Objective: To identify reproducible differences in diffusion MRI (dMRI) measures in military brai... more Objective: To identify reproducible differences in diffusion MRI (dMRI) measures in military brain injury, using a meta-analysis of multiple cohorts. Background: Traumatic brain injury (TBI) is one of the most common injuries affecting members of the United States military and armed services worldwide. Injuries can affect combat readiness in the immediate post-injury phase, and can also lead to long-term cognitive impairments and adverse health consequences. Diffusion MRI (dMRI) offers sensitive metrics of brain injury, and is complementary to more traditional imaging modalities. Only a few studies have used dMRI in military brain injury and they have found mixed results, partly due to limited power in small samples. Design/Methods: Participants were assessed from 4 different projects for a total of 369 TBI/concussion participants and 202 comparison participants never diagnosed with TBI. All cohorts included participants who were either United States Veterans or Active Duty Service ...
Objective: To identify alterations in subcortical gray matter (GM) volume in Active Duty Service ... more Objective: To identify alterations in subcortical gray matter (GM) volume in Active Duty Service Members (ADSM) and Veterans of the United States military with history of traumatic brain injury (TBI), with greater power from multi-site mega-analysis. Background: TBI is one of the most common injuries affecting armed service members across the world. Injuries can affect combat readiness and can lead to long-term cognitive impairments and adverse health consequences. Altered subcortical GM volume may contribute to poor outcome. Reliable neuroimaging biomarkers of TBI have been elusive, often due to small sample size. Design/Methods: Participants were assessed through three different projects – DoD Alzheimer’s Disease Neuroimaging Initiative, Imaging Support of Study of Cognitive Rehabilitation Effectiveness in Mild Traumatic Brain Injury, and Chronic Effects of Neurotrauma Consortium, totaling 199 participants reporting at least one TBI (178M/21F) and 170 participants without history ...
Understanding risk for epilepsy among individuals who sustain a mild traumatic brain injury (mTBI... more Understanding risk for epilepsy among individuals who sustain a mild traumatic brain injury (mTBI) is crucial for effective intervention and prevention. However, mTBI is frequently undocumented or poorly documented in health records. Further, health records are non-continuous, such as when individuals move through health systems (e.g., from Department of Defense (DoD) to Veterans Affairs (VA), or between jobs in the civilian sector), making population-based assessments of this relationship challenging. Here, we introduce the Military INjuries-Understanding post-Traumatic Epilepsy [MINUTE] study, which integrates data from the Veterans Health Administration with self-report survey data for post-9/11 Veterans (n=2603) with histories of TBI, epilepsy, and controls without a history of TBI or epilepsy. This paper describes the MINUTE study design, implementation, hypotheses, and initial results across four groups of interest for neurotrauma; 1. Control, 2. Epilepsy, 3. TBI, and 4. Post-traumatic epilepsy (PTE). Using combined survey and health record data, we test hypotheses examining lifetime history of TBI, and the differential impacts of TBI, epilepsy, and PTE on functional outcomes. The MINUTE study revealed high rates of undocumented lifetime TBIs among Veterans with epilepsy who had no evidence of TBI in VA medical records. Further, worse physical functioning and health-related quality of life was found for individuals with Epilepsy+TBI compared to those with either epilepsy or TBI alone. This effect was not fully explained by TBI severity. These insights provide valuable opportunities to optimize the resilience, delivery of health services, and community reintegration of veterans with TBI and complex comorbidity.
Efforts to characterize the late effects of traumatic brain injury (TBI) have been in progress fo... more Efforts to characterize the late effects of traumatic brain injury (TBI) have been in progress for some time. In recent years much of this activity has been directed towards reporting of chronic traumatic encephalopathy (CTE) in former contact sports athletes and others exposed to repetitive head impacts. However, the association between TBI and dementia risk has long been acknowledged outside of contact sports. Further, growing experience suggests a complex of neurodegenerative pathologies in those surviving TBI, which extends beyond CTE. Nevertheless, despite extensive research, we have scant knowledge of the mechanisms underlying TBI-related neurodegeneration (TReND) and its link to dementia. In part, this is due to the limited number of human brain samples linked to robust demographic and clinical information available for research. Here we detail a National Institutes for Neurological Disease and Stroke Center Without Walls project, the COllaborative Neuropathology NEtwork Char...
Background: Headache is a common symptom reported following concussion/mild traumatic brain injur... more Background: Headache is a common symptom reported following concussion/mild traumatic brain injury. The Department of Defense's clinical recommendation (CR) describes guidance for primary care providers for the management of post-traumatic headache (PTH) in Service members. Objective: The objective of this study is to examine the association between training on the CR with provider clinical practice, patient behaviors, and symptom recovery. Methods: Participants were healthcare providers and two patient groups (one receiving care as usual [CAU] and another receiving care after provider training on PTH CR [CR+]). Providers were interviewed at three time points: (1) prior to CAU enrollment; (2) after CAU enrollment, but prior to training; and (3) after CR+ follow-up. Data from the second and third provider interview were used to evaluate a potential difference between provider practices pre-and post-training (n = 13). Patients were enrolled within 6 months of concussion. Patient outcomes (including neurobehavioral and headache symptoms) were assessed at three time-points: within 72 h (n = 35), at 1-week (n = 34) and at 1-month post-enrollment (n = 27). Results: Most follow-up care reported by providers were recommended within 72 h of initial visit post-training vs. >1 week pre-training. Additionally, providers reported a greater number of visits based on patient symptoms after training than before. Post-training, most providers reported referring patients to higher level of care "as needed," if not "very rarely," compared to 25% reported referrals prior to training. At 1-week post-enrollment the CR+ patient group reported more frequent medical provider visits compared to the CAU group. This trend was reversed at the 1-month follow-up whereby more CAU Remigio-Baker et al. Post-concussive Headache Management Training Impact reported seeing a medical provider compared to CR+. By 1-week post-enrollment, fewer patients in the CR+ group reported being referred to any other providers or specialists compared to the CAU group. No differences in patient outcomes by provider training was found. Conclusion: The study results demonstrate the feasibility of training on the Management of Headache Following Concussion CR in order to change provider practices by promoting timely care, and promoting patient compliance as shown through improvement in follow-up visits and more monitoring within the primary care clinic.
As a result of armed conflict, head trauma from exposure to blasts is an increasing critical heal... more As a result of armed conflict, head trauma from exposure to blasts is an increasing critical health issue, particularly among military service members. Whilst numerous studies examined the burden of blast-related brain injuries on service members', few systematic reviews have been published. This work provides a comprehensive summary of the evidence on blast-related mild traumatic brain injury (mTBI) burden in active U.S. military service members and inactive Veterans, describing characteristics and outcomes. Records published up to April 2017 were identified through a search of PubMed, Web of Science, Scopus, Ovid MEDLINE, and Cochrane Library. Records-based and original research reporting on U.S. military service members and Veterans with mild blast TBI were included. Data on subject characteristics, exposure, diagnostic criterion, and outcomes were extracted from included studies using a standardized extraction form and were presented narratively. Of the 2,290 references identified by the search, 106 studies with a total of 37,515 participants met inclusion criteria for blast-related mTBI. All but nine studies were based out of military or Veteran medical facilities. Unsurprisingly, men were over-represented (75-100%). The criteria used to define blast-related mTBI were consistent; however, the methodology used to ascertain whether individuals met those criteria for diagnosis were inconsistent. The diagnosis, most prevalent among the Army, heavily relied on self-reported histories. Commonly reported adverse outcomes included hearing disturbances and headaches. The most frequently associated comorbidities were post-traumatic stress disorder, depression, anxiety, sleep disorders, attention disorders, and cognitive disorders. The primary objective of this review was to provide a summary of descriptive data on blast-related mTBI in a U.S. military population. Low standardization of the methods for reaching diagnosis and problems in the study reporting emphasize the importance to collect high-quality data to fill knowledge gaps pertaining to blast-related mTBI.
Objective To provide a preliminary assessment of the current clinical practice for the treatment ... more Objective To provide a preliminary assessment of the current clinical practice for the treatment of post-traumatic headache following concussion in military primary health care settings. Background Headache is one of the most common symptoms post-concussion; however, little is known of the current clinical practices of primary care providers (on the treatment of post-traumatic headache), particularly in military settings. Methods Study participants were primary care providers (n = 65) who treated active duty Service members suffering from post-traumatic headache at two military installations. Qualitative data gathered via semi-structured interviews were used to describe provider practices and experience in treating patients with post-traumatic headache. Results Some patterns of care across primary care providers treating post-traumatic headache were consistent with the Department of Defense-recommended clinical recommendation (e.g., recommendation of both pharmacological and non-pharmacological treatment [89.4%]; engaging in follow-up care [100%]). Differences existed in timing of follow-up from initial visit [16.9% reporting within 24 hours; 21.5% reporting within 48-72 hours; and 26.2% reporting more than 1 week], the factors contributing to the type of care given (e.g., symptomatology [33.0%], injury characteristic [24.2%], patient characteristic [13.2%]) and the
Traumatic brain injury (TBI) is common among military personnel and is often followed by a hetero... more Traumatic brain injury (TBI) is common among military personnel and is often followed by a heterogeneous array of clinical, cognitive, behavioral, mood, and neuroimaging changes. This inconsistent presentation makes it difficult to establish or validate biological and imaging markers that could help improve diagnostic and prognostic accuracy in this patient population. The purpose of this manuscript is to describe both the challenges and opportunities when conducting research with Service Members and Veterans and introduce the Enhancing NeuroImaging Genetics through Meta-Analysis (ENIGMA) Military Brain Injury working group. ENIGMA is a worldwide consortium focused on improving replicability and analytical power through data sharing and collaboration. In this paper, we discuss challenges affecting efforts to aggregate data in this patient group. In addition, we highlight how “big data” approaches might be used to understand better the role that each of these variables might play in ...
Traumatic brain injury (TBI) is a well-known consequence of participation in activities such as m... more Traumatic brain injury (TBI) is a well-known consequence of participation in activities such as military combat or collision sports. But the wide variability in eliciting circumstances and injury severities makes the study of TBI as a uniform disease state impossible. Military Service members are under additional, unique threats such as exposure to explosive blast and its unique effects on the body. This review is aimed toward TBI researchers, as it covers important concepts and considerations for studying blast-induced head trauma. These include the comparability of blast-induced head trauma to other mechanisms of TBI, whether blast overpressure induces measureable biomarkers, and whether a biodosimeter can link blast exposure to health outcomes, using acute radiation exposure as a corollary. This examination is contextualized by the understanding of concussive events and their psychological effects throughout the past century’s wars, as well as the variables that predict sustainin...
Concussions, or mild traumatic brain injuries (mTBI), are the most common, potentially clinically... more Concussions, or mild traumatic brain injuries (mTBI), are the most common, potentially clinically debilitating, neurological injury associated with military combat, sports, vehicular accidents and domestic trauma (1). Awareness efforts surrounding the identification and management of concussions have existed for decades, but, given the recent Gulf Wars and concerns regarding repeated concussions in sports, there has been increasing attention focused on them. Research efforts to systematically and conclusively categorize and understand the diagnosis, short-term management and late effects of mTBIs remain nascent. There are a number of studies (2) supporting the incidence of concussive injuries from the Afghanistan (Operation Enduring Freedom [OEF]), Iraq (Operation Iraqi Freedom [OIF]) and subsequent worldwide War on Terror (Operation New Dawn [OND]) wars. The incidence of concussions from these conflicts ranges from 6% to 20% among all U.S. Service members (SMs) (3,4). Approximately 40% ofOEF–OIF–ONDconcussedVeterans seeking care at Veterans Affairs Medical Centers (VAMCs), which represents nearly 8% of all those deployed in these conflicts, report persistent neurosensory (headache, hearing, tinnitus, vision), somatic (balance, coordination, sleep), cognitive (executive function, memory) and behavioural symptoms (irritability, anxiety) (5). Additionally, secondary co-morbidities thatmay be associated with the traumatic episode but are not directly physically related to the actual brain trauma, such as post-traumatic stress disorder (PTSD), depression, substance abuse or low back or joint pain, may be seen in more than three-quarters of these Veterans with combat-associated concussions, adding to the diagnostic and management complexity (5). In 2013, as a response to theNational ResearchAction Plan (6), the Departments of Veterans Affairs and Defense jointly-funded the Chronic Effects of Neurotrauma Consortium (CENC) (www. cenc.rti.org) (7). Consisting of more than 50 leading clinical, translational, epidemiologic and basic scientists from more than 30 academic universities, 15 VAMCs and 12 military treatment facilities (see Figure 1), CENC is a nationwide consortium focused on identifying and characterizing the anatomic, molecular and physiological mechanisms of combat-associated mTBI, evaluating how co-morbidities are associated with and exacerbated by combat-associated mTBI and studying treatment and rehabilitation strategies for the shortand long-term effects of combat-associated mTBI. To date, CENC has initiated 10 major clinical, animal and epidemiologic studies that are supported by five centralized, research and administrative infrastructure cores. This report examines the findings to date of the six clinical projects, describes the growing cohort of Veterans and SMs and identifies emerging cross-study similarities and differences. Whereas this report provides a cross-sectional, broad stroke comparison of six of the CENC clinical studies, this special issue also contains 14 other papers that present more nuanced findings on individual CENC studies. There are a number of papers reporting on various aspects of a smaller sample of the currently 1450+ participants enrolled in CENC’s longitudinal study. These include the association of mTBI with pain, functional brain connectivity and cortical thickness, balance performance, Department of Veterans Affairs (VA) -defined service-connected disability and with the biomarker tau, as well as a description of its highly successful recruitment strategies and the factor structure of the battery of neuropsychological assessments used in the sample. Other papers in this issue describe findings on the longitudinal changes in neuroimaging and neuropsychiatric status of postdeployment Veterans, sensory dysfunction in the context of TBI and the association of mTBI with ventricular volume changes and characterize those individuals receiving opioid therapy for chronic pain. Of additional interest, there are also two papers describing advances in mTBI methodology, including an assessment of quantitative magnetic resonance imaging metrics in the brain through the use of a novel phantom and a description of a novel white matter imaging technique. Finally, there is a paper evaluating the impact of age on acute post-TBI neuropathology findings using CENC’s standardized mouse model for repetitive mTBI.
Medical imaging plays a critical role in the rapid diagnosis, effective triage, and management of... more Medical imaging plays a critical role in the rapid diagnosis, effective triage, and management of complex poly-trauma patients. High-quality medical imaging can be accomplished successfully in a deployed or wartime setting. Due to advances in aggressive resuscitation techniques and the speed of the latest generation computed tomography scanners (64-detector and beyond), rapid trauma scans utilizing computed tomography and ultrasound imaging can routinely be performed prior to taking the patient to the operating room potentially providing the trauma team with lifesaving information. This clinical practice guideline provides an overview of the imaging modalities available in austere settings, the equipment required, and the role that each plays in triaging and diagnosis of the acutely injured poly-trauma patients.
Physical Medicine and Rehabilitation Clinics of North America
The purpose of this article is to inform the reader of the historical aspects of the Polytrauma S... more The purpose of this article is to inform the reader of the historical aspects of the Polytrauma System of Care, understand the solutions that were implemented in addressing the continuum of care needs for service members and veterans, and provide an understanding of ongoing research efforts that will inform future solutions to strategically identified future care needs.
Introduction: In recent years, there has been growing discussion to better understand the pathoph... more Introduction: In recent years, there has been growing discussion to better understand the pathophysiological mechanisms of traumatic brain injury and post-traumatic stress disorder and how they may be linked to an increased risk of neurodegenerative diseases including Alzheimer's disease in veterans. Methods: Building on that discussion, and subsequent to a special issue of Alzheimer's & Dementia published in June 2014, which focused on military risk factors, the Alzheimer's Association convened a continued discussion of the scientific community on December 1, 2016. Results: During this meeting, participants presented and evaluated progress made since 2012 and identified outstanding knowledge gaps regarding factors that may impact veterans' risk for later life dementia. Discussion: The following is a summary of the invited presentations and moderated discussions of both the review of scientific understanding and identification of gaps to inform further investigations.
Proceedings. IEEE International Symposium on Biomedical Imaging, 2018
Traumatic brain injury (TBI) is a significant cause of morbidity in military Veterans and Service... more Traumatic brain injury (TBI) is a significant cause of morbidity in military Veterans and Service Members. While most individuals recover fully from mild injuries within weeks, some continue to experience symptoms including headaches, disrupted sleep, and other cognitive, behavioral or physical symptoms. Diffusion magnetic resonance imaging (dMRI) shows promise in identifying areas of structural disruption and predicting outcomes. Although some studies suggest widespread structural disruption after brain injury, dMRI studies of military brain injury have yielded mixed results so far, perhaps due to the subtlety of mild injury, individual differences in injury location, severity and mechanism, and comorbidity with other disorders such as post-traumatic stress disorder (PTSD), depression, and substance abuse. We present preliminary dMRI results from the ENIGMA (Enhancing Neuroimaging Genetics through Meta-Analysis) military brain injury working group. We found higher fractional anisot...
Despite the large number of promising neuroprotective agents identified in experimental traumatic... more Despite the large number of promising neuroprotective agents identified in experimental traumatic brain injury (TBI) studies, none has yet shown meaningful improvements in long-term outcome in clinical trials. To develop recommendations and guidelines for preclinical testing of pharmacological or biological therapies for TBI, the Moody Project for Translational Traumatic Brain Injury Research hosted a symposium attended by investigators with extensive experience in pre-clinical TBI testing. The symposium participants discussed issues related to preclinical TBI testing including experimental models, therapy and outcome selection, study design, data analysis, and dissemination. Consensus recommendations included the creation of a manual of standard operating procedures with sufficiently detailed descriptions of modeling and outcome measurement procedures to permit replication. The importance of the selection of clinically relevant outcome variables, especially related to behavior test...
Determine if mild traumatic brain injury (mTBI) history is associated with balance disturbances. ... more Determine if mild traumatic brain injury (mTBI) history is associated with balance disturbances. Chronic Effects of Neurotrauma Consortium (CENC) centres. The CENC multi-centre study enrols post-9/11 era Service Members and Veterans with combat exposure. This sample (n = 322) consisted of enrolees completing initial evaluation by September 2016 at the three sites conducting computerized dynamic post-urography (CDP) testing. Observational study with cross-sectional analyses using structural equation modelling. Comprehensive structured interviews were used to diagnose all lifetime mild traumatic brain injuries (mTBIs). The outcome, Sensory Organization Test (SOT), was measured on CDP dual-plate force platform. Other studied variables were measured by structured interviews, record review and questionnaires. The overall positive/negative mTBI classification did not have a significant effect on the composite equilibrium score. However, the repetitive mTBI classification showed lower scor...
Objective: To identify reproducible differences in diffusion MRI (dMRI) measures in military brai... more Objective: To identify reproducible differences in diffusion MRI (dMRI) measures in military brain injury, using a meta-analysis of multiple cohorts. Background: Traumatic brain injury (TBI) is one of the most common injuries affecting members of the United States military and armed services worldwide. Injuries can affect combat readiness in the immediate post-injury phase, and can also lead to long-term cognitive impairments and adverse health consequences. Diffusion MRI (dMRI) offers sensitive metrics of brain injury, and is complementary to more traditional imaging modalities. Only a few studies have used dMRI in military brain injury and they have found mixed results, partly due to limited power in small samples. Design/Methods: Participants were assessed from 4 different projects for a total of 369 TBI/concussion participants and 202 comparison participants never diagnosed with TBI. All cohorts included participants who were either United States Veterans or Active Duty Service ...
Objective: To identify alterations in subcortical gray matter (GM) volume in Active Duty Service ... more Objective: To identify alterations in subcortical gray matter (GM) volume in Active Duty Service Members (ADSM) and Veterans of the United States military with history of traumatic brain injury (TBI), with greater power from multi-site mega-analysis. Background: TBI is one of the most common injuries affecting armed service members across the world. Injuries can affect combat readiness and can lead to long-term cognitive impairments and adverse health consequences. Altered subcortical GM volume may contribute to poor outcome. Reliable neuroimaging biomarkers of TBI have been elusive, often due to small sample size. Design/Methods: Participants were assessed through three different projects – DoD Alzheimer’s Disease Neuroimaging Initiative, Imaging Support of Study of Cognitive Rehabilitation Effectiveness in Mild Traumatic Brain Injury, and Chronic Effects of Neurotrauma Consortium, totaling 199 participants reporting at least one TBI (178M/21F) and 170 participants without history ...
Understanding risk for epilepsy among individuals who sustain a mild traumatic brain injury (mTBI... more Understanding risk for epilepsy among individuals who sustain a mild traumatic brain injury (mTBI) is crucial for effective intervention and prevention. However, mTBI is frequently undocumented or poorly documented in health records. Further, health records are non-continuous, such as when individuals move through health systems (e.g., from Department of Defense (DoD) to Veterans Affairs (VA), or between jobs in the civilian sector), making population-based assessments of this relationship challenging. Here, we introduce the Military INjuries-Understanding post-Traumatic Epilepsy [MINUTE] study, which integrates data from the Veterans Health Administration with self-report survey data for post-9/11 Veterans (n=2603) with histories of TBI, epilepsy, and controls without a history of TBI or epilepsy. This paper describes the MINUTE study design, implementation, hypotheses, and initial results across four groups of interest for neurotrauma; 1. Control, 2. Epilepsy, 3. TBI, and 4. Post-traumatic epilepsy (PTE). Using combined survey and health record data, we test hypotheses examining lifetime history of TBI, and the differential impacts of TBI, epilepsy, and PTE on functional outcomes. The MINUTE study revealed high rates of undocumented lifetime TBIs among Veterans with epilepsy who had no evidence of TBI in VA medical records. Further, worse physical functioning and health-related quality of life was found for individuals with Epilepsy+TBI compared to those with either epilepsy or TBI alone. This effect was not fully explained by TBI severity. These insights provide valuable opportunities to optimize the resilience, delivery of health services, and community reintegration of veterans with TBI and complex comorbidity.
Efforts to characterize the late effects of traumatic brain injury (TBI) have been in progress fo... more Efforts to characterize the late effects of traumatic brain injury (TBI) have been in progress for some time. In recent years much of this activity has been directed towards reporting of chronic traumatic encephalopathy (CTE) in former contact sports athletes and others exposed to repetitive head impacts. However, the association between TBI and dementia risk has long been acknowledged outside of contact sports. Further, growing experience suggests a complex of neurodegenerative pathologies in those surviving TBI, which extends beyond CTE. Nevertheless, despite extensive research, we have scant knowledge of the mechanisms underlying TBI-related neurodegeneration (TReND) and its link to dementia. In part, this is due to the limited number of human brain samples linked to robust demographic and clinical information available for research. Here we detail a National Institutes for Neurological Disease and Stroke Center Without Walls project, the COllaborative Neuropathology NEtwork Char...
Background: Headache is a common symptom reported following concussion/mild traumatic brain injur... more Background: Headache is a common symptom reported following concussion/mild traumatic brain injury. The Department of Defense's clinical recommendation (CR) describes guidance for primary care providers for the management of post-traumatic headache (PTH) in Service members. Objective: The objective of this study is to examine the association between training on the CR with provider clinical practice, patient behaviors, and symptom recovery. Methods: Participants were healthcare providers and two patient groups (one receiving care as usual [CAU] and another receiving care after provider training on PTH CR [CR+]). Providers were interviewed at three time points: (1) prior to CAU enrollment; (2) after CAU enrollment, but prior to training; and (3) after CR+ follow-up. Data from the second and third provider interview were used to evaluate a potential difference between provider practices pre-and post-training (n = 13). Patients were enrolled within 6 months of concussion. Patient outcomes (including neurobehavioral and headache symptoms) were assessed at three time-points: within 72 h (n = 35), at 1-week (n = 34) and at 1-month post-enrollment (n = 27). Results: Most follow-up care reported by providers were recommended within 72 h of initial visit post-training vs. >1 week pre-training. Additionally, providers reported a greater number of visits based on patient symptoms after training than before. Post-training, most providers reported referring patients to higher level of care "as needed," if not "very rarely," compared to 25% reported referrals prior to training. At 1-week post-enrollment the CR+ patient group reported more frequent medical provider visits compared to the CAU group. This trend was reversed at the 1-month follow-up whereby more CAU Remigio-Baker et al. Post-concussive Headache Management Training Impact reported seeing a medical provider compared to CR+. By 1-week post-enrollment, fewer patients in the CR+ group reported being referred to any other providers or specialists compared to the CAU group. No differences in patient outcomes by provider training was found. Conclusion: The study results demonstrate the feasibility of training on the Management of Headache Following Concussion CR in order to change provider practices by promoting timely care, and promoting patient compliance as shown through improvement in follow-up visits and more monitoring within the primary care clinic.
As a result of armed conflict, head trauma from exposure to blasts is an increasing critical heal... more As a result of armed conflict, head trauma from exposure to blasts is an increasing critical health issue, particularly among military service members. Whilst numerous studies examined the burden of blast-related brain injuries on service members', few systematic reviews have been published. This work provides a comprehensive summary of the evidence on blast-related mild traumatic brain injury (mTBI) burden in active U.S. military service members and inactive Veterans, describing characteristics and outcomes. Records published up to April 2017 were identified through a search of PubMed, Web of Science, Scopus, Ovid MEDLINE, and Cochrane Library. Records-based and original research reporting on U.S. military service members and Veterans with mild blast TBI were included. Data on subject characteristics, exposure, diagnostic criterion, and outcomes were extracted from included studies using a standardized extraction form and were presented narratively. Of the 2,290 references identified by the search, 106 studies with a total of 37,515 participants met inclusion criteria for blast-related mTBI. All but nine studies were based out of military or Veteran medical facilities. Unsurprisingly, men were over-represented (75-100%). The criteria used to define blast-related mTBI were consistent; however, the methodology used to ascertain whether individuals met those criteria for diagnosis were inconsistent. The diagnosis, most prevalent among the Army, heavily relied on self-reported histories. Commonly reported adverse outcomes included hearing disturbances and headaches. The most frequently associated comorbidities were post-traumatic stress disorder, depression, anxiety, sleep disorders, attention disorders, and cognitive disorders. The primary objective of this review was to provide a summary of descriptive data on blast-related mTBI in a U.S. military population. Low standardization of the methods for reaching diagnosis and problems in the study reporting emphasize the importance to collect high-quality data to fill knowledge gaps pertaining to blast-related mTBI.
Objective To provide a preliminary assessment of the current clinical practice for the treatment ... more Objective To provide a preliminary assessment of the current clinical practice for the treatment of post-traumatic headache following concussion in military primary health care settings. Background Headache is one of the most common symptoms post-concussion; however, little is known of the current clinical practices of primary care providers (on the treatment of post-traumatic headache), particularly in military settings. Methods Study participants were primary care providers (n = 65) who treated active duty Service members suffering from post-traumatic headache at two military installations. Qualitative data gathered via semi-structured interviews were used to describe provider practices and experience in treating patients with post-traumatic headache. Results Some patterns of care across primary care providers treating post-traumatic headache were consistent with the Department of Defense-recommended clinical recommendation (e.g., recommendation of both pharmacological and non-pharmacological treatment [89.4%]; engaging in follow-up care [100%]). Differences existed in timing of follow-up from initial visit [16.9% reporting within 24 hours; 21.5% reporting within 48-72 hours; and 26.2% reporting more than 1 week], the factors contributing to the type of care given (e.g., symptomatology [33.0%], injury characteristic [24.2%], patient characteristic [13.2%]) and the
Traumatic brain injury (TBI) is common among military personnel and is often followed by a hetero... more Traumatic brain injury (TBI) is common among military personnel and is often followed by a heterogeneous array of clinical, cognitive, behavioral, mood, and neuroimaging changes. This inconsistent presentation makes it difficult to establish or validate biological and imaging markers that could help improve diagnostic and prognostic accuracy in this patient population. The purpose of this manuscript is to describe both the challenges and opportunities when conducting research with Service Members and Veterans and introduce the Enhancing NeuroImaging Genetics through Meta-Analysis (ENIGMA) Military Brain Injury working group. ENIGMA is a worldwide consortium focused on improving replicability and analytical power through data sharing and collaboration. In this paper, we discuss challenges affecting efforts to aggregate data in this patient group. In addition, we highlight how “big data” approaches might be used to understand better the role that each of these variables might play in ...
Traumatic brain injury (TBI) is a well-known consequence of participation in activities such as m... more Traumatic brain injury (TBI) is a well-known consequence of participation in activities such as military combat or collision sports. But the wide variability in eliciting circumstances and injury severities makes the study of TBI as a uniform disease state impossible. Military Service members are under additional, unique threats such as exposure to explosive blast and its unique effects on the body. This review is aimed toward TBI researchers, as it covers important concepts and considerations for studying blast-induced head trauma. These include the comparability of blast-induced head trauma to other mechanisms of TBI, whether blast overpressure induces measureable biomarkers, and whether a biodosimeter can link blast exposure to health outcomes, using acute radiation exposure as a corollary. This examination is contextualized by the understanding of concussive events and their psychological effects throughout the past century’s wars, as well as the variables that predict sustainin...
Concussions, or mild traumatic brain injuries (mTBI), are the most common, potentially clinically... more Concussions, or mild traumatic brain injuries (mTBI), are the most common, potentially clinically debilitating, neurological injury associated with military combat, sports, vehicular accidents and domestic trauma (1). Awareness efforts surrounding the identification and management of concussions have existed for decades, but, given the recent Gulf Wars and concerns regarding repeated concussions in sports, there has been increasing attention focused on them. Research efforts to systematically and conclusively categorize and understand the diagnosis, short-term management and late effects of mTBIs remain nascent. There are a number of studies (2) supporting the incidence of concussive injuries from the Afghanistan (Operation Enduring Freedom [OEF]), Iraq (Operation Iraqi Freedom [OIF]) and subsequent worldwide War on Terror (Operation New Dawn [OND]) wars. The incidence of concussions from these conflicts ranges from 6% to 20% among all U.S. Service members (SMs) (3,4). Approximately 40% ofOEF–OIF–ONDconcussedVeterans seeking care at Veterans Affairs Medical Centers (VAMCs), which represents nearly 8% of all those deployed in these conflicts, report persistent neurosensory (headache, hearing, tinnitus, vision), somatic (balance, coordination, sleep), cognitive (executive function, memory) and behavioural symptoms (irritability, anxiety) (5). Additionally, secondary co-morbidities thatmay be associated with the traumatic episode but are not directly physically related to the actual brain trauma, such as post-traumatic stress disorder (PTSD), depression, substance abuse or low back or joint pain, may be seen in more than three-quarters of these Veterans with combat-associated concussions, adding to the diagnostic and management complexity (5). In 2013, as a response to theNational ResearchAction Plan (6), the Departments of Veterans Affairs and Defense jointly-funded the Chronic Effects of Neurotrauma Consortium (CENC) (www. cenc.rti.org) (7). Consisting of more than 50 leading clinical, translational, epidemiologic and basic scientists from more than 30 academic universities, 15 VAMCs and 12 military treatment facilities (see Figure 1), CENC is a nationwide consortium focused on identifying and characterizing the anatomic, molecular and physiological mechanisms of combat-associated mTBI, evaluating how co-morbidities are associated with and exacerbated by combat-associated mTBI and studying treatment and rehabilitation strategies for the shortand long-term effects of combat-associated mTBI. To date, CENC has initiated 10 major clinical, animal and epidemiologic studies that are supported by five centralized, research and administrative infrastructure cores. This report examines the findings to date of the six clinical projects, describes the growing cohort of Veterans and SMs and identifies emerging cross-study similarities and differences. Whereas this report provides a cross-sectional, broad stroke comparison of six of the CENC clinical studies, this special issue also contains 14 other papers that present more nuanced findings on individual CENC studies. There are a number of papers reporting on various aspects of a smaller sample of the currently 1450+ participants enrolled in CENC’s longitudinal study. These include the association of mTBI with pain, functional brain connectivity and cortical thickness, balance performance, Department of Veterans Affairs (VA) -defined service-connected disability and with the biomarker tau, as well as a description of its highly successful recruitment strategies and the factor structure of the battery of neuropsychological assessments used in the sample. Other papers in this issue describe findings on the longitudinal changes in neuroimaging and neuropsychiatric status of postdeployment Veterans, sensory dysfunction in the context of TBI and the association of mTBI with ventricular volume changes and characterize those individuals receiving opioid therapy for chronic pain. Of additional interest, there are also two papers describing advances in mTBI methodology, including an assessment of quantitative magnetic resonance imaging metrics in the brain through the use of a novel phantom and a description of a novel white matter imaging technique. Finally, there is a paper evaluating the impact of age on acute post-TBI neuropathology findings using CENC’s standardized mouse model for repetitive mTBI.
Medical imaging plays a critical role in the rapid diagnosis, effective triage, and management of... more Medical imaging plays a critical role in the rapid diagnosis, effective triage, and management of complex poly-trauma patients. High-quality medical imaging can be accomplished successfully in a deployed or wartime setting. Due to advances in aggressive resuscitation techniques and the speed of the latest generation computed tomography scanners (64-detector and beyond), rapid trauma scans utilizing computed tomography and ultrasound imaging can routinely be performed prior to taking the patient to the operating room potentially providing the trauma team with lifesaving information. This clinical practice guideline provides an overview of the imaging modalities available in austere settings, the equipment required, and the role that each plays in triaging and diagnosis of the acutely injured poly-trauma patients.
Physical Medicine and Rehabilitation Clinics of North America
The purpose of this article is to inform the reader of the historical aspects of the Polytrauma S... more The purpose of this article is to inform the reader of the historical aspects of the Polytrauma System of Care, understand the solutions that were implemented in addressing the continuum of care needs for service members and veterans, and provide an understanding of ongoing research efforts that will inform future solutions to strategically identified future care needs.
Introduction: In recent years, there has been growing discussion to better understand the pathoph... more Introduction: In recent years, there has been growing discussion to better understand the pathophysiological mechanisms of traumatic brain injury and post-traumatic stress disorder and how they may be linked to an increased risk of neurodegenerative diseases including Alzheimer's disease in veterans. Methods: Building on that discussion, and subsequent to a special issue of Alzheimer's & Dementia published in June 2014, which focused on military risk factors, the Alzheimer's Association convened a continued discussion of the scientific community on December 1, 2016. Results: During this meeting, participants presented and evaluated progress made since 2012 and identified outstanding knowledge gaps regarding factors that may impact veterans' risk for later life dementia. Discussion: The following is a summary of the invited presentations and moderated discussions of both the review of scientific understanding and identification of gaps to inform further investigations.
Proceedings. IEEE International Symposium on Biomedical Imaging, 2018
Traumatic brain injury (TBI) is a significant cause of morbidity in military Veterans and Service... more Traumatic brain injury (TBI) is a significant cause of morbidity in military Veterans and Service Members. While most individuals recover fully from mild injuries within weeks, some continue to experience symptoms including headaches, disrupted sleep, and other cognitive, behavioral or physical symptoms. Diffusion magnetic resonance imaging (dMRI) shows promise in identifying areas of structural disruption and predicting outcomes. Although some studies suggest widespread structural disruption after brain injury, dMRI studies of military brain injury have yielded mixed results so far, perhaps due to the subtlety of mild injury, individual differences in injury location, severity and mechanism, and comorbidity with other disorders such as post-traumatic stress disorder (PTSD), depression, and substance abuse. We present preliminary dMRI results from the ENIGMA (Enhancing Neuroimaging Genetics through Meta-Analysis) military brain injury working group. We found higher fractional anisot...
Despite the large number of promising neuroprotective agents identified in experimental traumatic... more Despite the large number of promising neuroprotective agents identified in experimental traumatic brain injury (TBI) studies, none has yet shown meaningful improvements in long-term outcome in clinical trials. To develop recommendations and guidelines for preclinical testing of pharmacological or biological therapies for TBI, the Moody Project for Translational Traumatic Brain Injury Research hosted a symposium attended by investigators with extensive experience in pre-clinical TBI testing. The symposium participants discussed issues related to preclinical TBI testing including experimental models, therapy and outcome selection, study design, data analysis, and dissemination. Consensus recommendations included the creation of a manual of standard operating procedures with sufficiently detailed descriptions of modeling and outcome measurement procedures to permit replication. The importance of the selection of clinically relevant outcome variables, especially related to behavior test...
Determine if mild traumatic brain injury (mTBI) history is associated with balance disturbances. ... more Determine if mild traumatic brain injury (mTBI) history is associated with balance disturbances. Chronic Effects of Neurotrauma Consortium (CENC) centres. The CENC multi-centre study enrols post-9/11 era Service Members and Veterans with combat exposure. This sample (n = 322) consisted of enrolees completing initial evaluation by September 2016 at the three sites conducting computerized dynamic post-urography (CDP) testing. Observational study with cross-sectional analyses using structural equation modelling. Comprehensive structured interviews were used to diagnose all lifetime mild traumatic brain injuries (mTBIs). The outcome, Sensory Organization Test (SOT), was measured on CDP dual-plate force platform. Other studied variables were measured by structured interviews, record review and questionnaires. The overall positive/negative mTBI classification did not have a significant effect on the composite equilibrium score. However, the repetitive mTBI classification showed lower scor...
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Papers by Sidney Hinds