Case report of a soldier with primary blast brain injury.

Primary blast injury of the central nervous system is described in a service-member exposed to a large ordinance explosion. Neuroimaging abnormalities are described together with normalization of the fractional anisotrophy on diffusion tensor imaging after follow-up imaging studies.

Head injury as a PTSD predictor among Oklahoma City bombing survivors.

BACKGROUND: The aim of the Oklahoma City (OKC) bombing retrospective review was to investigate the relationship between physical injury, environmental contributors, and psychiatric disorders such as posttraumatic stress disorder (PTSD) in an event-based, matched design study focused on injury. METHODS: The 182 selected participants were a random subset of the 1,092 direct survivors from the OKC bombing. Only 124 of these 182 cases had a full complement of medical/clinical data in the OKC database. These 124 cases were assessed to explore relationships among PTSD diagnoses, levels of blast exposure, and physical injuries. Associations among variables were statistically tested using contingency analysis and logistic regression. RESULTS: Comparison of the PTSD cases to symptoms/diagnoses reported in the medical records reveals a statistically significant association between PTSD and head/brain injuries associated with head acceleration. PTSD was not highly correlated with other injuries. Although blast pressure and impulse were highly correlated with head injuries, the correlation with PTSD was not statistically significant. Thus, a correlation between blast pressure and PTSD may exist, but higher fidelity pressure calculations are required to elucidate this potential relationship. CONCLUSIONS: This study provides clear evidence that head injury is associated with subsequent PTSD, giving caregivers' information on what physical injuries may suggest the development of psychologic disorders to aid them in developing a profile for the identification of future survivors of terrorist attacks and Warfighters with brain injuries and potential PTSD.

Rehabilitation of traumatic brain injury in active duty military personnel and veterans: Defense and Veterans Brain Injury Center randomized controlled trial of two rehabilitation approaches.

OBJECTIVES: To determine the relative efficacy of 2 different acute traumatic brain injury (TBI) rehabilitation approaches: cognitive didactic versus functional-experiential, and secondarily to determine relative efficacy for different patient subpopulations. DESIGN: Randomized, controlled, intent-to-treat trial comparing 2 alternative TBI treatment approaches. SETTING: Four Veterans Administration acute inpatient TBI rehabilitation programs. PARTICIPANTS: Adult veterans or active duty military service members (N=360) with moderate to severe TBI. INTERVENTIONS: One and a half to 2.5 hours of protocol-specific cognitive-didactic versus functional-experiential rehabilitation therapy integrated into interdisciplinary acute Commission for Accreditation of Rehabilitation Facilities-accredited inpatient TBI rehabilitation programs with another 2 to 2.5 hours daily of occupational and physical therapy. Duration of protocol treatment varied from 20 to 60 days depending on the clinical needs and progress of each participant. MAIN OUTCOME MEASURES: The 2 primary outcome measures were functional independence in living and return to work and/or school assessed by independent evaluators at 1-year follow-up. Secondary outcome measures consisted of the FIM, Disability Rating Scale score, and items from the Present State Exam, Apathy Evaluation Scale, and Neurobehavioral Rating Scale. RESULTS: The cognitive-didactic and functional-experiential treatments did not result in overall group differences in the broad 1-year primary outcomes. However, analysis of secondary outcomes found differentially better immediate posttreatment cognitive function (mean+/-SD cognitive FIM) in participants randomized to cognitive-didactic treatment (27.3+/-6.2) than to functional treatment (25.6+/-6.0, t332=2.56, P=.01). Exploratory subgroup analyses found that younger participants in the cognitive arm had a higher rate of returning to work or school than younger patients in the functional arm, whereas participants older than 30 years and those with more years of education in the functional arm had higher rates of independent living status at 1 year posttreatment than similar patients in the cognitive arm. CONCLUSIONS: Results from this large multicenter randomized controlled trial comparing cognitive-didactic and functional-experiential approaches to brain injury rehabilitation indicated improved but similar long-term global functional outcome. Participants in the cognitive treatment arm achieved better short-term functional cognitive performance than patients in the functional treatment arm. The current increase in war-related brain injuries provides added urgency for rigorous study of rehabilitation treatments. (http://ClinicalTrials.gov ID# NCT00540020.).

Traumatic brain injury risk while parachuting: comparison of the personnel armor system for ground troops helmet and the advanced combat helmet.

Military paratroopers are inherently at risk for a variety of injuries when they jump, including traumatic brain injuries (TBIs). U.S. Army paratroopers rely on their ballistic helmets for protection against TBIs when jumping. Currently, two different helmets are available to Army paratroopers, that is, the personnel armor system for ground troops helmet and the advanced combat helmet. This study compared the incidence of self-reported, jump-related TBIs in a small sample of paratroopers (N = 585) using each type of helmet. Data were obtained from surveys of soldiers at Fort Bragg, North Carolina. The overall relative risk of sustaining a TBI while jumping was 2.3 times (95% confidence interval, 1.3-4.3) higher for personnel armor system for ground troops helmet users. Most of the increase in risk was accounted for by the most-minor TBIs (American Academy of Neurology grade 1 or 2 concussion).

Traumatic brain injuries sustained in the Afghanistan and Iraq wars.

OVERVIEW: When traumatic brain injury (TBI) occurs simultaneously with more obviously life-threatening wounds, it may go unrecognized. Civilians and military personnel working in or near combat zones are at risk for this injury. Blast-related and closed-head injuries, rather than penetrating injuries, constitute the majority of TBIs in this population. The authors describe the experiences of the Defense and Veterans Brain Injury Center team at Walter Reed Army Medical Center in Washington, DC, and present a composite case to illustrate the nurse's role in the assessment and care of the TBI patient.

How satisfied are soldiers with their ballistic helmets? A comparison of soldiers' opinions about the advanced combat helmet and the personal armor system for ground troops helmet.

Many factors are considered during ballistic helmet design, including comfort, weight, fit, and maintainability. These factors affect soldiers' decisions about helmet use; therefore, rigorous research about soldiers' real-life experiences with helmets is critical to assessing a helmet's overall protective efficacy. This study compared soldiers' satisfaction and problem experience with the advanced combat helmet (ACH) and the personal armor system for ground troops (PASGT) helmet. Data were obtained from surveys of soldiers at Fort Bragg, North Carolina. Ninety percent of ACH users were satisfied overall with their helmet, but only 9.5% of PASGT users were satisfied (p < 0.001). The most frequently reported problems for the ACH involved malfunctioning helmet parts. The most frequently reported problems for the PASGT involved discomfort. This analysis indicated that there was a strong soldier preference for the ACH over the PASGT, which could enhance its already superior protective qualities. It also demonstrated the usefulness of soldiers' assessments of protective equipment.

Guidelines for the pharmacologic treatment of neurobehavioral sequelae of traumatic brain injury.

There is currently a lack of evidence-based guidelines to guide the pharmacological treatment of neurobehavioral problems that commonly occur after traumatic brain injury (TBI). It was our objective to review the current literature on the pharmacological treatment of neurobehavioral problems after traumatic brain injury in three key areas: aggression, cognitive disorders, and affective disorders/anxiety/ psychosis. Three panels of leading researchers in the field of brain injury were formed to review the current literature on pharmacological treatment for TBI sequelae in the topic areas of affective/anxiety/ psychotic disorders, cognitive disorders, and aggression. A comprehensive Medline literature search was performed by each group to establish the groups of pertinent articles. Additional articles were obtained from bibliography searches of the primary articles. Group members then independently reviewed the articles and established a consensus rating. Despite reviewing a significant number of studies on drug treatment of neurobehavioral sequelae after TBI, the quality of evidence did not support any treatment standards and few guidelines due to a number of recurrent methodological problems. Guidelines were established for the use of methylphenidate in the treatment of deficits in attention and speed of information processing, as well as for the use of beta-blockers for the treatment of aggression following TBI. Options were recommended in the treatment of depression, bipolar disorder/mania, psychosis, aggression, general cognitive functions, and deficits in attention, speed of processing, and memory after TBI. The evidence-based guidelines and options established by this working group may help to guide the pharmacological treatment of the person experiencing neurobehavioral sequelae following TBI. There is a clear need for well-designed randomized controlled trials in the treatment of these common problems after TBI in order to establish definitive treatment standards for this patient population.

Predictive value of an early Glasgow Outcome Scale score: 15-month score changes.

OBJECT: Does an early Glasgow Outcome Scale (GOS) assessment provide a reliable indicator of later outcome in a patient with traumatic brain injury (TBI)? The authors examined the utility of the GOS during early treatment as a predictor of outcome score 15 months postinjury by analyzing outcome score change in a group of patients with closed head injuries. METHODS: Glasgow Outcome Scale scores assessed within 3 months of injury (baseline) were compared with scores obtained at 15 months postinjury in 121 patients, primarily young military personnel. Score changes between baseline and 8 months postinjury were also studied in a subgroup of 72 patients. The impact of initial injury severity (determined by the duration of unconsciousness) on score change was also explored. The GOS scores at three time points within the 15-month period-baseline (within 3 months of injury), 8, and 15 months postinjury-were examined to ascertain when the maximal GOS score had been reached. CONCLUSIONS: Baseline GOS score was a reliable predictor of outcome in patients with an initial score of 5 (no disability) or 4 (mild disability), but not in patients with an initial score of 3 (severe disability). Patients who remained unconscious for more than 24 hours did not have significantly lower outcome scores than those who experienced loss of consciousness for less than 24 hours at 15 months postinjury. Interestingly, the duration of unconsciousness did not affect the likelihood of an improved score during the study period in patients with a GOS score of 3 or 4 at baseline. An updated evaluation conducted after the early phases of treatment is needed to provide a realistic prognosis of severe TBI.

Duration of cognitive impairment after sports concussion.

OBJECTIVE: We sought to determine the duration of cognitive impairment after sports concussion. METHODS: We conducted a study with a prospective design in which 729 athletes underwent preseason baseline testing by being administered a computerized neuropsychological test battery, followed by retesting at regular intervals after they sustained sports-related concussions. A control group consisting of nonconcussed athletes drawn from the same baseline population underwent testing at parallel intervals. RESULTS: Cognitive impairment in this primarily American Academy of Neurology Grade II sample of boxing concussions was apparent on the day of injury and at 1 to 2 days postinjury. Recovery of cognitive performance occurred during the 3- to 7-day interval. Comparison with control subjects showed that absent or attenuated practice effects, in addition to frank deterioration from baseline, were indications of recent concussion. CONCLUSION: The present findings of recovery during the 3- to 7-day interval postinjury are consistent with the American Academy of Neurology Grade II return-to-play practice parameters suggesting a 1-week time-out from participation in contact sports.

Traumatic brain injuries sustained in the Afghanistan and Iraq wars.

UNLABELLED: Because these injuries can go unrecognized, nurses stateside need to know how to recognize possible cases and how to help. OVERVIEW: When traumatic brain injury (TBI) occurs simultaneously with more obviously life-threatening wounds, it may go unrecognized. Civilians and military personnel working in or near combat zones are at risk for this injury. Blast-related and closed-head injuries, rather than penetrating injuries, constitute the majority of TBIs in this population. The authors describe the experiences of the Defense and Veterans Brain Injury Center team at Walter Reed Army Medical Center in Washington, DC, and present a composite case to illustrate the nurse's role in the assessment and care of the TBI patient.

Recent neuroimaging techniques in mild traumatic brain injury.

Mild traumatic brain injury (TBI) is characterized by acute physiological changes that result in at least some acute cognitive difficulties and typically resolve by 3 months postinjury. Because the majority of mild TBI patients have normal structural magnetic resonance imaging (MRI)/computed tomography (CT) scans, there is increasing attention directed at finding objective physiological correlates of persistent cognitive and neuropsychiatric symptoms through experimental neuroimaging techniques. The authors review studies utilizing these techniques in patients with mild TBI; these techniques may provide more sensitive assessment of structural and functional abnormalities following mild TBI. Particular promise is evident with fMRI, PET, and SPECT scanning, as demonstrated by associations between brain activation and clinical outcomes.

Hospital admissions associated with traumatic brain injury in the US Army during peacetime: 1990s trends.

INTRODUCTION: This paper examines 10-year trends in traumatic brain injury (TBI)-related hospitalization rates for active duty US Army personnel in the 1990s. It does this within the context of various factors, including enhanced injury prevention policies and changed hospital admission practices, that may have affected TBI hospitalization rates. It also compares TBI hospitalization rates in the Army to those from an age-comparable segment of the US civilian population over this time period. METHODS: Crude (unadjusted) incidence rates for all active duty US Army personnel hospitalized with a TBI diagnosis from fiscal years (FY) 1990 to 1999 were calculated. Once the trends were identified, the percentage change in the overall rate, as well as the rates for different TBI severity levels, and in-hospital deaths from FY1990 and FY1999 were analyzed. Changes in age- and gender-specific rates as well as crude rates for cases with and without other injuries and cases treated in military and civilian hospitals were also analyzed. Rate ratios were used to compare aggregated 5-year TBI hospitalization rates in the Army to rates for civilians 17-49 years of age during the following time periods: 1990-1994 and 1995-1999. The rates used in the comparison were adjusted to control for differences in age and gender. RESULTS: The overall incidence of TBI-related hospitalization in the Army decreased 75% from FY1990 to FY1999. The rates for all TBI severity levels decreased, but the rate for mild TBI decreased more than the rates for moderate and severe TBI. The rate of in-hospital deaths from TBI also decreased. Rates decreased similarly for males and females, across all age groups, as well as for cases with and without other injuries. TBI rates decreased for Army personnel treated in military hospitals but changed minimally for Army personnel treated in civilian hospitals. The Army's TBI hospitalization rates were generally higher than civilian rates in the early 1990s but by the late 1990s, most of the Army's rates were lower than or equal to the civilian rates. CONCLUSIONS: The incidence of TBI-related hospitalization in the active duty US Army decreased markedly (75%) during the 1990s. As a result, most of the Army's TBI hospitalization rates were lower than civilian rates by the late 1990s. Effective injury prevention and changes in the Army population were two of the factors that likely contributed to the decrease in rates for all TBI severity levels, while changes in hospital admission practices likely contributed to the disproportionate decrease in the Army's rates for mild TBI.

Headache after moderate and severe traumatic brain injury: a longitudinal analysis.

OBJECTIVES: To measure longitudinally headache (HA) after moderate and severe traumatic brain injury (TBI) and to examine potential association with demographic, injury, and psychologic factors. DESIGN: Cohort study. SETTING: Four Veterans Administration rehabilitation facilities (Minneapolis, Palo Alto, Richmond, Tampa) within the Defense and Veterans Brain Injury Center. PARTICIPANTS: Consecutive patients (military or veteran beneficiaries) with moderate or severe TBI (N=109) who during acute rehabilitation consented to data collection and who completed 6- and 12-month follow-up evaluations. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: HA frequency, location, type, and incapacitation levels measured during prospective neurologic assessments. RESULTS: Nearly 38% (41/109) of patients had acute posttraumatic headache (PTHA) symptoms; most often in a frontal location (20/41), most often of daily frequency (31/41), and showing no relation to injury severity, emotional, or demographic variables. Postacutely, PTHA symptom severity declined within the group. Better individual improvement was associated with less anxiety and depression at 6-month follow-up. Almost all subjects (21/22) with PTHA symptoms that persisted into the 6-month follow-up period reported symptoms again at 12-month follow-up. CONCLUSIONS: PTHA severity in this sample of persons with moderate and severe TBI showed a pattern of improvement that leveled off by 6 months posthospitalization.

An examination of the California Verbal Learning Test II to detect incomplete effort in a traumatic brain-injury sample.

Clinical neuropsychologists are frequently called on to distinguish people who appear impaired on neuropsychological testing due to putting forth incomplete effort from those who have genuine cognitive deficits. Because traditional measures of effort are becoming accessible over the Internet and within the legal community and their purpose may be obvious to potential malingerers, nontraditional effort measures have been newly investigated. Using discriminant function analysis, this study explores whether five California Verbal Learning Test-Second Edition (CVLT-II) variables could differentiate between head-injured patients who were putting forth full effort and those who were putting forth incomplete effort. The discriminant function seemed to best predict those who put forth adequate effort while testing (95.6% correct) but not those who failed to put forth adequate effort during testing (only 13.8% correct). Hence, although the overall classification rate was moderately impressive (75.8%), the model's sensitivity in classification of the incomplete effort group was low. Cautious applications for these findings are discussed.

Association of COMT Val158Met genotype with executive functioning following traumatic brain injury.

Catechol-O-methyltransferase (COMT) is thought to functionally modulate dopamine neurons, thus likely influencing frontal-executive functioning. High enzyme activity (COMT Val) and low enzyme activity (COMT Met) are functional polymorphisms resulting from a G to A transition in exon 4 (codon 158) of the human COMT gene. Decreased cortical dopamine should result in poorer executive functioning. Therefore, the authors hypothesized that individuals with traumatic brain injury (TBI) and the low enzyme activity polymorphism would perform better on tests of executive functioning than individuals with the high enzyme activity polymorphism. One hundred thirteen individuals referred to the Defense and Veterans Brain Injury Center underwent a comprehensive TBI evaluation and were genotyped for the COMT polymorphism. Comparison of mean differences among the COMT genotype groups for several measures of aspects of executive functioning was conducted using analysis of variance (ANOVA) with adjustment for multiple comparisons. Homozygotes for the higher activity allele made more perseverative responses on the Wisconsin Card Sorting Test, while homozygotes for the lower activity allele had the least number of perseverative responses. While it cannot be determined whether TBI influenced the association of COMT Val158Met to executive functioning, these data extend the known relationship of genotype to executive performance seen in healthy comparison subjects and individuals with schizophrenia to individuals with TBI.

Post concussion syndrome.

Individuals sustaining mild traumatic brain injuries often report a constellation of physical, cognitive, and emotional/behavioral symptoms referred to as post concussion symptoms (PCS). The most commonly reported post concussion symptoms are headache, dizziness, decreased concentration, memory problems, irritability, fatigue, visual disturbances, sensitivity to noise, judgment problems, depression, and anxiety. Although these PCS often resolve within one month, in some individuals PCS can persist from months to years following injury and may even be permanent and cause disability. When this cluster of PCS is persistent in nature, it is often called the post concussion syndrome or persistent PCS. Both physiological and psychological etiologies have been suggested as causes for persistent post concussion symptoms and this has led to much controversy and debate in the literature. Most investigators now believe that a variety of pre-morbid, injury-related, and post-morbid neuropathological and psychological factors contribute to the development and continuation of these symptoms in those sustaining mild traumatic brain injury (MTBI).

Functional assessment of executive abilities following traumatic brain injury.

PRIMARY OBJECTIVE: The Test of Functional Executive Abilities (TOFEA) is a measure of real-world planning/problem-solving abilities. The present study sought to identify the relationship between the TOFEA and traditional executive measures. DESIGN: Correlational and principal components factor analyses were conducted using the TOFEA and traditional neuropsychological executive measures. METHODS: Participants were 340 patients with traumatic brain injury. All participants underwent neuropsychological and speech-language assessments. RESULTS: Factor analysis of the TOFEA yielded a two-factor solution, planning/initiation and awareness/comprehension. Correlational analysis between the TOFEA and traditional measures demonstrated only a weak relationship. Factor analysis indicated a four factor executive solution with the TOFEA loading on the third planning/initiation and reasoning factor. CONCLUSIONS: The data support the notion that there is no one single measure of frontal-executive functioning, but rather these tests represent different executive components and, as such, more than one measure should be used in a comprehensive assessment.