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Intimate partner violence (IPV) affects 1 in 3 women and has intensified during the COVID-19 pandemic. Although most injuries are to the head, face, and neck, leaving survivors vulnerable to sustaining traumatic brain injury (TBI), the intersection of IPV and TBI remains largely unrecognized. This article reports on COVID-19–related effects, barriers, needs, and priorities to health care and support services for women survivors of IPV-TBI. Using a participatory research model, we engaged 30 stakeholders in virtual meetings drawn from an IPV-TBI Knowledge to Practice Network in two virtual meetings. Stakeholders included women survivors, service providers, researchers, and decision makers across the IPV, TBI, and healthcare sectors. Data were gathered through small group breakout sessions facilitated by the research team using semistructured discussion guides. Sessions were recorded, transcribed verbatim, and analyzed using thematic analysis techniques. Stakeholders were given the opportunity to contribute to the analysis and knowledge transfer through member checking activities. Ethics approval was obtained through the University of Toronto. Stakeholders shared that COVID-19 has increased rates and severity of IPV and barriers to services and help-seeking. These effects have been exacerbated by infrastructure difficulties in rural and remote areas, including limited access to services. They noted the need to carefully consider implications of virtual care such as safety, privacy, and usability. Requests from survivors for peer support have increased significantly, indicating a need for more formalized and better-supported peer roles. Stakeholders further noted that an overwhelming lack of awareness of the intersection of IPV-TBI continues. Increasing education and awareness among health care and IPV service providers, survivors, and the public remains a priority. The COVID-19 pandemic has intensified IPV-TBI, increased challenges for women survivors, and accentuated the continued lack of IPV-TBI awareness. Key recommendations for health care and rehabilitation to address this priority are discussed.

ObjectivesConcussions are a major public health concern, and, thus, specific policies have been developed for implementation targeting vulnerable populations such as school-aged children and youth in the school setting, in whom the majority of concussions are sports related. Currently, concussion policies exist in various jurisdictions, including Canada’s first concussion policy for schools, Ontario’s PPM158, initiated in 2014. However, these policies are often variable in terms of content and comprehensiveness. Our objective was to develop a consensus for the content of concussion policy for schools.MethodsFollowing a pilot study in one Ontario school board in 2015, which identified missing elements in existing concussion policy, we employed a modified Delphi method to develop consensus for the content of concussion public policy for schools. We used an integrated knowledge translation approach with participation from a multidisciplinary stakeholder group of 20 experts including principals, school board directors, physicians, policymakers, public health representatives and parents.ResultsBased on the experts, we created a list of 30 policy recommendations for concussion policy in the school setting. This comprehensive list reflects the diverse perspectives of the experts and addresses the role of parents, teachers, coaches, school administrators, referees, trainers, physicians/nurse practitioners, public health and students.ConclusionsThis is the first expert consensus for content of concussion public policy for schools and can be used for policy development or enhancement in schools in other jurisdictions. We provide a comprehensive list of 30 recommendations to guide best practices for policy development and implementation to enhance school-based concussion prevention and management.

Intimate partner violence (IPV) affects up to 1 in 3 women over their lifetime and has intensified during the COVID-19 pandemic. Although most injuries are to the head, face, and neck, the intersection of IPV and brain injury (BI) remains largely unrecognized. This article reports on unexplored COVID-19-related impacts on service providers and women survivors of IPV/BI.To explore the impact of the COVID-19 pandemic on survivors and service providers.Purposeful sampling through the team's national Knowledge-to-Practice (K2P) network and snowball sampling were used to recruit 24 participants across 4 categories: survivors, executive directors/managers of organizations serving survivors, direct service providers, and employer/union representatives.This project used a qualitative, participatory approach using semistructured individual or group interviews. Interviews were conducted via videoconferencing, audio-recorded, and transcribed. Transcripts were thematically analyzed by the research team to identify themes.COVID-19 has increased rates and severity of IPV and barriers to services in terms of both provision and uptake. Three main themes emerged: (1) implications for women survivors of IPV/BI; (2) implications for service delivery and service providers supporting women survivors of IPV/BI; and (3) key priorities. Increased risk, complex challenges to mental health, and the impact on employment were discussed. Adaptability and flexibility of service delivery were identified as significant issues, and increased outreach and adaptation of technology-based services were noted as key priorities.The COVID-19 pandemic has intensified IPV/BI, increased challenges for women survivors and service providers, and accentuated the continued lack of IPV/BI awareness. Recommendations for service delivery and uptake are discussed.

The aim of this topical issue on Brain Injury (BI) and Intimate Partner Violence (IPV) is to address a long neglected gap in research, education and practice in both the IPV and BI literature. The need for practitioners, decision-policy makers and affected women to be aware of the co-occurrence of IPV and BI has only increased during the COVID-19 pandemic. BI in this issue includes traumatic brain injury and also potential hypoxic ischemic brain injuries from strangulation assaults. This novel issue includes a broad range of contributions led by authors from the US, Canada and Australia using a variety of methodologies. Topics covered improve our understanding characteristics and outcomes of non-fatal strangulation and neurobehavioral symptoms in both survivors and perpetrators. New data on neuroimaging correlates of IPV related BI is presented as well as prevalence of IPV and BI in diverse contexts. This collection also addresses the impact of IPV in both service users and providers during the COVID-19 pandemic and reports on an emergency summit from a diverse set of stakeholders from a national IPV-TBI knowledge the practice network. Further, this issue highlights the impact of a promising health advocacy intervention that offers tools that can be downloaded and provides information about a newly formed Partner Inflicted Task Force. We are optimistic that the papers in this issue will further the field and prepare the way for additional research that will expand knowledge of IPV-related BI to other understudied groups yet to be examined.

Objectives: Primary: To explore anti-Mullerian Hormone (AMH) levels in community dwelling women following TBI. Secondary: To explore the relation of AMH to menstrual cycle, cognition, distress and ...

Concussion public policies have been developed to address the burden of concussions. The aim of the present study was to examine implementation compliance, barriers, and facilitators of Canada's first concussion public policy, Ontario's Policy/Program Memorandum 158: School Board Policies on Concussion (PPM158).An electronic survey was sent to 515 randomly selected elementary and high school principals across specific geographic, language, and publicly funded school types in Ontario. Data were analyzed using both qualitative and quantitative methods.One hundred and thirty-five principals responded to the survey (26%). Concussion education was provided to teachers in 81% of schools, to students in 83%, and coaches in 79%. Additionally, 89% reported having a return-to-learn protocol in place and 90% reported having a return-to-play protocol. Implementation barriers included difficulties in providing concussion education to parents (42%), obtaining notes from physicians, and maintaining the volume of documentation. Eighty-seven percent of respondents believed that PPM158 improves student well-being.Identified implementation barriers and facilitators can inform concussion policy practices to improve student well-being. We recommend: (1) an appointed concussion policy lead at each school, (2) electronic documentation, (3) determining the optimal education format to improve parent/guardian education, (4) fostering relationships between schools and health care professionals, and (5) student concussion education in every grade in Ontario schools.

BackgroundTraumatic brain injury (TBI) is a public health concern that can occur in a range of contexts. Work-related TBI (wrTBI) is particularly concerning. Despite overall work-related injury claims decreasing, the proportion of claims that are wrTBI have increased, suggesting prevention and support of wrTBI requires ongoing attention.ObjectivesThis review aimed to provide updated information on the burden and risk factors of wrTBI among the working adult population.MethodsMedline, Embase, PsycINFO, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) were searched using a combination of TBI, work, and epidemiology text words and medical subject headings. Two reviewers independently assessed articles for inclusion. Meta-analyses were conducted to estimate prevalence and mortality of wrTBI and a narrative synthesis was conducted to provide additional context.ResultsPooled proportions meta-analyses estimate that 17.9% of TBIs were work-related and 6.3% of work-related injuries resulted in TBI, with 3.6% of wrTBI resulting in death. Populations of wrTBI were predominantly male (76.2%) and were 40.4 years of age, on average. The most commonly reported industries for wrTBI were education and training, healthcare and social assistance, construction, manufacturing, and transportation. Falls, being struck by an object or person, motor vehicle collisions, and assaults were the most commonly reported mechanisms of wrTBI.ConclusionsA better understanding of the epidemiology of wrTBI can inform prevention and management strategies. This review highlights existing gaps, including a notable lack of sex or gender stratified data, to direct future investigation.PROSPERO registration numberCRD42020169642.

Introduction Evidence of the effect of comorbid spinal cord injury (SCI) on cognitive outcome of persons undergoing rehabilitation following newly diagnosed traumatic brain injury (TBI) is limited. We conducted a population-based study to investigate this effect. Objective Cognitive outcomes in patients with TBI with and without a comorbid SCI were compared in a population-based cohort study. Setting/participants Adult patients diagnosed with TBI were identified and followed for one year through provincial health administrative data; those who entered inpatient rehabilitation were studied. Design A retrospective matched cohort study using the National Rehabilitation Reporting System data of all acute care and freestanding rehabilitation hospitals in Ontario, Canada. Main measures The exposure was a comorbid SCI in patients with diagnosed TBI. Exposed patients were matched to unexposed (TBI-only) on sex, age, injury severity, and income, in a ratio of one to two. Gain differences in the cognitive subscale of the Functional Independence Measure were compared between exposed and unexposed patients using multivariable mixed linear model, controlling for comorbidity propensity score, gains in motor function, and rehabilitation care indicators. Results Over the first year post injury, 12,750 (0.84%) of all TBI patients entered inpatient rehabilitation, of whom 1,359 (10.66%) had a comorbid SCI. A total of 1,195 exposed patients (65.4% male, mean age 50.9 ±20.6 for males and 61.8±21.8 for females) were matched to 2,390 unexposed patients. Controlling for confounding, exposed patients had lower cognitive gain (beta,-0.43; 95% CI [-0.72, -0.15]), for both males (beta -0.39; 95% CI [-0.75, -0.03]) and females (beta, -0.51; 95% CI [-0.97, -0.05]) patients. The adverse effects of comorbid SCI were driven largely by lower gains in problem solving and comprehension. Conclusions Adult patients with TBI and comorbid SCI showed a lower cognitive domain response to inpatient rehabilitation than patients with TBI alone. Identifying patients at risk for worse cognitive outcomes may facilitate development of targeted strategies that improve cognitive outcomes. Level III Retrospective Study. This article is protected by copyright. All rights reserved.

Purpose: The purpose of this study was to explore rehabilitation clinicians' understanding of how sex and gender facilitate or hinder care provided to patients with traumatic brain injury (TBI).Materials and methods: Sixteen clinicians from various specialities, attending to patients with TBI from a large rehabilitation hospital in Ontario, Canada, were recruited using purposive sampling. Data was collected through semi-structured interviews and thematic analysis was used to identify reoccurring themes.Results: Three themes that facilitate or hinder care of TBI patients were identified: (1) knowledge and evidence; (2) gender and other aspects of recovery; and (3) family caregiving. Lack of education about the topic and inconsistent scientific evidence limited clinicians' attention to sex and gender topics. Social, financial, and cultural characteristics of patients were considered to be more relevant than their sex and gender. The gendered nature of caregiving and its burden on caregivers' health were acknowledged.Conclusions: Currently, attention to topics of sex and gender as they may influence patients' recovery is limited. However, clinicians are willing to be educated on these topics to enhance rehabilitation care. Further research on the gendered nature of interactions between patient, clinician, and family caregiver during recovery is warranted.IMPLICATIONS FOR REHABILITATIONSex and gender matter for patients undergoing recovery for their traumatic brain injury; however, clinical attention to this topic is limited.Based on the clinicians' perceptions, resources that address patients' psychosocial vulnerabilities should be prioritized (e.g., unequal access to care, financial status, cultural diversity etc.).Clinicians highlighted that psychosocial vulnerability and patients' life roles, before and after injury, are sex and gender specific.Guidelines about sex and gender influences in traumatic brain injury rehabilitation have the potential to enhance clinical practice.

This scoping review mapped the current evidence about community-based physical activity (PA) interventions for individuals with moderate-to-severe traumatic brain injury (TBI) and identified the reported health-related outcomes, measurement tools used, and considerations given to sex and gender.Searches were conducted in six academic databases for peer-reviewed articles (MEDLINE, EMBASE, Cochrane CENTRAL, CINAHL, SPORTDiscus, and PEDro). PRISMA Scoping Review guidelines were followed. Two reviewers independently screened articles for inclusion and extracted data for the analysis with a modified Consensus on Exercise Reporting Template (CERT). Health-related outcomes were classified with domains of the International Classification of Function, Disability and Health (ICF).19 studies were identified. Seven PA intervention types were included. CERT scores varied (Identified PA interventions from this review revealed common characteristics that led to improved outcomes. Proposed recommendations aim to improve future research and community practice. There is a pressing need for more sex and gender considerations in PA research after moderate-to-severe TBI.

For centuries, the study of traumatic brain injury (TBI) has been centred on historical observation and analyses of personal, social, and environmental processes, which have been examined separately. Today, computation implementation and vast patient data repositories can enable a concurrent analysis of personal, social, and environmental processes, providing insight into changes in health status transitions over time. We applied computational and data visualization techniques to categorize decade-long health records of 235,003 patients with TBI in Canada, from preceding injury to the injury event itself. Our results highlighted that health status transition patterns in TBI emerged along with the projection of comorbidity where many disorders, social and environmental adversities preceding injury are reflected in external causes of injury and injury severity. The strongest associations between health status preceding TBI and health status at the injury event were between multiple body system pathology and advanced age-related brain pathology networks. The interwoven aspects of health status on a time continuum can influence post-injury trajectories and should be considered in TBI risk analysis to improve prevention, diagnosis, and care.

Traumatic brain injury (TBI) and mental health and/or substance use challenges (MHSU) are commonly co-occurring and prevalent in individuals experiencing homelessness; however, evidence suggests that systems of care are siloed and organized around clinical diagnoses. Research is needed to understand how housing and housing supports are provided to this complex and understudied group in the context of siloed service systems. This study aimed to describe critical characteristics of housing and housing supports for individuals with concurrent TBI and MHSU from the perspectives of service users with TBI and MHSU and housing service providers. Using basic qualitative description, in-depth interviews were conducted with 16 service users and 15 service providers. Data were analyzed using thematic analysis techniques. Themes capture core processes in finding and maintaining housing and the critical housing supports that enabled them: (1) overcoming structural barriers through service coordination, education and awareness raising, and partnerships and collaborations; and (2) enabling engagement in meaningful activity and social connection through creating opportunities, training and skills development, and design of home and neighborhood environments. Implications for practice, including the urgent need for formalized TBI and MHSU education, support for service providers, and potential interventions to further enable core housing processes are discussed.

Objective Non-native English speaking workers with a mild work-related traumatic brain and/or head injury are a vulnerable and underrepresented population in research studies. The researchers present their experiences with recruiting and performing qualitative interviews with non-native English speaking individuals with a work-related mild traumatic brain injury, and provide recommendations on how to better include this vulnerable population in future research studies. This paper presents considerations regarding ethics, recruitment challenges, interview preparation and debriefing, sex & gender and language and cultural issues must be made when working with this vulnerable population. Results The researchers discuss critical issues and provide recommendations in recruiting and engaging with non-native English language workers including ethics, recruitment challenges, interview preparation and debriefing, sex & gender and language, and cultural considerations that must be made when working with this population. The study recommendations advise investigators to spend more time to learn about the non-native English participants in the mild wrTBI context, to be familiar with the vulnerabilities and specific circumstances that these workers experience. By increasing their awareness of the challenging facing this vulnerable population, the intention is to provide better care and treatment options through evidence-based research and practice.

Objective: To compare components of inpatient rehabilitation (IR) for patients with traumatic brain injury (TBI) between Canada and the US facilities. Design: Secondary analysis of the TBI-practice-based evidence dataset. Participants: Patients with TBI who had a higher Functional Independence Measure (FIMTM) cognitive function score (≥21) that were admitted to 1 IR facility in Canada (n = 103) and 9 IR facilities in the US (n = 401). Main measures: demographic and clinical characteristics, type and intensity of activities by discipline, discharge location, FIM-Rasch score, social participation and quality of life. Results: Time from injury to rehabilitation admission was significantly longer in the Canadian cohort and they experienced a longer rehabilitation length of stay (p .8). Patients in Canada received a greater total time of individual therapy and lower intensity of interventions per week from all disciplines. They also showed a higher score at discharge in FIM components, while US patients had better cognitive recovery and community participation long-term post-discharge. Conclusions: This study informs stakeholders of the large variation in service provision for patients who were treated in these two countries. These findings suggest the need for robust analyzes to investigate predictors of short and long-term outcomes considering the variation in health-care delivery. List of abbreviations: TBI: traumatic brain injury, CSI: comprehensive severity index, LoS: length of stay, OT: occupational therapy, PT: physical therapy, SLP: speech language pathology, IR: inpatient rehabilitation.

This research synthesized scientific evidence on the impact of interventions for adults with traumatic spinal cord injury on cognition, to understand if current intervention approaches are appropriate in light of the risk of post-injury cognitive impairments.Medline, Central, Embase, Scopus, PsycINFO and PubMed were searched for intervention in persons with SCI assessing cognition pre- and post-intervention. Study quality was completed using the National Institutes of Health quality assessment tools. Results were grouped by type of intervention. The meta-analysis involved calculation of pooled effect sizes for interventions utilizing the same cognitive measure.Eleven studies of moderate quality discussed drug therapy, transcutaneous tibial nerve stimulation, diet modification and dietary supplements, and inpatient rehabilitation. Some aspects of cognition were negatively affected by drugs while diet modification and supplement use, and transcutaneous tibial nerve stimulation showed no evidence of a difference in cognitive scores when compared with no intervention. Inpatient rehabilitation revealed a small but beneficial effect, when results of seven studies were pooled.Evidence on the effects of interventions on cognitive functioning in patients with traumatic spinal cord injury is sparse and inconclusive, so work in this area is timely. It is valuable to know not only which interventions are effective for improving cognition, but also how other commonly used interventions, intended to treat other injury sequela, can affect cognition. PROSPERO: CRD42018087238.Implications for rehabilitationHistorically, rehabilitation of patients with traumatic spinal cord injury has targeted physical impairments, with little attention to cognition; this research aimed to understand if current interventions are appropriate in light of the risk of patients' cognitive impairments. Evidence on the effects of drug therapy, diet and dietary supplements interventions on cognitive functioning in traumatic spinal cord injury is sparse and inconclusive.Combining multiple inpatient rehabilitation interventions shows a positive but heterogeneous effect on the cognitive functioning; interventions applied earlier show greater gains.A major challenge for clinicians is to select an outcome measure sensitive to change over time, and to relate the results to patients' change in cognitive abilities with intervention applicationResearch to understand the functional effect of spinal cord injury on the widely distributed networks of the central and autonomic nervous systems subserving cognition, is timely.

Objectives To explore the patterns of cognitive and motor recovery at 4 time points from admission to 9 months after discharge from inpatient rehabilitation (IR) and to investigate the association of therapeutic factors and conditions before and after discharge with long-term outcomes. Design Secondary analysis of traumatic brain injury (TBI) and practice-based evidence dataset. Setting IR in Ontario, Canada. Participants Patients with TBI consecutively admitted for IR between 2008 and 2011 who had data available from admission to 9 months after discharge (N=85). Interventions Not applicable. Main Outcome Measure FIM-Rasch cognitive and motor scores at admission, discharge, 3 months after discharge, and 9 months after discharge. Results Cognitive and motor recovery showed similar patterns of improvement with recovery up to 3 months but no significant change from 3 to 9 months. Having fewer postdischarge health conditions was associated with better long-term cognitive scores (95% confidence interval, -13.06 to -1.2) and added 9.9% to the explanatory power of the model. More therapy time in complex occupational therapy activities (95% confidence interval, .02 to .09) and fewer postdischarge health conditions (95% confidence interval, -19.5 to -3.8) were significant predictors of better long-term motor function and added 14.3% and 7.2% to the explanatory power of the model, respectively. Conclusion Results of this study inform health care providers about the influence of the timing of IR on cognitive and motor recovery. In addition, it underlines the importance of making patients and families aware of residual health conditions following discharge from IR.

IntroductionWorkplace violence carries a substantial economic loss burden. Up to 10% of all traumatic brain injury (TBI) admissions result from physical assault. There remains a paucity of research on assault as a mechanism of injury, taking into account sex, and its association with work re-entry.ObjectivesThe aim of this study was to characterise, by sex, the sample of workers who had sustained a work-related mild TBI (wr-mTBI) and to assess the independent influence of assault, as a mechanism of injury, on time away from work.MethodsA population-based retrospective cohort of workers’ compensation claimants in Australia (n=3129) who had sustained a wr-mTBI was used for this study. A multivariable logistic regression analysis assessed whether workers who had sustained wr-mTBI as a result of assault (wr-mTBI-assault) were more likely to claim time off work compared with workers who had sustained a wr-mTBI due to other mechanisms.ResultsAmong claimants who sustained a wr-mTBI, 9% were as a result of assault. The distribution of demographic and vocational variables differed between the wr-mTBI-assault, and not due to assault, both in the full sample, and separately for men and women. After controlling for potential confounding factors, workers who sustained wr-mTBI-assault, compared with other mechanisms, were more likely to take days off work (OR 2.14, 95% CI 1.53 to 2.99) within a 3-month timeframe.ConclusionThe results have policy-related implications. Sex-specific and workplace-specific prevention strategies need to be considered and provisions to support return-to-work and well-being within this vulnerable cohort should be examined.

Background: Traumatic brain injury is a neurological disorder of biopsychosocial nature influenced by sex and gender interactions across the lifespan. Traumatic brain injury sustained during adolescence can result in cognitive and social communication impairments that compromise the development and maintenance of intimate social relationships. This can increase both short and long-term vulnerability to poor mental health, social isolation, lack of meaningful friendships, exploitation, and abuse. Females with traumatic brain injury experience greater loss of confidence and have increased risk of victimization, sexual abuse, and violence. This paper aims to provide a framework to inform gender specific rehabilitation of social communication and intimacy, to enhance positive social outcomes for girls and women with Traumatic Brain Injury.Methods: The framework is developed through presentation of a conceptual, multi-dimensional model of intimacy and discussion of current evidence regarding trauma-related cognitive/social-communication impairments and considerations regarding social media.Results: Intimacy is strongly influenced by today's technology-informed "youth culture" and for those with Traumatic Brain Injury, is impacted by cognitive and social communication impairments. Females experience different challenges in recovery and experience of intimacy. There is a need to support girls and women with Traumatic Brain Injury as they develop intimate relationships.Conclusions: This framework can guide the development of female gender-specific rehabilitation and inform future research to promote positive social outcomes.Implications for rehabilitationIntimate relationships are a critical component of mental health and an important part of human development; however, the challenges faced by adolescent girls and woman with TBI in developing and maintaining intimate relationships are often overlooked in traditional rehabilitation programs.A multi-dimensional model of intimacy will help rehabilitation professionals understand the complexities of interventions needed to support healthy intimacy, as well as for harm prevention.Rehabilitation professionals play an important role in advocating for gender-specific supports and interventions.There is a need for early interventions, grounded in today's technological and social media culture, that will support healthy intimacy for adolescent girls and women with TBI.

Background: The cervical spine region can be especially vulnerable to concurrent injury in concussion, with research suggesting that females may be at greater risk due to their weaker and anatomically distinct necks. The main objective of our research was to study sex differences in the rate of neck injury comorbidity across the life span among patients with a concussion diagnosis in the emergency department (ED) setting, by cause of injury (motor vehicle collisions [MVC] and sports). Materials and Methods: All patients with a first concussion-related ED visit between fiscal years 2002/2003 and 2011/2012 (inclusive) in Ontario were identified in population-based health administrative data using the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Canada (ICD-10-CA) codes. Age-dependent odds ratios of comorbid neck injury for sex were estimated using polynomial multivariable logistic regression models, adjusting for sociodemographic characteristics. Results: Females with a concussion had significantly higher odds of sustaining a comorbid neck injury between the ages of 5–49 years for all concussion-related ED visits, 15–49 years for MVC-related concussion ED visits, and 10–39 years for sports-related concussion ED visits, holding all other covariates in the model constant. Conclusions: These results support the consideration of increased screening for comorbid neck injuries, particularly for females, to allow for early intervention. Furthermore, the increased risk of comorbid neck injury in females with a concussion-related ED visit was age-dependent, with the interaction between sex and age following a nonlinear trend. As such, future studies on concussions should consider linear and nonlinear sex and age interactions.

Despite indications that TBI may be a precursor of cognitive decline and subsequent development of Alzheimer's disease, little is known about the time course of this relationship and the factors involved. This systematic review summarizes the evidence pertinent to this subject matter. All English language studies of longitudinal design, and works cited within them, found in six literature databases, were considered, and their quality assessed. Of 65 articles appraised, 44 studies were selected. Results were organized by timing of assessments, injury severity, and cognitive domains assessed. Differences in the course of cognitive performance were observed across injury severity groups and cognitive domains, with differential proportions of reports of improvement, decline, or no change over time. The evidence for genetic, sex-, age-, and injury-related factors as determinants of cognitive outcome was inconsistent. The non-uniform trajectory of cognitive performance post-TBI supports the notion that this construct is non-homogeneous, and that different factors influence its course. Agreement on a core set of predictors and consideration of psychometric properties of outcome measures is needed.

Traumatic brain injury (TBI), a leading cause of both death and disability worldwide, is highly prevalent among individuals who intersect with the criminal justice system. TBI is associated with increased behavioural, psychological, or negative outcomes, such as higher rates of mental health problems, aggression, and violent offending that may lead to negative interactions with the criminal justice system, reincarceration, and recidivism. Although rehabilitation is often recommended and holds promise in addressing TBI-related impairments, there is currently a paucity of reviews on rehabilitation for individuals with TBI who intersect with the criminal justice system (CJS). Concurrently, to the best of our knowledge, there is currently no review that considers rehabilitation among individuals with TBI who intersect with all parts of the CJS (i.e., policing, courts, corrections, and parole). This protocol is for a scoping review to address the above gaps, specifically, to identify the types of rehabilitation interventions and/or programs available to, or used by, individuals with TBI who intersect with all parts of the CJS. Primary research articles that meet pre-defined inclusion criteria will be identified from electronic databases (MEDLINE® ALL, Embase and Embase Classic, Cochrane CENTRAL Register of Clinical Trials, CINAHL, APA PsycINFO, Applied Social Sciences Index and Abstracts, Criminal Justice Abstracts, Nursing and Allied Health, and Dissertation and These Global), reference lists of included articles, and scoping or systematic reviews. Grey literature will also be searched to identify non-peer-reviewed reports. Retrieved articles will be screened by two reviewers and any disagreements will be resolved by a third reviewer. Data will be summarized quantitatively and analyzed using content analytic techniques. Intersecting identities will be charted and considered in the analysis. Stakeholders will be engaged to obtain feedback on preliminary results and the implications of findings. The scoping review will summarize the current state of rehabilitation available to, or used by, individuals with TBI who intersect with all parts of the CJS to (a) inform opportunities to integrate rehabilitation in the criminal justice system for diverse individuals and (b) identify opportunities for future research.

This study identified the social determinants of health (SDoH) associated with psychological distress in adults with and without a self-reported history of traumatic brain injury (TBI), stratified by sex. Data from the 2014–2017 cycles of the Centre for Addiction and Mental Health Monitor Survey, a representative survey of adults ≥18 years in Ontario, Canada, were analyzed (N = 7,214). The six-item version of the Kessler Psychological Distress Scale was used to determine moderate to severe psychological distress. Self-reported lifetime TBI was defined as a head injury resulting in a loss of consciousness for ≥5 minutes or at least one-night stay in the hospital (16.4%). Among individuals reporting a history of TBI, 30.2% of males and 40.1% of females reported psychological distress (p = 0.0109). Among individuals who did not report a history of TBI, 17.9% of males and 23.5% of females reported psychological distress (p

IntroductionReturning to work and sustaining employment can be a significant challenge for traumatic brain injury (TBI) survivors. Within the literature, there is recurring support for the role of workplace accommodations in effective and early return-to-work (RTW). To date, however, there has been a lack of systematic reviews exploring the specific role of workplace accommodations within the context of RTW after TBI. The primary objective of this protocol is to outline the methodological approach that will be undertaken to systematically review the literature and to assess the effectiveness of workplace accommodations in facilitating RTW.Methods and analysisA total of nine databases will be searched systematically using the concepts ‘Brain injury,’ ‘RTW’ and ‘Job Accommodations.’ Study selection will be performed independently by three reviewers, based on predetermined eligibility criteria through two rounds of screening using, first, the title and abstract, followed by a full-text search. Extracted information will include the study’s purpose, design, and setting; the data source and type; the severity of TBI and the diagnostic criterion used; a comprehensive description of the intervention provided; the RTW outcome variables and the statistical methods used, etc. The data will be tabulated and narratively synthesised. Systematic review registration: This protocol has been registered with International Prospective Register of Systematic Reviews.Ethics and disseminationAs this review intends to use pre-existing published studies hence research ethics board approvals will not be required. Nevertheless, this review will follow the ethical and governance standards in the data management and presentation of results. The findings from this review will potentially be published in a peer-reviewed scientific journal (electronically and in print). The results of this review will be presented at both national/international conferences and shared with stakeholders influencing RTW practices.PROSPERO registration numberCRD42016043517.

Traumatic brain injuries (TBI) and mental health or substance use disorders (MHSU) are global public health concerns due to their prevalence and impact on individuals and societies. However, care for individuals with TBI and MHSU remains fragmented with a lack of appropriate services and supports across the continuum of healthcare. This systematic review provided an evidence-based foundation to inform opportunities to mobilize and adapt existing resources to integrate care for individuals with TBI and MHSU by comprehensively summarizing existing integrated activities and reported barriers and facilitators to care integration. MEDLINE, EMBASE, PsycINFO, CINAHL, Cochrane Central Register of Controlled Trials, Sociological Abstracts, and Dissertations & Theses Global were independently reviewed by two reviewers based on pre-determined eligibility criteria. Data on the integration activity, level and type of integration, reported barriers and facilitators, and the strategies aligning with the World Health Organization’s (WHO) Framework on Integrated Person-Centred Care were extracted to form the basis for a narrative synthesis. Fifty-nine peer-reviewed articles were included, describing treatments (N = 49), programs (N = 4), or screening activities (N = 7). Studies discussing clinical integration at the micro- (N = 38) and meso- (N = 10) levels, service integration at the micro- (N = 6) and meso- (N = 5) levels, and functional integration at the meso-level (N = 1) were identified. A minority of articles reported on facilitators (e.g., cognitive accommodations in treatment plans; N = 7), barriers (e.g., lack of education on cognitive challenges associated with TBI; N = 2), or both (N = 6), related to integrating care. This review demonstrated that integrated TBI and MHSU care already exists across a range of levels and types. Given the finite and competing demands for healthcare resources, cognitive accommodations across treatment plans to facilitate integrated TBI and MHSU care should be considered. Multidisciplinary teams should also be explored to provide opportunities for education among health professionals so they can be familiar with TBI and MHSU.Trial registration:Prospero Registration:CRD42018108343.

INTRODUCTION Comorbidities in people with traumatic brain injury (TBI) may negatively impact injury recovery course and result in long-term disability. Despite the high prevalence of several categories of comorbidities in TBI, little is known about their association with patients' functional outcomes. We aimed to systematically review the current evidence to identify comorbidities that affect functional outcomes in adults with TBI. EVIDENCE ACQUISITION A systematic search of Medline, Cochrane Central Register of Controlled Trials, Embase and PsycINFO was conducted from 1997 to 2020 for prospective and retrospective longitudinal studies published in English. Three researchers independently screened and assessed articles for fulfillment of the inclusion criteria. Quality assessment followed the Quality in Prognosis Studies tool and the Scottish Intercollegiate Guidelines Network methodology recommendations. EVIDENCE SYNTHESIS Twenty-two studies of moderate quality discussed effects of comorbidities on functional outcomes of patients with TBI. Cognitive and physical functioning were negatively affected by comorbidities, although the strength of association, even within the same categories of comorbidity and functional outcome, differed from study to study. Severity of TBI, sex/gender, and age were important factors in the relationship. Due to methodological heterogeneity between studies, meta-analyses were not performed. CONCLUSIONS Emerging evidence highlights the adverse effect of comorbidities on functional outcome in patients with TBI, so clinical attention to this topic is timely. Future research on the topic should emphasize time of comorbidity onset in relation to the TBI event, to support prevention, treatment, and rehabilitation. PROSPERO registration (CRD 42017070033).

In this report, we identify existing issues and challenges related to research on traumatic brain injury (TBI) in females and provide future directions for research. In 2017, the National Institutes of Health, in partnership with the Center for Neuroscience and Regenerative Medicine and the Defense and Veterans Brain Injury Center, hosted a workshop that focused on the unique challenges facing researchers, clinicians, patients, and other stakeholders regarding TBI in women. The goal of this "Understanding TBI in Women" workshop was to bring together researchers and clinicians to identify knowledge gaps, best practices, and target populations in research on females and/or sex differences within the field of TBI. The workshop, and the current literature, clearly highlighted that females have been underrepresented in TBI studies and clinical trials and have often been excluded (or ovariectomized) in preclinical studies. Such an absence in research on females has led to an incomplete, and perhaps inaccurate, understanding of TBI in females. The presentations and discussions centered on the existing knowledge regarding sex differences in TBI research and how these differences could be incorporated in preclinical and clinical efforts going forward. Now, a little over 2 years later, we summarize the issues and state of the science that emerged from the "Understanding TBI in Women" workshop while incorporating updates where they exist. Overall, despite some progress, there remains an abundance of research focused on males and relatively little explicitly on females.

BACKGROUND: Recent studies have started disentangling components of disturbed sleep as part of the post-concussive syndrome, but little is known about the workers with an injury’ perspectives on post-injury sleep changes or what causes these changes. OBJECTIVES: To determine the effects of work-related concussion/mild traumatic brain injury (wr-mTBI) on perceptions of refreshing sleep in workers with an injury and to identify the relevant factors responsible for sleep changes. METHODS: We studied post-concussive changes in sleep in 66 adults (50% male workers, 42% aged 30–50 years, median post-injury days: 155) who had sustained wr-mTBI and experienced functional limitations long after the injury. We collected sociodemographic, occupational and health status data and identified variables related to post-concussive changes in refreshing sleep. RESULTS: Forty-seven workers with wr-mTBI (79% of male workers, 64% of female workers) perceived their sleep as being refreshing before injury and unrefreshing afterwards (χ2 = 67.70 for change, χ2 = 27.6 for female and χ2 = 41.1 for male workers, p

Concussions are associated with a range of cognitive, neuropsychological and behavioral sequelae that, at times, persist beyond typical recovery times and are referred to as postconcussion syndrome (PCS). There is growing support that concussion can disrupt network-based connectivity post-injury. To date, a significant knowledge gap remains regarding the sex-specific impact of concussion on resting state functional connectivity (rs-FC). The aims of this study were to (1) investigate the injury-based rs-FC differences across three large-scale neural networks and (2) explore the sex-specific impact of injury on network-based connectivity. MRI data was collected from a sample of 80 concussed participants who fulfilled the criteria for postconcussion syndrome and 31 control participants who did not have any history of concussion. Connectivity maps between network nodes and brain regions were used to assess connectivity using the Functional Connectivity (CONN) toolbox. Network based statistics showed that concussed participants were significantly different from healthy controls across both salience and fronto-parietal network nodes. More specifically, distinct subnetwork components were identified in the concussed sample, with hyperconnected frontal nodes and hypoconnected posterior nodes across both the salience and fronto-parietal networks, when compared to the healthy controls. Node-to-region analyses showed sex-specific differences across association cortices, however, driven by distinct networks. Sex-specific network-based alterations in rs-FC post concussion need to be examined to better understand the underlying mechanisms and associations to clinical outcomes.

Research shows that gender influences men's health-related beliefs and behaviours - including those within the context of traumatic brain injury (TBI) - making it a factor that should be considered when designing and implementing interventions for this population. To incorporate an understanding of such gendered influences in future educational materials for men with TBI, as well as their caregivers and clinicians, this qualitative study was informed by social constructionism, and aimed to explore how gender is related to men's post-TBI perceptions and behaviours in rehabilitation and recovery. Semi-structured interviews were conducted with 22 men with mild and moderate-severe TBI at the acute (≤ 3 months post-TBI) and chronic (> 3 months post-TBI) phases of injury. A reflexive thematic analysis approach was applied to interview data, guided by the concept of hegemonic masculinity as described by Connell, R.W. (2005. Masculinities [2nd ed.]. Polity). Three key themes were identified: (1) "I'm a man, I'm a rock": Undermining treatment, (2) "I'm going to face that challenge": Facilitation of recovery, and (3) "I don't feel as useful as a guy as I was before": Perceptions on return to work. These findings may be translated into gender-informed therapy strategies and materials.

Sex and gender considerations are understood as essential components of knowledge translation in the design, implementation and reporting of interventions. Integrating sex and gender ensures more relevant evidence for translating into the real world. Canada offers specific funding opportunities for knowledge translation projects that integrate sex and gender. This Commentary reflects on the challenges and solutions for integrating sex and gender encountered in six funded knowledge translation projects. In 2018, six research teams funded by the Canadian Institutes of Health Research’s Institute of Gender and Health met in Ottawa to discuss these challenges and solutions. Eighteen participants, including researchers, healthcare professionals, trainees and members of the Institute of Gender and Health, were divided into two groups. Two authors conducted qualitative coding and thematic analysis of the material discussed. Six themes emerged, namely Consensus building, Guidance, Design and outcomes effectiveness, Searches and recruitment, Data access and collection, and Intersection with other determinants of health. Solutions included educating stakeholders on the use of sex and gender concepts, triangulating perspectives of researchers and end-users, and participating in organisations and committees to influence policies and practices. Unresolved challenges included difficulty integrating sex and gender considerations with principles of patient-oriented research, a lack of validated measurement tools for gender, and a paucity of experts in intersectionality. We discuss our findings in the light of observations of similar initiatives elsewhere to inform the further progress of integrating sex and gender into the knowledge translation of health services research findings.

Background Current understandings of the etiology of traumatic brain injury (TBI) and the trajectory of care significantly lack consideration for the inclusion of Black populations. The global prevalence of TBI is increasing, particularly in North America and Europe where approximately 65 million people are affected every year. Although community integration is an ultimate goal of rehabilitation post injury, persons with TBI, particularly Black populations continually face challenges with regards to unmet needs along the continuum of care including meaningful participation and vocation, resulting in occupational deprivation. While integrated care is seen as an appealing approach to service delivery, little is known about what this means for Black people with TBI. This protocol produces the first critical transdisciplinary (CTD) scoping review mapping the extent, range, and nature of integrated care pathways for Black people experiencing TBI. Methods CTD provides an analytical tool with a health equity lens that will be applied as both a methodology and theory for undertaking this review. Under the methodological guidance of Arksey and O’Malley, CTD will be used to map the literature and better understand the elements of integrated care pathways for Black people experiencing TBI. To identify the published literature, several databases will be searched including MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, CINAHL, PsycINFO, and Sociological Abstracts. Discussion The application of CTD compels health-care providers, administrators, clinician-scientists, rehabilitation specialists, and scholars in the field of TBI and integrated care to re-examine hidden assumptions about racism, racialization, and Blackness that are often embedded in current visions of health for all. The health equity lens of CTD asks about who is accounted for in the research and clinical literature and who is absented. It is anticipated that applying the health equity lens of CTD will provide a critical examination of the literature and illuminate significant implications for integrated care for Black persons experiencing TBI. Systematic review registration Not applicable.

Objective To identify determinants of discharge disposition from acute care among survivors of hypoxic-ischemic brain injury (HIBI), stratified by sex. Design Population-based retrospective cohort study using provincial data in Ontario, Canada. The determinants were grouped into predisposing, need, and enabling factors using the Anderson Behavioral Model. Setting Acute care. Participants Survivors of HIBI aged ≥20 years at the time of hospitalization and discharged alive from acute care between April 1, 2002, and March 31, 2017. There were 7492 patients with HIBI, of whom 28% (N=2077) survived their acute care episode. Interventions Not applicable. Main Outcome Measures Discharge disposition from acute care, categorized as complex continuing care (CCC), long-term care (LTC), inpatient rehabilitation (IR), home with support, home without support, and transferred to another acute care. Results The discharge dispositions for the 2077 survivors were IR 23.4% (n=487), CCC 19.5% (n=404), LTC 6.2% (n=128), home without support 31.2% (n=647), home with support 15.1% (n=314), and other 4.6%. Multinomial multivariable logistic regression analysis using home without support as the reference category revealed that female patients were significantly more likely than male patients to be discharged to LTC/CCC. Those who were older, were frail, and had longer stay in acute care or special care unit (SCU) were more likely to be discharged to LTC/CCC. The only significant determinant for IR was longer stay in acute care. Survivors with cardiac-related injury were less likely to be discharged to LTC/CCC. Income was a significant factor for male patients but not for female patients in the sex-stratified analysis. The following variables were investigated but were not significant determinants in this study: need factors (comorbidity score, prior psychiatric disorders, health care utilization) and enabling factors (income quintile, rural area of residence). Conclusions Predisposing (age, sex) and need factors (frailty, acute care days, SCU days, type of injury) were significant determinants of discharge disposition from acute care after HIBI. In spite of a system with universal coverage, sex differences were found, with more female patients being discharged to CCC/LTC rather than IR, controlling for age and other confounders. These findings should be considered in appropriate discharge planning from acute care for survivors of HIBI.

Traumatic Brain Injury (TBI) is a serious hidden health issue disproportionately affecting people who experience incarceration.We examined the association between TBI and serious disciplinary charges among men and women sentenced by the courts to terms of two or more years.The study originated in Ontario, Canada and used linked administrative health and correctional data. The cohort included adults experiencing their first federal sentence between 1998 and 2011 (N = 12,038). We examined disciplinary charges incurred 2 years post-sentence commencement. TBI was defined using the International Classification of Diseases (ICD-9 and ICD-10) diagnostic codes. Robust Poisson regression was conducted to assess the association between TBI and disciplinary charges.The prevalence of TBI for the full sample was 13.2%. One-third of adults with a recent TBI had a serious disciplinary charge. The unadjusted risk of incurring a serious charge for those with a history of TBI was 39% higher than those with no history of TBI (CI: 1.29-1.49). The adjusted risk was 1.14 (CI: 1.06-1.22).TBI is a serious health concern that makes it difficult for incarcerants to adjust to prison. Additional support/resources are needed to support those with histories of TBI.

ObjectivesMuch is known about the demands of caregiving for persons with dementia (PWD) and its effects on family caregivers, however sex and gender aspects have received less attention. We synthesized the evidence on sex and gender distinctions in: (1) the caregiving burden and (2) the impact of caregiving on the physical and mental health of family caregivers of PWD.DesignSystematic review.Data sourcesMedline, Embase, PsycINFO and Cumulative Index to Nursing and Allied Health Literature between January 2007 and October 2019 were searched.Eligibility criteria for selecting studiesIncluded studies met the following criteria: (1) examine experiences and/or impacts of caregiving among family caregivers of individuals with any form of dementia; (2) report sex and/or gender distribution of study population and/or report results stratified by sex and/or gender, and (3) include both male and female family caregivers.Data extraction and synthesisTwo independent reviewers extracted the data and assessed risk of bias using the Critical Appraisal Skills Program checklist and National Institutes of Health Quality Assessment Tool for Observational Cohort and Cross-sectional Studies. Data were synthesized using a narrative synthesis approach.ResultsA total of 22 studies were included. Caregiving burden was measured using various methods. A majority of studies reported higher burden among females. All studies that did not report a sex and gender difference in caregiving burden accounted for confounders. Findings on sex and gender differences on physical and mental health conditions were inconsistent with most studies failing to account for confounders in their analyses.ConclusionsCurrent evidence on sex and gender differences in caregiving burden, mental and physical health is limited. Findings suggest presence of sex and gender differences in caregiving burden. Given the variety of mental and physical health constructs that were examined, further research is required to substantiate the evidence. PROPSERO Registration Number: CRD 42018070032.

Background: Individuals who have experienced a work-related mild traumatic brain injury face a variety of challenges when returning to work. Research has demonstrated that the implementation of wor...

IntroductionRehabilitation is key to improving outcomes and quality of life after traumatic brain injury (TBI). However, individuals experiencing homelessness are rarely represented in research that informs evidence-based rehabilitation guidelines even though TBI is disproportionately prevalent among this population. This protocol is for a scoping review to explore the extent to which rehabilitation, including the types of rehabilitation interventions, is available to, or used by, individuals who experience homelessness and TBI to inform (1) opportunities to integrate rehabilitation for individuals experiencing homelessness and TBI, (2) considerations for existing clinical and practice guidelines for rehabilitation and (3) recommendations for future research.Methods and analysisThe scoping review will be guided by six stages described in scoping review methodology frameworks. Electronic databases (MEDLINE, Embase and Embase Classic, Cochrane CENTRAL Register of Clinical Trials, CINAHL, APA PsycINFO, Applied Social Sciences Index and Abstracts, and Nursing and Allied Health), reference list of included articles and scoping or systematic reviews identified from the search and grey literature, defined as reports from relevant brain injury, housing and rehabilitation organisations, will be searched. Two reviewers will independently screen all articles based on predetermined inclusion and exclusion criteria. A descriptive numerical summary of data items will be provided and qualitative content analytic techniques will be used to identify and report common themes. Preliminary findings will be shared with stakeholders to seek feedback on the implications of the results.Ethics and disseminationEthics review will not be required, as only publicly available data will be analysed. Findings from the scoping review will be published in a peer-reviewed journal and presented at scientific meetings and to stakeholders, defined as service providers in the housing and TBI sectors; health professionals who provide care for individuals with TBI and/or homelessness; health administrators, decision-makers and policy-makers; researchers; and caregivers or family members of individuals with lived experience of TBI and homelessness.

Objective and background Sleep stage disruption in persons with mild traumatic brain injury (mTBI) has received little research attention. We examined deviations in sleep stage distribution in persons with mTBI relative to population age- and sex-specific normative data and the relationships between such deviations and brain injury-related, medical/psychiatric, and extrinsic factors. Patients and methods We conducted a cross-sectional polysomnographic investigation in 40 participants diagnosed with mTBI (mean age 47.54 ± 11.30 years; 56% males). Measurements At the time of investigation, participants underwent comprehensive clinical and neuroimaging examinations and one full-night polysomnographic study. We used the 2012 American Academy of Sleep Medicine recommendations for recording, scoring, and summarizing sleep stages. We compared participants' sleep stage data with normative data stratified by age and sex to yield z -scores for deviations from available population norms and then employed stepwise multiple regression analyses to determine the factors associated with the identified significant deviations. Results In patients with mTBI, the mean duration of nocturnal wakefulness was higher and consolidated sleep stage N2 and REM were lower than normal ( p p = 0.018, and p = 0.010, respectively). In multivariate regression analysis, several covariates accounted for the variance in the relative changes in sleep stage duration. No sex differences were observed in the mean proportion of non-REM or REM sleep. Conclusions We observed longer relative nocturnal wakefulness and shorter relative N2 and REM sleep in patients with mTBI, and these outcomes were associated with potentially modifiable variables. Addressing disruptions in sleep architecture in patients with mTBI could improve their health status.

This paper presents highlights from a program of research addressing sex and gender among persons with traumatic brain injury (TBI) relevant to the Canadian context. Epidemiological trends based on health administrative data are examined, and their implications for policy and practice are considered. Further, the authors discuss the need to proactively address TBI in marginalized populations and in the workplace, two areas that have not received widespread attention.

An increasing number of patients are able to survive traumatic brain injuries (TBIs) with advanced resuscitation. However, the role of their pre-injury health status in mortality in the following years is not known. Here, we followed 77,088 consecutive patients (59% male) who survived the TBI event in Ontario, Canada for more than a decade, and examined the relationships between their pre-injury health status and mortality rates in excess to the expected mortality calculated using sex- and age-specific life tables. There were 5792 deaths over the studied period, 3163 (6.95%) deaths in male and 2629 (8.33%) in female patients. The average excess mortality rate over the follow-up period of 14 years was 1.81 (95% confidence interval = 1.76–1.86). Analyses of follow-up time windows showed different patterns for the average excess rate of mortality following TBI, with the greatest rates observed in year one after injury. Among identified pre-injury comorbidity factors, 33 were associated with excess mortality rates. These rates were comparable between sexes. Additional analyses in the validation dataset confirmed that these findings were unlikely a result of TBI misclassification or unmeasured confounding. Thus, detection and subsequent management of pre-injury health status should be an integral component of any strategy to reduce excess mortality in TBI patients. The complexity of pre-injury comorbidity calls for integration of multidisciplinary health services to meet TBI patients' needs and prevent adverse outcomes.

Aim: This research aimed to gain an understanding of biological sex and social gender phenomena experienced by patients with traumatic brain injury in recovery, and to understand the educational needs of this group.Methods: We conducted semi-structured interviews of 40 adult patients (22 men, 18 women) of different ages, education levels, and ethnicities, with diagnoses of mild and moderate-severe traumatic brain injury at the acute and chronic stages post-injury.Results: Applying classic content analysis with inductive coding, three overarching themes that limited patients' knowledge and subsequent efforts to obtain information on the topic emerged: (1) the complexity of sex and gender subject matters, (2) patients' dependence on others, and (3) uncertainty about the course of recovery. The first diminished the patient's desire to seek further information. Dependence on others and trust that others were in a better position to use the information, compelled patients to redirect the need for education to clinicians, significant others, and the public on the unique post-injury experiences of men and women. Uncertainty about what to expect in the acute phases, and a feeling of identity loss in the chronic phases, established patients' desire to seek out only the information they believed to be necessary for them to carry on with life.Conclusions: In developing recommendations for patient education, variations in patients' knowledge and desire for information, and the reasons behind these variations, should be considered. Improving injury prognosis requires taking into account the gendered context of injury and recovery from it.IMPLICATIONS FOR REHABILITATIONSex/gender issues in traumatic brain injury are complex; the challenge is identifying which information is most relevant for patients; this research assessed patients' knowledge of and interest in sex/gender-related topics in traumatic brain injury.Evidence shows most patients unable to differentiate between sex and gender, but when asked about living as a man or woman with traumatic brain injury, disturbed gender roles and identities became evident.Gender shapes the health status trajectory and outcomes of patients with traumatic brain injury which becomes evident when attention is paid to patients' personal life stories.To improve traumatic brain injury prognosis, clinicians should tailor management plans taking into account gender, an amalgamation of biological, behavioural, cultural, and social characteristics of their patients.In research, explicit and consistent consideration of the interrelated constructs of sex and gender would produce a better understanding of the different mechanisms that shape the course of traumatic brain injury.

ObjectivesComorbidity in traumatic brain injury (TBI) has been recognised to alter the clinical course of patients and influence short-term and long-term outcomes. We synthesised the evidence on the effects of different comorbid conditions on early and late mortality post-TBI in order to (1) examine the relationship between comorbid condition(s) and all-cause mortality in TBI and (2) determine the influence of sociodemographic and clinical characteristics of patients with a TBI at baseline on all-cause mortality.DesignSystematic review.Data sourcesMedline, Central, Embase, PsycINFO and bibliographies of identified articles were searched from May 1997 to January 2019.Eligibility criteria for selecting studiesIncluded studies met the following criteria: (1) focused on comorbidity as it related to our outcome of interest in adults (ie, ≥18 years of age) diagnosed with a TBI; (2) comorbidity was detected by any means excluding self-report; (3) reported the proportion of participants without comorbidity and (4) followed participants for any period of time.Data extraction and synthesisTwo independent reviewers extracted the data and assessed risk of bias using the Quality in Prognosis Studies tool. Data were synthesised through tabulation and qualitative description.ResultsA total of 27 cohort studies were included. Among the wide range of individual comorbid conditions studied, only low blood pressure was a consistent predictors of post-TBI mortality. Other consistent predictors were traditional sociodemographic risk factors. Higher comorbidity scale, scores and the number of comorbid conditions were not consistently associated with post-TBI mortality.ConclusionsGiven the high number of comorbid conditions that were examined by the single studies, research is required to further substantiate the evidence and address conflicting findings. Finally, an enhanced set of comorbidity measures that are suited for the TBI population will allow for better risk stratification to guide TBI management and treatment.PROSPERO registration numberCRD42017070033

Objectives To understand how health status preceding traumatic brain injury (TBI) affects relative functional gain after inpatient rehabilitation using a data mining approach. Design Population-based, sex-stratified, retrospective cohort study using health administrative data from Ontario, Canada (39% of the Canadian population). Setting Inpatient rehabilitation. Participants Patients 14 years or older (N=5802; 63.4% male) admitted to inpatient rehabilitation within 1 year of a TBI-related acute care discharge between April 1, 2008, and March 31, 2015. Interventions Not applicable. Main Outcome Measures Relative functional gain (RFG) in percentage, calculated as ([discharge FIM−admission FIM]/[126−admission FIM]×100). Health status prior to TBI was identified and internally validated using a data mining approach that categorized all International Classification of Diseases, 10th revision, codes for each patient. Results The average RFG was 52.8%±27.6% among male patients and 51.6%±27.1% among female patients. Sex-specific Bonferroni adjusted multivariable linear regressions identified 10 factors of preinjury health status related to neurology, emergency medicine, cardiology, psychiatry, geriatrics, and gastroenterology that were significantly associated with reduced RFG in FIM for male patients. Only 1 preinjury health status category, geriatrics, was significantly associated with RFG in female patients. Conclusions Comorbid health conditions present up to 5 years preceding the TBI event were significantly associated with RFG. These findings should be considered when planning and executing interventions to maximize functional gain and to support an interdisciplinary approach. Best practices guidelines and clinical interventions for older male and female patients with TBI should be developed given the increasingly aging population with TBI.

Objectives: The objective of this scoping review is to examine the extent, range, and nature of literature targeting health-care professionals on the prevalence and outcome of intimate partner violence (IPV)-related traumatic brain injury (TBI). The purpose is to gain an understanding of prevalence, investigate screening tool use, generate IPV/TBI-specific support recommendations, and identify suggestions for future research. Method: The review was guided by Arksey and O’Malley’s five stages for conducting a scoping review. A comprehensive search of nine databases revealed 1,739 articles. In total, 42 published research papers that focused specifically on TBI secondary to IPV were included in the study. Synthesis: The literature reports inconsistencies in prevalence rates from IPV-related TBI. There are no current standardized screening practices in use, though the literature calls for a specialized tool. Frontline professionals would benefit from education on signs and symptoms of IPV-related TBI. Empirical studies are needed to generate reliable data on prevalence, experience, and needs of brain-injured survivors of TBI. Conclusions: Findings from this study demonstrate the need for the development of an IPV-sensitive screening tool, more accurate data on prevalence, an interprofessional approach to care, and raised awareness and education on the diffuse symptoms of IPV-related TBI.

OBJECTIVES: Assault by strangulation has the potential for severe brain injury or death. The objectives of this study were to describe the profile of individuals who had strangulation-related emergency department (ED) or acute care visits, and to explore 1-year readmission outcomes among survivors. METHODS: A population-based retrospective cohort study was conducted using health administrative data in Ontario, Canada. Adults aged 15 years and older who were seen in the ED or acute care with assault by strangulation between fiscal years 2002/2003 and 2016/2017 were included in the study. Bivariate analyses were conducted to compare the patient profile and subsequent readmissions within 1 year of discharge, stratified by sex. RESULTS: A total of 586 patients were included in the study. The majority of these patients were seen in the ED (93%), predominantly female (70%), aged ≤ 39 years (68%), and of lower income quintiles of ≤ 3 (73%). Of the 579 patients who survived the initial admission, 52% had subsequent ED readmission and 21% had acute care readmission within 1 year. In sex-stratified analyses, a higher proportion of females were between 20 to 39 years (58.7% vs. 44.1%, p = 0.001), discharged home (88% vs. 81%, p

Background: Traumatic brain injury (TBI) as a result of intimate partner violence (IPV) is a significant health concern; yet, little is known about the intersection between the two. Existing research is scarce, limiting the ability of health care providers to develop effective supports. This pilot project surveyed the IPV support community in Toronto, Canada to understand the degree of existing TBI-specific knowledge and relevant services available among these service providers and to seek to bridge the divide between research and practice by developing a national knowledge-to-practice network to support brain-injured women survivors of IPV. Materials and Methods: In phase 1, 68 agencies providing IPV support services were invited to complete an anonymous online survey. In phase 2, 22 stakeholders attended a workshop held to disseminate existing knowledge, develop a national knowledge-to-practice network, and determine next steps in research and practice. Results: The results highlighted a general lack of TBI awareness and understanding among IPV service providers. In addition, participants stated that frontline workers and women survivors of IPV alike do not recognize signs or symptoms of TBI. Recommendations addressing research gaps, professional and public education, and service development were identified and are discussed herein. Conclusions: The identified lack of TBI knowledge among IPV service providers highlights the immediate need to increase education among management and frontline workers. Further investigation identifying best practices for knowledge transfer are suggested. The development of a national strategy addressing education, research, and funding is critical for successful uptake and integration of TBI-sensitive services within the IPV sector.

IntroductionThe initiation and translation of sex-sensitive and gender-sensitive research programmes into clinically useful considerations for patients with traumatic brain injury (TBI) have been difficult. Clinical frameworks are currently not specific according to sex and gender, despite evidence that these constructs influence the incidence, course and outcome of patients with TBI. The present protocol outlines a strategy for a research programme, supported by the Canadian Institutes of Health Research (CIHR) Institute of Gender and Health, which explores sex and gender topics in the context of TBI, with the goal of building an infrastructure to facilitate the implementation of sex/gender-sensitive research findings into clinical considerations.Methods and analysisA comprehensive multistep research programme is proposed to support three research objectives: (1) documentation of important concepts and ideas for education on topics of sex and gender in the TBI context using a knowledge-user feedback framework, current scientific evidence and the research team’s expertise; (2) development of educational materials for patients with TBI, significant others and clinicians providing care that account for sex/gender and (3) testing the application of these educational materials for feasibility and effectiveness. This programme supports the CIHR Institute’s mission by facilitating partnership with knowledge users across clinical, research, academic and community sectors, through a range of platforms and activities.Ethics and disseminationThe Research Ethics Board of the University Health Network has approved the programme. It is anticipated that this work will add significant value to the advancement of the field of sex, gender and health by serving as a model to foster the integration of these constructs across the spectrum of disorders. This will transform clinical practices and ensure that generated knowledge is translated into improved training programmes, policies and health services that are responsive to the diverse needs of men and women with TBI.PROSPERO registration numberCRD42018098697

BACKGROUND: Electrical injuries are a common cause of work-related injury in male dominated skilled trades. OBJECTIVES: In this study we explored how issues of gender, masculinities and institutional workplace practices shape expectations of men and their choices when returning to work following a workplace electrical injury. METHODS: Twelve workers, who suffered an electrical injury, and twelve employer representatives, completed semi-structured interviews. Using thematic analysis we identified key themes related to how masculinities influenced men's health and safety during the return to work process. RESULTS: Strong identification with worker roles can influence injured workers decisions to return to work 'too early'. A desire to be viewed as a strong, responsible, resilient worker may intersect with concerns about job loss, to influence participants' decisions to not report safety issues and workplace accidents, to not disclose post-injury work challenges, and to not request workplace supports. Institutionalized workplace beliefs regarding risk, de-legitimization of the severity of injuries, and the valorization of the "tough" worker can further re-enforce dominant masculine norms and influence return to work processes and health and safety practices. CONCLUSIONS: Workplaces are key sites where gender identities are constructed, affirmed and institutionalized. Further research is warranted to examine how established masculine norms and gendered workplace expectations can influence workplace health and safety in male dominated high risk occupations. Future research should also evaluate strategies that encourage men to discuss post-injury work challenges and request supports when work performance or health and safety issues arise during the return to work process. Language: en

OBJECTIVES: To examine the etiology, prevalence and severity of physical violence- precipitated work-related traumatic brain injury (wrTBI) in Ontario, Canada. METHODS: Cross-sectional study using data abstracted from the Ontario Workplace Safety and Insurance Board (WSIB) claims files in 2004. Descriptive analyses were conducted to determine the distribution of worker/employment/incident characteristics. RESULTS: Workplace physical violence that resulted in a TBI accounted for 6.6% percent of all TBI injury claims. Female workers, primarily in the health care/social services sector, accounted for over half of all TBIs. Most workers were assaulted by consumers/clients. Forty five percent of injuries occurred among workers with less than 3 years of employment. CONCLUSIONS: This paper identifies profiles of workers and workplaces for targeted preventive efforts. Future studies are needed to further address risk factors by sex and outcomes, such as length of disability and health care cost. Language: en

Symptoms that persist subsequent to a work-related traumatic brain injury (wrTBI) influence the ability to return to work (RTW) and indicate areas of functional disability, as classified in the International Classification of Functioning, Disability and Health (ICF) framework.The purpose of this study was to describe the relationship between RTW status and ICF framework domains in men and women with a wrTBI.A retrospective chart review of 209 consecutive workers with TBI (mild TBI: 71.8%; mean age: 40.2 ± 11.1, men: 71.3%) was conducted. Workers were assessed during the chronic post-injury phase, at the neurology service of a large rehabilitation hospital in Ontario, Canada in 2003. Frequency distributions were calculated and chi-square tests performed.At the point of assessment, 78.0% of workers were in receipt of disability benefits, while the remainder had returned to work on a full- or part-time basis. Significant differences were observed in the Body Functions and Structures domain of the ICF model, specifically clinical diagnoses of depression, anxiety, pain disorders; self-perceived cognitive disturbance, and certain psychosocial factors (p 0.05), between workers who had returned to work and those who had not. When stratified according to sex, these associations remained significant only in men.The factors outlined above should be subject to further TBI research, as indicators for RTW. The lack of significant findings in women warrants further exploration of variables within the physical and social environmental domains of the ICF.

ObjectiveTo understand how pre-injury health status present five-years preceding traumatic brain injury (TBI) affects direct medical cost two years post-injury.MethodsPatients age ≥19 years in the emergency department (ED) or acute care for a TBI between April 1, 2007 and March 31, 2014 in Ontario, Canada (N = 55,669) were identified from population-based health administrative data. Forty-three factors of pre-injury health status (i.e., comorbidities and personal, social, and environmental factors) that were internally validated for the TBI population were assessed in this study. The outcome of interest was direct medical cost within two years of discharge. Sex-specific multivariable linear regressions were conducted to understand the associations between direct medical cost within two years of discharge and pre-injury health status.ResultsPatients who received care in the ED (81.9% of total sample) incurred a median cost of $2,492/male patient (average $12,342/patient) and $3,508/female patient (average $65,285/patient) within two years of injury; 37 pre-injury factors were significantly associated with increased direct medical costs. Patients who first received care for their TBI in acute care (18.1%) incurred a median cost of $25,081/male patient (average $63,060/patient) and $30,277/female patient (average $65,285/patient) within two years of injury; 21 factors were significantly associated with increased direct medical costs. Among more prevalent factors, those associated with increased medical cost by at least 50% included mental health disorders, substance abuse, disorders or medical conditions frequently observed among the elderly, cardiovascular disorders, stroke and emergencies involving the brain, metabolic disorders and abdominal symptoms, conditions and symptoms of abdomen and pelvis, genitourinary disorders and disorders of prostate, and pulmonary abdominal and other emergencies.ConclusionsDirect medical costs two years post-TBI differed significantly between patients with and without adverse pre-existing health status. Interdisciplinary teams to promote early identification of pre-existing health conditions and appropriate management and integration of these conditions in TBI care across the continuum of healthcare may be opportunities to reduce direct medical costs post-injury.