NABIS Abstracts 2022 : The Journal of Head Trauma Rehabilitation

Secondary Logo

Journal Logo

Abstracts

NABIS Abstracts 2022

Author Information
Journal of Head Trauma Rehabilitation: November/December 2022 - Volume 37 - Issue 6 - p E502-E608
doi: 10.1097/HTR.0000000000000845
  • Free

figure1

3 Long-term Outcomes From Child TBI: Tracking Recovery Across 20 Years

Vicki Anderson1-3; Louise Crowe, Cathy Catroppa1-3; Nicholas Ryan1,4

1Murdoch Children's Research Institute, Parkville, Victoria, Australia; 2University of Melbourne, Parkville, Victoria, Australia; 3Royal Children's Hospital, Parkville, Victoria, Australia; 4Deakin University, Burwood, Victoria, Australia

Traumatic brain injury (TBI) sustained in childhood can be considered a chronic condition, due to its lifelong consequences, impacting multiple functional domains: physical abilities, academic achievement, mental health status, and social competence. The impact of injury severity is well established, with poorer outcomes associated with more severe TBI. However, emerging evidence suggests that the nature of postinjury deficits, and the mechanisms underlying them, may vary across childhood, characterized by a complex interplay of biopsychosocial factors. Thus, from a clinical perspective, the targets for intervention may not be static but, rather, change along with developmental demands and environmental influences. To date, few studies have systematically tracked child TBI into adulthood using a multidomain framework.

This presentation (i) describes the findings of a 20-year prospective, longitudinal research program, which has tracked children's recovery across 7 time points, exploring both biological (injury severity indices, neuroimaging, blood biomarkers) and environmental influences (socioeconomic status, family function, parent mental health and burden), and multiple functional domains (adaptive, cognitive, academic, social, mental health), quality of life; (ii) considers the implications of our findings for building a dynamic rehabilitation model that takes into account key mechanisms underpinning child function at major developmental stages; and (iii) introduces recent evidence-based child and family-focused intervention models applicable following child TBI.

5 Initial Clinical Presentation and Rehabilitation Pathways for Young, School Aged-Children With Concussion

Elizabeth Teel

McGill University, Montreal, Canada

Objectives

Concussions are common among elementary school-aged children (5-12 years old). Few studies have investigated the clinical presentation and recovery needs of young children with concussion, which is necessary to optimize recovery strategies to their developmental needs. Therefore, the purpose of this study was to describe and compare initial physiotherapy findings and prescribed rehabilitation pathways for elementary school-aged children with concussion.

Methods

Prospectively collected clinical data from young children presenting to the Montreal Children's Hospital Concussion Clinic between September 2017 and August 2019 were analyzed. Outcomes of interest included (1) findings from the initial physiotherapy examination (cervical range of motion, Post-Concussion Symptom Inventory [PCSI], Bruininks-Oseretsky Test of Motor Proficiency Edition 2 [BOT-2] Body Coordination domain, composed of Bilateral Coordination and Balance subtests, and a modified version of the Vestibular/Ocular Motor Screen [VOMS], where, in addition to documenting symptom provocation, the physiotherapist reports any abnormal eye movement pattern [eg, nystagmus, overshoot/undershoot] observed during the test); and (2) rehabilitation pathways (exercise, vestibular, and cervical therapy) prescribed to patients. We compared patients across several age groupings (5-7 years: n = 52; 8-10 years: n = 146; 11-12 years: n = 183) using Kruskal-Wallis (continuous) or Chi-square (categorical) tests, with roughly equal numbers of boys (n = 208) and girls (n = 179) represented in the sample.

Results

The 11- to 12-year-olds were significantly more likely to have 1 or more clinician-observed abnormal finding during the VOMS (5-7 years: n = 0, 0%; 11-12 years: n = 27, 16%; χ12 = 7.69, P = .006) and cervical examination (5-7 years: n = 1, 2%; 11-12 years: n = 35, 21%; χ12 = 7.69, P = .006) than 5- to 7-year-olds only. The 5- to 7-year-old group had significantly better norm-referenced BOT-2 Bilateral Coordination scale scores than the 8- to 10-year-old and 11- to 12-year-old groups: median scaled scores (IQR): 5-7 years = 20 (18-21); 8-10 years = 18.5 (16-20); 11-12 years = 19 (17-20); χ12 = 9.11, P = .01). No group differences in BOT-2 balance, BOT-2 body coordination, or postinjury PCSI scores were observed. For rehabilitation outcomes, significant differences were observed for exercise-based therapy (5-7 years: n = 8, 15.4%; 8-10 years: n = 61, 41.8%; 11-12 years: n = 80, 43.7%; χ12 = 14.36, P < .001), vestibular therapy (5-7 years: n = 0, 0%; 8-10 years: n = 14, 9.6%; 11-12 years: n = 43, 23.5%; χ12 = 22.94, P < .001), and cervical therapy (5-7 years: n = 0, 0%; 8-10 years: n = 5, 3.4%; 11-12 years: n = 20, 10.9%; χ12 = 11.69, P = .003), with 11- to 12-year-olds more frequently prescribed rehabilitation.

Conclusions

In our sample, 5- to 7-year-olds with concussion presented with fewer abnormalities on visual/vestibular and cervical assessments, as well as fewer rehabilitation needs, than 11- to 12-year-olds. The frequency and severity of deficits observed at the initial physiotherapy appointment, and the subsequent need for rehabilitation, in our sample appear lower than values reported for adolescents and young adults with concussion throughout the literature. These findings could be driven by several factors, including physiological differences influencing injury and recovery, mechanism of injury, or sample-specific differences, and should be explored in the future.

6 The Effect of Oral Mucosal Mesenchymal Stem Cells Administration on Inflammatory and Oxidative Stress Outcomes of Liver Following Experimental Traumatic Brain Injury

Nazanin Sabet1; Behshad Mofid2; Mohammad Khaksari3,4; Zahra Soltani3,4; Eshagh Alizadeh2

1Research Center of Tropical and Infectious Diseases, Kerman University of Medical Sciences, Kerman, Iran; 2Physiology Research Center, Institute of Neuropharmacology, Kerman University of Medical Sciences, Kerman, Iran; 3Endocrinology and Metabolism Research Center, Institute of Basic and Clinical Physiology Sciences, Afzalipour School of Medicine, Kerman University of Medical Sciences, Kerman, Iran; 4Dept. Physiology, Afzalipour Faculty of Medicine, Kerman University of Medical Sciences, Kerman, Iran

Introduction

Traumatic brain injury (TBI)–induced inflammatory mediators are transferred from damaged brain tissue to the bloodstream and produce a systemic inflammatory response in peripheral organs, including liver. In this study, the effect of oral mucosal mesenchymal stem cell (MSC) treatment following TBI was evaluated on inflammatory and oxidative stress agents in liver.

Materials and Methods

In this study, 24 Wistar adult male rats were used. Animals were divided into 4 groups: sham, TBI, vehicle, and stem cell (SC). Oral mucosal MSCs (2 × 106 cells) were injected intravenously 1 and 24 hours after injury. Liver inflammation by measuring the levels of interleukin-1β (IL-1β), interleukin-6 (IL-6), and interleukin-10 (IL-10) and oxidative stress by measuring the levels of malondialdehyde (MDA), protein carbonyl (PC), total antioxidant capacity (TAC), superoxide dismutase (SOD), and catalase (CAT) were evaluated at 48 hours postinjury.

Results

TBI resulted in a significant increase in liver IL-1β, IL-6, MDA, and PC levels compared with the sham group. The levels of liver SOD, TAC, CAT, and IL-10 reduced following TBI. The administration of MSCs following TBI prevented increasing levels of IL-1β, IL-6, MDA, and PC and decreasing levels of SOD, TAC, CAT, and IL-10 in liver.

Conclusion

The administration of MSCs derived from the oral mucosa following TBI could probably reduce liver inflammation and oxidative stress. Therefore, the administration of oral MSCs can be considered for more research to confirmation the use in TBI patients.

8 Combining Music Therapy Techniques With Physical Therapy in an Individual Following Brain Injury: A Case Study in the Use of Both Patterned Sensory Enhancement and Rhythmic Auditory Stimulation

Heather McLean; Michelle Melicosta; Nicole Spurgeon

Kennedy Krieger Institute, Owings Mills, United States

Objective

This was a case study of a patient with a complex medical history admitted to an inpatient pediatric rehabilitation hospital following an acquired brain injury (ABI) looking at the use of Patterned Sensory Enhancement (PSE) and then progressing to Rhythmic Auditory Stimulation (RAS) for gross motor functional recovery. Both PSE and RAS have been shown to be beneficial in adults with varying diagnoses as well as children with spastic diplegic cerebral palsy (CP). The premise of this study was to assess the benefit of each in an individual with a pediatric brain injury. PSE is a neurologic music therapy technique that uses rhythmic, melodic, harmonic, and dynamic-acoustical elements of music to provide temporal, spatial, and force cues for movements that reflect functional exercises and activities of daily living. RAS is defined as a therapeutic application of pulsed rhythmic or musical stimulation in order to improve gait or gait-related aspects of movement.

Interventions

PSE was utilized in physical therapy sessions for improvement in sit-to-stand transfers, and RAS was utilized for gait progression. For PSE trials, the patient completed sit to stand initially without music to achieve baseline time and allow physical therapist (PT) and board certified music therapist (MT) to assess movement patterns. Timed sit to stand was then performed with PSE music provided. For RAS trials, the patient performed a 10-m walk test without music for a baseline and then completed the same timed test with RAS musical accompaniment. Sessions were completed as a co-treatment with MT and PT.

Results

This patient showed improvements in functional transfers as well as gait during a 10-m walk test with the addition of PSE and RAS, respectively. During PSE, baseline timed sit-to-stand trial was 4.05 seconds; with PSE times decreased to 2.51 seconds and 1.98 seconds. During RAS, baseline 10-m walk test was 14.91 seconds; with RAS, times decreased to 11.33 seconds and 10.02 seconds using a strummed chord pattern, and 8.55 seconds, using a broken chord pattern at a slightly faster tempo.

Conclusions

This case study demonstrates that both PSE and RAS are beneficial for this individual with an ABI and are promising modalities in the gross motor functional recovery during pediatric inpatient rehabilitation admissions following brain injury. This also reinforces music's role as a “force cue.” Future studies should address the following: increased sample size, repetition of techniques over multiple days, use of varied tempos, patterns, and timing with MT, and longer-term monitoring of impact.

9 Long-term Risk for Mood and Anxiety Disorders After Pediatric Traumatic Brain Injury: A Population-Based Birth Cohort Analysis

Dmitry Esterov; Allen Brown; Julie Witkowski; Dana Mccall; Amy Weaver

Mayo Clinic, Rochester, United States

Introduction

While an association between pediatric traumatic brain injury (TBI) and increased psychiatric symptoms early after injury has been widely described, the long-term risk of mood and anxiety disorders remains unclear. To better understand the long-term association between early childhood TBI and risk of development of mood and anxiety disorders, we conducted a population-based birth cohort study, comparing individuals with TBI prior to age 10 years with 2 age- and sex-matched referents from the same birth cohort, to determine the risk of subsequent development of mood and anxiety disorders by the age of 25 years.

Methods

This population-based study utilized a birth cohort of 5518 individuals born from January 1, 1976, through December 31, 1982. TBI cases prior to the age of 10 years (“index date”) were identified electronically using an exhaustive list of diagnostic codes and manually confirmed and classified by injury severity using the Mayo Classification System for TBI Severity. Each TBI case was matched to 2 sex- and age-matched referents from the same birth cohort with no history of TBI prior to the index date. Clinical diagnostic codes prior to the age of 25 years were electronically obtained and classified into an anxiety, mood, or bipolar diagnosis and then each diagnosis was manually confirmed. Cox proportional hazards regression models were fit to estimate the association between childhood TBI status and being diagnosed with the psychiatric condition of interest, adjusting for the child's race and mother's age and education level at the child's birth. Associations were summarized using hazard ratios (HRs) and corresponding 95% CIs.

Results

Among 561 TBI cases and 1122 matched referents, 115 TBI cases and 215 referents were diagnosed with at least one anxiety, mood, or bipolar diagnosis. There was no significant association between childhood TBI status and anxiety (adjusted HR = 1.01; 95% CI, 0.71-1.43, P = .97). The risk of a subsequently diagnosed mood disorder (bipolar or depression) was 16% higher in individuals who experienced a childhood TBI than referents; however, this association was not statistically significant (adjusted HR = 1.16; 95% CI, 0.92-1.47; P = .21). When the cohort was stratified by sex, a significantly increased risk of a subsequently diagnosed mood disorder in individuals with a childhood TBI compared with referents was observed among females (adjusted HR = 1.40; 95% CI, 1.04-1.89; P = .025) but not among males (adjusted HR = 0.91; 95% CI, 0.61-1.36; P = .65), although this difference in risk was not statistically significant based on the test for interaction (P = .12).

Conclusions

Individuals with TBI, caregivers, and clinicians should be reassured that isolated TBI prior to the age of 10 years is not significantly associated with an increased risk of anxiety or mood disorder by the age of 25 years. Further studies are needed to identify certain individuals at increased risk and to further understand sex differences in outcomes.

10 Case Characterization and Perceptions of Athletic Trainers Regarding Medical Disqualification Following Concussion

Michelle Weber Rawlins1; Tamara Valovich McLeod2; Julianne Schmidt3

1San Diego State University, San Diego, California, United States;2A. T. Still University, Mesa, Arizona, United States; 3The University of Georgia, Athens, Georgia, United States

Objective

Medical disqualification (MDQ) following concussion is a challenging decision clinicians encounter, with little evidence-based guidance. In addition, athletic trainers (ATs) are highly involved in concussion management and female clinicians report higher levels of pressure to prematurely return athletes to play after concussion. Therefore, the first step in understanding this complicated process should include an examination into the AT's perceptions of factors that should be considered in MDQ cases following concussion, including sex differences in ATs as males and females may weigh case characteristics differently in when to consider sport retirement. The purpose of this study was to (1) describe the frequency and characteristics of MDQ cases ATs have been involved in and (2) compare MDQ following concussions perceptions between male and female ATs.

Methods

ATs (n = 502) employed at the collegiate setting completed at least one item in a cross-sectional, validated survey (response rate = 7.7%, n = 502/6500; male = 175, 34.9%; female = 235, 46.8%; prefer not to answer = 4, 0.8%; no response = 88, 17.5%; age = 35.3 ± 10.8 years). The survey included 3 sections of MDQ experience and specific case information (22 items maximum), MDQ beliefs (18 items maximum), and demographic items (13 items maximum). Participants were able to access the survey for 4 weeks, with weekly reminders. We addressed aim 1 using descriptive statistics and aim 2 using Mann-Whitney U tests to compare perceptions of MDQ following concussion between male and female respondents.

Results

Nearly half of respondents had been involved in an MDQ case following concussion (49.0%, n = 246; not involved = 51.0%, n = 256), with ATs being involved in an average of 2.3 ± 1.9 cases (n = 241). ATs reported that MDQ patients had 4.6 ± 2.1 concussions, on average. ATs most frequently perceived athlete concussion history should be considered in MDQ decision (87.1%, n = 437), followed by long-term health (86.1%, n = 432), medical professionals' opinion and recommendation (85.7%, n = 430), and long-term health-related quality of life (85.7%, n = 430). Male respondents believed a median of 4 concussions were “too many before MDQ should be considered” (interquartile range [IQR] = 3.00-5.00), while females respondents believed 5 concussions should be considered (median = 5.00, IQR = 4.00-6.00; P = .004, n = 393). Males and female ATs had similar perceptions of sport contact level (P = .423, n = 410) or patient sex (P = .779, n = 410) as considerations during MDQ decision-making.

Conclusions

Our findings highlight that nearly half of our sample was involved in an MDQ case following concussion and navigated this process without guidelines or recommendations. Without these guidelines or recommendations, it is unsurprising that some perceptions of factors that should be included varied among sexes. The number of ATs involved in MDQ cases following concussion and the factors that guided this decision-making process warrant further research to develop evidence-based recommendations that assist all clinicians in making these difficult decisions for both adult and pediatric patients.

11 Pitfalls in Medicolegal Assessments in the Netherlands, Offering a Sneak Peek at a Possible Dutch Solution

Monique Piegza

Tolsma Consult, Eindhoven, the Netherlands

The medicolegal assessment of people who have experienced acute/chronic disability following traumatic brain injury is a common process across the world. However, individual countries and regions can have widely different systems of assessment and decision-making in who receives benefits. For example, the incidence of back pain is equivalent in the United States and in Japan, but claims of disability in the United States are an order of magnitude greater. One factor with the capacity to influence determination of disability and compensation is how assessments are completed. In this presentation, the speaker discusses the difficulties medical experts experience while evaluating patients and writing medicolegal reports. The author gives an overview of the Dutch (compensation) system and the role of the medical expert within this system. Furthermore, you will learn more about the history of the Dutch way of handling claims in litigation and disability, the position of the medical experts within this system, and the method they have developed to ensure a more transparent, systematic, and standardized approach to assessing clients in a medicolegal environment. This system aims to produce fair and comparable results for similar cases.

13 Impact Force Differences on Natural Grass Versus Synthetic Turf Football Fields

Nathaniel Villanueva1; Ian Chun1; Alyssa Fujiwara1; Emily Leibovitch1; Brennan Yamamoto2; Loren Yamamoto1

1John A. Burns School of Medicine–Honolulu, Hawaii, United States; 2University of Hawaii Applied Research Laboratory, Honolulu, Hawaii, United States

Introduction

In previous studies of high school sports, more than 15% of concussions were attributed to contact with the playing surface. While artificial turf fields are increasing in popularity due to lower maintenance costs, artificial turf has been associated with more ankle and knee injuries, with inconclusive data on concussions. In this study, natural grass and artificial football fields were compared in terms of deceleration on fall impact.

Methods

Accelerometers were placed on the forehead, apex of the head, and right ear of a Century Body Opponent Bag (BOB) manikin. A Riddell HITS football helmet was secured onto the head of the manikin over the accelerometers. This manikin was dropped onto natural grass (n = 10) and artificial turf (n = 9) high school football fields. The manikin was dropped from a stationary position at a height of 60 cm onto its front, back, and left side. Each of these drops was conducted 10 times at the 40-yard line, 20-yard line, and end zone. The net deceleration on impact was calculated as a net vector from each of the 3 accelerometers' x, y, and z vectors from the 3 different locations on the manikin's head (9 vector measurements per drop).

Results

Mean values for the multiple drops were calculated for each accelerometer and drop type for each field. All accelerometers in forward and backward falls, and one accelerometer inside falls, showed significantly greater impact force on synthetic turf than the natural grass surfaces.

Conclusion

Impact force was higher on synthetic fields for all drop types for at least one of the accelerometer locations. These findings suggest that concussion risk might be higher for athletes playing on artificial turf fields.

15 Stroke in Patient With Controlled Preexisting Hypercoagulability After COVID-19 Vaccine Booster: A Case Report

Yi Zhou; Talya Fleming

JFK Johnson Rehabilitation Institute, Edison, New Jersey, United States

Stroke is one of the leading causes of disability worldwide. Physiatrists provide rehabilitation care to promote functional recovery in survivors of stroke as well as secondary prevention to prevent future medical complications. This is the case of a 55-year-old woman with factor V Leiden and protein C deficiency who developed an ischemic stroke following her mRNA COVID-19 vaccine booster dose. On admission, she presented with acute-onset right-sided weakness and numbness. Subsequent magnetic resonance imaging revealed an acute left thalamic, left posterior internal capsule, and bilateral middle cerebellar infarcts. She received the BNT162b2 vaccine booster dose 27 days prior to admission. Prior to this incident, she was successfully maintained on the same dose of enoxaparin for 19 years without clotting event along with recent outpatient hematology monitoring. After medical stabilization, she was admitted to the acute inpatient rehabilitation facility where she regained full motor strength and gait, although numbness persisted. Following consultation with her outpatient hematologist, she was discharged at an independent level with unchanged enoxaparin dosing. This case report seeks to raise curiosity among the medical community regarding the evaluation and management of risk factors associated with ischemic stroke in the era of COVID-19. Physicians caring for hypercoagulable patients with thrombotic complications are encouraged to not only consider SARS-CoV-2 infection but also the timing of COVID-19 vaccination, whether it is at presentation or follow-up. Future studies should research the potential relationship between the mRNA COVID-19 vaccine booster and thrombotic events in patients with inherently increased clotting risk.

16 A Modal Analysis Procedure of the Human Brain for Brain Injury Diagnosis

Mariusz Ziejewski; Jayse McLean; Mehran Fereydoonpour; Ghodrat Karami

North Dakota State University, Fargo, North Dakota, United States

Brain injury criteria that are focused on acceleration and forces are poorly understood in the frequency domain. Injury can be more destructive around the brain's resonant frequencies with the external applied loading and motion. Waves of vibration are sent throughout the brain during an assault on the human head under impacts or high motions. These waves propagate and attenuate at different rates within the brain depending on the magnitude and direction of loading. Like any other dynamic systems, the human brain subjected to vibration exhibits natural frequencies and natural modes of vibration. These modal vibrations and increase in strain cause excessive stretching of brain tissue and can lead to mild traumatic brain injury (TBI). By conducting modal analysis and identifying these resonant frequencies, we can measure the risk of injury and reduce or possibly even eliminate vibrations in these frequency ranges. This presentation employs a finite elements method to simulate the impacts for different impact angles on a human head. A numerical technique based on dynamic mode decomposition (DMD) will be used to extract the modal properties for the brain tissue in regions near the corpus callosum and brain stem. Using the finite element software LS-DYNA, brain nodal displacements will be collected from a human head model and subjected to DMD. DMD can extract the dynamic characteristics of a system without having to define the underlying system itself, which lends it to be very useful for both numerical and experimental data. The study aims to identify a frequency range in which the brain is more susceptible to vibration, with the end goal of better understanding the brain in the frequency domain and preventing future TBIs. Three modal frequencies were identified with frequency ranges of 44-68, 68-155, and 114-299 Hz. It is found that the impact angle, displacement direction, and region of the brain have a significant impact on the modal response of brain tissue during any impact. The study also provides insight into the effects of impact angle, displacement direction, and different regions of the brain. The data provided show that each variable had a significant effect on the modal frequencies and decay rates. Each impact angle resulted in significantly different modal frequencies. For specific modes and displacement angles, there was some evidence of slight mirroring over the coronal plane but as an average across all the data, there were no similarities seen between impact angles.

17 Reading Comprehension in Preschool Children With Traumatic Brain Injuries: A Latent Profile Analysis

Lama Farran1; Juliet Haarbauer-Krupa2; Diana Mindrila1

1University of West Georgia, Carrollton, Georgia, United States; 2Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, United States

Children who sustain a traumatic brain injury (TBI) are vulnerable to disruption of new and emerging skills, namely, language and reading, that impact academic performance, vocational outcomes, and life quality. Compared with school-aged children, children younger than 5 years are particularly vulnerable to the effects of TBI. Evidence suggests increased vulnerability and long-standing changes in functioning from a younger age of injury, manifesting in cognitive changes that impact language learning, thereby placing children at risk for reading difficulties. The purpose of this study was to (1) identify the latent profiles that underlie the data based on individuals' scores on language and executive function assessments and (2) determine whether latent profile membership is a significant predictor of reading comprehension in the early elementary years. Findings indicate an association between these skills, highlighting the importance of assessing increasingly complex language skills in preschoolers after TBI. In this study, reduced reading comprehension performance was associated with executive function problems and lower performance on story recall, which also requires more complex language use. These findings highlight the importance of assessing more complex language skills after TBI, especially for preschool children.

18 The Association of Padded Headgear With Concussion and Injury Risk in Junior Australian Football: A Prospective Cohort Study

Jennifer Makovec Knight; Biswadev Mitra; Andrew McIntosh; Teresa Howard; Patrick Clifton; Michael Makdissi; Jeffrey Rosenfeld; Peter Harcourt; Catherine Willmott

Monash University, Melbourne, Victoria, Australia

Objectives

To assess whether padded headgear was associated with the incidence of suspected sports-related concussion, non–sports-related concussion head injury, and injuries to other body regions in junior Australian football.

Design

Prospective cohort injury surveillance.

Methods

There were 400 junior players (42.5% female) enrolled across 2 seasons. Suspected sports-related concussion was defined by detection of observable signs on the field and medical assessment or missed match(es) due to suspected sports-related concussion. Non–sports-related concussion head injury and injuries to other body regions were defined as those that received medical assessment or resulted in a missed match.

Results

There were 20 teams monitored over 258 matches; 204 players (2484 player-hours) wore mandated headgear throughout the season and 196 (2246 player-hours) did not. The incidence rate of suspected sports-related concussion was 3.17 (95% CI, 3.04-3.30) per 1000 player-hours, and no differences were observed between males and females (risk ratio = 1.11; 95% CI, 0.40-3.06). Headgear use was not associated with suspected sports-related concussion (risk ratio = 1.09; 95% CI, 0.41-2.97), non–sports-related concussion head injury (risk ratio = 0.27; 95% CI, 0.06-1.31), or injuries to other body regions (risk ratio = 1.41; 95% CI, 0.79-2.53).

Conclusions

Headgear use was not associated with a reduced risk of suspected sports-related concussion, non–sports-related concussion head injury, or injuries to other body regions. There was no difference in the rate of suspected sports-related concussion in female compared with male players; however, rates of non–sports-related concussion head injury and injuries to other body regions were higher in male players.

19 Service Delivery Models for the Management of Pediatric and Adolescent Concussion: A Systematic Review

Jacqueline Purtzki1,2; Haley Chizuk3,4; Aaiush Jain3; Jacob McPherson3,4; Michelle Zafron5; Mohammad Haider3; John Leddy3,4; Barry Willer3,6

1Division of Physical Medicine and Rehabilitation and Department of Paediatrics, University of British Columbia, Vancouver, British Columbia, Canada; 2GF Strong Rehabilitation Centre, Vancouver, British Columbia, Canada; 3UBMD Orthopedics and Sports Medicine, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York, United States; 4Department of Rehabilitation Sciences, School of Public Health and Health Professions, State University of New York at Buffalo, Buffalo, New York, United States; 5University Libraries, University at Buffalo, Buffalo, New York, United States; 6Department of Psychiatry, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York, United States

Objective

This systematic review examines the current peer-reviewed literature on pediatric concussion service delivery models (SDM) and relevant cost analyses.

Data Sources

PubMed, EMBASE (Elsevier), CINAHL Plus (EBSCO), APA PsycINFO (EBSCO), and Web of Science Core Collection, limited to human trials published in English from January 1, 2001, to January 10, 2022.

Study Selection

Included (i) peer-reviewed and (ii) evidence-based studies; (iii) described service delivery and/or associated healthcare costs; and (iv) described mild traumatic brain injury, concussion, or postconcussion symptoms of children and adolescents. Studies describing emergency department (ED)–based interventions, adults, and moderate to severe brain injuries were excluded.

Data Extraction

The search resulted in 1668 articles. Utilizing Rayyan software, 2 reviewers independently completed title and abstract screening, followed by a full-text screening of potentially included articles. A third blinded reviewer resolved inclusion/exclusion conflicts amongst the other reviewers. This resulted in 28 articles included.

Data Synthesis

Each of the 28 articles was grouped into one of the following 3 categories: generalist-based services (7); specialist-based services (12); and web/telemedicine services (6). One article discussed both generalists and specialists. Four studies discussed costs relevant to SDMs.

Conclusions

This review highlights the need for more discussion and formalized evaluation of SDMs to better understand concussion management. Overall, there is more literature on specialist-based services than generalist-based services. Specialists and generalists have overarching similarities but differ often in their approach to pediatric concussion management. Cost analysis data are sparse and need to be researched further.

20 Predictors of Later Need for Psychiatric Care Following Pediatric Mild Traumatic Brain Injury

Mari Saarinen1; Nea Isaksson1; Nina Erkinjuntti1; Tero Vahlberg2; Sanna Koskinen3; Leena Himanen4; Olli Tenovuo5; Tuire Lähdesmäki1

1Department of Pediatric Neurology, Turku University Hospital and University of Turku, Turku, Finland; 2Department of Biostatistics, Turku University Hospital and University of Turku, Turku, Finland; 3Department of Psychology and Logopedics, University of Helsinki, Helsinki, Finland; 4Department of Psychology, University of Turku, Turku, Finland; 5Department of Clinical Neurosciences, Turku University Hospital and University of Turku, Turku, Finland

Objectives

To investigate whether a later need for psychiatric care following pediatric mild traumatic brain injury (mTBI) could be predicted with neuropsychological test performance or child- or parent-reported injury symptoms at 1 to 3 months following injury.

Methods

The study was conducted in Child Neurology outpatient clinic at Turku University Hospital, Finland. Clinical and neuropsychological data from 120 children and adolescents, aged 7 to 15 years, treated between 2010 and 2016 due to mTBI, and had undergone neuropsychological evaluation within 1 to 3 months following injury, were retrospectively retrieved from the hospital records. Neuropsychological test performances, parental questionnaires on child's learning and behavior, and presence of injury symptoms reported by child or parent were used as predicting variables.

Results

Information processing speed (P = .04), child- or parent-reported emotion regulation deficit (P = .014), impulsivity (P = .013), and presence of headache (P = .026) and verbal processing difficulties (P = .042) were independent predictors for having later contact in psychiatric care.

Conclusions

Neuropsychological examination carried out within 1 to 3 months post- mTBI, containing measure of processing speed, injury symptom interview, and parental questionnaires on learning and behavioral issues of the child, seems to be helpful in detecting the patients with a heightened risk for developing later psychiatric problems. Targeted support and guidance for this group of children and adolescents and their families are recommended to prevent development of an unfavorable psychosocial outcome.

21 Acquired Brain Injury in Childhood: The Knowledge and Training Needs of Special Educational Needs Coordinators in UK Schools

Emma Woolf2; Emily Bennett1; Shirley Thomas2

1Nottingham Children's Hospital, Nottingham, United Kingdom; 2The University of Nottingham, Nottingham, United Kingdom

Background

Childhood acquired brain injury (ABI) has a prevalence higher than any other neurodevelopmental disorder (McGuire et al., 1998; McKinlay et al., 2008). However, recent evidence has indicated that educational professionals have a limited understanding of ABI and its impact on education (Linden et al., 2013; Howe & Ball, 2017). As a result, children and young people (CYP) with an ABI may not receive the level of support they require at school, ultimately affecting their developmental and educational outcomes. Within UK schools, support for CYP with additional needs is overseen by the Special Educational Needs Coordinator (SENCo). The aim of this study was to explore whether these professionals had knowledge of childhood ABI and had received training on how to effectively support CYP with ABI in school.

Method

Fifty-four SENCos took part in the study and were asked to complete a survey to establish their knowledge of and misconceptions about childhood ABI; their experience of working with ABI; their opportunities for training; and their perspectives on how knowledge/training about ABI for teachers could be improved.

Results

SENCos showed limited knowledge of childhood ABI. This was reflected in the number of misconceptions held and the proportion of SENCos highlighting significant gaps in training. Qualitative analysis identified 5 core areas for training development. The study also identified an issue regarding access to funding for CYP with ABI, with 20% of participants stating it was “difficult” and 40% “extremely difficult” to obtain funding.

Conclusions

Findings demonstrate a need for training on childhood ABI within education. The SENCos participating in the study had rarely received training, and there were significant gaps detected in their understanding of ABI. Gaining funding to meet a CYP's new needs was also identified as a challenge for SENCos, perhaps due to their limited knowledge of the condition and the lack of awareness of ABI in the wider education and Local Education Authority systems. The study emphasizes the need for further research to identify barriers to funding and for statutory training for SENCos who, statistically, are likely to work with high numbers of CYP with ABI across their careers.

22 Active-8 Your Brain: A Physical Activity Intervention for Young People With an Acquired Brain Injury in COVID—Times and Beyond

Emily Bennett; Eleanor Williams; Sophie Thomas

Nottingham Children's Hospital, Nottingham, United Kingdom

Background and Aims

Clinical work with young people (YP) with an acquired brain injury (ABI) highlighted concerns about reduced levels of physical activity (PA). Despite being very active before their ABI, many are unable to participate in sports they previously enjoyed, or find participation more challenging due to physical and cognitive impairments, and ongoing fatigue. This results in decreased fitness, weight gain, increased frustration, and limited exposure to the social and emotional benefits of PA. Given the potential gains of regular exercise for mood, cognition, fatigue, and sleep (eg, Mabbot et al., 2014), it was anticipated YP with an ABI would benefit from rehabilitative support to increase PA. We describe an 8-week intervention for YP aged 11 to 18 years that aims to increase post-ABI PA. Case examples of delivery in person and remotely during the COVID-19 pandemic are used to highlight the benefits, challenges, and adaptability of PA interventions for this population.

Method

Nine YP aged 11 to 18 years took part in an intervention to increase PA; 2 during the COVID-19 pandemic. They were given a Fitbit and asked to track their PA over a 2-week baseline period. YP were then seen by a psychologist for an intervention session and supported in setting goals targeting their PA levels. Participants completed an 8-week intervention, which included weekly contact to set goals and to discuss progress and challenges. YP and parents completed questionnaires both pre- and postintervention. During COVID-19, the intervention was delivered remotely. Two case examples are presented to illustrate the intervention and results.

Results

Participants generally engaged well and selected a range of activities to set goals around. All completed the intervention and said they would recommend it to others. Qualitative feedback highlighted positive outcomes, and YP reported being physically active was more important to them after completion. Parents also found the program valuable. Case examples highlight clear benefits and transferability to remove delivery. A number of challenges to a PA-focused intervention for the ABI population were identified.

Conclusions

Initial findings demonstrate the potential value of intervention aimed at increasing PA levels post-ABI. Case examples highlight important benefits and challenges within this population. Experiences of remote delivery during the COVID-19 pandemic are discussed.

24 Serum Serotonin Levels Following Pyruvate Treatment in Rats With Combined Blast TBI and Stress

Pushpa Sharma

Uniformed Services University of the Health Sciences, Bethesda, Maryland, United States

Background

According to the Department of Defense and the Veterans Brain Injury Center, 22% of all combat casualties from the recent Afghanistan and Iraq conflicts are blast-induced mild traumatic brain injuries (bTBIs) and often result in posttraumatic stress disorder (PTSD)–like symptoms including mood disorders and cognitive impairments. The intriguing question is “Why not all soldiers with mTBI have PTSD”? Although it is widely reported that a serotonin deficiency plays a role in increased depression, the relationship of serum serotonin with PTSD-like symptoms following blast TBI has not been examined before.

The objectives of this study were to (1) understand the effects of combined stress and bTBI on serum serotonin levels, and (2) examine if an increase of serotonin with sodium pyruvate can attenuate and treat the effects of bTBI and stress.

Methods

Adult male Sprague-Dawley rats were exposed to (1) stress alone—stress by our military relevant stress paradigm method; (2) stress + blast (10 psi × 3) by blast overpressure to induce a mild TBI. Rats in these 2 treatment groups received sodium pyruvate (1 g/kg every 24 hours); (3) continued treatment until 7 days postinjury, followed by 3 weeks of pyruvate washout period; and (4) continued treatment until 27 days postinjury. Control animals received the same volume of distilled water. Rats were also subjected to neurobehavioral tests till the end of the study. Blood collected at various time points was analyzed for serum serotonin. Brain and intestines were also examined for serotonin levels.

Results

Serum serotonin was significantly reduced in the presence of stress ± TBI. This effect was reversed by pyruvate treatment. Intestinal serotonin was significantly increased in stressed animals and reduced in rats with TBI. Pyruvate normalized these serotonin levels. Serotonin levels were differently expressed in prefrontal cortex and hippocampus areas, suggesting the role of brain parts in memory and cognitive deficits following TBI and stress. Long-term with short-term pyruvate: Veterans Administration differs over time; at day 3, nonblasted animals had less depression than animals followed at day 27.

Conclusions

Regular monitoring of serum serotonin levels following TBI can predict the severity of stress-related symptoms, and short-term neuroprotective effects of pyruvate in reducing the stress-related symptoms of TBI cannot be underestimated.

25 Craig Hospital's Neurobehavioral Rehabilitation Program

Arielle Reindeau; Ashlee Beaner

Craig Hospital, Englewood, Colorado, United States

Rehabilitation hospitals that facilitate the care of patients with traumatic brain injuries are faced with a number of challenges. Hospital staff must ensure patient safety, educate family members, and promote environments that aid patient progress. Challenging behavior in the acute rehabilitation setting can impede both learning and functioning during a crucial time in patient recovery. Craig Hospital's Neurobehavioral Rehabilitation Program is pioneering evidence-based behavior management within the acquired brain injury (ABI) population. Through this program, Craig is reshaping how staff, families, and patients work to proactively increase adaptive behaviors that allow the recovery process to be maximized. During this interactive presentation, Arielle Reindeau, BCBA, and Ashlee Beaner, BSN, RN, CWOCN, will provide participants with tools and strategies to manage behavior throughout their settings. This presentation will review behavior planning, evidence-based interventions, and data collection to support methods throughout the recovery process.

26 Age at Injury as an Important Variable for Understanding Depression and Decision-Making Outcomes Following Mild Head Injury

Smit Patel; Sean Robb; Dawn Good

Brock University, St Catharines, Ontario, Canada

Objective

Interruptions to neurodevelopment that result from traumatic brain injury (TBI) often add considerable complexity to the interpretation of neuropsychological findings postinjury in clinical practice. While initial rehabilitative targets focus primarily on physical functioning postinjury, long-term life satisfaction has been linked to social reintegration. Two threats to effective social reintegration include depressive symptoms and changes in decision-making. The orbitofrontal cortex (OFC), a structure that is vulnerable to injury during mild head injury (MHI), has been functionally implicated in both of these sequelae postinjury and documented as having a late developmental maturation. Injury to the OFC has been linked to impaired regulation of autonomic physiological arousal (Hiser & Koenigs, 2017), resulting in physiological underarousal as a measure of electrodermal activation (EDA). Our laboratory has demonstrated a robust finding of autonomic underarousal following MHI (Baker & Good, 2014; Noordt & Good, 2011) and linked this to (1) reduced learning on measures of decision-making during conditions of uncertainty, (2) reduced sensitivity to punishment (Robb & Good, 2015), and (3) greater endorsement of somatic relative to affective depressive symptoms (Robb & Good, 2018). Given the development of the OFC continues well into early adulthood, the behavioral and cognitive consequences following TBI are likely to differ depending on the age the injury took place (Karver et al., 2012). Despite greater plasticity in the nervous system being associated with earlier development (ie, Kennard principle), previous evidence suggests that earlier injury to frontal systems is associated with more substantive behavioral and cognitive challenges than later injuries (eg, Anderson et al., 1999). This research serves to characterize depressive symptoms and decision-making processes as a function of age at injury for persons with MHI and contrasts this to persons without a history of MHI.

Methods

Eighty-six Brock University students (35% with MHI) were recruited to complete multiple neuropsychological assessments and self-report questionnaires. Measures of autonomic arousal (EDA), decision-making (IGT), depression (BDI-II), and MHI history including age at injury were collected during this study.

Results

Individuals with a history of MHI displayed reduced EDA at baseline, reduced sensitivity to punishment, and greater somatic depressive symptoms. Individuals who sustained their MHI earlier in development (between 0 and 15 years of age) exhibited lower EDA and greater insensitivity to punishment on the IGT than those who sustained their injuries later in development (ages 16-25 years). Finally, those with earlier injuries endorsed more affective depressive symptoms, whereas those with later injuries reported more somatic depressive complaints.

Conclusions

Collectively, these findings demonstrate that age at injury is an important variable for clinical consideration as it relates to the assessment of depressive symptoms and decision-making, with earlier injuries being associated with worse outcomes. These findings parallel research depicting OFC developmental maturation.

27 Sensation-Seeking and Mild Head Injury: Relationships Among Athletic Status, Injury Characteristics, and Different Aspects of Sensation-Seeking

Caitlyn Gallant; Francesco Amodio; Dawn Good

Brock University, St Catharines, Ontario, Canada

Objectives

Previous investigations have demonstrated that certain personality traits, such as sensation-seeking and impulsivity, increase the risk that one will incur a traumatic brain injury (TBI; Liebel et al., 2021). Specifically, this relationship is well established in the context of high-risk sports, where it has been shown that those with a greater propensity toward sensation-seeking are more likely to participate in high-risk sports and more vulnerable to sustaining a TBI (Liebel et al., 2020). Nonetheless, it has also been demonstrated that concussive injuries and subconcussive exposure are associated with physiological underarousal (Gallant et al., 2020) and that these autonomic changes can increase one's tendency to engage in thrill-seeking behaviors (Alcock et al., 2018). Therefore, the purpose of this study was to further investigate the relationships among athletic status, mild head injury (MHI), and sensation-seeking.

Methods

University students (N = 228; mean age = 20.05 years; 83% female), with (42.1%) and without (57.9%) a reported history of MHI participated in this research. Thirty-nine percent of participants were athletes (low-risk: 66.3%; high-risk: 33.7%), participating in university sports at the time of study completion. Participants completed the Sensation Seeking Scale (SSS-V; Zuckerman, 2007) to assess different facets of sensation-seeking (eg, disinhibition, thrill and adventure seeking, experience seeking, and boredom susceptibility) and a demographic questionnaire that provides information about participants' head injury and athletic histories.

Results

Participants with a history of MHI were found to have higher total sensation-seeking scores than their noninjured counterparts (t226 = 3.32, P = .001) and injury severity was positively associated with sensation-seeking (r228 = 0.25, P < .001). Specifically, those with more severe injuries had higher scores across all subscales of the SSS-V, and these relationships persisted when controlling for age, sex, and athletic status. In contrast, high-risk athletic status was not associated with higher levels of sensation-seeking across all subscales, nor was athletic status in general (ie, athlete vs nonathlete). Furthermore, when athletes and nonathletes were examined independently, injury severity was only associated with the Disinhibition subscale of the SSS-V among nonathletes, while it was related to all SSS-V subscales (except for the Disinhibition subscale) among athletes.

Conclusions

Taken together, these findings indicate that MHI status is associated with sensation-seeking and that those with more severe injuries have the highest postinjury levels. Thus, elevated levels of sensation-seeking in athletes may act as a risk factor for MHI; however, among athletes preexisting tendencies toward sensation-seeking may be amplified by TBI. Overall, these results imply that sensation-seeking may be a risk factor for MHI and a symptom postinjury.

28 Investigating Cannabis Use in Individuals With a History of Mild Head Injury and a Psychiatric Condition

Rachel Luczon; Dawn Good

Brock University, St. Catharines, Ontario, Canada

Objective

Several studies have found that following traumatic brain injury (TBI), individuals can experience impaired ability to manage and regulate emotional responses toward negatively valenced stimuli, and this emotion dysregulation is reflected in both their ability to cognitively evaluate the stimuli and physiologically/autonomically respond to an emotionally provocative stimulus (eg, Neumann et al., 2014; Aboulafia-Brakha et al., 2016). This challenge is amplified in persons with various mental health issues, an additional symptom response in persons with TBI (Lew et al., 2008). Given the recent legalization of recreational cannabis in Canada (Potter & Weinstock, 2019), European countries, and several states in the United States, the objective of this study was to examine cannabis use severity in persons with a history of mild head injury (MHI) and/or a diagnosed psychiatric condition. Furthermore, this study examines whether those with both a history of MHI and a diagnosed psychiatric condition demonstrate different cannabis use patterns compared with those with an MHI, psychiatric condition, or neither.

Methods

Using a cross-sectional design, 84 participants (mean age = 21.9 years) were recruited from Brock University. Fifty-one percent reported neither a history of MHI nor a psychiatric diagnosis; 14% reported MHI only; 18% psychiatric diagnosis only; 17% reported a history of both. Of those with MHI, 48% experienced their injury pre-16 years of age. Participants answered questions from the Everyday Living Questionnaire regarding their history of health, head injury, and cannabis use patterns. Cannabis use severity was examined within the context of a history of MHI and/or diagnosed psychiatric condition.

Results

Analyses showed that the groups varied significantly in terms of their severity of use. More specifically, those with a history of MHI or a psychiatric condition reported greater cannabis use severity than those without (27%). Moreover, those with both a history of MHI and psychiatric condition report the greatest use of cannabis (at a rate of 79%) compared with those with only MHI, psychiatric condition, or neither.

Conclusion

Overall, individuals with a history of both MHI and psychiatric conditions demonstrated greater cannabis use than those with MHI, psychiatric condition, or neither. This is particularly concerning, given that greater cannabis use has been associated with an increase in psychiatric symptoms (Degenhardt et al., 2003; Lev-Ran et al., 2013). Furthermore, past research has found that those with an MHI are more likely to use cannabis to ameliorate symptoms of MHI despite reporting exacerbated symptoms (Gallant et al., 2020). The results from this study implicate that those with a history of MHI and a psychiatric condition may be using cannabis to cope with their symptoms when, in turn, cannabis use may result in the opposite effect.

30 “Communication and Cooperation”: Hearing the Voices of Parents to Improve Return to Education After Childhood ABI

Emily Bennett1; Alison Fletcher1,2; Emily Talbot1; Louise Robinson1

1Nottingham Children's Hospital, Nottingham, United Kingdom; 2The Children's Trust, Tadworth, United Kingdom

Background

Returning to education (RtE) after a moderate or severe acquired brain injury (ABI) can be one of the most challenging stages in a child's rehabilitation. Parents play a crucial role in the process, and hearing their lived experience can prove invaluable to professionals and teachers hoping to effectively support the return. While there is much that can be done to facilitate an effective RtE, there has been limited exploration of the experiences and views of parents about what can both help and hinder the process. A service evaluation was designed to capture the views of parents who had recently supported their children with RtE to inform future service provision, pathway development, and to add parent voices to the currently sparse evidence base.

Methods

A service evaluation was completed to explore the views of parents/carers of children and young people with ABI, about the process of returning to education, and the support they received from healthcare professionals at a regional center in the United Kingdom. Questionnaires were sent to parents of patients treated for an ABI in the last 2 years (N = 60). The evaluation focused on core themes around the process of returning to education and the level of support required and received by the child/young person, the nature and utility of assistance received from different professionals and services, participation and integration in school life on return, and the key challenges and positives experienced.

Results

Thirty-one parents (response rate = 52%) returned the questionnaires. Their children were aged between 5 and 18 years, and all had sustained an ABI over 6 months ago. Quantitative data collected provide an overview of the nature of post-ABI difficulties, the amount of school missed, and the support required on return to school. Thematic analysis was conducted on the qualitative responses to questions about the challenges and successes within the RtE process and advice they would offer other parents. Five key themes emerged, which offer insight into the changed roles of parents, the challenges of newly acquired difficulties, and the importance of communication with school and ABI professionals.

Conclusions

Parents/carers offer crucial insight into the challenges of the RtE process. Their lived experience highlights important factors for service development and reminds professionals of the key components of an effective return.

32 Single-Case Series Evaluation of a Novel 12-Week Treatment of Persistent Postconcussion Symptoms After Mild Traumatic Brain Injury

Jack Nguyen1; Adam McKay1,2; Jennie Ponsford1,2; Katie Davies3; Michael Makdissi4,5; Sean Drummond1; Jonathan Reyes1; Jennifer Makovec Knight1; Tess Peverill3; James Brennan4,5; Catherine Willmott1,2,5

1Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Victoria, Australia; 2Monash-Epworth Rehabilitation Research Centre, Melbourne, Victoria, Australia; 3Neurological Rehabilitation Group, Melbourne, Victoria, Australia; 4Olympic Park Sports Medicine Centre, Melbourne, Victoria, Australia; 5Australian Football League, Melbourne, Victoria, Australia

Objectives

To evaluate the feasibility and preliminary efficacy of a novel interdisciplinary intervention that incorporates neuropsychology, physiotherapy, and medical treatments to reduce persistent postconcussion symptom (PPCS) severity.

Methods

A nonconcurrent single-case experimental design with 1- and 3-month follow-ups and randomization to multiple baseline lengths (2, 4, or 6 weeks) was repeated across 15 participants (53% female) with mild traumatic brain injury (mTBI) (mean age = 38.27 years, SD = 15.68; mean time since injury = 112.33 days; range, 30-373 days). The 12-week treatment, iRECOveR (Interdisciplinary REhabilitation for COncussion Recovery), incorporated goal-setting, psychoeducation, activity scheduling, anxiety management training, and sleep intervention, within a cognitive-behavioral framework, as well as medical review and management, and movement, exercise, and manual therapy targeted toward oculomotor, vestibular, cervical, and autonomic systems. Target behavior was severity of postconcussion symptoms, assessed via the Rivermead Post-Concussion Symptoms Questionnaire, 3 times weekly during baseline and treatment phases. Secondary outcomes included measures of mood, sleep and fatigue, physical functioning, health-related quality of life, and illness perceptions. Primary and secondary outcomes were assessed at baseline, pretreatment, posttreatment, and 1- and 3-month follow-ups. Goal attainment scaling (GAS) was used during the treatment to measure personally meaningful goals. Feasibility of the intervention was measured by recruitment and retention rates, treatment adherence, proportion of completion of treatment sessions, and rates of engagement with weekly homework. Data were analyzed visually and statistically. Participant experiences of the trial were explored through qualitative interviews.

Results

iRECOveR was found to be feasible in terms of engagement. For preliminary efficacy, analysis of the 15 cases showed moderate-large effect sizes in reducing PPCSs in 12 of 15 cases, although only 7 reached statistical (Tau-U) and clinical (visual analysis) significance. These improvements were maintained at 1- and 3-month follow-ups and were accompanied by reductions in fatigue, sleep difficulties, symptoms of depression, anxiety, and stress, and illness perceptions. All participants had clinically significant improvements in at least one outcome, with 81% of individual therapy goals achieved using GAS.

Conclusions

Results suggest that iRECOveR may reduce PPCSs severity and/or mood, fatigue and sleep difficulties and improve physical functioning, return to activity, health-related quality of life, and illness perceptions. While most participants endorsed some residual postconcussion symptoms at posttreatment and at follow-up time points, responses to qualitative interviews and GAS demonstrated that goals were attained, suggesting that while symptom reduction is not always achieved, other areas of function can improve (eg, increases in activity, participation, and ability to manage symptoms). Findings underscore the potential benefit of coordinated treatments in reducing PPCS burden and contributing to functional goal attainment. This pilot data will inform the trial design of a phase II randomized controlled trial.

33 Validation of the Yale Swallow Protocol in Traumatic Brain Injury: A Prospective Videofluoroscopic Study

Justin Weppner1-3; Stephanie Jackson1; Michelle Marks1

1Carilion Clinic, Roanoke, Virginia, United States; 2Virginia Tech Carilion School of Medicine, Roanoke, Virginia, United States; 3Edward Via College of Osteopathic Medicine, Blacksburg, Virginia, United States

Introduction

Laryngotracheal aspiration of food and liquid can increase mortality rates, reduce the quality of life, and increase economic costs in persons with traumatic brain injury (TBI). The Yale Swallow Protocol (YSP) is a pass or fail tool used to identify those who require a comprehensive swallowing assessment. The YSP comprises a 3-ounce (oz) water swallow challenge, a brief cognitive assessment, and an oral mechanism examination. A pass is scored when the participant drinks the entire 3 oz without coughing or choking during or immediately after completion.

Objective

This prospective, multirater validation study aimed to investigate agreement for aspiration risk between videofluoroscopic swallow studies (VFSSs) and the YSP in individuals with moderate-to-severe TBI.

Design

Participants were 50 consecutive adults (≥18 years old) with acute moderate-severe TBI, defined as the highest Glasgow Coma Scale (GCS) score of less than 13 in the first 24 hours after injury, who were referred for dysphagia testing. Exclusion criteria included the presence of a tracheostomy tube and the inability to participate in dysphagia testing. All participants were administered the YSP by 2 experienced speech-language pathologists trained in protocol administration. Failure criteria were inability to drink the entire amount, interrupted drinking, or coughing during or immediately after drinking. Following YSP administration, all participants immediately completed a VFSS. A speech-language pathologist and a radiologist, blinded to protocol results, reviewed the VFSS to determine aspiration status in a binary (yes/no) manner.

Results

Interrater agreement for thin-liquid aspiration was 100% for the speech-language pathologist and the radiologist on VFSS. Interrater agreement for thin-liquid aspiration was 100% for the 2 speech-language pathologists on the YSP. Sixteen participants passed, and 34 failed the 3-oz water swallow challenge part of the protocol. Of the 34 individuals who failed the protocol, 30 aspirated on VFSS (true-positives) and 4 did not aspirate on VFSS (false-positives). Sensitivity for the YSP = 96.7%, specificity = 78.9%, positive predictive value = 88.2%, and negative predictive value = 93.8%. Among participants, longer acute hospital length of stay and lower best GCS score in the first 24 hours of hospitalization were associated with dysphagia (P = .03 and P = .046, respectively).

Conclusions

The YSP is an effective screening tool for clinically relevant dysphagia in patients with moderate-to-severe TBI. The strength of the YSP lies in its substantial negative predictive value (93.8), meaning that patients who pass the protocol have a 6.2% chance of aspirating on VFSS. The prospective data from this study indicate that the YSP can be a reliable and valid option to screen for aspiration risk in the acute care setting. Future research is needed with a larger sample to understand better the patient characteristics for persons with TBI who pass bedside swallow studies but fail the VFSS.

34 Improving Care Coordination Following Pediatric TBI: Results From a Scoping Review and Interviews With Key Stakeholders

Jennifer Lundine1,2; Susan Davies3

1Department of Speech and Hearing Science, The Ohio State University, Columbus, Ohio, United States; 2Nationwide Children's Hospital Division of Clinical Therapies & Inpatient Rehabilitation Program, Columbus, Ohio, United States; 3Department of Counselor Education & Human Services, University of Dayton, Dayton, Ohio, United States

Objectives

More research is needed in the field of pediatric traumatic brain injury (TBI) to direct coordination of care throughout short- and long-term recovery.

Methods

This presentation focuses on 2 related projects that address this research-to-practice gap. The first project was a large scoping review aimed at summarizing the current body of research related to care coordination for children with special healthcare needs (CSHCN) to help inform future clinical and research activities for youth with TBI. The review followed the PRISMA framework and methodology for scoping reviews (PRISMA-ScR), with searches in the following databases: OVID/MEDLINE, CINAHL, PsycINFO, EMBASE, and ERIC, using the specific search terms related to our topic. The second project involved semistructured interviews with key stakeholders to gather their perspectives and describe their experiences related to care coordination for children with TBI.

Results

A total of 2498 articles were identified for the scoping review and included articles were divided into 3 distinct groups focusing on studies examining care coordination for CSHCN and their relationship to school (n = 12), care coordination tools (n = 21), and care coordination personnel (n = 31). Care coordination interventions for CSHCN used in educational settings focused on relationship-building strategies, clear procedures and roles, and education of members of the school community. Studies examining telehealth, online tools, care plans, and family training care coordination interventions for CSHCN have shown positive outcomes and would be relevant strategies to improve the care of children with TBI. Implementation of care coordinators, whether in the form of individuals, dyads, or teams, resulted in overall positive outcomes for CSHCN and their families across the following domains: healthcare utilization, cost of care, disease status, parent and child quality of life, and healthcare satisfaction and perception of care. The second project involved interviews of 21 individuals representing key stakeholders who shared their perspectives and experiences related to care coordination for children with TBI. Participants represented Canada and 10 states within the United States. On average, they reported 20.5 years of experience related to pediatric TBI. Participants represented the following groups: survivor of TBI, caregiver of young person with TBI, physiatrist, allied health (physical therapy, occupational therapy, speech-language pathology), social work, school personnel (nurse, special education professional), researcher, and neuropsychologist. Themes identified from these interviews reflected barriers to effective treatment, care coordination, and education and strategies that could improve care coordination for youth with TBI.

Conclusions

Together, these projects align to provide a pathway for future clinical and research work that aims to improve care coordination for children with TBI. As demonstrated in research focused on CSHCN, improving care coordination for children with TBI has the potential to lessen the long-term challenges families and survivors experience and reduce the gaps in medical, rehabilitation, and educational support.

35 Teachers' Understanding of the Prevalence and Needs of Children With Acquired Brain Injury in a UK Primary School—A Small-Scale Evaluation

James Tonks; Harriet Dismore

University of Exeter Medical School/Haven Clinical Psychology Practice, Bude, United Kingdom

Acquired brain injury (ABI) is highly prevalent in childhood. In the longer term, these children are at 4-fold increased risk of severe mental disorder in adulthood, with coexisting offending behavior occurring in males (Timonen et al., 2002). As adolescents they are significantly more likely to engage in difficult to manage socioemotionally challenging behavior (Tonks et al., 2009). Teachers' understanding of the condition is reportedly poor despite the high prevalence of children with history of ABI in schools and the special educational needs (SEN) that these children have during development (Linden, Braiden & Miller, 2013; Ettel et al., 2016).

The aim of this evaluation was to explore teachers' understanding of childhood ABI in terms of its prevalence and how well teachers perceive that schools and wider services support these children. A questionnaire was administered to 13 teachers in a large UK primary school. The school was fairly representative, with 17.5% of children placed on the Record of Need, 2.3% of children receiving an Education Health Care Plan (EHCP), with the remaining 15.3% identified with SEN. This compares with the national average published by the Office for National Statistics (2021), which indicates that 12.2% of all pupils have SEN, with 3.7% of all pupils having an EHCP.

Consistent with existing findings, analysis of both quantitative and qualitative responses indicates that the teachers were not aware that ABI is highly prevalent. They were aware of less subtle effects of injury that might alert them, such as epilepsy, or problematic behavior, but they were less aware of the need for caution in relation to hidden effects of injury that would apply to primary school-aged children. They felt that they would be able to identify children with ABI and converse to the evidence base (Tonks et al., 2009, 2017). Most thought that education and health services (including child and adolescent mental health services) are providing reasonable support. Positively, when given the example of poor outcome in terms of childhood ABI history being overrepresented in prison populations (as reported by Timonen et al., 2002; Williams et al 2010), respondents did intuitively recognize that poor outcome could be linked to poor understanding and lack of early support, and they recognized that there is neurodevelopmental and psychological risk associated with lack of support. In conclusion, the teachers participating in this evaluation did demonstrate that they lacked knowledge of the issues, highlighting the need greater resources and training in managing the additional challenges they face in appropriately supporting children with ABI history in primary schools. In a context where childhood ABI is associated with such poor outcome, there was both a lack of awareness of the neurodiverse needs that this group have and the lack of awareness that further specialist training is needed.

36 A Systematic Review of Context-Specific Neuropsychological Interventions for Children and Young People With Brain Injuries

Nicola Birdsey1; Peter Tucker2; Alex Pass1; Mhairi Kristoffersen1; Josie Millar1

1University of Bath, Bath, United Kingdom; 2Recolo UK Ltd, London, United Kingdom

Background

Neuropsychological support for children with brain injuries has traditionally involved individualized interventions that focus on specific aspects of functioning in isolation. This singular focus places expectations on the child to generalize this new learning to other areas of functioning and everyday settings. In recent years, clinical neuropsychologists have recognized the importance of delivering interventions that are embedded in meaningful social contexts and involve others from the individual's support system. However, limited attention has been given to context-specific interventions in the pediatric literature, and the evidence base for the effectiveness of contextually situated interventions remains unclear.

Objective

This study sought to review the evidence base for context-specific neuropsychological interventions that seek to improve functioning in children with brain injuries.

Method

Systematic searches of PsychNET, PubMed, and Web of Science identified 3625 studies, with 21 studies meeting inclusion criteria. All studies were independently screened by 2 reviewers at both title and abstract and full-text review. A quality assessment was undertaken by 2 independent reviewers. A narrative approach was used to synthesize the findings.

Results

A total of 1272 children and young people with brain injuries were included in this review (mean age: 10.95 years). Nine studies were randomized controlled trials, and 2 studies employed a quantitative descriptive case series design. Studies were identified across 6 domains: attention and memory (n = 2), executive function (n = 5), cognition (n = 4), behavior (n = 8), family functioning (n = 2), and social competence (n = 2).

Conclusion

This review indicates that there is a growing evidence base for the use of neuropsychological interventions being undertaken in meaningful social contexts. However, a number of factors preclude firm conclusions from being drawn with regard to efficacy. Primarily, there are a small number of studies in each neuropsychological domain, along with the lack of consistency in outcome measures, the absence of follow-up data across studies, and the limited reporting on effect sizes. Further high-quality longitudinal research is therefore needed to fully demonstrate the value of context-specific neuropsychological interventions to improve functioning across different domains in children with brain injuries.

37 TEaM Pilot Study on Screening for Pediatric mTBI in Emergency Departments

Alex Hall2; Juliet Haarbauer-Krupa1; Rachel Bull2; Jonathan Ratcliffe2; Shabnam Jain2,3; Hal Simon2; Gerry Gioia4; Paula Tucker5; Dan WU6; David Wright2

1Division of Injury Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, United States; 2Emory University School of Medicine, Atlanta, Georgia, United States; 3Children's Healthcare of Atlanta, Atlanta, Georgia, United States; 4Children's National Hospital, Washington, District of Columbia, United States; 5Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia, United States; 6Grady Memorial Hospital, Emory University School of Medicine, Atlanta, Georgia, United States

Children have the highest rate of emergency department (ED) visits for traumatic brain injury (TBI) of all age groups. An injury of any severity to the developing brain can disrupt a child's developmental trajectory and may result in restrictions in school classwork requirements and participation in activities such as sports and extracurricular clubs and projects. As a result of a TBI of any severity, children may experience changes in their health, thinking, and behavior that affect learning, self-regulation, and social participation, all of which are important in becoming a productive adult. Unlike other developmental health conditions in children who are diagnosed at birth, TBI is an acquired condition that can occur anytime during childhood, with the potential for a sudden alteration in development.

Emergency physicians are often the initial, and only, clinical providers for patients who have sustained a mild traumatic brain injury (mTBI). Previous research on adults older than 18 years suggests that 30% to 50% of the mTBIs presenting to the ED go undiagnosed. A recent study found that a screening instrument integrated in ED triage observed 38 621 individuals at high risk for mTBI, and only 50% of those were subsequently diagnosed with mTBI. In the current study, the primary objective was to determine if these findings were consistent in a pediatric population by evaluating the frequency of a documented mTBI evaluation, initial diagnosis, discharge plans, and parent education among children identified as being at high risk for mTBI according to an integrated screening instrument at triage.

At a pediatric level 1 trauma center, triage nurses screened children using 2 simple questions: “Did an injury occur?” and “Was the mechanism consistent with mTBI?” If the 2 questions were positive, a third question was asked: “Was there a period of altered mental status?” Patients were considered at high risk for mTBI if all responses were positive. Data were abstracted from the electronic medical record. Triage screening results, patient characteristics, clinician characteristics and documentation, and disposition features were analyzed. Patient characteristics included age, sex, race, primary language, payer type, and disposition (ie, hospital admission, discharge to home). Clinician characteristics and documentation included practice location (ie, ED physician, urgent care physician, pediatrician), mTBI evaluation (ie, history and physical), diagnoses (ie, concussion, nonspecific head injury), and delivery of discharge education.

This session describes pilot study findings and implications for healthcare provider diagnosis and care management of children who experience a concussion and present to the ED.

38 Stakeholder Perspectives on Navigating the Pediatric Concussion Experience: Exploring the Needs for Improved Communication Across the Care Continuum

Douglas Gomez1; Ann Glang1; Juliet Haarbauer-Krupa2; Rachel Bull4; Paula Tucker4; Jonathan Ratcliffe4; Alex Hall4; Gerard Gioia3; Shabnam Jain5; Usha Sathian5; Harold Simon5; David Wright4

1University of Oregon, Eugene, Oregon, United States; 2Centers for Disease Control and Prevention, Atlanta, Georgia, United States; 3Children's National Hospital, Washington, District of Columbia, United States; 4Emory University School of Medicine, Atlanta, Georgia, United States; 5Children's Healthcare of Atlanta, Atlanta, Georgia, United States

Children receive care for concussion in a variety of settings depending on the level of acuity and time since the initial injury (Haarbauer-Krupa et al., 2017). Settings can include emergency departments, intensive care units, inpatient rehabilitation programs, primary care offices, outpatient rehabilitation services, and the educational system. The transition from medical care to school services is also characterized by substantial variability (CDC, 2018; Ennis et al., 2017). Returning to school and accessing services in the educational system are a unique transition for children. The majority of research to date has described the transition process from hospital to school for hospitalized children. (It has been shown that the return-to-school process is critical to positive outcomes and that a successful return to school requires integration between entities, specifically the hospital, parents, and the school; Dettmer et al., 2014.) Children who receive systematic transition services as part of their medical care are more likely to be identified for specialized support services at school and their parents report greater satisfaction with school support (Glang et al., 2008). It is important for the healthcare and school systems to communicate so that medical providers can offer information to schools about the injury diagnosis and child's health (Gioia, 2014). Currently, the CDC supports a project to better understand clinical decision support that includes an examination of discharge instructions for school-aged children (aged 6-17 years) from medical providers. As part of this project, the team conducted focus groups with stakeholders who received this information, including parents, educational personnel, school nurses, and athletic trainers. The focus groups inquired about the type of information received from medical providers at the time of injury diagnosis.

Data from focus groups were analyzed using a thematic analysis approach. The transcribed data were entered into a qualitative data analysis application (Dedoose, version 8.0.35). Consistent with Braun and Clarke (2006), researchers used an inductive (bottom-up) coding process, described semantic themes from a realist epistemology, and provided a rich description of the data set. The analysis began with an intensive review of transcripts to organize and code the data across stakeholder groups and settings. This analysis was iterative and, though codes were generated initially, the next step of the analysis involved the creation of overarching themes, for example, communication from healthcare providers, which were derived from the relationships between the initial codes. Themes were then discussed and augmented by the primary research group to arrive at formal titles and definitions for each theme.

The purpose of this session is to present the themes from these focus groups to better understand how to improve communication from medical providers about the concussion and the process of returning to school.

42 Evaluation of the Virtual Implementation of a Community-Based Support Program for People With Acquired Brain Injury Since the COVID-19 Pandemic

Tammy Kuchynski; Kimberly Turner

University of Ottawa, Montreal, Quebec, Canada

Context

The COVID-19 pandemic has necessitated a rapid transition to virtual care for community organizations providing essential supports to individuals with acquired brain injury (ABI) and highlighted the importance of better-understanding virtual service implementation.

Objectives

This evaluation examines the virtual implementation of the Personal Support/Independence Training (PSIT) program offered by Vista Centre Brain Injury Services (VCBIS) since March 2020. Specifically, we examined differences in staff time allocation, training and resources provided, the advantages, disadvantages, and satisfaction with virtual implementation.

Methods

We held 2 focus groups with staff members. Focus groups were audio recorded and transcribed for qualitative analysis. We examined administrative data from staff time sheets. A survey was distributed to clients through the online platform Qualtrics to examine their resource and training needs, level of computer anxiety, and satisfaction with the virtual program. Support to complete the online survey was provided.

Results

The evaluation revealed that the staff's training and resource needs were well met, but some clients continue to face barriers to accessing hardware, and many clients would benefit from increased training. Technical issues were difficult to address because of the variety of software platforms used.

Conclusions

Strengths of VCBIS's transition to virtual care included supporting staff's resource and training needs. Our main recommendations are for VCBIS to focus on providing clients with low-cost access to the hardware needed to participate in virtual care, to establish a unified software platform, and to provide additional small group and one-on-one training sessions with clients.

43 A Pilot Clinical Trial on Efficacy of Telerehabilitation Compared to In-Clinic Rehabilitation Program in Adults With Persistent Symptoms Following a Mild Traumatic Brain Injury

Pierre Langevin1,2,4; Philippe Fait3; Pierre Frémont1; Marc-Olivier Dubé1,2,4; Jean-Sébastien Roy1,4

1Université Laval, Quebec City, Quebec, Canada; 2Clinique Cortex, Quebec City, Quebec, Canada; 3Université de Québec à Trois-Rivières, Trois-Rivières, Quebec, Canada; 4CIRRIS, Quebec City, Quebec, Canada

Background

Mild traumatic brain injury (mTBI) is an acknowledged public health problem. Up to 25% of adult with mTBI present persistent symptoms. Headache, dizziness, nausea, and neck pain are the most commonly reported symptoms and are frequently associated with cervical spine and vestibular impairments. The most recent international consensus statement (2016 Berlin consensus) recommends the addition of an individualized rehabilitation approach for mTBI with persistent symptoms. The addition of an individualized rehabilitation approach including the evaluation and treatment of cervical and vestibular impairments leading to symptoms such as neck pain, headache and dizziness is then recommended and has been proven effective. Recently, the COVID-19 pandemic has led tele-consultations to seek healthcare professionals in primary care. The benefit of such a telerehabilitation approach compared with in-clinic rehabilitation program should therefore be further investigated.

Objective

The objective of this study was to compare the effects of an in-clinic cervicovestibular rehabilitation program combined with a symptom-limited aerobic exercise (SLAE) program with the same program in a telerehabilitation format in adults with persistent symptoms following mTBI on severity of symptoms and other indicators of clinical recovery.

Methods

In this parallel-group nonrandomized clinical trial, 40 adults with persistent symptoms following mTBI were assigned to (1) an in-clinic 6-week cervicovestibular rehabilitation program combined with SLAE program (n = 30) OR (2) the same program performed in a telerehabilitation format (n = 10). All participants took part in 4 evaluation sessions (baseline, weeks 6, 12, and 26) performed by a blinded evaluator. The primary outcome was the Post-Concussion Symptoms Scale (PCSS). The secondary outcomes were Numerical Pain Rating Scale (NPRS), Neck Disability Index (NDI), Headache Disability Inventory (HDI), Dizziness Handicap Inventory (DHI), and time-to-return to function. Nonparametric analysis for longitudinal data was used to evaluate the effect of interventions on outcomes.

Results

For the PCSS total score, and PCSS number of symptoms, there were group-by-time interactions at 6-month follow-up (P < .05); clinically significant time effects were observed for both groups (P < .05). There were group-by-time interactions at all time point follow-up for the global rating of change (P < .05) and the NPRS neck pain (P < .01) in favor of the in-clinic rehabilitation program. There were no group-by-time interactions for other outcome measures.

Conclusion

The study indicates that an in-clinic cervicovestibular rehabilitation combined with SLAE program was superior to the same telerehabilitation program in terms of symptoms improvement and global rating of change in mTBI with persistent symptoms. However, other outcome measures were equally improved after either the in-clinic or the telerehabilitation program. These results must be interpreted with caution, given the limited number of participants in the telerehabilitation group and the nonrandomized group allocation.

44 Enabling Participation in Children and Young People With Acquired Brain Injuries and Their Families—A Mixed-Methods Study—Preliminary Results

Rachel Keetley1,2; Joseph C. Manning1,2; Jane Williams2; Iain Stewart3; Kathryn Radford1

1University of Nottingham, Nottingham, United Kingdom; 2Nottingham Children's Hospital, Nottingham, United Kingdom; 3Imperial College London, London, United Kingdom

Introduction

Annually around 40 000 children and young people (CYP) in the United Kingdom sustain an acquired brain injury (ABI). Many experience significant, lifelong impairments that impact on physical and psychological development, health-related quality of life (HRQoL), educational achievement, and social participation. We aimed to explore the longer-term needs of CYP with ABI aged 5 to 18 years and their families in one region of the United Kingdom.

Patients and Methods

Mixed-methods study. CYP aged 5 to 18 years with ABIs and their parents were recruited through a regional specialist pediatric neurorehabilitation service. A cross-sectional survey consisting of demographic questions and standardized measures of pediatric HRQoL (PedsQL) and participation (CASP), parental HRQoL and family functioning (PedsQL-FIM), and parental anxiety and depression (Parental Health Questionnaire-4) was completed by the parent or CYP. Additional free-text questions captured parent and CYP goals and impact of COVID-19 lockdowns. Qualitative interviews were completed with a 20% subsample to gain more in-depth understanding of CYP and parental unmet needs, as well as facilitators and barriers to participation. Survey data were analyzed using descriptive statistics, and interviews were transcribed verbatim and analyzed using Framework analysis. Ethical approval was gained (REC-20/EM/0258) from the UK Health Research Authority.

Results

Ninety-five survey responses (response rate 30%) were received from 49 parents, 41 CYP, and 5 parent-proxy, representing 51 families. Forty-five percent of CYP respondents had had a brain tumor. Sixty-seven percent of CYP had impaired HRQoL (PedsQL median = 64.17; IQR = 43.33-78.33; range, 18.75-93.33), and the CASP indicated 72% had severely impaired social participation (CASP median = 80.63; IQR = 61.25-94.44; range, 35-100). More than half of parents (53%) reported reduced parental HRQoL and family functioning (PedsQL-FIM median = 56.25; IQR = 39.58-74.31; range, 16.67-100). According to PHQ-4 cutoff values, 37% of parents were at risk of anxiety, depression, or both (PHQ-4 median = 4; IQR = 2-6; range, 0-12). Parent and CYP goals were mapped to the International Classification of Functioning, Disability and Health: Child and Youth version (ICF-CY). Most goals mapped to Activity and Participation domains, with 93% for CYP and 83% for parents. “Recreation and leisure” goals were the top priority for both parents and CYP. Ten interviews were conducted with CYP-parent dyads. Preliminary key themes are the need for long-term key-worker support, support to identify new or unrecognized needs, reaccess to rehabilitation services, and specific needs around transition to adult services.

Conclusion

Preliminary findings highlight the long-term impact of ABI on CYP and family HRQoL and CYP social participation. Recreation and leisure activities are important goals for CYP with ABI and their parents. Rehabilitation should address both participation goals and the psychological well-being of CYP with ABI and their parents and access to services should be lifelong.

45 A Case Study in Complete Symptoms Resolution in Postconcussion Syndrome Following a 5-Day Multimodal Intensive Rehabilitation Program

Austin Jones

Plasticity Centers, Orlando, Florida, United States

The patient was a Caucasian, 45-year-old, left-handed, woman, who presented with an acquired brain injury. Her primary complaints included dizziness, difficulty with her balance, and severe headaches, which had negatively impacted her life. She stated that her symptoms began after she was involved in a 5 car accident in February 2015 and that there were no factors that caused her symptoms to become better or worse, but that they were always the same. Previous studies include MRI and Lyme testing. Previous care included physical therapy, vestibular therapy, medications, acupuncture, and exercise/strength training. Previous medical history included Botox injections, 2 right shoulder surgical procedures, a left wrist surgery, platelet rich plasma injections in her right shoulder, acupuncture, and steroid injections. Diagnostics were performed and consisted of vital signs with orthostatic challenges, CAPS (Computerized Assessment of Postural Systems), VOG (Video-Oculography), King-Devick, Saccadometry, C3 Logix out of the Cleveland Clinic (Standard Assessment of Cognition, Trails A, Trails B, Digit Symbol Substitution, Simple Reaction Time, Complex Reaction Time, Visual Acuity), and Cambridge Brain Sciences (Verbal Reasoning, Working Memory, Spatial Short-Term Memory, Visuospatial Processing, Deductive Reasoning, and Response Inhibition). A neurological examination was also performed, demonstrating color desaturation on the left eye, right square-wave jerks observed with ophthalmoscope and VOG, increased pinwheel sensation with V1 on the right, decreased pinwheel sensation with V3 on the left, left-side extensor weakness with the thumb, fingers, and finger abductors, bilateral decreased gain in manual VOR/Halmagyi testing, dysmetria finger-nose-finger testing, with bilateral below normal allotted inaccuracies with eyes closed finger-nose-finger testing, hypometric pursuits upward, hypermetric pursuits downward, decreased gain in optokinetics downward, 5 out of 10 in anti-saccade testing in the horizontal plane, in gait without dual tasking a decreased left arm swing, a postural waist strategy due to instability, gait with dual tasking demonstrated a slowing in stride length and freezing in posture, left eye suppression in near gaze, a physiologic tremor was observed, and the patient scored an 86 on her general symptom severity score. She was enrolled in a 5-day intensive multimodal brain optimization program that included HBOT (hyperbaric oxygen therapy), photobiomodulation, noninvasive neuromuscular electrical stimulation, neuromuscular reeducation, gaze stability exercises, vestibular therapy in a multiaxial rotational chair, and sensorimotor training and integration therapies. After the 5-day program, findings from the neurological examination moved within normal limits, there were no square wave jerks in observation with an ophthalmoscope, yet still present in a decreased form on her VOG, and her general symptom severity score decreasing from 86 to 0. While this result is outside of the normal result, it does warrant further investigation and implementation of intensive multiday and patient-specific multimodal therapies for brain injuries.

46 Creating Maps of Attention Using Virtual Reality for Brain-Injured and Spatial Neglect Patients

Michael Norwood1; David Ross Painter1; Chelsea Hannah Marsh1,2; Trevor Hine2; Daniel Harvie3; Susan Jones4; Ben Chen5; Kelly Dungey4; Marilia Libera6; Leslie Gan7; Julie Bernhardt8; Elizabeth Kendall1; Heidi Zeeman1

1The Hopkins Centre, Menzies Health Institute Queensland, Griffith University, Nathan, Queensland, Australia; 2School of Applied Psychology, Griffith University, Gold Coast, Queensland, Australia; 3Innovation, Implementation, and Clinical Translation in Health (IImpact in Health), Allied Health and Human Performance, University of South Australia, Adelaide, Australia; 4Neurosciences Rehabilitation Unit, Gold Coast University Hospital, Gold Coast, Queensland, Australia; 5Allied Health and Rehabilitation, Emergency and Specialty Services, Gold Coast Health, Gold Coast, Queensland, Australia; 6Psychology Department, Logan Hospital, Logan, Queensland, Australia; 7Rehabilitation Unit, Logan Hospital, Logan, Queensland, Australia; 8Florey Institute of Neuroscience and Mental Health, Heidelberg, Queensland, Australia

Objectives

To describe the results from a research program examining the feasibility of using virtual reality (VR) to map, in 3-dimensional (3D), a brain-injured patient's attention and spatial attention; to explore if VR can assess for hemispatial neglect; and to provide clinically relevant visual outputs.

Methods

Patients were consecutively recruited through 2 hospital rehabilitation departments in Southeast Queensland, Australia, and performance on the VR game was compared against healthy controls. Following consent, patients completed traditional pen-paper neuropsychological tests for neglect including the clock drawing, line cancellation, and letter cancellation. Later in the week, they completed the VR game. The game involved patients finding targets (L's) amongst distractors (T's) through various levels of a 3D VR space. Levels increased in difficulty through increasing the number of distractors and the field of vision required. Reaction time and accuracy data were collected. Attention maps were created by tracking eye-gaze, controller, and head set movement. Acceptability was measured through motion sickness and gaming experience surveys.

Results

All healthy controls and patients reported the VR as acceptable; motion sickness was minimal and enjoyment high. Patient and healthy control performance was significantly different on reaction times but not accuracy. Various analyses indicated the Attention Atlas was able to identify spatial biases in patients. Attention maps were a visually effective way to present a patient's spatial attention strengths and weakness to clinicians.

Conclusions

The Attention Atlas was an enjoyable, low-risk method for assessing for attention issues and for hemispatial neglect. The system identified patient outliers with potential attention problems, given normative control and patient data. The Attention Atlas produces a visual, clinically relevant assessment of a patient's spatial attention. Implications for improved assessment and rehabilitation for both patients and clinicians are significant. The Attention Atlas may be useful for more subtle cases of neglect, which may be more difficult to detect on pen-paper methods but that have significant impact on functional activities such as driving. This approach also suggests that VR can identify potential attention problems in those deemed intact by the current standard.

47 Constructing a Dutch Register on Childhood Aphasia

Femke Nouwens1; Ineke van der Meulen1,2; Robert Pangalila1; Gerard Ribbers2

1Rijndam Rehabilitation, Rotterdam, the Netherlands; 2Erasmus MC—University Medical Center, Dept. of Rehabilitation Medicine, Rotterdam, the Netherlands

Background

Aphasia is a language deficit resulting from brain damage. In adults, a third of patients with stroke acquire aphasia. Although rare, children with acquired brain injury can also suffer from aphasia. As this group is very heterogeneous regarding etiology, age, and level of language acquisition, little is known on the effectiveness of speech and language treatment (SLT) on acquired childhood aphasia (ACA). Randomized controlled trials are scarce, and large observational studies are lacking. Still, several studies in small groups show that ACA is a chronic condition, seriously impeding daily life. To improve care for children with ACA, we need accurate longitudinal data from a large group of children.

Objectives

To gain more insight into ACA, language recovery after ACA, the effect of SLT, and satisfaction with SLT.

Methods

In this longitudinal, multicenter, prospective, observational study with a follow-up of 5 years, we included children aged 2 to 18 years, who require SLT for acquired language or communication problems after brain injury. This is a national register, in which many Dutch centers treating children with ACA are participating. In the first stage of the study, we conducted a Delphi procedure among professionals of 23 Dutch healthcare institutions, yielding core outcome sets of language tests for 4 age categories. Data on etiology, language deficits, and SLT are collected through Gemstracker, a tool for online data collection.

In a pilot of 6 months, we tested and optimized online data collection. Online questionnaires on etiology, psychosocial, and SLT data were completed by parents and speech-language therapists. Language tests were conducted within a month of onset and 6 months later.

Results

The response rate was high: 86%. Eighteen children were included. ACA was caused by a stroke (n = 7), trauma (n = 7), epilepsy (n = 1), a tumor (n = 2), and one cause was unclear. More than 33% of the children had severe word-finding difficulties and were unable to communicate verbally. Six months later, 38% of the children improved in spontaneous speech and word finding, but none of them showed complete language recovery. Language performance deteriorated in 12% and remained stable in 50% of the children. More than 65% of the parents and children were satisfied with SLT and noticed a beneficial effect. ACA had a large impact on the families.

Conclusion

This Dutch database provides valuable and clinically relevant information on ACA. Parents were willing to participate in the study and reported good satisfaction with SLT. The finding that none of the children fully recovered after 6 months, together with the large impact of ACA on the families, shows the need to gain more insight into this condition. Thus, we need longitudinal data from a large group. More insight into ACA will help improve care for this significant and chronic impairment.

49 Treating Chronic Symptoms of Pediatric Acquired Brain Injury Through a Telehealth Intervention: A Feasibility Study of the Child in Context Intervention (CICI)

Ingvil L. Holthe1,2; Nina Rohrer-Baumgartner1; Edel J. Svendsen1,3,4; Anine P. Strand-Saugnes5; Solveig Lægreid Hauger1,2; Marit Forslund6; Ida Borgen2,6; Hege P. Øra1; Ingerid Kleffelgård6; Line Kildal Bragstad7,8; Shari L. Wade9,10; Marianne Løvstad1,2

1Sunnaas Rehabilitation Hospital, Nesodden, Norway; 2Institute of Psychology, University of Oslo, Oslo, Norway; 3Institute of Health and Society, University of Oslo, Oslo, Norway; 4Department of Nursing and Health Promotion, Oslo Metropolitan University, Oslo, Norway; 5Statped (Norwegian Service for Special Needs Education), Gjøvik, Norway; 6Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway; 7Institute of Clinical Medicine, University of Oslo, Oslo, Norway; 8Oslo Metropolitan University, Oslo, Norway; 9Division of Physical Medicine and Rehabilitation, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States; 10University of Cincinnati College of Medicine, Cincinnati, Ohio, United States

Background

Children with acquired brain injury (ABI) often struggle with multiple impairments, including cognitive, social, emotional, and behavioral challenges, yet there is a lack of evidence-based knowledge about rehabilitation. The current study was a feasibility study of a planned randomized controlled trial. The intervention was directed toward children with ABI and their families at least 1 year postinjury and aimed to enhance everyday functioning at home and in school by defining individualized rehabilitation goals and strategies.

Aims

The feasibility study aimed to evaluate adherence to the study protocol, child and caregiver acceptability of the intervention including usefulness of the SMART-goal-approach, recruitment procedures, burden of the assessment protocol, and videoconferencing in treatment delivery.

Methods

Six children, 12 parents, and 6 schools participated. The children (aged 11-16 years, 3 boys and 3 girls) had sustained a traumatic brain injury (2), anoxia (2), or brain hemorrhage (2) 1 to 13 years prior to the intervention. The families received a telerehabilitation intervention in the second half of 2020 consisting of 7 individualized sessions, 4 school meetings, and a parent seminar. Feasibility was assessed through detailed logs of the study and through a custom-made acceptability scale for the participating families and therapists (scored 0-4, lowest to highest).

Results

All families and schools had a 100% completion of the intervention. Every family but one achieved goal attainment as expected or better on all goals (mean 3 goals per family), whereas one family achieved 2 of 3 goals. The SMART-goal approach was rated as very useful (median = 4; range, 2-4). Families and therapists rated the intervention as feasible and acceptable compared with a priori defined criteria, including feasible treatment delivery through the telehealth solution. Compliance with the protocol was high as defined by detailed logs of the sessions (mean 96%). The parent ratings of working alliance and usefulness of the intervention was high (median score = 4; range, 3-4), whereas the children showed more variation (median = 3; range, 0.5-4). The burden of the assessments was deemed as high. The recruitment procedures were feasible but time-consuming. Both families and schools experienced the school intervention as very useful.

Conclusions

The child in context intervention proved to be feasible and acceptable for families, schools, and therapists, although with an extra focus on the engagement of the children. As the use of external strategies in cognitive rehabilitation of children with ABI tends to be the most reliable approach, it was considered acceptable and to a certain degree expected that the alliance and communication with the parents was superior to that of the children. Adaptations were made by reducing the number of questionnaires and neuropsychological tests as well as redefining primary outcomes as parent reported brain injury symptom severity (HBI) and enhanced parenting self-efficacy (TOPSE).

50 Practice-Based Evidence: How Well Do We Collect Routine Clinical Data and What Do Rehab Practitioners Think About the Process: A Service Evaluation

Peter Tucker; Emma Brooks; Sophie Gosling

Recolo UK Ltd, Bath, United Kingdom

Background

The international collaboration of the Common Data Elements (CDE) group recommend best outcome measures for research in pediatric acquired brain injury (ABI) population (McCauley et al., 2012). Routinely collected clinical data on children can be flawed, uncertain, proximate, and sparse or “FUPS” (Wolpert & Rutter, 2018).

Recolo UK Ltd provides community-based neuropsychological rehabilitation for children, young people, and young adults. Associates collect data from their assessments and reviews to identify impairments and monitor outcome, using measures recommended by CDE (Gosling, 2015).

Aims to ask: Are there gaps in the clinical data set? Why? What are barriers and challenges to data collection?

Method

Two phases: Frequency counts of data and practitioner interviews. Clients have a wide range of age (0-18 years), brain injury type, and severity. In clinical practice, associates evaluated 267 children with brain injury and their families.

Measures: (a) PedsQL, FAD, BRIEF, SDQ, CASP; (b) Interview scripts.

Procedure: (a) Frequency analysis of questionnaires collected 2013-2019; (b) 6 associates recruited as “participants” for semistructured interview. A purposive sampling method was adopted. Thematic analysis (Braun & Clarke, 2006) performed.

Results

(a) There are large gaps in the database. The totals completed measures at baseline ranges from n = 163-41 (PEDS-FIM-parent; PEDSQL core-child). Most commonly reviewed once were PEDS-FIM, PEDS-QL, and SDQ (n = 35, 34, and 28, respectively).

(b) Five key themes were identified from the interview scripts: impact of outcome measures on clients; construct of outcome measurement; culture of goal setting; helpful aspects of outcome measurement; and barriers to data collection.

Conclusions

There were gaps in data collection. The clinical data are FUPS. The interviews describe barriers and facilitators to data collection. Recommendations are given to address the issues by increasing knowledge and skills, improving the technology, and including nomothetic (goals) and idiographic (questionnaires) outcomes.

51 How Good Are Our Goals? Understanding SMARTness in a Pediatric Neuropsychological Rehabilitation Service

Peter Tucker1; Sophie Gosling1; Katie Byard1; Rebecca Ashton1; Fergus Gracey2

1Recolo UK Ltd, Bath, United Kingdom; 2University of East Anglia, Norwich, United Kingdom

Background and Aims

Goal setting is a key ingredient in rehabilitation with children and young people (Ylvisaker, 1998). It should be a core competency of any member of a rehabilitation team (Wade, 2009). Goals in rehabilitation should be SMART (Specific, Measurable, Achievable, Realistic, and Timed). This study employed a service evaluation in order to (1) examine reliability of goal quality rating items according to established SMART criteria; and (2) identify goals associated with poorer “SMARTness” to inform goal setting and audit practice.

Method

As part of a service evaluation cycle, a project was undertaken to evaluate the quality of a sample (n = 100) of anonymized pediatric neuropsychological rehabilitation goals. The text of each goal was rated by 4 senior practitioners within the service according to criteria set within a goals questionnaire (Grant & Ponsford, 2014). Five items relating to SMARTness were used, with a highest possible score 20.

Results

SMART tool total scores were normally distributed (mean = 12.36; SD = 3.19; range, 5-20). Calculation using all 5 items provided a “good” interrater reliability (ICC = 0.824). Items on the tool attracting low IRR included “Does the goal assess criteria that are process oriented?” (ICC = 0.288). Seventy-seven percent of the goal sample had “high” to “excellent” IRR; 68% of these goals (n = 53) were rated as having a high level of SMARTness; and 32% (n = 24) were rated as low in SMARTness. Goals with low IRR included those with generalized wording (eg, “to attend all Southend United FC activities as they are planned”); ambiguous goal difficulty (eg, “to sit my exams [first mocks and then GCSEs] in a way that helps me do my best whilst managing energy levels well”); and poorly defined tasks (eg, “mum to be receiving appropriate therapy for depression by X”). Goals rated reliably low on SMARTness had poor goal specificity (eg, “to find out good things about my brain, what I do and to like myself”).

Conclusions

Rehabilitation practitioners can use this tool to quantify SMARTness of rehabilitation goals set with children, young people, and their families. Not all individual items on the tool have adequate reliability and require modification. It is yet to be determined how SMARTness of goals relate to their meaningfulness to the client or their achievement in rehabilitation?

52 Exploring Patterns of Sensory Reactivity in a Postconcussion Population

Steve Van Lew2; Christina Finn1

1NYU Langone Medical Center, New York, United States; 2New York Institute of Technology, Old Westbury, New York, United States

Background

Approximately 10% to 20% of individuals who sustain a concussion will experience postconcussion symptoms beyond 10 to 14 days that may be classified as persistent postconcussive symptoms. Clinical manifestation of persistent symptoms is diverse and includes a variety of neurological sequelae, many of which are not always outwardly apparent, but yet have the potential to impact daily activities and functioning. A particular area of symptoms, sensory reactivity was explored in this study to ascertain patterns of sensory hypo- and hyperreactivity along with possible associations between these patterns and quality of life (QOL) and everyday functional outcomes.

Methods

This study was a prospective, cross-sectional, correlative, quantitative study using a consecutive and convenience sampling model. The research participants postconcussion were recruited from an outpatient occupational therapy program at an academic medical center. Normative data from 2 different sensory processing outcome tools were used in the analysis.

Results

The total sample size was N = 28, which included (n = 9) males and (n = 19) females. Research participants exhibited statistically mean differences in all 4 quadrants of the Adult Sensory Profile (ASP) (P < .000) and half of the subgroups for the Adult Sensory Processing Scale (ASPS) when comparing participants' scores to the normative data associated with each outcome tool. There were some moderate to strong correlations between the scores from the sensory processing outcome tools and the scores from the QOL and everyday function outcome tools. For the ASP outcome tool, there was a moderate (r = −0.356, P = .810), negative correlation between the sensory sensitivity ASP quadrant and the Satisfaction with Life Scale and a strong positive correlation between this ASP quadrant and the Functional Status Examination (r=.690, p<0.000). ASPS results indicate a range of correlation coefficients from (r = 0.280-0.628) for the 5 ASPS subgroups and the Functional Status Examination outcome measure. Eighty percent (n = 4) of these subgroups had a moderate to strong positive coefficient.

Conclusion

Individuals experiencing persistent postconcussion symptoms may experience higher levels of sensory reactivity than the normative population data. The results also suggest that there may be a relationship between these higher levels of sensory reactivity patterns and decreased QOL and everyday function. Future research should focus on developing a greater understanding of how sensory patterns may impact daily functioning. In addition, future studies should focus on exploring treatment strategies to maximize function and QOL in individuals who experience patterns of sensory hyperreactivity.

53 Support “In-Hand” for Families—A Digital Health Intervention Following Concussion and Brain Injury

Gerard Anderson

Child Brain Injury Trust, Baynards Green, United Kingdom

CBIT in Hand is an innovative digital health intervention offering users the ability to access immediate support through their mobile devices. It is part of a virtual support service set up in response to COVID-19 as a way of outreaching families. The app provides personalized information, signposting advice, products and services, and access to legal support. It is a way of users self-managing and then if needed accessing direct support through our virtual support team. Need was identified following a lack of follow-up support and advice after discharge from the Accident and Emergency (A&E) department, parental knowledge on how to support mild traumatic brain injury (TBI) did not exist, and disrupted and protracted return to school.

Increased pressure on health service teams with nonclinical questions (sensory difficulties/sleep difficulties/emotional dysregulation), longer than expected recovery post-TBI, and hospital teams having a limited knowledge on this cohort.

More than 500 000 children and young people attend A&E departments every year with a head injury (Nice Guidelines, 2017). Approximately half have a concussion, and 45 000 have significant issues with a brain injury whether it be mild, moderate, or severe. CBIT currently supports around 1400 families a year through our integrated model of support—many families simply do not know that CBIT exists and have to wait until they are either referred or they have to Google search for an appropriate intervention.

Supporting families when children are admitted with a head injury is time consuming for hospital staff and reduces their capacity to deal with immediate clinical needs. They are also required to identify the very small number of patients with serious acute brain injuries. There is usually very little consistent information available in A&E departments—a fast-paced setting with primary information logged and little or no follow-up information given. Furthermore, if there is no immediate cause for concern, children with concussion are often sent home sometimes without any follow-up information or with a simple information sheet that may have been photocopied many times, so is often hard to read and very generic.

Using the latest technology CBIT in Hand offers hospital staff and families an innovative way of working to reduce the nonclinical support they undertake with head injuries, brain injuries, and concussion. CBIT at Hand was launched in April 2021 and offers an invaluable source of up-to-date information about concussion, brain injury, and specialist services. It provides personalized guides including follow-up concerns, family support, financial support, legal support, access to support groups, education support. It provides immediate access to NHS information and access to virtual support coordinator through a special messaging service. More than 1000 users have downloaded CBIT in Hand. Initially piloted in 2 A&E departments with a rollout to the remaining trauma centers during 2022.

54 Self-perception of Communication Competence After Mild Traumatic Brain Injury

Rocio Norman

University of Texas Health Science Center San Antonio, San Antonio, Texas, United States

Objectives

Individuals with mild traumatic brain injury (mTBI) are at risk for communication disorders (Norman, 2013; Parrish, Roth, Roberts, & Davie, 2009). There is a need for studies that characterize mTBI-related communication and propose new methods of capturing everyday communication problems.

An alternative to standardized tests is the use of self-report questionnaires specifically designed to capture traumatic brain injury (TBI)-related communication deficits. Self-report measures can have more clinical relevance than standardized tests, because they identify problems at the functional and individual levels.

The LaTrobe Communication Questionnaire (LCQ; Douglas, Bracy, & Snow, 2007; Douglas & O'Flaherty, 2000) has been reliably used in TBI research and in clinical settings. The LCQ has high internal and external validity, a stable factor structure, and high interrater reliability. The LCQ was developed with the purpose of capturing everyday communication performance in adolescents and adults with TBI (Douglas et al., 2007). The LCQ has primarily been used in studies of moderate to severe TBI, including studies of adolescents with TBI (Douglas, 2010; Struchen et al., 2008), and significant differences have been found between participants with TBI and healthy comparison groups.

Methods

In a sample of acute and chronic individuals with mTBI (emergency department and community recruitment), we tested whether these 2 groups were significantly different in their report of communication competence on the LCQ-30 (Douglas, 2007). As a secondary analysis, we also explored whether scores between men and women were different. Because research has shown it takes time for individuals with TBI to adequately self-identify problems, we predicted that individuals in the chronic group would report more problems on the LCQ (ie, higher scores). Because women with mTBI often report more symptoms postinjury than men, we predicted women in the sample would also have higher scores on the LCQ than men.

Results

Nineteen adults with acute mTBI and 33 adults with chronic mTBI were included in the final sample. Mean age was 28.4 years for the acute group and 28.6 years for the chronic group. Using independent-samples t tests, mean LCQ-30 scores were compared. A significant difference was found between mean LCQ scores between the groups (t = −3.147, df = 35.732, P = .00332), with the chronic group reporting more symptoms. No significant differences were found between male and female respondents (t = −0.010868, df = 22.824, P = .9914).

Conclusions

Results of this study demonstrate that the timing of self-report communication questionnaires is important. This finding is consistent with cognitive studies, which suggest a low report of symptoms in the acute setting because patients do not fully endorse symptoms early in the recovery course and that the onset of symptoms begins away from the medical setting as the individual attempts to return to normal activities.

55 Community-Based Interventions After Acquired Brain Injury: A Systematic Review of Interventions Including Family Members

Solveig Hauger1,2; Ida Borgen2,4; Marianne Løvstad1,2; Juan Lu3; Marit Forslund4; Ingerid Kleffelgård4; Nada Andelic4,6; Cecilie Røe4,5

1Department of Research, Sunnaas Rehabilitation Hospital, Nesodden, Norway; 2Department of Psychology, Faculty of Social Sciences, University of Oslo, Oslo, Norway; 3Division of Epidemiology, Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, Virginia, United States; 4Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway; 5Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway; 6Center for Habilitation and Rehabilitation Models and Services (CHARM), Institute of Health and Society, University of Oslo, Oslo, Norway

Objectives

Acquired brain injury (ABI) represents an extensive global health problem and is a leading cause of disability and lifelong difficulties. Persons with ABI experience a wide range of symptoms related to physical, communicative, cognitive, behavioral, and/or vocational functioning, as well as problems with community integration and participation. Reduced health-related quality of life and increased levels of psychological distress are reported both by patients and family members. Patients' long-lasting ABI-related problems may affect family functioning, at the same time as the family serves as an important support system. However, few studies have evaluated the effectiveness of community-based interventions that include family members. The objective of this review was to assess community-based interventions targeting adult patients' ABI-related problems in the chronic phase (≥6 months) and involvement of a family member or significant other.

Methods

A review of interventions including family members as part of a comprehensive systematic review of community-based controlled intervention studies published before February 2021 was undertaken using the following: systematic searches were done in databases, MEDLINE, PsycINFO, Database of Abstracts of Reviews of Effects (DARE), and Cochrane Central Register of Controlled Trials (Cochrane Library), and inclusion of English peer-reviewed full-text articles; randomized or controlled community-based intervention studies; sample size of 20 or more participants; and 3 or more intervention sessions. Two reviewers independently extracted data for the synthesis. Quality was assessed using the criteria developed by Cicerone and colleagues.

Results

The full search returned 7386 publications, whereof 49 eligible studies were included in the comprehensive systematic review, revealing a diverse range of community-based interventions. In total, 20 (41%) of the studies included a family member or significant other. The degree of family involvement varied between the studies, from active involvement, where the intervention was delivered to the dyad of participant and significant other, to a passive role, where family members were only included in assessment and psychoeducation. Several studies lacked a clear description of how a family member was involved, and only 9 studies had a family member or significant other as part of the inclusion criteria. Only half of the interventions involving family members were included in the overall meta-analyses on outcome measures targeting functional capacities, participation, and quality of life. While the meta-analyses showed a lack of pooled effects, an inspection of the confidence intervals showed large variability of effects within each of the studies including family members.

Conclusions

ABI is a family affair, but this comprehensive review showed that less than half of the included community-based intervention studies involved a family member or significant other. Future studies should ensure active family participation and provide a detailed description of family member participation, to disentangle effective ingredients related to family involvement in interventions aiming to improve functional capacities, participation, and quality of life in adults with ABI.

56 Transdisciplinary Medication Education in Acute and Residential Brain Injury Rehabilitation Units

Allison Capizzi; Chenal Roberts; Kate Gorman; Erin Armstrong; Chitra Gowda

VA Palo Alto Polytrauma System of Care, Palo Alto, California, United States

Objective

This session offers a framework for an educational program for self-medication management in patients with brain injury. The goal of this program is to promote patient independence and prevent adverse drug events (ADEs).

Introduction

Complications from ADEs are common and especially problematic in patients with brain injury. The importance of teaching medication management during hospitalization to prevent future ADEs is well documented. Acute and post-acute rehabilitation settings serve as a platform for safe and successful transitions into the community. Self-medication programs have been implemented in hospital systems as part of this transition process. However, the nature of and priorities given to these different programs vary. The VA Palo Alto Polytrauma System of Care was recognized for medication education by CARF International. The authors offer to share their expertise in operating this educational program on their acute inpatient rehabilitation (AIR) and post-acute brain injury (PABI) residential rehabilitation units.

Methods

In the AIR setting, medication management is introduced through a call-for-meds (CFM) program. Patients are instructed to notify their nurse each time a medication is due. Nursing documents the patient's ability to call on time in their standard shift reports. The PABI unit offers a self-medication program (SMP). The SMP is divided into 3 levels denoting progress from dependence on nursing for medications to independence in safely managing their own pill box. In both settings, medication management is a line item within the interdisciplinary team template prompting discussion about medication management at each meeting. For selected patients, the medication list is created considering their specific functional needs. For example, patients with visual deficits may require larger print, while others may require icons rather than written descriptions of a medication indication. Nursing collaborates with therapists to develop the patient-specific curriculum. The curriculum is designed to address multiple therapy goals including cognitive function, fine motor skills, visual scanning, problem solving, and time management. Sessions include filling a pill box, reading medication labels, learning medication indications, reporting side effects, requesting a refill, and what to do in an emergency. Assistive technology such as phone applications is used as an adjunct to the education program. Examples will be provided at the conference.

Results

This transdisciplinary medication management program is an area for future collaborative research. This program has the potential to translate into international rehabilitation program guidelines.

Conclusion

Medication management is an essential component to recovery for many patients living with brain injury. A transdisciplinary curriculum in medication management incorporates key components of a neurorehabilitation regimen. These programs empower patients and promote independence and a safe return to community.

57 Caregiver and Student Perspectives on School Services for Students With TBI During the COVID-19 Pandemic

Jennifer Lundine1; Cara Palusak2; Libby Crook3; Drew Nagele4; Angela Ciccia3

1The Ohio State University, Columbus, Ohio, United States; 2Heritage College of Osteopathic Medicine, Ohio University Dublin Campus, Dublin, Ohio, United States; 3Department of Psychological Sciences, Case Western Reserve University, Cleveland, Ohio, United States; 4Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania, United States

Objectives

The objective of the School Transition After Traumatic Brain Injury (STATBI) project is to rigorously evaluate the impact of BrainSTEPS, a formal return-to-school (RTS) program, on academic, social, and health outcomes for students in grades K-12 who have experienced TBI of any severity, compared to students who have no formal RTS programming. In 2020, the study shifted to examine the effects of COVID-related educational changes on students who experienced a traumatic brain injury (TBI) prior to the pandemic.

Methods

STATBI uses a mixed-methods, cohort-controlled research design. The institutional review board–approved protocol includes electronic survey administration and virtual interviews with parents and children. The data included in this presentation are cross-sectional, although the full STATBI protocol is longitudinal. Measures include standardized assessments of executive function, participation, social, and cognitive abilities, in addition to semistructured interviews with parents, students, teachers, and BrainSTEPS team members. This presentation focuses on themes identified from interviews with caregivers whose child experienced a TBI prior to the COVID-19 pandemic, with interviews taking place between spring 2020 and 2021.

Results

Of the 46 families that completed majority of the protocol, the average student age was 14.2 years (SD = 3.3). The sample included students with mild (n = 19), moderate (n = 12), and severe (n = 13) TBI. The average age at injury was 11.8 years (SD = 4.3) and average time since injury was 2.7 years (SD = 2.1). A total of 41 caregivers completed interviews. Caregivers discussed the impact of COVID-19–related school changes on their child with TBI. Most families reported that their students were attending school in either a hybrid model (40.9%, n = 18) or fully remote (45.5%, n = 20). Families reported the following areas of accommodation were needed: physical accommodations (25%, n = 11), learning/thinking (36.4%, n = 16), and behavioral/social (22.7%, n = 10). Interviews with caregivers and students are currently being analyzed using reflective thematic analysis to reflect the themes expressed by these key stakeholders. Overall, themes focused on 3 primary areas: the impact of COVID-19 on their child's health, school performance and/or services, and socialization with peers.

Conclusions

The STATBI project is unique in its focus on RTS for youth with TBI, and these data are particularly pertinent as they highlight the impact of COVID-19–related school changes on students who experienced a TBI prior to the beginning of the pandemic. Our sample included many students who reported having mild injuries but who continued to have academic needs that warranted a referral to the BrainSTEPS program. A majority of the enrolled participants were engaged in school via hybrid or remote options, with a consistent minority requiring academic supports. Implications of COVID-19–related school changes on students with TBI based on data collected during the first—unique and challenging—year of a longitudinal study will be discussed.

58 Social, Health, and Academic Performance of Children With TBI Engaged in a Formal Return-to-School Support Program

Angela Ciccia1; Jennifer Lundine2; Drew Nagele3; Libby Crook1; Jessica Riccardi4

1 Department of Psychological Sciences, Case Western Reserve University, Cleveland, Ohio, United States; 2The Ohio State University, Columbus, Ohio, United States; 3Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania, United States; 4Department of Communication Sciences & Disorders, University of Maine, Orono, Maine, United States

Objectives

The objective of the School Transition After Traumatic Brain Injury (STATBI) project is to rigorously evaluate the impact of BrainSTEPS, a formal return-to-school (RTS) program, on academic, social, and health outcomes for students in grades K-12 who have experienced TBI of any severity, compared with students who have no formal RTS programming.

Methods

STATBI uses a mixed-methods, cohort-controlled research design. The institutional review board–approved protocol includes electronic survey administration and virtual interviews with parents and children. The data included in this presentation are cross-sectional, although the full STATBI protocol is longitudinal. Measures include standardized assessments of executive function, participation, social, and cognitive abilities, in addition to semistructured interviews with parents, students, teachers, and BrainSTEPS team members. This presentation focuses on the specific academic, social, and health functioning for 117 school-aged children and adolescents at the time of study enrollment (spring 2020-spring 2022) using the following measures: Academic (NeuroQoL Cognitive, Child Behavior Checklist School Competence, BRIEF parent), Health (PROMIS Global Health, Post-Concussion Symptom Inventory [mild TBI only], Child Health Questionnaire), and Social (NeuroQoL Social, Strengths and Difficulties Questionnaire). The Vineland Adaptive Behavior Scale is the primary outcome measure for this study and assesses all domains.

Results

Of the 117 families that completed the majority of the protocol, the median student age was 14.2 years (SD = 3.3; range, 5.49-19.32 years) at time of enrollment. Males made up 41.5% of the sample, 74% were White, 8.4% Black, 9.1% Hispanic/Latino, and 12.3% multiracial; 38% of the sample qualified for free/reduced lunch. The average age at injury was 12.3 years (SD = 4.2). The sample included students with mild (48.5%), moderate (21.6%), and severe (27.7%) TBIs. Leading injury mechanisms included sports (29.4%), falls (14.6%), and car accidents (22.8%). Nearly half (48.1%) of youth with TBI were admitted to inpatient rehabilitation, and 67.6% reported receiving hospital-to-school transition services. Data from all standardized measures detailed earlier are being analyzed for descriptive and comparative purposes and will be available at the time of this presentation.

Conclusions

The STATBI project is unique in its focus on RTS for youth with TBI, and this presentation will describe academic, social, and health functioning for a large sample of school-aged youth with TBI who participate in a formal RTS program, specifically at the time of study enrollment. Our sample includes many students who reported having mild injuries but who continued to have academic needs that warranted a referral to the BrainSTEPS program. This talk will highlight ongoing study progress and implications for those studying RTS programs for students with TBI.

59 Predictors of Health-Related Quality of Life in Children With TBI

Libby Crook1; Jessica S. Riccardi3; Jennifer Lundine2; Angela Ciccia1

1 Department of Psychological Sciences, Case Western Reserve University, Cleveland, Ohio, United States; 2Department of Speech and Hearing Science, The Ohio State University, Columbus, Ohio, United States; 3Department of Communication Sciences & Disorders, University of Maine, Orono, Maine, United States

Objectives

To determine child- and family-related predictors of parent-reported health-related quality of life (HRQoL) outcomes for children with traumatic brain injury (TBI).

Methods

This study is a secondary analysis of data collected as part of a larger research project, “School Transition After Traumatic Brain Injury” (STATBI). STATBI has an institutional review board–approved protocol that includes parents of children in kindergarten through 12th grade enrolled in BrainSTEPS (a formal program in Pennsylvania that supports students with brain injury as they return to school). Demographic and injury-related factors were collected via caregiver report. The Child Health Questionnaire (CHQ)-PF28 was used to measure HRQoL for children with TBI, with higher scores indicating more positive quality of life. The McMaster Family Assessment Device (FAD) General Functioning subscale short version was used to measure family functioning, with higher scores indicating worse family functioning. Bivariate analyses (ie, point biserial and Pearson correlations) were conducted amongst all predictor variables (ie, injury severity, injury mechanism, time since injury, parent education, single-income home, qualifying for free or reduced lunch, medical care sought, hospitalization, special education) and HRQoL (outcome variable). A simple linear regression analysis was also conducted examining the relationship between family functioning (predictor variable) and HRQoL (outcome variable).

Results

Forty-eight children with TBI were included in this sample. Most children experienced a persistent mild TBI (54.2%), sought medical care (100%) with overnight hospitalization (68.8%), and were on average 1.6 years postinjury (SD = 1.73). More robust demographic characteristics will be included in the presentation. On average, children's family functioning was not considered problematic. Alternatively, children's physical quality of life was below the average range, and psychosocial quality of life was within the average range. Injury severity (P = .020), being hospitalized overnight (P = .042), and family functioning (P = .020) were significantly correlated with HRQoL. No other variables were significantly correlated with quality of life. Simple linear regression results revealed family functioning was a significant predictor of HRQoL (F1,47 = 6.87, P < .05, R2 = 0.13).

Conclusions

Children with TBI are at risk for poorer HRQoL even into the chronic stage of recovery, indicating ongoing care is critical. Specifically, children with more severe injuries reported lower quality of life, reinforcing the importance of following these children in the long term to ensure appropriate service provision and management of ongoing problems that might be impacting their quality of life. While children who were hospitalized overnight also had lower HRQoL, this might be explained by severity of injury such that children with more severe injuries are more likely to require hospitalization. Children with positive family functioning had higher quality of life, reinforcing the need and importance of supports and services for families post-TBI.

60 Young Males Have the Highest Odds of Developing Novel Suicidal Ideation Within 365 Days Following a Concussion

Alexander Ballatori; Alison Haddad; Shane Shahrestani

The Mac Parkman Foundation for Adolescent Concussive Trauma, Los Angeles, California, United States

Introduction

Concussions are a form of mild traumatic brain injury (mTBI) that most commonly occur following blunt trauma to the head and may result in a temporary loss of consciousness. The purpose of this study is to assess the effects of age and sex in developing novel suicidal ideation following a concussion.

Methods

In this study, we used the Healthcare Cost and Utilization Project (HCUP) Nationwide Readmissions Database (NRD) from years 2010-2019. Patients who were readmitted within one calendar year after being admitted previously for mTBI in the 2010-2019 NRDs were identified (n = 206 070). Multivariable binomial regression analysis was performed to determine the relationship between novel psychiatric disorders following mTBI and patient age and sex.

Results

The mean age for all patients was 50.9 ± 26.2, with 43.9% being female. Patients demonstrating novel suicidal ideation within 1 year of mTBI were younger compared with other cohorts (47.6 ± 18.0 years). Furthermore, patients with novel suicidal ideation were predominantly male (male: 61.4%; female: 38.6%). Multivariable analysis controlling for potential confounding demonstrated that lower age and male sex may predict novel suicidal ideation after mTBI (P < .007).

Conclusion

This study found that lower age and male sex may predict novel suicidal ideation. There is still much work to be done in order to understand how patient demographics should dictate medical management following mTBI and concussion.

61 Risk Factors for Developing Novel Depression and Anxiety Following Mild Traumatic Brain Injury

Alexander Ballatori; Alison Haddad, Shane Shahrestani

The Mac Parkman Foundation for Adolescent Concussive Trauma, Los Angeles, California, United States

Introduction

Mild traumatic brain injury (mTBI), including concussion, has recently garnered attention as a risk factor for psychiatric illness. Here, we apply predictive modeling to a contemporary cohort of patients to evaluate the incidence of new-onset depression and anxiety following mTBI.

Methods

In this study, we used the Healthcare Cost and Utilization Project (HCUP) Nationwide Readmissions Database (NRD) from years 2010-2019. Patients who were readmitted within one calendar year after being admitted previously for mTBI in the 2010-2019 NRDs were identified (n = 206 070). Multivariable binomial regression analysis was performed to determine the relationship between novel psychiatric disorders following mTBI and patient demographics including age, sex, Charlson Comorbidity Index (CCI), insurance, and median income.

Results

The mean age for all patients was 50.9 ± 26.2, with 43.9% being female and an average CCI of 3.0 ± 2.6. Overall, an additional 3866 (1.9%) patients were reported to have novel depression and 3449 (1.7%) patients were reported to have novel anxiety at the time of readmission following mTBI. Multivariable analysis found that female sex and Medicare/Medicaid insurance types may predict novel anxiety following mTBI (P < .05). Furthermore, a similar analysis found that lower age, higher CCI, and Medicare/Medicaid insurance types may predict novel depression following mTBI (P < .05).

Conclusion

mTBI may result in novel depression or anxiety within 1 year of insult, and patient demographic factors may significantly influence the development of novel psychiatric disease. Further longitudinal research is warranted to cement these findings.

62 Are Mild Traumatic Brain Injury and Concussion Separate Entities? A Pilot Study Using Functional Magnetic Resonance Imaging

Sarah McCabe; Jen-Kai Chen; Alain Ptito; Rajeet Saluja

McGill University, Montreal, Canada

Objectives

The terms mild traumatic brain injury (mTBI) and concussion are often used interchangeably in research and clinical settings. Their operational definitions, however, have important differences that create diagnostic controversies. With the concussion definition (1), developed in the context of sport, patients do not need to present with one of the objective clinical signs (eg, loss of consciousness), but instead only postconcussive symptoms (PCSs), whereas all are essential for the mTBI definition (2). This leads to challenges when PCSs are present, but patients lack the hallmark features of mTBI after injury. Through use of task-based functional magnetic resonance imaging (fMRI), we aimed to determine if the terms mTBI and concussion are synonymous, or if the operational definitions need to be revisited to be more inclusive of all patients. We investigated fMRI activation patterns between individuals fitting the diagnostic criteria of mTBI (2) and those fitting the definition of concussion (1) without the mTBI criteria.

Methods

Symptomatic patients within 1 month of injury who fit either the mTBI criteria (2) or the concussion criteria (1), as well as age- and sex-matched controls, were recruited for this study. Using a verbal working memory task previously validated by our group (3), we compared fMRI blood-oxygen-level-dependent (BOLD) signal changes between groups. All MRI images were preprocessed and analyzed using a validated software package developed at the Montreal Neurological Institute.

Results

Preliminary results from between-group subtraction revealed differences in task-related BOLD signal changes. Increased activation in the concussion versus mTBI group was found in the dorsolateral prefrontal cortex, premotor cortex, and supplementary motor area. The mTBI group had greater activation than the concussion group in posterior cerebral regions, in both temporal and occipital lobes. Both the mTBI and concussion groups showed decreased activations in the dorsolateral prefrontal cortex compared with healthy controls.

Conclusions

Individuals diagnosed with concussion and mTBI had different task-related fMRI activations, suggesting that concussion and mTBI should be treated as distinct diagnostic entities. These results have important and immediate implications, as access to services and treatment plans differ based on the diagnosis given. Revisions of injury definitions are thus encouraged, with the long-term goal of uniformity in the diagnostic processes and management of these injuries across disciplines.

66 MR Spectroscopy 1 Month After Mild TBI Correlates With Clinical and Cognitive Outcomes at 4 and 14 Months

Anna Chen1; Teresa Gerhalter1; Seena Dehkharghani1,2; Rosemary Peralta1; Fatemeh Adlparvar1; Martin Gajdošík1; Mickael Tordjman1,3; Julia Zabludovsky1; Sulaiman Sheriff4; Sinyeob Ahn5; James Babb1; Tamara Bushnik6; Alejandro Zarate6; Jonathan Silver7; Brian Im6; Stephen Wall8; Guillaume Madelin1; Ivan Kirov1,2,9

1Center for Biomedical Imaging, Department of Radiology, New York University Grossman School of Medicine, New York City, New York, United States; 2Department of Neurology, New York University Grossman School of Medicine, New York City, New York, United States; 3Department of Radiology, Cochin Hospital, Paris, France; 4Department of Radiology, University of Miami Miller School of Medicine, Miami, Florida, United States; 5Siemens Medical Solutions USA Inc, Malvern, Pennsylvania, United States; 6Department of Rehabilitation Medicine, New York University Grossman School of Medicine, New York, United States; 7Department of Psychiatry, New York University Grossman School of Medicine, New York, United States; 8Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine, New York City, New York, United States; 9Center for Advanced Imaging Innovation and Research, Department of Radiology, New York University Grossman School of Medicine, New York City, New York, United States

Introduction

A mild traumatic brain injury (mTBI) is a serious event caused by an external force to the head, resulting in heterogeneous cognitive, behavioral, emotional, and physical symptoms that may persist for months following injury. Proton magnetic resonance spectroscopic imaging (1H-MRSI) in mTBI has shown changes in metabolite markers of membrane turnover (choline, Cho), cell energy (creatine, Cr) and signaling (glutamate plus glutamine, Glx), astrogliosis (myo-inositol, mI), and neuronal integrity (N-acetyl-aspartate, NAA). To assess how these metabolites relate to future clinical presentation, we examined the associations between mTBI patients' metabolite levels at approximately 1 month postinjury, and their clinical outcomes at 4 and 14 months postinjury.

Methods

Twenty-six mTBI patients (age range = 18-61 years), 1 month postinjury (visit 1), were scanned on a 3T Siemens Prisma magnet using a 20-channel head coil. Whole-brain 1H-MRSI data were processed using a linear regression approach in atlas-defined frontal, parietal, temporal, and occipital lobes to separately assess white and gray matter (WM, GM) alterations within these regions. Nineteen patients at visit 2 (age = 18-61 years; 3-5 months postinjury) and 12 patients at visit 3 (age = 20-62 years, 11-16 months postinjury) completed the Rivermead Post-Concussion Symptoms Questionnaire (RPQ; symptoms) and the Brief Test of Adult Cognition by Telephone (BTACT; cognitive ability across subdomains of memory, executive function, and reasoning). Spearman's correlations were used to examine the associations between metabolite levels, RPQ total score, and BTACT composite z-score. Statistical significance was defined as P < .05.

Results

Visit 2 BTACT scores directly correlated with visit 1 WM Glx (frontal R = 0.67) and WM NAA (frontal R = 0.58; parietal R = 0.63; occipital R = 0.52). Visit 2 RPQ scores indirectly correlated with visit 1 GM NAA (frontal R = −0.66; parietal R = −0.59).

Visit 3 BTACT scores directly correlated with visit 1 GM Cho (frontal R = 0.85), WM Cho (in all lobes, R = 0.61-0.78), and WM Cr (occipital R = 0.83). No correlations were found between visit 3 RPQ scores and any metabolite in any region.

Discussion

A main finding was the correlation between NAA levels and RPQ scores. Specifically, a larger number of future symptoms were predicted by lower GM NAA in 2 of the brain lobes. This suggests that diffuse GM neuronal dysfunction may drive more pronounced future symptoms.

Worse cognitive scores at visit 2 were predicted by lower WM NAA and Glx, again implicating neuronal dysfunction, but also the glutamate-glutamine cycle. Visit 3 BTACT scores were predicted by the glial marker, Cho, with lower levels correlating with worse scores. However, since by visit 3, most patients had positive z-scores (indicating better performance than the median for their age and sex), the importance of these findings is unclear.

Overall, the results highlight potential metabolic differences between physiological and neurobehavioral recovery trajectories following injury and show that 1H-MRSI–derived metabolites may have utility for predicting 4- and 14-month outcome after mTBI.

67 Changes in Functional Brain Activity Following Exercise in Acute Pediatric Brain Injury: Preliminary Findings

Bhanu Sharma; Eric Koelink; Carol DeMatteo; Michael Noseworthy; Brian Timmons

McMaster University, Hamilton, Ontario, Canada

Background

Concussions are among the most common sport-related injuries in children. The status quo of pediatric concussion management was physical activity avoidance until symptom resolution. However, there now exists compelling evidence to suggest that submaximal aerobic exercise can improve symptom burden in acute concussion, whereas strict rest immediately following injury may worsen or increase risk of persisting symptoms. Consequently, clinical and scientific opinions are shifting toward prescribing submaximal aerobic exercise and/or encouraging physical activity in the acute stages of concussion for the benefit of symptom resolution. The problem is that we do not know how specific episodes of exercise immediately following injury affect the concussed pediatric brain. This is the first study to examine the effects of acute submaximal aerobic exercise on functional brain activity in children with concussion.

Methods

Prospective cohort study (with matched controls). Children with sports-related concussion (and age- and sex-matched healthy controls) completed a baseline magnetic resonance imaging study to examine resting state functional activity. Then, study participants completed a 10-minute bout of submaximal aerobic exercise, akin to that being prescribed as part of concussion management. Participants then reentered the MRI within 2 minutes to examine differences in resting state functional activity. Children with a history of multiple concussions or other neurological comorbidity were excluded.

Results

We report on preliminary findings based on 6 children with concussion and 4 healthy controls. We found that there were no pre/postexercise changes in resting state functional activity in healthy controls (threshold, t = 2.771, P = .05). However, in children with concussion, there were multiple regions in the brain with reduced resting state functional activity following exercise, principally the inferior parietal lobule and post-central gyrus. Similarly, with group-wise comparisons, reductions in functional activity were observed in concussed but not healthy children after—but not before—exercise.

Discussion

While recruitment is ongoing, our preliminary findings suggest that while exercise may benefit symptom recovery, it may increase neurological vulnerability in children with concussion. These findings raise important questions about the role of exercise in pediatric concussion management, and whether the timing and type of exercise need to be optimized to promote symptom recovery and brain health.

70 Rehabilitation for Children With Chronic Acquired Brain Injury in the Child in Context Intervention (CICI) Study: Study Protocol for a Randomized Controlled Trial

Nina Rohrer-Baumgartner1; Ingvil Laberg Holthe1,2; Edel Jannecke Svendsen1,3,4; Cecilie Røe4-6; Jens Egeland2,7; Eli Marie Killi8; Maria Sandhaug8; Anine Strand-Saugnes8; Hilde Margrete Dahl9; Ann-Elise Kristoffersen8; Shari Wade10,11; Marianne Løvstad1,2

1Department of Research, Sunnaas Rehabilitation Hospital, Nesodden, Norway; 2Institute of Psychology, University of Oslo, Oslo, Norway; 3Department of Nursing and Health Promotion, Oslo Metropolitan University, Oslo, Norway; 4Research Centre for Habilitation and Rehabilitation Services and Models (CHARM), University of Oslo, Oslo, Norway; 5Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway; 6Institute of Clinical Medicine, University of Oslo, Oslo, Norway; 7Vestfold Hospital Trust, Tønsberg, Norway; 8Statped: Norwegian Service for Special Needs Education, Oslo, Norway; 9Department of Clinical Neurosciences for Children, Oslo University Hospital, Oslo, Norway; 10Division of Physical Medicine and Rehabilitation, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States; 11University of Cincinnati College of Medicine, Cincinnati, Ohio, United States

Background

Pediatric acquired brain injury (pABI) is associated with long-term cognitive, behavioral, social, and emotional problems, which may affect quality of life, school, and family functioning. Yet, there is a lack of evidence-based community-centered rehabilitation programs for chronic pABI, and these children do not systematically receive comprehensive rehabilitation. The Child in Context Intervention (CICI) study is a pragmatic randomized controlled trial (RCT) for children with chronic pABI, which aims to evaluate the effectiveness of an individualized and goal-oriented intervention targeting everyday functioning of the child and family.

Methods

Children aged 6 to 16 years with magnetic resonance imaging/computed tomography–verified intracranial abnormalities will be included in the CICI study if they have persistent self- or parent-reported cognitive, emotional, and/or behavioral challenges 1 year or more after insult and attend school regularly. A total of 70 families will be randomized 1:1 to an intervention or a control group. The intervention consists of 7 family sessions, 1 parent seminar, and 4 school sessions delivered over approximately 6 months. The parent seminar will be held in person, while the other sessions will mainly be video based. The children's and families' self-reported major challenges in everyday life will be targeted using SMART goals. Evidence-based strategies, when available, will be applied to achieve the goals, combined with psychoeducation. Goal Attainment Scaling (GAS) will be used to evaluate goal attainment. Data are collected at baseline and after approximately 6 and 9 months. External assessors are blinded to group allocation. Primary outcomes are parent-reported brain injury symptoms in children and parenting self-efficacy at 9 months follow-up. Secondary outcomes include child-reported brain injury symptoms, quality of life, executive functioning in daily life, parent emotional symptoms, family functioning, and unmet family health care needs. A process evaluation will be conducted.

Discussion

The current study provides an innovative approach to rehabilitation for children in the chronic phase of ABI and their families. This complex intervention may contribute to the development of evidence-based, high-quality rehabilitation for a large patient group, which is underrepresented in clinical research. It may also improve collaboration between specialized rehabilitation facilities, schools and local healthcare services. Inclusion for the trial started in May 2021.

Trial registration: ClinicalTrials.gov, NCT04798859. Registered on March 12, 2021.

71 Family Impact in Children and Young Adults With Acquired Brain Injury; Outcomes Over Time in a Rehabilitation Cohort

Florian Allonsius1,2; Arend de Kloet1; Frederike van Markus-Doornbosch1; Jorit Meesters1-3; Cedric Kromme1,2; Thea Vliet Vlieland1,2; Menno Van Der Holst1,2

1Basalt Rehabilitation, the Hague, the Netherlands; 2Leiden University Medical Center, Leiden, the Netherlands; 3The Hague University of Applied Science, the Hague, the Netherlands

Introduction

Acquired brain injury (ABI) in children and young adults may have a persisting impact on families. A few cross-sectional cohort studies showed considerable family impact after ABI. Patients with ABI who are referred for rehabilitation are often more severely affected, and a higher impact has been reported for this group. However, there is a lack of knowledge on how family impact develops over time.

Objective

To study family impact over time in an outpatient rehabilitation cohort of children and young adults with ABI and to determine influencing factors to provide knowledge for improving rehabilitation treatment.

Patients

Families of patients (5-24 years old) referred to rehabilitation due to ABI.

Methods

For this multicenter longitudinal study (10 Dutch rehabilitation centers), families were asked to complete 2 outcome measures at admission (T0) and 1 and 2 years thereafter (T1/T2): the 36-item PedsQL Family-Impact-Module (total score/4 subscale scores) to study family impact, and the 23-item PedsQL generic-core-set 4.0 to assess parent perceived patients' health-related quality of life (HRQoL) (scores 0-100, lower scores-higher impact/lower HRQoL). In addition, patient, family, and disease characteristics were collected at admission. Descriptive statistics were used for all outcomes and linear regression analyses to investigate factors related to family impact (eg, age, sex, injury type/severity, time since onset, information needs, family/patient HRQoL, premorbid problems). Linear mixed models were used to determine change over time (change scores; 95% CI).

Results

Two-hundred forty-six families participated at T0 and 71 and 72 at T1 and T2, respectively. The patients' median age (T0) was 14 years (IQR = 11;16) and 65 (26%) had a nontraumatic brain injury (nTBI). The mean total FIM score (T0) was 71.7 (SD = 16.4) and for HRQoL 61.4 (SD = 17.0). Parents scored lowest on the Worrying subscale (64.1, SD = 19.5). The family impact was significantly higher when parents experienced a lack of help/information, reported diminished quality of life of their child, had a child with nTBI, were referred to rehabilitation more than 6 months after onset, and when premorbid physical, mental, and/or emotional problems were present (all Ps < .05). Over the course of time, the mean FIM total score slightly improved, T1: +1.7 (−0.8 to −4.2); T2: +3.2 (−0.04 to −6.5), yet not significantly. HRQoL improved significantly over time, but only between T0 and T1, +10.8 (7.4 to −14.2), P < .001, T1-T2 +0.03 (−3.10 to −3.17)).

Conclusion/Discussion

This study showed that family impact after ABI in children and young adults referred for rehabilitation treatment is considerable, especially in patients with nTBI, premorbid problems, and diminished HRQoL. Furthermore, the results show that family impact does not appear to decrease with time, although the HRQoL of the patients improved. The findings of this study underline the importance of measuring family impact in rehabilitation and may help better tailor/provide support to reduce this possible impact.

72 Implementing New Technology in Healthcare: Experiences of Providing Support and Training to Users of a Novel Rehabilitation Goal-Setting Software Application

Penny Trayner1,2; Abbe Wilson1

1Clinical Neuropsychology Services Ltd, Manchester, United Kingdom; 2Division of Psychology and Mental Health, University of Manchester, Manchester, United Kingdom

The onset of the COVID-19 global pandemic accelerated the need for a digital transformation of healthcare service delivery, as in-person contact was restricted, necessitating the increased use of remote appointments and virtual clinical intervention. While the benefits of the digital revolution have been evident, the training needs of professionals using these new technologies and the support they require to make best use of these innovations have been less explored. There is increased recognition of how technology can be time and cost-effective. However, effectiveness and use of software depend on the right amount of training and support provided to the users.

Rehabilitation goal setting is a crucial but complex component of neurorehabilitation. It involves specific processes (eg, a functional assessment, Goal Attainment Scaling, SMART framework). However, coordination and communication of data between clinicians, patients, and other individuals involved in goal setting can be difficult to track and monitor. Goal Manager is a cloud-based platform designed to facilitate clinicians in undertaking best practice rehabilitation goal setting, while ensuring progress is tracked and communication is clear. Digital solutions like Goal Manager have been emphasized as a key need following the onset of the COVID-19 pandemic.

This study describes how training provided to individual services impacts implementation of Goal Manager and other digital solutions. This qualitative study has surveyed clinicians working in independent and voluntary sector services, considering their pre- and posttraining knowledge, competency, and confidence in goal-setting practices, as well as in using healthcare software and technology more widely. Outcomes are discussed regarding the experience and perceived effectiveness of formal training and individual coaching. Conclusions regarding the right amount of support, training, and leadership required for new technology to be implemented effectively are discussed, including the need for an individually tailored approach and follow-up support and training. Recommendations will guide services looking to implement digital solutions on staff training and support considerations.

73 Hip Flexion Weakness Is a Frequent Objective Finding in the Postconcussive Athletic Physical Exam

Eden Maxwell3; Cindi Laukes2; Greg Carter4; Willow Affleck3; Bill Rosen1,2,4

1Bill S. Rosen, MD, PC, Missoula, Montana, United States; 2Neural Injury Center, University of Montana, Missoula, Montana, United States; 3Hellgate High School, Missoula, Montana, United States; 4St Luke's Rehabilitation Institute, Spokane, Washington, United States

Motor abnormalities have been observed in postconcussive athletes. Problems with balance, delayed motor execution, and increased excitability of inhibitory neurons in the motor cortex have been reported. Previously concussed athletes are also more likely to suffer an anterior cruciate ligament tear than their nonconcussed peers. Moreover, athletes who have experienced a single concussion are more likely to sustain a second concussive event than their peers are likely to suffer a first concussion. The role motor impairments may play in this increased risk of injury is not known. Based on the increased risk of subsequent injuries, it can be hypothesized that our current return-to-play screening methods are not ideal.

Among concussed athletes and also in the general population, we have observed impairments in balance and motor execution/recruitment, apraxia, and weakness, especially of the hip flexors. Isolated weakness of the hip flexors has not previously been reported; yet, we have found such weakness to be a common finding, when correctly assessed. Testing of hip flexion strength is not included in the more common concussion screens, such as the Sports Concussion Assessment Tool 5. The goal of this pilot study was to determine if the incidence of hip flexion weakness was more common in concussed than in nonconcussed student athletes, and if so, whether this increase was statistically significant.

Thirty-two student athletes aged 14 to 19 years were examined. Of these, 11 had been concussed 1 to 2 times over the past 3 years. All were currently actively participating in sports, and some were involved in multiple sports. Sporting activities included cycling, cross-country running and skiing, football, soccer, swimming, and volleyball. Hip flexion strength was measured in supine, lying on an examination plinth. Strength was assessed with the examined limb flexed to 30° at the hip and neutral at the knee, with the corresponding limb remaining in a neutral position on the plinth. Hip flexion was manually opposed by the examiner's right hand only, grasping the ankle, just proximal to the joint line. If the examinee was unable to keep the limb elevated above the plinth, the hip flexors were considered weak. All weak muscles were tested 3 times to confirm weakness and ensure the initial observation was not a misunderstanding of instructions. Three of 18 nonconcussed athletes (14%) had weakness of their hip flexors. In the concussed group, 8 of 11 (73%) had weakness. Utilizing a paired chi-square test, our findings are significant to P < .05.

Hip flexion weakness following concussion is a common finding in our pilot study. It would be appropriate for physicians, athletic trainers, and physical therapists to attentively evaluate hip flexor strength in initial sports screening and when examining the concussed individual. Further study of this finding is indicated.

74 “It Will Get Better, But It Hasn't Gotten Better”: Preliminary Qualitative Study of the Experience of Access to Specialized Health Services for Adult With Persistent MTBI Symptoms

Julien Dery1,3; Pascale Simard1,3; Elaine De Guise2,4; Marie-Eve Lamontagne1,3

1Université Laval, Quebec City, Quebec, Canada; 2Université de Montréal, Montreal, Quebec, Canada; 3Interdisciplinary Research Centre for Rehabilitation and Social Integration (CIRRIS), Quebec, Canada; 4Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal (CRIR), Montreal, Quebec, Canada

Background

Adults with persistent symptoms after mild traumatic brain injury (mTBI) experience important impacts on day-to-day activities and lead to functional consequences. Some people may have difficulty going through the recovery process and finding the appropriate health information or services for their condition and symptoms. As accessing specialized health services is often a challenge for this population, their experience and impacts on symptom persistence need to be examined in order to improve access to these services.

Objective

We aim to explore the experience of access and waiting time for specialized health services with adult having persistent symptoms after mTBI.

Methods

We conducted a qualitative study using semistructured interviews. We recruited adults with mTBI (Npreliminary = 5) after receiving services in a specialized multidisciplinary rehabilitation program. Interviews focused on participants' health services pathway after their injury, their perception of waiting, barriers and facilitators of access, and impacts on their condition. Interviews were recorded and transcribed, and verbatim were analyzed using inductive thematic analysis (NVivo).

Results

Most mentioned that they did not receive health services immediately after their accident but waited several weeks before seeking help. Participants expressed experiencing symptoms of anxiety, depression, worry, sadness, and demotivation before reaching for specialized health services. They all agreed that they did not receive enough straightforward information on the course of recovery and on health services available for them and that exacerbated mental health symptoms. Participants stated the need for more accessible services and information during the period between the trauma and the first appointment for specialized health services.

Conclusion

Preliminary findings showed that the participants experienced uncertainty and lack of information regarding recovery and availability of health services after their injury. This uncertainty combined with waiting process can exacerbate symptoms, so interventions to support or educate people with mTBI should be available while waiting for specialized health services.

75 Diminished Fluency After TBI: Is It Just Apathy?

Jeannie Lengenfelder1,2; Aubree Alexander1,2; Jacqueline Leddy1; Nicholas Pek3; Nancy Chiaravalloti1,2

1Kessler Foundation, East Hanover, New Jersey, United States; 2Rutgers, New Jersey Medical School, Newark, New Jersey, United States; 3Montclair State University, Montclair, New Jersey, United States

Objectives

The current study examined verbal and design fluency in individuals with moderate to severe traumatic brain injury (TBI) and the relationship between fluency performance and the presence of apathy.

Participants/Methods

Fifty-five individuals with TBI (age: M = 39.05, SD = 11.66; education: M = 14.16, SD = 1.92; months since injury: M = 109.90, SD = 12.48) were compared with 30 healthy control (HC) participants (age: M = 35.50, SD = 12.73; education: M = 14.57, SD = 1.83) on the DKEF-S Verbal Fluency (VF) and Design Fluency (DF) measures. Individuals with TBI were also administered the Apathy Evaluation Scale (AES) to evaluate apathy.

Results

Individuals with TBI were found to produce significantly fewer designs than HC on all 3 conditions of DF (filled dots: F1,84 = 10.95, P = .001; empty dots: F1,84 = 15.02, P = .000; switching: F1,84 = 17.90, P = .000). Similarly, individuals with TBI produced significantly fewer words than HC on all 3 conditions of VF (phonemic fluency: F1,84 = 5.77, P = .019; semantic fluency: F1,84 = 11.30, P = .001; switching: F1,84 = 12.89, P = .001). Using a cutoff score of 37 on the AES, individuals with TBI were subdivided into 2 groups (TBI+, TBI−) based on the presence of apathy, with 25% of individuals indicating significant presence of apathy (TBI+). When examining fluency performance in those 2 groups, no difference was found on any of the DF or VF measures between TBI+ and TBI−.

Conclusions

Apathy is common after TBI and has been correlated with reduced performance in executive functions. In the current work, individuals with TBI differed from healthy participants on executive functioning measures of fluency as expected; however, the presence of apathy did not impact their fluency performance. In fact, individuals with TBI who had apathy performed similarly to those without apathy on both DF and VF in the current work. These findings indicate that apathy is not solely responsible for the reduced fluency performance but rather impairments in executive functioning itself. Such information can inform clinicians when targeting cognitive rehabilitation of executive functions.

76 Hidden Social Inequalities in Pediatric Neurorehabilitation

Jenny Jim; Gemma Costello

The Children's Trust, Tadworth, United Kingdom

Objectives

This presentation hopes to elevate awareness of the adverse social-political elements (ASPs) that children and young people with acquired brain injury (ABI) contend with, as analogous to adverse childhood events (ACEs). By doing so, we demonstrate what we feel can be changed in the systems around children, young people, and families (CYPF) that would affect positive change for long-term outcomes. We present our psychosocial team's reflective process to engage meaningfully in understanding the ASPs that our CYPF face and to think about areas for future learning and responsiveness.

Method

We used the systems from the ecological systems model (Bronfenbrenner, 1979) to reflect as a team about ASPs. These were explored in the context of those we were consciously aware of and to give voice to unsaid or factors previously unknown to us that might influence CYPF outcomes and lived experience.

We then spoke to a small number of CYPF affected by ABI to understand their lived experience and used our professional experiences to reflect as a team on the themes that arose.

Findings

We will describe the themes that emerged from our reflections and conversations with CYPF. We share our own discovery and subsequent ownership of hidden/unsaid/unheeded sociopolitical inequalities in neurorehabilitation and the actions we intend to take forward across the system and life span.

These include:

  • Creating environments that promote creativity, compassion and inclusion, where we value speaking up and sharing diverse identities, while role modeling inclusive behaviors. This might include nonableist, collectivist, and non-Western ideals that empower and enable CYPF.
  • Investing the time and capacity on true coproduction to look at how meetings are run, what services are delivered, exploring bias in who engages/is asked to participate in such conversations.
  • Challenging stigmatizing views and societal norms that limit CYPF's potential and promote empowering and adequate independence/connectedness as desired.
  • Acknowledging how we use our own power and influence on systems outside of our own, for example, housing, care packages versus cost of residential care.

Conclusion

CYPF affected by ABI are facing a triad of disadvantage relating to invisibility—what is not seen, said, or heard—this relates to the invisibility of injuries that affect the lived experience of the CYPF, the hidden nature of the population on a global scale, and the hidden social inequalities that affect them across the life span.

CYPF living with brain injury face multiple hidden social inequalities. This is one team's attempt to create spaces to reflect on our practice and what actions we can take to mitigate against these. We look to elevate the unsaid or unheeded stories of CYPF affected by ABI.

77 Oculomotor and Vestibular Endurance Screening (MoVES) Protocol and Visual Quality of Life on an Adult Population

Jacqueline Theis1,2; Sophia Starzynski3; Stuti Mohan3; Chang Yaramothu3

1Virginia Neuro-optometry, Richmond, Virginia, United States; 2Concussion Care Centre of Virginia, Richmond, United States; 3School of Applied Engineering and Technology, New Jersey Institute of Technology, Newark, New Jersey, United States

Objectives

The objectives of this prospective study were to evaluate the impact of concussion on the endurance of the visual system and its effects on the visual quality of life in an adult population.

Methods

Adults aged 18 to 65 years old referred to a neuro-optometry clinic for visual complaints postconcussion were recruited to participate in this study. After obtaining informed consent, data were collected from the routine comprehensive neuro-optometric evaluation of the oculomotor system including near point of convergence (NPC), horizontal/vertical saccades, and horizontal/vertical vestibular-oculomotor reflex (VOR) using the Oculomotor and Vestibular Endurance Screening (MoVES) protocol. Near points were repeated 3 times to observe endurance. Saccades, vergence facility, and VOR tasks were objectively performed for 1 minute (unless the patient was unable to complete a full minute), with metrics broken down every 15 seconds. Participants were additionally asked to evaluate their visual quality of life on a new survey instrument called Visual Quality of Life with Time (VisQuaL-T). The survey asked participants to describe how long it would take (0-15, 15-30, 30-45, 60+ minutes) them to experience visual or physical symptoms while performing 10 routine daily tasks (eg, reading, watching TV, in a crowded location). Each time range was given a weight between 0 (0-15 minutes) and 3 (60+ minutes) and an average composite score between 0 and 3 was generated per participant.

Results

Eighteen participants (13 females) have been recruited to date with an average age of 38.8 ± 10.6 years. Average time between injury and baseline measurement was 22.2 ± 29.1 months. The average NPC break was 11.4 ± 8.2, 12.2 ± 8.4, 13.2 ± 9.7 cm, respectively, for the 3 trials with a recovery of 18.2 ± 11.2, 20.5 ± 12.1, and 21.1 ± 12.2 cm, respectively. The average VisQuaL-T composite score was 1.81 ± 0.53, which equates to approximately 20 minutes of activities before symptom provocation. Participants made 33.3 ± 17.7, 24.9 ± 20.2, 16.2 ± 21.8, and 9.3 ± 18.6 horizontal saccades in the first, second, third, and fourth 15-second blocks of a minute. For vertical saccades, the numbers of eye movements were 34.3 ± 23.3, 22.7 ± 22.3, 17.6 ± 23.0, and 15.8 ± 22.3 in each quarter of the minute. Vergence eye movements (19.8 ± 15.6, 12.9 ± 13.9, 8.0 ± 12.3, 5.3 ± 10.7), horizontal VOR (24.6 ± 22.3, 15.2 ± 12.0, 14.2 ± 16.3, 9.3 ± 12.3), and vertical VOR (22.4 ± 27.2, 13.0 ± 19.9, 11.8 ± 19.4, 13.1 ± 9.9) showed a similar decrease in the number of eye and head movements.

Conclusions

These data suggest that the visual system fatigues with time in patients with postconcussion oculomotor dysfunction, which is consistent with their symptoms of inability to perform visual tasks for long periods of time. Of clinical importance, data also indicate that it is important for clinicians to perform individual oculomotor testing for longer than 30 seconds, as endurance and symptom provocation could be missed if not tested long enough on a diagnostic examination.

78 Presence of Accommodative Dysfunction Postconcussion in an Adult Population

Jacqueline Theis1,2; Sophia Starzynski3; Stuti Mohan3; Chang Yaramothu3

1Virginia Neuro-optometry, Richmond, Virginia, United States; 2Concussion Care Centre of Virginia, Richmond, Virginia, United States; 3School of Applied Engineering and Technology, New Jersey Institute of Technology, Newark, New Jersey, United States

Objectives

The objectives of this prospective study were to evaluate the impact of concussion on the visual accommodative system in an adult population.

Methods

Adults aged 18 to 65 years old referred to a neuro-optometry clinic for visual complaints postconcussion were recruited to participate in this study. Data were collected, after obtaining informed consent, from the routine comprehensive neuro-optometric evaluation. Measurements of the accommodative system (ability of the eye to change focus) included monocular near point of accommodation (NPA) and accommodative facility testing using ±1.50 flipper lens. NPA was performed 3 times for each eye, and flipper testing was attempted for 30 seconds for right eye, left eye, and both eyes using a suprathreshold (2 log scales above threshold near acuity) letter target. Participants wore their habitual preconcussion refractive correction, which was no correction, single-vision distance correction in either glasses, or contact lenses. When necessary, near aids were used for participants (n = 3) who required them to see the near target.

Results

Eighteen participants (13 females) were recruited to date with an average age of 38.8 ± 10.6 years and range of 20 to 55 years. The average time from injury to baseline measurement was 22.2 ± 29.1 months. The difference from age-expected NPA (cm) was calculated for each trial. On average for each of the 3 trials, the right eye NPA (−3.0+7.5, −4.1+7.6, −5.1+7.6) and left eye NPA (−5.0+9.9, −6.1+10.0, −6.8+10.4) were reduced beyond age-expected norms and worsened with repeat testing. Eleven out of 18 (61%) participants had an NPA that was different (>2-cm difference) in their right eye versus the left eye. The majority of participants (83%) had accommodative insufficiency (AI), while 3 participants aged 48 to 52 years had overaccommodation/accommodative spasm (AS) confirmed with facility testing (unable to relax focus with plus lenses). Facility testing for those with AI revealed 40% (6/15) of participants were unable or slow to engage accommodation, which is consistent with an AI diagnosis. However, 20% (3/15) were unable to relax accommodation but could engage it with facility testing, and 20% (3/15) were unable to engage or relax their accommodation, which would make correction of the AI with glasses difficult.

Conclusion

Accommodative testing is rarely performed in the adult population due to the onset of presbyopia after the age of 38 years. However, these data suggests that accommodative dysfunction, including accommodative insufficiency is beyond presbyopic expectations. Asymmetric accommodation, accommodative spasm, and accommodative infacility are also prevalent in the adult population with traumatic brain injury.

The data show the importance for all clinicians to measure (at minimum) monocular NPA and compare with age-expected norms to diagnose posttraumatic accommodative dysfunction and to refer for neuro-optometric evaluation and treatment using either glasses or vision therapy.

79 Qualitative Feasibility Data Related to the Child in Context Intervention (CICI) Study

Eli Marie Killi1; Edel Jannecke Svendsen2; Ingvil Laberg Holthe2; Nina Rohrer-Baumgartner2; Line Kildal Bragstad3; Marianne Løvstad2; Maria Sandhaug1

1Statped, Department of Research & Development, Oslo, Norway; 2Sunnaas Rehabilitation Hospital, Department of Research, Oslo, Norway; 3University of Oslo, Department of Nursing Science and CHARM/Oslo Metropolitan University, Department of Occupational Therapy, Prosthetics and Orthotics, Oslo, Norway

Background

Children with acquired brain injury (ABI) struggle with complex impairments in the chronic phase, including cognitive, social, and emotional challenges. However, evidence-based rehabilitation recommendations are sparse for children with ABI and their families in this phase. The current study presents qualitative data from a feasibility trial to prepare for the randomized controlled trial (RCT): The Child in Context Intervention (CICI). The CICI study is an individualized, goal-centered, home-based intervention delivered mainly through videoconferencing.

Objective

To explore the feasibility and acceptability of the study protocol as experienced by the children, the parents, and the teachers.

Method

Qualitative approach with 18 digital semistructured individual interviews with the 3 groups of participants, including the children aged 11 to 15 years (n = 6), parents (n = 11), and teachers (n = 6). All children had clinical ABI diagnoses (traumatic brain injury: n = 2; hemorrhages: n = 2; anoxic injuries: n = 2). The interview guides focus on the outcome, collaboration, codetermination, and need for adjustments in the future definitive RCT protocol.

Results

The CICI intervention was perceived as acceptable and feasible to teachers, especially rewarding for parents, and somewhat less acceptable for children. All parents expressed a high degree of satisfaction regarding collaboration and codetermination in the study. Some teachers struggled to see the relevance fully, along with an experience of not having enough influence regarding the scheduling of meetings, but all experienced constructive collaboration that contributed to a better understanding of the children. As anticipated, the children's enthusiasm about participating varied. Some of the children felt there were too many meetings, and the questionnaires were not perceived as relevant from the children's point of view. Children and parents expressed a wish for physical meetings in favor of digital meetings.

Conclusion

This qualitative study has provided rich and detailed information about the children's, parents', and teachers' experiences and perceptions of the CICI proved feasible and acceptable for families and schools. Adaptations will be made for the future RCT by reducing the number of questionnaires. Understandably, children with cognitive challenges and varying degrees of insight can be less engaged in telerehabilitation. Therefore, efforts will be made to continue to engage children in videoconferences.

80 Fatigue in Young Patients With Acquired Brain Injury in an Outpatient Rehabilitation Setting; A 2-Year Follow-up

Florian Allonsius1,2; Frederike Van Markus1; Arend de Kloet1; Thea Vliet Vlieland2; Menno van der Holst1,2

1Basalt Rehabilitation Center, the Hague, the Netherlands; 2Leiden University Medical Center, Leiden, the Netherlands

Objective

Impairments after acquired brain injury (ABI) are common in young patients, including “less visible” impairments of body functions such as fatigue. As knowledge of the long-term course of fatigue in young patients with ABI, who are in the rehabilitation phase of recovery, is scarce, this study aimed to describe fatigue from admission to rehabilitation up to 2 years thereafter in this group of patients.

Methods

This longitudinal, national, multicenter study (10 rehabilitation centers) included patients with ABI (traumatic [TBI] and nontraumatic [nTBI] brain injury) between 5 and 24 years of age who were referred to outpatient rehabilitation clinics. The assessments were performed at admission (T0) and 1 (T1) and 2 years (T2) later and included the PedsQL Multidimensional Fatigue Scale (MFS), which yields a total score and 3 subscale scores: general fatigue, cognitive fatigue, and sleep/rest fatigue. The total and subscale scores range from 0 to 100, with a lower score indicating higher fatigue levels. Furthermore, demographic and injury-related characteristics of patients were collected at T0. Descriptive statistics were used to describe the outcomes (means, standard errors [SE]). The PedsQL MFS scores over time were examined using linear mixed models and presented with (estimated) means (SE) for the T0 scores and change scores (95% CI) for T0-T1, T1-T2, and T0-T2.

Results

Two hundred twenty-three patients were included, with a median age of 15 years (IQR = 12-16); 167 (75%) had a TBI; 132 of 176 (79%) were classified as “mild.” Forty percent of the patients were referred for outpatient rehabilitation more than 6 months after brain injury onset. At admission (T0), the patients reported high levels of fatigue (mean = 50.0; SE = 1.2). The highest fatigue levels were found on the Cognitive Fatigue subscale (mean = 45.5; SE = 1.6). Over the course of 2 years, the mean total MFS score improved significantly between T0 and T1 (9.3; 95% CI, 4.9-13.6) and T0/T2 (9.5; 95% CI, 4.9-14.1), while the improvement between T1 and T2 was marginal and did not reach statistical significance (0.2; 95% CI, −4.5 to 4.9). However, fatigue remained a considerable problem 2 years after admission.

Conclusions

Young patients with ABI referred to an outpatient rehabilitation clinic reported high levels of fatigue at referral. Fatigue scores improved over time, especially in the first year after referral to outpatient rehabilitation. This study underlines the importance of targeting and measuring fatigue over the course of time before during and after a young patient with ABI is admitted to rehabilitation.

81 Fatigue in Young Patients With Acquired Brain Injury in the Rehabilitation Setting: Categorizing and Interpreting Fatigue Severity Levels.

Florian Allonsius1,2; Arend de Kloet1; Frederike van Markus1; Thea Vliet Vlieland2; Menno van der Holst1,2

1Basalt Rehabilitation Center, the Hague, the Netherlands; 2Leiden University Medical Center, Leiden, the Netherlands

Objectives

Persisting fatigue in young patients with acquired brain injury (ABI) is common. However, to better target fatigue after the onset of ABI, there are no clear ways to categorize and interpret fatigue severity in individual patients. Fatigue outcomes are often presented on a continuous scale (0-100) with a specific (total) score. However, categorizing “fatigue severity levels” based on scores from a healthy reference population could help better interpret fatigue. To date, such levels are not available. This study aims to determine/categorize fatigue severity among children/adolescents/young adults with ABI in the outpatient rehabilitation setting compared with healthy peers.

Methods

This cross-sectional study included children (5-12 years)/adolescents (13-17 years)/young adults (18-25 years) admitted to outpatient rehabilitation. To determine fatigue, patients completed the PedsQL Multidimensional Fatigue Scale (MFS). It yields a total score and 3 subscale scores: general fatigue; cognitive fatigue; and sleep/rest fatigue. The total and subscale scores range from 0 to 100, with a lower score indicating higher fatigue levels. In addition, demographic/injury-related characteristics were collected. Descriptive statistics were used to describe all outcomes. To categorize fatigue severity levels, mean (SD) total scores and subscale scores from a reference population were used to make 4 severity-level categories and could be presented in a normal distribution curve.

  • Category 1: more than +1 SD from the mean score: less fatigued than healthy peers;
  • Category 2: between −1 SD and +1 SD from the mean score: comparably fatigued compared with healthy peers
  • Category 3: between −1 SD and −2 SD from the mean score: moderately more fatigued
  • Category 4: more than −2 SD from the mean score: severely more fatigued than healthy peers

Results

Two-hundred twenty-three patients were included, with a median age of 15 years (IQR = 12-16), and 167 (75%) had a traumatic brain injury; 132 of 176 (79%) were classified as “mild.” All scores of patients with ABI were considerably lower than those from the reference population. In children, the mean total PedsQL MFS score was 57.5 (14.0) versus 77.6 (20.4) in healthy peers. The total mean scores for adolescents were 50.1 (17.1) versus 75.2 (12.1) and for young adults 40.2 (17.5) versus 71.8 (14.6); both reached statistical significance (P < .05). Results after categorizing fatigue severity showed that the proportions of patients who were “severely more fatigued than healthy peers” (category 4) were 9%/50%/58% among children/adolescents/young adults. These results show that especially adolescents and young adults were severely more fatigued compared to healthy peers.

Conclusions

Measuring and categorizing fatigue into severity levels look promising and applicable to clinical practice as they provide more insight into how big a “problem” is compared with “normal.” It could help to better target fatigue, improve goal setting, and enhance the evaluation of individualized treatment related to fatigue in young patients receiving rehabilitation treatment.

83 Assessing the Informational and Resource Needs of Individuals and Their Caregivers in the First 5 Years After Traumatic Brain Injury

Natalie Jenkins; Olga Garduño-Ortega; Michelle Smith; Tamara Bushnik

NYU Langone—Rusk Rehabilitation, New York, United States

To describe informational needs, as part of a Resource and Education Provision Program (REPP), of individuals impacted by traumatic brain injury (TBI). To document areas of additional educational and resource needs of individuals with TBI and their caregivers and attain a better understanding of reasons for no additional information provision during across the first 5 years of recovery.

Individuals with TBI and their caregivers who participated in a New York City–based center of the nationwide Traumatic Brain Injury Model Systems (TBIMS). This center's initiative, REPP, was initiated after identifying and tracking unmet resource and educational needs at different times of recovery based on individual requests and observations during the research follow-up at 1, 2, and 5 years postinjury.

Participants eligible to receive REPP packets and completed year 1, year 2, or year 5 follow-up questionnaire were included in this analysis (N = 320). Information provided to participants was categorized as follows: Outpatient Healthcare Services & Programs, TBI Online Resources, Advocacy-related & Public Benefits, Caregiver-specific, Understanding TBI, Physical Health, Emotional & Behavioral Health, Cognitive Health, and Interpersonal Aspects. Descriptive statistics were utilized to measure the variables of interest.

At time of injury, most participants (N = 228) identified as male (82.5%), English- (65.5%) or Spanish-speaking (25.2%), Hispanic (33.6%), White (31%) or Black (23%), and had an average age of 48 years (SD = 18). Across all years, on an average, 99% of participants (N = 320) received REPP standard educational packets; of those who received REPP additional information (N = 214), 63% were individuals with TBI and 74% were caregivers. Most participants (89%) who did not receive additional information reported they did not need any additional information or resource materials.

With respect to REPP additional informational provision, at year 1, most participants received information in the areas of Understanding TBI (survivors 67%; caregivers 44%), followed by Physical Health (survivors 8%; caregivers 16%) and TBI Online Resources (survivors 9%; caregivers 9%). At year 2, most participants received information in the areas of Understanding TBI (survivors 27%; caregivers 45%), followed by Cognitive Health (survivors 18%; caregivers 20%), and TBI online resources (survivors 12%; caregivers 9%), while survivors received more information in the areas of Emotional & Behavioral Health (12%), Physical Health (14%) and Outpatient Healthcare Services & Programs (10%). At year 5, participants mostly received additional materials in the areas of TBI Online Resources (survivors 52%; caregivers 35%), followed by Outpatient Healthcare Service Information (survivors 18%; caregivers 19%), and Advocacy-related & Benefits Services (survivors 9%; caregivers 23%).

These findings support the needs for standard informational and resource provision accounting for needs after brain injury. However, this study also identified changing and overlapping provision of additional educational and resource materials between individuals living with TBI and their caregivers across the first 5 years of recovery post-TBI.

84 The Effect of Initial Hematocrit on Functional Outcomes After Traumatic Brain Injury

Rachel Teranishi1; Stephanie Gray2; Mark Newman3; Toan Huynh2; Shanti Pinto3

1Atrium Health Carolinas Rehabilitation, Charlotte, North Carolina, United States; 2Carolinas Medical Center, Charlotte, North Carolina, United States; 3University of Texas Southwestern Medical Center, Dallas, Texas, United States

Objectives

The relationship between anemia and functional outcomes after traumatic brain injury (TBI) has not been well established. Similarly, there is no agreement in the literature regarding the effect of transfusions, nor what transfusion threshold should be used to optimize recovery. The goal of the present study was to investigate whether there is an association between the initial hematocrit (Hct) upon admission to the acute care hospital and functional outcomes up to 5 years post-TBI.

Methods

Participants included a sample of adults with moderate to severe TBI enrolled at a single TBI Model Systems (TBIMS) site between 1999 and 2012. Acute care data were obtained from an institutional Level I Trauma Center database, and information from the 2 databases was linked for individual participants based on at least 2 patient identifiers. The final sample for analysis included 669 persons and only those were included if Hct was collected within 30 minutes of arrival to the hospital. Individuals were categorized by anemia severity based on Hct scores as defined by the World Health Organization (WHO): mild anemia for Hct, 33%-35.9%; moderate anemia for Hct, 24%-32.9%; and severe anemia for Hct, <23.9%. Demographic information, injury-related variables, and functional outcomes as measured by the Functional Independence Measure (FIM), Disability Rating Scale (DRS), and Glasgow Outcome Scale-Extended (GOSE), at 1, 2, and 5-year follow-up time points were collected. To assess the relationship between Hct and functional outcomes, the Kruskal-Wallis test was used to compare continuous data between groups and the chi-square test was used to compare categorical variables.

Results

The majority of individuals had Hct at or above normal range at admission to the hospital. Of those with Hct < 36%, 78 (11.7%) individuals were classified as having mild anemia, 103 (15.4%) had moderate anemia, and 19 (2.8%) had severe anemia. Gender, cause of injury, and whether craniotomy or craniectomy was performed were significantly associated with anemia severity. The acute care and rehabilitation hospital length of stay were not affected by anemia severity. Similarly, there was no difference in functional outcomes based on the FIM, DRS, or GOSE at 1, 2, or 5 years after injury.

Conclusion

Mild, moderate, and severe levels of anemia did not adversely affect functional outcomes in patients with TBI at discharge from rehabilitation or at follow-up at 1, 2, and 5 years postinjury. This suggests that long-term functional outcomes are not impacted by initial Hct at hospital admission.

85 Educating Families of Brain Injury Patients During Acute Rehabilitation: A Quality Improvement Project

Yi Zhou1,2; Stacey Jou1,2; Kathryn Altonji1,2; Hayk Petrosyan1; Brian Greenwald1,2; Richard Malone1,2; Lei Lin1,2

1Hackensack Meridian JFK Johnson Rehabilitation Institute, Edison, New Jersey, United States; 2Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, United States

Introduction

Lack of information is often cited as a source of distress for families and caregivers of patients with brain injury during the recovery process. Prior studies have identified that families value being well informed and receiving information as early as possible. The Model Systems Knowledge Translation Center (MSKTC) Traumatic Brain Injury Model Systems (TBIMS) Factsheets have been developed to provide education and translate health information into easy to understand language. The factsheets are peer-reviewed and informationally published materials on brain injury available online for the brain injury community.

Objectives

This is a quality improvement project with the purpose of educating family members of brain injury patients about acute inpatient rehabilitation and providing a reliable source of information (MSKTC TBIMS Factsheets).

Materials and Methods

The study was conducted in the brain injury unit of an acute inpatient rehabilitation facility. A total of N = 30 family members participated in the study. Educational sessions were provided verbally by phone based on the MSKTC TBIMS Traumatic Brain Injury and Acute Inpatient Rehabilitation Factsheet. The sessions addressed the purpose of brain injury rehabilitation, the roles of the interdisciplinary team, general discharge planning, and how to access the MSKTC TBIMS Factsheets. Surveys with 5 confidence statements and Likert scale graded responses were verbally administered by phone immediately before and after each educational session to evaluate for the understanding of acute inpatient rehabilitation, assess awareness of the TBIMS Factsheets, and provide time for participant feedback.

Results

Of the family members who were offered to be part of the study, 93.8% (30/32) participated in the sessions. There was a statistically significant increase in confidence for all 5 confidence statements when comparing pre- and posteducation responses (P < .05, Wilcoxon signed-rank test).

Conclusion

This quality improvement project presents an effective and feasible framework for teaching, improving communication, and providing valuable information to families early in the brain injury rehabilitation course.

87 Family-Centered Service in Pediatric Acquired Brain Injury Rehabilitation: The Family Perspective

Taylor Jenkin1,2; Kate D'Cruz3; Vicki Anderson1,2,4,5; Adam Scheinberg1,5,6; Sarah Knight1,5,6

1Murdoch Children's Research Institute/The University of Melbourne, Altona, Victoria, Australia; 2Melbourne School of Psychological Sciences, The University of Melbourne, Melbourne, Victoria, Australia; 3La Trobe University, Melbourne, Victoria, Australia; 4Royal Children's Hospital, Melbourne, Victoria, Australia; 5Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia; 6Victorian Paediatric Rehabilitation Service, Royal Children's Hospital, Melbourne, Victoria, Australia

Background and Objectives

Pediatric acquired brain injury (ABI) can significantly impact children/adolescents and their families, and family-centered service is considered best practice in pediatric ABI rehabilitation. However, families report unmet needs during rehabilitation and there is no universal model to guide clinicians and services in implementing this approach, with a lack of research evidence informed by the lived experience of families. This qualitative study explored experiences of family-centered rehabilitation from the perspectives of parents/caregivers, siblings, and children/adolescents with ABI.

Methods

Semistructured interviews were conducted with participants from 8 families and included 10 parents/caregivers, 5 siblings, and 4 children/adolescents with moderate to severe ABI who had participated in a statewide pediatric rehabilitation service. Interview transcripts and researcher reflective memos were analyzed using constructivist grounded theory methods.

Results

Two themes and subthemes were developed: (1) Working together as a team: Valuing clinicians' expert knowledge; Doing rehabilitation together; and Sharing family knowledge; and (2) Navigating rehabilitation as a family: Recognizing family needs; Juggling family life; and Making rehabilitation work for the family.

Participants reflected on the centrality of the child/adolescent with ABI, who is the focus of rehabilitation for the family. While participants described family needs and the impacts of ABI on the entire family, the experiences of the families were closely tied to the support needs of the child/adolescent with ABI.

Participants also reflected on how family needs, life, and involvement in rehabilitation change over time and across different rehabilitation stages as the child/adolescent and family develop.

Conclusions

This study contributes to an evidence base to guide clinicians and services in supporting family needs and involvement in rehabilitation following pediatric ABI. The findings provide insights into the experiences of children/adolescents with ABI and their family members in rehabilitation and highlight the value of active collaboration, drawing upon the shared expertise among the child/adolescent, family, and rehabilitation clinicians. The findings also underscore the importance of clinicians striving to develop an understanding of families' unique contexts to determine how to best support and involve them in rehabilitation.

89 Inpatient School Programs and Hospital-School Transition in a Severe Brain Injury Unit at Ferrara University Hospital: A Case Report

Antonella Bergonzoni1; Marina Macca2; Chiara Forlani3; Federica Vezzali3; Susanna Lavezzi2

1Neuropsychological Rehabilitation Unit, Ferrara University Hospital, Ferrara, Italy; 2Severe Brain Injury Unit, Ferrara University Hospital, Ferrara, Italy; 3Comprehensive State Institute “Alda Costa,” Ferrara, Italy

Inpatient school programs allow all students affected by severe pathologies to continue their studies while they are hospitalized. In our brain injury unit, school programs are included in the individualized rehabilitation plan (IRP) of pediatric brain-injured patients with complex motor, cognitive-behavioral, and communication disabilities. We describe our experience with an 18-year-old patient who was attending the fourth year of a professional institute when he reported brain injury. The patient was admitted for intensive care after traumatic brain injury and polytrauma that occurred in April 2018 and was subsequently recommended for intensive inpatient rehabilitation in May 2018. In the beginning, he showed grade 3 axonal diffuse injury and disorder of consciousness corresponding to an unresponsive state. A computed tomographic scan revealed brain swelling as well as bilateral frontal and left thalamic lesions. In September, we observed emergence from minimally conscious state, with a cognitive status corresponding to Level of Cognitive Function (LCF) 5, double hypertonic hemiplegia, and severe dysarthria. The patient started daily neuropsychological treatment and, in February 2019, hospital-based school programs twice a week. At that moment, cognitive impairments corresponding to LCF 6 with severe memory problems and communication disabilities related to dysarthria were present. An augmentative communication system through the use of tablet was proposed in order to facilitate ordinary communication as well as participation in school activities. School attendance continued during the entire period of hospitalization. In the beginning, he attended classes with hospital-based teachers. Later, a teacher belonging to the professional institute attended by the patient with expertise in informatics was also involved in the program. Teachers were informed and educated about the patient's impairments and residual disabilities, especially the cognitive-behavioral and communication ones, and participated in the periodical meetings with the family. After the discharge in October 2019, the patient was readmitted at school. From March 2020, he attended the online classes held by school teachers and sometimes with the support of the hospital school teachers because of the COVID-19 pandemic. Both school teachers and hospital school teachers helped the student to prepare for the oral high school final examination. The patient got the diploma in June 2020.

90 Inpatient School Programs: Experience in a Severe Brain Injury Unit at Ferrara University Hospital From 2012 to 2022

Marina Macca1; Antonella Bergonzoni2; Chiara Forlani3; Federica Vezzali3; Susanna Lavezzi1

1Severe Brain Injury Unit, Ferrara University Hospital, Ferrara, Italy; 2Neuropsychological Rehabilitation Unit, Ferrara University Hospital, Ferrara, Italy; 3Comprehensive State Institute “Alda Costa,” Ferrara, Italy

In Italy, hospital-bound school programs depend on local public school institutions and are authorized by special school-hospital agreements. The aim is to ensure education during hospitalization, recognition of school attendance, promote humanization of healthcare, and facilitate school reentry after discharge. Our hospital-bound school was established in 2001; it carries on programs within the individualized rehabilitation plan of pediatric severe brain-injured patients with Level of Cognitive Function (LCF) 5 or more in collaboration with the interprofessional rehabilitation team. Teachers are informed and educated about the patient's motor, cognitive-behavioral, and communication impairments and residual disabilities and participate in periodical team meetings with the patient and families. The main objectives are as follows: observing cognitive skills related to the academic level and behavioral skills in a nontherapeutic context; acquiring new academic skills through personalized learning; and supporting the rehabilitation programs through the identification and development of new learning strategies. In order to support school reintegration, contacts with class teachers are provided. If necessary, predischarge meetings are also conducted. Follow-up 1 month after discharge is performed in order to determine if there are any difficulties in participation and/or reintegration in the classroom. In total, 24 patients, aged 6 to 21 years (average age 14 years), attended in-hospital school programs within our neurorehabilitation unit between 2012 and 2022. The etiology of brain injury was traumatic in 20 patients and nontraumatic in 4 patients. LCF at admission ranged from 5 to 8, Disability Rating Scale (DRS) category from 7 to 3. Students attended primary school in 6 cases, secondary school in 6 cases, and high school in 12 cases. Time of attendance of school programs ranged from 1 to 31 weeks (average 8.3 weeks). At discharge, LCF ranged from 5 to 8, DRS category from 7 to 1. All patients but 2 (22/24) returned to school and 11 of them required school support. Good compliance from families and patients and strong collaboration with the rehabilitation team was observed in all cases.

91 Characterizing Global Resource Inequality in Management of Traumatic Brain Injury: Results From the Global Neurotrauma Outcome Study (GNOS) Provider Profiling Questionnaire

Mohammed Bashir1; David Clark2; Alexis Joannides2; Peter Hutchinson2; David Menon3

1University of Cambridge, Cambridge, United Kingdom; 2Department of Clinical Neurosciences, Addenbrooke's Hospital, Cambridge, United Kingdom; 3Division of Anaesthesia, Addenbrooke's Hospital, Cambridge, United Kingdom

Introduction

Traumatic brain injury (TBI) is a major cause of morbidity and mortality worldwide. Guideline implementation is associated with improved outcomes; however, management is resource intensive and may not always be feasible to implement, especially in low-resource settings. Despite this, little international data exist evaluating capacity for TBI management. We aimed to characterize international resource availability for the management of TBI and compare provisions across different levels of human development.

Methods

We constructed a questionnaire with 50 items assessing specific resource availability at different stages of TBI management: prehospital, surgery, neurocritical care, and rehabilitation. This was sent to 159 neurosurgical units from 57 countries of different levels of human development which participated in the Global Neurotrauma Outcomes Study. Development was described using the Human Development Index (HDI) and countries were stratified as very high-HDI, high-HDI, medium-HDI, and low-HDI. Questionnaire results were analyzed using descriptive statistics and differences between development levels were tested using appropriate parametric and nonparametric tests. Interrater reliability was assessed by comparing answers of independent respondents from the same institution.

Results

In total, 153 units (96%) completed and returned the questionnaire and centers in very high-HDI, high-HDI, medium-HDI, and low-HDI countries comprised 51%, 22%, 18% and 9% of responses, respectively. Most centers were government funded (85%) and located in urban areas (96%). Median interrater reliability was found to be fair (κ = 0.478). Resource availability and guideline usage were poorest in the prehospital and rehabilitation phases across all HDI strata and best during the surgical management Phase. Amongst all respondents, the prehospital phase was most frequently indicated as the phase for which changes would most improve patient outcomes; intensive care and prehospital care were chosen most amongst centers of less developed regions, while rehabilitation was chosen most by very high-HDI centers. Centers of less developed regions had significantly fewer resources at all phases and most notably lacked provisions at the prehospital, intensive care, and rehabilitation phases. No low-HDI center indicated regular access to basic monitoring and treatment during the prehospital phase. Low-HDI centers were less likely to manage severe TBI patients in specialized intensive care units (ICUs). These centers had significantly limited access to basic management and investigations like intravenous fluids and blood counts in the ICU and only the most developed centers had sufficient access to invasive monitoring. All centers other than the most developed had extremely limited rehabilitation capacity; however, this was least indicated by low-HDI centers as the phase for which changes would most improve patient outcomes.

Conclusion

Capacity for TBI management varies between different human development settings, and populations of less developed regions greatly lack access to evidence-based care. These findings highlight the need for context-specific management guidelines and help direct global health efforts targeting this disparity.

92 Impact of Childhood Acquired Brain Injury on Siblings: A Narrative Review

Mélodie Vallée1; Anne Boissel2; Doctor Mathilde Chevignard3

1University of Rouen/Saint-Maurice Hospital, Rouen/Saint-Maurice, France; 2University of Rouen, Rouen, France; 3Saint-Maurice Hospital/Sorbonne University, Saint-Maurice/Paris, France

Objectives

Childhood acquired brain injury (ABI) is the leading cause of death and childhood acquired disability and represents a major public health issue. ABI causes a number of long-standing motor, cognitive, and behavioral impairments, which impact participation and quality of life. These modifications have an impact in the long term on the whole family, including siblings. The impact of childhood ABI on siblings has been understudied. Thus, the aim of this narrative literature review was to analyze the extent and nature of research on the impact of childhood ABI on siblings and synthetize those results in a descriptive way in order to increase knowledge on siblings' specific needs and develop relevant interventions and supports.

Method

This literature review was based on the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) and the Population-Concept-Context (PCC) methods. A systematic search of 3 databases (PubMed, EMBASE, EBSCOhost) was performed up to May 2021. References listed in other literature reviews related to the subject were examined to identify and add relevant research. Studies addressing issues around siblings of children with ABI were included. No language, location, or date restrictions were applied.

Results

A total of 36 articles were identified and analyzed. Overall, there is a paucity of research on this issue, but interest is increasing over time. Despite variable results, the current literature highlights the negative impact of childhood ABI on family functioning and relationships (findings regarding family functioning, parental attention, relationships, family roles, and the care of the brain-injured individual). The trajectory and quality of life of siblings of children with ABI are modified (findings regarding changes in injured persons and siblings, social stigma, sibling trajectory and quality of life, siblings' needs, and coping strategies). ABI causes psychological distress and has a negative impact on their behavior (focused on the impact of ABI on the psychological health of siblings, including depression, stress, and self-esteem). Finally, findings show that professionals lack knowledge and training on these issues.

Conclusion

This literature review confirms that few studies have been conducted on this topic, and they are heterogeneous, and sometimes contradictory, which may be explained, in part, by the variable and sometimes insufficient methodologies and samples. The impact of childhood ABI on siblings is clear and affects several domains. Although the impact of ABI on siblings has long been considered insignificant compared with that on spouses and parents, this review shows that there is a specific and significant impact on siblings that remains understudied and underaddressed by professionals in terms of diagnosis and targeted interventions. Further studies on this theme therefore appear necessary in order to propose appropriate support for patients' siblings according to their age and situation.

93 Light Readaptation Strategies for Posttraumatic Photophobia and Clinical Considerations for Return to Screen Time

Jacqueline Theis1,2

1Virginia Neuro-Optometry, Richmond, Virginia, United States; 2Concussion Care Centre of Virginia, Richmond, Virginia, United States

Introduction

Photophobia occurs in 50% to 55% of patients with traumatic brain injury. Most notably, patients with traumatic brain injury are often highly sensitive to short-wavelength light including light emitted from fluorescent lights and electronic devices. Clinically, photophobia has a significant impact on quality of life, as it may cause patients to self-isolate at home to avoid external light triggers, which will reduce their capacity to participate in outdoor activities and return to work or school.

Objectives

This presentation reviews the current evidence-based hypotheses of the neuropathophysiology of photophobia. It will specifically elaborate on the differential diagnosis of light sensitivity posttraumatic brain injury. This presentation also discusses the controversial utility of tinted lenses and clinical experience in light readaptation strategies for photophobia management. It overviews considerations for medications, timing for ophthalmologic referral, and recommendations on electronics and screen time use in the acute, subacute, and chronic time frames. It also provides a list of accommodation considerations for visual demands in returning to work and school to minimize symptom provocation.

Methods

Information is presented based upon an evidence-based review of the literature as well as clinical recommendations and case-based examples.

Results

There are multiple pathophysiological pathways underlying photophobia in relation to intrinsically photosensitive retinal ganglion cells and the trigeminovascular system. Because of overlap of pain pathways and comorbidities of traumatic brain injury including dry eye, migraine, cervicogenic headache, medications, subarachnoid hemorrhage, ocular, and psychiatric disease, there are many differentials as to the etiology of a patient's photophobia. Recent retrospective studies have suggested that the use of tinted lenses in the subacute and chronic phases of traumatic brain injury recovery will interfere with natural neural adaptation and thus prolong recovery and in some cases exacerbate photophobia. Use of tints and avoiding light can exacerbate photophobia due to natural retinal dark adaptation. However, it is well documented in the literature that some tinted lenses are useful for photosensitive migraine. Since photophobia may resolve when one of these comorbidities is addressed, consideration of a differential diagnosis in photophobia management is crucial.

Conclusions

Constant use of dark tinted lenses indoors should be advised against in posttraumatic photophobia in subacute and chronic traumatic brain injury without migraine. Avoidance of electronic devices will not aid in readaptation to their use, and light readaptation guidance may expedite return to these activities. Further research is needed to objectify diagnosis and management of photophobia and further explore wavelength dependence.

94 Age at Injury and Postinjury Outcomes 7 to 8 Years After Severe Traumatic Brain Injury in Children/Adolescents and Adults: Findings From the Traumatisme Grave de l'Enfant (TGE) and the Paris-TBI Cohort Studies

Mathilde Chevignard1-3; Hugo Câmara-Costa2,3; Hanna Toure Pellen1; Philippe Meyer4; Claire Jourdan5; Eleonore Bayen2,3,6; Alexis Ruet7; Claire Vallat-Azouvi8; Georges Dellatolas3; Philippe Azouvi9,10

1Saint Maurice Hospitals, Rehabilitation Department for Children With Acquired Brain Injury, and Outreach Team for Children and Adolescents With Acquired Brain Injury, Saint Maurice, France; 2Sorbonne Université, CNRS, INSERM, Laboratoire d'Imagerie Biomédicale (LIB), Paris, France; 3Sorbonne Université, GRC 24 Handicap Moteur Cognitif et Réadaptation (HaMCre), AP-HP, Paris, France; 4Assistance Publique des Hôpitaux de Paris (APHP) Centre—Université de Paris, Paris, France; 5Physical Medicine and Rehabilitation Department, Lapeyronie Hospital, CHRU de Montpellier, Montpellier, France; 6Assistance Publique-Hôpitaux de Paris (APHP), Groupe Hospitalier Pitié-Salpêtrière, Service De Médecine Physique Et Réadaptation, Paris, France; 7Physical Medicine and Rehabilitation Department, CHU Caen, INSERM, Caen, France; 8Laboratoire DysCo, Paris 8 University, Saint Denis, France; 9AP-HP, GH Paris Saclay, Hôpital Raymond Poincaré, service de Médecine Physique et de Réadaptation, Garches, France; 10Université Paris-Saclay, UVSQ, INSERM, CESP, Villejuif, France

Introduction

The present study sought to determine the effect of age at injury on the overall disability levels observed in a sample of children/adolescents and adults followed longitudinally 7 to 8 years after severe traumatic brain injury (STBI).

Methods

We used data from 2 prospective longitudinal cohorts aimed at assessing overall outcome in children/adolescents 7 years following STBI (Traumatisme Grave de l'Enfant [TGE] cohort) and in adults 8 years postinjury (PariS-TBI cohort). The follow-up included 39 children/adolescents (TGE cohort, mean age at injury = 7.5 years, SD = 4.6; range, 0.3-14.7) and 86 adults (PariS-TBI cohort, mean age at injury = 33.7 years, SD = 13.8; range, 14.6-74.3) who sustained STBI (Glasgow Coma Scale [GCS] score of 8 or less for children and adults, and/or Injury Severity Score [ISS] > 16 for children). Both studies assessed baseline demographics (age, gender, educational level) and initial injury severity (GCS, ISS, length of coma). The follow-up assessment included comparable measures of clinician-rated overall disability (Glasgow Outcome Scale Extended [GOS-E]) and clinical/neurological recovery, as well as self- and/or proxy-reported questionnaires assessing school/work situation, anxiety/depression symptoms, quality of life, and perceived burden by the caregiver.

Results

Age at injury was not associated with the GOS-E scores 7 to 8 years postinjury but was associated with length of coma and presence of motor deficits. Children evidenced shorter coma durations despite an overall level of postinjury disability comparable with adults, and adults tended to report more frequently the presence of postinjury motor deficits and greater fatigue levels when than children. In children/adolescents, the ISS predicted uniquely the postinjury GOS-E score, while for adults the most significant predictors were the GCS score, coma duration, and the number of completed years of education. For both children/adolescents and adults, overall disability 7 to 8 years postinjury correlated with a range of concurrent difficulties including school/work adaptations, presence of motor deficits and anxiety/depression symptoms, lower health-related quality of life, and higher levels of perceived burden reported by the caregivers.

Discussion

STBI occurring either in childhood or in adulthood encompasses a wide range of difficulties in the long term, but the impact of the initial injury severity underlying these impairments might be different according to age at injury. Our results underline the potential of using comparable measures for assessing overall and specific outcomes among pediatric and adult populations.

95 Parental Report of Levels of Care and Needs 7 Years After Severe Childhood Traumatic Brain Injury: Results of the Traumatisme Grave de l'Enfant (TGE) Cohort Study

Mathilde Chevignard1-3,5; Hugo Câmara-Costa2,3; Eleonore Bayen2-4; Hanna Toure Pellen5; Philippe Meyer6; Georges Dellatolas3

1Saint Maurice Hospitals, Saint Maurice, France; 2Sorbonne Université, CNRS, INSERM, Laboratoire d'Imagerie Biomédicale, LIB, Paris, France; 3Sorbonne Université, GRC 24, Handicap Moteur Cognitif et Réadaptation—HaMCre, Paris, France; 4Department of Physical Rehabilitation Medicine, Pitié-Salpêtrière Hospital (AP-HP), Paris, France; 5Rehabilitation Department for Children With Acquired Brain Injury, and Outreach Team for Children and Adolescents With Acquired Brain Injury, Saint Maurice Hospitals, Saint Maurice, France; 6Assistance Publique des Hôpitaux de Paris (APHP). Centre—Université de Paris, Paris, France

Introduction

Childhood traumatic brain injury (TBI) is a major public health concern. Severe TBI often leads to significant physical, cognitive, and behavioral impairments, which have long-standing impact on the child's functioning, participation, education, and quality of life. The Care and Needs Scale (CANS) and the Pediatric Care and Needs Scales (PCANS) were developed for adults (>15 years) and children (5-15 years) to assess the type and amount of assistance needed. The purpose of this study was (1) to study the utility of the CANS and the PCANS to assess the level of care and needs in children and young adults who experienced severe childhood TBI compared with a matched control group, and (2) to specify the factors (sociodemographic, injury-related, and concurrent outcome measures) associated with parental report of high levels of care and needs.

Methods

From the 65 children (0-15 years) consecutively admitted to the Parisian regional TBI reference intensive care unit following severe TBI and included in this prospective longitudinal study, 39 patients (age at injury: M =7.5 years, SD = 4.6; age at assessment: M = 15.3, SD = 4.4; initial Glasgow Coma Scale score: M = 5.7, SD = 1.7; length of coma: M = 6.7, SD = 4.9 days) were followed 7 years postinjury and compared with a control group matched for age, sex, and parental education level (n = 34).

We used the CANS and the PCANS, completed by the caregivers during a semistructured interview, to assess the primary outcome. Concurrent measures included overall level of disability and parent- and/or self-reported questionnaires assessing executive functioning, behavior, quality of life, fatigue, participation, and caregivers' burden.

Results

We used the CANS in 18 participants with TBI and 18 controls aged 16 years or older, and the PCANS with 21 TBI participants and 15 controls aged younger than 16 years. In the control group, the level of care and needs was very homogeneous for the CANS, whereas PCANS scores were extremely variable. The level of care and needs was higher in the TBI group than in the control group, the difference being significant with the CANS only. We defined 2 TBI subgroups, a subgroup of high-level needs (n = 19), including participants with scores higher than all the controls, and a low-level needs subgroup, including the remaining participants (n = 20). High level of dependency was significantly associated with initial TBI severity (higher length of coma), receipt of special education, higher levels of behavioral problems, executive function deficits, fatigue, and lower levels of participation. Caregivers' burden was strongly associated with the CANS.

Discussion and Conclusion

The CANS provides a simple and reliable measure of the support needed in the long term after childhood TBI. The PCANS scores were not significantly different between groups, which seems to illustrate the difficulty to accurately assess mild-to-moderate deficits of functionally independent/adaptive behavior in children based exclusively on parental reports.

96 Assessment of Everyday Life Executive Functioning Following Ischemic or Hemorrhagic Childhood Stroke Using the BRIEF Questionnaire

Mathilde Chevignard1-5; Camille Eveilleau1; Aude Mariller1,2; Hanna Toure Pellen1-3; Valentine Verdier1,3; Emmanuelle Pineau-Chardon1,3; Nathalie Fournet7; Jean-Luc Roulin7; Arnaud Roy6,8

1Saint Maurice Hospitals, Saint Maurice, France; 2Rehabilitation Department for Children With Acquired Neurological Injury, Saint Maurice Hospitals, Saint Maurice, France; 3Outreach Team for Children and Adolescents With Acquired Brain Injury, Saint Maurice Hospitals, Saint Maurice, France; 4Sorbonne Université, Laboratoire d'Imagerie Biomédicale, LIB, Paris, France; 5Sorbonne Université, Groupe de Recherche Clinique n°24 Handicap Cognitif et Moteur et Réadaptation (HaMCRe), Paris, France; 6University of Angers, Laboratory of Psychology of Pays de la Loire, EA4638, Angers, France; 7Univ. Grenoble Alpes, Univ. Savoie Mont Blanc, CNRS, LPNC, Grenoble, France; 8Neurofibromatosis Clinic and Learning Disabilities Reference Center, Nantes University Hospital, Nantes, France

Introduction

Childhood stroke is a rare condition that can cause cognitive impairments, including executive functions deficits, although few studies have focused on this topic, especially using ecological assessments. The purpose of this study was to describe executive functioning profile after childhood stroke using both standardized neuropsychological tests and the Behavior Rating Inventory of Executive Functions (BRIEF) questionnaire, parent (BRIEF-P) and teacher (BRIEF-E) versions, to study demographic and medical factors associated with executive functioning and to compare parent and teacher ratings of executive functioning.

Methods

Retrospective collection of demographic, medical, neurological, and neuropsychological data, including the BRIEF questionnaire, regarding assessments conducted between 2011 and 2020 in children who were hospitalized and/or followed up in a rehabilitation department following childhood stroke (ischemic or hemorrhagic). The BRIEF questionnaire comprises 8 subscales, leading to 3 composite scores (mean T-score 50; SD = 10; a score ≥65 is considered in the clinical range).

Results

In total, 50 children (60% boys; age at stroke: mean = 8.5 years, SD = 4.46; range, 0.30-17.80; time since stroke: mean = 3.18 years, SD = 3.46; range, 0.16-12.13). On neuropsychological assessments, intellectual ability was within the average or low average range (processing speed index 1 SD below expected values) and children had significant deficits in sustained attention, divided attention, and cognitive flexibility.

For the BRIEF questionnaire, scores were significantly high on all BRIEF-P subscales and composite indices (all Ps < .05), with worse scores in the Working Memory subscale (mean = 59.93, SD = 13.75, 1 SD above expected values) and the 3 composite indices of behavior regulation (BRI; mean = 58.28, SD = 15.42), metacognition (MI; mean = 57.98, SD = 13.92), and global executive composite (GEC; mean = 58.02, SD = 13.99). T-scores were in the clinical range (≥65) in 23.9% to 34.78% of cases, and one-third of GEC scores were in the clinical range, indicating significant executive functioning deficits in everyday life. The values were similar for BRIEF-E (n = 14) but did not differ significantly from the norms, except for the Initiation (mean = 60.86, SD = 15.48, P = .021) and Working Memory (mean = 60.79, SD = 17.39, P = .037) subscales. BRIEF-P and BRIEF-E were significantly correlated for most subscales and composite indices (rho = 0.657-0.815). Finally, BRIEF scores were strongly associated with the type of ongoing education at the time of assessment.

Discussion and Conclusion

Deficits in executive functions are frequent following childhood stroke and have an impact on everyday life, both at home and in the classroom. This confirms the need to monitor the development of these children in the long term in order to detect possible deficits and implement appropriate and timely interventions (rehabilitation, guidance, or school adaptations, etc).

97 The Feasibility of Transcranial Direct Current Stimulation as an Adjunct to Inpatient Physiotherapy in Children and Youth With Moderate to Severe Acquired Brain Injury

Jennifer Ryan1,2; Deryk Beal1,2; Darcy Fehlings1,2; Danielle Levac3; Virginia Wright1,2,4

1Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada; 2Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada; 3School of Rehabilitation, University of Montreal, Montreal, Quebec, Canada; 4Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada

Objectives

Rehabilitation technologies, such as transcranial direct current stimulation (tDCS), have potential to improve motor outcomes in children and youth with moderate to severe acquired brain injury (ABI). tDCS modulates cortical activity and is thought to enhance neuroplasticity when combined with motor skill practice. The subacute stage of ABI is a time when children have the most potential for motor improvement and typically participate in inpatient physiotherapy to address mobility goals. Physiotherapy is an ideal form of motor practice to pair with tDCS because it is individualized to address child-specific gross motor goals. The objective of our study was to evaluate the feasibility of tDCS as an adjunct to traditional inpatient physiotherapy in children with ABI.

Methods

This feasibility randomized control trial allocated children (5-18 years old) with moderate to severe ABI to receive 20 minutes of active or sham anodal tDCS immediately prior to their existing inpatient physiotherapy at Holland Bloorview Kids Rehabilitation Hospital for a total of 16 sessions. Participants, physiotherapists, assessors, and primary investigators were blinded to treatment allocation. The following feasibility indicators were evaluated against a priori targets: eligibility, recruitment, retention, tolerance, and preliminary treatment effect. Inpatient ABI admissions were screened on a weekly basis (2020-2021) together with the child's treating physiotherapist and a study physician.

Results

Of 232 children admitted over 21 months, 6 children were eligible and 4 enrolled (2 traumatic brain injury, 2 stroke). One participant completed the entire study protocol, 2 were withdrawn from the study for unrelated medical reasons, and one was unable to commence the study due to COVID-19 restrictions. The eligibility rate (2.6%) was well below the a priori target (20%). Frequent reasons for exclusion were as follows: age (n = 67), brain tumor (n = 37), seizures (n = 26), short admission (n = 12), behavior (n = 8), or decreased tolerance (n = 8). Pre/post-tDCS session tracking indicated that participants tolerated tDCS, with itchiness being the primary transient side effect, and allowed researchers to differentiate between tDCS side effects and symptoms commonly experienced after ABI (eg, headaches, dizziness). The participant who completed the study changed by 33% points on the Gross Motor Function Measure (GMFM-88) during the study protocol, substantially higher than the mean change (18% points) associated with inpatient rehabilitation.

Conclusions

While the few children with moderate to severe ABI who received study treatment tolerated tDCS, feasibility study targets were not met. Given the potential role that tDCS has in improving motor function and the need for stringent eligibility criteria, future inpatient pediatric tDCS research should be multisite to increase enrollment. Some children with ABI may not be ready for tDCS until after discharge and therefore an outpatient tDCS and physiotherapy protocol should also be explored.

98 Evaluating the Clinical Effectiveness of Telerehabilitation During the Pandemic

Laiba Ahmed1,2; Peter Tucker1

1Recolo UK Ltd, London, United Kingdom; 2University of Bristol, Bristol, United Kingdom

Background

In the wake of the COVID-19 pandemic, a reboot for rehabilitation was required (Phillips et al., 2020). Social distancing requirements in lockdown meant clinicians within Recolo UK Ltd delivered rehabilitation remotely since March 2020.

Objectives

To assess clinical effectiveness of rehabilitation delivered in the period of lockdown compared with previous face-to-face rehabilitation within Recolo.

Methods

The clinical effectiveness of therapy pre- and during lockdown was reported using survey of perceived effectiveness and comparative clinical outcome analysis.

Survey

Ten parents of children receiving rehabilitation and 10 practitioners delivering rehabilitation. A clinical effectiveness questionnaire derived from the Child and Adolescent Verona Service Satisfaction Scale (child and adolescent mental health services SS) (Ayton et al., 2007) and the Survey of Parent Satisfaction with Paediatric Neuropsychological Evaluations (Bodin et al., 2008). Recolo practitioners' perception of clinical effectiveness was reported by the Chapman et al. (2020) Clinician's Survey. In addition, global preference questions were asked of parents and practitioners. A paired-samples t test was carried out to compare the parents' effectiveness perception. A Friedman test was carried out to compare clinicians' and parents' preferences.

Outcome

Questionnaires completed by parents of children undergoing rehabilitation were CASP, PedsQL-Core/Family Impact/Fatigue and SDQ: Two sets of T1-T2 change scores were calculated for the 2 different periods: (1) prepandemic (pre-2020) and (2) during pandemic (2020-21). Independent t tests were used to compare the difference between means at these periods.

Results

Survey Results

Remote rehabilitation is considered nonsignificantly more effective than face-to-face according to parents (t9 =2.145, P = .06). Both parents and practitioners preferred face-to-face rehabilitation, then blended, and finally remote. However, the differences were nonsignificant for parents (χ22 = 5.765, P = .065) but significant for clinicians (χ22 = 7.538, P = .023).

Outcomes Results

None of the change scores showed statistically significant differences when the 2 periods were compared. However, the participation measure showed increased participation in period 1 and reduced participation in period 2 (t20 = 0.624, P = .54). Health-related quality of life did not change significantly in both periods (t21 = 0.96, P = .92). Regarding family impact, there was no significant progress at both periods (t27 = 0.068, P = .82). Measures of fatigue (t11 = 0.043, P = .96) and emotional difficulty (t31 = 0.83, P = .41) showed very little difference between the periods.

Conclusions and Recommendation

Given nonsignificant differences in perceived and actual change ratings of clinical effectiveness, remote interventions appeared to have some level of acceptability. Discrimination between lockdown and treatment modality effects on outcome is not demonstrable from this method. There is a need for finer-grained analysis of the therapy modality delivered in and out of lockdown. We also recommend increasing survey sample size and adding qualitative interviews into a future study.

99 Cerebral Dysregulation: A Refined Look at the Process of Disrupted Autoregulation

Brandon Lucke-Wold; Coulter Small; Matthew Goldman

University of Florida, Gainesville, Florida, United States

Cerebral autoregulation has classically been taught on a sigma-shaped curve with a sharp drop off and sharp rise at either end of the spectrum. Historically, the regulation maintains careful homeostatic levels despite external or internal dynamic changes. When proposed dysregulation occurs in the setting of injury, it has been postulated to affect the more flattened plateau phase. We argue herein that the curve is more dynamic and susceptible to influence and dysregulation at all phases of the curve including the sharp drop off and sharp rise at either end. This can be mediated by primary and secondary mechanisms as we discuss in detail and show with experimental data. Furthermore, we highlight lessons learned from hypothermia studies and the inherent limitations of intracranial monitoring to capture continuous variables. More importantly, however, is the use of anesthetic agents and temporizing intracranial pressure control methods, which may have more robust downstream consequences than once envisioned. We carefully evaluate the known literature and introduce topics based on our own clinical data for discussion that warrant further investigation via preclinical and clinical experimentation.

100 Cerebrospinal Fluid Leak in Facial Trauma: Identifying Clinical Risk Factors With a Retrospective Analysis

Brandon Lucke-Wold; Zachary Sorrentino; Kevin Pierre

University of Florida, Gainesville, Florida, United States

Cerebrospinal fluid (CSF) leak occurs most commonly following skull fracture, with a CSF leakage incidence of 25% in facial fracture. This study aims to identify demographic and injury characteristics correlated with the highest risk of CSF leak in patients with known facial fracture.

Retrospective data were collected from a previously described trauma registry from 2010 to 2019. Patients older than 18 years with any type of facial fracture, known CSF leak status, available neuroimaging, and hospital admission were included. Chi-square analysis was used for demographic and injury characteristic data.

A total of 79 patients with CSF leak and 4907 patients without CSF leak were included in the database. Patients with CSF leak tended to be younger than those without CSF leak (M ± SE: 38.45 ± 0.28 vs 44.08 ± 0.28, P = .0197). CSF leak depended on the mechanism of injury (χ2 = 55.02, df = 36, P = .0221) and was more common in patients with a lower Glasgow Coma Scale (GCS) score (7.95 ± 0.58 vs 12.21 ± 0.10, P < .05), LeFort type 2&3 and pan-facial fractures compared with all other facial fracture types (8.1% vs 1.2%, P < .05), and radiographic midline shift (29.4% vs 9.1%, P < .05). There was a trend toward a higher proportion of males in those with CSF leak than in those without (83.3% vs 73.7% males, P = .073).

Facial fractures often present with CSF leak, and certain demographic and injury risk factors including younger age, worse GCS score, evidence of midline shift, and high-energy mechanisms of injury are correlated with increased risk and warrant close screening and follow-up for CSF leak detection. Lefort type 2&3 and pan-facial fractures are at high risk of CSF leak.

101 Pretend Play Ability in Preschool-Aged Children With an Acquired Brain Injury

Adrienne Thorne

Kids Rehab, Children's Hospital at Westmead, Westmead, New South Wales, Australia

This study compared the self-initiated pretend play abilities of preschool-aged children with an acquired brain injury (ABI) and their neurotypical peers. Pretend play is the primary form of play for preschool-aged children. It is essential for cognitive, language, and social skill development and peer engagement.

A nonexperimental group comparison was conducted between 22 preschool-aged neurotypical children (M = 52.8 months, SD = 7.1 months) and 21 children with an ABI (M = 50.5 months, SD = 11.9 months). The children were evaluated individually using the Child-Initiated Pretend Play Assessment (ChIPPA) and the Australian Developmental Screening Test (ADST, Cognitive and Language subtests).

The children with an ABI had significantly lower scores in pretend play ability than their neurotypical peers as measured by the percentage of elaborate play actions in both the conventional (P < .000) and symbolic (P < .000) sections of the ChIPPA, as well as the number of object substitutions (P < .000). The children with an ABI completed significantly less of the play time required than their neurotypical peers (P = .001); 66% could not play for the required time. The children with an ABI had considerably more difficulty incorporating a narrative in their play. There was no significant difference in the ChIPPA scores of the children with an ABI injured before and after the age of 18 months, nor between children with a severe and moderate injury.

The quality and quantity of pretend play of preschool-aged children with an ABI appears to be significantly impacted by their ABI. Assessment of pretend play ability and direct intervention in ABI rehabilitation by occupational therapists is essential to enable children with an ABI to participate in pretend play and garner the developmental benefit this affords.

102 Pretend Play and Executive Function of Preschool-Aged Children With an Acquired Brain Injury

Adrienne Thorne

Kids Rehab, Children's Hospital at Westmead, Westmead, New South Wales, Australia

We had observed that preschool-aged children with an acquired brain injury (ABI), although able to perform structured tasks that were developmentally appropriate, were unable to produce age-appropriate pretend play.

We considered why it might be that a child can engage in age-appropriate structured tabletop tasks like completing a jigsaw or drawing prewriting shapes but not play out a narrative with farm animals.

As pretend play is a complex cognitive skill, we examined the literature about cognitive deficits in children with an ABI to discover the long-term pervasive impact of executive dysfunction in this population. Pretend play after all requires the inhibition of reality, the use of symbols, the remembering of roles, and then the skill of adding to the construct in play with others. These abilities would appear to be congruent with executive function, in particular with inhibition and working memory.

In order to further understand the relationship between pretend play and executive function, we assessed these abilities in children with and without an ABI. This was done with the intention of providing insight into the difficulties children with an ABI face and possible opportunities for improved outcomes from rehabilitation.

The children with an ABI (n = 21) had significantly more difficulty producing age-appropriate pretend play and executive function ability than their neurotypical peers (n = 22).

There was also a strong correlation between pretend play ability and working memory. The application of a Generalized Linear Model revealed pretend play ability to be predictive of executive function ability.

Understanding the relationship between emerging executive function ability and pretend play development in preschool-aged children with an ABI is essential in the provision of comprehensive rehabilitation.

103 Feasibility and Effectiveness of Eye Movement Training for Improved Reading Function in Children and Adolescents After Acquired Brain Injury

Katarina Lauruschkus1,2; Helena Magnusson2; Julia Falkenstrom2

1Lund University, Lund, Sweden; 2Skane Region, Lund, Sweden

Objectives

The eye movement ability is often affected by acquired brain injury (ABI). Visual deficits after ABI contribute to reading difficulties and fatigue, with a negative effect on the reading speed. For children and adolescents, who prior to the ABI read fluently, a poor reading function may decrease their motivation for school activities. In clinical practice, eye movement training has shown some positive effects on the reading function. Knowledge about feasibility, effectiveness, duration, frequency, and intensity of the eye movement training is lacking. Therefore, the aim was to develop and evaluate eye movement training for improved reading function for children and adolescents with visual deficits after ABI.

Methods

Ten children and adolescents with visual deficits after ABI were included in this study and performed eye movement training for 20 minutes daily under 3 weeks in their homes or at school. At baseline, after 3 weeks and after 3 months of vision assessments, a reading speed test and the Revised Convergence Insufficiency Symptom Survey (CISS) were performed at the Habilitation Services. At baseline, participants and their parents were introduced to the home training program. Individual support during the intervention period was given by phone calls or text messages.

Results

All participants completed the training period, and most children improved their reading function, measured by reading speed and CISS symptoms after 3 weeks and 3 months. No negative results were reported.

Conclusions

Eye movement training was feasible and effective for the participating children and adolescents with visual deficits after ABI and may be considered as a cost-effective intervention for this patient group. A full-scale randomized controlled trial is needed to confirm our results.

104 Screening of Prospective Rehabilitation Patients During a Pandemic and Beyond

Nicole Cash; Aoife Skeffington; Ingrid Vriend

Evelina London Children's Hospital, London, United Kingdom

Introduction and Aim

The COVID-19 pandemic led to a rapid transition to remote consultations to minimize virus transmission (Leone et al., 2021). As outlined by Gajarawala et al. (2021), technological advances are increasing because telehealth is an efficient and effective tool for improving healthcare access and outcomes; yet, several barriers to telehealth practice remain to be overcome. The Neurorehabilitation Service at Evelina London Children's Hospital (ELCH) opened in January 2018 to provide dedicated beds for medically stable children and young people (CYP) requiring neurorehabilitation following acute brain injury (ABI). The therapy-led multidisciplinary team (MDT) screens prospective patients prior to acceptance in order to assess if the service is appropriate for the CYP's needs and determine length of stay. Prior to the pandemic, screening was face to face in the referring hospital, meeting first therapists and then CYP and parents/carers. The onset of COVID-19 necessitated changes to screening as infection risks prevented visiting facilities. This article reviews the process in the 2 years prior to and 2 years from the start of the pandemic, looking at challenges and strengths of this process and possible future quality improvement.

Data Points Prepandemic

We received 31 referrals and accepted 17 for rehabilitation. There were a total of 7 screening visits and 11 face-to-face screenings of internal patients. A total of 6 were rejected, and 4 overseas patients were screed on just documentation. Six declined the rehabilitation offer.

Data Points Following Onset of COVID-19

There were a total of 33 referrals received, and we accepted 17 for rehabilitation. Three did not meeting referral criteria, and 1 declined assessment. We had 6 face-to-face screenings of internal referrals, and 21 virtual screenings were completed.

Challenges

In the pivot to telemedicine, the challenges of patient's reliable access to technology and the patient moving from view made observation difficult. Assessing functional level and under/overestimating rehabilitation needs proved challenging. Other difficult moments included explaining expectations and visitation policies of ELCH unit versus the referring unit, having sensitive conversations on screen, and place of getting a hands-on assessment of muscle tone. We also found forming a therapeutic relationship with CYP and caregivers was difficult.

Strengths

All our participants received a visual assessment and were not required long travel times for treatment. We were able to provide a wider treatment team even if team members were working remotely and assessments continued during the pandemic, preventing closure of services.

Conclusions

Despite difficulties with technology, telehealth assessment is likely to remain in place. It is time efficient and allows more children to have formal preassessment.

Next Steps and Plans for Future Improvement

Day-case assessment is being considered where level of need is unclear following video screening. Planned quality improvement project is being considered to formally survey all referring hospital clinicians alongside internal review of recent patients to survey of all service users on referral and admission process.

106 Behavior Problems 7 Years After Childhood Severe Traumatic Brain Injury: Results of the Traumatisme Grave de l'Enfant (TGE) Study

Mathilde Chevignard1-4; Lilia Tokpo1,2; Hugo Câmara-Costa3,4; Hanna Toure Pellen1,2; Philippe Meyer5; Georges Dellatolas4

1Saint Maurice Hospitals, Saint Maurice, France; 2Rehabilitation Department for Children With Acquired Neurological Injury, Saint Maurice Hospitals, Saint Maurice, France; 3Sorbonne Université, Laboratoire d'Imagerie Biomédicale, LIB, CNRS, INSERM, Paris, France; 4Sorbonne Université, GRC 24 Handicap Moteur et Cognitif et Réadaptation (HaMCRe), Paris, France; 5Pediatric Anesthesiology Department, Necker Enfants Malades University Hospital, Université de Paris, Paris, France

The aim of this study was to investigate the occurrence of long-term behavioral problems 7 years after severe pediatric traumatic brain injury (TBI) and their evolution over time at 3 months, 1, 2, and 7 years postinjury.

Methods

This study was drawn from the 7-year follow-up of patients included in the Traumatisme Grave de l'Enfant (TGE) longitudinal cohort: 34 participants (38% girls; age at injury: mean = 7.6, SD = 4.7 years; age at assessment: mean = 15, SD = 4.6 years) underwent comprehensive assessment 7 years after severe childhood TBI (Glasgow Coma Scale [GCS] score ≤ 8 upon admission and/or an Injury Severity Score [ISS] > 16). The TGE study included a control group matched by age, gender, and parental education to participants with TBI at the 7-year follow-up. A subgroup of 20 participants with TBI had available behavioral assessment at 3 months, 1, and 2 years postinjury. We assessed behavioral problems with age-appropriate self- and parent reports of the Achenbach's Behavioral Checklist, which allowed examining 8 syndrome scales of behavioral problems together with 3 composite measures of Internalizing, Externalizing, and Total problems. Additional data included sociodemographic background (gender, parental educational level), initial injury severity (GCS, ISS, length of coma), and specific outcomes assessed 7 years postinjury (Glasgow Outcome Scale, ongoing education, intellectual functioning, executive functions, participation, quality of life, fatigue, and family functioning).

Results

When compared with the control group, self- and parent-reported behavioral problems were significantly higher in participants with TBI for aggressive behavior and thought problems, with a significant proportion (42% and 36%) above the clinical cutoff for externalizing problems. Participants with TBI reported more behavioral difficulties than controls for withdrawn/depressed, somatic complaints, and intrusive behavior, while parents reported significant difficulties on rule-breaking behavior, attention and social problems. There was a tendency of parent-reported behavioral problems to increase over time between 3 months and 7 years postinjury for externalizing (from the 8 participants above the clinical cutoff 7 years postinjury, 5 participants were below the cutoff 3 months postinjury) and total problems (5/10 participants). Greater initial injury severity (longer length of coma and higher ISS) was associated with increased rates of parent-reported externalizing problems.

Conclusions

The present findings underline the association between initial injury severity and the significantly large occurrence of behavioral problems several years postinjury. Our results highlight the importance of long-term follow-up and individualized interventions for children who had severe TBI, since they are at risk for exhibiting externalizing behavioral problems together with a range of cognitive and psychosocial difficulties, including greater overall disability, lower intellectual ability, participation and quality of life, increased sense of subjective fatigue, and poorer family functioning in the long term.

108 The Relation Between SMART Goal Construction and Level of Goal Attainment: A Service Evaluation in the Pediatric Neurorehabilitation Service Recolo Ltd

Lorena Medina Rivas; Peter Tucker

Recolo UK Ltd, Bristol, United Kingdom

Background and Aims

The SMART acronym is widely known as a goal-setting standard across different fields such as business and sports (Locke & Latham, 2002). However, there is insufficient evidence to establish that this standard maximizes goal attainment in neurorehabilitation settings (Evans & Krasny-Pacini, 2017). This study aims to fill the gap in existing literature and improve goal-setting techniques within Recolo Ltd by exploring if SMART goals are positively associated with higher goal attainment in neurorehabilitation settings.

This service evaluation assessed (1) variability of data within the Goal Attainment Scaling (GAS) Light template, and (2) the relationship between goals' “SMARTness” ratings and level of change (from baseline to scaled goal achievement) within the GAS 5-point scale. The ultimate aim was to improve future goal-setting and rehabilitation outcomes.

Methods

This service evaluation was a retrospective within-subjects design. An adapted, 7-item version of the Grant and Ponsford Checklist was used to assess the “SMARTness” of n = 165 anonymized pediatric neuropsychological rehabilitation goals. Two trained rehabilitation practitioners were recruited to rate each goal against the checklist (range, 0-14). Interrater reliability (IRR) was calculated per goal, the overall measure, and individual measure items. Demographic data were not included in the sample.

Two criteria were taken to refine data for the correlational analysis: (1) an IRR cutoff score (κ ≥ 0.41) of SMARTness score per goal, and (2) including only the goals containing both baseline function and postintervention achievement status. This significantly reduced the sample size (n = 30).

Results

Of the 165 goals on GAS sheets, 42.4% contained data in every section, 45.5% contained both “baseline” and “scaled achievement” data. IRR of the overall goal sample and measure was fair (mean = 0.378; SD = 0.40; κ = 0.399; Landis & Koch, 1977). Of the 30 goals with complete data and moderate or higher IRR (mean = 0.74, SD = 0.22, κ = 0.65), SMARTness and level of change were negatively correlated (Tb29 = −0.4, P = .006). A secondary analysis was performed for each SMART component; only the Attainability component within the SMART acronym had a significant negative correlation with level of change (Tb29 = −0.347, P = .019).

Conclusions

Amount of data provided within the GAS Light template was variable. Goal recording can be improved by completing all sections of the GAS Light format. Automated methods of goal setting are recommended to facilitate completion of all sections. SMARTness rating can be improved by using SMART-GEM, which has higher reliability (Bowman et al., 2015). A negative association between SMARTness and goal attainment may be due to (a) “unSMART” goals are more likely to be judged to be achieved by practitioners; or (b) attainment is less influenced by SMARTness and more by a different factor (eg, meaningfulness of the goal to the client/patient; McPherson et al., 2014).

111 Physical Examination of the Concussed Pediatric Patient at Karolinska University Hospital

Måns Widlund Hoxter

Karolinska Institute, Stockholm, Sweden

At Karolinska University Hospital in Stockholm, Sweden, clinicians meet numerous concussed patients every year. Most children and adolescents who experience a concussion recover within a few days or weeks. However, a significant minority of concussed children experience persistent symptoms for many weeks, months, or even years after the injury.

As a physiotherapist in the traumatic brain injury (TBI) team, specialized in pediatric care, we saw the need to assess and manage these patients in a more consistent manner in order to establish adequate treatment, both in the early phase after concussion and for patients with prolonged symptoms. There is an overlap in symptoms between concussive and nonconcussive injuries, and it is important to determine physiological function affected by concussion to improve patient outcomes.

After visiting SickKids Hospital in Toronto in 2014, attending the IPBIS conference in Rome in 2017, and searching the literature for physical examination and recommendations after concussion, we now evaluate concussed patients in a standardized, evidence-based practice.

We measure postconcussive symptoms by using the Rivermead Post-Concussion Symptoms Questionnaire (RPQ), where individual item scores reflect the presence and severity of postconcussive symptoms. In addition, we screen the patient with a neurological examination with emphasis on static and dynamic balance tests and do a vestibular ocular motor screening (VOMS).

Furthermore, we screen for neck injuries since symptoms from the neck can closely mimic those of head injury. One test we frequently use is the cervical relocation test, which measures cervical proprioception.

For those patients who experience signs of exercise intolerance, we perform the Buffalo Concussion Treadmill Test in order to assess the degree of exercise tolerance and identify the heart rate at which concussion-specific exacerbation occurs.

We have also developed factsheets for returning to school, sports, and activity after a concussion.

I will attend the IPBIS conference in New York, and I would love to present how we perform a clinical evaluation and diagnose and treat the concussed pediatric patient.

112 Stable and Time-Varying Mechanisms for Fatigue From 6 to 12 Months Postinjury—A Multilevel Repeated-Measures Study

Daniel Løke1,2; Nada Andelic3,4; Eirik Helseth5,6; Olav Vassend2; Stein Andersson2,7; Jennie L. Ponsford8,9; Cathrine Tverdal5,6; Cathrine Brunborg10; Marianne Løvstad1,2

1Department of Research, Sunnaas Rehabilitation Hospital, Nesodden, Norway; 2Department of Psychology, Faculty of Social Sciences, University of Oslo, Oslo, Norway; 3Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway; 4Institute of Health and Society, Center for Habilitation and Rehabilitation Models and Services (CHARM), University of Oslo, Oslo, Norway; 5Department of Neurosurgery, Ullevål Hospital, Oslo University Hospital, Oslo, Norway; 6Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway; 7Psychosomatic and CL Psychiatry, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway; 8Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Clayton, Victoria, Australia; 9Monash-Epworth Rehabilitation Research Centre, Epworth Healthcare, Richmond, Victoria, Australia; 10Oslo Centre for Biostatistics and Epidemiology, Research Support Services, Oslo University Hospital, Oslo, Norway

Objectives

Persistent fatigue is a common sequela of traumatic brain injury (TBI), and studies examining covariates and predictors often implicate an abundance of biopsychosocial mechanisms involved in its initiation, exacerbation, and amelioration. The current study aimed to untangle the intricate complex of factors often associated with fatigue after TBI and generate a clinically applicable model informing us of stable and time-varying mechanisms involved in initiation and maintenance of fatigue following TBI.

Methods

In total, 103 patients with radiologically verified TBI were included prospectively from the Neurosurgical Department, OUS Ullevål Hospital, and evaluated 6 and 12 months following injury. The study employed several fatigue-related patient-reported outcomes (PROMS), neuropsychological instruments, injury severity indices, and PROMS assessing pain, psychological distress, personality traits, somatic symptom burden, resilience, behavioral activation and inhibition, negative life events, and loneliness. Multilevel factor analysis was conducted, and hybrid mixed-effects multilevel regression analysis was employed, to segregate between- and within-subject effects in the relationships between fatigue and associated factors.

Results

A single fatigue factor was found to underlie the various fatigue PROMS, with considerable intraindividual stability in fatigue across time (intraclass correlation = 0.78). Factors associated with fatigue were found to measure separate underlying dimensions: (1) Psychosocial Robustness (negative loadings from trait neuroticism, psychological distress, and loneliness, and positive loadings from Resilience subscales relating to self-efficacy and positive prospects for the future, and trait extraversion, conscientiousness, and optimism); (2) Somatic Vulnerability (positive loadings from measures of pain severity and dispersion, somatic symptom burden, daytime sleepiness, and insomnia severity); and (3) Injury Severity (Abbreviated Injury Scale—Head and Direct Discharge to Rehabilitation). Somatic Vulnerability demonstrated particularly strong stable associations with fatigue, and Psychosocial Robustness and Injury Severity also had smaller but significant effects. Together, these 3 factors along with female gender explained 61% of the variance in fatigue due to stable differences between subjects.

Within-subject analyses showed that fatigue levels decreased significantly from 6 to 12 months. Changes in pain severity, somatic symptom burden, psychological distress, and behavioral inhibition were positively associated with changes in fatigue and explained 22% of the variance in fatigue within subjects. Post hoc analyses showed that improvements in neuropsychological performance from 6 to 12 months postinjury were associated with improvement in fatigue.

Conclusions

This study demonstrated that several previously implicated factors show robust effects in distinguishing individuals with TBI regarding fatigue levels, but only a select few exert additional within-subject effects across time. Factors such as pain severity and psychological distress display synchronous changes along with fatigue and should be especially targeted in rehabilitation programs of patients with persistent fatigue after TBI.

114 A Mindfulness-Based Communication Enhancement (MBCE) Program for Special Forces With TBI: Using Quality Improvement Methodology

Megan Vaughan

US Department of Veterans Affairs, Department of Defense, Richmond, Virginia, United States

Background

Individuals with traumatic brain injury (TBI) or reoccurring concussions have a constellation of deficits, including cognitive-communication disorders in memory, processing speed, and attention, negatively impacting information processing and discourse (MacDonald, 2017). These functionally pronounced needs decrease verbal and nonverbal communication effectiveness skills (Sohlberg, 2019).

Noted within the TBI population are Active-Duty Special Forces Green Berets Operators. These individuals have additional contributing factors impacting their premorbid communication skill set, such as belonging to a relatively small, insular community with similar psychological and physiological makeups (Farina et al., 2019).

These soldiers are now returning home and admitting to one of the 5 TBI Polytrauma System of Care National Sites in the United States for physical, emotional, and cognitive-communication therapy. On average, they are 10 years post-onset of their initial injury. Following discharge, the patients must be equipped with the cognitive-communication tools needed to seamlessly reintegrate with family and transition to civilian employment. Using quality improvement methodology for translational implementation science, a gap in care was identified: no consistent treatment methodology to address social and vocational communication needs with TBI to focus on functional transitional communication. This gap negatively impacted social integration, meaningful interactions, and performance in vocational and community settings.

Method

Using quality improvement methodology for translational implementation science and the Plan-Do-Study-Act (PDSA) method, a multidisciplinary team of healthcare professionals, psychology, occupational therapy, recreational therapy, vocational counseling, a medical physician, and speech-language pathologists, as well as Active Duty soldiers across 3 states and across 2 entities, the Department of Defense and the Veterans Health Administration, formed a team to identify the best approach for creating a systematic model for social communication.

Through reviews of the literature and current approaches to TBI, high level, mild social communication needs (Paice et al., 2020) and novel applications of mindfulness practices already established in brain injury therapy (Acabchuk et al., 2021), an 8-week mindfulness communication group protocol was developed, implemented, and evaluated for Active-Duty Special Forces Green Berets.

Aim

To measure the effectiveness of the group, the following aims for social communication improvement were established:

  • 20% improvement in communication competency as measured by the Conversational Skills Rating Scale;
  • 20% improvement in pragmatically appropriate interactions as measured by the Pragmatic Rating Scale; and
  • 20% improvement in perspective-taking as measured by the Interpersonal Reactivity Index-Perspective Taking subscale (IRI).

Results

The first cycle achieved an average of 47% improvement across measures. Using the PDSA method, adjustments were made to cycle 2 after studying the outcome variables. Cycle 2 resulted in 66% improvement on average across outcome measures. The group was trialed in both Richmond, Virginia, and Tampa, Florida—2 of the 5 treatment sites. Results were maintained 3 months after treatment during follow-up with cycle 1 participants.

115 Social Participation and Navigation (SPAN): Adaptation, Usability, and Implementation for Youth and Young Adult Brain Tumor Survivors

Gary Bedell

Tufts University, Medford, Massachusetts, United States

Background

Social Participation And Navigation (SPAN; Bedell et al., 2017; Narad et al., 2018; Wade et al., 2018), was initially developed to promote social participation of teenagers with traumatic brain injuries. SPAN consists of 4 main components: (1) virtual coaching with trained/supervised college students; (2) college student coach training and supervision; (3) website with online resources (spanprogram.com); and (4) goal planning web-based app to assist with creating and monitoring goals, strategies, and plans to achieve social participation goals.

Objectives

The presentation describes SPAN and how it was modified, implemented, and pilot tested for adolescent and young adult (AYA) brain tumor survivors (ages 15-23 years). Phases 1 and 2 results are described briefly. Phase 3 results are discussed in more depth.

Phase 1: Methods and Results

We obtained key stakeholder feedback and made minor modifications to coach training (more readings, resources, and content related to brain tumor; more time for coaches to practice and obtain feedback).

Phase 2: Methods and Results

A brief usability trial was conducted. Four AYA survivors (2 adolescents; 2 young adults) received 4 virtual (Zoom) coaching sessions from trained graduate occupational therapy student coaches. All participants used the SPAN website and goal planning app, were able to create and work on social participation goals and plans, and found all components useful, particularly the virtual coaching. Moderate effect sizes were found, indicating increased pre- to post-trial Social Participation Scale scores (Involvement, d = 0.45; Confidence, d = 0.60). Very large effect sizes (d = 1.86) were found in SPAN-specific Skills Confidence Scale scores (scale includes items on goal planning, self-regulation, and social communication).

Phase 3: Methods and Results

We are implementing the full version of SPAN (up to 10 weekly sessions) with 12 AYA survivors (4 adolescents; 8 young adults). Results focus on participants' goal achievement and changes in pre- to post-trial scores on the Social Participation (Involvement and Confidence) and SPAN-specific Skills Confidence Scales. Also, key results address formative and summative feedback from participants, parents (of adolescent survivors), and coaches such as issues related to COVID-19 and the flexibility that was needed for scheduling and tailoring procedures and approaches to best fit individual participant needs, preferences, and realities (eg, explored varied methods to address goal planning; broadened the scope of goals targeted and focus of the coaching sessions; and expanded outreach to participants and parents when needed).

Conclusions

Results were informative across phases and continue to point to potential benefits of SPAN and areas where further refinements will be necessary for future use and wider dissemination.

116 A Comprehensive Study of the Factors That Motivate the Frequent and Effective Usage of Augmentative and Alternative Communications (AAC) Devices

Diane Bienek1; Katandria Johnson1; Shreya Korgaonkar1,2; Victor Pedro1; Tiffany Robertson1; Farid Shiraz1; Rich Lyon1; Priscilla Amponsah1

1iBRAIN, Manhattan, New York, United States; 2Robotics and Rehabilitation Laboratory, Columbia University, Manhattan, New York, United States

Objective

This research aims to identify various factors that can motivate a student to use the augmentative and alternative communications (AAC) devices frequently and effectively in a school setting.

Methods

In this case study, a male student was observed for the AAC device usage frequency of responses, using his eye-gaze device. His response time and accuracy utilizing the device usage were also measured for the effectiveness throughout his school day. The student's response time and accuracy were observed specifically while working on “cause and effect” and “less and more.” The student was exposed to his eye-gaze device during daily activity sessions, that is, academic, occupational therapy, physical therapy, speech therapy, and music therapy at school.

Results

The preliminary results showed that when the student was exposed to his device in a quieter environment with less than 4 people around him, he tended to be less distracted and therefore responded to every 9 out of 10 questions, with a response accuracy ranging between 80% and 90%. It was discovered that pairing him with highly motivating activities such as his favorite music, books, and videos resulted in the AAC device becoming his congenial communication tool. Additional results show that sitting position, environment, prior activities, and body tone and rigidity were factors that affected his device usage frequency and effectiveness. It was observed when student is not toning and is sitting on a mat or on someone's lap, he responds to questions within 5 seconds, which is 3 seconds faster than when on his activity chair and toning.

Conclusion

This study highlights that there are multiple factors that determine the successful usage of AAC devices in the school setting. Further studies with lengthier observations and additional interventions are needed to determine which factors and approaches will result in greatest usage and eventually lead to development of best practices with these devices.

120 Interdisciplinary Approach to the Comprehensive Rehabilitation of a Client With Severe Ataxia After Intracerebral Hemorrhage: A Case Study

Rebecca Askew; Sarah Norton

Scripps Encinitas Outpatient Rehabilitation Services, Encinitas, California, United States

Ataxia as a result of brain injury can impact an individual's independence with functional mobility and other motor-based functions like swallowing throughout the course of their recovery. Difficulty with coordination of movement due to ataxia can affect swallowing strength, timing, and coordination, as well as postural control, limiting the ability to navigate the environment safely. The best practice patterns for the treatment of clients with ataxia continue to evolve. Traditional rehabilitation occurs with each modality presented individually and often has a client working toward impairment-based recovery or compensation specific to each domain (eg, mobility, postural control, swallowing). Interdisciplinary treatment is a unique approach for the client with ataxia (due to brain injury), allowing a team approach toward recovery that includes the practitioners, the client, and their family. Through the interdisciplinary treatment approach, the team and the client can engage in rehabilitation efforts that focus more on restoration of the active participation in life roles, allowing the client the most support and autonomy in their recovery process.

This 28-year-old man suffered a nontraumatic intracerebral hemorrhage, with intraventricular extension, requiring suboccipital craniotomy. Initial evaluation revealed profound oropharyngeal dysphagia, resulting in nil per os (NPO) status and percutaneous endoscopic gastrostomy (PEG) tube placement, and he was dependent with his functional mobility, requiring a reclining wheelchair for his mobility-related activities of daily living (ADL). The client participated in an intensive 6½-hour interdisciplinary program, 4 to 5 days a week for 8 months, in a group milieu involving individual therapy sessions with speech therapists, occupational therapists, physical therapists, and social work, as well as combined community sessions with the interdisciplinary team. Specific to his speech and physical therapy needs, evidence-based treatments such as McNeill Dysphagia Therapy Program (MDTP) and High-Intensity Gait Training (HIGT) were implemented to allow specific impairments to be addressed in concert with each other in every therapy session.

This case is an example of how an interdisciplinary team can work together. The patient is now able to perform all nutrition needs orally and can navigate his home and immediate community with a walker. This case exemplifies how an interdisciplinary program offers the ability for a whole team to best support the goals of the client, potentially leading to increased overall independence in instrumental and mobility-related ADL, thereby improving participation in life roles.

121 Cognitive-Linguistic Skills of Adults Who Suffered a Diffuse Axonal Injury in Childhood or Youth

Marjaana Raukola-Lindblom1; Linda Ljungqvist2; Timo Kurki1,3; Heikki Hämäläinen1; Olli Tenovuo1,4

1University of Turku, Turku, Finland; 2City of Turku, Turku, Finland; 3Terveystalo Medical Center, Turku, Finland; 4Turku University Hospital, Turku, Finland

Background

Cognitive-linguistic disorders after traumatic brain injury (TBI) are common and persistent. These include difficulties in language production, comprehension, reading, and writing. These deficits result from underlying cognitive and related neural impairments. Cognitive-linguistic difficulties are recognized even in pure diffuse axonal injury (DAI). These can produce long-term impairments in social participation.

Cognitive-linguistic skills after DAI have been investigated in adult populations, but there is a lack of studies on outcomes after DAI suffered in childhood or young age and how it affects adolescence. When DAI is suffered as a child or at young age, these deficits may affect their learning, situating in working life, and establishing their independent lives. These deficits may still be recognizable when achieving adulthood and need extra attention.

Objectives

In this conference, we present a subgroup of adults who have suffered DAI as a child or at young age and present their cognitive-linguistic outcome compared with a control group. In this study, we use a novel test battery.

Method

Selected cognitive-linguistic subtests of the Finnish KAT-test were applied to 10 adults who had suffered moderate to severe DAI, aged between 9 and 18 years, and 27 healthy controls. The participants with DAI were in the chronic stage. The groups were compared in 4 composite scores created for our previous study and in 14 separate cognitive-linguistic subtests included in these composites.

Results and Conclusion

We hypothesize that the results indicate that performance is poorer in cognitive-linguistic measures for the participants with DAI than in the control group. Based on our hypothesis, we conclude that the DAI suffered in childhood or at young age is still identifiable later in adulthood. The rehabilitation needs may need to be evaluated when achieving adulthood. The updated results and the conclusions will be presented at the conference.

122 Substance Use and Psychiatric Disorders in Patients With Acquired Brain Injury During Inpatient Specialized Rehabilitation; Occurrence and Consequences for Rehabilitation: A Norwegian Cohort Study.

Anja Schanke Sundet1; Caroline Ustvedt2; Solveig Lægreid Hauger1,3; Ingrid Amalia Havnes4,5; Angelina Sergeeva6; Jeanette Kleven7; Laila Skogstad8; Nada Andelic9,10; Grethe Månum5,11; Marianne Løvstad1,3

1Department of Research, Sunnaas Rehabilitation Hospital, Bjørnemyr, Norway; 2Department of Traumatic Brain Injury, Sunnaas Rehabilitation Hospital, Bjørnemyr, Norway; 3Department of Psychology, Faculty of Social Sciences, University of Oslo, Oslo, Norway; 4Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway; 5Department of Clinical Medicine, University of Oslo, Oslo, Norway; 6Sunnaas Rehabilitation Hospital, Nesoddtangen, Bjørnemyr, Norway; 7Department of Multi-Trauma, Neurology and Burns, Sunnaas Rehabilitation Hospital, Nesoddtangen, Bjørnemyr, Norway; 8Departments of Health and Care Sciences, The Arctic University of Norway, Tromsø, Norway; 9Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway; 10Center for Habilitation and Rehabilitation Models and Services (CHARM), Institute of Health and Society, University of Oslo, Oslo, Norway; 11Beitostølen Healthsports Center, Beitostølen, Norway

Background

It is well established that a significant proportion of patients in need of rehabilitation after acquired brain injury (ABI) have pre- and comorbid psychiatric or substance use disorders (SUDs). Despite this, patients with psychiatric disorders or SUDs are typically excluded from rehabilitation research and prone to be lost to follow-up in outcome studies, leaving evidence-based rehabilitation programs uninformed by the role of comorbid psychiatric disorders or SUDs.

Objectives

To explore the occurrence of pre- and comorbid psychiatric disorders or SUDs in patients receiving post-acute brain injury rehabilitation, and its influence on the length of specialized rehabilitation.

Methods

Patients were recruited at Sunnaas Rehabilitation Hospital from Depts. of Traumatic Brain Injury, Spinal Cord Injury, and Multi-trauma, Neurology and Burns, from January 2020 through February 2021. Inclusion criteria were age older than 18 years and admission to specialized post-acute rehabilitation due to acute injury or illness. Data from patients with ABI are reported here. Assessment of psychiatric disorders and SUDs was based on information in medical charts, diagnostic interviews using the M.I.N.I Plus neuropsychiatric interview, the Alcohol Use Disorder Identification Test (AUDIT), and the Drug Use Disorder Identification Test (DUDIT). A wide range of sociodemographics, injury characteristics, and variables relating to the rehabilitation process were recorded.

Results

Of the 131 patients, 33 were admitted for brain injury rehabilitation (8 females and 25 males, mean age 49 years, SD = 15). The majority of patients with ABI had a traumatic brain injury (TBI) (n = 28), the remaining 5 had toxic encephalopathy, encephalitis, epilepsy, and anoxic brain injury. Eleven patients (27%) qualified for a comorbid psychiatric disorder or SUD. The most common disorder was alcohol dependence (F10.2) and harmful alcohol use (F10.1) (7/11), followed by anxiety (F43.1, F43.2, F41.1) and depression (F33.1) (4/11). Nearly half (16; 48%) met the criteria for a premorbid psychiatric disorder or SUD. Significantly more patients with TBI and comorbid psychiatric disorder or SUD were still in posttraumatic confusional state at admissions (P = .05), and they had significantly longer length of rehabilitation (71 vs 55 days, P = .01) than patients without a comorbid psychiatric disorder or SUD. There was, however, no significant difference between these 2 groups regarding the distribution of injury severity scores or in the number of days from the injury/illness debut to admission to Sunnaas.

Conclusions

Approximately one-third of the patients with ABI qualified for a substance use or psychiatric disorder, primarily alcohol dependence and harmful use. Results suggest that patients with comorbid substance use or psychiatric disorders have a prolonged posttraumatic confusional state and are in need of longer rehabilitation. This should be taken into account when planning for rehabilitation of these patients.

123 Emotional and Behavioral Problems in Children Following Acute Infectious Encephalitis

Kristian Bergman1; Riikka Lovio2; Ronny Wickström1

1Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden; 2Neuropediatric Unit, Karolinska University Hospital, Stockholm, Sweden

Objectives

Infectious encephalitis in childhood is a serious condition. Although mortality is generally low in developed countries, long-term outcome is adverse in many cases. Severe consequences are often recognized at discharge and clinical follow-up. In contrast, less obvious symptoms, such as emotional and behavioral problems, may remain unrecognized. The purpose of the current study was to describe the emotional and behavioral outcomes following infectious encephalitis in childhood.

Methods

Children treated for infectious encephalitis at the Karolinska University Hospital, Stockholm, Sweden, between May 2011 and May 2016, were prospectively identified. Emotional and behavioral problems were assessed with an age-appropriate version of the Child Behavior Checklist (CBCL). Caregivers were asked to rate their child's premorbid function during hospitalization and again at a follow-up, 18 months postdischarge. The 2 broad-band scales Internalizing Problems and Externalizing Problems were used respectively, and the Total Problems score was used as a summary measure of emotional and behavioral difficulties.

Results

A total of 28 children completed CBCL prospectively, 14 girls (50%) and 14 boys (50%). Mean age at follow-up was 90.3 months (range, 40-224 months), and mean time between discharge and follow-up was 18.8 months (range, 17-23 months). There was a significant difference between the premorbid (M = 42.8, SD = 9.5) and follow-up ratings (M = 48.0, SD = 11.4, P = .01 on the Internalizing Problems scale of the CBCL. No statistically significant differences were seen between the premorbid (M = 43.9, SD = 8.9) and follow-up ratings (M = 46.6, SD = 9.4) on the Externalizing Problems scale. Ratings did not differ significantly on the Total Problems scale for the premorbid (M = 42.6, SD = 8.7) and follow-up ratings (M = 46.4, SD = 10.2).

Conclusions

Children with infectious encephalitis may be at an increased risk of suffering from internalizing emotional problems, such as anxiousness, feeling depressed, or experience increased somatic concerns. The increase in symptoms is likely subtle and thus warrants screening in the clinical follow-up.

124 Improving Hospital-to-School Transition at Discharge From a Tertiary Pediatric Hospital Following Moderate to Severe Traumatic Brain Injury Through the Development of a School Information Booklet

Claire Connellan1,2; Avril Carey3; Amy Cadden4; Irwin Gill1,5

1Children's Health Ireland at Temple Street, Dublin, Ireland; 2Graduate School of Healthcare Management, Royal College of Surgeons in Ireland, Dublin, Ireland; 3Beaumont Hospital School, Dublin, Ireland; 4Department of Psychology, Children's Health Ireland at Temple Street, Dublin, Ireland; 5School of Medicine, University College Dublin, Dublin, Ireland

Background

Pediatric traumatic brain injury (TBI) is a significant cause of acquired disability, much of which is underrecognized and misattributed. There are additional obstacles in Ireland in comparison with the United States. In the United States, reporting on TBI has been mandatory since 1992 under the Individuals with Disability Education Act, driving policy formation, research, and funding. This is not the case in Ireland. With known gaps in educator knowledge and training in TBI, and limited outpatient rehabilitation nationally, the Irish pediatric TBI population is at risk of having their difficulties misattributed or missed and their needs unmet.

This study was conducted in the single national pediatric neurosurgical center in Ireland, which is home to an acute pediatric rehabilitation service. Returning to school is an important part of recovery, but there is currently no formal process for hospital-to-school transition or communication or any dedicated classroom follow-up. Instead, this is ad hoc. Children not partaking in transition programs are less likely to receive school supports, and interagency communication has been consistently reported as vital but lacking. We sought to improve school notification of TBI and provide information and resources if problems arose.

Objectives

The intervention aim was that 60% of teachers self-report that the booklet provided useful information to recognize TBI issues and access supports 2 months after implementation. A Donabedian structure, process, and outcome model was used. Measures included staff awareness of the project prior to implementation (structure measure), the proportion of the target population discharged with the booklet (process measure), and the number of parents reporting they gave the booklet to the school (outcome measure).

Methods

This project used quality improvement (QI) methodology. Readiness for change was assessed, stakeholder engagement and communication were fostered, and collective leadership practiced to collaboratively create a booklet and incorporate it into the discharge process. Evaluation by telephone consultation with parents and email questionnaire with schoolteachers is planned, with mixed quantitative and qualitative measures.

Results

Plan-Do-Study-Act cycles with core stakeholders (a teacher, a neuropsychologist, and a pediatric rehabilitation specialist) resulted in a draft booklet. This was tested with 2 teachers unfamiliar with TBI. This was vital, resulting in changes not considered by the change team, for example, language clarity, inclusion of more examples. This real-world application also resulted in inclusion of a summary page for teachers under time pressure needing immediate information. Implementation planning is ongoing, and further participant feedback is expected in August 2022.

Conclusions

Recognition of educational difficulties after pediatric TBI is challenging in the Irish context. This project takes steps to improve transition services for school-aged children discharged from the national pediatric neurosurgical center following moderate-severe TBI. Using QI principles, results will enable improved service delivery and reduced unwanted variation.

125 Physical and Intellectual Abilities in Pediatric Survivors of a Fossa Posterior Tumor Following Multidisciplinary Rehabilitation

Catharine Vander Linden; Robin De Wilde; Mathieu Decock

Ghent University Hospital, Child Rehabilitation, Gent, Belgium

Objective

Short- and long-term consequences of treatment of childhood fossa posterior tumor are extensively reported in literature; however, articles enlightening physical function throughout rehabilitation and its correlation with intelligence quotient (IQ) are sparse. Physical dysfunctioning may impact the child's development, activities, daily living, and the ability to return to school and socialize with friends.

The main goals of our study were (1) to examine physical functioning and the IQ of pediatric survivors of a fossa posterior tumor, using a standardized measure with comparison with normative data; (2) to evaluate progression during a multidisciplinary rehabilitation program; and (3) to determine if there is a difference in physical functioning and the IQ between the different histopathological tumors (medulloblastoma, ependymoma, astrocytoma). Because cognitive function is related to gross motor function in small children and children with cerebral palsy, (4) our final goal was to search for a correlation between the gross motor functioning and cognitive functioning in children with a fossa posterior tumor.

Methods

A retrospective cohort study design was used with data of 56 children who followed a multidisciplinary program in the Child Rehabilitation Centre of the Ghent University Hospital, over the period 2005-2020. Descriptive statistical analysis was performed with the use of nonparametric tests and linear regression for the relationship between gross motor functioning and IQ.

Results of 3 norm-referenced tools to measure gross and fine motor skills in children were assembled: the Bruininks-Oseretsky Test of Motor Proficiency Second Edition (BOT-2), the Peabody Developmental Motor Scale (PDMS-2), and the Purdue Pegboard Test (PPT).

Results

Nearly all children suffered from a disturbed balance at the time of administration, which was mainly associated with medulloblastoma. We noted a further deterioration of mobility in the lower limbs (especially ankle dorsiflexion) in children with a medulloblastoma at the end of the rehabilitation (mean = 444 days, 3-5 times/wk, 2 hours). The mean score distribution of “Grasping” and “Visual-Motor-Integration” of the PDMS-2 was situated in the norm reference average range at the beginning but dropped underneath the average at the end. The overall scores of the PPT also showed a negative evolution throughout rehabilitation. The mean IQ was 90.94, with a mean verbal IQ of 95.11 and a mean performal IQ of 87.41 at the time of administration, which is low average in comparison with an age-appropriate standard population. We observed a drop of nearly 10% in all IQs in the cohort children with a medulloblastoma at the end of the rehabilitation. There is a strong correlation between the Total-IQ and the Body Coordination score (BOT-2), with a positive correlation coefficient of 0.519.

Conclusion

Pediatric survivors of a fossa posterior tumor experience impaired physical and intellectual abilities, with more decline during oncological treatment despite simultaneously intensive multidisciplinary rehabilitation.

126 Piloting a Clinical Trial to Reduce Persisting Symptoms Following Pediatric Concussion

Michael Takagi1-3; Franz Babl1,3,4; Gavin Davis1; Audrey McKinlay1; Alison Crichton1,2; Stephen Hearps1; Cathriona Clarke1; Nicholas Anderson1; Kevin Dunne1,4; Peter Barnett1,4; Vicki Anderson1-4

1Murdoch Children's Research Institute, Parkville, Victoria, Australia; 2Monash University, Clayton, Victoria, Australia; 3University of Melbourne, Parkville, Victoria, Australia; 4Royal Children's Hospital, Parkville, Victoria, Australia

Objectives

Pediatric concussion is among the most common injuries sustained in childhood, with an estimated 33 million concussions occurring worldwide annually. Fortunately, the majority of children recover on their own within days to weeks postinjury. However, approximately 30% continue to experience persistent postconcussive symptoms (pPCS) at 4 weeks postinjury. The factors contributing to delayed recovery are poorly understood but are likely to be multifactorial. To date, interventions targeting delayed recovery in children have largely been unimodal (eg, strict rest) with limited success. The aim of the present study was to pilot the effectiveness of a multimodal, symptom-tailored intervention to accelerate postconcussion symptom recovery in children and adolescents.

Methods

Children with concussion, aged 8 to 18 years, were recruited from The Royal Children's Hospital (RCH) emergency department via telephone call 2 to 4 weeks postinjury. There were 3 assessment points: baseline (1 month postinjury); postintervention (3 months postinjury); and follow-up (6 months postinjury). The multimodal intervention included psychoeducation, physiotherapy, and psychology delivered by psychologists and physiotherapists. There were up to 8 weeks of intervention, with each session lasting 60 minutes. The primary outcome measure was symptom score on the Post-Concussion Symptom Inventory (PCSI). Participants who had recovered (ie, returned to preinjury symptom levels as measured by the PCSI) were discharged from the intervention.

Results

We enrolled 18 participants into the study, but only 9 remained enrolled up to the 6-month time point. The majority of participants were successfully discharged from the intervention before the full 8 weeks, and all participants showed a significant decrease in pPCS relative to baseline. Significant improvement was also seen in multiple secondary measures including return to normal activities (eg, school, sport), fatigue, and mental health.

Conclusions

The present study demonstrated the feasibility and effectiveness of a multimodal intervention to manage pPCS in children and adolescents.

127 Neuropsychological Assessment Through the Coma Recovery Scale Revised and the Coma Near Coma Scale in a Sample of Pediatric Patients With Disorder of Consciousness

Susanna Frigerio1; Sandra Strazzer1; Erika Molteni2; Katia Colombo1; Valentina Pastore1; Claudia Fedeli1; Susanna Galbiati1

1Irccs E. Medea, Bosisio Parini, Italy; 2School of Biomedical Engineering & Imaging Sciences, and Centre for Medical Engineering, King's College London, London, United Kingdom

Brain injury acquired in pediatric age (ABI) is a rare but lifelong impacting condition, with increasing epidemiology in Europe and in the world, and with growing social and economic burden (Lash & Lash 2004; Bale et al., 2015). One common sequela of severe ABI is the disorder of consciousness (DoC), the assessment of which is the main challenge for centers delivering acute and post-acute inpatient rehabilitation (Barlow, 2013; Eilander et al., 2005).

The Coma Recovery Scale-Revised (CRS-R) has emerged as the gold standard measure for the neurobehavioral assessment of the level of consciousness in adult patients emerging from a coma. However, its measurement validity in pediatrics has only been ascertained in healthy cases to date.

Increasing use of the CRS-R in single case studies and case series of children with DoC imposes appropriate comparison against previously validated tools.

In this observational, prospective, longitudinal study, we evaluated the CRS-R in a cohort of pediatric patients with DoC. We recruited 40 consecutive patients 5 to 18 years of age with brain lesions due to traumatic and nontraumatic etiologies, severe DoC at admission to post-acute care, and Glasgow Coma Scale (GCS) score of 8 or less at insult.

We applied the CRS-R to describe the level of consciousness, and the Coma/Near Coma Scale (CNCS), previously tested in children (Molteni et al., 2020), as an index scale. We explored the agreement between the 2 instruments, also in relation to the different etiologies.

The correlation between the overall evaluation provided by the 2 scales was moderate (r = 0.71).

The analysis of single CRS-R domains showed that the decrease in CNCS levels corresponded to gradual score increase in the visual and auditory domain on the CRS-R. However, the motor domain responses were captured by the lowest CNCS levels only.

The outcome of 37 patients after 12 months from the event was calculated. Our results showed that more than 2 out of 3 patients emerged to consciousness after 1 year from the event, and only 11 patients did not emerge.

The main implication of CRS-R validation in pediatrics is that the clinical evidence of DoC acquires comparability across ages. This includes prognostic prediction across the entire life span and reconciles the interpretation of studies in children and adults.

128 Caregivers Connecting After ABI (CCABI): Expanding Caregiver Support, Coping, and Knowledge

Sara Stevens1,2; Mary Stewart2; Hiba Al-Hakeem1; Caron Gan1; Lies Ferriman2; Melissa Ngo2; Shannon Scratch1,2

1Bloorview Research Institute, Toronto, Ontario, Canada; 2Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada

Introduction

Caregivers experience emotional hardship and family stress following their child's acquired brain injury (ABI). Essential care such as ABI education, coping skills, and peer support can enhance family functioning and caregiver well-being; however, these needs are often unmet. There is limited research evaluating peer support groups for caregivers of children and youth with ABI during inpatient phases of rehabilitation. Given the heightened emotional concerns and information learning curve that families experience in the beginning of their rehabilitation journey, it is important to address caregivers' needs. Caregivers Connecting after ABI (CCABI) is an educational and psychosocial group-based program offered to caregivers of children with ABI during their hospital stay.

Objectives

The aim of this study was to evaluate the clinical utility of CCABI during families' inpatient phase of rehabilitation. The research questions are as follows: (1) How do caregivers describe their experience with CCABI? and (2) How does the participation of caregivers in CCABI affect their ABI knowledge, coping with rehabilitation, and social support?

Methods

CCABI involves weekly 1-hour sessions in a drop-in format for caregivers in the inpatient unit at a Canadian pediatric rehabilitation hospital. CCABI is facilitated by a clinical neuropsychologist and a social worker, and its content is based on research highlighting the necessity of caregiver support as they care for children with ABI. Participants for the study included 10 caregivers (all mothers) of children with ABI (ages 4-15 years, M = 10.4 years; SD = 4.50). Types of ABI included brain tumor, stroke, multiple sclerosis, and traumatic brain injury. The length of inpatient family stay ranged from 5 to 12 weeks (M = 8.4 weeks, SD = 2.59). Semistructured interviews were conducted to document caregivers' experience with CCABI. Qualitative content analysis was utilized to interpret the data.

Results

A visual model was developed to capture the salient features of caregivers' experience with CCABI. It includes 3 categories: (1) Getting Ready; (2) CCABI Group Participation; and (3) Leaving Supported. Participants joined CCABI due to personal interest, recommendation from other caregivers, and recommendation from other clinicians. CCABI was shown to be a valuable program for caregivers to receive informational and social support from facilitators and other caregivers with similar lived experiences. Also, CCABI was described as an outlet to share stories in a safe space. Feelings of validation, gratitude, and confidence were reported following CCABI participation.

Conclusion

Integrating family needs into clinical rehabilitation helps improve caregiver support and functioning, which can reflect positively on the well-being of their child. CCABI provides caregivers with a foundation to build ABI knowledge and to receive social support from others. The CCABI program provides insights into supportive strategies to improve the well-being of families during the inpatient rehabilitation phase following ABI.

129 Establishing an Acute Rehabilitation Service in a Tertiary Pediatric Hospital: A Quality Improvement Project

Sinead Leahy1; Jillian Pounch1; Irwin Gill1,2

1Acute Rehabilitation Service, Children's Health Ireland at Temple Street, Dublin, Ireland; 2School of Medicine, University College Dublin, Dublin, Ireland

Background

In 2020, Children's Health Ireland at Temple Street became the single national pediatric neurosurgical center for Ireland. In response to increased caseload and an influx in new staff, the Acute Rehabilitation Team used quality improvement methodology to establish baseline data and improve timeliness and efficiency of initial rehabilitation referrals and reviews, child and family satisfaction, reduce unwanted variation in practice, and address perceived barriers to interdisciplinary working.

Methods

We cross-referenced the hospital neurosurgical and rehabilitation databases to identify delayed and missed referrals to rehabilitation. We surveyed children and families to assess satisfaction with processes of care. Review of medical records was performed to assess to what extent initial therapy assessments were conducted jointly or without duplication. We surveyed team members regarding perceived barriers to interdisciplinary care and engaged in shared process mapping. Quality improvement methodology and tools were used including Plan-Do-Study-Act (PDSA) cycles, run charts, Pareto charts, and driver diagrams.

Results

Surveys of children and families, while positive, identified a number of areas for improvement. At initial assessment, families reported “retelling their story” to multiple team members who seldom conducted joint sessions. Surveys of staff identified a number of perceived barriers to interdisciplinary working. Three key issues accounted for more than 80% of these: lack of knowledge of the roles of other therapists; a lack of joint sessions; and recent significant staff turnover. Joint process mapping identified discrepancies between “work as imagined” and “work as performed,” with opportunities for improved consistency identified. Review of medical records identified frequent unplanned variation in practice, with inconsistent assessment times and formats and significant duplication across disciplines. Baseline data (June-December 2021) revealed that late referral to rehabilitation (rather than delays in responding to referrals) was the main cause of delayed rehabilitation review. Late referral occurred in 15 of 32 (46.5%) patients referred during that period. In response to these findings, we implemented a number of changes via PDSA cycles. From February 2022, a Rehabilitation Clinical Nurse Specialist joined the neurosurgical team on a minimum of 1 ward round per week; compared to a median of 3 missed referrals per month prior, there were 2 missed referrals in February 2022 and 1 in March 2022. All rehabilitation reviews requested were performed within 72 hours during this period. To target the reported poor understanding of individual roles, we asked team members to outline the components of their own roles. These were cross-referenced and shared to highlight areas of shared responsibility. A shared assessment framework is in development to support joint initial assessments.

Conclusion

We describe the use of quality improvement methodology via direct engagement with stakeholders to reduce unwanted variation and embed interdisciplinary working within an acute rehabilitation service in a tertiary pediatric hospital.

130 SpeelsBrein (Playfull Brain)

Marleen Van Der Wees1,2

1Libra Rehabilitation & Audiology, Eindhoven, The Netherlands; 2Educational Sciences, Utrecht University, Utrecht, The Netherlands

Interventions targeting neurocognitive functions, such as attention and executive functions (EFs), in the first years of life may have a larger impact on child development than interventions administered later on in childhood. However, in early childhood rehabilitation, interventions targeting neurocognitive functions are not typically available. This study aims to evaluate the implementation and pilot test effects of an intervention focusing on neurocognitive functions in early childhood in children at risk for brain damage.

Parents play an important role in the recovery and development of their child. By integrating targeted play activities in the daily routine of parents and children at home, positive effects on child neurocognitive development may be expected. SpeelsBrein (SB) is an informative activity book with psychoeducation about neurocognitive development of the young brain and playful activities that help parents play and have fun with their child and simultaneously stimulate aspects of neurocognitive development.

Objective

Objectives of the current project are to (A) study the implementation of SB in clinical practice for parents with a child with (possible) brain damage (ie, traumatic brain injury [TBI], brain tumor, preterm birth, and cerebral palsy), and (B) pilot test the effect of SB on parent-child play.

Methods

(A) Thirty interviews were conducted with parents from the target groups who received the SB book. (B) Parents receive training in the SB method through psychoeducation and a guided play session. Before and after the training, they fill in questionnaires on their child's play and make a short recording while playing with their child. In addition, attention and EFs are tested in children.

Results

(A) Interviews show that parents are positive about SB. SB is new information. They report spontaneously playing differently with their child after having received the SB book. (B) The pilot study is ready to recruit parents and children. First results are expected in 6 months.

131 Intensive Day Rehabilitation Following Acquired Brain Injury for Young People in Western Australia, 2011-2019

Irwin Gill1; Sue-Anne Davidson1; Rae Robinson1; Paul Stevenson2; Dayna Pool1; Jane Valentine1

1Kids Rehab WA, Perth Children's Hospital, Perth, Australia; 2Telethon Kids Institute, University of Western Australia, Perth, Australia

Background

iRehab is an intensive specialist day rehabilitation service based at Perth Children's Hospital (PCH) in Western Australia. It is open to young people who experience disability due to acquired brain injury (ABI), cerebral palsy, spinal cord disorders, and other causes of disability. Child-centered clinical evaluation using standardized measures of functioning are an integral part of iRehab service design. We aimed to describe the characteristics, goals, and outcomes of young people with ABI who attended iRehab.

Method

This is a retrospective cohort study of all young people with ABI who attended iRehab from October 2011 to February 2019. Demographic information was recorded. Goals and outcomes were determined by domains and scores on the Children's Function Independence Measure (WeeFIM), Canadian Occupational Performance Measure (COPM), and Goal Attainment Scale (GAS); each is routinely performed at admission to and discharge from iRehab and at 6 months postdischarge. Linear mixed-effects models were applied.

Results

Of 586 total admissions to iRehab during the study period, 125 (21.3%) had a primary diagnosis of ABI. Commonest etiologies were trauma (35; 28%), tumor (32; 25.6%), and stroke (19; 15.2%). In total, 65.7% of patients with TBI were male. Patients with ABI identified goals in diverse COPM domains at admission to iRehab. The most commonly identified domains were Functional Mobility (35% of all goals), Play/School Leisure (22%), Self-Care (20%), Socialization (12%), and Active Recreation (6%). Significant improvements were measured in WeeFIM, COPM, and GAS scores between admission and discharge; these improvements were maintained at 6-month follow-up. Mean WeeFIM total score at admission was 70.9 (SD = 30.9), improving to 79.3 (SD = 30.5) at discharge and 86.6 (SD = 25.6) at 6-month follow-up. Statistically significant improvements were seen in Mobility, Self-care, and Cognitive subscores. COPM mean scores were 2.79 (95% CI, 2.60-2.98) points greater at discharge than at admission, and 3.09 (95% CI, 2.84-3.34) points greater at 6/12 postdischarge than at admission. Satisfaction and Performance scores were closely correlated. GAS mean T-scores at discharge and 6 months postdischarge were 50 and 58.1, respectively, indicating goal attainment within the “expected” range of 40 to 60.

Conclusions

Young people with ABI in Western Australia attending iRehab experienced improvements in functional independence, performance, and satisfaction as measured by standardized measures. These improvements are maintained at 6-month follow-up. iRehab admissions typically directly followed the young person's acute admission with ABI and are likely to have reduced inpatient length of stay and the burden of hospital admission on child and family. This model of care could be beneficial in other centers. Further research and comparison with Australasian Rehabilitation Outcomes Centre (AROC) data are ongoing to examine the effect of the iRehab program on length of inpatient admission and child outcomes.

132 GMFM Is a Tool for Functional Motor Improvement Tracking During Rehabilitation In-Stay in Pediatric Acquired Brain Injury

Elena Beretta2; Erika Molteni1; Marc Modat1; Sandra Strazzer2

1King's College London, South Bank, London, United Kingdom; 2IRCCS E. Medea, Bosisio Parini, Italy

Gross Motor Function Measure (GMFM-88) is a tool for motor assessment widely used in functional rehabilitation. GMFM was employed in a center for pediatric patients receiving intensive in-staying physiotherapy rehabilitation after an acquired brain injury (ABI). The aim of the study was to assess the capability of GMFM to detect changes in gross motor functions in children during the in-staying period. We prospectively examined data from a large group of 150 consecutive pediatric patients with ABI. GMFM was administered at 3 time points: at admission, after complete delivery of the first set of intensive rehabilitation sessions, and at discharge. The mean age of patients was 4.7 years (SD = 3.2); there were 69 females. The median Glasgow Coma Scale (GCS) score was 6. Mean days of coma were 69 (SD = 116). Fifty-one children had traumatic ABI, 32 had encephalitis, 24 had anoxia, 14 had hemorrhagic stroke, 12 had ischemic stroke, 6 had tumor resection, and 11 had other etiologies. Total and average GMFM scores showed increase over the 3 time points.

One-way analysis of variance showed significant effect of time for both Total GMFM (F = 67.8, P < .001) and Average GMFM (F = 67.4, P < .001). Analogously, all the 5 GMFM domains increased from time point 1 (admittance) to subsequent time points 2 and 3, until discharge. Multivariate analysis of variance confirmed the effect of time, overall (F = 13.8, P < .001) and for each domain of the scale. At admission, GMFM correlated with the Level of Cognitive Functioning Scale (LOCFAS, rho = 0.55) and Glasgow Outcome Scale (GOS, rho = 0.54) scores, after correction for age and sex. At discharge, GMFM correlated with LOCFAS (rho = 0.40, P < .001) and GOS (rho = 0.49), motor damage (rho = 0.48), insurgence of epilepsy (rho = −0.55), and days of coma (rho = −0.68) (P < .001 for all correlations).

We conclude that GMFM is an appropriate tool to evaluate patients' rapid improvements during the in-staying period. It proved to effectively capture improvements in all the 5 GMFM domains: (A) Lying and Rolling; (B) Sitting; (C) Crawling and Kneeling; (D) Standing; and (E) Walking, Running, and Jumping. At discharge, it showed relationship with the severity and complication of disease, as indicated by correlations with days of coma and epilepsy, as well as neuropsychological scales such as LOCFAS.

133 Holistic Family Support Through and After COVID-19

Gerard Anderson

Child Brain Injury Trust, Baynards Green, United Kingdom

Introduction

Bronfenbrenner ecological systems theory describes child development as a series of complex interactions affected by multiple levels across a child's life. This includes the child's siblings, parents, and extended family members, through to community, school, health, cultural values, laws, and customs.

As a UK-wide service supporting families across trauma, rehabilitation, and surgical wards through to reintegration into community service and onward to adult services, the Child Brain Injury Trust provides a hybrid service of both in-person and virtual support focusing on smart outcomes. This is achieved by acting as a scaffold around the family. As a family develops healthy independent coping mechanisms, the scaffold is reduced in line with the reduction of support needs.

Method

The current research presents a mixed-methods analysis of how the Child Brain Injury Trust has developed services throughout the pandemic. This ranges from how support is provided to hospital teams through to the reintegration back into education and the transition into adult services. It provides an analysis of how support has been adapted for families affected by acquired brain injury, including nonaccidental injuries and brain tumor (benign and malignant).

Results

Over the last 2 years, the COVID-19 pandemic has had widespread consequences on healthcare systems and services across the world, resulting in prolonged recovery postinjury or illness. It has resulted in extensive changes to how support is provided and how scaffolding is placed around families during inpatient stays, discharge, and through to the reintegration back into education and community services.

Throughout the pandemic, we have seen significant changes in referral pathways and patterns and to changes in causes of acquired brain injury. From an increase in nonaccidental injuries to the time children and young people are admitted post–initial concerns, we have seen an impact on recovery and the way follow-up support is provided.

Findings show that changes have occurred in referral routes, changing from health professionals back to self-referrals from parents and family members. Nonclinical support services have been restricted in their ability to support families on hospital wards, and staff have been affected by illness and redeployment to other departments and wards.

Conclusion

Despite developments of COVID-19 public health measures, many children are continuing to sustain injuries that could be avoided and are being left without adequate support postdischarge; however, with the right support in place to scaffold a child and their family, prolonged discharge and delayed recovery can be avoided. From support to prepare a family predischarge through to virtual family events and virtual home visits, adaptations can be made to primary care services and community services that improve the transition through to adult service and rehabilitation post–acquired brain injury.

134 Interdisciplinary Collaboration and the Medical, Neurocognitive, and Physical Rehabilitation of a Pediatric Patient With Complex Neurofibromatosis Type 1: A Case Study

Brittany Ryan; Colleen Sutherland; Didem Inanoglu

Franciscan Children's, Brighton, Colorado, United States

The presentation of children with neurofibromatosis type-1 (NF1) varies significantly between each individual. More severe forms of the condition can result in the development of malignant nerve sheath tumors or may compromise multiple body systems, ultimately leading to death. Cognitive and behavioral phenotypes of NF1 have been described and have known associations with lower IQ scores, visuospatial impairment, and other cognitive deficits. Patients with NF1 are also predisposed to various brain tumors including optic pathway gliomas, brain stem gliomas, and glioblastomas. The neurologic impacts of NF1 are extensive and have significant implications for development and overall functioning.

The patient is a 2.5-year-old girl with advanced NF1, with multiple plexiform neurofibromas involving her occipital skull, airway, cervical spine (diagnosed prenatally), chest, abdomen, and lower extremities resulting in airway compromise, compression of major vessels, renal involvement, tibial and hip dysplasia, hearing loss, and global developmental delay. This patient has been hospitalized since birth due to the severity of her condition and need for ongoing medical management. She was transferred to post-acute care at 6 months of age for continued care coordination and rehabilitation.

Her goals of care consist of medical stability including optimization of her pulmonary function, growth, and weight gain, as well as developmental progression with emphasis on achieving age-appropriate milestones and promoting improved quality of life. Her care team is multidisciplinary, with medical subspecialists such as neuro-oncology, otolaryngology, pulmonology, physiatry, and cardiology, as well as physical (PT), occupational (OT), and speech therapy, child life, expressive therapies, and palliative care contributing to her overall plan. The patient had been seen for direct PT, OT, and speech services weekly since her initial admission to long-term acute care. Therapeutic goals have focused on acquiring cognitive, swallow, fine motor, and gross motor skills. While promoting functional mobility and independence, we have simultaneously taken a preventive approach with the use of orthoses and a multimodal family-centered functional task-oriented approach to prevent secondary complications and minimize deformities and risk of injury.

Despite the complex nature of this patient's condition and the severity of her associated comorbidities, this patient has thrived in the post-acute care setting. Thanks to the collaborative and integrative approach to her care, this patient has made exceptional progress in areas such as ambulation, pulmonary rehabilitation, and cognitive development.

135 Subacute Language Performance in Young Children With Traumatic Brain Injury

Carly Cermak1,2; Shannon Scratch1-3; Nick Reed1,2,4; Deryk Beal1,2,5

1Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada; 2Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada; 3Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; 4Department of Occupational Science and Occupational Therapy, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; 5Department of Speech-Language Pathology, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada

Background

A traumatic brain injury (TBI) that occurs in young children (eg, <6 years of age) significantly impacts motor, cognitive, and language development. However, little is known about language recovery in the subacute time period (eg, within 3 months of injury) of early childhood TBI. The literature is particularly sparse regarding children reported to have premorbid language delays and children who are multilingual. Understanding subacute language recovery in young children is essential for improving pediatric TBI management.

Methods

A retrospective medical record review study was completed at a single-site inpatient pediatric rehabilitation hospital in an urban setting with a large population of multilingual speakers. Inclusion criteria were children aged 15 months to 5 years 11 months with a diagnosis of closed TBI and who were within 3 months of injury. Descriptive analyses of language performance and effect sizes were calculated for children with standard scores from norm-referenced measures.

Results

Of 60 available charts, 24 met inclusion criteria. There was a larger number of children with receptive language scores (n = 24) than expressive language scores (n = 18). Scores came from either the Preschool-Language Scale-Fourth Edition (PLS-4; n = 11), the Oral and Written Language Scale–Second Edition (n = 7), the Clinical Evaluation of Language Fundamentals–Second Edition (n = 5), or the Clinical Evaluation of Language Fundamentals–Fourth Edition (n = 1). For children with scores in both language areas (n = 18), most children (72%) scored within the average range. For the handful of children with below-average language scores, these children were described as having language delays preinjury (n = 2), lower exposure to English (n = 1), information processing difficulties (n = 1), and difficulties with formulation and organization of language (n = 1). Effects of TBI on language performance varied by language measure, with the PLS-4 demonstrating no effect, particularly for expressive language.

Conclusion

Assessment of language skills in young children in the subacute stage of recovery from TBI can be challenging due to the possible implications of dual-language learning, premorbid language impairments, and the wide range of development acceptable for this age group. To improve pediatric TBI management, protocols for language sampling and interpretation need to be developed, particularly in the subacute stage of recovery

136 Education Professionals' Knowledge and Experience of Students With Childhood Acquired Brain Injury—Emerging Data From a PhD Study in Ireland

Avril Carey; Manolis Adamakis; Vanessa Rutherford

School of Education, University College Cork (UCC), Cork, Ireland

Objectives

Brain injury is often mistaken for a low-incidence educational consideration addressed minimally in preservice teacher training, with persistent misconceptions reported in the international literature (Linden et al., 2013; Ernst et al., 2016). This is an underresearched area in the Irish education field. This mixed-methods study explores education professionals' knowledge and experiences in supporting students with an acquired brain injury (ABI) in Ireland. More specifically, this part of the study aimed to determine educational professionals' understanding of the implications of childhood traumatic brain injury (TBI) and to examine their training needs in this area.

Methods

The sample consisted of 354 educational professionals across primary, secondary, and special school sectors. Twenty-six percent were principals, 68% teachers, and 6% other educational professionals. An online survey contained 43 questions adapted from the Common Misconceptions about Traumatic Brain Injury Questionnaire (CM-TBI) (Linden et al., 2013) and the TBI Knowledge Survey (TBIKS) (Ettel et al., 2016), which determined knowledge levels. A subsequent section examined professional self-efficacy in providing support for students with both TBI and other ABIs. Open-ended responses provided qualitative data on experiences and training needs. Statistical analysis with IBM SPSS 27.0 included descriptive (M ± SD, %) and inferential (t test and Pearson r correlations) statistics.

Results

The knowledge section of the survey exposed significant gaps in educators' understanding of TBI. Only 7% of participants (n = 27) scored 60% or above. Thirty-three percent (n = 118) scored in the 40% to 59% range, with the majority (54%; n = 191) scoring between 0% and 39% range. Three percent (n = 13) recorded a score of zero, with 1% (n = 5) demonstrating substantial misconceptions on the subject. Participants expressed a lack of knowledge across all areas of the topic (“don't know” was chosen in 42% of all options).

Nonetheless, in rating their confidence in supporting this student cohort, 49% (n = 175) rated themselves positively and 43% (n = 153) as not confident, with 7% (n = 26) as neutral. Statistically significant group differences were observed between those who reported some training in the area of brain injury (n = 62) and no training (n = 292) (t = 5.75, P < .001, d = 0.804). The number of students that participants had previously supported was positively correlated with their knowledge score (r = 0.261, P ≤ .001). From the qualitative data, those with experience identified communication with rehabilitation professionals and training as positive factors for school reentry success.

Conclusions

This is a small section of a broader study exploring educator needs around ABI in Ireland. These data suggest misconceptions and gaps in teacher knowledge in this area. Given the subtlety and visibility of post-ABI sequelae, the disparity between knowledge and self-reported confidence levels may suggest that educators are unaware of their knowledge gap and therefore unlikely to seek assistance or training to ensure appropriate support is provided for students. The next phase will explore lived experiences of teachers and parents.

137 Very Long-term Follow-up in Children With Disorder of Consciousness After Severe Acquired Brain Injury

Claudia Corti1; Susanna Frigerio1; Katia Colombo1; Valentina Pastore1; Claudia Fedeli1; Erica Vanni1; Susanna Galbiati1; Erika Molteni2; Sandra Strazzer1

1Scientific Institute, Irccs E. Medea, Bosisio Parini, Italy; 2School of Biomedical Engineering & Imaging Sciences, King's College London, United Kingdom

Objectives

The present study aimed to describe the emergence to a conscious state in a sample of children and adolescents with severe acquired brain injury (ABI). The second aim was to explore the functional outcomes at long term follow-up, assessed through different neuropsychological and functional tools.

Methods

This retrospective, observational study included children who sustained a severe ABI at an age less than 19 years and were admitted to inpatient rehabilitation between January 1, 2002, and December 31, 2021. Out of a total of 1018 patients with ABI, a sample of 694 children was selected for this work as they fulfilled the following inclusion criteria: nonprogressive ABI, Glasgow Coma Scale (GCS) score 8 or less at insult and duration of coma of at least 1 day. To investigate long-term functional outcomes and state of consciousness, the last evaluation performed in our center was considered for those patients receiving more than 1 clinical follow-up. The assessment was carried out using various neuropsychological (eg, Coma Near Coma Scale, Coma Recovery Scale-Revised, IQ scales) and functional (eg, GCS, Functional Independent Measure scores) tools.

Results

Out of the 694 included patients, 244 were females (35.2%) and 450 were males (64.8%), having a mean age of 8.09 years (SD = 5.66; range, 0.14-18.97) at insult. The most frequent etiology was traumatic brain injury (55.0%), followed by anoxia (15.3%), stroke (10.8%), infection (10.2%), and other (8.7%). At long-term follow-up, 122 (17.4%) patients have never emerged from the disorder of consciousness (DOC). At the last follow-up, conducted at a median interval of 2.71 years after the event (range, 0.04-19.9), 5.6% of children had died, while 13.6% of patients had a DOC: 49 patients were in a vegetative state, 34 patients in a minimally conscious state minus (MCS−) and 11 patients in an MCS+. Of the other 572 patients, 64.1% of children regained consciousness within 1 month of injury, 18.3% within 2 months, 7.4% within 3 months, 8.2% within 6 months, and 2.0% within 1 year. Regarding the functional outcomes of these patients, 45.5% of patients had severe disability, while 35.5 had moderate/good motor, intellectual, and functional recovery.

Conclusions

Data on the incidence of DOC in children are largely missing, and little evidence is available on the clinical evolution of this condition over time. In order to contribute to clinical knowledge, a large group of children with DOC was evaluated in this work. Among them, approximately 90% of patients admitted to our service with severe ABI emerged from DOC within the first 3 months after the injury and more than one-third of them (35%) managed to obtain a good functional recovery at long-term follow-up.

139 Rethinking and Implementing the Strengths-Based Approach for People With Traumatic Brain Injury; Successes, Learning, and Future Directions

Pascale Simard1,2; Samuel Turcotte4,5; Catherine Vallée2,3; Marie-Eve Lamontagne1,2

1Centre interdisciplinaire de recherche en réadaptation et intégration sociale, Quebec, Canada; 2Université Laval, Quebec City, Quebec, Canada; 3Centre de recherche CERVO-Université Laval, Quebec City, Quebec, Canada; 4Centre de recherche de l'Institut universitaire en gériatrie de Montréal, Montreal, Quebec, Canada; 5Université de Montréal, Montreal, Quebec, Canada

Introduction

Community-based organizations can play a crucial role in supporting people who are living with a moderate to severe traumatic brain injury (TBI). The Strengths-Based Approach (SBA) builds on the strengths of individuals and the resources of their community to foster community integration and support the realization of personal goals. While SBA was originally designed for people living with mental health disorders, there is a growing interest in adapting this approach for other population groups. A Canadian community organization strives to implement fully this approach with people living with a TBI and living in the community, while identifying the elements of the approach that require adaptations.

Objective

To document the implementation of this approach in a community organization, identifying the challenges and the needed adaptations in serving people living with TBI and their families.

Methods

Three focus groups with community workers were carried out. The interview guide was based on the 5 domains of the Consolidated Framework for Implementation Research (CFIR): (1) the intervention; (2) the internal setting; (3) the external context; (4) the implementation process; and (5) the characteristics of the individuals involved. Discussions were recorded and transcribed verbatim. Data were analyzed using a deductive and inductive approach.

Preliminary Results

All community workers of the organization (n = 14) agreed to participate in the focus group. Participants identified challenges in their use of SBA related to the intervention itself (eg, the intervention require time, while results are not readily visible). Practitioners also reported that SBA was more challenging to use with people who were impulsive and those who were living with apathy or memory problems. Establishing and following up an action plan, as needed in SBA, did not seem to be well suited with their needs. Group supervision was identified as the most positive and appreciated aspect of SBA.

Conclusion

This study is a crucial step toward making necessary adjustments to the implementation strategy and thus increasing acceptability and usability. This study will contribute to the body of knowledge on the implementation of this new intervention method to support social rehabilitation of people living with a TBI.

141 Importance of Feedback Valence on Learning in Individuals With Traumatic Brain Injury

Olesya Iosipchuk; Ekaterina Dobryakova

Kessler Foundation, East Hanover, New Jersey, United States

We showed that participants with traumatic brain injury (TBI) are more likely to benefit from the feedback presented after a delay. However, less is known about the effects of feedback valence on learning in TBI subjects. We previously showed that healthy individuals are better at retaining information when presented with positive feedback in a delayed condition, but negative feedback also resulted in higher percent accuracy than the accuracy in the immediate condition. Thus, it is important to establish whether TBI individuals can benefit more from positive or negative feedback during their rehabilitation. In this study, we wanted to examine the influence of positive and negative feedback on learning. This was achieved by using functional magnetic resonance imaging (fMRI) while 28 participants were completing a word-pair association task. Feedback for each word pair was presented either immediately or after a 25-minute delay. We found no differences in the mean percent accuracy for positive and negative feedback between immediate and delayed feedback conditions. Using FSL voxel-based morphometry (VBM), we examined whether there are differences in gray matter composition in relation to both conditions. In addition, we found that TBI participants were more confident in their choices after receiving positive feedback than negative receiving feedback within the same condition (P < .05). These results suggest that, although individuals with TBI benefit from delayed feedback during learning, feedback valence might not play a significant role in performance accuracy but has an effect on level of confidence.

142 The Relationship Between Dual-Task Efficiency and Useful Field of View in Youth Clinically Recovered From Concussion and Uninjured Controls

Adrian Svingos1,2; Kayla Huntington1; Hsuan Wei Chen1; Beth Slomine1,2; Stacy Suskauer1,2

1Kennedy Krieger Institute, Baltimore, Maryland, United States; 2Johns Hopkins University School of Medicine, Baltimore, Maryland, United States

Objectives

Athletes with concussion are at an increased risk of sustaining new orthopedic injuries and concussions after clearance for return to play. Emerging evidence suggests that this risk may be associated with inefficiency in cognitive and motor dual tasking that may not be feasible to assess as part of traditional return-to-play evaluations. Therefore, there is interest in identifying valid clinical tools that measure or could be used to improve dual-task efficiency in this population. The Useful Field of View (UFOV) assessment is a computerized adaptive measure of higher-order visual processing and selective/divided attention that may relate to dual-task efficiency. Furthermore, UFOV has an associated training program that can be completed remotely and may translate to improved dual-task performance. Here, we examine the relationship between UFOV and dual-task performance measured with the Dual-Task Screen (DTS) in a sample of youth with concussion after medical clearance and uninjured controls.

Methods

Participants included 58 youth (Mage = 14.89 years, SD = 2.13; 41.4% female) enrolled in a longitudinal study focused on ongoing neural and motor recovery after medical clearance from concussion. We examined the relationship between UFOV scores (lower scores are better) and demographic variables of interest (age, sex, advanced sport participation, IQ). In a subset of participants who completed the DTS (n = 13), we examined the association between UFOV and dual-task effect scores (higher scores are better). Spearman's correlations were conducted due to normality threats.

Results

All participants performed at the ceiling on the UFOV processing speed subtest (17 ms) except for one 10-year-old with a history of concussion who was excluded as an outlier (>3.29 SD). UFOV divided attention and selective attention scores ranged from 17 to 220 ms (M = 45.38, SD = 30.46) and 36 to 280 ms (M = 87.34, SD = 43.42), respectively. After trimming outliers, UFOV scores were not significantly associated with age, sex, advanced sport participation, or IQ. UFOV divided attention was significantly associated with performance on a wall toss and serial subtraction dual task requiring rapid integration of visual, cognitive (working memory), and motor abilities (rho = −0.652, P = .016) but not on a dual-cognitive (verbal fluency) and gait task with less overt visual processing demands (rho = −0.012, P = .968). There were no significant associations between other UFOV subtests and dual-task effect scores.

Conclusions

Although preliminary, results suggest a strong relationship between UFOV divided attention and performance on a dual task with competing cognitive and visual-motor demands. This supports potential clinical utility of the UFOV assessment, which can be administered quickly (in <8 minutes on average in our sample) and remotely via synchronous video- and audioconferencing. Further work should explore the extent to which UFOV training may translate to improved dual-task efficiency or other outcomes relevant to youth at risk for reinjury after clinical recovery from concussion.

143 Assessment of Everyday Executive Functioning Using the BRIEF in Children and Adolescents Treated for Brain Tumor

Jeanne Roche1; Mathilde Chevignard2-4; Jean-Luc Roulin5; Hugo Câmara-Costa3,6; Arnaud Roy7,8

1SMAEC, Miribel, France; 2Rehabilitation Department for Children With Acquired Neurological Injury, and Outreach Team for Children and Adolescents With Acquired Brain Injury, Saint Maurice Hospitals, Saint-Maurice, France; 3Laboratoire d'Imagerie Biomédicale, LIB, Sorbonne Université, Paris, France; 4GRC 24 HaMCRe, Handicap Moteur et Cognitif et Réadaptation, Sorbonne Université, Paris, France; 5University Grenoble Alpes, University Savoie Mont Blanc, CNRS, LPNC, Grenoble, France; 6Université Paris-Saclay, Université Paris-Sud, UVSQ, CESP, INSERM, Villejuif, France; 7Laboratory of Psychology Pays de la Loire, EA4638, UBL, Angers University, Angers, France; 8Centre Référent des Troubles d'Apprentissage, Centre de Compétence Nantais de Neurofibromatose, Hôpital Femme-Enfant-Adolescent, CHU de Nantes, Nantes, France

Objective

Childhood brain tumors and their treatment often negatively affect development of executive functions (EFs) during childhood. Previous studies have reported EF deficits, associated with the most frequent pediatric brain tumors, mostly using performance-based neuropsychological assessments or, more recently, from questionnaires assessing EFs in everyday life. This study aimed to assess everyday life EFs following pediatric brain tumor in a larger and more histologically diverse sample than previously reported and to study clinical and demographic factors influencing outcome.

Methods

An assessment of executive functioning was undertaken using parent ratings of the Behavior Rating Inventory of Executive Function (BRIEF) in a large sample of children treated for various brain tumors (n = 153). A systematic analysis of all subscales and composite indices of the BRIEF questionnaire was performed. Mean T-scores and percentages of participants exhibiting significantly elevated T-scores (T ≥ 65) were considered. The following clinical and demographic factors were collected: age at diagnosis, age at assessment, parental education level, and use of cranial radiation therapy. The association between each of these factors and parent-reported executive functioning was investigated.

Results

Among the sample (56% boys; age at diagnosis: mean = 6, SD = 3.61); age at assessment: mean = 11.8, SD = 3.39), significant difficulties were found in the 3 composite indices and in 6 of the 8 BRIEF subscales (T-scores ≥ 65; P < .001 in all cases), with a high frequency of complaints. The highest level of difficulties was observed in the Working Memory subscale (mean T-score = 61.82; P < .001; 37% of participants exhibiting clinically significant scores vs 4%-8% in the reference population), whereas hardly any deficit was found for the Inhibition and Organization of Materials subscales. Both older age at assessment and younger age at diagnosis were significantly associated with higher levels of parent-reported difficulties, particularly for metacognition (R2 = 0.085; P < .05).

Conclusions

Parents of children treated for brain tumors report widespread and persistent deficits in EFs that negatively affect their everyday functioning. These difficulties vary from patient to patient. Including analysis of all clinical scales and composite indices allows a more comprehensive approach and enables to specify the patients' executive profile. This study focused on the consequences of EF deficits on everyday life functioning, but a comprehensive approach of EFs requires the combined use of performance-based measures and questionnaires.

144 Systematic Clinical Practice Guidelines for Pediatric Traumatic Brain Injury in Finland? A Survey of Real-Life Practices

Tuire Lähdesmäki1,2; Arno Hirvonen2; Nina Erkinjuntti1,2

1Turku University Hospital, Turku, Finland; 2University of Turku, Turku, Finland

Objective

The aim of the study was to investigate the availability of systematic clinical practice guidelines (CPGs) and follow-up protocols for pediatric traumatic brain injury (pTBI) in Finland.

Background

The cumulative incidence of pTBI in Finland is reported to be similar to other European countries (99/100 000), but in the report there were marked regional differences in the pTBI incidence (Wilson et al., 2017). In Finland, systematic CPGs exist only for adult TBI treatment. The treatment of severe and moderate pTBI is centralized in 5 university hospitals' pediatric surgery, neurosurgery, pediatric intensive care, and pediatric neurology units. The neuropediatric follow-up of all pTBI subtypes is organized in pediatric neurology units of regional central hospitals in addition to university hospitals.

Methods

A survey was conducted for 5 university hospitals' pediatric neurology units, covering all geographic healthcare areas of Finland. The availability of a systematic protocol for assessing and treating children with head trauma (age <16 years) in pediatric emergency units and pediatric clinics was inquired. If missing a systematic protocol, the CPGs of the university hospital were collected. The contents of the protocols or guidelines were compared between each other and with published literature on pTBI CPGs.

Results

Four of 5 Finnish university hospitals had a written protocol for acute assessment of pTBI. The diagnostic criteria for acute pTBI, indications for acute brain computed tomography, and recommendations for the pediatric follow-up varied moderately between the centers. All centers also recommended a follow-up after mild TBI, but the length of the follow-up varied between the centers. The used protocols fulfilled the criteria of dichotomous clinical practice rules more than systematic evidence-based guidelines. The decision rules were modifications of internationally published evidence (eg, Dunning et al., 2006). The neuropsychological assessment guideline was the most consistent part of the studied 4 protocols. The greatest degree of variation was observed in the regional guidelines of mild pTBI.

Conclusions

In Finland, in the treatment of pTBI regionally modified international guidelines are used. National systematic CPGs are needed also for pTBI, especially in the field of mild pTBI.

146 Accelerated Aging Posttraumatic Brain Injury Revealed by Electrophysiological Markers of Executive Attention

Nayoung Kim1; Keith Jamison1; Abhishek Jaywant1; Arindam Chowdhury1; Tracy Butler1; Kristen Dams-O'Connor2; N. Jeremy Hill3; Nicholas Schiff1; Amy Kuceyeski1; Sudhin Shah1

1Weill Cornell Medicine, New York City, New York, United States; 2Icahn School of Medicine at Mount Sinai, New York City, New York, United States; 3National Center for Adaptive Neurotechnologies, Albany, New York, United States

Executive attention impairments are a persistent and debilitating consequence of traumatic brain injuries (TBIs). The similarity between post-TBI impairments in attention and those seen in the elderly have led to the suggestion that TBI results in accelerated and premature aging. Currently, there are no targets for therapeutic interventions or sensitive prognostic models predicting the emergence of age-related neurodegenerative diseases. In this study, we derive a direct and quantifiable measure of neuronal activity specific to executive attention that reflects individual pathophysiology in subjects with TBI and an age-matched non–brain-injured sample. We first show that subjects with TBI, as a group, are impaired on processing speed and executive attention, even after adjusting for the effect of normal aging on these measures. Electrophysiological markers of executive attention processing in the midline frontal regions reveal that, as a group, subjects with TBI experience cognitive load similarly for both low- and high-demand trials; this is consistent with findings in older adults. Individual specific analyses reveal a strong effect of aging in the frontal electrophysiological responses in non–brain-injured controls; changes are seen starting in the mid-40s. On an individual basis, these reductions have a significant relationship with performance. In subjects with moderate-severe TBI, executive attention pathophysiology is consistent with those who are 8 to 10 years older than chronological age. The specific observations of frontal response reductions in subjects with TBI is consistent with the anterior forebrain mesocircuit hypothesis for cognitive impairments following a wide range of brain injuries; our results provide novel correlative data in support of specific pathophysiological mechanisms underlying cognitive deficits and accelerated aging. Collectively, our findings provide biomarkers that may serve as therapeutic targets and allow tracking of recovery of large-scale network function following brain injuries.

147 Speech, Language, and Neuroimaging Outcomes Following Childhood Stroke: A Scoping Review

Christine Muscat1,2; Sarah McCabe2; Angela Morgan3-5; Deryk Beal1,2

1University of Toronto, Toronto, Ontario, Canada; 2Bloorview Research Institute, Toronto, Ontario, Canada; 3University of Melbourne, Melbourne, Victoria, Australia; 4Murdoch Children's Research Institute, Parkville, Victoria, Australia; 5Royal Children's Hospital, Parkville, Victoria, Australia

Background

Childhood stroke affects approximately 1.2 to 8 in 100 000 children (De Viber et al., 2017; Mallick et al., 2014; Agrawal et al., 2009); among these children, 50% to 74% display impairments in speech (apraxia, dysarthria) and language (aphasia) functioning (Sherman et al., 2021). Greenham and colleagues (2020) concluded that research has neglected to report on interventions for the treatment of speech and language difficulties in the subacute phase following childhood stroke. In addition, although extensive literature on speech, language, and neuroimaging outcomes following stroke in the adult population exists (ie, Sebastian & Breining 2018; Saur & Hatwigsen, 2012; Seghier et al., 2016), research regarding rehabilitation interventions for children following stroke in both acute and post-acute phases are limited (Heart and Stroke Foundation, 2016; Taze & Valente, 2011).

Objectives

The primary objective of this scoping review was to synthesize the peer-reviewed literature describing the speech, language, and neuroimaging outcomes following childhood stroke. We aimed to highlight key speech and language outcome measures, characteristics, and their associated neural outcomes via brain imaging measures, following childhood stroke that have been observed to date in the literature. The secondary objective was to identify gaps in the literature regarding childhood stroke for future study consideration.

Methods

Manuscripts pertaining to speech, language, and neuroimaging outcomes were extracted from MEDLINE, EMBASE, and PsycINFO databases. Peer-reviewed, English publications with data on speech, language, and/or neuroimaging outcomes following childhood stroke were included in this scoping review. All obtained studies were published prior to 2022; observational in design; and primarily focused on the subacute phase of childhood stroke. Articles were screened by 3 reviewers, and data were extracted from the remaining articles.

Results

From 3087 studies, 11 met inclusion criteria for review. Of the 11 included studies, 2 reported speech outcomes, 11 reported language outcomes, and 4 reported functional magnetic resonance imaging outcomes. The preliminary findings of this scoping review indicate a primary focus in the literature on the acute phase following childhood stroke, with no standardization of assessment tools used to examine the speech and language outcomes post-childhood stroke and limited documentation of the associated neural correlates.

Conclusion

Overall, future research investigating speech, language, and neural outcomes in the subacute phase following childhood stroke is warranted. The results of this scoping review will help inform the next essential steps required to develop innovative and more personalized rehabilitative assessments and intervention plans for children following stroke.

148 Effectiveness of High-Intensity Gait Training to Improve Ataxic Gait After Brain Injury: A Case Study

Rebecca Askew1; Heather David2

1Scripps Encinitas Outpatient Rehabilitation Services, Encinitas, California, United States; 2Hawai'i Pacific University, Honolulu, Hawaii, United States

Ataxia is an impairment after acquired or traumatic brain injury that can impact postural stability and ultimately functional mobility independence with walking. The treatment of gait disturbance due to ataxia lacks practice guidelines. The purpose of this case study was to describe the functional changes after High-Intensity Gait Training (HIGT) intervention in postural stability and functional mobility independence as measured by the Berg Balance Scale (BBS), Severity of Ataxia Rating Scale (SARA), and independence with walking.

This client was a 28 years old man who suffered a nontraumatic intracerebral hemorrhage requiring suboccipital craniotomy. At initial evaluation for outpatient physical therapy after 1 month in acute rehabilitation, the patient presented in a reclining wheelchair with head support, had an initial BBS score of 2/56, required maximum assist of 2 people to ambulate 25 ft, and his SARA score was 31/40. His goals were to walk, eat, and drink without assistance. He participated in HIGT during physical therapy for 60-minute sessions for 40 weeks, 1 to 3 times per week. He made gains in postural stability, ataxia, functional mobility, and walking independence. His outcomes include an improvement in BBS score from 2/56 to 36/56, SARA score of 12/40 from 31/40, and his ambulation independence improved from maximum assist of 2 people to ambulating on his own with an front wheeled walker in his home and his community.

This case suggests that using HIGT for clients after brain injury who have ataxia is a promising treatment intervention that can improve postural stability, functional mobility independence, and independence with walking. High Intensity Gait Training as an evidence based practice approach in clients with ataxia warrants further study.

150 The Impact of Speed of Processing on Treatment Response to Learning and Memory Rehabilitation Intervention in Individuals With TBI

Aubree Alexander1,2; Silvana L. Costa1,2; Caroline H. Armknecht1; Kristen Costanza1; John DeLuca1,2; Nancy D. Chiaravalloti1,2

1Kessler Foundation, East Hanover, New Jersey, United States; 2Rutgers New Jersey Medical School, Newark, New Jersey, United States

Objective

Traumatic brain injury (TBI) often results in cognitive impairments in processing speed (PS) and new learning and memory (NLM). The Kessler Foundation modified Story Memory Technique (KF-mSMT) has been shown to improve NLM in individuals with TBI and other neurological conditions. In individuals with TBI, treatment with KF-mSMT was associated with improved NLM of a paragraph but not of a list of words. In a study of individuals with multiple sclerosis (MS) who received KF-mSMT, secondary data analysis indicated that individuals with deficits in both PS and NLM did not demonstrate maximal benefit from KF-mSMT, while those with only a memory deficit showed significant benefit. The current study examined the role of PS in benefit from KF-mSMT in persons with TBI.

Methods

The current study was a secondary analysis of data obtained from a randomized controlled clinical trial examining the efficacy of KF-mSMT in individuals with TBI. Sixty-two individuals with TBI were randomly assigned to the treatment (n = 31) or placebo control group (n = 31). Groups did not differ in age or time since injury, but the control group had greater years of education (t64 = −2.77, P = .007). Neuropsychological assessment was conducted at baseline and 1 week after completing treatment. The secondary analysis outcome measure of interest was CVLT-II learning slope at immediate follow-up. PS was assessed with the oral version of the Symbol Digit Modalities Test (SDMT).

Results

Analysis of covariance (ANCOVA) was used to examine treatment effects (CVLT-II learning slope at follow-up), with baseline learning slope and PS performance as covariates. There was a trend toward significance for the model (F1, 58 = 3.82, P = .055, partial eta square = 0.06), indicating an increased effect of treatment after controlling for both baseline memory and PS. Baseline learning slope was a significant covariate (F1,62 = 37.3, P < .001, partial eta square = 0.39), as was PS (F1,62 = 5.52, P = .002, partial eta square = 0.09). After accounting for the influence of PS, individuals in the treatment group were more likely to show improved CVLT-II slope (list learning ability) after KF-mSMT intervention.

Conclusions

Consistent with findings in individuals with MS, PS exerted a significant influence on ability to benefit from KF-mSMT in individuals with TBI. This secondary data analysis provides insight into the initial lack of an observed treatment effect for list learning slope in persons with TBI, as processing speed exerts a significant impact on treatment benefits. Specifically, individuals with better PS abilities demonstrate greater benefit from treatment with KF-mSMT. Such findings lend additional support to the notion that some TBI patients may benefit from implementing PS interventions before engaging in learning and memory rehabilitation programs.

151 Parental Experience After Early Childhood Concussion: A Qualitative Approach

Dominique Dupont1; Danaë Larivière-Bastien1,2; Miriam Beuachamp1,2

1Université of Montréal, Montreal, Quebec, Canada; 2CHU Sainte-Justine, Montreal, Quebec, Canada

Objective

The prevalence of concussions in early childhood, between the ages of 0 and 5 years, is high and its effects are understudied. Caregivers occupy a central role in early childhood when the effects of parental traits (eg, mental health and affective state) and perspectives (eg, burden) on child recovery trajectory may be especially important (Beauchamp et al., 2020; PARENT model). Most studies focusing on child traumatic brain injury (TBI) outcome use quantitative measures of health and functional status in the form of questionnaires to document parental factors and mental health. However, this approach only provides a partial picture of the parent's experience and psychological state. Qualitative designs can provide additional insight into the lived experience and main concerns of parents of children with TBI but have mainly been used after moderate to severe forms of pediatric TBI. It is therefore unclear what unique perspectives are associated with the experience of parents whose child sustains concussion, and no qualitative study of parent perspective has been conducted in the youngest developmental group (<5 years). This study aimed to document caregiver experience and perception following concussion in their young child.

Methods

Fifty-nine parents of children who sustained mild TBI between 6and 60 months of age (mean age= 40.3 months, SD = 20.1 months; 27 boys) were invited to participate in a face-to-face semistructured interview regarding their experience. The interview (about 10-20 minutes) consisted of 7 questions aiming to document parents' feelings, opinions, and perceptions regarding their child's accident, recovery, and health care management. Audio recording of the interviews were first transcribed verbatim and analyzed thematically using QSR NVivo software. A coding guide, designed to structure the coding, was developed based on the analysis of 6 initial interviews.

Results

Four main themes emerged from the analysis: concerns following the injury; impact on family functioning; advice to other parents; and level of satisfaction in the healthcare system. Subthemes included parents' negative affective state and concerns regarding their child's physical, cognitive, and emotional development. Impacts on the family included not only subthemes of negative emotional states (ie, anxiety and sadness) but also positive outcomes, such as family union. Parental advice was evoked around the idea of being proactive after their child's injury (ie, calling a health hotline for guidance, going to the hospital immediately) and trusting their health professional. As for healthcare, the main subthemes gathered around global satisfaction in the services and feelings of gratefulness.

Conclusion

Understanding affective responses and burden in parents is critical to providing targeted resources, support, and intervention after early concussion for both children and their caregivers. Gathering parental perspectives during this developmental stage may be especially critical, given that their affective state and response to child behavior and changes contribute to the course of recovery.

152 Factors Associated With Optimal Recovery 18 Months Post–Early Mild Traumatic Brain Injury

Olivier Aubuchon; Dominique Dupont; Lara-Kim Huynh; Marilou Séguin; Miriam Beauchamp

University of Montreal, Montreal, Quebec, Canada

Introduction

Pediatric mild traumatic brain injury (mTBI) can lead to postconcussive symptoms and cognitive, behavioral, and quality of life issues (Fineblit et al., 2016), which usually resolve in about 70% of children within 3 months (Zemek et al., 2016). mTBI is highly prevalent during preschool (early mTBI; McKinlay et al., 2008) but poorly studied. At this age, family environment may factor into prognosis (Beauchamp et al., 2021). Emerging work suggests there may be value in understanding optimal outcome (“wellness”) to identify factors that promote recovery after mTBI (Beauchamp et al., 2019).

Objective

(1) To document the proportion of children with optimal well-being following early mTBI; (2) to study the evolution of well-being; and (3) to identify the familial and sociodemographic factors that contribute to early mTBI well-being.

Method

In total, 190 children with early mTBI (mTBI; n = 69; mean age [Mage] = 3.62 years, SD = 0.95), orthopedic injury (OI; n = 50; Mage = 3.45 years, SD = 0.96), or typical development (TDC; n = 71; Mage = 3.58 years, SD = 1.00) were assessed at 6 (T1) and 18 (T2) months postinjury (mTBI and OI groups) on a battery of cognitive tests. Parents participated in interactive activities with their child and completed questionnaires. Participants were dichotomized as high or low well-being, with the former defined as follows: (1) good cognition (no 2 scores <1 SD on cognitive battery); (2) good quality of life (score >65.4 on the Pediatric Quality of Life Inventory); (3) fewer than 3 postconcussive symptoms; and (4) no behavioral issues (T-score <65 on the Child Behavior Checklist). Predictors included child age and sex, parent education, parent-child attachment and interaction quality, parenting stress, and child negative affectivity temperament.

Results

There were significantly fewer children with mTBI in the high well-being group at T1 (χ1,1402 = 8.15, P = .005) and T2 (χ1,1402 = 9.05, P = .003) compared with TDC. The OI group had no significant proportion differences with mTBI and TDC. Analysis showed no differences between T1 and T2 for all groups. Logistic regression indicated that lower child negative affectivity at T1 (B = −0,717, ES = 0.332, Wald = 5.300, P = .031) and higher quality of parent-child interaction at T1 (B = 0.514, ES = 0.238, Wald = 6.357, P = .031) predicted well-being in the mTBI group at T2. The prediction models for the OI and TDC groups were significant for age, with older age predicting well-being.

Discussion

Well-being after early mTBI appears to be lower compared with children developing typically and does not seem to evolve between 6 and 18 months postinjury. Family factors could represent loci for promoting good outcomes after early mTBI.

154 Therapeutic Engagement Mediates the Effect of Sleep Fragmentation on Rehabilitation Progress After Pediatric Brain Injury

Anthony Lequerica1,2; Hannah Aura Shoval2,4; Jessica Ace3; Theodore Yip5; Sabrina Dieffenbach2; Claire Marchetta6; John DeLuca1,2

1Kessler Foundation, East Hanover, New Jersey, United States; 2Rutgers New Jersey Medical School, Newark, New Jersey, United States; 3JFK Johnson Rehabilitation Institute, Edison, New Jersey, United States; 4Morristown Medical Center, Morristown, New Jersey, United States; 5University of North Carolina, Chapel Hill, North Carolina, United States; 6Children's Specialized Hospital, New Brunswick, New Jersey, United States

Objectives

To examine the relationship between sleep fragmentation, therapeutic engagement, and rehabilitation progress in a sample of pediatric rehabilitation inpatients.

Methods

A sample of 29 consecutive brain injury admissions at a Northeastern children's rehabilitation hospital, with ages ranging from 5 to 17 years (M = 12.7, SD = 3.5). The sample was 31% female. Parents provided permission and children gave informed assent in accordance with local institutional review board guidelines. Participants wore an ActiGraph, a wrist accelerometer used to measure the sleep-wake cycle, over a period of 7 days. Within the rest interval between 22:00 and 6:00, a sleep fragmentation index (SFI) was calculated by summing (1) the proportion of all epochs from sleep onset to sleep offset that were mobile and (2) the proportion of all immobile bouts from sleep onset to sleep offset 1 minute or less in duration. The Rehabilitation Therapy Engagement Scale-Revised (RTES-R), a 15-item rating scale assessing engagement in therapy, was completed by physical therapists across 5 weekdays. The RTES-R total scores were averaged over the 5 days coinciding with the average SFI across 5 nights. The WeeFIM, a measure of functional status, was administered by trained staff at rehabilitation admission and discharge. Rehabilitation progress was operationally defined as a modified WeeFIM efficiency score (mWFE) calculated as the proportion of potential gains achieved from admission to discharge divided by the rehabilitation length of stay.

Results

An unadjusted regression model demonstrated a significant relationship between the SFI and the RTES-R (r = −0.40, P = .015) and between the SFI and mWFE (r = −0.41, P = .013). When the RTES-R was added to a regression model with SFI as the predictor and mWFE as the dependent variable, it accounted for a significant portion of the variance (β = .62, P < .001) and rendered the relationship between the SFI and mWFE no longer significant (β = −.17, P = .291), suggesting a mediating effect of the RTES-R.

Conclusions

Therapeutic engagement is an important predictor of progress in rehabilitation that is associated with sleep quality and may largely explain the relationship between poor sleep quality and rehabilitation progress. Although functional status assessments are a standard part of pediatric brain injury rehabilitation, facilities should consider implementing validated measures of sleep quality and therapeutic engagement. Objective measurement of these factors can identify patients who may be in need of targeted interventions to improve sleep and/or engagement in their rehabilitation therapies. Further research is needed to determine whether these measures are sensitive to change over time so that the effectiveness of interventions can be objectively quantified to maximize progress.

Disclosures

This research was supported by the Dwight and Church Employee Giving Fund. The authors have no conflicts of interest to disclose.

155 Benefits of Modern Technology in Pediatric Pain Management: Virtual Reality Videos and Holograms for Reducing Fear and Anxiety Before and During Hospital Procedures

Anneli Kolk1,2; Alina Roštšinskaja1,2; Christen Kööp1; Marianne Saard1,2

1University of Tartu, Tartu, Estonia; 2Children's Clinic of Tartu University Hospital, Tartu, Estonia

Objectives

Management of medical fear and procedural pain is a challenging mission in pediatric care. Distraction techniques are considered as one of the most effective nonpharmacological opportunities. The aim of this study was, first, to assess children's fear reduction due to educational video before doctor's visit and hospital procedures, and second, to implement novel pain management tool kit: holographic technical 3D animations. To our knowledge, holograms have not been used as distractions in hospitals for children before.

Methods

This study was performed in the Children's Clinic of Tartu University Hospital. The educational study group consisted of 28 children (aged 5-13 years) coming to doctor's visits or undergoing hospital procedures. Children were presented with a 6-minute educational video. Younger children were shown the video on iPad and older in virtual reality (VR). A visual analog scale (VAS) for pain (Wong-Baker Faces Pain Rating Scale) was modified for measuring children's fear before and after showing the video. Holographic study group consisted of 51 children (aged 5 months to 13 years). Children undergoing painful hospital procedures, such as intravenous cannulation and blood draws, were presented with playful holographic videos on HYPERVSN 3D device. Holographic display is a 4-ray rotor that spins fast, resulting in 33 holographic animations. Nurses evaluated children's pain with the FLACC scale (1997) during procedures before and after initiating holographic distractions.

Results

Hospital fear reported by children before a doctor's visit or procedure had reduced due to informing and comforting via the educational video. At first assessment with VAS, fear levels reported by children were approximately 3 times higher than on second assessment. Parents' feedback showed that younger children needed guidance and explanations by parents or medical staff to concentrate and comprehend the video.

Before distraction with holograms, 17.5% of children presented with severe, 56% with moderate, and 22.8% with mild discomfort. The number of higher fear scores significantly (P < .0001) increased with age: maximal fear level 7 to 10 occurred in 58.3% of children aged 12 to 18 years compared with 33.3% in children aged 0 to 3 years. After viewing holograms, children's pain scores on the FLACC scale had decreased significantly (P < .0001) at second assessment by 4.01 points (out of 10).

Conclusions

Educational videos for children could be effective tools in preventing fear in hospital settings before a doctor's visit and painful procedures (vaccinations). Videos are suitable for children 5 years and older, with higher levels of language comprehension. VR is motivating for children with advantages like novel, flexibility, and safe environment. During procedures, active holographic distraction technique was an effective multipurpose pain management tool kit for children of different ages, including smaller children (aged 10-13 months). We recommend healthcare providers to use educational videos and novel hologram technology in hospital settings.

The study was funded by the Estonian Science Foundation PRG789.

156 Evaluation of Motor Control Following Pediatric Traumatic Brain Injury: A Pilot Study

Nanette Aldahondo1,2; Amy Schulz1; Michael H. Schwartz1,2,; Andrew J. Ries1

1Gillette Children's Specialty Healthcare, St Paul, Minnesota, United States; 2University of Minnesota, Minneapolis, Minnesota, United States

Objective

To determine if Walking Dynamic Motor Control (Walk-DMC), a measure used to quantify motor control, is useful for pediatric patients with a traumatic brain injury (TBI) by (1) helping evaluate the severity of the injury, (2) measuring the progress of motor recovery, and (3) estimating the prospects for motor recovery.

Methods

This is an observational, exploratory study with a convenience sample of children/adolescents who sustained a severe TBI and completed inpatient rehabilitation in a pediatric center. Once participants demonstrated the ability to walk 30 consecutive steps, Walk-DMC was assessed twice weekly during a Six-Minute Walk Test (6MWT) for the first 2 weeks of enrollment, followed by weekly assessments until discharge from the inpatient rehabilitation unit. Other clinical measures of mobility and balance such as the Pediatric Berg Balance Scale (PBS), 6MWT, and Timed Up and Go (TUG) were also collected at these time points as the patient's mobility allowed. All measures were collected again at the standard of care follow-up 6 months postinjury.

Results

Four patients (aged 10-19 years; 2 males, 2 females) with severe TBI (initial Glasgow Coma Scale score ≤8) were enrolled in this pilot study. All participants demonstrated a reduction compared with normal values in their Walk-DMC during the first week of assessment. All standard-of-care clinical measures (PBS, 6MWT, and TUG) demonstrated an initial reduction, followed by improvement over the course of the study period. Walk-DMC scores improved over the course of the study period but did so over a longer course than the standard-of-care clinical measures. Although PBS and TUG did in some patients return to the normal range, Walk-DMC did not normalize in any of the participants by the 6-month post-TBI assessment.

Conclusions

Walk-DMC was diminished after severe TBI, which is consistent with decreases in standard-of-care measures including PBS, 6MWT, and TUG. Throughout the study, participants demonstrated improvement in all standard-of-care measures as the participants improved by subjective clinical assessment. As Walk-DMC was still suppressed at the 6-month post-TBI assessment for all participants, it may be that Walk-DMC is more sensitive to detecting ongoing neurologic impairment than other clinical measures. Future assessments will include a repeat assessment 1 to 2 years postinjury to determine if Walk-DMC continues to be diminished compared with the standard-of-care clinical measurements.

157 Improving Transitions to Community Services in Partnership With Brain Injury Associations

Valérie Poulin1,4; Marie-Ève Lamontagne3,4; Émilie Raymond3,4; Benoît Durand2; Olivier Piquer2-4; Mélodie Nicole1; Doriane Charbonneau1; Vincent Lessard1

1Université du Québec à Trois-Rivières, Trois-Rivières, Quebec, Canada; 2Association TCC des deux-rives, Quebec, Canada; 3Université Laval, Quebec City, Quebec, Canada; 4Centre interdisciplinaire de recherche en réadaptation et intégration sociale (CIRRIS), Quebec City, Quebec, Canada

Introduction

People living with traumatic brain injury (TBI) and their family caregivers need to have better access to community services that address their evolving needs and promote participation in the home and community settings throughout life transitions.

Objective

The purpose of this study was to identify concrete actions with key stakeholders in the health and social services sectors to address priority issues for improving transitions and integration into community services after a TBI.

Methodology

This action research was conducted in partnership with a TBI association offering services to community living TBI survivors in 2 sociodemographic regions (including urban, semi-urban, and rural communities) in the province of Quebec, Canada. In the first phase of the study, a list of key issues related to transitions and integration into community services was identified based on the data from semistructured interviews with 11 people living with TBI and 12 family caregivers. From this list, 3 issues were prioritized using a consensus-based methodology (TRIAGE) in a virtual group meeting involving 16 participants representing partners from the voluntary, health, and social services sectors. Participants then engaged in small group discussions using the World Café methodology to identify cross-sectoral solutions for implementation. The qualitative data from interviews and group discussions were analyzed using a thematic content analysis that combined inductive and deductive approaches and were validated with representatives from the TBI association.

Results

From the initial list of 15 issues, participants identified 3 priorities to be addressed in the short to medium term: (1) supporting transitions between rehabilitation services and brain injury associations; (2) improving community awareness and education about brain injury; and (3) strengthening cross-sector collaboration among key stakeholders involved in post-TBI transitions and community integration. For each priority, several actions for implementation were identified such as (1) strategies to improve systematic referral and linkages to TBI associations for individuals living with TBI and their families throughout life transitions; (2) the creation of brain injury awareness and education brigades that include individuals living with TBI as well as representatives from TBI associations and rehabilitation services; and (3) strategies to share learning tools and inspiring practices across partners and sectors (eg, community mental health services, primary care services, housing).

Conclusion

These findings will guide the development and implementation of cross-sectoral practices to optimize transition mechanisms and support integration into community services for people living with TBI and their caregivers.

158 Child and Robot: A New Level of Communication—Either Science Fiction or Real Life?

Alina Roštšinskaja1,2; Marianne Saard1; Christen Kööp1; Kätlin Kits1; Triinu-Liis Loit1; Liisa Uutsalu2; Anneli Kolk1,2

1University of Tartu, Tartu, Estonia; 2Children's Clinic of Tartu University Hospital, Tartu, Estonia

Objectives

Social robots are made to engage in interactions with humans, being one of the crucial future technologies in neurorehabilitation. Robot Pepper (created by Softbanks 2014) is characterized by multiple functions and high levels of anthropomorphization. The aim of our study was to evaluate child-robot interaction (CRI) during neurorehabilitation or hospital visits.

Methods

The study was performed in the Children's Clinic of Tartu University Hospital. In total, 45 children aged 4 to 16 years participated: 31 with different neurological diagnoses and 14 children developed typically during their hospital visit. To evolve communication skills and prosocial behavior in children, an Estonian-based interface for child-like robot Pepper (height 120 cm, weight 28 kg) was developed by the authors. Behavioral and communicative applications were programmed by the authors using Neurotolge technology. Interaction was examined in 2 ways: therapists' observations of CRI and a survey conducted with children based on 4 sociocultural concepts (altogether 15 questions). Children also evaluated their own and Pepper's emotional states on Smilyometer.

Results

Observation showed that all 45 children quickly engaged with Pepper (taking social contact in 1-3 seconds), implementing prosocial behavior and their mood immediately lifted. On Smilyometer, children evaluated their own mood and Pepper's mood as happy (4-5 points out of 5). Children used verbal and nonverbal communication skills: normal or loud volume of voice, holding eye contact, smiling, and expressing positive emotions. Some children petted or hugged the robot, naming it their friend. All children showed interest in pictures that Pepper showed them on tablet. All children but one participated in nonverbal tasks that Pepper provided (eg, “show how you breathe deeply”). The survey revealed children's perception of Pepper: likability, 93%; safety, 76%; intelligence, 89%; and anthropomorphism, 68%.

Conclusions

We found that the anthropomorphic design of Pepper enhances acceptance, interaction, and communication with children of different ages. Children's messages about CRI were positive in 100% of cases. They found Pepper to be friendly, cheerful, smart, and safe by adding benefits to the rehabilitation process and reducing hospital fear and helping promote well-being in hospitalized children.

The study was funded by the Estonian Science Foundation PRG789.

161 Exploring the Adaptability of Teach-ABI for High School Educators

Christine Provvidenza1,2; Hiba Al-Hakeem2; Elizabeth Ramirez3; Rick Rusyn3; Shannon Scratch1,2,4

1Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada; 2Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada; 3Department of Occupational Science & Occupational Therapy, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; 4 Department of Paediatrics, University of Toronto and Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada

Background

Acquired brain injury (ABI) can have a cognitive, physical, and psychosocial impact on youth, which affect their performance in school. Students with ABI experience challenges returning to school due to lack of educator support in terms of ABI knowledge, awareness, and strategies to help students in the classroom. Researchers at a pediatric rehabilitation hospital in Toronto created Teach-ABI, an online professional development module designed to help elementary school educators support students with ABI. While the goal of the original Teach-ABI was tailored to elementary school educators, it is important to consider the secondary school context and the unique resources needed by educators to support high school students.

Objectives

Study objectives were to determine the adaptability of Teach-ABI to address high school teachers' needs in supporting students with ABI. The research questions were as follows: (1) What are the perspectives of high school educators on Teach-ABI elementary as an online professional development module? and (2) How can Teach-ABI be adapted to align with the high school context and the needs of educators?

Methods

Interviews were conducted with high school educators to determine the adaptability of Teach-ABI. Interview questions were informed and guided by implementation science and adaptation frameworks, specifically the Consolidated Framework for Implementation Research, the Framework for Reporting Adaptations and Modifications-Enhanced, and the Intervention Mapping for adaptation framework. Directed content analysis was used to examine the interview transcripts. Preidentified codes were derived from the domains of implementation and adaptation frameworks.

Results

Nine participants reviewed the module. Participant comments were organized into 3 categories: (1) reflections on the usefulness of Teach-ABI elementary; (2) adaptation of Teach-ABI for the high school context; and (3) thinking about implementation. Participants described the module as user-friendly and informative. Feedback confirmed that Teach-ABI can be adapted to create a resource for high school educators. Instructional methods such as case studies, videos, and school accommodations need to be adapted and tailored to the high school environment.

Conclusion

Teach-ABI was identified as a foundational professional development module that can be adapted for use by high school educators. Integrating end-user feedback, garnered through the use of implementation science and adaptation frameworks, will be essential in creating a high school version of Teach-ABI for educators to best support high school students with ABI.

162 Social Deficit Profiles in Children With Neurological Disorders Assessed by Structured Model of Neurorehab

Marianne Saard1,2; Alina Roštšinskaja1,2; Christen Kööp1; Anneli Kolk1,2

1University of Tartu, Tartu, Estonia; 2Children's Clinic of Tartu University Hospital, Tartu, Estonia

Objectives

Children with neurological disorders (NDs) often present with social competence (SC) deficits. Developing evidence-based pediatric interventions requires the assessment of children's social profiles, which reveal specific social components that need to be targeted in the rehabilitation process. The aim of the study was to evaluate the SC profiles of children with ND prior to rehabilitation using the theoretical base of the Structured Model of Neurorehab.

Methods

We have previously presented the Structured Model of Neurorehab (Kolk et al., 2019) with assessment and intervention tools for the remediation of sociocognitive deficits in children. So far, 60 children with ND (with diagnosis like epilepsy, traumatic brain injury, tic disorder, or stroke), aged 8 to 13 years, and 16 healthy age-matched controls have participated in the baseline assessments, which were based on the evaluation tools from the structured model.

Results

At baseline, parents answered the BRIEF questionnaire. Based on parental assessment, 64% of children with ND presented with impairments in behaviors related to executive dysfunctions. Patients' scores were significantly higher than the average scores of the healthy children (study group median = 61, Q1-Q3 = 56-69, vs norm T = 50, P < .005). The most impaired components of SC in patients were emotion recognition, Theory of Mind (ToM) abilities, cooperation, verbal/nonverbal communication skills, and pragmatics (Friendship Observation Scale scores 10%-50% out of 100). Patients lacked conflict resolution (median 38% out of 100%) and empathy skills (25%). In the Sentence Completion Task, children reported lack of friends, behavioral problems, bullying, and social anxiety. In the Spence Anxiety Scale, 52% of children with ND reported fears of physical injury, 38% described obsessive-compulsive behavior, 33% social anxiety, 33% symptoms of generalized anxiety, 29% panic disorder, and 29% revealed separation anxiety. Subtests under the Social domain of NEPSY-II neuropsychological assessment battery showed that patients had significantly lower scores in verbal ToM skills compared with age-matched norms (P < .001)—35.6% of patients had scores below the normal range. The ToM Stories test revealed significantly lower scores in understanding intentional lying compared with age-matched test norms (P < .005).

Conclusions

Evaluation tools based on our theoretical structured model for sociocognitive deficit rehabilitation have effectively described children's individual social profiles. The children with ND showed various impaired components in SC and often expressed anxieties. Children with ND need novel multicomponent neurorehabilitation methods, which target the specific impaired SC components. Assessment based on evidence-based models, which structurally allow detection of impaired subfunctions, is important to be used prior to the rehabilitation process to plan suitable training programs, as well as to evaluate primary and long-term effects of rehabilitation after the training period.

The study was funded by the Estonian Science Foundation PRG789.

163 Characterizing the Evolution of Vestibulo-ocular Reflex Function Over Time in Children and Adolescents After a Mild Traumatic Brain Injury

Adrienne Crampton1; Kathryn Schneider3-5; Lisa Grilli2; Mathilde Chevignard6-8; Michal Katz-Leurer9; Miriam Beauchamp10,11; Chantel Debert12; Isabelle Gagnon1,2

1School of Physical and Occupational Therapy, McGill University, Montreal, Quebec, Canada; 2Montreal Children's Hospital-McGill University Health Center, Montreal, Quebec, Canada; 3Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada; 4Alberta Children's Hospital Research Institute, Calgary, Alberta, Canada; 5Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada; 6Sorbonne Université, CNRS, INSERM, Laboratoire d'Imagerie Biomédicale, LIB, Paris, France; 7Sorbonne Université, GRC 24 Handicap Moteur et Cognitif et Réadaptation, Paris, France; 8Rehabilitation Department for Children With Acquired Neurological Injury and Outreach Team for Children and Adolescents With Acquired Brain Injury, Saint Maurice Hospitals, Saint-Maurice, France; 9Physical Therapy Department, University of Tel-Aviv, Tel-Aviv, Israel; 10ABC's Laboratory, Ste-Justine Hospital Research Center, Montreal, Quebec, Canada; 11Department of Psychology, University of Montreal, Montreal, Quebec, Canada; 12Department of Clinical Neuroscience, University of Calgary, Calgary, Alberta, Canada

Objectives

Impairments to vestibulo-ocular reflex (VOR) function following pediatric mild traumatic brain injury (mTBI) have been reported. Such impairments may be associated with more negative prognosis, affecting one's physical and mental well-being, emphasizing the need to more fully understand how they evolve. As such, our objectives were (i) to determine the extent to which performance on clinical and computerized tests of VOR function, and of its supportive oculomotor (OM) system, vary over time in children and adolescents within 21 days, 3 months, and 6 months after an mTBI; and (ii) to describe the proportion of children and adolescents with mTBI presenting with abnormal scores on VOR and OM tests at each time point.

Methods

This was a prospective, longitudinal study that took place at a tertiary care pediatric hospital. Thirty-six participants with mTBI aged 6 to 18 years were included. Participants were assessed on a battery of VOR and OM tests within 21 days of injury (T1), at 3 months (T2), and at 6 months (T3) post-mTBI. Clinical measures included the vestibular/ocular motor screening tool (VOMS) measuring induced symptom provocation (0-10/10 for headache, dizziness, nausea, and fogginess) and performance (normal/abnormal) on VOR and OM tasks; computerized measures included a reflexive saccade test measuring response latency (milliseconds), a video head impulse test measuring VOR gain, and a dynamic visual acuity test (LogMAR change). Generalized estimating equations (parameter estimates and odd ratios [ORs]) estimated the effect of time. Proportions above and below normal cutoff values (³2/10 increase) were determined.

Results

Our sample consisted of 52.8% females, with a mean age 13.98 (SD = 2.4) years and assessed on average 19.07 (range, 8-33) days following injury. An effect of age on visual motion sensitivity (OR = 1.43, P = .03) and of female sex on near point of convergence (OR = 0.19, P = .03) was identified. Change over time indicating improvement was demonstrated by VOMS global symptom provocation (T1-T2: OR = 9.90, P = .012), vertical smooth pursuit performance (T1-T2: OR = 4.04, P = .03; T1-T3: OR = 3.12, P = .04), vertical voluntary saccade performance (OR = 6.06, P = .005; T1-T3: OR = 5.91, P = .01), and right VOR gain (OR = 0.07, P = .01). Version performance and VOR symptom provocation showed high abnormal proportions (14.71%-41.18% and 12.12%-15.15%, respectively) at T1, trending toward recovery and stabilizing by T2 and T3.

Conclusions

Results indicate that impairments to the VOR pathway may be present, potentially driving symptom provocation. Vertical version findings underline the need to include relevant tasks in assessment batteries. As pathways involved in vertical smooth pursuits and saccades differ from those involved in the horizontal movements, failing to assess one direction may result in overlooking an impairment. Findings demonstrate the added value of including symptom and performance-based measures when assessing the VOR, as well as the relative stability of constructs measured beyond 3 months post-mTBI.

164 Early Estimation of Length of Hospital Admission Following Acquired Brain Injury in Children: A Potential Use of the Rehabilitation Complexity Scale

Orla McNerney1; Jillian Pounch1; Irwin Gill1,2

1Acute Rehabilitation Service, Children's Health Ireland at Temple Street, Dublin, Ireland; 2School of Medicine, University College Dublin, Dublin, Ireland

Background

Outcomes after acquired brain injury (ABI) in children are challenging to predict in the immediate aftermath of an injury. Prognostication is known to be important to families. The Rehabilitation Complexity Scale was initially developed for use in adults to provide a measure of the complexity of the rehabilitation needs of a given person. In the United Kingdom, it is used to designate appropriate locations of care and measure cost-effectiveness of rehabilitation. Its use has been described in children, but it has not yet been validated for pediatric populations. We aimed to investigate correlations between initial Rehabilitation Complexity Scale (RCS-E) score and length of inpatient admission in children admitted to a tertiary neurosurgical and rehabilitation center in Ireland following ABI.

Methods

This study was conducted in an acute rehabilitation service within a tertiary pediatric hospital; these services are colocated with rehabilitation provided on-site. The RCS-E is administered as standard within 1 week of admission for all patients accessing the Acute Rehabilitation Service. Data pertaining to initial RCS-E scores and length of inpatient admission were extracted from the rehabilitation database. Admission of 28 days or longer has been interpreted by some authors as inferring the occurrence of a “probable severe ABI requiring rehabilitation (PSABIR).” RCS-E scores for patients with admissions of 28 days or longer were compared with those admitted for less than 28 days. An independent-samples t test was performed. All admissions were divided into subgroups based on the initial RCS-E score (0-4, 5-9, 10-14, 15-19, 20-25). The Kruksal-Wallis test was performed to test for statistically significant differences between the medians of the groups.

Results

Forty completed admissions were noted from June 2021 to February 2022. Initial RCS-E scores for patients admitted for 28 days or longer were higher than those of patients admitted for less than 28 days (18.67 vs 9.77, P < .001). Length of stay (LOS) was significantly correlated with the initial RCS-E score. Median LOS for RCS-E 0-4 was 2 days, increasing to 8 days for RCS-E 5-9, 11 days for RCS-E 10-14, 26 days for RCS-E 15-19, and 78 days for patients with initial RCS-E scores of 20 or higher (test statistic h = 27.29, critical χ² = 9.49).

Conclusion

Initial RCS-E scores were associated with an increased likelihood of longer inpatient admissions in this cohort. The Rehabilitation Complexity Scale has potential value as an early prognostic tool following ABI in children. LOS will be affected by service structure and design, which will vary between centers. Further research in larger cohorts and analysis of RCS-E subscores may be of value in further determining how best to apply this tool, as well as in examining the potential reasons for outliers within RCS-E categories.

165 Evaluation of the Impact of a Concussion Assessment Pathway for Children Presenting With Acute Concussion to a Pediatric Emergency Department

Stephanie McFarland1; Savithiri Ratnapalan2; Niranjala Perera2; James Murphy1; Gregory Harvey1; Shannon Scratch1

1Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada; 2Hospital for Sick Children (SickKids), Toronto, Ontario, Canada

Objective

Implementing the use of clinical risk scores for Predicting Persistent Post-Concussive Problems in Pediatrics (5P screen) to identify children and youth at risk for prolonged symptoms in acute care settings has been challenging. The objective of this project was to evaluate the impact of implementation the 5P clinical risk screen in a pediatric emergency department (ED) to increase appropriate concussion assessments and referrals of children most likely to benefit from interdisciplinary specialized care at Holland Bloorview Concussion Clinic less than 4 weeks from injury.

Methods

An interdisciplinary collaboration was established between the Concussion Clinic at Holland Bloorview and the ED at the Hospital for Sick Children to the identify learning needs and interventions needed to promote clinical risk assessment of children presenting with concussions in the ED and to ensure appropriate referrals to the concussion clinic. With cocreation among physicians and nurses in the ED, educational material with PowerPoint slides were developed and actively disseminated to physicians, physician assistants, and nurses in addition to small group teaching sessions during shifts. The assessment tools were incorporated into the electronic medical record (EMR) system, and referral forms were made available in all sections of the ED. Mixed methods are being used to evaluate impact. A retrospective medical record review was completed in the hospital EMR systems to capture 5P screen usage frequency and clinical outcomes. Qualitative narrative analysis was conducted to identify client and family experiences captured through open-ended surveys at discharge.

Preliminary Results

There were 329 children presenting with concussion diagnosis who were screened using the 5P screen in the ED throughout 2021. This was an increased uptake of the 5P screen, with 61% of all concussion visits using the 5P screen compared with 0% in 2020. Of those screened, 75 children were referred to specialized care from the ED and 45 of those were seen at Holland Bloorview's concussion clinic. All children referred to interdisciplinary specialized care at Holland Bloorview were appropriate referrals at moderate or high risk on persistent postconcussion symptoms and were seen within 7 to 10 days of referral from the ED. Initial qualitative analysis of narratives shows meaningful functional improvement and reduction of postconcussive symptoms in children referred to the clinic.

Conclusion

A multimodal approach to implementation of a concussion assessment and referral system in an ED improved appropriate concussion assessments in supporting high-risk children and youth to receive the right care at the right time. Ensuring fast access to specialized concussion care for high-risk children and families (ie, <4 weeks) has improved clinical outcomes in preventing secondary issues that can contribute to the chronicity of concussion.

Funding

Ontario Neurotrauma Foundation catalyst funds. Previously presented at the Virtual World Brain Injury Conference in 2021.

166 Differences in Pupillary Light Reflex Metrics After Concussion Persist at Clinical Recovery

Christina Master1,2; Olivia Podolak1; Daniele Fedonni1; Kenneth Ciuffreda3; Nabin Joshi4; Kristi Metzger1; Catherine McDonald5; Susan Margulies6; Matthew Grady1,2; Kristy Arbogast1,2

1The Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States; 2University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States; 3State University of New York College of Optometry, New York City, New York, United States; 4Tesseract Health, New York City, New York, United States; 5University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, United States; 6Georgia Institute of Technology and Emory University, Atlanta, Georgia, United States

Background

Pupillary light reflex (PLR) metrics have been demonstrated to differ in adolescents with concussion from those in healthy controls, with concussed individuals manifesting enhancement of those metrics. What is currently not known is whether or not these PLR metrics in concussed adolescents return back to the range of metrics observed in healthy controls when the concussed adolescents appear clinically recovered from their concussion.

Objective

To determine the potential utility of PLR metrics as physiological biomarker for concussion recovery.

Design, Setting, and Participants

Prospective cohort of adolescents between 12 and 19 years of age with PLR assessment conducted between August 1, 2017, and May 11, 2021, recruited from a specialty concussion program and private suburban high school. The study cohort included healthy adolescents (n = 203) and adolescents with a diagnosis of concussion (n = 106) who were determined to be clinically recovered at their final visit for clinical care.

Methods

The distribution of demographic and clinical characteristics for adolescents recovered from concussion was compared with healthy controls using χ2 statistics for categorical variables (sex, race/ethnicity, and history of concussion) and F tests for age. The means of the PLR metrics were compared among adolescents with concussion and controls with one-way analysis of variance using F tests. We accounted for multiplicity by calculating Bonferroni corrections for the 9 PLR metrics; we present the 99.44% CIs around the mean values and the mean differences between comparison groups.

Results

Six of 9 metrics continued to be significantly greater among concussed cases after the Bonferroni correction (minimum pupil diameter: 2.96 mm vs 2.66 mm; difference, 0.31; 99.4% CI, 0.17-0.44; percentage constriction: 37.84% vs 32.91%; difference, 4.93; 99.4% CI, 2.98-6.88; average constriction velocity: 3.09 mm/s vs 2.50 mm/s; difference, 0.59; 99.4% CI, 0.38-0.79; average dilation velocity, 1.34 mm/s vs 1.24 mm/s; difference, 0.11; 99.4% CI, 0.01-0.20; peak dilation velocity: 1.86 mm/s vs 1.66 mm/s; difference, 0.20; 99.4% CI, 0.08-0.31; and T75: 1.73 seconds vs 1.46 seconds; difference, 0.27; 0.10-0.44) compared with healthy adolescents.

Conclusion

These findings suggest that enhancement of PLR metrics in concussed adolescents may persist after concussion and may not return to normal at the time of clinical recovery, which may have implications for return to risk activities such as contact or collision sports.

167 New Modern Technology in Pediatric Neurorehabilitation: PowerVR Program for Remediation of Social Deficits in Children With Neurological Disorders

Marianne Saard1; Alina Roštšinskaja1,2; Christen Kööp1; Liisa Uutsalu2; Triinu-Liis Loit1; Kätlin Kits1; Anneli Kolk1,2

1University of Tartu, Tartu, Estonia; 2Children's Clinic of Tartu University Hospital, Tartu, Estonia

Objectives

Social deficit (SD) is often present in children with neurological disorders (NDs), but evidence-based intervention methods remain undeveloped. Modern interactive technologies represent an attractive approach to train difficult real-world situations in safe environments. The aim of this study was to implement a combined technological platform PowerVR, consisting of multitouch-multiuser tabletops (MMT) and virtual reality (VR) platforms to enhance social competence in children with ND.

Methods

The PowerVR rehabilitation program incorporates both individual and paired intervention sessions for children with social deficits. Sixty children with ND (epilepsy, traumatic brain injury, tics, or stroke), aged 8 to 13 years, and 16 healthy age-matched controls participated in baseline assessments for pretraining evaluations. Thereafter, 16 patients (M = 10.5 years, SD = 1.8) completed trainings with postintervention assessments after the rehabilitation process. Interactive applications were implemented for paired trainings on MMT: Snowflake on Multitouch-Tabletop and NoProblem on DiamondTouch Tabletop (2 age-matched patients trained together). In individual trainings, 10 VR social metaphors (created by the authors) and NeuroVR (VirtualisVR rehabilitation program) on HTC Vive VR device were used. In NeuroVR, children reacted to changing colors of balls with hand movements; seeing their opposite hand in VR while practicing with the other hand, etc. Simultaneous monitoring of vital signs (heart rate [HR], blood pressure) during individual training with social metaphors was implemented.

Results

After the paired interventions, children's cooperation, communication, and metacognitive skills improved significantly (up to 50% increase in FOS subscales). Patients' general verbal Theory of Mind skills and understanding false beliefs (P < .005) increased. In VR environment, children practiced in various socially and emotionally challenging situations. Most difficult social metaphor based on HR changes was in cinema. VR social metaphors improved children's social attention, communication, emotional attitude, gestural behaviors, and decreased social anxiety (by Sentence Completion Task, Spence Anxiety Scale). Children's feedback showed that their ability to start conversations improved and they experienced less bullying. In NeuroVR, using techniques like Mirror/Ball and Electric Track, children practiced fine motor skills, hand-eye cooperation, coordination, and attention. Mirror/Ball and Electric Track techniques were especially promising in children with stroke.

Conclusions

Children with ND need novel technological rehabilitation methods, like PowerVR program, which allow extensive training of various impaired functions while being motivating and ensuring good compliance. Advantages of using VR are flexibility, safe environment, and precise performance measurement. Rehabilitation based on our combined method trains children's social skills individually and decreases social anxiety, in addition to developing cooperation skills in paired training. The combined technology-based PowerVR method appears to be a promising platform for improving social communication skills in children with ND.

The study was funded by the Estonian Science Foundation PRG789.

168 Quantifying the Relationship Between Clinician-Administered Measures of Vestibulo-ocular Reflex and Oculomotor Function and Patient-Reported Outcome After Pediatric Mild TBI

Isabelle Gagnon1,5; Kathryn Schneider2-4; Lisa Grilli5; Mathilde Chevignard6-8; Michal Katz-Leurer9; Miriam Beauchamp10,11; Chantel Debert12

1School of Physical and Occupational Therapy, McGill University, Montreal, Quebec, Canada; 2Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada; 3Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada; 4Hotchkiss Brain Institute, University of Calgary, Calgary, Canada; 5Montreal Children's Hospital-McGill University Health Centre, Montreal, Quebec, Canada; 6Sorbonne Université, CNRS, INSERM, Laboratoire d'Imagerie Biomédicale, LIB, Paris, France; 7Sorbonne Université, GRC 24 Handicap Moteur et Cognitif et Réadaptation, Paris, France; 8Rehabilitation Department for Children With Acquired Neurological Injury and Outreach Team for Children and Adolescents With Acquired Brain Injury, Saint Maurice Hospitals, Saint-Maurice, France; 9Physical Therapy Department, University of Tel-Aviv, Tel-Aviv, Israel; 10ABC's Laboratory, Ste-Justine Hospital Research Center, Montreal, Canada; 11Department of Psychology, University of Montreal, Montreal, Quebec, Canada; 12Department of Clinical Neuroscience, University of Calgary, Calgary, Alberta, Canada

Objectives

Forces involved in mild traumatic brain injury (mTBI) can lead to visual and vestibular impairments. In pediatric mTBI, high rates of abnormalities are observed in vestibulo-ocular reflex (VOR) and oculomotor (OM) function. While it has been demonstrated that such clinical findings post-mTBI may lead to a more negative prognosis, there remains a lack of understanding of how measured impairments may affect a child or adolescent's daily functioning. Therefore, our objectives were to determine the extent to which clinician administered measures of VOR and OM function relate to patient-reported levels of activity limitations and participation in children and adolescents within 21 days postinjury.

Methods

This cross-sectional study took place at a tertiary care pediatric hospital. In total, 101 participants with mTBI aged 6 to 18 years were included. Participants were assessed on a battery of VOR and OM tests within 21 days of injury. Outcome measures included the Dizziness Handicap Inventory (DHI) and the Cardiff Visual Ability Questionnaire (CVAQ) to measure patient-reported vestibular and visual functional abilities, respectively. The Vestibular/Ocular Motor Screening Tool (VOMS) (considering both symptom provocation and performance on each task), Head Thrust Test (positive/negative), computerized Dynamic Visual Acuity (DVA) Test (LogMAR), and video Head Impulse Test (gain) were administered to assess VOR and OM function. Linear regressions examined the associations between clinician-administered measures of VOR and OM function and patient-reported functional outcomes.

Results

Our sample consisted of 101 youth (54.4% female) with a mean age of 13.92 (SD = 2.63) years and mean time since injury of 18.26 (SD = 6.16) days. Associations were found between (1) DHI score and age (1.773; CL, 0.473 to 3.073; P = .01), VOR symptom provocation (18.499; CL = 11.312 to 25.686; P ≤ .001), and DVA (−29.433; CL, −59.206 to −2.60; P = .03); and (2) version symptom provocation and CVAQ score (0.796; CL, 0.185 to 1.406; P = .01). High abnormal proportions were found on both VOMS VOR performance (21.21%) and VOMS version performance (56.70%). Of both statistical and clinical significance was the association between symptom provocation induced by VOR and the DHI, indicating that the presence of symptom provocation on VOR VOMS tasks would increase DHI score by 18.499 (P ≤ .01) points, as well as the association between symptom provocation induced by OM tasks and the CVAQ, indicating that the presence of symptom provocation on VOMS version tasks would increase CVAQ score by 0.796 (P = .01) logits.

Conclusions

Findings highlight that symptom provocation induced by VOR and OM tasks is associated with poorer patient-reported functional outcome, underlining the detrimental impact of symptoms on one's daily functioning. Elevated proportions of abnormal function demonstrated on VOR and version performance variables emphasize a need for both objective and symptom-based measures. Our findings will assist clinicians when interpreting patient-reported measures activity limitation and participation.

169 Exploring the Intended Concussion Reporting Behaviors of High School Students

Kylie Mallory1,2; Katherine Wilson2,3; Andrea Hickling2,3; Nick Reed1-3

1Rehabilitation Sciences Institute, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; 2Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada; 3Department of Occupational Science and Occupational Therapy, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada

Background

Concussions are an increasing public health concern and are underreported among youth. Factors such as lack of knowledge that a concussion has occurred, negative perceived norms, and environmental pressures from coaches and teammates can contribute to underreporting. Existing concussion reporting surveys for youth have been primarily developed for athletes, despite all youth being at risk for sustaining a concussion. To address this gap, a novel concussion survey based on the Theory of Planned Behaviour (TPB) was delivered school-wide to all students within Canadian high schools.

Objectives

(1) To identify high school students' concussion knowledge, attitudes, subjective norms, self-efficacy, and intended behaviors toward reporting a concussion to an adult; and (2) to explore the influence of demographic variables and concussion knowledge on attitudes, subjective norms, self-efficacy, and intended behaviors toward reporting a concussion to an adult.

Methods

The novel concussion survey was completed by 1330 high school students (M = 15.31 years, SD = 1.32 years; range, 12-19 years). All students attending 9 high schools across 4 Canadian provinces were invited to complete an online survey that contained 7 sections, with up to 44 questions related to reporting a concussion to an adult. The survey included questions about demographics, concussion knowledge, attitudes, subjective norms, self-efficacy, and intended concussion reporting behaviors. Relationships between variables were explored using Wilcoxon rank sum tests and Spearman's rank-order correlation coefficients, with P values adjusted using the Benjamini-Hochberg correction.

Results

Concussion knowledge scores ranged from 3 to 12 (M = 9.53, SD = 2.17; total possible score of 12) and overall concussion reporting scores ranged from 16 to 56 (M = 44.54, SD = 6.70; total possible score of 56). Females scored significantly higher on attitudes (W = 1765, P < .001), subjective norms (W = 1746, P < .001), self-efficacy (W = 1856, P < .01), and intended behaviors (W = 1753, P < .001) than males. Compared with younger students, older students scored significantly higher on attitudes (rho = 0.12, P < .001), subjective norms (rho = 0.07, P < .05), self-efficacy (rho = 0.09, P < .01), and intended behaviors (rho = 0.11, P < .001). In addition, students with higher concussion knowledge scored significantly higher on attitudes (rho = 0.19, P < .001), subjective norms (rho = 0.09, P < .01), and intended behaviors (rho = 0.13, P < .001) than students with lower knowledge. Students who participated in sports at high risk for a concussion (hockey, soccer, basketball, football) had lower self-efficacy (W = 8342, P < .05) and intended behaviors (W = 8470, P < .01) than students who did not participate in these sports. Having a personal concussion history or knowing someone with a concussion history had no significant relationship with intended concussion reporting behaviors.

Conclusions

These findings indicate high school students who are female, older, and who have higher concussion knowledge may be more likely to report a concussion to an adult. This highlights the potential to inform targeted youth concussion education initiatives, particularly aimed at improving concussion reporting to ensure that youth have the appropriate knowledge and skills to report a concussion to an adult.

170 Returning to Education Post–Acquired Brain Injury: Time for Change in the United Kingdom

Gemma Costello1,7; Emily Bennett2,7; Chloe Hayward3,7; Lisa Turan4,7; Petrina Sill5,7; Nathan Hughes6,7; Emily Morley3,7; Louise Blakeborough3

1The Children's Trust, Tadworth, United Kingdom; 2Nottingham Children's Hospital, Nottingham, United Kingdom; 3United Kingdom Acquired Brain Injury Forum, London, United Kingdom; 4Child Brain Injury Trust, Bicester, United Kingdom; 5Eden Dora Trust, Sheffield, United Kingdom; 6Sheffield University, Sheffield, United Kingdom; 7National Acquired Brain Injury Learning and Education Syndicate, London, United Kingdom

We describe the national developments with regard to childhood acquired brain injury (ABI) following the Time for Change report of the All Party Parliamentary Group for Acquired Brain Injury, submitted to parliament in October 2018. We outline the government's response to the report's recommendations around education and describe the subsequent progress made by the National ABI Learning and Education Syndicate (N-ABLES), formed to support and progress the Time for Change recommendations on a political and national level. We identify the primary steps taken by N-ABLES to raise the profile of childhood ABI within the world of education and share the results of early engagements with key organizations, such as NASEN, Whole School SEND, and the Department for Education. We then outline the national best practice guidance around supporting children and young people with an ABI to return to education, developed by N-ABLES, and the ongoing developments as we continue to seek policy change.

172 Validation of the Overt Behavior Scale—In Session (OBS-INS): A Tool for Assessing Challenging Behaviors Following Acquired Brain Injury in the Inpatient Setting

Ileana Herrin1; Lindsey Harik; Chynah Blankenship; Elizabeth Larkin; Rachelle Wilmore; Glen Kelly; Graham Simpson; Katy Mitchell

TIRR Memorial Hermann, Houston, Texas, United States

Objective

Individuals with acquired brain injury (ABI) may exhibit a range of challenging behaviors (CBs) including aggression, impulsivity, perseveration, inappropriate sexual behaviors, disinhibition, and restlessness (Kelly et al., 2008; McAllister, 2013). CBs often preclude community integration, and individuals with ABI may require multiple hospitalizations as a result of these challenging behaviors. Accurate and reliable measurement of challenging behaviors is required for effective treatment planning (Janzen et al., 2014). Current scales used to measure behavior often collapse unsafe behaviors into broad behavioral domains (eg, “aggression”), assess only one domain of behavior, or do not operationally define behaviors. In order to optimally measure behavior, the Overt Behavior Scale (OBS) was identified and trialed in an inpatient rehabilitation facility. The OBS was selected because of its ability to assess and define an array of CBs exhibited following ABI; however, this scale was developed for community use. Therefore, the OBS was further modified and adapted into the Overt Behavior Scale-In Session (OBS-INS) by assessing commonly seen CBs in inpatient settings, their occurrence within treatment sessions, and their impact on clinician workflow. Study investigators aim to determine the reliability and validity of the OBS-INS in accurately assessing CBs in an acute inpatient setting.

Method

Quantitative data include inter- and intrarater reliability of the OBS-INS scores following observation of video recorded therapy sessions and convergent/divergent validity of the OBS-INS as compared with the Agitated Behavior Scale, Disability Rating Scale, and BERG Balance Scale.

Results

Preliminary data reveal that the addition of the Restlessness category in the OBS-INS allows for increased accuracy of restlessness ratings as compared with the OBS. The types of categories scored correlate with further need for interdisciplinary discussion to manage CBs.

Conclusions

The OBS-INS allows for more operationally defined behaviors, capturing the breadth of CBs within acute and chronic ABI in inpatient settings. In addition, the OBS-INS provides valuable clinical data such as the occurrence of CBs within a treatment session and the level of disruption clinicians face as a result of CBs. Improved definition, and thus identification, of CBs allows for improved efficiency and accuracy of intervention.

173 Determining Optimal Screening Guidelines for Novel Anxiety and Depression Following Mild Traumatic Brain Injury

Alexander Ballatori; Alison Haddad; Shane Shahrestani

The Mac Parkman Foundation for Adolescent Concussive Trauma, Los Angeles, California, United States

Introduction

Mild traumatic brain injury (mTBI), also known as concussion, affects more than 1.5 million people in the United States per year according to recent estimates. There currently exist no good screening guidelines for psychiatric illness following mTBI. Here, we use big data analytics to determine the optimal screening timeline for anxiety and depression following mTBI.

Methods

In this study, we used the Healthcare Cost and Utilization Project (HCUP) Nationwide Readmissions Database (NRD) from years 2010 to 2019. Patients who were readmitted within 1 calendar year after being admitted previously for mTBI in the 2010-2019 NRDs were identified (n = 206 070). Patients included in this study reported no anxiety or depression during primary admission for mTBI but were found to have anxiety or depression upon readmission within 1 calendar year. Density plots were generated to determine the optimal time for neuropsychiatric screening for anxiety and depression following mTBI.

Results

The mean age for all patients was 50.9 ± 26.2 years, with 43.9% being female. A total of 3449 patients reported anxiety within 1 calendar year, and a total of 3866 patients reported depression within 1 calendar year. The mode for number of days until development of novel anxiety following mTBI was 20.3 days, and the mode for number of days until development of novel depression following mTBI was 21.3 days. The median for number of days until development of novel anxiety following mTBI was 65.5 days, and the median for number of days until development of novel depression following mTBI was 69.5 days.

Conclusion

A majority of novel anxiety and depression presents within 3 months of primary mTBI event. Until now, guidelines for neuropsychiatric testing following mTBI have not been explored. These data suggest that neuropsychiatric screening 3 months following mTBI may capture a majority of novel anxiety and depression cases, and regular screening after this point may further allow for appropriate intervention and psychiatric care following mTBI.

174 Determining Optimal Screening Guidelines for Novel Suicidal Ideation and Homicidal Ideation Following Mild Traumatic Brain Injury

Alexander Ballatori; Alison Haddad; Shane Shahrestani

The Mac Parkman Foundation for Adolescent Concussive Trauma, Los Angeles, California, United States

Introduction

Mild traumatic brain injury (mTBI), also known as concussion, affects more than 1.5 million people in the United States per year according to recent estimates. There currently exist no good screening guidelines for psychiatric illness following mTBI. Here, we use big data analytics to determine the optimal screening timeline for suicidal ideation (SI) and homicidal ideation (HI) following mTBI.

Methods

In this study, we used the Healthcare Cost and Utilization Project (HCUP) Nationwide Readmissions Database (NRD) from years 2010 to 2019. Patients who were readmitted within 1 calendar year after being admitted previously for mTBI in the 2010-2019 NRDs were identified (n = 206 070). Patients included in this study reported no SI or HI during primary admission for mTBI but were found to have SI or HI upon readmission within 1 calendar year. Density plots were generated to determine the optimal time for neuropsychiatric screening for SI and HI following mTBI.

Results

The mean age for all patients was 50.9 ± 26.2 years, with 43.9% being female. A total of 818 patients reported SI within 1 calendar year, and a total of 88 patients reported HI within 1 calendar year. The mode for number of days until development of novel SI following mTBI was 28.6 days, and the mode for number of days until development of novel HI following mTBI was 51.6 days. The median for number of days until development of novel SI following mTBI was 70 days, and the median for number of days until development of novel HI following mTBI was 66.5 days.

Conclusion

A majority of novel SI and HI presents within 3 months of primary mTBI event. Until now, guidelines for neuropsychiatric testing following mTBI have not been explored. These data suggest that neuropsychiatric screening 3 months following mTBI may capture a majority of novel SI and HI cases, and regular screening after this point may further allow for appropriate intervention and psychiatric care following mTBI.

175 School Life Following Acquired Brain Injury: An Interpretative Phenomenological Analysis of the Experiences of Adolescents, Their Parents, and Teachers in the Irish Context

Liz Lane; Michele Dunleavy

Mary Immaculate College, University of Limerick, Limerick, Ireland

Aims

Research on acquired brain injury (ABI) has acknowledged the importance of environmental factors in the rehabilitation process. Given that adolescents spend a large proportion of their time in the school setting, schools are considered to play a vital role. Currently, there is a paucity of research in Ireland about the experience of school following ABI and this study aimed to fill this gap in knowledge. This study aimed to explore adolescents' lived experience of school following ABI and the experiences of their parents and teachers in supporting them.

Method

The study was situated within the interpretivist paradigm and used a multiperspectival qualitative design. Interpretative phenomenological analysis (IPA) was chosen as the methodological framework. Three adolescents and their mothers were recruited through a gatekeeper, a tertiary neurorehabilitation service. Two teachers were recruited by contacting the adolescents' schools. Semistructured interviews were conducted, and the data were analyzed according to guidelines from Smith and colleagues (2022).

Results

Four themes were identified: the new normal—things have changed; challenging the new normal—I am still capable; negotiation of the new normal with others—a multidirectional process; and punctuating the new normal—COVID-19. A central element of the lived experience was the advent of the new normal. For the adolescents, friendship loss and the reconstruction of self with others were significant facets of the new normal. The parents' experience of supporting their child in school was characterized by managing, challenging, and negotiating the new normal. They described how they took on many different roles when supporting their child: cheerleader, advocate, instigator, architect of the positive, fighter, protector, and collaborator. The teachers' experience of supporting an adolescent with ABI centered around the negotiation of the new normal. The culture of the school, input from rehabilitation services, and supportive relationships with colleagues were all highlighted as being essential to the process. COVID-19 had the capacity to either positively or negative affect the new normal, dependent on time since injury.

Conclusion

It is anticipated that the findings will contribute to practice in both educational psychology and education in how support is provided to this cohort of young people in the school setting. Identity and friendship loss featured hugely in the adolescents' narratives, and this has implications for the practice of educational psychologists. The findings emphasized the importance of involving adolescents with ABI in the negotiation of school supports and also highlighted the complexity of adolescent friendships after ABI.

176 Recovery Patterns in Pediatric Disorders of Consciousness After Traumatic, Anoxic, and Vascular Brain Injuries

Alexandra Roth; Laura Luke-Browning

Bethany Children's Health Center, Oklahoma City, Oklahoma, United States

Objective

To date, much of the pediatric disorders of consciousness (DOC) literature focuses primarily on traumatic brain injury alone or comparisons between traumatic and nontraumatic brain injury etiologies, with less information available on outcomes of nontraumatic brain injury etiologies. The goal of the current study was to determine whether recovery patterns in children with DOC differed across traumatic, anoxic, and vascular injuries during admission to an inpatient pediatric rehabilitation program. Awareness of different patterns of recovery based on brain injury etiology can inform prognostic conversations and decisions regarding the timing and duration of rehabilitation.

Methods

Researchers completed a retrospective medical record review of children who were admitted to a specialized inpatient brain injury DOC program at a post-acute, freestanding pediatric rehabilitation hospital. Children were grouped on the basis of the etiology of their brain injury (traumatic, anoxic, or vascular). Level of consciousness and emergence from DOC were defined on the basis of results of the Coma Recovery Scale-Revised (CRS-R). Chi-square tests of independence were performed to assess the relationship between brain injury etiology and rates of minimally conscious state (MCS) diagnosis and emergence. One-way analysis of variance (ANOVA) procedures were completed to compare the effect of brain injury etiology on time with an MCS diagnosis and time to emergence.

Results

The sample included 29 children aged 1 to 17 years (M = 10.52, SD = 5.30). Average length of stay within the brain injury DOC program was 100.28 days. Children in traumatic, anoxic, and vascular brain injury groups did not differ in their rates of receiving an MCS diagnosis (χ2,292 = 5.26, P = .072) or the time from injury to MCS diagnosis (F2,15 = 2.89, P = .087). However, there were significant group differences in rates of emergence (χ2,292 = 8.40, P = .015) and time from injury to emergence (F2,8 = 5.04, P = .038). Children in the vascular brain injury group (100%) were more likely to emerge than those in the traumatic (35.7%) or anoxic (18.2%) brain injury groups (P = .005). However, those with vascular injuries took a significantly longer time to emerge than those with traumatic injuries (M = 166.50 vs 70.80 days).

Conclusions

Findings revealed that children with vascular brain injuries had a prolonged recovery time, yet a higher rate of emergence when compared with children with traumatic and anoxic brain injuries. Children with vascular brain injuries leading to DOC may benefit from longer admissions to rehabilitation programs. If admission to rehabilitation is not possible after a vascular brain injury, a systematic plan should be established for serial monitoring and assessment in an outpatient setting to identify late emergence and potential readiness for rehabilitation.

177 Pilot Examination of Fine Motor Control in Youth Recovered From Concussion and Healthy Controls in the Minnesota Handwriting Assessment

Kayla Huntington; Adrian Svingos; Hsuan-Wei Chen; Beth Slomine; Stacy Suskauer

Kennedy Krieger Institute, Baltimore, Maryland, United States

Objective

Emerging data suggest persisting alterations in motor control even after clinical recovery from concussion. In school-aged children (7-12 years), subtle motor deficits have been shown to correlate with precision in handwriting, a fundamental fine motor task for children. The goal of this pilot study was to examine fine motor control, as assessed via precision in handwriting, in youth aged 10 to 17 years who had recently recovered from concussion (mild traumatic brain injury [mTBI]) and healthy controls using the Minnesota Handwriting Assessment (MHA).

Participants

Participants included 14 youth (mean age = 13.093 years, SD = 2.19; range, 10-17 years; 57.14% males) at their first exposure to the task in a longitudinal study examining neural recovery following mTBI. The sample comprised 7 participants clinically recovered from mTBI (mean days since injury = 69.00, SD = 52.157) and 7 never-injured controls.

Methods

The MHA examines fine motor control in letter formation through measurement of legibility, form, alignment, size, and spacing. Participants copy a nonsense sentence, “The brown jumped lazy quick fox over” using a Wacom digital tablet for automated assessment. Three conditions are tested: the participant is asked to copy the sentence in the exact shape and size as the sample (copy), trace over printed text (trace), and trace over printed text as quickly as possible (speed). Lower MHA scores reflect more precision. The PANESS is a brief motor examination designed to evaluate subtle neuromotor signs in pediatric populations, which is sensitive to subtle motor deficits in children recently recovered from mTBI. Nonparametric tests were used to examine between-group differences in MHA scores and correlations between MHA scores and total PANESS score.

Results

There were no significant differences between the mTBI and control groups for copy (P = .902), trace (P = .456), or speed (P = .620) conditions. A 10-year-old girl in the mTBI group was an outlier (>2 SDs from entire cohort mean) with poor performance on MHA copy and PANESS; she also had the worst score for MHA speed. After removing this outlier, plots of MHA data versus PANESS scores revealed that, among the remaining participants with mTBI, there was a negative association of MHA copy (rho = −0.9, P = .04) and speed (rho = −1, P < .001) scores with PANESS (worse MHA associated with better PANESS). There were no significant associations between MHA and PANESS scores in the control group.

Conclusion

Based on this pilot sample, the MHA may identify an important subgroup of younger children with broader subtle motor deficits potentially impacting daily function. In addition, these data suggest that some youth who had recovered from mTBI may favor accuracy over speed of movements, particularly in formal testing environments. Future work should examine these associations in a larger sample size as well as compare MHA scores with other motor and cognitive assessments.

178 Towards Practice-Based Evidence of Rehabilitation Outcomes in Community-Dwelling Individuals With Acquired Brain Injury: Protocol for a Pilot Study

Lucas DiRienzo1,2; Dar'ya Semenova1,2

1University of Ottawa, Faculty of Medicine, Ottawa, Ontario, Canada; 2Vista Centre Brain Injury Services, Ottawa, Ontario, Canada

Introduction

Vista Centre Brain Injury Services (VCBIS) is a community organization providing a wide range of rehabilitation services for individuals with acquired brain injury (ABI), including assisted living services, personal support and independence training, and coordination for support groups. Disabilities related to ABI are often complex and cause physical, cognitive, and psychosocial impairments that are limiting to many areas of life. A multidimensional approach to rehabilitation for these individuals is thus required. VCBIS is committed to improving their services to support clients in achieving personalized care goals. However, research aiming to evaluate rehabilitation outcomes is challenging. Practice-based evidence (PBE) research is an observational strategy designed to document healthcare interventions in detail (such as rehabilitation) and assess which treatments are most strongly associated with positive outcomes, after controlling for patient characteristics. In this pilot study, we assess the feasibility of a PBE study design for evaluating rehabilitation outcomes in individuals with ABI enrolled in a VCBIS rehabilitation service.

Objectives

(1) To describe the application of PBE methodology to ABI rehabilitation delivered by a community organization (VCBIS) and; (2) to identify validated health and social outcome measures that can be reliably collected from individuals with ABI, in a manner which is cost-effective and feasible over longer (eg, >6 month) periods of observation.

Methods

To inform our approach, we will conduct a focused review of peer-reviewed studies that have applied PBE methodology in ABI or other areas, such as rehabilitation for stroke, joint replacement, and traumatic spinal cord injury. In consultation with community stakeholders, including individuals and families impacted by ABI, we will select a set of measures to establish baseline characteristics of VCBIS clients, monitoring their physical and mental status, social well-being, and satisfaction. Additional feedback will be reported by VCBIS staff and clients to identify the barriers and facilitators in the implementation of this observational strategy. The pilot study period will be of 2 months. All VCBIS clients will provide informed consent prior to study enrollment. We will present findings on changes in client satisfaction, physical, mental, and social well-being over the study period, as well as key barriers and facilitators to PBE implementation identified by staff and clients.

Impact

Results of this work will provide a framework for collecting data on factors that are associated with rehabilitation outcomes from community services offered by VCBIS. PBE research in this context serves to provide increasingly personalized services and establish support systems tailored to the unique needs of individuals with ABI.

179 Management of Cognitive Fatigue After Acquired Brain Injury

Jessica Martinez; Kate Koschei

Scripps, San Diego, California, United States

Following brain injury, many individuals experience cognitive fatigue. Cognitive fatigue can impact participation in home, community, and work activities as well as performance in habits, routines, roles, and rituals. Cognitive fatigue can be a negative influence on an individual's long-term quality of life and well-being. In order to address these limitations, one must learn to identify contributing factors, recognize symptoms, and successfully manage cognitive fatigue.

Initially, individuals who experience brain injuries are often unaware of possible causative factors, such as decreased cognitive processing speed. They may not recognize early indicators of fatigue, including headache, muscle tension, loss of focus, or change in physical functioning. Finally, one will often attempt to persevere, which can lead to frustration, errors, and poor performance in functional activities.

The ultimate goal is to improve cognitive endurance and activity tolerance by implementing strategies to manage fatigue. One approach to mitigate the effects of cognitive fatigue is to enable individuals with brain injury to identify exacerbating elements, increase awareness of symptoms, and develop a custom fatigue management plan.

In a comprehensive brain injury rehabilitation program, individuals who present with cognitive fatigue receive education regarding cognitive fatigue etiology and symptoms. A sample ordinal scale is used as a tool to identify one's exacerbating factors, track the course of their fatigue, and determine interventions to successfully manage symptoms. All team members participate in this treatment intervention: care managers, occupational therapists, physical therapists, rehab aides, social workers, and speech pathologists. Subsequently, the individual and the treatment team collaborate to develop a personalized and unique cognitive fatigue scale. Participation in functional activities within the program offers an opportunity to utilize the scale to manage symptoms. The therapeutic goal is for one to apply the personalized scale and strategies for successful cognitive fatigue management in the home, community, and workplace.

180 Using Virtual Technologies to Prevent Injuries in Adolescents With ABI

Sarah Anderson1; Sarah Pierce1; Taylor Stamper1; Jennifer Lundine1,2; Amy Darragh1

1The Ohio State University, Columbus, Ohio, United States; 2Nationwide Children's Hospital, Columbus, Ohio, United States

Objectives

The long-term objective of this study was to increase the home safety of adolescents with acquired brain injuries (ABIs) by improving their ability to identify and respond to common household hazards (eg, fire safety, household chemicals, trip hazards) using a virtual simulation training system. The goal of this pilot work was to (1) identify safety hazards and concerns for adolescents with ABI in home environments, and (2) identify adaptations to an existing virtual simulation training system, the HH-VSTS, to improve relevancy and usability for adolescents with ABI.

Methods

Using a mixed-methods participatory approach, we engaged 3 stakeholder groups in interviews, activities, and HH-VSTS testing: adolescents with ABI, their caregivers, and healthcare providers who work with this population. The institutional review board–approved protocol includes surveys on demographics, adaptive function, home hazards, and HH-VSTS usability. Semistructured individual and group interviews with stakeholders were conducted from summer 2021 to summer 2022 in person or via online video call. Interviews lasted 2 to 2.5 hours and were conducted over 1 or more sessions. Interviews included facilitated discussion, a priority hazard identification activity, and demonstration of the HH-VSTS through video and live play. This presentation reports themes related to recovery, home safety, and HH-VSTS usability identified by healthcare providers supporting adolescents and young adults with ABI.

Results

To date, 12 providers have participated in the study. All providers identified as White females, with an average age of 37.75 years (SD = 9.84). Professional representation was distributed as follows: 25.00% occupational therapists, 33.33% physical therapists, 25.00% speech-language pathologists, and 16.67% other. Clinicians reported an average of 10.92 years (SD = 9.70) of clinical experience working with the adolescent ABI population, which made up roughly 25% to 50% of their reported caseloads. About 50% of clinicians reported “sometimes” addressing community reintegration skills (including home assessment, community mobility, etc), while “sometimes” (41.67%), “often” (25.00%), or “always” (25.00%) addressing home safety. Recorded interviews with healthcare providers are currently being analyzed using content analysis to identify and organize themes related to study objectives.

Conclusions

This study uniquely focuses on the home safety concerns of adolescents with ABI as expressed by the healthcare providers who support this population. While data collection analysis is currently ongoing, preliminary results of these stakeholder participants indicate that a broad group of professionals is treating this population and addressing the home safety needs of their clients. Further outcomes relating to the provider participants' interview and questionnaire data about safety hazards and the HH-VSTS usability will be discussed and directions for future research identified.

183 The Relationships of Teacher-Rated Executive Functions to Academic Skills After Early Childhood Moderate to Severe Traumatic Brain Injury (TBI) and Orthopedic Injury (OI)

Yasmine Jassal1; Christine Petranovich1; Keith Yeates2; H. Gerry Taylor3; Terry Stancin4; Shari Wade5

1Children's Hospital Colorado, Aurora, Colorado, United States; 2University of Calgary, Calgary, Alberta, Canada; 3Nationwide Children's Hospital, Columbus, Ohio, United States; 4MetroHealth Medical Center, Cleveland, Ohio, United States; 5Cincinnati Children's Hospital, Cincinnati, Ohio, United States

Objective

Recovery following early childhood TBI is complex and multifaceted. It depends on numerous injury and noninjury factors, especially those related to the family and home environment. Few studies to date have identified prognostic factors within the academic environments of children with histories of moderate to severe TBI, despite documented neurocognitive (eg, executive functioning [EF]) and academic vulnerabilities within this population. This study addresses this gap in the literature by investigating the utility of integrating teacher ratings to monitor long-term neurocognitive recovery after early childhood TBI.

Method

Utilizing a concurrent cohort/prospective research design on data from the Ohio Head Injury Outcomes study, this study utilized hierarchical linear modeling to examine relationships between academic achievement (Word Reading, Math Calculation, and Written Expression subtests from the Woodcock-Johnson Tests of Achievement, Third Edition) and teacher-rated EF (General Executive Composite [GEC] of the Behavior Rating Inventory of Executive Functioning) in a sample of 130 children who sustained an orthopedic injury (OI; n = 72), moderate TBI (n = 42), or severe TBI (n = 16) between 3 and 7 years of age. At data collection, the average age was 11.92 years, with a mean time- since injury of 6.83 years. The models controlled for injury-related factors (age at injury, group, and time since injury), demographic variables (sex and social-economic status), and parent-reported EF (BRIEF GEC).

Results

Teacher BRIEF GEC did not significantly differ between injury groups (P > .05). Parent BRIEF GEC in the moderate and severe TBI groups was than the OI group (Ps < .05). Parent BRIEF GEC did not significantly differ between the moderate and severe TBI groups (P > .05). Using hierarchical linear regression, teacher BRIEF GEC accounted for a statistically significant amount of variance in a child's academic achievement in the areas of written expression (P < .05) and word reading (P < .01), controlling for injury-related factors (age at injury, group, time since injury), demographic variables (social-economic status, sex), and parent BRIEF GEC. Teacher BRIEF GEC did not account for a significant amount of variance in math calculation skills (P > .05). Of note, group was nonsignificantly associated with academic achievement (P > .05).

Conclusion

Providers working with children with early childhood traumatic injury are at risk for overlooking the functional impact of such injuries without the valuable and unique input of their teacher. While these results indicate that the associations of teacher-rated EF with academic achievement may depend on the skill being measured, teachers are uniquely placed to monitor and identify areas of further need or intervention as the child navigates the complex milieu of life after traumatic injury. These results highlight the value of collaboration between a child's educators, medical teams, and family to individualize recommendations and provide appropriate surveillance.

184 Depressive Symptoms in Individuals With Persistent Postconcussion Symptoms: A Systematic Literature Review and Meta-analysis

Maude Lambert1,2; Elena Sheldrake2,3; Audrey-Ann Denault4; Shannon Scratch2,3,5

1School of Psychology, University of Ottawa, Ottawa, Ontario, Canada; 2Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada; 3Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada; 4Department of Psychology, University of Calgary, Calgary, Alberta, Canada; 5Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada

Objectives

Concussion is a common injury among adolescents and adults. Approximately 15% to 30% of cases present with persistent postconcussion symptoms (PPCS), which can lead to reduced quality of life, and higher levels of disability continue for 4 weeks or more postinjury in adolescents and 3 months or more in adults. There is a known bidirectional link between PPCS and mental health outcomes. The overarching aim of the current review was to synthesize the association between depressive symptoms and PPCS in individuals across the life span. To our knowledge, the hypothesis that PPCS may be associated with depressive symptoms has not been corroborated in meta-analyses. A second aim of the current study was to investigate potential moderators of that relationship and determine whether the association differed on the basis of age, sex, time since injury, history of previous concussion, and history of preexisting mental illness.

Methods

To scope the literature, 4 databases were searched: Ovid MEDLINE, CINAHL, PsycINFO, and EMBASE. The definition of PPCS was limited to physician-diagnosed or self-reported concussion, with symptoms lasting for a minimum of 4 weeks. Search terminology of PPCS was broad, including but not limited to searches including mTBI, concussion, and PPCS. Although the original search, which was part of scoping review completed by our team, was broader and encompassed several mental health outcomes, study selection was more precise and narrowed for the current review, only focusing on depressive symptoms. As such, 11 591 studies underwent title and abstract screening. After full review screening of 538 studies, 41 studies were extracted for the broader scoping review. From the extracted studies, one final round of screening was completed to distinguish the articles including outcomes on depressive symptoms specifically, leading to a total number of 19 studies included in this review.

Results

Of the 19 studies included in the review, all were cohort methodological designs, the majority being adult populations (n = 12), and heterogeneous distribution of males and females (>50% male, n = 9). The statistical analysis of the data is currently ongoing and data are preliminary. The overall effect size for the association between depressive symptoms and PPCS, as well as the moderator(s) of this relationship, has yet to be determined.

Conclusions

Based on preliminary data and given that most studies focused on adult populations, it is evident that child and youth PPCS studies that investigate the relationship with depression are much needed. Such research has significant public health implications as it represents an important step forward toward a greater general understanding of PPCS and the PPCS–mental health relationship, thereby potentially allowing for the development of strategies for effective prevention and earlier intervention to optimize recovery trajectories and improve outcomes. Additional work is required.

185 Electrophysiology Reveals Cognitive-Linguistic Deficits After Concussion: Evidence From the N400 ERP

Patrick Ledwidge1,2; Christa Jones3; Chloe Huston4; Madison Trenkamp1,2; Bryan Bator1; Jennie Laeng5; Erin Neff1,2; Elizabeth Castro1,2

1Department of Psychology, Baldwin Wallace University, Berea, Kentucky, United States; 2Department of Neuroscience, Baldwin Wallace University, Berea, Kentucky, United States; 3Department of Communication Sciences & Disorders, Baldwin Wallace University, Berea, Kentucky, United States; 4Department of Psychology, The Ohio State University, Columbus, Ohio, United States; 5Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, United States

Objectives

Language comprehension deficits and alterations to the N400 event–related brain potential (ERP) are commonly reported in aphasia and moderate-to-severe traumatic brain injury (TBI) but are seldom investigated after mild TBI, such as concussion. Recorded from the electroencephalogram (EEG), the N400 component of the ERP provides a neurophysiological index of lexical-semantic retrieval and is associated with clinically meaningful differences in language comprehension. There were 2 objectives to this study: First, to examine the impact of concussion on the N400 ERP within 1 month after brain injury. Our second objective was to establish the extent to which individual differences in the postconcussion N400 would be associated with individual patterns of cognitive-linguistic and symptom recovery.

Methods

Sixteen young adults with a recent concussion (≤30 days) and 16 age-, gender-, and sport- (if athlete) matched controls participated in all study procedures. To elicit the N400 ERP, 256-electrode EEG was recorded while participants read 132 individual sentences on a computer screen. Sentence final words were either semantically congruent (50%) or semantically incongruent (50%) endings (eg, “They rested under a tree in the shade/horn”). The expectancy of the sentence final word was normed offline in a cloze judgment task, and the N400 ERP was measured as the amplitude of the incongruent-minus-congruent difference wave to the sentence final words. A licensed and certified speech-language pathologist or PhD-level psychologist administered to participants the Cognitive-Linguistic Quick Test (CLQT). Finally, participants reported their current experience of concussion-like symptoms using the Post-Concussion Symptom Scale.

Results

The concussion group demonstrated significantly poorer memory, language, and executive functioning on the CLQT than controls. During the sentence-processing EEG task, concussion participants also generated a significantly more negative and frontally distributed N400 during the early (200-300 ms) and peak (300-400 ms) time course of the ERP component compared with the control group. Among the concussion participants, larger N400 amplitudes were significantly correlated with fewer symptoms, faster response time, and superior executive functioning. Multiple regression results indicated that concussion occurrence and concussion-like symptoms have opposite associations with the N400: a concussion and male gender were associated with a more negative N400 effect, but the N400 effect weakened with the increase of postconcussion symptoms.

Conclusions

Acute changes in cognitive-linguistic neurophysiology are present within the first 30 days after concussion and underlie individual differences in functional recovery. Individuals who are asymptomatic may leverage a hyperactive brain response to compensate for their brain injury. It is incumbent upon neurophysiological models of TBI recovery to consider differences in patient recovery profiles. Future research is necessary to establish the N400 as a possible target for cognitive-linguistic rehabilitation after brain injury.

186 Advocacy for Brain-Based Disorders: Understanding Caregiver, Professional, and Administrator Perspectives

Kathleen Scaler Scott1; Claire O'Connor1; Lizel Dalangin1; Amanda Cunningham1; Grace Breslin1; Nicole Circelli1; Morgan Sherman1; Katandria Johnson2; Safiya Ferryman2; Lindsay Kaffl2; Amanda Catone2

1Monmouth University, West Long Branch, New Jersey, United States; 2iBRAIN, Manhattan, New York, United States

This preliminary ethnographic study presents the analysis of interviews of 6 administrators, 6 rehabilitation professionals (speech-language pathologists, physical therapists, occupational therapists, assistive technology), 6 educators (teachers and paraprofessionals), and 6 caregivers of school-aged children with traumatic brain injuries or other brain-based disorders. The goal of the study was to identify perspectives of all team members regarding which factors lead to effective planning for the needs of students. Clinical implications and future research will be discussed.

187 An Ethical Approach to Detecting Covert Consciousness

Michael Young

Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, United States

Objective

To develop an ethical road map for responsible research and translation of advanced neurotechnologies to detect covert consciousness in settings of uncertainty.

Background

Shortcomings of the bedside behavioral examination in reliably detecting consciousness generate profound dilemmas for clinicians and surrogates facing decisions about continuation of life-sustaining therapy, pain control, prognostication, and resource allocation in patients with disorders of consciousness (DoC). These issues are magnified in pediatric contexts. Novel neuroimaging and electrophysiologic techniques that aim to improve diagnostic accuracy for patients with DoC are under investigation, yet little is known about ethical concerns surrounding their use.

Design/Methods

We applied normative philosophical, historical, and ethical analysis to identify and critically evaluate ethical implications of emerging neurotechnologies for detecting covert consciousness in research and clinical settings.

Results

Four neuroethical principles emerged through initial normative analysis to guide responsible translation of neurotechnologies for the detection of consciousness in clinical practice: (1) promote equity in neurotechnology access; (2) embed neuroethics research to capture perspectives of patients, surrogates, clinicians, and researchers to inform emerging clinical paradigms; (3) communicate uncertainty about data yielded by novel neurotechnologies with clinical teams, patients, and surrogates, while acknowledging the meaningful diagnostic and prognostic information that they could uncover; (4) sensitize DoC nosology and diagnostic criteria to breakthroughs in neurotechnology. Democratizing access to optimal DoC care requires a multilevel approach to facilitate equitable dissemination and adoption of neurotechnologies. Commitment to making pipelines open access, interoperable, and scalable may help ensure that technologies do not remain siloed at their source.

Conclusions

Development and deployment of novel neurotechnologies to detect covert consciousness promises to improve the accuracy of diagnosis and prognosis for patients with DoC but raises a host of novel ethical challenges that we identified and which require further study. Promoting equity in neurotechnology access, communicating uncertainty, embedding neuroethics research, and optimizing DoC nosology are key steps to ensure responsible clinical translation.

188 Healthcare Utilization and Direct Physician Costs Following a Concussion in Ontario: A Population-Based Study

Laura Langer1; Mark Bayley1,2; Charissa Levy3; Sarah Munce1,4,5; Alan Tam1,2; David Lawrence1,6,7; Claire de Oliveira8-11

1University Health Network–Toronto Rehab, Toronto, Ontario, Canada; 2Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; 3Toronto ABI Network, Toronto, Ontario, Canada; 4Department of Occupational Science & Occupational Therapy, University of Toronto, Toronto, Ontario, Canada; 5Rehabilitation Sciences Institute and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; 6Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, Ontario, Canada; 7Mt Sinai Hospital, Toronto, Canada; 8Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Ontario, Canada; 9Centre for Health Economics and Hull York Medical School, University of York, York, England; 10ICES, Toronto, Ontario, Canada; 11Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada

Background

Concussion affects 1.2% of the population of Ontario annually; rural regions of the province and children have higher rates of concussion. An estimated 10% to 30% of people diagnosed with a concussion will experience prolonged symptoms and will require ongoing specialized medical care to treat their symptoms.

Objective

To characterize postconcussion healthcare access and patterns in Ontario.

Methods

Using administrative healthcare-linked databases held by ICES, all residents of Ontario with a concussion diagnosis by either primary care physicians (ICD-9 code 850) or emergency departments (EDs; ICD-10 code S06) between 2008 and 2016 were identified. Cases were tracked for 2 years following injury for concussion-related healthcare utilization with relevant specialist physicians (ie, neurology, ENT, physiatry, psychiatry, ophthalmology, etc). Billing fee codes, specialist codes, and time from index to visit were analyzed. Healthcare costs were estimated from the third-party public payer perspective (ie, the Ontario Ministries of Health) using a cost algorithm available at ICES, which employs a bottom-up/micro-costing approach to cost services at the individual patient level.

Results

In total, 1 330 036 cases were identified; 2 years of healthcare tracking after injury was available for cases diagnosed between 2008 and 2014 (n = 1 022 588). Eighty percent of all cases were diagnosed in the ED, though the percentage identified by primary care physicians increased over time. More than 85% of cases identified in the ED had follow-up by a primary care physician after their injury with a mean time between ED diagnosis and follow-up by primary care of 83.9 days; rural regions had a mean of more than 100 days. In total, 51.9% of adults and 50.3% children/youth required at least 1 specialist visit for their concussion after injury. The mean number of specialist visits was 3.2 (SD = 9.2) and a median of 2 visits for those who sought specialized care after their concussion; mean time between index and first specialist visit was 203.8 (SD = 192.9) days for adults, 213.5 (SD = 201.0) days for rural individuals, and 276.0 days for pediatric cases. There were 67 420 neurology visits, 70 404 psychiatry visits, 13 571 neurosurgery visits, 19 780 physiatry visits, 101 788 ENT visits, and 103 417 ophthalmology visits associated with the concussion cohort in the 2 years following their injury. Healthcare costs associated with concussion in Ontario were approximately $18 million CAD per annum. Specialties with the highest per patient cost were physiatry ($553.10), psychiatry ($479.15), and neurology ($230.12).

Conclusions

There are discrepancies in postconcussion healthcare access and utilization based on age group and living in a rural/nonrural classified area. Addressing these differences will improve access to concussion care. Direct physician costs related to diagnosing and treating concussions are substantial, with physiatry and psychiatry presenting highest per patient costs.

191 Parent-Reported Symptoms in Children With Noncredible Cognitive Performance Post–Mild Traumatic Brain Injury: Learning From Clinical Data

Danielle Ploetz1; Kathryn Ritchie1; Carolyn Caldwell1; Stacy Suskauer1,2; Beth Slomine1,2

1Kennedy Krieger Institute, Baltimore, Maryland, United States; 2Johns Hopkins University School of Medicine, Baltimore, Maryland, United States

Background

Children who sustain mild traumatic brain injury (mTBI) or concussion often experience nonspecific cognitive, affective, physical, and sleep-related symptoms in the acute period following injury. The Post-Concussion Symptom Inventory-2 (PCSI-2) is a standardized parent-rating scale of symptoms associated with mTBI that includes embedded symptom validity scales to assess overreporting or inconsistent responding. Previous studies have suggested that children who exhibit noncredible performance on neuropsychological tests endorse a high level of postconcussion symptoms; however, it is unclear whether a proxy report of symptoms in children who exhibit noncredible performance would yield the same relationship.

Aims

In this study, we aim to better understand the parent-reported symptoms of pediatric patients identified as putting forth suboptimal effort during cognitive screening.

Methods

We reviewed PCSI-2 data for a subset of participants aged 8 to 18 years who were evaluated in a specialty concussion clinic between January 2015 and June 2019. All participants in this sample performed below the cutoff on more than 1 stand-alone performance validity test and had retrospective pre- and postinjury PCSI-2 ratings completed by a parent. Ratings of 5 or 6 across 2 of 4 items (balance problems, clumsiness, visual concerns, and acting nervous) suggest validity concerns on the negativity scale. Inconsistent ratings on 4 pairs of similar items (discrepancy >10) suggested validity concerns on the inconsistency scale.

Results

Within the initial group of 68 children with extracted data, baseline and postinjury parent-reported PCSI-2 scores were available for 36 children (n = 36, Mage = 14.34, SDage = 2.12). Median time since injury was 27 days. In this subset, 19.4% (n = 7) had invalid PCSI-2 postinjury parent ratings based on embedded symptom validity measures. Of patient data flagged as invalid, most (n = 6) had an elevated negativity scale, indicating concern for overreporting. In this sample, we observed a much higher rate of elevated negativity scores than the published standardization sample (ie, <2%). One participant had a highly inconsistent pattern of responses. No patients had invalid retrospective preinjury ratings by parents. The most commonly endorsed postinjury symptom was headaches (97.2%), followed by light sensitivity (86.1%) and tiredness (86.1%). The most commonly endorsed retrospective preinjury symptom was irritability (44.4%), followed by headache (41.7%) and feeling more emotional (41.7%).

Discussion

Children who present with noncredible effort have a high rate of symptom validity concerns, primarily concerns related to overreporting by parents. Additional research is needed in a larger sample to better understand the relationship between noncredible effort, parent-reported symptom validity concerns, and changes related to both over the course of recovery.

192 Addressing the Needs of Youth With Traumatic Brain Injury (TBI) in the Criminal Justice System: Development and Implementation of a TBI Education and Training Program for Justice Staff and Professionals

Catherine Wiseman-Hakes; Sukhman Baath; Matthew Eaton-Kent; Lyn Turkstra

McMaster University, Hamilton, Ontario, Canada

Traumatic brain injury (TBI) sustained during childhood or adolescence is of particular significance, given the vulnerability of developing brains. Children and youth with TBI may experience long-term consequences including cognitive and communication problems that can negatively impact school success and socialization. Difficulties such as poor behavioral self-regulation, misunderstanding of social cues, slow processing, challenges with comprehension of abstract language, and conversational exchange can lead to exploitation, abuse, criminal justice involvement, and mental health challenges. Social isolation is also common, as these challenges make it difficult for the youth to follow conventional social norms. It is not surprising that youth with TBI are overrepresented in the criminal justice system internationally. Furthermore, these challenges can have major negative consequences for youth at all stages of the criminal justice procedures and beyond as they may be misinterpreted as rudeness, defiance, or lack of cooperation. While awareness of brain injury in the justice system is increasing, justice staff and professionals lack the knowledge and skills to understand and effectively support and mitigate these challenges. To address this gap, education and training of justice professionals and frontline staff are critical steps toward a justice system that is responsive to the needs of youth with TBI.

This presentation reports on the development and implementation of an education and training program using a Sequential Intercept Model, a model from the US Substance Abuse and Mental Health Services Administration (SAMSHA) that has been used successfully for justice-involved people with mental and substance in the United States and Canada. The aim was to develop a potential “best practice model” of education and training for key justice staff who support youth in the criminal justice system in Ontario, Canada. With funding from the Ontario Neurotrauma Foundation, a group of key stakeholders was developed and training needs were identified to inform a program that would equip staff with knowledge and resources to support youth clients in navigating the criminal justice system.

Training materials were adapted from competencies established by the Oregon Center for Brain Injury Research and Training (CBIRT) and included additional information regarding the cognitive-communication and social cognition and communication challenges that can impact youth across all stages of the justice trajectory. Separate training was delivered to youth Probation Officers, staff, and clinical staff of a Youth Mental Health and Justice facility, Youth Court staff including Judges, Justice of the Peace, Crown Attorneys, and Criminal Defense lawyers. Findings support the routine implementation of education and training for all youth justice staff.

194 Fighting for AC—Home or Bust: A Case Study Following a Global Anoxic Brain Injury

Lynette Holmes; Emily Nicholas

Spaulding Rehabilitation Hospital Boston, Boston, Massachusetts, United States

Background

Studies define quality of life (QoL) as “a multidimensional construct consisting of the evaluation of several domains: physical/functional, psychological, social, cognitive and others” (Souza et al., 2007). Early prognostic predictions occasionally lead to withdrawal of life-sustaining measures in patients after a severe anoxic brain injury. Such was suggested in the case of A.C. and her family.

Case Presentation

A.C., a 13-year-old adolescent girl, sustained a global anoxic brain injury secondary to cardiac arrest. During her 6-week acute care stay, discussion regarding maintenance of life support occurred with her parents. They elected to continue care and pursue the rehabilitation process. A.C. was subsequently transferred to an acute inpatient rehabilitation hospital in an unresponsive wakefulness state. Upon admission, family verbalized plans to transition back home and into the community regardless of progress or intensity of care needed. A family-centered care lens was applied with these goals in mind. After a 10-week length of stay, A.C. was discharged into the community with a Coma Recovery Scale-Revised (CRS-R) score of 12, denoting emergence from a minimally conscious state.

Objective

This presentation reviews A.C.'s trajectory and outcomes, reiterates the importance of family-centered practice, and explores QoL considerations at different points across the continuum of care.

Discussion

“WHO defines Quality of Life as an individual's perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns” (WHO, 2012). QoL viewpoints vary between families, healthcare communities, and the general public. Our interdisciplinary team consisting of MD, nursing, speech-language pathology, occupational therapy, physical therapy, CL, CM, and social work embraced the family's values during daily cares, when establishing treatment plans, and during discharge planning. Therefore, in the case of A.C., her family's decision to sustain her life continues to bring them joy. We will highlight continued progress, family comments postdischarge (“1% better every day”), and attitudes toward QoL.

195 Improving Pediatric Concussion Care in a Tertiary Center Concussion Clinic: A Nursing-Led Multidisciplinary Initiative.

Erika-Pier Caron-Brulotte1; Hugo Paquin2,5; Soha Rached-d'Astous2; Miriam Beauchamp3,4; Sophie Boissonneault5; Marie-Gabrielle Delisle5; Ariane Boutin2

1Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada; 2Department of Pediatric Emergency Medicine, CHU Sainte-Justine, University of Montreal, Montreal, Quebec, Canada; 3CHU Sainte-Justine Research Center, University of Montreal, Montreal, Quebec, Canada; 4Department of Psychology, University of Montreal, Montreal, Quebec, Canada; 5Concussion Clinic, Division of Traumatology, CHU Sainte-Justine, University of Montreal, Montreal, Quebec, Canada

Background

Effective intervention during the acute phase of pediatric concussion, including reassurance and education, is essential for management.

Aim

To evaluate whether an early nursing-led in-person information session optimizes care and improves resources utilization after concussion.

Methods

A pre/postintervention retrospective medical record review of a random sample of patients (aged 6-17.5 years) diagnosed with concussion in the emergency department (ED) was conducted. The primary outcome was the proportion of concussed children who required a medical consultation with a concussion specialist physician as per the standardized pathway. Secondary outcomes included the total number of phone calls and medical follow-ups, as the proportion of patients requiring consultation with other professionals.

Results

In total, 331 patients were included (165 in the pre- and 166 in the postintervention group), with an overall median age of 12.6 years (IQR = 9.9-15.0). In the postintervention group, 24 of 159 (15%) patients required medical consultation compared with 35/159 (22%) in the preintervention group (crude OR = 0.62; 95% CI, 0.35-1.11). After adjusting for age, sex, number of days since injury to ED visit as a history of migraine and past concussion, being in the postintervention group was associated with a 45% decrease in the odds of requiring medical consultation (OR = 0.55; 95% CI, 0.30-1.01) (P = .056) and a 54% decrease in the odds of requiring physiotherapy or psychological referral (OR = 0.46; 95% CI, 0.24-0,90) (P = .023). In those patients, the rate of medical visits was similar between the 2 groups (2.0 vs 1.9 visits). Overall, the rate of phone calls carried out by nurses in the postintervention group was 32% (95% CI, 20-44) (P < .001) lower than in the preintervention group.

Conclusions

The findings provide empirical support for the value and efficacy of this innovative nursing-led intervention in concussion management and could be applied in other clinics that may have more limited resources.

196 Raynaud's Phenomenon With Methylphenidate Treatment in a Patient With TBI

Kayli Gimarc; Cherry Junn

University of Washington Department of Rehabilitation Medicine, Seattle, Washington, United States

Setting

Tertiary care clinic.

Patient

The patient was a 36-year-old woman who sustained moderate traumatic brain injury in January 2021. She had persistent neurocognitive deficits, visual deficits, vestibular dysfunction, hypopituitarism, and migraine as sequelae of traumatic brain injury (TBI).

Case Description

The patient was started on immediate-release methylphenidate 5 mg twice daily in October 2021 for neurocognitive deficits including difficulty with attention and processing speed. The dose was increased to 10 mg twice daily, with good clinical effect on cognitive symptoms, and subsequently switched to comparable dose of extended-release methylphenidate in January 2022. In the following 1 to 2 months, she developed worsening temperature sensitivity of digits, toes greater than fingers, and coldness of feet and hands. She then developed purple/blue discoloration of distal toes. She had no other significant changes to her health and no other medication changes in the interim. No other adverse effects of medication were noted. She had no prior history of temperature sensitivity, vasculopathy, Raynaud's phenomenon, or cardiovascular disease.

Assessment

Raynaud's phenomenon is characterized by vasospasm of vessels in the digits and is associated with color change and pain. Peripheral vasculopathy, including Raynaud's phenomenon, has been infrequently reported with post-marketing use of formulations of methylphenidate at therapeutic doses. There are several existing reports of methylphenidate-induced Raynaud's phenomenon in pediatric patients with attention-deficit/hyperactivity disorder (ADHD). In comparison, there are scarce reports of methylphenidate-induced Raynaud's phenomenon in adult patients with ADHD. To the authors' knowledge, methylphenidate-induced Raynaud's phenomenon has not been previously reported in the treatment of neurocognitive deficits secondary to TBI in adults. Methylphenidate-induced Raynaud's phenomenon is thought to be dose-dependent, and symptoms may resolve with drug cessation. Our patient's dose of extended-release methylphenidate was decreased, with subsequent improvement in symptoms and purple/blue discoloration of toes.

Conclusion

Peripheral vasculopathy including Raynaud's phenomenon is a rare adverse effect associated with methylphenidate and is of clinical importance to physicians treating patients with brain injury. Symptoms tend to develop within the first 2 years of drug treatment; thus, particular vigilance is warranted during this period, especially as dose titration occurs. Increased awareness will expedite dose titration and symptomatic management.

197 Seizure and EEG Findings in Abusive Head Trauma

Brittnie Bartlett1; Elaine Seto1,2; Sarah Risen1,2

1Baylor College of Medicine, Houston, Texas, United States; 2Texas Children's Hospital, Houston, Texas, United States

Objective

As the number one cause of severe head trauma in children younger than 1 year and the number 3 cause in children of all ages, abusive head trauma (AHT) is a significant public health concern. AHT has a high mortality rate, and children surviving have poor functional outcomes, often associated with acute clinical variables including seizure activity. We seek to describe clinical and neurophysiological findings in children with AHT throughout the continuum of injury and recovery.

Methods

Retrospective analysis of patients presenting to a pediatric tertiary care center over the span of 3 years (March 2018-February 2021) with expert confirmed AHT. Clinical data, including electroencephalographic (EEG) findings, anti-seizure medications, and developmental outcomes, were obtained from the medical records. Descriptive statistics are used for this preliminary review.

Results

In total, 105 patients younger than 5 years were admitted with AHT; 57% (n = 60) had seizures either as part of their clinical presentation or during admission. Of these, 40% had a clinical seizure on presentation and during the admission, 40% had a clinical seizure on presentation only, and 20% developed seizures during the admission. Continuous EEG was obtained in 67 patients, with seizure activity detected in 36 children (53%), most often subclinical seizures (88.9%, n = 32). Nearly one-fourth of children with AHT monitored experienced exclusively subclinical seizures. Only one patient had a normal EEG prior to discharge. Levetiracetam was the most common anti-seizure medication used for treatment and prophylaxis, followed by fosphenytoin and phenobarbital. One-third of this cohort had status epilepticus, with 13 patients requiring continuous anesthetic infusion. While half (n = 52) of children with AHT were discharged on anti-seizure medications, only 6 patients (6%) went on to develop epilepsy. Half of patients discharged on anti-seizure medications (n = 26) obtained an outpatient EEG prior to weaning medications. Data analyzing the relationships among seizure activity, inpatient anti-seizure medication treatment and duration, evolution of EEG findings over the course of recovery, and neurodevelopmental outcomes are forthcoming.

Conclusion

Seizures are a common acute complication of AHT, though few patients develop epilepsy following discharge. Further review of EEG variables over time and inpatient seizure management as they relate to outpatient management and neurodevelopmental outcomes may provide guidance in treating children with AHT. Proper evaluation and management of this vulnerable population are important to optimize functional outcomes.

198 Compensatory Cognitive Training in 3 Veterans With and Without Brain Injury

Angela Reif; Andrea Ginella

The University of Akron, Akron, Ohio, United States

Compensatory Cognitive Training (CCT) is a cognitive treatment program (previously Cognitive Symptom Management and Rehabilitation Therapy [CogSMART]) created to target cognitive symptoms associated with mild traumatic brain injury (mTBI). Individuals with a history of mTBI often demonstrate persistent deficits in attention and concentration, learning and memory, and executive functioning. The CCT program focuses on providing instruction, discussion, and activities designed to inform clients about cognitive strategies and external aids to improve daily-life functioning impacted by cognitive deficits due to brain injury. This training program has typically been completed in VA (Veterans Affairs) facilities with veterans with mTBI who served within Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND).

Previous research has found that of the veterans who served in OEF, OIF, and OND and sought medical treatment at a VA facility, 21% screened positive for brain injury. Importantly, regardless of the presence of a history of mTBI, changes in cognitive performance have been reported in veterans following deployment including impairments in attention, verbal learning, and visual-spatial memory. Thus, the current pilot study examines the effectiveness of the CCT program provided within a university clinic and administered to 3 veterans with and without a history of traumatic brain injury.

All data for cases used within this study have been collected. The current study examines the data collected for 3 cases of individuals who completed an individualized CCT program provided by a speech-language pathology graduate student and supervised by a licensed speech-language pathologist in a university audiology and speech center. Participants included 1 participant with and 2 participants without a diagnosis of traumatic brain injury, but all with self-reported cognitive deficits. All participants completed the 10-module CCT program within 60- to 90-minute sessions. All participants were undergraduate students and participated in the Saint Louis University Mental Status (SLUMS) Examination for assessment of cognition. In addition, self-reported cognitive problems and pretraining strategy use were assessed by the Cognitive Problems and Strategies Assessment. The study describes findings on measures of cognition (SLUMS assessment), pre- and posttraining on the Cognitive Problems and Strategies Assessment, and results on the CogSMART Evaluation of the training program in order to describe the effectiveness of CCT for each participant and across participants. Preliminary analysis of the CogSMART Evaluation ratings revealed an average rating of 3.4 (moderately to very helpful) on a scale of 1 to 5 (1 “not helpful” to 5 “extremely helpful”) across all participants' item ratings. Qualitative CogSMART Evaluation comments are also summarized and described in relation to quantitative ratings on the Cognitive Problems and Strategies Assessment. In addition, ratings of strategy use pre- and posttraining are presented and discussed in relation to CogSMART Evaluation ratings.

199 Impact of Post-Deployment Assessment & Treatment (PDAT) Inpatient Rehabilitation Program on Social Roles and Community Interaction in Veterans With a History of mTBI/Polytrauma Comorbidities

Danielle Kurlander1; James Muir1; Jeff Chan1; Andrew Kayser1; Zach Skiles2; Sharon Willock1; Jeffrey Kixmiller1

1VA Northern California Health Care System, Martinez, California, United States; 2University of California, San Francisco, San Francisco, United States

Objectives

To assess the impact of a novel interdisciplinary rehabilitation program on social roles and community interactions in veterans with mild traumatic brain injury (mTBI)/polytrauma and comorbid medical, psychiatric, and substance use diagnoses.

Methods

The Community Integration Questionnaire-Revised (CIQ-R) was used to evaluate social roles and community interaction before-and-after novel PDAT (Post-Deployment Assessment & Treatment) inpatient rehabilitation program. Participants were 34 male residents (26-61 years of age, M = 36.88 years, SD = 10.07), 70% were non-Hispanic Caucasian, 9% Asian/Pacific Islander, 9% Hispanic, 12% Native American/Alaskan Native, mean education was 12.87 years (SD = 1.75; range, 9-19). All participants had a history of mTBI. Common health comorbidities included trauma/stress-related disorders, mood disorders, sleep disorders, and problems with alcohol misuse.

Results

Veterans' integration into the home and community measured by CIQ-R total scores (M = 11.21, SD = 5.48) was significantly improved after participation in the program (M = 17.32, SD = 5.23; t33 = 5.14, P < .001). Furthermore, results showed significant improvement on all 4 CIQ-R subdomains including Home Integration and Social Integration (t = 4.04 and 4.46, respectively; both Ps < .001), as well as Productivity and Electronic Social Media (t = 3.06 and 3.08, respectively; both Ps < .005). Covariates and potential moderators will be further detailed.

Conclusions

Results demonstrate that PDAT inpatient rehabilitation program participation is associated with significant improvements across multiple domains of Community Integration (social roles and community interaction) in veterans presenting with mTBI/polytrauma and comorbid medical, psychiatric, and substance use diagnoses. Treatment plans including emphasis on community reintegration may help create and maintain positive feedback loops wherein improvements in mood/subjective well-being and greater community focus/participation might function synergistically and become self-reinforcing. Future analyses will explore questions around causality, and relations between community integration and improvements also demonstrated with regard to mood/psychiatric, cognitive functions, sleep, chronic pain, and overall quality of life.

200 Pupillometry Components and Postconcussion Symptom Assessment in Pediatric Patients

Theodore Heyming; Jennifer Hayakawa; John Schomberg; Sharief Taraman; William Loudon; Kellie Bacon; Bryan Lara; Rachel Pearson

Children's Hospital of Orange County, Orange, California, United States

Objective

Traumatic brain injury (TBI) is a leading cause of disability and death in children. Concussion is the most prevalent type of TBI and can result in persistent postconcussive symptoms. An objective and definitive diagnostic biomarker for concussion would improve diagnosis, management, assessment of recovery, decrease radiation exposure, and reduce cost. Pupillary light reflex/responsivity has been found to be significantly delayed in patients with mild TBI, but further study is warranted. Our objective was to examine pupillary metrics, standardized neurocognitive tests, and objective balance assessment in pediatric patients with concussion versus patients without concussion (controls).

Methods

Pediatric patients with concussions and age/gender-matched controls were recruited at a quaternary care children's hospital. Pupillary metrics were collected at initial visits, 2 weeks, and 3 months for concussed patients, and at initial visits and 3 months for controls. Pupil metrics (size, dilation velocity, constriction velocity, time to 75% dilation, minimum contraction, and dilation latency) were assessed using pupillometers (NPI-200 and PLR-3000). Post-Concussion Symptom Score (PCSS) (12-18 years), Post-Concussion Symptom Inventory PCSI (5-11 years), and Balance Error Scoring System (BESS) measurements were also collected. Analysis was performed using generalized linear mixed-effects models.

Results

A total of 64 concussed participants and 35 control participants were recruited for this analysis. In concussed children aged 5 to 11 years, pupil constriction latency and mean pupil constriction velocity were found to be significantly different in distribution when compared with nonconcussed controls. Concussed patients were found to have a significantly slower pupil constriction velocity and mean pupil constriction velocity (3.01 mm/s, 4.6) than controls (3.38 mm/s, 5), P = .03 and P = .005, respectively. In children 12 to 18 years of age, pupil dilation velocity was significantly slower in patients with concussions (1.2 mm/s) than controls (1.3 mm/s), P = .01. Pupil constriction latency (P = .02), neurological pupil index (P = .02), and mean constriction velocity (P = .03) were significantly associated with PCSS in patients 12 to 18 years of age. In patients 5 to 11 years of age, initial pupil size (P = .009) and constriction velocity (P = .01) were significant predictors of PCSI score. In patients 12 to 18 years of age, an increase of log 1 mm/s in pupil constriction velocity was associated with a significant increase in total BESS scores (P = .03). Initial pupil size and time to 75% pupil size were significantly associated with a decrease in PCSI score in patients 5 to 11 years of age (P = .03 and P = .004, respectively).

Conclusion

Pupillary responses are significantly different in concussed patients compared with age- and gender-matched nonconcussed controls in the 5-11 and 12-18 years old pediatric populations seen in this study. This suggests that with further study, pupillometry may become an objective and reliable diagnostic tool for the assessment, management, and treatment of pediatric patients with or at risk for concussion.

201 Post-Deployment Assessment & Treatment (PDAT) Inpatient Rehabilitation Program Improves Sleep Quality in Veterans With a History of mTBI/Polytrauma Comorbidities

Danielle Kurlander1; James Muir1; Jeff Chan1; Andrew Kayser1; Zach Skiles2; Jeffrey Kixmiller1

1VA Northern California Health Care System, Martinez, California, United States; 2University of California, San Francisco, San Francisco, United States

Objectives

To evaluate the impact of a novel interdisciplinary inpatient rehabilitation program on sleep quality in veterans with mild traumatic brain injury (mTBI)/polytrauma and comorbid medical, psychiatric, and substance use diagnoses.

Methods

The Pittsburgh Sleep Quality Index (PSQI) was used to evaluate sleep quality before-and-after novel PDAT inpatient rehabilitation program. Participants were 1 female and 41 male residents (24-61 years of age, M = 36.27; SD = 9.50), 76% were non-Hispanic Caucasian, 7% Asian/Pacific Islander, 2% African American, 10% Hispanic, 5% Native American/Alaskan Native, mean education was 12.77 years (SD = 1.58; range, 9-19). All participants had a history of mTBI. Common health comorbidities included trauma/stress-related disorders, mood disorders, sleep disorders, and problems with alcohol misuse.

Results

Sleep disordered symptoms measured by PSQI total scores (M = 14.19, SD = 4.06) were significantly reduced after participation in the program (M = 11.17, SD = 3.49; t41 = −5.09, P < .001). PSQI subcomponent scores are further detailed. Covariates and potential moderators also are further detailed.

Conclusion

Results demonstrate that PDAT inpatient rehabilitation program participation is associated with significant sleep quality improvements in veterans presenting with mTBI/polytrauma and comorbid medical, psychiatric, and substance use diagnoses. Findings can inform developing treatment approaches within a TBI/polytrauma rehabilitation setting. Prior studies point to the importance of treating sleep problems as a necessary component of integrated care planning for mood/stress disorders, cognitive concerns, chronic pain, and other conditions presenting comorbidly with mTBI. While relations between sleep, posttraumatic stress disorder (PTSD), and pain syndromes are complicated, previous studies suggest that PTSD often drives sleep disturbance more so than chronic pain. Because the PDAT program provides both trauma-focused therapies and cognitive behavioral therapy for insomnia interventions, we will investigate which contributes more to the observed sleep improvements. Future analyses will explore questions around causality and relations between sleep quality and improvements also demonstrated with regard to mood/psychiatric, cognitive functions, chronic pain, community integration, and overall quality of life.

202 Patient and Provider Reflections on Improving Care for Persistent Postconcussion Symptoms

Elizabeth Sandel2,3; Conor Gormally1

1Concussion Alliance, Seattle, Washington, United States; 2University of California/Davis School of Medicine, Davis, California, United States; 3Paradigm Healthcare Services, Walnut Creek, California, United States

The authors examine the complexities of and barriers to navigating the care process for treating persistent postconcussion symptoms from the perspectives of a physiatrist board-certified in Brain Injury Medicine and a patient in his sixth year of persistent symptoms. A TRACK-TBI study examining symptom persistence in patients with concussion presenting to level 1 trauma centers found that 50% of patients who had had computed tomographic scans ordered endorsed 3 or more symptoms at 1 year postinjury, and 70% endorsed at least one (Machamer et al., 2022). After extensive review, there is a distinct lack of high-quality epidemiological data on the incidence of persistent postconcussion symptoms (or postconcussion syndrome), though estimates range between 5% and 30%. The authors offer their experience and expertise from both sides of the medical system. They critique the concussion literature regarding definitions, diagnostic coding systems (International Classification of Disease, Diagnostic and Statistical Manual, etc), concussion guidelines, and the international consensus statement concerning care for people with persistent postconcussion symptoms. They also explore the definition, elements, and benefits of “patient-centered care” outlined and promoted by the Institute of Medicine more than 20 years ago. The authors offer a perspective on how reforming care delivery and patient encounter systems based on this “patient-centered care” model could improve outcomes for patients with concussion with persistent symptoms—they share their current efforts to create education on patient-centered care for providers. Gormally's commentary ends with a discussion of initiatives he has taken as a cofounder of Concussion Alliance, an organization that aims to educate and advocate for individuals who have sustained concussions, especially those with persistent symptoms. Dr Sandel ends with a discussion of her mission to educate the public through a website and her book, Shaken Brain: The Science, Care, and Treatment of Concussion.

203 The Effects of Neurocognitive Function and Postconcussion Symptoms on Daily Driving Behavior Among Adolescents With a Mild Traumatic Brain Injury: A Preliminary Analysis

Gabriela Sherrod1; Jingzhen Yang2; Benjamin McManus1; Thomas Kerwin2; Sam Marcrum1; Kenisha Hicks2; Sean Brown2; Despina Stavrinos1

1University of Alabama at Birmingham, Birmingham, Alabama, United States; 2Nationwide Children's Hospital, Columbus, Ohio, United States

Objectives

The present study sought to examine the effects of postconcussive symptoms and neurocognitive functioning on return-to-driving trajectories among adolescents during the acute postinjury phase of a mild traumatic brain injury (mTBI).

Introduction

During the acute postinjury phase of an mTBI, patients experience rapid neurocognitive changes in various domains such as attention, reaction time, and vision. Returning to drive after mTBI is frequently an immediate goal for adolescents wanting to resume daily activities; however, the neurocognitive domains affected by mTBI are also those that are critical to safe driving behaviors. While physical and cognitive rests are commonly prescribed for mTBI patients, physicians have little guidance to determine when it is safe for their patients to resume driving. Clearly, evidence is needed to inform clinical guidelines on when adolescents can return to drive after mTBI.

Methods

Multisite data collection for this study is ongoing. Currently, 10 adolescents (3 males, 7 females) aged 16 to 22 years (Mage = 18.9 years, SD = 1.91) have been enrolled. Participants with mTBI were enrolled within 96 hours of initial injury and completed a minimum of 3 weekly in-person assessments. Participants remained enrolled for up to 9 weeks or until symptom resolution, whichever came first. Weekly appointments included neurocognitive assessments using the NIH Toolbox and ImPACT cognitive batteries. Between weekly appointments, participants provided reporting of their daily postconcussion symptoms (PCS, measured by the Post-Concussion Symptom Scale) and daily driving behaviors.

Anticipated Results and Conclusion

Mixed-effects growth models will be used to estimate the trajectory of driving over time following injury, as well as the effect of weekly changes in neurocognitive variables. Pilot data using a sample of adolescents 2 weeks postinjury have shown that faster baseline reaction time performance was associated with increased average daily driving over time. Therefore, reaction time is anticipated to predict daily driving in this acute postinjury sample. A better understanding of PCS and neurocognitive changes at and after the acute postinjury phase can help elucidate at what point adolescents can begin to safely reintroduce driving into their daily activities.

204 Running Virtual Interventions Studies: Key Lessons Learned During the COVID-19 Pandemic

Hiba Al-Hakeem1,2; Andrea Hickling1; Brendan Lam1; Sara Marshall1; Shannon Scratch1

1Bloorview Research Institute, Toronto, Ontario, Canada; 2University of Windsor, Windsor, Ontario, Canada

Background

Youth with acquired brain injuries (ABIs) experience physical, psychosocial, and academic challenges. Research demonstrates that empirically validated interventions tailored to meet the needs of youth with ABI enhance their health outcomes. COVID-19 effects have posed significant limitations and barriers to offering in-person interventions required for support. It is important to explore the elements that promote successful delivery of virtual programs that address the unique needs of families and youth with ABI. The NOvEL Lab, an active interdisciplinary intervention laboratory, has substantial experience with delivering different types of virtual interventions to foster the well-being of youth with ABI and their families.

Objective

To describe the lessons learned from delivering research-led interdisciplinary interventions to support the well-being of youth with ABI and immediate family members and to support the training of school educators.

Methods

A collective case-study design is used to develop key lessons learned from our team's experiences delivering 3 interventions during the past 2 years in Ontario, Canada. The interventions are (1) Move&Connect, a group-based intervention that has 2 arms for both youth with persistent concussion and their caregivers. It provides social support and psychoeducation to caregivers and combines these elements with active rehabilitation for youth. (2) iSibworkS, a peer-support cognitive-behavioral intervention designed for siblings of youth with disabilities, including ABI. (3) Teach-ABI, an online professional development module designed for educators to support students' return to school after ABI. We have enrolled (n = 20) families dealing with ABI and (n = 30) school educators. Multiple sources of data were used to summarize the lessons learned, including in-depth interviews with participants, field notes, and many rounds of discussion and reflection with team investigators.

Results

Key areas of consideration were identified when delivering virtual interventions: (1) fostering engagement during virtual activities; (2) facilitating inter-team communications for ongoing reflection on intervention delivery; and (3) assessing intervention outcomes through data triangulation. Virtual engagement was fostered through facilitator support, content sharing, and interactive discussions. Field notes are used to document participant engagement activities and their verbal and nonverbal communications. Practicing team reflexivity enabled investigators to address challenges as they arose and provided feedback on intervention delivery effectiveness. Utilizing data triangulation to understand intervention outcomes was important to our data analysis. The use of in-depth interviews provided context to the quantitative data as some trends were unexpected because of the impact of COVID-19.

Conclusion

The findings from the 3 studies stress the importance of offering virtual intervention to support youth with ABI in connected domains: youth health, family, and school settings. The intervention studies identified key issues that can be useful for researchers who want to implement clinical programs virtually to support the well-being of youth with similar challenges.

205 Clinical EEG and P300 Used for Tracking Cortical Improvement From TBI Interventions Using Rapid Testing and Advanced Computer Algorithms

Frank Palermo

PM&R, University of Colorado Medicine, Denver, Colorado, United States

Successful medical, therapeutic, and stimulation to improve brain function following acquired brain injury (ABI) requires objective baselines. Electroencephalogram (EEG)-based cortical evoked potentials are consistent physiological markers. EEG frequencies and amplitudes are known to shift following medication or neuromodulation interventions. Advanced computer algorithms are now able to evaluate EEG activity and categorize individual patients into groups through cluster analysis. Clusters show uninjured control brain activity grouping contrasted with an injured patient who displays EEG activity quantified into a grouping consistent with prior brain injury. As patients respond to neurorehabilitation interventions, the individual EEG markers progress in the anticipated direction toward the uninjured clustering. Clinically, we have seen brain physiologic activity shift in the desired direction before noting functional improvement.

Methods and Materials

EEG with audio P300 was collected as part of a health screening examination for studies through Colorado University, Boone Heart Institute Denver, and WAVi Medical. In total, 2025 subjects aged 13 to 90 years were evaluated for baseline both for preseason sports in the younger groups and before engaging in rehabilitation interventions for the 54 patients who had sustained a closed head injury from blunt trauma or blast exposure. Nineteen active channel EEGs were evaluated with eyes closed EEGs followed by a 4-minute cortical P300 test using the standard “odd ball” paradigm. Computer analysis of the EEG produced peak alpha frequency, background and target response cortical coherence at 3 frequency clusters, brain processing delay, physical response, and P300 amplitudes for each electrode. Individual subjects' EEGs were analyzed using eigen clustering positioning individual vector scores within 3-dimensional (3D) group clustering of a cohort of 150 known patients with traumatic brain injury (TBI) in comparative relation to uninjured subjects.

Results

Validity of the tests was substantiated because of the test-retest consistency. P300 amplitudes and cortical delays were tested. An SD of 12% was reported. Pre/postconcussion amplitudes and delays changed over 40% (−28% to −64%) at 24 hours following mild TBI. As the subjects improved clinically, the EEG signals improved in 70% at 2 weeks and 90% returned to within 2 SD at 2 months. Upon repeat testing, individual alpha frequency peak activity remained stable over the course of 0 to 2 years in a test-retest data set. Eigen cluster analysis of raw EEG waves showed clear separation between statistically plotted characteristics of uninjured controls and those with a history of TBI. These statistical plots are presented in 3D mapping. Individual subject plots align within their respective groups.

With successful intervention, individuals trend toward the uninjured control statistical plots. Physiological improvement appears to precede clinical or functional improvement.

Conclusions

New and adapted computer techniques applied to standard EEG and ERP (event-related brain potential) analysis of TBI patients, both recent or chronic TBI, help track brain physiological progress. Rapid and simplified procedures also add to the clinical and research protocols.

206 Developing Formal Theories of Persistent Postconcussion Symptoms: How Computational Models Can Advance Our Field

Brendan Lam1,2; Shannon Scratch1

1Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada; 2Yale University, New Haven, Connecticut, United States

Objectives

Theories, models, and frameworks of persistent postconcussion symptoms (PPCS) tend to give broad explanations and vague predictions of its etiology. For example, many posit that PPCS arises from a variety of biopsychosocial factors, such as life stress, anxiety, and the biomechanical impact of the initial injury. These explanations offer some insight into the causes of PPCS. However, they are difficult to falsify because they often do not make specific predictions that are easily testable. In contrast, formal theories in the clinical and health sciences have become popular because they make quantifiable predictions of the phenomena they are trying to explain. The purpose of this presentation is to show the potential of formal theories in advancing our understanding of PPCS. Moreover, we demonstrate how computational models (ie, instantiations of these theories) can explain the etiology of PPCS as a complex system.

Methods

We present an overview of popular theories, models, and frameworks of PPCS. Next, we present examples of computational models from the clinical sciences and how they can be applied to PPCS. This involves demonstrating 2 computational models, their properties, and their explanatory value.

Results

In the first example, we present a reinforcement learning model that connects trait anxiety to within-subject variability of PPCS and symptom trajectories. The second example conceptualizes PPCS as the outcome of a nonlinear dynamical system. Borrowing from the current literature, it proposes a regulatory feedback mechanism of fear avoidance, catastrophizing, and concussion symptoms. A computational approach is able to capture the complexity of PPCS by explicitly modeling the mechanisms and processes that may lead to concussion symptoms. Unlike traditional approaches, dynamical systems or reinforcement learning can represent processes (eg, symptom expectations exacerbating future symptoms) as parameters in the model.

Conclusions

When theories are formalized as computational models, they can explain the onset of PPCS, symptom trajectories, and provide targets for intervention. We argue that this framework provides a better way of studying the mechanisms behind PPCS by bridging the gap between our verbal hypothesis and our statistical model.

207 A Cross-sectional Study of Caregivers and Service Providers Adapting to COVID-19 in a Canadian Brain Injury Service Organization

Koorosh Kashanian1,2; Domenica Cirone1,3; Youssef Saddiki1; Erica Shligold1; Ramtin Hakimjavadi1; Lucas DiRienzo1; Dar'ya Semenova1

1Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada; 2University of Western Ontario, London, Ontario, Canada; 3McGill University, Montreal, Quebec, Canada

Because of COVID-19, many healthcare organizations have experienced disruptions to their service. Both the transition from in-person to online and the reverse have proved challenging for centers, making it hard to provide effective service balanced with appropriate safety precautions. Vista Centre Brain Injury Services (VCBIS), a Canadian organization based in Ottawa, is responsible for providing rehabilitation services to clients with brain injuries. As such, they have made many modifications to providing services over the course of the pandemic. This study aims to elucidate and compare the impact of these changes on VCBIS staff. We surveyed staff to assess their demographic, physical, social, and psychological well-being, as well as satisfaction with their responsibilities.

Between January 1 and February 15, 2022, staff members at VCBIS were asked to complete a survey examining how changes in service due to COVID-19 may have affected their job satisfaction and physical, psychological, and social well-being. There were a total of 79 questions containing a combination of binary and linear numeric response formats. Questions asked staff members to reflect on their experience since the onset of the pandemic (“retrospective component”) and/or their thoughts and feelings about the future of the pandemic as it relates to their employment (“prospective component”). For descriptive statistics, numeric variables are presented as means with SDs and categorical variables are presented with frequencies and percentages. As mentioned earlier, we tested for the differences in responses between this study and a similar survey, which was conducted in early 2021 using an independent-samples t test.

Fourteen members responded to the survey during the response period from January to February (79% female, 21% male). Most reported their age in the 30- to 39-year range and 60-year-or-older range. Statistical analysis indicates significance in having more frequent changes in the amount of time spent on personal life activities, as well as the impact on sleeping habits, dietary habits, and exercise patterns.

The results of this study have important implications for VCBIS service delivery, team management, and funding distribution. Because of the long-lasting impact of the pandemic, it is important to consider these findings as VCBIS operates through the pandemic and transitions back to normal services. Comparing the results with last year's data demonstrates that the COVID-19 pandemic service changes have impacted staff, suggesting the need for additional support and resources to improve staff work productivity, satisfaction, and overall well-being. Given that many health organizations have had to readjust as a result of the pandemic, it is expected that staff outside VCBIS may share similar experiences.

208 Daily Cares in Brain Injury: A Case Study

Lynette Holmes; Emily Nicholas

Spaulding Rehabilitation Hospital Boston, Boston, Massachusetts, United States

Background

Differentiating vegetative state (VS)/unresponsive wakefulness syndrome (UWS) from minimally conscious state (MCS) unfortunately remains challenging, especially in the pediatric population. The importance of accurate diagnosis for families is vital as it may impact decisions, access to care, and placement options. In addition, there is limited research and training for those treating this population; therefore, case studies continue to be highly informative to guide care plans.

Case Presentation

After a cardiac arrest requiring a 6-week acute care stay, a 13-year-old adolescent girl, presented to an Inpatient Rehabilitation Hospital with a diagnosis of a severe anoxic brain injury. An initial Coma Recovery Scale-Revised (CRS-R) score of 7 denoting a VS/UWS was recorded with subsequent scores of 4 to 5 over a 9-week length of stay. Surprisingly, on week 10, the last week of her stay, functional and accurate use of nonverbal communication via head movement occurred, scoring a 12 on the CRS-R denoting emergence from a minimally conscious state. The patient was discharged home communicating with a reliable and consistent nonverbal yes/no head movement system. Introduction to augmentative and alternative communication (AAC) was attempted; however, both the patient and her family were not emotionally ready for implementation.

Objective

The goal of this retrospective case study was to provoke discussion regarding importance of formal assessment (CRS-R) as well as informal measures (head control, mouth opening, etc) during daily cares/interactions.

Discussion

The importance of the family role in rehabilitation has been documented in numerous studies, and they are often the first to notice changes during interactions. Family often assists in completing daily cares and functional task with the patient. They are coached to communicate with the patient, establish routines, and encourage the patient to respond. In this case, it was noted during her last week. The patient's first sign of interacting with the environment/others to be oral motor command following while completing oral care with her mother. Prior to that, IQBA results targeting auditory localization varied for different reasons, most notable periods of irritability. Is there a case to measure improvements in physical movements such as head control, mouth opening, to guide speech-language pathology plan of care?

209 Introducing PRISM to Clinical Practice in Residential Neurorehabilitation Setting for Severe Acquired Brain Injury (ABI)

Lorna Wales1; Rob Forsyth2; Gemma Kelly1

1The Children's Trust, Tadworth, United Kingdom; 2Newcastle University, Newcastle, United Kingdom

Introduction

Neurorehabilitation is a complex and multifaceted intervention. Evaluating rehabilitation outcomes is challenging, with little knowledge of the components of the program delivered. Paediatric Rehabilitation IngredientS Measure (PRISM) is a new tool to capture rehabilitation input in pediatric multidisciplinary neurorehabilitation.

Aim

To explore the introduction of PRISM for a cohort of severe pediatric acquired brain injury (ABI).

Methods

PRISM was introduced to one UK neurorehabilitation center. The multidisciplinary team completed PRISM monthly using consensus to identify the priority rehabilitation ingredients that week (child/family active practice; child/family explicit learning of strategies; child/family mental well-being; advocating for child in community; other management; equipment/adaptations).

Results

Six months of data collection was done. There were 20 children/young people (2 hypoxic injuries, 6 inflammatory, 5 stroke, 6 traumatic, and 1 tumor). Average age at injury was 9 years (range, 1-16 years), and average time since injury was 23 weeks (range, 7-47 weeks). A variety of PRISM profiles were captured for children/young people, with some having a large bias toward active practice, others toward emotional health, etc. Case example illustrates the proportion of time spent on rehabilitation activities early in the placement—child active practice (0.17); child's learning of explicit knowledge (0.35); community professionals' learning explicit knowledge (0.07); and other management of child activity and function (0.41). PRISM captures a change in priority later in the program. Proportions now reflect greater time spent on child active practice (0.59); more time on community professionals' explicit learning (0.16); and a new priority of advocating for child/family in community (0.25). Further examples demonstrate that for some there was a decrease in the importance of active practice in favor of other supports for the child, for example, parental explicit learning. Following informal training and support, the team found PRISM calculator tool easy to use.

Conclusion

PRISM captures the individualized and dynamic rehabilitation input offered to children/young people with differing needs following severe ABI. This tool facilitates team and family discussion about the priorities of rehabilitation at any given time. Alongside child/family goals, PRISM data could facilitate decision-making for suitable outcome measures and help manage expectations. Research is required to explore the relationship between PRISM inputs and child/family outcomes following severe ABI.

210 The Experiences of Using the Family Needs Questionnaire–Pediatric Version (FNQ-P) in a Multidisciplinary Team Supporting Young People (YP) With Acquired Brain Injury (ABI) in the Community

Lorna Wales; Natalie Martlew; Nicola Morgan

The Children's Trust, Tadworth, United Kingdom

Introduction

Brain injury is the most common cause of disability in the United Kingdom, with around 35 000 children admitted annually due to traumatic causes. Regardless of severity, it can lead to lifelong difficulties affecting the child/young person and their family.

Brain Injury Community Service (BICS) supports children with acquired brain injury (ABI) including those with concussion. The Family Needs Questionnaire–Pediatric Version (FNQ-P) provides information on family members' perceptions of whether needs have been met. The questionnaire addresses 6 areas including health information, emotional support, and community support.

Methods

BICS routinely sent FNQ-P to families prior to first face-to-face visit. Support provided to complete unanswered items. Analysis of completed questionnaires is done by using descriptive statistics and qualitative analysis of commonly reported themes.

Results

In total, 184 families (traumatic: n = 90; nontraumatic: n = 94) participated. Age at injury was 0 to 17 years. The mean total score was 86 (range, 7-197). Three items with lowest mean score were “to receive information on the impact of drugs or alcohol after a brain injury”; “to share my feelings about my child with someone who has gone through a similar experience”; “to have access to counseling to help me cope and to understand the different feelings I have (eg, anger, roller coaster of emotions).” Three items with highest mean score were “to have information from professionals explained in terms and in a language I can understand”; “to have questions answered thoroughly/respectfully in a timely manner”; “to feel that medical or rehabilitation staff show respect for my child's family needs or wishes.” Missing data were reported across all sections. Instrumental/practical support had most missing data (n = 17). Team feedback contained positive experiences and challenges. Additional feedback (36 families) expanded on individual child's situation. Some clarified difficulties completing form.

Discussion/Conclusion

For younger children and those with milder injuries, a number of questions were not applicable. Although this caused some confusion for families, the tool opened conversations to build rapport with families and discuss sensitive topics such as emotional well-being.

The team plans to address the group needs for drug/alcohol information and access to family support. While FNQ-P may not be necessary as a routine one-off measure for this cohort, the team will continue to evaluate the tool for capturing outcome of community-based intervention.

211 BREINSTRAAT.NL: Digital Disclosure of Peer Expertise by Young People With ABI

Arend De Kloet1; Menno van der Holst1,2; Bram Reurings3; Martine Kapitein4; Carla Hendriks5; Roeli Wierenga1; Ana Broos6; Shari Wade7; Gary Bedell8

1Basalt Rehabilitation, the Hague, the Netherlands; 2Leiden University Medical Center, Leiden, the Netherlands; 3The Hague University of Applied Sciences, the Hague, the Netherlands; 4Breinsupport, Arnhem, the Netherlands; 5Heliomare, Wijk aan Zee, the Netherlands; 6one of the 5 moderators, former patients with ABI, Haarlem, the Netherlands; 7University of Cincinnati and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States; 8Tufts University, Boston, Massachusetts, United States

Background

Young ones are worrying about questions and uncertainty dealing with the consequences of acquired brain injury (ABI): for example, Am I the only one? How do others cope? How to deal with parents and friends incomprehension? Research shows that knowledge and insight into self-management and dealing with changed daily living can be positively influenced by using patient expertise of peers. Young people are asking for a digital platform so that they can decide for themselves whether, how, and when they want to join.

Objectives

Develop and implement a sustainable, digital, self-managed peer support/patient expertise platform usable in all phases of care and meeting the needs and wishes of the target group.

Methods

Five focus groups were organized to get a complete picture of the wishes and needs, desired content, and functionality (WP1). Through iterative design including patient stakeholders (text, design, testing), we subsequently built the platform and conducted a pilot examining content and usability in 3 rehabilitation centers with patients, parents, and professionals before launching (WP2). Followed by stepwise implementation in the Netherlands: rehabilitation, special education, acute and chronic care and internet, with ongoing evaluation of usage and satisfaction (WP3).

Results

Top 5 requests of the focus groups: disclosure of peer/patient expertise; smart agenda with energy monitor; information age group specific, compact and visual; content for parents; and interaction (forum, chat) only with peers. Pilot testing taught us that young people do not read the psychoeducation on the home page or read it poorly (solution: instruction video), smartphone access is a favorite, need of reminders, and parents need of interaction (solution: separate chat for parents). The platform was launched in September 2021, is free of costs and privacy proof, with 5 young people with ABI as moderator. The program includes a general psychoeducation section with content for parents, family, and professionals, and a private portion that is only accessible for young people via log-in. This section consists of: My Community (chat with open-closed groups; available separately for parents as well); My Questions (forum and videos); My Story (own profile); My Dashboard (overview of personal posts, activities and relevant topics, based on My Story and activity on My Questions); and My Agenda (combination of tools to better manage available energy and goal setting, based on Social Participation And Navigation).

Discussion

Breinstraat.nl could be part of therapy, for example, enhances findability and active/optimal usage. The platform facilitates the implementation of (elements of) products such as Teenage Online Problem Solving or Acceptance and Commitment Therapy. Translation of Breinstraat.nl in other languages can be a next step.

212 Prevalence of Minor Traumatic Brain Injury in Early Childhood

Deborah Levine1; Sean Rose2; Junxin Shi2; Krista Wheeler2; Rachel Stanley2; Miriam Beauchamp3

1NewYork-Presbyterian/Weill Cornell Medicine, New York City, New York, United States; 2Nationwide Children's Hospital, Columbus, Ohio, United States; 3University of Montreal/Sainte Justine Hospital Research Center, Montreal, Quebec, Canada

Background

Mild traumatic brain injury (mTBI) or concussion accounts for millions of healthcare visits to emergency departments (EDs). Much of the current scientific literature focuses on the effects of these injuries in school-aged children and sports-related injuries. However, mTBIs in the early childhood age period (0-6 years) are common and increasing in prevalence. Injuries in this age group pose diagnostic challenges and can affect functioning in a range of domains but are poorly described. To better understand their occurrence, we describe the prevalence of mTBIs in early childhood from a national sample of ED visits.

Methods

The Nationwide Emergency Department Sample (NEDS) was queried for pediatric patients aged younger than 7 years with mTBI from 2016 to 2018. Patients were excluded if they were diagnosed with abuse or drowning, died in the ED or hospital, had an injury severity score of more than 15, or Current Procedural Terminology (CPT) codes for neurosurgical intervention, intubation, or blood product transfusion.

Results

National estimates included 1 069 453 patients. Most injured patients were 0 to 2 years old (64%) and male (58%). Seventy-two percent of children suffered head injury due to a fall. Most children were evaluated in areas populated by more than 1 million people (53%) and in non-children's hospitals (91%). More than half of patients utilized Medicaid (55%) or lived in a zip code with less than 50% median household income (59%). More than 83% were diagnosed with unspecified injury of head, with 75% of those receiving CPT codes of low to moderate complexity of medical decision-making. As age increased, the unspecified injury of head diagnosis was used less often in favor of a concussion diagnosis. Overall, 99% of patients were discharged from the ED. Computed tomographic scan of the head was performed in 20% of patients.

Conclusion

Early childhood mTBI is prevalent in the United States. Many of these children are infants or toddlers, injured due to falls, and are treated largely in non-children's hospitals. The most common diagnostic code associated with these injuries is unspecified injury of head. This information can guide future education and research in early childhood TBI.

214 MyBrainPacer App Use May Improve Symptoms Following an mTBI

Marquise Bonn1,2; Samantha Bloom1; Dalton Wolfe1,2; Laura Graham1-3

1Western University, London, Ontario, Canada; 2Lawson Health Research Institute, London, Ontario, Canada; 3Parkwood Institute, London, Ontario, Canada

Background

Managing daily activities and symptom exacerbation is difficult for many individuals following a mild traumatic brain injury (mTBI). Although many individuals with an mTBI seek care, wait-lists for care can be several months. A mobile application, MyBrainPacer, was created to improve healthcare access and help these individuals pace and plan their days and track their symptoms.

Objective(s)

The purpose of this study was to evaluate whether individuals with an mTBI improved their symptoms and increased their number of daily activities while using the MyBrainPacer app.

Methods

Individuals with an mTBI used MyBrainPacer for a minimum of 8 weeks. Participants completed the Rivermead Post-Concussion Symptom Questionnaire (RPQ) when registering for the app and again every 4 weeks. Participants also completed a General Symptom Questionnaire every 2 weeks, where they rated their average symptoms as much worse, somewhat worse, no difference, somewhat better, or much better. Participants were able to increase their number of daily activities as their symptoms improved. Visual inspection was used to identify trends according to baseline RPQ score and change in RPQ values from the first to last day of app use.

Results

Fifteen individuals (aged 50.9 ± 12.3 years; 13 females) used MyBrainPacer for 203.7 ± 94.1 days following an mTBI. On average, participants decreased their RPQ score by 8.4 ± 10.4 points between their first and last days of use. Change in daily point value and General Symptom Questionnaire responses varied, and no trends were observed according to baseline or change in RPQ score.

Conclusions

Individuals with an mTBI may reduce the number and severity of symptoms by using MyBrainPacer to pace and plan daily activities. However, individual responses are variable, regardless of baseline or change in symptoms. Larger studies are needed to confirm these preliminary trends.

216 The Hybrid Operative Suite With Intraoperative Biplane Rotational Angiography in Pediatric Cerebrovascular Neurosurgery: Utility and Lessons Learned

John Yue; Diana Chang; Michael Travis Caton; Alexander Haddad; Cecilia Dalle Ore; Thomas Wozny; Albert Wang; Daniel Tonetti; Kurtis Auguste; Peter Sun; Daniel Cooke; Steven Hetts; Adib Abla; Nalin Gupta; Jarod Roland

University of California San Francisco, San Francisco, California, United States

Introduction

The benefits of performing open and endovascular procedures in a hybrid neuroangiography surgical suite include confirmation of treatment results and reduction in the number of procedures, leading to improved efficiency of care. Combined procedural suites are infrequently used in pediatric facilities due to technical and logistical limitations. We report the safety, utility, and lessons learned from a single-institution experience using a hybrid suite equipped with biplane rotational digital subtraction angiography and pan-surgical capabilities.

Methods

We conducted a retrospective review of consecutive cases performed at our institution that utilized the hybrid neuroangiography surgical suite from February 2020 to August 2021. Demographics, surgical metrics, and imaging results were collected from the electronic medical record. Outcomes, interventions, and nuances for optimizing preoperative/intraoperative setup and postoperative care were presented.

Results

Eighteen procedures were performed in 17 patients (mean age 13.4 years; range, 6-19 years). Cases included 14 arteriovenous malformations (85.7% ruptured), 1 dural arteriovenous fistula, 1 mycotic aneurysm, and 1 hemangioblastoma. The average operative time was 416 minutes (range, 321-745 minutes). There were no intraoperative or postoperative complications. All patients were alive at most recent follow-up (range, 0.1-14.7 months). Five patients had anticipated postoperative deficits arising from their initial hemorrhage, and 12 returned to baseline neurological status. Specific and unique applications of the hybrid neuroangiography surgical suite are presented.

Discussion/Conclusion

The hybrid neuroangiography surgical suite is a safe option for pediatric cerebrovascular pathologies requiring combined surgical and endovascular intervention. Hybrid cases can be completed within the same anesthesia session and reduces the need for return to the operating room for resection or surveillance angiography. High-quality intraoperative angiography enables diagnostic confirmation under a single procedure, mitigating risk of morbidity and accelerating recovery. Effective multidisciplinary planning enables preoperative angiograms to be completed to inform the operative plan immediately prior to definitive resection.

217 Predictors of Extreme Hospital Length of Stay After Traumatic Brain Injury

John Yue; Nishanth Krishnan; Alexander Haddad; Anthony Digiorgio

University of California San Francisco, San Francisco, California, United States

Introduction

Hospital length of stay (HLOS) after traumatic brain injury (TBI) is an important metric of injury severity, resource utilization, and care quality. Risk factors for protracted HLOS after TBI are understudied and require further characterization.

Methods

Data for adult patients presenting to a US level 1 trauma/tertiary referral center diagnosed with acute TBI and discharged between August 1, 2019, and April 1, 2022, were extracted from the hospital electronic health record. Patients with extreme HLOS (XHLOS, >99th percentile of institutional TBI HLOS) were compared with TBI patients without XHLOS. Socioeconomic status (SES), clinical/injury factors, and discharge disposition were analyzed. Statistical significance was assessed at P < .05.

Results

In 1652 TBI patients, median HLOS was 3.0 days (interquartile range [IQR] = 2-8). The XHLOS threshold was 70 days or more (N = 18; range, 78-146 days). XHLOS was associated with younger age (50.4 vs 59.6 years; P = .042), injury severity (severe TBI: 55.6% vs 11.4%; P < .001), low SES (72.2% vs 31.4%; P < .001), and Medicaid insurance (77.8% vs 30.1%; P < .001). A greater proportion of XHLOS patients died in hospital (22.2% vs 8.1%) or were discharged to post-acute care facility (77.8% vs 16.3%; P < .001). No XHLOS patients were discharged to home. In XHLOS patients alive at discharge, medical stability was documented at median 39 days postinjury (IQR = 28-58; range, 24-72), and patients were hospitalized for an additional median 56 days before discharge (IQR = 26.5-78.5; range, 10-104).

Conclusions

TBI patients with XHLOS were more likely to have severe injuries, low SES, and Medicaid insurance. XHLOS is associated with requiring post-acute care placement and in-hospital mortality. XHLOS patients alive at discharge often demonstrated medical stability long before date of placement, underscoring the complex relationships between SES, insurance coverage, and outcome. These findings have important implications for quality improvement and resource utilization at acute care hospitals and await validation from multicenter retrospective studies and prospective trials.

218 Neuroinflammatory Biomarkers for Traumatic Brain Injury Diagnosis and Prognosis: Results From the TRACK-TBI Pilot Study

John Yue1; Firas Kobeissy2; Sonia Jain3; Ryan Phelps1; Zhihui Yang2; Hansen Deng4; Xiaoying Sun3; Miri Rabinowitz4; Ava Puccio4; Sabrina Taylor1; Frederick Korley6; Amy Markowitz1; David Okonkwo4; Ramon Diaz-Arrastia5; Geoffrey Manley1

1University of California San Francisco, San Francisco, California, United States; 2University of Florida, Gainesville, Florida, United States; 3University of California San Diego, San Diego, California, United States; 4University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States; 5University of Pennsylvania, Philadelphia, Pennsylvania, United States; 6University of Michigan, Ann Arbor, Michigan, United States

Background

The relationship between systemic inflammation and traumatic brain injury (TBI) is complex. We investigate associations between candidate inflammatory markers and clinical confirmation of TBI diagnosis and prognosis.

Methods

The prospective, multicenter Transforming Research and Clinical Knowledge in Traumatic Brain Injury Pilot (TRACK-TBI Pilot) study enrolled TBI patients triaged to head computed tomographic (CT) scan within 24 hours of injury. Healthy controls (HCs) from the community and orthopedic controls (OCs) who suffered systemic trauma without TBI were included. Plasma was extracted and 40 inflammatory markers with robust preclinical and clinical data were analyzed using the Meso Scale Discovery V-Plex Panel (Meso Scale Diagnostics, Rockville, Maryland); in addition, the alarmin high mobility group box 1 (HMGB-1) was run separately on the Shino-Test ELISA (Shino-Test Corporation, Japan). Median and interquartile range (IQR) were presented. The area under the receiver operating characteristic curve (AUC) was used to evaluate biomarker discriminatory ability for TBI diagnosis (TBI vs OC/HC), TBI severity (Glasgow Coma Scale [GCS] score 3-12 vs 13-15), radiographic presence of traumatic intracranial lesions (CT-positive [CT+] vs CT-negative [CT−]), and 3- and 6-month functional outcome using the Glasgow Outcome Scale-Extended (GOSE). Outcome was dichotomized to unfavorable (GOSE score 1-4; death or severe disability) versus favorable (GOSE 5-8; moderate disability or good recovery). AUC > 0.7 was considered acceptable. Biomarker levels are reported in pg/mL. Statistical significance was assessed at P < .05.

Results

The analytical sample included 168 TBI subjects, 28 OCs, and 18 HCs. Markers statistically associated with clinical diagnosis included IL-6, IL-10, IL-16, MCP-4, TARC, HMGB-1, SAA, and CRP. Markers that associated with TBI severity included IL-6, IL-10, IL-15, IL-16, TARC, HMGB-1, SAA, and CRP. Markers that associated with radiographic TBI included IL-6, IL-10, IL-15, IL-16, HMGB-1, SAA, and CRP.

Markers with acceptable discrimination for TBI versus OC included HMGB-1 (AUC = 0.840), IL-1b (0.792), IL-16 (0.781), c-fibronectin (0.773), IL-7 (0.736), TARC (0.726), PlGF (0.718), and VEGF-D (0.721). Markers with acceptable discrimination for TBI versus HC included IL-6 (AUC = 0.917), PlGF (0.880), IL-10 (0.868), HMGB-1 (0.866), IL-4 (0.818), c-fibronectin (0.806), IL-8 (0.758), IL-7 (0.758), IL-5 (0.748), TARC (0.745), and IL-16 (0.724). Markers with acceptable discrimination for radiographic injury on CT included SAA (AUC = 0.767), IL-6 (0.757), CRP (0.733), and IL-15 (0.724).

Markers with acceptable discrimination for 3-month favorable versus unfavorable outcome included IL-15 (AUC = 0.738) and IL-2 (AUC = 0.705). Markers with acceptable discrimination for 6-month outcome included IL-15 (AUC = 0.704) and SAA (0.704).

Conclusions

We identified a distinct profile of neuroinflammatory proteins detectable in systemic circulation within 24 hours of acute TBI, which may have importance in TBI diagnosis, severity differentiation, and prognosis. A validation study is ongoing. Future research on the integration of specific neuroinflammatory pathways and systems biology network will provide valuable insight to elucidate the evolution of injury from acute to subacute and chronic phases and yield potential targets for therapeutic intervention and/or blockade.

219 “MyGuide: Concussion-Teen Edition”—A New Customizable, Evidence-Based Self-management Website for Teens With Concussion

Jacqueline Purtzki1-3; Catherine Chan1,2; Gina Galway2; Louise Hazemi2,4; Katie Griffin2; Erin Sellar2; Katherine Wong1,2

1University of British Columbia, Vancouver, British Columbia, Canada; 2GF Strong Rehab Centre, Vancouver, British Columbia, Canada; 3VCH Research Institute, Vancouver, British Columbia, Canada; 4Vancouver School Board, Vancouver, British Columbia, Canada

Mild traumatic brain injuries (mTBIs), or concussions, are one of the most common injuries amongst adolescents, responsible for nearly 14 500 visits to the emergency department (ED) in British Columbia, a population of approximately 3 million, alone. The rate of ED visits is highest among those aged 0 to 24 years. It is widely known that ED visits only represent the “tip of the iceberg.”

Recovery is not universally easy or quick. An estimated 30% of adolescents will develop persistent postconcussion symptoms, defined as having symptoms lasting longer than 1 month, and about 11% to 30% (some studies state 40%) report symptoms at 3 months postinjury. Persisting symptoms result in negative outcomes, including decreased quality of life, family stress, and absenteeism from school, and substantial increases in healthcare utilization and costs.

Despite strong evidence that early active treatment results in faster recovery, timely access to evidence-based treatment remains unavailable for many youths. Lack of access to primary concussion care and financial, geographic, and sociodemographic disparities are the most common reasons, only worsened by the pandemic-related strain on healthcare resources. Currently, at GF Strong Rehabilitation Centre's Adolescent Complex Concussion Clinic (AC3), we are only able to treat approximately 100 adolescents with persistent and very complex concussion presentations per year. It is imperative to improve access to evidence-based, teen-appropriate, and individualized tools for recovery as an adjunct to primary care in the community.

To address the obstacles to accessibility and timeliness of evidence-based treatment, we developed the “MyGuide: Concussion-Teen Edition” website for adolescents aged 12 to 18 years. The purpose of the website is to provide teenagers with a customizable education and management tool that provides psychoeducation about concussion recovery and provides actionable tips and guidance on how to manage specific symptoms and develops a recovery plan tailored to each teen's priorities for returning to valued activities (eg, sports, school) as an adjunct to medical care. This website hopes to give patients, parents, coaches, and healthcare providers timely access to evidence-based information to prevent the progression of symptoms into a chronic state. This is essential to reduce the individual and societal burden of concussions.

220 Characterizing the Relationship Between Baseline PCL-5 Score and Length of Concussion Recovery in Military Service Academy Cadets and Midshipmen

Jennifer Brewington Dickerson1; Jonathon Jackson2; Susan Perkins1; Rachel Kenny1; Brenna McDonald1; Thomas McAllister1

1Indiana University, Indianapolis, Indiana, United States; 2United States Air Force Academy, El Paso County, Colorado Springs, Colorado, United States

Objectives

To analyze the relationship between PCL-5 scores (PTSD Checklist for DSM-5; indicative of distress from traumatic events) and subsequent concussion recovery in military service academy cadets and midshipmen. It was hypothesized that a higher PCL-5 score prior to injury may complicate trajectory of concussion recovery.

Methods

These data are from the Concussion Assessment, Research, and Education Consortium (CARE), funded by the US Department of Defense and the NCAA. CARE is a multisite study researching the immediate- and long-term effects of concussion. A detailed description of the CARE Consortium methods and procedures has been published1; data used here were collected from July 2018 to July 2021. The PCL-5, a widely used questionnaire for military personnel, is a 20-item measure assessing the severity of DSM-5 posttraumatic stress disorder (PTSD) symptoms in the preceding month.2 Items are rated from 0 (not at all) to 4 (extremely) and summed to calculate a total score. The PCL-5 was administered to participants at the CARE study entry (preinjury baseline). Spearman's rank correlation was computed to assess the relationship between PCL-5 score and length of return to activity (RTA) measured in days. Participant PCL-5 scores were also dichotomized into high and low groups using a median split.

Results

Of the 493 unique cadets and midshipmen who sustained a concussion during their participation in CARE, 147 did not have PCL-5 score at baseline; 3 additional participants did not have a recorded RTA date, and an estimate could not easily be made. This left 343 participants for analysis consisting of cadets and midshipmen aged 17 to 24 years, 42% female, who sustained a concussion in competition (18.5%), during practice/trainings (60.7%), or outside of their sport (20.8%). In this cohort, the median PCL-5 total score was 4 and the median RTA interval was 20 days. However, 6% of the participants had scores consistent with a diagnosis of probable PTSD. Furthermore, baseline PCL-5 score was positively correlated with RTA interval (r = 0.16, P = .003). Median RTA time was 23 days in the high PCL-5 group and 18 in the low PCL-5 group. Based on a Wilcoxon rank-sum test, the RTA distributions are significantly different between the low and high groups (z = −2.78, P = .005).

Conclusions

While as a group this cohort did not have elevated mean PCL-5 scores, the results do suggest a relationship between PCL-5 total score and RTA time. There was a significant but low Spearman correlation, which demonstrates that as PCL-5 total score goes up, time to RTA increases. When dichotomized by median PCL-5 scores, RTA is longer when PCL-5 score is higher. Further analysis will examine other factors related to RTA in order to assess the correlation more closely.3

221 An Interdisciplinary School Model to Promote Gait Improvements in People With Brain-Based Disorders

Diane Bienek1; Eileen Dougherty1; Shreya Korgaonkar1,2; Victor Pedro1; Tiffany Semm1; Katandria Johnson1; Priyanshi Domadia1; Nicolette Sorenson1; Jordyn Salm1

1International Institute for the Brain, New York City, New York, United States; 2Robotics and Rehabilitation (ROAR) Laboratory, Columbia University, New York, USA

Objective

People with moderate-to-severe brain-based disorders have limitations in learning, communication, and physical abilities that restrict their participation, including educational settings. Motor impairments significantly hamper school participation in this population and an interdisciplinary approach can be more beneficial for delivering physical therapy (PT) services. We present a data-driven interdisciplinary school model (iBRAIN) for children and adolescents with brain-based disorders for achieving motor goals based on annual Individualized Education Plans (IEPs), monitoring their health, improving their education, and enhancing their quality of school life.

Methods

The interdisciplinary model conceptualizes 2 main segment areas that encompass “Cognitive Skills, Communication & Social Development” and “Physical Development, Behavioral & Environmental Support.” Specialized related services (ie, clinicians) and educators (ie, teachers and teacher assistants) are grouped within each area and coordinated by the social work team. We propose an intensive schedule (eg, 3-5 weekly sessions during 60 minutes) in individual sessions (“pullouts”), in which paraprofessionals help students navigate their school life. Interdisciplinary collaborations between providers (“co-treatments”), and between providers and teachers (“push-ins”), are scheduled and planned a priori to work on education-related objectives. Weekly presentations (“Grand Rounds”) are held with the student's school team and other school professionals, family, and a medical school consultant. Across the 4 school quarters, Grand Rounds promote unbiased constructive feedback to decide whether the current PT approach is the best available strategy to address the students' IEP goal/s related to ambulation.

Results

The interdisciplinary model was examined with Pearson's product-moment correlation analysis. A 5-point Likert scale was used to determine performance progression on a daily basis. As representative data, performance in a gait-related goal in PT was averaged per week during the first and second quarters. A significant moderate positive association between averaged weekly performance and school quarters was found (r = 0.58, P = .003; 95% CI, 0.22-0.80). Further examination per quarter demonstrated that the improvement rate was higher during the second quarter (slope = 0.014 and R2 = 20%) than during the first quarter (slope = −0.003 and R2 = 2%). Therefore, the interdisciplinary model may be driving positive outcomes across time.

Conclusions

The present model and measurable improvements is in line with the US Department of Education's Individuals with Disabilities Education Act (IDEA). It provides interdisciplinary structure to successfully conceptualize and operationalize a school approach for people with moderate-to-severe brain-based disorders. The model embraces a formalized communication system among students and their relatives as well as their providers, social workers, and medical professionals who are not daily involved in the school-based care of the students. The model is organized to objectively monitor progression and data-driven strategies to address the IEP goals in this population. We believe our school model empowers students to develop their full potential in school through interdisciplinary teamwork.

222 Self-feeding Training Intervention Therapy for Canavan Disease

Priscilla Amponsah; Diane Bienek; Katandria Johnson; Rich Lyon; Victor Pedro; Tiffany Robertson; Claudia Rzucidlo

International Institute for the Brain, New York City, New York, United States

Objectives

It is well understood that children with Canavan disease (CD), which leads to spongiform degeneration of white brain matter, display severe impairment of psychomotor development.

We expect this case subject, who has participated in a novel gene replacement therapy, to demonstrate improvement in motor capabilities related to self-feeding activities. This research aims to demonstrate an increase in the subject's participation during self-feeding activities by bringing a loaded spoon to his mouth and making contact with his tongue.

Methods

We recorded the subject's progress during self-feeding practice at a frequency of approximately 5 times a week, for the duration of 30 to 60 minutes, utilizing moderate-maximum assistance through tactile/visual/verbal cueing. The timeline of observation began in the first quarter of 2022. The parameters used to quantify motor skills improvement included baseline standardized assessment from the field of speech-language pathology.

Results

Our preliminary results demonstrated improvement in the subject's motor skills. The subject increased in his arm movement accuracy, jaw extension, and tongue utilization while self-feeding. His voluntary participation in maneuvering his arm toward a spoon, along with lively vocalizations/facial expressions, was also of noted improvement. He presented an increase in the frequency of self-feeding, from 1/5 trials to 3/5 trials, demonstrating progress in this activity of daily living (ADL).

Conclusion

This study's outcomes is to demonstrate the possibility that the novel gene therapy utilized may be a helpful treatment for children with CD and offer hope in improving the child's abilities in performing ADL, which includes self-feeding.

223 Music Therapy to Support Speech-Language Improvements

Priscilla Amponsah; Diane Bienek; Katandria Johnson, Ricy Lyon; Jackie Murphy; Victor Pedro; Tiffany Robertson

International Institute for the Brain, New York City, New York, United States

Objective

Children with traumatic brain injury and brain-based disorders are impacted by severe cognitive, motor, sensory, and speech impairments. According to the National Apraxia Association, “apraxia of speech (AOS) is an impaired ability to perform speech movements.”

Current research in music therapy supports its use as an intervention for speech and language impairments. This longitudinal case study aims to explore music therapy as an effective intervention for improvement in breath support, rate of speech, and coordination of overall speech production for pediatric students with traumatic brain injury (TBI).

Methods

A single case study was designed with a TBI student diagnosed with apraxia. Music therapy interventions of auditory rhythmic cueing and metric cueing were utilized to provide cues for breath support, rate of speech, and coordination of overall speech production. Another technique used in this is therapeutic singing intervention, which is facilitated by a board-certified music therapist and consisted of precomposed or improvised music that is familiar or engaging for the student.

Results

Preliminary results show that music therapy is an effective intervention to utilize to provide cues for this case study's breath support, rate of speech, and coordination of overall speech production. Using neurologic music therapy technique, the subject is generalizing use of singing activities to address functional elements of speech production like breath support articulation and prosody.

Conclusions

The target goal is to increase participation and communication of students with TBI. It is hopeful that this novel study provides a framework for assessing student's ability to speak-sing phrases within the context of music therapy to increase functional communication during activities of daily living.

226 Exploring Caregiver and Participant Experiences of the Program for the Education and Enrichment of Relational Skills (PEERS)

Rose Gilmore1,2; Jenny Ziviani3; Sarah McIntyre4; Sarah Goodman1; Zephanie Tyack5; Leanne Sakzewski1

1Queensland Cerebral Palsy and Rehabilitation Research Centre, University of Queensland, Brisbane, Queensland, Australia; 2Queensland Paediatric Rehabilitation Service, Queensland Children's Hospital, Brisbane, Queensland, Australia; 3School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Queensland, Australia; 4Cerebral Palsy Alliance Research Institute, The University of Sydney, Sydney, New South Wales, Australia; 5Child Health Research Centre, The University of Queensland, Brisbane, Queensland, Australia

Objectives

This study explored the experience of adolescents with brain injury and their caregivers who participated in the Program for the Education and Enrichment of Relational Skills (PEERS) in Australia. Possible adaptations that might enhance the experience of participating in the intervention and potentially improve outcomes in social functioning for this population of adolescents were also explored.

Methods

In total, 27 adolescents and 31caregivers, who completed the PEERS intervention as part of a randomized controlled trial, contributed to focus groups at the end of the 14-week program. Semistructured interviews guided focus groups. An interpretive description methodology was used to understand participants' experiences in the program and suggestions for improvements.

Results

Findings highlighted what participants valued, challenges faced, how social abilities changed, and potential enhancements. Thematic analysis of data revealed 5 central themes. Expectations versus experience explored the variety of participant experiences and expectations. Learning new skills addressed the content and delivery of the intervention, highlighting skills and strategies participants gained. Connecting and belonging represented the value placed on the group experience. Growing in confidence reflected the changes in everyday social experiences and “where to from here?” provided many suggestions for adaptation to improve practice.

Conclusions

After taking part in the PEERS social skills group intervention, many adolescents with brain injury and their caregivers perceived improvement in their social participation and had suggestions for improving the group experience.

Author Index

-
A
Abla, Adib 216
Ace, Jessica 154
Adamakis, Manolis 136
Adlparvar, Fatemeh 66
Affleck, Willow 73
Ahmed, Laiba 98
Ahn, Sinyeob 66
Aldahondo, Nanette 156
Alexander, Aubree 75, 150
Al-Hakeem, Hiba 128, 161, 204
Alizadeh, Eshagh 6
Allonsius, Florian 71, 80, 81
Altonji, Kathryn 85
Amodio, Francesco 27
Amponsah, Priscilla 116, 222, 223
Andelic, Nada 55, 112, 122
Anderson, Gerard 53, 133
Anderson, Nicholas 126
Anderson, Sarah 180
Anderson, Vicki 3, 87, 126
Andersson, Stein 112
Arbogast, Kristy 166
Armknecht, Caroline H. 150
Armstrong, Erin 56
Ashton, Rebecca 51
Askew, Rebecca 120, 148
Aubuchon, Olivier 152
Auguste, Kurtis 216
Azouvi, Philippe 94
B
Baath, Sukhman 192
Babb, James 66
Babl, Franz 126
Bacon, Kellie 200
Ballatori, Alexander 60, 61, 173, 174
Barnett, Peter 126
Bartlett, Brittnie 197
Bashir, Mohammed 91
Bator, Bryan 185
Bayen, Eleonore 94, 95
Bayley, Mark 188
Beal, Deryk 97, 135, 147
Beaner, Ashlee 25
Beauchamp, Miriam 152, 163, 168, 195, 212
Bedell, Gary 115, 211
Bennett, Emily 21, 22, 30, 170
Beretta, Elena 132
Bergman, Kristian 123
Bergonzoni, Antonella 89, 90
Bernhardt, Julie 46
Beuachamp, Miriam 151
Bienek, Diane 116, 221, 222, 223
Birdsey, Nicola 36
Blakeborough, Louise 170
Blankenship, Chynah 172
Bloom, Samantha 214
Boissel, Anne 92
Boissonneault, Sophie 195
Bonn, Marquise 214
Borgen, Ida 49, 55
Boutin, Ariane 195
Brennan, James 32
Breslin, Grace 186
Brewington Dickerson, Jennifer 220
Brooks, Emma 50
Broos, Ana 211
Brown, Allen 9
Brown, Sean 203
Brunborg, Cathrine 112
Bull, Rachel 37, 38
Bushnik, Tamara 66, 83
Butler, Tracy 146
Byard, Katie 51
C
Cadden, Amy 124
Caldwell, Carolyn 191
Câmara-Costa, Hugo 94, 95,106, 143
Capizzi, Allison 56
Carey, Avril 124, 136
Caron-Brulotte, Erika-Pier 195
Carter, Greg 73
Cash, Nicole 104
Castro, Elizabeth 185
Caton, Michael Travis 216
Catone, Amanda 186
Catroppa, Cathy 3
Cermak, Carly 135
Chan, Catherine 219
Chan, Jeff 199, 201
Chang, Diana 216
Charbonneau, Doriane 157
Chen, Anna 66
Chen, Ben 46
Chen, Hsuan Wei 142, 177
Chen, Jen-Kai 62
Chevignard, Mathilde 92, 94, 95, 96, 106, 143, 163, 168
Chiaravalloti, Nancy 75, 150
Chizuk, Haley 19
Chowdhury, Arindam 146
Chun, Ian 13
Ciccia, Angela 57, 58, 59
Circelli, Nicole 186
Cirone, Domenica 207
Ciuffreda, Kenneth 166
Clark, David 91
Clarke, Cathriona 126
Clifton, Patrick 18
Colombo, Katia 127, 137
Connellan, Claire 124
Cooke, Daniel 216
Corti, Claudia 137
Costa, Silvana L. 150
Costanza, Kristen 150
Costello, Gemma 76, 170
Crampton, Adrienne 163
Crichton, Alison 126
Crook, Libby 57, 58, 59
Crowe, Louise 3
Cunningham, Amanda 186
D
Dahl, Hilde Margrete 70
Dalangin, Lizel 186
Dalle Ore, Cecilia 216
Dams-O'Connor, Kristen 146
Darragh, Amy 180
David, Heather 148
Davidson, Sue-Anne 131
Davies, Katie 32
Davies, Susan 34
Davis, Gavin 126
D'Cruz, Kate 87
De Guise, Elaine 74
De Wilde, Robin 125
Debert, Chantel 163, 168
Decock, Mathieu 125
Dehkharghani, Seena 66
Delisle, Marie-Gabrielle 195
Dellatolas, Georges 94, 95, 106
DeLuca, John 150, 154
DeMatteo, Carol 67
Denault, Audrey-Ann 184
Deng, Hansen 218
Dery, Julien 74
Diaz-Arrastia, Ramon 218
Dieffenbach, Sabrina 154
Digiorgio, Anthony 217
DiRienzo, Lucas 178, 207
Dismore, Harriet 35
Dobryakova, Ekaterina 141
Domadia, Priyanshi 221
Dougherty, Eileen 221
Drummond, Sean 32
Dubé, Marc-Olivier 43
Dungey, Kelly 46
Dunleavy, Michele 175
Dunne, Kevin 126
Dupont, Dominique 151, 152
Durand, Benoît 157
de Kloet, Arend 71, 80, 81, 211
de Oliveira, Claire 188
E
Eaton-Kent, Matthew 192
Egeland, Jens 70
Erkinjuntti, Nina 20, 144
Esterov, Dmitry 9
Eveilleau, Camille 96
F
Fait, Philippe 43
Falkenstrom, Julia 103
Farran, Lama 17
Fedeli, Claudia 127, 137
Fedonni, Daniele 166
Fehlings, Darcy 97
Fereydoonpour, Mehran 16
Ferriman, Lies 128
Ferryman, Safiya 186
Finn, Christina 52
Fleming, Talya 15
Fletcher, Alison 30
Forlani, Chiara 89, 90
Forslund, Marit 49, 55
Forsyth, Rob 209
Fournet, Nathalie 96
Frémont, Pierre 43
Frigerio, Susanna 127, 137
Fujiwara, Alyssa 13
G
Gagnon, Isabelle 163, 168
Gajdošík, Martin 66
Galbiati, Susanna 127, 137
Gallant, Caitlyn 27
Galway, Gina 219
Gan, Caron 128
Gan, Leslie 46
Garduño-Ortega, Olga 83
Gerhalter, Teresa 66
Gill, Irwin 124, 129, 131, 164
Gilmore, Rose 226
Gimarc, Kayli 196
Ginella, Andrea 198
Gioia, Gerard 38
Gioia, Gerry 37
Glang, Ann 38
Goldman, Matthew 99
Gomez, Douglas 38
Good, Dawn 26, 27, 28
Goodman, Sarah 226
Gormally, Conor 202
Gorman, Kate 56
Gosling, Sophie 50, 51
Gowda, Chitra 56
Gracey, Fergus 51
Grady, Matthew 166
Graham, Laura 214
Gray, Stephanie 84
Greenwald, Brian 85
Griffin, Katie 219
Grilli, Lisa 163, 168
Gupta, Nalin 216
H
Haarbauer-Krupa, Juliet 17, 37, 38
Haddad, Alexander 216, 217
Haddad, Alison 60, 61, 173, 174
Haider, Mohammad 19
Hakimjavadi, Ramtin 207
Hall, Alex 37, 38
Hämäläinen, Heikki 121
Harcourt, Peter 18
Harik, Lindsey 172
Harvey, Gregory 165
Harvie, Daniel 46
Hauger, Solveig 55, 122
Havnes, Ingrid Amalia 122
Hayakawa, Jennifer 200
Hayward, Chloe 170
Hazemi, Louise 219
Hearps, Stephen 126
Helseth, Eirik 112
Hendriks, Carla 211
Herrin, Ileana 172
Hetts, Steven 216
Heyming, Theodore 200
Hickling, Andrea 169, 204
Hicks, Kenisha 203
Hill, N. Jeremy 146
Himanen, Leena 20
Hine, Trevor 46
Hirvonen, Arno 144
Holmes, Lynette 194, 208
Holthe, Ingvil L. 49
Howard, Teresa 18
Hughes, Nathan 170
Huntington, Kayla 142, 177
Huston, Chloe 185
Hutchinson, Peter 91
Huynh, Lara-Kim 152
Huynh, Toan 84
I
Im, Brian 66
Inanoglu, Didem 134
Iosipchuk, Olesya 141
Isaksson, Nea 20
J
Jackson, Jonathon 220
Jackson, Stephanie 33
Jain, Aaiush 19
Jain, Shabnam 37, 38
Jain, Sonia 218
Jamison, Keith 146
Jassal, Yasmine 183
Jaywant, Abhishek 146
Jenkin, Taylor 87
Jenkins, Natalie 83
Jim, Jenny 76
Joannides, Alexis 91
Johnson, Katandria 116, 186, 221, 222, 223
Jones, Austin 45
Jones, Christa 185
Jones, Susan 46
Joshi, Nabin 166
Jou, Stacey 85
Jourdan, Claire 94
Junn, Cherry 196
K
Kaffl, Lindsay 186
Kapitein, Martine 211
Karami, Ghodrat 16
Kashanian, Koorosh 207
Katz-Leurer, Michal 163, 168
Kayser, Andrew 199, 201
Keetley, Rachel 44
Kelly, Gemma 209
Kelly, Glen 172
Kendall, Elizabeth 46
Kenny, Rachel 220
Kerwin, Thomas 203
Khaksari, Mohammad 6
Kildal Bragstad, Line 49, 79
Killi, Eli Marie 70, 79
Kim, Nayoung 146
Kirov, Ivan 66
Kits, Kätlin 158, 167
Kixmiller, Jeffrey 199, 201
Kleffelgård, Ingerid 49, 55
Kleven, Jeanette 122
Knight, Sarah 87
Kobeissy, Firas 218
Koelink, Eric 67
Kolk, Anneli 155, 158, 162, 167
Kööp, Christen 155, 158, 162, 167
Korgaonkar, Shreya 116, 221
Korley, Frederick 218
Koschei, Kate 179
Koskinen, Sanna 20
Krishnan, Nishanth 217
Kristoffersen, Ann-Elise 70
Kristoffersen, Mhairi 36
Kromme, Cedric 71
Kuceyeski, Amy 146
Kuchynski, Tammy 42
Kurki, Timo 121
Kurlander, Danielle 199, 201
L
Laberg Holthe, Ingvil 70, 79
Lægreid Hauger, Solveig 49
Laeng, Jennie 185
Lähdesmäki, Tuire 20, 144
Lam, Brendan 204, 206
Lambert, Maude 184
Lamontagne, Marie-Eve 74, 139, 157
Lane, Liz 175
Langer, Laura 188
Langevin, Pierre 43
Lara, Bryan 200
Larivière-Bastien, Danaë 151
Larkin, Elizabeth 172
Laukes, Cindi 73
Lauruschkus, Katarina 103
Lavezzi, Susanna 89, 90
Lawrence, David 188
Leahy, Sinead 129
Leddy, Jacqueline 75
Leddy, John 19
Ledwidge, Patrick 185
Leibovitch, Emily 13
Lengenfelder, Jeannie 75
Lequerica, Anthony 154
Lessard, Vincent 157
Levac, Danielle 97
Levine, Deborah 212
Levy, Charissa 188
Libera, Marilia 46
Lin, Lei 85
Ljungqvist, Linda 121
Loit, Triinu-Liis 158, 167
Løke, Daniel 112
Loudon, William 200
Lovio, Riikka 123
Løvstad, Marianne 49, 55, 70, 79, 112, 122
Lu, Juan 55
Lucke-Wold, Brandon 99, 100
Luczon, Rachel 28
Luke-Browning, Laura 176
Lundine, Jennifer 34, 57, 58, 59, 180
Lyon, Rich 116, 222
Lyon, Ricy 223
M
Macca, Marina 89, 90
Madelin, Guillaume 66
Magnusson, Helena 103
Makdissi, Michael 18, 32
Makovec Knight, Jennifer 18, 32
Mallory, Kylie 169
Malone, Richard 85
Manley, Geoffrey 218
Manning, Joseph C 44
Månum, Grethe 122
Marchetta, Claire 154
Marcrum, Sam 203
Margulies, Susan 166
Mariller, Aude 96
Markowitz, Amy 218
Marks, Michelle 33
Marsh, Chelsea Hannah 46
Marshall, Sara 204
Martinez, Jessica 179
Martlew, Natalie 210
Master, Christina 166
Maxwell, Eden 73
McAllister, Thomas 220
McCabe, Sarah 62, 147
Mccall, Dana 9
McDonald, Brenna 220
McDonald, Catherine 166
McFarland, Stephanie 165
McIntosh, Andrew 18
McIntyre, Sarah 226
McKay, Adam 32
McKinlay, Audrey 126
McLean, Heather 8
McLean, Jayse 16
McManus, Benjamin 203
McNerney, Orla 164
McPherson, Jacob 19
Medina Rivas, Lorena 108
Meesters, Jorit 71
Melicosta, Michelle 8
Menon, David 91
Metzger, Kristi 166
Meyer, Philippe 94, 95, 106
Millar, Josie 36
Mindrila, Diana 17
Mitchell, Katy 172
Mitra, Biswadev 18
Modat, Marc 132
Mofid, Behshad 6
Mohan, Stuti 77, 78
Molteni, Erika 127, 132, 137
Morgan, Angela 147
Morgan, Nicola 210
Morley, Emily 170
Muir, James 199, 201
Munce, Sarah 188
Murphy, Jackie 223
Murphy, James 165
Muscat, Christine 147
N
Nagele, Drew 57, 58
Neff, Erin 185
Newman, Mark 84
Ngo, Melissa 128
Nguyen, Jack 32
Nicholas, Emily 194, 208
Nicole, Mélodie 157
Norman, Rocio 54
Norton, Sarah 120
Norwood, Michael 46
Noseworthy, Michael 67
Nouwens, Femke 47
O
O'Connor, Claire 186
Okonkwo, David 218
Ø
Øra, Hege P. 49
P
Painter, David Ross 46
Palermo, Frank 205
Palusak, Cara 57
Pangalila, Robert 47
Paquin, Hugo 195
Pass, Alex 36
Pastore, Valentina 127, 137
Patel, Smit 26
Pearson, Rachel 200
Pedro, Victor 116, 221, 222, 223
Pek, Nicholas 75
Peralta, Rosemary 66
Perera, Niranjala 165
Perkins, Susan 220
Petranovich, Christine 183
Petrosyan, Hayk 85
Peverill, Tess 32
Phelps, Ryan 218
Piegza, Monique 11
Pierce, Sarah 180
Pierre, Kevin 100
Pineau-Chardon, Emmanuelle 96
Pinto, Shanti 84
Piquer, Olivier 157
Ploetz, Danielle 191
Podolak, Olivia 166
Ponsford, Jennie 32, 112
Pool, Dayna 131
Poulin, Valérie 157
Pounch, Jillian 129, 164
Provvidenza, Christine 161
Ptito, Alain 62
Puccio, Ava 218
Purtzki, Jacqueline 19, 219
R
Rabinowitz, Miri 218
Rached-d'Astous, Soha 195
Radford, Kathryn 44
Ramirez, Elizabeth 161
Ratcliffe, Jonathan 37, 38
Ratnapalan, Savithiri 165
Raukola-Lindblom, Marjaana 121
Raymond, Émilie 157
Reed, Nick 135, 169
Reif, Angela 198
Reindeau, Arielle 25
Reurings, Bram 211
Reyes, Jonathan 32