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To examine the functioning of military service members 5 years after completing a randomized controlled trial (RCT) of cognitive rehabilitation for mild traumatic brain injury (mTBI).Home-based telephonic interview and internet-based self-ratings.Sixty-nine of the 126 (55%) active-duty service members who were enrolled in a 4-arm RCT of cognitive rehabilitation 3 to 24 months after mTBI and were successfully contacted by phone 5 years later. Original and 5-year follow-up participants in each of 4 RCT treatment arms included: psychoeducation ( n = 32 original, n = 17 follow-up), computer ( n = 30 original, n = 11 follow-up), therapist-directed ( n = 30 original, n = 23 follow-up), integrated ( n = 34 original, n = 18 follow-up).Inception cohort evaluated 5 years after completion of an RCT of cognitive rehabilitation.Postconcussion symptoms (Neurobehavioral Symptom Inventory total score), psychological distress (Symptom Checklist-90-revised Global Severity Index score), and functional cognitive/behavioral symptoms (Key Behaviors Change Inventory total average score).Participants' postconcussive symptoms and psychological distress improved at the 5-year follow-up. Functional cognitive/behavioral symptoms were not significantly improved, but therapeutic gains were maintained across time, to 5 years after completing the RCT.In this sample of military personnel, postconcussive symptoms and psychological distress significantly improved from posttreatment to 5 years after cognitive rehabilitation, regardless of treatment arm. Functional cognitive/behavioral symptoms significantly improved with treatment while treatment gains were maintained at the 5-year follow-up. Replication of these results with a larger sample and interim data between 18 weeks and 5 years post-treatment is needed.

Objective The study objective was to determine whether number of concussions would affect symptom improvement following cognitive rehabilitation (CR) interventions. Method Service members (N = 126) with concussion history completed a 6-week randomized control trial of CR interventions. Participants were stratified based on self-reported lifetime concussion frequency. Outcome measures included the Paced Auditory Serial Addition Test (PASAT), the Global Severity Index (GSI) from the Symptom Checklist-90-Revised, and the Key Behaviors Change Inventory (KBCI). Results Mixed-model analyses of variance revealed a significant main effect for time on cognitive, psychological, and neurobehavioral functioning. A significant main effect for the number of concussions was observed for GSI and KBCI, but not PASAT. Interactions between the number of concussions and time were not significant for any of the outcome variables. Conclusions Over the 6-week interval, improvements were found for all participants across all outcome measures. Number of concussions did not affect improvements over time.

Objective Vocational functioning was examined in a cohort of military service members 5 years after completing a randomized, 4-arm controlled trial (RCT) exploring the efficacy of cognitive rehabilitation (CR) for persistent cognitive symptoms following mTBI. Methods Inception cohort design included 69 of the 103 participants (67%) who completed both the study intervention and a 6-week follow-up, contacted by phone at 5-year follow-up. Outcome measures included post-concussive symptoms, emotional distress, functional cognitive complaints, and occupational status. Participants were dichotomized into good and poor occupational outcome groups (Good — returned to duty or retired at the end of the term of service; Poor — medically retired or found unfit for duty by a medical evaluation board). Results Results of a 2X4 contingency table analysis (good/poor occupational outcome by CR treatment group) found 44% of the sample had good occupational outcomes at 5 years. Good outcomes did not significantly differ by CR treatment arm: psychoeducation 56%, computer-directed 18%, therapist-directed 43%, therapist-directed plus psychotherapeutic intervention 50%, χ2(3) = 4.213, p = 0.239. Logistic regression predicting occupational outcome by CR treatment arm found no significant findings of treatment arm (Computer vs. Psychoeducation β = −1.755, p = 0.059; Therapist-directed vs Psychoeducation β = −0.514, p = 0.434; Integrated vs. Psychoeducation β = −0.251, p = 0.716). Psychoeducation treatment arm was coded as the reference group. Conclusions Contrary to our hypotheses, long-term vocational outcomes were lower than expected, despite reductions in overall post-concussive complaints, functional cognitive difficulties, and emotional distress, underscoring the complexity of vocational functioning in post-deployment service members.

Objective:National Death Index data were examined to describe mortality patterns among older veterans who are homeless.Methods:Homelessness and health care records from the U.S. Department of Veterans Affairs were used to identify old (ages 55–59) and older (ages ≥60) veterans who were (N=4,475) or were not (N=20,071) homeless. Survival functions and causes of death of the two samples over an 11-year follow-up period were compared.Results:Substantially more veterans who were homeless (34.9%) died compared with the control sample (18.2%). Veterans who were homeless were approximately 2.5 years younger at time of death compared with the control sample. Older veterans who were homeless had the lowest survival rate (58%). No disease category appeared to be critical in reducing survival time. Suicide was twice as frequent in the homeless (.4%) versus the control (.2%) sample.Conclusions:Older veterans who were homeless experienced excess mortality and increased suicide risk.

This study examined whether self-efficacy differentiated treatment responders from non-responders in a trial of cognitive rehabilitation (CR) for postconcussive symptoms. 126 service members with mild TBI seen on average 9.5 months since injury completed one of four cognitive rehabilitation treatments for 6 weeks. The four treatment arms were: (1) Psychoeducation control, (2) Self-administered computerized CR, (3) Interdisciplinary CR, and (4) Interdisciplinary CR integrated with CBT. Outcome was assessed across time (baseline, and 6, 12, and 18 weeks post-treatment) for three domains: psychological (Symptom Checklist-90-Revised; SCL-90-R), cognitive (Paced Auditory Serial Addition Test; PASAT), and functional/behavioural (Key Behaviors Change Inventory; KBCI). Mixed model ANOVAs tested for self-efficacy differences across time in treatment responders versus non-responders, as defined by reliable change indices. A significant interaction was found on the SCL-90 such that responders had increasing self-efficacy with respect to psychological symptoms across four time points, whereas non-responders' self-efficacy did not change. Perceived self-efficacy at the beginning of treatment was associated with treatment engagement within the psychological domain for responders only, suggesting a mediating role in treatment outcome. Overall, results suggest that increasing patients' level of self-efficacy may be important for successful treatment of psychological distress in those with remote concussion.

Purpose/objective Effective treatment for postconcussive symptoms (PCS) immediately following mild traumatic brain injury (mTBI) includes reassurance, support, education about mTBI, and symptom management. However, effective treatments for chronic postconcussive-like symptoms, particularly with mental health comorbidities, remain unclear. Research Method/Design: We conduct a critical review of the treatment literature for chronic PCS, present exemplar studies of two alternative treatment approaches (i.e., cognitive rehabilitation (CR) and psychotherapy with various cognitive-behavioral therapy (CBT) approaches) and compare their relative effectiveness, and examine other literature to compare treatment benefits of one approach over another. Results This review and comparisons found CBT approaches to be 5 to 6 times more potent in reducing chronic PCS than CR. Conclusions/implications Based on these findings we encourage rehabilitation professionals to "re-conceptualize" the factors that likely underlie chronic PCS and the most effective treatment for this condition. We propose that CBT interventions focusing on comorbid and underlying mental health issues should be an essential, not adjunctive, treatment approach for chronic PCS. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Determine factors that affect responsiveness to cognitive rehabilitation (CR) interventions in service members (SMs) who sustained mild traumatic brain injury (mTBI).126 SMs with a history of mTBI 3 to 24 months postinjury participated in a randomized clinical trial of one of four, 6-week treatment arms: (a) psychoeducation, (b) computer-based CR, (c) therapist-directed manualized CR, and (d) therapist-directed CR integrated with cognitive-behavioral psychotherapy. Practice-adjusted reliable change scores (RCS) were calculated for the three primary outcome measures: Paced Auditory Serial Addition Test (PASAT), Symptom Checklist-90 Revised (SCL-90-R) Global Severity Index (GSI), and Key Behaviors Change Inventory (KBCI). Hierarchical logistic regression was used to predict RCS. Variables considered were: (a) demographic, (b) injury characteristics, (c) comorbid mental health conditions, (d) nonspecific treatment variables (i.e., team vs. no-team milieu), and (e) specific treatment elements.No predictor variables were associated with RCS improvements on the PASAT or the SCL-90-R. Comorbid depression (p.02) and team-treatment milieu (p.02) were associated with RCS improvement on the KBCI. Specific CR (ps.65) and psychotherapy treatments (p.26) were not associated with improvements on any outcome. There was evidence that self-administered computer CR was not only not beneficial, but negatively associated with cognitive and neurobehavioral improvement.Although reliable improvements were found on the PASAT and KBCI, no specific treatment intervention effects were found. Rather, comorbid depression and team-milieu treatment environment were associated with improvement, but only on the KBCI. Comorbid depression was associated with higher rates of improvement. (PsycINFO Database Record

OBJECTIVE To examine differences in objective neurocognitive performance and subjective cognitive symptoms in individuals with a history of a single concussion, multiple concussions, orthopedic injuries, and posttraumatic stress disorder (PTSD). METHOD Participants included 116 military service members who sustained a mild traumatic brain injury (mTBI) during combat deployment. Subjects were subdivided into groups based on concussion frequency: a single concussion (n = 42), 2 concussions (n = 21), and 3 or more concussions (n = 53). Eighty-one subjects sustained an orthopedic injury (n = 60) during deployment or were diagnosed with PTSD (n = 21), but had no history of mTBI. Subjects completed a battery of neuropsychological tests and self-report measures of postconcussive symptoms, PTSD symptoms, and psychopathology. RESULTS No differences were found among the concussion groups on a composite neuropsychological measure. The PTSD group had the highest number of symptom complaints, with the 2-concussion and 3-plus-concussion groups being most similar to the PTSD group. The concussion groups showed a nonsignificant pattern of increasing distress with increasing number of concussions. CONCLUSIONS The current findings are consistent with meta-analytic results showing no differential effect on neuropsychological functioning due to multiple concussions. Results also support the burden of adversity hypothesis suggesting increasing symptom levels with increasing psychological or physically traumatic exposures.

Objective To evaluate and compare the existing Neurobehavioral Symptom Inventory factor structure models to determine which model provides the best overall fit for postconcussion symptoms and determine which model is useful across different samples (eg, with and without mild traumatic brain injury [TBI] history). Setting N/A. Participants A Florida National Guard sample (N = 3098) and a national Department of Veterans Affairs sample (N = 48,175). Design Retrospective structural equation modeling was used to compare 16 alternative factor structure models. First, these 16 possible models were examined separately in both samples. Then, to determine whether the same factor structures applied across subsamples within these samples, the models were compared for those deployed and those not deployed in the Florida National Guard sample and between those with TBI confirmed on clinical evaluation and those who were determined not to have sustained a TBI within the Department of Veterans Affairs sample. Main measures Neurobehavioral Symptom Inventory. Results A 4-factor model--vestibular, somatic, cognitive, and affective--had the best overall fit, after elimination of 2 items (ie, hearing problems and appetite disturbance), and was most applicable across samples. Conclusions These findings extend the findings of Meterko et al to other samples. Because findings were consistent across sample and subsamples, the current findings are applicable to both Department of Veteran Affairs and Department of Defense postdeployment medical evaluation settings.

While memory deficits are consistently found to be a salient problem in individuals with moderate to severe traumatic brain injury (TBI), the specific memory processes (i.e., encoding, consolidation, and retrieval) underlying the verbal memory deficit are disputed in the literature. The current study evaluated the recovery of these verbal memory processes over time. A TBI patient group evaluated acutely after the injury (baseline) and again at 6 months and 1 year post injury was compared to a demographically similar control group evaluated only once. The current results replicated previous findings in support of an impaired consolidation hypothesis as the primary deficit underlying memory impairment in TBI. These deficits are reflected in relatively more rapid forgetting through 1 year post injury and relatively less proactive interference up to 6 months post injury.

OBJECTIVE:: To examine the relative contributions of preinjury, injury severity, and acute postinjury variables in predicting outcomes at 1 year following moderate-severe traumatic brain injury (TBI). DESIGN:: Secondary analysis of a prospective longitudinal cohort study. SETTING:: Four Veterans Affairs Medical Center acute inpatient rehabilitation programs. PARTICIPANTS:: Active duty military or veterans with a nonpenetrating moderate-to-severe TBI. MAIN OUTCOME MEASURES:: Independent living status (N = 280) and work status (N = 248) at one year postinjury. RESULTS:: Preinjury characteristics as a group accounted for the largest amount of variance in independent living status at 1 year; however, posttraumatic amnesia (PTA) uniquely explained the largest amount of variance (8.8%). Those with less than 60 days PTA were 9 times more likely to be independent; those with less than 30 days PTA were 3 times more likely to be independent. In contrast, acute postinjury characteristics accounted for the largest amount of variance in work status, with time to rehabilitation explaining the most unique variance (10.4%). Those with less than 48 days time to rehabilitation were 2.4 times more likely to be productive. CONCLUSIONS:: This study highlights the differential contribution of variables in the prediction of 2 specific functional outcomes in a military sample, adding to our current body of knowledge to assist clinicians, patients and their families following TBI. Language: en

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

Purpose To compare coping effectiveness training (CET) with supportive group therapy (SGT) for anxiety, depression, and adjustment to injury in an acute spinal cord injury/dysfunction (SCI/D) rehabilitation population. CET was shown to result in decreased anxiety and depression symptoms when compared to historical no-treatment control groups (Kennedy, Duff, Evans, & Beedie, 2003; King & Kennedy, 1999). The present study sought to extend those findings with a comparison of CET to an alternative active therapy condition, SGT. Research method Participants (N = 40) entering a hospital-based program were assigned to treatment condition using block randomization. Questionnaire mood measures were completed at program admission, program discharge, and 3-month postdischarge follow-up. Adjustment to disability was assessed at follow-up only. Analyses of variance tested for group differences in anxiety, depression, and adjustment to injury. Results Both groups reported reductions in mood symptoms with no differences between treatment conditions. However, similar reductions were obtained after fewer sessions of CET. Symptoms of depression increased in both groups following hospital discharge. Conclusions Clinical and research implications, including innovative interventions during the period after discharge, are discussed.

INTRODUCTION Individuals with traumatic brain injury (TBI) often have difficulty accurately perceiving changes in their level of functioning postinjury [1]. Unawareness of deficits contributes to problems across life areas, including return to productive employment [2] and maintenance of close relationships [2-4]. Of relevance to rehabilitation efforts, a patient who is unaware of deficits is less likely to actively participate in treatment or may refuse to participate altogether. For patients with more severe cognitive or behavioral deficits, unawareness can pose serious safety concerns. Although patients with TBI who demonstrate unawareness of deficits, or anosognosia, typically have normal intelligence [5-6], they may manifest a variety of cognitive impairments during neuropsychological evaluation, including impaired memory ability [7-8], compromised executive functioning [9-10], and decreased fine motor speed [11]. Discrepancies have been noted, however, with some studies suggesting little to no relationship between level of awareness and performance on other cognitive measures [11-13]. This disparity has often been attributed to different methods of awareness assessment [12,14-15], although variance across studies in the injury severity and acuteness of participants could also be the cause. Several approaches are used for assessing degree of awareness. The most common approach is an interview or checklist-based comparison of discrepancies between patient self-ratings of their postinjury problems and ratings by others (family members or treatment staff). The larger the discrepancy (other rater reporting greater problems than the individual with TBI), the larger the patient's underlying self-awareness deficit. Another method is comparing patients' self-ratings with their neuropsychological performance. The rationale is that patients with unawareness should demonstrate primarily executive dysfunction because of limited self-monitoring ability [9]. A third method is structured or semi-structured interviews, such as the Self-Awareness of Deficits Interview [16], which involves an examiner asking the patient specific questions, with family members verifying the answers. The assessment is then scored according to a preestablished rating scale. A final method of assessment is rating actual behaviors that indicate unawareness on outcome measures such as the Key Behaviors Change Inventory (KBCI) [17]. Ratings typically are completed by family members. Other direct rating scales of unawareness used in TBI are the Patient Competency Rating Scale for Neurorehabilition (PCRS-NR) [18] and the Awareness Questionnaire (AQ) [19]. In a recent comparison of the latter two instruments, the original PCRSNR and the AQ were only modestly correlated, although they both predicted employability equally well from patient-clinician discrepancies [20]. In terms of self-other discrepancy ratings, mixed results have been found in the literature regarding degree of unawareness following TBI. For example, in individuals with primarily moderate to severe TBI, Cavallo and colleagues found that 39 percent of their patient and family member pairs were in high agreement about the patient's functioning 1 to 3 years postinjury on the Problem Checklist of the New York University Head Injury Family Interview [21]. High agreement was defined as agreement on the presence or absence of at least 75 percent of 34 common post-TBI problems. For 26 percent of the patient and family member pairs, the patient endorsed twice as many problems as the family member, and for 35 percent of the pairs, the family member endorsed twice as many problems as the patient. No differences were found for demographic variables or injury severity between these groups. Seel and colleagues reported generally good postinjury agreement between injured individuals and family members using the Neurobehavioral Functioning Inventory, an instrument that contains 70 items and assesses specific behaviors and symptoms across six scales-depression, somatic, memory/attention, communication, aggression, and motor [22]. …

The objective of this study was to examine the prevalence of long-term psychiatric, neurologic, and psychosocial morbidities of self-reported mild traumatic brain injury (MTBI). A cross-sectional cohort sample of three groups was examined: those who had not been injured in a motor vehicle accident nor had a MTBI (n = 3,214); those who had been injured in an accident but did not have a MTBI (n = 539); and those who had a MTBI with altered consciousness (n = 254). Logistic regression analyses were used to model odds ratios for the association between group and outcome variables while controlling demographic characteristics, comorbid medical conditions, and early-life psychiatric problems. Compared with uninjured controls, MTBI increased the likelihood of depression and postconcussion syndrome. MTBI also was associated with peripheral visual imperceptions and impaired tandem gait. Similarly, the MTBI group had poorer psychosocial outcomes including an increased likelihood of self-reported disability, underemployment, low income, and marital problems. Results suggest that MTBI can have adverse long-term psychiatric, neurologic, and psychosocial morbidities.

To examine the risk of sustaining a traumatic brain injury (TBI) associated with prior psychiatric conditions beyond that of fixed demographic variables.Retrospective cohort study of non-referred community-dwelling male US veterans.Two-hundred and seventy-one individuals who sustained a TBI with altered consciousness were compared with 630 controls without a history of head injury, selected from a larger sample of 3766.Hierarchical logistic regression analyses were used to model odds ratios and 95% confidence intervals for the unique association between pre-existing psychiatric disorders and the likelihood of incurring a TBI while adjusting for demographic characteristics and other known predictor variables. Mood (odds ratio 2.48, 95% confidence interval 1.23-5.01), anxiety (OR 1.64, 95% CI 1.01-2.68) and conduct disorders (OR 1.66, 95% CI 1.16-2.38) increased the risk of head injury.The pre-existence of psychiatric illness, particularly depression, anxiety and conduct disorder, increased the future risk of incurring a TBI. The implementation of early identification and treatment of psychiatric conditions may potentially lower risk and reduce yearly incidence rates of TBI.

Objectives In this analysis of a cohort of older homeless veterans, we examined psychosocial, health, housing, and employment characteristics to identify predictors of mortality. Method Our sample of 3,620 older veterans entered Veteran Affairs homeless programs in years 2000-2003. Fifteen variables from a structured interview described this sample and served as predictors. National Death Index data for years 2000-2011 were used to ascertain death. Survival table analyses were conducted to estimate and plot cumulative survival functions. To determine predictors and estimate hazard functions, Cox proportional hazards regression analysis was conducted. Results Five variables (presence of a serious health issue, hospitalization for alcohol abuse, alcohol dependency, unemployment for 3 years, and age 60+) were associated with increased risk of death; three (non-White, drug dependency, and dental problems) were associated with reduced risk. A risk score, based on total unit-weighted risk for all eight predictors, was used to identify three groups that were found to differ significantly in mortality. Conclusions These analyses underline the jeopardy faced by older homeless veterans in terms of early death. We were able to identify several variables associated with mortality; more importantly, we were able to show that a risk score based on status for these variables was significantly related to survival.

Theorists have proposed models of executive functioning, and functional neuroimaging and factor analytic studies have attempted to examine the components of executive functioning. These studies have arrived at different conclusions and many empirical studies are wrought with methodological confounds. The purpose of this exploratory study was to investigate the subcomponents of executive abilities while addressing some of the limitations common in previous studies. Neuropsychological test data were obtained from a sample of individuals with a history of TBI seen at one-year follow-up (n=104). Principal components factor analysis was conducted and yielded three factors that accounted for 52.7% of the variance. The first factor included higher-order executive functions with two components: self-generative behavior and cognitive flexibility/set shifting. The second factor appeared to represent mental control, particularly of ongoing working memory. The third factor consisted of memory errors, representing failure to inhibit reporting of inaccurate information. Although the results are not entirely consistent with any of the current theoretical models of executive function, they appear to be most consistent with the 1986 model of Stuss and Benson.

Mild traumatic brain injury (MTBI) is common, yet few studies have examined neuropsychological outcomes more than 1 year postinjury. Studies of nonreferred individuals with MTBI or studies with appropriate control groups are lacking, but necessary to draw conclusions regarding natural recovery from MTBI. We examined the long-term neuropsychological outcomes of a self-reported MTBI an average of 8 years postinjury in a nonreferred community-dwelling sample of male veterans. This was a cross-sectional cohort study derived from the Vietnam Experience Study. Three groups matched on premorbid cognitive ability were examined, those who (1) had not been injured in a MVA nor had a head injury (Normal Control;n= 3214), (2) had been injured in a motor vehicle accident (MVA) but did not have a head injury (MVA Control;n= 539), and (3) had a head injury with altered consciousness (MTBI;n= 254). A MANOVA found no group differences on a standard neuropsychological test battery of 15 measures. Across 15 measures, the average neuropsychological effect size of MTBI compared with either control group was −.03. Subtle aspects of attention and working memory also were examined by comparing groups on Paced Auditory Serial Addition Test (PASAT) continuation rate and California Verbal Learning Test (CVLT) proactive interference (PI). Compared with normal controls, the MTBI group evidenced attention problems in their lower rate of continuation to completion on the PASAT (odds ratio = 1.32,CI= 1.0–1.73) and in excessive PI (odds ratio = 1.66,CI= 1.11–2.47). Unique to the MTBI group, PASAT continuation problems were associated with left-sided visual imperceptions and excessive PI was associated with impaired tandem gait. These results show that MTBI can have adverse long-term neuropsychological outcomes on subtle aspects of complex attention and working memory. (JINS, 2005,11, 228–236.)

This study investigates the extent to which working memory, motor speed and perceptual processing speed influence Wechsler Adult Intelligence Scale-III (WAIS-III) Processing Speed Index (PSI) scores. Sixty-eight adult outpatients with Traumatic Brain Injury (TBI) of varying severity and complete data on all outcome measures were identified. Two cases with outlying values on one outcome measure were omitted from the final sample. Working memory was measured by the Working Memory Index score from the WAIS-III. Motor speed was measured as score on the Halstead-Reitan Finger Oscillation Test (finger tapping) and perceptual processing as score on the Trail Making Test--Part B. In hierarchical multiple regression analyses, working memory accounted for 10% of the variance in PSI scores, whereas motor speed only accounted for 3%. An independent measure of perceptual processing, Trail Making Test--B, accounted for 26% of the variance in WAIS-III PSI scores. The total variance accounted for by the three factors was 56%. Findings confirm that the WAIS-III PSI scores of individuals who have received a TBI reflect perceptual processing speed, with an additional component attributable to working memory. Motor speed made only a small contribution to WAIS-III PSI scores in the present sample.

Kolitz BP, Vanderploeg RD, Curtiss G. Development of the Key Behaviors Change Inventory: a traumatic brain injury behavioral outcome assessment instrument. Arch Phys Med Rehabil 2003;84:277-84. Objective: To describe the development and initial validation of a neurobehavioral outcome measure, the Key Behaviors Change Inventory (KBCI), for individuals with traumatic brain injury (TBI). Design: Scale construction and development, and validity study. Setting: Large state university and postal survey. Participants: Seventy-five volunteer undergraduate students and 25 volunteer collateral informants of individuals with TBI participated in the item-analysis phase. Thirty members of the Brain Injury Association and 20 members of the National Multiple Sclerosis Society rated both an identified patient and an age- and gender-equated control in the validation phase. Interventions: Not applicable. Main Outcome Measures: Content validity was examined through expert panel item sorts. Scale internal consistencies were examined with the Cronbach [alpha ]. Construct validity was examined by comparing scale elevations between controls and 2 neurologic groups. Results: Item-analysis procedures resulted in 8 scales of 8 items each: inattention, impulsivity, unawareness of problems, apathy, interpersonal difficulties, communication problems, somatic difficulties, and emotional adjustment. Internal consistency reliability coefficients ranged from .82 to .91. Multivariate analysis of variance revealed significant (P[le ].001) differences in scale elevations among TBI, multiple sclerosis (MS), and control groups. The TBI and MS groups scored significantly higher than the control group on all scales; a subset of KBCI scales discriminated between the 2 neurologic groups. Conclusion: The KBCI was both sensitive and specific to typical behavioral changes after TBI, thus supporting its usefulness in rehabilitation settings. Cross-validation and development of a normative database are future steps necessary in its development. [copy ] 2003 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

Wilde, Boake, and Sherer (1995) examined the discrepancy between Long Delayed Free Recall (LDFR) and Recognition Discriminability (RD)--the California Verbal Learning Test (CVLT) index thought to indicate the presence of memory retrieval problems--and found little evidence to recommend its use in traumatic brain injury (TBI). The present investigation re-examined this index from the perspective of a continuum of retrieval deficit severity. CVLT performance was examined in 122 TBI patients, and 2 retrieval deficit indicators of varying severity were evaluated. Memory-impaired control groups were matched with retrieval deficit groups on initial acquisition and demographic characteristics. Individuals with a LDFR/RD discrepancy did not show predicted differences on other CVLT indices of retrieval problems, similar to the findings of Wilde et al. (1995). In contrast, individuals with a consistent discrepancy between free recall and semantic cued recall (Short and Long Delay) had greater improvement with recognition cueing and made fewer intrusive errors than controls. Individuals who benefited from semantic cues (where retrieval of the target word is still required) also benefited from recognition cues (where retrieval demands are minimal). Evidence supported the existence of a continuum of retrieval deficit severity. An LDFR/RD discrepancy without performance improvement from semantic cueing appears to indicate a more severe retrieval deficit, whereas performance improvement from both recognition and semantic cueing indicates less severe retrieval deficits.

The Key Behaviors Change Inventory (KBCI) was developed to assess executive, behavioral, and emotional functioning following brain insults and to track the course of recovery. The purpose of this study was to investigate, in an elderly memory disorder clinic sample, the convergent and discriminant validity of the KBCI by examining the relationships between various measures of executive functioning and the KBCI scales that theoretically relate to executive functions. The KBCI was administered to the caregivers of 97 consecutive patients who came to a memory disorders clinic seeking services. The KBCI scales of Inattention, Apathy, Unawareness of Problems, and Communication Problems were significantly correlated with cognitive measures of executive functioning but not with measures of memory, visuospatial abilities or global cognitive functioning. In contrast, KBCI scales of Interpersonal Difficulties, Somatic Difficulties, and Emotional Adjustment were not related to any cognitive measures, either executive or nonexecutive. Contrary to predicted findings, the Impulsivity Scale was not associated with cognitive measures of executive functioning. This lack of relationship most likely reflects the failure to include executive measures of orbitofrontal functioning in this study. Results provide convergent and discriminant validity support for the KBCI. The KBCI may be a useful tool for assessing and tracking the executive, behavioral, and emotional sequelae of neurologic disorders.

The effects of depression and anxiety, as assessed by MMPI D and Pt scales, on memory performance was examined in 3999 veterans who completed the California Verbal Learning Test (CVLT). Depressive symptoms (without anxiety) had an adverse effect on immediate recall of new information and the total amount (but not rate) of acquisition; however, retrieval and retention were unaffected. On the other hand, high levels of anxiety did not have significant detrimental effects on any aspect of memory functioning assessed including immediate recall, total amount acquired, retention, and retrieval of novel information. However, when depression was compounded by anxiety, there was not only an adverse effect on immediate recall and amount (but not rate) of acquisition, but also on the retrieval of newly learned information. We conclude that the presence of comorbid anxiety may, in part, account for the variability in previous research findings regarding the effects of depression on memory functioning.

The Neurobehavioral Symptom Inventory (NSI) is a self-report measure of symptoms commonly associated with Post-Concussion Syndrome (PCS) that may emerge after mild traumatic brain injury (mTBI). Despite frequent clinical use, no NSI norms have been developed. Thus, the main objective of this study was to establish NSI normative data using the four NSI factors (i.e., vestibular, somatic, cognitive, and affective) identified by Vanderploeg, Silva, et al. ( 2014 ) among nonclinical epidemiological samples of deployed and non-deployed Florida National Guard members as well as a reference sample of Guard members with combat-related mTBI. In addition, NSI subscale profile patterns were compared across four distinct subgroups (i.e., non-deployed-nonclinical, deployed-nonclinical, deployed-mTBI, and deployed-PTSD). The deployed-nonclinical group endorsed greater PCS symptom severity than the non-deployed group, and the mTBI group uniformly endorsed more symptoms than both nonclinical groups. However, the PTSD group endorsed higher symptom severity relative to the other three subgroups. As such, this highlights the non-specificity of PCS symptoms and suggests that PTSD is associated with higher symptom endorsement than mTBI.

Consideration of symptom exaggeration or overt malingering is of particular importance in assessment of alleged mild head trauma and other mild or questionable personal injury situations. Validity is the extent to which tests assess what they were designed to measure. The determination of invalidity is part of the overall neuropsychological interpretation process. In neuropsychology a line of validity assessment research has developed, leading to three general approaches to validity and/or malingering assessment: (a) symptom validity measures, (b) invalid patterns of performance on clinical neuropsychological measures, and (c) concomitant extra-test behavioral information or observations. In each case some aspect of behavior is compared to an external standard or to other intra-subject behavior. Inconsistencies and discrepant comparisons are cause for validity concerns. These approaches are described and recommendations are provided based on the extant literature. However, validity assessment is difficult and at times ambiguous in part because real and feigned deficits are not mutually exclusive. In some clinical situations the most that can be said about an invalid performance is that it is not indicative of the true neurobehavioral capabilities of the person being evaluated, and is not consistent with the presumed etiologic event.

CVLT and WMS–R Digit Span variables were used to calculate indexes of seven specific short- and long-term memory processes: working memory span and central executive functions, and long-term memory encoding, consolidation, retention, retrieval, control abilities. Scores on these indexes were then cluster-analyzed to determine whether subtypes of memory performance exist that correspond to deficits in these theoretical memory constructs. Parallel analyses were conducted with two large samples (N = 150 and N = 151) of individuals who had sustained a traumatic brain injury (TBI). Findings showed that TBI results in subgroups of memory disorders with specific deficits in consolidation, retention, and retrieval processes. Control problems (keeping track of list versus non-list items) only appeared in conjunction with retrieval deficits. Working memory span and central executive functioning (i.e., the ability to manipulate information in working memory) do not appear to be deficits characteristic of TBI as no such clusters emerged in the analyses. By using specific indexes of memory processes, and in contrast to previous studies, patterns of memory dysfunction were found that correspond to deficits in theoretically meaningful memory constructs. (JINS, 2001, 7, 574–585.)

Material-specific memory refers to the ability to learn and recall new episodic information on the basis of the nature of the stimulus material (e.g., verbal vs. nonverbal-visuospatial). Structural equation modeling was used to analyze data from a sample of patients with traumatic brain injury to compare 3 models of memory functioning: material-specific, material-specific plus general, and general (non-material-specific). The models were examined separately for acquisition, delayed free recall, and retention aspects of memory. Results suggest that, at least in a population with traumatic brain injury, the acquisition of new information takes place in a material-specific memory fashion, delayed free recall involves both material-specific and general (non-material-specific) memory components, but retention relies primarily on general (non-material-specific) memory processes.

Family stress following traumatic brain injury (TBI) is well documented. Previous studies have shown that family adaptation and the use of coping strategies moderate the stresses of TBI in the long term. However, relatively little is known about the impact on the family and family response during the acute stage of recovery. The present study used Olson's Circumplex Model to examine acute changes in family structure and examined changes in coping responses pre- and post-TBI. Wives of 20 male TBI survivors completed the Couples Version of the Family Adaptability and Cohesion Evaluation Scales-II (FACES-II) and the Coping Responses Inventory (CRI). These questionnaires were completed retrospectively for a stressful event that occurred six months prior to the TBI, then for the current period following the TBI. Results found that 60% of all families experienced a significant change in structure following TBI. As predicted by the Circumplex Model, balanced families changed most, with 70% changing to the extreme type post-TBI. Focus of coping (problem versus emotion) and coping techniques (cognitive versus behavioral) also changed significantly from pre- to post-TBI and differed, depending on post-TBI family structure. Family interventions based on these differences in family structure and coping are presented.

In this study, we examined relationships between the full five-factor (FF; Costa & McCrae, 1985, 1992; Digman, 1990) and Holland's (1985a) RIASEC models of personality in a sample of 1,034 adults. The NEO Personality Inventory-Revised (Costa & McCrae, 1992) and the Self-Directed Search (Holland, 1985c) provided measures of the FF and RIASEC dimensions, respectively. Canonical correlation analyses provided evidence primarily for a pattern of linkages between the FF Extraversion, Openness, and Agreeableness measures and the RIASEC Enterprising, Artistic, and Social scales. Findings from this and previous studies indicated that the FF model appears to ignore the Realistic dimension and provides coverage of the Investigative and Conventional dimensions in women only. In turn, the RIASEC model appears to provide modest coverage of the FF Neuroticism and Conscientiousness domains for women and not at all for men.

The four neurological patient groups and the normals from the Wisconsin Card Sorting Test (WCST) standardization sample were used to examine the discriminability of the WCST's indices. Results reveal consistent differentiation of normals from the patient groups on all WCST variables, with classification rates averaging 71% accuracy. However, patient groups with frontal, diffuse, and nonfrontal lesions were not consistently discriminable from each other. The results suggest that the WCST is most usefully conceptualized as a measure of executive abilities that involves the frontal lobes, but should not be considered solely as a marker of isolated frontal lobe pathology.

The underlying latent structure of the Wisconsin Card Sorting Test (WCST) was examined in sets of nonpatient normals and neurologically impaired individuals. Making use of the WCST standardization sample, a factor-analytic procedure was employed to evaluate the instrument's structure. The findings revealed that in normal individuals, the WCST is best described by a unitary factor. In contrast, in neurological patients with either focal or diffuse impairment, performance on this test is primarily explained on the basis of two factors: Problem Solving/Perseveration and Loss of Set. The inclusion of nonperseverative errors on this second factor was more obvious in neurological patients with focal lesions.

The Continuous Visual Memory Test (CVMT) employs complex ambiguous designs and a recognition format to assess visual memory. The CVMT has proven sensitive to effects of head trauma, Alzheimer's Disease, unilateral right-hemisphere CVA, and normal aging. Recently, an alternate form for the CVMT was developed. This study examined the equivalence of Forms I and II. Subjects were 40 normal adults and 52 patients of mixed neurological and psychiatric etiology. Subjects were administered both forms of the CVMT. Data analysis revealed no significant differences between forms for either the acquisition or delayed tasks. Generalizability coefficients ranged from .45 to .72. Variance attributable to differences in CVMT form was essentially zero. Hierarchical multiple regression analysis revealed that age but not education or gender significantly predicted all CVMT scores.

Factor analysis was conducted on attention, information processing, verbal and visual memory scores of 112 patients. Factor structure did not vary as a function of age. The Expanded Paired Associates Test, Verbal Selective Reminding Test, Continuous Recognition Memory Test, and Continuous Visual Memory Test defined a general memory factor. The PASAT, WMS Mental Control, and WAIS-R Digit Span defined an attention/information processing factor. Immediate Visual Reproduction (VR) loaded primarily on visual/nonverbal intelligence, whereas delayed VR loaded primarily with the memory factor. The Trail Making Test, Part B was more closely associated with visual/nonverbal intelligence than with attention/information processing. Serial Digit Learning was more closely associated with attention/information processing than with general memory.

Khantzian (1985) has proposed a model of substance abuse that asserts that some drug-dependent individuals select a drug of choice to provide relief from specific painful affective states. This study was undertaken to examine the self-medication hypothesis in four groups of substance abusers defined by their use of specific drugs. The Personality Assessment Inventory (Morey, 1991), an inventory characterized by scales of homogeneous clinical content, was used to examine group differences in symptomatology and personality traits. Results suggest that there are traits or symptoms that separate various groups of drug-dependent patients, but not in concordance with the self-medication hypothesis.

The Wechsler Adult Intelligence Scale-Revised (Wechsler, 1981) standardization data were analyzed to determine the frequency of relative intersubtest scatter. The relative scatter range was defined as the difference between the highest and lowest subtest scores based on the value of the highest subtest. This approach provides the greatest precision in scatter analysis to determine whether the amount of scatter obtained in clinical profiles is rare enough to be considered abnormal. For ease of clinical use, tables are provided that report frequency of a minimum (lowest) subtest score by each level of maximum (highest) subtest score. Potential scatter range, rather than overall level of intelligence, was the primary determinant of the magnitude of scatter; the greater the possible range the larger the magnitude of scatter

Chest optimization, an evidence-based protocol-guided multimodal chest physiotherapy consisting of body positioning, sputum mobilization, bronchodilation, and lung hyperinflation, may be routinely administered to ventilator-dependent patients with low cervical spinal cord injury (CSCI) for improving pulmonary functional outcomes that facilitate weaning from mechanical ventilation. We undertook this study to determine whether position-specific chest optimization was associated with changes in spontaneous breathing trial (SBT) duration. Cardiac output (CO), alveolar minute volume (MValv), carbon dioxide elimination (VCO(2)), and static chest compliance (Cst) were measured during chest optimization; then MValv and rapid shallow breathing index (RSBI) were measured during SBT. Study participants (N = 12) were clinically stable ventilator-dependent patients with low CSCI. Trendelenburg chest optimization (TCO) was associated with significant increases in SBT (p < 0.001), CO (p < 0.001), MValv (p < 0.003), VCO(2) (p < 0.001), and Cst (p < 0.002). SBT following TCO was associated with significant increases in MValv (p < 0.03) and RSBI (p < 0.002). These preliminary findings suggest the importance of proper recumbent body positioning during evidence-based, protocol-guided multimodal chest physiotherapy for ventilator-dependent patients with low CSCI.

The construct validity of the Continuous Visual Memory Test (CVMT), a new measure of visual recognition memory was evaluated based on the performance of 92 healthy, normal adults. A series of factor analyses were conducted utilizing marker variables for verbal memory, visual memory, attention and concentration, and verbal and visual/nonverbal intellectual functions. CVMT acquisition scores were associated with verbal and visual/nonverbal intellectual factors as well as with attentional ability. The CVMT delayed recognition score was shown to be a factorially “pure” measure of visual memory.

The Minnesota Multiphasic Personnality Inventory scores of 93 male and 186 female headache patients were subjected to a cluster analysis. Four distinct clusters were derived for both men and women. A second sample (52 men, 177 women) was used for cross-validation purposes and again 4 distinct clusters were found for both men and women

Vanderploeg RD, Belanger HG, Curtiss G. Mild traumatic brain injury and posttraumatic stress disorder and their associations with health symptoms. Objective To determine the association of various symptoms and psychiatric diagnoses with a remote history of mild traumatic brain injury (MTBI) and a current diagnosis of posttraumatic stress disorder (PTSD). Design Cross-sectional cohort study. Setting Nonclinical. Participants Three groups of randomly selected community dwelling male U.S. Army Vietnam-era veterans: healthy control (n=3218), those injured in a motor vehicle collision (MVC) but without a head injury (MVC injury control; n=548), and those who had an MTBI (n=278). Interventions None. Main Outcome Measures Prevalence of psychiatric diagnoses, physical, cognitive, and emotional symptoms, and course of PTSD across time. Results Logistic regression procedures were used to determine group association with symptoms and psychiatric diagnosis after controlling for demographic variables, combat intensity, medical disorders, and other current psychiatric conditions. MTBI was associated with headaches, memory problems, sleep problems, and fainting even after controlling for current psychiatric problems (including PTSD), as well as demographic variables, combat intensity, and comorbid medical conditions. MTBI also was associated with a current diagnosis of PTSD even controlling for other demographic, psychiatric, and medical covariates. MTBI did not moderate or mediate the relationship between PTSD and current symptomatology. However, MTBI did adversely affect long-term recovery from PTSD (odds ratio=1.59, 95% CI, 1.07–2.37). PTSD also was associated with physical, cognitive, and emotional symptoms, and had a larger effect size than MTBI. Conclusions MTBI, even in the chronic phase years postinjury, is not a benign condition. It is associated with increased rates of headaches, sleep problems, and memory difficulties. Furthermore, it can complicate or prolong recovery from preexisting or comorbid conditions such as PTSD. Similarly, PTSD is a potent cocontributor to physical, cognitive, and emotional symptoms.

Objectives To determine the relative efficacy of 2 different acute traumatic brain injury (TBI) rehabilitation approaches: cognitive didactic versus functional-experiential, and secondarily to determine relative efficacy for different patient subpopulations. Design Randomized, controlled, intent-to-treat trial comparing 2 alternative TBI treatment approaches. Setting Four Veterans Administration acute inpatient TBI rehabilitation programs. Participants Adult veterans or active duty military service members (N=360) with moderate to severe TBI. Interventions One and a half to 2.5 hours of protocol-specific cognitive-didactic versus functional-experiential rehabilitation therapy integrated into interdisciplinary acute Commission for Accreditation of Rehabilitation Facilities-accredited inpatient TBI rehabilitation programs with another 2 to 2.5 hours daily of occupational and physical therapy. Duration of protocol treatment varied from 20 to 60 days depending on the clinical needs and progress of each participant. Main outcome measures The 2 primary outcome measures were functional independence in living and return to work and/or school assessed by independent evaluators at 1-year follow-up. Secondary outcome measures consisted of the FIM, Disability Rating Scale score, and items from the Present State Exam, Apathy Evaluation Scale, and Neurobehavioral Rating Scale. Results The cognitive-didactic and functional-experiential treatments did not result in overall group differences in the broad 1-year primary outcomes. However, analysis of secondary outcomes found differentially better immediate posttreatment cognitive function (mean+/-SD cognitive FIM) in participants randomized to cognitive-didactic treatment (27.3+/-6.2) than to functional treatment (25.6+/-6.0, t332=2.56, P=.01). Exploratory subgroup analyses found that younger participants in the cognitive arm had a higher rate of returning to work or school than younger patients in the functional arm, whereas participants older than 30 years and those with more years of education in the functional arm had higher rates of independent living status at 1 year posttreatment than similar patients in the cognitive arm. Conclusions Results from this large multicenter randomized controlled trial comparing cognitive-didactic and functional-experiential approaches to brain injury rehabilitation indicated improved but similar long-term global functional outcome. Participants in the cognitive treatment arm achieved better short-term functional cognitive performance than patients in the functional treatment arm. The current increase in war-related brain injuries provides added urgency for rigorous study of rehabilitation treatments. (http://ClinicalTrials.gov ID# NCT00540020.).

Mild traumatic brain injury (TBI) is characterized by acute physiological changes that result in at least some acute cognitive difficulties and typically resolve by 3 months postinjury. Because the majority of mild TBI patients have normal structural magnetic resonance imaging (MRI)/computed tomography (CT) scans, there is increasing attention directed at finding objective physiological correlates of persistent cognitive and neuropsychiatric symptoms through experimental neuroimaging techniques. The authors review studies utilizing these techniques in patients with mild TBI; these techniques may provide more sensitive assessment of structural and functional abnormalities following mild TBI. Particular promise is evident with fMRI, PET, and SPECT scanning, as demonstrated by associations between brain activation and clinical outcomes.

We evaluated a 23 year-old man after recovery from encephalitis. In contrast to the expected pattern of increasingly better acquisition across the 5 learning trials of the California Verbal Learning Test (CVLT-2), he produced a "J-shaped" curve (Trials 1-5: 8,6,6,9,11). Because he also demonstrated excessive levels of proactive interference as well as poor divided attention, we hypothesized that his atypical learning pattern was due to a build-up of proactive interference secondary to executive dyscontrol. Using a large sample of 4462 healthy adult men, we identified four groups exhibiting various learning patterns. We found that a learning pattern similar to this patient (i.e., a drop after trial 1 followed by recovery) was rare (1.1% of the sample). Individuals with this learning pattern demonstrated increased perseverative responses, as well as greater difficulty maintaining cognitive set on the Wisconsin Card Sorting Test, decreased attentional control on the Paced Auditory Serial Addition Test, and greater levels of proactive interference on the CVLT. Taken together, the results of the study suggest that an early drop, followed by a recovery in learning trial performance, is associated with executive dyscontrol.

This chapter has focused on group data regarding outcomes following mTBI. However, in both the clinical and the medicallegal context, it is not the group but rather the individual who is the focus of interest. The question is no longer “What factors influence outcome following mTBI?” but rather “What is causing the symptoms or problems in this particular case?” The clinical arena can accommodate an ambiguous interactive systemic model of causality, but a legal arena is seeking to assign definitive responsibility. Also, in the individual case, it is often very difficult, if not impossible, to attribute mildly abnormal findings such as slightly more proactive memory interference than normal, mild balance difficulties, occasional visual imperceptions, headaches, dizziness, fatigue, and memory complaints to a particular etiology. Such a pattern of symptoms could represent (1) brain dysfunction, (2) a normal population variant, (3) pre-existing mental health problems (e.g., depression and anxiety), (4) pre-existing or coexisting medical problems (e.g., chronic pain syndrome, multiple sclerosis, hypertension, acquired immunodeficiency syndrome, alcohol-abuse-related complications), (5) inadequate patient effort on examination or outright malingering, or (6) a combination of these factors. Furthering the difficulty in determining etiological factors is weighing the degree to which pre-existing poor coping skills, selfbeliefs/ expectations, poor social support, medical iatrogenesis, or litigationbased iatrogenesis might amplify and extend residual post-mTBI problems. A conservative but limited approach for the health care provider might lie in time-tested, clinically validated diagnostic evaluations, a careful history of preinjury and postinjury symptoms and functioning, and a reliance on the medical linear model of causality. However, an increasingly used approach relies on the examination of multiple potential predisposing factors, causative agents, and perpetuating factors that interactively influence each other. Causality determination requires (1) examination of all relevant etiological events or factors, (2) investigation of the initial clinical presentation as being more or less consistent with those potential causative agents, (3) tracking ongoing or emerging symptoms as being consistent with the medical literature regarding potential causative agents and not consistent with other potential etiological factors, and (4) examination of findings from diagnostic procedures as being consistent with the clinical history, the nature and course of symptoms, and suspected explanatory causative factors. Only if a chronologically consistent and clinically logical pattern of results emerges after an alleged causal event can findings be attributed to it.

G. Tremont, S. Halpert, D. J. Javorsky, and R. A. Stern (2000) found that individuals with executive dysfunction were more impaired on less structured versus more structured verbal memory tasks. In the present study, the authors investigated the relationship between executive functions and memory in patients with a history of traumatic brain injury by examining the effect of executive functioning on more structured and less structured verbal and visual memory tasks at baseline and 1-year follow-up. Matched subgroups controlled for differences in severity of neuropsychological impairment unrelated to specific executive functions. The G. Tremont et al. (2000) findings were not replicated. Results showed that when acuteness and severity of injury were controlled, executive impairment played no significant role in performance on either more or less structured memory tasks. However, regardless of structure, executive functions played a role in visual memory performance, suggesting that visual memory may be a more fluid ability than verbal memory.