Community Reintegration Problems Among Veterans and Active Duty Service Members With Traumatic Brain Injury

Impact of Post-Traumatic Epilepsy on Mental Health and Multidimensional Outcome and Quality of Life: An NIDILRR TBIMS Study

Traumatic brain injury (TBI) and subsequent post-traumatic epilepsy (PTE) often impair daily activities and mental health (MH), which contribute to long-term TBI-related disability. PTE also affects driving capacity, which impacts functional independence, community participation, and satisfaction with life (SWL). However, studies evaluating the collective impact of PTE on multidimensional outcomes are lacking. Thus, we generated a model to investigate how PTE after moderate-to-severe (ms)TBI affects TBI-associated impairments, limits activities and participation, and influences SWL. Of 5108 participants with msTBI enrolled into the National Institute for Disability, Independent Living, and Rehabilitation Research TBI Model Systems between 2010 and 2018 and with seizure-event data available at year-1 post-TBI, 1214 had complete outcome data and 1003 had complete covariate data used for analysis. We constructed a conceptual framework illustrating hypothesized interrelationships between year-1 PTE, driving status, functional independence measure (FIM), depression and anxiety, as well as year-2 participation, and SWL. We performed univariate and multivariable linear and logistic regressions. A covariate-adjusted structural equation model (SEM), using the lavaan package (R), assessed the conceptual framework's suitability in establishing PTE links with outcomes 1-2 years post-injury. Multiple parameters were evaluated to assess SEM fit. Year-1 PTE was correlated with year-1 FIM motor (standardized coefficient, βstd = -0.112, p = 0.007) and showed a trend level association with year-1 FIM cognition (βstd = -0.070, p = 0.079). Individuals with year-1 PTE were less likely to drive independently at year 1 (βstd = -0.148, p < 0.001). In addition, FIM motor (βstd = 0.323, p < 0.001), FIM cognition (βstd = 0.181, p = 0.012), and anxiety (βstd = -0.135, p = 0.024) influenced driving status. FIM cognition was associated with year-1 depression (βstd = 0.386, p < 0.001) and year-1 anxiety (βstd = 0.396, p < 0.001), whereas year-1 FIM motor (βstd = 0.186, p = 0.003), depression (βstd = -0.322, p = 0.011), and driving status (βstd = 0.233, p < 0.001) directly affected year-2 objective life participation metrics. Moreover, year-1 depression (βstd = -0.382, p = 0.001) and year-2 participation (βstd = 0.160, p < 0.001) had direct effects on year-2 SWL. SWL was influenced indirectly by year-1 variables, including functional impairment, anxiety, and driving status-factors that impacted year-2 participation directly or indirectly, and consequently year-2 SWL, forming a complex relationship with year-1 PTE. A sensitivity analysis SEM showed that the number of MH disorders was associated with participation and SWL (p < 0.001), and this combined MH variable was directly related to driving status (p < 0.02). Developing PTE during year-1 after msTBI affects multiple aspects of life. PTE effects extend to motor and cognitive abilities, driving capabilities, and indirectly, to life participation and overall SWL. The implications underscore the crucial need for effective PTE management strategies during the first year post-TBI to minimize the adverse impact on factors influencing multidimensional year-2 participation and SWL outcomes. Addressing transportation barriers is warranted to enhance the well-being of those with PTE and msTBI, emphasizing a holistic approach. Further research is recommended for SEM validation studies, including testing causal inference pathways that might inform future prevention and treatment trials.

Neurobehavioral Symptoms Partially Mediate the Effects of Depression and PTSD on Participation for Veterans With Mild Traumatic Brain Injury: A Cross-Sectional Study

OBJECTIVE

To examine whether neurobehavioral symptoms mediate the relationship between comorbid mental health conditions (major depressive disorder [MDD] and/or posttraumatic stress disorder [PTSD]) and participation restriction among Veterans with mild traumatic brain injury (mTBI).

SETTING

Veterans Health Administration (VHA).

PARTICIPANTS

National sample of Veterans with mTBI who received VHA outpatient care between 2012 and 2020.

DESIGN

Secondary data analysis of VHA clinical data. We specified a latent variable path model to estimate relationships between: (1) comorbid mental health conditions and 3 latent indicators of neurobehavioral symptoms (vestibular-sensory; mood-behavioral; cognitive); (2) latent indicators of neurobehavioral symptoms and 2 latent indicators of participation restriction (social and community participation; productivity); and (3) comorbid mental health conditions and participation restriction.

MAIN MEASURES

International Classification of Diseases codes, Neurobehavioral Symptom Inventory, and Mayo-Portland Adaptability Inventory Participation Index to measure mental health conditions, neurobehavioral symptoms, and participation restrictions, respectively.

RESULTS

Indirect effect estimates indicated that comorbid MDD and/or PTSD was associated with greater social and community participation restrictions, as mediated by mood-behavioral (β = .22-.33; 99% CI 0.18-0.4; small to medium effect) and cognitive symptoms (β = .08-.13; 99% CI 0.05-0.18; small effect), and with greater productivity restrictions, as mediated by vestibular-sensory (β = .06-.11; 99% CI 0.04-0.15; small effect) and cognitive symptoms (β = .08-.13; 99% CI 0.05-0.18; small effect). Direct effect estimates indicated that comorbid MDD and/or PTSD was associated with greater challenges with both social and community participation (β = .19-.40; 99% CI 0.12-0.49; small to medium effect) and productivity (β = .08-.44; 99% CI -0.02 to 0.55; small to medium effect).

CONCLUSION

Neurobehavioral symptoms partially mediated the impact of MDD and/or PTSD on participation restrictions among Veterans with mTBI. These findings advance the understanding of explanatory mechanisms underlying participation challenges among Veterans with comorbid mTBI and mental health challenges, thereby informing the development of tailored intervention strategies.

Cognitive Performance is Associated With 1-Year Participation and Life Satisfaction Outcomes: A Traumatic Brain Injury Model Systems Study

OBJECTIVE

To determine, in persons with traumatic brain injury (TBI), the association between cognitive change after inpatient rehabilitation discharge and 1-year participation and life satisfaction outcomes.

DESIGN

Secondary analysis of prospectively collected TBI Model Systems (TBIMS) data.

SETTING

Inpatient rehabilitation and community.

PARTICIPANTS

499 individuals with TBI requiring inpatient rehabilitation who completed the Brief Test of Adult Cognition by Telephone (BTACT) at inpatient rehabilitation discharge (ie, baseline) and 1-year postinjury.

MAIN OUTCOME MEASURES

Participation Assessment with Recombined Tools-Objective (PART-O) and Satisfaction with Life Scale (SWLS).

RESULTS

Of 2,840 TBIMS participants with baseline BTACT, 499 met inclusion criteria (mean [standard deviation] age = 45 [19] years; 72% male). Change in BTACT executive function (EF) was not associated with 1-year participation (PART-O; β = 0.087, 95% CI [-0.004, 0.178], P = .061) when it was the sole model predictor. Change in BTACT episodic memory (EM) was associated with 1-year participation (β = 0.096, [0.007, 0.184], P = .035), but not after adjusting for demographic, clinical, and functional status covariates (β = 0.067, 95% CI [-0.010, 0.145], P = .089). Change in BTACT EF was not associated with life satisfaction total scores (SWLS) when it was the sole model predictor (β = 0.091, 95% CI [-0.001, 0.182], P = .0503). Change in BTACT EM was associated with 1-year life satisfaction before (β = 0.114, 95% CI [0.025, 0.202], P = .012) and after adjusting for covariates (β = 0.103, [0.014, 0.191], P = .023). In secondary analyses, change in BTACT EF was associated with PART-O Social Relations and Out and About subdomains before (Social Relations: β = 0.127, 95% CI [0.036, 0.217], P = .006; Out and About: β = 0.141, 95% CI [0.051, 0.232], P = .002) and after (Social Relations: β = 0.168, 95% CI [0.072, 0.265], P < .002; Out and About: β = 0.156, 95% CI [0.061, 0.252], P < .002) adjusting for functional status and further adjusting for covariates (Social Relations: β = 0.127, 95% CI [0.040, 0.214], P = .004; Out and About: β = 0.136, 95% CI [0.043, 0.229], P = .004). However, only the models adjusting for functional status remained significant after multiple comparison correction (ie, Bonferroni-adjusted alpha level = 0.002).

CONCLUSION

EF gains during the first year after TBI were related to 1-year social and community participation. Gains in EM were associated with 1-year life satisfaction. These results highlight the potential benefit of cognitive rehabilitation after inpatient rehabilitation discharge and the need for interventions targeting specific cognitive functions that may contribute to participation and life satisfaction after TBI.

Emotional, Behavioral, and Cognitive Symptom Associations With Community Participation in Chronic Traumatic Brain Injury

OBJECTIVES

To determine the association between self-reported emotional and cognitive symptoms and participation outcomes in chronic traumatic brain injury (TBI) and to explore the relative contribution of self-reported versus performance-based cognition to participation outcomes.

SETTING

Community.

PARTICIPANTS

Community-dwelling adults ( n = 135) with a lifetime history of mild to severe TBI.

DESIGN

Secondary analysis of a cross-sectional study on neurobehavioral symptoms in chronic TBI.

MAIN MEASURES

Behavioral Assessment Screening Tool (BAST) (Negative Affect, Fatigue, Executive Dysfunction, Impulsivity, Substance Abuse subscales) measured self-reported neurobehavioral symptoms; Participation Assessment with Recombined Tools (Productivity, Social Relations, and Out and About) measured self-reported participation outcomes; and Brief Test of Adult Cognition by Telephone (BTACT) measured performance-based cognition (Episodic Memory and Executive Function summary scores) in a subsample ( n = 40).

RESULTS

The BAST Executive Dysfunction was significantly associated with less frequent participation and had the strongest effect on participation in all participation domains. No other BAST subscales were associated with participation, after adjusting for all subscale scores and age, with the exception of BAST Impulsivity, which was associated with more frequent Social Relationships. Exploratory analysis in the sample including the BTACT revealed that, after accounting for subjective Executive Dysfunction using the BAST, performance-based Executive Function was associated with Productivity and Working Memory was associated with Social Relations, but neither was associated with being Out and About; the BAST Executive Dysfunction remained significant in all models even after including BTACT scores.

CONCLUSIONS

Self-reported Executive Dysfunction contributed to participation outcomes after mild to severe TBI in community-dwelling adults, whereas self-reported emotional and fatigue symptoms did not. Performance-based cognition measures may capture different variability in participation after injury.

Neuropsychological functioning, neurobehavioral symptoms, and community reintegration in unstably housed veterans with mental health conditions

Objective: Returning Veterans often have conditions (e.g. posttraumatic stress disorder [PTSD], depression, and history of traumatic brain injury [TBI]) associated with cognitive dysfunction and problems with work, school, housing, and relationships. Rehabilitative efforts in Veterans aim to promote community reintegration, or successful adjustment in one's home, community, and desired social roles. We examined associations between neuropsychological performance, neurobehavioral symptoms, and community reintegration in Veterans. Method: 89 Iraq/Afghanistan Veterans at risk for homelessness and receiving residential mental healthcare completed a neuropsychological assessment and the Community Reintegration for Service Members-Computer Adaptive Test (CRIS-CAT). Neuropsychological components were derived using Principal Component Analysis. Bivariate Pearson correlations between neuropsychological variables, neurobehavioral symptoms, and CRIS-CAT scales (Extent of Participation, Perceived Limitations, and Satisfaction) were used to determine significant correlates of community reintegration. Regression models were used to examine associations between bivariate-significant neuropsychological components, neurobehavioral symptoms, and CRIS-CAT scales. Results: Bivariate analyses revealed that better community reintegration was associated with better performance in attention/executive functioning and fewer neurobehavioral symptoms. Three regression models examining predictors of variance in Extent of Participation, Perceived Limitations, and Satisfaction in community reintegration were statistically significant overall, with only fewer affective symptoms emerging as significantly and uniquely associated with greater participation and greater satisfaction in community functioning. Conclusions: Veterans with fewer affective symptoms reported greater participation and satisfaction with community functioning. Future longitudinal research examining associations between neurobehavioral symptoms, cognition, and risk factors of poorer community reintegration in unstably housed Veterans is warranted.

Subject and Family Perspectives from the Central Thalamic Deep Brain Stimulation Trial for Traumatic Brain Injury: Part II

This is the second paper in a two-part series describing subject and family perspectives from the CENTURY-S (CENtral Thalamic Deep Brain Stimulation for the Treatment of Traumatic Brain InjURY-Safety) first-in-human invasive neurological device trial to achieve cognitive restoration in moderate to severe traumatic brain injury (msTBI). To participate, subjects were independently assessed to formally establish decision-making capacity to provide voluntary informed consent. Here, we report on post-operative interviews conducted after a successful trial of thalamic stimulation. All five msTBI subjects met a pre-selected primary endpoint of at least a 10% improvement in completion time on Trail-Making-Test Part B, a marker of executive function. We describe narrative responses of subjects and family members, refracted against that success. Interviews following surgery and the stimulation trial revealed the challenge of adaptation to improvements in cognitive function and emotional regulation as well as altered (and restored) relationships and family dynamics. These improvements exposed barriers to social reintegration made relevant by recoveries once thought inconceivable. The study's success sparked concerns about post-trial access to implanted devices, financing of device maintenance, battery replacement, and on-going care. Most subjects and families identified the need for supportive counseling to adapt to the new trajectory of their lives.

Vocational Outcomes of Service Members and Veterans After Traumatic Brain Injury: A Scoping Review

OBJECTIVE

The purpose of this scoping review was to evaluate the current literature related to vocational outcomes among US service members and veterans with traumatic brain injury (TBI).

METHODS

Seven research databases (Ovid MEDLINE, PsycINFO, EMBASE, CINAHL Plus, Cochrane Library, Scopus, and SPORTDiscus) were queried for human studies between the database inception and February, 2020. We included studies that focused on US service members and veterans who sustained a TBI and their vocational outcomes. Conference abstracts, systematic reviews, literature reviews, editorials, consensus reports, commentaries, dissertations, and qualitative studies were excluded. Two rounds of independent reviews were performed. Details of study design, intervention, and vocational outcomes were recorded.

RESULTS

The search yielded 5667 articles; 48 articles met inclusion criteria. Forty-three studies were observational (90%), and 5 were randomized controlled trials. A majority of interventions were in the outpatient setting (71%). Interventions related to return to work and duty utilized physical therapy and occupational therapy to address cognitive skills and functional deficits and provide supportive employment.

CONCLUSION

Community reintegration research among service members and veterans with brain injuries is underdeveloped. Because of heterogeneity of severity and smaller sample sizes, no consensus was reached on interventions that improve vocational outcomes. Evidence thus far suggests that future studies should incorporate an interdisciplinary team approach beyond physical therapy and occupational therapy, longer-term outcomes, and sample subgroups.

Associations between Post-Traumatic stress disorder symptoms and automobile driving behaviors: A review of the literature

Human factors are responsible for most motor vehicle accidents that occur on the road. Recent work suggests that symptoms of posttraumatic stress disorder (PTSD) are linked to reduced driving safety, yet none have provided a comprehensive review of this small, emerging literature. The present review identified twenty-two studies reporting associations between PTSD and driving behaviors. Among these, longitudinal designs (k = 3) and studies using objective driving performance measures (e.g., simulators) (k = 2) were rare. Most studies (k = 18) relied on brief screener measures of PTSD status/symptoms or a prior chart diagnosis, while few used a standardized structured interview measure to determine PTSD status (k = 4), and only a small number of studies assessed PTSD symptom clusters (k = 7). PTSD was most frequently associated with increased rates of hostile driving behaviors (e.g., cutting off others), unintentional driving errors (e.g., lapses in attention) and negative thoughts and emotions experienced behind the wheel. Findings regarding risk of motor vehicle accident and driving-related legal issues were variable, however relatively few studies (k = 5) explored these constructs. Future directions are discussed, including the need for work focused on concurrent PTSD symptom/driving-related changes, more comprehensive PTSD and driving assessment, and consideration of the contributions of comorbid traumatic brain injury history and other neurological and psychiatric conditions on driving outcomes.

Childhood Trauma Differentially Impacts Depression and Stress Associations with Reintegration Challenges Among Post-9/11 U.S. Veterans

BACKGROUND

Post-9/11 veterans exhibit high prevalence of deployment stress, psychological conditions, and traumatic brain injury (TBI) which impact reintegration, especially among those with a history of interpersonal early life trauma (I-ELT). The relative importance of each risk factor is unclear.

PURPOSE

We examined major deployment and clinical exposures of reintegration challenges among veterans with and without I-ELT.

METHOD

We analyzed cross-sectional data of 155 post-9/11 veterans from the Translational Research Center for TBI and Stress Disorders study.

FINDINGS

Depression severity had the strongest association with reintegration challenges, followed by posttraumatic stress disorder (PTSD) severity, post-deployment stress, and deployment safety concerns. Deployment safety concerns had a stronger, significant association among veterans with I-ELT. In nearly every model, PTSD and depression severities were weaker for veterans with I-ELT, compared to those without.

DISCUSSION

Clinicians should consider the relative risk of concurrent clinical conditions and trauma histories when considering veterans' reintegration needs.

Predictors of Driving Status in Service Members and Veterans at 1 Year Posttraumatic Brain Injury: A VA TBI Model Systems Study

OBJECTIVE

To identify predictors of driving status in service members and veterans 1 year following a traumatic brain injury (TBI).

SETTING

The 5 Department of Veterans Affairs (VA) Polytrauma Rehabilitation Centers (PRCs).

PARTICIPANTS

A total of 471 service members and veterans (128 with mild/complicated mild TBI and 343 with moderate/severe TBI) who received TBI-focused inpatient rehabilitation at one of the VA PRCs and who participated in a 1-year postinjury follow-up assessment.

DESIGN

Secondary analysis from the Department of Veterans Affairs Polytrauma Rehabilitation Centers Traumatic Brain Injury Model Systems (VA PRC TBIMS) national database.

MAIN MEASURES

Primary outcome was a single item that assessed driving status at 1 year postinjury. Predictor variables included demographics; sensory impairment, substance use, and employment status at time of injury; PTSD symptoms reported at study enrollment; and functional impairment rated at rehabilitation discharge.

RESULTS

In unadjusted bivariate analyses, among those with a mild/complicated mild TBI, older age and greater functional impairment were associated with lower likelihood of driving. Among those with a moderate/severe TBI, discharge to a nonprivate residence, greater functional impairment, and higher PTSD symptoms were linked to lower likelihood of driving. Adjusted multivariate analyses indicated that functional impairment was uniquely associated with driving status in both TBI severity groups. After controlling for other predictors, self-reported PTSD symptoms, particularly dysphoria symptoms, were associated with lower likelihood of driving in both severity groups.

CONCLUSION

Given the significance of clinician-rated functional impairment and self-reported PTSD symptoms to the prediction of driving status 1 year post-TBI among service members and veterans, rehabilitation efforts to improve functioning and reduce negative affect may have a positive impact on driving and community integration.

The Traumatic Brain Injury Model Systems National Database: A Review of Published Research

The Traumatic Brain Injury Model Systems (TBIMS) is the largest longitudinal TBI data set in the world. Our study reviews the works using TBIMS data for analysis in the last 5 years. A search (2015–2020) was conducted across PubMed, EMBASE, and Google Scholar for studies that used the National Institute on Disability, Independent Living and Rehabilitation Research NIDILRR/VA-TBIMS data. Search terms were as follows: [“TBIMS” national database] within PubMed and Google Scholar, and [“TBIMS” AND national AND database] on EMBASE. Data sources, study foci (in terms of data processing and outcomes), study outcomes, and follow-up information usage were collected to categorize the studies included in this review. Variable usage in terms of TBIMS' form-based variable groups and limitations from each study were also noted. Assessment was made on how TBIMS' objectives were met by the studies. Of the 74 articles reviewed, 23 used TBIMS along with other data sets. Fifty-four studies focused on specific outcome measures only, 6 assessed data aspects as a major focus, and 13 explored both. Sample sizes of the included studies ranged from 11 to 15,835. Forty-two of the 60 longitudinal studies assessed follow-up from 1 to 5 years, and 15 studies used 10 to 25 years of the same. Prominent variable groups as outcome measures were “Employment,” “FIM,” “DRS,” “PART-O,” “Satisfaction with Life,” “PHQ-9,” and “GOS-E.” Limited numbers of studies were published regarding tobacco consumption, the Brief Test of Adult Cognition by Telephone (BTACT), the Supervision Rating Scale (SRS), general health, and comorbidities as variables of interest. Generalizability was the most significant limitation mentioned by the studies. The TBIMS is a rich resource for large-sample longitudinal analyses of various TBI outcomes. Future efforts should focus on under-utilized variables and improving generalizability by validation of results across large-scale TBI data sets to better understand the heterogeneity of TBI.

Early chronic systemic inflammation and associations with cognitive performance after moderate to severe TBI

BACKGROUND

Cognitive dysfunction adversely effects multiple functional outcomes and social roles after TBI. We hypothesize that chronic systemic inflammation exacerbates cognitive deficits post-injury and diminishes functional cognition and quality of life (QOL). Yet few studies have examined relationships between inflammation and cognition after TBI. Associations between early chronic serum inflammatory biomarker levels, cognitive outcomes, and QOL 6-months and 12-months after moderate-to-severe TBI were identified using unweighted (uILS) and weighted (wILS) inflammatory load score (ILS) formation.

METHODS

Adults with moderate-to-severe TBI (n ​= ​157) completed neuropsychological testing, the Functional Impairment Measure Cognitive Subscale (FIM-Cog) and self-reported Percent Back to Normal scale 6 months (n ​= ​139) and 12 months (n ​= ​136) post-injury. Serial serum samples were collected 1-3 months post-TBI. Cognitive composite scores were created as equally weighted means of T-scores derived from a multidimensional neuropsychological test battery. Median inflammatory marker levels associated with 6-month and 12-month cognitive composite T-scores (p ​< ​0.10) were selected for ILS formation. Markers were quartiled, and quartile ranks were summed to generate an uILS. Marker-specific β-weights were derived using penalized ridge regression, multiplied by standardized marker levels, and summed to generate a wILS. ILS associations with cognitive composite scores were assessed using multivariable linear regression. Structural equation models assessed ILS influences on functional cognition and QOL using 12-month FIM-Cog and Percent Back to Normal scales.

RESULTS

ILS component markers included: IL-1β, TNF-α, sIL-4R, sIL-6R, RANTES, and MIP-1β. Increased sIL-4R levels were positively associated with overall cognitive composite T-scores in bivariate analyses, while remaining ILS markers were negatively associated with cognition. Multivariable receiver operator curves (ROC) showed uILS added 14.98% and 31.93% relative improvement in variance captured compared to the covariates only base model (age, sex, education, Glasgow Coma Scale score) when predicting cognitive composite scores at 6 and 12 months, respectively; wILS added 33.99% and 36.87% relative improvement in variance captured. Cognitive composite mediated wILS associations with FIM-Cog scores at 12 months, and both cognitive composite and FIM-Cog scores mediated wILS associations with QOL.

CONCLUSIONS

Early chronic inflammatory burden is associated with cognitive performance post-TBI. wILS explains greater variance in cognitive composite T-scores than uILS. Linking inflammatory burden associated with cognitive deficits to functional outcome post-TBI demonstrates the potential impact of immunotherapy interventions aimed at improving cognitive recovery post-TBI.

A Scoping Review of Predictors of Community Integration Following Traumatic Brain Injury: A Search for Meaningful Associations

OBJECTIVE

The purpose of this scoping review was to identify predictors of community integration for adults with traumatic brain injury.

DATA SOURCES

We searched the PubMed and PsycINFO databases and reviewed references of included studies. We selected studies exploring multiple components of community integration, including instrumental activities of daily living, leisure activities, and social activities. A total of 53 studies were included.

DATA EXTRACTION

We extracted data on sample size and sample characteristics (stage of injury and recovery, severity) and examined predictor variables, outcome measures for community integration, and significant findings, reported as correlations.

DATA SYNTHESIS

We found that the predictors of community integration fell into 4 categories: demographics, injury characteristics, disability and impairments, and environmental factors. There was large variability in reported relationships for demographics (r = 0.01-0.43), injury characteristics (r = 0.01-0.58), disability/functional impairments (r = 0.003-0.98) and environmental factors (r = 0.11-0.58). Cognition, disability, mobility/physical functioning, mood, social support, and length of posttraumatic amnesia had the strongest relationships with community integration outcomes.

CONCLUSIONS

Strategies for the management of cognitive, physical, and emotional functioning, and building and training a strong support system, may facilitate community integration outcomes. Additional work is warranted to further explore the discrepancies found among studies.

Self-reported Participation Restrictions Among Male and Female Veterans With Traumatic Brain Injury in Veterans Health Administration Outpatient Polytrauma Programs

OBJECTIVES

To identify areas of most restricted self-reported participation among veterans with traumatic brain injury (TBI), explore associations among participation restriction and clinical characteristics, and examine differences in participation restrictions by sex.

DESIGN

Retrospective cross-sectional design.

SETTING

National VA Polytrauma System of Care outpatient settings.

PARTICIPANTS

Veterans with a confirmed TBI event (N=6065).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE(S)

Mayo-Portland Participation Index (M2PI), a 5-point Likert-type scale with 8 items. Total score was converted to standardized T score for analysis.

RESULTS

The sample consisted of 5679 male and 386 female veterans with ≥1 clinically confirmed TBI events (69% white; 74% with blast exposure). The M2PI items with greatest perceived restrictions were social contact, leisure, and initiation. There were no significant differences between men and women on M2PI standardized T scores. Wilcoxon rank-sum analyses showed significant differences by sex on 4 items: leisure, residence, employment, and financial management (all P<.01). In multinomial logistic regression on each item controlling for demographics, injury characteristics, and comorbidities, female veterans had significantly greater relative risk for part-time work and unemployment on the employment item and significantly less risk for impairment on the residence and financial management item.

CONCLUSIONS

There was no significant difference between men and women. Veterans on M2PI standardized T scores, which masks differences in response patterns to individual items. Clinical teams should be encouraged to discuss perceived restrictions with patients and target these areas in treatment planning. Future work is needed to investigate the psychometric properties of the M2PI by biological sex.

Factors associated with employment and work perception in combat-exposed veterans

PURPOSE/OBJECTIVE

The purpose of this study was 2-fold: (a) to evaluate whether perception of work ability is associated with employment status in a sample of combat-exposed veterans, and (b) to determine whether the same sets of variables that are associated with employment status are also associated with perception of work ability. Research Method/Design: In this cross-sectional study, veterans (N = 83) underwent a neuropsychological assessment and completed questionnaires assessing demographic characteristics, combat-related experiences, and psychiatric and neurobehavioral/health-related symptoms. Primary outcomes of interest were employment status (unemployed vs. employed) and veterans' perception of whether their ability to work has declined due to an ongoing condition (yes vs. no).

RESULTS

A chi-square analysis revealed a significant relationship between perception of work ability and employment status. Additionally, psychiatric and neurobehavioral/health-related symptoms were associated with employment status and perception of work ability, whereas demographic characteristics (i.e., service-connected disability rating) and combat-related experiences (i.e., mTBI history) were only associated with perception of work ability. Objective cognitive functioning was not associated with employment status or perception of work ability.

CONCLUSIONS/IMPLICATIONS

Although preliminary, results suggest that perception of work ability is an important factor to consider when evaluating employment-related outcomes in veterans. Moreover, results indicate that while there is some overlap among the variables associated with employment status and perception of work ability, additional variables are linked with perception of work ability. Taken together, these findings suggest that perception of one's ability to work and factors that influence it may be particularly important treatment targets in the veteran population. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

A conceptual framework to promote career development for vocational rehabilitation consumers with traumatic brain injuries

The purpose of this article is to describe the Illinois Work and Well-being Model (ILW2M), a multi-domain framework for conceptualizing the employment development of people with traumatic brain injuries (TBIs). The model emphasizes the interaction of contextual and career development domains to improve participation in the areas of work, society, community, and home. A brief discussion of potential implications regarding vocational rehabilitation research and service is offered with the overall goal of reinforcing employment development as the foundation of vocational rehabilitation services for adults with TBIs.

Thirty Years of National Institute on Disability, Independent Living, and Rehabilitation Research Traumatic Brain Injury Model Systems Center Research-An Update

The Traumatic Brain Injury Model Systems Center (TBIMSC) program was established by the National Institute on Disability, Independent Living, and Rehabilitation Research in 1987, with the goal of conducting research to improve the care and outcomes for individuals with moderate-to-severe traumatic brain injury (TBI). This article provides an update on TBIMSC research program activities since 2010 when a similar article was published. It includes (1) discussion of TBIMSC program management and infrastructure; (2) detail on the management, data quality, access, use, and knowledge translation of the TBIMSC National Database, with more than 16 000 participants with follow-up out to 25 years postinjury to date; (3) an overview of the TBIMSC site-specific studies and collaborative module research; (4) highlights of several collaborative initiatives between the TBIMSCs and other federal, advocacy, and research stakeholders; (5) an overview of the vast knowledge translation occurring through the TBIMSC program; and (6) discussion of issues that impact on the data collection methods for and contents of the TBIMSC National Database. On the occasion of the 30th anniversary of the TBIMSC program, this article highlights many of the accomplishments of this well-established, multicenter TBI research consortium.

Functional Outcome and Mental Health Symptoms in Military Personnel and Veterans Pursuing Postsecondary Education After Traumatic Brain Injury: A VA TBI Model Systems Study

Background

TBI is a leading cause of disability among veterans and active duty military personnel, and presents an obstacle to community reintegration. Prior studies examining adult survivors of TBI pursuing postsecondary education have methodological flaws that limit the understanding the scope and severity of sequelae experienced by persons with TBI who attend college.

Objective

To describe (a) physical and cognitive functioning, and (b) postconcussion and mental health symptoms in veterans and military personnel (V/M) with traumatic brain injury (TBI) enrolled in postsecondary education programs after discharge from rehabilitation.

Method

Cross-sectional study. Participants were recruited from five Veterans Affairs (VA) Polytrauma Rehabilitation Centers, enrolled in the VA TBI Model Systems parent study, and attending school during follow-up (N= 155). Outcome measures included the Functional Independence Measure (FIM), Neurobehavioral Symptom Inventory (NSI), Post-traumatic Stress Disorder (PTSD) Checklist-Civilian version (PCL-C), Patient Health Questionnaire-Depression (PHQ-9), and Generalized Anxiety Disorder Questionnaire (GAD-7).

Findings

Participants were mostly male (92.9%) and White (81.4%), with mild (40.0%), moderate (11.5%), severe (34.5%), or very severe TBI (23.0%). Depression, anxiety, PTSD, and postconcussion symptoms were lowest in participants with very severe TBI and highest in those with mild TBI. There were no significant differences in FIM across TBI severity levels.

Conclusion

This study supports the need for rehabilitation counselors, educators, and administrators to prepare future practitioners to deliver tailored services to student V/M with TBI. These services can facilitate successful community reintegration and transition into civilian school settings. Symptom profiling may inform personalized cognitive interventions to enhance these students’ academic success.

Veteran Coffee Socials: A Community-Building Strategy for Enhancing Community Reintegration of Veterans

Veterans transitioning from military to civilian life are vulnerable to a loss of social support and an increase in isolation from their communities, which can exacerbate other difficulties they may be experiencing, such as physical or mental health problems. Veteran Coffee Socials are an innovative community-building pilot intervention designed to foster social support and community between veterans. In seven target communities, certified peer specialists initiated and facilitated weekly "Veteran Coffee Socials"-open peer support groups for veterans, held in local coffee shop or restaurants. Over a 9-month period, an average of 8.5 veterans attended each meeting, for a total of 2236 veteran engagements across seven towns. A range of activities were identified as commonly occurring during these Veteran Coffee Socials. Veteran attendees routinely formed relationships with each other, representatives from community organizations, and staff from local and VA healthcare resources. One of the most common activities involved veterans receiving information and directions for enrollment into needed healthcare supports and to local community resources. Case descriptions are provided illustrate the potential positive impact of this intervention to build community and expand social support for returning veterans through the examination of three individual and three group examples.

Cognitive impairment after traumatic brain injury is associated with reduced long-term depression of excitatory postsynaptic potential in the rat hippocampal dentate gyrus

Traumatic brain injury can cause loss of neuronal tissue, remote symptomatic epilepsy, and cognitive deficits. However, the mechanisms underlying the effects of traumatic brain injury are not yet clear. Hippocampal excitability is strongly correlated with cognitive dysfunction and remote symptomatic epilepsy. In this study, we examined the relationship between traumatic brain injury-induced neuronal loss and subsequent hippocampal regional excitability. We used hydraulic percussion to generate a rat model of traumatic brain injury. At 7 days after injury, the mean modified neurological severity score was 9.5, suggesting that the neurological function of the rats was remarkably impaired. Electrophysiology and immunocytochemical staining revealed increases in the slope of excitatory postsynaptic potentials and long-term depression (indicating weakened long-term inhibition), and the numbers of cholecystokinin and parvalbumin immunoreactive cells were clearly reduced in the rat hippocampal dentate gyrus. These results indicate that interneuronal loss and changes in excitability occurred in the hippocampal dentate gyrus. Thus, traumatic brain injury-induced loss of interneurons appears to be associated with reduced long-term depression in the hippocampal dentate gyrus.

The Association Between PTSD and Functional Outcome Is Mediated by Perception of Cognitive Problems Rather Than Objective Neuropsychological Test Performance

Posttraumatic stress disorder (PTSD) has been consistently linked to poorer functional outcomes, including quality of life, health problems, and social and occupational functioning. Less is known about the potential mechanisms by which PTSD leads to poorer functional outcomes. We hypothesized that neurocognitive functioning and perception of cognitive problems would both mediate the relationship between PTSD diagnosis and functioning. In a sample of 140 veterans of the recent wars and conflicts in Iraq and Afghanistan, we assessed PTSD symptoms, history of traumatic brain injury (TBI), depression, self-report measures of quality of life, social and occupational functioning, and reintegration to civilian life, as well as perception of cognitive problems. Veterans also completed a comprehensive neuropsychological battery of tests. Structural equation modeling revealed that perception of cognitive problems, but not objective neuropsychological performance, mediated the relationship between PTSD diagnosis and functional outcomes after controlling for TBI, depression, education, and a premorbid IQ estimate, b = -6.29, 95% bias-corrected bootstrapped confidence interval [-11.03, -2.88], showing a large effect size. These results highlight the importance of addressing appraisals of posttrauma cognitive functioning in treatment as a means of improving functional outcomes.