There is a great deal of literature in civilian rehabilitation settings that documents the tremendous impact a brain injury has on both the injured person and the family as a whole. TBI is a leading cause of both death and disability world-wide and is often cited as the signature injury of the ongoing OEF/OIF conflict. In 2005, Congress recognized the severity of injuries that military personnel were encountering in the OEF/OIF conflicts and created the Polytrauma System of Care (PSC). While the PSC has made great efforts to provide innovative and effective treatment for active duty and veteran patients, little is known about the needs of their family members. Given the tremendous impact TBI has on families and the important caregiving role assumed by many, there is an urgent need to better understand their needs. The Family Needs Questionnaire (FNQ) was administered to 44 family members of patients at the Polytrauma Rehabilitation Center (PRC) at McGuire Veterans Affairs Medical Center (VAMC) over a 30 month period. Family members rated 40 needs indicating the importance and extent to which needs were met. Results were compared with findings from similar studies in civilian rehabilitation settings. A review of the rated needs indicated that PRC families rated the needs in the Health Information domain as most important and most frequently met. In addition, PRC family members rated Emotional Support and Instrumental Support as least important and most frequently unmet. Overall results were consistent with findings in civilian rehabilitation research, but subtle differences were examined. Exploratory analyses were conducted to examine a subset of family variables associated with needs indices. Needs were rated differently based on respondents', gender, income, relationship to patient, and time since injury. Results highlight similarities across family needs in rehabilitation settings. However, there remains a need for further research within VAMC PRC's that include a larger more diverse sample and participants utilizing both inpatient and outpatient services.

The purpose of this study was to examine the relationship between both self-efficacy for caregiving and personal gain and several variables related to well-being in caregivers (N = 70) of veterans who sustained a traumatic brain injury (TBI). Specifically, the relationship between self-efficacy for caregiving and perceived physical health and the relationship between personal gain related to caregiving and depression and anxiety was examined. The relationship between caregiver personal gain and perceived care recipient behavior was also examined. Exploratory analyses considered kinship and racial/ethnic differences. This was a secondary analysis of pilot data collected at four Polytrauma Rehabilitation Centers (PRC) of the United States Department of Veterans Affairs. It was a cross-sectional, pen and paper-based survey study mailed to caregivers of non-OEF/OIF veterans who were treated at a PRC for TBI between 2001 and 2008. Results suggest that self-efficacy for caregiving is not associated with subjective health or physical functioning in the caregiver. There was also no direct effect of personal gain associated with caregiving on depression or anxiety. However, perceived burden was found to mediate the relationship between personal gain associated with caregiving and both depression and anxiety. No significant differences were found between Caucasian and non-Caucasian caregivers in number of hours spent providing care, perceived burden, or subjective health. Non-Caucasian caregivers reported significantly higher levels of physical functioning. No differences were found between parental and non-parental caregivers on measures of depression, anxiety, or perceived burden. These findings suggest that interventions for caregivers should focus on helping them find meaning in caregiving and articulate ways in which they have benefitted from caregiving. By helping caregivers highlight the benefits of caregiving, perceived burden may be decreased, which in turn may result in lower depression and anxiety levels.

Following traumatic brain injury (TBI), neuroinflammation contributes to the secondary injury. Microglia are the resident immune cells of the central nervous system (CNS), and when activated can exert either protective or detrimental effects on surrounding tissue. They are often segregated into subpopulations based on their type of activation, either pro- inflammatory (M1, classically activated), or anti-inflammatory (M2, alternatively activated). Minocycline, an anti-inflammatory drug, is known to be neuroprotective and to have effect on microglia. However, the effect of minocycline on subpopulations of inflammatory cells in the acute stage following injury is unclear. It is also unclear whether minocycline has a different treatment effect on injury-induced inflammatory responses in young and aged populations. In this study, we compared the effect of minocycline treatments on the microglial markers and the M2 subtype in both young (3-month-old) and aged (20-month-old) rats, sacrificed at three days after a moderate controlled cortical impact (CCI) injury. Minocycline treatments were either given beginning at 30 minutes post-injury or 4 hours post-injury for three days. Inflammatory cell markers ED1, OX6, and Iba1, as well as Arginase 1, a marker for alternatively activated macrophages/microglia, were used to label inflammatory cells. Staining intensity of each marker was analyzed in both the peri-lesion cortical tissue and the ipsilateral hippocampus regions. Our findings have found that 3-day minocycline treatment significantly attenuated TBI- induced inflammatory cell response especially in the aged rats. Minocycline treatment did not show any significant changes in the prevalence of the M2 phenotype. Our findings suggest that minocycline may exert its anti-inflammatory effect mostly on inhibition of M1 phenotype rather than promoting M2 phenotype.

Thèse numérisée par la Direction des bibliothèques de l'Université de Montréal.

Traumatic brain injury (TBI) is a major cause of death among trauma patients and is associated with a high rate of mortality due to complications such as bacterial pneumonia, sepsis, and subsequent coagulopathies. While severe TBI is positively associated with the development of pneumonia, mild traumatic brain injury (mTBI) results in a paradoxical decrease in mortality following bacterial pneumonia via an unidentified mechanism. New evidence suggests that mTBI stimulates vagus nerve signaling resulting in an anti-inflammatory state that is mediated by neurotransmitters (NT) such as acetylcholine (ACh) and substance P (Sub P). This anti-inflammatory state induced by mTBI has been correlated with an increased resistance to pneumonia (PNA) in mice and has been shown to be mediated in part by increased bacterial clearance in the lungs via enhanced neutrophil recruitment. However, it has not been investigated whether this reduced mortality is due to alterations in the coagulation system and if they have any effect on either the severity or occurrence of disseminated intravascular coagulation (DIC), a common sequelae of pneumonia-induced sepsis. Our study investigates whether administration of mTBI prior to pneumonia challenge in mice decreases mortality by ameliorating DIC. We assess and define DIC in our mouse models by changes in plasma coagulation parameters including fibrinogen, D-dimer, and plasminogen activator inhibitor-1 (PAI-1) Our study found that mTBI administration prior to pneumonia significantly decreased mortality in mice gavaged with high concentrations of Pseudomonas aeruginosa (Psd.). We also found that mTBI administration prior to pneumonia rescued fibrinogen levels and increased D-dimer levels in plasma, suggesting a compensated fibrinolytic state and amelioration of DIC. Circulating neutrophil and absolute leukocyte counts were also increased in mTBI/pneumonia models compared to those with pneumonia alone, supporting previous evidence implicating mTBI as the origin of enhanced bacterial clearance in lungs. Taken together, these data suggest that the increase in survival seen in patients with mTBI is in part due to alterations in coagulation.

Introduktion: Efter en förvärvad hjärnskada kan det inte tas för givet att kroppen upplevs som självklar i vardagslivet. Många har både fysiska och kognitiva funktionsnedsättningar. Syfte: Studiens syfte var att få en fördjupad förståelse för hur personer med förvärvad hjärnskada upplever sin kropp och fysisk aktivitet i det dagliga livet. Metod: Intervjuer genomfördes med 15 strategiskt utvalda personer som hade utretts för förvärvad hjärnskada. De intervjuades vid ett tillfälle 1-5 år efter debuten. Personerna var i yrkesverksam ålder och hade lättare motorisk och/eller lätt/måttlig kognitiv, emotionell eller personlighetsmässig funktionsnedsättning. Intervjuerna transkriberades och analyserades med the Empirical Phenomenological Psychological Method (EPP-metoden). Resultat: Ett övergripande tema och sex huvudteman identifierades. Det övergripande temat ”Ett nytt sätt att vara i världen” står för ett existentiellt uppvaknande. ”På väg hemåt” speglar processen att det tar tid att anpassa sig till sin nya livssituation, samt att komma till ett stadie av acceptans.”Tiden- en ny betydelse” handlar om att vardagen levs i ett långsammare tempo.”Tröttheten - en ständig följeslagare” belyser att tröttheten är ständigt närvarande. ”Kroppen döljer” beskriver fler av de dolda och osynliga funktionshindren som kan följa. ”Kroppen kommunicerar” och sänder signaler både inåt och utåt vilket individerna måste lära sig att känna igen. ”Kroppen kräver underhåll” visar på behovet av samt inställningen till fysisk aktivitet i ett långtidsperspektiv. Konklusion: Rehabiliteringspersonal behöver ha en djup kunskap om hur personer med förvärvad hjärnskada upplever sin kropp för att kunna vara ett stöd för dem när det gäller att finna lämpliga strategier hur vardagslivet hanteras. / Introduction: That the body can be taken for granted in daily life after an acquired brain injury is an incorrect notion. Individuals experience both physical and cognitive disabilities. Aim: The aim of this study was a deeper understanding of how people with an acquired brain injury experience their body and physical activity in daily life. Method: The interviews were conducted with 15 strategically recruited persons who have been examined for their brain injury. They were interviewed individually on one occasion, 1-5 years after the onset. The persons were of working age and had mild motor disability and/or mild to moderate cognitive, emotional disability or disturbance in personality. The interviews were transcribed verbatim and analysed with the Empirical Phenomenological Psychological Method (the EPP-method). Results: One general theme and six main themes where identified. The general theme” A new way to be in life” stands for an existential wake-up. “On the way home” is a reflection of the process that it takes time to readapt to the new situation of life and reach acceptance. “Time- a new meaning” is about daily life which continues in a slower pace. “Tiredness- the constant companion” shows that you have to take tiredness in consideration. “The body hides” sheds light on the hidden and invisible disabilities which can follow. “The body communicates” and sends signals both inwards and outwards which the individuals has to learn to recognize. “The body needs maintenance” shows the need of physical activity through life and describes the attitudes. Conclusion: The rehabilitation persons need a profound knowledge of how individuals with acquired brain injury experience their body as being a support for them when it comes to managing daily life.

Objectives: To examine the association between traumatic brain injury (TBI) in delinquent youth and facial emotion recognition (FER) abilities, offending, behavioural difficulties, aggression, empathic sadness and parenting. Participants & Setting: Forty-eight delinquent youth, aged 14 to 19 years, recruited from Youth Offending Teams and Targeted Youth Support. Main Measures: A cross sectional case-control design compared individuals in a TBI versus a non-TBI group on a forced-choice, FER paradigm assessing recognition accuracy to six basic emotions. Self-reported measures of TBI, behavioural difficulties, experience of parenting, reactive and proactive aggression, and empathic sadness. Results: History of TBI was reported by 68.7% of the sample, with 94% including a loss of consciousness. No significant differences were found between TBI and non-TBI groups on FER accuracy. Participants in the TBI group self-reported significantly higher proactive and reactive aggression and lower levels of parental supervision as compared to the non-TBI group. Tendency to incorrectly give ‘anger’ as a response on the FER task was strongly positively associated with proactive and reactive aggression. Conclusions: Future research requires larger samples recruited across settings to further investigate the association between FER abilities and TBI in this population. Findings highlight the need for TBI to be appropriately assessed and managed in delinquent youth, and highlights important aggression differences.

Introduction: Trauma centers (TC) are the only institutions with resources to manage patients with severe traumatic brain injury (TBI). We chose to examine potential barriers to access to TC care for TBI patients. Methods: Administrative datasets were used to evaluate access to TC among patients with severe TBI. We examined triage practices of EMS in TBI. Finally, we analyzed surveys to capture the beliefs, perceptions and knowledge of ED physicians with respect to TBI. Results: 57% of patients in Ontario had any access to a TC following TBI. Of patients who had potential access to a TC from the scene of injury as defined by pre-hospital triage guidelines, 60% of patients were undertriaged. Challenges that ED physicians faced with managing TBI, included lack of beds at TC and difficulty attaining transport resources. Conclusion: Access to TC care for patients with TBI is impeded by patient and system level factors.

Traumatic brain injury (TBI) is a major cause of death and disability throughout the world with few pharmacological treatments available for individuals who suffer from neurological morbidities associated with TBI. Cellular and molecular pathological processes initiated at the time of injury develop into neurological impairments, with chronic sleep disorders (insomnia, hypersomnolence) being among the somatic, cognitive and emotional neurological impairments. Immediately post-injury, TBI patients report excessive daytime sleepiness, however, discordant opinions suggest that individuals should not be allowed to sleep or should be frequently awoken following brain injury. To provide adequate medical care, it is imperative to understand the role of acute post-traumatic sleep on the recovery of neurological function after TBI. The aim of this thesis was to examine post-traumatic sleep after experimental TBI, defined as an increase in sleep during the first hours post-injury. In these studies, we non-invasively measured sleep activity following diffuse brain injury induced by midline fluid percussion injury to examine the architecture of post-traumatic sleep in mice. We detected significant injury-induced increases in acute sleep for six hours regardless of injury severity or time of day injury occurred. We found concurrent increases in cortical levels of the sleep promoting inflammatory cytokine interleukin 1-beta. We extended the timeline of post-injury sleep recording and found increases in post-traumatic sleep are distinctly acute with no changes in chronic sleep following diffuse TBI. Further, we investigated if post-traumatic sleep was beneficial to neurological outcome after brain-injury by disrupting post-traumatic sleep. Disruption of post-traumatic sleep did not worsen functional outcome (neuromotor, sensorimotor, cognition) at one week after diffuse TBI. With sufferers of TBI not always seeking medical attention, our final studies investigated over-the-counter analgesics and their effect on post-traumatic sleep and functional outcome. Acute administration of analgesics with varying anti-inflammatory properties had little effect on post-traumatic sleep and functional outcome. Overall, these studies demonstrated translational potential and suggest sleep after a concussion is part of the natural recovery from injury. While disrupting sleep does not worsen outcome, it is in no way beneficial to recovery. Additionally, a single analgesic dose for pain management following concussion plays little role in short term outcome.

Introduction: Trauma centers (TC) are the only institutions with resources to manage patients with severe traumatic brain injury (TBI). We chose to examine potential barriers to access to TC care for TBI patients. Methods: Administrative datasets were used to evaluate access to TC among patients with severe TBI. We examined triage practices of EMS in TBI. Finally, we analyzed surveys to capture the beliefs, perceptions and knowledge of ED physicians with respect to TBI. Results: 57% of patients in Ontario had any access to a TC following TBI. Of patients who had potential access to a TC from the scene of injury as defined by pre-hospital triage guidelines, 60% of patients were undertriaged. Challenges that ED physicians faced with managing TBI, included lack of beds at TC and difficulty attaining transport resources. Conclusion: Access to TC care for patients with TBI is impeded by patient and system level factors.