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Remigio-Baker RA, Hungerford LD, Bailie JM, Ivins BJ, Lopez J, Ettenhofer ML. The Patient Global Impression of Change as a complementary tool to account for neurobehavioral and mental health symptom improvement for patients with concussion. Disabil Rehabil 2024:1-9. [PMID: 38821113 DOI: 10.1080/09638288.2024.2346233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 04/17/2024] [Indexed: 06/02/2024]
Abstract
PURPOSE The purpose of this study was to determine the extent to which patient's perspective of symptom improvement, as indexed by the Patient Global Impression of Change (PGIC) survey, is associated with symptom improvement on common measures of neurobehavioral and mental health symptoms following concussion. MATERIALS AND METHODS Data were from 449 US active duty service members receiving treatment in interdisciplinary programs for their concussion. PGIC rating (range = 1-7) was evaluated for compatibility in assessing improvement in or clinically-elevated neurobehavioral (using Neurobehavioral Symptom Inventory [NSI]) and mental health (using Post-traumatic Stress Disorder Checklist, DSM-5 [PCL-5] and Patient Health Questionnaire [PHQ-8]) symptoms. RESULTS Higher PGIC scores were related to a higher prevalence of clinically-relevant decrease in NSI, PCL-5 or PHQ-8 scores. Participants with a PGIC rating of 3+ (vs.<3) were about 2.2 (CI = 1.4-3.5), 1.6 (CI = 1.1-1.3), and 2.7 (CI = 1.4-5.1) times more likely to report clinically-relevant decrease in NSI, PCL-5 and PHQ-8 symptoms, respectively. CONCLUSION PGIC may help providers incorporate patients' perspectives on symptom improvement achieved during rehabilitation. An approach combining PGIC with surveys such as NSI, PCL-5 and PHQ-8 may provide a more comprehensive understanding of symptom improvement and realistic view of expectations for what would be deemed recovery to pre-injury symptom levels.
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Affiliation(s)
- Rosemay A Remigio-Baker
- Traumatic Brain Injury Center of Excellence, Silver Spring, MD, USA
- Compass Government Solutions, Annapolis, MD, USA
| | - Lars D Hungerford
- Traumatic Brain Injury Center of Excellence, Silver Spring, MD, USA
- General Dynamics Information Technology, Falls Church, VA, USA
- Naval Medical Center San Diego, San Diego, CA, USA
| | - Jason M Bailie
- Traumatic Brain Injury Center of Excellence, Silver Spring, MD, USA
- General Dynamics Information Technology, Falls Church, VA, USA
- Naval Hospital Camp Pendleton, Camp Pendleton, CA, USA
| | - Brian J Ivins
- Traumatic Brain Injury Center of Excellence, Silver Spring, MD, USA
- General Dynamics Information Technology, Falls Church, VA, USA
| | - Juan Lopez
- Traumatic Brain Injury Center of Excellence, Silver Spring, MD, USA
- General Dynamics Information Technology, Falls Church, VA, USA
- Naval Hospital Camp Pendleton, Camp Pendleton, CA, USA
| | - Mark L Ettenhofer
- Traumatic Brain Injury Center of Excellence, Silver Spring, MD, USA
- General Dynamics Information Technology, Falls Church, VA, USA
- Naval Medical Center San Diego, San Diego, CA, USA
- Department of Psychiatry, University of California, San Diego, CA, USA
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Scimeca LM, Cothran T, Larson JE, Held P. Factor analysis of the neurobehavioral symptom inventory in veterans with PTSD and no history of mild TBI. APPLIED NEUROPSYCHOLOGY. ADULT 2024; 31:173-180. [PMID: 34860619 DOI: 10.1080/23279095.2021.2007386] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
It is well established that long-term postconcussive symptoms following a mild traumatic brain injury (mTBI) are associated with underlying physical, emotional, and behavioral conditions. The Neurobehavioral Symptom Inventory (NSI) is a measure used to assess neurobehavioral symptoms that can occur following a mTBI and has demonstrated a 3- or 4-factor structure in veterans. The present study aimed to investigate the factor structure of veterans with PTSD without a history of mTBI. A confirmatory factor analysis (CFA) was conducted on a sample of 221 treatment-seeking veterans and service members with PTSD and without a history of mTBI. Results supported a 4-factor structure comprised of vestibular, somatic, cognitive, and affective domains in veterans with PTSD. Subsequent, correlational analyses between the four NSI factors and the four subscales of the Posttraumatic Stress Disorder Checklist - Fifth Edition (PCL-5) revealed high correspondence between the cognitive and affective factors of the NSI and the negative alterations in mood and cognitions and hyperarousal symptom subscales of PTSD. Collectively, findings demonstrated that the NSI functions similarly in veterans with PTSD with or without a history of mTBI. Findings suggest that neurobehavioral symptoms assessed by the NSI appear to be nonspecific and not explicitly associated with mTBI.
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Affiliation(s)
- Lauren M Scimeca
- Department of Psychiatry, Rush University Medical Center, Chicago, IL, USA
- Department of Psychology, Illinois Institute of Technology, Chicago, IL, USA
| | - Thomas Cothran
- Department of Psychiatry, Rush University Medical Center, Chicago, IL, USA
| | - Jon E Larson
- Department of Psychology, Illinois Institute of Technology, Chicago, IL, USA
| | - Philip Held
- Department of Psychiatry, Rush University Medical Center, Chicago, IL, USA
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Weightman MM, King LA, Fino PC, Dibble LE, Pelo R, Michielutti PG, Richard H, Parrington L, Lester ME, Hoppes CW. Reconsidering Vestibular/Ocular Motor Screening Cutoff Scores for Concussion. Mil Med 2024; 189:e714-e720. [PMID: 37856171 DOI: 10.1093/milmed/usad394] [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: 06/01/2023] [Revised: 09/04/2023] [Accepted: 09/26/2023] [Indexed: 10/20/2023] Open
Abstract
INTRODUCTION Vestibular/Ocular Motor Screening (VOMS) is often part of a comprehensive evaluation to identify acute mild traumatic brain injury. Most of the reports describe the use of the VOMS in adolescents/young adults and not in older adults or military service members. The purpose of this study was to describe VOMS findings in healthy civilians and active duty military service members up to the age of 50 years. MATERIALS AND METHODS Seventy-seven healthy civilians between 18 and 50 years of age (22 males, age 31.8 [9.0] years) participated across three sites in addition to 40 healthy active duty service members (25 males, age 27.5 [4.9] years) from one site. Demographics, Neurobehavioral Symptom Inventory scores, mean near point convergence (NPC) distance, and Total Symptom Change (TSS) scores from the VOMS were evaluated. RESULTS For civilians, the group mean NPC distance was 4.98 (3.8) cm. For military service members, the group mean NPC distance was 6.17 (4.57) cm. For civilians, the mean TSS was 1.2 (2.3) with 53.2% reporting 0 TSS, 27.3% reporting one TSS, and 19.5% reporting two or more TSS. For military service members, the mean TSS was 0.20 (0.72) with 92.5% reporting 0 TSS, 0% reporting one TSS, and 7.5% reporting two or more TSS. Age did not correlate with the mean NPC distance and TSS in healthy civilians and active duty military service members. CONCLUSIONS Reconsideration of the Military Acute Concussion Evaluation, Version 2 cutoff value for abnormal mean NPC distance may be warranted to improve diagnostic accuracy in both civilian and military adult populations. Similarly, re-evaluating criteria for interpreting the TSS results of the VOMS, specifically in civilians, may be warranted.
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Affiliation(s)
| | - Laurie A King
- Department of Neurology, Oregon Health & Science University, Portland, OR 97239, USA
| | - Peter C Fino
- Department of Health & Kinesiology, University of Utah, Salt Lake City, UT 84112, USA
| | - Leland E Dibble
- Department of Physical Therapy and Athletic Training, University of Utah, Salt Lake City, UT 84108, USA
| | - Ryan Pelo
- Department of Physical Therapy and Athletic Training, University of Utah, Salt Lake City, UT 84108, USA
| | | | - Holly Richard
- Army-Baylor University Doctoral Program in Physical Therapy, Joint Base San Antonio-Fort Sam Houston, TX 78234, USA
| | - Lucy Parrington
- Department of Dietetics, Human Nutrition and Sport, La Trobe University, Melbourne, Victoria 3086, Australia
| | - Mark E Lester
- Department of Physical Therapy, University of Texas-Rio Grande Valley, Edinburg, TX 78539, USA
| | - Carrie W Hoppes
- Army-Baylor University Doctoral Program in Physical Therapy, Joint Base San Antonio-Fort Sam Houston, TX 78234, USA
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Remigio-Baker RA, Bailie JM, Ettenhofer ML, Cordero E, Hungerford LD. The Impact of Lifetime Traumatic Brain Injury (TBI) on Mental Health Symptoms among Service Members in Interdisciplinary TBI Programs. Mil Med 2023; 188:199-207. [PMID: 37948227 DOI: 10.1093/milmed/usad085] [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: 11/21/2022] [Revised: 02/14/2023] [Accepted: 05/04/2023] [Indexed: 11/12/2023] Open
Abstract
INTRODUCTION Traumatic brain injury (TBI) is highly prevalent among active duty service members (ADSMs) and imposes a significant health burden, particularly on mental health (e.g., post-traumatic stress disorder [PTSD] and depressive symptoms). Little is known about how TBI setting characteristics impact PTSD and depressive symptom expression in service members undergoing interdisciplinary TBI care. MATERIALS AND METHODS The study included 455 patients enrolled in interdisciplinary, outpatient TBI programs within the military health system. Using Poisson regression with robust error variance, TBI injury setting characteristics (i.e., before military service, during military training, and during noncombat/combat deployment) were evaluated against clinically-elevated PTSD (PTSD Checklist, DSM-5 score ≥ 33) and depressive (Patient Health Questionnaire-8 score ≥ 15) symptoms. RESULTS In adjusted models, TBI sustained before military service was associated with less likelihood for clinically-elevated PTSD symptoms at pretreatment (prevalence ratio [PR] = 0.76, confidence interval [CI] = 0.60-0.96) and post-treatment (PR = 0.67, CI = 0.52-0.87). TBI sustained during combat deployment, however, resulted in the greatest impact on clinically-elevated pretreatment PTSD (PR = 1.49, CI = 1.16-1.91) and depressive (PR = 1.47, CI = 1.06-2.03) symptoms. Null results were found between military training/noncombat deployment and mental health symptoms. Regardless of the TBI setting, following TBI treatment, there remained 37.5% (n = 180) and 24.8% (n = 108) with clinically-elevated PTSD and depressive symptoms, respectively. CONCLUSIONS There was a differential impact of TBI settings, particularly between TBI sustained before military service and that from combat deployment among ADSMs enrolled in outpatient TBI programs. This may be indicative of differences in the characteristics of these environments (e.g., injury severity) or the impact of such an event during recovery from current TBIs. The large percentage of ADSMs who present with clinically-elevated mental health symptoms after treatment may suggest the need for additional resources to address mental health needs before, during, and after treatment in TBI programs.
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Affiliation(s)
- Rosemay A Remigio-Baker
- Traumatic Brain Injury Center of Excellence (TBICoE), Silver Spring Metro Center I, Silver Spring, MD 20910, USA
- Compass Government Solutions, Annapolis, MD 21401, USA
| | - Jason M Bailie
- Traumatic Brain Injury Center of Excellence (TBICoE), Silver Spring Metro Center I, Silver Spring, MD 20910, USA
- General Dynamics Information Technology, Falls Church, VA 22042, USA
- Naval Hospital Camp Pendleton, Camp Pendleton, CA 92055, USA
| | - Mark L Ettenhofer
- Traumatic Brain Injury Center of Excellence (TBICoE), Silver Spring Metro Center I, Silver Spring, MD 20910, USA
- General Dynamics Information Technology, Falls Church, VA 22042, USA
- Naval Medical Center of San Diego, 34800 Bob Wilson Dr, San Diego, CA 92134, USA
- University of California, San Diego, 9500 Gilman Drive, La Jolla, CA 92093, USA
| | - Evelyn Cordero
- Traumatic Brain Injury Center of Excellence (TBICoE), Silver Spring Metro Center I, Silver Spring, MD 20910, USA
- General Dynamics Information Technology, Falls Church, VA 22042, USA
- Naval Hospital Camp Pendleton, Camp Pendleton, CA 92055, USA
| | - Lars D Hungerford
- Traumatic Brain Injury Center of Excellence (TBICoE), Silver Spring Metro Center I, Silver Spring, MD 20910, USA
- General Dynamics Information Technology, Falls Church, VA 22042, USA
- Naval Medical Center of San Diego, 34800 Bob Wilson Dr, San Diego, CA 92134, USA
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Scarlett E, Lu LH, Cummings LD, Bowles AO. Neurobehavioral Symptom Inventory Item-Level Change Complements the Reliable Change Method. J Head Trauma Rehabil 2023; 38:E312-E317. [PMID: 36602279 DOI: 10.1097/htr.0000000000000850] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVE To determine correspondence between the statistically derived 8-point reliable change index for the Neurobehavioral Symptom Inventory (NSI) against clinically significant item-level change in symptom severity from intake to discharge for mild traumatic brain injury (mTBI). SETTING Brain Injury Rehabilitation Service at Brooke Army Medical Center, Fort Sam Houston, San Antonio, Texas. PATIENTS In total, 655 active-duty service members with a diagnosis of mTBI who received treatment and completed self-report measures between 2007 and 2020. DESIGN Observational retrospective analysis of outpatient clinical outcomes data. MAIN MEASURES NSI total score change was used to divide patients into responder and nonresponders based on whether they met an 8-point decrease between intake and discharge. In addition, patients who had at least one NSI item that changed from a rating of 3 (severe) or 4 (very severe) at intake to a rating of 0 (none) or 1 (mild) at discharge were coded as an individual with significant item-level change. RESULTS Forty-five percent of the sample had significant item-level change and were classified as responders according to the reliable change method. Eight percent of the sample had significant item-level change but did not meet the 8-point reliable change threshold. Fifteen percent of the sample did not experience significant item-level change but were classified as responders according to reliable change. Thirty-one percent did not meet either method's criterion for change. Classification agreement between the reliable change and item-level change methods was 76%, which was statistically significant ( = 181.32, P < .001). CONCLUSION There is good correspondence between reliable change and item-level change on the NSI in this population. Reliable change is easily calculated and thus much more accessible than the item-level change method. There may be some situations where calculating item-level change may be helpful.
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Affiliation(s)
- Emily Scarlett
- Brain Injury Rehabilitation Service, Department of Rehabilitation Medicine, Brooke Army Medical Center (Mss Scarlett and Cummings and Drs Lu and Bowles), and Traumatic Brain Injury Center of Excellence, Defense Health Agency (Dr Lu), JBSA Fort Sam Houston, Texas; The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc, Bethesda, Maryland (Ms Scarlett); and General Dynamic Information Technology, Falls Church, Virginia (Dr Lu)
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Lange RT, Lippa S, Brickell TA, Gill J, French LM. Serum Tau, Neurofilament Light Chain, Glial Fibrillary Acidic Protein, and Ubiquitin Carboxyl-Terminal Hydrolase L1 Are Associated with the Chronic Deterioration of Neurobehavioral Symptoms after Traumatic Brain Injury. J Neurotrauma 2023; 40:482-492. [PMID: 36170576 DOI: 10.1089/neu.2022.0249] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The purpose of this study was to examine the association of serum tau, neurofilament light chain (NFL), glial fibrillary acidic protein (GFAP), and ubiquitin carboxy-terminal hydrolase L1 (UCHL-1) concentrations evaluated within the first 12 months after a military-related TBI, with longitudinal changes in neurobehavioral functioning extending two or more years post-injury. Participants were 84 United States service members and veterans (SMVs) prospectively enrolled in the Defense and Veterans Brain Injury Center of Excellence/Traumatic Brain Injury Center 15-Year Longitudinal TBI Study, separated into three discreet groups: (a) uncomplicated mild TBI (MTBI; n = 28), (b) complicated mild, moderate, severe, and penetrating TBI combined (STBI; n = 29], and (c) non-injured controls (NIC, n = 27). Participants completed a battery of self-report neurobehavioral symptom measures (e.g., depression, post-traumatic stress disorder [PTSD], post-concussion, anxiety, somatic, cognitive, and neurological symptoms) within 12 months of injury (baseline), and then again at two or more years post-injury (follow-up). At baseline, participants also completed a blood draw to determine serum concentrations of tau, NFL, GFAP, and UCHL-1 using an ultra-sensitivity assay method. In the MTBI and STBI groups (using hierarchical regression analyses), (1) baseline tau concentrations predicted the deterioration of neurobehavioral symptoms from baseline to follow-up on measures of anxiety, PTSD, depression, post-concussion, somatic, and neurological symptoms (accounting for 10-28% of the variance); (2) NFL predicted the deterioration of depression, post-concussion, somatic, cognitive, and neurological symptoms (10-32% variance); (3) GFAP predicted the deterioration of post-concussion, PTSD, depression, anxiety, somatic, neurological, and cognitive symptoms (11-43% variance); and (4) UCHL-1 predicted the deterioration of anxiety, somatic, and neurological symptoms (10-16% variance). In the NIC group, no meaningful associations were found between baseline biomarker concentrations and the deterioration of neurobehavioral symptoms on the majority of measures. This study reports that elevated tau, NFL, GFAP, and UCHL-1 concentrations within the first 12 months of injury are associated with the deterioration of neurobehavioral symptoms that extends to the chronic phase of recovery after a TBI. These findings suggest that a blood-based panel including these biomarkers could be a useful prognostic tool to identifying those individuals at risk of poor future outcome after TBI.
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Affiliation(s)
- Rael T Lange
- Traumatic Brain Injury Center of Excellence, Silver Spring, Maryland, USA.,Walter Reed National Military Medical Center, Bethesda, Maryland, USA.,National Intrepid Center of Excellence, Bethesda, Maryland, USA.,Contractor, General Dynamics Information Technology, Silver Spring, Maryland, USA.,University of British Columbia, Vancouver, Briish Columbia, Canada.,Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Sara Lippa
- Walter Reed National Military Medical Center, Bethesda, Maryland, USA.,National Intrepid Center of Excellence, Bethesda, Maryland, USA.,Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Tracey A Brickell
- Traumatic Brain Injury Center of Excellence, Silver Spring, Maryland, USA.,Walter Reed National Military Medical Center, Bethesda, Maryland, USA.,National Intrepid Center of Excellence, Bethesda, Maryland, USA.,Contractor, General Dynamics Information Technology, Silver Spring, Maryland, USA.,Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Jessica Gill
- Johns Hopkins University, Baltimore, Maryland, USA
| | - Louis M French
- Traumatic Brain Injury Center of Excellence, Silver Spring, Maryland, USA.,Walter Reed National Military Medical Center, Bethesda, Maryland, USA.,National Intrepid Center of Excellence, Bethesda, Maryland, USA.,Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
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Remigio-Baker RA, Hungerford LD, Ettenhofer ML, Barnard LL, Babakhanyan I, Ivins B, Stuessi K, Monasterio CDJ, Bailie JM. Presenting symptoms as prognostic measures of mental health recovery among service members with concussion. Front Neurol 2023; 13:1070676. [PMID: 36712430 PMCID: PMC9880328 DOI: 10.3389/fneur.2022.1070676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 12/12/2022] [Indexed: 01/15/2023] Open
Abstract
Background Comorbid mental illness may negatively impact recovery from concussion. This study evaluated whether the level of symptom clusters at clinic intake contribute to poor mental health recovery in concussed patients during treatment, which may in turn serve as a target intervention. Objective The objective of this study is to examine the association between the level of initial symptoms and mental health symptoms among service members with concussion. Methods Data were obtained from 483 active duty service members treated in interdisciplinary treatment programs for traumatic brain injury, all of which were concussions. Pre-treatment symptom clusters included self-reported hyperarousal, dissociation/depression, cognitive dysfunction/headache and neurological symptoms. The outcomes, clinically-relevant decreases in depressive symptoms (assessed by the 8-item Patient Health Questionnaire, PHQ-8) and PTSD symptoms (assessed by the PTSD Checklist for DSM-5, PCL-5), were defined as a decrease in PHQ-8 > 5 and PCL-5 > 7, respectively. Poisson regression with robust error variance was used to evaluate the relationship between the level of each symptom cluster and clinically-relevant decrease in outcomes. Results Participants with higher (vs. lower) levels of pre-treatment hyperarousal and dissociation/depression symptom cluster were less likely to improve in depressive and PTSD symptoms during treatment. The level of cognitive/headache and neurological symptom clusters were not significantly associated with any symptom changes. Conclusion These findings support the need for individualized treatment for symptoms identified and treated after determining concussion history, with particular attention to high levels of hyperarousal and dissociation/depression prior to treatment.
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Affiliation(s)
- Rosemay A. Remigio-Baker
- Traumatic Brain Injury Center of Excellence (TBICoE), Silver Spring, MD, United States,General Dynamics Information Technology, Falls Church, VA, United States,*Correspondence: Rosemay A. Remigio-Baker ✉
| | - Lars D. Hungerford
- Traumatic Brain Injury Center of Excellence (TBICoE), Silver Spring, MD, United States,General Dynamics Information Technology, Falls Church, VA, United States,Naval Medical Center at San Diego, San Diego, CA, United States
| | - Mark L. Ettenhofer
- Traumatic Brain Injury Center of Excellence (TBICoE), Silver Spring, MD, United States,General Dynamics Information Technology, Falls Church, VA, United States,Naval Medical Center at San Diego, San Diego, CA, United States,University of California, San Diego, La Jolla, CA, United States
| | - Lori L. Barnard
- Traumatic Brain Injury Center of Excellence (TBICoE), Silver Spring, MD, United States,General Dynamics Information Technology, Falls Church, VA, United States,Naval Hospital Camp Pendleton, Intrepid Spirit 7, Camp Pendleton, CA, United States
| | - Ida Babakhanyan
- Traumatic Brain Injury Center of Excellence (TBICoE), Silver Spring, MD, United States,General Dynamics Information Technology, Falls Church, VA, United States,Naval Hospital Camp Pendleton, Intrepid Spirit 7, Camp Pendleton, CA, United States
| | - Brian Ivins
- Traumatic Brain Injury Center of Excellence (TBICoE), Silver Spring, MD, United States,General Dynamics Information Technology, Falls Church, VA, United States
| | - Keith Stuessi
- Traumatic Brain Injury Center of Excellence (TBICoE), Silver Spring, MD, United States,General Dynamics Information Technology, Falls Church, VA, United States
| | - Carlos Diego J. Monasterio
- Traumatic Brain Injury Center of Excellence (TBICoE), Silver Spring, MD, United States,General Dynamics Information Technology, Falls Church, VA, United States,Naval Medical Center at San Diego, San Diego, CA, United States
| | - Jason M. Bailie
- Traumatic Brain Injury Center of Excellence (TBICoE), Silver Spring, MD, United States,General Dynamics Information Technology, Falls Church, VA, United States,Naval Hospital Camp Pendleton, Intrepid Spirit 7, Camp Pendleton, CA, United States
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8
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Remigio-Baker RA, Hungerford LD, Lee-Tauler SY, Bailie JM, Caswell M, Babakhanyan I, Ettenhofer ML. Disparities in mental health symptoms recovery across race/ethnicity and education level following mild traumatic brain injury. DIALOGUES IN HEALTH 2022; 1:100048. [PMID: 38515877 PMCID: PMC10953859 DOI: 10.1016/j.dialog.2022.100048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 09/10/2022] [Accepted: 09/20/2022] [Indexed: 03/23/2024]
Abstract
Purpose The purpose of this study was to investigate the relationship between race/ethnicity and post-concussive mental health (i.e., depressive, post-traumatic stress disorder [PTSD]) and neurobehavioral symptoms among service members, and whether this association differed by education level. Methods The study sample consisted of 524 patients from a multidisciplinary US military outpatient treatment facility for post-concussive symptoms. Poisson regression with robust error variance was utilized to investigate outcome (i.e., clinically-elevated depressive [Patient Health Questionnaire-8 ≥15], PTSD [PTSD Checklist, DSM 5 ≥38] and neurobehavioral [Neurobehavioral Symptom Inventory >75th percentile] symptoms at admission and last follow-up in this cohort study. Modification by education level (low [no college degree] vs. high [associate's degree or higher]) was additionally evaluated. Results The relationship between race/ethnicity and mental health/neurobehavioral symptoms varied by education level (p-interaction: depressive symptoms = 0.002, PTSD symptoms = 0.035, neurobehavioral symptoms = 0.040). Specifically, non-Whites were at a significantly higher prevalence for clinically-elevated depressive symptoms post-treatment than Whites, but only among those with higher education level (PR = 2.22, CI = 1.37-3.59). A similar trend was demonstrated for PTSD and neurobehavioral symptoms. Conclusion Military healthcare may need to increase depression-focused treatment options that are acceptable for racial/ethnic minority patients, particularly those with higher education, while they are recovering from comorbid traumatic brain injury.
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Affiliation(s)
- Rosemay A. Remigio-Baker
- Traumatic Brain Injury Center of Excellence (TBICoE), Silver Spring, MD, USA
- General Dynamics Information Technology, Falls Church, VA, USA
| | - Lars D. Hungerford
- Traumatic Brain Injury Center of Excellence (TBICoE), Silver Spring, MD, USA
- General Dynamics Information Technology, Falls Church, VA, USA
- Naval Medical Center San Diego, San Diego, CA, USA
| | - Su Yeon Lee-Tauler
- Henry M. Jackson Foundation, Bethesda, MD, USA
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Jason M. Bailie
- Traumatic Brain Injury Center of Excellence (TBICoE), Silver Spring, MD, USA
- General Dynamics Information Technology, Falls Church, VA, USA
- Naval Hospital Camp Pendleton, Camp Pendleton, CA, USA
| | - Melissa Caswell
- Traumatic Brain Injury Center of Excellence (TBICoE), Silver Spring, MD, USA
- General Dynamics Information Technology, Falls Church, VA, USA
- Naval Hospital Camp Pendleton, Camp Pendleton, CA, USA
| | - Ida Babakhanyan
- Traumatic Brain Injury Center of Excellence (TBICoE), Silver Spring, MD, USA
- General Dynamics Information Technology, Falls Church, VA, USA
- Naval Hospital Camp Pendleton, Camp Pendleton, CA, USA
| | - Mark L. Ettenhofer
- Traumatic Brain Injury Center of Excellence (TBICoE), Silver Spring, MD, USA
- General Dynamics Information Technology, Falls Church, VA, USA
- Naval Medical Center San Diego, San Diego, CA, USA
- University of California, San Diego, La Jolla, CA, USA
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9
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Characteristics of Responders and Nonresponders in a Military Postconcussion Rehabilitation Program. J Head Trauma Rehabil 2022; 37:E458-E466. [PMID: 35617677 DOI: 10.1097/htr.0000000000000792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To characterize treatment responders and nonresponders as measured by the Neurobehavioral Symptom Inventory (NSI) in order to understand whether certain traits in our patient population would characterize favorable response. SETTING Brain Injury Rehabilitation Service at Brooke Army Medical Center, Fort Sam Houston, San Antonio, Texas. PATIENTS In total, 655 active duty military patients with a diagnosis of mild traumatic brain injury (mTBI) who received treatment between 2007 and 2020 and completed self-report measures as part of routine care. DESIGN Observational retrospective analysis of outpatient clinical outcomes data. MAIN MEASURES The primary outcome measure was the NSI, divided into the responder and nonresponder groups. Responders were defined by reliable change in NSI total score (decrease of ≥8 points from intake to discharge). FINDINGS Responders (n = 395) reported a higher level of symptom burden at intake on the NSI. Women responded proportionally more (70%) than men (58%). After treatment, responders reported improvements on all measures evaluated while nonresponders reported no change or slightly worse symptoms. Logistic regression analysis showed that posttraumatic stress symptoms at intake decreased odds of favorable treatment response while satisfaction with social relationships increased odds of favorable treatment response. CONCLUSION The results from this process improvement project suggested that posttraumatic symptoms warrant programmatic attention in TBI clinics while social relationships may be a protective factor that can be capitalized to enhance troop readiness. Systematic examination of these characteristics should be conducted on a larger population within the military health system.
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Troyanskaya M, Pastorek NJ, Wilde EA, Tombridge KA, Day AM, Levin HS, Scheibel RS. Risk factors for decline in cognitive performance following deployment-related mild traumatic brain injury: A preliminary report. Neurocase 2021; 27:457-461. [PMID: 34783300 DOI: 10.1080/13554794.2021.2002912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Thorough identification of risk factors for delayed decline in cognitive performance following combat-related mild traumatic brain injury (mTBI) is important for guiding comprehensive post-deployment rehabilitation. In a sample of veterans who reported at least one deployment-related mTBI, preliminary results indicate that factors including a history of loss of consciousness over 1 min, current obesity and hypertension, and Black race were more prevalent in those with decreased scores on a measure of memory function. These factors should be considered by clinicians and researchers working with current and former military personnel.
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Affiliation(s)
- Maya Troyanskaya
- Michael E. DeBakey Veterans Affairs Medical Center Houston, TX, USA.,H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine. Houston, Tx, USA
| | - Nicholas J Pastorek
- Michael E. DeBakey Veterans Affairs Medical Center Houston, TX, USA.,H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine. Houston, Tx, USA
| | - Elisabeth A Wilde
- H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine. Houston, Tx, USA.,Department of Neurology, University of Utah School of Medicine. Salt Lake City, UT, USA.,George E. Wahlen Veterans Affairs Medical Center. Salt Lake City, Ut, USA
| | | | - Alyssa M Day
- Michael E. DeBakey Veterans Affairs Medical Center Houston, TX, USA.,Department of Psychology. Houston, University of Houston, TX, USA
| | - Harvey S Levin
- Michael E. DeBakey Veterans Affairs Medical Center Houston, TX, USA.,H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine. Houston, Tx, USA.,Department of Neurology, Baylor College of Medicine. Houston, Tx, USA.,Department of Neurosurgery, Baylor College of Medicine. Houston, TX, USA.,Department of Pediatrics, Baylor College of Medicine. Houston, Tx, USA.,Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine. Houston, TX, USA
| | - Randall S Scheibel
- Michael E. DeBakey Veterans Affairs Medical Center Houston, TX, USA.,H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine. Houston, Tx, USA
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11
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Assonov D. Two-Step Resilience-Oriented Intervention for Veterans with Traumatic Brain Injury: A Pilot Randomized Controlled Trial. CLINICAL NEUROPSYCHIATRY 2021; 18:247-259. [PMID: 34984068 PMCID: PMC8696289 DOI: 10.36131/cnfioritieditore20210503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The present randomized parallel two-arm pilot study aimed to compare the efficacy of two-step resilience-oriented intervention with treatment as usual in veterans with mild to moderate traumatic brain injury. METHOD Two-step Resilience-Oriented Intervention (TROI) is a brief psychological intervention that targets cognitive (step 1) and emotional (step 2) factors of resilience and consists of six 1-hour sessions. Overall, 70 Ukrainian veterans serviced in Anti-Terrorist Operation / Joint Forces Operation were randomly assigned to an intervention group (TROI group) or a control group that underwent treatment as usual (TAU group). For pre- (T1) and post-treatment (T2) assessment the Connor-Davidson Resilience Scale (CD-RISC), Hospital Anxiety and Depression Scale (HADS), Montreal Cognitive Assessment Scale (MoCA), Neurobehavioral Symptom Inventory (NSI), Posttraumatic Stress Disorder Checklist 5 (PCL-5), Chaban Quality of Life Scale (CQLS), Positive and Negative Affect Scale (PANAS) were used. RESULTS Multivariable linear regression with the treatment group, gender, baseline cognitive performance level and TBI severity as the independent variables revealed statistically significant improvements in the TROI group in resilience (CD-RISC), cognitive performance (MoCA), postconcussive symptoms (NSI), posttraumatic symptoms (PCL-5), positive affect (PANAS) and quality of life (CQLS) comparing to such in TAU group. We found no statistically significant differences between groups in depression, anxiety (HADS) and negative affect (PANAS) outcomes. Additionally, Wilcoxon signed-rank test revealed that participants who completed two-step resilience-oriented intervention had significantly improved scores for all outcomes compared to the baseline (p < 0.05). CONCLUSIONS In summary, we can tentatively conclude that adding TROI to the standard treatment measures may improve the resilience and sustainable symptoms in veterans with TBI when compared with standard treatment. Targeting cognitive and emotional factors like problem-solving, decision-making, positive thinking can promote resilience in veterans with TBI and be useful in facilitating recovery from injury. Results of this pilot study are promising, but the intervention needs to be studied in a larger trial.
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Affiliation(s)
- Dmytro Assonov
- Department of Medical Psychology, Psychosomatic Medicine and Psychotherapy, Bogomolets National Medical University, Kyiv, Ukraine,Corresponding author Dmytro Assonov, E-mail:
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12
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DeGraba TJ, Williams K, Koffman R, Bell JL, Pettit W, Kelly JP, Dittmer TA, Nussbaum G, Grammer G, Bleiberg J, French LM, Pickett TC. Efficacy of an Interdisciplinary Intensive Outpatient Program in Treating Combat-Related Traumatic Brain Injury and Psychological Health Conditions. Front Neurol 2021; 11:580182. [PMID: 33536993 PMCID: PMC7848806 DOI: 10.3389/fneur.2020.580182] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 11/27/2020] [Indexed: 01/06/2023] Open
Abstract
Background: Since 2000, over 413,000 US service members (SM) experienced at least one traumatic brain injury (TBI), and 40% of those with in-theater TBIs later screened positive for comorbid psychological health (PH) conditions, including post-traumatic stress disorder (PTSD), depression, and anxiety. Many SMs with these persistent symptoms fail to achieve a recovery that results in a desirable quality of life or return to full duty. Limited information exists though to guide treatment for SMs with a history of mild TBI (mTBI) and comorbid PH conditions. This report presents the methods and outcomes of an interdisciplinary intensive outpatient program (IOP) in the treatment of SMs with combat-related mTBI and PH comorbidities. The IOP combines conventional rehabilitation therapies and integrative medicine techniques with the goal of reducing morbidity in multiple neurological and behavioral health domains and enhancing military readiness. Methods: SMs (n = 1,456) with residual symptoms from mTBI and comorbid PH conditions were treated in a 4-week IOP at the National Intrepid Center of Excellence (NICoE) at Walter Reed National Military Medical Center (WRNMMC). The IOP uses an interdisciplinary, holistic, and patient-centric rehabilitative care model. Interdisciplinary teams provide a diagnostic workup of neurological, psychiatric, and existential injuries, and from these assessments, individualized care plans are developed. Treatment response was assessed using the Neurobehavioral Symptom Inventory (NSI), PTSD Checklist-Military Version (PCL-M), Satisfaction With Life Scale (SWLS), Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), Epworth Sleepiness Scale (ESS), and Headache Impact Test-6 (HIT-6) and administered at admission, discharge, and at 1, 3, and 6 months post-discharge. Findings: Following treatment in the IOP, the symptomatic patients had statistically significant and clinically meaningful improvements across all outcome measures. The largest effect size was seen with GAD-7 (r = 0.59), followed by PHQ-8 (r = 0.56), NSI (r = 0.55), PCL-M (r = 0.52), ESS (r = 0.50), SWLS (r = 0.49), and HIT-6 (r = 0.42). In cross-sectional follow ups, the significant improvements were sustained at 1, 3, and 6 months post-discharge. Interpretation: This report demonstrates that an interdisciplinary IOP achieves significant and sustainable symptom recovery in SMs with combat-related mTBI and comorbid PH conditions and supports the further study of this model of care in complex medical conditions.
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Affiliation(s)
- Thomas J. DeGraba
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD, United States
- Department of Neurology, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Kathy Williams
- Credence Management Solutions, Vienna, VA, United States
| | - Robert Koffman
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD, United States
| | - Jennifer L. Bell
- Psychological Health Center of Excellence, J9, Defense Health Agency, McClean, VA, United States
| | - Wendy Pettit
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD, United States
| | - James P. Kelly
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD, United States
- Department of Neurology, University of Colorado School of Medicine, Marcus Institute for Brain Health, Aurora, CO, United States
| | | | - George Nussbaum
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD, United States
| | - Geoffrey Grammer
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD, United States
| | - Joseph Bleiberg
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD, United States
| | - Louis M French
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD, United States
| | - Treven C. Pickett
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD, United States
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13
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Babakhanyan I, Jensen M, Remigio-Baker RA, Sargent P, Bailie JM. Use of a randomized clinical trial design to study cognitive rehabilitation approaches to enhance warfighter performance. Contemp Clin Trials Commun 2020; 20:100660. [PMID: 33094194 PMCID: PMC7568183 DOI: 10.1016/j.conctc.2020.100660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 08/11/2020] [Accepted: 09/16/2020] [Indexed: 11/09/2022] Open
Abstract
Within the military, cognitive readiness is essential to ensure the warfighter can return to highly demanding combat training and deployment operations. The warfighter must be able to make split second decisions and adapt to new tools and environments. After a traumatic brain injury, clinicians helping the warfighter must have techniques that address warfighter cognitive readiness. Current rehabilitation for cognitive complaints used in military medicine are modeled after civilian therapies which focus on remediating moderate to severe impairment through building compensatory strategies. This traditional approach to cognitive rehabilitation does not translate well to mild traumatic brain injury (mTBI) where impairments are subtle, nor does it meet the needs of our warfighters in deployed and combat training environments. Challenging our current methods is critical in adapting to the needs of this highly valued population to ensure that our warfighters are able to carry out mission critical decision making. Here we present a review of our best current practices for cognitive rehabilitation, describe the limitations our traditional approaches impose for mTBI in military personnel, and present an alternative treatment called Strategic Memory Advanced Reasoning Training (SMART) that can be adopted through a randomized clinical trial design. We propose directly comparing traditional treatment approaches with a novel cognitive rehabilitation strategy which has been well validated outside of the military setting. Procedures were developed to execute this clinical trial in a way that is most relevant to the study population by establishing ecologically valid outcome metrics.
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Affiliation(s)
- Ida Babakhanyan
- Defense and Veterans Brain Injury Center, Silver Spring, MD, USA
- Naval Hospital Camp Pendleton, Camp Pendleton, CA, USA
- General Dynamics Health Solutions, Fairfax, VA, USA
| | - Melissa Jensen
- Defense and Veterans Brain Injury Center, Silver Spring, MD, USA
- Naval Hospital Camp Pendleton, Camp Pendleton, CA, USA
- General Dynamics Health Solutions, Fairfax, VA, USA
| | - Rosemay A. Remigio-Baker
- Defense and Veterans Brain Injury Center, Silver Spring, MD, USA
- Naval Hospital Camp Pendleton, Camp Pendleton, CA, USA
- Henry M. Jackson Foundation, Bethesda, MD, USA
| | - Paul Sargent
- Naval Hospital Camp Pendleton, Camp Pendleton, CA, USA
| | - Jason M. Bailie
- Defense and Veterans Brain Injury Center, Silver Spring, MD, USA
- Naval Hospital Camp Pendleton, Camp Pendleton, CA, USA
- General Dynamics Health Solutions, Fairfax, VA, USA
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14
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Esterov D, Lennon RJ, Bergquist T, Brown A. Predictors of neurobehavioral symptom reporting in a community based sample with mild traumatic brain injury. NeuroRehabilitation 2020; 47:65-77. [DOI: 10.3233/nre-203082] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Affiliation(s)
- Dmitry Esterov
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN, USA
| | - Ryan J. Lennon
- Department of Health Sciences Research, Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Thomas Bergquist
- Department of Physical Medicine and Rehabilitation, Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
| | - Allen Brown
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN, USA
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15
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Feasibility of Mild Traumatic Brain Injury Assessment Based on Cardiovascular Response to Postural Change. J Head Trauma Rehabil 2020; 35:E422-E428. [PMID: 32472839 DOI: 10.1097/htr.0000000000000582] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine the feasibility of short-term cardiovascular responses to postural change as a screening tool for mild traumatic brain injury (mTBI), using heart rate metrics that can be measured with a wearable electrocardiogram sensor. SETTING Military TBI clinic. DESIGN Data collected from active-duty service members who had sustained a medically diagnosed mTBI within the prior 72 hours and from age- and sex-matched controls. Cardiac data collected while participants performed a sequence of postural changes. MAIN MEASURES Model classification compared with clinical mTBI diagnosis. RESULTS Cardiac biomarkers of mTBI were identified and logistic regression classifiers for mTBI were developed from different subsets of biomarkers. The best model achieved 90% sensitivity and 69% specificity using data from 2 different postural changes. CONCLUSION Noninvasive measurement of cardiovascular response to postural change is a promising approach for field-deployable post-mTBI screening.
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16
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Hergert DC, Mayer AR, Hutchinson K, Sadek JR, Quinn DK. Medical Cannabis Reduced Agitation in Acquired Brain Injury: A Case Study. PSYCHOSOMATICS 2020; 61:819-824. [PMID: 32111375 DOI: 10.1016/j.psym.2020.01.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 01/21/2020] [Accepted: 01/21/2020] [Indexed: 01/08/2023]
Affiliation(s)
- Danielle C Hergert
- The Mind Research Network/Lovelace Biomedical and Environmental Research Institute, Pete & Nancy Domenici Hall, Albuquerque, NM.
| | - Andrew R Mayer
- The Mind Research Network/Lovelace Biomedical and Environmental Research Institute, Pete & Nancy Domenici Hall, Albuquerque, NM; Department of Neurology, University of New Mexico Health Sciences Center, Albuquerque, NM; Department of Psychiatry and Behavioral Sciences, University of New Mexico Health Sciences Center, Albuquerque, NM; Psychology Department, University of New Mexico, Albuquerque, NM
| | - Kent Hutchinson
- Department of Psychology and Neuroscience, University of Colorado, Boulder, CO
| | - Joseph R Sadek
- Department of Neurology, University of New Mexico Health Sciences Center, Albuquerque, NM; Department of Psychiatry and Behavioral Sciences, University of New Mexico Health Sciences Center, Albuquerque, NM; Behavioral Health Care Line, New Mexico VA Health Care System, Albuquerque, NM
| | - Davin K Quinn
- Department of Psychiatry and Behavioral Sciences, University of New Mexico Health Sciences Center, Albuquerque, NM
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17
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Cole WR, Cecchini AS, Remigio-Baker RA, Gregory E, Bailie JM, Ettenhofer ML, McCulloch KL. “Return to duty” as an outcome metric in military concussion research: Problems, pitfalls, and potential solutions. Clin Neuropsychol 2020; 34:1156-1174. [DOI: 10.1080/13854046.2020.1715484] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Wesley R. Cole
- Intrepid Spirit, Womack Army Medical Center, Fort Bragg, NC, USA
| | - Amy S. Cecchini
- Intrepid Spirit, Womack Army Medical Center, Fort Bragg, NC, USA
- Geneva Foundation, Tacoma, WA, USA
| | - Rosemay A. Remigio-Baker
- Defense and Veterans Brain Injury Center, Silver Spring, MD, USA
- Naval Hospital Camp Pendleton, Camp Pendleton, CA, USA
- Henry M. Jackson Foundation, Bethesda, MD, USA
| | - Emma Gregory
- Defense and Veterans Brain Injury Center, Silver Spring, MD, USA
| | - Jason M. Bailie
- Defense and Veterans Brain Injury Center, Silver Spring, MD, USA
- Naval Hospital Camp Pendleton, Camp Pendleton, CA, USA
- General Dynamics Health Solutions, Falls Church, VA, USA
| | - Mark L. Ettenhofer
- Defense and Veterans Brain Injury Center, Silver Spring, MD, USA
- Naval Medical Center San Diego, San Diego, CA, USA
- American Hospital Services Group, Exton, PA, USA
- University of California San Diego, San Diego, CA, USA
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18
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Psychological Symptoms and Rates of Performance Validity Improve Following Trauma-Focused Treatment in Veterans with PTSD and History of Mild-to-Moderate TBI. J Int Neuropsychol Soc 2020; 26:108-118. [PMID: 31658923 DOI: 10.1017/s1355617719000997] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Iraq and Afghanistan Veterans with posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI) history have high rates of performance validity test (PVT) failure. The study aimed to determine whether those with scores in the invalid versus valid range on PVTs show similar benefit from psychotherapy and if psychotherapy improves PVT performance. METHOD Veterans (N = 100) with PTSD, mild-to-moderate TBI history, and cognitive complaints underwent neuropsychological testing at baseline, post-treatment, and 3-month post-treatment. Veterans were randomly assigned to cognitive processing therapy (CPT) or a novel hybrid intervention integrating CPT with TBI psychoeducation and cognitive rehabilitation strategies from Cognitive Symptom Management and Rehabilitation Therapy (CogSMART). Performance below standard cutoffs on any PVT trial across three different PVT measures was considered invalid (PVT-Fail), whereas performance above cutoffs on all measures was considered valid (PVT-Pass). RESULTS Although both PVT groups exhibited clinically significant improvement in PTSD symptoms, the PVT-Pass group demonstrated greater symptom reduction than the PVT-Fail group. Measures of post-concussive and depressive symptoms improved to a similar degree across groups. Treatment condition did not moderate these results. Rate of valid test performance increased from baseline to follow-up across conditions, with a stronger effect in the SMART-CPT compared to CPT condition. CONCLUSION Both PVT groups experienced improved psychological symptoms following treatment. Veterans who failed PVTs at baseline demonstrated better test engagement following treatment, resulting in higher rates of valid PVTs at follow-up. Veterans with invalid PVTs should be enrolled in trauma-focused treatment and may benefit from neuropsychological assessment after, rather than before, treatment.
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19
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Harch PG, Andrews SR, Rowe CJ, Lischka JR, Townsend MH, Yu Q, Mercante DE. Hyperbaric oxygen therapy for mild traumatic brain injury persistent postconcussion syndrome: a randomized controlled trial. Med Gas Res 2020; 10:8-20. [PMID: 32189664 PMCID: PMC7871939 DOI: 10.4103/2045-9912.279978] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 11/19/2019] [Accepted: 12/16/2019] [Indexed: 12/18/2022] Open
Abstract
Persistent postconcussion syndrome (PPCS) after mild traumatic brain injury (mTBI) is a significant public health and military problem for which there is limited treatment evidence. The aim of this study was to determine whether forty 150 kPa hyperbaric oxygen therapies (HBOTs) can improve symptoms and cognitive function in subjects with the PPCS of mTBI, using a randomized controlled crossover design with 2-month follow-up. Sixty-three civilian and military subjects with mTBI/PPCS were randomized to either 40 HBOTs at 150 kPa/60 minutes, once daily, 5 days per week in 8 weeks or an equivalent no-treatment control period. The Control Group was then crossed over to HBOT. Subjects underwent symptom, neuropsychological, and psychological testing, before and after treatment or control with retesting 2 months after the 40th HBOT. Fifty subjects completed the protocol with primary outcome testing. HBOT subjects experienced significant improvements in Neurobehavioral Symptom Inventory, Memory Index, Automated Neuropsychological Assessment Metrics, Hamilton Depression Scale, Hamilton Anxiety Scale, Post-Traumatic Stress Disorder Checklist, Pittsburgh Sleep Quality Index, and Quality Of Life after Brain Injury compared to the Control Group. After crossing over to HBOT the Control Group experienced near-identical significant improvements. Further improvements were experienced by both groups during the 2-month follow-up period. These data indicate that 40 HBOTs at 150 kPa/60 minutes demonstrated statistically significant improvements in postconcussion and Post-Traumatic Stress Disorder symptoms, memory, cognitive functions, depression, anxiety, sleep, and quality of life in civilian and military subjects with mTBI/PPCS compared to controls. Improvements persisted at least 2 months after the 40th HBOT. The study was registered on ClinicalTrials.gov (NCT02089594) on March 18, 2014 and with the U.S. Food and Drug Administration under Investigational New Drug #113823. The Institutional Review Boards of the United States Army Medical Research and Materiel Command Office of Research Protections Human Research Protection Office and the Louisiana State University School of Medicine (approval No. 7381) approved the study on May 13, 2014 and December 20, 2013, respectively.
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Affiliation(s)
- Paul G. Harch
- Department of Medicine, Section of Emergency and Hyperbaric Medicine, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Susan R. Andrews
- Department of Medicine and Psychiatry, School of Medicine, Louisiana State University Health Sciences Center, Metairie, LA, USA
| | - Cara J. Rowe
- CaTS Clinical Translational Unit, Tulane University School of Medicine, LA, New Orleans, LA, USA
| | | | - Mark H. Townsend
- Louisiana State University-Ochsner Psychiatry Residency Training Program, Department of Psychiatry, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Qingzhao Yu
- School of Public Health, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Donald E. Mercante
- School of Public Health, Louisiana State University Health Sciences Center, New Orleans, LA, USA
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20
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Bailie JM, Remigio-Baker RA, Cole WR, McCulloch KL, Ettenhofer ML, West T, Ahrens A, Sargent P, Cecchini A, Malik S, Mullins L, Stuessi K, Qashu FM, Gregory E. Use of the Progressive Return to Activity Guidelines May Expedite Symptom Resolution After Concussion for Active Duty Military. Am J Sports Med 2019; 47:3505-3513. [PMID: 31718246 DOI: 10.1177/0363546519883259] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Clinical recommendations for concussion management encourage reduced cognitive and physical activities immediately after injury, with graded increases in activity as symptoms resolve. Empirical support for the effectiveness of such recommendations is needed. PURPOSE To examine whether training medical providers on the Defense and Veterans Brain Injury Center's Progressive Return to Activity Clinical Recommendation (PRA-CR) for acute concussion improves patient outcomes. STUDY DESIGN Cohort study; Level of evidence, 2. METHODS This study was conducted from 2016 to 2018 and compared patient outcomes before and after medical providers received an educational intervention (ie, provider training). Patients, recruited either before or after intervention, were assessed at ≤72 hours, 1 week, 1 month, 3 months, and 6 months after a concussion. The participant population included 38 military medical providers and 106 military servicemembers with a diagnosed concussion and treated by one of the military medical providers: 58 patient participants received care before the intervention (ie, provider training) and 48 received care after intervention. The primary outcome measure was the Neurobehavioral Symptom Inventory. RESULTS The patients seen before and after the intervention were predominantly male (89.7% and 93.8%, respectively) of military age (mean ± SD, 26.62 ± 6.29 years and 25.08 ± 6.85 years, respectively) and a mean ± SD of 1.92 ± 0.88 days from injury. Compared with patients receiving care before intervention, patients receiving care after intervention had smaller increases in physical activities (difference in mean change; 95% CI, 0.39 to 6.79) and vestibular/balance activities (95% CI, 0.79 to 7.5) during the first week of recovery. Although groups did not differ in symptoms at ≤72 hours of injury (d = 0.22; 95% CI, -2.21 to 8.07), the postintervention group reported fewer symptoms at 1 week (d = 0.61; 95% CI, 0.52 to 10.92). Postintervention patients who completed the 6-month study had improved recovery both at 1 month (d = 1.55; 95% CI, 5.33 to 15.39) and 3 months after injury (d = 1.10; 95% CI, 2.36 to 11.55), but not at 6 months (d = 0.35; 95% CI, 5.34 to 7.59). CONCLUSION Training medical providers on the PRA-CR for management of concussion resulted in expedited recovery of patients.
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Affiliation(s)
- Jason M Bailie
- Investigation performed at Camp Pendleton, California, USA, Fort Bragg, California, USA and Naval Medical Center San Diego, San Diego, California, USA
| | - Rosemay A Remigio-Baker
- Investigation performed at Camp Pendleton, California, USA, Fort Bragg, California, USA and Naval Medical Center San Diego, San Diego, California, USA
| | - Wesley R Cole
- Investigation performed at Camp Pendleton, California, USA, Fort Bragg, California, USA and Naval Medical Center San Diego, San Diego, California, USA
| | - Karen L McCulloch
- Investigation performed at Camp Pendleton, California, USA, Fort Bragg, California, USA and Naval Medical Center San Diego, San Diego, California, USA
| | - Mark L Ettenhofer
- Investigation performed at Camp Pendleton, California, USA, Fort Bragg, California, USA and Naval Medical Center San Diego, San Diego, California, USA
| | - Therese West
- Investigation performed at Camp Pendleton, California, USA, Fort Bragg, California, USA and Naval Medical Center San Diego, San Diego, California, USA
| | - Angelica Ahrens
- Investigation performed at Camp Pendleton, California, USA, Fort Bragg, California, USA and Naval Medical Center San Diego, San Diego, California, USA
| | - Paul Sargent
- Investigation performed at Camp Pendleton, California, USA, Fort Bragg, California, USA and Naval Medical Center San Diego, San Diego, California, USA
| | - Amy Cecchini
- Investigation performed at Camp Pendleton, California, USA, Fort Bragg, California, USA and Naval Medical Center San Diego, San Diego, California, USA
| | - Saafan Malik
- Investigation performed at Camp Pendleton, California, USA, Fort Bragg, California, USA and Naval Medical Center San Diego, San Diego, California, USA
| | - Lynita Mullins
- Investigation performed at Camp Pendleton, California, USA, Fort Bragg, California, USA and Naval Medical Center San Diego, San Diego, California, USA
| | - Keith Stuessi
- Investigation performed at Camp Pendleton, California, USA, Fort Bragg, California, USA and Naval Medical Center San Diego, San Diego, California, USA
| | - Felicia M Qashu
- Investigation performed at Camp Pendleton, California, USA, Fort Bragg, California, USA and Naval Medical Center San Diego, San Diego, California, USA
| | - Emma Gregory
- Investigation performed at Camp Pendleton, California, USA, Fort Bragg, California, USA and Naval Medical Center San Diego, San Diego, California, USA
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21
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Neuropsychological Performance and Subjective Symptom Reporting in Military Service Members With a History of Multiple Concussions: Comparison With a Single Concussion, Posttraumatic Stress Disorder, and Orthopedic Trauma. J Head Trauma Rehabil 2019. [PMID: 29517589 DOI: 10.1097/htr.0000000000000375] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To examine differences in objective neurocognitive performance and subjective cognitive symptoms in individuals with a history of a single concussion, multiple concussions, orthopedic injuries, and posttraumatic stress disorder (PTSD). METHOD Participants included 116 military service members who sustained a mild traumatic brain injury (mTBI) during combat deployment. Subjects were subdivided into groups based on concussion frequency: a single concussion (n = 42), 2 concussions (n = 21), and 3 or more concussions (n = 53). Eighty-one subjects sustained an orthopedic injury (n = 60) during deployment or were diagnosed with PTSD (n = 21), but had no history of mTBI. Subjects completed a battery of neuropsychological tests and self-report measures of postconcussive symptoms, PTSD symptoms, and psychopathology. RESULTS No differences were found among the concussion groups on a composite neuropsychological measure. The PTSD group had the highest number of symptom complaints, with the 2-concussion and 3-plus-concussion groups being most similar to the PTSD group. The concussion groups showed a nonsignificant pattern of increasing distress with increasing number of concussions. CONCLUSIONS The current findings are consistent with meta-analytic results showing no differential effect on neuropsychological functioning due to multiple concussions. Results also support the burden of adversity hypothesis suggesting increasing symptom levels with increasing psychological or physically traumatic exposures.
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22
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Defense and Veterans Brain Injury Center: The First 25 Years. J Head Trauma Rehabil 2018. [DOI: 10.1097/htr.0000000000000389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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