Influence of Mild Traumatic Brain Injury (TBI) and Posttraumatic Stress Disorder (PTSD) on Pain Intensity Levels in OEF/OIF/OND Veterans

Global prevalence of poor sleep quality in military personnel and veterans: A systematic review and meta-analysis of epidemiological studies

Poor sleep quality is prevalent among members of the military but rates of poor sleep quality vary between studies. This study examined the global prevalence of poor sleep quality in military personnel and veterans as well as possible moderators of prevalence differences between studies. PubMed, EMBASE, Web of Science, and PsycINFO were systematically searched from their inception dates to September 1, 2022. Studies were included if they were conducted on military personnel and/or veterans and prevalence estimates of poor sleep quality could be generated from assessments with standardized tools. A random-effects model was used to calculate the pooled prevalence and its 95% confidence intervals (CIs). Fifty-nine studies (N = 28,100) were included for analysis with sample sizes ranging from 14 to 8481. Two studies were rated as "high quality" (3.39%), while 57 were rated as "moderate quality" (96.61%). The overall pooled prevalence of poor sleep quality in military personnel and veterans was 69.00% (95% CI: 62.33-75.30%); pooled rates were 57.79% (95% CI: 49.88-65.50%) and 82.88% (95% CI: 74.08-90.21%) for active duty personnel and veterans, respectively. Subgroup analyses indicated study region, study design, sampling method, Pittsburg Sleep Quality Index cut-off values, and service type moderated prevalence of poor sleep quality. Meta-regression analyses indicated sample size, mean age, depression and posttraumatic stress disorder (PTSD) were associated with prevalence differences between studies. Poor sleep quality was more common in both active duty military personnel and veterans who were older and those who reported PTSD or depression. Regular monitoring of sleep quality and sleep hygiene should be promoted in this population. More relevant studies in middle- and low-income countries should also be conducted.

Yoga Plus Mantram Repetition to Reduce Chronic Pain in Veterans With Post-Traumatic Stress Disorder: A Feasibility Trial

Background

Veterans with post-traumatic stress disorder (PTSD) are more likely to report chronic pain than veterans without PTSD. Yoga has been shown to reduce both chronic pain and PTSD symptoms in clinical trials. The goal of our study was to assess the feasibility and acceptability of conducting a randomized controlled trial (RCT) that combined yoga and mantram repetition (Yoga + MR) into one program for military veterans with both chronic pain and PTSD.

Methods

In this feasibility RCT, 27 veterans were randomized to either Yoga + MR or a relaxation intervention. Due to the COVID-19 pandemic, in-person recruitment, assessments, and intervention attendance were re-evaluated. Although remote delivery of aspects of the study were utilized, interventions were delivered in-person. Feasibility benchmarks met included full recruitment in 12 months or less, 75%+ retention at initial follow-up assessment, 50%+ attendance rate, and 75%+ of participants satisfied with the interventions.

Results

The sample was racially and ethnically diverse, and 15% of participants were women. Participant recruitment lasted approximately 11 months. Out of 32 participants initially randomized, two participants asked to be dropped from the study and three did not meet PTSD symptom criteria. For the remaining 27 participants, retention rates were 85% at 12 weeks and 81% at 18 weeks. Participants attended 66% of in-person yoga and 55% of in-person relaxation sessions. Satisfaction was high, with 100% of yoga participants and 75%/88% of relaxation participants agreeing or strongly agreeing they were satisfied with the intervention/instructors. After 12 weeks (end of intervention), Yoga + MR participants reported reduced back-pain related disability (primary outcome), reduced alcohol use, reduced fatigue, and increased quality of life, while relaxation group participants reported reductions in pain severity, PTSD symptoms, and fatigue.

Conclusions

Amidst many research challenges during the pandemic, recruitment, retention, and efficacy results from this feasibility trial support advancement to a larger RCT to study Yoga + MR for chronic pain and PTSD.

Pleiotropic endophenotypic and phenotype effects of GABAergic neurosteroid synthesis deficiency in posttraumatic stress disorder

PTSD is associated with deficits in synthesis of progesterone metabolites such as allopregnanolone and pregnanolone that potently facilitate gamma-amino-butyric acid (GABA) effects at GABA_A receptors. These neurosteroids modulate neuronal firing rate, regional brain connectivity, and activation of amygdala-mediated autonomic nervous system, hypothalamic-pituitary-adrenal axis, and behavioral reactions to unconditioned and conditioned threat. They also play critical roles in learning and memory processes such as extinction and extinction retention and inhibit toll-like receptor activation of intracellular pro-inflammatory pathways. Deficient synthesis of these neurosteroids thus may contribute to individually variable PTSD clinical phenotypes encompassing symptom severity, capacity for PTSD recovery, and vulnerability to common PTSD-comorbidities such as major depression, chronic pain, alcohol and nicotine dependence, cardiovascular disease, metabolic syndrome, reproductive disorders, and autoimmune conditions.

Association between perceived distress and salivary cortisol in veterans with mTBI

Mild traumatic brain injury (mTBI) is one of the most common injuries experienced by Veterans and can frequently result in a variety of post-concussive symptoms. Post-concussive headaches (PCH), one of the most common symptoms, can persist for years after the injury occurred. The long-lasting impacts of PCH can be extremely distressing for Veterans, thus necessitating the need to find reliable biomarkers that directly relate to subjective feelings of distress. Yoga-based interventions have been shown to improve both subjective and objective markers of stress. Techniques used in yoga, such as the focus on releasing muscular tension, are also recommended as strategies for treating PCH. Thus, yoga-based interventions provide a unique context for the comparison of subjective and objective measures of distress in Veterans with PCH. In this secondary, exploratory analysis, we examined the relationship between perceived distress and cortisol in sixteen Veterans with mTBI and long-term PCH within the context of a yoga intervention feasibility study. The Visual Analogue Scale (VAS), a validated tool for measuring subjective distress, was administered to participants immediately before and after 75-min yoga classes, which occurred twice weekly over eight weeks. Participants also provided salivary cortisol (pre- and post-yoga) at in-person sessions (eight) to compare to changes in VAS scores. We found that VAS scores were significantly reduced within five of the eight assessed yoga classes, but there were no significant changes in cortisol levels. No significant correlations were found between VAS scores and salivary cortisol levels. When looking at how cortisol levels changed over time (i.e., over the series of eight yoga sessions), there was a significant downward trajectory in post-yoga cortisol, but not after taking pre-class cortisol into account (i.e., within yoga session cortisol change over time). Taken together, we found that subjective distress, but not cortisol was reduced by yoga classes. These data suggest that salivary cortisol did not match changes in perceived distress, thus emphasizing the ongoing challenges of relating subjective and objective measures.

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Perceived distress can negatively impact post-concussive symptoms.

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Efforts are needed to relate objective and subjective measures of distress.

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Subjective distress and salivary cortisol were examined within yoga sessions.

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Subjective distress, but not cortisol was reduced within 5 of 8 yoga classes.

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These data highlight the challenges of relating subjective and objective measures.

Correlates of sleep disturbance in Veterans with traumatic brain injury and chronic pain: A cross-sectional study

BACKGROUND

Few studies have investigated sleep in Veterans with comorbid traumatic brain injury (TBI) and chronic pain.

OBJECTIVE

To describe mood and cognitive correlates with sleep disturbance in a sample of Veterans with both TBI and chronic pain.

RESEARCH METHOD

Cross-sectional, correlational analyses were completed using baseline data from a randomized controlled trial comparing psychosocial treatments for pain in Veterans with TBI. Enrollment occurred between July 2015 and January 2017. Self-report measures of hours slept, insomnia severity, depression and PTSD symptoms were collected along with a brief neuropsychological assessment.

RESULTS

Participants (n = 221) were an average age of 37.2 years (SD = 8.2) and mostly male (89%). Participants reported sleeping an average of 4.9 h a night (SD = 1.4) with an average Insomnia Severity Index (ISI) score of 17.4 (SD = 5.4) suggesting moderate insomnia symptoms. Fewer hours slept was associated with higher depression scores (r = -0.28, p < 0.001) and slower processing speed (r = 0.23, p < 0.001). Increasing insomnia severity was associated with greater depression (r = 0.57, p < 0.001) and PTSD symptoms (r = 0.44, p < 0.001), and slower processing speed (r = -0.22, p < 0.001).

CONCLUSIONS

The average ISI score was above the clinical cut off for insomnia diagnosis. Results suggest that those with more severe insomnia symptoms report higher depression and PTSD symptoms as well as exhibit slower processing speed. Improving sleep in this population may be important for improving outcome following TBI.

Factors Associated with the Development of Persistent Pain after mTBI

BACKGROUND

Persistent pain after mild traumatic brain injury (mTBI) is widely experienced, yet little is known about who is at risk for experiencing persistent pain after their injury.

AIMS

The purpose of this study was to 1) determine if there are factors associated with later experiencing persistent pain after mTBI and 2) examine if there are symptom patterns associated with the experience of persistent pain.

DESIGN

Secondary analysis was conducted using de-identified data from an NIH-funded longitudinal study.SettingsParticipants were enrolled in the emergency department.

PARTICIPANTS

Participants were aged 21 to 92 and all had experienced mTBI.

METHODS

We examined baseline characteristics, symptoms, and injury related variables associated with the endorsement of persistent pain among those with mTBI (N = 183) from baseline to 6 months post-injury. In order to identify a persistent pain phenotype, exploratory factor analysis was used to determine which symptoms co-occur with persistent pain.

RESULTS

Persistent pain was found in 78% of those with mTBI. Those with lower overall health status at day 7 and at 1-month following injury had greater odds of developing persistent pain. Those with higher levels of general health status and physical function health status at day 7 and 1 month, and those with higher levels of overall health related status at 1 month had significantly lesser odds of persistent pain at 6 months. Factor analysis revealed that persistent pain and co-occurring symptoms (anxiety, depression, dizziness, nausea and vomiting, sleep disturbance, poor memory, poor concentration, longer to think and light sensitivity) loaded on one factor, indicating that these symptoms are associated.

CONCLUSIONS

Those at increased risk for persistent pain should be screened beginning early in the recovery trajectory to reduce their risk of developing persistent pain. Identification of a phenotype offers potential for recognition of symptoms that cluster with persistent pain, improving the ability to treat patients more holistically, and develop interventions to support recovery from injury.

Post-mTBI Pain Interference in a U.S. Military Population: A Chronic Effects of Neurotrauma Consortium Study

INTRODUCTION

Chronic pain is a significant problem for service members and veterans with mild traumatic brain injury (mTBI). While the root cause of pain is not clearly understood, comorbidities may contribute to how their pain disrupts their functional status, a construct termed "pain interference." The purpose of this study is to examine the associations between mTBI, other comorbidities, and pain interference.

MATERIALS AND METHODS

The sample comprised participants with mTBI(s) from The Chronic Effects of Neurotrauma Consortium multicenter observational study. Potential concussive events were identified using a modified Ohio State University traumatic brain injury (TBI) Identification interview and then further with a structured interview. Pain interference was measured with the TBI quality-of-life pain interference score, which was categorized into insignificant, moderate, and high pain interference. Comorbidities of interest included anxiety, depression, post-traumatic stress disorder, insomnia, and arthritis. Multivariable relationships were analyzed using logistic regression.

RESULTS

The analysis sample included 346 participants with mTBI(s). In adjusted analysis, those with high pain interference were more likely to have history of ≥ 3 TBIs (odds ratio (OR) 3.1, 95% confidence interval [CI] 1.4, 6.9) and to have clinical levels of post-traumatic stress disorder (OR 5.4, 95% CI 1.9, 15.7), depression (OR 2.5, 95% CI, 1.0, 6.1), anxiety (OR 4.9, 95% CI, 2.0, 11.7), and sleep disturbances (OR 6.1, 95% CI 2.0, 19.0) versus those with insignificant pain interference.

CONCLUSION

These results identify clinical features of veterans and service members with mTBI(s) who are at highest risk for pain-related disability. These findings also demonstrate the need to consider mental health and sleep problems in their pain evaluation and treatment approach.

Factors That Affect Emergency Responder Wellbeing: Considerations for Public Health Responders

PURPOSE

The purpose of this study is to identify key risk factors that could negatively affect public health emergency responders' health and wellbeing. We seek to use this information to provide recommendations and strategies to mitigate such risks.

DESIGN/METHODOLOGY/APPROACH

A narrative review of the peer-reviewed literature on wellbeing of military personnel and other responders was conducted. Data was grouped and categorized according to overarching domains.

FINDINGS

Factors associated with wellbeing were categorized into 5 domains: (1) demographics; (2) mental health concerns; (3) social networks; (4) work environment; and (5) postdeployment life. The strategies identified to promote wellbeing included mental health assessments, preparedness trainings, debriefs in the field, postdeployment debriefs, resources in the field, and further postdeployment decompression strategies.

ORIGINALITY/VALUE

This study provides a unique understanding of the risk factors associated with poor health and wellbeing outcomes in public health emergency response work by extending the body of knowledge that focuses on other types of emergency and military response.

Mobile Neurofeedback for Pain Management in Veterans with TBI and PTSD

OBJECTIVE

Chronic pain is common in military veterans with traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD). Neurofeedback, or electroencephalograph (EEG) biofeedback, has been associated with lower pain but requires frequent travel to a clinic. The current study examined feasibility and explored effectiveness of neurofeedback delivered with a portable EEG headset linked to an application on a mobile device.

DESIGN

Open-label, single-arm clinical trial.

SETTING

Home, outside of clinic.

SUBJECTS

N = 41 veterans with chronic pain, TBI, and PTSD.

METHOD

Veterans were instructed to perform "mobile neurofeedback" on their own for three months. Clinical research staff conducted two home visits and two phone calls to provide technical assistance and troubleshoot difficulties.

RESULTS

N = 36 veterans returned for follow-up at three months (88% retention). During this time, subjects completed a mean of 33.09 neurofeedback sessions (10 minutes each). Analyses revealed that veterans reported lower pain intensity, pain interference, depression, PTSD symptoms, anger, sleep disturbance, and suicidal ideation after the three-month intervention compared with baseline. Comparing pain ratings before and after individual neurofeedback sessions, veterans reported reduced pain intensity 67% of the time immediately following mobile neurofeedback. There were no serious adverse events reported.

CONCLUSIONS

This preliminary study found that veterans with chronic pain, TBI, and PTSD were able to use neurofeedback with mobile devices independently after modest training and support. While a double-blind randomized controlled trial is needed for confirmation, the results show promise of a portable, technology-based neuromodulatory approach for pain management with minimal side effects.

Neurophysiological relationship of neuromuscular fatigue and stress disorder in PTSD patients

INTRODUCTION

Apart from mental disorders, other complications that have been reported in some patients with Post-Traumatic Stress Disorder (PTSD), include physical pain and being quick to fatigue, which can severely affect the patients' daily life. Therefore, this study aims to evaluate the relationship between PTSD and physical fatigue in people with PTSD.

METHOD

18 military men with (n = 9) and without PTSD (n = 9), with an age range of 45-60 years, volunteered to participate. They were randomly assigned into two groups: PTSD and non-PTSD groups. Recording of the surface electromyography (EMG) in a specific muscle was conducted twice in both groups, once at baseline and then again after a single session of fatiguing exercise. Data were analyzed by ANOVA with repeated measure (2✕2) at the significance level of 0.05.

RESULTS

Results showed that there was a significant main effect of intervention on electrical activity and neural conduction variables in the PTSD group (p = 0.04, p = 0.02). There was also an effect of time for the both variables (P < 0.001).

CONCLUSION

Stress disorders may affect the time to fatigue in PTSD patients and subsequently cause some difficulties in their daily life.

A test of the fear avoidance model to predict chronic pain outcomes in a polytrauma sample

BACKGROUND

Chronic musculoskeletal pain is a complex problem, particularly for individuals with head injury and comorbid psychiatric conditions. The Fear Avoidance Model offers one of the strongest opportunities to conceptualize comorbid traumatic injury and pain, but this model is largely untested.

OBJECTIVE

This study tests the Fear Avoidance Model of chronic pain using a sample from a study of polytrauma patients in a large Department of Veterans Affairs facility who participated in a federally-funded study of interdisciplinary chronic pain management.

METHODS

The present study comprises a secondary analysis of 93 veterans with chronic pain, head injury, posttraumatic stress symptoms and a history of persistent opioid use. Standardized measures of Fear Avoidance Model risk factors (e.g., pain catastrophizing, fear avoidance beliefs, anxiety, depression) were examined as cross-sectional predictors of pain-related disability.

RESULTS

Secondary data analysis revealed that Fear Avoidance Model factors accounted for almost 40% of the variance in pain-related disability, with pain catastrophizing and depression demonstrating the strongest relationships with disability. A summary variable combining all four factors revealed a 6% increase in disability for each factor that was clinically significant for the sample patients.

CONCLUSIONS

This study represents the first attempt to examine a complex, theoretical model of pain in a comorbid pain and TBI sample. Findings revealed a strong relationship between this model and pain-related disability that outperforms pain intensity ratings. This model could be used to guide better treatment for comorbid pain and TBI.

Associations Between Multiple Remote Mild TBIs and Objective Neuropsychological Functioning and Subjective Symptoms in Combat-Exposed Veterans

OBJECTIVE

The purpose of this study was to evaluate relationships between multiple mild traumatic brain injuries (mTBIs) and objective and subjective clinical outcomes in a sample of combat-exposed Veterans, adjusting for psychiatric distress and combat exposure.

METHOD

In this cross-sectional study, 73 combat-exposed Iraq/Afghanistan Veterans were divided into three groups based on mTBI history: 0 mTBIs (n = 31), 1-2 mTBIs (n = 21), and 3+ mTBIs (n = 21). Veterans with mTBI were assessed, on average, 7.78 years following their most recent mTBI. Participants underwent neuropsychological testing and completed self-report measures assessing neurobehavioral, sleep, and pain symptoms.

RESULTS

MANCOVAs adjusting for psychiatric distress and combat exposure showed no group differences on objective measures of attention/working memory, executive functioning, memory, and processing speed (all p's > .05; ηp2 = .00-.06). In contrast, there were significant group differences on neurobehavioral symptoms (p's = < .001-.036; ηp2 = .09-.43), sleep difficulties (p = .037; ηp2 = .09), and pain symptoms (p < .001; ηp2 = .21). Pairwise comparisons generally showed that the 3+ mTBI group self-reported the most severe symptoms, followed by comparable symptom reporting between the 0 and 1-2 mTBI groups.

CONCLUSIONS

History of multiple, remote mTBIs is associated with elevated subjective symptoms but not objective neuropsychological functioning in combat-exposed Veterans. These results advance understanding of the long-term consequences of repetitive mTBI in this population and suggest that Veterans with 3+ mTBIs may especially benefit from tailored treatments aimed at ameliorating specific neurobehavioral, sleep, and pain symptoms.

Multimorbidity and quality of life after blast-related injury among US military personnel: a cluster analysis of retrospective data

Background

Blast injury emerged as a primary source of morbidity among US military personnel during the recent conflicts in Iraq and Afghanistan, and led to an array of adverse health outcomes. Multimorbidity, or the presence of two or more medical conditions in an individual, can complicate treatment strategies. To date, there is minimal research on the impact of multimorbidity on long-term patient-reported outcomes. We aimed to define multimorbidity patterns in a population of blast-injured military personnel, and to examine these patterns in relation to long-term quality of life (QOL).

Methods

A total of 1972 US military personnel who sustained a blast-related injury during military operations in Iraq and Afghanistan were identified from clinical records. Electronic health databases were used to identify medical diagnoses within the first year postinjury, and QOL was measured with a web-based assessment. Hierarchical cluster analysis methods using Ward’s minimum variance were employed to identify clusters with related medical diagnosis categories. Duncan’s multiple range test was used to group clusters into domains by QOL.

Results

Five distinct clusters were identified and grouped into three QOL domains. The lowest QOL domain contained one cluster with a clinical triad reflecting musculoskeletal pain, concussion, and mental health morbidity. The middle QOL domain had two clusters, one with concussion/anxiety predominating and the other with polytrauma. The highest QOL domain had two clusters with little multimorbidity aside from musculoskeletal pain.

Conclusions

The present study described blast-related injury profiles with varying QOL levels that may indicate the need for integrated health services. Implications exist for current multidisciplinary care of wounded active duty and veteran service members, and future research should determine whether multimorbidity denotes distinct post-blast injury syndromes.

Psychological Symptoms and Rates of Performance Validity Improve Following Trauma-Focused Treatment in Veterans with PTSD and History of Mild-to-Moderate TBI

OBJECTIVE

Iraq and Afghanistan Veterans with posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI) history have high rates of performance validity test (PVT) failure. The study aimed to determine whether those with scores in the invalid versus valid range on PVTs show similar benefit from psychotherapy and if psychotherapy improves PVT performance.

METHOD

Veterans (N = 100) with PTSD, mild-to-moderate TBI history, and cognitive complaints underwent neuropsychological testing at baseline, post-treatment, and 3-month post-treatment. Veterans were randomly assigned to cognitive processing therapy (CPT) or a novel hybrid intervention integrating CPT with TBI psychoeducation and cognitive rehabilitation strategies from Cognitive Symptom Management and Rehabilitation Therapy (CogSMART). Performance below standard cutoffs on any PVT trial across three different PVT measures was considered invalid (PVT-Fail), whereas performance above cutoffs on all measures was considered valid (PVT-Pass).

RESULTS

Although both PVT groups exhibited clinically significant improvement in PTSD symptoms, the PVT-Pass group demonstrated greater symptom reduction than the PVT-Fail group. Measures of post-concussive and depressive symptoms improved to a similar degree across groups. Treatment condition did not moderate these results. Rate of valid test performance increased from baseline to follow-up across conditions, with a stronger effect in the SMART-CPT compared to CPT condition.

CONCLUSION

Both PVT groups experienced improved psychological symptoms following treatment. Veterans who failed PVTs at baseline demonstrated better test engagement following treatment, resulting in higher rates of valid PVTs at follow-up. Veterans with invalid PVTs should be enrolled in trauma-focused treatment and may benefit from neuropsychological assessment after, rather than before, treatment.

PTSD as a Mediator in the Relationship Between Post-Concussive Symptoms and Pain Among OEF/OIF/OND Veterans

Introduction

Traumatic brain injury (TBI), pain, and post-traumatic stress disorder (PTSD) commonly co-occur in Veteran populations, particularly among Veterans returning from the recent conflicts in Iraq and Afghanistan. Extant research indicates that both TBI and PTSD can negatively impact pain broadly; however, less is known about how these variables impact one another. The current study examines the impact of self-reported post-concussive symptoms on both pain severity and pain interference among Veterans with PTSD who screened positive for a possible TBI, and subsequently, evaluates the potential mediating role of PTSD in these relationships.

Materials and Methods

Participants were 126 combat Veterans that served in Operation Enduring Freedom, Operation Iraqi Freedom, or Operation New Dawn who were being evaluated for participation in a multisite treatment outcomes study. As part of an initial evaluation for inclusion in the study, participants completed several self-report measures and interviews, including the Brief Traumatic Brain Injury Screen, Neurobehavioral Symptom Inventory, Brief Pain Inventory, and the Clinician Administered PTSD Scale, which were utilized in these analyses.

Results

For pain severity, greater post-concussive symptoms significantly predicted increased pain severity with a significant indirect effect of post-concussive symptoms on pain severity through PTSD (indirect effect = 0.03; 95% confidence interval = 0.0094-0.0526). Similar results were found for pain interference (indirect effect = 0.03; 95% confidence interval = 0.0075-0.0471).

Conclusions

These findings replicate and extend previous findings regarding the relationship between TBI, pain, and PTSD. Self-reported post-concussive symptoms negatively impact both pain severity and pain interference among Veterans with probable TBI, and PTSD serves as a mediator in these relationships. Clinically, these results highlight the importance of fully assessing for PTSD symptoms in Veterans with a history of TBI presenting with pain. Further, it is possible that providing effective PTSD treatment to reduce PTSD severity may provide some benefit in reducing post-concussive and pain symptoms.

Pain with traumatic brain injury and psychological disorders

Traumatic brain injury (TBI) is the cause for long-term disability in more than 3 million patients in the US alone, with chronic pain being the most frequently reported complain. To date, predisposing mechanisms for chronic pain in TBI patients are largely unknown. Psychological disorders, including post-traumatic stress disorder, depression and anxiety following TBI are commonly reported comorbidities to post-traumatic pain. Long term consequences can be debilitating and affect quality of life even when the injury is mild. In this review, we present the most commonly reported chronic pain conditions across the spectrum of severity of TBI, mainly focusing on mild TBI. We discuss chronic post- traumatic headaches, widespread pain as well as post-traumatic central pain. We discuss pain in the context of injury severity and military versus civilian populations. We are only starting to understand the biological mechanisms behind post-traumatic pain and associated psychological distress following TBI, with genetic, biochemical and imaging studies pointing to the dopaminergic, neurotrophic factors and the role of Apolipoprotein. Physiological and neurological mechanisms are proposed to partially explain this interaction between post-traumatic pain and psychological distress. Nevertheless, the evidence for the role of structural brain damage remains incomplete and to a large extent debatable, as it is still difficult to establish clear causality between brain trauma and chronic pain. Finally, general aspects of management of chronic pain post-TBI are addressed.

Increased Sleep Disturbances and Pain in Veterans With Comorbid Traumatic Brain Injury and Posttraumatic Stress Disorder

STUDY OBJECTIVES

Veterans are at an increased risk for traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD), both of which are associated with sleep disturbances and increased pain. Furthermore, sleep disturbances and pain are reciprocally related such that each can exacerbate the other. Although both TBI and PTSD are independently linked to sleep disturbances and pain, it remains unclear whether Veterans with comorbid TBI+PTSD show worse sleep disturbances and pain compared to those with only TBI or PTSD. We hypothesized that sleep and pain would be worse in Veterans with comorbid TBI+PTSD compared to Veterans with only TBI or PTSD.

METHODS

Veterans (n = 639) from the VA Portland Health Care System completed overnight polysomnography and self-report questionnaires. Primary outcome variables were self-reported sleep disturbances and current pain intensity. Participants were categorized into four trauma-exposure groups: (1) neither: without TBI or PTSD (n = 383); (2) TBI: only TBI (n = 67); (3) PTSD: only PTSD (n = 126); and (4) TBI+PTSD: TBI and PTSD (n = 63).

RESULTS

The PTSD and TBI+PTSD groups reported worse sleep compared to the TBI and neither groups. The TBI+PTSD group reported the greatest pain intensity compared to the other groups.

CONCLUSIONS

These data suggest sleep and pain are worst in Veterans with TBI and PTSD, and that sleep is similarly impaired in Veterans with PTSD despite not having as much pain. Thus, although this is a complex relationship, these data suggest PTSD may be driving sleep disturbances, and the added effect of TBI in the comorbid group may be driving pain in this population.

Impact of PTSD on post-concussive symptoms, neuropsychological functioning, and pain in post-9/11 veterans with mild traumatic brain injury

Prior work suggested that post-traumatic stress disorder (PTSD) worsens post-concussive symptoms (PCS), neuropsychological functioning, and pain-related outcomes in post-9/11 veterans. However, the impact of PTSD in the context of mild traumatic brain injury (mTBI) is not entirely clear. We evaluated possible differences among veterans with deployment-related mTBI with and without PTSD, and a comparison group. We hypothesized that veterans with comorbid mTBI and PTSD would report more PCS, perform worse on neuropsychological tasks, and report greater pain intensity and maladaptive pain coping relative to those without PTSD. Ninety (15 female, 75 male) post-9/11 veterans completed measures of psychiatric functioning, PCS, deployment-related mTBI, pain intensity, pain coping, and a brief neuropsychological evaluation. Veterans with comorbid mTBI and PTSD reported significantly higher PCS across domains, and greater pain intensity and maladaptive coping. They also performed more poorly on measures of recall, but not on measures of attention, encoding, or executive functioning. Findings suggest that PTSD results in greater PCS in the context of mTBI, and is associated with greater pain catastrophizing, worse recall, greater pain intensity, and greater illness-focused coping than in mTBI alone. PCS symptoms, recall, and pain coping may be of clinical importance for post-9/11 veterans with the "polytrauma triad."

The polytrauma clinical triad in patients with chronic pain after motor vehicle collision

Background

The polytrauma clinical triad (PCT) is a complex disorder composed of three comorbid diagnoses of chronic pain, post-traumatic stress disorder (PTSD), and postconcussion syndrome (PCS). PCT has been documented in veterans returning from deployment, but this is the first report on PCT prevalence in nonmilitary personnel after a motor vehicle collision (MVC).

Methods

Data were drawn from routine intake assessments completed by 71 patients referred to a community-based clinic for chronic pain management. All patients completed the post-traumatic stress disorder checklist for the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (PCL-5), and Rivermead Post-Concussion Symptoms Questionnaire (RPQ) during a standardized intake assessment. An additional modified RPQ score was derived to address previously reported symptom overlap between PCS and chronic pain.

Results

Standard and modified RPQ scores yielded PCS prevalence rates of 100% and 54.9% in our sample, respectively. Results suggest that a modified RPQ score, limited to visual and vestibular symptoms, may be more useful PCS screening criteria in patients with chronic pain. PTSD screening criteria on the PCL-5 were met by 85.9% of the patients. More than half of the patients referred for chronic pain after MVC met criteria for PCT (52.1%). Patients who met PCT criteria reported worse headache, overall pain, and sleep quality outcomes.

Conclusion

Among patients in our sample with chronic pain after MVC, more than half met criteria for PCT. A modified approach to RPQ scoring limited to visual and vestibular symptoms may be required to screen for PCS in these patients.

Sleep, Sleep Disorders, and Circadian Health following Mild Traumatic Brain Injury in Adults: Review and Research Agenda

A rapidly expanding scientific literature supports the frequent co-occurrence of sleep and circadian disturbances following mild traumatic brain injury (mTBI). Although many questions remain unanswered, the preponderance of evidence suggests that sleep and circadian disorders can result from mTBI. Among those with mTBI, sleep disturbances and clinical sleep and circadian disorders contribute to the morbidity and long-term sequelae across domains of functional outcomes and quality of life. Specifically, along with deterioration of neurocognitive performance, insufficient and disturbed sleep can precede, exacerbate, or perpetuate many of the other common sequelae of mTBI, including depression, post-traumatic stress disorder, and chronic pain. Further, sleep and mTBI share neurophysiologic and neuroanatomic mechanisms that likely bear directly on success of rehabilitation following mTBI. For these reasons, focus on disturbed sleep as a modifiable treatment target has high likelihood of improving outcomes in mTBI. Here, we review relevant literature and present a research agenda to 1) advance understanding of the reciprocal relationships between sleep and circadian factors and mTBI sequelae and 2) advance rapidly the development of sleep-related treatments in this population.

Functional brain connectivity and cortical thickness in relation to chronic pain in post-911 veterans and service members with mTBI

OBJECTIVES

Investigate the relation of chronic pain interference to functional connectivity (FC) of brain regions and to cortical thickness in post-911 Veterans and Service Members (SMs) who sustained a mild traumatic brain injury (mTBI).

METHODS

This is an observational study with cross-sectional analyses. A sample of 65 enrollees completing initial evaluation at a single site of the Chronic Effects of Neurotrauma Consortium (CENC) reported pain interference ratings on the TBI QOL. Functional connectivity and cortical thickness were measured.

RESULTS

Severity of pain interference was negatively related to FC of the default mode network (DMN), i.e., participants who reported more severe pain interference had less FC between mesial prefrontal cortex and posterior regions of the DMN including posterior cingulate cortex and precuneus. Cortical thickness of specific regions was positively related to severity of pain interference.

CONCLUSION

The more that pain was perceived to interfere with daily life, the less the FC between regions in a network associated with self-referential thought and mind wandering. Although cortical thickness in specific brain regions was positively related to severity of pain interference, follow-up longitudinal data, control group data, and study of individual differences in this cohort will expand this initial report and replicate these findings.

Pain and chronic mild traumatic brain injury in the US military population: a Chronic Effects of Neurotrauma Consortium study

PRIMARY OBJECTIVES

To describe the association between mild traumatic brain injury (mTBI) and pain intensity and pain interference outcomes while accounting for potential confounders and mediators including environmental factors and comorbidities in a cohort of US Veterans of the Iraq and Afghanistan wars.

RESEARCH DESIGN

Cross-sectional snapshot of baseline data from a prospective, longitudinal study.

METHODS

Effects of mTBI on pain intensity and pain interference were compared between participants with or without mTBI exposure. Data were analysed using covariate-adjusted regression analyses as well as structural equation modelling (SEM) methods to assess the robustness of findings across different modelling assumptions. As results of the two approaches were consistent with respect to the overall association between mTBI exposure and pain, the results focus primarily on the SEM findings.

RESULTS

The mTBI exposed group reported significantly greater indices of post-traumatic stress disorder (PTSD), depression, anxiety and sleep disturbance. After accounting for other factors, mTBI exposure was significantly, but indirectly associated with the pain interference and pain intensity outcomes.

CONCLUSIONS

mTBI is strongly associated with pain intensity and pain interference in this sample. However, the effect appears to be mediated by other common mTBI comorbidities: PTSD, depression, anxiety and sleep disturbance.

Repeated Exposure to Experimental Pain Differentiates Combat Traumatic Brain Injury with and without Post-Traumatic Stress Disorder

Mild traumatic brain injury (mTBI) and post-traumatic stress disorder (PTSD) are highly comorbid conditions that often co-occur with chronic pain. We have shown that women with PTSD subsequent to intimate partner violence show attenuated brain response to repeated experimental pain that was related to symptoms of avoidance. The aim of this study was to extend our past findings to males with combat trauma and to examine brain response to experimental pain in men with and without PTSD who sustained mTBI during combat. Seventy male veterans performed an experimental pain paradigm during functional magnetic resonance imaging fMRI. Of the 70 total subjects, 46 self-reported a history of mTBI during combat (46 of 70). Of those with mTBI, 26 also met criteria for PTSD (26 of 46). As in our previous study, we examined change in brain activity to repeated heat pain with linear mixed-effects modeling for group by administration interaction effects. We observed a significant group by administration interaction to repeated heat pain within insular, frontal, and parietal cortices, such that the control group showed increased activation over time, whereas mTBI groups (mTBI-only, mTBI + PTSD) showed decreased activation within bilateral anterior insulas (AIs) between administrations. Importantly, change in the right AI response was inversely correlated with avoidance symptoms, but only in those with comorbid mTBI + PTSD. Further, in the comorbid group, greater AI attenuation was associated with decreased connectivity with anterior cingulate (ACC). The current study provides further evidence that repeated exposure to brief painful stimuli results in attenuation of insula activation over time in traumatized individuals. Further, in PTSD, AI shows greatest attenuation in those with the highest level of avoidance-a finding that was replicated across diverse samples. Thus, this mechanism may be a generalized mechanism of maladaptive response to experimental pain in those with significant trauma.