Clinical relevance of subthreshold PTSD versus full criteria PTSD following traumatic brain injury in U.S. service members and veterans

BACKGROUND

The purpose of this cross-sectional study was to examine the influence of subthreshold posttraumatic stress disorder (PTSD) and full PTSD on quality of life following mild traumatic brain injury (mTBI).

METHODS

Participants were 734 service members and veterans (SMV) classified into two injury groups: uncomplicated mild TBI (MTBI; n = 596) and injured controls (IC, n = 139). Participants completed a battery of neurobehavioral measures, 12-or-more months post-injury, that included the PTSD Checklist Civilian version, Neurobehavioral Symptom Inventory, and select scales from the TBI-QOL and MPAI. The MTBI group was divided into three PTSD subgroups: No-PTSD (n = 266), Subthreshold PTSD (n = 139), and Full-PTSD (n = 190).

RESULTS

There was a linear relationship between PTSD severity and neurobehavioral functioning/quality of life in the MTBI sample. As PTSD severity increased, significantly worse scores were found on 11 of the 12 measures (i.e.

, MTBI

Full-PTSD > Sub-PTSD > No-PTSD). When considering the number of clinically elevated scores, a linear relationship between PTSD severity and neurobehavioral functioning/quality of life was again observed in the MTBI sample (e.g., 3-or-more elevated scores: Full-PTSD = 92.1 %, Sub-PTSD = 61.9 %, No-PTSD = 19.9 %).

LIMITATIONS

Limitations included the use of a self-report measure to determine diagnostic status that may under/overcount or mischaracterize individuals.

CONCLUSION

PTSD symptoms, whether at the level of diagnosable PTSD, or falling short of that because of the intensity or characterization of symptoms, have a significant negative impact on one's quality of life following MTBI. Clinicians' treatment targets should focus on the symptoms that are most troubling for an individual and the individual's perception of quality of life, regardless of the diagnosis itself.

Longitudinal health outcomes in caregivers of military members with traumatic brain injury

PURPOSE/OBJECTIVE

To examine longitudinal change in health-related quality of life (HRQOL) in caregivers of service members/veterans with traumatic brain injury and factors associated with clinically elevated symptoms.

RESEARCH METHOD/DESIGN

Caregivers (N = 220) completed nine HRQOL outcome measures and 10 risk factor measures at a baseline evaluation and follow-up evaluation 3 years later. Caregiver's responses on the nine HRQOL outcome measures were classified into four clinical change categories based on the presence/absence of clinically elevated T-scores (≥ 60 T) at baseline and follow-up: (a) Persistent (baseline ≥ 60T + follow-up ≥ 60 T), (b) Developed (baseline < 60 T + follow-up ≥ 60 T), (c) Improved (baseline ≥ 60 T + follow-up < 60 T), and (d) Asymptomatic (baseline < 60 T + follow-up < 60 T). A clinical change composite score was calculated by summing the number of Persistent or Developed HRQOL outcome measures and used to create three clinical change groups: (a) No Symptoms (n = 69, zero measures), (b) Some Symptoms (n = 88, one to three measures), and (c) Numerous Symptoms (n = 63, four to nine measures).

RESULTS

Of the nine HRQOL outcome measures, Bodily Pain, Perceived Stress, Sleep-Related Impairment, and Fatigue were most frequently classified as Persistent or Developed from baseline to follow-up in the entire sample. A linear relationship was found between the vast majority of risk factors across the three clinical change groups at baseline and follow-up (Numerous > Some > None). The risk factors were correlated with the number of elevated HRQOL symptoms at baseline and follow-up. Most Asymptomatic or Persistent caregivers did not have meaningful change (≥ 1 SD) in HRQOL scores. A sizable proportion of Developed or Improved caregivers had either meaningful or no change in HRQOL scores.

CONCLUSIONS/IMPLICATIONS

There is a need for ongoing clinical services for military caregivers. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Elevated Serum Tau and UCHL-1 Concentrations Within 12 Months of Injury Predict Neurobehavioral Functioning 2 or More Years Following Traumatic Brain Injury: A Longitudinal Study

OBJECTIVE

Blood-based biomarkers have received considerable attention for their diagnostic and prognostic value in the acute and postacute period following traumatic brain injury (TBI). The purpose of this study was to examine whether blood-based biomarker concentrations within the first 12 months of TBI can predict neurobehavioral outcome in the chronic phase of the recovery trajectory.

SETTING

Inpatient and outpatient wards from 3 military medical treatment facilities.

PARTICIPANTS

A total of 161 service members and veterans classified into 3 groups: ( a ) uncomplicated mild TBI (MTBI; n = 37), ( b ) complicated mild, moderate, severe, penetrating TBI combined (STBI; n = 46), and ( c ) controls (CTRL; n = 78).

DESIGN

Prospective longitudinal.

MAIN MEASURES

Participants completed 6 scales from the Traumatic Brain Injury Quality of Life (ie, Anger, Anxiety, Depression, Fatigue, Headaches, and Cognitive Concerns) within 12 months (baseline) and at 2 or more years (follow-up) post-injury. Serum concentrations of tau, neurofilament light, glial fibrillary acidic protein, and UCHL-1 at baseline were measured using SIMOA.

RESULTS

Baseline tau was associated with worse anger, anxiety, and depression in the STBI group at follow-up ( R2 = 0.101-0.127), and worse anxiety in the MTBI group ( R2 = 0.210). Baseline ubiquitin carboxyl-terminal hydrolase L1 (UCHL-1) was associated with worse anxiety and depression at follow-up in both the MTBI and STBI groups ( R2 Δ = 0.143-0.207), and worse cognitive concerns in the MTBI group ( R2 Δ = 0.223).

CONCLUSIONS

A blood-based panel including these biomarkers could be a useful tool for identifying individuals at risk of poor outcome following TBI.

Women Report Worse Neurobehavioral Symptoms than Men following Mild Traumatic Brain Injury in U.S. Military Service Members

Women are more directly involved in combat operations today than ever before, currently making up 18.6% of officers and 16.8% of enlisted personnel in the US military. However, women continue to be underrepresented in military research. Studies which do consider gender differences in traumatic brain injury (TBI) outcomes have shown that women report significantly more post-concussive symptoms compared to men. Conclusions for true gender differences related to TBI is hard to make without controlling for non-TBI factors. The objective of this study was to examine the effects of gender specific to mild TBI (MTBI) sequelae from injured and non-injured control groups and investigate the role of PTSD in symptom reporting. It should be noted that the terms gender and men/women are used in this paper in place of sex or males/females given we are not discussing biological attributes. A total of 966 U.S. military service members and veterans where include in the study. Of the total sample, 455 men and 46 women where in the MTBI group, 285 men and 31 women in the Injured Controls group (IC), 111 men and 38 women in the Non-injured Controls group (NIC). Postconcussive and quality of life symptoms were compared for men and women while controlling for combat exposure. MTBI and IC groups were also stratified by PTSD presentation. Measures used included the Neurobehavioral Symptom Inventory (NSI), PTSD Checklist (PCL-C), Traumatic Brain Injury Quality of Life (TBI-QOL), and Combat Exposure Scale. In the MTBI group, women had worse scores on NSI total, NSI Somatosensory and Affective clusters; and the TBI-QOL Anxiety, Fatigue, and Headache scales (n2=.018 to .032, small to small-medium effect sizes). When PTSD was present, women had worse scores on the NSI Somatosensory cluster only (n2=.029, small-medium effect size). In contrast, when PTSD was absent, women had worse scores on the NSI Somatosensory and Affective clusters, and the TBI-QOL Anxiety and Headache scales compared to men (n2=.032 to .063, small to medium effect sizes). In the IC group, women had worse scores on the NSI Cognitive cluster and the TBI-QOL Fatigue and Pain Interference scales (n2=.024 to .042, small to small-medium effect sizes). However, group differences were no longer found when stratified by PTSD sub-groups. In the NIC group, there were no significant group differences for all analyses. We were able to identify symptoms unique to women recovering from MTBI which were not present following other forms of physical injury or healthy controls. However, the impact of PTSD exacerbates the symptom profile and its comorbidity with MTBI equates most of the noted gender differences.

Clinical, Biomarker, and Research Tests Among US Government Personnel and Their Family Members Involved in Anomalous Health Incidents

Importance

Since 2015, US government and related personnel have reported dizziness, pain, visual problems, and cognitive dysfunction after experiencing intrusive sounds and head pressure. The US government has labeled these anomalous health incidents (AHIs).

Objective

To assess whether participants with AHIs differ significantly from US government control participants with respect to clinical, research, and biomarker assessments.

Design, Setting, and Participants

Exploratory study conducted between June 2018 and July 2022 at the National Institutes of Health Clinical Center, involving 86 US government staff and family members with AHIs from Cuba, Austria, China, and other locations as well as 30 US government control participants.

Exposures

AHIs.

Main Outcomes and Measures

Participants were assessed with extensive clinical, auditory, vestibular, balance, visual, neuropsychological, and blood biomarkers (glial fibrillary acidic protein and neurofilament light) testing. The patients were analyzed based on the risk characteristics of the AHI identifying concerning cases as well as geographic location.

Results

Eighty-six participants with AHIs (42 women and 44 men; mean [SD] age, 42.1 [9.1] years) and 30 vocationally matched government control participants (11 women and 19 men; mean [SD] age, 43.8 [10.1] years) were included in the analyses. Participants with AHIs were evaluated a median of 76 days (IQR, 30-537) from the most recent incident. In general, there were no significant differences between participants with AHIs and control participants in most tests of auditory, vestibular, cognitive, or visual function as well as levels of the blood biomarkers. Participants with AHIs had significantly increased fatigue, depression, posttraumatic stress, imbalance, and neurobehavioral symptoms compared with the control participants. There were no differences in these findings based on the risk characteristics of the incident or geographic location of the AHIs. Twenty-four patients (28%) with AHI presented with functional neurological disorders.

Conclusions and Relevance

In this exploratory study, there were no significant differences between individuals reporting AHIs and matched control participants with respect to most clinical, research, and biomarker measures, except for objective and self-reported measures of imbalance and symptoms of fatigue, posttraumatic stress, and depression. This study did not replicate the findings of previous studies, although differences in the populations included and the timing of assessments limit direct comparisons.

Convergent and Discriminant Validity of the Blast Exposure Threshold Survey in United States Military Service Members and Veterans

The Blast Exposure Threshold Survey (BETS) is a recently developed and promising new self-report measure of lifetime blast exposure (LBE). However, there are no studies that have examined the psychometric properties of the BETS, which currently limits its clinical utility. The purpose of this study was to examine the convergent and discriminant validity of the BETS by comparing the BETS Generalized Blast Exposure Value (GBEV) to six variables hypothesized to be associated with LBE (i.e., single-item LBE, combat exposure, years in the military, number of combat deployments, and military occupation specialty [MOS]) and three variables hypothesized not to be associated with LBE (i.e., age at the time of injury, estimated pre-morbid Full-Scale Intelligence Quotient [FSIQ], and resilience). Participants were 202 United States service members and veterans prospectively enrolled from three military medical treatment facilities (68.7%) and via community recruitment initiatives (31.3%). Participants completed the BETS, Combat Exposure Scale (CES), Deployment Risk and Resiliency Inventory-2 Combat Experiences (DRRI-2 CE), Traumatic Brain Injury-Quality of Life Resilience scale, and a brief structured interview. For some analyses, participants were classified into two blast risk MOS groups: high (n = 89) and low (n = 94). The BETS GBEV was not significantly correlated with all three non-blast related variables (rs = 0.01 to rs = -0.12). In contrast, GBEV was significantly (p < 0.001) associated with all blast-related variables; single-item LBE (rs = 0.76), CES (rs = 0.58), number of combat deployments (rs = 0.53), DRRI-2 CE (rs = 0.48), and high blast risk MOS (r = 0.36, medium effect size). However, a stronger relationship was found between the blast-related variables and three modified GBEV scores when excluding some small weapons categories; single-item LBE (rs = 0.80-0.82), CES (rs = 0.64-0.67), number of combat deployments (rs = 0.56), DRRI-2 CE (rs = 0.51-0.53), and high blast risk MOS (r = 0.42-0.49, medium-large effect size). This is the first study to examine the psychometric properties of the BETS. Overall, these results offer support for the convergent and discriminant validity of the BETS. In order to ensure that the BETS can be confidently used as a valid and reliable measure of LBE, more research is needed to further examine the psychometric properties of the test, particularly with regard to the establishment of test-retest reliability.

Lifetime blast exposure is not related to cognitive performance or psychiatric symptoms in US military personnel

Objective: The present study aimed to examine the impact of lifetime blast exposure (LBE) on neuropsychological functioning in service members and veterans (SMVs). Method: Participants were 282 SMVs, with and without history of traumatic brain injury (TBI), who were prospectively enrolled in a Defense and Veterans Brain Injury Center (DVBIC)-Traumatic Brain Injury Center of Excellence (TBICoE) Longitudinal TBI Study. A cross-sectional analysis of baseline data was conducted. LBE was based on two factors: Military Occupational Speciality (MOS) and SMV self-report. Participants were divided into three groups based on LBE: Blast Naive (n = 61), Blast + Low Risk MOS (n = 96), Blast + High Risk MOS (n = 125). Multivariate analysis of variance (MANOVA) was used to examine group differences on neurocognitive domains and the Minnesota Multiphasic Personality Inventory-2 Restructured Form. Results: There were no statistically significant differences in attention/working memory, processing speed, executive functioning, and memory (Fs < 1.75, ps > .1, ηp2s < .032) or in General Cognition (Fs < 0.95, ps > .3, ηp2s < .008). Prior to correction for covariates, lifetime blast exposure was related to Restructured Clinical (F(18,542) = 1.77, p = .026, ηp2 = .055), Somatic/Cognitive (F(10,550) = 1.99, p = .033, ηp2 = .035), and Externalizing Scales (F(8,552) = 2.17, p = .028, ηp2 = .030); however, these relationships did not remain significant after correction for covariates (Fs < 1.53, ps > .145, ηp2s < .032). Conclusions: We did not find evidence of a relationship between LBE and neurocognitive performance or psychiatric symptoms. This stands in contrast to prior studies demonstrating an association between lifetime blast exposure and highly sensitive blood biomarkers and/or neuroimaging. Overall, findings suggest the neuropsychological impact of lifetime blast exposure is minimal in individuals remaining in or recently retired from military service.

Cumulative Blast Exposure During a Military Career Negatively Impacts Recovery from Traumatic Brain Injury

Sub-concussive injuries have emerged as an important factor in the long-term brain health of athletes and military personnel. The objective of this study was to explore the relationship between service member and veterans (SMVs) lifetime blast exposure and recovery from a traumatic brain injury (TBI). A total of 558 SMVs with a history of TBI were examined. Lifetime blast exposure (LBE) was based on self-report (M = 79.4, standard deviation = 392.6; range = 0-7500) categorized into three groups: Blast Naive (n = 121), Low LBE (n = 223; LBE range 1-9), and High LBE (n = 214; LBE >10). Dependent variables were the Neurobehavioral Symptom Inventory (NSI) and Post-traumatic Stress Disorder Checklist-Civilian (PCL-C) and the Traumatic Brain Injury Quality of Life (TBI-QOL). Analyses controlled for demographic factors (age, gender, and race) as well as TBI factors (months since index TBI, index TBI severity, and total number lifetime TBIs). The Blast Naive group had significantly lower NSI and PCL-C scores compared with the Low LBE group and High LBE group, with small to medium effect sizes. On the TBI-QOL, the Blast Naïve group had better quality life on 10 of the 14 scales examined. The Low LBE did not differ from the High LBE group on the PCL-C, NSI, or TBI-QOL. Blast exposure over an SMV's career was associated with increased neurobehavioral and post-traumatic stress symptoms following a TBI. The influence of psychological trauma associated with blasts may be an important factor influencing symptoms as well as the accuracy of self-reported estimates of LBE.

Serum GFAP, NfL, and tau concentrations are associated with worse neurobehavioral functioning following mild, moderate, and severe TBI: a cross-sectional multiple-cohort study

Introduction

The purpose of this study was to examine whether blood-based biomarkers associate with neurobehavioral functioning at three time points following traumatic brain injury (TBI).

Materials and methods

Participants were 328 United States service members and veterans (SMVs) prospectively enrolled in the Defense and Veterans Brain Injury Center-Traumatic Brain Injury Center of Excellence (DVBIC-TBICoE) 15-Year Longitudinal TBI Study, recruited into three groups: uncomplicated mild TBI (MTBI, n = 155); complicated mild, moderate, severe TBI combined (STBI, n = 97); non-injured controls (NIC, n = 76). Participants were further divided into three cohorts based on time since injury (≤12 months, 3-5 years, and 8-10 years). Participants completed the Minnesota Multiphasic Personality Inventory-2-Restructured Format (MMPI-2-RF) and underwent blood draw to measure serum concentrations of glial fibrillary acidic protein (GFAP), neurofilament light (NfL), and tau. A total of 11 MMPI-2-RF scales were examined (e.g., depression, anxiety, anger, somatic, cognitive symptoms). Stepwise hierarchical regression models were conducted within each group.

Results

Significant associations were found between biomarkers and MMPI-2-RF scales (all p < 0.05; R2Δ > 0.10). GFAP was inversely related to (a) neurological complaints in the MTBI group at ≤12 months, (b) demoralization, anger proneness in the STBI group at ≤12 months, and (c) head pain complaints in the STBI group at 8-10 years. NfL was (a) related to low positive emotions in the NIC group; and inversely related to (b) demoralization, somatic complaints, neurological complaints, cognitive complaints in the MTBI group at ≤12 months, (c) demoralization in the STBI group at ≤12 months, and (d) demoralization, head pain complaints, stress/worry in the STBI group at 3-5 years. In the STBI group, there were meaningful findings (R2Δ > 0.10) for tau, NFL, and GFAP that did not reach statistical significance.

Discussion

Results indicate worse scores on some MMPI-2-RF scales (e.g., depression, stress/worry, neurological and head pain complaints) were associated with lower concentrations of serum GFAP, NfL, and tau in the sub-acute and chronic phase of the recovery trajectory up to 5 years post-injury, with a reverse trend observed at 8-10 years. Longitudinal studies are needed to help elucidate any patterns of association between blood-based biomarkers and neurobehavioral outcome over the recovery trajectory following TBI.

High Lifetime Blast Exposure Using the Blast Exposure Threshold Survey Is Associated With Worse Warfighter Brain Health Following Mild Traumatic Brain Injury

The purpose of this study was to extend previous research by examining the relationship between lifetime blast exposure and neurobehavioral functioning after mild TBI (MTBI) by (a) using a comprehensive measure of lifetime blast exposure, and (b) controlling for the influence of post-traumatic stress disorder (PTSD). Participants were 103 United States service members and veterans (SMVs) with a medically documented diagnosis of MTBI, recruited from three military treatment facilities (74.8%) and community-based recruitment initiatives (25.2%, e.g., social media, flyers). Participants completed a battery of neurobehavioral measures 12 or more months post-injury (Neurobehavioral Symptom Inventory, PTSD-Checklist PCLC, TBI-Quality of Life), including the Blast Exposure Threshold Survey (BETS). The sample was classified into two lifetime blast exposure (LBE) groups: High (n = 57) and Low (n = 46) LBE. In addition, the sample was classified into four LBE/PTSD subgroups: High PTSD/High LBE (n = 38); High PTSD/Low LBE (n = 19); Low PTSD/High LBE (n = 19); and Low PTSD/Low LBE (n = 27). The High LBE group had consistently worse scores on all neurobehavioral measures compared with the Low LBE group. When controlling for the influence of PTSD (using ANCOVA), however, only a handful of group differences remained. When comparing measures across the four LBE/PTSD subgroups, in the absence of clinically meaningful PTSD symptoms (i.e., Low PTSD), participants with High LBE had worse scores on the majority of neurobehavioral measures (e.g., post-concussion symptoms, sleep, fatigue). When examining the total number of clinically elevated measures, the High LBE subgroup consistently had a greater number of clinically elevated scores compared with the Low LBE subgroup for the majority of comparisons (i.e., four to 15 or more elevated symptoms). In contrast, in the presence of clinically meaningful PTSD symptoms (i.e., High PTSD), there were no differences between High versus Low LBE subgroups for all measures. When examining the total number of clinically elevated measures, however, there were meaningful differences between High versus Low LBE subgroups for those comparisons that included a high number of clinically elevated scores (i.e., six to 10 or more), but not for a low number of clinically elevated scores (i.e., one to five or more). High LBE, as quantified using a more comprehensive measure than utilized in past research (i.e., BETS), was associated with worse overall neurobehavioral functioning after MTBI. This study extends existing literature showing that lifetime blast exposure, that is largely subconcussive, may negatively impact warfighter brain health and readiness beyond diagnosable brain injury.

Lifetime Blast Exposure Is Not Related to White Matter Integrity in Service Members and Veterans With and Without Uncomplicated Mild Traumatic Brain Injury

This study examines the impact of lifetime blast exposure on white matter integrity in service members and veterans (SMVs). Participants were 227 SMVs, including those with a history of mild traumatic brain injury (mTBI; n = 124), orthopedic injury controls (n = 58), and non-injured controls (n = 45), prospectively enrolled in a Defense and Veterans Brain Injury Center (DVBIC)/Traumatic Brain Injury Center of Excellence (TBICoE) study. Participants were divided into three groups based on number of self-reported lifetime blast exposures: none (n = 53); low (i.e., 1-9 blasts; n = 81); and high (i.e., ≥10 blasts; n = 93). All participants underwent diffusion tensor imaging (DTI) at least 11 months post-injury. Tract-of-interest (TOI) analysis was applied to investigate fractional anisotropy and mean, radial, and axial diffusivity (AD) in left and right total cerebral white matter as well as 24 tracts. Benjamini-Hochberg false discovery rate (FDR) correction was used. Regressions investigating blast exposure and mTBI on white matter integrity, controlling for age, revealed that the presence of mTBI history was associated with lower AD in the bilateral superior longitudinal fasciculus and arcuate fasciculus and left cingulum (βs = -0.255 to -0.174; ps < 0.01); however, when non-injured controls were removed from the sample (but orthopedic injury controls remained), these relationships were attenuated and did not survive FDR correction. Regression models were rerun with modified post-traumatic stress disorder (PTSD) diagnosis added as a predictor. After FDR correction, PTSD was not significantly associated with white matter integrity in any of the models. Overall, there was no relationship between white matter integrity and self-reported lifetime blast exposure or PTSD.

Health outcomes before and during the COVID-19 pandemic in caregivers of service members and veterans with traumatic brain injury

PURPOSE

To examine change in health-related quality of life (HRQOL) during the COVID-19 pandemic in caregivers of service members/veterans (SMVs) with traumatic brain injury (TBI), by comparing HRQOL during the first year of the pandemic to HRQOL 12 months pre-pandemic.

METHODS

Caregivers (N = 246) were classified into three COVID-19 Pandemic Impact groups based on impact ratings of the pandemic on HRQOL: No Impact (n = 50), Mild Impact (n = 117), and Moderate-Severe Impact (n = 79). Caregivers completed 19 measures across physical, social, caregiving, and economic HRQOL domains, and a measure of SMV Adjustment. T-scores were used to determine individual symptom trajectories for each measure as follows: Asymptomatic (pre + during < 60 T); Developed (pre < 60 + during ≥ 60 T); Improved (pre ≥ 60 T + during < 60 T); and Persistent (pre + during ≥ 60 T).

RESULTS

Using ANOVA, during the pandemic, the Moderate-Severe Impact group reported worse scores on 19 measures (d = 0.41-0.89) compared to the No Impact group and 18 measures (d = 0.31-0.62) compared to the Mild Impact group (d  = 0.31-0.38). The Mild Impact group reported worse scores on two measures compared to the No Impact group (d = 0.42-0.43). Using the entire sample, the majority of HRQOL measures were classified as Asymptomatic (47.2-94.7%), followed by Persistent (2.4-27.2%). Few were classified as Developed (0.4-12.6%) or Improved (2.4-13.8%). Using repeated measures ANOVA, no meaningful effects sizes were found for mean scores on all measures completed pre-pandemic compared to during the pandemic (d ≤ 0.17).

CONCLUSION

The vast majority of caregivers reported stability in HRQOL pre-pandemic compared to during the pandemic. The COVID-19 pandemic was not associated with a high prevalence of decline in caregiver HRQOL.

Longitudinal health-related quality of life in military caregivers no longer providing care

PURPOSE/OBJECTIVE

To examine health-related quality of life (HRQOL) in caregivers when providing care and no longer providing care to service members/veterans with traumatic brain injury.

RESEARCH METHOD/DESIGN

Participants included 466 caregivers enrolled in a 15-year longitudinal study. During an annual follow-up evaluation, a subsample of caregivers self-identified as no longer providing care and were retained in the study as a No Longer Caregiving group (n = 48). Scores on HRQOL measures when providing care (baseline) and no longer providing care (follow-up) were examined. Scores on HRQOL measures were also compared with the remaining 418 caregivers (Caregiving group).

RESULTS

The most frequent reasons for no longer caregiving were no longer being in a relationship with the SMV and the SMV had recovered/no longer required care. The No Longer Caregiving group at follow-up reported better scores on five measures compared to baseline, and three measures compared to the Caregiving group. There were no differences in the proportion of clinically elevated scores on HRQOL measures for the No Longer Caregiving group between baseline and follow-up. Compared to the Caregiving group, the No Longer Caregiving group reported a higher prevalence of clinical elevated scores on General Life Satisfaction at baseline and follow-up, and worse scores on Caregiving Relationship Satisfaction and the Couples Satisfaction Index at baseline.

CONCLUSIONS/IMPLICATIONS

While some improvement in HRQOL was noted when caregivers were no longer providing care, many continued to report elevated scores. Services and supports are required for caregivers when providing care, but also when transitioning out of a caregiving role. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Normative Ranges for, and Interrater Reliability of, Rotational Vestibular and Balance Tests in U.S. Military Service Members and Veterans

PURPOSE

The objectives of this study were to (a) describe normative ranges-expressed as reference intervals (RIs)-for vestibular and balance function tests in a cohort of Service Members and Veterans (SMVs) and (b) to describe the interrater reliability of these tests.

METHOD

As part of the Defense and Veterans Brain Injury Center (DVBIC)/Traumatic Brain Injury Center of Excellence 15-year Longitudinal Traumatic Brain Injury (TBI) Study, participants completed the following: vestibulo-ocular reflex suppression, visual-vestibular enhancement, subjective visual vertical, subjective visual horizontal, sinusoidal harmonic acceleration, the computerized rotational head impulse test (crHIT), and the sensory organization test. RIs were calculated using nonparametric methods and interrater reliability was assessed using intraclass correlation coefficients between three audiologists who independently reviewed and cleaned the data.

RESULTS

Reference populations for each outcome measure comprised 40 to 72 individuals, 19 to 61 years of age, who served either as noninjured controls (NIC) or injured controls (IC) in the 15-year study; none had a history of TBI or blast exposure. A subset of 15 SMVs from the NIC, IC, and TBI groups were included in the interrater reliability calculations. RIs are reported for 27 outcome measures from the seven rotational vestibular and balance tests. Interrater reliability was considered excellent for all tests except the crHIT, which was found to have good interrater reliability.

CONCLUSION

This study provides clinicians and scientists with important information regarding normative ranges and interrater reliability for rotational vestibular and balance tests in SMVs.

Health outcomes in caregivers of service members and veterans with traumatic brain injury enrolled in the U.S. Veterans Affairs Caregiver Support Program

To explore health outcomes in caregivers of service members and veterans (SMV) with traumatic brain injury (TBI) enrolled in two programs within the U.S. Department of Veterans Affairs (VA) Caregiver Support Program (CSP) (General and Comprehensive Programs) and those not enrolled. Participants were 290 caregivers classified into three groups: (a) General Program (n = 34); (b) Comprehensive Program (n = 104); and (c) Not Enrolled (n = 152). Main outcome measures assessed caregiver health-related quality of life (HRQOL), SMV functional ability, and caregiver needs. Compared to the Not Enrolled group, the General, and Comprehensive Program groups reported worse scores on five of 25 caregiver HRQOL measures and had a higher proportion of elevated scores on two measures. The Comprehensive Program group reported worse scores on an additional seven HRQOL measures and a higher proportion of elevated scores on three measures compared to the Not Enrolled group. Over 20% of caregivers in each group reported clinically elevated scores on eight HRQOL measures. Few differences between caregiver groups were identified for unmet needs. In the total sample, eight HRQOL measures consistently emerged that were more strongly associated with caregiver needs. Caregivers enrolled in the VA CSP tended to report worse HRQOL and caring for a SMV with worse functional ability compared to those not enrolled. A better understanding of health care utilization for those not enrolled in the CSP and in need of help is required. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Changes in Outpatient Healthcare Utilization and Costs Following Mild Traumatic Brain Injury Among Service Members in the Military Health System by Preexisting Behavioral Health Condition Status

OBJECTIVE

To evaluate changes in healthcare utilization and cost following an index mild traumatic brain injury (mTBI) diagnosis among service members (SMs). We hypothesized that differences in utilization and cost will be observed by preexisting behavioral health (BH) diagnosis status.

SETTING

Direct care outpatient healthcare facilities within the Military Health System.

PARTICIPANTS

A total of 21 984 active-duty SMs diagnosed with an index mTBI diagnosis between 2017 and 2018.

DESIGN

This retrospective study analyzed changes in healthcare utilization and cost in military treatment facilities among SMs with an index mTBI diagnosis. Encounter records 1 year before and after mTBI were assessed; preexisting BH conditions were identified in the year before mTBI.

MAIN MEASURES

Ordinary least squares regressions evaluated difference in the average change of total outpatient encounters and costs among SMs with and with no preexisting BH conditions (eg, posttraumatic stress disorder, adjustment disorder). Additional regressions explored changes in utilization and cost within clinic types (eg, mental health, physical rehabilitation).

RESULTS

There was a 39.5% increase in overall healthcare utilization during the following year, representing a 34.8% increase in total expenditures. Those with preexisting BH conditions exhibited smaller changes in overall utilization (β, -4.9; [95% confidence interval (CI), -6.1 to -3.8]) and cost (β, $-1873; [95% CI, $-2722 to $-1024]), compared with those with no BH condition. The greatest differences were observed in primary care clinics, in which those with prior BH conditions exhibited an average decreased change of 3.2 encounters (95% CI, -3.5 to -3) and reduced cost of $544 (95% CI, $-599 to $-490) compared with those with no prior BH conditions.

CONCLUSION

Despite being higher utilizers of healthcare services both pre- and post-mTBI diagnosis, those with preexisting BH conditions exhibited smaller changes in overall cost and utilization. This highlights the importance of considering prior utilization and cost when evaluating the impact of mTBI and other injury events on the Military Health System.

Efficient Estimation of the Binaural Masking Level Difference Using a Technique Based on Manual Audiometry

PURPOSE

The Masking Level Difference (MLD) has been used for decades to evaluate the binaural listening advantage. Although originally measured using Bekesy audiometry, the most common clinical use of the MLD is the CD-based Wilson 500-Hz technique with interleaved N0S0 and N0Sπ components. Here, we propose an alternative technique based on manual audiometry as a faster way of measuring the MLD. The article describes the advantages to this administration technique and evaluates if it is a viable alternative for the Wilson technique.

METHOD

Data were retrospectively analyzed on 264 service members (SMs). All SMs completed both the Wilson and Manual MLDs. Descriptive and correlational statistics were applied to evaluate the comparisons between the two techniques and highlight the differences. Equivalence measures were also completed to compare the tests using a standardized cutoff score. Analyses were also made to compare both techniques to subjective and objective measures of hearing performance.

RESULTS

Moderate to high positive correlations were determined between Wilson and Manual measures of each threshold (N0Sπ and N0S0). Although the Manual and Wilson MLD techniques produced significantly different thresholds, simple linear transformations can be used to obtain approximately equivalent scores on the two tests, and agreement was high for using these transformed scores to identify individuals with substantial MLD deficits. Both techniques had moderate test-retest reliability. The Manual MLD and components had stronger correlations to the subjective and objective hearing measures than the Wilson.

CONCLUSIONS

The Manual technique is a faster method for obtaining MLD scores that is just as reliable as the CD-based Wilson test. With the significant reduction in assessment time and comparable results, the Manual MLD is a viable alternative for direct use in the clinic.

Serum Tau, Neurofilament Light Chain, Glial Fibrillary Acidic Protein, and Ubiquitin Carboxyl-Terminal Hydrolase L1 Are Associated with the Chronic Deterioration of Neurobehavioral Symptoms after Traumatic Brain Injury

The purpose of this study was to examine the association of serum tau, neurofilament light chain (NFL), glial fibrillary acidic protein (GFAP), and ubiquitin carboxy-terminal hydrolase L1 (UCHL-1) concentrations evaluated within the first 12 months after a military-related TBI, with longitudinal changes in neurobehavioral functioning extending two or more years post-injury. Participants were 84 United States service members and veterans (SMVs) prospectively enrolled in the Defense and Veterans Brain Injury Center of Excellence/Traumatic Brain Injury Center 15-Year Longitudinal TBI Study, separated into three discreet groups: (a) uncomplicated mild TBI (MTBI; n = 28), (b) complicated mild, moderate, severe, and penetrating TBI combined (STBI; n = 29], and (c) non-injured controls (NIC, n = 27). Participants completed a battery of self-report neurobehavioral symptom measures (e.g., depression, post-traumatic stress disorder [PTSD], post-concussion, anxiety, somatic, cognitive, and neurological symptoms) within 12 months of injury (baseline), and then again at two or more years post-injury (follow-up). At baseline, participants also completed a blood draw to determine serum concentrations of tau, NFL, GFAP, and UCHL-1 using an ultra-sensitivity assay method. In the MTBI and STBI groups (using hierarchical regression analyses), (1) baseline tau concentrations predicted the deterioration of neurobehavioral symptoms from baseline to follow-up on measures of anxiety, PTSD, depression, post-concussion, somatic, and neurological symptoms (accounting for 10-28% of the variance); (2) NFL predicted the deterioration of depression, post-concussion, somatic, cognitive, and neurological symptoms (10-32% variance); (3) GFAP predicted the deterioration of post-concussion, PTSD, depression, anxiety, somatic, neurological, and cognitive symptoms (11-43% variance); and (4) UCHL-1 predicted the deterioration of anxiety, somatic, and neurological symptoms (10-16% variance). In the NIC group, no meaningful associations were found between baseline biomarker concentrations and the deterioration of neurobehavioral symptoms on the majority of measures. This study reports that elevated tau, NFL, GFAP, and UCHL-1 concentrations within the first 12 months of injury are associated with the deterioration of neurobehavioral symptoms that extends to the chronic phase of recovery after a TBI. These findings suggest that a blood-based panel including these biomarkers could be a useful prognostic tool to identifying those individuals at risk of poor future outcome after TBI.

Cross-walk comparison of the DVBIC-TBICoE and LIMBIC-CENC combat-related concussion prospective longitudinal study datasets

OBJECTIVE

To describe and compare cohorts between two large, longitudinal, federally-funded TBI studies of Service members and veterans across demographic, self-report, and neuropsychological variables.

DESIGN

Analysis of data from the DVBIC-TBICoE and LIMBIC-CENC prospective longitudinal studies (PLS).

SETTING

Recruitment locations spanning Department of Defense and Veterans Affairs hospitals across the U.S.

PARTICIPANTS

1,463 participants enrolled in the DVBIC-TBICoE study and divided among non-injured (NIC) (n=191), injured control (IC) (n=349), mild TBI (mTBI) (n=682), and (moderate-severe-penetrating TBI (smcTBI) (n=241) subgroups. 1,550 participants enrolled in the LIMBIC-CENC study and divided between IC (n=285) and mTBI (n=1,265) subgroups. IC and mTBI study groups were compared across demographic and military characteristics, self-reported symptoms, and neuropsychological test scores.

INTERVENTIONS

None MAIN OUTCOME MEASURES: Neurobehavioral Symptom Inventory (NSI), PTSD Checklist-Military Version (PCL-C), TBI Quality of Life (TBI-QOL), Test of Premorbid Functioning (TOPF), Wechsler Adult Intelligence Scale-IV (WAIS-IV) Visual Puzzles, Symbol Search, Coding, Letter-Number Sequencing, and Digit Span, Trail Making Test (TMT), Delis-Kaplan Executive Functioning System (DKEFS) Verbal Fluency, Letter Fluency, and Category Fluency, California Verbal Learning Test-II (CVLT-II), and Grooved Pegboard (GP).

RESULTS

Compared to DVBIC-TBICoE, LIMBIC-CENC participants have higher enrollment age, education level, proportion of Black race, and time from injury as well as less combat deployments and are less likely to be married. The distribution of military service branches also differed. Further, symptom profiles differed between cohorts. LIMBIC-CENC participants endorsed higher posttraumatic stress disorder symptomatology. DVBIC-TBICoE study IC participants endorsed higher somatosensory and vestibular symptoms (medium effect sizes). Other symptom measure differences had very small effect sizes (≤0.2). Differences were found on many cognitive test results, but are difficult to interpret given the demographic differences and generally very small effect sizes.

CONCLUSIONS

The heavy use of NIH common data elements in both studies and collaboration with the DVBIC-TBICoE study team on development of the LIMBIC-CENC assessment battery enabled this comparative analysis. Results highlight unique differences in study cohorts, and adds perspective and interpretability for assimilating past and future findings.

White Matter Integrity Relates to Cognition in Service Members and Veterans after Complicated Mild, Moderate, and Severe Traumatic Brain Injury, But Not Uncomplicated Mild Traumatic Brain Injury

The extant literature investigating the relationship between diffusion tensor imaging (DTI) and cognition following traumatic brain injury (TBI) is limited by small sample sizes and inappropriate control groups. The present study examined DTI metric differences between service members and veterans (SMVs) with bodily injury (Trauma Control; TC), uncomplicated mild TBI (mTBI), complicated mild TBI (compTBI), and severe-moderate TBI combined (smTBI), and how DTI metrics related to cognition within each group. Participants were 226 SMVs (56 TC, 112 mTBI, 29 compTBI, 29 smTBI) with valid neuropsychological testing and DTI at least 11 months post-injury. The smTBI group demonstrated decreased fractional anisotropy (FA) and increased axial diffusivity (AD), mean diffusivity (MD), and radial diffusivity (RD) of the cerebral white matter (CWM) and several individual white matter tracts compared with the TC, mTBI, and compTBI groups (all ps < 0.05; rs = 0.17 to 0.49). The TC, mTBI, and compTBI groups did not differ in terms of any DTI metrics. Within the smTBI group, FA, AD, MD, and RD of the total CWM and several white matter tracts were related to Processing Speed (|rs|: 0.43 to 0.66; ps < 0.05), and/or Delayed Memory (|rs|: 0.41 to 0.67; ps < 0.05). In the compTBI group, Processing Speed was related to left arcuate fasciculus and superior longitudinal fasciculus (SLF) FA, MD, and RD, as well as left uncinate fasciculus MD and RD. In contrast, there were no significant relationships between DTI metrics and cognition/emotional functioning within the mTBI or TC groups. Overall, findings suggest a dose-response relationship between TBI severity and the strength of the relationship between white matter integrity and cognitive performance, with essentially no relationship in mTBI, some findings in compTBI, and several strongly significant relationships in smTBI. In contrast to previously reported findings, there were no differences in DTI metrics between controls, mTBI, and compTBI, and DTI metrics were unrelated to cognition in our relatively large mTBI group.

Risk factors for the presence and persistence of posttraumatic stress symptoms following traumatic brain injury in U.S. service members and veterans

This study aimed to identify risk factors predictive of the presence and persistence of posttraumatic stress disorder (PTSD) symptom reporting following traumatic brain injury (TBI). Participants were 1,301 U.S. service members and veterans (SMVs) divided into four groups: uncomplicated mild TBI (mTBI; n = 543); complicated mild, moderate, severe, and penetrating TBI (n = 230); injured controls (n = 340); and noninjured controls (n = 188). We examined 25 factors related to demographic, injury-related, military-specific, treatment/health care need, and mental health/social support variables. Seven factors were statistically associated with the presence of DSM-IV-TR symptom criteria for PTSD: premorbid IQ, combat exposure, depression, social participation, history of mTBI, need for managing mood and stress, and need for improving memory and attention, p < .001 (51.3% variance). When comparing the prevalence of these risk factors in a longitudinal cohort (n = 742) across four PTSD trajectory groups (i.e., asymptomatic, improved, developed, persistent), a higher proportion of participants in the persistent PTSD group reported worse depression, a lack of social participation, and history of mTBI. Additionally, a higher proportion of participants in the persistent and developed PTSD groups reported the need for managing mood/stress and improving memory/attention. When considered simultaneously, the presence of ≥ 1 or ≥ 2 risk factors was associated with a higher proportion of participants in the developed and persistent PTSD groups, ps < .001. These risk factors may be useful in identifying SMVs at risk for the development and/or persistence of PTSD symptoms who may need intervention.

Relationship satisfaction among spouse caregivers of service members and veterans with comorbid mild traumatic brain injury and post-traumatic stress disorder

This study examined relationship satisfaction and health-related quality of life (HRQOL) among spouse caregivers assisting service members and veterans (SMV) with comorbid uncomplicated mild traumatic brain injury (MTBI) and post-traumatic stress disorder (PTSD). Spouse caregivers (N = 205) completed the Couples Satisfaction Index (CSI), 12 HRQOL measures, and the Mayo-Portland Adaptability Inventory 4^th Edition (MPAI-4). T-scores were classified as "clinically elevated" using a cutoff of ≥60T. The sample was also classified into "Satisfied" (≥13.5, n = 113, 55.0%) or "Dissatisfied" (<13.5, n = 92, 44.0%) relationship categories. Using stepwise regression analysis, Anxiety, Family Disruption, Vigilance, Emotional Support, Feeling Trapped, and MPAI-4 Adjustment were identified as the strongest predictors of CSI total scores (p < 0.001), accounting for 41.6% of the variance. Squared semi-partial correlations revealed that 18.1% of the variance was shared across all six measures, with 7.8% to 1.5% of unique variance accounted for by each measure separately. When comparing the number of clinically elevated measures simultaneously, the Dissatisfied group consistently had a higher number of clinically elevated scores compared to the Satisfied group (e.g., 3-or-more clinically elevated scores: Dissatisfied = 40.2%, Satisfied = 8.8%, OR = 6.93, H = 0.76). Caring for a SMV with comorbid TBI and PTSD can have a profound impact on the spouse caregiver's HRQOL, relationship satisfaction, and family functioning. The findings from the current study continue to support the need for family involvement in the SMV's treatment plan, but more effort is needed to integrate behavioral health treatment that focuses on the family member's own issues into military TBI and PTSD systems of care.

Caregiver sleep impairment and service member and veteran adjustment following traumatic brain injury is related to caregiver health-related quality of life

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.

A-15 Impact of Lifetime Blast Exposure on Cognitive and Psychiatric Functioning of Warfighters

Objective: Some military occupation specialties (MOS) such as Special Forces are at high risk for lifetime blast exposure (LBE). These individuals are at risk for some medical conditions but the impact of LBE on service members and veterans (SMVs) cognitive and psychiatric function is unknown.

Methods: 281 SMVs completed an assessment of Attention/Working Memory, Processing Speed, Executive Function, Memory, and Psychiatric function. Average age was 35.86 (SD = 9.84) and 61.2% had at least moderate combat exposure and 32.4% had no history of traumatic brain injury (TBI). 61 participants had no LBE, 113 were in a high-risk MOS and had LBE (M = 211.23, SD = 395.1), and 107 were not in a high-risk MOS but had LBE (M = 92.7, SD =222.9).

Results: Cognitively, a small effect for LBE was observed on Processing Speed (p = 0.015, ηp2 = 0.037), but not for the other domains. Psychiatrically, a medium effect was observed (p &lt; 0.001, ηp2 = 0.103). Higher LBE was associated with Somatic Complaints, Low Positive Emotions and Aberrant Experiences. However, after controlling for covariates (sex, ethnicity, post-traumatic stress, combat exposure, alcohol use, and TBI) there was no impact of LBE.

Conclusion: LBE may negatively impact processing speed and psychiatric function; however, the relative impact of LBE compared to other factors such as post-traumatic stress, substance abuse, and TBI needs further investigation. The views expressed are those of the authors and do not necessarily represent the official policy or position of the Defense Health Agency or any other U.S. government agency. For more information contact dha.TBICOEinfo@mail.mil. UNCLASSIFIED.

APOE Is Associated With Serum Tau Following Uncomplicated Mild Traumatic Brain Injury

Background and Objectives

APOE e4 has been linked to poor outcome following traumatic brain injury (TBI); however, the mechanisms behind this relationship are unclear. Few studies have investigated the relationship between the APOE genotype and established brain related protein biomarkers following TBI. The purpose of this study was to examine this relationship in service members and veterans (SMVs) following TBI.

Methods

Participants were 209 SMVs [124 uncomplicated mild TBI (mTBI); 85 complicated mild, moderate, severe, or penetrating TBI (mod-sev TBI)] prospectively enrolled in the DVBIC-TBICoE 15-Year Longitudinal TBI Study. APOE genotyping was undertaken using non-fasting blood serum samples. Participants were divided into three groups: APOE e2+, APOE e3/e3, and APOE e4+.

Results

In participants with mTBI, those with the APOE e2 allele had significantly lower levels of tau than those with APOE e4 (p = 0.005, r = 0.43, medium-large effect size). Those with APOE e3/e3 trended toward having higher tau than those APOE e2+ (p = 0.076, r = 0.20, small-medium effect size) and lower tau than those with APOE e4+ (p = 0.062, r = 0.21, small-medium effect size). There were no significant differences in biomarkers based on APOE in the mod-sev TBI group.

Discussion

This study is the first to demonstrate APOE genotype is related to serum tau levels following a mTBI, extending prior findings to human serum following mTBI. In addition to higher serum tau levels in APOE e4 carriers, lower tau levels were observed in APOE e2 carriers, suggesting a possible protective effect.

Longitudinal changes of white matter microstructure following traumatic brain injury in U.S. military service members

The purpose of this study was to analyze quantitative diffusion tensor imaging measures across the spectrum of traumatic brain injury severity and evaluate their trajectories in military service members. Participants were 96 U.S. military service members and veterans who had sustained a mild traumatic brain injury [including complicated mild traumatic brain injury (n = 16) and uncomplicated mild traumatic brain injury (n = 68)], moderate-severe traumatic brain injury (n = 12), and controls (with or without orthopaedic injury, n = 39). All participants had been scanned at least twice, with some receiving up to five scans. Both whole brain voxel-wise analysis and tract-of-interest analysis were applied to assess the group differences of diffusion tensor imaging metrics, and their trajectories between time points of scans and days since injury. Linear mixed modelling was applied to evaluate cross-sectional and longitudinal diffusion tensor imaging metrics changes within and between groups using both tract-of-interest and voxel-wise analyses. Participants with moderate to severe traumatic brain injury had larger white matter disruption both in superficial subcortical and deep white matter, mainly over the anterior part of cerebrum, than those with mild traumatic brain injury, both complicated and uncomplicated, and there was no evidence of recovery over the period of follow-ups in moderate-severe traumatic brain injury, but deterioration was possible. Participants with mild traumatic brain injury had white matter microstructural changes, mainly in deep central white matter over the posterior part of cerebrum, with more spatial involvement in complicated mild traumatic brain injury than in uncomplicated mild traumatic brain injury and possible brain repair through neuroplasticity, e.g. astrocytosis with glial processes and glial scaring. Our results did not replicate 'V-shaped' trajectories in diffusion tensor imaging metrics, which were revealed in a previous study assessing the sub-acute stage of brain injury in service members and veterans following military combat concussion. In addition, non-traumatic brain injury controls, though not demonstrating any evidence of sustaining a traumatic brain injury, might have transient white matter changes with recovery afterward. Our results suggest that white matter integrity following a remote traumatic brain injury may change as a result of different underlying mechanisms at the microstructural level, which can have a significant consequence on the long-term well beings of service members and veterans. In conclusion, longitudinal diffusion tensor imaging improves our understanding of the mechanisms of white matter microstructural changes across the spectrum of traumatic brain injury severity. The quantitative metrics can be useful as guidelines in monitoring the long-term recovery.

Aggression in Military Members With Mild Traumatic Brain Injury and Post-Traumatic Stress Disorder Is Associated With Intimate Partner Health-Related Quality of Life

OBJECTIVE

We aimed to examine the relationship between service member/veteran (SMV) aggression and health-related quality of life (HRQOL) in their intimate partners.

METHODS

This prospective cohort study included 201 female intimate partner caregivers of post-9/11 male SMVs with a diagnosis of uncomplicated mild traumatic brain injury and post-traumatic stress disorder from a military treatment facility. Caregivers completed 17 HRQOL measures and rated the level the SMV experiences problems with verbal or physical expressions of irritability, anger, or aggression on the Mayo-Portland Adaptability Inventory, 4th edition. Caregivers were classified into three SMV Aggression groups: i) none or very mild (n = 53); ii) mild (n = 47); and iii) moderate or severe (n = 101). HRQOL scores were classified as clinically elevated using a cutoff of 60T or higher.

RESULTS

Using χ² analysis, the moderate or severe group had a significantly higher proportion of clinically elevated scores on 15 HRQOL measures compared with the none or very mild group, and six measures compared with the mild group. The mild group had higher scores on two measures compared with the none or very mild group. Using analysis of covariance (and controlling for caregiver strain), the moderate or severe group had significantly higher scores on 11 HRQOL measures compared with the none or very mild group, and two measures compared with the mild group. The mild group had higher scores on five measures compared with the none or very mild group.

CONCLUSIONS

Many caregivers who report moderate to severe SMV aggression after a traumatic brain injury, report poor HRQOL beyond the strain of care provision. Traumatic brain injury and post-traumatic stress disorder programs should screen for and treat SMV aggression, and attend to the health needs of their caregivers.

Pain interference and health-related quality of life in caregivers of service members and veterans with traumatic brain injury and mental health comorbidity

PURPOSE

To examine (1) the relationship between caregiver pain interference with caregiver health-related quality of life (HRQOL), caregiver age, and service member/veteran (SMV) functional ability, and (2) change in caregiver pain interference longitudinally over 5 years.

METHOD

Participants were 347 caregivers of SMVs diagnosed with traumatic brain injury (TBI). Caregivers completed the SF-12v2 Health Survey Bodily Pain scale at an initial baseline evaluation and up to four annual follow-up evaluations. Caregivers were divided into three pain interference groups: High Pain Interference (n = 104), Neutral Pain Interference (n = 117), and Low Pain Interference (n = 126). Caregivers also completed 15 HRQOL measures and a measure of SMV functional ability.

RESULTS

The High Pain Interference group reported more clinically elevated scores on 13 measures compared to the Low Pain Interference group, and seven measures compared to the Neutral Pain Interference group. The Neutral Pain Interference group had more clinically elevated scores on three measures compared to the Low Pain Interference group. The High and Neutral Pain Interference groups were older than the Low Pain Interference group. Parent caregivers were older than intimate partner/sibling caregivers, but did not report worse pain interference. Caregiver age, and measures of Fatigue, Strain, Perceived Rejection, and Economic QOL were the strongest predictors of pain interference (p < .001), accounting for 28.2% of the variance. There was minimal change in Bodily Pain scores over five years. The interaction of time and age was not significant (X² = 2.7, p = .61).

CONCLUSION

It is important to examine pain in the context of HRQOL in caregivers, regardless of age.

Blood Biomarkers Predict Future Cognitive Decline after Military-Related Traumatic Brain Injury

BACKGROUND

Traumatic brain injury (TBI) has been associated with increased likelihood of late-life dementia; however, the mechanisms driving this relationship are elusive. Blood-based biomarkers may provide insight into these mechanisms and serve as useful prognostic indicators of cognitive recovery or decline following a TBI.

OBJECTIVE

The aim of this study was to examine blood biomarkers within one year of TBI and explore their relationship with cognitive decline.

METHODS

Service members and veterans (n=224) without injury (n=77), or with history of bodily injury (n=37), uncomplicated mild TBI (n=55), or more severe TBI (n=55), underwent a blood draw and neuropsychological assessment within one year of their injury as part of a case-control study. A subsample (n=87) completed follow-up cognitive assessment.

RESULTS

In the more severe TBI group, baseline glial fibrillary acidic protein (p=.008) and ubiquitin C-terminal hydrolase-L1 (p=.026) were associated with processing speed at baseline, and baseline ubiquitin C-terminal hydrolase-L1 predicted change in immediate (R2Δ=.244, p=.005) and delayed memory (R2Δ=.390, p=.003) over time. In the mild TBI group, higher baseline tau predicted greater negative change in perceptual reasoning (R2Δ=.188, p=.033) and executive functioning (R2Δ=.298, p=.007); higher baseline neurofilament light predicted greater negative change in perceptual reasoning (R2Δ=.211, p=.012).

CONCLUSION

Baseline ubiquitin C-terminal hydrolase-L1 strongly predicted memory decline in the more severe TBI group, while tau and neurofilament light strongly predicted decline in the mild TBI group. A panel including these biomarkers could be particularly helpful in identifying those at risk for future cognitive decline following TBI.

Correlative Factors for Traumatic Brain Injury in Combat Ocular Trauma

INTRODUCTION

Traumatic brain injury (TBI) remains a significant source of disability for active duty service members in both deployed and training settings as well as those who have left active service. Service members with ocular trauma are at risk for a TBI and should be screened appropriately. Early detection results in treatment to minimize long-term sequelae which can often be debilitating. This study is the first to evaluate different combat-related ocular injuries and their associations with TBI.

MATERIALS AND METHODS

A secondary analysis of existing data was conducted from a prospective study of patients who sustained combat ocular trauma (COT) during Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) between 2006 and 2020. Clinical data of a total of 88 participants were gathered and each case reviewed, including patient demographics, injury-related factors, history of TBI, and treatments rendered. All cases were then categorized to compare COT (n = 13) versus COT-T (Combat Ocular Trauma associated with TBI; n = 75). The Fisher's exact test was completed for each category to assess for predictive factors of TBI within the ophthalmic trauma cohort. Odds ratios were calculated with their 95% CI.

RESULTS

When compared to COT, COT-T was significantly associated with closed globe injuries (56%; OR 4.24, 95% CI 1.08-16.67), blast injuries (89.3%; OR 3.72, 95% CI 0.93-14.9), multiple surgeries (89%; OR 2.51, 95% CI 0.57-11.08), anterior segment injuries (69.3%; OR 1.41, 95% CI 0.42-4.79), optic nerve injuries (24%; OR 1.05, 95% CI 0.26-4.25), orbital fractures (48%; OR 2.08, 95% CI 0.59-7.34), enucleation (17.3%; OR 2.52, 95% CI 0.300-21.08), the use of eye protection (68.6%; OR 2.18, 95% CI 0.57-8.32), and the need to undergo plastic surgery (78.7%; OR 2.30, 95% CI 0.66-8.02). Significant factors associated with COT included penetrating injury (30.8%; OR 0.027, 95% CI 0.07-1.08), posterior segment injuries (92%; OR 0.264, 95% CI 0.032-2.17), bilateral injuries (76.9%; OR 0.678, 95% CI 0.17-2.69), and bilateral blindness (7.7%; OR 0.857, 95% CI 0.092-7.99).

CONCLUSIONS

Patients who have sustained combat-related ocular injuries, specifically blast injury, anterior segment injury, or an orbital fracture, were noted to be more likely to have also sustained a TBI. However, of the evaluated variables in predicting the co-occurrence of TBI, only closed globe injury was identified as statistically significant. Service members with injuries requiring multiple surgical procedures, reconstructive plastic surgery, or enucleation of an eye were also more likely to be diagnosed with a TBI, but these variables were not found to be predictive of TBI among ocular trauma patients. The presence of eye protection was not protective against TBI. Further studies are needed to find significant predictors of TBI in combat ocular trauma patients to assist in the early and accurate detection of TBI.

Extracellular vesicle neurofilament light is elevated within the first 12-months following traumatic brain injury in a U.S military population

Traumatic brain injury (TBI) can be associated with long-term neurobehavioral symptoms. Here, we examined levels of neurofilament light chain (NfL) and glial fibrillary acidic protein (GFAP) in extracellular vesicles isolated from blood, and their relationship with TBI severity and neurobehavioral symptom reporting. Participants were 218 service members and veterans who sustained uncomplicated mild TBIs (mTBI, n = 107); complicated mild, moderate, or severe TBIs (smcTBI, n = 66); or Injured controls (IC, orthopedic injury without TBI, n = 45). Within one year after injury, but not after, NfL was higher in the smcTBI group than mTBI (p = 0.001, d = 0.66) and IC (p = 0.001, d = 0.35) groups, which remained after controlling for demographics and injury characteristics. NfL also discriminated the smcTBI group from IC (AUC:77.5%, p < 0.001) and mTBI (AUC:76.1%, p < 0.001) groups. No other group differences were observed for NfL or GFAP at either timepoint. NfL correlated with post-concussion symptoms (rs = - 0.38, p = 0.04) in the mTBI group, and with PTSD symptoms in mTBI (rs = - 0.43, p = 0.021) and smcTBI groups (rs = - 0.40, p = 0.024) within one year after injury, which was not confirmed in regression models. Our results suggest the potential of NfL, a protein previously linked to axonal damage, as a diagnostic biomarker that distinguishes TBI severity within the first year after injury.

Low resilience following traumatic brain injury is strongly associated with poor neurobehavioral functioning in U.S. military service members and veterans

OBJECTIVE

The purpose of this study was to examine the relationship between resilience and self-reported neurobehavioral functioning following traumatic brain injury (TBI) in U.S. military service members and veterans (SMVs). A secondary objective was to examine the interaction between resilience and posttraumatic stress disorder (PTSD) on neurobehavioral functioning.

METHOD

Participants included 795 SMVs classified into four groups: Uncomplicated Mild TBI (MTBI; n=300); Complicated Mild, Moderate, Severe, or Penetrating TBI (STBI, n 162); Injured Controls (IC, n=185); and Non-injured Controls (NIC, n=148). Two independent cohorts were evaluated - those assessed within 1-year of injury and those assessed 10-years post-injury. SMVs completed self-report measures including the PTSD Checklist-Civilian version, Neurobehavioral Symptom Inventory, and TBI-Quality of Life.

RESULTS

Results showed that (1) lower resilience was strongly associated with poorer neurobehavioral functioning across all groups at 1-year and 10-years post-injury, and (2) PTSD and resilience had a robust influence on neurobehavioral functioning at both time periods post-injury, such that SMVs with PTSD and low resilience displayed the poorest neurobehavioral functioning.

CONCLUSION

Results suggest that regardless of injury group and time since injury, resilience and PTSD strongly influence neurobehavioral functioning following TBI among SMVs. Future research evaluating interventions designed to enhance resilience in this population is indicated.

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

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.

Analysis of Discourse Production to Assess Cognitive Communication Deficits Following Mild Traumatic Brain Injury With and Without Posttraumatic Stress

PURPOSE

Cognitive communication deficits can be difficult to assess in individuals with mild traumatic brain injury (mTBI). However, the use of discourse analysis as a direct and sensitive metric of cognitive communication skills has shown promising clinical utility for other TBI severity levels. This exploratory study investigated discourse production in service members and veterans (SMVs) with uncomplicated mTBI with and without posttraumatic stress disorder (PTSD) and SMVs with neither mTBI or PTSD.

METHOD

Fifteen SMVs with mTBI and PTSD, 26 with mTBI, and 25 controls with no brain injury (NBI) and without PTSD were given a wordless picture story to elicit spontaneous discourse. Discourse samples were analyzed for global coherence, word count, the use of negative emotion words, cognitive process words, nonfluencies, and story completeness.

RESULTS

Results revealed a significant difference between the mTBI (Mdn = 3.33) and NBI (Mdn = 3.50) groups, χ²(3) = 6.044, p = .017, ε² = .03, for global coherence. Word count differed significantly between the mTBI + PTSD (Mdn = 135) and NBI (Mdn = 195) groups, χ²(3) = 7.968, p = .006, ε² = .06. No other group differences were observed.

DISCUSSION

Structural features of discourse production may serve as potential markers of cognitive communication deficits in mTBI. Furthermore, PTSD may contribute to verbal fluency deficits in individuals with mTBI. Additional research is needed to develop discourse-related measures that are more sensitive to the effects of mTBI and PTSD.

Post-Traumatic Stress Disorder Symptoms Are Related to Cognition after Complicated Mild and Moderate Traumatic Brain Injury but Not Severe and Penetrating Traumatic Brain Injury

Although post-traumatic stress disorder (PTSD) has been associated with worse cognitive outcomes after mild traumatic brain injury (TBI), its impact has not been evaluated after more severe TBI. This study aimed to determine whether PTSD symptoms are related to cognition after complicated mild, moderate, severe, and penetrating TBI. Service members (n = 137) with a history of complicated mild/moderate TBI (n = 64) or severe/penetrating TBI (n = 73) were prospectively enrolled from United States Military Treatment Facilities. Participants completed a neuropsychological assessment one year or more post-injury. Six neuropsychological composite scores and an overall test battery mean (OTBM) were considered. Participants were excluded if there was evidence of invalid responding. Hierarchical linear regressions were conducted evaluating neuropsychological performance. The interaction between TBI severity and PTSD Checklist-Civilian version total score was significant for processing speed (β = 0.208, p = 0.034) and delayed memory (β = 0.239, p = 0.021) and trended toward significance for immediate memory (β = 0.190, p = 0.057) and the OTBM (β = 0.181, p = 0.063). For each of these composite scores, the relationship between PTSD symptoms and cognition was stronger in the complicated mild/moderate TBI group than the severe/penetrating TBI group. Within the severe/penetrating TBI group, PTSD symptoms were unrelated to cognitive performance. In contrast, within the complicated mild/moderate TBI group, PTSD symptoms were significantly related to processing speed (R²Δ = 0.077, β = -0.280, p = 0.019), immediate memory (R²Δ = 0.197, β = -0.448, p < 0.001), delayed memory (R²Δ = 0.176, β = -0.423, p < 0.001), executive functioning (R²Δ = 0.100, β = -0.317, p = 0.008), and the OTBM (R²Δ = 0.162, β = -0.405, p < 0.001). The potential impact of PTSD symptoms on cognition, over and above the impact of brain injury alone, should be considered with service members and veterans with a history of complicated mild/moderate TBI. In addition, in research comparing cognitive outcomes between patients with histories of complicated-mild, moderate, severe, and/or penetrating TBI, it will be important to account for PTSD symptoms.

A-15 PTSD Symptoms Are Related to Cognition Following Complicated Mild and Moderate TBI, but Not Severe and Penetrating TBI

Objective

Despite the strong evidence suggesting post-traumatic stress disorder (PTSD) symptoms negatively impact cognition following mild traumatic brain injury (TBI), little is known about this relationship in more severe TBI. This study investigates the relationship between PTSD symptoms and cognitive performance following complicated mild, moderate, severe, and penetrating TBI.

Methods

Participants were 137 U.S. military service members and veterans (SMVs) with a history of complicated mild or more severe TBI prospectively enrolled in the Defense and Veterans Brain Injury Center (DVBIC)/Traumatic Brain Injury Center of Excellence (TBICoE) 15-Year Longitudinal TBI Study. Participants were divided into two groups: complicated mild/moderate TBI (n = 64) and severe/penetrating TBI (n = 73). Participants completed a neuropsychological assessment, including the PTSD Checklist-Civilian Version one year or more post-injury. Six neuropsychological composite scores and an overall test battery mean (OTBM) were considered. Participants who failed symptom validity tests were excluded. Hierarchical linear regressions were conducted evaluating neuropsychological performance.

Results

TBI severity (βs:-0.163 to −0.253, ps &lt; 0.04) and PTSD symptoms (βs:-0.189 to −0.212), ps &lt; 0.03) were related to neuropsychological performance in the overall sample. Within the severe/penetrating TBI group, PTSD symptoms were unrelated to cognitive performance. Within the complicated mild/moderate TBI group, PTSD symptoms were significantly related to processing speed (R2Δ = 0.080, β = −0.284, p = 0.016), immediate memory (R2Δ = 0.204, β = −0.453, p &lt; 0.001), delayed memory (R2Δ = 0.180, β = −0.426, p &lt; 0.001), executive functioning (R2Δ = 0.102, β = −0.319, p = 0.007), and the OTBM (R2Δ = 0.170, β = −0.413, p &lt; 0.001).

Discussion

PTSD symptom severity was significantly related to neuropsychological performance in SMVs with complicated mild/moderate TBI. PTSD symptoms should be considered when evaluating patients with a history of complicated mild to moderate TBI.

A randomized clinical trial of plasticity-based cognitive training in mild traumatic brain injury

Clinical practice guidelines support cognitive rehabilitation for people with a history of mild traumatic brain injury (mTBI) and cognitive impairment, but no class I randomized clinical trials have evaluated the efficacy of self-administered computerized cognitive training. The goal of this study was to evaluate the efficacy of a self-administered computerized plasticity-based cognitive training programmes in primarily military/veteran participants with a history of mTBI and cognitive impairment. A multisite randomized double-blind clinical trial of a behavioural intervention with an active control was conducted from September 2013 to February 2017 including assessments at baseline, post-training, and after a 3-month follow-up period. Participants self-administered cognitive training (experimental and active control) programmes at home, remotely supervised by a healthcare coach, with an intended training schedule of 5 days per week, 1 h per day, for 13 weeks. Participants (149 contacted, 83 intent-to-treat) were confirmed to have a history of mTBI (mean of 7.2 years post-injury) through medical history/clinician interview and persistent cognitive impairment through neuropsychological testing and/or quantitative participant reported measure. The experimental intervention was a brain plasticity-based computerized cognitive training programme targeting speed/accuracy of information processing, and the active control was composed of computer games. The primary cognitive function measure was a composite of nine standardized neuropsychological assessments, and the primary directly observed functional measure a timed instrumental activities of daily living assessment. Secondary outcome measures included participant-reported assessments of cognitive and mental health. The treatment group showed an improvement in the composite cognitive measure significantly larger than that of the active control group at both the post-training [+6.9 points, confidence interval (CI) +1.0 to +12.7, P = 0.025, d = 0.555] and the follow-up visit (+7.4 points, CI +0.6 to +14.3, P = 0.039, d = 0.591). Both large and small cognitive function improvements were seen twice as frequently in the treatment group than in the active control group. No significant between-group effects were seen on other measures, including the directly-observed functional and symptom measures. Statistically equivalent improvements in both groups were seen in depressive and cognitive symptoms.

Apolipoprotein E e4 is associated with worse self-reported neurobehavioral symptoms following uncomplicated mild traumatic brain injury in U.S. military service members

Past research has found a relationship between the apolipoprotein E (APOE) e4 allele and worse neurobehavioral functioning following mild traumatic brain injury (MTBI) in civilian populations. The purpose of this study was to examine this relationship in service members and veterans (SMVs) following MTBI. Participants were 151 SMVs (103 uncomplicated MTBI; 48 Injured Controls [IC]) prospectively enrolled in the DVBIC-TBICoE 15-Year Longitudinal TBI Study. Participants completed a battery of self-reported neurobehavioral symptom measures on average 76.2 months post-injury (SD = 31.8). APOE genotyping was undertaken using non-fasting blood samples. Participants were classified into four subgroups based on injury (MTBI vs. IC) and APOE e4 allele status (e4 present/absent). In the IC group, there were no significant differences across APOE e4 status subgroups for all measures. In the MTBI group, participants with the APOE e4 allele had significantly worse scores on measures of depression, pain, anxiety, grief, positive well-being, social participation, and resilience compared to those without the e4 allele (d = .44 to d = .69). When comparing the number of 'clinically elevated' neurobehavioral measures simultaneously, the MTBI/e4 present subgroup consistently had a higher number of elevated measures compared to the MTBI/e4 absent, IC/e4 present, and IC/e4 absent subgroups. The APOE e4 allele was associated with poorer neurobehavioral outcome in SMVs in the chronic phase of recovery following MTBI. APOE e4 could be incorporated into screening tools to predict SMVs at risk for poor long-term neurobehavioral outcome in an effort to provide early intervention to improve long-term clinical outcome.

Unhealthy family functioning is associated with health-related quality of life among military spouse caregivers

OBJECTIVE

The current study examines health-related quality of life (HRQOL) and family functioning in a sample of spouse caregivers assisting post-9/11 service members and veterans (SMV) following traumatic brain injury (TBI).

METHOD

Participants were 316 spouse (and partner) caregivers of SMVs following a mild, moderate, severe, or penetrating TBI. Caregivers completed the Family Assessment Device General Functioning subscale, 24 HRQOL questionnaires, and the Mayo-Portland Adaptability Inventory (4th ed.; MPAI-4). The sample was divided into two family functioning groups: Healthy Family Functioning (HFF; n = 162) and Unhealthy Family Functioning (UFF; n = 154). Scores on HRQOL measures that generate T scores using normative data were classified as "clinically elevated," using a cutoff of > 60T.

RESULTS

Compared with the HFF group, caregivers in the UFF group reported worse scores on all HRQOL measures and worse SMV functional ability on the MPAI-4 Adjustment Index and Anxiety, Depression, and Irritability/Anger/Aggression items (all ps < .001, ds = .41-1.36). A significantly higher proportion of the UFF group had clinically elevated HRQOL scores compared with the HFF group on the majority of measures (Hs = .24-.75). When examining all HRQOL measures simultaneously, the UFF group consistently had a significantly higher cumulative percentage of clinically elevated scores compared with the HFF group (e.g., ≥ 5 clinically elevated scores: UFF = 53.9% vs. HFF = 22.2%; H = .68).

CONCLUSIONS

Caring for a SMV following TBI with comorbid mental health problems may have negative implications for their family functioning and the caregiver's HRQOL. Family-centered interventions could be beneficial for military families experiencing distress following SMV TBI and mental health comorbidity. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Sleep disturbances following traumatic brain injury are associated with poor neurobehavioral outcomes in U.S. military service members and veterans

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.

Syllabic Diadochokinesis in Adults With and Without Traumatic Brain Injury: Severity, Stability, and Speech Considerations

Purpose Syllabic diadochokinesis (DDK) is a standard assessment task for motor speech disorders. This study aimed to compare rate and regularity of DDK according to the presence or absence of traumatic brain injury (TBI) and severity of TBI, examine the stability of DDK over time, and explore associations between DDK and extemporaneous speech. Method Military service members and veterans were categorized into three groups: no history of TBI (control), uncomplicated mild TBI (mTBI), and moderate through severe (including penetrating) TBI (msTBI). Participants produced rapid alternating-motion and sequential-motion syllable repetitions during one or two sessions. A semi-automated protocol determined syllabic rate and regularity. Perceptual ratings of selected participants' connected speech samples were compared to DDK results. Results Two hundred sixty-three service members and veterans provided data from one session and 69 from two sessions separated by 1.9 years (SD = 1.0). DDKs were significantly slower overall for mTBI and msTBI groups compared to controls. Regularity of productions did not differ significantly across groups. A significant Group × Task interaction revealed that the msTBI group produced sequential-motion syllable repetitions but not alternating-motion repetitions with greater regularity, whereas the opposite occurred for control and mTBI groups. DDK results did not differ significantly between sessions. Perceptual speech analysis for 30 participants, including 20 with atypical or questionable DDK performance, revealed two participants with mildly abnormal speech. Conclusions Overall, DDK productions are slower than normal in adults with moderate, severe, and penetrating TBI and are stable over time. Regularity of productions did not differentiate groups, although this result differed according to task. There were surprisingly few people identified with disordered speech, making comparisons to DDK data tenuous, and indicating that dysarthria is a rare complication in a population of adults with mostly uncomplicated mTBI who are not selected from referrals to a speech-language pathology clinic.

The Impact of Combat Ocular Trauma and Traumatic Brain Injury on Vision- and Health-Related Quality of Life Among U.S. Military Casualties

PURPOSE

The purpose of this study was to assess visual and health-related quality of life (QOL) among U.S. military service members who sustained combat ocular trauma (COT) with or without associated traumatic brain injury (TBI).

METHODS

This was a single-center, prospective observational study of U.S. service members (n = 88) with COT who were treated at Walter Reed National Military Medical Center. Participants completed the National Eye Institute Visual Function Questionnaire (VFQ-25) at enrollment and at follow-up (>1 year) and supplemental surveys: Neurobehavioral Symptom Inventory, the Medical Outcomes 36-item Short Form Survey (SF-36), and Mayo-Portland Adaptability Inventory.

RESULTS

Initial and follow-up VFQ-25 showed a statistically significant increase in median scores for near activities (initial: 75.0, follow-up 83.3; P = .004) and peripheral vision (initial: 50.0, follow-up: 75.0; P = .009) and in composite scores (initial: 79.5, follow-up: 79.8; P = .022). Comparing those who did (n = 78) and did not (n = 8) have a TBI history, there were no significant differences in median change in VFQ-25 composite scores (with TBI: 2.3 vs. no TBI: 10.7; P = .179). Participants with a TBI history had a significantly lower median SF-36 General Health score (with TBI: 67.5 vs. no TBI: 92.5; P = .009).

CONCLUSIONS

Vision-related QOL of COT patients is generally good in the long term. However, those with both COT and a history of TBI conditions showed significantly worse functioning in several domains than those without TBI. As TBI is a common finding in COT, this association is an important factor impacting this population's overall clinical presentation and daily functions.

Intracranial Abnormalities Are Associated With Fewer Self-Reported Symptoms in Military Service Members Following Moderate-to-Severe Traumatic Brain Injury

OBJECTIVE

This study examined the relationship between intracranial abnormalities (ICAs) and self-reported neurobehavioral and posttraumatic stress (PTS) symptoms in members of the military with moderate-to-severe traumatic brain injury (msTBI).

METHOD

Participants included 539 members of the US military with nonpenetrating msTBI. Self-reported neurobehavioral and PTS symptoms were assessed using the Neurobehavioral Symptom Inventory and the PTSD Checklist-Civilian Version. ICAs were categorized as present/absent (by subtype) based upon medical record review. Spearman rank-order correlations and stepwise multiple regression analyses examined univariate and combined predictive relationships between ICAs and self-reported symptoms.

RESULTS

The presence of any ICA was associated with reduced self-reported neurobehavioral and PTS symptoms. ICA-associated reductions were largest for PTS, followed by affective and cognitive neurobehavioral symptoms, and relatively weak for somatic/sensory and vestibular symptoms. Effects of different types of ICAs were comparable. Greater time since injury was related to greater symptom report, whereas duration of loss of consciousness and posttraumatic amnesia were not consistently related to self-reported symptoms.

CONCLUSIONS

Results suggest that ICAs are associated with suppression of reported PTS and neurobehavioral symptoms-potentially via reduction in self-awareness. These findings support comprehensive, objective evaluation to identify impairments in self-awareness and functioning in msTBI patients.

Burden of Behavioral Health Comorbidities on Outpatient Health Care Utilization by Active Duty Service Members With a First Documented mTBI

OBJECTIVE

More than 280,000 Active Duty Service Members (ADSMs) sustained a mild traumatic brain injury (mTBI) between 2000 and 2019 (Q3). Previous studies of veterans have shown higher utilization of outpatient health clinics by veterans diagnosed with mTBI. Additionally, veterans with mTBI and comorbid behavioral health (BH) conditions such as post-traumatic stress disorder, depression, and substance use disorders have significantly higher health care utilization than veterans diagnosed with mTBI alone. However, few studies of the relationship between mTBI, health care utilization, and BH conditions in the active duty military population currently exist. We examined the proportion of ADSMs with a BH diagnosis before and after a first documented mTBI and quantified outpatient utilization of the Military Health System in the year before and following injury.

MATERIALS AND METHODS

Retrospective analysis of 4,901,840 outpatient encounters for 39,559 ADSMs with a first documented diagnosis of mTBI recorded in the Department of Defense electronic health record, subsets of who had a BH diagnosis. We examined median outpatient utilization 1 year before and 1 year after mTBI using Wilcoxon signed rank test, and the results are reported with an effect size r. Outpatient utilization is compared by BH subgroups.

RESULTS

Approximately 60% of ADSMs experience a first mTBI with no associated BH condition, but 17% of men and women are newly diagnosed with a BH condition in the year following mTBI. ADSMs with a history of a BH condition before mTBI increased their median outpatient utilization from 23 to 35 visits for men and from 32 to 42 visits for women. In previously healthy ADSMs with a new BH condition following mTBI, men more than tripled median utilization from 7 to 24 outpatient visits, and women doubled utilization from 15 to 32 outpatient visits.

CONCLUSIONS

Behavioral health comorbidities affect approximately one-third of ADSMs following a first mTBI, and approximately 17% of previously healthy active duty men and women will be diagnosed with a new BH condition in the year following a first mTBI. Post-mTBI outpatient health care utilization is highly dependent on the presence or absence of BH condition and is markedly higher is ADSMs with a BH diagnosis in the year after a first documented mTBI.

Efficacy of an Interdisciplinary Intensive Outpatient Program in Treating Combat-Related Traumatic Brain Injury and Psychological Health Conditions

Background: Since 2000, over 413,000 US service members (SM) experienced at least one traumatic brain injury (TBI), and 40% of those with in-theater TBIs later screened positive for comorbid psychological health (PH) conditions, including post-traumatic stress disorder (PTSD), depression, and anxiety. Many SMs with these persistent symptoms fail to achieve a recovery that results in a desirable quality of life or return to full duty. Limited information exists though to guide treatment for SMs with a history of mild TBI (mTBI) and comorbid PH conditions. This report presents the methods and outcomes of an interdisciplinary intensive outpatient program (IOP) in the treatment of SMs with combat-related mTBI and PH comorbidities. The IOP combines conventional rehabilitation therapies and integrative medicine techniques with the goal of reducing morbidity in multiple neurological and behavioral health domains and enhancing military readiness.

Methods: SMs (n = 1,456) with residual symptoms from mTBI and comorbid PH conditions were treated in a 4-week IOP at the National Intrepid Center of Excellence (NICoE) at Walter Reed National Military Medical Center (WRNMMC). The IOP uses an interdisciplinary, holistic, and patient-centric rehabilitative care model. Interdisciplinary teams provide a diagnostic workup of neurological, psychiatric, and existential injuries, and from these assessments, individualized care plans are developed. Treatment response was assessed using the Neurobehavioral Symptom Inventory (NSI), PTSD Checklist—Military Version (PCL-M), Satisfaction With Life Scale (SWLS), Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), Epworth Sleepiness Scale (ESS), and Headache Impact Test-6 (HIT-6) and administered at admission, discharge, and at 1, 3, and 6 months post-discharge.

Findings: Following treatment in the IOP, the symptomatic patients had statistically significant and clinically meaningful improvements across all outcome measures. The largest effect size was seen with GAD-7 (r = 0.59), followed by PHQ-8 (r = 0.56), NSI (r = 0.55), PCL-M (r = 0.52), ESS (r = 0.50), SWLS (r = 0.49), and HIT-6 (r = 0.42). In cross-sectional follow ups, the significant improvements were sustained at 1, 3, and 6 months post-discharge.

Interpretation: This report demonstrates that an interdisciplinary IOP achieves significant and sustainable symptom recovery in SMs with combat-related mTBI and comorbid PH conditions and supports the further study of this model of care in complex medical conditions.

Post-Traumatic Stress Disorder Is Associated with Neuropsychological Outcome but Not White Matter Integrity after Mild Traumatic Brain Injury

The aim of this study was to examine neuropsychological functioning and white matter integrity, in service members and veterans (SMVs) after mild traumatic brain injury (MTBI), with versus without post-traumatic stress disorder (PTSD). Participants were 116 U.S. military SMVs, prospectively enrolled from the Walter Reed National Military Medical Center (Bethesda, MD), who had sustained an MTBI (n = 86) or an injury without TBI (i.e., Injured Control [IC]; n = 30). Participants completed a battery of neuropsychological measures (neurobehavioral and -cognitive), as well as diffusion tensor imaging (DTI) of the brain, on average 6 years post-injury. Based on diagnostic criteria for PTSD, participants in the MTBI group were classified into two subgroups: MTBI/PTSD-Present (n = 21) and MTBI/PTSD-Absent (n = 65). Participants in the IC group were included only if they were classified as PTSD-Absent. The MTBI/PTSD-Present group had a significantly higher number of self-reported symptoms on all neurobehavioral measures (e.g., depression), and lower scores on more than half of the neurocognitive domains (e.g., processing speed), compared to the MTBI/PTSD-Absent and IC/PTSD-Absent groups. There were no significant group differences for the vast majority of DTI measures, with the exception of a handful of regions (i.e., superior longitudinal fascicle and superior thalamic radiation). These results suggest that there is 1) a strong relationship between PTSD and poor neuropsychological outcome after MTBI and 2) a lack of a relationship between PTSD and white matter integrity, as measured by DTI, after MTBI. Concurrent PTSD and MTBI should be considered a risk factor for poor neuropsychological outcome that requires early intervention.

TBI-CareQOL military health care frustration in caregivers of service members/veterans with traumatic brain injury

PURPOSE

Caregivers of service members/veterans (SMVs) encounter a number of barriers when navigating the military health care system. The purpose of this study was to develop a new measure to assess potential caregiver frustration with the systems of care and benefits in the United States Departments of Defense and Veterans Affairs.

METHOD

The TBI-CareQOL Military Health Care Frustration measure was developed using data from 317 caregivers of SMVs with TBI who completed an item pool comprised of 64 questions pertaining to anger or frustration with accessing military health care services.

RESULTS

Exploratory and confirmatory factor analyses supported the retention of 58 items. Constrained graded response model (GRM) overall fit and item fit analyses and differential item functioning investigations of age and education factors supported the retention of 43 items in the final measure. Expert review and GRM item calibration products were used to inform the selection of two 6-item static short forms (TBI-CareQOL Military Health Care Frustration-Self; TBI-CareQOL Military Health Care Frustration-Person with TBI) and to program the TBI-CareQOL Military Health Care Frustration computer adaptive test (CAT). Preliminary data supported the reliability (i.e., internal consistency and test-retest reliability) as well as the validity (i.e., convergent, discriminant, and known-groups) of the new measure.

CONCLUSIONS

The new TBI-CareQOL Military Health Care Frustration measure can be used to examine caregiver perceptions of and experience with the military health care system, to target improvements. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Assessing vigilance in caregivers after traumatic brain injury: TBI-CareQOL Caregiver Vigilance

OBJECTIVE

Caregivers of individuals with traumatic brain injury (TBI) frequently experience anxiety related to the caregiver role. Often this is due to a caregiver's perceived need to avoid people and situations that might upset or "trigger" the care recipient. There are currently no self-report measures that capture these feelings; thus, this article describes the development and preliminary validation efforts for the TBI-Caregiver Quality of Life (CareQOL) Caregiver Vigilance item bank.

DESIGN

A sample of 532 caregivers of civilians (n = 218) or service members/veterans (SMVs; n = 314) with TBI completed 32 caregiver vigilance items, other measures of health-related quality of life (RAND-12, Patient-Reported Outcomes Measurement Information System [PROMIS] Depression, PROMIS Social Isolation, Caregiver Appraisal Scale), and the Mayo-Portland Adaptability Inventory-4.

RESULTS

The final item bank contains 18 items, as supported by exploratory and confirmatory factor analysis, item response theory graded response modeling (GRM), and differential item functioning investigations. Expert review and GRM calibration data informed the selection of a 6-item short form and programming of a computer adaptive test. Internal consistency reliability for the different administration formats were excellent (reliability coefficients ≥ .90). Three-week test-retest stability was supported (i.e., r ≥ .78). Correlations between vigilance and other self-report measures supported convergent and discriminant validity (0.01 ≤ r ≤ .69). Known-groups validity was also supported.

CONCLUSIONS

The new TBI-CareQOL Caregiver Vigilance computer adaptive test and corresponding 6-item short form were developed using established rigorous measurement development standards, providing the first self-report measure to evaluate caregiver vigilance. This development work indicates that this measure exhibits strong psychometric properties. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Caring for a service member or Veteran following traumatic brain injury influences caregiver mental health

This study examined factors related to poor mental health in caregivers assisting service members and Veterans (SMV) following traumatic brain injury (TBI). Participants were 201 military caregivers (96.0% female; Age: M = 39.2 years, SD = 10.2) of SMVs following a mild, moderate, severe, or penetrating TBI. The SF-36v2 Health Survey, Caregiver Appraisal Scale, Mayo-Portland Adaptability Inventory-4, and Caregiver Questionnaire were completed. Caregivers were divided into two mental health groups: Poor Mental Health (n = 108) and Good Mental Health (n = 93). Factors related to poor caregiver mental health were worse general health and stress appraisal, less personal time, unmet needs, and greater financial and employment strain. Factors also related to poor caregiver mental health included assisting a SMV who had sustained a mild TBI, did not have significant hospital care, had post-traumatic stress disorder, depression, and/or anxiety, was experiencing greater functional disability, and was experiencing physical expressions of irritability, anger, and aggression (all p's<.05; d =.29 to d =.64; OR = 1.911 to OR = 4.984). For many military caregivers, poor mental health may be related to the SMVs ongoing comorbid mental health symptoms and less so neurological impairment related to the brain injury. TBI treatment programs require a holistic approach that addresses the behavioral health concerns of both SMVs and their caregivers.