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Meshberg-Cohen S, Cook JM, Fischer IC, Pietrzak RH. Mild Traumatic Brain Injury in U.S. Military Veterans: Results from the National Health and Resilience in Veterans Study. Psychiatry 2024:1-15. [PMID: 39186319 DOI: 10.1080/00332747.2024.2392226] [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: 08/27/2024]
Abstract
OBJECTIVE This study provides nationally representative data on the prevalence, risk factors, and associated mental health and functional outcomes of mild traumatic brain injury (mTBI) in U.S. military veterans. METHODS Data (N = 4,069) were analyzed from the National Health and Resilience in Veterans Study (NHRVS). Analyses estimated mTBI prevalence, exposure to different mTBI injuries, and past-week mTBI symptoms (i.e. persistent post-concussive symptoms [PCS]). Comparisons were made between veterans with and without mTBI+PCS on sociodemographic, military, trauma, and psychiatric characteristics. Associations between mTBI+PCS and measures of cognitive, mental, and psychosocial functioning were examined. RESULTS Overall, 43.7% endorsed a possible mTBI event on the Veterans Affairs' Mild TBI Injury Screening and Evaluation tool, and 10.0% screened positive for mTBI. After combining a self-reported healthcare professional diagnosis of concussion/mTBI/TBI (5.8%) with a positive mTBI screen, the prevalence of mTBI+PCS was 3.0%. Veterans with specific trauma characteristics (e.g. adverse childhood events), military service (e.g. combat), and lifetime psychiatric conditions were more likely to have mTBI+PCS. mTBI+PCS was associated with increased odds of current posttraumatic stress disorder, major depressive disorder, generalized anxiety disorder, and drug use disorder. These veterans also scored significantly lower on cognitive, mental, and psychosocial functioning. CONCLUSIONS Overall, 3.0% of veterans had mTBI+PCS, suggesting that while mTBI may be prevalent in this population, the majority will likely recover without developing chronic symptoms. Those with mTBI+PCS are at significant risk for comorbid psychiatric diagnoses and poorer psychosocial functioning relative to those without mTBI+PCS, and early targeted identification may assist in prevention of disability and recovery.
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Kryza-Lacombe M, Santiago R, Hwang A, Raptentsetsang S, Maruyama BA, Chen J, Cassar M, Abrams G, Novakovic-Agopian T, Mukherjee P. Resting-State Connectivity Changes After Goal-Oriented Attentional Self-Regulation Training in Veterans With Mild Traumatic Brain Injury: Preliminary Findings from a Randomized Controlled Trial. Neurotrauma Rep 2023; 4:420-432. [PMID: 37405257 PMCID: PMC10316036 DOI: 10.1089/neur.2022.0074] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/06/2023] Open
Abstract
Mild traumatic brain injury (mTBI) can have lasting consequences on cognitive functioning and well-being. Goal-Oriented Attentional Self-Regulation (GOALS) training has been shown to improve attention and executive functioning, as well as emotional functioning, in veterans with chronic TBI. An ongoing clinical trial (NCT02920788) is further evaluating GOALS training, including underlying neural mechanisms of change. The present study aimed to examine training-induced neuroplasticity by resting-state functional connectivity (rsFC) changes in GOALS versus active control. Veterans with a history of mTBI ≥6 months post-injury (N = 33) were randomly assigned to GOALS (n = 19) or an intensity-matched active control group (Brain Health Education [BHE] training; n = 14). GOALS consists of attention regulation and problem solving applied to individually defined, relevant goals through a combination of group, individual, and home practice sessions. Participants underwent multi-band resting-state functional magnetic resonance imaging at baseline and post-intervention. Exploratory 2 × 2 mixed analyses of variance identified pre-to-post changes in seed-based connectivity for GOALS versus BHE in five significant clusters. GOALS versus BHE demonstrated a significant increase in right lateral pre-frontal cortex connectivity with the right frontal pole and right middle temporal gyrus, as well as increased posterior cingulate connectivity with the pre-central gyrus. Rostral pre-frontal cortex connectivity with the right precuneus and the right frontal pole decreased in GOALS versus BHE. These GOALS-related changes in rsFC point to potential neural mechanisms underlying the intervention. This training-induced neuroplasticity may play a role in improved cognitive and emotional functioning post-GOALS.
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Affiliation(s)
- Maria Kryza-Lacombe
- Mental Illness Research Education and Clinical Centers, Department of Veterans Affairs, San Francisco VA Health Care System, San Francisco, California, USA
- University of California, San Francisco, San Francisco, California, USA
| | - Rachel Santiago
- Department of Veterans Affairs, San Francisco VA Health Care System, San Francisco, California, USA
| | - Anna Hwang
- Department of Veterans Affairs, San Francisco VA Health Care System, San Francisco, California, USA
- University of California, San Francisco, San Francisco, California, USA
| | - Sky Raptentsetsang
- Department of Veterans Affairs, San Francisco VA Health Care System, San Francisco, California, USA
- University of California, San Francisco, San Francisco, California, USA
| | - Brian A. Maruyama
- Department of Veterans Affairs, San Francisco VA Health Care System, San Francisco, California, USA
| | - Jerry Chen
- Department of Veterans Affairs, San Francisco VA Health Care System, San Francisco, California, USA
| | | | - Gary Abrams
- Department of Veterans Affairs, San Francisco VA Health Care System, San Francisco, California, USA
- University of California, San Francisco, San Francisco, California, USA
| | - Tatjana Novakovic-Agopian
- Department of Veterans Affairs, San Francisco VA Health Care System, San Francisco, California, USA
- University of California, San Francisco, San Francisco, California, USA
| | - Pratik Mukherjee
- Department of Veterans Affairs, San Francisco VA Health Care System, San Francisco, California, USA
- University of California, San Francisco, San Francisco, California, USA
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Vas A, Luedtke A, Ortiz E, Mackie N, Gonzalez S. Cognitive Rehabilitation: Mild Traumatic Brain Injury and Relevance of OTPF. Occup Ther Int 2023; 2023:8135592. [PMID: 37283959 PMCID: PMC10241584 DOI: 10.1155/2023/8135592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 04/30/2023] [Accepted: 05/05/2023] [Indexed: 06/08/2023] Open
Abstract
There is increased awareness of the long-term cognitive sequelae of mild traumatic brain injury (mTBI). Therefore, researchers and clinicians have developed and tested cognitive training protocols to address these challenges. The current review summarized literature that examined existing cognitive rehabilitation/training programs. Specifically, the review listed the impact of these programs on functional domains informed by the Occupational Therapy Practice Framework (OTPF). Literature between the years 2008 and 2022 was gathered from nine databases. Results indicate that several cognitive rehabilitation programs have proven to positively influence domains of occupation, client factors, performance, and context. Occupational therapy practitioners have an opportunity to engage in mTBI management. Furthermore, adopting domains of OTPF may guide assessments, treatment planning, and long-term follow-up.
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Affiliation(s)
- Asha Vas
- School of Occupational Therapy, Texas Woman's University, Dallas, TX 75235, USA
| | - Anna Luedtke
- Baylor Scott & White Medical Center, Dallas, Texas, USA
| | - Eryn Ortiz
- Thrive Skilled Pediatric Care, Dallas, Texas, USA
| | - Natalie Mackie
- School of Occupational Therapy, Texas Woman's University, Dallas, TX 75235, USA
| | - Samantha Gonzalez
- School of Occupational Therapy, Texas Woman's University, Dallas, TX 75235, USA
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Kornblith E, Schweizer S, Abrams G, Gardner R, Barnes D, Yaffe K, Novakovic-Agopian T. Telehealth delivery of group-format cognitive rehabilitation to older veterans with TBI: a mixed-methods pilot study. APPLIED NEUROPSYCHOLOGY. ADULT 2023:1-13. [PMID: 37044120 DOI: 10.1080/23279095.2023.2199160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Abstract
Traumatic brain injury (TBI) is common among Veterans and may interact with aging, increasing risk for negative cognitive, emotional, and functional outcomes. However, no accessible (i.e., in-home) group interventions for TBI targeted to older adults exist. Goal Oriented Attentional Self-Regulation (GOALS) is a manualized, group cognitive rehabilitation training that improves executive function and emotional regulation among Veterans with TBI and healthy older adults. Our objectives were to adapt GOALS for delivery to older Veterans via in-home video telehealth (IVT) and evaluate feasibility and participant-rated acceptability of the telehealth GOALS intervention (TeleGOALS). Six Veterans 69+, with multiple TBIs completed the 10-session intervention in groups of 2. One participant withdrew, and another completed the remaining sessions alone (total n enrolled = 8). Required adaptations were noted; questionnaire responses were quantified; and feedback was analyzed and coded to identify themes. Quantitative and qualitative methods were used to examine feasibility (i.e., recruitment and retention) and participant-rated acceptability. Minimal adaptations were required for IVT delivery. Key themes emerged: (a) the importance of telehealth logistics, (b) facilitators' roles in prioritizing interpersonal connection, and (c) telehealth's capability to create opportunities for community reintegration. Thematic saturation (the point at which feedback from respondents is consistent and no further adaptations are required) was achieved. Participants stated they would likely recommend TeleGOALS to other Veterans. Although further study with a larger, more diverse sample is required, the adapted TeleGOALS intervention appears highly feasible and acceptable for older Veterans with TBI able and willing to participate in a group-format IVT intervention.
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Affiliation(s)
- Erica Kornblith
- San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
- Department of Psychiatry, University of California San Francisco (UCSF), San Francisco, CA, USA
| | - Sara Schweizer
- Northern California Institute for Research and Education, San Francisco, CA, USA
| | - Gary Abrams
- San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
- Department of Neurology, UCSF, San Francisco, CA, USA
| | - Raquel Gardner
- San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
- Department of Neurology, UCSF, San Francisco, CA, USA
| | - Deborah Barnes
- Department of Psychiatry, University of California San Francisco (UCSF), San Francisco, CA, USA
- Department of Epidemiology & Biostatistics, UCSF, San Francisco, CA, USA
| | - Kristine Yaffe
- San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
- Department of Psychiatry, University of California San Francisco (UCSF), San Francisco, CA, USA
- Northern California Institute for Research and Education, San Francisco, CA, USA
- Department of Neurology, UCSF, San Francisco, CA, USA
- Department of Epidemiology & Biostatistics, UCSF, San Francisco, CA, USA
| | - Tatjana Novakovic-Agopian
- San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
- Department of Psychiatry, University of California San Francisco (UCSF), San Francisco, CA, USA
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Crocker LD, Jurick SM, Merritt VC, Keller AV, Hoffman SN, Davey DK, Jak AJ. Mechanisms through which executive dysfunction influences suicidal ideation in combat-exposed Iraq and Afghanistan veterans. Clin Neuropsychol 2022; 36:2073-2092. [PMID: 34524071 DOI: 10.1080/13854046.2021.1974566] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVE Executive dysfunction has previously been associated with suicidality, but it remains unclear how deficits in executive functioning contribute to increased suicidal thoughts and behaviors. Although it has been proposed that poorer executive functioning leads to difficulty generating and implementing appropriate coping strategies to regulate distress and inhibit suicidal thoughts and behaviors, studies have not systematically examined these relationships. Therefore, the present study examined various hypotheses to elucidate the mechanisms through which executive dysfunction influences suicidal ideation (SI) in combat-exposed Iraq/Afghanistan veterans. METHOD Veterans who endorsed SI were compared to those who denied SI on demographic and diagnostic variables and measures of neuropsychological functioning, psychological symptoms, coping styles, and combat experiences. Serial mediation models were tested to examine mechanistic relationships among executive functioning, psychological distress, coping, and SI. RESULTS Those who endorsed SI had worse executive functioning, greater psychological distress, and greater avoidant coping relative to those who denied SI. Serial mediation model testing indicated a significant indirect path, such that executive dysfunction increased psychological distress, which in turn increased avoidant coping, leading to SI. CONCLUSIONS Findings support and extend previous hypotheses regarding how executive functioning contributes to increased risk of suicidality via increased distress and avoidant coping. Intervention efforts focused on reducing suicidality may benefit from techniques that enhance executive functioning (e.g. computerized training, cognitive rehabilitation) and in turn reduce distress prior to targeting coping strategies.
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Affiliation(s)
- Laura D Crocker
- Research Service, VA San Diego Healthcare System, San Diego, CA, USA.,Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System, San Diego, CA, USA
| | - Sarah M Jurick
- Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System, San Diego, CA, USA.,Department of Psychiatry, School of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Victoria C Merritt
- Research Service, VA San Diego Healthcare System, San Diego, CA, USA.,Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System, San Diego, CA, USA.,Department of Psychiatry, School of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Amber V Keller
- San Diego Joint Doctoral Program in Clinical Psychology, San Diego State University/University of California, San Diego, CA, USA
| | - Samantha N Hoffman
- San Diego Joint Doctoral Program in Clinical Psychology, San Diego State University/University of California, San Diego, CA, USA
| | - Delaney K Davey
- Research Service, VA San Diego Healthcare System, San Diego, CA, USA
| | - Amy J Jak
- Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System, San Diego, CA, USA.,Department of Psychiatry, School of Medicine, University of California San Diego, La Jolla, CA, USA.,Psychology Service, VA San Diego Healthcare System, San Diego, CA, USA
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Maruyama BA, Abrams G, Kornblith E, Posecion LF, McQuaid JR, Neylan TC, Groberio J, Chen AJW, Novakovic-Agopian T. Improvement in executive functioning after Goal-Oriented Attentional Self-Regulation training is associated with reduction in PTSD hyperarousal symptoms among veterans with comorbid PTSD and mild TBI. APPLIED NEUROPSYCHOLOGY-ADULT 2021:1-9. [PMID: 34410839 DOI: 10.1080/23279095.2021.1960531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Goal-Oriented Attentional Self-Regulation (GOALS) is a cognitive rehabilitation training program that combines mindfulness-based attention regulation with individualized goal management strategies to improve functioning in daily life after traumatic brain injury (TBI). While not a specific target of GOALS training, previous research has indicated improvements in emotional functioning following GOALS training, specifically symptoms related to depression and posttraumatic stress disorder (PTSD). The current study is based on the hypothesis that improvements in cognitive control processes related to executive functioning and attention after GOALS training generalize to improvements in emotional functioning, thereby resulting in reductions in emotional distress. The current study analyzed archival data from 33 Veteran participants with a confirmed diagnosis of PTSD and a history of mild TBI who received either GOALS training or a psychoeducational intervention matched for time, therapist attention, and participation format. Regression analysis was used to assess the strength of the relationship between improvements in Overall Attention/Executive Functioning and decreases in hyperarousal symptoms associated with PTSD. Results from the regression analysis revealed that improvements in Overall Attention/Executive Functioning after GOALS was significantly associated with reductions in hyperarousal symptoms associated with PTSD (R2 = 0.26, F(1,15) = 5.01, β = -.51, p < .05). The current findings suggest that cognitive improvements after GOALS training may lead to changes in emotional functioning, resulting in decreased emotional distress. This is important, particularly in VA settings, because the results potentially highlight additional areas of research and focus on the treatment of comorbid mild TBI and PTSD among Veterans.
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Affiliation(s)
- Brian A Maruyama
- Department of Veterans Affairs, San Francisco VA Health Care System, San Francisco, CA, USA
| | - Gary Abrams
- Department of Veterans Affairs, San Francisco VA Health Care System, San Francisco, CA, USA.,University of California, San Francisco, CA, USA
| | - Erica Kornblith
- Department of Veterans Affairs, San Francisco VA Health Care System, San Francisco, CA, USA.,University of California, San Francisco, CA, USA
| | - Lainie F Posecion
- Department of Veterans Affairs, San Francisco VA Health Care System, San Francisco, CA, USA
| | - John R McQuaid
- Department of Veterans Affairs, San Francisco VA Health Care System, San Francisco, CA, USA.,University of California, San Francisco, CA, USA
| | - Thomas C Neylan
- Department of Veterans Affairs, San Francisco VA Health Care System, San Francisco, CA, USA.,University of California, San Francisco, CA, USA
| | - Jessica Groberio
- Department of Veterans Affairs, San Francisco VA Health Care System, San Francisco, CA, USA
| | - Anthony J-W Chen
- University of California, San Francisco, CA, USA.,Department of Veterans Affairs, VA Northern California Health Care System, Martinez, CA, USA
| | - Tatjana Novakovic-Agopian
- Department of Veterans Affairs, San Francisco VA Health Care System, San Francisco, CA, USA.,University of California, San Francisco, CA, USA
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Novakovic-Agopian T, Posecion L, Kornblith E, Abrams G, McQuaid JR, Neylan TC, Burciaga J, Joseph J, Carlin G, Groberio J, Maruyama B, Chen AJW. Goal-Oriented Attention Self-Regulation Training Improves Executive Functioning in Veterans with Post-Traumatic Stress Disorder and Mild Traumatic Brain Injury. J Neurotrauma 2020; 38:582-592. [PMID: 33019861 DOI: 10.1089/neu.2019.6806] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Difficulties in executive-control functions are common sequelae of both traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD). The goal of this study was to assess whether a cognitive rehabilitation training that was applied successfully in civilian and military TBI would be effective for military Veterans with comorbid PTSD and mild TBI (mTBI). In the previous study, Veterans with a history of mild to severe TBI improved significantly after goal-oriented attentional self-regulation (GOALS) training on measures of attention/executive function, functional task performance, and emotional regulation. The objective of this study was to assess effects of GOALS training in Veterans with comorbid PTSD and mTBI. Forty Veterans with a current PTSD diagnosis and history of mTBI (6+ months post) were randomized to either five weeks of GOALS or Brain-Health Education (BHE) training matched in time and intensity. Evaluator-blinded assessments at baseline and post-training included neuropsychological and complex functional task performance, and self-report measures of emotional functioning/regulation. After GOALS but not BHE training, participants significantly improved from baseline on primary outcome measures of: overall complex attention/executive function neuropsychological performance composite (F = 12.35, p = 0.001; Cohen d = 0.48), and overall mood disturbance -POMS emotional regulation self-report (F = 4.29, p = 0.05, Cohen d = 0.41). In addition, GOALS but not BHE participants indicated a significant decrease in PTSD symptoms (PCL-M Total Score) (F = 4.80, p = 0.05, Cohen d = 0.60), and demonstrated improvement on complex functional task performance-GPS Learning and Memory (F = 5.06, p = 0.05, Cohen d = 0.56]. Training in attentional self-regulation applied to participant-defined goals may improve cognitive functioning in Veterans with comorbid PTSD and mTBI. Improving cognitive control functioning may also improve functioning in other domains such as emotional regulation and functional performance, potentially making it particularly relevant for Veterans with a history of mTBI and comorbid psychiatric symptoms.
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Affiliation(s)
- Tatjana Novakovic-Agopian
- San Francisco VA Health Care System, San Francisco, California, USA.,University of California, San Francisco, San Francisco, California, USA.,VA Northern California Health Care System, Martinez, California, USA
| | - Lainie Posecion
- San Francisco VA Health Care System, San Francisco, California, USA
| | - Erica Kornblith
- San Francisco VA Health Care System, San Francisco, California, USA.,University of California, San Francisco, San Francisco, California, USA
| | - Gary Abrams
- San Francisco VA Health Care System, San Francisco, California, USA.,University of California, San Francisco, San Francisco, California, USA
| | - John R McQuaid
- San Francisco VA Health Care System, San Francisco, California, USA.,University of California, San Francisco, San Francisco, California, USA
| | - Thomas C Neylan
- San Francisco VA Health Care System, San Francisco, California, USA.,University of California, San Francisco, San Francisco, California, USA
| | - Joaquin Burciaga
- San Francisco VA Health Care System, San Francisco, California, USA
| | - Jeremy Joseph
- San Francisco VA Health Care System, San Francisco, California, USA.,University of California, San Francisco, San Francisco, California, USA
| | - Gerald Carlin
- San Francisco VA Health Care System, San Francisco, California, USA
| | - Jessica Groberio
- San Francisco VA Health Care System, San Francisco, California, USA
| | - Brian Maruyama
- San Francisco VA Health Care System, San Francisco, California, USA
| | - Anthony J W Chen
- University of California, San Francisco, San Francisco, California, USA.,VA Northern California Health Care System, Martinez, California, USA
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Kornblith E, Posecion L, Abrams G, Chen AJW, Burciaga J, D'Esposito M, Novakovic-Agopian T. Long-Term Effect of Cognitive Rehabilitation Regardless of Prerehabilitation Cognitive Status for Veterans with TBI. APPLIED NEUROPSYCHOLOGY-ADULT 2019; 28:436-448. [PMID: 31456428 DOI: 10.1080/23279095.2019.1652174] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Persisting difficulties in executive functioning (EF) are common after traumatic brain injury (TBI). Cognitive rehabilitation can be effective, but the impact of pretreatment neurocognitive functioning on long term effects of rehabilitation is unknown. Because this information can impact treatment planning, we examined the relationship between prerehabilitation neurocognitive status and long-term effects of EF training. Archival data were drawn from a trial of Goal-Oriented Attentional Self-Regulation group-format EF training for Veterans with TBI [mild-severe; 11 years postinjury; 96% male, 32% nonwhite, 14.21 years education (SD 1.72), 41.13 years old (SD 11.39)]. Using prerehabilitation neurocognitive performance, participants were clustered into cognitive difficulty (CD) and cognitively normal (CN) groups. Six-plus months after EF rehabilitation training, participants completed a structured telephone interview and/or in-person cognitive/functional/emotional assessment using standardized measures of cognitive, daily, and emotional functioning frequently employed in TBI research. At 6+ months post-EF training compared to prerehabilitation, CD and CN improved in multiple cognitive (Overall Attention/EF: F(1,18) = 26.17, partial η2 = .59; Total Memory: F(1,18) = 6.82, partial η2 = .28) and functional domains (Goal Processing Scale [GPS] total score: F(1,15) = 6.71, partial η2 = .31). CD improved more than CN on Learning and Memory functional domain [F(1,15) = 6.10, partial η2 = .29]. Results of our small archival analysis raise the possibility that Veterans with chronic TBI may demonstrate long-term effects of EF training.
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Affiliation(s)
- Erica Kornblith
- San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Lainie Posecion
- San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Gary Abrams
- San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA.,University of California, San Francisco, CA, USA
| | - Anthony J-W Chen
- University of California, San Francisco, CA, USA.,Rehabilitation, Veterans Affairs Northern California Health Care System, Martinez, CA, USA.,University of California, Berkeley: Berkeley, CA
| | - Joaquin Burciaga
- University of California, Berkeley: Berkeley, CA.,Children's Health Council, Palo Alto, CA, USA
| | - Mark D'Esposito
- Children's Health Council, Palo Alto, CA, USA.,Helen Wills Neuroscience Institute, University of California Berkeley, Berkeley, CA, USA
| | - Tatjana Novakovic-Agopian
- San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA.,University of California, San Francisco, CA, USA
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