Brian J. Ivins

Traumatic brain injury screening: preliminary findings in a US Army Brigade Combat Team.

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

Traumatic Brain Injury, Posttraumatic Stress Disorder, and Postconcussive Symptom Reporting Among Troops Returning From Iraq

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

Traumatic Brain Injury in the United States: An Epidemiologic Overview

A basic description of severity and frequency is needed for planning healthcare delivery for any disease process. In the case of traumatic brain injury, severity is typically categorized into mild, moderate, and severe with information from a combination of clinical observation and self-report methodologies. Recent US civilian epidemiological findings measuring the frequency of mortality and morbidity of traumatic brain injury are presented, including demographic and etiological breakdowns of the data. Falls, motor vehicle accidents, and being struck by objects are the major etiologies of traumatic brain injury. US civilian and Army hospitalization trends are discussed and compared. Features of traumatic brain injuries from Operation Iraqi Freedom and Operation Enduring Freedom are discussed.

Neuropsychological test performance in soldiers with blast-related mild TBI.

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

The Structure of Postconcussive Symptoms in 3 Us Military Samples

Objective:To evaluate alternative models of symptom clusters for the 22-item Neurobehavioral Symptom Inventory. Participants:Three military samples, including 2 nonclinical samples (n = 2420, n = 4244) and 1 sample of individuals with recent head injury (n = 617). Methods:In the first sample, exploratory factor analysis of Neurobehavioral Symptom Inventory responses was performed with tests of significant factors and model fit. In the other 2 samples, confirmatory factor analysis evaluated the fit of 3 models: 2- and 3-factor models based on the initial exploratory factor analysis, and a 9-factor model based on prior research. Main Outcome Measures:The exploratory factor analysis used 2 tests for the number of factors: Parallel Analysis and Minimum Average Partial test. Confirmatory factor analysis models were evaluated using 2 measures of model fit, Root Mean Square Error of Approximation and Comparative Fit Index. Results:Postconcussive symptoms can be described accurately by the 9 factors. However, the model of 3 intercorrelated factors, reflecting cognitive, affective, and somatic/sensory symptoms, fits the data more parsimoniously with little loss in model fit. Conclusion:Although the 9-cluster result from prior research provides a valid description of the relations among items of the inventory, a 3-factor model, consisting of somatic/sensory, affective, and cognitive factors, provides nearly as good a fit to the data, with greater parsimony. We encourage clinicians and researchers to conceptualize the Neurobehavioral Symptom Inventory in terms of 3 coherent clusters of symptoms rather than as 22 individual items.

Performance on the Automated Neuropsychological Assessment Metrics in a nonclinical sample of soldiers screened for mild TBI after returning from Iraq and Afghanistan: a descriptive analysis.

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

Traumatic brain injury in U.S. Army paratroopers: Prevalence and character

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

Risk Factors for Postconcussion Symptom Reporting after Traumatic Brain Injury in U.S. Military Service Members

The purpose of this study was to identify factors that are predictive of, or associated with, postconcussion symptom reporting after traumatic brain injury (TBI) in the U.S. military. Participants were 125 U.S. military service members (age: M=29.6 years, standard deviation [SD]=8.9, range=18-56 years) who sustained a TBI, divided into two groups based on symptom criteria for postconcussional disorder (PCD): PCD-Present (n=65) and PCD-Absent (n=60). Participants completed a neuropsychological evaluation at Walter Reed Army Medical Center (M=9.4 months after injury, SD=9.9; range: 1.1 to 44.8). Factors examined included demographic characteristics, injury-related variables, psychological testing, and effort testing. There were no significant group differences for age, sex, education, race, estimated premorbid intelligence, number of deployments, combat versus non-combat related injury, or mechanism of injury (p>0.098 for all). There were significant main effects for severity of body injury, duration of loss of consciousness, duration of post-traumatic amnesia, intracranial abnormality, time tested post-injury, possible symptom exaggeration, poor effort, depression, and traumatic stress (p<0.044 for all). PCD symptom reporting was most strongly associated with possible symptom exaggeration, poor effort, depression, and traumatic stress. PCD rarely occurred in the absence of depression, traumatic stress, possible symptom exaggeration, or poor effort (n=7, 5.6%). Many factors unrelated to brain injury were influential in self-reported postconcussion symptoms in this sample. Clinicians cannot assume uncritically that endorsement of items on a postconcussion symptom checklist is indicative of residual effects from a brain injury.

Influence of bodily injuries on symptom reporting following uncomplicated mild traumatic brain injury in US military service members.

Objective:To examine the relations among bodily injuries, traumatic stress, and postconcussion symptoms in a sample of combat-injured US service members who sustained a mild traumatic brain injury. Participants:One hundred and thirty-seven service members evaluated and treated at Walter Reed Army Medical Center following medical evacuation from the combat theater of Operation Enduring Freedom and Operation Iraqi Freedom. All had sustained an uncomplicated mild traumatic brain injury and concurrent bodily injuries. Procedure:Participants completed 2 symptom checklists within 3 months of injury. Severity of bodily injuries was quantified with a modified version of the Injury Severity Score that excluded intracranial injuries (ISSmod). Participants were classified into 4 ISSmod groups: minor (n = 17), moderate (n = 48), serious (n = 40), severe/critical (n = 32). Main outcome measures:Neurobehavioral Symptom Inventory (NBSI) and the Posttraumatic Stress Disorder Checklist-Civilian version (PCLC). Results:There was a significant negative association between ISSmod scores and the NBSI and PCLC total scores. There were significant main effects across the 4 groups for the NBSI and PCLC total scores. The highest NBSI and PCLC scores were consistently found in the ISSmod minor group, followed by the moderate, serious, and severe/critical groups. Conclusions:While it might be expected that greater comorbid physical injuries would be associated with greater symptom burden, in this study as the severity of bodily injuries increased, symptom burden decreased. Hypothesized explanations include: underreporting of symptoms; increased peer support; disruption of fear conditioning due to acute morphine use; or delayed expression of symptoms.

Factors influencing postconcussion and posttraumatic stress symptom reporting following military-related concurrent polytrauma and traumatic brain injury.

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.