Community reintegration and participation have been shown to be significantly correlated to improved Quality of Life (QoL) following moderate to severe traumatic brain injury (msTBI), yet these models often come with significant levels of unaccounted variability (Pierce and Hanks, 2006). Measures for community participation frequently employ objective measures of participation, such as number of outings in a week or current employment status (Migliorini et al., 2016), which may not adequately account for lifestyle differences, especially in aging populations. Less often integrated are subjective measures of an individual’s own belongingness and autonomy within the community (Heineman et al., 2011), also referred to as their participation enfranchisement (PE). The present study examines three questions pertinent to the potential clinical value of PE. First, do measures of objective participation significantly predict an individual’s PE ratings? Second, are both types of measures equally successful predictors of QoL for aging individuals with chronic-stage msTBI. Finally, would controlling for either objective or subjective integration ratings enable neurocognitive assessments to better predict QoL post injury?

41 older-adults (M= 65.32; SD= 7.51) with a history of msTBI were included (M= 12.59 years post-injury;SD= 8.29) for analysis. Subjective community integration was measured through the Participation Enfranchisement Survey. The Participation Assessment with Recombined Tools-Objective (PART-O) provided the objective measurement of participation. Quality of life was assessed through the Quality of Life after Brain Injury (QOLIBRI). An estimate of neurocognitive performance was created through the Brief Test of Adult Cognition by Telephone (BTACT), which includes six domains including: verbal-learning and memory (immediate and delayed recall), working memory (digit-span backwards), reasoning (number sequencing), semantic fluency (category fluency), and processing speed (backwards counting). Performance on the BTACT, PE ratings, and PART-O scores were included as the dependent variables in stepwise, linear regression models predicting QoL ratings to assess the differential contribution of the dependent variables and potential interaction effects.

While both the PART-O (f(1,39)=5.52;p=.024,n2=.124) and the PE survey (f(1,39)=14.31 ;p<.001,n2=.268) significantly predicted QoL, the addition of PE in the PART-O model resulted in significant (20.9%) reduction in unaccounted variance. Further in the model controlling for PE, PART-O no longer provides a significant (p=.15) contribution to the model estimating QoL (f(2,38)=8.41; p=.001). Performance on the BTACT correlated with PART-O (p<.0001), but not PE (p=.13) ratings. Finally, across two models controlling for BTACT performance, PE (p=.002,partial n2=.23), but not PART-O (p=.28,partial n2=.031) contributed significantly to QoL predictions. No significant interactions between PART-O, PE, and/or BTACT were observed when added to any model.

MsTBI impacts nearly every facet of an individual’s life, and as such, improving QoL post-injury requires a broad, yet well-considered approach. The objective ratings of participation, subjective PE, BTACT performance, all independently predicted quality of life in this sample. However, after controlling for neurocognitive assessment performance, PE was shown to independently contribute to quality of life, while the PART-O ratings no longer provided significant contribution. While community integration is a vital factor to consider for long-term rehabilitation, tailoring what “integration” means to the patient may hold significant potential to improve long-term quality of life.

It has been posited that alcohol use may confound the association between greater concussion history and poorer neurobehavioral functioning. However, while greater alcohol use is positively correlated with neurobehavioral difficulties, the association between alcohol use and concussion history is not well understood. Therefore, this study investigated the cross-sectional and longitudinal associations between cumulative concussion history, years of contact sport participation, and health-related/psychological factors with alcohol use in former professional football players across multiple decades.

Former professional American football players completed general health questionnaires in 2001 and 2019, including demographic information, football history, concussion/medical history, and health-related/psychological functioning. Alcohol use frequency and amount was reported for three timepoints: during professional career (collected retrospectively in 2001), 2001, and 2019. During professional career and 2001 alcohol use frequency included none, 1-2, 3-4, 5-7 days/week, while amount included none, 12, 3-5, 6-7, 8+ drinks/occasion. For 2019, frequency included never, monthly or less, 2-4 times/month, 2-3 times/week, >4 times/week, while amount included none, 1-2, 3-4, 5-6, 7-9, 10+ drinks/occasion. Scores on a screening measure for Alcohol Use Disorder (CAGE) were also available at during professional career and 2001 timepoints. Concussion history was recorded in 2001 and binned into five groups: 0, 1-2, 3-5, 6-9, 10+. Depression and pain interference were assessed via PROMIS measures at all timepoints. Sleep disturbance was assessed in 2001 via separate instrument and with PROMIS Sleep Disturbance in 2019. Spearman’s rho correlations tested associations between concussion history and years of sport participation with alcohol use across timepoints, and whether poor health functioning (depression, pain interference, sleep disturbance) in 2001 and 2019 were associated with alcohol use both within and between timepoints.

Among the 351 participants (Mage=47.86[SD=10.18] in 2001), there were no significant associations between concussion history or years of contact sport participation with CAGE scores or alcohol use frequency/amount during professional career, 2001, or 2019 (rhos=-.072-.067, ps>.05). In 2001, greater depressive symptomology and sleep disturbance were related to higher CAGE scores (rho=.209, p<.001; rho=.176, p<.001, respectively), while greater depressive symptomology, pain interference, and sleep disturbance were related to higher alcohol use frequency (rho=.176, p=.002; rho=.109, p=.045; rho=.132, p=.013, respectively) and amount/occasion (rho=.215, p<.001; rho=.127, p=.020; rho=.153, p=.004, respectively). In 2019, depressive symptomology, pain interference, and sleep disturbance were not related to alcohol use (rhos=-.047-.087, ps>.05). Between timepoints, more sleep disturbance in 2001 was associated with higher alcohol amount/occasion in 2019 (rho=.115, p=.036).

Increased alcohol intake has been theorized to be a consequence of greater concussion history, and as such, thought to confound associations between concussion history and neurobehavioral function later in life. Our findings indicate concussion history and years of contact sport participation were not significantly associated with alcohol use cross-sectionally or longitudinally, regardless of alcohol use characterization. While higher levels of depression, pain interference, and sleep disturbance in 2001 were related to greater alcohol use in 2001, they were not associated cross-sectionally in 2019. Results support the need to concurrently address health-related and psychological factors in the implementation of alcohol use interventions for former NFL players, particularly earlier in the sport discontinuation timeline.

Some active-duty military service members and veterans experience combinations of persistent traumatic stress, depression, suicidal ideation, anger, aggressive behavior, substance misuse, sleep disturbance, complicated grief, moral injury, headaches and migraines, chronic bodily pain, and cognitive weakness or deficits. The purpose of this study is to describe the clinical outcomes of active-duty service members and veterans who have completed the traumatic brain injury (TBI) and brain health track of a two-week intensive clinical treatment and rehabilitation program.

The sample included 141 participants, with a history of TBI, in the Intensive Clinical Program (ICP). The ICP is a multidisciplinary, two-week treatment and rehabilitation program for active duty service members and veterans with complex psychological, cognitive, and physical health concerns. The program is comprised of daily individual therapy, group psychotherapy, psychoeducation, skills-building groups, and complementary and alternative medicine treatments. Participants in the ICP completed the following measures prior to initiating treatment and immediately following completion of treatment: Neurobehavioral Symptom Inventory (NSI), Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5), Patient Health Questionnaire-9 (PHQ-9), Self-Efficacy for Symptom Management Scale (SE-SMS), and Patient-Reported Outcomes Measurement Information System (PROMIS)-Satisfaction with Participation in Social Roles and Activities-Short Form 8a, version 1.0 (PROMIS-S). Wilcoxon signed ranks tests were used to examine differences in scores on self-report measures from pretreatment to posttreatment for the full sample and within three subgroups stratified by age (in years: 20-34; 35-45; and 46-66). For the NSI, changes in the proportion of participants endorsing moderate or worse levels of individual symptoms from pretreatment to posttreatment were assessed using McNemar’s tests. Alpha levels were set at p<0.05 for all analyses.

Participants reported statistically significant improvements across all of the administered measures (NSI, PCL-5, PHQ-9, PROMIS-S, and SE-SMS) upon conclusion of treatment. Effect sizes ranged from medium to large (d=0.34-1.04) for the full sample. Effect sizes were largely consistent across age subgroups (20-34: d=0.32-1.05; 35-45: d=0.55-0.96; 46-66: d=0.28-1.05). The magnitude of change on the SE-SMS appeared to be less with increasing age (20-34: d=1.05; 35-45: d=0.69; 46-66: d=0.28). Individual item analyses for the NSI revealed statistically significant reductions in the proportion of participants endorsing moderate or greater severity from pretreatment to posttreatment for 18 of 22 symptoms.

Active duty service members and veterans participating in the two-week TBI and brain health intensive clinical program reported considerable symptom reduction at the conclusion of the program. Further research is indicated to assess the durability of symptom reduction.

Return to driving after moderate-to-severe traumatic brain injury (TBI) is often a key step in recovery to regain independence. Survivors are often eager to resume driving and may do so despite having residual cognitive limitations from their injury. A better understanding is needed of how cognition and self-awareness impact survivors’ driving after injury. This study examined the influence of cognition and self-awareness on driving patterns following moderate-to-severe TBI.

Participants were 350 adults aged 19-87 years (mean age = 46 years; 70% male) with history of moderate-to-severe TBI, who resumed driving and were enrolled in the TBI Model System. Cross-sectional data were obtained ranging 1-30 years post injury, including questions on driving practices, the Brief Test of Adult Cognition by Telephone (BTACT), and the Functional Independence Measure (FIM). Self-awareness of cognitive function was measured via the discrepancy between dichotomized ratings (intact versus impaired) of objective cognitive testing (BTACT) and self-reported cognitive function (FIM Cognition subscale). Driving patterns included frequency (driving 'more than once a week’ versus 'once a week or less') and restricted driving behavior (total number of driving situations the survivor described as restricted, ranging 0-15). Regression analyses were conducted to examine the relationships between cognition, self-awareness, and each driving outcome (frequency and restriction), followed by causal mediation analyses to examine the mediating effect of self-awareness. Demographics (age, sex, education), injury characteristics (time since injury, injury severity, history of seizures in past year), and medical/social factors (family income, motor function, urban-rural classification) were included in the models as covariates.

Thirty-nine percent of survivors had impaired self-awareness, 88% of survivors drove numerous times per week, and the average survivor reported limited driving in 6 situations (out of 15 total situations). Cognition was inversely related to impaired self-awareness (OR = 0.03, p < 0.001) and inversely related to restricted driving behavior (b = -0.79, p < 0.001). Motor function was positively related to impaired self-awareness (OR = 1.28, p < 0.01). Cognition was not related to driving frequency, and self-awareness did not mediate the relationships between cognition and driving patterns (all p > 0.05).

Most survivors who drive after their injury are driving frequently, but the situations they drive in differ based on their cognitive ability. Impaired self-awareness of cognitive deficits is common after TBI, and self-awareness of cognitive function does not affect driving patterns. Future research needs to focus on how cognition affects nuanced aspects of driving behavior after injury (i.e., types of situations survivors drive in).

Previous research has shown that positive outcomes are associated with receiving a neuropsychological evaluation (NPE). The current project examined hospitalization outcomes following an NPE in a sample of patients who had sustained a traumatic brain injury (TBI). Hospitalization rates were compared between the two years pre- and two years post-evaluation. The role that insurance status plays on these health outcomes was also examined. This project is part of a growing effort to evaluate outcomes of clinical neuropsychological services in order to better characterize the broad health impacts of NPEs.

Participants for the current study come from the Optum® de-identified Electronic Health Record dataset. The final sample included 245 patients who completed at least one NPE and were diagnosed with a TBI, according to ICD codes associated with their healthcare records. Patients were aged 21-87 (M = 51.55, SD = 16.74) with an average Charleston Comorbidity Index of 1.77 (SD = 2.41). The sample consisted of 124 females (50.6%), 121 males (49.4%). The majority of the sample identified as non-Hispanic white (N = 213; 86.9%), while 8.6% identified as another race or ethnicity. Regarding insurance, the most common insurance type was commercial (61.6%), followed by Medicare (13.5%), Medicaid (9.4%), and uninsured (6.5%). Those with unknown insurance status, race, or ethnicity were excluded from analyses of those variables.

Hospitalization incidence for the sample was significantly lower in the two years following a NPE, X2(1, N = 245) = 26.98, p < .001, compared to the two years prior. The mean number of hospitalizations were also lower following a NPE (t(244) = 4.83, p < .001). Insurance status did not show a significant main effect or interaction on mean number of hospitalizations over time. Regarding demographic variables, there was no significant main effects of race/ethnicity group or interaction between race/ethnicity and hospitalization rate change over time. However, there was a significant interaction between hospitalization rate change over time and gender (F(242) = 4.74, p = 0.030). A significant decrease in hospitalizations over time was seen for males (p < .001), while females showed a trend-level decrease that approached significance (p = .06).

Consistent with previous research, significant reductions in hospitalization incidence and mean number of hospitalizations were seen following a NPE. This finding did not vary based on insurance status. However, hospitalization outcomes varied as a function of gender. These findings suggest that completing a NPE following a traumatic brain injury may contribute to improved hospitalization outcomes, but it does not appear that this benefit is seen equally for all patients. Insurance status may play a role in accessibility to care and hospitalization outcomes in this population, but that relationship is likely influenced by other factors, including racial identity, gender, and income. Future research is needed to investigate the extent that NPEs impact hospitalization rates in the broader context of insurance, demographic factors, and socioeconomic status.

To assess the impact of injury severity on disease specific quality of life after Traumatic Brain Injury

The study was carried out in Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India after obtaining ethical clearance from Institute Ethics Committee. Sixty consecutive patients aged 18 and above with moderate to severe TBI (GCS score of 3-12 at admission) attending the Outpatient Department of Neurosurgery Specialty were screened. Out of 60 participants, 40 had moderate TBI (GCS 9-12) and 20 patients had severe TBI (GCS 3-8). The participants having any pre-existing major psychiatric disorders, intellectual disability, current or past history of substance abuse, degenerative and/or progressive condition, terminal illness and past history of TBI were excluded. Written informed consent was obtained from each participant. Socio-demographic details and information about clinical status at the time of admission and discharge were obtained from participant and hospital records. Disease specific quality of life was measured by QOLIBRI (Quality of life after brain injury). It is a self-reported measure comprising of 37 items. The first part assesses the subjects’ satisfaction with his HRQL in 4 domains (cognition, self, daily life and autonomy, and social relationships). The second part measures how much the subject is bothered after TBI in 2 domains (emotions and physical problems). The other tools administered were Glasgow Outcome Scale and Barthel’s Index of Activities of Daily Living (functional status); Mini Mental State Examination (cognitive status): Hospital Anxiety and Depression Scale (anxiety and depression).

The data was analyzed using statistical package for social sciences software version 21 (SPSS). There were no significant differences between both groups with regard to age, gender, education status, marital status, family type and place of residence. Both groups were similar with regard to mode of injury and duration of injury. With regard to treatment during admission both group had significant differences. Among severe TBI group 90% underwent surgical intervention whereas among moderate TBI group only 45% underwent surgical intervention. Significant difference was present in GCS score at discharge between both the groups. After 6 months of injury both group had no significant difference with regard to functional status, global cognitive functioning, anxiety and depression. With regard to quality of life significant difference emerged between the groups on QOLIBRI total score. On various subscales of QOLIBRI - significant differences were noted only in the domains of social relationship and emotions. There were no differences between them on domains of cognition, self, daily life and physical problems.

After 6 months of TBI, the participants in both groups (Moderate TBI and severe TBI) had similar functioning with regard to daily activities and psychological functioning. With regard to quality of life both groups emerged to be significantly different on overall quality of life and domains of social relationship and emotions.

Metacognitive deficits are common following traumatic brain injury (TBI), and this has important implications for recovery, social relationships, and rehabilitative outcomes (Chiou et al., 2011; Flashman & McAllister, 2002; Ownsworth & Fleming, 2005). Metacognitive deficits have historically been measured using self-report (Allen & Ruff, 1990; Newman et al., 2000; Sherer et al., 1995; Sherer et al., 1998), which is problematic as individuals with an awareness of deficit cannot accurately reflect on their own condition (Akturk & Sahin, 2011). In the past two decades, studies have transitioned to using more objective measures to assess metacognition, including error monitoring tasks (McAvinue et al., 2005; Yeung & Summerfield, 2012) and tasks using retrospective confidence judgments (RCJs) (Busey et al., 2000). Importantly, both tasks are used to study “metacognition,” but clear distinctions as to what domains these tasks measure has not been elucidated. Additionally, both tasks have been linked to executive functioning broadly, but error detection tasks are uniquely associated with measures of attention and self-reported anxiety (Hoerold et al., 2008; O’Keefe et al., 2007), indicating that there may be distinct processes that comprise metacognition. It is a goal to determine what domains these tasks represent so proper assessments of metacognitive ability can be conducted in this population.

Participants included 23 older adults with moderate-severe TBI and 16 age, sex, and education matched healthy control (HC) individuals ages 53-80. All participants received identical neuropsychological test batteries, including two tasks of metacognition (error monitoring task, RCJ task), neurocognitive tasks of attention (Digit Span - Forward, Trail Making Test A) and executive functioning (Digit Span - Backward, Trail Making Test B), and a self-report measure of anxiety (Brief Symptom Inventory - Anxiety subscale). To determine overlapping constructs measured by the two metacognitive tasks, these tasks were correlated with each other and with an attention composite, executive functioning (EF) composite, and anxiety measure in the TBI and HC groups.

In the TBI group, the metacognitive tasks were significantly correlated with each other (r=-0.47, p=0.022). The RCJ task was associated with EF (r=0.47, p=0.025), but not with attention (r=0.20, p=0.358) or anxiety (r=0.25, p=0.248). The error detection task was associated with EF (r=-0.48, p=0.021) and attention (r=-0.46, p=0.026), but not with anxiety (r=-0.19, p=0.383). In the HC group, there were no significant associations between the metacognitive tasks, or between either metacognitive task and EF, attention, or anxiety.

For older adults sustaining TBI, tasks of error detection and tasks using retrospective confidence judgments measured an overlapping construct, with both having an association with executive functioning and only the error detection task being associated with attention. Interestingly, these associations were not found in a healthy control sample of older adults. Both metacognitive tasks have been used in the literature to measure errors of awareness, but this study provides insight that these tasks are measuring different domains of metacognitive ability in older individuals with TBI. Use of multiple tasks of metacognitive ability in this population can help to describe where the deficits of awareness occur following TBI.

Traumatic brain injury (TBI), very common in the United States (US) and occurring at highest rates in older adulthood, is a documented risk factor for cognitive impairment and dementia. However, the full scope of the problem is unknown, as comparative incidence of TBI among older adults is poorly characterized. Moreover, the effect of demographics (race/ethnicity, sex) and cognitive and medical status, as well as education, socioeconomic status, and other social determinants of health (SDOH) on TBI risk is not well understood. We aimed to explore the impact of demographics, cognitive and medical status, and SDOH on vulnerability to new TBIs among older adults.

Enrollees 65 and older in the nationally representative Health and Retirement Study (HRS) who consented to have their survey data linked to Medicare claims and had not experienced a head injury prior to HRS enrollment were studied. We used claims data 2000-2018 to obtain incident TBI diagnoses and harnessed the detailed demographic, cognitive, medical, and SDOH information available in the HRS. Incident TBI was defined using inpatient and outpatient International Classification of Disease (ICD 9 and 10) codes received the same day as an emergency room (ER) visit code and a computed tomography (CT) scan code, occurring after the enrollee’s baseline HRS interview. We calculated descriptive statistics and bivariate associations for TBI status with demographic and SDOH characteristics measured at baseline using sample weights to account for the complex survey design.

Of respondents meeting inclusion criteria (n=9273) during the study follow-up period of 18 years, 8.9% received emergency room treatment for a TBI. Older adults who experienced TBI during the study period were more likely to be female (p=0.0006), and white (p=0.0001), to have normal cognition (vs. cognitive impairment or dementia, p=0.0011), higher education (p<0.0001), and higher income (p=0.01). Having lung disease (p=0.0003) or functional impairment (p=0.03) at baseline were protective against experiencing a TBI.

Our results suggest that almost 9% of US older adults received ER treatment for a new TBI during the 18-year study period, and that race, sex, and SDOH factors may increase risk for, or be protective against, TBI. This novel investigation into the impact of demographics and SDOH on incident TBI suggests access to care may impact who gets treatment for TBI. Further study is indicated and may lead to opportunities for both targeted intervention (e.g., primary TBI prevention) to groups most at risk as well as identification and mollification of the most relevant structural and contextual factors (e.g., access to care) to reduce risk of TBI among older adults.

To determine the association between blood markers of white matter injury (e.g., serum neurofilament light and phosphorylated neurofilament heavy) and a novel neuroimaging technique measuring microstructural white matter changes (e.g., diffusion kurtosis imaging) in regions (e.g., anterior thalamic radiation and uncinate fasciculus) known to be impacted in traumatic brain injury (TBI) and associated with symptoms common in those with chronic TBI (e.g., sleep disruption, cognitive and emotional disinhibition) in a heterogeneous sample of Veterans and non-Veterans with a history of remote TBI (i.e., >6 months).

Participants with complete imaging and blood data (N=24) were sampled from a larger multisite study of chronic mild-moderate TBI. Participants ranged in age from young to middle-aged (mean age = 34.17, SD age = 10.96, range = 19-58) and primarily male (66.7%). The number of distinct TBIs ranged from 1-5 and the time since most recent TBI ranged from 0-30 years. Scores on a cognitive screener (MoCA) ranged from 22-30 (mean = 26.75). We performed bivariate correlations with mean kurtosis (MK) in the anterior thalamic radiation (ATR; left, right) uncinate fasciculus (UF; left, right), and serum neurofilament light (NFL), and phosphorylated neurofilament heavy (pNFH). Both were log transformed for non-normality. Significance threshold was set at p<0.05.

pNFH was significantly and negatively correlated to MK in the right (r=-0.446) and left (r=-0.599) UF and right (r=-0.531) and left (r=-0.469) ATR. NFL showed moderate associations with MK in the right (r=-0.345) and left (r=-0.361) UF and little to small association in the right (r=-0.063) and left (r=-0.215) ATR. In post-hoc analyses, MK in both the left (r=0.434) and right (r=0.514) UF was positively associated with performance on a frontally-mediated list-learning task (California Verbal Learning Test, 2nd Edition; Trials 1-5 total).

Results suggest that serum pNFH may be a more sensitive blood marker of microstructural complexity in white matter regions frequently impacted by TBI in a chronic mild-moderate TBI sample. Further, it suggests that even years after a mild-moderate TBI, levels of pNFH may be informative regarding white matter integrity in regions related to executive functioning and emotional disinhibition, both of which are common presenting problems when these patients are seen in a clinical setting.

There are many common beliefs within the general public about Chronic Traumatic Encephalopathy (CTE) that contradict research findings and scientific evidence. Therefore, the goal of this study was to examine the accuracy of CTE knowledge across three diverse samples.

The three groups included in the sample were 333 college students (54%), 196 individuals from the public (32%), and 90 psychology trainees/clinicians (54%) for a total of 619 participants. Online surveys were used to collect the CTE knowledge accuracy (i.e., the number correct divided by the total number of questions) of the sample. The questions about CTE were adapted from Merz et al. (2017) and from the Sports Neuropsychology Society’s “CTE: A Q and A Fact Sheet.”

Overall, CTE knowledge accuracy was 52% (M = 51%, SD = .24). Regarding inaccurate beliefs, two-thirds of the sample believed that CTE was related to sports participation alone even if a head injury did not occur, and most participants believed that CTE could be caused by a single injury. Additionally, confidence in CTE knowledge was positively correlated with willingness to allow their child to play a high contact sport despite overall low CTE knowledge accuracy. Last, many participants reported education (67%) and health care providers (61%) as their main sources of CTE information while only 18% of participants cited television/movies. However, when asked to provide additional details about their CTE information source, many participants cited ESPN specials and the movie “Concussion” as the main reason they learned of the condition and sought out additional information.

The results of this study are consistent with previous research on CTE knowledge accuracy. This further supports the need for clinicians and researchers to address misconceptions by providing information and scientific facts.

Individuals who have experienced traumatic brain injury (TBI) are at an elevated risk for worsened physical and psychological outcomes. Increased rates of anxiety and depression, along with cognitive issues, are common post-TBI. While there is some evidence that anxiety and depression may affect objective cognitive performance, less is known about their effect on other factors that are associated with the individual’s capacity to complete the task, such as perceived workload of the cognitive task. Workload represents an individual’s perception of task difficulty and serves as a proxy for the magnitude of mental demands a given task places on an individual. Preliminary findings in the literature suggest that individuals with TBI commonly report greater workload when completing cognitive tasks compared to neurotypical peers, but the influence of anxiety and depression on survivors’ workload remains unclear. Considering the elevated rates of psychological and cognitive problems in individuals with TBI, the present study examined the moderating role of anxiety and depression on TBI survivor workload perception of a stress-inducing working memory task.

Ten participants with moderate to severe TBI and eight neurologically healthy controls performed the Paced Auditory Serial Addition Task (PASAT). After completing the PASAT, participants reported their subjective workload using the NASA task load index (NASA-TLX). Participants also completed measures of psychological functioning, including the Chicago Multiscale Depression Inventory (CMDI) and the State-Trait Anxiety Inventory (STAI). Relationships between workload and depression and trait anxiety were examined using linear regression.

Linear regression was employed for both the TBI and the healthy control groups to assess the influence of trait anxiety and depression on perceived workload. There was no significant difference between the TBI and HC NASA perceived workload scores. Within the TBI group, there was a significant anxiety by depression interaction (b = -.015, p < .001). Simple slopes analyses revealed that for TBI participants reporting low depression, perceived workload increased with increased anxiety (b = .093, p < .001). For TBI participants reporting high depression, perceived workload decreased as anxiety increased (b = -.38, p = .03). While there was also significant anxiety by depression interaction in the healthy control group (b = .033, p = .04), simple slopes analyses revealed that there were no significant associations for healthy controls.

These results demonstrate that in TBI, level of depression moderates the relationship between anxiety and workload perception. The pattern observed in the TBI group was unique from controls. The present findings suggest that post-TBI, higher depression may temper the influence of anxiety on stressful cognitive task performance and workload rating. The tempering effect of high depression in TBI may represent a biased reporting style or impaired assessment of task difficulty, which may ultimately affect the individual’s capacity to accomplish a task well.

Mobile phone reminding apps can be used by people with acquired brain injury (ABI) to compensate for their memory impairments. However off-the-shelf apps may be difficult to use. ApplTree has been developed to be accessible to this group, compared to off-the-shelf reminding apps such as Google Calendar. This pilot feasibility trial aimed to establish the feasibility of running (and issues that should be addressed to complete) a randomised controlled trial comparing ApplTree to Google Calendar in an ABI community treatment setting.

Adults with self or other reported memory difficulty after an ABI were enrolled (n=39). Those who completed the baseline phase were randomised (n=29) and randomly allocated to the Google Calendar or ApplTree intervention. They were shown a 30 minute video tutorial of the app and an assessment on their ability to use it. Timely completion of everyday memory tasks were measured for a 3 week pre-intervention baseline and 3 week post-intervention follow-up phase. Participants also completed neuropsychological tests assessing memory, attention and executive function and gave qualitative feedback on the app and their experience in the trial.

Recruitment rate was 58% of the target (29 were randomised, n=50 was the target in 2 years). Retention rate was 65.5% and adherence rate was 57.9%. While the feasibility trial was not powered to calculate efficacy, there was a 13% increase in everyday memory tasks completed on time for those in the ApplTree group (n=10) compared to baseline and no change for the Google Calendar group (n=9). Feasibility results indicate 72 participants would need to fully complete a trial to detect the minimum clinically important difference (12.5% increase in successful performance of everyday memory tasks) in the efficacy of ApplTree compared to Google Calendar, should such a difference exist.

The challenges with recruitment of people receiving community care for ABI are highlighted in this trial and discussed along with the impact of the Covid-19 pandemic. Methodological considerations for researchers or clinicians looking to measure everyday memory ability are discussed. The majority (19 of 21) of participants who were given an app were capable of learning to use it during an hour-long session. This indicates it is a feasible intervention that community ABI services could offer. Participant feedback highlighted the merits of design features implemented in ApplTree that can improve the uptake and utility of reminding apps.

Semantic verbal fluency (SVF) has traditionally been correlated with activity in the left anterior temporal lobe. Damage to the anterior temporal lobe, such as from a traumatic brain injury (TBI) or neurodegenerative disease, can result in impairments in semantic fluency and language expression. Although the orbitofrontal cortex (OFC) is not well studied as being correlated to this process, its functional connectivity to language-related brain regions, such as the inferior frontal gyrus (Broca’s area), suggests it may also play a role in SVF. In fact, preliminary research has shown that lesions in the OFC are associated with semantic fluency deficits (Almairac et al. 2015). As such, the goal of this study was to investigate whether OFC volume correlates with SVF in a population of Veterans with a prior TBI.

Thirty-five Veterans who sustained TBIs were included in this study (11% female, age M = 41.77, SD = 11.27; years of education M =14.94, SD = 1.62). All participants underwent a magnetic resonance imaging (MRI) and regional normative volumes were standardized to account for differences in brain size (volume of brain area/total brain volume). Participants were given the Delis Kaplan Executive Function System (D-KEFS) verbal fluency subtest to measure verbal generativity. A Pearson correlation was conducted to investigate the relationship between OFC volume and SVF performance. Post hoc analysis was conducted with Veterans who met the criteria for a TBI sustained by a blast to the head (n = 25).

A significant positive correlation emerged between left OFC volume and semantic fluency (category subtest; p = .03, r = .35). Additional analyses with Veterans with blast-related TBIs indicated a significant correlation between the volume of the OFC and performance on the category (p = .02, r = .45), and switching (p = .02, r = .43) subtests of the D-KEFS verbal fluency test.

These findings demonstrate a correlation between the volume of the left OFC and SVF performance. Specifically, Veterans with TBIs had decreased volume of the OFC which correlated with deficits on a SVF task. Among Veterans with blast-related TBIs, both category and category switching subtests correlated with OFC volume. Given the functional connectivity between the OFC and language areas of the brain, this study highlights the importance of analyzing associated cortical regions beyond the anterior temporal lobe when studying SVF performance.

Metacognition refers to one’s ability to make online, in-the-moment judgments regarding their own cognitive performance, and has significant implications for one’s abilities to function in daily life. It has been documented that individuals with TBI often present with metacognitive deficits, and are slower than neurotypical peers in making such judgments. Preliminary attempts have been made to determine how neural contributions to metacognitive functioning differ after injury. Studies thus far have found unique roles of prefrontal gray matter volume and inter-network connectivity in metacognitive functioning after injury, but functional activation directly associated with metacognitive processing has yet to be investigated. This event-related functional magnetic resonance imaging (fMRI) study aimed to document differences in functional activation between adults with TBI and neurotypical peers when completing metacognitive confidence judgments.

16 adults with moderate to severe TBI and 10 healthy adults (HCs) completed a metacognitive task while in the fMRI scanner. All participants were exposed to target slides with polygons arranged in various positions, then asked to identify the target slide from a group including 3 other distractor slides. Following each response, participants provided a metacognitive retrospective confidence judgment (RCJ) by rating their confidence that the answer they provided was correct. Meta d', a signal-detection based metric of metacognitive accuracy, was calculated. FSL FEAT was used for processing and analysis of the imaging data. Contrasts were created to model activation that was greater when RCJs were made compared to target recognition, mixed effects modeling was then used to investigate group differences. Cluster based thresholding set to z>2.3, p<0.01 was used for multiple comparisons correction.

Healthy controls performed significantly better on the target identification task (p<0.01), and were faster at making RCJs (p=0.03). Individuals with TBI had greater meta d’ scores (p=0.03). Significant activation beyond what was present during target recognition (RCJ>recognition) was found in left supramarginal gyrus, left posterior cingulate, and left cerebellum when individuals with TBI made RCJs, while HCs showed significant activation in the left precuneus, and bilateral superior temporal gyri. Individuals with TBI demonstrated more activation in the lateral occipital cortex bilaterally and the left cerebellum than HCs when completing RCJs. HCs presented with more activation in the left supramarginal gyrus than the TBI group when making RCJs.

The areas of activation present in both the TBI and HC groups are consistent with previous imaging findings from studies of healthy samples. Interestingly, two structures previously implicated in self-directed cognition and consciousness, the posterior cingulate and precuneus, were differentially activated by the groups. The lack of a common network between the two groups suggests that survivors may rely on separate neural substrates to facilitate metacognition after injury. The TBI group was found to recruit more functional areas when completing the RCJs. These findings, paired with the behavioral data indicating metacognitive performance differences, suggests that neural recruitment may occur after injury to allow for survivors to engage in making metacognitive judgments. Future qualitative investigations of the metacognitive judgments are needed to determine the compensatory nature of this postinjury recruitment.

To investigate differences of the perceived unmet needs in a post-acute brain injury sample when referred to Resource Facilitation (RF) among various race/ethnic groups.

The methodology utilizied within this study consisted of a retrospective chart review, which was sourced from a clinical database serving chronic outpatients in the Midwest region. The main outcome measure was the Service of Unmet Needs & Service Use (SUNSU). The sample consisted of N = 455 subjects, which included a small sample size of Hispanics (N=7). Therefore, African American and Hispanic groups were combined for a total minority sample (N=84). Clinical disorders included within the study was an ABI from either stroke, anoxic injury, ruptured aneurysm, or tumor resection surgery. Eligibility criteria included participants’ admission into a RF program, a vocational goal, and a diagnosis of a moderate to severe TBI or other ABI. Lastly, key sociodemographic features included age, race, ethnicity, education, and sex.

Significant differences were found between ethnic groups (white non-Hispanics and minority group) in terms of years of education (p=<.01). White non-Hispanics had higher education (M=13.39, SD=2.23), reported significantly more rural addresses (40.2%, p=<.01), and had private insurance coverage more frequently than the minority group (33.7%, p=<.01). The full model was statistically significant, R2=.077 = F(4,450) = 9.387, p<.0001; adjusted R2 = .069. The addition of ethnicity led to a statistically significant increase in R2 of .019, F(1,450) =9.025, p<.0005.

Ethnicity was found to be a predictive factor for greater unmet needs even after controlling for insurance, employment status, and urbanicity. It is currently unknown RF’s success rate in providing culturally competent services to different racial/ethnic groups, which consider factors such as primary language spoken, immigration status, and additional ethnocultural factors that could deter accurate reporting of unmet needs by minoritized groups. Future studies should investigate barriers in referring and meeting eligibility for this program and analyze post-treatment data to determine if the impact of racial, geographic, and insurance disparities is mitigated with RF treatment.

Cognitive flexibility, typically measured using neuropsychological tasks of set-shifting, has been associated with mental and physical health, social relationships, resilience, and overall quality of life (Diamond, 2013; Chen et al., 2014; Davis et al., 2010; de Abreu et al., 2014; Genet et al., 2011). Previous research has found conflicting results regarding the relationship between set-shifting and various measures of functional outcomes in individuals with traumatic brain injury (Allanson et al., 2017). The present study examined the relationship between cognitive flexibility and adaptive functioning in individuals with acquired brain injuries (ABI).

Participants in this research are adults (n = 116) with severe, chronic ABI who completed a neuropsychological evaluation through Bancroft Neurorehab between 2012-2022. Participants ranged in age from 20.4 - 67.8 years (M = 45.8). Individuals included in data analysis completed Trails A and B, Wide Range Achievement Test, Fourth Edition (WRAT-4) Word Reading, and Texas Functional Living Scale (TFLS). Set-shifting ability was measured using Trails B and adaptive functioning was measured using the TFLS. Word reading ability, measured using the WRAT-4, was included as a covariate to account for the impact of word reading difficulties on Trails B performance.

A simple linear regression was conducted to examine if Trails B T-score (M = 24.7) and WRAT-4 Word Reading Standard Score (M = 87.8) predicted TFLS Total T-score (M = 35.8). The overall regression model was statistically significant (R2 = .351, F(2, 113) = 32.0, p < .001). It was found that lower performances on Trails B (ß = .272, p <.001) and WRAT-4 Word Reading (ß = .189, p <.001) both significantly predicted a lower TFLS Total T-score.

Set-shifting and word reading ability significantly predicted the overall adaptive functioning score on the TFLS which adds to a body of literature that suggests that the ability to think and behave flexibly affects functional aspects of everyday living. These findings are consistent with previous literature regarding the association between cognitive flexibility and adaptive functioning in the general population, and these results add to the growing body of research on cognitive flexibility in individuals with brain injury. Clinicians may use an individual’s set-shifting performance to estimate and further assess potential difficulties in completing activities of daily living. This information may assist in subsequent treatment planning and identifying treatment goals of cognitive rehabilitation consistent with rehabilitation psychology’s goals of increasing levels of adaptive functioning and quality of life (Division 22 of the American Psychological Association, n.d.). Future research may examine if certain domains of adaptive functioning are more or less affected by impairments in cognitive flexibility. Future research may also examine patterns of set-shifting performance, such as sequencing errors vs. set-loss errors, associated with specific areas of insult.

Modern perspectives of rehabilitation after traumatic brain injury (TBI) emphasize the importance of individualized holistic approaches (i.e., physical and psychological adjustment) and collaboration toward goals (e.g., among the survivor, rehabilitation professionals, family/friends, etc.). Recent research has sought to employ a holistic, value-based approach (via the Valued Living Questionnaire) to measuring goals and whether those with TBI are acting in accordance with them, and quality of life outcomes. However, no research has examined whether rehabilitation practices are consistent with survivor values using this framework. The aim of the current study was to investigate the impact of value-consistent rehabilitation practices on quality of life and psychological adjustment outcomes in those with TBI.

The current study included a sample of 73 adults with a history of TBI (M years since injury = 7.6, SD = 9.7) between the ages of 18 and 72 (Mage = 44.0 years, SD = 13.1; 73% female, 90.4% white) who had participated in outpatient rehabilitation. Individuals were recruited from brain injury support groups on Facebook and completed a series of surveys measuring TBI severity [Ohio State University Traumatic Brain Injury Identification Method-Short Form (OSU-TBI-ID)], value-consistent rehabilitation practices [modified Valued Living Questionnaire (VLQ)], life satisfaction [Life Satisfaction Questionnaire-9 (LiSat-9)], and psychological flexibility [Acceptance & Action Questionnaire - Acquired Brain Injury (AAQ-ABI)]. Discrepancy scores were calculated to compare perceived importance of and how helpful rehabilitation was for each VLQ domain. Bivariate Pearson correlations were conducted to investigate the relationships between value-consistent rehabilitation, life satisfaction, and psychological flexibility.

The VLQ domains with the greatest discrepancies were spirituality (-2.26), marriage/intimate relations (-2.06), and family relations (-2.02) such that rehabilitation helped less in these domains despite their importance. Greater levels of value-consistent rehabilitation were related to higher levels of life satisfaction overall (r = 0.40, p < 0.001) and lower levels of reactive avoidance of emotions related to one’s brain injury (r = -0.26, p = 0.03). In terms of specific domains of life satisfaction, greater value-consistent rehabilitation was related to higher levels of vocational (r= 0.44, p < .001), physical self-care (r = 0.28, p = 0.018), and friendship satisfaction (r= 0.41, p < .001).

Our findings suggest rehabilitation practices may not be acting proportionately with TBI survivor values. Moreover, our results suggest value-consistent rehabilitation is important for long term quality of life and psychological adjustment outcomes. Future work should seek to identify factors that optimize opportunity for individualized treatment.

Research indicates that Veterans with a history of traumatic brain injury (TBI) are at increased risk for dementia. Although the precise mechanisms underlying this relationship are poorly understood, remote TBI may exacerbate normal age-related changes to cerebral white matter (WM) and result in cognitive decline. However, Veterans commonly experience a constellation of mental (e.g., post-traumatic stress disorder [PTSD] and depression) and vascular (e.g., diabetes, hypertension, obesity) health conditions that have also been implicated in pathologic cerebral WM and cognitive aging trajectories. Therefore, the present study sought to (1) clarify the effects of remote TBI within the context of PTSD, depression, and vascular risk on WM micro- and macrostructure, and (2) explore if WM integrity is associated with cognition in a sample of Vietnam-Era Veterans.

The sample consisted of 195 male Veterans ages 60-80 (mean age=69.3) enrolled in the Department of Defense-Alzheimer’s Disease Neuroimaging Initiative (DoD-ADNI) study. 102 Veterans met criteria for TBI by sustaining a head-injury that resulted in a loss of consciousness, alteration of consciousness, or post-traumatic amnesia. Current and/or lifetime PTSD was designated by scores >30 on the Clinician-Administered PTSD Scale. The Geriatric Depression Scale was used as a continuous measure of depression. A vascular risk score (0-3) was calculated based on diabetes, hypertension, and obesity (BMI >30 kg/m2). An executive functioning composite was created by averaging sample-specific z-scores for Trail Making Tests (A and B), with higher scores indicating worse performance. Voxelwise analysis of WM microstructure (fractional anisotropy [FA]) was conducted with Tract-Based Spatial Statistics (TBSS), using non-parametric permutation testing with threshold-free cluster enhancement. SPM’s Lesion Segmentation Tool was used to investigate WM macrostructure (WM hyperintensity [WMH] volume). Lesion probability maps were masked to restrict WMH volume calculations to WM. Robust regression using M-estimation and predictive R2 calculated using 10-fold cross-validation examined WMH volume, predictor, and cognitive associations. Age was a covariate in all WM analyses, and education was a covariate in all cognitive analyses.

TBSS analysis revealed widespread, significant negative relationships between vascular risk and FA across numerous WM tracts (p’s<0.05). These associations remained significant after adjusting for TBI history, PTSD, and depression. TBSS identified significant positive relationships between executive functioning performance and FA across similar brain regions (p’s<0.05). Robust regressions revealed that vascular risk significantly predicted WMH volume (p=0.006; ß=0.161; R2=0.093), whereas TBI history, PTSD, and depression did not (p’s=0.107-0.166; ß's=-0.089-0.101). WMH volume significantly predicted executive functioning (p=0.002; ß=0.216; R2=0.105), whereas TBI history, PTSD, depression, and vascular risk did not (p’s=0.123-0.888; ß's=-0.012-0.125).

Our results suggest that vascular health, relative to remote TBI, PTSD, and depression, may be more robustly associated with cerebral WM micro- and macrostructure in older Veterans. Furthermore, poorer WM integrity is associated with poorer cognitive performance. These findings underscore the importance of vascular health interventions in preventing negative brain and cognitive aging outcomes in Veterans, independent of TBI history. Future studies might leverage other neuroimaging modalities (e.g., functional MRI) to further investigate the effects of vascular health on aging in Veterans with a history of TBI.

Social participation (SP) represents a key goal in TBI rehabilitation, as it allows the individual to return to active and purposeful roles in the community. However, studies on predictors of SP specific to post-acute universally accessible specialized rehabilitation pathways following TBI are scarce. Our objectives were thus to 1) characterize a literature-based set of pre-injury, injury-related, and post-injury variables, as well as SP (measured with the MPAI-4 Participation scale) in individuals participating in inpatient-outpatient or outpatient rehabilitation pathways within a universally accessible and organized trauma continuum of care and 2) assess the use of these variables to predict SP outcome after TBI for each rehabilitation pathway.

Participants (N = 372) were adults admitted between 2016 and 2020 to an inpatient-outpatient rehabilitation pathway or an outpatient rehabilitation pathway after sustaining a mild, moderate or severe TBI. The French-Canadian adaptation of the MPAI-4 questionnaire (Malec, 2005; Guerrette & McKerral, 2021; McKerral et al., 2014) presents three subscales (Abilities, Adjustment, Participation) and a total score, assessing functional and SP outcome after TBI. The MPAI-4 is completed for all individuals at admission and discharge in three major rehabilitation centers in the greater Montreal region. Independent variables consisted of sociodemographic and clinical characteristics collected from medical files and rehabilitation databases. Outcome measures consisted of a general SP level (MPAI-4 Participation subscale score at discharge from outpatient rehabilitation) and productivity status at discharge (productive if employed, child rearing, homemaker, student or volunteering; unproductive if unemployed or retired). Multiple and logistic regressions investigated the predictive value of each variable for SP outcome and productivity, separately for each rehabilitation pathway.

Samples’ sociodemographic and clinical characteristics differed between rehabilitation pathways. The inpatient-outpatient sample presented older age, lower productivity before TBI and poorer SP levels at admission and discharge from rehabilitation. However, both samples showed significant improvement on SP levels during rehabilitation. For the inpatient-outpatient rehabilitation path, general SP outcome was significantly predicted by three variables (education years, MPAI-4 Ability and Adjustment scores at rehabilitation intake; R2 = 49%), whereas productivity status at discharge was significantly predicted by age at time of injury (R2 = 72%). For the outpatient rehabilitation path, general SP outcome was significantly predicted by five variables: premorbid hypertension, mental health diagnosis, total indirect rehabilitation hours received, MPAI-4 Abilities and Adjustment scores at rehabilitation intake (R2 = 47%), while productivity status at discharge was significantly predicted by age at time of injury and education years (R2 = 44%).

Different TBI rehabilitation care pathways showed distinct sample characteristics, as well as different premorbid and post-injury predictors of SP outcome and productivity. This highlights the importance of being aware of the potential limited generalizability of previously identified predictors when extrapolated to different clinical, rehabilitation and sociocultural contexts. The predictive models obtained could help clinicians identify more accurately patients at risk of showing poorer SP and productivity outcomes at end of rehabilitation, influence intervention approaches put forward with these individuals and set more appropriate goals and expectations.

Following a traumatic brain injury (TBI), the majority of patients report difficulties with prospective memory (PM). However, there is not always a significant relationship between subjective and objective PM measures. Several variables may influence the degree of severity of perceived difficulties, including the severity of the injury and psychoemotional status. The aim of this study was to determine whether the severity of the TBI and anxiety and depressive symptoms were related to objective and subjective difficulties of PM.

50 patients (mean age = 31,3 years old) with a TBI (20 mild and 30 moderate/severe) in the post-acute phase of recovery and 15 matched healthy control participants (mean age = 32,3 years old) were recruited. They completed inventories assessing the presence of anxiety (BAI) and depressive (BDI) symptoms and performed the Ecological test of prospective memory (TEMP), an objective measure of PM. The Comprehensive Assessment of PM (CAPM), a subjective measure of PM, was also filled out by participants and their relatives.

In patients with moderate/severe TBI, significant correlations were found between the CAPM and the BDI (r =.601, p<.001) and the BAI (r =.507, p=.004). A negative correlation was also observed between the relatives’ CAPM scores and the performance of the patients on the TEMP (r= -.374, p=.042). In patients with mild TBI, there was only a strong significant correlation between the CAPM and the BAI scores (r =.574, p=.008). However, no other correlation was significant between this group of patients and their relatives. Additionally, results on the TEMP were not significantly correlated with the CAMP completed by healthy control participants or their relatives. A linear regression conducted in the group of participants with TBI showed that BAI and BDI scores are the only significant predictors of the results on the CAPM (31% of the variance), while TBI severity is the only significant predictor of the results on the TEMP (37% of the variance).

The perception of PM difficulties in patients with a TBI does not seem to be related to their objective performance. Anxiety and depressive symptoms appear to influence their perception more than their objective performance. As suggested by their relatives, a decrease in self-awareness could explain the lack of relationship between subjective PM difficulties of patients with moderate/severe TBI and their objective performance. On the other hand, TBI severity is more strongly related to objective performance on PM tests. These results highlight the importance of using different measures to accurately assess PM and the various factors influencing this construct.