Women Vs. Brain Injury

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BRAIN INJURY professional vol. 17 issue 2





Women vs. Brain Injury


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BRAIN INJURY professional

vol. 17 issue 2


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Editor in Chief Message Guest Editor’s Message Expert Interview Useful Resources Technology Article


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Women with Brain Injury: Past, Present and Future Katherine Price Snedaker, LCSW

Exercise in Concussed Females

John Leddy, MD • Barry Willer, PhD


Traumatic Brain Injury Among Female Veterans


Brain Injuries We Overlook: TBIs From Intimate-Partner Violence


Clarity in Databases to Account for the Global Public Health Epidemic


Factors Affecting Recovery Trajectories in Pediatric Female Concussion

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Maheen Mausoof Adamson, PhD • Odette A. Harris, MD, MPH

Eve M. Valera

Jonathan Lifshitz, PhD

Christina L. Master, MD, FAAP, CAQSM, FACSM • Natasha Desai, MD, FACEP, CAQSM

Refocusing Care in Girls with Post-concussion Symptoms

Nick Reed, MScOT, PhD, OT Reg (Ont)

Adolescent Females More Likely to be Diagnosed with an Endocrine Disorder After a TBI J. Bryce Ortiz, PhD


Natural Progression of Symptom Change and Recovery from Concussion in a Pediatric Population Andrée-Anne Ledoux, PhD


Provider Competencies for Disorders of Consciousness: Minimum Competency Recommendations Proposed by the ACRM-NIDILRR Workgroup Theresa Bender Pape, MA, CCC-SLP, Dr.PH, FACRM Nathan D. Zasler, MD, DABPM&R, FAAPM&R, FACRM, BIM-C, CBIST

Brain Injury Professional is a membership benefit of the North American Brain Injury Society and the International Brain Injury Association

BRAIN INJURY PROFESSIONAL PUBLISHER J. Charles Haynes, JD CO-EDITOR IN CHIEF Beth Slomine, PhD - USA CO-EDITOR IN CHIEF Nathan Zasler, MD - USA ASSOCIATE EDITOR Juan Arango-Lasprilla, PhD – Spain TECHNOLOGY EDITOR Stephen K. Trapp, PhD - USA EDITOR EMERITUS Debra Braunling-McMorrow, PhD - USA EDITOR EMERITUS Ronald C. Savage, EdD - USA DESIGN AND LAYOUT Kristin Odom ADVERTISING SALES Megan Bell-Johnston EDITORIAL ADVISORY BOARD Nada Andelic, MD - Norway Philippe Azouvi, MD, PhD - France Mark Bayley, MD - Canada Lucia Braga, PhD - Brazil Ross Bullock, MD, PhD - USA Fofi Constantinidou, PhD, CCC-SLP, CBIS - USA Gordana Devecerski, MD, PhD - Serbia Sung Ho Jang, MD - Republic of Korea Cindy Ivanhoe, MD - USA Inga Koerte, MD, PhD - USA Brad Kurowski, MD, MS - USA Jianan Li, MD, PhD - China Christine MacDonell, FACRM - USA Calixto Machado, MD, PhD - Cuba Barbara O’Connell, OTR, MBA - Ireland Lisandro Olmos, MD - Argentina Caroline Schnakers, PhD - USA Lynne Turner-Stokes, MD - England Olli Tenovuo, MD, PhD - Finland Asha Vas, PhD, OTR - USA Walter Videtta, MD – Argentina Thomas Watanabe, MD – USA Alan Weintraub, MD - USA Sabahat Wasti, MD - Abu Dhabi, UAE Gavin Williams, PhD, FACP - Australia Hal Wortzel, MD - USA Mariusz Ziejewski, PhD - USA EDITORIAL INQUIRIES Managing Editor Brain Injury Professional PO Box 131401, Houston, TX 77219-1401 Tel 713.526.6900 Email: mbell@hdipub.com Website: www.nabis.org ADVERTISING INQUIRIES Megan Bell-Johnston Brain Injury Professional HDI Publishers PO Box 131401, Houston, TX 77219-1401 Tel 713.526.6900 Email: mbell@internationalbrain.org NATIONAL OFFICE North American Brain Injury Society PO Box 1804, Alexandria, VA 22313 Tel 703.960.6500 / Fax 703.960.6603 Website: www.nabis.org ISSN 2375-5210 Brain Injury Professional is a quarterly publication published jointly by the North American Brain Injury Society and HDI Publishers. © 2020 NABIS/HDI Publishers. All rights reserved. No part of this publication may be reproduced in whole or in part in any way without the written permission from the publisher. For reprint requests, please contact, Managing Editor, Brain Injury Professional, PO Box 131401, Houston, TX 77219-1400, Tel 713.526.6900, Fax 713.526.7787, e-mail mbell@hdipub.com.

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from the

editor in chief

I am delighted to serve as Editor-in-Chief for this edition of Brain Injury Professional that explores sex and gender differences in brain injury. Over the last decade, there has been increased focus among brain injury professionals about the unique issues faced by women and girls after brain injury. The impetus for this attention is in large part due to efforts of the PINK Concussions. PINK Concussions is a non-profit organization that focuses on education and care for women and girls with brain injuries from concussion, violence, accident, or military service.

Beth S. Slomine, PhD, ABPP

Our guest editor for this special edition on Women Vs. Concussions, Katherine Price Snedaker, is the founder and Executive Direct of PINK Concussions. Through her tireless advocacy, including multiple speaking engagements, mobilization of leaders in the field and strong presence on social media, she has championed the movement to ensure that the unique needs of women and girls with brain injury are identified, understood and addressed. I am so pleased that Ms. Snedaker has taken her time and efforts to organize this stellar issue. Snedaker has assembled an all-star cast of brain injury experts to showcase our understanding of brain injury in women and girls. The edition starts with discussion of the past, present, and future directions of PINK Concussions. Articles that follow cover a range of topics including sex differences following concussion in women and girls, unique issues facing female Veterans and those injured through intimate partner violence, and differences in endocrine functioning among males and females. The issue also includes an interview with Dr. Angela Colantonio, an internationally recognized researcher who studies issues related to women and brain injury. Finally, while we are not able to meet in person in the upcoming months, please mark your calendars for webinar series organized by the International Brain Injury Association, the International Paediaric Brain Injury Society, and North American Brain Injury Society. Upcoming events include TeleTherapy through Pandemic and Beyond (September 29, 2020), Updates on Diagnosis, Prognosis, and Management of Pediatric Disorders of Consciousness (November 12), and Childhood stroke: implications for clinical interventions (on behalf of the Swedish National Network for Rehabilitation after Childhood Acquired Brain Injuries – SVERE) (January 14). Also, please mark your calendars for the upcoming 34 Annual NABIS Medical and Legal Issues Conference in Brain Injury which will take place virtually January 14 – 15, 2020. For more information on the upcoming webinars and events, please visit to https:// www.internationalbrain.org.

Editor Bio Beth Slomine, PhD, ABPP is co-director of the Center for Brain Injury Recovery and director of neuropsychology training and neuropsychological rehabilitation services at Kennedy Krieger Institute. She is a Professor of Psychiatry & Behavioral Sciences and Physical Medicine & Rehabilitation at Johns Hopkins University School of Medicine. She is a licensed psychologist, board certified clinical neuropsychologist, and board certified subspecialist in pediatric neuropsychology. Research interests include developing neurobehavioral assessment tools and understanding factors influencing outcome following pediatric neurological injury. Dr. Slomine has authored >80 peer-reviewed manuscripts, numerous book chapters, and co-edited a textbook entitled Cognitive Rehabilitation for Pediatric Neurological Conditions.

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from the

guest editor

As you open this issue of Brain Injury Professional (BIP), you may ask yourself, “Do I need to know about sex or gender differences in brain injury if I treat every one of my patients as an individual? Could brain injury research on the differences in females versus males actually help me with my patients”? I often hear these questions from medical professionals before I am about to present at a conference. And the answer to both questions is yes! I am confident that the articles assembled in this issue will help you see your patients through a different lens; and in the end, this research will offer you new insights and directions for the way you manage women and girls in your practice.

Katherine Snedaker, LCSW

Editor Bio Katherine Price Snedaker, LCSW, is the Executive Director and Founder of PINK Concussions, a 501c3 non-profit, which focuses on brain injury in women and girls from sport, domestic violence/ assault, accidents or military service. Since launching PINK Concussions in 2013, Katherine has been an outspoken leader, an international speaker, an award-winning brain injury professional, a researcher published in peer-reviewed journals, and a relentless voice for women and girls with brain injury.

For the purposes of this issue, the definition of sex is the biological differences between males and female, including genetic, hormonal and physiological differences. The definition of gender is social construct based upon interpersonal roles or personal identification and is ofent but not always concordant with biological sex. These terms should not be used interchangeably. This issue of BIP will explore sex as well as some gender differences in brain injury with a lookback on the history of neurological research as well as a review of the current studies of some of the experts who are leading the way. Too often in the past, research in differences between men and women in brain injury were based on self-reporting and subject to biases in the tests, scales, and researcher interpretation. I would like to share some of the exciting new research which is giving us a picture to clearly show differences - making the invisible injury now visible. In the field of imaging, we will review the recent work of Dr. Doug Smith and his team on their newfound discovery of sex differences in axonal structure underlying differential outcomes from in vitro traumatic axonal injury. Using ultrastructural analysis, Dr. Smith’s work in both rodents and humans revealed for the first time that female axons are at greater risk of failure during trauma under the same applied loads than in male axons. To address the lack of brain research in female veterans, Dr. Maheen Adamson and Dr. Odette Harris have conducted neuroimaging studies using cortical thickness to quantify sex differences after TBI. In addition, despite lower numbers, women in the military have been shown to suffer from unique physical, mental, and functional challenges. This work is very important as more women join the military and more female veterans are accessing healthcare in the VA medical centers, and again is part of this important work of making an invisible injury now visible. In their research with injured athletes at the University at Buffalo, Drs. Barry Willer and John Leddy will summarize their work on sex differences in sport-related concussion (SRC) and how different recovery protocols seem to improve outcomes. As their research suggests, the oversubscribed prescription of “Total Rest” of past years may have been particularly harmful to women who were told by their doctors to avoid all physical activity until symptom resolution after concussion. In cross-section of interpersonal violence (IPV) and brain injury, Dr. Eve Valera reviews her brain injury research on females which dates back to the early 2000s. Her research suggests that IPV related brain injuries and repetitive mTBI in women in violent homes occurs at high rates and is associated with a range of very negative outcomes. Also, featured in this issue are several short summaries of recent research as well as an interview with Dr. Angela Colantonio on her leadership role as the Director of the University of Toronto Rehabilitation Sciences Institute, where she and her staff are training the next generation of scientists to integrate sex and gender considerations in research as well as having launched the abuse and brain injury website tool kit (www. abitoolkit.ca). I am very honored to be the guest editor and appreciate all the medical professionals and researchers who contributed their work to create this issue. It is my hope that after reading these articles, you do see your patients through a different lens; and in the end, you are inspired to apply this research to help women and girls in your practice. Thank you for taking the time to read this issue.

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Women with Brain Injury: Past, Present and Future Katherine Price Snedaker, LCSW “Women and girls suffer silently or scream for help where there seems to be none for too long - they are our mothers, daughters, granddaughters, sisters, nieces, and friends.” (Marilyn Price Spivack, conversation, 2019) In the past, there has been little interest in the field of neurology in the prevalence, recovery experience, or long-term outcomes for women with brain injuries. From the battlefield to the sports arena, brain injury in men has been the focus of medical research and the topic in the press for centuries. This sole focus on men has left women out of research studies, media coverage, and general conversation at all levels, especially when brain injury is inflicted by violent partners or spouses. While women sustain brain injuries in similar ways to men - in sports, in motor vehicle collisions, during slips/falls or assaults, at work or during military service- there is an absence of research on women with brain injuries. Until very recently, there was no sex-specific research to focus on the most effective, evidence-based rehabilitation or treatment for women after a brain injury (BI). While evidence is now emerging on better approaches to manage female athletes with brain injuries1, 2 , there are still no answers to the question of what rehabilitation options would be best based on a patient’s sex and age. For example, we don’t know the answer yet on how best to manage the brain injury of a ten-year-old girl verses a post-menopausal women in her 80s. In our own families and across our communities, there is a huge social cost to this lack of sex and gendered medical information for women which inhibits timely diagnosis, proper management, and evidence-based intervention across the care continuum of BI. In this article, I will touch on some of the relevant highlights in the past history of brain injury science, point out emerging research to watch, and share about the PINK Concussions’ journey over the last decade.

Looking Back “The football fields of our nation have been a vast proving ground or laboratory for the study of tragic neurological sequelae of head and neck trauma in man.” - Dr. Richard Schneider in 19673 After World War II, there was a large increase in brain injury research, which the research subjects were entirely male as data showed that more men sought brain injury treatment than women. In the laboratory, male animals were used instead of females because the reproductive cycles of female lab animals were shown to affect the outcome of the testing. It was decades before sex would be seen as an important biological variable and worth studying. The predominantly male doctors focused on men in research highly centered around football, and their findings in men subjects were simply applied to women patients.

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The women’s movement of the 1970's along with Title IX started to change the landscape for women with new opportunities in sports and some of the first mainstream news articles about domestic violence. But in medical research, the cultural and societal norms at the time still affected the type of research conducted on women as well as how the results and conclusions researchers made. Now when reviewing research of the past, it is essential to ask questions about the gender bias in how past studies were designed and conducted, results measured, and how those results were interpreted. It must be noted the truly pioneering work of Marilyn Spivack, Founder and CEO, National Head Injury Foundation NHIF who after her daughter’s brain injury, started in 1990 to organize and advocate for research on brain injury in women with meetings with multiple federal agencies including National Institute of Health (NIH), Centers for Disease Control and Prevention (CDC), National Institute of Neurological Disorders and Stroke (NINDS), National Institute of Neurological and Communicative Disorders (NINCDS¬), and National Institute for Health Research (NIHR). The first mention of brain injury’s sequelae in a woman was by chance in 1990 peer-reviewed paper by Dr. G. W. Roberts on a 76year old woman who was the victim of domestic violence.4 Dr. Roberts was conducting a study on boxers and he was notified of the cauliflower-like ears on the corpse of a woman who had been brought to the morgue. And following the same year, a paper was written by Dr. Patrick Hof about the brain of a 24-year old Autistic woman who had caused her own death by head-banging.5 From my 2015 interview (Dr. PR Hof, interview, 2015) with Dr. Hof, he states that he originally looked at this woman’s brain because it was rare opportunity to examine the brain of a woman with autism and “was a big surprise that we actually found lesions” that matched the pathology in of the brains of boxers at they were studying at that time.

While these two papers did first connect the dots to violence and sequelae of brain injury in women, these two papers did not generate more scientific exploration or any media attention at the time. These two women were not the “Mike Websters” of their time, and still to this day, these papers stand alone in peer-review journals. These women whose brain-injuries made scientific history did so by chance and circumstance, not by a pivot of the medical field to study women. During this period while researchers did examine women who sustained injury from violence, their symptoms were described in psychiatric and psychological terms. The actual physical effect of violence on the women’s brains was not the cultural lens through which abused women were viewed and thus lens colored the resulting scientific research. For a deeper dive on this topic, there is an excellent review in the 2020 essay by Stephen T. Casper and Kelly O'Donnell7 comparing how boxers and victims of domestic violence were seen as patients with brain injuries. Their essay examines how brain injury in male boxers was described starting in 1928, with a focus on the physical aspects of the injury and how they related to function. And in contrast, the majority of the literature on women who sustained injury from violence focused on their symptoms described in psychiatric and psychological terms.

A New Era “Women were not included in the protocols at NIH, the famous study, take an aspirin a day, keep the doctor, you know, a heart attack away. (This study) was done on ten thousand male medical students. Can you believe that? I mean this was twenty years ago (1990s), it wasn’t two hundred years ago, it wasn’t before World War II.” - Barbara Mikulski, social worker and first elected woman Democratic U.S. senator, interview, 2010 As the new century began, a few passionate, devoted female researchers, working with little funding in the shadow of male sports, started asking important questions to improve our understanding of how the brains of women are affected by injury. As awareness of sex and gender-based issues grew, emerging new research on women’s brain injury in sport and military concussion began. Over the next decade, the public interest in brain injury grew with NFL lawsuit, the CDC’s push for concussion education in youth sports, and even a Hollywood movie “Concussion.” As the general public’s awareness grew, the press responded in kind with more articles about brain injury and slowly some reporters started asking questions about female athletes.

Female Brain injury in Sports In 2000, Tracey Covassin, a Canadian PhD student and hockey fan, became interested in studying concussions for her dissertation. While examining the literature on concussions, she realized that the majority of research focused on football, ice hockey, and boxing injuries – sports that are all dominated by male athletes. But she thought what about female athletes? Did female athletes also get concussions at a similar rate as males and did they have similar symptoms? In order to investigate if females were at a higher risk for concussion compared to males in similar sports, she acquired National Collegiate Athletic Association (NCAA) data. Her study, published in 2003, revealed that female collegiate athletes participating in soccer, basketball and softball had a greater risk for a concussion compared to males participating in those same sports8.

Covassin, now Director of the Sports Concussion Laboratory at Michigan State University, is considered to be a pioneer in this work which has now been validated multiple times in sports with similar rules between females and males. For example, higher rates of concussions for females relative to males have been found for soccer, basketball and baseball/softball7. As to why these differences exist, Covassin suggests that, “Female athletes may be at a greater risk for concussion due to an increase in angular acceleration at the neck, female hormones, decreased neck strength and mass, or ballto-head size ratio in soccer athletes.” Summarized in the American Medical Society for Sports Medicine Position Statement of 2012, the Concussion in Sport report9 concluded that in sports with similar rules female athletes sustain more concussions than their male counterparts. In addition, female athletes experience or report a higher number and severity of symptoms as well as a longer duration of recovery than male athletes in several studies. And in the increasing volume of studies in the last ten years, research continues to support the importance of studying sex and gender differences in brain injury. Certain populations are at greater risk of developing Prolonged Concussion Symptoms, formerly called, Post Concussion Syndrome, PCS10,11,12,13. And in these studies, females were shown to have Worse prognosis after concussion14 , Longer time to resolve symptoms15, more PCS following a Motor Vehicle Accident16;, More likely to develop PCS after a single concussive event17. So while the evidence for higher rates of concussions in female athletes was building, the controversy of “why” would echo for another decade. Did women just “report” more concussions than men? Was there some sex difference in brain/head/neck structure, hormones or something at the cellular level to cause the difference in rate? And what role did gender play in concussion education and culture? For women and girls’ sports, what medical resources/ personal were available on the field or in the locker room? And given the recent gains for women’s sports, what motivation was there for female athletes to report or hide concussions?

Female Brain injury from IPV or Domestic Violence "My research has shown high rates of IPV-related TBI and associations between TBIs and women’s cognitive and psychological functioning. What we don’t know is the degree to which these “hidden injuries” are negatively impacting these women’s abilities to succeed in judicial and shelter settings, or impacting their ability to escape the abusive situations.”- Dr. Eve Valera, Director of the Valera Lab, Associate Professor in Psychiatry at Harvard Medical School, and Research Scientist at Massachusetts General Hospital. Alongside the new focus on female athletes and brain injury, there is an emerging group of researchers who focus on brain injury in women as a result of intentionally inflicted violence by their partners. From the pioneering work of Dr. Eve Valera (see her article in this edition), it is now estimated that the number of women who have sustained a partner-inflicted brain injury is estimated to be staggeringly high – the sheer numbers of women who are affected are more than the brain injuries in NFL players or the military combined.

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Yet brain injury from domestic violence (DV) or intimate-partner violence (IPV) is still rarely discussed in medical conferences or mentioned in news stories on brain injury. Raising awareness of brain injury due from IPV or domestic violence has always been a key part of the PINK Concussions mission - equally important alongside the focus on brain injury in athletes and women in military service. In my experience of planning multiple summits, I have found some people uncomfortable with the topic of domestic violence as one that maybe less appealing to audiences than a sports or military injury – making it essential for PINK Concussions to continue to increase awareness of domestic violence and brain injury. And while the connection between IPV and brain injury may seem obvious, historically, the medical community viewed symptoms reported by women caused by domestic violence solely the result of psychological trauma. Now experts in this field are raising awareness that the signs and symptoms to be can associated with brain injury. The “life difficulties” these women faced were chalked up to either a mental health issue or the result of trauma. Brain injury had not been considered by survivors nor professionals working with survivors as a possible impact of the violence.

In the military and veteran population, women also sustained brain injuries from blasts, MVA, as well as falls, assaults and military sexual trauma but there was very little research on females. Pioneers in their field, Drs. Odette Harris and Maheen Adamson,15 sought to diminish the gap in research by characterizing a cohort of female veterans who have sustained a mild TBI (mTBI) and compare them to a matched, male veteran sample at VA Palo Alto Polytrauma Systems of Care (PSC). They specifically matched on mechanism of injury, time from injury to assessment, and age at assessment. Their work showed sex had a moderate effect on mTBI postconcussive symptom presentation, and a significant sex difference was found in the cognitive domain of the Neurobehavioral Symptom Inventory (NSI), which is designed to measure post-concussive symptoms. Additionally, they found that there were more females living alone than males, and more unemployed females not seeking employment compared to men. To better characterize the neural mechanisms underlying these sex differences, Adamson and Harris examined cortical thickness in MRI scans of male and female brains with and without TBI. In a matched sample, more cortical thinning was apparent in females compared to their healthy counterparts, than men compared to their years after TBI.

A Picture is Worth a Thousand Words

PINK Concussions

Because women’s pain and symptoms seem to be often viewed by doctors and family members from psychiatric and psychological terms rather than having a physical origin, I have been following up on any scientific breakthroughs in imaging to see if higher resolution MRI scans or any new technology could illustrate the sex differences in brain injury. So many female patients have been told over the years that their pain was psychiatric and could not be from their brain injury, and until there was evidence that could be seen in a scan, a photo, or test, it would be hard to change the minds of many in the medical community and general public.

“If brain injury is the invisible illness of our time, then within this invisible injury, women are the invisible patients.” – Katherine Snedaker, LCSW, CEO/Founder of PINK Concussions

Last year was the year when Dr. Doug Smith and his team published the landmark study10-14 using imaging to finally give a clear picture of sex differences in axonal structure underlying differential outcomes from in vitro traumatic axonal injury. Using ultrastructural analysis, Smith’s work in both rodents and humans revealed for the first time that female axons were consistently smaller with fewer microtubules than male axons.

In 2012, I launched PINK Concussions first as an informational website, and in 2015, when it became the first non-profit to focus on female brain injury from sport, domestic violence, accidents, or military service. PINK Concussions held the first summit on female brain injury in 2016, hosted at Georgetown University Medical School with 65 experts serving as moderators or presenting data in front of 220 participants. Since the first summit, PINK Concussions has organized six additional summits including a military summit in Palo Alto VA Medical Center, a pediatric female summit in Rome at International Pediatric Brain Injury Society, and the International Brain Injury World Congress in Toronto.

Computational modeling of traumatic axonal injury showed that these structural differences place microtubules in female axons at greater risk of failure during trauma under the same applied loads than in male axons. No longer a figment of her imagination or her unstable mood, there was finally a picture that could help explain some of the sex differences in her brain injury. (see the illustration on the right) Dr. Smith’s discovery truly gives the women’s brain injury movement the evidence to support what so many female patients have experienced and a solid ground to push forward for a consideration for sexbased treatment and rehabilitation.

Female Brain Injury in the Military “Women are becoming more prominent in all fields—including the military. If we don’t understand the differences in biology and/or symptomatology, it could cause a major burden for society going forward. Individual differences must be analyzed through the lens of gender.”15

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Used with permission of author. Computational modeling of traumatic axonal injury showed that these structural differences place

PINK also produced the first summit on CTE in Women hosted by Mount Sinai in New York City. These events along with over 75 presentations have provided training for over 7,000 civilian and military medical professionals, students, and researchers. Past event, expert speakers, and expert interviews on key topics are listed on PINKconcussions.org. PINK Concussions’ mission for 2020-2021, is to drive change and innovation to develop and implement gender-responsive, evidencebased strategies for the identification, management and support of women and girls with brain injuries. While research shows females may have different injury rates, symptoms, and rates of recovery, PINK concussions was the first organization to ask why the medical community does not yet have any female-specific guidelines, protocols, care plans or education resources for women with brain injury including concussions. To this goal, PINK Concussions challenges researchers to expand their brain injury studies to include sex and gender differences as well as conducts original research in public and private schools with plans to publish several papers in 2020. PINK Concussions Annual Awards have been given since 2016, to recognized leaders in science and advocacy. Following up on the first PINK Concussions paper16 on the gender differences of adult athletes who hide concussions in 2016, Jason Bouton, MSATC, and I approached ten private schools the following year to study high school age students and their experience of concussions. In 2020, we have published two papers on these high school athletes in the peer reviewed Journal of School Health18 and Brain Injury 19, with Dana Waltzman, Jill Daugherty, and Dr. David Wang. We have more additional papers ready for submission on public vs private students and concussions.

In our second private school paper, one of the differences I felt was most important was that while the vast majority of students were able to return to a full academic workload in less than a week or between 1 and 3 weeks after their concussion, girls took longer to return to school and sports than boys. Girls were less likely to return to school and sports in less than a week, and more likely to return in more than 3 weeks than their male counterparts. Our findings were further evidence to suggest that girls take longer to recover than boys after sustaining a concussion. Also, we found that a quarter of students reported pretending to have a faster recovery from their concussion in order to return to school or sports. More girls than boys reported pretending to have a faster recovery to return to school than boys. In addition to research and conferences, PINK Concussion facilitates 12 online international Facebook support groups for over 6,000 women, teen girls, parents/caregivers, medical professionals/ researchers, and women veterans. These online groups are free and very active on a 24-hour basis 7-days a week. There are groups for those interested in exploring more about research projects, topics on substance abuse, and learn ways to become an advocate for others.

PINK Concussions Partner-Inflicted Brain Injury Task Force In December 2017, NIH hosted a two-day event Understanding Brain Injury in Women Workshop, which conceptualized across multiple discussions of shared interest between PINK Concussions, TBI researchers, and NINDS Program staff to put a focus on the sex and gender differences in traumatic brain injury.

A Nationally Recognized Leader in Brain Injury Care and Research The Center for Brain Injury Recovery at Kennedy Krieger Institute is a leading research institution offering comprehensive brain injury care, from concussion to severe brain injury, including inpatient and outpatient services, and telehealth consultations and care. To learn more or make an appointment at our Baltimore area locations, visit KennedyKrieger.org/BrainInjuryCenter or call 443-923-9400.

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PINK Concussion's #PINKBrainPledge “In recent months, society has seen a cultural paradigm shift where women are speaking out with a new voice. The PINK Concussion #PINKBrainPledge is part of that positive change where any woman can pledge her brain - those with TBI or PSTD or both or neither - and join the movement to change the future of brain injury research." Katherine Snedaker, Founder and Executive Director of PINK Concussions After surveying national brain banks in 2017, PINK Concussions discovered that studies focused on brain injury were severely lacking in female brain tissue. After interviewing brain bank leaders on their recruitment needs,

PINK Concussions participated as a member of the agenda development working group for the workshop that was sponsored by multiple NIH institutes and centers (ICs), the Veteran Affairs (VA), and Defense and Veterans Brain Injury Center (DVBIC). A summary of the meeting can be found on the NINDS website20, the summary white paper21, and the entirety of the meeting can be viewed via NIH VideoCast22. After participating on the domestic violence and brain injury panel at the NIH’s Workshop, PINK Concussions, Dr. Eve Valera, Dr. Katherine Iverson and I wanted to create a way to bring together brain injury researchers and practitioners in the domestic violence/ intimate partner violence (DV/IPV) field on a regular basis. With increasing awareness of brain injury in women, brain injury researchers were beginning to raise concerns about brain injuries from Domestic Violence as practitioners in the DV/IPV field began to wonder if brain injury was part of the trauma experienced by their clients. While it seemed logical there should be a place for these two groups of researchers to connect and compare ideas, both groups, with some exceptions, were publishing and presenting within their own professional silos, we joined with Toronto-based Dr. Angela Colantonio and PhD Candidate, Lin Haag as well as social worker, Rachel Ramirez of the Ohio DV Network to form a domestic violence related brain injury task force. Since its first monthly call in January of 2018, the PINK Concussions Task Force has worked to bridge the gap to improve the lives of those impacted by violence-inflicted TBI by creating an open space for learning, inspiration and collaboration among those working in brain injury and gender-based violence. The task force which meets on Zoom has over 200 members consisting in 35 US states as well as 9 countries outside of the US. The task force welcomes students, clinicians and researchers at all levels to join the group and share their work and experiences with DV/IPV-related TBI. Our June Task presentation was given by Monique R. Pappadis, MEd, PhD on "Black Women’s Experience with Brain Injury and IPV/ DV." Dr. Pappadis summarized research on the disproportionate impact of BI and IPV on ethnic minorities with emphasis on Black/ African American women. This presentation also describes the experiences of Black women with access to services and encourage the use of cultural humility to guide interactions with diverse populations. Information about the task force, recordings of all past calls and links to press on group members can be found at on the PINK Concussions website at https://www.pinkconcussions.com/ violence.

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PINK Concussions sought a national partner to launch the #PINKBrainPledge to encourage women to pledge to donate their brains. Through the #PINKBrainPledge women can pledge their brains and sign-up for IRB-approved research studies. The purpose of these pledges is solely for research; no fundraising campaigns are associated with any #PINKBrainPledge. In January 2018, the U.S. Department of Veterans Affairs (VA) announced a collaboration between its National Center for PTSD and PINK Concussions23, encouraging women to pledge their brains for research on the effects of traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD). All women are eligible to donate - civilian/active-duty/veteran - with or without TBI/PTSD.). In early 2019, PINK Concussions launched a formal collaboration with the Brain Injury Research Center at Mount Sinai in New York City to recruit women for the Late Effects of TBI (LETBI) Brain Donor Program led by Dr. Kristen Dams-O’Connor. A primary goal of the LETBI project is to identify clinical characteristics of TBI-related dementia and neurodegenerative disease so that a diagnosis can be made during life – when there is still a chance for treatment. The LETBI project enrolls both men and women with brain injury for clinical data collection during life. PINK Concussions has continued to build collaborations around the world by recruiting for brain banks in the US, Canada, England, Scotland and Northern Ireland. In late 2019, the Glasgow Brain Injury Research Group led by Dr Willie Stewart announced a partnership with PINK Concussions #PINKBrainPledge24, will be encouraged women in the UK to pledge to donate their brains to the Glasgow Traumatic Brain Injury Archive to study the effects of brain injury, including its link to chronic traumatic encephalopathy, also known as CTE.

Call to Action “We can reorient science - for example, a kind of medicine much more directed toward the enormous number of women's health problems which are neglected now. But the original givens of this science are the same for men and for women. Women simply have to steal the instrument; they don't have to break it, or try, a priori, to make of it something totally different. Steal it and use it for their own good.”- Simone de Beauvoir, Alice Jardine – in an 1979 Interview with Simone de Beauvoir Let now be the time where we, together, take this new science, reoriented from the past view of women as a carbon copy of men, and use it for our own good – to improve the lives of women with brain injury. In choosing to read this issue, you have already started, and I hope you will help us to continue this essential work.

In our practices, families and across our communities, we must call for the medical community to create gender-specific guidelines, protocols, or resources for women with brain injury.

20. Mausoof-Adamson M. Traumatic Brain Injury among Female Veterans. Brain Injury Professional. 2020;17(2):

Now is the time for brain injury researchers and medical providers to pause and look at their work through the lens of sex and gender differences for our mothers, sisters, and daughters.

22. Daugherty J, Waltzman D, et al. Concussion Experiences in New England Private Preparatory High School Students Who Played Sports or Recreational Activities. J School Health. 2020; 90: 527-537. doi:10.1111/josh.12899

24. NINDS website, https://www.ninds.nih.gov/News-Events/Events-Proceedings/Events/UnderstandingTraumatic-Brain-Injury-Women-Workshop, 2020.

• • •

What do women need to know about their brains and how best to protect them? What could be improved in the management of women’s injuries? What aspect of medical management should change bases on the genetic and hormonal differences we are finding between males and females. What new approach could be tried? What new questions could be asked?

Every woman with a brain injury deserves a medical and rehab team who practices with sex and gender-specific consideration for her symptoms, acute care, recovery plan and the supports she may need. Her journey back to health can be improved with the appropriate care, education about sex differences in brain injury, and as well as improved support systems at home, school, and work. There is much work to be done and we can all make a difference. Join the ground-breaking doctors and researchers in this issue along with many others on the PINK Concussions Professional Advisory Board and take a stand to see women with brain injury as women as well as individuals who are unique. The research being conducted today, I believe, will lead to a brighter future with better identification, management and outcomes for women and new advances that may be able to help men as well. References 1. Leddy JJ, Haider MN, et al. Early subthreshold aerobic exercise for sport-related concussion: a randomized clinical trial. JAMA Pediatrics, Epub ahead of print. 2019; doi:doi:10.1001/ jamapediatrics.2018.4397 2. Willer B, Leddy JJ. Exercise in Concussed Females. Brain Injury Professional. 2020;17(2) 3. Richard Scheider quote – https://www.slideshare.net/neurotrauma/bailes-julian 4. Roberts GW, Whitwell HL, et al. Letters to the Editor: Dementia in a punch-drunk wife. The Lancet. April 14, 1990; 335(8694):918-919.DOI: https://doi.org/10.1016/0140-6736(90)90520-F 5. Hof PR, Knabe R, et al. Neuropathological observations in a case of autism presenting with self-injury behavior. Acta Neuropathol. 1991;82(4):321-326. doi:10.1007/BF00308819 6. https://www.pinkconcussions.com/blogreal/2015/11/20/lucy 7. Casper ST, O’Donnell K. The punch-drunk boxer and the battered wife: Gender and brain injury research. Social Science & Medicine. 2020 January; 245:https://doi.org/10.1016/j.socscimed.2019.112688 8. Covassin T, Swanik C, Sachs ML. Sex differences and the incidence of concussions among intercollegiate athletes. Journal of Athletic Training. 2003; 38(3):238 – 244 9. Gessel LM, Fields SK, et al. Concussions among United States high school and collegiate athletes. J Athl Train. 2007;42(4):495-503. 10. Kimberly G Harmon, Jonathan A Drezner, Matthew Gammons, et al. American Medical Society for Sports Medicine position statement: concussion in sport Br J Sports Med 2013 47: 15-26 doi: 10.1136/ bjsports-2012-091941 11. Broshek, D. K., Kaushik, T., Freeman, J. R., Erlanger, D., Webbe, F., & Barth, J. T. (2005). Sex differences in outcome following sports-related concussion, Journal of Neurosurgery, 102(5), 856-863. Retrieved Aug 27, 2020, from https://thejns.org/view/journals/j-neurosurg/102/5/article-p856.xml 12. Brown DA, Elsass JA, Miller AJ, Reed LE, Reneker JC. Differences in Symptom Reporting Between Males and Females at Baseline and After a Sports-Related Concussion: A Systematic Review and Meta-Analysis. Sports Med. 2015;45(7):1027-1040. doi:10.1007/s40279-015-0335-6

21. Sanderson J, Weathers MR, et al. I Was Able to Still Do My Job on the Field and Keep Playing” An Investigation of Female and Male Athletes’ Experiences With (Not) Reporting Concussions. Communication & Sport. 2017; DOI:10.1177/2167479515623455.

23. Dana Waltzman D, Daugherty J, et al. Concussion reporting, return to learn, and return to play experiences in a sample of private preparatory high school students, Brain Injury. 2020; DOI: 10.1080/02699052.2020.1793388

25. Summary white paper https://www.ninds.nih.gov/sites/default/files/tbi_workshop_summary_-_ december_18-19_2017_508c_0.pdf. 26. NIH VideoCast https://videocast.nih.gov/summary.asp?Live=26249&bhcp=1. 27. VA’s National PTSD Brain Bank Collaborates With PINK Concussions Group, https://www.va.gov/opa/ pressrel/pressrelease.cfm?id=4000. 28. #PINKBrainPledge, https://www.pinkconcussions.com/take-the-pledge.

How “Her Brain Injury” was Viewed by her Community “If brain injury is the invisible illness of our time, then within this invisible injury, women are the invisible patients.” – Katherine Snedaker, LCSW, CEO/Founder of PINK Concussions Regardless of etiology of injury (eg., sports, military, or IPV) and biological differences that may impact outcome, women and girls experience brain within the community context. While every patient deserves to be treated as an individual, and each brain injury is unique, there are sex and gender forces at play which affect how a woman with a brain injury can be viewed or judged by her family, community, employer or school. As more men than women have acknowledged brain injuries, a woman and the people around her will likely know more men who have had concussions and may judge the woman’s symptom pattern and length of recovery by the male experience. Even the patient herself can question the speed of her recovery or the severity of her symptoms do not match the male experience she knows. Family members, school staff or employers may judge her experience to be abnormal, malingering or conclude there may be other "non-brain injury issues" at play. Without proper education of patient, family and community supports, women and girls with brain injury including concussion, can experience an additional lack of support, doubt, isolation and anxiety beyond that which comes with brain injury.

13. King D, Brughelli M, Hume P, Gissane C. Assessment, management and knowledge of sport-related concussion: systematic review. Sports Med. 2014;44(4):449-471. doi:10.1007/s40279-013-0134-x 14. Iverson GL, Gardner AJ, Terry DP, et al. Predictors of clinical recovery from concussion: a systematic review. Br J Sports Med. 2017;51(12):941-948. doi:10.1136/bjsports-2017-097729 15. Furger RE, Nelson LD, Brooke Lerner E, McCrea MA. Frequency of Factors that Complicate the Identification of Mild Traumatic Brain Injury in Level I Trauma Center Patients. Concussion. 2016;1(2):CNC11. doi:10.2217/cnc.15.11 16. Bock S, Grim R, Barron TF, et al. Factors associated with delayed recovery in athletes with concussion treated at a pediatric neurology concussion clinic. Childs Nerv Syst. 2015;31(11):2111-2116. doi:10.1007/ s00381-015-2846-8 17. Ramage-Morin PL. Motor vehicle accident deaths, 1979 to 2004. Health Rep. 2008;19(3):45-51. 18. Tator CH, Davis HS, Dufort PA, et al. Postconcussion syndrome: demographics and predictors in 221 patients. J Neurosurg. 2016;125(5):1206-1216. doi:10.3171/2015.6.JNS15664 19. Dollé J-P, Jaye A, et al. Newfound sex differences in axonal structure underlie differential outcomes from in vitro traumatic axonal injury. Experimental Neurology. 2018; 300:121-134,

Author Bio Katherine Price Snedaker, LCSW, is the Executive Director and Founder of PINK Concussions, a 501c3 non-profit, which focuses on brain injury in women and girls from sport, domestic violence/ assault, accidents or military service. Snedaker is an award-winning international speaker, brain injury professional, researcher, and has a family member with a brain injury.

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Exercise in Concussed Females John Leddy, MD • Barry Willer, PhD Concussion is a subtype of mild traumatic brain injury (TBI) and is the result of sudden deceleration and rotational forces applied to the brain that trigger an acute and subacute pathophysiological metabolic response in the absence of gross structural changes to the brain1. In the US alone, it is estimated that there are 1.6-3.8 million sport-related concussions (SRC) a year2. The first summary and agreement statement of the 2001 consensus conference on concussion in sport held in Vienna recommended that SRC be treated by strict rest followed by a graduated return to play3. Despite the fact that prescribed rest has been the treatment of choice for almost twenty years,4 there has been surprisingly little research to support it5. In fact, a randomized controlled trial (RCT) on concussed adolescents from the emergency department6 showed that participants prescribed five days of strict rest reported more symptoms and had slower symptom resolution when compared with those prescribed usual care (one or two days of rest followed by a stepwise return to activity). Research on sex differences in concussion recovery has produced conflicting results, with some studies finding females take longer to recover7 while others do not8. It should be noted that none of these studies on sex differences compared outcomes from specific treatments. In a recent RCT of sub-symptom threshold aerobic exercise versus a placebo-like progressive stretching program prescribed within one week of SRC, we demonstrated that aerobic exercise safely reduced recovery time for both male and female adolescent athletes alike9. Our study, however, did not have a comparison group prescribed rest after concussion. In a quasi-experimental trial published in the Archives of Physical Medicine and Rehabilitation in 2019, we added a relative rest comparison group to the two treatment arms of our RCT to compare recovery times across the three treatment interventions10.

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The secondary purpose of this study was to compare the recovery trajectory of females with males. Adolescent athletes (aged 13-18 years) presenting within 10 days of SRC (mean 5 days after injury) received a recommendation for rest (Rest Group, n=48). Their outcomes were compared with matched samples of adolescents assigned to aerobic exercise (Exercise Group, n=52) or placebo-like stretching (Placebo Group, n=51). The rest group recovered in a mean of 16 days, which was significantly delayed (p=0.020) when compared with the exercise group (13 days). The placebo group recovered in 17 days. Four percent of the exercise group, 14% of the placebo group and 13% of the rest group had delayed recovery (defined as symptoms persisting more than 30 days). This study showed that relative rest and a placebo-like stretching program were very similar in days to recovery and symptom improvement pattern after SRC. Both conditions were less effective, however, than early sub-symptom threshold aerobic exercise. Furthermore, the incidence of delayed recovery was lower for the exercise group (4%) yet almost identical for the rest and placebo groups (13% and 14%, respectively). A study with a much larger sample size of adolescents from the emergency room11 found that 30% of 2413 children with concussion had delayed recovery beyond 30 days from injury, making our 4% with the exercise group look very good. With respect to females in our study, while they reported slightly higher symptoms at the initial visit than males in each group, these differences were not statistically significant. Importantly, males and females in each group did not differ in recovery time or incidence of delayed recovery. Interestingly, there was a sharp rise in symptom scores the day after the initial visit in females who had been prescribed relative rest. Conversely, there was a sharp decline of symptoms in females who were prescribed aerobic exercise or placebo stretching, which was not observed in the males.

The mechanism for this observation is not clear but it is possible that females advised to rest after SRC may have ruminated, which increased their symptoms. Studies12,13 have shown that females tend to ruminate about medical conditions more than males, with one report 14 linking increased rumination and depressive symptoms after mild TBI in females to brain-derived neurotrophic factor (BDNF, which repairs neurons after injury) gene polymorphisms. It may therefore be particularly important for medical providers to avoid recommendations for strict rest and to recommend active treatment for females early after SRC to avoid early exacerbation of symptoms. Unfortunately, this study did not obtain any information about the menstrual cycle or hormonal levels, something which will be essential to future studies that examine clinical outcomes of females following SRC. Why might sub-threshold aerobic exercise help females recover from concussion? Among the many physiological differences between males and females is cerebral blood flow (CBF) regulation. Females have greater CBF both at rest15 and during exercise16 versus males. A small controlled study published by our group in 2016 evaluated the control of CBF during exercise in females with persistent post-concussive symptoms (PPCS) before and after a sub-symptom threshold aerobic exercise treatment program16. CBF was measured by transcranial Doppler during the Buffalo Concussion Treadmill Test (BCTT). The concussed female athletes had significantly greater CBF versus a healthy matched control group at similar treadmill workloads in association with appearance of symptoms and premature exercise cessation. Sub-threshold aerobic exercise normalized CBF during exercise in the concussed females in association with symptom resolution and restoration of normal exercise tolerance. This study also found evidence of normalization of autonomic nervous system (ANS) dysfunction after exercise. The ANS is responsible for maintaining physiological homeostasis in the face of physiological stressors experienced by the body (for example, after injury or during changes in activity or emotion). ANS dysfunction17 after concussion appears to limit or blunt the appropriate response to physiological stressors, as revealed by measures of cerebrovascular vasoreactivity18, blood pressure regulation 19, heart rate variability20, and CO2 sensitivity16. Exercise is one type of stressor that elicits symptoms when the stress level exceeds a tolerable level. Thus, sub-symptom threshold aerobic exercise training may stress physiological systems within the body’s auto-regulatory capabilities after concussion to incrementally restore ANS control to normal 21. Females demonstrate altered ANS function in the first week after SRC12, which may help to explain why aerobic exercise, which improves ANS function, may be particularly effective for concussed females. Females are different than males physiologically; thus, it is not surprising that they respond to a physiological injury such as concussion differently than males. Our work has shown that concussed females appear to be susceptible to symptom exacerbation when prescribed strict rest, which may have been particularly harmful to them during the decades we were recommending that they abstain from all physical activity until symptom resolution after concussion. The good news is that females appear to respond equally to males when advised to resume activities while staying below their individual symptom-exacerbation thresholds and even when prescribed early sub-threshold aerobic exercise treatment after SRC. Further research into sex differences in concussion recovery is needed, and it is recommended that such differences be examined within the context of the female hormonal milieu as well as current treatment recommendations.

References 1. Barth JT, Freeman JR, et al., Acceleration-Deceleration Sport-Related Concussion: The Gravity of It All. J Athl Train. 2001;36(3):253-256. 2. Langlois JA, Rutland-Brown W, et al. The epidemiology and impact of traumatic brain injury: a brief overview. J Head Trauma Rehabil. 2006;21(5): 375-378. 3. Aubry M, Cantu R, Dvorek J, et al. Summary and agreement statement of the First International Conference on Concussion in Sport, Vienna 2001. Recommendations for the improvement of safety and health of athletes who may suffer concussive injuries. Br J Sports Med. 2002 Feb;36(1):6-10. 4. Moser RS, Schatz P, et al. Examining prescribed rest as treatment for adolescents who are slow to recover from concussion. Brain Inj. 2015;29(1):58-63. doi:10.3109/02699052.2014.964771 5. Silverberg ND, & Iverson GL. Is rest after concussion “the best medicine?”: recommendations for activity resumption following concussion in athletes, civilians, and military service members. J Head Trauma Rehabil. 2013;28(4):250-259. 6. Thomas DG, Apps JN, et al. Benefits of Strict Rest After Acute Concussion: A Randomized Controlled Trial. Pediatrics. 2015; 135(2):213-223. doi:10.1542/peds.2014-0966 7. Henry LC, Elbin RJ, et al. Examining Recovery Trajectories After Sport-Related Concussion With a Multimodal Clinical Assessment Approach. Neurosurgery. 2016 doi:10.1227/NEU.0000000000001041 8. Frommer LJ, Gurka KK, et al. Sex differences in concussion symptoms of high school athletes. J Athl Train. 2011; 46(1): 76-84. 9. Leddy JJ, Haider MN, et. al. Early subthreshold aerobic exercise for sport-related concussion: a randomized clinical trial. JAMA Pediatrics, Epub ahead of print. 2019. doi:doi:10.1001/jamapediatrics.2018.4397 10. Willer BS, Haider MN, et al. Comparison of Rest to Aerobic Exercise and Placebo-like Treatment of Acute Sport-Related Concussion in Male and Female Adolescents. Arch Phys Med Rehabil. 2019; 100(12):22672275. doi:10.1016/j.apmr.2019.07.003 11. Grool AM, Aglipay M, et al. Asociation between early participation in physical activity following acute concussion and persistent postconcussive symptoms in children and adolescents. JAMA. 2016; 316(23):25042514. 12. Johnson BD, O'Leary MC, et. al. Face cooling exposes cardiac parasympathetic and sympathetic dysfunction in recently concussed college athletes. Physiol Rep. 2016; 6(9):, e13694. doi:10.14814/ phy2.13694 13. Lohaus A, Vierhaus M, et al. Rumination and symptom reports in children and adolescents: Results of a cross-sectional and experimental study. Psychology & health. 2013;28(9):1032-1045. 14. Gabrys RL, Dixon K, et. al. Self-Reported Mild Traumatic Brain Injuries in Relation to Rumination and Depressive Symptoms: Moderating Role of Sex Differences and a Brain-Derived Neurotrophic Factor Gene Polymorphism. Clinical journal of sport medicine: official journal of the Canadian Academy of Sport Medicine. 2019 Nov;29(6):494-499. doi: 10.1097/JSM.0000000000000550. 15. Satterthwaite TDm Shinohara RT, et al. Impact of puberty on the evolution of cerebral perfusion during adolescence. Proc Natl Acad Sci U S A. 2014;111(23):8643-8648. doi:10.1073/pnas.1400178111 16. Clausen M, Pendergast DR, et al. Cerebral Blood Flow During Treadmill Exercise Is a Marker of Physiological Postconcussion Syndrome in Female Athletes. J Head Trauma Rehabil. 2016; 31(3): 215-224. doi:10.1097/HTR.0000000000000145 17. Esterov D, Greenwald B. Autonomic dysfunction after mild traumatic brain injury. Brain sciences. 2017; 7(8): 100. 18. Serador J, Tosto J, et al. Cerebrovascular Regulation is Impaired Immediately Post Concussion and Associated with Increased Estimated ICP. The FASEB Journal. 2015;29(1 Supplement): 800.811. 19. Bishop S, Dech R, et al, Acute stages of concussion: Suppression of blood pressure during postural hemodynamic drives. Journal of Cerebral Blood Flow and Metabolism. 2016;36, 292. doi:10.1177/0271678X16639008 20. Blake TA, McKay CD, et al. The impact of concussion on cardiac autonomic function: A systematic review. Brain Inj. 2016; 30(2), 132-145: doi:10.3109/02699052.2015.1093659 21. Leddy JJ, Kozlowski K. Regulatory and autoregulatory physiological dysfunction as a primary characteristic of post concussion syndrome: implications for treatment. NeuroRehabilitation. 2007;22(3):199-205.

Author Bios John J. Leddy, MD, is Professor of Clinical Orthopedics and Rehabilitation Sciences at the University at Buffalo Jacobs School of Medicine and Biomedical Sciences, a Fellow of the American College of Sports Medicine and of the American College of Physicians. He is the Medical Director of the University at Buffalo Concussion Management Clinic, a Member of the Expert Panel for the Berlin Fifth International Consensus Conference on Concussion in Sport, and a consultant to the NIH on sport concussion research. In conjunction with Dr. Barry Willer, he developed the Buffalo Concussion Treadmill Test. Barry Willer, MD, is Professor, Department of Psychiatry at the University at Buffalo Jacobs School of Medicine and Biomedical Sciences and a member of the Board of Directors the North American Brain Injury Society. He is the Director of Research for the University at Buffalo Center for Research on Concussion. He has a long history of research on acquired brain injury, including director of the first Center of Research on Community Integration, which developed the original data center for the TBI model systems program. He also authored the Community Integration Questionnaire and the Whatever It Takes model for TBI rehabilitation.

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Traumatic Brain Injury Among Female Veterans Maheen Mausoof Adamson, PhD • Odette A. Harris, MD, MPH

In military conflicts since 2000, more than 383,947 military personnel have sustained Traumatic Brain Injuries (TBI).1 The majority of the non-penetrating TBI’s sustained were classified as mild (mTBI) resulting in a research focus on this sub-population. Numerous publications have detailed this cohort’s psychological and functional outcomes.2-9 However, these data represent a cohort that is almost entirely male (~95%). Despite the growing presence of females in the military,10,11 and even though females accounted for up to 15% of the classified mTBI cases as reported by the Armed Forces Health Surveillance Center in 2010,12 females were either included as part of the cohort and not separately analyzed or were excluded in these studies. Thus, the majority of TBI research has focused on male data13 and less is known about the natural history, pathophysiology, and outcomes for TBI among females. Although fewer in number, female veterans with TBI have been suggested to suffer from unique physical, mental, and social challenges. This potential sex bias may have broad impacts on the accurate diagnosis, treatment, and recovery of female active duty and veteran service members13. More importantly, risk factors for TBI are changing. As the number of females in sports, military combat, and other high-risk activities rise, so too does the rate of females with TBI, and evidence of sex-related differences in TBI outcomes. The National Collegiate Athletic Association (NCAA) surveillance program from 2004 to 2009 demonstrated females had a 1.4 times higher concussion rate than males playing the same sport, and lost more playtime afterward; guidelines for return-to-play are already changing to consider an athlete’s sex14. In the military, females with TBI are 30% more likely than males to experience post-traumatic stress disorder (PTSD); 4 times as likely to develop problems with substance abuse; and 2.7 times more likely to be unemployed13. These difficulties interfere with reintegration into civilian society and lead to 7x higher rates of homelessness among injured female veterans13. Survivors of domestic violence comprise another understudied atrisk population. Thought to affect up to 20 million females, 92% of whom are thought to have been struck in the head by their abusers, domestic violence is a potential source of TBI that could dwarf cases from the military and athletics combined 15.

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In addition, veteran females are at higher risk for domestic violence than civilian females; almost one-fifth of veteran females’ screen positive for intimate partner violence13. Given the numbers, the need to understand sex-related differences in TBI has never been greater. Within the Veteran Administration Healthcare system, the best representation of TBI across the continuum of care in all patients is the infrastructure established by the Polytrauma Network Sites (PNS). Early reports of sex differences for the Operation Iraqi Freedom (OIF)/Operation Enduring Freedom (OEF) cohorts were often secondary findings and offer mixed results for PTSD diagnosis rates.7 More recently, there have been a few reports specifically addressing sex differences.7,9,16 Still, limitations exist in literature representing female VA Polytrauma/TBI patients leading to major gaps in a clear understanding of the role of sex in military Polytrauma/TBI phenomenology, treatment, and outcomes. As one of the four original national centers within the Polytrauma System of Care (PSC), we sought to diminish this gap by characterizing our PNS cohort of female veterans who have sustained an mTBI and comparing them to a matched, male veteran sample17. We specifically matched on mechanism of injury, time from injury to assessment, and age at assessment. Sex has a moderate effect on mTBI post-concussive symptom presentation, and a significant sex difference was found in the cognitive domain of the Neurobehavioral Symptom Inventory (NSI). Additionally, we found that there were more females living alone than males, and more unemployed females not seeking employment compared to men17. There has been considerable exploration of axonal integrity and functional network connectivity in TBI using diffusion tensor imaging (DTI) and resting state functional MRI (rs- fMRI), respectively. Anatomical change as measured by cortical thickness presents a relatively new modality for TBI research. Warner et al.18 was among the first to identify specific areas of regional cortical thinning in TBI patients, including the inferior parietal cortex, pars orbitalis, pericalcarine cortex, and supramarginal gyrus. Thickness in these areas predicted Glasgow Outcome Scale (GOS) scores.

Cortical thickness in specific areas also predicts a variety of functional outcomes related to TBI, such as memory and verbal learning, as measured by event- based prospective memory EBPM19, pain20, as well as PTSD, depression, and other post- concussive symptoms21. To our knowledge, only one other study has used cortical thickness to quantify sex differences after TBI: Shao et al.22 found females with TBI had a significantly thicker left caudal anterior cingulate cortex (ACC) than males with TBI. Thickness also correlated with higher scores on the Posttraumatic Stress Disorder Checklist Civilian Version (PCL-C). To better characterize the neural mechanisms underlying these sex differences, we examined cortical thickness in males and females with and without TBI in our cohort (n=56)23,24. Female healthy adults had significantly greater global and local cortical thickness than male healthy subjects. In the TBI population, females showed cortical atrophy in more places than males, including in several fronto-executive regions, the insula, and critical hubs of the limbic system (p<.05). In other words, more cortical thinning was apparent in females than men years after TBI. Thickness in these areas predicted individual performance on measures of verbal memory (California Verbal Learning Test) and executive function (Trails B). Yet, this brain- behavior relationship was driven by males: for males, cortical thickness predicts California Verbal Learning Test and Trails B performance; in females, cortical thickness is uncoupled from the functions they serve in males. To our knowledge these are the first studies to demonstrate this sex-related brain- behavior relationship in TBI population. These sex similarities and differences of anatomical properties help understand the mechanisms underlying the symptomology profiles shown in previous studies. Nonetheless, there remains a significant knowledge gap in the sex differences in TBI. Increased female representation in the military heralds an increased risk of TBI for female soldiers, and medical professionals must be prepared to address the unique health challenges in the face of changing demographics among the veteran TBI population. The Institute of Medicine has recommended that the Department of Defense and Department of Veterans Affairs take steps to reduce health and quality of life disparities between males and females and to provide health care that is sensitive to females needs and preferences25. This should include efforts to provide tailored treatments for this population’s unique symptom profile and brain architecture and to mitigate the impacts of symptoms on functional outcomes such as employment, marital status, and living situation. References 1. Defense and Veterans Brain Injury Center. DoD worldwide numbers for TBI. Defense and Veterans Brain Injury Center: Falls Church, VA. 2018. Retrieved from https://dvbic.dcoe.mil/dod-worldwide-numbers-tbi (Accessed on November 13, 2018). 2. Schneiderman, AI, Braver, ER, Kang, HK. Understanding sequelae of injury mechanisms and mild traumatic brain injury incurred during the conflicts in Iraq and Afghanistan: persistent postconcussive symptoms and posttraumatic stress disorder. Am J Epidemiol. 2018;167:1446–52. 3. Hendricks, AM, Amara, J, Baker, E, Charns, MP, Gardner, JA, Iverson, KM, Kimerling, R, Krengel, M, Meterko, M, Pogoda, TK, Stolzmann, KL, Lew, HL. Screening for mild traumatic brain injury in OEF-OIF deployed US military: an empirical assessment of VHA's experience. Brain Inj. 2013;27:125–34. 4. Sayer, NA, Cifu, DX, McNamee, S, Chiros, CE, Sigford, BJ, Scott, S, Lew, HL Rehabilitation needs of combatinjured service members admitted to the VA Polytrauma Rehabilitation Centers: the role of PM&R in the care of wounded warriors. PM R. 2009;1:23–8. 5. Iverson, KM, Hendricks, AM, Kimerling, R, Krengel, M, Meterko, M, Stolzmann, KL, Baker, E, Pogoda, TK, Vasterling, JJ, Lew, HL. Psychiatric diagnoses and neurobehavioral symptom severity among OEF/OIF VA patients with deployment-related traumatic brain injury: a gender comparison. Women's Health Issues. 2011;21:S210–7. 6. Lew, HL, Otis, JD, Tun, C, Kerns, RD, Clark, ME, Cifu, DX. Prevalence of chronic pain, posttraumatic stress disorder, and persistent postconcussive symptoms in OIF/OEF veterans: polytrauma clinical triad. J Rehabil Res Dev. 2009;46:697–702. 7. Maguen, S, Ren, L, Bosch, JO, Marmar, CR, Seal, KH. Gender differences in mental health diagnoses among Iraq and Afghanistan veterans enrolled in veterans affairs health care. Am J Public Health. 2010;100:2450–56. 8. Wilk, JE, Herrell, RK, Wynn, GH, Riviere, LA, Hoge, CW. Mild traumatic brain injury (concussion), posttraumatic stress disorder, and depression in U.S. soldiers involved in combat deployments: association with postdeployment symptoms. Psychosom Med. 2012;74:249–57.

9. Iverson, KM, Pogoda, TK, Gradus, JL, Street, AE. Deployment-related traumatic brain injury among Operation Enduring Freedom/Operation Iraqi Freedom veterans: associations with mental and physical health by gender. J Womens Health. 2013;22:267–75. 10. Fox, AB, Walker, BE, Smith, BN, King, DW, King, LA, Vogt, D. Understanding how deployment experiences change over time: comparison of female and male OEF/OIF and Gulf War veterans. Psychol Trauma. 2016;8:135–40. 11. Brickell, TA, Lippa, SM, French, LM, Kennedy, JE, Bailie, JM, Lange, RT. Female service members and symptom reporting after combat and non-combat-related mild traumatic brain injury. J Neurotrauma. 2017;34:300–12. 12. Meyer, K. Traumatic brain injury: Same or different. Washington, DC: Defense and Veterans Brain Injury Center; 2011. 13. Kim, L. H., Quon, J. L., Sun, F. W., Wortman, K. M., Adamson, M. M., & Harris, O. A. (2018). Traumatic brain injury among female veterans: a review of sex differences in military neurosurgery. Neurosurgical Focus, 45(6), E16. https://doi.org/10.3171/2018.9.FOCUS18369. 14. Covassin, T., Moran, R., & Elbin, R. J. (2016). Sex Differences in Reported Concussion Injury Rates and Time Loss From Participation: An Update of the National Collegiate Athletic Association Injury Surveillance Program From 2004–2005 Through 2008– 2009. Journal of Athletic Training, 51(3), 189–194. https://doi. org/10.4085/1062-6050-51.3.05. 15. Jackson, H., Philp, E., Nuttall, R. L., & Diller, L. (2002). Traumatic brain injury: A hidden consequence for battered female. Professional Psychology: Research and Practice, 33(1), 39–45. https://doi. org/10.1037/0735-7028.33.1.39. 16. King, N. Permanent post concussion symptoms after mild head injury: a systematic review of age and gender factors. NeuroRehabilitation. 2014;34:741–8. 17. Gray, M., Adamson, M.M., Thompson, R.C., Kapphahn, K.I., Han, S., Chung, J.S., & Harris, O.A. Sex Differences in Symptom Presentation and Functional Outcomes in a Matched Sample of Veterans with Mild TBI. (Under revision). 18. Warner, M. A., Youn, T. S., Davis, T., Chandra, A., Marquez de la Plata, C., Moore, C., … Diaz-Arrastia, R. (2010). Regionally selective atrophy after traumatic axonal injury. Archives of Neurology, 67(11), 1336–1344. https://doi.org/10.1001/archneurol.2010.149. 19. Palacios, E. M., Sala-Llonch, R., Junque, C., Fernandez-Espejo, D., Roig, T., Tormos, J. M., … Vendrell, P. (2013). Long-term declarative memory deficits in diffuse TBI: correlations with cortical thickness, white matter integrity and hippocampal volume. Cortex; a Journal Devoted to the Study of the Nervous System and Behavior, 49(3), 646–657. https://doi.org/10.1016/j.cortex.2012.02.011. 20. Michael, A. P., Stout, J., Roskos, P. T., Bolzenius, J., Gfeller, J., Mogul, D., & Bucholz, R. (2015). Evaluation of Cortical Thickness after Traumatic Brain Injury in Military Veterans. Journal of Neurotrauma, 32(22), 1751–1758. https://doi.org/10.1089/neu.2015.3918. 21. Newsome, M. R., Wilde, E. A., Bigler, E. D., Liu, Q., Mayer, A. R., Taylor, B. A., … Levin, H. S. (2018). Functional brain connectivity and cortical thickness in relation to chronic pain in post-911 veterans and service members with mTBI. Brain Injury, 32(10), 1236–1244. https://doi.org/10.1080/02699052.2018.149 4853. 22. Shao, M., Cao, J., Bai, L., Huang, W., Wang, S., Sun, C., … Yan, Z. (2018). Preliminary Evidence of Sex Differences in Cortical Thickness Following Acute Mild Traumatic Brain Injury. Frontiers in Neurology, 9. https://doi.org/10.3389/fneur.2018.00878. 23. Sun, F.W., Kang, X., Main, K.L., Soman, S., Kong, J., Rappoport, M., Thordarson, M., Kolakowsky-Hayner, S., Furst, A.J., Ashford, J.W., Kim, L.H., Harris, O.A., & Adamson, M.M. Sex differences in traumatic brain injury: an analysis of symptomology and neural changes. (Under revision). 24. Kang, X., Main, K. L., Milazzo, A-C, Soman, S., Kong, J., Kolakowsky-Hayner, S., Furst, A.J., Ashford, J.W., Harris, O.A., & Adamson, M.M. Sex Difference of Cortical Thickness and Diffusion Properties for The Patients with Traumatic Brain Injury. (Submitted). 25. Institute of Medicine. Returning home from Iraq and Afghanistan: assessment of readjustment needs of veterans, service members, and their families. Washington, DC: The National Academies Press; 2013.

Author Bios Maheen Mausoof Adamson, PhD, is clinical associate professor of Neurosurgery at Stanford School of Medicine and Senior Scientist at Department of Rehabilitation at VA Palo Alto. She completed her undergraduate degrees in neurobiology and women studies at the University of California, Irvine. She then completed her Ph.D. in neuroscience from the University of Southern California and a postdoctoral fellowship in Psychiatry and Behavioral Sciences at Stanford School of Medicine. Dr. Adamson’s expertise and interests span employing translational neuroscience methodologies for diagnostic and treatments for frequent health problems in patients with neurological disorders. She has been a leader in identifying gender differences in the brain injury population, particularly in Veterans. She currently serves as PI and Site-PI on numerous neuromodulation clinical trials under the Department of Veterans Affairs and Department of Defense funded grants. Odette Harris, MD, MPH, is a Professor of Neurosurgery at Stanford University School of Medicine, Vice Chair, Diversity and Director of Brain Injury for Stanford Medical Center.  Dr Harris manages and coordinates the medical and surgical care of all patients suffering from traumatic brain injury that are admitted to the Stanford System.  Dr. Harris is also the Deputy Chief of Staff, Rehabilitation at the Veterans Affairs Palo Alto Health Care System, which includes responsibilities for the varied programs of the Polytrauma System of Care, Spinal Cord Injury, Blind Rehabilitation Services, Recreational Therapy and Physical Medicine and Rehabilitation.

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The Brain Injuries We Overlook: TBIs From IntimatePartner Violence Eve M. Valera

Jan had become isolated from her family and friends living with her husband. When she left the house just to get the mail he became enraged and accused her of infidelity if she failed to pick up the phone. He would regularly slam her head into door jams as she walked through the house. When he was really angry such an act would result in a “dinger” that would leave her “woozy”, confused, and briefly disoriented. He held her head under bath and pool water on several occasions and strangled her if she did not perform her “wifely” duties. He threw her off of a porch and chased her down the street with a shotgun after which he beat her up and strangled her into unconsciousness. She remembers waking up with a shotgun in her mouth and that she had lost bladder control. She was forced to lie to the paramedics and hospital personnel about what had happened as her husband loomed over her on the gurney ensuring she would not get him in trouble. After 1.5 years of abuse like this and with the help of a friend, Jan finally managed to escape by leaving the house in the middle of the night while he was away. She has not returned to this day, yet, 26 years later, she still lives with effects of this abuse every day. Jan used to have the reading comprehension of a senior in college when she was in 8th grade and now she finds herself sounding out simple words because they do not make sense to her. She needs to consult a dictionary for words that she used to know and has “read a million times.” She reports terrible word finding difficulties, trouble remembering names of people she knew well and had relationships with, as well as frequently forgetting her train of thought when talking to others. She reports struggling with depression, anxiety and panic attacks ever since the abuse. Jan never quite understood why she suffered with these difficulties years after she was out of the situation and in a safe and healthy marriage. She thought she was dementing at the age of 46 and it scared her. It was only after she read an article linking traumatic brain injuries (TBIs) with intimate-partner violence (IPV) that Jan finally made the connection in her own life. Since that time Jan has used this information to heal and has a renewed sense of purpose and hope. She is an advocate for other women experiencing IPVrelated TBI and, despite her continued challenges, she also feels strength and peace about her past and current life. Jan is one of the many women who have sustained repetitive mild TBIs (mTBIs) from IPV. IPV is simply defined as violence perpetrated by a current or former spouse, partner, significant other, boyfriend, or girlfriend. It is the most common form of violence against women, the number one cause of homicide for women globally, and is highly prevalent 1,2. Epidemiological data show that globally, nearly 1 in 3 women aged 15 and older have experienced physical and/or sexual IPV at some point in their lives 859-8651.

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Furthermore, reports show that the majority of injuries sustained from IPV are to the neck and higher3. Women report having their head hit with hard objects such as fists, hammers and bats, slammed against walls and doors, and kicked with work boots. Women are also thrown downstairs, violently shaken and strangled into unconsciousness4. Data have shown that many of these types of abuses lead to a range of brain injuries (BIs) for women, with the majority being mild TBIs, and often repetitive TBIs, but also hypoxic and/or ischemic strangulation-related injuries 4,5. Though good epidemiological data are lacking, estimates for the number of women who have experienced repetitive IPV-related BIs are in the millions in the US alone6. I, and many others, consider this to be a public health epidemic. Yet, the general public appears to be largely unaware of this issue and/or unsure of how to address it. As such, there has been a growing recognition of the need for research and education in this area. Unfortunately, studies designed to understand the rate and effects of TBIs in these women are scant. Studies that have addressed this issue have shown relationships between IPV-related TBIs (or “possible” IPV-related TBI) and depression, PTSD symptoms and probable PTSD, lower perceptions of mental and physical health, cognitive difficulties, and high rates of post-concussive symptoms5-8. My data, going back to the early 2000s, suggest that IPV related BI, and repetitive mTBI occur at high rates and are associated with a range of negative outcomes. In a sample of 99 women, we found that 74% of the women who reported a history of physical abuse sustained at least one BI, and 51% sustained repetitive BIs – which for many women like Jan were “too many to count”5. Furthermore, a BI score based on number, recency and severity of BIs, was shown to be negatively associated with measures of learning, memory, and cognitive flexibility, as well as positively associated with measures of depression, anxiety, worry, general distress and PTSD symptomatology. In short, these data support the idea that BIs - and in particular repetitive BIs - are negatively affecting both cognitive and psychological functioning in these women, and the more BIs that are sustained, the more the women are negatively affected. More recently, my group has published the only two imaging studies designed to examine IPV-related TBI (in stark contrast to the plethora of imaging studies on athletic or military-related TBI). For both of these studies we focused on examining neural connectivity as that has been acknowledged as being critical for optimal behavior and functioning. In the first study,4 we examined functional connectivity between two networks within the brain and found that the degree of connectivity was negatively associated with women’s BI scores (that were based on the number, recency and severity of BIs sustained).

Additionally, the degree to which these two networks were connected was positively associated with the women’s ability to learn a list of words and remember those words 20 minutes later. In the second study, we examined structural connectivity, and found an association between women’s BI scores and measures of structural connectivity in two of three regions we examined6. Critically, in all of these studies, we controlled for partner-abuse severity to ensure that it was the BIs, and not just abuse itself, that was accounting for these relationships.

References 1.Devries KM, Mak JYT, García-Moreno C, et al. The global prevalence of intimate partner violence against women. Science. 2013;340(6140):1527-28. 2.Stöckl H, Devries K, Rotstein A, et al. The global prevalence of intimate partner homicide: A systematic review. Lancet. 2013;382:859-865. 3.Wu V, Huff H, Bhandari M. Pattern of physical injury associated with intimate partner violence in women presenting to the emergency department: a systematic review and meta-analysis. Trauma Violence Abuse. 2010;11(2):71-82. 4.Valera E, Kucyi A. Brain injury in women experiencing intimate partner-violence: neural mechanistic evidence of an "invisible" trauma. Brain Imaging Behav. 2017;11(6):1664-1677. 5.Valera EM, Berenbaum H. Brain injury in battered women. J Consult Clin Psychol. 2003;71(4):797-804. 6.Valera EM, Cao A, Pasternak O, et al. White matter correlates of mild traumatic brain injuries in women

subjected to intimate-partner violence: A preliminary study. J Neurotrauma. 2019;36(5):661-668. Canoeing at Vinland’s main campus in Loretto, Minnesota In sum, although there are very limited data on this topic, the data 7.Campbell J, Anderson J, McFadgion A, et al. The effects of intimate partner violence and probably that we do have suggests that IPV-related TBIs occur at a high rate traumatic brain injury on Central nervous system symptoms. J Womens Health. 2018;27:761-767. and are associated with a host of negative outcomes. Given the 8.Iverson KM, Pogoda TK. Traumatic brain injury among women veterans: an invisible wound of intimate partner violence. Med Care. 2015;53:S112-9. high rate of partner violence, it is our responsibility to consider the possibility of TBI not only in every woman who reports a history of IPV, but also in every woman we see. The first step in any treatment for a TBI is acknowledging that it has occurred and helping to ensure that no more will occur. At the very least, we should be prepared to Author Bio give women the information they need to make informed decisions about their lives. They should know that “dings” to the head are Eve Valera, PhD, is Associate Professor in for Psychiatry at Harvard Vinland Center provides drug and alcohol treatment adults with potentially very serious and that the more they receive, the more Medical School and Research Scientist at Massachusetts General including traumatic brain injury, alcohol likely they are to have immediate as wellcognitive as potentially disabilities, lifelong Hospital. She has worked for nearly 25 yearsfetal to understand the consequences of traumatic brain injuries resulting from intimate negative outcomes. Even if additional treatment and interventions spectrum disorder and learning disabilities. We make all possible partner-violence, has authored nearly 50 publications, is a reviewer may be useful or required, just this little bit of “screening” and accommodations deficits and individual styles. for more than 60 journals, and has obtainedlearning numerous grants to education – which can take very little time - can have a powerful for cognitive support her research. Her work has been featured in numerous effect on a woman’s life. I should know – it was one of my articles Located in Loretto, Minnesota just(e.g., 20TVmiles west of Minneapolis. news— sources news, NYT Magazine, Forbes, CBC Canadian that Jan read helping her to transform her life. radio), and she is actively engaged in training stakeholders (shelter

drug & alcohol treatment for adults with disabilities

law enforcement, judicial personnel) and raising awareness of• this public health epidemic. (763)479-3555 workers, VinlandCenter.org

(Note: I fully acknowledge that IPV occurs to men as well as women. However, for a number of reasons, I have chosen to focus on women here. All forms of IPV are unacceptable.)




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BRAIN INJURY professional 19

Clarity in Databases to Account for the Global Public Health Epidemic Jonathan Lifshitz, PhD In the 1990s, the public health awareness for traumatic brain injury (TBI) delivered the message that one occurred every 15 seconds, which calculated to an incidence of 1.5-2.1 million per year in the United States. At that time, transportation was reported as a leading cause of TBI, likely because the national highway traffic safety administration (NHTSA) held the most comprehensive database on fatal and nonfatal collisions. Other causes of injury included firearms, falls, and ‘other,’ which were drawn possibly from existing law enforcement and emergency department databases. In the early 2000s, mild TBI in athletics and the military emerged as signature clinical conditions. Subsequently, the record keeping on sport, military, and Veteran TBIs accelerated. Today, numerous and broad databases exist across demographics and populations to realistically estimate incidence in these populations. The most recent estimates from the CDC using 2014 data indicate 2.87 million TBIs in the US annually. The leading cause of TBI is falls, followed by being struck by or against an object. Even so, the estimates may under-represent the true incidence due to under-reporting of more mild TBI. In this issue of Brain Injury Professional, the focus on intimate partner violence (IPV)-related TBI has unknown epidemiology. Some occurrences of IPV-related TBI may be captured in emergency room, hospitalization, and mortality data. Considering that the majority of assaults occur between intimate partners, in the privacy of their living conditions, most may never be reported or recorded. If current best estimates are correct, then one in four women and one in seven men will experience domestic violence, a broader term than IPV. Using 2017 estimates of 325.7 million Americans (165.3 million women; 160.4 million men), there could be 64.2 million Americans living with domestic violence experiences. For these individuals, the assaults, often more than one or too many to count, were focused on the head, neck, or face in 80-92% of the cases. Evidence of prolonged neurological symptoms consistent with TBI have been reported in the range of 30-77%, which is in accordance of the stereotypical image of a survivor with a black eye. To this end, tens of millions of Americans may have neurological symptoms from one or more TBIs dating back days to decades. As a point of comparison, 5.8 million Americans have Alzheimer’s. Acute neurological symptoms of uncomplicated TBI diminish with time. In complicated cases, post-concussive symptoms (PCS) impair cognitive, somatic, and emotional function. One or more symptoms may reduce quality of life, require treatment, and likely involve time and resources to recover. Newer terminology expands TBI as a disease of persistent post-concussive symptoms (PPCS), which provides quantitative metrics to diagnose and recommend treatment. These academic distinctions apply best to single, isolated TBI for which rest and recovery can be prescribed.

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For the individual living with symptoms from IPV-related TBI, the more apt terminology would be constant post-concussive symptoms (CPCS), since repeated brain injuries, oftentimes without any reasonable paths to be removed from the situation, would summate symptoms over time. Although treatable, repeated TBI can leave permanent damage invisible upon first impression. Further Reading Baxter K, Hellewell SC. Traumatic Brain Injury within Domestic Relationships: Complications,Consequences and Contributing Factors. Journal of Aggression, Maltreatment & Trauma. 2019; 28:6, 660-676. DOI: 10.1080/10926771.2019.1602089 Casper ST, O’Donnell K. The punch-drunk boxer and the battered wife: Gender and brain injury research. Social Science & Medicine. 2020; 245: 112688. doi: 10.1016/j.socscimed.2019.112688

Author Bio Jonathan Lifshitz, PhD, directs the Translational Neurotrauma Research Program as Professor of Child Health at the University of Arizona, Barrow Neurological Institute at Phoenix Children’s Hospital, and the Phoenix VA Health Care System. His research efforts investigate traumatic brain injury as a disease process that dismantles, repairs, and regenerates circuits in the brain, with a focus on inflammation mechanisms and rehabilitation. He earned a Bachelors in Neuroscience from UCLA, a PhD in Neuroscience from University of Pennsylvania, and completed fellowships at UPenn and VCU. He leads local, state, and federal funded projects, including ones on cardiovascular risk factors, lung injury, and domestic violence. He chairs the Arizona Governor’s Council on Spinal and Head Injury, co-hosts the COM-P podcast ReImagine Medicine, and is the Lead Scientist and Director of Research and Development for The CACTIS Foundation.

Save the Date! Inaugural Conference on

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Program Committee

Caroline Schnakers, PhD (USA)

Roberto Llorens, PhD (Spain)

Nathan Zasler, MD (USA)

Enrique Noé, MD, PhD (Spain)

A joint conference organized by the International Brain Injury Association and the Universitat Politècnica de València

October29-October 27 – 29, 2021 September 1, 2020

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BRAIN INJURY professional 19

Factors Affecting Recovery Trajectories in Pediatric Female Concussion Christina L. Master, MD, FAAP, CAQSM, FACSM • Natasha Desai, MD, FACEP, CAQSM

Multiple studies have shown that females have more difficulty with concussion compared to males. There have been studies that show females have high rates of concussion per athletic exposure, high symptom burden, and longer recovery times. However, the data is conflicting regarding the extent of sex-based differences in concussion making it important to investigate these issues further. There are a number of theories relating to intrinsic differences between the sexes as a possible cause of these differences, including neck strength and hormonal effects. Our original research “Factors Affecting Recovery Trajectories in Pediatric Female Concussion” was an initial attempt to see if sex-based differences occurred in recovery patterns in children with concussion. Our study1 examined children with prolonged recovery, defined as greater than 4 weeks. A retrospective secondary analysis of 192 unique subjects with the diagnosis of sport related concussion who presented to our sub-specialty office in a large children’s hospital system was performed. There were 117 males and 75 females, relatively well matched in terms of age, pre-existing conditions, and previous concussions, except that females did have a significantly higher baseline GPA and males did have significantly higher rate of learning disabilities. The main factors examined were time to presentation for specialty care for concussion, the physical exam, symptoms and clinical features, as well as outcomes including the time to return to school and sports participation, normalization of clinical exam and neurocognitive testing. Similar to prior studies, we found that females had higher symptom scores at initial evaluation and also had a longer time to recovery in all outcome measures than the males.

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We found that females returned to school later (4 vs. 3 days), returned to exercise later (13 vs. 7 days), had neurocognitive recovery later (68 vs. 40 days), had later vision and vestibular (balance) recovery (77 vs. 34 days) and returned to full sport far later (119 vs. 45 days). We also found that the median days to presentation to subspecialty evaluation was significantly longer in females than males, 15 days for females and 9 days for males. When we controlled for time to presentation, examining only the subset of the cohort who presented for specialty concussion care within 14 days, the apparent sex-based differences in outcomes disappeared. Our finding that females and males who presented within 14 days of injury, their recovery times were not significantly different. This would imply that an extrinsic factor, delay to subspecialty diagnosis and treatment, may be a major contributing factor to prolonged recovery in females rather than intrinsic sex-based differences. In males there was a significant correlation of time to initial presentation and time to recovery. In females, it trended towards the same pattern but did not reach significance. Our study was not designed to determine the reason for the delay to specialty concussion care for females, but we surmise that differences in sideline medical presence and access to medical support may play a factor. Since athletic training support is a limited resource, at the interscholastic high school level, girls’ sports do not enjoy the protections of Title IX as women’s sports do in college.

We would hypothesize that lack of immediate access to medical coverage on the sidelines at the time of injury for female sports, in practice and competition, may lead to a delay in concussion identification and care as well as subsequent presentation for specialty concussion care This may inherently delay appropriate treatment and thereby potentially delay concussion recovery. Individualized specialty concussion care can mitigate the effects of excessive rest or activity in the acute recovery timeframe. As research advances and our understanding of the role of rest and activity modification becomes more refined, the early implementation of active recovery approaches such as subsymptom threshold exercise may also improve recovery for those who seek subspecialty sooner rather than later in the recovery process. Further study is need to investigate this hypothesis. There are a few important limitations that should be mentioned. This study examined time to presentation to specialty concussion care and did not assess time to presentation to the emergency room or primary care and it is possible that improving care at those points of care would also improve outcomes for girls. As concussion practice continues to evolve, these extrinsic factors may be changing even as we speak and there may be changes that have already occurred in practice that could already be closing this gap in outcomes for girls. Nonetheless, our study highlights the fact that modifiable extrinsic factors should be considered in addition to intrinsic factors when examining sex-differences in outcomes in concussion. References

Author Bios Christina L. Master, MD, is a Professor of Clinical Pediatrics at the University of Pennsylvania Perelman School of Medicine with over two decades of experience in clinical pediatrics. Dr. Master is board-certified in pediatrics and brain injury medicine with additional qualification in sports medicine and is a fellow of the American College of Sports Medicine. She treats over 800 youth with concussion annually in her outpatient practice. She is cofounding director of Minds Matter, the concussion program for children at CHOP that provides clinical care, community outreach and conducts research in youth concussion. Her particular research emphasis has been in furthering our understanding of visual deficits following concussion as a target for intervention for those with prolonged symptoms in addition to identifying objective physiologic biomarkers for concussion. Natasha Desai, MD, is the Associate Chief of Sports Medicine Physicians in the Department of Orthopedics at Columbia University Irving Medical Center and the Assistant Team Physician for Columbia University Athletics. Dr. Desai received her BS in Neuroscience from UCLA in 2005 and her Medical Doctorate from George Washington University School of Medicine in 2010. She completed residency in Emergency Medicine at The Mount Sinai Hospital in 2014 and a fellowship in Sports Medicine at the Children’s Hospital of Philadelphia and University of Pennsylvania in 2015. She is board certified in both Emergency Medicine and Sports Medicine. She has been involved in numerous research projects focused on mild TBI and concussion.

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Desai N, Wiebe DJ, et al. Factors Affecting Recovery Trajectories in Pediatric Female Concussion. Clin J Sport Med. 2019 Sep;29(5):361-367

Textbook of Traumatic Brain Injury, Third Edition Edited by Jonathan M. Silver, M.D., Thomas W. McAllister, M.D., and David B. Arciniegas, M.D.


espite the increased public awareness of traumatic brain injury (TBI), the complexities of the neuropsychiatric, neuropsychological, neurological, and other physical consequences of TBI of all severities across the lifespan remain incompletely understood by patients, their families, healthcare providers, and the media. Keeping pace with advances in the diagnosis, treatment, and science of TBI, the Textbook of Traumatic Brain Injury, Third Edition, comprehensively fills this gap in knowledge. Nearly all 50 chapters feature new authors, all of them experts in their field. The Textbook of Traumatic Brain Injury is a must-read for all of those working in any of the multitude of disciplines that contribute to the care and rehabilitation of persons with brain injury. This new volume is also a potentially useful reference for policymakers in both the public and private sectors. 2019 • 985 pages • ISBN 978-1-61537-112-9 • Hardcover • $195.00 • Item #37112 2019 • 985 pages • ISBN 978-1-61537-247-8 • eBook • $156.00 • Item #37247 Order @ www.appi.org Email: appi@psych.org | Phone:1-800-368-5777 20% Discount for American Psychiatric Association Members 25% Discount for APA Resident-Fellow Members

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Refocusing Care in Girls with Post-concussion Symptoms Nick Reed, MScOT, PhD, OT Reg (Ont) Children and youth with concussion are often asked “how is your headache?” but perhaps instead they should be asked, “what do you need, want and love to do?” Concussion care often focuses on post-concussion symptoms, but for many with a concussion it is the impact that these symptoms have on their ability to engage in daily activities that can be of most concern. Our research team at the University of Toronto asked female youth with a concussion what are the activities that they are having the most issues engaging with - what they need, want or love to do - however, as result of their concussion, they cannot. Published in the British Journal of Occupational Therapy, our study found that female youth with concussion had difficulty engaging in a wide range of activities. “Many of the youth expressed difficulty returning to sports and school, which was to be expected, however what was most interesting was the wide range of other activities identified by our study participants - everything from watching movies, engaging in the arts, having sleepovers with friends, even daily hydration and nutrition,” said Dr. Anne Hunt, one of the study authors. A takeaway from this study is that the lives of children can be impacted by concussion in many ways and that concussion care should focus on what children can and cannot do, rather than only post-concussion symptoms. So next time you are helping a child with a concussion, instead of asking about their symptoms, perhaps ask “what do you need, want and love to do?” After all, if you don’t ask, you won’t know, and you can’t help. References Sang, RC, Vawda Y, et al. An Innovative approach to measuring youth concussion recovery: Occupational performance. British Journal of Occupational Therapy (Epub ahead of print). 2019; https://doi. org/10.1177/0308022619851415

Author Bio Nick Reed, MScOT, PhD, OT Reg (Ont), completed his Bachelor of Kinesiology at McMaster University, his Masters of Science in Occupational Therapy at the University of Toronto, and his PhD in Rehabilitation Sciences at the University of Toronto. He is an Associate Professor within the Department of Occupational Science and Occupational Therapy and a member of the Rehabilitation Sciences Institute at the University of Toronto. His work focuses on developing, delivering and evaluating research, educational and clinical programming specific to youth and concussion. His passion is helping youth do the things they need, want and love to do in their lives.

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Adolescent Females More Likely to be Diagnosed with an Endocrine Disorder After a TBI J. Bryce Ortiz, PhD Hormones are regulated by various brain regions and glands in the body - collectively termed the endocrine system. This system, particularly the hormones, plays a critical role in childhood growth and development. Most notably, in early adolescence, hormones govern pubertal development. In our recent study, we determined whether traumatic brain injuries (TBIs) in childhood affect the endocrine system and if this differed between females and males, because the parts of the endocrine system in the brain are vulnerable to the mechanical forces of TBI. In the United States, childhood TBIs account for over 812,000 emergency department visits every year and are a leading cause of childhood morbidity and mortality. TBIs result from a violent blow or jolt to the head or body, and may result in damage to various brain regions, including brain regions that control the endocrine system. In this study, we collected patient data from the Arizona Health Care Cost Containment System (AHCCCS; the Arizona Medicaid program) database and identified all patients who were diagnosed with a TBI and subsequently diagnosed with an endocrine disorder. The data revealed that pediatric TBI patients, aged 0-18, had a 3.2-fold higher odds of being diagnosed with an endocrine disorder. When looking at the difference between female and male patients, we found that females were more likely to be diagnosed with an endocrine disorder after a TBI compared to male subjects. Females were more likely to be diagnosed with an endocrine disorder at an earlier age (ages 5-8) compared to males who were diagnosed with an endocrine disorder at a later age (ages 8-12). Moreover, females had a shorter time gap between the TBI and the endocrine disorder compared to males. Delayed diagnosis of an endocrine disorder can leave individuals with a lifetime of health care issues, including stunted growth, sugar dysregulation, obesity, hypertension, and cognitive challenges. Doctors, nurses, and all practitioners, including parents, caregivers, coaches, and trainers should screen children with TBI for endocrine disorders within six months of the injury. References Ortiz JB, Sukhina A, Balkan B, et al. Epidemiology of Pediatric Traumatic Brain Injury and HypothalamicPituitary Disorders in Arizona. Front. Neurol. 2020;10:1410. doi: 10.3389/fneur.2019.01410

Author Bio J. Bryce Ortiz, PhD, is a post-doctoral researcher at the University of Arizona College of Medicine - Phoenix and Barrow Neurological Institute at Phoenix Children’s Hospital. Bryce received a BS in Psychology from Arizona State University in 2011 and a Master’s in Psychology in 2013. He then completed a PhD in Behavioral Neuroscience from Arizona State University in 2017. For Bryce’s dissertation he studied the effects of stress on the brain and behavior with a focus on the mechanisms of how individuals recover from a period of chronic stress. He also studied how hormones, including stress hormones and sex hormones, alter brain structure and function. During his postdoctoral researcher, he has been researching how hormones are affected following pediatric traumatic brain injuries and how these changes affect sleep and development.

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Natural Progression of Symptom Change and Recovery from Concussion in a Pediatric Population Andrée-Anne Ledoux, PhD The expected duration for recovery after pediatric concussions is broad, ranging from days to months and even years. However, the epidemiology of the natural progression of recovery remains poorly described through childhood and adolescence. Our study goal was to examine the progression of self-reported recovery following a pediatric concussion over the initial three months after injury. We studied the recovery patterns and their associations with sex and age. In this study, we prospectively enrolled 3,063 children and adolescents who presented within 48 hours of injury at nine emergency departments across Canada and who were diagnosed with a concussion. Participants were aged 5 to 18 years old with an acute concussion, enrolled from August 2013 to May 2015. Recovery was measured with a validated tool (Post-Concussion Symptom Inventory) in the emergency department and at 1-, 2-, 4-, 8- and 12-weeks post-injury. Results demonstrated that for all ages, the greatest recovery gains occurred primarily in the 1st week, with modest gains in the 2nd week. Beyond two weeks, symptom recovery significantly slows.

Recovery curves in adolescent boys plateaued between 2- and 4- weeks compared to adolescent girls where recovery curves plateaued between 4- and 8- weeks. While the majority of adolescent boys recovered to baseline within four weeks, the majority of adolescent girls still exhibited post-concussion symptoms beyond twelve weeks after the initial injury. Recovery sex differences are likely multifactorial, and might be explained by anthropometric, axonal size, and pubertal hormonal differences, and higher rates of injury and symptom reporting in girls. In conclusion, recovery differs by both age and sex; both of these factors must be considered when informing families of expected recovery and to personalize concussion management. References Ledoux AA, Tang K, et al. Natural Progression of Symptom Change and Recovery from Concussion in a Pediatric Population. JAMA Pediatrics. 2019;173(1):e183820. DOI:10.1001/jamapediatrics.2018.3820

Author Bio Andrée-Anne Ledoux, PhD, is a Scientist for the Children’s Hospital of Eastern Ontario Research Institute (CHEO), Assistant Professor for the Department of Cellular Molecular Medicine and Adjunct Professor for the School of Psychology at University of Ottawa and Adjunct Professor in the Department of Neuroscience at Carleton University. Andrée-Anne completed an MA/PhD in Experimental Psychology and Behavioural Neuroscience from University of Ottawa in 2013. She completed a Postdoctoral Fellowship, studying pediatric concussion recovery trajectories at CHEO in 2019. With state-of-the-art neuroimaging techniques she studies neural correlates of recovery patterns in pediatric concussion.

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Provider Competencies for Disorders of Consciousness: Minimum Competency Recommendations Proposed by the ACRM-NIDILRR Workgroup Theresa Bender Pape, MA, CCC-SLP, Dr.PH, FACRM • Nathan D. Zasler, MD, DABPM&R, FAAPM&R, FACRM, BIM-C, CBIST Patients with disorders of consciousness (DoC) after brain injury have complex medical and medical rehabilitation needs requiring specialized skills and high levels of care and surveillance. The need for standards of care for complex populations, such as patients with DoC, was identified in the Medicare Payment Advisory Commission’s 2019 Report to Congress. This report, ‘The Medicare and Proposed Reforms to the Health Care Delivery System,’ calls for a 2-tiered regulatory approach to establishing provider competencies and the 2nd tier specifically specifies provider competencies for patients with specialized or very high care needs. Considering the long-standing need for standards that can be used to determine if providers and programs match the specialized care needs of patients with DoC, the DoC Special Interest Groups of the American Congress of Rehabilitation Medicine (ACRM) as well as National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) convened a multidisciplinary panel of experts to review the literature and draft recommendations. These recommendations, based on a modified Delphi voting process, provide standards of care for use in determining if provider competencies are aligned with care needs of patients with DoC (Giacino JT, Whyte J, Nakase-Richardson R, et al., 2020). The primary purpose of this paper was to provide evidenceinformed guidance to programs, payors and caregivers involved in the care of persons with DoC on the essential services and processes needed to address the specialized needs of this population via explication of the minimum competencies necessary to do so. The recommendations emphasize neurorehabilitation related care of persons with DoC and are generally applicable across settings including but not necessarily limited to acute care hospitals, longterm acute care hospitals (LTACs), community -based long-term specialized brain injury programs and skilled nursing facilities (SNFs). To focus on the functionally important elements of optimal care, the recommendations are framed according to required capacities, infrastructure and operating procedures that should be deployed for evaluation, monitoring, treatment, and service provision more generally (such as family education and support). The position paper includes twenty-one recommendations that are organized into four categories: diagnostic and prognostic assessment, treatment, transitioning care/long-term care needs and management of ethical issues. Within each category, recommendations provide guidance for daily clinical decisions that are made with the goal of optimizing each patient’s function. With few exceptions, these recommendations focus on infrastructure requirements and operating procedures for the provision of DoCfocused neurorehabilitation services across subacute and post-acute settings. The position paper also includes an audit check list, which providers, payors, and consumers can use to assess a DoC program’s compliance with the minimum competency recommendations proposed by the ACRM-NIDILRR Workgroup. A major strength of the ACRM-NIDILRR Workgroup’s recommendations is that they provide guidance, for routine clinical decision-making that have the potential to influence a patient’s neurological and functional outcome.

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This is important when considering that clinical reasoning for patients in states of DoC occurs within a context of uncertainty. Clinical uncertainty includes, for example, the paucity of definitive evidence guiding clinicians in the use of results from clinical assessments in treatment planning and prognostication. This context of clinical uncertainty means that clinical decision-making is a trial and error process in many situations. Given the goal of optimizing each patient’s function and neurorecovery, each recommendation provides clinicians with factors and circumstances to consider when making these daily and critical decisions. While the recommendations address the training and needs of caregivers, the guidance informs clinical reasoning and should not be regarded as the sole perspective for informing medical rehabilitation decisions. Providers should consider how to implement these recommendations to inform their reasoning, but this should not be considered guidance on shared decision making with the caregiver whose perspective is equally important during medical rehabilitation planning. In conclusion, the minimum competency, evidence informed, consensus-based recommendations are deemed crucial to assuring that those patients with DoC are both appropriately monitored and managed as many of them will regain consciousness as well as improve their functional capabilities. The position statement also emphasizes the importance of specialized multidisciplinary neurorehabilitation care of patients with DoC regardless of their time post-injury or their level of neurorecovery. Reference Giacino JT, Whyte j, Nakase-Richardson R, et al. Minimum competency recommendations for programs that provide rehabilitation services for persons with disorders of consciousness: A position statement of the American Congress of Rehabilitation Medicine, and the National Institute on Disability, Independent Living, and Rehabilitation Rresearch Traumatic Brain Injury Model Systems. Arch PMR. 2020; 101(6):1072-1089. doi: 10.1016/j.apmr.2020.01.013.

Author Bios Theresa L. Bender Pape, Dr.PH, MA, CCC-SLP/L, FACRM is a clinical neuroscientist with a dual appointment at Edward Hines, Jr VA Hospital and Northwestern University Feinberg School of Medicine. Her translational research track in neural plasticity in neurorehabilitation of traumatic brain injury (TBI) is founded on her clinical TBI specialty as a Speech-Language Pathologist. Throughout her career, she has synthesized her clinical background with training in neurosciences, neural plasticity, central nervous system repair, psychometrics, health services methods and statistical methodology. Nathan Zasler, MD, is CEO & Medical Director for Concussion Care Centre of Virginia, Ltd., as well as CEO & Medical Director for Tree of Life Services, Inc. Dr. Zasler is board certified in PM&R, fellowship trained in brain injury and subspecialty certified in Brain Injury Medicine. He is an affiliate professor in the VCU Department of Physical Medicine and Rehabilitation, Richmond, VA, and an adjunct associate professor in the Department of Physical Medicine and Rehabilitation at the University of Virginia, Charlottesville. He is Chairperson Emeritus of IBIA and currently serves as Vice-Chairperson. He is co-chief editor of Brain Injury, NeuroRehabilitation and Brain Injury Professional. Dr. Zasler is an advocate, educator, clinical researcher, inventor, entrepreneur and busy practicing clinician who is involved with community-based neurorehabilitation, chronic pain management, and health care consultation, both clinical and medicolegal.

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for Clinical Interventions (on behalf 10. http://www.corboydemetrio.com/news-121.html Source: of the Swedish Network for “This paperNational was presented at the Proceedings of the 1st Rehabilitation after Childhood Acquired Annual Conference on Brain – SVERE), January 14, by the SysteMed 11. Injuries Environmental Toxicology, sponsored Corporation m Fairborn, Ohio on 9, 10th and Webinar session.and Forheld more information, 11 September 1970.“ visit www.internationalbrain.org. 14-15: 34th Annual NABIS Medical and ABOUT AUTHOR Legal Issues THE Conference in Brain Injury, Gordon Johnson is a leading attorney, advocate January 14-15, Virtual Meeting. and author on brain injury. HeFor is a 1979 cum more information, laude graduate ofvisit the University of Wisconsin www.internationalbrain.org. law school and a journalism grad from North-

western University. He has authored some of the

September most read web pages in brain injury. He is the Past Chair of the Traumatic Brain Injury Liti-

Group, American Association of Justice. 16:gation EBIS Conference, September was appointed Wisconsin’s Governor to 16,He Brussels, Belgium.byFor more the state’s sub-agency, TBI Task Force from information, please visit the ebissociety.org. 2002 – 2005. He is also the author of two novels on brain injury, Crashing Minds and Concussion is Forever.

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expert interview

with Angela Colantonio, PhD, OT Reg. (Ont.), FCAHS, FACRM Describe your role as an educator? As Director of the University of Toronto Rehabilitation Sciences Institute, I have the privilege of training the next generation of scientists that includes sex and gender considerations in research. Our lab also extends education to researchers, service providers, users and the general public. What distinguishes your research program? What innovative approaches have you taken?

Expert Bio Dr. Angela Colantonio is the Director of the University of Toronto’s Rehabilitation Sciences Institute, and a Professor in the department of Occupational Science and Occupational Therapy. She is also a Senior Research Scientist at the KITE/Toronto Rehabilitation InstituteUniversity Health Network. Dr. Colantonio heads an internationally recognized research program on acquired brain injury, which focuses on women, sex and gender, return-to-work, violence, and marginalized populations (www. abiresearch.utoronto. ca). She has authored over 270 publications and has presented to over 500 research, clinical and lay audiences. She is a Fellow of the Canadian Academy of Health Sciences, the American Congress of Rehabilitation Medicine and the American College of Epidemiology. She received the 2015 Robert L. Moody Prize for Distinguished Initiatives in Brain Injury Research and Rehabilitation and a Distinguished Member and Women and Rehabilitation Science Award from the American Congress of Rehabilitation Medicine.

Our research team has been on understudied brain injury populations such as injured workers, older adults, indigenous, homeless, justice involved and persons injured by assault including in the intimate partner context with a sex and gender lens. We have also used innovative knowledge transfer approaches such as research informed theatre and involve end users of the research throughout the research process (www.abiresearch.utoronto.ca). What are some research highlights relating to sex and gender? We reported long term outcomes specific to women such as menstrual cycle disruption, post partum difficulties and the ability to conceive after TBI. Also we have reported differential patterns of injury by sex as well as differences in comorbidities in the population.

We published models that can be applied to sex and gender related work in brain injury. We conducted the first studies of TBI in intimate partner contexts in Canada and created a toolkit for front line providers (www.abitoolkit.ca). What have you found most rewarding in your work? It’s gratifying to have feedback by persons affected by brain injury, brain injury associations and organizations like PINK Concussions that our work matters and that it is useful. I am grateful for the support of persons affected by brain injury. What are three key areas of research on concussions in females we need to focus on in the next few years? We need to better understand biological vulnerabilities as well as comorbidities and the interaction with the psychosocial environment. More research is needed in understudied areas such as concussion among older adults, diverse ethnicities/races and contexts such as intimate partner violence. Further, we need to know the best way to integrate this knowledge to make a difference for persons affected.

About the Interviewer Dr. Ron Savage has worked with children, adolescents and young adults with neuro-developmental disabilities for over 45 years. He is currently on the Board of Directors for PINK Concussions, dedicated to understanding the unique differences in concussions and brain injuries in the female brain. Previously, Dr Savage was the Founding Chair of the International Pediatric Brain Injury Society (IPBIS), President of the Sarah Jane Brain Foundation, Chairman of the North American Brain Injury Society (NABIS), Editor of Brain Injury Professional, and served on the Board of Governors for the International Brain Injury Association (IBIA).

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Useful Resources Would you like to learn more about sex and gender differences in brain injury? These websites, podcasts and e-newsletters are great places to continue learning and stay up to date on future findings

PINK Concussions Website www.PINKconcussions.org PINK Concussions has a website with expert videos, stories of women with the experience of brain injury, events, updates on research, and ten online support groups for young women, women, parents/ caregivers of women with brain injury, female veterans and more.

bsite : https://abitoolkit.ca

Concussion Corner

NORA Weekly Digest

Podcast sed & Brain Injured is a website focused on the intersection of intimate partner violence and

E-newsletter nora.bulletinhealthcare.com/ matic brain injury which was created for front-line workers as well as survivors. This website serves as subscribe www.jessicaschwartzpt.com

Concussion Corner is a podcast founded

Jessica B. Schwartz PT, and DPT, practice CSCS olkit to provide information,byresources, research recommendations for providing brain

y informed services.

is a resource for interdisciplinary conversations about concussion-related topics in healthcare, advocacy, and sport. Concussion Corner podcasts are available on Apple Podcasts, Google Play, and Spotify.

Abused and Brain Injured Website abitoolkit.ca

ewsletter : https://nora.bulletinhealthcare.com/subscribe

NORA Weekly Digest is a newsletter published by the Neuro-Optometric Rehabilitation Association, International (NORA). It keeps readers up-to-date on current medical, research, and other news relevant to patients, caregivers, and health care professionals interested in neurological recovery and vision rehabilitation.

The Concussion Alliance E-newsletter www.concussionalliance.org/ newsletter

Abused & Brain Injured is a website focused on the intersection of intimate The Concussion Alliance newsletter was partner violence and traumatic brain injury created by the nonprofit of the same name which was created for workers as RA Weekly Digest is a newsletter published byfront-line the Neuro-Optometric Rehabilitation Association, which was founded by a mother and son, well as survivors. This website serves as a Malayka and Conor Gormally. This biweekly toolkit to provide information, resources, synopses of recent research and rnational (NORA). It keeps readers on current medical, relevant researchup-to-date and practice recommendations for research, and other newscontains news. providing brain injury informed services.

atients, caregivers, and health care professionals interested in neurological recovery and vision


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Fourth International Conference on

Pediatric Acquired Brain Injury

Save the date! For the first time in the United States, this interdisciplinary conference brings together professionals committed to improving the outcome of children and young people with brain injury!

A unique educational event promoting wellbeing in children and young people with acquired brain injury and their families

New York New Yorker Hotel October 6-9

2021 Administrative assistance from:

For conference information: www.internationalbrain.org For IPBIS information: www.ipbis.org BRAIN INJURY professional 23

Technology: Evalu8NOW Stephen K. Trapp, PhD

To address a range of clinical concerns, a number of standardized assessments can be enabled on the Evalu8NOW system. Assessments with evidence for validity and reliability are available in domains pertaining to pain, anger, mood, cognitive functions, sleep, activity level, and medication adherence. These are intended to measure treatment plan effectiveness as well as provide indicators of an at-risk patient.

The range of brain injury symptoms and related behaviors that occur between visits with a care provider represent an opportunity for novel assessment and intervention. Coping with pain, managing emotions, and navigating complex social situations can be missed opportunities to reinforce skills traditionally addressed in clinicbased neurorehabilitation. Most providers still rely upon patient self-report or collateral descriptions from caregivers to assess for functional areas to target. Unfortunately, these retrospective reports are often limited by inaccuracies and response bias. With the advance of mobile health (mHealth) technology, there are new opportunities to address this space between clinic visits. Specifically, opportunities exist for in situ assessment and intervention for a range of brain injury effects. Health behavior research and clinical care has increasingly focused on mHealth technology for behavior change, health promotion and disease prevention.(Castelnuovo et al., 2015; Cole-Lewis & Kershaw, 2010; Fjeldsoe, Marshall, & Miller, 2009; Steinhubl, Muse, & Topol, 2013) This trend is especially pertinent to neurorehabilitation, in which mobile technology has utility in evaluation and treatment outside of the clinic space.(Rodríguez, Vázquez, Casas, & de la Cuerda, 2018) Specifically, mHealth can offer unique opportunities to ecologically assess and embed an intervention within a person’s daily context.(Castelnuovo et al., 2015) This approach is growing in value as mHealth technology becomes more easily adoptable, increasingly cost-efficient, and more robust in its sensing capabilities. A technology that enables mobile neurorehabilitation solutions is the Evalu8NOW system by CreateAbility. Evalu8NOW is a customizable platform for a range of web-based assessments and interventions. These apps are designed to address a range of needs including behavioral health, safety monitoring, and disease management. Assessments are conducted on mobile devices, like a tablet, and enabled by a neutral avatar to enhance receptivity by the client. Further, these apps are both patient and provider facing, in which real-time data can be collected to personalize treatment strategies. Steve Sutter, CEO and founder of CreateAbility, developed this system to enable clinicians to have greater presence with their clients outside of a traditional clinic visit. Design of this technology was user-centered in which end-users were involved in a range of development aspects, such as informing the design to naming the apps. Mr. Sutter described the inspiration for the technology began when addressing needs of individuals with cognitive decline in rural areas. This project impressed upon him the range of factors salient to disease management that could be assessed remotely to tailor treatment.

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Mr. Sutter described a dedication for methods-informed development of the CreateAbility technologies. Accordingly, he partners with neurorehabilitation clinical researchers like Dr. Lance Trexler, Executive Director of the Brain Injury Rehabilitation Research and Program Development at the Rehabilitation Hospital of Indiana. Internal research is directed by a four-phase process of scientific inquiry from design to technology transfer. The first phase includes preliminary research on technology ideation. Phases two and three include feasibility studies and iterative development. The final stage includes examination of commercialization pathways. Similar to other technology developers, the results of these studies are applied internally. Considering the context under COVID-19 precautions and the expansion of telehealth services, mHealth options like Evalu8NOW exemplify creative next steps for neurorehabilitative care. Accordingly, there is a call for greater exploration of these tools to address a range of conditions and examine the mechanisms for change associated with the technology. Emerging options, such as just-in-time adaptive intervention approaches, will provide value as these technologies are more readily available for and used by neurorehabilitation clinicians. Disclosure: The author has no association with the research or technology reviewed in this article. CreateAbility technology development and testing has been sponsored by a number of extramural awards including, but not limited to: USDA Award 2015-04161; Department of Health and Human Services, AOD Traumatic Brain Injury State Demonstration Grant Program, Administration For Community Living Grant No. 90TBSG0034-02-00; NIDILRR Grant # 90BISB0009; and USDA Award 2019-33610-29738.

References Castelnuovo G, Zoppis I, et al. Managing chronic pathologies with a stepped mHealth-based approach in clinical psychology and medicine. Frontiers in psychology. 2015; 6. Cole-Lewis H, Kershaw T. Text messaging as a tool for behavior change in disease prevention and management. Epidemiologic reviews. 2010; 32(1):56-69. Fjeldsoe BS, Marshall AL, Miller YD. Behavior change interventions delivered by mobile telephone shortmessage service. American journal of preventive medicine.2009;36(2):165-173. Rodríguez MS, Vázquez SC, et al. Neurorehabilitation and apps: A systematic review of mobile applications. Neurología (English Edition). 2018;33(5):313-326. Steinhubl SR, Muse ED, Topol EJ. Can mobile health technologies transform health care? JAMA. 2013; 310(22): 2395-2396.

Author Bio Stephen K. Trapp, PhD, is a member of the Department of Psychology at the George E. Wahlen Veterans Affairs Salt Lake City Health Care System. His research focuses on rehabilitation technology and crosscultural rehabilitation. These areas are examined in order to address shared rehabilitation needs across cultures with unifying technology.


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Madison Schwartz, Stanford Law, Randall H. Scarlett, Randall A. Scarlett, Ronnie Pang, Olga Rios, Mary Anne Scarlett, and Brendan D. Nay.

SCARLETT LAW GROUP Scarlett Law Group is a premier California personal injury law firm that in two decades has become one of the state’s go-to practices for large-scale personal injury and wrongful death cases, particularly those involving traumatic brain injuries. With his experienced team of attorneys and support staff, founder Randall Scarlett has built a highly selective plaintiffs’ firm that is dedicated to improving the quality of life of its injured clients. “I live to assist people who have sustained traumatic brain injury or other catastrophic harms,” Scarlett says. “There is simply no greater calling than being able to work in a field where you can help people obtain the treatment they so desperately need.” To that end, Scarlett and his firm strive to achieve maximum recovery for their clients, while also providing them with the best medical experts available. “As a firm, we ensure that our clients receive both

the litigation support they need and the cutting-edge medical treatments that can help them regain independence,” Scarlett notes. Scarlett’s record-setting verdicts for clients with traumatic brain injuries include $10.6 million for a 31-year-old man, $49 million for a 23-year-old man, $26 million for a 7-year-old, and $22.8 million for a 52-year-old woman. In addition, his firm regularly obtains eight-figure verdicts for clients who have endured spinal cord injuries, automobile accidents, big rig trucking accidents, birth injuries, and wrongful death. Most recently, Scarlett secured an $18.6 million consolidated case jury verdict in February 2014 on behalf of the family of a woman who died as a result of the negligence of a trucking company and the dangerous condition of a roadway in Monterey, Calif. The jury awarded $9.4 million to Scarlett’s clients, which ranks as



415.352.6264 | FAX 415.352.6265


one of the highest wrongful death verdicts rendered in recent years in the Monterey County Superior Court. “Having successfully tried and resolved cases for decades, we’re prepared and willing to take cases to trial when offers of settlement are inadequate, and I think that’s ultimately what sets us apart from many other personal injury law firms,” observes Scarlett, who is a Diplomate of the American Board of Professional Liability Attorneys. In 2015, Mr. Scarlett obtained a $13 million jury verdict for the family of a one year old baby who suffered permanent injuries when a North Carolina Hospital failed to diagnose and properly treat bacterial meningitis that left the child with severe neurological damage. Then, just a month later, Scarlett secured an $11 million settlement for a 28-year-old Iraq War veteran who was struck by a vehicle in a crosswalk, rendering her brain damaged.

Articles inside

Technology Article article cover image

Technology Article

pages 34-36
Expert Interview article cover image

Expert Interview

pages 30-31
Useful Resources article cover image

Useful Resources

pages 32-33
Natural Progression of Symptom Change and Recovery from Concussion in a Pediatric Population article cover image

Natural Progression of Symptom Change and Recovery from Concussion in a Pediatric Population

page 27
Provider Competencies for Disorders of Consciousness: Minimum Competency Recommendations Proposed by the ACRM-NIDILRR Workgroup article cover image

Provider Competencies for Disorders of Consciousness: Minimum Competency Recommendations Proposed by the ACRM-NIDILRR Workgroup

pages 28-29
Adolescent Females More Likely to be Diagnosed with an Endocrine Disorder After a TBI article cover image

Adolescent Females More Likely to be Diagnosed with an Endocrine Disorder After a TBI

page 26
Refocusing Care in Girls with Post-concussion Symptoms article cover image

Refocusing Care in Girls with Post-concussion Symptoms

pages 24-25
Traumatic Brain Injury Among Female Veterans article cover image

Traumatic Brain Injury Among Female Veterans

pages 16-17
Clarity in Databases to Account for the Global Public Health Epidemic article cover image

Clarity in Databases to Account for the Global Public Health Epidemic

pages 20-21
Women with Brain Injury: Past, Present and Future article cover image

Women with Brain Injury: Past, Present and Future

pages 8-13
Factors Affecting Recovery Trajectories in Pediatric Female Concussion article cover image

Factors Affecting Recovery Trajectories in Pediatric Female Concussion

pages 22-23
Brain Injuries We Overlook: TBIs From Intimate-Partner Violence article cover image

Brain Injuries We Overlook: TBIs From Intimate-Partner Violence

pages 18-19
Exercise in Concussed Females article cover image

Exercise in Concussed Females

pages 14-15
Editor in Chief Message article cover image

Editor in Chief Message

pages 5-6
Guest Editor’s Message article cover image

Guest Editor’s Message

page 7
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