NeuroRehabilitation - Volume 26, issue 3

Authors: Moore, David F. | Jaffee, Michael S.

Article Type: Editorial

Abstract: The effects of blast on biological tissue are documented for some organ systems such as the lung. In the central nervous system (CNS) the mechanism of CNS injury following blast wave is unclear. For example is there a selective effect of blast on varying brain region or white matter bundles. The effect of blast on traumatic brain injury (TBI) has come into particular focus with the Global War on Terror and Operation Iraqi Freedom and Operation Enduring Freedom where TBI has become known as the signature injury of these conflicts. The reason for the prominence of TBI in these particular …conflicts as opposed to others is unclear but may result from the increased survivability of blast due to improvements in body armor. In the current series of articles in the Journal some developments of current research concepts in relation to military traumatic brain injury (TBI) are highlighted together with many remaining unsolved questions. Show more

DOI: 10.3233/NRE-2010-0553

Citation: NeuroRehabilitation, vol. 26, no. 3, pp. 179-181, 2010

Authors: Drake, Angela I. | Meyer, Kimberly S. | Cessante, Lynne M. | Cheung, Catherine R. | Cullen, Maren A. | McDonald, Eric C. | Holland, Martin C.

Article Type: Research Article

Abstract: A precise estimate of the rates of traumatic brain injury (TBI) in returning combat troops is difficult to establish given the challenges of screening large numbers of military personnel returning from combat deployments. The Brief Traumatic Brain Injury Screen (BTBIS) was implemented in the First Marine Expeditionary Force between 2004 and 2006. Nine percent of the 7909 marines who completed the BTBIS were considered having a positive screen; that is, they endorsed at least one injury mechanism and indicated a change in mental status at the time of injury. The majority of combat-related TBI's were due to multiple injury agents …with the next largest group related to blast exposure only. Most importantly, of those who screened positive for TBI 70.5% (n = 500) were first identified by the screen. Service members who endorsed items on the BTBIS were contacted for follow-up assessment of persistent symptoms related to TBI and clinical referrals were made as needed. Given the rate of positive TBI screens in this non-referred sample of military personnel returning from a combat deployment, routine TBI screening appears valuable in screening individuals who might not be identified otherwise. Furthermore, this study appears to refute the contention that routine TBI screening will result in an over-identification of TBI in this population. Show more

Keywords: Blast, combat veteran, injury mechanism, Iraq, Afghanistan, Marines, military, post-deployment, prevalence, screening, traumatic brain injury

DOI: 10.3233/NRE-2010-0554

Citation: NeuroRehabilitation, vol. 26, no. 3, pp. 183-189, 2010

Authors: Kennedy, Jan E. | Cullen, Maren A. | Amador, Ricardo R. | Huey, Judith C. | Leal, Felix O.

Article Type: Research Article

Abstract: Traumatic combat events can lead to neurobehavioral and stress-related symptoms among military troops. Physical injuries received during combat are associated with increased symptom report [8]. The effect of a concurrent mild traumatic brain injury (mTBI) on this relationship is unknown and forms the basis for this report. Subjects included a cohort of 274 male service members who received a blast-related mTBI during deployment in Iraq. They completed symptom ratings on the Posttraumatic Stress Disorder Checklist-Civilian version (PCL-C) and Neurobehavioral Symptom Inventory (NSI). Service members with mTBI, but no other associated physical injuries had higher symptom ratings than those who received …mTBI plus associated injuries. Results suggest that in the presence of an invisible injury, such as mTBI, associated bodily injuries may be at least partially protective against the development of stress and neurobehavioral symptoms. It is proposed that an invisible wound, such as mTBI, creates ambiguity regarding the etiology of symptoms and expected course of recovery and leads to increased emotional and somatic symptom report. However, the observable nature of an associated physical injury and the systematic rehabilitation involved in recovery from such an injury provide a focus for attention and measurable progress toward recovery that serve to reduce emotionally-based symptom reports. Show more

Keywords: Mild traumatic brain injury , blast injury, PTSD, associated injuries, PCS

DOI: 10.3233/NRE-2010-0555

Citation: NeuroRehabilitation, vol. 26, no. 3, pp. 191-197, 2010

Authors: Ivins, Brian J.

Article Type: Research Article

Abstract: 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. Show more

Keywords: Traumatic brain injury, incidence rates, US Army, blasts, war-related

DOI: 10.3233/NRE-2010-0556

Citation: NeuroRehabilitation, vol. 26, no. 3, pp. 199-212, 2010

Authors: Lew, Henry L. | Weihing, Jeffrey | Myers, Paula J. | Pogoda, Terri K. | Goodrich, Gregory L.

Article Type: Research Article

Abstract: The present review characterizes dual sensory impairment (DSI) as co-existing auditory and visual deficits in TBI that can be peripherally or centrally based. Current research investigating DSI in the military population, along with applicable research which focuses on unimodal deficits, is considered. Due to the heterogenous nature of TBI lesions, an important challenge that the clinician faces is ruling out the influence of multiple sensory deficits and/or the influence of cognitive processes on diagnosis and rehabilitation of the patient. Treatment options for DSI involve remediation of the sensory deficits via existing sensory aids or training exercises.

Keywords: Dual sensory impairment, DSI, auditory, hearing, visual, military, blast

DOI: 10.3233/NRE-2010-0557

Citation: NeuroRehabilitation, vol. 26, no. 3, pp. 213-222, 2010

Authors: Kennedy, Jan E. | Leal, Felix O. | Lewis, Jeffrey D. | Cullen, Maren A. | Amador, Ricardo R.

Article Type: Research Article

Abstract: Purpose: To examine the proportion and severity of stress-related symptoms in U.S. service members with mild traumatic brain injuries (mTBI) received during deployment to Operation Iraqi Freedom (OIF) or Operation Enduring Freedom (OEF). Stress-related symptoms reported by service members with mTBI from explosive munitions are compared to symptoms reported by those with mTBI received from other mechanisms (i.e. falls, motor vehicle accidents). Methods: Posttraumatic stress, as measured by scores on the Posttraumatic Stress Disorder Checklist (PCL-C), for a sample of 586 OIF/OEF service members with blast-related mTBI was compared to a sample of 138 OIF/OEF service members with …non-blast mTBI selected from retrospective review of research records. Results: Re-experiencing symptoms such as flashbacks and nightmares were higher for the blast mTBI group than for the non-blast mTBI group. Symptoms on other PTSD clusters and total score did not significantly differ between groups. Equivalent proportions of the blast and non-blast groups endorsed severe PTSD symptoms, with total PCL-C scores greater than or equal to 50. Conclusions: Consistent with prior reports, high levels of posttraumatic stress symptoms occur in a substantial proportion of service members who experienced deployment-related blast and non-blast mTBI. Results suggest that the psychological rehabilitation of OIF/OEF service members with mTBI from explosive blast should include particular attention to addressing re-experiencing symptoms. Show more

Keywords: Mild traumatic brain injury, blast injury, PTSD

DOI: 10.3233/NRE-2010-0558

Citation: NeuroRehabilitation, vol. 26, no. 3, pp. 223-231, 2010

Authors: Cooper, Douglas B. | Mercado-Couch, Janyna M. | Critchfield, Edan | Kennedy, Jan | Vanderploeg, Rodney D. | DeVillibis, Carita | Gaylord, Kathryn M.

Article Type: Research Article

Abstract: Objective: To examine the relationship between mild traumatic brain injury (mTBI), psychiatric conditions, pain medications, and injury severity on cognitive functioning in service members admitted to a burn unit. We hypothesize that psychiatric co-morbidity and pain medications will have a stronger relationship with cognitive dysfunction than mTBI diagnosis in this population. Method: Retrospective review of clinical evaluations (n = 194) completed between September 2005 – October 2007 on service members with burn injuries secondary to explosive munitions. Evaluations were completed during the acute stage of recovery (mean = 7.87 weeks). mTBI diagnosis (n = 50) was …made through a clinical interview using ACRM criteria [1]. Exclusion criteria included duration of posttraumatic amnesia > 24 hours (n = 10); and inability to complete neurocognitive measures due to severe bimanual burns and/or amputations (n = 17). Cognitive functioning was evaluated using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). Results: Subjects who sustained mTBI demonstrated significantly greater difficulty on the RBANS visuospatial and attention/processing speed indices. A hierarchical linear regression, using mTBI diagnosis, psychiatric diagnosis, time since injury, presence of pain medications, and measures of trauma severity as predictive factors, found that mTBI diagnosis had a significant, but small unique effect on cognitive functioning. Contrary to our hypothesis, psychiatric co-morbidity was not shown to have a significant effect on this population of acutely injured service members. Conclusions: While the relationship between severe TBI and cognitive functioning is well established, the relationship between mTBI and its effects on cognitive and behavioral abilities is less clear. The current study demonstrates that mTBI and analgesic medications have a small effect neurocognitive functioning in this population. Continued examination of this relationship is warranted. Show more

Keywords: Mild traumatic brain injury, blast injury, cognitive dysfunction

DOI: 10.3233/NRE-2010-0559

Citation: NeuroRehabilitation, vol. 26, no. 3, pp. 233-238, 2010

Authors: Helmick, Katherine | members of Consensus Conference

Article Type: Research Article

Abstract: A consensus conference on cognitive rehabilitation for mild traumatic brain injury was conducted by the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury and the Defense and Veterans Brain Injury Center. Fifty military and civilian subject matter experts from a broad range of clinical and scientific disciplines developed clinical guidance for the care of Service Members with persistent post-concussion cognitive symptoms three or more months post injury. "Cognitive rehabilitation" was identified to be a broad group of diverse services. Specific services within this rubric were identified as effective or not, and were evaluated both as single-services and …as combined integrated cognitive rehabilitation programs. Co-morbidities were acknowledged and addressed, but the conference and ensuing guidance focused primarily upon treatment of cognitive impairment. Guidance regarding effective services addressed the areas of assessment, intervention, outcome measurement, and treatment program implementation. Show more

DOI: 10.3233/NRE-2010-0560

Citation: NeuroRehabilitation, vol. 26, no. 3, pp. 239-255, 2010

Authors: Hoffman, Stuart W. | Shesko, Kristina | Harrison, Catherine R.

Article Type: Research Article

Abstract: Traumatic Brain Injury has been labeled the “silent epidemic” in our current wars. Both CBO and the RAND reports predict that the costs of these injuries will be both extensive and enduring. The projected costs are based not only upon the loss contribution of these warriors to our economy, but also the long-term medical and assistive care that will be needed to support these veterans for decades to come. Thus, the primary goal of the Assisted Living Pilot Project (ALPP) at the Defense and Veterans Brain Injury Center – Johnstown (DVBIC-J) is to promote the ability of the injured warrior …to move from assisted living to living independently and to be self-supporting by providing a continuum of care. To accomplish this goal the DVBIC-J ALPP is providing full set of traditional services (physical, occupational, speech, psychological/cognitive, social/familial, vocational, and spiritual), along with “cutting-edge” rehabilitative treatment technologies. These cutting-edge therapies include transdisciplinary clinical consultations, interactive patient and family counseling, and telemedicine-teleconferencing for clinical evaluations and family/significant other care participation. These services will be available to those who require assisted living through their progression to community re-entry. The ALPP also serves as a vehicle for clinical trials to investigate the effects of an enriched environment (e.g., recreational therapies, massage, multisensory stimulation, etc.) on neurorehabilitation therapy, rural telemedicine for servicemembers with traumatic brain injury, and long-term outcome measures of those who have received neurorehabilitation services at the DVBIC-J site. DVBIC-J is also developing collaborative projects with universities and private industry to create an incubator for new rehabilitation technologies. The technologies that DVBIC-J will be focusing on will include assistive technologies (to assist cognitive, physical, and communicative impairments), virtual and augmented reality simulations (for both diagnosis and treatment of TBI and PTSD), and telecommunication technologies to improve rehabilitation services to those warriors that have returned to their homes in rural areas. Show more

DOI: 10.3233/NRE-2010-0561

Citation: NeuroRehabilitation, vol. 26, no. 3, pp. 257-269, 2010

Authors: Lew, Henry L. | Amick, Melissa M. | Kraft, Malissa | Stein, Murray B. | Cifu, David X.

Article Type: Research Article

Abstract: The driving abilities of service members returning from Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) have not been well reported and are an important aspect of their return to normal life. This article reviews the unique risk factors for unsafe driving in this cohort. In particular, the cognitive and psychological symptoms of mild traumatic brain injury and postraumatic stress disorder, two of the most common diagnoses affecting these returning warriors, are specified, and their possible association with impaired driving is examined. The potential negative impact of the “battlemind driving tactics” (i.e., evasive driving skills) acquired by these service members …as part of their military tours is also highlighted. The article concludes with comments about the functional consequences of impaired driving in this population, including limits to participation in rehabilitation and community reintegration, as well as recognition of the need for further research in this area. Show more

Keywords: Traumatic brain injury, post traumatic stress disorder, motor vehicle crashes, deployment, evasive driving skills, veterans

DOI: 10.3233/NRE-2010-0562

Citation: NeuroRehabilitation, vol. 26, no. 3, pp. 271-278, 2010

Authors: Martin, Elisabeth Moy | French, Louis | Janos, Alicia

Article Type: Research Article

Abstract: Service members who have had a traumatic brain injury (TBI) in a war theatre [Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF)] may have associated injuries far different and/or more complex (i.e., polytrauma) than injuries obtained outside the theatre of operation. This article expands on what has been learned from monitoring patients injured during peacetime to the newly injured war veterans being monitored in the home setting via routine telephonic follow-up. As Tanielian et al. state TBI, post traumatic stress disorder (PTSD) and major depression may occur during and following deployment/s which then pose a significant health risk to …these veterans. This is particularly important as veterans of these two conflicts may incur these “invisible wounds of war”. Thus, safe and effective monitoring of these veterans by nurses/case managers in the home/ community setting becomes important in the recovery process. Show more

Keywords: Telephonic follow-up, traumatic brain injury

DOI: 10.3233/NRE-2010-0563

Citation: NeuroRehabilitation, vol. 26, no. 3, pp. 279-283, 2010

Authors: Doncevic, Selina | Boerman, Heidi L.

Article Type: Research Article

Abstract: This article will address and describe the military continuum of care and its implications for the health care providers intimately involved in the treatment of service members who sustain traumatic brain injuries (TBI). Clinical Practice Guidelines have been created and distributed for treatment of TBI sustained by service members in both the deployed setting and in the continental United States (CONUS). The military has established specific levels of care each with specific purpose in the treatment continuum that extends from the battlefield to the most advanced military treatment facility (MTF). The health care providers who care for this particular patient …population can also face unique opportunities, challenges and rewards. Show more

DOI: 10.3233/NRE-2010-0564

Citation: NeuroRehabilitation, vol. 26, no. 3, pp. 285-290, 2010