Utility of the Neurobehavioral Symptom Inventory As an Outcome Measure: A VA TBI Model Systems Study

Distinct Functional MRI Connectivity Patterns and Cortical Volume Variations Associated with Repetitive Blast Exposure in Special Operations Forces Members

Background Special operations forces members often face multiple blast injuries and have a higher risk of traumatic brain injury. However, the relationship between neuroimaging markers, the cumulative severity of injury, and long-term symptoms has not previously been well-established in the literature. Purpose To determine the relationship between the frequency of blast injuries, persistent clinical symptoms, and related cortical volumetric and functional connectivity (FC) changes observed at brain MRI in special operations forces members. Materials and Methods A cohort of 220 service members from a prospective study between January 2021 and May 2023 with a history of repetitive blast exposure underwent psychodiagnostics and a comprehensive neuroimaging evaluation, including structural and resting-state functional MRI (fMRI). Of these, 212 met the inclusion criteria. Participants were split into two datasets for model development and validation, and each dataset was divided into high- and low-exposure groups based on participants' exposure to various explosives. Differences in FC were analyzed using a general linear model, and cortical gray matter volumes were compared using the Mann-Whitney U test. An external age- and sex-matched healthy control group of 212 participants was extracted from the SRPBS Multidisorder MRI Dataset for volumetric analyses. A multiple linear regression model was used to assess correlations between clinical scores and FC, while a logistic regression model was used to predict exposure group from fMRI scans. Results In the 212 participants (mean age, 43.0 years ± 8.6 [SD]; 160 male [99.5%]) divided into groups with low or high blast exposure, the high-exposure group had higher scores for the Neurobehavioral Symptom Inventory (NSI) (t = 3.16, P < .001) and Posttraumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (PCL-5) (t = 2.72, P = .01). FC differences were identified in the bilateral superior and inferior lateral occipital cortex (LOC) (P value range, .001-.04), frontal medial cortex (P < .001), left superior frontal gyrus (P < .001), and precuneus (P value range, .02-.03). Clinical scores from NSI and PCL-5 were inversely correlated with FC in the LOC, superior parietal lobule, precuneus, and default mode networks (r = -0.163 to -0.384; P value range, <.001 to .04). The high-exposure group showed increased cortical volume in regions of the LOC compared with healthy controls and the low-exposure group (P value range, .01-.04). The predictive model helped accurately classify participants into high- and low-exposure groups based on fMRI data with 88.00 sensitivity (95% CI: 78.00, 98.00), 67% specificity (95% CI: 53.00, 81.00), and 73% accuracy (95% CI: 60.00, 86.00). Conclusion Repetitive blast exposure leads to distinct alterations in FC and cortical volume, which correlate with neurobehavioral symptoms. The predictive model suggests that even in the absence of observable anatomic changes, FC may indicate blast-related trauma. © RSNA, 2025 Supplemental material is available for this article.

Exposure to Adverse Childhood Experiences Predicts Increased Neurobehavioral Symptom Reporting in Adults with Mild Traumatic Brain Injury

The objective of this study was to understand whether exposure to adverse childhood experiences (ACEs) before 18 years of age predicts increased neurobehavioral symptom reporting in adults presenting for treatment secondary to persistent symptoms after mild traumatic brain injury (mTBI). This cross-sectional study identified 78 individuals with mTBI from 2014 to 2018 presenting for treatment to an outpatient multidisciplinary rehabilitation clinic. Neurobehavioral symptom inventory (NSI-22) scores were collected on admission, and ACEs for each patient were abstracted by medical record review. A linear regression model was used to assess if an individual who experienced at least one ACE before age 18 resulted in significantly different neurobehavioral scores compared with those not reporting any history of an ACE before age 18. Participants who reported at least one ACE before age 18 had significantly increased NSI-22 scores on admission to the rehabilitation clinic compared with patients without history of ACEs (mean difference 10.1, p = 0.011), adjusted for age and gender. For individuals presenting for treatment after mTBI, a history of ACEs before age 18 was associated with increased neurobehavioral symptoms.

Sex differences in postconcussive symptom reporting in those with history of concussion: Findings from the federal interagency traumatic brain injury research (FITBIR) database

Objective: This study investigated influence of biological sex on postconcussive symptoms (PCS) following concussion using the Federal Interagency Traumatic Brain Injury Research (FITBIR) database. Method: All studies with publicly released data as of 4/7/21 that included both males and females, enough information to determine severity of injury consistent with concussion, a measure of PCS, and objective measures of neurocognitive functioning were used. This resulted in 6 studies with a total of 9890 participants (3206 females, 6684 males); 815 participants completed the Neurobehavioral Symptom Inventory (NSI), 471 completed the Rivermead Post-Concussion Symptoms Questionnaire (RPSQ), and 8604 completed the Sport Concussion Assessment Tool-3rd Edition (SCAT 3). Questionnaires were harmonized and the following symptom composite scores were computed: total score, somatic, cognitive, and affective. Data were analyzed using linear mixed-effects models. Results: Females endorsed higher total symptoms relative to males and that military personnel endorsed higher symptoms relative to civilians. Additionally, there was a small but significant interaction effect, such that female military personnel endorsed even higher symptoms than would be predicted by the main effects. Similar patterns were observed for somatic, cognitive, and affective symptom domains. Conclusions: Further understanding sex differences in PCS reporting is key to informing the most appropriate treatment options. Future work will need to examine whether sex differences in symptom reporting is due to sex differences in endorsement styles or genuine differences in symptom presentation, as well as the relationship between study population (e.g., military, civilian, sport) and sex on objective cognitive functioning and other functional outcomes.

The impact of different neurobehavioral symptoms on suicidal ideation and perceived likelihood of future suicidality

Existing literature suggests that psychological and functional impairment, independent of head injury severity, can increase suicide risk. This study explores the impacts of self-perceived dysfunction within four neurobehavioral symptom clusters-vestibular (e.g., dizziness, balance), somatosensory (e.g., headaches, nausea, vision), affective (e.g., anxious, irritable mood), and cognitive (e.g., concentration, memory, indecision)-on current suicidal ideation and the perceived likelihood of future suicidal ideation and attempts. Community participants (n = 309; Mage = 36.88; 51.6% female; 79.6% White) completed the Neurobehavioral Symptom Inventory (NSI) and the Self-Injurious Thoughts and Behaviors-Short Form (SITBI-SF). Quantile regression analysis was used to explore the effects of the four neurobehavioral symptom clusters at different levels of suicidal ideation intensity, perceived likelihood of future suicidal ideation, and self-perceived likelihood of future suicide attempt. Controlling for past head injuries and suicide attempts, affective symptoms were significantly associated with a moderate and high average intensity of current suicidal ideation. Somatosensory symptoms were significantly associated with a moderate perceived likelihood of future suicidal ideation. Finally, vestibular symptoms were significantly associated with a moderate perceived likelihood of a future suicide attempt. These findings highlight the critical need to consider a broader spectrum of symptoms, including chronic physical symptoms, when assessing suicide risk. Furthermore, they underscore the need to expand beyond affective symptoms as an explanation for increased suicidality and examine additional mechanisms through which chronic physical symptoms can increase suicide risk.

Long Noncoding RNA VLDLR-AS1 Levels in Serum Correlate with Combat-Related Chronic Mild Traumatic Brain Injury and Depression Symptoms in US Veterans

More than 75% of traumatic brain injuries (TBIs) are mild (mTBI) and military service members often experience repeated combat-related mTBI. The chronic comorbidities concomitant with repetitive mTBI (rmTBI) include depression, post-traumatic stress disorder or neurological dysfunction. This study sought to determine a long noncoding RNA (lncRNA) expression signature in serum samples that correlated with rmTBI years after the incidences. Serum samples were obtained from Long-Term Impact of Military-Relevant Brain-Injury Consortium Chronic Effects of Neurotrauma Consortium (LIMBIC CENC) repository, from participants unexposed to TBI or who had rmTBI. Four lncRNAs were identified as consistently present in all samples, as detected via droplet digital PCR and packaged in exosomes enriched for CNS origin. The results, using qPCR, demonstrated that the lncRNA VLDLR-AS1 levels were significantly lower among individuals with rmTBI compared to those with no lifetime TBI. ROC analysis determined an AUC of 0.74 (95% CI: 0.6124 to 0.8741; p = 0.0012). The optimal cutoff for VLDLR-AS1 was ≤153.8 ng. A secondary analysis of clinical data from LIMBIC CENC was conducted to evaluate the psychological symptom burden, and the results show that lncRNAs VLDLR-AS1 and MALAT1 are correlated with symptoms of depression. In conclusion, lncRNA VLDLR-AS1 may serve as a blood biomarker for identifying chronic rmTBI and depression in patients.

Vocational Outcomes of Service Members and Veterans After Traumatic Brain Injury: A Scoping Review

OBJECTIVE

The purpose of this scoping review was to evaluate the current literature related to vocational outcomes among US service members and veterans with traumatic brain injury (TBI).

METHODS

Seven research databases (Ovid MEDLINE, PsycINFO, EMBASE, CINAHL Plus, Cochrane Library, Scopus, and SPORTDiscus) were queried for human studies between the database inception and February, 2020. We included studies that focused on US service members and veterans who sustained a TBI and their vocational outcomes. Conference abstracts, systematic reviews, literature reviews, editorials, consensus reports, commentaries, dissertations, and qualitative studies were excluded. Two rounds of independent reviews were performed. Details of study design, intervention, and vocational outcomes were recorded.

RESULTS

The search yielded 5667 articles; 48 articles met inclusion criteria. Forty-three studies were observational (90%), and 5 were randomized controlled trials. A majority of interventions were in the outpatient setting (71%). Interventions related to return to work and duty utilized physical therapy and occupational therapy to address cognitive skills and functional deficits and provide supportive employment.

CONCLUSION

Community reintegration research among service members and veterans with brain injuries is underdeveloped. Because of heterogeneity of severity and smaller sample sizes, no consensus was reached on interventions that improve vocational outcomes. Evidence thus far suggests that future studies should incorporate an interdisciplinary team approach beyond physical therapy and occupational therapy, longer-term outcomes, and sample subgroups.

Free-living gait does not differentiate chronic mTBI patients compared to healthy controls

Background

Physical function remains a crucial component of mild traumatic brain injury (mTBI) assessment and recovery. Traditional approaches to assess mTBI lack sensitivity to detect subtle deficits post-injury, which can impact a patient’s quality of life, daily function and can lead to chronic issues. Inertial measurement units (IMU) provide an opportunity for objective assessment of physical function and can be used in any environment. A single waist worn IMU has the potential to provide broad/macro quantity characteristics to estimate gait mobility, as well as more high-resolution micro spatial or temporal gait characteristics (herein, we refer to these as measures of quality). Our recent work showed that quantity measures of mobility were less sensitive than measures of turning quality when comparing the free-living physical function of chronic mTBI patients and healthy controls. However, no studies have examined whether measures of gait quality in free-living conditions can differentiate chronic mTBI patients and healthy controls. This study aimed to determine whether measures of free-living gait quality can differentiate chronic mTBI patients from controls.

Methods

Thirty-two patients with chronic self-reported balance symptoms after mTBI (age: 40.88 ± 11.78 years, median days post-injury: 440.68 days) and 23 healthy controls (age: 48.56 ± 22.56 years) were assessed for ~ 7 days using a single IMU at the waist on a belt. Free-living gait quality metrics were evaluated for chronic mTBI patients and controls using multi-variate analysis. Receiver operating characteristics (ROC) and Area Under the Curve (AUC) analysis were used to determine outcome sensitivity to chronic mTBI.

Results

Free-living gait quality metrics were not different between chronic mTBI patients and controls (all p > 0.05) whilst controlling for age and sex. ROC and AUC analysis showed stride length (0.63) was the most sensitive measure for differentiating chronic mTBI patients from controls.

Conclusions

Our results show that gait quality metrics determined through a free-living assessment were not significantly different between chronic mTBI patients and controls. These results suggest that measures of free-living gait quality were not impaired in our chronic mTBI patients, and/or, that the metrics chosen were not sensitive enough to detect subtle impairments in our sample.

Caregiver Characteristics of Adults with Acute Traumatic Brain Injury in the United States and Latin America

Objectives: To compare characteristics of caregivers of adults with acute traumatic brain injury (TBI) in the U.S. and Latin America (Mexico and Colombia). Design: Secondary data analysis of two cohorts. Cohort 1: English-speaking caregivers of adults with TBI in the U.S. (n = 80). Cohort 2: Spanish-speaking caregivers of adults with TBI in Mexico or Colombia (n = 109). Results: Similarities between the U.S. and Latin American caregiver groups, respectively, were: predominantly women (81.3%, 81.7%, respectively); spouses/domestic partners (45%, 31.2%); and motor vehicle accident (41.5%, 48.6%) followed by fall etiologies (40%, 21.1%). Differences between U.S. and Latin American caregivers were: age (49.5 years, 41.5 years, p < 0.001); employment status ((Χ52 = 59.63, p < 0.001), full-time employment (63.7%, 25.7%), homemaker (2.5%, 31.2%), and retired (17.5%, 1.8%)); violence-related etiology (2.5%, 15.6%); and severity of depressive symptoms (M = 7.9, SD = 5.8; M = 5.8, SD = 5.7; p = 0.014). Conclusions: TBI caregivers in the U.S. were older and employed full-time or retired more often than those in Latin America. Violence-related etiology was nearly five times more common in Latin America, raising concerns for potential implications of post-traumatic stress and family adjustment after injury. Although both groups likely could use mental health support, this was particularly true of the U.S. cohort, maybe due to differential demographics, mechanisms of injury, or family and community support.

History of Mild Traumatic Brain Injury Affects Static Balance Under Complex Multisensory Manipulations

A recent study in active duty military in the Coast Guard suggested lifetime experience with mTBI was associated with subtle deficits in postural control when exposed to multisensory discordance (i.e. rotating visual stimulation). The present study extended postural assessments to veterans recruited from the community. Service veterans completed the Defense Veteran Brain Injury Center (DVBIC) TBI Screening Tool, PTSD Checklist (PCL-5), and neurobehavioral symptom inventory (NSI). Postural control was assessed using a custom designed virtual reality based device, which assessed center of pressure (COP) sway in response to six conditions designed to test sensory integration by systematically combining three visual conditions (eyes open, eyes closed, and rotating scene) with two somatosensory conditions (firm or foam surface). Veterans screening positive for lifetime experience of mTBI (mTBI+) displayed similar postural sway to veterans without lifetime experience of mTBI (mTBI-) on basic assessment of eyes open or closed on firm and foam surface. mTBI+ veterans displayed greater sway than mTBI- veterans in response to the rotating visual stimuli while on a foam surface. Similar to previous research the degree of sway was affected by the number of lifetime experiences of mTBI. Increased postural sway was not related to PTSD, NSI, or, balance-specific symptom expression. In summary, veterans who experienced mTBI over their lifetime exhibited dysfunction in balance control as revealed by challenging conditions with multisensory discordance. These balance-related signs were independent of self-reported balance-related symptoms or other symptom domains measured by the NSI, which can provide a method for exposing otherwise covert dysfunction long after experience of mTBI.

The Military Injuries: Understanding Post-Traumatic Epilepsy Study: Understanding Relationships among Lifetime Traumatic Brain Injury History, Epilepsy, and Quality of Life

Understanding risk for epilepsy among persons who sustain a mild (mTBI) traumatic brain injury (TBI) is crucial for effective intervention and prevention. However, mTBI is frequently undocumented or poorly documented in health records. Further, health records are non-continuous, such as when persons move through health systems (e.g., from Department of Defense to Veterans Affairs [VA] or between jobs in the civilian sector), making population-based assessments of this relationship challenging. Here, we introduce the MINUTE (Military INjuries-Understanding post-Traumatic Epilepsy) study, which integrates data from the Veterans Health Administration with self-report survey data for post-9/11 veterans (n = 2603) with histories of TBI, epilepsy and controls without a history of TBI or epilepsy. This article describes the MINUTE study design, implementation, hypotheses, and initial results across four groups of interest for neurotrauma: 1) control; 2) epilepsy; 3) TBI; and 4) post-traumatic epilepsy (PTE). Using combined survey and health record data, we test hypotheses examining lifetime history of TBI and the differential impacts of TBI, epilepsy, and PTE on quality of life. The MINUTE study revealed high rates of undocumented lifetime TBIs among veterans with epilepsy who had no evidence of TBI in VA medical records. Further, worse physical functioning and health-related quality of life were found for persons with epilepsy + TBI compared to those with either epilepsy or TBI alone. This effect was not fully explained by TBI severity. These insights provide valuable opportunities to optimize the resilience, delivery of health services, and community reintegration of veterans with TBI and complex comorbidity.

Link between Mild Traumatic Brain Injury, Poor Sleep, and Magnetic Resonance Imaging: Visible Perivascular Spaces in Veterans

Impaired clearance of perivascular waste in the brain may play a critical role in morbidity after mild traumatic brain injury (mTBI). We aimed to determine the effect of mTBI on the burden of magnetic resonance imaging (MRI)-visible perivascular spaces (PVSs) in a cohort of U.S. military veterans and whether sleep modulates this effect. We also investigated the correlation between PVS burden and severity of persistent post-concussive symptoms. Fifty-six Iraq/Afghanistan veterans received 3 Tesla MRI as part of a prospective cohort study on military blast mTBI. White matter PVS burden (i.e., number and volume) was calculated using an established automated segmentation algorithm. Multi-variate regression was used to establish the association between mTBIs sustained in the military and PVS burden. Covariates included age, blood pressure, number of impact mTBIs outside the military, and blast exposures. Correlation coefficients were calculated between PVS burden and severity of persistent post-concussive symptoms. There was a significant positive relationship between the number of mTBIs sustained in the military and both PVS number and volume (p = 0.04). A significant interaction was found between mTBI and poor sleep on PVS volume (p = 0.04). A correlation was found between PVS number and volume, as well as severity of postconcussive symptoms (p = 0.03). Further analysis revealed a moderate correlation between PVS number and volume, as well as balance problems (p < 0.001). In Iraq/Afghanistan veterans, mTBI is associated with an increase in PVS burden. Further, an interaction exists between mTBI and poor sleep on PVS burden. Increased PVS burden, which may indicate waste clearance dysfunction, is associated with persistent post-concussive symptom severity.

Network topology changes in chronic mild traumatic brain injury (mTBI)

BACKGROUND

In mild traumatic brain injury (mTBI), diffuse axonal injury results in disruption of functional networks in the brain and is thought to be a major contributor to cognitive dysfunction even years after trauma.

OBJECTIVE

Few studies have assessed longitudinal changes in network topology in chronic mTBI. We utilized a graph theoretical approach to investigate alterations in global network topology based on resting-state functional connectivity in veterans with chronic mTBI.

METHODS

50 veterans with chronic mTBI (mean of 20.7 yrs. from trauma) and 40 age-matched controls underwent two functional magnetic resonance imaging scans 18 months apart. Graph theory analysis was used to quantify network topology measures (density, clustering coefficient, global efficiency, and modularity). Hierarchical linear mixed models were used to examine longitudinal change in network topology.

RESULTS

With all network measures, we found a significant group × time interaction. At baseline, brain networks of individuals with mTBI were less clustered (p = 0.03) and more modular (p = 0.02) than those of HC. Over time, the mTBI networks became more densely connected (p = 0.002), with increased clustering (p = 0.001) and reduced modularity (p < 0.001). Network topology did not change across time in HC.

CONCLUSION

These findings demonstrate that brain networks of individuals with mTBI remain plastic decades after injury and undergo significant changes in network topology even at the later phase of the disease.

Interaction Between Psychiatric Symptoms and History of Mild TBI When Evaluating Postconcussion Syndrome in Veterans

INTRODUCTION

Symptoms of postconcussive syndrome (PCS) after mild TBI (mTBI) have been shown to resolve quickly, yet new research raises questions about possible long-term effects of this condition. It is not clear how best to address assessment and treatment when someone reports lingering symptoms of PCS. One self-report measure used by the VA and the DoD is the Neurobehavioral Symptom Inventory (NSI), but this measure may be affected by underlying psychiatric symptoms. We investigated whether the NSI is sensitive to mTBI after considering a number of psychiatric and demographic factors.

METHODS

This study examined which factors are associated with NSI scores in a Veteran sample (n = 741) that had recently returned from deployment.

RESULTS

Post-traumatic stress disorder (PTSD) and depression accounted for most of the variance on the NSI. Although history of mTBI was initially related to NSI, this association was no longer significant after other covariates were considered.

CONCLUSIONS

The NSI score was primarily explained by symptoms of PTSD and depression, suggesting that the NSI is not specific to the experience of a brain injury. We recommend cautious interpretation when this measure is used in the chronic phase after mTBI, especially among patients with comorbid depression or PTSD.

Long-Term Impact of Mild Traumatic Brain Injuries on Multiple Functional Outcomes and Epigenetics: A Pilot Study with College Students

People who suffer a mild traumatic brain injury (mTBI) have heterogeneous symptoms and disease trajectories, which make it difficult to precisely assess long-term complications. This pilot study assessed and compared deficits in cognitive, psychosocial, visual functions, and balance performance between college students with and without histories of mTBI. Global DNA methylation ratio (5-mC%) in blood was also compared as a peripheral epigenetic marker. Twenty-five volunteers participated, including 14 healthy controls (64.3% females; mean age of 22.0) and 11 mTBI cases (27.3% females; mean age of 28.7 years) who self-reported mTBI history (63.6% multiple; 2.5 ± 1.29 injuries) with 7.1 years on average elapsed following the last injury. Every participant was assessed for cognitive (executive function, memory, and processing speed), psychological (depression, anxiety, and sleep disturbances), and visual function (by King–Devick and binocular accommodative tests); force-plate postural balance performance; and blood 5-mC% levels. Students with mTBI showed poorer episodic memory, severe anxiety, and higher blood 5-mC% ratio, compared to controls (all p’s < 0.05), which were still significant after adjusting for age. No differences were detected in sleep problems (after adjusting for age), visual function, and postural balance. These findings identified changes in multiple functions and peripheral epigenetics long after mTBI.

Validating the usefulness of the NSI validity-10 with the MMPI-2-RF

Purpose/Aim of the Study: The Neurobehavioral Symptom Inventory (NSI) is a 22-item self-report measure created to quantify the somatosensory, cognitive, and affective symptoms of Post-concussive Syndrome. Developers of the NSI used a subset of 10 items, the Validty-10, to measure symptom overreporting. We compared the Validity-10 versus the remaining NSI items (i.e., the Remaining-12) for how accurately they detect symptom exaggeration on the Minnesota Multiphasic Personality Inventory Second Edition - Restructured Form (MMPI-2-RF).Materials and Methods: We used a sample of 45 veterans evaluated in a Polytrauma/TBI Clinic of a Midwest VA Healthcare System who completed the NSI and MMPI-2-RF.Results: The Vaidity-10, Remaining-12, and Total Score all strongly correlated with mean of the MMPI-2-RF validity scales (r = .65, .67, and .70, respectively), illustrating equivalency among the various NSI scores. Groups were created based on significant T score elevation on any MMPI-2-RF validity scale (i.e. F-r > 119, or Fp-r, F-s, FBS, or RBS > 99). ROC analyses demonstrated that areas under the curve were equivalent for NSI Total Score (.84), Validity-10 (.81), and Remaining-12 (.81) in detecting overreporting.Conclusions: These findings do not support the notion that the Validity-10 has unique utility as an embedded symptom validity scale and highlights the likelihood that NSI Total Score can also serve this function.

Use of the Progressive Return to Activity Guidelines May Expedite Symptom Resolution After Concussion for Active Duty Military

BACKGROUND

Clinical recommendations for concussion management encourage reduced cognitive and physical activities immediately after injury, with graded increases in activity as symptoms resolve. Empirical support for the effectiveness of such recommendations is needed.

PURPOSE

To examine whether training medical providers on the Defense and Veterans Brain Injury Center's Progressive Return to Activity Clinical Recommendation (PRA-CR) for acute concussion improves patient outcomes.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

This study was conducted from 2016 to 2018 and compared patient outcomes before and after medical providers received an educational intervention (ie, provider training). Patients, recruited either before or after intervention, were assessed at ≤72 hours, 1 week, 1 month, 3 months, and 6 months after a concussion. The participant population included 38 military medical providers and 106 military servicemembers with a diagnosed concussion and treated by one of the military medical providers: 58 patient participants received care before the intervention (ie, provider training) and 48 received care after intervention. The primary outcome measure was the Neurobehavioral Symptom Inventory.

RESULTS

The patients seen before and after the intervention were predominantly male (89.7% and 93.8%, respectively) of military age (mean ± SD, 26.62 ± 6.29 years and 25.08 ± 6.85 years, respectively) and a mean ± SD of 1.92 ± 0.88 days from injury. Compared with patients receiving care before intervention, patients receiving care after intervention had smaller increases in physical activities (difference in mean change; 95% CI, 0.39 to 6.79) and vestibular/balance activities (95% CI, 0.79 to 7.5) during the first week of recovery. Although groups did not differ in symptoms at ≤72 hours of injury (d = 0.22; 95% CI, -2.21 to 8.07), the postintervention group reported fewer symptoms at 1 week (d = 0.61; 95% CI, 0.52 to 10.92). Postintervention patients who completed the 6-month study had improved recovery both at 1 month (d = 1.55; 95% CI, 5.33 to 15.39) and 3 months after injury (d = 1.10; 95% CI, 2.36 to 11.55), but not at 6 months (d = 0.35; 95% CI, 5.34 to 7.59).

CONCLUSION

Training medical providers on the PRA-CR for management of concussion resulted in expedited recovery of patients.

Rasch Analysis of Postconcussive Symptoms: Development of Crosswalks and the Brain Injury Symptom Scale

OBJECTIVE

The first aim of this study was to develop a Rasch-based crosswalk between 2 postconcussive symptom measures, the Neurobehavioral Symptom Inventory (NSI) and the Rivermead Postconcussive Symptom Questionnaire (RPQ). The second goal was to utilize Rasch analysis to formulate a new proposed scale containing the best theoretical and psychometric items.

DESIGN

Prospective cohort observational study.

SETTING

Three acute inpatient rehabilitation hospitals in the United States.

PARTICIPANTS

Community-dwelling persons (N=497) who were previously hospitalized and were diagnosed with mild to severe traumatic brain injury. Participants were (1) 18-64 years old; (2) could give informed consent; (3) able to complete study measures in English; (4) did not have an interfering medical or psychiatric condition.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

NSI, RPQ.

RESULTS

Rasch analysis revealed 4 subdimensions across the 2 scales: cognitive, affective, physical, and visual. Crosswalk tables were generated for the first 3. Visual items were too few to generate a crosswalk. Iterative Rasch analysis produced a new scale with items rated from none to severe including the best items in each of these dimensions.

CONCLUSIONS

The NSI and RPQ have considerable overlap and measure the same overarching constructs. Crosswalk tables may be helpful for clinicians and researchers to convert scores from 1 measure to the other. A more psychometrically sound scale, the Brain Injury Symptom Scale, composed of items from the NSI and RPQ, is proposed and will need further validation.

[Formula: see text]Interpreting change on the neurobehavioral symptom inventory and the PTSD checklist in military personnel

OBJECTIVE

The purpose of this study was to examine the prevalence and stability of symptom reporting in a healthy military sample and to develop reliable change indices for two commonly used self-report measures in the military health care system.

PARTICIPANTS AND METHOD

Participants were 215 U.S. active duty service members recruited from Fort Bragg, NC as normal controls as part of a larger study. Participants completed the Neurobehavioral Symptom Inventory (NSI) and Posttraumatic Checklist (PCL) twice, separated by approximately 30 days.

RESULTS

Depending on the endorsement level used (i.e. ratings of 'mild' or greater vs. ratings of 'moderate' or greater), approximately 2-15% of this sample met DSM-IV symptom criteria for Postconcussional Disorder across time points, while 1-6% met DSM-IV symptom criteria for Posttraumatic Stress Disorder. Effect sizes for change from Time 1 to Time 2 on individual symptoms were small (Cohen's d = .01 to .13). The test-retest reliability for the NSI total score was r = .78 and the PCL score was r = .70. An eight-point change in symptom reporting represented reliable change on the NSI total score, with a seven-point change needed on the PCL.

CONCLUSIONS

Postconcussion-like symptoms are not unique to mild TBI and are commonly reported in a healthy soldier sample. It is important for clinicians to use normative data when evaluating a service member or veteran and when evaluating the likelihood that a change in symptom reporting is reliable and clinically meaningful.