Computer-based cognitive rehabilitation research in a military treatment facility: Recruitment, compliance, and lessons learned

BACKGROUND

Evidence-based approaches to cognitive rehabilitation are limited; however, new technologies such as brain-training computer programs provide opportunities for novel interventions.

OBJECTIVE

This paper describes a randomized controlled training study in a military treatment facility with service members who had combat-related cognitive symptoms. It examines challenges in study design and implementation, and provides "lessons learned" with proposed solutions.

METHODS

Participants were randomly assigned to one of two 6-week computer-based cognitive training (CBCT) programs or a treatment-as-usual (TAU) control group. Feasibility assessments included reasons for consent refusal, compliance, and drop-out rates.

RESULTS

The intended sample size for the study was 114 participants before attrition. Of 291 patients referred over 2.5 years, 120 were eligible, 38 consented to participate, and 18 completed the study. Forty-two percent of the participants assigned to CBCT groups completed the required 30 sessions in 6.5 to 32 weeks. Study-design factors that affected enrollment and compliance included eligibility restrictions, lack of a computer-based control condition, and inflexible scheduling.

CONCLUSIONS

Successful implementation of a high-dose computer-based clinical trial will require design changes such as expanded inclusion criteria, control by sham computer program or wait-list, dosing flexibility, and web-based options.

A multisite study of the relationships between blast exposures and symptom reporting in a post-deployment active duty military population with mild traumatic brain injury

Explosive devices have been the most frequent cause of traumatic brain injury (TBI) among deployed contemporary U.S. service members. The purpose of this study was to examine the influence of previous cumulative blast exposures (that did or did not result in TBI) on later post-concussion and post-traumatic symptom reporting after sustaining a mild TBI (MTBI). Participants were 573 service members who sustained MTBI divided into four groups by number of blast exposures (1, 2, 3, and 4-10) and a nonblast control group. Post-concussion symptoms were measured using the Neurobehavioral Symptom Inventory (NSI) and post-traumatic stress disorder (PTSD) symptoms using the Post-traumatic Checklist-Civilian version (PCL-C). Results show groups significantly differed on total NSI scores (p<0.001), where symptom endorsement increased as number of reported blast exposures increased. Total NSI scores were significantly higher for the 3- and 4-10 blast groups compared with the 1- and 2-blast groups with effect sizes ranging from small to moderate (d=0.31 to 0.63). After controlling for PTSD symptoms using the PCL-C total score, NSI total score differences remained between the 4-10-blast group and the 1- and 2-blast groups, but were less pronounced (d=0.35 and d=0.24, respectively). Analyses of NSI subscale scores using PCL-C scores as a covariate revealed significant between-blast group differences on cognitive, sensory, and somatic, but not affective symptoms. Regression analyses revealed that cumulative blast exposures accounted for a small but significant amount of the variance in total NSI scores (4.8%; p=0.009) and total PCL-C scores (2.3%; p<0.001). Among service members exposed to blast, post-concussion symptom reporting increased as a function of cumulative blast exposures. Future research will need to determine the relationship between cumulative blast exposures, symptom reporting, and neuropathological changes.

Military personnel with chronic symptoms following blast traumatic brain injury have differential expression of neuronal recovery and epidermal growth factor receptor genes

Objective: Approximately one-quarter of military personnel who deployed to combat stations sustained one or more blast-related, closed-head injuries. Blast injuries result from the detonation of an explosive device. The mechanisms associated with blast exposure that give rise to traumatic brain injury (TBI), and place military personnel at high risk for chronic symptoms of post-concussive disorder (PCD), post-traumatic stress disorder (PTSD), and depression are not elucidated.

Methods: To investigate the mechanisms of persistent blast-related symptoms, we examined expression profiles of transcripts across the genome to determine the role of gene activity in chronic symptoms following blast-TBI. Active duty military personnel with (1) a medical record of a blast-TBI that occurred during deployment (n = 19) were compared to control participants without TBI (n = 17). Controls were matched to cases on demographic factors including age, gender, and race, and also in diagnoses of sleep disturbance, and symptoms of PTSD and depression. Due to the high number of PCD symptoms in the TBI+ group, we did not match on this variable. Using expression profiles of transcripts in microarray platform in peripheral samples of whole blood, significantly differentially expressed gene lists were generated. Statistical threshold is based on criteria of 1.5 magnitude fold-change (up or down) and p-values with multiple test correction (false discovery rate <0.05).

Results: There were 34 transcripts in 29 genes that were differentially regulated in blast-TBI participants compared to controls. Up-regulated genes included epithelial cell transforming sequence and zinc finger proteins, which are necessary for astrocyte differentiation following injury. Tensin-1, which has been implicated in neuronal recovery in pre-clinical TBI models, was down-regulated in blast-TBI participants. Protein ubiquitination genes, such as epidermal growth factor receptor, were also down-regulated and identified as the central regulators in the gene network determined by interaction pathway analysis.

Conclusion: In this study, we identified a gene-expression pathway of delayed neuronal recovery in military personnel a blast-TBI and chronic symptoms. Future work is needed to determine if therapeutic agents that regulate these pathways may provide novel treatments for chronic blast-TBI-related symptoms.

Influence of the severity and location of bodily injuries on post-concussive and combat stress symptom reporting after military-related concurrent mild traumatic brain injuries and polytrauma

Traumatic brain injuries (TBI) sustained in combat frequently co-occur with significant bodily injuries. Intuitively, more extensive bodily injuries might be associated with increased symptom reporting. In 2012, however, French et al. demonstrated an inverse relation between bodily injury severity and symptom reporting. This study expands on that work by examining the influence of location and severity of bodily injuries on symptom reporting after mild TBI. Participants were 579 US military service members who sustained an uncomplicated mild TBI with concurrent bodily injuries and who were evaluated at two military medical centers. Bodily injury severity was quantified using a modified Injury Severity Score (ISSmod). Participants completed the Neurobehavioral Symptom Inventory (NSI) and the Posttraumatic Stress Disorder Checklist (PCL-C), on average, 2.5 months post-injury. There was a significant negative association between ISSmod scores and NSI (r=-0.267, p<0.001) and PCL-C (r=-0.273, p<0.001) total scores. Using linear regression to examine the relation between symptom reporting and injury severity across the six ISS body regions, three body regions were significant predictors of the NSI total score (face; p<0.001; abdomen; p=0.003; extremities; p<0.001) and accounted for 9.3% of the variance (p<0.001). For the PCL-C, two body regions were significant predictors of the PCL-C total score (face; p<0.001; extremities; p<0.001) and accounted for 10.5% of the variance. There was an inverse relation between bodily injury severity and symptom reporting in this sample. Hypothesized explanations include underreporting of symptoms, increased peer support, disruption of fear conditioning because of acute morphine use, or delayed expression of symptoms.

Factors influencing postconcussion and posttraumatic stress symptom reporting following military-related concurrent polytrauma and traumatic brain injury

The purpose of this study was to identify factors that are predictive of, or associated with, high endorsement of postconcussion and posttraumatic stress symptoms following military-related traumatic brain injury (TBI). Participants were 1,600 U.S. service members (age: M = 27.1, SD = 7.1; 95.4% male) who had sustained a mild-to-moderate TBI and who had been evaluated by the Defense and Veterans Brain Injury Center at one of six military medical centers. Twenty-two factors were examined that included demographic, injury circumstances/severity, treatment/evaluation, and psychological/physical variables. Four factors were statistically and meaningfully associated with clinically elevated postconcussion symptoms: (i) low bodily injury severity, (ii) posttraumatic stress, (iii) depression, and (iv) military operation where wounded (p < .001, 43.2% variance). The combination of depression and posttraumatic stress symptoms accounted for the vast majority of unique variance (41.5%) and were strongly associated with, and predictive of, clinically elevated postconcussion symptoms [range: odds ratios (OR) = 4.24-7.75; relative risk (RR) = 2.28-2.51]. Five factors were statistically and meaningfully associated with clinically elevated posttraumatic stress symptoms: (i) low bodily injury severity, (ii) depression, (iii) a longer time from injury to evaluation, (iv) military operation where wounded, and (v) current auditory deficits (p < .001; 65.6% variance accounted for). Depression alone accounted for the vast majority of unique variance (60.0%) and was strongly associated with, and predictive of, clinically elevated posttraumatic stress symptoms (OR = 38.78; RR = 4.63). There was a very clear, strong, and clinically meaningful association between depression, posttraumatic stress, and postconcussion symptoms in this sample. Brain injury severity, however, was not associated with symptom reporting following TBI.

Postconcussional disorder and PTSD symptoms of military-related traumatic brain injury associated with compromised neurocircuitry

Traumatic brain injury (TBI) is a common combat injury, often through explosive blast, and produces heterogeneous brain changes due to various mechanisms of injury. It is unclear whether the vulnerability of white matter differs between blast and impact injury, and the consequences of microstructural changes on neuropsychological function are poorly understood in military TBI patients. Diffusion tensor imaging (DTI) techniques were used to assess the neurocircuitry in 37 U.S. service members (29 mild, 7 moderate, 1 severe; 17 blast and 20 nonblast), who sustained a TBI while deployed, compared to 14 nondeployed, military controls. High-dimensional deformable registration of MRI diffusion tensor data was followed by fiber tracking and tract-specific analysis along with region-of-interest analysis. DTI results were examined in relation to post-concussion and post-traumatic stress disorder (PTSD) symptoms. The most prominent white matter microstructural injury for both blast and nonblast patients was in the frontal fibers within the fronto-striatal (corona radiata, internal capsule) and fronto-limbic circuits (fornix, cingulum), the fronto-parieto-occipital association fibers, in brainstem fibers, and in callosal fibers. Subcortical superior-inferiorly oriented tracts were more vulnerable to blast injury than nonblast injury, while direct impact force had more detrimental effects on anterior-posteriorly oriented tracts, which tended to cause heterogeneous left and right hemispheric asymmetries of white matter connectivity. The tractography using diffusion anisotropy deficits revealed the cortico-striatal-thalamic-cerebellar-cortical (CSTCC) networks, where increased post-concussion and PTSD symptoms were associated with low fractional anisotropy in the major nodes of compromised CSTCC neurocircuitry, and the consequences on cognitive function were explored as well.

Perfusion deficits in patients with mild traumatic brain injury characterized by dynamic susceptibility contrast MRI

Perfusion deficits in patients with mild traumatic brain injury (TBI) from a military population were characterized by dynamic susceptibility contrast perfusion imaging. Relative cerebral blood flow (rCBF) was calculated by a model-independent deconvolution approach from the tracer concentration curves following a bolus injection of gadolinium diethylenetriaminepentaacetate (Gd-DTPA) using both manually and automatically selected arterial input functions (AIFs). Linear regression analysis of the mean values of rCBF from selected regions of interest showed a very good agreement between the two approaches, with a regression coefficient of R = 0.88 and a slope of 0.88. The Bland-Altman plot also illustrated the good agreement between the two approaches, with a mean difference of 0.6 ± 12.4 mL/100 g/min. Voxelwise analysis of rCBF maps from both approaches demonstrated multiple clusters of decreased perfusion (p < 0.01) in the cerebellum, cuneus, cingulate and temporal gyrus in the group with mild TBI relative to the controls. MRI perfusion deficits in the cerebellum and anterior cingulate also correlated (p < 0.01) with neurocognitive results, including the mean reaction time in the Automated Neuropsychological Assessment Metrics and commission error and detection T-scores in the Continuous Performance Test, as well as neurobehavioral scores in the Post-traumatic Stress Disorder Checklist-Civilian Version. In conclusion, rCBF calculated using AIFs selected from an automated approach demonstrated a good agreement with the corresponding results using manually selected AIFs. Group analysis of patients with mild TBI from a military population demonstrated scattered perfusion deficits, which showed significant correlations with measures of verbal memory, speed of reaction time and self-report of stress symptoms.

Functional MRI in the investigation of blast-related traumatic brain injury

This review focuses on the application of functional magnetic resonance imaging (fMRI) to the investigation of blast-related traumatic brain injury (bTBI). Relatively little is known about the exact mechanisms of neurophysiological injury and pathological and functional sequelae of bTBI. Furthermore, in mild bTBI, standard anatomical imaging techniques (MRI and computed tomography) generally fail to show focal lesions and most of the symptoms present as subjective clinical functional deficits. Therefore, an objective test of brain functionality has great potential to aid in patient diagnosis and provide a sensitive measurement to monitor disease progression and treatment. The goal of this review is to highlight the relevant body of blast-related TBI literature and present suggestions and considerations in the development of fMRI studies for the investigation of bTBI. The review begins with a summary of recent bTBI publications followed by discussions of various elements of blast-related injury. Brief reviews of some fMRI techniques that focus on mental processes commonly disrupted by bTBI, including working memory, selective attention, and emotional processing, are presented in addition to a short review of resting state fMRI. Potential strengths and weaknesses of these approaches as regards bTBI are discussed. Finally, this review presents considerations that must be made when designing fMRI studies for bTBI populations, given the heterogeneous nature of bTBI and its high rate of comorbidity with other physical and psychological injuries.

Neuropsychological outcome from uncomplicated mild, complicated mild, and moderate traumatic brain injury in US military personnel

This study compared the neuropsychological outcome in military personnel following mild-to-moderate traumatic brain injury (TBI). Participants were 83 service members divided into three injury severity groups: uncomplicated mild TBI (MTBI; n = 24), complicated MTBI (n = 17), and moderate TBI (n = 42). Participants were evaluated within 6 months following injury (73% within 3 months) using neurocognitive testing and the Personality Assessment Inventory (PAI). There were no significant differences between the three groups on the majority of neurocognitive measures. Similarly, there were no significant differences between the three groups on the majority of PAI clinical scales (all p > .05), with the exception of two scales. The uncomplicated MTBI group had significantly higher scores on the Anxiety-Related Disorders and Aggression scales compared with the complicated MTBI group, but not the moderate TBI group. Overall, these results suggest that within the first 6 months post injury, there were few detectable differences in the neuropsychological outcome following uncomplicated MTBI, complicated MTBI, or moderate TBI in this military sample.

Influence of poor effort on neuropsychological test performance in U.S. military personnel following mild traumatic brain injury

The purpose of this study was to examine the influence of poor effort on neuropsychological test performance in military personnel following mild traumatic brain injury (MTBI). Participants were 143 U.S. service members who sustained a TBI, divided into three groups based on injury severity and performance on the Word Memory Test and four embedded markers of poor effort: MTBI-pass (n = 87), MTBI-fail (n = 21), and STBI-pass (n = 35; where STBI denotes severe TBI). Patients were evaluated at the Walter Reed Army Medical Center on average 3.9 months (SD = 3.4) post injury. The majority of the sample was Caucasian (84.6%), was male (93.0%), and had 12+ years of education (96.5%). Measures included the Personality Assessment Inventory (PAI) and 13 common neurocognitive measures. Patients in the MTBI-fail group performed worse on the majority of neurocognitive measures, followed by the Severe TBI-Pass group and the MTBI-pass group. Using a criterion of three or more low scores <10th percentile, the MTBI-fail group had the greatest rate of impairment (76.2%), followed by the Severe TBI-Pass group (34.3%) and MTBI-pass group (16.1%). On the PAI, the MTBI-fail group had higher scores on the majority of clinical scales (p < .05). There were a greater number of elevated scales (e.g., 5 or more elevated mild or higher) in the MTBI-fail group (71.4%) than in the MTBI-pass group (32.2%) and Severe TBI-Pass group (17.1%). Effort testing is an important component of postacute neuropsychological evaluations following combat-related MTBI. Those who fail effort testing are likely to be misdiagnosed as having severe cognitive impairment, and their symptom reporting is likely to be inaccurate.

Outcomes from a pilot study using computer-based rehabilitative tools in a military population

Novel therapeutic approaches and outcome data are needed for cognitive rehabilitation for patients with a traumatic brain injury; computer-based programs may play a critical role in filling existing knowledge gaps. Brain-fitness computer programs can complement existing therapies, maximize neuroplasticity, provide treatment beyond the clinic, and deliver objective efficacy data. However, these approaches have not been extensively studied in the military and traumatic brain injury population. Walter Reed National Military Medical Center established its Brain Fitness Center (BFC) in 2008 as an adjunct to traditional cognitive therapies for wounded warriors. The BFC offers commercially available "brain-training" products for military Service Members to use in a supportive, structured environment. Over 250 Service Members have utilized this therapeutic intervention. Each patient receives subjective assessments pre and post BFC participation including the Mayo-Portland Adaptability Inventory-4 (MPAI-4), the Neurobehavioral Symptom Inventory (NBSI), and the Satisfaction with Life Scale (SWLS). A review of the first 29 BFC participants, who finished initial and repeat measures, was completed to determine the effectiveness of the BFC program. Two of the three questionnaires of self-reported symptom change completed before and after participation in the BFC revealed a statistically significant reduction in symptom severity based on MPAI and NBSI total scores (p &lt; .05). There were no significant differences in the SWLS score. Despite the typical limitations of a retrospective chart review, such as variation in treatment procedures, preliminary results reveal a trend towards improved self-reported cognitive and functional symptoms.

Care coordination in military traumatic brain injury

Traumatic brain injury (TBI)-an injury to the brain that may or may not create lasting impairment for the survivor-has been recognized as a major public health problem by the Centers for Disease Control ( Langlois, Rutland-Brown, & Thomas, 2006 ). Ongoing conflicts in Iraq and Afghanistan have highlighted the problem for the military ( Warden, 2006 ). Many soldiers are exposed to severe impact to the head resulting in TBI. As those with TBI transition to their home locality, civilian social workers and other providers will be involved in their care. This article examines the medical and emotional implications of mild TBI and offers suggestions for care of those affected, both the service member and his/her family.

Case report of a soldier with primary blast brain injury

Primary blast injury of the central nervous system is described in a service-member exposed to a large ordinance explosion. Neuroimaging abnormalities are described together with normalization of the fractional anisotrophy on diffusion tensor imaging after follow-up imaging studies.

Assessing and treating veterans with traumatic brain injury

Conflicts in Iraq and Afghanistan have resulted in greater proportions of service members with traumatic brain injury than in prior conflicts. These brain injuries range from the mild (concussion) to severe, and have enormous implications for clinical practice with these soldiers. The highly stressful and dangerous context in which these injuries are sustained set them apart in significant ways from brain injuries seen in civilian settings. The associated emotional toll of the environment and comorbid injuries, often resulting from blast exposure, complicates the clinical picture. In this article, the authors describe the complex presentations in this population of traumatically brain injured combat veterans and illustrate with case vignettes.

Antibiotic regimens for endometritis after delivery

BACKGROUND

Postpartum endometritis, which is more common after cesarean section, occurs when vaginal organisms invade the endometrial cavity during labor and birth. Antibiotic treatment is warranted.

OBJECTIVES

The effect of different antibiotic regimens for the treatment of postpartum endometritis on failure of therapy and complications was systematically reviewed.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's trials register (30 January 2004).

SELECTION CRITERIA

Randomized trials of different antibiotic regimens for postpartum endometritis, after cesarean section or vaginal birth, where outcomes of treatment failure or complications were reported were selected.

DATA COLLECTION AND ANALYSIS

We abstracted data independently and made comparisons between different types of antibiotic regimen based on type of antibiotic and duration and route of administration. Summary relative risks were calculated.

MAIN RESULTS

Thirty-eight trials with 3983 participants were included. Fifteen studies comparing clindamycin and an aminoglycoside with another regimen showed more treatment failures with the other regimen (relative risk (RR) 1.44; 95% confidence interval (CI) 1.15 to 1.80). Failures of those regimens with poor activity against penicillin resistant anaerobic bacteria were more likely (RR 1.94; 95% CI 1.38 to 2.72). In three studies that compared continued oral antibiotic therapy after intravenous therapy with no oral therapy, no differences were found in recurrent endometritis or other outcomes. In four studies comparing once daily with thrice daily dosing of gentamicin there were fewer failures with once daily dosing. There was no evidence of difference in incidence of allergic reactions. Cephalosporins were associated with less diarrhea.

REVIEWERS' CONCLUSIONS

The combination of gentamicin and clindamycin is appropriate for the treatment of endometritis. Regimens with activity against penicillin- resistant anaerobic bacteria are better than those without. There is no evidence that any one regimen is associated with fewer side effects. Once uncomplicated endometritis has clinically improved with intravenous therapy, oral therapy is not needed.

Antibiotic regimens for endometritis after delivery

BACKGROUND

Post-partum endometritis, which is more common after cesarean section, occurs when vaginal organisms invade the endometrial cavity during labour and birth. Antibiotic treatment is warranted.

OBJECTIVES

The effect of different antibiotic regimens for the treatment of postpartum endometritis on failure of therapy and complications was systematically reviewed.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's trials register and the Cochrane Controlled Trials Register. Date of last search: June 2001.

SELECTION CRITERIA

Randomised trials of different antibiotic regimens for postpartum endometritis, after cesarean section or vaginal birth, where outcomes of treatment failure or complications were reported were selected.

DATA COLLECTION AND ANALYSIS

Data were abstracted independently by the reviewers. Comparisons were made between different types of antibiotic regimen, based on type of antibiotic and duration and route of administration. Summary relative risks were calculated.

MAIN RESULTS

Forty-seven trials were included. Overall the studies were methodologically poor. In the intent-to-treat analysis, fifteen studies comparing clindamycin and an aminoglycoside with another regimen showed more treatment failures with another regimen (relative risk (RR) 1.32; 95% confidence interval (CI) 1.09-1.60). Failures of those regimens with poor activity against penicillin resistant anaerobic bacteria were more likely (RR 1.53; 95% CI 1.10-2.13). In four studies that compared continued oral antibiotic therapy after intravenous therapy, no differences were found in recurrent endometritis or other outcomes. There was no evidence of difference in incidence of allergic reactions. Cephalosporins were associated with less diarrhea.

REVIEWER'S CONCLUSIONS

The combination of gentamicin and clindamycin is appropriate for the treatment of endometritis. Regimens with activity against penicillin resistant anaerobic bacteria are better than those without. There is no evidence that any one regimen is associated with fewer side effects. Once uncomplicated endometritis has clinically improved with intravenous therapy, oral therapy is not needed.

A 39-year followup of the Genain quadruplets

The Genains, a unique group of monozygotic female quadruplets, all developed a schizophrenic disorder by age 24. They have been studied since the 1950s, because of the rarity of this occurrence (estimated to be one in 1.5 billion) and because their illnesses varied in severity. The identical inheritance would tend to rule out genetic differences as the cause of the neuropsychological differences; however, we cannot disentangle the effects of early brain injury and harsh punitive treatment as factors accounting for the differences in the severity of their disorders. We conducted neuropsychological examinations of the Genains at age 66, compared their test profiles, and contrasted certain test scores at 66 with those at ages 27 and 51. Test results indicate generally stable (or even improved) performance over time and support the notion that cognitive decline is not a degenerative process in schizophrenia. The Genains remind us of the exquisite interaction among variables that must be understood before additional, satisfactory progress can be made in preventing the development and predicting the course of schizophrenia.

Screening for developmental dysplasia of the hip

Screening programs relying primarily on physical examination techniques for the early detection and treatment of congenital hip abnormalities have not been as consistently successful as expected. Since the 1980s, increased attention has been given to ultrasound imaging of the hip in young infants (less than five months of age) as a possible tool for improving patient outcomes. Although ultrasound examination may not provide advantages over careful repeated physician examination for universal screening, a growing body of evidence indicates that ultrasound surveillance of mild abnormalities can reduce the need for bracing without worsening outcomes. Radiographic documentation of hip normality after the femoral nucleus of ossification has appeared (at three to five month of age) is still appropriate to rule out hip dysplasia.

Multinational neuropsychological testing: performance of children and adults

We obtained neuropsychological assessment data on persons from five countries whose ages range from 8 to 90 years. Participants were assessed in four languages. The results from the multivariate analyses indicate that reaction-time measures obtained in tests of sustained attention are minimally affected by country of origin and level of education. In contrast, tests assessing the ability to focus attention and solve a problem, to shift strategies, and to inhibit an automatic response tendency differ significantly by country and level of education. Most of these differences tend to disappear at about the age of 54. The data provide partial support for the hypothesis of commonality of some neuropsychological functions across cultures.