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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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Kennedy JE, Warren JB, Lu LHJ, Lawrence CY, Reid MW. Symptomatic Recovery from Concussion in Military Service Members with and Without Associated Bodily Injuries. Neurotrauma Rep 2024; 5:787-799. [PMID: 39184179 PMCID: PMC11342052 DOI: 10.1089/neur.2024.0041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/27/2024] Open
Abstract
Research has found that service members (SMs) with mild traumatic brain injury (mTBI) and co-occurring bodily injuries endorse lower chronic postconcussive symptom severity than SMs with mTBI and no bodily injuries. Investigations were conducted with primarily post-9/11 war-era SMs with blast injuries. The current study explores these findings in a cohort of more heterogeneous and recently evaluated military SM. Possible reasons suggested for the earlier findings include SMs with bodily injuries report fewer postconcussive symptoms due to (1) focusing attention on extra-cranial injuries and associated pain; (2) receiving more interpersonal and medical support, lowering distress; (3) using analgesics such as morphine or opioids; or (4) experiencing delayed postconcussive symptoms. The current investigation evaluates each of these hypothesized reasons for the earlier findings and the generalizability of the findings to a more recent sample. Data were extracted from 165 SMs in a TBI repository at a U.S. military medical center. All participants reported a history of an mTBI, confirmed by a clinical interview to meet Veterans Affairs and Department of Defense criteria. Other bodily injuries received at the time of the mTBI were documented with the Abbreviated Injury Scale (AIS). Multiple regression models evaluated the ability of the four hypothesized mechanisms to predict postconcussive symptom severity, measured by the Neurobehavioral Symptom Inventory. SMs with bodily injuries (n = 48) reported nonsignificantly lower postconcussive symptoms than SMs with no bodily injuries (n = 117). The level of subjective pain was a determinant of postconcussive symptom severity among SMs with a history of mTBI, with or without associated bodily injuries. Social support was a weaker negative predictor of postconcussive symptoms among SMs with no associated bodily injuries.
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Affiliation(s)
- Jan Elizabeth Kennedy
- Contractor, General Dynamics Information Technology (GDIT), Falls Church, Virginia, USA
- Traumatic Brain Injury Center of Excellence (TBICoE), Research Portfolio Management Division, Research & Engineering Directorate, Defense Health Agency, Falls Church, Virginia, USA
- Brooke Army Medical Center, Neurology Service (MCHE-ZDM-N), JBSA Fort Sam Houston, Fort Sam Houston, Texas, USA
| | - Joseph Booth Warren
- Traumatic Brain Injury Center of Excellence (TBICoE), Research Portfolio Management Division, Research & Engineering Directorate, Defense Health Agency, Falls Church, Virginia, USA
- Brooke Army Medical Center, Neurology Service (MCHE-ZDM-N), JBSA Fort Sam Houston, Fort Sam Houston, Texas, USA
- Contractor, CICONIX, LLC, Annapolis, Maryland, USA
| | - Lisa Hsiao-Jung Lu
- Contractor, General Dynamics Information Technology (GDIT), Falls Church, Virginia, USA
- Traumatic Brain Injury Center of Excellence (TBICoE), Research Portfolio Management Division, Research & Engineering Directorate, Defense Health Agency, Falls Church, Virginia, USA
- Brooke Army Medical Center, Neurology Service (MCHE-ZDM-N), JBSA Fort Sam Houston, Fort Sam Houston, Texas, USA
| | - Cristina Yvette Lawrence
- Traumatic Brain Injury Center of Excellence (TBICoE), Research Portfolio Management Division, Research & Engineering Directorate, Defense Health Agency, Falls Church, Virginia, USA
- Brooke Army Medical Center, Neurology Service (MCHE-ZDM-N), JBSA Fort Sam Houston, Fort Sam Houston, Texas, USA
- Contractor, CICONIX, LLC, Annapolis, Maryland, USA
| | - Matthew Wade Reid
- Traumatic Brain Injury Center of Excellence (TBICoE), Research Portfolio Management Division, Research & Engineering Directorate, Defense Health Agency, Falls Church, Virginia, USA
- Brooke Army Medical Center, Neurology Service (MCHE-ZDM-N), JBSA Fort Sam Houston, Fort Sam Houston, Texas, USA
- Contractor, CICONIX, LLC, Annapolis, Maryland, USA
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Darr AJ, Babakhanyan I, Caswell M, Alia Westphal B, Bailie JM. Efficacy of Computerized vs. Traditional Cognitive Interventions for the Treatment of Chronic mTBI Symptoms Among Service Members. Mil Med 2024; 189:530-538. [PMID: 39160812 DOI: 10.1093/milmed/usae180] [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: 11/29/2023] [Revised: 03/01/2024] [Accepted: 03/27/2024] [Indexed: 08/21/2024] Open
Abstract
INTRODUCTION Military service members (SMs) with mild traumatic brain injury (mTBI or concussion) frequently report cognitive and behavioral difficulties. Currently, military clinical guidelines recommend clinician-run, manualized cognitive rehabilitation (CR) to treat these symptoms; however, it is unclear whether this approach adequately addresses the unique needs of warfighters. Computerized cognitive training (CCT) programs represent an innovative, promising approach to treating cognitive difficulties; however, whether these programs can effectively remediate cognitive impairment in individuals with mTBI remains unclear. MATERIALS AND METHODS A total of 65 SMs with a history of at least 1 diagnosed mTBI were recruited from a military hospital. Participants received 1 of 2 interventions: Clinician-run, manualized CR (Study of Cognitive Rehabilitation Effectiveness [SCORE]; n = 37), consisting of 60 total intervention hours over 6 weeks, or CCT (n = 28), in which participants trained with either a commercial CCT (n = 14) or noncommercial CCT (n = 14), for a total of 12 hours over 4 weeks. Participants were assessed pre- and postintervention, using a combination of self-report and objective outcome measures: Key Behaviors Change Inventory (KBCI), a self-report measure of functional difficulties; Paced Auditory Serial Addition Test (PASAT), an objective cognitive assessment that measures both information processing speed and sustained and divided attention; and Symbol Digit Modalities Test (SDMT), an objective cognitive assessment that measures information processing speed. RESULTS Mixed ANOVA revealed no interaction effect between intervention type and time (pre- and postassessment) on the PASAT (P = .643, ηp2 = 0.003), SDMT (P = .423, ηp2 = 0.010), or KBCI (P = .434, ηp2 = 0.010); however, there was a significant within-group main effect (time) on all 3 outcome measures (PASAT P < .001, ηp2 = 0.54; SDMT P < .001, ηp2 = 0.25; and KBCI P = .001, ηp2 = 0.15). On average, participants showed improvement over baseline on the PASAT (SCORE delta = 6.98, SD = 7.25, P < .001; CCT delta = 7.79, SD = 6.45, P < .001), SDMT (SCORE delta = 4.62, SD = 8.82, P = .003; CCT delta = 6.58, SD = 10.81, P = .003), and KBCI (SCORE delta = -3.22, SD = 7.09, P = .009; CCT delta = -2.00, SD = 4.72, P = .033). Additional analysis comparing the relative effectiveness of the 2 different CCTs revealed that while training with either program resulted in improved performance on the PASAT (P < .001, ηp2 = 0.627), SDMT (P = .003, ηp2 = 0.286), and KBCI (P = .036, ηp2 = 0.158), there was no interaction effect of CCT program type and change over time for any measure (PASAT P = .102, ηp2 = 1.00; SDMT P = .317, ηp2 = 0.038; and KBCI P = .719, ηp2 = 0.005). CONCLUSIONS We showed that CCT programs do not differ in efficacy compared to clinician-run, manualized CR for treating symptoms associated with mTBI; however, exploratory analyses suggest that each approach may have distinct advantages for treating specific symptoms. Additionally, we showed that the improvement in the CCT intervention did not differ between those who trained using the commercial program vs. those who trained with the noncommercial program.
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Affiliation(s)
- Andrew J Darr
- Traumatic Brain Injury Center of Excellence, Silver Spring, MD 20910, USA
- General Dynamics Information Technology, Silver Spring, MD 20910, USA
- Intrepid Spirit Center, Naval Hospital Camp Pendleton, Oceanside, CA 92058, USA
| | - Ida Babakhanyan
- Traumatic Brain Injury Center of Excellence, Silver Spring, MD 20910, USA
- General Dynamics Information Technology, Silver Spring, MD 20910, USA
- Intrepid Spirit Center, Naval Hospital Camp Pendleton, Oceanside, CA 92058, USA
| | - Melissa Caswell
- Traumatic Brain Injury Center of Excellence, Silver Spring, MD 20910, USA
- General Dynamics Information Technology, Silver Spring, MD 20910, USA
- Intrepid Spirit Center, Naval Hospital Camp Pendleton, Oceanside, CA 92058, USA
| | - Bs Alia Westphal
- Traumatic Brain Injury Center of Excellence, Silver Spring, MD 20910, USA
- General Dynamics Information Technology, Silver Spring, MD 20910, USA
- Intrepid Spirit Center, Naval Hospital Camp Pendleton, Oceanside, CA 92058, USA
| | - Jason M Bailie
- Traumatic Brain Injury Center of Excellence, Silver Spring, MD 20910, USA
- General Dynamics Information Technology, Silver Spring, MD 20910, USA
- Intrepid Spirit Center, Naval Hospital Camp Pendleton, Oceanside, CA 92058, USA
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Ozturk ED, Zhang Y, Lai MHC, Sakamoto MS, Chanfreau-Coffinier C, Merritt VC. Measurement Invariance of the Neurobehavioral Symptom Inventory in Male and Female Million Veteran Program Enrollees Completing the Comprehensive Traumatic Brain Injury Evaluation. Assessment 2024; 31:967-979. [PMID: 37710416 DOI: 10.1177/10731911231198214] [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: 09/16/2023]
Abstract
This study evaluated measurement invariance across males and females on the Neurobehavioral Symptom Inventory (NSI) in U.S. military veterans enrolled in the VA Million Veteran Program. Participants (N = 17,059; males: n = 15,450; females: n = 1,609) included Veterans who took part in the VA Traumatic Brain Injury (TBI) Screening and Evaluation Program and completed the NSI. Multiple-group confirmatory factor analyses investigated measurement invariance of the NSI 4-factor model. The configural (comparative fit index [CFI] = 0.948, root mean square error of approximation [RMSEA] = 0.060) and metric (CFI = 0.948, RMSEA = 0.058) invariance models showed acceptable fit. There was a minor violation of scalar invariance (Δχ2 = 232.50, p < .001); however, the degree of noninvariance was mild (ΔCFI = -0.002, Δ RMSEA = 0 . 000 ). Our results demonstrate measurement invariance across sex, suggesting that the NSI 4-factor model can be used to accurately assess symptoms in males and females following TBI. Findings highlight the importance of considering validity of measurement across study groups to increase confidence that a measure is interpreted similarly by respondents from different subgroups.
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Affiliation(s)
- Erin D Ozturk
- VA San Diego Healthcare System (VASDHS), San Diego, CA, USA
- San Diego State University and University of California San Diego Joint Doctoral Program in Clinical Psychology, San Diego, CA, USA
| | - Yichi Zhang
- University of Southern California, Los Angeles, CA, USA
| | - Mark H C Lai
- University of Southern California, Los Angeles, CA, USA
| | - McKenna S Sakamoto
- VA San Diego Healthcare System (VASDHS), San Diego, CA, USA
- Penn State University, University Park, PA, USA
| | | | - Victoria C Merritt
- VA San Diego Healthcare System (VASDHS), San Diego, CA, USA
- University of California San Diego, La Jolla, CA, USA
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Kinney AR, Brenner LA, Nance M, Mignogna J, Cobb AD, Forster JE, Ulmer CS, Nakase-Richardson R, Bahraini NH. Factors Influencing Adherence to Insomnia and Obstructive Sleep Apnea Treatments among Veterans with Mild Traumatic Brain Injury. Behav Sleep Med 2024; 22:553-570. [PMID: 38420915 DOI: 10.1080/15402002.2024.2322517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
OBJECTIVE To understand factors influencing adherence to recommended treatment for insomnia and obstructive sleep apnea (OSA) among Veterans with mild traumatic brain injury (mTBI). METHOD Semi-structured interviews (n = 49) with 29 clinical stakeholders and 20 Veterans were conducted. Clinical stakeholders included Veterans Health Administration providers and policymakers involved in the management of mTBI and/or sleep disorders. Veterans included those with a clinician-confirmed mTBI with a recent history of insomnia disorder and/or OSA treatment. Themes were identified using a Descriptive and Interpretive approach. RESULTS Barriers to sleep disorder treatment adherence included factors associated with the patient (e.g., negative appraisal of treatment benefit), intervention (e.g., side effects), health conditions (e.g., cognitive challenges), health care system (e.g., limited availability of care), and socioeconomic status (e.g., economic instability). Similarly, facilitators of adherence included patient- (e.g., positive appraisal of treatment benefit), intervention- (e.g., flexible delivery format), condition- (e.g., accommodating cognitive impairments), health care system- (e.g., access to adherence support), and socioeconomic-related factors (e.g., social support). CONCLUSIONS Interviews revealed the multi-faceted nature of factors influencing adherence to sleep disorder treatment among Veterans with mTBI. Findings can inform the development of novel interventions and care delivery models that meet the complex needs of this population.
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Affiliation(s)
- Adam R Kinney
- Veteran Affairs Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC) for Suicide Prevention, Rocky Mountain MIRECC, Aurora, CO
- Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Lisa A Brenner
- Veteran Affairs Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC) for Suicide Prevention, Rocky Mountain MIRECC, Aurora, CO
- Departments of Physical Medicine and Rehabilitation, Psychiatry, and Neurology, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Morgan Nance
- Veteran Affairs Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC) for Suicide Prevention, Rocky Mountain MIRECC, Aurora, CO
- Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Joseph Mignogna
- Veteran Affairs Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC) for Suicide Prevention, Rocky Mountain MIRECC, Aurora, CO
- Departments of Physical Medicine and Rehabilitation, Psychiatry, and Neurology, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Audrey D Cobb
- Veteran Affairs Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC) for Suicide Prevention, Rocky Mountain MIRECC, Aurora, CO
| | - Jeri E Forster
- Veteran Affairs Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC) for Suicide Prevention, Rocky Mountain MIRECC, Aurora, CO
- Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Christi S Ulmer
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs, Durham, NC
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC
| | - Risa Nakase-Richardson
- Research Service, James A. Haley Veterans Hospital, Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of South Florida, Tampa
| | - Nazanin H Bahraini
- Veteran Affairs Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC) for Suicide Prevention, Rocky Mountain MIRECC, Aurora, CO
- Departments of Physical Medicine and Rehabilitation and Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, CO
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Kinney AR, Schneider AL, King SE, Yan XD, Forster JE, Bahraini NH, Brenner LA. Identifying and Predicting Subgroups of Veterans With Mild Traumatic Brain Injury Based on Distinct Configurations of Postconcussive Symptom Endorsement: A Latent Class Analysis. J Head Trauma Rehabil 2024; 39:247-257. [PMID: 38259092 DOI: 10.1097/htr.0000000000000890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
OBJECTIVE To identify distinct subgroups of veterans with mild traumatic brain injury (mTBI) based on configurations of postconcussive symptom (PCS) endorsement, and to examine predictors of subgroup membership. SETTING Outpatient Veterans Health Administration (VHA). PARTICIPANTS Veterans with clinician-confirmed mTBI who completed the Neurobehavioral Symptom Inventory (NSI), determined using the Comprehensive Traumatic Brain Injury Evaluation database. Individuals who tended to overreport symptoms were excluded via an embedded symptom validity scale. DESIGN Retrospective cohort study leveraging national VHA clinical data from 2012 to 2020. Latent class analysis (LCA) with a split-sample cross-validation procedure was used to identify subgroups of veterans. Multinomial logistic regression was used to examine predictors of subgroup membership. MAIN MEASURES Latent classes identified using NSI items. RESULTS The study included 72 252 eligible veterans, who were primarily White (73%) and male (94%). The LCA supported 7 distinct subgroups of veterans with mTBI, characterized by diverging patterns of risk for specific PCS across vestibular (eg, dizziness), somatosensory (eg, headache), cognitive (eg, forgetfulness), and mood domains (eg, anxiety). The most prevalent subgroup was Global (20.7%), followed by Cognitive-Mood (16.3%), Headache-Cognitive-Mood (H-C-M; 16.3%), Headache-Mood (14.2%), Anxiety (13.8%), Headache-Sleep (10.3%), and Minimal (8.5%). The Global class was used as the reference class for multinomial logistic regression because it was distinguished from others based on elevated risk for PCS across all domains. Female (vs male), Black (vs White), and Hispanic veterans (vs non-Hispanic) were less likely to be members of most subgroups characterized by lesser PCS endorsement relative to the Global class (excluding Headache-Mood). CONCLUSION The 7 distinct groups identified in this study distill heterogenous patterns of PCS endorsement into clinically actionable phenotypes that can be used to tailor clinical management of veterans with mTBI. Findings reveal empirical support for potential racial, ethnic, and sex-based disparities in PCS among veterans, informing efforts aimed at promoting equitable recovery from mTBI in this population.
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Affiliation(s)
- Adam R Kinney
- Veteran Affairs Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC) for Suicide Prevention, Aurora, Colorado (Drs Kinney, Forster, Bahraini, and Brenner, Ms Schneider, and Messrs King and Yan); and Departments of Physical Medicine and Rehabilitation (Drs Kinney, Forster, Bahraini, and Brenner), Psychiatry (Drs Bahraini and Brenner), and Neurology (Dr Brenner), Anschutz Medical Campus, University of Colorado, Aurora
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Biscardi M, Grossinger Z, Colantonio A, Bayley M, Mollayeva T. Efficacy of restitutive interventions for oculomotor deficits in adults with mild traumatic brain injury: a systematic review and meta-analysis. Brain Inj 2024; 38:499-513. [PMID: 38433498 DOI: 10.1080/02699052.2024.2320163] [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: 07/31/2023] [Accepted: 02/13/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND Mild traumatic brain injury (mTBI) can cause persistent symptoms suggestive of oculomotor deficits. This research synthesized evidence on restitutive interventions for reducing oculomotor deficits in adults with mTBI to understand if these interventions have clinical utility for improving recovery. METHODS Medline, EMBASE, CINHAL, PsychInfo, and Scopus, databases were searched for experimental studies published in English. We rated risk of bias (RoB) using recommended tools, and the certainty of the evidence according to GRADE guidelines. We conducted meta-analyses for similar outcomes reported in at least two studies. RESULTS Out of 5,328 citations, 12 studies (seven case series and five crossover design), with a combined sample size of 354 participants; (43% males) met the inclusion criteria and were analyzed. The analysis revealed a trend toward improvement of oculomotor deficits and visual tasks in response to restitutive intervention. None of the studies addressed sex or gender effects. All studies had high RoB, suggesting low certainty in the reported results. DISCUSSION Restitutive interventions may be beneficial for adults with oculomotor deficits after mTBI, however overall certainty of the evidence remains low. Future efforts must include enhancing attention to study methodology and reporting, sex and gender analyses, and reaching a consensus on outcome measures. PROSPERO REGISTRATION NUMBER CRD42022352276.
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Affiliation(s)
- Melissa Biscardi
- Rehabilitation Sciences Institute, Temerty Faculty of Medicine, Toronto, Ontario, Canada
| | - Zane Grossinger
- Rehabilitation Sciences Institute, Temerty Faculty of Medicine, Toronto, Ontario, Canada
| | - Angela Colantonio
- Rehabilitation Sciences Institute, Temerty Faculty of Medicine, Toronto, Ontario, Canada
| | - Mark Bayley
- Hull Ellis Concussion and Research Clinic, Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
| | - Tatyana Mollayeva
- KITE Research Institute, Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
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Moore BM, Stark RK, D'Angelo EC. Multidisciplinary care for patients with persistent symptoms following concussion: a systematic review. Disabil Rehabil 2024; 46:1760-1775. [PMID: 37147858 DOI: 10.1080/09638288.2023.2205663] [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: 09/27/2022] [Accepted: 04/14/2023] [Indexed: 05/07/2023]
Abstract
PURPOSE To systematically characterize and assess the effectiveness of multidisciplinary care for patients with persistent post-concussion symptoms (PPCS). MATERIALS AND METHODS Only studies describing multidisciplinary treatment, defined as intervention provided by no less than 2 healthcare disciplines, each with independent scopes of practice, for patients with PPCS were considered. RESULTS A total of 8 of the 1357 studies identified were included. The studies were comprised of heterogenous patient populations, care delivery systems, healthcare providers, treatment approaches, and outcomes. CONCLUSIONS Findings suggest multidisciplinary care, using a needs-based approach with individual- or group-based interventions, may be more beneficial than usual care to; 1) immediately reduce concussion-related symptom complaints and improve mood and quality of life in adolescents following sports-related concussion (SRC) and, 2) may produce immediate and lasting improvements in symptom complaints of young, primarily female, adults following a non-SRC. Future studies should clearly describe the decision-making processes used to deliver care through a needs-based approach and prioritize the inclusion of objective, performance-based measures to assess outcomes.
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Affiliation(s)
- Brian M Moore
- Department of Physical Therapy, CA State University, Sacramento, CA, USA
| | - Rachel K Stark
- Research and Instruction Department, California State University, Sacramento, CA, USA
| | - Elisabeth C D'Angelo
- Department of Communication Sciences and Disorders, California State University, Sacramento, CA, USA
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Dismuke-Greer C, Esmaeili A, Ozieh MN, Gujral K, Garcia C, Del Negro A, Davis B, Egede L. Racial/Ethnic and Geographic Disparities in Comorbid Traumatic Brain Injury-Renal Failure in US Veterans and Associated Veterans Affairs Resource Costs, 2000-2020. J Racial Ethn Health Disparities 2024; 11:652-668. [PMID: 36864369 PMCID: PMC10474245 DOI: 10.1007/s40615-023-01550-4] [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] [Received: 07/01/2022] [Revised: 02/08/2023] [Accepted: 02/13/2023] [Indexed: 03/04/2023]
Abstract
Studies have identified disparities by race/ethnicity and geographic status among veterans with traumatic brain injury (TBI) and renal failure (RF). We examined the association of race/ethnicity and geographic status with RF onset in veterans with and without TBI, and the impact of disparities on Veterans Health Administration resource costs. METHODS Demographics by TBI and RF status were assessed. We estimated Cox proportional hazards models for progression to RF and generalized estimating equations for inpatient, outpatient, and pharmacy cost annually and time since TBI + RF diagnosis, stratified by age. RESULTS Among 596,189 veterans, veterans with TBI progressed faster to RF than those without TBI (HR 1.96). Non-Hispanic Black veterans (HR 1.41) and those in US territories (HR 1.71) progressed faster to RF relative to non-Hispanic Whites and those in urban mainland areas. Non-Hispanic Blacks (-$5,180), Hispanic/Latinos ($-4,984), and veterans in US territories (-$3,740) received fewer annual total VA resources. This was true for all Hispanic/Latinos, while only significant for non-Hispanic Black and US territory veterans < 65 years. For veterans with TBI + RF, higher total resource costs only occurred ≥ 10 years after TBI + RF diagnosis ($32,361), independent of age. Hispanic/Latino veterans ≥ 65 years received $8,248 less than non-Hispanic Whites and veterans living in US territories < 65 years received $37,514 less relative to urban veterans. CONCLUSION Concerted efforts to address RF progression in veterans with TBI, especially in non-Hispanic Blacks and those in US territories, are needed. Importantly, culturally appropriate interventions to improve access to care for these groups should be a priority of the Department of Veterans Affairs priority for these groups.
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Affiliation(s)
- Clara Dismuke-Greer
- Health Economics Resource Center (HERC), Ci2i, VA Palo Alto Healthcare System, 795 Willow Road, 152 MPD, Menlo Park, CA, 94025, USA.
| | - Aryan Esmaeili
- Health Economics Resource Center (HERC), Ci2i, VA Palo Alto Healthcare System, 795 Willow Road, 152 MPD, Menlo Park, CA, 94025, USA
| | - Mukoso N Ozieh
- Center for Advancing Population Science (CAPS), Division of Internal Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
- Department of Medicine, Division of Nephrology, Medical College of Wisconsin, Milwaukee, WI, USA
- Division of Nephrology, Clement J. Zablocki VA Medical Center, Milwaukee, WI, USA
| | - Kritee Gujral
- Health Economics Resource Center (HERC), Ci2i, VA Palo Alto Healthcare System, 795 Willow Road, 152 MPD, Menlo Park, CA, 94025, USA
| | - Carla Garcia
- Health Economics Resource Center (HERC), Ci2i, VA Palo Alto Healthcare System, 795 Willow Road, 152 MPD, Menlo Park, CA, 94025, USA
| | | | - Boyd Davis
- Department of English Emerita, College of Liberal Arts & Sciences, The University of North Carolina at Charlotte, Charlotte, NC, USA
| | - Leonard Egede
- Center for Advancing Population Science (CAPS), Division of Internal Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
- Department of Medicine, Division of General Internal Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
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10
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Bielanin JP, Metwally SAH, Paruchuri SS, Sun D. An overview of mild traumatic brain injuries and emerging therapeutic targets. Neurochem Int 2024; 172:105655. [PMID: 38072207 DOI: 10.1016/j.neuint.2023.105655] [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: 10/31/2023] [Revised: 12/01/2023] [Accepted: 12/03/2023] [Indexed: 01/01/2024]
Abstract
The majority of traumatic brain injuries (TBIs), approximately 90%, are classified as mild (mTBIs). Globally, an estimated 4 million injuries occur each year from concussions or mTBIs, highlighting their significance as a public health crisis. TBIs can lead to substantial long-term health consequences, including an increased risk of developing Alzheimer's Disease, Parkinson's Disease (PD), chronic traumatic encephalopathy (CTE), and nearly doubling one's risk of suicide. However, the current management of mTBIs in clinical practice and the available treatment options are limited. There exists an unmet need for effective therapy. This review addresses various aspects of mTBIs based on the most up-to-date literature review, with the goal of stimulating translational research to identify new therapeutic targets and improve our understanding of pathogenic mechanisms. First, we provide a summary of mTBI symptomatology and current diagnostic parameters such as the Glasgow Coma Scale (GCS) for classifying mTBIs or concussions, as well as the utility of alternative diagnostic parameters, including imaging techniques like MRI with diffusion tensor imaging (DTI) and serum biomarkers such as S100B, NSE, GFAP, UCH-L1, NFL, and t-tau. Our review highlights several pre-clinical concussion models employed in the study of mTBIs and the underlying cellular mechanisms involved in mTBI-related pathogenesis, including axonal damage, demyelination, inflammation, and oxidative stress. Finally, we examine a selection of new therapeutic targets currently under investigation in pre-clinical models. These targets may hold promise for clinical translation and address the pressing need for more effective treatments for mTBIs.
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Affiliation(s)
- John P Bielanin
- University of Pittsburgh School of Medicine, Pittsburgh, PA, 15213, USA; Department of Neurology, University of Pittsburgh, Pittsburgh, PA, 15213, USA; Pittsburgh Institute for Neurodegenerative Disorders, University of Pittsburgh, Pittsburgh, PA, 15213, USA
| | - Shamseldin A H Metwally
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA, 15213, USA; Pittsburgh Institute for Neurodegenerative Disorders, University of Pittsburgh, Pittsburgh, PA, 15213, USA
| | - Satya S Paruchuri
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA, 15213, USA; Pittsburgh Institute for Neurodegenerative Disorders, University of Pittsburgh, Pittsburgh, PA, 15213, USA
| | - Dandan Sun
- University of Pittsburgh School of Medicine, Pittsburgh, PA, 15213, USA; Department of Neurology, University of Pittsburgh, Pittsburgh, PA, 15213, USA; Pittsburgh Institute for Neurodegenerative Disorders, University of Pittsburgh, Pittsburgh, PA, 15213, USA; Veterans Affairs Pittsburgh Health Care System, Pittsburgh, PA, 15213, USA.
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11
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Jurick SM, McCabe CT, Watrous JR, MacGregor AJ, Walton SR, Stewart IJ, Walker LE, Galarneau MR. Associations between health-related behaviors and self-reported cognitive symptoms in U.S. military personnel injured on deployment. J Psychiatr Res 2023; 165:48-55. [PMID: 37459778 DOI: 10.1016/j.jpsychires.2023.07.001] [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] [Received: 04/05/2023] [Revised: 06/28/2023] [Accepted: 07/04/2023] [Indexed: 09/03/2023]
Abstract
Health behaviors may be core contributors to cognition and mental health following mild traumatic brain injury (TBI). The aims of the present study examined: (1) whether health behaviors including sleep duration, alcohol use, and physical activity differed in injured military personnel with and without deployment-related mild TBI history and (2) the relative contributions of health behaviors and deployment-related mild TBI history to self-reported cognitive, posttraumatic stress disorder (PTSD), and depressive symptoms. Participants included 3076 military personnel injured on deployment participating in the Wounded Warrior Recovery Project, an ongoing web-based study. Military personnel with deployment-related mild TBI history reported similar rates of physical activity and levels of alcohol problems as those without, but were less likely to report receiving the recommended duration of sleep. When adjusting for demographic and injury variables, all three health behaviors were associated with cognitive, PTSD, and depressive symptoms. Alcohol problems demonstrated significant but small effects across all outcomes measures (ηp2=.01) whereas physical activity was associated with slightly larger effects albeit still within the small range (ηp2=.02-0.04). Duration of sleep bordered a medium effect for cognitive symptoms (ηp2=.05) and was in the medium range for PTSD and depressive symptoms (ηp2=.06). Although deployment-related mild TBI history was significant in all models, effect sizes were small (ηp2=.01). Findings from the present study provide support that health behaviors have stronger effects with regard to cognitive, PTSD, and depressive symptoms compared to deployment-related mild TBI history in military personnel and, given their modifiable nature, may represent treatment targets in this population.
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Affiliation(s)
- Sarah M Jurick
- Leidos, 4161 Campus Point Ct, San Diego, CA, 92121, USA; Naval Health Research Center, 140 Sylvester Road, San Diego, CA, 92106, USA.
| | - Cameron T McCabe
- Leidos, 4161 Campus Point Ct, San Diego, CA, 92121, USA; Naval Health Research Center, 140 Sylvester Road, San Diego, CA, 92106, USA; Uniformed Services University, 4301 Jones Bridge Rd, Bethesda, MD, 20814, USA
| | - Jessica R Watrous
- Leidos, 4161 Campus Point Ct, San Diego, CA, 92121, USA; Naval Health Research Center, 140 Sylvester Road, San Diego, CA, 92106, USA; Uniformed Services University, 4301 Jones Bridge Rd, Bethesda, MD, 20814, USA
| | - Andrew J MacGregor
- Naval Health Research Center, 140 Sylvester Road, San Diego, CA, 92106, USA
| | - Samuel R Walton
- School of Medicine Physical Medicine and Rehabilitation, Virginia Commonwealth University, 1201 E Marshall St #4-100, Richmond, VA, 23298, USA
| | - Ian J Stewart
- Uniformed Services University, 4301 Jones Bridge Rd, Bethesda, MD, 20814, USA
| | - Lauren E Walker
- David Grant USAF Medical Center, 101 Bodin Circle, Bldg. 777, Travis AFB, CA, 94535, USA
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McBride WR, Eltman NR, Swanson RL. Blood-Based Biomarkers in Traumatic Brain Injury: A Narrative Review With Implications for the Legal System. Cureus 2023; 15:e40417. [PMID: 37325684 PMCID: PMC10266433 DOI: 10.7759/cureus.40417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2023] [Indexed: 06/17/2023] Open
Abstract
Traumatic brain injury (TBI) is an increasingly recognized diagnosis with significant, and often costly, associated consequences. Yet, despite their increased recognition, TBIs remain underdiagnosed. This issue is especially prominent in the context of mild TBI (mTBI), where there often exists little to no objective evidence of brain injury. In recent years, considerable effort has been made to better define and interpret known objective markers of TBI, as well as identify and explore new ones. An area of particular interest has focused on research related to blood-based biomarkers of TBI. Advancements in our understanding of TBI-related biomarkers can make it possible to characterize the severity of TBI with greater accuracy, improve our understanding of staging within both the injury process and the recovery process, and help us develop quantifiable metrics representative of reversal and recovery from a brain injury following trauma. Proteomic and non-proteomic blood-based biomarkers are being studied extensively and have shown promise for these purposes. Developments in this realm have significant implications not only for clinical care but also for legislation, as well as civil and criminal litigation. Despite their substantial potential, most of these biomarkers are not yet ready for use within the clinical setting, and therefore, are not appropriate for use within the legal or policy-making systems at this time. Given that existing standardization for the accurate and reliable use of TBI biomarkers is currently insufficient for use within either the clinical or legal realms, such data can be vulnerable to misuse and can even result in the abuse of the legal system for unwarranted gain. Courts will need to carefully evaluate the information presented in their role as gatekeepers of the admissibility of scientific evidence within the legal process. Ultimately, the development of biomarkers should lead to improved clinical care following TBI exposure, coherent and informed laws surrounding TBI, and more accurate and just results in litigation surrounding TBI-related sequelae.
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Affiliation(s)
- William R McBride
- Forensic Psychiatry, Rutgers Robert Wood Johnson Medical School, Piscataway, USA
| | - Nicholas R Eltman
- Center for Neurotrauma, Neurodegeneration and Restoration, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, USA
- Physical Medicine and Rehabilitation, Rowan-Virtua School of Osteopathic Medicine, Stratford, USA
| | - Randel L Swanson
- Center for Neurotrauma, Neurodegeneration and Restoration, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, USA
- Physical Medicine and Rehabilitation, University of Pennsylvania Perelman School of Medicine, Philadelphia, USA
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Gartell R, Morris J, Wallace T. Feasibility of Using a Mobile App Supported Executive Function Intervention in Military Service Members and Veterans with mTBI and Co-Occurring Psychological Conditions. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:2457. [PMID: 36767823 PMCID: PMC9915093 DOI: 10.3390/ijerph20032457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 01/24/2023] [Accepted: 01/24/2023] [Indexed: 06/18/2023]
Abstract
This pilot study assessed the feasibility of using SwapMyMood, a smartphone application supporting evidence-based strategies for emotion regulation and problem-solving as a supplement to conventional care for military service members and veterans (SM/Vs) experiencing chronic symptoms of mild traumatic brain injury (mTBI) and co-occurring psychological conditions. Eight military SM/Vs were recruited from an intensive outpatient program. Participants were block randomized to an experimental group (conventional care plus use of the SwapMyMood app) or a conventional care only group for six weeks. Conventional care included instruction on problem-solving and emotion regulation strategies using traditional paper manuals and protocols. Effects on the knowledge and use of strategies and related goal attainment were measured. Patient-reported outcomes were measured via several validated problem-solving and emotion regulation scales. No differences were found between groups in goal attainment, global executive function, problem-solving, emotion regulation, and knowledge of how to use the problem-solving and emotion regulation strategies targeted. Experimental group participants rated the application positively, demonstrating feasibility of integration of the app into clinical care. The implementation of SwapMyMood is feasible in a clinical setting. SwapMyMood may be a clinically effective supplemental tool for supporting executive function in SM/Vs with mTBI and co-occurring psychological conditions.
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Affiliation(s)
- Rebecca Gartell
- SHARE Military Initiative, Shepherd Center, Atlanta, GA 30309, USA
| | - John Morris
- Virginia C. Crawford Research Institute, Shepherd Center, Atlanta, GA 30309, USA
| | - Tracey Wallace
- SHARE Military Initiative, Shepherd Center, Atlanta, GA 30309, USA
- Virginia C. Crawford Research Institute, Shepherd Center, Atlanta, GA 30309, USA
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Alarie C, Gagnon I, de Guise E, McKerral M, Kersalé M, Hoog BVH, Swaine B. A Remotely Delivered Progressive Walking Intervention for Adults With Persistent Symptoms of a Mild Traumatic Brain Injury: Feasibility and Exploration of Its Impact. FRONTIERS IN REHABILITATION SCIENCES 2022; 3:898804. [PMID: 36189010 PMCID: PMC9397951 DOI: 10.3389/fresc.2022.898804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 06/06/2022] [Indexed: 11/13/2022]
Abstract
Introduction Persistent post-concussion symptoms following a mild traumatic brain injury (mTBI) can impact function and participation of adults. Physical activity is recommended to reduce symptoms and foster return to normal activities. Adults with a mTBI may have personal factors or experience accessibility issues restricting physical activity. Walking is a physical activity accessible to most that could be delivered remotely. Objectives Determine the feasibility, safety, and acceptability of a remotely delivered progressive walking intervention designed for adults with persistent mTBI symptoms and explore its effects on health-related outcomes. Methodology This feasibility study using a single-group pre-post mixed methods convergent parallel design was conducted remotely. Adults aged 18–65 years with a mTBI reporting persistent symptoms for ≥3 months were recruited. The 8-week remote progressive walking intervention aimed to increase the weekly number of steps walked by 40% based on a 1-week baseline measured by a Fitbit Inspire 2 activity monitor. Feasibility measures were about the intervention, its remote delivery, safety, and acceptability. Health-related outcomes were post-concussion symptoms, kinesiophobia, mood, sleep, fatigue, and quality of life. Semi-structured exit interviews were recorded and transcribed verbatim. Quantitative and qualitative data were analyzed separately, and results merged, compared, and contrasted. Descriptive statistics and paired samples t-tests were used. The qualitative analyses followed an iterative content analysis approach using reflexivity and triangulation of sources. Results Twenty adults (16 women) aged 42.5 ± 11.51 years with persisting symptoms for 9.25 ± 6.43 months participated, adhered to 94.38% of sessions, completed the intervention, and found it to be feasible, safe and acceptable. Participants increased weekly total number of steps walked (change = 14,886 ± 18,283; t = 3.55, p = 0.002). Severity of post-concussion symptoms (change = −6.42 ± 10.69; t = −2.62, p = 0.018), kinesiophobia (change = −5 ± 6.86; t = 3.18, p = 0.005), anxiety (change = −1.53 ± 3.01; t = −2.21, p = 0.04), and fatigue (change = −10.21 ± 10.20; t = −4.37, p < 0.001) were reduced, whilst quality of life improved (change = 10.58 ± 13.35; t = 3.46, p = 0.003). Participants' perceptions corroborate most quantitative results; they felt improved self-efficacy about physical activity and provided five key recommendations. Discussion This study demonstrates the feasibility, safety, and acceptability of the remote 8-week progressive walking intervention, a promising approach to reduce persisting symptoms, improve physical activity level health-related outcomes and quality of life of adults with persistent post-concussion symptoms following a mTBI.
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Affiliation(s)
- Christophe Alarie
- École de Réadaptation, Faculté de Médecine, Université de Montréal, Montréal, QC, Canada
- Institut Universitaire sur la Réadaptation en Déficience Physique de Montréal (IURDPM), Montréal, QC, Canada
- Centre de Recherche Interdisciplinaire en Réadaptation du Montréal Métropolitain (CRIR), Montréal, QC, Canada
| | - Isabelle Gagnon
- School of Physical and Occupational Therapy, Faculty of Medicine and Health Sciences, McGill University, Montréal, QC, Canada
- Trauma Center and Pediatric Emergency Medicine, Montreal Children's Hospital, McGill University Health Center and Research Institute of the McGill University Health Center, Montréal, QC, Canada
| | - Elaine de Guise
- Institut Universitaire sur la Réadaptation en Déficience Physique de Montréal (IURDPM), Montréal, QC, Canada
- Centre de Recherche Interdisciplinaire en Réadaptation du Montréal Métropolitain (CRIR), Montréal, QC, Canada
- Département de Psychologie, Faculté des Arts et des Sciences, Université de Montréal, Montréal, QC, Canada
| | - Michelle McKerral
- Institut Universitaire sur la Réadaptation en Déficience Physique de Montréal (IURDPM), Montréal, QC, Canada
- Centre de Recherche Interdisciplinaire en Réadaptation du Montréal Métropolitain (CRIR), Montréal, QC, Canada
- Département de Psychologie, Faculté des Arts et des Sciences, Université de Montréal, Montréal, QC, Canada
| | - Marietta Kersalé
- École de Réadaptation, Faculté de Médecine, Université de Montréal, Montréal, QC, Canada
- Institut Universitaire sur la Réadaptation en Déficience Physique de Montréal (IURDPM), Montréal, QC, Canada
- Centre de Recherche Interdisciplinaire en Réadaptation du Montréal Métropolitain (CRIR), Montréal, QC, Canada
| | - Béatrice van het Hoog
- École de Réadaptation, Faculté de Médecine, Université de Montréal, Montréal, QC, Canada
- Institut Universitaire sur la Réadaptation en Déficience Physique de Montréal (IURDPM), Montréal, QC, Canada
- Centre de Recherche Interdisciplinaire en Réadaptation du Montréal Métropolitain (CRIR), Montréal, QC, Canada
| | - Bonnie Swaine
- École de Réadaptation, Faculté de Médecine, Université de Montréal, Montréal, QC, Canada
- Institut Universitaire sur la Réadaptation en Déficience Physique de Montréal (IURDPM), Montréal, QC, Canada
- Centre de Recherche Interdisciplinaire en Réadaptation du Montréal Métropolitain (CRIR), Montréal, QC, Canada
- *Correspondence: Bonnie Swaine
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Pendlebury GA, Oro P, Haynes W, Byrnes TR, Keane J, Goldstein L. Advocacy for Change: An Osteopathic Review of Traumatic Brain Injury Among Combat Veterans. Cureus 2022; 14:e25051. [PMID: 35719755 PMCID: PMC9199571 DOI: 10.7759/cureus.25051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2022] [Indexed: 11/24/2022] Open
Abstract
As a "signature injury" of the Iraq and Afghanistan wars, traumatic brain injury (TBI) remains a major health concern among military service members. Traumatic brain injury is associated with a wide range of symptoms which may be cognitive, emotional, psychological, biochemical, and social in nature. Mild TBI (mTBI) ranks as the most common traumatic brain injury among veterans. Due to the absence of specific symptoms, mTBI diagnosis may be challenging in acute settings. Repetitive traumatic brain injury during combat deployments can lead to devastating chronic neurodegenerative diseases and other major life disruptions. Many cases of TBI remain undetected in veterans and may lead to long-term adverse comorbidities such as post-traumatic stress disorder (PTSD), suicide, alcohol disorders, psychiatric diagnoses, and service-related somatic dysfunctions. Veterans with TBI are almost twice as likely to die from suicide in comparison to veterans without a history of TBI. Veterans diagnosed with TBI experience significant comorbid conditions and thus advocacy for improved care is justified and necessary. Given the complexity and variation in the symptomatology of TBI, a personalized, multimodal approach is warranted in the evaluation and treatment of veterans with TBI and other associated conditions. As such, this review provides a broad overview of treatment options, with an emphasis on advocacy and osteopathic integration in the standard of care for veterans.
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