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Bailie JM, Lippa SM, Hungerford L, French LM, Brickell TA, Lange RT. Cumulative Blast Exposure During a Military Career Negatively Impacts Recovery from Traumatic Brain Injury. J Neurotrauma 2024; 41:604-612. [PMID: 37675903 DOI: 10.1089/neu.2022.0192] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/08/2023] Open
Abstract
Sub-concussive injuries have emerged as an important factor in the long-term brain health of athletes and military personnel. The objective of this study was to explore the relationship between service member and veterans (SMVs) lifetime blast exposure and recovery from a traumatic brain injury (TBI). A total of 558 SMVs with a history of TBI were examined. Lifetime blast exposure (LBE) was based on self-report (M = 79.4, standard deviation = 392.6; range = 0-7500) categorized into three groups: Blast Naive (n = 121), Low LBE (n = 223; LBE range 1-9), and High LBE (n = 214; LBE >10). Dependent variables were the Neurobehavioral Symptom Inventory (NSI) and Post-traumatic Stress Disorder Checklist-Civilian (PCL-C) and the Traumatic Brain Injury Quality of Life (TBI-QOL). Analyses controlled for demographic factors (age, gender, and race) as well as TBI factors (months since index TBI, index TBI severity, and total number lifetime TBIs). The Blast Naive group had significantly lower NSI and PCL-C scores compared with the Low LBE group and High LBE group, with small to medium effect sizes. On the TBI-QOL, the Blast Naïve group had better quality life on 10 of the 14 scales examined. The Low LBE did not differ from the High LBE group on the PCL-C, NSI, or TBI-QOL. Blast exposure over an SMV's career was associated with increased neurobehavioral and post-traumatic stress symptoms following a TBI. The influence of psychological trauma associated with blasts may be an important factor influencing symptoms as well as the accuracy of self-reported estimates of LBE.
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Affiliation(s)
- Jason M Bailie
- Traumatic Brain Injury Center of Excellence, Silver Spring, Maryland, USA
- Naval Hospital Camp Pendleton, Camp Pendleton, California, USA
- General Dynamics Information Technology, Fairfax, Virginia, USA
| | - Sara M Lippa
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Lars Hungerford
- Traumatic Brain Injury Center of Excellence, Silver Spring, Maryland, USA
- General Dynamics Information Technology, Fairfax, Virginia, USA
- Naval Medical Center San Diego, San Diego, California, USA
| | - Louis M French
- Traumatic Brain Injury Center of Excellence, Silver Spring, Maryland, USA
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Tracey A Brickell
- Traumatic Brain Injury Center of Excellence, Silver Spring, Maryland, USA
- General Dynamics Information Technology, Fairfax, Virginia, USA
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- University of British Columbia, Vancouver, British Columbia, Canada
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Rael T Lange
- Traumatic Brain Injury Center of Excellence, Silver Spring, Maryland, USA
- General Dynamics Information Technology, Fairfax, Virginia, USA
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- University of British Columbia, Vancouver, British Columbia, Canada
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2
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Caberwal T, Cecchini AS, Wentz LM, Berry-Cabán CS. Prevalence of Neck Pain in Soldiers as a Result of Mild Traumatic Brain Injury-Associated Trauma. Mil Med 2024; 189:e182-e187. [PMID: 37384536 DOI: 10.1093/milmed/usad228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 05/19/2023] [Accepted: 06/20/2023] [Indexed: 07/01/2023] Open
Abstract
INTRODUCTION Many of the injury mechanisms that cause mild traumatic brain injury (mTBI) also create forces commonly associated with whiplash, resulting in cervical pain injury. The prevalence of associated neck pain with mTBI is not well established. There is a strong indication that injury to the cervical spine may aggravate, cause, and/or impact recovery of symptoms and impairments associated with the concussive event and its primary effect on the brain. The purpose of this study is to help identify the prevalence of ensuing cervical pain within 90 days of a previously documented mTBI and to examine the role of neck pain during concurrent concussive symptoms, in a military population stationed at a large military installation. MATERIALS AND METHODS This retrospective design utilized a de-identified dataset using predetermined search and filter criteria, which included male active duty service members (SMs), 20 to 45 years of age, who received medical care at any clinic on Fort Liberty (Fort Bragg, NC) during fiscal year (FY) 2012 to FY 2019, with documented cervicalgia and mTBI (via the International Classification of Diseases, 9th and 10th Revision, Clinical Modification codes), verified using electronic medical records. The final dataset served as the basis for subject sampling and was analyzed to determine the total number of documented cervicalgia and mTBI diagnoses. Results are presented as descriptive statistics. Approval for this study was received from the Andrews University Office of Research (18-097) and the Womack Army Medical Center Human Protections Office. RESULTS Between FY 2012 and FY 2019, 14,352 unique SMs accessed a Fort Bragg, NC health care facility, at least once (Table I). Overall, 52% of SMs diagnosed with cervicalgia were found to have a previously diagnosed mTBI during the 90 days before the cervicalgia diagnosis. In contrast, the prevalence of same-day cervicalgia and mTBI diagnosis was <1% (Table IV). The prevalence of isolated cervicalgia diagnosis at any time during the reporting period was 3%, whereas isolated mTBI diagnosis was 1% (Table III). CONCLUSIONS Over 50% of SMs diagnosed with cervicalgia had sustained a documented mTBI within 90 days prior, whereas less than 1% were diagnosed with cervicalgia at the time of initial primary care or emergency room encounter following the mTBI event. This finding suggests that the close anatomical and neurophysiological connections between the head and the cervical spine are both likely to be impacted through the same mechanism of injury. Delayed evaluation (and treatment) of the cervical spine may contribute to lingering post-concussive symptoms. Limitations of this retrospective review include the inability to assess the causality of the relationship between neck pain and mTBI, as only the existence and strength of the prevalence relationship can be identified. The outcome data are exploratory and intended to identify relationships and trends that may suggest further study across installations and across mTBI populations.
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Affiliation(s)
- Tara Caberwal
- Womack Army Medical Center, Fort Bragg, NC 28310, USA
| | | | - Laurel M Wentz
- Department of Nutrition and Health Care Management, Appalachian State University, Boone, NC 28607, USA
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3
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Chung JS, Jouk A, Licona NP, Terry JH, Harris OA. In her own words: a phenomenological analysis of stories told by female service members and veterans after traumatic brain injury. Disabil Rehabil 2023; 45:4086-4093. [PMID: 36398683 DOI: 10.1080/09638288.2022.2146766] [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: 03/30/2022] [Accepted: 11/05/2022] [Indexed: 11/19/2022]
Abstract
PURPOSE Given the majority of Service Members and Veterans (SMV) who have sustained a traumatic brain injury (TBI) are male, the female experience with TBI has not been captured in the general understanding of TBI. To improve understanding of the experience of female SMV after TBI utilizing a qualitative phenomenological approach on stories as told by female SMV. MATERIALS AND METHODS Ten female SMV participated in storytelling workshops and created video stories documenting their personal experience with TBI. Workshops were hosted by the VA Palo Alto Health Care System Polytrauma System of Care (VAPAHCS PSC). A grounded thematic analysis was conducted on the video stories. RESULTS Three common content themes emerged from all the stories: (1) negative psychological and emotional impacts of TBI, (2) acceptance and healing process associated with recovery, and (3) military contexts. Negative psychological and emotional impacts included intrapersonal impacts such as negative emotions, suicidal ideation, and dealing with cognitive and physical challenges, and interpersonal impacts in relationships and loss of independence. Notably, all the stories acknowledged an acceptance and healing process, characterized by several subthemes including motivational factors, TBI education, spirituality, and advocacy work. Lastly, each story mentioned military context, highlighting the unique experience within this population. CONCLUSIONS This phenomenological examination adds evidence-based understanding to the experience after TBI among female SMV. Each story uncovered nuanced and multifaceted issues that women experience in their TBI recovery. Our findings provide context to guide future intervention on the care, support, and TBI recovery for the female SMV population.
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Affiliation(s)
- Joyce S Chung
- Polytrauma System of Care, VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Alexandra Jouk
- Polytrauma System of Care, VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Nytzia P Licona
- Polytrauma System of Care, VA Palo Alto Health Care System, Palo Alto, CA, USA
- University of Illinois Chicago, Palo Alto, CA, USA
| | - Jennifer H Terry
- Polytrauma System of Care, VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Odette A Harris
- Polytrauma System of Care, VA Palo Alto Health Care System, Palo Alto, CA, USA
- Stanford University, Stanford, CA, USA
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Cogan AM, Bailie JM. Therapeutic Relationship in mTBI Rehabilitation: The Disparity Between the Illness Experience and Clinical Definitions. Mil Med 2023; 188:e3010-e3016. [PMID: 37192051 DOI: 10.1093/milmed/usad143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 01/15/2023] [Accepted: 04/25/2023] [Indexed: 05/18/2023] Open
Abstract
INTRODUCTION A positive therapeutic relationship is characterized by trust and mutually perceived genuineness. It is positively associated with patients' adherence to treatment, satisfaction, and health outcomes. When service members with a history of mild traumatic brain injury (mTBI) present to rehabilitation clinics with nonspecific symptoms, a disparity between their experience of disability and clinical expectations of mTBI may disrupt the establishment of a positive therapeutic relationship between patients and providers. The objectives of this study are to (1) explore disparities between military service members and rehabilitation clinicians about the clinical diagnosis and illness experience of mTBI and (2) identify barriers to the establishment of a positive therapeutic relationship. MATERIALS AND METHODS This is a qualitative descriptive study of military service members with prior mTBI (n = 18) and clinicians (n = 16) who participated in interviews and focus groups. Data were analyzed thematically using Kleinman's framing of illness experience and clinical diagnosis. RESULTS Three themes reflected the potential breakdowns in the therapeutic relationship. The first theme, clinical expectations for post-injury recovery versus patients' experience of ongoing disability, reflects the inconsistency between clinicians' expectations of symptom resolution within 90 days following mTBI and service members' experiences of symptoms that worsened over several months or years. The second theme, symptom attribution to mental health conditions versus tissue injury, describes the difficulty in attributing symptoms to the physical impact of the mTBI or mental health diagnoses that may also stem from the injury event. The third theme, suspected malingering versus valid disability, describes clinicians' reports of frustration with cases in which they suspected malingering for secondary gains in contrast with service members' feelings that their problems were not taken seriously by clinicians. CONCLUSIONS This study extended previous research on therapeutic relationships by examining the situation of mTBI rehabilitation services for military service members. The findings reinforce the best practice recommendations of acknowledging patients' experiences, addressing the presenting symptoms and problems, and encouraging progressive return to activity following mTBI. Acknowledgment of and attention to patients' illness experience by rehabilitation clinicians is necessary and important for supporting a positive therapeutic relationship and ultimately to optimize patients' health outcomes and reduce disability.
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Affiliation(s)
- Alison M Cogan
- Mrs. T. H. Chan Division of Occupational Science and Occupational Therapy, University of Southern California, Los Angeles, CA 90089, USA
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA 90073, USA
| | - Jason M Bailie
- Traumatic Brain Injury Center of Excellence (TBICoE), Defense Health Agency (DHA), Intrepid Spirit, Naval Hospital Camp Pendleton, Oceanside, CA 92058, USA
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Van Wyck D, Kolls BJ, Wang H, Cantillana V, Maughan M, Laskowitz DT. Prophylactic treatment with CN-105 improves functional outcomes in a murine model of closed head injury. Exp Brain Res 2022; 240:2413-2423. [PMID: 35841411 DOI: 10.1007/s00221-022-06417-4] [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: 01/25/2022] [Accepted: 07/04/2022] [Indexed: 11/30/2022]
Abstract
The treatment of traumatic brain injury (TBI) in military populations is hindered by underreporting and underdiagnosis. Clinical symptoms and outcomes may be mitigated with an effective pre-injury prophylaxis. This study evaluates whether CN-105, a 5-amino acid apolipoprotein E (ApoE) mimetic peptide previously shown to modify the post-traumatic neuroinflammatory response, would maintain its neuroprotective effects if administered prior to closed-head injury in a clinically relevant murine model. CN-105 was synthesized by Polypeptide Inc. (San Diego, CA) and administered to C57-BL/6 mice intravenously (IV) and/or by intraperitoneal (IP) injection at various time points prior to injury while vehicle treated animals received IV and/or IP normal saline. Animals were randomized following injury and behavioral observations were conducted by investigators blinded to treatment. Vestibulomotor function was assessed using an automated Rotarod (Ugo Basile, Comerio, Italy), and hippocampal microglial activation was assessed using F4/80 immunohistochemical staining in treated and untreated mice 7 days post-TBI. Separate, in vivo assessments of the pharmacokinetics was performed in healthy CD-1. IV CN-105 administered prior to head injury improved vestibulomotor function compared to vehicle control-treated animals. CN-105 co-administered by IP and IV dosing 6 h prior to injury also improved vestibulomotor function up to 28 days following injury. Microglia counted in CN-105 treated specimens were significantly fewer (P = 0.03) than in vehicle specimens. CN-105 improves functional outcomes and reduces hippocampal microglial activation when administered prior to injury and could be adapted as a pre-injury prophylaxis for soldiers at high risk for TBI.
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Affiliation(s)
- David Van Wyck
- 3Rd Special Forces Group (A), U.S. Army Special Operations Command, 111 Enduring Freedom Drive (Stop A), Fort Bragg, NC, 28310, USA. .,Department of Neurology, Duke University School of Medicine, Durham, NC, 27710, USA.
| | - Bradley J Kolls
- Department of Neurology, Duke University School of Medicine, Durham, NC, 27710, USA
| | - Haichen Wang
- Department of Neurology, Duke University School of Medicine, Durham, NC, 27710, USA
| | - Viviana Cantillana
- Department of Neurology, Duke University School of Medicine, Durham, NC, 27710, USA
| | | | - Daniel T Laskowitz
- Department of Neurology, Duke University School of Medicine, Durham, NC, 27710, USA.,Department of Neurobiology, Duke University School of Medicine, Durham, NC, 27710, USA.,Aegis-CN LLC., 701 W Main Street, Durham, NC, 27701, USA
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6
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Lange RT, French LM, Bailie JM, Merritt VC, Pattinson CL, Hungerford LD, Lippa SM, Brickell TA. Clinical utility of PTSD, resilience, sleep, and blast as risk factors to predict poor neurobehavioral functioning following traumatic brain injury: A longitudinal study in U.S. military service members. Qual Life Res 2022; 31:2411-2422. [PMID: 35076825 DOI: 10.1007/s11136-022-03092-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/14/2022] [Indexed: 10/19/2022]
Abstract
PURPOSE This study examined the clinical utility of post-traumatic stress disorder (PTSD), low resilience, poor sleep, and lifetime blast exposure as risk factors for predicting future neurobehavioral outcome following traumatic brain injury (TBI). METHODS Participants were 591 U.S. military service members and veterans who had sustained a TBI (n = 419) or orthopedic injury without TBI (n = 172). Participants completed the Neurobehavioral Symptom Inventory, PTSD Checklist, and the TBI-Quality of Life (TBI-QOL) scale at baseline and follow-up. RESULTS Using the four risk factors at baseline, 15 risk factor combinations were examined by calculating odds ratios to predict poor neurobehavioral outcome at follow-up (i.e., number of abnormal scores across five TBI-QOL scales [e.g., Fatigue, Depression]). The vast majority of risk factor combinations resulted in odds ratios that were considered to be clinically meaningful (i.e., ≥ 2.5) for predicting poor outcome. The risk factor combinations with the highest odds ratios included PTSD singularly, or in combination with poor sleep and/or low resilience (odds ratios = 4.3-72.4). However, poor sleep and low resilience were also strong predictors in the absence of PTSD (odds ratios = 3.1-29.8). CONCLUSION PTSD, poor sleep, and low resilience, singularly or in combination, may be valuable risk factors that can be used clinically for targeted early interventions.
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Affiliation(s)
- Rael T Lange
- Traumatic Brain Injury Center of Excellence, Silver Spring, MD, USA. .,Walter Reed National Military Medical Center, Bethesda, MD, USA. .,National Intrepid Center of Excellence, Bethesda, MD, USA. .,University of British Columbia, Vancouver, BC, Canada. .,General Dynamics Information Technology, Falls Church, VA, USA.
| | - Louis M French
- Traumatic Brain Injury Center of Excellence, Silver Spring, MD, USA.,Walter Reed National Military Medical Center, Bethesda, MD, USA.,National Intrepid Center of Excellence, Bethesda, MD, USA.,Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Jason M Bailie
- Traumatic Brain Injury Center of Excellence, Silver Spring, MD, USA.,Naval Hospital Camp Pendleton, Oceanside, CA, USA.,General Dynamics Information Technology, Falls Church, VA, USA
| | - Victoria C Merritt
- VA San Diego Healthcare System, San Diego, CA, USA.,University of California San Diego, La Jolla, CA, USA
| | | | - Lars D Hungerford
- Traumatic Brain Injury Center of Excellence, Silver Spring, MD, USA.,Naval Medical Center San Diego, San Diego, CA, USA.,General Dynamics Information Technology, Falls Church, VA, USA
| | - Sara M Lippa
- Walter Reed National Military Medical Center, Bethesda, MD, USA.,National Intrepid Center of Excellence, Bethesda, MD, USA
| | - Tracey A Brickell
- Traumatic Brain Injury Center of Excellence, Silver Spring, MD, USA.,Walter Reed National Military Medical Center, Bethesda, MD, USA.,National Intrepid Center of Excellence, Bethesda, MD, USA.,Uniformed Services University of the Health Sciences, Bethesda, MD, USA.,General Dynamics Information Technology, Falls Church, VA, USA
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7
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Stroupe KT, Jordan N, Richman J, Bond GR, Pogoda TK, Cao L, Kertesz SG, Kyriakides TC, Davis LL. Cost-Effectiveness of Individual Placement and Support Compared to Transitional Work Program for Veterans with Post-traumatic Stress Disorder. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2021; 49:429-439. [PMID: 34677786 DOI: 10.1007/s10488-021-01173-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2021] [Indexed: 11/28/2022]
Abstract
Post-traumatic stress disorder (PTSD) leads to significant disability, unemployment, and substantial healthcare costs. The cost-effectiveness of vocational rehabilitation (VR) interventions is important to consider when determining which services to offer. This study assesses the cost-effectiveness and return on investment of Individual Placement and Support (IPS) compared to transitional work (TW) programs. Employment outcomes from a multisite randomized trial comparing IPS to TW in military veterans with PTSD (n = 541) were linked to Veterans Health Administration (VHA) archival medical record databases to examine the comparative cost-effectiveness and return on investment. Effectiveness was defined as hours worked and income earned in competitive jobs. Costs for VR, mental health, and medical care and income earned from competitive sources were annualized and adjusted to 2019 US dollars. The annualized mean cost per person of outpatient (including vocational services) were $3970 higher for IPS compared to TW ($23,245 vs. $19,276, respectively; P = 0.004). When TW income was included in costs, mean grand total costs per person per year were similar between groups ($29,828 IPS vs. $26,772 TW; P = 0.17). The incremental cost-effectiveness analysis showed that while IPS is more costly, it is also more effective. The return on investment (excluding TW income) was 32.9% for IPS ($9762 mean income/$29,691 mean total costs) and 29.6% for TW ($7326 mean income/$24,781 mean total costs). IPS significantly improves employment outcomes for individuals with PTSD with negligible increase in healthcare costs and yields very good return on investment compared to non-IPS VR services.
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Affiliation(s)
- Kevin T Stroupe
- Center of Innovation for Complex Chronic Healthcare, Hines VA Hospital, 5000 South 5th Ave (151H), Hines, IL, 60141, USA. .,Department of Public Health Sciences, Parkinson School of Health Sciences and Public Health, Loyola University Chicago, Maywood, IL, USA.
| | - Neil Jordan
- Center of Innovation for Complex Chronic Healthcare, Hines VA Hospital, 5000 South 5th Ave (151H), Hines, IL, 60141, USA.,Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Joshua Richman
- Birmingham VA Medical Center, Birmingham, AL, USA.,Department of Surgery, University of Alabama School of Medicine, Birmingham, AL, USA
| | - Gary R Bond
- Westat, Rivermill Commercial Center, 85 Mechanic Street, Suite C3-1, Lebanon, NH, 03766, USA
| | - Terri K Pogoda
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Building 9, Office 218, 150 South Huntington Avenue (152M), Boston, MA, 02130, USA.,Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, MA, USA
| | - Lishan Cao
- Center of Innovation for Complex Chronic Healthcare, Hines VA Hospital, 5000 South 5th Ave (151H), Hines, IL, 60141, USA
| | - Stefan G Kertesz
- Birmingham VA Medical Center, Birmingham, AL, USA.,Department of Medicine, University of Alabama School of Medicine, Birmingham, AL, USA
| | - Tassos C Kyriakides
- West Haven Cooperative Studies Program Coordinating Center, VA Connecticut Health Care System, 950 Campbell Avenue, West Haven, CT, 06516, USA
| | - Lori L Davis
- Research and Development Service, Tuscaloosa VA Medical Center-Psychiatry, 3701 Loop Rd, Tuscaloosa, AL, 35404, USA.,Department of Psychiatry and Behavioral Neurobiology, University of Alabama School of Medicine, Birmingham, AL, USA
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8
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Shepherd-Banigan M, Pogoda TK, McKenna K, Sperber N, Van Houtven CH. Experiences of VA vocational and education training and assistance services: Facilitators and barriers reported by veterans with disabilities. Psychiatr Rehabil J 2021; 44:148-156. [PMID: 32597666 PMCID: PMC9677616 DOI: 10.1037/prj0000437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To understand the experiences of veterans with disabilities and caregiving needs who use Department of Veterans Affairs (VA) vocational and education services, including Supported Employment, the Post-9/11 GI Bill, and Vocational Rehabilitation and Employment. METHOD We conducted 26 joint semistructured interviews with post-9/11 veterans who had used at least one of three vocational and education services, and their family members who were enrolled in a VA Caregiver Support Program. RESULTS VA vocational and education services helped veterans with disabilities transition from the military into civilian life by providing skills and incremental exposure to engaging in everyday life tasks. Veteran motivation, caregiver support, and engaged staff at VA and academic institutions were key drivers of veteran success. Veterans who experienced challenges cited the following barriers: health problems, concerns about benefits loss if they became employed, and VA and academic programs that did not accommodate the needs of nontraditional veteran learners. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE There is a need to bolster VA vocational and educational services for veterans with disabilities in several domains, including modifying the roles of frontline staff and increasing communication between vocational counselors and health care teams to better accommodate the veteran's health-related limitations. Providing a vocational rehabilitation navigator to help veterans identify opportunities within VA and work/educational settings that are a good match for the veteran's goals and abilities could also be beneficial across vocational and educational services. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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Affiliation(s)
- Megan Shepherd-Banigan
- Durham Veterans Affairs Health Services Research and Development (HSR&D), Center of Innovation to Accelerate Discovery and Practice Transformation(ADAPT),VA Durham Healthcare System
| | - Terri K Pogoda
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System
| | - Kevin McKenna
- Department of Population Health Sciences, Duke School of Medicine
| | - Nina Sperber
- Durham Veterans Affairs Health Services Research and Development (HSR&D), Center of Innovation to Accelerate Discovery and Practice Transformation(ADAPT),VA Durham Healthcare System
| | - Courtney H Van Houtven
- Durham Veterans Affairs Health Services Research and Development (HSR&D), Center of Innovation to Accelerate Discovery and Practice Transformation(ADAPT),VA Durham Healthcare System
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9
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Ettenhofer ML, Remigio-Baker RA, Bailie JM, Cole WR, Gregory E. Best Practices for Progressive Return to Activity after Concussion: Lessons Learned from a Prospective Study of U.S. Military Service Members. Neurotrauma Rep 2020; 1:137-145. [PMID: 33274343 PMCID: PMC7703689 DOI: 10.1089/neur.2020.0023] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Primary care providers can play a crucial role in the clinical management of concussion. However, many providers lack up-to-date information about best practices for rest and return to activity after these injuries. Most research on this topic has been conducted in athletes, and so less is known about how to assist patients with returning to activity in other settings and populations. This article provides a review of best practices for management of progressive return to activity after concussion, with an emphasis on "lessons learned" from the Defense and Veterans Brain Injury Center (DVBIC) Progressive Return to Activity (PRA) study, a multi-site longitudinal research project conducted to evaluate concussion management practices and the effectiveness of provider training on DVBIC clinical recommendations (CRs). Provider clinical practices and patient outcomes were examined at three U.S. military treatment facilities before and after providers completed a standardized training on DVBIC PRA CRs. In summary, research findings provide additional support that concussion recovery can be influenced by patients' activity levels after injury. Patients with concussion may experience poorer outcomes if they return to pre-injury levels of activity too rapidly, but they may also be at risk for prolonged symptoms if they fail to increase activity levels over time after an initial period of rest. Additionally, training primary care providers in return to activity guidelines can result in more effective patient education and better clinical outcomes. This knowledge can be used to inform best practices for progressive return to activity in both civilian and military settings.
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Affiliation(s)
- Mark L. Ettenhofer
- Defense and Veterans Brain Injury Center, Silver Spring, Maryland, USA
- Naval Medical Center San Diego, San Diego, California, USA
- General Dynamics Information Technology, Fairfax, Virginia, USA
- University of California, San Diego, La Jolla, California, USA
| | - Rosemay A. Remigio-Baker
- Defense and Veterans Brain Injury Center, Silver Spring, Maryland, USA
- Naval Hospital Camp Pendleton, Camp Pendleton, California, USA
- Henry M. Jackson Foundation, Bethesda, Maryland, USA
| | - Jason M. Bailie
- Defense and Veterans Brain Injury Center, Silver Spring, Maryland, USA
- General Dynamics Information Technology, Fairfax, Virginia, USA
- Naval Hospital Camp Pendleton, Camp Pendleton, California, USA
| | - Wesley R. Cole
- Defense and Veterans Brain Injury Center, Silver Spring, Maryland, USA
- Womack Army Medical Center, Fort Bragg, North Carolina, USA
| | - Emma Gregory
- Defense and Veterans Brain Injury Center, Silver Spring, Maryland, USA
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10
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Chakraborty N, Hammamieh R, Gautam A, Miller SA, Condlin ML, Jett M, Scrimgeour AG. TBI weight-drop model with variable impact heights differentially perturbs hippocampus-cerebellum specific transcriptomic profile. Exp Neurol 2020; 335:113516. [PMID: 33172833 DOI: 10.1016/j.expneurol.2020.113516] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 09/28/2020] [Accepted: 10/21/2020] [Indexed: 01/14/2023]
Abstract
The degree of brain injury is the governing factor for the magnitude of the patient's psycho- and physiological deficits post-injury, and the associated long-term consequences. The present scaling method used to segregate the patients among mild, moderate and severe phases of traumatic brain injury (TBI) has major limitations; however, a more continuous stratification of TBI is still elusive. With the anticipation that differentiating molecular markers could be the backbone of a robust method to triage TBI, we used a modified closed-head injury (CHI) Marmarou model with two impact heights (IH). By definition, IH directly correlates with the impact force causing TBI. In our modified CHI model, the rat skull was fitted with a helmet to permit a diffuse axonal injury. With the frontal cortex as the focal point of injury, the adjacent brain regions (hippocampus, HC and cerebellum, CB) were susceptible to diffuse secondary shock injury. At 8 days post injury (po.i.), rats impacted by 120 cm IH (IH120) took a longer time to find an escape route in the Barnes maze as compared to those impacted by 100 cm IH (IH100). Using a time-resolved interrogation of the transcriptomic landscape of HC and CB tissues, we mined those genes that altered their regulations in correlation with the variable IHs. At 14 days po.i., when all rats demonstrated nearly normal visuomotor performance, the bio-functional analysis suggested an advanced healing mechanism in the HC of IH100 group. In contrast, the HC of IH120 group displayed a delayed healing with evidence of active cell death networks. Combining whole genome rat microarrays with behavioral analysis provided the insight of neuroprotective signals that could be the foundation of the next generation triage for TBI patients.
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Affiliation(s)
- Nabarun Chakraborty
- Geneva Foundation, Medical Readiness Systems Biology, Walter Reed Army Institute of Research, Silver Spring, MD 20910, United States of America; Medical Readiness Systems Biology, Walter Reed Army Institute of Research, Silver Spring, MD 20910, United States of America.
| | - Rasha Hammamieh
- Medical Readiness Systems Biology, Walter Reed Army Institute of Research, Silver Spring, MD 20910, United States of America
| | - Aarti Gautam
- Medical Readiness Systems Biology, Walter Reed Army Institute of Research, Silver Spring, MD 20910, United States of America
| | - Stacy-Ann Miller
- Medical Readiness Systems Biology, Walter Reed Army Institute of Research, Silver Spring, MD 20910, United States of America; ORISE, Medical Readiness Systems Biology, Walter Reed Army Institute of Research, Silver Spring, MD 20910, United States of America
| | - Michelle L Condlin
- Military Nutrition Division, US Army Research Institute of Environmental Medicine, 10 General Greene Ave, Bldg 42, Natick, MA 01760, United States of America
| | - Marti Jett
- Medical Readiness Systems Biology, Walter Reed Army Institute of Research, Silver Spring, MD 20910, United States of America
| | - Angus G Scrimgeour
- Military Nutrition Division, US Army Research Institute of Environmental Medicine, 10 General Greene Ave, Bldg 42, Natick, MA 01760, United States of America
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11
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Shepherd-Banigan M, Sperber N, McKenna K, Pogoda TK, Van Houtven CH. Leveraging institutional support for family caregivers to meet the health and vocational needs of persons with disabilities. Nurs Outlook 2019; 68:184-193. [PMID: 31570147 DOI: 10.1016/j.outlook.2019.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 08/09/2019] [Accepted: 08/25/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Family caregivers might enhance veteran engagement in health and nonhealth services (i.e., vocational/educational assistance). PURPOSE To describe how veterans with disabilities perceive their recovery needs, identify types of social support from caregivers that help veterans engage in Veterans Affairs (VA) health and nonhealth services, and explore participant views of VA institutional support for caregivers to help veterans engage in these services. METHODS Joint in-depth qualitative interviews with U.S. veterans and family caregivers (n = 26). FINDINGS Caregivers performed social support functions that helped veterans engage in health and vocational/educational services and institutional support from VA enhanced caregivers' capacity. DISCUSSION Caregivers are well positioned to align health and nonhealth services with patient needs to enhance recovery. Staffing a point person for caregivers within the health system is key to help families develop a coordinated plan of treatment and services to improve patient success across health and nonhealth domains. Nurses are well suited to perform this role.
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Affiliation(s)
- Megan Shepherd-Banigan
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, NC; Department of Population Health Sciences, Duke University School of Medicine, Durham, NC.
| | - Nina Sperber
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, NC; Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
| | - Kevin McKenna
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
| | - Terri K Pogoda
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA; Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, MA
| | - Courtney H Van Houtven
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, NC; Department of Population Health Sciences, Duke University School of Medicine, Durham, NC; Duke-Margolis Center for Health Policy, Duke University, Durham, NC
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12
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Røe C, Tverdal C, Howe EI, Tenovuo O, Azouvi P, Andelic N. Randomized Controlled Trials of Rehabilitation Services in the Post-acute Phase of Moderate and Severe Traumatic Brain Injury - A Systematic Review. Front Neurol 2019; 10:557. [PMID: 31244748 PMCID: PMC6563754 DOI: 10.3389/fneur.2019.00557] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 05/09/2019] [Indexed: 12/21/2022] Open
Abstract
Background and aims: There is a gap in knowledge regarding effective rehabilitation service delivery in the post-acute phase after traumatic brain injury (TBI). Recently, Gutenbrunner et al. proposed a classification system for health-related rehabilitation services (International Classification System for Service Organization in Health-related Rehabilitation, ICSO-R) that could be useful for contrasting and comparing rehabilitation services. The ICSO-R describes the dimensions of Provision (i.e., context of delivered services), Funding (i.e., sources of income and refunding), and Delivery (i.e., mode, structure and intensity) at the meso-level of services. We aim to: -Provide an overview of randomized, controlled trials (RCTs) with rehabilitation service relevance provided to patients with moderate and severe TBI in the post-acute phase using the ICSO-R as a framework; and -Evaluate the extent to which the provision, funding and delivery dimensions of rehabilitation services were addressed and differed between the intervention arms in these studies. Materials and methods: A systematic literature search was performed in OVID MEDLINE, EMBASE, CINHAL, PsychINFO, and CENTRAL, including multidisciplinary rehabilitation interventions with RCT designs and service relevance targeting moderate and severe TBI in the post-acute phase. Results: 23 studies with 4,644 TBI patients were included. More than two-thirds of the studies were conducted in a hospital-based rehabilitation setting. The contrast in Context between the intervention arms often co-varied with Resources. The funding of the services was explicitly described in only one study. Aspects of the Delivery dimension were described in all of the studies, and the Mode of Production, Intensity, Aspects of Time and Peer Support were contrasted in the intervention arms in several of the studies. A wide variety of outcome measures were applied often covering Body function, as well as the Activities and Participation domains of the International Classification of Functioning, Disability, and Health (ICF). Conclusion: Aspects of service organization and resources as well as delivery may clearly influence outcome of rehabilitation. Presently, lack of uniformity of data and collection methods, the heterogeneity of structures and processes of rehabilitation services, and a lack of common outcome measurements make comparisons between the studies difficult. Standardized descriptions of services by ICSO-R, offer the possibility to improve comparability in the future and thus enhance the relevance of rehabilitation studies.
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Affiliation(s)
- Cecilie Røe
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital Ulleval, Oslo, Norway.,Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Research Centre for Habilitation and Rehabilitation Models and Services, Faculty of Medicine, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Cathrine Tverdal
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital Ulleval, Oslo, Norway
| | - Emilie Isager Howe
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital Ulleval, Oslo, Norway
| | - Olli Tenovuo
- Department of Neurology, University of Turku, Turku, Finland.,Turku University Hospital, Turku, Finland
| | - Philippe Azouvi
- Service de Médecine Physique et de Réadaptation, Hôpital Raymond-Poincaré, Garches, France.,Université de Versailles Saint-Quentin, Montigny-Le-Bretonneux, France
| | - Nada Andelic
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital Ulleval, Oslo, Norway.,Research Centre for Habilitation and Rehabilitation Models and Services, Faculty of Medicine, Institute of Health and Society, University of Oslo, Oslo, Norway
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13
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Predictors of Employment Status in Male and Female Post-9/11 Veterans Evaluated for Traumatic Brain Injury. J Head Trauma Rehabil 2019; 34:11-20. [DOI: 10.1097/htr.0000000000000404] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Wyse JJ, Pogoda TK, Mastarone GL, Gilbert T, Carlson KF. Employment and vocational rehabilitation experiences among veterans with polytrauma/traumatic brain injury history. Psychol Serv 2018; 17:65-74. [PMID: 30265073 DOI: 10.1037/ser0000283] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Evidence suggests that Iraq and Afghanistan war veterans with polytrauma/traumatic brain injury (TBI) history and neurobehavioral symptoms may face difficulties returning to work, yet also encounter barriers to accessing, navigating, and engaging in Department of Veterans Affairs (VA) vocational rehabilitation programs. This study utilized qualitative interviews and focus groups with veterans with documented polytrauma/TBI history to explore veterans' perceived barriers to employment and vocational rehabilitation program participation, as well as to solicit thoughts regarding interest in an evidence-based vocational rehabilitation program, the Individual Placement and Support model of Supported Employment (IPS-SE). Veterans identified physical, emotional, cognitive, and interpersonal barriers to finding and maintaining work that they described as linked with their polytrauma/TBI symptoms and sequelae. Communication and logistical issues were described as the primary barriers to vocational rehabilitation program access, while barriers to program utilization included eligibility characteristics, fear of losing financial benefits, and a military-cultural belief of self-sufficiency that made help-seeking difficult. Finally, veterans endorsed key aspects of IPS-SE, such as staff serving as translators, advocates, and navigators of the job search and maintenance process. Policy recommendations are addressed. (PsycINFO Database Record (c) 2020 APA, all rights reserved).
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Affiliation(s)
- Jessica J Wyse
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System
| | - Terri K Pogoda
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System
| | | | - Tess Gilbert
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System
| | - Kathleen F Carlson
- Center to Improve Veteran Involvement in Care, and National Center for Rehabilitative Auditory Research (NCRAR), VA Portland Health Care System
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