Blessen C. Eapen

The prevalence of epilepsy and association with traumatic brain injury in veterans of the Afghanistan and Iraq wars

Objective:To examine the association of epilepsy with traumatic brain injury (TBI) in Afghanistan and Iraq (Operation Enduring Freedom [OEF]/Operation Iraqi Freedom [OIF]) Veterans. Design:Cross-sectional observational study. Participants:A total 256 284 OEF/OIF Veterans who received inpatient and outpatient care in the Veterans Health Administration in fiscal years 2009-2010. Main Outcome Measures:We used algorithms developed for use with International Classification of Diseases, Ninth Revision, Clinical Modification, codes to identify epilepsy, TBI (penetrating TBI [pTBI]/other TBI), and other risk factors for epilepsy (eg, stroke). TBI and other risk factors were identified prior to the index date (first date of seizure or October 1, 2009) for primary analyses. Results:Epilepsy prevalence was 10.6 per 1000 (N = 2719) in fiscal year 2010; age-adjusted prevalence was 6.1. Of 37 718 individuals with a diagnosis of TBI, 29 297 Veterans had a diagnosis of TBI prior to the index date. Statistically significant associations were found between epilepsy and prior TBI diagnosis (pTBI: adjusted odds ratio = 18.77 [95% confidence interval, 9.21-38.23]; other TBI: adjusted odds ratio = 1.64 [1.43–1.89]). Conclusions:Among OEF/OIF Veterans, epilepsy was associated with previous TBI diagnosis, with pTBI having the strongest association. Because war-related epilepsy in Vietnam War Veterans with TBI continued 35 years postwar, a detailed, prospective study is needed to understand the relationship between epilepsy and TBI severity in OEF/OIF Veterans.

Treatment of persistent post-concussive symptoms after mild traumatic brain injury: a systematic review of cognitive rehabilitation and behavioral health interventions in military service members and veterans

Increased prevalence of traumatic brain injury (TBI) has been associated with service members and veterans who completed combat deployments in support of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF). Management of persistent post-concussive symptoms (PCS) has been a challenge to healthcare providers throughout the Military and Veterans Healthcare Systems, as well as civilian healthcare providers, due in part to the chronic nature of symptoms, co-occurrence of behavioral health disorders such as depression, Posttraumatic Stress Disorder (PTSD), and substance use disorders, and fear of a potential stigma associated with psychiatric diagnoses and behavioral health treatment(s). This systematic review examined non-pharmacologic behavioral health interventions and cognitive rehabilitation interventions for PCS in military service members and veterans with a history of mild TBI (mTBI). Six electronic databases were searched with specific term limitations, identifying 121 citations. Ultimately, 19 articles met criteria for inclusion in this systematic review. Studies were broadly categorized into four subtypes: psychoeducational interventions, cognitive rehabilitation, psychotherapeutic approaches, and integrated behavioral health interventions for PCS and PTSD. The review provides an update of the empirical evidence for these four types of interventions for PCS in active duty service members and veterans. Recommendations for future research are discussed, including the need to expand and improve the limited evidence basis on how to manage persistent post-concussive symptoms in this population.

Traumatic brain injury in veterans of the wars in Iraq and Afghanistan: communication disorders stratified by severity of brain injury.

Abstract Objective: To describe the prevalence of communication disorders in veterans of the wars in Iraq and Afghanistan with traumatic brain injury (TBI). Design: Retrospective study of the prevalence of aphasia, fluency and voice disorders among veterans with different severity levels of TBI. Data was obtained from the VA National repository for OEF/OIF/OND veterans who received VA care in Fiscal Years 2010 and 2011. Results: Among the 303 716 veterans in this study, 1848 were diagnosed with a communication disorder; 40% of these were also diagnosed with a TBI. Voice disorders were the most prevalent diagnosis (3.5 per 1000) followed by aphasia (1.9 per 1000) and fluency disorder (0.7 per 1000). Individuals with a TBI diagnosis were more likely to have a diagnosis of aphasia, followed by fluency and then voice disorder. The odds ratio (OR) of aphasia with TBI was 11.09–252.75 (95% CI = 8.78–441.52, p < 0.01). OR for fluency disorders with TBI was 3.58–10.41 (95% CI = 2.56–42.40, p < 0.01) and association of voice disorders with TBI was significant for all levels of TBI severity (OR = 1.5–6.61, 95% CI = 1.24–14.05, p < 0.01). Conclusions: Veterans who sustained a TBI were more likely to have a diagnosis of a communication disorder, regardless of TBI severity. Those with TBI, including mild TBI, should be screened and evaluated for communication disorders.

A cohort study examining headaches among veterans of Iraq and Afghanistan wars: Associations with traumatic brain injury, PTSD, and depression

To describe the prevalence and persistence of headache and associated conditions in an inception cohort of U.S. veterans of Iraq and Afghanistan wars.

Rehabilitation of Moderate-to-Severe Traumatic Brain Injury

Traumatic brain injury (TBI) is defined as an alteration in brain function, or other evidence of brain pathology, caused by an external force. Traumatic brain injury is a leading cause of morbidity and disability and is considered a major public health concern. Traumatic brain injury sequelae can lead to long-term impairments in physical, cognitive, behavioral, and social function. Traumatic brain injury rehabilitation requires an interdisciplinary holistic team approach in the management of medical complications, the prevention of further disability, and helping patients return to their highest level of independence. The authors review TBI pathophysiology, grading severity, common medical complications, cognitive rehabilitation, prognosis, and common outcomes used in TBI rehabilitation.

Predictors of Employment Outcomes in Veterans With Traumatic Brain Injury: A VA Traumatic Brain Injury Model Systems Study.

Objectives:To examine the length of time to return to work (RTW) among service members and veterans (SM/V) with traumatic brain injury (TBI) and to identify variables predictive of RTW. Setting:Department of Veterans Affairs Polytrauma Rehabilitation Centers (VA PRC). Participants:SM/V enrolled in the VA PRC Traumatic Brain Injury Model Systems database who were of 18 to 60 years of age and admitted with the diagnosis of TBI. Design:Prospective observational cohort study. Main Outcome Measures:Employment status at 1-year postinjury follow-up; Time to Employment (ie, number of days it took to RTW) as documented during 1-year postinjury follow-up. Results:The final sample (n = 293) included male (96%) SM/V with severe TBI (69%). Approximately 21% of the sample participants were employed at 1 year postinjury. Younger individuals who self-identified as nonminority returned to work sooner. Significant associations were observed for time to employment for cause of injury and injury severity. Conclusions:Few SM/V with moderate to severe TBI returned to work at 1 year postinjury. Predictors such as younger age at the time of injury, minority status, and severity of TBI affected time to and probability of RTW. Findings from this study have important implications for rehabilitation planning and service delivery across the continuum of recovery.

Increasing Prevalence of Chronic Lung Disease in Veterans of the Wars in Iraq and Afghanistan

Research from the wars in Afghanistan and Iraq have focused on traumatic brain injury (TBI) and mental health conditions; however, it is becoming clear that other health concerns, such as respiratory illnesses, warrant further scientific inquiry. Early reports from theater and postdeployment health assessments suggested an association with deployment-related exposures (e.g., sand, burn pits, chemical, etc.) and new-onset respiratory symptoms. We used data from Veterans Affairs medical encounters between fiscal years 2003 and 2011 to identify trends in chronic obstructive pulmonary disease, asthma, and interstitial lung disease in veterans. We used data from Veterans Affairs and Department of Defense sources to identify sociodemographic (age, sex, race), military (e.g., service branch, multiple deployments) and clinical characteristics (TBI, smoking) of individuals with and without chronic lung diseases. Generalized estimating equations found significant increases over time for chronic obstructive pulmonary disease and asthma in both unadjusted and adjusted analyses. Trends for interstitial lung disease were significant only in adjusted analyses. Age, smoking, and TBI were also significantly associated with chronic lung diseases; however, multiple deployments were not associated. Research is needed to identify which characteristics of deployment-related exposures are linked with chronic lung disease.

Rehabilitation of Persistent Symptoms After Concussion

One of the more challenging aspects beyond acute concussion management occurs when symptoms do not resolve as anticipated over time. The term postconcussion syndrome generally refers to a presentation of multiple ongoing symptoms months to years from injury, typically comprised of physical, cognitive, and emotional complaints such as headaches, poor sleep, poor concentration, dizziness, and irritability. Although individual factors vary, the condition is often regarded as multifactorial. Persistent issues can pose a threat to full community reintegration following concussion and reduce overall quality of life; thus early recognition and treatment are essential to optimize long-term outcomes.

Neuroprosthetics in amputee and brain injury rehabilitation.

&NA; The goals of rehabilitation medicine programs are to promote health, restore functional impairments and improve quality of life. The field of neuroprosthetics has evolved over the last decade given an improved understanding of neuroscience and the incorporation of advanced biotechnology and neuroengineering in the rehabilitation setting to develop adaptable applications to help facilitate recovery for individuals with amputations and brain injury. These applications may include a simple cognitive prosthetics aid for impaired memory in brain‐injured individuals to myoelectric prosthetics arms with artificial proprioceptive feedback for those with upper extremity amputations. The integration of neuroprosthetics into the existing framework of current rehabilitation approaches not only improves quality‐of‐care and outcomes but help broadens current rehabilitation treatment paradigms. Although, we are in the infancy of the understanding the true benefit of neuroprosthetics and its clinical applications in the rehabilitation setting there is tremendous amount of promise for future research and development of tools to help facilitate recovery and improve quality of life in individuals with disabilities.

Traumatic Brain Injury Severity, Comorbidity, Social Support, Family Functioning, and Community Reintegration Among Veterans of the Afghanistan and Iraq Wars

OBJECTIVE To examine the association between traumatic brain injury (TBI) severity; social, family, and community reintegration outcomes; and return to work status among post-9/11 veterans in Department of Veterans Affairs (VA) care. DESIGN Retrospective observational cohort study. SETTING Mail/online survey fielded to a national sample of veterans. PARTICIPANTS Sample of post-9/11 veterans with at least 3 years of VA care stratified according to TBI severity and comorbidities who completed and returned surveys (N=2023). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Deployment Risk and Resilience Inventory-2 family functioning and social support subscales; Military to Civilian Questionnaire; and employment status. RESULTS Bivariate analyses revealed that veterans with every classification of TBI severity reported significantly more difficulty on social, family, and community reintegration outcomes than those with no TBI. In the fully adjusted model, veterans with unclassified and moderate/severe TBI reported significantly more difficulty with community reintegration and were less likely to be employed relative to those with no TBI; those with unclassified TBI also reported significantly more difficulty with family functioning. Veterans with mild TBI also reported significantly more difficulty with community reintegration. CONCLUSIONS This study provides insight into long-term outcomes associated with TBI in post-9/11 veterans and suggests that exposure to TBI has a negative effect on social and family functioning, community reintegration, and return to work even after controlling for comorbidity, deployment experiences, and sociodemographic characteristics. Additional research is required to explicate what appears to be complex interactions among TBI severity, psychosocial well-being, combat exposures, and socioeconomic resources in this population.