Complicating factors associated with mild traumatic brain injury: impact on pain and posttraumatic stress disorder treatment

A conceptual framework for a neurophysiological basis of art therapy for PTSD

Post-traumatic stress disorder (PTSD) is a heterogeneous condition that affects many civilians and military service members. Lack of engagement, high dropout rate, and variable response to psychotherapy necessitates more compelling and accessible treatment options that are based on sound neuroscientific evidence-informed decision-making. Art therapy incorporates elements proven to be effective in psychotherapy, such as exposure, making it a potentially valuable treatment option. This conceptual paper aims to inform the neurophysiological rationale for the use of art therapy as a therapeutic approach for individuals with PTSD. A narrative synthesis was conducted using literature review of empirical research on the neurophysiological effects of art therapy, with supporting literature on neuroaesthetics and psychotherapies to identify art therapy factors most pertinent for PTSD. Findings were synthesized through a proposed framework based on the triple network model considering the network-based dysfunctions due to PTSD. Art therapy's active components, such as concretization and metaphor, active art engagement, emotion processing and regulation, perspective taking and reframing, and therapeutic alliance, may improve symptoms of PTSD and prompt adaptive brain functioning. Given the scarcity of rigorous studies on art therapy's effectiveness and mechanisms of alleviating PTSD symptoms, the suggested framework offers a neurophysiological rationale and a future research agenda to investigate the impact of art therapy as a therapeutic approach for individuals with PTSD.

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

Objective

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

Methods

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

Results

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

Conclusions and Clinical Significance

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

Synergistic effect of mild traumatic brain injury and alcohol aggravates neuroinflammation, amyloidogenesis, tau pathology, neurodegeneration, and blood-brain barrier alterations: Impact on psychological stress

After a mild traumatic brain injury (mTBI), victims often experience emotional/psychological stress such as heightened irritability, anxiety, apathy, and depression. Severe mental health complications are common in military populations following a combat-acquired TBI and intensified unhealthy alcohol use. The high prevalence of alcohol abuse among TBI victims underscores how alcohol abuse exacerbates emotional/psychological symptoms such as depression and anxiety. The experimental mTBI was induced in vivo by fluid percussion injury (15 psi) in mice and ethanol diet feeding continued for 28 days. We analyzed different biomarkers of the biochemical mechanisms and pathophysiology of neurological damage, and functional outcome of psychological stress by sucrose preference, and light-dark tests. We demonstrated that the synergistic effect of TBI and alcohol leads to psychological stress such as depression and anxiety. The studies showed that oxidative stress, amyloidogenesis, tau pathology, neuroinflammation, and neurodegeneration markers were elevated, and glial activation and blood-brain barrier (BBB) damage were exacerbated during the synergistic effect of TBI and alcohol. Further, we studied the biochemical mechanisms of psychological stress that showed the significant reduction of 5-HT1AR, neuropeptide-Y, and norepinephrine, and an increase in monoamine oxidase-a in the combined effect of TBI and alcohol. This work suggested that the combined TBI and alcohol-induced effect leads to depression and anxiety, via sequential biochemical changes that cause neuroinflammation, amyloidogenesis, tau pathology, neurodegeneration, and BBB alterations. This clinically relevant study will contribute to developing a comprehensive therapeutic approach for patients suffering from TBI and alcohol-mediated neurological damage and psychological stress.

Cognitive Behavioral Therapy for Veterans With Comorbid Posttraumatic Headache and Posttraumatic Stress Disorder Symptoms: A Randomized Clinical Trial

Question

Do cognitive behavioral therapies for posttraumatic headache and posttraumatic stress disorder (PTSD) symptoms improve headache-related disability in veterans compared with treatment per usual?

Findings

A randomized clinical trial of 193 post-9/11 combat veterans with posttraumatic headache and PTSD symptoms found headache disability was significantly improved with cognitive behavioral therapy for headaches compared with treatment per usual. Though participants randomly assigned to cognitive processing therapy reported significantly greater improvement in PTSD symptom severity compared with treatment per usual, there was no significant effect of cognitive processing therapy on headache disability.

Meaning

Cognitive behavioral therapies are efficacious treatments for veterans with comorbid posttraumatic headache and PTSD symptoms.

Importance

Posttraumatic headache is the most disabling complication of mild traumatic brain injury. Posttraumatic stress disorder (PTSD) symptoms are often comorbid with posttraumatic headache, and there are no established treatments for this comorbidity.

Objective

To compare cognitive behavioral therapies (CBTs) for headache and PTSD with treatment per usual (TPU) for posttraumatic headache attributable to mild traumatic brain injury.

Design, Setting, and Participants

This was a single-site, 3–parallel group, randomized clinical trial with outcomes at posttreatment, 3-month follow-up, and 6-month follow-up. Participants were enrolled from May 1, 2015, through May 30, 2019; data collection ended on October 10, 2019. Post-9/11 US combat veterans from multiple trauma centers were included in the study. Veterans had comorbid posttraumatic headache and PTSD symptoms. Data were analyzed from January 20, 2020, to February 2, 2022.

Interventions

Patients were randomly assigned to 8 sessions of CBT for headache, 12 sessions of cognitive processing therapy for PTSD, or treatment per usual for headache.

Main Outcomes and Measures

Co–primary outcomes were headache-related disability on the 6-Item Headache Impact Test (HIT-6) and PTSD symptom severity on the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (PCL-5) assessed from treatment completion to 6 months posttreatment.

Results

A total of 193 post-9/11 combat veterans (mean [SD] age, 39.7 [8.4] years; 167 male veterans [87%]) were included in the study and reported severe baseline headache-related disability (mean [SD] HIT-6 score, 65.8 [5.6] points) and severe PTSD symptoms (mean [SD] PCL-5 score, 48.4 [14.2] points). For the HIT-6, compared with usual care, patients receiving CBT for headache reported −3.4 (95% CI, −5.4 to −1.4; P < .01) points lower, and patients receiving cognitive processing therapy reported −1.4 (95% CI, −3.7 to 0.8; P = .21) points lower across aggregated posttreatment measurements. For the PCL-5, compared with usual care, patients receiving CBT for headache reported −6.5 (95% CI, −12.7 to −0.3; P = .04) points lower, and patients receiving cognitive processing therapy reported −8.9 (95% CI, −15.9 to −1.9; P = .01) points lower across aggregated posttreatment measurements. Adverse events were minimal and similar across treatment groups.

Conclusions and Relevance

This randomized clinical trial demonstrated that CBT for headache was efficacious for disability associated with posttraumatic headache in veterans and provided clinically significant improvement in PTSD symptom severity. Cognitive processing therapy was efficacious for PTSD symptoms but not for headache disability.

Trial Registration

ClinicalTrials.gov Identifier: NCT02419131

Investigation of the Relationship Between Frequency of Blast Exposure, mTBI History, and Post-traumatic Stress Symptoms

INTRODUCTION

Post-traumatic stress disorder (PTSD) and mild traumatic brain injury (mTBI) are common conditions among military personnel that frequently co-occur. This study investigated relationships between self-reported blast exposure, mTBI history, and current post-traumatic stress (PTS) symptoms in a population of active duty service members (n = 202) from the Intensive Outpatient Program at the National Intrepid Center of Excellence.

MATERIALS AND METHODS

Participants were divided into four mTBI groups (0, 1, 2, and 3+) and four blast exposure groups (0-10, 11-100, 101-1,000, and 1,000+). Self-reported lifetime mTBI and blast history were obtained via the Ohio State University TBI Identification Method. PTSS severity was obtained via the PTSD Checklist-Civilian version (PCL-C). Several secondary measures of depression, anxiety, chronic mTBI symptoms, and sleep were also assessed.

RESULTS

The total PCL-C scores differed significantly between mTBI groups, with significant differences detected between the 0/1 mTBI groups and the 3+ mTBI groups. Similar group differences were noted across the three PCL-C subgroup scores (avoidance, re-experiencing, and hyperarousal); however, when comparing the proportion of group participants meeting DSM-IV criteria for each symptom cluster, significant differences between mTBI groups were only noted for avoidance (P = .002). No group differences were noted in PTS symptom severity or distribution between blast groups.

CONCLUSIONS

This study demonstrates an association between lifetime mTBI history and PTS symptom severity and distribution but failed to identify the significant group in self-reported symptoms between the blast exposure groups. Results suggest that additional research is needed to understand the neurobiological mechanism behind these associations and the need for the development of precise assessment tools that are able to more accurately quantify significant lifetime sub-concussive and blast exposures experienced by service members in training and combat operations.

Early Stage Longitudinal Subcortical Volumetric Changes following Mild Traumatic Brain Injury

Objective: To investigate early brain volumetric changes from acute to 6 months following mild traumatic brain injury (mTBI) in deep gray matter regions and their association with patient 6-month outcome.Methods: Fifty-six patients with mTBI underwent MRI and behavioral evaluation at acute (<10 days) and approximately 1 and 6 months post injury. Regional volume changes were investigated in key gray matter regions: thalamus, hippocampus, putamen, caudate, pallidum, and amygdala, and compared with volumes from 34 healthy control subjects. In patients with mTBI, we further assessed associations between longitudinal regional volume changes with patient outcome measures at 6 months including post-concussive symptoms, cognitive performance, and overall satisfaction with life.Results: Reduction in thalamic and hippocampal volumes was observed at 1 month among patients with mTBI. Such volume reduction persisted in the thalamus until 6 months. Changes in thalamic volumes also correlated with multiple symptom and functional outcome measures in patients at 6 months.Conclusion: Our results indicate that the thalamus may be differentially affected among patients with mTBI, resulting in both structural and functional deficits with subsequent post-concussive sequelae and may serve as a biomarker for the assessment of efficacy of novel therapeutic interventions.

Health Phenotypes and Neurobehavioral Symptom Severity Among Post-9/11 Veterans With Mild Traumatic Brain Injury: A Chronic Effects of Neurotrauma Consortium Study

OBJECTIVE

To evaluate whether neurobehavioral symptoms differ between groups of veterans with mild traumatic brain injury (mTBI) classified by health characteristics.

PARTICIPANTS

A total of 71 934 post-9/11 veterans with mTBI from the Chronic Effects of Neurotrauma Consortium Epidemiology warfighter cohort.

DESIGN

Cross-sectional analysis of retrospective cohort.

MAIN MEASURES

Health phenotypes identified using latent class analysis of health and function over 5 years. Symptom severity measured using Neurobehavioral Symptom Inventory; domains included vestibular, somatic, cognitive, and affective.

RESULTS

Veterans classified as moderately healthy had the lowest symptom burden while the polytrauma phenotype group had the highest. After accounting for sociodemographic and injury characteristics, polytrauma phenotype veterans had about 3 times the odds of reporting severe symptoms in each domain compared with moderately healthy veterans. Those veterans who were initially moderately healthy but whose health declined over time had about twice the odds of severe symptoms as consistently healthier Veterans. The strongest associations were in the affective domain. Compared with the moderately healthy group, veterans in other phenotypes were more likely to report symptoms substantially interfered with their daily lives (odds ratio range: 1.3-2.8).

CONCLUSION

Symptom severity and interference varied by phenotype, including between veterans with stable and declining health. Ameliorating severe symptoms, particularly in the affective domain, could improve health trajectories following mTBI.

Postdeployment Polytrauma Diagnoses Among Soldiers and Veterans Using the Veterans Health Affairs Polytrauma System of Care and Receipt of Opioids, Nonpharmacologic, and Mental Health Treatments

OBJECTIVES

To determine the proportion of Army soldiers who utilized care in the Veterans Health Administration (VHA) Polytrauma System of Care (PSC) within the postdeployment year and to describe prevalence of polytrauma diagnoses, and receipt of opioids, nonpharmacologic treatments (NPTs), and mental health treatments in the VHA during the year following first PSC utilization.

SETTING

VHA's 4-tiered integrated PSC network of specialized rehabilitation services for military members and veterans with polytrauma.

PARTICIPANTS

Soldiers and veterans who used the PSC during the postdeployment year after an Afghanistan or Iraq deployment ending in fiscal years 2008-2011.

DESIGN

Population-based cohort study.

MAIN MEASURES

Prevalence of polytrauma diagnoses (ie, traumatic brain injury [TBI], posttraumatic stress disorder [PTSD], and chronic pain [CP]), VHA utilization rates of opioid prescriptions, NPT, and specialty mental health treatment within 1 year of PSC utilization.

RESULTS

In total, 2.6% of the sample (n = 16 590) used the PSC during the postdeployment year. Among PSC users, CP (76.5%), PTSD (53.1%), and TBI (48.6%) were common and more frequently found together than in isolation; 26.6% filled an opioid prescription, 35.5% received at least 1 NPT, and 83.8% received specialty mental health treatment in the VHA within 1 year of PSC utilization.

CONCLUSION

CP was the most common polytrauma condition among PSC users, highlighting the importance of incorporating interdisciplinary pain management approaches within the PSC, with an effort to reduce reliance on long-term opioid therapy and improve rehabilitation.

Prevalence of Pain Diagnoses and Burden of Pain Among Active Duty Soldiers, FY2012

INTRODUCTION

Soldiers are at risk for acute and chronic pain due to the mental and physical challenges of military duties and ongoing training for force readiness. With the burden of pain on any individual attributable across pain sources, a broad perspective that goes beyond prior characterizations of pain is important. We aim to further the understanding of pain's effects among non-deployed active duty soldiers and the Military Health System (MHS), by describing prevalence of 10 painful conditions, reported pain levels, duration of pain and impact of pain on military duty limitations.

METHODS

Data are from the MHS Data Repository including outpatient MHS direct care encounters, claims for outpatient purchased care from civilian providers, and vital records, for all soldiers continuously enrolled in TRICARE and not deployed in FY 2012. Ten pain-related diagnostic categories were conceptually derived for this analysis and identified using ICD-9-CM diagnostic codes. We report the FY 2012 prevalence at the soldier-level (N = 297,120) for each pain category as a primary diagnosis, as well as in any diagnostic position, and at the soldier-level for reported pain level, duration, and military duty limitations. Institutional Review Board approval was obtained prior to analyses.

RESULTS

Overall, 63% of soldiers had at least one pain diagnosis and 59% had a primary pain diagnosis during FY 2012. Back and neck pain (22%), non-traumatic joint disorders (28%), and other musculoskeletal pain (30%) were the most frequent categories for primary diagnosis. Nearly two-thirds of soldiers had a primary pain diagnosis in more than one category, and 23% in four or more categories. Moderate or severe pain levels were reported at least once during the year by 55% of soldiers who had a primary pain diagnosis. In the subsample of soldiers with primary pain in the first quarter, duration and chronicity of pain diagnoses varied by pain category: the back and neck pain category was the most common for both persistent pain occurring in each quarter of FY 2012 (23%) and chronic pain lasting for at least 3 mo (62%). In most pain categories, the majority of soldiers were released without duty limitations.

CONCLUSION

These data provide a deeper understanding of pain diagnoses and burden of pain among active duty soldiers. A substantial proportion of soldiers with pain diagnoses were seen for pain self-reported as only mild, or that did not result in significant restrictions in military duty limitations. However, given the prevalence of multiple pain diagnoses and common reports of moderate or severe pain and long duration, complex interventions may be required to minimize the effect of pain on force readiness. This encounters-based analysis is likely an underestimate of presence of pain, and does not include contextual factors that could better describe the true effect of pain among this population.

PTSD as a Mediator in the Relationship Between Post-Concussive Symptoms and Pain Among OEF/OIF/OND Veterans

Introduction

Traumatic brain injury (TBI), pain, and post-traumatic stress disorder (PTSD) commonly co-occur in Veteran populations, particularly among Veterans returning from the recent conflicts in Iraq and Afghanistan. Extant research indicates that both TBI and PTSD can negatively impact pain broadly; however, less is known about how these variables impact one another. The current study examines the impact of self-reported post-concussive symptoms on both pain severity and pain interference among Veterans with PTSD who screened positive for a possible TBI, and subsequently, evaluates the potential mediating role of PTSD in these relationships.

Materials and Methods

Participants were 126 combat Veterans that served in Operation Enduring Freedom, Operation Iraqi Freedom, or Operation New Dawn who were being evaluated for participation in a multisite treatment outcomes study. As part of an initial evaluation for inclusion in the study, participants completed several self-report measures and interviews, including the Brief Traumatic Brain Injury Screen, Neurobehavioral Symptom Inventory, Brief Pain Inventory, and the Clinician Administered PTSD Scale, which were utilized in these analyses.

Results

For pain severity, greater post-concussive symptoms significantly predicted increased pain severity with a significant indirect effect of post-concussive symptoms on pain severity through PTSD (indirect effect = 0.03; 95% confidence interval = 0.0094-0.0526). Similar results were found for pain interference (indirect effect = 0.03; 95% confidence interval = 0.0075-0.0471).

Conclusions

These findings replicate and extend previous findings regarding the relationship between TBI, pain, and PTSD. Self-reported post-concussive symptoms negatively impact both pain severity and pain interference among Veterans with probable TBI, and PTSD serves as a mediator in these relationships. Clinically, these results highlight the importance of fully assessing for PTSD symptoms in Veterans with a history of TBI presenting with pain. Further, it is possible that providing effective PTSD treatment to reduce PTSD severity may provide some benefit in reducing post-concussive and pain symptoms.

Effectiveness and harms of mental health treatments in service members and veterans with deployment-related mild traumatic brain injury

BACKGROUND

Co-morbidity of psychiatric conditions with traumatic brain injury (TBI) is common among service members and Veterans from recent deployments. Practice guidelines for mild TBI (mTBI) recommend management of co-occurring psychiatric conditions with existing treatments, but it is unclear whether the effectiveness of treatments for psychiatric conditions is impacted by mTBI. We conducted a systematic literature review to examine the effectiveness and harms of pharmacological and non-pharmacological treatments for posttraumatic stress disorder, depressive disorders, substance use disorders, suicidal ideation or attempts, and anxiety disorders in the presence of co-morbid deployment-related mTBI.

METHODS

We searched bibliographic databases for peer-reviewed, English language studies published from 2000 to October 2017. Two reviewers independently completed abstract triage and full text review.

RESULTS

We identified 7 studies (5 pre-post and 2 secondary analysis). Six assessed psychotherapy and one reported on hyperbaric oxygen therapy (HBO₂). Studies comparing outcomes by TBI history found that a history of TBI does not affect treatment outcomes. Harms were reported only for HBO₂ and were mild. No study examined the effectiveness of treatments for substance use disorders or suicidal ideation, or the effectiveness of pharmacological interventions for the psychiatric conditions of interest in service members and Veterans with mTBI.

LIMITATIONS

Studies lacked usual care or wait-list control groups and no randomized trials were found, making the strength of evidence insufficient.

CONCLUSIONS

Evidence is insufficient to fully assess the impact of TBI on the effectiveness of treatments for psychiatric conditions. Higher quality evidence with definitive guidance for providers treating this population is needed.

The Role of Pain Catastrophizing in Cognitive Functioning Among Veterans With a History of Mild Traumatic Brain Injury

OBJECTIVE

To determine the role of pain catastrophizing (PC) in neuropsychological functioning in veterans with a history of mild traumatic brain injury (TBI).

PARTICIPANTS

Thirty-nine Iraq and Afghanistan combat veterans evaluated in the post-acute phase following mild TBI.

METHODS

Participants underwent psychiatric and TBI clinical interviews, neuropsychological tests, and self-report assessments of PC, pain intensity, depression, and posttraumatic stress disorder symptoms. Cognitive functioning composite scores of executive functioning, processing speed, and learning and memory were created. Composites were entered as dependent variables into separate linear regressions to examine relations with PC.

RESULTS

Greater PC was associated with worse executive functioning and processing speed even when controlling for confounding variables.

CONCLUSIONS

One's interpretation of pain, in addition to pain intensity, has implications for cognitive functioning. Future research is encouraged to determine whether adaptive pain coping mechanisms improve cognitive functioning or, alternatively, whether cognitive rehabilitation strategies reduce PC.

Impact of PTSD on post-concussive symptoms, neuropsychological functioning, and pain in post-9/11 veterans with mild traumatic brain injury

Prior work suggested that post-traumatic stress disorder (PTSD) worsens post-concussive symptoms (PCS), neuropsychological functioning, and pain-related outcomes in post-9/11 veterans. However, the impact of PTSD in the context of mild traumatic brain injury (mTBI) is not entirely clear. We evaluated possible differences among veterans with deployment-related mTBI with and without PTSD, and a comparison group. We hypothesized that veterans with comorbid mTBI and PTSD would report more PCS, perform worse on neuropsychological tasks, and report greater pain intensity and maladaptive pain coping relative to those without PTSD. Ninety (15 female, 75 male) post-9/11 veterans completed measures of psychiatric functioning, PCS, deployment-related mTBI, pain intensity, pain coping, and a brief neuropsychological evaluation. Veterans with comorbid mTBI and PTSD reported significantly higher PCS across domains, and greater pain intensity and maladaptive coping. They also performed more poorly on measures of recall, but not on measures of attention, encoding, or executive functioning. Findings suggest that PTSD results in greater PCS in the context of mTBI, and is associated with greater pain catastrophizing, worse recall, greater pain intensity, and greater illness-focused coping than in mTBI alone. PCS symptoms, recall, and pain coping may be of clinical importance for post-9/11 veterans with the "polytrauma triad."

Sleep, Sleep Disorders, and Circadian Health following Mild Traumatic Brain Injury in Adults: Review and Research Agenda

A rapidly expanding scientific literature supports the frequent co-occurrence of sleep and circadian disturbances following mild traumatic brain injury (mTBI). Although many questions remain unanswered, the preponderance of evidence suggests that sleep and circadian disorders can result from mTBI. Among those with mTBI, sleep disturbances and clinical sleep and circadian disorders contribute to the morbidity and long-term sequelae across domains of functional outcomes and quality of life. Specifically, along with deterioration of neurocognitive performance, insufficient and disturbed sleep can precede, exacerbate, or perpetuate many of the other common sequelae of mTBI, including depression, post-traumatic stress disorder, and chronic pain. Further, sleep and mTBI share neurophysiologic and neuroanatomic mechanisms that likely bear directly on success of rehabilitation following mTBI. For these reasons, focus on disturbed sleep as a modifiable treatment target has high likelihood of improving outcomes in mTBI. Here, we review relevant literature and present a research agenda to 1) advance understanding of the reciprocal relationships between sleep and circadian factors and mTBI sequelae and 2) advance rapidly the development of sleep-related treatments in this population.

Chronic Pain, TBI, and PTSD in Military Veterans: A Link to Suicidal Ideation and Violent Impulses?

The polytrauma clinical triad refers to the co-occurrence of chronic pain, traumatic brain injury (TBI), and posttraumatic stress disorder (PTSD). Despite research implicating dyadic relationships between these conditions and adverse outcomes, scant research has examined the polytrauma clinical triad's relation to suicide or violence. The present cross-sectional study was designed to examine whether this complex clinical presentation increases risk of suicidal ideation and violent impulses after accounting for other established risk factors. Veterans who served in the military since September 11, 2001 (N = 667) who reported chronic pain completed an interview and self-report battery. Bivariate analyses showed that suicidal ideation and violent impulses both correlated with PTSD, TBI+PTSD, pain intensity and interference, drug abuse, and major depressive disorder (MDD). Multiple regression analyses showed that: 1) race, chronic pain with PTSD, alcohol abuse, and MDD significantly predicted suicidal ideation, 2) pain interference, chronic pain with TBI, chronic pain with PTSD, chronic pain with TBI+PTSD, drug abuse, and MDD significantly predicted violent impulses, and 3) pain interference was a more critical predictor of suicidal and violent ideation than pain intensity. Implications for risk assessment and treatment are discussed.

PERSPECTIVE

This article presents results from a study examining predictors of suicide and violence risk among a sample of post-9/11 U.S. Veterans with chronic pain. Health care professionals should assess for pain interference, TBI, PTSD, depression, and alcohol/drug abuse when conducting risk assessments with this population.

Exploration of Factors Related to Depressive Symptomatology in Family Members of Military Veterans With Traumatic Brain Injury

Traumatic brain injury (TBI) is a family affair, affecting those with the injury and their families. Psychological distress, often measured as depression or depressive symptoms, is highly prevalent among family members. Predictors of depression in family members of civilians with TBI have been examined, but predictors of depression in family members of military veterans have received very little research attention and are poorly understood. To address the knowledge gap, this study explored factors related to depressive symptoms in family members of veterans in the United States, using an ecological framework. Baseline data from 83 family members were used. Family members with higher caregiver burden, presence of a veteran with posttraumatic stress disorder (PTSD), and greater financial difficulty experienced significantly more depressive symptoms. Findings suggest that efforts to support family members and decrease their depression should aim to reduce caregiver burden and financial difficulty, and help family members cope with veteran PTSD and TBI. Family-focused interventions are needed.

The Relationship Between Chronic Pain and Neurocognitive Function: A Systematic Review

OBJECTIVE

Understanding the relationship between chronic pain and neurocognition has important implications for the assessment and treatment of patient experiencing pain. This paper provides an overview of the current literature examining the neurocognition-chronic pain relationship and suggests future avenues of research, along with a discussion of clinical implications of the literature findings. Consideration of potential moderators and mediators of this relationship, as well as a brief discussion of the importance of future research in special populations at particular risk for these problems, are also a focus of this paper.

METHODS

This systematic review summarizes the findings of clinical studies in which neurocognitive performance was measured in chronic pain samples. A literature search led to the inclusion of 53 articles in the review.

RESULTS

Studies of neurocognitive performance in clinical chronic pain samples support a relationship between chronic pain and neurocognitive abnormalities, particularly on tests of memory, attention, and processing speed, with mixed data regarding executive functioning.

DISCUSSION

Several factors may moderate or mediate the relationship between chronic pain and neurocognitive functioning, including mood symptoms, medication side effects, and intensity and/or chronicity of pain. Limitations in the literature include a paucity of methodologically rigorous studies controlling for confounding variables (eg, opioid analgesia) and a limited number of studies examining the relationship between chronic pain and traumatic brain injury (a potential precipitant of both pain and neurocognitive impairment). Nonetheless, findings from the existing literature have significant clinical implications, including for populations with heightened risk of both pain and neurocognitive disorders.

The association between posttraumatic stress symptoms, depression, and length of hospital stay following traumatic injury

OBJECTIVE

The present study examined the relationship between posttraumatic stress symptoms (PTSS) and depression symptoms with hospital outcome measures to explore how psychiatric factors relate to hospital length of stay (LOS).

METHOD

Participants were adults admitted to a large Level I Trauma Center for longer than 24h. Depression was assessed at hospitalization using the Patient Health Questionnaire (PHQ-8), and PTSS was measured by the Primary Care PTSD Screen (PC-PTSD). Hospital outcome information was collected from the hospital's trauma registry. Pearson correlations were performed.

RESULTS

460 participants (mean age=44years, SD=16.8; 65.4% male) completed the study. Baseline PTSS and depression were significantly correlated with longer hospital LOS while controlling for demographics and injury severity (p=0.026; p=0.023). Both PTSS-positive and depression-positive groups had an average increased hospital LOS of two days.

CONCLUSIONS

A significant proportion of individuals who are admitted to the hospital following trauma may be at risk for depression and PTSS, which may then increase hospital LOS. As national attention turns to reducing healthcare costs, early screenings and interventions may aid in minimizing psychiatric symptoms in trauma patients, in turn reducing the cost and outcomes associated with total hospital LOS.

Post-concussion symptoms and chronic pain after mild traumatic brain injury are modulated by multiple locus effect in the BDNF gene through the expression of antisense: A pilot prospective control study

Background: Mild traumatic brain injury (mTBI) often results in post-concussion symptoms, chronic pain, and sleepiness. Genetic factors are thought to play an important role in poor prognosis.

Aims: The aims of this study are to (1) document the prevalence of pain and post-concussion symptoms in mTBI patients in acute and chronic phases (2) determine whether candidate genes predispose to post-concussive symptoms and pain.

Methods: Posttraumatic symptoms, evaluated using the Rivermead Post-Concussion Symptoms Questionnaire, and pain were assessed in 94 mTBI patients in the acute phase as well as in 22 healthy controls. Assessment was repeated in 36 patients after one year who agreed to participate in the follow-up visit. Gene polymorphisms and expression were assessed in mTBI patients and healthy controls.

Results: In the acute phase, mTBI patients with pain (69%) presented more psychological symptoms and sleepiness and were less able to return to work than those without pain. At one year, 19% of mTBI patients had persistent pain and psychological distress. Two haplotypes (H2 and H3) in the brain-derived neurotrophic factor (BDNF) gene were shown to be respectively deleterious and protective against post-concussion symptoms and pain in both acute and chronic phases. Protective haplotype H3 was associated with a decreased expression of the anti-sense of BDNF (BDNF-AS). Deleterious haplotype H2 predicted the development of chronic pain at one year, whereas H3 was protective.

Conclusions: This pilot study suggests a protective mechanism of a multilocus effect in BDNF, through BDNF-AS, against post-concussion symptoms and pain in the acute phase and possibly chronic pain at one year post-mTBI. The role of antisense RNA should be validated in larger cohorts.

Reduced P3b brain response during sustained visual attention is associated with remote blast mTBI and current PTSD in U.S. military veterans

Approximately 275,000 American service members deployed to Iraq or Afghanistan have sustained a mild traumatic brain injury (mTBI), with 75% of these incidents involving an explosive blast. Combat-related mTBI is frequently associated with comorbid mental health disorders, especially posttraumatic stress disorder (PTSD). Attention problems, including sustained attention, are common cognitive complaints of veterans with TBI and PTSD. The present study sought to examine neural correlates of sustained attention in veterans with blast mTBI and/or current PTSD. In 124 veterans of Operations Enduring and Iraqi Freedom (OEF/OIF), we examined event-related potentials (ERPs) elicited by targets and non-targets during performance of a degraded-stimulus continuous performance task (DS-CPT). Four groups, consisting of veterans with blast-related mTBI only, current PTSD only, both blast mTBI and PTSD, and a control group, were studied. Compared to all other groups, blast mTBI only participants were more likely to respond regardless of stimulus type during the DS-CPT. During target detection, the three mTBI/PTSD groups showed reduced amplitude of the P3b (i.e., P300) ERP at Pz compared to the control group. P3b of the three affected groups did not differ from each other. These results suggest that parietal P3b amplitude reduction during target detection in the DS-CPT task may be an index of brain pathology after combat trauma, yet the diminished brain response fails to differentiate independent effects of blast-related mTBI or severity of PTSD symptomatology.

Post-9/11 Veterans and Their Partners Improve Mental Health Outcomes with a Self-directed Mobile and Web-based Wellness Training Program: A Randomized Controlled Trial

Background

Veterans with history of deployment in the Global War on Terror face significant and ongoing challenges with high prevalences of adverse psychological, physical, spiritual, and family impacts. Together, these challenges contribute to an emerging public health crisis likely to extend well into the future. Innovative approaches are needed that reach veterans and their family members with strategies they can employ over time in their daily lives to promote improved adjustment and well-being.

Objective

The objective of this study was to evaluate effects of use of a Web-based, self-directed program of instruction in mind- and body-based wellness skills to be employed by Global War on Terror veterans and their significant relationship partners on mental health and wellness outcomes associated with postdeployment readjustment.

Methods

We recruited 160 veteran-partner dyads in 4 regions of the United States (San Diego, CA; Dallas, TX; Fayetteville, NC; and New York, NY) through publicity by the Iraq and Afghanistan Veterans of America to its membership. Dyads were randomly allocated to 1 of 4 study arms: Mission Reconnect (MR) program alone, MR plus the Prevention and Relationship Enhancement Program (PREP) for Strong Bonds weekend program for military couples, PREP alone, and waitlist control. We administered a battery of standardized and investigator-generated instruments assessing mental health outcomes at baseline, 8 weeks, and 16 weeks. Dyads in the MR arms were provided Web-based and mobile app video and audio instruction in a set of mindfulness-related stress reduction and contemplative practices, as well as partner massage for reciprocal use. All participants provided weekly reports on frequency and duration of self-care practices for the first 8 weeks, and at 16 weeks.

Results

During the first 8-week reporting period, veterans and partners assigned to MR arms used some aspect of the program a mean of 20 times per week, totaling nearly 2.5 hours per week, with only modest declines in use at 16 weeks. Significant improvements were seen at 8 and 16 weeks in measures of posttraumatic stress disorder, depression, sleep quality, perceived stress, resilience, self-compassion, and pain for participants assigned to MR arms. In addition, significant reductions in self-reported levels of pain, tension, irritability, anxiety, and depression were associated with use of partner massage.

Conclusions

Both veterans and partners were able to learn and make sustained use of a range of wellness practices taught in the MR program. Home-based, self-directed interventions may be of particular service to veterans who are distant from, averse to, or prohibited by schedule from using professional services. Leveraging the partner relationship may enhance sustained use of self-directed interventions for this population. Use of the MR program appears to be an accessible, low-cost approach that supports well-being and reduces multiple symptoms among post-9/11 veterans and their partners.

Trial Registration

Clinicaltrials.gov NCT01680419; https://clinicaltrials.gov/ct2/show/NCT01680419 (Archived by WebCite at http://www.webcitation.org/6jJuadfzj)

Treatment of persistent post-concussive symptoms after mild traumatic brain injury: a systematic review of cognitive rehabilitation and behavioral health interventions in military service members and veterans

Increased prevalence of traumatic brain injury (TBI) has been associated with service members and veterans who completed combat deployments in support of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF). Management of persistent post-concussive symptoms (PCS) has been a challenge to healthcare providers throughout the Military and Veterans Healthcare Systems, as well as civilian healthcare providers, due in part to the chronic nature of symptoms, co-occurrence of behavioral health disorders such as depression, Posttraumatic Stress Disorder (PTSD), and substance use disorders, and fear of a potential stigma associated with psychiatric diagnoses and behavioral health treatment(s). This systematic review examined non-pharmacologic behavioral health interventions and cognitive rehabilitation interventions for PCS in military service members and veterans with a history of mild TBI (mTBI). Six electronic databases were searched with specific term limitations, identifying 121 citations. Ultimately, 19 articles met criteria for inclusion in this systematic review. Studies were broadly categorized into four subtypes: psychoeducational interventions, cognitive rehabilitation, psychotherapeutic approaches, and integrated behavioral health interventions for PCS and PTSD. The review provides an update of the empirical evidence for these four types of interventions for PCS in active duty service members and veterans. Recommendations for future research are discussed, including the need to expand and improve the limited evidence basis on how to manage persistent post-concussive symptoms in this population.

Primary blast causes mild, moderate, severe and lethal TBI with increasing blast overpressures: Experimental rat injury model

Injury severity in blast induced Traumatic Brain Injury (bTBI) increases with blast overpressure (BOP) and impulse in dose-dependent manner. Pure primary blast waves were simulated in compressed gas shock-tubes in discrete increments. Present work demonstrates 24 hour survival of rats in 0–450 kPa (0–800 Pa∙s impulse) range at 10 discrete levels (60, 100, 130, 160, 190, 230, 250, 290, 350 and 420 kPa) and determines the mortality rate as a non-linear function of BOP. Using logistic regression model, predicted mortality rate (PMR) function was calculated, and used to establish TBI severities. We determined a BOP of 145 kPa as upper mild TBI threshold (5% PMR). Also we determined 146–220 kPa and 221–290 kPa levels as moderate and severe TBI based on 35%, and 70% PMR, respectively, while BOP above 290 kPa is lethal. Since there are no standards for animal bTBI injury severity, these thresholds need further refinements using histopathology, immunohistochemistry and behavior. Further, we specifically investigated mild TBI range (0–145 kPa) using physiological (heart rate), pathological (lung injury), immuno-histochemical (oxidative/nitrosative and blood-brain barrier markers) as well as blood borne biomarkers. With these additional data, we conclude that mild bTBI occurs in rats when the BOP is in the range of 85–145 kPa.

Influence of Mild Traumatic Brain Injury (TBI) and Posttraumatic Stress Disorder (PTSD) on Pain Intensity Levels in OEF/OIF/OND Veterans

OBJECTIVE

Mild traumatic brain injury (mTBI) and posttraumatic stress disorder (PTSD) are common among US veterans of Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND). We postulated that these injuries may modulate pain processing in these individuals and affect their subjective pain levels.

DESIGN

Cross-sectional.

SUBJECTS

310 deployed service members of OEF/OIF/OND without a lifetime history of moderate or severe TBI were included in this study.

METHODS

All participants completed a comprehensive evaluation for Blast Exposure, mTBI, PTSD, and Pain Levels. The Boston Assessment of TBI-Lifetime Version (BAT-L) was used to assess blast exposure and potential brain injury during military service. The Clinician-Administered PTSD Scale (CAPS) characterized presence and severity of PTSD. The Visual Analog Scale (VAS) was used to assess pain intensity over the previous month before the interview, with higher scores indicative of worse pain. Statistical analysis was performed by ANOVA and results were adjusted for co-morbidities, clinical characteristics and demographic data.

RESULTS

In comparison to control participants (veterans without mTBI or current PTSD), veterans with both current PTSD and mTBI reported the highest pain intensity levels, followed by veterans with PTSD only (P < 0.0001 and P = 0.0005, respectively). Pain levels in veterans with mTBI only were comparable to control participants.

CONCLUSIONS

Comorbid PTSD and mTBI is associated with increased self-reported pain intensity. mTBI alone was not associated with increased pain.

Chronic pain acceptance incrementally predicts disability in polytrauma-exposed veterans at baseline and 1-year follow-up

War veterans are at increased risk for chronic pain and co-occurring neurobehavioral problems, including posttraumatic stress disorder (PTSD), depression, alcohol-related problems, and mild traumatic brain injury (mTBI). Each condition is associated with disability, particularly when co-occurring. Pain acceptance is a strong predictor of lower levels of disability in chronic pain. This study examined whether acceptance of pain predicted current and future disability beyond the effects of these co-occurring conditions in war veterans. Eighty trauma-exposed veterans with chronic pain completed a PTSD diagnostic interview, clinician-administered mTBI screening, and self-report measures of disability, pain acceptance, depression, and alcohol use. Hierarchical regression models showed pain acceptance to be incrementally associated with disability after accounting for symptoms of PTSD, depression, alcohol-related problems, and mTBI (total adjusted R(2) = .57, p < .001, ΔR(2) = .03, p = .02). At 1-year follow-up, the total variance in disability accounted for by the model decreased (total adjusted R(2) = .29, p < .001), whereas the unique contribution of pain acceptance increased (ΔR(2) = .07, p = .008). Pain acceptance remained significantly associated with 1-year disability when pain severity was included in the model. Future research should evaluate treatments that address chronic pain acceptance and co-occurring conditions to promote functional recovery in the context of polytrauma in war veterans.

Prolonged Exposure Therapy With Veterans and Active Duty Personnel Diagnosed With PTSD and Traumatic Brain Injury

The present study used archival clinical data to analyze the delivery and effectiveness of prolonged exposure (PE) and ancillary services for posttraumatic stress disorder (PTSD) among Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn veterans (N = 69) with histories of mild to severe traumatic brain injury (TBI). Data from standard clinical assessments of veterans and active duty personnel treated in both inpatient and outpatient programs at 2 Department of Veteran Affairs medical centers were examined. Symptoms were assessed with self-report measures of PTSD (PTSD Checklist) and depression (Beck Depression Inventory-II) before and throughout therapy. Mixed linear models were utilized to determine the slope of reported symptoms throughout treatment, and the effects associated with fixed factors such as site, treatment setting (residential vs. outpatient), and TBI severity were examined. Results demonstrated significant decreases in PTSD, B = -3.00, 95% CI [-3.22, -2.78]; t(210) = -13.5; p < .001, and in depressive symptoms, B = -1.46, 95% CI [-1.64, -1.28]; t(192) = -8.32; p < .001. The effects of PE treatment did not differ by clinical setting and participants with moderate to severe injuries reported more rapid gains than those with a history of mild TBI. The results provide evidence that PE may well be effective for veterans with PTSD and TBI.

Neuropsychiatric symptoms and expenditure on complementary and alternative medicine

OBJECTIVE

Neuropsychiatric symptoms affect 37% of US adults. These symptoms are often refractory to standard therapies, and patients may consequently opt for complementary and alternative medicine therapies (CAM). We sought to determine the demand for CAM by those with neuropsychiatric symptoms compared to those without neuropsychiatric symptoms as measured by out-of-pocket expenditure.

METHOD

We compared CAM expenditure between US adults with and without neuropsychiatric symptoms (n = 23,393) using the 2007 National Health Interview Survey. Symptoms included depression, anxiety, insomnia, attention deficits, headaches, excessive sleepiness, and memory loss. CAM was defined per guidelines from the National Institutes of Health as mind-body therapies, biological therapies, manipulation therapies, or alternative medical systems. Expenditure on CAM by those without neuropsychiatric symptoms was compared to those with neuropsychiatric symptoms.

RESULTS

Of the adults surveyed, 37% had ≥ 1 neuropsychiatric symptom and spent $14.8 billion out-of-pocket on CAM. Those with ≥ 1 neuropsychiatric symptom were more likely than those without neuropsychiatric symptoms to spend on CAM (27.4% vs 20.3%, P < .001). Likelihood to spend on CAM increased with number of symptoms (27.2% with ≥ 3 symptoms, P < .001). After adjustment was made for confounders using logistic regression, those with ≥ 1 neuropsychiatric symptom remained more likely to spend on CAM (odds ratio [OR] = 1.34; 95% CI, 1.22-1.48), and the likelihood increased to 1.55 (95% CI, 1.34-1.79) for ≥ 3 symptoms. Anxiety (OR = 1.40 [95% CI, 1.22-1.60]) and excessive sleepiness (OR = 1.36 [95% CI, 1.21-1.54]) were the most closely associated with CAM expenditure.

CONCLUSIONS

Those with ≥ 1 neuropsychiatric symptom had disproportionately higher demand for CAM than those without symptoms. Research regarding safety, efficacy, and cost-effectiveness of CAM is limited; therefore, future research should evaluate these issues given the tremendous demand for these treatments.

Exploration of Individual and Family Factors Related to Community Reintegration in Veterans With Traumatic Brain Injury

BACKGROUND

Community reintegration (CR) poses a major problem for military veterans who have experienced a traumatic brain injury (TBI). Factors contributing to CR after TBI are poorly understood.

OBJECTIVE

To address the gap in knowledge, an ecological framework was used to explore individual and family factors related to CR.

DESIGN

Baseline data from an intervention study with 83 veterans with primarily mild to moderate TBI were analyzed. Instruments measured CR, depressive symptoms, physical health, quality of the relationship with the family member, and sociodemographics. Posttraumatic stress disorder and TBI characteristics were determined through record review.

RESULTS

Five variables that exhibited significant bivariate relationships with CR (veteran rating of quality of relationship, physical functioning, bodily pain, posttraumatic stress disorder diagnosis, and depressive symptoms) were entered into hierarchical regression analysis. In the final analysis, the five variables together accounted for 35% of the variance, but only depression was a significant predictor of CR, with more depressed veterans exhibiting lower CR.

CONCLUSIONS

Efforts to support CR of Veterans with TBI should carefully assess and target depression, a modifiable factor.

Profile analyses of the Personality Assessment Inventory following military-related traumatic brain injury

Personality Assessment Inventory (PAI) profiles were examined in 160 U.S. service members (SMs) following mild-severe traumatic brain injury (TBI). Participants who sustained a mild TBI had significantly higher PAI scores than those with moderate-severe TBI on eight of the nine clinical scales examined. A two-step cluster analysis identified four PAI profiles, heuristically labeled "High Distress", "Moderate Distress", "Somatic Distress," and "No Distress". Postconcussive and posttraumatic stress symptom severity was highest for the High Distress group, followed by the Somatic and Moderate Distress groups, and the No Distress group. Profile groups differed in age, ethnicity, rank, and TBI severity. Findings indicate that meaningful patterns of behavioral and personality characteristics can be detected in active duty military SMs following TBI, which may prove useful in selecting the most efficacious rehabilitation strategies.

Exploring the Relationship Between Mild Traumatic Brain Injury Exposure and the Presence and Severity of Postconcussive Symptoms Among Veterans Deployed to Iraq and Afghanistan

OBJECTIVE

The aim of this study was to describe the association between mild traumatic brain injury (mTBI) and persisting postconcussive symptoms according to symptom category, number, and severity.

DESIGN

The study design was observational.

PARTICIPANTS

The study sample comprised veterans (≥18 years of age) deployed in Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) conflicts who had not received any treatment for mTBI in the 30 days preceding study enrollment.

METHODS

Veterans were interviewed and completed testing in a single day. The Standard TBI Diagnostic Interview and the Clinician-Administered PTSD Scale were used. Testing included the Neurobehavioral Symptom Inventory and a full neuropsychological battery. Gold standard classification methods were utilized to determine presence/absence of mTBI. For each of the 5 symptom outcomes, an adjusted multiple linear regression model (negative binomial count models) accounting for effects of socio-demographic variables and behavioral health conditions was used.

MAIN OUTCOME MEASURES

Self-report of neurobehavioral symptoms categorized as affective, cognitive, somatic, and vestibular symptoms, in addition to the instruments specified above.

RESULTS

OEF/OIF veterans with mTBI, relative to veterans with no mTBI, were observed to have 30% more symptoms overall (P < .001), 34% more somatic symptoms (P < .001), 22% more cognitive symptoms (P = .008), 15% more affective symptoms (P = .017), and 59% more vestibular symptoms (P < .001). For adjusted models, variables significantly related to number of symptoms across all 4 symptom categories were anxiety (all P < .001) and insomnia (all P < .001). For the adjusted models, variables significantly related to symptom severity across all 4 symptom categories were insomnia (all P < .001), depression (P < .001-.05) and anxiety (all, P < .001).

CONCLUSIONS

OEF/OIF veterans with mTBI, relative to veterans with no mTBI, have significantly more and significantly more severe persisting symptoms, with vestibular symptoms reported with the greatest frequency. After accounting for behavioral health conditions and socio-demographic factors, OEF/OIF veterans with mTBI compared to veterans without mTBI had significantly more cognitive, affective, vestibular, and somatic symptoms persisting 4.8 years after the mTBI event(s).

Considerations for return to work following traumatic brain injury

Population-based studies have demonstrated that a history positive for traumatic brain injury (TBI) can result in cognitive impairment, behavioral alterations, and pain. These outcomes can and do influence occupational function, can affect others in the workplace, and raise concerns about workplace safety upon re-entry to the workplace. Risk for long-term impairment and disability can in some cases be mitigated by assessment of capabilities relative to job duties, conservative return-to-work schedules, and, in some cases, interventions to support that return. For those in occupations at high risk for brain injury, including first responders, soldiers, and construction workers, the long-term risk of brain injury as a risk factor for neurodegenerative disease must and should inform increased concern for those with repeated injuries to the brain over the course of their lifetime and career. This chapter reviews the risks of TBI, considers factors that optimize functional recovery, and discusses potential interventions and factors that aid in return to the workplace.

Close-range blast exposure is associated with altered functional connectivity in Veterans independent of concussion symptoms at time of exposure

Although there is emerging data on the effects of blast-related concussion (or mTBI) on cognition, the effects of blast exposure itself on the brain have only recently been explored. Toward this end, we examine functional connectivity to the posterior cingulate cortex, a primary region within the default mode network (DMN), in a cohort of 134 Iraq and Afghanistan Veterans characterized for a range of common military-associated comorbidities. Exposure to a blast at close range (<10 meters) was associated with decreased connectivity of bilateral primary somatosensory and motor cortices, and these changes were not different from those seen in participants with blast-related mTBI. These results remained significant when clinical factors such as sleep quality, chronic pain, or post traumatic stress disorder were included in the statistical model. In contrast, differences in functional connectivity based on concussion history and blast exposures at greater distances were not apparent. Despite the limitations of a study of this nature (e.g., assessments long removed from injury, self-reported blast history), these data demonstrate that blast exposure per se, which is prevalent among those who served in Iraq and Afghanistan, may be an important consideration in Veterans' health. It further offers a clinical guideline for determining which blasts (namely, those within 10 meters) are likely to lead to long-term health concerns and may be more accurate than using concussion symptoms alone.

Combat-related blast exposure and traumatic brain injury influence brain glucose metabolism during REM sleep in military veterans

Traumatic brain injury (TBI), a signature wound of Operations Enduring and Iraqi Freedom, can result from blunt head trauma or exposure to a blast/explosion. While TBI affects sleep, the neurobiological underpinnings between TBI and sleep are largely unknown. To examine the neurobiological underpinnings of this relationship in military veterans, [(18)F]-fluorodeoxyglucose positron emission tomography (FDG PET) was used to compare mTBI-related changes in relative cerebral metabolic rate of glucose (rCMRglc) during wakefulness, Rapid Eye Movement (REM) sleep, and non-REM (NREM) sleep, after adjusting for the effects of posttraumatic stress (PTS). Fourteen veterans with a history of blast exposure and/or mTBI (B/mTBI) (age 27.5±3.9) and eleven veterans with no history (No B/mTBI) (age 28.1±4.3) completed FDG PET studies during wakefulness, REM sleep, and NREM sleep. Whole-brain analyses were conducted using Statistical Parametric Mapping (SPM8). Between group comparisons revealed that B/mTBI was associated with significantly lower rCMRglc during wakefulness and REM sleep in the amygdala, hippocampus, parahippocampal gyrus, thalamus, insula, uncus, culmen, visual association cortices, and midline medial frontal cortices. These results suggest that alterations in neurobiological networks during wakefulness and REM sleep subsequent to B/mTBI exposure may contribute to chronic sleep disturbances and differ in individuals with acute symptoms.

Randomized, Sham-Controlled, Feasibility Trial of Hyperbaric Oxygen for Service Members With Postconcussion Syndrome: Cognitive and Psychomotor Outcomes 1 Week Postintervention

Background Mild traumatic brain injury (mTBI) and residual postconcussion syndrome (PCS) are common among combatants of the recent military conflicts in Iraq and Afghanistan. Hyperbaric oxygen (HBO2) is a proposed treatment but has not been rigorously studied for this condition. Objectives In a secondary analysis, examine for possible effects on psychomotor (balance and fine motor) and cognitive performance 1 week after an HBO2 intervention in service members with PCS after mTBI. Methods A randomized, double-blind, sham control, feasibility trial comparing pretreatment and posttreatment was conducted in 60 male active-duty marines with combat-related mTBI and PCS persisting for 3 to 36 months. Participants were randomized to 1 of 3 preassigned oxygen fractions (10.5%, 75%, or 100%) at 2.0 atmospheres absolute (ATA), resulting in respective groups with an oxygen exposure equivalent to (1) breathing surface air (Sham Air), (2) 100% oxygen at 1.5 ATA (1.5 ATAO2), and (3) 100% oxygen at 2.0 ATA (2.0 ATAO2). Over a 10-week period, participants received 40 hyperbaric chamber sessions of 60 minutes each. Outcome measures, including computerized posturography (balance), grooved pegboard (fine motor speed/dexterity), and multiple neuropsychological tests of cognitive performance, were collected preintervention and 1-week postintervention. Results Despite the multiple sensitive cognitive and psychomotor measures analyzed at an unadjusted 5% significance level, this study demonstrated no immediate postintervention beneficial effect of exposure to either 1.5 ATAO2 or 2.0 ATAO2 compared with the Sham Air intervention. Conclusions These results do not support the use of HBO2 to treat cognitive, balance, or fine motor deficits associated with mTBI and PCS.

Performance on the Green Word Memory Test following Operation Enduring Freedom/Operation Iraqi Freedom-era military service: Test failure is related to evaluation context

This study investigates prior reports of high neuropsychological symptom validity test (SVT) failure rates in post-deployed Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) active and veteran military personnel, using a large, multi-site sample (N = 214) drawn from three levels of the Department of Defense/Department of Veterans Affairs (VA) Polytrauma System of Care. The sample failure rate and its relationship to research versus dual research/clinical context of evaluation were examined, in addition to secondary variables explored in prior studies. Results yielded an overall failure rate of 25%, lower than prior reports describing OEF/OIF active-duty and veteran military personnel. Findings also supported the hypothesis that SVT failure rates would differ by context (dual > research). Participants with traumatic brain injury (TBI) failed more frequently than those without TBI in the dual context but not in the research context. Secondary analyses revealed that failure rates increased in the presence of depression, posttraumatic stress disorder, and male sex but were unrelated to active versus veteran military status, service connection (SC) or percentage of SC, age, education, or ethnicity. Further research is required to elucidate the underpinnings of these findings in light of the limited literature and variability between OEF/OIF-related SVT studies, as well as the substantial diagnostic and treatment implications for VA.

Induction of oxidative and nitrosative damage leads to cerebrovascular inflammation in an animal model of mild traumatic brain injury induced by primary blast

We investigate the hypothesis that oxidative damage of the cerebral vascular barrier interface (the blood-brain barrier, BBB) causes the development of mild traumatic brain injury (TBI) during a primary blast-wave spectrum. The underlying biochemical and cellular mechanisms of this vascular layer-structure injury are examined in a novel animal model of shock tube. We first established that low-frequency (123kPa) single or repeated shock wave causes BBB/brain injury through biochemical activation by an acute mechanical force that occurs 6-24h after the exposure. This biochemical damage of the cerebral vasculature is initiated by the induction of the free radical-generating enzymes NADPH oxidase 1 and inducible nitric oxide synthase. Induction of these enzymes by shock-wave exposure paralleled the signatures of oxidative and nitrosative damage (4-HNE/3-NT) and reduction of the BBB tight-junction (TJ) proteins occludin, claudin-5, and zonula occluden 1 in the brain microvessels. In parallel with TJ protein disruption, the perivascular unit was significantly diminished by single or repeated shock-wave exposure coinciding with the kinetic profile. Loosening of the vasculature and perivascular unit was mediated by oxidative stress-induced activation of matrix metalloproteinases and fluid channel aquaporin-4, promoting vascular fluid cavitation/edema, enhanced leakiness of the BBB, and progression of neuroinflammation. The BBB leakiness and neuroinflammation were functionally demonstrated in an in vivo model by enhanced permeativity of Evans blue and sodium fluorescein low-molecular-weight tracers and the infiltration of immune cells across the BBB. The detection of brain cell proteins neuron-specific enolase and S100β in the blood samples validated the neuroastroglial injury in shock-wave TBI. Our hypothesis that cerebral vascular injury occurs before the development of neurological disorders in mild TBI was further confirmed by the activation of caspase-3 and cell apoptosis mostly around the perivascular region. Thus, induction of oxidative stress and activation of matrix metalloproteinases by shock wave underlie the mechanisms of cerebral vascular BBB leakage and neuroinflammation.

Mild traumatic brain injury and treatment response in prolonged exposure for PTSD

A proportion of U.S. veterans returning from Iraq and Afghanistan have experienced mild traumatic brain injury (mTBI), which is associated with increased risk for developing posttraumatic stress disorder (PTSD). Prolonged Exposure (PE) has proven effectiveness in the treatment of PTSD; however, some clinicians have reservations about using PE with individuals with a history of mTBI. We examined the impact of PE for veterans with PTSD and with or without a history of mTBI in a naturalistic sample of 51 veterans who received PE at a Veterans Health Administration PTSD clinic. We also analyzed previously collected data from a controlled trial of 22 veterans randomly assigned to PE or present centered therapy. For both sets of data, we found that PE reduced symptom levels and we also did not detect an effect for mTBI, suggesting that PE may be helpful for individuals with PTSD and a history of mTBI.

Managing behavioral health needs of veterans with traumatic brain injury (TBI) in primary care

Traumatic brain injury (TBI) is a frequent occurrence in the United States, and has been given particular attention in the veteran population. Recent accounts have estimated TBI incidence rates as high as 20 % among US veterans who served in Afghanistan or Iraq, and many of these veterans experience a host of co-morbid concerns, including psychiatric complaints (such as depression and post-traumatic stress disorder), sleep disturbance, and substance abuse which may warrant referral to behavioral health specialists working in primary care settings. This paper reviews many common behavioral health concerns co-morbid with TBI, and suggests areas in which behavioral health specialists may assess, intervene, and help to facilitate holistic patient care beyond the acute phase of injury. The primary focus is on sequelae common to mild and moderate TBI which may more readily present in primary care clinics.

Promoting reintegration of National Guard veterans and their partners using a self-directed program of integrative therapies: a pilot study

This article reports pilot data from phase I of a project to develop and evaluate a self-directed program of integrative therapies for National Guard personnel and significant relationship partners to support reintegration and resilience after return from Iraq or Afghanistan. Data are reported on 43 dyads. Intervention was an integrated multimedia package of guided meditative, contemplative, and relaxation exercises (CD) and instruction in simple massage techniques (DVD) to promote stress reduction and interpersonal connectedness. A repeated measures design with standardized instruments was used to establish stability of baseline levels of relevant mental health domains (day 1, day 30), followed by the intervention and assessments 4 and 8 weeks later. Significant improvements in standardized measures for post-traumatic stress disorder, depression, and self-compassion were seen in both veterans and partners; and in stress for partners. Weekly online reporting tracked utilization of guided exercises and massage. Veterans reported significant reductions in ratings of physical pain, physical tension, irritability, anxiety/worry, and depression after massage, and longitudinal analysis suggested declining baseline levels of tension and irritability. Qualitative data from focus groups and implications for continued development and a phase II trial are discussed.

Cognitive sequelae of blast-induced traumatic brain injury: recovery and rehabilitation

Blast-related traumatic brain injury (bTBI) poses a significant concern for military personnel engaged in Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF). Given the highly stressful context in which such injury occurs, psychiatric comorbidities are common. This paper provides an overview of mild bTBI and discusses the cognitive sequelae and course of recovery typical of mild TBI (mTBI). Complicating factors that arise in the context of co-morbid posttraumatic stress disorder (PTSD) are considered with regard to diagnosis and treatment. Relatively few studies have evaluated the efficacy of cognitive rehabilitation in civilian mTBI, but we discuss cognitive training approaches that hold promise for addressing mild impairments in executive function and memory, akin to those seen in OEF/OIF veterans with bTBI and PTSD. Further research is needed to address the patient and environmental characteristics associated with optimal treatment outcome.