Ontario Neurotrauma Foundation Research Articles

CPAP Therapy for 4 Months Improves Sleep Quality, Daytime Alertness, Fatigue, and Mental Health in People with Chronic Spinal Cord Injury and Moderate-to-Severe Sleep-Related Breathing Disorder: The Preliminary Results of an Ongoing Prospective Study. (S38.002)

<h3>Objective:</h3> To examine the cognitive and psychological effects of continuous positive airway pressure (CPAP) therapy in people with chronic spinal cord injury (SCI) and moderate-to-severe sleep-related breathing disorder (SRBD). <h3>Background:</h3> SRBDs are common but under-recognized after SCI. <h3>Design/Methods:</h3> An ongoing single-arm clinical trial (NCT04007380) aims to evaluate the effects of 4 months of CPAP therapy on cognition and mental health in people with SCI who were diagnosed with moderate-to-severe SRBD. Outcomes included the Epworth Sleepiness Scale, Medical Outcomes Study Sleep Scale, Fatigue Severity Scale, Depression, Anxiety &amp; Stress Scale-21, and Montreal Cognitive Assessment (MoCA). The participants shared their experience in a 1-hour semi-structured interview (qualitative analysis). <h3>Results:</h3> By September 2022, we screened 31 individuals (10 females, 21 males; ages range: 37–79 years; mean age: 58.4 years) with complete motor (n=14) or incomplete SCI at cervical (n=20) or thoracic level. Time from SCI onset varied from 4 to 793 months (mean time: 190.5 months). Of the 31 screened participants, the apnea-hypopnea index (AHI) varied from 2.6 to 83.7 events per hour (mean AHI: 23.0). Of the 24 individuals who initiated CPAP therapy, 11 individuals have completed it, whereas three individuals withdrew from the study. The overall mean adherence rate to CPAP was 78.6%; mean nighttime CPAP usage was approximately 5 hours. Daytime sleepiness (p=0.003) and sleep quality (p&lt;0.001) significantly improved with CPAP therapy. Fatigue significantly decreased with CPAP therapy (p=0.048). Mental health indicators improved with CPAP therapy (p=0.049). There was a numeric increase in MoCA scores, but this did not reach significance yet (p=0.160). All 11 participants confirmed that CPAP therapy had a positive impact in their lives. <h3>Conclusions:</h3> Our preliminary results suggest that 4 months of CPAP therapy significantly improves sleep quality, and reduces daytime sleepiness, fatigue, stress, anxiety and mood in people with chronic SCI. The participants’ adherence to CPAP therapy was high (78.6%). <b>Disclosure:</b> The institution of Dr. Furlan has received research support from Wings for Life Spinal Cord Research Foundation. The institution of Dr. Furlan has received research support from Craig H Neilsen Foundation. The institution of Dr. Furlan has received research support from Ontario Neurotrauma Foundation. The institution of Dr. Furlan has received research support from Cervical Spine Research Society. The institution of Dr. Furlan has received research support from J P Bickell Foundation. The institution of Dr. Furlan has received research support from Praxis Spinal Cord Institute. The institution of Dr. Furlan has received research support from Cervical Spine Research Society. Dr. Hitzig has nothing to disclose. Dr. Boulos has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Jazz Pharmaceuticals. Dr. Boulos has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Paladin Labs. Dr. Boulos has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Eisai. Dr. Boulos has received research support from Interaxon. The institution of Dr. Boulos has received research support from The Mahaffy Family Research Fund. The institution of Dr. Boulos has received research support from Canadian Institutes of Health Research. The institution of Dr. Boulos has received research support from Slamen-Fast New Initiatives in Neurology Award. The institution of Dr. Boulos has received research support from Green Mountain . Dr. Boulos has received personal compensation in the range of $5,000-$9,999 for serving as a speaker with Jazz Pharmaceuticals.

Untreated Moderate-to-Severe Sleep-Related Breathing Disorders Are Associated with Increased Frequency of Episodes of Autonomic Dysreflexia during Sleep in Individuals with Subacute or Chronic Spinal Cord Injury: A Prospective Cross-Sectional Study. (P1-13.002)

<h3>Objective:</h3> This ongoing cross-sectional study is focused on the potential association between moderate-to-severe sleep-related breathing disorders (SRBDs) and more severe cardiovascular dysfunction following spinal cord injury (SCI). <h3>Background:</h3> Sleep-related breathing disorders (SRBDs) are common and under-recognized among individuals living with spinal cord injury (SCI). SRBDs can affect the sympathetic response, but the impact of untreated SRBDs on cardiovascular autonomic function after SCI remains incompletely understood. <h3>Design/Methods:</h3> This cross-sectional study included adults with subacute/chronic (≥1 month after SCI onset), cervical or high-thoracic (T6 or above) SCI. The diagnosis of SRBD was established using a home-based/hospital unattended sleep screening test that quantifies the apnea-hypopnea index (AHI). Moderate-to-severe SRBD was defined as an AHI ≥ 15 events per hour. Episodes of autonomic dysreflexia (AD) were defined as a sudden increase in systolic blood pressure (BP) ≥ 20 mmHg. <h3>Results:</h3> This study included 45 individuals (14 females, 31 males with ages from 20 to 84 years; mean age: 57.0 years) with motor complete (n=22) or incomplete (n=24) SCI at cervical (n=38), or high thoracic levels. Time from SCI onset varied from 1.5 months to 52 years (mean time: 49.4 months). Mean AHI was 16.0 events per hour (AHI range: 0.8–51.7). The AHI was not associated with systolic BP (mean+/−SEM: 122.0+/−2.2 mmHg; p=0.903), diastolic BP (72.6+/−3.0 mmHg; p=0.639), mean arterial pressure (90.1+/−2.4 mmHg; p=0.714), and heart rate (70.6+/−1.4 bpm; p=0.669) during sleep. However, the AHI was significantly, positively correlated with the number of silent episodes of AD (mean +/− SEM: 3.6+/−0.4; Rsqr=0.220, p=0.001) during sleep, after excluding other causes of AD. <h3>Conclusions:</h3> The results of this cross-sectional study suggest that more severe SBRBs are associated with frequent silent episodes of AD during sleep among individuals with SCI. Future research is needed to assess the effects of continuous positive airway pressure (CPAP) therapy on cardiovascular dysfunction following SCI. <b>Disclosure:</b> The institution of Dr. Furlan has received research support from Wings for Life Spinal Cord Research Foundation. The institution of Dr. Furlan has received research support from Craig H Neilsen Foundation. The institution of Dr. Furlan has received research support from Ontario Neurotrauma Foundation. The institution of Dr. Furlan has received research support from Cervical Spine Research Society. The institution of Dr. Furlan has received research support from J P Bickell Foundation. The institution of Dr. Furlan has received research support from Praxis Spinal Cord Institute. The institution of Dr. Furlan has received research support from Cervical Spine Research Society. Dr. Loh has stock in Dara3D. Dr. Boulos has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Jazz Pharmaceuticals. Dr. Boulos has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Paladin Labs. Dr. Boulos has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Eisai. Dr. Boulos has received research support from Interaxon. The institution of Dr. Boulos has received research support from The Mahaffy Family Research Fund. The institution of Dr. Boulos has received research support from Canadian Institutes of Health Research. The institution of Dr. Boulos has received research support from Slamen-Fast New Initiatives in Neurology Award. The institution of Dr. Boulos has received research support from Green Mountain . Dr. Boulos has received personal compensation in the range of $5,000-$9,999 for serving as a speaker with Jazz Pharmaceuticals.

Engaging target users to appraise and refine clinical practice guidelines in pediatric concussion: An integrated knowledge translation approach

Background Clinical practice guidelines are systematically developed statements that assist clinicians in making evidence informed decisions regarding patient care. Within pediatric concussion, the Ontario Neurotrauma Foundation released the Guidelines for Diagnosing and Managing Pediatric Concussion in 2014. The purpose of this study was to evaluate the 2014 guidelines using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) evaluation tool, in addition to a brief knowledge translation survey, and to utilize the collected feedback from end users to inform improvements to support an updated version. An integrated knowledge translation approach was employed using clinical experts as guideline appraisers. Methods A purposive sample of researchers, physicians, allied health professionals, policy makers, educators and knowledge translation experts involved in updating the guidelines (N = 31) completed the AGREE II Likert scale survey regarding the 2014 guideline, and provided written justifications for their ratings. Domain and item AGREE II scaled scores were reported stratified by demographic factors, and written justifications were synthesized using content analysis to determine areas of improvement for the 2014 guideline. Results Appraisers scored the editorial independence (88.9%) and scope and purpose (80.8%) domains the highest, indicating high quality. The guidelines scored the lowest in the applicability domain (69.3%). Participants with less than 10 years of experience in their respective disciplines, as well as physicians and allied health professionals consistently provided higher ratings across domains compared to other professions. Conclusions The process of evaluating the 2014 guideline resulted in these important outcomes: (1) identified areas of the guideline that may have affected the lack of previous clinical uptake while abiding by a clinical practice guideline development framework; (2) shared and informed decision making regarding content and format of the revised clinical practice guideline; and (3) targeted content, clinical questions and dissemination strategies, which are key to clinical uptake.

Seizure Prophylaxis Following Moderate to Severe Traumatic Brain Injury: Retrospective Investigation of Clinical Practice and the Impact of Clinical Guidelines.

BackgroundPost-traumatic seizure (PTS) is a major complication of traumatic brain injury (TBI). However, there has been controversy in the literature regarding whether anticonvulsants should be used prophylactically to prevent it, and there is significant variability in practice. The objective of this study is to describe seizure prophylaxis practices after moderate to severe TBI and to determine whether the use of seizure prophylaxis increased following the recommendations of the Quebec Institut National d'Excellence en Santé et Services Sociaux and the Ontario Neurotrauma Foundation (INESSS-ONF) guidelines. This study will also compare the characteristics of patients who receive the recommended prophylaxis and those who do not.MethodsAll adult patients admitted to a level-1 trauma centre for moderate to severe TBI were eligible for this study (n = 96). Medical records including patient age, sex, Glasgow Coma Scale (GCS) score, mechanism of injury, and occurrence of PTS were reviewed in a retrospective manner regarding the administration of recommended seizure prophylaxis.ResultsThe proportion of patients receiving the recommended seizure prophylaxis was 8%. There was no significant increase after the release of the INESSS-ONF guidelines (p: 0.38). There were no significant differences in demographics, injury characteristics, or rates of early PTS between patients receiving the recommended prophylaxis and those not receiving it (p: >0.05).ConclusionThe results indicate that the use of the recommended seizure prophylaxis after moderate to severe TBI is low and that the release of the INESSS-ONF guidelines did not increase its use. Patient and injury factors do not appear to influence the use of seizure prophylaxis. These results highlight variability in seizure prophylaxis practices and the importance of understanding local practice patterns. Implementation strategies should be identified to increase adherence to the recommendations and improve patient care.

Characterisation of serum total tau following paediatric traumatic brain injury: a case-control study

Traumatic brain injury (TBI) is a major health problem in children. Blood-based biomarkers interpreted by use of normative values might improve the accuracy of diagnosis. Ultrasensitive assays can quantify serum concentrations of the neuronal microtubule-associated protein tau, which is increased in adult brains following TBI. We aimed to determine if serum total tau correlates with TBI diagnosis, severity, and radiological findings on CT scans in children younger than 18 years. In this case-control study, we included venous blood samples from healthy control children in the Canadian Laboratory Initiative on Pediatric Reference Intervals (CALIPER) biobank. For TBI cases, we recruited children (aged 0-17 years) who presented to the emergency department within 24 h of a TBI in three tertiary-care paediatric hospitals (Toronto, Vancouver, and Melbourne). Children were eligible if they required hospital observation for a minimum of 4 h or admission to the intensive care unit, and were excluded if they had had hospital treatment for a previous TBI, had birth trauma, or their parents could not speak English or French and therefore could not readily give consent. All available control samples were used and a case-control match was therefore not done. Venous and arterial blood samples were collected from patients with TBI within 28 h of injury (day 1). We used an ultrasensitive single-molecule immunoassay to measure serum total tau in blood samples. We first generated reference intervals of serum total tau from the control group, and used these normative data to interpret injury-associated changes in serum total tau in children with TBI. Concentrations of serum tau were measured in all CALIPER participants and patients with TBI, and no participants were excluded before analysis. We included samples from 416 control participants from the CALIPER cohort. Median total tau concentrations did not differ between sexes (p=0·12), but three significant reference intervals based on age groups were identified (1-3 years [0·88-19·2 pg/mL], 4-15 years [0·93-5·31 pg/mL], and 16-19 years [0·79-4·20 pg/mL]). Blood samples were obtained from 158 patients with TBI recruited between April 30, 2011, and June 28, 2013. Serum total tau on day 1 of TBI was negatively associated with Glasgow Coma Scale (GCS) score (rs=-0·42, 95% CI -0·55 to -0·28, p<0·0001). Median total tau was 2·86 pg/mL (IQR 1·52-4·83) in patients with GCS score 13-15 points (n=114), 7·08 pg/mL (3·75-41·1) in those with GCS score 9-12 points (n=13), and 8·48 pg/mL (2·53-70·6) in those with GCS score 3-8 points (n=31). Notably, participants who had GCS scores of 15 points had median total tau concentrations (2·57 pg/mL [1·50-4·61]) indistinguishable from those of control participants (2·46 pg/mL [1·77-3·42]), whereas those with GCS score 13-14 points had elevated total tau (6·41 pg/mL [2·97-42·5]). Serum total tau was not strongly associated with CT findings in patients with mild TBI. Serum total tau might help to differentiate between patients with mild TBI (GCS 13-14 vs GCS 15), but larger studies are needed to validate these results before this biomarker can be used for diagnosis and prognosis. Canadian Institutes of Health Research, Ontario Neurotrauma Foundation, and Victoria Neurotrauma Foundation.

Evidence-based treatment of mild TBI: A service audit and checklist to improve concordance with guidelines

Purpose:Widespread acceptance of treatment options for mild traumatic brain injury (mTBI) has so farbeen limited in the UK. Guidelines have been created to standardise treatment, based on expert consensus (Ontario Neurotrauma Foundation; ONF). However, research indicates that clinician guidelines are not always used consistently. This paper audits the use of ONFguidelines in one mTBI clinic and explores recommendations to improve concordance.Methods:Criterion-based audit was used to assess guideline usage for patients seen within the clinic between January and August 2016.Results and conclusion:Results indicated that the clinic provided thorough assessment and reliable information, although intervention guidelines were not used consistently. Inter-rater reliability suggests patient notes were difficult to interpret.Outcome:A checklist was developed to guide clinics in recording assessment and intervention in line with ONF guidelines. A pilot is required to assess usability.

Evidence-Based Physiatry: The Center for Disease Control Guideline on Pediatric Mild Traumatic Brain Injury and the Expanded Role of Physiatry.

A mild traumatic brain injury (mTBI) or concussion is the most commonly occurring type of traumatic brain injury in adults and children. Between 2005 and 2009, the United States Center for Disease Control estimated 2–3 million pediatric mTBI-related emergency department and primary care visits occurred. Although there are subtle variation in definitions of mTBI, a consensus has formed around defining this injury as an acute neurological disturbance manifesting with confusion and/or disorientation after a mechanical force to the head and meeting the following parameters: (1) length of loss of consciousness of less than 30 mins; (2) posttraumatic amnesia less than 24 hrs; and (3) a Glasgow Coma Scale of 13–15, 30 mins after injury or at time of presentation to medical care. Guidelines have emerged to direct treatment of specific groups that commonly sustain mTBI, such as the Consensus Statement on Concussion in Sport directed at student athletes, the Ontario Neurotrauma Foundation guidelines for those with mTBI and persistent symptoms, and Veteran’s Affairs/Department of Defense guidelines for mTBI in military service members and veterans. However, evidence based guidelines for pediatric mTBI in the United States were lacking until the most recently published Center for Disease Control Guideline on the Diagnosis and Management of mTBI among Children (https://www.cdc.gov/media/releases/2018/p0904-tbi-guidelines.html).1 GUIDELINE DEVELOPMENT AND METHODOLOGY The new Center for Disease Control guideline is a set of 19 recommendations based on a systematic review of the literature and expert consensus. Clinical questions were developed by the Pediatric Mild Traumatic Brain Injury Work Group, a panel of experts that included rehabilitation specialists and physiatrists. Guidelines were developed in three clinical areas diagnosis, prognosis, and management/treatment. A systematic review of pediatric mTBI and related topics from 1990 to 2015 was conducted using the American Academy of Neurology Guidelines. Each recommendation was based on evidence obtained in the systematic review as well as other relevant scientific information and expert opinion deemed significant by the work group. This work considered strength of evidence as well as additional factors, such as the risks and benefits of the recommendation, importance of the recommendation, feasibility, patient preference, and financial cost. WHAT ARE THE HIGHLIGHTS IN THE NEW GUIDELINES? These guidelines outline a series of practical and feasible recommendations for emergency department, primary care, and specialty providers focusing on readily available mTBI assessment tools, early identification of poor prognostic factors, and education and active rehabilitation as mainstays of treatment. A complete list of recommendations is located in the guideline supplement and patient and family resources are available online (https://www.cdc.gov/traumaticbraininjury/PediatricmTBIGuideline.html).1 In summary, the guideline recommends against the routine use of neuroimaging or serum based biomarkers for diagnosis of mTBI, except when intracranial injury is suspected. Age-appropriate symptom inventories and computer-based cognitive testing should not be used alone but in conjunction with clinical assessment. In the area of prognosis, the guidelines strongly support education of patients and families about the general course of recovery in pediatric mTBI (1–3 mos) and risk factors that are associated with prolonged recovery (premorbid conditions, injury, and noninjury-related factors). Close monitoring of individuals with multiple risk factors for prolonged symptoms and referral to specialty care within 4–6 weeks of injury if symptoms persist. The guidelines strongly support education of patients and families regarding warning signs in the acute period, the emergence of postconcussive symptoms, prevention of a second, overlapping head injury, and guidance for return to school and activity. Although rest was once the mainstay of concussion treatment, the guideline emphasizes a brief period (2–3 days) of reduced activity in the acute period followed by a gradual return to school and noncontact physical activity that does not exacerbate symptoms. The guideline supports the use of individualized return to school plans based on symptom severity and highlights the importance of a collaborative effort in return to school recommendations. Referral specialists and formal neuropsychological testing is recommended in students struggling with return to school or with persistent cognitive symptoms, respectively. Treatment recommendations focus on multidisciplinary care and dedicated symptom-based treatments for acute and chronic headache, sleep dysfunction, and vestibular and oculomotor symptoms are provided. WHY IS THIS RELEVANT TO PHYSIATRISTS? Physiatrists are uniquely positioned to care for children with mTBI because of their role in leading multidisciplinary rehabilitation teams and their specific clinical expertise in pediatric rehabilitation, sports medicine, and traumatic brain injury. The guideline recommends referral to specialty and rehabilitation care in the early subacute period meaning that the number of children with mTBI referred to specialists, such as physiatry, will likely increase. The guideline supports a paradigm shift in the treatment of mTBI from a rest and recover model to an active rehabilitation, symptom-based approach including physical activity, cognitive activity, and specialized rehabilitation (i.e., vestibular). Such an approach is an ideal forum to leverage physiatric skills.

Maintenance of diet participation in individuals with spinal cord injury: effect on mood and neuropathic pain.

One-year follow-up of a randomized clinical trial. Examine voluntary dietary compliance 1 year following the cessation of the intervention and the persistence of accrued benefits related to neuropathic pain and mood. Outpatient rehabilitation program within the Niagara region. Five individuals (4 female, 1 male; age 50.6 ± 11.8 years) with chronic SCI (C5-L3; ISNCSCI: A-D; 7-40 years post injury) who had previously completed a 3-month anti-inflammatory diet were reassessed after 1 year for measures related to dietary compliance, CES-D scores of depression, and NPQ scores of neuropathic pain. There was a significant reduction in diet compliance at the 1-year follow-up in comparison to the end of the dietary intervention at 3 months (92.6% versus 43.0%, p < 0.01). CES-D scores showed a trend toward an increase from 3 months to follow-up (8.0 versus 21.4, p = .10) whereby follow-up CES-D scores were no longer statistically different from baseline (p = 0.74). Sensory NPQ scores showed no significant change from 3 months to follow-up (25.2 versus 29.1, p = 0.42) and remained significantly lower than baseline (p = 0.02). Affective NPQ scores were significantly increased from 3 months to follow-up (27.7 versus 40.1, p = 0.05). Sensitivity NPQ scores showed no significant change from 3 month to follow-up (28.2 versus 33.5, p = 0.34), but returned to a score that was statistically similar to baseline (p = 0.15). These results emphasize the importance of continued compliance to a diet with anti-inflammatory properties for the purposes of maintaining benefits related to mood and neuropathic pain in individuals with SCI. This study was supported by the Ontario Neurotrauma Foundation.

Common Data Elements for Concussion in Tertiary Care: Phase One in Ontario.

Standardized data collection for traumatic brain injury (TBI) (including concussion) using common data elements (CDEs) has strengthened clinical care and research capacity in the United States and Europe. Currently, Ontario healthcare providers do not collect uniform data on adult patients diagnosed with concussion. The Ontario Concussion Care Strategy (OCCS) is a collaborative network of multidisciplinary healthcare providers, brain injury advocacy groups, patient representatives, and researchers with a shared vision to improve concussion care across the province, starting with the collection of standardized data. The International Framework of Functioning Disability and Health was selected as the conceptual framework to inform the selection of CDEs. The CDEs recommended by the OCCS were identified using key literature, including the National Institute of Neurological Disorders and Stroke-Zurich Consensus Statements for concussion in sport and the Ontario Neurotrauma Foundation Concussion/mTBI clinical guidelines. The OCCS has recommended and piloted CDEs for Ontario that are readily available at no cost, clinically relevant, patient friendly, easy to interpret, and recognized by the international scientific community. The implementation of CDEs can help to shift Ontario toward internationally recognized standard data collection, and in so doing yield a more comprehensive evidence-based approach to care while also supporting rigorous research.

Advancing research and clinical care in the management of neuropathic pain after spinal cord injury: Key findings from a Canadian summit

ABSTRACTBackground: Optimal management of neuropathic pain (NP) is essential to enhancing health-related quality of life for individuals living with spinal cord injury (SCI). A key strategic priority for the Ontario Neurotrauma Foundation (ONF) and Rick Hansen Institute (RHI) is optimizing NP management after SCI.Aims: A National Canadian Summit, sponsored by ONF and RHI, was held to develop a strategic plan to improve NP management after SCI.Methods: In a one-day meeting held in Toronto, Ontario, a multidisciplinary panel of 18 Canadian stakeholders utilized a consensus workshop methodology to (1) describe the current state of the field, (2) create a long-term vision, and (3) identify steps for moving into action.Results: A review of the current state of the field identified strengths including rigourously developed evidence syntheses and practice landscape documentation. Identified gaps included limited evidence on NP hindering recommendation development in evidence syntheses, absence of a national strategy, care silos with limited cross-continuum connections, limited consumer involvement, and limited practice standard implementation. The panel identified key themes for a long-term vision to improve the management of SCI NP in Canada, including establishing an integrated collaborative network; standardized care and outcome evaluation; education; advocacy; and directing resources to innovative solutions. The panel identified the next step as prioritization of areas that will have the greatest impact in a 5-year time frame.Conclusion: A strategic plan outlining a long-term vision to improve management of NP after SCI in Canada was developed and will inform future activities of the sponsors.

Direct referral and physical activity counselling upon discharge from spinal cord injury rehabilitation

Sixteen-week follow-up study. To evaluate the efficacy of referral from a health-care provider to regular exercise combined with 16 weeks of counselling support following discharge from inpatient or outpatient spinal cord injury (SCI) rehabilitation. Two rehabilitation centres in Canada. Seventeen participants (age 42.1±10.6 years, C3-T12, ASIA impairment score A-C) were recruited at discharge from inpatient (n=9; 5.2±1.3 months post-injury) or outpatient (n=8; 14.2±3.8 months post-injury) rehabilitation and were given a referral for regular exercise. Telephone counselling support was provided and adherence to the prescribed program was monitored for 16 weeks. There was a nonsignificant difference in exercise adherence rates (percentage of available sessions attended) between participants discharged from inpatient (71.4±44.9%) and those from outpatient (39.5±27.2%) rehabilitation programs. The most common barriers to participation were physical health problems (50%) and transportation (36%). An exercise beliefs questionnaire revealed that participants value exercise at discharge from rehabilitation, despite the common report of a relative lack of confidence in their ability to perform or adapt aerobic and resistance exercises to their specific capabilities. A system of direct referral and ongoing counselling support following discharge from either inpatient or outpatient SCI rehabilitation appears to encourage sustained participation, although future health promotion strategies should continue to provide specific information about how to adapt and complete aerobic and resistance exercises. Rick Hansen Institute and Ontario Neurotrauma Foundation.

Net costs of hospital-acquired and pre-admission PUs among older people hospitalised in Ontario

To determine the net cost of hospital-acquired and pre-admission pressure ulcers (PUs) in an acute-care setting in Ontario, Canada. Cases of PUs were identified among hospitalised patients using Ontario Case Costing Initiative (OCCI) data from 2002-2006. Inpatient costs included direct and overhead costs.To determine the net cost of PUs, cases were matched controlling for age, gender, most responsible diagnosis and comorbidity. Mean net costs were estimated using Bayesian linear mixed models methods. Results were also reported by PU severity. In our study, there were 1351 cases of hospital-acquired PUs and 2523 cases of preadmission PUs over 5 years. Net cost of hospital-acquired PU ranged between CA$44000 for a category II PU to CA$90000 for a category IV PU. For pre-admission PU net cost was between CA$11 000 to CA$18500 for category II and category IV PU, respectively.The net cost of treating hospital-acquired PU is higher than pre-admission PU. Costs increase with increasing PU severity. The total net adjusted hospitalisation cost of a hospital-acquired PU in Ontario was CA$44000-90000, compared with CA$11 000-18500 for a pre-admission PU. Future studies should determine the attributable cost of PU using patient-level data to verify the accuracy of the study results.

Investigating relationships between arterial stiffness and collagen turnover in humans

Understanding the factors regulating changes in vascular structure may assist in designing strategies for decreasing the development and progression of cardiovascular disease. Previous research has shown links between various markers of collagen turnover and arterial stiffness in clinical populations (McNulty, 2006 &amp; Chatzikyriakou, 2008). The purpose of this study was to investigate the relationship between functional assessments and blood markers of arterial wall structure. Arterial stiffness and markers of collagen turnover were assessed in 20 overweight women, 20 elderly healthy men, 23 individuals with coronary artery disease, 16 individuals with spinal cord injury and 10 young healthy men. Carotid artery stiffness was determined through assessment of common carotid artery distensibility with simultaneous B‐mode ultrasound imaging and applanation tonometry. Fasting venous blood samples were analyzed for serum levels of pro‐collagen type I (PIP) and cross‐linked telopeptide of collagen type I (CTX); markers of type I collagen synthesis and degradation, respectively. There was a significant positive relationship observed between CTX and carotid artery distensibility (R = 0.330, p = 0.001) and a weak but significant inverse relationship (R = −0.224, p = 0.034) observed between carotid artery distensibility and type I collagen turnover, expressed as a ratio of PIP to CTX. These findings suggest a link exists between type I collagen turnover and central arterial distensibility, however this relationship appears to be opposite to that previous observed in the literature in older hypertensive individuals (McNulty, 2006). Funded by Canadian Institute of Health Research, Natural Sciences and Engineering Research Council, Innovation Center for US Dairy, Dairy Farmers of Canada and the Ontario Neurotrauma Foundation.

Working memory in youth following sports-related concussion: is it still working? an fMRI study

ObjectiveTo compare working memory performance and related brain activity using fMRI in concussed youth and healthy age-matched control subjects.DesignStandard T1 and T2* weighted echo planar images for blood oxygenation level...

Neuroimaging dual task performance in youth after sports-related concussion: an fMRI study

ObjectiveTo identify the neural substrates of a dual-task paradigm and evaluate performance in concussed versus non-concussed youth 3–6 months post-injury.DesignStandard structural (T1, T2, FLAIR, DTI) and functional (single-shot T2*-weighted pulse...

Player aggression affects head impact biomechanics in youth ice hockey players

ObjectiveTo evaluate the effect of player aggression on head impact biomechanics.DesignProspective cohort.SettingField (on-ice) study.ParticipantsThirty-seven volunteer ice hockey players (age=15.0±1.0 years, height=173.5±6.2 cm, mass=66.6±9.0 kg, playing experience=2.9±3.7 years).InterventionsParticipants were equipped with...

The two Janes we knew and loved

After a brief, but courageous battle with a rare and aggressive cancer, Dr. Jane Gillett passed away February 16, 2011. Dr. Gillett was the Medical Director of the Acquired Brain Injury Program at Hamilton Health Sciences, Hamilton, Ontario, Canada and an Associate Professor at McMaster University since 2002. She was also the Founder and President of the International Paediatric Brain Injury Society (IPBIS), and was the Chair of the Knowledge Mobilization Committee for the Ontario Neurotrauma Foundation. She developed the Paediatric Acquired Brain Injury Community Outreach Program (PABICOP) in London,Ontario in 1999, and remained a strong advocate for the program model, which she continued to champion locally, nationally and internationally. At the time of her death Dr. Gillett was in the process of leading the work on a funded proposal, which would begin development of a similar program in Northern Ontario [1]. As memorial comments from around the world indicate [2], there were two Janes. Dr. Gillett was a unique and wonderful blend of passionate physician and professional and, a fun loving, generous, affectionate and compassionate friend. She cared deeply for children, youth and adults with ABI and was committed to creating professional alliances and programs with national and international implications. Let’s examine how she came to be such a unique personality. Initially, Dr. Gillett trained as a speech-language pathologist with a special interest in neurological speech disorders. Her career aspirations led her to medical training with a special interest in children and acquired brain injury. Jane graduated from the Univer-

Updates From the Third Federal Interagency Conference on Traumatic Brain Injury

Updates From the Third Federal Interagency Conference on Traumatic Brain Injury

Effect of On-ice General Aerobic Fitness on Head Impact Biomechanics in Youth Hockey Players

A current focus of youth concussion prevention is centered on intrinsic factors that may mitigate the severity of head impacts sustained by young athletes. Athletes with decreased general aerobic fitness (GAF) may be more likely to fatigue and less likely to overcome the impact forces associated with body collisions during participation. PURPOSE: To examine the effect of GAF on head impact biomechanics in youth ice hockey players. METHODS: A quasi-experimental field study included 37 hockey players (age=15.0±1.0 yrs, ht=173.5±6.2 cm, mass=66.6±9.0 kg) equipped with accelerometer-instrumented helmets capable of recording linear and rotational acceleration during participation. Players completed the Faught Aerobic Skate Test (FAST) during three ice sessions (training, sessions 1 and 2) while wearing protective equipment. The FAST is an on-ice analogy to a traditional Leger-Boucher shuttle run "beep" test. The mean laps attained during the FAST (across both test sessions) and estimates of volume of maximal oxygen consumption (VO2max) were recorded. Participants were then separated into three GAF tertiles for each outcome (i.e. most fit, moderately fit, least fit) for the purposes of comparing our head impact biomechanics (linear and rotational acceleration) across GAF levels. RESULTS: Athletes attaining the highest number of laps during the FAST experienced greater head impact biomechanics (linear: 18.0 g, 95% CI: 17.4-18.6; rotational: 1678.6 rad/s2, 95% CI: 1573.7-1790.4) than athletes with the lowest GAF (linear: 17.1 g, 95% CI: 16.7-17.5; rotation: 1497.8 rad/s2, 95% CI: 1406.9-1594.5) (linear: F2,29 = 3.93, P = 0.031; rotation: F2,29 = 3.46, P = 0.045). A significant difference in linear acceleration was observed (F2,29 = 8.51; P < 0.001) suggesting athletes with the highest GAF levels based on estimated VO2max experienced higher linear accelerations (18.0 g; 95% CI: 17.7-18.2) than those who represented the lowest GAF tertile in our sample (17.0 g; 95% CI: 16.6-17.4). CONCLUSION: Increasing GAF does not appear to reduce head impact severity. We speculate those with greater GAF were more likely to have participated in late stages of competition where increased aggression may have resulted in more severe head impacts. Supported by Ontario Neurotrauma Foundation, NOCSAE, and USA Hockey.

The canadian best practices portal for health promotion and chronic disease prevention: a place to go for program planning in injury prevention in sport

BackgroundWhile participation in sports contributes to health and well being, it also increases risk for injury in both amateur and professional athletes. Consequently, the prevention of sport injuries ranks relatively...