Objective: Identify patients with specific emergency department (ED) discharge diagnoses who later report symptoms associated with a mild traumatic brain injury (MTBI), compare frequency and severity of MTBI symptoms by discharge diagnoses, investigate the frequency of head injury education provided to ED patients with each diagnosis, and finally, to learn what type of changes have occurred in the lives of patients as a result of their injury. Methods: Fifty-two ED patients, aged 18 to 28 who were at least two weeks post injury, spoke English and were discharged with a diagnosis of concussion/closed head injury (CHI), head laceration, motor vehicle crash (MVC), whiplash/cervical strain, facial/jaw fractures or multiple injuries were invited to participate. Participants completed the Post Concussive Symptom Scale (PCSS), a demographic questionnaire and then a series of open-ended questions about the impact the injury had on their lives. Results: MTBI symptoms on the PCSS were reported by 84.6% (n = 44) of respondents with a range of 1 – 23 different symptoms per participant. Headache (69.2%) and fatigue (61.5%) were the most common symptoms. Males (51% of the participants) reported on average 6.76 symptoms (S.D. = 6.53) whereas females reported an average of 12.68 symptoms (S.D. = 6.32). A large percentage (83.3%, n = 10) of participants with a MVC diagnosis reported severity scores in the moderate range (mean = 3.17; S. D. = 0.27) in all four PCSS categories (physical, thinking, sleep and emotional) representing the highest severity scores reported overall. Participants diagnosed with a concussion/CHI received the most (74%) head injury education of all discharge diagnoses, but only half (51%) received written information. The most common quality of life change was that 70.3% of survey participants became more cautious. Conclusion: Participants with a discharge diagnosis not commonly associated with brain injury reported having MTBI symptoms at least two weeks post injury with females reporting twice as many symptoms as males reported. Head injury education provided in the ED was lacking for all participants and although participants involved in a MVC reported having the most severe MTBI symptoms they had the least head injury education. All health care providers, especially nurses working in the ED, need to look beyond physical complaints and recognize injuries associated with increased risk for developing MTBI symptoms. Proactive ED identification of patients with "at risk" injuries by nurses would likely promote increased MTBI education and thereby result in fewer missed MTBI diagnoses.

Thesis (Ph.D.)--Boston University / The widespread use of Improvised Explosive Devices (IEDs) in the Wars in Iraq and Afghanistan has caused a dramatic increase in shockwave-induced mild Traumatic Brain Injury (mTBI), leading mTBI to be dubbed the 'signature injury' of modern warfare. Currently, the pathology of shockwave-induced mTBI is unknown , and it is diagnosis is based on self-reported symptoms and combat history. While the etiological mechanism has not yet been determined , it is becoming increasingly accepted that shockwaves themselves are the brain-damaging agent that emanate from IEDs. To assess how mild, sub-lethal shockwaves might damage brain tissue, we developed an in vitro assay to deliver shockwaves to neuronal cells in culture, and then assayed several properties of these cells that affect their function. This assay involved exposing rat cortical and hippocampal primary neuronal cultures to shockwaves of increasing magnitude generated with a biolistic Gene Gun. The Gene Gun produces shockwaves of sufficient overpressure to cause cognitive impairment in animal models of shockwave-induced mTBI. Our results show that overpressures of ~1.0 pound per square inch (psi) caused transient membrane permeability for molecules up to ~12 nanometers in diameter. This change in membrane permeability was accompanied by a transient decrease in cellular ATP levels and synaptic densities. This synaptic degeneration correlated with changes in the level and phosphorylation state of several synaptic proteins examined. Similar results were observed in dissected rat retinas suggesting that these shockwave-induced effects can occur in complex tissues, such as the brain. Based on these findings we propose that shockwaves damage cellular membranes, leading to a decrease in intracellular ATP, and ultimately to a reduced numbers of synapses, the part of neurons most important for learning, memory and behavior. Additional experiments in whole animals will be required to ascertain whether shockwave-induced cellular damage and synaptic degeneration plays an etiological role in shockwave-induced mTBI.

This study examines the background and qualifications of plaintiff and defense experts using the H-Index score as quantification of expert background and qualifications. The goal is to better understand the similarities and differences among the professionals offering paid expert witness testimony in mild traumatic brain injury (mTBI) civil litigation. In this quantitative study, descriptive statistics include the mean and standard deviation scores for the data to support examining measures of central tendency and variance, respectively. The study includes the use of logistic regression and the Wilcoxon signed-rank test, and their statistical assumptions were tested to determine whether they would be used or if it was more appropriate to use a non-parametric test. The study included two research questions: How do the qualifications of plaintiff and defense expert witnesses in mild traumatic brain injury civil litigation compare? and to what extent does a higher h-index correlate with a favorable litigation outcome in a mild traumatic brain injury case? The findings for the hypothesis tests associated with the research questions led to the acceptance of the null hypothesis in each test. There was a lack of asymptotic significance in Hypothesis 1 and a lack of significance in Hypothesis 2. The findings from these tests shall support the discussion of the implications of this research and the direction of future research.

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.

Children and youth who suffer a mild traumatic brain injury or concussion are at risk for a number of negative outcomes. The symptoms of concussion and the management of these symptoms can be disruptive to the child’s everyday activities, especially if they are prolonged. Depression can result and may complicate the course of recovery. Depression has overlapping symptoms with concussion and is thought to lengthen the recovery period. There has been much research done in populations of mixed severities of brain injury but very little addresses children with concussion. Knowledge in this area is crucial due to depression’s impact on all aspects of functioning as well as the potential alteration of the child’s developmental trajectory. The purpose of this research was to examine the risks and predictors of depression following concussion in youth and to explore the experiences of a subsample of youth and their families with prolonged recovery from concussion, complicated by depression. Chapter One provides a review of the current literature setting the context for the research within what is known about concussion in youth, what is known about depression in youth and because of the early stages of this type of research, what is known about depression as an outcome of concussion in all age groups. Chapter Two presents a study highlighting the tangible risk for depression in a sample of children being followed in a tertiary care clinic (N=92). Significant predictors of depressive symptomatology were found to be the need for hospital admission and high symptom scores in the first few days and weeks after injury, which may be valuable information for prevention, early identification and treatment of youth at risk for depression after concussion. Chapter Three provides an in-depth exploration of the experiences of youth and families who have gone through prolonged recovery from concussion with significant depressive symptomatology. A phenomenological approach was used with six participants and their families who were interviewed and their responses analyzed. A trajectory of recovery was identified; common themes within each of four key stages of the trajectory were discussed and illustrated using direct quotes from the participants. Chapter Four outlines the important implications of these two studies for health care professionals; particularly in raising awareness of the mental health outcomes of concussion. Knowledge of the impact of debilitating symptoms, activity restrictions and depression can inform discussions early after a concussion to prepare and possibly prevent some of the losses experienced by youth that can lead to depression. / Thesis / Master of Science Rehabilitation Science (MSc)

Each year in the United States, approximately 1.35 million people are a ected by mTBI (aka concussion) and subsequent cognitive impairment. Approximately 33% of mTBI cases results in persistent long-term cognitive de cits despite no abnormalities appearing on conventional neuroimaging scans. Therefore, an accurate and reliable imaging method is needed to determine injury location and extent of healing. The goal of this study was to characterize and quantify mTBI through DTI, an advanced MRI technique that encodes voxel-wise tissue water microstructural di usivity as a tensor, as well as QSM, which measures iron deposition within tissues. We hypothesized that personalizing the analysis of DTI and QSM will provide a better understanding of trauma-induced microstructural damage leading to improved diagnosis and prognosis accuracy. Through regression analysis, a preliminary comparison between DTI data to QSM measurements was performed to determine potential correlations between the two MRI techniques. Further, a large database of healthy pediatric brain DTI data was downloaded and each was warped into a standardized brain template to ultimately use for voxel-wise z-score analysis of individual mTBI patients (n=26). This allowed localization and quantitation of abnormal regions on a per-patient basis. Signi cant abnormalities were commonly observed in a number of regions including the longitudinal fasciculus, fronto-occipital fasciculus, and corticospinal tract, while unique abnormalities were localized in a host of other areas (due to the individuality of each childs injury). Further, through group-based Bonferroni corrected T-test analysis, the mTBI group was signi cantly di erent from controls in approximately 65% of regions analyzed. These results show that DTI is sensitive to the detection of microstructural changes caused by mTBI and has potential to be a useful tool for improving mTBI diagnosis accuracy / Thesis / Master of Applied Science (MASc) / Concussions affect over one million people in the United States each year. In a number of cases, these individuals must cope with persistent long-term cognitive impairment resulting from the injury. A current, significant problem is that concussion cannot be reliably diagnosed using conventional CT and MR imaging methods. Therefore, an accurate and reliable imaging method is needed to determine both injury location and severity, as well as to monitor healing. The goal of this study was to quantify concussion through MR imaging techniques known as Di ffusion Tensor Imaging and Quantitative Susceptibility Mapping, which accurately model the brain's mi- crostructure. Analysis utilizing these MRI methods found signifi cant abnormalities in a number of brain regions of concussed subjects relative to healthy individuals. These results suggest that DTI, in particular, is sensitive to microstructural changes caused by concussions and has the potential to be a useful tool for improving diagnosis accuracy.

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Traumatic brain injury (TBI) is the most common injury in childhood, and it is the leading cause of disability. Early childhood is an area of specific interest because it is a period of rather significant vulnerability to longer-standing problems. Better health and behavior-related outcomes generally improve when diagnosis occurs early enough to inform evidence-based interventions adequately. However, there continues to be relatively weak identification of concussions in early childhood, and misdiagnoses often lead children to receive the incorrect intervention if they receive intervention at all. Clinicians need to identify symptoms of a concussion immediately following injury. To this end, the present study examines the literature to determine domains, and any narrow abilities impacted following a concussion. Assessments items were generated based on a review of published norm references tests and task demands analyses (n = 18). Testing items were cross-referenced using developmental literature to ensure they were appropriate for assessment for children age 3 years. Via the Delphi survey method, a heterogeneous panel of experts (Round 1 n = 17; Round 2 n = 13), including physicians, psychologists, school nurses, speech and language pathologists, and athletic trainers, offered their opinion regarding what areas are impacted following a concussion. The panel provided clarification on the operational definitions and agreed that the testing items, indeed, were developmentally appropriate. The group also decided that a paraprofessional could administer the items with minimal training, which is an essential consideration because children in early childhood are often cared for by professionals untrained in assessment, working in daycare or preschool settings. The present study concludes that, indeed, an evaluation of concussions symptoms that are like traditional sideline assessments is possible. However, the results of this assessment are only preliminary, and there was no evidence for validity based on response processes or relations to other variables; likewise, reliability data are unavailable at this time. Recommendations for future research are included, and ideas to move toward standardization are presented. Recommendations for the training of paraprofessionals in these assessment procedures, too, are outlined. / School Psychology