Significant advances in the research of sport-related concussion (SRC) and repetitive head impacts (RHI) over the previous decade have translated to improved injury identification, diagnosis, and management. However, an objective gold standard for SRC/RHI treatment has remained elusive. SRC often result in heterogenous clinical outcomes, and the accumulation of RHI over time is associated with long-term declines in neurocognitive functioning. Medical management typically entails an amalgamation of outpatient medical treatment and psychiatric and/or behavioral interventions for specific symptoms rather than treatment of the underlying functional and/or structural brain injury. Transcranial photobiomodulation (tPBM), a form of light therapy, has been proposed as a non-invasive treatment for individuals with traumatic brain injuries (TBI), possibly including SRC/RHI. With the present proof-of-concept pilot study, we sought to address important gaps in the neurorehabilitation of former athletes with a history of SRC and RHI by examining the effects of tPBM on neurocognitive functioning.

The current study included 49 participants (45 male) with a history of SRC and/or RHI. Study inclusion criteria included: age 18-65 years and a self-reported history of SRC and/or RHI. Exclusion criteria included: a history of neurologic disease a history of psychiatric disorder, and MRI contraindication. We utilized a non-randomized proof-of-concept design of active treatment over the course of 8-10 weeks, and neurocognitive functioning was assessed at pre- and post-treatment. A Vielight Neuro Gamma at-home brain tPBM device was distributed to each participant following baseline assessment.

Participants completed standardized measures of neurocognitive functioning, including the California Verbal Learning Test (CVLT-3), Delis Kaplan Executive Function System (D-KEFS), Continuous Performance Test (CPT-3), and The NIH Toolbox Cognition Battery. Neurocognitive assessments were collected prior to and following tPBM treatment. Paired t-tests and Wilcoxon’s signed-rank tests were used to evaluate change in performance on measures of neurocognitive functioning for normal and nonnormal variables, respectively, and estimates of effect size were obtained.

Study participants’ ability for adapting to novel stimuli and task requirements (i.e., fluid cognition; t=5.96; p<.001; d=.90), verbal learning/encoding (t=3.20; p=.003; d=.48) and delayed recall (z=3.32; p=.002; d=.50), processing speed (t=3.13; p=.003; d=.47), sustained attention (t=-4.39; p<.001; d=-.71), working memory (t=3.61; p=.001; d=.54), and aspects of executive functioning improved significantly following tPBM treatment. No significant improvements in phonemic and semantic verbal fluencies, reading ability, and vocabulary were shown following tPBM treatment.

The results of this pilot study demonstrate that following 8-10 weeks of active tPBM treatment, retired athletes with a history of SRC and/or RHI experienced significant improvements in fluid cognition, learning and memory, processing speed, attention, working memory, and aspects of executive functioning. Importantly, the majority of effect sizes ranged from moderate to large, suggesting that tPBM has clinically meaningful improvements on neurocognitive functioning across various cognitive domains. These results offer support for future research employing more rigorous study designs on the potential neurorehabilitative effects of tPBM in athletes with SRC/RHI.

Blast-related traumatic brain injury (bTBI) is one of the most common injuries among Veterans who have served in recent wars in Iraq and Afghanistan. Despite representing a distinct mechanism of injury, long-term clinical and functional outcomes of bTBI are generally comparable with non-blast-related traumatic brain injury (TBI). However, controversy remains over whether bTBI etiology differentially impacts emotional regulation and neurocognition - particularly with respect to post-traumatic stress disorder (PTSD) and verbal and visual memory. Through diffusion tensor imaging (DTI), the present study investigates the microstructural pathophysiology of bTBI, compared to non-blast TBI, in neural pathways involved in emotional regulation and cognitive control.

Participants included 36 Veterans (25% female; age M = 36.33, SD = 10.11; years of education M = 15.67, SD = 2.34). Axial diffusivity (AD) in networks of emotional and cognitive control was acquired using magnetic resonance imaging (MRI) with a DTI protocol. Analyses of variance (ANOVA) were used to compare Veterans with self-reported bTBI (n = 23) to those with non-blast-related TBI (n = 13).

In the left hemisphere, Veterans with bTBI exhibited significantly smaller AD in axonal projections from the caudate nucleus (CN) to the orbitofrontal cortex (OFC), as well as in projections from the putamen to the OFC (p < 0.05). In the right hemisphere, Veterans with bTBI also exhibited significantly smaller AD in networks connecting the hippocampus to the amygdala (p < 0.05).

Compared to Veterans with non-blast-related TBI, Veterans with bTBI exhibited decreased AD in neural pathways from the CN to the OFC, the putamen to the OFC, and the hippocampus to the amygdala - indicative of increased axonal injury in these areas. Our results suggest that, on a microstructural level, emotional and cognitive networks are susceptible to longitudinal blast-related white matter damage. This is consistent with the literature in post-concussion syndrome (PCS) and provides a potential mechanism underlying results previously reported from this sample, describing subjective cognitive complaints in the absence of objective clinical deficits. As such, therapies that target networks of emotional and cognitive control may be particularly beneficial for Veterans with bTBI.

Concussion patients frequently report increased distractibility, with more than half endorsing “concentration difficulty”. Previous studies have demonstrated impairments in maintaining attention and voluntary attentional allocation in concussion patients. However, involuntary attentional allocation (distraction) is not well understood in the context of concussion. The goal of this study was to examine distraction in acute pediatric concussion patients, monitoring frontal lobe activity using functional near-infrared spectroscopy (fNIRS) - a noninvasive measure of local hemodynamic activity - to elucidate whether post-concussion distractibility is associated with the availability of attentional control resources.

Participants included concussion patients (cases; n=19) presenting to specialty care within 28 days of injury (M=8.05, SD=5.55) and controls (n=16) presenting for reasons other than concussion. Participants were 13-17 years old (M=14.83, SD=1.10) and 57.1% female. Participants completed a computerized measure of behavioral distraction (the additional singleton paradigm) while frontal lobe activity was recorded using fNIRS 4-channel split sensor. On each trial, an array of shapes (five squares and one circle) was presented, and participants reported the orientation of a line segment inside a target shape (circle). The search array included a distractor (a square that differed in color) on 50% of trials. For each participant, the fNIR signal for epochs of each trial type (distractor present/absent) were averaged and subjected to a linear regression in which the data were fitted to a hemodynamic response function (HRF).

34 participants (19 cases, 15 controls) were included in our behavioral analysis. Reaction time (RT) was significantly slower on distractor present compared to distractor absent trials; F(1,32)=17.151, p<.001. There was no significant effect of group (case/control) on RT (F(1,32)=1.24, p=.273) or interaction between group and trial type (F(1,32)=1.05, p=.313). 29 participants (15 cases, 14 controls) were included in fNIRS analyses. The effect of group and distractor presence/absence on oxygenated hemoglobin (HbO2) was examined for each channel. A significant effect of distractor presence/absence was observed in channel 3; F(1,27)=8.510, p=.007. There were no significant effects of group or interactions between group and distractor presence/absence.

Lastly, a capture index was calculated for each participant by subtracting average RT on distractor absent trials from distractor present trials and correlated with HbO2 (beta weights averaged across trial type) for each group at each channel. No significant correlations were observed. There was a trend towards a negative correlation for case participants, particularly in channel 1, which strengthened when an outlier was removed (r=-.407, p=.149).

Reaction time and frontal lobe activity - which serves as a proxy for attentional control resources - were significantly higher when a distractor was present. Although there were no significant differences in behavioral distraction between groups, concussion patients trended towards higher levels of frontal lobe activity. Likewise, although not statistically significant, there was a trend towards a negative correlation for cases such that more attentional control resources (i.e., higher frontal lobe activity) was associated with less behavioral distraction (i.e., smaller capture index). This suggests that concussion patients may recruit more neural resources to produce comparable behavioral responses to healthy controls.

Recent conceptualizations of concussion symptoms have begun to shift from a latent perspective (which suggests a common cause; i.e., head injury), to a network perspective (where symptoms influence and interact with each other throughout injury and recovery). Recent research has examined the network structure of the Post-Concussion Symptom Scale (PCSS) cross-sectionally at pre-and post-concussion, with the most important symptoms including dizziness, sadness, and feeling more emotional. However, within-subject comparisons between network structures at pre-and post-concussion have yet to be made. These analyses can provide invaluable information on whether concussion alters symptom interactions. This study examined within-athlete changes in PCSS network connectivity and centrality (the importance of different symptoms within the networks) from baseline to post-concussion.

Participants were selected from a larger longitudinal database of high school athletes who completed the PCSS in English as part of their standard athletic training protocol (N=1,561). The PCSS is a 22-item self-report measure of common concussion symptoms (i.e., headache, vomiting, dizziness, etc.) in which individuals rate symptom severity on a 7-point Likert scale. Participants were excluded if they endorsed history of brain surgery, neurodevelopmental disorder, or treatment history for epilepsy, migraines, psychiatric disorders, or alcohol/substance use. Network analysis was conducted on PCSS ratings from a baseline and acute post-concussion (within 72-hours post-injury) assessment. In each network, the nodes represented individual symptoms, and the edges connecting them their partial correlations. Estimations of the regularized partial correlation networks were completed using the Gaussian graphical model, and the GLASSO algorithm was used for regularization. Each symptom’s expected influence (the sum of its partial correlations with other symptoms) was calculated to identify the most central symptoms in each network. Recommended techniques from Epskamp et al. (2018) were completed for assessing the accuracy of the estimated symptom importance and relationships. Network Comparison Tests were conducted to observe changes in network connectivity, structure, and node influence.

Both baseline and acute post-concussion networks contained negative and positive relationships. The expected influence of symptoms was stable in both networks, with difficulty concentrating having the greatest expected influence in both. The strongest edges in the networks were between symptoms within similar domains of functioning (e.g., sleeping less was associated with trouble falling asleep). Network connectivity was not significantly different between networks (S=0.43), suggesting the overall degree to which symptoms are related was not different at acute post-concussion. Network structure significantly differed at acute post-concussion (M=0.305), suggesting specific relationships in the acute post-concussion network were different than they were at baseline. In the acute post concussion network, vomiting was less central and sensitivity to noise and mentally foggy more central.

PCSS network structure at acute post-concussion is altered, suggesting concussion may disrupt symptom networks and certain symptoms’ associations with the experience of others after sustaining a concussive injury. Future research should compare PCSS networks later in recovery to examine if similar structural changes remain or return to baseline structure, with the potential that observing PCSS network structure changes post-concussion could inform symptom resolution trajectories.

The increasing incidence rates of concussive injuries, specifically among the youth age demographic, has led to the Center for Disease Control and Prevention to classify these injuries as a “silent epidemic.” While symptoms from concussion typically remit within four weeks, many experience symptoms that persist beyond what is typically expected. For children, the persistence of symptoms can have damaging side-effects that impact daily functioning and the progression through developmental and educational milestones. Recent research highlights factors that modify the nature of outcomes after a concussive injury. For youth-aged individuals, one such factor is the presence of premorbid conditions. A growing body of research suggests children with learning disorders (LDs) may be more susceptible to negative symptom outcomes across neuropsychological domains. Therefore, the purpose of this study is to further examine the influence of developmental learning disorders on concussion outcomes among youths.

Youths between 7 and 19 years of age that sought care at a concussion specialty clinic were screened for inclusion in the current study. The final sample of included 54 patients who reported having a neurodevelopmental LD between the ages of 8 and 17 and 54 patients without LDs matched on age, race/ethnicity, and gender to serve as paired case-controls. Measures of post-concussive physical symptoms (Modified Balance Error Scoring System; Quality of Life in Neurological Disorders: Neuro-QoL-SD, Neuro-QoL-F), emotional state (BAI, BDI), parent report measure of behavioral manifestations of cognitive functioning (Behavioral Rating Inventory of Executive Function), and select measures from the CogState automated test battery (i.e., One-Back, Two-Back, Groton Maze Learning, and Groton Maze Recall) were administered during the patient’s first examination at the clinic. Patients were instructed by the provider to follow-up at the clinic between two-three weeks for a repeat examination. The current study examined concussion outcome variables via two (group: LD, control) by two (time: initial examination, follow-up examination) repeated measures ANCOVAs where time between injury and the first examination was included as a covariate to control for the duration of elapsed days since injury.

Regarding cognitive symptoms, parent reported behaviors associated with executive functioning symptoms increased over time to reach clinically significant levels for the LD group, while symptoms decreased and remained within normal limits for the control group. Performance-based measures of cognition revealed no significant interactions or group/time differences. Additionally, the LD group showed more intense balance problems compared to the control group and symptom trends suggest LD participants may be more susceptible to prolonged, clinically significant, balance problems. With respect to sleep disturbances and fatigue, symptoms remained within normal limits across groups and time. Depression and anxiety symptoms remained within normal limits across groups and time as well.

Results highlight more intense balance problems and parent-reported executive dysfunction following concussion for youths with LDs compared to those without LDs. Additionally, though not significantly different

than the control group, results reveal several symptom domains in which the level of dysfunction meets clinical significance for the LD group participants only. As such, this study highlights the continued need for the scientific study of risk factors for vulnerable populations to aid in assessment and prevention efforts, especially for youths with LD.

External validation of symptom severity classification levels for the PostConcussion Symptom Inventory (PCSI).

Two distinct samples of parents and children, ages 8-18, participated from a: (1) prospective multicenter cohort study (Predicting Persistent Post-concussive Problems in Pediatrics, 5P) (Zemek et al., 2016), including parents (n=2,852), adolescents (n=1,087; mean age=15.13; 54% male), and children (n=1,271; mean age=10.70; 65% male) and (2) published clinic sample at Children’s National Hospital (CN) including parents (n=1,197; adolescents, n=835; children, n=326) (Gioia et al., 2019). Participants completed the age-specific Post-Concussion Symptom Inventory (PCSI): Mean time postinjury = 8 hours (5P), 6 days (PCSI2), generating a post-pre-injury difference (RAPID) score. The distribution of the RAPID scores for the Total Symptom and 4 subscales (physical, emotional, cognitive, sleep/fatigue) were examined to define 4 symptom severity classification levels (minimal - within the CI for recovered, low <20th %tile, moderate 21-79th %tile, high >80th %tile) for the respective samples. These severity distributions were compared between the two distinct datasets.

ANOVAs were performed to examine group differences in the mean scores for each of the 4 classification levels. No significant differences were found for all the RAPID score distributions with minimal effect sizes (<.1% variance) for the parents, adolescents and children. PCSI RAPID Total Score ranges for the severity classifications were as follows: Minimal-Parent and adolescent groups 5P<=5, Clinic <=5; Children: 5P<=3, Clinic<=3; Low- Parents 5P 6-15, Clinic 6-13; Adolescents 5P 6-19, Clinic 6-16; Children: 5P 4-7, Clinic: 4-7; Moderate-Parents 5P 16-49, Clinic 14-47; Adolescents 5P 20-56, Clinic 17-51; Children 5P 8-17, Clinic: 818; High- Parents: 5P>=50, Clinic >=48; Adolescents 5P >=57, Clinic >=52; Children 5P >=18, Clinic >=19).

Our findings reveal a parallel distribution of RAPID scores in the two distinct 5P and Clinic patient populations, yielding nearly identical severity classification level parameters across all five PCSI symptom domains (total score, physical, cognitive, emotional, and sleep/fatigue). The present investigation provides evidence of validity for the use of these severity classification levels across the ED and specialty clinic settings.

Patients with persistent post-concussion symptoms (PPCS) experience prolonged recovery (e.g., headache, fatigue, or dizziness) lasting >2 months post injury. These symptoms are thought to be maintained by several biopsychosocial factors including dysregulated stress responses, such as pain catastrophizing, that may drive behavioral avoidance and contribute to mood symptoms and cognitive difficulties. Conditions with similar symptomatology to PPCS (e.g., anxiety disorders, somatosensory disorders, chronic pain, etc.) also exhibit maladaptive thought patterns like pain catastrophizing as well as decrements in certain aspects of cognitive performance; however little is known about how pain catastrophizing might relate to neuropsychological performance in youth with PPCS. Therefore, the purpose of this study was to examine the relationship between pain catastrophizing and neuropsychological performance in youth participants with PPCS.

A prospective case-control study design was used to examine 29 participants between the ages of 13 to 23. Participants were divided into two groups: 1) patients with PPCS (2-16 months post-injury; n = 15) and 2) age-matched, non-injured controls (n = 14). Participants completed the Pain Catastrophizing Scale (PCS) to determine degree of catastrophic thinking related to pain experience and the Beck Depression Inventory (BDI). Neuropsychological performance was assessed using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) and a modified version of the Paced Auditory Serial Addition Test (PASAT) where performance was evaluated by total correct and error type (i.e., commission and omission) across 5 trials. ANCOVA was used to compare group differences in pain catastrophizing and neuropsychological tests scores while controlling for age and linear regressions examined the relationship between PCS total score and each neuropsychological test score while controlling for level of depression.

Overall, the PPCS group reported significantly higher levels of pain catastrophizing on the PCS compared to the control group (p < 0.01). For neuropsychological performance, the PPCS group scored significantly lower than the control group on List Learning (p < 0.01), Semantic Fluency (p < 0.05), and List Recall (p < 0.01) on the RBANS and made significantly higher omission errors (but not commission) on the PASAT(p <.01). Higher pain catastrophizing was also associated with poorer neuropsychological performance on the exact same tasks the PPCS group performed worse than controls. There was no significant interaction by group in the impact of PCS scores on neurocognitive performance.

Compared to controls, youth PPCS patients reported higher levels of pain catastrophizing. Additionally, pain catastrophizing was associated with poorer neuropsychological performance. These findings suggest that increased pain catastrophizing after head injury could contribute to poorer cognitive performance in youth. As such, interventions that target maladaptive cognitive coping styles like pain catastrophizing may be especially helpful for patients with PPCS.

When neuropsychologists serve as consultants to schools, concussion management programs are associated with fewer referrals, faster cognitive recovery, and reduced incidence of protracted recovery compared to programs with physician consultants. However, accessing neuropsychological services can be challenging due to geographical and financial barriers. Particularly in rural areas, travel associated with post-concussion management can represent as a significant financial and time burden. Increasing accessibility to neuropsychologists has the potential to address these concerns, while also providing quality care to more

individuals. The current study aims to assess the cost-effectiveness and clinical outcomes of a remote, neuropsychologist-led consultation model of concussion management. We hypothesized that this remote model would save patients both money and time, while also improving patient outcomes.

604 high school concussion cases occurring between May 2019 and May 2022 were reviewed; 571 were included in the current analysis. The sample was 51% male with a mean age of 15.8 years (SD=1.32). All students took ImPACT tests following suspected concussions, with tests administered at the school by certified athletic trainers or nurses. Test results were electronically reviewed by the consulting neuropsychologist. Interpretations and recommendations were then sent via email to the school official. Cognitive recovery, defined as the days from the injury to the final ImPACT test, and incidence of repeat concussions, or concussions occurring within 3 months of a previous concussion, were used as indicators of patient outcomes. Financial burden was determined by calculating the round-trip distance in miles from the patient’s school to the neuropsychologist’s medical center, then multiplying this number by the 2022 standard mileage reimbursement rate of $0.63/mile to determine the travel cost for a single consultation.

The sample consisted of 571 individual concussion cases and 1,285 total ImPACT tests. An average of 2.25 tests were administered for each concussion case (SD=0.90), with an average of 18.47 days to the final test (SD=16.59). 8 concussions (1.4% of total concussions) occurred within 3 months of a previous injury. The distance from schools to the closest available neuropsychologist ranged from 2.4 to 102 miles. The remote nature of the consultation model allowed for patients to avoid up to 204 miles, or up to 4.5 hours, of driving for each consultation. Thus, patients saved anywhere from $3.00 to $127.50 in travel costs per consultation.

The remote nature of this consultation model yielded a similar cognitive recovery time to previous literature, indicating that it may be as effective as in-person consultation. Repeat concussions represented less than 1.5% of concussion cases, indicating that care was successful enough to prevent second concussions in the majority of the sample. The remote nature of the model also saved patients time (up to 4.5 hours of driving) and money (up to $127.50 in travel costs). Thus, a remote consultation model has the potential to increase access to first-rate concussion care in rural settings, while also being cost- and time-effective for patients.

Neuropsychological assessment is the cornerstone of concussion management, and the nature of its delivery can vary widely. While literature concerning post-concussion care typically revolves around in-person evaluation, the proliferation of computerized neuropsychological tests (CNTs) has allowed for some distance between concussion patients and the neuropsychologist. In the wake of a global pandemic, several papers describing the use of telehealth for concussion care have emerged; however, the small samples found in these studies may suggest that access to care remains an issue. Additionally, telehealth may not be a sustainable fee-for-service approach as CMS aims to curtail telehealth reimbursement for behavioral health clinicians. The objective of the present study is to describe a remote neuropsychological consultation model of concussion management and evaluate its productivity and impact in a rural setting.

In this model, a neuropsychologist based at an academic medical center in the northeastern United States consulted to middle school, high school, and collegiate concussion management programs. Students typically were administered baseline ImPACT tests prior to participation in sports, and all students in the current sample completed post-injury ImPACT tests as part of return to play protocols. The neuropsychologist read test results through the test’s online portal, then communicated interpretation and recommendations via email or phone to the school’s representative (e.g., athletic trainer, athletic director, or school nurse). 837 unique concussions were recorded between 2019 and 2022. After removing abnormal cases (e.g., COVID-19 school closures, extended college breaks, non-concussions, and non-return to play decisions), 790 unique concussions (51.4% male) were included for analysis, with a mean age of 16.84 years (SD=2.17). Descriptive statistics were used to characterize the sample.

Across 790 unique concussions, 7 were middle school, 571 were high school, and 212 were college students. 1,750 total postinjury ImPACT tests were administered over the three-year period. Per concussion, an average of 2.22 (SD=0.90) tests were used. Average time to the last ImPACT given was 18.47 days (SD=16.59), with a median of 15 days. Ten concussions (1.27% of total concussions) occurred within 3 months of a previous injury. The distance between schools and the medical center ranged from 2.4 to 102 miles (M=60.29; SD=34.34).

The current study suggests that there is value in a remote model of neuropsychological consultation for concussion management. While telehealth offers a promising method of evaluation for concussion, it may be inaccessible and present reimbursement challenges. The remote consultation model described here increases access to care by eliminating in-person visits, which decreases demand for physical space at medical centers and increases access to rural populations with seemingly no negative effect on care. This consultation model also allows neuropsychologists working in concussion management more flexibility, potentially increasing the volume of cases they can assess. This program evaluation suggests remote models have merit, but replication studies in different regions of the country are needed.

Youth athletes with concussion are at an increased risk of sustaining new concussions and orthopedic injuries after clearance for return-to-play. There are training programs, extensively studied in other patient populations, which can improve performance in cognitive domains that have been implicated in sport-related injury and re-injury after concussion (i.e., visual attention/processing speed). The Useful Field of View (UFOV) is one such training program, accompanied by a computerized adaptive assessment for evaluating response to training and maintenance in clinical trials. Remote UFOV assessment administration may help improve adherence, particularly in assessing long-term training effects. The current study explores the feasibility of virtual UFOV assessment and equivalence with in-person administration in youth clinically recovered from concussion and healthy controls.

Participants included youth ages 10-18 enrolled in a longitudinal study examining neural recovery following medical clearance from concussion. UFOV was attempted in 61 participants (Mage=15.06; SD=2.00; n=19 in-person; n=42). Of these, 7 virtual administrations were discontinued due to computer limitations, and 1 in-person administration was excluded due to overall performance validity concerns. This resulted in a total sample of 53 participants (Mage=15.02, SD=2.00, 58.5% male; n=14 concussion, Mdays_since_injury=272.64, SD=185.35; n=39 controls). UFOV was administered either in-person (n=18) using manual guidelines or virtually (n=35) on the participant’s computer using video-conference screen-share and a secondary device for an additional view of the participant and their keyboard/mouse. For virtual visits, the examiner recorded concerns about the remote testing environment (e.g., screen glare, viewing distance not measured appropriately), and analyses were conducted with and without cases with concerns. Between-group (in-person vs virtual administration) demographic differences were examined using chi-square tests/t-tests. Mann-Whitney U tests were used to examine for differences in UFOV scores (ms; higher scores are worse) by administration context (in-person vs. virtual) given threats to normality.

For virtual administrations, the most commonly reported concerns about the remote testing environment were related to lighting (n=12) and viewing distance (n=3). There were no significant differences in age, sex, concussion history, sport participation history, or IQ by administration context (in-person vs. virtual). UFOV performance did not vary significantly by administration context for processing speed or divided attention subtests, but performance on the selective attention subtest was significantly better in the virtual administration group (Median in-person =93.33; Medianvirtual=63.33; U=203.00, p=0.035). This trend persisted after removing an outlier (>2SD; p=0.065) and after removing cases where lighting (p=0.060) and screen-viewing distance (p=0.085) were not adequately controlled.

Though preliminary, results suggest that UFOV can be administered virtually, in youth with and without a history of concussion, but that those assessed virtually using their home computer may have an advantage, particularly for the selective attention subtest. This may be due to comfort level within the home environment or subtle differences in viewing distance that were not appreciated by the examiner remotely. Importantly, not all participants were able to complete the assessment virtually due to computer limitations. Future work with larger samples size should examine the extent to which completers vary from non-completers in terms of sociodemographic variables.

Much of the pediatric concussion literature focuses on sports and recreation related injuries, while there is a relative paucity of research on the cognitive and psychological sequelae associated with assault. However, it is understood that children with assault-related injuries demonstrate a longer recovery time. This case series reviews the data of four teenagers who were administered cognitive, emotional, and behavioral screeners after sustaining an assault related concussion.

Four pediatric female patients (ages 13,14,15,15) with a recent history of concussion due to physical assault presented for evaluation at a hospital-based concussion clinic. All four patients were administered a computerized cognitive screener as well as self-report measures for mood, anxiety, post-traumatic stress disorder (PTSD), and sleep disturbance.

All four of the pediatric cases reported significant symptoms of PTSD, depression, anxiety, and sleep disturbance. For all four patients, the most notable problems across cognitive performance measures were observed in the areas of simple and complex attention.

Results of this case series revealed clinically significant anxiety, depression, PTSD-symptoms, and sleep disturbance in conjunction with poor simple and complex attention. These pediatric cases illustrate the potential link between assault-related concussions, emotional and behavioral symptoms, and cognitive functioning. Furthermore, assault-related concussions may elevate risk toward attentional problems associated with psychological distress. Early evaluation of PTSD and mood related symptomatology is suggested to best support treatment planning and recovery in this population. Future studies are needed to explore the nature of the relationship between cognitive and emotional sequelae in patients who present with assault-related concussions.

Consideration of individual differences in recovery after concussion has become a focus of concussion research. Sex and racial/ethnic identity as they may affect reporting of concussion symptoms have been studied at single time points but not over time. Our objective was to investigate the factors of self-defined sex and race/ethnicity in reporting of lingering concussion symptoms in a large sample of adolescents.

Concussed, symptomatic adolescents (n=849; Female=464, Male=385) aged 13-18 years were evaluated within 30 days of injury at a North Texas Concussion Registry (ConTex) clinic. Participants were grouped by self-defined race/ethnicity into three groups: Non-Hispanic Caucasian (n=570), Hispanic Caucasian (n=157), and African American (n=122). Measures collected at the initial visit included medical history, injury related information, and the Sport Concussion Assessment Tool-5 Symptom Evaluation (SCAT-5SE). At a three-month follow-up, participants completed the SCAT-5SE. Pearson’s Chi-Square analyses examined differences in categorical measures of demographics, medical history, and injury characteristics. Prior to analysis, statistical assumptions were examined, and log base 10 transformations were performed to address issues of unequal group variances and nonnormal distributions. A three-way repeated measures ANOVA (Sex x Race/Ethnicity x Time) was conducted to examine total severity scores on the SCAT-5SE. Bonferroni post-hoc tests were performed to determine specific group differences. SPSS V28 was used for analysis with p<0.05 for significance. Data reported below has been back transformed.

A significant interaction of Time by Race/Ethnicity was found for SCAT-5SE scores reported at initial visit and three-month follow-up (F(2, 843)=7.362, p<0.001). To understand this interaction, at initial visit, Race/Ethnicity groups reported similar levels of severity for concussion symptoms. At three month follow-up, African Americans reported the highest level of severity of lingering symptoms (M= 3.925, 95% CIs [2.938-5.158]) followed by Hispanic Caucasians(M= 2.978, 95% CIs [2.2663.845]) and Non-Hispanic Caucasians who were the lowest(M= 1.915, 95% CIs [1.6262.237]). There were significant main effects for Time, Sex, and Race/Ethnicity. Average symptom levels were higher at initial visit compared to three-month follow-up (F(1, 843)=1531.526, p<0.001). Females had higher average symptom levels compared to males (F(1, 843)=35.58, p<0.001). For Race/Ethnicity (F(2, 843)=9.236, p<0.001), Non-Hispanic Caucasians were significantly different than African Americans (p<0.001) and Hispanic Caucasians (p=0.021) in reported levels of concussion symptom severity.

Data from a large sample of concussed adolescents supported a higher level of reported symptoms by females, but there were no significant differences in symptom reporting between sexes across racial/ethnic groups. Overall, at three-months, the African American and Hispanic Caucasians participants reported a higher level of lingering symptoms than Non-Hispanic Caucasians. In order to improve care, the difference between specific racial/ethnic groups during recovery merits exploration into the factors that may influence symptom reporting.

Children who sustain a mild traumatic brain injury (mTBI) are at increased odds of additive injury and continue to show altered motor performance relative to never-injured peers after being medically cleared (MC) to return to normal activities. There is a critical need to determine when children can return to activities without risk of short and long-term adverse effects, with research showing high reinjury rates for 3-12 months after RTP. The Physical and Neurological Examination for Subtle Signs (PANESS) measures subtle signs of motor impairment during gait, balance, and timed motor functions. Recent literature has demonstrated that PANESS timed motor function can distinguish between children medically cleared post-mTBI compared to never-injured controls. The present study examined performance on timed motor tasks in youth medically cleared from mTBI following medical clearance and 3-months later, compared to never-injured peers.

25 children (Mage=14.16, SD=2.46; Male=68%) were enrolled within 6 weeks of medical clearance from mTBI (Mdays post MC=33, SD=13.4, Range=2-59) along with 66 typically developing, never-injured controls (Mage=13.9, SD=2.22; Male=50%). Group differences were evaluated for the Timed Motor section of the PANESS at enrollment and at a 3-month follow-up (Mdays from enrollment to follow-up=95.90, SD=12.69, Range=62-129). This 3-month follow-up occurred on average 4 months after medical clearance (Mdays from MC to follow-up=130.08, SD=17.58, Range=92 - 164). The Timed Motor section includes Repetitive (foot tapping, hand patting, and finger tapping) and Sequential (heel-toe rocking, hand pronate/supinate, finger sequencing) raw time scores, measured in seconds. The Total Timed Motor Speed score is the combination of Repetitive and Sequential Movement and the side-to-side tongue item.

At 3-month follow-up, mTBI participants (M=67.55, SD=8.26, Range=53.66-83.88) performed worse than controls (M=63.09, SD=10.23, Range=39.86-100.51) on Total Timed Motor Speed, t(89)= 1.95, p<0.05), including when controlling for age and sex, F(1, 87)=4.67, p<0.05. At the same time point, mTBI participants (M=36.54, SD=5.47, Range=28.74-49.17) performed worse on Sequential Speed than controls (M=32.93, SD=6.1, Range=21.49-56.76), t(89)=2.59, p<0.01, including when controlling for age and sex, F(1, 87)=7.687, p<0.01). Although groups performed similarly on Sequential Speed at the initial time point, mTBI participants exhibited a trend of less improvement from initial to follow-up (MmTBI=-1.69, Mcontrol=-3.68, t(90)=1.445, p=0.076).

Although groups did not significantly differ on Timed Motor Speed items at the initial time point, the mTBI group showed consistently lower scores than controls at both time points and less improvement over time. Results indicate that Total Timed Motor Speed, specifically Sequential Speed, may be a sensitive marker of persisting differences in high-level motor and cognitive learning/control in children who have been medically cleared after mTBI. More data are needed to evaluate these findings over a longer time period, and future studies should examine behavioral markers concurrently with physiologic brain recovery over time.

A fundamental challenge for people with severe mental illness (SMI) is how to deal with cognitive impairments, which are common in this population and limit daily functioning. Cognitive remediation (CR) is a psychological intervention that targets these cognitive impairments to improve everyday functioning. However, reduced neural plasticity in people with SMI might hinder newly learned cognitive skills to sustain. Transcranial Direct Current Stimulation (tDCS) can promote this neural plasticity, which could enhance learning and result in longer-lasting improvements in cognitive and daily functioning. This study aimed to investigate the acceptability of the combination of CR and tDCS for people with severe mental illness who live in residential psychiatric facilities.

We interviewed participants of the ongoing HEADDSET pilot trial. In this pragmatic, randomized, controlled pilot trial, participants (individuals with SMI, 18 years or older, living in psychiatric facilities) received CR in combination with concurrent active tDCS (n = 13) or sham tDCS (n = 13) twice weekly for 16 weeks (32 sessions in total). We invited participants who finished the trial’s training period (n = 16) to participate in the interviews. According to the Theoretical Framework of Acceptability (Sekhon et al., 2017), we assessed seven components of acceptability: Affective attitude, burden, intervention coherence, ethicality, opportunity costs, perceived effectiveness, and self-efficacy.

Twelve of the 16 participants participated in the interviews: seven completers (attended at least 20 of the 32 sessions; M = 22.7, range = 20-25) and five non-completers (M = 11.6, range = 9-15). The reasons for not completing the protocol were mainly unrelated to the training (i.e., prolonged illness, substance abuse, personal circumstances). Only one participant did not complete the training because of its intensity. Independent of whether participants completed the intervention, they were positive about the training. They reported that they liked the CR program CIRCuiTS, that participating in the training was not a burden and that, in their opinion, the training could help others. Moreover, all participants observed improvement in their cognitive functioning, and six individuals (three completers and three non-completers) observed improvements in their everyday life (e.g., fewer problems with doing groceries, being more organized, and being able to concentrate and read a book). Overall, the participants would recommend the training to others. Non-completers of the intervention would recommend the CR with tDCS, while completers neither recommended nor advised against the addition of tDCS. Participants who understood and could explain how the training works reported more improvements in daily life, were better at formulating their treatment goals, and stated that the treatment goals were more relevant to them compared to the participants who were unable to do so.

The combined intervention of CR and tDCS was acceptable to individuals with severe mental illness, the participation in the training was no burden to both completers and non-completers, and participants reported personal benefits for their cognitive functioning and everyday life. Future studies should investigate the effectiveness of the intervention in larger randomized controlled trials.

The goal of our study was to examine the possible effects of a strategies-based training intervention on objective memory performance and subjective memory in healthy older adults. While slight declines in memory naturally occur in the aging process, these changes may impact the quality of life for older adults.

Patients (n = 11, aged 50-80, mean age = 70.73, SD = 4.41) with subjective memory complaints were recruited from memory clinics within an academic medical center. All participants engaged in one-on-one, three one-hour memory training sessions over the course of several weeks to undergo strategies-based training intervention (e.g., mnemonics). All participants completed neuropsychological battery of tests at baseline and at post-intervention (about 8-10 weeks after baseline). Tests included the Montreal Cognitive Assessment (MoCA), the Hopkins Verbal List Test (HVLT-R), the Visual Reproduction subtest of the Weschler Memory Scale (WMS-IV), and the Multiphasic Memory Questionnaire.

Data were analyzed using a mixed between-within subjects ANOVA and t-tests. Groups were created based on the participant’s MoCA score. While a total of 11 participants completed baseline testing and the memory training sessions, two did not return for post-intervention testing; as such their data were excluded from analyses. Older adults with a MoCA score of 26-30 (n = 6), but not older adults with a MoCA score 25 and below (n = 3), had a significant improvement in visual learning and encoding, F (1, 7) = 10.028, r = .50, p < .05. The high MoCA performers demonstrated an improved performance in their immediate visual memory from baseline (M = 10, SD = 3.53) to post-intervention (M = 12, SD = 3.35), t(9) = .895, p = .001 (two-tailed). Ratings of memory satisfaction among high MoCA performers also increased from baseline (M = 48, SD = 11.47) to post-intervention (M = 51, SD = 5.43), t(9) = .707, p < .05 (two-tailed). Among both groups, a significant increase in perceived memory ability was demonstrated from baseline (M = 50, SD =10.1) to post-intervention (M = 54, SD = 12.35), t(8) = .807, p < .05 (two-tailed).

These findings indicate that a brief memory training program may improve visual encoding and subjective memory in healthy older adults with memory concerns. Individuals with subjective memory concerns who undergo a cognitive training program seem to demonstrate improved encoding of nonverbal material. These participants also reported a greater memory satisfaction and improved perceived memory ability after completion of a memory training program. Interestingly, these findings were only seen in adults whose MoCA performance was within normal limits. Although a systematic review suggests the improvement of memory performances on cognitively impaired participants (Simon, Yokomizo, & Bottino, 2012), this may not have been demonstrated in the current study due to a low sample size and/or to the brief duration of the cognitive training. Future directions include increasing sample size and offering booster sessions to explore whether cognitively impaired adults may benefit from repetition.

Inductive reasoning training has been found to be particularly effective at improving inductive reasoning, with some evidence of improved everyday functioning and driving. Telehealth may be useful for increasing access to, reducing time and travel burdens of, and reducing the need for physical spaces for cognitive training. On the other hand, telehealth increases technology burden. The present study investigated the feasibility and effectiveness of implementing an inductive reasoning training program, designed to mimic the inductive reasoning arm used in a large multi-site clinical trial (Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE)), via telehealth (using Zoom and Canvas as delivery platforms).

31 older adult participants (mean age = 71.2, range = 65-85; mean education = 15.5, range = 13-18; 64.5% female; 87.1% white) received 10-sessions of telehealth-delivered inductive reasoning training over 5 weeks. Comparison groups (inductive reasoning trained and no-contact controls) were culled from the in-person ACTIVE trial via propensity matching. All participants completed three pretest and posttest inductive reasoning measures (Word Series, Letter Series, Letter Sets), as well as a posttest measure assessing participant perceptions of the telehealth intervention. In addition, at the end of each of the ten training sessions, participants received a final inductive reasoning assessment.

Telehealth participants provided high levels of endorsement suggesting that the telehealth training program was useful, reliable, easy to use and interact on, and employed a useable interface. Participants were generally satisfied with the training program. With regard to performance, telehealth participants demonstrated greater gains than untrained controls on Letter Series [F(1, 116) = 9.81, p = 0.002, partial eta-squared = 0.084] and Letter Sets [F(1, 116) = 8.69, p = 0.004, partial eta-squared = 0.074], but did not differ in improvement on Word Series [F(1, 116) = 1.145, p = 0.287, partial eta-squared = 0.010]. Furthermore, telehealth participants evinced similar inductive reasoning gains as matched inperson inductive reasoning trained participants on Letter Series [F(1, 116) = 1.24, p = 0.226, partial eta-squared = 0.01] and Letter Sets [F(1, 116) = 1.29, p = 0.259, partial eta-squared = 0.01], but demonstrated fewer gains in Word Series performance [F(1, 116) = 25.681, p = < 0.001, partial eta-squared = 0.181]. On the end-of-session reasoning tests, telehealth-trained participants showed a similar general pattern of improvement across the ten training sessions and did not differ significantly from in-person trained comparison participants.

Cognitive training via telehealth evinced similar gains across nearly all measures as its in-person counterpart. However, telehealth also led to substantial challenges regarding the telehealth training platform. Despite these challenges, participants reported perceiving increased competence with computer use, peripherals (mice, trackpad), and videoconferencing. These may be ancillary benefits of such training and may be maximized if more age-friendly learning management systems are investigated. Overall, this study suggests that telehealth delivery may be a viable form of cognitive training in inductive reasoning, and future studies could increase performance gains by optimizing the online training platform for older adults.

Cognitive training using a visual speed-of-processing task, called the Useful Field of View (UFOV) task, reduced dementia risk and reduced decline in activities of daily living at a 10-year follow-up in older adults. However, there is variability in the level of cognitive gains after cognitive training across studies. One potential explanation for this variability could be moderating factors. Prior studies suggest variables moderating cognitive training gains share features of the training task. Learning trials of the Hopkins Verbal Learning Test-Revised (HVLT-R) and Brief Visuospatial Memory Test-Revised (BVMT-R) recruit similar cognitive abilities and have overlapping neural correlates with the UFOV task and speed-ofprocessing/working memory tasks and therefore could serve as potential moderators. Exploring moderating factors of cognitive training gains may boost the efficacy of interventions, improve rigor in the cognitive training literature, and eventually help provide tailored treatment recommendations. This study explored the association between the HVLT-R and BVMT-R learning and the UFOV task, and assessed the moderation of HVLT-R and BVMT-R learning on UFOV improvement after a 3-month speed-ofprocessing/attention and working memory cognitive training intervention in cognitively healthy older adults.

75 healthy older adults (M age = 71.11, SD = 4.61) were recruited as part of a larger clinical trial through the Universities of Florida and Arizona. Participants were randomized into a cognitive training (n=36) or education control (n=39) group and underwent a 40-hour, 12-week intervention. Cognitive training intervention consisted of practicing 4 attention/speed-of-processing (including the UFOV task) and 4 working memory tasks. Education control intervention consisted of watching 40-minute educational videos. The HVLT-R and BVMT-R were administered at the pre-intervention timepoint as part of a larger neurocognitive battery. The learning ratio was calculated as: trial 3 total - trial 1 total/12 - trial 1 total. UFOV performance was measured at pre- and post-intervention time points via the POSIT Brain HQ Double Decision Assessment. Multiple linear regressions predicted baseline Double Decision performance from HVLT-R and BVMT-R learning ratios controlling for study site, age, sex, and education. A repeated measures moderation analysis assessed the moderation of HVLT-R and BVMT-R learning ratio on Double Decision change from pre- to post-intervention for cognitive training and education control groups.

Baseline Double Decision performance significantly associated with BVMT-R learning ratio (β=-.303, p=.008), but not HVLT-R learning ratio (β=-.142, p=.238). BVMT-R learning ratio moderated gains in Double Decision performance (p<.01); for each unit increase in BVMT-R learning ratio, there was a .6173 unit decrease in training gains. The HVLT-R learning ratio did not moderate gains in Double Decision performance (p>.05). There were no significant moderations in the education control group.

Better visuospatial learning was associated with faster Double Decision performance at baseline. Those with poorer visuospatial learning improved most on the Double Decision task after training, suggesting that healthy older adults who perform below expectations may show the greatest training gains. Future cognitive training research studying visual speed-of-processing interventions should account for differing levels of visuospatial learning at baseline, as this could impact the magnitude of training outcomes.

Finding effective, innovative, and accessible methods of coping with and mitigating stress has been increasingly relevant in the midst of the COVID-19 pandemic. To do so, it is important to understand the impact of acute stress responses on cognition, behavior, and emotional functioning. The young adult population in particular has been known to show higher levels of stress. Studies have shown that deep breathing interventions are associated with improved affect, decreased stress levels, and improved cognitive functioning. The autonomic nervous system, particularly the functioning of the vagus nerve, has been thought to be a key mechanism in the effect of breathing on stress and mood. Most studies to date investigating the efficacy of breathing practices in stress reduction and mood improvement have lacked appropriate methodology, including adequate control groups, randomization, and cross-sectional designs. This single-blind, randomized, waitlist-controlled study investigated the feasibility of using a mobile application to train in resonance frequency breathing and its efficacy in reducing stress and improving cognitive functioning in a non-clinical sample of young adults with elevated stress.

80 healthy young adults with elevated stress levels were recruited from the NY/NJ community and the Queens College undergraduate research subject pool. Inclusion criteria: ages 18-29, Perceived Stress Scale score >13. Exclusion criteria: regular (at least 3 times per week) practice of any form of meditation, yoga, or breathing exercise; severe medical or psychiatric disorder; active suicidal ideation; drug or alcohol abuse within the past year; use of medication with a known negative impact on cognition or autonomic nervous system (ANS) arousal. Participants were randomized to a waitlist control group or breathing group. Participants in the breathing group were instructed to complete 10-minute breathing sessions using the free mobile application “The Breathing App” twice a day for five days per week for four weeks. Cognitive assessments were administered over the phone (pre and post-treatment) and self-report measures were completed online due to quarantine restrictions.

There were no significant main effects of group across any of the neuropsychological variables, including verbal memory, letter fluency, category fluency, cognitive flexibility, processing speed, basic attention span, and working memory. This indicated that breathing training did not significantly impact neuropsychological performance. Mediation analysis also demonstrated that breathing training did not indirectly lead to improvement in basic attention, processing speed, working memory, set-shifting, verbal fluency, category fluency, or cognitive flexibility, through its effects on stress reduction.

These results do not support literature suggesting that breathing at resonance frequency is associated with improved cognitive functioning such as greater cognitive flexibility, improved decision-making, stronger response inhibition, faster processing speed, and increased working memory. Future study designs should consider implementing active control groups (e.g., mindfulness meditation) and differential dosages of the breathing treatment.

The objective of the present study is to expand our understanding of visual complaints in people with multiple sclerosis (MS) with the aim of exploring potential rehabilitation approaches for treating visual complaints. Visual complaints are increasingly recognized as a core manifestation of MS. Up to 90% of people with MS report all kinds of visual complaints, such as blurry vision, double vision, being blinded by bright light, a reduced visual field and having trouble with depth perception. Since intact vision is quintessential to many activities of daily life, such as reading or car driving, these complaints affect independent participation to a great extent. The complaints cannot be fully explained by optical neuritis (a common symptom of MS) or other treatable visual or ophthalmological disorders. Moreover, there are no rehabilitation programs available for visual complaints in people with MS. However, the complaints are not yet understood well enough to develop effective rehabilitation strategies to reduce the impact of the visual complaints.

Visual complaints were assessed using the Screening Visual Complaints questionnaire. 68 people with MS with visual complaints, and 37 with hardly any visual complaints received a standard visual function assessment and a neuropsychological assessment. Correlations between the visual complaints, visual functions and cognitive functions were calculated. In addition, correlations were calculated between several visual functions and a composite score of the neuropsychological assessment.

Only some specific visual measures related to visual complaints, with small to moderate effect sizes. While most specific cognitive functions did not show correlations, measures indicative of overall cognitive capacity in people with MS (such as motor speed) consistently correlated with different kinds of visual complaints. Additionally, visual functions that related to visual complaints also correlated with the composite score for cognitive functioning.

Our study serendipitously showed that in developing or composing effective rehabilitation strategies for visual complaints, we should look beyond a person’s visual functioning: first, the overall cognitive capacity should be taken into account. Second, visual functioning and cognitive functioning are closely related. These results indicate that visual complaints may be a result of a general decline of the visual and/or cognitive system as one. When treating these complaints, low vision rehabilitation and neuropsychological rehabilitation strategies may be combined. Strategies should not focus on specific visual or cognitive functions, but at making the visual world more easily accessible, or more easily visible, to reduce the impact on the visual system and cognitive capacity. Strategies could range from applying more contrast in the environment to psycho-education. Future research should focus on developing rehabilitation programs and assessing their effectiveness in people with MS or with other types of non-acquired brain injuries.

The study aimed to develop, validate and field test the cognitive screening tool for use in outpatient departments within health facilities in Uganda.

In the rural eastern region of Uganda, twenty-three (23) purposively selected health facilities and administered a scientifically derived cognitive screening tools to all eligible older persons. We conducted an inter-rater reliability in all the health facilities using three raters. Diagnosis of dementia (DSM IV) was classified as a major cognitive impairment and was quality checked by physiatrist who were blinded to results of the screening assessment.

The area under the receiver operating characterizes (AUROC) curve in health facilities was 0.912. The inter-rater reliability was good (Intra-class correlation coefficient of 0.692 to 0.734). the predictive accuracy of the tool to discriminate between dementia and other cognitive impairment was 0.892. In regression modal, the cognitive screening tool, didn’t appear to be biased by age.

The cognitive screening tool if performed well among the older persons, can be proved useful for screening dementia in other developing countries.