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Kinney AR, Brenner LA, Nance M, Mignogna J, Cobb AD, Forster JE, Ulmer CS, Nakase-Richardson R, Bahraini NH. Factors influencing shared decision-making for insomnia and obstructive sleep apnea treatment among Veterans with mild traumatic brain injury. J Clin Sleep Med 2024; 20:801-812. [PMID: 38189353 PMCID: PMC11063707 DOI: 10.5664/jcsm.10994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 12/28/2023] [Accepted: 12/29/2023] [Indexed: 01/09/2024]
Abstract
STUDY OBJECTIVES We elicited perspectives of clinical stakeholders and Veterans regarding barriers and facilitators to implementing shared decision-making (SDM) for comorbid mild traumatic brain injury (mTBI) and sleep disorders in the Veterans Health Administration. We also compared the perspectives of clinical stakeholders and Veterans regarding determinants of SDM. METHODS Semistructured interviews were conducted with 29 clinical stakeholders and 20 Veterans (n = 49). Clinical stakeholders included Veterans Health Administration providers and policymakers involved in the management of mTBI and/or sleep disorders (insomnia disorder, obstructive sleep apnea). Veterans included those with a clinician-confirmed mTBI who received care for insomnia disorder and/or obstructive sleep apnea within the past year. Themes were identified using a descriptive and interpretive approach to qualitative analysis. We compared results across clinical stakeholders and Veterans. RESULTS Barriers to implementing SDM were identified by both groups at the patient (eg, mTBI sequalae), provider (eg, deprioritization of Veteran preferences), encounter (eg, time constraints), and facility levels (eg, reduced care access). Similarly, both groups identified facilitators at the patient (eg, enhanced trust), provider (eg, effective communication), encounter (eg, decision support), and facility levels (eg, mitigating access barriers). Integrated services and provider discontinuity were factors identified by clinical stakeholders and Veterans alone, respectively. CONCLUSIONS Our study revealed factors shaping the implementation of SDM at the levels of the patient, provider, encounter, and facility. Findings can inform the development of strategies aimed at implementing SDM for comorbid mTBI and sleep disorders, promoting patient-centered care and enhancing clinical outcomes. CITATION Kinney AR, Brenner LA, Nance M, et al. Factors influencing shared decision-making for insomnia and obstructive sleep apnea treatment among Veterans with mild traumatic brain injury. J Clin Sleep Med. 2024;20(5):801-812.
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Affiliation(s)
- Adam R. Kinney
- Veteran Affairs Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC) for Suicide Prevention, Aurora, Colorado
- University of Colorado, Anschutz Medical Campus, Department of Physical Medicine and Rehabilitation, Aurora, Colorado
| | - Lisa A. Brenner
- Veteran Affairs Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC) for Suicide Prevention, Aurora, Colorado
- University of Colorado, Anschutz Medical Campus, Departments of Physical Medicine and Rehabilitation, Psychiatry, and Neurology, Aurora, Colorado
| | - Morgan Nance
- Veteran Affairs Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC) for Suicide Prevention, Aurora, Colorado
- University of Colorado, Anschutz Medical Campus, Department of Physical Medicine and Rehabilitation, Aurora, Colorado
| | - Joseph Mignogna
- Veteran Affairs Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC) for Suicide Prevention, Aurora, Colorado
| | - Audrey D. Cobb
- Veteran Affairs Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC) for Suicide Prevention, Aurora, Colorado
| | - Jeri E. Forster
- Veteran Affairs Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC) for Suicide Prevention, Aurora, Colorado
- University of Colorado, Anschutz Medical Campus, Department of Physical Medicine and Rehabilitation, Aurora, Colorado
| | - Christi S. Ulmer
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs, Durham, North Carolina
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Risa Nakase-Richardson
- Research Service, James A. Haley Veterans Hospital, Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of South Florida, Tampa, Florida
| | - Nazanin H. Bahraini
- Veteran Affairs Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC) for Suicide Prevention, Aurora, Colorado
- University of Colorado, Anschutz Medical Campus, Departments of Physical Medicine and Rehabilitation and Psychiatry, Aurora, Colorado
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Tsalatsanis A, Dismuke-Greer C, Kumar A, Hoffman J, Monden KR, Magalang U, Schwartz D, Martin AM, Nakase-Richardson R. Cost-Effectiveness of Sleep Apnea Diagnosis and Treatment in Hospitalized Persons With Moderate to Severe Traumatic Brain Injury. J Head Trauma Rehabil 2024:00001199-990000000-00146. [PMID: 38652666 DOI: 10.1097/htr.0000000000000951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
OBJECTIVE To assess the cost-effectiveness of alternative approaches to diagnose and treat obstructive sleep apnea (OSA) in patients with traumatic brain injury (TBI) during inpatient rehabilitation. SETTING Data collected during the Comparison of Sleep Apnea Assessment Strategies to Maximize TBI Rehabilitation Participation and Outcome (C-SAS) clinical trial (NCT03033901) on an inpatient rehabilitation TBI cohort were used in this study. STUDY DESIGN Decision tree analysis was used to determine the cost-effectiveness of approaches to diagnosing and treating sleep apnea. Costs were determined using 2021 Centers for Medicare and Medicaid Services reimbursement codes. Effectiveness was defined in terms of the appropriateness of treatment. Costs averted were extracted from the literature. A sensitivity analysis was performed to account for uncertainty. Analyses were performed for all severity levels of OSA and a subgroup of those with moderate to severe OSA. Six inpatient approaches using various phases of screening, testing, and treatment that conform to usual care or guideline-endorsed interventions were evaluated: (1) usual care; (2) portable diagnostic testing followed by laboratory-quality testing; (3) screening with the snoring, tiredness, observed apnea, high BP, BMI, age, neck circumference, and male gender (STOP-Bang) questionnaire; (4) Multivariable Apnea Prediction Index (MAPI) followed by portable diagnostic testing and laboratory-quality testing; (5) laboratory-quality testing for all; and (6) treatment for all patients. MAIN MEASURES Cost, Effectiveness, and Incremental Cost-Effectiveness Ratio (ICER). RESULTS Phased approaches utilizing screening and diagnostic tools were more effective in diagnosing and allocating treatment for OSA than all alternatives in patients with mild to severe and moderate to severe OSA. Usual care was more costly and less effective than all other approaches for mild to severe and moderate to severe OSA. CONCLUSIONS Diagnosing and treating OSA in patients with TBI is a cost-effective strategy when compared with usual care.
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Affiliation(s)
- Athanasios Tsalatsanis
- Author Affiliations: Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, Florida (Dr Tsalatsanis and Dr Kumar); Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California (Dr Dismuke-Greer); Department of Rehabilitation Medicine, University of Washington School of Medicine, Seattle, Washington (Dr Hoffman); Department of Rehabilitation Medicine, University of Minnesota Medical School, Minneapolis, Minnesota (Dr Monden); The Ohio State University Wexner Medical Center, Columbus, Ohio (Dr Magalang); and Medicine Service (Dr Schwartz) Mental Health and Behavioral Science Service (Dr Martin), and Polytrauma TBI Rehabilitation (Dr Nakase-Richardson), James A. Haley Veterans' Hospital, Tampa, Florida
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Olsen M, Zeitzer JM, Nakase-Richardson R, Musgrave VH, Sorensen HBD, Mignot E, Jennum PJ. A deep transfer learning approach for sleep stage classification and sleep apnea detection using wrist-worn consumer sleep technologies. IEEE Trans Biomed Eng 2024; PP:1-12. [PMID: 38498753 DOI: 10.1109/tbme.2024.3378480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/20/2024]
Abstract
Obstructive sleep apnea (OSA) is a common, underdiagnosed sleep-related breathing disorder with serious health implications Objective - We propose a deep transfer learning approach for sleep stage classification and sleep apnea (SA) detection using wrist-worn consumer sleep technologies (CST). Methods - Our model is based on a deep convolutional neural network (DNN) utilizing accelerometers and photo-plethysmography signals from nocturnal recordings. The DNN was trained and tested on internal datasets that include raw data from clinical and wrist-worn devices; external validation was performed on a hold-out test dataset containing raw data from a wrist-worn CST. Results - Training on clinical data improves performance significantly, and feature enrichment through a sleep stage stream gives only minor improvements. Raw data input outperforms feature-based input in CST datasets. The system generalizes well but performs slightly worse on wearable device data compared to clinical data. However, it excels in detecting events during REM sleep and is associated with arousal and oxygen desaturation. We found; cases that were significantly underestimated were characterized by fewer of such event associations. Conclusion - This study showcases the potential of using CSTs as alternate screening solution for undiagnosed cases of OSA. Significance - This work is significant for its development of a deep transfer learning approach using wrist-worn consumer sleep technologies, offering comprehensive validation for data utilization, and learning techniques, ultimately improving sleep apnea detection across diverse devices.
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Skop KM, Bajor L, Sevigny M, Swank C, Tallavajhula S, Nakase-Richardson R, Miles SR. Response to letter regarding "Exploring the relationship between sleep apnea and vestibular symptoms following traumatic brain injury". PM R 2024; 16:307-308. [PMID: 37794687 DOI: 10.1002/pmrj.13074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 09/19/2023] [Indexed: 10/06/2023]
Affiliation(s)
- Karen M Skop
- Physical Medicine and Rehabilitation Services, Department of Physical Therapy, James A. Haley Veterans' Hospital, Tampa, Florida, USA
- Morsani College of Medicine, University of South Florida, School of Physical Therapy, Tampa, Florida, USA
| | - Laura Bajor
- Mental Health and Behavioral Sciences Service, James A. Haley Veterans' Hospital, Tampa, Florida, USA
- Department of Psychiatry & Behavioral Neurosciences, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
- Harvard South Shore Psychiatry Training Program, Brockton, Massachusetts, USA
| | - Mitch Sevigny
- Research Department, Craig Hospital, Englewood, Colorado, USA
| | - Chad Swank
- Baylor Scott & White Research Institute for Rehabilitation, Dallas, Texas, USA
- Baylor Scott White Research Institute, Dallas, Texas, USA
| | - Sudha Tallavajhula
- University of Texas McGovern Medical School, Houston, Texas, USA
- TIRR Memorial Hermann Neurological Sleep Disorders Center, Houston, Texas, USA
| | - Risa Nakase-Richardson
- Mental Health and Behavioral Sciences and Defense and Veterans' Brain Injury Center, James A. Haley Veterans' Hospital, Tampa, Florida, USA
- Morsani College of Medicine, Pulmonary and Sleep Medicine Division, University of South Florida, Tampa, Florida, USA
| | - Shannon R Miles
- Mental Health and Behavioral Sciences Service, James A. Haley Veterans' Hospital, Tampa, Florida, USA
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Kinney AR, Brenner LA, Nance M, Mignogna J, Cobb AD, Forster JE, Ulmer CS, Nakase-Richardson R, Bahraini NH. Factors Influencing Adherence to Insomnia and Obstructive Sleep Apnea Treatments among Veterans with Mild Traumatic Brain Injury. Behav Sleep Med 2024:1-18. [PMID: 38420915 DOI: 10.1080/15402002.2024.2322517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
OBJECTIVE To understand factors influencing adherence to recommended treatment for insomnia and obstructive sleep apnea (OSA) among Veterans with mild traumatic brain injury (mTBI). METHOD Semi-structured interviews (n = 49) with 29 clinical stakeholders and 20 Veterans were conducted. Clinical stakeholders included Veterans Health Administration providers and policymakers involved in the management of mTBI and/or sleep disorders. Veterans included those with a clinician-confirmed mTBI with a recent history of insomnia disorder and/or OSA treatment. Themes were identified using a Descriptive and Interpretive approach. RESULTS Barriers to sleep disorder treatment adherence included factors associated with the patient (e.g., negative appraisal of treatment benefit), intervention (e.g., side effects), health conditions (e.g., cognitive challenges), health care system (e.g., limited availability of care), and socioeconomic status (e.g., economic instability). Similarly, facilitators of adherence included patient- (e.g., positive appraisal of treatment benefit), intervention- (e.g., flexible delivery format), condition- (e.g., accommodating cognitive impairments), health care system- (e.g., access to adherence support), and socioeconomic-related factors (e.g., social support). CONCLUSIONS Interviews revealed the multi-faceted nature of factors influencing adherence to sleep disorder treatment among Veterans with mTBI. Findings can inform the development of novel interventions and care delivery models that meet the complex needs of this population.
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Affiliation(s)
- Adam R Kinney
- Veteran Affairs Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC) for Suicide Prevention, Rocky Mountain MIRECC, Aurora, CO
- Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Lisa A Brenner
- Veteran Affairs Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC) for Suicide Prevention, Rocky Mountain MIRECC, Aurora, CO
- Departments of Physical Medicine and Rehabilitation, Psychiatry, and Neurology, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Morgan Nance
- Veteran Affairs Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC) for Suicide Prevention, Rocky Mountain MIRECC, Aurora, CO
- Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Joseph Mignogna
- Veteran Affairs Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC) for Suicide Prevention, Rocky Mountain MIRECC, Aurora, CO
- Departments of Physical Medicine and Rehabilitation, Psychiatry, and Neurology, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Audrey D Cobb
- Veteran Affairs Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC) for Suicide Prevention, Rocky Mountain MIRECC, Aurora, CO
| | - Jeri E Forster
- Veteran Affairs Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC) for Suicide Prevention, Rocky Mountain MIRECC, Aurora, CO
- Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Christi S Ulmer
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs, Durham, NC
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC
| | - Risa Nakase-Richardson
- Research Service, James A. Haley Veterans Hospital, Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of South Florida, Tampa
| | - Nazanin H Bahraini
- Veteran Affairs Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC) for Suicide Prevention, Rocky Mountain MIRECC, Aurora, CO
- Departments of Physical Medicine and Rehabilitation and Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, CO
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Garofano JS, Nakase-Richardson R, Barnett SD, Yablon SA, Evans C, Zaim N. Delirium following traumatic brain injury in adolescents: Symptomatology and prediction of ability to return to school or employment 1-year post-injury. PM R 2024; 16:122-131. [PMID: 37314306 DOI: 10.1002/pmrj.13025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 03/21/2023] [Accepted: 05/13/2023] [Indexed: 06/15/2023]
Abstract
BACKGROUND There is a limited evidence-base describing clinical features of delirium in youth. What is known is largely extrapolated from studies of adults or samples with heterogeneous etiologies. It is unclear if the symptoms experienced by adolescents differ from those experienced by adults, or the degree to which delirium impacts the ability of adolescents to return to school or work. OBJECTIVE To describe delirium symptomatology among adolescents following a severe traumatic brain injury (TBI). Symptoms were compared by adolescent delirium status and across age groups. Delirium and its relationship with adolescent employability 1 year post-injury was also examined. DESIGN Exploratory secondary analysis of prospectively collected data. SETTING Free-standing rehabilitation hospital. PATIENTS Severely injured TBI Model Systems neurorehabilitation admissions (n = 243; median Glasgow Coma Scale = 7). The sample was divided into three age groups (adolescents, 16-21 years, n = 63; adults 22-49 years, n = 133; older adults ≥50 years, n = 47). INTERVENTIONS Not applicable. MEASURES We assessed patients using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnostic criteria and the Delirium Rating Scale-Revised 98 (DRS-R-98). The employability item from the Disability Rating Scale was the primary 1-year outcome. RESULTS Most items on the DRS-R-98 differentiated delirious from non-delirious adolescents. Only "delusions" differed among age groups. Among adolescents, delirium status 1 month post-TBI provided acceptable classification of employability prediction 1 year later (area under the curve [AUC]: 0.80, 95% confidence interval [CI]: 0.69-0.91, p < .001). Delirium symptom severity (AUC: 0.86, 95% CI: 0.68-1.03, SE: 0.09; p < .001) and days of post-traumatic amnesia (AUC: 0.85, 95% CI: 0.68-1.01, SE: 0.08; p < .001) provided excellent prediction of outcomes for TBI patients in delirium. CONCLUSIONS Delirium symptomatology was similar among age groups and useful in differentiating the delirium status within the adolescent TBI group. Delirium and symptom severity at 1 month post-TBI were highly predictive of poor outcomes. Findings from this study support the utility of DRS-R-98 at 1 month post-injury to inform treatment and planning.
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Affiliation(s)
| | | | | | - Stuart A Yablon
- Mary Free Bed Rehabilitation Hospital, Grand Rapids, Michigan, USA
| | - Clea Evans
- Methodist Rehabilitation Center, Jackson, Mississippi, USA
| | - Nadia Zaim
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Patel RS, Krause-Hauch M, Kenney K, Miles S, Nakase-Richardson R, Patel NA. Long Noncoding RNA VLDLR-AS1 Levels in Serum Correlate with Combat-Related Chronic Mild Traumatic Brain Injury and Depression Symptoms in US Veterans. Int J Mol Sci 2024; 25:1473. [PMID: 38338752 PMCID: PMC10855201 DOI: 10.3390/ijms25031473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 01/15/2024] [Accepted: 01/22/2024] [Indexed: 02/12/2024] Open
Abstract
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.
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Affiliation(s)
- Rekha S. Patel
- Research Service, James A. Haley Veteran’s Hospital, 13000 Bruce B Downs Blvd., Tampa, FL 33612, USA; (R.S.P.); (S.M.)
| | - Meredith Krause-Hauch
- Department of Molecular Medicine, University of South Florida, Tampa, FL 33612, USA;
| | - Kimbra Kenney
- Department of Neurology, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA;
| | - Shannon Miles
- Research Service, James A. Haley Veteran’s Hospital, 13000 Bruce B Downs Blvd., Tampa, FL 33612, USA; (R.S.P.); (S.M.)
- Department of Psychiatry & Behavioral Neurosciences, Morsani College of Medicine, University of South Florida, Tampa, FL 33620, USA
| | - Risa Nakase-Richardson
- Chief of Staff Office, James A. Haley Veteran’s Hospital, Tampa, FL 33612, USA;
- Department of Internal Medicine, Pulmonary, Critical Care and Sleep Medicine, University of South Florida, Tampa, FL 33620, USA
| | - Niketa A. Patel
- Research Service, James A. Haley Veteran’s Hospital, 13000 Bruce B Downs Blvd., Tampa, FL 33612, USA; (R.S.P.); (S.M.)
- Department of Molecular Medicine, University of South Florida, Tampa, FL 33612, USA;
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Hanks R, Ketchum JM, Peckham M, Sevigny M, Sander AM, Martin AM, Agtarap S, Beaulieu CL, Callender L, Hammond FM, Lengenfelder J, Rabinowitz AR, Walker WC, Hoffman JM, Harrison-Felix C, Nakase-Richardson R. Associations of Chronic Pain With Psychosocial Outcomes After Traumatic Brain Injury: A NIDILRR and VA TBI Model Systems Collaborative Project. J Head Trauma Rehabil 2024; 39:18-30. [PMID: 38167716 PMCID: PMC10807629 DOI: 10.1097/htr.0000000000000921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
OBJECTIVE To examine the differences in participation, life satisfaction, and psychosocial outcomes among individuals with traumatic brain injury (TBI) endorsing current, past, or no chronic pain. SETTING Community. PARTICIPANTS Three thousand eight hundred four TBI Model Systems participants 1 to 30 years of age postinjury classified into 1 of 3 groups based on their pain experience: current pain, past pain, no pain completed a Pain Survey at their usual follow-up appointment which on average was approximately 8 years postinjury. DESIGN Multisite, cross-sectional observational cohort study. MAIN OUTCOME MEASURES Sociodemographic and injury characteristics and psychosocial outcomes (ie, satisfaction with life, depression, anxiety, posttraumatic stress disorder [PTSD], sleep quality, community participation). RESULTS Persons with current chronic pain demonstrated higher scores on measures of PTSD, anxiety, and depression, and the lower scores on measures of sleep quality, community participation and satisfaction with life. Those with resolved past pain had mean scores for these outcomes that were all between the current and no chronic pain groups, but always closest to the no pain group. After adjusting for sociodemographic and function in multivariate analysis, having current chronic pain was associated with more negative psychosocial outcomes. The largest effect sizes (ES; in absolute value) were observed for the PTSD, depression, anxiety, and sleep quality measures (ES = 0.52-0.81) when comparing current pain to past or no pain, smaller ES were observed for life satisfaction (ES = 0.22-0.37) and out and about participation (ES = 0.16-0.18). When comparing past and no pain groups, adjusted ES were generally small for life satisfaction, PTSD, depression, anxiety, and sleep quality (ES = 0.10-0.23) and minimal for participation outcomes (ES = 0.02-0.06). CONCLUSIONS Chronic pain is prevalent among individuals with TBI and is associated with poorer psychosocial outcomes, especially for PTSD, depression, anxiety, and sleep disturbance. The results from this study highlight the presence of modifiable comorbidities among those with chronic pain and TBI. Persons who experience persistent pain following TBI may be at greater risk for worse psychosocial outcomes.
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Affiliation(s)
- Robin Hanks
- Department of Physical Medicine and Rehabilitation, School of Medicine, Wayne State University, Detroit, Michigan (Dr Hanks); Research Department, Craig Hospital, Englewood, Colorado (Drs Ketchum, Agtarap, and Harrison-Felix, Ms Peckham, and Mr Sevigny); H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Brain Injury Research Center, TIRR Memorial Hermann, Houston, Texas (Dr Sander); Mental Health and Behavioral Science Service, James A. Haley Veterans' Hospital, Tampa, Florida (Dr Martin); Department of Psychiatry and Behavioral Neurosciences, University of South Florida, Tampa (Dr Martin); Department of Physical Medicine and Rehabilitation, College of Medicine, The Ohio State University, Columbus (Dr Beaulieu); Baylor Scott & White Institute for Rehabilitation, Dallas, Texas (Ms Callender); Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Rehabilitation Hospital of Indiana, Indianapolis (Dr Hammond); Department of Physical Medicine Rehabilitation, Rutgers-New Jersey Medical School, Newark (Dr Lengenfelder); Kessler Foundation, East Hanover, New Jersey (Dr Lengenfelder); Department of Physical Medicine and Rehabilitation, Moss Rehabilitation Research Institute, Elkins Park, Pennsylvania (Dr Rabinowitz); Department of Physical Medicine & Rehabilitation, School of Medicine, Virginia Commonwealth University, Richmond (Dr Walker); Department of Rehabilitation Medicine, School of Medicine, University of Washington, Seattle (Dr Hoffman); MHBS/Polytrauma, James A. Haley Veterans Hospital, Tampa, Florida (Dr Nakase-Richardson); Sleep and Pulmonary Division, Department of Internal Medicine, University of South Florida, Tampa (Dr Nakase-Richardson); and Defense Health Agency, Traumatic Brain Injury Center of Excellence, Tampa, Florida (Dr Nakase-Richardson)
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9
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Hoffman JM, Ketchum JM, Agtarap S, Dams-O'Connor K, Hammond FM, Martin AM, Sevigny M, Walker WC, Harrison-Felix C, Zafonte R, Nakase-Richardson R. Characterizing Extreme Phenotypes for Pain Interference in Persons With Chronic Pain Following Traumatic Brain Injury: A NIDILRR and VA TBI Model Systems Collaborative Project. J Head Trauma Rehabil 2024; 39:31-42. [PMID: 38032832 PMCID: PMC10841036 DOI: 10.1097/htr.0000000000000909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
OBJECTIVE To define and characterize extreme phenotypes based on pain interference for persons with chronic pain following traumatic brain injury (TBI). SETTING Eighteen Traumatic Brain Injury Model System (TBIMS) Centers. PARTICIPANTS A total of 1762 TBIMS participants 1 to 30 years post-injury reporting chronic pain at their most recent follow-up interview. PRIMARY MEASURES The Brief Pain Inventory (BPI) interference scale, sociodemographic, injury, functional outcome, pain, and treatment characteristics. RESULTS Participants were predominantly male (73%), White (75%), middle-aged (mean 46 years), and who were injured in motor vehicle accidents (53%) or falls (20%). Extreme phenotypes were identified based on upper and lower 25th percentiles to create low-interference ( n = 441) and high-interference ( n = 431) extreme phenotypes. Bivariate comparisons found several sociodemographic, injury, function, pain, and treatment differences between extreme phenotype groups, including significant differences ( P < .001) on all measures of concurrent function with those in the low-interference extreme phenotype experiencing better function than those in the high-interference extreme phenotype. Lasso regression combined with logistic regression identified multivariable predictors of low- versus high-interference extreme phenotypes. Reductions in the odds of low- versus high-interference phenotypes were significantly associated with higher pain intensity (odds ratio [OR] = 0.33), having neuropathic pain (OR = 0.40), migraine headache (OR = 0.41), leg/feet pain (OR = 0.34), or hip pain (OR = 0.46), and more pain catastrophizing (OR = 0.81). CONCLUSION Results suggest that for those who experience current chronic pain, there is high variability in the experience and impact of pain. Future research is needed to better understand how pain experience impacts individuals with chronic pain and TBI given that pain characteristics were the primary distinguishing factors between phenotypes. The use of extreme phenotypes for pain interference may be useful to better stratify samples to determine efficacy of pain treatment for individuals with TBI.
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Affiliation(s)
- Jeanne M Hoffman
- Department of Rehabilitation Medicine, University of Washington School of Medicine, Seattle (Dr Hoffman); Craig Hospital Research Department, Englewood, Colorado (Drs Ketchum, Agtarap, and Harrison-Felix and Mr Sevigny); Icahn School of Medicine at Mount Sinai, New York, New York (Dr Dams-O'Connor); Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine and Rehabilitation Hospital of Indiana, Indianapolis (Dr Hammond); Mental Health and Behavioral Science Service, James A. Haley Veterans Hospital, Tampa, Florida, and Department of Psychiatry and Behavioral Neurosciences, University of South Florida, Tampa (Dr Martin); Department of Physical Medicine and Rehabilitation, School of Medicine, Virginia Commonwealth University, Richmond (Dr Walker); Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, and Harvard Medical School, Boston, Massachusetts (Dr Zafonte); and MHBS/Polytrauma, James A. Haley Veterans Hospital, Tampa, Florida, and Sleep and Pulmonary Division, Department of Internal Medicine, University of South Florida, Tampa, and Defense Health Agency Traumatic Brain Injury Center of Excellence, Tampa, Florida (Dr Nakase-Richardson)
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Ketchum JM, Hoffman JM, Agtarap S, Hammond FM, Martin AM, Walker WC, Zafonte R, Harrison-Felix C, Nakase-Richardson R. Relationship Between Extreme Pain Phenotypes and Psychosocial Outcomes in Persons With Chronic Pain Following Traumatic Brain Injury: A NIDILRR and VA TBI Model Systems Collaborative Project. J Head Trauma Rehabil 2024; 39:56-67. [PMID: 38032831 PMCID: PMC10842936 DOI: 10.1097/htr.0000000000000908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
OBJECTIVE To examine the relationship between extreme pain phenotypes (interference and improvement) and psychosocial outcomes among those with chronic pain after traumatic brain injury (TBI). SETTING Community. PARTICIPANTS In total, 1762 TBI Model Systems (TBIMS) participants 1 to 30 years postinjury reporting chronic pain. DESIGN Multisite, cross-sectional, observational cohort study. PRIMARY MEASURES Life satisfaction, posttraumatic stress, depression and anxiety symptoms, sleep and participation, the Brief Pain Inventory (BPI) interference scale, and the Patient's Global Impression of Change (PGIC). RESULTS Persons in the extreme high interference phenotype (vs extreme low interference phenotype) and/or extreme no change phenotype (vs extreme improvement phenotype) had poorer psychosocial outcomes, with extreme pain interference phenotypes having a larger effect on outcomes than extreme perceived improvement phenotypes. After controlling for covariates, large effect sizes (ES) related to pain interference were observed for posttraumatic stress symptoms (ES = -1.14), sleep quality (ES = -1.10), depression (ES = -1.08), anxiety (ES = -0.82), and life satisfaction (ES = 0.76); effect sizes for participation outcomes, although significant, were relatively small (ES = 0.21-0.36). Effect sizes related to perceived improvement were small for life satisfaction (ES = 0.20) and participation (ES = 0.16-0.21) outcomes. Pain intensity was identified as a meaningful confounding factor of the relationships between extreme phenotypes and posttraumatic stress, depression, anxiety, and sleep quality. CONCLUSIONS Examination of extreme phenotypes provides important insights into the experience of individuals living with chronic pain and TBI. Results suggest that the relationships among a variety of characteristics of the person, their experience with pain, and treatment of pain are complex. Further research is needed to better understand these complex relationships and how differences in pain interference and perceived improvement from treatment can assist in assessment and treatment of chronic pain after TBI.
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Affiliation(s)
- Jessica M Ketchum
- Craig Hospital Research Department, Englewood, Colorado (Drs Ketchum, Agtarap, and Harrison-Felix); Department of Rehabilitation Medicine, University of Washington School of Medicine, Seattle (Dr Hoffman); Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine & Rehabilitation, Hospital of Indiana, Indianapolis (Dr Hammond); Mental Health and Behavioral Science Service (Dr Martin) and MHBS/Polytrauma (Dr Nakase-Richardson), James A. Haley Veterans Hospital, VA Tampa Health Care, Tampa, Florida; Department of Psychiatry and Behavioral Neurosciences (Dr Martin) and Sleep and Pulmonary Division, Department of Internal Medicine (Dr Nakase-Richardson), University of South Florida, Tampa; Department of Physical Medicine and Rehabilitation, School of Medicine, Virginia Commonwealth University, Richmond (Dr Walker); Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, and Harvard Medical School, Boston, Massachusetts (Dr Zafonte); and Defense Health Agency Traumatic Brain Injury Center of Excellence, Tampa, Florida (Dr Nakase-Richardson)
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Hoffman JM, Nakase-Richardson R, Harrison-Felix C. Informing Our Understanding of Chronic Pain Epidemiology, Extreme Outcomes, and Healthcare Access Among Persons With Hospitalized TBI: A NIDILRR and VA TBI Model Systems Collaborative Project. J Head Trauma Rehabil 2024; 39:1-4. [PMID: 38167714 DOI: 10.1097/htr.0000000000000926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Affiliation(s)
- Jeanne M Hoffman
- Department of Rehabilitation Medicine, University of Washington School of Medicine, Seattle (Dr Hoffman); Chief of Staff Office, James A. Haley Veterans Hospital, Tampa, Florida (Dr Nakase-Richardson); Sleep and Pulmonary Division, Department of Internal Medicine, University of South Florida, Tampa (Dr Nakase-Richardson); Defense Health Agency Traumatic Brain Injury Center of Excellence, Tampa, Florida (Dr Nakase-Richardson); and Craig Hospital Research Department, Englewood, Colorado (Dr Harrison-Felix)
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Harrison-Felix C, Sevigny M, Beaulieu CL, Callender L, Dams-O'Connor K, Hammond FM, Hanks R, Ketchum JM, Martin AM, Marwitz JH, Peckham M, Rabinowitz AR, Sander AM, Sterling A, Walker WC, Nakase-Richardson R, Hoffman JM. Characterization and Treatment of Chronic Pain After Traumatic Brain Injury-Comparison of Characteristics Between Individuals With Current Pain, Past Pain, and No Pain: A NIDILRR and VA TBI Model Systems Collaborative Project. J Head Trauma Rehabil 2024; 39:5-17. [PMID: 38167715 DOI: 10.1097/htr.0000000000000910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
OBJECTIVE To estimate the prevalence of chronic pain after traumatic brain injury (TBI) and identify characteristics that differ from those without chronic pain. SETTING Community. PARTICIPANTS A total of 3804 TBI Model Systems (TBIMS) participants who completed the Pain Survey at TBIMS follow-up. DESIGN A multisite, cross-sectional observational cohort study. MAIN OUTCOME MEASURES Functional outcomes, pain experience, and treatment. RESULTS 46% reported current chronic pain, 14% reported past (post-injury) chronic pain, and 40% reported no chronic pain. Bivariate differences in sociodemographic and injury characteristics between the 3 pain groups were generally small in effect size, reflecting little clinical difference. However, medium effect sizes were seen for all functional outcomes, such that individuals with current chronic pain had worse functional outcomes compared with individuals in the past pain or no pain groups. Treatment utilization rates were higher for individuals with current chronic pain compared with past pain, with medical treatments being most frequently utilized. Individuals with past pain perceived more improvement with treatment than did those with current chronic pain as represented by a large effect size. CONCLUSIONS Chronic pain affects approximately 60% of those living with TBI. The implications of chronic pain for functional outcomes support inclusion of pain metrics in prognostic models and observational studies in this population. Future research is needed to proactively identify those at risk for the development of chronic pain and determine the efficacy and access to pain treatment.
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Affiliation(s)
- Cynthia Harrison-Felix
- Craig Hospital Research Department, Englewood, Colorado (Drs Harrison-Felix and Ketchum, Mr Sevigny, and Ms Peckham); Department of Physical Medicine and Rehabilitation, The Ohio State University College of Medicine, Columbus (Dr Beaulieu); Baylor Scott and White Institute for Rehabilitation, Dallas, Texas (Ms Callender); Icahn School of Medicine at Mount Sinai, New York, New York (Dr Dams-O'Connor); Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine and Rehabilitation Hospital of Indiana, Indianapolis (Dr Hammond); Department of Physical Medicine and Rehabilitation, Wayne State University School of Medicine, Detroit, Michigan (Dr Hanks); Mental Health and Behavioral Science Service (Dr Martin) and MHBS/Polytrauma (Dr Nakase-Richardson), James A. Haley Veterans Hospital, Tampa, Florida; Department of Psychiatry and Behavioral Neurosciences, University of South Florida, Tampa, Florida (Dr Martin); Department of Physical Medicine and Rehabilitation, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham (Ms Marwitz); Department of Physical Medicine and Rehabilitation, Moss Rehabilitation Research Institute, Elkins Park, Pennsylvania (Dr Rabinowitz); H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine and Brain Injury Research Center, TIRR Memorial Hermann, Houston, Texas (Dr Sander); Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, and Harvard Medical School, Boston, Massachusetts (Ms Sterling); Department of Physical Medicine and Rehabilitation, School of Medicine, Virginia Commonwealth University, Richmond (Dr Walker); Sleep and Pulmonary Division, Department of Internal Medicine, University of South Florida, Tampa, and Defense Health Agency Traumatic Brain Injury Center of Excellence, Tampa, Florida (Dr Nakase-Richardson); and Department of Rehabilitation Medicine, University of Washington School of Medicine, Seattle (Dr Hoffman)
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Nakase-Richardson R, Cotner BA, Martin AM, Agtarap SD, Tweed A, Esterov D, O'Connor DR, Ching D, Haun JN, Hanks RA, Bergquist TF, Hammond FM, Zafonte RD, Hoffman JM. Provider Perspectives of Facilitators and Barriers to Reaching and Utilizing Chronic Pain Healthcare for Persons With Traumatic Brain Injury: A Qualitative NIDILRR and VA TBI Model Systems Collaborative Project. J Head Trauma Rehabil 2024; 39:E15-E28. [PMID: 38167719 PMCID: PMC10768799 DOI: 10.1097/htr.0000000000000923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
OBJECTIVE To identify facilitators and barriers to reaching and utilizing chronic pain treatments for persons with traumatic brain injury (TBI) organized around an Access to Care framework, which includes dimensions of access to healthcare as a function of supply (ie, provider/system) and demand (ie, patient) factors for a specified patient population. SETTING Community. PARTICIPANTS Clinicians (n = 63) with experience treating persons with TBI were interviewed between October 2020 and November 2021. DESIGN Descriptive, qualitative study. MAIN MEASURES Semistructured open-ended interview of chronic pain management for persons with TBI. Informed by the Access to Care framework, responses were coded by and categorized within the core domains (reaching care, utilizing care) and relevant subdimensions from the supply (affordability of providing care, quality, coordination/continuity, adequacy) and demand (ability to pay, adherence, empowerment, caregiver support) perspective. RESULTS Themes from provider interviews focused on healthcare reaching and healthcare utilization resulted in 19 facilitators and 9 barriers reaching saturation. The most themes fell under the utilization core domain, with themes identified that impact the technical and interpersonal quality of care and care coordination/continuity. Accessibility and availability of specialty care and use of interdisciplinary team that permitted matching patients to treatments were leading thematic facilitators. The leading thematic barrier identified primarily by medical providers was cognitive disability, which is likely directly linked with other leading barriers including high rates of noncompliance and poor follow-up in health care. Medical and behavioral health complexity was also a leading barrier to care and potentially interrelated to other themes identified. CONCLUSION This is the first evidence-based study to inform policy and planning for this complex population to improve access to high-quality chronic pain treatment. Further research is needed to gain a better understanding of the perspectives of individuals with TBI/caregivers to inform interventions to improve access to chronic pain treatment for persons with TBI.
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Affiliation(s)
- Risa Nakase-Richardson
- Mental Health and Behavioral Sciences/Polytrauma (Drs Nakase-Richardson and Martin), Research Service/Polytrauma (Dr Cotner and Ms O'Connor), and Research Service (Dr Haun), James A. Haley Veterans Hospital, Tampa, Florida; Sleep and Pulmonary Division (Dr Nakase-Richardson), Department of Internal Medicine (Dr Cotner), and Department of Child and Family Studies, College of Behavioral Health and Community Sciences (Dr Ching), University of South Florida, Tampa; Defense Health Agency Traumatic Brain Injury Center of Excellence, Tampa, Florida (Dr Nakase-Richardson and Ms Tweed); Craig Hospital Research Department, Englewood, Colorado (Dr Agtarap); 9Line, LLC, Tampa, Florida (Ms Tweed); Mayo Clinic College of Medicine and Science, Rochester, Minnesota (Drs Esterov and Bergquist); Tampa Veterans Research and Education Foundation, Tampa, Florida (Dr Ching); Department of Physical Medicine and Rehabilitation, Wayne State University School of Medicine, Detroit, Michigan (Dr Hanks); Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine & Rehabilitation Hospital of Indiana, Indianapolis (Dr Hammond); Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, Massachusetts (Dr Zafonte); and Department of Rehabilitation Medicine, University of Washington School of Medicine, Seattle (Dr Hoffman)
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Hoffman JM, Ketchum JM, Agtarap S, Dams-O'Connor K, Hammond FM, Martin AM, Sevigny M, Walker WC, Harrison-Felix C, Zafonte R, Nakase-Richardson R. Characterizing Extreme Phenotypes for Perceived Improvement From Treatment in Persons With Chronic Pain Following Traumatic Brain Injury: A NIDILRR and VA TBI Model Systems Collaborative Project. J Head Trauma Rehabil 2024; 39:43-55. [PMID: 38032837 PMCID: PMC10840786 DOI: 10.1097/htr.0000000000000905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
OBJECTIVE To define and characterize extreme phenotypes based on perceived improvement in pain for persons with chronic pain following traumatic brain injury (TBI). SETTING Eighteen Traumatic Brain Injury Model System (TBIMS) Centers. PARTICIPANTS A total of 1762 TBIMS participants 1 to 30 years post-injury reporting chronic pain at their most recent follow-up interview. PRIMARY MEASURES The Patient's Global Impression of Change (PGIC) related to pain treatment. Sociodemographic, injury, functional outcome, pain, and pain treatment characteristics. RESULTS Participants were mostly male (73%), White (75%), middle-aged (mean 46 years), injured in motor vehicle accidents (53%), or falls (20%). Extreme phenotypes were created for an extreme improvement phenotype ( n = 512, 29.8%) defined as "moderately better" or above on the PGIC and an extreme no-change group ( n = 290, 16.9%) defined as no change or worse. Least absolute shrinkage and selection operator (LASSO) regression combined with logistic regression identified multivariable predictors of improvement versus no-change extreme phenotypes. Higher odds of extreme improvement phenotype were significantly associated with being female (odds ratio [OR] = 1.85), married versus single (OR = 2.02), better motor function (OR = 1.03), lower pain intensity (OR = 0.78), and less frequent pain, especially chest pain (OR = 0.36). Several pain treatments were associated with higher odds of being in the extreme improvement versus no-change phenotypes including pain medication (OR = 1.85), physical therapy (OR = 1.51), yoga (OR = 1.61), home exercise program (OR = 1.07), and massage (OR = 1.69). CONCLUSION Investigation of extreme phenotypes based on perceived improvement with pain treatment highlights the ability to identify characteristics of individuals based on pain treatment responsiveness. A better understanding of the biopsychosocial characteristics of those who respond and do not respond to pain treatments received may help inform better surveillance, monitoring, and treatment. With further research, the identification of risk factors (such as pain intensity and frequency) for treatment response/nonresponse may provide indicators to prompt changes in care for individuals with chronic pain after TBI.
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Affiliation(s)
- Jeanne M Hoffman
- Department of Rehabilitation Medicine, University of Washington School of Medicine, Seattle (Dr Hoffman); Craig Hospital Research Department, Englewood, Colorado (Drs Ketchum, Agtarap, and Harrison-Felix and Mr Sevigny); Icahn School of Medicine at Mount Sinai, New York, New York (Dr Dams-O'Connor); Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine and Rehabilitation Hospital of Indiana, Indianapolis (Dr Hammond); Mental Health and Behavioral Science Service, James A. Haley Veterans Hospital, Tampa, Florida, and Department of Psychiatry and Behavioral Neurosciences, University of South Florida, Tampa (Dr Martin); Department. of Physical Medicine and Rehabilitation, School of Medicine, Virginia Commonwealth University, Richmond (Dr Walker); Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, and Harvard Medical School, Boston, Massachusetts (Dr Zafonte); and MHBS/Polytrauma, James A. Haley Veterans Hospital, Tampa, Florida, and Sleep and Pulmonary Division, Department of Internal Medicine, University of South Florida, Tampa, and Defense Health Agency Traumatic Brain Injury Center of Excellence, Tampa, Florida (Dr Nakase-Richardson)
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Nakase-Richardson R, Cotner BA, Agtarap SD, Martin AM, Ching D, O'Connor DR, Tweed A, Haun JN, Hanks RA, Bergquist TF, Hammond FM, Zafonte RD, Hoffman JM. Provider Perceived Facilitators and Barriers to Identifying, Perceiving, and Seeking Healthcare for Chronic Pain After TBI: A Qualitative NIDILRR and VA TBI Model Systems Collaborative Project. J Head Trauma Rehabil 2024; 39:E1-E14. [PMID: 38167718 PMCID: PMC10768806 DOI: 10.1097/htr.0000000000000922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
OBJECTIVE Identify determinants to chronic pain healthcare for persons with traumatic brain injury (TBI) informed by an Access to Care Framework. Findings related to the Access Framework's core domains of identifying a need, perceptions of the need, and seeking healthcare are reported. SETTING Community. PARTICIPANTS Healthcare providers (n = 63) with 2 or more years of experience treating persons with TBI interviewed between October 2020 and November 2021. DESIGN Descriptive, qualitative study. MAIN MEASURES Semi-structured interviews with open-ended questions of chronic pain management for persons with TBI. Informed by the Access Framework, responses were coded by and categorized within the domains of identifying healthcare needs, perceptions of needs, and factors related to healthcare seeking from the supply and demand perspective. RESULTS For the overall sample, 14 facilitators and 6 barriers were endorsed by more than 20% of the provider cohort. Top facilitators included on-site availability of needed resources and treatments (94%), adequate time and provider capability to ensure patient comprehension of diagnosis and treatment plans (83%), and establishing patient motivation and buy-in with the treatment plan (75%). Barriers most endorsed included policies impacting access (46%), wait times for services (41%), and patient uncertainty regarding telehealth commonly due to cognitive and physical challenges (37%). Unique determinants are reported across civilian versus Department of Veterans Affairs (VA) healthcare systems and different provider types. CONCLUSION This is the first evidence-based study to inform policy and planning to improve access to high-quality chronic pain treatments for persons with TBI. Results will inform future interventions at the systems, patient, and policy levels of healthcare that can be tailored to healthcare settings (VA, Civilian) and types of providers (rehabilitation therapists, psychologists, and medical). Evidence-informed interventions may help minimize healthcare disparities experienced by persons with TBI and facilitate access to high-quality, evidence-informed chronic pain care.
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Affiliation(s)
- Risa Nakase-Richardson
- James A. Haley Veterans' Hospital, Tampa, Florida (Dr Nakase-Richardson); Sleep and Pulmonary Division, Department of Internal Medicine, University of South Florida, Tampa (Drs Nakase-Richardson and Cotner); Traumatic Brain Injury Center of Excellence, Defense Health Agency, Tampa, Florida (Dr Nakase-Richardson and Ms Tweed); Research Service/Polytrauma, James A. Haley Veterans' Hospital, Tampa, Florida (Drs Cotner and Haun and Ms O'Connor); Research Department, Craig Hospital, Englewood, Colorado (Dr Agtarap); Mental Health and Behavioral Sciences/Polytrauma, James A. Haley Veterans' Hospital, Tampa, Florida (Dr Martin); Tampa Veterans Research and Education Foundation, Tampa, Florida (Dr Ching); Department of Child & Family Studies, College of Behavioral & Community Sciences, University of South Florida, Tampa (Dr Ching); 9Line, LLC, Tampa, Florida (Ms Tweed); Department of Physical Medicine and Rehabilitation, School of Medicine, Wayne State University, Detroit, Michigan (Dr Hanks); Mayo Clinic College of Medicine and Science, Rochester, Minnesota (Dr Bergquist); Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine & Rehabilitation Hospital of Indiana, Indianapolis (Dr Hammond); Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Boston (Dr Zafonte); and Department of Rehabilitation Medicine, University of Washington School of Medicine, Seattle (Dr Hoffman)
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Haun JN, Nakase-Richardson R, Cotner BA, Agtarap SD, Martin AM, Tweed A, Hanks RA, Wittine L, Bergquist TF, Hoffman JM. Stakeholder Engagement to Identify Implementation Strategies to Overcome Barriers to Delivering Chronic Pain Treatments: A NIDILRR and VA TBI Model Systems Collaborative Project. J Head Trauma Rehabil 2024; 39:E29-E40. [PMID: 38167720 PMCID: PMC10768800 DOI: 10.1097/htr.0000000000000920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
OBJECTIVE The purpose of this article is to illustrate the process of stakeholder-engaged intervention mapping approach to identify implementation strategies to overcome data-driven prioritized barriers to receiving chronic pain services for persons with traumatic brain injury (TBI). SETTING Community. PARTICIPANTS Healthcare providers (n = 63) with 2 or more years' experience treating persons with TBI, interviewed between October 2020 and November 2021 provided data for identification of barriers. TBI, chronic pain, and qualitative research subject matter experts (SMEs) participated in the mapping approach. DESIGN Participatory-based research design, using descriptive and intervention mapping approaches. RESULTS Four barriers to accessing chronic pain treatment by persons with TBI which emerged from provider interviews were prioritized for intervention mapping: cognitive deficits of patients (67%); patient comorbidities (63%); mental health and/or substance abuse issues (59%); and patient participation (62%). SMEs used prioritized barriers to develop 4 primary objectives and implementation strategies designed to: (1) engage consumers to validate and identify strategies; (2) tailor pain treatment and delivery to overcome barriers; (3) develop and disseminate guidelines and best practices when delivering care to persons with TBI to support spread; and (4) increase awareness, skills, and readiness of workforce to deliver pain treatment to persons with TBI. SMEs used an evidence-based approach to develop a mapping matrix of the prioritized barriers, implementation objectives, and aligned implementation strategies to impact change. CONCLUSION Implementation science is needed to facilitate knowledge translation into practice for this complex population to overcome barriers to care. Implementation strategies to address barriers to accessing chronic pain care for individuals with TBI were chosen through a participatory approach to engaging SMEs to support these rehabilitation implementation efforts. Future work includes gathering input from individuals with TBI and chronic pain and to move the intervention (implementation) mapping matrix forward to inform future implementation research, policy, and practice.
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Affiliation(s)
- Jolie N Haun
- Research Service/Polytrauma (Drs Haun and Cotner) and Mental Health and Behavioral Sciences/Polytrauma (Drs Nakase-Richardson and Martin), James A. Haley Veterans' Hospital, Tampa, Florida; Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City (Dr Haun); Sleep and Pulmonary Division, Department of Internal Medicine, University of South Florida, Tampa (Dr Nakase-Richardson); Traumatic Brain Injury Center of Excellence, Defense Health Agency, Tampa, Florida (Dr Nakase-Richardson and Ms Tweed); Department of Internal Medicine, University of South Florida, Tampa (Dr Cotner); Research Department, Craig Hospital, Englewood, Colorado (Dr Agtarap); 9Line, LLC, Tampa, Florida (Ms Tweed); Department of Physical Medicine and Rehabilitation, School of Medicine, Wayne State University, Detroit, Michigan (Dr Hanks); Medicine, James A. Haley Veterans' Hospital, Tampa, Florida (Dr Wittine); Mayo Clinic College of Medicine and Science, Rochester, Minnesota (Dr Bergquist); and Department of Rehabilitation Medicine, University of Washington School of Medicine, Seattle (Dr Hoffman)
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Skop KM, Bajor L, Sevigny M, Swank C, Tallavajhula S, Nakase-Richardson R, Miles SR. Exploring the relationship between sleep apnea and vestibular symptoms following traumatic brain injury. PM R 2023; 15:1524-1535. [PMID: 37490363 DOI: 10.1002/pmrj.13044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 05/09/2023] [Accepted: 07/14/2023] [Indexed: 07/27/2023]
Abstract
BACKGROUND Traumatic brain injury (TBI) is a complex health problem in military veterans and service members (V/SM) that often involves comorbid vestibular impairment. Sleep apnea is another comorbidity that may exacerbate, and/or be exacerbated by, vestibular dysfunction. OBJECTIVE To examine the relationship between sleep apnea and vestibular symptoms in V/SM diagnosed with TBI of any severity. DESIGN Multicenter cohort study; cross-sectional sample. SETTING In-patient TBI rehabilitation units within five Veterans Affairs (VA) Polytrauma Rehabilitation Centers. PARTICIPANTS V/SM with a diagnosis of TBI (N = 630) enrolled in the VA TBI Model Systems study. INTERVENTION Not applicable. METHODS A multivariable regression model was used to evaluate the association between sleep apnea and vestibular symptom severity while controlling for relevant covariates, for example, posttraumatic stress disorder (PTSD). MAIN OUTCOME MEASURES Lifetime history of sleep apnea was determined via best source reporting. Vestibular disturbances were measured with the 3-item Vestibular subscale of the Neurobehavioral Symptom Inventory (NSI). RESULTS One third (30.6%) of the sample had a self-reported sleep apnea diagnosis. Initial analysis showed that participants who had sleep apnea had more severe vestibular symptoms (M = 3.84, SD = 2.86) than those without sleep apnea (M = 2.88, SD = 2.67, p < .001). However, when the data was analyzed via a multiple regression model, sleep apnea no longer reached the threshold of significance as a factor associated with vestibular symptoms. PTSD severity was shown to be significantly associated with vestibular symptoms within this sample (p < .001). CONCLUSION Analysis of these data revealed a relationship between sleep apnea and vestibular symptoms in V/SM with TBI. The significance of this relationship was affected when PTSD symptoms were factored into a multivariable regression model. However, given that the mechanisms and directionality of these relationships are not yet well understood, we assert that in terms of clinical relevance, providers should emphasize screening for each of the three studied comorbidities (sleep apnea, vestibular symptoms, and PTSD).
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Affiliation(s)
- Karen M Skop
- Physical Medicine and Rehabilitation Services, Department of Physical Therapy, James A Haley Veterans' Hospital, Tampa, Florida, USA
- Morsani College of Medicine, University of South Florida, School of Physical Therapy, Tampa, Florida, USA
| | - Laura Bajor
- Mental Health and Behavioral Sciences Service, James A Haley Veterans' Hospital, Tampa, Florida, USA
- Department of Psychiatry & Behavioral Neurosciences, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
- Harvard South Shore Psychiatry Training Program, Brockton, Massachusetts, USA
| | - Mitch Sevigny
- Research Department, Craig Hospital, Englewood, Colorado, USA
| | - Chad Swank
- Baylor Scott & White Research Institute for Rehabilitation, Dallas, Texas, USA
- Baylor Scott White Research Institute, Dallas, Texas, USA
| | - Sudha Tallavajhula
- University of Texas McGovern Medical School, Houston, Texas, USA
- TIRR Memorial Hermann Neurological Sleep Disorders Center, Houston, Texas, USA
| | - Risa Nakase-Richardson
- Mental Health and Behavioral Sciences and Defense and Veterans' Brain Injury Center, James A. Haley Veterans' Hospital, Tampa, Florida, USA
- Morsani College of Medicine, Pulmonary and Sleep Medicine Division, University of South Florida, Tampa, Florida, USA
| | - Shannon R Miles
- Mental Health and Behavioral Sciences Service, James A Haley Veterans' Hospital, Tampa, Florida, USA
- Department of Psychiatry & Behavioral Neurosciences, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
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Dismuke-Greer CE, Almeida EJ, Silva MA, Dams-O'Connor K, Rocek G, Phillips LM, Negro AD, Walker WC, Nakase-Richardson R. Impact of Posttraumatic Amnesia Duration on Traumatic Brain Injury (TBI) First Year Hospital Costs: A Veterans Affairs TBI Model Systems Study. Arch Phys Med Rehabil 2023:S0003-9993(23)00222-8. [PMID: 37084937 DOI: 10.1016/j.apmr.2023.03.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 03/20/2023] [Accepted: 03/24/2023] [Indexed: 04/23/2023]
Abstract
OBJECTIVE To examine the association between severity of traumatic brain injury (TBI) as measured by duration of post-traumatic amnesia (PTA) and first year hospitalization costs for service members and veterans (SMVs) treated for TBI at Polytrauma Rehabilitation Centers (PRCs) within the Veterans Health Administration (VHA). DESIGN Multivariable models of merged datasets from the VA TBI Model Systems (VA-TBIMS) national database containing TBI clinical characterization including PTA with VHA hospital cost data. SETTING Five VA PRCs. PARTICIPANTS VA-TBIMS participants with known PTA who received inpatient rehabilitation within 1 year of their TBI at any of 5 PRCs between 2010-2020. INTERVENTIONS N/A MAIN OUTCOME MEASURES: Total, acute care, rehabilitation, intensive care unit (ICU), and surgery costs across all VA hospitals. RESULTS A total of 717 SMVs (mean age 36.9 years, 94.1% male, 76.8% non-Hispanic White, 7.8% active duty) met inclusion criteria for the unadjusted analyses. Unadjusted mean total hospital costs in the first-year post TBI were approximately $201,214 higher for those with PTA duration ≥24 hours ($351,157) than PTA <24 hours ($149,943). In adjusted models (n=583), each additional day of PTA duration incrementally increased total ($1453), rehabilitation ($1324), ICU ($78) and surgery ($39) costs. Other significant covariates included age, acute care length of stay, Disability Rating Scale on rehabilitation admission, penetrating violent cause of injury, and drug abuse. CONCLUSIONS This study demonstrates that PTA as a quantitative measure of TBI severity significantly impacts first-year hospitalization costs of SMVs treated at PRCs. Each additional day of PTA was associated with higher total, rehabilitation, ICU, and surgery costs. Mean first year hospital costs were also found to exceed the highest budget allocation to VHA facilities for a veteran treated at a PRC. These findings have possible implications for hospital care provision for those receiving inpatient rehabilitation in VHA settings.
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Affiliation(s)
| | | | - Marc A Silva
- Mental Health and Behavioral Sciences Section (MHBSS), James A. Haley Veterans' Hospital, Tampa, FL; Department of Psychiatry & Behavioral Neurosciences, Morsani College of Medicine, University of South Florida, Tampa, FL; Department of Internal Medicine Sleep & Pulmonary Division, Morsani College of Medicine, University of South Florida, Tampa, FL
| | - Kristen Dams-O'Connor
- Department of Rehabilitation and Human Performance, Icahn School of Medicine, New York, NY; Department of Neurology, Icahn School of Medicine, New York, NY
| | - George Rocek
- Research and Development Service, James A. Haley Veterans' Hospital, Tampa, FL
| | - Leah M Phillips
- Research and Development Service, James A. Haley Veterans' Hospital, Tampa, FL
| | - Ariana Del Negro
- Tampa VA Research and Education Foundation, Inc, Temple Terrace, FL
| | - William C Walker
- Department of Physical Medicine and Rehabilitation, School of Medicine, Virginia Commonwealth University, Richmond, VA
| | - Risa Nakase-Richardson
- Mental Health and Behavioral Sciences Section (MHBSS), James A. Haley Veterans' Hospital, Tampa, FL; Department of Internal Medicine Sleep & Pulmonary Division, Morsani College of Medicine, University of South Florida, Tampa, FL; DHA Traumatic Brain Injury Center of Excellence, Tampa, FL
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Dams-O'Connor K, Juengst SB, Bogner J, Chiaravalloti ND, Corrigan JD, Giacino JT, Harrison-Felix CL, Hoffman JM, Ketchum JM, Lequerica AH, Marwitz JH, Miller AC, Nakase-Richardson R, Rabinowitz AR, Sander AM, Zafonte R, Hammond FM. Traumatic brain injury as a chronic disease: insights from the United States Traumatic Brain Injury Model Systems Research Program. Lancet Neurol 2023; 22:517-528. [PMID: 37086742 DOI: 10.1016/s1474-4422(23)00065-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 12/14/2022] [Accepted: 01/31/2023] [Indexed: 04/24/2023]
Abstract
Traumatic brain injury (TBI) is a global health priority, associated with substantial burden. Historically conceptualised as an injury event with finite recovery, TBI is now recognised as a chronic condition that can affect multiple domains of health and function, some of which might deteriorate over time. Many people who have had a TBI remain moderately to severely disabled at 5 years, are rehospitalised up to 10 years post-injury, and have a reduced lifespan relative to the general population. Understanding TBI as a chronic disease process can be highly informative for optimising care, which has traditionally focused on acute care. Chronic brain injury care models must be informed by a holistic understanding of long-term outcomes and the factors that can affect how care needs evolve over time. The United States Traumatic Brain Injury Model Systems of Care follows up individuals with moderate-to-severe TBI for over 30 years, allowing characterisation of the chronic (2-30 years or more post injury) functional, cognitive, behavioural, and social sequelae experienced by individuals who have had a moderate-to-severe TBI and the implications for their health and quality of life. Older age, social determinants of health, and lower acute functional status are associated with post-recovery deterioration, while younger age and greater functional independence are associated with risky health behaviours, including substance misuse and re-injury. Systematically collected data on long-term outcomes across multiple domains of health and function are needed worldwide to inform the development of models for chronic disease management, including the proactive surveillance of commonly experienced health and functional challenges.
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Affiliation(s)
- Kristen Dams-O'Connor
- Brain Injury Research Center, Department of Rehabilitation and Human Performance, Brain Injury Research Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA. kristen.dams-o'
| | - Shannon B Juengst
- Brain Injury Research Center, TIRR Memorial Hermann, Houston, TX, USA; Department of Physical Medicine & Rehabilitation, UT Southwestern Medical Center, Dallas, TX, USA
| | - Jennifer Bogner
- Department of Physical Medicine and Rehabilitation, The Ohio State University, Columbus, OH, USA
| | - Nancy D Chiaravalloti
- Center for Traumatic Brain Injury Research, Kessler Foundation, East Hanover, NJ, USA; Department of Physical Medicine and Rehabilitation, New Jersey Medical School, Rutgers University, Newark, NJ, USA
| | - John D Corrigan
- Department of Physical Medicine and Rehabilitation, The Ohio State University, Columbus, OH, USA
| | - Joseph T Giacino
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, MA, USA; Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, USA
| | | | - Jeanne M Hoffman
- Department of Rehabilitation Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | | | - Anthony H Lequerica
- Center for Traumatic Brain Injury Research, Kessler Foundation, East Hanover, NJ, USA
| | - Jennifer H Marwitz
- Department of Physical Medicine and Rehabilitation, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL, USA
| | - A Cate Miller
- National Institute on Disability, Independent Living, and Rehabilitation Research, Administration for Community Living, US Department of Health and Human Services, Washington, DC, USA
| | - Risa Nakase-Richardson
- Research Service, James A Haley Veterans Hospital, Tampa, FL, USA; Department of Internal Medicine, Pulmonary and Sleep Medicine Division, University of South Florida, Tampa, FL, USA
| | - Amanda R Rabinowitz
- Department of Physical Medicine and Rehabilitation, Moss Rehabilitation Research Institute, Elkins Park, PA, USA; Department of Physical Medicine and Rehabilitation, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Angelle M Sander
- Brain Injury Research Center, TIRR Memorial Hermann, Houston, TX, USA; H Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX, USA
| | - Ross Zafonte
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, MA, USA; Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, USA; Massachusetts General Hospital, Brigham and Women's Hospital, Boston, MA, USA
| | - Flora M Hammond
- Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Indianapolis, IN, USA; Rehabilitation Hospital of Indiana, Indianapolis, IN, USA
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Hamilton JA, Ketchum JM, Hammond FM, Peterson MD, Zasler ND, Eapen BC, Adamson MM, Galhorta PP, Harris O, Nakase-Richardson R. Comparison of veterans affairs and NIDILRR traumatic brain injury model systems participants with disorders of consciousness. Brain Inj 2023; 37:282-292. [PMID: 36539996 DOI: 10.1080/02699052.2022.2158226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To characterize demographic, pre-injury, and outcome data within the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) and Veterans Affairs (VA) Traumatic Brain Injury Model Systems (TBIMS) cohorts with severe traumatic brain injury (TBI) with no command-following ability at time of admission to acute rehabilitation. DESIGN Retrospective cohort. SETTING NIDILRR and VA TBI Model Systems (TBIMS) centers. PARTICIPANTS 396 NIDILRR and 72 VA participants without command-following ability who experienced TBI with subsequent Disorder of Consciousness (DoC). MAIN OUTCOME MEASURE Pre-injury and injury characteristics, rehabilitation outcomes, and 1-year self-reported outcomes. RESULTS VA TBIMS cohort included individuals who were active duty or had military service before their injury. The VA cohort were more likely to be re-hospitalized at 1-year follow-up or residing in a long-term care or rehab setting. The NIDILRR TBIMS cohort had higher FIM and DRS scores at rehabilitation discharge, while the VA participants saw longer lengths of stay and higher numbers of "violent" injury types. CONCLUSIONS This study allows for a better understanding of the comparability between VA and NIDILRR DoC cohorts providing guidance on how veteran and civilian samples might be merged in future TBIMS studies to explore predictors of recovery from a DoC.
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Affiliation(s)
| | | | - Flora M Hammond
- Department Physical Medicine and Rehabilitation, Indiana University School of Medicine, Rehabilitation Hospital of Indiana, Carolinas Rehabilitation, 4141 Shore Drive 46254, Indianapolis, Indiana
| | | | - Nathan D Zasler
- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, Virginia
| | - Blessen C Eapen
- Division of Physical Medicine and Rehabilitation, Physical Medicine and Rehabilitation Service, VA Greater Los Angeles Health Care System, Los Angeles, California
| | - Maheen Mausoof Adamson
- Department of Neurosurgery, Rehabilitation Service, VA Palo Alto Health Care System, Palo Alto, California
| | - Pawan P Galhorta
- VA Palo Alto Health Care System, Palo Alto, CA, Program Director, Polytrauma Rehabilitation Center
| | - Odette Harris
- Department of Neurosurgery, Director, Brain Injury, Stanford University School of Medicine
| | - Risa Nakase-Richardson
- Mental Health and Behavioral Sciences, James A. Haley Veterans Hospital, Defense Health Agency TBI Center of Excellence at James A. Haley Veterans Hospital, Tampa, Florida
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Nakase-Richardson R, Kretzmer T, Agtarap S, Pinto S, Reindeau A, Shapiro-Rosenbaum A. Program Elements That Promote Successful Management Of Brain-Injury Related Behaviors: Qualitative Survey Of Providers. Arch Phys Med Rehabil 2023. [DOI: 10.1016/j.apmr.2022.12.131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2023]
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Ching D, O'Connor D, Martin A, Takagishi C, Kane G, Scott S, Hoffman J, Harrison-Felix C, Nakase-Richardson R, Cotner B. Organizational Facilitators and Barriers to Providing Treatment to Persons with TBI and Chronic Pain. Arch Phys Med Rehabil 2023. [DOI: 10.1016/j.apmr.2022.12.118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2023]
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Cotner B, O'Connor D, Silva M, Carlozzi N, Finn J, Hammond F, Hoffman J, Chung J, Nakase-Richardson R. Facilitators and Barriers to Accessing Care by Service Members and Veterans With Traumatic Brain Injury. Arch Phys Med Rehabil 2023. [DOI: 10.1016/j.apmr.2022.12.083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2023]
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Miles SR, Martindale SL, Flanagan JC, Troyanskaya M, Reljic T, Gilmore AK, Wyant H, Nakase-Richardson R. Putting the pieces together to understand anger in combat veterans and service members: Psychological and physical contributors. J Psychiatr Res 2023; 159:57-65. [PMID: 36657315 DOI: 10.1016/j.jpsychires.2023.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 12/19/2022] [Accepted: 01/09/2023] [Indexed: 01/13/2023]
Abstract
Dysregulated anger can result in devastating health and interpersonal consequences for individuals, families, and communities. Compared to civilians, combat veterans and service members (C-V/SM) report higher levels of anger and often have risk factors for anger including posttraumatic stress disorder (PTSD), traumatic brain injury (TBI), pain, alcohol use, and impaired sleep. The current study examined the relative contributions of established variables associated with anger (e.g., combat exposure, current PTSD symptoms, history of TBI, pain interference, and hazardous alcohol use) in 1263 C-V/SM. Sleep impairments, represented by poor sleep quality and obstructive sleep apnea (OSA) risk, were also evaluated as potential mediators of the relationships between established risk factors and anger, and therefore potential modifiable treatment targets. Multiple regression model results revealed that PTSD symptoms (β = 0.517, p < .001), OSA risk (β = 0.057, p = .016), pain interference (β = 0.214, p < .001), and hazardous alcohol use (β = 0.054, p = .009) were significantly associated with anger. Results of the mediation models revealed that OSA risk accounted for the association between PTSD and anger, in addition to the association between pain interference and anger. The current study extends previous literature by simultaneously examining factors associated with anger using a multivariable model in a large sample of C-V/SM. Additionally, treating OSA may be a novel way to reduce anger in C-V/SM who have PTSD and/or pain interference.
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Affiliation(s)
- Shannon R Miles
- Mental Health and Behavioral Sciences Service, James A. Haley Veterans' Hospital, Tampa, FL, USA; Division of Psychiatry & Behavioral Sciences, Morsani College of Medicine, University of South Florida, Tampa, FL, USA.
| | - Sarah L Martindale
- W.G. (Bill) Hefner VA Healthcare System, Salisbury, NC, USA; Wake Forest School of Medicine, Winston-Salem, NC, USA.
| | - Julianne C Flanagan
- Medical University of South Carolina, Charleston, SC, USA; Ralph H. Johnson VA Medical Center, Charleston, SC, USA.
| | - Maya Troyanskaya
- Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX, USA; Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA.
| | - Tea Reljic
- Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL, USA.
| | - Amanda K Gilmore
- Department of Health Policy & Behavioral Sciences, School of Public Health, Georgia State University, Atlanta, GA, USA.
| | - Hannah Wyant
- University of South Florida, Morsani College of Medicine, Tampa, FL, USA.
| | - Risa Nakase-Richardson
- Mental Health and Behavioral Sciences Service, James A. Haley Veterans' Hospital, Tampa, FL, USA; Traumatic Brain Injury Center of Excellence, Defense Health Agency, James A. Haley Veterans' Hospital, Tampa, FL, USA; Pulmonary and Sleep Medicine Division, Department of Internal Medicine, University of South Florida, Tampa, FL, USA.
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Silva MA, Miles SR, O'Neil-Pirozzi TM, Arciniegas DB, Klocksieben F, Dismuke-Greer CE, Walker WC, Nakase-Richardson R. Alternative Structure Models of the Traumatic Brain Injury Rehabilitation Needs Survey: A Veterans Affairs TBI Model Systems Study. Arch Phys Med Rehabil 2023:S0003-9993(23)00048-5. [PMID: 36736804 DOI: 10.1016/j.apmr.2023.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 12/20/2022] [Accepted: 01/03/2023] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To explore the factor structure of the Rehabilitation Needs Survey (RNS). DESIGN Secondary analysis of observational cohort study who were 5-years post-traumatic brain injury (TBI). SETTING Five Inpatient Rehabilitation Facilities. PARTICIPANTS Veterans enrolled in the TBI Model Systems longitudinal study who completed the RNS at 5-year follow-up (N=378). MAIN OUTCOME MEASURE(S) RNS. RESULTS RNS factor structure was examined with exploratory factor analysis (EFA) with oblique rotation. Analyses returned 2- and 3-factor solutions with Cronbach alphas ranging from 0.715 to 0.905 and corrected item-total correlations that ranged from 0.279 to 0.732. The 2-factor solution accounted for 61.7% of the variance with ≥3 exclusively loading items on each factor with acceptable internal consistency metrics and was selected as the most parsimonious and clinically applicable model. Ad hoc analysis found the RNS structure per the EFA corresponded with elements of the International Classification of Functioning, Disability and Health (ICF) conceptual framework. All factors had adequate internal consistency (α≥0.70) and 20 of the 21 demonstrated good discrimination (corrected item-total correlations≥0.40). CONCLUSIONS The 2-factor solution of the RNS appears to be a useful model for enhancing its clinical interpretability. Although there were cross-loading items, they refer to complex rehabilitation needs that are likely influenced by multiple factors. Alternatively, there are items that may require alteration and redundant items that should be considered for elimination.
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Affiliation(s)
- Marc A Silva
- Mental Health & Behavioral Sciences Section (MHBSS), James A. Haley Veterans' Hospital, Tampa, FL; Department of Psychiatry and Behavioral Neurosciences, Morsani College of Medicine, University of South Florida, Tampa, FL; Department of Psychology, University of South Florida, Tampa, FL; Division of Pulmonary and Sleep Medicine, Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL.
| | - Shannon R Miles
- Mental Health & Behavioral Sciences Section (MHBSS), James A. Haley Veterans' Hospital, Tampa, FL; Department of Psychiatry and Behavioral Neurosciences, Morsani College of Medicine, University of South Florida, Tampa, FL
| | - Therese M O'Neil-Pirozzi
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA; Department of Communication Sciences and Disorders, Northeastern University, Boston, MA
| | - David B Arciniegas
- Marcus Institute for Brain Health, University of Colorado-Anschutz Medical Campus, Aurora, CO; Department of Psychiatry & Behavioral Sciences, University of New Mexico School of Medicine, Albuquerque, NM
| | - Farina Klocksieben
- Research Methodology and Biostatistics Core, Office of Research, University of South Florida, Tampa, FL
| | - Clara E Dismuke-Greer
- Health Economics Resource Center (HERC), Center for Innovation to Implementation (Ci2i), VA Palo Alto Healthcare System, Menlo Park, CA
| | - William C Walker
- Department of Physical Medicine and Rehabilitation (PM&R), School of Medicine, Virginia Commonwealth University, Richmond, VA; PM&R Service, Richmond Veterans Affairs Medical Center, Central Virginia VA Health Care System, Richmond, VA
| | - Risa Nakase-Richardson
- Mental Health & Behavioral Sciences Section (MHBSS), James A. Haley Veterans' Hospital, Tampa, FL; Division of Pulmonary and Sleep Medicine, Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL; Defense Health Agency Traumatic Brain Injury Center of Excellence at James A. Haley Veterans Hospital, Tampa, FL
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Martin AM, Pinto SM, Tang X, Hoffman JM, Wittine L, Walker WC, Schwartz DJ, Kane G, Takagishi SC, Nakase-Richardson R. Associations between early sleep-disordered breathing following moderate-to-severe traumatic brain injury and long-term chronic pain status: a Traumatic Brain Injury Model Systems study. J Clin Sleep Med 2023; 19:135-143. [PMID: 36591795 PMCID: PMC9806770 DOI: 10.5664/jcsm.10278] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 08/31/2022] [Accepted: 09/01/2022] [Indexed: 01/07/2023]
Abstract
STUDY OBJECTIVES To explore the relationship between polysomnography-derived respiratory indices and chronic pain status among individuals following traumatic brain injury (TBI). METHODS Participants (n = 66) with moderate to severe TBI underwent polysomnography during inpatient acute rehabilitation and their chronic pain status was assessed at 1- to 2-year follow-up as part of the TBI Model Systems Pain Collaborative Study. Pairwise comparisons across pain cohorts (ie, chronic pain, no history of pain) were made to explore differences on polysomnography indices. RESULTS Among our total sample, approximately three-quarters (74.2%) received sleep apnea diagnoses utilizing American Academy of Sleep Medicine criteria, with 61.9% of those endorsing a history of chronic pain. Of those endorsing chronic pain, the average pain score was 4.8 (standard deviation = 2.1), with a mean interference score of 5.3 (2.7). Pairwise comparisons revealed that those endorsing a chronic pain experience at follow-up experienced categorically worse indicators of sleep-related breathing disorders during acute rehabilitation relative to those who did not endorse chronic pain. Important differences were observed with elevations on central (chronic pain: 2.6; no pain: 0.8 per hour) and obstructive apnea (chronic pain: 15.7; no pain: 11.1 per hour) events, as well as oxygen desaturation indices (chronic pain: 19.6; no pain: 7.9 per hour). CONCLUSIONS Sleep-disordered breathing appears worse among those who endorse chronic pain following moderate-to-severe TBI, but additional research is needed to understand its relation to postinjury pain. Prospective investigation is necessary to determine how clinical decisions (eg, opioid therapy) and intervention (eg, positive airway pressure) may mutually influence outcomes. CLINICAL TRIAL REGISTRATION Registry: ClinicalTrials.gov; Name: Comparison of Sleep Apnea Assessment Strategies to Maximize TBI Rehabilitation Participation and Outcome (C-SAS); URL: https://clinicaltrials.gov/ct2/show/NCT03033901; Identifier: NCT03033901. CITATION Martin AM, Pinto SM, Tang X, et al. Associations between early sleep-disordered breathing following moderate-to-severe traumatic brain injury and long-term chronic pain status: a Traumatic Brain Injury Model Systems study. J Clin Sleep Med. 2023;19(1):135-143.
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Affiliation(s)
- Aaron M. Martin
- Mental Health and Behavioral Sciences Section (MHBSS), James A. Haley Veterans’ Hospital, Tampa, Florida
- Department of Psychiatry and Behavioral Neurosciences, University of South Florida, Tampa, Florida
| | - Shanti M. Pinto
- Department of Physical Medicine and Rehabilitation, Utah Southwestern, Dallas, Texas
- Department of Physical Medicine and Rehabilitation, Carolinas Rehabilitation, Charlotte, North Carolina
| | - Xinyu Tang
- Tampa VA Research and Education Foundation, Inc., Tampa, Florida
| | - Jeanne M. Hoffman
- Department of Rehabilitation Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Lara Wittine
- Division of Pulmonary and Sleep Medicine, Department of Internal Medicine, University of South Florida, Tampa, Florida
| | - William C. Walker
- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, Virginia
| | - Daniel J. Schwartz
- Division of Pulmonary and Sleep Medicine, Department of Internal Medicine, University of South Florida, Tampa, Florida
| | - Georgia Kane
- Department of Neurology, University of South Florida, Tampa, Florida
- Headache Center of Excellence, James A. Haley Veterans’ Hospital, Tampa, Florida
| | - S. Curtis Takagishi
- Mental Health and Behavioral Sciences Section (MHBSS), James A. Haley Veterans’ Hospital, Tampa, Florida
- Headache Center of Excellence, James A. Haley Veterans’ Hospital, Tampa, Florida
| | - Risa Nakase-Richardson
- Mental Health and Behavioral Sciences Section (MHBSS), James A. Haley Veterans’ Hospital, Tampa, Florida
- Division of Pulmonary and Sleep Medicine, Department of Internal Medicine, University of South Florida, Tampa, Florida
- Defense Health Agency Traumatic Brain Injury Center of Excellence at James A. Haley Veterans Hospital, Tampa, Florida
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Kumar RG, Klyce D, Nakase-Richardson R, Pugh MJ, Walker WC, Dams-O'Connor K. Associations of Military Service History and Health Outcomes in the First Five Years after Traumatic Brain Injury. J Neurotrauma 2022. [PMID: 36401499 DOI: 10.1089/neu.2022.0340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
For many years, experts have recognized the importance of studying traumatic brain injury (TBI) among active-duty service members and veterans. A majority of this research has been conducted in Veterans Administration (VA) or Department of Defense settings. However, far less is known about military personnel who seek their medical care outside these settings. Studies that have been conducted in civilian settings have either not enrolled active duty or veteran participants, or failed to measure military history, precluding study of TBI outcomes by military history. The purpose of the present study was to determine associations between military history and medical (prevalence of 25 comorbid health conditions), cognition (Brief Test of Adult Cognition by Telephone), and psychological health (Patient Health Questionnaire-9 [PHQ-9], Generalized Anxiety Disorder-7, suicidality [9th item from PHQ-9]) in the first 5 years after TBI. In this prospective study, we analyzed data from the TBI Model Systems National Database. Participants were 7797 individuals with TBI admitted to one of 21 civilian inpatient rehabilitation facilities from April 1, 2010, to November 19, 2020, and followed up to 5 years. We assessed the relationship between military history (any versus none, combat exposure, service era, and service duration) and TBI outcomes. We found specific medical conditions were significantly more prevalent 1 year post-TBI among individuals who had a history of combat deployment (lung disorders, post-traumatic stress disorder [PTSD], and sleep disorder), served in post-draft era (chronic pain, liver disease, arthritis), and served >4 years (high cholesterol, PTSD, sleep disorder). Individuals with military history without combat deployment had modestly more favorable cognition and psychological health in the first 5 years post-injury relative to those without military history. Our data suggest that individuals with TBI with military history are heterogeneous, with some favorable and other deleterious health outcomes, relative to their non-military counterparts, which may be driven by characteristics of service, including combat exposure and era of service.
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Affiliation(s)
- Raj G Kumar
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Daniel Klyce
- Department of Physical Medicine and Rehabilitation, School of Medicine, Virginia Commonwealth University (VCU), Richmond, Virginia, USA.,Mental Health Service, Central Virginia VA Health Care System, Richmond, Virginia, USA.,Sheltering Arms Institute, Richmond, Virginia, USA
| | - Risa Nakase-Richardson
- Mental Health and Behavior Sciences, Defense Health Agency TBI Center of Excellence, James A. Haley Veterans Hospital, Tampa, Florida, USA.,Pulmonary/Sleep Medicine Division, Department of Internal Medicine, University of South Florida, Tampa, Florida, USA
| | - Mary Jo Pugh
- Informatics, Decision-Enhancement and Analytic Sciences Center, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA.,Department of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - William C Walker
- Department of Physical Medicine and Rehabilitation, School of Medicine, Virginia Commonwealth University (VCU), Richmond, Virginia, USA.,Sheltering Arms Institute, Richmond, Virginia, USA.,PM&R Service, Richmond Veterans Affairs Medical Center, Central Virginia Veterans Affairs Health Care System, Richmond, Virginia, USA
| | - Kristen Dams-O'Connor
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Haun JN, Nakase-Richardson R, Melillo C, Kean J, Benzinger RC, Schneider T, Pugh MJV. This is test MS2 5 Dec 2022 (Preprint). J Med Internet Res 2022; 12:e44776. [PMID: 37159250 DOI: 10.2196/44776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 03/17/2023] [Accepted: 03/21/2023] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The traumatic brain injury (TBI) Intensive Evaluation and Treatment Program (IETP) is an innovative modality for delivering evidence-based treatments in a residential, inpatient format to special operational forces service members and veterans with mild TBI. IETPs provide bundled evidence-based assessment, treatment, referral, and case management in concordance with the existing guidelines for mild TBI and commonly co-occurring comorbidities. To date, there has been no formal characterization or evaluation of the IETP to understand the determinants of implementation across the system of care. The goal of our partnered evaluation initiative (PEI) with an operational partner, the Physical Medicine and Rehabilitation National Program Office, is to facilitate the full implementation of the IETP across all 5 Veterans Health Administration TBI-Centers of Excellence (TBI-COE) and to inform minimum standards while supporting the unique characteristics of each site. OBJECTIVE This IETP partnered evaluation will describe each of the 5 TBI-COE IETP services and state of implementation to identify opportunities for adaptation and scale, characterize the relationship between patient characteristics and clinical services received, evaluate the outcomes for participants in the IETP, and inform ongoing implementation and knowledge translation efforts to support IETP expansion. In alignment with the goals of the protocol, ineffective treatment components will be targeted for deimplementation. METHODS A 3-year concurrent mixed methods evaluation using a participatory approach in collaboration with the operational partner and TBI-COE site leadership will be conducted. Qualitative observations, semistructured focus groups, and interviewing methods will be used to describe IETP, stakeholder experiences and needs, and suggestions for IETP implementation. Quantitative methods will include primary data collection from patients in the IETP at each site to characterize long-term outcomes and patient satisfaction with treatment and secondary data collection to quantitatively characterize patient-level and care system-level data. Finally, data sets will be triangulated to share data findings with partners to inform ongoing implementation efforts. RESULTS Data collection began in December 2021 and is currently ongoing. The results and deliverables will inform IETP characterization, evaluation, implementation, and knowledge translation. CONCLUSIONS The results of this evaluation seek to provide an understanding of the determinants affecting the implementation of IETPs. Service member, staff, and stakeholder insights will inform the state of implementation at each site, and quantitative measures will provide options for standardized outcome measures. This evaluation is expected to inform national Physical Medicine and Rehabilitation Office policies and processes and knowledge translation efforts to improve and expand the IETP. Future work may include cost evaluations and rigorous research, such as randomized controlled trials. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/44776.
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Affiliation(s)
- Jolie N Haun
- James A. Haley Veterans' Hospital, Research Service, Tampa, FL, United States
- College of Public Health, University of South Florida, Tampa, FL, United States
| | - Risa Nakase-Richardson
- James A. Haley Veterans' Hospital, Research Service, Tampa, FL, United States
- Pulmonary/Sleep Medicine Division, Department of Internal Medicine, University of South Florida, Tampa, FL, United States
| | - Christine Melillo
- James A. Haley Veterans' Hospital, Research Service, Tampa, FL, United States
| | - Jacob Kean
- VA Salt Lake City Health Care System, VA Informatics and Computing Infrastructure, Salt Lake City, UT, United States
| | - Rachel C Benzinger
- James A. Haley Veterans' Hospital, Research Service, Tampa, FL, United States
| | - Tali Schneider
- James A. Haley Veterans' Hospital, Research Service, Tampa, FL, United States
| | - Mary Jo V Pugh
- VA Salt Lake City Health Care System, Informatics, Decision-Enhancement and Analytic Sciences Center, Salt Lake City, UT, United States
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Steward KA, Silva MA, Maduri P, Tang X, Wittine L, Dams-O'Connor K, Nakase-Richardson R. Obstructive sleep apnea is associated with worse cognitive outcomes in acute moderate-to-severe traumatic brain injury: A TBI Model Systems study. Sleep Med 2022; 100:454-461. [PMID: 36252414 DOI: 10.1016/j.sleep.2022.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 09/07/2022] [Accepted: 09/19/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To examine the relationship between polysomnography-classified obstructive sleep apnea (OSA) severity and cognitive performance in acute moderate-to-severe traumatic brain injury (TBI). METHOD This was a cross-sectional, secondary analysis leveraging data from a clinical trial (NCT03033901) and TBI Model Systems. Sixty participants (mean age = 50 ± 18y, 72% male, 67% white) with moderate-to-severe TBI from five civilian rehabilitation hospitals were assessed at one-month post-injury. Participants underwent Level 1 polysomnography. OSA severity was classified as mild, moderate, and severe using the Apnea-Hypopnea Index (AHI). Associations between OSA metrics of hypoxemia (nadir and total time spent below 90%) and AHI with cognition were examined. Cognition was assessed with the Brief Test of Adult Cognition by Telephone (BTACT), which is comprised of six subtests assessing verbal memory, attention/working memory, processing speed, language, and executive function. RESULTS Over three-quarters of this acute TBI sample (76.7%) were diagnosed with OSA (no OSA n = 14; mild OSA n = 19; moderate/severe OSA n = 27). After adjustment for age, gender, and education, those with OSA had worse processing speed, working memory, and executive functioning compared to those without OSA. Compared to those with moderate/severe OSA, those with mild OSA had worse working memory and executive function. CONCLUSIONS OSA is highly prevalent during acute stages of TBI recovery, and even in mild cases is related to poorer cognitive performance, particularly in the domains of attention/working memory and executive functioning. Our results support the incorporation of OSA diagnostic tools and interventions into routine clinical care in rehabilitation settings.
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Affiliation(s)
- Kayla A Steward
- Mental Health and Behavioral Sciences, James A. Haley Veteran's Hospital, Tampa, FL, USA.
| | - Marc A Silva
- Mental Health and Behavioral Sciences, James A. Haley Veteran's Hospital, Tampa, FL, USA; Department of Internal Medicine, Pulmonary, Critical Care, and Sleep Medicine Division, University of South Florida, Tampa, FL, USA; Department of Psychiatry and Behavioral Neurosciences, University of South Florida, Tampa, FL, USA; Department of Psychology, University of South Florida, Tampa, FL, USA
| | - Prathusha Maduri
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Xinyu Tang
- Tampa VA Research and Education Foundation, Inc., Tampa, FL, USA
| | - Lara Wittine
- AdventHealth Tampa Sleep Center, Tampa, FL, USA; Department of Internal Medicine, James A. Haley Veteran's Hospital, Tampa, FL, USA
| | - Kristen Dams-O'Connor
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Risa Nakase-Richardson
- Mental Health and Behavioral Sciences, James A. Haley Veteran's Hospital, Tampa, FL, USA; Department of Internal Medicine, Pulmonary, Critical Care, and Sleep Medicine Division, University of South Florida, Tampa, FL, USA; Defense Health Agency TBI Center of Excellence, Tampa, FL, USA
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Silva M, Miles S, O-Neil-Pirozzi T, Klocksieben F, Dismuke-Greer C, Walker W, Nakase-Richardson R. Principal Component Analysis of the Traumatic Brain Injury Rehabilitation Needs Survey: Comparison of Three Models. Arch Phys Med Rehabil 2022. [DOI: 10.1016/j.apmr.2022.08.809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
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Martin A, Pinto S, Tang X, Hoffman J, Wittine L, Walker W, Schwartz D, Kane G, Takagishi C, Nakase-Richardson R. Polysomnographic Differences Following Moderate-Severe Traumatic Brain Injury (TBI) Among Individuals With Chronic Pain. Arch Phys Med Rehabil 2022. [DOI: 10.1016/j.apmr.2022.08.608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
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Dismuke-Greer C, Almeida E, Silva M, Rocek G, Phillips L, Walker W, Nakase-Richardson R. Impact of Post-Traumatic Amnesia on Traumatic Brain Injury (TBI) First Year Hospitalization Costs in TBIMS. Arch Phys Med Rehabil 2022. [DOI: 10.1016/j.apmr.2022.08.580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
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Loyo K, Wittine L, Silva M, Ketchum J, Hammond F, Chung J, Kretzmer T, Nakase-Richardson R. Causes of Mortality Among Veterans Previously Hospitalized After Traumatic Brain Injury. Arch Phys Med Rehabil 2022. [DOI: 10.1016/j.apmr.2022.08.772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
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Silva MA, Lee JM, Garcia A, Dams-O'Connor K, Nakase-Richardson R. Research Letter: Impact of Obstructive Sleep Apnea Disease Duration on Neuropsychological Functioning After Traumatic Brain Injury: A Veterans Affairs TBI Model Systems Study. J Head Trauma Rehabil 2022; 37:E496-E501. [PMID: 35687890 PMCID: PMC10249369 DOI: 10.1097/htr.0000000000000797] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine the relationship between obstructive sleep apnea (OSA) disease duration and cognitive functioning in those with a history of traumatic brain injury (TBI). We hypothesized that longer OSA duration would predict poorer cognitive performance. SETTING Inpatient brain injury units at a Veterans Affairs (VA) Polytrauma Rehabilitation Center. PARTICIPANTS Participants in the VA TBI Model Systems multicenter longitudinal study who enrolled in a modular substudy (April 15, 2018, to January 15, 2021) examining cognition following TBI. All participants had received inpatient rehabilitation for TBI and reported a diagnosis of OSA ( n = 89, mean age = 40.8 years, 97% male, 81% White). Reported duration of OSA ranged from 2 to 7 years (mean = 4.2; SD = 3.9). DESIGN Retrospective analysis of prospective cohort, cross-sectional. MAIN MEASURES Brief Test of Adult Cognition by Telephone (BTACT). RESULTS Controlling for age, education, and time to follow commands, OSA disease duration was negatively associated with delayed verbal memory ( R2Δ = 0.053, F(1,84) = 5.479, P = .022). Performance in other cognitive domains was not significantly associated with OSA disease duration. CONCLUSION This study provides preliminary evidence that longer duration of OSA (ie, time since diagnosis) has a negative impact on verbal memory in those with a history of hospitalized TBI. This finding extends the literature (which focused on the general population) on the cognitive impact of OSA and is consistent with hypothesized mechanisms such as hippocampal damage and secondary impact of fatigue. Findings suggest that early OSA identification and treatment may be prudent for persons with TBI.
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Affiliation(s)
- Marc A Silva
- Mental Health and Behavioral Sciences Section, James A. Haley Veterans' Hospital, Tampa, Florida (Drs Silva, Lee, Garcia, and Nakase-Richardson); Departments of Internal Medicine (Drs Silva and Nakase-Richardson) and Psychiatry and Behavioral Neurosciences (Dr Silva), University of South Florida, Tampa; Traumatic Brain Injury Center of Excellence, Tampa, Florida (Dr Garcia); Departments of Rehabilitation and Human Performance and Neurology, Icahn School of Medicine at Mount Sinai, New York, New York (Dr Dams-O'Connor)
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Silva MA, Arriola NB, Radwan CK, Womble BM, Healey EA, Lee JM, Aloia MS, Nakase-Richardson R. Improving sleep apnea treatment adherence after traumatic brain injury: A nonrandomized feasibility study. Rehabil Psychol 2022; 67:461-473. [PMID: 36355639 PMCID: PMC10166197 DOI: 10.1037/rep0000473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
PURPOSE/OBJECTIVE To evaluate the feasibility of a psychological intervention designed to increase Positive Airway Pressure (PAP) adherence, adapted with cognitive accommodations for comorbid obstructive sleep apnea (OSA) and traumatic brain injury (TBI). RESEARCH METHOD/DESIGN This was an open-label single arm (nonrandomized) study. Eligibility criteria were moderate-to-severe TBI, OSA diagnosis, prescribed PAP, nonadherent, and able to consent. Participants were recruited from inpatient and outpatient settings at a tertiary care hospital. The four-module manualized intervention was delivered primarily via telehealth. Feasibility aspects measured included eligibility, recruitment, and retention rates; session duration and attendance; and characteristics of outcome and process measures (e.g., completion rates, data distribution). Symptom measures included the Epworth Sleepiness Scale, Fatigue Severity Scale, Functional Outcomes of Sleep Questionnaire, Self-Efficacy Measure for Sleep Apnea, OSA Treatment Barriers Questionnaire (OTBQ), and Kim Alliance Scale-Revised. RESULTS Of 230 persons screened, 14.3% were eligible. Recruitment rate (n = 17) was 51.5%. Retention rate (n = 13) was 76.5%. Treatment completers had no missing data. The OTBQ deviated from normality, but other measures had adequate skew (< 2.0) and kurtosis (< 7.0) and were free from significant floor and ceiling effects (<15%). Change score effect sizes were minimal to moderate (d = .10-.77). There were no adverse events. CONCLUSIONS/IMPLICATIONS These results inform ways in which procedures should be modified to enhance the success of a future clinical trial testing the efficacy of this adherence intervention. Inclusion criteria should be reconsidered, and recruitment sites expanded, to capture eligible persons and adequately power an efficacy study. (PsycInfo Database Record (c) 2022 APA, all rights reserved).
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Affiliation(s)
- Marc A. Silva
- Mental Health and Behavioral Sciences Service, James A. Haley Veterans’ Hospital
- Division of Pulmonary, Critical Care & Sleep Medicine, Department of Internal Medicine, University of South Florida
- Department of Psychiatry and Behavioral Neurosciences, University of South Florida
| | | | | | - Brent M. Womble
- Mental Health Service Line, Hunter Holmes McGuire VA Medical Center
| | - Erica A. Healey
- Mental Health and Behavioral Sciences Service, James A. Haley Veterans’ Hospital
| | - Jaylene M. Lee
- Mental Health and Behavioral Sciences Service, James A. Haley Veterans’ Hospital
| | - Mark S. Aloia
- National Jewish Health, 1400 Jackson St, Denver, CO 8020 USA
- Philips, Inc., Amstelplein 2, 1096 BC Amsterdam, Netherlands
| | - Risa Nakase-Richardson
- Mental Health and Behavioral Sciences Service, James A. Haley Veterans’ Hospital
- Division of Pulmonary, Critical Care & Sleep Medicine, Department of Internal Medicine, University of South Florida
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Kondziella D, Amiri M, Othman MH, Beghi E, Bodien YG, Citerio G, Giacino JT, Mayer SA, Lawson TN, Menon DK, Rass V, Sharshar T, Stevens RD, Tinti L, Vespa P, McNett M, Venkatasubba Rao CP, Helbok R, Akbari Y, Boly M, Dangayach N, Edlow B, Foreman B, Gilmore E, Hammond FM, Hemphill JC, Human T, Madden LK, Mainali S, Meyfroidt G, Monti M, Nakase-Richardson R, Nyquist P, Olson D, Park S, Provencio JJ, Puybasset L, Sarwal A, Shutter L, Witherspoon B, Whyte J, Ziai W. Incidence and prevalence of coma in the UK and the USA. Brain Commun 2022; 4:fcac188. [PMID: 36132425 PMCID: PMC9486895 DOI: 10.1093/braincomms/fcac188] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 05/19/2022] [Accepted: 07/14/2022] [Indexed: 11/14/2022] Open
Abstract
The epidemiology of coma is unknown because case ascertainment with traditional methods is difficult. Here, we used crowdsourcing methodology to estimate the incidence and prevalence of coma in the UK and the USA. We recruited UK and US laypeople (aged ≥18 years) who were nationally representative (i.e. matched for age, gender and ethnicity according to census data) of the UK and the USA, respectively, utilizing a crowdsourcing platform. We provided a description of coma and asked survey participants if they—‘right now’ or ‘within the last year’—had a family member in coma. These participants (UK n = 994, USA n = 977) provided data on 30 387 family members (UK n = 14 124, USA n = 16 263). We found more coma cases in the USA (n = 47) than in the UK (n = 20; P = 0.009). We identified one coma case in the UK (0.007%, 95% confidence interval 0.00–0.04%) on the day of the survey and 19 new coma cases (0.13%, 95% confidence interval 0.08–0.21%) within the preceding year, resulting in an annual incidence of 135/100 000 (95% confidence interval 81–210) and a point prevalence of 7 cases per 100 000 population (95% confidence interval 0.18–39.44) in the UK. We identified five cases in the USA (0.031%, 95% confidence interval 0.01–0.07%) on the day of the survey and 42 new cases (0.26%, 95% confidence interval 0.19–0.35%) within the preceding year, resulting in an annual incidence of 258/100 000 (95% confidence interval 186–349) and a point prevalence of 31 cases per 100 000 population (95% confidence interval 9.98–71.73) in the USA. The five most common causes were stroke, medically induced coma, COVID-19, traumatic brain injury and cardiac arrest. To summarize, for the first time, we report incidence and prevalence estimates for coma across diagnosis types and settings in the UK and the USA using crowdsourcing methods. Coma may be more prevalent in the USA than in the UK, which requires further investigation. These data are urgently needed to expand the public health perspective on coma and disorders of consciousness.
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Affiliation(s)
- Daniel Kondziella
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital , Blegdamsvej 9 , DK-2100 Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen , Copenhagen 2100 , Denmark
| | - Moshgan Amiri
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital , Blegdamsvej 9 , DK-2100 Copenhagen, Denmark
| | - Marwan H Othman
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital , Blegdamsvej 9 , DK-2100 Copenhagen, Denmark
| | - Ettore Beghi
- Department of Neuroscience, Istituto di Ricerche Farmacologiche Mario Negri IRCCS , Milan 20156 , Italy
| | - Yelena G Bodien
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School , Boston, MA 02115 , USA
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School , Boston, MA 02114 , USA
| | - Giuseppe Citerio
- NeuroIntensive Care, ASST di Monza , Monza 20900 , Italy
- School of Medicine and Surgery, Università Milano Bicocca , Milan 20100 , Italy
| | - Joseph T Giacino
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School , Boston, MA 02115 , USA
| | - Stephan A Mayer
- Department of Neurology, New York Medical College , Valhalla, NY 10595 , USA
| | - Thomas N Lawson
- College of Nursing, The Ohio State University , Columbus, OH 43210 , USA
| | - David K Menon
- Division of Anaesthesia, University of Cambridge , Cambridge CB2 2QQ , UK
| | - Verena Rass
- Department of Neurology, Neuro-Intensive Care Unit, Medical University of Innsbruck , Innsbruck 6020 , Austria
| | - Tarek Sharshar
- Neuro-anesthesiology and Intensive Care Medicine, Sainte-Anne Hospital, Paris-Descartes University , Paris 75006 , France
- Experimental Neuropathology, Infection and Epidemiology Department, Institut Pasteur , Paris 75015 , France
| | - Robert D Stevens
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine , Baltimore, MD 21287 , USA
- Department of Neurology, The Johns Hopkins University School of Medicine , Baltimore, MD 21218 , USA
- Department of Neurosurgery, The Johns Hopkins University School of Medicine , Baltimore 21287, MD , USA
| | - Lorenzo Tinti
- Department of Neuroscience, Istituto di Ricerche Farmacologiche Mario Negri IRCCS , Milan 20156 , Italy
| | - Paul Vespa
- Department of Neurology, David Geffen School of Medicine at UCLA , Los Angeles, CA 90095 , USA
- Department of Neurosurgery, David Geffen School of Medicine at UCLA , Los Angeles, CA 90095 , USA
| | - Molly McNett
- College of Nursing, The Ohio State University , Columbus, OH 43210 , USA
| | - Chethan P Venkatasubba Rao
- Division of Vascular Neurology and Neurocritical Care, Baylor College of Medicine and CHI Baylor St Luke's Medical Center , Houston, TX 77030 , USA
| | - Raimund Helbok
- Department of Neurology, Neuro-Intensive Care Unit, Medical University of Innsbruck , Innsbruck 6020 , Austria
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Martin A, Tang X, Pinto S, Hoffman J, Schwartz D, Wittine L, Walker W, Kane G, Takagishi S, Nakase-Richardson R. 0632 Early sleep-disordered breathing in moderate-to-severe traumatic brain injury (TBI) is linked with chronic pain status at long-term follow-up: A TBI Model Systems study. Sleep 2022. [DOI: 10.1093/sleep/zsac079.629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Introduction
Sleep disorders and chronic pain (pain of >3 months duration) are common after traumatic brain injury (TBI). A recently completed multi-center trial found that two-thirds of adults with moderate-to-severe TBI had sleep apnea diagnosed during polysomnography (PSG) completed during inpatient rehabilitation. Although a bidirectional relationship between sleep and pain exists, attention to sleep apnea as a specific diagnosis and its possible role in chronic pain following TBI has not been explored. We hypothesized that PSG-derived respiratory indices shortly following TBI would be worse among those reporting chronic pain at 1- to 2-year follow-up compared to those without chronic pain.
Methods
Sample (N=66) derived from overlapping cohorts across two separate multicenter studies. Participants with moderate to severe TBI underwent PSG during inpatient rehabilitation and completed a telephone follow-up interview to assess chronic pain status using standardized measures at 1-2 years post-TBI (610-day average). Pairwise comparisons across participants with and without chronic pain were made to determine the magnitude of clinically significant differences on respiratory indices including oxygen desaturation, central and obstructive apneas, and total apnea-hypopnea index (AHI).
Results
Presence of chronic pain at follow-up was associated with elevated central apnea events (2.6) and oxygen desaturation (19.6) relative to those without chronic pain (0.8 and 7.9, respectively). Important differences were also seen between obstructive and total apnea hypopnea index (AHI) using Centers for Medicaid and Medicare Services scoring criteria, with those in the chronic pain cohort being 6.5 and 8.7 points higher than their non-pain counterparts, respectively. Group differences on obstructive and total AHI were considered minor when using the American Academy of Sleep Medicine scoring criteria, although those with current pain experienced categorically worse sleep apnea (total AHI = 19 versus 12.4).
Conclusion
This is the first study to find an association between PSG-derived respiratory indices and long-term chronic pain status following moderate-to-severe TBI. Sleep apnea represents an important modifiable factor following injury that may contribute to long-term pain-related outcomes. Given the prominence of chronic pain several years post injury, future studies should investigate the role of sleep apnea and early intervention among those following moderate-to-severe TBI to determine impact on long-term rehabilitation and pain outcomes.
Support (If Any)
PCORI; CER-1511-33005); VA TBI Model Systems Program of Research; GDIT; NIDILRR 90DPTB0008. Clinicaltrial.gov Registration Number: NCT03033901.
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Affiliation(s)
- Aaron Martin
- James A. Haley Veterans' Hospital, Mental Health & Behavioral Sciences Service
| | - Xinyu Tang
- Tampa VA Research and Education Foundation, Inc
| | - Shanti Pinto
- Department of Physical Medicine and Rehabilitation, Carolinas Rehabilitation
| | - Jeanne Hoffman
- Division of Rehabilitation Psychology, Department of Rehabilitation Medicine, University of Washington School of Medicine
| | - Daniel Schwartz
- Department of Internal Medicine, Division of Pulmonary and Sleep Medicine, University of South Florida
| | - Lara Wittine
- Department of Internal Medicine, Division of Pulmonary and Sleep Medicine, University of South Florida
| | - William Walker
- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University
| | - Georgia Kane
- Department of Neurology, University of South Florida
| | - S Takagishi
- James A. Haley Veterans' Hospital, Mental Health & Behavioral Sciences Service
| | - Risa Nakase-Richardson
- Defense Health Agency Traumatic Brain Injury Center of Excellence at James A. Haley Veterans Hospital
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Miles SR, Pruiksma KE, Slavish D, Dietch JR, Wardle-Pinkston S, Litz BT, Rodgers M, Nicholson KL, Young-McCaughan S, Dondanville KA, Nakase-Richardson R, Mintz J, Keane TM, Peterson AL, Resick PA, Taylor DJ. Sleep disorder symptoms are associated with greater posttraumatic stress and anger symptoms in U.S. army service members seeking treatment for PTSD. J Clin Sleep Med 2022; 18:1617-1627. [PMID: 35197191 DOI: 10.5664/jcsm.9926] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Characterize associations between sleep impairments and posttraumatic stress disorder (PTSD) symptoms, including anger, in service members seeking treatment for PTSD. METHODS Ninety-three US Army personnel recruited into a PTSD treatment study completed the baseline assessment. State of the science sleep measurements included (1) retrospective, self-reported insomnia, (2) prospective sleep diaries assessing sleep patterns and nightmares, and (3) polysomnography (PSG) measured sleep architecture and obstructive sleep apnea-hypopnea (OSAH) severity. Dependent variables included self-report measures of PTSD severity and anger severity. Pearson correlations and multiple linear regression analyses examined if sleep symptoms, not generally measured in PTSD populations, were associated with PTSD and anger severity. RESULTS All participants met PTSD, insomnia, and nightmare diagnostic criteria. Mean sleep efficiency = 70%, total sleep time = 5.5 hours, obstructive sleep apnea/hypopnea (OSAH index ≥ 5) = 53%, and clinically significant anger = 85%. PTSD severity was associated with insomnia severity (β =.58), nightmare severity (β = .24), nightmare frequency (β = .31), and time spent in Stage 1 sleep (β = .27, all p < .05). Anger severity was associated with insomnia severity (β =37), nightmare severity (β = .28), and OSAH during rapid eye movement (β = .31, all p < .05). CONCLUSIONS Insomnia and nightmares were related to PTSD and anger severity, and OSAH was related to anger. Better assessment and evidence-based treatment of these comorbid sleep impairments in service members with PTSD and significant anger, should result in better PTSD, anger, and quality of life outcomes. CLINICAL TRIALS REGISTRATION Registry: ClinicalTrials.gov; Name: Treatment of Comorbid Sleep Disorders and Post Traumatic Stress Disorder; Identifier: NCT02773693; URL: https://clinicaltrials.gov/ct2/show/NCT02773693.
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Affiliation(s)
- Shannon R Miles
- James A. Haley Veterans' Hospital, Tampa, FL.,Division of Psychiatry & Behavioral Sciences, Morsani College of Medicine, University of South Florida, Tampa, FL
| | - Kristi E Pruiksma
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX.,Research and Development Service, South Texas Veterans Health Care System, San Antonio, TX
| | - Danica Slavish
- Department of Psychology, University of North Texas, Denton, TX
| | - Jessica R Dietch
- School of Psychological Science, Oregon State University, Corvallis, OR
| | | | - Brett T Litz
- Massachusetts Veterans Epidemiological Research and Information Center, VA Boston Healthcare System, Boston, MA.,Department of Psychiatry, Boston University School of Medicine, Boston, MA.,Department of Psychological and Brain Sciences, Boston University, Boston, MA
| | | | | | - Stacey Young-McCaughan
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX.,Research and Development Service, South Texas Veterans Health Care System, San Antonio, TX
| | - Katherine A Dondanville
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Risa Nakase-Richardson
- James A. Haley Veterans' Hospital, Tampa, FL.,Division of Pulmonary and Sleep Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL
| | - Jim Mintz
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX.,Research and Development Service, South Texas Veterans Health Care System, San Antonio, TX
| | - Terence M Keane
- Department of Psychiatry, Boston University School of Medicine, Boston, MA.,Behavioral Science Division, National Center for PTSD at VA Boston Healthcare System, Boston, MA
| | - Alan L Peterson
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX.,Research and Development Service, South Texas Veterans Health Care System, San Antonio, TX.,Department of Psychology, University of Texas at San Antonio, San Antonio, TX
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Miles SR, Silva MA, Lang B, Hoffman JM, Venkatesan UM, Sevigny M, Nakase-Richardson R. Sleep apnea and posttraumatic stress after traumatic brain injury (TBI): A Veterans Affairs TBI Model Systems study. Rehabil Psychol 2021; 66:450-460. [PMID: 34871026 DOI: 10.1037/rep0000389] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Traumatic brain injury (TBI) is a complex health problem in military veterans and service members (V/SM) that often co-occurs with psychological and medical conditions such as posttraumatic stress disorder (PTSD) and sleep apnea. We aimed to examine if sleep apnea is associated with the presence and severity of PTSD in V/SM with TBI of all severities. RESEARCH METHOD The study examined participants at varying times since their TBI (N = 602) enrolled in the Veterans Affairs TBI Model Systems database. Frequency of self-reported sleep apnea diagnosis was calculated in a cross-sectional sample. Prevalence of co-occurring sleep apnea and probable PTSD was tested with a chi-square analysis. A multivariable regression model evaluated the association between sleep apnea and PTSD symptom severity while controlling for relevant covariates. RESULTS Almost 32% of the sample stated they had been diagnosed with sleep apnea. In those reporting sleep apnea, 32% also had probable PTSD; 19% of those without sleep apnea had probable PTSD. The regression demonstrated sleep apnea was significantly associated with PTSD symptom severity (p < .001). Greater number of TBIs, recent mental health treatment, being deployed to a combat zone, and greater years since TBI were also significant predictors of PTSD symptom severity (all p < .05). CONCLUSIONS TBI, PTSD, and sleep apnea are often comorbid in V/SM. We expand the literature by demonstrating that sleep apnea was associated with PTSD severity. A multipronged approach to TBI rehabilitation that addresses sleep and psychological distress is recommended for enhancing health outcomes in this population. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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Moberg J, Royer A, Brennan E, Nakase-Richardson R. Outcomes of the Suicidal Ideation Assessment Protocol Decision Tree Responses from the Tampa VA TBI Model Systems Research Study. Arch Phys Med Rehabil 2021. [DOI: 10.1016/j.apmr.2021.07.640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Cotner B, O'Connor D, Nakase-Richardson R, Scott S, Hoffman J. Facilitators and Barriers to Non-Pharmacologic Chronic Pain Treatment for Service Members and Veterans with Traumatic Brain Injury. Arch Phys Med Rehabil 2021. [DOI: 10.1016/j.apmr.2021.07.674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Martin AM, Almeida EJ, Starosta AJ, Hammond FM, Hoffman JM, Schwartz DJ, Fann JR, Bell KR, Nakase-Richardson R. The Impact of Opioid Medications on Sleep Architecture and Nocturnal Respiration During Acute Recovery From Moderate to Severe Traumatic Brain Injury: A TBI Model Systems Study. J Head Trauma Rehabil 2021; 36:374-387. [PMID: 34489388 DOI: 10.1097/htr.0000000000000727] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To describe patient and clinical characteristics associated with receipt of opioid medications and identify differences in sleep quality, architecture, and sleep-related respiration between those receiving and not receiving opioid medications. SETTING Acute inpatient rehabilitation care for moderate to severe traumatic brain injury (TBI). PARTICIPANTS A total of 248 consecutive admissions for inpatient rehabilitation care following moderate to severe TBI (average age of 43.6 years), who underwent level 1 polysomnography (PSG) (average time since injury: 120 days) across 6 sites. DESIGN Cross-sectional, secondary analyses. MAIN MEASURES The PSG sleep parameters included total sleep time (TST), sleep efficiency (SE), wake after sleep onset, rapid eye movement (REM) latency, sleep staging, and arousal and awakening indices. Respiratory measures included oxygen saturation, central apnea events per hour, obstructive apnea and hypopnea events per hour, and total apnea-hypopnea index. RESULTS After adjustment for number of prescribed medication classes, those receiving opioid medications on the day of PSG experienced increased TST relative to those not receiving opioid medications (estimated mean difference [EMD] = 31.58; 95% confidence interval [CI], 1.9-61.3). Other indices of sleep did not differ significantly between groups. Among respiratory measures those receiving opioids on the day of PSG experienced increased frequency of central sleep apnea events during total (EMD = 2.92; 95% CI, 0.8-5.0) and non-REM sleep (EMD = 3.37; 95% CI, 1.0-5.7) and higher frequency of obstructive sleep apnea events during REM sleep (EMD = 6.97; 95% CI, 0.1-13.8). Compared with those who did not, receiving opioids was associated with lower oxygen saturation nadir during total sleep (EMD = -3.03; 95% CI, -5.6 to -0.4) and a greater number of oxygen desaturations across REM (EMD = 8.15; 95% CI, 0.2-16.1), non-REM (EMD = 7.30; 95% CI, 0.3-14.4), and total sleep (EMD = 8.01; 95% CI, 0.8-15.2) Greater total apnea-hypopnea index was observed during REM (EMD = 8.13; 95% CI, 0.8-15.5) and total sleep (EMD = 7.26; 95% CI, 0.08-14.4) for those receiving opioids. CONCLUSION Opioid use following moderate to severe TBI is associated with an increase in indicators of sleep-related breathing disorders, a modifiable condition that is prevalent following TBI. As sleep-wake disorders are associated with poorer rehabilitation outcomes and opioid medications may frequently be administered following traumatic injury, additional longitudinal investigations are warranted in determining whether a causal relation between opioids and sleep-disordered breathing in those following moderate to severe TBI exists. Given current study limitations, future studies can improve upon methodology through the inclusion of indication for and dosage of opioid medications in this population when examining these associations.
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Affiliation(s)
- Aaron M Martin
- Mental Health & Behavioral Sciences Service (MHBSS), James A. Haley Veterans' Hospital, Tampa, Florida (Drs Martin and Richardson); Departments of Psychiatry and Behavioral Neurosciences (Dr Martin) and Internal Medicine, Division of Pulmonary and Sleep Medicine (Drs Richardson and Schwartz), University of South Florida, Tampa; Defense Health Agency Traumatic Brain Injury Center of Excellence at James A. Haley Veterans Hospital, Tampa, Florida (Dr Richardson); Research Department, Craig Hospital, Englewood, Colorado (Ms Almeida); Department of Rehabilitation Medicine, Division of Rehabilitation Psychology, University of Washington School of Medicine, Seattle (Drs Starosta and Hoffman); Department of Physical Medicine & Rehabilitation, Indiana University, Indianapolis (Dr Hammond); Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle (Dr Fann); and Department of Physical Medicine and Rehabilitation, University of Texas Southwestern Medical Center, Dallas (Dr Bell)
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Adams RS, Ketchum JM, Nakase-Richardson R, Katz DI, Corrigan JD. Prevalence of Drinking Within Low-Risk Guidelines During the First 2 Years After Inpatient Rehabilitation for Moderate or Severe Traumatic Brain Injury. Am J Phys Med Rehabil 2021; 100:815-819. [PMID: 33782273 PMCID: PMC9344375 DOI: 10.1097/phm.0000000000001753] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT The objective of this retrospective, longitudinal study was to investigate the prevalence of drinking within the recommended limits (i.e., low-risk drinking) after moderate/severe traumatic brain injury (TBI). Data were drawn from the National Institute on Disability, Independent Living, and Rehabilitation Research TBI Model Systems National Database, a longitudinal dataset closely representative of the US adult population requiring inpatient rehabilitation for TBI. The sample included 6348 adults with moderate or severe TBI (injured October 2006-May 2016) who received inpatient rehabilitation at a civilian TBI Model Systems center and completed the alcohol consumption items preinjury and 1 and 2 yrs postinjury. National Institute on Alcohol Abuse and Alcoholism guidelines define low-risk drinking as no more than 4 drinks per day for men or 3 drinks per day for women and no more than 14 drinks per week for men or no more than 7 drinks per week for women. Low-risk drinking was common both before and after TBI, with more than 30% drinking in the low-risk level preinjury and more than 25% at 1 and 2 yrs postinjury. Postinjury, most drinkers consumed alcohol in the low-risk level regardless of preinjury drinking level. Definitive research on the long-term outcomes of low-risk alcohol consumption after more severe TBI should be a high priority.
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Affiliation(s)
- Rachel Sayko Adams
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, Waltham, MA
- Veterans Health Administration, Rocky Mountain Mental Illness Research Education and Clinical Center, 1700 N Wheeling Street, Aurora, CO, 80045
| | - Jessica McKinney Ketchum
- Traumatic Brain Injury Model Systems, National Data and Statistical Center, Craig Hospital, Englewood, CO
| | | | - Douglas I. Katz
- Department of Neurology, Boston University School of Medicine, Boston, MA
| | - John D. Corrigan
- Department of Physical Medicine & Rehabilitation, Wexner Medical Center, The Ohio State University, Columbus, OH
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Miles SR, Silva MA, Neumann D, Dillahunt-Aspillaga C, Corrigan JD, Tang X, Eapen BC, Nakase-Richardson R. Demographic and Mental Health Predictors of Arrests Up to 10 Years Post-Traumatic Brain Injury: A Veterans Affairs TBI Model Systems Study. J Head Trauma Rehabil 2021; 36:E240-E248. [PMID: 33528175 DOI: 10.1097/htr.0000000000000640] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Examine rates and predictors of arrests in Veterans and Service Members (V/SM) who received inpatient rehabilitation for traumatic brain injury (TBI). SETTING Veterans Administration (VA) Polytrauma Rehabilitation Centers. PARTICIPANTS A total of 948 V/SM drawn from the VA TBI Model Systems cohort with arrest data up to 10 years post-TBI. DESIGN Longitudinal cohort study; secondary analysis of pre-TBI characteristics predicting post-TBI arrests. MAIN MEASURES Disclosure of arrests pre-TBI and up to10 years post-TBI. RESULTS Thirty-six percent of the sample had been arrested prior to their TBI; 7% were arrested post-TBI. When considering all variables simultaneously in a multivariate model, pre-TBI mental health treatment (adjusted odds ratio [aOR] = 4.30; 95% confidence interval [CI]: 2.03-9.14), pre-TBI heavy alcohol use (aOR = 3.04; CI: 1.08-8.55), and number of follow-up interviews (aOR = 2.05; CI: 1.39-4.50) were significant predictors of post-TBI arrest. CONCLUSION Arrest rates of V/SM prior to TBI were consistent with rates of arrest for people of similar ages in the United States. Post-TBI rates were lower for V/SM than published rates of post-TBI arrests in civilians with TBI. As part of rehabilitation planning for V/SM with TBI, providers should assess for preinjury mental health services and alcohol misuse to (1) identify those who may be at risk for postinjury arrests and (2) provide relevant resources and/or supports.
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Affiliation(s)
- Shannon R Miles
- Mental Health and Behavioral Sciences, James A. Haley Veterans' Hospital, Tampa, Florida (Drs Miles, Silva, and Nakase-Richardson); Department of Psychiatry & Behavioral Neurosciences, University of South Florida, Tampa, Florida (Drs Miles and Silva); Department of Internal Medicine, Division of Pulmonary and Sleep Medicine, University of South Florida, Tampa, Florida (Drs Silva and Nakase-Richardson); Defense and Veterans Brain Injury Center, James A. Haley Veterans' Hospital, Tampa, Florida (Drs Silva and Nakase-Richardson); Department of Psychology, University of South Florida, Tampa, Florida (Dr Silva); Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Indianapolis, Indiana (Dr Neumann); Rehabilitation Hospital of Indiana, Indianapolis, Indiana (Dr Neumann); Rehabilitation & Mental Health Counseling Program, Department of Child & Family Studies, University of South Florida, Tampa, Florida (Dr Dillahunt-Aspillaga); Research Service, James A. Haley Veterans' Hospital, Tampa, Florida (Dr Dillahunt-Aspillaga); Department of Physical Medicine and Rehabilitation, The Ohio State University, Columbus, Ohio (Dr Corrigan); Tampa VA Research and Education Foundation, Inc, Tampa, Florida (Dr Tang); Department of Physical Medicine and Rehabilitation, VA Greater Los Angeles Health Care System, Los Angeles, California (Dr Eapen); and David Geffen School of Medicine at UCLA, Los Angeles, California (Dr Eapen)
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Werner JK, Shahim P, Pucci JU, Lai C, Raiciulescu S, Gill JM, Nakase-Richardson R, Diaz-Arrastia R, Kenney K. Poor sleep correlates with biomarkers of neurodegeneration in mild traumatic brain injury patients: a CENC study. Sleep 2021; 44:6024975. [PMID: 33280032 DOI: 10.1093/sleep/zsaa272] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 11/19/2020] [Indexed: 01/24/2023] Open
Abstract
STUDY OBJECTIVES Sleep disorders affect over half of mild traumatic brain injury (mTBI) patients. Despite evidence linking sleep and neurodegeneration, longitudinal TBI-related dementia studies have not considered sleep. We hypothesized that poor sleepers with mTBI would have elevated markers of neurodegeneration and lower cognitive function compared to mTBI good sleepers and controls. Our objective was to compare biomarkers of neurodegeneration and cognitive function with sleep quality in warfighters with chronic mTBI. METHODS In an observational warfighters cohort (n = 138 mTBI, 44 controls), the Pittsburgh Sleep Quality Index (PSQI) was compared with plasma biomarkers of neurodegeneration and cognitive scores collected an average of 8 years after injury. RESULTS In the mTBI cohort, poor sleepers (PSQI ≥ 10, n = 86) had elevated plasma neurofilament light (NfL, x̅ = 11.86 vs 7.91 pg/mL, p = 0.0007, d = 0.63) and lower executive function scores by the categorical fluency (x̅ = 18.0 vs 21.0, p = 0.0005, d = -0.65) and stop-go tests (x̅ = 30.1 vs 31.1, p = 0.024, d = -0.37). These findings were not observed in controls (n = 44). PSQI predicted NfL (beta = 0.22, p = 0.00002) and tau (beta = 0.14, p = 0.007), but not amyloid β42. Poor sleepers showed higher obstructive sleep apnea (OSA) risk by STOP-BANG scores (x̅ = 3.8 vs 2.7, p = 0.0005), raising the possibility that the PSQI might be partly secondary to OSA. CONCLUSIONS Poor sleep is linked to neurodegeneration and select measures of executive function in mTBI patients. This supports implementation of validated sleep measures in longitudinal studies investigating pathobiological mechanisms of TBI related neurodegeneration, which could have therapeutic implications.
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Affiliation(s)
- J Kent Werner
- Department of Neurology, Uniformed Services University of Health Sciences, Bethesda, MD.,Center for Neuroscience and Regenerative Medicine, Bethesda, MD
| | - Pashtun Shahim
- National Institutes of Health, Bethesda, MD.,Center for Neuroscience and Regenerative Medicine, Bethesda, MD
| | - Josephine U Pucci
- Department of Neurology, Uniformed Services University of Health Sciences, Bethesda, MD
| | - Chen Lai
- National Institutes of Health, Bethesda, MD
| | - Sorana Raiciulescu
- Department of Neurology, Uniformed Services University of Health Sciences, Bethesda, MD
| | | | - Risa Nakase-Richardson
- Department of Internal Medicine, Sleep and Pulmonary Division, University of South Florida, Tampa, FL.,Defense and Veterans Brain Injury Center, Tampa, FL.,James A. Haley Veterans Hospital, Tampa, FL
| | | | - Kimbra Kenney
- Department of Neurology, Uniformed Services University of Health Sciences, Bethesda, MD
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Garcia A, Wilde EA, Tate D, Reljic T, Kenney K, Troyanskaya M, Agyemang A, Walker WC, Nakase-Richardson R. 787 OSA Risk is Associated with Number of White Matter Hyperintensities, But History of Mild TBI is Not: A LIMBIC-CENC Study. Sleep 2021. [DOI: 10.1093/sleep/zsab072.784] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
Individuals with a history of mild traumatic brain injury (mTBI) have higher risk levels for obstructive sleep apnea (OSA). However, no studies have examined the association between OSA and white matter hyperintensities (WMHs) in this group. The purpose of this study is to explore the relationship between OSA risk, mTBI, and WMHs in a military cohort with a history of combat deployment.
Methods
Secondary analyses were conducted from a large clinical database of a multi-center, longitudinal study of current and former military personnel. Participants were included who had complete STOPBANG (sleep apnea risk) data and MRI. Univariable and multivariable regressions were conducted, including age, race, gender, education, hypertension, diabetes, history of mTBI, and STOPBANG score in the models.
Results
The final sample (N=1017) included participants with (n=823) and without (n=194) a history of mTBI. The sample was predominantly male (87%) with a median age of 38 (IQR; 32–48). WMHs were reported in 37% of the sample. Univariate analyses revealed that increasing age, female sex, hypertension, diabetes, and higher sleep apnea risk score were each positively associated with higher number of WMHs, while a history of lifetime mTBI exposure was not associated. Multivariable analyses revealed that of these factors, only age remained associated with WMH presence. When restricting the sample to the 37% with WMHs, OSA risk and female sex were each associated with higher number of WMHs (p<.05), but history of mTBI was not.
Conclusion
Consistent with the literature in non-brain injured populations, age was the strongest predictor of WMH presence and number. In those with identified WMHs, OSA risk was a significant predictor of WMH number, while history of mTBI was not. Thus, in persons with mTBI, presence of WMHs may be linked to sleep comorbidities, providing potential treatment targets. Limitations include assessment of OSA rather than established diagnosis.
Support (if any)
Defense and Veterans Brain Injury Center (HT0014-19-C-004), DOD(W81XWH-13-2-0095), VA(I01 CX001135). The views expressed in this abstract are those of the authors and do not necessarily represent the official policy or position of the Defense Health Agency, Department of Defense, or any other U.S. government agency. For more information, please contact dha.TBICoEinfo@mail.mil. UNCLASSIFIED
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Affiliation(s)
- Amanda Garcia
- Traumatic Brain Injury Center of Excellence (TBICoE)
| | | | | | | | - Kimbra Kenney
- Uniformed Services University of the Health Sciences
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Matarese C, Nakase-Richardson R, Almeida E, Whyte J, Nallu S, Anderson W, Schwartz D, Kieffer K. 788 Is Dysphagia a Marker for Obstructive Sleep Apnea (OSA) in Traumatic Brain Injury (TBI) Patients: A VA TBI Model System Study. Sleep 2021. [DOI: 10.1093/sleep/zsab072.785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
Recent work has highlighted prevalent obstructive not central sleep apnea following traumatic brain injury (TBI). Treatment of comorbid OSA may facilitate neurologic recovery but widespread screening is limited. Mixed support exists for the presence of dysphagia as a biomarker of OSA in the general population and stroke patients. Dysphagia is common following TBI; however, no study has examined the relation between OSA and dysphagia in this cohort. Leveraging data from a recent six-center clinical trial of OSA and TBI during inpatient rehabilitation, this secondary analysis examined the association between OSA severity indices and proxy measures of dysphagia.
Methods
Level 1 polysomnography (PSG) was used to assess OSA (AHI ≥ 5 and ≥ 15) during inpatient rehabilitation for the overall sample (N=248; 203 male; 60.6% severe injury) evaluated at a median of 120.6 days post-TBI and subset ≤ 60 days post-injury. Dysphagia was approximated as the presence of a PEG tube and/or a modified texture diet (MTD) on the day of PSG. Chi square and Fisher’s Exact tests were utilized for group comparisons.
Results
As previously reported, OSA in this cohort was prevalent (68.2% (n=169) at AHI ≥ 5 and 33.5% (n=83) AHI ≥ 15) with predominantly obstructive events. 27.4% (n=68) met criteria for dysphagia combining proxy measures (34 peg; 49 MTD). No significant difference was found for presence of dysphagia across OSA severity cutoffs (AHI ≥ 5 & 15; p=0.1029 & 0.5959). When examining OSA across the individual proxy measures, persons without a peg tube were significantly more likely to have OSA at AHI ≥ 5 (62.5% vs 5.65%; p=0.0003) and AHI ≥ 15 (31.05% vs 2.42%; p=0.0353). When examining participants less than 60 days post-TBI, the group differences remained.
Conclusion
The incidence of dysphagia in TBI patients, as indexed by a modified diet or presence of a feeding tube, was not elevated in those with OSA. Sample bias (for undergoing Level 1 PSG and improvement facilitating inpatient rehabilitation admission) may have contributed to findings. Finally, future work with more sensitive indices of dysphagia is needed to accurately evaluate this association.
Support (if any)
PCORI (CER-1511–33005), NIIDLRR (90DPTB0004)
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Cotner B, Nakase-Richardson R, Gius B, Fournier L, Watach A, Hoffman J. 806 Barriers to screening and diagnosis of obstructive sleep apnea during inpatient traumatic brain injury rehabilitation. Sleep 2021. [DOI: 10.1093/sleep/zsab072.803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Introduction
Obstructive Sleep Apnea (OSA) is prevalent after moderate to severe traumatic brain injury (TBI) and may diminish recovery when left untreated. Despite the demonstrated importance of treating OSA following TBI, assessment for OSA during or soon after inpatient rehabilitation for TBI is limited. Little is known about barriers to implementing OSA screening and early diagnosis during inpatient rehabilitation thus hindering the translation of evidence-based OSA assessment procedures into clinical practice and potentially delaying necessary OSA treatment. The current analysis explored facilitators and barriers to implementing OSA screening tools in an inpatient rehabilitation setting from the perspectives of end user stakeholders.
Methods
Patients, families, industry, clinical providers and administrators participated in a two-day meeting following completion of a diagnostic clinical trial of OSA screening and diagnostic tools during inpatient rehabilitation. Stakeholders were provided with open ended questions generated by study investigators and given the opportunity to respond on paper or a “graffiti wall” (i.e., white board). Example questions include “What are the greatest needs of the healthcare system related to sleep apnea and TBI?” and “What are the key things we need to consider to move results into real-world practice?” Qualitative content analyses using a rapid matrix approach were conducted from stakeholder feedback obtained during the two-day meeting, which included a guided review of emerging OSA research and discussion of potential implementation barriers of OSA assessment during inpatient rehabilitation.
Results
Improved screening and treatment practices for OSA were the greatest needs identified. To meet these needs, stakeholders identified the importance of improving patient, family, and staff understanding of OSA (e.g., health literacy) and other sleep disorders through education; inpatient rehabilitation access to resources (technology; sleep providers); and reimbursement for additional inpatient procedures.
Conclusion
Although treatment of OSA is crucial for recovery during inpatient rehabilitation following TBI, barriers to earlier recognition, diagnosis, and treatment of OSA exists across several different domains, including education, resources, and funding policies. Findings support future implementation efforts to translate evidence-based care into practice to improve patient outcomes.
Support (if any)
PCORI-NCT03033901
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Mahoney EJ, Silva MA, Reljic T, Dams-O'Connor K, Hammond FM, Monden KR, Chung JS, Dillahunt-Aspillaga C, Nakase-Richardson R. Rehabilitation Needs at 5 Years Post-Traumatic Brain Injury: A VA TBI Model Systems Study. J Head Trauma Rehabil 2021; 36:175-185. [PMID: 33201036 DOI: 10.1097/htr.0000000000000629] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Describe rehabilitation needs and factors associated with unmet needs at 5 years post-traumatic brain injury (TBI). SETTING Five Veterans Affairs (VA) polytrauma rehabilitation centers (PRCs). PARTICIPANTS VA TBI Model Systems participants (N = 283; 96% male, 75%, 57% severe TBI). DESIGN Prospective observational cohort. MAIN MEASURES Rehabilitation Needs Survey (21-item survey that assesses cognitive, emotional, social, and functional needs); Craig Hospital Inventory of Environmental Factors (25-item survey of potential environmental barriers). RESULTS Participants endorsed a mean of 8 (SD: 6.2) ongoing and 3 (SD: 4.7) unmet rehabilitation needs at 5 years post-TBI. Approximately 65% of participants reported at least 1 rehabilitation need that remained unmet. The number and nature of needs differed across TBI severity groups. In unadjusted and adjusted linear regression models, Black race and environmental barriers (Craig Hospital Inventory of Environmental Factors total score) were predictive of unmet needs (P < .001). Those with greater unmet needs reported the physical environment (54%-63%), informational sources (54%), social attitudes (55%), healthcare access (40%), public policy (32%-37%), transportation availability (33%), and in-home assistance (32%) as the most frequent environmental barriers at 5 years post-TBI. CONCLUSION Veterans and Service Members continue to have rehabilitation needs at 5 years post-TBI. Veterans Affairs programs to address ongoing needs and policy to support them are needed.
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Affiliation(s)
- Elaine J Mahoney
- Mental Health and Behavioral Sciences (MHBS) (Drs Mahoney, Silva, and Nakase-Richardson) and Defense and Veterans Brain Injury Center (DVBIC) (Drs Silva and Nakase-Richardson), James A. Haley Veterans' Hospital, Tampa, Florida; Departments of Psychiatry and Behavioral Neurosciences (Dr Silva), Psychology (Dr Silva), Child & Family Studies (Dr Dillahunt-Aspillaga), and Internal Medicine, Division of Pulmonary and Sleep Medicine (Dr Nakase-Richardson), University of South Florida, Tampa; Morsani College of Medicine, University of South Florida, Tampa (Ms Reljic); Departments of Rehabilitation Medicine (Dr Dams-O'Connor) and Neurology (Dr Dams-O'Connor), Icahn School of Medicine at Mount Sinai, New York, New York; Department of Physical Medicine & Rehabilitation, Indiana University School of Medicine, Indianapolis (Dr Hammond); Rehabilitation Hospital of Indiana, Indianapolis (Dr Hammond); Research Department, Craig Hospital, Englewood, Colorado (Dr Monden); Department of Rehabilitation Medicine, University of Minnesota, Minneapolis (Dr Monden); VA Palo Alto Health Care System, Palo Alto, California (Dr Chung); and Research Service, James A. Haley Veterans' Hospital, Tampa, Florida (Dr Dillahunt-Aspillaga)
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50
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Kowalski RG, Hammond FM, Weintraub AH, Nakase-Richardson R, Zafonte RD, Whyte J, Giacino JT. Recovery of Consciousness and Functional Outcome in Moderate and Severe Traumatic Brain Injury. JAMA Neurol 2021; 78:548-557. [PMID: 33646273 DOI: 10.1001/jamaneurol.2021.0084] [Citation(s) in RCA: 63] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Importance Traumatic brain injury (TBI) leads to 2.9 million visits to US emergency departments annually and frequently involves a disorder of consciousness (DOC). Early treatment, including withdrawal of life-sustaining therapies and rehabilitation, is often predicated on the assumed worse outcome of disrupted consciousness. Objective To quantify the loss of consciousness, factors associated with recovery, and return to functional independence in a 31-year sample of patients with moderate or severe brain trauma. Design, Setting, and Participants This cohort study analyzed patients with TBI who were enrolled in the Traumatic Brain Injury Model Systems National Database, a prospective, multiyear, longitudinal database. Patients were survivors of moderate or severe TBI who were discharged from acute hospitalization and admitted to inpatient rehabilitation from January 4, 1989, to June 19, 2019, at 1 of 23 inpatient rehabilitation centers that participated in the Traumatic Brain Injury Model Systems program. Follow-up for the study was through completion of inpatient rehabilitation. Exposures Traumatic brain injury. Main Outcomes and Measures Outcome measures were Glasgow Coma Scale in the emergency department, Disability Rating Scale, posttraumatic amnesia, and Functional Independence Measure. Patient-related data included demographic characteristics, injury cause, and brain computed tomography findings. Results The 17 470 patients with TBI analyzed in this study had a median (interquartile range [IQR]) age at injury of 39 (25-56) years and included 12 854 male individuals (74%). Of these patients, 7547 (57%) experienced initial loss of consciousness, which persisted to rehabilitation in 2058 patients (12%). Those with persisting DOC were younger; had more high-velocity injuries; had intracranial mass effect, intraventricular hemorrhage, and subcortical contusion; and had longer acute care than patients without DOC. Eighty-two percent (n = 1674) of comatose patients recovered consciousness during inpatient rehabilitation. In a multivariable analysis, the factors associated with consciousness recovery were absence of intraventricular hemorrhage (adjusted odds ratio [OR], 0.678; 95% CI, 0.532-0.863; P = .002) and intracranial mass effect (adjusted OR, 0.759; 95% CI, 0.595-0.968; P = .03). Functional improvement (change in total functional independence score from admission to discharge) was +43 for patients with DOC and +37 for those without DOC (P = .002), and 803 of 2013 patients with DOC (40%) became partially or fully independent. Younger age, male sex, and absence of intraventricular hemorrhage, intracranial mass effect, and subcortical contusion were associated with better functional outcome. Findings were consistent across the 3 decades of the database. Conclusions and Relevance This study found that DOC occurred initially in most patients with TBI and persisted in some patients after rehabilitation, but most patients with persisting DOC recovered consciousness during rehabilitation. This recovery trajectory may inform acute and rehabilitation treatment decisions and suggests caution is warranted in consideration of withdrawing or withholding care in patients with TBI and DOC.
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Affiliation(s)
- Robert G Kowalski
- Department of Neurology, University of Colorado School of Medicine, Aurora.,Research Department, Craig Hospital, Englewood, Colorado
| | - Flora M Hammond
- Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Indianapolis
| | - Alan H Weintraub
- Research Department, Craig Hospital, Englewood, Colorado.,CNS Medical Group, Englewood, Colorado
| | - Risa Nakase-Richardson
- Mental Health and Behavioral Sciences, James A. Haley Veterans Hospital, Tampa, Florida.,Sleep Medicine Division, Department of Internal Medicine, University of South Florida, Tampa
| | - Ross D Zafonte
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital and Harvard Medical School, Boston
| | - John Whyte
- Moss Rehabilitation Research Institute, Elkins Park, Pennsylvania
| | - Joseph T Giacino
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital and Harvard Medical School, Boston
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