Development of a Traumatic Brain Injury Model System Within the Department of Veterans Affairs Polytrauma System of Care

Predictors of Psychiatric Hospitalization After Discharge From Inpatient Neurorehabilitation for Traumatic Brain Injury

OBJECTIVE

To examine, among persons discharged from inpatient rehabilitation for traumatic brain injury (TBI), the degree to which pre-TBI factors were associated with post-TBI hospitalization for psychiatric reasons. The authors hypothesized that pre-TBI psychiatric hospitalization and other pre-TBI mental health treatment would predict post-TBI psychiatric hospitalization following rehabilitation discharge, up to 5 years post-TBI.

SETTING

Five Veterans Affairs Polytrauma Rehabilitation Centers.

PARTICIPANTS

Participants with nonmissing rehospitalization status and reason, who were followed at 1 year (N = 1006), 2 years (N = 985), and 5 years (N = 772) post-TBI.

DESIGN

A secondary analysis of the Veterans Affairs TBI Model Systems, a multicenter, longitudinal study of veterans and active-duty service members with a history of mild, moderate, or severe TBI previously admitted to comprehensive inpatient medical rehabilitation. This study examined participants cross-sectionally at 3 follow-up timepoints.

MAIN MEASURES

Psychiatric Rehospitalization was classified according to Healthcare Cost and Utilization Project multilevel Clinical Classifications diagnosis terminology (Category 5).

RESULTS

Rates of post-TBI psychiatric hospitalization at years 1, 2, and 5 were 4.3%, 4.7%, and 4.1%, respectively. While bivariate comparisons identified pre-TBI psychiatric hospitalization and pre-TBI mental health treatment as factors associated with psychiatric rehospitalization after TBI across all postinjury timepoints, these factors were statistically nonsignificant when examined in a multivariate model across all timepoints. In the multivariable analysis, pre-TBI psychiatric hospitalization was significantly associated with increased odds of post-TBI psychiatric hospitalization only at 1-year post-TBI (adjusted odds ratio = 2.65; 95% confidence interval, 1.07-6.55, P = .04). Posttraumatic amnesia duration was unrelated to psychiatric rehospitalization.

CONCLUSIONS

Study findings suggest the limited utility of age, education, and pre-TBI substance use and mental health utilization in predicting post-TBI psychiatric hospitalization. Temporally closer social and behavior factors, particularly those that are potentially modifiable, should be considered in future research.

Mortality Among Veterans Following Traumatic Brain Injury: A Veterans Administration Traumatic Brain Injury Model System Study

Few studies have examined long-term mortality following traumatic brain injury (TBI) in a military population. This is a secondary analysis of a prospective, longitudinal study that examines long-term mortality (up to 10 years) post-TBI, including analyses of life expectancy, causes of death, and risk factors for death in service members and veterans (SM/V) who survived the acute TBI and inpatient rehabilitation. Among 922 participants in the study, the mortality rate was 8.3% following discharge from inpatient rehabilitation. The mean age of death was 54.5 years, with death occurring on average 3.2 years after injury, and with an average 7-year life expectancy reduction. SM/V with TBI were nearly four times more likely to die compared with the U.S. general population. Leading causes of death were external causes of injury, circulatory disease, and respiratory disorders. Also notable were deaths due to late effects of TBI itself and suicide. Falls were a significant mechanism of injury for those who died. Those who died were also more likely to be older at injury, unemployed, non-active duty status, not currently married, and had longer post-traumatic amnesia, longer rehabilitation stays, worse independence and disability scores at rehabilitation discharge, and a history of mental health issues before injury. These findings indicate that higher disability and less social supportive infrastructure are associated with higher mortality. Our investigation into the vulnerabilities underlying premature mortality and into the major causes of death may help target future prevention, surveillance, and monitoring interventions.

Associations of Chronic Pain With Psychosocial Outcomes After Traumatic Brain Injury: A NIDILRR and VA TBI Model Systems Collaborative Project

OBJECTIVE

To examine the differences in participation, life satisfaction, and psychosocial outcomes among individuals with traumatic brain injury (TBI) endorsing current, past, or no chronic pain.

SETTING

Community.

PARTICIPANTS

Three thousand eight hundred four TBI Model Systems participants 1 to 30 years of age postinjury classified into 1 of 3 groups based on their pain experience: current pain, past pain, no pain completed a Pain Survey at their usual follow-up appointment which on average was approximately 8 years postinjury.

DESIGN

Multisite, cross-sectional observational cohort study.

MAIN OUTCOME MEASURES

Sociodemographic and injury characteristics and psychosocial outcomes (ie, satisfaction with life, depression, anxiety, posttraumatic stress disorder [PTSD], sleep quality, community participation).

RESULTS

Persons with current chronic pain demonstrated higher scores on measures of PTSD, anxiety, and depression, and the lower scores on measures of sleep quality, community participation and satisfaction with life. Those with resolved past pain had mean scores for these outcomes that were all between the current and no chronic pain groups, but always closest to the no pain group. After adjusting for sociodemographic and function in multivariate analysis, having current chronic pain was associated with more negative psychosocial outcomes. The largest effect sizes (ES; in absolute value) were observed for the PTSD, depression, anxiety, and sleep quality measures (ES = 0.52-0.81) when comparing current pain to past or no pain, smaller ES were observed for life satisfaction (ES = 0.22-0.37) and out and about participation (ES = 0.16-0.18). When comparing past and no pain groups, adjusted ES were generally small for life satisfaction, PTSD, depression, anxiety, and sleep quality (ES = 0.10-0.23) and minimal for participation outcomes (ES = 0.02-0.06).

CONCLUSIONS

Chronic pain is prevalent among individuals with TBI and is associated with poorer psychosocial outcomes, especially for PTSD, depression, anxiety, and sleep disturbance. The results from this study highlight the presence of modifiable comorbidities among those with chronic pain and TBI. Persons who experience persistent pain following TBI may be at greater risk for worse psychosocial outcomes.

Characterization and Treatment of Chronic Pain After Traumatic Brain Injury-Comparison of Characteristics Between Individuals With Current Pain, Past Pain, and No Pain: A NIDILRR and VA TBI Model Systems Collaborative Project

OBJECTIVE

To estimate the prevalence of chronic pain after traumatic brain injury (TBI) and identify characteristics that differ from those without chronic pain.

SETTING

Community.

PARTICIPANTS

A total of 3804 TBI Model Systems (TBIMS) participants who completed the Pain Survey at TBIMS follow-up.

DESIGN

A multisite, cross-sectional observational cohort study.

MAIN OUTCOME MEASURES

Functional outcomes, pain experience, and treatment.

RESULTS

46% reported current chronic pain, 14% reported past (post-injury) chronic pain, and 40% reported no chronic pain. Bivariate differences in sociodemographic and injury characteristics between the 3 pain groups were generally small in effect size, reflecting little clinical difference. However, medium effect sizes were seen for all functional outcomes, such that individuals with current chronic pain had worse functional outcomes compared with individuals in the past pain or no pain groups. Treatment utilization rates were higher for individuals with current chronic pain compared with past pain, with medical treatments being most frequently utilized. Individuals with past pain perceived more improvement with treatment than did those with current chronic pain as represented by a large effect size.

CONCLUSIONS

Chronic pain affects approximately 60% of those living with TBI. The implications of chronic pain for functional outcomes support inclusion of pain metrics in prognostic models and observational studies in this population. Future research is needed to proactively identify those at risk for the development of chronic pain and determine the efficacy and access to pain treatment.

Exploring the relationship between sleep apnea and vestibular symptoms following traumatic brain injury

BACKGROUND

Traumatic brain injury (TBI) is a complex health problem in military veterans and service members (V/SM) that often involves comorbid vestibular impairment. Sleep apnea is another comorbidity that may exacerbate, and/or be exacerbated by, vestibular dysfunction.

OBJECTIVE

To examine the relationship between sleep apnea and vestibular symptoms in V/SM diagnosed with TBI of any severity.

DESIGN

Multicenter cohort study; cross-sectional sample.

SETTING

In-patient TBI rehabilitation units within five Veterans Affairs (VA) Polytrauma Rehabilitation Centers.

PARTICIPANTS

V/SM with a diagnosis of TBI (N = 630) enrolled in the VA TBI Model Systems study.

INTERVENTION

Not applicable.

METHODS

A multivariable regression model was used to evaluate the association between sleep apnea and vestibular symptom severity while controlling for relevant covariates, for example, posttraumatic stress disorder (PTSD).

MAIN OUTCOME MEASURES

Lifetime history of sleep apnea was determined via best source reporting. Vestibular disturbances were measured with the 3-item Vestibular subscale of the Neurobehavioral Symptom Inventory (NSI).

RESULTS

One third (30.6%) of the sample had a self-reported sleep apnea diagnosis. Initial analysis showed that participants who had sleep apnea had more severe vestibular symptoms (M = 3.84, SD = 2.86) than those without sleep apnea (M = 2.88, SD = 2.67, p < .001). However, when the data was analyzed via a multiple regression model, sleep apnea no longer reached the threshold of significance as a factor associated with vestibular symptoms. PTSD severity was shown to be significantly associated with vestibular symptoms within this sample (p < .001).

CONCLUSION

Analysis of these data revealed a relationship between sleep apnea and vestibular symptoms in V/SM with TBI. The significance of this relationship was affected when PTSD symptoms were factored into a multivariable regression model. However, given that the mechanisms and directionality of these relationships are not yet well understood, we assert that in terms of clinical relevance, providers should emphasize screening for each of the three studied comorbidities (sleep apnea, vestibular symptoms, and PTSD).

Role of sex and gender in concussion outcome differences among patients presenting to the emergency department: a systematic review

OBJECTIVE

This systematic review aimed to identify research involving adults presenting to the emergency department (ED) with a concussion to document the reporting of sex and/or gender according to the Canadian Institutes of Health Research (CIHR) guidelines, the prevalence of sex and gender-based analysis (SGBA) and to summarise sex and/or gender-based differences in ED presentation, management and outcomes.

DESIGN

Systematic review.

METHODS

Electronic databases and grey literature were searched to identify studies that recruited adult patients with concussion from the ED. Two independent reviewers identified eligible studies, assessed quality and extracted data. A descriptive summary of the evidence was generated, and sex and/or gender reporting was examined for accuracy according to standardised criteria.

RESULTS

Overall, 126 studies were included in the analyses. A total of 80 (64%) studies reported sex and/or gender as demographic information, of which 51 (64%) included sex and/or gender in their analysis; however, 2 (3%) studies focused on an SGBA. Sex was more accurately reported in alignment with CIHR definitions than gender (94% vs 12%; p<0.0001). In total, 25 studies used an SGBA for outcomes of interest. Males and females experience different causes of concussion, 60% of studies documented that females had less frequent CT scanning while in the ED, and 57% of studies reported that postconcussion syndrome was more prevalent in females and women.

CONCLUSION

This systematic review highlighted that sex is reported more accurately than gender, approximately half of studies did not report either sex and/or gender as demographic information, and one-third of studies did not include SGBA. There were important sex and gender differences in the cause, ED presentation, management and outcomes of concussions.

PROSPERO REGISTRATION NUMBER

CRD42021258613.

Female athlete health domains: a supplement to the International Olympic Committee consensus statement on methods for recording and reporting epidemiological data on injury and illness in sport

The IOC made recommendations for recording and reporting epidemiological data on injuries and illness in sports in 2020, but with little, if any, focus on female athletes. Therefore, the aims of this supplement to the IOC consensus statement are to (i) propose a taxonomy for categorisation of female athlete health problems across the lifespan; (ii) make recommendations for data capture to inform consistent recording and reporting of symptoms, injuries, illnesses and other health outcomes in sports injury epidemiology and (iii) make recommendations for specifications when applying the Strengthening the Reporting of Observational Studies in Epidemiology-Sport Injury and Illness Surveillance (STROBE-SIIS) to female athlete health data.In May 2021, five researchers and clinicians with expertise in sports medicine, epidemiology and female athlete health convened to form a consensus working group, which identified key themes. Twenty additional experts were invited and an iterative process involving all authors was then used to extend the IOC consensus statement, to include issues which affect female athletes.Ten domains of female health for categorising health problems according to biological, life stage or environmental factors that affect females in sport were identified: menstrual and gynaecological health; preconception and assisted reproduction; pregnancy; postpartum; menopause; breast health; pelvic floor health; breast feeding, parenting and caregiving; mental health and sport environments.This paper extends the IOC consensus statement to include 10 domains of female health, which may affect female athletes across the lifespan, from adolescence through young adulthood, to mid-age and older age. Our recommendations for data capture relating to female athlete population characteristics, and injuries, illnesses and other health consequences, will improve the quality of epidemiological studies, to inform better injury and illness prevention strategies.

Examining the Relationship Between Sleep Apnea Diagnosis and Suicide Risk in Veterans With Traumatic Brain Injury: A VA TBI Model Systems Study

OBJECTIVE

Obstructive sleep apnea (OSA) is a common sleep disorder in people with traumatic brain injury (TBI). Although sleep disturbances have been associated with an increased risk of suicide compared with the general population, the relationship between OSA and suicide risk after TBI is not well documented. In this study, we hypothesized that OSA diagnosis would predict suicide risk in veterans with TBI.

SETTING

Five Veterans Affairs (VA) Polytrauma Rehabilitation Centers.

PARTICIPANTS

Participants were drawn from the VA TBI Model Systems study, with follow-up interviews at year 1 ( n = 392), year 2 ( n = 444), year 5 ( n = 498), or year 10 ( n = 252) post-TBI (7.8%-14.5% follow-up attrition).

DESIGN

This was a retrospective analysis from observational data using logistic regression with repeated measurements. Suicide ideation and suicide attempts were examined as outcomes at each follow-up to evaluate the relationship between OSA and suicide risk after adjusting for other risk factors determined a priori via literature review.

MAIN MEASURES

Suicidal ideation (Patient Health Questionnaire-9 item 9), suicide attempt during the past year (self-reported), and OSA diagnosis (self-reported).

RESULTS

Contrary to study hypotheses, OSA diagnosis had no statistically significant association with suicide ideation or attempt after accounting for known predictors. However, greater depression symptoms, headache severity, and pre-TBI suicidal ideation and attempts predicted suicide risk at follow-up after accounting for other predictors.

CONCLUSIONS

Results of this study did not support a relationship between OSA and suicide risk, possibly due to methodological limitations of OSA measurement. Future research on this topic should include objective measures of OSA severity and OSA treatment including adherence. Although suicide is a low base rate occurrence, the impact is disastrous and further research is needed to mitigate suicide risk.

A Network Analysis of the PART-O at 1 and 2 Years After TBI: A Veterans Affairs Model Systems Study

OBJECTIVE

The construct of participation after traumatic brain injury (TBI) can be difficult to operationalize. Psychometric network analysis offers an empirical approach to visualizing and quantifying the associations between activities that comprise participation, elucidating the relations among the construct's components without assuming the presence of a latent common cause and generating a model to inform future measurement methods. The current research applied psychometric network analysis to the Participation Assessment with Recombined Tools-Objective (PART-O) within a sample of service members and veterans (SM/Vs) with a history of TBI at 1 and 2 years ( T1 and T2 ) postinjury.

PARTICIPANTS

Participants ( N = 663) were SM/Vs with a history of TBI who completed comprehensive inpatient rehabilitation services at a Department of Veterans Affairs (VA) Polytrauma Rehabilitation Center (PRC).

SETTING

Five VA PRCs.

DESIGN

Cross-sectional, retrospective analysis of data from the VA TBI Model Systems study.

MAIN MEASURES

PART-O.

RESULTS

Network analysis demonstrated that the PART-O structure was generally consistent over time, but some differences emerged. The greatest difference observed was the association between "spending time with friends" and "giving emotional support" to others. This association was more than twice as strong at T2 as at T1 . The "out of the house" item was most central, as demonstrated by dense connections within its own subscale (Out and About) and items in other subscales (ie, Social Relations and Productivity). When examining items connecting the 3 subscales, the items related to giving emotional support, internet use, and getting out of the house emerged as the strongest connectors at T1 , and the internet was the strongest connector at T2 .

CONCLUSION

Providing emotional support to others is associated with greater participation across multiple domains and is an important indicator of recovery. Being out and about, internet use, and engagement in productive activities such as school and work shared strong associations with Social Relations. Network analysis permits visual conceptualization of the dynamic constructs that comprise participation and has the potential to inform approaches to measurement and treatment.

Advancing Health Equity in Neurologic Disorders and Stroke: Stakeholder Insights Into Health Disparities, Research Gaps, and Potential Interventions

OBJECTIVES

The purpose of this study was to analyze the National Institute of Neurological Disorders and Stroke (NINDS) Request for Information (RFI) input from the public-including health care providers, researchers, patients, patient advocates, caregivers, advocacy organizations, professional societies, and private and academic stakeholders with an interest in health disparities (HDs) in neurologic disease. RFI questions were structured to solicit input on what stakeholders believe are neurologic disease HD research priorities, drivers of health inequity, and potential interventions. Furthermore, these stakeholder insights were examined within the context of contemporary scientific literature and research frameworks on health equity and health disparities.

BACKGROUND

The NINDS published a RFI from March 31 to July 15, 2020. The RFI analysis presented here is part of a larger strategic planning process aimed to guide future NINDS efforts in neurologic disorder health equity (HE) research and training. The public commented on facilitators of HDs, populations that experience HDs (HDPs), potential interventions, and research opportunities related to HDs in neurologic disease and/or care in the United States across the lifespan. Responses were analyzed using qualitative methodology. Frequently suggested interventions were thematically clustered using the interpretive phenomenological analysis methodology and are presented in this article to provide a stakeholder-identified roadmap for advancing HE.

RESULTS

Respondents identified socioecological factors as driving HDs in 89% of determinants reported. Stakeholder-reported HD determinants and subsequent interventions could be classified into the following conceptual categories: HDP neurospecialty care access, innovative HDP engagement and research inclusion strategies, and development of a well-trained clinician-scientist HD workforce. Clustering of the feedback from patient and patient-adjacent respondents (i.e., caretakers and patient advocates) highlighted the prevalence of patient-provider interpersonal factors and limited resources driving access-to-care barriers among their sentiments.

DISCUSSION

Respondent sentiments suggest prioritization of social determinants of health (SDOH) research, shifting away from the common target of biological and behavioral themes addressed in the existing body of HE research provided by the stakeholder. Overall, respondents suggest focusing research prioritization on access to care, engagement across the HE research and care landscape, and HE workforce development.

Long-term Multidomain Patterns of Change After Traumatic Brain Injury: A TRACK-TBI LONG Study

BACKGROUND AND OBJECTIVES

Traumatic brain injury (TBI) may be a chronic condition carrying risk of future sequelae; few prospective studies examine long-term postinjury outcomes. We examined the prevalence of functional, cognitive, and psychiatric change outcomes from 1 to 7 years postinjury.

METHODS

Transforming Research and Clinical Knowledge in TBI LONG (TRACK-TBI LONG) participants were prospectively enrolled within 24 hours of injury and followed up to 1 year postinjury; a subset participated in long-term follow-up from 2 to 7 years postinjury. Reliable change thresholds for the Brief Test of Adult Cognition by Telephone General Composite (cognition) and Brief Symptom Inventory (BSI)-18 (psychiatric) were derived from orthopedic trauma controls (OTCs). Multiple assessments were completed (postinjury baseline assessment and 2 or 3 visits 2-7 years postinjury) within a sample subset. Change was assessed for functional outcome (Glasgow Outcome Scale-Extended [GOSE]) and self-report/informant report of decline. Prevalence ratios for outcomes classified as stable, improved, and declined were reported individually and collectively. The Fisher exact test and log-binomial regression models examined factors associated with decline and improvement.

RESULTS

Of the sample (N = 1,264; mild TBI [mTBI], Glasgow Coma Scale [GCS] 13-15, n = 917; moderate-to-severe TBI [msTBI], GCS 3-12, n = 193; or OTC n = 154), "stable" was the most prevalent outcome. Functional outcome showed the highest rates of decline, regardless of TBI severity (mild = 29%; moderate/severe = 23%). When measures were collectively considered, rates of decline included mTBI (21%), msTBI (26%), and OTC (15%). Age and preinjury employment status were associated with functional decline (per 10 years; relative risk [RR] 1.16, 95% CI 1.07-1.25, p < 0.001; higher in retired/disabled/not working vs full-time/part-time; RR 1.81, 95% CI 1.33-2.45, respectively) in the mTBI group. Improvement in functional recovery 2-7 years postinjury was associated with higher BSI scores (per 5 points; RR 1.11, 95% CI 1.04-1.18, p = 0.002) and GOSE score of 5-7 (GOSE = 8 as reference; RR 2.64, 95% CI 1.75-3.97, p < 0.001). Higher BSI scores and identifying as Black (RR 2.28, 95% CI 1.59-3.25, p < 0.001) were associated with a greater likelihood of improved psychiatric symptoms in mTBI (RR 1.21, 95% CI 1.14-1.29, p < 0.001). A greater likelihood of cognitive improvement was observed among those with higher educational attainment in msTBI (per 4 years; RR 2.61, 95% CI 1.43-4.79, p = 0.002).

DISCUSSION

Function across domains at 1-year postinjury, a common recovery benchmark, undergoes change across the subsequent 6 years. Results support consideration of TBI as a chronic evolving condition and suggest continued monitoring, rehabilitation, and support is required to optimize long-term independence and quality of life.

Selective neuroimmune modulation by type I interferon drives neuropathology and neurologic dysfunction following traumatic brain injury

Accumulating evidence suggests that type I interferon (IFN-I) signaling is a key contributor to immune cell-mediated neuropathology in neurodegenerative diseases. Recently, we demonstrated a robust upregulation of type I interferon-stimulated genes in microglia and astrocytes following experimental traumatic brain injury (TBI). The specific molecular and cellular mechanisms by which IFN-I signaling impacts the neuroimmune response and neuropathology following TBI remains unknown. Using the lateral fluid percussion injury model (FPI) in adult male mice, we demonstrated that IFN α/β receptor (IFNAR) deficiency resulted in selective and sustained blockade of type I interferon-stimulated genes following TBI as well as decreased microgliosis and monocyte infiltration. Phenotypic alteration of reactive microglia also occurred with diminished expression of molecules needed for MHC class I antigen processing and presentation following TBI. This was associated with decreased accumulation of cytotoxic T cells in the brain. The IFNAR-dependent modulation of the neuroimmune response was accompanied by protection from secondary neuronal death, white matter disruption, and neurobehavioral dysfunction. These data support further efforts to leverage the IFN-I pathway for novel, targeted therapy of TBI.

Comparison of veterans affairs and NIDILRR traumatic brain injury model systems participants with disorders of consciousness

OBJECTIVE

To characterize demographic, pre-injury, and outcome data within the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) and Veterans Affairs (VA) Traumatic Brain Injury Model Systems (TBIMS) cohorts with severe traumatic brain injury (TBI) with no command-following ability at time of admission to acute rehabilitation.

DESIGN

Retrospective cohort.

SETTING

NIDILRR and VA TBI Model Systems (TBIMS) centers.

PARTICIPANTS

396 NIDILRR and 72 VA participants without command-following ability who experienced TBI with subsequent Disorder of Consciousness (DoC).

MAIN OUTCOME MEASURE

Pre-injury and injury characteristics, rehabilitation outcomes, and 1-year self-reported outcomes.

RESULTS

VA TBIMS cohort included individuals who were active duty or had military service before their injury. The VA cohort were more likely to be re-hospitalized at 1-year follow-up or residing in a long-term care or rehab setting. The NIDILRR TBIMS cohort had higher FIM and DRS scores at rehabilitation discharge, while the VA participants saw longer lengths of stay and higher numbers of "violent" injury types.

CONCLUSIONS

This study allows for a better understanding of the comparability between VA and NIDILRR DoC cohorts providing guidance on how veteran and civilian samples might be merged in future TBIMS studies to explore predictors of recovery from a DoC.

Predicting Functional Dependency in Patients with Disorders of Consciousness: A TBI-Model Systems and TRACK-TBI Study

Importance

There are currently no models that predict long-term functional dependency in patients with disorders of consciousness (DoC) after traumatic brain injury (TBI).

Objective

Fit, test, and externally validate a prediction model for 1-year dependency in patients with DoC 2 or more weeks after TBI.

Design

Secondary analysis of patients enrolled in TBI Model Systems (TBI-MS, 1988-2020, Discovery Sample) or Transforming Research and Clinical Knowledge in TBI (TRACK-TBI, 2013-2018, Validation Sample) and followed 1-year post-injury.

Setting

Multi-center study at USA rehabilitation hospitals (TBI-MS) and acute care hospitals (TRACK-TBI).

Participants

Adults with TBI who were not following commands at rehabilitation admission (TBI-MS; days post-injury vary) or 2-weeks post-injury (TRACK-TBI).

Exposures

In the TBI-MS database (model fitting and testing), we screened demographic, radiological, clinical variables, and Disability Rating Scale (DRS) item scores for association with the primary outcome.

Main Outcome

The primary outcome was death or complete functional dependency at 1-year post-injury, defined using a DRS-based binary measure (DRS Depend ), indicating need for assistance with all activities and concomitant cognitive impairment.

Results

In the TBI-MS Discovery Sample, 1,960 subjects (mean age 40 [18] years, 76% male, 68% white) met inclusion criteria and 406 (27%) were dependent at 1-year post-injury. A dependency prediction model had an area under the receiver operating characteristic curve (AUROC) of 0.79 [0.74, 0.85], positive predictive value of 53%, and negative predictive value of 86% for dependency in a held-out TBI-MS Testing cohort. Within the TRACK-TBI external validation sample (N=124, age 40 [16], 77% male, 81% white), a model modified to remove variables not collected in TRACK-TBI, had an AUROC of 0.66 [0.53, 0.79], equivalent to the gold-standard IMPACT core+CT score (0.68; 95% AUROC difference CI: -0.2 to 0.2, p=0.8).

Conclusions and Relevance

We used the largest existing cohort of patients with DoC after TBI to develop, test and externally validate a prediction model of 1-year dependency. The model’s sensitivity and negative predictive value were greater than specificity and positive predictive value. Accuracy was diminished in an external sample, but equivalent to the best-available models. Further research is needed to improve dependency prediction in patients with DoC after TBI.

Barriers and Facilitators to Accessing Rehabilitation Health Care: A Veterans Affairs Traumatic Brain Injury Model Systems Qualitative Study

OBJECTIVE

To compare barriers and facilitators to accessing health care services among service members and veterans (SMVs) by traumatic brain injury (TBI) severity groups.

DESIGN

Qualitative descriptive study guided by an access to health care services conceptual framework.

SETTING

Five Veterans Affairs (VA) polytrauma rehabilitation centers.

PARTICIPANTS

SMVs (N=55, including 10 caregivers as proxies) ≥2 years post-TBI recruited from the VA TBI Model Systems and grouped by TBI severity (mild/moderate, severe).

MAIN OUTCOME MEASURES

Barriers and facilitators accessing care.

RESULTS

The main facilitators included ease of communicating with providers to help SMVs identify and utilize appropriate health care, family advocates who promoted engagement in health care, ability to use government and community facilities, and online resources or equipment. Distance to services was uniformly identified as a main barrier for both patient groups. However, facilitators and barriers to health care access differed by TBI severity. SMVs with severe TBI highlighted the role of nonprofit organizations in promoting health care engagement and the availability of VA specialty residential programs in meeting health care needs. Having unrecognized health care needs in chronic stages and communication difficulties with providers were more commonplace for those with greater TBI severity and affected quality of care. Those with mild/moderate TBI highlighted challenges associated with paying for services in the community and scheduling of services.

CONCLUSIONS

Barriers and facilitators exist across multiple dimensions of a health care access framework and vary by TBI severity. Results suggest possible mechanistic links between health care access and SMV health outcomes. Findings support current policy and practice efforts to facilitate health care access for SMVs with TBI but highlight the need for tailored approaches for those with greater disability.

Exploring racial/ethnic disparities in rehabilitation outcomes after TBI: A veterans affairs model systems study

BACKGROUND

Almost one-third of the U.S. military population is comprised of service members and veterans (SMVs) of color. Research suggests poorer functional and psychosocial outcomes among Black and Hispanic/Latine vs. White civilians following traumatic brain injury (TBI).

OBJECTIVE

This study examined racial/ethnic differences in 5-year functional independence and life satisfaction trajectories among SMVs who had undergone acute rehabilitation at one of five VA TBI Model Systems (TBIMS) Polytrauma Rehabilitation Centers (PRCs).

METHODS

Differences in demographic and injury-related factors were assessed during acute rehabilitation among White (n = 663), Black (n = 89) and Hispanic/Latine (n = 124) groups. Functional Independence Measure (FIM) Motor, FIM Cognitive, and Satisfaction with Life Scale (SWLS) scores were collected at 1, 2, and 5 years after injury. Racial/ethnic comparisons in these outcome trajectories were made using hierarchical linear modeling.

RESULTS

Black SMVs were less likely than White and Hispanic/Latine SMVs to have been deployed to a combat zone; there were no other racial/ethnic differences in any demographic or injury-related variable assessed. In terms of outcomes, no racial/ethnic differences emerged in FIM Motor, FIM cognitive, or SWLS trajectories.

CONCLUSION

The absence of observable racial/ethnic differences in 5-year outcome trajectories after TBI among SMVs from VA TBIMS PRCs contrasts sharply with previous research identifying disparities in these same outcomes and throughout the larger VA health care system. Individuals enrolled in VA PRCs are likely homogenized on key social determinants of health that would otherwise contribute to racial/ethnic disparities in outcome trajectories.

Alternative Structure Models of the Traumatic Brain Injury Rehabilitation Needs Survey: A Veterans Affairs TBI Model Systems Study

OBJECTIVE

To explore the factor structure of the Rehabilitation Needs Survey (RNS).

DESIGN

Secondary analysis of observational cohort study who were 5-years post-traumatic brain injury (TBI).

SETTING

Five Inpatient Rehabilitation Facilities.

PARTICIPANTS

Veterans enrolled in the TBI Model Systems longitudinal study who completed the RNS at 5-year follow-up (N=378).

MAIN OUTCOME MEASURE(S)

RNS.

RESULTS

RNS factor structure was examined with exploratory factor analysis (EFA) with oblique rotation. Analyses returned 2- and 3-factor solutions with Cronbach alphas ranging from 0.715 to 0.905 and corrected item-total correlations that ranged from 0.279 to 0.732. The 2-factor solution accounted for 61.7% of the variance with ≥3 exclusively loading items on each factor with acceptable internal consistency metrics and was selected as the most parsimonious and clinically applicable model. Ad hoc analysis found the RNS structure per the EFA corresponded with elements of the International Classification of Functioning, Disability and Health (ICF) conceptual framework. All factors had adequate internal consistency (α≥0.70) and 20 of the 21 demonstrated good discrimination (corrected item-total correlations≥0.40).

CONCLUSIONS

The 2-factor solution of the RNS appears to be a useful model for enhancing its clinical interpretability. Although there were cross-loading items, they refer to complex rehabilitation needs that are likely influenced by multiple factors. Alternatively, there are items that may require alteration and redundant items that should be considered for elimination.

Surveying the Landscape: A Review of Longitudinal TBI Studies in Service Member and Veteran Populations

Traumatic brain injury (TBI) is known to be a signature wound of the post-9/11 conflicts. In response, the U.S. Department of Defense (DOD) and other federal organizations have directed significant investments toward TBI research on characterizing injury populations and understanding long-term outcomes. To address legislative requirements and research gaps, several observational, longitudinal TBI studies were initiated as an effective means of investigating TBI clinical management, outcomes, and recovery. This review synthesizes the landscape (i.e., requirements and gaps, infrastructure, geography, timelines, TBI severity definitions, military and injury populations of interest, and measures) of DOD-funded longitudinal TBI studies being conducted in service member and veteran (SMV) populations. Based on the landscape described here, we present recommended actions and solutions that would allow a consolidated and cooperative future state of longitudinal TBI research, optimized continued investments, and advances in the state of the science without redundancy.

Measuring long-term outcomes after injury: current issues and future directions

Maximizing long-term outcomes for patients following injury is the next challenge in the delivery of patient-centered trauma care. The following review outlines three important components in trauma outcomes: (1) data gathering and monitoring, (2) the impact of traumatic brain injury, and (3) trajectories in recovery and identifies knowledge gaps and areas for needed future research.

Research Letter: Impact of Obstructive Sleep Apnea Disease Duration on Neuropsychological Functioning After Traumatic Brain Injury: A Veterans Affairs TBI Model Systems Study

OBJECTIVE

To examine the relationship between obstructive sleep apnea (OSA) disease duration and cognitive functioning in those with a history of traumatic brain injury (TBI). We hypothesized that longer OSA duration would predict poorer cognitive performance.

SETTING

Inpatient brain injury units at a Veterans Affairs (VA) Polytrauma Rehabilitation Center.

PARTICIPANTS

Participants in the VA TBI Model Systems multicenter longitudinal study who enrolled in a modular substudy (April 15, 2018, to January 15, 2021) examining cognition following TBI. All participants had received inpatient rehabilitation for TBI and reported a diagnosis of OSA ( n = 89, mean age = 40.8 years, 97% male, 81% White). Reported duration of OSA ranged from 2 to 7 years (mean = 4.2; SD = 3.9).

DESIGN

Retrospective analysis of prospective cohort, cross-sectional.

MAIN MEASURES

Brief Test of Adult Cognition by Telephone (BTACT).

RESULTS

Controlling for age, education, and time to follow commands, OSA disease duration was negatively associated with delayed verbal memory ( R2Δ = 0.053, F(1,84) = 5.479, P = .022). Performance in other cognitive domains was not significantly associated with OSA disease duration.

CONCLUSION

This study provides preliminary evidence that longer duration of OSA (ie, time since diagnosis) has a negative impact on verbal memory in those with a history of hospitalized TBI. This finding extends the literature (which focused on the general population) on the cognitive impact of OSA and is consistent with hypothesized mechanisms such as hippocampal damage and secondary impact of fatigue. Findings suggest that early OSA identification and treatment may be prudent for persons with TBI.

Health Conditions Among Special Operations Forces Versus Conventional Military Service Members: A VA TBI Model Systems Study

OBJECTIVE

To examine traumatic brain injury (TBI) characteristics and comorbid medical profiles of Special Operations Forces (SOF) Active Duty Service Member/Veterans (ADSM/Vs) and contrast them with conventional military personnel.

SETTING

The 5 Veterans Affairs (VA) Polytrauma Rehabilitation Centers.

PARTICIPANTS

A subset of participants in the VA TBI Model Systems multicenter longitudinal study with known SOF status. These included 157 participants who identified as SOF personnel (average age = 41.8 years; 96% male, 81% active duty), and 365 who identified as Conventional Forces personnel (average age = 37.4 years; 92% male, 30% active duty).

DESIGN

Retrospective analysis of prospective cohort, cross-sectional.

MAIN MEASURES

The Health Comorbidities Interview.

RESULTS

SOF personnel were more likely to have deployed to a combat zone, had more years of active duty service, and were more likely active duty at time of TBI. SOF personnel were more likely to have had mild TBI (vs moderate/severe) and their TBI caused by violent mechanism. SOF personnel had a higher number of comorbidities, with more diagnoses of chronic pain, osteoarthritis, hyperlipidemia, hip fractures, and obstructive sleep apnea.

CONCLUSION

SOF personnel are at a higher risk for multimorbidity after TBI. Current rehabilitation practices should incorporate early screening and treatment of common conditions in this population, while future practices may benefit from a focus on prevention.

Psychosocial and Functional Predictors of Depression and Anxiety Symptoms in Veterans and Service Members With TBI: A VA TBI Model Systems Study

OBJECTIVE

To identify psychosocial and functional predictors of self-reported depression and anxiety symptoms at year 2 following traumatic brain injury (TBI).

SETTING

Five Department of Veterans Affairs (VA) Polytrauma Rehabilitation Centers (PRCs) within the TBI Model Systems (TBIMS).

PARTICIPANTS

A total of 319 service members/veterans enrolled in VA TBIMS who were eligible for and completed both 1- and 2-year follow-up evaluations.

DESIGN

Secondary analysis from multicenter prospective longitudinal study.

MAIN MEASURES

Demographic, injury-related, military, mental health, and substance use variables. Questionnaires included the Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), and Neurobehavioral Symptom Inventory. Rating scales included the Participation Assessment with Recombined Tools-Objective and Disability Rating Scale.

RESULTS

The final sample was largely male (96%) and predominantly White (65%), with a median age of 27 years. In unadjusted analyses, pre-TBI mental health treatment history and year 1 employment status, community activity, sleep difficulties, and self-reported depression and anxiety symptoms were associated with year 2 PHQ-9 scores; pre-TBI mental health treatment history and year 1 community activity, social contact, problematic substance use, sleep difficulties, and self-reported depression and anxiety symptoms were associated with year 2 GAD-7 scores. In multivariable analyses, only year 1 community activity and depression symptoms uniquely predicted year 2 PHQ-9 scores, and only year 1 employment status, community activity, problematic substance use, and anxiety symptoms uniquely predicted year 2 GAD-7 scores.

CONCLUSION

Anxiety and depression commonly occur after TBI and are important treatment targets. Some predictors (eg, participation and substance use) are modifiable and amenable to treatment as well. Early identification of anxiety and depression symptoms is key.

Race/Ethnicity and Community Participation Among Veterans and Service Members With Traumatic Brain Injury: A VA Traumatic Brain Injury Model Systems Study

OBJECTIVE

To examine racial/ethnic disparities in community participation among veterans and active duty service members with traumatic brain injury (TBI).

SETTING

Five Department of Veterans Affairs (VA) TBI Model Systems (TBIMS) Polytrauma Rehabilitation Centers (PRCs). Participants: Three hundred forty-two community-dwelling adults (251 White, 34 Black, and 57 Hispanic) with TBI enrolled in the VA TBIMS National Database who completed a 1-year follow-up interview. Mean age was 38.6 years (range, 19-84 years).

DESIGN

Cross-sectional analysis of a prospective observational cohort study. Main Measures: Community participation at 1 year postinjury assessed by 3 domains of the Participation Assessment with Recombined Tools-Objective (PART-O): Out & About, Productivity, and Social Relations.

RESULTS

Significant differences were observed among race/ethnicity groups in PART-O Productivity and Out & About domains without controlling for relevant participant characteristics; Productivity scores were significantly higher for non-Hispanic Black than for non-Hispanic White participants (t = 2.40, P = .0169). Out & About scores were significantly higher for Hispanic than for non-Hispanic White participants (t = 2.79, P = .0056). However, after controlling for demographic, injury severity, and 1-year follow-up characteristics, only differences in the Out & About domain remained statistically significant (t = 2.62, P = .0094), with scores being significantly higher for Hispanics than for non-Hispanic Whites.

CONCLUSIONS

The results, which differ from findings from studies conducted in non-VA healthcare settings where there are greater racial/ethnic disparities in participation outcomes, could reflect differences between military and civilian samples that may reduce disparities.

Network Analysis of Neurobehavioral and Posttraumatic Stress Disorder Symptoms One Year after Traumatic Brain Injury: A Veterans Affairs TBI Model Systems Study

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.

Neurobehavioral Symptoms in U.S. Special Operations Forces in Rehabilitation After Traumatic Brain Injury: A TBI Model Systems Study

INTRODUCTION

Special Operations Forces (SOF) personnel are at increased risk for traumatic brain injury (TBI), when compared with conventional forces (CF). Prior studies of TBI in military samples have not typically investigated SOF vs. CF as specific subgroups, despite documented differences in premorbid resilience and post-injury comorbidity burden. The aim of the current study was to compare SOF vs. CF on the presence of neurobehavioral symptoms after TBI, as well as factors influencing perception of symptom intensity.

MATERIALS AND METHODS

This study conducted an analysis of the prospective veterans affairs (VA) TBI Model Systems Cohort, which includes service members and veterans (SM/V) who received inpatient rehabilitation for TBI at one of the five VA Polytrauma Rehabilitation Centers. Of those with known SOF status (N = 342), 129 participants identified as SOF (average age = 43 years, 98% male) and 213 identified as CF (average age = 38.7 years, 91% male). SOF vs. CF were compared on demographics, injury characteristics, and psychological and behavioral health symptoms. These variables were then used to predict neurobehavioral symptom severity in univariable and multivariable analyses.

RESULTS

SOF personnel reported significantly greater posttraumatic stress disorder (PTSD) symptoms but less alcohol and drug use than the CF. SOF also reported greater neurobehavioral symptoms. When examining those with TBIs of all severities, SOF status was not associated with neurobehavioral symptom severity, while race, mechanism of TBI, and PTSD symptoms were. When examining only those with mTBI, SOF status was associated with lower neurobehavioral symptoms, while PTSD severity, white race, and certain mechanisms of injury were associated with greater neurobehavioral symptoms.

CONCLUSIONS

Among those receiving inpatient treatment for TBI, SOF SM/V reported higher neurobehavioral and symptom severity. PTSD was the strongest predictor of neurobehavioral symptoms and should be considered an important treatment target in both SOF and CF with co-morbid PTSD/TBI. A proactive human performance approach towards identification and treatment of psychological and neurobehavioral symptoms is recommended for SOF.

Performance validity testing via telehealth and failure rate in veterans with moderate-to-severe traumatic brain injury: A veterans affairs TBI model systems study

BACKGROUND

The COVID-19 pandemic has led to increased utilization of teleneuropsychology (TeleNP) services. Unfortunately, investigations of performance validity tests (PVT) delivered via TeleNP are sparse.

OBJECTIVE

The purpose of this study was to examine the specificity of the Reliable Digit Span (RDS) and 21-item test administered via telephoneMETHOD:Participants were 51 veterans with moderate-to-severe traumatic brain injury (TBI). All participants completed the RDS and 21-item test in the context of a larger TeleNP battery. Specificity rates were examined across multiple cutoffs for both PVTs.

RESULTS

Consistent with research employing traditional face-to-face neuropsychological evaluations, both PVTs maintained adequate specificity (i.e., >  90%) across previously established cutoffs. Specifically, defining performance invalidity as RDS <  7 or 21-item test forced choice total correct <  11 led to <  10%false positive classification errors.

CONCLUSIONS

Findings add to the limited body of research examining and provide preliminary support for the use of the RDS and 21-item test in TeleNP via telephone. Both measures maintained adequate specificity in veterans with moderate-to-severe TBI. Future investigations including clinical or experimental "feigners" in a counter-balanced cross-over design (i.e., face-to-face vs. TeleNP) are recommended.

Rehabilitation Needs at 5 Years Post-Traumatic Brain Injury: A VA TBI Model Systems Study

OBJECTIVE

Describe rehabilitation needs and factors associated with unmet needs at 5 years post-traumatic brain injury (TBI).

SETTING

Five Veterans Affairs (VA) polytrauma rehabilitation centers (PRCs).

PARTICIPANTS

VA TBI Model Systems participants (N = 283; 96% male, 75%, 57% severe TBI).

DESIGN

Prospective observational cohort.

MAIN MEASURES

Rehabilitation Needs Survey (21-item survey that assesses cognitive, emotional, social, and functional needs); Craig Hospital Inventory of Environmental Factors (25-item survey of potential environmental barriers).

RESULTS

Participants endorsed a mean of 8 (SD: 6.2) ongoing and 3 (SD: 4.7) unmet rehabilitation needs at 5 years post-TBI. Approximately 65% of participants reported at least 1 rehabilitation need that remained unmet. The number and nature of needs differed across TBI severity groups. In unadjusted and adjusted linear regression models, Black race and environmental barriers (Craig Hospital Inventory of Environmental Factors total score) were predictive of unmet needs (P < .001). Those with greater unmet needs reported the physical environment (54%-63%), informational sources (54%), social attitudes (55%), healthcare access (40%), public policy (32%-37%), transportation availability (33%), and in-home assistance (32%) as the most frequent environmental barriers at 5 years post-TBI.

CONCLUSION

Veterans and Service Members continue to have rehabilitation needs at 5 years post-TBI. Veterans Affairs programs to address ongoing needs and policy to support them are needed.

Development of the traumatic brain injury Rehabilitation Needs Survey: a Veterans Affairs TBI Model Systems study

PURPOSE

To describe the development of the Rehabilitation Needs Survey (RNS) for persons in the chronic phase of traumatic brain injury (TBI) recovery.

MATERIALS AND METHODS

RNS items were generated following a literature review (January - March 2015) on the topic of rehabilitation needs and revised via consensus from an expert panel of TBI clinicians and researchers. The RNS was added to the VA TBI Model Systems longitudinal study; data collection occurred between 2015-2019. Needs were classified as current (if endorsed) or absent; if current, needs were classified as unmet if no help was received. Need frequency and association with rehabilitation outcomes were presented.

RESULTS

Eight studies examined rehabilitation needs and formed the initial item pool of 42 needs. This was reduced to form the 21-item RNS which was administered at year 1 (n = 260) and year 2 (n = 297) post-TBI. Number of needs endorsed was 8-9, and number of unmet needs was 1-2, on average. Number of needs was correlated with functional status, neurobehavioral symptoms, and mental health symptoms (p < 0.05) suggesting support for convergent validity of the RNS.

CONCLUSION

The RNS is a new measure of rehabilitation needs following TBI. Further investigation into its psychometrics and clinical utility is recommended.Implications for rehabilitationVeterans and Service Members with traumatic brain injury across the severity spectrum have ongoing rehabilitation needs during the chronic phase of recovery.The Rehabilitation Needs Survey is a standardized measure of rehabilitation needs following traumatic brain injury.Identification of unmet rehabilitation needs is important for raising awareness of service gaps and providing justification for resource allocation.

Evolution of Irritability, Anger, and Aggression after Traumatic Brain Injury: Identifying and Predicting Subgroups

The current prospective, multi-center, longitudinal cohort study examined how veterans/service members (V/SM) changed in their irritability, anger, and aggression (IAA) scores from admission to discharge in post-acute rehabilitation settings. The goals were to identify trajectory subgroups, and explore if there were different predictors of the subgroups. V/SM (n = 346) from five Veterans Affairs TBI Model Systems Polytrauma Rehabilitation Centers participated. The sample was mostly men (92%) and identified as white (69%), black (13%), and other races (18%). Median age was 28 years, and 78% had sustained a severe TBI. Staff rated IAA at admission and discharge using the Mayo-Portland Adaptability Inventory-4 item#15. Four IAA trajectory subgroups were identified: (1) no IAA at admission or discharge (n = 89, 25.72%), (2) resolved IAA (n = 61, 17.63%), (3) delayed onset IAA (n = 31, 8.96%), and (4) persistent IAA (n = 165, 47.69%). Greater post-traumatic stress disorder (PTSD) symptoms were the only consistent predictor of belonging to all the subgroups who had IAA compared with the no IAA subgroup. We conclude that IAA had different trajectories after a TBI. The majority of V/SM had persistent impairment from IAA, a quarter of the sample had no impairment from IAA, and fewer participants had resolving or worsening IAA. Findings emphasize the importance of educating providers and family of the different ways and times that IAA can manifest after TBI. Timely diagnosis and treatment of PTSD symptoms during and after rehabilitation are critical treatment targets.

What is the risk of recurrent concussion in children and adolescents aged 5-18 years? A systematic review and meta-analysis

OBJECTIVE

We aimed to examine the risk of concussion in children with a previous history of concussion.

DESIGN

Systematic review and meta-analysis. The primary outcome was number of children with and without a previous lifetime history of concussion who sustained a diagnosed concussion within each study period. Risk of bias was assessed using the Newcastle-Ottawa Scale. A random effects model was used to estimate a pooled risk ratio (RR) with corresponding 95% CIs; results were summarised in forest plots.

DATA SOURCES

Four electronic databases (MEDLINE, Embase, CINAHL, SPORTDiscus) and selected reference lists were searched (PROSPERO registration No CRD42019135462).

ELIGIBILITY CRITERIA

Original English language peer-reviewed publications that compared concussion risk in children aged 5-18 years with and without a previous concussion history in which risk estimates were reported or able to be calculated.

RESULTS

Of 732 identified studies, 7 studies representing 23 411 children (risk of bias range, 7-9; maximum possible score=9) were included for meta-analysis. Pooled risk of sustaining a concussion was more than three times greater in children with a previous concussion compared with those with no previous concussion (RR=3.64; 95% CI: 2.68 to 4.96; p<0.0001; I ²=90.55%). Unreported sex-stratified data precluded direct comparison of concussion risk in male versus female athletes.

CONCLUSION

Previously concussed children have four times the risk of sustaining a concussion compared with those with no previous concussion history. This should be a consideration for clinicians in return to sport decision-making. Future studies examining subsequent recurrent concussion in youth sports must consider sex differences.

Unmet Rehabilitation Needs Indirectly Influence Life Satisfaction 5 Years After Traumatic Brain Injury: A Veterans Affairs TBI Model Systems Study

OBJECTIVE

To describe the association between unmet rehabilitation needs and life satisfaction 5 years after traumatic brain injury (TBI).

DESIGN

Prospective observational cohort.

SETTING

Five Veterans Affairs (VA) Polytrauma Rehabilitation Centers.

PARTICIPANTS

VA TBI Model Systems participants (N=301); 95% male; 77% white; average age, 39±14y).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Satisfaction With Life Scale (SWLS).

RESULTS

Average SWLS score was 22±8. Univariable analyses demonstrated several statistically significant predictors of life satisfaction, including employment status, participation, psychiatric symptom severity, past year mental health treatment, and total number of unmet rehabilitation needs (all P<.05). Multivariable analyses revealed that depression and participation were each associated with life satisfaction. An ad hoc mediation model suggested that unmet rehabilitation needs total was indirectly related to life satisfaction. Total unmet rehabilitation needs ranged from 0-21 (mean, 2.0±3.4). Correlational analyses showed that 14 of the 21 unmet rehabilitation needs were associated with life satisfaction.

CONCLUSIONS

Findings support the need for rehabilitation engagement in later stages of TBI recovery. Ongoing assessment of and intervention for unmet rehabilitation needs in the chronic phase of recovery have the potential to mitigate decline in life satisfaction.

Vocational Rehabilitation in the Veterans Health Administration Polytrauma System of Care: Current Practices, Unique Challenges, and Future Directions

OBJECTIVE/PURPOSE

Veterans and service members (V/SMs) with traumatic brain injury (TBI) and comorbid conditions are treated in the Veterans Health Administration (VHA) Polytrauma System of Care (PSC). These V/SMs comprise a unique population with distinct needs for restoring community reintegration, including participation in meaningful employment. Low employment rates after TBI vary and are influenced by many factors. Employment is a central aspect of the VHA priority of facilitating adjustment, and addressing vocational needs alongside healthcare is critical to community reintegration. The purpose of this article is to outline current practices of addressing vocational rehabilitation in the PSC, discuss the unique challenges in serving Veterans with polytrauma, and outline future directions to improve vocational services and outcomes.

METHODS

Briefly review literature on V/SM with TBI and employment, describe the PSC and VHA vocational programs for V/SM with polytrauma, and synthesize proceedings on vocational rehabilitation from the 2017 VHA "Community Reintegration in the Polytrauma System of Care" meeting.

CONCLUSIONS

To advance and expand vocational services the following guidelines were recommended: (1) designing flexible services based on individualized needs, (2) increasing access to vocational services through communication and collaboration, (3) promoting cross-disciplinary education and engagement in vocational care, and (4) systematically tracking employment outcomes.

Incidence and predictors of adherence to sleep apnea treatment in rehabilitation inpatients with acquired brain injury

OBJECTIVE

The purpose of this study was to describe incidence and assess predictors of adherence to Positive Airway Pressure (PAP) therapy for Obstructive Sleep Apnea (OSA) in persons with acquired brain injury (ABI).

METHODS

A 2012-2015 retrospective analysis of consecutive ABI patients admitted for neurorehabilitation, referred for polysomnography (PSG), and prescribed PAP for OSA. Univariable linear regressions were conducted to examine predictors of average hours of nightly PAP use. Univariable logistic regressions were conducted to examine predictors of PAP adherence using the conventional clinical definition of ≥4 h per night ≥70% of the time. Persons with traumatic etiology were separately analyzed.

RESULTS

ABI etiology was 51% traumatic, 36% stroke, and 13% other nontraumatic causes. Nearly two-thirds were nonadherent to PAP. For the overall sample, higher average nightly PAP usage was significantly predicted by positive hypertension diagnosis (β = 0.271, p = 0.019). Likewise, greater adherence based on the conventional cutoff was predicted by poorer motor functioning at hospital admission (OR = 0.98, p = 0.001) and lower oxygen saturation nadir (OR = 0.99, p = 0.003). For those with traumatic injuries, greater adherence was predicted by poorer functional status at hospital admission (OR = 0.98, p = 0.010) and positive hypertension diagnosis (OR = 0.16, p = 0.023).

CONCLUSIONS

In this study of hospitalized neurorehabilitation patients with ABI and comorbid OSA, predictors of adherence included lower oxygen saturation, poorer functional status and hypertension diagnosis, perhaps signifying the role of greater severity of illness on treatment adherence. High rates of refusal and nonadherence to frontline PAP therapy for sleep apnea is a concern for persons in recovery form ABI who are at a time of critical neural repair.

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.

Linking the GAD-7 and PHQ-9 to the TBI-QOL Anxiety and Depression Item Banks

OBJECTIVE

To link scores on commonly used measures of anxiety (7-item Generalized Anxiety Disorder Scale; GAD-7) and depression (9-item Patient Health Questionnaire; PHQ-9) to the Traumatic Brain Injury Quality of Life (TBI-QOL) measurement system.

SETTING

5 Traumatic Brain Injury Model Systems.

PARTICIPANTS

A total of 385 individuals with traumatic brain injury (TBI) (31% complicated mild; 14% moderate; and 54% severe).

DESIGN

Observational cohort.

MAIN MEASURES

GAD-7, PHQ-9, TBI-QOL Anxiety v1.0 and TBI-QOL Depression v1.0.

RESULTS

Item response theory-based linking methods were used to create crosswalk tables that convert scores on the GAD-7 to the TBI-QOL Anxiety metric and scores on the PHQ-9 to the TBI-QOL Depression metric. Comparisons between actual and crosswalked scores suggest that the linkages were successful and are appropriate for group-level analysis. Linking functions closely mirror crosswalks between the GAD-7/PHQ-9 and the Patient-Reported Outcomes Measurement Information System (PROMIS), suggesting that general population linkages are similar to those from a TBI sample.

CONCLUSION

Researchers and clinicians can use the crosswalk tables to transform scores on the GAD-7 and the PHQ-9 to the TBI-QOL metric for group-level analyses.

Postrehabilitation Mental Health Treatment Utilization in Veterans With Traumatic Brain Injury: A VA TBI Model Systems Study

OBJECTIVE

To identify preinjury variables related to mental health treatment utilization at 2 years post-traumatic brain injury (TBI).

SETTING

Veterans Affairs (VA) TBI Model Systems includes 5 VA Polytrauma Rehabilitation Centers.

PARTICIPANTS

Veterans and service members enrolled in TBI Model Systems who completed the year 2 follow-up assessment and provided mental health information. Sample was largely male (97%) and White (72%), with median age of 30 years.

DESIGN

Participants with elevated mental health symptoms were identified by measures of depression, anxiety, and posttraumatic distress; suicide attempt in the past year; or problematic substance use in the past year. Forty-seven percent of participants had elevated mental health symptoms at 2 years postinjury. Among those with elevated symptoms, comparisons were made between those who sought mental health treatment in past year and those who did not.

MAIN MEASURES

Demographic, historic, environmental, psychological/mental health, and injury/rehabilitation variables.

RESULTS

Within the sample, 23% denied utilizing mental health services. Nonutilizers were more likely to deny a preinjury mental health treatment history, to report problematic substance use at year 2, and to report lower levels of internalizing symptoms than the treatment utilizers.

CONCLUSION

Veterans and service members with elevated mental health symptoms may require tailored tactics to promote treatment utilization post-TBI.

Assessing Postconcussive Reaction Time Using Transport-Based Morphometry of Diffusion Tensor Images

BACKGROUND AND PURPOSE

Cognitive deficits are among the most commonly reported post-concussive symptoms, yet the underlying microstructural injury is poorly understood. Our aim was to discover white matter injury underlying reaction time in mild traumatic brain injury DTI by applying transport-based morphometry.

MATERIALS AND METHODS

In this retrospective study, we performed DTI on 64 postconcussive patients (10-28 years of age; 69% male, 31% female) between January 2006 and March 2013. We measured the reaction time percentile by using Immediate Post-Concussion Assessment and Cognitive Testing. Using the 3D transport-based morphometry technique we developed, we mined fractional anisotropy maps to extract the common microstructural injury associated with reaction time percentile in an automated manner. Permutation testing established statistical significance of the extracted injuries. We visualized the physical substrate responsible for reaction time through inverse transport-based morphometry transformation.

RESULTS

The direction in the transport space most correlated with reaction time was significant after correcting for covariates of age, sex, and time from injury (Pearson r = 0.44, P < .01). Inverting the computed direction using transport-based morphometry illustrates physical shifts in fractional anisotropy in the corpus callosum (increase) and within the optic radiations, corticospinal tracts, and anterior thalamic radiations (decrease) with declining reaction time. The observed shifts are consistent with biologic pathways underlying the visual-spatial interpretation and response-selection aspects of reaction time.

CONCLUSIONS

Transport-based morphometry discovers complex white matter injury underlying postconcussive reaction time in an automated manner. The potential influences of edema and axonal loss are visualized in the visual-spatial interpretation and response-selection pathways. Transport-based morphometry can bridge the gap between brain microstructure and function in diseases in which the structural basis is unknown.

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.

Altered brain microstructure in association with repetitive subconcussive head impacts and the potential protective effect of jugular vein compression: a longitudinal study of female soccer athletes

PURPOSE

To (1) quantify white matter (WM) alterations in female high school athletes during a soccer season and characterise the potential for normalisation during the off-season rest period, (2) determine the association between WM alterations and exposure to repetitive subconcussive head impacts, and (3) evaluate the efficacy of a jugular vein compression collar to prevent WM alterations associated with head impact exposure.

METHODS

Diffusion tensor imaging (DTI) data were prospectively collected from high school female soccer participants (14-18 years) at up to three time points over 9 months. Head impacts were monitored using accelerometers during all practices and games. Participants were assigned to a collar (n=24) or non-collar group (n=22). The Tract-Based Spatial Statistics approach was used in the analysis of within-group longitudinal change and between-group comparisons.

RESULTS

DTI analyses revealed significant pre-season to post-season WM changes in the non-collar group in mean diffusivity (2.83%±2.46%), axial diffusivity (2.58%±2.34%) and radial diffusivity (3.52%±2.60%), but there was no significant change in the collar group despite similar head impact exposure. Significant correlation was found between head impact exposure and pre-season to post-season DTI changes in the non-collar group. WM changes in the non-collar group partially resolved at 3 months off-season follow-up.

DISCUSSION

Microstructural changes in WM occurred during a season of female high school soccer among athletes who did not wear the collar device. In comparison, there were no changes in players who wore the collar, suggesting a potential prophylactic effect of the collar device in preventing changes associated with repetitive head impacts. In those without collar use, the microstructural changes showed a reversal towards normal over time in the off-season follow-up period.

Predictors of Satisfaction With Life in Veterans After Traumatic Brain Injury: A VA TBI Model Systems Study

OBJECTIVE

To identify predictors of satisfaction with life in Veterans 1 year after traumatic brain injury (TBI).

SETTING

The VA TBI Model Systems (TBIMS) project includes 5 Veterans Affairs (VA) Polytrauma Rehabilitation Centers.

PARTICIPANTS

Veterans enrolled in the VA TBIMS study who completed the Satisfaction With Life Scale at year 1 follow-up. The sample is largely male (96%) and Caucasian (72%), with a median age of 27 years upon enrollment.

DESIGN

Prospective observational cohort study measuring including demographics (eg, education), preinjury variables (eg, mental health history and employment), and military variables (eg, injury during deployment and injury during active duty status).

MAIN OUTCOME MEASURE

Satisfaction With Life Scale.

RESULTS

Multivariate regression analyses revealed that age, marital status, preinjury employment status, preinjury mental health history, and active duty status at the time of injury were significant predictors of life satisfaction at year 1 follow-up.

CONCLUSIONS

Results of this study suggest that satisfaction with life in Veterans with TBI is mediated by several factors that might inform rehabilitation interventions and discharge recommendations. Preinjury variables and active duty status (a unique aspect of the Veteran population) influence life satisfaction at 1 year postinjury. Limitations and future clinical implications will be discussed.

Rehospitalization in the First Year Following Veteran and Service Member TBI: A VA TBI Model Systems Study

OBJECTIVE

To determine the incidence and causes of rehospitalization following military or Veteran traumatic brain injury (TBI).

SETTING

Department of Veterans Affairs (VA) Veterans Health Administration Polytrauma Rehabilitation Centers (VHA PRCs).

PARTICIPANTS

Consecutive sample of VHA TBI Model System participants (N = 401).

DESIGN

Prospective observational cohort study.

MAIN MEASURES

Number and type of rehospitalizations in first year post-TBI.

RESULTS

Forty-one percent of 401 participants were rehospitalized. Rehospitalization status was associated with greater injury severity and receipt of TBI while active duty. Of those rehospitalized, 30% had 2 or more readmissions. Participants experiencing multiple rehospitalizations (2+) were more likely to have sustained their TBI during deployment than those with none or single rehospitalization. This group also sustained more severe injuries and spent more time in VA PRC inpatient rehabilitation. Common reasons for rehospitalization included inpatient rehabilitation (33%), unspecified (26%), orthopedic (10%), seizures (8%), infection (8%), and psychiatric (7%).

CONCLUSION

This is the first study examining military and Veteran rehospitalization following TBI requiring inpatient rehabilitation at a VA PRC. Findings indicate frequent rehospitalizations in the first year postinjury, suggesting the need for preventive models of health maintenance following inpatient rehabilitation discharge. Greater surveillance of those with deployment-related TBI or active duty at the time of injury and greater TBI severity may be warranted.

Relationship Stability After Traumatic Brain Injury Among Veterans and Service Members: A VA TBI Model Systems Study

OBJECTIVE

To explore stability of relationships and predictors of change in relationship status 2 years following TBI/polytrauma.

SETTING

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

PARTICIPANTS

A total of 357 active duty service members and Veterans enrolled in the Veterans Affairs Polytrauma Rehabilitation Centers Traumatic Brain Injury Model Systems database with complete marital status information at 2 years postinjury.

DESIGN

Prospective, longitudinal, multisite.

MAIN MEASURES

Relationship status change was defined as change in marital status (single/never married; married; divorced/separated) at 2-year follow-up, compared with status at enrollment.

RESULTS

At the time of enrollment, 134 participants (38%) were single/never married; 151 (42%) were married, and 72 (20%) were divorced/separated. Of those married at enrollment, 78% remained married at year 2 while 22% underwent negative change. Multivariable analyses revealed that age and education at the time of injury and mental health utilization prior to injury were significant predictors of relationship change. Among those who were single/divorced/separated at the time of enrollment, 87% remained so at year 2 while 13% underwent positive change. Injury during deployment significantly predicted positive relationship change.

CONCLUSIONS

The unmalleable, preinjury characteristics identified may be used as potential triggers for education, prevention, surveillance, and couples therapy, if needed.

Change in body mass index within the first-year post-injury: a VA Traumatic Brain Injury (TBI) model systems study

OBJECTIVE

To describe change in body mass index (BMI) and weight classification 1-year post- traumatic brain injury (TBI) among Veterans and service members.

DESIGN

Prospective observational cohort study.

SETTING

VA Polytrauma Rehabilitation Centers.

PARTICIPANTS

Veterans and service members (N = 84) enrolled in VA Traumatic Brain Injury Model Systems (VA TBIMS) study with BMI scores at enrollment and 1-year post-injury.

INTERVENTIONS

N/A.

MAIN OUTCOME MEASURES

BMI scores from height and weight and weight classifications (underweight, normal weight, overweight, obese classes 1-3) defined by WHO.

RESULTS

Twenty per cent were obese at time of injury and 24% were obese at 1-year post-injury. Cross-tab analyses revealed 7% of normal weight and 24% overweight participants at time of injury as obese Class 1 one-year post-injury. Univariate models found BMI and tobacco smoking at time of injury were significant predictors of higher BMI scores 1-year post-TBI. Multivariable models found BMI at time of injury and motor functioning, were significant predictors. Preinjury BMI, tobacco smoking and PTSD symptom severity predicted change in weight category.

CONCLUSION

While obesity among service members and Veterans post-TBI is below national averages, trends in weight gain between time of injury and 1-year follow-up were observed. Implications for health promotion and chronic disease management efforts with regards to rehabilitation for injured military are discussed. List of Abbreviations: BMI, Body mass index; BRFSS, Behavioural Risk Factor Surveillance; GCS, Glasgow Coma Scale; FIM, Functional Independence Measure; NIDILRR, National Institute on Independent Living and Rehabilitation Research; PCL-C, PTSD checklist-civilian; PSTD, Post-traumatic stress disorder; VA, Veterans Affairs; VA PRC, Veterans Affairs Polytrauma Rehabilitation; VA TBIMS, Veterans Affairs TBI Model Systems.

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

OBJECTIVES

To examine community reintegration problems among Veterans and military service members with mild or moderate/severe traumatic brain injury (TBI) at 1 year postinjury and to identify unique predictors that may contribute to these difficulties.

SETTING

VA Polytrauma Rehabilitation Centers.

PARTICIPANTS

Participants were 154 inpatients enrolled in the VA TBI Model Systems Program with available injury severity data (mild = 28.6%; moderate/severe = 71.4%) and 1-year postinjury outcome data.

DESIGN

Prospective, longitudinal cohort.

MAIN MEASURES

Community reintegration outcomes included independent driving, employability, and general community participation. Additional measures assessed depression, posttraumatic stress, and cognitive and motor functioning.

RESULTS

In the mild TBI (mTBI) group, posttraumatic stress disorder and depressive symptoms were associated with lower levels of various community reintegration outcomes. In the moderate/severe TBI group, cognition and motor skills were significantly associated with lower levels of community participation, independent driving, and employability.

CONCLUSION

Community reintegration is problematic for Veterans and active duty service members with a history of TBI. Unique comorbidities across injury severity groups inhibit full reintegration into the community. These findings highlight the ongoing rehabilitation needs of persons with TBI, specifically evidence-based mental healthcare, in comprehensive rehabilitation programs consistent with a chronic disease management model.

Utility of the Neurobehavioral Symptom Inventory As an Outcome Measure: A VA TBI Model Systems Study

OBJECTIVE

To examine the utility of the Neurobehavioral Symptom Inventory (NSI)-a measure of postconcussion symptoms used within the Veterans Health Administration-as an index of rehabilitation outcome.

SETTING

Veterans Administration Polytrauma Rehabilitation Centers Traumatic Brain Injury (TBI) Model Systems program.

PARTICIPANTS

A total of 159 Veterans (14% with mild TBI; 86% with moderate-severe TBI).

MAIN MEASURES

Disability Rating Scale; Functional Independence Measure; Glasgow Outcome Scale-Extended; NSI; Participation Assessment with Recombined Tools-Objective; Posttraumatic Stress Disorder Checklist-Civilian Version; Satisfaction With Life Scale; Supervision Rating Scale.

ANALYSES

Correlations and exploratory factor analyses examined the interrelations among outcome measures. Hierarchical regression analyses were utilized to determine if the NSI predicted rehabilitation outcome measures after controlling for demographic variables, TBI severity, and time since injury. NSI reliable changes from pretreatment to 1-year follow-up were examined. Receiver operating characteristics curve analyses were conducted to evaluate the ability of changes in the NSI to predict meaningful change in functioning and employment status.

RESULTS

The NSI correlated with psychological distress measures. The NSI administered prior to brain injury rehabilitation had limited predictive utility beyond satisfaction with life. A minority of patients (32%) demonstrated reliable changes on the NSI from baseline to 1-year follow-up. Changes on the NSI were not predictive of meaningful change in employment or functioning.

CONCLUSION

The NSI was not useful for assessing meaningful change in a sample of mixed severity TBI patients.