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OBJECTIVE To evaluate factors impacting opioid receipt among active-duty service members (SMs) following a first mild traumatic brain injury (mTBI). SETTING Active-duty SMs receiving care within the Military Health System. PARTICIPANTS In total, 14 757 SMs who have sustained an initial mTBI, as documented within electronic health records (EHRs), between 2016 and 2017. DESIGN A retrospective analysis of EHR metadata. MAIN MEASURES Multivariable logistic regression assessed factors impacting opioid receipt and initiation. Factors include demographics, military characteristics, and preexisting clinical conditions, including prior opioid prescription. RESULTS Of the sample population, 33.4% (n = 4927) were prescribed opioids after their initial mTBI, of which, 60.6% (n = 2985) received opioids for the first time following injury. Significant risk factors associated with the increased probability of opioid receipt included age, gender, and preexisting behavioral health and musculoskeletal conditions. Military characteristics also exhibited changes in the probability of opioid receipt, both among initiation and new prescription. No changes were observed among race, nor among those with preexisting headaches or migraines. CONCLUSION Despite concerns about the negative impact on recovery, the prescribing of opioids is common in this population of active-duty SMs first diagnosed with an mTBI. As several demographic and preexisting health conditions are factors in the receipt of opioids post-mTBI, the entire medical history of these patients should be considered prior to prescription. Understanding these factors may further inform policy for opioid use in the Military Health System.

Objective To evaluate trends in the extant literature on mild traumatic brain injury (mTBI) in military service members and veterans using network analysis based on a comprehensive search of original, peer-reviewed research articles involving human participants published between January 1, 2010, and December 31, 2019. Specifically, we employed network analysis to evaluate associations in the following areas: (1) peer-reviewed journals, (2) authors, (3) organizations/institutions, and (4) relevant key words. Participants Included studies were published in peer-reviewed journals available on Web of Science database, using US military service members or veterans. Design Bibliometric network analytical review. Main measures Outcomes for each analysis included number of articles, citations, total link strength, and clusters. Results The top publishing journals were (1) Journal of Head Trauma and Rehabilitation, (2) Military Medicine, (3) Brain Injury, (4) Journal of Neurotrauma, and (5) Journal of Rehabilitation Research and Development. The top publishing authors were (1) French, (2) Lange, (3) Cooper, (4) Vanderploeg, and (5) Brickell. The top research institutions were (1) Defense and Veterans Brain Injury Center, (2) Uniformed Services University of the Health Sciences, (3) University of California San Diego, (4) Walter Reed National Military Medical Center, and (5) Boston University. The top co-occurring key words in this analysis were (1) posttraumatic stress disorder (PTSD), (2) persistent postconcussion symptoms (PPCS), (3) blast injury, (4) postconcussion syndrome (PCS), and (5) Alzheimer's disease. Conclusions The results of this network analysis indicate a clear focus on veteran health, as well as investigations on chronic effects of mTBI. Research in civilian mTBI indicates that delaying treatment for symptoms and impairments related to mTBI may not be the most precise treatment strategy. Increasing the number of early, active, and targeted treatment trials in military personnel could translate to meaningful improvements in clinical practices for managing mTBI in this population.

OBJECTIVE To describe changes in the prevalence and clinical correlates of noise sensitivity (NS) in mild traumatic brain injury (mTBI) across a 12-month period and to determine whether NS at an early stage of recovery has predictive value for later postconcussive symptoms. SETTING A mixed urban and rural region of New Zealand. PARTICIPANTS Data for 341 adults (201 males, 140 females; age range from 16 to 91 years) were extracted from a 1-year TBI incidence, and outcomes study was conducted in New Zealand. DESIGN Secondary analysis of data from a community-based, longitudinal population study of an mTBI incidence cohort collected within 1 week of injury (baseline) and at 1, 6, and 12 months postinjury. MAIN MEASURES Measures at baseline (within 2 weeks of the injury) and 1, 6, and 12 months included the Rivermead Post-concussion Symptoms Questionnaire and its NS item, the Hospital Depression and Anxiety Scale, and the computerized CNS-Vital Signs neurocognitive test. RESULTS NS progressively declined postinjury, from 45% at baseline to 28% at 12 months. In turn, NS showed itself as a significant predictor of future postconcussive symptoms. CONCLUSION Taken together with previous research, the findings of the current study indicate that NS may have clinical utility in flagging vulnerability to persistent postconcussive symptoms.

Background Special Operations Forces (SOF) combat soldiers are frequently exposed to blast and blunt neurotrauma, most often classified as mild traumatic brain injury (mTBI). Repetitive mTBI may increase the risk of developing long-term neurological sequelae. Identifying changes in neuroinflammatory biomarkers before chronic conditions emerge could serve as preliminary evidence of developing neuropathology. Objective To determine the effects of mTBI history, lifetime mTBI incidence, and recency on blood biomarker concentrations of axonal protein neurofilament light (NfL), glycolytic enzyme neuron-specific enolase (NSE), astrocyte-expressed S100 calcium-binding protein B (S100B), and neurotrophic cytokine interleukin-6 (IL-6) in healthy, active duty SOF combat soldiers. Methods Self-reported mTBI history/recency and fasted blood samples were collected in this cross-sectional study of 104 asymptomatic SOF combat soldiers. Biomarker concentrations were quantified using commercial enzyme-linked immunosorbent assays. Mann-Whitney U and Kruskal-Wallis tests were used to compare groups. Post hoc tests with appropriate corrections were conducted as warranted. Results Soldiers with mTBI history had higher NSE concentrations than those without (z = -2.60, P = .01). We also observed significant main effects of lifetime mTBI incidence on NSE (χ(3) = 9.52, P = .02) and S100B (χ(3) = 8.21, P = .04) concentrations and a significant main effect of mTBI recency on NfL concentration (χ(2) = 6.02, P = .049). Conclusion The SOF combat soldiers with mTBI history had increased NSE. Longitudinal studies in this population are needed due to between-subject heterogeneity in biomarker concentrations. The NfL concentrations in our SOF combat soldiers-regardless of mTBI history or recency-were similar to values previously reported in civilian acute TBI patients.

OBJECTIVE To determine the feasibility of short-term cardiovascular responses to postural change as a screening tool for mild traumatic brain injury (mTBI), using heart rate metrics that can be measured with a wearable electrocardiogram sensor. SETTING Military TBI clinic. DESIGN Data collected from active-duty service members who had sustained a medically diagnosed mTBI within the prior 72 hours and from age- and sex-matched controls. Cardiac data collected while participants performed a sequence of postural changes. MAIN MEASURES Model classification compared with clinical mTBI diagnosis. RESULTS Cardiac biomarkers of mTBI were identified and logistic regression classifiers for mTBI were developed from different subsets of biomarkers. The best model achieved 90% sensitivity and 69% specificity using data from 2 different postural changes. CONCLUSION Noninvasive measurement of cardiovascular response to postural change is a promising approach for field-deployable post-mTBI screening.

OBJECTIVE: To examine how postural control changes following pediatric mild traumatic brain injury. SETTING: Urban pediatric emergency department. PARTICIPANTS: Children 11 to 16 years old who presented within 6 hours of sustaining mild traumatic brain injury. DESIGN: Prospective observational cohort followed for 1 month. MAIN MEASURES: Total center of pressure path velocity and path velocity within distinct frequency bands, ranging from moderate to ultralow, were recorded by the Nintendo Wii Balance Board during a 2-legged stance. Measurements were recorded in 2 separate tests with eyes open and closed. The scores of the 2 tests were compared, and a Romberg quotient was computed. RESULTS: Eleven children were followed for 1 month postinjury. The ultralow frequency, which reflects slow postural movements associated with exploring stability boundaries, was lower (p =.02) during the eyes closed stance acutely following injury. The Romberg quotient for this frequency was also significantly lower acutely following injury (p =.007) than at 1 month. CONCLUSION: Following mild traumatic brain injury, children acutely demonstrate significantly more rigid sway patterns with eyes closed than with eyes open, which were highlighted by the Romberg quotient. The Romberg quotient could allow for accurate identification and tracking of postural instability without requiring knowledge of preinjury balance ability. Language: en

Objective To identify socioeconomic, demographic, and caregiver factors associated with children attending primary care provider (PCP) follow-up after emergency department (ED) evaluation for mild traumatic brain injury (mTBI). Setting Pediatric trauma center ED. Participants Children 8 to 18 years of age sustaining mTBI less than 48 hours prior to an ED visit. Mean age of the 183 participants was 12 years with no significant differences between those who attended follow-up and those who did not in race, ethnicity, insurance provider, or PCP office setting. Design Thirty-day longitudinal cohort study. Main measures Insurance type, PCP practice setting, and a caregiver attitudes survey regarding mTBI recovery and management (5 questions each scored on a 5-point Likert scale). The primary outcome was attending a PCP follow-up visit within 1 month of injury. Results Females were more likely than males to attend PCP follow-up (adjusted odds ratio: 2.27 [95% confidence interval: 1.00-5.18]). Increasing scores on the caregiver attitudes survey indicating greater concerns about recovery were significantly associated with attending PCP follow-up (adjusted odds ratio: 1.12 per unit increase in composite score [95% confidence interval: 1.02-1.23]). No other socioeconomic, demographic, or injury characteristics were associated with attending PCP follow-up. Conclusions The ED counseling regarding PCP follow-up of mTBI should stress the importance of follow-up care to monitor recovery and identify presence of lingering symptoms.

Objective A panel of biomarkers is needed to definitively diagnose mild traumatic brain injury (mTBI). There is a clear role for the inclusion of an inflammatory biomarker. This study looked to find a relationship between high sensitivity C-reactive protein (hsCRP), an inflammatory biomarker, and mTBI. Setting Neurology department of high-volume tertiary orthopedic hospital. Participants Individuals diagnosed with mTBI (n = 311, age 21 ± 12 years, 53% female). Design Retrospective cohort study. Main measures hsCRP levels; postconcussive symptoms; demographics. Results Continuous hsCRP levels were transformed into quartiles, as defined by less than 0.200 mg/L for quartile 1 (Q1); 0.200 to 0.415 mg/L for quartile 2 (Q2); 0.415 to 1.100 mg/L for quartile 3 (Q3); and greater than 1.100 mg/L for quartile 4 (Q4). Mean hsCRP was elevated in the cohort of individuals who presented within 1 week of injury and was found to significantly decrease between the first visit and 4 weeks postinjury (P = .016). Initial hsCRP level was positively correlated with age (r = 0.163, P = .004), and age significantly increased between quartiles (P = .013). Patients with increased age (odds ratio: 3.48) and those who endorsed headache (odds ratio: 3.48) or fatigue (odds ratio: 2.16) were significantly associated with increased risk of having an hsCRP level in Q4. Conclusion hsCRP may be a viable addition to acute and longitudinal biomarker panels for diagnosis and prognosis of mTBI.

OBJECTIVE To determine differences in rehabilitation trajectories and return to work (RTW) and social outcomes in individuals with mild traumatic brain injury (mTBI) with and without significant psychiatric histories at index hospitalization. SETTING Three level 1 trauma centers participating in the Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) consortium. PARTICIPANTS A total of 305 individuals with index mTBI enrolled in the TRACK-TBI pilot project. DESIGN Secondary analysis of data from the TRACK-TBI pilot study. MAIN MEASURES Chart review and patient/family interview at emergency department (ED) admission, ED clinical data, ED discharge plan, functional interview data at 3- and 6-month outcomes, Trail Making Tests, the Wechsler Adult Intelligence Scale, Fourth Edition, Processing Speed Index, the California Verbal Learning Test, Second Edition, and the Craig Handicap Assessment and Reporting Technique. RESULTS Controlling for neurological history and CT lesion at ED admission, participants with and without psychiatric histories did not differ in terms of treatment, return to work, or reported social function. Individuals with psychiatric histories demonstrated lower processing speed and reported reduced satisfaction with occupational function at outcome. CONCLUSIONS Individuals with mTBI and psychiatric histories may require specialized rehabilitation planning to address increased risk for cognitive difficulties and occupational dissatisfaction at outcome. CT lesion may independently influence outcomes.

Objective To examine the effect of state youth traumatic brain injury (TBI) legislation on pediatric emergency department (ED) utilization for sports and recreation-related mild TBIs (mTBIs). Participants ED visits by children ages 5 to 18 years between 2006 and 2014 in the Pediatric Health Information System database (N = 452 900). Design Retrospective analysis. Main measures Rates of ED visits, and injury comparison groups (mTBI, moderate to severe TBI, minor head injury, and long bone fracture). Results Of the 452 900 ED visits, 123 192 (27.2%) were for mTBI, along with visits for moderate to severe TBIs (n = 5190), minor head injuries (n = 54 566), and long bone fractures (n = 269 952). ED visits for mTBIs were more common among males (67.5%), children ages 10-14 years (42.1%), and the privately insured (50.6%). The proportion of mTBI ED visits increased significantly, particularly from 5 years prelegislation to immediately postlegislation (57.8 to 94.8 mTBI visits per 10 000 ED visits). A similar trend was observed for minor head injuries; however, no significant changes were observed for moderate to severe TBIs and long bone fractures. Conclusion Pediatric ED utilization trends for the injury comparison groups differed from each other, and from pre- and post-TBI legislation. Further research assessing effects of TBI legislation on healthcare utilization is warranted.

Objective Posttraumatic stress disorder (PTSD), history of mild traumatic brain injury (mTBI), and executive function (EF) difficulties are prevalent in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans. We evaluated the contributions of injury variables, lower-order cognitive component processes (processing speed/attention), and psychological symptoms to EF. Participants OEF/OIF Veterans (N = 65) with PTSD and history of mTBI were administered neuropsychological tests of EF and self-report assessments of PTSD and depression. Results Those impaired on one or more EF measures had higher PTSD and depression symptoms and lower processing speed/attention performance than those with intact performance on all EF measures. Across participants, poorer attention/processing speed performance and higher psychological symptoms were associated with worse performance on specific aspects of EF (eg, inhibition and switching) even after accounting for injury variables. Although direct relationships between EF and injury variables were equivocal, there was an interaction between measures of injury burden and processing speed/attention such that those with greater injury burden exhibited significant and positive relationships between processing speed/attention and inhibition/switching, whereas those with lower injury burden did not. Conclusion Psychological symptoms as well as lower-order component processes of EF (attention and processing speed) contribute significantly to executive dysfunction in OEF/OIF Veterans with PTSD and history of mTBI. However, there may be equivocal relationships between injury variables and EF that warrant further study. Results provide groundwork for more fully understanding cognitive symptoms in OEF/OIF Veterans with PTSD and history of mTBI that can inform psychological and cognitive interventions in this population.

OBJECTIVES To examine whether the association between posttraumatic stress disorder (PTSD) and injury perceptions (ie, consequences, emotional representations, and coherence) differs for Veterans with mild traumatic brain injury (mTBI) compared with Veterans with non-TBI (ie, orthopedic). PARTICIPANTS Eighty Veterans injured during post-9/11 deployments. DESIGN Observational, 2×2 factorial design. MAIN MEASURES Injury histories ascertained using the Ohio State University TBI-Identification Method and Deployment Injury Questionnaire; Injury Perception Questionnaire-Revised (injury perceptions); Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (PTSD diagnosis); and PTSD Symptom Checklist-Civilian Version (PTSD symptoms). RESULTS The association between PTSD diagnosis and injury perceptions did not differ between Veterans with mTBI and those with non-TBIs, adjusting for age, subjective pain, and depressive symptoms. PTSD symptom severity was significantly associated with injury consequences (P < .0001) and emotional representations (P < .0001), irrespective of injury type (mTBI vs non-TBI). Only injury coherence was associated with a significant interaction between PTSD symptom severity and mTBI (P = .04). CONCLUSION PTSD symptom severity influences perceptions about mTBI and non-TBIs sustained during deployment. Altering injury perceptions may be an important treatment target for Veterans with co-occurring PTSD and deployment-related injuries.

Objectives To investigate sleep and its predictors in preschoolers with mild traumatic brain injury (mTBI). Participants and procedure The sample included 225 children, aged 18 to 60 months, divided into 3 groups: children with accidental mTBI (n = 85), children with orthopedic injury (n = 58), and typically developing children (n = 82). Retrospective reports of preinjury sleep and family functioning were obtained as part of a baseline assessment at the time of recruitment. Parental ratings of sleep problems were collected 6 months postinjury on the full sample, and actigraphy data were collected on a subset of children. Demographic, preinjury, and periinjury factors were examined as potential predictors of sleep outcomes. Results No group differences were found in ratings of sleep problems or for nighttime sleep duration and sleep efficiency, as measured by actigraphy. Besides, preexisting sleep disturbances and brain injury resulting in alteration of consciousness were identified as predictors of poorer sleep in the mTBI group. Conclusion Although mTBI did not result in group-level sleep disturbances 6 months postinjury, the findings suggest that premorbid and injury-related factors place some children at risk for poorer sleep after mTBI. These factors should be documented so clinicians can intervene early.

OBJECTIVE: Using advanced shape analysis derived from volumetric MRI, to assess interactions of subcortical structure with subjective symptom reporting associated with mild TBI (mTBI). PARTICIPANTS: Seventy-six cognitively symptomatic individuals with mTBI and 59 service members sustaining only orthopedic injury. DESIGN: Descriptive cross-sectional study. MAIN MEASURES: Self-report symptom measures included the Post-Traumatic Stress Disorder Checklist-Military (PCL-M), Neurobehavioral Symptom Inventory (NSI), and Symptom Checklist-90-Revised (SCL-90-R). High-dimensional measures of shape characteristics were generated from volumetric MRI for seven subcortical structures in addition to standard volume measures. RESULTS: Several significant interactions between group status and symptom measures were observed across the various shape measures. These interactions were revealed in the right thalamus and globus pallidus for each of the shape measures, indicating differences in structure thickness and expansion/contraction for these regions. No relationships with volume were observed. CONCLUSION: Results provide evidence for the sensitivity of shape measures in differentiating symptomatic mTBI individuals from controls, while volumetric measures did not exhibit this same sensitivity. Disruptions to thalamic nuclei identified here highlight the role of the thalamus in the spectrum of symptoms associated with mTBI. Additional work is needed to prospectively, and longitudinally, assess these measures along with cognitive performance and advanced multimodal imaging methods to extend the utility of shape analysis in relation to functional outcomes in this population.

OBJECTIVES:Examine the effects of posttraumatic amnesia (PTA) duration on neuropsychological and global recovery from 1 to 6 months after complicated mild traumatic brain injury (cmTBI). PARTICIPANTS:A total of 330 persons with cmTBI defined as Glasgow Coma Scale score of 13 to 15 in emergency department, with well-defined abnormalities on neuroimaging. METHODS:Enrollment within 24 hours of injury with follow-up at 1, 3, and 6 months. MEASURES:Glasgow Outcome Scale-Extended, California Verbal Learning Test II, and Controlled Oral Word Association Test. Duration of PTA was retrospectively measured with structured interview at 30 days postinjury. RESULTS:Despite all having a Glasgow Coma Scale Score of 13 to 15, a quarter of the sample had a PTA duration of greater than 7 days; half had PTA duration of 1 of 7 days. Both cognitive performance and Extended Glasgow Outcome Scale outcomes were strongly associated with time since injury and PTA duration, with those with PTA duration of greater than 1 week showing residual moderate disability at 6-month assessment. CONCLUSIONS:Findings reinforce importance of careful measurement of duration of PTA to refine outcome prediction and allocation of resources to those with cmTBI. Future research would benefit from standardization in computed tomographic criteria and use of severity indices beyond Glasgow Coma Scale to characterize cmTBI.

BACKGROUND: There is a paucity of evidence-based interventions for mild traumatic brain injury (mTBI). OBJECTIVE: To evaluate the feasibility and potential benefits of an interactive, Web-based intervention for mTBI. SETTING: Emergency department and outpatient settings. PARTICIPANTS: Of the 21 adolescents aged 11 to 18 years with mTBI recruited from November 2013 to June 2014 within 96 hours of injury, 13 completed the program. DESIGN: Prospective, open pilot. INTERVENTION: The Web-based Self-Management Activity-restriction and Relaxation Training (SMART) program incorporates anticipatory guidance and psychoeducation, self-management and pacing of cognitive and physical activities, and cognitive-behavioral principles for early management of mTBI in adolescents. MAIN MEASURES: Primary: Daily Post-Concussion Symptom Scale (PCSS). Secondary: Daily self-reported ratings of activities and satisfaction survey. RESULTS: Average time from injury to baseline testing was 14.0 (standard deviation = 16.7) hours. Baseline PCSS was 23.6 (range: 0-46), and daily activity was 1.8 (range: 0-5.75) hours. Repeated-measures, generalized linear mixed-effects model analysis demonstrated a significant decrease of PCSS at a rate of 2.0 points per day that stabilized after about 2 weeks. Daily activities, screen time, and physical activity increased by 0.06 (standard error [SE] = 0.04, P =.09), 0.04 (SE = 0.02, P =.15), and 0.03 (SE = 0.02, P =.05) hours per day, respectively, over the 4-week follow-up. Satisfaction was rated highly by parents and youth. CONCLUSIONS: Self-Management Activity-restriction and Relaxation Training is feasible and reported to be helpful and enjoyable by participants. Future research will need to determine the comparative benefits of SMART and ideal target population. Language: en

To present a heuristic model of a symptom attribution and classification algorithm (SACA) for mild traumatic brain injury (mTBI).VA Polytrauma sites.422 Veterans.Cross-sectional.SACA, Comprehensive TBI Evaluation (CTBIE), Structured TBI Diagnostic Interview, Minnesota Multiphasic Personality Inventory (MMPI-2-RF), Letter Memory Test, Validity-10.SACA and CTBIE diagnoses differ significantly (P.01). The CTBIE, compared with SACA, attributes 16% to 500% more symptoms to mTBI, behavioral health (BH), mTBI + BH and symptom resolution. Altering SACA criteria indicate that (1) CTBIE determination of cognitive impairment yields 27% to 110% more mTBI, mTBI + BH and symptom resolution diagnoses, (2) ignoring timing of symptom onset yields 32% to 76% more mTBI, mTBI + BH and Other Condition diagnoses, (3) Proportion of sample having questionably valid profiles using structured TBI diagnostic interview and MMPI-2-RF and Letter Memory Test is 26% whereas with CTBIE item number 23 and Validity-10 is 6% to 26%, (4) MMPI-2-RF F-scale is the only measure identifying Veterans with posttraumatic amnesia for more than 24 hours as having questionably valid profiles.Symptom attribution-based diagnoses differ when using status quo versus the SACA. The MMPI-2-RF F-scale, compared with the Validity-10 and Letter Memory Test, may be more precise in identifying questionably valid profiles for mTBI + BH. The SACA provides a framework to inform clinical practice, resource allocation, and future research.

BACKGROUND: Blast-related mild traumatic brain injury (blast mTBI) is a signature wound of recent US military conflicts in the Middle East, but the relatedness of postconcussive symptoms (PCS) to the blast mTBI is unclear, and longitudinal symptom data are sparse. OBJECTIVES: To characterize postdeployment symptom levels and trajectories and to determine relationship to blast mTBI. METHODS: A total of 216 participants within 2 years of blast exposure during deployment underwent structured interviews or algorithmic questionnaires for blast mTBI. Detailed symptom inventories for PCS, pain, posttraumatic stress disorder, and depression were taken serially at enrollment, 6 months, and 12 months later. Repeated-measure analysis of variance models were built. RESULTS: Up to 50% of participants had at least 1 high-grade blast mTBI (with posttraumatic amnesia), 31% had low-grade only, and 19% had neither. Within the entire cohort, all 4 composite symptom scores started high and stayed unchanged. Between blast mTBI groups, symptom scores differed at every time point with some evidence of convergence over time. The PCS groups, different by definition to start, diverged further over time with those initially more symptomatic becoming relatively more so. CONCLUSIONS: History of blast mTBI accompanied by posttraumatic amnesia is associated with greater nonspecific symptoms after deployment, and prognosis for improvement when symptoms are prominent is poor. Language: en

OBJECTIVE: To compare cognitive rehabilitation (CR) interventions for mild traumatic brain injury (mTBI) with standard of care management, including psychoeducation and medical care for noncognitive symptoms. SETTING: Military medical center. PARTICIPANTS: A total of 126 service members who received mTBI from 3 to 24 months before baseline evaluation and reported ongoing cognitive difficulties. INTERVENTIONS: Randomized clinical trial with treatment outcomes assessed at baseline, 3-week, 6-week, 12-week, and 18-week follow-ups. Participants were randomly assigned to one of four 6-week treatment arms: (1) psychoeducation, (2) computer-based CR, (3) therapist-directed manualized CR, and (4) integrated therapist-directed CR combined with cognitive-behavioral psychotherapy (CBT). Treatment dosage was constant (10 h/wk) for intervention arms 2 to 4. MEASURES: Paced Auditory Serial Addition Test (PASAT); Symptom Checklist-90 Revised (SCL-90-R); Key Behaviors Change Inventory (KBCI). RESULTS: No differences were noted between treatment arms on demographics, injury-related characteristics, or psychiatric comorbidity apart from education, with participants assigned to the computer arm having less education. Using mixed-model analysis of variance, all 4 treatment groups showed a significant improvement over time on the 3 primary outcome measures. Treatment groups showed equivalent improvement on the PASAT. The therapist-directed CR and integrated CR treatment groups had better KBCI outcomes compared with the psychoeducation group. Improvements on primary outcome measures during treatment were maintained at follow-up with no differences among arms. CONCLUSIONS: Both therapist-directed CR and integrated CR with CBT reduced functional cognitive symptoms in service members after mTBI beyond psychoeducation and medical management alone. Language: en

OBJECTIVE: To examine the value of posttraumatic headaches in predicting return to work (RTW) in patients with mild traumatic brain injury (MTBI). SETTING AND PARTICIPANTS: A total of 109 participants recruited from an outpatient head injury rehabilitation center, British Columbia, Canada. DESIGN: Logistic regression analyses of secondary data. MAIN MEASURE: The Numerical Pain Rating Scale (NPRS), measure of headache intensity. Nine resulting NPRS scores were used to predict successful versus unsuccessful RTW. RESULTS: The largest effect size [odds ratio Exp(B)] value of 0.474] indicated that the odds of returning to work successfully are more than cut in half for each unit increase in NPRS rating. CONCLUSION: To the author's knowledge, this is the first study of the impact of headache intensity on RTW for patients with MTBI. Posttraumatic headache severity after MTBI should be taken into account when developing models to predict RTW for this population. Headache intensity may act as a confounding variable for at least some injury characteristics (eg, cognitive functioning) and may add to the inconsistencies in the TBI and MTBI literature. RESULTS may be utilized to guide rehabilitation efforts in planning RTW for patients with MTBI. Language: en

OBJECTIVE: To describe the methodology and report primary outcomes of an exploratory randomized clinical trial (RCT) of aerobic training for management of prolonged symptoms after a mild traumatic brain injury (mTBI) in adolescents. SETTING: Outpatient research setting. PARTICIPANTS: Thirty adolescents between the ages of 12 and 17 years who sustained a mTBI and had between 4 and 16 weeks of persistent symptoms. DESIGN: Partially blinded, pilot RCT of subsymptom exacerbation aerobic training compared with a full-body stretching program. MAIN MEASURES: The primary outcome was postinjury symptom improvement assessed by the adolescent's self-reported Post-Concussion Symptom Inventory (PCSI) repeated for at least 6 weeks of the intervention. Parent-reported PCSI and adherence are also described. RESULTS: Twenty-two percent of eligible participants enrolled in the trial. Repeated-measures analysis of variance via mixed-models analysis demonstrated a significant group × time interaction with self-reported PCSI ratings, indicating a greater rate of improvement in the subsymptom exacerbation aerobic training group than in the full-body stretching group (F = 4.11, P =.044). Adherence to the home exercise programs was lower in the subsymptom exacerbation aerobic training group compared with the full-body stretching group (mean [SD] times per week = 4.42 [1.95] vs 5.85 [1.37], P CONCLUSION: Findings from this exploratory RCT suggest subsymptom exacerbation aerobic training is potentially beneficial for adolescents with persistent symptoms after an mTBI. These findings and other recent research support the potential benefit of active rehabilitation programs for adolescents with persistent symptoms after an mTBI. Larger replication studies are needed to verify findings and improve generalizability. Future work should focus on determining the optimal type, timing, and intensity of active rehabilitation programs and characteristics of individuals most likely to benefit. Language: en

OBJECTIVE The purpose of the study was to evaluate the efficacy of group-based compensatory cognitive training (CCT) for Operation Enduring Freedom (OEF)/Operation Iraqi Freedom(OIF)/Operation New Dawn (OND) Veterans with a history of mild traumatic brain injury. METHOD One hundred nineteen OEF/OIF/OND Veterans with history of mild traumatic brain injury participated at 3 sites, and 50 of the Veterans were randomized to CCT group, while 69 Veterans were randomized to the usual care control group. The CCT group participated in 10 weeks of CCT. Both CCT and usual care groups were assessed at baseline, 5 weeks (midway through CCT), 10 weeks (immediately following CCT), and 15 weeks (5-week follow-up) on measures of subjective cognitive complaints, use of cognitive strategies, psychological functioning, and objective cognitive performance. RESULTS Veterans who participated in CCT reported significantly fewer cognitive and memory difficulties and greater use of cognitive strategies. They also demonstrated significant improvements on neurocognitive tests of attention, learning, and executive functioning, which were 3 of the cognitive domains targeted in CCT. CONCLUSIONS Findings indicate that training in compensatory cognitive strategies facilitates behavioral change (ie, use of cognitive strategies) as well as both subjective and objective improvements in targeted cognitive domains.

To investigate the effect of sleep disturbances on functional and social outcomes after mild traumatic brain injury.Outpatient traumatic brain injury clinic in a tertiary trauma center.A total of 374 mild traumatic brain injury patients were assessed within 3 months of injury and followed up every 3 months for 1 year.Analysis of a historical cohort in a naturalistic clinical setting.At each visit, symptoms of concussion and psychological distress and indices of functional and social outcomes were measured with the Rivermead Postconcussion Questionnaire, 28-item General Health Questionnaire, and Rivermead Head Injury Follow-up Questionnaire, respectively. Changes in outcome scores over time were explored using repeated measures analysis of variance and compared between subjects with persistent (SD) and recovered (SR) sleep disturbances. Predictors of functional/social outcome were determined using linear regression.The percentages of subjects reporting sleep disturbances at each time point were 71.9%, 57.2%, 55.1%, and 53.7%, respectively. For functional and social outcomes, significant effects of time (F3,315 = 9.54; P.001), group (SD vs SR) F1,317 = 5.32; P = .022, and time X group interaction F3,315 = 4.14; P = .007 were found. Persistent sleep disturbance (P = 0.011) and higher symptom burden at 6 months postinjury (P.0001) were independent predictors of poorer outcome.Sleep disturbance, independent of psychological distress, is an important prognostic factor of functional and social outcomes after mild traumatic brain injury.

Objective: To characterize and compare the sleep-wake behavior of individuals following a mild traumatic brain injury (mTBI) with that of noninjured healthy controls. Setting: Community. Participants: Fourteen participants with a recent mTBI (M-age = 28.07; SD = 10.45; n = 10 females) and 34 noninjured controls (M-age = 23.70; SD = 7.30; n = 31 females). Design: Cross-sectional. Main Measures: Battery of subjective sleep measures and 14 days of sleep-wake monitoring via actigraphy (objective measurement) and concurrent daily sleep diary. Results: Participants who had sustained an mTBI self-reported significantly higher sleep-related impairment, poorer nightly sleep quality, and more frequently met criteria for clinical insomnia, compared with controls (d = 0.76-1.11, large effects). The only significant between-group difference on objective sleep metrics occurred on sleep timing. On average, people with a recent history of mTBI fell asleep and woke approximately 1 hour earlier than did the controls (d = 0.62-0.92, medium to large effects). Conclusion: Participants with a history of mTBI had several subjective sleep complaints but relatively few objective sleep changes with the exception of earlier sleep timing. Future research is needed to understand the clinical significance of these findings and how these symptoms can be alleviated. Interventions addressing subjective sleep complaints (eg, cognitive behavior therapy for insomnia) should be tested in this population.

OBJECTIVE: Evaluate sleep quality, its correlates, and the effect of telephone-based problem-solving treatment (PST) in active duty postdeployment service members with mild traumatic brain injury (mTBI) SETTING:: Randomized clinical trial. PARTICIPANTS: Active duty service members with combat-related mTBI. STUDY DESIGN: Education-only (EO) and PST groups (N = 178 each) received printed study materials and 12 educational brochures. The PST group additionally received up to 12 PST telephone calls addressing participant-selected issues. Outcomes were evaluated postintervention (6 months) and at 12 months. MAIN MEASURE: Pittsburgh Sleep Quality Index. RESULTS: Sleep quality was manifestly poor in both groups at baseline (Pittsburgh Sleep Quality Index = 12.5 ± 4). Overall sleep quality was significantly different between the PST and EO groups at 6 months (P =.003) but not at 12 months. Longitudinally, PST significantly improved sleep quality at 6 months (P =.001) but not over the follow-up. Low sleep quality was associated with concussion symptoms, pain, depression, and posttraumatic stress disorder at all time points (P CONCLUSIONS: Sleep disorders, common in postdeployment service members with mTBI, are strongly associated with the presence of pain, posttraumatic stress disorder, and depression. Telephone-based PST may be an effective therapeutic approach for reducing sleep disorders in this population. Research should focus on maintenance of treatment gains. Language: en

OBJECTIVE To explore the taxonomy of combat-related mild traumatic brain injury (mTBI) based on symptom patterns. PARTICIPANTS Up to 1341 military personnel who experienced a combat-related mTBI within 2 years of evaluation. MEASURES Neurobehavioral Symptom Inventory and PTSD Checklist-Civilian Version (PCL-C). RESULTS Cluster analysis revealed the following 4 subtypes: primarily psychiatric (posttraumatic stress disorder) group, a cognitive group, a mixed symptom group, and a good recovery group. The posttraumatic stress disorder cluster (21.9% of the sample) reported symptoms related to hyperarousal and dissociation/depression with few complaints related to cognition or headaches. The cognitive group (21.5% of the sample) had primarily cognitive and headache complaints with few mood symptoms. The mixed profile cluster included 18.6% of the sample and was characterized by a combination of mood complaints (hyperarousal and dissociation/depression), cognitive complaints, and headaches. The largest cluster (37.8% of the sample) had an overall low symptom profile and was labeled the "good recovery" group. CONCLUSIONS The results support a unique taxonomy for combat-related mTBI. The clinical differences among these subtypes indicate a need for unique treatment resources and programs.

CASE SCENARIO:: A middle aged man suffered a mild traumatic brain injury (MTBI) at work due to a fall. The diagnosis of MTBI was based solely on self-reported altered mental status. All neuroimaging results and neurological examination findings were negative in the acute and chronic phases. There was no other history of MTBI or neurological condition. The patient had been out of work since the injury (1 year ago) and received wage replacement benefits through a Workers' Compensation company. An attorney was assisting the patient with Workers' Compensation proceedings, settlement negotiations, and possible civil litigation. The patient had been evaluated in clinical settings by multiple doctoral and nondoctoral level healthcare providers. Upon the patient's request, all healthcare providers signed disability forms attesting to disability (50%-100%). The disability determinations were based primarily on self-report and, in some cases, were influenced by behavioral observations (eg, crying) but not by objective examination findings. The patient was held out of work for more than a year despite neuropsychological testing results showing unequivocal evidence of exaggeration and/or malingering. The patient went to a Workers' Compensation hearing and was told that for benefits to continue, the disability rating must be 100% from all providers. The patient contacted the healthcare provider(s) who provided a 50% disability rating and informed them of this. Without any further evaluation, and based purely on the phone call, written documentation was provided on the same day declaring that the patient was 100% (totally) disabled. Per standard Workers' Compensation language, the disability note also stated that the patient's complaints were consistent with his or her history of the injury. Language: en

OBJECTIVE: Previously published mild traumatic brain injury (mTBI) management guidelines provide very general recommendations to return individuals with mTBI to activity. This lack of specific guidance creates variation in military rehabilitation. The Office of the Army Surgeon General in collaboration with the Defense and Veterans Brain Injury Center, a component center of the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury, convened an expert working group to review the existing literature and propose clinical recommendations that standardize rehabilitation activity progression following mTBI. PARTICIPANTS: A Progressive Activity Working Group consisted of 11 Department of Defense representatives across all service branches, 7 Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury representatives, and 8 academic/research/civilian experts with experience assessing and treating individuals with mTBI for return to activity. An expert working group meeting included the Progressive Activity Working Group and 15 additional subject matter experts. METHODS: In February 2012, the Progressive Activity Working Group was established to determine the need and purpose of the rehabilitation recommendations. Following literature review, a table was created on the basis of the progression from the Zurich consensus statement on concussion in sport. Issues were identified for discussion with a meeting of the larger expert group during a July 2012 conference. Following development of rehabilitation guidance, the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury coordinated a similar process for military primary care providers. RESULTS: End products for rehabilitation and primary care providers include specific recommendations for return to activity after concussion. A 6-stage progression specifies activities in physical, cognitive, and balance/vestibular domains and allows for resumption of activity for those with low-level or preinjury symptom complaints. CONCLUSIONS: The clinical recommendations for progressive return to activity represent an important effort to standardize activity progression across functional domains and offer providers duty-specific activities to incorporate into intervention. Recommendations were released in January 2014. Language: en

OBJECTIVE To examine resilience as a predictor of change in self-reported fatigue after mild traumatic brain injury (MTBI). PARTICIPANTS A consecutive series of 67 patients with MTBI and 34 orthopedic controls. DESIGN Prospective longitudinal study. MAIN MEASURES Resilience Scale, Beck Depression Inventory-Second Edition, and Pain subscale from Ruff Neurobehavioral Inventory 1 month after injury and Barrow Neurological Institute Fatigue Scale 1 and 6 months after injury. RESULTS Insomnia, pain, and depressive symptoms were significantly correlated with fatigue, but even when these variables were controlled for, resilience significantly predicted the change in fatigue from 1 to 6 months after MTBI. In patients with MTBI, the correlation between resilience and fatigue strengthened during follow-up. In controls, significant associations between resilience and fatigue were not found. CONCLUSION Resilience is a significant predictor of decrease in self-reported fatigue following MTBI. Resilience seems to be a relevant factor to consider in the management of fatigue after MTBI along with the previously established associated factors (insomnia, pain, and depressive symptoms).

OBJECTIVE To determine factors affecting outcome of comprehensive outpatient rehabilitation of individuals who sustained a mild traumatic brain injury. PARTICIPANTS From a 4-year series of referrals, 49 nonconsecutive participants met criteria for mild traumatic brain injury (ie, loss of consciousness 12). SETTING Outpatient, community-based postconcussion clinic at a rehabilitation hospital. MAIN MEASURES Participants and therapy staff completed the Mayo-Portland Adaptability Inventory-Fourth Edition (MPAI-4) at the initiation and conclusion of treatment. Participants were also administered the Trail Making Test at the start of treatment. RESULTS Participants generally gave poorer adaptability ratings than staff at the beginning and discharge of treatment. Regression analyses revealed that after controlling for baseline ratings, psychiatric history was associated with worse participant-rated MPAI-4 Adjustment scores at treatment discharge, whereas better Trail Making Test Part B performance at initiation of treatment predicted better participant-rated MPAI-4 Ability at treatment discharge. CONCLUSIONS Premorbid demographic and baseline neurocognitive factors should be taken into account prior to comprehensive treatment of mild traumatic brain injury, as they can influence long-term outcomes. Adaptability ratings from both staff and participants can be useful in gaining different perspectives and assessing factors affecting recovery.

To examine factors relating to return to work (RTW) following mild traumatic brain injury (mTBI).One hundred and nine patients (Age: M = 37.4 years, SD = 13.2; 52.3% women) who sustained an mTBI.Inception cohort design with questionnaires and neuropsychological testing completed approximately 3 to 4 weeks postinjury.Emergency Department of Tampere University Hospital, Finland.Self-report (postconcussion symptoms, depression, fatigue, and general health) and neurocognitive measures (attention and memory).The cumulative RTW rates were as follows: 1 week = 46.8%, 2 weeks = 59.6%, 3 weeks = 67.0%, 4 weeks = 70.6%, 2 months = 91.7%, and 1 year = 97.2%. Four variables were significant predictors of the number of days to RTW: age, multiple bodily injuries, intracranial abnormality at the day of injury, and fatigue ratings (all P.001). The largest amount of variance accounted for by these variables in the prediction of RTW was at 30 days following injury (P.001, R = 0.504). Participants who returned to work fewer than 30 days after injury (n = 82, 75.2%) versus more than 30 days (n = 27, 24.8%) did not differ on demographic or neuropsychological variables.The vast majority of this cohort returned to work within 2 months. Predictors of slower RTW included age, multiple bodily injuries, intracranial abnormality at the day of injury, and fatigue.

Objective: To identify preinjury coping profiles among adults with uncomplicated mild traumatic brain injury (mTBI) and complicated mTBI and to determine whether preinjury coping profiles contribute to the prediction of emotional functioning and quality of life (QOL) 3 months post-mTBI. Participants: One hundred eightyseven persons with medically documented mTBI (uncomplicated mTBI, n = 89; complicated mTBI, n = 98) were recruited from the emergency center of a level I trauma center and followed in community 3 months post-mTBI. Measures: The Ways of Coping Questionnaire was administered within 2 weeks of injury. Cluster analysis was used to group participants on basis of their preinjury use of problem-focused and avoidant coping strategies. The Brief Symptom Inventory and the 36-item Short-Form Health Survey were administered 3 months postinjury. Results: Cluster analysis distinguished 3 distinct preinjury coping profiles that were differentially associated with outcomes. Participants who used avoidant coping showed the worse emotional functioning and QOL outcomes, although this cluster also reported high usage of problem-focused strategies. Preinjury coping profiles explained a significant proportion of the variance in depression, anxiety, and mental health QOL at 3 months postinjury beyond that accounted for by demographic characteristics and mTBI severity. Conclusions: Cluster analysis holds practical value in illustrating the pattern of coping strategies used by person with uncomplicated and complicated mTBI. It appears worthwhile to address coping in future trials of interventions that are aimed at improving emotional functioning

PURPOSE To examine whether patients with mild traumatic brain injury (mTBI) receiving text messaging-based education and behavioral support had fewer and less severe postconcussive symptoms than those not receiving text-message support. Our secondary objective was to determine the feasibility of using text messaging to assess daily symptoms and provide support to patients with mTBI. DESIGN Randomized controlled trial with 14-day follow-up. PARTICIPANTS Convenience sample of 43 adult emergency department patients with mTBI. INTERVENTION Fourteen days of timed SMS (short-message service) symptom assessments (9 AM: headaches; 1 PM: difficulty concentrating; 5 PM: irritability or anxiety) with self-care support messages. MAIN MEASURES SMS symptom reports, Rivermead Postconcussion Symptoms Questionnaire. RESULTS Compared with the control group, intervention participants trended to lower odds of reporting headaches (odds ratio [OR] = 0.38; 95% confidence interval [CI]: 0.07-1.99), concentration difficulty (OR = 0.32; 95% CI: 0.04-2.24), and irritability or anxiety (OR = 0.33; 95% CI: 0.05-2.35). There were also trends of lower mean scores for headaches (0.99 vs 1.19; P = .5), difficulty concentrating (0.88 vs 1.23; P = .2), and irritability/anxiety (1.00 vs 1.62; P = .06). There were high response rate to SMS symptom assessments and high satisfaction with the intervention. CONCLUSION Those receiving the text messaging-based education and support had fewer and less severe postconcussive symptoms than the controls but none of the differences reached statistical significance. Further evaluation of more robust mobile interventions and larger sample of participants are still needed.

OBJECTIVE:: To examine the influence of anxiety sensitivity (AS) and alexithymia as potential mediators for the development of psychological distress and postconcussion syndrome after mild traumatic brain injury (mTBI). PARTICIPANTS:: Sixty-one patients with mTBI assessed at a mean of 2.38 weeks after injury and demographically matched healthy controls (n = 61). MEASURES:: Twenty-item Toronto Alexithymia Scale, Anxiety Sensitivity Index, State-Trait Anxiety Inventory, and Rivermead Post Concussion Questionnaire. RESULTS:: The mTBI group reported significantly higher levels of AS, alexithymia, psychological distress, and postconcussion (PC) symptom scores than controls. High AS and alexithymia in the mTBI group were associated with a greater number of PC symptoms and higher levels of psychological distress than patients scoring low on these measures and controls. In the mTBI group, a combination of AS and low mood explained 52.6% of the variance in PC symptom reporting. A combination of trait-anxiety, alexithymia, and PC symptoms explained 77.2% of the variance in levels of mood. CONCLUSION:: A combination of low mood and high AS may act as a psychological diathesis for the development of persisting PC symptoms. Early identification could provide a focus for early intervention to prevent the development of postconcussion syndrome after mTBI. Language: en

OBJECTIVES:: As provenance of postconcussion symptoms after mild traumatic brain injury (mTBI) is controversial, with similar rates found in other populations, we aimed to identify postconcussion symptoms specific to mTBI compared with controls. We also compared differences between complicated and uncomplicated mTBIs. SETTING:: Hospital emergency department. PARTICIPANTS:: Adult individuals (34 individuals with complicated mTBI, 76 individuals with uncomplicated mTBI, and 47 orthopedic controls) who sought care in the emergency department and were consecutively recruited by post at 2 weeks postinjury. MAIN MEASURES:: Rivermead Postconcussion Symptom Questionnaire. Preinjury factors were used as covariates. RESULTS:: Compared with orthopedic controls, complicated mTBI group reported greater severity of headaches, dizziness, and nausea, as well as concentration difficulties, suggesting that these are neurogenic. Severity of other symptoms measured on the Rivermead Postconcussion Symptom Questionnaire was not significantly different between these groups, suggesting that these are psychogenic. Differences were evident between the 2 mTBI samples on the items of dizziness, nausea, fatigue, sleep disturbance, and concentration difficulties. CONCLUSIONS:: Neurogenic and psychogenic postconcussion symptoms were identified at the acute-phase postinjury. Findings suggest that treating persons with mTBI as a homogenous sample is not prudent. This should inform prognostic models and follow-up support offered after leaving the emergency department. Language: en

OBJECTIVE:: To evaluate the effectiveness of the mindfulness-based stress reduction (MBSR) program tailored to individuals with mild traumatic brain injury (mTBI). DESIGN:: A convenience sample recruited from clinical referrals over a 2-year period completed outcome measures pre- and posttreatment intervention. SETTING:: Post-acute brain injury rehabilitation center within a suburban medical facility. PARTICIPANTS:: Twenty-two individuals with mTBI and a time postinjury more than 7 months. Eleven participants were men and 11 were women, ranging in age from 18 to 62 years. INTERVENTION:: A 10-week group (with weekly 2-hour sessions) modeled after the MBSR program of Kabat-Zinn, but with modifications designed to facilitate implementation in a population of individuals with brain injury. (The treatment involved enhancement of attentional skills, in addition to increased awareness of internal and external experiences associated with the perspective change of acceptance and nonjudgmental attitude regarding those experiences). MAIN OUTCOME MEASURES:: Perceived Quality of Life Scale, Perceived Self-Efficacy Scale, and the Neurobehavioral Symptom Inventory. Secondary measures included neuropsychological tests, a self-report problem-solving inventory, and a self-report measure of mindfulness. RESULTS:: Clinically meaningful improvements were noted on measures of quality of life (Cohen d = 0.43) and perceived self-efficacy (Cohen d = 0.50) with smaller but still significant effects on measures of central executive aspects of working memory and regulation of attention. CONCLUSION:: The MBSR program can be adapted for participants with mTBI. Improved performance on measures associated with improved quality of life and self-efficacy may be related to treatment directed at improving awareness and acceptance, thereby minimizing the catastrophic assessment of symptoms associated with mTBI and chronic disability. Additional research on the comparative effectiveness of the MBSR program for people with mTBI is warranted. Language: en

Objective To examine the relation between diffusion tensor imaging (DTI) of the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI). Participants Sixty patients with MTBI and 34 patients with orthopedic/soft-tissue injuries (Trauma Controls) prospectively enrolled from consecutive admissions to a level 1 trauma center. Procedure Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury. Participants also completed a postconcussion symptom checklist. The MTBI group was divided into 2 subgroups based on the International Classification of Diseases, Tenth Revision symptom criteria for postconcussion disorder (PCD): PCD Present (n = 21), PCD Absent (n = 39). Main outcome measures Measures of fractional anisotropy and mean diffusivity for the genu, body, and splenium of the corpus callosum. Participants also completed the British Columbia Post-Concussion Symptom Inventory. Results The MTBI group reported more postconcussion symptoms than the trauma controls. There were no significant differences between MTBI and trauma control groups on all DTI measures. In the MTBI sample, there were no significant differences on all DTI measures between those who did and did not meet the International Classification of Diseases, Tenth Revision research criteria for postconcussion disorder. Conclusions These data do not support an association between white matter integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI.

OBJECTIVE:: To investigate the factor structure and internal consistency of the Brief COPE, adapted for use with adults with mild traumatic brain injury (MTBI). DESIGN:: Prospective cohort study. SETTING:: Hospital based emergency department and concussionclinic. PARTICIPANTS:: A total of 147 adults meeting diagnostic criteria for MTBI. MAIN MEASURE:: Brief COPE. ANALYSES:: The previously reported 9-factor structure of the Brief COPE wastested by using confirmatory factor analysis (CFA) and then exploratory factor analysis (EFA). The Cronbach α was computed for both the original subscales and those derived from EFA. RESULTS:: The CFA provided a less than satisfactory fit for the 9-factor model. While the EFA solution was very similar to that ofthe original scale, the reliability of some derived subscales was low. Further analyses identified improved internalconsistency with a 3-factor model reflecting approach, avoidance, and help-seeking coping styles. CONCLUSIONS:: The Brief COPE has satisfactory psychometric properties for use in MTBI but may be morereliably and meaningfully interpreted using 3 dimensions/subscales rather than 9. Language: en

OBJECTIVE Coated-platelets are procoagulant platelets that are elevated in patients with large-vessel ischemic stroke and are associated with stroke recurrence. Because of recent reports showing an increased risk for stroke following traumatic brain injury (TBI), we undertook a pilot study to investigate coated-platelet synthesis in veterans with TBI. DESIGN Cross-sectional study. PARTICIPANTS Forty patients with a diagnosis of mild TBI (mTBI) and 40 controls without a history of TBI and matched for age, gender, and ethnicity/race were enrolled in the study. MAIN MEASURE Coated-platelet levels were determined in patients with mTBI and controls. The time period since most recent injury ranged from 6 months to 9 years. RESULTS Coated-platelet levels were significantly higher for mTBI patients than for controls (mean ± SD = 52.0% ± 14.0% vs 35.4% ± 13.0%; P < .0001). No relationship between these levels and the length of time since the last injury was found (P = .5). CONCLUSIONS Coated-platelet levels are markedly and persistently elevated in individuals with mTBI. These data suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a TBI.

Background: Both the Departments of Defense and Veterans Health Administration have developed and implemented screening procedures for identification of possible deployment-related traumatic brain injury (TBI). Objective: To review population-based screening procedures for TBI, particularly mild TBIs, and discuss potential harms/costs versus benefits of such TBI screening. Methods: The principles commonly used in population-based screening for various medical conditions are identified. These principles are applied to screening for TBI. The potential harms and costs are compared with potential benefits of screening for mild TBI. Results: The core conditions essential for beneficial medical screening—progressive disease, symptoms related to the identified disease, suitable tests or examinations for accurate diagnosis, and accepted and effective treatment—are not present within the context of TBI screening. Potential harms/costs outweigh any potential benefits of population-based screening for TBI. Conclusion: On the basis of generally accepted medical screening principles and assumptions, population screening for mild TBI is unnecessary at best and potentially harmful at worst. Because nonspecific, postconcussion-like symptoms can be effectively treated in a symptom-specific manner, tying them to concussion through a screening and evaluation process is wasteful and potentially harmful.

To examine the influence of depression on postconcussion symptom reporting in patients following mild traumatic brain injury (MTBI).Sixty patients referred to a specialty clinic following MTBI, 58 outpatients with Structured Clinical Interview for DSM-diagnosed depression, and 72 healthy community control participants.Participants with MTBI were divided into 2 subgroups on the basis of self-reported symptoms of depression (23 MTBI-depressed, 37 MTBI-not depressed). All participants completed a postconcussion symptom questionnaire.British Columbia Post-concussion Symptom Inventory.There were significant differences in total reported postconcussion symptoms among all 4 groups (all P.002; Cohen's d = 0.68-3.24, large to very large effect sizes; MTBI-depresseddepressed outpatientsMTBI-no depressionhealthy controls). There were significant differences in the number of symptoms endorsed (P.05), with the highest number of symptoms endorsed by the MTBI-depressed group, followed by depressed outpatients, MTBI-no depression, and healthy controls.Patients who experience MTBIs and who have a postinjury recovery course complicated by significant depression report more postconcussion symptoms, and more severe symptoms, than (a) outpatients with depression, and (b) patients with MTBIs who do not have significant symptoms of depression.

OBJECTIVE: To investigate the utility of a brief emergency department (ED) bedside screen for the prediction of postconcussive symptoms at 3 months following mild traumatic brain injury (MTBI). PARTICIPANTS: One hundred patients with MTBI (78% men; mean age = 33.6 years); 2 control groups (each n = 100), a "minor nonhead injury" group (77% men; mean age = 32.2 years) and an "uninjured ED visitor" group (78% men; mean age = 33.6 years). MAIN MEASURES: Brief measures of neuropsychological functioning, acute pain, and postural stability were collected in the ED; telephone follow-up at 3 months using the Rivermead Post-Concussion Symptoms Questionnaire was undertaken. RESULTS: Neuropsychological deficits, acute pain, and postural instability in the ED were significantly associated with postconcussive symptoms at 3-month follow-up. A regression formula using 3 easily obtainable measures obtained during acute stage of injury-immediate and delayed memory for 5 words and a visual analog scale score of acute headache-provided 80% sensitivity and 76% specificity for the prediction of clinically significant symptoms at 3 months postinjury. CONCLUSION: A small combination of variables assessable in the ED may predict MTBI patients likely to experience persistent postconcussive symptoms.

PURPOSE: To examine the extent to which children and adolescents with a mild traumatic brain injury (MTBI) comply with the activity restrictions received upon discharge from a pediatric trauma center. PARTICIPANTS: Thirty-four children with MTBI (aged 8-16 years) and 34 control children matched for age, sex, and premorbid level of physical activity. MAIN MEASURE: Activity diary documenting the exact level of activity during 3 consecutive days during the 1st, 4th, and 12th week post-MTBI (corresponding time intervals for controls) and the Physical Activity Questionnaire. RESULTS: Fifteen pairs of children (MTBI + control) completed the diaries for all 3 assessment times (77% participation rate among consecutive admissions and 44% compliance rate with diary completion). Although some children engaged in activities before the end of the 4-week restriction period, the majority of the children followed the recommendations they received. Children with MTBI maintained a lower level of energy expenditure at the 1- and 4-week evaluations than did the noninjured children, but not at the 12-week evaluation. CONCLUSION: Children with MTBI usually comply with the activity restrictions they receive upon discharge from the hospital. Language: en

OBJECTIVE: To determine whether childhood mild traumatic brain injury (MTBI) is associated with behavioral problems in adolescence. PARTICIPANTS: Children from a longitudinal birth cohort (initial N = 1265) were assigned to 1 of 3 groups: (1) inpatient group (n = 19) comprised children admitted to hospital for MTBI before age 5 years; (2) outpatient group (n = 57), children with any incidence of MTBI before age 5 seen by a general practitioner or at an accident and emergency department and sent home; (3) reference control group (n = 839). OUTCOME MEASURES: Maternal and self-report regarding attention deficit/hyperactivity disorder, conduct disorder, anxiety disorder, mood disorder, and alcohol or illicit substance abuse/dependence obtained using Diagnostic and Statistical Manual of Mental Disorders (Third Edition Revised) criteria. RESULTS: At age 14 to 16 years, children who had been hospitalized for MTBI during preschool years were significantly more likely to show symptoms of attention deficit/hyperactivity disorder (odds ratio = 4.2), conduct disorder/oppositional defiant disorder (odds ratio = 6.2), substance abuse (odds ratio = 3.6), and mood disorder (odds ratio = 3.1) but not anxiety disorder. CONCLUSIONS: Preschool MTBI is associated with persistent negative effects on psychosocial development. These continuing problems are consistent with the view that preschool years represent a period of particular vulnerability following MTBI. Language: en

Background: Mild traumatic brain injury (mTBI) without frank neurological disturbance has been linked to persistent physical, cognitive, and affective disturbances in some cases. The cognitive sequelae of this syndrome represent the most frequently studied symptoms, yet the legacy of such injuries on communicative functions remains largely undetermined. Methods: A detailed language profile of a 19-year-old woman, 1 year 10 months following mTBI is compared with a matched normative cohort of 10 participants with nonneurological impairment. Results: Deficits in attention, lexical access, complex lexical-semantic manipulation, response monitoring, and organization were revealed as a consequence of mTBI. Conclusions: This profile provides support for hypotheses pertaining to neuronal fallout mechanisms within the frontal lobes as a consequence of mild neurological insult.

Mild traumatic brain injuries (MTBIs) are of increasing concern in both the military and civilian populations as the potential long-term effects and costs of such injuries are being further recognized. Injuries from conflicts in Afghanistan and Iraq have increased public awareness and concern for TBI. The Proponency Office for Rehabilitation and Reintegration, Office of the Surgeon General, US Army tasked a team of physical and occupational therapists to assemble evidence-informed guidelines for assessment and intervention specific to MTBI. Given the paucity of specific guidelines for physical therapy related to MTBI, we focused on literature that dealt with the specific problem area or complaint of the Service member following MTBI. Recommendations, characterized as practice standards or practice options based on strength of evidence, are provided relative to patient/client education, activity intolerance, vestibular dysfunction, high-level balance dysfunction, posttraumatic headache, temporomandibular disorder, attention and dual-task performance deficits, and participation in exercise. While highlighting the need for additional research, this work can be considered a starting point and impetus for the development of evidence-based practice in physical therapy for our deserving Service members.

BACKGROUND: A vast majority of traumatic brain injuries sustained by military personnel are mild in severity. In 2008, the United States Department of Defense officially mandated a screening program designed to identify deployment-related mild traumatic brain injuries and associated residual symptoms. OBJECTIVE: This article reviews this screening program, illustrates the clinical and methodological challenges associated with screening, and makes recommendations for improving the process of screening for mild traumatic brain injuries and related symptoms. Language: en

OBJECTIVE: To determine whether screening for a blast mechanism of concussion identifies individuals at higher risk of persistent postconcussive symptoms (PCS). SETTING: United States Army post. PARTICIPANTS: 3952 US Army infantry soldiers were administered anonymous surveys 3 to 6 months after returning from a yearlong deployment to Iraq. MAIN OUTCOME MEASURES: Self-reported concussion (defined as an injury that resulted in being "dazed, confused, or 'seeing stars'"; "not remembering the injury"; or "losing consciousness [knocked out]): Patient Health Questionnaire 15-item scale for physical symptoms and PCS; Posttraumatic Stress Disorder Checklist; and Patient Health Questionnaire depression module. RESULTS: Of the 587 soldiers (14.9% of the total sample) who met criteria for concussion, 201 (34.2%) reported loss of consciousness, and 373 (63.5%) reported only an alteration of consciousness without loss of consciousness; 424 (72.2%) reported a blast mechanism, and 150 (25.6%) reported a nonblast mechanism. Among soldiers who lost consciousness, blast mechanism was significantly associated with headaches and tinnitus 3 to 6 months postdeployment compared with a nonblast mechanism. However, among the larger group of soldiers reporting concussions without loss of consciousness, blast was not associated with adverse health outcomes. CONCLUSIONS: Blast mechanism of concussion was inconsistently associated with PCS, depending on the definition of concussion utilized. A self-reported history of blast mechanism was not associated with persistent PCS for the majority of US soldiers with concussions. Language: en

OBJECTIVE: To evaluate the sensitivity of three recently developed questionnaires to mild traumatic brain injury (MTBI)-related effects. DESIGN: Comparison of an MTBI group, within 3 weeks of injury, to a normal control group. SETTING: Outpatient rehabilitation clinic. SUBJECTS: 120 MTBI patients and 120 age, education, sex, and preinjury socioeconomic status-matched normal control subjects. MAIN OUTCOME MEASURES: The Problem Checklist (PCL) from the New York Head Injury Family Interview to assess MTBI symptoms, the Short Form-36 Health Survey (SF-36) to assess functional burden associated with health problems, and the Community Integration Questionnaire (CIQ) to assess home, social, and productive activities. RESULTS: Patients' self-ratings on the PCL and SF-36, but not the CIQ, were generally worse than those of the normal controls. The largest differences were obtained on SF-36 measures that appear to assess musculoskeletal injury effects. CONCLUSIONS: The PCL and SF-36 show promise as sensitive measures of MTBI-related effects. The SF-36 may be particularly useful in evaluating associated musculoskeletal injuries, which might otherwise be overlooked by MTBI health care providers. Language: en

OBJECTIVE To report preliminary empirical data on a novel, developmentally appropriate, observational postconcussive symptoms inventory for infants, toddlers, and preschoolers. SETTING Emergency departments of 2 tertiary, urban pediatric hospitals. PARTICIPANTS Ninety-eight children (0-8 years of age; mean age at injury = 33.00, SD = 24.7 months) with mild traumatic brain injury (concussion) divided into younger (0-2 years) and older (3-8 years) age groups. DESIGN Observational study. MAIN MEASURE The Report of Early Childhood Traumatic Injury Observations & Symptoms (REACTIONS) documents 17 postconcussive symptoms representing observable manifestations thereof and was completed by parents in the acute (24-48 hours; n = 65), subacute (7-14 days; n = 78), and/or persistent phase (25-35 days; n = 72) post-mild traumatic brain injury. RESULTS Different patterns of postconcussive symptoms were reported by age group, with behavioral manifestations particularly salient in younger children. More children younger than 2 years had sleep and comfort-seeking symptoms at each of the 3 postinjury time points. CONCLUSION Postconcussive symptoms may manifest differently after mild traumatic brain injury sustained during early childhood. To fully understand and address their presence and evolution, developmentally sound measures such as the REACTIONS inventory are required.