DTT scans were acquired for three portions of the ARAS, so the upper ventral and dorsal, and then all three were compared across the board. So the hypothesis that the scientists at the time stated that they believe that injury of the ARAS would be associated with loss of consciousness in terms of minutes indicated by TBI severity grouping. That means based on the amount of time that someone had lost quote unquote consciousness and their GCS and all of those rankings used to make mild moderate TBI groupings, they believe that the ARAS level of injury that was detected by DTT would correlate in terms of if it's a major TBI injury, then people would have less of a glow showing on those DTT scans. So what were the results? The results were injury was found in all three components of the ARAS and all three groups across the board. So all three groups showed that the ARAS was not functioning. Now, let me remind you, what is the ARAS? The ARAS helps with bringing the cerebral cortex, the part of your brain to consciousness. So all three were injured across the board. Now, injury severity was different between the three TBI groups in the upper ARAS, but as we came down between moderate and severe, it kind of blurred the lines between the lower and dorsal ventral ARAS. Let me show you how all that looks. I mean, it sounds great when I talk about it, but it looks a lot better. So if you take a look at this right here, you'll see I've circled the severe TBI. You know, we saw this earlier. You'll see that the ARAS function highlighted by the DTT is severely diminished compared to the mild and even our control, of course, but you'll see that that upper ARAS across the board was different when we start from mild, moderate, to all the way to severe. Like I said, when we got to the lower dorsal and lower ventral, they kind of were very similar when it came to moderate and severe, but they were still pretty different when it came to mild, comparing mild to severe. So what does all that mean? What do these scans mean? What does it mean for the future of classification of TBI? Let's talk about that right now. So results suggest that analysis of the ARAS using DTT would be helpful in determining the severity of TBI. That means, you know, DTT is a really popular technique. It's able to create an image of the brain that goes beyond the traditional MRI, but it's pretty limited in terms of how often it is used to classify TBI. Of course, getting a DTT done is expensive. It can take more time, and something like the Glasgow Coma Scale, which I'm able to go in and do on a patient in two, three minutes, might be a lot more frugal, but it is another cool little technique that can help us see how severe brain injury is. Possible limitations stated in the study. First, DTT analysis is operator-dependent, meaning that the image created depends a little bit on the person doing the actual DTT. So it's possible that some of the images aren't as clear or aren't showing the full image that we're looking for. Another thing is that DTT parameters could change with the passage of time after onset. A lot of these patients, there were patients at the hospital that had come in after traumatic brain injury or something that caused traumatic brain injury, and so their scans were done at a relatively quick period. Who's to say that the neuroplasticity that can happen within the next couple of months or years will show a completely different scan? And so the authors of this article were upfront and honest in saying that, who knows what a DTT could show for a patient that suffered a severe TBI months or years down the line. So that was something also very cool to think about. That being said, I'm close to nine minutes here, but we're gonna finish. If anyone has any questions, I believe we finished right on time, right, Nathan? And I'd love to hear Dr. Sheetal's input as well, ma'am. So thank you guys. Thank you, Bill. Go ahead and share for us, and then let's throw it to Dr. Bhattacharya for her first thoughts. Sure, so DTI is super interesting. When I was a fellow, and of course this is a long time ago for you guys, back in 2009, through the Veterans Administration, we did have DTI. We had a, we were super excited. We had a three Tesla MRI. And when we had DTI, we realized there's a lot of limitations to it. One is access. So not many facilities out there have DTI. Like we're at Ohio State, our DTI is for research purposes only. You know, where I did residency, we had DTI, but you also have to look at the radiologist reading it. So one of the things that Bill brought up was, you know, the operator dependent. Operator dependent is twofold. One, the tech that's actually running it, and if they have the software to run it, but two is, you know, the radiologist to read it. Not all radiologists are trained in it. And so when you look at DTI, you see all those different colors. You see the blue, the pinks, the purples, you know, the browns, those are all showing axons, and they're showing the different directions of the axons. So when we look at fractional anisotropy, what that really means is the diffusion of water across those axons. And what you'll actually see when you look at a DTI scan is that like you saw in those scans, the decrease in volume, but you also see these little punctate hemorrhages or at least punctate areas throughout each axon to see where the shearing injury has happened. So, you know, in general, when we think about more severe TBIs, we're thinking they're going to have a lot more shearing injuries. They're going to have, you know, they're more likely to have disorders of consciousness. So one of the things that was interesting in this article was they did not look at people that had prolonged disorders of consciousness. They only looked at people that had a loss of consciousness as a result of TBI, whether it was mild, moderate, severe. So when we look at our prolonged disorders of consciousness, this is where I really want to use the DTI because I want to see is their injury severity not only in the ARAS, but other areas and parts of the ARAS that are really interesting to us is the thalamus. So, you know, if they have a lot of damage in the thalamus, are there potential things that we could do? And some of the things that we're doing in a research standpoint is looking at deep brain stimulation to help people wake up from a prolonged disorders of consciousness or have emerged to consciousness as a result of it. So, you know, looking at these types of scans, this is a great preliminary study that shows us that DTI can be very helpful, but at the same time, you know, it's really where, who is actually reviewing it? Who's actually reading it? And how prevalent is it to even get these scans? They are expensive, but it's really more access to care issues. And then the other part that's really interesting, you know, all the time I deal with patients with mild brain injury and they usually have no imaging findings. Their MRIs are negative, their regular MRIs are negative, their CTs are negative, but yet they have all these symptoms. So DTI has actually been shown in some early studies that if you get it within 48 hours of injury, you can actually see areas of, you know, change in the diffusion of water in those mild TBIs. But when you go months, weeks, years out, you're not gonna see that. So the other comment on the conclusion that Bill made was, you know, it's also time since injury. So would things be changing if you're further out from injury? In this article, you know, when you look at the demographics, most people, they were around two months post injury. So, you know, plus or minus a month or two here or there, but really they were pretty early on after injury. So would there be changes down the road? Are these types of scans helpful? Because the number one thing I always get is from patients and their families is should we get another scan? And I'm like, there's no point in getting another scan because I can clinically see you improving. What is my scan gonna show us? But having scans like this, or, you know, we talk about functional MRI, we talk about different types of MRIs out there. There's MEG scans, which is magnetoencephalograms. And then we look at, you know, some of the general, like looking at hemocytin and staining on gradient echo and things like that. So there's all these different MRI techniques out there, but are any of them gonna help us with prognostication? And we really don't have that answer yet. And that's really what we wanna look at for the imaging. Our imaging yet is not smart enough to help us with prognostication, but it can help us with determining severity for sure. You know, and, but do we really need DTI to help us clinically? Not so much, but do we maybe want it for our prolonged disorders of consciousness? Yes, and that's where I think this article could have been a little bit better is if they actually compared people in prolonged disorders of consciousness. And are they still having, or are they having like valerian degeneration? Are they doing serial DTI on someone like that that are they actually degenerating areas of the ERS? So from my standpoint, this article is really good in the fact that it brings out the light of what DTI or DTT can really help us with and why these imaging techniques are so important to have more and more technology when we compare it. It also helps us figure out, you know, mild, moderate, severe. Yes, you can use things like, and they talked about it in this article, post-traumatic amnesia. You can use a Glasgow coma scale. You can use length of loss of consciousness. And that all tells you about severity of your brain injury. But really being able to see it in a picture like that is, you know, speaks volumes to be able to see. But then again, I've had a patient with, whose MRI imaging looks like the severe TBI imaging that you saw today. And they're walking out the door and they're back to driving and work and school and everything. Whereas someone that has the moderate is still, you know, wheelchair dependent or having quite a bit of, you know, other functional issues. So the MRIs can help us look at loss of consciousness, length of loss of consciousness, can help us look at, you know, what structures in the brain are injured, but doesn't necessarily correlate clinically all the time. So I do love having more imaging out there. I do love the fact that there is more imaging being studied and more technology coming out. But I don't think we're yet at the point clinically to be able to use it yet. Awesome. But great work, Bill. Good summary of the article. Thank you, ma'am. All right. Any questions from our audience? Y'all can come on camera, but comments in the chat, however you prefer. Yes, a question that came to mind. By the way, thank you, Bill, for a great presentation. Thank you, Dr. Parveshi, for your input. The only time I've kind of really seen this imaging is on like a medical legal, like TBI, infraction clinic that I did. It seemed that like the position was using it to show evidence that there was a TBI, like kind of in court, you know, when you're kind of fighting the legal system. I guess, Dr. Parveshi, do you have any experience with this as far as like medical legal work goes or have you seen it used in that case, you know, beyond research? Yeah, so we do use imaging quite a bit. Medical legal wise, what your comment is 100% true, especially with our mild TBIs. And that's why I was saying, you know, with mild TBIs, we do need better imaging techniques because our general CTs and MRIs don't always have correlation to what we're seeing clinically or even in neuropsych testing. So medical legally, though, since DTI is not used as a first line in clinical, by the time we even are able to get DTI or get to a place that actually has DTI and that has a radiologist that can read it and has really good technique, you're not really going to find a lot of data from that yet. Now, I do think that it will be very helpful in the future for us to be able to get people to get services when they have a mild brain injury. And even if their imaging doesn't show it, but they're having some ongoing symptoms that prevent return to work, prevent return to a lot of activities for them to be able to get, you know, not only legal remuneration for their damages, but also, you know, being able to get services that they need. So I think this has a huge value for potential medical legal. However, we don't have as robust broad access to it. So it could be in one location, you know, large academic centers, large cities, and have availability. But when you have someone that, you know, potentially the mild TBI in rural America, you're not going to be able to get a DTI scan. It's requested. And then the question is, is time since injury, you know, a lot of the medical legal cases are going on maybe a year post injury before they even get to court. And then they're asking for these images. And is it too late to get them? So I think there's still some work that needs to be done with DTI and our standards of care for our mild concussion patients, at least. And there was another question in the chat as well. So I'll pull that up. Could the correlation with some TBI scale like the Ranchos help moving this to the next step? So that's a really good question. So the Rancho scale, for those that don't know what it is, the Rancho scale is really the scale that we use to look at TBI recovery. And so where people are on the trajectory of recovery. And so, you know, we have a scale from 1 to 10. And, you know, 1, 2, and 3 are people in a disordered consciousness usually from coma, unresponsive wakefulness to minimally conscious. And then 4, 5, 6 and beyond, 4, 5, and 6 people are still in a post-traumatic confusional state or post-traumatic amnesia. They're confused, agitated, or confused and slowly getting appropriate. Really 7, 8, 9, and 10 is where we have more, you know, people are out of post-traumatic amnesia. They still have cognitive disabilities. And it's all of us, you know, that have no issues. So there could be, but I think the really looking at it because the DTI really tells us about more, you know, severity of injury and where the location of injury is. Looking at it on the scale to be able to say, you know, they are now at a range of 4 and their MRI correlates with that and an MRI correlates to the range of 8. I don't think that's going to ever happen because you have encephalomalacia, you have malaria and degeneration. So even though people are clinically improving on the range of scale, their imaging findings may not change at all. So I really, the range of scale I don't think is something that we can correlate to imaging findings at all. But good question. Awesome. So that's a good discussion. Just want to save time for our next presenter, Greg. I guess quick plug for all you who are MS3s or MS2s out there eventually looking for additional rotation in the PMR. Disorders of Conscious Programs aren't everywhere, so just keep a lookout for them. It's a really awesome learning experience that takes you to a whole depth of TBI that you might not get in a traditional TBI rotation. So just a plug for all y'all when you look out for additional rotations in the future. Next up, we have Gregory Friedberg, second year med student out of the Ohio State University College of Medicine. He'll be talking about biopsychosocial factors associated with attention problems in children after traumatic brain injury. You can take away whenever you're ready, Greg. Hold on one second. I got to figure out how I did that before with the presentation. All good. I hope I don't take a whole 15 minutes trying to figure that out because I'm not good with technology here. Let's see. Okay, you guys are probably seeing my notes at least. I have to switch it though, I know. Hold on one second. How did I do it before? Do you remember? Not sure. You did it from your end. I'm not exactly sure. It was like a thing where you clicked specifically like on the presentation. We don't see your notes right now. If you can see. You do not see them? We do not see them. Okay. I'm about to make it so you can. And then I'm going to switch it. You can see them right now, right? Yes. Okay. All right, I'm going to change that. It's not working. Okay, you can see the notes, I'm sure. There we go. Okay, I think I found it. Can you see my notes? Nope, just the presentation. Wonderful. All right. Sorry about that. All right, so hi everyone. My name is Greg. I'm a second year medical student at Ohio State, and I'll be presenting on the topic. I won't repeat the title there just because it's a little bit of a mouthful there, but it's a systematic review of about 40 articles that was published in March of 2021 in the American Journal for PM&R, and it was actually conducted in Cincinnati, Ohio, so I wanted to stay local with this one. So moving forward, just a quick case study to start out. So imagine that this patient is presenting to your clinic. They're an eight-year-old male presenting with worsening attention-related problems. They were diagnosed with ADHD pretty early on in their youth, which could explain the symptoms that are presented today, but his parents and teachers have reported some inappropriately increased prevalence of inattentiveness, exaggerated outbursts at home and in class, as well as some newly dramatic fidgeting when they're sitting down, and they state these symptoms worsened or started worsening about six to eight months ago, and when asked about any triggering events from the past year, his parents recall being involved in a motor vehicle accident in which their son sustained a concussion. So you begin, as the astute physician that you are, to suspect an exacerbation of this patient's ADHD from a recent traumatic brain injury. So as you start to gather more of their history, here's a summary of some of the findings that you get, and from this list, I'm asking the people in the audience to pick about three of them that you think most predispose them to the development of this secondary attention problem from their injury. So what exactly do you think was the greatest contributor of three of these that could have led to these worsening of their ADHD symptoms? So take a little bit, pick three of your favorites. You don't have to type them in the chat, but you can if you want. Take a little bit, and then we'll revisit this at the end of the presentation. So what do you think contributed most? We've got another couple of seconds here. Okay, if you didn't get a chance to do it, we'll revisit it later, but moving on. So with that case study in the background area, I just wanted to dive into some background before we get to the article. So quick definition of traumatic brain injury according to the National Institute of Neurological Restorative Stroke. TBI is a form of acquired brain injury due to sudden trauma that causes damage to the brain. It's a leading cause of child morbidity and mortality. In the U.S. emergency department, data accumulated in the year of this publication, 660,000 cases were seen. And the most common causes of those were falls, abuse, and motor vehicle accidents. So pretty prevalent thing that we're bound to see as medical students, especially once around rounds. But also want to make sure we define attention deficit and hyperactivity disorder, or ADHD, a mental disorder affecting children and adults that's characterized by one of, or a combination of one or more of the following things, being inattention, hyperactivity, and impulsivity. And you can see a chart on the right-hand side of this slide here that talks about those symptoms in a little bit more detail. But ADHD, also something that's super common. 8.4% of children are said to have it, with 2.5% of adults. So definitely not something that we can ignore since it affects such, oh, I'm sorry. Just screwed it up in the presentation a little bit. Since it affects so many people worldwide. So for the purposes of this presentation, I'm going to be using the term ADHD, attention problems, things like that, and interchanges. depending on the context, as both were discussed in the articles that this analysis went into. So lastly, let's connect these two ideas. So TBIs, unsurprisingly enough, heighten the risk of developing attention problems, especially in kids. So one such study found that up to a third of children without pre-injury diagnosis of ADHD met criteria for ADHD after having experienced a traumatic brain injury. So that's an example of what we call secondary ADHD, meaning the onset or worsening of symptoms came on after a secondary insult like a brain injury. So there's plenty of factors that play a role in why this occurred. So there isn't really a comprehensive review of all of them together though. So that's the purpose of this article is kind of to bring in all these other articles that have individually looked into factors that can either predispose someone to developing secondary ADHD or attention problems or protect them from it. So, and this is important because as physicians, if we identify these early enough, we can optimize treatment, intervene early, and save their function from getting any worse after they experienced a TBI. So moving on here. So getting more into it. First off, just a reminder with the systematic review, they went through tons of articles here. And on the right-hand side, you can kind of see the process they went through. To simplify it, there were 3,480 articles and studies that eventually dwindled down to 40 after the reviewer's process here. So they pulled from three databases being Medline, PsychInfo, and CINAHL. And then the relevant search terminology is also displayed on the slide, the kinds of words and key phrases they were looking for. In order to be included, they were looking for studies of human subjects that had to be observational in nature, be peer-reviewed, written in English, and contain a pediatric TBI cohort with a mean age below 18. So it was actually about kids. And then also had to evaluate the association of risk factors with the development of attention problems after TBI. The studies that were selected were all from before August of 2020, just because this article was written in 2021. And then the quality of all of these studies was measured using a modified version of what's called the Downs and Black Checklist. And then it's also worth noting that these studies specifically were looking at analysis of attention problems that were clinically apparent, not ones that they found out from like cognitive and neuropsychosocial skill tests done in the clinic or something. Because currently, diagnosis of ADHD, standard practice for that is assessing it off of like parents' and teachers' anecdotes. It's not something that we really test for in the clinic, specifically with quantitative measures. It's more so something that is clinically diagnosable. So moving forward here, after all these 40 articles were examined, all of the different risk factors were put into three categories, being biological, psychological, and social. So we're gonna dive into each one of those. For biological, first one that was discussed was injury severity. And this is an injury-related biological factor. And we mentioned the Glasgow Coma Scale earlier, where like a 13 to 15 is a mild TBI, nine to 12 is moderate, and then three to eight is severe. And then other rating scales were used in these articles, like a Conner's Rating Scale, a Child Behavioral Checklist. Those are some other ones that were mentioned. But basically, this had 25 studies on injury severity, and 10 of which said there was an increased incidence of secondary problems in situations with severe TBI. So someone who had a severe injury, those people went on to develop more severe attention problems. And that was especially prevalent in the acute phase post-injury. So in the first six months after they got hurt and then also in those who had sustained previous head injuries too. So they've had multiple TBIs. A few studies, specifically they noted 11 of them found quite the opposite saying there was no correlation but they didn't really dive deeper into that in this article. So it was kind of just a mixed bag of like, well, some people don't believe what all those other ones were saying, but, and they didn't really elaborate much further. And the next factor that was looked at was time post-injury. This one was also a little bit of a mixed bag. Immediately they mentioned five or so studies that found no effect of time. So once they were hurt over time, did symptoms worsen, did symptoms get better? There wasn't really a correlation that was seen in some of those studies. Whereas others denoted a worsening of symptoms in the six months after injury, especially for those severe TBI, but also in other categories too. And then one stat that I found particularly interesting from that was that 15% of children in one of the studies of those with TBI met the criteria for ADHD in 12 months post-injury, but then up to 24, 21% of that same cohort met those criteria. So there was an increase of 6% in that extra 12 month period, suggesting that symptoms do in fact persist or worsen over that two year post-injury period. But of course, like I said, not all of them said that. Some of them actually said that symptoms got better over time. And while like they might peak over six months, the months thereafter, they get better. So really just a mixed bag with this, which is a common theme you'll see. Onto some more patient-related ones here. These are biological factors as well. First off with sex, four studies discussed this, so a pretty small one. Two of which said that sex wasn't predictive. One of which said that being male was predictive. And then one that said being male with pre-existing ADHD was predictive. So a lot of caveats there. So we'll elaborate on pre-existing ADHD later, but with this one, there wasn't really a solid conclusion. For age, there were a few Taiwanese studies that were talked about with children zero to eight, and even pre one years old, that developed SADHD in nine months follow-up more compared to others who were older. And then another that saw more in those age zero to five versus six to 10. So more prevalent in younger age was the theme. Some studies refuted that, but some of those studies specifically were mentioned to have less statistical significance of those data. And then also that one of them looked at age as just one of many factors that they were analyzing. So they said that their results may have been age masked because they weren't focusing on how does age affect the onset of attention problems after TBI. They were looking at many things, and it just so happened that age was not one of those factors in their studies. So common theme here was that younger age did lead to an exacerbation of those symptoms more so than usual. Moving on, we have some biomarker studies. There was only one mentioned here discussing things like NSE, S100B, and NCAM, and a few other inflammatory markers by themselves weren't found to have much predictive value, but with pre-injury problems taken into account as well, or pre-injury behavioral factors, they were found to have some correlation. And then with genes, there was a polygenic study that talked about how the genes that predispose someone to ADHD in general do not predispose someone to having secondary ADHD development after TBI. So it wasn't really a correlation in those. As for imaging, and this actually ties into what Bill was talking about with the anisotropy studies, there was actually a finding that things that caused SADHD development more so were things like less brain anisotropy found on DTT, and then also lower caudate volume and the presence of lesions in like the orbital frontal cortex, right caudate detainment, and then other brain contusions in the subdural hemorrhages, but specifically not in the frontal lobe. So there were some imaging findings that did correlate, some that did not. Moving on to psychological, first off, previous ADHD diagnosis, which I mentioned earlier, pretty general consensus here was that pre-injury ADHD patients, like they had it before they got injured. The injury was not the cause of it, they already had it, did exhibit greater attention problems after injury. So they claimed that, and with that, with having said that, a stat that I found really interesting was the prevalence of worsened attention was seen in 82% of children with pre-injury ADHD versus 32% of those without pre-injury ADHD. So that difference of 50% could probably be accounted for because they had a pre-existing diagnosis. Next on pre-injury behavior problems, only three studies talking about that one, one of which said that it did predispose them to it if they had like some sort of behavioral issue. If they didn't, or another study said there was no correlation, kind of a mixed bag there, so no concrete conclusion. And then some touched on pre-injury adaptive behaviors and functioning, and talked about how in patients who are six months post-injury, socialization and communication skills, if they had poor skills in those categories, they were likely to also have SADHD onset after TBI than others. And then in 12 to 24 months, not only that, but also psychological adversity came into play. Do you need to say something Nathan? Just want to give you a three minute warning, but good job. Cool. All right. And then for social, last things to mention, socioeconomic status was a pretty strong predictor saying that people with lower socioeconomic status had a higher prevalence of secondary attention problems develop up to 24 months after injury. And then also those with lower maternal education level too had a greater onset of SADHD as well. And then the last factor that this looked at talked about things like family functioning, psychiatric history and behaviors, such as like permissive parenting, family dysfunction, and then warm responsiveness towards their children when they're doing like any kind of task, if they're encouraging them, things like that. And for these ones, it was found that more common than not greater behavioral problems were prevalent in those with greater family dysfunction. Even though not every article agreed on that front, that was kind of the general consensus. So here's an evaluation of all those risk factors on one page. A lot to get through. I tried to just summarize it as most predictive and then less predictive. So there's most predictive being age, TBI severity, the number of TBIs, preexisting ADHD, adaptive behaviors, lower socioeconomic status, parental functioning, and imaging findings. And so going back to those risk factors from the beginning, if you chose any one of these six, you were likely on the right track. So take a look at that. And then let's wrap this up. Some conclusions really quickly. First off, SADHD development post-TBI is pretty complex. Not something that it's easy to get through in a 15-minute presentation, but obviously a lot of factors that come into play. Some of those major ones that I mentioned come into play were younger age, preexisting ADHD diagnosis, poor injury, adaptive functioning, socioeconomic status, and family function as well. And by identifying these early inpatients, we can hopefully intervene early and minimize the impact of attention problems on these patients. Study limitations. Again, this was 40 studies that were all pretty small and some even non-randomized. And with that, the downs in black checklist that I was talking about, most of them scored an 11 to 16 out of 28 on there. So the statistical power of all of those studies, it's not super strong, definitely lower than I'm sure the authors wanted. But that said, it's also just hard to compare all these studies across the board because while we do have things like the Glasgow Chromoscale and whatnot, there is no universally agreed upon way to measure attentional function. So with this, we're going off anecdotes, parents, teachers, what they believe they are seeing in their kids, and not quantitative measures to find out their levels of dysfunction. So it's also hard to compare the results of all these studies, not only because they measured them in different ways, but also because ADHD in general is just a very subjective thing to diagnose. It's very clinically relevant symptoms only, and what might be severe to one person might be moderate to another. So that also makes this difficult. For future directions, just talking about finding more of those factors is something that I wrote down here, but also finding out if the interventions that incorporate, let's say we notice something, someone with lower socioeconomic status is more at risk, how can we intervene and help them? And do our interventions actually help them long-term? Could be some more studies into that. And then also more studies into the biomarkers and neuropsychological changes that I was mentioning earlier. There's not a ton understood there and not enough studies out there, and that could be something that could be of great clinical utility. There are my references, and that's all I've got. Awesome. Thank you, Greg. Let's shoot on over to Dr. Bishi for her thoughts. Oh, lots of thoughts about this article. So it's a very robust article. It has a lot of data in it. It's a very, a lot to go through. So great work, Greg, on kind of sorting through all that and really trying to put it together. A couple of different things. So the articles that they looked at, there was, it was a lot of subjective. There was a ton of subjective with families and everything, but we use a lot of neuropsychological testing to really get good quantitative data on how people are doing from an attention, concentration, memory standpoint. So we can use neuropsych testing to get us quantity and get us that data that we need. However, in the articles that they reviewed, there wasn't a lot of that. And so when they started looking at some of the things that would be more objective findings like imaging, I thought it was really interesting in here where the imaging didn't really correlate. And then a lot of the times, you know, I always teach, well, the corpus callosum, like if you get hit there, your attention is going to have issues. And it's actually true. And some of the studies did show that and some did not. So it was kind of a mixed bag, but there's also different. And as Greg kind of pointed out there early on his presentation with the TBI, with the acceleration, deceleration forces, so many parts of the brain control attention. It's not just the corpus callosum. It can be the frontal lobes. It could be, you know, because there's visual attention, there's auditory attention, and then there's, you know, just the in general of being able to pay attention. So some of those things are there. Plus behavioral changes are an issue. And a lot of the behavioral changes can result in inattention. So if people have depression, anxiety, those can all turn into an attention problem. And it could be really a mood disorder and not necessarily an attention problem. So it is a really mixed bag when you think about attention, deficit after a brain injury, but even before. So one thing that I always tell everyone and always teach everyone is that if they had a preexisting condition, the brain injury is not going to make it better. It's not going to miraculously say, oh, poof, you're better. It's actually going to potentially make everything worse. So, and it's with any really dysfunction when it comes to prior brain injuries. So attention and concentration is one, but, you know, other things like anxiety, depression, behavioral changes, all of those things can actually worsen as a result of a brain injury. So, and then when you look at some of those, like depression, some of the things that people will talk about in depression is loss of short-term memory and difficulty with attention and not necessarily are they ADHD, they're really depressed, you know? So it is a very mixed bag with these factors, but one thing to recognize, and exactly kind of what Greg was bringing up with the case that he presented was, you know, there are all of these factors for that kid. There were all of those factors that could be a potential causing of all of his symptoms. And it may not necessarily all be chalked up to the brain injury. Some could be worsening from it. Some could be other factors because even social factors without a brain injury can worsen kids' behaviors, you know? So there's a lot of different things out there. But the other thing that was really neat in this article, and I don't know if you touched on it too much, Greg, was that find the, look for it early. Like recognizing it early is a key because if you can recognize it early, there are the interventions you can do. And one of the other things that they did show with some of the reviews is that there was improvement after over 24 months in a lot of the cases, not all of them and not all of the articles, but there was quite a bit to say about improvement too. So if we can catch it early on, and then the last comment that Greg put in there about, you know, do some of our interventions help? Can we do interventions that can help? And that's part of the, if we can identify it early on and we can potentially tackle it either with therapies or medication or testing or psychological interventions, then we can potentially mitigate it from worsening or being an ongoing problem. So a lot to unpack in this article, but it actually gave a really nice overview of the fact that there are so many factors to behavioral changes and to attention problems after a brain injury that we as physiatrists, when we look at a patient, we're looking at them as a whole from top to bottom. You know, we're not just looking at their one symptom of this. We're looking at everything that's gonna be potentially hindering their function. So this article really brought to light as a physiatrist, what we will be doing, you know, what we are doing for patients and looking at them as a whole and really helping them get back into functioning community, et cetera. So it's a really great article for, you know, for us to be able to review, to help us recognize, hey, we do have to take care of the whole person. It's not just that one symptom or that one thing. Awesome. Thank you, Dr. Paget. And thank you, Greg. Questions from our audience? And that's okay, we don't, we still have time. We're Dr. Raveshi at the end as well, talking about Zach's article. Do wanna make a quick plug for y'all who enjoy this experience and enjoy this event. We do have a fresh new slate of topics for the journal club that are continuing. You can look up kind of what those themes are via the link below that I posted in the chat. If you're curious about presenting again or want to present in the future, take a look at that. And then we're gonna move on to our next presenter. So next up we have Zachary Kaufman, our third year medical student out of California North State University. We're talking about the Virtual Reality Grocery Store, a focus group study of a promising intervention for mild traumatic brain injury and post-traumatic stress disorder. Take it away, Zach. Thank you, Nathan, good to be here and strong presentations from everybody leading up. Appreciate you guys. I understand that it's 5.50 right now and I'm definitely gonna go past 6 p.m. So if you have to leave, you're only gonna break my heart into a million pieces. No, it's okay, honestly, if you guys have to leave, I get it, we're all busy people. So let me just get this started off. So like Nathan said, my name is Zach Kaufman. I'm an MS3 at California North State. And today I'll be presenting a paper by the name of VMART, a Virtual Reality Grocery Store. It's a focus group study of a promising intervention for mild traumatic brain injury and post-traumatic stress disorder. The objective of the paper was to examine the potential usability, relevance, and acceptability of VMART, which is a virtual reality grocery store as an assessment and intervention tool for veterans with mild traumatic brain injury. So worth noting, this is a study about the development of a piece of software. It's not necessarily a study comparing the efficacy of this to standard of care treatment. So just keeping that in mind moving forward. I saw that there were gonna be a couple of M2s here today. So I wanted to throw some pathophysiological board style questions, because I know you guys have step one coming up. So I'll read these out loud and then I'll give you guys a chance to answer. So the first question is, which of the following neurotransmitters is responsible for secondary injury in the setting of TBI? And the second question is, which of the following may be encountered after a patient suffers a traumatic blow to the head? So I'll give you guys a few seconds to throw some answers in the chat or speak out loud. All right, going once, going twice, and sold. Moving forward. So the answer to the first question is glutamate, but it's not just glutamate. The way that this works is essentially after traumatic brain injury, there's an apparent depolarization of some of the neurons, releases glutamate and aspartate, which causes an influx of calcium, which can lead to both indirect and direct methods of cytotoxicity, eventually ending in apoptosis. And for the second question, and for the second question, we have all of the above. And I know that from our studies, a lot of us have probably seen things like diffuse axonal injury, all the different types of hematomas that you have to learn in neurology. But one of the things that I wanted to highlight was coagulopathy, because that was new for me to see. About one third of patients with severe TBI have a systemic release of tissue factor in brain phospholipids, which as you guys have seen, can activate one of the coagulation cascades and lead to a coagulopathy. So kind of cool. So before we get into the paper, I wanted to talk about traumatic brain injury and what its definitions and symptomatology are. So a definition of TBI would be an alteration in brain function or other evidence of brain pathology caused by an external force. Super broad definition, very wide range of disease. And so I wanted to talk about symptoms of mild TBI and concussion, because that's what's going to be referred to in this paper. And I just wanted to highlight a couple of symptoms here. So bothered by light and noise, attention and concentration problems, problems with memory, anxiety, and irritability. These are some things that will be talked about a little bit later on in the study. So let's keep that in mind. How does TBI affect the armed forces? This study really focuses on veterans. So I wanted to talk about this. Up to 88 to 97% of veterans from specific squadrons are exposed to blast injuries. And of those, 47 to 59% result in head and neck injuries that lead to a diagnosis of TBI. And in the last five years alone, over 100,000 military personnel have been diagnosed with traumatic brain injury. And there are some similarities between symptomatology of mild traumatic brain injury and PTSD, namely the ones that I mentioned in the last slide. And this is important because studies have been ongoing since actually 1999, showing treatment of PTSD symptoms with virtual reality and of actually having some pretty good success. And that leads us to V-Mart, a virtual reality grocery store. This is a software that was initially inspired by a software called Bravemind or Virtual Iraq, which was meant to be a desensitization virtual reality therapy for veterans with PTSD. And what it did was mimic combat scenarios like foot patrols and firefights to help veterans basically desensitize themselves from these memories. But it raised the question for the authors, well, what about transition to civilian life? You're not really going to get into a firefight in civilian life. So that raised the idea for the virtual reality grocery store. Now, the authors chose a grocery store for multiple reasons. One, we all go to grocery stores on either like a daily or a weekly basis, depending on your shopping habits. Two, there are multiple different challenges that you have to deal with in a grocery store that most of us don't really think about on a day-to-day basis. For one, there's a lot of white, there's a lot of noise, and there's a lot of movements, which can be very distracting for patients with mild traumatic brain injury. And also there are a lot of memory and decision-making challenges. You have to remember what you want to buy today. You also have to make a lot of decisions that don't have a concrete answer. So for example, a therapist using V-Mart might ask a participant to buy a box of cereal with the highest amount of fiber content for the most reasonable price. There's no concrete answer, and it's a decision that you or I would make every single day and not think twice about. But for somebody with a mild traumatic brain injury, it can actually be very stressful and can even keep them from going to the store altogether. So V-Mart was designed with the intention to challenge cognitive and emotional domains of practice, cognitive being things like recall, memory, budgeting, and time management, and emotional overwhelm being things like irritability and anger. It's a fully functional grocery store. It has about seven aisles with, I think, 60 different items, and it gives you the opportunity for a series of animate and inanimate interactions. So for example, you could actually pick up a box of cereal off of the shelf, you could read its price, and you could actually read its nutritional value, which will help these veterans really kind of get used to interacting with multiple different items throughout the store. And in terms of animate interactions, there are multiple NPCs or non-player characters throughout the virtual reality. And of note, there is a clerk at the end of the shopping experience that has a bunch of different dialogue options that the therapist controls. And all of the dialogue is meant to be provocative for the veterans, things talking about politics and the war and opinions of veterans and things like that, really trying to rile them up. We'll see off to the left, this is actually a figure from the paper. This is actually a picture of V-Mart. And on the right, you have a therapist at the therapist console, dictating how many non-player characters there are, how many external stimuli there are, what the clerk at the checkout will say. And on the left, we have a participant who is engaging with V-Mart. And normally when we think of virtual reality, we think of a headset with a couple of gloves, but they thought that that would be a little too stimulating for the veterans. So what they did was hook it up like a video game, essentially. So how did they carry out the study? Like I said earlier, it's a focus group study. It has six total groups with three different qualifications. They met at the beginning of the study. And then again, later on, after implementations had been made to the program, there are therapists, there are veterans with neither MTBI or PTSD, and I'll refer to these as V-naught just to save us all the time of hearing me say TBI 50 or 40 times. Then there'll be veterans with MTBI plus or minus PTSD, and I'll refer to these as V-prime. The program was developed using what's called feature-driven development model, which is a fancy way of saying there was teamwork. The clinical teams would basically say to the technical teams, this is what we need. And the technical teams would say, we'll see how feasible that is. They would put it together, give it back to the clinical teams, and they would rinse and repeat this process until each feature was foolproof. There were a series of inclusion and exclusion criteria like there would be for any study. For therapists, they needed to have 20% of their practice dedicated to patients with MTBI or PTSD. The veterans had to have a diagnosis of one of these two things. They had to have a diagnosis of MTBI plus or minus PTSD, and they had to be deployed on one or more of the following operations. The exclusion criteria were access one and two psychiatric disorders, neurologic disorders, uncontrolled vertigo, and narcolepsy. The way that the study would roll out was essentially the focus groups would get together. Everyone would have a chance to utilize V-Mart. Then they would get together and they would discuss pros and cons, what they liked, what they didn't like, what could be improved. They would all get what's called a systems usability scale for quantitative feedback. They would remodel the program, and then they would repeat at a later date. So the systems usability scale is a 10 question Likert scale that's scored out of 100. It's been validated multiple times, and specifically with healthcare, it's been found that a score of 70 or above is the standard of usability for healthcare settings. And in terms of analysis, they use what's called thematic analysis with a constant comparative method. If anybody wants to ask me about that later, I'll do my best. This is just an example of the systems usability scale for everybody. So results. The therapists of note were the first group at the initial focus group to actually use the program. So a lot of their feedback had to do with just technical difficulties. They said things like those who are video game naive, who had never played a video game before might be at a disadvantage in using this program. They also said that there was just a lot of choppiness, not very much fluidity, and it would be hard to assess somebody's development or irritability with the program because they might just be irritated with the actual controls themselves. And they said that it was a little too bare bones. It lacked appropriate additional or external stimuli. At the follow-up, they were actually quite pleased. They said that it had ecological validity, or in other words, you can get a lot of bang for your buck without having to actually utilize resources to get the participant or the veteran out of your clinical practice and into the real world. And they also said that it would be good for dealing with overstimulation and irritability compared to some of the patients that they see in their own practice. Results for the V-naught group. Before, they had some similar concerns with regards to functionality of the program. They said that it needed some fine tuning, but they were actually overall pretty pleased with it. They said that it would be a successful memory challenge. You know, a lot of these veterans have friends who do have diagnoses of MTBI, and they talk about how much these guys actually struggle with these memory tasks on a day-to-day basis. And they also spoke to, you know, the addition of these stimuli that were actually quite emotionally triggering for them, let alone the veterans with diagnoses of mild traumatic brain injury or PTSD. This group was actually also the final group to use the program after it had gone through multiple feature-driven developments. They said that the movement fluidity had really improved, that the conversation fluency had improved, with some of them remarking that the conversation was as real as it could possibly be given the circumstances of you playing with an Xbox controller sitting across the table from a real person. And they also commented on the success of what they refer to, or at least the study refers to as the sound architecture. And this means essentially, for example, in this study there are multiple different non-player characters, like I said earlier, and you can actually overhear their conversations. And in some cases there might be babies crying, there might be the noise of thunder outside of the store, and this is meant to add in external stimuli to startle the target population, which is the V-prime, the veterans with MTBI. In their before focus group, they got to use this a little bit later on than some of the other groups, so they really commented on the realism and its attention to detail. In their final follow-up, they were actually quite emotionally aroused by the program. They said that they were really frightened by the sound architecture features that I referenced earlier, and one veteran even said, if the dialogue was designed to provoke, then the dialogue was effective. And they were referring to the clerk giving really provocative dialogue options to them. In terms of quantitative data, this is the systems usability ratings that I spoke about before. There were significant improvements from the initial to the follow-up focus groups for all three groups. Of note, all three of these have a mean of above 70, which as I said earlier, is validated for use in healthcare settings. And something else to highlight is that the therapist group actually had the lowest score. And this might be due to the fact that the therapist had to operate the console, and they get to dictate not only what the participant is doing, but they also dictate how many different characters are within the grocery store, how many different external stimuli they encounter, and also what the clerk is saying back and forth with them. So they have to monitor a lot of different things, and the difficulty might actually impact their perception of the program. So in terms of discussion, the limitations of this study are fairly obvious. One, there's a really small sample size. I believe that for the veterans with PTSD and MTBI, there were three at the initial and four at the follow-up, despite the study's best efforts for retention. They knew they would have some trouble with retention with that group. And second, this is all stakeholder data. So basically everyone that they collected data from had a direct say in how the program would turn out at the end. So, you know, if you say, hey, Zach, I would really love it if you do this instead of this, and I do that, you're probably going to be more pleased than if I just did something random that would please you normally, right? So you can have some falsely elevated data as well. The next steps for the study would be feasibility trials, and by this they mean packaging up the program and delivering it to therapists. And without any one-on-one training, could they unbox this, read the manual, and bring it into their practice? And then two, efficacy trials. How does this actually hold up compared to a current standard of treatment? And one of the last things that I just wanted to say about this study, which is just a bit of input, I like that it really highlights this question that exists in all areas of medicine, but perhaps nowhere more so than PM&R, which is what happens to our patients after they leave the hospital or after they leave the clinic when they're no longer in our line of sight? How do they get through their day, not just in terms of their physical health, but in terms of their kind of emotional ability to cope with their diagnoses? So that concludes my presentation for you. I hope you enjoyed it. Thank you, Zach. And Dr. Vichy, any thoughts? Yeah, so gaming is actually near and dear to my heart. So we've done a lot with gaming in our department where we're doing gaming for recovery from a stroke. We are using VR for rec therapy and community reintegration. So having a program like this is really fantastic. And I'm currently working on a project on creating a gaming console as well for TBI recovery. So this is actually really cool stuff that is going on. And it's really neat to be able to bring this technology to rehab and especially trying to bring it to multiple different populations. And some of the things that this article highlighted nicely was really taking into factors of the PTSD piece because you don't really recognize when you're creating games like this how things can get overwhelming. But at the same time, you want some of those things to be overwhelming because you want people to be able to create strategies on how to manage their PTSD in situations like this because they're very real situations going into the community. And so I was actually really lucky too, again, in fellowship to be able to work with some of the Braveware software as well. I got to work at Walter Reed and see some of that in action where they were using VR headsets and bringing people back into theater. So it was really cool to see. And just where it's progressed to is really neat too. So virtual reality, gaming, it all has a huge, huge arena in rehab and bringing technology to rehab. And so people always talk about screen time after TBI. And I always tell patients' families and let them play video games when they go home because they actually are really, really good things to help people, not only from hand-eye coordination and manual dexterity, but also problem solving, memory, attention skills. Now, granted, do I want them on a video game for eight hours a day? No. But one to two hours for them to play at home, whether it's a gaming system and whether it's VR or not, there's a lot of good things with it. And having a system like this with V-Mart, it's really cool. If you ever get to play with V-Mart, you really should get a chance. You really should because it's really neat to be able to use a controller, walk through a grocery store, be able to remember items that you need to get and be able to create your budget and be able to pay and walk out. No one realizes how much activity that really is for a brain to do, where you're trying to remember your list, go to the grocery store, pick everything up, get in line, make sure you have enough cash or money on you, check out, bag your stuff and get back home. That's a lot of brain activity to do that. A lot of patients with brain injury get very exhausted just even doing that one task in a day. And so having things where we can actually immerse them into those environments before they would actually physically go into the environment really helps to be able to help them make strategies, help them anticipate things that could be happening, help them be able to really desensitize too. So part of PTSD treatment that we talk about is desensitization. And especially now with COVID times, we can't really, we were all secluded into the house and not able to go places. And we love our Instacart and all of that stuff, but I mean, these types of things really help us from inpatient rehab as well, because we can't take people on community reentry tasks when they're in inpatient rehab. So having gaming systems like this, where we can actually virtually immerse them into those, and then we can help figure out, you know, what kinds of rehab needs they have and work with all the different therapists. So I do agree. One thing that they did mention in the focus groups from the therapist standpoint, because the way this game was put together is that the therapist would be on one side giving prompts, and then the patients on the other side actually working with the system. So there was some complexity from the therapist side. And they did say that it was really a little difficult to use to be able to set it up. But I think the other thing to think about, you know, in the future, if this can turn into an AI type thing, is you wouldn't need the therapist there. So these are potentially things that people could purchase for their homes on their Xbox console and be able to play it at home and not have to use skilled therapy time for these type of activities. And then they could actually download the results and then bring them to their therapist and be like, hey, these are the areas I played the game at home, I did this, and I practice it. And this is how I progressed. And then the skilled therapist, when they go to therapy sessions, can actually work on some of those tasks. So the nice part, you know, especially in the world of insurance these days, too, right, we only get so many therapy visits in a year. And, you know, you really want to use the skilled therapist time for things that they have access to, and not necessarily some of these things where if we could have gaming systems for people at home, that they could purchase or they could have, you know, you know, apps or whatever to play, that that could really help them with their recovery when they're not in skilled therapy as well. So to me, gaming is a huge, huge part of what the future of rehab and some things that we really need to work with our computer engineers on. And I, you know, the way that they had this to really have the engineers, you know, program and create and then a clinician playing with it and giving them feedback and constantly doing that. That's, you know, some of the work that I'm doing with our system, too, is being the clinician and giving feedback to the engineers, because I have no clue. I'm not tech savvy, I have no clue how to program anything. But, you know, like being able to give that clinical feedback. So these are also areas that I talked to residents about, too, for how can you as a physician get involved in some, you know, research and be the clinical, if you're not a researcher, right? Like, we don't all have to be tenure track researchers that are, you know, coming up with all these ideas. But we can as clinicians be involved in some of these things and help to give feedback and really help to be able to say, well, you know, I have patients with brain injury that have these issues. You know, what kind of games or what kinds of things can we create? And then you work with an engineer and then together you can make a collaborative project. So there's some really cool things with gaming that are a huge part of what the future of rehab should be, and currently. So thanks for bringing this article up, Zach, and, you know, you did a great job summarizing it and bringing in all of the different things from the focus groups, too, because those are things that help enhance systems. So one of the things I talked about was that they had glitches, but then they used these focus groups to really help improve the glitches, and that's exactly what you need to do. It's what all the big gaming companies do, Xbox, PlayStation, they have you beta test it, right? And then they get all the feedback from it and then they improve the system and then they send it out for, you know, full use. And so these are the same kind of concepts. Thank you, Dr. Pesci. Any last minute questions from our audience? I know we're over time, but I want to give our audience a chance to ask a question if there's one out there. All right, going once, going twice. All right, if there is none, I'll go ahead and kind of close us out. So thank you all for attending our Journal Club tonight. Thanks again for Dr. Pesci, especially for great comments and kind of adding clinical applicability. Great talks from Greg, Zach, and Bill. Next Journal Club I'll post in the chat is going to be spinal cord injury themed on March 15th. So feel free to tune in for that for some more learning and the PM&R realm of things. And thank you all for coming. Thank you guys. Thank you for

systematic review

biopsychosocial factors

attention problems

traumatic brain injury

TBI

risk factors

virtual reality grocery store

V-Mart

assessment

intervention tool