Impact of Prior Brain Injury on Concussion Recovery in Military Personnel: Evaluation of Timing Between Concussions.

OBJECTIVE: To evaluate the potential impact of timing between the current and the most recent previous concussions on symptom severity among acutely concussed active duty military Service members (SMs). SETTING: Three military installations. PARTICIPANTS: Eighty-four SMs aged 18 to 44 years who sustained a concussion within 72 hours of enrollment. No previous concussion within 1 year preenrollment. DESIGN: Longitudinal study with enrollment within 72 hours of injury, and follow-up at 1 week and 1 month postinjury. MAIN MEASURES: Lifetime concussion history (yes/no) and recency of the latest concussion (no history, relatively more recent [1 to <6 years ago], and more remote [6+ years ago]) from the current concussion using the Ohio State University Traumatic Brain Injury Identification Method-Interview Form. Symptom severity (total and by categories: cognitive, affective, somatosensory, vestibular) at all time points using the Neurobehavioral Symptoms Inventory. RESULTS: Concussion history assessed as having any previous concussion was not found significantly related to symptom severity (total or by categories) following a current concussion. However, when timing between concussion was taken into account, time since previous concussion was significantly related to symptomatology, whereby those with relatively more recent previous concussion had greater total symptoms within 72 hours of injury and at 1 week postinjury (though not at 1 month) than those with more remote previous concussion (≤72 hours: difference = 15.4, 95% CI = 1.8 to 29.1; 1 week: difference = 15.2, 95% CI = 1.2 to 29.2) or no history (≤72 hours: difference = 11.6, 95% CI = 0.4 to 22.8; 1 week: difference = 13.9, 95% CI = 2.4 to 25.4). When evaluated by symptom category, this relationship was particularly important on affective and somatosensory symptoms. CONCLUSION: In recently concussed active duty SMs, the timing between the current and previous concussions may be an important factor in determining prognosis. Clinical assessment of concussion history that accounts for the timing of the most recent event may be necessary to identify patients who may require a more conservative plan of care and more gradual return to activity in the acute recovery stage.

Beliefs About the Influence of Rest During Concussion Recovery May Predict Activity and Symptom Progression Within an Active Duty Military Population.

OBJECTIVES: To evaluate relationships between beliefs about the impact of rest and the level of activities and symptoms over time among active duty Service members sustaining concussion, and whether these relationships vary by provision of concussion education. DESIGN: Longitudinal study using multilevel modeling to assess the relationship between beliefs about rest within 72 hours of concussion and change in activity and symptom level over time, as well as interaction by concussion education at the initial clinic visit. SETTING: Three military treatment facilities. PARTICIPANTS: Study participants included active duty Service members diagnosed with a concussion (N=111; median age, 24 y). Individuals with previous history of concussion within 12 months of study enrollment were excluded. INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: Activity questionnaire and the Neurobehavioral Symptom Inventory assessed within 72 hours of concussion; at 1 week; and at 1, 3, and 6 month(s) postinjury. RESULTS: Receipt of concussion education from providers was significantly associated with greater belief that rest influences concussion recovery. Greater belief that rest influences symptom recovery at the acute stage of concussion was associated with a greater increase in activities over time, but only among those who received education from their provider. Additionally, greater belief about the influence of rest was related to a more rapid decrease in symptoms over time. CONCLUSIONS: Concussed Service members who underestimate the influence of rest during acute recovery may be at risk for poorer recovery. Treatment of Service members with postconcussive symptoms should consider patient knowledge and/or beliefs about rest and recovery, which may influence prognosis. Our results support the provider's use of concussion education to correct potential misconceptions that may negatively impact symptom recovery.

Activity Level During Acute Concussion May Predict Symptom Recovery Within an Active Duty Military Population.

OBJECTIVE: To evaluate the impact on symptom resolution of activity acutely following a concussion and the role of acute-phase symptoms on this relationship among active duty service members (SMs). SETTING: Three military installations. PARTICIPANTS: Sixty-two SMs aged 18 to 44 years who sustained a concussion within 72 hours of enrollment. DESIGN: Longitudinal design with data collected within 72 hours of injury (baseline, n = 62) and at 1 week (n = 57), 1 month (n = 50), 3 months (n = 41), and 6 months (n = 40) postinjury. MAIN MEASURES: Baseline activity level using a 60-item Activity Questionnaire. Symptom level at baseline and during follow-up using Neurobehavioral Symptoms Inventory. RESULTS: Significant interaction (Pi < .05) was found, with significant main effects (P < .05) limited to SMs with elevated baseline symptomatology. Among these participants, greater baseline total activity was significantly related to greater vestibular symptoms at 1, 3, and 6 months (ß = .61, .63, and .59, respectively). Significant associations were also found for particular types of baseline activity (eg, physical; vestibular/balance; military-specific) and symptoms at 1, 3, and/or 6 months postinjury. CONCLUSION: These results provide support for clinical guidance that symptomatic SMs, particularly those with high levels of acute symptoms, may need to avoid excessive activity acutely following concussion.

The Relationship of Adverse Childhood Events to Smoking, Overweight, Obesity and Binge Drinking Among Women in Hawaii.

OBJECTIVES: To evaluate how the associations of adverse childhood events (ACEs) with smoking, overweight, obesity and binge drinking differ by race/ethnicity among women, including a large, understudied cohort of Asians and Native Hawaiians/Pacific Islanders (NHOPIs). METHODS: The number and type (household dysfunction, and physical, verbal and sexual abuse) of ACEs were examined in relation to adulthood smoking, overweight, obesity and binge drinking among 3354 women in Hawaii using the 2010 Behavioral Risk Factor Surveillance System data using Poisson regression with robust error variance. We additionally investigated for interaction by race/ethnicity. Covariates included age, race/ethnicity, education, emotional support, healthcare coverage, and the other health outcomes. RESULTS: Overall, 54.9 % reported at least 1 ACE. The prevalence of smoking (PR = 1.40 (1 ACE) to PR = 2.55 [5+ ACEs]), overweight (PR = 1.22 [1 ACE] to PR = 1.31 [5+ ACEs]) and obesity (PR = 1.00 [1 ACE] to PR = 1.85 [5+ ACEs]) increased with increasing ACE count. Smoking was associated with household dysfunction (PR = 1.67, CI = 1.26-2.22), and physical (PR = 2.04, CI = 1.50-2.78) and verbal (PR = 1.62, CI = 1.25-2.10) abuse. Obesity was also significantly related to household dysfunction (PR = 1.22, CI = 1.01-1.48), and physical (PR = 1.36, CI = 1.10-1.70), verbal (PR = 1.35, CI = 1.11-1.64) and sexual (PR = 1.53, CI = 1.25-1.88) abuse. Among Asians, sexual abuse was associated with a lower prevalence of binge drinking (PR = 0.26, CI = 0.07-0.93), which was significantly different from the null association among Whites (interaction p = 0.02). CONCLUSION: Preventing/addressing ACEs may help optimize childhood health, and reduce the likelihood of smoking/obesity among women including Asians/NHOPIs. Further studies are warranted to evaluate the sexual abuse-binge drinking association among Asians, which may support the need for culturally-tailored programs to address ACEs.

Sex and race/ethnic disparities in the cross-sectional association between depressive symptoms and muscle mass: the Multi-ethnic Study of Atherosclerosis.

BACKGROUND: The cross-sectional area of total muscle mass has been reported to decrease by about 40% for those 20-60 years of age. Depressive symptoms may discourage motivation to engage in physical activity such as strength training shown to negate muscle loss. Inflammation related to depressive symptoms may also contribute to muscle atrophy. Physiological differences by sex and race/ethnicity may also modify the association between depression and muscle mass. Evidence on the relationship between depression (or depressive symptoms) and adiposity has been mounting; however, little is known about the depressive symptoms-muscle mass association. We sought to determine the association between elevated depressive symptoms (EDS) and lean muscle mass and whether this varies by sex and race/ethnicity. METHODS: Evaluating 1605 adults (45-84 years of age) from the Multi-ethnic Study of Atherosclerosis Abdominal Body Composition, Inflammation and Cardiovascular Disease Study, we examined the cross-sectional association between EDS (Center for Epidemiologic Studies for Depression Scale score≥16 and/or antidepressant use) and computed tomography-measured abdominal lean muscle mass using linear regression. Muscles were evaluated as a whole and by functionality (locomotion vs. stabilization/posture). Covariates included height, body mass index, sociodemographics, comorbidities, inflammatory markers and health behaviors (pack-years of smoking, alcohol locomotion compared to men, total intentional exercise, daily caloric intake). Sex and race/ethnicity were assessed as potential modifiers. Statistical significance was at a p<0.05 for main effects and <0.20 for interaction. RESULTS: Men with elevated depressive symptoms had 5.9 cm2 lower lean muscle mass for locomotion compared to men without EDS, fully-adjusted (CI=-10.5, -1.4, p=0.011). This was statistically significantly different from the null finding among women (interaction p=0.05). Chinese participants with EDS had 10.2 cm2 lower abdominal lean muscle mass for locomotion compared to those without EDS (fully-adjusted, CI=-18.3, -2.1, p=0.014), which was significantly different from the null relationship among White participants (interaction p=0.04). No association was observed between elevated depressive symptoms and muscle for stabilization/posture evaluating the whole population or stratified by sex or race/ethnicity. CONCLUSIONS: In the presence of elevated depressive symptoms, men and Chinese participants may have lower muscle mass, particularly for locomotion.

Adverse Childhood Events are Related to the Prevalence of Asthma and Chronic Obstructive Pulmonary Disorder Among Adult Women in Hawaii.

PURPOSE: In the US, women surpass men in the prevalence of lung diseases. Limited studies exist on the association of adverse childhood events (ACEs) to asthma and chronic obstructive pulmonary disorder (COPD) particularly among women and cohorts of understudied populations (e.g., Pacific Islanders). This study evaluated the ACEs-asthma and ACEs-COPD relationships among women in Hawaii and the contribution of poor health factors (smoking, binge drinking, and obesity) in these associations. METHODS: Using data from 3363 women in the Behavioral Risk Factor Surveillance System-Hawaii, we assessed how self-reported ACEs [count and type (household dysfunction, and physical, verbal and sexual abuse)] relate to asthma and COPD. Multivariable log-binomial regression, accounting for the sampling design, and model adjustments for socio-demographics, healthcare access, emotional support, current smoking, binge drinking, and BMI status were used to generate prevalence ratios. RESULTS: For every increase in ACE count, the likelihood for asthma increased by 7 % (CI = 1.02-1.13), and for COPD, by 21 % (CI = 1.12-1.31) accounting for socio-demographics, healthcare access, and emotional support. Verbal abuse was also associated with greater likelihood for asthma independent of these covariates (PR = 1.43, CI = 1.14-1.79). Household dysfunction (PR = 1.82, CI = 1.15-2.82) and physical (PR = 2.01, CI = 1.20-3.37), verbal (PR = 2.24, CI = 1.38-3.65) and sexual (PR = 1.81, CI = 1.10-2.97) abuse were all associated with COPD using similar adjustments. Additional adjustment for smoking, binge drinking, and BMI status did not impact the ACE-asthma associations and only modestly attenuated the ACE-COPD relationships. CONCLUSIONS: Primary and secondary prevention of ACEs may optimize the health of young girls in Hawaii, and reduce the burden of asthma and COPD among women in the state.

Physical environment may modify the association between depressive symptoms and change in waist circumference: the multi-ethnic study of atherosclerosis.

BACKGROUND: Although the bidirectional association between depressive symptoms and adiposity has been recognized, the contribution of neighborhood factors to this relationship has not been assessed. OBJECTIVE: This study evaluates whether physical and social neighborhood environments modify the bidirectional relationship between depressive symptoms and adiposity (measured by waist circumference and body mass index). METHODS: Using data on 5,122 men and women (ages 45 to 84 years) from the Multi-Ethnic Study of Atherosclerosis (MESA) we investigated whether neighborhood physical (i.e., walking environment and availability of healthy food) and social (i.e., safety, aesthetics, and social coherence) environments modified the association between the following: (1) baseline elevated depressive symptoms (Center for Epidemiologic Study Depression Scale score ≥ 16) and change in adiposity (as measured by waist circumference and body mass index) and (2) baseline overweight/obesity (waist circumference > 102 cm for men and >88 cm for women, or body mass index ≥ 25 kg/m(2)) and change in depressive symptoms using multilevel models. Neighborhood-level factors were obtained from the MESA Neighborhood Study. RESULTS: A greater increase in waist circumference in participants with vs without elevated depressive symptoms was observed in those living in poorly-rated physical environments but not in those living in better-rated environments (interaction p = 0.045). No associations were observed with body mass index. Baseline overweight/obesity was not associated with change in depressive symptoms and there was no modification by neighborhood-level factors. CONCLUSIONS: Elevated depressive symptoms were associated with greater increase in waist circumference among individuals living in poorly-rated physical environments than in those in better-rated physical environments. No association was found between overweight/obesity and change in depressive symptoms.

Adverse childhood events and current depressive symptoms among women in Hawaii: 2010 BRFSS, Hawaii.

Research on the association between adverse childhood events (ACEs) and depression among women in Hawaii is scarce. ACEs have been linked to unfavorable health behaviors such as smoking and binge drinking which are more prevalent in the state compared to the US overall. The concomitant presence of ACEs with smoking or binge drinking may explain the excess depression prevalence in Hawaii compared to the national average. Using data of women residing in the state (2010 Hawaii Behavioral Risk Factor Surveillance System Survey), we examined the association between ACEs count or type (household dysfunction and physical, verbal and sexual abuse) and current depressive symptoms (CDS), in addition to modification by current smoking status (smoked >100 cigarettes in a lifetime and currently smoke) and binge drinking (consumed ≥4 alcoholic beverage within the past month and in ≥1 occasion(s)). Evaluation of ACEs before age 18 consisted of 11 indicators. Eight indicators of the Patient Health Questionnaire (PHQ-8) were used to assess CDS. All analyses utilized logistic regression taking into account sampling design. The odds ratio of having CDS between those with versus without ACEs increased per increasing number of ACEs (1 ACE: OR = 2.11, CI = 1.16-3.81; 2 ACEs: OR = 2.90, CI = 1.51-5.58; 3 or 4 ACEs: OR = 3.94, CI = 2.13-7.32; 5+ ACEs: OR = 4.04, CI = 2.26-7.22). Household dysfunction (OR = 2.10, CI = 1.37-3.23), physical abuse (OR = 1.67, CI = 1.08-2.59), verbal abuse (OR = 3.21, CI = 2.03-5.09) and sexual abuse (OR = 1.68, CI = 1.04-2.71) were all positively associated with CDS. Verbal abuse had the strongest magnitude of association. Neither current smoking status nor binge drinking modified the relationship between ACEs count (or type) and CDS. In conclusion, the presence of ACEs among women in Hawaii was indicative of CDS in adulthood, notably verbal abuse. Further, a dose response existed between the number of ACEs and the odds for CDS. The concomitant exposure to ACEs and current smoking status or binge drinking did not elevate odds for CDS.

The Patient Global Impression of Change as a complementary tool to account for neurobehavioral and mental health symptom improvement for patients with concussion.

PURPOSE: The purpose of this study was to determine the extent to which patient's perspective of symptom improvement, as indexed by the Patient Global Impression of Change (PGIC) survey, is associated with symptom improvement on common measures of neurobehavioral and mental health symptoms following concussion. MATERIALS AND METHODS: Data were from 449 US active duty service members receiving treatment in interdisciplinary programs for their concussion. PGIC rating (range = 1-7) was evaluated for compatibility in assessing improvement in or clinically-elevated neurobehavioral (using Neurobehavioral Symptom Inventory [NSI]) and mental health (using Post-traumatic Stress Disorder Checklist, DSM-5 [PCL-5] and Patient Health Questionnaire [PHQ-8]) symptoms. RESULTS: Higher PGIC scores were related to a higher prevalence of clinically-relevant decrease in NSI, PCL-5 or PHQ-8 scores. Participants with a PGIC rating of 3+ (vs.<3) were about 2.2 (CI = 1.4-3.5), 1.6 (CI = 1.1-1.3), and 2.7 (CI = 1.4-5.1) times more likely to report clinically-relevant decrease in NSI, PCL-5 and PHQ-8 symptoms, respectively. CONCLUSION: PGIC may help providers incorporate patients' perspectives on symptom improvement achieved during rehabilitation. An approach combining PGIC with surveys such as NSI, PCL-5 and PHQ-8 may provide a more comprehensive understanding of symptom improvement and realistic view of expectations for what would be deemed recovery to pre-injury symptom levels.

Concussion significantly impacts cognitive, physical and mental health, and active duty service members (SMs) are at high risk due to their occupation demands.The Patient Global Impression of Change (PGIC) assesses symptom improvement, as perceived by the patient, which may align better with usual/pre-injury level symptoms prior to injury compared to other common measures of neurobehavioral and mental health symptoms for concussion patients.A comprehensive approach in which PGIC is included in symptom assessment may provide a better understanding of symptom improvement and provide a more realistic view of expectations for what would be deemed recovery to usual/pre-injury level or improvement in symptoms.

Phenotyping Depression After Mild Traumatic Brain Injury: Evaluating the Impact of Multiple Injury, Gender, and Injury Context.

The chronic mental health consequences of mild traumatic brain injury (TBI) are a leading cause of disability. This is surprising given the expectation of significant recovery after mild TBI, which suggests that other injury-related factors may contribute to long-term adverse outcomes. The objective of this study was to determine how number of prior injuries, gender, and environment/context of injury may contribute to depressive symptoms after mild TBI among deployed United States service members and veterans (SMVs). Data from the Long-term Impact of Military-Relevant Brain Injury Consortium Prospective Longitudinal Study was used to assess TBI injury characteristics and depression scores previously measured on the Patient Health Questionnaire-9 (PHQ-9) among a sample of 1456 deployed SMVs. Clinical diagnosis of mild TBI was defined via a multi-step process centered on a structured face-to-face interview. Logistical and linear regressions stratified by gender and environment of injury were used to model depressive symptoms controlling for sociodemographic and combat deployment covariates. Relative to controls with no history of mild TBI (n = 280), the odds ratios (OR) for moderate/severe depression (PHQ-9 ≥ 10) were higher for SMVs with one mild TBI (n = 358) OR: 1.62 (95% confidence interval [CI] 1.09-2.40, p = 0.016) and two or more mild TBIs (n = 818) OR: 1.84 (95% CI 1.31-2.59, p < 0.001). Risk differences across groups were assessed in stratified linear models, which found that depression symptoms were elevated in those with a history of multiple mild TBIs compared with those who had a single mild TBI (p < 0.001). Combat deployment-related injuries were also associated with higher depression scores than injuries occurring in non-combat or civilian settings (p < 0.001). Increased rates of depression after mild TBI persisted in the absence of post-traumatic stress disorder. Both men and women SMVs separately exhibited significantly increased depressive symptom scores if they had had combat-related mild TBI. These results suggest that contextual information, gender, and prior injury history may influence long-term mental health outcomes among SMVs with mild TBI exposure.

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.

Disparities in mental health symptoms recovery across race/ethnicity and education level following mild traumatic brain injury.

Purpose: The purpose of this study was to investigate the relationship between race/ethnicity and post-concussive mental health (i.e., depressive, post-traumatic stress disorder [PTSD]) and neurobehavioral symptoms among service members, and whether this association differed by education level. Methods: The study sample consisted of 524 patients from a multidisciplinary US military outpatient treatment facility for post-concussive symptoms. Poisson regression with robust error variance was utilized to investigate outcome (i.e., clinically-elevated depressive [Patient Health Questionnaire-8 ≥15], PTSD [PTSD Checklist, DSM 5 ≥38] and neurobehavioral [Neurobehavioral Symptom Inventory >75th percentile] symptoms at admission and last follow-up in this cohort study. Modification by education level (low [no college degree] vs. high [associate's degree or higher]) was additionally evaluated. Results: The relationship between race/ethnicity and mental health/neurobehavioral symptoms varied by education level (p-interaction: depressive symptoms = 0.002, PTSD symptoms = 0.035, neurobehavioral symptoms = 0.040). Specifically, non-Whites were at a significantly higher prevalence for clinically-elevated depressive symptoms post-treatment than Whites, but only among those with higher education level (PR = 2.22, CI = 1.37-3.59). A similar trend was demonstrated for PTSD and neurobehavioral symptoms. Conclusion: Military healthcare may need to increase depression-focused treatment options that are acceptable for racial/ethnic minority patients, particularly those with higher education, while they are recovering from comorbid traumatic brain injury.

Presenting symptoms as prognostic measures of mental health recovery among service members with concussion.

Background: Comorbid mental illness may negatively impact recovery from concussion. This study evaluated whether the level of symptom clusters at clinic intake contribute to poor mental health recovery in concussed patients during treatment, which may in turn serve as a target intervention. Objective: The objective of this study is to examine the association between the level of initial symptoms and mental health symptoms among service members with concussion. Methods: Data were obtained from 483 active duty service members treated in interdisciplinary treatment programs for traumatic brain injury, all of which were concussions. Pre-treatment symptom clusters included self-reported hyperarousal, dissociation/depression, cognitive dysfunction/headache and neurological symptoms. The outcomes, clinically-relevant decreases in depressive symptoms (assessed by the 8-item Patient Health Questionnaire, PHQ-8) and PTSD symptoms (assessed by the PTSD Checklist for DSM-5, PCL-5), were defined as a decrease in PHQ-8 > 5 and PCL-5 > 7, respectively. Poisson regression with robust error variance was used to evaluate the relationship between the level of each symptom cluster and clinically-relevant decrease in outcomes. Results: Participants with higher (vs. lower) levels of pre-treatment hyperarousal and dissociation/depression symptom cluster were less likely to improve in depressive and PTSD symptoms during treatment. The level of cognitive/headache and neurological symptom clusters were not significantly associated with any symptom changes. Conclusion: These findings support the need for individualized treatment for symptoms identified and treated after determining concussion history, with particular attention to high levels of hyperarousal and dissociation/depression prior to treatment.

Designing research on concussion treatment in the military setting: Important challenges to consider.

Traumatic brain injury (TBI) is highly prevalent on a global scale with concussion being the most common of all TBIs. Concussion research on rehabilitation and symptom resolution is well-established, particularly among athletes, but less is known about the recovery of active duty service members (ADSMs). In a population whose occupational environment increases risk for such injury, it is imperative that treatment is optimized to achieve successful rehabilitation. The military setting, however, has challenges that must be accounted for when developing proposals to study the benefits of new interventions or treatment. This review will provide a discussion on those challenges to better understand the considerations that are essential during the developmental phase of concussion studies within the military setting. This review aims to provide investigators novice to the military setting an overview of considerations when researching concussion among ADSMs.

Use of a randomized clinical trial design to study cognitive rehabilitation approaches to enhance warfighter performance.

Within the military, cognitive readiness is essential to ensure the warfighter can return to highly demanding combat training and deployment operations. The warfighter must be able to make split second decisions and adapt to new tools and environments. After a traumatic brain injury, clinicians helping the warfighter must have techniques that address warfighter cognitive readiness. Current rehabilitation for cognitive complaints used in military medicine are modeled after civilian therapies which focus on remediating moderate to severe impairment through building compensatory strategies. This traditional approach to cognitive rehabilitation does not translate well to mild traumatic brain injury (mTBI) where impairments are subtle, nor does it meet the needs of our warfighters in deployed and combat training environments. Challenging our current methods is critical in adapting to the needs of this highly valued population to ensure that our warfighters are able to carry out mission critical decision making. Here we present a review of our best current practices for cognitive rehabilitation, describe the limitations our traditional approaches impose for mTBI in military personnel, and present an alternative treatment called Strategic Memory Advanced Reasoning Training (SMART) that can be adopted through a randomized clinical trial design. We propose directly comparing traditional treatment approaches with a novel cognitive rehabilitation strategy which has been well validated outside of the military setting. Procedures were developed to execute this clinical trial in a way that is most relevant to the study population by establishing ecologically valid outcome metrics.

Best Practices for Progressive Return to Activity after Concussion: Lessons Learned from a Prospective Study of U.S. Military Service Members.

Primary care providers can play a crucial role in the clinical management of concussion. However, many providers lack up-to-date information about best practices for rest and return to activity after these injuries. Most research on this topic has been conducted in athletes, and so less is known about how to assist patients with returning to activity in other settings and populations. This article provides a review of best practices for management of progressive return to activity after concussion, with an emphasis on "lessons learned" from the Defense and Veterans Brain Injury Center (DVBIC) Progressive Return to Activity (PRA) study, a multi-site longitudinal research project conducted to evaluate concussion management practices and the effectiveness of provider training on DVBIC clinical recommendations (CRs). Provider clinical practices and patient outcomes were examined at three U.S. military treatment facilities before and after providers completed a standardized training on DVBIC PRA CRs. In summary, research findings provide additional support that concussion recovery can be influenced by patients' activity levels after injury. Patients with concussion may experience poorer outcomes if they return to pre-injury levels of activity too rapidly, but they may also be at risk for prolonged symptoms if they fail to increase activity levels over time after an initial period of rest. Additionally, training primary care providers in return to activity guidelines can result in more effective patient education and better clinical outcomes. This knowledge can be used to inform best practices for progressive return to activity in both civilian and military settings.

"Return to duty" as an outcome metric in military concussion research: Problems, pitfalls, and potential solutions.

OBJECTIVE: "Return to duty" (RTD) is often used as an outcome metric in military concussion research, but is inconsistently defined across studies and presents several key problems to researchers. Using results from the Defense and Veterans Brain Injury Center's (DVBIC) Progressive Return to Activity (PRA) study, we highlight problems with RTD, and suggest solutions to inform future efforts. METHOD: 116 service members (SMs) were enrolled in one of two groups (pre-implementation and post-implementation of the PRA Clinical Recommendation [CR]). Data, including the Neurobehavioral Symptom Inventory (NSI-22), was collected within 72-hours of injury (baseline), and at 1-week, 1-month, 3-months, and 6-months post-injury. Our analyses focused on three time points: baseline, approximate RTD date, and post-RTD follow-up, with RTD data captured via self-report and electronic medical record (EMR). Secondary analyses included comparisons across PRA-CR implementation groups. RESULTS: Of those SMs (<50% of the sample) with both self-reported and EMR RTD dates, dates largely did not match (range 1 to 36 days). RTD (either date) also did not indicate symptom recovery, with >50% of SMs reporting "abnormally high" symptom levels (i.e., NSI-22 total ≥75th percentile) at RTD, and over 50% of SMs reporting at least one significant symptom (i.e., any NSI-22 item ≥ 2) after RTD. CONCLUSIONS: Our data demonstrate challenges encountered with a RTD outcome metric. Military concussion researchers should strive to use a well-defined RTD outcome metric. We propose defining RTD as a return to deployment readiness. Further, researchers should utilize Department of Defense definitions of Individual Medical Readiness and Deployment Limiting conditions to increase specificity of a RTD outcome metric. Improving the way RTD is captured will improve confidence that tools used after a SM sustains concussion are adequately informing RTD decisions.

Current patterns of primary care provider practices for the treatment of post-traumatic headache in active duty military settings.

OBJECTIVE: To provide a preliminary assessment of the current clinical practice for the treatment of post-traumatic headache following concussion in military primary health care settings. BACKGROUND: Headache is one of the most common symptoms post-concussion; however, little is known of the current clinical practices of primary care providers (on the treatment of post-traumatic headache), particularly in military settings. METHODS: Study participants were primary care providers (n = 65) who treated active duty Service members suffering from post-traumatic headache at two military installations. Qualitative data gathered via semi-structured interviews were used to describe provider practices and experience in treating patients with post-traumatic headache. RESULTS: Some patterns of care across primary care providers treating post-traumatic headache were consistent with the Department of Defense-recommended clinical recommendation (e.g., recommendation of both pharmacological and non-pharmacological treatment [89.4%]; engaging in follow-up care [100%]). Differences existed in timing of follow-up from initial visit [16.9% reporting within 24 hours; 21.5% reporting within 48-72 hours; and 26.2% reporting more than 1 week], the factors contributing to the type of care given (e.g., symptomatology [33.0%], injury characteristic [24.2%], patient characteristic [13.2%]) and the need for referral to higher level of care (e.g., symptomatology [44.6%], treatment failure [25.0%]). These variations may be indicative of individualized treatment which would be compliant with best clinical practice. CONCLUSION: The results of this study demonstrate the current clinical practice in military primary care settings for the treatment of post-traumatic headache which can potentially inform and improve implementation of provider training and education.

Provider Training in the Management of Headache Following Concussion Clinical Recommendation: Promoting a Standardized Means for Efficient Patient Recovery and Timely Return to Duty.

Background: Headache is a common symptom reported following concussion/mild traumatic brain injury. The Department of Defense's clinical recommendation (CR) describes guidance for primary care providers for the management of post-traumatic headache (PTH) in Service members. Objective: The objective of this study is to examine the association between training on the CR with provider clinical practice, patient behaviors, and symptom recovery. Methods: Participants were healthcare providers and two patient groups (one receiving care as usual [CAU] and another receiving care after provider training on PTH CR [CR+]). Providers were interviewed at three time points: (1) prior to CAU enrollment; (2) after CAU enrollment, but prior to training; and (3) after CR+ follow-up. Data from the second and third provider interview were used to evaluate a potential difference between provider practices pre- and post-training (n = 13). Patients were enrolled within 6 months of concussion. Patient outcomes (including neurobehavioral and headache symptoms) were assessed at three time-points: within 72 h (n = 35), at 1-week (n = 34) and at 1-month post-enrollment (n = 27). Results: Most follow-up care reported by providers were recommended within 72 h of initial visit post-training vs. >1 week pre-training. Additionally, providers reported a greater number of visits based on patient symptoms after training than before. Post-training, most providers reported referring patients to higher level of care "as needed," if not "very rarely," compared to 25% reported referrals prior to training. At 1-week post-enrollment the CR+ patient group reported more frequent medical provider visits compared to the CAU group. This trend was reversed at the 1-month follow-up whereby more CAU reported seeing a medical provider compared to CR+. By 1-week post-enrollment, fewer patients in the CR+ group reported being referred to any other providers or specialists compared to the CAU group. No differences in patient outcomes by provider training was found. Conclusion: The study results demonstrate the feasibility of training on the Management of Headache Following Concussion CR in order to change provider practices by promoting timely care, and promoting patient compliance as shown through improvement in follow-up visits and more monitoring within the primary care clinic.

Activity Level and Type During Post-acute Stages of Concussion May Play an Important Role in Improving Symptoms Among an Active Duty Military Population.

Background: Previous research demonstrates that early rest and gradual increases in activity after concussion can improve symptoms; however, little is known about the intensity and type of activity during post-acute time periods-specifically months post-injury-that may promote optimal recovery in an active duty service member (SM) population. Objective: The objectives of this study were to investigate how activity level and type at the post-acute stages of concussion (at 1 and 3 month[s] post-injury) impact subsequent symptoms among SMs, and how this relationship might differ by the level of symptoms at the time of injury. Methods: Participants included 39 SMs ages 19-44 years from 3 military installations who were enrolled within 72 h after sustaining a concussion. Linear regression was used to evaluate whether the association between activity level at 1 or 3 month(s) post-injury (as measured by a multi-domain Activity Questionnaire) and subsequent symptoms at 3 and/or 6 months (as measured by the Neurobehavioral Symptom Inventory) varied by the level of symptoms at acute stages of concussion. Partial correlation was used to evaluate relationships that did not differ by acute symptom level. Symptoms at the time of activity assessment (1 or 3 month[s]) were accounted for in all models, as well as activity level at acute stages of concussion. Results: Greater physical and vestibular/balance activity at 1 month were significantly correlated with lower symptoms at 3 months, but not at 6 months post-injury. There were no significant associations found between activity (total or by type) at 3 months and symptoms at 6 months. The association between activity level at either 1 or 3 months and subsequent symptoms at 3 and/or 6 months did not differ by the level of acute symptoms. Conclusion: The intensity and type of activities in which SMs engage at post-acute stages of concussion may impact symptom recovery. Although low levels of activity have been previously shown to be beneficial during the acute stage of injury, higher levels of activity may provide benefit at later stages. These findings provide support for the importance of monitoring and managing activity level beyond the acute stage of concussion.