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Clinical practice guidelines support cognitive rehabilitation for people with a history of mild traumatic brain injury (mTBI) and cognitive impairment, but no class I randomized clinical trials have evaluated the efficacy of self-administered computerized cognitive training. The goal of this study was to evaluate the efficacy of a self-administered computerized plasticity-based cognitive training programmes in primarily military/veteran participants with a history of mTBI and cognitive impairment. A multisite randomized double-blind clinical trial of a behavioural intervention with an active control was conducted from September 2013 to February 2017 including assessments at baseline, post-training, and after a 3-month follow-up period. Participants self-administered cognitive training (experimental and active control) programmes at home, remotely supervised by a healthcare coach, with an intended training schedule of 5 days per week, 1 h per day, for 13 weeks. Participants (149 contacted, 83 intent-to-treat) were confirmed to have a history of mTBI (mean of 7.2 years post-injury) through medical history/clinician interview and persistent cognitive impairment through neuropsychological testing and/or quantitative participant reported measure. The experimental intervention was a brain plasticity-based computerized cognitive training programme targeting speed/accuracy of information processing, and the active control was composed of computer games. The primary cognitive function measure was a composite of nine standardized neuropsychological assessments, and the primary directly observed functional measure a timed instrumental activities of daily living assessment. Secondary outcome measures included participant-reported assessments of cognitive and mental health. The treatment group showed an improvement in the composite cognitive measure significantly larger than that of the active control group at both the post-training [+6.9 points, confidence interval (CI) +1.0 to +12.7, P = 0.025, d = 0.555] and the follow-up visit (+7.4 points, CI +0.6 to +14.3, P = 0.039, d = 0.591). Both large and small cognitive function improvements were seen twice as frequently in the treatment group than in the active control group. No significant between-group effects were seen on other measures, including the directly-observed functional and symptom measures. Statistically equivalent improvements in both groups were seen in depressive and cognitive symptoms. [ABSTRACT FROM AUTHOR]

Objective To examine the influence of different performance validity test (PVT) cutoffs on neuropsychological performance, post-concussion symptoms, and rates of neurocognitive disorder and postconcussional syndrome following mild traumatic brain injury (MTBI) in active duty service members. Method Participants were 164 service members (Age: M = 28.1 years [SD = 7.3]) evaluated on average 4.1 months (SD = 5.0) following injury. Participants were divided into three mutually exclusive groups using original and alternative cutoff scores on the Test of Memory Malingering (TOMM) and the Effort Index (EI) from the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS): (a) PVT-Pass, n = 85; (b) Alternative PVT-Fail, n = 53; and (c) Original PVT-Fail, n = 26. Participants also completed the Neurobehavioral Symptom Inventory. Results The PVT-Pass group performed better on cognitive testing and reported fewer symptoms than the two PVT-Fail groups. The Original PVT-Fail group performed more poorly on cognitive testing and reported more symptoms than the Alternative PVT-Fail group. Both PVT-Fail groups were more likely to meet DSM-5 Category A criteria for mild and major neurocognitive disorder and symptom reporting criteria for postconcussional syndrome than the PVT-Pass group. When alternative PVT cutoffs were used instead of original PVT cutoffs, the number of participants with valid data meeting cognitive testing criteria for neurocognitive disorder or postconcussional syndrome decreased dramatically. Conclusion PVT performance is significantly and meaningfully related to overall neuropsychological outcome. By using only original cutoffs, clinicians and researchers may miss people with invalid performances. [ABSTRACT FROM AUTHOR]

Objective: Some military occupation specialties (MOS) such as Special Forces are at high risk for lifetime blast exposure (LBE). These individuals are at risk for some medical conditions but the impact of LBE on service members and veterans (SMVs) cognitive and psychiatric function is unknown. Methods: 281 SMVs completed an assessment of Attention/Working Memory, Processing Speed, Executive Function, Memory, and Psychiatric function. Average age was 35.86 (SD = 9.84) and 61.2% had at least moderate combat exposure and 32.4% had no history of traumatic brain injury (TBI). 61 participants had no LBE, 113 were in a high-risk MOS and had LBE (M = 211.23, SD = 395.1), and 107 were not in a high-risk MOS but had LBE (M = 92.7, SD =222.9). Results: Cognitively, a small effect for LBE was observed on Processing Speed (p = 0.015, ηp2 = 0.037), but not for the other domains. Psychiatrically, a medium effect was observed (p < 0.001, ηp2 = 0.103). Higher LBE was associated with Somatic Complaints, Low Positive Emotions and Aberrant Experiences. However, after controlling for covariates (sex, ethnicity, post-traumatic stress, combat exposure, alcohol use, and TBI) there was no impact of LBE. Conclusion: LBE may negatively impact processing speed and psychiatric function; however, the relative impact of LBE compared to other factors such as post-traumatic stress, substance abuse, and TBI needs further investigation. The views expressed are those of the authors and do not necessarily represent the official policy or position of the Defense Health Agency or any other U.S. government agency. For more information contact dha.TBICOEinfo@mail.mil. UNCLASSIFIED. [ABSTRACT FROM AUTHOR]

The purpose of this study was to identify factors that are predictive of, or associated with, high endorsement of postconcussion and posttraumatic stress symptoms following military-related traumatic brain injury (TBI). Participants were 1,600 U.S. service members (age: M = 27.1, SD = 7.1; 95.4% male) who had sustained a mild-to-moderate TBI and who had been evaluated by the Defense and Veterans Brain Injury Center at one of six military medical centers. Twenty-two factors were examined that included demographic, injury circumstances/severity, treatment/evaluation, and psychological/physical variables. Four factors were statistically and meaningfully associated with clinically elevated postconcussion symptoms: (i) low bodily injury severity, (ii) posttraumatic stress, (iii) depression, and (iv) military operation where wounded (p < .001, 43.2% variance). The combination of depression and posttraumatic stress symptoms accounted for the vast majority of unique variance (41.5%) and were strongly associated with, and predictive of, clinically elevated postconcussion symptoms [range: odds ratios (OR) = 4.24–7.75; relative risk (RR) = 2.28–2.51]. Five factors were statistically and meaningfully associated with clinically elevated posttraumatic stress symptoms: (i) low bodily injury severity, (ii) depression, (iii) a longer time from injury to evaluation, (iv) military operation where wounded, and (v) current auditory deficits (p < .001; 65.6% variance accounted for). Depression alone accounted for the vast majority of unique variance (60.0%) and was strongly associated with, and predictive of, clinically elevated posttraumatic stress symptoms (OR = 38.78; RR = 4.63). There was a very clear, strong, and clinically meaningful association between depression, posttraumatic stress, and postconcussion symptoms in this sample. Brain injury severity, however, was not associated with symptom reporting following TBI. [ABSTRACT FROM PUBLISHER]

This study compared the neuropsychological outcome in military personnel following mild-to-moderate traumatic brain injury (TBI). Participants were 83 service members divided into three injury severity groups: uncomplicated mild TBI (MTBI; n = 24), complicated MTBI (n = 17), and moderate TBI (n = 42). Participants were evaluated within 6 months following injury (73% within 3 months) using neurocognitive testing and the Personality Assessment Inventory (PAI). There were no significant differences between the three groups on the majority of neurocognitive measures. Similarly, there were no significant differences between the three groups on the majority of PAI clinical scales (all p > .05), with the exception of two scales. The uncomplicated MTBI group had significantly higher scores on the Anxiety-Related Disorders and Aggression scales compared with the complicated MTBI group, but not the moderate TBI group. Overall, these results suggest that within the first 6 months post injury, there were few detectable differences in the neuropsychological outcome following uncomplicated MTBI, complicated MTBI, or moderate TBI in this military sample. [ABSTRACT FROM AUTHOR]

The Genains, a unique group of monozygotic female quadruplets, all developed a schizophrenic disorder by age 24. They have been studied since the 1950s, because of the rarity of this occurrence (estimated to be one in 1.5 billion) and because their illnesses varied in severity. The identical inheritance would tend to rule out genetic differences as the cause of the neuropsychological differences; however, we cannot disentangle the effects of early brain injury and harsh punitive treatment as factors accounting for the differences in the severity of their disorders. We conducted neuropsychological examinations of the Genains at age 66, compared their test profiles, and contrasted certain test scores at 66 with those at ages 27 and 51. Test results indicate generally stable (or even improved) performance over time and support the notion that cognitive decline is not a degenerative process in schizophrenia. The Genains remind us of the exquisite interaction among variables that must be understood before additional, satisfactory progress can be made in preventing the development and predicting the course of schizophrenia. [ABSTRACT FROM PUBLISHER]

Objective Despite the strong evidence suggesting post-traumatic stress disorder (PTSD) symptoms negatively impact cognition following mild traumatic brain injury (TBI), little is known about this relationship in more severe TBI. This study investigates the relationship between PTSD symptoms and cognitive performance following complicated mild, moderate, severe, and penetrating TBI. Methods Participants were 137 U.S. military service members and veterans (SMVs) with a history of complicated mild or more severe TBI prospectively enrolled in the Defense and Veterans Brain Injury Center (DVBIC)/Traumatic Brain Injury Center of Excellence (TBICoE) 15-Year Longitudinal TBI Study. Participants were divided into two groups: complicated mild/moderate TBI (n = 64) and severe/penetrating TBI (n = 73). Participants completed a neuropsychological assessment, including the PTSD Checklist-Civilian Version one year or more post-injury. Six neuropsychological composite scores and an overall test battery mean (OTBM) were considered. Participants who failed symptom validity tests were excluded. Hierarchical linear regressions were conducted evaluating neuropsychological performance. Results TBI severity (βs:-0.163 to −0.253, ps < 0.04) and PTSD symptoms (βs:-0.189 to −0.212), ps < 0.03) were related to neuropsychological performance in the overall sample. Within the severe/penetrating TBI group, PTSD symptoms were unrelated to cognitive performance. Within the complicated mild/moderate TBI group, PTSD symptoms were significantly related to processing speed (R2Δ = 0.080, β = −0.284, p = 0.016), immediate memory (R2Δ = 0.204, β = −0.453, p < 0.001), delayed memory (R2Δ = 0.180, β = −0.426, p < 0.001), executive functioning (R2Δ = 0.102, β = −0.319, p = 0.007), and the OTBM (R2Δ = 0.170, β = −0.413, p < 0.001). Discussion PTSD symptom severity was significantly related to neuropsychological performance in SMVs with complicated mild/moderate TBI. PTSD symptoms should be considered when evaluating patients with a history of complicated mild to moderate TBI. [ABSTRACT FROM AUTHOR]

This study examined the prospective course of neurobehavioral symptom reporting and health-related quality of life within the first 3 years following moderate-to-severe traumatic brain injury (TBI). Participants were 52 U.S. service members who were evaluated following a moderate-to-severe TBI sustained in the combat theater during Operations Iraqi and Enduring Freedom (90.4%), or from other noncombat-related incidents. Participants completed the Neurobehavioral Symptom Inventory and Post-Traumatic Stress Disorder-Checklist within 3 months postinjury, and at least one follow-up telephone interview at 12 (n = 27), 24 (n = 31), or 36 months (n = 22) postinjury. Approximately half of the sample (41.9%-63.0%) reported "persistent" symptoms from baseline to follow-up. A substantial minority also "improved" (22.2%-31.8%) or "developed" new symptoms (3.7%-16.1%). Ongoing physical and mental health problems were also reported. The number of service members receiving mental health treatment significantly reduced between 12 and 36 months postinjury (48.1%-18.2%), while complaints of bodily pain significantly increased (40.7%-68.2%). Despite ongoing symptom reporting, few reported suicidal/homicidal ideation (6.5%-9.1%), and a substantial majority reported good/excellent health status (74.1%-90.9%) and satisfaction with their life (81.5%-90.9%). Continued support and care for all service members who sustain a combat-related moderate-to-severe TBI is recommended, regardless of the presence or absence of symptom reporting within the first few months postinjury. [ABSTRACT FROM AUTHOR]

This study examined health-related quality of life within the first 5 years following concurrent mild traumatic brain injury (MTBI) and polytrauma. Participants were 167 U.S. service members who had sustained a MTBI who had completed a brief neurobehavioral evaluation within 3 months postinjury and at least one telephone follow-up interview at 6 (n = 46), 12 (n = 89), 24 (n = 54), 36 (n = 42), 48 (n = 30) or 60 months (n = 25) postinjury. Within the first 5 years postinjury, service members reported ongoing headaches (67.4% to 92.0%), bodily pain (66.7% to 88.9%), medication use (71.7% to 92.0%), mental health treatment (28.3% to 60.0%), and the need for help with daily activities (18.5% to 40.0%). Problematic alcohol consumption was common within the first 24 months postinjury (23.9% to 29.2%). Many service members were working for pay (36.0% to 70.8%) though many reported a decline in work quality (16.0% to 30.4%). Despite ongoing symptom reporting, many service members reported that their medications were effective (43.3% to 80.0%), good/excellent health status (68.0% to 80.0%), and life satisfaction (79.6% to 90.5%). A minority reported suicidal or homicidal ideation (5.6% to 14.8%). Recovery from MTBI in a military setting is complex and multifaceted. Continued support and care for all service members who sustain a combat-related MTBI with polytrauma is recommended, regardless of the presence or absence of symptom reporting within the first few months postinjury. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to assess visual and health-related quality of life (QOL) among U.S. military service members who sustained combat ocular trauma (COT) with or without associated traumatic brain injury (TBI).Methods: This was a single-center, prospective observational study of U.S. service members (n = 88) with COT who were treated at Walter Reed National Military Medical Center. Participants completed the National Eye Institute Visual Function Questionnaire (VFQ-25) at enrollment and at follow-up (>1 year) and supplemental surveys: Neurobehavioral Symptom Inventory, the Medical Outcomes 36-item Short Form Survey (SF-36), and Mayo-Portland Adaptability Inventory.Results: Initial and follow-up VFQ-25 showed a statistically significant increase in median scores for near activities (initial: 75.0, follow-up 83.3; P = .004) and peripheral vision (initial: 50.0, follow-up: 75.0; P = .009) and in composite scores (initial: 79.5, follow-up: 79.8; P = .022). Comparing those who did (n = 78) and did not (n = 8) have a TBI history, there were no significant differences in median change in VFQ-25 composite scores (with TBI: 2.3 vs. no TBI: 10.7; P = .179). Participants with a TBI history had a significantly lower median SF-36 General Health score (with TBI: 67.5 vs. no TBI: 92.5; P = .009).Conclusions: Vision-related QOL of COT patients is generally good in the long term. However, those with both COT and a history of TBI conditions showed significantly worse functioning in several domains than those without TBI. As TBI is a common finding in COT, this association is an important factor impacting this population's overall clinical presentation and daily functions. [ABSTRACT FROM AUTHOR]

Objective: More than 280,000 Active Duty Service Members (ADSMs) sustained a mild traumatic brain injury (mTBI) between 2000 and 2019 (Q3). Previous studies of veterans have shown higher utilization of outpatient health clinics by veterans diagnosed with mTBI. Additionally, veterans with mTBI and comorbid behavioral health (BH) conditions such as post-traumatic stress disorder, depression, and substance use disorders have significantly higher health care utilization than veterans diagnosed with mTBI alone. However, few studies of the relationship between mTBI, health care utilization, and BH conditions in the active duty military population currently exist. We examined the proportion of ADSMs with a BH diagnosis before and after a first documented mTBI and quantified outpatient utilization of the Military Health System in the year before and following injury.Materials and Methods: Retrospective analysis of 4,901,840 outpatient encounters for 39,559 ADSMs with a first documented diagnosis of mTBI recorded in the Department of Defense electronic health record, subsets of who had a BH diagnosis. We examined median outpatient utilization 1 year before and 1 year after mTBI using Wilcoxon signed rank test, and the results are reported with an effect size r. Outpatient utilization is compared by BH subgroups.Results: Approximately 60% of ADSMs experience a first mTBI with no associated BH condition, but 17% of men and women are newly diagnosed with a BH condition in the year following mTBI. ADSMs with a history of a BH condition before mTBI increased their median outpatient utilization from 23 to 35 visits for men and from 32 to 42 visits for women. In previously healthy ADSMs with a new BH condition following mTBI, men more than tripled median utilization from 7 to 24 outpatient visits, and women doubled utilization from 15 to 32 outpatient visits.Conclusions: Behavioral health comorbidities affect approximately one-third of ADSMs following a first mTBI, and approximately 17% of previously healthy active duty men and women will be diagnosed with a new BH condition in the year following a first mTBI. Post-mTBI outpatient health care utilization is highly dependent on the presence or absence of BH condition and is markedly higher is ADSMs with a BH diagnosis in the year after a first documented mTBI. [ABSTRACT FROM AUTHOR]

Introduction: Program overview of a novel cognitive training platform at Walter Reed National Military Medical Center (WRNMMC) for service members with subjective cognitive complaints: analysis of patient participation, satisfaction with the program, and perceived areas of improvement.Materials and Method: Retrospective review of 1,030 participants from November 2008 through May 2017. Data were obtained within an approved protocol (WRNMMC-EDO-2017-0004/# 876230).Results: The program has shown growth in numbers of referrals, types of patient populations served, and patient visits. Patients report satisfaction with the program and endorse improvements in cognitive functions.Conclusions: This program model may benefit other military facilities looking to provide and assess novel therapeutic approaches. [ABSTRACT FROM AUTHOR]

Introduction: Prospective memory (PM) is the ability to remember the intention to perform an action in the future. Following mild traumatic brain injury (mTBI), the brain structures supporting such PM may be compromised. PM is essential for remembering activities specific to TBI survivors that promote recovery, such as following doctors' orders, taking necessary medications, completing physical rehabilitation exercises, and maintaining supportive social relationships. Since the year 2000, more than 315,897 US Service Members are reported to have sustained an mTBI1, yet little has been done to address possible PM concerns. Therefore, identifying impaired PM and interventions that may ameliorate such deficits is important. The primary aim of this study was to determine whether task encoding using implementation intentions leads to better PM performance than encoding using rote rehearsal in Service Members with mTBI (n = 35) or with bodily injuries but no TBI (n = 8) at baseline and 6 months later.Materials and Method: Participants were randomized to one of the two encoding conditions. They were asked to remember to complete a series of four tasks over the course of a 2-hour event-related potential session and to contact a staff member during a specified 2-hour window later that day. PM performance was assessed based on completion of each task at the appropriate time. IRB approval was obtained from The Catholic University of America, Walter Reed National Military Medical Center, and Ft. Belvoir Community Hospital.Results: Service Members with mTBI using implementation intentions outperformed those using rote rehearsal. The effect of injury type and the interaction between encoding condition and injury type did not yield differences that were statistically significant.Conclusions: The results suggest that implementation intentions may be a useful PM remediation strategy for those who have sustained mTBI. Future research should validate these findings in a larger sample. [ABSTRACT FROM AUTHOR]