Define the steps associated with implementation of evidence based practice. Describe barriers and solutions to implementation of evidence based practice in various work environments. Describe elements of evidence based practice as it relates to all phases of recovery from a brain injury.

The State of Kentucky has a high and increasing number of reported cases of traumatic brain injury (TBI), mostly attributed to motor vehicle crashes, falls, and being struck by or against an object. Young adults are among those most at-risk for experiencing a TBI through motor vehicle crashes. Using existing data from the Kentucky Post-School Outcomes Center (KyPSO), 90 youth with TBI were identified within a period of 6-years of the longitudinal study (2012-2017). The majority were males and White. Descriptive statistics, chi square, and logistic regression were used to examine the post-secondary outcomes for youth with TBI, using four demographic variables: gender, ethnicity, residence, and rural or urban status. None of these were associated with post-secondary outcomes for the sample. The results indicated that more than 50% of the youth with TBI had positive outcomes, yet they rarely used the services provided for them in the schools or at the workplace. This study suggests that, although the demographic characteristics did not predict post-secondary outcomes, other variables within education and employment yielded interesting results that could benefit rehabilitation counselors.

In the United States, 2.8 million people suffer a traumatic brain injury (TBI) annually. Between 25%-50% of TBI injuries happen under alcohol intoxication. It is not understood how alcohol impacts patient outcomes via secondary injury pathways. Secondary injury pathways offer a window for therapeutic interventions, but there has been little success finding effective medications. Slice cultures offer a way to study secondary injury mechanisms in a controlled manner. The transection injury can model excitotoxicy seen following TBI. The current studies examined the effect of alcohol intoxication and withdrawal at the time of injury, and the effect of a calpain inhibitor (MDL-28170) on cell death following a transection injury. Intoxication had no effect on cell death compared to the TBI condition. In the ethanol withdrawal (EWD) study, EWD did not increase cell death following the TBI except at 72 hours. There was no effect of MDL on cell death. The severity of the model may have caused a ceiling effect. Additionally, imaging points may not have been sufficient for proper characterization. Future studies should use a different injury mechanism and other imaging times should be considered.

Background: Ventilator-associated pneumonia is a major cause of morbidity and mortality for patients in an intensive care unit. Once present, ventilator-associated pneumonia is known to increase the duration of mechanical ventilation, time in the intensive care unit, and length of hospital stay. Patients with acquired brain injury are commonly admitted to the intensive care unit and considered to be at a high risk for the development of respiratory complications such as ventilator-associated pneumonia, which could potentially impact on the intensive care unit costs and outcomes. Respiratory physiotherapy is often provided to prevent and/or treat ventilator-associated pneumonia in patients with acquired brain injury. The theoretical rationale of the respiratory physiotherapy is to improve airway clearance and enhance ventilation which may reduce the incidence of pulmonary infections and thus ventilator-associated pneumonia, and may in turn decrease the duration of mechanical ventilation, prevent the need for tracheostomy and hence result in reduced costs and shorter hospital stay. Although respiratory physiotherapy may be beneficial in reversing or preventing ventilator-associated pneumonia, to date there are no data concerning the effectiveness of respiratory physiotherapy in patients with acquired brain injury. Hence from an evidence-based perspective, at present there is no justification for the role of respiratory physiotherapy in the management of patients with acquired brain injury in the intensive care unit. Aim: This two-part, prospective randomised controlled trial aimed to investigate the effect of regular prophylactic respiratory physiotherapy on the incidence of ventilator-associated pneumonia, duration of mechanical ventilation, and length of intensive care unit stay in adults with acquired brain injury, as compared to a control group (Part A). / The second part of the study (Part B) randomised those subjects from Part A who developed a ventilatorassociated pneumonia into a treatment or control group to establish if the provision of a regimen of regular respiratory physiotherapy influenced the outcome of ventilator-associated pneumonia. Additionally, this study also aimed to provide the first description of the financial costs of respiratory physiotherapy time in providing interventions to patients with acquired brain injury in the intensive care unit and investigated the cost effectiveness of respiratory physiotherapy interventions in decreasing the incidence of ventilator-associated pneumonia, duration of mechanical ventilation and length of intensive care unit stay. Subjects: 144 adult patients with acquired brain injury admitted with a Glasgow Coma Scale of nine or less, requiring intracranial pressure monitoring, and invasive ventilatory support for greater than 24 hours, were randomised to a treatment group or a control group. Methods: For subjects randomised to the treatment groups, the regimen of respiratory physiotherapy treatment was repeated six times per 24-hour period and continued until the subject was weaned from mechanical ventilatory support. Each respiratory physiotherapy intervention of 30 minute duration comprised a regimen of positioning, manual hyperinflation and suctioning. In both Parts A and B, the control group received standard nursing and medical care but no respiratory physiotherapy interventions. Results: Consent was obtained for 144 subjects, with 72 randomised for treatment in Part A. Part A groups were comparable with respect to demographic variables, with the exception of body mass index and gender distribution. / Using intention to treat philosophy, there were no significant differences for incidence of ventilator-associated pneumonia [Treatment Group 14/72 (19.4%) vs. Control 19/72 (26.4%); p = 0.32], duration of mechanical ventilation (hr) [172.8 vs. 206.3); p = 0.18], or length of intensive care unit stay (hr) [224.2 vs. 256.4; p = 0.22]. For subjects with acquired brain injury receiving this prophylactic regimen of respiratory physiotherapy in the intensive care unit, in an attempt to prevent ventilator-associated pneumonia, the cost of physiotherapy was $487 per subject. Comparatively the intensive care unit mechanical ventilation bed day cost was $33,380 per subject. The cost of Part A respiratory physiotherapy time for Treatment Group 1 was 1.7 per cent of the cost of subject's intensive care unit mechanical ventilation bed days. Thirty-three subjects (22.9%) from Part A developed ventilator-associated pneumonia, and were transferred to Part B and re-randomised, 17 to the Treatment Group 3. Part B groups were comparable with respect to demographic variables. No significant differences were detected in the dependent variables for Part B of the study, with similar duration of mechanical ventilation (hr) [342.0 vs. 351.0); p = 0. 89], and length of ICU stay (hr) [384.7 vs. 397.9; p = 0.84] noted. In those subjects with acquired brain injury in whom ventilator-associated pneumonia developed, the regimen of respiratory physiotherapy for the remaining duration of mechanical ventilation following diagnosis of ventilator-associated pneumonia costed an average of $788. Comparatively the intensive care unit bed day cost for the period of mechanical ventilation was $43,865. The cost of Part B respiratory physiotherapy time for Treatment Group 3 was 1.8 per cent of the cost of their intensive care unit mechanical ventilation bed days. / Subjects with a ventilator-associated pneumonia were significantly younger, were admitted with a lower Glasgow coma scale, and more likely to have been admitted with a chest injury than subjects without a ventilator-associated pneumonia. Duration of mechanical ventilation and length of intensive care unit stay were significantly increased in subjects with ventilatorassociated pneumonia, but length of hospital stay was not significantly different. Significant differences in the costs of respiratory physiotherapy and intensive care unit mechanical ventilation bed day costs were evident between those subjects with ventilator-associated pneumonia as compared to those without ventilator-associated pneumonia. For subjects with ventilator-associated pneumonia, the respiratory physiotherapy time cost was $1,029 per subject, compared to $510 for subjects without ventilator-associated pneumonia. The intensive care unit mechanical ventilation bed day cost for subjects with ventilator-associated pneumonia was $61,092 per subject, and $25,142 for those without a ventilator-associated pneumonia, giving an incremental health cost of $35,950 per episode of ventilatorassociated pneumonia. No significant differences were evident in the cost of respiratory physiotherapy as a per cent of the cost of their intensive care unit mechanical ventilation bed days, with findings of 1.4 per cent in those with ventilator-associated pneumonia and 1.1 per cent in those without ventilator-associated pneumonia. / Conclusion: Use of a regular prophylactic respiratory physiotherapy regimen comprising of positioning, manual hyperinflation and suctioning, in addition to routine medical and nursing care, did not appear to prevent ventilator-associated pneumonia, reduce length of ventilation or intensive care unit stay in adults with acquired brain injury. Furthermore, in those acquired brain injury subjects with ventilator-associated pneumonia, regular respiratory physiotherapy did not appear to expedite recovery in terms of reducing length of ventilation or intensive care unit stay. It can be concluded from the findings of this study that the presence of ventilator-associated pneumonia has a significant influence on morbidity and costs in subjects with acquired brain injury. Whilst statistically significant results were not found with clinical variables, it is suggested that the provision of a prophylactic respiratory physiotherapy regimen costing $487 per subject is a worthwhile investment in attempts to avoid the incremental health cost of $35,950 per episode of ventilator-associated pneumonia. In subjects with ventilator-associated pneumonia it is concluded that the cost of respiratory physiotherapy would not appear to be justified in attempts to reduce the duration of mechanical ventilation.

This study explores the processes and conditions surrounding long-term care decision-making and care management after traumatic brain injury. Grounded theory methodology and methods were used. Semi-structured interviews were conducted with a total of 51 participants in New South Wales, Australia. A grounded theory of care management was developed through constant comparison of data and cases and identified a social problem, a core social process, strategies, conditions and consequences. The basic social problem was the need for ongoing care, a problem which the person with brain injury and others managed collectively. Together, they determined an appropriate care location or living situation, configuration of carers and level of care. This study provides a framework for understanding preferred ways of living with care after brain injury. Increased autonomy was a desired outcome. Living alone and spending time alone were associated with increased autonomy and increased risk. A series of strategies and processes are suggested that allow professionals and family carers to gradually increase risk, and share responsibility for risk management. The findings have implications for health professional and legal practice, education, research and policy. / Doctor of Philosophy (PhD)

Very little is known about the effects of paediatric traumatic brain injury (TBI) on prospective memory, the memory for future intentions such as remembering to post a letter in the morning or do homework. The main aim of this thesis was to redress that shortcoming in the literature. To investigate the effects of paediatric TBI on prospective memory as reliably and fully as possible, the study of children and adolescents with brain injuries was preceded by a developmental study. Given that the process of recovery from brain injury is imposed on the ongoing process of development, it is important to understand more about the normal developmental trajectory of prospective memory first of all. Study 1 compared the prospective-memory performance of 88 normally developing children, adolescents and young adults. The main task was computerised, and its design was influenced by a prefrontal-lobe model because prospective memory is believed to be mediated by the prefrontal regions of the brain. Variables associated with prefrontal-lobe capacity were manipulated: the cognitive demand of an ongoing task, and the importance of the prospective task. Results of Study 1 found that children remembered to respond to fewer prospective cues than adolescents or adults, but that adolescents and adults remembered similarly. Further, the differences between the children's performance and the adolescents' and adults' widened as the cognitive demand of the ongoing task increased. However, the effects of increasing the cognitive demand did not vary between the adolescents and adults. It made no difference to anyone's performance whether the importance of remembering the prospective cues was stressed or not. On the other hand, performance on executive functions, as measured by the Self-Ordered Pointing Task (SOPT), the Stroop Colour Word Interference Test (Stroop), and the Tower of London (TOL), which are also believed to be affected by prefrontal capacity, produced the same age effects as were produced on the computerised prospective-memory task. Further, performance on the SOPT and Stroop predicted performance on the high-demand level of the prospective-memory task. Study 2 compared 34 children and adolescents with TBI with the non-injured children and adolescents from Study 1 on the same tasks. Results revealed that overall those with TBI had poorer prospective-memory performance than their non-injured peers. However, a different pattern of impairment was evident in the children than in the adolescents. Specifically, the children with TBI performed similarly to their non-injured peers, but the adolescents with TBI were significantly worse than the non-injured adolescents. This trend was most noticeable as the cognitive demand of the ongoing task increased. Further, the age and injury effects were reflected in the performances on the executive-function tests, and the TOL predicted performance on the high-demand, prospective-memory task in those with TBI. Study 3 aimed to examine the ecological validity of Study 2, by investigating whether the impairments in prospective memory in young people with TBI measured quantitatively, were matched with qualitative data. Twelve parents of children and adolescents with mild to severe TBI were interviewed about whether or not their children's injuries impacted on their memory (retrospective and prospective) in everyday life. Results showed that in general most children suffered memory losses as a result of their brain injuries, and that prospective-memory loss caused particular hardships for the children and their families. Taken together, the results of the current research revealed that the development of prospective memory reaches a peak of maturity in adolescence, and that adolescents with TBI show greater decrements in prospective memory than adolescents without TBI, but that this pattern is not evident in children, where those with TBI were not significantly different from those without. These findings give support to the prefrontal-lobe model of prospective memory by showing that prefrontal maturity, which reaches a peak during adolescence, reflects the prospective-memory performance of healthy adolescents, and prefrontal injury, which is very common with TBI, shows the effects of deficits more during adolescence than in earlier years when the prefrontal regions are not yet fully developed. Study 3 showed that impairments in prospective memory that result from TBI translate into disabilities in the real world. As a follow up it is recommended that rehabilitation strategies be designed to assist young people with prospective-memory impairments adjust better to school and the demands of everyday living. The prefrontal-lobe model should guide the design of such strategies.

Although it is well established that persons with traumatic brain injury (TBI) experience word retrieval difficulties, the underlying cause of these deficits is not known. Difficulties with word retrieval have negative social implications as they can impact on the ability to converse with others. The overarching goal of this dissertation was to determine the underlying cause of problems with word retrieval after TBI. To test word retrieval in this dissertation, participants were given a series of word fluency tasks and the speed of word generation was measured. In addition to measuring interresponse times, procedures used by Rohrer, Wixted, Salmon and Butters (1995) were also followed. This involved the calculation of parameter estimates to investigate whether slowed retrieval or degraded semantic stores were responsible for the patients� word retrieval difficulties. One parameter (N) was a measure of the total number of retrievable words and the second parameter (tau) was an estimate of mean latency. Study 1 was designed to trial the procedure and equipment adopted throughout this dissertation to analyse speech. University students were presented with categories on a computer screen and asked to generate as many exemplars as possible in 60 seconds. A PowerLab Chart sound system was used to measure the time that each word was generated. The results of Study 1 showed that the methodology of previous research could be replicated using the PowerLab Chart sound system. In Study 2, persons with postconcussion syndrome (PCS) and matched controls were given two word fluency tasks. Results showed that on both tasks patients recalled fewer words, had longer pauses between words, and took significantly longer to generate their first word than controls. Also, patients had a significantly reduced N relative to controls, but there was no difference in tau between patients and controls. Given that the participants had not finished responding and that parameter estimates require responses to be exhausted, Study 3 was designed to replicate the findings of Study 2 using an extended recall period. In Study 3, patients with PCS and matched controls completed a series of word fluency tasks and were given extended periods of time to generate words. Results showed that the patients obtained significantly fewer words on two of the tasks, but no evidence of slowed retrieval was found. There was also no difference in the estimates of N and tau between patients and controls. As the patients in Study 3 sustained more minor injuries than those in Study 2, Study 4 tested patients with severe TBI. In Study 4, patients with severe TBI and matched controls were given a series of word fluency tasks. Results showed that the patients generated fewer words and experienced slowed retrieval. Again, there was no difference in the estimates of N and tau between patients and controls. The results of Study 4 confirmed the hypothesis that slowed word retrieval is a consequence of TBI. Taken together, the results of this dissertation show that an underlying slowness of processing is the primary cause of problems with word retrieval in persons with TBI.

This study examines facilitated communication as it was experienced by three people who were affected by acquired brain injury. Facilitated communication is a type of augmentative communication purported to allow persons with a severe communication impairments to communicate. The assumption is made that people with global apraxia can communicate if given physical support. The technique usually involves a facilitator providing physical support to the arm, hand or elbow of the person with the severe communication impairment to assist them to point to objects, pictures, printed letters and words or to a keyboard. Facilitated communication is a controversial method because it is difficult to establish the existence, or extent of the facilitator's influence in the communication of the person with a disability. Although much of the research on facilitated communication has been conducted with people with intellectual or developmental disabilities, research on the use of the technique with people with brain injury offers several advantages. Firstly, most people with brain injury were known to be competent communicators prior to the brain injury. Secondly, many recover sufficiently to allow a retrospective examination of the issues that faced them when they were using the technique. Thirdly, there can be a large amount of data available about the person's diagnosis, their prognosis and the course of their history following the event. Consequently, the current study uses a case study methodology to explore the application of facilitated communication with people with brain injury and draws on personal recollections of people with brain injury, interviews with families and medical and therapist reports. The three people interviewed in the study displayed varying language and memory abilities. They indicated a preference for independent communication techniques and they reported frustrations with using facilitated communication. They quickly rejected the method when speech began to appear even though their speech was inadequate for communication purposes, for two of them, for an extended period. One of the interviewees reported that facilitator influence was overwhelming at times but not always present. Two of the interviewees felt that facilitated communication gave them a start in their recovery process. Two of the interviewees reported that meaningful exchanges with others occurred only with speech. In addition to these findings the study, although not experimental, was able to shed light on some of the contentious issues surrounding facilitated communication. The method is reported to be designed to overcome the motor difficulties of the disabled communicator by providing physical assistance to individuals with poor fine motor control thus breaking the perseveration cycle that can be present . However the task of coping with facilitator influence may actually require some motor skills. Also, the physical effort involved in using facilitated communication for some individuals may have been underestimated by its supporters. However the study has shown that some individuals with severe communication impairments felt that facilitated communication had some merit but saw their ability to communicate independently as the significant achievement in their recovery.

Hyper-activation of N-methyl-D-aspartate receptors (NRs) is associated with excitotoxic cell death during secondary injury following traumatic brain injury (TBI). The efficiency of the NR is dependent on the location of receptors in membrane raft microdomains that provide a platform for coupling of NRs and effector proteins. In many neurodegenerative diseases, activation of the autophagy pathway has been suggested to contribute to glutamate excitotoxicity, but whether increased autophagy signaling contributes to pathology after TBI has not been defined. In these studies, I investigate whether membrane rafts mediate NR signaling and autophagy in cortices of adult male rats subjected to moderate TBI and in sham-operated controls. These studies demonstrate that membrane rafts of the normal rat cortex contain a novel multi-protein signaling complex that links the NR2B glutamate receptor and the autophagic protein Beclin 1. TBI caused a rapid disruption of this complex in which NR2B and pCaMKII were recruited to membrane microdomains. Alteration in NR2B-Beclin 1 association in membrane rafts resulted in activation of autophagy as demonstrated by increased expression of key autophagic proteins Beclin 1, ATG 5 and ATG 7, and significant increases in autophagic vacuoles in neurons of traumatized brains. Administration of the NR2B antagonist RO 25-6981 significantly blocked TBI-induced redistribution of NR2B signaling intermediates and Beclin 1 and delayed the increase in autophagy protein expression in traumatized cortices. Thus, stimulation of autophagy by NR2B signaling may be regulated by redistribution of Beclin 1 in membrane rafts after TBI.

Disorders of consciousness (DOC) occur in severe cases of neurological disease and acquired brain injury, spanning the continuum from complete unresponsiveness (vegetative state) to partial conscious awareness with only erratic voluntary behavioral responses (minimally conscious state). Assessing the patient’s level of awareness of self and their environment through behavioral evaluation is notoriously difficult and may lead to misdiagnosis if residual cognitive function goes undetected. A number of studies (Di et al., 2007; Staffen et al., 2008; Coleman et al., 2007; Qin et al., 2010) applying brain-imaging methods to measure brain activity associated with processing self-referential stimuli (stimuli related to the self) have found similar responses between patients with DOC and healthy volunteers. The present study involved a unique pediatric patient with comorbid quadriplegia and non-communicative impaired awaress who underwent fMRI to explore brain activity associated with the auditory presentation of personally relevant language stimuli: the subject’s own name (SON) and a familiar voice (FV). Activation was observed in the left tranverse temporal gyrus across all auditory stimuli. Presentation of the SON revealed activation in the left ventromedial prefrontal cortex (vMPFC) and right dorsolateral prefrontal cortex (DLPFC) and presentation of the FV revealed activation in the left supramarginal gyrus. These findings provide evidence of preserved brain activity in this patient during the presentation of self-referential stimuli and therefore support the application of functional neuroimaging methods to detect residual brain activity in pediatric patients who display impaired awareness.