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PURPOSE: Sport-related concussions and migraine are both national healthcare concerns that cost billions of dollars in economic burden annually in the United States as well as cause hardship on the individual. More than 539,600 student-athletes in the United States will be directly affected by both comorbidities each year, and the health care providers that care for them will have to make decisions based on both conditions. How healthcare providers are educated on these two conditions, their attitudes in diagnosing and managing these conditions, and beliefs about their role has not been established (aim 1). Due to a common pathophysiology, pre-morbid migraine has been identified as a risk factor for worse outcomes after an individual sustains concussion. However, the impact of these conditions and prescribed medications on commonly used baseline assessments has not been identified (aims 2 and 3). This may have implications in student-athlete referral to other healthcare professionals, in interpretation of test results, and in management of post-injury cases. Many individuals diagnosed with migraine take daily preventative medication (e.g., topiramate); however, these medications have been identified to cause cognitive impairment but the deficit in the collegiate student athlete and on the baseline concussion assessment is unknown (aim 3). Since cognitive exams make up a large portion of the concussion baseline assessment, identifying any real or perceived deficits in these tests may also allow healthcare providers to make decisions for test interpretation for these individuals. PARTICIPANTS: For aim 1, certified athletic trainers from the National Athletic Trainers’ Association and targeted social media groups were recruited to take a novel electronic survey. A total of 576 individuals that completed more than 90% of the survey were included in the final analysis. Student-athletes participating in club and varsity sports at Temple University undergoing routine baseline concussion assessments were recruited to have their data included for aims 2 and 3 (non-migraine = 387, migraine = 33, missing migraine status = 137). METHODS: The survey for aim 1 consisted of 7 subgroups of questions: demographics, concussion, migraine, and comorbid knowledge and atttitudes and beliefs. Questions mainly consisted of true/false and likert-style questions. For aims 2 and 3, student-atheltes completed their routine annual concussion baseline assessment. This consisted of a health history questionnaire, symptom checklist, Hospital Anxiety and Depression Scale, cognitive assessments, postural control test, and vestibular/oculomotor exams. Indiviudals that self-reported a history of migraine were included in aim 3 for analysis of medication use. RESULTS: For aim 1, 61% of respondents had a masters degree and 40% worked in middle or high school athletics. Over 94% of respondents previously reported receiving concussion education, compared to only 40.5% for migraine education. Respondents were able to correctly identify an average of 74% of concussion signs and symptoms and 66% of migraine signs and symptoms. Collegiate and split positions were associated with more negative concussion attitudes and beliefs. A lack of previous concussion or migraine education was associated with more negative attitudes and beliefs. For each year clinically practicing, attitude and belief scores were slightly more positive (β = 0.03 – 0.70, p < 0.001). Females also generally had more positive attitudes and beliefs across outcomes (β = 1.09 – 2.61, p < 0.001). A total of 577 student-athletes were included in aims 2 and 3. Having migraine was associated with 2.36 more symptoms (p = 0.008) and a 5.20 higher severity score (p = 0.005). Migraine was also associated with a 5.58 higher odds of a slower reading time on the King-Devick (p < 0.01). From ImPACT, having migraine decreased visual memory composite by 9.97-points (p = 0.02) and visual motor composite score by 3.89-points (p = 0.07). Of the 33 student-athletes with migraine, 15 were taking a prescription medication, 3 were taking an over-the-counter medication or supplement, and 7 were taking both. None of the athletes were taking a daily preventative medicaton for migraine. The median Migraine Disability Assessment score was 4.5, indicating only little or no disability. The Brief Disability Questionniare showed no significant difference between those with and without migraine (Kruskall-Wallis (1) = 0.4, p = 0.50). Finally, there was high provider trust as measured with the modified Patient-Doctor Relationship Questionniare, and no significant difference between those with and without migraine (Kruskall-Wallis (1) = 1.59, p = 0.21). CONCLUSION: This was one of the first studies to identify athletic trainer knowledge, attitudes and beliefs surrounding concussion and migraine. Idenitfying groups with decreased atttitudes and beliefs can be used for targeted programming and ensuring these athletic trainers have support to increase knowledge and attitudes and beliefs for more positive patient outcomes. This study also determined that migraine affects some aspects of baseline concussion assesments. This can be used by clinicians during test interpretation for patient care. These student-athletes had low measures of disability and high levels of provider trust, key components for individuals with migraine to receive appropriate care. Concussion and migraine are significant healthcare concerns present in populations seen by athletic trainers. Future studies exploring post-concussion migraine effects and medication over the course of collegiate career should be considered. Adequate knowledge and positive attitudes and beliefs would be beneficial in ensuring appropriate medical care given to individuals experiencing these conditions. / Kinesiology

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Traumatic brain injuries (TBI) are a leading cause of death worldwide. Previous research supports a relationship between vitamin D and TBI outcomes; however, they rely on animal studies. This review aimed to examine the neuroprotective role of vitamin D in humans with TBIs. A search was completed (PubMed and Scopus) following PRISMA guidelines to review publications investigating the relationship between vitamin D deficiency (VDD) and TBI or the effect of vitamin D supplementation on TBI outcomes; 8 studies were identified. Patients had thefollowing ranges: 26-88% deficiency and 62-88% insufficiency compared to 24% and 49% of the general population. Supplementation reduced ventilation duration, improved the quality of consciousness, and significantly improved mini-mental status examination scores. Research showed high percentages VDD/insufficiency in TBI patients. Results remain consistent suggesting a neuroprotective effect of vitamin D. Further research is needed to understand the effect of vitamin D status and supplementation on TBIs.

Atrophy of the corpus callosum (CC) is a documented consequence of moderate-to-severe traumatic brain injury (TBI), which has been expressed as volume loss using quantitative magnetic resonance imaging (MRI). Other advanced imaging modalities such as diffusion tensor imaging (DTI) have also detected white matter microstructural alteration following TBI in the CC. The manner and degree to which macrostructural changes such as volume and microstructural changes develop over time following pediatric TBI and their relation to a measure of processing speed is the focus of this longitudinal investigation. As such, DTI and volumetric changes of the CC in participants with TBI and a comparison group at approximately three and 18 months post injury and their relation to processing speed were determined.

Researchers studying the long-term cognitive sequelae of mild traumatic brain injury (mTBI) have produced disparate results. Some studies have shown little to no long-term cognitive effects while others have shown that persistent cognitive sequelae continue to affect a subgroup of patients. Meta-analysis has been used to try to integrate these contrasting results to foster a coherent understanding of the cognitive outcomes following mTBI. However, previous meta-analyses of long-term cognitive sequelae have used studies from a period of mTBI research where methodological rigor has been called into question (Carroll, Cassidy, Holm, Kraus, & Coronado, 2004). Using studies from this period, meta-analysts found little to no effect for long-term cognitive sequelae after mTBI: g = 0.07, d = 0.12 (Binder, Rohling, & Larrabee, 1997), g = 0.11(Frencham, Fox, & Mayberry, 2005), and d = -0.07 (Rohling et al., 2011). The present meta-analysis was conducted to address problems with methodological rigor in the studies used in these previous meta-analyses and address differences in meta-analytic methodology (Pertab, James, & Bigler, 2009). Studies published between January 2003 and August 2010 were rated using the 4-tiered American Academy Neurology (AAN) guidelines for methodological rigor to ensure homogeneity and the methodological rigor of included studies. Seven studies were identified that met criteria for a rating of I or II and five met criteria for the lower ratings of III or IV. When studies of all ratings were combined, a significant effect of g = 0.45 was observed. When only studies rated I and II were combined, a significant effect of g = 0.52 was observed while a significant effect of g = 0.38 was observed when only studies rated III and IV were combined. These effect sizes for long-term cognitive sequelae are much larger than those found in previous meta-analyses. Based on these results, it is likely that methodological rigor and/or heterogeneity amongst included studies can impact meta-analytic effect sizes associated with long-term cognitive sequelae following mTBI. However, analyses did not show that more rigorous studies (i.e., those rated I or II) had significantly higher effect sizes than less rigorous studies (i.e., those rated III or IV), t(10) = .636, p = .845. This non-significant finding may be a result of the analysis being underpowered given the small k. Significant effects for neuropsychological domain were also observed and are reported. Additionally, a conceptual critique of mTBI is made with recommendations for future development of the rating system that Cappa, Conger, and Conger (2011) have put forth for objectively rating the methodological rigor of neuropsychological studies. Concerns are addressed related to the mTBI literature in the areas of mTBI definition, definition of cognitive impairment, problems with the constructs of post-concussion syndrome (PCS) and persistent post-concussion symptoms (PPCS), heterogeneity of outcome measurement, and unaccounted for variables.

With the advancement of protective gear and medical aid, soldiers are now surviving traumatic experiences that were once fatal. As a result, the prevalence of brain injury and posttraumatic stress disorder in military service members has grown. Those who have obtained brain injury are at risk of developing chronic traumatic encephalopathy, a neurodegenerative syndrome. To date, there is no cure, treatment, or diagnostic method (besides autopsy) for chronic traumatic encephalopathy. Because chronic traumatic encephalopathy and posttraumatic stress disorder present many of the same symptoms and have the possibility of deriving from the same traumatic experience, an investigation of a potential link is necessary. This study explores the possibility of chronic traumatic encephalopathy being misdiagnosed as posttraumatic stress disorder. This is done by analyzing the frequency of brain injury along with the comorbidity of posttraumatic stress disorder and brain injury. This thesis also proclaims the need for research that attempts to develop diagnostic criterion and treatment methods for chronic traumatic encephalopathy.

BACKGROUND: Several groups have instituted helmet initiatives with varying success across the world. Helmet use has been well documented to prevent traumatic brain injury. Despite the known benefits, many people, including university students, refuse to utilize helmets when riding bikes, mopeds, or motorcycles. We recognized a need within our community regarding the lack of helmet use at University of Florida and developed a program to institute change. METHODOLOGY: We identified community champions and hosted weekly round table discussion initiatives. Through these round table discussions we identified events already going on within the community and developed new opportunities to promote helmet use. We had stories from survivors and parents, utilized school administration support, and partnered with local bike shops. RESULTS: The pilot initiative was successful in increasing awareness across the city and got stakeholders excited in the process. It also spearheaded more data driven initiatives that will look at reduction of traumatic brain injuries in the clinical setting. CONCLUSION: This project highlights the University of Florida Helmet Initiative that has already generated renewed interest in safety and traumatic brain injury prevention. The school of nursing has implemented safety protocols and further support is being garnered by the administration across campus. Most importantly we have identified community champions that will carry the work forward.

The plan of care in occupational therapy for caregivers of children with acquired brain injury (ABI), created through goal setting, is the foundation for providing services in a pediatric neurorehabilitation setting. During the first year after the injury, caregivers often experience gaps in education, feelings of decreased competence, and decreased understanding of the recovery process. These factors can make developing goals a challenge for caregivers and service providers alike. Although a number of goal-setting mechanisms exist, they currently lack options sensitive to this population’s unique needs. This project set out to explore the clinical barriers involved in goal setting in pediatric rehabilitation and to develop a relevant solution that guides the process. The results identified two theoretical models to use as “lenses” by which the problem was explored and understood. An explanatory model was developed to highlight relationships among contributing factors. A thorough review of evidence was conducted and synthesized to support the explanatory model, and existing solutions explored. Shared-decision making in healthcare through the use of decision aids was identified and investigated as a promising direction for solution development. The Guide for Occupational ALliance (GOAL) in Pediatric Rehabilitation is a shared decision-making and measurement tool designed to facilitate collaborative goal setting with caregivers of children with ABI. The GOAL fosters a family-centered approach that provides education while facilitating discussion around caregiver preferences. Additionally, it gathers helpful outcome data on caregivers’ comfort and satisfaction with goal setting in order to gauge change over time. The GOAL implementation will involve gathering insights, testing the tool, and disseminating the findings. It will be evaluated in three phases: Phase 1, a needs-assessment process involving collection of caregiver and clinician data; Phase 2, a pilot test of the GOAL to explore its effectiveness, content relevance, validity, and benefits; and Phase 3, a repeated measure-outcomes study to understand its reliability, validity, and effectiveness. The GOAL provides an opportunity to enhance collaboration during goal setting with caregivers of children with ABI and their occupational therapy service providers for optimal outcomes.