The Impact of Lifetime Traumatic Brain Injury (TBI) on Mental Health Symptoms among Service Members in Interdisciplinary TBI Programs.

INTRODUCTION: Traumatic brain injury (TBI) is highly prevalent among active duty service members (ADSMs) and imposes a significant health burden, particularly on mental health (e.g., post-traumatic stress disorder [PTSD] and depressive symptoms). Little is known about how TBI setting characteristics impact PTSD and depressive symptom expression in service members undergoing interdisciplinary TBI care. MATERIALS AND METHODS: The study included 455 patients enrolled in interdisciplinary, outpatient TBI programs within the military health system. Using Poisson regression with robust error variance, TBI injury setting characteristics (i.e., before military service, during military training, and during noncombat/combat deployment) were evaluated against clinically-elevated PTSD (PTSD Checklist, DSM-5 score ≥ 33) and depressive (Patient Health Questionnaire-8 score ≥ 15) symptoms. RESULTS: In adjusted models, TBI sustained before military service was associated with less likelihood for clinically-elevated PTSD symptoms at pretreatment (prevalence ratio [PR] = 0.76, confidence interval [CI] = 0.60-0.96) and post-treatment (PR = 0.67, CI = 0.52-0.87). TBI sustained during combat deployment, however, resulted in the greatest impact on clinically-elevated pretreatment PTSD (PR = 1.49, CI = 1.16-1.91) and depressive (PR = 1.47, CI = 1.06-2.03) symptoms. Null results were found between military training/noncombat deployment and mental health symptoms. Regardless of the TBI setting, following TBI treatment, there remained 37.5% (n = 180) and 24.8% (n = 108) with clinically-elevated PTSD and depressive symptoms, respectively. CONCLUSIONS: There was a differential impact of TBI settings, particularly between TBI sustained before military service and that from combat deployment among ADSMs enrolled in outpatient TBI programs. This may be indicative of differences in the characteristics of these environments (e.g., injury severity) or the impact of such an event during recovery from current TBIs. The large percentage of ADSMs who present with clinically-elevated mental health symptoms after treatment may suggest the need for additional resources to address mental health needs before, during, and after treatment in TBI programs.

Brain bases of recovery following cognitive rehabilitation for traumatic brain injury: a preliminary study.

Many patients with traumatic brain injury (TBI) have persistent cognitive deficits, including decreased attention and working memory. This preliminary study examined fMRI data from a clinical trial implementing a 4-week virtual reality driving intervention to assess how sustained training can improve deficits related to traumatic brain injury. Previously-reported behavioral findings showed improvements in working memory and processing speed in those who received the intervention; this report explores the brain bases of these effects by comparing neural activity related to working memory (n-back task) and resting state connectivity before and after the intervention. In the baseline visit (n = 24), working memory activity was prominent in bilateral DLPFC and prefrontal cortex, anterior insula, medial superior frontal gyrus, left thalamus, bilateral supramarginal / angular gyrus, precuneus, and left posterior middle temporal gyrus. Following intervention, participants showed less global activation on the n-back task, with regions of activity only in the bilateral middle frontal cortex, posterior middle frontal gyrus, and supramarginal gyrus. Activity related to working memory load was reduced for the group that went through the intervention (n = 7) compared to the waitlist control group (n = 4). These results suggest that successful cognitive rehabilitation of working memory in TBI may be associated with increased efficiency of brain networks, evidenced by reduced activation of brain activity during cognitive processing. These results highlight the importance of examining brain activity related to cognitive rehabilitation of attention and working memory after brain injury.

Clinical validation of an optimized multimodal neurocognitive assessment of chronic mild TBI.

OBJECTIVE: Previous laboratory-based studies have shown that neurocognitive eye-tracking metrics are sensitive to chronic effects of mild traumatic brain injury (mTBI), even in individuals with normal performance on traditional neuropsychological measures. In this study, we sought to replicate and extend these findings in a military medical environment. We expected that metrics from the multimodal Fusion n-Back test would successfully distinguish chronic mTBI participants from controls, particularly eye movement metrics from the more cognitively challenging "1-Back" subtest. METHODS: We compared performance of participants with chronic mTBI (n = 46) and controls (n = 33) on the Fusion n-Back test and a battery of conventional neuropsychological tests. Additionally, we examined test reliability and the impact of potential confounds to neurocognitive assessment. RESULTS: Our results supported hypotheses; Fusion 1-Back metrics were successful in multimodal (saccadic and manual) classification of chronic mTBI versus control. In contrast, conventional neuropsychological measures could not distinguish these groups. Additional findings demonstrated the reliability of Fusion n-Back test metrics and provided evidence that saccadic metrics are resistant to confounding influences of age, intelligence, and psychiatric symptoms. INTERPRETATION: The Fusion n-Back test could provide advantages in differential diagnosis for complex brain injury populations. Additionally, the rapid administration of this test could be valuable for screening patients in clinical settings where longer test batteries are not feasible.

A randomized pilot study of mindfulness-based stress reduction in a young adult cancer sample: Feasibility, acceptability, and changes in patient reported outcomes.

BACKGROUND: The primary purpose of this study was to examine the feasibility and acceptability of participation in a randomized waitlist-controlled intervention of mindfulness-based stress reduction (MBSR) in a young adult cancer sample. A secondary aim was to examine patterns of change in patient reported outcomes (PROs) of physical, social, and emotional functioning. METHODS: Participants were enrolled at a large Midwestern comprehensive cancer center and randomized to MBSR or a waitlist control. Feasibility and acceptability were examined through enrollment metrics and a survey. PROs were gathered at baseline, 8-weeks, and 16-weeks. Descriptive statistics and mixed models were used in analyses. RESULTS: Of 597 eligible participants, 151 (26.5%) consented from which 126 (83.4%) completed baseline measures. Sixty-seven participants were randomized to MBSR, and 59 to the waitlist. Immediately following MBSR, the majority of respondents (72%-78%) reported their experience with mindfulness was very logical and useful to increasing their wellbeing. Compared to waitlist members, MBSR participant's scores on PROs improved in expected directions. CONCLUSIONS: Our findings suggest that recruitment for an intensive, in-person, multi-week supportive intervention can be challenging with young adults with cancer, similar to other cancer survivor populations; however once enrolled, feasibility and acceptability of MBSR was supported. Further, initial evidence on the role of MBSR on short-term changes in select PROs with this population was also demonstrated.

Neurocognitive Driving Rehabilitation in Virtual Environments (NeuroDRIVE): A pilot clinical trial for chronic traumatic brain injury.

BACKGROUND: Virtual reality (VR) technology may provide an effective means to integrate cognitive and functional approaches to TBI rehabilitation. However, little is known about the effectiveness of VR rehabilitation for TBI-related cognitive deficits. In response to these clinical and research gaps, we developed Neurocognitive Driving Rehabilitation in Virtual Environments (NeuroDRIVE), an intervention designed to improve cognitive performance, driving safety, and neurobehavioral symptoms. OBJECTIVE: This pilot clinical trial was conducted to examine feasibility and preliminary efficacy of NeuroDRIVE for rehabilitation of chronic TBI. METHODS: Eleven participants who received the intervention were compared to six wait-listed participants on driving abilities, cognitive performance, and neurobehavioral symptoms. RESULTS: The NeuroDRIVE intervention was associated with significant improvements in working memory and visual search/selective attention- two cognitive skills that represented a primary focus of the intervention. By comparison, no significant changes were observed in untrained cognitive areas, neurobehavioral symptoms, or driving skills. CONCLUSIONS: Results suggest that immersive virtual environments can provide a valuable and engaging means to achieve some cognitive rehabilitation goals, particularly when these goals are closely matched to the VR training exercises. However, additional research is needed to augment our understanding of rehabilitation for driving skills, cognitive performance, and neurobehavioral symptoms in chronic TBI.

A Scoping Review of Positive Lifestyle and Wellness Interventions to Inform the Development of a Comprehensive Health Promotion Program: "HealthPro".

Background. Lifestyle medicine has emerged as a transformational force in mainstream health care. Numerous health promotion and wellness programs have been created to facilitate the adoption of increased positive, modifiable health behaviors to prevent and lessen the effects of chronic disease. This article provides a scoping review of available health promotion interventions that focus on healthy adult populations in the past 10 years. Methods. We conducted a scoping review of the literature searching for health promotion interventions in the past 10 years. Interventions were limited to those conducted among healthy adults that offered a face-to-face, group-based format, with positive results on one or more health outcomes. We then developed a new health promotion intervention that draws on multiple components of included interventions. Results. Fifty-eight articles met our inclusion criteria. Physical activity was the primary focus of a majority (N = 47) of articles, followed by diet/nutrition (N = 40) and coping/social support (N = 40). Conclusions. Efficacious health promotion interventions are critical to address the prevention of chronic disease by addressing modifiable risk factors such as exercise, nutrition, stress, and coping. A new intervention, discussed is this article, provides a comprehensive approaches to health behavior change and may be adapted for future research.

Developing a Peer-to-Peer mHealth Application to Connect Hispanic Cancer Patients.

Cancer and its treatment can significantly impact health-related quality of life (HRQOL) (J Pain Symptom Manag 9 (3):186-192, 1994; Soc Sci Med 46:1569-1584, 1998), particularly for Hispanics (Healthcare Financ Rev 29 (4):23-40, 2008; Psycho-Oncology 21 (2):115-124, 2012). Moreover, providers of cancer support for this population may encounter unique challenges. Grounded in social capital theory, this study identified Spanish-speaking, Hispanic breast cancer survivor support needs and preferences for a mHealth intervention. A user-centered, community-engaged research design was employed, consisting of focus groups made up of constituents from a local Hispanic-serving, cancer support organization. Focus group audio-recordings, translated into English, were coded using a grounded theory analytic approach. First, lead researchers read the complete transcripts to obtain a general sense of the discussion. Next, coding rules were established (e.g., code at the most granular level; double and triple code if necessary, code exhaustively) and initial codebook was created through open-coding. Three new coders were trained to establish requisite kappa statistic levels (≥.70) for inter-rater reliability. With training and discussion, kappa estimates reached .81-.88. Focus group (n = 31) results revealed a mHealth intervention targeting Hispanic cancer patients should not only offer information and support on disease/treatment effects but also respond to the individual's HRQOL, particularly emotional and social challenges. Specifically, participants expressed a strong desire for Spanish content and to connect with others who had gone through a similar experience. Overall, participants indicated they would have access to and would use such an intervention. Findings indicate positive support for a mHealth tool, which is culturally tailored to Spanish speakers, is available in Spanish, and connects cancer patients with survivors.

eSalud: designing and implementing culturally competent ehealth research with latino patient populations.

eHealth is characterized by technology-enabled processes, systems, and applications that expedite accurate, real-time health information, feedback, and skill development to advance patient-centered care. When designed and applied in a culturally competent manner, eHealth tools can be particularly beneficial for traditionally marginalized ethnic minority groups, such as Latinos, a group that has been identified as being at the forefront of emerging technology use in the United States. In this analytic overview, we describe current eHealth research that has been conducted with Latino patient populations. In addition, we highlight cultural and linguistic factors that should be considered during the design and implementation of eHealth interventions with this population. With increasing disparities in preventive care information, behaviors, and services, as well as health care access in general, culturally competent eHealth tools hold great promise to help narrow this gap and empower communities.