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Over one million people suffer a traumatic brain injury every year, many of whom are students between the ages of 5 and 18. Using a qualitative case study approach, I wanted to discover the specific factors that both impede and help the school re-entry process for students in grades kindergarten through twelve so that these students can return to school on a full-time basis. The theoretical base behind this problem included motivation theories, memory theories, and emotion theories including self-determination theory, self-efficacy theory, Kübler-Ross Grief Cycle, and Lezak's stage model. Educators, including teachers, school counselors, and administrators, need to provide educational support to children with brain injuries and their families as a result of the Individuals with Disabilities Act of 1990, Public Law 101-476. However, if these individuals do not have a good understanding of what these students need to achieve optimal educational success, then the students will probably not be able to achieve their educational goals. Therefore, I searched for factors that affect the re-entry process. I used a qualitative case study approach in my methodology to complete this study. The sample used in this study included those students associated with the BrainSTEPS team local to my residence who were willing to participate, along with their parents, teachers, counselors, and administrators. Historical data were collected through medical and academic records. The bulk of the data came from interviews and observations I made; I then used the constant comparative method to analyze these data. I had several methods of verification in place to ensure the validity of this study and I did my best to hold the study to the highest ethical standards possible. The factors that were found to enhance the re-entry of students with brain injuries include: education and awareness prior to the injury occurring, the scheduling of frequent breaks during the school day, a gradual transition, providing each student with a brain injury with a non-injured study buddy in the classroom, teaching the student to become a self-advocate, constant communication between all of the key players that begins as early as possible, and support provided by the administration and therapists for the classroom teachers in the form of periodic check-ups. / Educational Administration

An examination of neck strength, and other possible predictors of concussion risk in university athletes and how these variables relate to concussion recovery in this cohort. / Concussion incidence in university athletes has been increased drastically over the last two decades. Prevention of concussion injuries is still elusive and scarcely reported in the literature. Certain athletes are at greater risk for concussion than others. Identifying these risk factors is an important first step in identifying those who are at highest risk for concussion. Concussions are biomechanical injuries therefore addressing the strength of the neck musculature might be a significant modifiable risk factor in concussion prevention. Greater neck strength may help to attenuate the forces that cause concussion and either prevent injury or decrease the severity. There are some known risk factors for concussion, including age and female sex, however this does not account for all of the variability in concussion incidence in university athletes. Further exploration into the importance of neck strength and concussion in university athletes is required to identify alternative prevention strategies available to athletes. The purpose of this research was to examine if neck strength and anthropometric variables are significant predictors of concussion risk and concussion recovery time in Canadian university athletes. Chapter One provides a review of the current literature on concussion. It presents the background information for concussion risk, etiology, assessment, and management in university athletes. This chapter also reviews the literature to date on neck strength in concussion and assessments of neck strength in athletes. Chapter Two presents a study evaluating the risk of concussion in a group of Canadian university varsity athletes (n = 246). Neck strength and anthropometric variables are assessed for their significance in predicting concussion risk in this cohort along with published covariates. Neck pain and past concussion history were found to be the most significant predictors of concussion in this population. Chapter Three provides an exploration into the importance of neck strength and anthropometric variables in length of recovery in concussed athletes (n = 35). The Sport Concussion Assessment Tool, 3rd edition was used to evaluate symptom intensity in these athletes. A multiple linear regression model was used to predict recovery time. Symptom score and neck pain were the only significant predictors of concussion recovery time in varsity athletes. Chapter Four presents the implications of the two aforementioned studies for clinical practice, future research, and policy recommendations. More in-depth assessments prior to the beginning of competition should be considered in identifying athletes who are at greatest risk for concussion. Athletes with significant past concussion history should be evaluated more closely and informed of their heightened risk for subsequent injury. / Thesis / Master of Health Sciences (MSc)

Background & Purpose: Sustaining an acquired brain injury (ABI) can often lead to admission to an inpatient rehabilitation program. The purpose of inpatient rehabilitation is to provide individualized, patient-centered therapy in order to facilitate community re-integration. Considering the patient perspective is beneficial for informing patient-centered care because clinicians and program administrators may develop greater awareness and understanding of patient needs and preferences. There is a lack of qualitative research investigating patient experiences and perspectives of ABI inpatient rehabilitation, and the majority of existing research was conducted in non-Canadian contexts. The present study was thus designed to describe and interpret patient experiences of an ABI inpatient rehabilitation program in urban Ontario. The purpose was to contribute to a patient lens that inpatient rehabilitation staff could consider in their work. Methods: An interpretive description approach was adopted for this qualitative study. Twelve participants were purposively sampled from a regional ABI rehabilitation program. They completed semi-structured interviews about their experiences. Interviews were transcribed, coded, and analyzed to identify major themes. Results: Three major themes were identified from the analysis and arranged around three time points. At the time point prior to admission to inpatient rehabilitation, the theme was “Life Rerouted,” where participants described their lives being diverted from what was “normal” after sustaining an ABI. Inpatient rehabilitation was seen as a way to return to their pre-injury life. The second theme described experiences within inpatient rehabilitation and was entitled, “Autonomy within Rehab.” Under this theme, participants emphasized the importance of personal autonomy over their choices and abilities while in rehabilitation, with three related sub-themes: interactions with clinicians, perceptions of institutional policy, and the involvement of family members. Under a minor theme, not directly related to aspects of autonomy, entitled “social comparisons,” participants also made comparisons of their recovery progress to other patients. The third and final theme reflected participants experiences just after discharge and was entitled, “Life (and Recovery) Go On.” Under this theme, participants described an ongoing recovery process leading to sentiments of both frustration and hope for the future. Discussion: An overarching key message was developed from these themes: “re-establishing personal identity is important to the recovery process.” Two theories (biographical disruption and relational autonomy) are used to interpret this message and describe the strategies and perspectives adopted by patients during inpatient rehabilitation as they attempted to cope with the psychosocial impacts of ABI on their lives. Conclusions: The findings of this study provide knowledge and a theoretical lens in which program staff can view and understand patients’ experiences, needs and preferences. These findings may enhance patient-centered care within the context of ABI inpatient rehabilitation. / Thesis / Master of Science (MSc)

Concussion, defined as a functional injury with complex symptomatology, affects millions annually and has been classified as a serious public health concern. Clinical tools currently available for concussion assessment fail to objectively measure cognitive function and thus, are inadequate for proper evaluation of the cognitive dysfunctions associated with the injury. As a result, investigation into the neurological consequences associated with concussion has become a prominent focus in neuroscience research. Traditionally, neuroimaging methods have been used primarily on concussion detection, while behavioural and neuropsychological assessments have been used for both concussion detection and cognitive-performance tracking. However, to date, minimal work has explored the use of neuroimaging to track the consequences of concussion at the neurophysiological level. Accordingly, the present thesis sought to investigate the clinical applicability of electroencephalography (EEG) as an effective neuroimaging tool capable of concussion detection, as well as its ability to objectively track neurophysiological changes over time. Event-related potentials (ERPs) were used to assess specific functions, or more accurately, dysfunctions of select cognitive processes as reflected by electrophysiological changes in the brain. Specifically, the Mismatch Negativity (MMN), N2b, and P300 were investigated to evaluate memory, attention, and executive control in concussed populations. The results of this thesis demonstrated alterations in each of the aforementioned ERPs, signifying cognitive dysfunctions linked to neurophysiological abnormalities in concussed populations. Of particular importance, Chapter 2 revealed the first instance of MMN abnormalities in a concussed population, Chapter 3 was the first to assess concussed adolescents at the acute stage of their injury, and Chapter 4 demonstrates the potential of ERPs to track neurophysiological changes from the acute to post-acute stages of the injury. Ultimately, the findings presented in this dissertation support the clinical viability of using ERPs to not only detect cognitive dysfunctions associated with concussion, but also to objectively track neurophysiological changes on the path to recovery. / Dissertation / Doctor of Philosophy (PhD)

Mild traumatic brain injury (mTBI)/ concussion accounts for 70-90% of all reported TBI cases in the United States and can cause long-term neurological outcomes that negatively impact quality of life. Previous studies revealed that increased blood-brain barrier (BBB) leakage is correlated with poor neurological outcomes after mTBI, yet the biological mechanisms linking BBB damage to the onset of neurological deficits after mTBI are not well understood. Previously, we found that astrocytes lose expression of homeostatic proteins after mTBI, characterizing the changes in astrocytic protein expression as an "atypical astrocyte response." Yet, the upstream mechanisms that induce this atypical astrocyte response after mTBI have yet to be elucidated. In models of more severe TBI, exposure to blood-borne factors triggers astrogliosis via upregulation in markers, such as glial fibrillary acidic protein (GFAP), but how exposure to blood-borne factors affects astrocyte protein expression in the context of mTBI is not well understood. Therefore, we hypothesized that mTBI-induced BBB damage causes atypical astrocytes via exposure to blood-borne factors. To test this hypothesis, we use a mTBI mouse model, two-photon microscopy, an endothelial cell-specific genetic ablation model, and serum-free primary astrocyte cultures. Here, we found that mTBI causes BBB damage through the loss of proteins involved in maintaining the BBB's physical and metabolic barriers, and BBB damage is sustained long-term after injury. Also, we demonstrated that leakage of blood-borne factors is sufficient to trigger atypical astrocytes, and plasma exposure triggers a similar response in vitro. Overall, these findings suggest that mTBI induces long-term BBB damage, and exposure to blood-borne factors triggers the loss of key homeostatic astrocytic proteins involved in maintaining healthy neuronal function. / Doctor of Philosophy / Mild traumatic brain injury (mTBI)/ concussion makes up 70-90% of all TBI cases reported in the United States and is commonly observed after car crashes, sports-related tackles, and blast exposure during military combat. People who experience mTBI develop debilitating long-term neurological consequences, such as sleep disturbances, depression, and dementia. Clinical data suggests mTBI causes damage to the barrier between the brain and blood, known as the blood-brain barrier (BBB). This damage has been correlated to the onset of poor neurological deficits, yet how damage to this barrier is causally linked to long-term neurological consequences remains to be fully understood. In our lab, we found that mTBI causes loss of proteins important for maintaining a healthy environment in the brain in specialized cells called astrocytes. However, the biological events that trigger the loss of protein expression in astrocytes after mTBI have yet to be fully investigated. Thus, we hypothesized that mTBI causes loss of these proteins via leakage of blood-borne factors. To test this hypothesis, we used a mTBI mouse model, two-photon microscopy, genetic manipulation, and cell cultures. In our studies, we found that mTBI triggers BBB damage via loss of proteins that make up its protective properties. Also, we demonstrated that leakage of blood-borne factors is sufficient to cause loss of astrocyte-specific proteins both in brain and cell cultures. Altogether, we show that a single mTBI is sufficient to cause loss of astrocyte-specific protein expression via exposure to blood-borne factors. These findings may point to targeting either the blood-borne factor(s) or their corresponding receptor pathways in astrocytes to halt the progression of long-term neurological deficits after mTBI.