Neuropsychologists' perspectives of chronic traumatic encephalopathy (CTE).

Objective: Chronic Traumatic Encephalopathy (CTE) has received significant media coverage as a major health concern for collision sport athletes and combat veterans. This survey study investigated neuropsychologists' perspectives of CTE.Methods: Neuropsychologists (N = 325) were contacted via electronic advertisement posted to popular neuropsychology professional listservs and completed a survey regarding their perspectives of: the proposed sequelae of repeated concussions, the strength of the CTE research base, and its media coverage.Results: Most respondents (91%) were at least somewhat familiar with the concept of CTE. Moderate uncertainty was reported (i.e. up to 30%) regarding the effects of repeated concussions. Most felt the research in support of CTE was unreliable (80%) and weak regarding claims that repeated concussions cause CTE (91%), independently cause behavioral/emotional/cognitive dysfunction (86%), or increase the risk for neurodegeneration (79%). Respondents agreed patients are concerned about CTE (92%), concerns are influenced by the media (96%) that presents a biased/alarmist view of CTE (96%), and patient recovery is influenced by their CTE beliefs (82%).Conclusions: There was strong agreement that the media presents an alarmist/biased view of CTE that influences patients concerns and outcomes following concussion. This presentation is incongruent with the perceptions of surveyed neuropsychologists who find the research in support of CTE to be weak and unreliable. More research is needed to determine the potential effects of repeated (sub)concussive events. As public knowledge will continue to be influenced by the media and health care professionals, future research should explore CTE perceptions across other health care disciplines.

Feasibility and acceptability of a brief intervention to improve mild traumatic brain injury recovery: Problem-solving training-concussion.

OBJECTIVE: Mild traumatic brain injuries (mTBIs) are common among Veterans. Although the majority of neurobehavioral symptoms resolve following mTBI, studies with Veteran samples demonstrate a high frequency and chronicity of neurobehavioral complaints (e.g., difficulties with attention, frustration tolerance) often attributed to mTBI. Recent opinions suggest the primacy of mental health treatment, and existing mTBI practice guidelines promote patient-centered intervention beginning in primary care (PC). However, trial evidence regarding effective clinical management in PC is lacking. This study evaluated the feasibility and acceptability of a brief, PC-based problem-solving intervention to reduce psychological distress and neurobehavioral complaints. RESEARCH METHOD/DESIGN: Mixed method open clinical trial of 12 combat Veterans with a history of mTBI, chronic neurobehavioral complaints, and psychological distress. Measures included qualitative and quantitative indicators of feasibility (recruitment and retention metrics, interview feedback), patient acceptability (treatment satisfaction, perceived effectiveness), and change in psychological distress as measured by the Brief Symptom Inventory-18. RESULTS: The protocol was successfully delivered via in-person and telehealth treatment modalities (4.3 sessions attended on average; 58% completed the full protocol). Patient interview data suggested that treatment content was personally relevant, and patients were satisfied with their experience. Treatment completers described the intervention as helpful and reported corresponding reductions in psychological distress (ES = 1.8). Dropout was influenced by the onset of the COVID-19 pandemic. CONCLUSIONS/IMPLICATIONS: Further study with a more diverse, randomized sample is warranted. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

The management and rehabilitation of post-acute mild traumatic brain injury.

DESCRIPTION: In June 2021, the U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) approved a joint clinical practice guideline for the management and rehabilitation care for those who have symptoms in the post-acute period following mild traumatic brain injury (mTBI). This synopsis describes some of the clinically important recommendations. METHODS: In January 2020, VA and DoD leaders assembled a joint VA/DoD guideline development team of multidisciplinary clinical stakeholders that developed key questions, systematically searched and evaluated the literature, created two 1-page algorithms, and refined 19 recommendations using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. The process closely conformed to the National Academy of Medicine's tenets for trustworthy clinical practice guidelines. RECOMMENDATIONS: This synopsis describes clinically important recommendations for the management and rehabilitation of mTBI. Outpatient primary care providers are the target audience for this synopsis and guideline. The current recommendations are an update from the 2016 VA/DoD Clinical Practice Guidelines for the Management of Concussion-Mild Traumatic Brain Injury.

Stimulation Induced Changes in Ratio Scaling Between and Within Hemispheres.

OBJECTIVES: This paper examines if ratio scaling, the principle behind the psychophysical Power Law, is similarly performed by the left and right cerebral hemispheres and how magnitude estimates derived in each hemisphere are integrated. METHOD: Three models of hemispheric integration were tested (dominance, summation, and inhibition) using a cross-modal matching procedure in right-handed, male subjects. Visual stimuli were presented to one or both hemispheres using a tachistoscopic method to test each model. Olfactory stimuli were also presented to one or both nares (hemispheres) to test the dominance and summation models. RESULTS: A dominance model was not supported as there was little difference in ratio scaling between hemispheres for either visual or olfactory stimuli. A summation model was supported for olfactory but not visual integration. Inter-hemispheric inhibition did not account for hemispheric integration. CONCLUSIONS: The most interesting findings stemmed from a comparison of experimental conditions within rather than between hemispheres. Ratio scaling parameters, the sizes of the exponents and constants, appeared to be driven by the amount of stimulation provided to a hemisphere - a greater amount being associated with higher exponents and lower constants. Variability in ratio scaling, how well data fit power functions, corresponded to whether the hemispheres received equal amounts of stimulation - equal stimulation producing a better fit than unequal stimulation. We conclude that stimulus induced cerebral activation influences the form of power functions; whereas equivalency of stimulation between hemispheres influenced the fit.

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

OBJECTIVE: To examine traumatic brain injury (TBI) characteristics and comorbid medical profiles of Special Operations Forces (SOF) Active Duty Service Member/Veterans (ADSM/Vs) and contrast them with conventional military personnel. SETTING: The 5 Veterans Affairs (VA) Polytrauma Rehabilitation Centers. PARTICIPANTS: A subset of participants in the VA TBI Model Systems multicenter longitudinal study with known SOF status. These included 157 participants who identified as SOF personnel (average age = 41.8 years; 96% male, 81% active duty), and 365 who identified as Conventional Forces personnel (average age = 37.4 years; 92% male, 30% active duty). DESIGN: Retrospective analysis of prospective cohort, cross-sectional. MAIN MEASURES: The Health Comorbidities Interview. RESULTS: SOF personnel were more likely to have deployed to a combat zone, had more years of active duty service, and were more likely active duty at time of TBI. SOF personnel were more likely to have had mild TBI (vs moderate/severe) and their TBI caused by violent mechanism. SOF personnel had a higher number of comorbidities, with more diagnoses of chronic pain, osteoarthritis, hyperlipidemia, hip fractures, and obstructive sleep apnea. CONCLUSION: SOF personnel are at a higher risk for multimorbidity after TBI. Current rehabilitation practices should incorporate early screening and treatment of common conditions in this population, while future practices may benefit from a focus on prevention.

Anosognosia in moderate-to-severe traumatic brain injury: A review of prevalence, clinical correlates, and diversity considerations.

METHOD: A comprehensive search of peer-reviewed articles was conducted from September to November 2020 using Google Scholar and PubMed databases. Key terms included "anosognosia," "self-awareness," "traumatic brain injury," and variants thereof. Our search was restricted to articles published in English within the last 25 years, although a few historical articles were included due to scientific merit. Articles were chosen based on methodological quality, inclusion of solely or predominantly msevTBI sample, and relevance to the current topic. CONCLUSIONS: Anosognosia is a multifaceted and domain-specific construct that affects the majority of those with msevTBI. It is related to TBI severity, injuries in right-hemispheric and cortical midline regions, specific aspects of executive function, psychological function, and cultural factors. We offer pragmatic advice for clinicians working with this population and discuss implications for the field regarding "best practices" of anosognosia assessment and intervention.

Accumulation of Good Intentions: How Individual Practice Guidelines Lead to Polypharmacy in the Treatment of Patients with Polytrauma.

Polytrauma clinical triad (PCT) is the comorbid occurrence of traumatic brain injury (TBI), posttraumatic stress disorder (PTSD), and pain after trauma. No clinical practice guidelines for postacute care of patients with PCT currently exist; instead, clinical practice guidelines have been published for the three conditions (TBI, PTSD, and pain) as distinct clinical entities. Using multiple, individual practice guidelines for a patient with PCT may lead to unintended prescription of multiple and potentially adversely interacting medications (ie, polypharmacy). Polypharmacy, especially that which includes central nervous system-acting medications, may lead to overdose, suicidality, and chronic symptomatology. Current individual guidelines for each condition of PCT do not address how to coordinate care for the polytraumatic diagnosis. The purpose of this Practice Management piece is to describe the unintended consequences of polypharmacy in patients with PCT and to discuss mitigation approaches including rational prescribing, nonpharmacologic alternatives, and interdisciplinary coordination.

On How Psychophysical Thresholds are Altered by Unilateral Brain Injury Due to Stroke.

OBJECTIVE: This study examined whether and how the absolute thresholds and the just noticeable difference thresholds for eleven, sensory/perceptual continua are altered by unilateral left and right hemisphere lesions due to stroke relative to healthy subjects. METHODS: The three subject groups were those with unilateral right hemisphere lesions (n=21), with unilateral left hemisphere lesions (n=13), and age-matched control subjects (n=76). Absolute thresholds of sensory detection and just noticeable difference thresholds were assessed for perceptual continua spanning the visual, tactile, proprioceptive, thermal, and gustatory sensory modalities. For stroke subjects, brain lesions were analyzed using subtraction techniques and volume analysis with the MRIcro and MRIcroN software programs. Stroke subjects also complete tests for spatial neglect, stroke severity and functional independence. RESULTS: There was no significant difference among subject groups regarding gender, race, hand dominance, age, or educational composition. There was no significant difference between subjects with right and left hemisphere lesions on measures of function, stroke severity, or lesion volume except for those with spatial neglect. The RHL group had a higher percentage of impaired perceptual continua (16%) than both normal controls (4%) and the LHL group (9%). If a stoke subject had an impaired threshold on one side of the body, they were ~5 times more likely to have an impaired threshold on the other side of the body. This result was more consistent and even exaggerated (~8 times more likely) in the small percentage of normal control subjects who demonstrated "impaired" sensory thresholds. Lesion volume was positively correlated with stroke severity and sensory threshold impairment, and it was negatively correlated with functional independence. CONCLUSIONS: When subjects, have difficulty detecting and discriminating sensory experiences, they tend to do so on both sides of the body. Unilateral right hemisphere stroke appeared to increase the relative frequency of altered thresholds occurring on the contralesional side of the body even though they made errors on both sides.

Unique Features of the US Department of Defense Multidisciplinary Concussion Clinics.

The US Department of Defense (DoD) and the Department of Veterans Affairs (VA) actively address care needs for a subset of service members (SMs) who experience prolonged symptoms and adverse sequelae interfering with their usual level of function after sustaining mild traumatic brain injury. The development of multidisciplinary concussion clinics and implementation of several reinforcing policies within the DoD and the VA address this unique patient population. A network known as the National Intrepid Center of Excellence and Intrepid Spirit Centers and the VA, primarily support these patients through intensive outpatient programs. The VA also has an inpatient program that utilizes specialized capabilities. The features unique to several of these centers are described in this article. While providing for similar patient care needs, each clinical setting implements unique evaluation and treatment modalities to target analogous goals of return to the highest functional level possible and develop life skills to enhance health, quality of life, and readiness to perform military duties. Currently, patient-reported outcomes are being collected.

Neurobehavioral Management of the Polytrauma Veteran.

Since the inception of the Afghanistan and Iraq wars, an increasing number of veterans have sought treatment from the Department of Veterans Affairs for combat-related injuries. Many veterans experience postconcussive symptoms, traumatic stress, chronic pain, sensory deficits, and/or headaches. The goal of this article was to highlight some of the challenges treatment providers may face, while providing rehabilitation specialists with important evaluation and treatment considerations in working with this population to maximize outcomes for these veterans.

Comorbid Posttraumatic Stress Disorder and Traumatic Brain Injury: Generalization of Prolonged-Exposure PTSD Treatment Outcomes to Postconcussive Symptoms, Cognition, and Self-Efficacy in Veterans and Active Duty Service Members.

OBJECTIVES: To examine (a) generalization of the effectiveness of prolonged exposure (PE) therapy for posttraumatic stress disorder (PTSD) in improving postconcussive symptoms (PCSs) and other outcomes in military service members and Veterans (VA) with histories of mild to severe traumatic brain injury (TBI), and (b) factors associated with PCS reduction. SETTING: VA polytrauma medical center. PARTICIPANTS: Consecutive referrals for PTSD treatment of Active Duty (n = 17) or Veterans (n = 27) diagnosed with PTSD and TBI (N = 44). MAIN OUTCOME MEASURES: Neurobehavioral Symptom Inventory, Key Behaviors Change Inventory, Self-Efficacy for Symptom Management, Posttraumatic Stress Disorder Checklist, and Beck Depression Inventory, 2nd edition. DESIGN: Post hoc analysis of archival clinical effectiveness program evaluation data. INTERVENTIONS: PE for PTSD. RESULTS: There were significant improvements on all outcome measures with large effect sizes (Cohen's d ranging from 0.68 to 2.02). Improvement on PCS (Cohen's d = 1.21) was associated with lower levels of VA service-connected disability and PE treatment completion. CONCLUSION: PE treatment-related improvements for participants with comorbid PTSD and TBI generalize from PTSD outcomes to PCS and other TBI-related outcomes. Positive outcomes were independent of TBI severity, treatment setting, or Veteran status, but dependent upon PE treatment completion and lower levels of VA service-connected disability.

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

OBJECTIVE: To identify preinjury variables related to mental health treatment utilization at 2 years post-traumatic brain injury (TBI). SETTING: Veterans Affairs (VA) TBI Model Systems includes 5 VA Polytrauma Rehabilitation Centers. PARTICIPANTS: Veterans and service members enrolled in TBI Model Systems who completed the year 2 follow-up assessment and provided mental health information. Sample was largely male (97%) and White (72%), with median age of 30 years. DESIGN: Participants with elevated mental health symptoms were identified by measures of depression, anxiety, and posttraumatic distress; suicide attempt in the past year; or problematic substance use in the past year. Forty-seven percent of participants had elevated mental health symptoms at 2 years postinjury. Among those with elevated symptoms, comparisons were made between those who sought mental health treatment in past year and those who did not. MAIN MEASURES: Demographic, historic, environmental, psychological/mental health, and injury/rehabilitation variables. RESULTS: Within the sample, 23% denied utilizing mental health services. Nonutilizers were more likely to deny a preinjury mental health treatment history, to report problematic substance use at year 2, and to report lower levels of internalizing symptoms than the treatment utilizers. CONCLUSION: Veterans and service members with elevated mental health symptoms may require tailored tactics to promote treatment utilization post-TBI.

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

OBJECTIVES: To examine community reintegration problems among Veterans and military service members with mild or moderate/severe traumatic brain injury (TBI) at 1 year postinjury and to identify unique predictors that may contribute to these difficulties. SETTING: VA Polytrauma Rehabilitation Centers. PARTICIPANTS: Participants were 154 inpatients enrolled in the VA TBI Model Systems Program with available injury severity data (mild = 28.6%; moderate/severe = 71.4%) and 1-year postinjury outcome data. DESIGN: Prospective, longitudinal cohort. MAIN MEASURES: Community reintegration outcomes included independent driving, employability, and general community participation. Additional measures assessed depression, posttraumatic stress, and cognitive and motor functioning. RESULTS: In the mild TBI (mTBI) group, posttraumatic stress disorder and depressive symptoms were associated with lower levels of various community reintegration outcomes. In the moderate/severe TBI group, cognition and motor skills were significantly associated with lower levels of community participation, independent driving, and employability. CONCLUSION: Community reintegration is problematic for Veterans and active duty service members with a history of TBI. Unique comorbidities across injury severity groups inhibit full reintegration into the community. These findings highlight the ongoing rehabilitation needs of persons with TBI, specifically evidence-based mental healthcare, in comprehensive rehabilitation programs consistent with a chronic disease management model.

EEG slow waves in traumatic brain injury: Convergent findings in mouse and man.

OBJECTIVE: Evidence from previous studies suggests that greater sleep pressure, in the form of EEG-based slow waves, accumulates in specific brain regions that are more active during prior waking experience. We sought to quantify the number and coherence of EEG slow waves in subjects with mild traumatic brain injury (mTBI). METHODS: We developed a method to automatically detect individual slow waves in each EEG channel, and validated this method using simulated EEG data. We then used this method to quantify EEG-based slow waves during sleep and wake states in both mouse and human subjects with mTBI. A modified coherence index that accounts for information from multiple channels was calculated as a measure of slow wave synchrony. RESULTS: Brain-injured mice showed significantly higher theta:alpha amplitude ratios and significantly more slow waves during spontaneous wakefulness and during prolonged sleep deprivation, compared to sham-injured control mice. Human subjects with mTBI showed significantly higher theta:beta amplitude ratios and significantly more EEG slow waves while awake compared to age-matched control subjects. We then quantified the global coherence index of slow waves across several EEG channels in human subjects. Individuals with mTBI showed significantly less EEG global coherence compared to control subjects while awake, but not during sleep. EEG global coherence was significantly correlated with severity of post-concussive symptoms (as assessed by the Neurobehavioral Symptom Inventory scale). CONCLUSION AND IMPLICATIONS: Taken together, our data from both mouse and human studies suggest that EEG slow wave quantity and the global coherence index of slow waves may represent a sensitive marker for the diagnosis and prognosis of mTBI and post-concussive symptoms.

Patient, Therapist, and System Factors Influencing the Effectiveness of Prolonged Exposure for Veterans With Comorbid Posttraumatic Stress Disorder and Traumatic Brain Injury.

In contrast to concerns that cognitive limitations and neurobehavioral symptoms (NBS) associated with traumatic brain injury (TBI) may inhibit treatment effectiveness, a recent study found prolonged exposure (PE) led to large reductions in posttraumatic stress disorder (PTSD) symptoms among Iraq-Afghanistan veterans with a range of TBI severity (article by Wolf, Kretzmer, Crawford, Thors, Wagner, Strom, Eftekhari, Klenk, Hayward, and Vanderploeg [J Trauma Stress 28:339-347, 2015]). We further examined this sample of 69 veterans to determine whether system, veteran, and therapist factors predicted clinically significant responses. Results of hierarchical, logistic regressions revealed that therapist training in PE and lower service connection were associated with increased odds of large decreases in PTSD symptoms after adjusting for the robust effect of PE sessions completed. Other patient-level factors including age, time since injury, and baseline NBS were unrelated to significant improvements. Findings emphasized the impact of PE dosage, indicated greater mastery of the protocol was beneficial, and showed that service connection could impede self-reported, clinically significant change during PE in this important cohort.

EEG slow waves in traumatic brain injury: Convergent findings in mouse and man.

OBJECTIVE: Evidence from previous studies suggests that greater sleep pressure, in the form of EEG-based slow waves, accumulates in specific brain regions that are more active during prior waking experience. We sought to quantify the number and coherence of EEG slow waves in subjects with mild traumatic brain injury (mTBI). METHODS: We developed a method to automatically detect individual slow waves in each EEG channel, and validated this method using simulated EEG data. We then used this method to quantify EEG-based slow waves during sleep and wake states in both mouse and human subjects with mTBI. A modified coherence index that accounts for information from multiple channels was calculated as a measure of slow wave synchrony. RESULTS: Brain-injured mice showed significantly higher theta:alpha amplitude ratios and significantly more slow waves during spontaneous wakefulness and during prolonged sleep deprivation, compared to sham-injured control mice. Human subjects with mTBI showed significantly higher theta:beta amplitude ratios and significantly more EEG slow waves while awake compared to age-matched control subjects. We then quantified the global coherence index of slow waves across several EEG channels in human subjects. Individuals with mTBI showed significantly less EEG global coherence compared to control subjects while awake, but not during sleep. EEG global coherence was significantly correlated with severity of post-concussive symptoms (as assessed by the Neurobehavioral Symptom Inventory scale). CONCLUSION AND IMPLICATIONS: Taken together, our data from both mouse and human studies suggest that EEG slow wave quantity and the global coherence index of slow waves may represent a sensitive marker for the diagnosis and prognosis of mTBI and post-concussive symptoms.

Insomnia symptoms and behavioural health symptoms in veterans 1 year after traumatic brain injury.

OBJECTIVE: Insomnia and behavioural health symptoms 1 year after traumatic brain injury (TBI) were examined in a clinical sample representative of veterans who received inpatient treatment for TBI-related issues within the Veterans Health Administration. METHODS: This was a cross-sectional sub-study (n = 112) of the Polytrauma Rehabilitation Centres' traumatic brain injury model system programme. Prevalence estimates of insomnia, depression, general anxiety, nightmares, headache and substance use, stratified by injury severity, were derived. Univariate logistic regression was used to examine unadjusted effects for each behavioural health problem and insomnia by injury severity. RESULTS: Participants were primarily male, < 30 years old and high school educated. Twenty-nine per cent met study criteria for insomnia; those with mild TBI were significantly more likely to meet criteria (43%) than those with moderate/severe TBI (22%), χ(2)(1, n = 112) = 5.088, p ≤ 0.05. Univariable logistic regression analyses revealed depressive symptoms and general anxiety were significantly associated with insomnia symptoms after TBI of any severity. Headache and binge drinking were significantly inversely related to insomnia symptoms after moderate/severe TBI, but not MTBI. CONCLUSIONS: Veterans with history of TBI, of any severity, and current insomnia symptoms may be at increased risk for depression and anxiety 1 year after TBI.

Prolonged Exposure Therapy With Veterans and Active Duty Personnel Diagnosed With PTSD and Traumatic Brain Injury.

The present study used archival clinical data to analyze the delivery and effectiveness of prolonged exposure (PE) and ancillary services for posttraumatic stress disorder (PTSD) among Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn veterans (N = 69) with histories of mild to severe traumatic brain injury (TBI). Data from standard clinical assessments of veterans and active duty personnel treated in both inpatient and outpatient programs at 2 Department of Veteran Affairs medical centers were examined. Symptoms were assessed with self-report measures of PTSD (PTSD Checklist) and depression (Beck Depression Inventory-II) before and throughout therapy. Mixed linear models were utilized to determine the slope of reported symptoms throughout treatment, and the effects associated with fixed factors such as site, treatment setting (residential vs. outpatient), and TBI severity were examined. Results demonstrated significant decreases in PTSD, B = -3.00, 95% CI [-3.22, -2.78]; t(210) = -13.5; p < .001, and in depressive symptoms, B = -1.46, 95% CI [-1.64, -1.28]; t(192) = -8.32; p < .001. The effects of PE treatment did not differ by clinical setting and participants with moderate to severe injuries reported more rapid gains than those with a history of mild TBI. The results provide evidence that PE may well be effective for veterans with PTSD and TBI.

Web-based psychoeducational intervention for postconcussion symptoms: a randomized trial.

The objective of this study was to investigate the effectiveness of a web-based educational intervention for reducing postconcussion symptoms. 158 participants with self-reported symptomatic mild traumatic brain injury were randomized to intervention versus control. There was no effect of intervention on symptom severity or attributions. Subgroup analyses suggested benefit of the web-based intervention in those receiving concurrent mental health treatment and in those participants with the greatest time since injury (>1 year after mild traumatic brain injury). Web-based educational intervention was not effective overall in this sample. However, there is some suggestion of promise in those receiving concurrent mental health treatment and with more chronic symptoms. Findings also suggest potential benefit of interventions targeting self-efficacy.

Using information from the electronic health record to improve measurement of unemployment in service members and veterans with mTBI and post-deployment stress.

OBJECTIVE: The purpose of this pilot study is 1) to develop an annotation schema and a training set of annotated notes to support the future development of a natural language processing (NLP) system to automatically extract employment information, and 2) to determine if information about employment status, goals and work-related challenges reported by service members and Veterans with mild traumatic brain injury (mTBI) and post-deployment stress can be identified in the Electronic Health Record (EHR). DESIGN: Retrospective cohort study using data from selected progress notes stored in the EHR. SETTING: Post-deployment Rehabilitation and Evaluation Program (PREP), an in-patient rehabilitation program for Veterans with TBI at the James A. Haley Veterans' Hospital in Tampa, Florida. PARTICIPANTS: Service members and Veterans with TBI who participated in the PREP program (N = 60). MAIN OUTCOME MEASURES: Documentation of employment status, goals, and work-related challenges reported by service members and recorded in the EHR. RESULTS: Two hundred notes were examined and unique vocational information was found indicating a variety of self-reported employment challenges. Current employment status and future vocational goals along with information about cognitive, physical, and behavioral symptoms that may affect return-to-work were extracted from the EHR. The annotation schema developed for this study provides an excellent tool upon which NLP studies can be developed. CONCLUSIONS: Information related to employment status and vocational history is stored in text notes in the EHR system. Information stored in text does not lend itself to easy extraction or summarization for research and rehabilitation planning purposes. Development of NLP systems to automatically extract text-based employment information provides data that may improve the understanding and measurement of employment in this important cohort.