The Brain Health Research Institute

Permanent link for this collectionhttp://hdl.handle.net/10292/21288

The Brain Health Research Institute (BHRI) (formerly The Traumatic Brain Injury Network) aims to unite people, services and research to discover how to improve brain health across the lifespan.

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Pervasive TBI and Inhibitory Control in a Male New Zealand Prison Population
(MDPI AG, 2026-06-15) Guy, Sam; Mahon, Susan; Webb, James; Dudley, Makarena; Theadom, Alice
Objective: Traumatic brain injury (TBI) is disproportionately prevalent in incarcerated populations, yet the potential impact on cognitive functioning remains underexplored. This study examined the relationship between TBI history and cognitive performance in a male prison population. Method: Sixty-three participants from Tongariro Prison completed a comprehensive neuropsychological assessment including measures of executive function, memory, processing speed, and perceptual reasoning, with embedded performance validity metrics. TBI history was assessed using the Ohio State University TBI Identification Method (OSU-TBI ID), premorbid function was assessed using the Speed and Capacity of Language Processing (SCOLP) Spot-the-Word task, mood was assessed using the Depression, Anxiety and Stress Scales (DASS-21), and alcohol and substance use were measured using the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST). Regression analyses explored the relationship between TBI history and cognitive functioning, controlling for premorbid function, mood, alcohol and substance use, and ethnicity. Results: Contrary to hypotheses, TBI frequency and severity were not associated with poorer cognitive performance in this population. However, a self-reported history of pervasive TBI—defined as repeated head impacts over a narrow time frame—was significantly associated with reduced performance on the Color–Word Interference Test (CWIT) inhibition task, indicating links to greater cognitive disinhibition. Conclusions: Findings suggest that experiencing at least one period of pervasive TBI may be associated with an impact on inhibition (but not other aspects of executive functioning) in men in prison. These results underscore the importance of nuanced TBI history assessment and highlight inhibition as a potential target for rehabilitation in incarcerated individuals exposed to repetitive head trauma.
Factors Influencing Equestrian Helmet Use, Purchase and Safety Perceptions: A Cross-sectional Study
(Elsevier, 2025-11-27) Gosbee, H; Hume, PA; Theadom, A
Objective Helmets play a critical role in preventing and reducing the severity of head injuries in high-risk sports. Understanding the factors influencing equestrian helmet use and safety perceptions is needed to optimise injury prevention strategies. Methods In this cross-sectional study of 596 equestrian participants aged ≥12 years, we assessed helmet use, factors influencing helmet purchase decisions, and perceptions of helmet safety. Chi square tests and regression models examined differences by age, professional status, jumping versus non-jumping disciplines and concussion history. Results Helmet use whilst riding was high (96 % participants). A high proportion of helmets used for competition (97 %) met at least one safety standard, however this was lower for recreational use (65 %). Younger equestrians (aged 12-44 years) and those who had not experienced a concussion were more likely to rank price as the most important factor for helmet purchase decision making. There were no differences by jumping or non-jumping equestrian disciplines or professional status. Older age and being female were independently linked with higher perceptions of helmet safety in the regression model (p = 0.01). Conclusion Safety messages need to focus on improving understanding of helmet standards and the reasoning behind safety recommendations to help reduce the injury risk in equestrian sports, particularly targeting adolescents/young adults.
A Population-based Study of Traumatic Brain Injury Incidence and Mechanisms in New Zealand: 2021–2022 Compared With 2010–2011
(Elsevier, 2026-01-22) Jones, K; Theadom, A; Starkey, N; Zeng, I; Ameratunga, S; Barker-Collo, S; Wilkinson-Meyers, L; Ao, BT; Henry, N; McClean, LA; Chua, J; Haumaha, L; Kahan, M; Christey, G; Hardaker, N; Jones, A; Dowell, A; Feigin, V
Background: Monitoring traumatic brain injury (TBI) incidence and epidemiological patterns is important for evidence-based strategic planning, policy, prevention, and resource allocation. We revisited population-based estimates and examined patterns of TBI incidence (all ages, severities) in 2021–2022 compared with 2010–2011 in New Zealand (NZ). Methods: Examining an urban (Hamilton) and rural (Waikato District) region in NZ (May 2021–April 2022, unintentionally following the start of the COVID-19 pandemic), we calculated crude annual age-, sex-, ethnic-, urban/rural area- and mechanism-specific TBI incidence per 100,000 person-years with 95% Confidence Intervals (CI). Poisson regression was used to derive adjusted Risk Ratios (aRRs) to compare age-standardised rates between sex, ethnicity, and area groups. Direct standardisation was used to age-standardise rates to the world population. We calculated Incidence Rate Ratios (IRRs) with 95% CI to compare 2021–2022 with 2010–2011 age-standardised rates. Findings: Total TBI incidence per 100,000 person-years was 852 cases (95% CI 816–890), including 791 cases (756–828) of mild TBI, and 61 cases (52–72) of moderate to severe TBI. TBI affected males more than females (IRR 1.31, 95% CI 1.29–1.33), and urban more than rural residents (IRR 1.57, 1.43–1.73). Most TBI (61%) occurred in people aged 15–64 years and were due to falls (48%). European and Asian peoples had lower risk of TBI than Māori (aRRs 0.68, 0.31 respectively). Compared to 2010–2011, total TBI incidence and rates among Māori were stable; TBI incidence was greater among females, urban residents, and adults aged ≥34 years; and TBI due to falls significantly increased (IRR 1.20, 95% CI 1.03–1.40). Interpretation: Noting increased risks for underestimation due to COVID-19, findings suggest overall TBI incidence rate in NZ was similar in 2021–2022 to 2010–2011, while highlighting changes in TBI distribution. Age-, sex-, area-, ethnic-, and mechanism-specific distributions should be considered when revisiting prevention strategies to reduce TBI incidence. Funding: Health Research Council of New Zealand of NZ.
The Impact of Balance Exercise on Brain Age and Brain Morphometry: Insights From MRI Analysis
(Springer, 2026-01-22) Narula, Varima; Taylor, Denise; McLaren, Ruth; Taylor, Rachael L; Mahon, Susan; Smith, Paul F; Chaudhary, Shikha; Winton, Roger W; Fernandez, Justin; Shim, Vickie; Wang, Alan
Physical exercise is known to delay the cognitive decline in the elderly. However, the effect of low-impact balance exercises such as yoga or Tai chi has not been explored in detail. This cross-sectional observational study used brain magnetic resonance imaging data to quantify and compare various brain structures between neurologically healthy adults aged between 55 and 65, divided into Control Group and Balance Exercise (BE) Group based on the self-reported balance exercise status. Various brain attributes such as brain age, cortical and subcortical volume, thickness, surface area, and mean curvature were extracted and computed using machine learning algorithm software like brainageR and FreeSurfer. Clinical functional assessments (balance, vestibular and cognitive measures) were also conducted for the participants. Statistical analyses were performed to determine any differences between the groups at a significance level of 5%. The BE group showed statistically significantly higher values for the right caudal anterior cingulate thickness, left and right superior temporal volume, left entorhinal volume and mean curvature, left frontal pole thickness, left superior temporal area and left inferior temporal thickness. A statistically significant cluster after correction for multiple comparisons was found in the left rostral middle frontal gyrus with a higher volume for BE group. Clinical functional assessments (balance, vestibular and cognitive) and brain age differences were nonsignificant. The significant brain regions in the BE group are involved in memory, cognition, focus, planning, language and auditory processing, decision making, emotional regulation and mental health and could be responsible for protecting and delaying the cognitive declines in the elderly.
Challenges and Opportunities of General Practitioners and Physiotherapists Managing Return to Play Following Sports Related Concussion: A Qualitative Study
(Physiotherapy New Zealand, 2026-03-21) Hancock, Colin; Chua, Jason; Theadom, Alice; Reid, Duncan
Physiotherapists in Aotearoa New Zealand, face challenges implementing evidence-based practice (EBP) for non-ambulatory children with cerebral palsy and intellectual disabilities (NACCPID) working within Hoffman’s model of EBP. Key challenges in the evidence component include limited NACCPID specific research. This project aims to review the literature on physiotherapy interventions for school-aged NACCPID to inform clinical practice and identify areas for future research within the Aotearoa New Zealand context. An integrative review was conducted, following Kutcher and LeBaron’s (2022) method. A systematic search, conducted in 2023, yielded 2,240 articles that were narrowed to 24 after applying inclusion criteria. Coding and thematic analysis were conducted in NVivo 12 following content analysis methods. Final codes were organised within the Te Whare Tapa Whā framework through collaborative review with a cultural advisor. This enabled a holistic view of health, addressing physical, mental, social, and spiritual wellbeing, incorporating Māori perspectives. Ten themes were generated relating to physiotherapy interventions for NACCPID: 1) individual needs; 2) self-esteem and positive emotions; 3) body systems; 4) optimising ability to move the body; 5) using the body to perform a task; 6) collaboration; 7) (in)dependence; 8) participation and inclusion; 9) resourcing; and, 10) accessible environments. Notably, power wheelchair training appears to have significant beneficial effects across all aspects of health, and it is important that the child and families’ individual needs, wants, likes, circumstances, and values are considered when choosing an intervention.
A Summary of the First Australian and Aotearoa New Zealand Clinical Practice Guideline for the Management of Mild Traumatic Brain Injury/Concussion and Persisting Post-concussion Symptoms
(The Royal Australian College of General Practitioners, 2026-02-01) Barlow, Karen M; Lim, Sheryl SY; Haines, Elizabeth; Cowen, Gill; Ponsford, Jennie; Theadom, Alice; Treleaven, Julia; Davis, Gavin; Anderson, Vicki; Babl, Franz; Cole, David; Cullen, Jennifer; Dalziel, Stuart; Fitzgerald, Melinda; Flavell, Howard; Yates, Caroline; Kimble, Rebecca; Olver, John; Orr, Rhonda; Ralfe, Mark; Rose, Michael; Rushworth, Nick; Browne, Gary; Mitchell, Gary; Tweedy, Sean
BACKGROUND: Mild traumatic brain injury (mTBI) and concussion are important healthcare issues, with ongoing and persisting symptoms significantly affecting a person's quality of life. Management is often challenging. OBJECTIVE: Using a case study example, this article outlines key updates and practical guidance for assessment and management of mTBI/concussion, informed by the newly developed Australian and Aotearoa New Zealand (ANZ) mTBI and concussion clinical practice guideline. DISCUSSION: The 'Australian and Aotearoa New Zealand Clinical Practice Guideline for the management of mild traumatic brain injury/concussion and persisting post-concussion symptoms in adults and children' is the first guideline to address the full scope of mTBI/concussion management across diverse ANZ populations. It provides general practitioners and other clinicians with practical, evidence-based recommendations for assessing and managing mTBI and persisting symptoms across all ages. Developed through multidisciplinary and consumer collaboration, it aims to promote consistent, high-quality care and reduce practice variation across healthcare settings.
Structural Brain Differences in Professional Australian Rules Footballers Following Mild Traumatic Brain Injury: When Head Size Matters
(Frontiers Media SA, 2026-01-16) Lee, Jackson M; Pardoe, Heath R; Parker, Donna M; Pedersen, Mangor; Makdissi, Michael; Abbott, David F; Jackson, Graeme D; Mito, Remika
Introduction Concussion, a type of mild traumatic brain injury common in collision sports, is thought to be associated with subtle brain changes that are not visually appreciable on conventional neuroimaging. This study quantified differences in subcortical volumes from structural MRI between 31 recently concussed professional Australian rules footballers (within 3 months of injury) and 37 healthy, non-athlete controls. Methods T1-weighted MRI were acquired at 3 T and processed using FreeSurfer. Hippocampal and amygdala volumes were normalized by estimated total intracranial volume (eTIV). Longitudinal changes were assessed in a subset of 12 footballers with follow-up MRI. Cortical thickness differences were also explored using vertex-wise analysis. Results Footballers exhibited lower proportional hippocampal and amygdala volumes, and reduced cortical thickness compared to controls. However, after exploring different methodological approaches for estimating intracranial volume (ICV), volumetric findings were seen to vary based on the ICV estimation method used for normalization. Discussion This study demonstrates subtle, likely persistent neuroanatomical differences between professional Australian rules footballers and non-athlete controls. Importantly, we advocate for cautious clinical interpretation of volumetric MRI findings considering methodological variabilities, particularly when inherent cohort differences (such as ICV) may bias results, and provide recommendations for future studies that examine volumetric changes in concussion cohorts.
Neuroimaging Correlates of Symptom Burden and Functional Recovery Following Mild Traumatic Brain Injury: A Systematic Review
(Elsevier BV, 2025-11-19) McGeown, Joshua P; Pedersen, Mangor; Mito, Remika; Theadom, Alice; Maller, Jerome J; Condron, Paul; Holdsworth, Samantha J
BACKGROUND: Mild traumatic brain injury (mTBI) represents 95% of all traumatic brain injuries. Despite being classified as "mild," mTBI can lead to persistent symptoms that impact quality of life. Diagnostic and management strategies rely heavily on subjective symptom reporting due to a lack of validated biomarkers. Identifying neuroimaging biomarkers to characterise the pathophysiological features underlying symptom burden and poor recovery is critical for improving mTBI management. OBJECTIVE: To synthesise evidence on cross-sectional, longitudinal, and prognostic links between Magnetic Resonance Imaging (MRI) features and mTBI symptom burden and functional recovery. METHODS: The review followed PRISMA guidelines. Systematic searches of MEDLINE, SCOPUS, and Cochrane Library identified mTBI studies with acute MRI data, measures of symptom burden or functional recovery, and at least one follow-up clinical timepoint, covering publications to July 18, 2025. Risk of bias was evaluated using the Quality in Prognostic Studies tool, and findings were synthesised narratively. RESULTS: Sixty-two of 7,232 articles were included. The review identified heterogeneous evidence across MRI modalities. Structural MRI findings showed limited correlation with clinical outcomes, while changes in white matter and functional connectivity were more strongly associated with symptom burden and recovery. Disruptions of integrative regions and association pathways such as the thalamus, superior longitudinal fasciculus, and cingulate cortex were linked to worse symptom burden and recovery outcomes. CONCLUSIONS: Acute MRI, when contextualised with clinical data, helps delineate correlates of mTBI symptom burden and functional recovery. To strengthen inference, future neuroimaging studies should prespecify and report symptom burden and functional recovery as core endpoints.
“I can remember thinking, like almost wishing, that the injuries would have been worse, because then I wouldn’t be questioned”: A Qualitative Study on Women’s Experience of Accessing Healthcare for Intimate Partner Violence-related Brain Injury
(MDPI AG, 2026-01-08) Valera, Eve M; Sanghvi, Isha; Sitto, Sarah Rose; Chua, Jason; Saadi, Altaf; Theadom, Alice
Background/Objectives: To identify the barriers and facilitators to accessing healthcare following intimate partner violence (IPV)-related brain injury (BI). Methods: Sixteen adult women participated in interviews about their experience of accessing healthcare following IPV-related BI. Interviews were transcribed verbatim and analyzed using the interpretative descriptive (ID) approach to identify themes and subthemes in the data. Results: Two themes, each with six subthemes related to healthcare seeking for IPV-related BI were identified: Theme 1—Deciding to seek and ability to access healthcare, comprising (a) severity of injury; (b) impact of injury; (c) ability to access medical services; (d) self-blame, fear, shame, and guilt; (e) contextual influences on healthcare seeking; and (f) previous negative interactions; and Theme 2—Complexity in identifying IPV-related BI, comprising (a) trauma can affect recall of events; (b) inability to distinguish IPV-related trauma or aging outcomes from BI sequelae; (c) the importance of trust in disclosure; (d) healthcare professionals need to ask the right questions and respond in the right way; (e) the complex nature of disclosure creates challenges for diagnosis; and (f) fear of being dismissed or judged. Conclusions: Many context-related factors influence whether women can seek treatment for IPV-related BIs. These factors need to be understood by first responders and medical professionals to improve the likelihood and speed of treatment seeking. Furthermore, challenges and fears associated with disclosure of IPV prevent women from seeking proper treatment. IPV training could be helpful in ensuring women feel safe with disclosure.
Head Impact Exposure in Junior and Adult Australian Football Players
(Wiley, 2018-04-01) Hecimovich, Mark; King, Doug; Dempsey, Alasdair; Murphy, Myles
This study measured and compared the frequency, magnitude, and distribution of head impacts sustained by junior and adult Australian football players, respectively, and between player positions over a season of games. Twelve junior and twelve adult players were tracked using a skin-mounted impact sensor. Head impact exposure, including frequency, magnitude, and location of impacts, was quantified using previously established methods. Over the collection period, there were no significant differences in the impact frequency between junior and adult players. However, there was a significant increase in the frequency of head impacts for midfielders in both grades once we accounted for player position. A comparable amount of head impacts in both junior and adult players has implications for Australian football regarding player safety and medical coverage as younger players sustained similar impact levels as adult players. The other implication of a higher impact profile within midfielders is that, by targeting education and prevention strategies, a decrease in the incidence of sports-related concussion may result.
Long-Term Cumulative Effects of Repeated Concussions in Cyclists: A Neurophysiological and Sensorimotor Study
(MDPI AG, 2025-10-22) Pearce, Alan J; King, Doug
Objectives: Sports-related concussion (SRC) is mostly associated with contact and combat sports. However, emerging evidence suggest that cyclists are also at risk of repeated concussion injury. Moreover, long-term neurophysiological outcomes in cycling cohorts remain underexplored. This novel study investigated the long-term effect of repetitive concussions in cyclists. Road, mountain biking (MTB), and BMX riders with a history of concussions and self-reported persistent symptoms were assess for neurophysiology and cognitive-motor performance compared to previously concussed cyclists with no ongoing symptoms. Both groups were compared to age-matched with controls. Methods: Using a cross-sectional between-group design, 25 cyclists with a history of concussions (15 symptomatic, 10 asymptomatic) and 20 controls completed symptom reporting, cognitive and balance assessments (SCAT5), sensorimotor testing using vibrotactile stimulation, and neurophysiological assessments via transcranial magnetic stimulation (TMS). Results: Symptomatic cyclists reported a higher number of concussions compared to asymptomatic cyclists (p = 0.041). Cognitive testing revealed large effects (d > 1.0), with impaired concentration in symptomatic cyclists compared to controls (p = 0.005). Motor assessments demonstrated large effects (d > 1.0), with slower tandem gait times (p < 0.001) and greater errors (p = 0.02) in the symptomatic group. Sensorimotor testing indicated slowed simple reaction times (p = 0.001) and poorer temporal order judgement (p = 0.038). TMS showed large effects (d > 1.0) in increased cortical inhibition in the symptomatic group, with prolong cortical silent periods (p < 0.05) and large effects (d > 1.0), and reduced short interval intracortical inhibition (p = 0.001) compared to asymptomatic cyclists and controls. Conclusions: Cyclists reporting persistent symptoms showed greater cortical inhibition and impaired cognitive-motor performance, consistent with findings in contact sport athletes. These results suggest that repeated concussions in cycling carry risk of chronic neurophysiological alterations. Cycling disciplines should consider more rigorous concussion identification protocols and stricter management strategies to mitigate persistent and long-term consequences.
Differences Between the Sexes in Concussion Knowledge and Attitudes in Community Football (Soccer) Players in New Zealand
(Elsevier BV, 2025-02-16) Hardaker, Natalie J; Hume, Patria A; Collins, Juno Barnett; King, Doug A; Sims, Stacy T; Selfe, James
Objectives: To evaluate self-reported concussion knowledge and attitudes in community football players in New Zealand, comparisons were made between the sexes and those with and without history of concussion. Design: Cross-sectional cohort study. Methods: The Rosenbaum Concussion Knowledge and Attitudes Survey (RoCKAS) was used for data collection and analysis. Players were recruited through the New Zealand Football registered player database. Results: Seventy-four players had data eligible for inclusion (55 % female). Thirty-four players (45 %) had previously diagnosed concussion (56 % female). Mean Concussion Knowledge Index (CKI) scores were significantly (p = 0.002) higher for male (20.8 ± 1.4) than female (19 ± 3.7) players. There were no significant sex differences in mean Concussion Attitude Index (CAI) scores (female 63.7 ± 11.4, male 65.6 ± 6.0; p = 0.427). Surprisingly, 32 % female and 39 % male players indicated that they would play on with symptoms of concussion. Comparison within female players showed a significantly higher CKI (20.3 ± 1.7 versus 18.8 ± 2.6; p = 0.025) and higher CAI (66.5 ± 4.9 versus 64.1 ± 5.9; p = 0.151) in players with a history of concussion. There were no within male player trends for CKI or CAI. Conclusions: Male players had a notably higher concussion knowledge (CKI) than female players. Females with a previously diagnosed concussion also had a notably higher CKI than female players with no concussion history. Therefore, healthcare professionals could play a key education role when managing players with concussion. Given over a third of players indicated that they would play on with symptoms of concussion, education should focus on short- and long-term impacts of concussion and potential consequences of concussion.
Mild and Moderate Traumatic Brain Injury: Screening, Documentation, and Referral to Concussion Services
(Elsevier, 2025-04-09) Zangi, Mahdi; Pickering, John W; Theadom, Alice; Than, Martin; Snell, Deborah L
BACKGROUND AND AIM: Screening of traumatic brain injuries (TBI) using different clinical assessment tools would facilitate diagnosis and effective inpatient follow-up. We aimed to describe rates of diagnosis, classification, documentation, and referral practices for TBI inpatients. MATERIAL AND METHODS: In a retrospective cohort study, we reviewed electronic clinical records of adult patients admitted to a hospital ward with head trauma from an emergency department (ED) in 2021. Data included demographics, injury, TBI diagnoses, and referral to concussion services. Factors predicting ED physician documentation and referral to concussion services were identified. RESULTS: Of approximately 34,000 adults admitted from the ED, 1059 presented with head trauma, and 609 (57.5 %) were diagnosed with TBI. There were 553 mild/moderate TBI cases with an incidence rate of 103.4 per 100,000 adult population in Canterbury. 14 % (n = 77) were referred to a concussion service. Predictors of ED-documented TBI included non-isolated head injury (OR:0.60), head CT request (OR:9.12), injured in street/public areas (OR:2.03). Older age and non-isolated head injury decreased odds of concussion service referral (0.96 and 0.46, respectively), while female and ED-documented TBI increased odds of referral (5.8 and 28, respectively). CONCLUSION: Better documentation of mild/moderate TBI might facilitate health care access, with efficient clinical decision making.
Sex-based Differences in Affective and Cognitive Empathy Following Severe Traumatic Brain Injury
(American Psychological Association, 2018-07-01) Zupan, B; Neumann, D; Babbage, D; Willer, B
Objective: To examine sex differences in self-ratings for affective and cognitive empathy for males and females with traumatic brain injury (TBI) and compare these to observer ratings. Method: Self and observer (e.g., spouse) ratings of affective and cognitive empathy were obtained for 160 participants (116 males) with severe TBI, using the Interpersonal Reactivity Index Empathic Concern (EC) and Perspective Taking (PT) subscales, respectively. Results: When compared to sex norms, female self-ratings were significantly lower for both subscales, whereas men's self-report ratings were only lower for PT. For EC, more women (44%) were found to be substantially below the normative means (≥2 SDs) than men (17%), p < .001. When comparing women and men with TBI, self-report and observer ratings indicated both sexes had similar empathy levels (both subscales). Self versus observer ratings showed that women's self-ratings were significantly higher than observer's ratings on PT (p < .001); men's self-ratings were significantly higher than observer's ratings on PT (p < .001) and EC (p = .009). Conclusions: In contrast to the typically observed superior female empathy, this study suggests this advantage may disappear after a TBI, and possibly result in a disadvantage compared to their uninjured female peers. Theoretical implications of self-awareness and cultural gender expectations for empathy are discussed.
Quantitative MRI T2 Relaxometry and Physical Activity in Acute Mild Traumatic Brain Injury: An Exploration of the Measurement and Modification of Potential Neuroinflammation
(Auckland University of Technology, 2025) Bedggood, Mayan
Mild traumatic brain injuries (mTBI) account for approximately 90% of all traumatic brain injuries (TBI) and are often associated with prolonged symptoms and functional impairments. Despite their prevalence and significant physical, psychosocial and financial impact, the underlying pathophysiology and factors influencing recovery remain poorly understood. mTBI typically results from a sudden impact, acceleration, deceleration, or rotational force, triggering a cascade of secondary injuries. A key component of this cascade is neuroinflammation, which, while initially protective, can lead to chronic deficits and neurodegeneration if prolonged or excessive. Despite the known role of inflammation in brain injury, significant gaps remain in understanding its influence on recovery and how it might be modulated. This thesis aims to address these gaps by investigating a method for measuring potential neuroinflammation and exploring a behavioural approach to modifying it. Forty male athletes (aged 16-35 years) were recruited within 14 days of sports-related mTBI, along with 52 age and sex-matched controls. T2-weighted MRI data were collected using a Carr-Purcell-Meiboom-Gill (CPMG) spin-echo sequence. Preprocessing included brain extraction, normalisation, smoothing, and grey matter masking. T2 relaxation times were estimated at each voxel using a monoexponential model in qMRLab. Participants also wore Axivity AX3 wrist accelerometers continuously for 15 days to capture physical activity data. Physical activity data were analysed using the GGIR, compositions and deltacomp packages in R. The thesis comprises three studies. Studies 1 and 2 assess the utility of MRI T2 relaxometry as a marker of neuroinflammation. Study 1 used a case series approach, statistically comparing individual mTBI participants to the control group via z-tests and voxel-wise z-maps. Results showed elevated T2 relaxation times in acute mTBI, with unique regional patterns per individual and follow-up scans in a subset of participants demonstrated reductions in T2 relaxation times, suggesting recovery. Study 2 complemented this with a group-level analysis. Independent samples t-tests with threshold-free cluster enhancement (TFCE) revealed significantly higher T2 relaxation times in the mTBI group, particularly in frontoparietal regions, as well as a negative correlation between T2 relaxation times and recovery time. Study 3 shifted the focus to intervention, using compositional data analysis to examine physical activity patterns post-injury. No significant group differences were found, supporting the tolerability of physical activity during early recovery. Although longer sleep duration initially correlated with prolonged recovery, this effect was attenuated after adjusting for baseline symptom severity. Together, the findings suggest that quantitative T2 relaxometry is a sensitive, non-invasive marker of brain changes potentially reflecting neuroinflammation. The correlation between T2 relaxation times and recovery time may emphasise a dual role of inflammation, beneficial in the acute phase but potentially harmful if prolonged. Study 3 supports the tolerability of physical activity during early recovery and highlights the utility of compositional analysis in understanding movement behaviours. Given the known anti-inflammatory effects of physical activity, its role in recovery may partially stem from modulating neuroinflammation. These findings support a more individualised approach to mTBI care, integrating objective measures with clinical assessments to identify patients at risk of prolonged inflammation and neurodegeneration. Future research should focus on longitudinal designs with more diverse samples and larger activity datasets to better understand recovery trajectories and optimise intervention timing. As the first to apply quantitative T2 relaxometry and compositional data analysis in mTBI, this thesis offers novel insights into brain changes and physical activity patterns following injury.
Highlighting Gaps in the Reporting of Aerobic Exercise Interventions for Mild Traumatic Brain Injury: A Systematic Review Using the TIDieR-Rehab Checklist
(Elsevier, 2025-11-06) Tracey, Isaac; Gomes, Emeline; Signal, Nada; Alder, Gemma; Forch, Katherine; Olsen, Sharon
Objective: To assess intervention reporting quality in randomised controlled trials (RCTs) comparing aerobic exercise with control interventions following mild traumatic brain injury (mTBI). Methods: Five databases were systematically searched for RCTs that compared the effect of aerobic exercise interventions with no intervention or another control, on symptom severity or recovery, in adolescents or adults with mTBI. Two reviewers independently screened articles, extracted data, and rated reporting quality using the TIDieR-Rehab checklist. Reporting completeness was quantified by intervention group and TIDieR-Rehab item. Authors were contacted to determine if reporting could be improved. Results: Within 13 included studies, overall reporting was moderate (62 % of TIDieR-Rehab items complete). Dosage items ‘Frequency’ (85 %) and ‘Intervention length’ (96 %) were well reported, whereas ‘Session duration’, ‘Essential elements amount’, ‘How challenging’, and ‘Regression/Progression’ were moderately reported (54 %–65 % complete). Personalisation and protocol deviations were poorly reported (12 %–23 %). On average, authors supplied 71 % of missing intervention details on request. Conclusions: The TIDieR-Rehab checklist revealed critical reporting gaps. Incomplete reporting of aerobic exercise parameters hinders clinical translation and limits investigation of optimal dosage parameters and underlying mechanisms. Poor reporting of personalisation and protocol deviations may mask necessary adaptations for individuals with mTBI. To improve reporting in this field, it is recommended that researchers utilise the TIDieR-Rehab checklist when planning and reporting their studies.
Preliminary Validation of a 10-item Version of the Depression, Anxiety and Stress Scale in a Mild Traumatic Brain Injury Sample
(CSIRO Publishing, 2025-10-21) Snell, Deborah L; Faulkner, Josh W; Siegert, RJ
BACKGROUND: In this study, we evaluated the psychometric properties of a 10-item version of the Depression, Anxiety and Stress Scale (DASS-10) in a mild traumatic brain injury (mild TBI) sample. METHODS: Treatment-seeking adults (n = 354; mean age 36.3 years, 62% women) were recruited from outpatient rehabilitation services in New Zealand. Participants completed the DASS-10 on average 11.5 (15.0) weeks after their injury. Dimensionality, reliability, person separation index and differential item functioning of the DASS-10 were examined using Rasch analyses. RESULTS: Initial fit to the Rasch model for the 10-item measure was good (χ2 = 78.6, d.f. = 70, P = 0.22), with high internal consistency (Cronbach's alpha 0.89, person separation index 0.86) and acceptable unidimensionality. There was no evidence of differential item functioning for any of the person factors tested (age, gender, ethnicity, education, mental health history). CONCLUSION: These findings provide preliminary support for the DASS-10 as a psychometrically sound measure of psychological distress for adults seeking treatment following mild TBI. The DASS-10 for mild TBI may be a helpful brief measure to triage mental health needs among persons referred to outpatient services after mild TBI.
Brain Injury Sense of Self Scale: Psychometric Development of a New Measure of Strength of Self-Identity After Traumatic Brain Injury
(Edizioni Minerva Medica, 2025-04-24) Thomas, Emily J; Taylor, William J; Siegert, Richard J; Levack, William M
BACKGROUND: There is growing awareness that traumatic brain injury (TBI) can have a significant and troublesome impact of a person's self-identity, yet few measurement tools exist to clinically evaluate this. AIM: The aim of this paper was to develop a patient-reported measure of strength of self-identity after TBI - the Brain Injury Sense of Self Scale (BISOSS). DESIGN: Measurement development and validation. SETTING: UK and New Zealand communities. POPULATION: One hundred and thirty-six people with TBI (68.4% [93/136]) male; mean age 47.9 years, SD 13.0 years; mean time post-TBI 11.2 years, SD 11.1 years; 74.3% (101/136) moderate to severe TBI). METHODS: Preliminary measurement items were generated from prior qualitative research, a concept analysis, and cognitive interviewing with survivors of TBI. Administration of the draft BISOSS, the Glasgow Outcome Scale, and the Sense of Coherence Scale to participants - with factor analysis, Rasch analysis, and construct validity testing to refine and test the draft BISOSS. RESULTS: After iterative refinements using the Rasch model to help guide item adjustments, BISOSS was comprised of three subscales (egocentric self, sociocentric self, and relational self), each which fit the Rasch model and demonstrated unidimensionality, adequate precision, absence of differential item functioning and adequate person separation index. BISOSS scores correlated well with employment status, leisure activities and positive family relationships. Participants' responses supported the notion that problems with self-identity were commonplace after TBI, with 40% of respondents self-reporting such problems. CONCLUSIONS: BISOSS is a valid measure, which conforms to measurement expectations for an interval scale and is in grounded in the language of people with TBI. It is now available as a validated tool for assessing self-identity issues post-TBI. Further work is required to assess whether the scale can change over time or is responsive to interventions targeted at strengthening self-identity. CLINICAL REHABILITATION IMPACT: Change in self-identity is a commonplace problem following TBI but is seldomly evaluated in clinical practice. BISOSS can be used to explore patient experiences of problems with self-identity after TBI and will help further our understanding of this phenomenon.
Associations Between Illness Perceptions, Distress, Self-Reported Cognitive Difficulties and Cognitive Performance After Mild Traumatic Brain Injury
(CSIRO Publishing, 2025-08-01) Snell, Deborah L; Faulkner, Josh W; Williman, Jonathan A; Silverberg, Noah D; Theadom, Alice; Surgenor, Lois J; Siegert, Richard J
Objectives To examine associations between subjective and objective cognitive problems, and factors potentially modifying these relationships, after mild traumatic brain injury (mTBI). Methods Treatment-seeking adults (n = 95) were assessed 6 weeks (Time 1) and then 6 months later (Time 2) after mTBI. Validated questionnaires assessed cognitive, emotional and somatic mTBI symptoms, distress, catastrophising, and beliefs about symptoms and recovery. Cognitive performance was measured using the National Institutes of Health Toolbox Cognition Battery. Using correlations and linear regression, we explored associations between psychological factors, objectively measured cognitive performance and self-reported cognitive symptoms. Results There were only modest correlations between subjective cognitive symptoms and objective cognitive performance at assessment timepoints. In contrast, there were medium to large correlations between subjective cognitive symptoms, post-concussion symptom burden and psychological factors. Post-concussion symptom burden and beliefs about symptoms and recovery at Time 1 predicted persisting self-reported cognitive symptoms at Time 2. Conclusions High post-concussion symptom burden and non-recovery expectations may increase risk for persistent subjectively experienced cognitive symptoms. Our findings may guide targeted treatment efforts focusing on factors with potential to influence cognitive symptom reporting after mTBI. Summary In this study, we investigated factors that might influence cognitive recovery after concussion. We found having many post-concussion symptoms and fears of nonrecovery may increase risk for persisting cognitive symptoms. Our findings may guide targeted treatment efforts focusing on factors with potential to influence cognitive symptom reporting after concussion.
The Prognostic Value of a Screening Tool for Psychological Risk Factors After Mild Traumatic Brain Injury: Prospective Studies in Canada and New Zealand
(BMJ, 2025-09-10) Mikolić, Ana; Snell, Deborah L; Theadom, Alice; Faulkner, Josh W; Zemek, Roger; Silverberg, Noah D
OBJECTIVE: To investigate the prognostic value of the Subgroups for Targeted Treatment (STarT) Screening Tool adapted for concussion (STarT-C) on persistent symptoms and disability at 6-9 months following mild traumatic brain injury (mTBI). DESIGN: Secondary analysis of two prospective studies: an observational cohort study in New Zealand and usual care control arm of a clinical trial in Canada (ClinicalTrials.gov Registry (NCT04704037)). SETTING: Participants in the New Zealand cohort were recruited from concussion clinics (five sites) and those in the Canadian cohort were recruited from emergency departments/urgent care centres (eight sites). PARTICIPANTS: New Zealand participants (n=93, median age 37 years, 60% women) were assessed at median=6 weeks post-injury (T1) and 6 months later (T2). Canadian participants (n=223, median age 38 years, 56% women) were assessed at median=2 weeks (T1) and 6 months later (T2). MAIN OUTCOME MEASURES: Symptoms at T2 were assessed using the validated Rivermead Postconcussion Symptoms Questionnaire (RPQ) and disability using the WHO Disability Assessment Schedule 2.0 12-item Interview. RESULTS: In linear regression analyses, the STarT-C predicted symptom burden (R2=18-36%) and disability (R2=15-18%) at T2 in both cohorts. While the additional prognostic value over and above baseline variables was substantial (delta R2 8-40%), the additional prognostic value over the RPQ at T1 was variable and generally lower (delta R2=1-9%). CONCLUSION: The STarT-C-a brief screening tool-predicted persistent symptoms and disability in adults following mTBI. The incremental prognostic value of the STarT-C over the RPQ may be variable, but regardless, the tool may be useful for identifying those at risk of prolonged recovery who may benefit from early psychological intervention.

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