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Objective: to determine the potential impacts of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) on the incidence of TBI-related hospitalization in the active duty US Army. Methods: All active duty Army personnel hospitalized with a TBI diagnosis during fiscal years 2000 through 2006 were identified in an administrative database. Annual crude incidence rates were calculated. Two-year adjusted incidence rates were calculated to compare TBI-related hospitalization rates in the Army to rates in the age-comparable segment of the US civilian population. Results: The overall incidence of TBI-related hospitalization in the active duty Army increased 105% from FY2000 to FY2006. There was a 60-fold increase in the hospitalization rate for TBIs attributed to weapons. The increases in TBI hospitalizations coincided with the occurrence of OEF/OIF. During OEF/OIF, the Army's hospitalization rates for moderate and severe TBIs were lower than civilian rates; however, the Army's hospitalization rate for mild TBIs was higher than civilian rates. Conclusion: OEF/OIF appear to have had a substantial impact on TBI-related hospitalization rates in the active duty US Army but differences between Army and civilian rates were not as excessive as expected. [ABSTRACT FROM AUTHOR]

PURPOSE: To characterize cognitive test performance in a sample of US Army soldiers who had served in Iraq and Afghanistan and were tested after returning to their home base. To determine whether if a self-reported history of deployment-related traumatic brain injury (TBI), lifetime history of TBI, and the current postconcussive symptom status affected cognitive test performance. METHODS: A convenience sample of 956 soldiers was administered the Automated Neuropsychological Assessment Metrics (ANAM) test battery as well as questionnaires asking about deployment-related TBI, lifetime TBI history, and current TBI-related symptoms. RESULTS: Consistent with past mild TBI (MTBI) research, having a history of deployment-related MTBI up to 2 years prior to cognitive testing was not associated with poor ANAM performance after deployment. There also were no associations between poor ANAM performance and the number of lifetime TBIs, and injury severity and the number of problematic postconcussive symptoms. CONCLUSIONS: A history of self-reported MTBI or current postconcussive symptoms does not increase the risk of cognitive impairment in service members returning from Iraq and Afghanistan. [ABSTRACT FROM AUTHOR]

Military paratroopers are inherently at risk for a variety of injuries when they jump, including traumatic brain injuries (TBIs). U.S. Army paratroopers rely on their ballistic helmets for protection against TBIs when jumping. Currently, two different helmets are available to Army paratroopers, that is, the personnel armor system for ground troops helmet and the advanced combat helmet. This study compared the incidence of self-reported, jump-related TBIs in a small sample of paratroopers (N = 585) using each type of helmet. Data were obtained from surveys of soldiers at Fort Bragg, North Carolina. The overall relative risk of sustaining a TBI while jumping was 2.3 times (95% confidence interval, 1.3-4.3) higher for personnel armor system for ground troops helmet users. Most of the increase in risk was accounted for by the most-minor TBIs (American Academy of Neurology grade 1 or 2 concussion). [ABSTRACT FROM AUTHOR]

Many factors are considered during ballistic helmet design, including comfort, weight, fit, and maintainability. These factors affect soldiers' decisions about helmet use; therefore, rigorous research about soldiers' real-life experiences with helmets is critical to assessing a helmet's overall protective efficacy. This study compared soldiers' satisfaction and problem experience with the advanced combat helmet (ACH) and the personal armor system for ground troops (PASGT) helmet. Data were obtained from surveys of soldiers at Fort Bragg, North Carolina. Ninety percent of ACH users were satisfied overall with their helmet, but only 9.5% of PASGT users were satisfied (p < 0.001). The most frequently reported problems for the ACH involved malfunctioning helmet parts. The most frequently reported problems for the PASGT involved discomfort. This analysis indicated that there was a strong soldier preference for the ACH over the PASGT, which could enhance its already superior protective qualities. It also demonstrated the usefulness of soldiers' assessments of protective equipment. [ABSTRACT FROM AUTHOR]

Objective: To examine elevated symptoms on health-related quality of life (HRQOL) measures over 2 years in caregivers of service members with traumatic brain injury (TBI). To compare outcomes to caregivers of veterans., Method: Caregivers ( N = 315) were classified into two groups: (a) service member caregiver group ( n = 55) and (b) veteran caregiver group ( n = 260). Caregivers completed 17 HRQOL measures at a baseline evaluation and follow-up evaluation 24 months later., Results: In the service member caregiver group, the highest frequency of clinically elevated T -scores (≥ 60 T) at baseline and follow-up were found on physical and psychological HRQOL measures (16.4%-30.9%). A higher proportion of the veteran caregiver group had clinically elevated scores on nine measures at baseline and seven measures at follow-up. Examining the number of clinically elevated scores simultaneously across all 17 measures, the service member caregiver group had multiple elevated scores (e.g., 4 or more: baseline = 25.5%, follow-up = 27.3%). A higher proportion of the veteran caregiver group had multiple clinically elevated scores for 13 comparisons at baseline ( h = .35-.82), but reduced to eight comparisons at follow-up ( h = .36-.63). In the service member caregiver group, the proportion of caregivers with clinically elevated scores at baseline and follow-up was equally dispersed across persistent and newly developed symptoms, but higher for persistent symptoms compared to developed symptoms in the veteran caregiver group., Conclusions: Many caregivers of service members reported clinically elevated scores across HRQOL domains and the prevalence increased over 2 years. More services for caregivers in the Department of Defense may be helpful in reducing the trajectory of newly developed symptoms long term. (PsycInfo Database Record (c) 2025 APA, all rights reserved).

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

Purpose/objective: To examine longitudinal change in health-related quality of life (HRQOL) in caregivers of service members/veterans with traumatic brain injury and factors associated with clinically elevated symptoms., Research Method/design: Caregivers ( N = 220) completed nine HRQOL outcome measures and 10 risk factor measures at a baseline evaluation and follow-up evaluation 3 years later. Caregiver's responses on the nine HRQOL outcome measures were classified into four clinical change categories based on the presence/absence of clinically elevated T -scores (≥ 60 T) at baseline and follow-up: (a) Persistent (baseline ≥ 60T + follow-up ≥ 60 T), (b) Developed (baseline < 60 T + follow-up ≥ 60 T), (c) Improved (baseline ≥ 60 T + follow-up < 60 T), and (d) Asymptomatic (baseline < 60 T + follow-up < 60 T). A clinical change composite score was calculated by summing the number of Persistent or Developed HRQOL outcome measures and used to create three clinical change groups: (a) No Symptoms ( n = 69, zero measures), (b) Some Symptoms ( n = 88, one to three measures), and (c) Numerous Symptoms ( n = 63, four to nine measures)., Results: Of the nine HRQOL outcome measures, Bodily Pain, Perceived Stress, Sleep-Related Impairment, and Fatigue were most frequently classified as Persistent or Developed from baseline to follow-up in the entire sample. A linear relationship was found between the vast majority of risk factors across the three clinical change groups at baseline and follow-up (Numerous > Some > None). The risk factors were correlated with the number of elevated HRQOL symptoms at baseline and follow-up. Most Asymptomatic or Persistent caregivers did not have meaningful change (≥ 1 SD) in HRQOL scores. A sizable proportion of Developed or Improved caregivers had either meaningful or no change in HRQOL scores., Conclusions/implications: There is a need for ongoing clinical services for military caregivers. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

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

Study Design: Using two observational methods and a within-subjects, counterbalanced design, this study aimed to determine if a computer's hardware and software settings significantly affected reaction time (RT) on the Automated Neuropsychological Assessment Metrics (Version 4) Traumatic Brain Injury Military (ANAM4 TBI-MIL)., Methods: Three computer platforms were investigated: Platform 1-older computers recommended for ANAM4 TBI-MIL administration, Platform 2-newer computers with settings downgraded to run like the older computers, and Platform 3-newer computers with default settings. Two observational methods were used to compare measured RT to observed RT on all three platforms: 1, a high-speed video analysis to compare the timing of stimulus onset and response to the measured RT and 2, comparing a preset RT delivered by a robotic key actuator activated by optic detector to the measured RT. Additionally, healthy active duty service members (n = 169) were administered a brief version of the ANAM4 TBI-MIL battery on each of the three platforms., Results: RT differences were observed with both the high-speed video and robotic arm analyses across all three computer platforms, with the smallest discrepancies between observed and measured RT on Platform 1, followed by Platform 2, then Platform 3. When simple reaction time (SRT) raw and standardized scores obtained from the participants were compared across platforms, statistically significant and clinically meaningful differences were seen, especially between Platforms 1 and 3., Conclusions: A computer's configurations have a meaningful impact on ANAM SRT scores. The difference in an individual's performance across platforms could be misinterpreted as clinically meaningful change., (© The Author(s) 2020. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permission@oup.com.)

Objective: Executive functioning encompasses interactive cognitive processes such as planning, organization, set-shifting, inhibition, self-monitoring, working memory, and initiating and sustaining motor and mental activity. Researchers therefore typically assess executive functioning with multiple tests, each yielding multiple scores. A single composite score of executive functioning, which summarizes deficits across a battery of tests, would be useful in research and clinical trials. This study examines multiple candidate composite scores of executive functioning using tests from the Delis-Kaplan Executive Function System (D-KEFS)., Method: Participants were 875 adults between the ages of 20 and 89 years from the D-KEFS standardization sample. Seven Total Achievement scores were used from three tests (i.e., Trail Making, Verbal Fluency, and Color-Word Interference) to form eight composite scores that were compared based on their psychometric properties and association with intelligence (IQ)., Results: The distributions of most composite scores were mildly to severely skewed, and some had a pronounced ceiling effect. The composite scores all showed a medium positive correlation with IQ. The composite scores were highly intercorrelated in the total sample and in four IQ subgroups (i.e., IQ <89, 90-99, 100-109, 110+), with some being so highly correlated that they appear redundant., Conclusions: This study is part of a larger research program developing a cognition endpoint for research and clinical trials with sound psychometric properties and utility across discrepant test batteries. Future research is needed to examine the reliability and ecological validity of these composite scores., (© The Author(s) 2020. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permission@oup.com.)

Objective: To assess agreement between four brief computerized neurocognitive assessment tools (CNTs), ANAM, CogState, CNS Vital Signs, and ImPACT, by comparing rates of low scores., Methods: Four hundred and six US Army service members (SMs) with and without acute mild traumatic brain injury completed two randomly assigned CNTs with order of administration also randomly assigned. We performed a base rate analysis for each CNT to determine the proportions of SMs in the control and mTBI groups who had various numbers of scores that were 1.0+, 1.5+, and 2.0+ standard deviations below the normative mean. We used these results to identify a hierarchy of low score levels ranging from poorest to least poor performance. We then compared the agreement between every low score level from each CNT pair administered to the SMs., Results: More SMs in the mTBI group had low scores on all CNTs than SMs in the control group. As performance worsened, the association with mTBI became stronger for all CNTs. Most if not all SMs who performed at the worst level on any given CNT also had low scores on the other CNTs they completed but not necessarily at an equally low level., Conclusion: These results suggest that all of the CNTs we examined are broadly similar but still retain some psychometric differences that need to be better understood. Furthermore, the base rates of low scores we present could themselves be useful to clinicians and researchers as a guide for interpreting results from the CNTs., (© The Author(s) 2019. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: The Automated Neuropsychological Assessment Metrics (Version 4) Traumatic Brain Injury Military (ANAM4 TBI-MIL) is commonly administered among U.S. service members both pre-deployment and following TBI. The current study used the ANAM4 TBI-MIL to develop a cognition summary score for TBI research and clinical trials, comparing eight composite scores based on their distributions and sensitivity/specificity when differentiating between service members with and without mild TBI (MTBI)., Method: Male service members with MTBI (n = 56; Mdn = 11 days-since-injury) or no self-reported TBI history (n = 733) completed eight ANAM4 TBI-MIL tests. Their throughput scores (correct responses/minute) were used to calculate eight composite scores: the overall test battery mean (OTBM); global deficit score (GDS); neuropsychological deficit score-weighted (NDS-W); low score composite (LSC); number of scores <50th, ≤16th percentile, or ≤5th percentile; and the ANAM Composite Score (ACS)., Results: The OTBM and ACS were normally distributed. Other composites had skewed, zero-inflated distributions (62.9% had GDS = 0). All composites differed significantly between participants with and without MTBI (p < .001), with deficit scores showing the largest effect sizes (d = 1.32-1.47). The Area Under the Curve (AUC) was lowest for number of scores ≤5th percentile (AUC = 0.653) and highest for the LSC, OTBM, ACS, and NDS-W (AUC = 0.709-0.713)., Conclusions: The ANAM4 TBI-MIL has no well-validated composite score. The current study examined multiple candidate composite scores, finding that deficit scores showed larger group differences than the OTBM, but similar AUC values. The deficit scores were highly correlated. Future studies are needed to determine whether these scores show less redundancy among participants with more severe TBIs., (© The Author(s) 2019. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

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

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

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

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

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

Cognitive impairment is a core clinical feature of traumatic brain injury (TBI). After TBI, cognition is a key determinant of post-injury productivity, outcome, and quality of life. As a final common pathway of diverse molecular and microstructural TBI mechanisms, cognition is an ideal endpoint in clinical trials involving many candidate drugs and nonpharmacological interventions. Cognition can be reliably measured with performance-based neuropsychological tests that have greater granularity than crude rating scales, such as the Glasgow Outcome Scale-Extended, which remain the standard for clinical trials. Remarkably, however, there is no well-defined, widely accepted, and validated cognition endpoint for TBI clinical trials. A single cognition endpoint that has excellent measurement precision across a wide functional range and is sensitive to the detection of small improvements (and declines) in cognitive functioning would enhance the power and precision of TBI clinical trials and accelerate drug development research. We outline methodologies for deriving a cognition composite score and a research program for validation. Finally, we discuss regulatory issues and the limitations of a cognition endpoint., Competing Interests: Author Disclosure Statement GLI has been reimbursed by the government, professional scientific bodies, and commercial organizations for discussing or presenting research relating to MTBI and sport-related concussion at meetings, scientific conferences, and symposiums. He has a clinical practice in forensic neuropsychology involving individuals who have sustained mild TBIs. He has received honorariums for serving on research panels that provide scientific peer review of programs. He is a co-investigator, collaborator, or consultant on grants relating to mild TBI funded by several organizations. He has received grant funding from pharmaceutical companies to do psychometric research using neuropsychological tests. He has received research support from neuropsychological test publishing companies in the past (not in the past 5 years). For the remaining authors, no competing financial interests exist. NDS receives salary support from a Vancouver Coastal Health Research Institute Clinician-Scientist Career Development Award. GLI acknowledges support from the INTRuST Posttraumatic Stress Disorder and Traumatic Brain Injury Clinical Consortium funded by the Department of Defense Psychological Health/Traumatic Brain Injury Research Program (X81XWH-07-CC-CSDoD), Harvard Integrated Program to Protect and Improve the Health of NFLPA Members, and the Mooney-Reed Charitable Foundation. GTM acknowledges support from NIH U01 NS086090-01, DOD USAMRAA W81XWH-13-1-0441, DOD W81XWH-14-2-0176, and One Mind. This work is related to the TBI Endpoints Development Initiative and a grant entitled Development and Validation of a Cognition Endpoint for Traumatic Brain Injury Clinical Trials.

Objective: The purpose of this study was to examine the prevalence and stability of symptom reporting in a healthy military sample and to develop reliable change indices for two commonly used self-report measures in the military health care system., Participants and Method: Participants were 215 U.S. active duty service members recruited from Fort Bragg, NC as normal controls as part of a larger study. Participants completed the Neurobehavioral Symptom Inventory (NSI) and Posttraumatic Checklist (PCL) twice, separated by approximately 30 days., Results: Depending on the endorsement level used (i.e. ratings of 'mild' or greater vs. ratings of 'moderate' or greater), approximately 2-15% of this sample met DSM-IV symptom criteria for Postconcussional Disorder across time points, while 1-6% met DSM-IV symptom criteria for Posttraumatic Stress Disorder. Effect sizes for change from Time 1 to Time 2 on individual symptoms were small (Cohen's d = .01 to .13). The test-retest reliability for the NSI total score was r = .78 and the PCL score was r = .70. An eight-point change in symptom reporting represented reliable change on the NSI total score, with a seven-point change needed on the PCL., Conclusions: Postconcussion-like symptoms are not unique to mild TBI and are commonly reported in a healthy soldier sample. It is important for clinicians to use normative data when evaluating a service member or veteran and when evaluating the likelihood that a change in symptom reporting is reliable and clinically meaningful.

Objective: To compare rates of traumatic brain injury (TBI) diagnosis before and after overseas military deployment., Design: We conducted a retrospective examination of a cohort of 119 353 active duty US military service members (Army, Navy, Air Force, and Marines) whose first lifetime overseas deployment began at any time between January 1, 2011, and December 31, 2011, and lasted at least for 30 days. For this cohort, TBI diagnoses were examined during the 76 weeks prior to deployment, during deployment, and 76 weeks following the end of deployment., Main Measures: 4-week rates of TBI diagnosis., Results: The risk of being diagnosed with TBI within 4 weeks after returning from deployment was 8.4 times higher than the average risk before deployment. The risk gradually decreased thereafter up to 40 weeks postdeployment. However, during the 41 to 76 weeks following deployment, risk stabilized but remained on average 1.7 times higher than before deployment., Conclusion: An increased rate of TBI diagnosis following deployment was identified, which may be partly due to delayed diagnosis of TBIs that occurred while service members were deployed. Also, the increased rate may partly be due to riskier behaviors of service members following deployment that results in an increased occurrence of TBIs.

Base rates of low ANAM4 TBI-MIL scores were calculated in a convenience sample of 733 healthy male active duty soldiers using available military reference values for the following cutoffs: ≤2nd percentile (2 SDs), ≤5th percentile, <10th percentile, and <16th percentile (1 SD). Rates of low scores were also calculated in 56 active duty male soldiers who sustained an mTBI an average of 23 days (SD = 36.1) prior. 22.0% of the healthy sample and 51.8% of the mTBI sample had two or more scores below 1 SD (i.e., 16th percentile). 18.8% of the healthy sample and 44.6% of the mTBI sample had one or more scores ≤5th percentile. Rates of low scores in the healthy sample were influenced by cutoffs and race/ethnicity. Importantly, some healthy soldiers obtain at least one low score on ANAM4. These base rate analyses can improve the methodology for interpreting ANAM4 performance in clinical practice and research., (© The Author 2014. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

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

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

Objectives: Analyze the contribution of mild traumatic brain injury (mTBI) and/or posttraumatic stress disorder (PTSD) to the endorsement of postconcussive (PC) symptoms during Post Deployment Health Assessment. Determine whether a combination of mTBI and PTSD was more strongly associated with symptoms than either condition alone., Methods: Cross-sectional study design where both the exposure, mTBI and/or PTSD, and the outcomes of interest, PC symptoms, were ascertained after return from deployment. Subjects were injured soldiers (n = 1247) from one Fort Carson Brigade Combat Team (n = 3973)., Main Outcome Measures: Positive history of PC symptoms., Results: PTSD and mTBI together were more strongly associated with having PC symptoms (adjusted prevalence ratio 6.27; 95% CI: 4.13-9.43) than either mTBI alone (adjusted prevalence ratio = 4.03; 95% CI: 2.67-6.07) or PTSD alone (adjusted prevalence ratio = 2.74; 95% CI: 1.58-4.74) after adjusting for age, gender, education, rank, and Military Occupational Specialty., Conclusions: In soldiers with histories of physical injury, mTBI and PTSD were independently associated with PC symptom reporting. Those with both conditions were at greater risk for PC symptoms than those with either PTSD, mTBI, or neither. Findings support the importance of continued screening for both conditions with the aim of early identification and intervention.

This exploratory study was conducted to increase understanding of neuropsychological test performance in those with blast-related mild traumatic brain injury (mTBI). The two variables of interest for their impact on test performance were presence of mTBI symptoms and history of posttraumatic stress disorder (PTSD). Forty-five soldiers postblast mTBI, 27 with enduring mTBI symptoms and 18 without, completed a series of neuropsychological tests. Seventeen of the 45 met criteria for PTSD. The Paced Auditory Serial Addition Test (Frencham, Fox, & Mayberry, 2005; Spreen & Strauss, 1998) was the primary outcome measure. Two-sided, 2-sample t tests were used to compare scores between groups of interest. Presence of mTBI symptoms did not impact test performance. In addition, no significant differences between soldiers with and without PTSD were identified. Standard neuropsychological assessment may not increase understanding about impairment associated with mTBI symptoms. Further research in this area is indicated., (Copyright 2010 APA, all rights reserved)

Objectives: The objective of this article is to report the proportion of soldiers in a Brigade Combat Team (BCT) with at least 1 clinician-confirmed deployment-acquired traumatic brain injury (TBI) and to describe the nature of sequelae associated with such injuries., Participants: Members of an Army unit (n = 3973) that served in Iraq were screened for history of TBI. Those reporting an injury (n = 1292) were further evaluated regarding sequelae. Of the injuries suffered, 907 were TBIs and 385 were other types of injury. The majority of TBIs sustained were mild., Methods: Postdeployment, responses to the Warrior Administered Retrospective Casualty Assessment Tool (WARCAT) facilitated clinical interviews regarding injury history and associated somatic (ie, headache, dizziness, balance) and neuropsychiatric symptoms (ie, irritability, memory). Traumatic brain injury diagnosis was based on the American Congress of Rehabilitation Medicine mild TBI criteria, which requires an injury event followed by an alteration in consciousness., Results: A total of 22.8% of soldiers in a BCT returning from Iraq had clinician-confirmed TBI. Those with TBI were significantly more likely to recall somatic and/or neuropsychiatric symptoms immediately postinjury and endorse symptoms at follow-up than were soldiers without a history of deployment-related TBI. A total of 33.4% of soldiers with TBI reported 3 or more symptoms immediately postinjury compared with 7.5% at postdeployment. For soldiers injured without TBI, rates of 3 or more symptoms postinjury and postdeployment were 2.9% and 2.3%, respectively. In those with TBI, headache and dizziness were most frequently reported postinjury, with irritability and memory problems persisting and presenting over time., Conclusion: Following deployment to Iraq, a clinician-confirmed TBI history was identified in 22.8% of soldiers from a BCT. Those with TBI were significantly more likely to report postinjury and postdeployment somatic and/or neuropsychiatric symptoms than those without this injury history. Overall, symptom endorsement decreased over time.

Introduction: This paper examines 10-year trends in traumatic brain injury (TBI)-related hospitalization rates for active duty US Army personnel in the 1990s. It does this within the context of various factors, including enhanced injury prevention policies and changed hospital admission practices, that may have affected TBI hospitalization rates. It also compares TBI hospitalization rates in the Army to those from an age-comparable segment of the US civilian population over this time period., Methods: Crude (unadjusted) incidence rates for all active duty US Army personnel hospitalized with a TBI diagnosis from fiscal years (FY) 1990 to 1999 were calculated. Once the trends were identified, the percentage change in the overall rate, as well as the rates for different TBI severity levels, and in-hospital deaths from FY1990 and FY1999 were analyzed. Changes in age- and gender-specific rates as well as crude rates for cases with and without other injuries and cases treated in military and civilian hospitals were also analyzed. Rate ratios were used to compare aggregated 5-year TBI hospitalization rates in the Army to rates for civilians 17-49 years of age during the following time periods: 1990-1994 and 1995-1999. The rates used in the comparison were adjusted to control for differences in age and gender., Results: The overall incidence of TBI-related hospitalization in the Army decreased 75% from FY1990 to FY1999. The rates for all TBI severity levels decreased, but the rate for mild TBI decreased more than the rates for moderate and severe TBI. The rate of in-hospital deaths from TBI also decreased. Rates decreased similarly for males and females, across all age groups, as well as for cases with and without other injuries. TBI rates decreased for Army personnel treated in military hospitals but changed minimally for Army personnel treated in civilian hospitals. The Army's TBI hospitalization rates were generally higher than civilian rates in the early 1990s but by the late 1990s, most of the Army's rates were lower than or equal to the civilian rates., Conclusions: The incidence of TBI-related hospitalization in the active duty US Army decreased markedly (75%) during the 1990s. As a result, most of the Army's TBI hospitalization rates were lower than civilian rates by the late 1990s. Effective injury prevention and changes in the Army population were two of the factors that likely contributed to the decrease in rates for all TBI severity levels, while changes in hospital admission practices likely contributed to the disproportionate decrease in the Army's rates for mild TBI., (Copyright (c) 2006 S. Karger AG, Basel.)

Background: This study presents self-reported traumatic brain injury (TBI) prevalence rates for 2,337 active duty U.S. Army soldiers who underwent baseline testing as part of a larger study of military TBI., Methods: A computerized self-report questionnaire was administered to a convenience sample of 2,337 highly functioning active-duty soldiers at Fort Bragg, North Carolina, who underwent baseline testing during a 13-month period in 1999 and 2000 as part of a larger ongoing Institutional Review Board-approved study examining the consequences of brain injuries among paratroopers., Results: Approximately 23% of all of the soldiers surveyed reported sustaining a TBI after joining the Army. More than twice as many paratroopers reported sustaining TBI after joining the Army than did nonparatroopers (p < 0.001). Parachute-related TBI accounted for this difference. Nearly all of these injuries were mild. Less than 2% of paratroopers and no nonparatroopers reported loss of consciousness lasting more than 20 minutes. It was also shown that paratroopers with a history of TBI before joining the Army had a higher prevalence of TBI while serving in the Army (35%) than paratroopers without prior TBI (27.2%) (p = 0.002)., Conclusion: This study demonstrates that parachuting appears to be a risk factor for mild TBI in the U.S. Army and that paratroopers with a history of TBI before joining the Army might be at somewhat increased risk of sustaining additional TBI while serving in the Army.