The Aim The aim of this study was to examine the effects of Animal Assisted Therapies with Farm Animals (AATF) with domesticated ducks on depression, anxiety, and self-efficacy in patients with traumatic brain injury (TBI) . Furthermore, the following hypothesis was tested: Engaging in AATF with domesticated ducks will be associated with decrease in depression, anxiety, and an increase in self-efficacy. Methods The study examined the effects of AATF on anxiety and depression among patients with TBI. Time series quasi-experimental design structure was utilized. At the beginning of the study participants received Hospital Anxiety and Depression Survey (HADS) and General Self Efficacy (GSE) questionnaires to evaluate the depression, anxiety, and self-efficacy. After that AAFT intervention started. AAFT intervention included two one-hour sessions interacting with ducks every week for 12 weeks. At the end of 12-week period participants received the same questioners. This was repeated in four weeks after the intervention ended to evaluate the residual effects of the intervention on anxiety and depression. Results General Linear Model was employed to examine changes in anxiety, depression, and self-efficacy. Participants presented with anxiety level decrease when means of pre and post intervention anxiety levels were compared. We discovered that these differences were significant based on an alpha value of .05, p = .009. There were no statistically significant differences between anxiety levels immediately post intervention and in four weeks the intervention was complete. There were no statistically significant differences discovered between depression levels pre, post, and retest. Also, there were no statistically significant differences discovered between self-efficacy levels pre, post, and retest. Conclusions Our study supported the part of hypothesis regarding an inverse association between time spent working with ducks and anxiety. Mastery of skills, vicarious experiences, and verbal persuasion may be the factors that contribute to the beneficial outcomes of the interactions between persons with TBI and domesticated ducks.

Traumatic brain injury (TBI) is a leading cause of disability in the United States (Coronado et al., 2011). There is a recognized need for better motor assessments to help mitigate these disabilities. Advances in markerless motion capture and in magnetic resonance imaging (MRI) provide an opportunity to improve clinical assessments, and link them to damage measured in MRI scans. The primary aims of this research were to 1) develop a quantitative motor assessment (QMA), and seed a normative database to enable comparison of impaired behavior to unimpaired, 2) test the sensitivity of the QMA, and 3) link QMA results to underlying TBI damage.The QMA developed in Aim 1 consisted of five tests: finger oscillation, tremor, visually guided movement, reaction time, and balance. We administered the QMA and traditional analgous tests to 132 healthy 18-50 year olds. We later added a coginitive motor integration (CMI) test and a stength-dexterity pinch test, then administered them to 31 (16 male, mean age = 24.7) healthy individuals. We seeded a normative database for the QMA and CMI measures. (A normative database for the pinch test already exists.) Correlations between the QMA and traditional tests were weak but the QMA results followed expected trends.In the second aim, 31 (16 male, mean age = 24.7 years) individuals with TBI completed all of the motor tests, and age- and gender-matched controls completed the CMI and pinch tests. We tested the sensivity of the QMA, the CMI and pinch tests, and traditional tests by their ability to correctly identify TBI subjects based solely on test results. The QMA was more sensitive than the other test groups. In Aim 3, we performed a stepwise regression to evaluate the relationship between motor deficits and brain injury, using motor test results and MRI images from the TBI and control groups. We found significant relationships between deficits in precision and increases in superior lateral ventricular volumes, deficits in pointing tasks and decreases in fractional anisotropy (FA) in the corticospinal tract, deficits in rhythmicity during finger oscillation and decreased FA in the thalamocortical tract. There were also relationships between each of the motor deficit measures and the FA values in the corpus callosum. This was the first step in showing that a quantitative motor assessment using markerless motion capture is feasible. The QMA is sensitive and can be linked to underlying brain damage. Though the QMA is not yet ready for clinical use, this research provides insights that will help address gaps in TBI rehabilitation.

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Objectives: A meta-analysis was conducted to determine the average effect size of internalizing and externalizing symptoms after pediatric traumatic brain injury across a range of severity (mild, moderate, and severe). Two-meta-regressions were also conducted to determine the role of age at injury at time since injury on these effect sizes.Participants and Methods: 9725 titles and abstracts were collected from PubMed, PsycInfo, and Web of Science. Of these, 63 full-text articles were examined for inclusion criteria to determine eligibility for the study. To be included, the studies needed to be published prior to March 2017 in English, needed to have a control group of either orthopedically injured or typically developing peers, and required a reliable and valuable measure of internalizing and externalizing symptoms in children. Studies were excluded for non-accidental head injuries or if the sample recruited was outside the range of 2-17 years old at the time of injury. The analysis was based on 16 studies including 1083 cases of mild TBI, 184 cases of moderate TBI, 214 cases of severe TBI, and 1605 control cases.Results: Analyses revealed a large effect size for internalizing symptoms of children with mild TBI (Hedges g = -0.624, p = 0.009), a small effect size for moderate TBI (Hedges g = -0.238, p = 0.029), and a large effect size for severe TBI (Hedges g = -0.923, p < .001). These findings indicate that parents rate childrens internalizing symptoms more severely for brain injured children than for typically developing or non-brain injured peers. These children may be experiencing more severe symptoms such as anxiety and depression regardless of injury severity. For externalizing symptoms, analyses demonstrated a moderate effect size for mild TBI (Hedges g = -0.531, p = 0.003), a small effect size for moderate TBI (Hedges g = -0.257, p = 0.007), and a large effect size for severe TBI (Hedges g = -0.909, p < .001). Thus, children who experienced a TBI demonstrated externalizing symptoms including hyperactivity and impulsivity with the largest effect size associated with severe TBI. The results of the meta-regressions indicated that only injury severity was a significant predictor of symptom severity.Conclusions: Using meta-analytic methods, we found that children who experience traumatic brain injury are rated as exhibiting more severe internalizing and externalizing symptoms across levels of severity. This effect was largest for severe injury and smallest for moderate injury. Caregivers and healthcare practitioners can use this information to better screen for and treat internalizing and externalizing symptoms in children after a traumatic brain injury.

Objectives: A meta-analysis was conducted to determine the average effect size of internalizing and externalizing symptoms after pediatric traumatic brain injury across a range of severity (mild, moderate, and severe). Two-meta-regressions were also conducted to determine the role of age at injury at time since injury on these effect sizes.Participants and Methods: 9725 titles and abstracts were collected from PubMed, PsycInfo, and Web of Science. Of these, 63 full-text articles were examined for inclusion criteria to determine eligibility for the study. To be included, the studies needed to be published prior to March 2017 in English, needed to have a control group of either orthopedically injured or typically developing peers, and required a reliable and valuable measure of internalizing and externalizing symptoms in children. Studies were excluded for non-accidental head injuries or if the sample recruited was outside the range of 2-17 years old at the time of injury. The analysis was based on 16 studies including 1083 cases of mild TBI, 184 cases of moderate TBI, 214 cases of severe TBI, and 1605 control cases.Results: Analyses revealed a large effect size for internalizing symptoms of children with mild TBI (Hedges g = -0.624, p = 0.009), a small effect size for moderate TBI (Hedges g = -0.238, p = 0.029), and a large effect size for severe TBI (Hedges g = -0.923, p <<> .001). These findings indicate that parents rate childrens internalizing symptoms more severely for brain injured children than for typically developing or non-brain injured peers. These children may be experiencing more severe symptoms such as anxiety and depression regardless of injury severity. For externalizing symptoms, analyses demonstrated a moderate effect size for mild TBI (Hedges g = -0.531, p = 0.003), a small effect size for moderate TBI (Hedges g = -0.257, p = 0.007), and a large effect size for severe TBI (Hedges g = -0.909, p <<> .001). Thus, children who experienced a TBI demonstrated externalizing symptoms including hyperactivity and impulsivity with the largest effect size associated with severe TBI. The results of the meta-regressions indicated that only injury severity was a significant predictor of symptom severity.Conclusions: Using meta-analytic methods, we found that children who experience traumatic brain injury are rated as exhibiting more severe internalizing and externalizing symptoms across levels of severity. This effect was largest for severe injury and smallest for moderate injury. Caregivers and healthcare practitioners can use this information to better screen for and treat internalizing and externalizing symptoms in children after a traumatic brain injury.

Both individual patient-related and injury-related factors predict functional outcomes following moderate-to-severe traumatic brain injury (M/S TBI). Other than binary outcomes such as death, little is known about the role of day-of-injury neuroimaging in predicting long- term outcomes. Classification systems for assessing the severity of injury using computerized tomography (CT) scans, such as the Marshall Classification System (MCS) or Rotterdam scale, have not been systematically studied to see how they relate to long-term rehabilitation and functional outcomes following M/S TBI. The MCS consists of six categories based on information about midline shift, basal cistern compression, surgery evacuation, and lesion size. The Rotterdam scale, however, is a summed score ranging from 1-6 based on the extent of basal cistern compression, extent of midline shift, presence/absence of an epidural lesion, and presence/absence of traumatic subarachnoid hemorrhage (tSAH) or intraventricular blood. The differences between these two CT scales suggest the possibility that MCS and Rotterdam scales may differ in their ability to predict subsequent rehabilitation outcomes. Thus, we compared the relative predictive value of MCS and Rotterdam scores on long-term rehabilitation functional outcomes using the Functional Independence Measure (FIM) at rehabilitation discharge and nine-month post-discharge follow up. The study included 88 participants (25 females, mean age: 42.0 [SD: 21.3]) with M/S TBI. Day-of-injury CT images were scored using both MCS and Rotterdam criteria. Functional outcomes were measured by the cognitive and motor subscales on the FIM at discharge and after nine-month follow up, and length of stay in rehabilitation. Data were analyzed using multiple linear regression models. Neither MCS nor Rotterdam scores nor rehabilitation length of stay significantly predicted motor or cognitive outcomes at discharge or nine-month follow-up. MCS and Rotterdam scales may have limited utility in predicting long- term functional outcome in a rehabilitation setting, but instead appear to be good predictors of acute outcomes, especially regarding mortality and elevated intracranial pressure (ICP). Future research could focus on CT characteristics such as midline shift to predict long-term rehabilitation outcomes to guide treatment instead of CT rating scales.

Magnetic resonance imaging is used to assess white matter (WM) abnormalities including total WM volumes and WM hyperintensities (WMHs). Comparisons between several qualitative and quantitative methods to assess WM that are used in research and clinical settings are lacking in pediatric traumatic brain injury (TBI). This study 1) WM methods including Scheltens ratings, manual tracings, NeuroQuant®, and FreeSurfer; (2) compared total WM volumes and WMHs to assess potentially similar reporting of WM integrity; and (3) assessed the relationship between cognitive functions (intelligence, attention, processing speed, and language) and WM in pediatric TBI.Sixty participants (65% male) between ages 8-13 years old, had a complicated-mild (53%), moderate (15%), or severe TBI (32%) with a mean age of 2.6 at the time of injury. NeuroQuant® WMH volumes had poor agreement (ICC = .24), and did not correlate (r = .12, p = .21) with manually traced WMH volumes. Scheltens WMH ratings had good to excellent agreement and correlated with NeuroQuant® (ICC = .62; r = .29, p = .005) and manually traced WMH volumes (ICC = .82; r = .50, p = .000). NeuroQuant® and FreeSurfer total WM volumes had fair agreement and were correlated (ICC = .52; r = .38, p = .004). No significant difference in total WM volumes were found between complicated-mild and moderate-severe TBI groups, and in subgroups with and without WMHs. Processing speed was significantly associated with Scheltens WMH ratings: p = .004, manually traced WMHs: p = .002, and NeuroQuant® WMHs: p = .007. No other association between cognitive functions and WM volumes or hyperintensities were found. Correlations between NeuroQuant® and manual tracings with processing speed differed by sex, where males had significant correlations but females did not. Deciding when to use manual tracing and NeuroQuant® WMH volumes and Scheltens ratings in clinical or research settings will depend on available resources (e.g., time, technology, funding, and expertise) and purpose of assessing WMHs. Total WM volumes did not appear to capture WM pathology as assessed by WMHs, likely due to the sample being underpowered and that total WM volumes possibly included WMHs. Limitations include restricted range of injury severity, heterogeneity of lesions, and small sample size. Additional research is needed in a larger sample of pediatric TBI.

Children and youth who suffer a mild traumatic brain injury or concussion are at risk for a number of negative outcomes. The symptoms of concussion and the management of these symptoms can be disruptive to the child’s everyday activities, especially if they are prolonged. Depression can result and may complicate the course of recovery. Depression has overlapping symptoms with concussion and is thought to lengthen the recovery period. There has been much research done in populations of mixed severities of brain injury but very little addresses children with concussion. Knowledge in this area is crucial due to depression’s impact on all aspects of functioning as well as the potential alteration of the child’s developmental trajectory. The purpose of this research was to examine the risks and predictors of depression following concussion in youth and to explore the experiences of a subsample of youth and their families with prolonged recovery from concussion, complicated by depression. Chapter One provides a review of the current literature setting the context for the research within what is known about concussion in youth, what is known about depression in youth and because of the early stages of this type of research, what is known about depression as an outcome of concussion in all age groups. Chapter Two presents a study highlighting the tangible risk for depression in a sample of children being followed in a tertiary care clinic (N=92). Significant predictors of depressive symptomatology were found to be the need for hospital admission and high symptom scores in the first few days and weeks after injury, which may be valuable information for prevention, early identification and treatment of youth at risk for depression after concussion. Chapter Three provides an in-depth exploration of the experiences of youth and families who have gone through prolonged recovery from concussion with significant depressive symptomatology. A phenomenological approach was used with six participants and their families who were interviewed and their responses analyzed. A trajectory of recovery was identified; common themes within each of four key stages of the trajectory were discussed and illustrated using direct quotes from the participants. Chapter Four outlines the important implications of these two studies for health care professionals; particularly in raising awareness of the mental health outcomes of concussion. Knowledge of the impact of debilitating symptoms, activity restrictions and depression can inform discussions early after a concussion to prepare and possibly prevent some of the losses experienced by youth that can lead to depression. / Thesis / Master of Science Rehabilitation Science (MSc)

Each year in the United States, approximately 1.35 million people are a ected by mTBI (aka concussion) and subsequent cognitive impairment. Approximately 33% of mTBI cases results in persistent long-term cognitive de cits despite no abnormalities appearing on conventional neuroimaging scans. Therefore, an accurate and reliable imaging method is needed to determine injury location and extent of healing. The goal of this study was to characterize and quantify mTBI through DTI, an advanced MRI technique that encodes voxel-wise tissue water microstructural di usivity as a tensor, as well as QSM, which measures iron deposition within tissues. We hypothesized that personalizing the analysis of DTI and QSM will provide a better understanding of trauma-induced microstructural damage leading to improved diagnosis and prognosis accuracy. Through regression analysis, a preliminary comparison between DTI data to QSM measurements was performed to determine potential correlations between the two MRI techniques. Further, a large database of healthy pediatric brain DTI data was downloaded and each was warped into a standardized brain template to ultimately use for voxel-wise z-score analysis of individual mTBI patients (n=26). This allowed localization and quantitation of abnormal regions on a per-patient basis. Signi cant abnormalities were commonly observed in a number of regions including the longitudinal fasciculus, fronto-occipital fasciculus, and corticospinal tract, while unique abnormalities were localized in a host of other areas (due to the individuality of each childs injury). Further, through group-based Bonferroni corrected T-test analysis, the mTBI group was signi cantly di erent from controls in approximately 65% of regions analyzed. These results show that DTI is sensitive to the detection of microstructural changes caused by mTBI and has potential to be a useful tool for improving mTBI diagnosis accuracy / Thesis / Master of Applied Science (MASc) / Concussions affect over one million people in the United States each year. In a number of cases, these individuals must cope with persistent long-term cognitive impairment resulting from the injury. A current, significant problem is that concussion cannot be reliably diagnosed using conventional CT and MR imaging methods. Therefore, an accurate and reliable imaging method is needed to determine both injury location and severity, as well as to monitor healing. The goal of this study was to quantify concussion through MR imaging techniques known as Di ffusion Tensor Imaging and Quantitative Susceptibility Mapping, which accurately model the brain's mi- crostructure. Analysis utilizing these MRI methods found signifi cant abnormalities in a number of brain regions of concussed subjects relative to healthy individuals. These results suggest that DTI, in particular, is sensitive to microstructural changes caused by concussions and has the potential to be a useful tool for improving diagnosis accuracy.

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