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Rowland JA, Martindale SL. Considerations for the assessment of blast exposure in service members and veterans. Front Neurol 2024; 15:1383710. [PMID: 38685944 PMCID: PMC11056521 DOI: 10.3389/fneur.2024.1383710] [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: 02/07/2024] [Accepted: 03/29/2024] [Indexed: 05/02/2024] Open
Abstract
Introduction Blast exposure is an increasingly present occupational hazard for military service members, particularly in modern warfare scenarios. The study of blast exposure in humans is limited by the lack of a consensus definition for blast exposure and considerable variability in measurement. Research has clearly demonstrated a robust and reliable effect of blast exposure on brain structure and function in the absence of other injury mechanisms. However, the exact mechanisms underlying these outcomes remain unclear. Despite clear contributions from preclinical studies, this knowledge has been slow to translate to clinical applications. The present manuscript empirically demonstrates the consequences of variability in measurement and definition across studies through a re-analysis of previously published data from the Chronic Effects of Neurotrauma Study 34. Methods Definitions of blast exposure used in prior work were examined including Blast TBI, Primary Blast TBI, Pressure Severity, Distance, and Frequency of Exposure. Outcomes included both symptom report and cognitive testing. Results Results demonstrate significant differences in outcomes based on the definition of blast exposure used. In some cases the same definition was strongly related to one type of outcome, but unrelated to another. Discussion The implications of these results for the study of blast exposure are discussed and potential actions to address the major limitations in the field are recommended. These include the development of a consensus definition of blast exposure, further refinement of the assessment of blast exposure, continued work to identify relevant mechanisms leading to long-term negative outcomes in humans, and improved education efforts.
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Affiliation(s)
- Jared A. Rowland
- Salisbury VA Healthcare System, Salisbury, NC, United States
- Veterans Integrated Service Network (VISN)-6 Mid-Atlantic Mental Illness, Research Education and Clinical Center (MIRECC), Durham, NC, United States
- Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Sarah L. Martindale
- Salisbury VA Healthcare System, Salisbury, NC, United States
- Veterans Integrated Service Network (VISN)-6 Mid-Atlantic Mental Illness, Research Education and Clinical Center (MIRECC), Durham, NC, United States
- Wake Forest School of Medicine, Winston-Salem, NC, United States
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2
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Lippa SM, Bailie JM, French LM, Brickell TA, Lange RT. Lifetime blast exposure is not related to cognitive performance or psychiatric symptoms in US military personnel. Clin Neuropsychol 2024:1-23. [PMID: 38494345 DOI: 10.1080/13854046.2024.2328881] [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: 09/25/2023] [Accepted: 03/05/2024] [Indexed: 03/19/2024]
Abstract
Objective: The present study aimed to examine the impact of lifetime blast exposure (LBE) on neuropsychological functioning in service members and veterans (SMVs). Method: Participants were 282 SMVs, with and without history of traumatic brain injury (TBI), who were prospectively enrolled in a Defense and Veterans Brain Injury Center (DVBIC)-Traumatic Brain Injury Center of Excellence (TBICoE) Longitudinal TBI Study. A cross-sectional analysis of baseline data was conducted. LBE was based on two factors: Military Occupational Speciality (MOS) and SMV self-report. Participants were divided into three groups based on LBE: Blast Naive (n = 61), Blast + Low Risk MOS (n = 96), Blast + High Risk MOS (n = 125). Multivariate analysis of variance (MANOVA) was used to examine group differences on neurocognitive domains and the Minnesota Multiphasic Personality Inventory-2 Restructured Form. Results: There were no statistically significant differences in attention/working memory, processing speed, executive functioning, and memory (Fs < 1.75, ps > .1, ηp2s < .032) or in General Cognition (Fs < 0.95, ps > .3, ηp2s < .008). Prior to correction for covariates, lifetime blast exposure was related to Restructured Clinical (F(18,542) = 1.77, p = .026, ηp2 = .055), Somatic/Cognitive (F(10,550) = 1.99, p = .033, ηp2 = .035), and Externalizing Scales (F(8,552) = 2.17, p = .028, ηp2 = .030); however, these relationships did not remain significant after correction for covariates (Fs < 1.53, ps > .145, ηp2s < .032). Conclusions: We did not find evidence of a relationship between LBE and neurocognitive performance or psychiatric symptoms. This stands in contrast to prior studies demonstrating an association between lifetime blast exposure and highly sensitive blood biomarkers and/or neuroimaging. Overall, findings suggest the neuropsychological impact of lifetime blast exposure is minimal in individuals remaining in or recently retired from military service.
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Affiliation(s)
- Sara M Lippa
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD, USA
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Jason M Bailie
- Traumatic Brain Injury Center of Excellence, Bethesda, MD, USA
- Naval Hospital Camp Pendleton, Oceanside, CA, USA
- General Dynamics Information Technology, Fairfax, VA, USA
| | - Louis M French
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD, USA
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
- Traumatic Brain Injury Center of Excellence, Bethesda, MD, USA
| | - Tracey A Brickell
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD, USA
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
- Traumatic Brain Injury Center of Excellence, Bethesda, MD, USA
- General Dynamics Information Technology, Fairfax, VA, USA
| | - Rael T Lange
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD, USA
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
- Traumatic Brain Injury Center of Excellence, Bethesda, MD, USA
- General Dynamics Information Technology, Fairfax, VA, USA
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
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3
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Newsome MR, Martindale SL, Davenport N, Dennis EL, Diaz M, Esopenko C, Hodges C, Jackson GR, Liu Q, Kenney K, Mayer AR, Rowland JA, Scheibel RS, Steinberg JL, Taylor BA, Tate DF, Werner JK, Walker WC, Wilde EA. Subcortical functional connectivity and its association with walking performance following deployment related mild TBI. Front Neurol 2023; 14:1276437. [PMID: 38156092 PMCID: PMC10752967 DOI: 10.3389/fneur.2023.1276437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 09/18/2023] [Indexed: 12/30/2023] Open
Abstract
Introduction The relation between traumatic brain injury (TBI), its acute and chronic symptoms, and the potential for remote neurodegenerative disease is a priority for military research. Structural and functional connectivity (FC) of the basal ganglia, involved in motor tasks such as walking, are altered in some samples of Service Members and Veterans with TBI, but any behavioral implications are unclear and could further depend on the context in which the TBI occurred. Methods In this study, FC from caudate and pallidum seeds was measured in Service Members and Veterans with a history of mild TBI that occurred during combat deployment, Service Members and Veterans whose mild TBI occurred outside of deployment, and Service Members and Veterans who had no lifetime history of TBI. Results FC patterns differed for the two contextual types of mild TBI. Service Members and Veterans with deployment-related mild TBI demonstrated increased FC between the right caudate and lateral occipital regions relative to both the non-deployment mild TBI and TBI-negative groups. When evaluating the association between FC from the caudate and gait, the non-deployment mild TBI group showed a significant positive relationship between walking time and FC with the frontal pole, implicated in navigational planning, whereas the deployment-related mild TBI group trended towards a greater negative association between walking time and FC within the occipital lobes, associated with visuo-spatial processing during navigation. Discussion These findings have implications for elucidating subtle motor disruption in Service Members and Veterans with deployment-related mild TBI. Possible implications for future walking performance are discussed.
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Affiliation(s)
- Mary R. Newsome
- Research Service Line, George E. Wahlen VA Medical Center, Salt Lake City, UT, United States
- Traumatic Brain Injury and Concussion Center, Department of Neurology, University of Utah, Salt Lake City, UT, United States
- H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX, United States
| | - Sarah L. Martindale
- Research and Academic Affairs Service Line, W. G. (Bill) Hefner VA Healthcare System, Salisbury, NC, United States
- Veterans Integrated Service Networks (VISN)-6 Mid-Atlantic Mental Illness, Research Education and Clinical Center (MIRECC), Durham, NC, United States
- Department of Physiology and Pharmacology, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Nicholas Davenport
- Research Service Line, Minneapolis VA Health Care System, Minneapolis, MN, United States
- Department of Psychiatry and Behavioral Sciences, University of Minnesota, Minneapolis, MN, United States
| | - Emily L. Dennis
- Research Service Line, George E. Wahlen VA Medical Center, Salt Lake City, UT, United States
- Traumatic Brain Injury and Concussion Center, Department of Neurology, University of Utah, Salt Lake City, UT, United States
| | - Marlene Diaz
- Research Service Line, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, United States
| | - Carrie Esopenko
- Department of Rehabilitation and Human Performance, Icahn School of Medicine, New York, NY, United States
| | - Cooper Hodges
- Department of Psychology, Brigham Young University, Provo, UT, United States
| | - George R. Jackson
- Parkinson's Disease Research, Education and Clinical Center (PADRECC), Michael E. DeBakey VA Medical Center, Houston, TX, United States
- Department of Neurology, Baylor College of Medicine, Houston, TX, United States
| | - Qisheng Liu
- Research Service Line, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, United States
- Center for Translational Research on Inflammatory Diseases (CTRID), Baylor College of Medicine, Houston, TX, United States
| | - Kimbra Kenney
- Department of Neurology, Uniform Services University, Bethesda, MD, United States
| | - Andrew R. Mayer
- The Mind Research Network/Lovelace Biomedical and Environmental Research Institute, Albuquerque, NM, United States
- Departments of Psychiatry and Behavioral Sciences, Psychology and Neurology, University of New Mexico, Albuquerque, NM, United States
| | - Jared A. Rowland
- Research and Academic Affairs Service Line, W. G. (Bill) Hefner VA Healthcare System, Salisbury, NC, United States
- Veterans Integrated Service Networks (VISN)-6 Mid-Atlantic Mental Illness, Research Education and Clinical Center (MIRECC), Durham, NC, United States
- Department of Neurobiology and Anatomy, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Randall S. Scheibel
- H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX, United States
- Research Service Line, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, United States
| | - Joel L. Steinberg
- Department of Psychiatry, Institute for Drug and Alcohol Studies, Virginia Commonwealth University, Richmond, VA, United States
| | - Brian A. Taylor
- Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - David F. Tate
- Research Service Line, George E. Wahlen VA Medical Center, Salt Lake City, UT, United States
- Traumatic Brain Injury and Concussion Center, Department of Neurology, University of Utah, Salt Lake City, UT, United States
| | - J. Kent Werner
- Department of Neurology, Uniform Services University, Bethesda, MD, United States
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD, United States
| | - William C. Walker
- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, VA, United States
| | - Elisabeth A. Wilde
- Research Service Line, George E. Wahlen VA Medical Center, Salt Lake City, UT, United States
- Traumatic Brain Injury and Concussion Center, Department of Neurology, University of Utah, Salt Lake City, UT, United States
- H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX, United States
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4
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Ord AS, Martindale SL, Jenks ER, Rowland JA. Subjective cognitive complaints and objective cognitive functioning in combat veterans: Effects of PTSD and deployment mild TBI. APPLIED NEUROPSYCHOLOGY. ADULT 2023:1-7. [PMID: 37991812 DOI: 10.1080/23279095.2023.2280807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2023]
Abstract
OBJECTIVES (1) Examine the relationship between subjective cognitive complaints and objective cognitive functioning in combat veterans; and (2) evaluate conditional effects of posttraumatic stress disorder (PTSD) and deployment-related mild traumatic brain injury (TBI) within that relationship. METHOD Combat veterans (N = 225, 86.22% male) completed a lifetime TBI interview, a structured interview assessing PTSD symptoms, a neuropsychological assessment battery, and a self-report measure of cognitive symptoms. RESULTS All correlations between subjective cognitive complaints and objective cognitive measures were not statistically significant. Hierarchical linear regression indicated that cognitive performance was not significantly related to cognitive complaints, but both PTSD diagnosis and history of deployment mild TBI explained a significant amount of unique variance in self-reported cognitive symptoms. Interactions between the studied variables were not significant. CONCLUSIONS PTSD and history of deployment mild TBI were uniquely related to cognitive complaints, but cognitive test performance was not. No confounding effects of PTSD or deployment mild TBI were observed in the relationship between cognitive performance and cognitive complaints. This provides support that symptom distress may be a better explanatory factor for perception of lower cognitive functioning than actual cognitive performance.
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Affiliation(s)
- Anna S Ord
- W. G. (Bill) Hefner VA Healthcare System, Salisbury, NC, USA
- Veterans Integrated Service Networks (VISN)-6 Mid-Atlantic Mental Illness, Research Education and Clinical Center (MIRECC), Durham, NC, USA
- College of Health and Behavioral Sciences, Regent University, Virginia Beach, VA, USA
| | - Sarah L Martindale
- W. G. (Bill) Hefner VA Healthcare System, Salisbury, NC, USA
- Veterans Integrated Service Networks (VISN)-6 Mid-Atlantic Mental Illness, Research Education and Clinical Center (MIRECC), Durham, NC, USA
- Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Elizabeth R Jenks
- W. G. (Bill) Hefner VA Healthcare System, Salisbury, NC, USA
- College of Health and Behavioral Sciences, Regent University, Virginia Beach, VA, USA
| | - Jared A Rowland
- W. G. (Bill) Hefner VA Healthcare System, Salisbury, NC, USA
- Veterans Integrated Service Networks (VISN)-6 Mid-Atlantic Mental Illness, Research Education and Clinical Center (MIRECC), Durham, NC, USA
- Wake Forest School of Medicine, Winston-Salem, NC, USA
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5
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Martindale SL, Belding JN, Crawford CD, Rowland JA. Validation of Military Occupational Specialty as a Proxy for Blast Exposure Using the Salisbury Blast Interview. J Neurotrauma 2023; 40:2321-2329. [PMID: 37058360 DOI: 10.1089/neu.2023.0067] [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] [Indexed: 04/15/2023] Open
Abstract
Abstract Evaluating large data sets precludes the ability to directly measure individual experiences, instead relying on proxies to infer certain constructs. Blast exposure is a construct of study currently in its infancy, resulting in diverse definitions and measurements across studies. The purpose of the present study was to validate military occupational specialty (MOS) as a proxy for blast exposure in combat veterans. A total of 256 veterans (86.33% male) completed the Salisbury Blast Interview (SBI) and Mid-Atlantic Mental Illness Research Education and Clinical Center (MIRECC) Assessment of Traumatic Brain Injury (MMA-TBI). MOS was collected through record review and categorized into low and high risk for blast exposure. Chi-square analyses and t tests compared SBI metrics between MOS categories. Receiver operating characteristic (ROC) analyses evaluated the diagnostic accuracy of MOS category in determining blast exposure severity. Veterans in high-risk MOS were more likely to have experienced blast and deployment TBI (ps < 0.001) than were those in low-risk MOS. ROC analyses indicated good specificity (81.29-88.00) for blast and deployment TBI outcomes, suggesting that low-risk MOS is generally associated with an absence of blast and deployment TBI outcomes. Sensitivity was low (36.46-51.14), indicating that MOS risk level was not a good predictor of the presence of these outcomes. Results demonstrate that high-risk MOSs will identify individuals with blast exposure and deployment TBI history whereas low-risk MOSs will capture a highly variable group. Accuracy of MOS categorization was not acceptable for diagnostic-level tests; however, results support its use as a screening measure for a history of exposure to blast, use in epidemiological studies, and considerations for military policy.
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Affiliation(s)
- Sarah L Martindale
- Mid-Atlantic Mental Illness Research, Education, and Clinical Center (MA-MIRECC), Research and Academic Affairs Service Line, W. G. (Bill) Hefner VA Healthcare System, Salisbury, North Carolina, USA
- Department of Physiology and Pharmacology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | | | - Cameron D Crawford
- Mid-Atlantic Mental Illness Research, Education, and Clinical Center (MA-MIRECC), Research and Academic Affairs Service Line, W. G. (Bill) Hefner VA Healthcare System, Salisbury, North Carolina, USA
| | - Jared A Rowland
- Mid-Atlantic Mental Illness Research, Education, and Clinical Center (MA-MIRECC), Research and Academic Affairs Service Line, W. G. (Bill) Hefner VA Healthcare System, Salisbury, North Carolina, USA
- Department of Physiology and Pharmacology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
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6
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Saar-Ashkenazy R, Naparstek S, Dizitzer Y, Zimhoni N, Friedman A, Shelef I, Cohen H, Shalev H, Oxman L, Novack V, Ifergane G. Neuro-psychiatric symptoms in directly and indirectly blast exposed civilian survivors of urban missile attacks. BMC Psychiatry 2023; 23:423. [PMID: 37312064 DOI: 10.1186/s12888-023-04943-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 06/07/2023] [Indexed: 06/15/2023] Open
Abstract
BACKGROUND Blast-explosion may cause traumatic brain injury (TBI), leading to post-concussion syndrome (PCS). In studies on military personnel, PCS symptoms are highly similar to those occurring in post-traumatic stress disorder (PTSD), questioning the overlap between these syndromes. In the current study we assessed PCS and PTSD in civilians following exposure to rocket attacks. We hypothesized that PCS symptomatology and brain connectivity will be associated with the objective physical exposure, while PTSD symptomatology will be associated with the subjective mental experience. METHODS Two hundred eighty nine residents of explosion sites have participated in the current study. Participants completed self-report of PCS and PTSD. The association between objective and subjective factors of blast and clinical outcomes was assessed using multivariate analysis. White-matter (WM) alterations and cognitive abilities were assessed in a sub-group of participants (n = 46) and non-exposed controls (n = 16). Non-parametric analysis was used to compare connectivity and cognition between the groups. RESULTS Blast-exposed individuals reported higher PTSD and PCS symptomatology. Among exposed individuals, those who were directly exposed to blast, reported higher levels of subjective feeling of danger and presented WM hypoconnectivity. Cognitive abilities did not differ between groups. Several risk factors for the development of PCS and PTSD were identified. CONCLUSIONS Civilians exposed to blast present higher PCS/PTSD symptomatology as well as WM hypoconnectivity. Although symptoms are sub-clinical, they might lead to the future development of a full-blown syndrome and should be considered carefully. The similarities between PCS and PTSD suggest that despite the different etiology, namely, the physical trauma in PCS and the emotional trauma in PTSD, these are not distinct syndromes, but rather represent a combined biopsychological disorder with a wide spectrum of behavioral, emotional, cognitive and neurological symptoms.
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Affiliation(s)
- R Saar-Ashkenazy
- Faculty of Social-Work, Ashkelon Academic College, 12 Ben Tzvi St, PO Box 9071, 78211, Ashkelon, Israel.
- Department of Cognitive-Neuroscience, Ben-Gurion University of the Negev, Beer-Sheva, Israel.
- Zlotowski Center for Neuroscience, Ben-Gurion University of the Negev, Beer-Sheva, Israel.
| | - S Naparstek
- Department of Psychology Ben-Gurion, University of the Negev, Beer-Sheva, Israel
- Department of Psychology, Bar-Ilan University, Ramat Gan, Israel
| | - Y Dizitzer
- Clinical Research Center, Soroka University Medical Center, Beer-Sheva, Israel
| | - N Zimhoni
- Clinical Research Center, Soroka University Medical Center, Beer-Sheva, Israel
| | - A Friedman
- Department of Cognitive-Neuroscience, Ben-Gurion University of the Negev, Beer-Sheva, Israel
- Zlotowski Center for Neuroscience, Ben-Gurion University of the Negev, Beer-Sheva, Israel
- Department of Medical Neuroscience, Dalhousie University, Halifax, NS, B3H4R2, Canada
| | - I Shelef
- Zlotowski Center for Neuroscience, Ben-Gurion University of the Negev, Beer-Sheva, Israel
- Department of Diagnostic Imaging, Soroka University Medical Center, Beer-Sheva, Israel
| | - H Cohen
- Anxiety and Stress Research Unit, Faculty of Health Sciences, Ministry of Health, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - H Shalev
- Department of Psychiatry, Soroka University Medical Center, Beer-Sheva, Israel
| | - L Oxman
- Clinical Research Center, Soroka University Medical Center, Beer-Sheva, Israel
| | - V Novack
- Clinical Research Center, Soroka University Medical Center, Beer-Sheva, Israel
| | - G Ifergane
- Department of Neurology, Soroka University Medical Center, Beer-Sheva, Israel
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Walker WC, O'Neil ME, Ou Z, Pogoda TK, Belanger HG, Scheibel RS, Presson AP, Miles SR, Wilde EA, Tate DF, Troyanskaya M, Pugh MJ, Jak A, Cifu DX. Can mild traumatic brain injury alter cognition chronically? A LIMBIC-CENC multicenter study. Neuropsychology 2023; 37:1-19. [PMID: 36174184 PMCID: PMC10117581 DOI: 10.1037/neu0000855] [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: 01/06/2023] Open
Abstract
OBJECTIVE While outcome from mild traumatic brain injury (mTBI) is generally favorable, concern remains over potential negative long-term effects, including impaired cognition. This study examined the link between cognitive performance and remote mTBIs within the Long-term Impact of Military-relevant Brain Injury Consortium-Chronic Effects of Neurotrauma Consortium (LIMBIC-CENC) multicenter, observational study of Veterans and service members (SMs) with combat exposure. METHOD Baseline data of the participants passing all cognitive performance validity tests (n = 1,310) were used to conduct a cross-sectional analysis. Using multivariable regression models that adjusted for covariates, including age and estimated preexposure intellectual function, positive mTBI history groups, 1-2 lifetime mTBIs (nonrepetitive, n = 614), and 3 + lifetime mTBIs (repetitive; n = 440) were compared to TBI negative controls (n = 256) on each of the seven cognitive domains computed by averaging Z scores of prespecified component tests. Significance levels were adjusted for multiple comparisons. RESULTS Neither of the mTBI positive groups differed from the mTBI negative control group on any of the cognitive domains in multivariable analyses. Findings were also consistently negative across sensitivity analyses (e.g., mTBIs as a continuous variable, number of blast-related mTBIs, or years since the first and last mTBI). CONCLUSIONS Our findings demonstrate that the average veteran or SM who experienced one or more mTBIs does not have postacute objective cognitive deficits due to mTBIs alone. A holistic health care approach including comorbidity assessment is indicated for patients reporting chronic cognitive difficulties after mTBI(s), and strategies for addressing misattribution may be beneficial. Future study is recommended with longitudinal designs to assess within-subjects decline from potential neurodegeneration. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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Affiliation(s)
- William C Walker
- Department of Physical Medicine and Rehabilitation, School of Medicine, Virginia Commonwealth University
| | | | - Zhining Ou
- Division of Epidemiology, Department of Internal Medicine, School of Medicine, University of Utah
| | - Terri K Pogoda
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System
| | | | | | - Angela P Presson
- Division of Epidemiology, Department of Internal Medicine, School of Medicine, University of Utah
| | - Shannon R Miles
- Mental Health and Behavioral Sciences Service, James A Haley Veterans' Hospital
| | - Elisabeth A Wilde
- H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine
| | - David F Tate
- Department of Physical Medicine and Rehabilitation, School of Medicine, Virginia Commonwealth University
| | | | - Mary Jo Pugh
- George E. Wahlen Veterans Affairs Salt Lake City Healthcare System
| | - Amy Jak
- VA San Diego Healthcare System
| | - David X Cifu
- Department of Physical Medicine and Rehabilitation, School of Medicine, Virginia Commonwealth University
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8
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Close proximity to blast: No long-term or lasting effect on cognitive performance in service members with and without TBI during blast exposure. J Int Neuropsychol Soc 2022:1-10. [PMID: 36200831 DOI: 10.1017/s1355617722000558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Blast related characteristics may contribute to the diversity of findings on whether mild traumatic brain injury sustained during war zone deployment has lasting cognitive effects. This study aims to evaluate whether a history of blast exposure at close proximity, defined as exposure within 30 feet, has long-term or lasting influences on cognitive outcomes among current and former military personnel. METHOD One hundred participants were assigned to one of three groups based on a self-report history of blast exposure during combat deployments: 47 close blast, 14 non-close blast, and 39 comparison participants without blast exposure. Working memory, processing speed, verbal learning/memory, and cognitive flexibility were evaluated using standard neuropsychological tests. In addition, assessment of combat exposure and current post-concussive, posttraumatic stress, and depressive symptoms, and headache was performed via self-report measures. Variables that differed between groups were controlled as covariates. RESULTS No group differences survived Bonferroni correction for family-wise error rate; the close blast group did not differ from non-close blast and comparison groups on measures of working memory, processing speed, verbal learning/memory, or cognitive flexibility. Controlling for covariates did not alter these results. CONCLUSION No evidence emerged to suggest that a history of close blast exposure was associated with decreased cognitive performance when comparisons were made with the other groups. Limited characterization of blast contexts experienced, self-report of blast distance, and heterogeneity of injury severity within the groups are the main limitations of this study.
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9
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Jurick SM, McCabe CT, Watrous JR, Walker LE, Stewart IJ, Galarneau MR. Prevalence and correlates of self-reported cognitive difficulties in deployment-injured U.S. military personnel. J Trauma Stress 2022; 35:1343-1356. [PMID: 35394076 DOI: 10.1002/jts.22833] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 02/22/2022] [Accepted: 02/26/2022] [Indexed: 11/11/2022]
Abstract
Cognitive difficulties typically resolve within days to weeks following mild traumatic brain injury (mTBI); however, a sizable proportion of individuals continue to report cognitive symptoms months to years later that are often associated with posttraumatic stress disorder (PTSD) and depression to a greater degree than a history of mTBI. The current study sought to evaluate the prevalence of self-reported cognitive difficulties as well as the relative contributions of demographic, injury-related, and mental health variables in a large study of U.S. military personnel injured during deployment since 2001. Slightly fewer than half (42.0%) of participants reported elevated cognitive difficulties compared with a normative population; however, this was driven primarily by those who screened positive for PTSD or depression. Hierarchical linear regression revealed that various demographic and injury factors, including lower educational attainment, retired or separated military status, enlisted rank, and a history of deployment-related mTBI, were associated with more self-reported cognitive difficulties, f2 = 0.07. Screening positive for PTSD or depression accounted for 32.1% of the variance in self-reported cognitive symptoms, f2 = 0.63, whereas injury variables, including a history of deployment-related mTBI, albeit significant in the model, accounted for 1.6%. The current findings add to the growing body of literature underscoring the importance of screening for and treating mental health conditions in injured military personnel.
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Affiliation(s)
- Sarah M Jurick
- Leidos, San Diego, California, USA.,Medical Modeling, Simulation, and Mission Support Department, Naval Health Research Center, San Diego, California, USA
| | - Cameron T McCabe
- Leidos, San Diego, California, USA.,Medical Modeling, Simulation, and Mission Support Department, Naval Health Research Center, San Diego, California, USA
| | - Jessica R Watrous
- Leidos, San Diego, California, USA.,Medical Modeling, Simulation, and Mission Support Department, Naval Health Research Center, San Diego, California, USA
| | | | - Ian J Stewart
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Michael R Galarneau
- Medical Modeling, Simulation, and Mission Support Department, Naval Health Research Center, San Diego, California, USA
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Turner SM, Sloley SS, Bailie JM, Babakhanyan I, Gregory E. Perspectives on Development of Measures to Estimate Career Blast Exposure History in Service Members and Veterans. Front Neurol 2022; 13:835752. [PMID: 35463137 PMCID: PMC9019559 DOI: 10.3389/fneur.2022.835752] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 03/11/2022] [Indexed: 11/13/2022] Open
Abstract
The Department of Defense (DOD) has recently prioritized the investigation of the acute and chronic adverse brain health and performance effects of low-level blast (LLB) generated by the use of weapons systems. While acute exposure can be quantified by sensor technology, career exposure has no widely accepted and validated measure for characterization. Currently, distinct research groups are developing and validating four promising measures to estimate career blast exposure history: the Salisbury Blast Interview, Blast Exposure Threshold Survey, Blast Ordnance and Occupational Exposure Measure, and the Blast Frequency and Symptom Severity. Each measure offers an assessment of blast history that is uniquely beneficial to addressing specific research questions. However, use of divergent strategies is not efficient to accelerate the field's understanding of the impact of career exposure and Service-connected health outcomes. As a DOD-wide solution, collaboration across these groups is required to develop a tool(s) that can be standardized across research studies and, ultimately, pared down to be implemented in clinical settings. Here, we overview the current four measures and provide a perspective on the way forward for optimization and/or combination in support of this solution.
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Affiliation(s)
- Stephanie M. Turner
- Traumatic Brain Injury Center of Excellence, Defense Health Agency, Silver Spring, MD, United States
- General Dynamics Information Technology, Silver Spring, MD, United States
- *Correspondence: Stephanie M. Turner
| | - Stephanie S. Sloley
- Traumatic Brain Injury Center of Excellence, Defense Health Agency, Silver Spring, MD, United States
- General Dynamics Information Technology, Silver Spring, MD, United States
| | - Jason M. Bailie
- Traumatic Brain Injury Center of Excellence, Defense Health Agency, Silver Spring, MD, United States
- General Dynamics Information Technology, Silver Spring, MD, United States
- Naval Hospital Camp Pendleton, Camp Pendleton, CA, United States
| | - Ida Babakhanyan
- Traumatic Brain Injury Center of Excellence, Defense Health Agency, Silver Spring, MD, United States
- General Dynamics Information Technology, Silver Spring, MD, United States
- Naval Hospital Camp Pendleton, Camp Pendleton, CA, United States
| | - Emma Gregory
- Traumatic Brain Injury Center of Excellence, Defense Health Agency, Silver Spring, MD, United States
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11
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Cifu DX. Clinical research findings from the long-term impact of military-relevant brain injury consortium-Chronic Effects of Neurotrauma Consortium (LIMBIC-CENC) 2013-2021. Brain Inj 2022; 36:587-597. [PMID: 35080997 DOI: 10.1080/02699052.2022.2033843] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
This is a summary of the published research from the 14 observational, longitudinal and big-data, epidemiological studies supported by the LIMBIC-CENC program from 2013-2021 examining the long-term effects of combat-related traumatic brain injury (TBI). Findings from these 43 primary and secondary analyses include: 1) unique fluid, advanced neuroimaging and electrophysiologic biomarkers associated with mild traumatic brain injury (mTBI), number of mTBIs and related dysfunction, 2) increases in a range of chronic difficulties, including neurosensory, sleep, pain, cognitive deficits, behavioral disorders, overall symptom burden, healthcare costs and service-connected disability, associated with mTBI, all-severity traumatic brain injury (TBI), blast exposure, and number of mTBIs, and 3) increases in the risk for suicide and neurodegeneration, including dementia and Parkinson's disease, associated with mTBI and all-severity TBI. Ongoing LIMBIC-CENC longitudinal and epidemiologic research will clarify, confirm and expand upon these findings.
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Affiliation(s)
- David X Cifu
- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, Virginia, USA.,Department of Veterans Affairs, Washington, DC, USA
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12
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Myers JR, Solomon NP, Lange RT, French LM, Lippa SM, Brickell TA, Staines S, Nelson J, Brungart DS, Coelho CA. Analysis of Discourse Production to Assess Cognitive Communication Deficits Following Mild Traumatic Brain Injury With and Without Posttraumatic Stress. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2022; 31:84-98. [PMID: 34932411 DOI: 10.1044/2021_ajslp-20-00281] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
PURPOSE Cognitive communication deficits can be difficult to assess in individuals with mild traumatic brain injury (mTBI). However, the use of discourse analysis as a direct and sensitive metric of cognitive communication skills has shown promising clinical utility for other TBI severity levels. This exploratory study investigated discourse production in service members and veterans (SMVs) with uncomplicated mTBI with and without posttraumatic stress disorder (PTSD) and SMVs with neither mTBI or PTSD. METHOD Fifteen SMVs with mTBI and PTSD, 26 with mTBI, and 25 controls with no brain injury (NBI) and without PTSD were given a wordless picture story to elicit spontaneous discourse. Discourse samples were analyzed for global coherence, word count, the use of negative emotion words, cognitive process words, nonfluencies, and story completeness. RESULTS Results revealed a significant difference between the mTBI (Mdn = 3.33) and NBI (Mdn = 3.50) groups, χ2(3) = 6.044, p = .017, ε2 = .03, for global coherence. Word count differed significantly between the mTBI + PTSD (Mdn = 135) and NBI (Mdn = 195) groups, χ2(3) = 7.968, p = .006, ε2 = .06. No other group differences were observed. DISCUSSION Structural features of discourse production may serve as potential markers of cognitive communication deficits in mTBI. Furthermore, PTSD may contribute to verbal fluency deficits in individuals with mTBI. Additional research is needed to develop discourse-related measures that are more sensitive to the effects of mTBI and PTSD.
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Affiliation(s)
- Jennifer Rae Myers
- National Military Audiology and Speech Pathology Center, Walter Reed National Military Medical Center, Bethesda, MD
| | - Nancy Pearl Solomon
- National Military Audiology and Speech Pathology Center, Walter Reed National Military Medical Center, Bethesda, MD
- Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Rael T Lange
- Traumatic Brain Injury Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD
- University of British Columbia, Vancouver, British Columbia, Canada
- General Dynamics Information Technology, Falls Church, VA
- Center of Excellence on Post-Traumatic Stress Disorder, Ottawa, Ontario, Canada
| | - Louis M French
- Uniformed Services University of the Health Sciences, Bethesda, MD
- Traumatic Brain Injury Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD
| | - Sara M Lippa
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD
| | - Tracey A Brickell
- Uniformed Services University of the Health Sciences, Bethesda, MD
- Traumatic Brain Injury Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD
- General Dynamics Information Technology, Falls Church, VA
- Center of Excellence on Post-Traumatic Stress Disorder, Ottawa, Ontario, Canada
| | | | | | - Doug S Brungart
- National Military Audiology and Speech Pathology Center, Walter Reed National Military Medical Center, Bethesda, MD
- Uniformed Services University of the Health Sciences, Bethesda, MD
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13
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Martindale SL, Ord AS, Rule LG, Rowland JA. Effects of blast exposure on psychiatric and health symptoms in combat veterans. J Psychiatr Res 2021; 143:189-195. [PMID: 34500348 DOI: 10.1016/j.jpsychires.2021.09.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 08/25/2021] [Accepted: 09/01/2021] [Indexed: 11/28/2022]
Abstract
Blast exposure is common among service members, but the chronic psychiatric effects associated with blast exposure are not well-characterized independent of a resulting mild traumatic brain injury (TBI). This analysis evaluated whether blast exposure severity was independently associated with or exacerbated symptom report beyond posttraumatic stress disorder (PTSD) and mild TBI. Participants were Iraq and Afghanistan combat veterans (N = 275; 86.55% male), 71.27% with history of blast exposure, 29.82% current diagnosis of PTSD, and 45.45% with mild TBI. All participants completed diagnostic interviews for PTSD, lifetime TBI, and lifetime blast exposure. Self-reported psychiatric and health outcomes included posttraumatic stress symptoms, depressive symptoms, neurobehavioral symptoms, sleep quality, pain interference, and quality of life. Blast severity was associated with PTSD (B = 2.00), depressive (B = 0.76), and neurobehavioral (B = 1.69) symptoms beyond PTSD diagnosis and mild TBI history. Further, blast severity accounted entirely (i.e., indirect/mediation effect) for the association between TBI and posttraumatic stress (B = 1.62), depressive (B = 0.61), and neurobehavioral (B = 1.38) symptoms. No interaction effects were present. Exposure to blast is an independent factor influencing psychiatric symptoms in veterans beyond PTSD and mild TBI. Results highlight that blast exposure severity may be a more relevant risk factor than deployment mild TBI in combat veterans and should be considered in the etiology of psychiatric symptom presentation and complaints. Further, severity of psychological distress due to the combat environment may be an explanatory mechanism by which blast exposure mediates the relationship between mild TBI and symptom outcomes.
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Affiliation(s)
- Sarah L Martindale
- Mid-Atlantic Mental Illness Research, Education, and Clinical Center (MA-MIRECC), Research & Academic Affairs Service Line, W. G. (Bill) Hefner VA Healthcare System, Salisbury, NC, USA; Department of Physiology & Pharmacology, Wake Forest School of Medicine, Winston-Salem, NC, USA.
| | - Anna S Ord
- Mid-Atlantic Mental Illness Research, Education, and Clinical Center (MA-MIRECC), Research & Academic Affairs Service Line, W. G. (Bill) Hefner VA Healthcare System, Salisbury, NC, USA; Department of Physiology & Pharmacology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Lakeysha G Rule
- Mid-Atlantic Mental Illness Research, Education, and Clinical Center (MA-MIRECC), Research & Academic Affairs Service Line, W. G. (Bill) Hefner VA Healthcare System, Salisbury, NC, USA
| | - Jared A Rowland
- Mid-Atlantic Mental Illness Research, Education, and Clinical Center (MA-MIRECC), Research & Academic Affairs Service Line, W. G. (Bill) Hefner VA Healthcare System, Salisbury, NC, USA; Department of Physiology & Pharmacology, Wake Forest School of Medicine, Winston-Salem, NC, USA
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14
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Ettenhofer ML, Hungerford LD, Agtarap S. Multimodal Neurocognitive Screening of Military Personnel With a History of Mild Traumatic Brain Injury Using the Bethesda Eye & Attention Measure. J Head Trauma Rehabil 2021; 36:447-455. [PMID: 33935223 DOI: 10.1097/htr.0000000000000683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To evaluate a neurocognitive eye tracking task, the Bethesda Eye & Attention Measure (BEAM), for use in cognitive screening of patients with a history of mild traumatic brain injury (TBI). SETTING US military TBI rehabilitation clinic. DESIGN/PARTICIPANTS Cross-sectional study of 191 military personnel receiving outpatient services related to history of mild TBI. Main measures: BEAM; neuropsychological screening measures of attention, processing speed, executive function, and memory. RESULTS Medium effect sizes were found for partial correlations (controlling for age) between key BEAM metrics and neuropsychological screening tests. Linear regression analyses demonstrated that BEAM saccadic eye movements and manual (button press) metrics each provided complementary value in measurement of cognitive performance, above and beyond effects of demographic factors and clinical characteristics. CONCLUSION This study provides initial support for the use of BEAM neurocognitive eye tracking in cognitive screening of adults with a history of mild TBI. BEAM saccadic metrics appear to be particularly well-suited for the assessment of visual attention. Study findings also highlight opportunities for greater cognitive sensitivity or testing efficiency that may be missed by tests measuring only one response modality at a time.
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Affiliation(s)
- Mark L Ettenhofer
- DHA Traumatic Brain Injury Center of Excellence, Silver Spring, Maryland (Drs Ettenhofer, Hungerford, and Agtarap); Naval Medical Center San Diego, San Diego, California (Drs Ettenhofer, Hungerford, and Agtarap); General Dynamics Information Technology, Falls Church, Virginia (Drs Ettenhofer, Hungerford, and Agtarap); University of California, San Diego, La Jolla, California (Dr Ettenhofer); and Uniformed Services University of the Health Sciences, Bethesda, Maryland (Dr Ettenhofer)
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15
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Clausen AN, Bouchard HC, Welsh-Bohmer KA, Morey RA. Assessment of Neuropsychological Function in Veterans With Blast-Related Mild Traumatic Brain Injury and Subconcussive Blast Exposure. Front Psychol 2021; 12:686330. [PMID: 34262512 PMCID: PMC8273541 DOI: 10.3389/fpsyg.2021.686330] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 06/03/2021] [Indexed: 12/21/2022] Open
Abstract
Objective: The majority of combat-related head injuries are associated with blast exposure. While Veterans with mild traumatic brain injury (mTBI) report cognitive complaints and exhibit poorer neuropsychological performance, there is little evidence examining the effects of subconcussive blast exposure, which does not meet clinical symptom criteria for mTBI during the acute period following exposure. We compared chronic effects of combat-related blast mTBI and combat-related subconcussive blast exposure on neuropsychological performance in Veterans. Methods: Post-9/11 Veterans with combat-related subconcussive blast exposure (n = 33), combat-related blast mTBI (n = 26), and controls (n = 33) without combat-related blast exposure, completed neuropsychological assessments of intellectual and executive functioning, processing speed, and working memory via NIH toolbox, assessment of clinical psychopathology, a retrospective account of blast exposures and non-blast-related head injuries, and self-reported current medication. Huber Robust Regressions were employed to compare neuropsychological performance across groups. Results: Veterans with combat-related blast mTBI and subconcussive blast exposure displayed significantly slower processing speed compared with controls. After adjusting for post-traumatic stress disorder and depressive symptoms, those with combat-related mTBI exhibited slower processing speed than controls. Conclusion: Veterans in the combat-related blast mTBI group exhibited slower processing speed relative to controls even when controlling for PTSD and depression. Cognition did not significantly differ between subconcussive and control groups or subconcussive and combat-related blast mTBI groups. Results suggest neurocognitive assessment may not be sensitive enough to detect long-term effects of subconcussive blast exposure, or that psychiatric symptoms may better account for cognitive sequelae following combat-related subconcussive blast exposure or combat-related blast mTBI.
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Affiliation(s)
- Ashley N. Clausen
- Kansas City VA Medical Center, Kansas City, MO, United States
- Duke-University of North Carolina at Chapel Hill Brain Imaging and Analysis Center, Duke University, Durham, NC, United States
- VA Mid-Atlantic Mental Illness Research, Education and Clinical Center (MIRECC), Durham Veteran Affairs Healthcare System, Durham, NC, United States
| | - Heather C. Bouchard
- Duke-University of North Carolina at Chapel Hill Brain Imaging and Analysis Center, Duke University, Durham, NC, United States
- VA Mid-Atlantic Mental Illness Research, Education and Clinical Center (MIRECC), Durham Veteran Affairs Healthcare System, Durham, NC, United States
| | | | | | - Rajendra A. Morey
- Duke-University of North Carolina at Chapel Hill Brain Imaging and Analysis Center, Duke University, Durham, NC, United States
- VA Mid-Atlantic Mental Illness Research, Education and Clinical Center (MIRECC), Durham Veteran Affairs Healthcare System, Durham, NC, United States
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, United States
- Center for Cognitive Neuroscience, Duke University, Durham, NC, United States
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