Active duty personnel as well as combat veterans of the United States often engage in military operations during their service that require deployments to participate in missions, which may lead to extended periods away from home. When active duty men and women are appointed to combat zones, they may return with psychological burdens such as post traumatic stress disorder, which can complicate their reintegration into civilian life. This study explored the experiences of combat veterans who faced challenges when returning home from a war zone, along with the experiences of their family members. The study involved 26 combat veterans, spouses, significant others, and parents. In data analysis, semistructured interview responses were given concerning personal experiences. The interviews produced a vast amount of information with manual notes. Participants discussed treatment, interventions, and strategies for family reintegration. Many of the veteran participants shared that family members did the 'best they could' to help them reintegrate. The themes received for the study were family reintegration, command strategies and intervention, community services, and mental health services. The study showed how combat veterans and family members can successfully complete family reintegration with social support as well as support from mental health professionals. In association with social change, psychologists, psychiatrists, mental health practioners, and licensed professional counselors may benefit from the findings of this study. Professionals involved with mental health treatments and assessments would learn how to connect with combat veterans and family members. This study supports the recommendation that combat veterans and family members receive services from mental health professionals.

Staff who work in front line, direct contact support positions with community based clients with acquired brain injuries (ABI) hold unique responsibilities, and face unique challenges in their work due to the combination of three key factors: autonomous work environments, socially sanctioned power status over clients, and the decision making deficits of clients with ABI. These factors further contribute challenges to staff in the presently complex and ambiguous outreach context, where the embedded ideologies of the medical model of treatment remain in tension with the purported ideologies of the social model of disability and client self determination that drive outreach services. Using constructivist grounded theory methods and narrative and interpretive analysis strategies, this research interviewed fifteen (15) ABI outreach support workers to explore and examine their perceptions of the outreach context, how they negotiate decision spaces, and how they deal with the central ethical dilemma of outreach - achieving balance between their duty of care and the client's dignity of risk. The thesis documents decision making strategies used by the interview participants, examines the factors that influence their decision space when in the field with clients, and explores the role staff awareness of professional and personal values plays in making decisions in the best of interest of the client. Staff awareness is shown to be a critical, yet oft neglected factor in consideration of staff ethical decision making in ABI outreach. Implications for best practices in the field are discussed. / PhD Doctorate

This qualitative study explored and described the lived experience of people with brain injuries with regard to resuming their worker roles. Based on the results, an occupational therapy practice model to facilitate return to work was developed. The theoretical framework of occupational science with emphasis on occupational risk factors informed the study. The research design was a theory generative design based on a qualitative, phenomenological, explorative and descriptive research approach utilizing the methods of theory generation as advocated by Chinn and Kramer (1999), Walker and Avant (2005) and Dickoff, James and Wiedenbach (1968).

Prosody is the melody and rhythm of speech and language. Prosodic ability is of great importance for communication, and has been shown to be affected in adults with acquired brain injury. Studies have shown that Swedish children with specific language impairment have prosodic  difficulties to a greater extent than e.g. English speaking peers. It is thereby possible that prosodic ability is more vulnerable also in Swedish speaking adults with acquired brain injury. The aim of the present study was to assess prosodic ability in adults with acquired brain injury, and to evaluate the prosodic assessment procedure that was used. The relationship between prosodic ability and general language ability, location of injury and post-onset time was examined. Fifteen adults with acquired brain injury participated, six women and nine men, aged between 30 and 82 years. The participants were tested with an assessment procedure for prosody and parts of Neurolinguistic Assessment of Aphasia (A-ning). Prosodic problems were found at word, phrase and discourse level. No clear links between prosodic ability and location of injury or time post-onset were found. However, a deviant usage of focal accents with a preserved ability to produce word accents as a result of right hemisphere injuries was found. Furthermore, a relationship between prosodic ability and general language ability was found. The prosodic procedure was proven useful for assessment of adults with acquired brain injury, but it needs additional revision. The present study contributes with additional knowledge of prosodic ability in native Swedish speaking adults with acquired brain injury. / Prosodi är talets och språkets melodi och rytm. Den prosodiska förmågan är av stor betydelse för kommunikationen, och är ofta påverkad hos vuxna personer med förvärvad hjärnskada. Forskning har visat att svenska barn med språkstörning har prosodiska svårigheter i större utsträckning än exempelvis engelsktalande barn med språkstörning. Därför är det möjligt att den prosodiska förmågan är mer sårbar även hos vuxna personer med förvärvad hjärnskada och svenska som modersmål. Syftet med föreliggande studie var att kartlägga prosodisk förmåga hos vuxna personer med förvärvad hjärnskada, samt att utvärdera det undersökningsmaterial för prosodi som användes. Sambandet mellan prosodisk förmåga och språkförmåga, skadelokalisation och tid sedan skada undersöktes. I studien deltog 15 vuxna personer, 6 kvinnor och 9 män, mellan 30 och 82 år med förvärvad hjärnskada. Deltagarna testades avseende prosodi samt med delar ur Neurolingvistisk afasiundersökning (A-ning). Resultatet visade att prosodiska avvikelser förekom hos deltagarna på ord- fras- och diskursnivå. Inga tydliga samband fanns mellan prosodisk förmåga och skadelokalisation eller tid sedan skada. Högersidiga skador föreföll dock ge svårigheter att använda fokal accent, trots bevarad förmåga att använda ordaccenter. Vidare sågs ett samband mellan prosodisk och språklig förmåga. Undersökningsmaterialet för prosodi var användbart för testning av personer med förvärvad hjärnskada, men behöver utarbetas ytterligare. Föreliggande studie bidrar till kunskapen om prosodisk förmåga hos vuxna personer med förvärvad hjärnskada och svenska som modersmål.

Severe Traumatic Brain Injury (sTBI) is a major cause of mortality and morbidity. At the Department of Neurosurgery Umeå University Hospital subjects with sTBI are treated with an intracranial pressure (ICP) guided therapy based on physiological principles, aiming to optimise the microcirculation of the brain so avoiding secondary brain injuries. The investigations in this thesis are unique in the sense that all patients with sTBI were treated according to the guidelines of an ICP targeted therapy based on the “Lund concept”. As the treatment is based on normalisation of the ICP, the accuracy and reliability of the measuring device is of outmost importance. Therefore the accuracy, drift, and complications related to the measuring device was prospectively studied (n=128). The drift was 0,9 ± 0,2 mmHg during a mean of 7,2 ± 0,4 days and the accuracy high. No clinical significant complications were noted. In 1997 uni- or bilateral decompressive hemi-craniectomy (DC) was introduced into the treatment guidelines. The effect of DC on the ICP and outcome was retrospectively analysed for subjects with sTBI treated 1998-2001. In the subjects who underwent DC the ICP was 36,4 mmHg immediately before and 12,6 mmHg immediately after the DC. The ICP then levelled out at just above 20 mmHg. The ICP was significant lower during the 72 hours following DC. The outcome did not differ between subjects who had undergone DC or not. Subclinical electroencephalographic seizures and status epilepticus have been reported to be common in subjects treated for traumatic brain injury (TBI). This can negatively influence the outcome giving rise to secondary brain injuries. The occurrence of seizures in subjects treated for TBI using continuous EEG monitoring was therefore prospectively studied. During 7334 hours of EEG recording in 47 patients no electroencephalographic seizures were observed. Theoretically, and based on animal studies, prostacyclin (PGI2) can improve the microcirculation of the brain, decreasing the risk for secondary ischaemic brain injury. PGI2 was introduced to the treatment in a prospective randomised double blinded study (epoprostenol 0,5 ng/kg/min). The effect of PGI1 pkt was analysed using the lactate/pyruvate ratio (L/P) measured by cerebral microdialysis in order to study the energy metabolism in the brain. The outcome was measured as Glasgow Outcome Scale (GOS) at 3 months follow-up. Forty-eight subjects were included. The L/P was pathological high during the first day, thereafter decreasing. There was no significant difference in L/P or outcome between the treated and non-treated group. At 3 months the mortality was 12,5% (95,8% was discharged alive from the ICU), and favourable outcome (GOS 4-5) was 52%. In the same study the brain injury biomarkers S-100B and NSE were followed twice a day for five days to evaluate brain injury and investigate the possible use of these biomarkers for outcome prediction. Initially the biomarkers were elevated to pathological levels which decreased over time. The biomarkers were significant elevated in subjects with Glasgow Coma Scale 3 (GCS) and GOS 1 compared with subjects with GCS 4-8 and GOS 2–5, respectively. A correlation to outcome was found but this correlation could not be used to predict clinical outcome. It is concluded that the ICP measurements are valid and the treatment protocol is a safe and solid protocol, yielding among the best reported results in the world, in regard to favourable outcome as well as in regard to mortality. Epoprostenol in the given dose was not shown to have any effects on the microdialysis parameters nor the clinical outcome. In sTBI L/P and brain injury biomarkers can not be used to predict the final outcome.

Prior research has established that a history of post-traumatic stress disorder (PTSD) and/or traumatic brain injury (TBI) increases the risk of suicide behavior. Few studies have examined the role of specific PTSD symptom clusters and suicide attempts. The current study is among a handful of studies that have examined the association between the presence of PTSD symptom clusters and suicide attempts among Veterans with PTSD and/or TBI. The study utilized archival data from a sample of 137 Veterans receiving mental health treatment at the Denver Veteran Affairs Medical Center. Results from logistic regression analyses indicated that PTSD symptom clusters were not associated with an increased risk for suicide behavior among individuals with and without a history of TBI. Results suggest that looking at the presence of PTSD symptoms is not sufficient to account for the risk of suicide behavior. Clinical and research implications on the need to examine the role of PTSD symptom severity and suicide behavior are discussed.

Traumatic brain injury (TBI) is a severe condition and a major cause of death and disability. There is no pharmacological treatment available in clinical practice today and knowledge of brain injury mechanisms is of importance for development of neuroprotective drugs. The aims of the thesis were to get a better understanding of astrocyte reactions and immune responses, as well as behavioral changes after focal unilateral cortical contusion injury and diffuse bilateral central fluid percussion injury in rats and mice. In the focal injury models, the astrocyte reactions were generally restricted to the ipsilateral hemisphere. After diffuse TBI, vimentin and glial fibrillary acidic protein (GFAP) positive reactive astrocytes were bilaterally expressed in brain regions even distant from the injury site, including regions where axonal injury was seen. Early after diffuse TBI, there was a robust immune response, including activation of macrophages/microglia (Mac-2+) and infiltration of neutrophils (GR-1+) and T-cells (CD3+). In order to measure functional outcome, the recently established Multivariate Concentric Square Field™ (MCSF) test for complex behaviors, including risk taking and explorative strategies was used. The Morris water maze (MWM) was applied for testing learning and memory. The MCSF test revealed alterations in risk taking, risk assessment and exploratory behavior, in the mice subjected to focal injury whereas mice subjected to the diffuse injury showed a deviant stereotyped behavior. After focal injury mice showed a decreased ability to adapt to the arena in the second trial, when tested repeatedly in the MCSF test. Mice subjected to diffuse injury had an impaired memory but not learning, in the MWM test. Post-injury treatment with the anti-inflammatory anti-interleukin-1β (IgG2 a/k) antibody showed a positive effect on functional outcome in the diffuse injury model. Altogether, the results demonstrate that focal and diffuse TBI models produce differences in cellular reactions and behavioral outcome and that the immune response plays a key role in the pathology after brain injury.

The overall goal of my research was to advance our understanding of the potential for novel compliant flooring systems to reduce the risk for fall-related injuries in older adults, including fall-related traumatic brain injury (TBI). This entailed an assessment of how these floors affect the competing demands of fall-related TBI – impact severity attenuation in concert with minimal concomitant impairments to balance control and postural stability. Two studies are included as part of this thesis. The first study used a mechanical drop tower to assess the effects of four traditional flooring systems and six novel compliant flooring conditions on the impact dynamics of a surrogate headform during the impact phase of simulated ‘worst- case’ head impacts. The second study entailed an assessment of the effect of two traditional and three novel compliant floors on the initial phase of the compensatory balance reactions of older adult men and women living in a residential-care facility environment following an externally induced perturbation using a tether-release paradigm. Overall, this thesis demonstrates that novel compliant floors substantially attenuate the forces and accelerations applied to the head during simulated worst- case impacts when compared to traditional flooring surfaces such as vinyl and carpet with underpadding. These benefits are achieved without compromising indices of balance control, supported by the finding that parameters characterizing early compensatory balance reactions were unaffected by the novel compliant floors tested. This work supports the introduction of pilot installations of novel compliant flooring systems into environments with high incidences of falls to test their effectiveness at reducing fall-related injuries in clinical settings.

Traumatic brain injury (TBI) results from a physical insult to the head and often results in temporary or permanent brain dysfunction. However, the cellular pathology remains poorly understood and there are currently no clinically effective treatments. The overall goal of this work was to develop and characterize a novel three-dimensional (3-D) in vitro paradigm of neural trauma integrating a robust 3-D neural co-culture system and a well-defined biomechanical input representative of clinical TBI. Specifically, a novel 3-D neuronal-astrocytic co-culture system was characterized, establishing parameters resulting in the growth and vitality of mature 3-D networks, potentially providing enhanced physiological relevance and providing an experimental platform for the mechanistic study of neurobiological phenomena. Furthermore, an electromechanical device was developed that is capable of subjecting 3-D cell-containing matrices to a defined mechanical insult, with a predicted strain manifestation at the cellular level. Following independent development and validation, these novel 3-D neural cell and mechanical trauma paradigms were used in combination to develop a mechanically-induced model of neural degeneration and reactive astrogliosis. This in vitro surrogate model of neural degeneration and reactive astrogliosis was then exploited to assess factors influencing neural stem cell (NSC) survival and integration upon delivery to this environment, revealing that specific factors in an injured environment were detrimental to NSC survival. This work has developed enabling technologies for the in vitro study of neurobiological phenomena and responses to injury, and may aid in elucidating the complex biochemical cascades that occur after a traumatic insult. Furthermore, the novel paradigm developed here may provide a powerful experimental framework for improving treatment strategies following neural trauma, and therefore serve as a valid pre-animal test-bed.

With over 50,000 deaths and 80,000 disorders annually in the United States resulting from traumatic brain injury (TBI), there is a demand for improved therapeutic strategies. Cell transplantation offers the potential to treat TBI by targeting multiple mechanisms in a sustained fashion. However, efforts are needed to improve survival and integration of transplanted cells, and ultimately enhance functional recovery. Using tissue engineering strategies, we aimed to mimic key aspects of fetal tissue grafts by combining neural stem cells with a fibronectin or laminin based scaffold that could be delivered to the injured brain in a minimally invasive fashion. We found that the incorporation of extracellular matrix proteins into a cell transplantation paradigm led to improved donor cell survival and restored cognitive ability for treated animals. To begin to examine how fibronectin and laminin mediate these improvements, we first examined the endogenous role of these two proteins in the injured brain. Using a clinically-relevant model of TBI, we found both proteins are increased in the injured brain at acute time points. The spatial localization of fibronectin and laminin with specific support cells in the brain suggests a role for these proteins in repair, warranting further investigation. Using conditional plasma fibronectin knockout animals, we found that fibronectin is neuroprotective to the traumatically injured brain. Specifically, injured fibronectin knockout animals had more severe motor and cognitive deficits, increased cell death, and decreased retention of phagocytic cells compared to injured wild type animals. Thus, we have identified novel therapeutic treatments for TBI which utilize tissue engineered transplants and/or exploit endogenous repair mechanisms for fibronectin.