Beth S. Slomine

Background: Training visual processing skills, a domain implicated in sport performance and injury risk, could reduce injuries among youth athletes. The useful field of view (UFOV) cognitive training program improves visual processing efficiency. While UFOV training has been extensively studied in aging populations and yields significant cognitive and functional benefits, it has yet to be examined in adolescents. Objective: The aim of this study is to preliminarily assess the feasibility and acceptability of UFOV training in youth and report on the magnitude of change in visual processing efficiency from pre- to posttraining. Methods: Six adolescent athletes (aged 14‐18 years) completed a 5-week adaptive, online, remote UFOV training program. The UFOV training program has a gamelike interface and increases in difficulty as participants accurately identify and locate targets that are rapidly displayed in the center and at the periphery of their screen amid distractors. Participants were assigned a total training dose of 250 levels across 5 weeks, with 5 scheduled sessions per week, each lasting approximately 25 minutes (equating to approximately 10.42 hours of assigned training time). Individuals met remotely with research staff weekly to receive coaching. We examined feasibility by calculating overall dose adherence (percentage of assigned levels completed) and regimen adherence (percentage of scheduled training sessions completed). Average overall acceptability, program usability, adoptability, and perceived benefit were calculated using responses to a posttraining survey, where item-level responses ranged from 1 to 7 on a Likert scale (responses greater than 4 reflected a view more positive than neutral toward the program). Participants completed the Double Decision Assessment pre- and posttraining to quantify the magnitude of change in visual processing efficiency. Results: In this pilot cohort, we observed strong dose (mean 95.33%, SD 11.43%) and regimen (mean 90.67%, SD 12.56%) adherence. Participants’ responses to the acceptability survey suggested positive views of the program overall (mean 5.47, SD 0.4) and in terms of usability (mean 5.69, SD 0.43), perceived benefit (mean 5.36, SD 0.69), and adoptability (mean 5.17, SD 0.61). All participants demonstrated improved visual processing efficiency from pre- to posttraining (mean difference of 168.67, SD 112.05 ms; Cohen d =1.51). Conclusions: Though preliminary, results suggest that UFOV training may be feasible and acceptable for adolescent athletes. All participants in this pilot study demonstrated improvements in visual processing efficiency after completing 5 weeks of training. Further research is needed to investigate the feasibility of implementing this training in other contexts, such as without research team support or in a group setting. Future work should also evaluate the extent to which UFOV training improves visual processing more than an active control intervention and whether visual processing improvements transfer to untrained skills to reduce the risk of sport-related injury.

Objective: To identify meaningful subgroups of adolescents with mTBI using physiologic and physical activity data obtained via consumer-grade smartwatches. Setting: Specialty concussion clinic. Participants: Eighty participants aged 13-18 within six months of mTBI diagnosis were enrolled. Sixty-one participants were included in the analysis. Design: Prospective longitudinal cohort study. Participants wore a Fitbit Sense 2. Heart rate and step count data collected within fourteen days of enrollment were included. Main measures: A group-based steps per minute (SPM) threshold (25th percentile; 10 SPM) and individualized heart rate threshold (20% heart rate reserve (HRR)) were used to classify each minute of active daytime data into quadrants: SPM>10 & HRR>20% (QI), SPM≤10 & HRR>20% (QII), SPM≤10 & HRR≤20% (QIII), and SPM>10 & HRR≤20% (QIV). Percentage of minutes in QI, QII, and QIV, mean steps per day, percentage of minutes with zero steps, mean SPM in QI, and resting heart rate were included in a k-means clustering algorithm. Subgroup differences by clustering variables were evaluated using Kruskal-Wallis tests. Results: Three subgroups emerged: Sedentary (n=12), Active (n=23), and Atypically Elevated Heart Rate (AEHR; n=26). Subgroups varied significantly on all clustering variables ( P <0.01). The Active subgroup took a high number of steps per day, had lower sedentary time, and had the highest mean SPM in QI. The Sedentary subgroup took fewer steps per day than the Active subgroup, had high sedentary time, and showed the highest resting heart rate. The AEHR subgroup took fewer steps per day than the Active subgroup, had high sedentary time, and spent a higher percentage of time with an atypically high heart rate response to low levels of activity than the other subgroups. Conclusions: Data from wearable devices can identify subgroups of adolescents with mTBI with distinct physiologic/physical activity profiles, which may ultimately be used to inform personalized activity prescriptions.

This study investigates sex differences in demographic and injury-related characteristics, along with recovery patterns, in children with mild traumatic brain injury (mTBI) who failed at least one Performance Validity Test (PVT). A retrospective analysis of 186 patients (8-18 years old; 65.1% females) from a specialty concussion clinic with non-credible effort on PVTs was conducted. Data on demographics, injury-related characteristics, symptoms, as well as recovery patterns, were analyzed. There were significant sex differences in age at injury, pre-injury academic status, ADHD prevalence, physical activity levels, and post-injury emotional symptoms. Girls exhibited longer recovery times, had more clinical visits, and received different provider recommendations. This study revealed significant sex differences between boys and girls with mTBI and non-credible effort on PVTs. These findings underscore the need for sex-informed approaches in pediatric mTBI management and highlight areas for future research.

Background: Clinicians are challenged by the ambiguity and uncertainty in assessing level of consciousness in individuals with disorder of consciousness (DoC). There are numerous challenges to valid and reliable neurobehavioral assessment and classification of DoC due to multiple environmental and patient-related biases including behavioral fluctuation and confounding or co-occurring medical conditions. Addressing these biases could impact accuracy of assessment and is an important aspect of the DoC assessment process. Methods: A pre-assessment checklist was developed by a group of interdisciplinary DoC clinical experts and researchers based on the existing literature, current validated tools, and expert opinions. Once finalized, the checklist was electronically distributed to clinicians with a range of experience in neurobehavioral assessment with DoC. Respondents were asked to use the checklist prior to completing a neurobehavioral assessment. A survey was also provided to respondents to obtain feedback regarding checklist feasibility and utility in optimizing the behavioral assessments. Results: Thirty-three clinicians completed the survey after using the checklist. Over half of the respondents were a combination of physicians, neuropsychologists, and physical therapists. All respondents served the adult DoC population and 42% percent had over ten years of clinical experience. Eighty percent reported they found the format of the checklist useful and easy to use. All respondents reported the checklist was relevant to preparing for behavioral assessment in the DoC population. Eighty-four percent reported they would recommend the use of the tool to other clinicians. Conclusions: The use of a pre-assessment checklist was found to be feasible and efficacious in increasing interdisciplinary clinician’s ability to optimize the patient and environment in preparation for neurobehavioral assessment. Initial results of clinicians’ perception of the utility of a pre-assessment checklist were positive. However, further validation of the tool is needed with larger sample sizes to improve representation of clinical use across disciplines and care settings.

Examine initial feasibility/utility of a telephone-administered measure in describing impact of child health on caregiver/family functioning in patients with a history of a disorder of consciousness (DoC) due to severe-acquired brain injury (ABI). Caregivers of patients admitted at least 1 year prior for inpatient rehabilitation with DoC completed a battery of measures administered via telephone examining the impact of child health on caregiver/family functioning (Pediatric Quality of Life Family Impact Module; PedsQL-FIM) and child functioning. Forty-one caregivers of unique patients (age = 5-22 years; M = 14.9, SD = 5.1; 63% male; time since injury = 1-18 years; M = 5.3; SD = 4.2) completed the telephone measures. PedsQL-FIM floor and ceiling effects were minimal (administration time = 5-16 min, M = 7.4; SD = 2.8). Family functioning was lowest in Daily Activities and highest in Family Relationships. Relative to caregivers of patients with mild-severe ABI, caregivers reported lower caregiver/family functioning. Correlations were moderate between child functioning and caregiver/family functioning on some PedsQL-FIM scales. Within this relatively small convenience sample, results indicate the PedsQL-FIM administered via telephone is feasible and useful in describing the impact of child health on caregiver/family functioning long after DoC associated with ABI. Future studies are needed to understand factors contributing to caregiver/family functioning to inform targeted interventions.

Background The fundamental gap obstructing forward progress of evidenced based care in pediatric and neonatal disorders of consciousness (DoC) is the lack of defining consensus-based terminology to perform comparative research. This lack of shared nomenclature in pediatric DoC stems from the inherently recursive dilemma of the inability to reliably measure consciousness in the very young. However, recent advancements in validated clinical exams and technologically sophisticated biomarkers of brain activity linked to future abilities are unlocking this previously formidable challenge to understanding the DoC in the developing brain. Methods To address this need, the first of its kind international convergence of an interdisciplinary team of pediatric DoC experts was organized by the Neurocritical Care Society’s Curing Coma® Campaign. The multidisciplinary panel of pediatric DoC experts proposed pediatric-tailored common data elements (CDEs) covering each of the CDE working groups including behavioral phenotyping, biospecimens, electrophysiology, family and goals of care, neuroimaging, outcome and endpoints, physiology and big Data, therapies, and pediatrics. Results We report the working groups’ pediatric-focused DoC CDE recommendations and disseminate CDE to be used in studies of pediatric patients with DoC. Conclusions The CDE recommended support the vision of progressing collaborative and successful internationally collaborative pediatric coma research.