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Objective: To identify distinct subgroups of veterans with mild traumatic brain injury (mTBI) based on configurations of postconcussive symptom (PCS) endorsement, and to examine predictors of subgroup membership., Setting: Outpatient Veterans Health Administration (VHA)., Participants: Veterans with clinician-confirmed mTBI who completed the Neurobehavioral Symptom Inventory (NSI), determined using the Comprehensive Traumatic Brain Injury Evaluation database. Individuals who tended to overreport symptoms were excluded via an embedded symptom validity scale., Design: Retrospective cohort study leveraging national VHA clinical data from 2012 to 2020. Latent class analysis (LCA) with a split-sample cross-validation procedure was used to identify subgroups of veterans. Multinomial logistic regression was used to examine predictors of subgroup membership., Main Measures: Latent classes identified using NSI items., Results: The study included 72 252 eligible veterans, who were primarily White (73%) and male (94%). The LCA supported 7 distinct subgroups of veterans with mTBI, characterized by diverging patterns of risk for specific PCS across vestibular (eg, dizziness), somatosensory (eg, headache), cognitive (eg, forgetfulness), and mood domains (eg, anxiety). The most prevalent subgroup was Global (20.7%), followed by Cognitive-Mood (16.3%), Headache-Cognitive-Mood (H-C-M; 16.3%), Headache-Mood (14.2%), Anxiety (13.8%), Headache-Sleep (10.3%), and Minimal (8.5%). The Global class was used as the reference class for multinomial logistic regression because it was distinguished from others based on elevated risk for PCS across all domains. Female (vs male), Black (vs White), and Hispanic veterans (vs non-Hispanic) were less likely to be members of most subgroups characterized by lesser PCS endorsement relative to the Global class (excluding Headache-Mood)., Conclusion: The 7 distinct groups identified in this study distill heterogenous patterns of PCS endorsement into clinically actionable phenotypes that can be used to tailor clinical management of veterans with mTBI. Findings reveal empirical support for potential racial, ethnic, and sex-based disparities in PCS among veterans, informing efforts aimed at promoting equitable recovery from mTBI in this population., Competing Interests: The authors declare no conflicts of interest.

Objective: To understand factors influencing adherence to recommended treatment for insomnia and obstructive sleep apnea (OSA) among Veterans with mild traumatic brain injury (mTBI)., Method: Semi-structured interviews ( n  = 49) with 29 clinical stakeholders and 20 Veterans were conducted. Clinical stakeholders included Veterans Health Administration providers and policymakers involved in the management of mTBI and/or sleep disorders. Veterans included those with a clinician-confirmed mTBI with a recent history of insomnia disorder and/or OSA treatment. Themes were identified using a Descriptive and Interpretive approach., Results: Barriers to sleep disorder treatment adherence included factors associated with the patient (e.g., negative appraisal of treatment benefit), intervention (e.g., side effects), health conditions (e.g., cognitive challenges), health care system (e.g., limited availability of care), and socioeconomic status (e.g., economic instability). Similarly, facilitators of adherence included patient- (e.g., positive appraisal of treatment benefit), intervention- (e.g., flexible delivery format), condition- (e.g., accommodating cognitive impairments), health care system- (e.g., access to adherence support), and socioeconomic-related factors (e.g., social support)., Conclusions: Interviews revealed the multi-faceted nature of factors influencing adherence to sleep disorder treatment among Veterans with mTBI. Findings can inform the development of novel interventions and care delivery models that meet the complex needs of this population.

Study Objectives: We elicited perspectives of clinical stakeholders and Veterans regarding barriers and facilitators to implementing shared decision-making (SDM) for comorbid mild traumatic brain injury (mTBI) and sleep disorders in the Veterans Health Administration. We also compared the perspectives of clinical stakeholders and Veterans regarding determinants of SDM., Methods: Semistructured interviews were conducted with 29 clinical stakeholders and 20 Veterans (n = 49). Clinical stakeholders included Veterans Health Administration providers and policymakers involved in the management of mTBI and/or sleep disorders (insomnia disorder, obstructive sleep apnea). Veterans included those with a clinician-confirmed mTBI who received care for insomnia disorder and/or obstructive sleep apnea within the past year. Themes were identified using a descriptive and interpretive approach to qualitative analysis. We compared results across clinical stakeholders and Veterans., Results: Barriers to implementing SDM were identified by both groups at the patient (eg, mTBI sequalae), provider (eg, deprioritization of Veteran preferences), encounter (eg, time constraints), and facility levels (eg, reduced care access). Similarly, both groups identified facilitators at the patient (eg, enhanced trust), provider (eg, effective communication), encounter (eg, decision support), and facility levels (eg, mitigating access barriers). Integrated services and provider discontinuity were factors identified by clinical stakeholders and Veterans alone, respectively., Conclusions: Our study revealed factors shaping the implementation of SDM at the levels of the patient, provider, encounter, and facility. Findings can inform the development of strategies aimed at implementing SDM for comorbid mTBI and sleep disorders, promoting patient-centered care and enhancing clinical outcomes., Citation: Kinney AR, Brenner LA, Nance M, et al. Factors influencing shared decision-making for insomnia and obstructive sleep apnea treatment among Veterans with mild traumatic brain injury. J Clin Sleep Med . 2024;20(5):801-812., (© 2024 American Academy of Sleep Medicine.)

Objective: To investigate whether participation restrictions, an indicator of need for occupational therapy (OT), was associated with outpatient OT utilization in the Veterans Health Administration (VHA) among Veterans with mild traumatic brain injury (mTBI), and whether this relation differs by facility characteristics., Design: In a secondary analysis of national VHA data, we used modified Poisson regression to model OT utilization (yes/no) as a function of participation restrictions (Mayo-Portland Adaptability Inventory Participation Index [M2PI]), facility characteristics, and covariates. Facility characteristics included complexity, geographic region, and self-reported access to specialty care. Covariates included prior OT utilization, sociodemographic factors, injury characteristics, and spatial access (eg, drive time). Interactions estimated whether the relation between participation restrictions and OT utilization differed across facility characteristics., Setting: Outpatient setting in the VHA., Participants: 8684 Veterans with a clinician-confirmed mTBI who received outpatient VHA care between 2012 and 2020 (N=8684)., Interventions: None., Main Outcome Measure(s): OT utilization was measured within a year of M2PI administration using VHA administrative data., Results: Many Veterans who did not receive OT reported participation limitations, indicating unmet need for OT (eg, 67% with leisure restrictions). Participation restrictions were associated with increased likelihood of receiving OT (risk ratio [RR]=1.01; 95% confidence interval [CI]=1.006-1.019), suggesting a tendency for Veterans' OT-related needs to be satisfied. However, interactions indicated that this was not the case among Veterans receiving care in lower complexity facilities, and those in the South. Veterans with longer drive times were less likely to receive OT (RR=0.82; 95% CI=0.744-0.904)., Conclusions: Participation restrictions were associated with OT utilization, yet many Veterans with mTBI who may have benefited did not receive such care. Specific barriers to accessing OT (eg, OT practitioner supply) should be investigated. Novel care models can ensure access to OT services among Veterans seeking care at less-resourced and/or geographically distant VHA facilities., (Published by Elsevier Inc.)

Objective: To examine racial and ethnic differences in suicide and drug and opioid-related overdose deaths among a population-based cohort of military service members who were diagnosed with a mild traumatic brain injury (mTBI) during military service., Design: Retrospective cohort., Setting: Military personnel receiving care within the Military Health System between 1999 and 2019., Participants: In total, 356 514 military members aged 18 to 64 years, who received an mTBI diagnosis as their index TBI between 1999 and 2019, while on active duty or activated., Main Measures: Death by suicide, death by drug overdose, and death by opioid overdose were identified using International Classification of Diseases, Tenth Revision (ICD-10) codes within the National Death Index. Race and ethnicity were captured from the Military Health System Data Repository., Results: Overall crude rates were 38.67 per 100 000 person-years for suicide; 31.01 per 100 000 person-years for drug overdose death; and 20.82 per 100 000 person-years for opioid overdose death. Crude and age-specific rates for military members who self-identified as Other were higher than all other racial/ethnic groups for all 3 mortality outcomes. Adjusting for age, suicide rates for those classified as Other were up to 5 times that of other racial/ethnic groups for suicide, and up to 11 and 3.5 times that of other race/ethnicity groups for drug and opioid overdose death, respectively., Conclusion: Findings extend previous knowledge regarding risk for suicide and deaths by drug overdose among those with mTBI and highlight new important areas for understanding the impact of race and ethnicity on mortality. Methodological limitations regarding classification of race and ethnicity must be addressed to ensure that future research provides a better understanding of racial and ethnic disparities in suicide and drug overdose mortality among military members with TBI., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: Psychosocial factors, including combat-related distress (e.g., posttraumatic stress disorder [PTSD]), contribute to postconcussive symptoms (PCS) among veterans with mild traumatic brain injury (mTBI). However, research on risk factors for PCS has focused solely on life-threatening combat experiences, neglecting the morally injurious dimension of combat-related trauma and associated implications for treatment. Morally injurious events (MIEs) are associated with PTSD symptoms among veterans, a robust risk factor of PCS. Nonetheless, the interplay between MIEs, PTSD symptoms, and PCS remains poorly understood. We sought to investigate MIEs as an indirect risk factor for PCS among Veterans with mTBI., Method: This cross-sectional study of 145 veterans with mTBI used path analysis to investigate whether PTSD symptoms mediated the relationship between MIEs (transgressions and betrayals) and PCS (mood-behavioral, vestibular-sensory, and cognitive domains) among 145 veterans with mTBI. We used the Moral Injury Event Scale, PTSD Checklist-Civilian Version, and Neurobehavioral Symptom Inventory to measure MIEs, PTSD, and PCS, respectively., Results: Perceived transgressions were indirectly associated with mood-behavioral (β = .21, p = .005), vestibular-sensory (β = .17, p = .005), and cognitive PCS (β = .20, p = .005), as mediated by PTSD. Greater transgressions were associated with more severe PTSD (β = .27, p = .003), and greater PTSD was associated with more severe mood-behavioral (β = .79, p < .001), vestibular-sensory (β = .64, p < .001), and cognitive PCS (β = .73, p < .001). Betrayals were not indirectly associated with PCS., Conclusions: Findings offer preliminary support for responses to MIEs being a modifiable risk factor for PCS among veterans. Interventions designed to foster veterans' recovery by targeting the unique emotions and beliefs associated with MIEs may be indicated. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Objective: Understand barriers and facilitators of implementing recommended practices for postconcussive sleep disturbance and headache, as outlined in the Veterans Administration/Department of Defense 2016 Clinical Practice Guideline (CPG) for mild traumatic brain injury (mTBI)., Design: Convergent parallel mixed methods., Setting: Ten national Veterans Health Administration (VHA) facilities., Participants: Twenty VHA stakeholders (14 clinicians; 4 researchers; 2 policymakers), 55% of whom were affiliated with a VHA polytrauma rehabilitation center (N=20)., Interventions: None., Main Outcome Measures: Stakeholders rated the quality of recommendations for sleep disturbance and headache using the Appraisal of Guidelines Research and Evaluation-Recommendations Excellence instrument. A descriptive analysis of item scores was performed to understand the following features of the recommendations: (1) clinical credibility (eg, evidence quality), (2) alignment with stakeholder values, and (3) implementability. We conducted semistructured interviews with stakeholders and used descriptive and interpretive analyses to reveal emergent themes. After analyzing the Appraisal of Guidelines Research and Evaluation-Recommendations Excellence and qualitative interview data, we synthesized the results into coherent conclusions (ie, meta-inferences) by comparing and contrasting respective findings., Results: Stakeholders highlighted that the mTBI CPG includes features that reflect clinical priorities (eg, alignment with veteran preferences), making it an appropriate standard of care and facilitating its implementation. However, stakeholders also identified that the design of the mTBI CPG, along with provider-level (eg, knowledge) and facility-level (eg, resources) factors, may create barriers for implementation. In addition to these potential barriers, stakeholders noted a lack of comprehensive and systematic efforts designed to promote the uptake of these recommendations. Findings also revealed stakeholder recommendations for addressing potential barriers (eg, decision support)., Conclusions: With the recent release of the 2021 mTBI CPG, decision makers are encouraged to incorporate information gathered from previous implementation efforts to promote adherence to updated recommendations. Study findings, including recommended changes suggested by stakeholders, offer information that can be leveraged to design such efforts and promote care quality and associated outcomes for veterans with mTBI., (Published by Elsevier Inc.)

Objective: To evaluate the feasibility and potential benefits of a manualized, brief cognitive-behavioral therapy-based intervention program for children and adolescents with persistent postconcussive symptoms., Setting: Two outpatient pediatric concussion programs in the United States., Participants: Patients aged 8 to 17 years who sustained concussions between 2 and 12 months prior to enrollment., Design: Pre-/postretrospective study., Main Measures: SCAT-3; HBI; PedsQL 4.0 Generic Core Scales; and RCADS., Results: Thirty children and adolescents completed the treatment program. Self- and parent-reported postconcussive symptoms, quality of life, and internalizing symptoms significantly improved with treatment. Mixed-effects models revealed a significant decline in self-reported postconcussive symptoms across treatment sessions, a = -2.07, SE = 0.25, P < .001. The largest change occurred between sessions 2 and 3, following the session focusing on concussion psychoeducation and sleep hygiene (estimated mean change between sessions 2 and 3 = -4.72, P < .0001)., Conclusions: Our findings indicate that a 6-session manualized cognitive behavioral intervention is feasible to initiate in an outpatient clinic 1 to 12 months following a pediatric mild traumatic brain injury. With a manualized format, clinicians at most levels of training should be able to implement this treatment manual and flexibly adapt as needed when working with children and adolescents who are experiencing delayed symptom recovery following concussion., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To evaluate the association between distal moderate/severe traumatic brain injury (TBI) history and the human gut microbiome., Setting: Veterans Affairs Medical Center., Participants: Veterans from the United States-Veteran Microbiome Project (US-VMP). Veterans with moderate/severe TBI (n = 34) were compared with (1) Veterans with a history of no TBI (n = 79) and (2) Veterans with a history of no TBI or mild TBI only (n = 297)., Design: Microbiome analyses from 16S rRNA gene sequencing with gut microbiota function inferred using PICRUSt2., Main Measures: α-Diversity and β-diversity of the gut microbiome, as well as taxonomic and functional signatures associated with moderate/severe TBI., Results: There were no significant differences in gut bacterial α- and β-diversity associated with moderate/severe TBI status. No differentially abundant taxa were identified when comparing samples from moderate/severe TBI to those with no TBI or no TBI/mild TBI., Conclusion: Results suggest that moderate/severe TBI-related changes to the gut microbiome do not persist for years postinjury.

Objective: Evaluate postconcussive symptom reporting and recovery., Setting: Public high school., Participants: Unmatched controls (n = 760); students who sustained a sports-related concussion (n = 77); matched controls (gender, grade, sport) (n = 77)., Design: Prospective longitudinal cohort study., Outcome Measure: Immediate Postconcussion Assessment and Cognitive Testing., Results: At baseline, athletes who went on to sustain concussions were more likely than unmatched controls to be younger (P = .02), male (P = .001), and participate in different sports (P < .0001) such as football (concussed = 52%, unmatched controls = 20%). Differences were also noted regarding a previous history of concussion (P = .045; concussed athletes = 26%; unmatched control athletes = 16%) and lifetime number of concussions (P = .05). At baseline, those whose sustained concussions during the study period were more likely than matched controls to report numbness (P = .01) and concentration problems (P = .01) and more likely than unmatched controls to report dizziness (P = .02), sensitivity to light (P = .01), sensitivity to noise (P = .002), and numbness (P = .02). However, when data were reanalyzed and those with a previous history of concussion were removed, differences between those who sustained concussions during the study period and matched controls were no longer significant; when compared to unmatched controls, sensitivity to light (P = .01) and vision problems (P = .04) remained significant. Among those who sustained concussions, median time to recovery was 6 days (95% confidence interval: 4-9), and 71 out of 77 (92%) recovered by the fourth postinjury evaluation (median: 20 days postinjury)., Conclusions: Course and time frame of recovery were variable. Data also suggest that a previous history of concussion may be contributing to baseline symptom reporting and highlight the potential enduring impact of history of concussion on sensorimotor function. However, further research as to whether preinjury measures of sensorimotor function may increase understanding regarding concussion risk is warranted.

Objective: To investigate linear relationships between dizziness, fatigue, and depression and posttraumatic stress disorder (PTSD) and objectively measured balance performance in Veterans with remote mild traumatic brain injury (mTBI)., Setting: Academic laboratory; Veterans Affairs Medical Center., Participants: Thirty Veterans (28 men) who served in Iraq/Afghanistan and whose most recent mTBI was sustained more than 6 months prior to enrollment., Design: Cross-sectional, observational trial., Main Measures: The Computerized Dynamic Posturography-Sensory Organization Test (CDP-SOT) and the Community Balance and Mobility (CB&M) scale measured balance. Dizziness (Dizziness Handicap Inventory), fatigue (Modified Fatigue Impact Scale), depression-related symptoms (Beck Depression Inventory-II), and PTSD-related symptoms (PTSD Checklist 5) were also measured., Results: Objectively measured balance, CDP-SOT composite, was impaired (mean score of 67.9). CDP-SOT scores correlated with dizziness (r = -0.53; P = .002), fatigue (r = -0.38; P = .03), depression (r = -0.55; P = .001), and PTSD symptoms (r = -0.53; P = .002). Dizziness, time since most recent mTBI, and PTSD symptoms and depression combined explained significant variability in CDP-SOT scores (R = 0.46; P = .003), as did fatigue depression and PTSD symptoms (R = 0.33; P = .01)., Conclusions: Impaired balance was identified among the cohort. Findings suggest that dizziness, fatigue, depression and PTSD, and time since most recent mTBI may influence balance performance. Additional research is needed to identify the potentially interrelated natural histories of these co-occurring symptoms.

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, ((c) 2018 APA, all rights reserved).)