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de Souza NL, Lindsey HM, Dorman K, Dennis EL, Kennedy E, Menefee DS, Parrott JS, Jia Y, Pugh MJV, Walker WC, Tate DF, Cifu DX, Bailie JM, Davenport ND, Martindale SL, O'Neil M, Rowland JA, Scheibel RS, Sponheim SR, Troyanskaya M, Wilde EA, Esopenko C. Neuropsychological Profiles of Deployment-Related Mild Traumatic Brain Injury: A LIMBIC-CENC Study. Neurology 2024; 102:e209417. [PMID: 38833650 PMCID: PMC11226312 DOI: 10.1212/wnl.0000000000209417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 02/29/2024] [Indexed: 06/06/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Traumatic brain injury (TBI) is a concern for US service members and veterans (SMV), leading to heterogeneous psychological and cognitive outcomes. We sought to identify neuropsychological profiles of mild TBI (mTBI) and posttraumatic stress disorder (PTSD) among the largest SMV sample to date. METHODS We analyzed cross-sectional baseline data from SMV with prior combat deployments enrolled in the ongoing Long-term Impact of Military-relevant Brain Injury Consortium-Chronic Effects of Neurotrauma Consortium prospective longitudinal study. Latent profile analysis identified symptom profiles using 35 indicators, including physical symptoms, depression, quality of life, sleep quality, postconcussive symptoms, and cognitive performance. It is important to note that the profiles were determined independently of mTBI and probable PTSD status. After profile identification, we examined associations between demographic variables, mTBI characteristics, and PTSD symptoms with symptom profile membership. RESULTS The analytic sample included 1,659 SMV (mean age 41.1 ± 10.0 years; 87% male); among them 29% (n = 480) had a history of non-deployment-related mTBI only, 14% (n = 239) had deployment-related mTBI only, 36% (n = 602) had both non-deployment and deployment-related mTBI, and 30% (n = 497) met criteria for probable PTSD. A 6-profile model had the best fit, with separation on all indicators (p < 0.001). The model revealed distinct neuropsychological profiles, representing a combination of 3 self-reported functioning patterns: high (HS), moderate (MS), and low (LS), and 2 cognitive performance patterns: high (HC) and low (LC). The profiles were (1) HS/HC: n=301, 18.1%; (2) HS/LC: n=294, 17.7%; (3) MS/HC: n=359, 21.6%; (4) MS/LC: n=316, 19.0%; (5) LS/HC: n=228, 13.7%; and (6) LS/LC: n=161, 9.7%. SMV with deployment-related mTBI tended to be grouped into lower functioning profiles and were more likely to meet criteria for probable PTSD. Conversely, SMV with no mTBI exposure or non-deployment-related mTBI were clustered in higher functioning profiles and had a lower likelihood of meeting criteria for probable PTSD. DISCUSSION Findings suggest varied symptom and functional profiles in SMV, influenced by injury context and probable PTSD comorbidity. Despite diagnostic challenges, comprehensive assessment of functioning and cognition can detect subtle differences related to mTBI and PTSD, revealing distinct neuropsychological profiles. Prioritizing early treatment based on these profiles may improve prognostication and support efficient recovery.
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Affiliation(s)
- Nicola L de Souza
- From the Department of Rehabilitation and Human Performance (N.L.D., K.D., C.E.), Icahn School of Medicine at Mount Sinai, New York, NY; Traumatic Brain Injury and Concussion Center (H.M.L., E.L.D., D.F.T., E.A.W.), Department of Neurology, University of Utah School of Medicine, Salt Lake City; George E. Wahlen VA Salt Lake City Healthcare System (H.M.L., E.L.D., D.F.T., E.A.W.), UT; VA Salt Lake City Health Care System (E.K., M.J.V.P.), Informatics, Decision-Enhancement and Analytic Sciences Center, UT; Department of Medicine (E.K., M.J.V.P.), Division of Epidemiology, University of Utah School of Medicine, Salt Lake City; Michael E. DeBakey VA Medical Center (D.S.M., R.S.S., M.T.), Houston, TX; The Menninger Psychiatric and Behavioral Services Department (D.S.M.), Baylor College of Medicine, Houston, TX; Department of Interdisciplinary Studies (J.S.P., Y.J.), School of Health Professions, Rutgers Biomedical and Health Sciences, Newark, NJ; Department of Physical Medicine and Rehabilitation (W.C.W., D.X.C.), School of Medicine, Virginia Commonwealth University, Richmond; Physical Medicine and Rehabilitation Service (W.C.W., D.X.C.), Richmond Veterans Affairs Medical Center, VA; Traumatic Brain Injury Center of Excellence (J.M.B.), Bethesda, MD; Naval Hospital Camp Pendleton (J.M.B.), Camp Pendleton, CA; General Dynamics Information Technology (J.M.B.), Fairfax, VA; Minneapolis VA Health Care System (N.D.D.), MN; Department of Psychiatry and Behavioral Sciences (N.D.D., S.R.S.), University of Minnesota, Minneapolis; Research and Academic Affairs Service Line (S.L.M., J.A.R.), W. G. (Bill) Hefner VA Healthcare System, Salisbury, NC; Department of Translational Neuroscience (S.L.M., J.A.R.), Wake Forest School of Medicine, Winston-Salem, NC; VA Portland Health Care System (M.O.), Portland, OR; Oregon Health & Science University (M.O.), Department of Psychiatry and Department of Medicine Informatics and Clinical Epidemiology, Portland; Mid-Atlantic (VISN-6) Mental Illness Research, Education, and Clinical Center (MIRECC) (S.L.M., J.A.R.), Durham, NC; Department of Neurobiology and Anatomy (J.A.R.), Wake Forest School of Medicine, Winston-Salem, NC; H. Ben Taub Department of Physical Medicine and Rehabilitation (R.S.S., M.T.), Baylor College of Medicine, Houston, TX; Minneapolis VA Health Care System (S.R.S.), MN
| | - Hannah M Lindsey
- From the Department of Rehabilitation and Human Performance (N.L.D., K.D., C.E.), Icahn School of Medicine at Mount Sinai, New York, NY; Traumatic Brain Injury and Concussion Center (H.M.L., E.L.D., D.F.T., E.A.W.), Department of Neurology, University of Utah School of Medicine, Salt Lake City; George E. Wahlen VA Salt Lake City Healthcare System (H.M.L., E.L.D., D.F.T., E.A.W.), UT; VA Salt Lake City Health Care System (E.K., M.J.V.P.), Informatics, Decision-Enhancement and Analytic Sciences Center, UT; Department of Medicine (E.K., M.J.V.P.), Division of Epidemiology, University of Utah School of Medicine, Salt Lake City; Michael E. DeBakey VA Medical Center (D.S.M., R.S.S., M.T.), Houston, TX; The Menninger Psychiatric and Behavioral Services Department (D.S.M.), Baylor College of Medicine, Houston, TX; Department of Interdisciplinary Studies (J.S.P., Y.J.), School of Health Professions, Rutgers Biomedical and Health Sciences, Newark, NJ; Department of Physical Medicine and Rehabilitation (W.C.W., D.X.C.), School of Medicine, Virginia Commonwealth University, Richmond; Physical Medicine and Rehabilitation Service (W.C.W., D.X.C.), Richmond Veterans Affairs Medical Center, VA; Traumatic Brain Injury Center of Excellence (J.M.B.), Bethesda, MD; Naval Hospital Camp Pendleton (J.M.B.), Camp Pendleton, CA; General Dynamics Information Technology (J.M.B.), Fairfax, VA; Minneapolis VA Health Care System (N.D.D.), MN; Department of Psychiatry and Behavioral Sciences (N.D.D., S.R.S.), University of Minnesota, Minneapolis; Research and Academic Affairs Service Line (S.L.M., J.A.R.), W. G. (Bill) Hefner VA Healthcare System, Salisbury, NC; Department of Translational Neuroscience (S.L.M., J.A.R.), Wake Forest School of Medicine, Winston-Salem, NC; VA Portland Health Care System (M.O.), Portland, OR; Oregon Health & Science University (M.O.), Department of Psychiatry and Department of Medicine Informatics and Clinical Epidemiology, Portland; Mid-Atlantic (VISN-6) Mental Illness Research, Education, and Clinical Center (MIRECC) (S.L.M., J.A.R.), Durham, NC; Department of Neurobiology and Anatomy (J.A.R.), Wake Forest School of Medicine, Winston-Salem, NC; H. Ben Taub Department of Physical Medicine and Rehabilitation (R.S.S., M.T.), Baylor College of Medicine, Houston, TX; Minneapolis VA Health Care System (S.R.S.), MN
| | - Katherine Dorman
- From the Department of Rehabilitation and Human Performance (N.L.D., K.D., C.E.), Icahn School of Medicine at Mount Sinai, New York, NY; Traumatic Brain Injury and Concussion Center (H.M.L., E.L.D., D.F.T., E.A.W.), Department of Neurology, University of Utah School of Medicine, Salt Lake City; George E. Wahlen VA Salt Lake City Healthcare System (H.M.L., E.L.D., D.F.T., E.A.W.), UT; VA Salt Lake City Health Care System (E.K., M.J.V.P.), Informatics, Decision-Enhancement and Analytic Sciences Center, UT; Department of Medicine (E.K., M.J.V.P.), Division of Epidemiology, University of Utah School of Medicine, Salt Lake City; Michael E. DeBakey VA Medical Center (D.S.M., R.S.S., M.T.), Houston, TX; The Menninger Psychiatric and Behavioral Services Department (D.S.M.), Baylor College of Medicine, Houston, TX; Department of Interdisciplinary Studies (J.S.P., Y.J.), School of Health Professions, Rutgers Biomedical and Health Sciences, Newark, NJ; Department of Physical Medicine and Rehabilitation (W.C.W., D.X.C.), School of Medicine, Virginia Commonwealth University, Richmond; Physical Medicine and Rehabilitation Service (W.C.W., D.X.C.), Richmond Veterans Affairs Medical Center, VA; Traumatic Brain Injury Center of Excellence (J.M.B.), Bethesda, MD; Naval Hospital Camp Pendleton (J.M.B.), Camp Pendleton, CA; General Dynamics Information Technology (J.M.B.), Fairfax, VA; Minneapolis VA Health Care System (N.D.D.), MN; Department of Psychiatry and Behavioral Sciences (N.D.D., S.R.S.), University of Minnesota, Minneapolis; Research and Academic Affairs Service Line (S.L.M., J.A.R.), W. G. (Bill) Hefner VA Healthcare System, Salisbury, NC; Department of Translational Neuroscience (S.L.M., J.A.R.), Wake Forest School of Medicine, Winston-Salem, NC; VA Portland Health Care System (M.O.), Portland, OR; Oregon Health & Science University (M.O.), Department of Psychiatry and Department of Medicine Informatics and Clinical Epidemiology, Portland; Mid-Atlantic (VISN-6) Mental Illness Research, Education, and Clinical Center (MIRECC) (S.L.M., J.A.R.), Durham, NC; Department of Neurobiology and Anatomy (J.A.R.), Wake Forest School of Medicine, Winston-Salem, NC; H. Ben Taub Department of Physical Medicine and Rehabilitation (R.S.S., M.T.), Baylor College of Medicine, Houston, TX; Minneapolis VA Health Care System (S.R.S.), MN
| | - Emily L Dennis
- From the Department of Rehabilitation and Human Performance (N.L.D., K.D., C.E.), Icahn School of Medicine at Mount Sinai, New York, NY; Traumatic Brain Injury and Concussion Center (H.M.L., E.L.D., D.F.T., E.A.W.), Department of Neurology, University of Utah School of Medicine, Salt Lake City; George E. Wahlen VA Salt Lake City Healthcare System (H.M.L., E.L.D., D.F.T., E.A.W.), UT; VA Salt Lake City Health Care System (E.K., M.J.V.P.), Informatics, Decision-Enhancement and Analytic Sciences Center, UT; Department of Medicine (E.K., M.J.V.P.), Division of Epidemiology, University of Utah School of Medicine, Salt Lake City; Michael E. DeBakey VA Medical Center (D.S.M., R.S.S., M.T.), Houston, TX; The Menninger Psychiatric and Behavioral Services Department (D.S.M.), Baylor College of Medicine, Houston, TX; Department of Interdisciplinary Studies (J.S.P., Y.J.), School of Health Professions, Rutgers Biomedical and Health Sciences, Newark, NJ; Department of Physical Medicine and Rehabilitation (W.C.W., D.X.C.), School of Medicine, Virginia Commonwealth University, Richmond; Physical Medicine and Rehabilitation Service (W.C.W., D.X.C.), Richmond Veterans Affairs Medical Center, VA; Traumatic Brain Injury Center of Excellence (J.M.B.), Bethesda, MD; Naval Hospital Camp Pendleton (J.M.B.), Camp Pendleton, CA; General Dynamics Information Technology (J.M.B.), Fairfax, VA; Minneapolis VA Health Care System (N.D.D.), MN; Department of Psychiatry and Behavioral Sciences (N.D.D., S.R.S.), University of Minnesota, Minneapolis; Research and Academic Affairs Service Line (S.L.M., J.A.R.), W. G. (Bill) Hefner VA Healthcare System, Salisbury, NC; Department of Translational Neuroscience (S.L.M., J.A.R.), Wake Forest School of Medicine, Winston-Salem, NC; VA Portland Health Care System (M.O.), Portland, OR; Oregon Health & Science University (M.O.), Department of Psychiatry and Department of Medicine Informatics and Clinical Epidemiology, Portland; Mid-Atlantic (VISN-6) Mental Illness Research, Education, and Clinical Center (MIRECC) (S.L.M., J.A.R.), Durham, NC; Department of Neurobiology and Anatomy (J.A.R.), Wake Forest School of Medicine, Winston-Salem, NC; H. Ben Taub Department of Physical Medicine and Rehabilitation (R.S.S., M.T.), Baylor College of Medicine, Houston, TX; Minneapolis VA Health Care System (S.R.S.), MN
| | - Eamonn Kennedy
- From the Department of Rehabilitation and Human Performance (N.L.D., K.D., C.E.), Icahn School of Medicine at Mount Sinai, New York, NY; Traumatic Brain Injury and Concussion Center (H.M.L., E.L.D., D.F.T., E.A.W.), Department of Neurology, University of Utah School of Medicine, Salt Lake City; George E. Wahlen VA Salt Lake City Healthcare System (H.M.L., E.L.D., D.F.T., E.A.W.), UT; VA Salt Lake City Health Care System (E.K., M.J.V.P.), Informatics, Decision-Enhancement and Analytic Sciences Center, UT; Department of Medicine (E.K., M.J.V.P.), Division of Epidemiology, University of Utah School of Medicine, Salt Lake City; Michael E. DeBakey VA Medical Center (D.S.M., R.S.S., M.T.), Houston, TX; The Menninger Psychiatric and Behavioral Services Department (D.S.M.), Baylor College of Medicine, Houston, TX; Department of Interdisciplinary Studies (J.S.P., Y.J.), School of Health Professions, Rutgers Biomedical and Health Sciences, Newark, NJ; Department of Physical Medicine and Rehabilitation (W.C.W., D.X.C.), School of Medicine, Virginia Commonwealth University, Richmond; Physical Medicine and Rehabilitation Service (W.C.W., D.X.C.), Richmond Veterans Affairs Medical Center, VA; Traumatic Brain Injury Center of Excellence (J.M.B.), Bethesda, MD; Naval Hospital Camp Pendleton (J.M.B.), Camp Pendleton, CA; General Dynamics Information Technology (J.M.B.), Fairfax, VA; Minneapolis VA Health Care System (N.D.D.), MN; Department of Psychiatry and Behavioral Sciences (N.D.D., S.R.S.), University of Minnesota, Minneapolis; Research and Academic Affairs Service Line (S.L.M., J.A.R.), W. G. (Bill) Hefner VA Healthcare System, Salisbury, NC; Department of Translational Neuroscience (S.L.M., J.A.R.), Wake Forest School of Medicine, Winston-Salem, NC; VA Portland Health Care System (M.O.), Portland, OR; Oregon Health & Science University (M.O.), Department of Psychiatry and Department of Medicine Informatics and Clinical Epidemiology, Portland; Mid-Atlantic (VISN-6) Mental Illness Research, Education, and Clinical Center (MIRECC) (S.L.M., J.A.R.), Durham, NC; Department of Neurobiology and Anatomy (J.A.R.), Wake Forest School of Medicine, Winston-Salem, NC; H. Ben Taub Department of Physical Medicine and Rehabilitation (R.S.S., M.T.), Baylor College of Medicine, Houston, TX; Minneapolis VA Health Care System (S.R.S.), MN
| | - Deleene S Menefee
- From the Department of Rehabilitation and Human Performance (N.L.D., K.D., C.E.), Icahn School of Medicine at Mount Sinai, New York, NY; Traumatic Brain Injury and Concussion Center (H.M.L., E.L.D., D.F.T., E.A.W.), Department of Neurology, University of Utah School of Medicine, Salt Lake City; George E. Wahlen VA Salt Lake City Healthcare System (H.M.L., E.L.D., D.F.T., E.A.W.), UT; VA Salt Lake City Health Care System (E.K., M.J.V.P.), Informatics, Decision-Enhancement and Analytic Sciences Center, UT; Department of Medicine (E.K., M.J.V.P.), Division of Epidemiology, University of Utah School of Medicine, Salt Lake City; Michael E. DeBakey VA Medical Center (D.S.M., R.S.S., M.T.), Houston, TX; The Menninger Psychiatric and Behavioral Services Department (D.S.M.), Baylor College of Medicine, Houston, TX; Department of Interdisciplinary Studies (J.S.P., Y.J.), School of Health Professions, Rutgers Biomedical and Health Sciences, Newark, NJ; Department of Physical Medicine and Rehabilitation (W.C.W., D.X.C.), School of Medicine, Virginia Commonwealth University, Richmond; Physical Medicine and Rehabilitation Service (W.C.W., D.X.C.), Richmond Veterans Affairs Medical Center, VA; Traumatic Brain Injury Center of Excellence (J.M.B.), Bethesda, MD; Naval Hospital Camp Pendleton (J.M.B.), Camp Pendleton, CA; General Dynamics Information Technology (J.M.B.), Fairfax, VA; Minneapolis VA Health Care System (N.D.D.), MN; Department of Psychiatry and Behavioral Sciences (N.D.D., S.R.S.), University of Minnesota, Minneapolis; Research and Academic Affairs Service Line (S.L.M., J.A.R.), W. G. (Bill) Hefner VA Healthcare System, Salisbury, NC; Department of Translational Neuroscience (S.L.M., J.A.R.), Wake Forest School of Medicine, Winston-Salem, NC; VA Portland Health Care System (M.O.), Portland, OR; Oregon Health & Science University (M.O.), Department of Psychiatry and Department of Medicine Informatics and Clinical Epidemiology, Portland; Mid-Atlantic (VISN-6) Mental Illness Research, Education, and Clinical Center (MIRECC) (S.L.M., J.A.R.), Durham, NC; Department of Neurobiology and Anatomy (J.A.R.), Wake Forest School of Medicine, Winston-Salem, NC; H. Ben Taub Department of Physical Medicine and Rehabilitation (R.S.S., M.T.), Baylor College of Medicine, Houston, TX; Minneapolis VA Health Care System (S.R.S.), MN
| | - J Scott Parrott
- From the Department of Rehabilitation and Human Performance (N.L.D., K.D., C.E.), Icahn School of Medicine at Mount Sinai, New York, NY; Traumatic Brain Injury and Concussion Center (H.M.L., E.L.D., D.F.T., E.A.W.), Department of Neurology, University of Utah School of Medicine, Salt Lake City; George E. Wahlen VA Salt Lake City Healthcare System (H.M.L., E.L.D., D.F.T., E.A.W.), UT; VA Salt Lake City Health Care System (E.K., M.J.V.P.), Informatics, Decision-Enhancement and Analytic Sciences Center, UT; Department of Medicine (E.K., M.J.V.P.), Division of Epidemiology, University of Utah School of Medicine, Salt Lake City; Michael E. DeBakey VA Medical Center (D.S.M., R.S.S., M.T.), Houston, TX; The Menninger Psychiatric and Behavioral Services Department (D.S.M.), Baylor College of Medicine, Houston, TX; Department of Interdisciplinary Studies (J.S.P., Y.J.), School of Health Professions, Rutgers Biomedical and Health Sciences, Newark, NJ; Department of Physical Medicine and Rehabilitation (W.C.W., D.X.C.), School of Medicine, Virginia Commonwealth University, Richmond; Physical Medicine and Rehabilitation Service (W.C.W., D.X.C.), Richmond Veterans Affairs Medical Center, VA; Traumatic Brain Injury Center of Excellence (J.M.B.), Bethesda, MD; Naval Hospital Camp Pendleton (J.M.B.), Camp Pendleton, CA; General Dynamics Information Technology (J.M.B.), Fairfax, VA; Minneapolis VA Health Care System (N.D.D.), MN; Department of Psychiatry and Behavioral Sciences (N.D.D., S.R.S.), University of Minnesota, Minneapolis; Research and Academic Affairs Service Line (S.L.M., J.A.R.), W. G. (Bill) Hefner VA Healthcare System, Salisbury, NC; Department of Translational Neuroscience (S.L.M., J.A.R.), Wake Forest School of Medicine, Winston-Salem, NC; VA Portland Health Care System (M.O.), Portland, OR; Oregon Health & Science University (M.O.), Department of Psychiatry and Department of Medicine Informatics and Clinical Epidemiology, Portland; Mid-Atlantic (VISN-6) Mental Illness Research, Education, and Clinical Center (MIRECC) (S.L.M., J.A.R.), Durham, NC; Department of Neurobiology and Anatomy (J.A.R.), Wake Forest School of Medicine, Winston-Salem, NC; H. Ben Taub Department of Physical Medicine and Rehabilitation (R.S.S., M.T.), Baylor College of Medicine, Houston, TX; Minneapolis VA Health Care System (S.R.S.), MN
| | - Yuane Jia
- From the Department of Rehabilitation and Human Performance (N.L.D., K.D., C.E.), Icahn School of Medicine at Mount Sinai, New York, NY; Traumatic Brain Injury and Concussion Center (H.M.L., E.L.D., D.F.T., E.A.W.), Department of Neurology, University of Utah School of Medicine, Salt Lake City; George E. Wahlen VA Salt Lake City Healthcare System (H.M.L., E.L.D., D.F.T., E.A.W.), UT; VA Salt Lake City Health Care System (E.K., M.J.V.P.), Informatics, Decision-Enhancement and Analytic Sciences Center, UT; Department of Medicine (E.K., M.J.V.P.), Division of Epidemiology, University of Utah School of Medicine, Salt Lake City; Michael E. DeBakey VA Medical Center (D.S.M., R.S.S., M.T.), Houston, TX; The Menninger Psychiatric and Behavioral Services Department (D.S.M.), Baylor College of Medicine, Houston, TX; Department of Interdisciplinary Studies (J.S.P., Y.J.), School of Health Professions, Rutgers Biomedical and Health Sciences, Newark, NJ; Department of Physical Medicine and Rehabilitation (W.C.W., D.X.C.), School of Medicine, Virginia Commonwealth University, Richmond; Physical Medicine and Rehabilitation Service (W.C.W., D.X.C.), Richmond Veterans Affairs Medical Center, VA; Traumatic Brain Injury Center of Excellence (J.M.B.), Bethesda, MD; Naval Hospital Camp Pendleton (J.M.B.), Camp Pendleton, CA; General Dynamics Information Technology (J.M.B.), Fairfax, VA; Minneapolis VA Health Care System (N.D.D.), MN; Department of Psychiatry and Behavioral Sciences (N.D.D., S.R.S.), University of Minnesota, Minneapolis; Research and Academic Affairs Service Line (S.L.M., J.A.R.), W. G. (Bill) Hefner VA Healthcare System, Salisbury, NC; Department of Translational Neuroscience (S.L.M., J.A.R.), Wake Forest School of Medicine, Winston-Salem, NC; VA Portland Health Care System (M.O.), Portland, OR; Oregon Health & Science University (M.O.), Department of Psychiatry and Department of Medicine Informatics and Clinical Epidemiology, Portland; Mid-Atlantic (VISN-6) Mental Illness Research, Education, and Clinical Center (MIRECC) (S.L.M., J.A.R.), Durham, NC; Department of Neurobiology and Anatomy (J.A.R.), Wake Forest School of Medicine, Winston-Salem, NC; H. Ben Taub Department of Physical Medicine and Rehabilitation (R.S.S., M.T.), Baylor College of Medicine, Houston, TX; Minneapolis VA Health Care System (S.R.S.), MN
| | - Mary Jo V Pugh
- From the Department of Rehabilitation and Human Performance (N.L.D., K.D., C.E.), Icahn School of Medicine at Mount Sinai, New York, NY; Traumatic Brain Injury and Concussion Center (H.M.L., E.L.D., D.F.T., E.A.W.), Department of Neurology, University of Utah School of Medicine, Salt Lake City; George E. Wahlen VA Salt Lake City Healthcare System (H.M.L., E.L.D., D.F.T., E.A.W.), UT; VA Salt Lake City Health Care System (E.K., M.J.V.P.), Informatics, Decision-Enhancement and Analytic Sciences Center, UT; Department of Medicine (E.K., M.J.V.P.), Division of Epidemiology, University of Utah School of Medicine, Salt Lake City; Michael E. DeBakey VA Medical Center (D.S.M., R.S.S., M.T.), Houston, TX; The Menninger Psychiatric and Behavioral Services Department (D.S.M.), Baylor College of Medicine, Houston, TX; Department of Interdisciplinary Studies (J.S.P., Y.J.), School of Health Professions, Rutgers Biomedical and Health Sciences, Newark, NJ; Department of Physical Medicine and Rehabilitation (W.C.W., D.X.C.), School of Medicine, Virginia Commonwealth University, Richmond; Physical Medicine and Rehabilitation Service (W.C.W., D.X.C.), Richmond Veterans Affairs Medical Center, VA; Traumatic Brain Injury Center of Excellence (J.M.B.), Bethesda, MD; Naval Hospital Camp Pendleton (J.M.B.), Camp Pendleton, CA; General Dynamics Information Technology (J.M.B.), Fairfax, VA; Minneapolis VA Health Care System (N.D.D.), MN; Department of Psychiatry and Behavioral Sciences (N.D.D., S.R.S.), University of Minnesota, Minneapolis; Research and Academic Affairs Service Line (S.L.M., J.A.R.), W. G. (Bill) Hefner VA Healthcare System, Salisbury, NC; Department of Translational Neuroscience (S.L.M., J.A.R.), Wake Forest School of Medicine, Winston-Salem, NC; VA Portland Health Care System (M.O.), Portland, OR; Oregon Health & Science University (M.O.), Department of Psychiatry and Department of Medicine Informatics and Clinical Epidemiology, Portland; Mid-Atlantic (VISN-6) Mental Illness Research, Education, and Clinical Center (MIRECC) (S.L.M., J.A.R.), Durham, NC; Department of Neurobiology and Anatomy (J.A.R.), Wake Forest School of Medicine, Winston-Salem, NC; H. Ben Taub Department of Physical Medicine and Rehabilitation (R.S.S., M.T.), Baylor College of Medicine, Houston, TX; Minneapolis VA Health Care System (S.R.S.), MN
| | - William C Walker
- From the Department of Rehabilitation and Human Performance (N.L.D., K.D., C.E.), Icahn School of Medicine at Mount Sinai, New York, NY; Traumatic Brain Injury and Concussion Center (H.M.L., E.L.D., D.F.T., E.A.W.), Department of Neurology, University of Utah School of Medicine, Salt Lake City; George E. Wahlen VA Salt Lake City Healthcare System (H.M.L., E.L.D., D.F.T., E.A.W.), UT; VA Salt Lake City Health Care System (E.K., M.J.V.P.), Informatics, Decision-Enhancement and Analytic Sciences Center, UT; Department of Medicine (E.K., M.J.V.P.), Division of Epidemiology, University of Utah School of Medicine, Salt Lake City; Michael E. DeBakey VA Medical Center (D.S.M., R.S.S., M.T.), Houston, TX; The Menninger Psychiatric and Behavioral Services Department (D.S.M.), Baylor College of Medicine, Houston, TX; Department of Interdisciplinary Studies (J.S.P., Y.J.), School of Health Professions, Rutgers Biomedical and Health Sciences, Newark, NJ; Department of Physical Medicine and Rehabilitation (W.C.W., D.X.C.), School of Medicine, Virginia Commonwealth University, Richmond; Physical Medicine and Rehabilitation Service (W.C.W., D.X.C.), Richmond Veterans Affairs Medical Center, VA; Traumatic Brain Injury Center of Excellence (J.M.B.), Bethesda, MD; Naval Hospital Camp Pendleton (J.M.B.), Camp Pendleton, CA; General Dynamics Information Technology (J.M.B.), Fairfax, VA; Minneapolis VA Health Care System (N.D.D.), MN; Department of Psychiatry and Behavioral Sciences (N.D.D., S.R.S.), University of Minnesota, Minneapolis; Research and Academic Affairs Service Line (S.L.M., J.A.R.), W. G. (Bill) Hefner VA Healthcare System, Salisbury, NC; Department of Translational Neuroscience (S.L.M., J.A.R.), Wake Forest School of Medicine, Winston-Salem, NC; VA Portland Health Care System (M.O.), Portland, OR; Oregon Health & Science University (M.O.), Department of Psychiatry and Department of Medicine Informatics and Clinical Epidemiology, Portland; Mid-Atlantic (VISN-6) Mental Illness Research, Education, and Clinical Center (MIRECC) (S.L.M., J.A.R.), Durham, NC; Department of Neurobiology and Anatomy (J.A.R.), Wake Forest School of Medicine, Winston-Salem, NC; H. Ben Taub Department of Physical Medicine and Rehabilitation (R.S.S., M.T.), Baylor College of Medicine, Houston, TX; Minneapolis VA Health Care System (S.R.S.), MN
| | - David F Tate
- From the Department of Rehabilitation and Human Performance (N.L.D., K.D., C.E.), Icahn School of Medicine at Mount Sinai, New York, NY; Traumatic Brain Injury and Concussion Center (H.M.L., E.L.D., D.F.T., E.A.W.), Department of Neurology, University of Utah School of Medicine, Salt Lake City; George E. Wahlen VA Salt Lake City Healthcare System (H.M.L., E.L.D., D.F.T., E.A.W.), UT; VA Salt Lake City Health Care System (E.K., M.J.V.P.), Informatics, Decision-Enhancement and Analytic Sciences Center, UT; Department of Medicine (E.K., M.J.V.P.), Division of Epidemiology, University of Utah School of Medicine, Salt Lake City; Michael E. DeBakey VA Medical Center (D.S.M., R.S.S., M.T.), Houston, TX; The Menninger Psychiatric and Behavioral Services Department (D.S.M.), Baylor College of Medicine, Houston, TX; Department of Interdisciplinary Studies (J.S.P., Y.J.), School of Health Professions, Rutgers Biomedical and Health Sciences, Newark, NJ; Department of Physical Medicine and Rehabilitation (W.C.W., D.X.C.), School of Medicine, Virginia Commonwealth University, Richmond; Physical Medicine and Rehabilitation Service (W.C.W., D.X.C.), Richmond Veterans Affairs Medical Center, VA; Traumatic Brain Injury Center of Excellence (J.M.B.), Bethesda, MD; Naval Hospital Camp Pendleton (J.M.B.), Camp Pendleton, CA; General Dynamics Information Technology (J.M.B.), Fairfax, VA; Minneapolis VA Health Care System (N.D.D.), MN; Department of Psychiatry and Behavioral Sciences (N.D.D., S.R.S.), University of Minnesota, Minneapolis; Research and Academic Affairs Service Line (S.L.M., J.A.R.), W. G. (Bill) Hefner VA Healthcare System, Salisbury, NC; Department of Translational Neuroscience (S.L.M., J.A.R.), Wake Forest School of Medicine, Winston-Salem, NC; VA Portland Health Care System (M.O.), Portland, OR; Oregon Health & Science University (M.O.), Department of Psychiatry and Department of Medicine Informatics and Clinical Epidemiology, Portland; Mid-Atlantic (VISN-6) Mental Illness Research, Education, and Clinical Center (MIRECC) (S.L.M., J.A.R.), Durham, NC; Department of Neurobiology and Anatomy (J.A.R.), Wake Forest School of Medicine, Winston-Salem, NC; H. Ben Taub Department of Physical Medicine and Rehabilitation (R.S.S., M.T.), Baylor College of Medicine, Houston, TX; Minneapolis VA Health Care System (S.R.S.), MN
| | - David X Cifu
- From the Department of Rehabilitation and Human Performance (N.L.D., K.D., C.E.), Icahn School of Medicine at Mount Sinai, New York, NY; Traumatic Brain Injury and Concussion Center (H.M.L., E.L.D., D.F.T., E.A.W.), Department of Neurology, University of Utah School of Medicine, Salt Lake City; George E. Wahlen VA Salt Lake City Healthcare System (H.M.L., E.L.D., D.F.T., E.A.W.), UT; VA Salt Lake City Health Care System (E.K., M.J.V.P.), Informatics, Decision-Enhancement and Analytic Sciences Center, UT; Department of Medicine (E.K., M.J.V.P.), Division of Epidemiology, University of Utah School of Medicine, Salt Lake City; Michael E. DeBakey VA Medical Center (D.S.M., R.S.S., M.T.), Houston, TX; The Menninger Psychiatric and Behavioral Services Department (D.S.M.), Baylor College of Medicine, Houston, TX; Department of Interdisciplinary Studies (J.S.P., Y.J.), School of Health Professions, Rutgers Biomedical and Health Sciences, Newark, NJ; Department of Physical Medicine and Rehabilitation (W.C.W., D.X.C.), School of Medicine, Virginia Commonwealth University, Richmond; Physical Medicine and Rehabilitation Service (W.C.W., D.X.C.), Richmond Veterans Affairs Medical Center, VA; Traumatic Brain Injury Center of Excellence (J.M.B.), Bethesda, MD; Naval Hospital Camp Pendleton (J.M.B.), Camp Pendleton, CA; General Dynamics Information Technology (J.M.B.), Fairfax, VA; Minneapolis VA Health Care System (N.D.D.), MN; Department of Psychiatry and Behavioral Sciences (N.D.D., S.R.S.), University of Minnesota, Minneapolis; Research and Academic Affairs Service Line (S.L.M., J.A.R.), W. G. (Bill) Hefner VA Healthcare System, Salisbury, NC; Department of Translational Neuroscience (S.L.M., J.A.R.), Wake Forest School of Medicine, Winston-Salem, NC; VA Portland Health Care System (M.O.), Portland, OR; Oregon Health & Science University (M.O.), Department of Psychiatry and Department of Medicine Informatics and Clinical Epidemiology, Portland; Mid-Atlantic (VISN-6) Mental Illness Research, Education, and Clinical Center (MIRECC) (S.L.M., J.A.R.), Durham, NC; Department of Neurobiology and Anatomy (J.A.R.), Wake Forest School of Medicine, Winston-Salem, NC; H. Ben Taub Department of Physical Medicine and Rehabilitation (R.S.S., M.T.), Baylor College of Medicine, Houston, TX; Minneapolis VA Health Care System (S.R.S.), MN
| | - Jason M Bailie
- From the Department of Rehabilitation and Human Performance (N.L.D., K.D., C.E.), Icahn School of Medicine at Mount Sinai, New York, NY; Traumatic Brain Injury and Concussion Center (H.M.L., E.L.D., D.F.T., E.A.W.), Department of Neurology, University of Utah School of Medicine, Salt Lake City; George E. Wahlen VA Salt Lake City Healthcare System (H.M.L., E.L.D., D.F.T., E.A.W.), UT; VA Salt Lake City Health Care System (E.K., M.J.V.P.), Informatics, Decision-Enhancement and Analytic Sciences Center, UT; Department of Medicine (E.K., M.J.V.P.), Division of Epidemiology, University of Utah School of Medicine, Salt Lake City; Michael E. DeBakey VA Medical Center (D.S.M., R.S.S., M.T.), Houston, TX; The Menninger Psychiatric and Behavioral Services Department (D.S.M.), Baylor College of Medicine, Houston, TX; Department of Interdisciplinary Studies (J.S.P., Y.J.), School of Health Professions, Rutgers Biomedical and Health Sciences, Newark, NJ; Department of Physical Medicine and Rehabilitation (W.C.W., D.X.C.), School of Medicine, Virginia Commonwealth University, Richmond; Physical Medicine and Rehabilitation Service (W.C.W., D.X.C.), Richmond Veterans Affairs Medical Center, VA; Traumatic Brain Injury Center of Excellence (J.M.B.), Bethesda, MD; Naval Hospital Camp Pendleton (J.M.B.), Camp Pendleton, CA; General Dynamics Information Technology (J.M.B.), Fairfax, VA; Minneapolis VA Health Care System (N.D.D.), MN; Department of Psychiatry and Behavioral Sciences (N.D.D., S.R.S.), University of Minnesota, Minneapolis; Research and Academic Affairs Service Line (S.L.M., J.A.R.), W. G. (Bill) Hefner VA Healthcare System, Salisbury, NC; Department of Translational Neuroscience (S.L.M., J.A.R.), Wake Forest School of Medicine, Winston-Salem, NC; VA Portland Health Care System (M.O.), Portland, OR; Oregon Health & Science University (M.O.), Department of Psychiatry and Department of Medicine Informatics and Clinical Epidemiology, Portland; Mid-Atlantic (VISN-6) Mental Illness Research, Education, and Clinical Center (MIRECC) (S.L.M., J.A.R.), Durham, NC; Department of Neurobiology and Anatomy (J.A.R.), Wake Forest School of Medicine, Winston-Salem, NC; H. Ben Taub Department of Physical Medicine and Rehabilitation (R.S.S., M.T.), Baylor College of Medicine, Houston, TX; Minneapolis VA Health Care System (S.R.S.), MN
| | - Nicholas D Davenport
- From the Department of Rehabilitation and Human Performance (N.L.D., K.D., C.E.), Icahn School of Medicine at Mount Sinai, New York, NY; Traumatic Brain Injury and Concussion Center (H.M.L., E.L.D., D.F.T., E.A.W.), Department of Neurology, University of Utah School of Medicine, Salt Lake City; George E. Wahlen VA Salt Lake City Healthcare System (H.M.L., E.L.D., D.F.T., E.A.W.), UT; VA Salt Lake City Health Care System (E.K., M.J.V.P.), Informatics, Decision-Enhancement and Analytic Sciences Center, UT; Department of Medicine (E.K., M.J.V.P.), Division of Epidemiology, University of Utah School of Medicine, Salt Lake City; Michael E. DeBakey VA Medical Center (D.S.M., R.S.S., M.T.), Houston, TX; The Menninger Psychiatric and Behavioral Services Department (D.S.M.), Baylor College of Medicine, Houston, TX; Department of Interdisciplinary Studies (J.S.P., Y.J.), School of Health Professions, Rutgers Biomedical and Health Sciences, Newark, NJ; Department of Physical Medicine and Rehabilitation (W.C.W., D.X.C.), School of Medicine, Virginia Commonwealth University, Richmond; Physical Medicine and Rehabilitation Service (W.C.W., D.X.C.), Richmond Veterans Affairs Medical Center, VA; Traumatic Brain Injury Center of Excellence (J.M.B.), Bethesda, MD; Naval Hospital Camp Pendleton (J.M.B.), Camp Pendleton, CA; General Dynamics Information Technology (J.M.B.), Fairfax, VA; Minneapolis VA Health Care System (N.D.D.), MN; Department of Psychiatry and Behavioral Sciences (N.D.D., S.R.S.), University of Minnesota, Minneapolis; Research and Academic Affairs Service Line (S.L.M., J.A.R.), W. G. (Bill) Hefner VA Healthcare System, Salisbury, NC; Department of Translational Neuroscience (S.L.M., J.A.R.), Wake Forest School of Medicine, Winston-Salem, NC; VA Portland Health Care System (M.O.), Portland, OR; Oregon Health & Science University (M.O.), Department of Psychiatry and Department of Medicine Informatics and Clinical Epidemiology, Portland; Mid-Atlantic (VISN-6) Mental Illness Research, Education, and Clinical Center (MIRECC) (S.L.M., J.A.R.), Durham, NC; Department of Neurobiology and Anatomy (J.A.R.), Wake Forest School of Medicine, Winston-Salem, NC; H. Ben Taub Department of Physical Medicine and Rehabilitation (R.S.S., M.T.), Baylor College of Medicine, Houston, TX; Minneapolis VA Health Care System (S.R.S.), MN
| | - Sarah L Martindale
- From the Department of Rehabilitation and Human Performance (N.L.D., K.D., C.E.), Icahn School of Medicine at Mount Sinai, New York, NY; Traumatic Brain Injury and Concussion Center (H.M.L., E.L.D., D.F.T., E.A.W.), Department of Neurology, University of Utah School of Medicine, Salt Lake City; George E. Wahlen VA Salt Lake City Healthcare System (H.M.L., E.L.D., D.F.T., E.A.W.), UT; VA Salt Lake City Health Care System (E.K., M.J.V.P.), Informatics, Decision-Enhancement and Analytic Sciences Center, UT; Department of Medicine (E.K., M.J.V.P.), Division of Epidemiology, University of Utah School of Medicine, Salt Lake City; Michael E. DeBakey VA Medical Center (D.S.M., R.S.S., M.T.), Houston, TX; The Menninger Psychiatric and Behavioral Services Department (D.S.M.), Baylor College of Medicine, Houston, TX; Department of Interdisciplinary Studies (J.S.P., Y.J.), School of Health Professions, Rutgers Biomedical and Health Sciences, Newark, NJ; Department of Physical Medicine and Rehabilitation (W.C.W., D.X.C.), School of Medicine, Virginia Commonwealth University, Richmond; Physical Medicine and Rehabilitation Service (W.C.W., D.X.C.), Richmond Veterans Affairs Medical Center, VA; Traumatic Brain Injury Center of Excellence (J.M.B.), Bethesda, MD; Naval Hospital Camp Pendleton (J.M.B.), Camp Pendleton, CA; General Dynamics Information Technology (J.M.B.), Fairfax, VA; Minneapolis VA Health Care System (N.D.D.), MN; Department of Psychiatry and Behavioral Sciences (N.D.D., S.R.S.), University of Minnesota, Minneapolis; Research and Academic Affairs Service Line (S.L.M., J.A.R.), W. G. (Bill) Hefner VA Healthcare System, Salisbury, NC; Department of Translational Neuroscience (S.L.M., J.A.R.), Wake Forest School of Medicine, Winston-Salem, NC; VA Portland Health Care System (M.O.), Portland, OR; Oregon Health & Science University (M.O.), Department of Psychiatry and Department of Medicine Informatics and Clinical Epidemiology, Portland; Mid-Atlantic (VISN-6) Mental Illness Research, Education, and Clinical Center (MIRECC) (S.L.M., J.A.R.), Durham, NC; Department of Neurobiology and Anatomy (J.A.R.), Wake Forest School of Medicine, Winston-Salem, NC; H. Ben Taub Department of Physical Medicine and Rehabilitation (R.S.S., M.T.), Baylor College of Medicine, Houston, TX; Minneapolis VA Health Care System (S.R.S.), MN
| | - Maya O'Neil
- From the Department of Rehabilitation and Human Performance (N.L.D., K.D., C.E.), Icahn School of Medicine at Mount Sinai, New York, NY; Traumatic Brain Injury and Concussion Center (H.M.L., E.L.D., D.F.T., E.A.W.), Department of Neurology, University of Utah School of Medicine, Salt Lake City; George E. Wahlen VA Salt Lake City Healthcare System (H.M.L., E.L.D., D.F.T., E.A.W.), UT; VA Salt Lake City Health Care System (E.K., M.J.V.P.), Informatics, Decision-Enhancement and Analytic Sciences Center, UT; Department of Medicine (E.K., M.J.V.P.), Division of Epidemiology, University of Utah School of Medicine, Salt Lake City; Michael E. DeBakey VA Medical Center (D.S.M., R.S.S., M.T.), Houston, TX; The Menninger Psychiatric and Behavioral Services Department (D.S.M.), Baylor College of Medicine, Houston, TX; Department of Interdisciplinary Studies (J.S.P., Y.J.), School of Health Professions, Rutgers Biomedical and Health Sciences, Newark, NJ; Department of Physical Medicine and Rehabilitation (W.C.W., D.X.C.), School of Medicine, Virginia Commonwealth University, Richmond; Physical Medicine and Rehabilitation Service (W.C.W., D.X.C.), Richmond Veterans Affairs Medical Center, VA; Traumatic Brain Injury Center of Excellence (J.M.B.), Bethesda, MD; Naval Hospital Camp Pendleton (J.M.B.), Camp Pendleton, CA; General Dynamics Information Technology (J.M.B.), Fairfax, VA; Minneapolis VA Health Care System (N.D.D.), MN; Department of Psychiatry and Behavioral Sciences (N.D.D., S.R.S.), University of Minnesota, Minneapolis; Research and Academic Affairs Service Line (S.L.M., J.A.R.), W. G. (Bill) Hefner VA Healthcare System, Salisbury, NC; Department of Translational Neuroscience (S.L.M., J.A.R.), Wake Forest School of Medicine, Winston-Salem, NC; VA Portland Health Care System (M.O.), Portland, OR; Oregon Health & Science University (M.O.), Department of Psychiatry and Department of Medicine Informatics and Clinical Epidemiology, Portland; Mid-Atlantic (VISN-6) Mental Illness Research, Education, and Clinical Center (MIRECC) (S.L.M., J.A.R.), Durham, NC; Department of Neurobiology and Anatomy (J.A.R.), Wake Forest School of Medicine, Winston-Salem, NC; H. Ben Taub Department of Physical Medicine and Rehabilitation (R.S.S., M.T.), Baylor College of Medicine, Houston, TX; Minneapolis VA Health Care System (S.R.S.), MN
| | - Jared A Rowland
- From the Department of Rehabilitation and Human Performance (N.L.D., K.D., C.E.), Icahn School of Medicine at Mount Sinai, New York, NY; Traumatic Brain Injury and Concussion Center (H.M.L., E.L.D., D.F.T., E.A.W.), Department of Neurology, University of Utah School of Medicine, Salt Lake City; George E. Wahlen VA Salt Lake City Healthcare System (H.M.L., E.L.D., D.F.T., E.A.W.), UT; VA Salt Lake City Health Care System (E.K., M.J.V.P.), Informatics, Decision-Enhancement and Analytic Sciences Center, UT; Department of Medicine (E.K., M.J.V.P.), Division of Epidemiology, University of Utah School of Medicine, Salt Lake City; Michael E. DeBakey VA Medical Center (D.S.M., R.S.S., M.T.), Houston, TX; The Menninger Psychiatric and Behavioral Services Department (D.S.M.), Baylor College of Medicine, Houston, TX; Department of Interdisciplinary Studies (J.S.P., Y.J.), School of Health Professions, Rutgers Biomedical and Health Sciences, Newark, NJ; Department of Physical Medicine and Rehabilitation (W.C.W., D.X.C.), School of Medicine, Virginia Commonwealth University, Richmond; Physical Medicine and Rehabilitation Service (W.C.W., D.X.C.), Richmond Veterans Affairs Medical Center, VA; Traumatic Brain Injury Center of Excellence (J.M.B.), Bethesda, MD; Naval Hospital Camp Pendleton (J.M.B.), Camp Pendleton, CA; General Dynamics Information Technology (J.M.B.), Fairfax, VA; Minneapolis VA Health Care System (N.D.D.), MN; Department of Psychiatry and Behavioral Sciences (N.D.D., S.R.S.), University of Minnesota, Minneapolis; Research and Academic Affairs Service Line (S.L.M., J.A.R.), W. G. (Bill) Hefner VA Healthcare System, Salisbury, NC; Department of Translational Neuroscience (S.L.M., J.A.R.), Wake Forest School of Medicine, Winston-Salem, NC; VA Portland Health Care System (M.O.), Portland, OR; Oregon Health & Science University (M.O.), Department of Psychiatry and Department of Medicine Informatics and Clinical Epidemiology, Portland; Mid-Atlantic (VISN-6) Mental Illness Research, Education, and Clinical Center (MIRECC) (S.L.M., J.A.R.), Durham, NC; Department of Neurobiology and Anatomy (J.A.R.), Wake Forest School of Medicine, Winston-Salem, NC; H. Ben Taub Department of Physical Medicine and Rehabilitation (R.S.S., M.T.), Baylor College of Medicine, Houston, TX; Minneapolis VA Health Care System (S.R.S.), MN
| | - Randall S Scheibel
- From the Department of Rehabilitation and Human Performance (N.L.D., K.D., C.E.), Icahn School of Medicine at Mount Sinai, New York, NY; Traumatic Brain Injury and Concussion Center (H.M.L., E.L.D., D.F.T., E.A.W.), Department of Neurology, University of Utah School of Medicine, Salt Lake City; George E. Wahlen VA Salt Lake City Healthcare System (H.M.L., E.L.D., D.F.T., E.A.W.), UT; VA Salt Lake City Health Care System (E.K., M.J.V.P.), Informatics, Decision-Enhancement and Analytic Sciences Center, UT; Department of Medicine (E.K., M.J.V.P.), Division of Epidemiology, University of Utah School of Medicine, Salt Lake City; Michael E. DeBakey VA Medical Center (D.S.M., R.S.S., M.T.), Houston, TX; The Menninger Psychiatric and Behavioral Services Department (D.S.M.), Baylor College of Medicine, Houston, TX; Department of Interdisciplinary Studies (J.S.P., Y.J.), School of Health Professions, Rutgers Biomedical and Health Sciences, Newark, NJ; Department of Physical Medicine and Rehabilitation (W.C.W., D.X.C.), School of Medicine, Virginia Commonwealth University, Richmond; Physical Medicine and Rehabilitation Service (W.C.W., D.X.C.), Richmond Veterans Affairs Medical Center, VA; Traumatic Brain Injury Center of Excellence (J.M.B.), Bethesda, MD; Naval Hospital Camp Pendleton (J.M.B.), Camp Pendleton, CA; General Dynamics Information Technology (J.M.B.), Fairfax, VA; Minneapolis VA Health Care System (N.D.D.), MN; Department of Psychiatry and Behavioral Sciences (N.D.D., S.R.S.), University of Minnesota, Minneapolis; Research and Academic Affairs Service Line (S.L.M., J.A.R.), W. G. (Bill) Hefner VA Healthcare System, Salisbury, NC; Department of Translational Neuroscience (S.L.M., J.A.R.), Wake Forest School of Medicine, Winston-Salem, NC; VA Portland Health Care System (M.O.), Portland, OR; Oregon Health & Science University (M.O.), Department of Psychiatry and Department of Medicine Informatics and Clinical Epidemiology, Portland; Mid-Atlantic (VISN-6) Mental Illness Research, Education, and Clinical Center (MIRECC) (S.L.M., J.A.R.), Durham, NC; Department of Neurobiology and Anatomy (J.A.R.), Wake Forest School of Medicine, Winston-Salem, NC; H. Ben Taub Department of Physical Medicine and Rehabilitation (R.S.S., M.T.), Baylor College of Medicine, Houston, TX; Minneapolis VA Health Care System (S.R.S.), MN
| | - Scott R Sponheim
- From the Department of Rehabilitation and Human Performance (N.L.D., K.D., C.E.), Icahn School of Medicine at Mount Sinai, New York, NY; Traumatic Brain Injury and Concussion Center (H.M.L., E.L.D., D.F.T., E.A.W.), Department of Neurology, University of Utah School of Medicine, Salt Lake City; George E. Wahlen VA Salt Lake City Healthcare System (H.M.L., E.L.D., D.F.T., E.A.W.), UT; VA Salt Lake City Health Care System (E.K., M.J.V.P.), Informatics, Decision-Enhancement and Analytic Sciences Center, UT; Department of Medicine (E.K., M.J.V.P.), Division of Epidemiology, University of Utah School of Medicine, Salt Lake City; Michael E. DeBakey VA Medical Center (D.S.M., R.S.S., M.T.), Houston, TX; The Menninger Psychiatric and Behavioral Services Department (D.S.M.), Baylor College of Medicine, Houston, TX; Department of Interdisciplinary Studies (J.S.P., Y.J.), School of Health Professions, Rutgers Biomedical and Health Sciences, Newark, NJ; Department of Physical Medicine and Rehabilitation (W.C.W., D.X.C.), School of Medicine, Virginia Commonwealth University, Richmond; Physical Medicine and Rehabilitation Service (W.C.W., D.X.C.), Richmond Veterans Affairs Medical Center, VA; Traumatic Brain Injury Center of Excellence (J.M.B.), Bethesda, MD; Naval Hospital Camp Pendleton (J.M.B.), Camp Pendleton, CA; General Dynamics Information Technology (J.M.B.), Fairfax, VA; Minneapolis VA Health Care System (N.D.D.), MN; Department of Psychiatry and Behavioral Sciences (N.D.D., S.R.S.), University of Minnesota, Minneapolis; Research and Academic Affairs Service Line (S.L.M., J.A.R.), W. G. (Bill) Hefner VA Healthcare System, Salisbury, NC; Department of Translational Neuroscience (S.L.M., J.A.R.), Wake Forest School of Medicine, Winston-Salem, NC; VA Portland Health Care System (M.O.), Portland, OR; Oregon Health & Science University (M.O.), Department of Psychiatry and Department of Medicine Informatics and Clinical Epidemiology, Portland; Mid-Atlantic (VISN-6) Mental Illness Research, Education, and Clinical Center (MIRECC) (S.L.M., J.A.R.), Durham, NC; Department of Neurobiology and Anatomy (J.A.R.), Wake Forest School of Medicine, Winston-Salem, NC; H. Ben Taub Department of Physical Medicine and Rehabilitation (R.S.S., M.T.), Baylor College of Medicine, Houston, TX; Minneapolis VA Health Care System (S.R.S.), MN
| | - Maya Troyanskaya
- From the Department of Rehabilitation and Human Performance (N.L.D., K.D., C.E.), Icahn School of Medicine at Mount Sinai, New York, NY; Traumatic Brain Injury and Concussion Center (H.M.L., E.L.D., D.F.T., E.A.W.), Department of Neurology, University of Utah School of Medicine, Salt Lake City; George E. Wahlen VA Salt Lake City Healthcare System (H.M.L., E.L.D., D.F.T., E.A.W.), UT; VA Salt Lake City Health Care System (E.K., M.J.V.P.), Informatics, Decision-Enhancement and Analytic Sciences Center, UT; Department of Medicine (E.K., M.J.V.P.), Division of Epidemiology, University of Utah School of Medicine, Salt Lake City; Michael E. DeBakey VA Medical Center (D.S.M., R.S.S., M.T.), Houston, TX; The Menninger Psychiatric and Behavioral Services Department (D.S.M.), Baylor College of Medicine, Houston, TX; Department of Interdisciplinary Studies (J.S.P., Y.J.), School of Health Professions, Rutgers Biomedical and Health Sciences, Newark, NJ; Department of Physical Medicine and Rehabilitation (W.C.W., D.X.C.), School of Medicine, Virginia Commonwealth University, Richmond; Physical Medicine and Rehabilitation Service (W.C.W., D.X.C.), Richmond Veterans Affairs Medical Center, VA; Traumatic Brain Injury Center of Excellence (J.M.B.), Bethesda, MD; Naval Hospital Camp Pendleton (J.M.B.), Camp Pendleton, CA; General Dynamics Information Technology (J.M.B.), Fairfax, VA; Minneapolis VA Health Care System (N.D.D.), MN; Department of Psychiatry and Behavioral Sciences (N.D.D., S.R.S.), University of Minnesota, Minneapolis; Research and Academic Affairs Service Line (S.L.M., J.A.R.), W. G. (Bill) Hefner VA Healthcare System, Salisbury, NC; Department of Translational Neuroscience (S.L.M., J.A.R.), Wake Forest School of Medicine, Winston-Salem, NC; VA Portland Health Care System (M.O.), Portland, OR; Oregon Health & Science University (M.O.), Department of Psychiatry and Department of Medicine Informatics and Clinical Epidemiology, Portland; Mid-Atlantic (VISN-6) Mental Illness Research, Education, and Clinical Center (MIRECC) (S.L.M., J.A.R.), Durham, NC; Department of Neurobiology and Anatomy (J.A.R.), Wake Forest School of Medicine, Winston-Salem, NC; H. Ben Taub Department of Physical Medicine and Rehabilitation (R.S.S., M.T.), Baylor College of Medicine, Houston, TX; Minneapolis VA Health Care System (S.R.S.), MN
| | - Elisabeth A Wilde
- From the Department of Rehabilitation and Human Performance (N.L.D., K.D., C.E.), Icahn School of Medicine at Mount Sinai, New York, NY; Traumatic Brain Injury and Concussion Center (H.M.L., E.L.D., D.F.T., E.A.W.), Department of Neurology, University of Utah School of Medicine, Salt Lake City; George E. Wahlen VA Salt Lake City Healthcare System (H.M.L., E.L.D., D.F.T., E.A.W.), UT; VA Salt Lake City Health Care System (E.K., M.J.V.P.), Informatics, Decision-Enhancement and Analytic Sciences Center, UT; Department of Medicine (E.K., M.J.V.P.), Division of Epidemiology, University of Utah School of Medicine, Salt Lake City; Michael E. DeBakey VA Medical Center (D.S.M., R.S.S., M.T.), Houston, TX; The Menninger Psychiatric and Behavioral Services Department (D.S.M.), Baylor College of Medicine, Houston, TX; Department of Interdisciplinary Studies (J.S.P., Y.J.), School of Health Professions, Rutgers Biomedical and Health Sciences, Newark, NJ; Department of Physical Medicine and Rehabilitation (W.C.W., D.X.C.), School of Medicine, Virginia Commonwealth University, Richmond; Physical Medicine and Rehabilitation Service (W.C.W., D.X.C.), Richmond Veterans Affairs Medical Center, VA; Traumatic Brain Injury Center of Excellence (J.M.B.), Bethesda, MD; Naval Hospital Camp Pendleton (J.M.B.), Camp Pendleton, CA; General Dynamics Information Technology (J.M.B.), Fairfax, VA; Minneapolis VA Health Care System (N.D.D.), MN; Department of Psychiatry and Behavioral Sciences (N.D.D., S.R.S.), University of Minnesota, Minneapolis; Research and Academic Affairs Service Line (S.L.M., J.A.R.), W. G. (Bill) Hefner VA Healthcare System, Salisbury, NC; Department of Translational Neuroscience (S.L.M., J.A.R.), Wake Forest School of Medicine, Winston-Salem, NC; VA Portland Health Care System (M.O.), Portland, OR; Oregon Health & Science University (M.O.), Department of Psychiatry and Department of Medicine Informatics and Clinical Epidemiology, Portland; Mid-Atlantic (VISN-6) Mental Illness Research, Education, and Clinical Center (MIRECC) (S.L.M., J.A.R.), Durham, NC; Department of Neurobiology and Anatomy (J.A.R.), Wake Forest School of Medicine, Winston-Salem, NC; H. Ben Taub Department of Physical Medicine and Rehabilitation (R.S.S., M.T.), Baylor College of Medicine, Houston, TX; Minneapolis VA Health Care System (S.R.S.), MN
| | - Carrie Esopenko
- From the Department of Rehabilitation and Human Performance (N.L.D., K.D., C.E.), Icahn School of Medicine at Mount Sinai, New York, NY; Traumatic Brain Injury and Concussion Center (H.M.L., E.L.D., D.F.T., E.A.W.), Department of Neurology, University of Utah School of Medicine, Salt Lake City; George E. Wahlen VA Salt Lake City Healthcare System (H.M.L., E.L.D., D.F.T., E.A.W.), UT; VA Salt Lake City Health Care System (E.K., M.J.V.P.), Informatics, Decision-Enhancement and Analytic Sciences Center, UT; Department of Medicine (E.K., M.J.V.P.), Division of Epidemiology, University of Utah School of Medicine, Salt Lake City; Michael E. DeBakey VA Medical Center (D.S.M., R.S.S., M.T.), Houston, TX; The Menninger Psychiatric and Behavioral Services Department (D.S.M.), Baylor College of Medicine, Houston, TX; Department of Interdisciplinary Studies (J.S.P., Y.J.), School of Health Professions, Rutgers Biomedical and Health Sciences, Newark, NJ; Department of Physical Medicine and Rehabilitation (W.C.W., D.X.C.), School of Medicine, Virginia Commonwealth University, Richmond; Physical Medicine and Rehabilitation Service (W.C.W., D.X.C.), Richmond Veterans Affairs Medical Center, VA; Traumatic Brain Injury Center of Excellence (J.M.B.), Bethesda, MD; Naval Hospital Camp Pendleton (J.M.B.), Camp Pendleton, CA; General Dynamics Information Technology (J.M.B.), Fairfax, VA; Minneapolis VA Health Care System (N.D.D.), MN; Department of Psychiatry and Behavioral Sciences (N.D.D., S.R.S.), University of Minnesota, Minneapolis; Research and Academic Affairs Service Line (S.L.M., J.A.R.), W. G. (Bill) Hefner VA Healthcare System, Salisbury, NC; Department of Translational Neuroscience (S.L.M., J.A.R.), Wake Forest School of Medicine, Winston-Salem, NC; VA Portland Health Care System (M.O.), Portland, OR; Oregon Health & Science University (M.O.), Department of Psychiatry and Department of Medicine Informatics and Clinical Epidemiology, Portland; Mid-Atlantic (VISN-6) Mental Illness Research, Education, and Clinical Center (MIRECC) (S.L.M., J.A.R.), Durham, NC; Department of Neurobiology and Anatomy (J.A.R.), Wake Forest School of Medicine, Winston-Salem, NC; H. Ben Taub Department of Physical Medicine and Rehabilitation (R.S.S., M.T.), Baylor College of Medicine, Houston, TX; Minneapolis VA Health Care System (S.R.S.), MN
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2
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Elliott JE, Ligman BR, Bryant-Ekstrand MD, Keil AT, Powers K, Olivo C, Neilson LE, Postuma RB, Pelletier A, Gagnon JF, Gan-Or Z, Yu E, Liu L, St Louis EK, Forsberg LK, Fields JA, Ross OA, Huddleston DE, Bliwise DL, Avidan AY, Howell MJ, Schenck CH, McLeland J, Criswell SR, Videnovic A, During EH, Miglis MG, Shprecher DR, Lee-Iannotti JK, Boeve BF, Ju YES, Lim MM. Comorbid neurotrauma increases neurodegenerative-relevant cognitive, motor, and autonomic dysfunction in patients with rapid eye movement sleep behavior disorder: a substudy of the North American Prodromal Synucleinopathy Consortium. Sleep 2024; 47:zsae007. [PMID: 38181205 DOI: 10.1093/sleep/zsae007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 12/13/2023] [Indexed: 01/07/2024] Open
Abstract
STUDY OBJECTIVES Rapid eye movement sleep behavior disorder (RBD) is strongly associated with phenoconversion to an overt synucleinopathy, e.g. Parkinson's disease (PD), Lewy body dementia, and related disorders. Comorbid traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD)-henceforth "neurotrauma" (NT)-increase the odds of RBD by ~2.5-fold and are associated with an increased rate of service-connected PD in Veterans. Thus, RBD and NT are both independently associated with PD; however, it is unclear how NT influences neurological function in patients with RBD. METHODS Participants ≥18 years with overnight polysomnogram-confirmed RBD were enrolled between 8/2018 to 4/2021 through the North American Prodromal Synucleinopathy Consortium. Standardized assessments for RBD, TBI, and PTSD history, as well as cognitive, motor, sensory, and autonomic function, were completed. This cross-sectional analysis compared cases (n = 24; RBD + NT) to controls (n = 96; RBD), matched for age (~60 years), sex (15% female), and years of education (~15 years). RESULTS RBD + NT reported earlier RBD symptom onset (37.5 ± 11.9 vs. 52.2 ± 15.1 years of age) and a more severe RBD phenotype. Similarly, RBD + NT reported more severe anxiety and depression, greater frequency of hypertension, and significantly worse cognitive, motor, and autonomic function compared to RBD. No differences in olfaction or color vision were observed. CONCLUSIONS This cross-sectional, matched case:control study shows individuals with RBD + NT have significantly worse neurological measures related to common features of an overt synucleinopathy. Confirmatory longitudinal studies are ongoing; however, these results suggest RBD + NT may be associated with more advanced neurological symptoms related to an evolving neurodegenerative process.
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Affiliation(s)
- Jonathan E Elliott
- VA Portland Health Care System, Research Service, Portland, OR, USA
- Oregon Health and Science University, Department of Neurology, Portland, OR, USA
| | | | | | - Allison T Keil
- VA Portland Health Care System, Research Service, Portland, OR, USA
- McGill University, Montreal Neurological Institute and Department of Neurology and Neurosurgery, Montréal, QC, Canada
| | - Katherine Powers
- VA Portland Health Care System, Research Service, Portland, OR, USA
| | - Cosette Olivo
- VA Portland Health Care System, Research Service, Portland, OR, USA
| | - Lee E Neilson
- VA Portland Health Care System, Research Service, Portland, OR, USA
- Oregon Health and Science University, Department of Neurology, Portland, OR, USA
| | - Ronald B Postuma
- McGill University, Montreal Neurological Institute and Department of Neurology and Neurosurgery, Montréal, QC, Canada
- Université du Québec à Montréal, Département of Psychology, Montréal, QC, Canada
- Hôpital du Sacré-Coeur de Montréal, Center for Advanced Research in Sleep Medicine, Montréal, QC, Canada
- Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Amélie Pelletier
- Hôpital du Sacré-Coeur de Montréal, Center for Advanced Research in Sleep Medicine, Montréal, QC, Canada
- Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Jean-François Gagnon
- Université du Québec à Montréal, Département of Psychology, Montréal, QC, Canada
- Hôpital du Sacré-Coeur de Montréal, Center for Advanced Research in Sleep Medicine, Montréal, QC, Canada
| | - Ziv Gan-Or
- McGill University, Montreal Neurological Institute and Department of Neurology and Neurosurgery, Montréal, QC, Canada
- McGill University, Department of Human Genetics, Montréal, QC, Canada
| | - Eric Yu
- McGill University, Montreal Neurological Institute and Department of Neurology and Neurosurgery, Montréal, QC, Canada
- McGill University, Department of Human Genetics, Montréal, QC, Canada
| | - Lang Liu
- McGill University, Montreal Neurological Institute and Department of Neurology and Neurosurgery, Montréal, QC, Canada
- McGill University, Department of Human Genetics, Montréal, QC, Canada
| | | | | | | | - Owen A Ross
- Mayo Clinic, Neurology and Medicine, Rochester, MN, USA
| | | | | | - Alon Y Avidan
- University of California Los Angeles, Neurology, Sleep Disorders Center, Los Angeles, CA, USA
| | - Michael J Howell
- University of Minnesota Medical Center, Department of Neurology, Minneapolis, MN, USA
- Hennepin County Medical Center, Minnesota Regional Sleep Disorders Center, Minneapolis, MN, USA
| | - Carlos H Schenck
- University of Minnesota Medical Center, Department of Neurology, Minneapolis, MN, USA
| | - Jennifer McLeland
- Washington University School of Medicine, Department of Neurology, Saint Louis, MO, USA
| | | | - Aleksandar Videnovic
- Massachusetts General Hospital, Movement Disorders Unit, Division of Sleep Medicine, Boston, MA, USA
- Harvard Medical School, Neurological Clinical Research Institute, Boston, MA, USA
| | - Emmanuel H During
- Stanford University, Psychiatry and Behavioral Sciences, Redwood City, CA, USA
- Stanford University, Neurology and Neurological Sciences, Palo Alto, CA, USA
- Mt Sinai School of Medicine, Department of Neurology, New York, NY, USA
| | - Mitchell G Miglis
- Stanford University, Psychiatry and Behavioral Sciences, Redwood City, CA, USA
- Stanford University, Neurology and Neurological Sciences, Palo Alto, CA, USA
| | - David R Shprecher
- Banner University Medical Center, Department of Neurology, Phoenix, AZ, USA
| | | | - Bradley F Boeve
- Mayo Clinic, Neurology and Medicine, Rochester, MN, USA
- NAPS Consortium Co-principal Investigators
| | - Yo-El S Ju
- Washington University School of Medicine, Department of Neurology, Saint Louis, MO, USA
- NAPS Consortium Co-principal Investigators
| | - Miranda M Lim
- Oregon Health and Science University, Department of Neurology, Portland, OR, USA
- Oregon Health and Science University, Department of Behavioral Neuroscience; Department of Pulmonary and Critical Care Medicine; Oregon Institute of Occupational Health Sciences, Portland, OR, USA
- VA Portland Health Care System, Mental Illness Research Education and Clinical Center; Neurology; National Center for Rehabilitative Auditory Research, Portland, OR, USA
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3
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Elliott JE, Brewer JS, Keil AT, Ligman BR, Bryant-Ekstrand MD, McBride AA, Powers K, Sicard SJ, Twamley EW, O’Neil ME, Hildebrand AD, Nguyen T, Morasco BJ, Gill JM, Dengler BA, Lim MM. Feasibility and acceptability for LION, a fully remote, randomized clinical trial within the VA for light therapy to improve sleep in Veterans with and without TBI: An MTBI 2 sponsored protocol: LION: A remote RCT protocol within VA. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.05.30.24308195. [PMID: 38853958 PMCID: PMC11160858 DOI: 10.1101/2024.05.30.24308195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2024]
Abstract
Sleep-wake disturbances frequently present in Veterans with mild traumatic brain injury (mTBI). These TBI-related sleep impairments confer significant burden and commonly exacerbate other functional impairments. Therapies to improve sleep following mTBI are limited and studies in Veterans are even more scarce. In our previous pilot work, morning bright light therapy (MBLT) was found to be a feasible behavioral sleep intervention in Veterans with a history of mTBI; however, this was single-arm, open-label, and non-randomized, and therefore was not intended to establish efficacy. The present study, LION (light vs ion therapy) extends this preliminary work as a fully powered, sham-controlled, participant-masked randomized controlled trial (NCT03968874), implemented as fully remote within the VA (target n=120 complete). Randomization at 2:1 allocation ratio to: 1) active: MBLT (n=80), and 2) sham: deactivated negative ion generator (n=40); each with identical engagement parameters (60-min duration; within 2-hrs of waking; daily over 28-day duration). Participant masking via deception balanced expectancy assumptions across arms. Outcome measures were assessed following a 14-day baseline (pre-intervention), following 28-days of device engagement (post-intervention), and 28-days after the post-intervention assessment (follow-up). Primary outcomes were sleep measures, including continuous wrist-based actigraphy, self-report, and daily sleep dairy entries. Secondary/exploratory outcomes included cognition, mood, quality of life, circadian rhythm via dim light melatonin onset, and biofluid-based biomarkers. Participant drop out occurred in <10% of those enrolled, incomplete/missing data was present in <15% of key outcome variables, and overall fidelity adherence to the intervention was >85%, collectively establishing feasibility and acceptability for MBLT in Veterans with mTBI.
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Affiliation(s)
- Jonathan E. Elliott
- VA Portland Health Care System, Portland, OR, USA
- Oregon Health & Science University, Department of Neurology, Portland, OR, USA
- Military Traumatic Brain Injury Initiative (MTBI), Bethesda, MD, USA
- VISN 20 Northwest Mental Illness Research, Education and Clinical Center (MIRECC), VA Puget Sound Health Care System, Seattle, WA, USA
| | | | | | | | | | | | | | | | - Elizabeth W. Twamley
- VA San Diego Health Care System, Research Service; Center of Excellence for Stress and Mental Health, San Diego, CA, USA
- University of California San Diego, Department of Psychiatry, La Jolla, CA, USA
| | - Maya E. O’Neil
- VA Portland Health Care System, Portland, OR, USA
- VISN 20 Northwest Mental Illness Research, Education and Clinical Center (MIRECC), VA Puget Sound Health Care System, Seattle, WA, USA
- Oregon Health & Science University, Medical Informatics and Clinical Epidemiology, Portland, OR, USA
- Oregon Health & Science University, Department of Psychiatry, Portland, OR, USA
| | - Andrea D. Hildebrand
- Oregon Health & Science University – Portland State University, School of Public Health, Biostatistics & Design Program, Portland, OR, USA
| | - Thuan Nguyen
- Oregon Health & Science University – Portland State University, School of Public Health, Biostatistics & Design Program, Portland, OR, USA
| | - Benjamin J. Morasco
- VA Portland Health Care System, Portland, OR, USA
- VISN 20 Northwest Mental Illness Research, Education and Clinical Center (MIRECC), VA Puget Sound Health Care System, Seattle, WA, USA
- Oregon Health & Science University, Department of Psychiatry, Portland, OR, USA
| | - Jessica M. Gill
- John’s Hopkins University, School of Nursing, Baltimore, MD, USA
| | | | - Miranda M. Lim
- VA Portland Health Care System, Portland, OR, USA
- Oregon Health & Science University, Department of Neurology, Portland, OR, USA
- Military Traumatic Brain Injury Initiative (MTBI), Bethesda, MD, USA
- VISN 20 Northwest Mental Illness Research, Education and Clinical Center (MIRECC), VA Puget Sound Health Care System, Seattle, WA, USA
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4
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Chow CM, Ekanayake K, Hackett D. Efficacy of Morning Shorter Wavelength Lighting in the Visible (Blue) Range and Broad-Spectrum or Blue-Enriched Bright White Light in Regulating Sleep, Mood, and Fatigue in Traumatic Brain Injury: A Systematic Review. Clocks Sleep 2024; 6:255-266. [PMID: 38920419 PMCID: PMC11202910 DOI: 10.3390/clockssleep6020018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 05/26/2024] [Accepted: 05/27/2024] [Indexed: 06/27/2024] Open
Abstract
Traumatic brain injury (TBI) profoundly affects sleep, mood, and fatigue, impeding daily functioning and recovery. This systematic review evaluates the efficacy of morning shorter wavelength lighting in the visible (blue) range and broad-spectrum or blue-enriched bright white light exposure in mitigating these challenges among TBI patients. Through electronic database searches up to May 2023, studies assessing sleep, circadian rhythm, sleepiness, mood, and fatigue outcomes in TBI patients exposed to morning shorter wavelength lighting in the visible (blue) range and broad-spectrum or blue-enriched bright white light were identified. Seven studies involving 309 participants met the inclusion criteria. Results indicated consistent advancement in sleep timing among individuals with mild TBI, alongside improvements in total sleep time, mood, and reduced sleepiness with both types of light exposure, particularly in mild TBI cases. Notably, two studies demonstrated alleviation of fatigue exclusively in severe TBI cases following light exposure. Despite promising findings, evidence remains limited, emphasizing the need for future research with standardized protocols to confirm the potential and optimize the benefits of light therapy for TBI recovery.
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Affiliation(s)
- Chin Moi Chow
- Sydney School of Health Sciences, Faculty of Medicine and Health, University of Sydney, Sydney 2006, Australia; (K.E.); (D.H.)
- Sleep Research Group, Charles Perkins Centre, University of Sydney, Sydney 2006, Australia
| | - Kanchana Ekanayake
- Sydney School of Health Sciences, Faculty of Medicine and Health, University of Sydney, Sydney 2006, Australia; (K.E.); (D.H.)
| | - Daniel Hackett
- Sydney School of Health Sciences, Faculty of Medicine and Health, University of Sydney, Sydney 2006, Australia; (K.E.); (D.H.)
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Neilson LE, Balba NM, Elliott JE, Scott GD, Mist SD, Butler MP, Heinricher MM, Lim MM. The potential role of chronic pain and the polytrauma clinical triad in predicting prodromal PD: A cross-sectional study of U.S. Veterans. Clin Park Relat Disord 2024; 10:100253. [PMID: 38689822 PMCID: PMC11059454 DOI: 10.1016/j.prdoa.2024.100253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 04/05/2024] [Accepted: 04/18/2024] [Indexed: 05/02/2024] Open
Abstract
Introduction The research criteria for prodromal Parkinson disease (pPD) depends on prospectively validated clinical inputs with large effect sizes and/or high prevalence. Neither traumatic brain injury (TBI), post-traumatic stress disorder (PTSD), nor chronic pain are currently included in the calculator, despite recent evidence of association with pPD. These conditions are widely prevalent, co-occurring, and already known to confer risk of REM behavior disorder (RBD) and PD. Few studies have examined PD risk in the context of TBI and PTSD; none have examined chronic pain. This study aimed to measure the risk of pPD caused by TBI, PTSD, and chronic pain. Methods 216 US Veterans were enrolled who had self-reported recurrent or persistent pain for at least three months. Of these, 44 met criteria for PTSD, 39 for TBI, and 41 for all three conditions. Several pain, sleep, affective, and trauma questionnaires were administered. Participants' history of RBD was determined via self-report, with a subset undergoing confirmatory video polysomnography. Results A greater proportion of Veterans with chronic pain met criteria for RBD (36 % vs. 10 %) and pPD (18.0 % vs. 8.3 %) compared to controls. Proportions were increased in RBD (70 %) and pPD (27 %) when chronic pain co-occurred with TBI and PTSD. Partial effects were seen with just TBI or PTSD alone. When analyzed as continuous variables, polytrauma symptom severity correlated with pPD probability (r = 0.28, P = 0.03). Conclusion These data demonstrate the potential utility of chronic pain, TBI, and PTSD in the prediction of pPD, and the importance of trauma-related factors in the pathogenesis of PD.
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Affiliation(s)
- Lee E. Neilson
- Department of Neurology, Oregon Health and Science University, Portland, OR, United States
- Neurology and Research Service, VA Portland Medical Center, Portland, OR, United States
- VA VISN20 Northwest Mental Illness Research Education and Clinical Center (MIRECC), Portland, OR, United States
| | - Nadir M. Balba
- Department of Neurology, Oregon Health and Science University, Portland, OR, United States
| | - Jonathan E. Elliott
- Department of Neurology, Oregon Health and Science University, Portland, OR, United States
- Neurology and Research Service, VA Portland Medical Center, Portland, OR, United States
- VA VISN20 Northwest Mental Illness Research Education and Clinical Center (MIRECC), Portland, OR, United States
| | - Gregory D. Scott
- Department of Pathology, Oregon Health and Science University, Portland, OR, United States
- Pathology and Laboratory Services, VA Portland Medical Center, Portland, OR, United States
| | - Scott D. Mist
- Department of Anesthesiology and Perioperative Medicine, Oregon Health and Science University, Portland, OR, United States
| | - Matthew P. Butler
- Department of Oregon Institute of Occupational Health Sciences, and Portland, OR, United States
- Department of Behavioral Neuroscience, Oregon Health and Science University, Portland, OR, United States
| | - Mary M. Heinricher
- Department of Behavioral Neuroscience, Oregon Health and Science University, Portland, OR, United States
- Department of Neurosurgery, Oregon Health and Science University, Portland, OR, United States
| | - Miranda M. Lim
- Department of Neurology, Oregon Health and Science University, Portland, OR, United States
- Neurology and Research Service, VA Portland Medical Center, Portland, OR, United States
- VA VISN20 Northwest Mental Illness Research Education and Clinical Center (MIRECC), Portland, OR, United States
- Department of Oregon Institute of Occupational Health Sciences, and Portland, OR, United States
- Department of Behavioral Neuroscience, Oregon Health and Science University, Portland, OR, United States
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Jotie JM, Gustafson JA, Fonda JR, Fortier CB, Milberg WP, Fortenbaugh FC. Association of mild traumatic brain injury, post-traumatic stress disorder, and other comorbidities on photosensitivity. Optom Vis Sci 2024; 101:90-98. [PMID: 38408306 DOI: 10.1097/opx.0000000000002104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2024] Open
Abstract
SIGNIFICANCE Photosensitivity is common after mild traumatic brain injury. However, this study demonstrates that photosensitivity is also impacted by common comorbidities that often occur with mild traumatic brain injury. Understanding how physical and psychological traumas impact photosensitivity can help improve provider care to trauma survivors and guide novel therapeutic interventions. PURPOSE This study aimed to characterize the association between mild traumatic brain injury and common comorbidities on photosensitivity in post-9/11 veterans. METHODS Existing data from the Translational Research Center for TBI and Stress Disorders cohort study were analyzed including traumatic brain injury history and post-traumatic stress disorder clinical diagnostic interviews; sleep quality, anxiety, and depression symptoms self-report questionnaires; and photosensitivity severity self-report from the Neurobehavioral Symptom Inventory. Analysis of covariance and multiple ordinal regression models were used to assess associations between mild traumatic brain injury and common comorbidities with photosensitivity severity. RESULTS Six hundred forty-one post-9/11 veterans were included in this study. An initial analysis showed that both mild traumatic brain injury and current post-traumatic stress disorder diagnosis were independently associated with higher photosensitivity ratings compared with veterans without either condition, with no interaction observed between these two conditions. Results of the ordinal regression models demonstrated positive associations between degree of photosensitivity and the number of mild traumatic brain injuries during military service and current post-traumatic stress disorder symptom severity, particularly hyperarousal symptoms, even when controlling for other factors. In addition, the degree of sleep disturbances and current anxiety symptoms were both positively associated with photosensitivity ratings, whereas depression symptoms, age, and sex were not. CONCLUSIONS Repetitive mild traumatic brain injury, post-traumatic stress disorder, anxiety, and sleep disturbances were all found to significantly impact photosensitivity severity and are therefore important clinical factors that eye care providers should consider when managing veterans with a history of deployment-related trauma reporting photosensitivity symptoms.
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Hanks R, Ketchum JM, Peckham M, Sevigny M, Sander AM, Martin AM, Agtarap S, Beaulieu CL, Callender L, Hammond FM, Lengenfelder J, Rabinowitz AR, Walker WC, Hoffman JM, Harrison-Felix C, Nakase-Richardson R. Associations of Chronic Pain With Psychosocial Outcomes After Traumatic Brain Injury: A NIDILRR and VA TBI Model Systems Collaborative Project. J Head Trauma Rehabil 2024; 39:18-30. [PMID: 38167716 PMCID: PMC10807629 DOI: 10.1097/htr.0000000000000921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
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.
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Affiliation(s)
- Robin Hanks
- Department of Physical Medicine and Rehabilitation, School of Medicine, Wayne State University, Detroit, Michigan (Dr Hanks); Research Department, Craig Hospital, Englewood, Colorado (Drs Ketchum, Agtarap, and Harrison-Felix, Ms Peckham, and Mr Sevigny); H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Brain Injury Research Center, TIRR Memorial Hermann, Houston, Texas (Dr Sander); Mental Health and Behavioral Science Service, James A. Haley Veterans' Hospital, Tampa, Florida (Dr Martin); Department of Psychiatry and Behavioral Neurosciences, University of South Florida, Tampa (Dr Martin); Department of Physical Medicine and Rehabilitation, College of Medicine, The Ohio State University, Columbus (Dr Beaulieu); Baylor Scott & White Institute for Rehabilitation, Dallas, Texas (Ms Callender); Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Rehabilitation Hospital of Indiana, Indianapolis (Dr Hammond); Department of Physical Medicine Rehabilitation, Rutgers-New Jersey Medical School, Newark (Dr Lengenfelder); Kessler Foundation, East Hanover, New Jersey (Dr Lengenfelder); Department of Physical Medicine and Rehabilitation, Moss Rehabilitation Research Institute, Elkins Park, Pennsylvania (Dr Rabinowitz); Department of Physical Medicine & Rehabilitation, School of Medicine, Virginia Commonwealth University, Richmond (Dr Walker); Department of Rehabilitation Medicine, School of Medicine, University of Washington, Seattle (Dr Hoffman); MHBS/Polytrauma, James A. Haley Veterans Hospital, Tampa, Florida (Dr Nakase-Richardson); Sleep and Pulmonary Division, Department of Internal Medicine, University of South Florida, Tampa (Dr Nakase-Richardson); and Defense Health Agency, Traumatic Brain Injury Center of Excellence, Tampa, Florida (Dr Nakase-Richardson)
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Nakase-Richardson R, Cotner BA, Martin AM, Agtarap SD, Tweed A, Esterov D, O'Connor DR, Ching D, Haun JN, Hanks RA, Bergquist TF, Hammond FM, Zafonte RD, Hoffman JM. Provider Perspectives of Facilitators and Barriers to Reaching and Utilizing Chronic Pain Healthcare for Persons With Traumatic Brain Injury: A Qualitative NIDILRR and VA TBI Model Systems Collaborative Project. J Head Trauma Rehabil 2024; 39:E15-E28. [PMID: 38167719 PMCID: PMC10768799 DOI: 10.1097/htr.0000000000000923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
OBJECTIVE To identify facilitators and barriers to reaching and utilizing chronic pain treatments for persons with traumatic brain injury (TBI) organized around an Access to Care framework, which includes dimensions of access to healthcare as a function of supply (ie, provider/system) and demand (ie, patient) factors for a specified patient population. SETTING Community. PARTICIPANTS Clinicians (n = 63) with experience treating persons with TBI were interviewed between October 2020 and November 2021. DESIGN Descriptive, qualitative study. MAIN MEASURES Semistructured open-ended interview of chronic pain management for persons with TBI. Informed by the Access to Care framework, responses were coded by and categorized within the core domains (reaching care, utilizing care) and relevant subdimensions from the supply (affordability of providing care, quality, coordination/continuity, adequacy) and demand (ability to pay, adherence, empowerment, caregiver support) perspective. RESULTS Themes from provider interviews focused on healthcare reaching and healthcare utilization resulted in 19 facilitators and 9 barriers reaching saturation. The most themes fell under the utilization core domain, with themes identified that impact the technical and interpersonal quality of care and care coordination/continuity. Accessibility and availability of specialty care and use of interdisciplinary team that permitted matching patients to treatments were leading thematic facilitators. The leading thematic barrier identified primarily by medical providers was cognitive disability, which is likely directly linked with other leading barriers including high rates of noncompliance and poor follow-up in health care. Medical and behavioral health complexity was also a leading barrier to care and potentially interrelated to other themes identified. CONCLUSION This is the first evidence-based study to inform policy and planning for this complex population to improve access to high-quality chronic pain treatment. Further research is needed to gain a better understanding of the perspectives of individuals with TBI/caregivers to inform interventions to improve access to chronic pain treatment for persons with TBI.
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Affiliation(s)
- Risa Nakase-Richardson
- Mental Health and Behavioral Sciences/Polytrauma (Drs Nakase-Richardson and Martin), Research Service/Polytrauma (Dr Cotner and Ms O'Connor), and Research Service (Dr Haun), James A. Haley Veterans Hospital, Tampa, Florida; Sleep and Pulmonary Division (Dr Nakase-Richardson), Department of Internal Medicine (Dr Cotner), and Department of Child and Family Studies, College of Behavioral Health and Community Sciences (Dr Ching), University of South Florida, Tampa; Defense Health Agency Traumatic Brain Injury Center of Excellence, Tampa, Florida (Dr Nakase-Richardson and Ms Tweed); Craig Hospital Research Department, Englewood, Colorado (Dr Agtarap); 9Line, LLC, Tampa, Florida (Ms Tweed); Mayo Clinic College of Medicine and Science, Rochester, Minnesota (Drs Esterov and Bergquist); Tampa Veterans Research and Education Foundation, Tampa, Florida (Dr Ching); Department of Physical Medicine and Rehabilitation, Wayne State University School of Medicine, Detroit, Michigan (Dr Hanks); Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine & Rehabilitation Hospital of Indiana, Indianapolis (Dr Hammond); Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, Massachusetts (Dr Zafonte); and Department of Rehabilitation Medicine, University of Washington School of Medicine, Seattle (Dr Hoffman)
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Scott GD, Neilson LE, Woltjer R, Quinn JF, Lim MM. Lifelong Association of Disorders Related to Military Trauma with Subsequent Parkinson's Disease. Mov Disord 2023; 38:1483-1492. [PMID: 37309872 DOI: 10.1002/mds.29457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 05/08/2023] [Accepted: 05/10/2023] [Indexed: 06/14/2023] Open
Abstract
BACKGROUND Trauma-related disorders such as traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD) are emerging as risk factors for Parkinson's disease (PD), but their association with development of PD and independence from comorbid disorders remains unknown. OBJECTIVE To examine TBI and PTSD related to early trauma in military veterans using a case-control study. METHODS PD was identified by International Classification of Diseases (ICD) code, recurrent PD-specific prescriptions, and availability of 5+ years of earlier records. Validation was performed by chart review by a movement disorder-trained neurologist. Control subjects were matched 4:1 by age, duration of preceding health care, race, ethnicity, birth year, and sex. TBI and PTSD were identified by ICD code and onset based on active duty. Association and interaction were measured for TBI and PTSD with PD going back 60 years. Interaction was measured for comorbid disorders. RESULTS A total of 71,933 cases and 287,732 controls were identified. TBI and PTSD increased odds of subsequent PD at all preceding 5-year intervals back to year -60 (odds ratio range: 1.5 [1.4, 1.7] to 2.1 [2.0, 2.1]). TBI and PTSD showed synergism (synergy index range: 1.14 [1.09, 1.29] to 1.28 [1.09, 1.51]) and additive association (odds ratio range: 2.2 [1.6, 2.8] to 2.7 [2.5, 2.8]). Chronic pain and migraine showed greatest synergy with PTSD and TBI. Effect sizes for trauma-related disorders were comparable with established prodromal disorders. CONCLUSIONS TBI and PTSD are associated with later PD and are synergistic with chronic pain and migraine. These findings provide evidence for TBI and PTSD as risk factors preceding PD by decades and could aid in prognostic calculation and earlier intervention. © 2023 International Parkinson and Movement Disorder Society. This article has been contributed to by U.S. Government employees and their work is in the public domain in the USA.
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Affiliation(s)
- Gregory D Scott
- Department of Pathology, Oregon Health and Science University, Portland, Oregon, USA
- Department of Pathology and Laboratory Services, VA Portland Medical Center, Portland, Oregon, USA
| | - Lee E Neilson
- Department of Neurology, Oregon Health and Science University, Portland, Oregon, USA
- Department of Neurology, VA Portland Medical Center, Portland, Oregon, USA
| | - Randy Woltjer
- Department of Pathology, Oregon Health and Science University, Portland, Oregon, USA
| | - Joseph F Quinn
- Department of Neurology, Oregon Health and Science University, Portland, Oregon, USA
- Department of Neurology, VA Portland Medical Center, Portland, Oregon, USA
| | - Miranda M Lim
- Department of Neurology, Oregon Health and Science University, Portland, Oregon, USA
- Department of Neurology, VA Portland Medical Center, Portland, Oregon, USA
- VA VISN20 Northwest Mental Illness Research Education and Clinical Center, Portland, Oregon, USA
- Department of Behavioral Neuroscience, Oregon Health and Science University, Portland, Oregon, USA
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10
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Kyyriäinen J, Andrade P, Hämäläinen E, Pitkänen A. Sleep Disturbance and Severe Hydrocephalus in a Normally Behaving Wistar Rat With Traumatic Brain Injury. Neurotrauma Rep 2023; 4:384-395. [PMID: 37350791 PMCID: PMC10282974 DOI: 10.1089/neur.2022.0090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/24/2023] Open
Abstract
We report on a case study of a Wistar rat that was investigated in detail because it exhibited no N3 sleep in electroencephalography (EEG) after lateral fluid-percussion injury (FPI)-induced traumatic brain injury (TBI). The rat (#112) belonged to a cohort of 28 adult Wistar rats exposed to lateral FPI. Rats were monitored by continuous video EEG for 30 days to follow-up on the evolution of sleep disturbances. The beam walking test was used to measure post-TBI functional recovery. Severity of the cortical lesion area, total brain volume, and cortical volume were measured from histological brain sections. Rat #112 had a normal body and skull appearance. Its baseline body weight did not differ from that of the rest of the cohort. At baseline, rat #112 crossed the beam in 6.3 sec (score range for the rest of the cohort, 4.7-44.3) and showed no evident slipping of the paws, scoring a 5.3 (score range for the rest of cohort, 4.3-6.0). On day 30 post-TBI, however, rat #112 was the only rat with a score of 0 on the beam. Histological analysis at 30 days post-TBI revealed a small 0.6-mm2 post-TBI lesion in the somatosensory cortex (lesion size range for the rest of the cohort, 1.2-10.9). The brain volume of rat #112 was 2-fold larger than the mean volume of the rest of the cohort (1592 vs. 758 mm3), the ventricles were remarkably enlarged, and the layered cerebral cortex was very thin. Analysis of the sleep EEG revealed that rat #112 had rapid eye movement sleep and wakefulness, but no N3 sleep, during the 72-h EEG epoch analyzed. This case report demonstrates that brain abnormalities presumably unrelated to the impact-induced cortical lesion, such as presumed pre-existing hydrocephalus, may worsen TBI-induced behavioral and electrographical outcome measures and complicate the assessment of the cause of the abnormalities.
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Affiliation(s)
- Jenni Kyyriäinen
- A.I. Virtanen Institute for Molecular Sciences, University of Eastern Finland, Kuopio, Finland
| | - Pedro Andrade
- A.I. Virtanen Institute for Molecular Sciences, University of Eastern Finland, Kuopio, Finland
| | - Elina Hämäläinen
- A.I. Virtanen Institute for Molecular Sciences, University of Eastern Finland, Kuopio, Finland
| | - Asla Pitkänen
- A.I. Virtanen Institute for Molecular Sciences, University of Eastern Finland, Kuopio, Finland
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11
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Rojczyk P, Seitz-Holland J, Kaufmann E, Sydnor VJ, Kim CL, Umminger LF, Wiegand TLT, Guenette JP, Zhang F, Rathi Y, Bouix S, Pasternak O, Fortier CB, Salat D, Hinds SR, Heinen F, O’Donnell LJ, Milberg WP, McGlinchey RE, Shenton ME, Koerte IK. Sleep Quality Disturbances Are Associated with White Matter Alterations in Veterans with Post-Traumatic Stress Disorder and Mild Traumatic Brain Injury. J Clin Med 2023; 12:2079. [PMID: 36902865 PMCID: PMC10004675 DOI: 10.3390/jcm12052079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 03/02/2023] [Accepted: 03/03/2023] [Indexed: 03/09/2023] Open
Abstract
Sleep disturbances are strongly associated with mild traumatic brain injury (mTBI) and post-traumatic stress disorder (PTSD). PTSD and mTBI have been linked to alterations in white matter (WM) microstructure, but whether poor sleep quality has a compounding effect on WM remains largely unknown. We evaluated sleep and diffusion magnetic resonance imaging (dMRI) data from 180 male post-9/11 veterans diagnosed with (1) PTSD (n = 38), (2) mTBI (n = 25), (3) comorbid PTSD+mTBI (n = 94), and (4) a control group with neither PTSD nor mTBI (n = 23). We compared sleep quality (Pittsburgh Sleep Quality Index, PSQI) between groups using ANCOVAs and calculated regression and mediation models to assess associations between PTSD, mTBI, sleep quality, and WM. Veterans with PTSD and comorbid PTSD+mTBI reported poorer sleep quality than those with mTBI or no history of PTSD or mTBI (p = 0.012 to <0.001). Poor sleep quality was associated with abnormal WM microstructure in veterans with comorbid PTSD+mTBI (p < 0.001). Most importantly, poor sleep quality fully mediated the association between greater PTSD symptom severity and impaired WM microstructure (p < 0.001). Our findings highlight the significant impact of sleep disturbances on brain health in veterans with PTSD+mTBI, calling for sleep-targeted interventions.
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Affiliation(s)
- Philine Rojczyk
- Psychiatry Neuroimaging Laboratory, Department of Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02145, USA
- cBRAIN, Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwig-Maximilians-University, 80336 Munich, Germany
| | - Johanna Seitz-Holland
- Psychiatry Neuroimaging Laboratory, Department of Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02145, USA
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Elisabeth Kaufmann
- Psychiatry Neuroimaging Laboratory, Department of Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02145, USA
- cBRAIN, Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwig-Maximilians-University, 80336 Munich, Germany
- Department of Neurology, Ludwig-Maximilians-University, 81377 Munich, Germany
| | - Valerie J. Sydnor
- Psychiatry Neuroimaging Laboratory, Department of Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02145, USA
| | - Cara L. Kim
- Psychiatry Neuroimaging Laboratory, Department of Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02145, USA
- cBRAIN, Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwig-Maximilians-University, 80336 Munich, Germany
| | - Lisa F. Umminger
- Psychiatry Neuroimaging Laboratory, Department of Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02145, USA
- cBRAIN, Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwig-Maximilians-University, 80336 Munich, Germany
| | - Tim L. T. Wiegand
- Psychiatry Neuroimaging Laboratory, Department of Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02145, USA
- cBRAIN, Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwig-Maximilians-University, 80336 Munich, Germany
| | - Jeffrey P. Guenette
- Psychiatry Neuroimaging Laboratory, Department of Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02145, USA
- Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Fan Zhang
- Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Yogesh Rathi
- Psychiatry Neuroimaging Laboratory, Department of Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02145, USA
- Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Sylvain Bouix
- Psychiatry Neuroimaging Laboratory, Department of Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02145, USA
- Department of Software Engineering and IT, École de Technologie Supérieure, Montreal, QC H3C 1K3, Canada
| | - Ofer Pasternak
- Psychiatry Neuroimaging Laboratory, Department of Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02145, USA
- Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Catherine B. Fortier
- Translational Research Center for TBI and Stress Disorders (TRACTS) and Geriatric Research, Education and Clinical Center (GRECC), VA Boston Healthcare System, Boston, MA 02130, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA 02215, USA
| | - David Salat
- Translational Research Center for TBI and Stress Disorders (TRACTS) and Geriatric Research, Education and Clinical Center (GRECC), VA Boston Healthcare System, Boston, MA 02130, USA
- Neuroimaging Research for Veterans (NeRVe) Center, VA Boston Healthcare System, Boston, 02115 MA, USA
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Department of Radiology, Boston, MA 02129, USA
| | - Sidney R. Hinds
- Department of Neurology, Uniformed Services University, Bethesda, MD 20814, USA
| | - Florian Heinen
- Department of Pediatric Neurology and Developmental Medicine and LMU Center for Children with Medical Complexity, Dr. von Hauner Children’s Hospital, Ludwig-Maximilians-University, 80337 Munich, Germany
| | - Lauren J. O’Donnell
- Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - William P. Milberg
- Translational Research Center for TBI and Stress Disorders (TRACTS) and Geriatric Research, Education and Clinical Center (GRECC), VA Boston Healthcare System, Boston, MA 02130, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA 02215, USA
- Neuroimaging Research for Veterans (NeRVe) Center, VA Boston Healthcare System, Boston, 02115 MA, USA
| | - Regina E. McGlinchey
- Translational Research Center for TBI and Stress Disorders (TRACTS) and Geriatric Research, Education and Clinical Center (GRECC), VA Boston Healthcare System, Boston, MA 02130, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA 02215, USA
- Neuroimaging Research for Veterans (NeRVe) Center, VA Boston Healthcare System, Boston, 02115 MA, USA
| | - Martha E. Shenton
- Psychiatry Neuroimaging Laboratory, Department of Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02145, USA
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
- Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Inga K. Koerte
- Psychiatry Neuroimaging Laboratory, Department of Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02145, USA
- cBRAIN, Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwig-Maximilians-University, 80336 Munich, Germany
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
- Graduate School of Systemic Neurosciences, Ludwig-Maximilians-University, 82152 Munich, Germany
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12
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Martin AM, Pinto SM, Tang X, Hoffman JM, Wittine L, Walker WC, Schwartz DJ, Kane G, Takagishi SC, Nakase-Richardson R. Associations between early sleep-disordered breathing following moderate-to-severe traumatic brain injury and long-term chronic pain status: a Traumatic Brain Injury Model Systems study. J Clin Sleep Med 2023; 19:135-143. [PMID: 36591795 PMCID: PMC9806770 DOI: 10.5664/jcsm.10278] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 08/31/2022] [Accepted: 09/01/2022] [Indexed: 01/07/2023]
Abstract
STUDY OBJECTIVES To explore the relationship between polysomnography-derived respiratory indices and chronic pain status among individuals following traumatic brain injury (TBI). METHODS Participants (n = 66) with moderate to severe TBI underwent polysomnography during inpatient acute rehabilitation and their chronic pain status was assessed at 1- to 2-year follow-up as part of the TBI Model Systems Pain Collaborative Study. Pairwise comparisons across pain cohorts (ie, chronic pain, no history of pain) were made to explore differences on polysomnography indices. RESULTS Among our total sample, approximately three-quarters (74.2%) received sleep apnea diagnoses utilizing American Academy of Sleep Medicine criteria, with 61.9% of those endorsing a history of chronic pain. Of those endorsing chronic pain, the average pain score was 4.8 (standard deviation = 2.1), with a mean interference score of 5.3 (2.7). Pairwise comparisons revealed that those endorsing a chronic pain experience at follow-up experienced categorically worse indicators of sleep-related breathing disorders during acute rehabilitation relative to those who did not endorse chronic pain. Important differences were observed with elevations on central (chronic pain: 2.6; no pain: 0.8 per hour) and obstructive apnea (chronic pain: 15.7; no pain: 11.1 per hour) events, as well as oxygen desaturation indices (chronic pain: 19.6; no pain: 7.9 per hour). CONCLUSIONS Sleep-disordered breathing appears worse among those who endorse chronic pain following moderate-to-severe TBI, but additional research is needed to understand its relation to postinjury pain. Prospective investigation is necessary to determine how clinical decisions (eg, opioid therapy) and intervention (eg, positive airway pressure) may mutually influence outcomes. CLINICAL TRIAL REGISTRATION Registry: ClinicalTrials.gov; Name: Comparison of Sleep Apnea Assessment Strategies to Maximize TBI Rehabilitation Participation and Outcome (C-SAS); URL: https://clinicaltrials.gov/ct2/show/NCT03033901; Identifier: NCT03033901. CITATION Martin AM, Pinto SM, Tang X, et al. Associations between early sleep-disordered breathing following moderate-to-severe traumatic brain injury and long-term chronic pain status: a Traumatic Brain Injury Model Systems study. J Clin Sleep Med. 2023;19(1):135-143.
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Affiliation(s)
- Aaron M. Martin
- Mental Health and Behavioral Sciences Section (MHBSS), James A. Haley Veterans’ Hospital, Tampa, Florida
- Department of Psychiatry and Behavioral Neurosciences, University of South Florida, Tampa, Florida
| | - Shanti M. Pinto
- Department of Physical Medicine and Rehabilitation, Utah Southwestern, Dallas, Texas
- Department of Physical Medicine and Rehabilitation, Carolinas Rehabilitation, Charlotte, North Carolina
| | - Xinyu Tang
- Tampa VA Research and Education Foundation, Inc., Tampa, Florida
| | - Jeanne M. Hoffman
- Department of Rehabilitation Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Lara Wittine
- Division of Pulmonary and Sleep Medicine, Department of Internal Medicine, University of South Florida, Tampa, Florida
| | - William C. Walker
- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, Virginia
| | - Daniel J. Schwartz
- Division of Pulmonary and Sleep Medicine, Department of Internal Medicine, University of South Florida, Tampa, Florida
| | - Georgia Kane
- Department of Neurology, University of South Florida, Tampa, Florida
- Headache Center of Excellence, James A. Haley Veterans’ Hospital, Tampa, Florida
| | - S. Curtis Takagishi
- Mental Health and Behavioral Sciences Section (MHBSS), James A. Haley Veterans’ Hospital, Tampa, Florida
- Headache Center of Excellence, James A. Haley Veterans’ Hospital, Tampa, Florida
| | - Risa Nakase-Richardson
- Mental Health and Behavioral Sciences Section (MHBSS), James A. Haley Veterans’ Hospital, Tampa, Florida
- Division of Pulmonary and Sleep Medicine, Department of Internal Medicine, University of South Florida, Tampa, Florida
- Defense Health Agency Traumatic Brain Injury Center of Excellence at James A. Haley Veterans Hospital, Tampa, Florida
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13
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Brickell TA, Wright MM, Sullivan JK, Varbedian NV, Nose KA, Rather LM, Tien NK, French LM, Lange RT. Caregiver sleep impairment and service member and veteran adjustment following traumatic brain injury is related to caregiver health-related quality of life. J Clin Sleep Med 2022; 18:2577-2588. [PMID: 35912703 PMCID: PMC9622982 DOI: 10.5664/jcsm.10164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 06/21/2022] [Accepted: 06/22/2022] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES To examine the relationship between caregiver sleep impairment and/or service member/veteran (SMV) adjustment post-traumatic brain injury, with caregiver health-related quality of life (HRQOL). METHODS Caregivers (n = 283) completed 18 measures of HRQOL, sleep impairment, and SMV adjustment. Caregivers were classified into 4 sleep impairment/SMV adjustment groups: 1) Good Sleep/Good Adjustment (n = 43), 2) Good Sleep/Poor Adjustment (n = 39), 3) Poor Sleep/Good Adjustment (n = 55), and 4) Poor Sleep/Poor Adjustment (n = 146). RESULTS The Poor Sleep/Poor Adjustment group reported significantly worse scores on most HRQOL measures and a higher prevalence of clinically elevated T-scores (≥ 60T) on the majority of comparisons compared to the other 3 groups. The Good Sleep/Poor Adjustment and Poor Sleep/Good Adjustment groups reported worse scores on the majority of the HRQOL measures and a higher prevalence of clinically elevated scores on 7 comparisons compared to the Good Sleep/Good Adjustment group. Fewer differences were found between the Good Sleep/Poor Adjustment and Poor Sleep/Good Adjustment groups. The Poor Sleep/Poor Adjustment group reported a higher prevalence of severe ratings for SMV Irritability, Anger, and Aggression compared to the Good Sleep/Poor Adjustment group. CONCLUSIONS While the presence of either caregiver sleep impairment or poor SMV adjustment singularly was associated with worse caregiver HRQOL, the presence of both sleep impairment and poor SMV adjustment was associated with further impairment in HRQOL. Caregivers could benefit from sleep intervention. Treatment of SMVs neurobehavioral problems may improve the SMV's recovery and lessen sleep problems, distress, and burden among their caregivers. CITATION Brickell TA, Wright MM, Sullivan JK, et al. Caregiver sleep impairment and service member and veteran adjustment following traumatic brain injury is related to caregiver health-related quality of life. J Clin Sleep Med. 2022;18(11):2577-2588.
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Affiliation(s)
- Tracey A. Brickell
- Traumatic Brain Injury Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland
- Uniformed Services University of the Health Sciences, Bethesda, Maryland
- Contractor, General Dynamics Information Technology, Silver Spring, Maryland
| | - Megan M. Wright
- Traumatic Brain Injury Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland
- Contractor, General Dynamics Information Technology, Silver Spring, Maryland
| | - Jamie K. Sullivan
- Traumatic Brain Injury Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland
- Contractor, General Dynamics Information Technology, Silver Spring, Maryland
| | - Nicole V. Varbedian
- Traumatic Brain Injury Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland
- Contractor, General Dynamics Information Technology, Silver Spring, Maryland
| | - Kathryn A. Nose
- Traumatic Brain Injury Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland
- Contractor, General Dynamics Information Technology, Silver Spring, Maryland
| | - Lauren M. Rather
- Traumatic Brain Injury Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland
- Contractor, General Dynamics Information Technology, Silver Spring, Maryland
| | - Nicole K. Tien
- Traumatic Brain Injury Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland
- Contractor, General Dynamics Information Technology, Silver Spring, Maryland
| | - Louis M. French
- Traumatic Brain Injury Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland
- Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Rael T. Lange
- Traumatic Brain Injury Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland
- Contractor, General Dynamics Information Technology, Silver Spring, Maryland
- University of British Columbia, Vancouver, British Columbia, Canada
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Balba NM, McBride AA, Callahan ML, Mist SD, Jones KD, Butler MP, Lim MM, Heinricher MM. Photosensitivity Is Associated with Chronic Pain following Traumatic Brain Injury. J Neurotrauma 2022; 39:1183-1194. [PMID: 35373595 PMCID: PMC9422792 DOI: 10.1089/neu.2022.0019] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Individuals with a history of traumatic brain injury (TBI) report increased rates of chronic pain. Photosensitivity is also a common chronic symptom following TBI and is prevalent among other types of chronic pain. The aim of this study was to better understand the relationship between chronic pain, pain-related disability, and photosensitivity in a TBI population. We quantified participants' visual photosensitivity thresholds (VPT) using an Ocular Photosensitivity Analyzer and measured pressure-pain sensitivity using pressure algometry. Participants also completed a battery of self-report measures related to chronic pain, TBI history, and mental health. A total of 395 participants completed testing, with 233 reporting a history of TBI. The TBI group was divided into 120 symptomatic TBI participants (s-TBI), and 113 asymptomatic TBI participants (a-TBI) based on their Neurobehavioral Symptom Inventory (NSI) scores. Participants in the s-TBI group scored significantly higher on self-reported chronic pain measures compared with a-TBI and no-TBI participants, including the Symptom Impact Questionnaire Revised (SIQR; p < 0.001) and the Michigan Body Map (MBM; p < 0.001). Despite differences in chronic pain complaints, groups displayed similar pressure-pain thresholds (p = 0.270). Additionally, s-TBI participants were more sensitive to light (lower VPT, p < 0.001), and VPT was correlated with SIQR scores across all participants (R = -0.452, p < 0.001). These data demonstrate that photosensitivity is associated with self-reported chronic pain and disability in individuals with chronic TBI symptomatology. Photosensitivity could therefore serve as a simple, more highly quantitative marker of high-impact chronic pain after TBI.
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Affiliation(s)
- Nadir M. Balba
- Department of Neurology, Oregon Health & Science University (OHSU), Portland, Oregon, USA
- Veterans Affairs Portland Health Care System, Portland, Oregon, USA
| | | | | | - Scott D. Mist
- Department of Anesthesiology and Perioperative Medicine, Oregon Health & Science University (OHSU), Portland, Oregon, USA
| | - Kim D. Jones
- School of Nursing, Linfield University, Portland, Oregon, USA
| | - Matthew P. Butler
- Department of Behavioral Neuroscience, Oregon Health & Science University (OHSU), Portland, Oregon, USA
- Oregon Institute of Occupational Health Sciences, Oregon Health & Science University (OHSU), Portland, Oregon, USA
| | - Miranda M. Lim
- Department of Neurology, Oregon Health & Science University (OHSU), Portland, Oregon, USA
- Veterans Affairs Portland Health Care System, Portland, Oregon, USA
- Department of Behavioral Neuroscience, Oregon Health & Science University (OHSU), Portland, Oregon, USA
- Oregon Institute of Occupational Health Sciences, Oregon Health & Science University (OHSU), Portland, Oregon, USA
- Department of Medicine, Oregon Health & Science University (OHSU), Portland, Oregon, USA
| | - Mary M. Heinricher
- Department of Behavioral Neuroscience, Oregon Health & Science University (OHSU), Portland, Oregon, USA
- Department of Neurological Surgery, Oregon Health & Science University (OHSU), Portland, Oregon, USA
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15
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Elliott JE, Keil AT, Mithani S, Gill JM, O’Neil ME, Cohen AS, Lim MM. Dietary Supplementation With Branched Chain Amino Acids to Improve Sleep in Veterans With Traumatic Brain Injury: A Randomized Double-Blind Placebo-Controlled Pilot and Feasibility Trial. Front Syst Neurosci 2022; 16:854874. [PMID: 35602971 PMCID: PMC9114805 DOI: 10.3389/fnsys.2022.854874] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 04/11/2022] [Indexed: 11/13/2022] Open
Abstract
Study Objectives Traumatic brain injury (TBI) is associated with chronic sleep disturbances and cognitive impairment. Our prior preclinical work demonstrated dietary supplementation with branched chain amino acids (BCAA: leucine, isoleucine, and valine), precursors to de novo glutamate production, restored impairments in glutamate, orexin/hypocretin neurons, sleep, and memory in rodent models of TBI. This pilot study assessed the feasibility and preliminary efficacy of dietary supplementation with BCAA on sleep and cognition in Veterans with TBI. Methods Thirty-two Veterans with TBI were prospectively enrolled in a randomized, double-blinded, placebo-controlled trial comparing BCAA (30 g, b.i.d. for 21-days) with one of two placebo arms (microcrystalline cellulose or rice protein, both 30 g, b.i.d. for 21-days). Pre- and post-intervention outcomes included sleep measures (questionnaires, daily sleep/study diaries, and wrist actigraphy), neuropsychological testing, and blood-based biomarkers related to BCAA consumption. Results Six subjects withdrew from the study (2/group), leaving 26 remaining subjects who were highly adherent to the protocol (BCAA, 93%; rice protein, 96%; microcrystalline, 95%; actigraphy 87%). BCAA were well-tolerated with few side effects and no adverse events. BCAA significantly improved subjective insomnia symptoms and objective sleep latency and wake after sleep onset on actigraphy. Conclusion Dietary supplementation with BCAA is a mechanism-based, promising intervention that shows feasibility, acceptability, and preliminary efficacy to treat insomnia and objective sleep disruption in Veterans with TBI. A larger scale randomized clinical trial is warranted to further evaluate the efficacy, dosing, and duration of BCAA effects on sleep and other related outcome measures in individuals with TBI. Clinical Trial Registration [http://clinicaltrials.gov/], identifier [NCT03990909].
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Affiliation(s)
- Jonathan E. Elliott
- VA Portland Health Care System, Portland, OR, United States,Department of Neurology, Oregon Health & Science University, Portland, OR, United States
| | | | - Sara Mithani
- National Institutes of Health, National Institute of Nursing Research, Bethesda, MD, United States
| | - Jessica M. Gill
- National Institutes of Health, National Institute of Nursing Research, Bethesda, MD, United States
| | - Maya E. O’Neil
- VA Portland Health Care System, Portland, OR, United States,Department of Psychiatry, Oregon Health & Science University, Portland, OR, United States,Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, OR, United States
| | - Akiva S. Cohen
- Perelman School of Medicine, Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA, United States,Anesthesiology, Children’s Hospital of Philadelphia, Joseph Stokes Research Institute, Philadelphia, PA, United States
| | - Miranda M. Lim
- VA Portland Health Care System, Portland, OR, United States,Department of Neurology, Oregon Health & Science University, Portland, OR, United States,Department of Behavioral Neuroscience, Oregon Health & Science University, Portland, OR, United States,Department of Medicine, Division of Pulmonary and Critical Care Medicine, Oregon Health & Science University, Portland, OR, United States,Oregon Institute of Occupational Health Sciences, Oregon Health & Science University, Portland, OR, United States,VA Portland Health Care System, National Center for Rehabilitation and Auditory Research, Portland, OR, United States,*Correspondence: Miranda M. Lim,
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16
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Latent Neuropsychological Profiles to Discriminate Mild Traumatic Brain Injury and Posttraumatic Stress Disorder in Active-Duty Service Members. J Head Trauma Rehabil 2022; 37:E438-E448. [PMID: 35452025 PMCID: PMC9585096 DOI: 10.1097/htr.0000000000000779] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To determine whether cognitive and psychological symptom profiles differentiate clinical diagnostic classifications (eg, history of mild traumatic brain injury [mTBI] and posttraumatic stress disorder [PTSD]) in military personnel. METHODS US Active-Duty Service Members (N = 209, 89% male) with a history of mTBI (n = 56), current PTSD (n = 23), combined mTBI + PTSD (n = 70), or orthopedic injury controls (n = 60) completed a neuropsychological battery assessing cognitive and psychological functioning. Latent profile analysis was performed to determine how neuropsychological outcomes of individuals clustered together. Diagnostic classifications (ie, mTBI, PTSD, mTBI + PTSD, and orthopedic injury controls) within each symptom profile were examined. RESULTS A 5-profile model had the best fit. The profiles differentiated subgroups with high (34.0%) or normal (21.5%) cognitive and psychological functioning, cognitive symptoms (19.1%), psychological symptoms (15.3%), and combined cognitive and psychological symptoms (10.0%). The symptom profiles differentiated participants as would generally be expected. Participants with PTSD were mainly represented in the psychological symptom subgroup, while orthopedic injury controls were mainly represented in the high-functioning subgroup. Further, approximately 79% of participants with comorbid mTBI and PTSD were represented in a symptomatic group (∼24% = cognitive symptoms, ∼29% = psychological symptoms, and 26% = combined cognitive/psychological symptoms). Our results also showed that approximately 70% of military personnel with a history of mTBI were represented in the high- and normal-functioning groups. CONCLUSIONS These results demonstrate both overlapping and heterogeneous symptom and performance profiles in military personnel with a history of mTBI, PTSD, and/or mTBI + PTSD. The overlapping profiles may underscore why these diagnoses are often difficult to diagnose and treat, but suggest that advanced statistical models may aid in identifying profiles representing symptom and cognitive performance impairments within patient groups and enable identification of more effective treatment targets.
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17
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Feasibility and preliminary efficacy for morning bright light therapy to improve sleep and plasma biomarkers in US Veterans with TBI. A prospective, open-label, single-arm trial. PLoS One 2022; 17:e0262955. [PMID: 35421086 PMCID: PMC9009710 DOI: 10.1371/journal.pone.0262955] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 12/20/2021] [Indexed: 11/19/2022] Open
Abstract
Mild traumatic brain injury (TBI) is associated with persistent sleep-wake dysfunction, including insomnia and circadian rhythm disruption, which can exacerbate functional outcomes including mood, pain, and quality of life. Present therapies to treat sleep-wake disturbances in those with TBI (e.g., cognitive behavioral therapy for insomnia) are limited by marginal efficacy, poor patient acceptability, and/or high patient/provider burden. Thus, this study aimed to assess the feasibility and preliminary efficacy of morning bright light therapy, to improve sleep in Veterans with TBI (NCT03578003). Thirty-three Veterans with history of TBI were prospectively enrolled in a single-arm, open-label intervention using a lightbox (~10,000 lux at the eye) for 60-minutes every morning for 4-weeks. Pre- and post-intervention outcomes included questionnaires related to sleep, mood, TBI, post-traumatic stress disorder (PTSD), and pain; wrist actigraphy as a proxy for objective sleep; and blood-based biomarkers related to TBI/sleep. The protocol was rated favorably by ~75% of participants, with adherence to the lightbox and actigraphy being ~87% and 97%, respectively. Post-intervention improvements were observed in self-reported symptoms related to insomnia, mood, and pain; actigraphy-derived measures of sleep; and blood-based biomarkers related to peripheral inflammatory balance. The severity of comorbid PTSD was a significant positive predictor of response to treatment. Morning bright light therapy is a feasible and acceptable intervention that shows preliminary efficacy to treat disrupted sleep in Veterans with TBI. A full-scale randomized, placebo-controlled study with longitudinal follow-up is warranted to assess the efficacy of morning bright light therapy to improve sleep, biomarkers, and other TBI related symptoms.
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18
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Gottshall JL, Agyemang AA, O’Neil M, Wei G, Presson A, Hewins B, Fisher D, Mithani S, Shahim P, Pugh MJ, Wilde EA, Devoto C, Yaffe K, Gill J, Kenney K, Werner JK. Sleep quality: A common thread linking depression, post-traumatic stress, and post-concussive symptoms to biomarkers of neurodegeneration following traumatic brain injury. Brain Inj 2022; 36:633-643. [DOI: 10.1080/02699052.2022.2037711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Affiliation(s)
- Jackie L. Gottshall
- Center for Neuroscience & Regenerative Medicine (CNRM), Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Amma A. Agyemang
- Department of Physical Medicine and Rehabilitation, School of Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Maya O’Neil
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, Portland, Oregon, USA
- Department of Psychiatry, Oregon Health & Science University, Portland, Oregon, USA
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon, USA
| | - Guo Wei
- Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Angela Presson
- Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Bryson Hewins
- School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Daniel Fisher
- School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Sara Mithani
- National Institute of Nursing Research, National Institutes of Health, Bethesda, Maryland, USA
| | - Pashtun Shahim
- Center for Neuroscience & Regenerative Medicine (CNRM), Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Rehabilitation Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland, USA
| | - Mary Jo Pugh
- Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Informatics, Decision-Enhancement and Analytics sciences Center, VA Salt Lake City Health Care System, Informatics, Decision-Enhancement and Analytic Sciences Center, Salt Lake City, Utah, USA
| | - Elisabeth A. Wilde
- Department of Neurology, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Department of Neurology, George E. Wahlen VA, Salt Lake City, Utah, USA
| | - Christina Devoto
- National Institute of Nursing Research, National Institutes of Health, Bethesda, Maryland, USA
| | - Kristine Yaffe
- Departments of Psychiatry and Behavioral Sciences, Neurology, and Epidemiology, University of California, San Francisco, California, USA
| | - Jessica Gill
- National Institute of Nursing Research, National Institutes of Health, Bethesda, Maryland, USA
| | - Kimbra Kenney
- Department of Neurology, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Department of Psychiatry, San Francisco Veterans Affairs Health Care System; 4150 Clement St. Box 181G, San Francisco, California, USA
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - J. Kent Werner
- Center for Neuroscience & Regenerative Medicine (CNRM), Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Rehabilitation Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland, USA
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19
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Lange RT, French LM, Bailie JM, Merritt VC, Pattinson CL, Hungerford LD, Lippa SM, Brickell TA. Clinical utility of PTSD, resilience, sleep, and blast as risk factors to predict poor neurobehavioral functioning following traumatic brain injury: A longitudinal study in U.S. military service members. Qual Life Res 2022; 31:2411-2422. [PMID: 35076825 DOI: 10.1007/s11136-022-03092-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/14/2022] [Indexed: 10/19/2022]
Abstract
PURPOSE This study examined the clinical utility of post-traumatic stress disorder (PTSD), low resilience, poor sleep, and lifetime blast exposure as risk factors for predicting future neurobehavioral outcome following traumatic brain injury (TBI). METHODS Participants were 591 U.S. military service members and veterans who had sustained a TBI (n = 419) or orthopedic injury without TBI (n = 172). Participants completed the Neurobehavioral Symptom Inventory, PTSD Checklist, and the TBI-Quality of Life (TBI-QOL) scale at baseline and follow-up. RESULTS Using the four risk factors at baseline, 15 risk factor combinations were examined by calculating odds ratios to predict poor neurobehavioral outcome at follow-up (i.e., number of abnormal scores across five TBI-QOL scales [e.g., Fatigue, Depression]). The vast majority of risk factor combinations resulted in odds ratios that were considered to be clinically meaningful (i.e., ≥ 2.5) for predicting poor outcome. The risk factor combinations with the highest odds ratios included PTSD singularly, or in combination with poor sleep and/or low resilience (odds ratios = 4.3-72.4). However, poor sleep and low resilience were also strong predictors in the absence of PTSD (odds ratios = 3.1-29.8). CONCLUSION PTSD, poor sleep, and low resilience, singularly or in combination, may be valuable risk factors that can be used clinically for targeted early interventions.
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Affiliation(s)
- Rael T Lange
- Traumatic Brain Injury Center of Excellence, Silver Spring, MD, USA. .,Walter Reed National Military Medical Center, Bethesda, MD, USA. .,National Intrepid Center of Excellence, Bethesda, MD, USA. .,University of British Columbia, Vancouver, BC, Canada. .,General Dynamics Information Technology, Falls Church, VA, USA.
| | - Louis M French
- Traumatic Brain Injury Center of Excellence, Silver Spring, MD, USA.,Walter Reed National Military Medical Center, Bethesda, MD, USA.,National Intrepid Center of Excellence, Bethesda, MD, USA.,Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Jason M Bailie
- Traumatic Brain Injury Center of Excellence, Silver Spring, MD, USA.,Naval Hospital Camp Pendleton, Oceanside, CA, USA.,General Dynamics Information Technology, Falls Church, VA, USA
| | - Victoria C Merritt
- VA San Diego Healthcare System, San Diego, CA, USA.,University of California San Diego, La Jolla, CA, USA
| | | | - Lars D Hungerford
- Traumatic Brain Injury Center of Excellence, Silver Spring, MD, USA.,Naval Medical Center San Diego, San Diego, CA, USA.,General Dynamics Information Technology, Falls Church, VA, USA
| | - Sara M Lippa
- Walter Reed National Military Medical Center, Bethesda, MD, USA.,National Intrepid Center of Excellence, Bethesda, MD, USA
| | - Tracey A Brickell
- Traumatic Brain Injury Center of Excellence, Silver Spring, MD, USA.,Walter Reed National Military Medical Center, Bethesda, MD, USA.,National Intrepid Center of Excellence, Bethesda, MD, USA.,Uniformed Services University of the Health Sciences, Bethesda, MD, USA.,General Dynamics Information Technology, Falls Church, VA, USA
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20
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Modarres MH, Elliott JE, Weymann KB, Pleshakov D, Bliwise DL, Lim MM. Validation of Visually Identified Muscle Potentials during Human Sleep Using High Frequency/Low Frequency Spectral Power Ratios. SENSORS (BASEL, SWITZERLAND) 2021; 22:55. [PMID: 35009594 PMCID: PMC8747095 DOI: 10.3390/s22010055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 12/17/2021] [Accepted: 12/20/2021] [Indexed: 06/14/2023]
Abstract
Surface electromyography (EMG), typically recorded from muscle groups such as the mentalis (chin/mentum) and anterior tibialis (lower leg/crus), is often performed in human subjects undergoing overnight polysomnography. Such signals have great importance, not only in aiding in the definitions of normal sleep stages, but also in defining certain disease states with abnormal EMG activity during rapid eye movement (REM) sleep, e.g., REM sleep behavior disorder and parkinsonism. Gold standard approaches to evaluation of such EMG signals in the clinical realm are typically qualitative, and therefore burdensome and subject to individual interpretation. We originally developed a digitized, signal processing method using the ratio of high frequency to low frequency spectral power and validated this method against expert human scorer interpretation of transient muscle activation of the EMG signal. Herein, we further refine and validate our initial approach, applying this to EMG activity across 1,618,842 s of polysomnography recorded REM sleep acquired from 461 human participants. These data demonstrate a significant association between visual interpretation and the spectrally processed signals, indicating a highly accurate approach to detecting and quantifying abnormally high levels of EMG activity during REM sleep. Accordingly, our automated approach to EMG quantification during human sleep recording is practical, feasible, and may provide a much-needed clinical tool for the screening of REM sleep behavior disorder and parkinsonism.
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Affiliation(s)
- Mo H. Modarres
- Mental Illness Research, Education and Clinical Center (MIRECC-VISN1), VA Bedford Health Care System, Bedford, MA 01730, USA;
| | - Jonathan E. Elliott
- VA Portland Health Care System, Portland, OR 97239, USA;
- Department of Neurology, Oregon Health & Science University, Portland, OR 97239, USA
| | | | - Dennis Pleshakov
- School of Medicine, Oregon Health & Science University, Portland, OR 97239, USA;
| | | | - Miranda M. Lim
- VA Portland Health Care System, Portland, OR 97239, USA;
- Department of Neurology, Oregon Health & Science University, Portland, OR 97239, USA
- National Center for Rehabilitative Auditory Research, VA Portland Health Care System, Portland, OR 97239, USA
- Department of Behavioral Neuroscience, Oregon Health & Science University, Portland, OR 97239, USA
- Oregon Institute of Occupational Health Sciences, Oregon Health & Science University, Portland, OR 97239, USA
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21
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Ozturk ED, Chanfreau-Coffinier C, Sakamoto MS, Delano-Wood L, Merritt VC. Characterization of Million Veteran Program (MVP) enrollees with Comprehensive Traumatic Brain Injury Evaluation (CTBIE) data: An analysis of neurobehavioral symptoms. J Psychiatr Res 2021; 145:230-242. [PMID: 34942434 PMCID: PMC9401093 DOI: 10.1016/j.jpsychires.2021.12.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 11/19/2021] [Accepted: 12/11/2021] [Indexed: 11/20/2022]
Abstract
The purpose of this study was to examine neurobehavioral symptom reporting in a large sample of military veterans (N = 12,144) who completed the Comprehensive Traumatic Brain Injury Evaluation (CTBIE) and enrolled in the VA's Million Veteran Program (MVP). The CTBIE is a clinician-administered interview that assesses for historical, deployment-related traumatic brain injury (TBI) and evaluates symptoms using the Neurobehavioral Symptom Inventory (NSI). Clinicians completing the CTBIE made clinical determinations about participants' (1) TBI diagnostic status (i.e., CTBIE+ or CTBIE-) and (2) current symptom etiology (i.e., Symptom Resolution, TBI, Behavioral Health, Comorbid TBI + Behavioral Health [Comorbid], or Other). We evaluated the association of TBI diagnostic status and symptom etiology group with neurobehavioral symptoms. Results showed a significant association between TBI diagnostic status and all NSI variables, with CTBIE+ veterans endorsing greater symptoms than CTBIE- veterans. There was also a significant association between symptom etiology group and all NSI variables; specifically, the Comorbid and Behavioral Health groups generally endorsed significantly greater symptoms compared to the other groups. Follow-up analyses showed that relative to the Symptom Resolution group, the Comorbid and Behavioral Health groups had increased odds of severe/very severe cognitive and affective symptoms, whereas the TBI and Other groups did not. Finally, presence of psychiatric symptoms, pain, post-traumatic amnesia, loss of consciousness, and blast exposure significantly predicted Comorbid symptom etiology group membership. Findings from this large epidemiologic MVP study have relevant clinical implications and further highlight the importance of prioritizing integrated behavioral health interventions for this vulnerable population.
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Affiliation(s)
- Erin D Ozturk
- San Diego State University/University of California, San Diego Joint Doctoral Program, San Diego, CA, United States
| | - Catherine Chanfreau-Coffinier
- VA Informatics and Computing Infrastructure (VINCI), VA Salt Lake City Health Care System, Salt Lake City, UT, United States
| | - McKenna S Sakamoto
- Research & Psychology Services, VA San Diego Healthcare System (VASDHS), San Diego, CA, United States
| | - Lisa Delano-Wood
- Research & Psychology Services, VA San Diego Healthcare System (VASDHS), San Diego, CA, United States; Department of Psychiatry, School of Medicine, University of California San Diego, La Jolla, CA, United States; Center of Excellence for Stress and Mental Health, VASDHS, San Diego, CA, United States
| | - Victoria C Merritt
- Research & Psychology Services, VA San Diego Healthcare System (VASDHS), San Diego, CA, United States; Department of Psychiatry, School of Medicine, University of California San Diego, La Jolla, CA, United States; Center of Excellence for Stress and Mental Health, VASDHS, San Diego, CA, United States.
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22
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Reilly ED, Robinson SA, Petrakis BA, Gardner MM, Wiener RS, Castaneda-Sceppa C, Quigley KS. Mobile Intervention to Improve Sleep and Functional Health of Veterans With Insomnia: Randomized Controlled Trial. JMIR Form Res 2021; 5:e29573. [PMID: 34889746 PMCID: PMC8704109 DOI: 10.2196/29573] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 10/22/2021] [Accepted: 10/28/2021] [Indexed: 01/14/2023] Open
Abstract
Background Insomnia is a prevalent and debilitating disorder among veterans. Cognitive behavioral therapy for insomnia (CBTI) can be effective for treating insomnia, although many cannot access this care. Technology-based solutions and lifestyle changes, such as physical activity (PA), offer affordable and accessible self-management alternatives to in-person CBTI. Objective This study aims to extend and replicate prior pilot work to examine whether the use of a mobile app for CBTI (cognitive behavioral therapy for insomnia coach app [CBT-i Coach]) improves subjective and objective sleep outcomes. This study also aims to investigate whether the use of the CBT-i Coach app with adjunctive PA improves sleep outcomes more than CBT-i Coach alone. Methods A total of 33 veterans (mean age 37.61 years, SD 9.35 years) reporting chronic insomnia were randomized to use either the CBT-i Coach app alone or the CBT-i Coach app with a PA intervention over 6 weeks, with outcome measures of objective and subjective sleep at pre- and posttreatment. Results Although the PA manipulation was unsuccessful, both groups of veterans using the CBT-i Coach app showed significant improvement from baseline to postintervention on insomnia (P<.001), sleep quality (P<.001), and functional sleep outcomes (P=.002). Improvements in subjective sleep outcomes were similar in those with and without posttraumatic stress disorder and mild-to-moderate sleep apnea. We also observed a significant but modest increase in objective sleep efficiency (P=.02). Conclusions These findings suggest that the use of a mobile app–delivered CBTI is feasible and beneficial for improving sleep outcomes in veterans with insomnia, including those with comorbid conditions such as posttraumatic stress disorder or mild-to-moderate sleep apnea. Trial Registration ClinicalTrials.gov NCT03305354; https://clinicaltrials.gov/ct2/show/NCT03305354
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Affiliation(s)
- Erin Dawna Reilly
- Mental Illness Research, Education, and Clinical Center, VA Bedford Healthcare System, Bedford, MA, United States.,Social and Community Reintegration Research, VA Bedford Healthcare System, Bedford, MA, United States.,University of Massachusetts Medical School, Worcester, MA, United States
| | - Stephanie A Robinson
- Center for Healthcare Outcomes and Implementation Research, VA Bedford Healthcare System, Bedford, MA, United States.,Pulmonary Division, Boston University School of Medicine, Boston, MA, United States
| | - Beth Ann Petrakis
- Center for Healthcare Outcomes and Implementation Research, VA Bedford Healthcare System, Bedford, MA, United States
| | | | - Renda Soylemez Wiener
- Center for Healthcare Outcomes and Implementation Research, VA Bedford Healthcare System, Bedford, MA, United States.,Pulmonary Division, Boston University School of Medicine, Boston, MA, United States
| | | | - Karen S Quigley
- Social and Community Reintegration Research, VA Bedford Healthcare System, Bedford, MA, United States.,Center for Healthcare Outcomes and Implementation Research, VA Bedford Healthcare System, Bedford, MA, United States.,Northeastern University, Boston, MA, United States
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23
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Robinson SA, Reilly ED, Petrakis BA, Wiener RS, Castaneda-Sceppa C, Quigley KS. Daily physical activity and sleep in veterans: the role of insomnia severity. J Behav Med 2021; 45:318-323. [PMID: 34718912 DOI: 10.1007/s10865-021-00260-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 10/02/2021] [Indexed: 11/24/2022]
Abstract
Physical activity (PA) is suggested as an easily accessible adjunctive lifestyle intervention for insomnia. It is not clear if PA is equally beneficial across different levels of insomnia severity. The current study examined the relationship between daily PA (steps) and sleep (duration, efficiency, and quality) across the spectrum of insomnia severity. Multilevel models estimated day-to-night relationships between PA and sleep, and if insomnia severity moderated these relationships. Days with greater PA were associated with nights with longer sleep duration. This was moderated by insomnia severity; PA was associated with longer sleep that night in participants with mild insomnia and associated with less sleep in those with severe insomnia. PA was not associated with sleep efficiency or quality. PA is potentially an easily accessible and impactful intervention to promote sleep duration in participants who are experiencing less severe sleep disturbance. More complex, resource-intensive interventions may be needed as insomnia severity increases.
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Affiliation(s)
- S A Robinson
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Bedford Healthcare System, Bedford, MA, USA. .,The Pulmonary Center, Boston University School of Medicine, Boston, MA, USA.
| | - E D Reilly
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Bedford Healthcare System, Bedford, MA, USA.,University of Massachusetts Medical School, Worcester, MA, USA
| | - B A Petrakis
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Bedford Healthcare System, Bedford, MA, USA
| | - R S Wiener
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Bedford Healthcare System, Bedford, MA, USA.,The Pulmonary Center, Boston University School of Medicine, Boston, MA, USA
| | | | - K S Quigley
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Bedford Healthcare System, Bedford, MA, USA.,Northeastern University, Boston, MA, USA
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24
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Babu Henry Samuel I, Breneman CB, Chun T, Hamedi A, Murphy R, Barrett JP. Compounding Effects of Traumatic Brain Injury, Military Status, and Other Factors on Pittsburgh Sleep Quality Index: A Meta-analysis. Mil Med 2021; 187:e589-e597. [PMID: 34557901 DOI: 10.1093/milmed/usab377] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 07/22/2021] [Accepted: 09/20/2021] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Traumatic brain injury (TBI) or concussion is a known risk factor for multiple adverse health outcomes, including disturbed sleep. Although prior studies show adverse effects of TBI on sleep quality, its compounding effect with other factors on sleep is unknown. This meta-analysis aimed to quantify the effects of TBI on subjective sleep quality in the context of military status and other demographic factors. MATERIALS AND METHODS A programmatic search of PubMed database from inception to June 2020 was conducted to identify studies that compared subjective sleep quality measured using Pittsburgh Sleep Quality Index (PSQI) in individuals with TBI relative to a control group. The meta-analysis included group-wise standard mean difference (SMD) and 95% CI. Pooled means and SDs were obtained for TBI and non-TBI groups with and without military service, and meta-regression was conducted to test for group effects. Exploratory analysis was performed to test for the effect of TBI, non-head injury, military status, sex, and age on sleep quality across studies. RESULTS Twenty-six articles were included, resulting in a combined total of 5,366 individuals (2,387 TBI and 2,979 controls). Overall, individuals with TBI self-reported poorer sleep quality compared to controls (SMD = 0.63, 95% CI: 0.45 to 0.80). Subgroup analysis revealed differences in the overall effect of TBI on PSQI, with a large effect observed in the civilian subgroup (SMD: 0.80, 95% CI: 0.57 to 1.03) and a medium effect in the civilian subgroup with orthopedic injuries (SMD: 0.40, 95% CI: 0.13 to 0.65) and military/veteran subgroup (SMD: 0.43, 95% CI: 0.14 to 0.71). Exploratory analysis revealed that age and history of military service significantly impacted global PSQI scores. CONCLUSIONS Poor sleep quality in TBI cohorts may be due to the influence of multiple factors. Military/veteran samples had poorer sleep quality compared to civilians even in the absence of TBI, possibly reflecting unique stressors associated with prior military experiences and the sequelae of these stressors or other physical and/or psychological traumas that combine to heightened vulnerability. These findings suggest that military service members and veterans with TBI are particularly at a higher risk of poor sleep and its associated adverse health outcomes. Additional research is needed to identify potential exposures that may further heighten vulnerability toward poorer sleep quality in those with TBI across both civilian and military/veteran populations.
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Affiliation(s)
- Immanuel Babu Henry Samuel
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD 20817, USA.,Department of Veterans Affairs, War Related Illness and Injury Study Center (WRIISC), Washington, DC 20422, USA
| | - Charity B Breneman
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD 20817, USA.,Department of Veterans Affairs, War Related Illness and Injury Study Center (WRIISC), Washington, DC 20422, USA
| | - Timothy Chun
- Department of Veterans Affairs, War Related Illness and Injury Study Center (WRIISC), Washington, DC 20422, USA
| | - Arghavan Hamedi
- Department of Veterans Affairs, War Related Illness and Injury Study Center (WRIISC), Washington, DC 20422, USA
| | - Rayelynn Murphy
- Cardiometabolic Health Unit, Washington DC VA Medical Center, Washington, DC 20422, USA
| | - John P Barrett
- Department of Veterans Affairs, War Related Illness and Injury Study Center (WRIISC), Washington, DC 20422, USA.,Department of Preventive Medicine and Biostatistics, Uniformed Services University, Bethesda, MD 20814, USA
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Elliott JE, Balba NM, McBride AA, Callahan ML, Street K, Butler MP, Heinricher MM, Lim MM. Different methods for TBI diagnosis influence presence and symptoms of post-concussive syndrome in US Veterans. J Neurotrauma 2021; 38:3126-3136. [PMID: 34382417 DOI: 10.1089/neu.2021.0031] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Common methods for evaluating history of traumatic brain injury (TBI) include self-report, electronic medical record review (EMR), and structured interviews such as the Head Trauma Events Characteristics (HTEC). Each has strengths and weaknesses, but little is known regarding how TBI diagnostic rates or the associated symptom profile differ among them. This study examined 200 Veterans recruited within the VA Portland Health Care System, each evaluated for TBI using self-report, EMR, and HTEC. Participants also completed validated questionnaires assessing chronic symptom severity in broad health-related domains (pain, sleep, quality of life, post-concussive symptoms). The HTEC was more sensitive (80% of participants in our cohort) than either self-report or EMR alone (40%). As expected from the high sensitivity, the HTEC+ group included many people with mild or no post-concussive symptoms. Participants were then grouped according to the degree of concordance across these three diagnostic methods: No-TBI, n=43; or TBI-positive in any one method (TBI-1dx, n=53), any two (TBI-2dx, n=45), or all three (TBI-3dx, n=59). The symptom profile of the TBI-1dx group was indistinguishable from the No TBI group. The TBI-3dx group carried the most severe symptom profile. These data show that understanding the method(s) used to ascertain TBI is essential when interpreting results from other studies, an issue that will be even more salient when interpreting data merged from multiple sources within centralized repositories (e.g., FITBIR). The development of a composite TBI assessment tool including self-report, medical record review, and neuropsychology outcomes is a crucial next step for the field.
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Affiliation(s)
- Jonathan E Elliott
- Department of Veterans Affairs, Research, 3170 SW US Veterans Highway, Portland, Oregon, United States, 97219.,Oregon Health & Science University, 6684, Neurology, 3181 SW Sam Jackson Park Rd, Portland, Oregon, United States, 97229;
| | - Nadir M Balba
- Department of Veterans Affairs, Research, Portland, Oregon, United States.,Oregon Health & Science University, 6684, Behavioral Neuroscience, Portland, Oregon, United States;
| | - Alisha A McBride
- Department of Veterans Affairs, Research, Portland, Oregon, United States;
| | - Megan L Callahan
- Department of Veterans Affairs, Research, Portland, Oregon, United States;
| | - Kendall Street
- Oregon Health & Science University, 6684, School of Nursing, Portland, Oregon, United States;
| | - Matthew P Butler
- Oregon Health & Science University, 6684, Oregon Institute of Occupational Health Sciences, Portland, Oregon, United States.,Oregon Health & Science University, 6684, Behavioral Neuroscience, Portland, Oregon, United States;
| | - Mary M Heinricher
- Oregon Health & Science University, 6684, Neurological Surgery, Portland, Oregon, United States.,Oregon Health and Science University, 6684, Behavioral Neuroscience, Portland, Oregon, United States;
| | - Miranda M Lim
- VA Portland Health Care System, Sleep Disorders Clinic, Pulmonary and Critical Care Medicine, Portland, Oregon, United States.,Oregon Health and Science University, 6684, Medicine, Neurology, and Behavioral Neuroscience, Portland, Oregon, United States;
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Werner JK, Shahim P, Pucci JU, Lai C, Raiciulescu S, Gill JM, Nakase-Richardson R, Diaz-Arrastia R, Kenney K. Poor sleep correlates with biomarkers of neurodegeneration in mild traumatic brain injury patients: a CENC study. Sleep 2021; 44:6024975. [PMID: 33280032 DOI: 10.1093/sleep/zsaa272] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 11/19/2020] [Indexed: 01/24/2023] Open
Abstract
STUDY OBJECTIVES Sleep disorders affect over half of mild traumatic brain injury (mTBI) patients. Despite evidence linking sleep and neurodegeneration, longitudinal TBI-related dementia studies have not considered sleep. We hypothesized that poor sleepers with mTBI would have elevated markers of neurodegeneration and lower cognitive function compared to mTBI good sleepers and controls. Our objective was to compare biomarkers of neurodegeneration and cognitive function with sleep quality in warfighters with chronic mTBI. METHODS In an observational warfighters cohort (n = 138 mTBI, 44 controls), the Pittsburgh Sleep Quality Index (PSQI) was compared with plasma biomarkers of neurodegeneration and cognitive scores collected an average of 8 years after injury. RESULTS In the mTBI cohort, poor sleepers (PSQI ≥ 10, n = 86) had elevated plasma neurofilament light (NfL, x̅ = 11.86 vs 7.91 pg/mL, p = 0.0007, d = 0.63) and lower executive function scores by the categorical fluency (x̅ = 18.0 vs 21.0, p = 0.0005, d = -0.65) and stop-go tests (x̅ = 30.1 vs 31.1, p = 0.024, d = -0.37). These findings were not observed in controls (n = 44). PSQI predicted NfL (beta = 0.22, p = 0.00002) and tau (beta = 0.14, p = 0.007), but not amyloid β42. Poor sleepers showed higher obstructive sleep apnea (OSA) risk by STOP-BANG scores (x̅ = 3.8 vs 2.7, p = 0.0005), raising the possibility that the PSQI might be partly secondary to OSA. CONCLUSIONS Poor sleep is linked to neurodegeneration and select measures of executive function in mTBI patients. This supports implementation of validated sleep measures in longitudinal studies investigating pathobiological mechanisms of TBI related neurodegeneration, which could have therapeutic implications.
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Affiliation(s)
- J Kent Werner
- Department of Neurology, Uniformed Services University of Health Sciences, Bethesda, MD.,Center for Neuroscience and Regenerative Medicine, Bethesda, MD
| | - Pashtun Shahim
- National Institutes of Health, Bethesda, MD.,Center for Neuroscience and Regenerative Medicine, Bethesda, MD
| | - Josephine U Pucci
- Department of Neurology, Uniformed Services University of Health Sciences, Bethesda, MD
| | - Chen Lai
- National Institutes of Health, Bethesda, MD
| | - Sorana Raiciulescu
- Department of Neurology, Uniformed Services University of Health Sciences, Bethesda, MD
| | | | - Risa Nakase-Richardson
- Department of Internal Medicine, Sleep and Pulmonary Division, University of South Florida, Tampa, FL.,Defense and Veterans Brain Injury Center, Tampa, FL.,James A. Haley Veterans Hospital, Tampa, FL
| | | | - Kimbra Kenney
- Department of Neurology, Uniformed Services University of Health Sciences, Bethesda, MD
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Berry RB, Beck E, Jasko JG. Effect of cloud-based sleep coaches on positive airway pressure adherence. J Clin Sleep Med 2021; 16:553-562. [PMID: 32022679 DOI: 10.5664/jcsm.8276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Decreased early positive airway pressure (PAP) adherence is predictive of poor long-term adherence. We hypothesized that cloud-based sleep coaches (CBSC) providing protocol-driven live telephone contact with patients starting treatment would improve early adherence. METHODS At PAP set-up patients were randomized to: (1) standard care (SC) including respiratory therapist PAP setup, wireless adherence monitoring, and elective use of a mobile adherence feedback application (PAPapp); or (2) SC+CBSC. Primary 3-month endpoints were adherence (all nights, nights used, % of nights ≥ 4 hours use, and % participants with ≥ 4 hours use on ≥ 70% of nights [% ≥ 4 ≥ 70%]) and secondary endpoints were change in Epworth sleepiness scale (ESS) and satisfaction with treatment and PAPapp use. RESULTS Two hundred fifty participants were randomized (SC 126, SC+CBSC 124). Characteristics SC versus SC+CBSC (mean ± SD) for age (55.2 ± 13.4 versus 54.9 ± 11.5 years), diagnostic apnea-hypopnea index (36.7 ± 21.1 versus 36.6 ± 20.6 events/h), and ESS (10.8 ± 6.1 versus 11.2 ± 6.0) did not differ. At 3 months, the % of days with ≥ 4 hours of PAP use (SC: 48.1 ± 36.8% versus SC+CBSC: 57.9 ± 35.4%, P = 0.032), use all nights (SC:3.7 ± 2.7 hours versus SC + CBSC: 4.4 ± 2.6 hours, P=0.027), and PAPapp use satisfaction were greater with SC+CBSC (intention to treat analysis). The [% ≥ 4 ≥ 70%] did not differ between groups in the intention to treat analysis but was higher in those completing CBSC interventions. The ESS improvement and patient satisfaction did not differ between groups. CONCLUSIONS The CBSC system improved PAP adherence at 3 months. CLINICAL TRIAL REGISTRATION Registry: ClinicalTrials.gov; Title: ThErapy Adherence Management in Veterans; Identifier: NCT03243487; URL: https://clinicaltrials.gov/ct2/show/NCT03243487.
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Affiliation(s)
- Richard B Berry
- Malcom Randall Veterans Affairs Medical Center, Gainesville, Florida.,Division of Pulmonary, Critical Care, and Sleep Medicine, University of Florida, Gainesville, Florida
| | - Emily Beck
- Malcom Randall Veterans Affairs Medical Center, Gainesville, Florida.,Division of Pulmonary, Critical Care, and Sleep Medicine, University of Florida, Gainesville, Florida
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Pattinson CL, Brickell TA, Bailie J, Hungerford L, Lippa SM, French LM, Lange RT. Sleep disturbances following traumatic brain injury are associated with poor neurobehavioral outcomes in U.S. military service members and veterans. J Clin Sleep Med 2021; 17:2425-2438. [PMID: 34216198 DOI: 10.5664/jcsm.9454] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES This study examined whether sleep disturbances were associated with neurobehavioral outcome following a traumatic brain injury (TBI) in a well characterized group of service members and veterans. METHODS Six-hundred and six participants were enrolled into the Defense and Veterans Brain Injury Center, 15-Year Longitudinal TBI study. All participants completed a battery of tests measuring self-reported sleep disturbances, neurobehavioral symptoms, and Posttraumatic Stress Disorder PTSD symptoms. Data were analyzed using analysis of variance with post-hoc comparisons. Four groups were analyzed separately: uncomplicated mild TBI (MTBI); complicated mild, moderate, severe, or penetrating - combined TBI (CTBI); injured controls (IC, i.e., orthopedic or soft-tissue injury without TBI); and non-injured controls (NIC). RESULTS A higher proportion of the MTBI group reported moderate-severe sleep disturbances (66.5%) compared to the IC (54.9%), CTBI (47.5%), and NIC groups (34.3%). Participants classified as having Poor Sleep had significantly worse scores on the majority of TBI-QOL scales compared to those classified as having Good Sleep, regardless of TBI severity or the presence of TBI. There was a significant interaction between sleep disturbances and PTSD. While sleep disturbances and PTSD by themselves were significant factors associated with worse outcome, both factors combined resulted in worse outcome than either singularly. CONCLUSIONS Regardless of group (injured or NIC), sleep disturbances were common and were associated with significantly worse neurobehavioral functioning. When experienced concurrently with PTSD, sleep disturbances pose significant burden to service members and veterans.
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Affiliation(s)
- Cassandra L Pattinson
- University of Queensland, Institute for Social Science Research, Brisbane, QLD, Australia
| | - Tracey A Brickell
- Defense and Veterans Brain Injury Center, Silver Spring, MD.,Walter Reed National Military Medical Center, Bethesda, MD.,National Intrepid Center of Excellence, Bethesda, MD.,Uniformed Services University of the Health Sciences, Bethesda, MD.,General Dynamics Information Technology, Falls Church, VA.,Centre of Excellence on Post-Traumatic Stress Disorder, Ottawa, ON, Canada
| | - Jason Bailie
- Defense and Veterans Brain Injury Center, Silver Spring, MD.,General Dynamics Information Technology, Falls Church, VA.,Naval Hospital Camp, Pendleton, CA
| | - Lars Hungerford
- Defense and Veterans Brain Injury Center, Silver Spring, MD.,General Dynamics Information Technology, Falls Church, VA.,Naval Medical Center, San Diego, CA
| | - Sara M Lippa
- Walter Reed National Military Medical Center, Bethesda, MD.,National Intrepid Center of Excellence, Bethesda, MD
| | - Louis M French
- Defense and Veterans Brain Injury Center, Silver Spring, MD.,Walter Reed National Military Medical Center, Bethesda, MD.,National Intrepid Center of Excellence, Bethesda, MD.,Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Rael T Lange
- Defense and Veterans Brain Injury Center, Silver Spring, MD.,Walter Reed National Military Medical Center, Bethesda, MD.,National Intrepid Center of Excellence, Bethesda, MD.,General Dynamics Information Technology, Falls Church, VA.,Centre of Excellence on Post-Traumatic Stress Disorder, Ottawa, ON, Canada.,University of British Columbia, Vancouver, Canada
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Sullan MJ, Crocker LD, Thomas KR, Orff HJ, Davey DK, Jurick SM, Twamley EW, Norman SB, Schiehser DM, Aupperle R, Jak AJ. Baseline sleep quality moderates symptom improvement in veterans with comorbid PTSD and TBI receiving trauma-focused treatment. Behav Res Ther 2021; 143:103892. [PMID: 34091276 DOI: 10.1016/j.brat.2021.103892] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 05/14/2021] [Accepted: 05/20/2021] [Indexed: 02/07/2023]
Abstract
Poor sleep quality is common among Veterans with posttraumatic stress disorder (PTSD) and history of traumatic brain injury (TBI). However, the relationship between sleep quality and treatment outcomes following trauma-focused interventions is less well-understood in this population. We sought to better understand whether 1) sleep quality changed as a result of trauma-focused treatment and 2) if baseline sleep quality moderated psychological and neurobehavioral treatment outcomes. Our sample consisted of 100 Iraq/Afghanistan era Veterans with PTSD and history of mild to moderate TBI who were randomized to one of two trauma-focused treatments: 1) Cognitive Processing Therapy (CPT) or 2) combined CPT and Cognitive Symptom Management and Rehabilitation Therapy (SMART-CPT). Self-reported sleep quality, psychiatric symptoms (PTSD and depression), and neurobehavioral concerns were assessed at multiple timepoints throughout the study. Multilevel modeling showed sleep quality did not improve, regardless of treatment condition. However, worse baseline sleep quality was associated with less improvement in PTSD symptoms and cognitive complaints. There was no effect of baseline sleep quality on change in depression symptoms. These findings suggest that more targeted treatments to address sleep quality either prior to or in conjunction with trauma-focused therapy may help to improve treatment outcomes for Veterans with comorbid PTSD and TBI history.
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Affiliation(s)
- Molly J Sullan
- Psychology Service, VA San Diego Healthcare System, 3350 La Jolla Village Dr, San Diego, CA, 92161, USA; Department of Psychiatry, University of California San Diego, 9500 Gilman Dr., San Diego, CA, 92093, USA
| | - Laura D Crocker
- Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System, 3350 La Jolla Village Dr, San Diego, CA, 92161, USA; Research Service, VA San Diego Healthcare System, 3350 La Jolla Village Dr., Building 13, San Diego, CA, 92161, USA
| | - Kelsey R Thomas
- Research Service, VA San Diego Healthcare System, 3350 La Jolla Village Dr., Building 13, San Diego, CA, 92161, USA; Department of Psychiatry, University of California San Diego, 9500 Gilman Dr., San Diego, CA, 92093, USA
| | - Henry J Orff
- Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System, 3350 La Jolla Village Dr, San Diego, CA, 92161, USA; Research Service, VA San Diego Healthcare System, 3350 La Jolla Village Dr., Building 13, San Diego, CA, 92161, USA; Department of Psychiatry, University of California San Diego, 9500 Gilman Dr., San Diego, CA, 92093, USA
| | - Delaney K Davey
- Research Service, VA San Diego Healthcare System, 3350 La Jolla Village Dr., Building 13, San Diego, CA, 92161, USA
| | - Sarah M Jurick
- Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System, 3350 La Jolla Village Dr, San Diego, CA, 92161, USA; Research Service, VA San Diego Healthcare System, 3350 La Jolla Village Dr., Building 13, San Diego, CA, 92161, USA; Department of Psychiatry, University of California San Diego, 9500 Gilman Dr., San Diego, CA, 92093, USA
| | - Elizabeth W Twamley
- Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System, 3350 La Jolla Village Dr, San Diego, CA, 92161, USA; Research Service, VA San Diego Healthcare System, 3350 La Jolla Village Dr., Building 13, San Diego, CA, 92161, USA; Department of Psychiatry, University of California San Diego, 9500 Gilman Dr., San Diego, CA, 92093, USA
| | - Sonya B Norman
- Psychology Service, VA San Diego Healthcare System, 3350 La Jolla Village Dr, San Diego, CA, 92161, USA; Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System, 3350 La Jolla Village Dr, San Diego, CA, 92161, USA; Department of Psychiatry, University of California San Diego, 9500 Gilman Dr., San Diego, CA, 92093, USA; National Center for PTSD, White River Junction, VT, USA
| | - Dawn M Schiehser
- Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System, 3350 La Jolla Village Dr, San Diego, CA, 92161, USA; Research Service, VA San Diego Healthcare System, 3350 La Jolla Village Dr., Building 13, San Diego, CA, 92161, USA; Department of Psychiatry, University of California San Diego, 9500 Gilman Dr., San Diego, CA, 92093, USA
| | - Robin Aupperle
- Laureate Institute for Brain Research, Tulsa, OK, USA; School of Community Medicine, University of Tulsa, Tulsa, OK, USA
| | - Amy J Jak
- Psychology Service, VA San Diego Healthcare System, 3350 La Jolla Village Dr, San Diego, CA, 92161, USA; Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System, 3350 La Jolla Village Dr, San Diego, CA, 92161, USA; Department of Psychiatry, University of California San Diego, 9500 Gilman Dr., San Diego, CA, 92093, USA.
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Bottari SA, Lamb DG, Murphy AJ, Porges EC, Rieke JD, Harciarek M, Datta S, Williamson JB. Hyperarousal symptoms and decreased right hemispheric frontolimbic white matter integrity predict poorer sleep quality in combat-exposed veterans. Brain Inj 2021; 35:922-933. [PMID: 34053386 DOI: 10.1080/02699052.2021.1927186] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Disrupted sleep is common following combat deployment. Contributors to risk include posttraumatic stress disorder (PTSD) and mild traumatic brain injury (mTBI); however, the mechanisms linking PTSD, mTBI, and sleep are unclear. Both PTSD and mTBI affect frontolimbic white matter tracts, such as the uncinate fasciculus. The current study examined the relationship between PTSD symptom presentation, lateralized uncinate fasciculus integrity, and sleep quality. METHOD Participants include 42 combat veterans with and without PTSD and mTBI. Freesurfer and Tracula were used to establish specific white matter ROI integrity via 3-T MRI. The Pittsburgh Sleep Quality Index and PTSD Checklist were used to assess sleep quality and PTSD symptoms. RESULTS Decreased fractional anisotropy in the right uncinate fasciculus (β = -1.11, SE = 0.47, p < .05) and increased hyperarousal symptom severity (β = 3.50, SE = 0.86, p < .001) were associated with poorer sleep quality. CONCLUSION Both right uncinate integrity and hyperarousal symptom severity are associated withsleep quality in combat veterans. The right uncinate is a key regulator of limbic behavior and sympathetic nervous system reactivity, a core component of hyperarousal. Damage to this pathway may be one mechanism by which mTBI and/or PTSD could create vulnerability for sleep problems following combat deployment.
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Affiliation(s)
- Sarah A Bottari
- Center for OCD, Anxiety, and Related Disorders, Department of Psychiatry, University of Florida, Gainesville, Florida, USA.,Department of Clinical and Health Psychology, College of Public Health and Health Professions, University of Florida, Gainesville, Florida, USA
| | - Damon G Lamb
- Center for OCD, Anxiety, and Related Disorders, Department of Psychiatry, University of Florida, Gainesville, Florida, USA.,Brain Rehabilitation Research Center, Malcom Randall VA Medical Center, Gainesville, Florida, USA.,Center for Cognitive Aging and Memory, McKnight Brain Institute, University of Florida, Gainesville, Florida, USA
| | - Aidan J Murphy
- Center for Cognitive Aging and Memory, McKnight Brain Institute, University of Florida, Gainesville, Florida, USA
| | - Eric C Porges
- Department of Clinical and Health Psychology, College of Public Health and Health Professions, University of Florida, Gainesville, Florida, USA.,Center for Cognitive Aging and Memory, McKnight Brain Institute, University of Florida, Gainesville, Florida, USA
| | - Jake D Rieke
- Brain Rehabilitation Research Center, Malcom Randall VA Medical Center, Gainesville, Florida, USA
| | - Michał Harciarek
- Department of Social Sciences, Division of Clinical Psychology and Neuropsychology, Institute of Psychology, University of Gdansk, Gdansk, Poland
| | - Somnath Datta
- Department of Biostatistics, College of Public Health and Health Professions, University of Florida, Gainesville, Florida, USA
| | - John B Williamson
- Center for OCD, Anxiety, and Related Disorders, Department of Psychiatry, University of Florida, Gainesville, Florida, USA.,Department of Clinical and Health Psychology, College of Public Health and Health Professions, University of Florida, Gainesville, Florida, USA.,Brain Rehabilitation Research Center, Malcom Randall VA Medical Center, Gainesville, Florida, USA.,Center for Cognitive Aging and Memory, McKnight Brain Institute, University of Florida, Gainesville, Florida, USA
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Sakamoto MS, Merritt VC, Jurick SM, Crocker LD, Hoffman SN, Jak AJ. Self-efficacy and coping style in Iraq and Afghanistan-era veterans with and without mild traumatic brain injury and posttraumatic stress disorder. J Clin Psychol 2021; 77:2306-2322. [PMID: 33991109 DOI: 10.1002/jclp.23154] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 03/23/2021] [Accepted: 04/12/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To examine self-efficacy and coping style in combat-exposed Veterans with and without mild traumatic brain injury (mTBI) history and posttraumatic stress disorder (PTSD). METHODS Veterans (N = 81) were categorized into four groups: comorbid mTBI and PTSD (n = 23), PTSD-only (n = 16), mTBI-only (n = 25), and combat-exposed controls (n = 17). Outcomes included the Self-Efficacy for Symptom Management Scale and the Brief Coping Orientation to Problems Experienced. RESULTS Significant group effects were found on self-efficacy and coping style, even when adjusting for total mTBIs and psychiatric comorbidities. Post-hoc analyses revealed that the comorbid and PTSD-only groups generally had lower self-efficacy than the mTBI-only and control groups and that the PTSD-only group used less action-focused coping than the mTBI-only and control groups. CONCLUSION Our results suggest that self-efficacy and coping style vary as a function of mTBI history and PTSD status and that it may be important to integrate these malleable factors into interventions for this population.
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Affiliation(s)
- McKenna S Sakamoto
- Research & Psychology Services, VA San Diego Healthcare System (VASDHS), San Diego, California, USA
| | - Victoria C Merritt
- Research & Psychology Services, VA San Diego Healthcare System (VASDHS), San Diego, California, USA.,Department of Psychiatry, School of Medicine, University of California San Diego, La Jolla, California, USA.,Center of Excellence for Stress and Mental Health, VASDHS, San Diego, California, USA
| | - Sarah M Jurick
- Research & Psychology Services, VA San Diego Healthcare System (VASDHS), San Diego, California, USA.,Department of Psychiatry, School of Medicine, University of California San Diego, La Jolla, California, USA.,Center of Excellence for Stress and Mental Health, VASDHS, San Diego, California, USA
| | - Laura D Crocker
- Research & Psychology Services, VA San Diego Healthcare System (VASDHS), San Diego, California, USA.,Center of Excellence for Stress and Mental Health, VASDHS, San Diego, California, USA
| | - Samantha N Hoffman
- Joint Doctoral Program (JDP) in Clinical Psychology, San Diego State University/University of California San Diego (SDSU/UC San Diego), San Diego, California, USA
| | - Amy J Jak
- Research & Psychology Services, VA San Diego Healthcare System (VASDHS), San Diego, California, USA.,Department of Psychiatry, School of Medicine, University of California San Diego, La Jolla, California, USA.,Center of Excellence for Stress and Mental Health, VASDHS, San Diego, California, USA
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Elevated and Slowed EEG Oscillations in Patients with Post-Concussive Syndrome and Chronic Pain Following a Motor Vehicle Collision. Brain Sci 2021; 11:brainsci11050537. [PMID: 33923286 PMCID: PMC8145977 DOI: 10.3390/brainsci11050537] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 04/16/2021] [Accepted: 04/21/2021] [Indexed: 11/17/2022] Open
Abstract
(1) Background: Mild traumatic brain injury produces significant changes in neurotransmission including brain oscillations. We investigated potential quantitative electroencephalography biomarkers in 57 patients with post-concussive syndrome and chronic pain following motor vehicle collision, and 54 healthy nearly age- and sex-matched controls. (2) Methods: Electroencephalography processing was completed in MATLAB, statistical modeling in SPSS, and machine learning modeling in Rapid Miner. Group differences were calculated using current-source density estimation, yielding whole-brain topographical distributions of absolute power, relative power and phase-locking functional connectivity. Groups were compared using independent sample Mann–Whitney U tests. Effect sizes and Pearson correlations were also computed. Machine learning analysis leveraged a post hoc supervised learning support vector non-probabilistic binary linear kernel classification to generate predictive models from the derived EEG signatures. (3) Results: Patients displayed significantly elevated and slowed power compared to controls: delta (p = 0.000000, r = 0.6) and theta power (p < 0.0001, r = 0.4), and relative delta power (p < 0.00001) and decreased relative alpha power (p < 0.001). Absolute delta and theta power together yielded the strongest machine learning classification accuracy (87.6%). Changes in absolute power were moderately correlated with duration and persistence of symptoms in the slow wave frequency spectrum (<15 Hz). (4) Conclusions: Distributed increases in slow wave oscillatory power are concurrent with post-concussive syndrome and chronic pain.
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Leng Y, Byers AL, Barnes DE, Peltz CB, Li Y, Yaffe K. Traumatic Brain Injury and Incidence Risk of Sleep Disorders in Nearly 200,000 US Veterans. Neurology 2021; 96:e1792-e1799. [PMID: 33658328 PMCID: PMC8055309 DOI: 10.1212/wnl.0000000000011656] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 12/23/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To test the hypothesis that veterans with traumatic brain injury (TBI) have an increased subsequent risk of sleep disorders, we studied the longitudinal association between TBI and incident sleep disorders in nearly 200,000 veterans. METHODS We performed a cohort study of all patients diagnosed with a TBI in the Veterans Health Administration system from October 1, 2001, to September 30, 2015, who were age-matched 1:1 to veterans without TBI. Veterans with prevalent sleep disorders at baseline were excluded. Development of sleep disorders was defined as any inpatient or outpatient diagnosis of sleep apnea, hypersomnia, insomnia, or sleep-related movement disorders based on ICD-9 codes after the first TBI diagnosis or the random selection date for those without TBI. We restricted the analysis to those with at least 1 year of follow-up. We used Cox proportional hazards models to examine the association between TBI and subsequent risk of sleep disorders. RESULTS The study included 98,709 veterans with TBI and 98,709 age-matched veterans without TBI (age 49 ± 20 years). After an average follow-up of 5 (1-14) years, 23,127 (19.6%) veterans developed sleep disorders. After adjustment for demographics, education, income, and medical and psychiatric conditions, those who had TBI compared to those without TBI were 41% more likely to develop any sleep disorders (hazard ratio 1.41 [95% confidence interval 1.37-1.44]), including sleep apnea (1.28 [1.24-1.32]), insomnia (1.50 [1.45-1.55]), hypersomnia (1.50 [1.39-1.61]), and sleep-related movement disorders (1.33 [1.16-1.52]). The association was stronger for mild TBIs, did not differ appreciably by presence of posttraumatic stress disorder, and remained after a 2-year time lag. CONCLUSION In 197,418 veterans without sleep disorders, those with diagnosed TBI had an increased risk of incident sleep disorders over 14 years. Improved prevention and long-term management strategies for sleep are needed for veterans with TBI.
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Affiliation(s)
- Yue Leng
- From the Department of Psychiatry (Y. Leng, A.L.B., D.E.B., K.Y.), Department of Epidemiology and Biostatistics (A.L.B., D.E.B., K.Y.), and Department of Neurology (K.Y.), University of California, San Francisco; and San Francisco Veterans Affairs Health Care System (A.L.B., D.E.B., C.B.P., Y. Li., K.Y.), CA.
| | - Amy L Byers
- From the Department of Psychiatry (Y. Leng, A.L.B., D.E.B., K.Y.), Department of Epidemiology and Biostatistics (A.L.B., D.E.B., K.Y.), and Department of Neurology (K.Y.), University of California, San Francisco; and San Francisco Veterans Affairs Health Care System (A.L.B., D.E.B., C.B.P., Y. Li., K.Y.), CA
| | - Deborah E Barnes
- From the Department of Psychiatry (Y. Leng, A.L.B., D.E.B., K.Y.), Department of Epidemiology and Biostatistics (A.L.B., D.E.B., K.Y.), and Department of Neurology (K.Y.), University of California, San Francisco; and San Francisco Veterans Affairs Health Care System (A.L.B., D.E.B., C.B.P., Y. Li., K.Y.), CA
| | - Carrie B Peltz
- From the Department of Psychiatry (Y. Leng, A.L.B., D.E.B., K.Y.), Department of Epidemiology and Biostatistics (A.L.B., D.E.B., K.Y.), and Department of Neurology (K.Y.), University of California, San Francisco; and San Francisco Veterans Affairs Health Care System (A.L.B., D.E.B., C.B.P., Y. Li., K.Y.), CA
| | - Yixia Li
- From the Department of Psychiatry (Y. Leng, A.L.B., D.E.B., K.Y.), Department of Epidemiology and Biostatistics (A.L.B., D.E.B., K.Y.), and Department of Neurology (K.Y.), University of California, San Francisco; and San Francisco Veterans Affairs Health Care System (A.L.B., D.E.B., C.B.P., Y. Li., K.Y.), CA
| | - Kristine Yaffe
- From the Department of Psychiatry (Y. Leng, A.L.B., D.E.B., K.Y.), Department of Epidemiology and Biostatistics (A.L.B., D.E.B., K.Y.), and Department of Neurology (K.Y.), University of California, San Francisco; and San Francisco Veterans Affairs Health Care System (A.L.B., D.E.B., C.B.P., Y. Li., K.Y.), CA.
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Li H, Flynn DM, Highland KB, Barr PK, Langford DJ, Doorenbos AZ. Relationship between Post-Traumatic Stress Disorder Symptoms and Chronic Pain Related Symptom Domains among Military Active Duty Service Members. PAIN MEDICINE 2021; 22:2876-2883. [PMID: 33690851 DOI: 10.1093/pm/pnab087] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE This study examined the relationships between symptom domains relevant to PTSD diagnosis, PTSD screening, and chronic pain-related symptoms (pain intensity, pain interference, physical function, fatigue, depression, anxiety, anger, satisfaction with social roles) experienced by active duty military service members with chronic pain. DESIGN Cross-sectional study. SETTING The Interdisciplinary Pain Management Center (IPMC) at Madigan Army Medical Center between 2014 and 2018. SUBJECTS Active duty service members receiving care at IPMC (N = 2,745). METHODS Independent sample t test was conducted to compare pain intensity and pain-related measures of physical, emotional and social functioning among patients with and without a PTSD diagnosis or PTSD positive screen (≥3 symptoms). Relative weight analysis was used to identify the relative importance of each PTSD symptom cluster (e.g., intrusion, avoidance, hyperarousal, emotional numbness) to pain and related domains. RESULTS Approximately 27.9% patients had a positive screen for PTSD, and 30.5% of the patients had a PTSD diagnosis. Patients with PTSD diagnosis and positive screening had higher Pain Interference and lower Physical Function and Social Satisfaction scores (P < 0.001), and had increased Anger, Anxiety, Fatigue, and Depression scores (P < 0.001). Emotional numbness accounted for the largest proportion of variance in average pain intensity, pain interference, and psychological functioning; while avoidance accounted for the largest proportion of variance in physical function. CONCLUSION To improve treatment effectiveness and overall functioning for active duty military patients, integrated treatment and therapies targeted to reducing chronic pain, and PTSD symptoms (focus on emotional numbness and avoidance) are recommended.
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Affiliation(s)
- Hongjin Li
- Department of Biobehavioral Nursing Science, College of Nursing, University of Illinois at Chicago.,University of Illinois Cancer Center, Chicago
| | - Diane M Flynn
- Department of Rehabilitative Medicine, Madigan Army Medical Center, Tacoma, Washington
| | - Krista B Highland
- Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, Uniformed Services University, Bethesda, Maryland.,Henry M. Jackson Foundation, Rockville, Maryland
| | - Patricia K Barr
- Department of Rehabilitative Medicine, Madigan Army Medical Center, Tacoma, Washington
| | - Dale J Langford
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle
| | - Ardith Z Doorenbos
- Department of Biobehavioral Nursing Science, College of Nursing, University of Illinois at Chicago.,University of Illinois Cancer Center, Chicago
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Saconi B, Polomano RC, Compton PC, McPhillips MV, Kuna ST, Sawyer AM. The influence of sleep disturbances and sleep disorders on pain outcomes among veterans: A systematic scoping review. Sleep Med Rev 2020; 56:101411. [PMID: 33348172 DOI: 10.1016/j.smrv.2020.101411] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 07/21/2020] [Accepted: 08/13/2020] [Indexed: 11/16/2022]
Abstract
Chronic nonmalignant pain, sleep disturbances and sleep disorders are highly prevalent conditions among U.S. military veterans. Evidence summaries highlight the influence of sleep on pain outcomes in the general adult population but not for the military veteran population. This is a significant gap as U.S. military veterans are an exceedingly high-risk population for both chronic pain and sleep disturbances and/or disorders. We aimed to review the influence of sleep disturbances and sleep disorders on pain outcomes among veterans with chronic nonmalignant pain. A systematic scoping review was conducted using PubMed/Medline, EMBASE, Scopus, CINAHL, and PsycINFO. Twenty-six out of 1450 studies from initial search were included in this review resulting in a combined sample size of N = 923,434 participants. Sleep disturbances and sleep disorders were associated with worse pain outcomes among veterans with chronic pain. Treatment-induced sleep improvements ameliorated pain outcomes in veterans with sleep disorders and sleep disturbances. Research is indicated to address an overlooked pain treatment opportunity - that of sleep disturbance and sleep disorder management.
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Affiliation(s)
- Bruno Saconi
- University of Pennsylvania School of Nursing, Philadelphia, PA, USA; Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA.
| | - Rosemary C Polomano
- University of Pennsylvania School of Nursing, Philadelphia, PA, USA; University of Pennsylvania Perelman School of Medicine, Department of Anesthesiology and Critical Care, USA.
| | - Peggy C Compton
- University of Pennsylvania School of Nursing, Philadelphia, PA, USA.
| | - Miranda V McPhillips
- University of Pennsylvania School of Nursing, Philadelphia, PA, USA; University of Pennsylvania Perelman School of Medicine Center for Sleep and Circadian Neurobiology, Philadelphia, PA, USA.
| | - Samuel T Kuna
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA; University of Pennsylvania Perelman School of Medicine Center for Sleep and Circadian Neurobiology, Philadelphia, PA, USA.
| | - Amy M Sawyer
- University of Pennsylvania School of Nursing, Philadelphia, PA, USA; Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA; University of Pennsylvania Perelman School of Medicine Center for Sleep and Circadian Neurobiology, Philadelphia, PA, USA.
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Merritt VC, Jurick SM, Crocker LD, Sullan MJ, Sakamoto MS, Davey DK, Hoffman SN, Keller AV, Jak AJ. Associations Between Multiple Remote Mild TBIs and Objective Neuropsychological Functioning and Subjective Symptoms in Combat-Exposed Veterans. Arch Clin Neuropsychol 2020; 35:491-505. [PMID: 32128559 DOI: 10.1093/arclin/acaa006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 12/17/2019] [Accepted: 01/13/2020] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE The purpose of this study was to evaluate relationships between multiple mild traumatic brain injuries (mTBIs) and objective and subjective clinical outcomes in a sample of combat-exposed Veterans, adjusting for psychiatric distress and combat exposure. METHOD In this cross-sectional study, 73 combat-exposed Iraq/Afghanistan Veterans were divided into three groups based on mTBI history: 0 mTBIs (n = 31), 1-2 mTBIs (n = 21), and 3+ mTBIs (n = 21). Veterans with mTBI were assessed, on average, 7.78 years following their most recent mTBI. Participants underwent neuropsychological testing and completed self-report measures assessing neurobehavioral, sleep, and pain symptoms. RESULTS MANCOVAs adjusting for psychiatric distress and combat exposure showed no group differences on objective measures of attention/working memory, executive functioning, memory, and processing speed (all p's > .05; ηp2 = .00-.06). In contrast, there were significant group differences on neurobehavioral symptoms (p's = < .001-.036; ηp2 = .09-.43), sleep difficulties (p = .037; ηp2 = .09), and pain symptoms (p < .001; ηp2 = .21). Pairwise comparisons generally showed that the 3+ mTBI group self-reported the most severe symptoms, followed by comparable symptom reporting between the 0 and 1-2 mTBI groups. CONCLUSIONS History of multiple, remote mTBIs is associated with elevated subjective symptoms but not objective neuropsychological functioning in combat-exposed Veterans. These results advance understanding of the long-term consequences of repetitive mTBI in this population and suggest that Veterans with 3+ mTBIs may especially benefit from tailored treatments aimed at ameliorating specific neurobehavioral, sleep, and pain symptoms.
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Affiliation(s)
- Victoria C Merritt
- Research & Psychology Services, VA San Diego Healthcare System (VASDHS), San Diego, CA, USA
| | - Sarah M Jurick
- Research & Psychology Services, VA San Diego Healthcare System (VASDHS), San Diego, CA, USA.,Center of Excellence for Stress and Mental Health, VASDHS, San Diego, CA, USA
| | - Laura D Crocker
- Research & Psychology Services, VA San Diego Healthcare System (VASDHS), San Diego, CA, USA.,Center of Excellence for Stress and Mental Health, VASDHS, San Diego, CA, USA
| | - Molly J Sullan
- Research & Psychology Services, VA San Diego Healthcare System (VASDHS), San Diego, CA, USA
| | - McKenna S Sakamoto
- Research & Psychology Services, VA San Diego Healthcare System (VASDHS), San Diego, CA, USA
| | - Delaney K Davey
- Research & Psychology Services, VA San Diego Healthcare System (VASDHS), San Diego, CA, USA
| | - Samantha N Hoffman
- San Diego Joint Doctoral Program in Clinical Psychology, State University/University of California San Diego (SDSU/UCSD), San Diego, CA, USA
| | - Amber V Keller
- Research & Psychology Services, VA San Diego Healthcare System (VASDHS), San Diego, CA, USA
| | - Amy J Jak
- Research & Psychology Services, VA San Diego Healthcare System (VASDHS), San Diego, CA, USA.,Center of Excellence for Stress and Mental Health, VASDHS, San Diego, CA, USA.,Department of Psychiatry, School of Medicine, University of California San Diego, La Jolla, CA, USA
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Frueh BC, Madan A, Fowler JC, Stomberg S, Bradshaw M, Kelly K, Weinstein B, Luttrell M, Danner SG, Beidel DC. "Operator syndrome": A unique constellation of medical and behavioral health-care needs of military special operation forces. Int J Psychiatry Med 2020; 55:281-295. [PMID: 32052666 DOI: 10.1177/0091217420906659] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE U.S. military special operation forces represent the most elite units of the U.S. Armed Forces. Their selection is highly competitive, and over the course of their service careers, they experience intensive operational training and combat deployment cycles. Yet, little is known about the health-care needs of this unique population. METHOD Professional consultations with over 50 special operation forces operators (and many spouses or girlfriends) over the past 6 years created a naturalistic, observational base of knowledge that allowed our team to identify a unique pattern of interrelated medical and behavioral health-care needs. RESULTS We identified a consistent pattern of health-care difficulties within the special operation forces community that we and other special operation forces health-care providers have termed "Operator Syndrome." This includes interrelated health and functional impairments including traumatic brain injury effects; endocrine dysfunction; sleep disturbance; obstructive sleep apnea; chronic joint/back pain, orthopedic problems, and headaches; substance abuse; depression and suicide; anger; worry, rumination, and stress reactivity; marital, family, and community dysfunction; problems with sexual health and intimacy; being "on guard" or hypervigilant; memory, concentration, and cognitive impairments; vestibular and vision impairments; challenges of the transition from military to civilian life; and common existential issues. CONCLUSIONS "Operator Syndrome" may be understood as the natural consequences of an extraordinarily high allostatic load; the accumulation of physiological, neural, and neuroendocrine responses resulting from the prolonged chronic stress; and physical demands of a career with the military special forces. Clinical research and comprehensive, intensive immersion programs are needed to meet the unique needs of this community.
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Affiliation(s)
- B Christopher Frueh
- Department of Psychology, University of Hawaii, Hilo, HI, USA.,Trauma and Resilience Center, Department of Psychiatry and Behavioral Sciences, University of Texas Health Sciences Center, Houston, TX, USA.,Department of Behavioral Health, Houston Methodist Hospital, Houston, TX, USA
| | - Alok Madan
- Trauma and Resilience Center, Department of Psychiatry and Behavioral Sciences, University of Texas Health Sciences Center, Houston, TX, USA.,Department of Behavioral Health, Houston Methodist Hospital, Houston, TX, USA
| | - J Christopher Fowler
- Trauma and Resilience Center, Department of Psychiatry and Behavioral Sciences, University of Texas Health Sciences Center, Houston, TX, USA.,Department of Behavioral Health, Houston Methodist Hospital, Houston, TX, USA
| | - Sasha Stomberg
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Major Bradshaw
- Trauma and Resilience Center, Department of Psychiatry and Behavioral Sciences, University of Texas Health Sciences Center, Houston, TX, USA.,Department of Behavioral Health, Houston Methodist Hospital, Houston, TX, USA
| | - Karen Kelly
- Department of Warfighter Performance, Naval Health Research Center, San Diego, CA, USA
| | - Benjamin Weinstein
- Trauma and Resilience Center, Department of Psychiatry and Behavioral Sciences, University of Texas Health Sciences Center, Houston, TX, USA.,Department of Behavioral Health, Houston Methodist Hospital, Houston, TX, USA
| | - Morgan Luttrell
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Sciences Center, Houston, TX, USA
| | - Summer G Danner
- Trauma and Resilience Center, Department of Psychiatry and Behavioral Sciences, University of Texas Health Sciences Center, Houston, TX, USA
| | - Deborah C Beidel
- Department of Psychology, University of Central Florida, Orlando, FL, USA
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Ord AS, Lad SS, Shura RD, Rowland JA, Taber KH, Martindale SL. Pain interference and quality of life in combat veterans: Examining the roles of posttraumatic stress disorder, traumatic brain injury, and sleep quality. Rehabil Psychol 2020; 66:31-38. [PMID: 32378923 DOI: 10.1037/rep0000333] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE The goal of this study was to examine the associations among posttraumatic stress disorder (PTSD), traumatic brain injury (TBI), sleep quality, pain interference, and quality of life in combat veterans. METHOD Veterans (N = 289, 86.51% male) completed the Mid-Atlantic MIRECC Assessment of Traumatic Brain Injury, the Clinician-Administered PTSD Scale for DSM-5, and measures of sleep quality, pain interference, and quality of life. RESULTS Hierarchical linear regressions evaluated associations between PTSD severity, deployment TBI severity, sleep quality, and the outcomes of pain interference and quality of life after adjusting for demographic variables and the number of nondeployment TBIs. PTSD severity, B = 0.15, SE B = 0.04, deployment TBI severity, B = 3.98, SE B = 1.01, and sleep quality, B = 0.74, SE B = 0.13, were significantly associated with pain interference, p < .001. PTSD severity, B = -0.57, SE B = 0.07, and pain interference, B = -0.45, SE B = 0.11, were significantly, independently associated with quality of life, p < .001. However, pain interference, B = -0.24, SE B = 0.11, was no longer significantly associated with quality of life when sleep quality, B = -1.56, SE B = 0.25, was included in the model. There was no significant association between deployment TBI severity and quality of life. Interactions among the studied variables were not significant for either of the outcome variables. CONCLUSIONS PTSD symptom severity, deployment TBI history, and sleep quality may be important to consider in treatment planning for veterans experiencing pain-related functional interference. For veterans with numerous conditions comorbid with pain, treatment plans may include interventions targeting sleep and PTSD to maximize quality of life improvements. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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Affiliation(s)
- Anna S Ord
- Mid-Atlantic Mental Illness Research, Education, and Clinical Center (MA-MIRECC)
| | - Sagar S Lad
- Mid-Atlantic Mental Illness Research, Education, and Clinical Center (MA-MIRECC)
| | - Robert D Shura
- Mid-Atlantic Mental Illness Research, Education, and Clinical Center (MA-MIRECC)
| | - Jared A Rowland
- Mid-Atlantic Mental Illness Research, Education, and Clinical Center (MA-MIRECC)
| | - Katherine H Taber
- Mid-Atlantic Mental Illness Research, Education, and Clinical Center (MA-MIRECC)
| | - Sarah L Martindale
- Mid-Atlantic Mental Illness Research, Education, and Clinical Center (MA-MIRECC)
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MacGregor AJ, Zouris JM, Watrous JR, McCabe CT, Dougherty AL, Galarneau MR, Fraser JJ. Multimorbidity and quality of life after blast-related injury among US military personnel: a cluster analysis of retrospective data. BMC Public Health 2020; 20:578. [PMID: 32345277 PMCID: PMC7189580 DOI: 10.1186/s12889-020-08696-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 04/13/2020] [Indexed: 11/25/2022] Open
Abstract
Background Blast injury emerged as a primary source of morbidity among US military personnel during the recent conflicts in Iraq and Afghanistan, and led to an array of adverse health outcomes. Multimorbidity, or the presence of two or more medical conditions in an individual, can complicate treatment strategies. To date, there is minimal research on the impact of multimorbidity on long-term patient-reported outcomes. We aimed to define multimorbidity patterns in a population of blast-injured military personnel, and to examine these patterns in relation to long-term quality of life (QOL). Methods A total of 1972 US military personnel who sustained a blast-related injury during military operations in Iraq and Afghanistan were identified from clinical records. Electronic health databases were used to identify medical diagnoses within the first year postinjury, and QOL was measured with a web-based assessment. Hierarchical cluster analysis methods using Ward’s minimum variance were employed to identify clusters with related medical diagnosis categories. Duncan’s multiple range test was used to group clusters into domains by QOL. Results Five distinct clusters were identified and grouped into three QOL domains. The lowest QOL domain contained one cluster with a clinical triad reflecting musculoskeletal pain, concussion, and mental health morbidity. The middle QOL domain had two clusters, one with concussion/anxiety predominating and the other with polytrauma. The highest QOL domain had two clusters with little multimorbidity aside from musculoskeletal pain. Conclusions The present study described blast-related injury profiles with varying QOL levels that may indicate the need for integrated health services. Implications exist for current multidisciplinary care of wounded active duty and veteran service members, and future research should determine whether multimorbidity denotes distinct post-blast injury syndromes.
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Affiliation(s)
- Andrew J MacGregor
- Medical Modeling, Simulation, and Mission Support Department, Naval Health Research Center, 140 Sylvester Road, San Diego, CA, 92106, USA.
| | - James M Zouris
- Medical Modeling, Simulation, and Mission Support Department, Naval Health Research Center, 140 Sylvester Road, San Diego, CA, 92106, USA
| | - Jessica R Watrous
- Medical Modeling, Simulation, and Mission Support Department, Naval Health Research Center, 140 Sylvester Road, San Diego, CA, 92106, USA.,Leidos, Inc., 140 Sylvester Road, San Diego, CA, 92106, USA
| | - Cameron T McCabe
- Medical Modeling, Simulation, and Mission Support Department, Naval Health Research Center, 140 Sylvester Road, San Diego, CA, 92106, USA.,Leidos, Inc., 140 Sylvester Road, San Diego, CA, 92106, USA
| | - Amber L Dougherty
- Medical Modeling, Simulation, and Mission Support Department, Naval Health Research Center, 140 Sylvester Road, San Diego, CA, 92106, USA.,Leidos, Inc., 140 Sylvester Road, San Diego, CA, 92106, USA
| | - Michael R Galarneau
- Medical Modeling, Simulation, and Mission Support Department, Naval Health Research Center, 140 Sylvester Road, San Diego, CA, 92106, USA
| | - John J Fraser
- Warfighter Performance Department, Naval Health Research Center, 140 Sylvester Road, San Diego, CA, 92106, USA
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Elliott JE, Opel RA, Pleshakov D, Rachakonda T, Chau AQ, Weymann KB, Lim MM. Posttraumatic stress disorder increases the odds of REM sleep behavior disorder and other parasomnias in Veterans with and without comorbid traumatic brain injury. Sleep 2020; 43:zsz237. [PMID: 31587047 PMCID: PMC7315766 DOI: 10.1093/sleep/zsz237] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 09/22/2019] [Indexed: 11/14/2022] Open
Abstract
STUDY OBJECTIVES To describe the crude prevalence of rapid eye movement (REM) sleep behavior disorder (RBD) following traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD) in Veterans, given potential relationships between TBI, PTSD, RBD, and neurodegeneration. METHODS Veterans (n = 394; 94% male; 54.4 ± 15.5 years of age) were prospectively/cross-sectionally recruited from the VA Portland Health Care System and completed in-lab video-polysomnography and questionnaires. TBI and PTSD were assessed via diagnostic screening and medical record review. Subjects were categorized into four groups after assessment of REM sleep without atonia (RSWA) and self-reported dream enactment: (1) "Normal," neither RSWA nor dream enactment, (2) "Other Parasomnia," dream enactment without RSWA, (3) "RSWA," isolated-RSWA without dream enactment, and (4) "RBD," RSWA with dream enactment. Crude prevalence, prevalence odds ratio, and prevalence rate for parasomnias across subjects with TBI and/or PTSD were assessed. RESULTS Overall prevalence rates were 31%, 7%, and 9% for Other Parasomnia, RSWA, and RBD, respectively. The prevalence rate of RBD increased to 15% in PTSD subjects [age adjusted POR: 2.81 (1.17-4.66)] and to 21% in TBI + PTSD subjects [age adjusted POR: 3.43 (1.20-9.35)]. No subjects met all diagnostic criteria for trauma-associated sleep disorder (TASD), and no overt dream enactment was captured on video. CONCLUSIONS The prevalence of RBD and related parasomnias is significantly higher in Veterans compared with the general population and is associated with PTSD and TBI + PTSD. Considering the association between idiopathic-RBD and synucleinopathy, it remains unclear whether RBD (and potentially TASD) associated with PTSD or TBI + PTSD similarly increases risk for long-term neurologic sequelae.
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Affiliation(s)
- Jonathan E Elliott
- VA Portland Health Care System, Portland, OR
- Department of Neurology, Oregon Health and Science University, Portland, OR
| | - Ryan A Opel
- VA Portland Health Care System, Portland, OR
| | | | | | | | - Kristianna B Weymann
- VA Portland Health Care System, Portland, OR
- School of Nursing, Oregon Health and Science University, Portland, OR
| | - Miranda M Lim
- VA Portland Health Care System, Portland, OR
- Department of Neurology, Oregon Health and Science University, Portland, OR
- Department of Behavioral Neuroscience, Oregon Health and Science University, Portland, OR
- Department of Medicine, Division of Pulmonary and Critical Care Medicine; Oregon Health & Science University, Portland, OR
- Oregon Institute of Occupational Health Sciences, Oregon Health and Science University, Portland, OR
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Sleep Disturbances Following Traumatic Brain Injury in Older Adults: A Comparison Study. J Head Trauma Rehabil 2020; 35:288-295. [DOI: 10.1097/htr.0000000000000563] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Psychological Symptoms and Rates of Performance Validity Improve Following Trauma-Focused Treatment in Veterans with PTSD and History of Mild-to-Moderate TBI. J Int Neuropsychol Soc 2020; 26:108-118. [PMID: 31658923 DOI: 10.1017/s1355617719000997] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Iraq and Afghanistan Veterans with posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI) history have high rates of performance validity test (PVT) failure. The study aimed to determine whether those with scores in the invalid versus valid range on PVTs show similar benefit from psychotherapy and if psychotherapy improves PVT performance. METHOD Veterans (N = 100) with PTSD, mild-to-moderate TBI history, and cognitive complaints underwent neuropsychological testing at baseline, post-treatment, and 3-month post-treatment. Veterans were randomly assigned to cognitive processing therapy (CPT) or a novel hybrid intervention integrating CPT with TBI psychoeducation and cognitive rehabilitation strategies from Cognitive Symptom Management and Rehabilitation Therapy (CogSMART). Performance below standard cutoffs on any PVT trial across three different PVT measures was considered invalid (PVT-Fail), whereas performance above cutoffs on all measures was considered valid (PVT-Pass). RESULTS Although both PVT groups exhibited clinically significant improvement in PTSD symptoms, the PVT-Pass group demonstrated greater symptom reduction than the PVT-Fail group. Measures of post-concussive and depressive symptoms improved to a similar degree across groups. Treatment condition did not moderate these results. Rate of valid test performance increased from baseline to follow-up across conditions, with a stronger effect in the SMART-CPT compared to CPT condition. CONCLUSION Both PVT groups experienced improved psychological symptoms following treatment. Veterans who failed PVTs at baseline demonstrated better test engagement following treatment, resulting in higher rates of valid PVTs at follow-up. Veterans with invalid PVTs should be enrolled in trauma-focused treatment and may benefit from neuropsychological assessment after, rather than before, treatment.
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Hoffman AN, Lam J, Hovda DA, Giza CC, Fanselow MS. Sensory sensitivity as a link between concussive traumatic brain injury and PTSD. Sci Rep 2019; 9:13841. [PMID: 31554865 PMCID: PMC6761112 DOI: 10.1038/s41598-019-50312-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 09/10/2019] [Indexed: 12/12/2022] Open
Abstract
Traumatic brain injury (TBI) is one of the most common injuries to military personnel, a population often exposed to stressful stimuli and emotional trauma. Changes in sensory processing after TBI might contribute to TBI-post traumatic stress disorder (PTSD) comorbidity. Combining an animal model of TBI with an animal model of emotional trauma, we reveal an interaction between auditory sensitivity after TBI and fear conditioning where 75 dB white noise alone evokes a phonophobia-like phenotype and when paired with footshocks, fear is robustly enhanced. TBI reduced neuronal activity in the hippocampus but increased activity in the ipsilateral lateral amygdala (LA) when exposed to white noise. The white noise effect in LA was driven by increased activity in neurons projecting from ipsilateral auditory thalamus (medial geniculate nucleus). These data suggest that altered sensory processing within subcortical sensory-emotional circuitry after TBI results in neutral stimuli adopting aversive properties with a corresponding impact on facilitating trauma memories and may contribute to TBI-PTSD comorbidity.
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Affiliation(s)
- Ann N Hoffman
- UCLA, Neurosurgery; Brain Injury Research Center, Los Angeles, USA.
- UCLA, Psychology, Los Angeles, USA.
- UCLA Steve Tisch BrainSPORT Program, Los Angeles, USA.
- Staglin Center for Brain and Behavioral Health, Life Sciences, UCLA, Los Angeles, USA.
| | | | - David A Hovda
- UCLA, Neurosurgery; Brain Injury Research Center, Los Angeles, USA
- UCLA Steve Tisch BrainSPORT Program, Los Angeles, USA
- UCLA, Medical and Molecular Pharmacology, Los Angeles, USA
| | - Christopher C Giza
- UCLA, Neurosurgery; Brain Injury Research Center, Los Angeles, USA
- UCLA Steve Tisch BrainSPORT Program, Los Angeles, USA
- UCLA Mattel Children's Hospital, Los Angeles, USA
| | - Michael S Fanselow
- UCLA, Psychology, Los Angeles, USA
- UCLA, Psychiatry and Biobehavioral Sciences, Los Angeles, USA
- Staglin Center for Brain and Behavioral Health, Life Sciences, UCLA, Los Angeles, USA
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Kanefsky R, Motamedi V, Mithani S, Mysliwiec V, Gill JM, Pattinson CL. Mild traumatic brain injuries with loss of consciousness are associated with increased inflammation and pain in military personnel. Psychiatry Res 2019; 279:34-39. [PMID: 31280036 DOI: 10.1016/j.psychres.2019.07.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 02/01/2019] [Accepted: 07/01/2019] [Indexed: 10/26/2022]
Abstract
Mild traumatic brain injuries (mTBI) are a pervasive concern for military personnel. Determining the impact of injury severity, including loss of consciousness (LOC) may provide important insights into the risk of psychological symptoms and inflammation commonly witnessed in military personnel and veterans following mTBI. US military personnel and veterans were categorized into three groups; TBI with LOC (n = 36), TBI without LOC (n = 25), Controls (n = 82). Participants reported their history of mTBI, psychological symptoms (post-traumatic stress disorder [PTSD] and depression), health-related quality of life (HRQOL), and underwent a blood draw. ANCOVA models which controlled for insomnia status and combat exposure indicated that both mTBI groups (with/without LOC) reported significantly greater depression and PTSD symptoms compared to controls; however, they did not differ from each other. The mTBI with LOC did report greater pain than both controls and mTBI without LOC. The TBI with LOC group also had significantly elevated IL-6 concentrations than both TBI without LOC and control groups. Within the mTBI groups, increased TNFα concentrations were associated with greater PTSD symptoms. These findings indicate that sustaining an mTBI, with or without LOC is detrimental for psychological wellbeing. However, LOC may be involved in perceptions of pain and concentrations of IL-6.
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Affiliation(s)
- Rebekah Kanefsky
- National Institutes of Health, National Institute of Nursing Research, 1 Cloister Court, Bldg 60, Bethesda, MD 20892, USA
| | - Vida Motamedi
- National Institutes of Health, National Institute of Nursing Research, 1 Cloister Court, Bldg 60, Bethesda, MD 20892, USA
| | - Sara Mithani
- National Institutes of Health, National Institute of Nursing Research, 1 Cloister Court, Bldg 60, Bethesda, MD 20892, USA
| | - Vincent Mysliwiec
- San Antonio Military Medical Center, Department of Sleep Medicine, 1100 Wilford Hall Loop, Bldg 4554, JBSA-Lackland, TX 78236, USA
| | - Jessica M Gill
- National Institutes of Health, National Institute of Nursing Research, 1 Cloister Court, Bldg 60, Bethesda, MD 20892, USA
| | - Cassandra L Pattinson
- National Institutes of Health, National Institute of Nursing Research, 1 Cloister Court, Bldg 60, Bethesda, MD 20892, USA.
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Sleep in posttraumatic stress disorder: A systematic review and meta-analysis of polysomnographic findings. Sleep Med Rev 2019; 48:101210. [PMID: 31518950 DOI: 10.1016/j.smrv.2019.08.004] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Revised: 07/22/2019] [Accepted: 08/16/2019] [Indexed: 02/05/2023]
Abstract
Polysomnographic studies have been performed to examine sleep abnormalities in posttraumatic stress disorder (PTSD), but clear associations between PTSD and sleep disturbances have not been established. A systematic review of the evidence examining the polysomnographic changes in PTSD patients compared with controls was conducted using MEDLINE, EMBASE, All EBM databases, PsycINFO, and CINAHL databases. Meta-analysis was undertaken where possible. The searches identified 34 studies, 31 of which were appropriate for meta-analysis. Pooled results indicated decreased total sleep time, slow wave sleep and sleep efficiency, and increased wake time after sleep onset in PTSD patients compared with healthy controls. PTSD severity was associated with decreased sleep efficiency and slow wave sleep percentage. Rapid eye movement (REM) sleep percentage was significantly decreased in PTSD patients compared with controls in studies including participants with mean age below 30 y, but not in studies with other mean age groups (30-40 y and >40 y). Our study shows that polysomnographic abnormalities are present in PTSD. Sex, age, PTSD severity, type of controls, medication status, adaptation night, polysomnographic scoring rules and study location are several of the demographic, clinical and methodological factors that contribute to heterogeneity between studies.
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Merritt VC, Jurick SM, Crocker LD, Hoffman SN, Keller AV, DeFord N, Jak AJ. Evaluation of objective and subjective clinical outcomes in combat veterans with and without mild TBI and PTSD: A four-group design. J Clin Exp Neuropsychol 2019; 41:665-679. [DOI: 10.1080/13803395.2019.1610161] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Victoria C. Merritt
- Psychology Service, VA San Diego Healthcare System (VASDHS), San Diego, CA, USA
| | - Sarah M. Jurick
- Psychology Service, VA San Diego Healthcare System (VASDHS), San Diego, CA, USA
- Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System, San Diego, CA, USA
| | - Laura D. Crocker
- Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System, San Diego, CA, USA
- Research Service, VA San Diego Healthcare System, San Diego, CA, USA
| | | | - Amber V. Keller
- Research Service, VA San Diego Healthcare System, San Diego, CA, USA
| | - Nicole DeFord
- Research Service, VA San Diego Healthcare System, San Diego, CA, USA
| | - Amy J. Jak
- Psychology Service, VA San Diego Healthcare System (VASDHS), San Diego, CA, USA
- Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System, San Diego, CA, USA
- Department of Psychiatry, School of Medicine, University of California San Diego, La Jolla, CA, USA
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