Assessing the Clinical Utility of a Wearable Device for Physiological Monitoring of Heart Rate Variability in Military Service Members with Traumatic Brain Injury

Introduction: Autonomic dysfunction has been implicated as a consequence of traumatic brain injury (TBI). Heart rate variability (HRV) may be a viable measure of autonomic dysfunction that could enhance rehabilitative interventions for individuals with TBI. This pilot study sought to assess the feasibility and validity of using the Zeriscope™ platform system in a real-world clinical setting to measure HRV in active-duty service members with TBI who were participating in an intensive outpatient program. Methods: Twenty-five service members with a history of mild, moderate, or severe TBI were recruited from a military treatment facility. A baseline assessment was conducted in the cardiology clinic where point validity data were obtained by comparing a 5-min recording of a standard 12-lead electrocardiogram (ECG) output against the Zeriscope platform data. Results: Compared with the ECG device, the Zeriscope device had a concordance coefficient (rc) of 0.16, falling below the standard deemed to represent acceptable accuracy in HR measurement (i.e., 0.80). Follow-up analyses excluding outliers did not significantly improve the concordance coefficient to an acceptable standard for the total participant sample. System Usability Survey responses showed that participants rated the Zeriscope system as easy to use and something that most people would learn to use quickly. Conclusions: This study demonstrated promise in ambulatory HRV measurement in a representative military TBI sample. Future research should include further refinement of such ambulatory devices to meet the specifications required for use in a military active-duty TBI population.

Network Analysis of Research on Mild Traumatic Brain Injury in US Military Service Members and Veterans During the Past Decade (2010-2019)

OBJECTIVE

To evaluate trends in the extant literature on mild traumatic brain injury (mTBI) in military service members and veterans using network analysis based on a comprehensive search of original, peer-reviewed research articles involving human participants published between January 1, 2010, and December 31, 2019. Specifically, we employed network analysis to evaluate associations in the following areas: (1) peer-reviewed journals, (2) authors, (3) organizations/institutions, and (4) relevant key words.

PARTICIPANTS

Included studies were published in peer-reviewed journals available on Web of Science database, using US military service members or veterans.

DESIGN

Bibliometric network analytical review.

MAIN MEASURES

Outcomes for each analysis included number of articles, citations, total link strength, and clusters.

RESULTS

The top publishing journals were (1) Journal of Head Trauma and Rehabilitation, (2) Military Medicine, (3) Brain Injury, (4) Journal of Neurotrauma, and (5) Journal of Rehabilitation Research and Development. The top publishing authors were (1) French, (2) Lange, (3) Cooper, (4) Vanderploeg, and (5) Brickell. The top research institutions were (1) Defense and Veterans Brain Injury Center, (2) Uniformed Services University of the Health Sciences, (3) University of California San Diego, (4) Walter Reed National Military Medical Center, and (5) Boston University. The top co-occurring key words in this analysis were (1) posttraumatic stress disorder (PTSD), (2) persistent postconcussion symptoms (PPCS), (3) blast injury, (4) postconcussion syndrome (PCS), and (5) Alzheimer's disease.

CONCLUSIONS

The results of this network analysis indicate a clear focus on veteran health, as well as investigations on chronic effects of mTBI. Research in civilian mTBI indicates that delaying treatment for symptoms and impairments related to mTBI may not be the most precise treatment strategy. Increasing the number of early, active, and targeted treatment trials in military personnel could translate to meaningful improvements in clinical practices for managing mTBI in this population.

Impact of Pre-Existing Migraine and Other Co-Morbid or Co-Occurring Conditions on Presentation and Clinical Course Following Deployment-Related Concussion

OBJECTIVE

To describe the clinical presentation and early clinical course of a sample of deployed U.S. military service members following concussion, underscoring the impact of pre-existing migraine and other co-occurring conditions. It is important to obtain a comprehensive clinical history to identify evidence of underlying migraine and other health conditions which may contribute to an individual's presenting symptoms influencing early management and outcomes following concussion. Early outcome measures assessed include headache treatment response and fitness for return to duty.

BACKGROUND

Acute concussion is reported to result in an array of somatic, cognitive, and behavioral symptoms. It is well established that these symptoms are not specific for concussion and may result from exacerbation of pre-existing or underlying medical conditions and factors. Although most symptoms attributable to concussion resolve within days to weeks, there is evidence that persistent symptoms beyond that specific recovery time may be attributable to factors other than concussion. Military populations are at risk for a number of recognized co-morbid and co-occurring conditions, as well as special situational and psychosocial factors which may influence symptoms and clinical course following concussion. In addition, combat-related concussion frequently occurs in the setting of a blast or military vehicle accidents thus causing concurrent injuries where musculoskeletal injuries may contribute to the clinical presentation. The resultant acute stress reaction, secondary to the traumatic experience associated with concussion, may also cause or aggravate underlying psychological co-morbidities that may influence presenting symptoms. Prior studies identified co-morbidities associated with chronic post-concussive syndrome, which we find are also present during the early phase following deployment-related concussion, thereby influencing presentation and impacting recovery. This retrospective chart review was intended to demonstrate the presence and potential impact of co-morbid and co-occurring conditions contributing to symptoms following concussion, especially migraine due to its high prevalence among post-traumatic headaches.

METHODS

Retrospective chart review was performed by the treating neurologist of 40 service members following concussion in the deployed environment. Clinical symptoms and co-morbid and co-occurring conditions including evidence of pre-existing migraine identified during comprehensive neurologic evaluations were collected. Both pre-deployment/pre-traumatic and post-traumatic headache features supporting migraine and early instituted headache management and treatment response are described. Rates of return to duty in this sample were also tabulated.

RESULTS

Headaches were the most frequently reported acute symptom following concussion in this deployed service member population (38/40 patients [98%]), followed by insomnia, tinnitus, impaired concentration, nausea, dizziness, anxiety, impaired balance, depression, and hearing loss. Co-occurring acute injuries, acute stress reaction, and recent onset medication overuse were the most frequent co-occurring conditions identified by the treating neurologist as potentially contributing to the service member's presentation. Chronic co-morbidities identified included chronic headache, anxiety/depression, insomnia, and post-traumatic stress disorder. Service members with 3 or more identified co-morbidities or co-occurring conditions were more likely to require evacuation from theater. Pre-deployment headaches were reported by 25/40 [63%] service members, with 5/40 [12.5%] reporting known prior personal history of migraine. Of those reporting pre-deployment headaches, 21/25 [84%] described migraine features and/or triggers, though most [(15/25) 60%] reported as infrequent. Daily post-traumatic headaches were frequent (26/38 [68%]) and associated with typical migraine features and/or triggers. Of those treated with triptans (16/40 patient [42%]), most (12/16 patient [75%]) showed positive treatment response.

CONCLUSIONS

Concussion in the deployed settings does not occur in isolation, with co-morbid and co-occurring conditions being common. Presence of multiple co-morbidities appears to influence clinical course and overall recovery. Post-traumatic headaches are often phenotypically fully consistent with migraine, and appear related to pre-existing migraine if supported by detailed pre-deployment headache history suggesting same. Careful and comprehensive history taking and evaluation is invaluable in identifying associated conditions including migraine, potentially helping clinicians with more accurate symptom attribution, diagnoses, and improved clinical management following acute concussion.

Toward spanning the quality chasm: an examination of team functioning measures

OBJECTIVE

To examine the effect of 5 measures of team functioning on patient outcomes.

DESIGN

Observational, exploratory, measurement. Team functioning surveys and patient outcomes collected 1 year apart in a clinical trial were analyzed. The findings are discussed in context of the domains of team functioning, team effectiveness, and quality improvement.

SETTING

27 Veterans Affairs medical centers.

PARTICIPANTS

Staff (t1: N=356; t2: N=273) on inpatient teams and patients (t1: N=4266; t2: N=3213) treated by the teams.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Five measures of team functioning (Physician Engagement, Shared Leadership, Supervisor Team Support, Teamness, and Team Effectiveness scales) and 3 measures of patient outcomes (functional improvement, discharge destination, and length of stay) were assessed at 2 time points with hierarchical generalized linear models to evaluate the association between team functioning measures and changes in patient outcomes.

RESULTS

Associations (P<.05) between team functioning measures and patient outcomes were found for 3 of the 15 analyses over the study period. Higher Physician Engagement scale score was associated with lower length of stay (P=.017), and increased scores on Teamness and Team Effectiveness scales correlated with higher rates of community discharge (P=.044 and .049, respectively).

CONCLUSIONS

This exploratory analysis revealed trends that team functioning corresponds with patient outcomes in clinically relevant patterns. An increase in community discharge and a decrease in length of stay were associated with higher scores of team functioning. Here, we find evidence that modifiable attributes of team functioning have a measurable effect on patient outcomes. Such findings are promising and support the need for further research on team effectiveness.

Differential SPECT activation patterns associated with PASAT performance may indicate frontocerebellar functional dissociation in chronic mild traumatic brain injury

Patients with mild traumatic brain injury (TBI) often complain of cognitive fatigue during the chronic recovery phase. The Paced Auditory Serial Addition Test (PASAT) is a complex psychologic measure that may demonstrate subtle deficiencies in higher cognitive functions. The purpose of this study was to investigate the brain activation of regional cerebral blood flow (rCBF) with PASAT in patients with mild TBI to explore mechanisms for the cognitive fatigue.

METHODS

Two groups consisting of 15 patients with mild TBI and 15 healthy control subjects underwent (99m)Tc-ethylene cysteine dimer SPECT at rest and during PASAT on a separate day. Cortical rCBF was extracted using a 3-dimensional stereotactic surface projection and statistically analyzed to identify areas of activation, which were compared with PASAT performance scores.

RESULTS

Image analysis demonstrated a difference in the pattern of activation between patients with mild TBI and healthy control subjects. Healthy control subjects activated the superior temporal cortex (Brodmann area [BA] 22) bilaterally, the precentral gyrus (BA 9) on the left, and the precentral gyrus (BA 6) and cerebellum bilaterally. Patients with mild TBI demonstrated a larger area of supratentorial activation (BAs 9, 10, 13, and 46) but a smaller area of activation in the cerebellum, indicating frontocerebellar dissociation.

CONCLUSION

Patients with mild TBI and cognitive fatigue demonstrated a different pattern of activation during PASAT. Frontocerebellar dissociation may explain cognitive impairment and cognitive fatigue in the chronic recovery phase of mild traumatic brain injury.

Older adults and neuropsychological rehabilitation following acquired brain injury

The literature related to neurorehabilitation methods specific to older adults is now emerging, the timing of which is important given the epidemiology of acquired brain injury in this population. Examined are epidemiological characteristics of acquired brain injury, with a focus on traumatic brain injury and stroke. Principles of geriatric neurorehabilitation are proposed by using a Neo-Lurian framework, and employing the PASS model of brain-behavior relationship forwarded by J. P. Das. Discussed are specific issues and strategies of geriatric neurorehabilitation by removing excess disability that complicates acquired brain injury. These include addressing depression, sleep disturbance, chronic pain, and social support. Restorative interventions may now also appear as a part of geriatric neurorehabilitation practices. A focus on team functioning as a critical contributor to functional outcomes in those older adults with acquired brain injury is presented along with future directions that capitalize upon the ideals of primary, secondary, and tertiary prevention.

Neuropsychological test performance in a cognitively intact sample of older Japanese American adults

The purpose of this paper was to present population-based data showing the effects of age on cognitive test performance in a sample of older Japanese American adults. In addition, the relative effects of education, gender, and primary spoken language were compared to effects that have been reported in the literature for majority culture older adults. Subjects included 201 non-demented Japanese American adults age 70 and older currently enrolled in the Kame Project, a prospective study of aging and dementia in King County, WA. Cognitive tests included the Consortium to Establish a Registry for Alzheimer's Disease (CERAD) neuropsychological assessment battery, WAIS-R Digit Span and Digit Symbol subtests, Trail Making Test, Purdue Pegboard, and Finger Tapping. Older age was associated with significantly (p<0.05) lower scores on all tests; less than high school education was associated with lower scores on all tests except Digit Span, Finger Tapping, and the Purdue Pegboard. Women and English-speaking participants scored higher than men and Japanese speakers on various tests of memory, attention, and visuomotor ability. These data reinforce the importance of using appropriately corrected norms when interpreting results of cognitive screening tests with minority culture older adults.

Cognitive improvement with treatment of depression following mild traumatic brain injury

The authors examined the effect of antidepressant treatment on cognitive performances in people with mild traumatic brain injury. An 8-week nonrandomized, single-blind, placebo run-in trial of sertraline was completed and neuropsychological testing measures were compared before and after the treatment trial. Results showed improvements in psychomotor speed, recent verbal memory, recent visual memory, and general cognitive efficiency. Improvements were also seen in self-perception of cognitive symptomatology. It appears that successful depression treatment resulted in significant alleviation of cognitive impairments, which may not have been accounted for by natural recovery alone.

Sertraline in the treatment of major depression following mild traumatic brain injury

An 8-week, nonrandomized, single-blind, placebo run-in trial of sertraline was conducted on 15 patients diagnosed with major depression between 3 and 24 months after a mild traumatic brain injury. On the Hamilton Rating Scale for Depression, 13 (87%) had a decrease in score of > or = 50% ("response"), and 10 (67%) achieved a score of < or = 7 ("remission") by week 8 of sertraline. There was statistically significant improvement in psychological distress, anger and aggression, functioning, and postconcussive symptoms with treatment.

Prevalence of dementia and its subtypes in the Japanese American population of King County, Washington state. The Kame Project

Studies of Asian populations generally have reported prevalence rates for dementia similar to those of predominantly Caucasian populations, but relative prevalence rates of Alzheimer's disease and vascular dementia have differed. Between May 1, 1992 and May 1, 1994, the prevalence rates of dementia, Alzheimer's disease, and vascular dementia were examined in the Japanese American population aged over 65 years in King County, Washington State. A total of 3,045 eligible individuals were identified in a census of persons who were of at least 50% Japanese heritage. Of 1,985 persons who participated in the baseline examination, 382 individuals of 450 sampled from all cognitive performance strata received a diagnostic evaluation. A total of 107 cases with a Clinical Dementia Rating (CDR) of > or = 1 met criteria for dementia according to the Diagnostic and Statistical Manual, 3rd edition, revised (DSM-III-R); 58 of these cases were diagnosed with Alzheimer's disease and 24 with multi-infarct dementia. The estimated prevalence rate for all dementias was 6.3% (95% confidence interval 5.9-6.8). Prevalence rates for dementia increased continuously with age and were 30%, 50%, and 74% for participants aged 85-89, 90-94, and > or = 95 years, respectively; for Alzheimer's disease, prevalence rates were 14%, 36%, and 58% for these three age groups. Rates for Alzheimer's disease were generally higher among women; for multi-infarct dementia, rates for men and women were similar. In the institutional population, the prevalence rate was 66%, and in the community, 2.9%. Persons with lower education had higher overall rates of dementia than those with higher education, but this tendency became weak and inconsistent when rates were age-stratified. The prevalence of dementia in this geographically defined population of Japanese Americans was somewhat higher than prevalence rates reported from Japan, and the distribution of dementia subtypes more closely resembled that found in Caucasian populations in North America and Europe than previously reported in Asian populations.

Psychiatric disorders and functional disability in outpatients with traumatic brain injuries

OBJECTIVE

This study examined psychiatric sequelae of traumatic brain injuries in outpatients and their relation to functional disability.

METHOD

Fifty consecutive outpatients with traumatic brain injuries who came to a brain injury rehabilitation clinic for initial evaluation were examined for DSM-III-R diagnoses with the use of the National Institute of Mental Health Diagnostic Interview Schedule. The patients completed the Medical Outcomes Study Health Survey to assess functional disability and a questionnaire to assess postconcussion symptoms and self-perceptions of the severity of their brain injuries and cognitive functioning.

RESULTS

Thirteen (26%) of the patients had current major depression, and an additional 14 (28%) reported a first-onset major depressive episode after the injury that had resolved. Twelve (24%) had current generalized anxiety disorder, and four (8%) reported current substance abuse. The group with depression and/or anxiety was significantly more impaired than the nondepressed/nonanxious patients according to the Medical Outcomes Study Health Survey measures of emotional role functioning, mental health, and general health perceptions. The depressed/anxious group also rated their injuries as significantly more severe and their cognitive functioning as significantly worse, despite the lack of significant differences in objective measures of severity of injury and Mini-Mental State examination scores. The depressed patients reported significantly more postconcussion symptoms that were increasing in severity over time.

CONCLUSIONS

Depression and anxiety are common in outpatients with traumatic brain injuries. Patients with depression or anxiety are more functionally disabled and perceive their injury and cognitive impairment as more severe. Depressed patients report more increasingly severe postconcussion symptoms.

Classification of the spectrum of mild traumatic brain injury

Mild traumatic brain injury (TBI) is a very common injury, resulting in immediate and possible long-term symptoms. The accurate and consistent definition of mild TBI is important in the initial and rehabilitation management of the injury, and in research concerning mild TBI. A definition of mild TBI has been developed by the Head Injury Interdisciplinary Special Interest Group of the American Congress of Rehabilitation Medicine. Within the spectrum of injury severity in mild TBI there are several classification systems, primarily used in management of acute mild TBI, that breakdown mild TBI into grades of injury severity. These are based upon the presence or absence of mental status changes, amnesia, loss of consciousness, anatomical lesion or neurological deficit.

Traumatic brain injury and chronic pain: differential types and rates by head injury severity

Traumatic brain injury has been associated with many physical and neurobehavioral consequences, including pain problems. Documented most has been the presence of posttraumatic headaches that are associated with the postconcussion syndrome. This study therefore examined types and rates of chronic pain problems in patients seen in an outpatient brain injury rehabilitation program. A total of 104 patients were evaluated, 66 of whom were male and 38 female, and the average time postinjury was 26 months. Headaches were the most frequent chronic pain problem across both mild and the moderate/severe groups, although in the former, a significantly higher frequency was noted (89%) when compared against the latter group. The same relative rates were seen for chronic neck/shoulder, back, and other pain problems. The mild group also showed a higher frequency of concurrent pain problems, whereas in the moderate/severe group only one patient had more than one chronic pain problem. Results also showed that in the mild group neck/shoulder accompanied headaches 47% of the time, and back pain coexisted with headaches 44% of the time. These results underscore the high frequency of chronic pain problems in the mild head injury population and implicate the need for avoiding the mislabeling of symptoms such attentional deficits or psychological distress as attributable only to head injury sequelae in those with coexisting chronic pain. Early identification and intervention of pain syndromes in the mild head-injury population is also suggested.

Anger management training for brain injured patients and their family members

Anger dyscontrol is a common occurrence after brain injury. The anger problems of brain injured persons create a burden for their caretakers who most frequently are their family members. Two single-case design studies are presented that demonstrate the efficacy of behavioral interventions for the control of anger problems in brain injured adults. Anger control was accomplished by training the patients in skills to control their own anger, and teaching family members behavior modification principles. In each case, the patient was taught to implement a self-talk method to decrease tension during the escalation period of an anger episode and to execute a time-out when aware of increased anger. Family members were trained in ways to monitor such problems and to identify antecedents to an outburst. They were given feedback and suggestions to modify their communication style with the patient so as to reduce patient irritability, and were taught ways to use a verbal cue to remind the patient to use pretrained self-control methods. Patients and family members were also asked to increase the number of pleasant events in which they engaged as a general means to decrease the patients' anger outbursts. These cases showed evidence that the treatment program reduced the frequency of anger outbursts and, in one case, increased the social participation by the patient immediately after treatment and at one-month and three-month follow-up assessments. The importance of having key family members involved in anger management training for brain injured patients is underscored, particularly when cognitive impairment limits patients' ability to benefit from and to retain the content of psychotherapy.

Use of the MMPI and MCMI in predicting outcome of lumbar laminectomy

This study compared the abilities of the MMPI and Millon Clinical Multiaxial Inventory (MCMI), using discriminant analyses, to predict outcome after lumbar laminectomy for chronic back pain. Sixty-nine males and 60 females with lumbar discogenic disease completed MMPIs and MCMIs before surgery and were classified as either having good or fair/poor surgical outcomes based on self-reported pain relief, return to work, restriction of activities, and medication use. Results showed both the MMPI and MCMI to have moderate ability to predict surgery outcome. A slightly higher classification hit rate was obtained with both instruments when age, sex, employment status, and presence of compensation/litigation issues also were entered into the prediction equation. Results indicate the need for caution in using either instrument to make predictions of surgery outcome in individual cases.

Japanese American response to psychological disorder: referral patterns, attitudes, and subjective norms

The underutilization of services by Japanese Americans has raised questions as to the variables that account for this phenomenon. The present study examined the referral patterns and their bases using the Fishbein-Ajzen model of attitude-behavior relationships. Vignettes describing disorders were each responded to by 106 Japanese Americans. Results indicated that self resources were the most commonly mentioned referral across disorders and generations, and that mental health resources only occasionally crossed the person's mind. Attitudes were as favorable for psychologists as preferred intentions though subjective norms were less favorable for psychologists. More severe disorders yielded more favorable attitudes and more permissible social norms than disorders of a lesser degree. These data suggest implementing mental health education programs in Japanese-American and other Asian-Pacific communities to increase service utilization by increasing awareness of mental health personnel as resources and to increase social norms in support thereof.