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Denby E, Dempster T, White T, Brockman K, Ellis H, Dharm-Datta S, Wilkinson D, Brunger H. Dizziness Directly Influences Postconcussion Symptoms and Is Predictive of Poorer Mental Health in UK Military Personnel: A Retrospective Analysis. J Head Trauma Rehabil 2024; 39:231-238. [PMID: 37773599 DOI: 10.1097/htr.0000000000000895] [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: 10/01/2023]
Abstract
OBJECTIVE To investigate the contribution of dizziness to postconcussion symptoms, depression, and anxiety symptoms. SETTING Mild traumatic brain injury (mTBI) service, Defence Medical Rehabilitation Centre, Stanford Hall. PARTICIPANTS Two hundred eighty-three UK military personnel from the Royal Navy, Royal Airforce, Royal Marines, and British Army. DESIGN A retrospective analysis of data from the Ministry of Defence medical records database. MAIN MEASURES Sixteen-item Rivermead Post Concussion Symptoms Questionnaire, Generalized Anxiety Disorder 7-item scale, Patient Health Questionnaire-9, The Dizziness Handicap Inventory. RESULTS Injuries from sports or falls were the most common mechanism of mTBI, accounting for 23%, respectively. Chi-square analysis indicated that individuals with dizziness and postconcussion symptoms (PCS) had greater severity of PCS, depression, and anxiety than those with PCS alone. Mediation analysis showed dizziness directly and independently influenced the severity of PCS, despite the indirect effects of mediating depression and anxiety symptoms. CONCLUSION Comorbid dizziness and PCS were predictive of poorer mental health compared with PCS alone. In addition, dizziness directly influenced the severity of PCS irrespective of the indirect effects of mental health symptoms. These observations suggest that treating dizziness with vestibular rehabilitation may improve PCS and mental health.
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Affiliation(s)
- Emma Denby
- School of Psychology, University of Kent, Canterbury, United Kingdom (Drs Denby and Wilkinson); School of Psychology and Life Sciences, Canterbury Christ Church University, Canterbury, United Kingdom (Drs Denby and Dempster);
- Mild Traumatic Brain Injury Service, Defence Medical Rehabilitation Centre, Stanford Hall, Loughborough, United Kingdom (Mss White and Brockman and Drs Ellis, Dharm-Datta, and Brunger)
| | - Tammy Dempster
- School of Psychology, University of Kent, Canterbury, United Kingdom (Drs Denby and Wilkinson); School of Psychology and Life Sciences, Canterbury Christ Church University, Canterbury, United Kingdom (Drs Denby and Dempster);
- Mild Traumatic Brain Injury Service, Defence Medical Rehabilitation Centre, Stanford Hall, Loughborough, United Kingdom (Mss White and Brockman and Drs Ellis, Dharm-Datta, and Brunger)
| | - Toni White
- School of Psychology, University of Kent, Canterbury, United Kingdom (Drs Denby and Wilkinson); School of Psychology and Life Sciences, Canterbury Christ Church University, Canterbury, United Kingdom (Drs Denby and Dempster);
- Mild Traumatic Brain Injury Service, Defence Medical Rehabilitation Centre, Stanford Hall, Loughborough, United Kingdom (Mss White and Brockman and Drs Ellis, Dharm-Datta, and Brunger)
| | - Katherine Brockman
- School of Psychology, University of Kent, Canterbury, United Kingdom (Drs Denby and Wilkinson); School of Psychology and Life Sciences, Canterbury Christ Church University, Canterbury, United Kingdom (Drs Denby and Dempster);
- Mild Traumatic Brain Injury Service, Defence Medical Rehabilitation Centre, Stanford Hall, Loughborough, United Kingdom (Mss White and Brockman and Drs Ellis, Dharm-Datta, and Brunger)
| | - Henrietta Ellis
- School of Psychology, University of Kent, Canterbury, United Kingdom (Drs Denby and Wilkinson); School of Psychology and Life Sciences, Canterbury Christ Church University, Canterbury, United Kingdom (Drs Denby and Dempster);
- Mild Traumatic Brain Injury Service, Defence Medical Rehabilitation Centre, Stanford Hall, Loughborough, United Kingdom (Mss White and Brockman and Drs Ellis, Dharm-Datta, and Brunger)
| | - Shreshth Dharm-Datta
- School of Psychology, University of Kent, Canterbury, United Kingdom (Drs Denby and Wilkinson); School of Psychology and Life Sciences, Canterbury Christ Church University, Canterbury, United Kingdom (Drs Denby and Dempster);
- Mild Traumatic Brain Injury Service, Defence Medical Rehabilitation Centre, Stanford Hall, Loughborough, United Kingdom (Mss White and Brockman and Drs Ellis, Dharm-Datta, and Brunger)
| | - David Wilkinson
- School of Psychology, University of Kent, Canterbury, United Kingdom (Drs Denby and Wilkinson); School of Psychology and Life Sciences, Canterbury Christ Church University, Canterbury, United Kingdom (Drs Denby and Dempster);
- Mild Traumatic Brain Injury Service, Defence Medical Rehabilitation Centre, Stanford Hall, Loughborough, United Kingdom (Mss White and Brockman and Drs Ellis, Dharm-Datta, and Brunger)
| | - Helen Brunger
- School of Psychology, University of Kent, Canterbury, United Kingdom (Drs Denby and Wilkinson); School of Psychology and Life Sciences, Canterbury Christ Church University, Canterbury, United Kingdom (Drs Denby and Dempster);
- Mild Traumatic Brain Injury Service, Defence Medical Rehabilitation Centre, Stanford Hall, Loughborough, United Kingdom (Mss White and Brockman and Drs Ellis, Dharm-Datta, and Brunger)
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MacGregor AJ, Crouch DJ, Zouris JM, Dougherty AL, Dye JL, Fraser JJ. Sex Differences in Postinjury Health Profiles Among U.S. Military Personnel Following Deployment-Related Concussion. J Womens Health (Larchmt) 2024; 33:515-521. [PMID: 38497537 DOI: 10.1089/jwh.2023.0068] [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: 03/19/2024] Open
Abstract
Background: Women in the U.S. military are now authorized to serve in direct combat occupations. This may increase their risk of combat injuries, such as concussion, in future conflicts. Knowledge of sex differences in health profiles after concussion is paramount for military medical planning efforts. The purpose of this study was to assess sex-related differences in health profiles among U.S. military personnel following deployment-related concussion. Materials and Methods: We conducted a retrospective study of service members who sustained a concussion during combat deployment between 2004 and 2013. Postinjury diagnoses were abstracted from outpatient encounters in electronic health records for 24 months after concussion. We used hierarchical clustering to identify clusters, termed "health profiles," and logistic regression to determine whether sex predicted membership in the health profiles. Results: The study sample included 346 women and 4536 men with deployment-related concussion. Five postinjury health profiles were identified and classified as no morbidity, back pain, tinnitus/memory loss, posttraumatic stress disorder/postconcussion syndrome, and multimorbidity. Women relative to men had higher odds of membership in the back pain (odds ratio [OR] = 1.32; 95% confidence interval [CI] = 1.05-1.67) and multimorbidity profiles (OR = 1.44; 95% CI = 1.03-2.00) and lower odds than men in the tinnitus/memory loss profile (OR = 0.62; 95% CI = 0.42-0.91). Conclusions: Postinjury health profiles among U.S. service members differ by sex following deployment-related concussion, particularly with a higher burden of multimorbidity among women than men, which may require interdisciplinary care. Women also had higher odds of membership in the back pain profile and lower odds in the tinnitus/memory loss profile than men. To prepare for future military operations where women may have greater exposure to combat, continued research elucidating health-related sex differences after deployment-related concussion is imperative.
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Affiliation(s)
- Andrew J MacGregor
- Medical Modeling, Simulation, and Mission Support Department, Naval Health Research Center, San Diego, California, USA
| | - Daniel J Crouch
- Medical Modeling, Simulation, and Mission Support Department, Naval Health Research Center, San Diego, California, USA
| | - James M Zouris
- Medical Modeling, Simulation, and Mission Support Department, Naval Health Research Center, San Diego, California, USA
| | - Amber L Dougherty
- Medical Modeling, Simulation, and Mission Support Department, Naval Health Research Center, San Diego, California, USA
- Leidos, Inc., San Diego, California, USA
| | - Judy L Dye
- Medical Modeling, Simulation, and Mission Support Department, Naval Health Research Center, San Diego, California, USA
- Leidos, Inc., San Diego, California, USA
| | - John J Fraser
- Operational Readiness and Health Directorate, Naval Health Research Center, San Diego, California, USA
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De Gasperi R, Gama Sosa MA, Perez Garcia G, Perez GM, Pryor D, Morrison CLA, Lind R, Abutarboush R, Kawoos U, Statz JK, Patterson J, Hof PR, Zhu CW, Ahlers ST, Cook DG, Elder GA. Metabotropic Glutamate Receptor 2 Expression Is Chronically Elevated in Male Rats With Post-Traumatic Stress Disorder Related Behavioral Traits Following Repetitive Low-Level Blast Exposure. J Neurotrauma 2024; 41:714-733. [PMID: 37917117 PMCID: PMC10902502 DOI: 10.1089/neu.2023.0252] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023] Open
Abstract
Many military veterans who experienced blast-related traumatic brain injuries in the conflicts in Iraq and Afghanistan currently suffer from chronic cognitive and mental health problems that include depression and post-traumatic stress disorder (PTSD). Male rats exposed to repetitive low-level blast develop cognitive and PTSD-related behavioral traits that are present for more than 1 year after exposure. We previously reported that a group II metabotropic receptor (mGluR2/3) antagonist reversed blast-induced behavioral traits. In this report, we explored mGluR2/3 expression following blast exposure in male rats. Western blotting revealed that mGluR2 protein (but not mGluR3) was increased in all brain regions studied (anterior cortex, hippocampus, and amygdala) at 43 or 52 weeks after blast exposure but not at 2 weeks or 6 weeks. mGluR2 RNA was elevated at 52 weeks while mGluR3 was not. Immunohistochemical staining revealed no changes in the principally presynaptic localization of mGluR2 by blast exposure. Administering the mGluR2/3 antagonist LY341495 after behavioral traits had emerged rapidly reversed blast-induced effects on novel object recognition and cued fear responses 10 months following blast exposure. These studies support alterations in mGluR2 receptors as a key pathophysiological event following blast exposure and provide further support for group II metabotropic receptors as therapeutic targets in the neurobehavioral effects that follow blast injury.
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Affiliation(s)
- Rita De Gasperi
- Research and Development Service, James J. Peters Department of Veterans Affairs Medical Center, Bronx, New York, USA
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Miguel A. Gama Sosa
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- General Medical Research Service, James J. Peters Department of Veterans Affairs Medical Center, Bronx, New York, USA
| | - Georgina Perez Garcia
- Research and Development Service, James J. Peters Department of Veterans Affairs Medical Center, Bronx, New York, USA
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Gissel M. Perez
- Research and Development Service, James J. Peters Department of Veterans Affairs Medical Center, Bronx, New York, USA
| | - Dylan Pryor
- Research and Development Service, James J. Peters Department of Veterans Affairs Medical Center, Bronx, New York, USA
| | - Chenel L-A. Morrison
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Northeast Regional Alliance Health Careers Opportunity Program, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Rachel Lind
- Research and Development Service, James J. Peters Department of Veterans Affairs Medical Center, Bronx, New York, USA
| | - Rania Abutarboush
- Department of Neurotrauma, Naval Medical Research Command, Silver Spring, Maryland, USA
- The Henry M. Jackson Foundation for the Advancement of Military Medicine Inc., Bethesda, Maryland, USA
| | - Usmah Kawoos
- Department of Neurotrauma, Naval Medical Research Command, Silver Spring, Maryland, USA
- The Henry M. Jackson Foundation for the Advancement of Military Medicine Inc., Bethesda, Maryland, USA
| | - Jonathan K. Statz
- Department of Neurotrauma, Naval Medical Research Command, Silver Spring, Maryland, USA
- The Henry M. Jackson Foundation for the Advancement of Military Medicine Inc., Bethesda, Maryland, USA
| | - Jacob Patterson
- Department of Neurotrauma, Naval Medical Research Command, Silver Spring, Maryland, USA
| | - Patrick R. Hof
- Nash Family Department of Neuroscience and Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Geriatrics and Palliative Care, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Mount Sinai Alzheimer's Disease Research Center and Ronald M. Loeb Center for Alzheimer's Disease, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Carolyn W. Zhu
- Research and Development Service, James J. Peters Department of Veterans Affairs Medical Center, Bronx, New York, USA
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Geriatrics and Palliative Care, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Stephen T. Ahlers
- Department of Neurotrauma, Naval Medical Research Command, Silver Spring, Maryland, USA
| | - David G. Cook
- Geriatric Research Education and Clinical Center, VA Puget Sound Health Care System, Seattle, Washington, USA
- Department of Medicine, Pharmacology, and Psychiatry, University of Washington, Seattle, Washington, USA
- Department of Behavioral Sciences, University of Washington, Seattle, Washington, USA
| | - Gregory A. Elder
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Mount Sinai Alzheimer's Disease Research Center and Ronald M. Loeb Center for Alzheimer's Disease, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Neurology Service, James J. Peters Department of Veterans Affairs Medical Center, Bronx, New York, USA
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Elder GA, Gama Sosa MA, De Gasperi R, Perez Garcia G, Perez GM, Abutarboush R, Kawoos U, Zhu CW, Janssen WGM, Stone JR, Hof PR, Cook DG, Ahlers ST. The Neurovascular Unit as a Locus of Injury in Low-Level Blast-Induced Neurotrauma. Int J Mol Sci 2024; 25:1150. [PMID: 38256223 PMCID: PMC10816929 DOI: 10.3390/ijms25021150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 01/11/2024] [Accepted: 01/11/2024] [Indexed: 01/24/2024] Open
Abstract
Blast-induced neurotrauma has received much attention over the past decade. Vascular injury occurs early following blast exposure. Indeed, in animal models that approximate human mild traumatic brain injury or subclinical blast exposure, vascular pathology can occur in the presence of a normal neuropil, suggesting that the vasculature is particularly vulnerable. Brain endothelial cells and their supporting glial and neuronal elements constitute a neurovascular unit (NVU). Blast injury disrupts gliovascular and neurovascular connections in addition to damaging endothelial cells, basal laminae, smooth muscle cells, and pericytes as well as causing extracellular matrix reorganization. Perivascular pathology becomes associated with phospho-tau accumulation and chronic perivascular inflammation. Disruption of the NVU should impact activity-dependent regulation of cerebral blood flow, blood-brain barrier permeability, and glymphatic flow. Here, we review work in an animal model of low-level blast injury that we have been studying for over a decade. We review work supporting the NVU as a locus of low-level blast injury. We integrate our findings with those from other laboratories studying similar models that collectively suggest that damage to astrocytes and other perivascular cells as well as chronic immune activation play a role in the persistent neurobehavioral changes that follow blast injury.
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Affiliation(s)
- Gregory A. Elder
- Neurology Service, James J. Peters Department of Veterans Affairs Medical Center, 130 West Kingsbridge Road, Bronx, NY 10468, USA
- Department of Neurology, Icahn School of Medicine at Mount Sinai, One Gustave Levy Place, New York, NY 10029, USA;
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, One Gustave Levy Place, New York, NY 10029, USA; (M.A.G.S.); (R.D.G.)
- Mount Sinai Alzheimer’s Disease Research Center and the Ronald M. Loeb Center for Alzheimer’s Disease, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (C.W.Z.); (P.R.H.)
| | - Miguel A. Gama Sosa
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, One Gustave Levy Place, New York, NY 10029, USA; (M.A.G.S.); (R.D.G.)
- General Medical Research Service, James J. Peters Department of Veterans Affairs Medical Center, Bronx, NY 10468, USA
| | - Rita De Gasperi
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, One Gustave Levy Place, New York, NY 10029, USA; (M.A.G.S.); (R.D.G.)
- Research and Development Service, James J. Peters Department of Veterans Affairs Medical Center, 130 West Kingsbridge Road, Bronx, NY 10468, USA;
| | - Georgina Perez Garcia
- Department of Neurology, Icahn School of Medicine at Mount Sinai, One Gustave Levy Place, New York, NY 10029, USA;
- Research and Development Service, James J. Peters Department of Veterans Affairs Medical Center, 130 West Kingsbridge Road, Bronx, NY 10468, USA;
| | - Gissel M. Perez
- Research and Development Service, James J. Peters Department of Veterans Affairs Medical Center, 130 West Kingsbridge Road, Bronx, NY 10468, USA;
| | - Rania Abutarboush
- Department of Neurotrauma, Operational and Undersea Medicine Directorate, Naval Medical ResearchCommand, 503 Robert Grant Avenue, Silver Spring, MD 20910, USA; (R.A.); (U.K.); (S.T.A.)
- The Henry M. Jackson Foundation for the Advancement of Military Medicine Inc., Bethesda, MD 20817, USA
| | - Usmah Kawoos
- Department of Neurotrauma, Operational and Undersea Medicine Directorate, Naval Medical ResearchCommand, 503 Robert Grant Avenue, Silver Spring, MD 20910, USA; (R.A.); (U.K.); (S.T.A.)
- The Henry M. Jackson Foundation for the Advancement of Military Medicine Inc., Bethesda, MD 20817, USA
| | - Carolyn W. Zhu
- Mount Sinai Alzheimer’s Disease Research Center and the Ronald M. Loeb Center for Alzheimer’s Disease, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (C.W.Z.); (P.R.H.)
- Research and Development Service, James J. Peters Department of Veterans Affairs Medical Center, 130 West Kingsbridge Road, Bronx, NY 10468, USA;
- Department of Geriatrics and Palliative Care, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - William G. M. Janssen
- Nash Family Department of Neuroscience, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA;
- Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - James R. Stone
- Department of Radiology and Medical Imaging, University of Virginia, 480 Ray C Hunt Drive, Charlottesville, VA 22903, USA;
| | - Patrick R. Hof
- Mount Sinai Alzheimer’s Disease Research Center and the Ronald M. Loeb Center for Alzheimer’s Disease, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (C.W.Z.); (P.R.H.)
- Department of Geriatrics and Palliative Care, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
- Nash Family Department of Neuroscience, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA;
- Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - David G. Cook
- Geriatric Research Education and Clinical Center, VA Puget Sound Health Care System, 1660 S Columbian Way, Seattle, WA 98108, USA;
- Department of Medicine, University of Washington, 1959 NE Pacific St., Seattle, WA 98195, USA
| | - Stephen T. Ahlers
- Department of Neurotrauma, Operational and Undersea Medicine Directorate, Naval Medical ResearchCommand, 503 Robert Grant Avenue, Silver Spring, MD 20910, USA; (R.A.); (U.K.); (S.T.A.)
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Ord AS, Martindale SL, Jenks ER, Rowland JA. Subjective cognitive complaints and objective cognitive functioning in combat veterans: Effects of PTSD and deployment mild TBI. APPLIED NEUROPSYCHOLOGY. ADULT 2023:1-7. [PMID: 37991812 DOI: 10.1080/23279095.2023.2280807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2023]
Abstract
OBJECTIVES (1) Examine the relationship between subjective cognitive complaints and objective cognitive functioning in combat veterans; and (2) evaluate conditional effects of posttraumatic stress disorder (PTSD) and deployment-related mild traumatic brain injury (TBI) within that relationship. METHOD Combat veterans (N = 225, 86.22% male) completed a lifetime TBI interview, a structured interview assessing PTSD symptoms, a neuropsychological assessment battery, and a self-report measure of cognitive symptoms. RESULTS All correlations between subjective cognitive complaints and objective cognitive measures were not statistically significant. Hierarchical linear regression indicated that cognitive performance was not significantly related to cognitive complaints, but both PTSD diagnosis and history of deployment mild TBI explained a significant amount of unique variance in self-reported cognitive symptoms. Interactions between the studied variables were not significant. CONCLUSIONS PTSD and history of deployment mild TBI were uniquely related to cognitive complaints, but cognitive test performance was not. No confounding effects of PTSD or deployment mild TBI were observed in the relationship between cognitive performance and cognitive complaints. This provides support that symptom distress may be a better explanatory factor for perception of lower cognitive functioning than actual cognitive performance.
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Affiliation(s)
- Anna S Ord
- W. G. (Bill) Hefner VA Healthcare System, Salisbury, NC, USA
- Veterans Integrated Service Networks (VISN)-6 Mid-Atlantic Mental Illness, Research Education and Clinical Center (MIRECC), Durham, NC, USA
- College of Health and Behavioral Sciences, Regent University, Virginia Beach, VA, USA
| | - Sarah L Martindale
- W. G. (Bill) Hefner VA Healthcare System, Salisbury, NC, USA
- Veterans Integrated Service Networks (VISN)-6 Mid-Atlantic Mental Illness, Research Education and Clinical Center (MIRECC), Durham, NC, USA
- Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Elizabeth R Jenks
- W. G. (Bill) Hefner VA Healthcare System, Salisbury, NC, USA
- College of Health and Behavioral Sciences, Regent University, Virginia Beach, VA, USA
| | - Jared A Rowland
- W. G. (Bill) Hefner VA Healthcare System, Salisbury, NC, USA
- Veterans Integrated Service Networks (VISN)-6 Mid-Atlantic Mental Illness, Research Education and Clinical Center (MIRECC), Durham, NC, USA
- Wake Forest School of Medicine, Winston-Salem, NC, USA
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Ly MT, Merritt VC, Ozturk ED, Clark AL, Hanson KL, Delano-Wood LM, Sorg SF. Subjective memory complaints are associated with decreased cortical thickness in Veterans with histories of mild traumatic brain injury. Clin Neuropsychol 2023; 37:1745-1765. [PMID: 36883430 DOI: 10.1080/13854046.2023.2184720] [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: 10/04/2022] [Accepted: 02/21/2023] [Indexed: 03/09/2023]
Abstract
Objective: Memory problems are frequently endorsed in Veterans following mild traumatic brain injury (mTBI), but subjective complaints are poorly associated with objective memory performance. Few studies have examined associations between subjective memory complaints and brain morphometry. We investigated whether self-reported memory problems were associated with objective memory performance and cortical thickness in Veterans with a history of mTBI. Methods: 40 Veterans with a history of remote mTBI and 29 Veterans with no history of TBI completed the Prospective-Retrospective Memory Questionnaire (PRMQ), PTSD Checklist (PCL), California Verbal Learning Test-2nd edition (CVLT-II), and 3 T T1 structural magnetic resonance imaging. Cortical thickness was estimated in 14 a priori frontal and temporal regions. Multiple regressions adjusting for age and PCL scores examined associations between PRMQ, CVLT-II scores, and cortical thickness within each Veteran group. Results: Greater subjective memory complaints on the PRMQ were associated with lower cortical thickness in the right middle temporal gyrus (β = 0.64, q = .004), right inferior temporal gyrus (β = 0.56, q = .014), right rostral middle frontal gyrus (β = 0.45, q = .046), and right rostral anterior cingulate gyrus (β = 0.58, q = .014) in the mTBI group but not the control group (q's > .05). These associations remained significant after adjusting for CVLT-II learning. CVLT-II performance was not associated with PRMQ score or cortical thickness in either group. Conclusions: Subjective memory complaints were associated with lower cortical thickness in right frontal and temporal regions, but not with objective memory performance, in Veterans with histories of mTBI. Subjective complaints post-mTBI may indicate underlying brain morphometry independently of objective cognitive testing.
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Affiliation(s)
- Monica T Ly
- Veterans Affairs San Diego Healthcare System (VASDHS), San Diego, CA, USA
- Department of Psychiatry, University of California San Diego Health, CA, USA
| | - Victoria C Merritt
- Veterans Affairs San Diego Healthcare System (VASDHS), San Diego, CA, USA
- Department of Psychiatry, University of California San Diego Health, CA, USA
- Center of Excellence for Stress and Mental Health, VASDHS, San Diego, CA, USA
| | - Erin D Ozturk
- Veterans Affairs San Diego Healthcare System (VASDHS), San Diego, CA, USA
- San Diego Joint Doctoral Program, San Diego State University/University of California San Diego, San Diego, CA, USA
| | - Alexandra L Clark
- Department of Psychology, The University of Texas at Austin, Austin, TX, USA
| | - Karen L Hanson
- Veterans Affairs San Diego Healthcare System (VASDHS), San Diego, CA, USA
- Department of Psychiatry, University of California San Diego Health, CA, USA
| | - Lisa M Delano-Wood
- Veterans Affairs San Diego Healthcare System (VASDHS), San Diego, CA, USA
- Department of Psychiatry, University of California San Diego Health, CA, USA
- Center of Excellence for Stress and Mental Health, VASDHS, San Diego, CA, USA
| | - Scott F Sorg
- Home Base, A Red Sox Foundation and Massachusetts General Hospital Program, Boston, MA, USA
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MacGregor AJ, D'Souza EW, Dougherty AL, Fraser JJ. Research Letter: Prevalence of Spine Injuries Among US Military Personnel With Combat-Related Concussion. J Head Trauma Rehabil 2023; 38:410-415. [PMID: 36730823 DOI: 10.1097/htr.0000000000000843] [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: 02/04/2023]
Abstract
OBJECTIVE To describe the prevalence of spine injuries among US service members with combat-related concussion. DESIGN AND PARTICIPANTS A retrospective review of medical records for US service members injured during combat operations in Iraq and Afghanistan between 2002 and 2020. The study sample included 27 897 service members categorized into 3 groups: concussion with loss of consciousness (LOC, n = 4631), concussion non-LOC ( n = 5533), and non-concussion ( n = 17 333). MAIN MEASURES Spine injuries were identified by International Classification of Diseases, Ninth Revision, Clinical Modification ( ICD-9-CM ) codes and classified by body region and nature of injury using the Barell injury diagnosis matrix. Differences in prevalence of spine injuries by concussion group were evaluated using χ 2 tests. RESULTS Spine injuries were most prevalent among service members with concussion LOC (31.1%), followed by concussion non-LOC (18.3%), and non-concussion (10.0%, P < .001). Sprains and strains were the most prevalent spine injury category, with injuries to the cervical, thoracic, and lumbar regions significantly more prevalent in the concussion groups ( P values < .001), particularly individuals with LOC compared with non-concussion. CONCLUSION The US military personnel with combat-related concussion, especially individuals with LOC, may also have spine injuries. Routine assessment for spine injury is recommended during concussion screening because this may impact clinical management and rehabilitation.
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Affiliation(s)
- Andrew J MacGregor
- Medical Modeling, Simulation, and Mission Support Department (Dr MacGregor, Mr D'Souza, and Ms Dougherty) and Operational Readiness and Health Directorate (Dr Fraser), Naval Health Research Center, San Diego, California; and Leidos, Inc, San Diego, California (Mr D'Souza and Ms Dougherty)
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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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9
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Garcia GP, Perez GM, Gasperi RD, Sosa MAG, Otero-Pagan A, Abutarboush R, Kawoos U, Statz JK, Patterson J, Zhu CW, Hof PR, Cook DG, Ahlers ST, Elder GA. (2R,6R)-Hydroxynorketamine Treatment of Rats Exposed to Repetitive Low-Level Blast Injury. Neurotrauma Rep 2023; 4:197-217. [PMID: 37020715 PMCID: PMC10068674 DOI: 10.1089/neur.2022.0088] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023] Open
Abstract
Many military veterans who experienced blast-related traumatic brain injuries (TBIs) in the conflicts in Iraq and Afghanistan suffer from chronic cognitive and mental health problems, including post-traumatic stress disorder (PTSD). Male rats subjected to repetitive low-level blast exposure develop chronic cognitive and PTSD-related traits that develop in a delayed manner. Ketamine has received attention as a treatment for refractory depression and PTSD. (2R,6R)-hydroxynorketamine [(2R,6R)-HNK] is a ketamine metabolite that exerts rapid antidepressant actions. (2R,6R)-HNK has become of clinical interest because of its favorable side-effect profile, low abuse potential, and oral route of administration. We treated three cohorts of blast-exposed rats with (2R,6R)-HNK, beginning 7-11 months after blast exposure, a time when the behavioral phenotype is established. Each cohort consisted of groups (n = 10-13/group) as follows: 1) Sham-exposed treated with saline, 2) blast-exposed treated with saline, and 3) blast-exposed treated with a single dose of 20 mg/kg of (2R,6R)-HNK. (2R,6R)-HNK rescued blast-induced deficits in novel object recognition (NOR) and anxiety-related features in the elevated zero maze (EZM) in all three cohorts. Exaggerated acoustic startle was reversed in cohort 1, but not in cohort 3. (2R,6R)-HNK effects were still present in the EZM 12 days after administration in cohort 1 and 27 days after administration in NOR testing of cohorts 2 and 3. (2R,6R)-HNK may be beneficial for the neurobehavioral syndromes that follow blast exposure in military veterans. Additional studies will be needed to determine whether higher doses or more extended treatment regimens may be more effective.
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Affiliation(s)
- Georgina Perez Garcia
- Research and Development Service, James J. Peters Department of Veterans Affairs Medical Center, Bronx, New York, USA
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Gissel M. Perez
- Research and Development Service, James J. Peters Department of Veterans Affairs Medical Center, Bronx, New York, USA
| | - Rita De Gasperi
- Research and Development Service, James J. Peters Department of Veterans Affairs Medical Center, Bronx, New York, USA
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Miguel A. Gama Sosa
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- General Medical Research Service, James J. Peters Department of Veterans Affairs Medical Center, Bronx, New York, USA
| | - Alena Otero-Pagan
- Research and Development Service, James J. Peters Department of Veterans Affairs Medical Center, Bronx, New York, USA
| | - Rania Abutarboush
- Department of Neurotrauma, Naval Medical Research Center, Silver Spring, Maryland, USA
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
| | - Usmah Kawoos
- Department of Neurotrauma, Naval Medical Research Center, Silver Spring, Maryland, USA
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
| | - Jonathan K. Statz
- Department of Neurotrauma, Naval Medical Research Center, Silver Spring, Maryland, USA
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
| | - Jacob Patterson
- Department of Neurotrauma, Naval Medical Research Center, Silver Spring, Maryland, USA
| | - Carolyn W. Zhu
- Research and Development Service, James J. Peters Department of Veterans Affairs Medical Center, Bronx, New York, USA
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Mount Sinai Alzheimer's Disease Research Center and Ronald M. Loeb Center for Alzheimer's Disease, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Geriatrics and Palliative Care, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Patrick R. Hof
- Nash Family Department of Neuroscience and Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Geriatrics and Palliative Care, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Mount Sinai Alzheimer's Disease Research Center and Ronald M. Loeb Center for Alzheimer's Disease, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - David G. Cook
- Geriatric Research Education and Clinical Center, VA Puget Sound Health Care System, Seattle, Washington, USA
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Stephen T. Ahlers
- Department of Neurotrauma, Naval Medical Research Center, Silver Spring, Maryland, USA
| | - Gregory A. Elder
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Mount Sinai Alzheimer's Disease Research Center and Ronald M. Loeb Center for Alzheimer's Disease, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Neurology Service, James J. Peters Department of Veterans Affairs Medical Center, Bronx, New York, USA
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10
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MacGregor AJ, Casachahua JD, Walton SR, Harbertson J, Jurick SM, Dougherty AL, McCabe CT, Watrous JR, Fraser JJ. Deployment-related concussion and long-term health-related quality of life among US military personnel. Qual Life Res 2023:10.1007/s11136-023-03367-4. [PMID: 36897531 DOI: 10.1007/s11136-023-03367-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/04/2023] [Indexed: 03/11/2023]
Abstract
PURPOSE To examine the relationship between deployment-related concussion and long-term health-related quality of life (HRQoL) among injured US military personnel. METHODS The study sample included 810 service members with deployment-related injuries between 2008 and 2012 who responded to a web-based longitudinal health survey. Participants were categorized into three injury groups: concussion with loss of consciousness (LOC; n = 247), concussion without LOC (n = 317), or no concussion (n = 246). HRQoL was measured using the 36-Item Short Form Health Survey physical and mental component summary (PCS and MCS) scores. Current post-traumatic stress disorder (PTSD) and depression symptoms were examined. Multivariable linear regression models assessed the effects of concussion on PCS and MCS scores, while controlling for covariates. RESULTS A lower PCS score was observed in participants with concussion with LOC (B = - 2.65, p = 0.003) compared with those with no history of concussion. Symptoms of PTSD (PCS: B = - 4.84, p < 0.001; MCS: B = - 10.53, p < 0.001) and depression (PCS: B = - 2.85, p < 0.001; MCS: B = - 10.24, p < 0.001) were the strongest statistically significant predictors of lower HRQoL. CONCLUSION Concussion with LOC was significantly associated with lower HRQoL in the physical domain. These findings affirm that concussion management should integrate physical and psychological care to improve long-term HRQoL and warrant a more detailed examination of causal and mediating mechanisms. Future research should continue to incorporate patient-reported outcomes and long-term follow-up of military service members to further define the lifelong impact of deployment-related concussion.
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Affiliation(s)
- Andrew J MacGregor
- Medical Modeling, Simulation, and Mission Support Department, Naval Health Research Center, 140 Sylvester Road, San Diego, CA, 92106, USA.
| | - John D Casachahua
- Warfighter Performance Department, Naval Health Research Center, San Diego, CA, USA
| | - Samuel R Walton
- Virginia Commonwealth University School of Medicine, Department of Physical Medicine and Rehabilitation, Richmond, VA, USA
| | - Judith Harbertson
- Medical Modeling, Simulation, and Mission Support Department, Naval Health Research Center, 140 Sylvester Road, San Diego, CA, 92106, USA.,Leidos, Inc, San Diego, CA, USA
| | - Sarah M Jurick
- Medical Modeling, Simulation, and Mission Support Department, Naval Health Research Center, 140 Sylvester Road, San Diego, CA, 92106, USA.,Leidos, Inc, San Diego, CA, USA
| | - Amber L Dougherty
- Medical Modeling, Simulation, and Mission Support Department, Naval Health Research Center, 140 Sylvester Road, San Diego, CA, 92106, USA.,Leidos, Inc, San Diego, CA, USA
| | - Cameron T McCabe
- Medical Modeling, Simulation, and Mission Support Department, Naval Health Research Center, 140 Sylvester Road, San Diego, CA, 92106, USA.,Leidos, Inc, San Diego, CA, USA
| | - Jessica R Watrous
- Medical Modeling, Simulation, and Mission Support Department, Naval Health Research Center, 140 Sylvester Road, San Diego, CA, 92106, USA.,Leidos, Inc, San Diego, CA, USA
| | - John J Fraser
- Operational Readiness and Health Directorate, Naval Health Research Center, San Diego, CA, USA
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11
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Gasperi RD, Gama Sosa MA, Perez Garcia GS, Perez GM, Abutarboush R, Kawoos U, Statz JK, Patterson J, Hof PR, Katsel P, Cook DG, Ahlers ST, Elder GA. Progressive Transcriptional Changes in the Amygdala Implicate Neuroinflammation in the Effects of Repetitive Low-Level Blast Exposure in Male Rats. J Neurotrauma 2023; 40:561-577. [PMID: 36262047 PMCID: PMC10040418 DOI: 10.1089/neu.2022.0282] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Chronic mental health problems are common among military veterans who sustained blast-related traumatic brain injuries. The reasons for this association remain unexplained. Male rats exposed to repetitive low-level blast overpressure (BOP) exposures exhibit chronic cognitive and post-traumatic stress disorder (PTSD)-related traits that develop in a delayed fashion. We examined blast-induced alterations on the transcriptome in four brain areas (anterior cortex, hippocampus, amygdala, and cerebellum) across the time frame over which the PTSD-related behavioral phenotype develops. When analyzed at 6 weeks or 12 months after blast exposure, relatively few differentially expressed genes (DEGs) were found. However, longitudinal analysis of amygdala, hippocampus, and anterior cortex between 6 weeks and 12 months revealed blast-specific DEG patterns. Six DEGs (hyaluronan and proteoglycan link protein 1 [Hapln1], glutamate metabotropic receptor 2 [Grm2], purinergic receptor P2y12 [P2ry12], C-C chemokine receptor type 5 [Ccr5], phenazine biosynthesis-like protein domain containing 1 [Pbld1], and cadherin related 23 [Cdh23]) were found altered in all three brain regions in blast-exposed animals. Pathway enrichment analysis using all DEGs or those uniquely changed revealed different transcription patterns in blast versus sham. In particular, the amygdala in blast-exposed animals had a unique set of enriched pathways related to stress responses, oxidative phosphorylation, and mitochondrial dysfunction. Upstream analysis implicated tumor necrosis factor (TNF)α signaling in blast-related effects in amygdala and anterior cortex. Eukaryotic initiating factor eIF4E (EIF4e), an upstream regulator of P2ry12 and Ccr5, was predicted to be activated in the amygdala. Quantitative polymerase chain reaction (qPCR) validated longitudinal changes in two TNFα regulated genes (cathepsin B [Ctsb], Hapln1), P2ry12, and Grm2. These studies have implications for understanding how blast injury damages the brain and implicates inflammation as a potential therapeutic target.
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Affiliation(s)
- Rita De Gasperi
- Research and Development Service, James J. Peters Department of Veterans Affairs Medical Center, Bronx, New York, USA
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Nash Family Department of Neuroscience and Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Miguel A. Gama Sosa
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- General Medical Research Service, James J. Peters Department of Veterans Affairs Medical Center, Bronx, New York, USA
- Department of Nash Family Department of Neuroscience and Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Georgina S. Perez Garcia
- Research and Development Service, James J. Peters Department of Veterans Affairs Medical Center, Bronx, New York, USA
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Gissel M. Perez
- Research and Development Service, James J. Peters Department of Veterans Affairs Medical Center, Bronx, New York, USA
| | - Rania Abutarboush
- Department of Neurotrauma, Naval Medical Research Center, Silver Spring, Maryland, USA
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
| | - Usmah Kawoos
- Department of Neurotrauma, Naval Medical Research Center, Silver Spring, Maryland, USA
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
| | - Jonathan K. Statz
- Department of Neurotrauma, Naval Medical Research Center, Silver Spring, Maryland, USA
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
| | - Jacob Patterson
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
- Parsons Corporation, Centreville, Virginia, USA
| | - Patrick R. Hof
- Department of Nash Family Department of Neuroscience and Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Geriatrics and Palliative Care, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Mount Sinai Alzheimer's Disease Research Center and Ronald M. Loeb Center for Alzheimer's Disease, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Pavel Katsel
- Research and Development Service, James J. Peters Department of Veterans Affairs Medical Center, Bronx, New York, USA
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - David G. Cook
- Geriatric Research Education and Clinical Center, VA Puget Sound Health Care System, Seattle, Washington, USA
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Stephen T. Ahlers
- Department of Neurotrauma, Naval Medical Research Center, Silver Spring, Maryland, USA
| | - Gregory A. Elder
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Nash Family Department of Neuroscience and Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Mount Sinai Alzheimer's Disease Research Center and Ronald M. Loeb Center for Alzheimer's Disease, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Neurology Service, James J. Peters Department of Veterans Affairs Medical Center, Bronx, New York, USA
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12
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Sullivan K, Keyter A, Jones K, Ameratunga S, Starkey N, Barker-Collo S, Webb J, Theadom A. Atypical symptom reporting after mild traumatic brain injury. BRAIN IMPAIR 2023; 24:114-123. [PMID: 38167586 DOI: 10.1017/brimp.2021.30] [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: 11/07/2022]
Abstract
OBJECTIVE Early reporting of atypical symptoms following a mild traumatic brain injury (mTBI) may be an early indicator of poor prognosis. This study aimed to determine the percentage of people reporting atypical symptoms 1-month post-mTBI and explore links to recovery 12 months later in a community-dwelling mTBI sample. METHODS Adult participants (>16 years) who had experienced a mTBI were identified from a longitudinal incidence study (BIONIC). At 1-month post-injury, 260 participants completed the Rivermead Post-Concussion Symptoms Questionnaire (typical symptoms) plus four atypical symptom items (hemiplegia, difficulty swallowing, digestion problems and difficulties with fine motor tasks). At 12 months post-injury, 73.9% (n = 193) rated their overall recovery on a 100-point scale. An ordinal regression explored the association between atypical symptoms at 1 month and recovery at 12 months post-injury (low = 0-80, moderate = 81-99 and complete recovery = 100), whilst controlling for age, sex, rehabilitation received, ethnicity, mental and physical comorbidities and additional injuries sustained at the time of injury. RESULTS At 1-month post-injury <1% of participants reported hemiplegia, 5.4% difficulty swallowing, 10% digestion problems and 15.4% difficulties with fine motor tasks. The ordinal regression model revealed atypical symptoms were not significant predictors of self-rated recovery at 12 months. Older age at injury and higher typical symptoms at 1 month were independently associated with poorer recovery at 12 months, p < 0.01. CONCLUSION Atypical symptoms on initial presentation were not linked to global self-reported recovery at 12 months. Age at injury and typical symptoms are stronger early indicators of longer-term prognosis. Further research is needed to determine if atypical symptoms predict other outcomes following mTBI.
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Affiliation(s)
- Karen Sullivan
- School of Psychology and Counselling, Queensland University of Technology, Brisbane, Australia
| | - Anna Keyter
- Auckland University of Technology, Auckland, New Zealand
| | - Kelly Jones
- National Institute for Stroke and Applied Neuroscience, Auckland University of Technology, Auckland, New Zealand
| | - Shanthi Ameratunga
- School of Population Health, University of Auckland, Auckland, New Zealand
| | - Nicola Starkey
- Faculty of Arts and Social Sciences, University of Waikato, Hamilton, New Zealand
| | | | | | - Alice Theadom
- National Institute for Stroke and Applied Neuroscience, Auckland University of Technology, Auckland, New Zealand
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13
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Kim SY, Soumoff AA, Raiciulescu S, Kemezis PA, Spinks EA, Brody DL, Capaldi VF, Ursano RJ, Benedek DM, Choi KH. Association of Traumatic Brain Injury Severity and Self-Reported Neuropsychiatric Symptoms in Wounded Military Service Members. Neurotrauma Rep 2023; 4:14-24. [PMID: 36726873 PMCID: PMC9886188 DOI: 10.1089/neur.2022.0063] [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: 01/12/2023] Open
Abstract
The impact of traumatic brain injury (TBI) severity and loss of consciousness (LOC) on the development of neuropsychiatric symptoms was studied in injured service members (SMs; n = 1278) evacuated from combat settings between 2003 and 2012. TBI diagnoses of mild TBI (mTBI) or moderate-to-severe TBI (MS-TBI) along with LOC status were identified using International Classification of Diseases, Ninth Revision (ICD-9) codes and the Defense and Veterans Brain Injury Center Standard Surveillance Case Definition for TBI. Self-reported psychiatric symptoms were evaluated for post-traumatic stress disorder (PTSD) with the PTSD Checklist, Civilian Version for PTSD, the Patient Health Questionnaire-9 for major depressive disorder (MDD), and the Patient Health Questionnaire-15 for somatic symptom disorder (SSD) in two time periods post-injury: Assessment Period 1 (AP1, 0.0-2.5 months) and Assessment Period 2 (AP2, 3-12 months). mTBI, but not MS-TBI, was associated with increased neuropsychiatric symptoms: PTSD in AP1 and AP2; MDD in AP1; and SSD in AP2. A subgroup analysis of mTBI with and without LOC revealed that mTBI with LOC, but not mTBI without LOC, was associated with increased symptoms as compared to non-TBI: PTSD in AP1 and AP2; MDD in AP1; and SSD in AP1 and AP2. Moreover, mTBI with LOC was associated with increased MDD symptoms in AP2, and SSD symptoms in AP1 and AP2, compared to mTBI without LOC. These findings reinforce the need for the accurate characterization of TBI severity and a multi-disciplinary approach to address the devastating impacts of TBI in injured SMs.
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Affiliation(s)
- Sharon Y. Kim
- Program in Neuroscience, Uniformed Services University, Bethesda, Maryland, USA
| | - Alyssa A. Soumoff
- Department of Psychiatry, Uniformed Services University, Bethesda, Maryland, USA.,Behavioral Health Directorate, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Sorana Raiciulescu
- Department of Preventive Medicine and Biostatistics, Biostatistics Consulting Center, Uniformed Services University, Bethesda, Maryland, USA
| | - Patricia A. Kemezis
- Behavioral Health Directorate, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Elizabeth A. Spinks
- Behavioral Health Directorate, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - David L. Brody
- Center for Neuroscience and Regenerative Medicine, Uniformed Services University, Bethesda, Maryland, USA.,Department of Neurology, Uniformed Services University, Bethesda, Maryland, USA
| | - Vincent F. Capaldi
- Program in Neuroscience, Uniformed Services University, Bethesda, Maryland, USA.,Department of Psychiatry, Uniformed Services University, Bethesda, Maryland, USA.,Center for the Study of Traumatic Stress, Uniformed Services University, Bethesda, Maryland, USA
| | - Robert J. Ursano
- Program in Neuroscience, Uniformed Services University, Bethesda, Maryland, USA.,Department of Psychiatry, Uniformed Services University, Bethesda, Maryland, USA.,Center for the Study of Traumatic Stress, Uniformed Services University, Bethesda, Maryland, USA
| | - David M. Benedek
- Program in Neuroscience, Uniformed Services University, Bethesda, Maryland, USA.,Department of Psychiatry, Uniformed Services University, Bethesda, Maryland, USA.,Center for the Study of Traumatic Stress, Uniformed Services University, Bethesda, Maryland, USA
| | - Kwang H. Choi
- Program in Neuroscience, Uniformed Services University, Bethesda, Maryland, USA.,Department of Psychiatry, Uniformed Services University, Bethesda, Maryland, USA.,Center for the Study of Traumatic Stress, Uniformed Services University, Bethesda, Maryland, USA.,Address correspondence to: Kwang H. Choi, PhD, Department of Psychiatry, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD 20814, USA.
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14
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Turkstra LS, Salanki K, MacIntyre E, Kim N, Jin J, Sprague S, Scott T, Bhandari M. What Is the Prevalence of Intimate Partner Violence and Traumatic Brain Injury in Fracture Clinic Patients? Clin Orthop Relat Res 2023; 481:132-142. [PMID: 36200843 PMCID: PMC9750668 DOI: 10.1097/corr.0000000000002329] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 06/28/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Individuals in violent intimate relationships are at a high risk of sustaining both orthopaedic fractures and traumatic brain injury (TBI), and the fracture clinic may be the first place that concurrent intimate partner violence (IPV) and TBI are recognized. Both IPV and TBI can affect all aspects of fracture management, but prevalence of TBI and comorbid TBI and IPV is unknown. QUESTIONS/PURPOSES (1) What are the previous-year and lifetime prevalence of IPV and TBI in women presenting to an outpatient orthopaedic fracture clinic? (2) What are the conditional probabilities of TBI in the presence of IPV and the reverse, to explore whether screening for one condition could effectively identify patients with the other? (3) Do patients with TBI, IPV, or both have worse neurobehavioral symptoms than patients without TBI and IPV? METHODS The study was completed in the fracture clinic at a community Level 1 trauma center in Southern Ontario from July 2018 to March 2019 and included patients seen by three orthopaedic surgeons. Inclusion criteria were self-identification as a woman, age 18 years or older, and the ability to complete forms in English without assistance from the person who brought them to the clinic (for participant safety and privacy). We invited 263 women to participate: 22 were ineligible (for example, they were patients of a surgeon who was not on the study protocol), 87 declined before hearing the topic of the study, and data from eight were excluded because the data were incomplete or lost. Complete data were obtained from 146 participants. Participants' mean age was 52 ± 16 years, and the most common diagnosis was upper or lower limb fracture. Prevalence of IPV was calculated as the number of women who answered "sometimes" or "often" to direct questions from the Woman Abuse Screening Tool, which asks about physical, emotional, and sexual abuse in the past year or person's lifetime. The prevalence of TBI was calculated as the number of women who reported at least one head or neck injury that resulted in feeling dazed or confused or in loss of consciousness lasting 30 minutes or less on the Ohio State University Traumatic Brain Injury Identification Method, a standardized procedure for eliciting lifetime history of TBI through a 3- to 5-minute structured interview. Conditional probabilities were calculated using a Bayesian analysis. Neurobehavioral symptoms were characterized using the Neurobehavioral Symptom Inventory, a standard self-report measure of everyday emotional, somatic, and cognitive complaints after TBI, with total scores compared across groups using a one-way ANOVA. RESULTS Previous-year prevalence of physical IPV was 7% (10 of 146), and lifetime prevalence was 28% (41 of 146). Previous-year prevalence of TBI was 8% (12 of 146), and lifetime prevalence was 49% (72 of 146). The probability of TBI in the presence of IPV was 0.77, and probability of IPV in the presence of TBI was 0.36. Thus, screening for IPV identified proportionately more patients with TBI than screening for TBI, but the reverse was not true. Neurobehavioral Symptom Inventory scores were higher (more symptoms) in patients with TBI only (23 ± 16) than those with fractures only (12 ± 11, mean difference 11 [95% CI 8 to 18]; p < 0.001), in those with IPV only (17 ± 11) versus fractures only (mean difference 5 [95% CI -1 to -11]; p < 0.05), and in those with both TBI and IPV (25 ± 14) than with fractures only (mean difference 13 [95% CI 8 to 18]; p < 0.001) or those with IPV alone (17 ± 11, mean difference 8 [95% CI -1 to 16]; p < 0.05). CONCLUSION Using a brief screening interview, we identified a high self-reported prevalence of TBI and IPV alone, consistent with previous studies, and a novel finding of high comorbidity of IPV and TBI. Given that the fracture clinic may be the first healthcare contact for women with IPV and TBI, especially mild TBI associated with IPV, we recommend educating frontline staff on how to identify IPV and TBI as well as implementing brief screening and referral and universal design modifications that support effective, efficient, and accurate communication patients with TBI-related cognitive and communication challenges. LEVEL OF EVIDENCE Level II, prognostic study.
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Affiliation(s)
- Lyn. S. Turkstra
- School of Rehabilitation Science, McMaster University, Hamilton, ON, Canada
- Centre for Advanced Research in Experimental and Applied Linguistics, McMaster University, Hamilton, ON, Canada
| | - Krista Salanki
- Centre for Advanced Research in Experimental and Applied Linguistics, McMaster University, Hamilton, ON, Canada
| | - Emily MacIntyre
- Centre for Advanced Research in Experimental and Applied Linguistics, McMaster University, Hamilton, ON, Canada
| | - Noel Kim
- Centre for Advanced Research in Experimental and Applied Linguistics, McMaster University, Hamilton, ON, Canada
| | - Jonathan Jin
- Centre for Advanced Research in Experimental and Applied Linguistics, McMaster University, Hamilton, ON, Canada
| | - Sheila Sprague
- Division of Orthopedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Taryn Scott
- Division of Orthopedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Mohit Bhandari
- Division of Orthopedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
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15
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Brickell TA, French LM, Varbedian NV, Sewell JM, Schiefelbein FC, Wright MM, Lange RT. Relationship satisfaction among spouse caregivers of service members and veterans with comorbid mild traumatic brain injury and post-traumatic stress disorder. FAMILY PROCESS 2022; 61:1525-1540. [PMID: 34859431 DOI: 10.1111/famp.12731] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 10/15/2021] [Accepted: 10/22/2021] [Indexed: 06/13/2023]
Abstract
This study examined relationship satisfaction and health-related quality of life (HRQOL) among spouse caregivers assisting service members and veterans (SMV) with comorbid uncomplicated mild traumatic brain injury (MTBI) and post-traumatic stress disorder (PTSD). Spouse caregivers (N = 205) completed the Couples Satisfaction Index (CSI), 12 HRQOL measures, and the Mayo-Portland Adaptability Inventory 4th Edition (MPAI-4). T-scores were classified as "clinically elevated" using a cutoff of ≥60T. The sample was also classified into "Satisfied" (≥13.5, n = 113, 55.0%) or "Dissatisfied" (<13.5, n = 92, 44.0%) relationship categories. Using stepwise regression analysis, Anxiety, Family Disruption, Vigilance, Emotional Support, Feeling Trapped, and MPAI-4 Adjustment were identified as the strongest predictors of CSI total scores (p < 0.001), accounting for 41.6% of the variance. Squared semi-partial correlations revealed that 18.1% of the variance was shared across all six measures, with 7.8% to 1.5% of unique variance accounted for by each measure separately. When comparing the number of clinically elevated measures simultaneously, the Dissatisfied group consistently had a higher number of clinically elevated scores compared to the Satisfied group (e.g., 3-or-more clinically elevated scores: Dissatisfied = 40.2%, Satisfied = 8.8%, OR = 6.93, H = 0.76). Caring for a SMV with comorbid TBI and PTSD can have a profound impact on the spouse caregiver's HRQOL, relationship satisfaction, and family functioning. The findings from the current study continue to support the need for family involvement in the SMV's treatment plan, but more effort is needed to integrate behavioral health treatment that focuses on the family member's own issues into military TBI and PTSD systems of care.
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Affiliation(s)
- Tracey A Brickell
- Traumatic Brain Injury Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- General Dynamics Information Technology, Silver Spring, Maryland, USA
- Centre of Excellence on Post-Traumatic Stress Disorder, Ottawa, ON, Canada
| | - Louis M French
- Traumatic Brain Injury Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Nicole V Varbedian
- Traumatic Brain Injury Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- General Dynamics Information Technology, Silver Spring, Maryland, USA
| | - Jessie M Sewell
- Traumatic Brain Injury Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- General Dynamics Information Technology, Silver Spring, Maryland, USA
| | - Faith C Schiefelbein
- Traumatic Brain Injury Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- General Dynamics Information Technology, Silver Spring, Maryland, USA
| | - Megan M Wright
- Traumatic Brain Injury Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- General Dynamics Information Technology, Silver Spring, Maryland, USA
| | - Rael T Lange
- Traumatic Brain Injury Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- General Dynamics Information Technology, Silver Spring, Maryland, USA
- Centre of Excellence on Post-Traumatic Stress Disorder, Ottawa, ON, Canada
- University of British Columbia, Vancouver, BC, Canada
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16
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Is Traumatic Brain Injury Severity in Service Members and Veterans Related to Health-Related Quality of Life in Their Caregivers? J Head Trauma Rehabil 2022; 37:338-349. [PMID: 35862894 DOI: 10.1097/htr.0000000000000802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVE To examine the relationship between service member/veteran (SM/V) traumatic brain injury (TBI) severity with caregiver health-related quality of life (HRQOL). SETTING Military treatment facility. PARTICIPANTS Caregivers (N = 316) of SM/Vs following a TBI divided into 2 groups based on SM/V TBI severity: (1) caregivers of SM/Vs following an uncomplicated mild TBI (UnMTBI Caregiver group, n = 246), and (2) caregivers of SM//Vs following a complicated mild, moderate, severe, or penetrating TBI (STBI Caregiver group, n = 70). The STBI Caregiver group was further divided into 2 subgroups: Parent (n = 21) versus Intimate Partner (n = 49). The UnMTBI Caregiver group consisted of intimate partners. DESIGN Prospective cohort. MAIN MEASURES Caregivers completed 15 HRQOL measures. RESULTS Using analysis of variance and chi-square analysis, the UnMTBI Caregiver group reported worse scores on 12 HRQOL measures and more clinically elevated scores for 6 of 15 comparisons than the STBI Caregiver group. The UnMTBI Caregiver group also reported worse scores on 10 HRQOL measures than intimate partners in the STBI Caregiver group and 5 measures than parents in the STBI Caregiver group. Parents reported worse scores on 3 measures than intimate partners in the STBI Caregiver group. The UnMTBI Caregiver group reported more clinically elevated scores for 7 of 15 comparisons than intimate partners in the STBI Caregiver group. CONCLUSION Intimate partner caregivers of an SM/V following a remote uncomplicated MTBI reported worse HRQOL than intimate partners and parent caregivers of an SM/V following a more severe TBI, mostly likely due to SM/V physical and mental health comorbidities. Interventions that focus on the SM/V's TBI and other comorbidities, the caregiver's behavioral health problems, and the relationship and family factors that interact with each other will likely have the most success in improving individual and family outcomes for military families.
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17
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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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18
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Brickell TA, Wright MM, Ferdosi H, French LM, Lange RT. Pain interference and health-related quality of life in caregivers of service members and veterans with traumatic brain injury and mental health comorbidity. Qual Life Res 2022; 31:3031-3039. [PMID: 35594013 DOI: 10.1007/s11136-022-03153-8] [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: 04/27/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE To examine (1) the relationship between caregiver pain interference with caregiver health-related quality of life (HRQOL), caregiver age, and service member/veteran (SMV) functional ability, and (2) change in caregiver pain interference longitudinally over 5 years. METHOD Participants were 347 caregivers of SMVs diagnosed with traumatic brain injury (TBI). Caregivers completed the SF-12v2 Health Survey Bodily Pain scale at an initial baseline evaluation and up to four annual follow-up evaluations. Caregivers were divided into three pain interference groups: High Pain Interference (n = 104), Neutral Pain Interference (n = 117), and Low Pain Interference (n = 126). Caregivers also completed 15 HRQOL measures and a measure of SMV functional ability. RESULTS The High Pain Interference group reported more clinically elevated scores on 13 measures compared to the Low Pain Interference group, and seven measures compared to the Neutral Pain Interference group. The Neutral Pain Interference group had more clinically elevated scores on three measures compared to the Low Pain Interference group. The High and Neutral Pain Interference groups were older than the Low Pain Interference group. Parent caregivers were older than intimate partner/sibling caregivers, but did not report worse pain interference. Caregiver age, and measures of Fatigue, Strain, Perceived Rejection, and Economic QOL were the strongest predictors of pain interference (p < .001), accounting for 28.2% of the variance. There was minimal change in Bodily Pain scores over five years. The interaction of time and age was not significant (X2 = 2.7, p = .61). CONCLUSION It is important to examine pain in the context of HRQOL in caregivers, regardless of age.
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Affiliation(s)
- Tracey A Brickell
- Traumatic Brain Injury Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD, USA. .,National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD, USA. .,Uniformed Services University of the Health Sciences, Bethesda, MD, USA. .,General Dynamics Information Technology, Silver Spring, MD, USA.
| | - Megan M Wright
- Traumatic Brain Injury Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD, USA.,National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD, USA.,General Dynamics Information Technology, Silver Spring, MD, USA
| | - Hamid Ferdosi
- General Dynamics Information Technology, Silver Spring, MD, USA.,Traumatic Brain Injury Center of Excellence, Silver Spring, MD, USA.,The George Washington University, Washington, DC, USA
| | - Louis M French
- Traumatic Brain Injury Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD, USA.,National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD, USA.,Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Rael T Lange
- Traumatic Brain Injury Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD, USA.,National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD, USA.,General Dynamics Information Technology, Silver Spring, MD, USA.,University of British Columbia, Vancouver, BC, Canada
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19
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Machamer J, Temkin N, Dikmen S, Nelson LD, Barber J, Hwang P, Boase K, Stein MB, Sun X, Giacino J, McCrea MA, Taylor SR, Jain S, Manley G. Symptom Frequency and Persistence in the First Year after Traumatic Brain Injury: A TRACK-TBI Study. J Neurotrauma 2022; 39:358-370. [PMID: 35078327 PMCID: PMC8892966 DOI: 10.1089/neu.2021.0348] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Symptom endorsement after traumatic brain injury (TBI) is common acutely post-injury and is associated with other adverse outcomes. Prevalence of persistent symptoms has been debated, especially in mild TBI (mTBI). A cohort of participants ≥17 years with TBI (n = 2039), 257 orthopedic trauma controls (OTCs), and 300 friend controls (FCs) were enrolled in the TRACK-TBI study and evaluated at 2 weeks and 3, 6, and 12 months post-injury using the Rivermead Post-Concussion Symptoms Questionnaire (RPQ). TBI participants had significantly higher symptom burden than OTCs or FCs at all times, with average scores more than double. TBI cases showed significant decreases in RPQ score between each evaluation (p < 0.001), decreasing ∼1.7 points per month between 2 weeks and 3 months and 0.2 points per month after that. More than 50% of the TBI sample, including >50% of each of the mild and moderate/severe TBI subsamples, continued to endorse three or more symptoms as worse than pre-injury through 12 months post-injury. A majority of TBI participants who endorsed a symptom at 3 months or later did so at the next evaluation as well. Contrary to reviews that report symptom resolution by 3 months post-injury among those with mTBI, this study of participants treated at level 1 trauma centers and having a computed tomography ordered found that persistent symptoms are common to at least a year after TBI. Additionally, although symptom endorsement was not specific to TBI given that they were also reported by OTC and FC participants, TBI participants endorsed over twice the symptom burden compared with the other groups.
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Affiliation(s)
- Joan Machamer
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Nancy Temkin
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA.,Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Sureyya Dikmen
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
| | - Lindsay D Nelson
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Jason Barber
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Phillip Hwang
- Department of Anatomy and Neurobiology, Boston University, Boston, Massachusetts, USA
| | - Kim Boase
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Murray B Stein
- Department of Psychiatry and Herbert Wertheim School of Public Health, Herbert Wertheim School of Public Health, University of California San Diego, La Jolla, California, USA
| | - Xiaoying Sun
- Biostatistics Research Center, Herbert Wertheim School of Public Health, University of California San Diego, La Jolla, California, USA
| | - Joseph Giacino
- Department of Rehabilitation Medicine, Spaulding Rehabilitation Hospital, Harvard Medical School, Charlestown, Massachusetts, USA
| | - Michael A McCrea
- Department of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Sabrina R Taylor
- Brain and Spinal Injury Center, San Francisco, California, USA.,Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Sonia Jain
- Biostatistics Research Center, Herbert Wertheim School of Public Health, University of California San Diego, La Jolla, California, USA
| | - Geoff Manley
- Brain and Spinal Injury Center, San Francisco, California, USA.,Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
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20
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Perez Garcia G, Perez GM, Otero-Pagan A, Abutarboush R, Kawoos U, De Gasperi R, Gama Sosa MA, Pryor D, Hof PR, Cook DG, Gandy S, Ahlers ST, Elder GA. Transcranial Laser Therapy Does Not Improve Cognitive and Post-Traumatic Stress Disorder-Related Behavioral Traits in Rats Exposed to Repetitive Low-Level Blast Injury. Neurotrauma Rep 2021; 2:548-563. [PMID: 34901948 PMCID: PMC8655798 DOI: 10.1089/neur.2021.0005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Many military veterans who experienced blast-related traumatic brain injuries (TBIs) in the conflicts in Iraq and Afghanistan suffer from chronic cognitive and mental health problems, including post-traumatic stress disorder (PTSD). Transcranial laser therapy (TLT) uses low-power lasers emitting light in the far- to near-infrared ranges. Beneficial effects of TLT have been reported in neurological and mental-health-related disorders in humans and animal models, including TBI. Rats exposed to repetitive low-level blast develop chronic cognitive and PTSD-related behavioral traits. We tested whether TLT treatment could reverse these traits. Rats received a 74.5-kPa blast or sham exposures delivered one per day for 3 consecutive days. Beginning at 34 weeks after blast exposure, the following groups of rats were treated with active or sham TLT: 1) Sham-exposed rats (n = 12) were treated with sham TLT; 2) blast-exposed rats (n = 13) were treated with sham TLT; and 3) blast-exposed rats (n = 14) were treated with active TLT. Rats received 5 min of TLT five times per week for 6 weeks (wavelength, 808 nm; power of irradiance, 240 mW). At the end of treatment, rats were tested in tasks found previously to be most informative (novel object recognition, novel object localization, contextual/cued fear conditioning, elevated zero maze, and light/dark emergence). TLT did not improve blast-related effects in any of these tests, and blast-exposed rats were worse after TLT in some anxiety-related measures. Based on these findings, TLT does not appear to be a promising treatment for the chronic cognitive and mental health problems that follow blast injury.
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Affiliation(s)
- Georgina Perez Garcia
- Research and Development Service, James J. Peters Department of Veterans Affairs Medical Center, Bronx, New York, USA
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Gissel M. Perez
- Research and Development Service, James J. Peters Department of Veterans Affairs Medical Center, Bronx, New York, USA
| | - Alena Otero-Pagan
- Research and Development Service, James J. Peters Department of Veterans Affairs Medical Center, Bronx, New York, USA
| | - Rania Abutarboush
- Department of Neurotrauma, Naval Medical Research Center, Silver Spring, Maryland, USA
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
| | - Usmah Kawoos
- Department of Neurotrauma, Naval Medical Research Center, Silver Spring, Maryland, USA
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
| | - Rita De Gasperi
- Research and Development Service, James J. Peters Department of Veterans Affairs Medical Center, Bronx, New York, USA
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Miguel A. Gama Sosa
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- General Medical Research Service, James J. Peters Department of Veterans Affairs Medical Center, Bronx, New York, USA
| | - Dylan Pryor
- Research and Development Service, James J. Peters Department of Veterans Affairs Medical Center, Bronx, New York, USA
| | - Patrick R. Hof
- Nash Family Department of Neuroscience and Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Geriatrics and Palliative Care, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Mount Sinai Alzheimer's Disease Research Center and Ronald M. Loeb Center for Alzheimer's Disease, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - David G. Cook
- Geriatric Research Education and Clinical Center, VA Puget Sound Health Care System, Seattle, Washington, USA
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Sam Gandy
- Research and Development Service, James J. Peters Department of Veterans Affairs Medical Center, Bronx, New York, USA
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Mount Sinai Alzheimer's Disease Research Center and Ronald M. Loeb Center for Alzheimer's Disease, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Barbara and Maurice A. Deane Center for Wellness and Cognitive Health and the Mount Sinai NFL Neurological Care Center, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Stephen T. Ahlers
- Department of Neurotrauma, Naval Medical Research Center, Silver Spring, Maryland, USA
| | - Gregory A. Elder
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Mount Sinai Alzheimer's Disease Research Center and Ronald M. Loeb Center for Alzheimer's Disease, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Neurology Service, James J. Peters Department of Veterans Affairs Medical Center, Bronx, New York, USA
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21
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Sorg SF, Werhane ML, Merritt VC, Clark AL, Holiday KA, Hanson KL, Jak AJ, Schiehser DM, Delano-Wood L. Research Letter: PTSD Symptom Severity and Multiple Traumatic Brain Injuries Are Associated With Elevated Memory Complaints in Veterans With Histories of Mild TBI. J Head Trauma Rehabil 2021; 36:418-423. [PMID: 33656481 PMCID: PMC8969182 DOI: 10.1097/htr.0000000000000659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The evaluation of memory complaints in mild traumatic brain injury (mTBI) remains an important clinical consideration, especially in the context of comorbid psychiatric symptoms such as posttraumatic stress disorder (PTSD). We compared subjective memory complaints in veterans with and without a history of mTBI, examined ratings between those with single versus multiple mTBIs, and investigated associations between memory complaints and PTSD symptom severity. METHODS 117 outpatient veterans (mTBI: n = 79 [single mTBI: n = 22, multiple mTBI: n = 57], military controls [MCs]: n = 38) completed a TBI history assessment, the Prospective-Retrospective Memory Questionnaire (PRMQ), and the PTSD Checklist-Military Version (PCL-M). RESULTS Hierarchical multiple regression showed that greater PCL-M scores significantly predicted elevated PRMQ-Total scores, accounting for 38% of the variance explained (P < .001). mTBI status predicted an additional 5% of variance in memory complaints (P < .01). The multiple-mTBI group endorsed more memory complaints than either MCs (P < .01) or the single-mTBI group (P < .05), who did not differ from MCs (P > .50). CONCLUSIONS Comorbid PTSD symptoms are an important factor when considering memory complaints in veterans with a reported history of mTBI. However, independent of comorbid PTSD symptoms, mTBI status-particularly in the context of repetitive neurotrauma-uniquely contributes to memory complaints. Findings suggest that veterans with a history of multiple mTBIs may be a particularly vulnerable group in need of specialized interventions and/or psychoeducation.
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Affiliation(s)
- Scott F Sorg
- Research and Psychology Services (Drs Sorg, Merritt, Clark, Hanson, Jak, Schiehser, and Delano-Wood) and Center of Excellence for Stress and Mental Health (Drs Jak, Schiehser, and Delano-Wood), VA San Diego Healthcare System, San Diego, California; SDSU/UC San Diego Joint Doctoral Program in Clinical Psychology, San Diego, California (Ms Holiday); Department of Psychiatry, University of California San Diego (Drs Sorg, Merritt, Clark, Hanson, Jak, Schiehser, and Delano-Wood); and Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle (Dr Werhane)
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22
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Klyce DW, West SJ, Perrin PB, Agtarap SD, Finn JA, Juengst S, Dams-O'Connor K, Eagye CB, Vargas TA, Chung JS, Bombardier CH. Network Analysis of Neurobehavioral and Posttraumatic Stress Disorder Symptoms One Year after Traumatic Brain Injury: A Veterans Affairs TBI Model Systems Study. J Neurotrauma 2021; 38:3332-3340. [PMID: 34652955 DOI: 10.1089/neu.2021.0200] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Traumatic brain injury (TBI) is often experienced under stressful circumstances that can lead to both symptoms of posttraumatic stress disorder (PTSD) and neurobehavioral symptoms of brain injury. There is considerable symptom overlap in the behavioral expression of these conditions. Psychometric network analysis is a useful approach to investigate the role of specific symptoms in connecting these two disorders and is thus well-suited to explore their interrelatedness. This study applied network analysis to examine the associations among PTSD and TBI symptoms in a sample of Service Members and Veterans (SM/Vs) with a history of TBI one year after injury. Responses to the Neurobehavioral Symptom Inventory (NSI) and PTSC Checklist-Civilian version (PCL-C) were obtained from participants who completed comprehensive inpatient rehabilitation services at five VA polytrauma rehabilitation centers. Participants (N = 612) were 93.1% male with an average age of 36.98 years at injury. The analysis produced a stable network. Within the NSI symptom groups, the frustration symptom was an important bridge between the affective and cognitive TBI symptoms. The PCL-C nodes formed their own small cluster with hyperarousal yielding connections with the affective, cognitive, and somatic symptom groups. Consistent with this observation, the hyperarousal node had the second strongest bridge centrality in the network. Hyperarousal appears to play a key role in holding together this network of distress and thus represents a prime target for intervention among individuals with elevated symptoms of PTSD and a history of TBI. Network analysis offers an empirical approach to visualizing and quantifying the associations among symptoms. The identification of symptoms that are central to connecting multiple conditions can inform diagnostic precision and treatment selection.
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Affiliation(s)
- Daniel Wesley Klyce
- Richmond VAMC, 20125, 1201 Broad Rock Blvd, Richmond, Virginia, United States, 23249.,Sheltering Arms Institute, 559078, Richmond, United States, 23233-7632;
| | - Samuel J West
- Virginia Commonwealth University, 6889, Department of Psychology, Richmond, Virginia, United States;
| | - Paul B Perrin
- Virginia Commonwealth University, Department of Psychology, Richmond, United States;
| | | | - Jacob A Finn
- Minneapolis VA Health Care System, 20040, Minneapolis, Minnesota, United States.,University of Minnesota Department of Psychiatry, 172737, Minneapolis, Minnesota, United States;
| | - Shannon Juengst
- University of Texas Southwestern, Physical Medicine & Rehabilitation; Rehabilitation Counseling, 5323 Harry Hines Blvd, Dallas, Texas, United States, 75390-9055;
| | - Kristen Dams-O'Connor
- Icahn School of Medicine at Mount Sinai, 5925, Rehabilitation Medicine, One Gustave Levy Place, Box 1163, New York, New York, United States, 10029; kristen.dams-o'
| | - C B Eagye
- Craig Hospital, 20588, Research Department, Englewood, Colorado, United States;
| | | | - Joyce S Chung
- Veterans Affairs Palo Alto Health Care System, Polytrauma, Palo Alto, California, United States;
| | - Charles H Bombardier
- University of Washington, Rehabilitation Medicine, Box 359612, Harborview Medical Center, 325 9th Avenue, Seattle, Washington, United States, 98104;
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23
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D'Silva LJ, Siengsukon CF, Devos H. Gaze stability in young adults with previous concussion history. J Vestib Res 2021; 30:259-266. [PMID: 32675433 DOI: 10.3233/ves-200706] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Disruption of visual-vestibular interaction after concussion can cause gaze instability with head movements. The long-term impact of concussion on gaze stability is unknown. OBJECTIVE This cross-sectional comparative pilot study examined gaze stability in the chronic stage after concussion (greater than one year). A secondary objective was to examine the relationship between gaze stability and sleep. METHODS Outcome measures included: 1. Gaze stability in logMAR (mean loss of dynamic visual acuity (DVA) in the yaw and pitch planes); 2. Pittsburgh Sleep Quality Index (PSQI); 3. Epworth Sleepiness Scale (ESS). Post-Concussion Symptom Scale (PCSS), time since injury, and number of concussions were collected for the people with concussion. RESULTS The study sample included thirty-four adults (mean age 23.35±1.3 years). Seventeen had a history of 1-9 concussions, with a mean duration of 4.4±1.9 years since last concussion; and 17 were age and sex-matched controls. Mean pitch plane DVA loss was greater in the concussion group compared to the control group (p = 0.04). Participants with previous concussion had lower sleep quality based on the PSQI (p = 0.01) and increased daytime sleepiness based on the ESS (p = 0.01) compared to healthy controls. Mean DVA loss in the pitch plane was significantly correlated with the PSQI (r = 0.43, p = 0.01) and the ESS (r = 0.41, p = 0.02). CONCLUSION Significant differences in dynamic visual acuity may be found in young adults long after a concussion, compared with those who have no concussion history. Furthermore, loss of dynamic visual acuity was associated with poorer sleep quality and higher daytime sleepiness.
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Affiliation(s)
- Linda J D'Silva
- Department of Physical Therapy Education, Rockhurst University, Kansas City, KS, USA
| | - Catherine F Siengsukon
- Department of Physical Therapy and Rehabilitation Science, University of Kansas Medical Center, Kansas City, KS, USA
| | - Hannes Devos
- Department of Physical Therapy and Rehabilitation Science, University of Kansas Medical Center, Kansas City, KS, USA
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24
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McDonald SD, Walker WC, Cusack SE, Yoash-Gantz RE, Pickett TC, Cifu DX, Mid-Atlantic Mirecc Workgroup V, Tupler LA. Health symptoms after war zone deployment-related mild traumatic brain injury: contributions of mental disorders and lifetime brain injuries. Brain Inj 2021; 35:1338-1348. [PMID: 34543115 DOI: 10.1080/02699052.2021.1959058] [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: 10/20/2022]
Abstract
PRIMARY OBJECTIVE To gain a better understanding of the complex relationship between combat deployment-related mild traumatic brain injury (mTBI) and persistent post-concussive symptoms (PPCSs), taking into consideration a wide range of potentially mediating and confounding factors. RESEARCH DESIGN Cross-sectional. METHODS AND PROCEDURES Subjects were 613 U. S. military Veterans and Service Members who served during operations Enduring Freedom, Iraqi Freedom, or New Dawn (OEF/OIF/OND) and completed a structured interview of mental disorders and a battery of questionnaires. Hierarchical binary logistic regression analyses were used to test the hypotheses. MAIN OUTCOMES AND RESULTS After accounting for mental disorders, lifetime mTBIs outside of OEF/OIF/OND deployment, medical conditions, and injury/demographic characteristics, deployment-related mTBI continued to be associated with several PPCSs (headaches, sleep disturbance, and difficulty making decisions). Deployment-related mTBI was also associated with two symptoms not normally associated with mTBI (nausea/upset stomach and numbness/tingling). CONCLUSIONS After adjusting for a wide range of factors, OEF/OIF/OND deployment-related mTBI was still associated with PPCSs on average 10 years after the injury. These findings suggest that mTBI sustained during OEF/OIF/OND deployment may have enduring negative health effects. More studies are needed that prospectively and longitudinally track health and mental health outcomes after TBI.
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Affiliation(s)
- Scott D McDonald
- Mental Health Service, Hunter Holmes McGuire Va Medical Center, Richmond, VA, USA.,Department Of Psychology, Virginia Commonwealth University, Richmond, VA, USA.,Department Of Physical Medicine And Rehabilitation, School Of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - William C Walker
- Mental Health Service, Hunter Holmes McGuire Va Medical Center, Richmond, VA, USA.,Department Of Physical Medicine And Rehabilitation, School Of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Shannon E Cusack
- Department Of Psychology, Virginia Commonwealth University, Richmond, VA, USA.,Virginia Institute for Psychiatric and Behavioral Genetics (Vipbg), School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Ruth E Yoash-Gantz
- Va Mid-Atlantic Mental Illness, Research, And Clinical Center, Durham, NC, USA
| | | | - David X Cifu
- Mental Health Service, Hunter Holmes McGuire Va Medical Center, Richmond, VA, USA.,Department Of Physical Medicine And Rehabilitation, School Of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | | | - Larry A Tupler
- Va Mid-Atlantic Mental Illness, Research, And Clinical Center, Durham, NC, USA.,Durham VA Medical Center, Durham, NC, USA.,Duke University Medical Center, Durham, NC, USA
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25
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MacGregor AJ, Shannon KB, Dougherty AL. Time Since Injury as a Factor in Post-Concussion Symptom Reporting among Military Service Members with Blast-Related Concussion. J Neurotrauma 2021; 38:2447-2453. [PMID: 33906380 DOI: 10.1089/neu.2020.7334] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Over the last decade, much research has been devoted to concussion among military personnel. Post-concussion symptoms after blast-related concussion are common, but it is unknown whether symptom reporting differs over time. This study's objective was to assess the relationship between time since injury and post-concussion symptom reporting. We conducted a retrospective review of existing records to identify service members who experienced blast-related concussion during deployment between 2007 and 2012 and who responded to a Post-Deployment Health Assessment (PDHA). The study population included 3690 military personnel grouped by time between injury and PDHA completion: 1-90 days (45.3%, n = 1,673), 91-180 days (33.0%, n = 1,216), or 181-365 days (21.7%, n = 801). Post-concussion symptoms assessed on the PDHA included headache, tinnitus, memory problems, concentration problems, difficulty making decisions, irritability, dizziness, and sleep problems. All post-concussion symptoms were higher for 91-180 days and 181-365 days after injury relative to 1-90 days, with the exception of dizziness. After adjustment for loss of consciousness, mental health comorbidity, and other covariates, the odds of reporting three or more post-concussion symptoms were significantly higher in those who completed the PDHA 91-180 days (odds ratio: 1.29; 95% confidence interval: 1.09-1.51) or 181-365 days after injury (odds ratio: 1.33; 95% confidence interval: 1.09-1.61), compared with the 1-90 days group. These findings suggest that refinements to in-theater medical care may be needed to reduce post-concussion symptom burden and improve the prospect of concussion recovery.
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Affiliation(s)
- Andrew J MacGregor
- Medical Modeling, Simulation, and Mission Support Department, Naval Health Research Center, San Diego, California, USA
| | - Kaeley B Shannon
- Medical Modeling, Simulation, and Mission Support Department, Naval Health Research Center, San Diego, California, USA
- Axiom Resource Management, Inc., San Diego, California, USA
| | - Amber L Dougherty
- Medical Modeling, Simulation, and Mission Support Department, Naval Health Research Center, San Diego, California, USA
- Leidos, Inc., San Diego, California, USA
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26
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Eagle SR, Collins MW, Dretsch MN, Uomoto JM, Connaboy C, Flanagan SD, Kontos AP. Network Analysis of Research on Mild Traumatic Brain Injury in US Military Service Members and Veterans During the Past Decade (2010-2019). J Head Trauma Rehabil 2021; 36:E345-E354. [PMID: 33741827 DOI: 10.1097/htr.0000000000000675] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate trends in the extant literature on mild traumatic brain injury (mTBI) in military service members and veterans using network analysis based on a comprehensive search of original, peer-reviewed research articles involving human participants published between January 1, 2010, and December 31, 2019. Specifically, we employed network analysis to evaluate associations in the following areas: (1) peer-reviewed journals, (2) authors, (3) organizations/institutions, and (4) relevant key words. PARTICIPANTS Included studies were published in peer-reviewed journals available on Web of Science database, using US military service members or veterans. DESIGN Bibliometric network analytical review. MAIN MEASURES Outcomes for each analysis included number of articles, citations, total link strength, and clusters. RESULTS The top publishing journals were (1) Journal of Head Trauma and Rehabilitation, (2) Military Medicine, (3) Brain Injury, (4) Journal of Neurotrauma, and (5) Journal of Rehabilitation Research and Development. The top publishing authors were (1) French, (2) Lange, (3) Cooper, (4) Vanderploeg, and (5) Brickell. The top research institutions were (1) Defense and Veterans Brain Injury Center, (2) Uniformed Services University of the Health Sciences, (3) University of California San Diego, (4) Walter Reed National Military Medical Center, and (5) Boston University. The top co-occurring key words in this analysis were (1) posttraumatic stress disorder (PTSD), (2) persistent postconcussion symptoms (PPCS), (3) blast injury, (4) postconcussion syndrome (PCS), and (5) Alzheimer's disease. CONCLUSIONS The results of this network analysis indicate a clear focus on veteran health, as well as investigations on chronic effects of mTBI. Research in civilian mTBI indicates that delaying treatment for symptoms and impairments related to mTBI may not be the most precise treatment strategy. Increasing the number of early, active, and targeted treatment trials in military personnel could translate to meaningful improvements in clinical practices for managing mTBI in this population.
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Affiliation(s)
- Shawn R Eagle
- Departments of Orthopaedic Surgery (Drs Eagle, Collins, and Kontos) and Sports Medicine and Nutrition (Drs Connaboy and Flanagan), University of Pittsburgh, Pittsburgh, Pennsylvania; UPMC Sports Medicine Concussion Program, Pittsburgh, Pennsylvania (Drs Collins and Kontos); US Army Medical Research Directorate-West, Walter Reed Army Institute of Research, Joint Base Lewis-McChord, Washington (Dr Dretsch); and VA Puget Sound Health Care System-American Lake Division, Tacoma, Washington (Dr Uomoto)
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27
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Piantino J, Schwartz DL, Luther M, Newgard C, Silbert L, Raskind M, Pagulayan K, Kleinhans N, Iliff J, Peskind E. Link between Mild Traumatic Brain Injury, Poor Sleep, and Magnetic Resonance Imaging: Visible Perivascular Spaces in Veterans. J Neurotrauma 2021; 38:2391-2399. [PMID: 33599176 PMCID: PMC8390772 DOI: 10.1089/neu.2020.7447] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Impaired clearance of perivascular waste in the brain may play a critical role in morbidity after mild traumatic brain injury (mTBI). We aimed to determine the effect of mTBI on the burden of magnetic resonance imaging (MRI)-visible perivascular spaces (PVSs) in a cohort of U.S. military veterans and whether sleep modulates this effect. We also investigated the correlation between PVS burden and severity of persistent post-concussive symptoms. Fifty-six Iraq/Afghanistan veterans received 3 Tesla MRI as part of a prospective cohort study on military blast mTBI. White matter PVS burden (i.e., number and volume) was calculated using an established automated segmentation algorithm. Multi-variate regression was used to establish the association between mTBIs sustained in the military and PVS burden. Covariates included age, blood pressure, number of impact mTBIs outside the military, and blast exposures. Correlation coefficients were calculated between PVS burden and severity of persistent post-concussive symptoms. There was a significant positive relationship between the number of mTBIs sustained in the military and both PVS number and volume (p = 0.04). A significant interaction was found between mTBI and poor sleep on PVS volume (p = 0.04). A correlation was found between PVS number and volume, as well as severity of postconcussive symptoms (p = 0.03). Further analysis revealed a moderate correlation between PVS number and volume, as well as balance problems (p < 0.001). In Iraq/Afghanistan veterans, mTBI is associated with an increase in PVS burden. Further, an interaction exists between mTBI and poor sleep on PVS burden. Increased PVS burden, which may indicate waste clearance dysfunction, is associated with persistent post-concussive symptom severity.
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Affiliation(s)
- Juan Piantino
- Department of Pediatrics, Division of Child Neurology, Doernbecher Children's Hospital, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Daniel L. Schwartz
- Layton Aging and Alzheimer's Disease Center, Neurology, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon, USA
- Advanced Imaging Research Center, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Madison Luther
- Department of Pediatrics, Division of Child Neurology, Doernbecher Children's Hospital, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Craig Newgard
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Lisa Silbert
- Layton Aging and Alzheimer's Disease Center, Neurology, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon, USA
- Portland Veterans Affairs Medical Center, Neurology, Portland, Oregon, USA
| | - Murray Raskind
- Veterans Affairs Northwest Network Mental Illness, Research, Education, and Clinical Center, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington, USA
| | - Kathleen Pagulayan
- Veterans Affairs Northwest Network Mental Illness, Research, Education, and Clinical Center, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington, USA
| | - Natalia Kleinhans
- Department of Radiology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Jeffrey Iliff
- Veterans Affairs Northwest Network Mental Illness, Research, Education, and Clinical Center, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington, USA
- Department of Neurology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Elaine Peskind
- Veterans Affairs Northwest Network Mental Illness, Research, Education, and Clinical Center, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington, USA
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28
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Haarbauer-Krupa J, Pugh MJ, Prager EM, Harmon N, Wolfe J, Yaffe K. Epidemiology of Chronic Effects of Traumatic Brain Injury. J Neurotrauma 2021; 38:3235-3247. [PMID: 33947273 PMCID: PMC9122127 DOI: 10.1089/neu.2021.0062] [Citation(s) in RCA: 82] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Although many patients diagnosed with traumatic brain injury (TBI), particularly mild TBI, recover from their symptoms within a few weeks, a small but meaningful subset experience symptoms that persist for months or years after injury and significantly impact quality of life for the person and their family. Factors associated with an increased likelihood of negative TBI outcomes include not only characteristics of the injury and injury mechanism, but also the person’s age, pre-injury status, comorbid conditions, environment, and propensity for resilience. In this article, as part of the Brain Trauma Blueprint: TBI State of the Science framework, we examine the epidemiology of long-term outcomes of TBI, including incidence, prevalence, and risk factors. We identify the need for increased longitudinal, global, standardized, and validated assessments on incidence, recovery, and treatments, as well as standardized assessments of the influence of genetics, race, ethnicity, sex, and environment on TBI outcomes. By identifying how epidemiological factors contribute to TBI outcomes in different groups of persons and potentially impact differential disease progression, we can guide investigators and clinicians toward more-precise patient diagnosis, along with tailored management, and improve clinical trial designs, data evaluation, and patient selection criteria.
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Affiliation(s)
- Juliet Haarbauer-Krupa
- Division of Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Mary Jo Pugh
- Informatics, Decision-Enhancement and Analytic Sciences Center, VA Salt Lake City, Salt Lake City, Utah, USA.,Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | | | | | | | - Kristine Yaffe
- Department of Neurology, University of California San Francisco, San Francisco, California, USA.,San Francisco Veterans Affairs Medical Center, San Francisco, California, USA.,Departments of Epidemiology/Biostatistics and Psychiatry, University of California San Francisco, San Francisco, California, USA
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Pattinson CL, Brickell TA, Bailie J, Hungerford L, Lippa SM, French LM, Lange RT. Sleep disturbances following traumatic brain injury are associated with poor neurobehavioral outcomes in U.S. military service members and veterans. J Clin Sleep Med 2021; 17:2425-2438. [PMID: 34216198 DOI: 10.5664/jcsm.9454] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES This study examined whether sleep disturbances were associated with neurobehavioral outcome following a traumatic brain injury (TBI) in a well characterized group of service members and veterans. METHODS Six-hundred and six participants were enrolled into the Defense and Veterans Brain Injury Center, 15-Year Longitudinal TBI study. All participants completed a battery of tests measuring self-reported sleep disturbances, neurobehavioral symptoms, and Posttraumatic Stress Disorder PTSD symptoms. Data were analyzed using analysis of variance with post-hoc comparisons. Four groups were analyzed separately: uncomplicated mild TBI (MTBI); complicated mild, moderate, severe, or penetrating - combined TBI (CTBI); injured controls (IC, i.e., orthopedic or soft-tissue injury without TBI); and non-injured controls (NIC). RESULTS A higher proportion of the MTBI group reported moderate-severe sleep disturbances (66.5%) compared to the IC (54.9%), CTBI (47.5%), and NIC groups (34.3%). Participants classified as having Poor Sleep had significantly worse scores on the majority of TBI-QOL scales compared to those classified as having Good Sleep, regardless of TBI severity or the presence of TBI. There was a significant interaction between sleep disturbances and PTSD. While sleep disturbances and PTSD by themselves were significant factors associated with worse outcome, both factors combined resulted in worse outcome than either singularly. CONCLUSIONS Regardless of group (injured or NIC), sleep disturbances were common and were associated with significantly worse neurobehavioral functioning. When experienced concurrently with PTSD, sleep disturbances pose significant burden to service members and veterans.
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Affiliation(s)
- Cassandra L Pattinson
- University of Queensland, Institute for Social Science Research, Brisbane, QLD, Australia
| | - Tracey A Brickell
- Defense and Veterans Brain Injury Center, Silver Spring, MD.,Walter Reed National Military Medical Center, Bethesda, MD.,National Intrepid Center of Excellence, Bethesda, MD.,Uniformed Services University of the Health Sciences, Bethesda, MD.,General Dynamics Information Technology, Falls Church, VA.,Centre of Excellence on Post-Traumatic Stress Disorder, Ottawa, ON, Canada
| | - Jason Bailie
- Defense and Veterans Brain Injury Center, Silver Spring, MD.,General Dynamics Information Technology, Falls Church, VA.,Naval Hospital Camp, Pendleton, CA
| | - Lars Hungerford
- Defense and Veterans Brain Injury Center, Silver Spring, MD.,General Dynamics Information Technology, Falls Church, VA.,Naval Medical Center, San Diego, CA
| | - Sara M Lippa
- Walter Reed National Military Medical Center, Bethesda, MD.,National Intrepid Center of Excellence, Bethesda, MD
| | - Louis M French
- Defense and Veterans Brain Injury Center, Silver Spring, MD.,Walter Reed National Military Medical Center, Bethesda, MD.,National Intrepid Center of Excellence, Bethesda, MD.,Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Rael T Lange
- Defense and Veterans Brain Injury Center, Silver Spring, MD.,Walter Reed National Military Medical Center, Bethesda, MD.,National Intrepid Center of Excellence, Bethesda, MD.,General Dynamics Information Technology, Falls Church, VA.,Centre of Excellence on Post-Traumatic Stress Disorder, Ottawa, ON, Canada.,University of British Columbia, Vancouver, Canada
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30
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Wang C, Shao C, Zhang L, Siedlak SL, Meabon JS, Peskind ER, Lu Y, Wang W, Perry G, Cook DG, Zhu X. Oxidative Stress Signaling in Blast TBI-Induced Tau Phosphorylation. Antioxidants (Basel) 2021; 10:antiox10060955. [PMID: 34203583 PMCID: PMC8232162 DOI: 10.3390/antiox10060955] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 05/08/2021] [Accepted: 06/01/2021] [Indexed: 12/25/2022] Open
Abstract
Traumatic brain injury caused by blast is associated with long-term neuropathological changes including tau phosphorylation and pathology. In this study, we aimed to determine changes in initial tau phosphorylation after exposure to a single mild blast and the potential contribution of oxidative stress response pathways. C57BL/6 mice were exposed to a single blast overpressure (BOP) generated by a compressed gas-driven shock tube that recapitulates battlefield-relevant open-field BOP, and cortical tissues were harvested at different time points up to 24 h after blast for Western blot analysis. We found that BOP caused elevated tau phosphorylation at Ser202/Thr205 detected by the AT8 antibody at 1 h post-blast followed by tau phosphorylation at additional sites (Ser262 and Ser396/Ser404 detected by PHF1 antibody) and conformational changes detected by Alz50 antibody. BOP also induced acute oxidative damage at 1 h post-blast and gradually declined overtime. Interestingly, Extracellular signal-regulated kinase (ERK) and c-Jun N-terminal kinase (JNK) were acutely activated in a similar temporal pattern as the rise and fall in oxidative stress after blast, with p38 showing a similar trend. However, glycogen synthase kinase-3 β (GSK3β) was inhibited at 1 h and remained inhibited for 24 h post blast. These results suggested that mitogen-activated protein kinases (MAPKs) but not GSK3β are likely involved in mediating the effects of oxidative stress on the initial increase of tau phosphorylation following a single mild blast.
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Affiliation(s)
- Chunyu Wang
- Department of Neurology, The Second Xiangya Hospital, Central South University, Changsha 410083, China;
- Department of Pathology, Case Western Reserve University, Cleveland, OH 44106, USA; (C.S.); (L.Z.); (S.L.S.); (Y.L.); (W.W.)
| | - Changjuan Shao
- Department of Pathology, Case Western Reserve University, Cleveland, OH 44106, USA; (C.S.); (L.Z.); (S.L.S.); (Y.L.); (W.W.)
| | - Li Zhang
- Department of Pathology, Case Western Reserve University, Cleveland, OH 44106, USA; (C.S.); (L.Z.); (S.L.S.); (Y.L.); (W.W.)
- Department of Endocrinology and Metabolism, Huashan Hospital, Fudan University, Shanghai 200240, China
| | - Sandra L. Siedlak
- Department of Pathology, Case Western Reserve University, Cleveland, OH 44106, USA; (C.S.); (L.Z.); (S.L.S.); (Y.L.); (W.W.)
| | - James S. Meabon
- VA Puget Sound Health Care System, Seattle, WA 98108, USA; (J.S.M.); (E.R.P.); (D.G.C.)
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA 98115, USA
| | - Elaine R. Peskind
- VA Puget Sound Health Care System, Seattle, WA 98108, USA; (J.S.M.); (E.R.P.); (D.G.C.)
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA 98115, USA
| | - Yubing Lu
- Department of Pathology, Case Western Reserve University, Cleveland, OH 44106, USA; (C.S.); (L.Z.); (S.L.S.); (Y.L.); (W.W.)
| | - Wenzhang Wang
- Department of Pathology, Case Western Reserve University, Cleveland, OH 44106, USA; (C.S.); (L.Z.); (S.L.S.); (Y.L.); (W.W.)
| | - George Perry
- Department of Biology, College of Science, University of Texas at San Antonio, San Antonio, TX 78229, USA;
| | - David G. Cook
- VA Puget Sound Health Care System, Seattle, WA 98108, USA; (J.S.M.); (E.R.P.); (D.G.C.)
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA 98115, USA
- Departments of Medicine and Pharmacology, University of Washington, Seattle, WA 98195, USA
| | - Xiongwei Zhu
- Department of Pathology, Case Western Reserve University, Cleveland, OH 44106, USA; (C.S.); (L.Z.); (S.L.S.); (Y.L.); (W.W.)
- Correspondence: ; Tel.: +1-216-368-5903
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Scrimgeour AG, Condlin ML, Loban A, DeMar JC. Omega-3 Fatty Acids and Vitamin D Decrease Plasma T-Tau, GFAP, and UCH-L1 in Experimental Traumatic Brain Injury. Front Nutr 2021; 8:685220. [PMID: 34150829 PMCID: PMC8211733 DOI: 10.3389/fnut.2021.685220] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 05/10/2021] [Indexed: 12/20/2022] Open
Abstract
Traumatic brain injury (TBI) results in neuronal, axonal and glial damage. Interventions targeting neuroinflammation to enhance recovery from TBI are needed. Exercise is known to improve cognitive function in TBI patients. Omega-3 fatty acids and vitamin D reportedly reduce inflammation, and in combination, might improve TBI outcomes. This study examined how an anti-inflammatory diet affected plasma TBI biomarkers, voluntary exercise and behaviors following exposure to mild TBI (mTBI). Adult, male rats were individually housed in cages fitted with running wheels and daily running distance was recorded throughout the study. A modified weight drop method induced mTBI, and during 30 days post-injury, rats were fed diets supplemented with omega-3 fatty acids and vitamin D3 (AIDM diet), or non-supplemented AIN-76A diets (CON diet). Behavioral tests were periodically conducted to assess functional deficits. Plasma levels of Total tau (T-tau), glial fibrillary acidic protein (GFAP), ubiquitin c-terminal hydrolase L1 (UCH-L1) and neurofilament light chain (NF-L) were measured at 48 h, 14 days, and 30 days post-injury. Fatty acid composition of food, plasma, and brain tissues was determined. In rats exposed to mTBI, NF-L levels were significantly elevated at 48 h post-injury (P < 0.005), and decreased to levels seen in uninjured rats by 14 days post-injury. T-tau, GFAP, and UCH-L1 plasma levels did not change at 48 h or 14 days post-injury. However, at 30 days post-injury, T-tau, GFAP and UCH-L1 all significantly increased in rats exposed to mTBI and fed CON diets (P < 0.005), but not in rats fed AIDM diets. Behavioral tests conducted post-injury showed that exercise counteracted cognitive deficits associated with mTBI. The AIDM diets significantly increased docosahexaenoic acid levels in plasma and brain tissue (P < 0.05), and in serum levels of vitamin D (P < 0.05). The temporal response of the four injury biomarkers examined is consistent with studies by others demonstrating acute and chronic neural tissue damage following exposure to TBI. The anti-inflammatory diet significantly altered the temporal profiles of plasma T-tau, GFAP, and UCH-L1 following mTBI. Voluntary exercise protected against mTBI-induced cognitive deficits, but had no impact on plasma levels of neurotrauma biomarkers. Thus, the prophylactic effect of exercise, when combined with an anti-inflammatory diet, may facilitate recovery in patients with mTBI.
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Affiliation(s)
- Angus G Scrimgeour
- Military Nutrition Division, US Army Research Institute of Environmental Medicine, Natick, MA, United States
| | - Michelle L Condlin
- Military Nutrition Division, US Army Research Institute of Environmental Medicine, Natick, MA, United States
| | - Andrei Loban
- Military Nutrition Division, US Army Research Institute of Environmental Medicine, Natick, MA, United States
| | - James C DeMar
- Blast-Induced Neurotrauma Branch, Center for Military Psychiatry and Neuroscience Research, Walter Reed Army Institute of Research (WRAIR), Silver Spring, MD, United States
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32
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Perez Garcia G, De Gasperi R, Gama Sosa MA, Perez GM, Otero-Pagan A, Pryor D, Abutarboush R, Kawoos U, Hof PR, Dickstein DL, Cook DG, Gandy S, Ahlers ST, Elder GA. Laterality and region-specific tau phosphorylation correlate with PTSD-related behavioral traits in rats exposed to repetitive low-level blast. Acta Neuropathol Commun 2021; 9:33. [PMID: 33648608 PMCID: PMC7923605 DOI: 10.1186/s40478-021-01128-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 02/07/2021] [Indexed: 12/14/2022] Open
Abstract
Military veterans who experience blast-related traumatic brain injuries often suffer from chronic cognitive and neurobehavioral syndromes. Reports of abnormal tau processing following blast injury have raised concerns that some cases may have a neurodegenerative basis. Rats exposed to repetitive low-level blast exhibit chronic neurobehavioral traits and accumulate tau phosphorylated at threonine 181 (Thr181). Using data previously reported in separate studies we tested the hypothesis that region-specific patterns of Thr181 phosphorylation correlate with behavioral measures also previously determined and reported in the same animals. Elevated p-tau Thr181 in anterior neocortical regions and right hippocampus correlated with anxiety as well as fear learning and novel object localization. There were no correlations with levels in amygdala or posterior neocortical regions. Particularly striking were asymmetrical effects on the right and left hippocampus. No systematic variation in head orientation toward the blast wave seems to explain the laterality. Levels did not correlate with behavioral measures of hyperarousal. Results were specific to Thr181 in that no correlations were observed for three other phospho-acceptor sites (threonine 231, serine 396, and serine 404). No consistent correlations were linked with total tau. These correlations are significant in suggesting that p-tau accumulation in anterior neocortical regions and the hippocampus may lead to disinhibited amygdala function without p-tau elevation in the amygdala itself. They also suggest an association linking blast injury with tauopathy, which has implications for understanding the relationship of chronic blast-related neurobehavioral syndromes in humans to neurodegenerative diseases.
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33
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Perez Garcia G, Perez GM, De Gasperi R, Gama Sosa MA, Otero-Pagan A, Pryor D, Abutarboush R, Kawoos U, Hof PR, Cook DG, Gandy S, Ahlers ST, Elder GA. Progressive Cognitive and Post-Traumatic Stress Disorder-Related Behavioral Traits in Rats Exposed to Repetitive Low-Level Blast. J Neurotrauma 2021; 38:2030-2045. [PMID: 33115338 DOI: 10.1089/neu.2020.7398] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Many military veterans who experienced blast-related traumatic brain injuries (TBI) in the conflicts in Iraq and Afghanistan currently have chronic cognitive and mental health problems including post-traumatic stress disorder (PTSD). Besides static symptoms, new symptoms may emerge or existing symptoms may worsen. TBI is also a risk factor for later development of neurodegenerative diseases. In rats exposed to repetitive low-level blast overpressure (BOP), robust and enduring cognitive and PTSD-related behavioral traits develop that are present for at least one year after blast exposure. Here we determined the time-course of the appearance of these traits by testing rats in the immediate post-blast period. Three cohorts of rats examined within the first eight weeks exhibited no behavioral phenotype or, in one cohort, features of anxiety. None showed the altered cued fear responses or impaired novel object recognition characteristic of the fully developed phenotype. Two cohorts retested 36 to 42 weeks after blast exposure exhibited the expanded behavioral phenotype including anxiety as well as altered cued fear learning and impaired novel object recognition. Combined with previous work, the chronic behavioral phenotype has been observed in six cohorts of blast-exposed rats studied at 3-4 months or longer after blast injury, and the three cohorts studied here document the progressive nature of the cognitive/behavioral phenotype. These studies suggest the existence of a latent, delayed emerging and progressive blast-induced cognitive and behavioral phenotype. The delayed onset has implications for the evolution of post-blast neurobehavioral syndromes in military veterans and its modeling in experimental animals.
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Affiliation(s)
- Georgina Perez Garcia
- Research and Development Service, James J. Peters Department of Veterans Affairs Medical Center, Bronx, New York, USA.,Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Gissel M Perez
- Research and Development Service, James J. Peters Department of Veterans Affairs Medical Center, Bronx, New York, USA
| | - Rita De Gasperi
- Research and Development Service, James J. Peters Department of Veterans Affairs Medical Center, Bronx, New York, USA.,Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Miguel A Gama Sosa
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,General Medical Research Service, James J. Peters Department of Veterans Affairs Medical Center, Bronx, New York, USA
| | - Alena Otero-Pagan
- Research and Development Service, James J. Peters Department of Veterans Affairs Medical Center, Bronx, New York, USA
| | - Dylan Pryor
- Research and Development Service, James J. Peters Department of Veterans Affairs Medical Center, Bronx, New York, USA
| | - Rania Abutarboush
- Department of Neurotrauma, Naval Medical Research Center, Silver Spring, Maryland, USA.,The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
| | - Usmah Kawoos
- Department of Neurotrauma, Naval Medical Research Center, Silver Spring, Maryland, USA.,The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
| | - Patrick R Hof
- Department of Nash Family Department of Neuroscience and Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Department of Geriatrics and Palliative Care, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Department of Mount Sinai Alzheimer's Disease Research Center and Ronald M. Loeb Center for Alzheimer's Disease, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - David G Cook
- Geriatric Research Education and Clinical Center, VA Puget Sound Health Care System, Seattle, Washington, USA.,Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Sam Gandy
- Research and Development Service, James J. Peters Department of Veterans Affairs Medical Center, Bronx, New York, USA.,Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Barbara and Maurice A. Deane Center for Wellness and Cognitive Health, and the Mount Sinai NFL Neurological Care Center, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Stephen T Ahlers
- Department of Neurotrauma, Naval Medical Research Center, Silver Spring, Maryland, USA
| | - Gregory A Elder
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Department of Mount Sinai Alzheimer's Disease Research Center and Ronald M. Loeb Center for Alzheimer's Disease, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Neurology Service, James J. Peters Department of Veterans Affairs Medical Center, Bronx, New York, USA
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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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Brain and blood biomarkers of tauopathy and neuronal injury in humans and rats with neurobehavioral syndromes following blast exposure. Mol Psychiatry 2021; 26:5940-5954. [PMID: 32094584 PMCID: PMC7484380 DOI: 10.1038/s41380-020-0674-z] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 12/31/2019] [Accepted: 01/30/2020] [Indexed: 12/14/2022]
Abstract
Traumatic brain injury (TBI) is a risk factor for the later development of neurodegenerative diseases that may have various underlying pathologies. Chronic traumatic encephalopathy (CTE) in particular is associated with repetitive mild TBI (mTBI) and is characterized pathologically by aggregation of hyperphosphorylated tau into neurofibrillary tangles (NFTs). CTE may be suspected when behavior, cognition, and/or memory deteriorate following repetitive mTBI. Exposure to blast overpressure from improvised explosive devices (IEDs) has been implicated as a potential antecedent for CTE amongst Iraq and Afghanistan Warfighters. In this study, we identified biomarker signatures in rats exposed to repetitive low-level blast that develop chronic anxiety-related traits and in human veterans exposed to IED blasts in theater with behavioral, cognitive, and/or memory complaints. Rats exposed to repetitive low-level blasts accumulated abnormal hyperphosphorylated tau in neuronal perikarya and perivascular astroglial processes. Using positron emission tomography (PET) and the [18F]AV1451 (flortaucipir) tau ligand, we found that five of 10 veterans exhibited excessive retention of [18F]AV1451 at the white/gray matter junction in frontal, parietal, and temporal brain regions, a typical localization of CTE tauopathy. We also observed elevated levels of neurofilament light (NfL) chain protein in the plasma of veterans displaying excess [18F]AV1451 retention. These findings suggest an association linking blast injury, tauopathy, and neuronal injury. Further study is required to determine whether clinical, neuroimaging, and/or fluid biomarker signatures can improve the diagnosis of long-term neuropsychiatric sequelae of mTBI.
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Otero MC, Rau HK, Shofer JB, Peskind ER, Pagulayan KF. Self-perceived irritability among OEF/OIF/OND veterans with a history of deployment-related mTBI: Associations with prospective memory and quality of life. Clin Neuropsychol 2020; 36:1384-1404. [PMID: 33327865 DOI: 10.1080/13854046.2020.1856413] [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: 10/22/2022]
Abstract
OBJECTIVE Examine relationships between self-perceived irritability, prospective memory, and quality of life (QOL) following mild traumatic brain injury (mTBI). Methods: 75 OEF/OIF/OND-era Veterans (56 deployment-related mTBI; 19 no history of TBI), were administered a battery of neuropsychological tests and self-report measures of mood and QOL. Self-perceived irritability was measured using the Neurobehavioral Symptom Inventory. Prospective memory (PM) was measured using the Memory for Intentions Test (MIST). Results: Self-perceived irritability was significantly higher for Veterans with, versus without, a history of deployment-related mTBI. Among Veterans with a history of mTBI, self-perceived irritability was inversely associated with PM performance, even after adjusting for PTSD severity. Greater self-perceived irritability was also associated with higher depressive symptoms and reduced QOL for perceived physical health, psychological health, social support, and environmental factors; however, only social support remained significant after adjusting for PTSD severity. Depression symptom severity was not significantly associated with PM, suggesting that PM may be uniquely related to self-perceived irritability rather than mood dysregulation more generally. Conclusions: Findings provide preliminary evidence of a relationship between PM and self-perceived irritability in Veterans with a history of mTBI. PM and irritability may be related via their mutual reliance on high-level cognitive control. Results illustrate possible cognitive and affective factors contributing to psychological and interpersonal challenges for this population. Future investigations with larger and more diverse samples are needed to replicate findings and explore potential mechanisms linking irritability and PM following mTBI.
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Affiliation(s)
- Marcela C Otero
- Department of Psychology, University of California, Berkeley, CA, USA.,Sierra Pacific Mental Illness Research, Education, and Clinical Center (MIRECC), Veterans Affairs (VA) Palo Alto Health Care System,Palo Alto, CA, USA.,Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Holly K Rau
- VA Northwest (VISN 20) MIRECC, VA Puget Sound Health Care System, Seattle, WA, USA
| | - Jane B Shofer
- VA Northwest (VISN 20) MIRECC, VA Puget Sound Health Care System, Seattle, WA, USA.,Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA
| | - Elaine R Peskind
- VA Northwest (VISN 20) MIRECC, VA Puget Sound Health Care System, Seattle, WA, USA.,Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA
| | - Kathleen F Pagulayan
- VA Northwest (VISN 20) MIRECC, VA Puget Sound Health Care System, Seattle, WA, USA.,Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA
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37
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D'Silva L, Devos H, Hunt SL, Chen J, Smith D, Rippee MA. Concussion symptoms experienced during driving may influence driving habits. Brain Inj 2020; 35:59-64. [PMID: 33297775 DOI: 10.1080/02699052.2020.1857839] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Objective: To examine the symptoms experienced and the change in driving habits in individuals with concussion.Materials and methods: A survey was created by a team of rehabilitation professionals who see persons with concussion in their clinics. The survey captured demographics, mechanism of injury, date of injury, symptoms experienced during driving, if drivers felt safe when driving, and changes in driving habits since the concussion. Non-parametric tests were used to compare symptoms experienced and driving habits across three groups which were created based on time since injury.Results: Of the 140 participants, 74% (104/140) had resumed driving after concussion; of these 27% (28/104) reported that they felt unsafe while driving. Forty-four per cent (46/104) experienced symptoms while driving, of which headache, and difficulty concentrating were the most common symptoms experienced throughout the concussion spectrum (acute to chronic phase). Most drivers (78/104, 75%) with concussion had changed their driving habits by driving less often and shorter distances, and by avoiding nighttime driving and heavy traffic areas.Conclusions: Headache and concentration problems were experienced by drivers regardless of the time since injury. Most drivers had made changes to their driving habits. Clinicians should consider the symptom burden patients experience and discuss driving restrictions to ensure driving safety.
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Affiliation(s)
- L D'Silva
- Department of Physical Therapy and Rehabilitation Science, University of Kansas Medical Center, Kansas, USA
| | - H Devos
- Department of Physical Therapy and Rehabilitation Science, University of Kansas Medical Center, Kansas, USA
| | - S L Hunt
- Department of Biostatistics and Data Science, University of Kansas Medical Center, Kansas, USA
| | - J Chen
- Center for Concussion Management, University of Kansas Health System, Kansas City, Kansas, USA
| | - D Smith
- Center for Concussion Management, University of Kansas Health System, Kansas City, Kansas, USA
| | - M A Rippee
- Center for Concussion Management, University of Kansas Health System, Kansas City, Kansas, USA
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38
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Carlozzi NE, Lange RT, French LM, Kallen MA, Boileau NR, Hanks RA, Nakase-Richardson R, Massengale JP, Sander AM, Hahn EA, Miner JA, Brickell TA. TBI-CareQOL military health care frustration in caregivers of service members/veterans with traumatic brain injury. Rehabil Psychol 2020; 65:360-376. [PMID: 31916805 PMCID: PMC7343601 DOI: 10.1037/rep0000305] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE Caregivers of service members/veterans (SMVs) encounter a number of barriers when navigating the military health care system. The purpose of this study was to develop a new measure to assess potential caregiver frustration with the systems of care and benefits in the United States Departments of Defense and Veterans Affairs. METHOD The TBI-CareQOL Military Health Care Frustration measure was developed using data from 317 caregivers of SMVs with TBI who completed an item pool comprised of 64 questions pertaining to anger or frustration with accessing military health care services. RESULTS Exploratory and confirmatory factor analyses supported the retention of 58 items. Constrained graded response model (GRM) overall fit and item fit analyses and differential item functioning investigations of age and education factors supported the retention of 43 items in the final measure. Expert review and GRM item calibration products were used to inform the selection of two 6-item static short forms (TBI-CareQOL Military Health Care Frustration-Self; TBI-CareQOL Military Health Care Frustration-Person with TBI) and to program the TBI-CareQOL Military Health Care Frustration computer adaptive test (CAT). Preliminary data supported the reliability (i.e., internal consistency and test-retest reliability) as well as the validity (i.e., convergent, discriminant, and known-groups) of the new measure. CONCLUSIONS The new TBI-CareQOL Military Health Care Frustration measure can be used to examine caregiver perceptions of and experience with the military health care system, to target improvements. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
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Affiliation(s)
- Noelle E. Carlozzi
- Department of Physical Medicine and Rehabilitation, University of Michigan; Ann Arbor, MI, USA
| | - Rael T. Lange
- Defense and Veterans Brain Injury Center, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Louis M. French
- Defense and Veterans Brain Injury Center, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Michael A. Kallen
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Nicholas R. Boileau
- Department of Physical Medicine and Rehabilitation, University of Michigan; Ann Arbor, MI, USA
| | - Robin A. Hanks
- Rehabilitation Institute of Michigan, Department of Psychology and Neuropsychology, Detroit, Michigan, USA
- Department of Physical Medicine and Rehabilitation, Wayne State University, Detroit, Michigan, USA
| | - Risa Nakase-Richardson
- MHBS, James A. Haley Veterans’ Hospital, Tampa, FL, USA
- Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | | | - Angelle M. Sander
- H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine & Harris Health System, Houston, TX, USA
- Brain Injury Research Center, TIRR Memorial Hermann, Houston, TX, USA
| | - Elizabeth A. Hahn
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jennifer A. Miner
- Department of Physical Medicine and Rehabilitation, University of Michigan; Ann Arbor, MI, USA
| | - Tracey A. Brickell
- Defense and Veterans Brain Injury Center, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
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Brickell TA, French LM, Lippa SM, Wright MM, Lange RT. Caring for a service member or Veteran following traumatic brain injury influences caregiver mental health. MILITARY PSYCHOLOGY 2020; 32:341-351. [PMID: 38536254 PMCID: PMC10013226 DOI: 10.1080/08995605.2020.1754149] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 04/06/2020] [Indexed: 10/23/2022]
Abstract
This study examined factors related to poor mental health in caregivers assisting service members and Veterans (SMV) following traumatic brain injury (TBI). Participants were 201 military caregivers (96.0% female; Age: M = 39.2 years, SD = 10.2) of SMVs following a mild, moderate, severe, or penetrating TBI. The SF-36v2 Health Survey, Caregiver Appraisal Scale, Mayo-Portland Adaptability Inventory-4, and Caregiver Questionnaire were completed. Caregivers were divided into two mental health groups: Poor Mental Health (n = 108) and Good Mental Health (n = 93). Factors related to poor caregiver mental health were worse general health and stress appraisal, less personal time, unmet needs, and greater financial and employment strain. Factors also related to poor caregiver mental health included assisting a SMV who had sustained a mild TBI, did not have significant hospital care, had post-traumatic stress disorder, depression, and/or anxiety, was experiencing greater functional disability, and was experiencing physical expressions of irritability, anger, and aggression (all p's<.05; d =.29 to d =.64; OR = 1.911 to OR = 4.984). For many military caregivers, poor mental health may be related to the SMVs ongoing comorbid mental health symptoms and less so neurological impairment related to the brain injury. TBI treatment programs require a holistic approach that addresses the behavioral health concerns of both SMVs and their caregivers.
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Affiliation(s)
- Tracey A. Brickell
- Defense and Veterans Brain Injury Center, Walter Reed National Military Medical Center, Bethesda, Maryland
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland
- Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Louis M. French
- Defense and Veterans Brain Injury Center, Walter Reed National Military Medical Center, Bethesda, Maryland
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland
- Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Sara M. Lippa
- Defense and Veterans Brain Injury Center, Walter Reed National Military Medical Center, Bethesda, Maryland
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Megan M. Wright
- Defense and Veterans Brain Injury Center, Walter Reed National Military Medical Center, Bethesda, Maryland
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Rael T. Lange
- Defense and Veterans Brain Injury Center, Walter Reed National Military Medical Center, Bethesda, Maryland
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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40
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Brickell TA, Wright MM, Lippa SM, Sullivan JK, Bailie JM, French LM, Lange RT. Resilience is associated with health-related quality of life in caregivers of service members and veterans following traumatic brain injury. Qual Life Res 2020; 29:2781-2792. [DOI: 10.1007/s11136-020-02529-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/12/2020] [Indexed: 11/30/2022]
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Lange RT, Lippa SM, Bailie JM, Wright M, Driscoll A, Sullivan J, Gartner R, Ramin D, Robinson G, Eshera Y, Gillow K, French LM, Brickell TA. Longitudinal trajectories and risk factors for persistent postconcussion symptom reporting following uncomplicated mild traumatic brain injury in U.S. Military service members. Clin Neuropsychol 2020; 34:1134-1155. [DOI: 10.1080/13854046.2020.1746832] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Rael T. Lange
- Defense and Veterans Brain Injury Center, Walter Reed National Military Medical Center, Bethesda, MD, USA
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD, USA
- University of British Columbia, Vancouver, Canada
| | - Sara M. Lippa
- Defense and Veterans Brain Injury Center, Walter Reed National Military Medical Center, Bethesda, MD, USA
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Jason M. Bailie
- Defense and Veterans Brain Injury Center, Naval Hospital Camp Pendleton, CA, USA
| | - Megan Wright
- Defense and Veterans Brain Injury Center, Walter Reed National Military Medical Center, Bethesda, MD, USA
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Angela Driscoll
- Defense and Veterans Brain Injury Center, Walter Reed National Military Medical Center, Bethesda, MD, USA
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Jamie Sullivan
- Defense and Veterans Brain Injury Center, Walter Reed National Military Medical Center, Bethesda, MD, USA
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Rachel Gartner
- Defense and Veterans Brain Injury Center, Walter Reed National Military Medical Center, Bethesda, MD, USA
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Daniel Ramin
- Defense and Veterans Brain Injury Center, Walter Reed National Military Medical Center, Bethesda, MD, USA
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Gabrielle Robinson
- Defense and Veterans Brain Injury Center, Walter Reed National Military Medical Center, Bethesda, MD, USA
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Yasmine Eshera
- Defense and Veterans Brain Injury Center, Walter Reed National Military Medical Center, Bethesda, MD, USA
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Kelly Gillow
- Defense and Veterans Brain Injury Center, Walter Reed National Military Medical Center, Bethesda, MD, USA
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Louis M. French
- Defense and Veterans Brain Injury Center, Walter Reed National Military Medical Center, Bethesda, MD, USA
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD, USA
- Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Tracey A. Brickell
- Defense and Veterans Brain Injury Center, Walter Reed National Military Medical Center, Bethesda, MD, USA
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD, USA
- Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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Brickell TA, Cotner BA, French LM, Carlozzi NE, O’Connor DR, Nakase-Richardson R, Lange RT. Severity of military traumatic brain injury influences caregiver health-related quality of life. Rehabil Psychol 2020; 65:2020-04060-001. [PMID: 31971431 PMCID: PMC7375900 DOI: 10.1037/rep0000306] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE/OBJECTIVE To examine the influence of traumatic brain injury (TBI) severity on the health-related quality of life of caregivers providing care to service members/veterans (SMV) following a TBI. Research Method/Design: Thirty caregivers (90.0% female; 70.0% spouse; age: M = 39.5 years, SD = 10.7) of SMVs who sustained a mild, moderate, severe, or penetrating TBI were recruited from Walter Reed National Military Medical Center and via community outreach to participate in one of six focus groups. Caregivers were classified into 3 TBI severity/caregiver groups: (a) moderate/severe/penetrating TBI caregiver group (n = 11); (b) mild TBI caregiver group (n = 10); and (c) equivocal TBI caregiver group (n = 9). Thematic analysis using a constant comparative approach was conducted with qualitative analysis software to identify common themes across the 3 severity/caregiver groups. RESULTS Eleven themes emerged: no time for self/needs last (83.3%), poor physical health (80.0%), increased stress/anxiety (76.7%), social isolation/loneliness (66.7%), lack of access to services (50.0%), impact on family life (46.7%), sleep issues (46.7%), finances/employment (36.7%), depression (30.0%), exhaustion (30.0%), and anger (16.7%). Exploratory pairwise comparisons revealed a higher proportion of the moderate/severe/penetrating TBI group endorsed 7 of the 11 themes (no time for self/needs last, increased stress/anxiety, impact on family life, sleep issues, finances/employment, exhaustion, anger, and increased stress/anxiety) compared with the other 2 groups. CONCLUSIONS/IMPLICATIONS It is important that caregivers of SMVs receive long-term support in their caregiving and parenting roles. Further work is required to understand the challenges caregivers experience in accessing services they need and how to effectively meet their needs across the care continuum. (PsycINFO Database Record (c) 2020 APA, all rights reserved).
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Affiliation(s)
- Tracey A. Brickell
- Defense and Veterans Brain Injury Center, Walter Reed National Military Medical Center, Bethesda, MD, USA
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Bridget A. Cotner
- Rehabilitation Outcomes Research Section, Research Service, James A Haley Veterans Hospital, Tampa, Florida, USA
- Defense and Veterans Brain Injury Center, James A. Haley Veterans Hospital, Tampa, Florida, USA
| | - Louis M. French
- Defense and Veterans Brain Injury Center, Walter Reed National Military Medical Center, Bethesda, MD, USA
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Noelle E. Carlozzi
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, Michigan, USA
| | - Danielle R. O’Connor
- Rehabilitation Outcomes Research Section, Research Service, James A Haley Veterans Hospital, Tampa, Florida, USA
- Defense and Veterans Brain Injury Center, James A. Haley Veterans Hospital, Tampa, Florida, USA
| | - Risa Nakase-Richardson
- Mental Health Behavioral Sciences, James A. Haley Veterans Hospital, Tampa, Florida, USA
- Morsani College of Medicine, Department of Internal Medicine, Division of Pulmonary and Sleep Medicine, University of South Florida, Tampa, Florida USA
| | - Rael T. Lange
- Defense and Veterans Brain Injury Center, Walter Reed National Military Medical Center, Bethesda, MD, USA
- University of British Columbia, Vancouver, British Columbia, Canada
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Urosevich TG, Boscarino JJ, Hoffman SN, Kirchner HL, Figley CR, Adams RE, Withey CA, Boscarino JA. Visual Dysfunction and Associated Co-morbidities as Predictors of Mild Traumatic Brain Injury Seen Among Veterans in Non-VA Facilities: Implications for Clinical Practice. Mil Med 2019; 183:e564-e570. [PMID: 29800265 DOI: 10.1093/milmed/usy102] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Accepted: 04/24/2018] [Indexed: 12/15/2022] Open
Abstract
Introduction Traumatic brain injury (TBI) and post-traumatic stress disorder are considered the signature injuries of the Iraq and Afghanistan conflicts. With the extensive use of improvised explosive devices by the enemy, the concussive effects from blast have a greater potential to cause mild TBI (mTBI) in military Service Members. These mTBI can be associated with other physical and psychological health problems, including mTBI-induced visual processing and eye movement dysfunctions. Our study assessed if any visual dysfunctions existed in those surveyed in non-Veterans Administration (VA) facilities who had suffered mTBI (concussive effect), in addition to the presence of concussion-related co-morbidities. Materials and Methods As part of a larger study involving veterans from different service eras, we surveyed 235 Veterans who had served during the Iraq and/or Afghanistan conflict era. Data for the study were collected using diagnostic telephone interviews of these veterans who were outpatients of the Geisinger Health System. We assess visual dysfunction in this sample and compare visual dysfunctions of those who had suffered a mTBI (concussive effect), as well as co-morbidities, with those in the cohort who had not suffered concussion effects. Results Of those veterans who experienced visual dysfunctions, our results reflected that the visual symptoms were significant for concussion with the subjects surveyed, even though all had experienced a mTBI event greater than five years ago. Although we did find an association with concussion and visual symptoms, the association for concussion was strongest with the finding of greater than or equal to three current TBI symptoms, therefore we found this to be the best predictor of previous concussion among the veterans. Conclusions Veterans from the Iraq/Afghanistan era who had suffered concussive blast effects (mTBI) can present with covert visual dysfunction as well as additional physical and psychological health problems. The primary eye care providers, especially those in a non-military/VA facility, who encounter these veterans need to be aware of the predictors of mTBI, with the aim of uncovering visual dysfunctions and other associated co-morbidities.
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Affiliation(s)
- Thomas G Urosevich
- Ophthalmology Service, Geisinger Clinic, 126 Market Way, Mount Pocono, PA
| | - Joseph J Boscarino
- Clinical Psychology Department, William James College, 1 Wells Avenue, Newton, MA
| | - Stuart N Hoffman
- Department of Sleep Medicine, Geisinger Clinic, 100N. Academy Avenue, Danville, PA
| | - H Lester Kirchner
- Biomedical and Translational Informatics, Geisinger Clinic, 100N. Academy Avenue, Danville, PA
| | - Charles R Figley
- School of Social Work, Tulane University, 127 Elk Place, New Orleans, LA
| | - Richard E Adams
- Department of Sociology, Kent State University, 215 Merrill Hall, Kent, Ohio
| | - Carrie A Withey
- Department of Epidemiology & Health Services Research, Geisinger Clinic, 100N. Academy Avenue, MC 44-00, Danville, PA
| | - Joseph A Boscarino
- Department of Epidemiology & Health Services Research, Geisinger Clinic, 100N. Academy Avenue, MC 44-00, Danville, PA
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Elder GA, Ehrlich ME, Gandy S. Relationship of traumatic brain injury to chronic mental health problems and dementia in military veterans. Neurosci Lett 2019; 707:134294. [PMID: 31141716 DOI: 10.1016/j.neulet.2019.134294] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 04/25/2019] [Accepted: 05/24/2019] [Indexed: 02/06/2023]
Abstract
Traumatic brain injury (TBI) is an unfortunately common event in military life. The conflicts in Iraq and Afghanistan have increased public awareness of TBI in the military. Certain injury mechanisms are relatively unique to the military, the most prominent being blast exposure. Blast-related mild TBI (mTBI) has been of particular concern in the most recent veterans although controversy remains concerning separation of the postconcussion syndrome associated with mTBI from post-traumatic stress disorder. TBI is also a risk factor for the development of neurodegenerative diseases including chronic traumatic encephalopathy (CTE) and Alzheimer's disease (AD). AD, TBI, and CTE are all associated with chronic inflammation. Genome wide association studies (GWAS) have identified multiple genetic loci associated with AD that implicate inflammation and - in particular microglia - as key modulators of the AD- and TBI-related degenerative processes. At the molecular level, recent studies have identified TREM2 and TYROBP/DAP12 as components of a key molecular hub linking inflammation and microglia to the pathophysiology of AD and possibly TBI. Evidence concerning the relationship of TBI to chronic mental health problems and dementia is reviewed in the context of its relevance to military veterans.
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Affiliation(s)
- Gregory A Elder
- Neurology Service, James J. Peters Department of Veterans Affairs Medical Center, 130 West Kingsbridge Road, Bronx, NY 10468, USA; Department of Neurology, Icahn School of Medicine at Mount Sinai, One Gustave Levy Place, New York, NY 10029, USA; Department of Psychiatry, Icahn School of Medicine at Mount Sinai, One Gustave Levy Place, New York, NY 10029, USA; Mount Sinai Alzheimer's Disease Research Center and the Ronald M. Loeb Center for Alzheimer's Disease, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA.
| | - Michelle E Ehrlich
- Department of Neurology, Icahn School of Medicine at Mount Sinai, One Gustave Levy Place, New York, NY 10029, USA; Mount Sinai Alzheimer's Disease Research Center and the Ronald M. Loeb Center for Alzheimer's Disease, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; Department of Pediatrics, Icahn School of Medicine at Mount Sinai, One Gustave Levy Place, New York, NY 10029, USA
| | - Sam Gandy
- Department of Neurology, Icahn School of Medicine at Mount Sinai, One Gustave Levy Place, New York, NY 10029, USA; Department of Psychiatry, Icahn School of Medicine at Mount Sinai, One Gustave Levy Place, New York, NY 10029, USA; Mount Sinai Alzheimer's Disease Research Center and the Ronald M. Loeb Center for Alzheimer's Disease, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; Research and Development Service, James J. Peters Department of Veterans Affairs Medical Center, 130 West Kingsbridge Road, Bronx, NY 10468, USA; NFL Neurological Care Center, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
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Karr JE, Rau HK, Shofer JB, Hendrickson RC, Peskind ER, Pagulayan KF. Variables associated with subjective cognitive change among Iraq and Afghanistan war Veterans with blast-related mild traumatic brain injury. J Clin Exp Neuropsychol 2019; 41:680-693. [DOI: 10.1080/13803395.2019.1611740] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Justin E. Karr
- Department of Psychology, University of Victoria, Victoria, British Columbia, Canada
- Veterans Affairs Northwest Network Mental Illness, Research, Education, and Clinical Center, Veterans Affairs Puget Sound Healthcare System, Seattle, WA, USA
| | - Holly K. Rau
- Veterans Affairs Northwest Network Mental Illness, Research, Education, and Clinical Center, Veterans Affairs Puget Sound Healthcare System, Seattle, WA, USA
| | - Jane B. Shofer
- Veterans Affairs Northwest Network Mental Illness, Research, Education, and Clinical Center, Veterans Affairs Puget Sound Healthcare System, Seattle, WA, USA
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA
| | - Rebecca C. Hendrickson
- Veterans Affairs Northwest Network Mental Illness, Research, Education, and Clinical Center, Veterans Affairs Puget Sound Healthcare System, Seattle, WA, USA
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA
| | - Elaine R. Peskind
- Veterans Affairs Northwest Network Mental Illness, Research, Education, and Clinical Center, Veterans Affairs Puget Sound Healthcare System, Seattle, WA, USA
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA
| | - Kathleen F. Pagulayan
- Veterans Affairs Northwest Network Mental Illness, Research, Education, and Clinical Center, Veterans Affairs Puget Sound Healthcare System, Seattle, WA, USA
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA
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Gama Sosa MA, De Gasperi R, Perez Garcia GS, Perez GM, Searcy C, Vargas D, Spencer A, Janssen PL, Tschiffely AE, McCarron RM, Ache B, Manoharan R, Janssen WG, Tappan SJ, Hanson RW, Gandy S, Hof PR, Ahlers ST, Elder GA. Low-level blast exposure disrupts gliovascular and neurovascular connections and induces a chronic vascular pathology in rat brain. Acta Neuropathol Commun 2019; 7:6. [PMID: 30626447 PMCID: PMC6327415 DOI: 10.1186/s40478-018-0647-5] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 12/06/2018] [Indexed: 01/15/2023] Open
Abstract
Much concern exists over the role of blast-induced traumatic brain injury (TBI) in the chronic cognitive and mental health problems that develop in veterans and active duty military personnel. The brain vasculature is particularly sensitive to blast injury. The aim of this study was to characterize the evolving molecular and histologic alterations in the neurovascular unit induced by three repetitive low-energy blast exposures (3 × 74.5 kPa) in a rat model mimicking human mild TBI or subclinical blast exposure. High-resolution two-dimensional differential gel electrophoresis (2D-DIGE) and matrix-assisted laser desorption/ionization (MALDI) mass spectrometry of purified brain vascular fractions from blast-exposed animals 6 weeks post-exposure showed decreased levels of vascular-associated glial fibrillary acidic protein (GFAP) and several neuronal intermediate filament proteins (α-internexin and the low, middle, and high molecular weight neurofilament subunits). Loss of these proteins suggested that blast exposure disrupts gliovascular and neurovascular interactions. Electron microscopy confirmed blast-induced effects on perivascular astrocytes including swelling and degeneration of astrocytic endfeet in the brain cortical vasculature. Because the astrocyte is a major sensor of neuronal activity and regulator of cerebral blood flow, structural disruption of gliovascular integrity within the neurovascular unit should impair cerebral autoregulation. Disrupted neurovascular connections to pial and parenchymal blood vessels might also affect brain circulation. Blast exposures also induced structural and functional alterations in the arterial smooth muscle layer. Interestingly, by 8 months after blast exposure, GFAP and neuronal intermediate filament expression had recovered to control levels in isolated brain vascular fractions. However, despite this recovery, a widespread vascular pathology was still apparent at 10 months after blast exposure histologically and on micro-computed tomography scanning. Thus, low-level blast exposure disrupts gliovascular and neurovascular connections while inducing a chronic vascular pathology.
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Abstract
Although concussions are common, they are complex, variable, and not entirely understood in terms of pathophysiology and treatment. The incidence of concussion is expected to continue to rise with the increased participation of youth in sports and improved awareness. The role of orthopedic surgeons in concussion management is murky. However, the existing literature does provide a foundation from which orthopedic surgeons who are exposed to concussed patients can function. [Orthopedics. 2019; 42(1):12-21.].
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Swan AA, Amuan ME, Morissette SB, Finley EP, Eapen BC, Jaramillo CA, Pugh MJ. Long-term physical and mental health outcomes associated with traumatic brain injury severity in post-9/11 veterans: A retrospective cohort study. Brain Inj 2018; 32:1637-1650. [DOI: 10.1080/02699052.2018.1518539] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Alicia A. Swan
- South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Megan E. Amuan
- Center for Health Care Organization and Implementation Research, Edith Nourse Rogers VA Medical Center, Bedford, MA, USA
| | - Sandra B. Morissette
- Department of Psychology, The University of Texas at San Antonio, San Antonio, TX, USA
| | - Erin P. Finley
- Department of Psychology, The University of Texas at San Antonio, San Antonio, TX, USA
| | | | | | - Mary Jo Pugh
- IDEAS 2.0 Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Division of Epidemiology, Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
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Brickell TA, French LM, Lippa SM, Lange RT. Burden among caregivers of service members and veterans following traumatic brain injury. Brain Inj 2018; 32:1541-1548. [DOI: 10.1080/02699052.2018.1503328] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Tracey A. Brickell
- Research Division, Defense and Veterans Brain Injury Center, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Louis M. French
- Research Division, Defense and Veterans Brain Injury Center, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Sara M. Lippa
- Research Division, Defense and Veterans Brain Injury Center, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Rael T. Lange
- Research Division, Defense and Veterans Brain Injury Center, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- University of British Columbia, Vancouver, British Columbia, Canada
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