September 14-17, 2011 New Orleans, Louisiana

Dear Colleagues,

It is with great pleasure that we present the accepted abstracts from the NABIS Ninth Annual Conference on Brain Injury in this issue of the Journal of Head Trauma Rehabilitation. The conference will take place in New Orleans, Louisiana, from September 14-17, 2011.

We are delighted to have received an increase in submissions of over 30% from our last event in 2010. Certainly it is encouraging that there is a growing body of research and findings that will help us to better treat patients with brain injury. For those of you unable to attend the NABIS meeting, we hope that the abstracts presented in the following pages will at least give you a feel for our annual event. In addition to the presentation of the abstracts included in this issue, over 40 invited speakers will present the latest advances in the science, rehabilitation, and treatment of traumatic brain injury. The full conference program is posted on the NABIS website, http://www.nabis.org.

The conference focuses on 4 concurrent education tracks covering the following topic areas: Medical-Clinical Best Practices, Research/Science, Life Long Living & Working, and Legal Issues in Brain Injury. Attendees include basic scientists, rehabilitation physicians, psychiatrists, psychologists, neuropsychologists, speech pathologists, occupational therapists, physical therapists, social workers, nurses, case managers, legal professionals, advocates, and all others working in the field of brain injury.

NABIS is pleased to announce that this year's conference will feature a full-day pre-conference course on Cognitive Rehabilitation and a special session on Blast Injury. Also new this year, training for certification in the Academy of Certified Brain Injury Specialists (ACBIS) will be offered on-site.

We hope that you will consider submitting your work for our 2012 meeting scheduled to take place in Miami. Better yet, we hope that you will also consider becoming a member of our multidisciplinary society. Whether it is in the area of research or clinical care, NABIS stands behind the premise that advances in science and practices based on application of the scientific evidence will ultimately provide the best outcomes for those with brain injuries and the community as a whole.

Sincerely,

Ronald C. Savage, EdD

Chairman, North American Brain Injury Society

Harvey E. Jacobs, PhD

Conference Chair

Mariusz Ziejewski, PhD

Abstract Chair

NABIS: http://www.nabis.org

0003

Developing and Teaching Compensatory Strategies: Functional Treatment Approaches for Persistent Cognitive and Language Deficits

Stephanie Volker

Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA

Introduction/Rationale

This presentation is intended for clinicians treating clients with cognitive or language disorders who would benefit from a more functional, outcome-based approach to therapy. Many pediatric clients, especially adolescents, benefit from specific skill training initially, but then seem to plateau or cannot generalize skills to carry over into functional activities. A shift from a traditional model of targeting skills, to one in which therapists work with the client and family to develop strategies to compensate for persistent deficits, is often very beneficial and can yield functional, tangible results.

Method/Approach

This presentation will provide clinicians with an overview of the types of cognitive and language skills that can be targeted with compensatory strategies and, therefore, significantly increase successful outcomes for patients. In addition, the course will provide an overview of how to assess the need for strategies, outline the steps to develop strategies, and present tips for successful training of the client and family for improved carryover into the "real world". This course can be expanded to include strategies specific to school return or job re-entry.

Results/Effects

This clinician has seen excellent progress made in terms of functional outcome goal attainment when this type of approach is utilized. The presentation will highlight several case studies, providing examples of each step of the process for development of strategies and recommended accommodations. Participants will be invited to work through a similar step-by-step procedure with a client example, and develop at least one new strategy to try to implement in their practice. This course will help clinicians think outside the box and to develop a fresh approach to therapy with those clients who would benefit.

Conclusions/Limitations

This course can apply to any professional working with individuals who have sustained a brain injury. While this presentation is based on one clinician's experience and independent development of strategies, the approach is well supported by current research. If desired, this course can be modified in several ways to include strategy development for both the adult and pediatric population centering only on functional outcomes for home and community, or cover strategy development related to functional outcomes for just the pediatric population, or be expanded to include examples for strategies applicable to the school setting for the pediatric population.

0004

Dimensions of Support, Hope, and Resiliency in Brain Injury Survivors and their Families

Barbara Barton

Western Michigan University, Kalamazoo, MI/Midwest, USA

Introduction/Rationale

A strong 'support system,' characterological resiliency, and the abstract concept of 'hope' regarding one's future orientation, provide a triumvirate biopsychosocial framework for treatment success. Deconstructing these concepts is critical for professionals to effectively assess the strengths consumers contribute to the rehabilitation process. A four-part model of a support system will be proposed; and a study of perspectives on survivors' and brain injury professionals' indicators of hope and resiliency will be discussed.

Method/Approach

Thirty-two brain injury professionals and fifteen brain injury survivors were surveyed, and their responses were analyzed utilizing an inductive content analysis method, regarding this question: "In your opinion, how would you define the concept of "hope" from the perspective of brain injury survivors?"

Results/Effects

Results indicate that both sets of respondents had very concrete contributors to hope, in the form of protective resiliency factors. Responses emerged in four primary domains of support: 1) practical, 2) emotional, 3) intellectual, and 4) spiritual.

Conclusions/Limitations

Treatment success is enhanced by identifying survivors' and families' resilient "protective factors" (that contribute to positive outcomes in the face of disordered stress) - and "risk factors" (sequelae that derail treatment). Traditional treatment approaches have aggregated these factors into one phrase: 'support system'. This research identified the multidimensionality of support, hope, and resiliency to encourage re-examination of survivor assessment and rehabilitation readiness. Generalization is limited, since survivors needed to understand abstract terminology that may be challenging for those with significant cognitive deficits. The results provide a useful framework for inquiry into these areas, and a re-examination of the nature of "support.

0005

Quantification of Pain-Related Impairment, According to the AMA Guides 5th Ed., and Its Correlation with the Physical Performance of Subjects with Central Nervous System Disorders from Poly-Trauma Combined with Chronic Non-Malignant Pain

Armando Miciano

Nevada Rehabilitation Institute, Las Vegas, NV, USA

Introduction/Rationale

The objective is to quantify pain-related impairments (PRI) of subjects with Central Nervous System Disorder (NSD) from Poly-Trauma combined with chronic non-malignant pain (CNP). The study used the self-reported Ratings Determining Impairment Associated with Pain (RDIP), from the AMA Guides to the Evaluation of Permanent Impairment, 5th Ed. and investigated the correlation between the patient-derived PRI and clinician-derived Physical Performance Test (PPT) scores. BACKGROUND: There has been no previous systematic research on neurologic impairment or the pain impairment rating system using the AMA Guides.

Method/Approach

A retrospective study was done in an Outpatient Rehabilitation Facility with 70 participants reporting Poly-trauma (ages 22-78 years). The Self-Administered Co-Morbidity identified 30 individuals with NSD afflicted with CNP. The RDIP quantified PRI via five sub-scales: Pain Severity; Activity Interference; Mood Effect; Global Pain Behaviour; and, Credibility. The PPT used were: 6-Minute Walk (6MWT), Berg Balance Scale (BBS), and Dynamic Gait Index (DGI). Pearson correlation coefficients (r) examined associations between RDIP and PPT. An alpha of 0.10 was used for statistical tests.

Results/Effects

Total RDIP resulted in: 0% mild PRI, 33% moderate, 22% moderately-severe and 45% severe PRI. The PRI with CNS disorders were mostly in severe sub-category. Mean Impairment Rating (IR) due to CNS was 46%. Neither age (F = 1.619, p = .168) nor gender (F = .717, p = .710) were significant factors. A statistically significant negative correlation was found between Total RDIP vs. 6MWT distance (r = -.506, p = .003), DGI (r = -.573, p < .001), and BBS (r = -.480, p = .005).

Conclusions/Limitations

The study found that subjects with NSD >2 years and chronic pain had moderate impairments due to the neurologic deficit(s) and had severe persistent pain-related impairments that significantly correlated to a short walk distance, low dynamic gait capacity, and high balance deficits. The study suggests that the RDIP should be studied further in larger population since it is a potential indicator of physical performance and a valuable alternative to PPT in a busy clinic practice.

0006

Quantitative Assessment of the Permanent Impairment due to Nervous System Disorder in Individuals with Traumatic Brain Injury, according to the AMA Guides to Evaluation of Permanent Impairment, 6th Edition: Impact on Health Care Utilization and Life Care Planning

Armando Miciano

Nevada Rehab Institute, Las Vegas, NV, USA

Introduction/Rationale

There has been no previous systematic research on the %NSD from the AMA Guides. The study determined the Nervous System Disorder Impairment percentage rating (%NSD), according to the AMA Guides to Evaluation of Permanent Impairment, 6th Edition and examined the relationship between %NSD, global physical health, and physical performance of individuals with Traumatic Brain Injury (TBI) due to poly-trauma of greater than two years duration.

Method/Approach

The retrospective study was done on 30 TBI subjects (>2 year poly-trauma duration; 19 men; ages 28-62) selected from outpatient rehabilitation clinic records. Main outcome measures used were %NSD, PROMIS Physical Function (PF), and 6-Minute Walk Test (6MWT). Subjects were stratified by %NSD, a neurologic impairment assessment system from the AMA Guides 6th Ed., based on: state of consciousness/level of awareness; mental status evaluation/integrative functioning; language use/understanding; and, behaviour & mood influence. Global Physical Health (GPH) was measured using the PROMIS Physical Function (PF) subscale, and the physical performance status (PPS) was calculated using the 6MWT.

Results/Effects

Clinical scores ranged: 10-55 %NSD (average 36%); PROMIS-PF 23.7 to 45.7 (average 31.8 T-score); 6MWT distance & metabolic equivalents (METS) 339-1330 feet (average 982 feet) & 1.58-2.93 METS (average 2.45 METS). %NSD were mostly in the mild severity, but GPH and PPS levels low. There was a trend relationship of the %NSD to the GPH and PPS.

Conclusions/Limitations

The study found that individuals with TBI due to poly-trauma >2 years: 1) had mild neurologic impairment ratings (using the AMA Guides 6th Ed.); 2) had low global physical health; 3) walked short distances; and, 4) had average energy expenditure capacity. Further study on the correlation of %NSD in TBI and GPH & PPS should be done.

0007

Determining the Physical Performance, Global Mental Health, Pain Impairment, and Multi-Morbidity Burden in Subjects with Traumatic Central Nervous System Disorder >Two Years Duration Combined with Chronic Pain: Impact on Health Care Utilization

Armando Miciano

Nevada Rehabilitation Institute, Las Vegas, NV, USA

Introduction/Rationale

The study determined the physical performance and global mental health, along with the pain-related impairment (PRI) using the Pain Disability Questionnaire (PDQ), a pain severity assessment from the AMA Guides to Evaluation of Permanent Impairment, 6th Ed. in subjects with central nervous system disorder due to trauma >two years duration combined with chronic pain.

Method/Approach

A retrospective study was done in a comprehensive outpatient rehabilitation facility on 29 of 100 subjects (19 men & 10 women, age 28-62). Outcome measures used were: Berg Balance Scale (BBS), PROMIS-Anxiety, PROMIS-Depression, PDQ, and Self-Administered Co-Morbidity Questionnaire (SCQ). Physical Performance Status (PPS) was calculated using BBS, and Global Mental Health (GMH) was measured using the PROMIS-Anxiety & PROMIS-Depression (AD) subscales. PRI was categorized by the PDQ, based on Functional Status (FS) and Psychosocial Distress Status (PS), and the SCQ measured the Multi-Morbidity Burden (MMB).

Results/Effects

Clinical scores ranged: BBS 8-56 out of 56 (average 42.0); PROMIS-Anxiety T-score 37-83 (average 60); PROMIS-Depression T-score 38-81 (average 59.2); total PDQ 6-150 of 150 (average 92); PDQ-Psychosocial (PS) 6-60 of 60 (average 36.71); and, SCQ 0-15 of 39 (average 7.0).

Conclusions/Limitations

Subjects with central nervous system disorder due to trauma >2 years duration combined with chronic pain tend to have good physical performance, decreased global mental health, moderate pain-related impairment, and mild multi-morbidity burden. The study found a trend relationship of the PPS to GMH, PS, and MMB. The study also found that the health burden of CNS injury care was extensive due to the clinical complexity of subjects. We recommend that the SCQ, PDQ, and PROMIS be used as part of comprehensive clinical measures for these difficult-to-manage subjects who need integrated care. Further study on the correlation of PPS, PROMIS, PDQ, and SCQ should be done.

0009

Relationship Between the Neuropsychological Assessment Battery (NAB) Daily Living Measures and Functional Skills in Post-acute Brain Injury Rehabilitation (PABIR)

Dennis Zgaljardic¹, Rebekah Miller⁴, Monica Watford², Sybil Yancy¹, Gabrielle Morales¹, Emilee Anderson⁴, Michelle Medina¹, Richard Temple³

1Transitional Learning Center, Galveston, TX, USA, 2University of Texas Medical Branch, Galveston, TX, USA, 3CORE Health Care, Drippings Springs, TX, USA, 4Transitional Learning Center, Lubbock, TX, USA

Introduction/Rationale

The Neuropsychological Assessment Battery (NAB; Stern & White, 2003) is a comprehensive neuropsychological test battery that incorporates five measures of "daily living" as a means to assess skills that are "congruent with an analogous real-world behaviour". The five daily living (DL) measures include: Driving Scenes (attention), Daily Living Memory (memory), Map Reading (spatial), Bill Payment (language), and Judgment (executive function). The purpose of the current study was to assess the ecological validity of the NAB DL measures using the Mayo-Portland Adaptability Inventory-4 (MPAI-4; Malec & Lezak, 2003).

Method/Approach

Forty-three individuals (67.4% male) with moderate to severe traumatic brain injury (TBI) admitted to a residential post-acute brain injury rehabilitation (PABIR) program were each administered the MPAI-4 and the five NAB DL measures. Hierarchical regression analysis was used to examine the predictive relationship between the five NAB DL measures and functional skills as assessed by the MPAI-4 including (a) Total score, (b) Ability subscale score [e.g., sensory, motor, cognition], (c) Adjustment subscale score [e.g., mood & interpersonal reactions], and the (d) Participation subscale score [e.g., social contacts, initiation, & money management].

Results/Effects

Hierarchical regression models revealed that scores from the NAB DL Bill Payment measure were significantly predictive of the MPAI-4 Total score and the Ability subscale score above and beyond the contribution of demographic and clinical variables. Scores from the NAB DL Map Reading measure were significantly predictive of the MPAI-4 Participation subscale score above and beyond the contribution of demographic and clinical variables. None of the DL measures or demographic or clinical variables was significantly predictive of the MPAI-4 Adjustment subscale score.

Conclusions/Limitations

The current findings appear to provide evidence for the ecological validity of the NAB DL Bill Payment task and the NAB DL Map Reading task with regard to functional activities assessed using the MPAI-4. The underlying functional skills assessed by these specific NAB DL measures (Bill Payment - check writing, check book reconciliation, and budgeting); Map Reading - visuospatial and visual scanning skills are commonly addressed in several facets within a PABIR program. The lack of a statistically significant association between the NAB DL measures and scores from the MPAI-4 Adjustment subscale demonstrates discriminant validity.

0012

Neurocognitive Assessment for Children Recovering from Brain Injury

Gillian Hotz

University of Miami Miller School of Medicine, Miami, FL, USA

Introduction/Rationale

Neurocognitive assessment of children recovering from traumatic (TBI) and acquired brain injury (ABI) is critical when tracking recovery and developing specific rehabilitation programs. The purpose of this study was to develop and validate a criterion referenced neurocognitive assessment, the Pediatric Test of Brain Injury (PTBI).

Method/Approach

The development of this assessment measure was conducted in two phases. In both phases, children between the ages of 6 and 16 years of age were administered the research versions of the PTBI. Data were analyzed using Item Response Theory (IRT) to determine ability scores for each item and t tests were used to validate the ability scores.

Results/Effects

In this study, the PTBI was administered to 257 subjects (TBI = 134, ABI = 46, Non-Injured = 77) from 15 test sites. This research version included ten subtests with 99 of the subjects included in the IRT analysis (33 matched from each group). All cases were matched by age (mean age = 10.7 years) and gender (14 males and 19 females per group). Significant differences (p < .05) between subtest scores and groups were identified for Orientation, Naming, Word Fluency, and Picture Recall subtests. The What Goes Together and Picture Recall subtests had the highest statistically significant correlations (p < .05) with the Glasgow Coma Scale (r = .58, r = .49) and Rancho Los Amigos Scale (r = .56, r = .50), respectively.

Conclusions/Limitations

The PTBI is a criterion referenced test that is a reliable and valid test that is useful for assessing neurocognitive abilities following a brain injury. The PTBI can be used during the acute and rehabilitation phases of recovery for monitoring functional changes, tracking recovery patterns and guiding decisions regarding strengths and weaknesses in order to implement effective rehabilitation programs.

0013

Quenching Your Thirst: A Rare Presentation of Combined Central and Extra-Pontine Myelinolysis

Bravein Amalakuhan, Arvin Parvathaneni, Sarah Hanna, Pramil Cheriyath, Rajinder Sahi

Pinnacle Health Hospitals Network, Harrisburg, PA, USA

Introduction/Rationale

Central Pontine Myelinolysis (CPM) caused by rapid correction of hyponatremia is rare and only 95 cases related to this specific cause have been reported between 1986-2002, with the incidence between 2002-2010 being unclear, but still likely small in number. We present a rare case of a 39 year old female with primary polydipsia, who developed severe hyponatremia, and consequently developed CPM and Extra-pontine Myelinolysis (EPM). Not only is having both CPM and EPM in a single patient extremely rare with few reported cases, this patient also illustrated a rare manifestation of CPM.

Method/Approach

CASE: A 39 year old female with past medical history of depression, PTSD, and alcohol abuse was transferred from another hospital after she presented with nausea, vomiting and headache. She reported self-induced vomiting over the last 3-4 weeks, and drinking 5-10 L of water daily. She was found to have severe hyponatremia (109 mmol/L). Her home medications included Celexa and Ambien. Her vital signs on admission were stable. Her initial physical examination showed no focal neurologic deficits. Upon arrival to our hospital, her sodium was 116 mmol/L, potassium 4.0 mmol/L, bicarbonate 27.7 mmol/l, creatinine 0.7 mg/dl, glucose 93 mg/dl, calcium 8.4 mg/dl, serum osmolality 236 mos/kg, and urine osmolality 87 mos/kg.

Results/Effects

The patient was placed on fluid restriction of 800 ml/day of NSS and her sodium levels were closely monitored. The next day her sodium level increased to 130 mmol/L, an increase of more than 20 mEq/24 hours. An MRI completed 48 hours after admission was normal. Eight days later, the patient developed new onset urinary incontinence and left eye nystagmus. A repeat MRI of the brain showed changes consistent with CPM, and cerebral white matter changes consistent with EPM. The patient's serum sodium stabilized to normal levels, and her neurological status remained stable until the time of discharge.

Conclusions/Limitations

Most case reports of CPM involve symptoms of paraplegia and extremity weakness. No literature is known to have described this presentation of CPM. It is possible that this rare presentation of CPM could be related to the extra-pontine white matter changes, but this is difficult to discern because few case reports exist describing EPM. CPM is rare and considering that only 10% of CPM cases present with secondary EPM, our case presentation gives researchers a rare glimpse of this unique group of patients. Osmotic Demyelination Syndrome as a whole is poorly understood, and further research on these conditions is greatly needed.

0014

The Relationship Between Glasgow Coma Score and Blood Superoxide Dismutase Activity in Patients with Traumatic Brain Injury

Aysegul Bayir, Aysel Kiyici

Selcuk University, Selcuklu Faculty of Medicine, Konya, Turkey

Introduction/Rationale

Brain damage after a head injury occurs primarily at impact and secondarily with the onset of auto- destructive processes. Early oxidative changes in the plasma, erythrocytes and cerebrospinal fluid have shown a significant correlation with neurological outcome in traumatic brain injury. The aim of this study is to investigate the relation between Superoxide Dismutase (SOD) levels and Glasgow Coma Score (GCS) on admission to emergency service in patients with head trauma.

Method/Approach

The subjects of this study are composed of patients with head injury. For each of them, GCS were calculated on admission to emergency department. SOD activity in the blood samples taken at acceptance was examined. To compare data, Mann-Whitney U and Chi Square tests were used. p <= 0.05 was taken as significance level.

Results/Effects

The study included a total of 115 patients (32 female, 83 male). Mean age of the patients was 36.1+/-27.5. It was found out that mean GCS of the patients was 5.7+/-4.3. The mean SOD activity of the patients was found to be 2914 (min. 1032-max. 5786) Ug/Hb. The mean SOD level was 2122 Ug/Hb for patients with GCS <8 (64 patients). The mean SOD level was 3679 Ug/Hb for patients with GCS >= 9 (51 patients). There was a significant difference between patients with GCS < 8 and patients with GCS >= 9 with respect to SOD activity (p = 0.021).

Conclusions/Limitations

There is a relationship between GCS and SOD in patients who have sustained head trauma. In these patients, SOD activity decreases as GCS decreases. The low SOD activity in patients with head trauma suggests severe brain injury.

0015

The Absence of Nrf2 Enhances NF-[kappa]B Dependent Inflammation Following Scratch Injury in Mouse Primary Astrocytes

Hao Pan, Handong Wang, Xiaoliang Wang, Lin Zhu, Lei Mao, Liang Giao

Department of Neurosurgery, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, Jiangsu Province, China

Introduction/Rationale

It has been proved that Nrf2 depletion enhances inflammation process through activation of NF-[kappa]B in mice brains after traumatic brain injury (TBI). However, little is known about the role of astrocytes on Nrf2 and NF-[kappa]B after TBI. In this study, we used primary cultured Nrf2 wild type or knockout astrocytes to study the influence of Nrf2 on the expression of pro-inflammatory cytokines after TBI.

Method/Approach

Primary cultured astrocytes from Nrf2 wild type or knock out mouse were scratched or not scratched. Then the DNA-binding activity of NF-[kappa]B was evaluated by EMSA. The mRNA and protein level of TNF-[alpha], IL-1[beta] and IL-6 were evaluated by RT-PCR and ELISA. The mRNA and protein level of MMP9 was studied by RT-PCR and western blot. Gelatin zymography was performed to check the activity of MMP9.

Results/Effects

After scratch, the activity of NF-[kappa]B and expression of pro-inflammatory cytokines mentioned above were up-regulated. The activity of MMP9 was elevated too. Such tendency was much more prominent in KO astrocytes than in WT astrocytes.

Conclusions/Limitations

These results suggest that absence of Nrf2 may induce more aggressive inflammation through activation of NF-[kappa]B and downstream pro-inflammatory cytokines in astrocytes.

0016

International Reflections on Accreditation as a Quality Strategy

Christine MacDonell

CARF International, Tucson, AZ, USA

Introduction/Rational

A brain injury changes the life of the person who sustains it and his or her family/support system. Internationally, health and human service providers strive to meet the unique and often complex medical, physical, cognitive, psychosocial, behavioural, vocational, educational, and recreational needs of persons with brain injury. Increasingly providers and regulators throughout the world are looking to accreditation to provide a framework for quality and a blueprint for person-centered service delivery throughout the continuum. This session discusses accreditation as a quality strategy and gives examples of successes and challenges inherent in implementing standards across various cultures and regulatory systems.

Method/Approach

Analysis is based on case studies regarding the impact of diversity and funding on service delivery along with interviews and information obtained from many countries dealing with the long-term issues of people with brain injury.

Results/Effects

This presentation provides an increased understanding of how countries can share strategies and how those strategies can impact participation of persons with brain injury in their communities of choice.

Conclusions/Limitations

Although limited funding is a universal challenge, methods of dealing with the long-term issues of persons with brain injury are reflective of unique diversity issues. Lessons can be learned from each.

0017

Combining Strategies to Promote the Generalization of Self-Management Skills

Ron Allen

Ivy Street School, Brookline, MA, USA

Introduction/Rationale

After brain injury, many individuals experience chronic behavioural dysregulation. More than managing physical and cognitive impairments, the inability to manage one's emotional and behavioural impairments represents the greatest barrier to successful community re-integration. Dialectical Behavior Therapy (DBT) (Linehan, 1993) has been applied successfully to diverse populations challenged with behavioural dysregulation.

In the present study, the original DBT Skills were modified for use by adolescents with brain injury in a residential treatment center. The modified DBT skills include: (1) Clear Picture/Mindfulness, (2) Balancing Acceptance and Change, (3) Choices have Consequences, (4) Old Me-New Me, (5) On-Track Action, and others.

Method/Approach

In an effort to promote generalization, each DBT Skills are taught in a variety of settings and modalities ("training multiple exemplars" and "teaching in context"). Finally, in an effort to promote generalization through the use of a "mediating stimulus", individual students are digitally filmed performing each of the skills, and the films are imported into their video phones (e.g., i-Phone). Students are instructed to review their self-portrayed skills during periods of escalating emotions in an effort to promote the use of self-management skills and reduce the occurrence of behavioural dyscontrol requiring staff intervention.

Results/Effects

It has been our observation that all of our students learn to name and discuss the 12 DBT Skills listed above. Anecdotally, many students are observed to practice the skills in vivo during emotionally challenging circumstances. However, a greater number of students fail to employ DBT Skills at the moment of emerging dyscontrol. It is hoped that (1) students will use their DBT Video Self-Portraits (either independently or with staff prompting) during periods of stress; (2) students will be observed subsequently employing identifiable self-management skills, and (3) the probability [?], duration, and intensity of the episodes of dyscontrol will decelerate.

Conclusions/Limitations

Individuals with brain injury are often described as impulsive, emotionally labile, and easily frustrated. Their emotional behaviours are observed to escalate quickly without their recognition. It is hoped that the use of their own behaviour as stimulus will facilitate their performance of self-management behaviours, and that the use of the mediation of their video performance will allow the generalization of behaviour control to a range of settings. If such generalization can be observed, the successful re-integration of our student into home, community school, and competitive employment can be further realized.

0018

Peripheral Thermal Injury Causes Blood-brain Barrier Dysfunction and Zonula Occludens-1 Expression Changes in Rat

Zeng-Xu Liu, De-Ming Liu, Xiang-Dong Wang, Hang-Hui Wang, Chong-Fa Zhou

Nanchang University, Nanchang, Jiang Province, China

Introduction/Rational

Mortality after serious systemic thermal injury may be linked to significant increases in cerebral vascular permeability and edema due to blood-brain barrier (BBB) disruption. Zonula occludens-1 (ZO-1), a protein of the tight junctions (TJ), lines the cytoplasmic face of intact TJ. The current study investigated whether disruption of BBB in a rat thermal injury model is associated with ZO-1 expression changes.

Method/Approach

The experimental Sprague-Dawley rat's models with severe scald (30%TBSAIII degree) were established. In this research, healthy Sprague-Dawley rats were separated into two groups as following: normal control, scald group which were divided into five post -scald groups: 3, 6, 12, 24h and 48h. Changes in BBB permeability were determined by detected Evans blue content in rats' brain. Brain edema was detected by calculating water content. Furthermore, in order to explore the molecular mechanism of BBB disruption in rats' brain, the expression levels of gene and protein of ZO-1were analyzed by semi-quantitative reverse transcription-polymerase chain reaction and western-blot analysis, respectively.

Results/Effects

Expression of brain ZO-1mRNA was significantly decreased 3 through 48h after burn. Expression of brain ZO-1 protein was significantly decreased at 24, 48h post thermal injury, however ZO-1 expression changes were not marked at 3, 6, 12h post thermal injury. Water content and Evan's blue dye of brain were significant began to increase at 3h and reached significant levels between 6 and 24h after thermal injury. While ZO-1 protein levels continued to decrease significantly through 48h.

Conclusions/Limitations

The decreases in ZO-1mRNA expression and protein, associated with increased BBB permeability following thermal injury, indicating ZO-1 may contribute to observed cerebral edema in peripheral thermal injury.

0019

Misclassification in Transition to Public School for Children with Traumatic Brain Injury

Cynthia Plotts¹, Joanne McGee¹

1Texas State University, San Marcos, TX, USA, 2Rescare Premier, San Marcos, TX, USA

Introduction/Rationale

Efficient and effective identification and transition to school for school-age children and adolescents with traumatic brain injury is necessary for optimal adjustment, but has been hampered by underreporting, misclassification, and inconsistent transition practices. Children who have experienced TBI are often not identified as needing special education or other services under this diagnostic classification. Misclassification can lead to unrealistic or inappropriate expectations and interventions within schools. Long-term implications include worsening of problems associated with TBI, and loss of tracking data that could be used for improved prevention and intervention.

Method/Approach

This study includes both empirical and case study data. Surveys and interviews with state health agency representatives, medical and rehabilitation providers, and special education directors, along with data gathered from state education and state health agencies were gathered to explore current practices in Texas for identifying and transitioning children with TBI to school. As an example, a case study of an 18-year-old male who acquired a closed head injury at age 7 years was selected to explore possible explanations and the resultant consequences for his misclassification as "Emotionally Disturbed" within the special education system.

Results/Effects

Results from the surveys, interviews, and database examinations confirm that children with TBI in Texas are likely under-identified or misclassified in school settings, with concomitant lack of coherent and consistent transition across treatment settings. In the case study, the subject showed little behavioural progress until his school district recognized TBI as a valid eligibility category, classified him appropriately, and implemented more targeted interventions. The case study highlights the importance of accurate assessment, eligibility classification, and treatment planning for students with TBI.

Conclusions/Limitations

Limitations of the findings from the survey/interview/database portion of the study include state-specific findings, difficulty in locating contact information for service providers in medical and school settings, and possible selective responding from the groups that were sampled. The survey response rate was fairly typical of survey research, around 30%, with resultant limitations on generalization. The case study, while not generalizable, illustrates that appropriate classification in schools systems for students with TBI can be uncertain and complex. However, appropriate classification is imperative as it dictates expectations, planning, interventions, and discipline procedures.

0020

Depletion of Nrf2 Enhances Inflammation Induced by Oxyhemoglobin (OxyHb) in Cultured Mice Astrocytes

Hao Pan, Handong Wang, Lin Zhu, Lei Mao, Liang Qiao, Xingfen Su

Department of Neurosurgery, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, Jiangsu Province, China

Introduction/Rationale

Nrf2-ARE pathway has been proved to be the key regulator in reducing inflammatory damage, that is involved in subarachnoid hemorrhage (SAH). Here, in a traditional in vitro SAH model, we investigated the effect of Nrf2 depletion on pro-inflammatory cytokines production.

Method/Approach

Primary cultured astrocytes from Nrf2 WT or KO mouse were exposed or not exposed to OxyHb. Then the DNA-binding activity of NF-[kappa]B was detected by EMSA. The expression of TNF-[alpha], IL-1[beta], IL-6 and MMP9 were evaluated. The activity of MMP9 was measured by Gelatin zymography.

Results/Effects

After exposure to OxyHb, NF-[kappa]B was activated and the expression of downstream pro-inflammatory cytokines was up-regulated in astrocytes. Such up-regulation was much higher in KO astrocytes than in WT astrocytes, meaning more aggravated inflammation in Nrf2 deficient astrocytes.

Conclusions/Limitations

These results suggest that astrocytes participate in inflammatory process after SAH and the absence of Nrf2 may induce more aggressive inflammation through activation of NF-[kappa]B pathway.

0021

Decreasing Unsolicited Physical Touching Behaviors in Persons with Acquired Brain Injury Using Reinforcement Interruption with Contingent Activity

Dixie Eastridge

Jeff Kupfer

Learning Services Neurobehavioral Institute, Lakewood CO, USA

Introduction/Rationale

Many individuals with acquired brain injuries benefit from learning pro-social behaviour to enhance the quality of relationships with community members.

Method/Approach

This study examined the effects of augmenting antecedent stimuli as a means of establishing and maintaining discrimination of a contingency of reinforcement that was successful in reducing the frequency of one problem behaviour (e.g., physical aggression) but not for another (e.g., non-aggressive physical contact), even though these two problem behaviours shared similar functions with individuals who have acquired brain injuries.

Results/Effects

Results suggest that verbal prompts to control physical touching may not be sufficient to decrease a behaviour unless the antecedent is tied to a behavioural consequence. Subjects received verbal prompts by trained staff to refrain from touching, however, these prompts failed to exert control over the behaviour until they were added to the contingency of reinforcement (reinforced interruption and contingent activity). When an antecedent cue was provided, physical touching decreased rapidly to near zero levels.

Conclusions/Limitations

Further studies in the area of brain injury rehabilitation should be conducted to evaluate the effectiveness of functional relations analysis between maladaptive social behaviours and reinforcement contingencies. The success of this approach in the treatment of maladaptive behaviours in persons with pervasive developmental disabilities holds promise with treating brain injury as well.

0022

Is Virtual Reality Gaming an Effective Adjunct to Traditional Therapy in Children and Adolescents with Traumatic Brain Injury?

Phyllis Palma, Erin McFarling, Sheryl Flynn, Therese Romero, Els Van Den Eynde, Maurice Sholas

Children's Healthcare of Atlanta, Atlanta, GA, USA

Introduction/Rationale

Video gaming has grown enormously among all populations. Because of the variety of opportunities with virtual reality (VR), many clinics have adopted this increasingly popular mode of therapeutic intervention. Virtual reality has been shown to improve locomotor activity, control volitional movement, decrease akinesia, improve balance and overall function. Furthermore, gains achieved through VR practice carry over in real-world activity, sometimes resulting in spontaneous functional improvement in activities of daily living. The aim of this study is to compare the use of a commercially available video game with traditional therapy as a treatment intervention to improve functional mobility in the pediatric population with traumatic brain injury.

Method/Approach

The study included 14 participants from Children's Healthcare of Atlanta Comprehensive Inpatient Rehabilitation Unit, aged 8-18 years (five females/eight males), with TBI and a Rancho Los Amigos rating of V or VI. The participants were randomly assigned to virtual reality (VR) or traditional therapy (TT) groups. Each group received 20-30 minutes of intervention for a minimum of 6 sessions. The VR group practiced balance exercises using the PlayStation II Sony TM Eye Toy(R) Play 2 while the TT group participated in conventional dynamic balance activities. Outcome measures included the Pediatric Berg Balance Scale, the Multi-Directional Reach Test (MDRT), the Wee-FIM II^SM and the Intrinsic Motivational Inventory.

Results/Effects

Both groups showed trends of improvement on all scales. There were no statistically significant differences in outcome between the VR group and the TT group, however, VR participants indicated a higher level of motivation. Clinically, a greater per cent improvement in functional gains was evident in the VR group based on the MDRT.

Conclusions/Limitations

Video games are an effective adjunct to traditional therapy for children and adolescents with TBI on an inpatient pediatric rehabilitation setting.

0023

A Systematic Review of Self-report and Facilitator/Barrier Predictors of Participation Outcomes for Persons with Traumatic Brain Injury

Mark Sherer¹, Angelle Sander², Jerome Caroselli¹, Lynne Davis¹, Allison Clark², Nicholas Pastorek³

1TIRR Memorial Hermann, Houston, TX, USA, 2Baylor College of Medicine, Houston, TX, USA, 3Michael E. DeBakey Veterans' Affairs Medical Center, Houston, TX, USA

Introduction/Rationale

Research has shown that persons with traumatic brain injury (TBI) may under-report or over-report residual effects of their injuries. As a result, clinicians and researchers have often discounted patient self-report and relied on other assessment techniques. However, recent work has emphasized patient self-report for health conditions. In an effort to better understand the utility of patient self-report of symptoms after TBI, we conducted a systematic review to examine the extent to which patient self-report of symptoms predicts participation outcome after TBI. We also conducted a systematic review on the utility of facilitator/barriers in prediction of participation outcomes after TBI.

Method/Approach

Pubmed, Psychinfo, and CINAHL databases were searched to obtain abstracts. Each of 724 abstracts/articles was reviewed for relevance by two judges. As a result of these reviews, 54 articles were retained for the final systematic reviews. Each article was reviewed, data abstracted, and graded for study quality. Of the 54 articles, 21 were graded I, II, or III based on criteria from the American Academy of Neurology (AAN) Clinical Practice Guideline Process Manual and 33 were graded IV. Determinations of predictive value of self-report and facilitator/barrier variables were based on the 21 articles with quality grades of I-III.

Results/Effects

For self-report variables, three were Probably Predictive of participation outcomes, one was Probably Not Predictive, two were Possibly Predictive, and one was Possibly Not Predictive. Self-report variables found to be Probably Predictive (and participation outcomes examined) were number of post-concussive symptoms (return to work), fatigue (return to work), and physical competence (return to work, need for supervision).

For facilitator/barrier variables, two were Possibly Predictive and one was Possibly Not Predictive. Facilitator/barrier variables found to be Possibly Predictive (and participation outcomes examined) were access to transportation (employment stability) and access to rehabilitation services (employment, weeks worked, hours worked per week).

Conclusions/Limitations

Results of the review revealed that there are several self-report variables and facilitator/barrier variable for which there is sufficient evidence to conclude that these variables are probably or possibly predictive of a variety of participation.

0024

Program Assessment of Community Integration Attributes (PACIA): Development of a New Tool to Evaluate Community Integration Programs

Shahriar Parvaneh, Errol Cocks

Curtin University, Perth, Western Australia, Australia

Introduction/Rationale

Despite considerable attention paid to community integration as a desired outcome, there exists no evidence-based framework explaining characteristics of successful community interventions for people with acquired brain injury (ABI).

Method/Approach

This study developed and pilot tested an instrument to evaluate the fidelity of programs aimed at community integration outcomes for adults with ABI. Fidelity was assessed against a program "theory" consisting of a set of principles describing community integration that were established in the initial phase of the research.

A representative group of stakeholders participated in iterative surveys, interviews, and a focus group to identify the themes and attributes that were used to construct the instrument. Basic properties of the instrument were explored by evaluating three ABI programs using a small team of trained evaluators.

Results/Effects

The instrument, PACIA (Program Assessment of Community Integration Attributes) consisted of seven themes comprised of 21 Attributes. The themes were: Person centred approaches and planning, Relationships, Working together, Development of skills, Community based practices, Support for service users, and Service setting and atmosphere. Indicators and sources of evidence were identified for each attribute and a process for the program evaluations was developed.

Conclusions/Limitations

Additional development of PACIA needs to occur, however the instrument showed satisfactory functionality, face and content validity, and inter-rater reliability. The instrument may be useful in development of program effectiveness in achieving community integration outcomes for people with ABI.

0025

The therapeutic efficacy of the antipsychotic drug aripiprazole after experimental traumatic brain injury

Thomas Phelps, Rose McAloon, Krishna Yelleswarapu, Alexandra Garcia, Mansi Shah, Jeffrey Cheng, Anthony Kline

Physical Medicine & Rehabilitation, Center for Neuroscience, Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA, USA

Introduction/Rationale

Antipsychotic drugs (APDs) are routinely administered after traumatic brain injury (TBI) to reduce agitation and aggression. However, APDs with D₂ receptor antagonist properties (e.g., haloperidol and risperidone) produce deleterious effects on behavioural recovery after TBI. Hence, the evaluation of APDs with different mechanisms of action is warranted. Aripiprazole (ARIP) exhibits 5-HT_1A and D₂ agonist activity, but not D₂ antagonism; studies from our laboratory have shown that pharmacological agents with these properties enhance behavioural outcome after TBI. The goal of this study was to test the hypothesis that ARIP will enhance motor and cognitive performance after TBI.

Method/Approach

Adult male rats were anesthetized and subjected to either a controlled cortical impact (2.8 mm tissue deformation at 4 m/s) or sham injury and then randomly assigned to TBI+ARIP (0.1, 0.5, or 1.0 mg/kg), TBI+VEH (1.0 mL/kg, saline Vehicle), Sham+ARIP (1.0 mg/kg) or Sham+VEH (1.0 mL/kg) groups (n = 7-8 per condition). Treatments were administered intraperitoneally once daily for 19 days. Motor (beam-walk/beam-balance) and cognitive (Morris water maze) performance was assessed on post-operative days 1-5 and 14-19, respectively.

Results/Effects

Sham groups did not differ and thus were pooled. No motor differences were revealed among the TBI+VEH and TBI+ARIP groups [p > 0.05]. No cognitive differences were revealed among the TBI+VEH and TBI+ARIP (0.5 and 1.0 mg/kg) groups [p > 0.05]. In contrast, the TBI+ARIP (0.1 mg/kg) group performed better in the water maze vs. the TBI+VEH group [p = 0.0036], and did not differ from SHAM controls [p > 0.05]. No deleterious effects were observed following chronic administration of ARIP after TBI. Furthermore, the lower dose of ARIP (0.1 mg/kg) facilitated the acquisition of spatial learning relative to the vehicle group and did not differ from SHAMs.

Conclusions/Limitations

The findings support our hypothesis and present ARIP as a safer APD for alleviating behavioural disturbances in TBI patients and perhaps also improving cognitive function.

0026

Aggressive Recovery Focused Physical Therapy

William Thornton

Irvine Head Injury, Southfield, MI, USA

Introduction/Rationale

Physical rehabilitation and the current standard of care need to revisit the type, intensity, and duration of physical therapy that will best stimulate/irritate/reactivate central pattern generation and/or promote desired neuroplastic changes.

Method/Approach

Discuss/review "traditional" versus "aggressive" physical therapy addressing dosage, type and focus on physical therapy modalities.

Results/Effects

Optimal Motor Rehabilitation Considerations including the appropriate time, type, intensity and environment for physical rehabilitation.

Conclusions/Limitations

Proposed Intensive Rehabilitation Parameters include 1-3 hours of therapy 3 to 5 days per week, couple the entire body while concentrating therapy below the original level of the lesion, implement closed chain exercise whenever possible, implement exercises that take clients through numerous levels of developmental sequences in addition to pre-gait/gait training, provide an enriched environment for all therapy procedures and the activity should be novel, complex, and involve in-depth cognitive processing.

0027

Effectiveness of Home- and Community-based Rehabilitation in a Large (n = 717) Cohort of Patients Disabled by Cerebrovascular Accident: Evidence of a Dose-Response Relationship

Irwin Altman², Shannon Swick³, James Malec¹

1PM&R, Indiana University School of Medicine & Rehabilitation Hospital of Indiana, Indianapolis, IN, USA, 2Gentiva Rehab Without Walls(R), Phoenix, AZ, USA, 3Gentiva Rehab Without Walls(R), Marshall, MI, USA

Introduction/Rationale

Using the Mayo-Portland Adaptability Inventory (MPAI-4) as a primary outcome measure, a large observational study demonstrated the effectiveness of home- and community-based rehabilitation (HCBR) for individuals with traumatic brain injury (TBI). The MPAI-4 was developed for assessment and outcome evaluation of individuals with TBI; its sensitivity to changes resulting from rehabilitation following cerebrovascular accident (CVA) is unknown. Objectives of the current study were (1) to assess the effectiveness of HCBR in a large cohort of individuals with disabilities secondary to CVA, and (2) to evaluate the sensitivity of the MPAI-4 to changes resulting from HCBR in this patient group.

Method/Approach

Individualized HCBR was provided by an interdisciplinary team to patients with disabilities due to CVA in 7 different locations within the same national rehabilitation corporation in 7 distinct geographical U.S. cities. Professional consensus ratings of participants were obtained on the MPAI-4 on admission and at discharge. The MPAI-4 yields a total score and subscale scores for the Ability, Adjustment, and Participation Indices. Effectiveness of these rehabilitation programs was evaluated by comparing changes on the MPAI-4 for a group of 717 participants who completed the entire prescribed rehabilitation program (PC) with a group of 142 participants who were precipitously discharged (PD).

Results/Effects

Using analysis of covariance, MPAI-4 Total scores at discharge for PC participants were compared to PD participants, controlling for level of disability (admission MPAI-4) and time since injury as covariates. PC participants showed greater improvement than PD participants (F = 116.58, p < .001) with a medium to large effect size (partial eta² = .12). Group differences and effect sizes were similar for the 3 index scores: Ability (F = 98.64, p < .001; partial eta² = .10), Adjustment (F = 104.17, p < .001; partial eta² = .11), and Participation (F = 76.21, p < .001; partial eta² = .08). Continued improvement was apparent on the Participation Index for a smaller group of PC participants assessed at 3- and 12-month follow-up.

Conclusions/Limitations

The effectiveness of HCBR to address disabilities secondary to CVA and the sensitivity of the MPAI-4 to treatment effects are indicated by significant improvements demonstrated by this large treatment cohort. The PC group who received the entire planned course of HCBR showed greater improvement on all MPAI-4 indices than the PD group who were discharged prior to completing the prescribed program. This dose-response relationship provides evidence of a causal relationship between treatment and outcome. Although the relatively small number completing follow-up limits interpretation, available data suggests that community participation continues to increase for program completers following discharge.

0028

Proactive Interventions for Decreasing Challenging Behaviours in People with TBI: Best Practice Strategies for Improving Quality of Life

Mahin Para-Cremer

Lakeview Specialty Hospital & Rehab, Waterford, WI, USA

Introduction/Rationale

A traumatic brain injury can be a devastating event with lifelong consequences. It has been shown that a proactive intervention for decreasing challenging behaviours in people with TBI improves the quality of life.

Method/Approach

Several interventions/clinical projects are reviewed including: a class wide intervention implementing differential reinforcement of alternative behaviours on an intermittent schedule implemented in multiple settings; a self-monitoring and reinforcement system for a young adult with Diabetes Insipidus; and the implementation of schedules and routines to increase rates of self-care completion and decrease challenging behaviors. In addition, case studies are reviewed to demonstrate the effectiveness of these intervention methods.

Results/Effects

In the class wide intervention, the rate of disruptive and challenging behaviours were significantly reduced. In addition classroom 1 had significant reductions in the rate of reprimands given by the teacher. For the young adult with DI, the rate and intensity of challenging behaviours was significantly reduced and long term behavioural stability maintained. For the adults with ABI, significant increases in completion of self-care tasks and decreases in challenging behaviours associated with these tasks were achieved.

Conclusions/Limitations

Proactive interventions to decrease challenging behaviours in people with acquired brain injuries are a critical component of treatment interventions. Both children and adults with ABI will have greater access to community supports and meaningful social interactions when challenging behaviours are minimized. In addition, people with ABI frequently have additional medical needs that increase the complexity of managing their challenging behaviours and require additional supports to achieve a higher quality of life.

0029

Quality of Life After Traumatic Brain Injury: The Clinical Use of the QOLIBRI, A Novel Disease-Specific Instrument

Jean-Luc Truelle¹

1EMN, Europe, France, 2EBIS, Europe, France

Introduction/Rationale

To report the clinical use of the QOLIBRI, a disease-specific measure of health-related quality of life after traumatic brain injury.

Method/Approach

The QOLIBRI, with 37 items in six scales, was completed by 795 patients in six languages. QOLIBRI scores were examined by variables likely to be influenced by rehab interventions and included socio-demographic, functional outcome, health status, and mental health variables.

Results/Effects

The QOLOBRI was self-completed by 73% of participants and 27% completed it in interview. It was sensitive to areas of life amenable to intervention, such as accommodation, work participation, health status (including mental health) and functional outcome.

Conclusions/Limitations

The QOLBRI provides information about a patient's subjective perception of his/her health-related quality of life that supplements clinical measures of functional outcome. It can be applied across different populations and cultures. It allows the identification of personal needs, the prioritization of therapeutic goals and the evaluation of individual progress. It may also be useful in clinical trials and in longitudinal studies of TBI recovery

0030

Empathy, Affect Recognition and Dysosmia in Persons with Traumatic Brain Injury

Barry Willer¹, Dawn Neumann², Alexander Radnovich², Duncan Babbage³, Barbra Zupan⁴, Machiko Tomita¹

1State University at New York at Buffalo, Buffalo, NY, USA, 2Indiana University, Indianapolis, IN, USA, 3Massey University, Wellington, New Zealand, 4Brock University, St. Catharines, ON, Canada

Introduction/Rationale

Objectives: 1) Compare individuals with traumatic brain injury (TBI) who have impaired olfactory function (dysosmia) to those with normal olfactory function (normosmia) on affect recognition and self-described empathy; 2) Determine the relative predictability of impaired affect recognition on empathy; 3) Determine the relative predictability of dysosmia on empathy.

Method/Approach

Design: Prospective quasi-experimental design. Setting: Community clinics in several sites. Participants: 106 participants with moderate to severe TBI (30 Females). Main Outcome measures: Smell test (BSIT); Facial and Vocal Affect recognition (DANVA-2); empathy questionnaires (IRI).

Results/Effects

Results: 59 (55.6%) participants had dysosmia; 48 (45.3%) participants had impaired affect recognition. Most participants with dysosmia also had impaired affect recognition (N = 33, 68.8%) however, facial and vocal affect recognition was not significantly worse for participants with dysosmia (t = 1.91, p = .061; t = 1.63, p = .11 respectively). Facial affect recognition impairment was not significantly related to empathy scores for participants with dysosmia (t = .184, p = .86) or normosmia (t = 1.28, p = .23). However, there was a strong relationship between dysosmia and empathy (t = 2.24, p = .01) for those also impaired in affect recognition.

Conclusions/Limitations

Conclusions: Prior research indicates that impaired olfactory function and empathy are associated with lesions in the orbital frontal cortex (OFC). This would explain the strong relationship between olfaction and empathy in persons with TBI. Although affect recognition would logically play a significant role in empathy, empathy appears to have independence from affect recognition except in those instances when both are impaired due to lesions in the OFC.

0031

Community Re-entry after Severe Traumatic Brain Injury in Adults

Jean-Luc Truelle, Patrick Fayol, Michele Montreuil, Mathilde Chevignard

University Hospital, Garches, France

Introduction/Rationale

Despite being the main cause of death and disability in young adults, traumatic brain injury (TBI) is a rather neglected epidemic. Community Integration of persons with TBI was, until recently, insufficiently informed by clinical research.

Method/Approach

Literature review between from 2008 to 2010 in Pubmed and psicinfo

Results/Effects

To bridge the gap between rehabilitation and community re-entry, the first task is to assess the person, using TBI-specific outcome measures. The second task is to provide re-entry programs, the effectiveness of which is assessed by those measures, using well designed studies. There are very few such studies. However, there are some effective comprehensive programs and others that are specifically targeted, dealing mainly with return to work, behaviour, and family issues. The complex psychological and environmental components of the disability require individualized and, often, long term care.

Conclusions/Limitations

For persons with severe TBI trying to achieve the best possible community integration a new semiology is required, not just limited to medical care, but also involving social and psychological care that is tailored to the needs of each individual and family, living within his/her environment. Currently, only a minority benefit from well-validated programs.

0032

Post-concussive Symptom Reporting Among U.S. Combat Veterans with Mild Traumatic Brain Injury from Operation Iraqi Freedom

Andrew MacGregor, Amber Dougherty, Janet Tang, Michael Galarneau

Naval Health Research Center, San Diego, CA, USA

Introduction/Rationale

Mild traumatic brain injury (TBI) is an emerging health concern among U.S. military personnel. The true burden of post-concussive symptoms and the potential mediating effect of psychological problems, such as post-traumatic stress disorder (PTSD) and depression, have been the subject of recent research. Previous research has suggested that many of the post-concussive symptoms following combat-related TBI can be attributed to co-occurring PTSD, but these studies were limited by self-report TBI data. The aim of this study was to examine post-concussive symptom reporting using a population of military personnel with provider-diagnosed TBI that occurred during Operation Iraqi Freedom.

Method/Approach

U.S. military personnel diagnosed with mild TBI (n = 334) or non-head injury (n = 658) were identified from the Expeditionary Medical Encounter Database (EMED). Unique aspects of the EMED include detailed point of injury information as well as the inclusion of persons with otherwise mild injuries who are subsequently returned to duty. Routine post-deployment questionnaires queried the individual for current health complaints. Logistic regression was used to examine post-concussive symptom reporting while accounting for mental health symptoms. A measure of self-rated health was used to identify symptomatic predictors of a decline from "good-excellent" to "fair-poor" health.

Results/Effects

Compared with non-head-injured personnel, those with TBI were more likely to be injured in a blast (88% vs. 42%) and had higher screen-positive rates for PTSD (28% vs. 17%) and depression (21% vs. 13%). After adjusting for PTSD, depression, age, injury severity, blast and combat exposure, personnel who sustained a TBI were significantly more likely to report headache (odds ratio [OR] = 3.37), back pain (OR = 1.79), memory problems (OR = 1.86), tinnitus (OR = 1.63), and dizziness (OR = 2.13) compared to those with non-head injuries. Among those with TBI, a self-reported decline in health was associated with depression (OR = 2.74), memory problems (OR = 5.07), and dizziness (OR = 10.60).

Conclusions/Limitations

Mild TBI is associated with a constellation of negative health consequences among U.S. military personnel. A unique aspect of this study was the identification of multiple elevated symptom complaints among mild TBI compared to non-head injuries even after adjusting for co-occurring mental health morbidity. Also unique to the present study was the ability to associate specific symptoms to declines in a service member's self-rated health, which may help in targeting and prioritizing clinical interventions with the goal of more efficient rehabilitation efforts. Continued research should focus on persistence of TBI symptoms over time and the effects of concomitant mental health conditions.

0033

Aligning Expectations: A Case Study About a Second Chance at Rehabilitation

Michael Mozzoni

Lakeview Neurorehabilitation Center, NH, Effingham, NH, USA

Introduction/Rationale

Often new clients admit to a program where the expectations are derived from case history, client, family/guardian and funder input. In this case the client was re-admitted after a short stay in another program. This unique situation allowed for a much clearer conceptualization of the problem and a more pointed alignment of expectations between the facility, client, family/guardian and funder.

Method/Approach

Pre-planning behavioural strategies and aligning expectations prior to admission resulted in a behavioural contract with clear rules and expectations. A tiered reinforcement system was utilized offering smaller more immediate reinforcement and feedback with a larger more valued re-enforcer following longer periods of program cooperation and participation.

Results/Effects

Data will be presented noting decelerations of challenging behaviours and improvements in positive behaviour targets. Decreased frequency of aggression and increased civil behaviour with resisting provocation resulted in less restrictive residential placement, improved quality of life and re-establishment of family support.

Conclusions/Limitations

Development of the behavioural plan pre-admission and post-admission will be discussed in the context of cooperation and continued alignment of expectations. Clear communications, rules and guidelines developed with the client, family/guardian, funder and facility can significantly improve expectations and cooperation especially for the client. Including the client before admission may provide a level of "buy-in" not usually present otherwise.

0034

Artefacts Affecting NeuroQuant(R) Automated Measures of Brain MRI Volumes

Alfred Ochs

David Ross

Virginia Institute of Neuropsychiatry, Midlothian, VA, USA

Introduction/Rationale

Several software packages are available to perform automated identification and volumetric analysis of MRI images of the brain in research-only applications. Recently, FDA approved software, NeuroQuant (NQ), has become available for clinical use. We have demonstrated (Ross, D.E., this conference) that this software is clinically useful in describing abnormalities in brain segments in patients who suffered a TBI. Even though the NQ analysis is fully automated, misidentification of brain structures may occur. Herein we describe pitfalls we encountered and explain how to avoid them.

Method/Approach

Patient's high resolution brain MRIs were sent to CorTechs Laboratories, La Jolla, CA, for NeuroQuant volumetric analysis. Segmentation results from the fully automated analysis consist of volume measures of 11 brain regions on both sides. Also returned are MPG and DICOM formatted MRI images with the segmented regions identified in distinct colors on each original MRI slice. Careful inspection of these color-coded MRI images revealed occasional misidentified segments leading to errors in the reported volumes.

Results/Effects

Two classes of artifacts occur, both of which cause NQ segmentation errors: those that interfere with the radiologist's interpretation of gray scale images and those that do not. Examples of the former include: (a) patient movement artifacts and (b) image loss and distortion caused by metallic implants, affecting the original image locally and the NQ analyses globally. Examples of the latter include (c) an MRI with a clipped (not imaged) scalp or skull and (d) not following the CorTechs Labs recommended MRI sequences exactly. In all cases, a NQ analysis will be performed, but may contain identification and measurement errors.

Conclusions/Limitations

Radiology technicians must be instructed how to modify their usual technique for MRI scanning to avoid segmentation artefacts in the subsequent NQ analysis. Ultimately though, it is the responsibility of the reporting physician to assure, through careful visual inspection, that the identified segments accurately represent the patient's brain.

0035

Scripps Brain Injury Day Treatment Program

Jessica Martinez

Scripps Health, Encinitas, CA, USA

Introduction/Rationale

The Scripps Encinitas Brain Injury Day Treatment Program is the first CARF accredited rehabilitation day treatment program in San Diego County. The program combines clinical expertise with personal support and individualized treatment programs to address each patient's unique physical, emotional, cognitive, social and vocational goals. With close to twenty years experience, the Scripps rehabilitation center has also provided treatment and care to hundreds of wounded military service members. We are successfully assisting adolescents and adults who have suffered a brain injury to return to independence in the community, work, school and/or volunteering.

Method/Approach

During the six and a half hour treatment day in which patients return home in the evening, patients receive individualized Occupational, Physical and Speech Therapies. Social services peer support groups, self-directed times, weekly community integration outings, work site and driving evaluations are also part of the milieu. In addition to aforementioned professionals, Neurology, Neuropsychology and Neuropsychiatry are also available by consultation to patients and are an integral part of the rehabilitation team.

Results/Effects

The Scripps Brain Injury Day Treatment Program is an excellent model for interdisciplinary outpatient day rehabilitation program. Sixty per cent of the patients return to work, school or volunteering at a modified level.

Conclusions/Limitations

At the conclusion of this presentation the participants will learn the elements of a successful program. We will also include the following: admission/discharge criteria, importance of interdisciplinary framework, community integration at a higher level, integrating dual task activities, CAPD (central auditory processing disorder) research, how to establish a community Concussion Clinic and the use of volunteers as an adjunct to the program.

0036

Integrating Dual Task Activities into Interdisciplinary Treatment of Mild Traumatic Brain Injury and Post-concussion Syndrome

Rebecca Askew, Laura Coca

Scripps Health, Encinitas, CA, USA

Introduction/Rationale

We at Scripps Memorial Hospital in Encinitas were the first CARF-accredited Brain Injury Program in San Diego. Our collective rehabilitative efforts help enable over 70 patients per year to successfully return to work and many more to their previous level of function as head of household, volunteer and student roles. Our Dual Task treatment approach is a unique therapeutic approach to integrate functional tasks into traditional therapy that translates into successful daily living.

Method/Approach

Recent literature highlights the challenges this patient population has with Dual Task Activities with regard to memory, attention, balance and gait stability. It is our purpose to explore ideas for the successful treatment of attention and cognitive impairments and the normalization of upright mobility. Interdisciplinary treatment approaches emphasizing "thinking on your feet" has allowed our patient population to experience successful return to demanding and diverse professional roles as well as recreational activities.

Results/Effects

Patients report that their ability to multi task and manage their lives has improved. Patients learn task analysis and strategies of how to be successful with complex activities. Therefore, they have shown increased success with integrating back to their previous vocational and avocational lives.

Conclusions/Limitations

At the conclusion of this presentation the participants will be able to:

* Identify appropriate dual task analysis for mTBI and PCS

* Integrate a variety of dual tasks into therapy sessions

* Integrate strategies specific to training attention and memory while mobile.

0037

Community Intervention and Concussion Management: Prevention, Education and Program Implementation

Rebecca Askew, Angela Lehmann, Tim Goldberg, Lee Anne Robotta, Heather David

Scripps Health, Encinitas, CA, USA

Introduction/Rationale

Scripps Memorial Hospital Encinitas is the first CARF-accredited Brain Injury program in San Diego. We are a forerunner in the prevention, treatment and comprehensive interdisciplinary management across the spectrum of brain injury from concussion to severe traumatic brain injury. The management, prevention and future impact of concussions in professional and amateur athletics has become a dynamic and evolving area of interest in both the literature and media. In 2009 Scripps Memorial Hospital in Encinitas established a Concussion Clinic.

Method/Approach

The Concussion Clinic has launched a county-wide campaign for bringing awareness to high school athletes, coaches and parents regarding the potential impact of concussion as well as second impact syndrome. The Scripps Concussion Clinic has adopted a protocol for taking the "guess work" out of return to play with the utilization of ImPACT testing. ImPACT testing is successfully and widely utilized in professional and collegiate athletics as a baseline neuro-cognitive tool for return to play.

Results/Effects

We at Scripps are interested in education, prevention and standardizing return to play across all high school athletics in order to diminish the potentially tragic effects of concussion. Data surrounding this program will be made available upon acceptance of presentation/poster.

Conclusions/Limitations

Our objective in this presentation is for you to have an increased awareness of concussion and understand how to implement a concussion management program utilizing an objective assessment tool in your community and high school athletic programs.

0038

Taking Community Integration to a Higher Level

Jessica Martinez

Scripps Health, Encinitas, CA, USA

Introduction/Rationale

Community integration is an important part of the holistic approach to providing rehabilitation to TBI survivors. Scripps Brain Injury Day Treatment Program is the CARF accredited rehabilitation program in San Diego County. Over seventy patients per year receive comprehensive outpatient rehabilitation in the all day program. We are successfully rehabilitating adolescents and adults to return to the work, school or volunteer setting.

Method/Approach

In this rehabilitative setting, successful completion of community integration activities serve as building blocks for the patient to transition back to work. Patients are an integral part of planning and assessment from complex, highly stimulating and goal oriented community integration therapeutic activities. Collaboration between the patients and interdisciplinary team takes place throughout as the patient prepares to return to work. Community integration outings include transportation terminals, college campuses, museums, sports outings, beach days, behind the scene tours at the San Diego Padres ballpark, and specific work sites.

Results/Effects

Approximately sixty percent of our patients return to a modified work, school or volunteer setting. Upon discharge from our program, patients are able to be successful participating in activities that are unique to their individualized interests.

Conclusions/Limitations

Rehabilitation professionals will learn how to plan, implement and make progress with interdisciplinary focused community outings. Return to work rehabilitation and work site evaluations will be discussed.

0039

Correlation between Central Auditory Processing and Brain Injury in Adults

Angela Lehmann, Julie Johns, Catherine Fabian

Scripps Health, Encinitas, CA, USA

Introduction/Rationale

Scripps Memorial Hospital provides an integrated, holistic program of therapy in a CARF certified Brain Injury Day Treatment Program. The goal of this program is to return patients with newly acquired brain injuries to return to a productive and satisfying life, either as head of household, volunteer work in the community or work re-entry.

In the course of this work, the therapy team noted that some patients with normal hearing were having difficulty understanding auditory information. The Speech Therapy and Audiology Departments collaborated to investigate the possible correlation between traumatic brain injury and an auditory processing disorder.

Method/Approach

Patients with auditory processing disorders may have difficulty hearing in the presence of noise, understanding conversations on the phone, understanding complex directions or long conversations, difficulty in social situations that require them to "read" meaning or inferences, difficulty with spelling, reading and writing or enjoying music.

The design of this project is to evaluate a group of patients with traumatic brain injury and apply a battery of tests designed to identify central auditory processing disorders. A control group, matched to age and gender, but without history of brain injury, is also being evaluated.

Results/Effects

It is hoped that this research will help to direct therapeutic approaches to make them more effective, efficient and accurate. It may also lead to further research into physiologic correlates with evoked potentials and imaging techniques.

Conclusions/Limitations

This is an initial study that could potentially lead to collaborative work to develop more accurate assessment tools and therapeutic approaches for diagnosis and treatment of this under-recognized disorder.

0040

The Use of Volunteers Within A Comprehensive Brain Injury Day Treatment Program

Suzanne Carr, Andrea Schwarb

Scripps Health, Encinitas, CA, USA

Introduction/Rationale

Volunteers are a valuable resource within a comprehensive brain injury program. The unique skill sets offered by our trained group of volunteers allow us to enhance our potential for success through groups and peer mentor program.

Method/Approach

Over seventy patients per year receive comprehensive outpatient rehabilitation in the all-day program with the overall goal of return to work, school, or volunteer roles. Peer Mentors may be matched to current patients for one-on-one support and mentoring, or may serve as a panelist within a support group. Program participants have identified the beneficial aspects of communicating with peers who have "walked in similar shoes. These volunteers contribute to a successful outcome for patients following the treatment plan in brain injury rehabilitation while providing a sense of hope and support to individuals in various phases of the program.

Results/Effects

Studies show that art, creative writing, and participation in sport/recreation are beneficial for increasing cognitive and motor functioning as well as for increasing attention, concentration, memory, and organization. In addition to the physical and cognitive benefits of these volunteer-led activities, participants also gain increased self-awareness, self-esteem, and social interaction. These groups allow the incorporation of a "participate to learn" philosophy that is visible throughout our program.

Conclusions/Limitations

At the conclusion of this presentation, participants will understand the value of successfully incorporating volunteers within a comprehensive day treatment program. Concepts will include successfully implemented groups and why each is supportive of the recovery process as Peer Mentor Program, Tennis, Art/Drawing, Creative Writing and Current Events.

0041

Phenylephrine Preserves Autoregulation After Female Traumatic Brain Injury But Aggravates Dysregulation in Males through K Channel Inhibition Via ET-1, ERK, and O₂^-

William Armstead¹, John Riley¹, Christian Kreipke², Monica Vavilala³

1University of Pennsylvania, Philadelphia PA, USA, 2Wayne State University, Detroit, MI, USA, 3University of Washington, Seattle, WA, USA

Introduction/Rationale

TBI contributes to morbidity in children; boys are disproportionately represented. ERK MAPK is unregulated more in males and reduces CBF after fluid percussion brain injury (FPI). Increased cerebral perfusion pressure (CPP) by means of phenylephrine (Phe) improves impairment of cerebral autoregulation after FPI through ERK modulation in a gender dependent manner: aggravated in males, but blocked in females. Activation of Katp and Kca channels produce cerebrovasodilation, contributing to autoregulation, both impaired after FPI. ET-1 contributes to impaired autoregulation via O₂^-. We hypothesized that K channel impairment and dysregulation after FPI will be prevented by Phe in a sex dependent manner through modulation of ET-1, O₂^-, and ERK.

Method/Approach

Pial artery diameter was determined before and after FPI in untreated, pre- and post-injury (30 min before or 30 min after) Phe, BQ 123, U 0126, and polyethylene glycol superoxide dismutase and catalase (PEGSOD), ET-1, ERK antagonists and free radical scavenger) treated male and female newborn pigs equipped with a closed cranial window. CSF ET-1 and ERK were quantified by ELISA. Data (n = 5) were analyzed by repeated measures ANOVA, with significance determined at p < 0.05.

Results/Effects

The Katp channel agonist cromakalim and Kca agonist NS 1619 produced vasodilation that was impaired more in males than females after FPI. Phe prevented reductions in cerebrovasodilation to K agonists in females, but further reduced dilation in males. Co-administration of BQ-123, U 0126, or PEGSOD with Phe fully restored dilation to K agonists in males, but had no further effect on K agonist dilation after FPI in females. Similar effects were noted for pial artery dilation during hypotension. CSF ET-1 release was greater in males than females after FPI; blunted by PHE in females, but aggravated in males. ERK up-regulation was blocked by PEGSOD.

Conclusions/Limitations

These data indicate that elevation of CPP with Phe, prevents impairment of cerebral autoregulation during hypotension after FPI, in a gender dependent manner, through modulation of ET-1 release. There is also impairment mediated bysubsequent sequential O₂^- and ERK MAPK up-regulation of Katp and Kca that induces cerebrovasodilation. These data suggest a role for gender dependent mechanisms in cerebral autoregulation after pediatric TBI.

0042

Treatment of Brain Trauma Persistent Vegetative State with Bone Marrow Stem Cells-Derived Neural Stem Cells (BMSCs-D-NSCs) Autotransplantation

DAI Yi-wu, XU Ru-xiang, ZHAO Chun-ping, YANG Zhi-jun

Bayi Brain Hospital, Beijing, China

Introduction/Rationale

It was observed that BMSCs-derived-NSCs tend toward the areas of brain stem injuries. This study is based on previous experiments by using BMSCs-derived-NSCs transplantation for the treatment of persistent vegetative state after brain injuries.

Method/Approach

1. CT, MR, EEG, AEP were taken after patients were admitted. 2. Patient's own bone marrow was gathered and underwent prolification and pre-differentiation. 3. BMSC-D-NSCS was transplanted into particular regions of brain by open-cranial surgery, stereo surgery or catheter intervention surgery. 4. Target regions included: the injured cortex, sub-ventricular region, corpus striatum, discus lentiformis, or middle cerebral artery of lesion side, vertebral artery. 5. 3 months after transplantation, the GCS, EEG, and AEP were examined.

Results/Effects

3-4 months after transplantation, the coma index, the electroencephalogram and the auditory evoked potential were significantly improved.

Conclusions/Limitations

Bone marrow derived neural stem cells can be used as "seed cells" to treat the missile-wound cerebral injury and its sequelae, to promote functional recovery of the central nervous system (consciousness, extremities function, urination function and defecation function).

0043

Application of Smart Equitest Balance Master Training for Severe Balance Disorder Caused by Cerebellar Hemorrhage in Children: A Case Report

Qiu Weihong, Lin Xiafei, Dou Zulin, Fu Yi

Rehabilitation department in Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China

Introduction/Rationale

To study the effects and feasibility of Smart Equitest Balance Master training for severe balance disorder caused by cerebellar hemorrhage in children, we used Smart Equitest Balance Master to measure the balance function of a 10-year-old boy with severe ataxia caused by cerebellar hemorrhage. He underwenttraining of balance function with a comprehensive and long-term balance training program.

Method/Approach

A 10-year-old boy with severe ataxia caused by cerebellar hemorrhage was assessed by Smart Equitest Balance Master and, according to the assessments, it provided him with different sensory function training, walking training, and up and down stairs training. He also received occupational therapy, acupuncture, physiotherapy and other comprehensive training. We also used the Berg Balance Scale (BBS) and Modified Barthel Index (MBI) to assess his balance function and ADL.

Results/Effects

After 22 weeks of balance training, the patient was improved in balance function and sensory function (especially vestibular function), gait, posture control and ADL. His BBS and MBI scores were also significantly improved. He has returned to school to continue his studies. Improvement was still maintained at 3 month follow-up.

Conclusions/Limitations

Smart Equitest Balance Master training can significantly improve balance function, motor function and ADL after cerebellar hemorrhage.

0044

Olfactory Dysfunction After Minor Head Trauma

Andrea Ciofalo, Giampietro Zambetti, Massimo Fusconi, Pietro Soldo, Antonio Greco, Martina Romeo, Catia Marinelli, Gianfranco Macri

Unit of Rhinology, Sense Organs Department, University of Rome "La Sapienza", Rome, Italy

Introduction/Rationale

Smell deficit is commonly due to head trauma that often causes the shearing of olfactory nerve axons at the level of the ethmoidal cribriform plate, but damage to encephalic olfactory structures is also possible. The degree of olfactory function and the influence of age, sex and time since injury are evaluated in this study of patients after head trauma.

Method/Approach

57 patients with complaints of smell dysfunction and 'minor' head trauma (Glasgow Coma Scale score >=13) were submitted to medical history, otorhinolaryngologic examination, nasal endoscopy, computerized tomography and magnetic resonance imaging and smell test to assess odor threshold, discrimination and identification (Sniffin' Sticks smell test).

Results/Effects

Imaging did not show any lesions of brain olfactory structures in these patients; 82.5% of them had anosmia and 12.5% had hyposmia. Females presented higher means of odor threshold, discrimination and identification than males; 60% of the patients were under 40 years of age; smell deficit was referred from 1 to 288 months after injury.

Conclusions/Limitations

Patients complaining of 'minor' head trauma-related olfactory dysfunction had anosmia, presumably due to shearing of the filia olfactoria. Young males presented a higher degree of deficit.

0045

The WestEnd Coop: Integrating A Therapeutic Small Business Model into Outpatient Cognitive and Behavioral Rehabilitation.

Sheldon Herring

Peace Rehabilitation Center, Greenville, SC, USA

Introduction/Rationale

Traditional vocational rehabilitation models of "evaluate-train-place" are frequently ineffective in working with persons with brain injury secondary to limited generalization of cognitive, social skills and work behavior training. Furthermore, the distinction between cognitive and behavioral issues and work behaviors is largely an artificial one and, furthermore, undermines generalization. Rehabilitation models that have incorporated work trials into outpatient programming have been effective within large treatment programs but are hard to implement on a local level.

Method/Approach

The goal of the WestEnd Coop is to improve cognitive and behavioral rehabilitation through participation in a continuum of real work tasks. Small business functions were integrated into daily therapy operations of a comprehensive brain injury program. Administrative considerations were facilitated by coverage through existing volunteer services. All Coop business functions are available as a laboratory for physical, cognitive and behavioral goals through skilled therapy during Physical, Occupational, Speech Therapy and psychological counseling. Patients are able to participate in work tasks in three capacities, as part of their on-going treatment and, later, as regular volunteers or hospital employees.

Results/Effects

HR policies were modified to accommodate training needs. Core business operations are sustained by a cohort of employed patients. Therapy staff can request projects tailored to specific treatment goals of individual patients. The Coop has expanded the number of "product lines" to include production tasks, service industry, promotional materials, jewellery and building maintenance. This p rogram has maintained CARF accreditation as a Brain Injury Vocational Rehabilitation Program. Program success is reflected in patient preference for Coop participation over alternative therapy activities. The Coop has contributed to the financial viability of the program by attracting funded cases through VR and Workers Compensation.

Conclusions/Limitations

Incorporating real work into outpatient cognitive and behavioral rehabilitation is feasible. One limitation has been that the current staffing model precludes billing some Coop tasks as skilled therapy. As a result, the hospital system is supporting current staff as they seek graduate training in Occupational Therapy. The program continues to experience challenges when patients, transitioning to employment but having significant behavioral challenges, must also comply with broader organization code of conduct.

0046

Early Predictors of Life Satisfaction One Year After TBI

Lynne Davis¹, Mark Sherer¹, Angelle Sander¹, Ron Seel²

1TIRR Memorial Hermann, Houston, TX, USA, 2Crawford Research Institute, Shepherd Center, Atlanta, GA, USA

Introduction/Rationale

Individuals with traumatic brain injury (TBI) often report lower satisfaction with life (SWL) than those without disabilities. Prediction of SWL has received less attention than the prediction of objective aspects of outcome. However, understanding predictors of SWL can be important for developing interventions to improve subjective well-being after injury. Past studies have focused on demographic and injury-related variables, leaving the possible predictive value of pre-injury characteristics largely unexplored. The purpose of this study was to investigate the predictive value of pre-injury features, above and beyond demographic and injury-related variables, to SWL at 1 year post-TBI in a large national sample.

Method/Approach

A retrospective, longitudinal design was used in a sample of 444 persons with moderate to severe TBI. Participants completed the Satisfaction with Life Scale 1 year after TBI. Demographic, injury-related, pre-injury functioning, and pre-injury condition data were collected during inpatient rehabilitation. Hierarchical linear regression was used to predict SWL using the following variable blocks: 1) injury-related (days to follow commands, cognitive and motor functional independence); 2) demographic (age, sex, race/ethnicity, marital status); 3) pre-injury functioning (education, productivity/employment); and 4) pre-injury conditions (psychiatric and substance use problems, severe sensory dysfunction, learning problems, prior TBI).

Results/Effects

Changes in explained variance were examined after entry of each block. Pre-injury functioning (block #3) contributed significantly to the explained variance in SWL scores (R² change = .03, p < .002), after accounting for injury-related (block #1) and demographic (block #2) variables; higher education was associated with greater SWL. Pre-injury conditions (block #4) also contributed significantly to the explained variance in SWL scores (R² change = .04, p < .0001), after accounting for injury-related, demographic, and pre-injury functioning variables; history of psychiatric difficulty and sensory/cognitive dysfunction/prior TBI were associated with lower SWL. The proportion of variance explained by the full model was 8.7%.

Conclusions/Limitations

Findings indicate that pre-injury variables are predictive of SWL at one year post-TBI, after accounting for injury-related and demographic variables. These findings are novel and suggest that predictors of SWL may differ from those associated with other types of outcomes more closely related to demographic and injury-related factors, such as employment and independence. These findings may also help inform the design of post-TBI clinical interventions by highlighting the importance of pre-injury factors, although the multi-factorial nature of SWL must be recognized.

0047

Atypical Presentation of Catatonia in a 20-year-old Male with a Traumatic Brain Injury: A Case Study

Nicole Joanne Wood, James Cohn, Cynthia Sorenson

Lakeview Specialty Hospital, Waterford, WI, USA

Introduction/Rationale

Catatonia is a syndrome that usually presents with disturbed motor functions, mood, and thought. It is often effectively treated using the benzodiazepine lorazepam. This article reports on a patient with an atypical presentation of catatonia that responded well to treatment with lorazepam.

Method/Approach

The case described is a 20-year-old male who had suffered a traumatic brain injury after a motor vehicle accident. While he did not display characteristic features of catatonia, such as mutism, stupor, or posturing, he did present with language processing and social interaction deficits. His speech did not fit criteria for any subtype of aphasia, and was characterized by fluent expressive speech with mild-moderate paraphasic errors and virtually complete inability to demonstrated language comprehension. He was treated with lorazepam because it was hypothesized that his symptoms were a result of catatonia.

Results/Effects

Treatment with a low dose of lorazepam successfully treated the patient's catatonia, and his inability to respond to questions or execute instructions and general lack of social reciprocity began to resolve within hours of the initial administration.

Conclusions/Limitations

This finding supports the use of lorazepam in treating patients with atypical presentation of catatonia.

0049

3D Visualization of Brain Atrophy from NeuroQuant Data Sets

Michael Havranek

Virginia Institute of Neuropsychiatry, Midlothian, VA, USA

Introduction/Rationale

NeuroQuant shows promising clinical applications in identifying brain atrophy by generating volumetric measurements of intraparenchymal subregions. NeuroQuant's ability to distinguish these subregions allows clinicians better accuracy in identifying abnormalities. The data outputted by NeuroQuant is presented in the traditional AP, sagittal and coronal sequential slices that make it difficult to comprehend the complete 3-dimensional shape of each subregion. Our goal was to expand the usefulness of NeuroQuant by developing a technique to accurately extract the NeuroQuant subregions and translate them into computerized models that can be rotated in 3D space, allowing for better visualization and comprehension of atrophied brain tissue.

Method/Approach

Colorized NeuroQuant data sets were exported as a series of individual images and individualized filters were applied to isolate each colored subregion. The images were then processed through DICOM imaging software and exported as objects into a 3D animation software where the subregions were individually color adjusted and compiled into a fully reconstructed brain. Cameras were positioned and lights were applied to the model to allow the viewer to view the model from various angles. The results were then compared with the original NeuroQuant data to evaluate accuracy, validity, and consistency.

Results/Effects

Computerized 3D models were successfully created. Due to lower resolution MRI scans having blurry tissue boundaries, the filter settings that isolate each colored region required human artisanship in order to ensure proper selection of tissue. It was realized that creating an effective lighting setup is crucial for exposing the subtleties of tissue atrophy Carefully chosen camera angles can expose structural abnormalities better than the orthogonal standards. When compared to the original NeuroQuant data sets, the 3D models matched the subregion tracings identified by NeuroQuant, and the visible areas of atrophy matched the findings indicated on the NeuroQuant morphometry reports.

Conclusions/Limitations

The ability to extract the NeuroQuant colored subregions of the brain and accurately reconstruct the size and shape of subregions adds usefulness to NeuroQuant by allowing for better visualization of brain structures. While NeuroQuant reports of morphometry quantify overall size of the subregions, 3D models allow both medical and non-medical audiences to appreciate the actual shape of atrophied brain regions and they also allow these audiences to compare bilateral asymmetry of entire structures rather than viewing partial cross-sections on traditional 2D slices. The 3D models offer a more comprehensive anatomical picture and, therefore, a greater appreciation and understanding of structural abnormalities suggested quantitatively by NeuroQuant.

0051

Mild Traumatic Brain Injury Assessment with Diffusion Tensor Imaging (DTI) and Positron Emission Tomography (PET) Scan and Neuropsychological Tests of Cognition and Attention

Joseph Wu, Varin Tsai

UCI Brain Imaging, Irvine, CA, USA

Introduction/Rationale

Objective: The objective of this study is to examine the relationships between diffusion tensor imaging (DTI) findings, local cerebral glucose metabolic findings on positron emission tomography (PET) and neuropsychological abnormalities in patients with mild traumatic brain injury (mTBI). We hypothesize that these patients will show abnormalities in fractional anisotropy and tractography in brain regions associated with attention and cognition. We further hypothesize that these patients will also show metabolic abnormalities on PET scan in brain regions that are the neural substrate for attention and cognition.

Method/Approach

Participants and Methods: Ten patients with mild traumatic brain injury with neuropsychological test battery deficits have had their deficits of attention and cognition correlated with MRI diffusion tensor imaging fractional anisotropy (FA) and tractography reconstruction and FDG PET scan. DTI FA in patients were compared with normative controls using statistical parametric mapping (SPM). FDG PET scans in patients were also compared with normative controls using SPM.

Results/Effects

Results: Significant z-map statistical abnormalities were found between DTI FA abnormalities in TBI patients with neuropsychological deficits on memory and executive function and attention using SPM. Significant patterns of correlation were also found between FDG PET scan abnormalities in cortical regions such as frontal and temporal cortex in TBI patients. Significant tractographic differences were found between mTBI and NC in tracts such as corpus callosum.

Conclusions/Limitations

Conclusions: MRI diffusion tensor imaging (DTI) studies of fractional anisotropy (FA) and tractography reconstructions and FDG PET are sensitive measures of white matter tract disruptions that are correlated with neuropsychological testing deficits of memory and executive function and attention. Examples of such clinical correlations will be discussed.

0052

The Clinical Utility of Serial Cognitive Testing after Mild Traumatic Brain Injury: A Pediatric Case Report

Anne Shandera-Ochsner, Sean Skinner, Amy Hessler, Dong Han

University of Kentucky, Lexington, KY, USA

Introduction/Rationale

Public and healthcare provider awareness of the acute effects of mild traumatic brain injury (mTBI) or concussion has increased rapidly in recent years. While imaging and lab work are typically insensitive to concussions, neuropsychological testing has been shown to detect impairment or decreased cognitive functioning, especially in the acute phase (Levin et al., 1987). One area of particular interest is the use of cognitive testing as an indicator of neurologic recovery, which may be best accomplished by a serial assessment approach (Moser et al., 2007).

Method/Approach

We review the case of a 15-year-old young man with a history of two probable concussions 1.5 months apart. Both were football-related. The patient reported confusion and post-traumatic amnesia for the events but no loss of consciousness. He did not seek medical attention until the second concussion. MRI of the brain was reportedly unremarkable. The patient reported mild somatic symptoms but denied cognitive changes. However, his parents reported that his grades had declined since the second concussion. Neuropsychological screening was conducted at 3 weeks (Time 1) and again at 7 weeks post-injury (Time 2).

Results/Effects

Time 1 test results revealed suspected declines in the domains of reaction time, mental flexibility, visual motor speed, and verbal fluency. Mental flexibility and reaction time were most notably below expectancy. Memory performances were also below the expected range. Time 1 profile was consistent with a Post-concussion Disorder. Results from Time 2 revealed improved mental flexibility and verbal fluency. However, reaction time and visual motor speed remained borderline impaired. Results at Time 1 and Time 2 were generally consistent with parent report but not the patient report.

Conclusions/Limitations

This case report of a 15-year old male student athlete, who sustained two concussions over the course of 1.5 months, demonstrates the utility of serial neuro-cognitive assessments in gauging cognitive recovery in a more objective fashion. This is especially helpful given unreliable patient report, suggesting the patient's limited insight or intentional false report (possible bias for return to play). This documentation is important in assisting pediatric patients in obtaining appropriate educational support/assistance during the recovery period following mTBI.

0053

Identification and Effects of Cerebral Salt Wasting Syndrome in Brain Injury Patients

Ruth Bettelheim

Fresh Ideas, Inc., St. John, U.S. Virgin Islands

Introduction/Rationale

There is research demonstrating that Cerebral Salt Wasting Syndrome (CSWS) can be caused by brain injury. It symptoms largely overlap with and exacerbate those of brain injury (BI). This knowledge has not been incorporated into diagnostic or treatment practices for BI patients, although diagnosis is inexpensive and noninvasive, and a completely effective low cost treatment is available.

Method/Approach

Review of the literature regarding incidence, diagnosis, treatment and presentation of CSWS in patients with brain injury, illustrated by case studies.

Results/Effects

The incidence of CSWS in some population samples of brain injury patients has been reported to be as high as 23%, although the exact number is unknown because BI patients are very seldom tested for CSWS. Unless they are diagnosed and treated, patients who have CSWS are prevented from fully utilizing and responding to rehabilitation efforts in all areas of functioning, including physical, social, and cognitive. Once treated, they significantly improve or fully recover functions that were previously impaired. These findings will be illustrated by case material.

Conclusions/Limitations

Practice should be changed such that all BI patients are routinely tested for CSWS and treated if necessary. Further research is urgently needed to better understand the incidence of CSWS for patients with various kinds of BI. Rehabilitation practitioners should be alerted to the signs and symptoms of CSWS, and strategies should be developed to take account of the possibility that undiagnosed and untreated CSWS may be impacting recovery.

0054

Integrating Affective Cognitive Processes into Brain Injury Rehabilitation

Ruth Bettelheim, Ph.D.¹, Geralynn Knorr, MS-CCC²

1Fresh Ideas, Inc., St. John, U.S. Virgin Islands, 2Cognitive Rehabilitative Services, Culver City, CA, USA

Introduction/Rationale

There is research demonstrating that cognition and memory are dependent upon, and indeed cannot be separated from, affect. Despite this knowledge, affect and its sensory concomitants are not an integral part of the focus of cognitive therapy for patients with brain injury (BI). Instead, metacognitive, higher level thought, repetition, practice, and other methods based upon educational, speech therapy, occupational therapy and cognitive behavioral therapy models have prevailed. It is imperative that brain injury rehabilitation incorporate current neuroscientific research about the way that memory and cognition work and rely upon emotion and affect to function.

Method/Approach

Review of recent neuroscience research demonstrating the reliance on and integration of cognition and memory with emotion and affect; analysis of the implications of these findings for rehabilitation strategies; illustrative examples drawn from case material.

Results/Effects

One of the many symptoms of BI is 'emotional flatness'. While emotional lability is often reported, remarkably, it is often combined with what is frequently called 'emotional flatness', 'apathy', 'anhedonia', and/or depression. Many patients with BI feel 'disconnected' from experiences, even from those they love. This common emotional distance or flatness seriously impedes recovery, since executive function, cognition, and memory all depend upon the ability to sense the physical sensorial concomitants of affect, as well as emotions themselves, with appropriate intensity. Case material will be presented to illustrate this.

Conclusions/Limitations

Research is urgently needed to develop and test rehabilitation strategies and practices that enhance the ability of patients with BI to 1) access their sensory affect and emotional responses in real time, 2) respond to them, and 3) utilize them to guide thought, memory and behavior. Existing research suggests that this could dramatically enhance the effectiveness of existing therapies.

0055

Perceptions of Impaired Functioning in ICU Survivors Following Acquired Brain Injury (ABI)

Meera Reddy, Mario Davidson, Wes Ely, James Jackson

Vanderbilt University School of Medicine, Nashville, TN, USA

Introduction/Rationale

Brain injuries are recognized in trauma intensive care unit (TICU) patients but a "brain injury" paradigm is rarely applied to patients in the medical intensive care unit (MICU). However, MICU patients commonly experience insults and exposures (e.g. hypoxia, delirium, sepsis) that may lead to acquired brain injuries (ABI), as evidenced by large numbers of MICU survivors experiencing significant and persistent cognitive impairment. Though research has objectively demonstrated the existence of neuropsychological deficits in these patients, questions exist regarding how this unrecognized population of ABI patients view their own post-ICU functioning and whether their perceptions of functioning are accurate.

Method/Approach

Subjects were adult patients who had been in a MICU and who were assessed at 3 and 12 months after MICU discharge with the Awareness Questionnaire (AQ), a 17-item assessment (patient and surrogate versions) used for other patients with brain injury. The AQ is comprised of items pertaining to awareness of cognitive, behavioral/affective, and motor-sensory functioning. Subjects were additionally evaluated with a neuropsychological battery that assessed wide-ranging domains of cognition including memory, attention/concentration, language, visual-spatial ability, and executive dysfunction. Descriptive statistics were calculated and [chi]2, Kruskal Wallis, and Wilcoxon signed rank and one-sample tests were employed.

Results/Effects

At 3 month follow-up, 73% of patients and 74% of surrogates reported that their overall functioning was worse than pre-MICU baseline compared to 73% and 71% of patients and surrogates at 12-months. No significant discrepancies were observed between patient and surrogate ratings at 3 or 12 month follow-up (-3, 5.5, 95% CI). Neither were significant differences in cognitive, behavioral/affective, and motor-sensory scores identified at 3 months (p = 0.21) or 12 months (p = 0.68). Lower total patient awareness scores were associated with longer duration of mechanical ventilation at 3 months (p = 0.0084) and at 12 months (p = 0.024).

Conclusions/Limitations

A significant majority of MICU survivors function at levels worse than baseline after experiencing ABI during critical illness and they report comparable degrees of functional decline in behavioral/affective, motor-sensory, and cognitive domains, despite current research identifying primarily cognitive problems. Patients do not report meaningful improvements in global or domain specific functioning from 3 months to 12 months after hospital discharge. MICU survivors have accurate awareness of deficits, as reflected in similar patient and surrogate ratings. Limitations include primary reliance on self-report data, the use of surrogate ratings as a "gold standard", and the absence of an objective report.

0056

Neuropsychological Sequelae in an Adolescent with Hypothalamic Glioma Resection, Panhypopirtuitarism, and VP Shunt: Implications for Treatment.

Nicole Joanne Wood, Timothy Wiedel

Lakeview Specialty Hospital, Waterford, WI, USA

Introduction/Rational

By taking into account neuropsychological limitations and strengths, it is possible to develop and implement an effective treatment strategy for an adolescent male with significant neurological, medical, behavioral, and emotional difficulties. This case study also used effective procedures found in neuro-behavioral rehabilitation for brain injuries, such as stimulation reduction and cueing.

Method/Approach

A neuropsychological assessment was performed and found significant deficits in processing speed, working memory, verbal learning, and affect recognition. A comprehensive treatment plan was initiated to reduce high frequency dangerous behaviors. For example, out of control behavior and food grabbing in the dining room was addressed through a stimulus reduction paradigm in the dining room. Given his working memory and verbal learning deficits, a traditional behavior therapy paradigm using reinforcement would not work. His intact executive functioning made it possible to use coping and social skills training for behavioral control, provided he had adequate cues for recognition.

Results/Effects

The comprehensive treatment plan reduced high frequency dangerous behaviors: elopement - down 100%, aggression - down 50-75%, self-injurious behavior - down 50%. Positive behaviors increased with coping strategies, social communication and peer interaction to 95% of most days (up from 40 to 60%). Managing dining room stimulation and food stealing has been a significant challenge. The resident has been able to spend a limited amount of time in the dining room by utilizing a curtain, blocking him from viewing the dining room, and preventing visual stimulation. Challenges included overcoming staff inconsistencies and stereotypes regarding the resident's motivation.

Conclusions/Limitations

The neuropsychological test results were clearly ecologically valid and were used to successfully implement a comprehensive treatment plan in a residential setting. For a child with significant neurological, medical, behavioral and emotional difficulties, successful treatment demands an adequate assessment of neuropsychological functioning. By taking into account his cognitive limitations and strengths, it was possible to develop and implement an effective treatment strategy. It is clear that prior treatment at different facilities failed to diminish his high frequency dangerous behaviors, in part, because previous neuropsychological findings had not been applied to the development of an effective treatment strategy.

0057

Community-Based Crisis Intervention for Survivors of ABI: An Interagency Initiative

Cynthia O'Donoghue¹, Cara Meixner¹, Michelle Witt², Elizabeth Bowman²

1James Madison University, Harrisonburg, VA, USA, 2Crossroads to Brain Injury Recovery, Inc., Harrisonburg, VA, USA

Introduction/Rationale

Over 250,000 Virginians of adult age are living with a disability as a result of acquired brain injury (ABI). Behavioral and cognitive issues, the most common debilitating consequences of a severe ABI (Milders, Fuchs, & Crawford, 2003), have a significant impact on a person's psychosocial adjustment and ability to reintegrate into the community. In Virginia, there is currently no publicly-funded option for neurobehavioral treatment for individuals affected by brain injury. These individuals are unable to access appropriate behavioral health services, leading to potential inappropriate placement in state and local psychiatric facilities, skilled nursing facilities, or the judicial system.

Method/Approach

This action trajectory research (Anderson & Herr, 2005) seeks to assess the barriers to behavioral health services, identify best practices and develop a model/protocol for crisis intervention for individuals with ABI. The team used a mixed-methods approach by deploying a survey instrument and facilitating a series of focus groups. The survey was deployed to regional providers through Qualtrics and the results were analyzed using SPSS/PASW17. The focus group data was analyzed using NVivo 8 and later triangulated with the survey data. The findings highlighted barrier themes and overall severity rankings that guided the project actions.

Results/Effects

Based on needs assessment results and an extensive best practices review, the research team assembled a workgroup of regional stakeholders. This interagency collaborative designed a cross-systems map using the sequential intercept model (Munetz & Griffin, 2006). The map served as the basis for the protocol/model that the team began to pilot in the community as crisis cases arose. Protocol evaluation using these case studies remains in progress. Concurrent to the protocol development, the project team also organized several training opportunities to address the previously identified educational gaps (i.e., PBS, BIFI). Outcomes measures related to these programs are under investigation.

Conclusions/Limitations

Preliminary findings support the necessity of an inclusive interagency approach to adequately respond to individuals in crisis. This intervention should reflect a continuum including outreach education and training, accurate screening and identification, risk assessment, and post stabilization community supports (e.g., case management). An additional consideration is that while providers report a need for training and education, it is unclear if increased preparation has a direct impact on systems change and accessibility of services. Another potential issue with local systems change is that providers may not feel empowered to champion change within state controlled systems. Further study is merited.

0058

Comparison of Selected Outcomes for Traumatic Brain Injury with Intracranial Hemorrhage Resulting from Falls

Tiffany Littleton, Terry Rives, Rajesh Gandhi

JPS Health Network, Fort Worth, Texas, USA

Introduction/Rationale

Falls are the second leading cause of trauma activations and often result in traumatic brain injury (TBI), a leading cause of morbidity and mortality. Guidelines for the diagnosis and management of TBI vary, but the literature is scant regarding the management of intracranial hemorrhages (ICH) <1 centimeter(cm). Current protocol at a Level I trauma center allows trauma surgeons to manage ICH <1 cm, but no evidence exists regarding the frequency of ICH management by trauma surgeons versus neurosurgeons or differences in patient outcome. We hypothesize no difference in outcomes for patients managed by a trauma surgeon compared with a neurosurgeon.

Method/Approach

This is a retrospective chart review of data collected in the trauma registry of JPS Health Network (JPS) from 2006 to 2011. Patients included in the study presented to JPS with fall as the primary mechanism of injury and TBI with an ICH <1 cm. Patients sustaining penetrating wounds and patients transferred to other acute care facilities were excluded from analysis.

Results/Effects

Between 2006 and 2011, 343 patients presented with a TBI resulting from a fall. Patients ranged in age from 13 to 100 years, with a mean age of 58.05 (SD = 21.48). Sixty-six percent were male (n = 225), 70% were white (n = 239), 88% (n = 302) received neurosurgical consultation, and 13% (n = 44) died. With respect to between neurosurgical management and trauma surgeon management, no significant differences were found between patients' condition on discharge, [chi]²(2) = 1.28, ns, destination at discharge, [chi]²(4) = 1.47, ns, and length of stay, F(1, 341) = 2.46, ns.

Conclusions/Limitations

Although not all TBIs are a result of falls, this homogenous sample of patients enables us to draw conclusions regarding patient outcomes based on management services in the absence of co-morbidities. With the expected increase of the aging population, we predict an increase in the number of trauma activations resulting from falls. Due to the demand placed on neurosurgeons for more severe brain injuries, these data suggest patients managed by trauma surgeons could have comparable outcomes to those managed by neurosurgeons when ICH <1 cm.

0059

Identification of Plasma Biomarkers of TBI Outcome Using Proteomic Approaches in an APOE Mouse Model

Fiona Crawford¹, Gogce Crynen¹, Jon Reed¹, Benoit Mouzon¹, Alex Bishop¹, Benjamin Katz¹, Scott Ferguson¹, John Phillips¹, Vani Ganapathi¹, Venkatarajan Mathura¹, Allen Roses², Michael Mullan¹

1Roskamp Institute, Sarasota, FL, USA, 2R. David Thomas Executive Training Center Duke University, Durham, NC, USA

Introduction/Rationale

The current lack of diagnostic and prognostic biomarkers for traumatic brain injury (TBI) confounds treatment and management of patients and is of increasing concern as the TBI population grows.

Method/Approach

We have generated plasma proteomic profiles from mice receiving TBI by controlled cortical impact at either 1.3 mm or 1.8 mm depth. We compared them against sham injured animals to identify plasma biomarkers specific to mild or severe TBI at 24 hrs, 1 month or 3 months post-injury. To identify possible prognostic biomarkers, we used APOE3 and APOE4 transgenic mice that demonstrate relatively favorable and unfavorable outcomes after TBI, respectively.

Results/Effects

Using a quantitative proteomics approach (isobaric tagging for relative and absolute quantitation - iTRAQ). We have identified proteins that are significantly modulated as a function of TBI and also in response to the TBI*APOE genotype interaction, the latter representing potential prognostic biomarkers. These preliminary data clearly demonstrate plasma protein changes that are not only injury-dependent but also interaction-dependent. Importantly, these results demonstrate the presence of TBI-dependent and interaction-dependent plasma proteins at a 3 month time point that is a considerable time after injury in the mouse model and will, potentially, be of significance for combat veterans receiving assessment at extended periods after injury.

Conclusions/Limitations

Our identification of clusters of functionally-related proteins indicates disturbance of particular biological modules that increases their value beyond that of solitary biomarkers. The next step is to translate these findings to human populations of TBI patients, with targeted investigation of patient plasma for disturbance of the same biological modules identified in mice.

0060

Proteomic analysis of APOE-genotype dependent influence on the brain's response to Traumatic Brain Injury

Fiona Crawford¹, Jon Reed¹, Gogce Crynen¹, Benjamin Katz¹, Alex Bishop¹, Benoit Mouzon¹, Scott Ferguson¹, John Phillips¹, Venkatarajan Mathura¹, Allen Roses², Michael Mullan¹

1Roskamp Institute, Sarasota, FL, USA, 2R. David Thomas Executive Training Center, Duke University, Durham, NC, USA

Introduction/Rationale

Currently, there are no effective therapies to treat TBI, especially the multiple long-term consequences that can persist and progress for years. It is anticipated that by gaining a more complete understanding of the neurodegenerative and neural repair mechanisms that are triggered in the brain in response to injury, it will be possible to identify or design more effective treatments.

Method/Approach

We have used a laboratory model of TBI and a quantitative proteomics approach (isobaric tagging for relative and absolute quantitation - iTRAQ) to generate brain proteomic profiles and identify cellular mechanisms that are triggered in response to TBI. Moreover, we have carried out these studies in mice transgenic for different isoforms of human APOE in order to discriminate between the cellular mechanisms associated with favorable (APOE3) versus unfavorable (APOE4) outcomes after TBI.

Results/Effects

Our data identify significant changes in the expression of many proteins in the mouse hippocampus and cortex at 24 hrs, 1 month and 3 months after TBI, including proteins with significantly different modulation in APOE3 compared to APOE4 mice. Using Ingenuity Pathway Analysis software, we have mapped these datasets of significantly modulated proteins onto known molecular relationships to determine the functional significance of the observed changes.

Conclusions/Limitations

These extensive datasets reveal molecular pathways that are dependent upon TBI, TBI severity, time-post-TBI, brain region and APOE genotype, many of which may represent targets for therapeutic intervention. In ongoing projects at our Institute, using both genetic and pharmacological approaches, we have confirmed the involvement of several of these pathways in the pathogenesis of TBI.

0061

Self-Esteem (SE) and Persistent Post-Concussion Syndrome Recovery (PPCS): Case Studies Depicting An Elusive Yet Salient Variable

Joel Becker¹

1Neurocognitive Diagnostic & Treatment Clinic, LLC:, Danielson, CT, USA, 2Member of the Connecticut Concussion Task Force, CT, USA

Introduction/Rational

PPCS is a daunting clinical phenomenon that health care providers themselves have difficulty fully describing. For the young person in recovery, it is a very challenging injury. In an instant, their social, academic, cognitive, emotional and physical functions can all be altered. The fact that there is no visible wound or overtly manifest impairment makes adjustment even harder. Prognosis, length of time needed for recovery and actual functional limitations can vary. Treatment must be individually determined in an ongoing process.

Method/Approach

The Case study method was applied as a clinical research tool. Item analysis of specific content correlating with the concept of self-esteem was conducted. Correlation between SE and recovery were qualitatively applied. Data obtained from structured inventories (BDI, BAI, PCSS) as well as clinical descriptions will be utilized.

Results/Effects

On a qualitative/clinical level, SE and neurocognitive functioning had an inferred relationship. Potential trends as well as investigative questions for statistical correlation and effect studies are discussed.

Conclusions/Limitations

The clinical phenomenon of SE and it's relationship to PPCS and recovery was explored. Qualitatively, there is an inferred relationship between SE and recovery status. Implications and suggestions for larger scale empirical studies are discussed. The importance of identifying this variable and monitoring it throughout recovery is emphasized. A Neurocognitive Care Plan incorporating SE as well as physical/emotional responses will be introduced.

0062

Traumatic Brain Injury Emergency Department Visits Meeting Systolic Blood Pressure and Respiratory Rate Criteria of the Centers for Disease Control and Prevention, American College of Surgeons Committee on Trauma Field Triage Guidelines

William Pearson, Mark Faul, David Sugerman, Lisa McGuire, Richard Hunt

Centers for Disease Control and Prevention, Division of Injury Response, Atlanta, GA, USA

Introduction/Rationale

Traumatic brain injury (TBI) has been identified as an important public health problem and understanding the management of this injury in the field and in the emergency department (ED) is critical to saving lives. The Centers for Disease Control and Prevention (CDC) in conjunction with the American College of Surgeons Committee on Trauma (ACS- COT) has developed triage guidelines for injured patients in the field that determine the need for transport to a trauma center using physiologic, anatomic, mechanistic and special consideration criteria. This analysis used national data to estimate the numbers of TBI ED visits meeting physiologic guidelines.

Method/Approach

Data from the 2008 National Hospital Ambulatory Medical Care Survey-Emergency Department (NHAMCS-ED) survey were used. TBI diagnosis was determined using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9) codes for skull fracture, concussion, intracranial injury (unspecified), and head injury (unspecified). Data on respiratory rate and systolic blood pressure for each ED visit were compared to the 2006 guidelines of respiratory rate <10 or >29 breaths per minute and systolic blood pressure of <90 mmHg. National estimates were made for the number of visits with diagnosed TBI transported by ambulance and meeting the specified criteria.

Results/Effects

In 2008, there were an estimated 2.1 million visits to the ED with a diagnosis of TBI and approximately 690,000 of these visits arrived by ambulance. Of all TBI ED visits, approximately 189,000 visits (9%) had a Respiratory Rate of <10 or >29 breaths per minute and approximately 346,000 (16%) had a systolic blood pressure <90 mmHg on arrival at the emergency department.

Conclusions/Limitations

The findings from these analyses demonstrate the importance of the development and enhancement of national triage guidelines that can potentially save lives and influence the transport of these patients to designated trauma centers. Two limitations should be noted. The first is that there is no measurement of Glasgow Coma Scale (GCS) in the NHAMCS-ED, a common predictor of TBI severity. The second is that it was not possible to determine trauma center designation for each emergency department in the sample. However, these data provide a better understanding of TBI ED visits at a national level.

0063

The Rise and Fall of Kallikrein 6 in Traumatic Brain Injury

HW Phipps, S Jackson, J Suber, CW Levenson, SI Blaber, M Blaber, JW VanLandingham

Florida State University, Tallahassee, FL, USA

Introduction/Rationale

Numerous studies support the role of kallikrein 6 (KLK6) as a critical component to various neuroinflammatory diseases and demyelination. Rising KLK6 is characteristic of multiple sclerosis and spinal cord injury. Falling KLK6 is characteristic of Alzheimer's disease. However, KLK6 with respect to traumatic brain injury (TBI) is unknown. The secondary neuroinflammatory cascades in the acute phase (first 72h) of TBI are often the most devastating to patient outcome. This study aims to identify KLK6 as a novel neuroinflammatory biomarker implicated in the acute phase post-TBI and subsequently establishes abundance of KLK6 in brain tissue as a function of time.

Method/Approach

Male Sprague Dawley rats were placed in one of five groups (n = 8); 6h injured, 24 h injured, 72 h injured, 96 h injured, and uninjured. Each injured rat was anesthetized with isoflurane and received a controlled cortical impact (CCI) to the medial frontal cortex with a 5mm diameter steel impactor at a velocity of 2.25 m/s to a depth of 3mm. At 6, 24, 72, or 96 hours, rats were sacrificed and tissue biopsied immediately surrounding injury site. Protein analysis was performed on all biopsies.

Results/Effects

Relative abundance of KLK6 in brain homogenate from penumbra increased over 7-fold within 6h (p < 0.01). Levels reduced to less than 3-fold by 24 h. No significance in KLK6 abundance was noted between injured and uninjured at 72 h and 96 h.

Conclusions/Limitations

Within 6 h, injured animals had a significant increase in KLK6 immediately surrounding the injury compared to the uninjured groups. Current studies are evaluating the correlation of brain tissue KLK6 to trends in serum; thus, enabling use of KLK6 as a blood biomarker of TBI. KLK6 expression is an important factor in the inflammatory cascade, myelin and axonal integrity post-TBI, and susceptibility pre-TBI.

0064

Community Integration Following Traumatic Brain Injury Rehabilitation: Is Intentional Injury a Factor?

Hwan Kim¹, Angela Colantonio¹, Deirdre Dawson², Mark Bayley¹

1Toronto Rehabilitation Institute, Toronto, Canada, 2Baycrest Hospital, Toronto, Canada

Introduction/Rationale

The aim of this study was to investigate community integration 3 to 6 months after in-patient rehabilitation. Moreover, this study aimed to examine intentional injury as an independent potential predictor of rehabilitation outcome, while controlling for age, gender, functional status and other relevant confounders. We hypothesized that community integration outcomes assessed by the Reintegration into Normal Living Index (RNLI) at 3 to 6 month after discharge from in-patient rehabilitation would be poorer for the patients with intentional TBI.

Method/Approach

This is a prospective cohort study utilizing population based acute care and inpatient rehabilitation records: Discharge Abstract Dataset (DAD) and National Rehabilitation Reporting System (NRS) from the Canadian Institute for Health Information (CIHI). The outcome measure for community integration in the dataset was the Reintegration into Normal Living Index (RNLI).

Results/Effects

Of the 243 TBI patients, 24(9.9%) were intentional TBI patients. Intentional TBI was significantly associated with lower score of 'Daily functioning' subcategory of the RNLI. Moreover, higher cognitive and motor FIM scores at discharge, employed status prior to admission, fewer co-morbidities and discharge home were associated with higher daily functioning RNLI. Additionally, cognitive FIM scores at discharge and discharge home were found to be significant factors predicting the 'Self perception' subcategory of the RNLI scores. Among the 11 RNLI subscales, the items of 'Recreation' and 'Family role' were significantly poorer for the intentional TBI group.

Conclusions/Limitations

People with intentional TBI are a distinct population in the rehabilitation setting in Canada. This population would benefit from addressing broader participation outcomes such as family roles and recreation.

0065

A Comprehensive Community Model for Research, Education and Treatment of Mild Traumatic Brain Injury

Jacob VanLandingham¹, John Suber¹, Helen Phipps¹, Sheree Porter², Judy Greenwald², Kimberly Johnson², Andrew Wong³, David Young³, April Bell⁴, Christopher Rumana⁴

1Florida State University College of Medicine, Tallahassee, Florida, USA, 2Tallahassee Memorial Healthcare, Tallahassee, Florida, USA, 3Tallahassee Orthopedic Center, Tallahassee Florida, USA, 4Tallahassee Neurological Clinic, Tallahassee, Florida, USA

Introduction/Rationale

1.2 million mild traumatic brain injuries (TBI) are documented in the United States each year. Mild TBI can lead to memory and attention deficits that impair function in both social and workplace environments. Individuals who sustain a mild TBI are predisposed to future TBIs that can lead to early mortality. Few treatment options are available for mild TBI. Given that high risk activities such as sporting events have been identified for mild TBI, research should be concentrated on prevention for these populations. A major issue is early identification of mild TBI that requires community (physicians, coaches, teachers) education.

Method/Approach

Basic Research-Rats (n = 6/group) were placed in 4 groups; injured, injured with progesterone (PROG) prior to injury, injured with PROG post-injury, uninjured. A repetitive mild head injury was used with 3 successive impacts. Clinical Research-7 athletic programs had players neuropsychologically tested (ImPACT) prior to the season. All players who were suspected of sustaining a mild TBI were re-tested and required to meet uninjured standards before returning to play. Education-All physicians and coaches/teachers were educated prior to the school year on identifying signs and symptoms of mild TBI. Diagnostics-Neuromotor impairment was correlated to cognitive deficits using quantitative EEG, virtual programs and a balance board.

Results/Effects

Basic Research-Prophylactic PROG significantly (p < 0.01) improved learning and memory function and reduced levels of anxiety compared to all other groups. Clinical Research-Over 90 athletes were identified as having sustained a mild TBI. All were required to reach un-injured standards for neuropsychological status prior to returning to play. No secondary TBIs were sustained in those who returned to play. Diagnostics-Patients who have alterations in electrical coherence between the frontal and temporal cortices along with memory and attention deficits as determined by quantitative EEG and neuropsychological testing have a significant (p < 0.01) increase in center of mass velocity (balance impairment) when cognitively challenged.

Conclusions/Limitations

A comprehensive approach for the management of concussion can be used to educate, treat and perform parallel basic and clinical research. This novel model was developed to improve safety and enhance recovery of cognitive and neuromotor deficits in patients who sustain a mild TBI. Our goal is to continue to refine this community model so it can be implemented in other regions across the country.

0066

Traumatic Brain Injury-Related Training for Correctional Officers and Correctional Health Care Providers; Proof of Concept in a State Prison System

Theresa Dulski¹, LaKissia Moss³, Elisabeth Pickelsimer², Marlena Wald¹, William Pearson¹, Pamela Lattimore⁴

1Centers for Disease Control and Prevention, Atlanta, GA, USA, 2Medical University of South Carolina, Charleston, SC, USA, 3University of South Carolina, Columbia, SC, USA, 4Research Triangle Institute, Research Park, NC, USA

Introduction/Rationale

Approximately 25-87% of offenders report having experienced a head injury or TBI versus 8.5% in the general population. The cognitive, behavioral, and physical sequelae of TBI can complicate management and treatment during incarceration. Since ~95% of the current 2.2 million US prison populations will be released, those with TBI will face challenges during community re-entry. Improved identification and management of offenders with a TBI history are necessary to improve reintegration. Thus, targeted education for correctional officers and correctional healthcare providers may address this public health problem as education programs have addressed infectious diseases in correctional settings (e.g., HIV).

Method/Approach

Objective: Adapt, deliver and evaluate education modules focused on the identification and management of offenders with TBI within the South Carolina prison system. Method: Using 2 pilot educational modules developed by the Minnesota Dept of Corrections, 1 for correctional officers, 1 for correctional healthcare providers, test learning objectives and curricula to ascertain generalizability and efficacy of the modules in another state's system. In addition, state-specific findings from a recent CDC-funded TBI prevalence study of adults within the South Carolina system will be integrated in both modules.

Results/Effects

Measures will include: pre-/post-instruction knowledge and attitudes regarding persons with TBI will be measured in both professional groups and compared with findings in Minnesota; institutional screening and management practices within the South Carolina system for persons with TBI will be examined and reported; the feasibility of routine TBI screening at intake for adult prisoners will be assessed; the feasibility of incorporating TBI status as part of release planning will be described.

Conclusions/Limitations

The efficacy of TBI-specific trainings may improve the identification and management of incarcerated persons with history of TBI As a result, these offenders with TBI may be better prepared to reintegrate back into their communities.

0067

Neurorehabilitation of the Mild to Moderate Brain Injury Survivor: A Two Year Study

Stacy Levesque¹, Christin Moses¹, Robert D. Voogt²

1Neurological Rehabilitation Living Centers, Covington, La, USA, 2Robert Voogt & Associates, Virginia Beach, VA, USA

Introduction/Rationale

To demonstrate improvements in independent living, new learning, and cognitive-linguistic skills in persons with TBI, despite severity and time elapsed, using a multidisciplinary approach and structured treatment programming.

Method/Approach

Utilizing specific goals and objectives tailored to each individuals needs for maintaining and establishing independence was followed by all therapeutic interventions and reinforced by four cognitive/social/behavioral classes a day, also including physical programming (YMCA), and social outings into the community each evening. Cognitive testing done both pre-treatment and post-treatment assisted in confirming improvements in functional daily living skills. Standardized Testing using the California Verbal Learning Test Second Edition Short Form (CVLT-II SF) was used to assess participants' ability to learn and remember verbal information at baseline, then following one year within the structure, and then again after a 2nd year.

Results/Effects

To analyze data, a t-test for two dependent means was used to initially test for significance. Overall it was determined that there was a statistically significant increase when comparing the mean scores of the Trial 1-4 Summary, Short Delay, Long Delay and Long Delay Cued Recall from 2008 to 2010.

Conclusions/Limitations

Individuals with significant cognitive deficits, despite severity and time elapsed, made improvements on ability to learn and remember verbal information, as seen on standardized testing and, subjectively, seen with social and behavioral skills.

0068

Cooperative Approach to Counselling Individuals with Communication Impairments

Nicholas Cioe¹, Jennifer Ramirez¹

1NeuroRestorative, Carbondale, IL, USA, 2Southern Illinois University, Carbondale, IL, USA

Introduction/Rationale

As social beings, communication is an essential component of human interaction and quality of life. Deficits related to communication are common after brain injury. Unfortunately, these impairments often make individuals inappropriate for counselling services. Speech and language pathologists are often the clinician forced to address emotional issues they may not be adequately prepared to handle.

Method/Approach

Reviews the essential dilemma (functional, ethical, professional) for post-acute rehabilitation programs providing services to individuals with communication impairments. Case study examples demonstrating the effectiveness of a speech language pathologist/counsellor co-treatment approach.

Results/Effects

Consistent with general response to counselling intervention, participant improvement is related to willingness to engage in therapeutic process. Improved quality of life and engaging other therapeutic components of a comprehensive post-acute brain injury rehabilitation program for those with positive response results in a better treatment outcome.

Conclusions/Limitations

Psychological adjustment to a brain injury is negatively affected by communication impairment. Utilization of a co-treatment approach controls for the functional, ethical, and professional dilemma associated with counselling individuals with communication impairments. Limitations: descriptive, non-qualitative design; therapist interaction dynamics important component of therapeutic intervention; availability of willing and qualified therapist to perform intervention.

0069

Mapping the Growth of Legislation in the U.S. to Help Improve Traumatic Brain Injury Identification and Management for School-Aged Athletes

Michael Lionbarger¹, Marlena Wald¹, Theresa Dulski², Lisa McGuire¹

1Division of Injury Response, National Center for Injury Prevention and Control (NCIPC), Centers for Disease Control and Prevention, Atlanta, GA, USA, 2Emory University School of Medicine, Atlanta, GA, USA

Introduction/Rationale

Traumatic Brain Injury(TBI) is public health problem in the US. Studies indicate that one recurrent injury or sustaining multiple mild TBI's, within a short time-span, can lead to permanent brain damage or even death, if the initial injury is not identified and treated. An NCIPC study found that during 2001-2005 children 5-18 years represented approximately 2.4 million sports and recreation (SR)-related emergency department visits; 5.6% (134,959) estimated to be TBI-related. Recently, states have begun to focus on developing SR-related TBI legislation to protect school-aged athletes. Prospectively monitoring geographic growth of these laws provides a unique policy perspective for decision-makers.

Method/Approach

Structured keyword (e.g., concussion, TBI, or student athlete) Internet searches were conducted using Google of publically available, state legislatures' websites. The policies found were then categorized based on the criteria included within the laws and whether or not they had been passed, or were still in the development stage. A map was then created using the information synthesized. State legislatures' websites requiring membership for search access to current legislative activities were considered to have no public information available.

Results/Effects

As of June 1, 2011, 26 of 50 US states have enacted laws addressing identification and TBI/concussion management among school-aged athletes in various capacities and 17 additional states have introduced school-aged concussion legislation since the beginning of 2010. Public information could not be found for the remaining 7 states.

Conclusions/Limitations

Since the 2009 passage of Washington's Zackery Lystedt law, other states have begun to draft or pass similar legislation for the identification and management of SR-related TBI/concussion in school-aged athletes. Further evaluation regarding the effectiveness of these laws is needed. A limitation to this study is that only publicly available information regarding state laws was included. States that were considered to have no information available could potential have either enacted school-aged concussion policies at a local-level or not included the introduced bill on the state legislature website.

0071

The Brain Check Survey: Expanding the Psychometric Properties of a School-based TBI Screening Tool

Pat L. Sample¹, Lisa Daunhauer¹, Judy Dettmer²

1Colorado State University, Fort Collins, CO, USA, 2Colorado Division of Vocational Rehabilitation, Denver, CO, USA

Introduction/Rationale

Many children with TBI demonstrate cognitive, behavioral, emotional, and physical problems. A discrepancy persists between number of students sustaining TBI, and frequency of students with TBI receiving special education services. We examined psychometrics of the Brain Check Survey (BCS), a tool designed to assist in identifying TBI in struggling students.

Hypotheses/Question: 1. TBI group will perform differently from typical (TYP) students in the BCS behaviors domain. 2. TBI group will perform differently from TYP students in the BCS symptoms domain. 3. TBI group will perform differently from students with learning disabilities (SPED) on the BCS behavior and symptoms domains. 4. What is TYP performance in behaviors and symptoms, by age group?

Method/Approach

Participants: Using stratified random (3 school levels, and 2 genders), and whole group methods, we recruited students from 5 school districts, urban, small urban, rural. Targeted students: typically-developing (TYP), with a learning disability (SPED), and with a diagnosed TBI. Instrument: The Brain Check Survey (BCS)-parent-report screening tool designed to initiate a school-based process of identifying TBI in children. Includes three domains: History of brain-related injuries or illnesses, symptoms, and behaviors, plus other descriptive questions. Data Analysis: Ordinal-level data from BCS, and unequally-sized groups, resulted in use of Kruskal-Wallis to test our hypotheses and answer question; followed by the Mann-Whitney U test for post-hoc analysis.

Results/Effects

* Total of 546 completed BCSs returned: 461 TYP, 51 TBI, and 34 SPED.

* TBI students had significantly higher scores on all 19 behaviors, and the total behaviors score; and significantly higher scores on all 15 symptoms, and the total symptoms score, than the TYP group.

* The TBI behaviors and symptoms scores were significantly higher than the SPED group scores, and on the total behaviors and symptoms scores.

* TYP group showed significant differences between school-based age groups for 5 behaviors: "listens," "waits turn," "reacts," "handles change," and "monitors"; and 7 symptoms: "headaches and/or migraines," "blackouts/fainting," "dizziness," "change in vision," "fatigue," "sleepiness," and "mood swings.

Conclusions/Limitations

These findings verified our known-group (TBI and SPED) validity hypothesis. The BCS distinguished between TYP and TBI students on the behavior and symptom domains. TYP students demonstrated differences in number of symptoms (5), and behaviors (7), across three age groups: elementary, middle, and high school. Interestingly, the TYP students had higher symptom scores in middle and high school, than in elementary school. These symptoms may reflect normal child development symptoms experienced by students as they approach and grow through puberty. The TBI group experienced no similar increases in symptoms with age. Limitations: Our TBI and SPED groups were of modest size.

0072

Protective Effects of Melatonin on the Experimental Traumatic Brain Injury Model in Rats

Mehmet Kanter

Department of Histology and Embryology, Faculty of Medicine, Trakya University, Edirne, Turkey

Introduction/Rational

The aim of this study was designed to evaluate the possible protective effects of melatonin on the experimental traumatic brain injury (TBI) model in rats.

Method/Approach

Twenty-four adult male Wistar albino rats were randomly divided into three groups: control, TBI and TBI+melatonin treatment; each group contain 8 animals. Rats were sacrificed at 4h after the onset of the TBI. Brain tissues were removed for biochemical and histopathological investigation.

Results/Effects

In the TBI group, we found severe degenerative changes, shrunken cytoplasm and extensively dark pyknotic nuclei in neurons, as well as vacuolization indicating tissue edema formation. The morphology of neurons in the melatonin treatment group was well protected. The caspase 3 immunopositivity was increased in degenerating neurons of the traumatic brain tissue. Treatment of melatonin markedly reduced the immunoreactivity of degenerating neurons. The amount of neuronal cell apoptosis was quantitatively higher in the TBI group than in the control group. Treatment of melatonin markedly reduced the reactivity and the number of apoptotic cells (TUNEL positive cells).

Conclusions/Limitations

In conclusion, melatonin treatment might be beneficial in preventing trauma-induced oxidative brain tissue damage, thus showing potential for clinical implications.

0073

Prenatal Brain Injury-Case Study

Slavica Golubovic, Vesna Stoilkovic

Faculty of Special Education and Rehabilitation, Belgrade, Serbia

Introduction/Rationale

This is a case study of a boy born in 2000 by Caesarean section. He sufferedasphyxia and hypotonia, started to walk at age 23 months and gait was discordant. He has had periodic autoaggressive behavior, presence of pica, polyphagia, polydipsia, enuresis and sleep disorder.

Method/Approach

An EEG registered paroxysms of high-voltage slow wave activity. A social scale of maturity was consistent with the age of 3.8 years, or SQ - 56. He is considered mentally retarded as is his mother, also. Because of hyperactivity (uncontrolled anger and aggression with other children, objects and adult persons) he is given Rissar. His behavior is getting worse, he rejects demands of his teachers, biting children and spitting. Intervention of a pedagogist has no effect, whereby whole behavior repeats with higher intensity.

Results/Effects

He recognizes themes and objects that he has had previous contact, repeats words that are spoken, produces simple sentences, and speaks in a more understandable way. Sometimes he spontaneously produces a more difficult sentence construction that is supported with adequate reward. Nonverbal abilities are better, he shows objects, is interested, tries to show with drawing what he wants, but drawing is immature for his age. He scribbles and doesn't know how to hold the pencil. What he visually perceives is connected with happenings and persons that are related to that perception. Now, he is physically stronger, and motor coordination is better.

Conclusions/Limitations

He demonstrates institutional syndrome, repeats words that he has heard from adults, but he does not understand their meaning, which is not in accordance with his age. Individual treatment is necessary for the whole day, with clear structured time adjusted to his needs and abilities, as his optimal and behavioral potentials can be further developed.

0074

Conflict Free Case Management, A Model for Quality and Cost Effectiveness: The Challenges of Long Term Brain Injury Rehabilitation in a Rural Southeastern State Experiencing Prolonged Financial Distress

Tonia Wells, MSW, CBIS¹, Carla Crain, PhD¹, Shannon Beaven², Cindy Whitehouse, RN, CCM³

1Kentucky Cabinet of Health and Family Services, DAIL, Frankfort, KY, USA, 2Kentucky Injury Prevention and Resource Center, University of Kentucky, Lexington, KY, USA, 3Eckman/Freeman and Associates, Lexington, KY, USA

Introduction/Rationale

Traumatic brain injury (TBI) is a significant problem in Kentucky. In 2007, over 4,500 TBI cases were reported through hospitals as admissions or fatalities. This does not include individuals treated outpatient, emergency rooms, and contiguous states. In 2010, the number appears to be over 25,000 individuals diagnosed with TBI, well above initial estimates. The TBI Trust Fund was created in 1998 to provide services to individuals. A Benefit Management Program (BMP) was established to govern operations. Eckman/Freeman Associates (E/FA)was selected by the Board to administer the BMP. The selection process was a significant milestone because E/FA, as a for profit corporation, was selected to work with state and other funding sources. The growing number of referrals and no increase in funding have been a concern.

Method/Approach

The Trust Fund is innovative, merging government and local programs, offering case management at no cost to individuals. Benchmarks are (1) Case managers who have the following a RN or MS in Social Work or Vocational Rehabilitation; 3 years' experience; five days training; catastrophic training; certifications as CDMS, CCM or CRRN and six hours annual TBI training, (2) Lead Case Manager (The Fund mandates "fund at last resort". Case managers are not involved when another case manager is assigned, (3) Local Case Management, (4) Conflict free case management, (E/FA is not affiliated with vendors or providing services). Referrals are need, quality and cost effectiveness based), (5) Case managers knowing insurance, public, non-profit and local resources and (6) work as needed not based on unnecessary guidelines:

Results/Effects

The Trust Fund, has provided 210,495 case management hours to 3,890 individuals January 2001-May 2011. The Trust Fund saved over $4,993,645.26 since August 2001 by case managers obtaining resources from community options and natural supports. The Trust Fund has accomplished these goals with minimal funding increases in the past ten years. The Trust Fund has become an exemplar model for case management throughout the Kentucky Health and Family Services Cabinet, implementing:

* Conflict-Free case management;

* Avoidance of duplicated services;

* Utilization of natural and local resources;

* Cost savings through identification of other resources;

* Exceptional consumer services that are client need based and easily accessible.

Conclusions/Limitations

The Trust Fund realizes the significance of TBI in Kentucky. Individuals served represented only 1% of those affected by brain injury in 2009. Kentucky is suffering financial shortfall. We work to protect the Fund from decreased funding and realize increased funding is difficult. The Board is exploring mechanisms addressing Kentuckians in the military with brain injuries. Kentucky has two military bases. Kentucky's population grew 7.4% 2000 to 2010, aging significantly. This will stress the Trust Fund as aging increases economic difficulty and incidence. The Board stretches every dollar; serving all referred; exploring alternative funding. The Trust Fund makes client-focused field case management a reality, serving in unstable economic times through sound benchmark practices and innovative cost-effectiveness.

0075

Developmental Dysgraphia in Primary School

Slavica Golubovic, Gordana Colic

Faculty of Special Education and Rehabilitation, Belgrade, Serbia

Introduction/Rationale

Developmental dysgraphia is basically defined as a disorder affecting otherwise normally developing children who show a reduced ability or an inability to acquire writing skills, even when exposed to an adequate educational system.

Method/Approach

We investigated 230 children in grades III and IV, 132 males and 98 females. Children were examined with The Scale for the Assessment of Handwriting Dysgraphia (Ajuriaguerra & Ozias) that consists of taking handwriting samples in the three forms of writing: dictation, a free composition and rewriting. The texts of the dictation and rewriting were identical and contained all the letters of the Cyrillic alphabet, while the free composition was titled: "An Experience of Mine".

Results/Effects

Results of investigation show that dysgraphia appears in 7.8% of the children. 10.4% of children with dysgraphia had characteristics of an unshapely handwriting while 81.7% had a shapely handwriting. Manifest dysgraphia in grade III was 8.2%, while in grade IV it was 5.9% of cases. Analysis concerning gender showed that dysgraphyiaand unshapely handwriting were manifest in children of both genders, with statistically significant differences regarding the presence of dysgraphia according to gender.

Conclusions/Limitations

Interventions in prevention and rehabilitation appear to be increasingly more intricate and interactive. The usage, as a first step, of intensive training techniques, performed with small groups in school and for short periods, warrant development and assessment; as a second step, other techniques require a dual relationship with a therapist.

0076

Diagnostic Accuracy of Emergency Department Concussion Evaluations: A 3-Month Descriptive Analysis

Jennifer M. Devine¹, Michael P. Alexander¹

1Division of Cognitive Neurology, Beth Israel Deaconess Medical Center, Boston, MA, USA, 2Department of Neurology, Harvard Medical School, Boston, MA, USA

Introduction/Rationale

The accuracy of concussion diagnoses is integral to the provision of appropriate and timely care. Concussion denotes mild brain injury with well-recognized possible residual disability. By improving diagnostic and treatment pathways for patients with concussion, it may be possible to improve both outcomes and resource allocation in this population. In the absence of a biologically meaningful measure of mild brain injury, consensus criteria define concussion for clinical, research and public health studies. We hypothesize that concussion diagnostic criteria are imperfectly applied in Emergency Department environments, and that this may adversely impact patient education, clinical care and research findings.

Method/Approach

A 3-month chart review was conducted for quality assurance purposes. Following ED evaluation for head injury, patients were referred to concussion clinic, and ED notes were sent automatically to concussion clinic physicians. From these, a descriptive analysis was performed. Records were reviewed by concussion clinic physicians to determine whether history and exams were consistent with American Academy of Neurology (AAN) criteria for concussion. In cases where patients presented distant from injury, diagnoses were determined from available details of initial injury. Results from this assessment were then compared to diagnoses assigned by ED staff.

Results/Effects

Thirty-nine patients were referred to concussion clinic; 85% saw >=2 ED providers. Between-provider diagnostic concordance was 48.5%. 36 of 39 (92.3%) patients were asked about >=1 AAN concussion symptom. Most commonly queried symptoms were loss of consciousness (97%), headache (53%), nausea/vomiting (48%), confusion (23%) and amnesia (23%). Mental status was documented in 13 of 39 (33%) charts. Twenty-six patients (67%) were diagnosed with concussion; 10 (38%) met concussion criteria. Thirteen patients (33%) were not diagnosed with concussion; 6 (46%) met concussion criteria. Compared to AAN criteria, ED evaluations were 63% sensitive, 30% specific and 44% accurate for concussion diagnosis.

Conclusions/Limitations

Multiple factors contribute to inaccurate diagnoses of concussion in the ED. Inconsistencies in history and examination lead to high rates of diagnostic discordance among providers and a low rate of diagnostic accuracy. Consistent with prior findings, patients with serious co-morbid injuries are often not evaluated for concussion. Alternately, patients with head trauma without evidence of concussion were frequently misdiagnosed with concussion. History elements with greater specificity for concussion (amnesia, confusion, balance impairments) were infrequently documented. These findings suggest that a focused educational intervention for ED providers could help improve concussion diagnostic accuracy without taxing limited provider time.

0077

Implementing Effective Concussion Management: One High School's Experience

Cathy Thomas, Laura Beck

Center on Brain Injury Research and Training, Eugene, OR, USA

Introduction/Rationale

As more states pass laws mandating concussion management in high school athletics, schools are looking for information and tools to assist them in implementing policies and procedures to protect student athletes.

Method/Approach

In the summer of 2010, Redmond High School (RHS) in Redmond, Oregon agreed to pilot-test best-practice implementation of Oregon's Max's Law-named for Max Conradt, a high school football player who took blows to the head in back-to-back games and suffered permanent brain injury. The law was passed in July 2009 and took effect during the 2010-11 school year. As part of best practice, RHS established a Sports Concussion Team in the fall of 2010. The RHS athletic director ensured that all coaches completed the Athletic Concussion Training for Coaches (http://activecoach.orcasinc.com).

Results/Effects

During the fall of 2010, 294 Redmond students participated in fall high school athletics. Of those, 22 students were pulled from play due to a suspected concussion, approximately 10%. Only 18 of those students actually sustained a concussion. Injured students stayed home from school, with complete rest, for an average of 2.38 days. Redmond teachers provided temporary accommodations during the first few weeks. Only six students required accommodations for more than two weeks.

Conclusions/Limitations

Starting in the fall of 2011, the Redmond School Board will review the district's concussion policy, and all coaches, teachers, and counsellors will take part in the annual training.

0078

Web-based Training in Family Advocacy

Karen McLaughlin¹, Ann Glang¹, Laura Beck¹, Cathy Thomas¹

1Oregon Center for Applied Science, Eugene, OR, USA, 2 Center on Brain Injury Research and Training, Eugene, OR, USA

Introduction/Rationale

This study examined the efficacy of an interactive multimedia intervention that provides training in advocacy skills for family members of individuals with traumatic brain injury (TBI).

Method/Approach

Participants were 201 individuals providing moderate to high levels of support to a family member with TBI. The design was a randomized trial with participants assigned to treatment (Brain Injury Partners: Advocacy Skills for Families website) or control (Brain Injury Association of America website) conditions. Measures delivered in an online questionnaire format were used to assess knowledge, skill application, behavioral intention, and overall life satisfaction at pre-test, post-test, and 3-month follow-up.

Results/Effects

Compared to the control group, the Brain Injury Partners group reported higher post-intervention adjusted means for application, knowledge, and attitudes scales. Univariate analyses showed that these measures were also statistically significant at follow-up. Satisfaction with life, assessed at follow-up but not post-test, approached significance.

Conclusions/Limitations

This study demonstrated the effectiveness of a web-based intervention to teach effective skills to caregivers advocating for a family member with TBI.

0079

Understanding Opinions About Concussions in High School Sports

Juliet Haarbauer-Krupa¹, Asa Revels¹, Kelley Mautz¹

1Brain and Spinal Injury Trust Fund Commission, Atlanta, GA, USA, 2Children's Healthcare of Atlanta, Atlanta, GA, USA, 3Emory University, Atlanta, GA, USA

Introduction/Rationale

Print, television, and social networking media contain prolific and varied messaging about sports related concussions. There is limited understanding of the impact that information has on coach, student-athlete and parent's knowledge and opinions about concussions, symptoms and proper management among student-athletes parents and coaches. The goal of this study was to identify the impact of current messaging on student-athlete, parent and coach opinions about concussion recognition and evaluation.

Method/Approach

Participants expressed opinions about concussions in focus groups and identified symptoms from a survey checklist. Focus group questions were based on the social cognitive theory, health belief model, and theory of reasoned action constructs identified by Glang and colleagues. Seventy-one participants (41 student-athletes, 21 parents and 9 coaches) from a suburban Atlanta high school identified the source of their concussion information, reported knowledge about symptoms, general knowledge about concussions, misperceptions, and actions.

Results/Effects

Coaches' opinions reflected required concussion training. Sources of concussion information for student-athletes and parents were primarily sports related media or a school athletic trainer. Parents relied on personal experience with concussions in high school to manage children's' symptoms. Only those who experienced concussion reported learning about management from their doctor. As a group, student-athletes identified 72% of concussion symptoms and parents/coaches identified 91%. Student -athletes indicated they would more likely to report their own concussion to parents than to a coach. Few would tell the coach about another player's concussion. Misperceptions were in the area of prevention and management.

Conclusions/Limitations

Coach training impacts opinions about concussion symptoms and course of action. For parents and student-athletes in high school athletic communities, concussion symptoms are known but with continued misperceptions about management. Participants in this study recommended additional information in school health classes, internet sources (Facebook, Web MD) and sports venues (ESPN, sports magazines).

0080

Childhood Head Injury: Causes, Outcome, and Outcome Predictors. A Nigerian Perspective

Olugbenga ODEBODE, A.M. ABUBAKAR

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

Introduction/Rationale

Head injury is the most common cause of death following trauma among children in most developed and underdeveloped countries. Until October 2000, general and orthopedic surgeons managed childhood head injury conservatively in our center.

Method/Approach

To determine outcome and outcome-predictors in children managed nonoperatively for head injury in Ilorin, Nigeria, a 10-year retrospective study of children managed for head injury was done. Outcome was measured by Glasgow outcome scoring. Clinical variables including age, gender, and post resuscitation Glasgow coma score were tested against Glasgow outcome score by linear regression analysis.

Results/Effects

267 children (173 males and 94 females) aged 16 years and below with head injuries (HI) were admitted. HI was predominantly secondary to road traffic crash (64.1%) and falls (30.7%). Other mechanisms include domestic, sports, assaults and fall of collapsed walls, water-pots, and coconut shells on victims' heads. HI were isolated in 60% of patients but associated with skeletal, facial, and spinal injuries in 58, 18, and seven cases, respectively. They were mild in 100 (37.5%), moderate in 73 (27.3%), but severe in 94 (35.2%) cases.

Conclusions/Limitations

Outcome was good in 207 (77.5%) but fatal in 38 (14.2%) children. Only age (p = 0.0206) and coma score (p = 0.0000), but not gender (p = 0.3043), predicted outcome.

0081

Readiness for Independence: Facilitation of the Transition to Adulthood for Teens with ABI

Juliet Haarbauer-Krupa¹

1Children's Healthcare of Atlanta, Atlanta, GA, USA, 2Emory University School of Medicine, Atlanta, GA, USA

Introduction/Rationale

Transition to adulthood, a move from dependence to independence, is a gradual process cumulating with less reliance on adults, increased personnel responsibilities, and participation in community activities. Beyond rehabilitation, there are limited options for transition planning and services for teens with brain injuries. Research describing transition outcomes for youth with ABI indicates that the presence of a medical home, self-determination and access to resources are skills that facilitate success. The goal of this paper is to describe a model intervention program that includes skill development in areas critical for transition to adulthood and outcomes for transition readiness.

Method/Approach

The BRAIN Program (Bringing Rehabilitation and Injury recovery to New Levels) is a two -week evidenced-based, intensive program to teach transition skills and offer access to resources to achieve post high school goal attainment. A peer coach model is utilized to provide skills training for communication, self-management, fitness and health/wellness. Access to resources is provided for school, vocational rehabilitation, leisure and health and wellness.

Results/Effects

Participants were 18 teens with acquired brain injury enrolled in the 2009, 2010 and 2011 programs. Qualitative data analyses from each year lead to the development of the Readiness for Independence Questionnaire (Haarbauer-Krupa & Gilleland, 2011) as an outcome tool for program evaluation. Findings from the 2011 pilot study of this measure will be presented.

Conclusions/Limitations

Teens with acquired brain injuries benefit from programs that offer training for skills important for the transition process and access to resources.

0082

Evaluating the Applicability of an Adapted Mindfulness-Based Meditation Program Among Vinland's National Center's Clients

Gisli Kristofersson¹, Tom Beckers¹, Rick Krueger¹

1Univeristy of Minnesota, Minneapolis, MN, USA, 2Vinland National Center, Loretto, MN, USA

Introduction/Rationale

Mindfulness meditation has proven to be an effective stress reduction technique for different patient populations. This project was jointly developed by Vinland National Center, Loretto, Minnesota and the Center for Spirituality and Healing (CSH), University of Minnesota to adapt and develop a mindfulness intervention for Vinlands clients. Mindfulness is a low cost, safe and efficacious intervention for numerous disorders and appears an appropriate intervention for this population given their sensitivity to medications, their high incidence of depression and anxiety and the impulsivity that often accompanies TBI, which studies have shown can likely be reduced by mindfulness practice.

Method/Approach

Purpose: To describe the feasibility of a four-week Adapted-MBSR program for persons suffering from SUDs and TBI's and other cognitive disabilities, often accompanied by various mental health problems. The focus was placed on the effect that mindfulness meditation practice has on patient satisfaction and on staff's work satisfaction. The necessary adaptations of the MBSR curriculum to the needs of the /SUDs/TBI population will also be discussed.

Methods: A program evaluation was implemented with individual interviews and focus groups including both staff and patients to assess the feasibility and effects of the adapted MBSR program.

Results/Effects

Findings: The preliminary findings suggest that it is feasible to implement an adapted MBSR program in an inpatient treatment facility for persons suffering from SUDs, TBI's or other cognitive disabilities along with various mental health issues. Feedback from Vinland staff and patients has been very positive and no adverse effects have been noted to date.

Conclusions/Limitations

The limitation of the program evaluation mainly lies in its design. But the results gained from this method are only an indication about the feasibility and acceptability of the adapted MBSR curriculum for the SUDs/TBI population. Next steps include a research study planned in the fall on the effects of the adapted MBSR program on the quality of life, depression, impulsivity and anxiety levels on persons suffering from SUDs/TBI.

0083

Amyloid Pathway in Human Cortex Surgically Excised After Traumatic Brain Injury

Mauricio Palacios, Efrain Buritica

Lina Becerra, Diana Marcela Gonzalez, Martha Isabel Escobar, Hernan Pimienta

Universidad del Valle, Cali, Valle del Cauca, Colombia

Introduction/Rationale

Background: Acute over expression of amyloid precursor protein (APP) has been observed after traumatic brain injury, but it is unknown if it corresponds to an attempted repair of the neuron or a neurodegenerative processes. In the present study, we collected freshly resected human brain tissue to describe the amyloid pathway in subjects who underwent decompressive craniectomy after TBI.

Method/Approach

Slices from eight subjects were kept in acute organotypic culture for fourteen hours. Samples were collected at 2,6,8 and 14 hours and fixed for immunohistochemistry to NeuN and APP. Four specimens of the subjects were processed for immunofluorescence and analyzed with confocal microscopy. Control post-mortem tissue without neurological diseases was used.

Results/Effects

APP expression increased in neurons in layers III, IV and V, between two and six hours. After eight hours, we observed an increase of immunoreactivity to APP in hypertrophic astrocytes in supragranular layers and decreased expression in neurons. The expression of APP co-localized with BACE-1, and NeuN in pyramidal neurons of layers III and V, and we also observed increased of BACE-1 in neurons along cortical layers. A positive A- beta amyloid oligomers-were seen in neurons, but with less stained cytoplasm and darker nuclei in supra and infragranular layers, with incipient amyloid deposits in every specimens.

Conclusions/Limitations

These preliminary results suggest a repair response of APP after TBI, but it could fail and end in a neurodegenerative pathway

0084

The Effects of Brain Injury on the Ability to Make Predictive Inferences While Reading

Richard Thurlow, Catherine McGeehan

Widener University, Chester, PA, USA

Introduction/Rationale

Beeman (1993) first established that adults recovering from right hemisphere lesions have difficulty in making coherence inferences. Further research has supported the importance of the right hemisphere in generating coherence and predictive inferences (Virtue, Parrish, & Jung-Beeman, 2008; Lehman-Blake & Tompkins, 2001; Beeman, Bowden, & Gernsbacher, 2000).

In the study reported here, adults recovering from brain injury (primarily RH, primarily LH, or bilateral) read simple passages that ended before a highly predictable outcome. They were then asked to predict what they thought would happen next. Their predictions were compared to answers given by persons without brain injury.

Method/Approach

Sixteen subjects recovering from traumatic brain injury were recruited, all of whom were inpatients or outpatients at a rehabilitation facility near Philadelphia. Four subjects had primary injury to the left hemisphere (LHD), six had primary injury to the right hemisphere (RHD), and six had bilateral damage (BD).

The subjects read a total of 23 short passages (fourth grade reading level), all of which ended with a highly predictable outcome (established by unanimous predictions generated by persons without a brain injury). Subjects then wrote (or dictated) their predictions regarding what they thought would occur next.

Results/Effects

The results were clearly different between the LHD subjects and the other two groups. LHD subjects' predictions matched the normal control group 80% of the time. The RHD group matched only 69% of the time and the BD group matched 72% of the time.

A conservative interpretation of the responses does indicate that the groups were more similar when predictions that did not immediately follow the passages' temporal sequence were included as accurate predictions. However, further analysis of the inaccurate predictions reveals more subtle differences between the groups.

Conclusions/Limitations

Despite the small sample size in this study, it appears that left hemisphere damage causes less interference with predictive inference processing than does right hemisphere damage. If this is supported by further research, it would imply that persons with LHD have greater ability with complex language than indicated by their expressive output. In contrast, it would also mean that persons with RHD have greater difficulty with high-level language processing.

These findings could influence how clinicians establish treatment plans and set goals for their clients.

0085

An Instrumented Four Square Step Test for Patients After Traumatic Brain Injury (TBI)

Denise Gobert, Gregory Propst, Lindsey Katt, Dustin Kreitner

Texas State University, San Marcos, Texas, USA

Introduction/Rationale

With the advent of evidence-based practice guidelines, rehabilitation strategies have been challenged to demonstrate improved reliability and validity standards to measure TBI patient responses to balance retraining.^1,2 Although objective gait analysis techniques have been widely accepted as an important resource for clinical decision-making, clinicians have yet to take full advantage of objective measures to assess TBI patient functional recovery and response to treatment.

The purpose of this pilot study was to demonstrate the practical use of an instrumented Four Square Step Test as an objective measure of functional recovery post TBI.

Method/Approach

25 participants were placed into two groups: TBI Group (n = 6) at least 6 months after TBI, age 50.47 +/-15.77 years and Control Group (n = 17), age 25.3 +/- 4.17 years without any known neurological disorder. All participants received a clinical assessment of balance using a standardized protocol incorporating a computerized 4' x 4' pressure sensor floor mat (GaitRite, Inc). Participant outcomes included FSST scores and customized measurements of COM/COP activity to characterize Movement Velocity, Weight Symmetry, Movement Path Coefficient of Variation, and a Normalized Stability Index. Patients were assessed at initial evaluation and at the last treatment session at 6 weeks.

Results/Effects

Non-parametric descriptive statistics including the Mann Whitney U and Wilcoxon Rank tests compared group responses over time. In addition, a multivariate regression model was used to find significant indicators of movement quality to calculate minimum detectable change values. Alpha level was set at 0.05. Preliminary results indicate that a simple computerized sensor mat system demonstrates higher sensitivity to patient response changes over time compared to standard timed scores used to describe balance function in TBI patients. A detailed summary of proposed methods will be discussed for use in typical clinic settings to augment assessment of TBI patients during functional recovery.

Conclusions/Limitations

Contemporary physical therapy practice for balance retraining for TBI patients has evolved into a patient-centered management model. To further refine this model, documentation of TBI patient outcomes is needed for the development of clinical predication rules (CPRs) to guide the patient/client management process, including prognosis and intervention.² The addition of objective measurements to standardized clinical assessment tools will better stratify TBI patients into treatment categories using MDC scores and, therefore, better predict treatment response.^3,4

0086

Mild or Severe Brain Injury, What Do SPECT Scans Reveal?

Colin King

Rainbow/Rehabilitation Centers, Ypsilanti, MI, USA

Introduction/Rationale

Over the years, treatment providers have established criteria for distinguishing between a mild and severe brain injury. Clients diagnosed with a mild brain injury sometimes go untreated, or are often seen as malingering, or are denied full access to care. In the recent past, many veterans have returned home not diagnosed as having a brain injury but having manifested problems similar to those who have sustained a severe brain injury. This research focuses on using SPECT scans with clients who were previously diagnosed as having a mild brain injury to highlight the impact of their deficits that sometimes are severe.

Method/Approach

An examination of actual SPECT scans of clients previously diagnosed as having a mild brain injury. Comparing this group of clients (mild brain injury) with others who have been diagnosed as having a severe brain injury to see whether there is a statistical difference in behaviors, motivation, and functional outcomes

Results/Effects

Clients who were previously diagnosed with a mild brain injury sometimes have equally severe behavioral problems as those who were diagnosed with a severe brain injury.

In effect, there is no statistical difference in severity of behavioral problems between clients who have been diagnosed with a mild brain injury when compared with those who have a severe brain injury

Conclusions/Limitations

A diagnosis of a mild brain injury should not preclude a person from gaining access to care, especially when behavioural problems are apparent. These persons should have equal access to services just like their counterparts who have sustained a severe brain injury.

0087

Effect of Aerobic Exercise on Cortical Activation and Working Memory Following Traumatic Brain Injury

Grant Hennington¹, Byung-chul Park¹, Dana Seifert¹, Jeanne Lojovich¹, Michael Armstrong¹, James Carey¹

1University of Minnesota, Minneapolis, MN, USA, 2Minneapolis VAMC, Minneapolis, MN, USA

Introduction/Rationale

TBI is on the rise in the active duty US military population and is frequently associated with impairments in working memory. Cortical regions currently considered to play a role in this system includes the dorsolateral prefrontal cortex (DLPFC), anterior cingulate (ACC) and precuneus (PreC). In animal and human models, these regions have shown improved levels of activity in human and animal models following aerobic exercise as well as improved cognitive performance.

The aim of this study was to investigate changes in the cortical activity and working memory performance in three TBI survivors after following a 12 week aerobic exercise program.

Method/Approach

Three male subjects (mean age 39.6 +/- 16.9) with severe, non-penetrating TBI (6.3 +/- 5.0 years post-injury). Cortical activation was obtained using 3T fMRI during performance of a visual fixation condition (control), 0-back and 2-back conditions of the N-back working memory task. Scans were performed on 3 different days prior to and after a 12 week aerobic exercise program consisting of 3, 40 minute sessions per week. Analysis of changes in activation during the N-back task was performed using Brain Voyageur. Measurements of working memory were measured through the accuracy and reaction time on the N-back task.

Results/Effects

Following completion of the 12-week exercise program all 3 subjects demonstrated a decrease in the intensity of the caudal ACC and PreC and right DLPFC areas during the 0-back task compared to the control task. However, an increase in the intensity and voxel count in the left DLPFC was noted during the 0-back task compared to the 2-back task. In 2 of the subjects, an increase in the intensity of the ACC and the right DLFPC was also noted during the 2-back task when compared to the 0-back task.

Conclusions/Limitations

Participation in aerobic exercise resulted in significant changes in cortical activation in the ACC, PreC & DLPFC and working memory. This pilot study contributes to emerging evidence supporting the use of aerobic exercise following severe TBI and indicates the need for further research to determine if these findings exist in a larger population.

0088

Cognitive Home Evaluation and Treatment Transition: A Case Study Approach

Virginia Martin, Bonnie Schaude

Shepherd Center, Atlanta, Georgia, USA

Introduction/Rationale

Early completion of the home evaluation focusing on cognitive issues provides information to the treatment team regarding the actual set-up of the client's real life environment. This provides information to the treatment team which allows them to develop unique treatment goals and strategies. The team develops alternative solutions that better fit the needs of the client. It also allows for client/caregivers to implement strategies in the home and provide feedback to the therapists. Following completion of rehabilitation, the Personal Support Services staff provides training in the home assisting the client in becoming more independent, taking greater responsibility over their daily life skills and requiring less supervision.

Method/Approach

The Cognitive Home Evaluation includes demographics, home and community accessibility assessment, assessment of cognitive daily functions within the home and community, cognitive system strategy analysis and summary recommendations. The treatment team bases the treatment goals on the information in this evaluation. Following discharge, the staff providing Personal Support Services makes weekly visits during which they address the needs specific to the client. They include, but are not limited to, safety in the home, time management, organization, medication management, meal preparation, cleaning, yard work, bill payment, budgeting, etc. The primary goal is to increase independence and require less supervision.

Results/Effects

Primary outcomes were assessed by comparing the change from baseline to program completion. The majority of clients (88%) required less supervision as measured the Supervision Rating Scale. For 71% of clients, a clinically significant change was observed that would allow caregivers to return to work.

Conclusions/Limitations

The outcomes of the clients participating in the Cognitive Home Evaluation and Personal Support Services Program indicate success of the program based on the acquired levels of independence by the clients and their decreased need for supervision. Clients also demonstrated significant improvement in self-ratings of performance and satisfaction during before and after measurements.

0089

Exploring the "good old days" Bias in Paediatric Mild Traumatic Brain Injury

Basil Kadoura², Brian Brooks¹, Susan Crawford¹, Karen Barlow¹

1University of Calgary, Calgary, Alberta, Canada, 2McGill University, Montreal, Quebec, Canada

Introduction/Rationale

The "good old days" bias refers to the tendency for patients to view themselves as healthier and asymptomatic prior to any negative event. This phenomenon has been reported in adults following a mild traumatic brain injury (mTBI). As there is no diagnostic test for post-concussive syndrome and we rely on patient report of symptoms common in normal and unhealthy populations, this phenomenon becomes highly relevant to the assessment and management of mTBI. The aim of this study is to explore the "good old days" bias in the follow-up of paediatric mTBI in comparison to those with an extra-cranial injury (ECI).

Method/Approach

This was a prospective population based study of outcome following mTBI in children and the methodology has been reported previously (Barlow et al, 2010). Parents and children were contacted 7-10 days post-injury and asked to complete a questionnaire of post-concussive symptomatology in the week before the injury (pre-injury symptoms) and to complete the same questionnaire reporting symptoms in the last three days (post-injury symptoms). Where children were considered to be symptomatic, follow-up took place at one month and monthly intervals until asymptomatic. Any cases were both child and adolescent as well as parent report of symptoms were identified.

Results/Effects

30 mTBI and 12 ECI parent/adolescent reports were identified. Comparisons by group revealed no significant difference in degree of symptoms reported or number of symptoms reported pre-injury and no significant difference at 7 to 10 days post-injury. However, parents of adolescents with mTBI endorsed significantly fewer symptoms as mild or worse than parents of children with ECI (mean 2.34 vs 6.18) pre-injury; F (1, 37) = 4.27, p = .046) and tended to endorse more symptoms as mild or worse at first post-injury visit 7 to 10 days alter (mean 8.1 versus 4.3; F (1,40) = 3.94, p = .054).

Conclusions/Limitations

The influence of the "good old days" bias in the parent reporting of symptoms following paediatric mTBI may be significant and is worthy of further investigation.

0090

Do Ill-Fitting Helmets Amplify the Risk of Head Injury Among Youth Football Players? A Biomechanical Analysis, with Discussion for Applicability to Military Protection

John Lloyd¹, Joseph Gutmann¹, Gianluca DelRossi²

1James A Haley VA Hospital, Tampa, Florida, USA, 2University of South Florida, Tampa, Florida, USA

Introduction/Rationale

Children's sports helmets are often borrowed, hand-me-downs, or perhaps even fortuitously acquired at a local garage sale. Therefore, the likelihood of their helmet being an imperfect fit is presumably higher than among professional players. However, the consequences of an imperfect fit are rarely considered. Furthermore, as childrens' head size increases, they may grow out of their current helmet, but be required to continue to use it.

It was hypothesized that an ill-fitting helmet would provide the wearer with less than optimal protection from head injury. A biomechanical evaluation was thus designed and conducted to investigate this issue.

Method/Approach

Using a pendulum apparatus, an impact equivalent to 300 g (based on unprotected status) was imposed on a Hybrid III 50th percentile head form with neck, mounted on a linear bearing table (see figures, below). Repeated measures of impact duration, force and linear acceleration were acquired across three football helmets of various age, design and technology. All helmets were sized to correctly fit the 50th percentile male head (circumference: 584 mm). The same impact tests were then repeated using a 5th percentile female Hybrid III head form (circumference: 546 mm).

Results/Effects

Head Injury Criterion (HIC) values were computed and compared between the different size head forms. Our results show that an ill-fitting football helmet produced a higher average HIC value, across helmets, which is indicative of a greater risk of serious head/brain injury. Thus a loosely-fitting helmet provides sub-optimal head protection to the wearer.

Conclusions/Limitations

Considering that the human brain continues to develop until early to mid-twenties and that developing brains are believed to be both more susceptible to injury and require a longer period of recovery following mild injury, it is especially important to provide optimal head protection to our children through properly fitted sports helmets. This is also true of new military enlistees as many are younger and may be equally at risk of head trauma, with potentially serious consequences.

0091

Toward A Biomechanical Understanding of Brain Kinematics in Cadavers Associated with Traumatic Brain Injury (TBI)

Joseph Gutmann¹, John Lloyd¹, Steven Scott¹, Orhan Arslan²

1James A Haley VA Hospital, Tampa, FL, USA, 2University of South Florida, Tampa, FL, USA

Introduction/Rationale

This work is built upon the investigative work of Lissner & Gaynor-Evans (1960) and Hardy et al (2001, 2007). We propose a biomechanical investigation of brain kinematics in cadavers associated with blast and blunt TBI. Lissner's landmark study used whole cadavers to measure the peak head acceleration associated with simple linear skull fracture - the results of which have been widely applied to automotive and child safety product development. Hardy's group utilized high-speed bi-planar x-ray to study brain motion in response to various traumas.

Method/Approach

Recent advances in MEMS instrumentation have provided the opportunity for the first time to implant micro tri-axial accelerometers and tri-axial gyroscopes in various regions of the cerebrum, without sacrificing brain tissue integrity or cerebral-spinal fluid production and circulation. In view of the new advances in instrumentation, we plan to investigate complex brain kinematics in response to various blast and blunt stimuli in frozen and embalmed cadavers.

Results/Effects

Drs Gutmann and Arslan will utilize stereotactic surgical techniques to implant MEMS sensors in various regions of the brain. The effect of blast on brain kinematics will first be examined by deploying air cannon at various intensities and distances from the specimen (skull). Next, brain response to blunt impact stimuli will be studied using a linear impactor. Impact intensities will begin at sub-concussive levels (40 g) and increase until skull integrity is sacrificed.

Conclusions/Limitations

The results from this study will lead to an improved understanding of brain kinematics associated with blast and blunt trauma and, subsequently, treatment methodologies. By distinguishing the relative linear and rotational motions of the brain, this knowledge may also improve designs and testing methods for head protection systems in the military and in sports.

0092

Simulation of Mechanical Properties of the Brain Matter Under Impact and Creep-Recovery Tests

Asghar Rezaei, Ghodrat Karami, Mariusz Ziejewski

North Dakota State University, Fargo, ND, USA

Introduction/Rational

The objective of this study was to establish a model that could show behavior of the porcine brains under creep-recovery and impact experiments as a pre-step for modeling the brain under impact and blast loadings. An experimental-constitutive modeling procedure was used. Under most circumstances, human tissues exhibit characteristics of viscoelastic materials. To simulate viscoelastic behavior of materials, various combinations of springs and dashpots were suggested to represent the stiffness and damping characteristics, in the forms of assemblage of Maxwell and Voigt models, and their parameters were extracted.

Method/Approach

Various specimens of porcine brain tissues (substances closely related to human brains) were studied, in deformation regions where the brain might become injured, under various impact loadings and creep -recovery tests. A four-element spring-dashpot model (a combination of Maxwell and Voigt models in series and composed of two springs and two dashpots were employed to show the brain behavior, particularly under creep recovery and stress relaxation tests. A finite element (FE) analysis of the tested specimens was conducted under the impact and creep-recovery tests carried out with the parametric data from the four element mechanical modeling.

Results/Effects

Close correlations between the experimental results and the FE modeling was recognized.

Conclusions/Limitations

The mechanical constitutive parameters, from such experiment-mechanical modeling, provided data for predicting the behavior of the brain under many circumstances. (Funded by the Army Research Office).

0093

Helmet-Head Interactions under Ballistic Impacts - A Study on the Effects of Padding

Jazi M. Salimi, A. Rezaie, G. Karami, F. Azami, M. Ziejewski

North Dakota State University, Fargo, ND, USA

Introduction/Rational

Ballistic impacts are major sources of traumatic brain injuries (TBIs). Although ballistic helmets are highly effective in preventing severe injuries, the skull and brain can still become injured from a ballistic attack, as well as from other types of insults such as blasts, or kinematical impacts. The efficiency of the helmet depends mostly on the types of materials used for the helmet shell and padding. This paper presents the results of a computational study on the effect of the padding materials in a helmet-head interaction, and on the severity of the brain injury.

Method/Approach

The helmet, head, and padding were modeled by Finite Elements (FEs). KEVLAR was considered to be the material for the helmet; however, various types of padding material were chosen to evaluate the response on the human head during ballistic impact insults. At an initial stage, the head model was assumed to be a spherical shape. To model a realistic situation, the helmet was placed on a fidelity-head model that included the complete skull and the brain. Using simulation, the compound head and helmet were then subjected to a bullet impacting the helmet.

Results/Effects

Head intracranial pressure and kinematical parameters of the brain motion were determined for different materials of the padding. (Funded by the Army Research Office).

Conclusions/Limitations

The results showed the degree of injury to the brain and, thus, the efficiency of the padding when ballistic impacts occur.