Differences in Posttraumatic Stress Disorder, Depression, and Attribution of Symptoms in Service Members With Combat Versus Noncombat Mild Traumatic Brain Injury

Prevalence of PTSD in Active Duty Members with Mild Traumatic Brain Injury: Systematic Review and Meta-analysis

INTRODUCTION

Traumatic brain injury (TBI), particularly mild TBI (mTBI), is a significant health concern for U.S. active duty service members (ADSMs), with potential implications for psychiatric outcomes including PTSD. Despite recognizing this association, the prevalence of PTSD among ADSMs with mTBI remains unclear.

MATERIALS AND METHODS

The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A thorough search in PubMed, CINAHL, Embase, and PsycINFO databases from 2008 to 2024 focused on identifying studies involving ADSMs with PTSD and mTBI. The R software (version 4.3.2) was employed for meta-analysis with the "meta" and "meta prop" packages.

RESULTS

Eight reviewed studies revealed a pooled prevalence estimate of PTSD among ADSMs with mTBI at 36% (95% CI, 30%-41%, P < .01, I2 = 96%). Cohort studies indicated a slightly higher prevalence of 38% (95% CI, 19%-59%, P < .01, I2 = 98%), whereas cross-sectional studies provided a marginally lower prevalence of 34% (95% CI, 27%-40%, P < .01, I2 = 92%).

CONCLUSION

Methodological differences, including diagnostic criteria variability, contribute to the observed variability in prevalence estimates. Despite methodological challenges, this study provides crucial insights into the pooled prevalence of comorbid PTSD and mTBI within the military, emphasizing the need for standardized methodologies and further research to refine understanding and support strategies for affected individuals.

Lifetime Traumatic Brain Injury and Risk of Post-Concussive Symptoms in the Millennium Cohort Study

Traumatic brain injury (TBI) is prevalent among active duty military service members, with studies reporting up to 23% experiencing at least one TBI, with 10-60% of service members reporting at least one subsequent repeat TBI. A TBI has been associated with an increased risk of cumulative effects and long-term neurobehavioral symptoms, impacting operational readiness in the short-term and overall health in the long term. The association between multiple TBI and post-concussive symptoms (PCS), however, defined as symptoms that follow a concussion or TBI, in the military has not been adequately examined. Previous studies in military populations are limited by methodological issues including small sample sizes, the use of non-probability sampling, or failure to include the total number of TBI. To overcome these limitations, we examined the association between the total lifetime number of TBI and total number of PCS among U.S. active duty military service members who participated in the Millennium Cohort Study. A secondary data analysis was conducted using the Millennium Cohort Study's 2014 survey (n = 28,263) responses on self-reported TBI and PCS (e.g., fatigue, restlessness, sleep disturbances, poor concentration, or memory loss). Zero-inflated negative binomial models calculated prevalence ratios (PRs) and 95% confidence intervals (CIs) for the unadjusted and adjusted associations between lifetime TBIs and PCS. A third of military participants reported experiencing one or more TBIs during their lifetime with 72% reporting at least one PCS. As the mean number of PCS increased, mean lifetime TBIs increased. The mean number of PCS by those with four or more TBI (4.63) was more than twice that of those with no lifetime TBI (2.28). One, two, three, and four or more TBI had 1.10 (95% CI: 1.06-1.15), 1.19 (95% CI: 1.14-1.25), 1.23 (95% CI: 1.17-1.30), and 1.30 times (95% CI: 1.24-1.37) higher prevalence of PCS, respectively. The prevalence of PCS was 2.4 (95% CI: 2.32-2.48) times higher in those with post-traumatic stress disorder than their counterparts. Active duty military service members with a history of TBI are more likely to have PCS than those with no history of TBI. These results suggest an elevated prevalence of PCS as the number of TBI increased. This highlights the need for robust, longitudinal studies that can establish a temporal relationship between repetitive TBI and incidence of PCS. These findings have practical relevance for designing both workplace safety prevention measures and treatment options regarding the effect on and from TBI among military personnel.

Validity and Responsiveness of the Portable Warrior Test of Tactical Agility After Rehabilitation in Service Members With Mild Traumatic Brain Injury

OBJECTIVE

The Portable Warrior Test of Tactical Agility (POWAR-TOTAL) is a performance-based test designed to assess active-duty service members diagnosed with mild traumatic brain injuries (mTBIs) and could potentially inform return to duty decisions. To examine the validity and responsiveness of the POWAR-TOTAL measure, this study collected self-reported and performance measures by active-duty service members before and after an episode of physical therapist care.

METHODS

Seventy-four individuals, enrolled in care for mTBI symptoms at 1 of 2 concussion specialty Intrepid Spirit Centers, were examined the week that they initiated physical therapy with the intention to return to active duty. Self-reported measures of concussion symptoms, pain, posttraumatic stress, headache, dizziness, and sleep quality were used, as were concurrent measures of mobility and balance. The POWAR-TOTAL task (motor and cognitive skills in single and dual-task conditions) was administered. Forty-nine active-duty service members returned for posttherapy testing using the same test battery. Effect sizes for change in measures were calculated. Construct validity was assessed by correlating change scores on POWAR with concurrent self-report and mobility measures. Responsiveness was evaluated using an anchor-based approach.

RESULTS

Significant improvements in self-reported and performance-based measures, including POWAR, were observed after therapy with moderate to large effect sizes. Improvement in POWAR performance correlated with improvement in both performance and self-reported measures. After therapy, individuals who registered improvement on the Patient Global Impression of Change scale demonstrated significantly faster POWAR motor performance than those who rated little or no improvement in their condition.

CONCLUSION

The POWAR-TOTAL captured improvement on a military-specific task after completing physical therapy for mTBI and could serve as an indicator of physical recovery and readiness for return to duty.

IMPACT

Challenging cognitive and motor measures for service members may aid in the assessment of recovery and the ability to successfully return to duty after concussion as part of a comprehensive examination approach.

Executive function improvement in response to meta-cognitive training in chronic mTBI / PTSD

Objective

We tested Goal Management Training (GMT), which has been recommended as an executive training protocol that may improve the deficits in the complex tasks inherent in life role participation experienced by those with chronic mild traumatic brain injury and post-traumatic stress disease (mTBI/PTSD). We assessed, not only cognitive function, but also life role participation (quality of life).

Methods

We enrolled and treated 14 individuals and administered 10 GMT sessions in-person and provided the use of the Veterans Task Manager (VTM), a Smartphone App, which was designed to serve as a "practice-buddy" device to ensure translation of in-person learning to independent home and community practice of complex tasks. Pre-/post-treatment primary measure was the NIH Examiner, Unstructured Task. Secondary measures were as follows: Tower of London time to complete (cTOL), Community Reintegration of Service Members (CRIS) three subdomains [Extent of Participation; Limitations; Satisfaction of Life Role Participation (Satisfaction)]. We analyzed pre-post-treatment, t-test models to explore change, and generated descriptive statistics to inspect given individual patterns of change across measures.

Results

There was statistically significant improvement for the NIH EXAMINER Unstructured Task (p < .02; effect size = .67) and cTOL (p < .01; effect size = .52. There was a statistically significant improvement for two CRIS subdomains: Extent of Participation (p < .01; effect size = .75; Limitations (p < .05; effect size = .59). Individuals varied in their treatment response, across measures.

Conclusions and Clinical Significance

In Veterans with mTBI/PTSD in response to GMT and the VTM learning support buddy, there was significant improvement in executive cognition processes, sufficiently robust to produce significant improvement in community life role participation. The individual variations support need for precision neurorehabilitation. The positive results occurred in response to treatment advantages afforded by the content of the combined GMT and the employment of the VTM learning support buddy, with advantages including the following: manualized content of the GMT; incremental complex task difficulty; GMT structure and flexibility to incorporate individualized functional goals; and the VTM capability of ensuring translation of in-person instruction to home and community practice, solidifying newly learned executive cognitive processes. Study results support future study, including a potential randomized controlled trial, the manualized GMT and availability of the VTM to ensure future clinical deployment of treatment, as warranted.

Military TBI—What civilian primary care providers should know

In June 2019, the Department of Veterans Affairs (VA) launched the VA Mission Act, which expanded veterans’ health-care access to the private sector. Since civilian primary care providers may see more veterans in their practice, it will be important to understand the unique experiences, comorbidities, and culture of this population in order to provide optimal care. Military service members (SMs) are at an increased risk for traumatic brain injury (TBI), and comorbidities, such as post traumatic stress disorder (PTSD), increasing the likelihood of prolonged symptoms. Military training and repetitive low-level blast exposure may cause symptoms similar to TBI or increase long-term negative effects in SMs. Military culture often has a strong influence in this population. Those who serve in the military identify with military values and have a strong team mentality, which places emphasis on the mission above all else, not accepting defeat, and not ever leaving a fellow SM behind. These values can impact the way a SM/veteran seeks care and/or communicates with his or her health-care provider. Taking a detailed history to understand how these factors apply, as well as screening for mental health comorbidities, are recommended. Understanding the military cultural influences can assist in promoting a stronger therapeutic alliance and encourage more open communication. Ultimately, it is the trusting and respectful relationship between the SM/veteran and the provider that will determine the most effective treatment and result in the most effective resolution of TBI and comorbid symptoms.