Computerized Cognitive Rehabilitation in Acquired Brain Injury: A Systematic Review

e76 Poster 231 Correlating Vertical Heterophoria Symptom Questionnaire With Injury Severity, Gender, and Age in TBI Patients William B. Gray (Wayne State University/Oakwood), Richard E. Hoyt, Saurabha Bhatnagar, David Buzas, Jay Merlin Meythaler Objective: To investigate the correlation between Glasgow Coma Scale (GCS) scores with scores on the Vertical Heterophoria Symptom Questionnaire (VHS-Q) in TBI patients between 18-80 years of age with headache and/or visual symptoms. Design: Observational e Cross-sectional Study (Questionnaire). Setting: Outpatient rehabilitation clinic. Participants: Patients screened were ages 18-80, had a documented TBI confirmed by evaluation from an experienced Physiatrist, and had complaints of headaches and/or visual symptoms. Exclusion criteria: patients with a history of cerebellar infarct, acoustic neuroma, blindness, or previously diagnosed binocular vision dysfunction. Consenting participants completed a 25-question VHS-Q. Interventions: None.All patients were provided routine clinical care. Main Outcome Measure(s): VHS-Q score (range of 0-75 with 16 or greater being a positive screen for Vertical Heterophoria) and GCS score. Results: 109 subjects screened, 99 met inclusion criteria and were included in the analysis. Distribution of TBI severity by GCS was 54 mild, 29 moderate, and 16 severe. There were 19% more patients than expected in the severe TBI group with a VHS-Q score < 16 (p Z 0.025).Females were more likely to have a positive VHS-Q screen where as males were less likely to have a positive VHS-Q screen (p Z 0.023).The 36-50 age group was less likely to have a negative VHS-Q score andthe 18-35 age group was more likely to have a negative VHS-Q score (p Z 0.009). Conclusions: Severity of TBI and age does not directly correlate with VHS-Q score.Further studies are required. Key Words: Brain Injuries, Glasgow Coma Scale, Strabismus Disclosure(s): None Disclosed. Poster 232 Structured Interview for Mild TBI After Military Blast: Interrater Agreement and Development of Diagnostic Algorithm William Walker (Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University) David X. Cifu, Anne M. Hudak, Gary Goldberg, Richard D. Kunz, Adam P. Sima Objective: 1) Measure agreement among clinicians’ mild Traumatic Brain Injury (TBI) diagnosis ratings, 2) using clinician consensus develop a fully structured diagnostic algorithm, and 3) assess accuracy of this algorithm in a separate sample. Design: Cross-sectional observational study with blinded diagnosis ratings. Setting: Veteran Affairs and Military ambulatory health clinics. Participants: Two samples (nZ66, nZ37) of individuals within two years of experiencing blast effects during military deployment. Interventions: Semi-structured interview using the newly developed VCU retrospective concussion diagnostic interview, blast version (VCU rCDI-B). Main Outcome Measure(s): Five highly trained TBI physicians gave blinded ratings of whether or not the worst experience was probably an mTBI. Results: Paired interrater reliability was extremely variable with kappa ranging 0.194-0.825. Using Sample-1 physician consensus ratings of probable mTBI (prevalence Z 84%), an algorithm was developed and refined from the fully structured portion of the VCU rCDI-B that considered certain symptom patterns more specific for mTBI than others. The accuracy of the final algorithm when prospectively applied against the

Brain Injury actual physician consensus in Sample-2 was almost perfect (correctly classified Z 97%, Cohen’s kappaZ0.91). Conclusions: Diagnosing suspected prior mild Traumatic Brain Injury (mTBI) in the context of a prior combat event with potential physical and psychological trauma is challenging. Clinical interview is prone to bias and existing standardized TBI interview instruments have limitations. We showed that highly trained clinicians often disagree on historical blast-related mTBI determinations. A fully structured interview algorithm was developed from their consensus diagnosis that may serve to enhance diagnostic standardization for clinical research in this population. Key Words: Assessment Tools, Traumatic Brain Injury, Military Injury, Concussion Disclosure(s): None Disclosed. This study was supported by a grant from US Army Medical Research & Material Command, Congressionally Directed Medical Research Program (CDMRP) grant# W91ZS Q8118N6200001; Epidemiological Study of Mild Traumatic Brain Injury Sequelae Caused by Blast Exposure during Operations Iraq Freedom and Enduring Freedom. Poster 233 A Mirror Therapy-Based Action Observation Protocol to Improve Motor Learning After Stroke Wouter Harmsen (Roneres), Johannes Bussmann, Ruud W. Selles, Henri Hurkmans, Gerard Ribbers Objective: To investigate whether a mirror therapy based-action observation protocol contributes to motor learning of the affected arm after stroke. Design: Randomized controlled trial. Setting: Rehabilitation Center. Participants: Outpatients with mild to moderate hemiparesis in the chronic stage after stroke. Interventions: A single mirror therapy-based Action Observation (AO) protocol vs. a single Control Observation (CO) protocol. Main Outcome Measure(s): The effects of a mirror therapy-based AO protocol on motor learning of the affected arm was investigated by evaluating a simple upper-arm reaching task in an experimental setup. Repeated measurements were performed to analyze short-term motor learning effects and improved motor task performance, with movement time of the movement trajectory as main outcome measure. Results: In total, 37 participants were randomly allocated to either the action observation (AO) or control observation (CO) group. Participants in both groups significantly improved motor task performance: 18.3% in the AO and 9.1 % in the CO group. Decrease was significantly more in the AO compared to the CO group (mean differenceZ .14 s, 95% CI [2.2, 33.6], pZ .026). Conclusions: A mirror therapy-based AO protocol significantly contributes to motor learning of the affected in patients in the chronic stage after stroke. Key Words: Action observation, Stroke, Mirror therapy, Motor learning, Upper-limbs Disclosure(s): None disclosed.

Poster 234 Computerized Cognitive Rehabilitation in Acquired Brain Injury: A Systematic Review Yelena Bogdanova (Boston University), Megan K. Yee, Vivian T. Ho Objective: Cognitive deficits (attention and executive function) are common in acquired brain injury (ABI). Recently, there have been a number of computerized programs aimed to train attention, executive function, and to prevent cognitive aging. No comprehensive review has been published on

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Brain Injury the use of computerized treatment programs as a rehabilitation tool in ABI. We conducted a systematic review of empirical research on computerized cognitive rehabilitation for attention and executive function after ABI. Design: Systematic Review. Data Sources: A literature search of Pubmed and PsychINFO was conducted using the key terms: computerized cognitive rehabilitation, traumatic brain injury (TBI), stroke, ABI, and executive functioning. Study Selection: Studies reporting on cognitive outcomes following computerized rehabilitation in adult participants with an ABI of any severity were included. Data Extraction: Articles were independently assessed by two reviewers, using Cicerone et al criteria. Data collected included sample size, diagnosis, intervention info, treatment schedule, assessment methods, and results. Data Synthesis: The initial searches yielded a total of 1075 hits; reduced to 121 after title review, which was further reduced to 27 once doubles were eliminated and abstracts were reviewed. Fourteen met inclusion criteria after being read. Nine studies met criteria for Class I, two met criteria for Class II, and three met Class III evidence criteria. There is evidence of improvement in executive functioning in ABI following computerized treatment. Studies were more commonly conducted in stroke patients. TBI studies often included smaller sample sizes and less adequate control groups. Conclusions: The evidence indicates improvements in executive functioning following computerized cognitive rehabilitation training. Additional studies are needed, especially in TBI. Key Words: Rehabilitation, Executive Function, TBI, Computerized cognitive training Disclosure(s): None Disclosed. Poster 235 LED Therapy Improves Sleep and Cognition In Chronic Moderate TBI: Pilot Case Studies Yelena Bogdanova (Boston University), Paula I. Martin, Michael D. Ho, Maxine H. Krengel, Vivian T. Ho, Megan K. Yee, Jeffrey A. Knight, Michael Hamblin, Margaret Naeser Objective: To probe the effect of noninvasive transcranial red/near-infrared (NIR) light-emitting diode (LED) treatment on sleep and cognitive function in patients with chronic moderate traumatic brain injury (TBI). Design: Case study. Setting: Outpatient clinical research unit. Participants: Two patients (1 female) with moderate TBI (medical records and clinical evaluation) and persistent cognitive dysfunction (at least 2 SD below average on one, or 1 SD below average on at least two neuropsychological tests of executive function and memory). Interventions: 18 sessions of transcranial LED therapy (3x/week for 6 weeks). LED therapy is non-invasive, painless, and non-thermal (500mW, FDA-cleared, non-significant risk device). Red/NIR photons increase ATP production and local rCBF in the areas of compromised cells. Main Outcome Measure(s): Standardized neuropsychological (executive function, memory), neuropsychiatric (depression, PTSD) and sleep measures (PSQI, actigraphy) were administered to participants pre- (T1), mid(T2), and one week (T3) post- LED treatment. Primary outcome measures: Stroop (executive function), CVLT-II (memory), BDI-II (depression), and actigraphy (sleep). Results: Both LED-treated cases showed marked improvement in sleep (actigraphy Total Sleep) 1 week post-LED treatment series (T3), as compared to pre-treatment (T1). P1 also improved in executive function, verbal memory, and Sleep Efficiency; while P2 significantly improved on measures of PTSD (PCL-M) and depression. No adverse events were reported. Conclusions: Our preliminary results showed that sleep and cognition can be improved by LED treatment in chronic moderate TBI. These findings

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e77 suggest that this novel noninvasive therapeutic approach (LED) has potential to reduce persistent cognitive symptoms in moderate TBI and associated neuropsychiatric symptoms (sleep disturbance, depression, and PTSD). Controlled studies are warranted. Key Words: Actigraphy, Low Level Light Therapy, Executive function, Sleep, Neurorehabilitation Disclosure(s): None Disclosed.

Poster 236 Psychiatric Comorbidities Among Individuals With Post Concussive Syndrome Yelena Goldin (JFK Johnson Rehabilitation Institute), Keith Ganci, Keith Cicerone Objective: To examine the frequency and nature of co-morbid psychiatric disorders among individuals with Post-Concussive Syndrome (PCS) seeking neuropsychological services and/or cognitive rehabilitation. Design: Observational cross-sectional. Setting: Clinical and research facility in a suburban medical center. Participants: 100 consecutive referrals for neuropsychological evaluation ofindividuals with presenting diagnosis of mild traumatic brain injury and/ or PCS (age 19-68, 40% male). Interventions: None. Main Outcome Measure(s): Three modules from the Patient Health Questionnaire (PHQ):1) PHQ-9, which assesses the presence and severity of depression; 2) PHQ-15, which assesses the presence and severity of somatization and somatoform disorder; and 3) GAD-7, which assesses the presence and severity of anxiety disorders.PTSD Checklist e Civilian Version (PCL-C) was used to screen for the presence of post-traumatic stress disorder (PTSD). All measures demonstrate good reliability and have been widely used in the assessment of individuals with chronic medical conditions. Neurobehavioral Symptom Inventory was used to assess the presence and severity of post-concussive symptoms. Results: The largest groups included individuals with PCS only who did not meet criteria for any of the four psychiatric disorders assessed (29%) and individuals who met criteria for three psychiatric conditions (27%).The remainder of the sample was comparably distributed among individuals who met criteria for one (14%), two (15%), and all four (15%) psychiatric conditions assessed.Among individuals who met criteria for one or more psychiatric disorder, somatization/somatoform disorder was the most prevalent conditions when occurring alone or in combination with other conditions, followed by depression, and anxiety.Post-traumatic stress disorder occurred in only 4 individuals (4% of the sample) and only when criteria for at least two other conditions were met.Patients with selective cognitive/cognitive-affective PCS symptoms were less likely to meet criteria for psychiatric co-morbidities, compared to patients with global PCS symptoms who were more likely to meet criteria for three psychiatric conditions (most prevalently somatization/somatoform disorder, depression, and anxiety). Conclusions: Approximately one third of the sample exhibited PCS without any psychiatric co-morbidities.Approximately two thirds of individuals with PCS met criteria for one or more psychiatric conditions, and approximately one third met criteria for three co-morbid psychiatric conditions. Contrary to the majority of the literature that suggests that depression and anxiety are the most common psychiatric conditions, our data indicate that somatization/somatoform disorder is most prevalent among individuals with PCS, followed by depression and anxiety.A diagnosis of PTSD was relatively uncommon in this sample and occurred in the context of global psychiatric dysfunction.Selective cognitive/ cognitive-affective PCS symptoms were less likely to be associated with psychiatric co-morbidities than global PCS symptomatology.Implications