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

Objective: A new brief computerized test battery that uses tactile stimulation, Brain Gauge (BG), has been proposed as a cognitive assessment aid and its developers have reported an almost perfect ability to distinguish acute mild traumatic brain injury (mTBI) patients from healthy controls. This investigation attempted to replicate those results and serve as an initial psychometrically and clinically focused analysis of BG., Methods: BG scores from 73 military service members (SM) assessed within 7 days after having a clinically diagnosed mTBI were compared to 100 healthy SMs. Mean scores were compared, score distributions were examined, and univariate and multivariate base rate analyses of low scores were performed., Results: SMs with mTBI had statistically significantly worse performance on both BG Reaction Time (RT) tests and the Sequential Amplitude Discrimination test as reflected by higher mean RT and RT variability and higher minimum detectable amplitude difference. SMs with mTBI also had a significantly lower whole-battery composite (i.e., Cortical Metric Symptom Score). Larger proportions of SMs with mTBI had lower overall performance than controls. However, at most only 26.9% of those with mTBI performed at potentially clinically meaningful cutoffs that were defined as various numbers of low scores that were prevalent in no more than 10% of the control group, which is equivalent to specificity ≥90% and sensitivity ≤26.9% for mTBI., Conclusion: Our analysis did not replicate the high level of classification accuracy reported by BG's developers. Pending further psychometric development, BG may have limited clinical utility for assessing mTBI patients., (© The Author(s) 2022. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permission@oup.com.)

Objective: Service members are frequently diagnosed with comorbid mild traumatic brain injury (mTBI) and posttraumatic stress disorder after returning from Afghanistan and Iraq. Little is known about how mTBI in the postacute and chronic phases combined with current posttraumatic stress disorder symptoms (PTS) affects performance on the Automated Neuropsychological Assessment Metrics, Version 4, Traumatic Brain Injury-Military (ANAM4) battery used by the US military. We examined postdeployment ANAM4 performance using conventional statistical methods, as well as rates of poor performance, below established cutoffs (<10th and ≤2nd percentile)., Methods: A total of 868 soldiers were assessed for history of mTBI during the most recent deployment, as well as, lifetime mTBI, current PTS, and current pain-related symptoms. The ANAM4 was also administered., Results: Soldiers with PTS and/or mTBI performed worse on ANAM4 relative to controls with those with both conditions performing worst. However, a nontrivial minority (∼10%-30%) of individuals with mTBI, PTS, or both had scores that were at or below the second percentile., Conclusion: Our results illustrate that a combination of mTBI and PTS is associated with worse ANAM4 performance than either condition alone. Furthermore, only a minority of soldiers with any, or both, of the conditions had ANAM deficits. The long-lasting impacts and unique contribution of each condition have yet to be determined.

Objective: Computerized neurocognitive assessment tools (NCATS) are often used as a screening tool to identify cognitive deficits after mild traumatic brain injury (mTBI). However, differing methodology across studies renders it difficult to identify a consensus regarding the validity of NCATs. Thus, studies where multiple NCATs are administered in the same sample using the same methodology are warranted., Method: We investigated the validity of four NCATs: the ANAM4, CNS-VS, CogState, and ImPACT. Two NCATs were randomly assigned and a battery of traditional neuropsychological (NP) tests administered to healthy control active duty service members (n = 272) and to service members within 7 days of an mTBI (n = 231). Analyses included correlations between NCAT and the NP test scores to investigate convergent and discriminant validity, and regression analyses to identify the unique variance in NCAT and NP scores attributed to group status. Effect sizes (Cohen's f2) were calculated to guide interpretation of data., Results: Only 37 (0.6%) of the 5,655 correlations calculated between NCATs and NP tests are large (i.e. r ≥ 0.50). The majority of correlations are small (i.e. 0.30 > r ≥ 0.10), with no clear patterns suggestive of convergent or discriminant validity between the NCATs and NP tests. Though there are statistically significant group differences across most NCAT and NP test scores, the unique variance accounted for by group status is minimal (i.e. semipartial R2 ≤ 0.033, 0.024, 0.062, and 0.011 for ANAM4, CNS-VS, CogState, and ImPACT, respectively), with effect sizes indicating small to no meaningful effect., Conclusion: Though the results are not overly promising for the validity of the four NCATs we investigated, traditional methods of investigating psychometric properties may not be appropriate for computerized tests. We offer several conceptual and methodological considerations for future studies regarding the validity of NCATs., (© The Author 2017. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction Headaches after concussion are highly prevalent, relatively persistent and are being treated like primary headaches, especially migraine. Methods We studied all new patients seen between August 2008 and December 2009 assessed by a civilian headache specialist at the TBI Center at Womack Army Medical Center, Fort Bragg, NC. We report sample demographics, injuries and headache characteristics, including time from injury to headache onset, detailed descriptions and International Classification of Headache Disorders second edition primary headache diagnosis type. Results A total of 95 soldiers reported 166 headaches. The most common injury cited was a blast (53.7%). Most subjects (76.8%) recalled the onset of any headache within 7 days of injury. The most commonly diagnosed headache was a continuous type with migraine features ( n = 31 (18.7%)), followed by chronic migraine (type 1.5.1, n = 14 (8.4%)), migraine with aura (type 1.2.1, n = 10 (6.0%)), hemicrania continua (type 4.7, n = 12 (7.2%)), chronic cluster (type 3.1.2, n = 6 (3.6%)) and headaches not otherwise classifiable (type 14.1, n = 5 (3.0%)) also present. The most clinically important was a continuous headache with migraine features. Conclusion We present a series of patients seen in a military treatment facility for headache diagnosis after concussion in whom we found migraine, as well as uncommon primary headache types, at frequencies that were much higher than expected.

Objective: To describe the diagnostic types and characteristics of headaches in soldiers with mild traumatic brain injury during the wars in Afghanistan and Iraq., Background: Persistent post-traumatic headache interferes with returns to activity or duty. The most commonly cited headache diagnosis after concussion is migraine. We hypothesize that headache diagnosis type, eg, migraine, is not sufficient to predict relationships with occupational outcomes after concussion., Methods: The study sample consisted of all new patients referred for headache evaluation at the Brain Injury Center at Womack Army Medical Center over a 1-year time period. The design was retrospective and observational. Clinical data reported included demographics, causes of injury, headache characteristics, and headache diagnosis type. After reviewing records for retention or severance from military service, the primary occupational outcome measure was departure from service due to medical cause as determined by a Medical Evaluation Board (MEB). The primary outcome measure was to test the strength of association between leaving service for MEB and headache characteristics or diagnosis., Results: A total of 95 patients (94% male) with concussion described 166 distinct headache types, the most common being migraine (60%) and trigeminal autonomic cephalalgia (24%). A total of 25% of all patients remained on active duty. A continuous headache of any type was present in 75% of patients and of these, 23% remained on active duty. Of the 51% of patients who had both a continuous and non-continuous headache, 17% remained on active duty (P < .001). Therefore, we report that a continuous headache, regardless of diagnosis type was associated with negative occupational outcomes. Regardless of headache duration, headache diagnosis type alone was not associated with soldiers' separations from service., Conclusions: Persistent post-traumatic headache is most likely to present with continuous pain. Migraine is the most common primary diagnosis type. The presence of a continuous headache was strongly associated with negative occupational outcomes. Primary headache diagnosis type was not. Headache characteristics, therefore, may be more important than diagnosis type when determining active duty status. Further prospective research is indicated., (© 2017 American Headache Society.)

Computerized neurocognitive assessment tools (NCATs) have become a common way to assess postconcussion symptoms. As there is increasing research directly comparing multiple NCATs to each other, it is important to consider the impact that order of test administration may have on the integrity of the results. This study investigates the impact of administration order in a study of four different NCATs; Automated Neuropsychological Assessment Metrics (ANAM4), CNS Vital Signs (CNS-VS), CogState, and Immediate Post-Concussion Assessment and Cognitive Test (ImPACT). A total of 272 healthy active duty Service Members were enrolled into this study. All participants were randomly assigned to take two of the four NCATs with order of administration counterbalanced. Analyses attempted to investigate the effect of administration order alone (e.g., Time 1 versus Time 2), the effect of administration order combined with the impact of the specific NCAT received at Time 1, and only the impact of the Time 1 NCAT on Time 2 score variability. Specifically, independent samples t tests were used to compare Time 1 and Time 2 scores within each NCAT. Additional t tests compared Time 1 to Time 2 scores with Time 2 scores grouped by the NCAT received at Time 1. One-way analysis of variance (ANOVA) was used to compare only an NCAT's Time 2 scores grouped by the NCAT received at Time 1. Cohen's d effect sizes were calculated for all comparisons. The results from this study revealed statistically significant order effects for CogState and CNS-VS, though with effect sizes generally indicating minimum practical value, and marginal or absent order effects for ANAM4 and ImPACT with no clinically meaningful implications. Despite finding minimal order effects, clinicians should be mindful of the impact of administering multiple NCATs in a single session. Future studies should continue to be designed to minimize the potential effect of test administration order.

Computerized neurocognitive assessment tools (NCATs) are increasingly used for baseline and post-concussion assessments. To date, NCATs have not demonstrated strong test-retest reliabilities. Most studies have used non-military populations and different methodologies, complicating the determination of the utility of NCATs in military populations. The test-retest reliability of four NCATs (Automated Neuropsychological Assessment Metrics 4 [ANAM4], CNS-Vital Signs, CogState, and Immediate Post-Concussion Assessment and Cognitive Test [ImPACT]) was investigated in a healthy active duty military sample. Four hundred and nineteen Service Members were randomly assigned to take one NCAT and 215 returned after approximately 30 days for retest. Participants deemed to have inadequate effort during one or both testing sessions, according to the NCATs scoring algorithms, were removed from analyses. Each NCAT had at least one reliability score (intraclass correlation) in the "adequate" range (.70-.79), only ImPACT had one score considered "high" (.80-.89), and no scores met "very high" criteria (.90-.99). However, overall test-retest reliabilities in four NCATs in a military sample are consistent with reliabilities reported in the literature and are lower than desired for clinical decision-making.

Objective: To investigate the potential cumulative impact of mild traumatic brain injury (MTBI) on postconcussive symptoms., Participants: A total of 224 active duty soldiers reporting MTBI within 1 year of testing. For 101, this MTBI was their only reported traumatic brain injury (TBI); 123 had sustained at least 1 additional MTBI during their lifetime. A No TBI control group (n = 224) was included for comparison., Main Measure: Self-report symptoms data via questionnaire. Within time since injury subgroups (≤3 months; Post-3 months), symptom endorsement (no symptoms, 1 or 2 symptoms, 3+ symptoms) among soldiers with 1 MTBI was compared with that of soldiers with 2 or more MTBIs. Injured soldiers' symptom endorsement was compared with that of soldiers who had not sustained a TBI., Results: Among the recently injured (≤3 months), those with 2 or more MTBIs endorsed significantly more symptoms than those with 1 MTBI: 67% of soldiers with 2 or more MTBIs reported 3+ symptoms, versus 29% of One MTBI soldiers. Among Post-3 month soldiers, there were no significant differences between MTBI groups. Overall, soldiers with MTBI endorsed significantly more symptoms than those without TBI., Conclusion: Past experience of MTBI may be a risk factor for increased symptom difficulty for several months postinjury. Clinicians should ascertain lifetime history of brain injury when evaluating patients for MTBI.