North American Brain Injury Society's Tenth Annual Conference on Brain Injury September 12–15, 2012 Miami, Florida

Source:

Journal of Head Trauma Rehabilitation

September/October 2012, Volume :27 Number 5 , page E1 - E41 [Free]

Article Content

Dear Colleagues,

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It is with great pleasure that we present the accepted abstracts from the North American Brain Injury Society's Tenth Annual Conference on Brain Injury in this issue of the Journal of Head Trauma Rehabilitation. The conference will take place in Miami, Florida, on September 12-15, 2012.

We are delighted to have received a positive increase in abstract submissions from our previous event in 2011. The uniformly high quality of the research submitted and broad range of topics clearly reflect the advance now being made across the continuum of care in the field of 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 the nearly 100 oral and poster presentations abstracted in this issue, over 40 invited speakers will present the latest advances in the science, rehabilitation and treatment of traumatic brain injury. The preliminary conference program is posted on the NABIS website, http://www.nabis.org.

Our 2012 NABIS conference planning committee has developed an integrated educational program that promises to be of interest to researchers, clinicians, administrators, and other brain injury professionals. The conference will be a four-day, multi-track event that will cover a wide range of brain injury topics including medical best practices, rehabilitation, research, life-long living, pediatrics, and advocacy. Attendees are comprised of 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.

New this year, NABIS is pleased to offer two important pre-conference sessions. The first session, entitled Perspectives in Pediatric Brain Injury, is an in-depth review of advances in pediatric brain injury and is presented jointly by NABIS and the KiDZ Neuroscience Center, Department of Neurosurgery & The Miami Project to Cure Paralysis University of Miami Miller School of Medicine. The second pre-conference session will address Neurotoxic Exposure with presentations from leading medical, neuropsychological, life care planning and legal experts. This workshop will discuss the types, assessment, treatment, rehabilitation, litigation and life care planning of neurotoxic exposure cases, which will be highlighted by current research and in-depth case reviews.

We hope that you will join us in Miami in September! We also encourage you to consider becoming a member of our multidisciplinary society by visiting http://www.nabis.org. 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

Tina Trudel, PhD

Conference Chair

Mariusz Ziejewski, PhD

Abstract Chair

NABIS: http://www.nabis.org

0004

The Value of CARF Accreditation for Brain Injury Specialty Programs

Christine MacDonell

CARF International, Tucson, AZ, USA

Introduction/Rationale

Accreditation is a tool that can be used by persons served, families/support systems, providers, and other stakeholders to identify a quality program. For over 20 years Commission on Accreditation of Rehabilitation (CARF) International has partnered with a variety of stakeholders to develop and refine standards for brain injury programs. With quality services for persons served as the context, an international standards advisory committee convened earlier this year to refine and update standards. Following an extensive field review that is open to the public, the new standards for brain injury specialty programs (BISPs) will be published by CARF in January 2013.

Method/Approach

CARF's standards for brain injury specialty programs (BISPs) apply to inpatient, outpatient, home and community-based, residential, and vocational programs that focus on the unique needs of persons with acquired brain injury (ABI). Services address minimizing the impact of impairments and secondary complications; reducing activity limitations; maximizing participation, including wellness, quality of life, and inclusion in the community; decreasing environmental barriers; and promoting self-advocacy. Organizations seeking accreditation for a BISP also meet CARF's ASPIRE to Excellence(R) standards which address an organization's business practices including assessing the environment, setting strategy, stakeholder input; implementing the plan, reviewing results, and effecting change.

Results/Effects

Accreditation as a BISP ensures that an organization maintains a focus on the unique medical, physical, cognitive, communication, psychosocial, behavioral, vocational, educational, accessibility, and leisure/recreational needs of persons with acquired brain injury and their families/support systems.

Conclusions/Limitations

Addressing both business and service delivery practices the standards offers a blueprint to organizations striving to provide value to their stakeholders, minimize risk, and continuously improve on how they do business.

0005

Primary Study for the Therapeutic Dose and Time Window of PicrosideII in Treating Cerebral Ischemic Injury in Rats

Yunliang Guo

Qingdao University Medical College, Qingdao, Shandong, China

Introduction/Rationale

This paper aims to explore the optimal therapeutic dose and time window of picrosede II for treating cerebral ischemic injury in rats according to the orthogonal test.

Method/Approach

The middle cerebral artery occlusion (MCAO) models were established by inserting, intraluminally, a thread into the middle cerebral artery (MCA) from the left external carotid artery (ECA). The successful rat models were randomly divided into sixteen groups according to the orthogonal layout of [L16(45)] and treated by injecting picroside II intraperitoneally with a different dose at different times. The neurological behavioral function was evaluated by Bederson's test and the cerebral infarction volume was measured by tetrazolium chloride (TTC) staining. The expressions of neuron specific enolase (NSE) and neuroglial mark-protein S-100 were determined by immunohistochemistry assay.

Results/Effects

The results indicated that the optimal compositions of the therapeutic dose and time window of picroside II in treating cerebral ischemic injury were ischemia 1.5h with 20mg/kg body weight, according to Bederson's test, 1.0h with 20mg/kg body weight according to cerebral infarction volume, and 1.5h with 20mg/kg body weight according to the expressions of NSE and S-100, respectively.

Conclusions/Limitations

Based on the principle of the minimization of the medication dose and the maximization of the therapeutic time window, the optimal composition of the therapeutic dose and time window of picroside II in treating cerebral ischemic injury should be injecting picroside II intraperitoneally with 20mg/kg body weight at ischemia 1.5h.

0006

Hope and Resiliency: A Model for Goal Attainment with Brain Injury Survivors

Barbara Barton

Western Michigan University, Kalamazoo, MI, USA

Study on Characteristics and Language Training Effect of Subcortex Aphasia

Wu Hui-xiang

Qiu Wei-hong

Wan Gui-fang

Kang Zhuang

Chen Shao-qiong

Xie Chun-qing

The Third Affiliatedof Sun Yat-sen University, Guangzhou City, China

Introduction/Rationale

The traditional ideas considered aphasia was caused by damage in the cortical language center, but lesions in subcortical structures could also produce aphasia, which was a special type of aphasia called subcortical aphasia. A common phenomenon was subcortical aphasics recoveried faster and the prognosis was also better than cortical aphasics, however, some subcortical aphasics had no obvious improvement after language training. The objective of this study is to screen the factors that affect severity of language disorder in subcortex aphasia, to analyze the characteristics of subcortex aphasia, the therapeutic effect of language training and to study its rehabilitation mechanism.

Method/Approach

Ten moderate degree subcortex aphasics and twelve severe degree subcortex aphasics were evaluated by Chinese Rehabilitation Research Center Aphasia Examination (CRRCAE) and the Boston Diagnostic Aphasia examination before and after four weeks of language training. The factors that affected severity of subcortex aphasia and characteristics were analyzed before training, and rehabilitation mechanism was examined before and after training.

Results/Effects

Severity of subcortex aphasia was related to age and the complication of apraxia of speech. There was a relatively high level in listening comprehension, reading, repeating and reading aloud abilities. After language rehabilitation therapy, language ability improved at different levels. All kinds of language abilities improved significantly in moderate degree subcortex aphasics. Comprehension and verbal communication capabilities increased obviously, but written communication abilities rarely advanced in severe degree subcortex aphasics.

Conclusions/Limitations

Age and the complication of apraxia of speech may be the important factors that influenced severity of language disorder in subcortex aphasia. There were specific clinical feature in subcortex aphasia. Almost all language abilities can be improved by language rehabilitation therapy, but the therapeutic effect between moderate degree subcortex aphasics and severe degree subcortex aphasics was different.

0010

The Effect of Hyperbaric Oxygen Therapy after Traumatic Brain Injury on Acute Blood-brain Barrier and the Expression of MMP-9mRNA

Zhou Jianguang

Liu Chnagyun

Shan Peijia

Zhou Yingqi

Ji Yufeng

No. 411 Hospital of CPLA, Shanghai, China

Introduction/Rationale

The purpose of this study was to observe the effect of high-pressure oxygen (HBO) on the blood-brain barrier and the expression of MMP-9mRNA after acute traumatic brain injury (TBI). The study also explored the effect of HBO treatments on acute brain injury mechanisms.

Method/Approach

Acute TBI was induced in Sprague-Dawley rats by the free fall method. At one hour after injury and 12 hours of HBO therapy (0.25MPa), samples of brain tissue were measured for water content at 24 hours after injury. Evans determination and the application of RT-PCR expression of MMP-9mRNA were observed.

Results/Effects

After 0.25MPa HBO treatment of acute TBI, comparison of brain water content with the untreated group decreased (P<0.01), the injured side and non-injured side of the hemisphere and hippocampus compared with EB and MMP-9mRNA untreated group decreased (P <0.01), 0.25MPa normoxicnitrogen group injury side and non-injured side of the hemisphere and no significant changes in the hippocampus EB (P> 0.05). 0.25MPa HBO treatment group and the hippocampal hemisphere damage and MMP-9mRNA high EB in non-injured side (P <0.05), brain water content level and EB was positively correlated (r = 0.523, P <0.05), and MMP-9mRNA positive correlation (r = 0.564, P <0.05).

Conclusions/Limitations

HBO treatment of acute traumatic brain injury can protect the blood-brain barrier, thereby reducing cerebral edema. One of the mechanisms is reduction of MMP-9 expression with HBO treatment.

0011

AppReview Website Project for the Brain Injury Community

Michelle Wild^1,2

1ID 4 the Web, Laguna Hills, CA, USA, 2Coastline Community College, Costa Mesa, CA, USA

Introduction/Rationale

Smart devices are rapidly growing in popularity as cognitive prosthetics; however, what's missing is a centralized database of app reviews relevant to the brain injury community. There are hundreds of thousands of apps available for smart devices. How does an individual with a cognitive disability sort through the vast array of apps? Current review sites are not unique to individuals living with cognitive challenges. Individuals may have their own lists of recommended apps that are shared with clients and/or other professionals; however, there is a growing need for a centralized database of critically reviewed apps for the brain injury community.

Method/Approach

The need for a centralized database of critically reviewed apps for the brain injury community was identified over a period of time during which I received many phone calls, from survivors and professionals alike, requesting recommendations for apps. The project described here provides the opportunity for both brain injury survivors and professionals to list apps that they are familiar with and to review apps listed in the database. Brain injury survivors and professionals within the VA, private rehabilitation centers, education, and other brain injury organizations were consulted as the project evolved. The outcome of this project is http://mccappreviews.com.

Results/Effects

http://Mccappreviews.com includes many specialized features to assist the brain injury community in finding appropriate apps. Features include moderated listings to assure apps are legitimate, moderated reviews to assure reviews are relevant, app categories relevant to the brain injury community, and unique review fields designed to gather information relevant to the brain injury community (e.g., "What cognitive skills do you think this app helps with?" and "How do you use this app in your everyday life?"). The site currently has over 100 apps listed. In addition, the site is listed as a referral on a number of sites, including http://Brainline.org.

Conclusions/Limitations

The site has evolved based on user feedback and suggestions since it was launched. One such upgrade involves users' ability to do a side-by-side comparison of a number of apps within a common category. Several side projects relate to the original project, including a monthly 30-minute app Webinar series related to top-rated apps from the site and AppBriefs, a series of brief app-specific instructional videos. The biggest challenge relates to informing the brain injury community of the site's existence. Future goals include partnering with those interested to enhance the site and make it a standard for the brain injury community.

0012

Traumatic Brain Injury Caregiver Focus Groups, Needs Assessment, Survey Results and Implications

Christina Dillahunt-Aspillaga¹

Douglas Monroe^2,3

1Brain Injury Association of Florida, Inc. BIAF, Tallahassee, Florida, USA, 2University of South Florida, College of Behavioral and Community Sciences, Department of Rehabilitation and Mental Health Counseling, Tampa, FL, USA, 3WellFlorida Council. Inc, Gainesville, FL, USA

Introduction/Rationale

Traumatic brain injury (TBI) is a complex and unique injury which encompasses a myriad of challenges for the survivor and relationships with family and friends. Sustaining a TBI results in familial strain due to the significant impact it has upon the role and function of the individual with TBI in the family and in the community. Caregivers of individuals with TBI face many challenges. Sequelae of TBI often include physical, emotional, psychological and psychosocial ramifications that are further complicated by limited access to educational materials, financial, and social resources and supports for both the caregiver and the individual with TBI.

Method/Approach

The Brain Injury Association of Florida, Inc. commissioned WellFlorida Council to conduct a needs assessment of caregivers of persons with TBI in the state of Florida. Focus groups were conducted to gain meaningful qualitative insights into the major caregiving issues among caregivers. Responses obtained during discussion theme areas manifested into the development of the questions for a TBI caregiver survey which was distributed to all caregivers whose loved ones participate in BIAF's TBI Resource Support Center. The purpose of the survey was to monitor the perception of critical support needs among caregivers and determine how these needs are being met.

Results/Effects

Focus group data indicates that the specific stage of caregiving, whether during the initial period of hospitalization, or the long-term survival process, is relevant and may predict caregiver needs. In the secondary module of the survey, respondents were asked to indicate the stage which they currently identify and were asked a set of questions with a comprehensive set of response options that apply to respondents who identify with any given stage. The 2011 TBI Caregiver Survey is a robust instrument designed to accurately assess the needs of caregivers in various stages of the caregiving process.

Conclusions/Limitations

The data suggests that in the context of challenging injuries and limited resources, caregivers often place the needs of the survivors, above their own needs. This impacts the physical, emotional, social, and psychological wellbeing of the caregiver.

These findings, while limited by the relatively small convenience sample of respondents, suggests that caregivers and their survivors would benefit from improvements to the caregiver support group infrastructure and campaigns to increase awareness about the support group resources available to caregivers within their communities. Results, insights and applications from this study will be presented.

Plans for future use of this survey will be discussed.

0013

A Rehabilitation-Relevant Dose Response of Environmental Enrichment Benefits Female Rats Similarly to Continuous Enrichment after Traumatic Brain Injury

Justine Koehler

Kevin Todd

Christina Monaco

Jeffrey Cheng

Anthony E. Kline

Physical Medicine & Rehabilitation, Safar Center for Resuscitation Research, Psychology, Center for Neuroscience, Center for the Neural Basis of Cognition, University of Pittsburgh, Pittsburgh, PA, USA

Introduction/Rationale

Traumatic brain injury (TBI) affects 700,000 females in the United States each year, making it a significant health care issue for which there are limited treatment options. One therapeutic strategy that has been investigated is environmental enrichment (EE). EE confers cognitive and motor recovery in female rats when provided continuously after TBI vs. standard (STD) housing. As a model of rehabilitation, continuous EE is not clinically relevant however, because TBI patients typically only receive 4-6 hours of rehabilitation per day. Whether abbreviated EE confers benefits similar to that of continuous EE in female rats is unknown.

Method/Approach

To investigate the potential efficacy of abbreviated EE after TBI, fully anesthetized female rats received a controlled cortical impact (2.8 mm tissue deformation at 4 m/s) or sham injury (i.e., no impact) and were randomly assigned to TBI + EE [4 hours], TBI + EE [6 hours], TBI + EE [continuous], or TBI + STD groups, and respective sham controls. Motor function (beam-balance/beam-walk and rotarod) was assessed on post-operative days 1-5 and every other day from 1-19, respectively. Spatial learning/memory (Morris water maze) was evaluated on days 14-19.

Results/Effects

The data showed that EE, regardless of dose, improved motor function compared to STD housing (p < 0.0001). Only continuous and 6 hour EE, however, enhanced cognitive function (p < 0.0001).

Conclusions/Limitations

These data demonstrate that abbreviated EE in female rats produces motor and cognitive benefits similar to continuous EE after TBI and thus abbreviated EE may be a pre-clinical model of rehabilitation. Future studies will further evaluate the potential benefits of abbreviated EE by combining it with various pharmacological therapies that may provide synergistic benefits.

0014

Factors Related to Community Integration and Relationship Quality after Traumatic Brain Injury

Sheri Bartel¹

Dawn Neumann²

Barbra Zupan³

Duncan Babbage⁴

Barry Willer⁵

1Carolinas Rehabilitation, Charlotte, NC, USA, 2Indiana University, Indianapolis, IN, USA, 3Brock University, St. Catharines, Ontario, Canada, 4Massey University, Wellington, New Zealand, 5State University of New York at Buffalo, Buffalo, NY, USA

Introduction/Rationale

The objectives were to determine 1) if poor affect recognition and empathy significantly explained community integration success for participants with traumatic brain injury (TBI); and 2) if reduced affect recognition, empathy and community integration after a TBI significantly accounted for the amount of relationship stress and support. Research suggests that people with TBI often lose the ability to recognize and empathize with others' emotions. Research also indicates that people with a TBI often have difficulty with community integration, and that the quality of their relationships is often compromised. Understanding how these variables are related can be useful for developing appropriate treatment.

Method/Approach

191 participants with moderate to severe TBI were tested for facial affect recognition (Diagnostic Assessment of Nonverbal Affect 2-Adult Faces). 158 family and friends of the participants with TBI reported on perceived Relationship Stress and Support (Life Stressors and Social Resources Inventory; LISRES); empathy (Empathic Concern, Perspective-taking; Interpersonal Reactivity Index) and Community Integration (Total, Home and Social Integration; CIQ) of the person with TBI. Participants were recruited from the USA, Canada and New Zealand. 70% of participants with TBI were male. On average, participants were 40 years old (range 21-65) and were 10 years post-injury (range: .5-42).

Results/Effects

Hierarchical regression revealed that affect recognition and empathy significantly accounted for 20% of total community integration (p<.001) and 22.5% of social integration variance (p<.001). Affect recognition, empathy and community integration significantly explained 31% of perceived relationship stress (p<.001), and 40% of perceived relationship support (p<.001).

Conclusions/Limitations

Affect recognition and empathy appear to play a significant role in community reintegration following TBI. Individuals with more empathy and better community integration were more likely to be involved in more supportive and less stressful relationships. It was a limitation that not every participant with a TBI had a family/friend to report on their behalf.

0015

Operation TBI Freedom: Re-shaping the Transition of Service Members/Veterans with Traumatic Brain Injury

Alfredia Johnson

Bridget Fogelberg

Rocky Mountain Human Services, Denver, CO., USA

Introduction/Rationale

With the high numbers of service members returning to contiguous United States (CONUS), after multiple deployments, there is a need for communities to assist with the transition of these service members/veterans. Injured service members/veterans are continuing to struggle with issues of substance abuse, financial stability, employment, relationships, social skills, suicide, and a plethora of other problems. These men and women are having difficulty re-shaping their new purpose after leaving their military careers and the struggles they are facing can affect their families, workplaces, and, ultimately, the communities of which they are a part.

Method/Approach

Operation TBI Freedom, a privately-funded program of Rocky Mountain Human Services, is a community-based, non-profit program that uses military peer case management to provide these much-needed supports and services to transitioning service members in the state of Colorado with traumatic brain injury (TBI). The program pairs the service member/veteran with a Military Support Specialist,(former military personnel themselves) and Certified Brain Injury Specialists (CBIS), to provide peer resource support, linking the service member/veteran to their benefits and other services including homelessness prevention, cognitive strengthening, assistive technology, wrap around family services, and educational and employment support.

Results/Effects

As of May 2012, Operation TBI Freedom has had 143 graduates from the two year program. Military Support Specialists have assisted clients in the following ways: homeless prevention assistance = 21% of clients; employment support = 27% of clients; mental health issues, including suicidal ideation = 52%; substance abuse issues = 13%; marital issues = 41%; education = 51%. In surveys conducted at the time of program completion, 81% of clients expressed that they strongly agree/agree that their lives had improved due to the services received from Operation TBI Freedom.

Conclusions/Limitations

More brain injury programs and resources are needed throughout the United States. The ratio of graduates to total program participants is due in large part to the relocation of service members/veterans. More peer support groups are needed to assist with the issues of TBI and suicides. With more knowledge of these issues, communities will be better equipped to assist these service members/veterans with their transition. Rocky Mountain Human Services will be expanding into the surrounding 10 states in the future with the hope of continuing to generate awareness of the issues facing service members/veterans.

0016

Enhancing the Adoption of Best Practices in Traumatic Brain Injury Rehabilitation

Marcia Scherer

Hanno Petras

Eileen Elias

University of Rochester Medical Center, Rochester, NY, USA

Introduction/Rationale

Research is needed on the effective assessment, assignment, and use of cognitive support technologies (CSTs) as TBI rehabilitation interventions to help individuals with traumatic brain injury (IWTBI) attain higher levels of cognitive functioning and community integration. While research shows that CSTs can improve cognitive functioning, there is a lack of evidence-based practices to guide rehabilitation professionals in ways to appropriately assess IWTBIs and assign CSTs so that they use them to support rehabilitation and everyday functioning. As a consequence, almost 90% of individuals with a cognitive impairment, including TBI, abandon use of these devices, thus limiting their rehabilitation potential.

Method/Approach

This presentation will identify the current, and needed, research to address the challenges in matching IWTBIs with appropriate CSTs that meet both their cognitive needs and their personal priorities. These findings emerged from a literature search that was conducted to: (1) identify the use of CSTs to compensate for cognitive impairments and their outcomes, and (2) derive correlates of CST use and nonuse among IWTBIs assessed for such a device.

Results/Effects

The presenters will discuss findings regarding: 1. how TBI-based rehabilitation providers currently use evidence-based tools to assess IWTBIs' readiness and match to CSTs; 2. how continued and appropriate use of CSTs by IWTBIs has led to improvements in functioning and enhanced community integration (e.g., participation in higher education, vocational training or employment); and 3. the gaps in necessary research-based results and needed actions to expand the knowledge base.

The presentation will increase awareness of the importance of expanding the evidence-base for CST readiness and use, as well as present a validated measure to assess CST readiness: Cognitive Support Technology Predisposition Assessment.

Conclusions/Limitations

The presentation will identify how findings obtained from the literature will enhance needed evidence-based research on CST use as an integral TBI rehabilitation treatment intervention. Areas of emphasis will include the importance of longitudinal analysis; IWTBI readiness for consistent and appropriate CST use; the importance of assessing CST readiness for use; and how the literature points out the importance of attaining medical insurance payer buy-in for CST use.

0018

Repetitive Transcranial Magnetic Stimulation (rTMS) for the Rehabilitation of Visuospatial Neglect Following Right Hemisphere Strokes: Details from an Ongoing Multicenter Double Blind Clinical Trial

Federica Rastelli¹

Monica Toba¹

Corinne Tchokotche²

Project Victory - A Brief, Intensive, Residential Treatment Program for Mild Traumatic Brain Injury from Combat-Related Blast Exposure: A Description and Preliminary Data Analysis

Gary Seale

Kay Eaton

Sybil Yancy

Shawn Jaffray

Transitional Learning Center at Galveston, Galveston, TX, USA

Introduction/Rationale

An estimated 1.64 million United States (US) armed forces troops have served in combat theatres in Afghanistan (Operation Enduring Freedom) and/or Iraq (Operation Iraqi Freedom) since October, 2001. According to a recent RAND report (Invisible Wounds of War, 2008), approximately 19.5%, or about 320,000 troops sustained mild traumatic brain injury (mTBI), or multiple concussions during deployment. Post acute brain injury rehabilitation services for this population are lacking. Project Victory was developed to provide interdisciplinary, residential post acute rehabilitation to active duty and veteran service men and women who sustained mTBI due to blast exposure while serving in OEF/OIF theatres of combat.

Method/Approach

The Project Victory program encouraged the development of skills and compensatory strategies necessary for safe performance of advanced activities of daily living (ADL's), use of external aids for memory compensation, use of prolonged exposure techniques for treatment of post traumatic stress disorder (PTSD), motivational interviewing and stage change techniques for treatment of substance use/abuse, use of the Shut-I protocol for sleep disorders, and community exposure for treatment of anxiety in community settings. Participants received 5-6 hours of skilled therapy, Monday-Friday, delivered by licensed/certified staff. Program effectiveness and treatment outcomes were evaluated by participant satisfaction surveys and by objective outcome measures administered at admission and discharge.

Results/Effects

Sixty-two percent (62%) of participants demonstrated improvement in function as measured by the Mayo Portland Adaptability Inventory-4 (MPAI-4). The greatest improvement was noted in the Ability subscale which measured ADL's and cognition. All participants reporting substance use/abuse upon admission showed improvement as measured by the Alcohol Use Disorders Intentification Test (AUDIT). Only 15% of participants returned to abusive levels of alcohol consumption after discharge. Seventy-five percent (75%) of participants reported fewer depressive symptoms as measured by the Center for Epidemologic Depression (CESD) scale, and 64% reported an increase in life satisfaction as measured by the Satisfaction with Life Scale (SWLS).

Conclusions/Limitations

Brief, intensive, residential treatment using an integrated, multidisciplinary and evidenced-based approach may be an effective post acute rehabilitation model for mTBI due to combat-related blast exposure. While the preliminary analysis of Project Victory appears promising, a number of limitations exist including small sample size and non-random assignment of participants to treatment. A significant number of participants were lost during follow-up; and maintenance of outcomes after discharge from Project Victory is therefore not known. Treating mTBI and accompanying co-morbidities as chronic conditions will be discussed.

0028

Tablets and Smartphones as Compensatory Memory Strategies.

Danny Ridley

Cynthia Bailey

Tea Reljic¹

Helen Georgiev¹

Benjamin Djulbegovic¹

Jeffrey Etchason²

Hannah Paxton²

Michelle Flores²

Ambuj Kumar¹

Service Utilization in the Community: Development of Stratifications of Care

Jennifer Anderson

Christen Mason

Alan Weintraub

Aimee Voth Siebert

Denver Options dba Rocky Mountain Human Services, Denver, CO, USA

Introduction/Rationale

Rocky Mountain Human Services, the contractor for the State of Colorado TBI Trust Fund, has served 3,332 individuals across the State since 2006. Due to the growing demand for services and expectation to increase number served, we are evaluating the most cost-effective way to deliver care based upon level of need. Over the course of this year, we are collaborating with Craig Hospital to analyze patterns and variables within our intake process to more specifically predict level of care. This predictable stratification of care model includes but is not limited to an implementable system offering Comprehensive, Supportive, and I&R Referral Services.

Method/Approach

Monthly meetings were convened with medical professionals and researchers from Craig Hospital to offer guidance on how to structure the evaluation-intake process. It was agreed that of the 220 questions on the intake assessment that we could identify 10 key questions that were significantly linked to the level of care assigned. A qualitative query of the on-site care coordinators was completed to identify predictors of level of care. Data was evaluated from 350 individuals who entered the Trust Fund from 9/2011-12/2011. Intake assessments were analyzed using the Chi-square tests of independence (differences of p = .05 or lower).

Results/Effects

As predicted, results indicated six questions that identified or differentiated stratification of care. Questions pertained to the following themes: access to financial benefits, housing, emotional well-being, medical needs, social supports, and volunteerism.

Focus groups will be conducted within the next 60 days to have the clients complete the Mayo Portland Inventory in order to compare the stratified level of care to the RMHS intake assessment's level of care. The subject pool will be 60 individuals from the original pool of 350. Additionally, a predictive analysis of data elements will be conducted on the 60 individuals.

Conclusions/Limitations

Initial evaluation of RMHS assessment tool were consistent with predictive results and program evaluation over the past six years. Further research needs to be completed to validate the most effective tool to determine appropriate Stratification of Care for community based care coordination programs. The tool needs to be cost-effective, easy to administer and scored. Tool needs to be sensitive to services clients receive outside of the Trust Fund and funds allocated to them through the program. We anticipate validating a tool to determine Stratification of Care within the next twelve months.

0035

Deep Water Horizon Blast Injury Survivors

Ralph Lilly

University of Texas Medical Center Houston, Houston, TX, USA

Introduction/Rationale

Case reports of six Deep Water Horizon Survivors are presented. Each sustained all of the components of Blast Injury. The components, primary, secondary, tertiary, and quaternary, were variable but severe in all instances. Rescue efforts, because of the circumstance, were variable, as was primary and secondary management. All of the survivors suffered complex neurobehavioral deficits, the major residual deficits to recovery being PTSD. Diagnostic methodology including imaging, psychiatric and neurolpsychologic assessment is reviewed. Team management and two year outcomes are reported.

Method/Approach

All of the survivors were seen on an outpatient basis at variable times following the explosion. The referrals were requested for the neurobehavioral complexities produced by the blast, resulting in the combination of Blast Overpressurization, Blunt Cranial Trauma, thermal burns, smoke inhalation, and exposure to life threatening circumstance and death. Management required detailed neuro and mental status exam, correlation of the diagnostic studies, and the establishment and monitoring of an ongoing interdisciplinary program. Photographic documentation of the explosion will be presented to support the enormity of such a trauma.

Results/Effects

The long term assessment of the neurobehavioral syndromes produced in survivors of a massive off-shore oil rig explosion is outlined. This experience provides a unique window supporting the currently accepted significance for a poly-organic evaluation for survivors of Blast Injuries. Special attention to the presence of PTSD as the most salient disabling feature in all the cases is discussed.

Conclusions/Limitations

The pathophysiologic features outlined in these cases associated with massive Blast Injury define the traumatic experience of blast injuries extending beyond the overpressurization factors of blast. While these case reports provide an avenue of prognostication, management planning, and the development of prophylactic guidelines, they more importantly reflect the need for active research on the parameters discussed.

0036

Brain Injury: Voices of a Silent Epidemic

Cindy Daniel¹

Andrew Palumbo²

Patrick Morrissey²

1Brain Injury Services, Springfield, VA, USA, 2Outside the Lab, Great Falls, VA, USA

Introduction/Rationale

Long-term outcomes from brain injury are difficult to predict and more challenging to fully understand. We see athletes who have been concussed, soldiers coming back from war with brain injuries, even political figures who have sustained brain injuries through assault whom lived to tell their stories. Even though traumatic brain injuries now receive unprecedented attention in popular media, the common perception of recovery still tends to gloss over the longer-term struggles that many face. What can we do to help others really understand what they are going through and to encourage successful reintegration?

Method/Approach

This workshop will debut a new video designed to help laypersons understand the impairments and changes in abilities that occur following brain injury. The video guides viewers through primary functions of the brain as presented by personal testimonials from survivors of brain injury regarding daily challenges and successes they face. It is also narrated by active professionals in the field.

Results/Effects

Individuals who view this video gain a better understanding and perspective regarding what individuals with brain injury experience by seeing and feeling their brain injuries through their personal experiences. The professional narration assures clear scientific and clinical grounding, something that is often absent from such intimate examinations. The video has also been recognized for its potential to teach a number of professions, such as clinicians, caregivers, attorneys and policymakers.

Conclusions/Limitations

Many survivors of brain injury can appear to be completely uninjured in their day-to-day lives, but the fact remains that altered brains often result in persistent hidden challenges that can have adverse and dramatic daily effects. Just as advances in neurology have improved the survival rate of those who sustain a brain injury, increased awareness and understanding of these injuries by laypersons and professionals will help improved recovery and reintegration of brain injury survivors. By exploring the cases presented in this video and tying them back to today's understanding of the brain, this silent epidemic is given a new voice that can speak to people unfamiliar to brain injury.

0037

Staying Connected Through Social Media: Connections for Compassionate Caring

James Conway

Teresa Flamini

Sharon Harton

Lauren Gower

ReMed Recovery Care, Paoli, PA, USA

Introduction/Rationale

The role of social media in re-establishing and maintaining social networks fosters reconnections with families and friends of individuals many years post injury. Many who prior to this opportunity faced social isolation and separation from loved ones. Social isolation and depression are among the most commonly reported problems after traumatic brain injury. Distance, transportation and other physical barriers often make getting out into the community difficult. Additionally, family fears and hesitation of social interaction due to perceived and/or historical behaviors may have previously acted as a barrier.

Method/Approach

Social networking opportunities like Skype, Facebook and email allow individuals to remain connected to family and friends as well as to form new relationships. The team working with individuals in a post acute brain injury setting built on social opportunities to keep connected with family members who lived a few hours away to across the country. The individuals with a TBI have significant expressive and receptive language difficulties or deficits which make traditional phone contact challenging. A progression from phone contact to email to Skype, Facebook and YouTube was facilitated by the team.

Results/Effects

The use of social networking has improved outcomes for both clients and families as personal and family barriers of poor self esteem, feelings of rejection and insecurity regarding relationships were reduced providing a portal for maintaining personal and family contact. Use of the types of interactive dialogue has enhanced relationships of clients, families, significant others and care providers."Seeing" their family member on Skype was a visual way for someone with a TBI to communicate when their disability affected speech, language and communication.

Conclusions/Limitations

There were several benefits to the types of social networking opportunities used which included easy access and low cost. A decrease in risk-taking behaviors, aggression and depressive statements was noted. Positive outcomes were seen in relationships with family members that previously appeared disconnected or unsure of how to interact with their loved one. Disabled individuals are faced with additional hazards with possibility of exposure to scam artists and required assistance to maintain safety in our ever-changing virtual social world. Some were limited to one or two types due to increased age or limited electronic access of family members. The potential benefits appear endless.

0038

Emergency Preparedness and Ensuring the Safety of Persons with Disabilities

Cindy Daniel

Brain Injury Services, Springfield, VA, USA

Introduction/Rationale

The most lethal part of an emergency is the lack of preparedness in dealing with it people are caught off guard, becoming confused, frightened, and disoriented. These challenges are even more pronounced for those with disabilities. This became alarmingly apparent in 2004 with Hurricane Katrina, when thousands of evacuated people simply fell through the cracks. After critical analysis of what went wrong and under new legislation mandating precise procedures, we now have more refined means of guiding people through emergency situations. The efficacy of which can be seen in more recent disasters such as Hurricane Gustav in 2008.

Method/Approach

The major failings in dealing with Katrina were a lack of communication, education and resources for dealing with large-scale chaos. For example, emergency service providers were simply ill-prepared for handling the volume of shocked people. As the result of responsive education and protocols put in place to solve these problems, by the time Hurricane Gustav hit four years later, supplies were made accessible more quickly, emergency workers were prepared to guide citizens out more efficiently and the general attitude through the emergency was significantly more calm and collected due to what the community and agencies had learned.

Results/Effects

We can be better prepared for future emergencies by distilling the lessons learned over the last eight years into these four steps of prevention:

Why don't we prepare?

Jia Wei Wang

Han Dong Wang

Zi Xiang Cong

Ding Ding Zhang

Nanjing university, Nanjing, China

Introduction/Rationale

Glutamate released by the traumatic brain injury (TBI) acts at the metabotropic glutamate receptors (mGluR), including the mGluR5. Substantial evidence has shown that microglia-associated neuroinflammation is involved in the pathophysiologic processes contributing to the neurologic deficits after TBI. Our previous study indicated that mGluR5 was expressed in active microglia in rats with TBI and in vitro studies have shown mGluR5 activation could inhibit the microglia-associated inflammation induced by LPS and protect the neuron challenged by b-amyloid. There is little known about whether mGluR5 activation could provide neuroprotection and reduce microglia-associated neuroinflammation in rats followed by TBI.

Method/Approach

Rats were randomly distributed into four groups: the sham group, the sham+vehicle group, the TBI+vehicle group, and the TBI+CHPG (selective mGluR5 agonist) group. 250 nmol CHPG were administrated through i.c.v. injection at thirty minutes after TBI. All rats were sacrificed at twenty-four hours after TBI. The neurologic scores and beam-walking scores were evaluated before sacrifice. Wet/dry weight method and Evans blue (EB) extravasation quantifying was used to assess the brain edema. ED1 immunofluorescence was performed. The level of IL-1[beta], IL-6 and TNF-[alpha] were determined by qPCR and ELISA. Fluoro-Jade C staining was used to detect the number of degenerating neurons.

Results/Effects

Post-TBI administration of CHPG could significantly improve the neurologic deficits, ameliorate the BBB impairment and reduce the brain edema induce by TBI. The number of TBI-induced excessive ED1⁺ microglia was also reduced by treatment with CHPG. Accordingly, the expression of microglia-associated inflammatory cytokines IL-1[beta], IL-6 and TNF-[alpha] and degenerating neurons were inhibited by CHPG treatment.

Conclusions/Limitations

CHPG could provide neuroprotection in rats following by TBI partially through inhibiting the microglia-associated neuroinflammation. However, further researches are needed to elucidate the mechanisms by which CHPG inhibits microglia-associated neuroinflammation.

0043

Processing Speed and Reaction Time: A Highly Fragile Cognitive Construct

Francis Sparadeo

Michael Meyerson

Dmitry Meyerson

Sparadeo & Associates, W. Warwick, R.I., USA

Introduction/Rationale

Processing speed is a cognitive construct that is a fundamental component of general intellectual functioning and is highly susceptible to disruption following neurological insult. Functional imaging studies have demonstrated that processing speed relies on recruitment of network areas including the PFC and the ACC. Processing speed impairment is the most common deficit associated with mTBI. Processing speed impairment has been documented in a myriad of neurological disorders such as multiple sclerosis, ADHD, diabetes, early dementia, learning disability, autism, chronic pain and others. Additionally, processing speed has also been shown to be impaired in such psychiatric disorders as depression and substance abuse.

Method/Approach

This study examined processing speed in several clinical populations and compared these measures utilizing ANOVA and bonferroni follow-up comparisons. The processing speed measures included a simple counting task (25 numbers test), reaction time on a memory task and reaction time on two separate concept formation tasks. Participants in the study were individuals referred for neuropsychological assessment and were divided into 5 diagnostic groups: mTBI (n = 208), cocaine users (n = 8), cannabis users (n = 27), heavy alcohol users (n = 49) and people with major depressive disorder (n = 39). Their test results were compared to healthy normal subjects (255).

Results/Effects

The results of this investigation indicate that mTBI patients were significantly impaired on all measures of speed and performance (this includes a brief memory test and two brief concept formation tests). All other clinical groups were slower on reaction time and general speed measures than the control group with the exception of cocaine abusers whose speed was generally normal but whose qualitative performance was lower than controls. The patients in the Major Depression group were as impaired as the TBI group on processing speed and reaction times for memory and concept formation, while their accuracy on these tasks was generally normal.

Conclusions/Limitations

This study is consistent with the literature in indicating that neurological insult is likely to be manifested in general cognitive inefficiency (slow speed). Furthermore, this inefficiency is easily detected in a direct measure of simple processing speed as well as simple measures of reaction time for memory and concept formation. Major depressive disorder has a similar impact on processing speed as mTBI. Cocaine abusers did not evidence processing speed impairment, however, it is important to note that the cocaine abusers were significantly younger than the other groups and processing speed is impacted by age. Substance use is associated with slow processing.

0044

Recognition of Nonverbal Facial and Vocal Affect Following Traumatic Brain Injury

Barbra Zupan¹

Duncan Babbage³

Dawn Neumann²

John Leddy

Scott Darling

John Baker

Amy Williams

Anthony Surace

Barry Willer

SUNY at Buffalo, Buffalo, NY, USA

Introduction/Rationale

The purpose of this study was to evaluate the value of computerized neuropsychological (NP) testing for establishing readiness to return to sport (and school) in adolescents after concussion relative to a standardized exercise treadmill test (the Buffalo Concussion Treadmill Test -BCTT¹).

Method/Approach

Retrospective analysis of prospectively collected data. Concussed athletes (n = 59, 46 M, mean age 15.7y) who reported symptom resolution completed Automated Neuropsychological Assessment Metrics (ANAM) computerized testing followed by the BCTT on the same day. ANAM sub-test performance (according to age normative data in the "Sport-High School Reference Data," 2010 ANAM Sports Medicine Battery User Manual) was evaluated. Athletes who exercised to voluntary exhaustion without symptom exacerbation were returned to sport following the Zurich Consensus Conference Guidelines. A telephone follow up was performed with athletes and a parent (for those under 18) asking about return to sport and school difficulties.

Results/Effects

54% of athletes had >=1 (range 1-6) ANAM subtests below average (9th percentile or below) and 22% had >=1 (range 1-4) ANAM subtests clearly below average (2nd percentile or below). All athletes exercised to exhaustion without exacerbation of symptoms on the BCTT and returned to sport. A telephone follow up with 30 athletes 3-41 months (mean 18.2+/-11.4) after return to sport revealed that none had experienced recurrence of symptoms during sport although 15/30 reported some symptoms with school activities. ANAM test performance did not predict symptoms reported on the day of the treadmill test or symptoms upon return to school.

Conclusions/Limitations

The ability of concussed high school athletes to exercise to exhaustion on the BCTT without symptom exacerbation in combination with the Zurich guidelines was 100% successful for return to sport. NP testing, at least in athletes who do not have a pre-injury "baseline" test, does not appear to be useful in the return to sport decision process and was not associated with symptoms in school. Evaluation of the predictive nature of NP testing might have been enhanced if athletes had baseline data. The primary outcome measure, safe return to sport, may not capture subtle cognitive issues represented by NP testing.

0049

MPAI-4 Depression item predicts quality of life following TBI

Nicole De Luca¹

Efrat Eichenbaum²

Alison Hartwig¹

Mary Brownsberger³

Karen Lindgren³

1La Salle University, Philadelphia, Pennsylvania, USA, 2Drexel University, Philadelphia, Pennsylvania, USA, 3Bancroft Brain Injury Services, Cherry Hill, New Jersey, USA

Introduction/Rationale

The current study is part of a series of investigations examining the relationship between brain injury rehabilitation outcomes, measured by the Mayo-Portland Adaptability Inventory (MPAI-4; Malec & Lezak, 2003), and quality of life (QoL), assessed by the WHO QOL-BREF (Chiu et al., 2006). The current study examined the relationship between MPAI-4 items, total QOL score, and four QoL domains (i.e., Physical, Psychological, Social, Environmental). Four MPAI-4 items were examined: Novel Problem-Solving, Self-Awareness, Depression and Leisure/Recreational Activity. We hypothesized that Depression and Self-Awareness limitations would significantly predict lower QoL, and that Leisure/Recreational Activity and Novel Problem-Solving abilities would predict higher QoL.

Method/Approach

Data was collected at Bancroft Brain Injury Services, a post-acute, community-based day treatment rehabilitation program in New Jersey, which serves adults with moderate-to-severe brain injury. Archival data from 51 persons were examined. Participants' mean age was 43.25 years (SD = 11.64). Mean time since injury was 16.88 years (SD = 9.33). Thirty-three participants (65.70%) were male; 18 (35.30%) were female. Forty participants (78.40%) identified as White, nine (17.60%) were African-American, one (2%) was Asian, and one (2%) was Hispanic. MPAI-4 was rated via professional consensus; participants self-reported quality of life.

Results/Effects

Linear regressions were utilized to assess the relationship among individual MPAI items and quality of life. Gender and race did not significantly predict QoL or MPAI scores and therefore were not entered as covariates. Preliminary results indicated that Depression significantly predicted both total QoL(Y = -3.54, X = 62.77, SE_b = 1.21, p < .05, R² = 0.14) and Psychological QoL (Y = -1.34, X = 16.10, SE_b = 0.40, p < .05, R² = 0.17). No significant associations were found among the Leisure, Self-Awareness, or Novel Problem-Solving MPAI-4 items and QoL.

Conclusions/Limitations

The MPAI-4 Depression item significantly predicted lower quality of life in TBI patients at a long-term, post-acute rehabilitation setting. This finding was consistent with previous literature addressing QoL among TBI patients. Thus, depression and mood may be important treatment targets in rehabilitation. The relationship among mood, self-awareness, activity levels, problem solving abilities, and QoL should be further examined. Study limitations included small sample size, the wide range of functional abilities and time since injury within the sample, and the use of individual MPAI items to assess complex constructs. Findings should be replicated using a multi-method assessment approach and larger sample.

0050

Case Study of Psychological Consequences of a Experiencing an Oil Rig Explosion

Burton Ashworth²

Jacqueline Bourassa¹

Lawrence Dilks¹

Billie Myers²

1Counseling Services of SWLA, Lake Charles, LA, USA, 2Fielding University, Santa Barbara, CA, USA

Introduction/Rationale

A 38 year old male experienced toxic gas inhalation, as well as exposure to a massive explosion on an oil rig drilling platform resulting in significant physical, cognitive and affective impairments. The purpose of this study is to discuss the psychological consequences as a result of the trauma, thereby adding to the knowledge base of psychological and neurological understanding.

Method/Approach Participant:

JD, a 38 year old male, acquired significant affective, physical, and cognitive impairment associated with noxious gas inhalation and resulting trauma due to witnessing a massive oil drilling platform explosion and the subsequent loss of life of personal associates.

Procedure:

A neuropsychological evaluation was conducted on an outpatient basis in August of 2010. After completing the consent and release forms, the client was administered 12 instruments over a two day period. The primary assessments were the Wechsler Adult Intelligence Scales Fourth Edition; Wide Range Achievement Test, Fourth Edition; Beck Depression Inventory, Second Edition and Beck Anxiety Inventory, among others.

Results/Effects

The results of the neuropsychological evaluation suggested a decline in overall cognitive ability and physical functionality. Additionally, there were deficiencies in memory (recent), executive functions (insight and abstraction), and language processing.

Conclusions/Limitations

Reported hyper vigilance, middle and terminal insomnia, intrusive thoughts and sexual dysfunction may be indicative of post traumatic disorder (PTSD). Relatives reported a distinct deterioration of social skills and personality normalcy. Elevations on measures of depression and anxiety were significant.

0051

Integrating Erickson Hypnosis Techniques and Cognitive Behavioral Strategies for the Treatment of Chronic Pain in Post-Concussion Syndrome

Lawrence Dilks¹

Jacqueline Bourassa²

1Counseling Services of SWLA, Lake Charles, LA, USA, 2McNeese State University, Lake Charles, LA, USA

Introduction/Rationale

Many concussion injuries result in a chronic pain disorder that is often reported as diffuse and lacking focus. Frequently chronic pain leads to a number of secondary issues that become intertwined and resistant to intervention. Cognitive Behavior Therapy (CBT) has won approval as an evidenced-based approach to the treatment of emotional disorders and has shown promise in the treatment of chronic pain.

This abstract focuses on discussing and demonstrating the integration of CBT and Erikson hypnotic techniques with seven individuals, who were involved in an offshore explosion, sustained concussion and were resistant to traditional psychotherapeutic intervention for pain.

Method/Approach Participants:

Seven males were referred for individual counselling as a consequence of injuries sustained in an explosion. Each possessed a concussion, mild to moderate in nature and suffered from chronic diffuse pain, depression and anxiety.

Therapeutic Methods:

A traditional approach to CBT was failing to achieve the determined therapeutic goals due to resistance. Consequently, Erickson techniques were integrated. These involved endorsing the resistance, therapeutic stories, distraction, visual imagery, mirroring and directed attention. These were blended with CBT strategies of redefining events, autogenic phrases, structured relaxation exercise, and identifying illogical and logical ideas.

Results/Effects

Clients were monitored for compliance and symptom relief by using the Beck Depression Inventory, second edition and self-report. Symptom resolution occurred slowly over time until discharge.

Conclusions/Limitations

By discussing and demonstrating the integration of two very different therapeutic techniques, participants may discover ways to enhance therapeutic activities and bring about improved resolution in counselling and cognitive rehabilitation. In this particular endeavor, the integration of CBT and Erickson techniques resulted in greater compliance and participation. The success suggests that cognitively impaired persons may benefit from the integration of other forms of intervention beyond counselling and benefits might be found for vocational training and the treatment of Post-Traumatic Stress Disorder. Further research is warranted.

0052

Neuronal Pentraxin 1: A Molecular Determinant of Hypoxic-Ischemic Brain Injury

Mir Ahamed Hossain

Hugo W. Moser Research Institute at Kennedy Krieger and Johns Hopkins Univ. School of Medicine, Baltimore, MD, USA

Introduction/Rationale

Neonatal hypoxic-ischemic brain injury is a leading cause of severe neurological disabilities and mortality in surviving infants and children; affecting the life of all ages and populations worldwide. Nonetheless, the mechanism(s) involved in this pathology in the developing brain remain inadequately understood. Therefore, it is of utmost importance to better understand the mechanism(s) underlying the hypoxic-ischemic injury in neonatal brain to devise effective therapy. Here, we report the induction of a novel neuronal protein 'neuronal pentraxin 1' (NP1), a member of a subfamily of "long-pentraxins", in neonatal brain injury following hypoxia-ischemia (HI), and that NP1 gene silencing is neuroprotective.

Method/Approach

We have used wild-type (WT) and NP1 knockout (NP1-KO) mouse cortical and hippocampal cultures, modeled in vitro, following exposure to oxygen glucose deprivation (OGD) that resembles human stroke episode and in vivo neonatal animal model of HI to examine the role of NP1 in hypoxic-ischemic brain injury. NP1 induction was determined by immunofluorescence, RT-qPCR and protein. To evaluate brain injury, infarct volume was measured in the injured hemisphere.

Results/Effects

Elevated expression of NP1was observed in cortical layers, hippocampal CA3, and CA1 areas of WT brains following HI. WT brains showed marked infarcts and volume loss in the ipsilateral-cerebral hemisphere but not the NP1-KO brains after HI. Primary cortical and hippocampal WT neurons showed an OGD time-dependent NP1 induction and cell death. NP1 gene silencing by siRNA in WT neurons, and NP1-/- neurons were significantly protected, whereas, overexpression of NP1 in WT and NP1-/- cells with pLenti6v5-Nptx1 further enhanced OGD-induced cell death. NP1 co-localized with AMPA GluR1in WT neurons, and that AMPA-induced cell death was significantly decreased in NP1-/- neurons.

Conclusions/Limitations

This study identifies NP1 as a mediator of hypoxic-ischemic injury in the brain. This is the first evidence for a pathophysiological function of NP1 in central neurons. Together these results clearly demonstrate a role of NP1 in the coupling between HI and neuronal death at the level of excitatory cascade. Our findings point to a novel molecular target of brain injury, and will foster new strategies for the clinical management of neonates suffering from HI insult. Supported by NIH RO1 NS046030 grant.

0053

Training of Gist-Based Strategic Reasoning in Adolescents with Chronic Traumatic Brain Injury

Lori G. Cook

Sandra B. Chapman

Nellie Evenson

Kami Vinton

Center for BrainHealth, The University of Texas at Dallas, Dallas, TX, USA

Introduction/Rationale

There is an urgent need to study the effects of cognitive training among adolescents whose higher order cognition is impaired by sustaining a traumatic brain injury (TBI). In contrast to good recovery of previously acquired skills and self-care activities in most adolescents with TBI, executive cognitive functions are often persistently impaired and implicated in poor school performance and social maladjustment, yet there has been limited focus on training to enhance cognitive function at chronic stages. Based on use-dependent neuroplasticity evidence that brain networks can be changed and cognitive function improved given intensive stimulation, this gap in research warrants attention.

Method/Approach

This study examined the effects of two forms of strategy-based training, including training of gist-based reasoning versus fact-based remembering, on ability to abstract meaning and recall details in 20 adolescents (ages 12-20) at least six months post-TBI. Impetus for this was based on research indicating a residual impairment in ability to extract "gist" or abstract meanings from information after TBI. Additionally, ability to encode meaning at an abstract rather than explicit level has been shown to enhance memory for details. Participants in each training group completed eight individual 45-minute sessions over one month, as well as pre- and post-training assessments.

Results/Effects

Preliminary results from the gist-training group revealed significantly improved strategic reasoning performance after training (p = .0002***) as well as improved ability to provide generalized interpretive statements (p = .0418*) and recall details (p = .0384*) from texts. Additionally, for the gist-training group, significant improvement was seen in untrained measures of executive function, namely those of working memory (p = .0318*) and inhibition (p = .0471*). For the fact-training group, preliminary findings indicate no significant gains in any of these trained or untrained domains.

Conclusions/Limitations

Overall, the implication is that a top-down complex reasoning approach (gist-training) is effective in remediating higher-order cognitive deficits in adolescents with chronic-stage traumatic brain injury. Further, top-down modulation of information has a positive impact on bottom-up processes such as recall of details. Additionally, preliminary evidence indicates benefits of the gist-based reasoning training on untrained measures of executive control such as working memory and inhibition. Future investigation should include long-term follow-up, determining if the effects of training on constructing gist meaning and/or remembering facts are maintained over time, as maintenance of training effects is critical for potential clinical application.

0054

A Randomized Controlled Trial of In-Person and Telephone Cognitive Behavioral Therapy for Major Depression after Traumatic Brain Injury

Jesse Fann

Charles Bombardier

Joshua Dyer

Steven Vannoy

Nancy Temkin

Sureyya Dikmen

Kenneth Marshall

Evette Ludman

University of Washington, Seattle, Washington, USA

Introduction/Rationale

Major depressive disorder (MDD) is perhaps the most common and disabling condition experienced by individuals with traumatic brain injury (TBI). Data shows that less than half of individuals with TBI and MDD receive any depression treatment and most patients prefer counseling over pharmacotherapy. Common barriers to depression treatment include difficulty with cognition, transportation, mobility, and accessibility. We developed an intervention aimed at overcoming these barriers. We describe the design, progress, and early data from a randomized clinical trial of in-person and telephone administered cognitive behavioral therapy (CBT) for persons with complicated mild to severe TBI and major depressive disorder (MDD).

Method/Approach

We developed a randomized controlled trial with three arms: in-person CBT, telephone CBT, and Usual Care. We utilized choice-stratified randomization, stratified by TBI severity (complicated mild/moderate or severe). The CBT intervention consists of 12 sessions over 16 weeks. The primary outcome is change in depression severity on the Hamilton Rating Scale for Depression at 8, 16, and 24 weeks assessed by a rater blinded to treatment condition. We also assess depression with the Patient Health Questionanire-9 (PHQ-9) at each session. We aim to recruit 90 adults within 10 years of TBI from hospital and community settings throughout the United States.

Results/Effects

We modified an empirically-supported telephone-based CBT protocol to accommodate cognitive impairments common in persons with TBI. We describe the challenges associated with modifying CBT for persons with TBI, including engaging support persons, monitoring and maintaining treatment fidelity, recruiting, treating, and retaining depressed persons with TBI. We began recruiting participants in 2008 and have enrolled 88. Preliminary data from PHQ-9 depression scores from intervention sessions will be presented. Thus far, of 44 participants who have completed the CBT intervention, 24 (55%) responded (>50% drop in PHQ-9). Telephone CBT appears to be equally efficacious with higher retention rates than in-person CBT.

Conclusions/Limitations

No randomized controlled trials of psychotherapy for MDD have yet been published. Preliminary findings from this RCT suggests that CBT for MDD may be feasible, acceptable and efficacious in persons with TBI. Telephone CBT holds particular promise for enhancing access and adherence to treatment without any decline in efficacy. Updated adherence and depression data will be presented. Because data collection is still ongoing, these preliminary findings must be interpreted with caution.

0055

Expected Payment Source for Traumatic Brain Injury Emergency Department Visits in the United States

Michael Lionbarger

William Pearson

Centers for Disease Control and Prevention, Atlanta, GA, USA

Introduction/Rationale

Traumatic Brain Injury (TBI) is a serious public health problem in the US. According to recent CDC estimates, the average annual incidence of a TBI alone and TBI in combination with other injuries or conditions was approximately 1.7 million during 2002-2006. The number of TBI cases seen in EDs increased from approximately 1.25 million in 2002 to 1.4 million in 2006. This analysis used national data to describe expected payment source of patients who were seen in an ED with a TBI.

Method/Approach

The 2009 National Hospital Ambulatory Medical Care Survey-Emergency Department (NHAMCS-ED) data were used to examine expected payment source for ED visits of patients where TBI was listed as one of three possible diagnoses. TBI was identified using International Classification of Diseases, Ninth Revision Clinical Modification codes obtained from ED records. Expected payment source was classified into three categories including private insurance or worker's compensation, Medicare or Medicaid, or Self-Pay or No Charge. Estimates and 95% confidence intervals were calculated for each of these measures.

Results/Effects

The majority of patients with a TBI-related ED visit had private insurance or worker's compensation as the expected payment source (46.2%, 40.6% - 51.9%). Medicare and Medicaid were the expected payment source for approximately one-third (34.9%, 30.1% - 40.1%) of the TBI-related ED visits while Self-Pay and No Charge made up nearly one-fifth (18.9%, 14.8% - 23.7%) of TBI-related ED visits.

Conclusions/Limitations

There is an increasing trend in TBI-related ED visits since 2002. The expected payment source for TBI-related ED visits are varied. From these analyses, it is unclear if payment source was a potential barrier to seeking treatment for a suspected TBI. Additional analysis will need to examine characteristics of the patients with TBI-related ED visits to target improved prevention strategies to limit the economic burden of TBI in the US.

0056

Rehabilitation Research and Training Center for Pediatric TBI Interventions

Shari L. Wade¹

Ann Glang²

Michael Kirkwood³

McKay Sohlberg⁴

Terry Stancin⁵

H. Gerry Taylor⁶

Keith O. Yeates⁷

1Department of Pediatrics, Cincinnati Children's Hospital Medical Center and College of Medicine, University of Cincinnati, Cincinnati, OH, USA, 2Center on Brain Injury Research and Training, Teaching Research Institute, Western Oregon University, Eugene, OR, USA, 3Children's Hospital Colorado, Dept. of Physical Medicine & Rehabilitation, Aurora, CO, USA, 4University of Oregon, Monmouth, OR, USA, 5MetroHealth Medical Center, Cleveland, OH, USA, 6Case Western Reserve University, Cleveland, OH, USA, 7Department of Pediatrics, Ohio State University, and Center for Biobehavioral Health, Research Institute at Nationwide Chidlren's Hospital, Columbus, OH, USA

Introduction/Rationale

Pediatric TBI results in a range of adverse cognitive, behavioral, and social consequences. Self-regulation, planning, and other higher order executive function skills may be particularly impaired. Families can also experience elevated burden and distress. There are few validated interventions for children and teens and their families dealing with a traumatic brain injury (TBI). The goal of the NIDRR-funded Rehabilitation Research and Training Center for Pediatric TBI Interventions is to advance the field of interventions for pediatric TBI through a systematic and coordinated approach of development, replication, and dissemination of promising intervention practices.

Method/Approach

The Center is conducting trials focusing on improving: 1)parenting skills and behavior problems in children 3-9; 2)functioning in teens 1-18; and 3)attention and executive functions in school-age children. Through the Common Data Elements initiative, we are developing a toolbox of measures that can be used to assess functional outcomes. The first trial compares short (6 sessions) and long (16 sessions) web-based parent-skills programs to internet-based resources. The second trial compares family-centered online problem solving (TOPS) to one-on-one problem-solving (TOPS-TO) or access to internet resources (IRC). Finally, Attention Intervention Management (AIM) examines the efficacy of cognitive training in remediating attention post-TBI.

Results/Effects

The three trials are underway and have recruited a total of 135 participants. We will present preliminary evidence from each of the trials including acceptability/feasibility, satisfaction and improvements in targeted child and family outcomes. Overall, families have responded positively to each of the interventions and have expressed a high level of satisfaction with the information and skills that they have learned. Participating children and adolescents also expressed satisfaction with the individual problem-solving and attention management programs. Moreover, families and participating adolescents reported improvements in child behavior and functioning in some but not all domains, supporting the utility of these programs.

Conclusions/Limitations

Given the high incidence of pediatric TBI and risk for long-term behavioral and family morbidity, it is critical to develop an evidence base regarding developmentally-targeted interventions and reliable and valid tools for assessing functional outcomes. We will discuss the progress that the RRTC for Pediatric TBI Interventions has made in addressing this goal and directions for future research. Given the heterogeneity of the population with respect to injury severity and family characteristics it is critical to identify which approaches are likely to be most effective for differing levels of severity and psychosocial burden.

0057

Enoxaparin in Management of Traumatic Brain Injury

Hamid Etemadrezaie

Humain Baharvahdat

Babak Ganjeifar

Samira Zabihyan

Hossein Mashhadinejad

Mohammad Farajirad

Mashhad University of Medical Sciences, Mashhad, Iran

Introduction/Rationale

Traumatic brain injury (TBI) is one of the most common cause of morbidity and mortality. Severe TBI is commonly associated with coagulopathy that is related with complications like delayed intracranial hematoma (DICH) or ischemia, causing poor outcome. Despite many advances, management of the coagulopathy in TBI is still challenging. Herein we evaluated the effect of high dose enoxaparin on the severe TBI outcome.

Method/Approach

Twenty-four patients were entered in this study, a double blinded clinical trial, in two parallel groups, taking either enoxaparin or normal saline (N/S) subcutaneously. The inclusion criteria were severe closed head injury, Glasgow coma scale between 5 and 8, no intracranial hematoma required evacuation, no coagulopathy, and onset of treatment within five hours of trauma. The enoxaparin (0.5 mg/kg) was injected within five hours of trauma, then every eight hours for total four doses. The clinical findings, laboratory data, imaging and Glasgow outcome scale were evaluated between two groups during hospitalization and at discharge.

Results/Effects

Out of 24 patients, 12 patients received enoxaparin (enoxaparin group, EG) and 12 normal saline (placebo group, PG). There was no difference between two groups for appearance of new intracranial hematoma (ICH) or ICH enlargement (2 in EG versus 1 in PG, p = 1.000). However the good recovery was double in EG (7 patients, 58,3%) in comparison of PG (3 patients, 25%), the difference did not reach any significancy (p = 0.098). There were two dead in PG and one in EG (p = 1.000).

Conclusions/Limitations

The result of this study showed that using high dose enoxaparin could be safe and could result in better outcome in severe TBI without significant intracranial hematoma.

0058

Counselor Assisted Problem Solving for Adolescent TBI-Improvements in Behavior

Shari L. Wade¹

Tanya Brown²

Michael Kirkwood³

Erin Hall^1,2

Vanessa Peregrim¹

Malka Isebee¹

Thomas Scalea¹

Deborah Stein¹

1R Adams Cowley Shock Trauma Center, Baltimore, MD, USA, 2Johns Hopkins School of Medicine, Baltimore, MD, USA

Introduction/Rationale

Identifying those at risk for post-traumatic emotional disorders (PTED) is an ongoing challenge. While there is some evidence that those with traumatic brain injury (TBI) are more susceptible to PTED, little association has been found between assigned overall injury severity and PTED. Using a cohort of trauma survivors with a variety of injury types and severities, our objective was to quantify the relationship between self-reported PTED and physical disability.

Method/Approach

Trauma clinic patients were asked to complete Rivermead Post-Concussive Symptoms Questionnaires (RPQ) and the 12 Item Short Form Health Survey (SF-12), previously validated surveys designed to measure symptoms post-concussive syndrome (including PTED) and relative health quality of. Emotional factor components (RPQ) and physical disabilities (SF-12) were collated. The independent relationship between PTED and physical disability was explored using multivariate logistic regression models controlling for brain injury severity, age, gender, insurance status, shock, overall injury severity score, and admission Glasgow Coma Score. Differences in the relationship between PTED and physical disability by brain injury severity were tested using interaction terms.

Results/Effects

Over a 14 month period, 384 patients had both RPQ and SF-12 forms completed. The prevalence of PTED was 17.4% (n = 67) and the prevalence of relative self-reported physical disability was 63.5% (n = 244). PTED was found to be independently associated with physical disability. Those patients with self-reported physical disability had 4 fold greater odds of also reporting PTED (aOR 4.25, 95% CI 1.17-15.44, p = 0.03). The severity of brain injury did not change the intensity of the relationship between physical disability and PTED (p-interaction = 0.8 for mild TBI, p-interaction = 0.4 for moderate/severe TBI).

Conclusions/Limitations

Unlike anatomical scales of injury severity, self-reported measures of PTED and physical disability were correlated. This correlation persisted after controlling for TBI. In the ongoing struggle to identify those survivors at most risk for PTED, it is necessary to consider measures outside assigned injury type, or severity. Patient self-report may provide more insight and indirectly capture coping strategies and patient factors undetected by traditional measures of severity.

0062

How Many Traumatic Brain Injured Patients Are Hospitalized in Level I or II Trauma Centers?

Mark Faul

David Sugerman

Jeneita Bell

Christopher Taylor

Likang Xu

Centers for Disease Control and Prevention, Atlanta, GA, USA

Introduction/Rationale

Among all injuries, traumatic brain injury (TBI) stands out as a major burden in terms of injury-related mortality and costs. Most moderate to severe TBI is seen in hospital settings. While level I or level II trauma centers have access to neurosurgical care on a 24-hour basis, the proportion of TBI-related hospitalized patients seen in these settings has never been answered in the literature. When comparing trauma center hospitalizations to all hospitalizations, differences in multiple trauma, or multiple injuries, and length of stay (LOS) across hospital settings were expected.

Method/Approach

Using Centers for Disease Control (CDC)defined TBI coding definitions from the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM), the total number of TBI hospitalizations was obtained using 2009 data from the National Hospital Discharge Survey. A TBI case was defined as TBI alone or in conjunction with other injuries or conditions. The total number of TBI-related hospitalizations seen at level I or II trauma centers was calculated with ICD-9-CM TBI codes using 2009 admission data from the National Trauma Data Bank.

Results/Effects

For 2009, the total number of US TBI-related hospitalizations, including people who died while hospitalized, was 361,146. The total number of patients hospitalized with TBI at a level I or II trauma center was 196,235. Thus, 54% of all TBI-related hospitalizations occurred in level I or II trauma centers. The LOS for all TBI-related hospitalizations was 5.92 days (95% CI: 5.22-6.62). The LOS for all TBI-related hospitalizations at a level I or II trauma center was 6.62 days (95% CI: 6.06-7.18). Multiple trauma among TBI patients was more common in trauma centers (83%) compared to all hospitalizations (63%).

Conclusions/Limitations

Utilization of trauma center resources for TBIs may be low considering the established lower mortality rate associated with treatment at trauma centers. The presence of multiple trauma appears to be a determining factor in trauma center care admissions. Given that adherence to the Brain Trauma Foundation guidelines is higher for severe TBI in trauma centers, a better understanding of hospital destination decision making is needed for TBI injured patients.

0063

Rehabilitation and Restorative Interventions based upon Performance-Based Physical Capacity Evaluation, a Work Physiological Model

Theodore Becker^1,2

Janet Mott¹

1Brain Injury Association of WA, Seattle, WA, USA, 2EPI, Everett, WA, USA

Introduction/Rationale

Post acute care of individuals who have sustained brain injuries includes various therapies to rehabilitate and restore practical functions for activities of daily living including work. The introduction of restorative work physiological science provides objective criteria upon which evidenced based practice can judge the return to work tolerance of these individuals. Utilization of the performance-based physical capacity evaluation establishes the foundation for the development and coordination of required services by the life care planner, vocational rehabilitation counselor, and/or case manager.

Method/Approach

The Performance-Based Physical Capacity Evaluation utilizes predictive work physiological science to determine the presence or absence of fatigue, and to quantitatively determine how many hours an individual who has sustained a brain injury can devote to work tasks. By means of repetitive measurements of oxygen consumption, energy expenditure, and heart rate, the direct correlation of these factors establishes, in an objective process, the tolerance for work and related activities of daily living for the individual.

Results/Effects

The completion of a Performance-Based Physical Capacity Evaluation results in the establishment of baseline objective data and the prediction of the needed process for restoration of stamina and endurance. The life care planner, vocational rehabilitation counselor, and/or case manager then initiates the necessary and required services based upon objective criteria to facilitate the individuals becoming as independent as possible.

Conclusions/Limitations

For many individuals who have sustained brain injuries, the physical issues of reduced stamina and endurance become significant barriers in their capacity to engage in work activities, as well as in the performance of other activities of daily living. Utilizing Performance-Based Physical Capacity Evaluation, a work physiological model, objective assessment of stamina and endurance occur. Rehabilitative and restorative therapies are planned based upon objective data and adhere to a model for objective measurements of oxygen consumption, energy expenditure, and heart, to further evaluate improvement.

Limitations include the lack of trained personnel, multiple geographical locations, and fee for service funding.

0064

Variation in Clinical Practice Among Comprehensive Sports Concussion Clinics

Kian Merchant-Borna¹

Brandon Stein¹

John Leddy²

Barry Willer²

Brian Reiger³

Claudine Ward³

John Baker²

Jessica Conroy¹

Jeffrey Bazarian¹

1University of Rochester Medical Center, Rochester, NY, USA, 2University of Buffalo School of Medicine and Biomedical Sciences, Buffalo, NY, USA, 3SUNY Upstate Medical University, Syracuse, NY, USA

Introduction/Rationale

Outcomes following a sports-related concussion are quite variable, with most recovering quickly but others lingering for months. Appropriate post-concussive management has the potential to improve long term outcomes. In the last decade, sports concussion clinics have evolved to meet this goal. However, there is little consensus on what the components of a comprehensive sports concussion clinic should include. The primary objective of this study was to elucidate the degree and types of variation that exist among the services provided by concussion clinics throughout the U.S. treating sports-related concussions.

Method/Approach

We performed an internet survey of a convenience sample of sports concussion clinics identified via internet-based search and personal communication. A total of 30 clinics were sent a 16 question survey asking about their clinic, personnel, cliental, and management plans. All responses were anonymous; the identity of respondents could not be identified.

Results/Effects

Response rate was 37% with the volume of patients seen per month ranging from 10 to >200. Provider types ranged from M.D. and Ph.D., to nurse practitioners and athletic trainers. MD/PhD provider area of expertise included internal, emergency, family, rehabilitation, and sports medicine, as well as neuropsychology. Affiliated academic department included rehabilitation, orthopedics, medicine, and neurosurgery. Although most (91%) clinics offered "in-office" computerized cognitive testing, "out-of-office" services offered varied, ranging from psychological testing (25%) and balance testing (45%), to EEG (27%), and blood testing (27%). 31% of clinics reported not prescribing medications to their concussion patients.

Conclusions/Limitations

The results from concussion clinic respondents suggest a substantial degree of variability in provider types, practices and services provided. This is an important first step in exploring the degree to which variation in clinical practices among sports concussion clinics influence outcomes. Wide variation in clinical practice, coupled with significant variation in outcome, suggests that post-concussive management could be improved. Clinical effectiveness trials may best be able to identify the aspects of post-concussion care most likely to improve outcome.

0065

Systematic Instruction of Assistive Technology for Cognition Following Brain Injury: A Manual for Trainers

Laurie Ehlhardt Powell

Robin Harwick

Ann Glang

Bonnie Todis

Center on Brain Injury Research and Training; the Teaching Research Institute of Western Oregon University, Eugene, OR, USA

Introduction/Rationale

Cognitive impairments are a serious consequence of acquired brain injury (ABI). Surveyed professionals indicate they lack evidence-based training practices for teaching their clients to effectively use assistive technology for cognition (ATC). ATC refers to systems such as tablets and smartphones used to compensate for cognitive impairments. Researchers at the Center on Brain Injury Research and Training (CBIRT) developed and experimentally evaluated the TATE (Training Assistive Technology in the Environment). The ATC Toolkit assists trainers in: (1) selecting an appropriate device matched to a client's needs and preferences; and (2) training ATC skills and routines to master everyday environments.

Method/Approach

A mixed methods approach was employed to develop the Toolkit. Themes from focus groups involving clinicians, survivors, and family members were incorporated into the prototype Toolkit, which was then pilot tested by four trainers and clients with ABI. A single-case experimental study was also conducted to determine the impact of using the Toolkit to train a 50-year old female, with moderate-severe cognitive impairments due to ABI, to use ATC for work-related tasks. The Toolkit was also field tested among rehabilitation professionals adn caregivers nationwide.

Results/Effects

With the use of the Toolkit, the 50-year old female's work performance improved significantly after she was systematically trained to use her device across work routines. The results of the field testing among rehabilitation professionals and caregivers, nationwide, are not yet available.

Conclusions/Limitations

The comprehensive approach to product development allowed for the researchers to: (a) explore in detail the constraints trainers face in supporting clients in their use of ATC (PAR focus groups); (b) experimentally evaluate the real-life impact of systematic trainign of ATC for a client with ABI (single case study); and (c) evaluate the imapct of using the Toolkit on trainers' self-efficacy (field testing). Taken together, these results compliment previous research supporting the incoporation of systematic training applied to ATC into clinical practice (e.g. Ehlhardt, Powell, Glang, Todis, Ettel, Sohlberg & Albin, 2012; Ehlhardt, Sohlberg, et al, 2008; Sohlberg et al, 2007).

This project was funded by the National Institute on Disability and Rehabilitation Research (NIDRR) Project # H133G090227.

0066

I-InTERACT Study Internet-Based Interacting Together Every Day: Recovering after Childhood TBI Pilot Study: TBI Inflicted by Abuse

Jennifer Mast²

Tanya Antonini³

Stacey Raj⁴

Karen Oberjohn¹

Kathi Makoroff¹

Shari Wade¹

1Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA, 2University of Cincinnati College of Medicine, Cincinnati, OH, USA, 3University of Cincinnati, Cincinnati, OH, USA, 4Miami University, Oxford, OH, USA

Introduction/Rationale

Abusive head trauma (AHT) causes significant pediatric morbidity and mortality. The incidence of AHT has increased during the past decade due to the economic recession. Despite evidence of poor long-term developmental and behavioral outcomes, virtually no post-acute interventions exist to facilitate long-term recovery. Given the centrality of family and the parent-child relationships on recovery, interventions to improve parenting skills may be particularly beneficial in improving child behavioral outcomes. To meet the needs of this population, the efficacy of a web-based intervention, with live coaching on parenting skills and parent-child interactions, was tested.

Method/Approach

A small randomized trial compared the efficacy of a web-based positive parenting skills intervention (I-InTERACT) to internet resources access (IRC). Participants included families of 8 children, aged 3-9 years, who had experienced an AHT and were well matched in terms of demographic characteristics. All families received computers, high-speed internet, and links to brain injury resources. In I-InTERACT, a trained counselor guided families through a 6-month online parenting skills-building program, while IRC families did not receive the I-InTERACT program. Parenting skills and child behavior were assessed at baseline and 3- and 6-months post-baseline.

Results/Effects

Group differences were assessed using ANCOVA. Participants in the I-InTERACT group displayed significantly higher rates of targeted positive parenting behaviors (specific praise, behavioral descriptions) at 3- and 6-month follow-ups compared to those in the IRC group. The I-InTERACT group had significantly lower levels of behaviors that parents were trained to avoid at follow-up, as well. Trends toward improvement were also noted in parent-reported child behavior with regard to the number of conduct problems a child displayed and the intensity with which they occurred, as well as for internalizing problems, externalizing problems, and oppositional defiant disorder problems.

Conclusions/Limitations

This study provides preliminary evidence for the efficacy of a web-based positive parenting skills intervention in improving parenting skills and child behavior for families whose child has experienced an AHT. I-InTERACT was well received by the participating families, and they exhibited positive changes in their interactions with their child. Overall, this intervention is likely to reduce the risk of long-term behavioral problems and disability, in young children at risk for long-term disability from AHT, in a cost-effective manner, and the intervention fulfills the large unmet need currently experienced by children with AHT and their families.

0067

Behavioral Executive Dysfunction as a Mediator of Injury Severity and Educational Outcomes in Pediatric TBI

Anne Arnett¹

Robin Peterson¹

Michael Kirkwood¹

Gerry Taylor³

Terry Stancin⁵

Tanya Brown⁴

Shari Wade²

1Children's Hospital Colorado, Aurora, CO, USA, 2Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, OH, USA, 3Case Western Reserve University, Rainbow Babies and Children's Hospital, University Hospitals Case Medical Center, Cleveland, OH, USA, 4Mayo Clinic, Rochester, MN, USA, 5MetroHealth Medical Center and Case Western Reserve University, Cleveland, OH, USA

Introduction/Rationale

Disruption of cognitive abilities and educational performance is commonly observed after pediatric traumatic brain injury (TBI). Among the most persistent sequelae are deficits in behaviors associated with executive functions (EF), including attention, inhibition, organization, and self-monitoring. However, performance-based tests of general cognitive, EF, and academic skills do not consistently predict functional outcomes beyond the effect of injury severity. Research suggests a discrepancy between academic skills and educational outcomes after pediatric TBI, with age appropriate academic skills despite difficulties in school. The current study proposes that EF behaviors mediate the association between injury severity and educational outcomes following pediatric TBI.

Method/Approach

A mediation model will be tested wherein EF behaviors apparent in everyday settings and cognitive performance mediate the association between injury severity and educational outcomes. It's hypothesized that the path from EF to educational outcomes will be significantly stronger than that from cognitive test performance. 132 adolescents who were hospitalized for moderate to severe TBI were recruited to participate in a randomized clinical intervention trial. Socioeconomic status and intervention designation were included as moderators. BRIEF parent- and self-reports, WASI, CVLT, and Wechsler PSI were collected within 6 months post-injury; educational outcomes were measured using the CAFAS 12 months later.

Results/Effects

Analyses are ongoing, thus, preliminary results are presented here; model results will be included in the conference presentation. The final group of 132 subjects included 65.15% males, 19.7% non-whites, and 38.63% adolescents with severe TBIs. The mean age of injury was 14.54 years (SD = 1.74) and mean time since injury at baseline was 3.56 months (SD = 1.74). Previous research using this sample found significant correlations between parent-report BRIEF and CAFAS educational scores at baseline: OR (CI) = 1.09 (1.04, 1.15), p < 0.01. Parent- and self-reports on the BRIEF were also significantly correlated at baseline, r = 0.51, p< 0.0001.

Conclusions/Limitations

Clinicians and researchers working with youth after TBI would benefit from increased ability to accurately predict educational outcomes in this population. Currently, cognitive performance-based tests provide little additional predictive value beyond the effect of injury severity. The results of the current study will clarify the role of EF in everyday settings in predicting educational outcomes after pediatric TBI. The results will promote development of individualized interventions as well as more accurate prognosis for adolescents who have sustained a TBI.

0069

mTBI on the Rise in the Past Ten Years 2002-2012: More Concussions or Improved Awareness vs Traumatic Injuries and ED Visits

David Milzman¹

Han Huang¹

Nikhil Murthy¹

Christine Trankiem²

Steve Swinford¹

1Georgetowun University School of Medicine, Washington, DC, USA, 2Washington Hospital Center, Washington, DC, USA

Introduction/Rationale

Minor traumatic brain injury (mTBI or concussion) has seen changes in resources devoted to education, and awareness as well as structured limitations on athletic concerns. Few studies, to date, have attempted to determine whether, increased occurrence is related to change in injury patterns, or to improvements in physician and public awareness and diagnosis. Objectives: To determine if mTBI rates are increasing faster than other traumatic injuries and whether detection is related to better diagnosis, or to increased occurrence.

Method/Approach

The Emergency Department (ED) and Trauma Center records were analyzed at ED and Trauma Centers in 2 metropolitan areas for the past decade 2000-2010. Trauma registries and the ED database were analyzed for trauma admits, ED visits and mTBI rates and treatment interventions including use of radiographic study and dispositions. mTBI defined as arrival GCS 15, possible loss of consciousness (LOC) and no other injury. Institutional Review Board (IRB) approval and data analysis was obtained and performed.

Results/Effects

Over 10 years, the study found rapid rise in past 5 year with number of concussions which increased by 140% compared to ED patient census and trauma patients volume increased only by 23.9%; p< 0.02. (Figure 1). There were also increases in use of computer tomography (CT) for concussion by 25.8% with less than 1.2% of mTBI patients having a positive finding on head CT and none requiring neurosurgical intervention. Patient in hospital admits rose at the same rate as new concussions. Despite rise in mTBI and neurosurgical admits, there was no rise in neurosurgical operative cases.

Conclusions/Limitations

There has been an effective impact on mTBI presentation and admission to our ED and trauma centers in the past five years. CT increased in use with no improved treatment intervention. Future studies will need to determine utility of admit compared to outpatient observation and neuropsychiatric intervention

0070

Cognitive Training Targeting TBI Related Attention Problems in Adolescents

Stacey P. Raj¹

Tanya N. Antonini¹

Holly L. MacPherson¹

Jennifer E. Taylor¹

McKay Sohlberg²

Beth Harn²

Jason Prideaux²

Shari L. Wade¹

1Cincinnati Childrens Hospital, Cincinnati, OH, USA, 2University of Oregon, Eugene, OR, USA

Introduction/Rationale

Children with traumatic brain injury (TBI) show increased rates of attention problems which may result in poor academic and social functioning. While numerous studies have examined the effects of cognitive rehabilitation programs addressing attention difficulties in adults, few have examined feasibility and efficacy of these interventions with adolescents, particularly adolescents with TBI-related attention problems. The few pediatric studies examining direct attention training in children with TBI have reported positive findings. The aim of this study was to examine the efficacy and feasibility of an adaption of the Attention Process Training Program (Sohlberg's Attention Information Management Program, AIM) for adolescents with TBI-related attention difficulties.

Method/Approach

A small trial of AIM was conducted with adolescents (13-17 years old) with attention difficulties post TBI. Participants completed computer-based attention exercises that were tailored to their attention difficulties, and identified and practiced meta-cognitive strategies to facilitate generalization. Weekly, adolescents had 10-15 individual computer-based sessions with a trained therapist and were instructed to engage in 3-4 in-home practice sessions. Attention was assessed pre- and post-intervention with a neuropsychological test battery as well as parent and adolescent ratings of attention and executive functioning. Feasibility and satisfaction were also assessed with a semi-structured interview following the intervention.

Results/Effects

Pre-post data from parent and self report measures (i.e., the Behavior Rating Inventory of Executive Functioning, Conner's Parent Rating Scale, Vanderbilt ADHD Parent Rating Scales), as well as results from a neuropsychological battery, which included select attention and executive functioning subtests from measures such as the Test of Everyday Attention, Delis-Kaplan Executive Functioning System, and the Peabody Picture Vocabulary Test, will be presented. In addition, feasibility data, and parent and adolescent satisfaction ratings will be presented.

Conclusions/Limitations

Cognitive rehabilitation interventions targeting attention difficulties following pediatric TBI may be a useful in reducing attention difficulties and associated academic and social challenges. This study reports on the effects of the AIM on parent and self-report measures of behavior and neurological functioning. Results from this pilot study will be used to guide a larger study utilizing this intervention with pediatric TBI samples.

0071

Unobserved Motor Deficits and Cognitive Problems in TBI may Impact Rehabilitation

Jeanne Charles¹

Julie Haarbauer-Krupa²

Chiropractic Cranial Treatment Protocol Increases Successful Outcome of the Multidisciplinary Care Model for Traumatic Brain Injury (TBI) Patients: A case series.

Esther Remeta²

Charles Blum¹

1Sacro Occipital Technique Organization - USA, Sparta, NC, USA, 2Chiropractic Research Institute, Advance, NC, USA

Introduction/Rationale

James Krause¹

Yue Cao¹

Cindy Harrison-Felix²

Posttraumatic Stress Disorder following an Offshore Explosion

Lawrence Dilks¹

Burton Ashworth²

Jackie Bourassa³

Billie Myers²

1Counseling Services, LA, USA, 2Fielding Graduate University, CA, USA, 3McNeese State University, LA, USA

Introduction/Rationale

The purpose of this study was to explore the posttraumatic stress disorder (PTSD) symptomatology in individuals who experienced an explosion on an offshore rig. According to the Diagnostic and Statistical Manual-IV-TR for an individual to have PTSD they must have: (1) experienced or witnessed a traumatic event; and/or (2) experienced intense fear, or horror. If at least one of those criteria is met, they must also meet the following criteria: (1) intrusive recollection; (2) avoidance; (3) hyper-arousal. The study attempted to answer the question: What trauma-related symptoms were present following the explosion that were not present prior to the explosion?

Method/Approach

This case study included four participants between the ages of 22 and 29 (M = 26). Each of the participants received a complete neuropsychological evaluation by a psychologist. Among the four participants, one participant had obtained a pre-morbid head injury and a medical diagnosis. No participants had a remarkable history.

Results/Effects

The results showed that all of the participants had PTSD and three of them also had a post-concussion. The symptoms they reported were intrusive thoughts, flashbacks, avoidance behaviors, nightmares, hyper-vigilance, anxiety, and fear. Among the four participants, two of them also reported jumpiness, fear of being lost, and guilt. Each of them provided an initial trauma narrative that contained similar descriptions of events with vivid recollections.

Conclusions/Limitations

Based on the results of the study, individuals exposed to an explosion experience many trauma-related symptoms that meet criteria for PTSD. Although it cannot be concluded that all individuals exposed to this environmental disasters were negatively affected, it can be concluded that these individuals suffered similar trauma-related symptoms and provided similar, vivid trauma narratives.

0082

Successful Scholastic Reintegration: Academic, Social and Behavioural Success for Students with ABI

Dawn Good¹

Peter Rumney²

Janette McDougall³

Sheila Bennett¹

Carol DeMatteo⁴

Anna McCormick⁵

1Brock University, St. Catharines, Canada, 2Bloorview Kids, Toronto, Canada, 3Thames-Valley Children's Centre, London, Canada, 4McMaster University, Hamilton, Canada, 5Ottawa Children's Treatment Centre, Ottawa, Canada

Introduction/Rationale

Students spend approximately 30% of their waking hours in school, providing both a natural and appropriate environment for psychosocial rehabilitation. This is especially important given that student's socio-emotional, behavioural, and scholastic outcomes after sustaining an acquired brain injury (ABI) are incredibly variable and independent of injury severity. Within the province of Ontario, ABI is not a recognized exceptionality within the school system, which impacts the student's ability to access the multitude of resources often required post-ABI. This province and Centre-wide research project serves to examine student-, parental-, teacher-, and school policy-based variables that influence students' successful reintegration within the school system.

Method/Approach

Students between the ages of 6 - 18 years, who are 1 - 5 years post-injury, were identified by health care providers and approached to consider participation in the study along with their respective parents. Their teachers and principals were approached with permission of the students and their respective school boards. Participants completed status-appropriate standardized and non-standardized measures (i.e., students were assessed with psycho-educational and neuropsychological tests and self-report measures; parents, teachers and principals completed questionnaires related to history, status, ABI knowledge, school policy, and the student). Regression analyses were conducted to identify variables that best predicted successful reintegration.

Results/Effects

The schools' policies and procedures (i.e., early intervention, philosophies of student inclusions, structured programming, and community reintegration, etc.), in addition to cognitive indices of injury severity (i.e., neuropsychological competency), best predicted the student's academic success, as well as their behavioural and social reintegration within the classroom setting. As expected, acute measures of physical injury severity (i.e., GCS, LOC, PTA and PCS) were not predictive of outcome. Modifiable variables, such as educator awareness and knowledge of ABI, particularly within schools that promote policies and procedures of inclusion, were predictive of successful social, behavioural and scholastic reintegration, over and above neuropsychological competency.

Conclusions/Limitations

These findings identify important 'modifiable' variables within the school system that can mediate the successful academic and social reintegration of students after an ABI. Improved educator knowledge and awareness and the promotion of early intervention and student inclusion policy are variables that can be changed, and are independent of the student's less-malleable injury. The results provide considerable rationale for the incorporation of these variables into 'best practice' guidelines for the province of Ontario and school systems elsewhere.

0083

ABI Identification in Combination with Educator Knowledge Promotes Social and Academic Success in Students with ABI

Kathy Wlodarczyk

Head Injuries Following Historic Tornadoes - Alabama, April 2011

David Sugerman

Thomas Niederkrotenthaler

Fernando Ovalle

Jeneita Bell

Rebecca Noe

Erin Parker

Douglas Mann

Victor L. Szwanki

Jay J. Mistry

Rowan University, Glassboro, NJ, USA

Introduction/Rationale

Research exists supporting the role of brain training increasing memory in patients suffering from brain pathologies such as dementia and Alzheimer's. Little research exists on the role of brain training increasing memory in patients who have suffered one or more concussions. The loss of memory is considered a primary symptom of concussion. One of the tools utilized to measure verbal and visual memory following a concussion is the cognitive assessment test IMPACT. This pilot investigation was done to determine if brain training can increase IMPACT scores on individuals with lower than normative data in the areas of verbal/visual memory.

Method/Approach

This investigation was done in a research laboratory and involved subjects utilizing an online brain training program. The cognitive assessment test IMPACT was utilized to measure baseline visual/verbal memory. Subjects were placed in a five week brain training program or a control group that received no cognitive training. Subjects were re-tested on IMPACT following a five week period. A total of 10 Division III athletes volunteered. Subjects were randomly placed in a group that did online brain training (N = 5) for 15 minutes a day 3x per week or a control group that did not participate. Training done through Fitbrains.

Results/Effects

The composite mean on verbal memory for the experimental group was 36.2, compared to 29.2 in the control group. The composite mean on visual memory for the experimental group was 36.0, compared to 3.60 for the control group. No significant difference was found in verbal memory (p = .76), and on visual memory (p = .15), between the experimental and control groups. Although the mean difference between the experimental and control groups was substantial, no significant differences were found due to small sample size.

Conclusions/Limitations

The effect of brain training on cognitive ability is worth further investigation with a larger sample size. In addition, further investigation on the role of cognitive training and concussion prevention and treatment should be examined.

0096

Determination of the Constitutive Viscoelastic Formula for Brainstem

Asghar Rezaei

Ghodrat Karami

Mariusz Ziejewski

North Dakota State University, Fargo, ND, USA

Introduction/Rationale

The purpose of the study presented here was to examine how behavior of soft tissues, such as the brainstem, can be predicted. The study examined the porcine brainstem under stress relaxation tests to characterize its mechanical properties and behavior.

Method/Approach

Under loading, and undergoing small deformation, the brainstem tissue behavior was simulated by Prony interpolations. The parameters of these models were extracted and examined to show their suitability and accuracies in comparison with the experimental data for the same tissue. In this regard, a sudden displacement ramp, as a stress relaxation, was applied to the brainstem to determine the time-dependent behavior of the tissue. The data was fitted optimally to extract the parameters of each model.

Results/Effects

Two and three term Prony series can be fitted to the experimental data for modeling purposes and the coefficient parameters can be similarly found through an optimization procedure. The results showed that two and three terms of the Prony series illustrated a close resemblance to the brainstem response. Based on the two-term Prony series, short-and long-term moduli of the same were derived as 7.88 and 1.87 kPa; and based on three-term Prony series, there were 7.92 and 1.74 kPa, respectively. The moduli were close to each other for both models.

Conclusions/Limitations

Both models of the Prony series can follow the behavior of the tissue, but a three-term Prony series follows the response of the sample more precisely. This indicates that the higher the number of terms, the more accurate the simulation becomes. The relaxation moduli, as well as the short- and long-term moduli (as intrinsic mechanical properties), of the tissue were derived.

0097

Helmet-Head Interactions under the Blast

Mehdi Salimi Jazi

Asghar Rezaei

Ghodrat Karami

Fardad Azarmi

Mariusz Ziejewski

North Dakota State University, Fargo, ND, USA

Introduction/Rationale

Blast events are a major source of traumatic brain injuries (TBIs). In recent years, computational studies have been conducted on the effect combat helmets have against blasts. Even when a helmet is used a brain can be injured at some level in a blast situation. The efficiency of the helmet mostly depends on the types of materials of which it is made, as well as the padding. This paper presents the results of a computational study on the effect a helmet has in reducing the level of the severity of the brain injury.

Method/Approach

In this study, the helmet and head were modeled by Finite Elements (FEs). In order to model a realistic situation, the helmet was placed on a fidelity head-model that included the complete components of the skull and brain. Appropriate contact conditions between the head components were included. Arbitrary Langrangian Eulerian (ALE) and penalty methods were used to simulate detonation and media, as well as the interaction between media and the head model. KEVLAR was considered to be the material for the helmet. A helmeted head model and a non-helmeted model were subjected to the same blast situation for comparison.

Results/Effects

The results of the brain's intracranial pressure (ICP), and kinematical parameters of the brain motion, were determined for the different masses of detonation. The results showed the degree of injury to the brain. It was determined that wearing the combat helmet noticeably decreases the level of ICP in the brain. The peak positive ICP was around 0.36 MPa without a combat helmet and 0.006 MPa with a helmet.

Conclusions/Limitations

The efficiency of a helmet can be examined during blast situations. The results show that the degree of injury to the brain, when wearing a combat helmet, is decreased because the helmet reduces the load transfer to the brain.

0098

Factors Influencing Post-Acute Brain Injury Rehabilitation Treatment Outcome

Nicholas Cioe

Southern Illinois University, Carbondale, IL, USA

Introduction/Rational

Brain injury has a tremendous effect on the United States. The medical system has a continuum of care available but many of these services are extremely expensive. Despite the effectiveness of residential post-acute brain injury rehabilitation (PABIR) resistance to provide adequate funding remains because of a dearth of randomized controlled trial (RCT) studies demonstrating effectiveness. Some research suggests observational trials are typically more representative of community samples and yield conclusions similar to RCT studies.

Method/Approach

This study uses a large multi-state naturalistic community-based sample of individuals who received residential PABIR. The purposes of this study were to (1) use logistic regression to identify a model that considered the relationships among the predictor variables to explain treatment outcome for individuals receiving residential PABIR and (2) better understand how self-awareness influences treatment outcome.

Results/Effects

The final model contained five independent variables (substance use at time of admit, functioning level at time of admit, change in awareness between discharge and admit, admit before or after 6 months post-injury, and length of stay in the program less than or greater than 2 months). The model was statistically significant, [chi]² (5, N = 434) = 194.751, p < .001, accounting for 36.2% (Cox & Snell R square) to 61.3% (Nagelkerke R square) of the variance in success rate, and correctly classified 89.4% of cases.

Conclusions/Limitations

Four of the five predictor variables (current substance use, change in awareness, LOS 2 months and TPI 6 months) made statistically significant contributions to the model. The strongest predictor of successful treatment outcome was change in awareness recording an odds ratio of 29.9 indicating that individuals who improved in self-awareness by at least one level were almost 30 times more likely to be in the successful outcome group, controlling for other factors in the model. Participants were also more likely to be in the successful outcome group if they admitted within 6-months post-injury (5.5x) and stayed longer than 2-months (4.4x). Findings also suggest that active substance use at time of admission did not prevent people from being successful.