Relationships and Evidence-Based Theoretical Perspectives on Persisting Symptoms and Functional Impairment Among Mild Traumatic Brain Injury and Behavioral Health Conditions.

The purpose of this study is to characterize and describe the relationships between symptoms and functional impairment following mild traumatic brain injury (mTBI) and behavioral health conditions (BHCs) in order to inform evidence-based theories on why symptoms and functional impairments persist in some individuals but not others. This is a retrospective, multi-site, cross-sectional study utilizing data collected from a total of 289 Operation Iraqi Freedom/Operation Enduring Freedom Veterans who were classified into diagnostic groups using the symptom attribution and classification algorithm and the VA clinical reminder and comprehensive traumatic brain injury evaluation. The Neurobehavioral Symptom Inventory was used to assess mTBI symptom number and severity. The World Health Organization Disability Assessment Schedule 2.0 was used to assess functional impairment. Symptom profiles differed between diagnostic groups irrespective of symptom attribution method used. Veterans with both mTBI and BHCs and those with BHCs alone had consistently greater number of symptoms and more severe symptoms relative to no symptom and symptoms resolved groups. Symptom number and severity were significantly associated with functional impairment. Both symptom number and functional impairment were significantly associated with the number of mTBI exposures. Together, these results informed evidence-based theories on understanding why symptoms and functional impairment persist among some OEF/OIF Veterans.

Familiar auditory sensory training in chronic traumatic brain injury: a case study.

PURPOSE: The evaluation and treatment for patients with prolonged periods of seriously impaired consciousness following traumatic brain injury (TBI), such as a vegetative or minimally conscious state, poses considerable challenges, particularly in the chronic phases of recovery. METHOD: This blinded crossover study explored the effects of familiar auditory sensory training (FAST) compared with a sham stimulation in a patient seven years post severe TBI. Baseline data were collected over 4 weeks to account for variability in status with neurobehavioral measures, including the Disorders of Consciousness scale (DOCS), Coma Near Coma scale (CNC), and Consciousness Screening Algorithm. Pre-stimulation neurophysiological assessments were completed as well, namely Brainstem Auditory Evoked Potentials (BAEP) and Somatosensory Evoked Potentials (SSEP). RESULTS: Results revealed that a significant improvement in the DOCS neurobehavioral findings after FAST, which was not maintained during the sham. BAEP findings also improved with maintenance of these improvements following sham stimulation as evidenced by repeat testing. CONCLUSIONS: The results emphasize the importance for continued evaluation and treatment of individuals in chronic states of seriously impaired consciousness with a variety of tools. Further study of auditory stimulation as a passive treatment paradigm for this population is warranted. Implications for Rehabilitation Clinicians should be equipped with treatment options to enhance neurobehavioral improvements when traditional treatment methods fail to deliver or maintain functional behavioral changes. Routine assessment is crucial to detect subtle changes in neurobehavioral function even in chronic states of disordered consciousness and determine potential preserved cognitive abilities that may not be evident due to unreliable motor responses given motoric impairments. Familiar Auditory Stimulation Training (FAST) is an ideal passive stimulation that can be supplied by families, allied health clinicians and nursing staff of all levels.

Association Between Alcohol Craving and Health-Related Quality of Life Among Veterans With Co-occurring Conditions.

BACKGROUND: Probable alcohol use disorder (AUD), mental health disorders (MHDs), and mild traumatic brain injury (mTBI) are endemic among U.S. Veterans of the recent conflicts in Iraq and Afghanistan. Previous research demonstrates that recent Veterans with AUD and MHD both with and without mTBI (MHD ± mTBI) self-report higher alcohol craving levels relative to Veterans with AUD only. Since it is unknown if alcohol craving negatively impacts health-related quality of life (HRQOL), the purpose of this study is to identify and describe the relationship between alcohol craving and HRQOL for recent Veterans with AUD alone and those with AUD and co-occurring conditions. METHODS: This cross-sectional study included Penn Alcohol Craving Scale (PACS) and Veterans RAND 36 Item Health Survey mental and physical component score data collected among recent Veterans with AUD (N = 29, n = 27 males): 14 combat controls, 15 MHD ± mTBI. The Alcohol Use Disorder Identification Test, consumption questions determined AUD classification. That is only Veterans scoring a 4 or above for males and a 3 or above for females on the Alcohol Use Disorder Identification Test, consumption questions were included in this study. Associations between alcohol craving and HRQOL were examined using correlations and regression models. RESULTS: There was a significant negative linear relationship between PACS and mental component score (p < 0.05) that did not significantly differ between groups. There was a significant negative curvilinear relationship between PACS and physical component score with a significant group effect. DISCUSSION: Greater alcohol craving was associated with poorer mental HRQOL. Physical HRQOL was also significantly associated with alcohol craving. These relationships have important implications for clinical assessment and treatment among people with AUD. These findings suggest that alcohol craving is an important symptom of AUD for clinicians to assess and focus their treatment upon because it may negatively impact HRQOL.

Healthcare utilization following mild traumatic brain injury in female veterans.

BACKGROUND: Mild traumatic brain injury (TBI) is a significant problem for Veterans. Gender differences in mild TBI outcomes such as return-to-work, resolution of symptoms and mental health diagnoses have been reported. The purpose of the study is to characterize gender differences in VA healthcare utilization in the year following mild TBI diagnosis. METHODS: This was a retrospective database study of 12 144 Veterans diagnosed with mild TBI in fiscal year 2008 and their healthcare utilization in the following year. RESULTS: The mean age was 43.6 ± 17 and the majority were men (94.1%). Overall, women had more outpatient utilization than men with mild TBI (mean: 48 vs. 37 visits; p ≤ 0.001). Adjusted analyses indicated that women had a rate of outpatient utilization 25% higher than men (IRR = 1.25, 95% CI = 1.17-1.33). It was found that 13.6% of the difference in outpatient utilization by gender could be explained by other factors such as race, age, marital status, geographic location and illness burden. CONCLUSION: Male Veterans had less outpatient utilization than females in the year following mild TBI diagnosis. Gender and other factors only accounted for a small portion of the differences observed; therefore, gender only partially accounts for differences in healthcare utilization following mild TBI.

Diagnostic accuracy studies in mild traumatic brain injury: a systematic review and descriptive analysis of published evidence.

OBJECTIVES: To synthesize evidence and report findings from a systematic search and descriptive analysis of peer-reviewed published evidence of the accuracy of tests used for diagnosing mild traumatic brain injury (mTBI). The article also summarizes points of concurrence and divergence regarding case definitions of mTBI identified during the review. TYPE: Systematic review and descriptive analysis of published evidence. LITERATURE SURVEY: A search of PubMed, PsychInfo, and the Cochrane Library for peer-reviewed publications between 1990 and July 6, 2011, identified 1218 abstracts; 277 articles were identified for full review, and 13 articles met the criteria for evaluation. METHODOLOGY: Manuscript inclusion criteria were (1) reported sensitivity (Se) and specificity (Sp), or reported data were sufficient to compute Se and Sp; (2) >1 participant in the study; (3) at least 80% of the study cohort was ≥18 years of age; and (4) written in English. Articles describing clinical practice guidelines, opinions, theories, or clinical protocols were excluded. Seven investigators independently evaluated each article according to the Standards for Reporting of Diagnostic Accuracy (STARD) criteria. SYNTHESIS: Findings indicate that all 13 studies involved civilian noncombat populations. In 7 studies, authors examined acute mTBI, and in 4 studies, historical remote mTBI was examined. In the 13 studies, Se ranged from 13%-92% and Sp ranged from 72%-99%, but confidence in these findings is problematic because the STARD review indicates opportunities for bias in each study. CONCLUSIONS: Findings indicate that no well-defined definition or clinical diagnostic criteria exist for mTBI and that diagnostic accuracy is currently insufficient for discriminating between mTBI and co-occurring mental health conditions for acute and historic mTBI. Findings highlight the need for research examining the diagnostic accuracy for acute and historic mTBI.

An evaluation of the Veterans Affairs traumatic brain injury screening process among Operation Enduring Freedom and/or Operation Iraqi Freedom veterans.

OBJECTIVE: To describe the early results of the U.S. Department of Veterans Affairs (VA) screening program for traumatic brain injury (TBI) and to identify patient and facility characteristics associated with receiving a TBI screen and results of the screening. DESIGN: National retrospective cohort study. SETTING: VA Medical facilities. PATIENTS: A total of 170,681 Operation Enduring Freedom and/or Operation Iraqi Freedom (OEF/OIF) Veterans who sought care at VA medical facilities from April 2007 to September 30, 2008. METHODS: Data were abstracted from VA administrative and operational databases, including patient demographics, facility characteristics, and outcomes. MAIN OUTCOME MEASUREMENTS: The main outcomes were receipt of and results of the TBI screen. RESULTS: The majority of veterans eligible received the TBI screen (91.6%). Screening rates varied by patient and facility characteristics. In all, 25% of screened veterans had probable TBI exposure, in which the majority of the exposures were blasts (85.0%). The rate of a positive TBI screen was 20.5% for the screened cohort. Male gender, service in the army, multiple deployments, and mental health diagnoses in the previous year were associated with a positive screen. CONCLUSIONS: TBI screening rates are high in VA; concomitant mental health diagnoses were highly prevalent in individuals with positive TBI screens. These data indicate that there will be a significant need for long-term health care services for veterans with TBI symptomatology.

Feasibility of instrumental swallowing assessments in patients with prolonged disordered consciousness while undergoing inpatient rehabilitation.

OBJECTIVE: To evaluate the feasibility, safety, and potential benefit of instrumental swallowing assessments for patients with prolonged disordered consciousness participating in rehabilitation. DESIGN: Case-control, retrospective. PARTICIPANTS: Thirty-five participants divided into 2 cohorts according to cognitive level at the time of baseline instrumental swallowing assessment. Group 1 (n = 17) participants were at Rancho Los Amigo (RLA) level II/III or RLA level III, while Group 2 (n = 18) participants were rated better than RLA level III. RESULTS: Aspiration and laryngeal penetration rates for both groups were similar (aspiration rate Group 1 = 41%, Group 2 = 39%; laryngeal penetration rate Group 1 = 59%, Group 2 = 61%). Overall, 76% (13/17) of Group 1 and 72% (13/18) of Group 2 were able to receive some type of oral feedings following baseline video fluoroscopic swallow study (VFSS) or endoscopic exam of the swallow (FEES). CONCLUSION: The majority of participants who underwent an instrumental swallowing examination while still functioning at RLA level II/III or RLA level III were able to return to some form of oral feedings immediately following their baseline examination. Swallowing as a treatment modality can be considered a part of the overall plan to facilitate neurobehavioral recovery for patients with prolonged disordered consciousness participating in rehabilitation.

Persons with disorders of consciousness: are oral feedings safe/effective?

PRIMARY OBJECTIVE: Evaluate the safety and efficacy of providing oral feedings to persons early in coma recovery following a severe brain injury. RESEARCH DESIGN: Descriptive, retrospective study. METHODS AND PROCEDURES: Medical chart reviews of all patients admitted to a rehabilitation hospital following severe brain injury. MAIN OUTCOMES AND RESULTS: Twenty-five patients met the inclusion criteria, 22 had a tracheostomy, and all were NPO. Subjects were divided into two cohorts. Group 1, n=10, mean age 43.5 years, received oral feedings early in coma recovery. Group 2, n=15, mean age 45.2 years, did not. Group 1, 30% returned to an oral diet of three meals daily at discharge from inpatient rehabilitation as compared to 40% in group 2 (chi2 = 0.260, p = 0.610). Average cost of care for group 1 = US$45 759 and group 2 = US$41 056 (p = 0.634). CONCLUSION: Safe therapeutic oral feedings, in accordance with findings from instrumental swallowing examinations, are possible for patients with disordered consciousness. The therapeutic oral feedings do not significantly increase the cost of care, but the effectiveness of oral feedings early in coma recovery requires further investigation.