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Kinney AR, Brenner LA, Nance M, Mignogna J, Cobb AD, Forster JE, Ulmer CS, Nakase-Richardson R, Bahraini NH. Factors Influencing Adherence to Insomnia and Obstructive Sleep Apnea Treatments among Veterans with Mild Traumatic Brain Injury. Behav Sleep Med 2024; 22:553-570. [PMID: 38420915 DOI: 10.1080/15402002.2024.2322517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
OBJECTIVE To understand factors influencing adherence to recommended treatment for insomnia and obstructive sleep apnea (OSA) among Veterans with mild traumatic brain injury (mTBI). METHOD Semi-structured interviews (n = 49) with 29 clinical stakeholders and 20 Veterans were conducted. Clinical stakeholders included Veterans Health Administration providers and policymakers involved in the management of mTBI and/or sleep disorders. Veterans included those with a clinician-confirmed mTBI with a recent history of insomnia disorder and/or OSA treatment. Themes were identified using a Descriptive and Interpretive approach. RESULTS Barriers to sleep disorder treatment adherence included factors associated with the patient (e.g., negative appraisal of treatment benefit), intervention (e.g., side effects), health conditions (e.g., cognitive challenges), health care system (e.g., limited availability of care), and socioeconomic status (e.g., economic instability). Similarly, facilitators of adherence included patient- (e.g., positive appraisal of treatment benefit), intervention- (e.g., flexible delivery format), condition- (e.g., accommodating cognitive impairments), health care system- (e.g., access to adherence support), and socioeconomic-related factors (e.g., social support). CONCLUSIONS Interviews revealed the multi-faceted nature of factors influencing adherence to sleep disorder treatment among Veterans with mTBI. Findings can inform the development of novel interventions and care delivery models that meet the complex needs of this population.
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Affiliation(s)
- Adam R Kinney
- Veteran Affairs Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC) for Suicide Prevention, Rocky Mountain MIRECC, Aurora, CO
- Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Lisa A Brenner
- Veteran Affairs Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC) for Suicide Prevention, Rocky Mountain MIRECC, Aurora, CO
- Departments of Physical Medicine and Rehabilitation, Psychiatry, and Neurology, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Morgan Nance
- Veteran Affairs Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC) for Suicide Prevention, Rocky Mountain MIRECC, Aurora, CO
- Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Joseph Mignogna
- Veteran Affairs Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC) for Suicide Prevention, Rocky Mountain MIRECC, Aurora, CO
- Departments of Physical Medicine and Rehabilitation, Psychiatry, and Neurology, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Audrey D Cobb
- Veteran Affairs Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC) for Suicide Prevention, Rocky Mountain MIRECC, Aurora, CO
| | - Jeri E Forster
- Veteran Affairs Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC) for Suicide Prevention, Rocky Mountain MIRECC, Aurora, CO
- Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Christi S Ulmer
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs, Durham, NC
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC
| | - Risa Nakase-Richardson
- Research Service, James A. Haley Veterans Hospital, Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of South Florida, Tampa
| | - Nazanin H Bahraini
- Veteran Affairs Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC) for Suicide Prevention, Rocky Mountain MIRECC, Aurora, CO
- Departments of Physical Medicine and Rehabilitation and Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, CO
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2
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Howard IM, Sedarsky K, Gallagher M, Miller M, Puffer RC. Combat-related peripheral nerve injuries. Muscle Nerve 2024. [PMID: 38837797 DOI: 10.1002/mus.28168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 04/09/2024] [Accepted: 04/24/2024] [Indexed: 06/07/2024]
Abstract
Active-duty service members (ADSM) and military Veterans represent a population with increased occupational risk for nerve injuries sustained both during training operations and wartime. Mechanisms of war-related nerve injuries have evolved over time, from the musket ball-related traumas described by S.W. Mitchell to complex blast injuries and toxic exposures sustained during Middle East conflicts in the 21st century. Commonly encountered nerve injury etiologies in this population currently include compression, direct trauma, nutritional deficits, traumatic limb amputation, toxic chemical exposures, or blast-related injuries. Expeditious identification and comprehensive, interdisciplinary treatment of combat-associated neuropathies, as well as prevention of these injuries whenever possible is critical to reduce chronic morbidity and disability for service members and to maintain a well-prepared military. However, diagnosis of a combat-associated nerve injury may be particularly challenging due to comorbid battlefield injuries or delayed presentation of neuropathy from military toxic exposures. Advances in imaging for nerve injury, including MRI and ultrasound, provide useful tools to compliment EMG in establishing a diagnosis of combat-associated nerve injury, particularly in the setting of anatomic disruption or edema. Surgical techniques can improve pain control or restoration of function. In all cases, comprehensive interdisciplinary rehabilitation provides the best framework for optimization of recovery. Further work is needed to prevent combat-associated nerve injuries and promote nerve recovery following injury.
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Affiliation(s)
- Ileana M Howard
- Rehabilitation Care Services, VA Puget Sound Healthcare System, Seattle, Washington, USA
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
| | - Kaye Sedarsky
- Department of Neurology, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Michael Gallagher
- Rehabilitation Care Services, VA Puget Sound Healthcare System, Seattle, Washington, USA
| | - Matthew Miller
- Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Ross C Puffer
- Department of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
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3
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Kinney AR, Yan XD, Schneider AL, Rickles E, King SE, O'Donnell F, Forster JE, Brenner LA. Unmet Need for Outpatient Occupational Therapy Services Among Veterans With Mild Traumatic Brain Injury in the Veterans Health Administration: The Role of Facility Characteristics. Arch Phys Med Rehabil 2023; 104:1802-1811. [PMID: 37116557 DOI: 10.1016/j.apmr.2023.03.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 03/21/2023] [Accepted: 03/31/2023] [Indexed: 04/30/2023]
Abstract
OBJECTIVE To investigate whether participation restrictions, an indicator of need for occupational therapy (OT), was associated with outpatient OT utilization in the Veterans Health Administration (VHA) among Veterans with mild traumatic brain injury (mTBI), and whether this relation differs by facility characteristics. DESIGN In a secondary analysis of national VHA data, we used modified Poisson regression to model OT utilization (yes/no) as a function of participation restrictions (Mayo-Portland Adaptability Inventory Participation Index [M2PI]), facility characteristics, and covariates. Facility characteristics included complexity, geographic region, and self-reported access to specialty care. Covariates included prior OT utilization, sociodemographic factors, injury characteristics, and spatial access (eg, drive time). Interactions estimated whether the relation between participation restrictions and OT utilization differed across facility characteristics. SETTING Outpatient setting in the VHA. PARTICIPANTS 8684 Veterans with a clinician-confirmed mTBI who received outpatient VHA care between 2012 and 2020 (N=8684). INTERVENTIONS None. MAIN OUTCOME MEASURE(S) OT utilization was measured within a year of M2PI administration using VHA administrative data. RESULTS Many Veterans who did not receive OT reported participation limitations, indicating unmet need for OT (eg, 67% with leisure restrictions). Participation restrictions were associated with increased likelihood of receiving OT (risk ratio [RR]=1.01; 95% confidence interval [CI]=1.006-1.019), suggesting a tendency for Veterans' OT-related needs to be satisfied. However, interactions indicated that this was not the case among Veterans receiving care in lower complexity facilities, and those in the South. Veterans with longer drive times were less likely to receive OT (RR=0.82; 95% CI=0.744-0.904). CONCLUSIONS Participation restrictions were associated with OT utilization, yet many Veterans with mTBI who may have benefited did not receive such care. Specific barriers to accessing OT (eg, OT practitioner supply) should be investigated. Novel care models can ensure access to OT services among Veterans seeking care at less-resourced and/or geographically distant VHA facilities.
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Affiliation(s)
- Adam R Kinney
- VA Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC), Aurora, CO; University of Colorado, Anschutz Medical Campus, Department of Physical Medicine and Rehabilitation, Aurora, CO.
| | - Xiang-Dong Yan
- VA Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC), Aurora, CO
| | - Alexandra L Schneider
- VA Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC), Aurora, CO
| | - Emma Rickles
- University of Colorado, Anschutz Medical Campus, Department of Physical Medicine and Rehabilitation, Aurora, CO
| | - Samuel E King
- VA Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC), Aurora, CO
| | - Frederica O'Donnell
- Department of Rehabilitation and Prosthetic Services, Veterans Health Administration, Washington, DC
| | - Jeri E Forster
- VA Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC), Aurora, CO; University of Colorado, Anschutz Medical Campus, Department of Physical Medicine and Rehabilitation, Aurora, CO
| | - Lisa A Brenner
- VA Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC), Aurora, CO; University of Colorado, Anschutz Medical Campus, Departments of Physical Medicine and Rehabilitation, Psychiatry, and Neurology, Aurora, CO
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4
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Hamilton JA, Ketchum JM, Hammond FM, Peterson MD, Zasler ND, Eapen BC, Adamson MM, Galhorta PP, Harris O, Nakase-Richardson R. Comparison of veterans affairs and NIDILRR traumatic brain injury model systems participants with disorders of consciousness. Brain Inj 2023; 37:282-292. [PMID: 36539996 DOI: 10.1080/02699052.2022.2158226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To characterize demographic, pre-injury, and outcome data within the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) and Veterans Affairs (VA) Traumatic Brain Injury Model Systems (TBIMS) cohorts with severe traumatic brain injury (TBI) with no command-following ability at time of admission to acute rehabilitation. DESIGN Retrospective cohort. SETTING NIDILRR and VA TBI Model Systems (TBIMS) centers. PARTICIPANTS 396 NIDILRR and 72 VA participants without command-following ability who experienced TBI with subsequent Disorder of Consciousness (DoC). MAIN OUTCOME MEASURE Pre-injury and injury characteristics, rehabilitation outcomes, and 1-year self-reported outcomes. RESULTS VA TBIMS cohort included individuals who were active duty or had military service before their injury. The VA cohort were more likely to be re-hospitalized at 1-year follow-up or residing in a long-term care or rehab setting. The NIDILRR TBIMS cohort had higher FIM and DRS scores at rehabilitation discharge, while the VA participants saw longer lengths of stay and higher numbers of "violent" injury types. CONCLUSIONS This study allows for a better understanding of the comparability between VA and NIDILRR DoC cohorts providing guidance on how veteran and civilian samples might be merged in future TBIMS studies to explore predictors of recovery from a DoC.
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Affiliation(s)
| | | | - Flora M Hammond
- Department Physical Medicine and Rehabilitation, Indiana University School of Medicine, Rehabilitation Hospital of Indiana, Carolinas Rehabilitation, 4141 Shore Drive 46254, Indianapolis, Indiana
| | | | - Nathan D Zasler
- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, Virginia
| | - Blessen C Eapen
- Division of Physical Medicine and Rehabilitation, Physical Medicine and Rehabilitation Service, VA Greater Los Angeles Health Care System, Los Angeles, California
| | - Maheen Mausoof Adamson
- Department of Neurosurgery, Rehabilitation Service, VA Palo Alto Health Care System, Palo Alto, California
| | - Pawan P Galhorta
- VA Palo Alto Health Care System, Palo Alto, CA, Program Director, Polytrauma Rehabilitation Center
| | - Odette Harris
- Department of Neurosurgery, Director, Brain Injury, Stanford University School of Medicine
| | - Risa Nakase-Richardson
- Mental Health and Behavioral Sciences, James A. Haley Veterans Hospital, Defense Health Agency TBI Center of Excellence at James A. Haley Veterans Hospital, Tampa, Florida
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5
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Adams RS, Hoover P, Forster JE, Caban J, Brenner LA. Traumatic Brain Injury Classification Variability During the Afghanistan/Iraq Conflicts: Surveillance, Clinical, Research, and Policy Implications. J Head Trauma Rehabil 2022; 37:361-370. [PMID: 36075868 PMCID: PMC9643596 DOI: 10.1097/htr.0000000000000775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Challenges associated with case ascertainment of traumatic brain injuries (TBIs) sustained during the Afghanistan/Iraq military operations have been widespread. This study was designed to examine how the prevalence and severity of TBI among military members who served during the conflicts were impacted when a more precise classification of TBI diagnosis codes was compared with the Department of Defense Standard Surveillance Case-Definition (DoD-Case-Definition). SETTING Identification of TBI diagnoses in the Department of Defense's Military Health System from October 7, 2001, until December 31, 2019. PARTICIPANTS Military members with a TBI diagnosis on an encounter record during the study window. DESIGN Descriptive observational study to evaluate the prevalence and severity of TBI with regard to each code set (ie, the DoD-Case-Definition and the more precise set of TBI diagnosis codes). The frequencies of index TBI severity were compared over time and further evaluated against policy changes. MAIN MEASURES The more precise TBI diagnosis code set excludes the following: (1) DoD-only extender codes, which are not used in other healthcare settings; and (2) nonprecise TBI codes, which include injuries that do not necessarily meet TBI diagnostic criteria. RESULTS When comparing the 2 TBI classifications, the DoD-Case-Definition captured a higher prevalence of TBIs; 38.5% were classified by the DoD-Case-Definition only (>164 000 military members). 73% of those identified by the DoD-Case-Definition only were diagnosed with nonprecise TBI codes only, with questionable specificity as to whether a TBI occurred. CONCLUSION We encourage the field to reflect on decisions made pertaining to TBI case ascertainment during the height of the conflicts. Efforts focused on achieving consensus regarding TBI case ascertainment are recommended. Doing so will allow the field to be better prepared for future conflicts, and improve surveillance, screening, and diagnosis in noncombat settings, as well as our ability to understand the long-term effects of TBI.
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Affiliation(s)
- Rachel Sayko Adams
- Institute for Behavioral Health, The Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts, USA
- VHA Rocky Mountain Mental Illness Research Education and Clinical Center, Aurora, Colorado, USA
| | - Peter Hoover
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD
| | - Jeri E. Forster
- VHA Rocky Mountain Mental Illness Research Education and Clinical Center, Aurora, Colorado, USA
- University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Jesus Caban
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD
| | - Lisa A. Brenner
- VHA Rocky Mountain Mental Illness Research Education and Clinical Center, Aurora, Colorado, USA
- University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
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6
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Swan AA, Akin FW, Amuan ME, Riska KM, Hall CD, Kalvesmaki A, Padilla S, Crowsey E, Pugh MJ. Disruptive Dizziness Among Post-9/11 Veterans With Deployment-Related Traumatic Brain Injury. J Head Trauma Rehabil 2022; 37:199-212. [PMID: 34320551 DOI: 10.1097/htr.0000000000000714] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To identify disruption due to dizziness symptoms following deployment-related traumatic brain injury (TBI) and factors associated with receiving diagnoses for these symptoms. SETTING Administrative medical record data from the Department of Veterans Affairs (VA). PARTICIPANTS Post-9/11 veterans with at least 3 years of VA care who reported at least occasional disruption due to dizziness symptoms on the comprehensive TBI evaluation. DESIGN A cross-sectional, retrospective, observational study. MAIN MEASURES International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes of dizziness, vestibular dysfunction, and other postconcussive conditions; neurobehavioral Symptom Inventory. RESULTS Increased access to or utilization of specialty care at the VA was significant predictors of dizziness and/or vestibular dysfunction diagnoses in the fully adjusted model. Veterans who identified as Black non-Hispanic and those with substance use disorder diagnoses or care were substantially less likely to receive dizziness and vestibular dysfunction diagnoses. CONCLUSIONS Access to specialty care was the single best predictor of dizziness and vestibular dysfunction diagnoses, underscoring the importance of facilitating referrals to and utilization of specialized, comprehensive clinical facilities or experts for veterans who report disruptive dizziness following deployment-related TBI. There is a clear need for an evidence-based pathway to address disruptive symptoms of dizziness, given the substantial variation in audiovestibular tests utilized by US providers by region and clinical specialty. Further, the dearth of diagnoses among Black veterans and those in more rural areas underscores the potential for enhanced cultural competency among providers, telemedicine, and patient education to bridge existing gaps in the care of dizziness.
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Affiliation(s)
- Alicia A Swan
- Department of Psychology, The University of Texas at San Antonio, San Antonio (Dr Swan and Ms Crowsey); South Texas Veterans Health Care System, San Antonio (Dr Swan); James H Quillen VA Medical Center, Mountain Home, Tennessee (Drs Akin and Hall); Departments of Audiology and Speech Language Pathology (Dr Akin) and Rehabilitative Sciences (Dr Hall), East Tennessee State University, Johnson City; Informatics, Decision-Enhancement and Analytic Sciences Center (IDEAS 2.0), VA Salt Lake City Health Care System, Salt Lake City, Utah (Mss Amuan and Padilla and Drs Kalvesmaki and Pugh); Department of Internal Medicine, University of Utah, Salt Lake City (Mss Amuan and Padilla and Drs Kalvesmaki and Pugh); Department of Head and Neck Surgery & Communication Sciences, Duke University, Durham, North Carolina (Dr Riska); and Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, North Carolina (Dr Riska)
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7
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McGeary DD, Resick PA, Penzien DB, McGeary CA, Houle TT, Eapen BC, Jaramillo CA, Nabity PS, Reed DE, Moring JC, Bira LM, Hansen HR, Young-McCaughan S, Cobos BA, Mintz J, Keane TM, Peterson AL. Cognitive Behavioral Therapy for Veterans With Comorbid Posttraumatic Headache and Posttraumatic Stress Disorder Symptoms: A Randomized Clinical Trial. JAMA Neurol 2022; 79:746-757. [PMID: 35759281 PMCID: PMC9237802 DOI: 10.1001/jamaneurol.2022.1567] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
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
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Affiliation(s)
- Donald D McGeary
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center San Antonio, San Antonio.,Department of Rehabilitation Medicine, The University of Texas Health Science Center at San Antonio, San Antonio.,South Texas Veterans Health Care System, San Antonio.,Department of Psychology, The University of Texas at San Antonio, San Antonio
| | - Patricia A Resick
- Department of Psychiatry and Behavioral Sciences, Duke Health, Durham, North Carolina
| | - Donald B Penzien
- Departments of Psychiatry and Behavioral Medicine & Neurology, Wake Forest University, Winston-Salem, North Carolina
| | - Cindy A McGeary
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center San Antonio, San Antonio.,South Texas Veterans Health Care System, San Antonio
| | - Timothy T Houle
- Department of Anesthesia, Massachusetts General Hospital, Boston
| | - Blessen C Eapen
- Greater Los Angeles Veterans Health Care System, Los Angeles, California.,Department of Physical Medicine and Rehabilitation, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles
| | - Carlos A Jaramillo
- Department of Rehabilitation Medicine, The University of Texas Health Science Center at San Antonio, San Antonio.,South Texas Veterans Health Care System, San Antonio
| | - Paul S Nabity
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center San Antonio, San Antonio.,South Texas Veterans Health Care System, San Antonio
| | - David E Reed
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center San Antonio, San Antonio
| | - John C Moring
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center San Antonio, San Antonio.,South Texas Veterans Health Care System, San Antonio
| | - Lindsay M Bira
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center San Antonio, San Antonio
| | - Hunter R Hansen
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center San Antonio, San Antonio
| | - Stacey Young-McCaughan
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center San Antonio, San Antonio.,South Texas Veterans Health Care System, San Antonio
| | - Briana A Cobos
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center San Antonio, San Antonio.,Department of Psychology, The University of Texas at San Antonio, San Antonio
| | - Jim Mintz
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center San Antonio, San Antonio.,South Texas Veterans Health Care System, San Antonio
| | - Terence M Keane
- Behavioral Science Division, National Center for PTSD, Boston, Massachusetts.,VA Boston Healthcare System, Boston, Massachusetts.,Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts
| | - Alan L Peterson
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center San Antonio, San Antonio.,South Texas Veterans Health Care System, San Antonio.,Department of Psychology, The University of Texas at San Antonio, San Antonio
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8
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Etchin AG, Fonda JR, Howard EP, Fortier CB, Milberg WP, Pounds K, McGlinchey RE. Childhood Trauma Differentially Impacts Depression and Stress Associations with Reintegration Challenges Among Post-9/11 U.S. Veterans. Nurs Outlook 2021; 70:323-336. [PMID: 34895737 DOI: 10.1016/j.outlook.2021.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 09/30/2021] [Accepted: 10/25/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Post-9/11 veterans exhibit high prevalence of deployment stress, psychological conditions, and traumatic brain injury (TBI) which impact reintegration, especially among those with a history of interpersonal early life trauma (I-ELT). The relative importance of each risk factor is unclear. PURPOSE We examined major deployment and clinical exposures of reintegration challenges among veterans with and without I-ELT. METHOD We analyzed cross-sectional data of 155 post-9/11 veterans from the Translational Research Center for TBI and Stress Disorders study. FINDINGS Depression severity had the strongest association with reintegration challenges, followed by posttraumatic stress disorder (PTSD) severity, post-deployment stress, and deployment safety concerns. Deployment safety concerns had a stronger, significant association among veterans with I-ELT. In nearly every model, PTSD and depression severities were weaker for veterans with I-ELT, compared to those without. DISCUSSION Clinicians should consider the relative risk of concurrent clinical conditions and trauma histories when considering veterans' reintegration needs.
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Affiliation(s)
- Anna G Etchin
- Translational Research Center for TBI & Stress Disorders, VA Boston Healthcare System, Boston, MA.
| | - Jennifer R Fonda
- Translational Research Center for TBI & Stress Disorders, VA Boston Healthcare System, Boston, MA; Department of Psychiatry, Boston University Medical Campus, Boston, MA; Department of Psychiatry, Harvard Medical School, Boston, MA
| | - Elizabeth P Howard
- Connell School of Nursing, Boston College, Chestnut Hill, MA; The Hinda and Arthur Marcus Institute for Aging Research (The Marcus Institute), Hebrew Senior Life, Boston, MA
| | - Catherine B Fortier
- Translational Research Center for TBI & Stress Disorders, VA Boston Healthcare System, Boston, MA; Department of Psychiatry, Harvard Medical School, Boston, MA; Geriatric Research Education and Clinical Center, VA Boston Healthcare System, Boston, MA
| | - William P Milberg
- Translational Research Center for TBI & Stress Disorders, VA Boston Healthcare System, Boston, MA; Department of Psychiatry, Harvard Medical School, Boston, MA; Geriatric Research Education and Clinical Center, VA Boston Healthcare System, Boston, MA
| | - Karen Pounds
- College of Nursing and Health Sciences, University of Massachusetts Dartmouth, North Dartmouth, MA
| | - Regina E McGlinchey
- Translational Research Center for TBI & Stress Disorders, VA Boston Healthcare System, Boston, MA; Department of Psychiatry, Harvard Medical School, Boston, MA; Geriatric Research Education and Clinical Center, VA Boston Healthcare System, Boston, MA
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9
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Swan AA, Nelson JT, Pogoda TK, Akin FW, Riska KM, Hall CD, Amuan ME, Yaffe K, Pugh MJ. Association of Traumatic Brain Injury With Vestibular Dysfunction and Dizziness in Post-9/11 Veterans. J Head Trauma Rehabil 2021; 35:E253-E265. [PMID: 31569144 DOI: 10.1097/htr.0000000000000513] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To describe the prevalence and impact of vestibular dysfunction and nonspecific dizziness diagnoses and explore their associations with traumatic brain injury (TBI) severity, mechanism, and postconcussive comorbidities among post-9/11 veterans. SETTING Administrative medical record data from the US Departments of Defense and Veterans Affairs (VA). PARTICIPANTS Post-9/11 veterans with at least 3 years of VA care. DESIGN Cross-sectional, retrospective, observational study. MAIN MEASURES International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes for TBI, vestibular dysfunction, dizziness, and other commonly associated postconcussive conditions; Neurobehavioral Symptom Inventory. RESULTS Of the 570 248 post-9/11 veterans in this sample, 0.45% had a diagnosis of vestibular dysfunction and 2.57% had nonspecific dizziness. Those with either condition were more likely to have evidence of TBI (57.11% vs 28.51%) and reported more disruption from neurobehavioral symptoms. Blast and nonblast injuries were associated with greater symptom disruption, particularly in combination. CONCLUSIONS There was a consistent, significant association between TBI and vestibular dysfunction or nonspecific dizziness, after controlling for sociodemographic factors, injury mechanism, and comorbid conditions. Given that most deployed post-9/11 veterans report blast and/or nonblast injuries, the need for prompt identification and management of these conditions and symptoms is clear.
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Affiliation(s)
- Alicia A Swan
- University of Texas at San Antonio (Dr Swan); Department of Defense Hearing Center of Excellence, Defense Health Agency, San Antonio, Texas (Dr Nelson); Ho-Chunk, Inc, Alexandria, Virginia (Dr Nelson); Department of Radiology and Imaging Sciences, School of Medicine, Indiana University, Indianapolis (Dr Nelson); Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, Massachusetts (Dr Pogoda); Boston University School of Public Health, Boston, Massachusetts (Dr Pogoda); James H. Quillen VA Medical Center, Mountain Home, Tennessee (Drs Akin and Hall); Departments of Audiology and Speech Language Pathology (Dr Akin) and Physical Therapy (Dr Hall), East Tennessee State University, Johnson City; Division of Head and Neck Surgery & Communication Sciences, Department of Surgery, Duke University, Durham, North Carolina (Dr Riska); Center for Health Care Organization and Implementation Research, Edith Nourse Rogers VA Medical Center, Bedford, Massachusetts (Ms Amuan); Departments of Psychiatry, Neurology and Epidemiology, School of Medicine, University of California San Francisco (Dr Yaffe); Informatics, Decision-Enhancement and Analytic Sciences Center (IDEAS 2.0), VA Salt Lake City Health Care System, Salt Lake City, Utah (Dr Pugh); and Department of Internal Medicine, The University of Utah, Salt Lake City (Dr Pugh)
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10
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Developing a Therapeutic Approach Toward Active Engagement for Veterans With Mild Traumatic Brain Injury. J Head Trauma Rehabil 2020; 34:141-149. [PMID: 31058756 DOI: 10.1097/htr.0000000000000490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Treatment of chronic mild traumatic brain injury (mTBI) or postdeployment syndrome can be challenging to frontline providers who care for our nation's war heroes. There is ample guidance available for symptom-based interventions, but relatively little information regarding the structure and language of the clinical encounter. Dynamic patient education centered upon relatable language, accessible analogies, and brain health can move the visit beyond historical diagnostics into a shared understanding of postdeployment barriers to reintegration. OBJECTIVE We aim to describe a practical, education-based clinical approach for chronic mTBI or postdeployment syndrome (mTBI/PDS). The foundation of this method is gathering the veteran's narrative, validating and normalizing his or her experience, highlighting neurobehavioral changes from combat that may represent barriers to full community reintegration, and transitioning to an emphasis on overall brain health. CONCLUSION The chronic mTBI or PDS clinical encounter can be enhanced by empowering the patient with relatable terms and concepts to describe his or her reintegration challenges and emphasizing factors of brain health. This approach can provide the patient with a base of understanding regarding his or her current symptoms, promote focus on factors for cognitive health, and orient the clinical encounter toward improved community reintegration and long-term cognitive wellness.
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11
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Cogan AM, Smith B, Bender Pape TL, Mallinson T, Eapen BC, Scholten J. Self-reported Participation Restrictions Among Male and Female Veterans With Traumatic Brain Injury in Veterans Health Administration Outpatient Polytrauma Programs. Arch Phys Med Rehabil 2020; 101:2071-2079. [PMID: 32795563 DOI: 10.1016/j.apmr.2020.06.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 06/30/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To identify areas of most restricted self-reported participation among veterans with traumatic brain injury (TBI), explore associations among participation restriction and clinical characteristics, and examine differences in participation restrictions by sex. DESIGN Retrospective cross-sectional design. SETTING National VA Polytrauma System of Care outpatient settings. PARTICIPANTS Veterans with a confirmed TBI event (N=6065). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE(S) Mayo-Portland Participation Index (M2PI), a 5-point Likert-type scale with 8 items. Total score was converted to standardized T score for analysis. RESULTS The sample consisted of 5679 male and 386 female veterans with ≥1 clinically confirmed TBI events (69% white; 74% with blast exposure). The M2PI items with greatest perceived restrictions were social contact, leisure, and initiation. There were no significant differences between men and women on M2PI standardized T scores. Wilcoxon rank-sum analyses showed significant differences by sex on 4 items: leisure, residence, employment, and financial management (all P<.01). In multinomial logistic regression on each item controlling for demographics, injury characteristics, and comorbidities, female veterans had significantly greater relative risk for part-time work and unemployment on the employment item and significantly less risk for impairment on the residence and financial management item. CONCLUSIONS There was no significant difference between men and women. Veterans on M2PI standardized T scores, which masks differences in response patterns to individual items. Clinical teams should be encouraged to discuss perceived restrictions with patients and target these areas in treatment planning. Future work is needed to investigate the psychometric properties of the M2PI by biological sex.
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Affiliation(s)
- Alison M Cogan
- Physical Medicine and Rehabilitation Service, Washington DC VA Medical Center, Washington, DC.
| | - Bridget Smith
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Edward Hines Jr VA Hospital, US Department of Veterans Affairs, Hines, Illinois; Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Theresa L Bender Pape
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Edward Hines Jr VA Hospital, US Department of Veterans Affairs, Hines, Illinois; Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois; Department of Physical Medicine and Rehabilitation, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Trudy Mallinson
- School of Medicine and Health Sciences, George Washington University, Washington, DC
| | - Blessen C Eapen
- Physical Medicine and Rehabilitation Service, VA Greater Los Angeles Health Care System, Los Angeles, California
| | - Joel Scholten
- Physical Medicine and Rehabilitation Service, Washington DC VA Medical Center, Washington, DC
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12
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Critchfield E, Bain KM, Goudeau C, Gillis CJ, Gomez-Lansidel MT, Eapen BC. A Model of Care for Community Reintegration. Phys Med Rehabil Clin N Am 2019; 30:43-54. [DOI: 10.1016/j.pmr.2018.08.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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13
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O'Rourke J, Critchfield E, Soble J, Bain K, Fullen C, Eapen B. The Utility of the Mayo-Portland Adaptability Inventory Participation Index (M2PI) in US Military Veterans With a History of Mild Traumatic Brain Injury. J Head Trauma Rehabil 2019; 34:30-35. [DOI: 10.1097/htr.0000000000000405] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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14
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Peterson M, Eapen BC, Himmler M, Galhotra P, Glazer D. Evolution of Care for the Veterans and Active Duty Service Members with Disorders of Consciousness. Phys Med Rehabil Clin N Am 2018; 30:29-41. [PMID: 30470427 DOI: 10.1016/j.pmr.2018.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The Veteran Health Administration Polytrauma Rehabilitation Center Emerging Consciousness Program (ECP) has served veterans and service members with disorders of consciousness (DOC) over the past 10 years. The ECP has evolved to meet the unique needs of this patient population, including updating admission criteria to follow evidence-based guidelines for the management of DOC, expanding the use of treatment modalities, and monitoring longitudinal outcomes. The authors review current assessment tools, medical management, and interventions and describe the current state of the ECP and how the evolution of the ECP has enhanced the care of veterans and service members with DOC.
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Affiliation(s)
- Michelle Peterson
- Physical Medicine and Rehabilitation Service, Polytrauma Rehabilitation Center (4K), Minneapolis VA Health Care System, One Veterans Drive, Minneapolis, MN 55417, USA.
| | - Blessen C Eapen
- Department of Physical Medicine and Rehabilitation, VA Greater Los Angeles Health Care System, 11301 Wilshire Boulevard, Los Angeles, CA 90073, USA
| | - Mary Himmler
- Physical Medicine and Rehabilitation Service, Polytrauma Rehabilitation Center (4K), Minneapolis VA Health Care System, One Veterans Drive, Minneapolis, MN 55417, USA
| | - Pawan Galhotra
- Physical Medicine and Rehabilitation Service, Polytrauma Rehabilitation Center, Palo Alto Health Care System, 3801 Miranda Avenue (PSC 117), Palo Alto, CA 94304, USA
| | - David Glazer
- Physical Medicine and Rehabilitation Service, Polytrauma Rehabilitation Center, Hunter Holmes McGuire VA Medical Center, 1201 Broad Rock Boulevard, Richmond, VA 23249, USA
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15
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Nnamani NS, Pugh MJ, Amuan ME, Eapen BC, Hudak SJ, Liss MA, Orman JA. Outcomes of Genitourinary Injury in U.S. Iraq and Afghanistan War Veterans Receiving Care from the Veterans Health Administration. Mil Med 2018; 184:e297-e301. [DOI: 10.1093/milmed/usy196] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 07/12/2018] [Indexed: 11/14/2022] Open
Affiliation(s)
- Nina S Nnamani
- US Army Institute of Surgical Research, 3698 Chambers Pass, JBSA Fort Sam Houston, TX
| | - Mary Jo Pugh
- Department of Epidemiology and Biostatistics, University of Texas Health San Antonio, 7703 Floyd Curl Drive, San Antonio, TX
- South Texas Veterans Health Care System, 7400 Merton Minter St., San Antonio, TX
| | - Megan E Amuan
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Hospital, 200 Springs Road, Bedford, MA
| | - Blessen C Eapen
- Polytrauma Rehabilitation Center, South Texas Veterans Health Care System, 7400 Merton Minter St., San Antonio, TX
- Department of Rehabilitation Medicine, University of Texas Health San Antonio, 7703 Floyd Curl Drive San Antonio, TX
| | - Steven J Hudak
- Urology Clinic, Department of Surgery, Brooke Army Medical Center, 3551 Roger Brooke Drive, JBSA Fort Sam Houston, TX
- Department of Surgery, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD
| | - Michael A Liss
- South Texas Veterans Health Care System, 7400 Merton Minter St., San Antonio, TX
- Department of Urology, University of Texas Health San Antonio, 7703 Floyd Curl Drive San Antonio, TX
| | - Jean A Orman
- Department of Surgery, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD
- Joint Trauma System, 3698 Chambers Pass, JBSA Fort Sam Houston, San Antonio, TX
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Swan AA, Nelson JT, Pogoda TK, Amuan ME, Akin FW, Pugh MJ. Sensory dysfunction and traumatic brain injury severity among deployed post-9/11 veterans: a Chronic Effects of Neurotrauma Consortium study. Brain Inj 2018; 32:1197-1207. [DOI: 10.1080/02699052.2018.1495340] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Alicia A. Swan
- South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Jeremy T. Nelson
- Department of Defense Hearing Center of Excellence, San Antonio, TX, USA
| | - Terri K. Pogoda
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA, USA
- Boston University School of Public Health, Boston, MA, USA
| | - Megan E. Amuan
- Center for Health Care Organization and Implementation Research, Edith Nourse Rogers VA Medical Center, Bedford, MA, USA
| | - Faith W. Akin
- James H Quillen VA Medical Center, Mountain Home, TN, USA
- Department of Audiology and Speech Language Pathology, East Tennessee State University, Johnson City, TN, USA
| | - Mary Jo Pugh
- South Texas Veterans Health Care System, San Antonio, TX, USA
- Department of Epidemiology and Biostatistics, University of Texas Health Science Center San Antonio, San Antonio, TX, USA
- Informatics, Decision-Enhancement and Analytic Sciences Center (IDEAS 2.0) VA Salt Lake City Health Care System and Department of Internal Medicine, University of Utah, USA
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Traumatic Brain Injury Severity, Comorbidity, Social Support, Family Functioning, and Community Reintegration Among Veterans of the Afghanistan and Iraq Wars. Arch Phys Med Rehabil 2018. [DOI: 10.1016/j.apmr.2017.05.021] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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