Indiana University-Purdue University Indianapolis (IUPUI) / Between 3.2 and 5.3 million U.S. civilians live with traumatic brain injury (TBI)-related disabilities. Although the post-acute phase of TBI has been recognized as both a discrete disease process and risk factor for chronic conditions, TBI is not recognized as a chronic disease. TBI epidemiology draws upon untimely, incomplete, cross-sectional, administrative datasets. The adoption of electronic health records (EHR) may supplement traditional datasets for public health surveillance and research. Methods Indiana constructed a state-wide clinical TBI registry from longitudinal (2004-2018) EHRs. This dissertation includes three distinct studies to enhance, evaluate, and apply the registry: 1) development and evaluation of a natural language processing algorithm for identification of TBI severity within free-text notes; 2) evaluation and comparison of the performance of the ICD-9-CM and ICD-10-CM surveillance definitions; and 3) estimating the effect of mild TBI (mTBI) on the risk of post-acute chronic conditions compared to individuals without mTBI. Results Automated extraction of Glasgow Coma Scale from clinical notes was feasible and demonstrated balanced recall and precision (F-scores) for classification of mild (99.8%), moderate (100%), and severe (99.9%) TBI. We observed poor sensitivity for ICD-10-CM TBI surveillance compared to ICD-9-CM (0.212 and 0.601, respectively), resulting in potentially 5-fold underreporting. ICD-10-CM was not statistically equivalent to ICD-9-CM for sensitivity (𝑑𝑑𝑑𝑑̂=0.389, 95% CI [0.388,0.405]) or positive predictive value (𝑑𝑑𝑑𝑑̂=-0.353, 95% CI [-0.362,-0.344]). Compared to a matched cohort, individuals with mTBI were more likely to be diagnosed with mental health, substance use, neurological, cardiovascular, and endocrine conditions. Conclusion ICD-9-CM and ICD-10-CM surveillance definitions were not equivalent, and the transition resulted in a underreporting incidence for mTBI. This has direct implications on existing and future TBI registries and the Report to Congress on Traumatic Brain Injury in the United States. The supplementation of state-based trauma registries with structured and unstructured EHR data is effective for studying TBI outcomes. Our findings support the classification of TBI as a chronic disease by funding bodies, which may improve public funding to replace legacy systems to improve standardization, timeliness, and completeness of the epidemiology and post-acute outcomes of TBI.

The aim of this research was to produce a reliable finite element model of a helmet, that could be used to simulate approval tests as well as impacts to investigate the safety offered. A 2D and 3D mesh was generated from the CAD file of an Easton Synergy 380 with HyperWorks, and then checked referring to standard parameter values. A few specimens cut from the liner were tested with the Instron Electropuls E3000 (Instron, High Wycombe, Great Britain) machine to determine Young’s modulus, Poisson’s ratio and the density of the EPP. The numerical model was characterised with appropriate materials with Ls-PrePost, such as ABS for the shell, EPP for the liner and steel for the impact anvil. The foam was implemented both with the *063_CRUSHABLE_FOAM and the *126_MODIFIED_HONEYCOMB card, in two different configurations. The helmet model was coupled with a finite element model of a HIII head form and three impact scenarios were set up. Backward, lateral and pitched impact were simulated and results were compared with those obtained from the experimental tests carried on at the MIPS. The two configurations were tested in all the three scenarios. The correlation between numerical and experimental results was evaluated by analysing the linear and rotational acceleration, and the rotational velocity, recorded by the accelerometer positioned inside the HIII headform. The parameters used were the Pearson correlation coefficient, the peak linear acceleration score, the shape of the curves, the time occurrence of peaks and the percentage of the difference between them. The first configuration showed good correlation scores (>85%) for the backward and lateral impact, for the rotational velocity and acceleration, while lower values were recorded for the pitched impact simulation. Lower values (70.88% and 77.76%) were obtained for the peak linear acceleration score, which stress the need for modifications of the contact definition in Ls-PrePost or a more detailed material testing. Worse results were recorded for the second configuration, but the smaller computational time required suggests that more attempts should be done in this direction.

Persons with traumatic brain injuries (TBI) who have engaged in problematic or illegal sexual behavior present with complex assessment and intervention needs yet remain understudied within the empirical literature. In the current exploratory analysis, important differences in adaptive and clinical functioning, adverse childhood experiences, and criminal offense history are examined in 25 persons with previous brain injury, 118 persons with intellectual disability but no known TBI, and 103 persons with no history of brain injury or intellectual disability, all of whom have engaged in problematic sexual behavior and who were residing in secure forensic inpatient care. Group differences were examined using comparisons of means and chi-squares. Results highlight important differences in education and employment experiences, diagnostic presentation, exposure to childhood maltreatment, and justice system involvement and characteristics of their sexual offense victims. Associations with prior literature and future research directions are discussed.

Veterans of Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn are presenting for treatment with high rates of combat-related posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI), spurring a need for clinical research on optimal treatment strategies. While exposure therapy has long been supported as an efficacious treatment for combat-related PTSD, some clinicians are hesitant to utilize this treatment for veterans with TBI history due to presumed cognitive deficits that may preclude successful engagement. The purpose of this study was to compare exposure therapy process variables in veterans with PTSD only and veterans with PTSD+TBI. Results suggest that individuals with PTSD+TBI engage successfully in exposure therapy, and do so no differently than individuals with PTSD only. Additional analyses indicated that regardless of TBI status, more severe PTSD was related to longer sessions, more sessions, and slower extinction rate during imaginal exposure. Finally, in a subset of participants, self-report of executive dysfunction did not impact exposure therapy process variables. Overall, findings indicate that exposure therapy should be the first-line treatment for combat-related PTSD regardless of presence of TBI history.

Att drabbas av traumatisk hjärnskada (Traumatic Brain Injury; TBI) innebär att hjärnan utsättas för ett yttre våld som kan orsaka kortvariga samt långvariga funktionsnedsättningar. Det kan medföra livsförsändningar både för den drabbade och för de närstående. Syftet med denna litteraturstudie var att beskriva upplevelsen av att vara närstående till en person med traumatisk hjärnskada. Studien utfördes i form av en litteraturstudie med kvalitativ innehållsanalys som analyserades med manifest ansats där människors upplevelse och erfarenheter var i fokus. I studien inkluderades 13 vetenskapliga artiklar. Under analysprocessen av valda artiklar identifierades sex slutkategorier; Ta ansvar och ge upp sina egna behov, Få förändrade och nya roller, Brist på information från hälso-och sjukvården, Vara psykiskt belastad, känsla av ensamhet och isolering; Förlust av relationer. Resultatet visade att närstående upplevde olika svårigheter relaterade till att leva med en person med traumatisk hjärnskada. Att vara närstående till en person med traumatisk hjärnskada kan skapa ekonomiska, sociala, psykiska, känslomässiga och sexuella konsekvenser vilket medför stora förändringar i sociala roller och relationer. Sjuksköterskor behöver kunskap om hur det är att vara närstående till personer med traumatisk hjärnskada samt ha en förståelse för deras upplevelse för att kunna bemöta dem på ett adekvat sätt. Sjuksköterskans kunskap och förståelse kan förbättra närståendes upplevelse av sjukvården samt att de får stöd i sin situation.

Within the past few decades brain injury, or traumatic brain injury (TBI), has gained widespread attention. Early focus was on more severe forms of TBI; severity typically measured using the Glasgow Coma Scale. In more recent years, however, mild traumatic brain injury (mTBI), most notably concussions, has gained increasing interest due to the high frequency of concussions suffered in athletes of all levels and, recently, in military personnel due to blast injuries. Studies being performed have focused not only on ways to help minimize the incidence of concussion as well as treating concussive symptoms, but also on detecting concussions. Many concussions go unreported due to inadequate knowledge of concussive symptoms amongst the general population. Because many concussions go unnoticed and hence unreported the individual who has sustained a concussion is at risk for a more serious injury in the future. One such injury is Second Impact Syndrome (SIS). Second Impact Syndrome is essentially a synergistic event where the sum of two seemingly mild concussions combine to create an event that is potentially fatal. The findings during the autopsy are that there is insignificant damage to the brain to cause death. The damage that occurs, however, is on a molecular level causing a strain on the metabolic processes of the brain called dysautoregulation. Without an understanding of the changes that have occurred on a molecular level in SIS the assignment of cause and manner of death is difficult for the medical examiner. Currently, in order to diagnose SIS, a thorough scene investigation, along with the documentation of a previous head injury is needed. Without a full understanding of SIS and the pathophysiology changes that take place a medical examiner (ME) could misclassify the cause and manner of death in a death due to SIS. In the future, eliminating the prerequisite of identification and documentation of previous head injuries in order to diagnose SIS is needed. This paper evaluates the literature on the current knowledge of TBI and concussions in an attempt to create a protocol on how a medical examiner should approach a case where autopsy findings are unremarkable.

Clinical Researchers recently identified NFL players and US military veterans as high-risk populations for sustaining repetitive Traumatic Brain Injury (TBI) and developing the neurodegenerative disease Chronic Traumatic Encephalopathy (CTE). American culture celebrates military veterans as national heroes, and NFL players as popular athletes and social icons. Both subcultures are constructed around hyper-masculine ideals embedded in tenants of violence and aggression, suffer repeated TBIs due to this nature, and are ultimately at high-risk for developing CTE. The TBI/CTE phenomenon also affects family members who assume care-taking responsibilities for these first two populations as their loved one’s symptoms persist. The purpose of this research is to understand the TBI/CTE experiences of NFL players, military veterans, and their caretakers, and how all three populations intersect with mediatization and the social and medical legitimation of TBI/CTE in America. Using narratives from all three populations, I explore how power dynamics within the NFL and US military have intersected with modern media outlets and functioned to socio-medically legitimize a sick role for those who suffer from persistent symptoms of TBI and CTE.

Traumatic brain injury (TBI) contributes to global mortality and disability more than any other traumatic injury. Individuals who sustained a TBI undergo profound changes in their cognitive, physical, and emotional functions. Noticeable behavioral changes include irritability, aggression, low self-awareness, impulsivity, rumination, and more. These contribute to the individual's inability to control emotions and thus participate in interactions and activities, naturally influencing the person, their environment, and the community. While traditional therapy approaches are beneficial for some of the mentioned challenges, extensive evidence shows that emotional regulation is not effectively addressed, often resulting in behavioral outcomes in the therapeutic environment alone. Mindfulness interventions focus on the present moment's thoughts, sensations, and surroundings with an open and curious mindset, helping participants cope with stressors that often lead to anxiety and problematic behavioral patterns. Nevertheless, the standard Mindfulness does not accommodate the TBI-related challenges. Cultivating Awareness by Living Mindfully (CALM), is a Mindfulness-based group intervention for adults who sustained a TBI. It aims to increase self-awareness and improve emotional regulation by practicing mindfulness techniques and implementing them in everyday activities and interactions. This 12-week program is low-cost and easily applicable to a variety of practice and community settings. The program incorporates principles from the latest evidence-based therapy approaches and is designed specifically to accommodate TBI-related challenges. The theoretical foundations consist of complementing knowledge bases including Mindfulness, the occupational therapy framework - the multi-context approach, and brain-based learning, which are principles from the latest research on optimizing learning for this population. This combination of frameworks aims to makes Mindfulness and its many associated health benefits accessible for individuals post-TBI. This doctoral paper includes a plan for program evaluation, funding, and dissemination

Brain injury has become the signature wound of Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF), based on estimates that 10% of all returning warriors may have sustained a brain injury secondary to blast exposures. Traumatic brain injury (TBI) affects the lives of survivors as well as their loved ones, and the consequences associated with TBI inform well-being for all involved. This research uses grounded theory to understand contributing factors of female spousal well-being, specifically the female partners of servicemen who have sustained mild to moderate traumatic brain injury (mMTBI) during combat in OIF/OEF. Through the use of sequential interviews and transcript analysis, the Combat Related Traumatic Brain Injury (CoRTs) Model of Spousal Well-Being emerged illustrating the dynamic relationships among supports, role engagement, the process of redefining self, perceptions of personal empowerment and subjective wellbeing. Four key conclusions were identified from these findings: a) mMTBI affects the life of the surviving service member as well as the life of his partner, b) the myriad consequences of combat-related mMTBI on the female spouse prompted these women to engage in a journey of redefining self, c) communities of influence became the centerpiece from which participants could move forward with their lives or remain in their current state, and d) successful engagement in roles of choice provided study participants experiences from which to establish their new self, fostered perceptions of empowerment, and informed well-being. The CoRTs Model of Well-Being and conclusions provide a framework for future programming designed to target the needs of veterans and family members whose lives have been disrupted by brain injury sustained in combat. / Ph. D.

The Aim The aim of this study was to examine the effects of Animal Assisted Therapies with Farm Animals (AATF) with domesticated ducks on depression, anxiety, and self-efficacy in patients with traumatic brain injury (TBI) . Furthermore, the following hypothesis was tested: Engaging in AATF with domesticated ducks will be associated with decrease in depression, anxiety, and an increase in self-efficacy. Methods The study examined the effects of AATF on anxiety and depression among patients with TBI. Time series quasi-experimental design structure was utilized. At the beginning of the study participants received Hospital Anxiety and Depression Survey (HADS) and General Self Efficacy (GSE) questionnaires to evaluate the depression, anxiety, and self-efficacy. After that AAFT intervention started. AAFT intervention included two one-hour sessions interacting with ducks every week for 12 weeks. At the end of 12-week period participants received the same questioners. This was repeated in four weeks after the intervention ended to evaluate the residual effects of the intervention on anxiety and depression. Results General Linear Model was employed to examine changes in anxiety, depression, and self-efficacy. Participants presented with anxiety level decrease when means of pre and post intervention anxiety levels were compared. We discovered that these differences were significant based on an alpha value of .05, p = .009. There were no statistically significant differences between anxiety levels immediately post intervention and in four weeks the intervention was complete. There were no statistically significant differences discovered between depression levels pre, post, and retest. Also, there were no statistically significant differences discovered between self-efficacy levels pre, post, and retest. Conclusions Our study supported the part of hypothesis regarding an inverse association between time spent working with ducks and anxiety. Mastery of skills, vicarious experiences, and verbal persuasion may be the factors that contribute to the beneficial outcomes of the interactions between persons with TBI and domesticated ducks.