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Objective: After a concussion, 1 in 3 patients report persistent symptoms and experience long-term consequences interfering with daily functioning, known as persistent concussion symptoms (PCS). Evidence suggests PCS is (partly) maintained by anxious thoughts about brain functioning, recovery, and experienced symptoms, leading to avoidance behaviors, which may prevent patients from meeting life demands. We aimed to investigate the efficacy of a newly developed intensive exposure intervention for individuals with PCS after concussion aimed to tackle avoidance behavior. Setting: Participants took part in the intervention at the Maastricht University faculty. Participants: Four participants who experienced PCS after concussion partook in the exploratory study. Participants’ age ranged between 20 and 32 (mean = 26.5, SD = 5.9) years, with an average length of time after the concussion of 9.8 months. Design: A concurrent multiple-baseline single-case design was conducted. The baseline period (A phase) length was randomly determined across participants (3, 4, 5, or 6 weeks). The exposure intervention (B phase) was conducted by psychologists over a 4-week period and consisted of 3 stages: exploration (2 sessions), active exposure (12 sessions conducted over 1 week), and 2 booster sessions. Main Measures: Participants answered daily questions on a visual analog scale related to symptom experience, satisfaction with daily functioning, and degree of avoidance of feared activities. Additional outcomes included symptom severity, catastrophizing, fear of mental activity, anxiety, depression, and societal participation. Results: Tau-U yielded significant effects (P < .05) for all participants on all measures when comparing baseline and intervention phases. The pooled standardized mean difference was high for all measures (symptom experience = 0.93, satisfaction of daily functioning = 1.86, and activity avoidance = −2.05). Conclusions: The results show efficacy of the newly developed intensive exposure treatment for PCS after concussion, which is based on the fear avoidance model. Replication in a larger heterogeneous sample is warranted and needed. [ABSTRACT FROM AUTHOR]

Objective: This study investigated influence of biological sex on postconcussive symptoms (PCS) following concussion using the Federal Interagency Traumatic Brain Injury Research (FITBIR) database. Method: All studies with publicly released data as of 4/7/21 that included both males and females, enough information to determine severity of injury consistent with concussion, a measure of PCS, and objective measures of neurocognitive functioning were used. This resulted in 6 studies with a total of 9890 participants (3206 females, 6684 males); 815 participants completed the Neurobehavioral Symptom Inventory (NSI), 471 completed the Rivermead Post-Concussion Symptoms Questionnaire (RPSQ), and 8604 completed the Sport Concussion Assessment Tool–3rd Edition (SCAT 3). Questionnaires were harmonized and the following symptom composite scores were computed: total score, somatic, cognitive, and affective. Data were analyzed using linear mixed-effects models. Results: Females endorsed higher total symptoms relative to males and that military personnel endorsed higher symptoms relative to civilians. Additionally, there was a small but significant interaction effect, such that female military personnel endorsed even higher symptoms than would be predicted by the main effects. Similar patterns were observed for somatic, cognitive, and affective symptom domains. Conclusions: Further understanding sex differences in PCS reporting is key to informing the most appropriate treatment options. Future work will need to examine whether sex differences in symptom reporting is due to sex differences in endorsement styles or genuine differences in symptom presentation, as well as the relationship between study population (e.g., military, civilian, sport) and sex on objective cognitive functioning and other functional outcomes. [ABSTRACT FROM AUTHOR]

Objective: It has been suggested that sport-related concussion (SRC) occurs more commonly on natural grass compared with artificial turf in contact sports. As playing surface is a potentially modifiable risk factor, this study sought to identify differences in symptoms following SRC on these 2 surfaces in a sample of young American football players. Design: Prospective. Setting: Part of the multi-institutional North Texas Concussion Registry (ConTex) research project. Participants: Ten-year-old to 24-year-old male American football players (n = 62) who had sustained a helmet-to-ground SRC and presented to a specialty concussion clinic within 14 days of injury. Independent variables: Helmeted impact with grass (n = 33) or artificial turf (n = 29). Main outcome measures: Severity and number of symptoms endorsed on the Sport Concussion Assessment Tool 5th Edition (SCAT5) Symptom Evaluation at the time of initial clinical evaluation. Results: Both groups were similar in mean time since injury, concussion history, and history of headache, but the artificial turf group was slightly older, with a mean age of 14.6 versus 13.6 years ( P = 0.039). Athletes who sustained a SRC on grass reported significantly higher mean total symptom severity scores (26.6 vs 11.6, P = 0.005) and total number of symptoms (10.3 vs 5.9, P = 0.006) compared with those who were injured on artificial turf. Conclusions: This may be the first study to examine postconcussive symptoms after SRC as they relate to playing surface. This small sample of young American football players reported higher symptom severity scores and higher total number of symptoms after SRC on natural grass compared with artificial turf. [ABSTRACT FROM AUTHOR]

Many Veterans who served in Iraq and Afghanistan struggle with posttraumatic stress disorder (PTSD) and the effects of traumatic brain injuries (TBI). Some people with a history of TBI report a constellation of somatic, cognitive, and emotional complaints that are often referred to as postconcussive symptoms (PCS). Research suggests these symptoms may not be specific to TBI. This study examined the impact of PTSD treatment on PCS in combat Veterans seeking treatment for PTSD. As part of a larger randomized control trial, 198 Operation Iraqi Freedom, Operation Enduring Freedom, Operation New Dawn (OIF/OEF/OND) Veterans with PTSD received Prolonged Exposure Therapy, sertraline, or the combination. Potential deployment related TBI, PCS, PTSD and depression symptoms were assessed throughout treatment. Linear mixed models were used to predict PCS change over time across the full sample and treatment arms, and the association of change in PTSD and depression symptoms on PCS was also examined. Patterns of change for the full sample and the subsample of those who reported a head injury were examined. Results showed that PCS decreased with treatment. There were no significant differences across treatments. No significant differences were found in the pattern of symptom change based on TBI screening status. Shifts in PCS were predicted by change PTSD and depression. Results suggest that PCS reduced with PTSD treatment in this population and are related to shift in depression and PTSD severity, further supporting that reported PCS symptoms may be better understood as non-specific symptoms. [ABSTRACT FROM AUTHOR]

Objective: This study seeks to advance the literature by disentangling the effects of deployment‐acquired traumatic brain injury (TBI) from comorbid postconcussive symptoms and PTSD symptoms on relationship distress. Background: Because TBI poses challenges to military marriages, understanding the predictors of relationship distress after TBI is important for helping service members cope with the effects of the injury. Method: Survey data from the U.S. Army STARRS Pre–Post Deployment Study, collected from 2,585 married service members before and after a combat deployment to Afghanistan, evaluated predictors of relationship distress 9 months after homecoming. Results: Deployment‐acquired TBI corresponded with more relationship distress controlling for predeployment brain health, but its predictive power was eclipsed by concurrent postconcussive symptoms and concurrent PTSD symptoms. Concurrent PTSD symptoms accounted for twice as much variance in relationship distress than concurrent postconcussive symptoms. Conclusion: Targeting and treating comorbid conditions may be essential for supporting military marriages after TBI. Implications: Military command, policymakers, and medical professionals may find value in broadening support services for TBI to include resources addressing postconcussive symptoms, PTSD symptoms, and relationship distress. [ABSTRACT FROM AUTHOR]

Objective: To identify both shared and unique groups of posttraumatic stress and postconcussive symptoms using bifactor analysis. Setting: Two large military outpatient traumatic brain injury (TBI) rehabilitation clinics in the Southwestern United States. Participants: A sample of 1476 Active Duty Service Members seeking treatment for a mild TBI sustained more than 30 days previously, without history of moderate or severe TBI, who completed measures of postconcussive and posttraumatic stress symptoms assessed at clinic intake. Design: Observational, correlational study with data taken from an institutional review board-approved clinical registry study. Main Measures: Neurobehavioral Symptom Inventory (NSI) and Posttraumatic Stress Disorder (PTSD) Checklist for Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (DSM-V) (PCL-5). Concurrent measures were Patient Health Questionnaire (PHQ-8), Pittsburgh Sleep Quality Index (PSQI), and Headache Impact Test (HIT-6). Results: Results identified a bifactor model demonstrating unique posttraumatic stress, depressive, cognitive, and neurological/somatic symptom groups that were still evident after accounting for a universal factor representing general distress. These symptom groups were differentially related to concurrently measured clinical outcomes. Conclusion: Use of a bifactor structure may help derive clinically useful signals from self-reported symptoms among Active Duty Service Members seeking outpatient treatment for mild TBI. [ABSTRACT FROM AUTHOR]

Chronic post-concussive symptoms are common after mild traumatic brain injury (mTBI) and are difficult to predict or treat. Thalamic functional integrity is particularly vulnerable in mTBI and may be related to long-term outcomes but requires further investigation. We compared structural MRI and resting state functional MRI in 108 patients with a Glasgow Coma Scale (GCS) of 13–15 and normal CT, and 76 controls. We examined whether acute changes in thalamic functional connectivity were early markers for persistent symptoms and explored neurochemical associations of our findings using PET data. Of the mTBI cohort, 47% showed incomplete recovery 6 months post-injury. Despite the absence of structural changes, we found acute thalamic hyperconnectivity in mTBI, with specific vulnerabilities of individual thalamic nuclei. Acute fMRI markers differentiated those with chronic post-concussive symptoms, with time- and outcome-dependent relationships in a sub-cohort followed longitudinally. Moreover, emotional and cognitive symptoms were associated with changes in thalamic functional connectivity to known serotonergic and noradrenergic targets, respectively. Our findings suggest that chronic symptoms can have a basis in early thalamic pathophysiology. This may aid identification of patients at risk of chronic post-concussive symptoms following mTBI, provide a basis for development of new therapies and facilitate precision medicine application of these therapies. [ABSTRACT FROM AUTHOR]

BackgroundSleep problems are common among Veterans with mild traumatic brain injury (mTBI) and may contribute to participation restrictions. However, explanatory mechanisms underlying this relationship are poorly understood. Sleep problems are associated with post-concussive symptoms (e.g., headaches). In turn, post-concussive symptoms contribute to participation restrictions. We hypothesized that post-concussive symptom severity mediates the purported relationship between sleep problems and participation restrictions among Veterans with mTBI.Materials and MethodsThis study was a retrospective analysis of clinical data among 8,733 Veterans with mTBI receiving Veterans Health Administration outpatient care. Sleep problems (yes/no) were identified using the sleep-related item from the Neurobehavioral Symptom Inventory (NSI). Post-concussive symptoms were measured using remaining NSI items. Participation restrictions were measured using the Mayo-Portland Adaptability Inventory Participation Index. We specified a latent variable path model to estimate relationships between: (1) sleep problems and three latent indicators of post-concussive symptoms [vestibular-sensory (e.g., headache)]; mood-behavioral [e.g., anxiety]; cognitive [e.g., forgetfulness]); and, (2) the three latent indicators of post-concussive symptoms and two latent indicators of participation restrictions (social and community participation [e.g., leisure activities]; productivity [e.g., financial management]). We examined the indirect effects of sleep problems upon participation restrictions, as mediated by post-concussive symptoms. Estimates were adjusted for sociodemographic factors (e.g., age), injury characteristics (e.g., blast), and co-morbid conditions (e.g., depression).Results87% of Veterans reported sleep problems. Sleep problems were associated with greater social and community participation restrictions, as mediated by mood-behavioral (β = 0.41, p

Objective: Female athletes may be more likely to sustain a concussion and may vary in symptom presentation and neurocognitive impairments as compared with males. Scientific literature is limited by subjective assessments and underproportioned representation of women—the scope and etiology of sex-based differences are unknown. This study investigates sex-based differences in sports concussion assessments among college varsity athletes. Design and Setting: Retrospective study of an institution's athletic head injury database. Participants: Acute postinjury and baseline data from 111 college athletes sustaining concussions between 2016 and 2018, diagnosed by a concussion specialist physician. Main Outcome Measures: Concussion assessments examined included the Sports Concussion Assessment Tool (SCAT5) and Vestibular Oculomotor Screening (VOMS) performed within 3 days (24-72 hours) of injury. Results: No significant difference by sex was observed in the SCAT5 total symptom evaluation scores or severity scores, Standardized Assessment of Concussion, or Balance Error Scoring System (P >.05) within 3 days of head injury. Females did report more "pressure in the head" severity scores from baseline to postconcussion (2.7 ± 1.5 increased symptomatology in females vs 1.8 ± 1.3 increase in males, P =.007). The VOMS test resulted in significant sex differences in smooth pursuit [0.6 ± 1.4 increase in females (P <.001) vs 0.2 ± 0.6 increase in males (P =.364)], horizontal saccades [0.6 ± 1.2 increase in females (P <.001) vs 0.2 ± 0.5 increase in males (P =.149)], and vertical saccades [0.9 ± 1.9 increase in females (P <.001) vs 0.3 ± 0.7 increase in males (P =.206)]. Conclusion: Our study did not show sex-based differences in baseline or acute postconcussive symptom reporting in most concussion assessment parameters, challenging previous research suggesting that females report more symptoms than males. Females did have significant differences in symptom provocation using the VOMS. [ABSTRACT FROM AUTHOR]

Lingering concussion symptoms can negatively impact a child's well-being, yet variability in recovery is poorly understood. To aid detection of those at risk for prolonged symptom duration, we explored postconcussion mood and sleep symptoms as predictors of recovery time in adolescent athletes. We utilized analyses designed to control for potentially confounding variables, such as concussion severity indicators and premorbid psychiatric history. Participants included 393 adolescent athletes (aged 12–18 years) evaluated in outpatient concussion clinics within 2 weeks after injury. Provider-documented date of symptom resolution was obtained via medical record review. Survival analysis for recovery time was conducted in the total sample, and separately for males and females using prior medical history (psychiatric disorder, prior concussion), injury-related factors (loss of consciousness, post-traumatic amnesia [PTA], concussion symptom severity), and psychological symptoms (General Anxiety Disorder-7 Item Scale, Patient Health Questionnaire-8 Item Depression Scale, Pittsburgh Sleep Quality Index) collected at initial clinic visit. PTA, concussion symptoms, and sleep quality were associated with recovery in the total sample (HRs = 0.64–0.99, ps <.05). When analyzed by sex, only concussion symptoms were associated with recovery for females (with females reporting greater symptom severity than males), while for males PTA and greater depression symptoms were significant predictors of recovery (HRs = 0.54–0.98, ps <.05). These findings identified differences in symptom presentation between sexes, particularly for mood symptoms, and suggest that assessment of postconcussive symptoms is useful in helping to identify individuals at risk for longer recovery. Continued exploration of post-injury psychological difficulties in athletes is warranted for better concussion management. [ABSTRACT FROM AUTHOR]

Objective: Understanding factors contributing to neurobehavioral symptom burden among intimate partner violence (IPV) survivors has important implications for prevention, screening, and intervention in this vulnerable population. This study aimed to (1) identify the relationship between childhood trauma and neurobehavioral symptoms among a shelter- and community-based sample of IPV survivors, including investigating the mediating role of posttraumatic stress symptoms and alexithymia in this relationship; (2) assess the association between IPV-related brain injury (BI) severity and neurobehavioral symptoms; and (3) assesses whether physical, emotional, or cognitive domains of neurobehavioral symptom burden show differential associations with childhood trauma or IPV-related BI. Setting: Community sites serving women who had experienced IPV such as domestic violence shelters and transitional housing sites. Participants: Women survivors of IPV with and without BI (n = 99), aged 18 to 54 years. Design: Retrospective, cross-sectional study design. Measures: The following self-reported questionnaires were used: Rivermead Post Concussion Questionnaire (RPQ); Childhood Trauma Questionnaire (CTQ); a modified version of the Conflict Tactics Scale; Brain Injury Severity Assessment (BISA); Clinician-Administered PTSD Scale for DSM IV ; and Toronto Alexithymia Scale. The final multivariate regression model assessed the association between childhood abuse, BI severity, and neurobehavioral symptoms (as measured by the RPQ) adjusting for age, educational attainment, and abuse in the past year. We created separate models with total neurobehavioral symptom score as an outcome, as well as somatic, emotional, and cognitive symptom scores. We used structural equation modeling to assess whether posttraumatic stress and alexithymia mediated the effect of childhood trauma and neurobehavioral symptoms. Results: Childhood trauma was associated with higher levels (P <.01) of overall neurobehavioral symptom burden in women independent of BI and specifically associated with RPQ Emotional and Somatic subscale symptoms (P ≤.05). BI was positively associated with somatic symptoms in the full sample and cognitive neurobehavioral symptoms in the sample of women with IPV-related BI (P <.05) independent of childhood trauma. Posttraumatic stress symptoms, but not alexithymia, partially mediated the effect of childhood trauma effect on neurobehavioral symptoms. Conclusion: Childhood trauma and BI should not be overlooked as part of efforts to meet the needs of IPV survivors who may experience a range of emotional, somatic, and cognitive symptoms. [ABSTRACT FROM AUTHOR]

Objective: To describe rates of mild traumatic brain injury (mTBI) with and without concurrent posttraumatic stress disorder a sample of former and current military personnel, and to compare the factor structure of the Neurobehavioral Symptom Inventory (NSI) based on whether participants sustained mTBI with and without a positive posttraumatic stress disorder (PTSD) screen. Setting: Participants recruited and tested at 7 Veterans Affairs (VA) sites and 1 military training facility as part of a national, longitudinal study of mental health, physical, and cognitive outcomes among veterans and service members. Participants: Total of 1540 former and current military personnel with a history of combat exposure. Design: Cross-sectional analysis of observational data, including confirmatory factor analysis. Main Measures: NSI and PTSD Checklist for DSM-5 (PCL-5). Results: Most participants (81.5%) had a history of mTBI and almost half of these screened positive for PTSD (40.5%); only 23.9% of participants without a history of mTBI screened positive for PTSD. Participants with a history of mTBI reported higher elevations of NSI and PCL-5 symptoms compared with those without a history of mTBI. Confirmatory factor analyses of the NSI demonstrated good model fit using a 4-factor structure (somatosensory, affective, cognitive, and vestibular symptoms) among groups of participants both with and without a history of mTBI. Conclusion: Symptoms of mTBI and PTSD are strongly associated with each other among veterans and service members with a history of combat exposure. The 4-factor NSI structure is supported among participants with and without a history of mTBI. These findings suggest the potential benefit of a holistic approach to evaluation and treatment of veterans and service members with concurrent and elevated postconcussive and posttraumatic stress symptoms. [ABSTRACT FROM AUTHOR]

Abstract Objectives This study aimed to investigate changes in three intrinsic functional connectivity networks (IFCNs; default mode network [DMN], salience network [SN], and task‐positive network [TPN]) in individuals who had sustained a mild traumatic brain injury (mTBI). Methods Resting‐state functional magnetic resonance imaging (rs‐fMRI) data were acquired from 27 mTBI patients with persistent postconcussive symptoms, along with 26 age‐ and sex‐matched controls. These individuals were recruited from a Level‐1 trauma center, at least 3 months after a traumatic episode. IFCNs were established based on seed‐to‐voxel, region‐of‐interest (ROI) to ROI, and independent component analyses (ICA). Subsequently, we analyzed the relationship between functional connectivity and postconcussive symptoms. Results Seed‐to‐voxel analysis of rs‐fMRI demonstrated decreased functional connectivity in the right lateral parietal lobe, part of the DMN, and increased functional connectivity in the supramarginal gyrus, part of the SN. Our TPN showed both hypo‐ and hyperconnectivity dependent on seed location. Within network hypoconnectivity was observed in the visual network also using group comparison. Using an ICA, we identified altered network functional connectivity in regions within four IFCNs (sensorimotor, visual, DMN, and dorsal attentional). A significant negative correlation between dorsal attentional network connectivity and behavioral symptoms score was also found. Conclusions Our findings indicate that rs‐fMRI may be of use clinically in order to assess disrupted functional connectivity among IFCNs in mTBI patients. Improved mTBI diagnostic and prognostic information could be especially relevant for athletes looking to safely return to play, as well for individuals from the general population with persistent postconcussive symptoms months after injury, who hope to resume activity.

This study aimed to elucidate the structure of the Rivermead Postconcussion Symptoms Questionnaire (RPQ) and evaluate its longitudinal and group variance. Factor structures were developed and compared in 1,011 patients with mild traumatic brain injury (mTBI; i.e., Glasgow Coma Scale score 13-15) from the Transforming Research and Clinical Knowledge in TBI study, using RPQ data collected at 2 weeks, and 3, 6, and 12 months postinjury. A bifactor model specifying a general factor and emotional, cognitive, and visual symptom factors best represented the latent structure of the RPQ. The model evinced strict measurement invariance over time and across sex, age, race, psychiatric history, and mTBI severity groups, indicating that differences in symptom endorsement were completely accounted for by these latent dimensions. While highly unidimensional, the RPQ has multidimensional features observable through a bifactor model, which may help differentiate symptom expression patterns in the future. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Objectives: This study aimed to investigate changes in three intrinsic functional connectivity networks (IFCNs; default mode network [DMN], salience network [SN], and task‐positive network [TPN]) in individuals who had sustained a mild traumatic brain injury (mTBI). Methods: Resting‐state functional magnetic resonance imaging (rs‐fMRI) data were acquired from 27 mTBI patients with persistent postconcussive symptoms, along with 26 age‐ and sex‐matched controls. These individuals were recruited from a Level‐1 trauma center, at least 3 months after a traumatic episode. IFCNs were established based on seed‐to‐voxel, region‐of‐interest (ROI) to ROI, and independent component analyses (ICA). Subsequently, we analyzed the relationship between functional connectivity and postconcussive symptoms. Results: Seed‐to‐voxel analysis of rs‐fMRI demonstrated decreased functional connectivity in the right lateral parietal lobe, part of the DMN, and increased functional connectivity in the supramarginal gyrus, part of the SN. Our TPN showed both hypo‐ and hyperconnectivity dependent on seed location. Within network hypoconnectivity was observed in the visual network also using group comparison. Using an ICA, we identified altered network functional connectivity in regions within four IFCNs (sensorimotor, visual, DMN, and dorsal attentional). A significant negative correlation between dorsal attentional network connectivity and behavioral symptoms score was also found. Conclusions: Our findings indicate that rs‐fMRI may be of use clinically in order to assess disrupted functional connectivity among IFCNs in mTBI patients. Improved mTBI diagnostic and prognostic information could be especially relevant for athletes looking to safely return to play, as well for individuals from the general population with persistent postconcussive symptoms months after injury, who hope to resume activity. [ABSTRACT FROM AUTHOR]

A good number of veterans while serving in recent combat zones experienced blast injuries resulting in traumatic brain injuries (TBIs), 80% of which were mild (m) with 25%–50% having prolonged postconcussive symptoms (PCSs). Neurofeedback (NFB) has demonstrated a decent degree of efficacy with mTBI PCSs in civilian and veteran populations. Using infra-low frequency NFB, the authors conducted a pilot study to determine the feasibility and initial efficacy with veterans. Because these results were promising, funding for a full clinical trial was subsequently applied for and acquired. [ABSTRACT FROM AUTHOR]

Objective: To identify risk factors for suicidal ideation (SI) following mild traumatic brain injury (mTBI). Setting: Eleven US level 1 trauma centers. Participants: A total of 1158 emergency department patients with mTBI (Glasgow Coma Scale score = 13-15) enrolled in the Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) study. Design: Prospective observational study; weights-adjusted multivariable logistic regression models (n's = 727-883) estimated associations of baseline factors and post-TBI symptoms with SI at 2 weeks and 3, 6, and 12 months postinjury. Main Measures: Patient Health Questionnaire, Rivermead Post-Concussion Symptoms Questionnaire. Results: Preinjury psychiatric history predicted SI at all follow-ups (adjusted odds ratios [AORs] = 2.26-6.33, Pvalues <.05) and history of prior TBI predicted SI at 2 weeks (AOR = 2.36, 95% confidence interval [CI] = 1.16-4.81, P = .018), 3 months (AOR = 2.62, 95% CI = 1.33-5.16, P = .005), and 6 months postinjury (AOR = 2.54, 95% CI = 1.19-5.42, P = .016). Adjusting for these baseline factors, post-TBI symptoms were strongly associated with SI at concurrent (AORs = 1.91-2.88 per standard deviation unit increase in Rivermead Post-Concussion Symptoms Questionnaire score; P values <.0005) and subsequent follow-up visits (AORs = 1.68-2.53; P values <.005). Most of the associations between post-TBI symptoms and SI were statistically explained by co-occurring depression. Conclusion: Screening for psychiatric and prior TBI history may help identify patients at risk for SI following mTBI. Awareness of the strong associations of post-TBI symptoms with SI may facilitate interventions to prevent suicide-related outcomes in patients with mTBI. [ABSTRACT FROM AUTHOR]

Objective: A considerable number of people experience persisting symptoms and functional limitations after mild traumatic brain injury (mTBI). It is unclear whether subtle white matter changes contribute to this phenomenon. In this systematic review, the authors evaluated whether microstructural white matter indices on advanced MRI are related to clinical dysfunction among patients without abnormalities on standard brain computed tomography (CT) or MRI (uncomplicated mTBI)., Methods: A search of multiple databases was performed. Studies with individuals who experienced blast-related, sports-related, or multiple mTBIs were excluded. Diffusion tensor imaging (DTI) and susceptibility-weighted imaging (SWI) metrics and cognitive, neuropsychiatric, or functional outcome measures were extracted from each study., Results: Thirteen studies were selected (participants with mTBI, N=553; healthy control group, N=438). Seven DTI studies evaluated cognitive function, with five reporting significant correlations between reduced white matter integrity and deficits in attention, processing speed, and executive function at 6-12 months after injury (three studies included only individuals with uncomplicated mTBI). Four studies found significant correlations between DTI metrics and persistent postconcussive symptoms after 3-12 months (one study included only individuals with uncomplicated mTBI). Two SWI studies reported conflicting findings regarding the relationship between the presence of microbleeds and postconcussive symptoms., Conclusions: The results revealed that indices of microstructural white matter integrity may relate to clinical presentation 3-12 months after injury in uncomplicated mTBI. However, analysis methods and brain regions studied varied across studies. Further research is needed to identify relationships between white matter indices in specific brain regions and symptom persistence beyond 12 months., Competing Interests: Dr. Deeley has served as an expert witness in personal injury cases involving traumatic brain injury. The other authors report no financial relationships with commercial interests.

Objectives: To determine the proportion of children with postconcussive symptoms (PCSs) and to explore the influence of noninjury and injury factors on parents' PCS report at 3 months postinjury. Design: A cross-sectional analysis of the 3-month postinjury data from a larger, prospective, longitudinal study. Methods: Parents and their child aged 2 to 12 years who presented at the emergency department with either a mild traumatic brain injury (mTBI) or a superficial injury to the head (SIH) were recruited. Parents reported their child's symptoms at the time of injury and at 3 months postinjury. Child, family/parent, and injury characteristics were considered as potential predictors. Logistic regression was conducted to determine which factors increase the likelihood of parents' PCS report. Results: At 3 months postinjury, 30% and 13% of children in the mTBI and SIH groups exhibited 1 or more symptoms, respectively. On the other hand, 18% (mTBI) and 8% (SIH) continued to have ongoing problems when 2 or more symptoms were considered at follow-up. The final model, which included child's sex, injury group, number of symptoms at the time of injury, and parental stress, had a significant predictive utility in determining parents' report of 1 or more symptoms at follow-up. Only parental stress continued to be a significant predictor when considering 2 or more symptoms at 3 months postinjury. Conclusions: Children with mTBI have worse outcomes than children with SIH at follow-up, with parents more likely to report 1 or more ongoing symptoms if their children had an mTBI. Postinjury assessment of parental stress and ongoing symptom monitoring in young children with mTBI will allow for timely provision of support for the family. [ABSTRACT FROM AUTHOR]

This study examined the relationship between postconcussive symptom domain and school attendance. Retrospective chart review was completed for 88 children aged 6 to 18 years who were evaluated within 30 days postinjury. Hierarchical multiple regression was used to assess the association of physical, cognitive, emotional, and sleep symptoms with extent of school attendance. A subgroup multiple regression analysis was conducted to evaluate whether age affected the relationship of symptoms to school attendance. After controlling for demographic variables and total number of symptoms, a higher number of postconcussive sleep symptoms strongly predicted less school attendance. Specifically, older children (≥14 years old) with more sleep symptoms demonstrated less school attendance. For children presenting for specialty care after concussion, sleep symptoms are unfavorably associated with return to school. Future work aimed at optimizing sleep regulation following concussion may assist with early reengagement in school as recommended by current concussion management guidelines. [ABSTRACT FROM AUTHOR]

Objectives: Whether mild traumatic brain injury (mTBI) sustained by children results in persistent or recurrent symptoms, over and above those experienced by children who solely sustain mild extracranial injuries, remains debated. The current prospective longitudinal case-controlled study aimed to examine the relative influence of injury and noninjury factors on symptoms in preschool and primary school-aged children who sustained an mTBI or mild extracranial injury at least 8 month earlier. Methods: Participants were 64 parents of children (31 mTBI, 33 trauma controls) who sustained injury between ages 2 and 12, whose postconcussive symptoms across the first 3-month postinjury have been previously described. The current study assessed postconcussive symptoms at 8 or more months postinjury (M = 24.3, SD = 8.4) and examined a range of injury and noninjury predictive factors. Results: At or beyond 8-month postinjury, symptom numbers in the mTBI group were comparable with those of the group who sustained mild extracranial injury. Educational attainment of parents (below or above high-school attainment level) was the only predictor of symptoms at follow-up, with preexisting learning difficulties approaching significance as a predictor. Conclusions: While our earlier study found that mTBI was associated with symptoms at 3-month postinjury, follow-up at more than 8 months showed mTBI no longer predicted symptom reporting. While mTBI contributes significantly to the presence of symptoms in the first few months postinjury, researchers and healthcare practitioners in this field need to consider the potential impact of noninjury factors on persistent or recurrent symptoms after mTBI. [ABSTRACT FROM AUTHOR]

Objective: To investigate somatic and cognitive postconcussive symptoms (PCS) using the symptom evaluation subtest (cSCAT3-SE) of the Child Sports Concussion Assessment Tool 3 (Child SCAT) in tracking PCS up to 2 weeks postinjury. Methods: A total of 96 participants aged 5 to 12 years (Mage = 9.55, SD = 2.20) completed three assessment time points: 48 h postinjury (T0), 2 to 4 days postinjury (T1), and 2 weeks postinjury (T2). The Wilcoxon signed-rank test was used to analyze differences between cognitive and somatic symptoms over time, while the Friedman test was used to analyze differences within symptom type over time. Results: Cognitive PCS were found to be significantly higher than somatic PCS at all assessment time points and were also found to significantly decline from 4 days onwards postinjury; in contrast, somatic PCS significantly declined as early as 48 hpostinjury. Discussion: Differences between cognitive and somatic PCS emerge as early as a few days postinjury, with cognitive PCS being more persistent than somatic PCS across 2 weeks. Research in symptom-specific interventions may be of benefit in helping young children manage severe PCS as early as 2 weeks postinjury. [ABSTRACT FROM AUTHOR]

Introduction: Headaches are the most common complaint after traumatic brain injury (TBI) and a significant cause of morbidity and disability among military personnel. Currently, there are a several measures which can assess headache disability, but there is a significant burden to assess each individual symptom given this heterogeneous polymorbid population. The objective of this proposed study was to validate the single headache item from the Neurobehavioral Symptom Inventory (NSI) compared to the 6-item Headache Impact Test (HIT-6).Materials and Methods: Participants included consecutive treatment-seeking outpatients at the Brain Injury Rehabilitation Service at the Brooke Army Medical Center from August 2007 to January 2010 who were administered a battery of assessment measures at initial intake, as part of usual care. Archival record review was conducted using procedures approved by the local Institutional Review Board. Inclusionary criteria included completion of both the HIT-6 and NSI. Participants with a cut-off score of >22 on the NSI Validity-10 were excluded in a post hoc analysis to validate findings among those who passed validity screen.Results: The Pearson correlation between the single-item NSI headache measure and the HIT-6 revealed at least 64% shared variance in this military sample (r = 0.8, p < 0.001), indication a high association between the two measures.Conclusion: The NSI single-item headache measure adequately captured headache severity in this military cohort. Use of the single-item NSI headache measure may minimize survey burden on participants whose primary complaint is not headaches, or who present with multiple symptoms. Future studies are needed to validate the single-item headache measure in other samples. [ABSTRACT FROM AUTHOR]

Objective: To understand the relationships between traumatic brain injury (TBI), blood biomarkers, and symptoms of posttraumatic stress disorder (PTSD), depression, and postconcussive syndrome symptoms. Design: Cross-sectional cohort study using multivariate analyses. Participants: One hundred nine military personnel and veterans, both with and without a history of TBI. Main Measures: PTSD Checklist-Civilian Version (PCL-C); Neurobehavioral Symptom Inventory (NSI); Ohio State University TBI Identification Method; Patient Health Questionnaire-9 (PHQ-9); Simoa-measured concentrations of tau, amyloid-beta (Aβ) 40, Aβ42, and neurofilament light (NFL). Results: Controlling for age, sex, time since last injury (TSLI), and antianxiety/depression medication use, NFL was trending toward being significantly elevated in participants who had sustained 3 or more TBIs compared with those who had sustained 1 or 2 TBIs. Within the TBI group, partial correlations that controlled for age, sex, TSLI, and antianxiety/depression medication use showed that tau concentrations were significantly correlated with greater symptom severity, as measured with the NSI, PCL, and PHQ-9. Conclusions: Elevations in tau are associated with symptom severity after TBI, while NFL levels are elevated in those with a history of repetitive TBIs and in military personnel and veterans. This study shows the utility of measuring biomarkers chronically postinjury. Furthermore, there is a critical need for studies of biomarkers longitudinally following TBI. [ABSTRACT FROM AUTHOR]

Objective: This study compares combat-related mild traumatic brain injury (mTBI) to non-combat-related mTBI in rates of posttraumatic stress disorder (PTSD) and depression after injury, severity of postconcussive symptoms (PCSs), and attribution of those symptoms to mTBI versus PTSD. Participants: A total of 371 active duty service members (SMs) with documented history of mTBI, divided into combat and non-combat-related cohorts. Design: Retrospective cohort study. Main Measures: Diagnoses of PTSD and depression based on medical record review and self-report. PCSs measured using Neurobehavioral Symptom Index. Attribution of symptoms based on a rating scale asking how much mTBI, PTSD, depression, deployment, or readjustment stress contributed to current symptoms. Results: Prevalence of PTSD was significantly higher after a combat-related mTBI, compared with a noncombat mTBI (P = .001). Prevalence of depression did not differ between the 2 groups. PCSs were high in both combat and noncombat mTBIs, with no statistical difference between groups. SMs with PTSD reported higher PCS, regardless of combat status. SMs without PTSD attributed symptoms mainly to mTBI, whereas SMs with PTSD, regardless of combat status, were much more likely to attribute symptoms to PTSD, depression, and deployment/readjustment stress. Conclusions: This research contributes to our understanding of the complex interplay between mTBI and PTSD in both combat and noncombat injuries within the military population and the importance of addressing both simultaneously. [ABSTRACT FROM AUTHOR]

Objective: In this cross-sectional study, the authors aimed to examine relationships between illness perception, measured as symptom attribution, and neurobehavioral and neurocognitive outcomes among veterans with a history of traumatic brain injury (TBI)., Methods: This study included 55 treatment-seeking veterans (N=43 with adequate performance validity testing) with a remote history of TBI (80% with mild TBI). Veterans completed a clinical interview, self-report questionnaires, and a neuropsychological assessment. A modified version of the Neurobehavioral Symptom Inventory (NSI) was administered to assess neurobehavioral symptom endorsement and symptom attribution. Composite scores were calculated from standardized cognitive tests to assess specific aspects of objective cognitive functioning, including memory, executive functioning, attention and working memory, and processing speed., Results: The symptoms most frequently attributed to TBI included forgetfulness, poor concentration, slowed thinking, and headaches. There was a significant positive association between symptom attribution and overall symptom endorsement (NSI total score) (r=0.675) and endorsement of specific symptom domains (NSI symptom domain scores) (r=0.506-0.674), indicating that greater attribution of symptoms to TBI was associated with greater symptom endorsement. Furthermore, linear regressions showed that symptom attribution was significantly associated with objective cognitive functioning, whereas symptom endorsement generally did not show this relationship. Specifically, greater attribution of symptoms to TBI was associated with worse executive functioning (β=-0.34), attention and working memory (β=-0.43), and processing speed (β=-0.35)., Conclusions: These findings suggest that veterans who routinely attribute neurobehavioral symptoms to their TBI are at greater risk of experiencing poor long-term outcomes, including elevated symptom endorsement and worse objective cognition. Although more research is needed to understand how illness perception influences outcomes in this population, these preliminary results highlight the importance of early psychoeducation regarding the anticipated course of recovery following TBI., Competing Interests: This article does not represent the views of the U.S. Department of Veterans Affairs or the U.S. government. The authors report no financial relationships with commercial interests.

Objective: To investigate the trajectory of sleep deficiency after concussion and examine its role as a predictor of postconcussive symptoms (PCS) over 3 weeks and at 3 months post-concussion. Design: This was a prospective pilot study of 29 adolescents recruited from a pediatric Emergency Department (69% female, mean age = 14.0 years, SD = 1.8) following a concussion. Methods: Adolescents completed questionnaire assessments at baseline, Weeks 1, 2, and 3 on PCS and sleep patterns. Concurrently, adolescents also completed a daily diary and wore an actigraph continuously to monitor sleep activity. At 3 months post-concussion, adolescents repeated questionnaire measures. Results: At enrollment, 53.6% reported severe PCS, and 12% maintained severe symptoms at 3 months. Over the first 3 weeks, sleep duration and daytime sleepiness gradually declined; however, insomnia symptoms remained unchanged. After accounting for age, sex and time since concussion, greater insomnia symptoms at enrollment were associated with more severe PCS at 3 weeks and 3 months (β = 1.17, p <.001). In contrast, sleep duration, efficiency, and waketime after sleep onset were not predictors. Conclusions: Study findings suggest that insomnia symptoms after concussion may provide a target for early intervention to reduce prolonged severity and duration of PCS. [ABSTRACT FROM AUTHOR]

We analyzed data from a cohort of recently deployed soldiers from 2 US Army bases, Fort Carson and Fort Bragg (2009 to 2015). Soldiers with and without a recent history of mild traumatic brain injury (mTBI) on deployment were evaluated within days of return and at 3, 6, and 12 months. Those with mTBI were more likely than those without to endorse ≥1 postconcussive symptom as "severe" and/or "very severe" (47% vs. 21%, baseline; adjusted relative risk (RR) = 1.71, 95% confidence interval: 1.51, 1.93, all time points), which remained significant after adjusting for posttraumatic stress disorder (adjusted RR = 1.34, 95% confidence interval: 1.20, 1.50). Prevalence and relative risks for 3 of the most common baseline symptoms remained constant over time: sleep problems (RR = 2.19), forgetfulness (RR = 2.56), and irritability (RR = 2.73). The pattern was slightly different for headache (baseline, RR = 3.44; 12 months, RR = 3.26), due to increased prevalence of headache in those without mTBI. The prevalence of clinically relevant postconcussive symptoms remained relatively constant over 1 year of follow-up, whether or not symptoms were associated with concussion. Service members with recent mTBI reported more symptoms than those without at all time points. [ABSTRACT FROM AUTHOR]

Objective: Prior work suggests that younger athletes may be more vulnerable to postconcussive syndrome. We investigated measures of clinical outcome and quantitative volumetric imaging in 10- to 14-year-old adolescent athletes to better understand the impact of concussion on this younger population. Setting: Outpatient clinics. Participants: Ten- to 14-year-old symptomatic pediatric sports concussion patients and typically developing active controls. Design: Prospective, observational multiclinic study. Main Measures: Demographics, magnetic resonance imaging, clinical assessments (neurocognitive function, postconcussive symptoms, mental health symptoms, quality of life). Results: Neuropsychological performance was comparable between groups while symptoms of mental health were discriminating and comprised the top regression model describing factors related to overall health behavior impairment. Concussion patients had smaller total brain volume as well as total intracranial volume in comparison with controls even though there was no difference on measures of natural development (age, height, weight, education, gender, and handedness). Conclusions: Findings indicate that 10- to 14-year-old concussion patients symptomatic at 1 month more likely exhibit mental health symptoms impairing health behavior than cognitive dysfunction. There may be a vulnerability for those with smaller brain volumes at the time of the exposure. The study provides new data to support further investigation into risk factors for prolonged symptoms in this younger athlete population. [ABSTRACT FROM AUTHOR]

This study investigated the dimensionality and measurement properties of the Neurobehavioral Symptom Inventory (NSI), a 22-item questionnaire of postconcussive symptoms, in a national sample of 9,679 Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) Veterans with mild traumatic brain injury. Dimensionality of the NSI was examined using exploratory factor analysis (EFA) and Rasch analysis. Rasch measurement properties, including overall fit, unidimensionality, item level statistics, and category functioning were examined for individual NSI symptom domains identified through EFA. Differential item functioning (DIF) analyses of subgroups based on gender and Posttraumatic Stress Disorder (PTSD) diagnosis were also conducted. Results showed that the NSI items are multidimensional and responses can be differentiated into 3 unidimensional domains reflecting Cognitive, Mood-Behavioral, and Vestibular-Sensory symptoms. All items in each of the 3 subscales demonstrated adequate fit to the Rasch model. In each domain, the item hierarchy was consistent with expectations regarding the theoretical ordering of symptoms. Some problems were observed regarding test targeting for all 3 subscales, such that items were generally concentrated around the mean ability level of the population. As such there were fewer items that differentiated between those at the upper and lower extremes of the scale. Differential item functioning (DIF) based on gender was noted for hearing difficulty. This item on average reflected a higher degree of severity for women than for men. There was no DIF based on PTSD status. Implications for using the NSI as an outcome measure are discussed. (PsycINFO Database Record [ABSTRACT FROM AUTHOR]

The objective was to characterize cognitive deficits and postconcussive symptoms in a pediatric population with no concussion, a single concussion, and ≥2 concussions, using a cross-sectional design. Cognitive function and postconcussive symptoms were assessed in participants (age 10-20) with no concussion (n = 1118), single concussion (n = 368), and repeated (≥2) concussions (n = 252). Analyses were adjusted for age and gender. Individuals with ≥2 concussions exhibited more total postconcussive symptoms; more loss of consciousness, amnesia and confusion; more headaches; and poorer cognitive function compared to no concussion and single concussion. Postconcussive symptoms may play a modulatory role in cognitive dysfunction after repeated concussions as those with loss of consciousness, amnesia, confusion, or headaches exhibited worse verbal memory, visual memory, visual-motor processing, and poorer impulse control compared to those without these symptoms. This analysis demonstrates that repeated concussions is associated with poorer cognitive function and postconcussive symptoms compared to a single concussion. [ABSTRACT FROM AUTHOR]

Objective: This study examined changes in postconcussive symptoms (PCS) over the acute postinjury recovery period, focusing on how daily PCSs differ between mild traumatic brain injury (mTBI) and other injury types. Setting: An urban emergency department (ED) in Western Pennsylvania. Subjects: A total of 108 adult patients with trauma being discharged from the ED were recruited and grouped by injury type: mild TBI (mTBI; n = 39), head injury without mTBI (HI: n = 16), and non-head-injured trauma controls (TCs: n = 53). Main Measures: Subjects completed a baseline assessment and an experience sampling method (ESM) protocol for 14 consecutive days postinjury: outcomes were daily reports of headaches, anxiety, and concentration difficulties. Results: Controlling for confounders, multilevel modeling revealed greater odds of headache and concentration difficulties on day 1 postinjury among the HI and mTBI groups (vs TCs). These odds decreased over time, with greater reductions for the HI and mTBI groups compared with TCs. By day 14, there were no group differences in PCS. In addition, only the HI group reported higher initial levels of anxiety and a steeper slope relative to TCs. Conclusion: Patients with HI, regardless of whether they meet the American Congress of Rehabilitation Medicines definition of mTBI, have higher odds of typical PCS immediately postinjury, but faster rates of recovery than TCs. ESM can improve understanding the dynamic nature of postinjury PCS. [ABSTRACT FROM AUTHOR]

Primary Objective: About 20% of Iraq and Afghanistan Veterans have sustained a traumatic brain injury (TBI), which can result in postconcussive symptoms and difficulty transitioning from the military to civilian employment and postsecondary education. To better inform programs help Veterans transition back into civilian life, we evaluated correlates of employment and postsecondary education enrolment among treatment-seeking Veterans with a history of TBI. Research Design: A cross-sectional design, using an archival database of VA medical records, was used to answer these research questions.Methods and Procedures: We examined demographic, TBI-related, postconcussive, psychiatric, and neuropsychological factors in 390 Veterans (86% with mild TBI) to determine what factors were associated with employment or enrolment in postsecondary education. Bivariate correlations and multivariate regression were used.Main Outcomes and Results: age, minority status, and service connected disability ratings were significantly associated with employment and postsecondary education enrolment in a multivariate context, whereas TBI-related factors and neurocognitive, postconcussive, and psychiatric symptom severity were not associated with employment or postsecondary education outcomes.Conclusions: Further research is needed to confirm these findings and to evaluate the contribution of age, minority status, and disability on successful return to work and/or school for Veterans with a history of TBI. [ABSTRACT FROM AUTHOR]

Objectives: To examine the frequency and nature of postconcussive symptoms (PCSs) and behavioral outcomes in young children following mild traumatic brain injury (mTBI) or concussion. Setting: Emergency department. Participants: Children aged 2 to 12 years presenting with either a concussion or minor bodily injury (control). Outcome Measurement: Parent ratings of PCS were obtained within 72 hours of injury, at 1 week, and 1, 2, and 3 months postinjury using a comprehensive PCS checklist. Preinjury behavior was examined at baseline using the Clinical Assessment of Behavior, which was readministered 1 and 3 months postinjury. Results: PCS burden following mTBI peaked in the acute phase postinjury but reduced significantly from 1 week to 1 month postinjury. Parents of children with mTBI reported more persistent PCSs up to 3 months postinjury than trauma controls, characterized mostly by behavioral and sleep-related symptoms. Subtle increases in problematic behaviors were observed from baseline (preinjury) to 1 month postinjury and persisted at 3 months postinjury; however, scores were not classified as clinically "at risk." Conclusions: A significant minority of young children experienced persistent PCS and problematic behavior following mTBI. Care must be taken when assessing PCS in younger children as method of PCS assessment may influence parental reporting. [ABSTRACT FROM AUTHOR]

Objective: This study investigates the contribution of pre-injury family functioning and resources on self-reported post-concussive symptoms and functional outcomes in persons with mild TBI (mTBI). Design: Participants with uncomplicated or complicated mTBIs were recruited from consecutive admissions to the emergency department of a level 1 trauma centre. Patients completed baseline assessments within 2 weeks of injury and an outcomes assessment at 3 months post-injury. Methods and procedures: One hundred and sixty-six adults with mTBI were included. Baseline measures of pre-injury history, family functioning and resources were obtained. Functional status assessments and self-reported measures of health, common TBI symptoms and psychological problems were administered at 3-months post-injury. Results: Data reduction of outcome measures using principle components analysis revealed two factors: self-reported post-concussive symptoms and current functional/participation status, explaining 60.53% of the variance. Family resources (β= –0.239,t(150) = –2.84,p= 0.005) and age (β= –0.170,t(150) = –2.19,p= 0.030), but not family functioning, were significant predictors of self-reported post-concussive symptoms at follow-up,R2= 0.051,F(5, 150) = 4.09,p= 0.002. Neither family resources nor functioning predicted current functional/participation status. Conclusions: Fewer family resources and younger age were associated with increased self-reported post-concussive symptoms. Fewer resources may be a potential risk factor to heightened perception of post-concussive symptoms. Providing low-cost counselling or resource facilitation services may improve outcomes for those with limited resources after mTBI. [ABSTRACT FROM PUBLISHER]

Approximately 20% of current-era Veterans have sustained a traumatic brain injury (TBI), which can result in persistent postconcussive symptoms. These symptoms may disrupt family and social functioning. We explored psychiatric, postconcussive, and cognitive factors as correlates of objective functioning and subjective satisfaction in family and social relationships. At entry into a supported employment study, 50 unemployed Veterans with a history of mild to moderate TBI and current cognitive impairment were administered baseline assessments. Multivariate stepwise regressions determined that higher levels of depressive symptomatology were strongly associated with less frequent social contact, as well as lower subjective satisfaction with family and social relationships. Worse verbal fluency predicted less frequent social contact, whereas worse processing speed and switching predicted higher levels of subjective satisfaction with family relationships. The pattern of results remained similar when examining those Veterans with only mild TBI. Depressive symptoms and cognitive functioning may affect Veterans' social contact and satisfaction with family and social relationships. Evidence-based interventions addressing depression and cognition may therefore aid in improving community reintegration and satisfaction with social and family relationships. [ABSTRACT FROM AUTHOR]

A comprehensive evaluation, including the assessment of neurobehavioral symptoms, has been instituted at the Department of Veterans Affairs (VA) healthcare system to address the large number of Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) Veterans returning with mild traumatic brain injuries (mTBIs). The Validity-10 is a measure of symptom overreporting embedded within the Neurobehavioral Symptom Inventory, a component of the comprehensive evaluation that assesses postconcussive symptom severity. The Validity-10 is composed of 10 unlikely/low-frequency items and a validated cutoff score to identify postconcussive symptom overreporting. We examined the items and cutoff used in the initial development and validation study of the Validity-10 through retrospective chart reviews of 331 treatment-seeking Veterans who sustained an mTBI. The Validity-10 exhibited significant relationships with psychiatric variables, VA service connection, and neuropsychological performance validity (all p < 0.01), but nonsignificant relationships with demographic and injury variables (all p > 0.05). Furthermore, the Validity-10 modestly predicted neuropsychological performance validity test failure over and above psychiatric comorbidities and VA service connection. The present study supports the use of the Validity-10 to assess symptom validity in treatment-seeking OIF/OEF Veterans with a history of mTBI. [ABSTRACT FROM AUTHOR]

Objective: Although white matter hyperintensity (WMH) pathology has been observed in the context of traumatic brain injury (TBI), the contribution of this type of macrostructural damage to cognitive and/or post-concussive symptomatology (PCS) remains unclear. Methods: Sixty-eight Veterans (mTBI = 46, Military Controls [MCs] = 22) with and without history of mild TBI (mTBI) underwent structural MRI and comprehensive cognitive and psychiatric assessment. WMH volume was identified as deep (DWMH) or periventricular (PVWMH) on fluid-attenuated inversion recovery (FLAIR) images. Results: Group analyses revealed that mTBI history was not associated with increased WMH pathology (p’s > 0.05). However, after controlling for post-traumatic stress disorder (PTSD) and intracranial volume, DWMH was associated with reduced short-and long-delayed memory performance within the mTBI group (p’s < 0.05). Additionally, after adjusting for PTSD and time since injury, regression analyses revealed that WMH was not associated with self-reported ratings of PCS (p’s > 0.05) in the mTBI group. Conclusions: The results demonstrate that, in relatively young Veterans with mTBI, DWMH differentially and negatively affects memory performance above and beyond the effects of PTSD symptoms. The findings may help to clarify prior mixed results as well as offer focused treatment implications for Veterans with history of neurotrauma and evidence of macrostructural white matter damage. [ABSTRACT FROM PUBLISHER]

Objectives To describe the prevalence and persistence of headache and associated conditions in an inception cohort of U.S. veterans of Iraq and Afghanistan wars. Background Iraq and Afghanistan war veterans (IAV) suffer from persistent and difficult-to-treat headaches that have been found to co-occur with traumatic brain injury (TBI) and other deployment related comorbidities. Methods This longitudinal retrospective cohort study used data from the national Veterans Health Administration (VA) data repository for IAV who first received VA care in 2008 (baseline) and also received care each year in 2009, 2010, and 2011. We used ICD-9-CM codes, to identify those treated for headache each year (2008-2011). Individuals with headache diagnosed each year were classified as having persistent headache. We also identified comorbidities that may be associated with baseline headache using algorithms validated for use with ICD-9-CM codes. Comorbidities included TBI, posttraumatic stress disorder (PTSD), depression, and conditions associated with these diagnoses (anxiety, memory/attention/cognition, neck pain, tinnitus/hyperacusis, photosensitivity/photo blurring, insomnia, malaise/fatigue, and vertigo/dizziness). Multivariable logistic regression analysis was used to determine characteristics associated with baseline headache as well as those associated with persistent headache. Results Among all IAV, 38,426 received their first year of VA care in 2008 and had care each year 2009-2011: 13.7% of these were diagnosed with headache in 2008. Veterans diagnosed with headache in 2008 were more likely than those without a headache diagnosis to also have a diagnosis of TBI alone (adjusted odds ratios [AOR] 6.75; 95% CI 5.79-7.86), TBI + depression (AOR 7.09; 95% CI 5.23-9.66), TBI + PTSD (AOR 10.16; 95% CI 8.96-11.53), TBI + PTSD + depression (AOR 9.40; 95% CI 8.12-10.09), and neck pain (AOR 2.44; 95% CI 2.14-2.77). Among those with headache diagnosis in 2008, 24.3% had a headache diagnosis each of the subsequent years of care (persistent headache). While diagnoses of TBI, PTSD, and/or depression at baseline were not associated with headache persistence, persistence was more likely for individuals with baseline tinnitus/hyperacusis (AOR 1.21; 95% CI 1.02-1.45), insomnia (AOR 1.19; 95% CI 1.02-1.39), and vertigo/dizziness (AOR 1.83; 95% CI 1.30-2.57). Conclusions Our results indicate that TBI alone is a strong predictor of headache in the first year of VA care among IAV and that comorbid psychiatric comorbidities increase the likelihood of headache among individuals with TBI. However, among those with baseline headache, only tinnitus, insomnia, and vertigo were baseline clinical predictors of headache persistence. These results suggest that attention to other symptoms and conditions early in the diagnosis and treatment of headaches may be important for understanding prognosis. These comorbidities offer potential targets for intervention strategies that may help address postdeployment headaches. [ABSTRACT FROM AUTHOR]

Objective: To investigate the rates of negative outcomes associated with all severities of traumatic brain injury (TBI), treated in all settings or not treated at all, in comparison to the general population. Participants: Coloradoans without injury, with injury but no TBI, with mild TBI but no loss of consciousness (LOC), mild TBI with LOC,moderate TBI, or severe TBI. Design: Statewide population-based survey. Main measures: Computer-assisted,modified Ohio State University TBI Identification Method; Behavioral Risk Factor Surveillance System and National Health Interview Survey questions; Satisfaction with Life Scale; and postconcussive symptoms. Results: Up to 42.5% of participants reported a lifetime history of at least 1 TBI. Multiple negative outcomes were found to increase in prevalence in a stepwise fashion in association with greater TBI severity, with the clearest patterns observed for disability, poor life satisfaction, and impaired memory. Conclusions: Traumatic brain injury was found to be associated with disability and other negative outcomes in a general population survey. This study does not allow us to examine the proximate causes of disability, but it suggests that TBI may serve to both cause disability directly and exacerbate the influence of other etiologies. These relations should be examined in subsequent studies. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Objective: To assess the relationship between postconcussive symptoms and quality of life (QOL) in Veterans with mild to moderate traumatic brain injury (TBI). Methods: Sixty-one Operation Enduring Freedom/Operation Iraqi Freedom/Persian Gulf War Veterans with a history of mild or moderate TBI, more than 6 months postinjury, and 21 demographically matched Veteran controls were administered self-report measures of QOL (World Health Organization Quality of Life--BREF) and postconcussive symptom severity (Neurobehavioral Symptom Inventory). Results: Perceived QOL was significantly worse in Veterans with mild-moderate TBI than in controls. In the TBI group, QOL was predominantly associated with affective symptoms, and moderate to strong correlations with fatigue and depression were evident across all QOL areas. Multivariate analyses revealed depression and fatigue to be the best predictors of Psychological, Social, and Environmental QOL, whereas sleep difficulty best predicted Physical QOL in mild-moderate TBI. Conclusion: Veterans with post-acute mild-moderate TBI evidence worse QOL than demographically matched Veteran controls. Affective symptoms, and specifically those of fatigue, depression, and sleep difficulty, appear to be the most relevant postconcussive symptoms predicting QOL in this population. These ?indings underscore the importance of examining specific symptoms as they relate to post-acute TBI QOL and provide guidance for treatment and intervention studies. [ABSTRACT FROM AUTHOR]

Cognitive difficulties are frequently reported by Operation Iraqi Freedom/Operation Enduring Freedom military personnel who sustained mild traumatic brain injuries (TBIs). The current study examined several potential factors that may contribute to self-reported cognitive difficulties in postdeployment clinical settings. Eighty-four subjects who sustained a mild or moderate TBI and reported cognitive difficulties underwent neurocognitive testing. Multiple regression analyses were used to determine the amount of variance in neurocognitive performance accounted for by the predictor variables (demographic, mechanism of injury, time since injury, headache severity, combat stress, postconcussive complaints, and effort/performance validity). The predictor variables collectively accounted for 51.7% of the variance in cognitive performance (F (8,72) = 11/99, p < 0.001). The most potent predictor of cognitive functioning was performance validity/ effort, which uniquely accounted for 16.3% of the variance (p < 0.01). Self-reported symptom severity, including postconcussive complaints, combat stress, and headache intensity, accounted for 7.2% of the variance (p < 0.05). Demographic factors and injury characteristics, such as time since injury and mechanism of injury, were not significant predictive factors of cognitive performance. The findings of the current study underscore the need to include measurement of effort as part of neurocognitive evaluation in postdeployment settings when evaluating cognitive complaints associated with mild TBI. [ABSTRACT FROM AUTHOR]

BACKGROUND: A minority of pediatric patients who have mild traumatic brain injury (mTBI) report persistent postconcussive symptoms. In adults, failure on validity tests, which help to detect exaggerated or feigned problems, is associated with symptom complaints. No pediatric studies have examined the relationship between validity test performance and symptom report. We hypothesized that children failing a validity test would report significantly more postconcussive symptoms than those passing. METHODS: Using a consecutive clinical case series design, we examined 191 patients aged 8 to 17 years seen for neuropsychological evaluation after mTBI. Participants were administered a validity test (Medical Symptom Validity Test; MSVT) and completed a graded symptom scale as part of a neuropsychological battery. RESULTS: A total of 23 participants (12%) failed the MSVT. The Fail group endorsed significantly more postconcussive symptoms than the Pass group, with a large effect size (P < .001; d = 1.1). MSVT performance remained a robust unique predictor of symptom report even after controlling for other influential factors (eg, female gender, premorbid psychiatric problems). CONCLUSIONS: A subset of children who had persistent complaints after mTBI may be exaggerating or feigning symptoms. If such negative response bias remains undetected, errors in etiologlc statements and less than optimal treatment may occur. Because the detection of invalid responding is well established in neuropsychology, clinical neuropsy- chologists should be incorporated routinely Into clinical care for patients who have persistent complaints. To better control for noninjury effects in future pediatric mTBI studies, researchers should add validity tests to neurobehavioral outcome batteries. [ABSTRACT FROM AUTHOR]

Objective: To empirically identify latent classes of service members according to persistent postconcussive symptom patterns and to characterize the identified classes relative to other postdeployment variables including posttraumatic stress disorder (PTSD) and mild traumatic brain injury (TBI) screening results. Such comparisons may directly inform policy regarding these routine assessments and translate to improved treatment decisions. Method: Self-report data were obtained for 12,581 combat-exposed male U.S. Navy and Marine Corps personnel who returned from deployment in 2008-2009 and completed a Post-Deployment Health Assessment (PDHA) and an associated Post-Deployment Health Reassessment (PDHRA). Persistent postconcussive symptoms indicated on the PDHRA were used as manifest variables in a latent class analysis yielding 4 distinct classes: systemic, cognitive/behavioral, comorbid, and nonpresenting. Results: Although the nonpresenting class endorsed few or no postconcussive symptoms, the systemic and cognitive/behavioral classes displayed elevated likelihoods of neurological and mental health symptoms, respectively. Members of the comorbid class had an increased probability of reporting a wide range of symptoms across both domains. Characterization of identified classes suggested that class membership may indicate the presence or absence of persistent conditions resulting from head injury and/or mental health issues. Under this assumption, estimated class membership probabilities implied a rate of probable neurological injury among this sample to be 17.9%, whereas the standard assessments aimed at identifying repercussions of mild TBI reported a positive screening rate of only 13.1%. Conclusions: Findings suggest that the routinely administered PDHA and PDHRA appear to underestimate the true prevalence of service members experiencing postdeployment health problems. Supplemental items or an alternative screening algorithm incorporating persistent postconcussive symptoms may enable identification of additional cases requiring treatment following return from deployment. [ABSTRACT FROM AUTHOR]

Traumatic brain injury (TBI) can result in cognitive impairments and persistent postconcussive symptoms that limit functional recovery, including return to work. We evaluated a 12 wk compensatory cognitive training intervention(Cognitive Symptom Management and Rehabilitation Therapy[CogSMART]) in the context of supported employment for Veterans with mild to moderate TBI. Participants were randomly assigned to receive 12 wk of supported employment plus CogSMART or enhanced supported employment that controlled for therapist attention (control). CogSMART sessions were delivered by the employment specialist and included psychoeducation regarding TBI; strategies to improve sleep, fatigue, headaches, and tension; and compensatory cognitive strategies in the domains of prospective memory, attention, learning and memory, and executive functioning. Compared with controls, those assigned to supported employment plus CogSMART demonstrated significant reductions in postconcussive symptoms (Cohen d = 0.97) and improvements in prospective memory functioning (Cohen d = 0.72). Effect sizes favoring CogSMART for posttraumatic stress disorder symptom severity, depressive symptom severity, and attainment of competitive work within 14 wk were in the small to medium range (Cohen d = 0.35-0.49). Those who received CogSMART rated the intervention highly. Results suggest that adding CogSMART to supported employment may improve postconcussive symptoms and prospective memory. These effects, as well as smaller effects on psychiatric symptoms and ability to return to work, warrant replication in a larger trial. [ABSTRACT FROM AUTHOR]

Background: Sleep problems are common among Veterans with mild traumatic brain injury (mTBI) and may contribute to participation restrictions. However, explanatory mechanisms underlying this relationship are poorly understood. Sleep problems are associated with post-concussive symptoms (e.g., headaches). In turn, post-concussive symptoms contribute to participation restrictions. We hypothesized that post-concussive symptom severity mediates the purported relationship between sleep problems and participation restrictions among Veterans with mTBI., Materials and Methods: This study was a retrospective analysis of clinical data among 8,733 Veterans with mTBI receiving Veterans Health Administration outpatient care. Sleep problems (yes/no) were identified using the sleep-related item from the Neurobehavioral Symptom Inventory (NSI). Post-concussive symptoms were measured using remaining NSI items. Participation restrictions were measured using the Mayo-Portland Adaptability Inventory Participation Index. We specified a latent variable path model to estimate relationships between: (1) sleep problems and three latent indicators of post-concussive symptoms [vestibular-sensory (e.g., headache)]; mood-behavioral [e.g., anxiety]; cognitive [e.g., forgetfulness]); and, (2) the three latent indicators of post-concussive symptoms and two latent indicators of participation restrictions (social and community participation [e.g., leisure activities]; productivity [e.g., financial management]). We examined the indirect effects of sleep problems upon participation restrictions, as mediated by post-concussive symptoms. Estimates were adjusted for sociodemographic factors (e.g., age), injury characteristics (e.g., blast), and co-morbid conditions (e.g., depression)., Results: 87% of Veterans reported sleep problems. Sleep problems were associated with greater social and community participation restrictions, as mediated by mood-behavioral ( β  = 0.41, p  < 0.001) and cognitive symptoms ( β  = 0.13, p  < 0.001). There was no evidence that vestibular-sensory symptoms mediated this relationship ( β  = -0.01, p  = 0.48). Sleep problems were associated with greater productivity restrictions, as mediated by vestibular-sensory ( β  = 0.16, p  < 0.001) and cognitive symptoms ( β  = 0.14, p  < 0.001). There was no evidence that mood-behavioral symptoms mediated this relationship ( β  = 0.02, p  = 0.37)., Discussion: Findings suggest that evidence-based sleep treatment should occupy a prominent role in the rehabilitation of Veterans with mTBI. Indirect effects of sleep problems differed when considering impact on social and community participation vs. productivity, informing individualized rehabilitative care for Veterans with mTBI., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (This work is authored by Adam R. Kinney, Xiang-Dong Yan, Alexandra Lindsay Schneider, Samuel King, Jeri E. Forster, Nazanin Bahraini and Lisa Anne Brenner on behalf of the U.S. Government and as regards Dr. Kinney, Dr. Yan, Dr. Schneider, Dr. King, Dr. Forster, Dr. Bahraini and Dr. Brenner, and the U.S. Government, is not subject to copyright protection in the United States. Foreign and other copyrights may apply.)

Several factors have been linked to severity of postconcussive-type (neurobehavioral) symptoms. In this study, predictors of neurobehavioral symptoms were examined using multivariate methods to determine the relative importance of each. Data regarding demographics, symptoms, current alcohol use, history of traumatic brain injury (TBI), orthopedic injuries, and psychiatric/developmental diagnoses were collected via questionnaire from 3027 university students. The most prominent predictors of symptoms were gender, history of depression or anxiety, history of attention-deficit/hyperactivity disorder or learning disability diagnosis, and frequency of alcohol use. Prior mild TBI was significantly related to overall symptoms, but this effect was small in comparison to other predictors. These results provide further evidence that neurobehavioral symptoms are multi-determined phenomena, and highlight the importance of psychiatric comorbidity, demographic factors, and health behaviors to neurobehavioral symptom presentation after mild TBI. (JINS, 2013, 19, 1–9) [ABSTRACT FROM PUBLISHER]