Screening for mild traumatic brain injury in OEF-OIF deployed US military: An empirical assessment of VHA's experience

A Network Analysis of the PART-O at 1 and 2 Years After TBI: A Veterans Affairs Model Systems Study

OBJECTIVE

The construct of participation after traumatic brain injury (TBI) can be difficult to operationalize. Psychometric network analysis offers an empirical approach to visualizing and quantifying the associations between activities that comprise participation, elucidating the relations among the construct's components without assuming the presence of a latent common cause and generating a model to inform future measurement methods. The current research applied psychometric network analysis to the Participation Assessment with Recombined Tools-Objective (PART-O) within a sample of service members and veterans (SM/Vs) with a history of TBI at 1 and 2 years ( T1 and T2 ) postinjury.

PARTICIPANTS

Participants ( N = 663) were SM/Vs with a history of TBI who completed comprehensive inpatient rehabilitation services at a Department of Veterans Affairs (VA) Polytrauma Rehabilitation Center (PRC).

SETTING

Five VA PRCs.

DESIGN

Cross-sectional, retrospective analysis of data from the VA TBI Model Systems study.

MAIN MEASURES

PART-O.

RESULTS

Network analysis demonstrated that the PART-O structure was generally consistent over time, but some differences emerged. The greatest difference observed was the association between "spending time with friends" and "giving emotional support" to others. This association was more than twice as strong at T2 as at T1 . The "out of the house" item was most central, as demonstrated by dense connections within its own subscale (Out and About) and items in other subscales (ie, Social Relations and Productivity). When examining items connecting the 3 subscales, the items related to giving emotional support, internet use, and getting out of the house emerged as the strongest connectors at T1 , and the internet was the strongest connector at T2 .

CONCLUSION

Providing emotional support to others is associated with greater participation across multiple domains and is an important indicator of recovery. Being out and about, internet use, and engagement in productive activities such as school and work shared strong associations with Social Relations. Network analysis permits visual conceptualization of the dynamic constructs that comprise participation and has the potential to inform approaches to measurement and treatment.

Comparing Outcomes of the Veterans Health Administration's Traumatic Brain Injury and Mental Health Screening Programs: Types and Frequency of Specialty Services Used

The Veterans Health Administration (VHA) screens veterans who deployed in support of the wars in Afghanistan and Iraq for traumatic brain injury (TBI) and mental health (MH) disorders. Chronic symptoms after mild TBI overlap with MH symptoms, for which there are already established screens within the VHA. It is unclear whether the TBI screen facilitates treatment for appropriate specialty care over and beyond the MH screens. Our primary objective was to determine whether TBI screening is associated with different types (MH, Physical Medicine & Rehabilitation [PM&R], and Neurology) and frequency of specialty services compared with the MH screens. A retrospective cohort design examined veterans receiving VHA care who were screened for both TBI and MH disorders between Fiscal Year (FY) 2007 and FY 2018 (N = 241,136). We calculated service utilization counts in MH, PM&R, and Neurology in the six months after the screens. Zero-inflated negative binomial regression models of encounters (counts) were fit separately by specialty care type and for a total count of specialty services. We found that screening positive for TBI resulted in 2.38 times more specialty service encounters than screening negative for TBI. Compared with screening positive for MH only, screening positive for both MH and TBI resulted in 1.78 times more specialty service encounters and 1.33 times more MH encounters. The TBI screen appears to increase use of MH, PM&R, and Neurology services for veterans with post-deployment health concerns, even in those also identified as having a possible MH disorder.

Characterizing Sex Differences in Clinical and Functional Outcomes Among Military Veterans with a Comprehensive Traumatic Brain Injury Evaluation (CTBIE): A Million Veteran Program (MVP) Study

Using a diverse sample of military Veterans enrolled in the VA's Million Veteran Program (N=14,378; n=1,361 females [9.5%]; all previously deployed), we examined sex differences on the Comprehensive Traumatic Brain Injury Evaluation (CTBIE), a structured traumatic brain injury (TBI) interview routinely administered within the VA. Confirmed TBI diagnoses were more frequent among males than females (65% vs. 58%). Additionally, when compared to females, a greater proportion of males with CTBIE-confirmed TBI histories experienced blast-related injuries and were employed. In contrast, a greater proportion of females reported experiencing falls, sustaining a TBI since deployment, and having more severe neurobehavioral symptoms (particularly affective-related symptoms). Results indicate that males and females experience differential clinical and functional outcomes in the aftermath of military TBI. Findings underscore the need to increase female representation in TBI research to increase understanding of sex-specific experiences with TBI and to improve the clinical care targeted to this vulnerable population.

Intrepid Spirit Centers: Considerations for Active Duty, National Guard, Reserves, and Retirees

BACKGROUND

Traumatic brain injury (TBI) is a significant concern to the military health system (MHS) and a signature wound of America's current conflict. To address the influx of patients with military-related TBI, the Department of Defense has partnered with the Fisher Foundation and the Intrepid Fallen Heroes Fund to establish the National Intrepid Center of Excellence and satellite network of Intrepid Spirit Centers. The purpose of this study is to review the prevalence of disease and geographic density of TBI among active duty, National Guard, reservist, and retired military populations in order to inform decision-making around the development of additional Intrepid Spirit Centers.

METHODS

We used the MHS Data Repository to perform a cross-sectional examination to assess the prevalence of TBI among active duty, National Guard, reservist, and retired military personnel from fiscal years (FY) 2016 to 2019. Statistical analyses included descriptive statistics on patient demographics and the prevalence of TBI.

RESULTS

We identified a total of 3,221,682 active duty, National Guard, reservists, and retired military personnel in the U.S. Army, Air Force, Navy, and Marine Corps during FY 2016 to 2019; 59.5% were active duty personnel, 23.1% were Retirees, and 17.4% were National Guard and reservists. A total of 72,002 were found to have a TBI-related diagnosis. Texas, North Carolina, and California had the highest case counts for TBI. High prevalence of TBI was found in Bexar County, TX, Muscogee County, GA, Okaloosa County, FL, San Diego County, CA, and Virginia Beach City, VA.

CONCLUSIONS

Additional Intrepid Spirit Centers are warranted to better meet the needs of active duty, active and inactive National Guard and reservists, and retired military personnel in locations including San Antonio, TX, and Columbus, GA. These locations currently have the medical infrastructure necessary to facilitate the care of wounded warriors and return to duty ensuring the health of the Nation's fighting force and veterans.

Associations Among PTSD and Postconcussive Symptoms in the Long-Term Impact of Military-Relevant Brain Injury Consortium-Chronic Effects of Neurotrauma Consortium Prospective, Longitudinal Study Cohort

OBJECTIVE

To describe rates of mild traumatic brain injury (mTBI) with and without concurrent posttraumatic stress disorder a sample of former and current military personnel, and to compare the factor structure of the Neurobehavioral Symptom Inventory (NSI) based on whether participants sustained mTBI with and without a positive posttraumatic stress disorder (PTSD) screen.

SETTING

Participants recruited and tested at 7 Veterans Affairs (VA) sites and 1 military training facility as part of a national, longitudinal study of mental health, physical, and cognitive outcomes among veterans and service members. Participants: Total of 1540 former and current military personnel with a history of combat exposure.

DESIGN

Cross-sectional analysis of observational data, including confirmatory factor analysis. Main Measures: NSI and PTSD Checklist for DSM-5 (PCL-5).

RESULTS

Most participants (81.5%) had a history of mTBI and almost half of these screened positive for PTSD (40.5%); only 23.9% of participants without a history of mTBI screened positive for PTSD. Participants with a history of mTBI reported higher elevations of NSI and PCL-5 symptoms compared with those without a history of mTBI. Confirmatory factor analyses of the NSI demonstrated good model fit using a 4-factor structure (somatosensory, affective, cognitive, and vestibular symptoms) among groups of participants both with and without a history of mTBI.

CONCLUSION

Symptoms of mTBI and PTSD are strongly associated with each other among veterans and service members with a history of combat exposure. The 4-factor NSI structure is supported among participants with and without a history of mTBI. These findings suggest the potential benefit of a holistic approach to evaluation and treatment of veterans and service members with concurrent and elevated postconcussive and posttraumatic stress symptoms.

Reference Values for the Headache Impact Test-6 Questionnaire

OBJECTIVE

To determine reference values for the Headache Impact Test-6 (HIT-6) in a young, physically active cohort and to examine the influence of sex, concussion history, headache history, and competitive sport level on HIT-6 scores.

DESIGN

Cross-sectional.

SETTING

United States Service Academy.

PARTICIPANTS

United States Service Academy cadets (N=2678) completed an HIT-6 questionnaire as part of their annual concussion baseline assessment. Cadets with a recent concussion were excluded from baseline testing.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Reference values were calculated and stratified by sex, concussion history, headache history, and competitive sport level. Mann-Whitney U and Kruskal-Wallis tests were used to examine the effect of sex, concussion history, headache history, and competitive sport level on HIT-6 scores (P<.05).

RESULTS

Of the 3599 cadets baselined, 2687 cadets (23% female) agreed to participate in the study and completed the HIT-6. Female participants reported significantly worse HIT-6 scores compared with male participants both with (P<.001) and without (P<.001) a concussion history. In both sexes, participants with a headache history reported worse scores than those with no headache/concussion history and a concussion history (all P<.005). Female cadets who participated in intramural athletics reported worse HIT-6 scores at baseline than female intercollegiate athletes (P=.003).

CONCLUSIONS

This is the first study to stratify HIT-6 data by sex, concussion history, headache history, and sport level in a collegiate population at risk for concussions. Sex and headache history appear to influence HIT-6 scores and should be given special consideration when interpreting health-related quality of life deficits due to headache.

Sex as a Biological Variable in Preclinical Modeling of Blast-Related Traumatic Brain Injury

Approaches to furthering our understanding of the bioeffects, behavioral changes, and treatment options following exposure to blast are a worldwide priority. Of particular need is a more concerted effort to employ animal models to determine possible sex differences, which have been reported in the clinical literature. In this review, clinical and preclinical reports concerning blast injury effects are summarized in relation to sex as a biological variable (SABV). The review outlines approaches that explore the pertinent role of sex chromosomes and gonadal steroids for delineating sex as a biological independent variable. Next, underlying biological factors that need exploration for blast effects in light of SABV are outlined, including pituitary, autonomic, vascular, and inflammation factors that all have evidence as having important SABV relevance. A major second consideration for the study of SABV and preclinical blast effects is the notable lack of consistent model design—a wide range of devices have been employed with questionable relevance to real-life scenarios—as well as poor standardization for reporting of blast parameters. Hence, the review also provides current views regarding optimal design of shock tubes for approaching the problem of primary blast effects and sex differences and outlines a plan for the regularization of reporting. Standardization and clear description of blast parameters will provide greater comparability across models, as well as unify consensus for important sex difference bioeffects.

Health Services Utilization, Health Care Costs, and Diagnoses by Mild Traumatic Brain Injury Exposure: A Chronic Effects of Neurotrauma Consortium Study

OBJECTIVE

To compare Veterans Health Administration (VHA) diagnoses, health services utilization, and costs by mild traumatic brain injury (mTBI) group (blast-related [BR] mTBI vs non-blast-related [NBR] mTBI vs no mTBI) among Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF)/Operation New Dawn (OND) veterans in the Chronic Effects of Neurotrauma Consortium multicenter observational study.

DESIGN

Prospective cohort study.

SETTING

Four Veterans Affairs Medical Centers.

PARTICIPANTS

OEF/OIF/OND veterans (N=472) who used Veterans Affairs Medical Centers services between 2002-2017.

INTERVENTIONS

Not applicable. Lifetime mTBI history was assessed via semistructured interviews.

MAIN OUTCOME MEASURES

VHA diagnoses, health services utilization, and costs.

RESULTS

Relative to NBR mTBI and no mTBI, veterans with BR mTBI were more likely to be male, have greater combat, and have controlled and uncontrolled detonations exposures (median BR, 15.0 vs NBR, 3.0 vs no mTBI, 3.0). They also had higher prevalence of headache, posttraumatic stress disorder, and anxiety diagnoses. Veterans with BR had the highest site-adjusted mean annual VHA utilization (26.31 visits; 95% confidence interval [CI], 26.01-26.61) relative to NBR (20.43 visits; 95% CI, 20.15-20.71) and no mTBI (16.62 visits; 95% CI, 16.21-17.04) and highest site adjusted mean annual VHA outpatient costs ($6480; 95% CI, $5842-$7187) relative to NBR ($4901; 95% CI, $4392-$5468) and no mTBI ($4069; 95% CI, $3404-$4864).

CONCLUSIONS

Veterans with BR mTBI had higher exposure to combat and detonation. BR was associated with greater prevalence of select diagnoses and higher health services utilization and costs relative to NBR and no mTBI. The role of health care needs from mTBI polytrauma, other deployment-related exposures, and VHA access warrants future research.

Intimate Partner Violence Among Female OEF/OIF/OND Veterans Who Were Evaluated for Traumatic Brain Injury in the Veterans Health Administration: A Preliminary Investigation

Many female veterans have deployed to Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND), and some experience traumatic brain injury (TBI). Although TBI is increasingly recognized as an important health issue for female OEF/OIF/OND veterans, there is little attention to stressful experiences that may exacerbate health problems or hinder recovery among veterans who may have experienced TBI. Lifetime intimate partner violence (IPV) is common among general samples of female veterans. Given the negative implications of IPV on women's health, it is important to understand whether there is a relationship between lifetime IPV and health functioning among female veterans who have experienced possible TBI. This study provides an exploration of lifetime IPV and its associations with physical and mental health, as well as community reintegration, among female OEF/OIF/OND veterans who have been evaluated for TBI. The sample comprised 127 female veterans who participated in a larger study that examined reintegration among OEF/OIF/OND veterans who received a TBI evaluation in the Veterans Heath Administration (VHA) and completed an assessment of lifetime IPV. Primary and secondary data sources included survey responses (e.g., health symptoms and reintegration) and VHA administrative data (e.g., health diagnoses). Results indicated that nearly two thirds (63.0%) of women who completed a TBI evaluation reported lifetime IPV, though clinician-confirmed TBI was not associated with IPV. Women who experienced IPV, compared with those who did not, reported higher levels of neurobehavioral symptoms and were significantly more likely to have diagnoses of back pain (48.6% vs. 30.0%, respectively) and substance abuse (12.2% vs. 0%, respectively). Notwithstanding, women with and without lifetime IPV reported similar levels of reintegration. Findings provide evidence that lifetime IPV may be common among female OEF/OIF/OND veterans who are evaluated for TBI, and that IPV is associated with several treatable health problems among this population.

The Deployment Trauma Phenotype and Employment Status in Veterans of the Wars in Iraq and Afghanistan

OBJECTIVES

To determine the prevalence of comorbid mild traumatic brain injury (mTBI), posttraumatic stress disorder (PTSD), and depression, termed the deployment trauma phenotype (DTP), and its constituent diagnoses' impact on unemployment status in a national cohort of veterans.

SETTING

Retrospective analysis of the comprehensive TBI evaluation, a Veterans Affairs-wide protocol for assessing TBI, employment status, and psychiatric impressions.

PARTICIPANTS

The final data set consisted of 48 821 veterans.

MAIN OUTCOMES AND MEASURES

Frequency of mTBI, PTSD, and depression in isolation and combinations and their association with unemployment status.

RESULTS

Age- and education-adjusted risk ratios (RRs) showed that the mTBI-only group was the least likely to be unemployed, RR = 0.65 (0.59-0.71). By contrast, the greatest likelihood of unemployment was associated with membership in the DTP group, RR = 1.45 (1.36-1.56), and the comorbid PTSD and depression group, RR = 1.39 (1.27-1.52). Furthermore, the DTP was nearly 3 times more prevalent (16.4%) in this sample compared with comorbid PTSD and depression (5.7%), indicating that the DTP conveys risk for unemployment to a significantly greater number of individuals.

CONCLUSIONS AND RELEVANCE

The comorbid and interactive conditions of PTSD, depression, and mTBI, rather than mTBI in isolation, were linked to significant risk for unemployment in this veteran cohort. These findings suggest that multifaceted assessments and interventions to improve postdeployment reintegration are needed.

Posttraumatic stress disorder and traumatic brain Injury: Sex differences in veterans

Around half of Iraq and Afghanistan war veterans with traumatic brain injury (TBI) have co-occurring posttraumatic stress disorder (PTSD). Research on the differences between male and female veterans with co-occurring PTSD/TBI is sparse. This study evaluated behavioral health differences between sexes with these conditions. Veterans (N = 1577) completed a structured psychiatric interview, TBI interview, and self-report interviews assessing sleep quality, alcohol use, substance use, pain, depression symptoms, PTSD symptoms, and combat exposure. Groups depended on the presence/absence of a lifetime PTSD diagnosis and history of TBI. Among veterans with PTSD and TBI, males and females were equally likely to meet criteria for current PTSD, and in the PTSD only group, male veterans were more likely to have current PTSD. Male veterans with PTSD were also more likely to meet criteria for lifetime alcohol and substance use disorders (AUD and SUD), and mild TBI. Although TBI severity did not differ between sexes in the TBI only group, female veterans were more likely to have a moderate/severe TBI among veterans with co-occurring PTSD. Female veterans without PTSD and TBI were more likely to have major depressive disorder (MDD). Significant sex differences were found for AUD, MDD, current PTSD, and TBI severity.

A systematic review of sex differences in concussion outcome: What do we know?

Objective: The purpose of this review was to examine sex differences in concussion, or mild traumatic brain injury (mTBI) outcome, updating previous critical reviews of the literature. Method: Within adult human studies, we reviewed a wide range of concussion outcome variables: prevalence of concussion, injury characteristics, postconcussion symptom trajectories and psychiatric distress, neuropsychological performance, and neuroimaging findings. Sports-related concussion, civilian, and military samples were included in the review. Results: Given the robust concussion literature, there is a relative paucity of research addressing sex differences following concussion. The majority of available studies focused on sports-related concussion, with fewer studies targeting other civilian causes of concussion or military-related concussion in females. Prevalence of concussion was generally reported to be higher in females than males. Although symptom reporting largely showed a pattern for females to report greater overall symptoms than males, examining individual symptoms or symptom clusters resulted in mixed findings between the sexes. Neuropsychological studies generally showed females performing more poorly than males on measures of visual memory following concussion, though this finding was not consistently reported. Conclusion: Research examining sex differences in humans following concussion, in general, is in its infancy, and exploration of sex differences in studies outside of the sports concussion domain is particularly nascent. Given the increased prevalence of concussion and potential higher symptom reporting among women, ongoing research is necessary to better understand the role of biological sex on outcome following concussion. Understanding sex differences has important implications for assessment, management, and treatment of concussion.

Trajectory of Postconcussive Symptoms 12 Months After Deployment in Soldiers With and Without Mild Traumatic Brain Injury: Warrior Strong Study

We analyzed data from a cohort of recently deployed soldiers from 2 US Army bases, Fort Carson and Fort Bragg (2009 to 2015). Soldiers with and without a recent history of mild traumatic brain injury (mTBI) on deployment were evaluated within days of return and at 3, 6, and 12 months. Those with mTBI were more likely than those without to endorse ≥1 postconcussive symptom as "severe" and/or "very severe" (47% vs. 21%, baseline; adjusted relative risk (RR) = 1.71, 95% confidence interval: 1.51, 1.93, all time points), which remained significant after adjusting for posttraumatic stress disorder (adjusted RR = 1.34, 95% confidence interval: 1.20, 1.50). Prevalence and relative risks for 3 of the most common baseline symptoms remained constant over time: sleep problems (RR = 2.19), forgetfulness (RR = 2.56), and irritability (RR = 2.73). The pattern was slightly different for headache (baseline, RR = 3.44; 12 months, RR = 3.26), due to increased prevalence of headache in those without mTBI. The prevalence of clinically relevant postconcussive symptoms remained relatively constant over 1 year of follow-up, whether or not symptoms were associated with concussion. Service members with recent mTBI reported more symptoms than those without at all time points.

Neurobehavioral symptom validity and performance validity in veterans: Evidence for distinct outcomes across data types

Self-reported traumatic brain injury (TBI) is common in combat veterans, and identification of psychiatric and neuropsychological consequences following TBI has become a priority for veteran healthcare. Given the importance of accurately capturing symptoms potentially related to TBI in VA settings, validity metrics are frequently used to evaluate both neuropsychological testing validity and the validity of symptom self-reports. The Validity-10 of the Neurobehavioral Symptom Inventory is one such metric that was designed to evaluate symptom over-reporting and thus identify individuals who may produce inconclusive testing profiles. However, the Validity-10's ability to predict objective effort during neuropsychological testing has not been sufficiently explored in veterans. Clinical evaluation data were collected from 295 veterans seeking treatment in a VA TBI clinic. We examined whether the Validity-10 can predict invalid performance on a battery of neuropsychological tests. Validity-10 was a poor predictor of performance validity metrics. Results provide a conceptual replication of earlier work demonstrating that performance and symptom validity are divergent. As such, separate evaluation of these domains is warranted during evaluations conducted in veteran TBI populations.

Post-deployment Mental Health Screening: A Systematic Review of Current Evidence and Future Directions

Population-based post-deployment screening programs within the Departments of Defense and Veterans Affairs have been implemented to assess for mental health conditions and traumatic brain injury. The purpose of this paper is to systematically review the literature on post-deployment screening within this context and evaluate evidence compared to commonly accepted screening implementation criteria. Findings reflected highly variable psychometric properties of the various screens, variable treatment referral rates following screening, low to moderate treatment initiation rates following screening, and no information on treatment completion or long-term outcomes following screening. In sum, the evidence supporting population based post-deployment screening is inconclusive. Implications are discussed.

Traumatic Brain Injury and Receipt of Prescription Opioid Therapy for Chronic Pain in Iraq and Afghanistan Veterans: Do Clinical Practice Guidelines Matter?

Clinical practice guidelines admonish against prescribing opioids for individuals with chronic pain and traumatic brain injury (TBI) because of increased risk for adverse outcomes, yet no studies have described opioid prescribing patterns in these higher-risk patients. Between October 2007 and March 2015, 53,124 Iraq and Afghanistan veterans with chronic pain not prescribed opioids in the previous year were followed for 1 year after completing a Comprehensive TBI Evaluation within the Department of Veterans Affairs health care facilities. Veterans reporting the most severe TBI sequelae (eg, loss of consciousness >30 minutes) were significantly more likely to receive short-term and long-term opioid therapy than those with less severe or no TBI sequelae (P values < .001). In analyses adjusted for sociodemographic characteristics, military service, pain disability, and previous nonopioid treatment modalities, veterans with moderate to severe TBI had a significantly increased risk of receiving opioid therapy. Veterans with moderate to severe TBI and comorbid post-traumatic stress disorder and depression had an even greater risk of initiating long-term opioid therapy in the year after the Comprehensive TBI Evaluation (adjusted relative risk = 3.57 [95% confidence interval = 2.85-4.47]). Higher-risk patients with chronic pain and TBI with mental health comorbidities may benefit from improved access to behavioral health and nonpharmacological therapies for chronic pain.

PERSPECTIVE

Paradoxically, veterans with greater TBI severity and comorbid mental health burden are more likely to be prescribed opioids for chronic pain. More vulnerable veterans may benefit from improved access to behavioral health and nonpharmacological modalities for chronic pain, because of the health and safety risks of opioids.

Screening for Remote History of Mild Traumatic Brain Injury in VHA: A Critical Literature Review

OBJECTIVE

The authors reviewed the existing literature on the Veterans Health Administration's (VHA's) traumatic brain injury (TBI) screening and evaluation program to provide a qualitative synthesis and critical review of results focusing on the psychometric properties of the screen.

METHODS

All studies of the VHA's screening and evaluation process were reviewed, both those involving primary data collection and those relying upon VHA data. Diagnostic statistics were summarized and also recalculated on the basis of a positive screening rate of 20%, the observed rate within the VHA, and an estimated population prevalence of TBI of 15% within the Department of Veterans Affairs (VHA).

RESULTS

The TBI screen within the VHA is administered to nearly every eligible patient. The majority of clinical presentations are deemed to be due to mental health and/or a combination of mental health and TBI factors. The screen has good internal consistency, variable test-retest reliability, and questionable validity, with poor agreement between the TBI screen and criterion standards overall. Studies based on nonrepresentative samples reported high sensitivity. Assuming the VHA's TBI screening rate of 20% in a hypothetical sample, sensitivity is poor (the screen misses 30%-60% of TBI cases). However, specificity remains adequate. Studies based on samples with high rates of TBI reported much higher positive predictive values (and slightly lower negative predictive values) than those observed when a hypothetical TBI prevalence of 15% was used.

CONCLUSION

Questions remain about the validity of the TBI screen. Future research should address the utility of screening for TBI.

Consistency of Self-Reported Neurocognitive Symptoms, Post-Traumatic Stress Disorder Symptoms, and Concussive Events From End of First Deployment to Veteran Health Administration Comprehensive Traumatic Brain Injury Evaluation by Operations Enduring Freedom/Iraqi Freedom/New Dawn Veterans

Objective

This study examined the consistency of self-reported symptoms and concussive events in combat veterans who reported experiencing concussive events.

Method

One hundred and forty, single deployed, Operation Enduring Freedom, Operation Iraqi Freedom and Operation New Dawn combat veterans with Veteran Health Administration (VHA) Comprehensive Traumatic Brain Injury Evaluations (CTBIE) and no post-deployment head injury were examined to assess consistency of self-reported (a) traumatic brain injury (TBI)-related symptoms, (b) post-traumatic stress disorder (PTSD)-related symptoms, and (c) TBI-related concussive events from soon after deployment to time of VHA CTBIE.

Results

Compared to their self-report of symptoms and traumatic events at the time of their Post-Deployment Health Assessment, at the time of their comprehensive VHA evaluation, subjects reported significantly greater impairment in concentration, decision making, memory, headache, and sleep. In addition, although half the subjects denied any PTSD symptoms post-deployment, approximately three quarters reported experiencing all four PTSD screening symptoms near the time of the VHA CTBIEs. At the latter time, subjects also reported significantly more TBI-related concussive events, as well as more post-concussive sequelae such as loss of consciousness immediately following these concussive events. Finally, although 84% reported a level of impairment so severe as to render all but the simplest activity doable, the vast majority simultaneously reported working and/or attending college.

Conclusions

These findings raise questions regarding the accuracy of veteran self-report of both near and distant traumatic events, and argue for the inclusion of contemporaneous Department of Defense (DOD) records in veteran assessment and treatment planning.

Acknowledging the Risk for Traumatic Brain Injury in Women Veterans

Since the Iraq and Afghanistan wars began, an unprecedented number of women have been engaging in combat operations. Likewise, the number of women using Department of Veterans Affairs (VA) services has doubled since 2001. Military service, and deployment to combat in particular, poses certain risks for traumatic brain injury (TBI)-for all service members. However, women may have additional military and nondeployment risk factors such as intimate partner violence (IPV). We briefly review the definition and classification issues related to TBI, as well as common acute and chronic health symptoms after TBI. Specific sex differences in prognosis after TBI, in particular the neurobehavioral symptoms, are also reviewed. We then focus on the emerging literature regarding TBI in women veterans including the etiologies, outcomes, and unique challenges this population faces. The article concludes with suggestions for enhanced screening by VA and non-VA providers alike, as well as directions for future research and clinical inquiry.

Clinical trials in mild traumatic brain injury

BACKGROUND

Traumatic brain injury is an increasingly prevalent injury seen in both civilian and military populations. Regardless of the mechanisms of injury, the most common sub-type of injury continues to be mild traumatic brain injury. Within the last decade, there has been tremendous growth in the literature regarding this disease entity.

PURPOSE

To describe the obstacles necessary to overcome in performing a rigorous and sound clinical research study investigating mild traumatic brain injury. This examination begins by a consideration of changing standards for good faith open and total reporting of any and all conflicts of interest or commitment. This issue is particularly critical in mTBI research. We next examine obstacles that include but are not limited to diagnostic criteria, inclusion/exclusion criteria, source of injury, previous history of injury, presence of comorbid conditions and proper informed consent of participants. Frequently, multi-center studies are necessary for adequate subject accrual with the added challenges of site coordination, data core management and site specific study conduct. We propose a total reversal to the traditional translational research approach where clinical studies drive new concepts for future basic science studies.

CONCLUSIONS

There have been few mild traumatic brain injury clinical trials in the literature with treatments/interventions that have been able to overcome many of these described obstacles. We look forward to the results of current and ongoing clinical mild traumatic brain injury studies providing the tools necessary for the next generation of basic science projects.

Update on the Epidemiology of Concussion/Mild Traumatic Brain Injury

Mild traumatic injuries to the brain (e.g., concussion) are common and have been recognized since antiquity, although definitions have varied historically. Nonetheless, studying the epidemiology of concussion helps clarify the overall importance, risk factors, and at-risk populations for this injury. The present review will focus on recent findings related to the epidemiology of concussion including definition controversies, incidence, and patterns in the population overall and in the military and athlete populations specifically. Finally, as this is an area of active research, we will discuss how future epidemiologic observations hold promise for gaining greater clarity about concussion and mild traumatic brain injury.

Assessing for mild TBI among Iraq and Afghanistan veterans: Outcomes of injury severity and neurological factors

OBJECTIVE

To investigate injury severity markers and neurological symptoms associated with clinician-confirmed mild traumatic brain injury (TBI) among Iraq and Afghanistan veterans.

SETTING

Department of Veterans Affairs (VA) medical centre and five affiliated community-based outpatient clinics.

PARTICIPANTS

Three hundred and fifty Iraq and Afghanistan veterans with positive initial VA TBI screens between 1 April 2007 and 1 June 2010 and clinician-confirmed TBI status by 1 December 2010.

METHODS

Retrospective-cohort study of medical record data. Main measures included clinician-confirmed TBI status, injury severity markers (e.g. loss of consciousness (LOC), post-traumatic amnesia (PTA) or confusion/disorientation) and neurological symptoms.

RESULTS

Among veterans who screened positive on the initial VA TBI and then received a clinician evaluation, 60% were confirmed to have a TBI diagnosis. Veterans reporting at least one LOC, confusion or PTA were almost 18-times more likely to receive a confirmed TBI diagnosis. Odds of clinician-confirmed TBI were 2.5-3-times greater among those who endorsed dizziness, poor coordination, headaches, nausea, vision problems and/or irritability, compared to those not endorsing these symptoms. Nausea had greatest utility for confirming a TBI.

CONCLUSIONS

Identification of neurologic symptoms that most contribute to a clinician-confirmed diagnosis of TBI has potential for streamlining detection of TBI and symptoms needed for treatment.

Posttraumatic dizziness and vertigo

Traumatic brain injury is an increasingly common public health issue, with the mild variant most clinically relevant for this chapter. Common causes of mild traumatic brain injury (mTBI) include motor vehicle accidents, athletics, and military training/deployment. Despite a range of clinically available testing platforms, diagnosis of mTBI remains challenging. Symptoms are primarily neurosensory, and include dizziness, hearing problems, headaches, cognitive, and sleep disturbances. Dizziness is nearly universally present in all mTBI patients, and is the easiest symptom to objectify for diagnosis. Aside from a thorough history and physical exam, in the near future specialized vestibular function tests will be key to mTBI diagnosis. A battery of oculomotor (antisaccade, predictive saccade) and vestibular tasks (head impulse test) has been demonstrated to sensitively and specifically identify individuals with acute mTBI. Vestibular therapy and rehabilitation have shown improvements for mTBI patients in cognitive function, ability to return to activities of daily living, and ability to return to work. Dizziness, as a contributor to short- and long-term disability following mTBI, is ultimately crucial not only for diagnosis but also for treatment.

Anticipating the traumatic brain injury-related health care needs of women veterans after the Department of Defense change in combat assignment policy

BACKGROUND

Female service members' presence in combat zones during Operation Enduring Freedom and Operation Iraqi Freedom is unprecedented both in terms of the number of women deployed and the nature of their involvement. In light of changing Department of Defense policy governing the deployment of women in combat zones, this article intends to set the groundwork for estimating future combat-related injuries and subsequent Veterans Health Administration (VHA) utilization while focusing on traumatic brain injury (TBI).

METHODS

The article summarizes and presents the results of a study that examines veterans who present to VHA for TBI evaluation. For a national sample of veterans, a dataset including information on post-screening utilization, diagnoses, and location of care was constructed. The dataset included self-reported health symptoms and other information obtained from a standardized national VHA post-screening clinical evaluation, the comprehensive TBI evaluation (CTBIE).

FINDINGS

Both women and men utilize high levels of VHA health care after a CTBIE. However, there are gender differences in the volume and types of services used, with women utilizing different services than their male counterparts and incurring higher costs, including higher overall and outpatient costs.

CONCLUSION

As women veterans seek more of their health care from the VHA, there will be a need for more coordinated care to identify and manage deployment-related TBI and common comorbidities such as posttraumatic stress disorder, depression, and chronic pain. Deployment-connected injuries are likely to rise because of the rescinding of the ban on women in combat. This in turn has critical implications for VHA strategic planning and budgeting.

Diffusion tensor imaging reveals acute subcortical changes after mild blast-induced traumatic brain injury

Mild blast-induced traumatic brain injury (mbTBI) poses special diagnostic challenges due to its overlapping symptomatology with other neuropsychiatric conditions and the lack of objective outcome measures. Diffusion tensor imaging (DTI) can potentially provide clinically relevant information toward a differential diagnosis. In this study, we aimed to determine if single and repeated (5 total; administered on consecutive days) mild blast overpressure exposure results in detectable structural changes in the brain, especially in the hippocampus. Fixed rat brains were analyzed by ex vivo DTI at 2 h and 42 days after blast (or sham) exposure(s). An anatomy-based region of interest analysis revealed significant interactions in axial and radial diffusivity in a number of subcortical structures at 2 h only. Differences between single- and multiple-injured rats were largely in the thalamus but not the hippocampus. Our findings demonstrate the value and the limitations of DTI in providing a better understanding of mbTBI pathobiology.

Psychiatric diagnoses and neurobehavioral symptom severity among OEF/OIF VA patients with deployment-related traumatic brain injury: a gender comparison

BACKGROUND

Traumatic brain injury (TBI) has substantial negative implications for the post-deployment adjustment of veterans who served in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF); however, most research on veterans has focused on males. This study investigated gender differences in psychiatric diagnoses and neurobehavioral symptom severity among OEF/OIF veterans with deployment-related TBI.

METHODS

This population-based study examined psychiatric diagnoses and self-reported neurobehavioral symptom severity from administrative records for 12,605 United States OEF/OIF veterans evaluated as having deployment-related TBI. Men (n = 11,951) and women (n = 654) who were evaluated to have deployment-related TBI during a standardized comprehensive TBI evaluation in Department of Veterans Affairs facilities were compared on the presence of psychiatric diagnoses and severity of neurobehavioral symptoms.

FINDINGS

Posttraumatic stress disorder (PTSD) was the most common psychiatric condition for both genders, although women were less likely than men to have a PTSD diagnosis. In contrast, relative to men, women were 2 times more likely to have a depression diagnosis, 1.3 times more likely to have a non-PTSD anxiety disorder, and 1.5 times more likely to have PTSD with comorbid depression. Multivariate analyses indicated that blast exposure during deployment may account for some of these differences. Additionally, women reported significantly more severe symptoms across a range of neurobehavioral domains.

CONCLUSION

Although PTSD was the most common condition for both men and women, it is also critical for providers to identify and treat other conditions, especially depression and neurobehavioral symptoms, among women veterans with deployment-related TBI.