often been studied as an undifferentiated black box with limited information to guide the practitioner in the delivery of care. Previous research has focused on effects of acute TBI rehabilitation interventions in the aggregate, without examining the effects of specific therapies or the interaction of care components with individual patient characteristics. The purpose of this study was to identify key therapeutic components of occupational therapy rehabilitation interventions associated with best outcomes for the TBI population, while controlling for patient characteristics. Methods: The multi-site collaborative federally funded TBI–practice based evidence study (TBI-PBE) enrolled 2205 individuals with TBI receiving inpatient rehabilitation at 10 participating facilities, nine within the US and one in Canada, over a 2-year time period. Each site obtained IRB approval for this observational study and attempted to enrol all patients 14 years and over admitted to the facility. TBI was defined as damage to brain tissue caused by external force and evidenced by loss of consciousness, post-traumatic amnesia, skull fracture or objective neurological findings. In the initial study phase, clinicians, including occupational therapists, developed disciplinespecific treatment taxonomies and, for each treatment session, documented their detailed interactions with the patient. In addition to the detailed, daily documentation of interventions performed in all therapy sessions, all medical procedures that were delivered were recorded. Data quality assurance included systematic training for clinical staff and chart abstracters, internal and external inter-rater reliability monitoring and electronic data verification. Results: Using multiple regression analyses, many predictor variables (i.e. occupational therapy activity intervention combinations) were found to be significantly associated with either better or poorer outcomes of discharge motor Functional Independence Measure (FIM), discharge cognitive FIM and other discharge FIM scores. When time spent in OT interventions within activities was added as predictors to the significant patient and injury variables, the increases in R2 varied from 3.9–39.9%. The increase in R2 was generally greater for patients with lower admission cognitive FIM levels than for patients with higher admission cognitive FIM levels. In addition, for those patients with lower admission cognitive FIM levels, there were distinct differences in the activity intervention combinations that impacted FIM outcomes for adults with TBI less than 65 and those 65 years and older. Conclusions: This is the first PBE study allowing for a systematic inquiry of current occupational therapy inpatient rehabilitation practices associated with motor and cognitive FIM outcomes for persons with TBI. For patients with lower admission cognitive FIM scores, this study identified several occupational therapy activity intervention combinations that were associated with better or poorer outcomes in adults with TBI under and over 65 years of age.

799

DOI: 10.3109/02699052.2014.892379

0758

Use of a home-based telerehabilitation platform for motor and cognitive treatment of a progressive spinocerebellar ataxia type 7 (SCA7): A case report Ruth Izquierdo, Alberto del Barco, Tatiana Ferreiro, Sonia Blasco, Pablo Gagliardo, Vicente Penades, & Javier Chirivella


Fivan, Valencia, Spain

Objectives: Spinocerebellar ataxia type-7 (SCA7) is an autosomaldominant neurodegenerative disorder characterized by a progressive loss of co-ordination and balance, retinal dystrophy and cognitive deficits. Methods: LC is a 43-year old male who was diagnosed 6 years ago with progressive SCA type-7. At the time, LC reported a gradual deterioration of balance and gait. He also experienced a reduced field of vision and ataxic dysarthria. Further clinical examination showed that he also suffered from bradykinesia. An MRI also showed discrete signs of cerebellar atrophy. The patient was assessed at baseline, 2 months after treatment started, at the end of treatment and 1 month later. The motor assessment instruments used included Tinetti performance-oriented mobility assessment (POMA), the Berg balance scale (BBS) and the unipodal stance time (UST) and the computerized posturography tool NEDSVE/IBV. The posturography study included analysis of sensory indexes, limits of stability and rhythmic weight shifts. LC also completed a full neuropsychological assessment. The clinical team scheduled a 60-minute motor rehabilitation session (to treat static and dynamic balance, co-ordination, lateral displacements amd transfers from a sitting to a kneeling position and from a single knee to a standing position) followed by a 60-minute cognitive rehabilitation session (which focused on attention, executive functions and visual perception) 5 days a week during 8 weeks. For his treatment, the patient used a motor and cognitive home-based telerehabilitation platform called neuro@homeÕ which uses clinicallydesigned videogames, virtual reality techniques, natural interfaces and remote monitoring by clinicians. Results: After 8 weeks of treatment, LC showed significant improvements in static amd dynamic balance, endurance and gait. The patient also showed improvements in attention and pre-frontal cognitive processes. Conclusions: The continuous use of a home-based telerehabilitation platform for both motor and cognitive rehabilitation has benefitted LC and it is believed that this success can be repeated with other patients suffering from spinocerebellar ataxia.

0759

Are clinical measures of cervical flexor endurance, divided attention and computerized dynamic visual acuity different in elite youth ice hockey players who report a previous history of

concussion compared to those who do not? Kathryn Schneider, Carolyn Emery, Jian Kang, & Willem Meeuwisse University of Calgary, Calgary, Alberta, Canada Objective: The objective of this study was to evaluate differences in baseline measures of cervical flexor endurance (CFE), walking while talking test (WWTT) and computerized dynamic visual acuity (cDVA) in elite youth ice hockey players who do and do not report a previous history of concussion. Methods: Five hundred and fifty Bantam (12–14 years) and Midget (15–17 years) ice hockey players participated in this cohort study. Participants completed a baseline questionnaire, including a question regarding previous history of concussion (yes/no) and baseline clinical tests (CFE, WWTT and cDVA) at the beginning of the season. Multivariate linear regression, adjusted for cluster, age group and sex was used to estimate mean differences in clinical measurement scores by concussion history (yes/no). Results: Individuals reporting a previous history of concussion were able to hold a test of cervical flexor endurance for a geometric mean time of 0.88 (95% CI ¼ 0.81, 0.97) seconds less than those who did not report a previous history of concussion (p ¼ 0.009). The time to complete WWTT complex compared to self-selected walking speed was a mean of 2.85 (1.09, 4,62) seconds slower in midget females with a previous history of concussion compared to those without a previous history of concussion. There was no evidence of a difference in cDVA scores at 120 per second. Players with previous concussion had significantly lower cDVA score at 85 per second than players without a previous concussion [cDVAleft ¼ 0.036 logMAR (95% CI ¼ 0.056, 0.016)]. Conclusions: Tasks of cDVA at 120 per second did not differ in individuals with a previous history of concussion compared to those without. Computerized dynamic visual acuity at 85 per second and cervical flexor endurance was lower in players with a previous history of concussion. The effect of past concussion history on tasks of divided attention depended on age group and gender. These findings allow a further understanding of clinical alterations that may persist following a concussion. Future research to understand the implications of these findings from an injury prevention standpoint is warranted.

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Patient with severe posttraumatic brainstem damage emerged from prolonged atonic coma into vegetative state: A case report Sergey Goryaynov, Evgenia Alexandrova, Vsevolod Shurkhay, Alexander Potapov, Natalia Zakharova, & Alexander Sichev Burdenko Neurosurgery Institute, Moscow, Moscow Region, Russia Background: Severe diffuse axonal injury (DAI) is a leading cause of prolonged vegetative state and death following traumatic brain injury (TBI), but the detailed mechanisms and prognostic factors in posttraumatic axonal brain injury are still unclear. Intensive care management in this case focuses on providing oxygenation, ensuring


800 brain perfusion and preventing even transient episodes of intracranial hypertension, arterial hypotension, hypoxia and hypercapnia. Recent imaging advances enabled classification of DAI into four grades based on the level of brain injury. The grade IV is associated with the worst outcome and death incidence. This case demonstrates a survived patient with DAI grade IV after prolonged (36 days) atonic coma. This work aims to describe the epidemiologic, clinical and neuroimaging features of post-traumatic DAI, treatment aspects and prognostic significance. Results: A 39 year old man had an accident while driving a motorcycle. He was unconscious on admission (GCS ¼ 4). Brain CT scan showed right hemispheric subdural haematoma, severe bilateral frontal and temporal lobes contusions and brainstem haematoma. MRI (T1, T2, FLAIR, SWI) revealed also multiple haemorrhages in brainstem (pons and medulla). Right parietotemporal craniectomy and evacuation of the subdural haematoma were performed at the first day. The patient remained in critical condition: GCS ¼ 3, absence of mesencephalic and pons reflexes. Active vasopressor and respiratory support was applied. On day 4 after the TBI the patient was transferred to the Burdenko Neurosurgery Institute. On day 5 he underwent extended right-side decompressive hemicraniectomy. In the post-operative period the patient still remained in deep coma accompanied by bilateral mydriasis, loss of midbrain and pontine reflexes. Therefore, another surgery followed consisting of right-side epidural haematoma evacuation and left-side decompressive hemicraniectomy. Postoperatively a slight improvement was observed in neurological status, but still the patient remained in a critical condition: GCS ¼ 3; pyramidal quadriplegia with muscular hypotonia; mesencephalic reflexes absence, superior and inferior pontine reflexes repression; preserved cough reflex. On day 36 after TBI the patient emerged from coma to a vegetative state: he started to move his right hand spontaneously, screw up his eyes, fix gaze with eyelids passively elevated and flex limbs in response to pain. The patient lacked the ability to open his eyes owing to bilateral injury of III nerve nuclei. Currently (day 70 after the injury) the patient continues treatment at the ICU of the Burdenko Institute. Conclusion: The presented case report has a certain value for the outcome prognosis after severe brainstem injury, since such patients rarely reach a hospital and often die during the few hours after the accident. It should also be emphasized that vegetative state cannot be properly diagnosed in patients with similar brainstem injuries, because they are unable to open their eyes due to bilateral midbrain segmental damage.

Brain Inj, 2014; 28(5–6): 517–878

Methods: Patients with a history of TBI and chronic pain will be treated with Scrambler Therapy for 10 consecutive sessions. Baseline pain levels using the Visual Analogue Scale, Psychological measures and cognitive measures will be gathered prior to treatment. Pain levels will be analysed before and after each treatment session. All patients will be followed for 6 months and the brief pain inventory as well as the Visual Analogue Scale will be re-administered and compared to pre-treament levels. Results: Preliminary information indicates pain relief rates above 70% at the time of treatment and also at 6-month follow-up. A recent study of patient’s with Complex Regional Pain Syndrome has demonstrated that 70% of the patients averaged 80% relief at 6 and 12 month follow-up. Conclusions: Scrambler Therapy (ST) is an electroanalgesic method of treating chronic neuropathic pain. Electrodes deliver a non-pain code through the skin (in an area above and below the pain) to the dorsal horn of the spinal cord and up to the brain through the spinothalamic tract. The ‘non-pain’ code travels witin the C-fibres and ultimately shuts down the pain neuromatrix. Recent research has indicated significant improvement in patients with various forms of neuropathic pain. The pain disorders seen with TBI are often ignored or have diminished importance since TBI issues are prominent. Preliminary evidence suggests that successful treatment of chronic pain in TBI patients result in improved cognitive functioning. Recent research indicates that chronic pain has a negative impact on cognitive function; therefore, the occurrence of chronic pain limits the cogntiive improvement expected in a patient with TBI.

0762

Late effects of TBI (LE-TBI) consortium: A multidisciplinary study to advance understanding of TBI outcomes Kristen Dams-O’Connor1, Paul Crane2, Ramon Diaz-Arrastia3, Wayne Gordon1, Dirk Keene2, Daniel Perl3, Joshua Sonnen2, & Brian Edlow4 1

0761

TBI, chronic pain and the use of scrambler therapy Frank Sparadeo1, Dmitry Meyerson2, & Stephen D’Amato3 1

Salve Regina University, Newport, RI, USA, 2University of Massachusetts, Amherst, MA, USA, 3Boston University, Boston, MA, USA Background: Traumatic brain injury (TBI) is often accompanied by chronic pain involving the head, neck or low back. Current methods of care for chronic pain have poor efficacy, are costly and can result in significant untoward effects (e.g. addiction, worsening pain, depression). A relatively new intervention that employs artificial intelligence to scramble the pain signal to the brain shows significant promise for future pain relief. Recent research has demonstrated significant pain relief in patients with complex regional pain syndrome, chronic failed back syndrome and peripheral neuropathy. Objectives: To emonstrate the impact of Scrambler Therapy on chronic pain in patient’s with TBI.

Icahn School of Medicine at Mount Sinai, New York, NY, USA, University of Washington, Seattle, WA, USA, 3Uniformed Services University of the Health Sciences, Rockville, MD, USA, 4Martinos Center/Massachusetts General Hospital, Boston, MA, USA 2

Objectives: This study will describe the methods and initial findings of a NIH/NINDS funded U01 project which aims to increase understanding of the late effects of traumatic brain injury (TBI) and chronic traumatic encephalopathy (CTE). The late effects of single and multiple TBI in non-athletes are poorly understood. CTE is incompletely described in convenience samples of athletes. The population incidence and prevalence, risk factors and causal role of multifocal tauopathy on associated symptoms are unknown. Likewise, the neuropathological consequences of single mild or moderate–severe TBI and its relationship with CTE and known dementias such as Alzheimer’s disease (AD) and Parkinson’s disease (PD) are unclear. The LE-TBI study provides an unprecedented opportunity to investigate TBI-related neurodegeneration in a well-characterized communitybased cohort. Methods: This study builds upon the Adult Changes in Thought (ACT) study, which includes one of the largest community-based brain banks in the world (521 autopsies to date; 20% have a documented TBI history). An additional cohort of individuals with moderate–severe TBI comes from the Brain Injury Research Center at Mount Sinai (BIRC-MS). Across both sites, 200 individuals will be evaluated with harmonized neurobehavioural, 3T MRI and genetic data collection procedures during life. Those who come to autopsy

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will undergo a uniform post-mortem neuropathology workup including state-of-the-art post-mortem imaging and whole brain serial-sectioning. Using appropriate statistical techniques, the incidence and prevalence of CTE and post-traumatic neurodegeneration will be estimated in community samples. These methods will allow examination of the neuropathological similarities and differences between single mild vs single moderate–severe TBI vs. repetitive trauma. The LE-TBI project will facilitate unprecedented evaluations of relationships between pre-mortem and post-mortem markers of TBI and CTE and lead to development of consensus criteria for CTE and late effects of TBI. Results: Methods and preliminary findings from the LE-TBI study will be presented; this will include neuropathological findings from the existing ACT autopsy cohort (20% with TBI history) using the Histelide approach to quantify pathologic tau and A species. Conclusions: Until now, TBI has never been studied in a populationbased cohort with brain autopsy end-points. By leveraging a population-based autopsy sample one can identify the implications of TBI and CTE for the population at large. By using state-of-the-art epidemiological, in vivo and ex vivo imaging, genetic, neuropathological and statistical methods, the LE-TBI study stands to dramatically improve understanding of the late effects of TBI and CTE.

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Update of guidelines for concussion/mild traumatic brain injury and persistent symptoms for adults

individuals having sustained concussion/mTBI, emergency nursing and insurance. Organizations represented include the Ontario Brain Injury Association and the Centers for Disease Control. External review occurred prior to publication. Results: The evaluation found that physician knowledge and confidence of persistent symptom management increased by using the guideline. Over 70% of the physicians indicating the guidelines changed their practice and 73.4% of physicians found the guidelines easy to use. Over 70% of the sports physicians commented that the guidelines had increased their confidence in the treatment of patients with concussion/mTBI. The ONF Guidelines for Concussion/Mild Traumatic Brain Injury and Persistent Symptoms were released on 24 September 2013, addressing diagnosis, initial and longer term management of persistent symptoms, as well as guidance for return-to-work and post-secondary education. They are available for free download on http://www.onf.org and http://www.concussionsontario.org. One week analytics showed 12 911 website hits on the Guidelines and this continues to be monitored. Conclusions: Few clinical practice guidelines are evaluated with users to obtain feedback and to highlight implementation barriers and facilitators. A knowledge translation exercise can be helpful at improving engagement and fostering future use of clinical practice guidelines. The resulting guideline reflects the most recent and strong base of evidence, broad and expert clinical guidance and considerations of user needs and input.

0765

Advanced visualization of subtle skull fractures and haematomas—How does it work in a realistic clinical setting?

Shawn Marshall1, Mark Bayley2, Diana Velikonja3, Scott McCullagh4, Donna Ouchterlony5, & Lindsay Berrigan6

Helmut Ringl, Puchstein Armin, Christian Czerny, & Stefan Hajdu

1

Medical University of Vienna, Vienna, Austria

The Ottawa Hospital Rehabilitation Centre, Ottawa, Ontario, Canada, 2Toronto Rehabilitation Institute, Toronto, Ontario, Canada, 3 Hamilton Health Sciences, Hamilton, Ontario, Canada, 4Sunnybrook Health Sciences, Toronto, Ontario, Canada, 5St. Michael’s Hospital, Toronto, Ontario, Canada, 6Dalhousie University, Halifax, Nova Scotia, Canada Objective: Concussion, also known as mild traumatic brain injury (mTBI), has become an injury epidemic. Most people will recover anywhere from a week up to 3 months, but 10–20% do not recover as expected and suffer from persistent symptoms that can impair their daily lives. The objective of this project was to evaluate the usefulness and usability of the first version of Guidelines for mTBI and Persistent Symptoms and to make use of the results along with the latest evidence to update the Guidelines. Methodology: The first version underwent a formal evaluation by sports and military physicians. Five 3-hour educational workshops using case examples of persistent symptoms were held across Ontario; four workshops with 64 sports medicine physicians and one workshop with 14 military physicians. A pre–post test design was used to determine whether participating physicians had changed their practice by using the mTBI guidelines. Enablers and barriers during the implementation were identified and used to identify improvements to the subsequent version. The update was sponsored by the Ontario Neurotrauma Foundation. Literature reviews identified relevant research since 2008. Related clinical guidelines published since 2009 were identified and the quality rated using the AGREE-II tool. A 7-member team led the guideline update utilizing the ADAPTE methodology for guideline development, working with a 35-member expert panel from Canada, the US and Australia. The panel included experts from rehabilitation and medical professions, sports, military,

Purpose: To retrospectively assess the detection rate for intracranial haematomas and skull fractures achieved with use of curved maximum intensity projections (MIPs) of the meningeal spaces and the external layer of the skull compared with the rate achieved by reading transverse sections of computed tomography (CT) alone in a realistic clinical setting. Materials and methods: This retrospective study was approved by the institutional review board, which waived informed consent. A total of 200 consecutive patients who underwent CT for minor cranial trauma were included. The Advanced Visualization algorithm unfolded the meningeal spaces and the external layer of the skull into plane 2D images. These patients were divided into two groups with 100 patients each. Two radiologists dictated complete cranial CT reports for all these patients separately from each other. The first radiologist reported the transverse sections of group 1 and the transverse sections as well as the unfolded reconstructions from group 2. The second radiologist reported the transverse sections and the unfolded reconstructions of group 1 and transverse sections from group 2. Radiologists were blinded to patient names and patient and group orders were randomly assigned. The time for the complete report was recorded for each patient for each reader and the dictated reports were analysed for the presence or absence of haematomas and fractures. The results were compared with a reference standard built by expert in neuroradiology and head and neck radiology who had all follow-up examinations and reconstructions available. Logistic regression with repeated measurements was used for statistical analysis. Results: The reference standard confirmed 12 intracranial haematomas and 18 cranial fractures. The mean lesion based detection rate for

802 dural haematomas was 50% (6/12) for transverse sections and 83.3% (10/12) for the combination of transverse sections and unfolded views. The mean lesion-based detection rate for fractures was 61% (11/18) for transverse sections and 88.8% (16/18) for the combination of transverse sections and unfolded views. The mean reading time for the combination of transverse sections and unfolded views was 17 seconds shorter than for transverse sections alone in patients without abnormal findings (93 and 110 seconds, respectively) and 6 seconds shorter than for patients with abnormal findings (154 and 160 seconds, respectively). The difference was significant for both groups with p50.001. Conclusion: Advanced visualization of the meningeal spaces and the external layer of the skull shortens the reporting time and significantly increase the sensitivity for epidural and subdural haematomas.

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Development of a risk weighted cumulative exposure metric for the analysis of head impact data Joel Stitzel1, Jillian Urban1, Elizabeth Davenport1, Joseph Maldjian2, Christopher Whitlow2, & Alexander Powers3 1

Virginia Tech - Wake Forest University School of Biomedical Engineering and Sciences, Winston-Salem, NC, USA, 2Department of Radiology (Neuroradiology), Winston-Salem, NC, USA, 3Department of Neurosurgery, Winston-Salem, NC, USA, 4Wake Forest University School of Medicine, Winston-Salem, NC, USA, 5Translational Science Institute, Winston-Salem, NC, USA Objectives: Sports-related concussion is the most common athletic head injury, with football having the highest rate among high school athletes. Neurocognitive testing, structural neuroimaging and functional neuroimaging are commonly used to assess changes in the brain pre- and post-season and are subsequently correlated with head impact data. Traditionally, biomechanical data used to assess athlete exposure has been limited to median impact, 95th percentile impact, number of impacts and summed acceleration for an athlete. While these metrics are valuable in assessing exposure, they do not capture the non-linear relationship between impact magnitude and concussion risk. The objective of this study is to develop a risk weighted cumulative exposure metric that may be used to better correlate with neurocognitive and neuroimaging data. This novel metric will then be applied to real-world head impact data collected at the youth and high school level to better understand age-specific cumulative exposure. Methods: Head impact exposure was measured by instrumenting the helmets of 36 youth football players (aged 9–12) and 40 high school football players (aged 14–18) with helmet mounted accelerometer arrays to measure linear and rotational acceleration. An impact exposure metric utilizing concussion injury risk curves was created to quantify cumulative exposure for each participating athlete over the course of the season. Impacts were weighted according to the associated risk due to linear acceleration and rotational acceleration alone, as well as the combined probability (CP) of injury associated with both. These risks are summed over the course of a season to generate risk weighted cumulative exposure (RWE). A non-parametric Wilcoxon test was performed to assess age group differences in RWE. Results: A total of 9772 impacts were collected over the course of a season for the youth athletes and 16 502 head impacts were collected for the high school athletes. The median (and 95th percentile impact) for the youth and high school athletes were 19 grams (50 grams) and 21 grams (58 grams), respectively. The youth athletes were found to have significantly lower cumulative exposure over the course of the season compared to the high school athletes for each of the three acceleration-based risk metrics analysed (RWELinear, RWERotational and

Brain Inj, 2014; 28(5–6): 517–878

RWECP, p50.001 for each). Within each group, athletes with the greatest number of impacts did not always result in the highest RWE for each acceleration type. Conclusions: Establishment of a risk-based cumulative exposure metric is vital to understanding the biomechanical basis of head injury that may occur over the course of the football season and potentially will have importance in correlating with potential pre- and post-season changes in the brain identified with magnetic resonance imaging, magnetoencephalography and other neurological tests.

0767

Neuropsychological performance in individuals with mild traumatic brain injury with and without post-traumatic stress disorder Katherine Lopez1, Sarah Levy1, John Dsurney1, & Leighton Chan2 1

Center for Neuroscience and Regenerative Medicine, Bethesda, MD, USA, 2National Institutes of Health, Clinical Center, Bethesda, MD, USA Objectives: Research has revealed increased prevalence of posttraumatic stress disorder (PTSD) following mild traumatic brain injuries (mTBI). While recent studies have focused on characterizing clinical features of co-morbid mTBI and PTSD, few efforts have been made to understand the cognitive sequelae of these co-occurring conditions. The present study seeks to examine cognitive functioning in mTBI patients with and without PTSD. Methods: A total of 23 subjects completed a comprehensive battery of neuropsychological assessments. Participants were divided into two groups with scores based on the PTSD Checklist (PCL). Participants with a PCL score444 were included in the PTSD positive group (n ¼ 13, mean age ¼ 39.9) while participants with score 20 were included in the PTSD negative group (n ¼ 10, mean age ¼ 44.2). Results: A univariate ANOVA revealed significant between-group differences (p50.05) in assessments measuring executive functioning and processing speed. The PTSD positive group showed greater impairments in problem-solving, cognitive flexibility and visual-motor processing speed. A post-hoc MANOVA showed further deficits in learning, immediate and delayed memory, concentration and working memory and visuospatial abilities. In addition, mTBI with co-morbid PTSD was associated with a greater number of neurobehavioural symptoms and lower satisfaction with life than subjects with mTBI alone. Conclusions: These findings suggest greater cognitive dysfunction, increased symptom complaints and poorer quality-of-life in mTBI patients with co-morbid PTSD.

0768

Effects of a neuropsychological rehabilitation programme aphasia: A case of motor afferent Arturo Lopez1, Maria Victoria Bartolome´2, & Valentina Ladera2 1

Autonumus University of Puebla, Puebla, Mexico, 2University of Salamanca, Salamanca, Spain Aphasia is defined as a systemic disorder of language due to brain damage. A. R. The proposed Luria, aphasia syndromes can be

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classified according to neuropsychological mechanism is based on alterations to the patient and this will help the diagnosis and rehabilitation. The problem of neuropsychological rehabilitation is an ongoing problem, because there are few studies that describe in detail the treatment to be used in aphasic patients. Most contemporary neuropsychology research focuses on aspects of diagnosis and leave in the background to rehabilitation and if occasionally resumed limited to patient training on specific tasks that attack the symptom. Also not solved is the problem concerning the brain basis underlying the rehabilitation of the functions, i.e. it is not clear what happens in the brain after recovering functions. The goal is to present the assessment and rehabilitation work performed on a patient with Afferent Motor Aphasia (diagnosis based on the proposal of AR Luria) and determine the effectiveness of the programme. It presents the content of the rehabilitation programme, examples of implementations of the patient before and after the intervention. On the neuropsychological assessment parameters pre- and posttreatment. The results showed that the rehabilitation programme led to changes in the patient’s psychic sphere, manifested in the improvement of higher mental functions. So to specifically observe changes in the patient’s verbal output which increased, significantly reducing verbal paraphasias presented at first, too, was more organized in their written and verbal executions, reducing collateral issues and improving written work as requested. It is argued that the neuropsychological rehabilitation programme developed from the central defect accurate analysis leading to the positive effects on the activity of the patient’s verbal and written.

0769

Age and recovery time following sport-related concussion Grant Iverson1, Maulik Purohit2, & Ross Zafonte1 1

Harvard Medical School, Boston, MA, USA, 2National Intrepid Center of Excellence: Intrepid Spirit One, Fort Belvoir, VA, USA

Objectives: It has been widely reported that most athletes with concussions recover functionally within 10 days. There is some evidence that children and adolescents take longer to recover. This study examined recovery time in student athletes between the ages of 13–23. Methods: Athletic trainers from multiple high schools and colleges in the US collected baseline and post-injury data via the SportsWareOnLine injury tracking system. A sample of convenience was selected from a large de-identified database. Subjects were included if (i) athletic trainers recorded concussions (n ¼ 176) or posttraumatic headache (n ¼ 5) as the diagnosis and (ii) the number of days prior to returning to play was entered. Their average age was 16.7 years (SD ¼ 2.2, range ¼ 13–23). Results: The median recovery time for the total sample was 12 days (M ¼ 17.7, SD ¼ 28.7, IQR ¼ 8.5–17.0, Range ¼ 1–344). For 13–17 year olds (n ¼ 134), the median recovery time was 13 days (M ¼ 19.1, SD ¼ 31.5, IQR ¼ 10–20, Range ¼ 2–344). For 18–19 year olds (n ¼ 27), the median recovery time was 11 days (M ¼ 17.0, SD ¼ 25.6, IQR ¼ 8– 16, Range ¼ 2–138). For 20–23 year olds (n ¼ 20), the median recovery time was 8 days (M ¼ 10.8, SD ¼ 9.0, IQR ¼ 6–15.25, Range ¼ 1–43). There was an overall main effect of age group on recovery time [Kruskal-Wallis (2,181) ¼ 10.0, p ¼ 0.007]. Pairwise comparisons revealed that the 13–17 year olds took longer to recover than the 20–23 year olds (p ¼ 0.012). The percentages who took longer than 10 days to return-to-play were as follows: total sample ¼ 62.7%, 13–17 year olds ¼ 68.7%, 18–19 year olds ¼ 51.9% and 20–23 year olds ¼ 40%. Conclusions: In this study, 63% of concussed athletes took longer than 10 days to recover and return-to-play. The 13–17 year olds took longer to return to play than the 20–23 year olds. The extent to which parents influenced time to return to sport or access to healthcare professionals for medical clearance was a factor in these results, could

not be determined. Therefore, firm conclusions about recovery time in younger athletes cannot be drawn from this uncontrolled descriptive study.

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Pathological changes in the brains of veterans with histories of blast exposure Jiwon Ryu1, Iren Horkayne-Szakaly2, Leyan Xu1, Charles Eberhart1, Juan C. Troncoso1, & Vassilis Koliatsos1 1 2

Johns Hopkins University School of Medicine, Baltimore, MD, USA, USARMY MEDCOM USAMRMC, Bethesda, MD, USA

Introduction: Blast injury to brain is a 100-year old problem with poorly characterized neuropathology. Blast injury has re-surfaced as health concern in the wake of Operation Iraqi Freedom (OIF)/ Operation Enduring Freedom (OEF), but also with respect to explosive terrorist threats on civilians. Methods: To characterize the neuropathology of blast injury, this study examined the brains of OIF/OEF veterans with immunocytochemical and general histochemical methods for the presence of axonal abnormalities (amyloid precursor protein [APP]-positive axonal swellings typical of diffuse axonal injury [DAI]) and compared them with cases of patients who die with similar agonal events (methadone overdose and/or anoxia-ischaemia), non-blast traumatic brain injury (TBI) (DAI from motor vehicle crashes and contusions from falls) and healthy controls. Key comparisons, i.e. between blast exposure with methadone overdose vs methadone overdose without prior blast history, were studied in greater detail in the mesial frontal lobe; comparison was based on the severity of axonal pathology assessed with unbiased stereology (areal fraction fractionator). The presence of tauopathy was also studied in brains with blast histories on separate sections. Results: In cases with blast history, DAI was found in several brain sites, especially the parasagittal frontal white matter and the corpus callosum, featured by lattices of abnormally swollen axons with perivascular distribution. This pattern was different from classical multifocal lesions encountered in cases of TBI due to motor vehicle accidents. Some opiate overdose cases showed similar lesions, but such lesions were significantly less intense than those of blast subjects from OIF/OEF. None of the blast cases showed tauopathy based on reactivity to phosphorylated tau antibodies AT8, PHF1, CP13 and MC1. Interpretation: These findings demonstrate that blast exposure is associated with a characteristic pattern of axonopathy that has not been described before, although a contributory role of opiate overdose and/or anoxia cannot be ruled out. In this case material, no signs of tauopathy classically associated with chronic sports injuries were found. Blast injury to brain may have complex neuropathology but may also include specific patterns of axonal damage.

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The utility of structural MRI as a predictor of neuropsychological outcome in TBI 1 month post injury: A pilot study Sarah Levy1, Katherine Lopez1, John Dsurney1, & Leighton Chan2

804 1


Center for Neuroscience and Regenerative Medicine, Bethesda, MD, USA, 2National Institutes of Health, Clinical Center, Bethesda, MD, USA

Brain Inj, 2014; 28(5–6): 517–878

Therapy, Faculty of Medicine, University of Toronto, Toronto, ON, Canada

Objectives: Previous literature on imaging in TBI has had mixed results regarding the predictive value of imaging findings on functional outcomes. McMahon et al. found no difference in functional outcome between mTBI patients who were CT positive or CT negative. Most of the previous literature has focused on CT findings and only more recently on MR findings. The objective of the current study is to compare outcome in participants with positive vs negative MRI findings using neuropsychological assessment, self-report measures and observational tests of functional outcome. Methods: Twelve participants (seven male, five female) with a mild/ moderate traumatic brain injury (TBI) were selected from a larger cohort enrolled in a larger observational study of TBI, based on having a comprehensive neuropsychological battery and MRI scan at 1 month post-injury. Participants had a mean age of 41.5 (SD ¼ 16.4) with 15.9 (SD ¼ 2.3) years of education. All participants had a loss or alteration of consciousness less than 30 minutes. Participants were classified into the MRI positive or MRI negative group based on the presence or absence of structural MRI abnormalities at 1 month postinjury. All participants underwent neuropsychological testing that evaluated the domains of motor function, attention, construction, language, memory and executive function. In addition, self-report questionnaires assessed cognitive and psychological symptoms and functional outcome was assessed by independence in daily living. Demographically corrected standard scores were transformed into adjusted Global Deficit Scores (GDS). The deficit scores were adjusted using pre-morbid functioning as the mean from which impairment was determined. A mean GDS score was then calculated by averaging the deficit scores across tests. Overall cognitive impairment was designated by a cut-off GDS measure of 40.05, as commonly used in the literature. Results: There was no significant difference between the two groups for age, education and estimated pre-morbid IQ. Half of the MRI negative group and one-third of the MRI positive group were cognitively impaired at 1 month post-injury, yet there was no significant difference between overall GDS score between groups (p ¼ 0.742). Within the self-report measures only a questionnaire counting depressive symptoms was significantly higher in the MRI negative group (p ¼ 0.04). In observational tests of functional outcome there was no difference between the two groups. Conclusion: Ultimately participants with positive MRI findings did not perform more poorly on cognitive measures or report more symptoms at 1 month compared to participants with no MRI findings. This study suggests that structural MRI findings obtained in the postacute phase may offer no better prediction of functional outcome over CT. More research is needed to elucidate imaging and other techniques may be better predictors of long-term outcome following TBI.

Objectives: Concussion or mild traumatic brain injury (mTBI) is one of the most commonly reported injuries in youth athletes. Neuropsychological testing, including an assessment of cognitive function, informs concussion evaluation and clinical management including return-to-play (RTP). Current paediatric graduated RTP protocols dictate that the athlete progress to the subsequent level once asymptomatic at the current level. As cognitive recovery largely overlaps with symptom resolution, it is thought that current RTP protocols allow sufficient time for cognitive recovery. The objective of this case report is to describe the recovery of a 12-year old female ice hockey player who sustained a mTBI during ice hockey play. This case report presents a description of cognitive performance at pre- and post-injury time intervals. Scant research exists regarding the influence of gender on recovery from sports-related mTBI; as such, the current study design is an appropriate starting point for research in this area and serves to add to the limited knowledge base regarding sports-related mTBI in this population. Methods: A case study was conducted to compare pre- and postinjury performance within a single female youth ice hockey player. Assessment of post-concussive symptoms (the Post-Concussion Scale-Revised) and working memory (verbal and non-verbal reaction time) was completed at baseline (pre-injury), days 3 and 6 post-injury and upon symptom resolution (day 22 post-injury). Additionally, a selective attention task (Stroop Color-Word Test) was completed at baseline and upon symptom resolution. Results: Performance on the Stroop Color-Word Test returned to baseline at symptom resolution. In contrast, performance on the working memory task (reaction time) did not return to baseline at symptom resolution. Conclusions: Performance on the Stroop Color-Word Test reflected the assumption that cognitive recovery largely overlaps with symptom resolution; however, performance on the working memory task (reaction time) did not reflect this assumption. Working memory allows for the manipulation of information held in short-term storage. Functionally, working memory allows an individual to respond to visual and spatial information in the environment. In the context of ice hockey, working memory allows a player to incorporate visual and spatial information (e.g. an opposing player’s movement) into split second decision-making; a change in working memory reaction time may result in a declined ability to respond to visual and spatial cues, potentially impacting athlete performance and safety. Future research is needed to explore measures of increased sensitivity and complexity to better inform the recovery of cognitive abilities in youth following sport-related mTBI. Measures of increased sensitivity may provide a more accurate index of readiness to RTP than is currently offered by post-concussion symptom report and common measures of cognitive performance. This case report has potential clinical implications for youth athletes in general and youth female ice hockey players specifically.

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Case report: Recovery following sports-related mild traumatic brain injury in a youth female ice hockey player

Discrepancies between expert readers in cranial CT performed for mild and moderate traumatic brain injury

Katie Mah1, Nick Reed2, Michelle Keightley2, & Talia Dick2

J. Stephen Huff1, & Douglas Oberly2

1

Graduate Department of Rehabilitation Sciences, University of Toronto, Toronto, ON, Canada, 2Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, ON, Canada, 3Department of Occupational Science and Occupational

1

University of Virginia, Charlottesville, VA, USA, 2BrainScope Company, Inc, Bethesda, MD, USA Objectives: To verify initial clinical site CT readings in traumatic brain injury by expert adjudication panel review.

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Methods: As part of a pivotal trial to detect traumatic brain injury using quantitative measures of brain electrical activity, CT scans were obtained as part of routine clinical care in patients with brain injury. Subjects enrolled were adults between the ages of 18–80 years, with GCS of 8–15 and were symptomatic from head injury. Most patients experienced minor traumatic brain injury defined as force delivered to the head and symptoms of concussion. Patients were evaluated in the emergency departments of 11 medical centres. As part of the trial, initial CT readings were made at each clinical site then images were electronically transmitted to a central site using DICOM standards and over-read blindly by three certified neuroradiologists. Adjudication was performed and final determination of truth was by majority score of the adjudication panel. Results: Twenty one of 137 scans (16.6%) of CT readings had discrepant results between initial site determinations and final adjudicated results, with most adjudications resulting in abnormal traumatic CT findings being interpreted as normal by the review panel. Additionally, all three adjudicators agreed with the positive reading in only 85% of the cases. Conclusions: Significant discrepancies were present between expert readers for cranial CT in TBI. Additional biomarkers are necessary to define the injury.

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Development and validation of the safety assessment measure for persons with TBI Ronald Seel1, Stephen Macciocchi1, & Craig Velozo2 1

Shepherd Center, Atlanta, GA, USA, 2Medical University of South Carolina, Charleston, SC, USA, 3University of Florida, Gainesville, FL, USA Objectives: Upon re-integration back to the home and community, heterogeneous impairments place persons with TBI at increased risk for subsequent unintentional injury or harm (UIH). This paper presents data on the development of the Safety Assessment Measure (SAM) for determining persons with TBI who are at risk for UIH. Methods: The SAM was developed using state-of-the art mixed, qualitative and quantitative methods. Research literature review, focus groups and cognitive interviewing were used for item development and content validation. A developmental sample was tested and single parameter Item Response Theory (Rasch) analyses were used to investigate the psychometric properties of the five SAM scales. Results: The SAM has five primary scales that assess factors associated with UIH: Cognitive Capacity, Visuomotor Capacity, Risk Perception, Health Compliance and Self-Regulation. The five SAM scales showed high content validty based on item ratings from a broad spectrum of rehabilitation therapists (n ¼ 26). A developmental sample (n ¼ 164) of persons with moderate and severe TBI who were rated by family members and treating rehabilitation therapists showed that the five scales demonstrated unidimensionality, good infit and outfit, very good levels of precision and high levels of internal consistency reliability. Conclusions: Initial evidence indicates that the SAM has good psychometric properties content validity, relaibility and precision and may serve as a measure of patient risk for unsafe events in the home and community.

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US Department of Defense progressive return to activity following mild TBI: An evidencebased clinical recommendation Katherine Helmick, Therese West, Robert LaButta, & Helen Coronel Defense and Veterans Brain Injury Center, Silver Spring, MD, USA Objectives: Mild traumatic brain injury (mTBI)/concussion is a common injury affecting many US service members both in war and peace time. Current literature recommends a gradual return to normal activity as soon as safely possible using a graded protocol. However, the graded progression of activity after concussion for symptomatic individuals is not standardized. These clinical recommendations were developed for use within the Military Health System and the Department of Veterans Affairs in order to standardize a graded, staged approach for the return to pre-injury activity consistent with current evidence. Methods: The Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE) and the Defense & Veterans Brain Injury Center (DVBIC) in collaboration with a broad range of clinical and academic subject matter experts developed clinical recommendations for the step-wise return to unrestricted activity. Consistent with the metabolic disturbances described by Hovda and others these recommendations give guidance for physical, vestibular and cognitive activities while defining activities to avoid. Results: The progressive return to activity recommendations: (1) Offer a conservative approach to recovery to enhance healing; (2) Provide a 6-stage progression from rest to full return to pre-injury activity; (3) Utilize the Neurobehavioural Symptom Inventory (NSI) for evaluating symptoms at each stage; (4) Defines the phase of Rest; (5) Give guidelines for progression, regression and referral; and (6) Provide two complimentary tiers of step-wise progression based upon experienced symptoms and provider expertise in rehabilitation. Conclusions: These clinical recommendations support patients with relatively few and mild symptoms being managed by primary care providers. Primary care management utilizes an education intervention, follows a relatively self-guided staged recovery and requires exertional testing before returning to pre-injury activity. Patients who are more symptomatic or who do not progress while in primary care management are referred to rehabilitation providers for a more intensive clinician-directed, daily monitored, staged recovery. The utility and adaptability of these clinical recommendations extends beyond military concussions, may be applied to athletes at the high school, collegiate and professional levels, as well as other concussive injuries in the civilian population.

0777

Evaluation of residual symptoms in subjects with single or multiple head injuries Christian Shenouda1, John Dsurney1, Shannon McNally2, Sarah Levy1, Katherine Lopez1, & Leighton Chan2 1

Center of Neuroscience and Regenerative Medicine, Bethesda, MD, USA, 2National Institues of Health, Bethesda, MD, USA


806 Introduction: The relationship between multiple traumatic brain injuries (TBIs) and chronic post-concussive symptoms is complex and multidimensional. At this time, the relationship between multiple head injuries and cognitive impairment, mood alteration and symptom reporting is still unclear. Some studies have found the number of concussions and the time interval between injures to be determinants of recovery. Other studies have shown no significant difference in overall cognitive functioning between athletes with no concussion history and a history of multiple concussive injuries. The purpose of this study was to examine the relationship between the number of head injuries and residual deficits in the domains of cognitive functioning, psychological functioning and symptom reporting. Methods: The subjects are 77 community-dwelling patients who were classified as having had a TBI. Participants were enrolled regardless of head injury severity. The sample consists of 45 males and 32 females ranging in age from 19–76 (M ¼ 44.12) who were evaluated between 30 days and 5 years post-injury. The Ohio State University (OSU) TBI Identification was administered and used to determine presence of multiple TBIs. A battery of validated measures assessing cognitive and psychological functioning as well as symptom quantification was administered. These measures included Test of Pre-morbid Functioning, California Verbal Learning Test-2 (CVLT-2), Trails A and B, WAIS-IV PSI, Brief Symptom Inventory (BSI-18), Beck Depression Inventory-2 (BDI-2) and the Neurobehavioural Symptom Inventory (NSI). Subjects were divided into two groups, those with a history of a single TBI and those with two or more lifetime TBIs using data obtained from the OSU. Individual scores from the psychological measures, symptom report and demographically corrected t-scores for neuropsychological test were compared using a one-way ANOVA. Results: Individuals with a history of multiple TBIs showed decreased processing and psychomotor speed as compared to those individuals with a history of a single TBI. The analysis showed increased levels of psychological symptoms in those with multiple head injures (as measured by BSI-18). Analysis of self-reported cognitive or depressive symptoms did not approach significant levels between the two groups. Discussion: There has been much discussion regarding chronic effects of multiple traumatic brain injuries. This analysis shows differences in cognitive domains of processing speed and psychomotor speed in individuals with multiple head injuries. Additionally, results of this study show increased rates of psychological symptoms in those individuals with multiple head injuries as measured by the BSI-18. These findings suggest that repetitive head injury may pre-dispose individuals to worse cognitive and psychological outcomes as compared to those individuals with an isolated head injury.

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Differential effects of bromocriptine and pergolide on working memory performance and brain activation patterns in individuals with mild traumatic brain injury (MTBI) Thomas McAllister1, Brenna McDonald1, Laura Flashman2, Richard Ferrell2, & Andrew Saykin1

Brain Inj, 2014; 28(5–6): 517–878

effect. Animal work suggests that D1 stimulation enhances WM. It has previously been shown that bromocriptine, a selective D2 agonist, did not improve WM or cerebral activation in individuals with mild traumatic brain injury (MTBI). Although there are no selective D1 agonists currently available for human use, pergolide is a mixed D1/D2 agonist. It was hypothesized that pergolide would improve WM performance and normalize brain activation patterns in individuals studied shortly after MTBI relative to healthy controls. Methods: Fifteen MTBI patients (ACRM criteria) were studied 1 month after their injury and compared to 17 healthy controls. At separate study visits participants were given 2 mg bromocriptine or 0.05 mg pergolide 2.5 hours before undergoing functional MRI 1 month after injury. Serum prolactin levels were assessed to central dopaminergic response. Participants performed a visual verbal n-back task with variable processing load requirements (0, 1, 2 and 3-back conditions) during the fMRI. Results: Groups did not differ demographically. There was a significant group-by-drug interaction (p ¼ 0.015) on a measure of mean performance across conditions of the n-back task. The MTBI group performed better when on pergolide than when on bromocriptine, while the controls performed worse on pergolide than bromocriptine. There was also a significant main effect of group, with controls performing better than those with MTBI (p ¼ 0.033) and of performance on bromocriptine, with controls performing better than the MTBI group (p ¼ 0.002). fMRI activation maps during the most challenging task condition (3-back40-back) also showed a significant group-by-drug interaction, with the MTBI group showing increased activation in WM circuitry regions including the left inferior frontal gyrus (Brodmann Area 46) while on pergolide relative to bromocriptine. Across all subjects there was a positive correlation between change in activation in this region and change in performance between drug conditions (r ¼ 0.431, p ¼ 0.014). Conclusion: These preliminary results provide additional evidence of alterations in dopaminergic function after MTBI. Further, they suggest that dopamine receptors differ with respect to their effect on cognition shortly after MTBI. Activation of D2 receptors may exacerbate WM problems, whereas activation of the D1 receptor may improve WM performance. This has implications for development of pharmacologic strategies to treat cognitive deficits after MTBI.

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A systematic review of the clinical course, natural history and prognosis for paediatric MTBI: Results of the International Collaboration on MTBI Prognosis (ICoMP) Ryan Hung1, Linda Carroll2, Carol Cancelliere3, Pierre Cote3, Peter Rumney1, Michelle Keightley1, Victor Coronado4, Britt-Marie Sta˚lnacke5, & J. David Cassidy3 1

1

Indiana University School of Medicine, Indianapolis, IN, USA, 2 Geisel School of Medicine at Dartmouth, Hanover, NH, USA Objectives: Evidence from animal and human studies suggests that dopaminergic mechanisms play an important role in the modulation of working memory (WM) circuitry. Dopamine D1 and D2 receptors differ with respect to patterns of regional brain distribution and

Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada, 2University of Alberta, Edmonton, Alberta, Canada, 3 University of Toronto, Toronto, Ontario, Canada, 4National Center for Injury Prevention and Control Centers for Disease Control and Prevention, Atlanta, GA, USA, 5Umea˚ University, Umea, Sweden Objective: To synthesize the best available evidence on prognosis after paediatric mild traumatic brain injury (MTBI).

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DOI: 10.3109/02699052.2014.892379

Methods: The databases MEDLINE and others were searched (2001– 2012) with terms including ‘craniocerebral trauma’, ‘prognosis’ and ‘children’. Reference lists of eligible articles were also searched. Systematic reviews, meta-analyses, randomized controlled trials and cohort and case-control studies were selected according to predefined inclusion and exclusion criteria. Studies had to have a minimum of 30 MTBI paediatric cases. In total, 77 914 titles and abstracts were screened for the entire review. Eligible studies were critically appraised using a modification of the Scottish Intercollegiate Guidelines Network (SIGN) criteria. Two reviewers independently reviewed each study and extracted data from accepted papers into evidence tables. The evidence was synthesized qualitatively according to modified SIGN criteria and prioritized according to design as exploratory or confirmatory. Results: Twenty-five papers were accepted as scientifically admissible for review. Most studies show that post-concussive symptoms resolve over time. Limited evidence from one cohort suggests that postconcussive symptoms may persist in those with lower cognitive ability and intracranial pathology on neuroimaging. Most studies reported no long-term MTBI-specific cognitive deficits in children. Limited evidence from one exploratory study shows that children with intracranial pathology may experience cognitive deficits up to 1 year post-injury. Preliminary evidence suggests that the risk of epilepsy is increased post-MTBI 10 years post-injury; however, there is insufficient high quality evidence at this time to support this link. Conclusions: Most studies show that post-concussive symptoms and cognitive deficits resolve with time; however, limited evidence suggests that children with intracranial pathology on imaging may experience persisting symptoms or deficits. Well-designed, long-term confirmatory studies are needed to confirm these findings.

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Evaluation of cognitive performance in collegiate athletes with and without a previous history of concussion Robin Wellington1, Nicholette Gabel2, Keenan Walker1, & Michelle Yakobson1 1

St. John’s University, Queens, NY, USA, 2Michigan Medical School Consortium, Ann Arbor, MI, USA Objective: The purpose of this study was to examine attention and memory differences in computerized neurocognitive performance among athletes with a previous history of concussions and athletes with no self-reported history of concussion in order to examine the possible long-term effects of concussions on cognition. Method: Retrospective analysis of baseline neurocognitive data of NCAA student-athletes. Neurocognitive performance was measured by a computerized neurocognitive test battery (Immediate Postconcussion Assessment and Cognitive Testing (ImPACT)). The sample included a total of 106 male and 87 female cases where individuals had self-reported concussion history as being (1) no history of concussion, (2) one previous concussion or (3) two previous concussions. Results: A dose–response gradient was found for previous concussions and decreased memory performance. There was a significant linear decline in performance on memory tests as the number of concussions increased from zero to two. Conclusion: The current study provided support for a dose–response model of concussion and memory performance decrements beginning at one or more previous concussions.

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The prevalence of epilepsy and association with traumatic brain injury in veterans of the Afghanistan and Iraq wars Mary Jo Pugh1, Jean Orman2, Carlos Jaramillo1, Martin Salinsky3, Shane McNamee4, Blessen Eapen1, Alan Towne4, & Jordan Grafman5 1

South Texas Veterans Healthcare System, San Antonio, TX, USA, US Army Institute for Surgical Research, San Antonio, TX, USA, 3 Portland VA Medical Center, Portland, OR, USA, 4Hunter Holmes McGuire VA Medical Center, Richmond, VA, USA, 5Rehabilitation Institute of Chicago, Chicago, IL, USA 2

Objective: While studies from prior wars and civilians have linked traumatic brain injury with epilepsy, little evidence is available for Veterans of the Afghanistan and Iraq (OEF/OIF/OND) wars. A recent investigation by the DoD indicated that epilepsy incidence increased 52% from 2006 to 2010, with 8% of those with epilepsy having a previously diagnosed TBI. However, those with more severe and penetrating TBI, who are at highest risk of post-traumatic epilepsy and more frequently discharged from the military, were underrepresented in that active duty population. The purpose of this study was to determine the prevalence of epilepsy in the population of OEF/OIF Veterans who receive VA care and to determine if TBI exposure was associated with epilepsy. Methods: This cross-sectional observational study utilized national inpatient and outpatient data. Participants included individuals who received care from the Veterans Health Administration (VA) in fiscal years 2009–2010. Algorithms developed for use with ICD-9-CM codes were used to identify patients who met criteria for epilepsy (VA algorithm), traumatic brain injury (TBI; Armed Forces Health Surveillance Center) and other risk factors for epilepsy (e.g. stroke, substance use disorder). TBI was divided into penetrating TBI (pTBI) and other TBI. TBI and other risk factors were identified prior to the index date (date of first seizure or 1 October 2009 for those without seizure). Results: Among 256 284 OEF/OIF veterans who received VA care in 2009–2010, 2719 met criteria for epilepsy. Epilepsy prevalence was 10.6 per thousand with an age-adjusted prevalence of 6.1. In addition, 29 297 veterans were diagnosed with TBI prior to the index date. Statistically significant associations were found between epilepsy and prior TBI diagnosis (pTBI: adjusted odds ratio (AOR) 18.77 (95% CI ¼ 9.21–38.23); other TBI AOR 1.64 (1.43–1.89)). Younger veterans (18–49 years vs 65 and older; AOR 2.22 [1.55–2.59] and those with prior stroke (AOR 5.50 [4.04–7.49]) were also significantly more likely to meet epilepsy criteria. Conclusions: Among OEF/OIF veterans, epilepsy was associated with a previous TBI diagnosis and pTBI had the strongest effect. Studies of war-related epilepsy in Vietnam War veterans with TBI have shown additional new cases of epilepsy accruing over decades post-war. A detailed prospective study is needed to understand the evolving relationship between epilepsy and TBI in OEF/OIF veterans.

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Effect of concussion and blast exposure on clinical symptoms following deployment of US military personnel

EEG cross-frequency coupling in mild traumatic brain injury Otis Smart1, Nicholas Kuzma2, & Miranda M. Lim3 1

1

1

1

Briana N. Perry , Mikias Wolde , Robin S. Howard , Jay Haran2, Justin Campbell3, Alia Creason4, Catalina Sher1, Lauren Stentz1, & Jack W. Tsao5 1

Walter Reed National Military Medical Center, Bethesda, MD, USA, SPAWAR Systems Center Pacific, San Diego, CA, USA, 3Space and Naval Warfare Systems Command (SPAWAR), San Diego, CA, USA, 4 Universal Consulting Services, Fairfax, VA, USA, 5US Navy Bureau of Medicine & Surgery, Falls Church, VA, USA


2

Objectives: Mild traumatic brain injury (mTBI), otherwise known as concussion, is a common battlefield injury. Past studies suggest a link between single and repetitive TBI and associated clinical symptoms, including sleep disturbance, headaches and memory problems. Through surveying US military personnel at the end of recent deployment, this study aimed to assess the impact of present and past concussion and blast exposure on mental health and postconcussive symptoms, which may aid in elucidating important causal relationships and identifying future at-risk populations. Methods: Following return from deployment, a 14-item questionnaire was administered to 2612 male US Marines, mean age 23.8 ± 0.1 years, from units which saw the greatest amount of combat during their deployments to Afghanistan. The questionnaire examined history of blast exposure, concussion and mental health and post-concussive symptoms, for both current and previous deployments, where applicable. Injuries and symptoms were assessed as either present or absent, while the number of blast exposures and instances of concussion were quantified. Blast distance was assessed using the minimum blast exposure distance reported. Results: Seven hundred and twenty-one (27.5%) Marines reported concussion during current deployment and 732 (28.0%) prior to deployment. Five hundred and ninety-one (22.6%), 104 (4.0%) and 26 (1.0%) Marines reported one, two or three or more current deployment concussions, respectively. Three hundred and ninetynine (15.3%), 185 (7.1%) and 147 (5.6%) Marines reported one, two and three or more prior concussions, respectively. In total, 2258 (86.4%) Marines reported exposure to blasts, with 2150 (82.3%) reporting blast exposure during current deployment and 668 (25.6%) during prior deployments. There was a higher incidence of all symptoms (memory problems, headaches, ringing in the ears, trouble sleeping, balance problems, irritability, light and noise sensitivity, trouble seeing, alertness, interpersonal distance and emotional numbing) in Marines with current deployment concussion compared to those without, as well as in Marines who reported current deployment blast exposure compared to those who did not. Marines who reported being closer to explosions had increased likelihood of being diagnosed with a concussion. Exact statistical analyses are delayed due to government furlough. Conclusions: Preliminary findings suggest that either a current concussion or a current blast exposure increases the risk of mental health and post-concussive symptoms in US military personnel, with concussion having a greater influence on the presence of postdeployment symptoms. These results have the potential to inform military healthcare, as well as identification of populations at risk for post-concussion and mental health symptoms.

Emory University, Atlanta, GA, USA, 2Portland State University, Portland, OR, USA, 3Portland VA Medical Center and Oregon Health & Science University, Division of Sleep Medicine, Portland, OR, USA Objectives: Mild traumatic brain injury often leads to persistent cognitive and neurobehavioural symptoms, but it is difficult to predict who is at risk. Quantitative electroencephalography (EEG) is a practical, non-invasive approach to classifying neurological disorders. Changes in EEG cross-frequency coupling are thought to reflect the state of information processing in the brain. Such EEG measures have recently been applied to Alzheimer’s disease, other dementias and epilepsy. This study sought to investigate the nature of crossfrequency EEG coupling in a mouse model of traumatic brain injury (TBI). Methods: Mice were randomized to receive either mild grade fluid percussion brain injury (n ¼ 6) or sham surgery (n ¼ 7) and were 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, rapideye-movement (REM) sleep and wakefulness (W)) across a 24-hour baseline period (i.e. light from 7am to 7 pm). Amplitude modulation coupling was computed from the EEG by fast Fourier transforming (FFT) bandpass filtered (i.e. delta (1–4 Hz), theta (4–8 Hz), alpha (8–12 Hz), beta (12–30 Hz), gamma (30–50 Hz)) signal envelopes (i.e. via Hilbert transformation) using a MATLAB algorithm, where the 150-point FFT frequency range represented the modulation frequencies that spanned 1–50 Hz. Subsequently, the continuous modulation frequencies were binned into delta, theta, alpha, beta and gamma bands, yielding 25 total coupling measures: Five modulation frequency bands and five carrier frequency bands. Statistical analyses were performed in MATLAB using Kruskal-Wallis analysis of variance and multiple comparisons with Wilcoxon-MannWhitney tests and Bonferroni corrected p values. Results: EEG analyses revealed statistically significant differences in amplitude modulation between TBI and sham mice for 12 out of 25 cross-frequency coupling measures (p50.0001, all values). Of particular interest, TBI mice showed significantly lower gamma-theta and alpha-delta coupling during the dark phase of wakefulness compared to sham control mice. Other modulation measures, such as gamma-beta (p ¼ 0.0719), theta-delta (p ¼ 0.0008) and theta-gamma (p ¼ 0.4335) coupling did not demonstrate notable statistical differences (0.0008 p 0.8887, all values). Conclusions: Fronto-parietal EEG cross-frequency coupling is persistently disrupted after mild TBI. Specific changes in gamma-theta or alpha-delta coupling could represent an EEG signature or biomarker of mild TBI, likely reflecting lasting changes in information processing. Interestingly, gamma-theta coupling has been shown to be critical for the formation of new memories and memory retrieval. Further investigation is warranted into the mechanisms underlying crossfrequency coupling alterations in TBI and whether these can predict functional outcomes.

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DOI: 10.3109/02699052.2014.892379

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Ethical decision-making for traumatic brain injury: A model to navigate the process

Task-related cerebral activation pre- and post-season in a cohort of collegiate contact sport athletes

Pennie Seibert1, CodieAnn DeHaas2, Jennifer Valerio1, & Christian Zimmerman1 1

Saint Alphonsus Regional Medical Center, Boise, ID, USA, Boise State University, Boise, ID, USA


2

Objectives: Those directly affected by traumatic brain injury (TBI) and their loved ones face numerous challenges on the road to recovery; one major challenge that places emotional hardship on individuals is the arduous process of ethical decision-making. A multitude of difficult decisions must be made to ultimately achieve an acceptable quality-of-life (QoL) post-injury. While an acceptable QoL ultimately resides in the determination of the injured individual, it is often the case with severe brain injury that the affected person is unable to contribute to the decision-making process. Particularly in the absence of advanced directives, these choices can evolve into a complex ethical dilemma for all involved. Patients, families and physicians struggle to ascertain the definitive effect of a life-sustaining procedure on eventual quality-of-life. An attempt to find a balance between what is assumed is in the best interest of the person who sustained injury and the predicted resultant QoL routinely results in conflict. Further complicating prediction, after injury a person may reconsider his/her ideal of QoL, rendering advanced directives insufficient. Currently, a variety of scales and measures are used to assess level of injury and predict outcomes; however, these measures fail to account for a range of factors relating to QoL and individuality within. Methods: This study used data gathered from multiple sources: outcomes data, questionnaires, observation and a model for superior recovery after brain injury to develop a decision model. Results: This model was designed to serve as a guide through the decision process when attempting to make predictions about QoL. It allows a direct course involving many choice points with multidimensional deliberation including topics such as ethics, spirituality, culture, financial drivers, individual differences and subjectivity. These are conveyed in hierarchical and multi-directional choice points to facilitate consideration of the range of intervening variables. The decision model has the ability to serve as an essential tool for the patient, his/her family members and healthcare providers to better serve the patient in a manner that is specifically tailored to the affected individual. Conclusions: Predicting potential QoL is an extraordinarily complex process that involves numerous ethical dilemmas. While standard practice measures do serve a purpose, they fail to address the entire field of experience. It is recognized that it is impractical and probably impossible to accurately and positively predict a potential and level of QoL post-CNS injury and medical intervention. Nevertheless, the decision model as a heuristic may serve to alleviate some of the stressors surrounding TBI, by providing a simplistic platform to carefully consider individuality and approach daunting ethical decisions. The ability to make informed, holistic decisions in TBI facilitates optimal treatment and improved eventual QoL.

Thomas McAllister1, James Ford2, Laura Flashman2, Arthur Maerlender2, Richard Greenwald3, Jonathan Beckwith3, & Richard Bolanger3 1

Indiana University School of Medicine, Indianapolis, IN, USA, Geisel School of Medicine at Dartmouth, Hanover, NH, USA, 3 Simbex, LLC, Lebanon, NH, USA 2

Objectives: There is growing concern that head impacts in contact sports lead to problems such as long-term cognitive decline and chronic traumatic encephalopathy. Studies of repetitive impacts not associated with diagnosed concussion are few and contradictory. One study reported abnormal cognitive indices and cerebral activation in season and post-season in high school athletes, while another showed post-season cognitive improvements in college athletes, probably related to practice effects. The goal of this study was to determine whether exposure to repetitive head impacts over a single season affects cerebral activation associated with working memory. Methods: Two athlete cohorts at Dartmouth College underwent pre- and post-season assessment. The contact sport cohort consisted of 37 football players and ice hockey players (men and women) without diagnoses of concussion during the index season. The non-contact sport cohort consisted of 46 varsity athletes on a variety of non-contact sport teams. Contact sport athletes wore helmets instrumented with HIT System technology (Riddell Inc., Rosemont, IL; Simbex, Lebanon NH) to record head impact exposure during all practices and games. Participants were assessed with functional MRI and neurocognitive measures. Scans were acquired on a research-dedicated 3T Philips Achieva magnet, using a Philips 8-channel SENSE Head Coil. Participants performed the n-back working memory task while in the scanner and a 2.5-hour battery of standardized neuropsychological tests at both time points. The California Verbal Learning Test-II (CVLT-II Total Acquisition Trials 1–5) was chosen as the primary cognitive outcome measure. Results: There were no significant cerebral activation differences at the pre-season assessment. Post-season, contact athletes showed an area of significantly reduced activation (FWE p ¼ 0.033) in working memory circuitry in the right inferior frontal cortex (Brodmann Area 9). The cluster peak activation in the contact athletes at post-season correlated with measures of recent head impact exposure (median 14 day HITsp: r ¼ 0.52 Spearman, p ¼ 0.001/p ¼ 0.025 FDR with correction for multiple comparisons) but was not significantly correlated with n-back performance measures. When eliminating the five contact athletes whose CVLT was significantly worse at the end of the season (regression based Z-score test, Z51.5), activation in this area was significantly correlated with CVLT performance (r ¼ 0.54, p ¼ 0.035 FDR). Conclusion: This study suggests a relationship between head impact exposure and cerebral activation on a working memory task. Although changes in activation were related to recent head impact exposure measures, only modest relationships were found with cognitive performance. Together with the absence of significant pre-season group differences, these results suggest that changes in task-related cerebral activation may relate to recent impacts and are of unclear functional significance. Further work is needed to assess whether such effects are persistent in some individuals.

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Brain Inj, 2014; 28(5–6): 517–878

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Use of disability rating scale for diagnostic screening in patients with disorders of consciousness 1

1

1

Matthew Doiron , Tran Duc , Anne Citorik , Stephanie Gilmore1, Anne O’Brien1, Marianne Beninato2, & Joseph Giacino1 1

Spaulding Rehabilitation Hospital, Charlestown, MA, USA, MGH Institute of Health Professions, Boston, MA, USA, 3 Harvard Medical School, Boston, MA, USA


2

Objectives: Previous studies have shown a high rate of misdiagnosis during one-off assessments of vegetative state (VS) and minimally conscious state (MCS). Serial assessments may decrease the likelihood of misdiagnosis; however, the administration time of the current reference standard, the Coma Recovery Scale-Revised (CRS-R), often limits the frequency of assessment. A standardized rating scale based on routine observations, such as the Disability Rating Scale (DRS), may have clinical utility as a supplemental measure in identifying patients who may be incorrectly deemed unconscious on the basis of a single assessment. Prior research has shown that an operational definition of MCS based on DRS performance (sub-scores: verbal ¼ 0–2, motor ¼ 0– 1, cognitive sub-scales53, functional ability 55,or employability 53) is moderately sensitive and highly specific to MCS. The objective of the current study was to determine if performance on specific DRS items can be used to improve detection of conscious awareness in patients with DOC. Methods: Data for this retrospective analysis (n ¼ 184, 133 males, mean age: 36 ± 15) were drawn from the recently-completed amantadine hydrochloride (AH) clinical trial. All subjects were diagnosed with post-traumatic VS or MCS based on the CRS-R and were between 4–16 weeks post-injury. For this study, subjects who met the previously-developed DRS criteria for MCS were excluded from the analysis, qualifying only those classified as VS. DRS subscores for the 84 eligible subjects were entered into a logistic regression to determine the strength of the relationship between each sub-scale and the CRS-R diagnosis. Results: Logistic regression showed a significant relationship between the eye opening sub-scale and CRS-R diagnosis (logistic coefficient ¼ 1.040, p50.05). Analysis of odds ratios indicated that subjects with spontaneous eye-opening (DRS E.O. score ¼ 0) were 3.79-times more likely to be in MCS than VS. Additionally, the odds of being in MCS systematically decreased to 0 as the DRS eye opening score increased (i.e. worsens) to 4. Adding spontaneous eye-opening to the existing DRS diagnostic criteria increased the sensitivity of the original DRS operational criteria for MCS by 22% (sensitivity ¼ 0.97) and decreased specificity by 58% (specificity ¼ 0.34). Conclusion: Findings suggest that the addition of spontaneous eye opening to the previously-published DRS diagnostic criteria increases the sensitivity of the DRS in detecting MCS. This modification resulted in lower specificity; however, false positive errors in this context (i.e. DRS indicates MCS when the patient is actually in VS) are less of a threat to appropriate clinical management as compared to false negative errors (i.e. DRS indicates VS when the patient is actually in MCS). Given the ease of use and brief completion time of the DRS, a more precise diagnostic screening version would improve clinical assessment in this population.

Predicting unsafe events in the home and community following TBI Ronald Seel1, Stephen Macciocchi1, & Craig Velozo2 1

Shepherd Center, Atlanta, GA, USA, 2Medical University of South Carolina, Charleston, SC, USA

Objectives: Upon re-integration back to the home and community, heterogeneous impairments place persons with TBI at increased risk for subsequent unintentional injury, harm and death. Risk of unintentional injury or harm is highest in the first 12 months following hospital discharge. Predicting the causes and protective factors for unsafe events may lead to interventions that can reduce risk of further injury and death. Methods: Family members completed the Safety Assessment Measure and a supporting questionnaire. Family members then tracked unsafe events over a 30-day period using a semi-structured tracking tool. An a priori defined model was evaluated using logistic regression. The amount of explained variance was based on Nagelkerke’s R2 and sensitivity and specifity were calculated. Discovery analyses were conducted using recursive partitioning ‘decision tree’ modelling to evaluate how impairment and environmental factors play a role in stratifying prognostic risk of 0, 1 or 2+ unsafe events in a 30 day observation window. Results: Caregivers reported that 46% of 155 persons with TBI had 140 unsafe events (32 actual injury or harm, 108 near misses) during a 1-month surveillance period, with the majority of unsafe events occurring in the home. Falls (22%) or collisions (5%) while ambulating, standing or transferring were the number one cause of unsafe events. Identifying or responding to potentially harmful persons or situations (12%); losing money or valuables (9%); and transportation (5%) were community-based activities involved in unsafe events. Managing medications and medical conditions (8%); managing stress, frustration and inappropriate behaviour (10%); knowing limits in recreational and sports activities (7%); using appliances, fire and sharp objects (8%); and using equipment, chemicals and utilities (6%) were sources of unsafe events. The SAM Cognitive Capacity and Visuomotor Capacity scale scores, lack of awareness of impairments and family level of supervision were significant predictors of unsafe events. The a priori defined model explained 31% of variance (Nagelkerke’s R2) in the occurrence of an unsafe event with equivalent sensitivity (77%) and specificity (75%). It was consistently found that persons at high risk for unsafe events have their risk substantially reduced when full-time supervision is provided. Spouses were more likely to reduce supervision regardless of patient severity than parents of adult children. Conclusions: Evidence indicates that safety in the home and community is a major concern following TBI and that a variety of activities can lead to unsafe events. Cognitive and Visuomotor Capacity and lack of awareness of impairments are primary risk factors for future unsafe events. Supervision at least once every 30 minutes can reduce the risk of unsafe event occurrence.

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Factors associated with the willingness to use technologydelivered mental healthcare amongst individuals with traumatic brain injury Patricia Johnson, Kristin Smith, Naomi Ennis, Donna Ouchterlony, & Topolovec-Vranic Jane


St. Michael’s Hospital, Toronto, Ontario, Canada Objectives: Mental health issues such as depression and anxiety are commonly observed amongst individuals following traumatic brain injury (TBI). A lack of access to mental health services and/or the motivation to access them have been cited as barriers to care for such patients warranting the need for alternative treatment approaches. The objective of this study was to determine whether specific demographic and/or technology aptitude factors were associated with the willingness to use computers and/or handheld devices as aides to mental healthcare. Methods: All patients attending an outpatient head injury clinic at an academic tertiary trauma centre in downtown Toronto, Canada between May 2010 and December 2012 were invited to participate in the study. Demographic and injury-related characteristics were collected and participants’ attitudes towards using technologybased approaches for mental healthcare were assessed using a questionnaire. Binary logistic regression modelling was conducted to explore which respondent characteristics were associated with the willingness to use a computer or handheld device as an aid to mental healthcare. The following predictors were tested: age, gender, education, frequency of computer use at home, knowledge and comfort level with email, severity of depression (Patient Health Questionnaire-9 score) and whether they were receiving mental healthcare at the time of survey completion. Results: Six hundred and three patients participated in the study, 497 from which full data were available for the regression analyses (55.5% male; mean age ¼ 40.4 years, SD ¼ 15.2, range ¼ 17–86). Two hundred respondents (40.2%) reported that they were receiving mental healthcare at the time of study participation. A majority of the participants indicated that they would be willing to use a computer (80.7%) or handheld device (66.6%) as aides to mental healthcare if they were available. Only knowledge and comfort level with email was a predictor of willingness to use a computer for mental healthcare (b ¼ 0.60, Wald 2(1) ¼ 21.13 p50.001). Younger age (b ¼ 0.02, Wald 2(1) ¼ 9.65, p ¼ 0.002), higher education level (graduate school compared to grade school: b ¼ 2.2, Wald 2(1) ¼ 5.77, p ¼ 0.016), knowledge and comfort level with email (b ¼ 0.24, Wald 2(1) ¼ 4.87, p ¼ 0.027) and whether they were currently receiving mental health treatment (b ¼ 0.73, Wald 2(1) ¼ 10.00, p ¼ 0.002) were predictors of the willingness-to-use a handheld device as an aid to mental healthcare. Conclusions: Patients who have sustained TBI are open and receptive to alternative modes of mental healthcare, such as the delivery of services/treatment with the aide of technologies such as computers and handheld devices. Increasing an individual’s knowledge and comfort level with using technology such as email is a modifiable factor which may enhance their willingness to use technology-based programmes to augment mental healthcare.

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Long-term management of persons with acquired brain injury and of their relatives: A neurosystemic approach Christine Croisiaux1, Jean-Michel Mazaux2, Jean-Marc Destaillats3, & Jean-Luc Truelle4 1

La Braise and EBIS, Brussels, Belgium, 2University Hospital, Bordeaux, France, 3University Hospital, Bordeaux, France, 4University Hospital, Garches, France

Objectives: To describe the theoritical framework, potential benefits, limits and difficulties in implementing the neurosystemic approach and compare how neurosystemic interviews are run in different European care programmes and institutions. The neurosystemic approach can target three objectives: (1) The systemic understanding of behavioural impairment; (2) The co-construction projects. Families together with the ABI-person build life projects including the consequences of the brain injury. Teams help families building care project that implements their life project. Consultation ‘disability and families’ can help families to develop their own life plan prevented by the suffering of the family; and (3) A therapeutic goal by supporting the family suffering from the head injury and from the family history. Methods: A first meeting of 35 professionals from the European Brain Injury Society (EBIS), working from acute stage to long-term, was held in Bordeaux, France, in October 2013. Difficulty in daily practice, benefit and finality of the neurosystemic approach with families and ABI-persons were debated according to the ‘Triage method’. The next meeting will be held in Brussels in early 2014. Results: Those 35 professionals, experts in traumatic brain injury and in the neurosystemic field, will propose recommendations to do with the use of this approach with ABI-persons and their relatives: How to introduce this approach? Which training is necessary for the professionals? How to organize the work? Material and human needs? Financial supports? Other items will be developed during the next workshop in Brussels. This experts group will also lead research projects to do with the neurosystemic approach: (1) Multicentric validation of a neurosystemic tool (GMAP) centred on a tripartite evaluation (patient, relatives, professionals) based on the ICF including environmental factors; (2) Measure of the effectiveness of the neurosystemic approach for the suffering family and for the quality-of-life of those patients and their families via the Qolibri; and (3) Neurosystemic evaluation of the behavioural impairments (comparing disinhibition vs apathy) and of family and social participation. Conclusions: EBIS intends to submit this research project to the next framework of the European Union’s Commission (FP8 program called Horizon 2020).

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Differences between parents and teachers’ reports on child’s emotional and behavioural problems following severe TBI: The moderating effect of time Tamar Silberg1, Dana Tal-Jacoby1, Miriam Levav2, Yuri Rassovsky1, & Amichai Brezner2

812 Bar Ilan University, Ramat Gan, Israel, 2Sheba Medical Center, Ramat Gan, Israel


1

Objectives: Current assessment standards for childhood psychopathology emphasize the importance of gathering data from multiple informants. Collecting information from parents and teachers of children following traumatic brain injury (TBI) has substantial clinical value when making diagnostic decisions. Yet, such a multi-informant approach has rarely been studied among children and adolescents at the chronic stage post-injury. The present study aimed to examine: (1) variations in parents’ and teachers’ reports of a wide range of emotional and behavioural problems among children who sustained severe TBI; (2) the level of agreement in the reports of two different informants (parents vs teachers) regarding child’s emotional and behavioural problems via two commonly used questionnaires; and (3) the effects of the time elapsed since injury on each rater’s reports. Methods: The Child Behavior Checklist (CBCL) and the Behavior Rating Inventory of Executive Functions (BRIEF) were completed by 42 parents and 42 teachers of children and adolescents (age range: 5 years 4 months–17 years 9 months) at least 1 year post-severe TBI (LOC46 hours; GCS510). Receiver Operating Characteristic (ROC) Curves were used to determine if time since injury can reliably distinguish children falling above and below clinical levels. Summary scales were used to examine the level of agreement between raters according to the time elapsed since injury using paired-t-tests and intra-class correlation coefficients (ICCs). Results: Overall it was found that the emotional and behavioural profile of the sample fell within the normal range in all summary scales of both CBCL and BRIEF questionnaires. The time elapsed provided a fair discriminant for both scales. The ‘optimal’ cut point for time elapsed since injury was between 22–24 months post- injury. The level of agreement regarding child’s emotional and behavioural problems between raters on both questionnaires was moderate, with higher concordance at the chronic stage post-injury. A significant difference was found in parents’ reports on child’s emotional and behavioural problems between children evaluated below 2 years post-injury and children evaluated above 2 years post-injury in both questionnaires. These differences were not observed in any of the teachers’ reports. Conclusions: Parents and teachers of children and adolescents following severe TBI differ in their perceptions regarding child’s emotional and behavioural problems. By addressing the effect of the time since injury, the present study highlights for the first time, the possibility that these perceptions may vary across time. Accordingly, when evaluating child’s emotional and behavioural state during the first stage following severe TBI (up to 2 years), professionals should seek multiple perspectives as they might shed light on the child’s broad ability to participate in his or her environment.

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Diffusion tensor imaging correlates of recognition memory in mild blast-related traumatic brain injury (mbTBI)

Brain Inj, 2014; 28(5–6): 517–878

persisting or emerging symptoms. Evidence of chronic traumatic encephalopathy (CTE), a neurodegenerative condition that can emerge after TBI, necessitates the tracking of symptoms, including memory, over time. Research results from different types of recognition memory, Yes–No (YN) and No Recall Forced Choice (NRFC) paradigms, suggest that these measures may be tapping independent memory processes active in various stages of dementia. YN sub-tests have shown associations with the hippocampus and the parahippocampus, while NRFC tests have appeared more related to the perirhinal cortex. Diencephalic nuclei have also been implicated in recognition memory. The objective of the current study was to characterize these different types of recognition memory in mbTBI and to correlate them with diffusion tensor imaging (DTI) results. Methods: Two groups of veterans were recruited, an mbTBI group (n ¼ 15) and a group without any TBI history who had served during recent conflicts (n ¼ 15). No participants had any condition that might confound results. All DTI scans were acquired with a Philips 3T scanner. A single shot echo-planar imaging sequence was used: TE ¼ 62 milliseconds, TR ¼ 2000–3000, image dimensions 128 128, FOV 224 224. For consistency with prior evaluations, 16 gradient directions and one b ¼ 0 were acquired for 50 contiguous slices of 3millimetre thickness. The University of Southern California Repeatable Episodic Memory Test (USC-REMT) assessed recognition memory. USC-REMT’s NRFC recognition is administered immediately after a second new word list is read to the patient; thus, recall trials providing additional learning are absent. Unlike the USC-REMT, some tests of verbal memory utilize words that are related by superordinate category, which can facilitate memory. Finally, the USC-REMT NRFC has three items from which to choose the target word, rather than the traditional two, further increasing difficulty. Age-adjusted group differences and dispersion metrics were computed for sub-tests of YN Hits, YN False Alarms and NRFC Accuracy. Results: Cases were younger than controls (p ¼ 0.028; mid-30s vs low 40s). However, there were no other significant group differences in years of education, body mass index or pre-morbid intelligence estimation. Age-adjusted analyses indicated that NRFC Accuracy was lower in cases vs controls (p ¼ 0.029), although there were no significant group differences in the YN sub-tests. Significant correlations between both recognition sub-tests and DTI metrics for thalamic and occipital tracts were found. Conclusions: Explanatory brain circuitry in the context of current results and extant literature will be discussed. Additional larger scale studies are needed to ascertain whether the unique structure of the USC-REMT produces a sub-test that could augment self-reported diagnosis and monitoring for mbTBI.

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Acknowledging the relationship shared by traumatic brain injury and sleep disorders Pennie Seibert1, Jennifer Valerio1, CodieAnn DeHaas2, Fred Grimsley1, & Christian Zimmerman1 1 2

Julie Chapman1, Christine Eickhoff1, Melody Powers1, Patrick Sullivan1, Laurie King2, Barbara Schwartz1, Marshall Balish1, Jonathan Pincus1, & Marc Blackman1 1

Veterans Affairs Medical Center, Washington, DC, USA, 2Oregon Health & Science University, Portland, OR, USA Objectives: Given the high incidence of TBI in veterans from recent conflicts and the heavy reliance on self-report for diagnosis, the identification of objective measures would likely augment the accuracy of diagnosis and assist with the monitoring of receding,

Saint Alphonsus Regional Medical Center, Boise, ID, USA, Boise State University, Boise, ID, USA

Objectives: Worldwide, an estimated 10 million people sustain a traumatic brain injury (TBI) annually. Following injury, those affected face numerous challenges, including motor and sensory impairments and the potential for psychiatric illness. TBI shares a complex relationship with sleep disorders (SDs). Indeed, it is often difficult to ascertain which came first, the SD or TBI. Following TBI, SDs often are undiagnosed because the symptoms associated with SDs are also symptoms caused by TBI (e.g. disruption of normal patterns for sleep, awareness, cognition, concentration, emotion, headaches, depression, etc.). This is problematic, as TBI has long been associated with

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cognitive deficits and reduced awareness, while sleepiness affects reaction time and all aspects of daytime functioning. Thus, it is plausible that the presence of a SD could contribute to functional disability post-TBI. TBI may both exacerbate pre-existing sleep issues and increase the likelihood of developing them. Considering the overlap in symptomatology, it is unsurprising that the prevalence of sleep disruptions following TBI is estimated to be 30–70%. The extent of these relationships has been constrained by difficulty in acquiring valid data from people whose diagnoses are based on a complete nocturnal polysomnography (NP) and multiple sleep latency tests (MSLT) because most TBI and sleep data is limited to reliance on selfreport. Methods: This study constructed a 111-item questionnaire to use in conjunction with Nocturnal Polysomnography studies (NPS), Multiple Sleep Latency tests (MSLT), the Epworth Sleepiness Scale (ESS) and medical chart reviews of participants referred for evaluation of SDs. Of 888 participants in this research, 44 sustained TBI. The 844 cases who presented for evaluation of SDs were used as a base of comparison for the 44 who sustained TBI previous to the sleep evaluation. Results: Data analysis comparing those with TBI and SDs to those with an SD only revealed a pattern of similar findings as well as demonstrated numerous significant differences. For example, the TBI/SD group spent less time in restorative stages of sleep, reported higher rates of difficulty with memory and attention to detail, difficulty maintaining sleep, nightmares, bizarre dreams and hypersomnolence. This study analysed sex differences in the TBI/SD group and found that women spent more time in stage N2 of sleep and experienced more sleep walking, difficulty waking and bizarre dreams. Conclusions: The unique psychological and physiological challenges TBI patients face often hinder the restorative sleep needed to facilitate recovery. As sleepiness in TBI augments cognitive deficits compared to other TBI subjects, it is likely that treatment of SDs will favourably impact rehabilitation. Considering the nature and scope of TBI and the inter-relatedness of TBI and SDs, it becomes necessary to address sleep when treating TBI concurrently to alleviate shared symptoms and achieve optimal outcomes.

She was unable to walk, had balance problems, developed body pain and was unable to return to school. She then developed seizurelike activity with a negative work-up. While at an activity she had a seizure type episode and became unable to move anything below the neck. She was admitted to the hospital unable to move for several days. An EEG and MRI were normal. She had a ‘la belle indifference’ affect and was started in a PT programme and supportive services. During a short admission she was able to recover ambulation and transitioned into an outpatient programme. In follow-up several months later, she is back to school and has resolution of most symptoms except for headaches. Conclusion: Somatoform disorders are a group of psychiatric disorders that are manifested by unexplained and often inconsistent physical exam and cognitive signs and symptoms. Patients must meet certain criteria including: no underlying medical/psychiatric diagnosis, malingering/factious disorders are ruled out and the condition must impact functional status. She met all three criteria and was diagnosed with a conversion disorder. With the on-going support of a multidisciplinary team, she has resolved her symptoms and is back to school. The team presents practical application of a treatment paradigm for adolescents with this disorder.

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A comparison of outcome measures for studying prognosis in older adults: Preliminary results from a pilot prospective cohort study Vicki Kristman1–5, Paula Reguly1, & Michel Be´dard1,3,5,6 1

0793

Concussion and conversion disorder: A case report Pamela Wilson, Jacqueline Murray, & David Baker Children’s Hospital Colorado, Aurora, CO, USA Objective: The typical child or athlete with a concussion will generally resolve symptoms within 1–2 weeks. There are, however, a few outliers that go onto protracted post-concussion symptoms and even a smaller population that may manifest a conversion type process. The case of a concussion that evolved into a conversion disorder was presented. Method: This is a retrospective single case report from a tertiary paediatric concussion programme. The data was obtained from her medical record including both in-patient and out-patient sources. Review of data also included neuropsychology testing, neuroimaging and EEG. Results: This case involves an adolescent female who was in a skiing accident. She caught an edge and hit her head on hard packed snow. She did not lose consciousness. She developed a mild headache but was able to continue skiing that day. Two days later she developed a severe headache and required an emergency room visit. She was followed for 4 weeks through primary care and in addition to postconcussion symptoms developed stuttering and memory loss. She was referred to a complex concussion programme. Her initial exam had several inconsistencies pointing toward a non-neurologic aetiology for some of the symptoms. Despite a rigorous support programme that was implemented, her symptoms intensified.

Department of Health Sciences, Lakehead University, Thunder Bay, Ontario, Canada, 2Institute for Work & Health, Toronto, Ontario, Canada, 3Division of Human Sciences, Northern Ontario School of Medicine, Thunder Bay, Ontario, Canada, 4Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada, 5 Centre for Education and Research on Aging & Health, Lakehead University, Thunder Bay, Ontario, Canada, 6St. Joseph’s Care Group, Thunder Bay, Ontario, Canada Objectives: Systematic reviews of outcome measures after brain injury have focused exclusively on moderate-to-severe injury or included a mixture of all severities. No study has described outcome measures after mild traumatic brain injury (MTBI), particularly in the older adult population. This study aimed to compare the sensitivity, specificity and responsiveness of four common outcome measures used after MTBI. Methods: A pilot prospective cohort study was conducted with older adults who experienced a MTBI and visited an emergency department in either Thunder Bay or Kingston, Ontario. Data were collected between 5 November 2012 and 3 October 2013. Participants were contacted by phone shortly after their emergency department visit (baseline) and again 6 months later. They were administered a questionnaire including four outcome measures: the Glasgow Outcome Scale (Extended) (GOSE), the Medical Outcomes Study 12-Item Short Form Health Survey (SF-12), the Rivermead PostConcussion Symptom Questionnaire (RPQ) and a single question on self-rated recovery. Category cut-offs for each measure were established from previously published guidelines. This study compared the sensitivity, specificity and responsiveness using the RPQ as a comparator. For responsiveness, participants were categorized to capture change: early recovery (recovered at both baseline and 6 months), no recovery (not recovered at either time point), improvement (not recovered at baseline, recovered by 6 months) and deterioration (recovered at baseline, not recovered at 6 months).


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Results: Fifty of 89 eligible individuals agreed to participate in the study (56.2% participation rate). As of 3 October 2013, 26 of 28 had completed follow-up interviews (7.1% attrition rate). The SF-12 mental component score (MCS) had good sensitivity for identifying recovery (93.6% (95% CI ¼ 78.6%, 99.2%) and 100% (95% CI ¼ 85.2%, 100%) at baseline and 6-months, respectively), while the GOSE and self-rated question had good specificity for identifying non-recovery at baseline (GOSE: 83.3% (95% CI ¼ 58.6%, 96.4%), self-rated: 100% (95% CI ¼ 81.5%, 100%)) and 6-months post-injury (GOSE and selfrated: 100% (95% CI ¼ 29.2%, 100%)). The MCS and RPQ identified little change and greatest proportion of early recovery (73.1% and 65.4%, respectively). The GOSE and self-rated question identified two participants with deterioration. These measures also reported less early recovery (GOSE: 34.6%, self-report: 11.5%). Conclusions: There is no one best measure to assess recovery from MTBI in older adults. Both MTBI-specific and generic tools reported varying results. The MCS and RPQ reported little change; however, this may be due to ceiling effects. The GOSE and the PCS found similar distributions of recovery over time. The self-rated question identified the least amount of early recovery. Concepts of recovery vary among the measures. Hence, this study recommends using multiple measures of recovery to capture the differing concepts.

significantly higher than in sham-injured slices at 24 hours (15.7 ± 4.6% vs 0.3 ± 0.1%; p50.01) and 48 hours (21.6 ± 5.8% vs 0.4 ± 0.1%; p50.001). The percentage of CA1 area with pixel intensity above the threshold in OHCs + BMSC at 24 hours (8.0 ± 2.3%) and 48 hours (9.2 ± 2.4%) was not significantly different compared to shaminjured OHCs. However, at 48 hours cell death was significantly smaller in OHCs + BMSC compared to the blast-exposed OHCs without BMSC (21.6 ± 5.8% vs 9.2 ± 2.4%; p50.05). Conclusion: While previous studies using in vitro bTBI models demonstrated cell damage at later time points following blast exposures, this study, for the first time, demonstrated that cell damage is initiated within 2 hours after blast exposure. Moreover, these preliminary data suggest that BMSC through release of different trophic factors and without direct cell-cell contact have the ability to decrease cell damage at relatively early time points when applied immediately following blast exposure, implying therapeutic potential.

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Monique Lanoix

Protective effect of bone marrowderived mesenchymal stem cell in in vitro model of blast traumatic brain injury Aleksandra Glavaski-Joksimovic, Anna Miller, Alok Shah, Brandy Aperi, Matthew Budde, Shekar Kurpad, Frank Pintar, & Brian Stemper Department of Neurosurgery, Medical College of Wisconsin and Zablocki Veterans Affairs Medical Center, Milwaukee, WI, USA Objectives: Blast traumatic brain injury (bTBI) is a prevalent cause of chronic disability among military personnel that can lead to devastating cognitive and emotional sequelae. To date, an effective therapy to halt or reverse the brain damage cascade has not been discovered. Whereas bone marrow-derived mesenchymal stem cells (BMSC) have proven effective in treating other neurodegenerative conditions, effectiveness of this therapy has not been assessed following bTBI. This study investigated the potential of BMSCs to protect brain tissue after blast exposure using an in vitro model of bTBI. Methods: Hippocampal sections (400 mm thick) were dissected from neonatal Sprague Dawley rats (P7–10). Organotypic hippocampal cultures (OHCs) were grown using the membrane interface method. At 8 days in culture, OHCs were exposed to a blast shockwave of 148.3 ± 8.5 kPa using a helium-driven open-ended shock tube. Immediately after exposure, OHCs were transferred to wells with rat BMSC. Co-cultures of BMSC and OHCs (OHCs + BMSC) were grown in serum-free medium for 48 hours. Incubator controls, sham-injured and injured-only OHCs were maintained for the same time period in serum-free medium without BMSC. At 2, 24 and 48 hours following blast exposure, cell death was assessed using the fluorescent dye propidium iodide (PI). Fluorescent images of PI staining were digitalized and analysed using Image J software (NIH). A pixel intensity threshold was set to encompass a majority of control section images. The area of the OHC CA1 region with pixel intensity above the threshold was quantified. Results were analysed with the repeated measure two-way ANOVA with Bonferroni post-test. Results: Blast exposure resulted in prominent cell death in OHC CA1 regions. Cell death was detected at 2 hours after exposure and progressed at 24 hours and 48 hours. The percentage of CA1 area with pixel intensity above the threshold in blast-exposed OHCs was

0796

Hidden face of neuroethics Appalachian State University, Boone, NC, USA Widely discussed topics in neuroethics include the risks factors of invasive techniques such as DBS for individuals; off-label use of these invasive techniques; and the legal and moral implications of imaging. The discussions surrounding these issues are crucial; however, the implications of these advances are not limited to the wizardry of medical and technological feats. This paper’s goal is to examine the meta-level implications of recent neurological advances in the care of traumatic brain injuries. Specifically, this study considers the impact of neurological advances on the continuum of care; that is, the institutional challenges brought about by advances in neurology. If patients can survive severe traumatic injury, if minimally conscious patients are owed care, what are the implications for their continuing care? What model of care would be suited to meet these individuals’ needs? These are questions that require adequate answers as the number of brain injuries and the diversity of outcomes of brain injuries is increasing. If medical advances are lauded, it behooves one to consider the long-term implications of such advances for the patients and their families. The sequelae of brain injuries, even mild ones, extend over long periods of time. At first glance, it might seem as if the chronic model of care would be the best model suited to the needs of individuals with brain injuries who require extended care services. As discussed in this paper, there are dissimilarities that make a straightforward adaption of this model unfeasible. Nevertheless, the particularities of brain injury care highlight some of the difficulties that are already present within the chronic care model of service delivery. Therefore, it is useful to consider the challenges of brain injury to this model of care delivery in order to address some of these problematic issues. The goal is 2-fold: first to understand how this reflection can serve to enhance the chronic care model. Second, it is to elaborate a model of care for persons with TBI that can better serve their needs and those of their families. This study focuses on the notion of autonomy as well as the assumption of decline that are at work in the chronic care model. It considers these assumptions in the context of brain injury and the manner in which they are problematic. The paper porceeds as follows: first, it explains the important features of the chronic care model. Next, it highlights some of the issues relevant to post-acute and post-rehabilitation traumatic brain injury care. This is followed by discussing the similarities and dissimilarities between individuals who typically require chronic care and those who have suffered traumatic brain injuries. Finally, the issues that need to be addressed in a model of brain injury care are highlighted.

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Processing of emotional facial expressions following mild traumatic brain injury: An ERP study in pre-schoolers

A preliminary examination of the relationship between brain volume and cognitive functioning in a traumatic brain injury sample

Fabien D’Hondt1, Phetsamone Vannasing2, Fanny Thebault-Dagher1, Cindy Beaudoin2, Jocelyn Gravel3, Annie Bernier1, Miriam Beauchamp1, & Maryse Lassonde1

John Dsurney1, Katherine Lopez1, Dzung Pham1, Shannon McNally2, Sarah Levy1, John Butman2, Andre van der Merwe1, Christian Shenouda1, & Leighton Chan2

1

1


University of Montreal, Department of Psychology, Montreal, Que´bec, Canada, 2Ste-Justine Hospital Research Center, Montreal, Que´bec, Canada, 3Sainte-Justine Hospital, Division of Emergency Medicine, Department of Paediatrics, Montreal, Que´bec, Canada Objectives: While the acute consequences of childhood traumatic brain injury (TBI) include serious physical and cognitive deficits, persistent behavioural and socio-emotional problems may be the most debilitating sequelae and appear to worsen with time since injury. Even mild TBI (mTBI) is known to result in increased risk for social and behavioural problems, although the exact consequences on socio-emotional function are still poorly understood. Moreover, despite evidence that the pre-school period is the most frequent and potentially the most damaging period for sustaining a brain injury, almost nothing is known of the first manifestations of socioemotional difficulties after early mTBI (under 5 years). In particular, it is unclear whether childhood TBI induces emotion recognition deficits, yet such dysfunction could lead to serious behavioural and social maladjustment. Indeed, the ability to assess the affective content of external cues is a key adaptive function, as it allows processing of potentially threatening or advantageous stimuli, as well as establishment of appropriate social interactions by enabling rapid decoding of the affective state of others from their facial expressions. The aim of the current study was, therefore, to investigate whether early mTBI can affect the processing of emotional facial expressions by studying brain responses in pre-schoolers that were presented with human faces expressing negative, neutral or positive emotions. Methods: Eleven pre-schoolers (mean age 55 ± 11 months; four females) who sustained mTBI and 15 healthy controls (mean age 52 ± 9 months; eight females) were asked to look at angry, neutral and happy faces and to try to feel the emotion expressed by the faces while event-related potentials (ERPs) were recorded. ERPs were analysed by means of baseline-to-peak method focusing on the facespecific ERP component, namely the N170. A brief parent-report measure of child empathy was also collected using the Griffith Empathy Measure. Results: While parent-reported empathy was not significantly different between the two populations, when pre-schoolers who sustained mTBI were compared to healthy controls, they showed: (1) reduced mean N170 peak amplitude in right occipito-temporal areas for angry and happy faces; and (2) delayed N170 peak latency in right occipitotemporal areas for happy faces. Conclusions: These results suggest that mTBI affects the processing of emotional facial expressions in pre-schoolers and that this deficit could depend on a right hemisphere dysfunction at the occipitotemporal level. In conclusion, although mTBI did not in this study induce a deficit in terms of empathy as measured via parent report, it appears that the early brain responses to emotional facial expressions and particularly to positive ones are impaired in pre-schoolers who sustain early mTBI. This study sheds new light on the emotional consequences of mTBI in early childhood, which could result in adverse social and behavioural outcomes.

Center for Neuroscience and Regenerative Medicine, Bethesda, MD, USA, 2NIH-Clinical Center, Bethesda, MD, USA

Introduction: With advances in MRI technology, brain segmentation, parcellation and volume analysis have become more readily available. To date, the use of these techniques have been limited in the population with traumatic brain injury (TBI). This study evaluated a population of subjects with a variety of head injury severities, at time points ranging from 30 days to 5 years post-injury. Automated wholebrain parcellation software were used to compute regional brain volumes and they were correlated with objective measures of cognitive functioning. Methods: The subjects are 17 community-dwelling patients who were classified as having had a TBI within the last 5 years. The subjects were in an ongoing longitudinal study of TBI and their most recent visit data was analysed. However, in some cases, only one visit, the first visit, data was analysed. The subjects were scanned on a Siemens 3T scanner. T1-weighted images were collected and parcellation was performed using FreeSurfer!. Brain volumes were obtained for intracranial volume, total grey matter, cortical white matter, left and right hippocampus, subcortical grey matter and left and right amygdale. Neuropsychological outcome measures were collected by trained study personnel. These included the core Common Data Elements for TBI as well as the Booklet Category Test (BCT), Trails, Grooved Peg Board, California Verbal learning Test (CVLT), WAIS-IV Symbol Search and Coding. Partial correlations were performed using demographically adjusted T-scores for neuropsychological measures. Age was used as a control in an attempt to adjust for losses in brain volume associated with advancing age. Results: The sample consisted of 12 males and five females, with four mild, 11 moderate and two severe injuries. The mean age of the cohort was 46 years (SD ¼ 18.88), with the mean time since injury being 15.24 months (SD ¼ 8.1). Significant correlations were found between brain volumes and cognitive functioning. Five of eight neuropsychological tests were positively correlated with total grey matter volume. Some of the stronger correlations included, Coding and Pegboard having the highest correlations (0.63 and 0.67, respectively). Pegboard was also strongly correlated with cortical white matter volume (0.63). Conclusions: Preliminary results suggest that there is a significant relationship between performance on neuropsychological testing and brain volumes in patients with TBI. This relationship exists for total and sub-cortical grey matter volume, as well as specific areas such as the hippocampus and cortical white matter volume. The results suggest that an early MRI in patients with TBI may have value as a treatment planning tool.

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Long-term follow-up study in brain injured patients with late recovery of consciousness Anna Estraneo1, Pasquale Moretta1, Vincenzo Loreto1, & Luigi Trojano2 1


Salvatore Maugeri Foundation, IRCCS, Scientific Institute, Telese Terme (BN), Italy, 2Department of Psychology, Second University of Naples, Caserta, Italy

Objective: To provide systematic observations about long-term outcome in patients with ‘late recovery’ of responsiveness. Methods: The study reports on 13 minimally conscious state patients (three females; age range ¼ 12–47 years) who recovered from vegetative state beyond 1 year (range ¼ 11–28 months) after severe TBI (n ¼ 6), haemorrhagic stroke (n ¼ 1) or anoxic brain injury (n ¼ 6). Patients were followed-up for at least 5 years after onset. This study assessed level of responsiveness and/or consciousness by means of Coma Recovery Scale-Revised; functional disability and motor and cognitive functioning were evaluated by Disability Rating Scale and Functional Independence Measure. In patients who recovered full consciousness, neuropsychological tests were specifically adapted for patients with very severe disabilities. Results: After having regained responsiveness, two patients died because of severe clinical complications. Among the remaining 11 patients, five were still in minimally conscious state at their last assessment, but four of them had recovered some complex behavioural responses to the environment, e.g. could follow simple commands, albeit inconsistently. Six patients were fully conscious at the last evaluation. Recovery of full consciousness was more often observed in TBI (4/6) than in non-TBI patients (2/7). Severe motor impairment and functional disability were present in both conscious and minimally conscious patients. No patient was autonomous in common daily life activities or in transfers. All conscious patients showed variable cognitive impairments, particularly in the executive and learning domains, and some of them also developed behavioural and psychological symptoms; such disturbances, however, did not preclude patients’ interaction with relatives and caregivers. Conclusions: This study documented here that late recovered patients can show further progression of clinical and neuropsychological conditions, even though in some cases improvements were minimal. The present study showed that, notwithstanding persistence of some brain plasticity allowing late recovery of responsiveness and consciousness, long-term outcome in such patients is often characterized by severe functional impairments. As a consequence, patients’ and their families’ quality-of-life is very poor. The severe motor (and cognitive) disabilities and musculoskeletal complications suggest that unresponsive brain injured patients need appropriate levels of rehabilitation since from the acute setting. In this perspective, this study might help clinicians to optimize levels of care, as regards intensity of the rehabilitation programme, in order to minimize motor disabilities.

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Verbal memory impairments among children with severe traumatic brain injury: Differential effect of age on the Rey Auditory Verbal Learning Test

Brain Inj, 2014; 28(5–6): 517–878

Tamar Silberg1, Jaana Ahonniska-Assa2, Roni Eliyahu3, Amichai Brezner2, & Eli Vakil1 1

Bar Ilan University, Ramat Gan, Israel, 2Sheba Medical Center, Ramat Gan, Israel, 3Tel-Aviv-Yafo Academic College, Tel Aviv, Israel Objectives: Memory problems are a major concern for children and adolescents following traumatic brain injury (TBI). However, it is often difficult to estimate the influence of childhood TBI on memory functions, since changes in memory functioning are observed over the course of child’s development. The current study aimed to examine the effect of childhood TBI on verbal memory abilities using the Rey Auditory Verbal Test (Rey-AVLT) which enables assessing a range of verbal memory processes in learning, recall and recognition. Additionally, the effect of age on verbal memory can also be extracted from the different Rey-AVLT measures. Specifically, the goals were to (1) compare performance on the Rey-AVLT between paediatric TBI patients and normal controls; (2) examine the effect of age on Re-AVLT performance among children with TBI; and (3) examine the effect of child and injury-related factors (i.e. injury severity, age at injury and general cognitive abilities (IQ) post-injury) on performance on the Rey-AVLT. Methods: The Hebrew version of the Rey-AVLT was administered to 67 children following severe TBI (M ¼ 12.3, SD ¼ 2.7), and to 67 matched controls. This study used the Rey-AVLT composite scores, which reflect a variety of verbal memory process. These composite scores are also reported to be age-sensitive. Based on the developmental trajectories reported on various cognitive domains including memory, this study determined a developmental ‘cut-off point’ and divided the sample into two groups: above and below 12 years of age at assessment. The effect of child and injury-related factors on Rey-AVLT performance was analysed in the TBI group. Results: A significant interaction was found between age at assessment and performance on the Rey-AVLT. It was found that the younger children in the TBI group performed within the normal range compared to matched healthy peers. In contrast, the older children in the TBI group deviated from the normal range and significantly differed from the young children following TBI. Injury severity level, as determined by the duration of Loss of Consciousness (LOC), was found to be the strongest predictor of verbal memory abilities. LOC positively correlated with impairments in immediate memory, learning rate and retrieval efficiency. Conclusions: The current results indicate that, following severe TBI, children show wide-ranging verbal memory impairments in learning, recall and recognition. These impairments were related to child’s injury severity level as measured by LOC duration. Furthermore, the results revealed that verbal memory impairments are evident only among older children following TBI and resemble memory disorders associated with frontal lobe deficits. These findings pertain to the sensitivity of the measure involved and speculate whether the REYAVLT allows for an in-depth examination of different aspects of memory abilities among young children following severe TBI.

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TBI ADAPTER: Traumatic brain injury assessment diagnosis advocacy prevention and treatment from the emergency room—A prospective observational study Latha Ganti, Pratik Patel, Aakash Bodhit, Yasamin Daneshvar, Donna York, Colleen Counsell, Lawrence Lottenberg, & Keith Peters

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DOI: 10.3109/02699052.2014.892379


University of Florida, Gainesville, FL, USA Objective: To report on a standardized approach to mild TBI evaluation in the ED, as well as factors predictive of poor outcome. Methods: Patients were included in the protocol if they were at least 18 years old, presented to the ED within 24 hours of their head injury from any mechanism and had a GCS between 13–15 at the time of ED presentation. The protocol consisted of the following steps: (1) demographics and clinical variables, (2) laboratory testing and computed tomography, (3) neuropscyhometric testing including the GOAT, Epworth sleepiness scale and Rivermead post-concussion survey and (4) visuooculomotor testing for phorias, fusional ranges, saccades, pursuits, accommodation, suppressions, fixation disparities and asthnopia survey. Patients were followed up via telephone once between 3–15 days, then once between 30–45 days for persisting/ newly developed symptoms that may indicate post-concussion syndrome, review of new medications and ensuring that patients understood any follow-up appointments. Results: A total of 816 patients have been through the TBI ADAPTER protocol to date. The majority of the cohort (94%) presented with a GCS of 15. Most patients (79%) arrived via EMS. The most common mechanism of injury was motor vehicle collision (49%) followed by fall (43%), assault (5%) and being struck on the head (3%). A total of 39% were admitted; they were more likely to have a lower GCS (p ¼ 0.0003), a lower mini-mental status examination (MMSE) score (p50.001) and have sustained multi-trauma (p50.0001) or being older (p50.0001). While post-head injury headache was most common, the occurrence of loss of consciousness (p50.0001), alteration of consciousness (p ¼ 0.002) and post- traumatic amnesia (p50.0001) after head injury were significantly associated with hospital admission. Non-contrast brain CT was performed in 85% of the cohort, with 7.6% being abnormal. Abnormal head CT scan was associated with significantly higher chances of hospital admission (74% vs 40%, p50.0001) and also significantly higher chances of return ED visit within 72 hours of discharge (18.4% vs 8.4%, p ¼ 0.039). Higher RPCSQ score was associated with hospital admission (p ¼ 0.004, mean score of 21.5 for admitted vs 13.7 for non-admitted). Abnormal tests for saccadic eye movements (48% vs 25%, p ¼ 0.017), suppression (80% vs 27%, p ¼ 0.011) and pursuit (48% vs 26%, p ¼ 0.041), all parts of the binocular vision assessment (BVA) were significantly associated with higher hospital admission rates, but none of the tests showed any significant association with abnormal CT scan findings. Conclusion: An emergency department based multi-disciplinary protocol for mild traumatic brain injury integrating practice, research and education not only appears to be feasible, but also easily portable to other settings. Data obtained from such a protocol provides valuable information on local demographics and needs, helping to further refine clinical care protocols.

Medicine, Houston, TX, USA, 6Cornerstone Medical Group, Franklin, TN, USA, 7Reed Neurological Research Center, Los Angeles, CA, USA, 8 Avanir Pharmaceuticals, Inc., Aliso Viejo, CA, USA

Objectives: Pseudobulbar affect (PBA) is a neurological condition that can occur following brain injury, stroke and a variety of neurological diseases affecting the brain. PBA is estimated to affect 2 million people in the US, including over 350 000 with TBI; however, awareness remains low and it is frequently unrecognized or misdiagnosed. PBA is characterized by sudden, frequent and uncontrollable episodes of laughing and/or crying that are excessive or inappropriate to the context and independent of the underlying mood. PBA episodes are often disruptive and embarrassing and may be highly distressing to patients and caregivers, potentially leading to social impairment and isolation. Dextromethorphan hydrobromide 20 mg and quinidine sulphate 10 mg (DMQ 20/10) is currently the only FDA-approved treatment for PBA. DMQ safety and efficacy studies were conducted in patients with amyotrophic lateral sclerosis and multiple sclerosis. A large open-label study (n ¼ 553) of patients with PBA due to a variety of conditions (including TBI, n ¼ 23), provided additional safety data; however, effectiveness was not studied. PRISM II has been initiated to generate data on the effectiveness, safety and tolerability of DMQ 20/10 specifically in patients with TBI (as well as in patients with stroke or dementia). Methods: PRISM II is a nationwide, open-label, multi-centre, 12-week study enrolling up to 750 patients (minimum 200 with TBI), at 150 study centres. Eligible patients are aged 18 years with a documented clinical diagnosis of PBA and baseline score 13 on the Center for Neurologic Study-Lability Scale (CNS-LS), an established PBA rating instrument. Patients with TBI due to a penetrating head injury are excluded. Patients are treated with DMQ 20/10 mg twice daily. The primary end-point is change from baseline in CNS-LS score. Determination of effectiveness is based on magnitude of CNS-LS change and comparison with results of previous Phase III studies. Additional treatment-related outcomes measures include: estimated PBA episode (laughing and/or crying) counts; Mini-Mental State Examination; visual analogue scale for quality-of-life; Clinician and Patient Global Impression (CGIC; PGIC); patients’ satisfaction with treatment; Patient Health Questionnaire (PHQ-9) (to evaluate mood symptoms) and disease-specific functional measures (the Neurobehavioural Functioning Inventory for TBI patients). Safety measures include monitoring of adverse events, concomitant medication usage and vital signs. Results: This US study is currently in progress. Interim results for enrolled patients will be provided at the time of the meeting. Conclusion: PRISM II will provide a prospective, systematic assessment of DMQ 20/10 effectiveness and safety as treatment for PBA in patients with TBI, stroke or dementia.

0802

A study to assess the safety, tolerability and effectiveness of dextromethorphan and quinidine in the treatment of pseudobulbar affect (PBA) [PRISM II] William Sauve1, Flora Hammond2, Richard Zorowitz3, Andrew Cutler4, Rachelle Doody5, Stephen D’Amico6, David Alexander7, & Charles Yonan8 1

Universal Health Services, King of Prussia, PA, USA, 2Indiana University School of Medicine, Indianapolis, IN, USA, 3Johns Hopkins Bayview Medical Center, Baltimore, MD, USA, 4Florida Clinical Research Center, LLC, Bradenton, FL, USA, 5Baylor College of

0803

Methodological issues and research recommendations for prognosis after mild traumatic brain injury: Results of the International Collaboration on MTBI Prognosis (ICoMP) Vicki Kristman1, Jo¨rgen Borg2, Alison Godbolt2, L. Rachid Salmi3, Carol Cancelliere4, Linda Carroll5, Lena Holm6, Catharina Nygren-de Boussard2, Jan Hartvigsen7, Uko Abara1, James Donovan4, & J. David Cassidy4

818 1


Department of Health Sciences, Lakehead University, Thunder Bay, Ontario, Canada, 2Department of Clinical Sciences, Rehabilitation Medicine, Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden, 3University Bordeaux, ISPED, Centre INSERM U897-Epidemiologie-Biostatistique, F-33000, Bordeaux, France, 4 Division of Health Care and Outcomes Research, Toronto Western Research Institute, University Health Network, University of Toronto, Toronto, Ontairo, Canada, 5Department of Public Health Sciences and Alberta Centre for Injury Control and Research, University of Alberta, Edmonton, Alberta, Canada, 6Division of Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden, 7Institute of Sports Science and Clinical Biomechanics, Faculty of Health, University of Southern Denmark, Odense, Denmark Objectives and methods: The International Collaboration on Mild Traumatic Brain Injury Prognosis (ICoMP) performed a comprehensive search and critical review of the literature from 2001–2012 to update the 2002 best-evidence synthesis conducted by the WHO Collaborating Centre for Neurotrauma, Prevention, Management and Rehabilitation on the prognosis of mild traumatic brain injury (MTBI). Results: Of 304 relevant studies, 109 were accepted as scientifically admissible. The methodological quality of the research literature on MTBI prognosis has not improved since the 2002 Task Force report. There are still many methodological concerns and knowledge gaps in the literature. This study reports and make recommendations on how to avoid methodological flaws found in prognostic studies of MTBI. Additionally, it discusses issues of MTBI definition and identify topic areas in need of further research to advance the understanding of prognosis after MTBI. Priority research areas include but are not limited to the use of confirmatory designs, studies of measurement validity, focus on the elderly, attention to litigation/compensation issues, the development of validated clinical prediction rules, the use of MTBI populations other than hospital admissions, continued research on the effects of repeated concussions, longer follow-up times with more measurement periods in longitudinal studies, an assessment of the differences between adults and children and an account for reverse causality and differential recall bias. Conclusions: Well-conducted studies in these areas will aid in understanding of MTBI prognosis and assist clinicians in educating and treating their MTBI patients.

0804

Implementing telemedicine as a viable means of treatment for traumatic brain injury Pennie Seibert1, Jennifer Valerio2, & CodieAnn DeHaas1

Brain Inj, 2014; 28(5–6): 517–878

effective, the bed count is insufficient to warrant a full-time specialist or when significant travel time is necessary to receive care. Because patients travel further for neurological care than any other type of treatment and costs and length of stay are important factors, the need for improved TBI care in remote areas is in high demand. Telemedicine or the use of computer equipment and technology to provide healthcare, has received increased recognition in an array of health applications. Telemedicine programmes have been implemented in some hospitals as a way to improve access to the expertise of critical care professionals. Methods: This study developed the Emergency Specialist Programme (ESP) to provide emergent specialty care consultations for STEMI, stroke, trauma and sepsis. In this programme, emergency physicians respond to requests for consults via the RP-7 Robot and the access centre, which serves as a single point of contact for consults, transports and bed control, then joins the consultation by utilizing multiPresence. This allows the access centre staff to see and hear the referring provider, emergency department physician and patient. Including the access centre staff in the telemedicine connection enables them to respond to requests to arrange transport or specialty consults immediately. Results: This study applied the research focus in TBI in conjunction with experience with the ESP programme to provide a TBI-specific model that can be utilized to implement telemedicine. Conclusions: In the TBI domain, telemedicine can counteract the challenge of treating TBI in rural areas, to greatly enhance and provide quality care. Programmes enable intensivists and critical care nurses to serve as a resource and support for healthcare providers in communities that would otherwise be without specialty expertise. Audio and video feed capabilities combined with access to x-rays, scans and lab results, provide a physician with the ability to make more informed decisions. Additionally, post-traumatic complications are common in TBI. Real-time monitoring could potentially detect and combat these complications. In the case of rural communities and military members, telemedicine has the potential to expedite TBI diagnosis and treatment from a distance.

0805

Use of HIRREM, a noninvasive neurotechnology, is associated with symptom reduction and increased heart rate variability among individuals with traumatic brain injury Charles Tegeler1, Catherine Tegeler1, Jared Cook1, Sung Lee2, Meghan Franco2, Lee Gerdes2, & Hossam Shaltout1 1

1

Saint Alphonsus Regional Medical Center, Boise, ID, USA, 2 Boise State Univeristy, Boise, ID, USA Objectives: Traumatic brain injury (TBI) is a leading cause of disability worldwide. Survivors of severe TBI frequently are hospitalized postinjury and experience long-term cognitive and physical impairments. Prognoses for patients who sustain a severe TBI worsen with increased time-to-treatment. Early contact between emergency medical services and the emergency room enables improved preparation. Readily accessible specialists such as neurosurgeons and intensivists can reduce the hospital length of stay and improve patient outcomes. Complications arise when those needing critical care do not have timely access to these and other necessary specialists. This problem is exacerbated at smaller care centres, rural areas and for military members where specialists either are not cost-

2

Wake Forest School of Medicine, Winston Salem, NC, USA, Brain State Technologies, LLC, Scottsdale, AZ, USA

Objectives: To evaluate high-resolution, relational, resonance-based, electroencephalic mirroring (HIRREM) as an adjunct to usual care for individuals with traumatic brain injury (TBI). TBI may be followed by heterogeneous symptoms including depressed mood, impaired sleep, post-traumatic stress and others, many associated with autonomic dysregulation. Studies of brain electrical activity in TBI report suboptimal proportionation between high and low frequencies and PTSD, often seen with TBI, has been associated with right temporal lobe over-activation. HIRREM generates feedback as audible tones derived from software algorithm-driven analysis of real time changes in brain electrical activity from scalp recordings, measured at highspectral resolutions, to facilitate auto-calibration of neural oscillations.

819


DOI: 10.3109/02699052.2014.892379

Methods: Twenty-one subjects (mean age ¼ 34.7, range ¼ 15–64, nine women) reporting symptoms relevant to prior TBI (related to sports for six, to military service for five) were enrolled in an IRB-approved, open label feasibility study of HIRREM for diverse clinical conditions. Subjects had a baseline HIRREM assessment followed by a median of 16 (range ¼ 10–36) HIRREM sessions (90 minutes each) over a median of 13 days (range ¼ 9–93). Temporal high frequency electroencephalic asymmetry scores (percentage basis) were calculated at baseline and for serial HIRREM sessions by measuring 1-minute epochs of high frequency (23–36 Hertz) amplitudes (microvolts) at bilateral temporal lobes (T3/T4), subtracting the value at T3 from that at T4 and dividing by the lesser of the two (yielding positive scores for right dominance). Blood pressure and heart rate were measured during recordings at baseline and after completion of the final HIRREM session, to assess cardiovascular autonomic regulation including heart rate variability (HRV). Results: After completing HIRREM, subjects on average reported reduced symptoms of insomnia (pre- to post-HIRREM change in the Insomnia Severity Index of 13.7 to 7.1, p50.0001), depression (change in CES-D of 24.3 to 12.7, p50.0001) and symptoms of post-traumatic stress (change in PCL-C of 44.7 to 32.7, p ¼ 0.0001). Measures of HRV improved after HIRREM (SDRR increased from 51.8 to 65.2 milliseconds, p ¼ 0.009). In subjects (n ¼ 8) who were initially right-temporal (T4) dominant (amplitudes 10% rightward), temporal asymmetry changed from a median of 49.7% to 2.5% (p ¼ 0.06). In those who were initially left-temporal (T3) dominant (n ¼ 9), asymmetry scores changed from a median of 30.4% to 18.9% (p ¼ 0.0004). For those who were initially 510% asymmetrical in either direction (n ¼ 4), asymmetry changed from a median of 4.0% to 14.9% (p ¼ 0.75). Conclusions: In this case series, use of HIRREM by individuals with prior TBI was associated with statistically significant reductions in clinical symptoms of insomnia, depression and post-traumatic stress and increased HRV. Trends were found for reduced temporal asymmetry among those who were 10% asymmetrical at baseline. Controlled clinical trials of HIRREM for TBI are warranted.

0806

The value of neurocognitive and oculomotor testing after mild TBI in the emergency department Latha Ganti, Pratik Patel, Aakash Bodhit, Yasamin Daneshvar, Sarah Ayala, & Keith Peters University of Florida, Gainesville, FL, USA Objective: Traditionally, neuropsychometric testing is performed weeks to months after head injury and mostly in patients who continue to have symptoms or difficulties. This study sought to determine whether these tests, when administered acutely, could assist in predicting shortterm outcomes after acute traumatic brain injury (TBI). Methods: This is an IRB approved retrospective review of all adult (18 years and higher) patients who came to the emergency medicine department of a healthcare facility with a Level-1 trauma centre with the primary diagnosis of TBI. Patients with a head injury from any mechanism that occurred within 24 hours of presentation to the Emergency department (ED), were enrolled prospectively after written informed consent and took two separate neurocognitive tests, the Galveston Orientation Amnesia Test (GOAT) and the Rivermead Post-Concussion Survey Questionnaire (RPCSQ). The GOAT is a 20-question instrument that is scored from 0–100 and the RPCSQ is a 30-question instrument with a score range from 0–65. Independent variables included raw scores on each of these tests; dependent variables included hospital admission, development of post-concussive syndrome (PCS) and 30-day re-admission rate. Statistical analyses were performed in JMP 10.0. Results: The median GOAT score was 99 (IQR ¼ 98–100, range ¼ 84– 00). Having a lower GOAT score was significantly associated with being

hospitalized (p ¼ 0.0139) and developing post-concussive syndrome (PCS) at the 30–45 day follow-up (p ¼ 0.0183, R2 ¼ 12.2%). The median RPCSQ score was 12 (IQR ¼ 5–23, range ¼ 0–61). A higher RPCSQ score was significantly associated with hospital admission (p ¼ 0.0113), re-admission to hospital within 30 days (p ¼ 0.0019) and evidence of PCS at days 3–15 post-injury (p ¼ 0.0001, R2 ¼ 22.6%). Conclusions: While not commonplace, neuropsychometric testing in the ED in the setting of acute head injury is both feasible and appears to have value in predicting hospital admission and who will suffer from PCS. These data are especially important in terms of helping patients understand what to expect, which in turn aids in their recovery.

0807

Goal-oriented executive function training in veterans with chronic TBI: Short and longer term outcomes Tatjana Novakovic-Agopian1, Gary Abrams1, Anthony Chen2, Michelle Murphy1, Anemarrie Rossi1, Gerald Carlin1, Fred Loya1, Deborah Binder2, Michelle Madore1, & Mark D’Esposito1 1 3

SFVA MC, San Francisco CA, USA, 2VA NCHCS, Martinez, CA, USA, UCSF, San Francisco, CA, USA, 4UC Berkeley, Berkeley, CA, USA

Objective: Some of the most common and disabling consequences of brain injury are deficits in executive control functions, such as selection, planning, maintenance and execution of goal-relevant activities. Goal-Oriented Attentional Self-Regulation (GOALS) training was designed to target these deficits with attention regulation training applied to participant-defined goals. In a pilot study individuals with chronic acquired brain injury significantly improved post-GOALS, but not brief control training, on measures of attention/ executive function, functional task performance and goal-directed control over neural processing on fMRI. The objective of this ongoing study is to assess immediate and long-term effects of GOALS training in Veterans with chronic TBI. Participants and methods: Twenty-four Veterans with chronic (6+ months) TBI and mild–moderate executive dysfunction were randomized to start with either 5 week of GOALS or an active control BrainHealth (EDU) training matched in time and intensity. Participants that started with EDU switched to GOALS during the second 5 weeks. Assessments at baseline, weeks 5, 10 and 6 months included neuropsychological, complex functional task performance and selfreport measures of emotional regulation. Results: At week 5 post-GOALS, but not EDU training, participants significantly improved from baseline on: (1) overall neuropsychological attention/executive function domain score and the following sub-domain scores: working memory, mental flexibility and generative ability; (2) overall complex functional task performance score and the following sub-domains: planning, self-monitoring, task execution, switching and maintenance of attention; and (3) emotional regulation self-report measures: Profile of Mood States–total mood disturbance, depression, tension, confusion and anger; PCLM–reexperience and avoidance; and BDI-II depression. At follow-up evaluation 6+ months post-GOALS training, participants maintained significant improvements relative to their baseline performance in most of the above domains and the majority reported incorporating trained strategies into their daily life. Conclusions: GOALS training may be promising in Veterans with chronic TBI. Improving cognitive control functioning may also improve functioning in other domains such as emotional regulation and functional performance. The challenges and importance of: (a) using participant-defined goals applied to relevant training; (b) using

820 ecologically valid assessment measures; and (c) assessing change in functioning at different levels, will be discussed.

Brain Inj, 2014; 28(5–6): 517–878

Sean Robb, & Dawn Good Brock University, St. Catharines, Ontario, Canada

0808

Prevalence of sleep and psychiatric disorders in patients who present to the emergency department with mild traumatic brain injury Latha Ganti, Pratik Patel, Aakash Bodhit, Yasamin Daneshvar, & Keith Peters


University of Florida, Gainesville, FL, USA Objective: Head injury and mild traumatic brain injury (TBI) are increasingly becoming more common presentations to Emergency Departments. Anecdotally it appears that many of these patients also have underlying sleep problems, anxiety and/or depression. This study investigates the frequency of these disorders in a mild TBI population. Methods: This is an IRB approved prospective review of all adult (18 years and higher) patients who came to the emergency medicine department of a healthcare facility with a Level-1 trauma centre with the primary diagnosis of TBI or some head-related injury. Patients were prospectively enrolled in the study, which included participation in the Emergency Department and a telephone follow-up on day 3–15, via written informed consent forms. Two tests were administered while the patient was in the ED. The Epworth Sleepiness Scale (ESS), which runs from 0–24, was used to assess for sleep disorders. A patient with a score of 10 on the ESS is considered ‘at risk’ for a sleep disorder based on his or her excessive daytime sleepiness behaviour. A standardized survey instrument specifically asking patients of any presence of anxiety, depression, psychoses or other mental illness was used to assess psychiatric illness. Data were entered in blinded fashion into REDCap and analysed using JMP 10.0 Pro. Results: The median age was 26, 44% were male and 12% sustained multi-trauma. The median ESS was 7.5 (IQR ¼ 5–11, range ¼ 0–16). The median Injury Severity Score (ISS) was 17 (IQR ¼ 6–37). Psychiatric history was significant for depression (17%), anxiety (12%), substance abuse (3%) and other psychiatric illness (4%). A history of depression was significantly associated with multi-trauma (p ¼ 0.0557) and higher ISS (p ¼ 0.0446). Similarly, a history of substance abuse was also associated with a higher ISS, as well as a higher 30-day hospital re-admission rate (p ¼ 0.0006). There was a trend towards statistical significance for higher risk of having persistent concussive symptoms in those with a history of substance abuse (p ¼ 0.055). Conclusions: The prevalence of psychiatric and sleep disorders in patients presenting to the ED with head injury is not insignificant. Furthermore, these disorders are associated with a higher risk of sustaining multi-trauma and higher ISS. Thus, it is important to solicit this history in TBI patients, both for the acute phase as well as for follow-up.

0809

Barriers to social integration: Decision-making strategies and depression in persons with mild and moderate traumatic brain injury

Objective: Much of the research literature has focused on the cognitive and physical sequelae following traumatic brain injury (TBI); comparatively less attention has been allocated to the socioemotional symptomatology that pose as barriers to social reintegration when returning to schools, work-places and communities. Although many barriers have been identified, decision-making and mood impairments are particularly costly, as they influence one’s degree of social inclusion. One area of the brain implicated in the pathophysiology of both of these challenges is the orbitofrontal cortex (OFC), a structure shown to be vulnerable to the biomechanical effects of coupe–contrecoupe and rotational forces that act on the skull during TBI impact, causing this area to collide with the bony protrusions that surround the orbits. This study investigates socioemotional barriers in university students with and without mild head injury (MHI), as well as a clinical sample with moderate TBI, as a means to illustrate the continuum of TBI and its impact on implicit and explicit strategies in decision-making and depressive symptomatology. Methods: Sixty university (30% MHI) and 20 community participants (50% moderate TBI, age- and sex-matched) completed the Iowa Gambling Task (IGT) while measures of physiological arousal were taken (i.e. pulse, respiration and electrodermal activation). Participants also completed self-report measures of psychopathology (i.e. SA-45, BDI, STAI, etc.). Results: Individuals reporting a neural injury illustrated a slower transition from ‘disadvantageous’ to ‘advantageous’ choices (leading to less overall gain), a pattern of decision-making indicative of less attention being allocated to prior losses. They were also physiologically under-aroused prior to making selections as compared to their non-injured cohort. This pattern of impaired decision-making was amplified with increased severity of injury (i.e. moderate TBI individuals had a slower learning transition than those with MHI). Lastly, for participants reporting a head injury, their learning rate on the last 50 trials of the IGT was found to significantly predict 79% of self-reported depressive symptomatology on the BDI (F(5, 16) ¼ 8.47, p ¼ 0.002). This relationship was not present for those without a head injury. Conclusions: These findings illustrate the continuum of injury severity proportionally relates to changes in decision-making whereby those with brain and head injuries were inclined to make riskier decisions which, in turn, lead to more adverse/less advantageous outcomes. This, in addition to alterations to physiological arousal, illustrates a neurally-based ‘dampening’ of ‘affect sensitivity’ in decision-making for those reporting a head injury. In addition, neuropsychological indices of OFC function were found to be predictive of self-reported depressive symptomology, illustrating the role that the OFC may have in the development of affective disorders following head injury.

0810

A systematic review of the risk of Parkinson’s disease after mild traumatic brain injury: Results of the International Collaboration on MTBI Prognosis (ICoMP) Connie Marras1, Cesar Hincapie2, Vicki Kristman3, Carol Cancelliere2, Sophie Soklaridis4, Alvin Li5, Jorgen Borg6, Jean-Luc af Geijerstam6, & J. David Cassidy7

821

DOI: 10.3109/02699052.2014.892379 1


Morton and Gloria Shulman Movement Disorders Centre, and the Edmond J. Safra Program in Parkinson’s Research, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada, 2Division of Health Care and Outcomes Research, Toronto Western Reserach Institute, University Health Network, University of Toronto, Toronto, Ontario, Canada, 3Department of Health Sciences, Lakehead University, Thunder Bay, Ontario, Canada, 4 Centre for Addiction and Mental Health, Toronto, Ontario, Canada, 5 Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada, 6Department of Clinical Sciences, Rehabilitation Medicine, Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden, 7Institute of Sports Science and Clinical Biomechanics, Faculty of Health, University of Southern Denmark, Odense, Denmark Objectives: To synthesize the best available evidence on the risk of Parkinson’s disease (PD) after mild traumatic brain injury (MTBI). Methods: MEDLINE and other databases were searched (1990–2012) with terms including ‘craniocerebral trauma’ and ‘parkinsonian disorders’. Reference lists of eligible articles were also searched. Systematic reviews, meta-analyses, randomized controlled trials and cohort and case-control studies were selected according to predefined criteria. Studies had to have a minimum of 30 concussion cases. 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. Evidence was synthesized qualitatively according to modified SIGN criteria. Results: Sixty-five studies were eligible and reviewed and five of these with a low risk of bias were accepted as scientifically admissible and form the basis of the findings. Among these admissible studies, the definitions of MTBI were highly heterogeneous. One study found a significant positive association between MTBI and PD (OR ¼ 1.5, 95% CI ¼ 1.4–1.7). The estimated OR decreased with increasing latency between MTBI and PD diagnosis, which suggests reverse causality. The other four studies did not find a significant association. Conclusions: The best available evidence argues against an important causal association between MTBI and PD. There are few high quality studies on this topic. Prospective studies of long duration would address the limitations of recall of head injury and the possibility of reverse causation.

Methods: Eight male OEF/OIF service personnel (military members, contractors or otherwise embedded) with mixed TBI/PTSD syndromes (including all with serious head injuries) referred to the Brain Wellness and Biofeedback Center of Washington were treated with an experimental adaptation of FNS for 20 sessions and also seen for pre–post laboratory examination at the USUHS Traumatic Injury Research Programme. Measures completed pre- and immediately post-treatment included, among others, the Rivermead Post-concussion Symptoms Questionnaire, Patient Health Questionnaire-9 (PHQ9: regarding depression), Symptom Checklist-90 (SCL-90), PTSD Checklist-Military Version and individual treatment session 0–10 ratings of current symptoms, including their most personally bothersome. Results: All measures evidenced statistically significant improvement or trends for improvement on t-test comparisons from pre- to immediately post-treatment on the questionnaires and checklists (e.g. Rivermead p ¼ 0.08, PHQ-9 p50.001, SCL-90 Global Severity Index p50.001, most bothersome current symptom Average Item ratings, p50.001). Qualitative data including comments by participants were consistent with this enhanced sense of well-being and everyday functioning. Conclusions: FNS intervention may offer the potential for amelioration of debilitating cognitive and emotional sequelae associated with persistent trauma spectrum syndromes. Symptoms of TBI/PTSD, including those most personally bothersome to participants, improved over the course of relatively brief FNS treatment and were further highlighted by other comments from participants regarding symptom levels, sense of well-being and everyday functioning. Neuro/physiological and neurocognitive correlates are also being examined and longer term follow-up data are being collected.

0812

Predictors of clinical outcome after TBI secondary to falls—An emergency department registry Pratik Patel, Aakash Bodhit, Yasamin Daneshvar, Keith Peters, & Latha Ganti University of Florida, Gainesville, FL, USA

0811

Improvements with neurotherapy for TBI/PTSD syndromes in OEF/ OIF service personnel David Nelson1, Mary Lee Esty2, David Keyser3, & Paul Rapp3 1

Sam Houston State University, Huntsville, TX, USA, 2Brain Wellness and Biofeedback Center of Washington, Bethesda, MD, USA, 3 Uniformed Services University of the Health Sciences, Bethesda, MD, USA Objectives: Positive results from a small pilot study (n ¼ 3) of treatment with neurotherapy to address complex trauma spectrum symptoms in OEF/OIF veterans have previously been reported. This study extends the report to include a larger sample of OEF/OIF service personnel with mixed TBI/PTSD syndromes regarding the effects on subjective symptom reports of treatment with the Flexyx Neurotherapy System (FNS) that uses minute electromagnetic pulses to subliminally stimulate the EEG.

Objective: To identify predictors of outcome in patients with traumatic brain injury (TBI) due to mechanism of fall. Methods: This is an IRB approved retrospective review of all adult (18 years and higher) patients who came to the emergency medicine department of a healthcare facility with a Level-1 trauma centre with the primary diagnosis of TBI. This was an observational cohort study of consecutive adults who sustained a head injury within the prior 24hours. It conducted at a Level-1 Trauma centre over 20 months. Data were entered into RedCap and JMP 10 and used to perform statistical analyses. Results: The cohort (n ¼ 590) had the following symptomatology: vomiting (9%); seizure (5%); LOC (41%); LOC430 minutes (12%); AOC (27%); post-traumatic amnesia (21%). Twenty-seven per cent were on an anticoagulant (AC) or antiplatelet (AP) agent. Fifty-three per cent had an abnormal head CT, 46% were admitted to the hospital, 20% had an ICU stay, 7% required neurosurgical intervention, 4% died in hospital, 12% were re-admitted within 30 days and 9% were dead at 3 months. In multivariate regression analyses, hospital admission was significantly associated with: higher age, p50.0001; male gender, p ¼ 0.0039; LOC, p ¼ 0.0074; PTA, p ¼ 0.0204; severe TBI, p ¼ 0.0402; and on AC/AP, p ¼ 0.0003. ICU admission was significantly associated with higher age, p50.0001; AOC, p ¼ 0.0078; and severe TBI, p50.0001. In-hospital death was significantly associated with higher age, p ¼ 0.0033, and severe TBI, p50.0001. Death at 3 months was significantly associated with higher age, p50.0001, and severe TBI,

822 p50.0001. Surgical intervention was significantly associated with higher age, p ¼ 0.0024, and severe TBI, p50.0001. Conclusions: Patients with symptoms such as alteration of consciousness and post-traumatic amnesia after traumatic brain injury as a result of fall are more likely to be admitted to the ICU with significantly longer ICU length of stay. Mild traumatic brain injuries in fall patients should not be overlooked in daily practices because of significant morbidity and mortality.

0813


The impact of life satisfaction on participation, independent living and vocational status during post-acute interdisciplinary rehabilitation in persons with acquired brain injury (ABI) Thomas Bergquist, Marietta Hoogs, Carrie Bronars, Alissa Butts, & Allen Brown Mayo Clinic, Rochester, USA Objective: This study investigates the impact of satisfaction with life during post-acute interdisciplinary rehabilitation after acquired brain injury (ABI) on participation, independent living and vocational status. Background: Post-acute brain rehabilitation has grown significantly in the last several decades with a focus on improving community participation in persons served. A growing body of research has demonstrated the impact of a variety of psychosocial factors on outcome. This study investigates the impact of satisfaction with life on outcome in persons receiving post-acute brain rehabilitation. Method: This study was a cohort of persons referred for post-acute brain rehabilitation. The setting was an outpatient rehabilitation clinic within a tertiary care centre. Ninety-two persons with complete data of 120 referred for outpatient rehabilitation after acquired brain injury who completed treatment between August 2011 and December 2012 were included. Participants were 54% male and averaged 52 years of age. Causes of ABI included stroke (37%), TBI (40%) and other (23%). All persons received interdisciplinary rehabilitation with the specific therapy determined by clinical need. Treatment lasted an average of 5 months. Outcome measures were given at admission to treatment and then again at discharge from treatment. The main outcome measures were: Satisfaction with Life Scale (SWLS); Patient Health Questionnaire (PHQ-9); Participation Index from the Mayo-Portland Adaptability Index (M2PI); Vocational Outcome Scale (VIS); and Independent Living Scale (ILS). To create a more homogeneous sample, a total of five patients with significantly discrepant (several years) times from injury to programme admission were excluded. A one-way ANOVA revealed no significant difference in SWLS (Total Score) across the three patient groups (i.e. Stroke, TBI, Other). Therefore, the groups were collapsed. SWLS at admission was moderately correlated to PHQ-9 admission score. Logistic regression was used to assess the predictive ability of SWLS on the outcome measures. From previous analyses it was found that the M2PI co-varied with multiple other measures. Therefore, the M2PI, as well as PHQ-9 admission score were entered in at Block 1. At Block 2, SWLS total score was entered at admission for the logistic regression. Results: SWLS was moderately correlated with PHQ-9 at programme admission. M2PI at admission was predictive of VIS and ILS at

Brain Inj, 2014; 28(5–6): 517–878

discharge. SWLS was not predictive of VIS or ILS above and beyond what is accounted for by M2PI score as admission. Conclusions: While not predictive of vocational or independent living status at programme discharge, satisfaction with life was correlated with mood at admission. It has previously been demonstrated that improvement in mood over the course of treatment is predictive of vocational and independent living status at programme dismissal. This suggests that measuring life satisfaction may be complex and at least in part impacted by mood state.

0814

Finding students with undiagnosed TBI: Colorado begins educational identification of TBI Pat Sample1, Judy Dettmer2, & David Greene1 1

Colorado State University, Fort Collins, CO, USA, 2Colorado Department of Health and Human Services, Denver, CO, USA

Objectives: (1) To develop and implement a new Colorado policy that adds to the current medical determination of a TBI, a non-medical school-based determination of TBI eligibility of students for IDEA services. (2) To test validity and reliability of the Brain Check Survey (BCS) screening tool to assist schools in substantiating a non-medical ‘significant history’ of TBI for un-diagnosed students. Methods: Enactment of the New Colorado Department of Education Policy (ECEA Rules: Rules for the Administration of the Exceptional Children–Colorado Department of Education: 1 CCR 301-8). From Rule 2–Definitions of IDEA Eligibility Categories: 2.08 (10) (a) To be eligible as a child with a traumatic brain injury, there must be evidence of the following criteria; 2.08 (10) (a) (i) Either medical documentation of a traumatic brain injury or a significant history of one or more traumatic brain injuries reported by a reliable and credible source and/or corroborated by numerous reporters; and the child displays educational impact most probably and plausibly related to the traumatic brain injury. Brain check survey: A total of 512 parents of students with TBI IEPs (n ¼ 51) and students considered Typical (n ¼ 461) from five CO school districts completed the BCS, for tool-testing purposes. (1) Tested the construct validity—factor analysis, using Principal component analysis and Varimax rotation; (2) Tested internal consistency—using Cronbach’s alpha; (3) Tested test–re-test reliability using intra-class correlation coefficient (ICC) statistic; and (4) Between Group Differences—using MANOVA tests: TBI vs Typical students. Results: Through the Colorado Department of Health and Human Services and the Colorado Department of Education, the state has developed a multi-step protocol for school district personnel to use as they begin implementing the Educational Identification of TBI process. This process will begin identifying with a traumatic brain injury (TBI) under-served and un-served students who have no medical documentation of a TBI, for purposes of eligibility for IDEAmandated services. The Brain Check Survey was found to have three factors: Symptoms, Behavioural Control and Cognitive Processing; and significantly high internal consistency, test–re-test reliability and differences on all items between the students with TBI and typical students. Conclusions: The Colorado Department of HHS and Colorado Department of Education: Giving in-service trainings on ED-ID for students missing TBI medical documentation. On-going evaluations of training and TBI Identification outcomes are scheduled. BCS is a valid and reliable parent-report screening tool for possible TBI in students. Colorado has adopted this tool as the first step in the ED-ID process.

823

DOI: 10.3109/02699052.2014.892379

0815

Psychological functioning and health-related quality-of-life in a Colombian sample of individuals 3 months post-stroke Jose´ Amilkar Calderon Chaguala´1, Helmer Chacoń Peralta1, Gina Paola Vergara Torres1, Diego Rivera2, Laiene Olabarrieta Landa2, Lourdes Infante St Clair3, & Juan Carlos Arango-Lasprilla4 Antonio Narinõ University, Ibague´, Tolima, Colombia, 2University of Deusto, Bilbao, Bizkaya, Spain, 3Universidad Autońoma de Baja California, Mexicali, Baja California, Mexico, 4IKERBASQUE. Basque Foundation for Science, Bilbao, Bizkaya, Spain


1

Objective: To examine the psychological functioning and healthrelated quality-of-life (HRQoL) in individuals with stroke. Participants: Forty Colombian individuals 3 months post-stroke and 40 matched healthy controls from Ibague, Colombia, were administered a comprehensive psychosocial evaluation. The Patient Health Questionnaire-9 (PHQ-9) was used as a measure of depression, StateTrait Anxiety Inventory (STAI) to measure state anxiety (STAI-S), Perceived Stress Scale (PSS) and the Short Form-36 (SF-36) to measure HRQoL. The groups were similar in gender, age and education (ps40.05). About half of each group were female and had an average age of 51. Seventy-two per cent of the stroke group suffered an ischaemic stroke. Results: The MANOVA comparing individuals with stroke vs healthy controls on all measures was significant (p’s50.001). Compared to healthy controls, individuals with stroke had significantly higher PHQ-9 (p50.001), STAI-S (p50.001) and PSS (p50.001) scores. Individuals with stroke had significantly lower scores on all SF-36 sub-scales: physical functioning (p50.001), role-physical (p50.001), role-emotional (p50.001), vitality (p50.001), mental health (p50.001), social functioning (p50.001), bodily pain (p50.001) and general health (p50.001). Conclusions: Compared to controls, individuals who had suffered a stroke 3 months prior reported significantly more depressive symptoms, higher levels of state anxiety and more stress. These individuals also reported significantly worse HRQoL across all domains measured on the SF-36. These findings are similar to those in the literature; however, this is one of the first studies to be conducted in a Latin American sample. The development and implementation of early psychological interventions in this population may improve these outcomes, facilitate recovery and prevent other long-term secondary consequences of these problems.

0816

Behavioural problems 6 months post-TBI in pre-school children Gabrielle Lalonde1, Jenny Bellerose1, Annie Bernier1, Cindy Beaudoin2, Jocelyn Gravel2, & Miriam H. Beauchamp2 1

Ste-Justine Hospital Research Center, Montreal, Quebec, Canada, Psychology Department, University of Montreal, Montreal, Quebec, Canada

2

Objectives: Evidence suggests that school-age children suffering from traumatic brain injury (TBI) have elevated risks of developing

behavioural problems. The relationship between early childhood TBI and subsequent behavioural impairments is less well established, although there is some evidence of increased behavioural problems in the case of severe TBI. Studies examining TBI have always been concerned with obtaining the best estimate of preinjury functioning. In paediatric populations, parental report is the most effective way to obtain such information given that preschoolers are too young to report for themselves. The aim of this study was, therefore, to evaluate the differences between parental reports of their children’s behaviour pre- and post-injury. It was expected that parents would report more behavioural problems post-injury. Methods: As part of a longitudinal study examining the cognitive and social repercussions of pre-school TBI, parents of 28 pre-schoolers (18–60 months) who sustained accidental mild, moderate or severe TBI (38% female) were recruited at the Emergency Department of SteJustine Hospital and asked to complete the Child Behaviour Checklist (CBCL) concerning their child’s behaviour in the weeks that preceded the injury. They were asked to complete the same questionnaire 6 months post-injury. Results: Children who sustained TBI demonstrated significant increases in behavioural problems post-injury on the following CBCL scales: Emotional Reactivity, t(27) ¼ 1.98, p ¼ 0.03, Withdrawal, t(27) ¼ 2.82, p ¼ 0.01, and Attention Problems, t(27) ¼ 2.39, p ¼ 0.01. Conclusions: Parental reports demonstrate that pre-school children with TBI were more emotionally reactive, more withdrawn and had more attentional difficulties 6 months post-injury. Attention problems are well-known and frequently-reported sequelae of TBI across the lifespan and the current data support this observation in a young group of children. It may seem contradictory that TBI exacerbates both withdrawal and emotionally reactive behaviour. A possible explanation is that emotionally reactive children may tend to instigate more conflicting situations with their family and peers, which could result in more distant and isolated behaviour. The present study highlights the importance of behavioural monitoring following TBI in pre-schoolers. Further analyses will examine behavioural profiles in children with TBI 12 months postinjury.

0817

Long-term outcome and recovery in adults with complex and catastrophic brain injuries Josie Turbach1, & Dawn Good2 1 2

ResCare Premier Canada, Niagara-on-the-Lake, Ontario, Canada, Brock University, St. Catharines, Ontario, Canada

Objectives: Studies with non-human animals have demonstrated the trajectory of neuroplasticity and recovery following a traumatic brain injury, but this has not been translated and generalized to human subjects. Recovery gains, particularly those of ‘slow[er] to recover’ or ‘complex’ catastrophic neural injuries, are often difficult to discern or describe due to limitations in the capacity for continued intensive data gathering beyond the acute or early post-acute phase. These measurement challenges are lessened within a residential rehabilitation setting where individuals are observed and receiving ongoing active neurorehabilitation for long-term living support 24 hours a day, 7 days a week. This study examines outcome and recovery of adults with acquired brain injury (ABI) in a residential rehabilitation setting for individuals residing in a facility for up to 16 years. Methods: Extensive and detailed data has been collected on 36 individuals who are living with the permanent effects of a severe ABI (GCS 8). Behaviour and specifically identified, individualized, goals have been charted on a daily basis from 1–16 years and organized in


824

Brain Inj, 2014; 28(5–6): 517–878

such a way that permit examination of recovery trajectories and outcomes. ‘Functional’ neuropsychological measures are assessed in terms of cognitive, physical and social/emotional status across the participants’ daily activities, community experiences and rehabilitation. Each participant’s contribution is highly individualized and unique as it is derived from his/her Individual Development Plan (IDP). Therefore, the data from the IDP were grouped into the broad categories of Cognitive Abilities, Social Engagement, Emotional Behaviour and Participation in Basic Activities of Daily Living (BADLs). For each participant a representative objective was chosen for each of these domains; and, to the extent possible, objectives were chosen for each participant in order to facilitate coherence of measurement across all participants. Results: Continued, gradual but conservative, gains are evident across time (i.e. even up to 16 years of rehabilitation history), without indications of stabilizing. Gains are not uniform, nor strictly linear, but demonstrate improvements in both levels of independence and reintegration. The overall trend for three of the four measures demonstrates increasing gains over time—performance of BADLs (R2 ¼ 0.64), social engagement (R2 ¼ 0.55) and cognition (R2 ¼ 0.46). Conclusions: Accumulated longitudinal data of ‘functional’ neuropsychological measures, both qualitative and quantitative, confirm continuing plasticity and recovery in persons with severe ABI even many years post-trauma. Gains are observed across the lifespan regardless, and potentially independent, of age at injury. These results and patterns of recovery are inconsistent with models of stalled neural plasticity and, instead, support ongoing enhancements over time through enrichment.

reported higher levels of sub-clinical psychopathy produced both reduced affective and cognitive empathy (p50.05). Personality interacted with MHI status such that those high in psychopathy and who reported a history of head injury, produced lower empathy ratings as well as reduced sensitivity to contextual information. Interestingly, the MHI group’s reduced EDA amplitude while viewing and rating the negative images (p50.05) was pronounced with more severe/complicated MHI. Finally, the MHI high psychopathy group committed more errors with angry and disgust expressions with accuracy correlating with affective, but not cognitive, empathy. Conclusions: These findings imply that personality variables interact with head trauma, such that sustaining a head injury in conjunction with certain personality traits may compromise one’s capacity for correctly recognizing emotion in others and experiencing empathy. This introduces additional challenges for successful integration and increase the risk of social isolation.

0818

University of Oxford, Oxford, UK

Personality and empathic differences in individuals with and without mild head injury (MHI) Tanvi Sharan, & Dawn Good Brock University, St. Catharines, Ontario, Canada Objectives: Difficulties in one’s capacity for empathy have been noted in individuals with acquired brain injury (ABI), particularly those with injuries to the Ventromedial Prefrontal Cortex (VMPFC). The VMPFC is associated with emotion regulation and injury to this area has been associated with reduced anticipatory physiological arousal, flattened affect, erratic lifestyle and anti-social behaviour. These presentations mimic components of psychopathic traits and are often described in the context of ‘acquired sociopathy’. The VMPFC is particularly vulnerable in persons with MHI who show reduced capacity to consider emotional status of others, respond less well to social affective cues (e.g. facial expression) and are physiologically underaroused (e.g. on measures of electrodermal activity (EDA) or heart rate (HR)) relative to their cohort, implicating a difference in their emotional response to various stimuli. Being less responsive to social cues, in conjunction with being unable to anticipate future consequences may impair their capacity to recognize the emotional responses of others and consequently be manifested as a ‘lack’ of empathy. The aim of the current study was to examine differences in empathy, affect recognition and arousal in a sample of university students with and without a reported history of MHI. Methods: One hundred and eight university students completed an emotional processing task in which they were asked to provide empathy ratings after viewing images (12 negative, 12 neutral) with, and without, accompanying verbal contexts either confirming or altering the emotional valence of the scenario. Participants’ physiological arousal (i.e. EDA, pulse) was recorded while they completed the task. Additionally, participants completed measures of Affect Recognition (NEPSY-II), empathy (QCAE) and sub-clinical psychopathy (SRP-III). Results: Relative to their cohorts, individuals reporting a MHI demonstrated reduced affective empathy, while persons who

0820

Social inclusion following childhood acquired brain injury (ABI): A qualitative exploration Anne-Marie Boylan

Objectives: The aims of this study were: (1) to explore children’s social experiences from their and their mothers’ perspectives; and (2) to uncover the factors that inhibit and/or promote social re-integration. Methods: Individual qualitative interviews were conducted with nine children and young people with ABI (six male, three female; aged 8–16 years; time post-injury 42 years) and their mothers. Participants were invited to discuss their/their child’s social experiences in key areas, including relationships, experiences of school and access to and participation in community life. The interviews were audio recorded, transcribed verbatim and analysed using interpretative phenomenological analysis. Results: A range of social inclusion was found amongst the children, which both they and their mothers played a key role in facilitating and inhibiting. Social inclusion was found to be complicated by experiences of conflict, stigmatization and peer rejection; anxietyrelated avoidance, self-protective strategies and maternal vigilance. The trauma of the injury and fears of its recurrence sometimes led mothers to become more protective of their children. As a consequence, they restricted children’s activities and differentiated them from other children by insisting they wore safety accessories and supervising their recreation time. However, the children’s desire to belong was found to remain unaffected by ABI and they reported many positive social experiences, such as having friends and being supported by peers. They also discussed the range of strategies they employ to improve their social inclusion. Conclusions: The impact of children’s ABI extends beyond the child to their mothers and this can have negative implications for social reintegration following injury. This research highlights the complex nature of social inclusion and the need for a multi-perspective approach to rehabilitation that incorporates both children and mothers.

0821

Patterns and outcomes of nonmissile penetrating head injuries; a multi-centre study

825

DOI: 10.3109/02699052.2014.892379

Muhammad Raji Mahmud1, Nasiru Jinjiri Ismail2, Ismail Hassan3, Bello Bala Shehu1, & Ahmad Misbahu2 National Hospital Abuja, Abuja, F.C.T., Nigeria, 2Regional Center for Neurosurgery, Sokoto, Sokoto, Nigeria, 3Aminu Kano Teaching Hospital, Kano, Kano, Nigeria


1

Objectives: Non-missile penetrating intracranial injuries resulting from impalement with objects are quite uncommon; they result from a wide range of objects ranging from nails to farm implements. This study is aimed at finding out how these patterns of presentation and extent of neurological damage directly affect outcome. Methods: This is a retrospective descriptive study of patients presenting with non-missile penetrating head injuries to three neurosurgical centres for a period of 21 months from January 2012 to September 2013. This study analysed the patterns of presentation, type of impaled object, resulting neurologic deficit, brain lobes affected and the outcome at discharge using the Glasgow outcome score. Results: Sixteen patients were analysed, 15 being males. The age ranged from 21 months to 50 years, presentation was delayed in most patients, only three patients presented within 1, 5 and 6 hours of injury, one presented after 24 hours, one presented after 18 years, while the rest presented within the range of 2 days to 30 days. Impaled objects include nails (in two cases), arrows, screw driver, hoe, axe, toy part, aluminium pot fragment, metallic objects and rock fragment. Four patients presented with hemiplegia, two with aphasia and one with long-term seizure disorder. Others had no neurologic deficits. Nine out of the 16 patients had their injuries in the frontal lobes, three had it in the parietal lobes, two had it in the temporal lobes, one had it in the occipital lobe, while one had it in the frontal, parietal and occipital lobes. Only six patients presented with mild deterioration in level of consciousness (GCS 13–14), all the rest were fully conscious at the time of presentation. One patient had extraction of the four impaled nails at a local drug store under unsterile conditions prior to presentation. One presented with a metallic fragment around the basal ganglia for 18 years, presenting only for persistent seizure disorder; he subsequently absconded from further treatment. Eleven of the patients had a Glasgow outcome score of 5 at the time of discharge; only three had a score of 4, while two had a score of 3. Conclusion: Despite the perceived doom associated with non-missile penetrating injuries by the populace, delay in presentation and wide array of impaled objects, non-missile penetrating head injuries are associated with a relatively good outcomes.

0824

Strategies that promote healthy community reintegration after an ABI: Survivors and professionals share their perspectives Mary-Ellen Thompson, & Fahmida Pardham Mary-Ellen Thompson, Ph.D. Practise in Speech, Language and Cognitive Communication, Belleville, ON, Canada Objectives: To identify strategies that promote healthy community integration and quality-of-life after an ABI. To compare strategeis identified by survivors, their family members and caregivers with strategies identified by experienced rehabilitation professionals. Methods: Survivors of ABI completed The Quality of Life Questionnaiare (QOLS) and participated in structured interviews which included a set of standard questions. The QOLS is a 16-item instrument that measures material and physical well being,

relationships with others, social, community and civic activities, personal development and fulfillment, recreation and independence. The structured interviews focused on losses survivors had faced, strategies they used to deal with their losses and possible things they had gained as a result of their injury. They were also asked to provide suggestions for other survivros and information that should be shared with the general public about ABI and the road to recovery. All participants in the study were at least 3 years post-injury and were living independently in the community. The nine survivor participants ranged in age from 18–55. Experienced rehabilitation professionals with a minimum 15 years experience also completed a similar structured interview and were asked to share their observations about successful strategies for community reintegration. All interviews were videotaped and were rated by four independent raters using content analysis. Results: Despite their many losses, survivors were able to identify several strategies that promoted healthy well-being. Content analysis of the structured interviews revealed several consistent themes that were important for re-integration into family and community life. There was general agreement across survivors as to the key components that helped them gain community reintegration, regardless of age, gender, employment or relationship status. As well, there was general agreement among professionals and between professionals and survivors regarding the key ingredients for successful re-integration. These key components will be discussed with concrete examples of meaningful activities that have helped survivors re-integrate into their communities successfully. Conclusions: Many survivors of ABI experience breakdowns in communication, social isolation and a wide range of physical and psychological effects that significantly afffect quality-of-life and healthy well-being. Although many individuals are missing domains that affect quality-of-life such as independence, a vocation and significant relationships, they have been able to find meaning and purpose in their communities. There was general agreement between professionals and survivors about the key components that lead to healthy well-being and successful reintegration after ABI. These findings are critical for the development of functional, meaningful rehabiliatation programmes for surivors of ABI and their families. The importance of fostering community support will also be discussed.

0825

‘I want to be me’: A qualitative exploration of recovery work in survivors of traumatic brain injury (TBI) Anne-Marie Boylan University of Oxford, Oxford, UK Objectives: The aims of this study are to explore the experience of traumatic brain injury (TBI) from the survivors’ perspective and to understand the post-TBI recovery work survivors undertake to reconstruct their lives. Method: As part of a wider study on life-changing injuries, 21 survivors of TBI (17 male, four female; aged 21–59 years) were interviewed about their experience of injury and life afterwards. Time post-injury ranged from 1–21 years. To ensure people had the capacity to consent, they were invited to describe the aims of the research and any potential costs/benefits of participating to the researcher on two occasions, including the day of the interview. During the interview, participants were invited to reflect on their pre-injury lives before talking about their injuries and undertaking an in-depth exploration of their experiences of rehabilitation, recovery and reintegration. With the participants’ permission, the interviews were video or audio recorded, transcribed verbatim and thematically analysed. The


826 findings will be illustrated with audio-visual excerpts from the interviews, which are currently available on www.healthtalkonline.org, a free, ethically funded online information resource about lifechanging injuries for survivors, families, friends and health and social care professionals. Findings: As a result of the numerous sequelae often associated with brain injury, the participants had changed and experienced significant difficulty in reconstructing the self after TBI. The analysis revealed several stages of ‘Recovery work’ the participants undertook as they attempted to find a new way of being in the world and establish a new normal. The recovery work was conceptualized on two levels: ‘reversion or recognition and relinquishment’ and ‘restoration and reintegration’. The pre-injury self was idealized after injury and people worked to revert to being that person. Others worked to recognize and accept their new changed self, a process often complicated by difficulty understanding why they had changed and yearning to be the person they were before. To do this, they often had to relinquish their notions of their former selves, which meant ensuring family members and friends did the same. They then progressed to restore previously taken for granted functions by devising strategies (often with rehabilitation professionals) to overcome the many challenges they faced following injury, with a view to re-establishing lost roles and achieving re-integration. Conclusions: Recovering from TBI can be a wearisome process when there doesn’t appear to be an end in sight. There are significant tensions that affect recovery and reconstruction of self following TBI and survivors need to be supported in doing this. Information provided by ‘experiential experts’, such as that provided on www.healthtalkonline.org, may aid in rehabilitation, recovery and re-integration.

0826

Neuroprotective effects of DHA after neonatal hypoxia-ischaemia Rønnaug Solberg1, Mariangela Longini2, Fabrizio Proietti2, Cosetta Felici2, Ola Didrik Saugstad1, & Giuseppe Buonocore2 1

Department of Pediatric Research, Oslo University Hospital Rikshospitalet, Oslo, Norway, 2Neonatology Unit, University Hospital of Siena, Siena, Italy

Objective: Perinatal hypoxic-ischaemic brain damage is a major cause of acute mortality and chronic neurologic morbidity in infants and children. Docosahexanoic acid (DHA) is a major component of brain membrane phospholipids and accumulates during late pregnancy. DHA has a role in neuroprotection after hypoxia and ischaemia by regulating multiple molecular pathways and gene expression. Isoprostanes, neuroprostanes and neurofurans have all become attractive biomarkers of oxidative damage and lipid peroxidation in brain tissue. Lately also 8-Homo Isoprostanes (F2-dihomo-isoprostanes) have emerged as an in vivo biomarker of free radical damage to myelin in white matter. The present study was conducted to simultaneously measure all four biomarkers in the cerebral cortex and the hippocampus of newborn pigs after hypoxia and resuscitation with ambient air with or without additional treatment with DHA. Methods: Global hypoxia was induced in newborn piglets (age 12–36 hours) until Base Excess 20 mmol L1 or mean arterial blood pressure 520 mmHg. One group (n ¼ 11) was resuscitated with ambient air (21% group) and another (n ¼ 10) received in addition DHA 5 mg kg1 4 hours after start of resuscitation (21% DHA group). The piglets were followed for 9.5 hours after end of hypoxia. Results: Treatment with 5 mg kg1 ducosahexanoic acid, DHA, 4.5 hours after severe hypoxia significantly attenuated lipid peroxidation

Brain Inj, 2014; 28(5–6): 517–878

in tissues from cortex and hippocampus. Nine and a half hours after the start of re-oxygenation and 5 hours after the single dose of DHA, there were less isoprostanes in the cortex and hippocampus compared with re-oxygenation with air (21%) alone, p ¼ 0.041 in cortex and p ¼ 0.006 in hippocampus. F2-dihomo-isoprostane, an indicator of white matter damage, was significantly lower in tissue from the hippocampus in the DHA treated group, p ¼ 0.038. Conclusions: Treatment with DHA after severe neonatal hypoxia can attenuate lipid peroxidation and brain damage in the newborn brain in both grey and white matter tissues. These novel findings add new knowledge on oxidative brain injury and point at a possible therapeutic intervention after perinatal asphyxia or severe hypoxia in both term and pre-term babies. DHA could thereby be an intervention therapy to partial rescue, also white matter damage after neonatal hypoxia-ischemia. DHA has a well-established safety record and has the ability to cross the blood–brain-barrier.

0827

Paediatric rehabilitation of antiNMDA encephalitis: Clinical course and challenges in management Ryan Hung, Ritu Puthen, Laura McAdam, Beverly Solomon, & Peter Rumney Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada Objective: This study will report the clinical features of patients with anti-NMDA encephalitis admitted to an inpatient rehabilitation programme and describe their outcomes. Methods: Retrospective chart review of all consecutive patients admitted with anti-NMDA encephalitis to the inpatient Brain Injury Rehabilitation programme at Holland Bloorview Kids Rehabilitation Hospital in Toronto, Ontario, Canada from 2009–2012. Results: Seven patients with anti-NMDA encephalitis were admitted for comprehensive inpatient rehabilitation which included physiotherapy, occupational therapy and speech language therapy. Fifty-seven per cent of patients were female. Mean age at diagnosis was 8.70 years (range ¼ 2.14–16.84). The mean time from onset of symptoms until admission to the rehabilitation programme was 2.15 months (range ¼ 1.27–7.03). Mean duration in the rehabilitation programme was 3.41 months. All patients presented with significant psychiatric and/or behavioural symptoms and cognitive deficits. Five patients had a history of involuntary movements. Three patients presented with seizures. Patients demonstrated improvement with multidisciplinary rehabilitation during their stay, although some had waxing and waning clinical courses. By discharge, all patients continued to have significant deficits. Mean duration of follow-up was 13.96 months. Although patients had improved physically at follow-up, cognitive deficits continued to persist for the majority of patients. Psychiatric symptoms had resolved and seizures were controlled on follow-up. Conclusion: The rehabilitation of patients with anti-NMDA encephalitis is challenging due to the complex clinical presentation involving neurological and psychiatric symptomatology. As a result, a comprehensive multi-disciplinary approach is necessary and should be tailored to each patient’s individual goals. The data shows that, while patients improve over time, they may still be at risk for persistent cognitive and functional deficits.

827

DOI: 10.3109/02699052.2014.892379

0828

Neuro@home: A software platform of clinically designed videogames specifically designed for the motor rehabilitation of stroke patients Pable Gagliardo1, Tatiana Ferreiro1, Ruth Izquierdo1, Gemma Mas2, Vicente Penades1, & Javier Chirivella1 Fivan, Valencia, Spain, 2Hospital la Pedrera, Denia, Spain


1

Objective: This study intends to show that a software-based motor rehabilitation platform can have a significant effect on the rehabilitation of balance, gait and on the performance of daily life activities of individuals who have suffered a stroke. Method: Seventeen patients participating in a stroke rehabilitation programme used neuro@home for their motor rehabilitation treatment plan. All 17 patients had suffered a stroke and were between 40–65 years old. Onset from injury was 3 months or less and they were found to have significant motor impairments that required motor rehabilitation. All patients were evaluated at baseline, 1 month after treatment started, at the end of treatment and 1 month later. All patients were assessed using the Tinetti performance-oriented mobility assessment (POMA), the Berg balance scale (BBS), the unipodal stance time (UST) and the timed up and go test. Patients were also assessed for performance in their daily life activities, using the UK FIM + FAM. A 60-minute motor rehabilitation session focusing on rehabilitation tasks specifically designed to rehabilitate trunk control, static and dynamic balance, co-ordination and lateral displacements 5 days a week during 8 weeks. For these sessions the clinical team used a motor and cognitive software-based rehabilitation platform calles neuro@homeÕ with more than 100 clinically designed videogames as rehabilitation tasks, using virtual reality techniques, natural interfaces and clinical data logging to facilitate monitoring by clinicians. ANOVAs with planned contrasts and Pearson’s correlations were performed and statistical significance level was set at 0.05. Results: After receiving a software-based motor rehabilitation treatment for 8 weeks, the patients showed significant improvements in static and dynamic balance, endurance and gait performance as measured by the above-mentioned instruments. Conclusions: The use of a software-based rehabilitation platform for motor rehabilitation, with continuous monitoring by the clinical team, has proved beneficial to the individuals that participated in the study. It is believed that other individuals who have suffered a stroke and who require motor rehabilitation could also benefit from a softwarebased motor rehabilitation platform.

0829

A scoping review and a quality evaluation of clinical practice guidelines for the rehabilitation of adults with moderate-tosevere traumatic brain injury Marie-Eve Lamontagne1, Bonnie Swaine2, Corinne St-Pierre1, & Catherine Truchon3

1

Universite´ Laval, Que´bec, Que´bec, Canada, 2CRIR, Montreál, Que´bec, Canada, 3INESSS, Que´bec, Que´bec, Canada

Objectives: Clinical practice guidelines (CPGs) are systematically developed statements that assist practitioners and patients about appropriate healthcare. The purpose of this study was to evaluate the scope and quality of CPGs for the rehabilitation of adults with moderate-to-severe traumatic brain injury. Methods: A systematic review was undertake in databases (CINAHL, MEDLINE, EMBASE and APA Psych NET) using key words ‘brain injury’ and ‘guidelines’ and in specific websites. CPGs were included if they were published in English or French, after January 2000. A scoping review on the characteristics and content of available CPGs for the rehabilitation of individuals with TBIMS was performed according to Arksey and O’Malley principles. Quality analysis was performed by four appraisers, using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool on the relevant CPGs. Results: Out of 512 potential documents found, seven guidelines met the inclusion criteria. The guidelines covered a large array of subjects, from TBI mechanism to community integration and return-to-work and they were heterogeneous with regard to their content. After the AGREE-II evaluation, only one CPG was strongly recommended by all appraisers, while others presented various levels of quality, especially with regard to stakeholder involvement, rigour of development and applicability. The intra-class correlation showed high agreement amongst appraisers for all analysed CPGs. Conclusions: There is a considerable variability in both content and quality of TBI CPGs. CPG development groups could improve the quality of the guidelines produced by considering the applicability and the rigour of development.

0830

How much does a TBI cost? Latha Ganti, Aakash Bodhit, Pratik Patel, Yasamin Daneshvar, & Keith Peters University of Florida, Gainesville, FL, USA Objective: To determine the predictors of hospital costs associated with traumatic brain injury. Methods: These data are derived from the Florida Brain and Spinal Cord injury prospective registry from the institution, a level I trauma centre. In order to be eligible for the BSCIP, the patient must be a legal resident of the state of Florida, have suffered a moderate-tosevere brain injury, be medically stable and there should be a reasonable expectation that, with the provision of appropriate services and supports, the person can return to a community-based setting, rather than reside in a skilled nursing facility. Data are limited to TBIs from 1 January 2012 to 30 June 2013. Costs information was obtained from total hospital charges vs actual collections. Statistical analyses were performed in JMP 10 for the Macintosh. Results: A total of 170 TBIs were identified during the study period. The median age of the cohort was 42, with an IQR of 24–60 years and a range of 9 months to 93 years. Seventy-eight per cent were male. The mechanism was 31% MVC, 18% fall, 23% recreational vehicles, 11% assault, 14% pedestrian struck, 2% gun shot wound and 1% selfinflicted. The median length of hospitalization was 16 days, with an IQR of 8–25 and a range of 1–60 days. The median hospitalization cost per TBI patient including emergency services was $162 523. Individual factors associated with increased hospitalization cost of TBI included: reduced probability of survival (p50.0001), increased hospital length of days (p50.0001), mechanism of injuries (pedestrian struck by vehicle [p ¼ 0.0001], recreational vehicle injury [p ¼ 0.005], motor vehicle accident [p ¼ 0.006], assault [p ¼ 0.05]; all compared to fall) and non-transferred patients (p ¼ 0.0003). On multivariate analysis, the factors that remained predictive for increased cost were a lower probability of survival (p ¼ 0.0006), a longer hospital length of stay

828 (p50.0001) and patients whose mechanism of injury was not a fall (p ¼ 0.039), when controlling for GCS score (p ¼ 0.0014). Conclusion: The cost of hospitalization for TBI is significantly increased by longer hospital stay, lower survival chance and higher GCS score, while cost is significantly lower for patients who sustain a TBI due to fall vs motor vehicle collision.

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Regional metabolite profiles in chronic sports-related concussion Alexander P. Lin1, Huijun Liao1, Sai Merugumala1, Robert A. Stern2, & Brian D. Ross1 Brigham and Women’s Hospital, Boston, MA, USA, 2Boston University School of Medicine, Boston, MA, USA


1

Objective: To establish an ante-mortem biomarker profile of repetitive brain trauma (RBT) in professional athletes in contact sports. Background: Professional athletes in contact sports suffer thousands of concussive and sub-concussive blows to their heads over the course of their career. The direction and points of impact are widely distributed; therefore, the long-term effects of injury in different regions of the brain is unknown. Four regions which have been established as acutely vulnerable in previous magnetic resonance spectroscopy (MRS) studies of more severe brain injury were selected to determine the chronic effects of milder injury that occurs in professional contact sports. Methods: Short-echo proton spectroscopy (TE ¼ 30 milliseconds, TR ¼ 2 seconds, 2 2 2 cm3, 128 averages) was acquired in the posterior (PGM) and anterior grey matter (AGM) in the cingulate gyrus and posterior (PWM) and anterior white matter (AWM) at the periventricular sub-cortical WM of the parietal and frontal lobes on a 3 T MRI (Siemens Verio) in five retired professional athletes including ex-NFL players with history of concussions and cognitive symptoms associated with RBT and chronic traumatic encephalopathy (CTE) and age and size-matched controls. Data was analysed using a linear combinations model analysis (LCmodel) and relative metabolite concentrations were quantified. Results: MRS showed glycerophosphorylcholine (GPC) and total choline (tCho; GPC + phosphocholine) to be significantly increased (p50.05) across the PGM, PWM and AWM. Increased concentrations of GPC and tCho have been shown to be markers of diffuse axonal injury, which appears to be reflected across both cortical and subcortical brain regions. Glutathione (GSH), an important anti-oxidant in the brain, decreased across all brain regions in athletes, which may be indicative of neuroinflammation. Counter-intuitively, N-acetyl aspartate (NAA), a putative marker of neuronal density, decreased in severe TBI and was increased in athletes compared to controls across all brain regions, although not significant. This is reported also in subacute sports-related concussion and may be the result of overcorrection. Results of this preliminary study show strong and longpersistent regional increases in choline. Other trends including decreased glutathione as a result of inflammation and increased NAA may be further in a larger study or other MRS methods. Metabolite changes which were found in both grey and white matter were surprisingly less obvious in the anterior grey matter. Conclusion: Differences in regional brain metabolite profiles may provide a personalized ante-mortem diagnostic tool for RBT, potentially predictive of autopsy diagnosis of CTE.

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An investigation of factors that influence socioemotional and academic gains in the classroom

Brain Inj, 2014; 28(5–6): 517–878

for students living with the effects of ABI Dawn Good1, Peter Rumney2, Sheila Bennett1, Janette McDougall3, Carol DeMatteo4, & Rhonda Martinussen2 1

Brock University, St. Catharines, Ontario, Canada, 2University of Toronto, Toronto, Ontario, Canada, 3Thames Valley Children’s Treatment Centre, London, Ontario, Canada, 4McMaster University, Hamilton, Ontario, Canada

Objectives: Acquired brain injury (ABI) is not an identified classification with the Ministry of Education in the province of Ontario and, as such, children and youth with ABI are not acknowledged formally within the school system and, as a result, cannot gain access to adequate ABI-targeted support. This research examines both subject-based (student, family) and systems-based (school/policy, educator) factors that predict performance outcomes for academic, emotional, psychosocial variables in an attempt to identify and ameliorate, barriers of successful return to and completion of school for children and youth who have sustained a moderate-to-severe ABI. Method: Children’s Treatment Centres, province-wide, assisted in the identification of students (6–18 years, 1–5 years post-injury, have returned to school) to participate in this study. Questionnaires, and for students, neuropsychological measures, were administered to students, parents and their respective teachers and principals. Each of these variables were entered into multiple regression analyses in order to examine the relative influence and contribution of each in terms of its contribution to the successful re-integration of students with their school environment. Results: Analyses indicate that student-based factors are important predictors of performance, particularly when assessed in terms of cognitive, as opposed to physical, indicators of capacity and function. Importantly, the variables that are ‘modifiable’, namely, systemsbased factors (e.g. as measured variously in terms of teachers’ knowledge of ABI and its sequelae), and, in certain circumstances, school policy (the types of supports that are provided, e.g. additional supports for teachers; or policy promoted, in terms of e.g. views on inclusion) were significantly predictive of social-emotional and academic outcomes. Conclusions: Measures of injury severity are more informative for treatment intervention and rehabilitation/school re-integration if they are based on cognitive status upon recovery, rather than on physical trauma at time of injury. Further, recommendations and opportunities for more effective assistance for the students who have experienced an ABI and are returning to the classroom can be derived based on teacher instruction and inclusion policy, particularly in the domains that go beyond academic performance and include social-emotional success of the student.

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The impact of traumatic brain injury on reading efficiency: Reading rate correlates with Trail Making Test performance in patients with mildto-moderate TBI Keith Main1, Salil Soman1, Maxwell Rappoport2, Micaela Thordarson2, Jennifer Kong3,

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J. Wesson Ashford3, Stephanie Kolakowsky-Hayner4, Ronald Schuchard3, & Maheen Adamson3 Stanford University, Stanford, CA, USA, 2Palo Alto University, Palo Alto, CA, USA, 3VA Palo Alto Health Care System, Palo Alto, CA, USA, 4 Santa Clara Valley Medical Center, San Jose, CA, USA


1

Objectives: The current research investigated the consequences of traumatic brain injury (TBI) on reading. Past research has shown that even mild TBI can result in perceptual deficits. This scenario often involves oculomotor difficulties in tracking and scanning of the visual field, such as accommodative dysfunction, versional loss and convergence insufficiency. These conditions hamper the motility and co-ordination of the eyes and are profoundly debilitating to sustained reading. To better understand this problem, the current research evaluated reading ability in patients with mild-to-moderate TBI. Neuropsychological testing assessed the extent of brain injury while time tests measured reading performance. Statistical analyses identify correlations between these measures. Methods: Approximately 30 patients diagnosed with mild-tomoderate TBI participated in the study. Patients were recruited from the War Related Injury and Illness Study Center (WRIISC) of the Palo Alto Veterans Healthcare System (VAPAHCS) as well as the Santa Clara Valley Medical Center. All participants were screened with a battery of neuropsychological measures before further testing. Accuracy and maximum reading rate were quantified with the Pepper Visual Skills for Reading Test (VRST), the Test of Word Reading Efficiency (TOWRE) and International Reading Speed Texts (IReST). Results: Reading rate performance scores were calculated by multiplying the speed in seconds in which a participant could complete a passage or word list by the percentage accuracy (i.e. number correctly read words divided by the total number of words). This study found significant negative correlations between a neuropsychological measure of attention and visual scanning, the Trail Making Task and the reading measures: VRST (r ¼ 0.50), TOWRE (r ¼ 0.61), IREST (r ¼ 0.69). Conclusions: These results indicate that reading rate is significantly affected by the extent and nature or traumatic brain injury. Further research is necessary to understand the neurology that underlies these deficits. Damage to specific white matter fascicles may hamper eye movement, but a general cognitive slowing may also contribute. Future work will attempt to relate these findings to diffusion tensor imaging (DTI) data which quantifies the integrity of white matter pathways.

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The relationship between executive functioning, working memory and speed of processing Nikos Konstantinou, Eva Pettemeridou, & Fofi Constantinidou University of Cyprus, Nicosia, Cyprus Objectives: Impairments in executive function and working memory (WM) are among the most common cognitive processes affected in patients with traumatic brain injury (TBI). This study investigated the relationship between measures of executive functioning, verbal working memory, visual working memory and speed of processing in a group of patients with chronic severe traumatic brain injury (TBI). Methods: A group of 17 males (range ¼ 21–60 years, mean age ¼ 33.6) with a primary diagnosis of a moderate-to-severe closed head injury were tested in a battery of paper-and-pencil neuropsychological and language tests. All patients were native speakers of Greek language

and all tests were translated and adapted in Greek language. The battery was designed to assess executive functioning (The Symbol Digits Modalities Test, The Verbal Fluency Test, Trail Making Test Part B, Rey Complex Figure Test), verbal working memory (Rey Auditory Verbal Learning Test, The Digit Span Test, Logical Memory sub-test of the Wechsler scale), visual working memory (Rey Complex Figure Test Copy, The Visual Span Test) and measures of speed of processing (Trail Making Test Part A, response time in the Verbal Fluency Test, experimental tasks of attention and reaction time). Scores from the neuropsychological tests assessing were combined into composite scores assessing each construct of interest. Each of the measures was converted into a Z-score and valenced such that lower scores indicated poorer performance. The resulting Z-scores for the measures within each construct were then averaged to derive a score for the constructed measure. Results: The executive functioning composite score exhibited a significant positive correlation with the visual and verbal WM scores and the speed of processing composite score. The verbal and visual WM score also exhibited a significant positive correlation. However, speed of processing was not correlated with either the verbal or the visual working memory score. Conclusions: These findings suggest that executive functioning depends on the capacity of both verbal and visual working memory as well as the speed of processing of an individual. Moreover, the findings indicate that verbal and visual WM capacity share common resources but these are independent from the speed with which information is being processed.

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Do risk factors differ for concussion and prolonged recovery following concussion in elite youth ice hockey players? Tracy Blake1, Willem Meeuwisse1, Kathryn Schneider1, Nicole Lemke2, Kirsten Taylor3, Jane Kang1, & Carolyn Emery1 1

Sport Injury Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada, 2Glen Sather Sport Medicine Clinic, University of Alberta, Edmonton, Alberta, Canada, 3 Department of Physical Therapy, Faculty of Rehabilitation Medicine, Edmonton, Alberta, Canada, 4University of Calgary Sport Medicine Centre, Calgary, Alberta, Canada Background: Identifying risk factors for concussion and prolonged recovery will inform the development of prevention strategies. Objective: To examine risk factors for concussion and prolonged recovery amongst elite youth ice hockey players. Design: Cohort study. Setting: Community ice rinks and sport medicine clinic (2011/2012 season). Participants: Male and female elite youth ice hockey players [781 Bantam (13–14 years) and Midget (15–17 years)]. Assessment of risk factors: Baseline age group, sex, previous concussion history and baseline total smptoms score (TSS), balance error score (BES) and standardized assessment of concussion (SAC) score were evaluated. Main outcome masurements: Players with a suspected concussion were referred to a sport medicine physician by the team therapist. Concussions with 410 days time loss were defined as prolonged recovery. Results: Concussion incidence rate ratios (IRR) were estimated using multivariate (concussion) and univariate (concussion with prolonged recovery) Poisson Regression analyses (cluster and exposure hour adjusted). Males were at greater risk of concussion than females

830 [IRR ¼ 1.44 (95% CI ¼ 1.09, 1.90)] (adjusting for previous history). In female players with no history of concussion, Bantam players were at a greater risk than Midget players [IRR ¼ 4.04 (95% CI ¼ 1.24, 13.19)]. In female players with a history of concussion, Midget players were at a greater risk than Bantam players [IRR ¼ 2.68 (95% CI ¼ 1.61, 4.46)]. Players with a baseline TSS in the lowest 25%ile were at a greater risk of concussion [IRR ¼ 1.50 (95% CI ¼ 1.03, 2.18)] and prolonged recovery [IRR ¼ 1.88 (95% CI ¼ 1.18, 2.99)]. Players with previous concussion history were at greater risk of prolonged recovery [IRR ¼ 2.02 (95% CI ¼ 1.29, 3.16)]. Baseline BES and SAC score were not risk factors. Conclusions: Age, sex, previous concussion history and baseline symptom reporting affect the risk of concussion and prolonged recovery in elite youth ice hockey players. This study will inform the development of youth sport concussion prevention strategies.

Brain Inj, 2014; 28(5–6): 517–878

hospitalized for MVC in the 5-year time frame than those who were not diagnosed with TBI (RR ¼ 9.9; CI ¼ 8.0–12.3). Those with diagnosed TBI remained at increased risk of MVC hospitalization even after controlling for demographics, military-related variables and mental health diagnoses (RR ¼ 8.3; CI ¼ 6.5–10.6). Conclusion: These results showed that veterans diagnosed with TBI in their first year post-deployment had nearly 10-times greater risk of MVC-related VA hospitalizations within 5 years of deployment compared to veterans without a first-year TBI diagnosis. This work suggests that veterans with TBI are in need of enhanced driving safety evaluation or driver rehabilitation services. Research is needed to examine associations between TBI and risk of all MVCs, not just those leading to VA hospitalization, to explore effects of TBI severity (mild, moderate or severe) on this risk and to develop and test interventions to reduce risk among veterans with TBI.

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Risk of hospitalization due to motor vehicle crashes among Iraq and Afghanistan war veterans diagnosed with traumatic brain injury Kathleen Carlson1, Maya O’Neil1, Lisa McAndrew2, Daniel Storzbach1, David Cifu3, & Nina Sayer4 1

Portland VA Medical Center, Portland, Oregon, USA, 2VA New Jersey Health Care System, East Orange, NJ, USA, 3Hunter Holmes McGuire VA Medical Center, Richmond, VA, USA, 4Minneapolis VA Health Care System, Minneapolis, MN, USA Objectives: Compared to veterans who have not deployed to combat zones, combat veterans are at increased risk of death due to motor vehicle crashes (MVC) for 5 years after their combat deployments. A large proportion of veterans deployed to Operations Enduring Freedom, Iraqi Freedom and New Dawn (OEF/OIF/OND) have sustained traumatic brain injury (TBI). Recent media reports have attributed veterans’ MVC risk to combat-related TBI; however, there has been no scientific evaluation of this claim. The objective was to examine the association between TBI diagnoses and MVC-related hospitalizations among OEF/OIF/OND veterans who use US Department of Veterans Affairs (VA) healthcare. Methods: Using national VA administrative data, this study identified OEF/OIF/OND veterans who enrolled in VA healthcare within a year of deployment and who used VA healthcare services consistently for 5 years. MVC-related hospitalizations within this 5-year window were identified using International Classification of Diseases-Ninth Revision diagnosis codes for injury that were associated with external cause-ofinjury codes for MVC. TBI and co-morbid diagnoses were also identified using diagnosis codes; this study focused on diagnoses assigned during the first year post-deployment in an attempt to exclude those associated with a MVC. Logistic regression was used to estimate the 5-year relative risk (RR) of MVC-related hospitalizations among those diagnosed with TBI vs those not diagnosed with TBI. Multivariate models controlled for demographics (age, gender, race/ ethnicity, education, marital status, distance to nearest VA), militaryrelated variables (branch, component, number of deployments, service connection) and first-year mental health diagnoses (posttraumatic stress disorder, depression, substance use disorder). Results: There were 117 551 veterans who consistently used VA healthcare for 5 years after deployment. Of these, 373 (0.3%) were hospitalized for injuries related to MVCs; most were male (87%) and 18–24 years old (33%). Those diagnosed with TBI in the first year after deployment (n ¼ 5442; 4.6%) were nearly 10-times more likely to be

The midwest advocacy project: A randomized practical behavioural trial of curriculum-based advocacy training Allen Brown1, Anne Moessner1, Thomas Bergquist1, Jay Mandrekar1, Nancy Diehl2, & Kathryn Kendall1 1

Mayo Clinic, Rochester, MN, USA, 2Mayo Clinic, Jacksonville, FL, USA

Objectives: The objective of this trial was to test whether a curriculumbased training programme experienced by individuals with TBI and their family members significantly improved their advocacy skills compared to a matched group engaged in self-directed advocacy activities. Background: Individuals surviving TBI and their families routinely identify gaps in community services and low levels of public awareness as barriers to full community participation, increasing the importance of promoting effective self- and systems-advocacy to influence the behaviour of community providers and public policymakers. However, the most effective means of imparting advocacy skills has yet to be determined. Mayo Clinic’s TBI Model System Centre collaborated with the Brain Injury Association of Minnesota (BIA-MN) to develop an advocacy training curriculum. The hypothesis was that participants receiving programmed advocacy training would show greater improvement on behavioural assessments of advocacy skill than those involved in self-directed advocacy training. Methods: The Brain Injury Associations (now Alliances) in Minnesota, Iowa and Wisconsin recruited individuals with TBI and their family members to participate. Consented subjects were randomized into the curriculum-based group or the self-directed group. Each group travelled to their State’s capital city one Saturday per month for 4 consecutive months to participate. The curriculum group in each state received the same core material customized for their state. The self-directed groups were oriented by staff to become the best advocates they could be, using any means or process. They were provided with basic office materials and an internet connection. At the beginning of the study period each participant, regardless of group, identified an advocacy topic important to them. At the beginning and end of the study period each participant wrote a mock letter and videotaped verbal testimony advocating for their cause, directed to an individual or agency. The primary outcome measure was the Advocacy Behavioural Rating Scale (ABRS) score for each participant’s letter and video, pre- and post-intervention, scored by two blinded raters. Results: There were no differences in age at intervention, sex or participant type (individual with TBI or family member) between the curriculum group (n ¼ 129) and self-directed group (n ¼ 128). There was no significant difference between treatment groups in pre–post

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differences in ABRS scores for letter writing or videos. When treatment groups were combined, family members—but not individuals with TBI—had a significant improvement in ABRS scores pre- to post-intervention. Conclusions: Family members, but not individuals with TBI, meeting together in a group can improve advocacy skills regardless of the setting or use of an organized, externally provided curriculum. Individuals with TBI may need intervention customized to their clinical needs to improve these skills. These findings have implications for advocacy organizations and policy-makers.

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Javier Chirivella1, Alberto del Barco1, Sonia Blasco1, Vicente Penades1, Gemma Mas2, & Pablo Gagliardo1

Sleep disturbance and acute changes in cognition among veterans with PTSD and mTBI 1


Christy Starr , & Eric Larson

2

1

University of California, Santa Cruz, CA, USA, 2Northwestern University, Chicago, IL, USA, 3Rehabilitation Institute of Chicago, Chicago, IL, USA

Objectives: Sleep disturbance is a common symptom of both posttraumatic stress disorder (PTSD) and mild traumatic brain injury (mTBI), which may exacerbate cognitive impairment and other symptoms associated with those conditions. The goal of the current study was to explore associations between aspects of sleep disturbance, cognitive impairment and self-reported symptoms among veterans with a history of mTBI and current PTSD. Methods: In a sample of 19, sleep was assessed via actigraphy and selfreport instruments including the Insomnia Severity Index (ISI), PROMIS and sleep-related items from Clinician Administered PTSD Scale (CAPS). Cognition was assessed via the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) at baseline and at a follow-up after the completion of 1 week of sleep monitoring. Effects of sleep disturbance were analysed through Pearson’s correlation with cognition as measured by RBANS performance at follow-up and by change in RBANS scores between assessment timepoints. Results: Analyses revealed that change in cognition as measured by RBANS indices was significantly related to several actigraphic measures of sleep including sleep efficiency (r ¼ 0.464) variability of risetime (r ¼ 0.510), variability in sleep efficiency (r ¼ 0.525) and variability of total minutes of sleep (r ¼ 0.447). Self-report sleep surveys and self-report symptom checklists were associated with cognition at follow-up but not with change scores. Cognition at follow-up as measured by the RBANS was related to sleep problems reported on the ISI (r ¼ 0.614), PROMIS (r ¼ 0.693) and CAPS Disturbing Dreams (r ¼ 0.463). Conclusions: It is likely that actigraphic variables are more sensitive to aspects of recent sleep disturbance that have acute effects on change in cognition. Similarly, it is possible that patients who complete selfreport measures, although instructed to rate symptoms over only a preceding week, are describing longstanding issues that have an effect on chronic cognition problems (as measured at follow-up without adjusting for baseline performance). The findings at followup are consistent with those reported by Wilkerson et al., who showed insomnia severity was significantly related to reduced cognition. The findings concerning sleep variability are consistent with reports of associations with poor clinical outcomes among individuals with insomnia. Finally the findings on the acute effects of bad sleep on cognition are consistent with a previous report by Stenuit and Kerkhofs. There is increasing evidence of the effect of sleep problems on recovery among veterans with PTSD and mTBI and further study is needed to inform treatment and improve outcome.

Neuro@home [II]: A software platform of clinically designed videogames designed for the cognitive rehabilitation of stroke patients

1

Fivan, Valencia, Spain, 2Hospital la Pedrera, Denia, Spain

Objective: This study pretends to show that a software-based cognitive rehabilitation platform can have a significant effect on the rehabilitation of attention, working memory, executive functions and visual perception of individuals who have suffered a stroke. Method: Twelve patients participating in a stroke rehabilitation programme used neuro@home for their cognitive rehabilitation treatment plan. All 12 patients had suffered a stroke, were between 40–65 years old, onset from injury was 3 months or less and were found to have significant cognitive impairments that required cognitive rehabilitation. All patients were evaluated at baseline, 1 month after treatment started, at end of treatment and 1 month later. All patients were assessed using the 7-minute screen, localization spatial WMS-III, spatial recall test, digit span WAIS-III and symbol digit modality test. Patients were also assessed for performance in their daily life activities, using the UK FIM + FAM. A 60-minute cognitive rehabilitation session focusing on rehabilitation tasks specifically designed to rehabilitate attention, working memory, executive funxctions and visual perception. For these sessions the clinical team used a motor and cognitive software-based rehabilitation platform called neuro@homeÕ with more than 100 clinically designed videogames as rehabilitation tasks, using virtual reality techniques, natural interfaces and clinical data logging to facilitate monitoring by clinicians. ANOVAs with planned contrasts and Pearson’s correlations were performed. Statistical significance level was set at 0.05. Results: After receiving a software-based cognitive rehabilitation treatment for 8 weeks, patients showed significant improvements in attention, memory or executive functions. Conclusions: The use of a software-based rehabilitation platform for cognitive rehabilitation, with continuous monitoring by the clinical team, has proved beneficial to the individuals that participated in the study. It is believed that other individuals who have suffered a stroke and who require cognitive rehabilitation could also benefit from such a software-based cognitive rehabilitation platform.

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Estimation of knowledge and preparedness to care for traumatic brain injury patients amongst acute trauma care nurses Colleen Counsell1, Donna York1, Aakash Bodhit2, & Latha Ganti2 1

Shands Hospital, Gainesville, FL, USA, 2University of Florida, Gainesville, FL, USA


832 Objective and background: To determine the extent of knowledge and awareness of traumatic brain injury (TBI) and perception about available resources and use, amongst nurses working in the acute trauma setting. Nurses remain in contact with admitted patients and their families during the majority of their hospital stay. They are bestsuited healthcare providers to facilitate TBI care, but the training and expertise are not always at an appropriate level. Methods: An anonymous survey was administered that addressed the preparedness to care for and to use available tools for TBI care, comprised of five questions: (1) The willingness of nursing to analyse and challenge current situations is strong; (2) Nurses plan effectively to achieve specific objectives or goals for the patient; (3) There is expertise in caring for TBI patients; (4) There are tools to provide safe care to these patients; and (5) There is oversight in patients with expert consultation. Answers followed a Likert scale, with these choices: Strongly disagree; Disagree; Neither disagree nor agree; Agree; and Strongly Agree. Thirty-one nurses working on the trauma floors and trauma ICU completed the survey (pre-test). Then all nurses completed just-in time (JIT) training and an educational module for TBI. After training, the same survey was given again (post-test) which was completed by 84 nurses. Composite scores were calculated for four categories by adding up scores (1, 2, 3, 4 or 5) of questions included in particular categories. T-tests were done to see the differences in composite scores between pre- and post-test. Results: The educational intervention resulted in a statistically significant increase in agree and strongly agree answers (p ¼ 0.0023, pre-M ¼ 13.2, post-M ¼ 15.8), in the post-test compared to their respective pre-test scores, suggesting that the education greatly increased the confidence and satisfaction of the nurses in feeling prepared to care for TBI patients in the acute hospital setting. Conclusion: In this study population, knowledge and awareness about available resources and specific requirements in care of TBI patients increased amongst nurses working in acute trauma units after a targeted educational intervention. They also felt more prepared to care for TBI patients and for collaboration with other disciplines. This could be expanded to study nurses providing rehabilitative TBI care as a next step.

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Effects of postural control training on a sway platform, observed in children with acquired CNS damage. Preliminary study Massimo Stortini1, Antonio Pasquale1, Paola Giannarelli1, Guerrino Rosellini2, & Enrico Castelli1 1

Bambino Gesu’ Children Hospital Scientific Institute, Rome, Italy, ITOP Orthopaedic Tecnologies, Palestrina (RM), Italy

2

Objectives: To introduce an assessment and intervention approach for babies and young children with acquired neurological impairment that focuses on treatment strategies for improving Postural Control (PC) inside the global rehabilitative approach. The assessment and treatment investigation of postural control, in sitting position, of children with acquired CNS damage had been largely neglected in the literature. Specific and well-timed training should be taken into consideration when planning a return to physical activities, particularly to those that require subtle balance skills. The goal of the present study is to fill this lack and compare the effect of two different kinds of treatment. Methods: An homogeneus sample of 14 children, average of 6, with acquired CNS (brain damage with 7 or less at GCS) and impairment in sitting postural control were assessed with the following scales: GOS, LCF, DRS (for evaluate the prognosis and assess the general

Brain Inj, 2014; 28(5–6): 517–878

functions), SACND-GMFM (for the assessment of postural control) and Wee-FIM (assessment of functional performance). The children were divided randomly in two groups: Control Group (CG) and Study Group (SG). The control group was trained with traditional neurorehabilitative treatment, instead the study group was trained with use of perturbation. In the training of the Study Group, an oscillating platform bearing on a central pin with reference to variable elastic fields (MMP) was used: an instrument that allows one to apply controlled sways and imbalances to the child posture with a proprioceptive reference fixed point. Treatment objective was to increase the skills, the adaptability and the stability of head, trunk, reaching/grasping postural control. Thus, the strategy concept has been gradually changing to allow for the functional flexibility, specificity and motor learning in postural behaviour. The training has been calibrated to the competences and the characteristics of each individual subject, with a graduation of difficulties and set up by different: position/stance, hold/orthosis, perturbation sequence, changing task and environmental demand in a specific perceptive context. Results: The results demonstrate a difference between two groups about the training average time for recovery of sitting position: 8 weeks (SG) vs 12 (CG). Furthermore, the children of the Study Group obtained a higher score in several SACND and GMFM items. Conclusions: This study discusses about the right time when to start the training: the way to assess and training the balance control is important for opening a window on the specific treatment of sitting position in children ABI. Furthermore, in the discussion one tried to argue about the changes in trend, level and variability for the intervention phases of each child with respect to the MRI analysis. The study can be considered preliminary and was limited by the relatively small number of subjects included.

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Response to occipital nerve block after traumatic brain injury in adolescents Trevor Seeger, Lisa Bodell, Thilinie Rajapakse, Lisette Lockyer, Michael Esser, & Karen Barlow University of Calgary, Calgary, Alberta, Canada Background: Traumatic brain injury (TBI) is a significant contributor to paediatric morbidity; not the least of which is post-traumatic headache. Bilateral greater occipital nerve blocks are an injection of anaesthetic and a steroid along the distribution of the occipital nerve. Their purpose is to reduce the frequency of post-traumatic headaches. There is little in the literature dictating the response of children with post-traumatic headache from greater occipital nerve block. Objective: To evaluate the response of adolescents with postconcussion symptoms to occipital nerve block. Methods: Prospective observational follow-up study of 14 children aged 13–18 (mean ± SD ¼ 15.5 ± 1.2), nine females with post-traumatic headache. Intervention: bilateral greater occipital nerve block using lidocaine and triamcinolone subcutaneously at the greater occipital. Participants were treated with occipital nerve block in clinic. Criteria for occipital nerve block included: occipital neuralgiform pain, tenderness over the occipital nerves and/or cervicogenic headache. Full response was considered a reduction in headache frequency of 50% or more, without increase in severity or length of headache. Preand post-nerve block Rivermead post-concussion symptom scores and paediatric quality-of-life scores were recorded. Results: Nerve blocks were received (mean ± SD) 5.6 ± 3.5 months after injury. Five patients had symptoms consistent with occipital neuralgia, while headache characteristics were mixed in others. Ten fully-responded, two reported partial improvement and two reported no change. Most often, headaches were daily and constant before the

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nerve block and reduced to a frequency of 55/month. Postconcussion symptom decreased from 43.0 ± 25.3 to 24.0 ± 12.0 preand post-treatment and quality-of-life scores increased from 45.7 ± 15.6 to 61.8 ± 27.0. Clinical details of the cases will be presented in the poster. The procedure was well tolerated; alopecia was reported in one patient, which resolved after 4 months. Conclusion: Occipital nerve block can be a useful treatment for posttraumatic headache in adolescents.

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Underlying cause of death after traumatic brain injury: A population-based medical record review analysis controlled for non-head trauma Allen Brown1, Jay Mandrekar1, Jeanine Ransom1, Nancy Diehl2, & Erica Bellamkonda1 1

Mayo Clinic, Rochester, MN, USA, 2Mayo Clinic, Jacksonville, FL, USA

Objectives: The purpose of this analysis was to compare the proportion of underlying causes of death by ICD-10 category in a population-based cohort of traumatic brain injury (TBI) cases with two sets of controls: (1) a matched population-based sample; and (2) a matched population-based sample that is controlled for non-head trauma. Background: It is widely accepted that traumatic brain injury (TBI) reduces life span and that this excess mortality is due to specific causes of death. Recent population-based analyses of TBI incidence, health-related cost and survival over the spectrum of disease have established that TBI epidemiology is dominated by the least severe injuries, that excess mortality associated with TBI exists only during the first 6 months after injury and that life span is not altered in 6month survivors after TBI compared to matched population-based controls when adjusted for non-head trauma. It is hypothesized that there would be no difference in the proportion of death for any specific cause of death category between cases and controls when controls are adjusted for non-head trauma. Methods: A random sample of Olmsted County, Minnesota residents with confirmed TBI from 1987–1999 was identified. Each case was assigned an age- and sex-matched non-TBI ‘regular’ control from the population. For ‘special’ cases with accompanying non-head injuries, two matched ‘special’ controls with non-head injuries of similar severity were assigned. The mean (SD) follow-up was 10.5 (5.98) years. Underlying cause for each death in the cohort was identified by searching the State of Minnesota Electronic Death Certificate database. The proportion of death was calculated for regular cases, regular controls, special cases and special controls and compared using Fisher’s exact test. Results: Two hundred and ninety-seven deaths occurred among the 2955 cases and controls. An underlying cause could not be determined for 30 deaths. Of 267 deaths, 89 occurred among 1036 regular cases and 93 deaths occurred among 1036 regular controls. Twenty-nine deaths occurred among 221 special cases and 56 deaths occurred among 441 special controls (for a single special case, only one special control was identified). The proportion of death was greatest for circulatory system causes, followed by external causes, death due to neoplasms, nervous system and respiratory system causes. Compared to controls, cases were more likely to die due to external causes. Controls were more likely to die due to causes related to neoplasm, circulatory, respiratory and nervous system or other causes (p50.05). Further regression-based analyses will be reported adjusting for age, gender, injury severity and time since injury. Conclusions: These findings suggest that the proportion of death in a population-based TBI cohort is different for some underlying cause of

death categories compared to the proportion of death in those categories among a matched population-based sample.

0845

Post-acute, medically stable and discharged—What’s next? A sustainable, non-medicalized model for long-term brain injury rehabilitation Rosa Mora, & Carol Welsh Services For Brain Injury, San Jose, CA, USA Background: According to 2011 data from the US National Institute for Disability and Rehabilitation Research, at least two-thirds of patients discharged from rehabilitation hospitals after a typical stay of 16 days get no further treatment. Rehabilitation experts say such coverage limits like those in place for brain injury are ‘unthinkable’ to comparable illnesses and injuries. Importance of long-term, comprehensive rehabilitation: Research supports the benefits of long-term rehabilitation. A recent study by Miller et al. found, ‘environmental enrichment —tructured hours of cognitive, physical and social activity—may protect against bi-lateral hippocampal atrophy in the chronic stages of moderate-to-severe traumatic brain injury. Greater environmental enrichment was associated with less bi-lateral hippocampal atrophy from 5–28 months. Clinical application of environmental enrichment should be considered for optimal maintenance of neurological functioning in the chronic stages of moderate-to-severe TBI’. A comprehensive continuum of care is one of the most effective methods of rehabilitation. A 2010 systematic review of the effectiveness of rehabilitation programmes for adults in the chronic phase after severe acquired brain injury found the following. ‘The investigated comprehensive rehabilitation programmes led to substantial improvement in daily life functioning and community integration of severe chronic brain injury patients, with lasting effects at follow-up. Day-treatment programmes had the highest level of evidence. Comprehensive rehabilitation programmes appear to be effective in terms of a reduction in psychosocial problems, a higher level of community integration and an increase in employment’. A non-medicalized long-term rehabilitation model: While acute care for brain injuries has made dramatic advancements, long-term rehabilitation still lacks widely accepted standards. With research supporting the benefits of comprehensive long-term rehabilitation, why isn’t it more widespread and recommended at patient discharge? Some of the leading rehabilitation hospitals in the US have tried to establish long-term rehabilitation programmes, but they were unsustainable. What are the programmatic elements of an effective, non-medicalized, comprehensive long-term rehabilitation model; what outcomes are possible; and how can it be sustained? Objectives/results/conclusions: (1) Provide a detailed presentation of a 25-year-old, non-medicalized, CARF-certified, long-term comprehensive rehabilitation model designed to enable the maximum independence possible for people with brain injuries at any stage of recovery. Customizable model spans from Assessment to Cognitive Rehabilitation Day Programming and Pre-Vocational/ILS Training to Work Readiness; Job Placement and Supported Employment. (2) Report on outcomes data; technology used in rehabilitation; and sustaining programme viability. Note: While client outcomes are not intended to replace rigorous scientific research, 25 years of experience has yielded valuable clinical data where little exists currently.

834

0846

Neuro plastic cities: Looking beyond hospitals and medical schools for neurotherapy

Brain Inj, 2014; 28(5–6): 517–878

Teresita Villasenõr Cabrera1, Luisa Fernanda Bohorquez Montoya1, Claudia Leticia Duenãs Gonzalez1, Lourdes Infante St Clair2, Laiene Olabarrieta Landa3, Diego Rivera3, Paul B. Perrin4, & Juan Carlos Arango-Lasprilla5 1

John C. Byler, & Monika Meulman


Brain Injury Association, Westborough, MA, USA Objectives: (1) To present the blocks and shortcomings that face recovering TBI patients in the traditional medical recovery model. (2) Moving beyond medical appointments, assessments, traditional recovery and support systems, this study examines a multidisciplinary, practical solutions, long-term TBI neurorehabilitation programme. (3) To highlight improvement in quality-of-life, pain reduction and symptom reduction using complementary modalities such as aromatherapy, massage therapy, therapeutic touch and meditation. Methods: Case studies of TBI patients: this study follows the process offered via traditional symptom management and support, plus longterm coping solutions. Recovery of physical abilities, emotional stability, mental processes and overall quality-of-life is monitored via interviews and follow-up reports. Introduction to complementary therapies is provided to case study patients, specifically: aromatherapy, massage therapy, therapeutic touch, meditation and breath work. Results: Case studies have shown that medical team recovery specialists are often not sufficient in providing the relief, care and recovery needed for TBI recovery. Appointments for check-ups, monitoring and support in the medical system are few and far between. Wait lists for specialists in hospitals and TBI specialty clinics determine how frequently and how quickly a TBI patient is seen and treated. Tremendous variety and continuous modulation of TBI symptoms and the uniqueness of each TBI case, makes it difficult supporting a TBI patient in the traditional medical system. TBI patients experienced a reduction of pain and relief of symptoms, after complementary therapies offered, in some cases instantly, as with aromatherapy (inhalation), massage (touch) and meditation/breath work (breath coaching support). Complementary healthcare practitioners such as aromatherapists, massage therapists, therapeutic touch workers and meditation teachers are available in abundance to provide continuous care, support and therapy programmes to complement scheduled medical care. Conclusion: Complementary health therapies such as aromatherapy (inhalation), non-invasive gentle healing therapies such as massage therapy, therapeutic touch and meditation (guided and home care) customize and personalize TBI recovery programmes, support symptom relief and improve quality-of-life, on the long journey to recovery from TBI. The traditional medical recovery model has many gaps. TBI patients tend to fall through these gaps and experience extended suffering from pain and other neurological symptoms. Many symptoms may only be experienced occasionally and may never manifest during scheduled medical appointments. On the road to recovery, best practices neurotherapy for TBI patients is to offer a combined medical and complementary healthcare interdisciplinary approach. Thus, ensuring the unique recovery needs of every TBI patient are met in a speedier and more comprehensive way, than by traditional recovery medical model alone.

0847

The influence of child TBI impairments on family caregiver mental health in Guadalajara, Me´xico

University of Guadalajara, Guadalajara, Mexico, 2Universidad Autońoma de Baja California, Mexicali, Baja California, Mexico, 3 University of Deusto, Bilbao, Bizkaya, Spain, 4Virginia Commonwealth University, Richmond, Virginia, USA, 5IKERBASQUE. Basque Foundation for Science, Bilbao, Bizkaya, Spain Objective: The purpose of this study was to examine the influence of three types of impairments in children with traumatic brain injury (TBI) on the mental health of family caregivers in Guadalajara, Mexico. Participants: Twenty-five caregivers of children with TBI completed measures of 29 physical (vision problems, headache, fatigue epilepsy, etc.), cognitive (attention, memory, language, thinking problems, etc.) and emotional and behavioural (Anxiety, aggression, antisocial behaviour, impulsivity, etc.) TBI impairments and of their own mental health (depression, satisfaction with life and burden). Results: A canonical correlation analysis between child TBI impairments and caregiver mental health variables revealed that the two sets of constructs were significantly related, r ¼ 0.74 (55.2% overlapping variance), l ¼ 0.40, 2(4) ¼ 19.03, p50.05., a large-sized effect. The standardized canonical coefficients for TBI impairment variables showed that emotional and behavioural problems loaded most highly (0.876). The coefficients for physical problems and cognitive problems were below 0.40. For the caregiver mental health variables, depression loaded most highly (0.917). This pattern of shared variance suggests that emotional and behavioural problems in children with TBI are highly and positively associated with caregiver depression. Conclusion: These results are the first to provide evidence that emotional and behavioural impairments in children with TBI from Latin America are the impairments most associated with caregiver mental health problems and highlight the need for interventions that target emotional and behavioural problems and help caregivers cope specifically with these impairments.

0848

Mild traumatic brain injury in a single male youth ice hockey player: Describing the recovery of self-reported symptoms, physical function and cognition Lee Verweel1, Michelle Keightley2, Talia Dick2, & Nick Reed2 1

Graduate Department of Rehabilitation Science, University of Toronto, Toronto, Ontario, Canada, 2Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada, 3Department of Occupational Science and Occupational Therapy, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada Objectives: Mild traumatic brain injury (mTBI) is of great concern within the paediatric sport population due to its high prevalence and potential impact on neurological development. Traditionally, decisions regarding youth athletes return-to-play following sport-related mTBI have been based on reports of post-concussion symptoms and the assessment of cognitive performance. To date, there remains a

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DOI: 10.3109/02699052.2014.892379

paucity of research exploring post-mTBI recovery specific to youth athletes and the appropriateness of the measures used to assess readiness to return-to-play. Methods: Results were drawn from a larger longitudinal study describing pre- and post-mTBI performance specific to self-report of symptoms, physical function and cognition. This case study describes pre- and post-mTBI performance of a single, typically-developing 11 year old male youth ice hockey player. Outcomes of interest included: Post-Concussion Symptom scale (PCS), Pegboard test, Stroop Color– Word test and measures to assess average verbal working memory reaction time (avgVWMRT). Results: The individual observed sustained a mTBI during ice hockey participation and exhibited PCS, Pegboard, Stroop and avgVWMRT scores that were elevated from pre-mTBI baseline. PCS, Pegboard and Stroop Color–Word test scores returned to baseline after 5 days; however, avgVWMRT remained elevated above baseline. Conclusions: Based on the findings of this case study, it is possible that some measures of post-concussion performance are more sensitive than others. Assessing readiness to return-to-play requires inclusive methods to ensure that the variety of physical and neurocognitive symptoms of mTBI have resolved. Further study exploring the measures that most accurately indicate recovery following mTBI in youth athletes is needed. This study acts as a first step towards further exploration and discovery of post-mTBI recovery specific to youth.

0849

Longitudinal characterization of neurobehavioural and neuropathological outcomes in hTau transgenic mice after single or repetitive mild traumatic brain injury Benoit Mouzon1, Joseph Olubunmi2, Christopher Acker3, Scott Ferguson2, Gogce Crynen2, Corbin Bachmeier2, Peter Davies3, William Stewart4, Michael Mullan2, & Fiona Crawford1 1

James A. Haley Veterans’ Hospital, Tampa, FL, USA, 2Roskamp Institute, Sarasota, FL, USA, 3Litwin-Zucker, Center for Research in Alzheimer’s Disease, Feinstein Institute for Medical Research, Manhasset, NY, USA, 4Southern General Hospital, Department of Neuropathology, Glasgow, UK, 5University of Glasgow, Glasgow, UK Objectives: Traumatic brain injury (TBI) is a recognized risk factor for later development of neurodegenerative disease. However, the mechanisms contributing to neurodegeneration following TBI remain obscure. Methods: With the mouse model of mild TBI (mTBI), this study initially reported in wild type mice measurable behavioural and neuropathological consequences which persist and evolve for some considerable time after injury, particularly following repetitive injury. This is manifest as continued and developing behavioural and pathological deficits up to 24 months following injury and characterized by persistent neuroinflammation associated with ongoing white matter degradation independent of soluble A40 or tau accumulation. This new study explores the role of tau after mTBI and characterizes the neurobehavioural and neuropathological outcomes, acutely and at 6 and 12 months, after single or repetitive mTBI in hTau mice that express the relevant six human tau isoforms on a null murine background. Results: The results reveal that hTau animals exposed to s-mTBI have minor learning deficits when compared to their sham controls but no

spatial memory deficits. For the same time points, the r-mTBI mice showed more learning impairment than s-mTBI at all timepoints tested and showed spatial memory deficits at 12 months. Accompanying these neurobehavioural deficits, concordant neuropathologies were observed. In particular, both injury groups displayed ongoing neuroinflammation in the corpus callosum up to 12 months post-injury. Low-tau ELISAs that quantitatively assess different epitopes of soluble tau relevant to various tauopathies: CP13 (pSer-202), RZ3 (pThr-231) and PHF1 (pSer-396/404) and aggregated DA9 (aa 102-140) revealed TBI-dependent increases at 24-hours postinjury and analysis of the 12-month timepoint is ongoing. To corroborate the biochemical findings, this study also carried out immunohistochemical analyses using CP13, RZ3, PHF1 and MC1, an antibody that recognizes only tau in a pathological conformation. In addition, p-tau was also quantitated as a ratio of phosphorylated tau protein to total tau protein and again an injury effect was observed at 24-hours post-injury. Conclusions: Given that the most significant pathological changes were observed in the corpus callosum rather than the hippocampus, it appears likely that the white matter pathology is responsible for the neurobehavioural deficits observed in this model. The chronic inflammation observed in both wild type and hTau animals in this mTBI paradigm suggest that inflammation may be a key contributor to the neurobehavioural deficits and, as such, represents a valid therapeutic target. Data from the additional timepoints will clarify the role of tau in TBI pathogenesis in this model.

0850

Emotional processing deficits: Relationship to executive functioning in TBI Jeannie Lengenfelder, Nancy Chiaravalloti, & Helen Genova Kessler Foundation, West Orange, NJ, USA Objectives: Emotional processing includes the ability to recognize facial affect and is necessary for communication and successful social relationships. Recent research suggests that deficits in emotional processing occur in a significant number of individuals following brain injury. The purpose of this work is to examine emotional processing in individuals with TBI as well as to examine the relationship between emotional processing deficits and cognitive abilities, mood and quality-of-life. Methods: Participants consisted of 49 individuals with moderate– severe TBI and 21 age- and education-matched HC. Emotional processing was assessed with the Facial Emotion Identification Test (FEIT). Individuals also received a full neuropsychological battery which included measures of executive functions as well as memory, intelligence, quality-of-life and emotional and social functioning. Results: Individuals with TBI had significantly fewer correct responses than healthy individuals when asked to identify the emotion of a face (p ¼ 0.001), demonstrating impairments in emotion identification. Emotional processing deficits correlated with cognitive abilities that require executive control including initiation (DKEFS Verbal Fluency, r ¼ 0.30), abstraction (Similarities, r ¼ 0.31), organizational strategies (CVLT Semantic Clustering, r ¼ 0.30) and working memory (Digit Span, r ¼ 0.33). Emotional processing did not correlate with other cognitive measures that did not require executive control such as verbal memory and visuospatial abilities. Conclusions: These data show that individuals with TBI do demonstrate deficits on emotional processing. Furthermore, these deficits correspond with difficulties in cognition that require greater frontal involvement or executive control. These deficits in emotional processing may have meaningful consequences for social functioning and quality-of-life for individuals with TBI as well as their family

836 members. This study will also discuss how these impairments will affect social and emotional functioning in individuals with TBI.

0851

Adolescents with vascular frontal lesion: A follow-up case study Clara Luz Cha´vez1, Guillermina Yań˜ez1, Cathy Catroppa2, Sulema Rojas1, Erick Escartin1, Stephen Hearps2, & Antonio Garcıá3 1

Universidad Nacional Autonoma de Me´xico, Me´xico, Mexico, Murdoch Children’s Research Institute, Victoria, Australia, 3Medical Unit of High Specialty ‘La Raza’ IMSS, Me´xico, Mexico


2

Background: Limited studies have been conducted investigating neuropsychological consequences of lesions in the prefrontal cortex during adolescence. Objective: The objective of this research is to understand the evolutionary course of the cognitive processes of adolescents who underwent surgery for resection of a focal vascular frontal lesion. Materials and methods: At the time of recruitment the three participants were between 15–16 years of age, two presented with an arteriovenus malformation and one a cavernous angioma. Cognitive functions, executive function and behaviour were assessed prior to surgery, 6 months post-discharge and 2 years post-discharge. Results: Verbal comprehension, perceptual organization, executive functions, behaviour regulation, emotion regulation and social skills present with significant changes after surgery. Conclusion: Cognitive changes after surgery are not homogeneous, executive functions and some cognitive functions seem to improve significantly, while other cognitive functions deteriorate over time.

0852

Missed acute care diagnosis of traumatic brain injury in patients with spinal cord injury: Frequency and risk-factors Bhanu Sharma1, Cheryl Bradbury1, Jasmin Corbie1, Sander Hitzig1, Colleen McGillivray1, Catharine Craven1, David Mikulis2, & Robin Green1 1

Toronto Rehabilitation Institute, Toronto, ON, Canada, 2Toronto Western Hospital, Toronto, ON, Canada Objectives: Over 30 years of research shows that traumatic brain injuries (TBI) and traumatic spinal cord injuries (SCI) frequently cooccur. However, anecdotal evidence from the clinic and others suggests that many cases of TBI in SCI patients are still not detected in acute care. To date, only one study (n ¼ 33; European rehabilitation centre) has investigated the frequency of missed acute care TBI diagnosis in SCI patients, finding that 60.9% of TBIs in SCI patients were missed. The objectives of this study were to replicate the above findings in a North American setting with a larger sample of patients and to examine whether any sub-groups of SCI patients were at elevated risk of missed acute care TBI diagnosis. Methods: Ninety-two SCI patients (C1-T12 AIS A-D) were consecutively recruited from a large, urban, spinal cord rehabilitation programme. Outcomes: (i) TBI was diagnosed using common neurological indices of brain injury (i.e. Glasgow Coma Scale [GCS], post-traumatic amnesia and loss of consciousness), neuroimaging (including CT and structural

Brain Inj, 2014; 28(5–6): 517–878

MRI) and neuropsychological assessment of memory, attention and executive function. Confounded diagnostic measures (e.g. a depressed GCS score in the presence of high levels of alcohol) were removed from the analysis in a pairwise fashion. (ii) Acute care TBI diagnosis was determined through medical record review plus corroboration with patient and family members where possible. Analyses: (i) The proportion of patients with missed diagnosis was computed. (ii) Chi-square analyses were used to compare the frequency of missed diagnosis between motor vehicle collision (MVC) and non-MVC patients. Results: The frequency of missed acute care TBI diagnosis in this sample was 58.5%. Patients injured outside of an MVC were significantly (p50.01) more likely to have a missed acute care TBI diagnosis than those injured in an MVC (75% vs 43%, respectively). However, there was a comparable percentage of missed acute care TBI diagnosis in patients with cervical level SCIs and injuries below the cervical level (79% vs 80%, respectively). Conclusions: Missed acute care diagnosis of TBI in SCI patients appears to be ubiquitous and non-MVC related TBIs were more likely to be missed than MVC-related injuries in this cohort. This study employed multiple diagnostic measures to identify TBI, which may not be feasible in acute settings, when patients are ventilated and/or sedated and the diagnostic goal is to rule out brain damage requiring acute intervention. Moreover, unless TBI symptoms are overt, a focus on SCI management or life-threatening injuries may consume medical attention. Nonetheless, failing to detect TBIs in SCI patients—even mild TBIs—precludes the opportunity for early treatment of brain injury, which can result in poorer long-term cognitive and behavioural outcomes. Approaches for improving detection of TBI in SCI patients are discussed.

0853

A profile of traumatic brain injury patients within home care, longterm care, complex continuing care and institutional mental health settings in a publicly insured population Angela Colantonio1, Jayden Hsueh1, Josian Petgrave1, John Hirdes2, & Katherine Berg1 1

University of Toronto, Toronto, Ontario, Canada, 2University of Waterloo, Waterloo, Ontario, Canada Objective: To identify demographic, health and service characteristics unique to traumatic brain injury (TBI) across post-acute care settings. Methods: This research involved secondary analyses of healthcare administrative data in Canada. This national sample included adults 18 years of age and older identified with a TBI code and patients with other neurological/non neurological conditions as a comparison group. A cross-sectional study design was utilized. Data from Canadian Home Care (RAI-HC), Mental Health (RAI-MH), Nursing Home and Complex Continuing Care Facilities (MDS 2.0) were used. Descriptive statistics were performed for TBI patients and patients with other diagnoses. The main measures were demographic and clinical characteristics, functional characteristics, mood and behaviour and treatment and medication variables. Results: The results showed that persons with TBI were different on several demographic and health characteristics when compared to persons with other conditions and across multiple care settings. The profile of patients with a TBI diagnostic code differed across care settings and also in relation to other clinical populations. Conclusion: This study addresses the dearth of information regarding the profile of adults suffering from brain trauma in different post-

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acute healthcare settings. Description of characteristics of TBI patients across different healthcare settings is important in order to understand and plan for the clinical management and rehabilitation.

0854

Internet use and privacy in individuals with traumatic brain injury in Neiva, Colombia Diana Milena Villarreal Nasayo1, Silvia Leonor Olivera Plaza1, Edgar Ricardo Valdivia1, Diego Rivera2, Laiene Olabarrieta Landa2, & Juan Carlos Arango Lasprilla3 Universidad Surcolombiana, Neiva, Huila, Colombia, 2University of Deusto, Bilbao, Bizkaya, Spain, 3KERBASQUE, Basque Foundation for Science, Bilbao, Bizkaya, Spain


1

Objective: To describe internet use in a group of individuals with traumatic brain injury (TBI), identify barriers to use for those with TBI who do not use the internet and compare privacy and confidentiality measures used with a healthy control group of internet users. Method: Fifty individuals with mild-to-severe TBI were recruited from the University hospital Hernando Moncaleano Perdomo in Neiva, Colombia and administered an internet use survey created specifically for the purposes of the present study. The sample was 70% male and had suffered a TBI an average of 5 years prior. They had a mean age of 38.2 years (SD ¼ 11.9) with an average of 9.3 years of schooling. Internet users from this group and a group of healthy control internet users also completed the Internet Privacy Scale. Results: Of the sample as a whole, 20% reported using the internet to look for information regarding their condition and 18% reported finding webpages with information related to their condition. Twenty per cent reported using the internet to receive assistance or information to help them manage their disability and 18% reported using the internet to help find information on healthcare specialists. Only 4% have used the internet to make medical appointments and only 16% believe that access to the internet has helped make their lives more independent. Of the sample as a whole, the top five reasons not to use the internet were: lack of knowledge about how to access and use it (32%), unaffordable (22%), lack of computer at home (20%), cognitive problems (14%) and lack of interest (12%). Other reasons included physical problems (6%), lack of usefulness (4%), emotional problems (2%), lack of security (2%) and lack of confidence (2%). Compared to a group of healthy controls, individuals with TBI who use the internet had significantly lower scores on the General Cautiousness sub-scale (12.4 vs 15.9, p50.05), Technical Protection sub-scale (13.5 vs 19.7, p ¼ 0.001) and Privacy Scale total score (88.4 vs 104.7, p50.05). The differences on the Privacy Concern sub-scale were marginally significant (62.6 vs 69.2, p ¼ 0.076). Conclusion: The internet can be a health information and healthcare resource for individuals with TBI. However, only one out of five individuals with TBI from Neiva, Colombia use the internet for this purpose. Those Colombians with TBI who do use the internet use less precaution and engage in less technical protection than healthy control internet users in their community. Interventions to address barriers in this population, such as increasing the availability of cognitively appropriate internet training and affordable access to computers and internet, as well as strategies to strengthen internet security measures in current users may improve quality-of-life and potentially impact other health-related outcomes in this growing population.

0856

Non-verbal medical symptom validity test performance in persons with traumatic brain injury and secondary gain incentives Nathan Zasler, Laura Nichols, & Emily Joyner Concussion Care Centre of Virginia, LTD., Richmond, VA, USA Objectives: To assess performance patterns on the Green’s Non-Verbal Medical Symptom Validity Test (NV-MSVT) among a consecutive group of patients with a history of mild-to-severe TBI who were seen in the context of worker’s compensation injury or personal injury litigation (the latter either as a patient or in an Independent Medical Examination context). Methods: Eighty-one individuals were prospectively and consecutively evaluated in an outpatient specialty brain injury medicine clinic over a 1-year period and were assessed for ‘effort’ on the Greeen’s NV-MSVT as part of a neuromedical work-up. All of the individuals in this study were involved in either a worker’s compensation case or had ongoing litigation surrounding their injury and claimed post-traumatic problems. The NV-MSVT is a computer-based assessment protocol that has embedded effort measures, as well as legitimate memory indices, but uses no actual words on screen as it is fully pictorial. It takes 5 minutes. It is now a commonly used validity check in the context of clinical, as well as clinicolegal assessment. The NV-MSVT discriminates between dementia and poor effort. People with dementia fail the NV-MSVT and people who are asked to fake bad fail it as well but do so in different ways. Results: Of the 81 paitents, 66 had sustained confirmed or presumptive mild brain injuries, six moderate brain injuries and nine severe brain injuries. The mean time post-injury for the severe TBI group was 2.88 years, moderate TBI group 3.66 years and mild TBI group was 4.92 years. The average age of the severe TBI group was 42 years old (seven males and two females), moderate TBI group 51 years old (four males, two females) and the mild TBI group 49 years (48 males and 18 females). There was a very high failure rate on effort testing using the NV-MSVT, with the fail rate being 43% for those with mild TBI, 50% for those with moderate TBI and 56% for those with severe TBI. Conclusions: Use of validity measures including effort measures such as the NV-MSVT can yield some concerning results regarding implications for the validity of test performance observed in individuals following TBI. Methodological limitations of this study will be elaborated on. The nature of these findings relative to implications for how individuals with TBI are assessed and what such findings mean will be discussed, as will the apparent higher failure rates on such tests in persons who have secondary gain incentives.

0857

A prospective study into the rate and pattern of neurological injury post-anoxic brain injury Eugene Wallace1, Colin Doherty1, & Arun Bokde2 1

St James Hospital, Dublin, Ireland, 2Trinity College Dublin, Dublin, Ireland


838 Objectives: A prospective study was undertaken into neurological injury post-cardiac arrest. In addition to clinical, neurophysiological and biochemical assessments two MRI scans in the acute phase using advanced imaging techniques were planned to identify the rate and pattern of oedema formation. This study aimed to identify potential surrogate markers of neurological injury so that future research into neuro-protective treatment strategies could be more easily evaluated. Methods: Multiple different assessment methods were employed including clinical, neurophysiological (Somatosensory Evoked Potentials), biochemical (Neuron Specific Enolase and S100 Beta levels at specified time points) and advanced neuroimaging techniques (such as Blood Oxygenation Level Dependent imaging, Voxel Based Morphometry, Tractography, Perfusion Weighted Imaging, MR Spectroscopy, etc.) to correlate the reliability and physiological basis of current assessment modalities. These MRI scans were performed as soon as possible following admission and as close as possible to 72 hours post-cardiac arrest (or 96 hours if the patient received therapeutic hypothermia) to correspond to recommended clinical assessments regarding prognostication. Results: Twelve patients were recruited to the study including eight who had two advanced MRI scans as envisaged in the protocol. Of these six had a good neurological outcome and the remainder either died or had a poor neurological outcome. From these patient’s Functional MRI data one was able to identify significant differences in the brain’s default mode network between the first and second scan and between patients who had a good neurological outcome vs those who didn’t. The analysis of this data is only partially complete at this stage as patient recruitment is on-going. Conclusion: Although the numbers were small, this study was conducted on a pilot basis. The end of enrolment is year end and this will allow complete analysis of results.

0858

Linear and rotational measurements of human mild traumatic brain injury Fidel Hernandez, Lyndia Wu, Michael Yip, Kevin Bui, Bradley Hammoor, Erik Ortega, Gregor Yock, Gerald Grant, Andrew Hoffman, & David Camarillo

Brain Inj, 2014; 28(5–6): 517–878

magnitude (L2-norm). Injury was diagnosed by sideline/ringside clinicians. Results: This study reports the first 6-DOF head acceleration measurement of mTBI in humans. The injury case involved loss-ofconsciousness (LOC) during a football game and was diagnosed by a sideline clinician. LOC is a rare and objective biomarker of mTBI, facilitating comparison to unequivocal non-injury (e.g. non-LOC) data. This non-injury dataset includes 501 head impacts measured in 6-DOF that did not result in LOC or injury diagnosis. The LOC case was characterized by high acceleration in specific directions: Linear acceleration of 100 grams and HIC of 383 in the lateral (left) direction; rotational acceleration of 12 900 radians s2 and change in rotational velocity of 66 radians s1 in the coronal plane. Other athletes in the dataset tolerated higher acceleration levels in other directions with no apparent injury. Conclusions: The results suggest that the human brain’s tolerance to traumatic acceleration is direction-dependent. Current sports and vehicle safety standards use acceleration magnitude to assess injury risk. However, this measure weighs accelerations in different anatomical directions equally and, based on this data set, predicts higher risk for certain non-injury events than the observed LOC case. Thus, magnitude measures may not accurately predict injury. Instead, injury tolerance appears to be a weighted combination of acceleration levels in different directions. LOC is a rare, objective diagnostic marker of mTBI; other symptoms are often subtle and result in under-reporting. Resolving directional sensitivities over a broader spectrum of mTBI can enable clinical translation of head instrumentation for high-throughput screening and diagnosis.

0859

Pennsylvania’s BrainSTEPS programme: The return to school and academics statewide concussion management team (CMT) project Brenda Eagan Brown, & Monica Vaccaro

Stanford University, Stanford, CA, USA

Brain Injury Association of Pennsylvania, Pennsylvania Department of Health, Pennsylvania Department of Education, New Castle, PA, USA

Objectives: Mild traumatic brain injury (mTBI) is linked to neurodegenerative disease found in military veterans and athletes. mTBI is thought to be caused by head acceleration during impact, but specific tolerable acceleration levels remain unclear. Animal studies suggest that acceleration tolerance varies substantially in different anatomical directions. However, directional sensitivity in humans is unknown due to subjective neurological outcomes and lack of head acceleration measurements during injury in all linear and rotational directions (i.e. six-degrees-of-freedom or 6-DOF). The objective was to measure injury and non-injury human head impacts in 6-DOF to determine if the human brain’s tolerance to injury is directiondependent. Methods: Novel instrumented mouthguards were used to measure head impact acceleration at American Football games and practices, boxing sparring sessions and mixed martial arts sparring sessions and match. 6-DOF measurements were acquired using a tri-axial accelerometer (translation in anterior, left and superior directions) and a tri-axial gyroscope (rotation in coronal, sagittal and horizontal planes). Impacts recorded by the mouthguards were confirmed by video. Common kinematic measures implicated in head injury were computed: maximum linear acceleration, Head Injury Criterion (HIC), maximum rotational acceleration and change in rotational velocity. These measures were compared by direction as well as by vector

Objectives: Participants will have a firm understanding of: (1) Implementation of a Concussion Return to School Protocol based on the Pennsylvania BrainSTEPS Concussion Management Team Project model; (2) Symptom-based educational accommodations for stages of acute and prolonged concussion; and (3) Roles and responsibilities of the Concussion Academic Monitor and Symptom Monitor . Methods: The statewide BrainSTEPS Brain Injury School Re-Entry Consulting Programme has been working to assist students with concussion return to school by creating a Concussion Return to School and Academics Protocol with the PA Department of Education; utilizing school-based Concussion Management Teams (CMTs). CMTs were formed to serve as the 1st layer of student support following concussion at the district level. Teams consist of one Academic Monitor and one Symptom Monitor who are trained by the BrainSTEPS Programme in concussion and who manage the student’s educational programme over the course of recovery. Schools are provided with an Electronic Concussion Toolkit consisting of a parent letter, adaptable letters to be sent to teachers detailing recommendations for adjusting accommodations over time, a concussion master student log for data collection reported to the BrainSTEPS programme twice a year, an academic monitoring tool and a student symptom monitoring tool. CMTs support students returning to the

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demands of school while promoting recovery. They evaluate data from the academic and symptom monitoring tools weekly to make decisions regarding the need to adjust accommodations and follow the trajectory of concussion resolution. The presentation will detail the specific academic and symptom monitoring roles school personnel can take on to collect data to drive educational decisionmaking. Results: Since January 2013, the Pennsylvania BrainSTEPS Programme has trained 520 Return-to-School CMTs, serving over 200 of the 500 Pennsylvania school districts. Data from the work of these teams are being collected twice a year and 100 teams submitted data in the early months of the programme including; date of concussion, concussion modifiers, number of days between concussion and return-to-school, dates of return to academic baseline, dates of symptom resolution and date referred to the BrainSTEPS programme if appropriate. Conclusions: School have embraced the CMT programme enthusiastically. What was intended to be a small pilot has resulted in an ongoing programme currently serving over 200 school districts. Additional teams are in the formative stages, with the goal of establishing CMTs in all 500 districts, private and charter schools across PA. Through this programme, educators at the local level are building capacity to manage students with concussion and make data-driven decisions about educational programming. The BrainSTEPS Programme is jointly funded by the PA Department of Health and the PA Department of Education and has been implemented by the Brain Injury Association of Pennsylvania since 2007.

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Unexpected high incidence of traumatic brain injury and other coexisting neuropsychiatric disorders among 605 consecutive obsessive-compulsive disorder genetics clinic admissions Anne Wilson, Zakar Rana, Liza Rubenstein, & Dennis Murphy National Institute of Mental Health, Bethesda, MD, USA While neuropsychiatric sequelae, particularly post-traumatic stress disorder, following traumatic brain injuries (TBI) have long been studied, less is known about relatively less common disorders such obsessive-compulsive disorder (OCD) and OCD spectrum disorders. OCD has a world-wide (including US) general prevalence of 2–2.5%. Neural circuit imaging and other studies have established the critical involvement of cortico-subcortical-thalamic-cortical (SCTC) plus basal ganglia pathways as mediators of OCD symptomatology. Orbitofrontal, mesial cortical and basal ganglia lesions have most notably been associated with OCD and related disorders, although most commonly by far OCD is idiopathic. As part of an ongoing genetics study, to date 605 successive NIMH clinic admissions have been evaluated using personal interviews (SCID, based on DSM4-TR) and extensive questionnaires. Ascertainment of concussive head trauma (HT) was based on reports of loss of consciousness/confusion following automobile accidents, sports and other related types of injuries (exact wording was identical to that of a prior epidemiologic study). Those OCD subjects with HT (n ¼ 128, total n ¼ 605, 21%) were compared with other consecutive OCD proband admissions (n ¼ 477, total n ¼ 605, 79%). These two groups did not differ in demographics, including mean age, ethnicity, marital status, education level, employment or mean income-but did differ in gender, with more males in the HT group (X2 ¼ 6.77, p ¼ 0.009) Seizure disorders were

more frequent in those with OCD and HT (X2 ¼ 12.50, p50.001), as were co-existing tics (X2 ¼ 5.69, p50.05) co-existing Tourette syndrome (X2 ¼ 9.88, p50.01). Major depressive disorder (X2 ¼ 4.92, p50.05) and Bipolar II disorder (X2 ¼ 14.64, p50.001) but not Bipolar I disorder constituted the only other neuropsychiatric disorders that differed between the two groups. There were no differences in Yale-Brown Obsessive Compulsive Scale (YBOCS) severity scores for obsessions or compulsions nor total YBOCS scores when OCD subjects with HT were compared to those without. A prior retrospective study found an association between head trauma and OCD in evaluating an epidemiologic, non-clinical community sample of 5034 individuals among whom 361 (8.5% weighted average) reported a history of brain trauma with loss of consciousness or confusion. An odds ratio of 2.1 was reported for OCD, representing a greater than 2-fold increase of the co-occurrence of OCD plus HT compared to controls without head injuries, after corrections for age, gender, marital status and socio-economic status. While several case reports and brief reviews have described de novo OCD and an excess of individuals with OCD following head trauma, this is the first examination of a large consecutive OCD clinic sample examining over 600 probands with OCD; 21% of individuals with OCD were found to have HT and associated co-existing features including seizures and several neuropsychiatric disorders.

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Vestibular dysfunction following paediatric traumatic brain injury—Prevalence and exploration of a novel diagnostic tool Taeyoung Peter Hong1, Alex Scurfield2, Kathryn Schneider2, Mariam Narous3, Michael Esser2, & Karen Maria Barlow2 1

University of Alberta, Edmonton, Canada, 2University of Calgary, Calgary, Canada, 3Alberta Children’ Hospital, Calgary, Canada

Background: It is well established that vestibular injury can occur with traumatic brain injury (TBI). Symptoms that could be related to vestibular dysfunction rather than a brain injury include vertigo, dizzines, and imbalance. Reports indicate that the incidence of dizziness or imbalance secondary to vestibular dysfunction may occur in up to 83% of adults following mild TBI. It is difficult, but clinically very relevant, to differentiate symptoms due to vestibular injury as the treatment is very different. Few studies have examined vestibular dysfunction in TBI in the paediatric population. In addition, little is known about what children and adolescents with TBI actually mean when they complain of ‘dizziness’. Objective: To examine the symptom of dizziness in children with TBI and investigate the prevalence of vestibular dysfunction in children with symptoms following a TBI using a novel diagnostic technique. Methods: Prospective cohort study. Children aged between 11–18 years with (a) mild TBI patients presenting to the Emergency Department (ED) within 7 days of their injury (acute/sub-acute); and (b) children with mild-to-severe TBI remaining symptomatic 1 month post-injury (chronic). Outcome measures: DizzyKids Questionnaire: A dizziness questionnaire was created using a literature search, professional consensus and face validity testing. Vestibular testing was performed using the Head Impulse test and the ICS Impulse goggles, a novel and well-tolerated diagnostic tool, used to detect vestibular dysfunction. Results: Thirty children, 21 males, aged 14.3 (SD ¼ 2.3) years were enrolled. Testing was completed in 9.5 ± 4.5 minutes and was well tolerated. There was a 10% prevalence of vestibular dysfunction in

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both the acute/sub-acute and chronic groups. Dizziness is a nonspecific complaint. True ‘vertiginous’ symptoms were not more likely to be associated with semicircular canal dysfunction. Conclusion: Vestibular dysfunction secondary to head trauma occurs in 10% of children with mild TBI and in those with chronic postconcussive symptoms. Further investigation is required to confirm this finding in a larger sample size. These methods can be easily used in the ED and clinic setting for assessing vestibular dysfunction in the paediatric population.

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Stuttering (fluency disorders) and traumatic brain injury in US veterans of Iraq and Afghanistan

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The development of a countywide community head injury service; the characteristics and needs of the first 100 clients and how they influenced rehabilitation content

Rocio Norman , Carlos Jaramillo , Blessen Eapen , Megan Amuan2, & Mary Jo Pugh1

Judith Allanson1, Kate Psaila2, Kerrie Bundock2, Sarah Moss2, Helen Palmer2, Andrew Bateman3, Fergus Gracey3, Donna Malley3, & Peter Hutchinson4

1

1

2

2

1


reviewed during the clinical evaluation for potentially problematic medications that could cause or exacerbate a fluency disorder.

1

1

South Texas Veterans Health Care System, San Antonio, Texas, USA, Center for Health Quality, Outcomes and Economic Research, Edith Nourse Rogers VA Hospital, Bedford, MA, USA Objectives: To Memorial describe the association between stuttering (fluency disorders), TBI and co-morbid mental health conditions such as posttraumatic stress disorder (PTSD) in a cohort of 309 675 veterans of Operation Iraqi Freedom and Operation Enduring Freedom (OEF/OIF). To determine whether veterans with fluency disorder were receiving potentially problematic pharmacological treatment affecting fluency. Methods: Using data from the Veterans Health Administration (VA) National data repository, Veterans were identified who were deployed in support of OEF/OIF and who received VA care in 2010 and 2011. Individuals with adult-onset fluency disorders were identified using ICD-9 codes 307.0, 784.52 and 784.59. Codes for developmental stuttering (315.35) and CVA-related stuttering (438.14) were excluded. Medications, including antidepressants (SSRI, SNRI, TCA), anxiolytics (clonazepam, alprazolam) and anti-epileptics (gabapentin, valproate, levitaracetam, lamotragine, carbamazepine) were identified using VA product name or VA class. This study performed bivariate analysis (chi-square statistic significant p50.05) and multivariable logistic regression (LR) analysis to determine the clinical characteristics of individuals with fluency disorders and the association of fluency disorders with TBI, PTSD and potentially problematic medications in this cohort. Results: Two hundred and thirty-five veterans were diagnosed with an adult-onset fluency disorder and over 66% received at least one potentially problematic medication. Using LR it was found that veterans diagnosed with a fluency disorder were more likely to be diagnosed with pain (Adjusted Odds Ratio (AOR) ¼ 1.72, CI ¼ 1.33– 2.24), insomnia (AOR ¼ 1.92, CI ¼ 1.46–2.52), substance abuse (AOR ¼ 1.61, CI ¼ 1.19–2.18), anxiety (AOR ¼ 2.49, CI ¼ 1.91–3.26), depression (AOR ¼ 2.72, CI ¼ 2.10–3.51) and headache (AOR ¼ 3.88, CI ¼ 3.0–5.02). Veterans with a diagnosis of only TBI (AOR ¼ 4.14, CI ¼ 2.24–7.65), only PTSD (AOR ¼ 3.07, CI ¼ 2.13–4.43) or both TBI and PTSD (AOR ¼ 9.77, CI ¼ 6.93–13.78) were more likely to be diagnosed with a fluency disorder compared to those with no diagnosis of TBI or PTSD. Veterans with a fluency disorder were also more likely to be prescribed potentially problematic medications including antidepressants (OR ¼ 2.73, CI ¼ 2.11–3.53) anxiolytics (OR ¼ 3.48, CI ¼ 2.64–4.59), anti-epileptic drugs (OR ¼ 3.01, CI ¼ 2.25– 4.04), neurostimulants (OR ¼ 3.05, CI ¼ 1.57–5.95) or atypical antipsychotics (OR ¼ 2.95, CI ¼ 2.07–4.21). Conclusions: Veterans with a co-morbid diagnosis of TBI and PTSD were more likely to be diagnosed with a fluency disorder. Those with a fluency disorder were also more likely to have been prescribed medications that negatively impact speech production. Communication is an integral part of community re-integration and fluency disorders are treatable conditions. Therefore, veterans should be carefully screened for fluency disorders, especially those with a history of TBI and/or PTSD. Furthermore, medication lists should be

Cambridge University Hospitals Trust, Cambridge, UK, Cambridgeshire Community Services, Cambridge, UK, 3 Oliver Zangwill Centre, Cambridge, UK, 4University of Cambridge, Cambridge, UK Objectives: A county-wide community-based head injury service was established in November 2009 for assessment and rehabilitation of people referred to a regional neurotrauma clinic. This study investigated the demographics and rehabilitation needs of referrals and report on how these influenced the content of interventions offered. Methods: Characteristics of the first 100 clients seen, until 1 July 2013, were collated from documented semi-structured interviews and questionnaires, including the Mayo Portland Adaptability Inventory4 (MPAI-4) and the Hospital Anxiety and Depression Score, completed at initial assessment. Results: Age range was relatively young; 16–70 years (Mean ¼ 39 years, SD ¼ 16) (17%521 years). The majority were male (71%). Forty per cent had sustained severe injury (GCS59); 33% had had mild injury (GCS413). Injury had resulted from Road Traffic Accidents (38%); falls (25%); and assaults (22%). Ten per cent of clients had fallen from bikes. Twenty-seven had received some rehabilitation in an inpatient setting before referral (nine in specialist inpatient behavioural units). Thirty-five were seen within 6–12 of injury while 28 were referred with difficulty more than 2 years after injury. Four did not attend for a rehabilitation assessment. No one reached ceiling or plateaued on the MPAI-4; mean total T-score ¼ 41.64 (SD ¼ 10.87) (mild–moderate limitations within a TBI population). Eighty-four identified rehabilitation goals (relating to work or study (54%); mood (33%); daily function (30.5%); cognition (19%); physical function (21%) and fatigue (20%). There was significant emotional morbidity with 53% of 80 who completed the HADS, scoring in the mild–severe range for anxiety and 41% for depression. Forty-nine required formal clinical psychology assessment of mood and cognition. Four were repeats in 14 who had been assessed previously. A total of 21 groups were set up to meet needs, covering nine different topics such as ‘understanding of brain injury’ (six groups were run for 33 clients; six additional groups for relatives); fatigue management; communication; cognitive strategies; and mood management. At referral, 9/80 clients previously in work or education had returned to previous roles. By 1 July 2013, following vocational rehabiliation, 43/80 had returned to work or education and three had retired. In contrast, 10/100 who had profound cognitive impairment were attending Headway regularly and eight had care packages. Conclusions: Many with mild injury presented with significant rehabilitation needs. The semi-structured interview and assessment battery identified a wide range of impairment, ability and participation after head injury. These data suggest that any county-wide specialized team will need to use assessments and have sufficient

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expertise and experience to deliver interventions appropriate for people with diverse physical and neuropsychological abilities and rehabilitation aims. As these measures were relevant to these service users they will be repeated at annual review to investigate effects of community rehabilitation.

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The role of apolipoprotein E (APOE) in outcome following traumatic brain injury (TBI): A systematic review David W. Lawrence, Paul Comper, & Michael G. Hutchison


University of Toronto, Toronto, ON, Canada Objective: Outcome following traumatic brain injury (TBI) is heterogeneous with recent effort focused on the predictive properties of genetic polymorphisms. The apolipoprotein E gene (APOE) has emerged a potential strong candidate for prognosticating TBI recovery, with the APOE"4 allele identified as a potential susceptibility marker for poor outcome. The influence of APOE post-TBI has been studied in all TBI severities with various outcome measures. This study attempts to comprehensively review, evaluate and summarize the literature that has examined the relationship between APOE and TBI outcome. Methods: MEDLINE databases were searched for all primary articles from database inception through July 2013. Three hundred and fortysix articles obtained by an electronic and hand search were reviewed for relevance. Seventy-four studies investigating the role of APOE on TBI outcome met criteria for inclusion in the present review. Results: A breakdown of the TBI severity of the 74 studies were: 24 investigating mild (mTBI), seven moderate (modTBI), 38 severe (sTBI) and severity was not reported in five studies. Various outcome measures have been employed, most frequently Glasgow-Outcome Scale (28.4%), followed by neuropsychological (NP) tests (27.0%), dementia diagnosis (14.9%) and functional (13.5%) and pathological (13.5%) indices. In mTBI, the association of APOE"4 on outcome was reported to be absent in 14 studies (58.3%), hazardous in nine (37.5%) and protective in one (4.2%). In modTBI studies, APOE"4 was observed to be hazardous in four studies (57.1%), non-contributory in two (28.6%) and protective in one (14.3%). In sTBI studies, the role of APOE"4 on outcome was hazardous in 22 (57.9%), absent in 13 (34.2%) and protective in three (8.1%). Of the 11 studies that investigated dementia as an outcome, seven (63.6%) observed a hazardous association with APOE"4 while four (36.4%) reported no association. Six out of 15 (40.0%) studies observed an association for worse clinical outcomes in APOE"4 carriers at 6-months post-TBI. After 9-months post-TBI, 11 out of 12 (91.7%) studies failed to observe an association between APOE"4 and poor clinical outcome. Five studies examined brain amyloid deposition following TBI, of which three (60%) observed a hazardous effect of APOE"4 and two (40%) failed to observe an association. No association between APOE"4 and NP testing, symptom severity, functionality, mortality, psychiatric illness, pathological indices, PTS, PTA or imaging abnormalities was observed post-TBI for any- and all-time intervals and injury severities. Conclusions: Overall, the association between APOE"4 and TBI outcome is weak. However, APOE"4 has greater influence over TBI outcome with increasing injury severity. Furthermore, APOE"4 is a potential susceptibility marker for dementia, poor-outcome at 6 months and amyloid deposition following TBI.

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Procedural memory and TBI: Is it spared across the board? Nathaniel Klooster, & Melissa Duff University of Iowa, Iowa City, IA, USA Background: Memory deficits are common following traumatic brain injury (TBI). A long held assumption is that declarative memory is disproportionately impaired while procedural memory is left intact. In fact, preserved procedural memory is often suggested as a possible mechanism to leverage in rehabilitation and efforts aimed at new learning. This assumption, however, has not received extensive empirical study, nor has there been a systematic examination of the different forms of procedural memory. Objectives: To examine whether procedural memory is intact in TBI across a battery of tests that measure different types of procedural learning. Methods: Seventeen participants who suffered a mild–moderate TBI are at least 6-months post-injury and have no other history of neurological insult or cognitive impairment were recruited from the Iowa Traumatic Brain Injury Registry. Participants were tested on a comprehensive battery of procedural memory tests including Rotary Pursuit (RP), a measure of motor learning, Mirror Tracing (MT), a perceptual skill and the Serial Reaction Time Task (SRT), which measures sequence learning, a cognitive skill. Results: As a group, patients showed significant learning on MT and SRT, but were impaired on RP. Individually, all patients showed impairment on at least one of the tests, with six of the 17 showing impairment on more than one. Conclusions: These findings challenge the standard account that TBI impairs only declarative memory while leaving procedural memory intact. It is unsurprising to find diverse patterns of impairment across these tasks considering the diffuse nature of neuropathology in TBI including damage to different brain regions and their interconnections and the resulting variability in both general and rehabilitation outcomes following TBI. These results suggest individualized interventions based on specific patterns of memory impairment may be a more fruitful approach towards the rehabilitation of TBI.

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Head impact classification using an instrumented mouthguard Lyndia Wu, Livia Zarnescu, Vaibhav Nangia, Bruce Cam, Maria Malone, Bradley Hammoor, Kevin Bui, & David Camarillo Stanford University, Stanford, CA, USA Objective: Head impacts in sports and other activities can cause traumatic brain injury. In particular, repeated concussive and subconcussive impacts increase the risk of long-term neurodegeneration. To investigate the cause of acute and chronic brain trauma, accurate and precise detection of potentially-injurious head impacts will help uncover the biomechanical mechanism of injury. Current instrumented helmet and mouthguard systems typically use a linear acceleration threshold to detect head impacts. However, many spurious nonimpact events, such as contacting the device by hand, can generate peak accelerations above the threshold and be falsely classified as head impacts. These misclassified events may skew conclusions when studying head injury mechanisms and tolerances. The objective is to design a mouthguard-based system that classifies head impacts with


842 higher sensitivity, specificity, accuracy and precision than acceleration thresholding. Methods: This study designed a head impact classification system that distinguishes head impacts from non-impacts through two steps. First, infrared proximity sensing of teeth is used to determine if the mouthguard is worn on the teeth. All off-teeth events are filtered out at this step. Second, on-teeth, non-impact events using a support vector machine (SVM) classifier trained on frequency domain features of linear acceleration and rotational velocity were rejected. The remaining events are classified as head impacts. Sensor data are collected using an instrumented mouthguard and both classification steps were trained in a controlled laboratory setting. Head impacts were reconstructed using a dummy head form and a spring-driven impactor. A human subject simulated a comprehensive set of nonimpact events identified from football practices and games. Using this labelled data set, the combined system was evaluated against a 10gram acceleration thresholding, which is commonly used in published helmet and mouthguard systems. Results: The present system performed significantly better than a 10gram acceleration threshold in head impact classification (98% sensitivity, 100% specificity, 99% accuracy and 100% precision, compared to 92% sensitivity, 58% specificity, 65% accuracy and 37% precision). Proximity sensing rejected all off-teeth events, including those with similar kinematics as head impacts and likely misclassified by SVM (e.g. impacting the mouthguard against a large object). The SVM classifier successfully rejected most on-teeth nonimpact events, including mouthguard biting, which were misclassified by proximity sensing. By combining these two complementary classification steps, the impact classification system achieved nearperfect performance in the laboratory. Conclusions: In-laboratory evaluation, the head impact classification system has improved accuracy compared to acceleration thresholding. The next step of this research is to train and evaluate the system with field data. Once adapted to be effective on the field, this system will help to more accurately and precisely capture head impacts for blunt head injury research. This technology also has clinical potential to be incorporated into on-field screening devices for real-time identification of head trauma.

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Rates of suicidal behaviour following traumatic brain injury (TBI): Five year follow-up data from the traumatic brain injury model systems (TBIMS) Lauren Fisher1, Paola Pedrelli1, Joseph Giacino2, Amber Cardoos1, Flora Hammond3, Jennifer Bogner4, Charles Bombardier5, Tessa Hart6, Thomas Bergquist7, Jessica Ketchum8, & Ross Zafonte2 1

Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA, 2Spaulding Rehabilitation Hospital/Harvard Medical School, Boston, MA, USA, 3Indiana University School of Medicine, Indianapolis, IN, USA, 4Ohio State University, Columbus, OH, USA, 5 University of Washington, Seattle, WA, USA, 6Moss Rehabilitation Research Institute, Elkins Park, PA, USA, 7Mayo Clinic, Rochester, MN, USA, 8Virginia Commonwealth University, Richmond, VA, USA Objectives: Individuals with TBI suffer from depression at a significantly higher rate than the general population and frequently face substantial impairment in overall functioning. Depressed individuals often experience suicidal ideation, which contributes to risk for suicide attempts and completed suicide. A few reports have demonstrated elevated rates of suicidal behaviour in TBI patients;

Brain Inj, 2014; 28(5–6): 517–878

however, most studies have utilized small samples, insufficient measures and brief follow-up periods. The current study examined suicidality among patients enrolled in the first, prospective, 20-year, multi-centre study examining the course of recovery and outcomes following acute neurotrauma and inpatient rehabilitation. Methods: Participants were enrolled in the Traumatic Brain Injury Model Systems (TBIMS). Follow-up data was examined at years 1 (n ¼ 3180), 2 (n ¼ 2042) and 5 (n ¼ 780). Participants who completed the PHQ-9 at year 1 were included in the current analyses. Suicidal ideation was assessed using the suicide item from the Patient Health Questionnaire (PHQ-9). The item assesses frequency with which a patient has had ‘thoughts that you would be better off dead, or of hurting yourself’ over the past 2 weeks. Responses include: 0 (not at all), 1 (several days), 2 (more than half the days) or 3 (nearly every day). Scores of 1 indicate the presence of suicidal ideation. PHQ-9 total score 10 was used to indicate the likely presence of major depression. Patients reported suicide attempt(s) within the last year. Results: At year 1, 10% of patients reported suicidal ideation. Of these, 6.4% reported having these thoughts several days, 1.8% more than half the days and 1.8% nearly every day. About 1.5% of patients reported a recent suicide attempt. Among depressed patients (21.4%), 34.3% reported suicidal thoughts and 3.4% reported a recent suicide attempt. At year 2, 9.2% of patients reported suicidal ideation. Of these, 5.5% reported having these thoughts several days, 1.5% more than half the days and 2.2% nearly every day. About 1% of patients reported a recent suicide attempt. Among depressed patients (20.2%), 31.6% reported suicidal thoughts and 4% reported a recent suicide attempt. At year 5, 7.1% of patients reported suicidal ideation. Of these, 5.3% reported having these thoughts several days, 1.0% more than half the days and 0.8% nearly every day. About 1.3% of patients reported a recent suicide attempt. Among depressed patients (17.7%), 26.8% reported suicidal thoughts and 2.9% reported a recent suicide attempt. Conclusions: Rates of suicidal behaviour in patients with moderate-tosevere TBI are higher than in the general population and similar to those seen in stroke patients. Rates of suicidal ideation in depressed patients with TBI are also high. Findings highlight the importance of assessment and treatment of depression and suidality in TBI patients. Identification of predictors of suicidality are needed to guide prevention and treatment in this population.

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An investigation of the influence of player and game characteristics on head impacts in female youth ice hockey players: A descriptive study Nick Reed1, Tim Taha2, & Michelle Keightley1,4 1

Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, ON, Canada, 2Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada, 3Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto, ON, Canada, 4Graduate Department of Rehabilitation Science, University of Toronto, Toronto, ON, Canada Objectives: The popularity of ice hockey amongst female youth has grown exponentially. In Canada, close to 80 000 females were registered to play ice hockey in 2011–2012, with the majority of theses females being under the age of 18 years. Despite the lack of intentional body checking, concussions remain a significant part of female ice hockey participation, indicating that impacts to the head are taking place. To date, the head impacts sustained by female youth ice hockey players have yet to be characterized. The objectives

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of this study were: (1) to describe the biomechanical characteristics of head impacts sustained by female youth ice hockey players during competition (frequency, acceleration, severity); and (2) to explore the influence of and interaction between player and game characteristics on head impacts sustained by female youth ice hockey players during competition. Methods: Twenty-seven female youth ice hockey players (age: 12.5 ± 0.52 years) wore instrumented ice hockey helmets from which biomechanical measures of head impacts were computed across 66 ice hockey games. Data specific to player, game and biomechanical head impact characteristics were recorded. Multiple regression was used to determine the factors most associated with head impacts of greater severity and frequency. Results: A four-way interaction revealed that, in older players who had a greater BMI and spent more time in active ice hockey participation (time on ice), playing the forward position significantly predicted greater linear acceleration of head impacts (Estimate ¼ 1.00; SE ¼ 1.00; t ¼ 2.80; p ¼ 0.008). A three-way interaction revealed that, in older players who had a greater BMI, playing the forward position significantly predicted greater rotational acceleration of head impacts (Estimate ¼ 26.01; SE ¼ 2.82; t ¼ 3.03; p ¼ 0.008). A two-way interaction revealed that, during tournament games, increased ice time significantly predicted increased severity of head impacts (Estimate ¼ 0.004; SE ¼ 0.002; t ¼ 2.28; p ¼ 0.03). A main effect revealed that having a higher BMI significantly predicted a higher number of head impacts sustained per game (Estimate ¼ 0.90; SE ¼ 1.04; t ¼ 2.73; p ¼ 0.008). Conclusions: This study presents for the first time a description of the biomechanical characteristics of head impacts occurring during youth female ice hockey competition, along with the influence of player and game characteristics on these impacts. This study acts as an initial step towards exploring the head impacts sustained in youth female ice hockey players. The replication of similar methodology in future studies across genders, age groups and sports, as well as the capture of the biomechanical characteristics of head impacts resulting in concussion, will further contribute to understanding of the risk factors specific to head impacts and concussion in youth athletes.

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Neuroleptic malignant syndrome after a single dose of haloperidol following TBI: A case report David Ripley, Steven Makovitch, & Korak Sarkar

lobes and bilateral cerebellar hemispheres. He required tracheotomy placement for respiratory failure, but was successfuly weaned from the ventilator and transferred to acute inpatient rehabilitation. His rehabilitation was progressing well, although he had difficulty with decannulation, with severe anxiety during attempts to cap his trach tube. Laryngoscopic evaluation failed to reveal stenosis or tracheal abnormality. He was transferred to acute care for observation in the ICU following decannulation. Approximately 1 hour after decanulation, the patient became anxious while being turned in bed, experienced airway decompensation and was promptly re-intubated. Just prior to a second attempt at decannulation later that day he was given 2 milligrams of intravenous haloperidol at 6 pm. Decanulation was successful and his overnight course was uneventful. However, the next morning at 10 am his temperature elevated to 102 Fahrenheit. Despite initiation of broad spectrum antibiotics, temperature subsequently rose to a nadir of 106.2 F. On exam he showed tremors and muscular rigidity. Serum creatine phosphokinase and myoglobin were elevated at 5642.5 and 8557, respectively. Urine myoglobin was elevated to 641 mcg L1. Neuroleptic malignant syndrome was suspected and cooling measures were initiated. He was given diazepam and IV dantrolene in addition to intravenous hydration. The patient had a rapid improvement in symptoms. Evaluation for other sources of fever, including sepsis were all negative. After medical stabilization he was transferred back to inpatient rehabilitation. Discussion: The diagnosis of NMS can be troublesome at times due to its heterogeneous nature of presentation and course. Diagnostic criteria established by an international consensus panel in 2011 will be discussed. This case illustrates the danger of even a single dose of haloperidol following TBI.

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Prospective investigation of white matter hyperintensities, haemorrhagic lesions and brain volume changes in concussed hockey players Michael Jarrett, Roger Tam, Enedino HernańdezTorres, Nancy Marin, Warren Perrera, Yinshan Zhao, Elham Shahinfard, David Li, Jack Taunton, & Alexander Rauscher University of British Columbia, Vancouver, BC, Canada

Rehabilitation Institute of Chicago, Chicago, IL, USA Introduction: Agitation can be a challenging problem after traumatic brain injury. Typical anti-psychotics are frequently used for control of agitation in the TBI patient due to their rapid onset of action and multiple routes of administration. However, the use of anti-psychotic agents may present significant complications. The first generation neuroleptic haloperidol has been associated with slowed motor recovery in a TBI animal model. Haloperidol has also been reported to cause neuroleptic malignant syndrome (NMS). NMS is a rare and potentially fatal disorder characterized by hyperthermia, generalized rigidity, autonomic instability, changes in mental status and elevation in creatine kinase. The authors present a case of NMS that developed after a single dose of haloperidol. This case is significant in that it is the first case report of NMS developing after only one dose. Case description: A previously healthy 18 year old male sustained a TBI from motor vehicle crash. He was intubated in the field and had a Glasgow Coma Scale score of 3. Imaging revealed a left frontal depressed skull fracture with pneumocephalus, left frontal contusion, diffuse axonal injury and restricted imaging in the bilateral occipital

Objective: To prospectively investigate concussion in hockey players by examining brain volume changes, white matter hyperintensities (WMHI) and microhaemorrhages. Methods: This study investigated two ice hockey teams (45 players, 20 female, 25 male, mean age 21.2 ± 3.1 years). All players received baseline MRI at 3 T and neuropsychological testing (SCAT2) at the beginning of the hockey season. Each pre-season, regular season and post-season game was observed by a physician not affiliated with the team who performed a clinical evaluation of players suspected to have received a concussion. Players with confirmed concussions underwent further MRI and neuropsychological tests at 72 hours, 2 weeks and 2 months post-injury. All players underwent end of season MRI and neuropsychological tests. MRI consisted of sagittal three dimensional T1-weighed scan, sagittal three dimensional fluid attenuated inversion recovery (FLAIR) and multi-echo susceptibility weighted imaging (SWI). Brain volume was measured using SIENA, an automated tool from the FMRIB software library. Haemorrhages and WMHI were identified by two radiologists working by consensus.


844 Results: The only microhaemorrhage observed in this study was seen in a single player’s baseline scan and all subsequent scans. Players had an average of 3.5 WMHI at baseline and 3.1 WMHI at the end of season, which is significantly more than expected in a similar population of healthy young adults. There was some variation in the number of WMHI observed over the course of the season but no significant trend was seen in either the concussed players or the full cohort. Lesions were principally found in the frontal lobe (75%). Lesions were found near the sulcal depths (mean distance ¼ 4.3 mm) and near the white matter/grey matter interface (mean distance ¼ 2.6 mm). Significant reduction in brain volume was observed at the end of season scans of both the concussed and non-concussed cohorts and 2 months after injury in the concussed players. A linear mixed-effects model was used to model the serial scans of concussed players and showed time after concussion to have a significant effect on brain atrophy. The 72hour and 2-week timepoints showed no significant change in brain volume when looked at separately. Conclusions: This study demonstrates that brain volume is reduced by concussions and after a season of playing ice hockey. The lack of volume increase shortly after concussion indicates that there is no oedema. The number of WMHI is significantly higher than expected for this age group. The numbers of WMHI and haemorrhages are not associated with concussion. The proximity of lesions to the sulcal depths has implications with current research in chronic traumatic encephalopathy in which tau neurofibrillary bundles are found in similar regions.

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The feasibility of computerized cognitive testing in the paediatric emergency room Aneesh Khetani1, Annie Khan2, Basil Kadoura2, Mariam Narous1, Brian Brooks1, & Karen Maria Barlow1 1

University of Calgary, Calgary, Canada, 2McGill University, Calgary, Canada Background: The majority of reported traumatic brain injuries (TBI) are treated at an emergency department (ED) and about half of these cases occur in patients younger than 19 years. Fourteen per cent of school-aged children with mild TBI are at risk of having postconcussive symptoms (PCS) and associated significant morbidity for 3 months or longer. Identifying such children at risk in the ED would be useful to both physicians and the families. A potential tool for identifying those at risk for PCS is computerized cognitive evaluation. This is normally done in a quiet, controlled environment of the neuropsychology laboratory which is a very different environment to the busy and noisy ED. Objectives: The aim of this study is to evaluate whether computerized cognitive testing can be incorporated into the ED management of children with concussion. Methods: A prospective controlled cohort study. A busy tertiary referral paediatric Emergency Department. Participants were children aged 8–18 years with acute mTBI/concussion and age-matched orthopaedic controls with a lower extremity injury. The feasibility of a 30 minute and 15 minute cognitive test battery was examined using an assessment tool created to assess feasibility factors such as parent, family, physician and medical staff attitudes to testing as well as environmental factors such as space, noise and waiting times that might impede testing. Results: Seventy-four children aged 12.7 (SD ¼ 2.2) years (male 54%) with mTBI were enrolled and 28 orthopaedic controls aged 13 (SD ¼ 2.4). Seventeen per cent of the mTBI group had a loss of consciousness at the time of injury, the average GCS was 15. Challenges encountered included noise, finding a testing location and extra-cranial injuries preventing testing. Most challenges were

Brain Inj, 2014; 28(5–6): 517–878

mitigated with changes in testing methodology. Overall participation rates improved from 27% to 73% by shortening the test battery to 15 minutes. Feasibility data will be presented. Conclusions: Feasibility data are important when considering computerized cognitive testing in the paediatric Emergency Room. This study, although highlighting the challenges to this novel procedure in an ED setting, suggests that computerized testing can be performed.

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White matter microstructure and cortical thickness in former NFL players Inga K. Koerte1, Michael Mayinger1, Katie Green1, Michelle Giwerc1, Brian Dahlben1, Eli Fredman1, Ryan Eckbo1, Christine M. Baugh1, Julie Stamm2, Nikos Makris1, Alexander Lin3, Ofer Pasternak1, Yogesh Rathi1, Robert A. Stern2, Martha E. Shenton4 1

Psychiatry Neuroimaging Laboratory, Department of Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA, 2Center for The Study of Traumatic Encephalopathy, Departments of Neurology and Neurosurgery, Boston University Medical School, Boston, MA, USA, 3Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA, 4Clinical Neuroscience Division, Laboratory of Neuroscience, Department of Psychiatry, VA Boston Healthcare System, Brockton, MA, USA, 5Institute for Clinical Radiology, LudwigMaximilians-Universita¨t, Munich, Germany

Objectives: To characterize white matter microstructure and cortical thickness in former National Football League (NFL) players compared to an age-matched control group of former elite non-contact sport athletes using diffusion tensor MR imaging (DTI) and T1 weighted. Methods: Twenty male retired NFL players (mean age ± SD: 58.6 ± 8.5 years) and a control group of 10 male age-matched control group of former elite non-contact sport athletes (mean age ± SD: 58.55 ± 8.1 years) were investigated on a 3T MR scanner. Group analyses were performed using tract-based spatial statistics (TBSS) and FreeSurfer, for DTI and T1w data, respectively. Results: Compared to controls, NFL players demonstrated lower fractional anisotropy (FA), as well as higher trace, radial diffusivity (RD) and axial diffusivity (AD) in large parts of the brain’s white matter that were most pronounced in the frontal lobes, the corpus callosum and the temporal lobes. A significant difference in cortical thickness was found in the middle and inferior temporal gyrus of the right hemisphere where former NFL players demonstrated a thinner cortex compared to controls. Conclusions: Low FA and high trace, RD and AD values are known to be associated with thinner myelin sheaths or reduced axon diameter. Reduced cortical thickness has often been associated with impaired neurocognitive function. Group differences in white matter microstructure and cortical thickness may be the result of frequent concussive and sub-concussive head trauma in former NFL players. Further investigation of these findings in association with cognitive function is needed.

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An early recovery assessment protocol (ERAP) for evaluating initial cognitive impairments following paediatric TBI

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DOI: 10.3109/02699052.2014.892379

Tamar Silberg, Orly Bar, Janna Landa, & Amichai Brezner


Sheba Medical Center, Ramat Gan, Israel Objectives: Prolonged intensive care and rehabilitation are often necessary during early recovery from childhood traumatic brain injury (TBI), even in the face of uncertain outcomes. This has resulted in the development of several scoring systems to determine prognosis during early phases of recovery. However, although such early evaluations are of utmost importance for planning interventions and effective rehabilitation in academic, emotional and social domains, no such assessment protocol has been reported following paediatric TBI. In the current study an Early Recovery Assessment Protocol (ERAP) was developed to assess a broad range of cognitive symptoms following paediatric TBI. This study aimed at understanding the nature of early cognitive recovery among children and adolescents post-TBI and at examining the relation between the specific recovery profile and initial cognitive and behavioural problems. Methods: Sixty-two school-aged children (M ¼ 11.8 years; SD ¼ 0.45 years) during inpatient rehabilitation following severe TBI were assessed with an extensive occupational therapy cognitive battery, which included the Rancho Los Amigos Cognitive Scale (RCS) for evaluation of cognitive and behavioural presentations as the child emerges from coma; the Children Orientation and Amnesia Test (COAT) for measuring post-traumatic confusion (PTC); and the three little words test to assess retrograde amnesia (PTA). Following resolution from PTA child’s cognitive profile was examined using the Test of everyday attention for children (TEA_CH); the Rivermead Behavioural Memory Test (RBMT) and the Behavioural Assessment of the Dysexecutive Syndrome for children (BADS_C). Results: The ERAP timeline: A mean of 26 days post-injury were observed until resolution from the confused-agitated state (RCS 4) and a mean of 30 days post-injury were observed until resolution from the confused–inappropriate, non-agitated state (RCS 5). Within 32 days from injury 50% of the children had resolved from the confused-appropriate state (RCS 6). Resolution from PTC occurred within a mean of 39 days post-injury and resolution from PTA was observed within a mean of 44 days from injury. Initial cognitive profile: between 60–73% of the sample performed at below average levels (Z-scores51) on the attention and EF index scales of the TEACH and BADS_C tests, in addition to 65% of the sample demonstrating severe memory impairments on the RBMT. Conclusions: The ERAP used in the current study is a combination of objective measures of early cognitive recovery and can be used as an early outcome measure following paediatric TBI. In addition, the results indicate that, during initial recovery from severe TBI, most of the children exhibit significant cognitive and behavioural problems. These findings have important clinical implications, suggesting that in the acute stages post-injury following severe TBI children are vulnerable to several cognitive deficits. Professionals and families should be aware of these limitations and structure expectations and rehabilitation programmes accordingly.

Objective: This study followed two teams of Canadian university hockey teams for a season in order to measure brain structure changes via diffusion MRI in concussed players as well as in players who completed a full season of hockey without being diagnosed as concussed. Methods: Subjects were scanned and underwent neuropsychological testing (SCAT2) before and after the hockey season. Players who were identified as concussed by an independent neurologist underwent additional scans and testing at 72 hours, 2 days and 2 weeks after injury. All MRI data were acquired on a Philips Achieva 3T scanner. DTI measures were compared at the various timepoints via voxelwise and region of interest based analyses. Voxelwise analysis was performed using FSL’s tract-based spatial statistics tool (TBSS) which compares the white matter skeletons of the cohorts while controlling for age, gender and SCAT2. For the region of interest analysis, a threshold wasestablished at 2 SD below the mean of the baseline measurement of each ROI defined in the JHU white matter atlas. A score was calculated for each ROI by subtracting the number of subjects with FA below the threshold at baseline from the number at end of season. This method has the advantage over a whole white matter analysis as it is sensitive to changes in specific regions while avoiding the multiple comparison problem of testing for reductions in each region separately. Both methods compared the full cohort end of season scan to the full cohort baseline scan and each serial timepoint of the concussed subjects to the concussed subjects’ baseline scans. Results: Region of interest results showed a significant non-zero ROI score for FA of the whole cohort at the end of season compared to baseline. This is interpreted as a net decrease in the structural integrity of the subjects’ white matter throughout the brain. This study did not have the statistical power to identify significant changes in the concussed subjects. Tract-based statistics showed decreased MD and AD 72 hours after concussion, increased AD, decreased FA and increased RD 2 weeks after concussion and decreased FA, increased AD RD and MD at 2 months in FA. Conclusion: As axonal injury from concussion is not known to be localized in any single brain region, tract-based results indicate only that regions of significant change in brain structure exist after concussion. Region on interest analysis shows clearly that over the course of the full season there are diffuse changes in white matter connectivity for the full cohort.

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Adult traumatic brain injury: Identifying predictors of posttraumatic amnesia in the acute care setting Maeve Lopreiato, Sarah Bryczkowski, Peter Yonclas, & Anne Mosenthal Rutgers-New Jersey Medical School, Newark, NJ, USA

0876

Prospective study of brain microstructure changes in concussed hockey players Michael Jarrett, Elham Shahinfard, Enedino Hernańdez-Torres, David Li, Jack Taunton, & Alexander Rauscher University of British Columbia, Vancouver, BC, Canada

Objectives: Post-traumatic amnesia (PTA) is often used as a predictive measure for long-term outcomes following traumatic brain injury (TBI). However, multiple risk factors beyond head injury may influence duration of PTA, particularly in the acute care setting. Modifiable predictors of PTA have not been well documented in the literature. The purpose of this study was to identify associations between severity of TBI on admission and clinical interventions that may impact the duration of PTA. Methods: Prospective and retrospective data were collected as part of a delirium prevention study in the surgical intensive care unit (SICU). Inclusion criteria for analysis in this study were: Age 50, head abbreviated injury scale (HAIS) score42 and PTA during the admission. Patients were excluded if they died in the hospital or failed to resolve PTA prior to discharge. Data collection included demographics, admitting diagnosis [HAIS, Glasgow Coma Scale (GCS),


846 isolated TBI], clinical interventions (blood transfusion, mechanical ventilation, benzodiazepine and propofol dose) and time to resolve PTA [t(PTA)]. T(PTA) was defined as 2 consecutive days documented ‘awake, alert and oriented 3’. Bivariate and multivariate analyses were completed. Results: Of 132 patients with TBI admitted to the SICU, over an 18month period in 2012 and 2013, 39 patients met inclusion criteria. The mean t(PTA) was 11.6 days (95% CI ¼ 6.5, 16.7; median ¼ 5.5). Patients with HAIS 3 resolved PTA significantly faster than those with HAIS43 (6.6 days vs 14, p ¼ 0.048). There were no associations between admitting GCS, blood transfusion requirement and isolated TBI (vs multi-trauma) with t(PTA). There were, however, several clinical interventions that negatively impacted t(PTA). These included ventilator days (correlation coefficient [CC] ¼ 0.76, p50.01), total SICU benzodiazepine dose (CC ¼ 0.45, p50.01) and total propofol dose (CC ¼ 0.63, p50.01). In a multivariate model considering age, GCS, HAIS, mechanical ventilation and benzodiazepine dose, only HAIS and mechanical ventilation remained significantly associated with t(PTA). Conclusion: Anatomic and physiologic scales have varying usefulness for predicting duration of PTA after TBI. Head abbreviated injury score (HAIS) was found to be associated with PTA duration; however, severity of TBI when defined by admitting GCS was not. This study identified several potentially modifiable predictors of PTA beyond head injury itself in the acute care setting that may influence its duration. These factors include mechanical ventilation and cumulative doses of benzodiazepines and propofol. These findings highlight the association of medications and mechanical ventilation on the duration of PTA.

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Prospective study of changes in myelin content after concussion Michael Jarrett, Elham Shahinfard, Enedino Hernańdez-Torres, David Li, & Alexander Rauscher University of British Columbia, Vancouver, BC, Canada Objective: Traumatic brain injury (TBI) is among the most common neurological disorders. Mild TBI is characterized as a diffuse axonal injury and is not detectable on traditional CT or MRI. While diffusion tensor imaging (DTI) measures are often used as an indirect marker for myelination, it is much preferable to use a direct, validated marker. This study uses myelin water fraction (MWF) to measure demyelination and remyelination in the human brain after concussion. Methods: Subjects were scanned and underwent neuropsychological testing (SCAT2) before and after the hockey season. Players who were identified as concussed by an independent neurologist underwent additional scans and testing at 72 hours, 2 days and 2 weeks after injury. All multi-echo T2 sequence was acquired on a Philips Achieva 3T scanner. The T2 decay was decomposed into myelin water and intra- and extra-cellular components according to a non-negative least squares fit. MWF was calculated as the myelin water contribution to the T2 decay curve divided by the total water contribution. MWF measures were compared at the various timepoints via voxelwise and region of interest based analyses. Voxelwise analysis was performed using FSL’s tract-based spatial statistics tool (TBSS) which compares the white matter skeletons of the cohorts while controlling for age, gender and SCAT2. For this region of interest analysis, a threshold was established at 2 SD below the mean of the baseline measurement of each ROI defined in the JHU white matter atlas. A score was calculated for each ROI by subtracting the number of subjects with MWF below the threshold at baseline from the number at the end of season. Both methods compared the full cohort end of season scan to

Brain Inj, 2014; 28(5–6): 517–878

the full cohort baseline scan and each serial timepoint of the concussed subjects to the concussed subjects’ baseline scans. Results: Region of interest analysis showed a significant non-zero ROI score for MWF of the whole cohort. Serial scans of concussed players did not have sufficient power to show significant differences. Voxelwise statistics showed a decrease in myelin water fraction in concussed subjects 72 hours after concussion. Tract-based statistics showed a significant decrease in myelin content at 72 hours postinjury, but not significant changes at the following timepoints. Conclusion: The short-term reduction in myelin observed after concussion and subsequent normalization at 2 weeks is consistent with the typical neurological progression of concussion. The full season changes in myelin content observed in the region of interest analysis is not replicated in the TBSS results. One must consider the possibility of diverse brain regions being affected throughout the cohort. The region of interest analysis accounts for this and clearly shows a full season effect.

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‘From start-up to CEO’: Development of game-assisted training for persons with brain injury to improve higher order functional cognition Fred Loya1, Nicholas Rodriguez1, Deborah Binder1, Bruce Buchanan1, Tatjana Novakovic-Agopian1, & Anthony J.-W. Chen1 1

VA Northern California Healthcare System, Martinez, CA, USA, VA San Francisco, CA, USA, 3University of California, Berkeley, CA, USA, 4University of California, San Francisco, CA, USA

2

Objective: The disruption of cognitive functions essential for goaldirected behaviour is a common and disabling sequel of brain injury. Effective and efficient goal attainment in complex settings requires the co-ordination of a continuum of processes, ranging from attentional control to task execution. Rehabilitation of these ‘gateway’ functions is an important goal with potential for far-reaching benefits; training efforts would benefit from improvements in training methods, including tools that support more intensive application and practice of cognitive skills. There is also a need for tools to gauge how effectively skills are employed across situations of varying complexity and challenge. The objectives were to (a) design and develop training tools consisting of technology-assisted game-based scenarios, unfolding in a narrative arc composed of situations that challenge goal-directed cognition, (b) test and refine these tools based upon user experiences, (c) develop a trainer-supported training protocol and (d) establish novel measurements that leverage the demands for functionally integrated cognition. Method: Game-based training tools (‘From Startup-to-CEO’) were developed for touch screen deployment and were user-tested by participants with (n ¼ 15) and without (n ¼ 8) history of brain injury. A range of quantitative and qualitative data based upon their experiences was collected. A seven-session manualized protocol was developed. A data management back end was developed to track behavioural parameters of interest and skill-related, trainingrelevant feedback screens were developed. Results: This study developed five different game ‘scenarios’ and 24 cognitive contexts which unfold within a narrative framework of the player establishing a new business and where game play is goalbased and challenged by disruption of target cognitive processes. Game scenarios require the goal-directed functional integration of cognitive processes, emphasizing working memory and multi-tasking. Training highlights learning attention regulation skills, applied across a spectrum of situations requiring attentional control, particularly

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DOI: 10.3109/02699052.2014.892379

redirection of attention when distracted. User feedback informed the refinement of game mechanics and design of disruptions and feedback for individuals. In-person training sessions provide opportunities to teach skills, observe their implementation and provide feedback based upon individual needs. A range of novel metrics was also developed, including assessment of goal-congruent behaviours and completion of multi-step tasks, especially in the context of disruptions. Conclusions: The systematic training, application and refinement of cognitive skills acquired with supervised training may be enhanced via game-based tools. ‘From Startup-to-CEO’ provides the opportunity for clinicians to directly observe how effectively patients apply skills across a variety of well-calibrated cognitive contexts and challenges and to intervene on an individual basis. Further, practice in applying skills in an integrated game-world that more closely approximates the complexity of goal-pursuit in naturalistic settings may increase transfer of intervention effects. Lessons learned from initial pilot testing will be discussed and the design of an ongoing intervention study will be presented.


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Sideline concussion testing in high school football on Guam Matthew Duenas1, & Rahul Jandial2 1

City of Hope Cancer and Research Institute, Division of Neurosurgery, Duarte, CA, USA, 2USC, Department of Biology, Los Angeles, CA, USA Objectives: The risks of repeated concussions and returning to play (RTP) prior to complete resolution of concussive symptoms is medically established. However, the implementation of RTP guidelines throughout high school sports is highly varied and at times notably absent. The island of Guam, a US territory, has robust youth athletics and lacks formal concussion reduction programmes and established RTP protocols. This presents a public health opportunity to limit the incidence of the ‘second-hit syndrome’ and other deleterious effects of youth concussions. Therefore, this study evaluated the impact and feasibility of high school football Sideline Concussion Testing (SCT) as a novel feature in Guam high school athletics. Methods: The target group of the study included 13 high school football players from the same team that were observed over a period of three consecutive football games. The players were initially given a past history questionnaire. The survey included questions on concussion history, loss of consciousness and medical evaluation for concussed players. Players were tested with a sideline concussion tool (King-Devick Test) and pre-season/pre-injury baseline scores were recorded. Players were followed through three games and, if observed to have contact with their head during a tackle or show concussive symptoms, they were removed from play and underwent SCT. Players were also tested after each game to look for unrecognized concussions. Results: The results of the survey showed 5/13 students to have a previous concussion and limited awareness of RTP guidelines. Of the five players that reported prior concussions, four stated ‘No’ to consulting medical professionals and having a period of no playing before returning to play. Additionally, the survey demonstrated a lack of understanding of what constitutes a concussion, where 5/8 individuals who answered ‘No’ to having a previous concussion answered ‘Yes’ to having incidents in sport that were described as ‘bell ringers’, ‘seeing stars’ and other classic symptoms of concussion. The SCT over the course of the three games showed three players to have concussions, with significant deviations from baseline time. Conclusions: The first use of SCT testing on Guam was feasible and the pilot effort identified potential areas of improvement. Results showed lack of established concussion definition, avoidance and RTP guidelines. Accordingly, a unique opportunity exists to provide concussion

awareness and injury reduction in high school sports on Guam through public health efforts that collaborate with players, parents, coaches and school administration.

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The prognosis value of a new cognitive assessment tool in TBI Marie-Julie Potvin1, Ve´ronique Paradis1, Pauline Brayet1, Erik Therrien2, Charles Overbeek2, Laurie-Anne Dion3, E´liane Ravenda-Bouchard2, Mathieu Laroche1, Isabelle Rouleau3, Nadia Gosselin2, Francis Bernard1, & Jean-François Gigue`re1 1

Hoˆpital du Sacre´-Coeur de Montreál, Montreal, Canada, 2Universite´ de Montreál, Montreal, Canada, 3Universite´ du Que´bec a` Montreál, Montreal, Canada Objective: The EXACT (EXAmen Cognitif Abre´ge´ en Traumatologie) is a new tool that has been specifically designed to briefly assess all cognitive functions of patients who sustained a traumatic brain injury (TBI) in order to determine their orientation at the time of discharge. This instrument is composed of 22 sub-tests (maximum score totalling 100 points) which can be performed in 15–45 minutes. The aim of this study was to evaluate if the EXACT can discriminate patients according to the severity of the TBI and to examine the influence of certain variables on their short- and long-term outcome. Participants and methods: The EXACT was administered to 239 patients who sustained a TBI (89 mild, 75 moderate and 75 severe) at the time of the hospital discharge, 91 normal control participants and 19 patients hospitalized for orthopaedic injuries (age range from 16–96 years). The Disability Rating Scale (DRS) was administered 1 year after the accident. Results: Analyses showed that the total score on the EXACT varies according to the severity of the TBI. However, the performance of the patients hospitalized for orthopaedic injuries was equivalent to those of mild TBI patients. Moreover, results on the EXACT were associated with the age (0.13), the Glasgow coma scale (0.32), the length of stay in intensive care unit (0.48) and the functional outcome of the patients 1 year after their accident (0.37). Comparisons of severe and moderate TBI patients with a score under or over the clinical cut-off (90) on the EXACT revealed significant differences. Patients with a score under this cut-off stayed longer in the intensive care unit (6 days or more) and they were treated with higher therapeutic intensity level (TiL). These patients also have a lower outcome than those with a score above the EXACT cut-off. Finally, TBI and substance abuse seem to have an additive effect with age. Indeed, TBI patients over 60 years old performed more poorly on the EXACT when they have chronic substance abuse problems, which was not the case for younger TBI patients. Conclusion: The EXACT appears to be a brief and useful clinical tool to assess the global cognitive functioning of patients during the acute phase of a TBI. This tool can contribute to predict the short- and longterm outcome of these patients.

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Back to the future: Improved fundamental examination techniques beat high-tech testing when differentiating brain trauma, psychological trauma and feigned trauma

848

Jerry McKenney1, & Seth Silverman2

Brain Inj, 2014; 28(5–6): 517–878 1

VA Northern California Health Care System, Martinez, CA, USA, University of California, Berkeley, CA, USA, 3San Francisco VA Medical Center, San Francisco, CA, USA, 4University of California, San Francisco, CA, USA

2

Legge Farrow, Houston, TX, USA, 2University of Houston School of Law, Houston, TX, USA


1

Objectives: Traumatic brain injury is a growing field of personal injury litigation. The financial damages sought by victims claiming these injuries has made detecting malingering and differentiating between traumatic brain injuries, psychiatric disorders and malingering very important to treating physicians, litigants, judges, insurance companies and patients. It is opined that the high stakes and large volume has led to over-use of and over-reliance on neuro-imaging studies and neuropsychological testing. These tools, because of their ostensibly objective nature, can be reassuring to evaluating physicians, even though they can produce unreliable and often inaccurate results, in part because they fail to take into account how the plaintiff truly functions. Instead of an accurate assessment, these tests can produce a two-dimensional assessment with little to no emphasis on actual functioning and impairment. Methods: The authors, a trial lawyer and a clinical and forensic psychiatrist, compared the efficacy of relying primarily on detailed direct and collateral interviews and collaboration with the legal discovery process as opposed to relying primarily on imaging technology and psychometric tests to assess these patients. Empirical evidence was used from actual litigated cases and validated conclusions by correlating them with similar cases in the legal literature. Results: A significantly better method for distinguishing real from feigned brain injury involves a combination of (a) careful and detailed collection of data from collateral sources, (b) improving physicians’ interviewing skills to enhance detection of key data and (c) more effective collaboration by the clinical and forensic examiners with lawyers and courts. Conclusions: With appropriate training, collaboration between medical and legal personnel, diligent document review, use of collateral information sources including family members and individuals who were familiar with the plaintiff before, during and after the alleged trauma and the use of extensive and intensive interviewing, might provide pertinent information specific to the individual being tested as opposed to neuropsychological testing and neuroimaging that is standardized and pertains to groups of people, not a specific person. Otherwise stated, the ‘old time’ approach might be more specific when compared to ‘objective and standardized methods’ that are being used more frequently. This approach might also produce less expensive and more accurate results than those obtained by relying primarily or exclusively on imaging and/or psychometric testing. These case studies highlight the limitations and potential pitfalls of over-reliance on CT/PET and other neuroimaging procedures and neuropsychological testing when treating or assessing patients who may have complex causation issues or secondary gain motivations that are not taken into account when utilizing higher technology and tests that replace clinical interviews.

The most common and persistent deficits from TBI affect the highest levels of cognition, disrupting functions that allow one to attend to, hold in mind and process important information in order to achieve one’s goals. The aim of the Pathfinder Apprentice (PFA) project is to develop and test a cognitive training method that targets ‘gateway’ processes of attention regulation for persons with brain injury utilizing game-based scenarios. A series of scenarios was developed with a narrative arc, challenging attention regulation in the context of working memory demands in functional tasks of increasing complexity. The project objectives are to (1) enhance understanding of the target cognitive skills, (2) provide calibrated contexts in which to apply and practice those skills and (3) develop an individual’s ability to recognize opportunities where they may transfer cognitive skills learned during the course of training to personal life contexts. This study tested to what extent these objectives were met in a case series. Four game scenarios were developed for PC and touchscreen deployment and tested by over 90 user-testers from clinical and scholastic settings with collection of a range of quantitative and qualitative data. This software was integrated into a standardized training protocol composed of six supervised training sessions spanning 5–6 weeks, emphasizing attentional self-regulation skills, with home practice assigned between sessions. Veterans with history of brain injury (n ¼ 8) with chronic residual cognitive symptoms but a wide range of profiles completed the protocol. Data from direct observation, interviews and questionnaires were obtained over the course of the intervention. Participants completing the training protocol were able to answer direct questions relating to the cognitive skills taught in PFA by the second week of training. They were able to verbalize when and where to appropriately apply training strategies, without trainer prompting, within 4 weeks of training. While participants were able to spontaneously generate and identify situations where application of strategies would be useful throughout game, self-directed application of strategies generally increased from the 4th session onward (particularly in scenarios requiring switching between tasks and managing distractions). All participants reported applying attention regulation skills during frustrating or overwhelming life situations outside the game by the 6th and final session. The game-based tools that have been developed provide concrete, experiential illustrations of training concepts. Programmed scenarios provide trainees with opportunities to repeatedly apply strategies for goal-directed attentional selfregulation. Participants reported generalization and application of training strategies to contexts outside of the game facilitated by practice within the game. This study suggests that there is an added value of game scenarios for cognitive skills training in enhancing transfer of skill application to personal life contexts. A demonstration of the software will be provided and additional lessons learned from this project will be discussed.

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‘Working your way up’ from simple to complex situations in game-assisted training of attention regulation for individuals with brain injury Nicholas Rodriguez1, Fred Loya1, Deborah Binder1, Bruce Buchanan2, Tatjana Novakovic-Agopian3, Michelle Murphy3, Maya Bruhns1, & Anthony Chen4

Correlations between interhemispheric connectivity and executive functioning after mild/ moderate traumatic brain injury Anna-Clare Milazzo1, Keith Main1, Salil Soman1, J. Wesson Ashford1, & Maheen Adamson1 1

VA Palo Alto Health Care System, Palo Alto, CA, USA, 2Stanford University, Stanford, CA, USA

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Objective: Difficulties with executive functioning are a common complaint following mild-to-moderate traumatic brain injury (TBI), possibly because of subtle damage to the corpus callosum resulting in less efficient inter-hemispheric communication. Resting-state fMRI measures the temporal coherence of the blood oxygen level dependent (BOLD) signal across spatial regions of the brain and is an indirect measure of co-ordinated neural activity. It is hypothesized that low scores on executive functioning tests will have a strong correlation with reduced connectivity between hemispheres. Methods: Twenty-nine participants with mild-to-moderate TBI and 14 healthy controls have participated so far. A resting-state fMRI brain scan and a high resolution T1 weighted structural scan were acquired for each subject on a 3T MRI scanner. Each brain volume is divided into several previously-defined functional regions of interest (ROI) parcels and the connectivity between each ROI is calculated using Pearson correlation. Each subject also completed the Trail Making Test Part B as a measure of executive functioning. Results: This study will present the results of the correlation between a test of executive function and resting-state fMRI connectivity in a cohort of mild-to-moderate TBI patients and healthy controls. Data collection and analysis are ongoing. Conclusion: It is expected that these results may provide insight into whether inter-hemispheric connectivity is related to the persistent lingering symptom of poor executive functioning following a TBI.

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Characterization of depression in moderate–severe traumatic brain injury: Longitudinal assessment of 58 patients at 2, 5, 12 and 24 + months post-injury 1

feelings of failure, guilt, punishment, being self-critical, thoughts of suicide, frequency of crying) and interpreted as a ‘Cognitive/Affective’ Factor; the second factor, represented by nine items (increased effort to complete tasks, poorer sleep, more tired, worse appetite, sexual disinterest, indecisive, health worries, unsatisfied and unattractive) was interpreted as a ‘Somatic/Injury’ Factor. The frequency of patients with at least a moderate level of depression on the BDI was 8.6% at 2 months, 13.8% at 5 months, 15.5% at 12 months and 19.0% at 24+ months, with the mean total BDI score showing a main effect of time approaching significance (p ¼ 0.058). Conclusions: Consistent with a previous longitudinal study, this study found substantively elevated depression at long-term follow-up, although this sample showed increasing (rather than decreasing) frequency of depression over time, with an increasing proportion of patients classified as moderately depressed or greater at each successive time point. Depression in this cohort was driven by two different dimensions, the first containing higher loadings from cognitive/affective items and a somatic/injury dimension. These findings underscore the problem of depression in patients with chronic moderate–severe TBI and shed light on factors underlying this disorder.

0886

The use of environmental enrichment interventions for patients with moderate-to-severe traumatic brain injury Bhanu Sharma, Jennifer Tomaszczyk, Brenda Colella, Greg Noack, & Robin Green Toronto Rehabilitation Institute, Toronto, ON, Canada

1

Jennifer C. Tomaszczyk , Brenda Colella , Bhanu Sharma2, Cheryl Bradbury1, Bruce K. Christensen3, Diana Frasca2, Mitesh Patel2, Kate Dupuis2, & Robin Green1 1

Toronto Rehabilitation Institute, Toronto, Ontario, Canada, University of Toronto, Toronto, Ontario, Canada, 3McMaster University, Hamilton, Ontario, Canada

2

Background: Previous studies have found a high prevalence of depression after moderate–severe traumatic brain injury (TBI). However, few have followed patients across multiple time points. Moreover, it is unclear whether particular dimensions of depressive symptoms contribute differently to depression in this population. Objectives: (i) To examine differential contributions of different dimensions of depression. (ii) To characterize frequency and severity of depression over time. Methods: A total of 185 patients with moderate–severe TBI were recruited for a larger study examining the natural history of cognitive, motor, psychosocial and neural function following brain injury. Patients were administered the Beck Depression Inventory (BDI) at 2, 5, 12 and 24 (or more) months post-injury. To examine whether a parsimonious set of underlying dimensions characterized depressive symptoms in these patients, data were submitted to principle axis factoring and varimax rotation. For the 58 patients who had BDI data at all time points, changes in mean total BDI scores across the four time points were examined using a repeated measures ANOVA of (controlling for age, years of education and injury severity, as measured by lowest Glasgow coma scale score). Results: Parallel analysis suggested a two factor solution, collectively accounting for 42% of matrix variance. The first factor was represented by eight items (discouraged about future, disappointed,

Objective: There is growing evidence for the benefits of environmental enrichment for patients recovering from traumatic brain injury (TBI). Intensification studies have suggested that enrichment improves recovery and findings from this laboratory have shown that environmental enrichment may buffer against degeneration in chronic TBI. The objectives of the current studies, therefore, were to (i) examine whether increased hours of in-patient therapy improve recovery in patients with moderate–severe TBI and (ii) evaluate the feasibility of administering environmental enrichment to moderate– severe TBI patients at home on a daily basis. Methods: Study 1: Thirty-six patients with moderate–severe TBI were administered increased hours of in-patient neurorehabilitation, up to double that of standard care. Changes in total Functional Independence Measure (FIM), cognitive FIM and motor FIM were compared to those of 36 case-matched controls. Study 2: Four moderate-to-severe TBI outpatients used an online cognitive training programme (‘Brain HQ’ from Posit Science) 5 days a week for 12 weeks for 30–60 minute sessions, with exact session duration determined through a self-calibration process. Feasibility was assessed through semi-structured weekly phone interviews and through the completion of a questionnaire designed for the current study that provided information on secondary effects of cognitive training, including fatigue, dizziness, irritability, mental acuity, confidence in abilities and satisfaction. The questionnaire was completed twice a week immediately post-intervention Results: Study 1: There was significantly greater change on the FIM cognitive score in the patients who underwent intensification (p50.05) as compared to carefully matched TBI controls who underwent standard clinical care. Study 2: All four patients were able to tolerate at least 11.3 minutes of the programme per day for the duration of the study, with the mean minutes/day ¼ 33.9, range ¼ 11.3–55.8 minutes. Factors that reduced tolerance included neck pain, scheduling conflicts and external disruptions. Amongst

850 two patients, post-session mental fatigue was reported occasionally during the first week. Logistical Internet problems occurred only once. A sense of satisfaction and enjoyment was reported by all patients on multiple occasions after completion of a training session, with a few reports of minor post-session mental fatigue, which dissipated after the first week. Conclusions: Intensification during in-patient neurorehabilitation resulted in greater cognitive improvements at discharge. Postdischarge, daily environmental enrichment using an online training programme was tolerated well, up to 30 minutes/day on average. Given the clear-cut benefits for patients with TBI, the current results support the use of environmental enrichment interventions in both the acute and sub-acute stages of recovery. Online cognitive training is a cost-effective means of extending rehabilitation to TBI outpatients, allowing them to remain cognitively enriched at home.


0887

Paediatric neurorehabilitation: Post-hospital outcome comparisons Gordon Horn, Frank Lewis, Robert Russell, & Victoria Harding NeuroRestorative, Boston, MA, USA Objectives: This study addressed post-hospital neurorehabilitation outcomes in a paediatric sample. The study objectives were to: (1) determine if differences exist from admission to discharge for the paediatric sample using the Mayo Portland Adaptability Inventory-4 (MPAI-4); (2) determine if differences exist between paediatric participants in active rehabilitation vs behaviourally intense rehabilitation; and (3) provide indication of discharge disposition based on sub-group affiliation (e.g. active rehabilitation vs behaviourally intense). Methods: The sample consisted of 74 brain injured paediatrics referred to post-hospital comprehensive rehabilitation. Forty-one of those participants met criteria for inclusion in the neurobehavioural intensity (NBI) group: (1) MPAI-4 scores of moderate-to-severe on Irritability, Novel Problem-Solving, Inappropriate Social Interaction and Impaired self-awareness and (2) onset to admission of greater than 8 months. The remaining subjects (33) met criteria for the active neurorehabilitation (NR) group. The average age of injury onset was 6.9 years, but the average time from injury onset to admission to the post-hospital programme was 8.3 years. The average age in the programme was 13.60 years (ranging from 2–18 years of age). The average length of stay for the entire sample was 5.25 months. The total sample was comprised mostly of traumatic brain injury (65%). The MPAI-4 was completed within 30 days of admission and again at discharge. Scores were converted to T-scores for comparison. Results: A Repeated Measures Multivariate Analysis of Variance revealed a significant main effect for Abilities F(1,73) ¼ 5.609, p ¼ 0.0001; Adjustment F(1,73) ¼ 5.654, p ¼ 0.0001; and Participation F(1,73) ¼ 7.775, p ¼ 0.0001. More specifically, follow-up analysis revealed no group differences (NR vs NBI) on the Mayo Portland Abilities and Participation admission scores. No significant group differences were found among the Mayo Portland Abilities and Adjustment scores at discharge. Significant differences were found between the groups on Mayo Portland Participation scores at discharge F(1,73) ¼ 4.112, p50.05. At the time of discharge, the Adjustment scores were not statistically different al though the two groups differed upon admission within this index (F ¼ 11.22, p5.001). Conclusion: Participation in the comprehensive post-hospital rehabilitation programmes led to significant reduction in disability for both

Brain Inj, 2014; 28(5–6): 517–878

the Paediatric NBI and the NR groups across the three indices of the Mayo Portland outcome measure. While both groups did not differ upon admission with Abilities or Participation, both groups differed statistically with Adjustment. However, based on the intervention effect, even those with significant behavioural impairments were able to show the same Adjustment outcome at discharge as those without behavioural intensity. Eighty-one per cent of the total sample was able to successfully return home following intervention within this milieu.

0888

Repeated rotation traumatic brain injury in the rat: Behavioural and diffusion tensor imaging outcomes Matthew Budde, Alok Shah, Michael McCrea, Frank Pintar, & Brian Stemper Medical College of Wisconsin, Milwaukee, WI, USA Objective: Recent studies have suggested that repetitive mild head trauma, even exposures below the threshold for concussion, may cause chronic neurodegeneration years or decades after the insults. In this study, a rat model of mild traumatic brain injury (mTBI) caused by rapid head rotational acceleration was examined with behavioural testing and advanced neuroimaging to understand consequences of repeated, sub-concussive head trauma. Methods: Rats were anaesthetized and subjected to head rotational acceleration (200 krad s2 magnitude with 2.7-millisecond duration) using a custom rotational acceleration device. Separate cohorts of animals received a single exposure (n ¼ 15), two identical exposures separated by 48 hours (n ¼ 15) or sham exposures (n ¼ 15). In the first week post-injury, behavioural tests were conducted including the Morris Water Maze (MWM) and Elevated Plus Maze (EPM). The microand macrostructural consequences of injury were investigated by imaging the fixed brains on a 9.4T MRI using diffusion tensor imaging (DTI) and deformation-based morphology (DBM). Significant groupwise differences were identified on a voxel-by-voxel basis of spatially registered images. Histological assessments included staining for astrocytes (GFAP) and neurofilaments (SMI32). Results: Animals subjected to two exposures had more pronounced behavioural changes than those with a single exposure, including increased exploratory activity (number of arm changes) and open arm time (seconds) in the EPM compared to controls. Animals with a single exposure were not significantly different than controls. Injured animals demonstrated limited cognitive deficit with a slower rate of increase for time spent in the target quadrant through successive MWM exposures. DTI results demonstrated a significant effect of the number of head injuries, with diffuse decreases in fractional anisotropy in the cortex and hippocampus indicative of microstructural injury. Similarly, DBM demonstrated significant macrostructural changes in corresponding regions. Histologically, diffuse reactive astrogliosis was observed in white matter and the hippocampus. Conclusions: In a rodent model of sub-concussive mTBI, two exposures caused greater behavioural and neuroimaging abnormalities than a single exposure. The non-invasive and non-surgical rotational injury model may be useful to understand the consequences of highly repetitive head trauma. In particular, human studies have indicated that cumulative head trauma exposure may be related to chronic neurodegeneration. Future studies in relevant models such as the one reported here will be essential to demonstrate a causative effect.

851

DOI: 10.3109/02699052.2014.892379

0889

Pilot study: Correlation between measurement of agreement and patient satisfaction surveys Henry M. Pittman


Touchstone Neurorecovery Center, Conroe, TX, USA Objective: In this study, an attempt was made to collect a collective clinical consciousness among Cognitive Therapist, Occupational Therapist, Physical Therapist and Speech Pathologist utilizing the Awareness Questionnaire–Clinical Form (AQ-CF). Then compare measurement of agreement with patient’s discharge satisfaction survey in which a high correlation is hypothesized. Methods: At least 2 weeks post-patient’s admission, the Awareness Questionnaire–Clinical Form (AQ-CF) was completed by therapists from each discipline. The total administration consists of 25 residents at a post-acute rehabilitation facility. Measurement of agreement was compared with patients’ discharge satisfaction survey score. Results: A measurement of agreement was found to be 95% among the therapists. Results from this study show a positive correlation between a collective clinical conscious and patient satisfaction. Conclusions: A collective clinical consciousness can be defined as when many individual disciplines are able to work together or treat a patient as a whole or one. The literature suggests that, when an interdisciplinary team is able to view the same problems areas of a patient, treatment is very effective and there’s a reduction of medical cost and overall patient satisfaction. Limitations of this study are the number of participants, time frame of completion of questionnaire and groupings of therapist-related patient satisfaction.

0890

Mid-life hypometabolism in the precuneus may be associated with prior history of traumatic brain injury (TBI) Salil Soman1, Jauhtai Cheng2, Steven Chao2, Jennifer Kong2, Maheen Adamson2, J. Ashford2, & Ansgar Furst1 1

Stanford University, Stanford, CA, USA, 2Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA Objective: To investigate whether TBI severity is associated with AD like metabolic decline independent of age in a cohort of mid-life veterans. Background: There is increasing evidence suggesting that a history of TBI is increasing the risk for dementia and may fasten its onset. However, it is unclear to what extent there is a specific link between TBI and AD. Methods: A convenience sample of mid-life veterans was selected from the study centre. Diagnosis of TBI severity and post-traumatic stress disorder (PTSD) was established using Alteration of Consciousness (AOC), Loss of Consciousness (LOC), Post-traumatic amnesia (PTA) and Clinician-Administered PTSD Scale (CAPS). All

patients underwent FDG imaging within 1 week of the examination. FDG scans were spatially normalized to the MNI FDG template in SPM8 and smoothed with at 6 mm kernel. Scans were then entered into a multiple regression analysis with TBI severity as a variable of interest and age as a nuisance variable. T-maps exploring negative correlations between TBI severity and metabolic decline where initially thresholded at p50.001 (uncorrected) followed by a volume-of-interest (VOI) analysis (30 mm sphere). Results: The sample consisted of 57 veterans (seven females), mean age of 46.8 years. (median ¼ 45.1), 31 mild TBI, five moderate TBI and 43 with PTSD. Glucose metabolism decreased significantly with increasing TBI severity in the right precuneus and left angular gyrus. VOI analyses with FWE multiple comparison correction at p50.05 confirmed the robustness of the effect. Conclusions: TBI severity is associated with AD-like metabolic decline within the precuneus and angular gyrus, independent of age.

0891

Interventions for managing skeletal muscle spasticity following traumatic brain injury: A Cochrane systematic review Kate Phillips, Veronica Pitt, Denise O’Connor, Russell Gruen, Marisa Chau, & Jason Wasiak Monash University, Melbourne, Australia Background: Management of skeletal muscle spasticity following traumatic brain injury (TBI) varies from other clinical populations (e.g. stroke) due to the complexity of behavioural and cognitive issues. Although there is a range of interventions used to manage spasticity, inconsistent use of these interventions is observed in clinical practice. To date there has been no systematic review of all interventions to manage spasticity in TBI. Objective: The aim of this review is to assess the effectiveness of interventions for managing spasticity to inform clinical practice. Methods: Ten electronic databases, three clinical trial registries, DARE and reference lists of included studies were searched for randomized, quasi-randomized and cross-over trials examining any intervention to manage spasticity. There were no language restrictions. Two authors independently selected trials for inclusion, performed data extraction and assessed risk of bias. Primary outcomes were spasticity measures and adverse effects. Secondary outcomes were body functions, activities and participation, classified according to the World Health Organization International Classification of Functioning, Disability and Health. Included studies were grouped and assessed based on intervention (pharmacological or non-pharmacological or a combination) and comparison (no treatment, placebo or an alternative intervention). Outcome data were pooled from studies that were clinically and statistically homogeneous. Dichotomous outcomes were expressed as relative risk (RR) with 95% confidence intervals (CI) and continuous outcomes expressed as mean differences (MD) with 95% CIs. Where data couldn’t be pooled a narrative summary was presented. Results and conclusions: Twenty-four studies were included in the review. Interventions tested included botulinum toxin (50% of papers), splinting, casting, baclofen, oral medications and electrotherapy. Pooling was limited due to heterogeneity in a dosage of interventions and timing of outcome measurement. An overview of the findings and their implications for practice will be presented.

852

0894

Long-term psychosocial outcomes 16 years following childhood traumatic brain injury Stefanie Rosema, Frank Muscara, Vicki Anderson, Celia Godfrey, Senem Eren, & Cathy Catroppa


Murdoch Children Research Institute, Parkville, Victoria, Australia Objective: Childhood traumatic brain injury (CTBI) is one of the most common causes of morbidity and impairment, with psychosocial outcomes seeming to be the most prolonged. Much research has been done on the short-term psychosocial outcomes after CTBI; however, not much is known about these outcomes in the long-term. The aim of this study was to investigate the long-term psychosocial outcomes rated by the young adults and their significant other. Participants and methods: This prospective longitudinal study recruited from a larger ongoing study started 16 years ago. Thirtythree participants with a CTBI agreed to participate during this followup. The young adults’ and significant ratings on socialization of the Adaptive Behaviour Assessment Scale and the ASEBA Adult Self report and Adult Behaviour Checklist were compared using the Intraclass coefficient. Results: The young adults and significant other seemed to agree on communication skills, alcohol and drug use; however, they did not agree on the other sub-scales of the ASEBA. Conclusions: The finding that the young adults and significant other do not seem to agree on the social scale and the ASR/ABCL sub-scales is worrying as the young adults with problems not identified by their environment have an elevated risk of not receiving the appropriate assistance in time. Further research is necessary to investigate how these symptoms are developing over time so early intervention can prevent psychosocial difficulties.

0895

Predicted poor neurological outcome is over-estimated by the CRASH prognosis calculator in severe TBI patients after early decompressive craniectomy Daniel Charry1, Andres M. Rubiano2, Juan C. Puyana3, Nancy Carney4, & Paul D. Adelson5 1

South Colombian University, Neiva, Huila, Colombia, 2MEDITECH Foundation, Neiva, Huila, Colombia, 3University of Pittsburgh Medical Center, Pittsburgh, PA, USA, 4Oregon Health Sciences University, Portland, OR, USA, 5Barrow Neurological Institute at Phoenix Childrens Hospital, Phoenix, AZ, USA Objectives: In 2004, a prognosis calculator was developed based on the analysis of a population sample of 10 008 patients with traumatic brain injury (TBI), included in the Corticosteroid Randomization after Significant Head Injury (CRASH) clinical trial in different countries. The calculator model predicts outcomes based on some variables including country, clinical and imaging findings in the emergency room. The aim of this study was to compare the estimation of outcome in severe TBI patients that underwent early primary cranial decompression in a university hospital in Colombia.

Brain Inj, 2014; 28(5–6): 517–878

Methods: One hundred and six severe TBI patients managed by an early decompressive craniectomy approach between 2009–2013 were analysed. Outcome was evaluated using the Glasgow Outcome Scale (GOS) and dichotomized for results as good neurological outcome (GOS 4–5) or poor neurological outcome (GOS 1–3). The CRASH calculator was used in order to analyse expected outcome in the same group of patients. Results were compared and measures of frequency were obtained to identify the differences. Results: Poor neurological outcome was established in 36 (33.9%) of the patients. Identified variables associated with poor outcome were midline shift, compressed basal cisterns and non-evacuated haematoma in the first CT. Unreactive pupils at emergency room arrival were also associated. Poor neurological outcome according to the CRASH calculator was predicted in 70 (66.2%) patients in the same sample. Conclusions: The CRASH prognosis calculator over-estimates poor neurological outcome, compared with real outcome in patients with severe TBI after early decompressive craniectomy in a university hospital in Colombia. Differences in the intensity of surgical treatment since 2004 could be taken into consideration to understand differences. Prediction of outcome with the CRASH calculator need to be analysed with caution in a new context where intensity of treatment of severe TBI patients have been evolved.

0897

Presentation of a treatment protocol of occupational therapy in the rehabilitation outcomes of traumatic brain injury Tito Filippo Rastelli, Paolo Milia, & Marco Caserio Istituto Prosperius tiberino, Umbertide Perugia, Italy Objectives: To identify factors relating to the intensity of rehabilitation services received and to ascertain the relation between injury outcomes, demographics, types of therapy and the intensity of rehabilitation services provided. Design: A systematic, prospective, non-randomized study with inpatient rehabilitation data collected between 2010–2013. Participants: A total of 280 consecutively enrolled patients with a mean age ± standard deviation of 34.3 ± 15.88 years recruited from a medical centre. To be included in the study, patients must have been at least 16 years of age, have presented to the emergency department within 24 hours of injury and have received acute care and inpatient rehabilitation. Interventions: Patients received comprehensive medical care along with a combination of rehabilitative therapies, including physical, occupational, psychologic and speech therapy. Main outcome measures: Therapy intensity; levels of functional independence, cognitive function, functional gain and treatment efficiency, as indicated by the FIMä instrument; rehabilitation length of stay (LOS); and charges. Results: Age predicted the intensity of both psychologic (p50.001) and total therapy (p50.01) services. Acute care LOS was also a significant predictor of psychologic services (050.01). Only admission motor FIM was relevant in predicting speech services intensity (p50.01). Therapy intensity was predictive of motor functioning at discharge (p50.001). However, therapy intensity did not predict cognitive gain (p50.05). Conclusions: This study is among the first multi-centre efforts to examine the potential benefits of individual therapy services. Findings support assertions that increased therapy intensity, particularly physical and psychologic therapies, enhances functional outcomes.

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DOI: 10.3109/02699052.2014.892379

0899

Formation of intracerebral haemorrhage after brain parenchymal catheterization Kyu Yong Cho, Jun Seob Lim, Byung Chan Lim, Jong Hyun Mun, & Rae Seop Lee


Kwangju Christian Hospital, Gwangju Metropolitan city, Republic of Korea Objective: To investigate the incidence rate and possible risk factors for catheter-induced haemorrhage (CIH) after brain parenchymal puncture. Methods: Between January 2011 and March 2013, 381 patients (572 punctures) who underwent brain parenchymal punctures were retrospectively evaluated. All patients were checked by computerized tomography scan for the detection of haemorrhage within 48 hours of catheter insertion. CIH was defined as any evidence of new haemorrhage on the post-procedural computerized tomography (CT) scan. The incidence rate and their possible risk factors were analysed by six different surgeons and characteristics of catheter device or patients background. Results: Of 381 patients, 572 punctures were performed and the haematomas were developed in 122 puncture cases (122/572, 21.3%). The risk factors related with CIH were Glasgow Coma Scale (GCS) score (p ¼ 0.01) and prothrombin time international normalized ratio (PT INR) (p ¼ 0.038). The amount of haemorrhage was minimal without additional operations. Conclusion: Patients with low GCS and high PT INR are implicated as potential risk factors for the parenchymal haemorrhage after CIH. Careful and delicate operation technique can help reduce postoperative complications in these patients.

0900

Skull fractures and intracranial injuries among hospital-admitted skateboarders Gail Tominaga, Frank Coufal, Kathryn Schaffer, & Jess Kraus Scripps Memorial Hospital La Jolla, La Jolla, CA, USA Background and objectives: In 2012 an estimated 114 000 persons in the US were treated in an Emergency Department (ED) or admitted to a hospital for an injury related to skateboard activity. While the National Electronic Injury Surveillance System estimated only 3% of these persons required hospital admission, this data, and that of others, suggests the proportion of patients admitted with serious injury is much higher and many of these have serious brain injuries. Unfortunately, details concerning the nature, type, severity and location of the head injuries are incomplete and, hence, the objective of this study is to document the frequency, multiplicity and types of intracranial lesions (ICL) and their relationship with skull fracture. Methods: Injured skateboarders, aged 15 and older, admitted to one Level II Trauma Centre from 1 January 2009 through 30 June 2013 were identified from the Trauma Registry. Demographic, exposure, diagnostic and outcome data were collected for analysis. Initial head CT scans were reviewed for number and types of ICL and presence of skull fracture. ICL included epidural haematoma (EDH), subdural haematoma (SDH), subarachnoid haemorrhage (SAH) and

haemorrhagic contusions (HC). The occurrence of ICL was compared by skull fracture status. Results: Ninety-four head injured skateboarders who had a head CT scan performed comprised the study sample. Median age was 19 years (range ¼ 15–50 years) and 94% were males. On initial head CT scan 51 patients had at least one head-Abbreviated Injury Score (h-AIS) level 3–5 injury; 82.3% (n ¼ 42) had a skull fracture and among these there were 89 individual brain injury diagnoses including 38.2% HC, 29% SAH, 27% SDH and 5.6% EDH. The odds of an ICL was 15times greater in the presence of a skull fracture than without a skull fracture (95% CI ¼ 5.5–44.5, p550.00001). Over 71% of those with a skull fracture and an ICL had two or more separate lesions. Among the nine patients with no skull fracture and an ICL, four had multiple lesions. The probability of multiple ICLs was not related to number of distinct skull fractures. Injury Severity Score (ISS) was 11.3 in those with skull fracture only, 14.4 in those with intracranial injury without skull fracture and 18.5 in those with skull fracture with intracranial lesions. Case fatality rate was 4.3/100. Conclusions: Skull fractures are common in skateboard-related head injuries. In those with skull fractures, multiple intracranial lesions are frequent. Intracranial lesions are also observed in patients without a skull fracture, suggesting due caution in ED assessment of skateboarders who have sustained any form of blunt or rotational forces to the head. Efforts at prevention through use of head protection must be re-energized.

0901

Long-term outcome after TBI; is mild injury really mild? Rajiv Singh, Guru Prasad, & Siva Nair Sheffield Teaching Hospitals, Sheffield, UK Objectives: Mild traumatic brain injury (MTBI) is generally considered to have a good outcome, certainly better than moderate-or-severe TBI. The aim was to try to ascertain whether any demographic factors affect outcome after brain injury, with particular regard to the severity of the injury. Methods: All admissions to a head injury observation unit over 2 years at a large teaching hospital were studied. After 1 year, extended Glasgow Outcome Score was assessed and compared to injury severity and other patient factors. Severity of TBI was measured by Glasgow Coma Score in the Emergency department. Patients in the emergency department with head injury are handed over to the rehabilitation brain injury team after 24 hours for any ongoing care. This group are looked after on a Head Injury Observation Unit separate from neurosurgery or long-stay neurorehabilitation wards. This study looked at this population with predominantly MTBI, at 1 year using the Extended Glasgow Outcome Score (GOSE) and compared to various patient features. Results: In 2007–2008 there were 432 admissions to the head injury unit who stayed for 24 hours or more. At 1 year follow-up, 220 individuals were available for study, of whom 91% were white, 31% had alcohol implicated in their injury and 7% were on warfarin and had been admitted as a precaution. Mean age was 44.4 years (SD ¼ 2.3) and median length of stay was 3 days (range ¼ 0–30). MTBI made up 70 (44%) cases, moderate 66 (41%) and severe was 24 (15%). The majority of patients had a good outcome at 1 year, with 50 (31.2%) in Good upper range, 55 (34.4%) in Good lower, 44 (27.5%) in Moderate upper, seven (4.3%) in Moderate lower, four (1.9%) in Severe outcome and death combined. A logistic regression, entering the variables age, gender, home situation, alcohol excess, warfarin, severity of injury and CT scan findings found that injury severity, living alone after head injury and the CT scan findings were associated with outcome based on GOSE. While there was a trend for outcome and severity of initial injury this did not reach statistical significance,

854 suggesting that there was no association between severity of brain injury and outcome. Conclusions: Previous work suggests that MTBI has better outcome than moderate or severe injury while still carrying significant morbidity. Part of the problem with earlier studies is the dependence on the shorter version of GOS which has only five outcome categories and probably oversimplifies outcome. The Extended GOS increases the categories available to eight and may help to differentiate outcome better. To date, this study does not show a difference between severity of TBI but the sample to date is small and the authors are continuing the study with ongoing follow-up to better ascertain the relationship between severity of TBI and outcome.

0902

Agitation after traumatic brain injury; predictors of outcome Brain Inj Downloaded from informahealthcare.com by RMIT University on 09/02/14 For personal use only.

Rajiv Singh, Guru Prasad, & Siva Nair Sheffield Teaching Hospitals, Sheffield, UK Objective: Agitation is common after head injury and affects outcome adversely. However, the incidence is reported as anything between 10–96%. Furthermore, few studies have looked at clinical features associated with agitation. This study sought to measure the incidence of agitation after traumatic brain injury (TBI) and the features associated with an adverse outcome. Design: Prospective cohort study of all TBI admissions to a neurorehabilitation unit over 30 months. Methods: All TBI admissions found to have agitation were treated by standard neurobehavioural programme with or without medication. A good outcome for agitation was defined as resolution of behaviour or discharge home with minimal care requirement. Outcome was compared to patient demographic features and treatment given and any associations were sought. Outcome measure: Resolution of agitation behaviour. Results: Over 30 months, there were 53 cases of agitation out of a total of 146 TBI admissions (36.3%). In terms of resolution of behaviour or discharge to home, 27 (51%) had a good outcome. A good outcome was associated with the type of pathology on CT scan (p ¼ 0.003), severity of agitation (p ¼ 0.02) and the duration of the behaviour (p ¼ 0.01) on a logistic regression analysis. Alcohol excess and type of treatment used for the behaviour were initially significant on univariate testing but dropped out of the logistic regression model. Therefore, the independent predictors of outcome are type of pathology, severity of agitation and duration of behaviour. Conclusions: Agitation is common after TBI. It has been found that certain features are associated with agitation and this is the first study to report an association with the type of pathology found on CT scan after TBI.

0903

Validation of a novel noninvasive ICP measurement technique Ari Katila1, Rolandas Zakelis2, Laimonas Bartussis2, Arminas Ragauskas2, Riikka Takala1, Olli Tenovuo3, Lars-Owe Koskinen4, Jan Malm4, & Anders Eklund5 1

Perioperative Services, Turku University Hospital, Turku, Finland, Telematics (BioMed) Science Laboratory, Kaunas University of Technology, Kaunas, Lithuania, 3Division of Clinical Neurosciences,

2

Brain Inj, 2014; 28(5–6): 517–878

Department of Rehabilitation and Brain Trauma, Turku University Hospital and Turku University, Turku, Finland, 4Department of Clinical Neuroscience, 5Department of Radiation Sciences-Biomedical Engineering, Umea University, Umea, Sweden Objectives: To conduct a prospective validation study (accuracy, precision, sensitivity, specificity) on patients with invasive ‘golden standard’ intracerebral pressure (ICP) sensors and simultaneously measuring non-invasive ICP based on ophthalmic artery blood flow parameters in the intracranial and extracranial segments of the artery with multi-depth transcranial Doppler measurements. Methods: The study population consisted of 110 primarily nonselected adult patients with severe brain injury or neurological disease (subarachnoid haemorrhage or intracranial haematoma) treated in the ICU and monitored with need for intracranial pressure measurement. Studies were performed in University Hospitals in Turku (Finland), Kaunas (Lithuania) and Umea˚ (Sweden) between December 2011 and June 2013. Patients in Turku were part of the EU granted 7th Framework Project TBICare study. The technique of this novel nICP has previously been described in the literature. Results: One hundred and ten patients, 171 independent paired measurement points from comparative non-invasive and invasive simultaneous ICP measurement studies. Bland and Altman plot of 171 paired non-invasive and invasive ICP data points shows that mean systematic error (accuracy) of non-invasive absolute ICP value measurement is equal to 0.03 mmHg (CL ¼ 0.965) and standard deviation of the random error (precision) SD ¼ 2.65 mmHg (CL ¼ 0.965). Area under curve AUC ¼ 0.94 (CL ¼ 95%, CI ¼ 0.89– 0.97). Sensitivity 73.7% (CL ¼ 95%, CI ¼ 51.2–88.2%) and specificity 94.7% (CL ¼ 95%, CI ¼ 90.0–97.3%) at the cut-off point which is equal to critical ICP threshold for TBI patients (ICP ¼ 20 mmHg). Conclusions: Negligible mean systematic error (0.03 mmHg) is statistically significant evidence that non-invasive absolute ICP value measurement technology does not need a patient-specific calibration. SD of data points obtained using parenchymal ICP transducers is a little bit bigger comparing with SD of data points obtained using ‘golden standard’ intraventricular ICP sensors or ‘golden standard’ ICP measurements via lumbar puncture.

0904

Post-discharge care of paediatric traumatic brain injury patients in Argentina: A randomized trial Nancy Carney1, Gustavo Petroni2, Silvia Lujan2, Nico Ballarini2, Hugo du Coudray1, & Gabriella Faguaga2 1

Oregon Health & Science University, Portland, OR, USA, 2University of Rosario, Rosario, Argentina

Objectives: The purpose of this project was to develop, in partnership with families of children with TBI, a post-discharge intervention provided by the family that is simple and sustainable and to introduce the intervention in a randomized controlled trial in Argentina. It is hypothesized that children with moderate-to-severe TBI who receive the family-provided intervention will have significantly better functional outcomes at 6-months post-discharge than those who receive standard care. Methods: This is a randomized controlled trial with blinded evaluation of outcomes. The setting includes seven Level 1 paediatric trauma centres in Argentina. All centres have intracranial pressure (ICP) monitoring as standard of care and follow the Guidelines for the Acute Medical Management of Severe Traumatic Brain Injury in Infants, Children, and Adolescents. Outcome measures taken at 3- and 6months post-injury include the Paediatric Cerebral Performance

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Category scale (PCPC), the Paediatric Overall Performance Category scale (POPC), selected modules of the Paediatric Quality-of-Life Inventory (PedsQL) and the Bob Brown Scale (BBS). Standard care group: Post-discharge standard care varies according to the family’s resources and abilities and the available state health services. All patients randomized to either the Intervention Group or the Standard Care Group receive standard care. Intervention group: A specially trained Community Resource Coordinator (CRC) is assigned to each family in the Intervention group before discharge from the hospital. The CRC directs the intervention, which consists of pre- and postdischarge meetings and the provision of a Family Resource Manual, with a focus on fidelity to primary care physician instructions and appointments. Results: The enrolment target has been met. There are 308 patients included in the study. Sixty-one per cent are male, with 65% being age 8 years or younger. About 30% had ambulance transport to the hospital. Thirty-five per cent had severe TBI, 21% moderate TBI and 44% complicated mild TBI. The majority of patients were injured in a motor vehicle accident. Investigators remain blinded to the study results pending completion of follow-up. The data analysis and results will be completed in January 2014 and will be presented with this abstract at the Congress. Conclusions: This study represents the first conducted in Latin America that documents the complete course of treatment for paediatric patients with TBI spanning hospital transport through hospital care and into the post-discharge setting. It is also the first to introduce, in a randomized trial, an intervention for post-discharge care in lowresource environments. The results will provide information about the epidemiology of paediatric TBI necessary to influence public policy and prevention efforts and about the influence of a simple familysupport intervention on outcomes for children with TBI.

0905

Examining the association between injury severity and neuropsychological and behavioural functioning in selfreported mild head injury Stefon van Noordt, Angela Dzyundzyak, Julie Baker, Katie Chiappetta, Tony Debono, & Dawn Good Brock University, St. Catharines, Ontario, Canada Objectives: This study examined differences in measures of neuropsychological functioning, personality and behaviour as a function of self-reported history of mild head injury (MHI). Specifically, it inspected differences across these measures in terms of nominal indices of self-reported injury severity. Methods: Across three independent samples, university students (Study 1, n ¼ 90; Study 2, n ¼ 44; Study 3, n ¼ 85) completed selfreport measures of behavioural outcomes (e.g. impulsivity) and personality (e.g. psychopathy), as well as performance-based measures of decision-making and cognitive control. Individuals provided demographic information regarding history of head trauma; injury severity was characterized by several factors including loss of consciousness, concussion, multiple injury events and other nominal factors such as symptom duration, secondary orthopaedic injuries and need for medical attention. Results: A consistent pattern emerged indicating a graded relationship between injury severity and behavioural risk-taking, such that nominal reports of greater injury severity are associated with poorer outcomes. Individuals reporting a history of MHI with concussion scored higher on indices of psychopathy as compared to individuals reporting a history of MHI without concussion, who also scored higher than the non-MHI cohort. This pattern was replicated when the

groups were categorized on the basis of frequency of head trauma. Those with two or more MHIs scored higher than individuals having sustained a single MHI, with the non-MHI controls scoring the lowest. Similarly, a separate study found that individuals reporting a MHI with loss of consciousness were faster at making moral judgements compared to those with a loss of consciousness, who were in turn faster than non-MHI subjects. These differences in decision-making were most pronounced for moral dilemmas that were emotionally charged and personal in nature. This sample also found that selfreported injury severity was negatively correlated with adaptive decision-making performance on the Iowa Gambling Task. Finally, this study manipulated arousal state in a third sample and found that, contrary to effects in non-MHI controls, individuals with a history of MHI exhibited better cognitive control when exposed to a relaxation condition compared to stress condition. Conclusions: The functional consequences of mild head injury in university students are subtle and manifest heterogeneously across individuals. Nevertheless, understanding about the subtlety of functional limitations can be enhanced by considering the associations between injury severity and performance across behavioural, personality and neuropsychological domains. This approach may be particularly useful in characterizing differences between intellectual competence and successful psychosocial behaviours and highlights the continuum of head trauma.

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Traditional medicine combined with non-traditional healing methods can alter the Glasgow coma scale results Pattie Hall N/A, To Be Determined, USA The Glasgow Coma Scale provides a score in the range 3–15; patients with scores of 3–8 are usually said to be in a coma. Coma is defined as no eye opening, no ability to follow commands and no word verbalizations. A 19 year-old male suffered a severe head injury when his motorcycle crashed into an oncoming pickup truck. He was not wearing a helmet and landed on the right side of his head. The patient was intubated with a GCS of 3–4 upon admission. CT scan of head showed large acute subdural haematoma, right frontal contusion with midline shift to the left. He underwent emergency right frontal craniotomy and evacuation of the subdural haematoma. The patient had a prolonged (19 day) course in the ICU where he was sedated and paralysed. While the doctors fought to save the patient’s life using traditional medicine, his mother used non-traditional healing modalities—Reike and Healing Touch, along with prayer and Lourdes holy water. The patient continued to progress on the neurologic exam and CT scan continued to improve. Six weeks after admittance to the hospital the patient was discharged to rehabilitation after undergoing a cranioplasty to fix the skull defect from the emergency craniotomy. The patient went on and completed college, got a full-time job, bought a home, married and will soon be a father. Miracle? To quote Dr Byron Bailey, the patient’s neurosurgeon, ‘He had so much pressure inside his head that most patients we can’t control it well enough to keep them able to recover. Once you get on that end of the curve, the pressure builds up, you start losing the ability to get beyond the pressure and the brain tissue starts dying. And for whatever reason he got to that edge, but never went over the edge. Certainly the odds were against him significantly and none of us had a good feeling this was going to work out. He did remarkably well’. This case illustrates that when you combine science with nontraditional healing methods and prayer, miracles can happen.

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Combined maxillofacial and skullbase fractures during sports activity Nikolaos Syrmos1, Efstratia Syrmou2, Argyrios Mylonas3, Georgios Gavridakis4, Georgios Mastorakis5, John Logothetis5, Vasileios Valadakis1, Kostantinos Grigoriou1, Vaitsa Giannouli6, Foteini Chatzinasiou7, Vasileios Moraitis1, Dimitrios Arvanitakis1, & Charalampos Iliadis1


1

Neurosurgery Department, Venizeleio General Hospital, Heraklion, Crete, Greece, 2School of Sports Science, 3Department of Anatomy, School of Sports Science, Aristotle University of Thessaloniki, Macedonia, Greece, 4Ct-scan Department, 5Maxillo-Facial Department, Venizeleio General Hospital, Heraklion, Crete, Greece, 6 Medical School, Aristotle University of Thessaloniki, Macedonia, Greece, 7Medical School, Athens University, Athens, Greece Aim: The aim of this study was to review cases of combined maxillofacial and skull-base fractures during sports activity. Materials and methods: During a 10-year period (2001–2010), 14 individuals with combined maxillofacial and skull-base fractures during sports activity were admitted to the hospital. Thirteen amateur athletes (92.8%) and one professional (football player) (7.2%), 11 males (78.45%) and three females (21.5%), mean age 28.5 years, range from 17–37 years. The fractures resulted mainly from falls during sea-related sports and motor-cycling activity (seven cases, 50%), ball sports (four cases, 28.5%) and contact sports activity (three cases, 21.5%). Results: Emergency CT-scan and 3D craniofacial reconstruction was performed in all 14 cases (100%). Surgery was required in two cases of zygomatic fractures and in one case of skull-base fracture associated with epidural haematoma of the posterior fossa (a 25-year old young lady after a severe motor-cycling road traffic accident). The commonest associated initial diagnosis was brain concussion in 12 cases (85.7%). Other injuries (leg and arm) were presented in five cases (35.7%). Conclusions: Accurate initial support and primary health aid care for combined maxillofacial and skull base injury patients appears to be necessary. Safety international standards are needed in order to prevent these types of injuries.

Brain Inj, 2014; 28(5–6): 517–878

during sports activity were admitted to the hospital. Fifteen amateur athletes and one professional (basket-ball player), 15 males and one female, mean age 30 years, range from 20–40 years. The injuries resulted mainly from falls during sea-related sports and motor-cycling activity, ball sports and contact sports activity. Results: Emergency CT-scan was performed in all 16 cases (100%) Surgery was required in three cases of severe cervical spine fractures. Other injuries (leg and arm) were presented in eight cases (50%). Conclusions: Accurate initial support and primary health aid care for combined cervical spine and skull base injury patients appears to be necessary. Safety international standards are needed in order to prevent these types of injuries.

0911

Combined brain and spine injuries during sports activity Nikolaos Syrmos1, Argyrios Mylonas2, Charalampos Iliadis1, Georgios Gavridakis3, Vasileios Valadakis1, Kostantinos Grigoriou1, & Dimitrios Arvanitakis1 1

Neurosurgery Department, Venizeleio General Hospital, Heraklion, Crete, Greece, 2Department of Anatomy, School of Sports Science, Aristotle University of Thessaloniki, Macedonia, Greece, 3 Ct-scan Department, Venizeleio General Hospital, Heraklion, Crete, Greece Aim: The aim of this study was to review cases of combined brain and spine injury during sports activity. Materials and methods: During a 6-year period (2004–2010), 36 individuals with combined brain and spine injuries during sports activity were admitted to the hospital. Thirty-two amateur athletes and four professional, 26 males and 10 females, mean age 26.5 years, range from 16–46 years. The injuries resulted mainly from falls during sea-related sports, motor-cycling activity, ball sports and contact sports activity. Results: Emergency CT-scan was performed in all 36 cases (100%). Surgery was required in three cases of severe brain injuries. Other injuries (leg and arm) were presented in 12 cases. Conclusions: Accurate initial support and primary health aid care for patients appears to be necessary for patients with combined brain and spine injuries. Safety international standards are needed in order to prevent these types of injuries.

0910

0912

Combined cervical spine and skull-base fractures during sports activity

Mild traumatic brain injuries during sports activity. Facing the problem in rural health

Nikolaos Syrmos1, Argyrios Mylonas2, Charalampos Iliadis1, Georgios Gavridakis3, Vasileios Valadakis1, Kostantinos Grigoriou1, & Dimitrios Arvanitakis1

Nikolaos Syrmos1, Argyrios Mylonas2, Andreas Televantos1, & Nikolaos Kapoutzis1 1

1

Neurosurgery Department, Venizeleio General Hospital, Heraklion, Crete, Greece, 2Department of Anatomy, School of Sports Science, Aristotle University of Thessaloniki, Macedonia, Greece, 3Ct-scan Department, Venizeleio General Hospital, Heraklion, Crete, Greece Aim: The aim of this study was to review cases of combined cervical spine and skull-base fractures during sports activity. Materials and methods: During a 11-year period (2001–2011), 16 individuals with combined cervical spine and skull-base fractures

Surgery Department, Goumenissa General Hospital, Goumenissa, Kilkis-Macedonia, Greece, 2Department of Anatomy, School of Sports Science, Aristotle University of Thessaloniki, Macedonia, Greece Aim: The aim of this study was to review cases of mild brain injuries during sports activity. Materials and methods: During a 6-year period (2004–2010), 56 individuals with mild traumatic brain injuries during sports activity were admitted to the hospital. Fifty-four amateur athletes and two professional, 36 males and 20 females, mean age 26.5 years, range

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DOI: 10.3109/02699052.2014.892379

from 16–46 years. The injuries resulted mainly from falls, motorcycling activity, ball sports and contact sports activity. Results: Neurological examination and radiological evaluation was performed in all 56 cases (100%). Further investigation and transportation was required in six cases. Other injuries (leg and arm) were presented in 12 cases. Conclusions: Accurate initial support and primary health aid care for patients appears to be necessary for patients with traumatic brain injuries during sports activity. Safety international standards are needed in order to prevent these types of injuries.

0913

Resolution and treatment of traumatic brain and spine injuries in primary health care unit


Nikolaos Syrmos, Andreas Televantos, & Nikolaos Kapoutzis Surgery Department, Goumenissa General Hospital, Goumenissa, Kilkis-Macedonia, Greece Introduction: Traumatic brain and spine injuries are a major public health problem worldwide. Aim: This study presents, initially, the resolution and the treatment of these injuries in a primary healthcare unit, in Central Macedonia Region and then various demographic features are analysed. Method: This study included 200 patients, 140 men (70%) and 60 women (30%). One hundred and twenty-eight (64%) of them suffering from traumatic brain injuries, 48 (24%) from spine injuries and 24 (12%) from both traumatic brain and spine injuries. The duration of the study was 24 months and the range of age was from 14–82 years. Results: The most common causes of injury were occupational injuries, road traffic accidents and injuries occurring at home, which caused mainly in male patients during spring and summer. Well-organized and efficient primary healthcare can help to maintain a good level of health for the rural Greek people.

0914

Predictors of very long-term socio-cognitive function and its relationship to social communication and externalizing behaviours in young adult survivors of paediatric TBI Nicholas Ryan1, Vicki Anderson1,2, Cathy Catroppa1, & Celia Godfrey1 1

Australian Centre for Child Neuropsychological Studies, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia, 2 Melbourne School of Psychological Sciences, The University of Melbourne, Melbourne, Victoria, Australia Background: Childhood TBI is a common cause of childhood disability and is associated with elevated risk for social impairment. Although preliminary evidence indicates that children with TBI demonstrate impairments in recognizing and interpreting emotions from nonverbal cues, long-term socio-cognitive outcomes remain poorly understood. Furthermore, few studies have examined the contribution of social cognitive impairments to communication and socioemotional adjustment outcomes as children with TBI make the transition to young adulthood. Aims and method: In a sample of 34 young adult survivors of paediatric traumatic brain injury (M age ¼ 20.62; injury age ¼ 1–7 years; M time since injury ¼ 16.55 years) and 16 age- and gendermatched healthy controls (M age ¼ 20.56), the present study aimed to investigate predictors of emotion perception and its relationship to social communication and externalizing behaviours rated by closeother proxies Results: Young adults with severe TBI exhibited significantly poorer emotion perception than healthy controls and peers with mild-tomoderate injuries. Further, poorer emotion perception was linked to reduced integrity of the posterior corpus callosum, lower family socioeconomic status (SES) and a less intimate family environment. Compared to controls the TBI group had significantly greater social communication difficulty, which was associated with more frequent externalizing behaviours and poorer emotion perception. Analyses demonstrated that reduced social communication mediated the relationship between poorer emotion perception and more frequent externalizing behaviours. Conclusions: The findings indicate that socio-cognitive impairments may indirectly increase the risk for externalizing behaviours among young adult survivors of childhood TBI and underscore the need for targeted social skills interventions delivered soon after injury and into the very long-term.

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Brain Inj, 2014; 28(5–6): 517–878


Index Aaro Jonsson, Catherine 0104, 0275 Aaronson, Justine 0085 Aas, Eline 0266 Abara, Uko 0803 Abbasi, Ammar 0468 Abbasi Fard, Salman 0271 Abdulrahman, Husham 0073, 0357 Abo, Masahiro 0134, 0204, 0296, 0722 Abrams, Gary 0807 Abuelsaad, Abdelaziz S. A. 0017 Accetta, Natascia 0439 Achim, Ame´lie M. 0478, 0503 Acker, Christopher 0849 Acosta, Sandra 0635 Adamson, Maheen 0276, 0367, 0480, 0833, 0884, 0890 Adeleke, Nurudeen Abiola 0278 Adelson, David 0146, 0148, 0895 Adeolu, A. A. 0726, 0732 Adeolu, J. O. 0732 Ader, Tiina 0569 Adeyemi, Moshood Folorunsho 0278 Adigun, T. A. 0732 Adnan, Johari Siregar 0558 Aegerter, Philippe 0238, 0240, 0287 af Geijerstam, Jean-Luc 0810 Agnihotri, Sabrina 0365 Agost Carrenõ, Cecilia 0554 Agrawal, Deepak 0092, 0532 Ahmadi, Naser 0621 Ahmed, Shameem 0411 Ahn, So Yeon 0322 Ahonniska-Assa, Jaana 0800 Ainslie, Philip 0605, 0744 Al Hraibat, Abdulaziz 0130 Alalade, Andrew 0715 Alaranta, Hannu 0288 Ala-Seppa¨la¨, Henna 0702, 0708 Alcan˜iz, Mariano 0456 Aleksijevic, Darina 0250 Alexander, David 0802 Alexandrescu, Roxana 0488 Alexandrova, Evgenia 0389, 0544, 0760 Alexandrovitch, Alexander 0476 Aligholi, Hadi 0289 Allaire, Anne-Sophie 0692 Allanson, Judith 0863 Allen, Andrew 0113 Allen, Elena 0470 Alonso, Andres Server 0247 Alsulaimani, Adnan Amin 0017 Al-Thani, Hassan 0073, 0357 Alturki, Abdulrahman Yaqub 0003 Amador, Ricardo R. 0667 Amador, Ricardo 0078, 0313 Amani, Reza 0642 Ameis, Arthur 0348 Amick, Melissa 0673 Amico, Enrico 0740 Aminmansour, Bahram 0271 Amiri, Fatemehsadat 0642 Amoros, Desiree 0479 Amuan, Megan 0498, 0500, 0862 Andelic, Nada 0154, 0170, 0214, 0218, 0234, 0236, 0247, 0266, 0431, 0519, 0590 Anderson, Jennifer 0511

Anderson, Vicki 0010, 0104, 0107, 0239, 0273, 0428, 0630, 0660, 0894, 0914 Anderson, William 0685 Andersson, Stein 0248, 0317, 0590 Andersson, Ulrike 0245 Andre´ll, Paulin 0164 Andre´-Obadia, Nathalie 0406 Ang, Wei Tech 0150 Angerova, Yvona 0391, 0442, 0445 Ani, Billy 0616 Anke, Audny 0170, 0431, 0519 Annibali, Joseph 0457 Ansley, Barbara 0477 Anstey, Kelley 0307 Antepohl, Wolfram 0640 Antunes, Fabiane 0461 Aperi, Brandy 0795 Arango Lasprilla, Juan Carlos 0854 Arango-Lasprilla, Juan 0139 Arango-Lasprilla, Juan C. 0214 Arango-Lasprilla, Juan Carlos 0090, 0106, 0138, 0147, 0184, 0186, 0395, 0815, 0847 Arbour, Caroline 0338, 0603 Arciniegas, David 0493, 0713, 0723 Arcuri, Francesco 0051, 0052, 0463 Armin, Puchstein 0765 Arnarson, Eirikur 0102, 0103 Arnkelsson, Gudmundur 0102, 0103 Arnold, Fiona 0572 Arnold, Todd 0402, 0604 Arvanitakis, Dimitrios 0909, 0910, 0911 Arvidsson, Daniel 0237 Asaba, Eric 0436 Asano, Yoshitaka 0084, 0235 Asemota, Anthony 0601 Asghar, Aziz 0176, 0177 Ashford, J. 0890 Ashford, J. Wesson 0833, 0884 Ashford, John 0276 Ashford, John Wesson 0480 Ashford, Wes 0367 Ashman, Teresa 0345 Asiedu, Nana 0409 Asim, Mohammad 0073 Asmussen, Sarah 0076, 0077, 0078, 0313, 0319, 0667 Assmus, Jo¨rg 0192 Astolfi, Laura 0440 Atkins, Joseph 0417, 0418 Au, Rhoda 0645 Avery-Cooper, Connor 0426 Ayala, Sarah 0806 Azadbakhsh, Mahdis 0365 Azerad, Sylvie 0238, 0240, 0287 Azicnuda, Eva 0439 Azli, Saiful 0623 Azouvi, Philippe 0238, 0240, 0287 Babbage, Duncan 0224 Babcock-Parziale, Judi 0509 Babl, Franz 0239, 0428, 0660 Babul, Aliya-Nur 0124, 0190 Bachalli Subbarao, Premalatha 0284 Bachmeier, Corbin 0849 Backhaus, Samantha 0223, 0225 Bacopulos, Aggie 0435 Badsha, Mohamed 0522, 0524 Baguley, Ian 0379, 0380

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DOI: 10.3109/02699052.2014.892379

Bahraini, Nazanin 0595 Bailey, Cynthia 0308, 0316 Bailey, Jessica 0402, 0604 Bailey, Mark 0350 Bailey, Zachary 0672 Bailie, Jason 0076, 0077, 0078, 0313, 0319, 0667 Bakas, Tamilyn 0113 Baker, Andrew 0502, 0603, 0747 Baker, David 0793 Baker, Julie 0750, 0905 Baker, Stephanie 0465 Bakhet, Mona 0130 Bakker, Kathleen 0630, 0633 Balaban, Carey 0474 Baldovı´-Felici, Amparo 0449 Balish, Marshall 0791 Ball, Alex 0384 Ballarini, Nico 0904 Balmaseda, Raquel 0479 Bamdad, Michael J. 0173 Band, Guido 0209 Bangirana, Paul 0167, 0171 Banks, Sarah 0620, 0748 Banta, Melissa 0526 Banville, Fre´de´ric 0306 Bar, Orly 0875 Bar, Yael 0423 Baratz-Goldstein, Renana 0068 Barber, Anita 0351 Barber, Jason 0704 Barden, Hannah 0379 Bar-Hen, Moran 0156 Bark, John S. 0653 Barker, Melinda 0633 Barlow, Karen Maria 0861, 0872 Barlow, Karen 0751, 0842 Barnhart, Bruce 0146, 0148 Barrett, Ryan S. 0757 Barrie, Sarah 0096 Bartfai, Aniko 0242 Bartolome´, Maria Victoria 0735, 0768 Bartussis, Laimonas 0903 Basciani, Mario 0712 Bateman, Andrew 0863 Battle, Mark 0293 Baugh, Christine M. 0683, 0874 Baugh, Christine 0645, 0738 Bausela Herreras, Esperanza 0160 Bautz-Holter, Erik 0192, 0266 Baxter, David 0709 Bay, Esther 0475 Bayen, Eleonore 0238, 0240, 0287 Bayley, Mark Bayley 0501 Bayley, Mark 0692, 0710, 0763 Bayley, Peter 0276, 0367, 0480 Beare, Richard 0660 Beaton, Dorcas 0423 Beattie, Aaron 0345, 0499 Beauchamp, Miriam H. 0478, 0589, 0656, 0816 Beauchamp, Miriam 0660, 0797 Beaudoin, Cindy 0589, 0656, 0797, 0816 Beaudoin, Judy 0616 Beaulieu, Cynthia 0746 Beaulieu-Bonneau, Simon 0447, 0510, 0665 Becker, Frank 0541, 0590 Becker, Marion 0110 Beckwith, Jonathan 0346, 0785 Be´dard, Michel 0794 Bedell, Gary 0478, 0503 Bekinschtein, Tristan 0053 Bell, Jeneita 0481, 0507, 0512

Bell, Kathleen 0704, 0756 Bellamkonda, Erica 0843 Bellavance, Alice 0424 Bellerose, Jenny 0589, 0656, 0816 Bellon, Kimberly 0373, 0374, 0375, 0378 Belmonte, Felipe 0114 Ben Romdhane, Manel 0330 Bender, Mark 0132 Benford, Brandi 0079 Beninato, Marianne 0786 Bennett, Sheila 0832 Berg, Katherine 0853 Berger, Monique A. M. 0099 Berger, Monique 0135, 0203, 0208, 0209, 0265 Bergeron, Valerie 0041 Berget, Anne Mette 0569 Bergman, Pernilla 0659 Bergquist, Thomas 0813, 0837, 0868 Bergstro¨m, Aileen 0436 Berkner, Paul 0417, 0418 Bernard, Francis 0364, 0388, 0390, 0533, 0881 Bernick, Charles 0620, 0748 Bernier, Annie 0589, 0656, 0797, 0816 Berntsen, Svein A. 0218 Berrigan, Lindsay 0763 Berthold-Lindstedt, Ma¨rta 0315 Bertrand, Justine 0658 Bessou, Helene 0050 Best, Nicholas 0650 Bezzina, Clive 0384 Bhalerao, Shree 0015, 0034, 0505 Bhargava, Deepti 0715 Bhaskar, S. 0059 Bhaumik, Dulal 0517 Bianchi, Luigi 0440 Bibb, James 0016 Bibb, James A. 0016 Biegon, Anat 0476 Biester, Rosette 0219 Bigby, Christine 0599 Bigler, Erin 0401 Bill, Alan 0196 Bin, Yang 0282 Binder, Deborah 0807, 0879, 0883 Birkett, Leslie 0088 Bishop, Scott 0744 Biston, Patrick 0472 Bivona, Umberto 0439 Bjo¨rkdahl, Ann 0582 Bjorkdahl, Ann 0583 Bjorndalen, Harald 0539 Bjuhr, Helena 0165 Blackman, Marc 0791 Blais, He´le`ne 0388, 0390 Blake, Tracy 0835 Blanchette, Andreanne 0191 Blasco, Sonia 0758, 0839 Block, Stephen 0511 Blomgren, Klas 0237 Blum, Charles 0404, 0405 Bobrow, Bentley 0146, 0148 Bodell, Lisa 0842 Bodhit, Aakash 0801, 0806, 0808, 0812, 0830, 0840 Bodlak, Igor 0442 Boes, Adilson 0728 Bogner, Jennifer 0731, 0868 Bohanna, India 0066 Bohorquez Montoya, Luisa Fernanda 0847 Bohuncak, Adam 0442 Boivin, Michael 0167, 0171, 0412 Bok, Chek Wai 0282


860 Bokde, Arun 0857 Bola, Michal 0666, 0668 Bolander, Richard 0346 Bolanger, Richard 0785 Bolden, Ashley 0140 Boly, Melanie 0049 Bombardier, Charles 0868 Bonds, Brandon 0506 Bonistall, Kristen 0451 Boon Seng, Liew 0558 Boon, Mebeline 0362 Bor, Hans 0255, 0559 Borg, Jorgen 0333, 0337, 0573, 0575, 0810 Borg, Jørgen 0154 Borg, Jo¨rgen 0587, 0803 Bori de Fortuny, Inma 0537 Borich, Michael 0124 Borlongan, Cesar 0635 Borras, Isabel 0671 Bortelova, Jana 0445 Bosma, Liesbeth 0584 Botome Nicol, Josi Mara 0728 Bottari, Carolina 0696 Boucher, Normand 0478, 0503 Bouix, Sylvain 0143, 0352, 0419 Bourgault, Patricia 0338 Bourgouin, Annie 0306 Bourlas, Alexandra 0645 Boyd, Lara 0124, 0751 Boyer, Cynthia 0197 Boylan, Anne-Marie 0820, 0825 Boyle, Eleanor 0333, 0348, 0574, 0575, 0578 Bradbury, Cheryl 0852, 0885 Braga, Lucia 0042 Bragin, Denis E. 0629 Bragina, Olga 0629 Branch, Craig 0143 Brander, Antti 0072, 0283 Brands, Ingrid 0393 Brause, Maarja 0312 Brayet, Pauline 0881 Breaud, Alan 0645 Brenner, Lisa 0434, 0593, 0595 Brezner, Amichai 0790, 0800, 0875 Brickell, Tracey 0076, 0077, 0078, 0313, 0319 Brickell, Tracey A 0667 Bridge, Helen 0215 Bristow, Melanie 0302 Brockway, Jo Ann 0756 Broeren, Jurgen 0237 Broga˚rdh, Christina 0245, 0335 Bronars, Carrie 0813 Brooks, Brian 0872 Brooks, Jordan 0484, 0545 Brooks, Neil 0302 Bro¨sel, Doreen 0670 Brown, Allen 0813, 0837, 0843 Brown, Margaret 0459 Brown, Richard G. 0444 Brownson, Claire 0223 Brubacher, Jeffrey 0419 Bruhns, Maya 0883 Brum, Christine 0477, 0610 Brunette, Ve´ronique 0364 Brunner, Iris Charlotte 0569 Bruno, Marie-Aure´lie 0716, 0740 Bruusgaard, Kari-Anette 0383 Bryczkowski, Sarah 0877 Buchanan, Bruce 0879, 0883 Budde, Matthew 0752, 0795, 0888 Buettner-Teleaga, Antje 0705

Brain Inj, 2014; 28(5–6): 517–878

Bui, Kevin 0858, 0866 Bunc, Gorazd 0263 Bundock, Kerrie 0863 Buonocore, Giuseppe 0826 Burgess, Cris 0466 Burnett, Tanis 0744 Burress, Catherine 0144 Bush, Erin 0527, 0531 Bushnik, Tamara 0374, 0375, 0473, 0499 Butingan, Nina 0528 Butman, John 0798 Butts, Alissa 0813 Buxo´-Masip, Xavier 0537 Byler, John C. 0846 Byom, Lindsey 0083 Cai, Phoebe 0352 Calderon Chaguala´, Jose´ Amilkar 0815 Caltagirone, Carlo 0439 Cam, Bruce 0866 Camarillo, David 0858, 0866 Cameron, Anita 0424 Camino, Julieta 0062 Campbell, Damien 0676, 0684 Campbell, Justin 0782 Campbell, Kimberly 0604 Campbell, Natalie 0381, 0382 Cancelliere, Carol 0333, 0337, 0573, 0574, 0575, 0578, 0587, 0779, 0803, 0810 Candelieri, Antonio 0052 Cantu, Robert 0645, 0738 Cao, Jie 0022, 0024 Cao, Ning 0586 Cappa, Paolo 0711 Caracuel, Alfonso 0138, 0139, 0186 Cardoos, Amber 0868 Cardoso, Struan 0307 Carey, Avril 0285 Carlesimo, Giovanni Augusto 0439 Carlin, Gerald 0807 Carlson, Kathleen 0836 Carne, William 0420 Carney, Nancy 0895, 0904 Carpenter, Keri 0708 Carroll, Linda 0333, 0337, 0573, 0578, 0779, 0803 Carroll, Linda J. 0587 Carvalho, Janessa 0576 Carver, Alissa 0323, 0324 Casado-Flores, Juan 0122 Casco, Fernando 0122 Caserio, Marco 0897 Casey, Sarah 0422, 0652 Casey, Scott 0714 Cassedy, Amy 0429, 0579, 0591 Cassell, Andre 0586 Cassidy, David 0348, 0350 Cassidy, David J. 0343, 0344 Cassidy, J. David 0333, 0337, 0573, 0574, 0575, 0578, 0587, 0779, 0803, 0810 Castanõ, Ana M. 0547 Castanõ-Leon, Ana M. 0538 Castejoń, Orlando 0413 Castelli, Enrico 0711, 0841 Castillo, Kathleen 0378 Castle, Wendy 0107 Castro, Maı¨te´ 0330, 0406 Cataldo, Nicolas 0553 Catani, Sheila 0469 Catano, Antonio 0472 Catherall, Juliette 0066 Catroppa, Cathy 0010, 0104, 0107, 0273, 0428, 0630, 0660, 0851, 0894, 0914


DOI: 10.3109/02699052.2014.892379

Catsman, Coriene 0265 Cattran, Charlotte 0183 Cavanagh, Jonathan 0743 Cechetti, Fernanda 0461 Cederberg, David 0286 Cepeda, Santiago 0547 Chacoń Peralta, Helmer 0815 Chai, Sze Ling 0130 Chambers, R. Andrew 0509, 0521 Champoux, Marie-Claude 0003, 0038, 0039 Chan, Leighton 0767, 0771, 0777, 0798 Chan, Roxanne 0475 Chan, Vincy 0674, 0675, 0677, 0678, 0679, 0680, 0681, 0682, 0687 Chandramouli, B. A. 0149 Chang, Eric 0528 Chang, Jae Hyeok 0327, 0328 Chang, Shin-Tsu 0585 Chang, Vicky 0597, 0598 Chantraine, Fre´de´ric 0168 Chao, Steven 0890 Chapman, Julie 0791 Chapman, Sandra 0401 Charry, Daniel 0895 Chaskis, Cristo 0472 Chatelle, Camille 0472 Chatzinasiou, Foteini 0909 Chau, Marisa 0891 Chaurasia, Ishwar Dayal 0311 Cha´vez, Clara Luz 0851 Chelyapina, Marina V. 0487 Chen, Amy 0674 Chen, Anthony 0807, 0883 Chen, Anthony J.-W. 0879 Chen, Hehong 0047 Chen, Jen-Kai 0262 Chen, Wan-Lin 0662 Chenchen, Guo 0048 Cheng, Jauhtai 0890 Cheng, Lijuan 0051 Cheong, Maxwell 0714 Cherkassky, Tamara 0126 Chew, Effie 0150 Chiang, Yung-Hsiao 0662 Chiappetta, Katie 0905 Chiaravalloti, Nancy 0455, 0664, 0850 Chieffo, Daniela 0711 Chikani, Vatsal 0146, 0148 Chirivella, Javier 0758, 0828, 0839 Chiu, Wen-Ta 0662 Cho, Kyu Suk 0631 Cho, Kyu Yong 0899 Choi, Chang Soon 0631 Choinie`re, Manon 0338, 0603 Chou, Li-Shan 0259 Choudhary, Ajay 0059 Chow, Tiffany 0435 Christensen, Bruce K. 0885 Chui, Adora 0658 Chung, Joyce 0189 Chung, Pearl 0611, 0613, 0618 Churchill, Katie 0747 Ciampa, Maria Agostina 0062 Ciarrochi, Joseph 0363 Cicerone, Keith 0468 Cicuendez, Marta 0538 Cifu, David 0420, 0836 Cifu, David X. 0257 Cincotti, Febo 0440 Citorik, Anne 0786 Ciurli, Paola 0439, 0469 Clark, Allison 0493, 0637, 0701, 0723

861 Clark, Kelly 0542 Clark-Wilson, Jo 0399 Clayton, Gerald 0737 Clemans, Tracy 0593 Clemente, Francisco 0114 Clough, Alan 0066 Coalter, Elizabeth 0314 Coburn, Anna 0516 Cocks, Errol 0175 Coehlo, Carl 0733 Coelho, Daniel 0570 Cohen, Akiva 0005 Cohen, Joyce 0119 Cohen, Miriam 0464 Colantonio, Angela 0063, 0300, 0343, 0344, 0350, 0424, 0597, 0598, 0674, 0675, 0677, 0678, 0679, 0680, 0681, 0682, 0687, 0747, 0853 Colella, Brenda 0885, 0886 Coleman, Lee 0660 Coles, Jonathan 0496, 0708 Collie, Alex 0598 Colobong, Romeo 0194 Colomer, Carolina 0449 Colton, Katie 0506 Colwell, Brittany 0724 Comper, Paul 0864 Coneely, Mark 0144 Conneely, Mark 0517 Connor, Mary 0372 Connors, Susan 0459 Constantinidou, Fofi 0834 Cook, Jared 0805 Cook, Lori 0141 Cooper, Andrew 0302 Cooper, Doug 0076 Cooper, Douglas 0313 Cooper, Douglas B. 0667 Cooper, Shelly 0714 Copolillo, Al 0454 Corbie, Jasmin 0852 Corneyllie, Alexandra 0406 Coronado, Victor 0337, 0574, 0779 Coronel, Helen 0776 Corrigan, John 0172, 0481, 0507, 0512, 0731 Corser-Jensen, Chelsea 0460 Cortese, Maria Daniela 0051, 0052, 0443, 0463 Coslett, H. Branch 0355 Cossette, Isabelle 0581 Costa, Alberto 0439 Costa, Camille 0162 Cote, Pierre 0333, 0337, 0348, 0573, 0779 Coˆte´, Pierre 0587 Cott, Cheryl 0063 Coufal, Frank 0900 Coughlan, Daniel 0366 Counsell, Colleen 0801, 0840 Couturier, Celine 0038, 0039 Couturier, Ce´line 0003 Cowley, Laura 0176, 0177 Coyne, Julia 0548 Cozzarelli, Tara 0067 Crane, Amy 0223 Crane, Paul 0762 Craven, Catharine 0852 Crawford, Fiona 0849 Creason, Alia 0782 Creˆte, Josianne 0309 Crichton, Ali 0239, 0633 Croisiaux, Christine 0789 Crossley, Louise 0660 Crowe, Louise 0428 Crynen, Gogce 0849


862 Cullen, Nora 0353 Cullinan, William 0752 Cummings, Kelianne 0298 Cuni-Dominguez, Laura 0537 Cusimano, Michael 0015, 0426, 0502, 0603 Cusimano, Michael D. 0300 Cuthbert, Jeff 0731 Cuthbert, Jeffrey 0481, 0507, 0511, 0512 Cutler, Andrew 0802 Czerny, Christian 0765 Czimskey, Natalie 0729 Czyzo, Julia 0747 D’Amato, Stephen 0761 D’Amico, Stephen 0802 da Silva Ramos, Sara 0182, 0183, 0216 da Silva, Sabrina Sabino 0728 Daggett, Virginia 0113 Dagher, Jehane H. 0162 Dahlben, Brian 0874 Dailler, Fre´de´ric 0406 Dairo, M. D. 0732 Damsga˚rd, Elin 0431 Dams-O’Connor, Kristen 0714, 0762 Daneshvar, Daniel 0645, 0738 Daneshvar, Yasamin 0801, 0806, 0808, 0812, 0830 Daniel, Cindy 0089 Daniel, Thomas 0403 Danilov, Yuri 0254 Dannebrock, Fernando Augusto 0725 Darnoux, Emmanuelle 0238, 0240, 0287 Davenport, Elizabeth 0766 Davidson, Leslie Freeman 0627 Davies, Peter 0849 Davis, Brittany 0525 Davis, Gavin 0107 Davis, Jennifer 0576 Davis, Karen D. 0220 Dawson, Deirdre 0423, 0658, 0696 de Burgh, H. Thomas 0303 de Guise, Elaine 0003, 0038, 0039, 0162, 0306 de Kloet, Arend 0042, 0135, 0203, 0208, 0209, 0265 de Kloet, Arend J. 0099 de Koning, M. E. 0246 de Koning, Peter 0584 De los Reyes Aragoń, Carlos Jose 0138 De los Reyes Aragoń, Carlos Jose´ 0184, 0186 De Lucia, Lucia 0703 de Novellis, Vito 0706 de Oliveira, Carla 0725 de Pasquale, Francesco 0469 De Quelen, Me´laine 0330 De Val, Marie-Daniele 0472 Dean, Natasha 0633 Dean, Philip 0385, 0386 Deane, Frank 0363 Debono, Tony 0905 Decker, Kathryn 0427 DeFelice, John 0709 DeGutis, Joseph 0305 DeHaas, CodieAnn 0784, 0792, 0804 Dei Cas, Paula 0212 deJoya, Anna 0086 Del Barco, Alberto 0758, 0839 DeLuca, John 0548 DeMatteo, Carol 0187, 0252, 0832 Demeester, Maud 0185 Demertzi, Athena 0740 DenBoer, John 0482 Deng, Hui 0022 Denney, Thomas 0403 Denninghoff, Kurt 0146, 0148

Brain Inj, 2014; 28(5–6): 517–878

Dennis, Maureen 0401 DePompei, Roberta 0310 Derakhshan, Iraj 0058, 0064 Deshpande, Gopikrishna 0403 Desjardins, Monique 0003, 0306 D’Esposito, Mark 0807 Destaillats, Jean-Marc 0789 Dettmer, Judy 0511, 0814 Devers, Amber 0526 Dhanda, Amit 0577 Dhar, Hitesh 0011 Dhawan, Jasbeer 0476 D’Hondt, Fabien 0797 Di Battista, Ashley 0010 Di Cosimo, Maria Rita 0439 Di Perri, Carol 1010 Di Rienzo, Filomena 0712 Di, Haibo 0051 Diaz, Cara 0577 Diaz, Dulce 0139 Diaz-Arrastia, Ramon 0762 Dick, Talia 0773, 0848 Diehl, Nancy 0837, 0843 Dıéz-Tejedor, Esuperio 0122 Dikmen, Sureyya 0704 Dilay, Angelica 0078, 0319 Dillahunt-Aspillaga, Christina 0108, 0110 Dilly, Michael 0444 Ding, Wenlong 0233, 0299, 0301, 0336 Dion, Laurie-Anne 0881 Ditchfield, Michael 0660 do Nascimento, Rita Iara 0725 Dobronyi, Isabelle 0300 Doherty, Colin 0857 Doiron, Matthew 0786 Dolce, Giuliano 0051, 0052, 0380, 0443, 0463 Domıńguez-Morales, Maria del Rosario 0648, 0649 Dominguez-Morales, Maria Rosario 0651 Donovan, James 0337, 0587, 0803 Doody, Rachelle 0802 Doron, Ravid 0694 Dorrego, Flavia 0552, 0553 Dorsch, Andrea 0549 Dorsey-Holliman, Brooke 0595 Doser, Karoline 0180 Douglas, Jacinta 0215, 0599 Downing, Marina 0095 Dretsch, Michael 0403 Dribbon, Michael 0548 Dsurney, John 0767, 0771, 0777, 0798 du Coudray, Hugo 0904 Duc, Tran 0786 Duclos, Catherine 0388, 0390 Duenãs Gonzalez, Claudia Leticia 0847 Duenas, Matthew 0880 Duff, Melissa 0865 Dugan, Kristin 0043 Dumont, Marie 0388, 0390 Duong, Thao 0377 Dupuis, Kate 0885 Dzyundzyak, Angela 0750, 0905 Eagan Brown, Brenda 0859 Eapen, Blessen 0498, 0500, 0781, 0862 Eberhart, Charles 0770 Ebrahimi Rad, Reza 0045 Ebuehi, Osaretin 0414 Eckbo, Ryan 0419, 0874 Edlow, Brian 0117, 0762 Eickhoff, Christine 0791 Eilander, Henk 0453 Eilander, Henk J. 0669

863


DOI: 10.3109/02699052.2014.892379

Eklund, Anders 0903 Elbourn, Elise 0556 Elder, Hinemoa 0081 El-Faramawy, Ahmed 0073 Elgh, Mattias 0242 Elgmark Andersson, Elisabeth 0217 Eliyahu, Roni 0800 Elkind, Jaclynn 0005 Ellamushi, Habib 0715 Ellis, Richard Darin 0113 El-Menyar, Ayman 0073, 0357 Elmsta˚hl, So¨lve 0431 Emanuelson, Ingrid 0151, 0237 Eme, Robert 0035 Emery, Carolyn 0751, 0759, 0835 Engel, Lisa 0423 Englander, Jeffrey 0374, 0375 Engstro¨m, Miriam 0315 Ennis, Naomi 0300, 0426, 0788 Ereifej, Evon 0672 Eren, Senem 0894 Erikson, Anette 0436 Eriksson, Gunilla 0436 Esbjornsson, Eva 0583 Esbjo¨rnsson, Eva 0582 Escartin, Erick 0851 Eshaghabadi, Arezou 0289 Esopenko, Carrie 0435 Espinosa, Irma 0139 Espinoza, Laura 0437 Esser, Michael 0347, 0842, 0861 Esterman, Michael 0305 Estraneo, Anna 0703, 0799 Esty, Mary Lee 0811 Etemadifar, Masoud 0125 Etheredge, Sara 0739 Ettel, Debbie 0459 Evans, Charlesnika 0509 Evans, David 0349 Evans, Kelli 0349 Eve, Megan 0182 Evensen, Kari-Anne Indredavik 0248, 0317 Ewing-Cobbs, Linda 0401 Faguaga, Gabriella 0904 Fairchild, Jennifer Kaci 0480 Falletta Caravasso, Chiara 0439, 0469, 0718 Fang, Raymond 0506 Faris, Veronica 0671 Farran, Allyson 0347 Faruqui, Rafey A. 0497 Faubert, Jocelyn 0448 Fedorov, Anton 0666 Feldman, Debbie 0306 Felici, Cosetta 0826 Feng, Lianyuan 0027 Feng, YanLi 0030 Ferguson, Scott 0849 Fernandez-Ortega, Juan-Francisco 0380 Ferrea, Monica 0552, 0553, 0554 Ferreiro, Tatiana 0758, 0828 Ferrell, Richard 0778 Ferreri, Heather 0548 Ferri, Joan 0456, 0479 Ferris, Nicholas 0483 Feyz, Mitra 0003, 0038, 0039, 0162 Fickas, Stephen 0109 Fievisohn, Elizabeth M. 0467 Figueroa, Jeanette 0671 Filipetti, Paul 0168 Fink, Gereon 0050 Finkelstein, Marsha 0627

Finnanger, Torun G. 0248, 0317 Fisher, Lauren 0868 Flashman, Laura 0778, 0785 Flekkoy, Kjell 0102, 0103 Flores Stevens, Lillian 0147 Fonda, Jennifer 0673, 0742 Forbes, Margie 0556 Ford, James 0785 Forget, Robert 0448 Formisano, Rita 0202, 0439, 0440, 0469, 0718 Forslund, Marit V. 0214 Forster, Jeri 0593, 0595 Fortier, Catherine 0673 Fortune, Donal G. 0415, 0416, 0422, 0652 Foti, Calogero 0368 Francis, Alan 0339 Franco, Hugo 0716 Franco, Meghan 0805 Franke, Laura Manning 0420 Franks, Chris 0190 Frantzeń, Janek 0496, 0702 Frasca, Diana 0885 Fraser, Robert 0756 Fredman, Eli 0874 French, Lou 0313 French, Louis 0076, 0077, 0078, 0319 French, Louis M. 0667 Freund, Paul 0133 Freund, Ronald 0460 Freytes, Magaly 0671 Fried, Moshe 0694 Friedman, Keren 0401 Frings-Dresen, Monique 0294 Fritts, Nathan 0738 Froelich, Kathleen 0144 Frolov, Dmitrii 0205 Fromm, Davida 0556 Fry, Danielle 0658 Frye, Richard E. 0651 Fufaeva, Ekaterina 0227 Fukuyama, Seisuke 0235 Fulford, Jonathan 0465 Furst, Ansgar 0890 ˚ sa 0179 Fyrberg, A Gabel, Nicholette 0780 Gagliardo, Pablo 0758, 0828, 0839 Gagner, Charlotte 0485 Gagnier, Ste´phane 0306 Gagnon, Isabelle 0370, 0448, 0588 Gainer, Rolf 0070 Gaither, Joshua 0146, 0148 Galante, Ray 0005 Galdzicki, Zygmunt 0169, 0325 Gall, Carolin 0666, 0668, 0670 Gallagher, Stephen 0415, 0416 Galvin, Jane 0273 Gan, Caron 0297 Ganti, Latha 0801, 0806, 0808, 0812, 0830, 0840 Gao, Huasong 0093 Gao, Yilu 0093 Garcıá, Antonio 0851 Garcıá-Bla´zquez, Carmen 0479 Gardani, Maria 0688, 0693, 0719 Gardner, Andrew 0105, 0465 Garg, Akshay 0614 Gargaro, Judith 0115, 0307, 0520, 0522, 0523, 0524 Garmaise, Evan 0365 Gary, Kelli 0454 Gates, Thomas 0379 Gavridakis, Georgios 0909, 0910, 0911 Gavrilov, Anton 0389


864 Gee, Teak Sheng 0623 Ge´linas, Ce´line 0338, 0603 Genova, Helen 0850 Genova, Helen M. 0664 Gentleman, Steve 0709 Gerber, Don 0231, 0434 Gerber, Gary 0115, 0307 Gerdes, Lee 0805 Gerhart, P. T. 0231 Ghadiri, Tahere 0289 Ghadiri Garjan, Tahereh 0450 Ghafouri, Nazdar 0640 Ghajar, Jamshid 0409, 0624 Ghout, Idir 0240, 0287 Giacino, Joseph 0049, 0050, 0786, 0868 Giacino, Joseph T. 0519 Giannarelli, Paola 0841 Giannouli, Vaitsa 0909 Gibbons, Liam 0693 Giglia, Lucy 0187 Gigue`re, Jean-François 0533, 0881 Gigue`re, Myriam 0665 Giguere, Myriam 0447, 0510 Gijzen, Rianne 0042 Gilardi, Julia 0552 Gill, Supria 0318 Gillenstrand, Jonas 0237 Gilmore, Stephanie 0786 Ginsberg, Annika 0345 Gioia, Gerard 0645 Giordani, Bruno 0167, 0171 Gittelman, Michael A. 0407 Giuffrida, Clare 0757 Giwerc, Michelle 0874 Giwerc, Michelle Y. 0683 Gladstone, Johnathan 0505 Glang, Ann 0459 Glang, Patrick 0741 Glavaski-Joksimovic, Aleksandra 0795 Gleason Williams, Jennifer 0113 Glegg, Stephanie 0477 Gleichgerrcht, Ezequiel 0462 Glintborg, Chalotte 0200 Glubo, Heather 0499 Glushakova, Olena 0080 Gobert, Denise 0043 Godbolt, Alison 0154, 0337, 0574, 0575, 0803 Godden, Tim 0524 Godfrey, Celia 0010, 0104, 0894, 0914 Goff, Emily 0366 Goldberg, Gary 0425 Goldman, Sarah 0067 Gollega, Ana 0625 Gomez, Manuel 0350 Gomez, Pedro A. 0538, 0547 Go´mez, Francisco 0716, 0740 Gonzales, Edson Luck 0631 Gonzalez, Federico 0628 Gonzalez, Karen 0628 Gonza´lez, Nataly 0106 Gonza´lez Gonza´lez, Nataly 0147 ´ frica 0122 Gonza´lez-Murillo, A Good, Dawn 0750, 0809, 0817, 0818, 0832, 0905 Goodell, Dayton 0460 Goodman, Alex 0403 Goossens, Paulien 0209 Gopalkrishna, Gururaj 0149 Gordon, David 0499 Gordon, Wayne 0459, 0714, 0762 Gorji, Ali 0289, 0295, 0450 Goryachev, Alexander 0389

Brain Inj, 2014; 28(5–6): 517–878

Goryaynov, Sergey 0760 Goselin, Nadia 0533 Gosselin, Nadia 0388, 0390, 0881 Gosseries, Olivia 0053, 0168, 0716, 0740 Goswami, Ruma 0220 Gottshall, Kim 0474 Gout, Idir 0238 Grabljevec, Klemen 0368 Gracey, Fergus 0863 Graef, Patrıćia 0461 Grafman, Jordan 0781 Graham, Carolyn 0420 Graham, Carolyn W. 0257 Graham, Daniel 0624 Graham, Deborah 0066 Grandinette, Sharon 0607 Grant, Gerald 0858 Gravel, Jocelyn 0589, 0656, 0797, 0816 Gray, Andrew 0486 Green, Gary 0176, 0177 Green, Hallie 0616 Green, Katie 0874 Green, Robin 0220, 0423, 0852, 0885, 0886 Greene, David 0814 Greenspoon, Dayna 0348 Greenwald, Richard 0346, 0785 Greer, David 0117 Greffou, Selma 0448 Greig, Nigel 0101 Greig, Nigel H. 0068 Grigoriou, Kostantinos 0909, 0910, 0911 Grigorovich, Alisa 0696 Grijalva, Israel 0867 Grilli, Lisa 0370, 0588 Grimsley, Fred 0792 Grissom, Thomas 0506 Group, Sofmer 0277 Grove, Tim 0438 Gruen, Russell 0891 Gruenwald, Lisa Marie 0302 Guardascione, Erica 0121 Guekht, Alla 0730 Guernon, Ann 0144, 0517, 0686 Guglielmino, Federica 0051, 0052 Gui, Ting 0299, 0301, 0336 Gunasena, Pradeepa 0494 Gunnarson, Eli 0659 Gupta, L. N. 0059 Gupta, Rajaneesh 0018 Gusev, Eugene 0730 Gutie´rrez-Fernańdez, Marıá 0122 Gutzmer, Bridgette 0132 Beauchamp, Miriam H. 0485, 0503 Haarbauer-Krupa, Julie 0310, 0358 Haarbauer-Krupa, Juliet 0471, 0481, 0507, 0512, 0720 Habbal, Dina 0049, 0053 Ha˚berg, Asta 0248 Hagberg-Van’t Hooft, Ingrid 0659 Haggerty, Kyle 0197 Hajdu, Stefan 0765 Hajhashemi, Arezou 0125 Hale, Jennifer 0086 Hall, Pattie 0906 Halldorsson, Jonas 0102, 0103 Halper, James 0648 Halpern, Jami 0197 Hamelius, Lena 0315 Hamill, Victoria 0096 Hammond, Flora 0046, 0223, 0484, 0545, 0802, 0868 Hammond, Flora M. 0481 Hammoor, Bradley 0858, 0866

865


DOI: 10.3109/02699052.2014.892379

Hamonet, Julia 0277 Han, Seol-Heui 0631 Handcock, Phil 0486 Hanley, Daniel 0495 Hanna, Steven 0477 Ha¨nninen, Timo 0111 Hansen, Tia 0200, 0279 Hanten, Gerri 0401 Hao, Amy 0345 Hara, Hiroyoshi 0204 Haran, Jay 0782 Harbinson, Meredith 0353 Harding, Victoria 0887 Hardy, Warren N. 0467 Haren, Tina 0321 Harlow, Alyssa 0066 Harmer, Alison 0606 Harris, Adrian 0465 Harris, Odette 0189 Harrison-Felix, Cynthia 0434, 0481, 0484, 0507, 0511, 0512, 0545 Hart, Brett 0420 Hart, Brett B. 0257 Hart, Tessa 0355, 0868 Hartikainen, Kaisa 0312 Hartmann, Alexander 0050 Harton, Brett 0144, 0517, 0521, 0690 Hartvigsen, Jan 0573, 0578, 0587, 0803 Hassaballa, Deena 0700 Hassan, Ismail 0821 Hassett, Leanne 0606 Haug Nordenmark, Tonje 0430, 0541 Hauger, Solveig L. 0519 Hauger, Solveig Lægreid 0590 Hawley, Carol 0303, 0369, 0432, 0539, 0540, 0580 Hayes, Ronald 0080 Hazrati, Lili-Naz 0220 He, Bin 0244, 0249 He, Xiaofei 0441 Hearps, Stephen 0851 Heaton, Kristin 0409 Hebert, Debbie 0696 Hedges, James 0624 Heggs Davis, Akilah 0358 Hehar, Harleen 0347 Heidenreich, Kim 0460 Hekmatnia, Ali 0125 Hellstrom, Torgeir 0247 Hellstrøm, Torgeir 0192 Hellyer, Pete 0709 Helmick, Katherine 0776 Helminen, Mika 0283 Hendricks, Henk 0380 Hendrickson, Peter 0549 Hendrickson, Susan 0562, 0572 Hendriks, Carla 0584 Hendrix, Cassandra 0310 Hengst, Julie 0701 Henricks, Jon 0616 Heran, Manraj 0419 Herceg, Mark 0451 Hermann, Michael 0570 Hermans, Eric 0397 Hernande´z, Adan 0016 Hernandez, Beatriz 0276 Hernandez, Fidel 0858 Hernańdez, Tiberio 0716 Hernańdez-Torres, Enedino 0871, 0876, 0878 Herrmann, Brian 0358 Herrold, Amy 0144, 0509, 0517, 0521 High, Walter 0509 Hilberink, Sander 0265

Hilberink, Sander R. 0099 Hilderman, Courtney 0190 Hincapie, Cesar 0333, 0337, 0573, 0574, 0575, 0810 Hincapie´, Cesar A. 0587 Hinds, Sidney 1006 Hinrichs, Hermann 0666 Hirani, Ella 0293 Hirdes, John 0853 Hirozane, Mayumi 0555 Hitzig, Sander 0852 Hoffberg, Adam 0593 Hoffer, Barry 0101 Hoffer, Michael 0474 Hoffman, Andrew 0858 Hoffman, Jeanne 0704 Hofman, Winni 0085 Holers, Michael 0140 Holland, Audrey 0556 Hollenberg, Robert 0187 Holloway, Mark 0490 Holm, Lena 0573, 0575, 0578, 0803 Holm, Lena W. 0587 Holsti, Liisa 0477 Holzbach, Anna 0525 Homaifar, Beeta 0595 Hong, Shen 0048 Hong, Taeyoung Peter 0861 Hoogs, Marietta 0813 Hopkins, Melissa 0408 Horkayne-Szakaly, Iren 0770 Horn, Gordon 0291, 0887 Horn, Susan D. 0757 Horneman, Go¨ran 0179 Horton, David 0189 Høst, Katja 0152 Hoste, Timothy 0657 Houston, Debbie 0633 Howard, Robin S. 0782 Howell, David 0259 Hoxie, Elva 0359 Høyer, Ellen 0331 Hralova, Michaela 0445 Hricik, Allison 0714 Hsiao, Sheng-Huang 0054 Hsieh, Ding-You 0535 Hsu, Wei-Lun 0535 Hsueh, Jayden 0853 Hu, Peter 0506 Hu, Xiaohua 0051 Hua, Susan Z. 0689 Huang, Sheng-Jean 0054 Huang, Shih-Yi 0644 Hubbard, William 0529 Huber, Jason 0016 Huff, J. Stephen 0774 Hui, Matthew 0747 Huie, Henry 0374 Humble, Will 0146, 0148 Huna-Baron, Ruth 0694 Hung, Anna 0591 Hung, Ryan 0337, 0348, 0779, 0827 Hunt, Cindy 0502, 0504 Hunt, Phillip 0742 Hunter, Jeralyn 0602 Hunter, Roger 0715 Hussain, Zakir 0411 Hutchinson, Peter 0708, 0863 Hutchison, Michael 0619, 0622 Hutchison, Michael G. 0864 Hyo¨tylaïnen, Tuulia 0708 Iarossi, Andrea 0712


866 Ibarra, Summer 0225 IIGiovine, Zach 0676, 0684 Ikuta, Nilo 0725, 0728 Iliadis, Charalampos 0909, 0910, 0911 Ilmer, Esther C. 0099 Im, Brian 0345, 0499 Inaji, Motoki 0612 ´ ngel 0097 Inchauspe, Adriań A Indredavik, Marit S. 0248, 0317 Infante St Clair, Lourdes 0815, 0847 Ingalhalikar, Madhura 0355 Ingebrigtsen, Tor 0137 Inoue, Tomoo 0714 Intiso, Domenico 0712 Intruvini, Silvia 0552, 0553, 0554 Irlam, Jacqueline 0633 Irlen, Helen 0457 Isaac, Linda 0480 Ishibashi, Satoru 0612 Ismail, Nasiru Jinjiri 0821 Isokuortti, Harri 0069 Itou, Kei-ichi 0084 Ivanhoe, Cindy 0567 Iverson, Grant 0105, 0403, 0417, 0418, 0419, 0769 Iverson, Grant L. 0069, 0072, 0111, 0195, 0446 Ivins, Brian 0076, 0078 Izquierdo, Ruth 0758, 0828 Jabocsson, Maria 0315 Jackson, Alexander 0293 Jackson, Anousha 0747 Jackson, Philip L. 0478, 0503 Jacobsson, Lars 0592 Jadwiszczokova, Andrea 0445 Jaiswal, Manoj K. 0169, 0325 Jakobs, Monique 0209 Janatova, Marketa 0442 Jandial, Rahul 0880 Jane, Topolovec-Vranic 0788 Jansari, Ashok 0491 Janssen, Joep 0208 Ja¨ntti, Sirkku 0708 Jaramillo, Carlos 0498, 0500, 0781, 0862 Jarrett, Michael 0871, 0876, 0878 Jaweed, Mohammad 0558, 0623 Jenkins, Shonna 0509 Jennings-Bell, Warren 0334, 0342 Jerstad, Tone 0519 Jeschke, Marc 0350 Jess, Kraus 0149 Ji, Songbai 0346, 0371, 0376 Jiang, Kevin 0700 Jirina, Zapletalova 0250 Joel, Marie-Eve 0287 Johansson, Birgitta 0163, 0164, 0165, 0166 John, Chandy 0171 Johnson, Andrea 0308 Johnson, Christopher 0474 Johnson, Danny 0080 Johnson, Patricia 0505, 0788 Jonasson, Per 0222 Jones, Gerty 0671 Jones, Paul 0293 Jones, Sam 0616 Jonker, Cees 0032 Jonker, Frank 0032 Jonsson, Cecilia 0217 Jordan, Neil 0509, 0521 Jorge, Ricardo 0458 Jorgensen, Allison L. 0653 Jorgensen-Wagers, Kendra 0717 Jourdan, Claire 0238, 0240, 0287

Brain Inj, 2014; 28(5–6): 517–878

Joyner, Emily 0856 ¨ hman 0312 Juha, O Julkunen, Juhani 0283 Jurcak, Sue Ellen 0657 Jusino, Kathia 0671 Jutras, Marie-Reine 0309 Kaczmarek, Kurt 0254 Kadoura, Basil 0872 Kagan, Corinne 0692, 0710 Kahn, Michelle 0270 Kaimovsky, Igor 0730 Kakuda, Wataru 0134, 0204, 0296, 0722 Kalanuria, Atul 0601 Kalousova, Barbora 0157 Kalyanasundaram, Madhanraj 0087 Kamal, Vineet K. 0532 Kamal, Vneet Kumar 0092 Kameneva, Marina V. 0629 Kammersgaard, Lars P. 0154 Kaneko, Yuji 0635 Kanematsu, Yukari 0235 Kang, Jane 0835 Kang, Jian 0751, 0759 Kanungo, Madhusudan 0018 Kaplan, Melissa 0043 Kapoutzis, Nikolaos 0912, 0913 Kapur, Kush 0521 Karami, Ghodrat 0320, 0394 Karaseva, Olga 0226 Karic, Tanja 0430, 0541 Karimzade, Fariba 0289 Karlsson, Jan-Olof 0166 Kataja, Anneli 0069, 0072 Katila, Ari 0496, 0702, 0708, 0903 Katt, Mae 0424 Katz, Douglas 0366 Katz, Jeffery 0403 Katz-Leurer, Michal 0229 Kaur, Sukhpal 0087 Kawahira, Kazumi 0561, 0596, 0698 Kawano, Hitoshi 0155, 0158 Kazemi, Hadi 0295 Kean, Michael 0660 Keebler, Molly 0141 Keene, Chesleigh 0140 Keene, Dirk 0762 Keightley, Michelle 0262, 0337, 0365, 0424, 0773, 0779, 0848, 0869 Keiski, Michelle 0261 Kendall, Kathryn 0837 Kenna, Alexandra 0673 Kennedy, Catharine F. 0372 Kennedy, Jan 0076, 0077, 0078, 0313, 0319 Kennedy, Jan E. 0667 Kennedy, Katie 0616 Kennedy, Mary 0530 Kenny, Belinda 0556 Keren, Ofer 0229 Kersey, Patrick 0402, 0604 Ketchum, Jessica 0868 Keyser, David 0811 Khajemogahi, Nahid 0642 Khan, Annie 0872 Khan, Fary 0611, 0613 Khan, Mushfiquddin 0253 Kharade, Sudha 0178 Khazali, Homayoun 0289 Khetani, Aneesh 0872 Kho, Phoebe 0107 Khoueir, Paul J. 0364 Kikuchi, Naohisa 0074 Killgore, William D. S. 0653


DOI: 10.3109/02699052.2014.892379

Killi, Eli Marie 0213 Kim, Bo Ra 0322 Kim, Doo Young Kim 0322 Kim, Ji Woon 0631 Kim, Junghoon 0355 Kim, Soo Kuon 0328 Kim, Von Gi 0205 Kim, Wanho 0322 Kimura, Tomoyuki 0204 Kimura-Kuroda, Junko 0155 King, Laurie 0791 King, Tricia 0310 Kinoshita, Lisa 0480 Kipman, Maia 0653 Kirkman, Emrys 0709 Kirkwood, Michael 0429 Kirsh, Bonnie 0350 Klaskova, Eva 0250 Kleffelgaard, Ingerid 0383 Kletzel, Sandra 0517 Kliem, Lisa 0438 Klimaj, Stefan 0470 Klobucar, Robert 0263 Klooster, Nathaniel 0865 Knifed, Eva 0133 Knight, Alison 0381, 0382 Knoph, Rein 0519 Knox, Lucy 0215, 0599 Ko, Hyun Myoung 0631 Ko, Mee Jung 0631 Ko, Sung Hwa 0328 Koenig, Sebastian 0455 Koerte, Inga K 0874 Ko¨hler, Sebastian 0393 Kohnen, Roy 0559 Kolade, Olusegun Adeola 0278 Kolakowsky-Hayner, Stephanie 0090, 0373, 0374, 0375, 0377, 0378, 0473, 0833 Koliatsos, Vassilis 0770 Kolivand, Peir Hossein 0295 Komuta, Yukari 0155 Kondo, Takahiro 0296 Kong, Jennifer 0276, 0367, 0480, 0833, 0890 Konstantinou, Nikos 0834 Kontos, Pia 0063, 0194 Koopmans, Raymond 0255, 0559 Korablev, Vladimir 0207 Kordonskiy, Anton 0128 Korolev, Vladimir 0207 Kortte, Kathleen 0425, 0701 Koshariya, Mahim 0311 Koskinen, Lars-Owe 0222, 0903 Koskinen, Sanna 0292 Kosmachev, Mikhail 0205 Kotchoubey, Boris 0014 Kovac, Stjepana 0295 Kozlowski, Odile 0212 Krahulik, David 0250 Kraus, Jess 0900 Krause, Marilyn 1023 Krause, Miriam 0268 Kravchuk, Alexander 0543 Krch, Denise 0090, 0455 Kreutzer, Jeffrey 0297 Kristman, Vicki 0333, 0337, 0350, 0573, 0574, 0587, 0794, 0803, 0810 Krizmanic, Tatjana 0368 Krohn, Franziska 0670 Krych, David 0219 Krylov, Vladimir 0127, 0128 Krynetskiy, Evgeny 0012 Kua, Ailene 0692

867 Kugadas, Meera 0681 Kukurin, George 0033 Kumar, Anil 0011 Kurowski, Brad G. 0407 Kurpad, Shekar 0752, 0795 Kuusinen, Venla 0312 Kuzma, Nicholas 0005, 0783 Kwok, Hong-Ting 0709 Kwon, Kyoung Ja 0631 Kyllo¨nen, Anna 0702, 0708 LaButta, Robert 0776 Lacerte, Michel 0348 Ladera, Valentina 0735, 0768 Lagares, Alfonso 0538, 0547 Lai, Daniel 0269 Laine´, France 0485 Lalonde, Gabrielle 0816 Lamarche, Yoan 0364 Lambregts, Suzanne 0135, 0265 Lambregts, Suzanne A. M. 0099 Lamontagne, Marie-Eve 0692, 0829 Lamoureux, Julie 0003, 0038, 0039 Lan, Yue 0441 Landa, Janna 0875 Landesman, Yosef 0635 Landry-Roy, Catherine 0656 Lange, Rael 0076, 0077, 0078, 0313, 0319, 0419, 0734 Lange, Rael T. 0667 Langenbahn, Donna 0290 Langer, Laura 0501 Langhammer, Birgitta 0116, 0131, 0131, 0234, 0236, 0383 Langley, Jenny 0340 Lannering, Birgitta 0237 Lanoix, Monique 0796 Laroche, Mathieu 0364, 0881 Larson, Eric 0838 Larson, Janet 0475 Larsson, Jerry 0583 Lassonde, Maryse 0797 Latifi, Rifat 0073 Laura, Acion 0458 Laurentiis, Sara 0439 Laureys, Steven 0049, 0050, 0051, 0053, 0168, 0255, 0472, 0716, 0740 Laviolette, Valerie 0510 Lavrijsen, Jan 0255, 0453, 0551, 0559 Lavrijsen, Jan C. M. 0669 Lawrence, David W. 0864 Lax, Ilyse 0365 La´zaro, Emelia 0071, 0228 Lazzeroni, Laura 0276 Le Gall, Maud 0212 LeBlanc, Joanne 0003, 0038, 0039 Ledbetter, Alexander 0109 Ledig, Christian 0496 Lee, Aiping 0190 Lee, Cheng Kiang 0282 Lee, Eminy 0535 Lee, Eun Joo 0631 Lee, Rae Seop 0899 Lee, Rosalind 0734 Lee, Sung 0805 Lehtima¨ki, Terho 0446 Lehto, Tommi 0288 Leigh, Richard 0601 Leiguarda, Ramoń 0304 Lemke, Nicole 0835 Lemsky, Carolyn 0520, 0522, 0523, 0524 Lengenfelder, Jeannie 0850 Leo, Kee Hao 0150 Leoń-Carrioń, Jose´ 0648, 0649, 0651 Leoń-Dominguez, Umberto 0648, 0651


868 Leoń-Domıńguez, Umberto 0649 Lepore, Natasha 0716 Lequerica, Anthony 0090 Lercher, Kirk 0614 Lesenfants, Damien 0053 Letzkus, Lisa 0044 Lev, Maria 0694 Levav, Miriam 0790 Le´veille´, Genevie`ve 0309 Levi, Richard 0222 Levin, Harvey 0401 Levin, Mindy F. 0191 Levine, Brian 0290, 0435 Levine, Jaime 0468 Levy, Charissa 0501, 0710 Levy, Sarah 0767, 0771, 0777, 0798 Lewine, Jeffrey 0457 Lewis, Frank 0291, 0887 Lexell, Jan 0592 Li, Alvin 0810 Li, David 0871, 0876, 0878 Li, Hong-Peng 0155, 0158 Li, Hye Sun 0322 Li, Xue 0509 Li, Yangmei 0747 Li, Yao 0506 Li, Zhi 0339 Li, Zhigang 0346 Lian, Jie 0005 Liang, Enhe 0047 Liao, Huijun 0683, 0831 Lichiello, Stephanie 0314 Lichterman, Boleslav 0543 Liebach, Annette 0321 Liew, Boon Seng 0623 Liffshiz, Galit 0427 Liimatainen, Suvi 0069 Likhterman, Leonid 0543 Lim, Byung Chan 0899 Lim, Jun Seob 0899 Lim, Miranda 0005 Lim, Miranda M. 0783 Lin, Alexander 0874 Lin, Alexander P. 0683, 0831 Lin, Kuan-Hung 0638 Lin, Wei-Chi 0054 Lindahl-Norberg, Annika 0274 Lindgren, Ingrid 0335 Lindgren, Karen 0197 Lindmark, Birgitta 0116, 0131 Lindstro¨m, Eric 0315 Ling, Josef 0470 Lingsma, Hester 0714 Lionbarger, Michael 0471 Lippa, Sara 0673 Lippert-Gruener, Marcela 0445 Lippert-Gru¨ner, Marcela 0391 Lipton, Michael 0143 Lischinsky, Alicia 0062, 0462 Lischka, Fritz W. 0169 Little, Deborah 0741 Liu, Kangding 0094, 0112, 0206 Liu, Yen-Chen 0535 Ljungqvist, Johan 0582 Lloreńs, Roberto 0449, 0452, 0456 Locatelli, Franco 0711 Lockyer, Lisette 0842 Logothetis, John 0909 Logsdon, Aric 0016 Loiselle, Carmen G. 0338 Longboat-White, Claudine 0424

Brain Inj, 2014; 28(5–6): 517–878

Longini, Mariangela 0826 Lo¨nnerblad, Malin 0659 Lopez, Arturo 0735, 0768 Lopez, Eduardo 0468 Lopez, Katherine 0767, 0771, 0777, 0798 Lopreiato, Maeve 0877 Loreto, Vincenzo 0703, 0799 Losacco, Justin 0140 Losoi, Heidi 0283, 0446 Lo¨tjo¨nen, Jyrki 0496 Lottenberg, Lawrence 0801 Loveless, Melinda 0704 Lovio, Riikka 0659 Løvstad, Marianne 0049, 0152, 0519, 0569, 0590 Lowe, Lynne 0067 Lowe, Mark 0748 Loya, Fred 0807, 0879, 0883 Lu, Juan 0266, 0454 Lu, Wan-Jung 0638, 0644 Luaute´, Jacques 0277, 0330, 0406 Lubillo, Santiago 0114 Lucas, Mary Paige 0145 Lujan, Silvia 0904 Lukjanov, Valeriy 0226 Lukow II, Herman 0314 Lukyanov, Valeriy 0227 Lundgaard Søberg, Helene 0383 Luongo, Livio 0706 Luoto, Teemu M. 0069, 0072, 0111, 0195, 0283, 0446 Lydersen, Stian 0248, 0317 Ma, Irene 0347 Ma, Yun-Li 0535 Maanpaä¨, Henna-Riikka 0702, 0708 Maas, Andrew 0714 Macciocchi, Stephen 0775, 0787 Machuca-Murga, Fernando 0649 MacIntyre, Alan 0719 MacLellan, Adam 0133 MacWhinney, Brian 0556 Maddox, Jill 0358 Maddox, Kyle 0113 Madore, Michelle 0807 Maerlender, Arthur 0785 Maestas, Kacey 0508, 0701, 0723, 0736 Maestas, Kacey L. 0493 Magen, Jed 0412 Magnadottir, Hulda 0102, 0103 Magnusson, Helga 0539 Magruder, Susannah 0717 Mah, Katie 0773 Mahmud, Muhammad Raji 0821 Mahoney, William 0187 Main, Keith 0276, 0367, 0480, 0833, 0884 Maines, Tanya 0429 Mainwaring, Lynda 0615, 0619, 0622 Maione, Sabatino 0706 Majerus, Steve 0049, 0050, 0051, 0053 Makan, Nadia 0124, 0190 Ma¨ki-Marttunen, Verońica 0304, 0312 Makovitch, Steven 0870 Makris, Nikos 0339, 0874 Maldjian, Joseph 0766 Malec, James 0046, 0223, 0225 Maleki, Mohammed 0003, 0038, 0039 Maller, Jerome 0483 Malley, Donna 0863 Mallinson, Trudy 0509, 0686 Mallu, Satya 0233 Malm, Jan 0903 Malomo, A. O. 0726, 0732 Malone, Maria 0866

869


DOI: 10.3109/02699052.2014.892379

Mandel, Yossi 0694 Mandell, Laurence 0749 Mandell, Robert 0749 Mandrekar, Jay 0837, 0843 Manley, Geoffrey 0714 Mann, Carmelinda 0189 Mannheimer, Clas 0164 Manning, Erin 0298 Mansfield, Elizabeth 0350 Manskow, Unn Sollid 0431 Mansoori, Naseem 0691 Maraj, Sara 0658 Marcoux, Judith 0003, 0038, 0039 Marcus, Hani 0489 Marcus, Hani J. 0572 Maresova, Dana 0445 Marin, Nancy 0871 Marincek, Crt 0368 Markarov, Yuri 0015 Markert, Ronald 0676, 0684 Markovic, Gabriela 0242 Marquardt, Thomas 0729 Marras, Carlo 0711 Marras, Connie 0574, 0810 Marsan, Jennifer 0523 Marsden, Katelyn R. 0605 Marshall, Katherine 0076, 0313 Marshall, Katie 0319 Marshall, Shawn 0692, 0710, 0763 Martin, Brett 0645, 0738 Martin, Jesus 0114 Martin, Kathy 0511 Martin, Sally 0580 Martinez, Kristina 0108 Martıńez, Darwin 0716 Martıńez Crespo, Gracia 0479 Martıńez Nogueras, Angel 0479 Martinez-Garre, Ma Carmen 0537 Martinez-Perez, Rafael 0538, 0547 Martıń-Silva, Isabel 0537 Martinussen, Rhonda 0832 Maruta, Jun 0409, 0624 Maruzzi, Giuseppe 0712 Marwitz, Jennifer 0314, 0473 Mas, Gemma 0828, 0839 Masanic, Cheryl 0505 Masˇ´ın, Michal 0719 Mason, Christen 0511 Massetti, Jennifer 0577 Massey, Trudi 0384 Massicci, Roberta 0439 Massicotte, Elsa 0478, 0503 Mastorakis, Georgios 0909 Mastro-Martıńez, Ignacio 0122 Mastronuzzi, Angela 0711 Matarazzo, Bridget 0593 Mate´rne, Marie 0639 Matesevac, Lisa 0358 Mathe´, Jean François 0277 Matos, Amilcar 0671 Matsuda, Fumiyo 0253 Matsumoto, Shuji 0561, 0596, 0698 Matsumoto-Miyazaki, Jun 0235 Mattia, Donatella 0440 Mattila, Jussi 0496 Maule, Alexis 0409 Max, Jeffrey 0401 Maxey, Matt 0070 Maxfield-Panker, Stephanie 0067 Mayer, Andrew 0470 Mayinger, Michael 0874

Mazaux, Jean Michel 0277 Mazaux, Jean-Michel 0789 McAdam, Laura 0348, 0827 McAllister, Thomas 0346, 0778, 0785 McAndrew, Lisa 0836 McCauley, Dilara 0635 McClean, Brian 0422, 0652 McClean, Michael 0645, 0738 McCrea, Michael 0752, 0888 McCrory, Paul 0486 McCullagh, Scott 0763 McCulloch, Karen 0067, 0627 McDermott, Hannah 0499 McDevitt, Jane 0012 McDonald, Brenna 0261, 0402, 0604, 0778 McDonald, Rachael 0273 McDonald, Skye 0556, 0557 McDougall, Janette 0832 McFadyen, Bradford 0581 McGeary, Cindy 0498 McGeary, Don 0498 McGillivray, Colleen 0852 McGlinchey, Regina 0305, 0673, 0742 McGlynn, Liane 0719 McGrath, Caroline 0422, 0652 McGuire, Lisa 0471 McIntosh, Anthony 0435 McIntosh, Elissa 0117 McKee, Ann 0645, 0738 McKelvey, Miechelle 0527, 0531 McKenney, Jerry 0882 McKerral, Michelle 0448 McLeod, Hamish 0363 McMillan, Thomas 0096, 0688, 0693, 0719 McMillan, Tom 0697, 0727, 0743, 0745 McNally, Shannon 0777, 0798 McNamara, Adam 0385, 0386 McNamara, Beverley 0175 McNamee, Shane 0144, 0781 Mead, Andrew 0303 Meadham, Hannah 0466 Meesters, Jorit 0209 Meeuwisse, Willem 0751, 0759, 0835 Mehdi Maneshi, Mohammad 0689 Mehech, Daniela 0377 Meister, Ingo 0050 Melen, Gustavo 0122 Mendez-Villarubia, Jose 0671 Menon, David K 0388, 0390 Menon, David 0496, 0708, 0714 Mercado, Roger 0305 Merugumala, Sai 0683, 0831 Mescherjakov, Semen 0226 Meulenbroek, Peter 0075 Meulman, Monika 0846 Meurice, Marielle 0458 Mewse, Avril 0466 Meyerson, Dmitry 0724, 0761 Meyerson, Michael 0724 Michalak, Alicja 0502, 0504, 0505 Michalkova, Kamila 0250 Midgley, Sarah 0176, 0177 Midkiff, Melanie 0685 Midwinter, Mark 0709 Mihal, Vladimir 0250 Mikulis, David 0852 Milazzo, Anna-Clare 0884 Milberg, William 0673, 0742 Milia, Paolo 0897 Miller, A. Cate 0481 Miller, Anna 0795


870 Miller, Cate 0512 Miller, Karen-Lee 0063, 0194 Miller, Kathryn 0268 Miller, Kelly J. 0667 Miller, Roby 0523 Millis, Scott 0105 Mills, Ana 0314 Minore, Bruce 0424 Minshuang, Qi 0091 Mironidou, Maria 0260 Misbach, Sadia 0130 Misbahu, Ahmad 0821 Missiuna, Cheryl 0187 Mitani, Sugao 0296 Mitchell, Carren 0215 Mitsakos, Anastasios 0260 Miwa, Kazuhiro 0084 Mochio, Kenjiro 0134 Modarres Mousavi, Mostafa 0289 Modarres Mousavi, Sayed Mostafa 0295, 0450 Modarres, Mo 0685 Modic, Michael 0748 Moein, Payam 0271 Moeller, Donald 0065 Moe-Nilssen, Rolf 0331 Moessler, Herbert 0025, 0027 Moessner, Anne 0837 Moewes, Christian 0666 Moger, Tron 0266 Mogi, Taichi 0555 Mohamadpour, Maliheh 0695 Moissinet, Florent 0168 Molina, Irma 0671 Molina, Ismael 0114 Moliner, Beleń 0452 Molla, Mahdieh 0045 Mollayeva, Shirin 0343 Mollayeva, Tatyana 0343, 0344 Momosaki, Ryo 0134 Momozaki, Ryo 0722 Monteith, Lindsey 0595 Monteleone, Brad 0605 Montenigro, Philip 0738 Monti, Martin 0051 Moody, Joel 0350 Moore Sohlberg, McKay 0109 Moore, Lynne 0665 Mora, Rosa 0845 Moraitis, Vasileios 0909 Moreno, Jhon Alexander 0106, 0147 Moretta, Pasquale 0703, 0799 Morey, Clare 0434 Morfiri, Eleni 0688 Morris, Mary 0121 Morris, Meg 0269 Morrissey, Ann-Marie 0636 Morrissey, Patrick 0089 Mortera, Marianne H. 0013 Moseley, Anne 0606 Mosenthal, Anne 0877 Moses, James 0318 Moss, Sarah 0863 Mossberg, Kurt 0086 Moss-Morris, Rona 0444 Mostofsky, Stewart 0351, 0542 Motin, Marina 0126 Motta, Keryl 0671 Mould, Andrew 0495 Moulisova, Vladimira 0719 Mouzon, Benoit 0849 Mudar, Raksha 0701

Brain Inj, 2014; 28(5–6): 517–878

Mudarshah, Rozliza 0130 Muir Giles, Gordon 0399 Mukherjee, Pratik 0624, 0714 Mukhopadhyay, A. K. 0691 Muldoon, Orla T. 0415, 0416 Mullah, Saad 0612 Mullan, Michael 0849 Mullick, Aditi 0191 Mullins, Terry 0146, 0148 Mun, Jong Hyun 0899 Munarriz, Pablo M. 0538, 0547 Murata, Yoshiko 0555 Muresanu, Dafin Fior 0021, 0025, 0026, 0027 Muriuki, Martin 0130 Murphy, Dennis 0860 Murphy, Mary Pat 0219 Murphy, Michelle 0807, 0883 Murphy, Sara 0474 Murray, Jacqueline 0737, 0793 Murray, Laura 0113 Muscara, Frank 0894 Mutaeva, Raisat 0730 Mychasiuk, Richelle 0347 Mygland, Aase 0218, 0234, 0236 Mylabathula, Sandhya 0609 Mylabathula, Swapna 0609 Mylonas, Argyrios 0909, 0910, 0911, 0912 Naderan, Morteza 0271 Nair, Siva 0901, 0902 Nakase-Richardson, Risa 0685 Nakasujja, Noeline 0167, 0171 Nalanga, Annie Jane Araneta 0566 Nalanga, Annie Jane 0282 Nangia, Vaibhav 0866 Naqvi, Anjum Zahra 0284 Naranjo, Valery 0452 Nariai, Tadashi 0612 Narous, Mariam 0861, 0872 Naunheim, Rosanne 0495 Navarro, Maria Dolores 0479 Nawrocky, Marta 0476 Nayar, Meenakshi 0400 Neary, Patrick 0744 Neher, Miriam 0140 Neils-Strunjas, Jean 0701 Nelson, David 0811 Nemeth, Alexander 0144, 0517 Nemoto, Edwin M. 0629 Nettel-Aguirre, Alberto 0751 Neumann, Dawn 0223, 0224, 0261 Ng, Amanda 0483 Ng, Justin 0365 Ng, Wai 0133 Ng, Yee Sien 0566 Nguyen, Joseph 0298 Nichols, Laura 0856 Nichols, Meline 0366 Nick, Todd 0508, 0713, 0736 Nie, Yunzhi 0051 Nielsen, Jørgen F. 0154 Nilsson, Ma˚ns 0136 Nirider, Coby 0316 Nishiyama, Norio 0235 Noack, Greg 0886 Noda, Arthur 0276 Noe, Enrique 0479 Noe´, Enrique 0452, 0456 Noirhomme, Quentin 0053, 0716, 0740 Noma, Tomokazu 0561, 0596, 0698 Nomura, Yu-ichi 0084 Nomura, Yuichi 0235

871


DOI: 10.3109/02699052.2014.892379

Norman, Rocio 0862 Norouzi, Rasoul 0271 Norup, Anne 0180, 0321 Norvell, Beth Ann 0132 Nott, Melissa 0379 Nourzad, Zahra 0289 Novak, Bryan 0167 Novakovic-Agopian, Tatjana 0807, 0879, 0883 Nowinski, Chris 0645 Nowinski, Christopher 0738 Nygren Deboussard, Catharina 0154 Nygren-de Boussard, Catharina 0333, 0337, 0573, 0575, 0587, 0803 Oakley, Ed 0239 Oberly, Douglas 0774 Oborna, Pavlina 0442 O’Brien, Anne 0786 O’Brien, Katy 0530 O’Brien, Lucy 0522, 0524 O’Brien, Terence 0123 Obuchowski, Nancy 0620, 0748 O’Callaghan, Annalise 0175 O’Connor, Denise 0891 O’Connor, Margaret 0339 Oddy, Michael 0182, 0183, 0216, 0727 Odebode, Timothy Olugbenga 0278 Odle, Cheryl 0144 Ohlsson, Kerstin 0245 ¨ hman, Juha 0069, 0072, 0111, 0195, 0283, 0446 O Ohno, Kikuo 0612 Oistensen Holthe, Oyvor 0170 Ojieh, Godwin 0414 Okamoto, Takatsugu 0204 Okazaki, Mitsutoshi 0555 Okhlopkov, Vladimir 0543 Okonkwo, David 0714 Okubo, Yoshiro 0608 Okumura, Ryuji 0235 Olabarrieta Landa, Laiene 0139, 0184, 0186, 0395, 0815, 0847, 0854 Olabarrieta, Laiene 0138 Olafsen, Kjell 0590 Olivera Plaza, Silvia Leonor 0147, 0395, 0854 Olivera, Silvia Leonor 0106 Olmos, Lisandro 0304 Olsen, Alexander 0248, 0317 Olsen, Christopher 0752 Olubunmi, Joseph 0849 Omarani Nava, Melodi 0045 O’Neil, Maya 0836 O’Neill, Brian 0688 Opheim, Arve 0331 Opoka, Robert 0167, 0171 Oresic, Matej 0708 Orhorhoro, I. O. 0726 Orman, Jean 0781 O’Rourke, Colleen 0358 Ortega, Erik 0858 Oshorov, Andrey 0389, 0754 Ostapovitch, Mary Anne 0625 Ostensjo, Sigrid 0241 Osternig, Louis 0259 O’Sullivan, Richard 0483 Oswald, Jennifer 0459 Ouchterlony, Donna 0502, 0504, 0505, 0710, 0763, 0788 Ouellet, Marie-Christine 0306, 0447, 0510, 0581, 0665 Outtrim, Joanne 0496, 0708 O’Valle, Myrtha 0479 Overbeek, Berno 0453 Overbeek, Charles 0533, 0881 Owen, Julia 0624 Owens, Thomas 0516 Owens, Tom 0316

Oyesanya, Tolu 0100 Ozonoff, Alexander 0645 Pabon, Mibel 0635 Pacheco, Jennifer 0714 Pack, Allan 0005 Pagnussat, Aline 0461 Palmer, Helen 0863 Palumbo, Andrew 0089 Pandey, R. M. 0092, 0532 Panenka, William 0419 Pangelinan, Melissa 0435 Paniccia, Melissa 0365 Pape, Theresa 0144, 0509, 0517, 0521, 0686, 0690 Paquet, Jean 0388, 0390 Paradis, Ve´ronique 0881 Parchani, Ashok 0073 Pardham, Fahmida 0824 Park, Jin Hee 0631 Parker, Drew 0355 Parkkari, Jari 0111 Parks, Sharyn 0720 Parrilla, Daćil 0114 Parrish, Todd 0144, 0517, 0521, 0690 Parrot, Devan 0223, 0225 Parrott, Devan 0219 Parsons, Daria 0674, 0681 Parveen, Sabiha 0268 Pasanen, Matti 0288 Pasquale, Antonio 0841 Pasternak, Ofer 0143, 0352, 0683, 0874 Patel, Mitesh 0885 Patel, Pratik 0801, 0806, 0808, 0812, 0830 Patil, Sheetalkumar 0178 Patil, Vijaya 0144, 0517 Patnaik, Ranjana 0021, 0025, 0026 Patrick, Peter 0044 Paul, Diane 0701 Paulsen, Catherine 0531 Paus, Toma´sˇ 0435 Paz, Grecia 0071 Pazdirek, Jiri 0130 Pazienza, Luigi 0712 Peach, Richard 0733 Pedrelli, Paola 0868 Peeples, Hanna 0268 Peeters, Els 0120 Pell, Jill 0743 Peluso, Julie 0616 Penades, Vicente 0758, 0828, 0839 Penetar, David M. 0653 Pennington, Michelle 0741 Peralta, Ruben 0073 Perez, Colleen 0474 Pe´rez-Sua´rez, Esther 0122 Perkes, Iain 0380 Perkins, Lucie 0386 Perl, Daniel 0762 Perrera, Warren 0871 Perrin, Fabien 0330, 0406 Perrin, Paul 0090, 0139 Perrin, Paul B. 0106, 0138, 0147, 0184, 0186, 0214, 0395, 0847 Perry, Briana N. 0782 Peter Kammersgaard, Lars 0321 Peters, Keith 0801, 0806, 0808, 0812, 0830 Petgrave, Josian 0853 Petrarca, Maurizio 0711 Petrocelli, Chantele 0724 Petroni, Gustavo 0904 Pettemeridou, Eva 0834 Pham, Dzung 0798 Phan, Pauline 0528


872 Phillips, Kate 0891 Pick, Chaim 0101 Pick, Chaim G. 0068 Pincus, Jonathan 0791 Pintar, Frank 0752, 0795, 0888 Pisotta, Monica 0505 Pitt, Veronica 0891 Pittman, Henry M. 0889 Plananska, Eva 0445 Plantier, David 0277 Plattner, Florian 0016 Pluta, John 0355 Polat, Uri 0694 Pollard, Ryan 0405 Pollonini, Luca 0648, 0651 Polupan, Alexander 0389 Polvivaara, Markus 0312 Polyak, Meg 0366 Pomerantz, Wendy J. 0407 Ponsford, Jennie 0095, 0483 Poon, Wai Sang 0020 Popugaev, Konstantin 0389, 0754 Porter, Eileen 0100 Poshataev, Kirill 0205, 0207 Posti, Jussi 0702, 0708 Potapov, Alexander 0389, 0543, 0544, 0754, 0760 Potter, Sebastian 0444 Potvin, Marie-Julie 0388, 0533, 0881 Poulsen, Ingrid 0321 Powell, Janet 0756 Powell, Janet M. 0757 Power, Emma 0556, 0557 Powers, Alexander 0766 Powers, Melody 0791 Pradat-Diehl, Pascale 0238, 0240, 0287 Prasad, Guru 0901, 0902 Prasad, Sukla 0018 Prasad, Vannemreaddy 0021 Pregelj, Rado 0267 Pretz, Chris 0507 Pretz, Christopher 0434, 0481, 0512 Prichep, Leslie 0495 Proietti, Fabrizio 0826 Prokhorenko, Olga 0076 Psaila, Kate 0863 Ptito, Alain 0262 Puccio, Ava 0714 Pugh, Mary Jo 0498, 0500, 0781, 0862 Pugliese, Maria Elena 0463 Puras, Yulia 0128 Purohit, Maulik 0117, 0769 Puthen, Ritu 0827 Puyana, Juan C. 0895 Qashu, Felicia 0319 Qizhou, Jiang 0048 Quijano, Carlos 0671 Quijano, Maria 0139 Quinn, Marie-Joseé 0390 Quintanar, Luis 0071, 0228 Quitadamo, Lucia Rita 0440 Rabiiu, T. B. 0726 Rabinstein, Alejandro 0380 Rachmany, Lital 0101 Radomski, Mary 0067 Radomski, Mary Vining 0627 Ragauskas, Arminas 0903 Rainer, Timothy 0020 Rajapakse, Thilinie 0842 Ramı´rez, Manuel 0122 Ramos, Ana 0538 Rana, Zakar 0860

Brain Inj, 2014; 28(5–6): 517–878

Randall, Alana 0270 Randall, Diane 0646 Ransom, Jeanine 0843 Rapp, Paul 0811 Rappoport, Maxwell 0833 Rashidkhani, Bahram 0642 Rassovsky, Yuri 0790 Rastelli, Tito Filippo 0897 Ratcliffe, Kevin 0340 Rathi, Yogesh 0143, 0874 Ratmansky, Motti 0156 Rauch, Scott L. 0653 Rauscher, Alexander 0871, 0876, 0878 Ravenda-Bouchard, E´liane 0881 Ravnik, Janez 0263 Reader, Marshalina 0424 Reda, Domenic 0144 Reddin, Christopher 0757 Reed, Matthew W. 0667 Reed, Nick 0365, 0773, 0848, 0869 Regner, Andrea 0725, 0728 Reguly, Paula 0794 Reid, Matthew 0313, 0319 Reilly, Mike 0616 Reinstrup, Peter 0286 Reiser, Vladimir 0293 Reistrup, Peter 0136 Remeta, Esther 0404, 0405 Renaux, Jerome 0053 Renton, Tian 0505 Reynolds, Matthew 0742 Rezaei, Asghar 0320, 0394 Rezai, Ali 0172 Rich, Megan 0140 Richard, Yvonne 0306 Richards, Stephanie 0268 Richter, Johan 0640 Rietdijk, Rachael 0557 Riganello, Francesco 0051, 0052, 0443, 0463 Riley, David 0645, 0738 Ringl, Helmut 0765 Rinne, Marjo 0288 Rinwa, Puneet 0011 Ripley, David 0434, 0870 Risen, Sarah 0351 Risetti, Monica 0440 Rivara, Frederick 0549 Rivera, Diego 0138, 0139, 0815, 0847, 0854 Rizzo, Albert 0455 Robart, Graham 0031 Robb, Sean 0809 Robbins, Clifford 0645, 0738 Robert, Robinson 0458 Robertson, Mary 0381, 0382 Robinson, Jedediah 0498 Rodin, Julianna 0005 Rodrigues Filho, Edison 0725 Rodriguez, Nicholas 0879, 0883 Rodrı´guez Dıáz, Melissa Alejandra 0184 Rodriguez-Gonza´lez, Susana 0537 Roe, Cecilie 0170, 0214, 0266, 0383 Røe, Cecilie 0154, 0192, 0519, 0541, 0590 Roebroeck, Marij 0265 Roebroeck, Marij E. 0099 Rojas, Sulema 0851 Roks, G. 0246 Romner, Bertil 0137 Ro¨nnba¨ck, Lars 0163, 0164, 0165, 0166 Rosario, Emily 0437 Rose, Hilary 0381, 0382 Rosellini, Guerrino 0841

873


DOI: 10.3109/02699052.2014.892379

Rosema, Stefanie 0894 Rosen, Charles L. 0016 Rosenblatt, Andrew 0305 Rosenow, Joshua 0144, 0517 Roshal, Leonid 0226 Rosman, Azmin Kass 0558, 0623 Ross, Brian D. 0831 Ross, Melody 0603 Rossi, Anemarrie 0807 Rossi, Francesco 0706 Rossini, Paolo Maria 0670 Rossitti, Sandro 0640 Rosti-Otaja¨rvi, Eija 0283 Rotem, hemda 0229 Roth, Ed 0602 Rouleau, Isabelle 0881 Rousseaux, Marc 0212 Rubenstein, Liza 0860 Rubiano, Andres M. 0895 Rubi-Fessen, Ilona 0050 Rubovitch, Vardit 0068, 0101 Rudolph, James 0742 Rueckert, Daniel 0496 Rugs, Deborah 0108 Ruhiu, Daniel 0130 Ruiz, Sabine 0330 Rumney, Peter 0348, 0779, 0827, 0832 Ruseckaite, Rasa 0598 Russel, Michael 0067 Russell, Robert 0303, 0887 Russell, Scott 0113 Russo, Mario 0712 Ryan, Jade 0300 Ryan, Nicholas 0914 Ryttersgaard, Trine 0281 Ryu, Jiwon 0770 Sabatini, Umberto 0439, 0469, 0718 Sabel, Bernhard 0663, 0666, 0668 Sabel, Bernhard A. 0670 Sabel, Magnus 0237 Sacher, Yaron 0126, 0156 Sachs, Frederick 0689 Sajitharan, Deena 0016 Sajja, Sujith 0529 Sajja, Sujith V. 0467 Sakayori, Takeshi 0608 Sakr, Magdy 0539, 0540 Salimi Jazi, Mehdi 0320 Salinsky, Martin 0781 Salmi, L. Rachid 0803 Salmon, Danielle 0486 Salorio, Cynthia 0542 Salvo, Jesse 0540 Sambasivan, Krithika 0370, 0588 Sample, Pat 0814 Samson, Dana 0491 Samson, Neha 0691 Samuel, Geoffrey 0282 Sander, Angelle 0508, 0713, 0723, 0736 Sander, Angelle M. 0493 Sandhaug, Maria 0218, 0234, 0236 Sannita, Walter 0052 Sannita, Walter G. 0443, 0463 Santiago-Sanchez, Michelaldemar 0671 Santos, Marlene 0747 Sarajuuri, Jaana 0288, 0292 Sarkar, Korak 0870 Sartor, Denise 0477 Sarvghad-Moghaddam, Hesam 0320 Sasanuma, Junichi 0204 Sashika, Hironobu 0074

Sato, Joao 0385 Saugstad, Ola Didrik 0826 Saunders, Ann 0401 Saury, Jean-Michel 0151, 0237 Sauseng, Paul 0386 Sauve, William 0802 Savard, Joseé 0665 Savin, Ivan 0389, 0754 Saw, Hay Mar 0566 Saxby, Brian 0642 Saxe, Jonathan 0676, 0684 Sayer, Nina 0836 Saykin, Andrew 0261, 0402, 0604, 0778 Scapinello, Sarah 0539, 0540 Schachar, Russell 0401 Schache, Anthony 0269 Schaffer, Kathryn 0900 Schaiper, Courtney 0407 Schanke, Anne-Kristine 0152, 0170, 0266, 0290, 0519, 0590 Scheenen, M. E. 0246 Scherder, Eric 0032 Scherer, Matthew 0627 Schinke, Jennifer 0746 Schlaug, Christiane 0670 Schmand, Ben 0085 Schmidt, M. J. 0219 Schnakers, Caroline 0049, 0050, 0051, 0052, 0053, 0472, 0590 Schneider, Kathryn 0751, 0759, 0835, 0861 Schnyer, David 0714 Schouten, Evert J. 0669 Schrandt, Jennifer 0476 Schreiber, Ce´line 0168 Schreiber, Shaul 0068 Schuchard, Ronald 0833 Schult, Marie-Louise 0242 Schwartz, Barbara 0791 Schwartz, Ben 0616 Schwartz, Daniel 0685 Schwartz, Lauren 0729 Schweiger, Avraham 0156 Scott, Selena 0610 Scotter, John 0489, 0562, 0572 Scudder, Bonnie 0437 Scurfield, Alex 0861 Sebastiani, Maria 0515 Seeger, Trevor 0842 Seel, Ronald 0775, 0787 Seeldrayers, Pierrette 0472 Seibert, Pennie 0784, 0792, 0804 Seichepine, Daniel 0738 Seiler, Stephen 0218 Selby, Peter 0524 Semenova, Janna 0226, 0227 Senthinathan, Arrani 0615, 0619, 0622 Senzaki, Akira 0608 Seong, Augene 0133 Sephton, Keith 0196, 0488 Serbedzija, Predrag 0460 Serrano, Ana 0122 Seung, Ha Na 0631 Shacham, Sharon 0635 Shah, Alok 0752, 0795, 0888 Shah, Rajendra 0497 Shahinfard, Elham 0871, 0876, 0878 Shaltout, Hossam 0805 Shapiro, Andrew 0616 Shapiro, Colin M. 0343, 0344 Shapiro, Emma 0318 Sharan, Tanvi 0818 Sharifzadeh, Mohammad 0450 Sharma, Aruna 0021, 0025, 0026, 0027


874 Sharma, B. S. 0691 Sharma, Bhanu 0852, 0885, 0886 Sharma, Hari Shanker 0021, 0025, 0026, 0027 Sharma, Pushpa 0079 Sharova, Helen V. 0487 Sharp, Dave 0465 Sharp, David 0709 Shastri, K. V. R. 0149 Shavelle, Robert 0484, 0545 Shears, Steven 0536 Shehu, Bello Bala 0821 Shem, Kazuko 0378 Shen, Huijuan 0019 Shen, Jianhong 0093 Sheng, Tong 0367, 0480 Shenouda, Christian 0777, 0798 Shenton, Martha 0143, 0352, 0419 Shenton, Martha E. 0683, 0874 Shepard, Samantha 0173 Sher, Catalina 0782 Sherer, Mark 0493, 0508, 0713, 0723, 0736 Sherman, Janet 0117 Sherrill, Duane 0146, 0148 Shetty, Teena 0298 Sheu, Joen-Rong 0626, 0644 Shewchuk, Jason 0419 Shiel, Agnes 0636 Shiels, Paul G. 0719 Shimizu, Masato 0204, 0296 Shimodozono, Megumi 0561, 0596, 0698 Shin, Chan Young 0631 Shin, Kirk 0528 Shin, Wanyong 0748 Shin, Yong Beom 0327, 0328 Shinoda, Jun 0084, 0235 Shohami, Esther 0476 Shokunbi, M. T. 0726, 0732 Shultz, Sandy 0123 Shurkhay, Vsevolod 0760 Si Larbi, M. Tahar 0130 Sichev, Alexander 0760 Siegert, Richard J. 0488 Signoracci, Gina 0593 Sigurdardottir, Solrun 0170, 0214, 0266, 0431 Siironen, Jari 0069 Siitari, Harri 0496, 0708 Sikander, Murtuza 0572 Sikorski, Alla 0171 Sikorskii, Alla 0167, 0412 Silberg, Tamar 0790, 0800, 0875 Sills, Cheryl 0078, 0313 Sills, Cheryl L. 0667 Silva, Paulo 0461 Silveira, Patricia Corso 0728 Silverberg, Noah 0105, 0734 Silverberg, Noah D. 0072, 0195 Silverman, Seth 0882 Silvestro, Daniela 0439 Sima, Adam 0420 Simard, Anne 0309 Simmons, Charlotte 0237 Simon, Daniel 0725, 0728 Simone, Valentina 0712 Simpson, Grahame 0363, 0379, 0593 Sing, Geoff 0354 Singer, Maxwell 0298 Singh, Amarjeet 0087 Singh, Amit Kumar 0059 Singh, Avtar 0253 Singh, Binoy Kr 0411 Singh, Inderjit 0253

Brain Inj, 2014; 28(5–6): 517–878

Singh, Rajiv 0901, 0902 Singh, Sheila 0187 Singh, Tajinder 0253 Singh, Tanvir 0016 Sinha, Sumit 0691 Sinopoli, Katia J. 0262 Siponkoski, Sini-Tuuli 0292 Sirois, Katia 0478, 0503 Sirois, Marie-Joseé 0665 Sjo¨lund, Anette 0237 Skalin, Elisabet 0659 Skandsen, Toril 0170, 0248, 0317, 0519 Skilbeck, Clive 0340, 0342 Skinner, Kimberly 0254 Skoglund, Thomas 0582 Skouen, Jan Sture 0192 Sladkova, Petra 0442 Slatyer, Mark 0334, 0340, 0342 Sluiter, Judith 0294 Smart, Otis 0783 Smedler, Ann Charlotte 0104 Smeros, Tasos 0634 Smith, Bridget 0509 Smith, Dori 0261 Smith, Jenna 0190 Smith, Kirsten 0444 Smith, Kristin 0505, 0788 Smith, Laurel 0627 Smith, Samantha 0384 Snipes, Daniel 0090 Soberg, Helene L. 0241 Soddu, Andrea 0716, 0740 Soklaridis, Sophie 0810 Solbakk, Anne-Kristin 0152 Solberg, Rønnaug 0826 Solı´s-Marcos, Ignacio 0649 Solomon, Bev 0710 Solomon, Beverly 0827 Solovieva, Yulia 0071, 0228, 0735 Soman, Salil 0833, 0884, 0890 Sommerfeld, Teri 0757 Sone, Daichi 0555 Sonnen, Joshua 0762 Soo, Cheryl 0010 Sorteberg, Angelika 0430, 0541 Soshensky, Rick 0037 Sosson, Charlotte 0491 Sotelo, Michael 0146, 0148 Soto Rodrı´guez, Ivań Andre´s 0395 Spaite, Daniel 0146, 0148 Spangsberg Kristensen, Karin 0321 Sparadeo, Francis 0724 Sparadeo, Frank 0761 Spencer, Joanna 0451 Sperry, Deidre 0088 Spielman, Lisa 0624 Spikman, J. M 0246 Spikman, Jacoba M. 0264 Spitz, Gershon 0483 Squirrell, Trevor 0699 Staccioli, Susanna 0711 Stahel, Philip 0140 Stalnacke, Britt-Marie 0333, 0337, 0575 Sta˚lnacke, Britt-Marie 0222, 0779 Stamm, Julie 0645, 0874 Stancin, Terry 0429, 0579, 0591 Stanghelle, Johan 0116, 0290 Stanton, Sue 0477 Stapert, Sven 0393 Starr, Christy 0838 Statom, Gloria 0629


DOI: 10.3109/02699052.2014.892379

Stazyk, Kathy 0187 Stein, Deborah 0577 Stein, Deborah M. 0506 Steiner, Monica 0144, 0517 Stemper, Brian 0752, 0795, 0888 Stenberg, Maud 0222 Stentz, Lauren 0782 Stephan, Angelique 0277 Stephens, Anne 0066 Stergiou-Kita, Mary 0350, 0696 Sterkin, Anna 0694 Stern, Robert 0645, 0738 Stern, Robert A. 0683, 0831, 0874 Sterr, Annette 0385, 0386 Stevens, Lilian 0106 Stevens, Lillian Flores 0395 Stevens, Robert 0601 Stevenson, Julie 0737 Stewart, Elaine 0727 Stewart, William 0849 Stibrant Sunnerhagen, Katharina 0582, 0583 Stickans, Lindsey 0604 Stitzel, Joel 0766 Stolwyk, Rene 0095 Stolz, Uwe 0146, 0148 Stortini, Massimo 0841 Storzbach, Daniel 0836 St-Pierre, Corinne 0829 Strachan, Nicole C. 0605 Strand, Liv Inger 0331 Strandberg, Thomas 0639 Strauss, David 0484, 0545 Strayer, Hillary 0145 Strother, Stephen 0435 Stubberud, Jan 0152, 0290 Subbakrishna, D. K. 0149 Sujith, Sajja 0672 Sullivan, John 0486 Sullivan, Patrick 0791 Summers, Louisa 0515 Sun, Yong-Xin 0158 Suskauer, Stacy 0351, 0542 Sutter, Megan 0090 Suykerbuyk, Jeff 0185 Sveen, Unni 0241 Svestkova, Olga 0442, 0445 Swaine, Bonnie 0306, 0665, 0692, 0829 Sychev, Alexander 0389, 0544 Syrmos, Nikolaos 0909, 0910, 0911, 0912, 0913 Syrmou, Efstratia 0909 Sysi-Aho, Marko 0708 Tabish, S. A. 0057 Tacchino, Chantal 0658 Taha, Tim 0262, 0869 Tajiri, Naoki 0635 Takada, Kaokuko 0074 Takala, Riikka 0702, 0708, 0903 Takei, Mitsuo 0204 Takeuchi, Kosei 0155 Tal-Jacoby, Dana 0790 Tallus, Jussi 0702, 0708 Tam, Roger 0871 Tamber, Anne-Lise 0383 Tamir, Sharon 0635 Tan, Chunfeng 0016 Tan, Chunzhen 0566 Tan, Xin Lin 0123 Tanaka, Tsukasa 0528 Tang, Ying 0030 Taniguchi, Go 0555 Tartaglia, Maria C. 0220

875 Tate, David 0313, 0500 Tate, David F. 0667 Tate, Robyn 0556, 0557 Tateno, Amane 0608 Tatlisumak, Turgut 0670 Tator, Charles 0710 Tator, Charles H. 0220 Taunton, Jack 0871, 0876 Taylor, Gerry 0429 Taylor, H. Gerry 0579, 0591 Taylor, Joy 0276 Taylor, Kirsten 0835 Teak Sheng, Gee 0558 Teasdale, Graham 0096 Tegeler, Catherine 0805 Tegeler, Charles 0805 Televantos, Andreas 0912, 0913 Tell, Laurence 0330 Temkin, Nancy 0549, 0704, 0756 Tenedieva, Valeria 0389, 0544 Tenovuo, Olli 0072, 0496, 0702, 0708, 0903 Ter Mors, Bert 0362, 0546 Ter Steeg, Anne Marie 0209 Terranova, Lauren 0614 Tewari, Manoj 0087 Tham, Kerstin 0436 Thebault-Dagher, Fanny 0797 Theriot, Jude 0755 Therrien, Erik 0881 Therrien, E´rik 0533 Thibaut, Aurore 0168 Thomas, Danny 0752 Thomas, Matthew 0646 Thompson, Mary-Ellen 0824 Thomsen, Ane Sondergaard 0200 Thomsen, Ane Søndergaard 0279 Thomson, Allan 0688 Thomson, Susan 0629 Thordarson, Micaela 0833 Thurairajah, Pravheen 0675 Ticha, Marie 0442 Tierney, Ryan 0012 Tillmann, Barbara 0330, 0406 Timmons, Brian 0252 Tistad, Malin 0647 Tkachenko, Olga 0653 To, Vivian 0528 Toda, Ketra 0374, 0375 Todd, Ryan 0034 Todis, Bonnie 0459 Togher, Leanne 0556, 0557 Tolfa, Maurizio 0712 Tomasson, Kristinn 0102, 0103 Tomaszczyk, Jennifer 0886 Tomaszczyk, Jennifer C. 0885 Tominaga, Gail 0900 Tong, Jianliang 0409 Tong, Wusong 0244, 0249 Topolovec-Vranic, Jane 0300, 0338, 0426, 0502, 0505, 0603, 0747 Toppi, Jlenia 0440 Torg, Joesph 0012 Tornas, Sveinung 0266 Torna˚s, Sveinung 0152 Torres, Katrina 0121 Tosta, Sandra 0457 Toure´, Mariama 0309 Tousignant, Beatrice 0503 Tousignant, Beátrice 0478 Towne, Alan 0781 Townend, William 0176, 0177 Traub, Carla 0173


876 Traynham, Stephanie 0403 Trembovelr, Victoria 0476 Trigg, William 0293 Tripodis, Yorghos 0645, 0738 Trksak, George H. 0653 Trojano, Luigi 0703, 0799 Troncoso, Juan C. 0770 Truchon, Catherine 0692, 0829 Truelle, Jean-Luc 0789 Tsai, Alan 0528 Tsai, Shin-Han 0662 Tsai, Yi-Hsin 0054 Tsao, Jack W. 0782 Tshibanda, Luaba 0716, 0740 Tsoller, Darina 0603 Tulsky, David 0736 Tuominen, Markku 0111 Turan, Lisa 0007, 0008 Turbach, Josie 0817 Turgeon, Alexis 0665 Turkstra, Lyn 0075, 0083, 0392, 0556 Turner, Ryan 0016 Turner-Stokes, Lynee 0400 Turner-Stokes, Lynne 0196, 0381, 0382, 0488 Turunen, Senni 0283 Tweedie, David 0068, 0101 Tyler, Mitchell 0254 Uhrig, Paula 0554 Unden, Johan 0137 Undeń, Johan 0136 Uram, Katie 0300 Urban, Jillian 0766 Urmy, Jahanara 0612 Uwandu, Chiedozie 0586 Vaccaro, Monica 0859 Vaidya, Nutan 0621 Vaidyanath, Chantal 0505 Vakil, Eli 0800 Valadakis, Vasileios 0909, 0910, 0911 Valadka, Alex 0714 Valdivia, Edgar Ricardo 0106, 0854 Valdivia Tagarife, Edgar Ricardo 0147, 0395 Valera, Eve 0339 Valerio, Jennifer 0784, 0792, 0804 Valiullina, Svetlana 0227 Vallat-Azouvi, Claire 0238, 0240, 0287 van Bennekom, Coen 0085, 0294 van der Horn, H. J. 0246 Van der Kouwe, Andre´ 0117 van der Merwe, Andre 0798 van der Naalt, J. 0246 van der Naalt, Joukje 0264 van der Ploeg, Hidde 0606 van Donkelaar, Paul 0605, 0744 van Dormolen, Max 0294 van Erp, Willemijn 0255 van Gils, Mark 0496 van Haastrecht, Klaasjan 0208, 0209 van Heugten, Caroline 0393 van Markus, Frederike 0265 van Markus-Doornbosch, Frederike 0120 van Noordt, Stefon 0905 van Stein Callenfels, Karen 0203, 0208 van Velzen, Judith 0294 Vandenheuvel, Sara 0392 VandeVord, Pamela 0529, 0672 VandeVord, Pamela J. 0467 Vanhaudenhuyse, Audrey 0716, 0740 Vannasing, Phetsamone 0797 Vannemreddy, Prasad 0026 Van’t Hooft, Ingrid 0274

Brain Inj, 2014; 28(5–6): 517–878

Vartanian, Oshin 0350 Vartiainen, Matti 0111, 0288 Vas, Asha 0141 Vassar, Mary 0714 Vaughn, Susan 0459 Vaziripour, Hossein 0125 Vazquez, Denise 0455 Velez, Ivan 0671 Velikonja, Diana 0477, 0610, 0763 Velnar, Tomaz 0263, 0267 Velozo, Craig 0775, 0787 Venhacova, Petra 0250 Vera, Evelyn 0478, 0503 Verbny, Yakov 0254 Verdecho, Ignacio 0449 Vergara Torres, Gina Paola 0815 Verger, Julie 0330 Verhoeven, Inge 0208, 0209 Verma, Ragini 0355 Verweel, Lee 0848 Vieira, Gilson 0385 Vik, Anne 0248, 0317 Vikane, Eirik 0192 Villalba, Ana 0479 Villarreal, Mirta 0304 Villarreal Nasayo, Diana Milena 0854 Villasenõr Cabrera, Teresita 0847 Villegas, Christine 0298 Villien, Marjorie 0117 Virji-Babul, Naznin 0124, 0190 Viscusi, Chad 0146, 0148 Visscher, Kristina 0392 Vivanco, Ana Ines 0062 Vliet Vlieland, Thea 0042, 0120, 0135, 0209 Voigt, Niesha 0298 Vokhiwa, Maclean 0412 von Koch, Lena 0647 von Steinbuechel, Nicole 0292 Vorobiov, Yuriy 0544 Vos, Pieter 0255 Wade, Christine 0577 Wade, Derick 0393 Wade, Shari 0429, 0579, 0591 Wainman-Lefley, Jessica 0697, 0727, 0743, 0745 Waldron, Brian 0422, 0652 Wales, Lorna 0369, 0432, 0438 Wa¨ljas, Minna 0283 Walker, Andrea 0043 Walker, Keenan 0780 Walker, Matthew 0144 Walker, William 0420, 0473 Walker, William C. 0257 Wallace, Colin 0744 Wallace, Eugene 0857 Walsh, R. Stephen 0415, 0416, 0422, 0652 Walworth, Jennifer 0746 Walz, Nicolay 0579 Wang, Chen-Pin 0500 Wang, Fuyan 0051 Wang, Jane 0190 Wang, JiaChuan 0030 Wang, Jin 0549 Wang, Li 0091 Wang, Wenjin 0299, 0301, 0336 Wang, Wenjing 0233 Wang, Xiao-Hong 0158 Wang, Xue 0144, 0517, 0521, 0690 Wang, Yang 0019, 0261, 0402 Wang, Yueming 0299, 0301, 0336 Wang, Yushi 0624 Ward, Earlise 0100

877


DOI: 10.3109/02699052.2014.892379

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Abstracts 2014.

2014 ACAPS Congress: Abstracts.

Research day 2014 abstracts.

RIMS 2014 - Abstracts.

IRSSD 2014 Meeting Abstracts.

ESGAR 2014 Book of Abstracts.

ACPA 2014 Oral Presentation Abstracts.

Introduction to the CPNP 2014 Poster Abstracts.

Selected reviews from the 2014 BMT Tandem meetings [corrected].

The College of Podiatry Annual Conference 2014: meeting abstracts.

Abstracts of the AAGBI WSM London, 15-17 January 2014.

Abstracts of presentations at the 2014 northeastern division meeting.

Abstracts of presentations at the 2014 potomac division meeting.

Abstracts of presentations at the 2014 pacific division meeting.

Abstracts of the 2014 International Society Developmental Psychobiology Meeting, November 12-14, 2014, Washington, DC, USA.

Abstracts Accepted for American Conference on Pharmacometrics 2014 (ACoP5), October 11-17, 2014, Las Vegas, Nevada.

Abstracts of the EuroHeartCare 2014, April 4-5, 2014 , Stavanger, Norway.

Erratum to: Abstracts from the ICBM 2014 Meeting.

Abstracts of presentations at the 2014 Caribbean division meeting.

2014 abstracts and posters: canadian pharmacists conference saskatoon, Saskatchewan.

Abstracts from the 2014 - 25th Anniversary SVM Scientific Sessions.

Abstracts of presentations at the 2014 southern division meeting.

Abstracts from the EAACI Skin Allergy Meeting 2014.

Abstracts of presentations at the 2014 north central division meeting.