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Traumatic brain injury (TBI) is a complex health problem in military veterans and service members (V/SM) that often co-occurs with psychological and medical conditions such as posttraumatic stress disorder (PTSD) and sleep apnea. We aimed to examine if sleep apnea is associated with the presence and severity of PTSD in V/SM with TBI of all severities.The study examined participants at varying times since their TBI (Almost 32% of the sample stated they had been diagnosed with sleep apnea. In those reporting sleep apnea, 32% also had probable PTSD; 19% of those without sleep apnea had probable PTSD. The regression demonstrated sleep apnea was significantly associated with PTSD symptom severity (TBI, PTSD, and sleep apnea are often comorbid in V/SM. We expand the literature by demonstrating that sleep apnea was associated with PTSD severity. A multipronged approach to TBI rehabilitation that addresses sleep and psychological distress is recommended for enhancing health outcomes in this population. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Introduction Special Operations Forces (SOF) personnel are at increased risk for traumatic brain injury (TBI), when compared with conventional forces (CF). Prior studies of TBI in military samples have not typically investigated SOF vs. CF as specific subgroups, despite documented differences in premorbid resilience and post-injury comorbidity burden. The aim of the current study was to compare SOF vs. CF on the presence of neurobehavioral symptoms after TBI, as well as factors influencing perception of symptom intensity. Materials and Methods This study conducted an analysis of the prospective veterans affairs (VA) TBI Model Systems Cohort, which includes service members and veterans (SM/V) who received inpatient rehabilitation for TBI at one of the five VA Polytrauma Rehabilitation Centers. Of those with known SOF status (N = 342), 129 participants identified as SOF (average age = 43 years, 98% male) and 213 identified as CF (average age = 38.7 years, 91% male). SOF vs. CF were compared on demographics, injury characteristics, and psychological and behavioral health symptoms. These variables were then used to predict neurobehavioral symptom severity in univariable and multivariable analyses. Results SOF personnel reported significantly greater posttraumatic stress disorder (PTSD) symptoms but less alcohol and drug use than the CF. SOF also reported greater neurobehavioral symptoms. When examining those with TBIs of all severities, SOF status was not associated with neurobehavioral symptom severity, while race, mechanism of TBI, and PTSD symptoms were. When examining only those with mTBI, SOF status was associated with lower neurobehavioral symptoms, while PTSD severity, white race, and certain mechanisms of injury were associated with greater neurobehavioral symptoms. Conclusions Among those receiving inpatient treatment for TBI, SOF SM/V reported higher neurobehavioral and symptom severity. PTSD was the strongest predictor of neurobehavioral symptoms and should be considered an important treatment target in both SOF and CF with co-morbid PTSD/TBI. A proactive human performance approach towards identification and treatment of psychological and neurobehavioral symptoms is recommended for SOF.

The objective of this retrospective, longitudinal study was to investigate the prevalence of drinking within the recommended limits (i.e., low-risk drinking) after moderate/severe traumatic brain injury (TBI). Data were drawn from the National Institute on Disability, Independent Living, and Rehabilitation Research TBI Model Systems National Database, a longitudinal dataset closely representative of the US adult population requiring inpatient rehabilitation for TBI. The sample included 6348 adults with moderate or severe TBI (injured October 2006-May 2016) who received inpatient rehabilitation at a civilian TBI Model Systems center and completed the alcohol consumption items preinjury and 1 and 2 yrs postinjury. National Institute on Alcohol Abuse and Alcoholism guidelines define low-risk drinking as no more than 4 drinks per day for men or 3 drinks per day for women and no more than 14 drinks per week for men or no more than 7 drinks per week for women. Low-risk drinking was common both before and after TBI, with more than 30% drinking in the low-risk level preinjury and more than 25% at 1 and 2 yrs postinjury. Postinjury, most drinkers consumed alcohol in the low-risk level regardless of preinjury drinking level. Definitive research on the long-term outcomes of low-risk alcohol consumption after more severe TBI should be a high priority.

Few studies have assessed the long-term functional outcomes of traumatic brain injury (TBI) in large, well-characterized samples. Using the Traumatic Brain Injury Model Systems cohort, this study assessed the maintenance of independence between years 5 and 15 post-injury and risk factors for decline. The study sample included 1381 persons with TBI who received inpatient rehabilitation, survived to 15 years post-injury, and were available for data collection at 5 or 10 years and 15 years post-injury. The Functional Independence Measure (FIM) and Disability Rating Scale (DRS) were used to measure functional outcomes. The majority of participants had no changes during the 10-year time frame. For FIM, only 4.4% showed decline in Self-Care, 4.9% declined in Mobility, and 5.9% declined in Cognition. Overall, 10.4% showed decline in one or more FIM subscales. Decline was detected by DRS Level of Function (24% with >1-point change) and Employability (6% with >1-point change). Predictors of decline factors across all measures were age >25 years and, across most measures, having less than or equal to a high school education. Additional predictors of FIM decline included male sex (FIM Mobility and Self-Care) and longer rehabilitation length of stay (FIM Mobility and Cognition). In contrast to studies reporting change in the first 5 years post-TBI inpatient rehabilitation, a majority of those who survive to 15 years do not experience functional decline. Aging and cognitive reserve appear to be more important drivers of loss of function than original severity of the injury. Interventions to identify those at risk for decline may be needed to maintain or enhance functional status as persons age with a TBI.

PURPOSE To describe the development of the Rehabilitation Needs Survey (RNS) for persons in the chronic phase of traumatic brain injury (TBI) recovery. MATERIALS AND METHODS RNS items were generated following a literature review (January - March 2015) on the topic of rehabilitation needs and revised via consensus from an expert panel of TBI clinicians and researchers. The RNS was added to the VA TBI Model Systems longitudinal study; data collection occurred between 2015-2019. Needs were classified as current (if endorsed) or absent; if current, needs were classified as unmet if no help was received. Need frequency and association with rehabilitation outcomes were presented. RESULTS Eight studies examined rehabilitation needs and formed the initial item pool of 42 needs. This was reduced to form the 21-item RNS which was administered at year 1 (n = 260) and year 2 (n = 297) post-TBI. Number of needs endorsed was 8-9, and number of unmet needs was 1-2, on average. Number of needs was correlated with functional status, neurobehavioral symptoms, and mental health symptoms (p

Objective: To examine the impact of bright white light (BWL) exposure on sleep quality in persons with recent traumatic brain injury (TBI).Design: Randomized, controlled device-sham studySetting: 3...

To describe the association between unmet rehabilitation needs and life satisfaction 5 years after traumatic brain injury (TBI).Prospective observational cohort.Five Veterans Affairs (VA) Polytrauma Rehabilitation Centers.VA TBI Model Systems participants (N=301); 95% male; 77% white; average age, 39±14y).Not applicable.Satisfaction With Life Scale (SWLS).Average SWLS score was 22±8. Univariable analyses demonstrated several statistically significant predictors of life satisfaction, including employment status, participation, psychiatric symptom severity, past year mental health treatment, and total number of unmet rehabilitation needs (all P.05). Multivariable analyses revealed that depression and participation were each associated with life satisfaction. An ad hoc mediation model suggested that unmet rehabilitation needs total was indirectly related to life satisfaction. Total unmet rehabilitation needs ranged from 0-21 (mean, 2.0±3.4). Correlational analyses showed that 14 of the 21 unmet rehabilitation needs were associated with life satisfaction.Findings support the need for rehabilitation engagement in later stages of TBI recovery. Ongoing assessment of and intervention for unmet rehabilitation needs in the chronic phase of recovery have the potential to mitigate decline in life satisfaction.

Objective To develop a measure of global functioning after moderate-severe TBI with similar measurement precision but a longer measurement range than the FIM. Design Phase 1: retrospective analysis of 5 data sets containing FIM, Disability Rating Scale, and other assessment items to identify candidate items for extending the measurement range of the FIM; Phase 2: prospective administration of 49 candidate items from phase 1, with Rasch analysis to identify a unidimensional scale with an extended range. Setting Six TBI Model System rehabilitation hospitals. Participants Individuals (N=184) with moderate-severe injury recruited during inpatient rehabilitation or at 1-year telephone follow-up. Interventions Participants were administered the 49 assessment items in person or via telephone. Main Outcome Measures Item response theory parameters: item monotonicity, infit/outfit statistics, and Factor 1 variance. Results After collapsing misordered rating categories and removing misfitting items, we derived the Brain Injury Functional Outcome Measure (BI-FOM), a 31-item assessment instrument with high reliability, greatly extended measurement range, and improved unidimensionality compared with the FIM. Conclusions The BI-FOM improves global measurement of function after moderate-severe brain injury. Its high precision, relative lack of floor and ceiling effects, and feasibility for telephone follow-up, if replicated in an independent sample, are substantial advantages.

OBJECTIVE Describe rehabilitation needs and factors associated with unmet needs at 5 years post-traumatic brain injury (TBI). SETTING Five Veterans Affairs (VA) polytrauma rehabilitation centers (PRCs). PARTICIPANTS VA TBI Model Systems participants (N = 283; 96% male, 75%, 57% severe TBI). DESIGN Prospective observational cohort. MAIN MEASURES Rehabilitation Needs Survey (21-item survey that assesses cognitive, emotional, social, and functional needs); Craig Hospital Inventory of Environmental Factors (25-item survey of potential environmental barriers). RESULTS Participants endorsed a mean of 8 (SD: 6.2) ongoing and 3 (SD: 4.7) unmet rehabilitation needs at 5 years post-TBI. Approximately 65% of participants reported at least 1 rehabilitation need that remained unmet. The number and nature of needs differed across TBI severity groups. In unadjusted and adjusted linear regression models, Black race and environmental barriers (Craig Hospital Inventory of Environmental Factors total score) were predictive of unmet needs (P < .001). Those with greater unmet needs reported the physical environment (54%-63%), informational sources (54%), social attitudes (55%), healthcare access (40%), public policy (32%-37%), transportation availability (33%), and in-home assistance (32%) as the most frequent environmental barriers at 5 years post-TBI. CONCLUSION Veterans and Service Members continue to have rehabilitation needs at 5 years post-TBI. Veterans Affairs programs to address ongoing needs and policy to support them are needed.

Objective: The purpose of this study was to examine perceived sleep-related impairment in caregivers of individuals with traumatic brain injury (TBI). Specifically, we examined the relationship between caregiver-perceived sleep-related impairment and different aspects of health-related quality of life (HRQOL) and explored whether these relationships were moderated by the perceived level of everyday function in the person with TBI. Method: Three hundred forty-one caregivers of individuals with TBI completed surveys to determine whether the association between sleep-related impairment and HRQOL was moderated by caregiver-perceived functional impairment of the person with injury. Participants completed measures from the Patient-Reported Outcomes Measurement Information System and the TBI-CareQOL. These measures were used to examine different aspects of HRQOL: caregiver-specific HRQOL, mental HRQOL, social HRQOL, and fatigue. The Mayo-Portland Adaptability Inventory-4 was used to measure caregiver perceptions of the level of everyday function in the person with injury. Results: Results indicated that caregiver-perceived sleep-related impairment was associated with each of the four HRQOL scores. This relationship was moderated by the caregiver-reported level of everyday function in the person with TBI for both caregiver-specific HRQOL and fatigue but not mental or social HRQOL. For caregiver-specific HRQOL and fatigue, caregiver-perceived sleep-related impairment was associated with worse HRQOL for those caring for individuals with lower perceived levels of everyday function, but not for those caring for individuals with higher levels of everyday function. Conclusions: Interventions to improve caregiver sleep and HRQOL should consider both psychosocial and environmental factors (i.e., factors related to the person with the TBI). (PsycInfo Database Record (c) 2020 APA, all rights reserved).

PURPOSE/OBJECTIVE To examine the influence of traumatic brain injury (TBI) severity on the health-related quality of life of caregivers providing care to service members/veterans (SMV) following a TBI. Research Method/Design: Thirty caregivers (90.0% female; 70.0% spouse; age: M = 39.5 years, SD = 10.7) of SMVs who sustained a mild, moderate, severe, or penetrating TBI were recruited from Walter Reed National Military Medical Center and via community outreach to participate in one of six focus groups. Caregivers were classified into 3 TBI severity/caregiver groups: (a) moderate/severe/penetrating TBI caregiver group (n = 11); (b) mild TBI caregiver group (n = 10); and (c) equivocal TBI caregiver group (n = 9). Thematic analysis using a constant comparative approach was conducted with qualitative analysis software to identify common themes across the 3 severity/caregiver groups. RESULTS Eleven themes emerged: no time for self/needs last (83.3%), poor physical health (80.0%), increased stress/anxiety (76.7%), social isolation/loneliness (66.7%), lack of access to services (50.0%), impact on family life (46.7%), sleep issues (46.7%), finances/employment (36.7%), depression (30.0%), exhaustion (30.0%), and anger (16.7%). Exploratory pairwise comparisons revealed a higher proportion of the moderate/severe/penetrating TBI group endorsed 7 of the 11 themes (no time for self/needs last, increased stress/anxiety, impact on family life, sleep issues, finances/employment, exhaustion, anger, and increased stress/anxiety) compared with the other 2 groups. CONCLUSIONS/IMPLICATIONS It is important that caregivers of SMVs receive long-term support in their caregiving and parenting roles. Further work is required to understand the challenges caregivers experience in accessing services they need and how to effectively meet their needs across the care continuum. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Objective To compare Veterans Health Administration (VHA) diagnoses, health services utilization, and costs by mild traumatic brain injury (mTBI) group (blast-related [BR] mTBI vs non–blast-related [NBR] mTBI vs no mTBI) among Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF)/Operation New Dawn (OND) veterans in the Chronic Effects of Neurotrauma Consortium multicenter observational study. Design Prospective cohort study. Setting Four Veterans Affairs Medical Centers. Participants OEF/OIF/OND veterans (N=472) who used Veterans Affairs Medical Centers services between 2002-2017. Interventions Not applicable. Lifetime mTBI history was assessed via semistructured interviews. Main Outcome Measures VHA diagnoses, health services utilization, and costs. Results Relative to NBR mTBI and no mTBI, veterans with BR mTBI were more likely to be male, have greater combat, and have controlled and uncontrolled detonations exposures (median BR, 15.0 vs NBR, 3.0 vs no mTBI, 3.0). They also had higher prevalence of headache, posttraumatic stress disorder, and anxiety diagnoses. Veterans with BR had the highest site-adjusted mean annual VHA utilization (26.31 visits; 95% confidence interval [CI], 26.01-26.61) relative to NBR (20.43 visits; 95% CI, 20.15-20.71) and no mTBI (16.62 visits; 95% CI, 16.21-17.04) and highest site adjusted mean annual VHA outpatient costs ($6480; 95% CI, $5842-$7187) relative to NBR ($4901; 95% CI, $4392-$5468) and no mTBI ($4069; 95% CI, $3404-$4864). Conclusions Veterans with BR mTBI had higher exposure to combat and detonation. BR was associated with greater prevalence of select diagnoses and higher health services utilization and costs relative to NBR and no mTBI. The role of health care needs from mTBI polytrauma, other deployment-related exposures, and VHA access warrants future research.

Objective To describe the cost benefit of 4 different approaches to screening for sleep apnea in a cohort of participants with moderate to severe traumatic brain injury (TBI) receiving inpatient rehabilitation from the payor’s perspective. Design A cost-benefit analysis of phased approaches to sleep apnea diagnosis. Setting Six TBI Model System Inpatient Rehabilitation Centers. Participants Trial data from participants (N=214) were used in analyses (mean age 44±18y, 82% male, 75% white, with primarily motor vehicle–related injury [44%] and falls [33%] with a sample mean emergency department Glasgow Coma Scale of 8±5). Intervention Not applicable. Main Outcome Cost benefit. Results At apnea-hypopnea index (AHI) ≥15 (34%), phased modeling approaches using screening measures (Snoring, Tired, Observed, Blood Pressure, Body Mass Index, Age, Neck Circumference, and Gender [STOPBANG] [–$5291], Multivariable Apnea Prediction Index MAPI [–$5262]) resulted in greater cost savings and benefit relative to the portable diagnostic approach (–$5210) and initial use of laboratory-quality polysomnography (–$5,011). Analyses at AHI≥5 (70%) revealed the initial use of portable testing (–$6323) relative to the screening models (MAPI [–$6250], STOPBANG [–$6237) and initial assessment with polysomnography (–$5977) resulted in greater savings and cost-effectiveness. Conclusions The high rates of sleep apnea after TBI highlight the importance of accurate diagnosis and treatment of this comorbid disorder. However, financial and practical barriers exist to obtaining an earlier diagnosis during inpatient rehabilitation hospitalization. Diagnostic cost savings are demonstrated across all phased approaches and OSA severity levels with the most cost-beneficial approach varying by incidence of OSA.

Objective The purpose of this study was to describe incidence and assess predictors of adherence to Positive Airway Pressure (PAP) therapy for Obstructive Sleep Apnea (OSA) in persons with acquired brain injury (ABI). Methods A 2012–2015 retrospective analysis of consecutive ABI patients admitted for neurorehabilitation, referred for polysomnography (PSG), and prescribed PAP for OSA. Univariable linear regressions were conducted to examine predictors of average hours of nightly PAP use. Univariable logistic regressions were conducted to examine predictors of PAP adherence using the conventional clinical definition of ≥4 h per night ≥70% of the time. Persons with traumatic etiology were separately analyzed. Results ABI etiology was 51% traumatic, 36% stroke, and 13% other nontraumatic causes. Nearly two-thirds were nonadherent to PAP. For the overall sample, higher average nightly PAP usage was significantly predicted by positive hypertension diagnosis (β = 0.271, p = 0.019). Likewise, greater adherence based on the conventional cutoff was predicted by poorer motor functioning at hospital admission (OR = 0.98, p = 0.001) and lower oxygen saturation nadir (OR = 0.99, p = 0.003). For those with traumatic injuries, greater adherence was predicted by poorer functional status at hospital admission (OR = 0.98, p = 0.010) and positive hypertension diagnosis (OR = 0.16, p = 0.023). Conclusions In this study of hospitalized neurorehabilitation patients with ABI and comorbid OSA, predictors of adherence included lower oxygen saturation, poorer functional status and hypertension diagnosis, perhaps signifying the role of greater severity of illness on treatment adherence. High rates of refusal and nonadherence to frontline PAP therapy for sleep apnea is a concern for persons in recovery form ABI who are at a time of critical neural repair.

Objective To determine the diagnostic sensitivity and specificity and comparative effectiveness of traditional sleep apnea screening tools in traumatic brain injury (TBI) neurorehabilitation admissions. Design Prospective diagnostic comparative effectiveness trial of sleep apnea screening tools relative to the criterion standard, attended level 1 polysomnography including encephalography. Setting Six TBI Model System Inpatient Rehabilitation Centers. Participants Between May 2017 and February 2019, 449 of 896 screened were eligible for the trial with 345 consented (77% consented). Additional screening left 263 eligible for and completing polysomnography with final analyses completed on 248. Intervention Not applicable. Main Outcome Measures Area under the curve (AUC) of screening tools relative to total apnea hypopnea index≥15 (AHI, moderate to severe apnea) measured at a median of 47 days post-TBI (interquartile range, 29-47). Results The Berlin high-risk score (receiving operating curve [ROC] AUC=0.634) was inferior to the Multivariable Apnea Prediction Index (MAPI) (ROC AUC=0.780) (P=.0211; CI, 0.018-0.223) and Snoring, Tired, Observed, Blood Pressure, Body Mass Index, Age, Neck Circumference, and Gender (STOPBANG) score (ROC AUC=0.785) (P=.001; CI, 0.063-0.230), both of which had comparable AUC (P=.7245; CI, −0.047 to 0.068). Findings were similar for AHI≥30 (severe apnea); however, no differences across scales was observed at AHI≥5. The pattern was similar across TBI severity subgroups except for posttraumatic amnesia (PTA) status wherein the MAPI outperformed the Berlin. Youden's index to determine risk yielded lower sensitivities but higher specificities relative to non-TBI samples. Conclusion This study is the first to provide clinicians with data to support a choice for which sleep apnea screening tools are more effective during inpatient rehabilitation for TBI (STOPBANG, MAPI vs Berlin) to help reduce comorbidity and possibly improve neurologic outcome.

Objectives To describe patient and clinical characteristics associated with receipt of opioid medications and identify differences in sleep quality, architecture, and sleep-related respiration between those receiving and not receiving opioid medications. Setting Acute inpatient rehabilitation care for moderate to severe traumatic brain injury (TBI). Participants A total of 248 consecutive admissions for inpatient rehabilitation care following moderate to severe TBI (average age of 43.6 years), who underwent level 1 polysomnography (PSG) (average time since injury: 120 days) across 6 sites. Design Cross-sectional, secondary analyses. Main measures The PSG sleep parameters included total sleep time (TST), sleep efficiency (SE), wake after sleep onset, rapid eye movement (REM) latency, sleep staging, and arousal and awakening indices. Respiratory measures included oxygen saturation, central apnea events per hour, obstructive apnea and hypopnea events per hour, and total apnea-hypopnea index. Results After adjustment for number of prescribed medication classes, those receiving opioid medications on the day of PSG experienced increased TST relative to those not receiving opioid medications (estimated mean difference [EMD] = 31.58; 95% confidence interval [CI], 1.9-61.3). Other indices of sleep did not differ significantly between groups. Among respiratory measures those receiving opioids on the day of PSG experienced increased frequency of central sleep apnea events during total (EMD = 2.92; 95% CI, 0.8-5.0) and non-REM sleep (EMD = 3.37; 95% CI, 1.0-5.7) and higher frequency of obstructive sleep apnea events during REM sleep (EMD = 6.97; 95% CI, 0.1-13.8). Compared with those who did not, receiving opioids was associated with lower oxygen saturation nadir during total sleep (EMD = -3.03; 95% CI, -5.6 to -0.4) and a greater number of oxygen desaturations across REM (EMD = 8.15; 95% CI, 0.2-16.1), non-REM (EMD = 7.30; 95% CI, 0.3-14.4), and total sleep (EMD = 8.01; 95% CI, 0.8-15.2) Greater total apnea-hypopnea index was observed during REM (EMD = 8.13; 95% CI, 0.8-15.5) and total sleep (EMD = 7.26; 95% CI, 0.08-14.4) for those receiving opioids. Conclusion Opioid use following moderate to severe TBI is associated with an increase in indicators of sleep-related breathing disorders, a modifiable condition that is prevalent following TBI. As sleep-wake disorders are associated with poorer rehabilitation outcomes and opioid medications may frequently be administered following traumatic injury, additional longitudinal investigations are warranted in determining whether a causal relation between opioids and sleep-disordered breathing in those following moderate to severe TBI exists. Given current study limitations, future studies can improve upon methodology through the inclusion of indication for and dosage of opioid medications in this population when examining these associations.

Objective To examine the relationship between staff perceived irritability, anger, and aggression and posttraumatic stress disorder (PTSD) in veterans with traumatic brain injury (TBI) of all severity levels. Design Longitudinal cohort design. Setting Veterans Affairs Polytrauma Transitional Rehabilitation Programs. Participants Veterans and service members with TBI of all severity levels enrolled in the Veterans Affairs Polytrauma Rehabilitation Centers’ Traumatic Brain Injury Model System national database (N=240). Interventions Not applicable. Main Outcome Measure Univariable and multivariable logistic regression modeling was used to examine the association between irritability, anger, and aggression and potential risk factors, including PTSD symptoms. Irritability, anger, and aggression was measured as a single construct using an item from the Mayo-Portland Adaptability Inventory-4 that was rated by program staff at admission and discharge from the inpatient rehabilitation program. PTSD symptoms were assessed using the PTSD Checklist–Civilian Version. Results PTSD symptoms uniquely predicted program staff-rated irritability, anger, and aggression at discharge even after controlling for severity of TBI, age, male sex, education, and annual earnings. The model explained 19% of the variance in irritability, anger, and aggression. Conclusions When TBI severity and PTSD symptoms were considered simultaneously in a sample of veterans, only PTSD symptoms predicted staff-rated irritability, anger, and aggression. Given the negative outcomes linked with irritability, anger, and aggression, veterans may benefit from assessment and treatment of PTSD symptoms within rehabilitation settings.

Traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD) can negatively affect quality of life and social functioning. This study examined the relationship between PTSD and social participation in a cohort of veterans and service members (V/SM). Participants included 242 adults enrolled in the Veterans Affairs Traumatic Brain Injury Model Systems (VA TBIMS) multicenter study. Social participation was measured with the Participation Assessment with Recombined Tools-Objective. PTSD symptoms were assessed with the PTSD Checklist-Civilian Version at admission, and TBI severity was determined with the Glasgow Coma Scale. Neither TBI severity nor PTSD were associated with lower social participation at 1-year post-TBI. Marital status was the only significant predictor of social participation within this sample of V/SM with primarily moderate to severe TBI. Married V/SM with TBI reported more social participation which could lead to better rehabilitation outcomes. Unmarried V/SM may need more assistance with engagement in social activities, which can be a rehabilitation treatment target.

BackgroundTBI is a leading cause of disability among veterans and active duty military personnel, and presents an obstacle to community reintegration. Prior studies examining adult survivors of TBI pursuing postsecondary education have methodological flaws that limit the understanding the scope and severity of sequelae experienced by persons with TBI who attend college.ObjectiveTo describe (a) physical and cognitive functioning, and (b) postconcussion and mental health symptoms in veterans and military personnel (V/M) with traumatic brain injury (TBI) enrolled in postsecondary education programs after discharge from rehabilitation.MethodCross-sectional study. Participants were recruited from five Veterans Affairs (VA) Polytrauma Rehabilitation Centers, enrolled in the VA TBI Model Systems parent study, and attending school during follow-up (N= 155). Outcome measures included the Functional Independence Measure (FIM), Neurobehavioral Symptom Inventory (NSI), Post-traumatic Stress Disorder (PTSD) Checklist-Civilian version (PCL-C), Patient Health Questionnaire-Depression (PHQ-9), and Generalized Anxiety Disorder Questionnaire (GAD-7).FindingsParticipants were mostly male (92.9%) and White (81.4%), with mild (40.0%), moderate (11.5%), severe (34.5%), or very severe TBI (23.0%). Depression, anxiety, PTSD, and postconcussion symptoms were lowest in participants with very severe TBI and highest in those with mild TBI. There were no significant differences in FIM across TBI severity levels.ConclusionThis study supports the need for rehabilitation counselors, educators, and administrators to prepare future practitioners to deliver tailored services to student V/M with TBI. These services can facilitate successful community reintegration and transition into civilian school settings. Symptom profiling may inform personalized cognitive interventions to enhance these students’ academic success.

The current prospective, multi-center, longitudinal cohort study examined how veterans/service members (V/SM) changed in their irritability, anger, and aggression (IAA) scores from admission to discharge in post-acute rehabilitation settings. The goals were to identify trajectory subgroups, and explore if there were different predictors of the subgroups. V/SM (n = 346) from five Veterans Affairs TBI Model Systems Polytrauma Rehabilitation Centers participated. The sample was mostly men (92%) and identified as white (69%), black (13%), and other races (18%). Median age was 28 years, and 78% had sustained a severe TBI. Staff rated IAA at admission and discharge using the Mayo-Portland Adaptability Inventory-4 item#15. Four IAA trajectory subgroups were identified: (1) no IAA at admission or discharge (n = 89, 25.72%), (2) resolved IAA (n = 61, 17.63%), (3) delayed onset IAA (n = 31, 8.96%), and (4) persistent IAA (n = 165, 47.69%). Greater post-traumatic stress disorder (PTSD) symptoms were the only consistent predictor of belonging to all the subgroups who had IAA compared with the no IAA subgroup. We conclude that IAA had different trajectories after a TBI. The majority of V/SM had persistent impairment from IAA, a quarter of the sample had no impairment from IAA, and fewer participants had resolving or worsening IAA. Findings emphasize the importance of educating providers and family of the different ways and times that IAA can manifest after TBI. Timely diagnosis and treatment of PTSD symptoms during and after rehabilitation are critical treatment targets.

Objective Examine rates and predictors of arrests in Veterans and Service Members (V/SM) who received inpatient rehabilitation for traumatic brain injury (TBI). Setting Veterans Administration (VA) Polytrauma Rehabilitation Centers. Participants A total of 948 V/SM drawn from the VA TBI Model Systems cohort with arrest data up to 10 years post-TBI. Design Longitudinal cohort study; secondary analysis of pre-TBI characteristics predicting post-TBI arrests. Main measures Disclosure of arrests pre-TBI and up to10 years post-TBI. Results Thirty-six percent of the sample had been arrested prior to their TBI; 7% were arrested post-TBI. When considering all variables simultaneously in a multivariate model, pre-TBI mental health treatment (adjusted odds ratio [aOR] = 4.30; 95% confidence interval [CI]: 2.03-9.14), pre-TBI heavy alcohol use (aOR = 3.04; CI: 1.08-8.55), and number of follow-up interviews (aOR = 2.05; CI: 1.39-4.50) were significant predictors of post-TBI arrest. Conclusion Arrest rates of V/SM prior to TBI were consistent with rates of arrest for people of similar ages in the United States. Post-TBI rates were lower for V/SM than published rates of post-TBI arrests in civilians with TBI. As part of rehabilitation planning for V/SM with TBI, providers should assess for preinjury mental health services and alcohol misuse to (1) identify those who may be at risk for postinjury arrests and (2) provide relevant resources and/or supports.

Research Objectives To identify treatments utilized by Service Members and Veterans (SMVs) with TBI and chronic pain and characterize access barriers and facilitators to non-pharmacologic treatments. Design A secondary data analysis of SMV with TBI interview data guided by a biopsychosocial model of pain management1-3 and framework for accessing healthcare services4. Setting Five geographically diverse VA Polytrauma Rehabilitation Centers (PRC) within the Department of Veterans Affairs. Participants The secondary data analysis includes a sample of 55 SMVs with chronic TBI (>2 years) who were enrolled in VA TBI Model Systems. Half the sample had severe TBI (56%) with a mean age of 43 at time of injury, were male (93%), and married (51%). Interventions N/A. Main Outcome Measures Facilitators and barriers to accessing non-pharmacologic chronic pain treatment. Results Thematic analysis revealed that chronic pain and/or headache was a common rehabilitation need. The use of polypharmacy (including opioid use) was a common theme for those reporting chronic pain concerns. Facilitators to accessing treatment (including non-pharmacological treatments) for chronic pain included the ability to use the VA Choice Program to access community care and family or other social support to advocate for treatment. The primary barriers to accessing care for chronic pain included having insufficient information about alternative treatment options. Conclusions Despite VA/DoD clinical practice guidelines advising against using opioids in persons with documented TBI, polypharmacy emerged as a theme in this study cohort. Findings highlight facilitators and barriers to alternative evidence-based treatments with implications for practice and policy. Author(s) Disclosures None.

Study Objectives Sleep disorders affect over half of mild traumatic brain injury (mTBI) patients. Despite evidence linking sleep and neurodegeneration, longitudinal TBI-related dementia studies have not considered sleep. We hypothesized that poor sleepers with mTBI would have elevated markers of neurodegeneration and lower cognitive function compared to mTBI good sleepers and controls. Our objective was to compare biomarkers of neurodegeneration and cognitive function with sleep quality in warfighters with chronic mTBI. Methods In an observational warfighters cohort (n = 138 mTBI, 44 controls), the Pittsburgh Sleep Quality Index (PSQI) was compared with plasma biomarkers of neurodegeneration and cognitive scores collected an average of 8 years after injury. Results In the mTBI cohort, poor sleepers (PSQI ≥ 10, n = 86) had elevated plasma neurofilament light (NfL, x̅ = 11.86 vs 7.91 pg/mL, p = 0.0007, d = 0.63) and lower executive function scores by the categorical fluency (x̅ = 18.0 vs 21.0, p = 0.0005, d = –0.65) and stop-go tests (x̅ = 30.1 vs 31.1, p = 0.024, d = –0.37). These findings were not observed in controls (n = 44). PSQI predicted NfL (beta = 0.22, p = 0.00002) and tau (beta = 0.14, p = 0.007), but not amyloid β42. Poor sleepers showed higher obstructive sleep apnea (OSA) risk by STOP-BANG scores (x̅ = 3.8 vs 2.7, p = 0.0005), raising the possibility that the PSQI might be partly secondary to OSA. Conclusions Poor sleep is linked to neurodegeneration and select measures of executive function in mTBI patients. This supports implementation of validated sleep measures in longitudinal studies investigating pathobiological mechanisms of TBI related neurodegeneration, which could have therapeutic implications.

Objective: To examine the relationship between medical comorbidities and psychological health outcomes at 2 and 5 years following traumatic brain injury (TBI). Method: Veterans Affairs (VA) TBI Model System participants who completed a 2-year (n = 225) and/or 5-year (n = 283) follow-up with a comorbidities interview were included in the current study. Psychological health outcomes were assessed using the Patient Global Impression of Change (PGIC), Patient Health Questionnaire-9 (PHQ-9), and Satisfaction with Life Scale (SWLS). While controlling for known predictors of outcome, the relationship of overall comorbidity burden to psychological outcomes was examined cross-sectionally using generalized linear regression at 2 and 5 years post-TBI. Lasso regularization was used to examine relationships of specific comorbid conditions to outcome. Results: Greater comorbidity burden was significantly associated with lower satisfaction with life at 2 and 5 years post-TBI and was associated with greater depressive symptomatology at 5 years post-TBI. Chronic pain was associated with lower satisfaction with life and greater depressive symptoms at both 2- and 5-year follow-up. Sleep apnea was associated with lower satisfaction with life and greater depressive symptoms at 5-year follow-up. Rheumatoid arthritis was associated with lower satisfaction with life and lower levels of perceived improvement in health and well-being at the 5-year follow-up. Implications: Results suggest that medical comorbidities may have a cumulative impact on adverse psychological health outcomes in chronic stages of TBI. This study further highlights the complexity of patients with TBI and the importance of identifying medical comorbidities as they provide potential targets for intervention. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

The contribution of sleep disturbance to persistent cognitive symptoms following a mild traumatic brain injury (mTBI) remains unclear. Obstructive sleep apnea (OSA) is very common, yet its relationship between risk factors for developing OSA and cognitive performance in those with history of mTBI has not been investigated. The current study examined OSA risk levels and its association with cognitive performance in 391 combat-exposed, post-911 veterans and service members (median age = 37 years) enrolled in the Chronic Effects of Neurotrauma Consortium (CENC) prospective multi-center study. Participants included those with and without mTBI (n = 326 and 65, respectively). When using clinical cut-offs, those with history of mTBI were more likely to be categorized as high risk for OSA (mTBI positive = 65% vs. mTBI negative = 51%). After adjustment for TBI status and demographic variables, increased OSA risk was significantly associated with worse performance on measures of complex processing speed and executive functioning (Wechsler Adult Intelligence Scale Fourth Edition Coding, Trail Making Test, part B) and greater symptom burden (Neurobehavioral Symptom Inventory). Thus, OSA, a modifiable behavioral health factor, likely contributes to cognitive performance following mTBI. Accordingly, OSA serves as a potential point of intervention to improve clinical and cognitive outcomes after injury.

Objective The goal of this study was to examine the association between characteristics of persons with traumatic brain injury (PwTBI) and perceived sleep-related impairment of the caregivers. Method Fifty-two dyads (n = 23 civilians, n = 29 service members/veterans [SMVs]) were enrolled. Caregivers completed the Patient-Reported Outcomes Measurement Information System Sleep-Related Impairment computer adaptive test, and PwTBI completed Quality of Life in Neurological Disorders measures of depression, anxiety, anger, cognitive functioning, and upper and lower extremity functioning. Hierarchical linear regression models, stratified by civilian/SMV group, were employed to assess prediction of caregiver-perceived sleep-related impairment from emotional distress of the PwTBI (anxiety, depressed mood, and anger) and perceived functional status of the PwTBI (cognitive, upper extremity, lower extremity functioning). Results Compared with caregivers of civilians, caregivers of SMVs reported higher perceived sleep-related impairment. Regression results showed that characteristics of the PwTBI accounted for moderate amounts of variance in the sleep-related impairment of caregivers of both civilians and SMVs. Within-group analyses showed that the strongest predictor of sleep-related impairment of caregivers of civilians was self-reported cognitive function of the PwTBI (β = -0.82, p = .08); the strongest predictor of sleep-related impairment of caregivers of SMVs was self-reported anger of the PwTBI (β = 0.54, p = .07). Conclusions In both caregivers of civilians and SMVs with TBI, characteristics of the PwTBI were related to perceived caregiver sleep-related impairment. These preliminary data can inform future research with larger samples that examine the impact of multiple characteristics of the caregiver and care recipient on caregiver sleep. Findings highlight the potential importance of considering the dynamics of the dyad in rehabilitation programming not only for the PwTBI but for caregivers as well. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Objectives: Individuals with moderate–severe traumatic brain injury (TBI) experience a transitory state of impaired consciousness and confusion often called posttraumatic confusional state (PTCS). This study examined the neuropsychological profile of PTCS. Methods: Neuropsychometric profiles of 349 individuals in the TBI Model Systems National Database were examined 4 weeks post-TBI (±2 weeks). The PTCS group was subdivided into Low (n=46) and High Performing PTCS (n=45) via median split on an orientation/amnesia measure, and compared to participants who had emerged from PTCS (n=258). Neuropsychological patterns were examined using multivariate analyses of variance and mixed model analyses of covariance. Results: All groups were globally impaired, but severity differed across groups (F(40,506)=3.44; pp2 =.206). Rate of forgetting (memory consolidation) was impaired in all groups, but failed to differentiate them (F(4,684)=0.46; p=.762). In contrast, executive memory control was significantly more impaired in PTCS groups than the emerged group: Intrusion errors: F(2,343)=8.78; pp2=.049; False positive recognition errors: F(2,343)=3.70; pp2=.021. However, non-memory executive control and other executive memory processes did not differentiate those in versus emerged from PTCS. Conclusions: Executive memory control deficits in the context of globally impaired cognition characterize PTCS. This pattern differentiates individuals in and emerged from PTCS during the acute recovery period following TBI. (JINS, 2019, 25, 302–313)

Objective To update the 1995 American Academy of Neurology (AAN) practice parameter on persistent vegetative state and the 2002 case definition for the minimally conscious state (MCS) by reviewing the literature on the diagnosis, natural history, prognosis, and treatment of disorders of consciousness lasting at least 28 days. Methods Articles were classified per the AAN evidence-based classification system. Evidence synthesis occurred through a modified Grading of Recommendations Assessment, Development and Evaluation process. Recommendations were based on evidence, related evidence, care principles, and inferences according to the AAN 2011 process manual, as amended. Results No diagnostic assessment procedure had moderate or strong evidence for use. It is possible that a positive EMG response to command, EEG reactivity to sensory stimuli, laser-evoked potentials, and the Perturbational Complexity Index can distinguish MCS from vegetative state/unresponsive wakefulness syndrome (VS/UWS). The natural history of recovery from prolonged VS/UWS is better in traumatic than nontraumatic cases. MCS is generally associated with a better prognosis than VS (conclusions of low to moderate confidence in adult populations), and traumatic injury is generally associated with a better prognosis than nontraumatic injury (conclusions of low to moderate confidence in adult and pediatric populations). Findings concerning other prognostic features are stratified by etiology of injury (traumatic vs nontraumatic) and diagnosis (VS/UWS vs MCS) with low to moderate degrees of confidence. Therapeutic evidence is sparse. Amantadine probably hastens functional recovery in patients with MCS or VS/UWS secondary to severe traumatic brain injury over 4 weeks of treatment. Recommendations are presented separately.

To identify prevalence and predictors of tobacco smoking among veterans and military service members (V/SM) with traumatic brain injury (TBI) admitted for rehabilitation.Participants were drawn from the VA TBI Model Systems multicentre longitudinal research study. Tobacco smoking was assessed both preinjury and at 1- or 2-year post-TBI follow-up for 336 participants.Smoking prevalence was 32% preinjury and 28% at follow-up. Most participants had a stable smoking pattern but 12% of preinjury non-smokers became smokers at follow-up. Preinjury smoking was the strongest predictor of post-TBI smoking. Higher cognitive function also predicted smoking at follow-up. In univariate analyses, smoking was predicted by lower education, preinjury mental health (MH) history, selected TBI severity metrics, and higher functional status at rehabilitation hospital discharge (Disability Rating Scale [DRS] and motor subscale of the Functional Independence Measure [FIM]).Study findings may help clinicians and administrators recognize who is at high risk for smoking following TBI, to plan for in-hospital and postdischarge screening and interventions.

Introduction Obstructive Sleep Apnea (OSA) is prevalent after moderate to severe traumatic brain injury (TBI) and may diminish recovery when left untreated. Despite the demonstrated importance of treating OSA following TBI, assessment for OSA during or soon after inpatient rehabilitation for TBI is limited. Little is known about barriers to implementing OSA screening and early diagnosis during inpatient rehabilitation thus hindering the translation of evidence-based OSA assessment procedures into clinical practice and potentially delaying necessary OSA treatment. The current analysis explored facilitators and barriers to implementing OSA screening tools in an inpatient rehabilitation setting from the perspectives of end user stakeholders. Methods Patients, families, industry, clinical providers and administrators participated in a two-day meeting following completion of a diagnostic clinical trial of OSA screening and diagnostic tools during inpatient rehabilitation. Stakeholders were provided with open ended questions generated by study investigators and given the opportunity to respond on paper or a “graffiti wall” (i.e., white board). Example questions include “What are the greatest needs of the healthcare system related to sleep apnea and TBI?” and “What are the key things we need to consider to move results into real-world practice?” Qualitative content analyses using a rapid matrix approach were conducted from stakeholder feedback obtained during the two-day meeting, which included a guided review of emerging OSA research and discussion of potential implementation barriers of OSA assessment during inpatient rehabilitation. Results Improved screening and treatment practices for OSA were the greatest needs identified. To meet these needs, stakeholders identified the importance of improving patient, family, and staff understanding of OSA (e.g., health literacy) and other sleep disorders through education; inpatient rehabilitation access to resources (technology; sleep providers); and reimbursement for additional inpatient procedures. Conclusion Although treatment of OSA is crucial for recovery during inpatient rehabilitation following TBI, barriers to earlier recognition, diagnosis, and treatment of OSA exists across several different domains, including education, resources, and funding policies. Findings support future implementation efforts to translate evidence-based care into practice to improve patient outcomes. Support (if any) PCORI-NCT03033901

Introduction Recent work has highlighted prevalent OSA after TBI. Vestibular dysfunction is also common and associated with adverse outcomes particularly in military personnel. Vestibular dysfunction has been identified in patients with moderate to severe OSA, yet the relationship remains unexplored in those with TBI. This study examined the relationship of vestibular dysfunction with OSA in a large cohort of Veterans and Military Service Members (V/SM) with documented TBI. Methods Data are secondary analyses from a five-center prospective observational cohort study of V/SM admitted for inpatient rehabilitation for TBI and enrolled in the VA TBI Model Systems. Participants completing study measures from 2015 to March of 2020 were included in analyses. Study measures includes the Centers for Disease and Control’s National Health and Nutrition Education Survey (NHANES, OSA item embedded) epidemiologic survey and Neurobehavioral Symptom Inventory (NSI). T-tests and chi-square tests compared patients with OSA to those without OSA on the vestibular subscale on the NSI. Results The sample was mostly male (93%), a mean of 38 years of age, and predominantly with mild (52%) or severe (41%) TBI. OSA was reported in 30.6% on the NHANES. Vestibular symptoms were more common among those with OSA (24%) compared to those without (12%) with a significant difference on the NSI Vestibular Total Score (3.84 vs 2.88 respectively; p Conclusion Participants with TBI and comorbid OSA are more likely to endorse the presence and greater severity of vestibular symptoms compared to those without OSA. Future research is needed to improve understanding of the inter-relationship of OSA and vestibular dysfunction to inform clinical management. Support (if any) VA TBIMS & TBICoE (HT0014-19-C-0004), NIDILRR, North Texas TBI Model System (Grant #90DPTB0013), TIRR TBIMS (Grant #90DPTB0016)

Research Objectives To identify differences sleep related respiration between those receiving and not receiving opioid medications. Design Cross-sectional, secondary analyses. Setting Acute inpatient rehabilitation for moderate to severe TBI. Participants 248 consecutive admissions who underwent level-1 polysomnography. Interventions Receipt of opioid medications on the day of polysomnography (PSG). Main Outcome Measures PSG including respiratory measures: oxygen saturation, central apneas events per hour, obstructive apneas and hypopnea events per hour, and total apnea-hypopnea index (AHI). Results After adjustment for number of prescribed medications, those receiving opioids on day of PSG experienced increased frequency of central sleep apnea events and higher frequency of obstructive sleep apnea events. Compared to those who did not, receiving opioids was associated with lower oxygen saturation nadir during and a greater number of oxygen desaturations across. Greater total AHI was observed for those receiving opioids. Conclusions Opioid use early after TBI appears to impact important sleep parameters and sleep related respiration that may influence recovery. Further investigation is needed to understand the impact of opioid medications, alone or in combination with other medications, on functional outcomes both early after TBI and in the chronic phase to develop recommendations on how and when to use these medications given their usage in managing pain after injury. Author(s) Disclosures Research reported in this article was funded through a Patient-Centered Outcomes Research Institute (PCORI) Award (CER-1511-33005). This research was sponsored by VHA Central Office VA TBI Model Systems Program of Research; Subcontract from General Dynamics Information Technology (W91YTZ13-C-0015; HT0014-19-C-0004) from the Defense Health Agency TBI Center of Excellence and National Institute on Disability, Independent Living, and Rehabilitation Research (University of Texas Southwestern Medical Center, 90DPTB0013-01-03; Indiana University School of Medicine, Rehabilitation Hospital of Indiana, 90DRTB0002; Division of Rehabilitation Psychology, Department of Rehabilitation Medicine, University of Washington School of Medicine, 90DPTB0008). The TBI Model Systems is a funded collaboration between the Department of Veterans Affairs and the Department of Health and Human Services: National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR). Clinicaltrial.gov Registration Number: NCT03033901.

Objective To characterize supervision levels across residential settings at 1 year post-TBI and explore predictors of supervision in a Veteran and Service-member population. Setting Five VA Polytrauma Rehabilitation Centers. Participants A total of 302 individuals enrolled in the VA TBI Model Systems (TBIMS) research program. Design Prospective, longitudinal, multisite. Main measures Primary residence and supervision levels measured via scores on the Supervision Rating Scale. For predictive modeling, scores were dichotomized into 2 groups: those that were fully independent/living alone or required only some supervision during the day (independent group, n = 195) and those that required overnight supervision, full-time indirect supervision, and full-time direct supervision (dependent group, n = 107). Results Thirty-five percent were receiving supervision at 1 year post-TBI across residential settings and 28% were living in alternative settings. Multivariate modeling indicated that older age and longer posttraumatic amnesia (PTA) were predictive of having a need for supervision at 1 year postinjury. Conclusions Supervision needs are long-term features of moderate and severe TBI. Results of this study lend support to the shift toward conceptualizing TBI as a chronic disease.

Introduction A recent meta-analytic report highlighted that obstructive sleep apnea was 12 times more prevalent in TBI (mixed severity) than in community-based samples. Recent studies highlight prevalent obstructive sleep apnea during acute inpatient rehabilitation which is a time of critical neural repair. Acute sleep disturbances are associated with therapy cooperation due to effects on daytime sleepiness and are associated with key rehabilitation outcomes. Given the high rates of OSA and risk for negative morbidity, this analysis sought to examine the feasibility of administering polysomnography (PSG) with EEG to diagnose sleep apnea during inpatient rehabilitation in persons with moderate to severe TBI. Methods This is a secondary analysis from a prospective diagnostic comparative effectiveness clinical trial (NCT03033901) that took place at six NIDILRR and one VA TBI Model System Centers. Participants were included if they met the TBI Model System case definition and slept at least 2 hours per night prior to PSG. PSG was conducted following AASM procedures in the participant’s hospital bed on the inpatient rehabilitation unit. Studies were scored by RPSGT staff and interpreted by a board certified sleep medicine physician at a centralized sleep scoring center in Tampa, FL. Results Of 896 potential TBI participants, 449 met initial eligibility and 345 consented for further screening; a final sample of 263 (76%) completed PSG during hospitalization. Primary reasons for not completing PSG included early discharge or medical instability (n=59) and last-minute withdrawal of consent for PSG (n=23). Of the 263 participants who completed PSG, 3 were excluded from analysis due to technical issues and 12 were excluded as the total sleep time (TST) was less than 120 minutes. Of the 248, 85.5% of the PSGs were rated as interpretable/scoreable by RPSGT and sleep physicians. Conclusion For a majority of participants, polysomnography is feasible during inpatient rehabilitation. Participants with shorter lengths of stay, medical instability, prolonged agitation may require polysomnography follow-up after discharge. Support Supported by PCORI (CER-1511-33005), VA TBIMS, DVBIC with subcontract from GDIT/GDHS (W91YTZ-13-C-0015, HT0014-19-C-0004), and NIDILRR (90DPTB00070, 90DPTB00130100, 90DPTB0008, 90DPT8000402, 90DPTB0001).

Introduction The objective of this study was to compare OSA, demographic, and TBI characteristics across the American Academy of Sleep Medicine (AASM) and Centers for Medicare and Medicare (CMS) scoring rules in moderate to severe TBI undergoing inpatient neurorehabilitation. Methods This is a secondary analysis from a prospective clinical trial of sleep apnea at six TBI Model System study sites (n=248). Scoring was completed by a centralized center using both the AASM and CMS criteria for OSA. Hospitalization and injury characteristics were abstracted from the medical record and demographics obtained by interview by trained research assistants using TBI Model System standard procedures. Results OSA was prevalent using the AASM (66%) and CMS (41.5%) criteria with moderate to strong agreement (weighted kappa = 0.64 (95%CI = 0.58, 0.70). Significant differences were observed for participants meeting AASM and CMS criteria (Agreement Group; AG) compared to those meeting criteria for AASM but not CMS (Disagreement Group; DG). At AHI ≥ 5, the DG (n=61) had lower Emergency Department Glasgow Coma Scale Scores consistent with greater injury severity (median 5 vs. 13, p = 0.0050), younger age (median 38 vs 58, p Conclusion The underestimation of sleep apnea using CMS criteria is consistent with prior literature; however, this is the first study to report the impact of the criteria in persons with moderate to severe TBI during a critical stage of neural recovery. Management of comorbidities in TBI has become an increasing focus for optimizing TBI outcomes. Given the chronic morbidity after moderate to severe TBI, the impact of CMS policy for OSA diagnosis for persons with chronic disability and young age are considerable. Support PCORI (CER-1511-33005), GDHS (W91YTZ-13-C-0015; HT0014-19-C-0004)) for DVBIC, NIDILRR (NSDC Grant # 90DPTB00070, #90DP0084, 90DPTB0013-01-00, 90DPTB0008, 90DPT80004-02).

Introduction For persons with moderate-to-severe traumatic brain injury (TBI), chronic cognitive impairment contributes to long term disability. Health comorbidities may contribute to the neurologic burden in TBI. Indeed, obstructive sleep apnea (OSA) is associated with neuropathological and cognitive changes. The objective of this study was to examine the relationship between OSA and cognition after TBI. Methods Participants were prior inpatient rehabilitation patients drawn from the Tampa VA TBI Model Systems longitudinal study. Post-discharge interviews occurred 2 to 6 years post-TBI. Participants reported whether they were diagnosed with OSA and completed the Brief Test of Adult Cognition by Telephone (BTACT) which measures recall, working memory, processing speed, fluency, and reasoning. Participants with polysomnography (PSG) were separately analyzed to examine the impact of sleep apnea severity (i.e., Apnea-Hypopnea Index [AHI]) on cognition. Results Participants (N=104) were mostly male (95.2%), age M=37.7 (SD=12.5), Education M=13.6 years (SD=2.1), and 45.2% were diagnosed with OSA. Participants with and without OSA did not differ by age, education, gender, or time since injury at time of BTACT (ps > .05). ANCOVAs were conducted examining OSA diagnosis on BTACT subscale scores, covarying TBI severity level, but results did not reach statistical significance (ps > .05). A subset of participants with OSA had PSG (n=27), AHI score quartiles = 6.7/10.4/21.6. Higher AHI was associated with poorer reasoning (Spearman ρ = -0.45, p = .019). Nonsignificant results were found for word recall (Spearman ρ = -0.35, p = .074) and processing speed (Spearman ρ = -0.36, p = .069). Conclusion Severity of sleep apnea may influence aspects of cognition among persons with TBI, although these results are preliminary and need replication with a larger and more representative sample. Support This work was supported by the Veterans Health Administration Central Office VA TBI Model Systems Program of Research and subcontract from General Dynamics Information Technology [W91YTZ-13-C-0015, HT0014-19-C-0004] from the Defense and Veterans Brain Injury Center (DVBIC); and from the United States Department of Veterans Affairs [W81XWH-13-2-0095]; and from the United States Department of Defense Congressionally Directed Medical Research Programs; and from the Patient Centered Outcomes Research Institute (PCORI) [CER-1511-33005].

Introduction Recent work has highlighted prevalent obstructive sleep apnea (OSA) after traumatic brain injury (TBI) when patients are vulnerable to disruption of neural repair. The recently completed clinical trial comparing screening and diagnostic tools for OSA during inpatient rehabilitation provided the opportunity to conduct economic modeling of phased approaches using actual trial findings to address one perspective (the payor) on the value of phased testing. Methods A cost-effectiveness analysis of four phased approaches to OSA diagnosis including initial utilization of portable sleep monitoring [HSAT] regardless of pre-test probability, determination of pre-test probability using two prediction models [STOPBANG, MAPI], and initial assessment using Level 1 polysomnography was conducted. The analyses were modeled assuming all participants were considered high risk thus a negative screen or portable diagnostic test would result in a participant being referred for Level 1 polysomnography. The cost aversion used in analyses were derived from a recent white paper on the economic modeling of untreated OSA. Trial data from 214 participants were used in analyses (mean age 44 [SD 18], 82% male, 75% white, with primarily motor-vehicle related injury [44%] and falls [33%] with a sample mean emergency department Glasgow Coma Scale of 8 (SD 5). Results At AHI ≥15 (33.6%), the prediction models (STOPBANG [-$5,291], MAPI [-$5,262]) resulted in greater cost savings and effectiveness relative to the HSAT approach (-$5,210) and initial use of Level 1 PSG (-$5,011). Sensitivity analyses at AHI ≥5 (70.1%) revealed the initial use of HSAT (-$6,322.85) relative to the prediction models (MAPI [-$6,249.71], STOPBANG [-$6,237) and initial assessment with Level 1 PSG (-$5,977) resulted in greater savings and cost effectiveness. Conclusion The high rates of sleep apnea after TBI highlight the importance of accurate diagnosis and treatment of this comorbid disorder. However, financial and practical barriers exist to obtaining an earlier diagnosis during inpatient rehabilitation hospitalization. Diagnostic cost savings are demonstrated across all phased approaches and OSA severity levels with the most cost-effective approach varying by incidence of OSA. Support PCORI (CER-1511-33005), GDHS (W91YTZ-13-C-0015; HT0014-19-C-0004)) for DVBIC, NIDILRR (NSDC Grant # 90DPTB00070, #90DP0084, 90DPTB0013-01-00, 90DPTB0008, 90DPT80004-02).

Introduction Recent studies highlight prevalent obstructive sleep apnea after moderate to severe TBI during a time of critical neural repair. The purpose of this study is to determine the diagnostic sensitivity, specificity and comparative effectiveness of traditional sleep apnea screening tools in TBI neurorehabilitation admissions. Methods This is a prospective diagnostic comparative effectiveness trial of sleep apnea screening tools (STOPBANG, Berlin, MAPI [Multi-Apnea Prediction Index]) relative Level 1 polysomnography at six TBI Model System Inpatient Rehabilitation Centers. Between 05/2017 and 02/2019, 449 of 896 screened were eligible for the trial with 345 consented (77% consented). Additional screening left 263 eligible for and completing polysomnography with final analyses completed on 248. The primary outcome was the Area Under the Curve (AUC) of screening tools relative to total apnea hypopnea index ≥15 (AHI, moderate to severe apnea) measured at a median of 47 days post-TBI (IQR 29-47). Results Participants were primarily young to middle age (AGE IQR 28,40,59), male (81%), white (74%), and had primarily severe TBI (IQR GCS 3,6,14). A subset (26%) had a history of military service. Results revealed that the Berlin high risk score (ROC-AUC=0.63) was inferior to the MAPI (ROC-AUC = 0.7802) (p=.0211, CI: 0.0181, 0.2233) and STOPBANG (ROCAUC = 0.7852) (p=.0006, CI: 0.0629, 0.2302); both of which had comparable AUC (p=.7245, CI: -0.0472, 0.0678). Findings were similar for AHI≥30 (severe apnea); however, no differences across scales was observed at AHI>5. The pattern was similar across TBI severity subgroups except for delirium or post-traumatic amnesia status wherein the MAPI outperformed the Berlin and STOPBANG. Youden’s Index to determine risk yielded lower sensitivities but higher specificities relative to non-TBI samples. Conclusion This study is the first to provide clinicians with data to support a choice for which sleep apnea screening tools are more effective during inpatient rehabilitation for moderate to severe TBI (STOPBANG, MAPI vs Berlin) to help reduce comorbidity and possibly improve neurologic outcome. Support PCORI (CER-1511-33005), GDHS (W91YTZ-13-C-0015; HT0014-19-C-0004)) for DVBIC, NIDILRR (NSDC Grant # 90DPTB00070, #90DP0084, 90DPTB0013-01-00, 90DPTB0008, 90DPT80004-02).

Purpose/objective Spiritual well-being has been associated with better quality of life outcomes in caregivers, but the associations among the care recipient's functional status, the caregiver's spiritual well-being, and the caregiver's health-related quality of life (HRQOL) is unknown. Research Method/Design: The study examined the Spiritual Well-Being Scale in caregivers of persons with traumatic brain injury (TBI; n = 335). Participants completed measures from the Patient-Reported Outcomes Measurement Information System, the Quality of Life in Caregivers of TBI, and the Caregiver Appraisal Scale. The Mayo-Portland Adaptability Inventory-4 (MPAI-4) measured care recipient's functional status. The association between religious well-being and existential well-being and HRQOL were examined with Pearson correlation coefficients. Multiple linear regressions examined the interaction between caregiver well-being and care recipient functional status on HRQOL outcomes accounting for demographic variables. Results Less favorable caregiver HRQOL was associated with military affiliation, male status, spousal caregiver relationship, and White race. MPAI-4 was moderately associated with all HRQOL subdomains. For spiritual well-being, existential well-being was moderately correlated with 9 of 16 HRQOL subdomains in comparison to religious well-being that demonstrated small correlations with 3 of 16 subdomains. MPAI-4 had negative effects on HRQOL regardless of spiritual well-being with higher existential well-being reducing the negative impact of the care recipient's functional impairment on HRQOL for significant HRQOL interactions. Conclusions/implications Interventions that encourage development and maintenance of life purpose and meaning in caregivers of persons with TBI, and less so, spirituality, might have beneficial effects on HRQOL when the person with injury has more functional limitations. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Purpose Caregivers of service members/veterans (SMVs) encounter a number of barriers when navigating the military health care system. The purpose of this study was to develop a new measure to assess potential caregiver frustration with the systems of care and benefits in the United States Departments of Defense and Veterans Affairs. Method The TBI-CareQOL Military Health Care Frustration measure was developed using data from 317 caregivers of SMVs with TBI who completed an item pool comprised of 64 questions pertaining to anger or frustration with accessing military health care services. Results Exploratory and confirmatory factor analyses supported the retention of 58 items. Constrained graded response model (GRM) overall fit and item fit analyses and differential item functioning investigations of age and education factors supported the retention of 43 items in the final measure. Expert review and GRM item calibration products were used to inform the selection of two 6-item static short forms (TBI-CareQOL Military Health Care Frustration-Self; TBI-CareQOL Military Health Care Frustration-Person with TBI) and to program the TBI-CareQOL Military Health Care Frustration computer adaptive test (CAT). Preliminary data supported the reliability (i.e., internal consistency and test-retest reliability) as well as the validity (i.e., convergent, discriminant, and known-groups) of the new measure. Conclusions The new TBI-CareQOL Military Health Care Frustration measure can be used to examine caregiver perceptions of and experience with the military health care system, to target improvements. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Background OSA is prevalent during a time of critical neural repair after traumatic brain injury (TBI). The diagnostic utility of existing sleep studies is needed to inform clinical management during acute recovery from TBI. Research Question This study aimed to evaluate the non-inferiority and diagnostic accuracy of a portable level 3 sleep study relative to level 1 polysomnography in hospitalized neurorehabilitation patients with TBI. Study Design and Methods This is a prospective clinical trial conducted at six TBI Model System study sites between May 2017 and February 2019. Of 896 admissions, 449 were screened and eligible for the trial, with 345 consented. Additional screening left 263 eligible for and completing simultaneous administration of both level 1 and level 3 sleep studies, with final analyses completed on 214 (median age = 42 years; ED Glasgow Coma Scale = 6; time to polysomnography [PSG] = 52 days). Results Agreement was moderate to strong (weighted kappa = 0.78, 95% CI, 0.72-0.83) with the misclassification commonly occurring with mild sleep apnea due to underestimation of apnea hypopnea index (AHI). Most of those with moderate to severe sleep apnea were correctly classified (n = 54/72). Non-inferiority was not demonstrated: the minimum tolerable specificity of 0.5 was achieved across all AHI cutoff scores (lower confidence limits [LCL] range, 0.807-0.943), but the minimum tolerable sensitivity of 0.8 was not (LCL range, 0.665-0.764). Interpretation Although the non-inferiority of level 3 portable diagnostic testing relative to level 1 was not established, strong agreement was seen across sleep apnea indexes. Most of those with moderate to severe sleep apnea were correctly identified; however, there was risk of misclassification with level 3 sleep studies underestimating disease severity for those with moderate to severe AHI and disease presence for those with mild AHI during early TBI neurorehabilitation.

Background: Research has shown that number of and blast-related Traumatic Brain Injuries (TBI) are associated with higher levels of service-connected disability (SCD) among US veterans. This study builds and tests a prediction model of SCD based on combat and training exposures experienced during active military service.Methods: Based on 492 US service member and veteran data collected at four Department of Veterans Affairs (VA) sites, traditional and Machine Learning algorithms were used to identify a best set of predictors and model type for predicting %SCD ≥50, the cut-point that allows for veteran access to 0% co-pay for VA health-care services.Results: The final model of predicting %SCD ≥50 in veterans revealed that the best blast/injury exposure-related predictors while deployed or non-deployed were: 1) number of controlled detonations experienced, 2) total number of blast exposures (including controlled and uncontrolled), and 3) the total number of uncontrolled blast and impact exposures.Conclusions and Relevance: We found that the highest blast/injury exposure predictor of %SCD ≥50 was number of controlled detonations, followed by total blasts, controlled or uncontrolled, and occurring in deployment or non-deployment settings. Further research confirming repetitive controlled blast exposure as a mechanism of chronic brain insult should be considered.

Survivors of brain injury who have disorders of consciousness often have chronic functional deficits and disability. Obstructive sleep apnoea, a sleep-related breathing disorder, is a medical comorbid condition common among persons with brain injury and is injurious to health. Research on obstructive sleep apnoea treatment among brain-injured patients-particularly persons with disorders of consciousness-is sparse. This case study describes a patient with severe brain injury admitted for neurorehabilitation in a minimally conscious state. Obstructive sleep apnoea was identified and treated. Treatment compliance was variable, and functional motor and cognitive improvement were observed during periods of better compliance. Study design does not permit casual attribution for functional improvement, but identification and treatment of obstructive sleep apnoea are suggested as a possible way to promote recovery after brain injury.

Introduction Individuals with a history of mild traumatic brain injury (mTBI) have higher risk levels for obstructive sleep apnea (OSA). However, no studies have examined the association between OSA and white matter hyperintensities (WMHs) in this group. The purpose of this study is to explore the relationship between OSA risk, mTBI, and WMHs in a military cohort with a history of combat deployment. Methods Secondary analyses were conducted from a large clinical database of a multi-center, longitudinal study of current and former military personnel. Participants were included who had complete STOPBANG (sleep apnea risk) data and MRI. Univariable and multivariable regressions were conducted, including age, race, gender, education, hypertension, diabetes, history of mTBI, and STOPBANG score in the models. Results The final sample (N=1017) included participants with (n=823) and without (n=194) a history of mTBI. The sample was predominantly male (87%) with a median age of 38 (IQR; 32–48). WMHs were reported in 37% of the sample. Univariate analyses revealed that increasing age, female sex, hypertension, diabetes, and higher sleep apnea risk score were each positively associated with higher number of WMHs, while a history of lifetime mTBI exposure was not associated. Multivariable analyses revealed that of these factors, only age remained associated with WMH presence. When restricting the sample to the 37% with WMHs, OSA risk and female sex were each associated with higher number of WMHs (p Conclusion Consistent with the literature in non-brain injured populations, age was the strongest predictor of WMH presence and number. In those with identified WMHs, OSA risk was a significant predictor of WMH number, while history of mTBI was not. Thus, in persons with mTBI, presence of WMHs may be linked to sleep comorbidities, providing potential treatment targets. Limitations include assessment of OSA rather than established diagnosis. Support (if any) Defense and Veterans Brain Injury Center (HT0014-19-C-004), DOD(W81XWH-13-2-0095), VA(I01 CX001135). The views expressed in this abstract are those of the authors and do not necessarily represent the official policy or position of the Defense Health Agency, Department of Defense, or any other U.S. government agency. For more information, please contact dha.TBICoEinfo@mail.mil. UNCLASSIFIED