Doctor of Philosphy (PhD) / Agitation following traumatic brain injury (TBI) is characterised by a heightened state of activity with disorganised information processing that interferes with learning and achieving functional goals. This thesis outlines a series of studies across four research phases, investigating how occupational performance of adults with TBI is affected by agitated behaviour and information processing difficulties. Clinicians report the presence of agitation interferes with engagement in therapy and achievement of rehabilitation goals. Research Phase One used a retrospective chart review of 80 adults with severe TBI to identify a high incidence of agitated behaviour during inpatient TBI rehabilitation. Agitated behaviour was associated with lengthier rehabilitation admission, prolonged duration of post-traumatic amnesia (PTA), and poor cognitive functioning at discharge. The association between agitation and poor cognition persisted for at least two years after discharge, highlighting the significant impact of agitated behaviour on people’s ability to relearn cognitive skills for daily function. These initial research findings directed subsequent research phases, in which an information processing model was adopted to examine application of cognitive strategies during occupational performance. An emerging occupational therapy assessment, The Perceive, Recall, Plan and Perform (PRPP) System of Task Analysis, was selected as the primary method for evaluating how application of cognitive strategies during occupational performance is affected in agitated patients. Clinical utility of this measure was established in a case study of an adult demonstrating severely agitated behaviour during inpatient TBI rehabilitation, followed by examination of instrument reliability and validity with ten experienced occupational therapists and five adults with agitated behaviour following brain injury. The PRPP System of Task Analysis emerged as a valid and reliable method for determining strategy application deficits during occupational performance of adults with agitated behaviour, in acute stages of TBI rehabilitation. Consistent patterns of processing deficits were related to the Perceive and Recall Quadrants of the PRPP System. The assessment tool forms part of a dynamic, interactive assessment and intervention system. The PRPP System of Intervention was evaluated in the final research phase, using an experimental single case design with replication across eight adults. The effectiveness of PRPP Intervention was examined in comparison to conventional occupational therapy in an ABAB design. Efficacy of the PRPP Intervention was demonstrated, with patients applying significantly more information processing strategies to occupational performance tasks during PRPP Intervention than during conventional occupational therapy sessions. Agitated behaviour concurrently reduced over the period of the study. Relationships between information processing and agitated behaviour are hypothesised.

Diss. (sammanfattning) Göteborg : Göteborgs universitet, 2006. / Härtill 4 uppsatser.

Thesis (M.A.)--Miami University, Dept. of Speech Pathology and Audiology, 2004. / Title from first page of PDF document. Includes bibliographical references (p. 54-59).

Few authors report comprehensive psychometric data for their acquired brain injury (ABI) outcome indices (e.g., items analyses, test-retest reliability, survivor-proxy agreement, internal consistency, convergent validity). Even fewer authors submit their indices to modern psychometric analyses, like Rasch analysis. The purpose of this dissertation was to evaluate the traditional and modern psychometric properties of a new index of brain injury outcome: the Functional Outcome Profile (FOP). One hundred and thirteen mixed (estimated mild, moderate, and severe injury) ABI survivors and 22 significant others participated in the study. Items analyses (n = 113) revealed that all items were endorsed by at least one ABI survivor, suggesting that the FOP assessed areas relevant to ABI survivors. However most items, composite scores, and the total score had distributions that were negatively skewed. One-week test-retest reliability correlations for the total score, composites, and items (n = 25) were generally in the moderate to strong range (r > 0.7), while survivor-proxy agreement correlations for the items (n = 22) were generally in the moderate range (r = 0.5 to 0.7). The internal consistency scores (n = 113) for 5 of the 8 composite scales and for the full FOP were good (Cronbach α > 0.7). Concurrent-convergent validity analyses revealed that the FOP correlated moderately well with the Mayo-Portland Adaptability Index (MPAI-4) (r = -0.75), but that it did not correlate with injury-related information (e.g., age at injury, time since injury, estimated severity). Rasch calibration of the FOP resulted in a 62-item index that fit the Rasch model well and that demonstrated good reliability and separation. Overall, the results suggest that the FOP has good traditional and modern psychometric properties when used with community-based outpatient ABI survivors. Future studies with the FOP should focus on improving the FOP’s clinical utility and further verifying its convergent and divergent validity.

Acquired Brain Injury (ABI) can cause balance and mobility deficits with activity and participation limitations. Repetitive Functional Task Practice (RFTP), currently best practice to promote recovery, is often not delivered at an adequate volume due to limited resources. This case series looked at the feasibility of treating community-dwelling people with ABI, in a group format, thus allowing economical, intense rehabilitation. Four participants attended for four weeks, three days/week, 4.25 hours/day. One-to-one and semi-supervised therapy was delivered with one therapist and one assistant. 89.51 minutes of RFTP and 134.82 minutes of total physical therapeutic activity was delivered per day. Participant satisfaction was good. All participants improved on some clinical measures. Three participants improved single and dual-task balance measures. This project established feasibility, allowed the formation of guiding principles for and supported the value of future research and development of this ABI Boot Camp model. / February 2016

The primary goal of the American football helmet has been protection of players against skull fractures and other traumatic brain injuries (TBI) [Cantu 2003, Benson 2009]. TBI can result from short, high magnitude linear impact events typical of when the head impacts a hard surface [Gilcrhist 2003, Doorly 2007]. The modern helmet, which has evolved and become well designed to mitigate TBI injuries, does not offer sufficient protection against injury such as concussion, and the incident rate remains high in sport [Broglio 2009, Rowson 2012]. Researchers speculate rotation of the head leads to shear strain on the brain tissue, which may be the underlying mechanism of injury leading to concussive type injuries [Gennarelli 1971, Ommaya 1974, Gennarelli 1982, Prange 2002, Gilcrhist 2003, Aare 2003, Zhang 2004, Takhounts 2008, Greenwald 2008, Meaney 2011]. This has led researchers to investigate new liner materials and technologies to improve helmet performance and include concussive injury risk protection by attempting to address rotational acceleration of the brain [Mills 2003, Benson 2009, Caserta 2011, Caccese 2013]. To improve current football helmet designs, technology must be shown to reduce the motion of the brain, resulting in lower magnitudes of dynamic response thus reducing maximum principal strain and the corresponding risk of injury [Margulies 1992, Zhang 2004, Mills 2003, Kleiven 2007, Yoganandan 2008 Caserta 2011, McAllister 2012, Caccese 2013, Post 2013, Fowler 2015, Post 2015a/b]. Recent research has studied the use of decoupling liner systems in addition to the existing liner technology, to address resultant rotational acceleration. However, none of this previous work has evaluated the results in terms of the relationship between brain motion, tissue strain, and injury risk reduction. This thesis hypothesises the use of decoupling strategies to reduce the dominant coordinate component of acceleration in order to decrease maximum principal strain values. The dominant component of acceleration, defined as the coordinate component with the highest contribution to the resultant acceleration for each impact, is a targetable design parameter for helmet innovation. The objective of this thesis was to demonstrate the effect liner strategies to reduce the dominant component of rotational acceleration to decrease maximum principal strain in American football helmets.

Hypertonic saline (HS) is an accepted treatment for traumatic brain injury (TBI). However, the behavioral and cognitive consequences following HS administration have not thoroughly been examined. Recent preclinical evidence has suggested that nicotinamide (NAM) is beneficial for recovery of function following TBI. The first study compared the behavioral and cognitive consequences of HS and NAM as competitive therapeutic agents for the treatment of TBI. Following controlled cortical impact (CCI), bolus administrations of NAM (500 mg/kg), 7.5% HS, or 0.9% saline vehicle (1.0 mL/kg) were given at 2, 24, and 48 hrs post-CCI. Behavioral results revealed that animals treated with NAM and HS showed significant improvements in beam walk and locomotor placing compared to the Vehicle group. The Morris water maze (MWM) retrograde amnesia test was conducted on day 12 post-CCI and showed that all groups had significant retention of memory compared to injured, Vehicle-treated animals. Working memory was also assessed on days 18-20 using the MWM. The NAM and Vehicle groups quickly acquired the task; however, HS animals showed no acquisition of this task. Histological examinations revealed that the HS-treated animals lost significantly more cortical tissue than either the NAM or Vehicle-treated animals. HS-treated animals showed a greater loss of hippocampal tissue compared to the other groups. In general, NAM showed a faster rate of recovery than HS without this associated tissue loss. Study 1 suggested that future research into HS should include drug injection time course studies. Multiple injections may be responsible for the notable tissue damage. Therefore, it is possible that fewer injections will result in comparable behavioral recovery and less tissue damage that was observed. Due to the detrimental effects of 7.5% HS on cognition and hippocampal tissue following multiple administration in study 1, the proposed second study sought to study the behavioral and cognitive effects of HS using either single or multiple injection regime. The proposed study entailed a lengthier testing schedule than in study 1 and included the same histological examination to compare the different dosages. Additionally, edema formation was measured 24 hours following each drug endpoint in order to delineate the possible underlying mechanism of the observed deficits. In Study 2, HS tended to improve function on motor, sensorimotor and neurological tasks. Although this was a trend on all tests, animals treated with a single administration of HS overall performed better on all tasks compared to those receiving double or multiple injections. In the retrograde amnesia test, although not significant, the Sham, HS-2, and HS-24 animals showed improvement; whereas, the Vehicle and HS-48 animals showed no improvement in performance. This could possibly be linked to the additional hippocampal tissue loss that was noted in the HS-48 animals. In the working memory paradigm, the HS-2 and Vehicle groups had longer latencies to reach the platform than did the Sham group. However, after the first testing day, there were no significant differences between any of the groups. All animals treated with HS performed at the same rate and their performance either stayed the same over the three day testing period or became worse. It appears these animals were unable to learn and improve in the new memory acquisition task which is comparable to the results found in study 1. In study 1, there were again no observed hippocampal volume differences between the Sham and Vehicle-treated animals. However, there was extensive hippocampal tissue damage observed in all of the HS groups. Furthermore, animals treated with a single administration of HS had less hippocampal loss than those with double or multiple doses. Those animals receiving more than one dose of HS lost significantly more hippocampal tissue than the Vehicle group. The results of study 2 are comparable, and support, the results of study 1. Both studies support the strengths and weakness of HS therapy following TBI. Although there are potential benefits of HS therapy, there are also detrimental risks involved. Cognitive and structural damage could possible occur if the dosage amounts are not closely studied and monitored. Although the use of HS may be beneficial to reduce ICP following TBI, it appears that the use of HS may also lead to direct or indirect tissue loss possibly by chronic cellular dehydration. Stronger or more delineated effects may be noticed using higher doses or concentrations of HS in future studies. However, due to the nature of these results, caution should be advised with the use of all therapeutic usage of HS until further detailed studies are conducted.

Concussions are injuries that can result in debilitating symptoms, suffered by people of all ages, with children being at elevated risk for injury. Falls account for over 20% of head injuries worldwide, and up to 50% of concussive injuries in children. Following a concussion, children typically take longer for symptoms to resolve compared to adults. It is unknown whether or not children are more, less, or equally susceptible to concussive injury based on the mechanical response, with researchers divided on the subject. There is currently a paucity of published data for concussive injuries in children, with few studies investigating impact biomechanics and strain response in the brain using FE models. Those that exist typically rely on scaled adult models that do not capture age-dependent geometric properties, material properties of tissues, and the developmental stage of the brain reflected by the patterns of grey and white matter within the brain. Newer child models are being developed, however at present they are focused on car crash investigations that do not offer an accurate reflection of sports-related impacts, and those that could be experienced from day-to-day activities since impact characteristics (e.g. magnitude, duration, surface compliance) differ largely between these types of events. Strain magnitudes differ between events causing concussion in adults (falls, collisions, punches, and projectiles), so it follows that the unique impact characteristics of car crash events do not typically coincide with those associated with sports impacts. Car crash events can result in much longer impact durations compared to sporting impacts (100 ms duration in car crashes vs. 5-30 ms in sports impacts). The purpose of this thesis was to assess how the mechanical response of the brain in young children near 6 years old differs from an adult brain in cases resulting in concussive injury for sports impacts. Study one created a novel FE model of a 6-year-old brain, using medical images to extract an accurate representation of the geometry and tissues inside the head of a 6-year-old child. The developmental stage of the younger brain was captured using a highly-refined mesh to accurately represent the folds of white matter within the cerebrum. With no intracranial data for child cadavers available, published data of adult cadavers was used to validate the brain motion from impacts. Comparisons were made to a scaled adult model to highlight how the different model constructions influence brain motion and resulting strains. The new model showed higher correlation to the cadaver data compared to the scaled model, and yielded “good biofidelity” measures when assessed using a modified version of the normalized integral square error method. For young children, the new model was proposed to be more appropriate for concussion investigations as it captures age-appropriate geometry, material properties, and developmental stage of the brain, reflected in the patterns and volumes of grey and white matter within the brain. Study two tested the model for sensitivity across three levels of surface compliance and impact velocity consistent with sport impact events, and compared strain responses to a scaled adult model. The 6-year-old model showed unique strain responses compared to the scaled adult model with peak strains being lower across most impact events. Strain patterns also differed between models, with less strain being transmitted into the white matter in the 6-year-old model. Low compliance impacts yielded highest differences in strains (~30%), moderate compliance impacts yielded more similar strains (~9% lower), with high compliance impacts showing a location dependent response with frontal impacts being 14% lower, and side impacts being 9% higher than the scaled model. The sensitivity study characterized the model responses, allowing for better comparisons between the two different model constructions. Study three then compared the strain responses of reconstructed real-world concussive events for both children and adults. Forty cases of concussion from falls in children and adults (20 children aged 5-7, 20 adults) were reconstructed using physical models, with the measured impact kinematics used to load the FE models. Concussive cases of children showed lower strains than adults, finding a velocity driven relationship since the child concussions occurred at lower impact velocities compared to the adults. Lower peak strains, as well as cumulative strains in the child cases suggest that children are vulnerable to concussion at lower strain compared to adults. Protective strategies for children should address this vulnerability, no longer relying on product scaling to create head protection for youth.

While participation in youth sports bolster a myriad of health benefits, it can also pose a risk to the athlete's health from the increasing prevalence of repetitive mild traumatic brain injuries (TBI), often referred to as concussions. The adverse effects from repeated traumatic blows give a combination of acute symptoms, which may potentially develop into long-term complications. There is little known about the epidemiology of concussions, and thus the development of an animal model would help enhance our understanding of this potentially debilitating injury. An appropriate animal model should mimic the conditions of how concussions occur, in that there is not an invasive method to induce the injury and follows the same biomechanics. In our adolescent repetitive mild TBI model, we utilized a free-falling weight to deliver the traumatic blow to anesthetized mice that allowed free head rotation after impact. The injured group received one hit daily over the course of three days. The mice then underwent several behavioral tests to analyze the cognitive deficits, and the pathology of the tissue was analyzed via silver, Hematoxylin and Eosin (H&E), and Fluoro Jade-B staining. The injured mice developed both short- and long-term memory and spatial learning deficits, symptoms commonly found in concussed athletes, but failed to show deficits in anxiety and depression tests. The Fluoro Jade-B, silver and H&E staining resulted in negative signals for cell death. This study properly demonstrates repetitive mild TBIs in an adolescent mice model.

Please note: creative writing theses are permanently embargoed in OpenBU. No public access is forecasted for these. To request private access, please click on the locked Download file link and fill out the appropriate web form. / Richard and Nancy's son Jason has been in a car accident and suffered a brain-injury. Yesterday, he woke up from his coma, and he's finally home. Now, Richard and Nancy are forced to face one another, to deal with the blame they level at each other, the guilt they feel, and more importantly, their completely counter views on Jason's recovery. As they try to fight to get their son into the Shepherd Center, one of the best brain-injury rehab centers in the country, they must defend their home from Nancy's sister, Carol, her husband, Rick, and the secret they bring with them. Nancy and Richard must come to terms with their son's injury, forgive each other, and discover the truth of what really happened the night of the accident. / 2031-01-01