Research into traumatic brain injury (TBI) mechanisms is essential for the development of methods to prevent its occurrence. One of the most common ways to incur a TBI is from falls, especially for the young and very old. The purpose of this thesis was to investigate how the acceleration loading curves influenced the occurrence of different types of TBI, namely: epidural hematoma, subdural hematoma, subarachnoid hemorrhage, and contusion. This investigation was conducted in three parts. The first study conducted reconstructions of 20 TBI cases with varying outcomes using MADYMO, Hybrid III, and finite element methodologies. This study provided a dataset of threshold values for each of the TBI injuries measured in parameters of strain and stress. The results of this study indicated that using a combined reconstructive approach produces results which are in keeping with the literature for TBI. The second study examined how the characteristics of the loading curves which were produced from each reconstruction influenced the outcome using a principal components analysis. It was found that the duration of the event accounted for much of the variance in the results, followed with the acceleration components. Different curve characteristics also accounted for differing amounts of variance in each of the lesion types. Study 3 examined how the dynamic response of the impact influenced where in the brain a subdural hematoma (SDH) could occur. It was found that the largest magnitudes of acceleration produced SDH in the parietal lobe, and the lowest in the occipital lobe. Overall this thesis examined the mechanism of injury for TBI using a large dataset with methodologies which complement each other’s limitations. As a result in depth information of the nature of TBI was attained and information provided which may be used to improve future protection and standard development.

Traumatic brain injury (TBI) effects a large number of individuals, both civilians and military personnel, every year. The neuroinflammatory response mounted in the brain following a head injury continues long after the effects of initial subside. While it was initially thought to only occur in moderate or severe TBI, the deleterious effects of this cascade have recently been identified in patients with mild TBI (mTBI). Hypopituitarism is an often underreported condition and can result from TBI of all severity. The long-term sequelae of TBI can manifest in or exacerbate many other comorbidities of brain injury, such as neuroendocrine dysfunction or mental health conditions. Both TBI and hypopituitarism can present with symptoms similar to some psychiatric disorders, or exacerbation comorbid conditions. Veteran patients presenting to their primary care providers with symptoms of irritability, depression, anxiety, or cognitive and behavioral changes may meet criteria to receive diagnoses of psychiatric illnesses prevalent in the military population, while not being evaluated for pituitary dysfunction, and thus receive inadequate treatment. The proposed study aims to identify the prevalence of patients that are receiving psychiatric treatment that have both a history of mTBI and reduced levels of pituitary hormones on serum assays. By identifying a significant portion of this population, future studies can assess the impact that hormonal replacement has on success of psychotherapy, resolution of symptoms, and impact on functional status, among other factors.

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This quantitative research is on the efficacy of Minnesota Statute 144.574 enacted in 2005 in response to the growing awareness of behavior leading to inflicted Traumatic Brain Injuries (iTBI) in infants and children. The model for this research is grounded in the Theory of Reasoned Action wherein the education of new parents which graphically explains the physiologic changes to the structural architecture of the brain post-trauma, paired with their signature on a social contract (SC), demonstrated a reduction in incidence. Because the enacted statute does not include the signing of a SC, nor does it require face-to-face education as in the model, Statute 144.574 cannot claim to be completely grounded in medical science. The result is that neither legislators nor the medical and public health community know whether the statute is effective in lowering incidence. This research was designed to explore the difference in the incidence pre-and post-enactment, in rural vs. urban communities, the proportion of incidence and ethnicity, and an ordinal shift in the distribution of severity. All births in Minnesota from 1998 through 2017 were included. Cases defined using International Classification of Disease were extracted from secondary data from the brain and spinal cord injury, hospital discharge, and vital statistics databases. A Z-test was employed to compare the incidence in a control cohort of infants and children born prior to enactment to the incidence of same in an interventional cohort born post-enactment. Results suggest the statute has not resulted in lowering incidence, have uncovered an unanticipated statistically significant increase in rural vs. urban incidence, yet point to a trend in favor of less severe iTBI. These results represent a positive social change which is grounded in the society's imperative and social justice of protecting children by informing public health officials, caregivers, and legislators of the need for meaningful reform and strengthening of programs leading to lowering the incidence of iTBI in children in Minnesota.

Music therapists have utilized technology in their clinical work for decades. Yet music therapy delivered in a telehealth model – telemusic therapy – has rarely been described in the literature until recently. This study stems from telemusic therapy services the researcher-interventionist was contracted to provide to adult acquired brain injury (ABI) survivors. The existing literature has primarily reported on synchronous telemusic therapy conducted via internet-based videoconference platforms with individual clients or groups who were colocated but not face-to-face with the clinician. Technological issues were cited as limitations. Only one article described small group telemusic therapy where participants were each located at their individual homes; no literature was found for large groups of non-colocated participants. Further, the telemusic therapy literature very rarely reports empirical data. This thesis presents the results of a pilot study exploring the feasibility and effectiveness of telemusic therapy on well-being for adult brain injury survivors who participate independently from their homes. This retrospective study utilized a quasi-experimental, pre/post-session repeated measures design to examine data from a 20-session, 10-week, group telemusic therapy program (N = 15). Clinician-developed pre/post measures of well-being were administered each session. A Qualtrics Likert scale survey exploring audiovisual quality, emotional support, the therapeutic relationship, and social-emotional connection between participants was issued during the 5th and 10th weeks. Results: Mean and median difference of pre/post measures were significant for increasing well-being at α = 0.5. Frequency distributions of the survey ratings of more than or very much adequate for quality of audio and video: 78.6% – 85.7%; ratings of more than or very much adequate for emotional support, formation of a therapeutic relationship and creating connections with other participants, respectively: 85.7%, 78.6%, 92.9 %. The results support the feasibility and effectiveness of group telemusic therapy for increasing well-being in adult ABI survivors who attend from their individual homes. Study limitations include small N, low return rate for surveys, and unvalidated measures.It is noteworthy that in each session, the music therapy group successfully engaged in real-time active music making with all members playing and all microphones on. No audio delay was detected. This phenomenon has been described in the literature as improbable. The cause of such low latency is unknown. These findings demonstrate that participants using personal computers or laptops and residential broadband Internet experience the audio and visual components of synchronous music therapy as more than adequate. A real-time telehealth model is a viable means for providing group music therapy. / Music Therapy

Purpose: Interdisciplinary research in epidemiology, neurology, neuroscience, and sports medicine commonly highlight the dangerous short- and long-term sequelae of sport-related concussions (SRC). Despite advancements in clinical evaluation and recognition, many SRCs are not properly diagnosed and managed, leaving many athletes in danger of acute and chronic neurological deficits. Epidemiological studies suggest the prevalence of chronic traumatic encephalopathy (CTE) is three times, and Alzheimer's disease is four times greater in former athletes with a history of SRC than non-athletes. The underlying mechanisms linking SRC and contact-sport participation to neurodegeneration are not fully understood. Herein, I hypothesized that transient insufficiency of the lymphatic and glymphatic clearance systems in the central nervous system (CNS) could play a crucial role in the SRC-mediated neurological conditions. Therefore, this study aimed to examine the differences in plasma levels of extracellular vesicles (EV) that are associated with the lymphatic and glymphatic clearance systems of the CNS among athletes following sport-related head impacts. Participants: Plasma EV concentrations were analyzed in collegiate athletes (controls n=29, SRC n=19) with and without SRC. In a parallel study, fourteen college-aged soccer players participated in a laboratory-based, repetitive subconcussion paradigm. All participants provided written informed consent, and the study was approved by institutional review board at Temple University. Methods: We evaluated EVs containing markers associated with the CNS lymphatic and glymphatic systems, including lymphatic vessel endothelial hyaluronan receptor 1 (LYVE1), astrocyte-specific glial fibrillary acidic protein (GFAP), aquaporin 4 (AQP4), and the platelet and endothelial cell adhesion molecule 1(PECAM-1 or CD31). Tetraspanin-28 (CD81) was used as an EV-specific marker. Blood samples from athlete controls were collected once during preseason baseline assessments. Samples from athletes with SRC were collected within 72 hours of injury. Whole blood was double-centrifuged to obtain platelet-poor plasma, snap-frozen in liquid nitrogen, and stored at -80°C until analyzed. Quantification of plasma EVs was performed using spectral flow cytometry. Mann-Whitney U tests were used for group comparisons of single and double-positive EV concentrations, and receiver-operating characteristic curve (ROC) and area under the curve (AUC) analyses assessed diagnostic efficacy. Within-group changes in plasma EVs following repetitive, subconcussive head impacts were assessed with Friedman's test using Dunn's correction for multiple comparisons. Results: Among athletes with SRC, plasma concentrations of LYVE1+EVs and CD31+EVs were significantly elevated within 72 hours of injury compared to controls (LYVE1+EVs, p < 0.0001; CD31+EVs, p = 0.005). ROC analysis revealed plasma concentrations of LYVE1+EVs demonstrated significant diagnostic accuracy to differentiate athletes with SRC from athlete controls (AUC: 0.971, 95% C.I. = 0.933-1.000, p < 0.0001). Notably, concentrations of LYVE1+/CD81+ double-positive EVs, CD31+/CD81+ double-positive EVs, and GFAP+/CD81+ double-positive EVs were significantly higher among athletes with SRC within 72 hours of injury compared to control athletes (p < 0.0001; p = 0.0002; p < 0.0001, respectively). Plasma AQP4+/GFAP+ double-positive EVs and AQP4+/CD81+ double-positive EVs were not. However, plasma concentrations of GFAP+/CD81+ double-positive EVs and AQP4+/GFAP+ double-positive EVs were significantly elevated after repetitive, subconcussive head impacts (p < 0.0001 and p = 0.004, respectively). Conclusion: Plasma concentrations of double-positive EVs, including LYVE1+/CD81+EVs, CD31+/CD81+EVs, and GFAP+/CD81+EVs, may be promising biomarkers for acute SRC. EVs associated with the glymphatic system, GFAP+/CD81+EVs and AQP4+/GFAP+EVs, were significantly elevated after repetitive subconcussive head impacts. The differences observed in EV responses to SRC and subconcussion may provide novel mechanistic insights about sport-associated neurodegeneration for current and future athletes. / Kinesiology

The purpose of this thesis is to explore the changes to family dynamics that result from invisible symptoms of acquired brain injury The perspective put forth is that of individuals living with invisible symptoms of acquired brain injury. This study is based on a thematic analysis of the findings from nine semi-structured interviews with individuals (aged 24-64 yrs.; 6 men, 3 women) who have been formally diagnosed with an acquired brain injury. The data is interpreted and discussed using a critical framework, specifically, Critical Disability Theory. The findings from this analysis illustrate how invisible symptoms such as cognitive impairments, memory loss, mood changes etc., of acquired brain injury affect family dynamics in relation to emotional roles, domestic roles, financial roles, and perception and treatment of the affected individual. These changes were either exacerbated or minimized by the assumptions, misconceptions and knowledge level of the individual’s family in relation to understanding brain injury and the ways in which disability can manifest. Also important to family relations are the perceptions of participants that they must prove that they do have a disability; the roles healthcare professionals play in the validation of the injuries, both to the individual and the family; and how powerfully dominant constructions of disability – and invisible acquired brain injury in particular – are ingrained in social discourse and impact upon family dynamics for people living with invisible acquired brain injury. Lastly, an important part of this research is a compilation of recommendations put forth by the participants for healthcare professionals to keep in mind when working with individuals who either are suspected of having or have an acquired brain injury. / Thesis / Master of Social Work (MSW)

OBJECTIVE: Gunshot wounds to the head (GSWH) are devastating injuries with a grim prognosis. Several prognostic scores have been created to estimate mortality and functional outcome, including the so-called Baylor score, an uncomplicated scoring method based on bullet trajectory, patient age, and neurological status on admission. This study aimed to validate the Baylor score within a temporally, institutionally, and geographically distinct patient population. METHODS: Data were obtained from the trauma registry at a level I trauma center in the southeastern US. Patients with a GSWH in which dural penetration occurred were identified from data collected between January 1, 2009, and June 30, 2019. Patient demographics, medical history, bullet trajectory, intent of GSWH (e.g., suicide), admission vital signs, Glasgow Coma Scale score, pupillary response, laboratory studies, and imaging reports were collected. The Baylor score was calculated directly by using its clinical components. The ability of the Baylor score to predict mortality and good functional outcome (Glasgow Outcome Scale score 4 or 5) was assessed using the receiver operating characteristic curve and the area under the curve (AUC) as a measure of performance. RESULTS: A total of 297 patients met inclusion criteria (mean age 38.0 [SD 15.7] years, 73.4% White, 85.2% male). A total of 205 (69.0%) patients died, whereas 69 (23.2%) patients had good functional outcome. Overall, the Baylor score showed excellent discrimination of mortality (AUC = 0.88) and good functional outcome (AUC = 0.90). Baylor scores of 3-5 underestimated mortality. Baylor scores of 0, 1, and 2 underestimated good functional outcome. CONCLUSIONS: The Baylor score is an accurate and easy-to-use prognostic scoring tool that demonstrated relatively stable performance in a distinct cohort between 2009 and 2019. In the current era of trauma management, providers may continue to use the score at the point of admission to guide family counseling and to direct investment of healthcare resources.

Youth football players ages 8-12 may incur hundreds of repeated head impacts (RHI) each season. Evidence suggests concussive brain injury during childhood may disrupt normal developmental processes resulting in long-term impairments. However, little research has investigated the long-term effects of incurring RHI during critical periods of neurodevelopment. Rapid myelination and cerebral blood flow rates, peaks in regional cortical thickness and volumes of specific structures, refinement of regional connectivity, and other neurodevelopmental changes occurring in the brain from ages 10-12 could create a window of vulnerability to RHI. The objective of this research was to determine the relationship between exposure to RHI prior to age 12, during a critical period of neurodevelopment, and later-life brain structure and function. Former National Football League (NFL) players ages 40-65 were divided into two groups based on their age of first exposure (AFE) to RHI through tackle football: AFE <12 and AFE ≥12. In the first study, we observed significantly lower scores on objective tests of executive functioning, memory, and estimated verbal IQ in those who began playing football prior to age 12 compared to those who began playing at age 12 or older. Next, we used diffusion tensor imaging (DTI) to examine the structural integrity of the corpus callosum (CC) and observed that the AFE <12 group had significantly lower fractional anisotropy (FA) as well as a greater decline in FA with age in anterior CC regions than the AFE ≥12 group. Lastly, we used advanced DTI tractography techniques to examine seven CC regions. Significant differences between AFE groups in associations between CC diffusion measures and cognition, mood, and behavior were found. The results of this research suggest that incurring RHI through tackle football during a critical neurodevelopmental period prior to age 12 may result in later-life structural and functional consequences, including cognitive, mood, and behavioral impairments; alterations in white matter structure; and greater vulnerability of white matter to the normal aging process. If replicated with longitudinal designs, larger samples, and athletes whose highest level of play was youth, high school, or college, these findings may have implications for safety recommendations for youth sports.

A biofidelic finite element model was developed from an acquired set of CT scans for a range of human head and UAS impacts to provide simulations of multiple velocity scenarios of impact severity at four impact orientations on the human head. The hypothesis was that a correlation existed between the total amounts of kinetic energy of the impact from the UAS and human head collision, as well as that location of impact plays a role in the injury risk sustained. Linear acceleration, angular velocity, and pressure data values were calculated for each individual simulated case and then further correlated to injury risks that represent the severity of damage that would be sustained from the collision. Resulting data proved to show that impact kinetic energy, impact orientation, and impact response of the head and UAS all play vital roles in the amount of damage that is sustained from the impact collisions.