Analysis of US Veterans Health Administration comprehensive evaluations for traumatic brain injury in Operation Enduring Freedom and Operation Iraqi Freedom Veterans

OBJECTIVE

To describe neurobehavioural symptoms in Iraq and Afghanistan war veterans evaluated for traumatic brain injury (TBI) through the Veterans Health Administration (VHA) TBI screening and evaluation programme.

DESIGN

An observational study based on VHA administrative data for all veterans who underwent TBI Comprehensive Evaluation between October 2007 and June 2010.

RESULTS

55,070 predominantly white, non-Hispanic, male Veterans with a positive TBI screen had comprehensive TBI evaluations completed during the study period. Moderate-to-severe symptoms were common in the entire sample, both in those with and without a clinician-diagnosed TBI. However, the odds of reporting symptoms of this severity were significantly higher in those diagnosed with TBI compared to those without a TBI diagnosis, with odds ratios ranging from 1.35-2.21. TBI-specialty clinicians believed that in the majority of diagnosed TBI cases both behavioural health conditions and TBI contributed to patients' symptom presentation.

CONCLUSIONS

The VHAs TBI screening and evaluation process is identifying individuals with ongoing neurobehavioural symptoms. Moderate-to-severe symptoms were more prevalent in veterans with TBI-specialty clinician determined TBI. However, the high rate of symptom reporting also present in individuals without a confirmed TBI suggest that symptom aetiology may be multi-factorial in nature.

Demographics, clinical practice patterns, and concerns of physiatrists in the State of Hawai'i: 2011

BACKGROUND

Although the State of Hawai'i overall may have an adequate number of physiatrists, there are physiatrist shortages on the neighbor islands. This study describes the demographics, practice type, and most important concerns of current practicing physiatrists within the state of Hawai'i.

METHODS

A phone survey was conducted of 44 actively practicing Hawai'i physiatrists. Eligible participants were members of either the American Academy of Physical Medicine and Rehabilitation (AAPMR) or the Hawai'i Society of Physical Medicine and Rehabilitation.

RESULTS

Thirty-six of 44 local physiatrists responded to the survey. Thirty-two of the thirty-six (89%) respondents were currently practicing on O'ahu, nine (25% of respondents) completed medical school at University of Hawai'i, 19 (58% of respondents) were not planning on recruiting in their practice for at least five years and the physiatrists' most common concerns included poor reimbursement, practice management problems, and high workload.

DISCUSSION

Further recruitment efforts should be tailored to attracting physiatrists to our neighbor islands. Increasing reimbursement, addressing hospital administration issues, developing a musculoskeletal fellowship program, and increasing incentives to practice on neighbor islands are proposed changes that would directly address the concerns of Hawai'i's physiatrists.

Assessment and treatment of common persistent sequelae following blast induced mild traumatic brain injury

The ongoing wars in Iraq and Afghanistan and terrorist activity worldwide have been associated with an increased incidence of blast injuries. While blast injuries share similarities with blunt or penetrating traumatic injuries, there are unique mechanistic elements of blast injury that create increased vulnerability to damage of specific organs. This review highlights the mechanism of blast-related injury, describes the common sequelae of blast exposure that may impact rehabilitation care, and summarizes the intervention strategies for these blast-related sequelae.

Recommendations for the use of common outcome measures in traumatic brain injury research

This article summarizes the selection of outcome measures by the interagency Traumatic Brain Injury (TBI) Outcomes Workgroup to address primary clinical research objectives, including documentation of the natural course of recovery from TBI, prediction of later outcome, measurement of treatment effects, and comparison of outcomes across studies. Consistent with other Common Data Elements Workgroups, the TBI Outcomes Workgroup adopted the standard 3-tier system in its selection of measures. In the first tier, core measures included valid, robust, and widely applicable outcome measures with proven utility in TBI from each identified domain, including global level of function, neuropsychological impairment, psychological status, TBI-related symptoms, executive functions, cognitive and physical activity limitations, social role participation, and perceived health-related quality of life. In the second tier, supplemental measures were recommended for consideration in TBI research focusing on specific topics or populations. In the third tier, emerging measures included important instruments currently under development, in the process of validation, or nearing the point of published findings that have significant potential to be superior to some older ("legacy") measures in the core and supplemental lists and may eventually replace them as evidence for their utility emerges.

Potential driving issues in combat returnees

The driving abilities of service members returning from Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) have not been well reported and are an important aspect of their return to normal life. This article reviews the unique risk factors for unsafe driving in this cohort. In particular, the cognitive and psychological symptoms of mild traumatic brain injury and postraumatic stress disorder, two of the most common diagnoses affecting these returning warriors, are specified, and their possible association with impaired driving is examined. The potential negative impact of the "battlemind driving tactics" (i.e., evasive driving skills) acquired by these service members as part of their military tours is also highlighted. The article concludes with comments about the functional consequences of impaired driving in this population, including limits to participation in rehabilitation and community reintegration, as well as recognition of the need for further research in this area.

Health literacy among patients diagnosed with movement disorders: a pilot study

OBJECTIVE

The study sought to examine the functional health literacy in a sample of geriatric patients diagnosed with movement disorders. The hypothesis was that the study group would demonstrate marginal levels of health literacy scores on a standardized health literacy instrument.

DESIGN/SETTING

The study used a prospective analysis of patients referred to an outpatient movement disorders clinic in a Veterans Affairs Medical Center.

PATIENTS

Fifty-four men with a movement disorder volunteered for the study, with data analysis conducted on 44 of these patients.

MAIN OUTCOME MEASUREMENTS

The primary outcome measure was the Test of Functional Health Literacy in Adults (TOFHLA).

RESULTS

Members of the current sample demonstrated adequate health literacy and scored significantly higher on the TOFHLA relative to the measure's normative sample. Younger age, more education, and higher Mini Mental Status Examination (MMSE) scores were predictive of health literacy.

CONCLUSIONS

The extant literature strongly suggests that limited health literacy is a frequent problem across the United States and represents a considerable obstacle to the effective delivery of health care. In a group of movement disorder subjects with a Folstein MMSE of at least 24, health literacy was generally well preserved. Years with movement disorder and severity of disorder did not impact health literacy. Thus, practitioners should not be prejudiced in a belief that individuals with movement disorders cannot manage their medications.

A pilot study of vitamin D and balance characteristics in middle-aged, healthy individuals

OBJECTIVE

To examine what relationship exists between 25-hydroxyvitamin D (25-OHD) levels and postural competency in the middle-aged, healthy individual.

DESIGN

A community convenience sample.

SETTING

Major medical center employees.

SUBJECTS

Thirty-five healthy individuals older than 40 years of age who demonstrated appropriate cognition and physical stability. Specific exclusion criteria included any prior history of hip, knee, or ankle fracture or surgery.

METHODS

Questionnaire regarding exercise and sun exposure, vitamin D blood level, followed by computerized dynamic posturography (CDP) assessment of balance.

MAIN OUTCOME MEASUREMENTS

CDP scores of individuals with normal and subnormal vitamin D levels.

RESULTS

Thirteen male and 22 female subjects had a mean age of 56.0 years (standard deviation, 7.6; range, 42-77). Self-reported, retrospective mean weekly sun exposure was 7.36 hours (standard deviation, 6.4 hours). Twenty-six subjects (76.5%) described themselves as regular exercisers. Mean 25-OHD level for the sample was 21.5 ng/mL (standard deviation, 12.1 ng/mL). When subjects were divided into those with low and high 25-OHD levels, there was no significant difference in composite limits of stability reaction time scores (mean, 0.98 seconds and 0.84 seconds; P = .23), composite maximal velocity scores (4.2 degrees /second and 5.5 degrees /second; P = .08), composite end point excursion (70.3% and 70.1%; P = .95), and directional control composite scores (71.0% and 71.4%; P = .93). The two groups also showed no significant differences in rhythmic weight shifting left and right as well as forward and backward.

CONCLUSIONS

Unlike studies involving elderly subjects, this study of younger, healthy subjects did not demonstrate a relationship between vitamin D and balance.

Psychiatric diagnoses among Iraq and Afghanistan war veterans screened for deployment-related traumatic brain injury

The authors examined psychiatric diagnoses in administrative records for 13,201 United States military veterans who were screened for traumatic brain injury (TBI) in Department of Veterans Affairs facilities. Over 80% of the veterans with positive TBI screens had psychiatric diagnoses. Compared to veterans with negative TBI screens, those with positive screens, but without confirmed TBI status, were three times more likely to have a posttraumatic stress disorder (PTSD) diagnosis and were two times more likely to have depression and substance-related diagnoses. Among veterans with positive TBI screens, those with clinically confirmed TBI status were more likely than those without confirmed TBI status to have diagnoses for PTSD, anxiety, and adjustment disorders. These findings have implications for health care delivery and provider education.