Greg J Lamberty

Mindfulness-Based Stress Reduction for Posttraumatic Stress Disorder Among Veterans: A Randomized Clinical Trial

IMPORTANCE Mindfulness-based interventions may be acceptable to veterans who have poor adherence to existing evidence-based treatments for posttraumatic stress disorder (PTSD). OBJECTIVE To compare mindfulness-based stress reduction with present-centered group therapy for treatment of PTSD. DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial of 116 veterans with PTSD recruited at the Minneapolis Veterans Affairs Medical Center from March 2012 to December 2013. Outcomes were assessed before, during, and after treatment and at 2-month follow-up. Data collection was completed on April 22, 2014. INTERVENTIONS Participants were randomly assigned to receive mindfulness-based stress reduction therapy (n = 58), consisting of 9 sessions (8 weekly 2.5-hour group sessions and a daylong retreat) focused on teaching patients to attend to the present moment in a nonjudgmental, accepting manner; or present-centered group therapy (n = 58), an active-control condition consisting of 9 weekly 1.5-hour group sessions focused on current life problems. MAIN OUTCOMES AND MEASURES The primary outcome, change in PTSD symptom severity over time, was assessed using the PTSD Checklist (range, 17-85; higher scores indicate greater severity; reduction of 10 or more considered a minimal clinically important difference) at baseline and weeks 3, 6, 9, and 17. Secondary outcomes included PTSD diagnosis and symptom severity assessed by independent evaluators using the Clinician-Administered PTSD Scale along with improvements in depressive symptoms, quality of life, and mindfulness. RESULTS Participants in the mindfulness-based stress reduction group demonstrated greater improvement in self-reported PTSD symptom severity during treatment (change in mean PTSD Checklist scores from 63.6 to 55.7 vs 58.8 to 55.8 with present-centered group therapy; between-group difference, 4.95; 95% CI, 1.92-7.99; P=.002) and at 2-month follow-up (change in mean scores from 63.6 to 54.4 vs 58.8 to 56.0, respectively; difference, 6.44; 95% CI, 3.34-9.53, P < .001). Although participants in the mindfulness-based stress reduction group were more likely to show clinically significant improvement in self-reported PTSD symptom severity (48.9% vs 28.1% with present-centered group therapy; difference, 20.9%; 95% CI, 2.2%-39.5%; P = .03) at 2-month follow-up, they were no more likely to have loss of PTSD diagnosis (53.3% vs 47.3%, respectively; difference, 6.0%; 95% CI, -14.1% to 26.2%; P = .55). CONCLUSIONS AND RELEVANCE Among veterans with PTSD, mindfulness-based stress reduction therapy, compared with present-centered group therapy, resulted in a greater decrease in PTSD symptom severity. However, the magnitude of the average improvement suggests a modest effect. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01548742.

Development of a traumatic brain injury model system within the Department of Veterans Affairs Polytrauma System of Care.

Background:In 2008, the Department of Veterans Affairs Polytrauma Rehabilitation Centers partnered with the National Institute on Disability and Rehabilitation Research to establish a Model Systems program of research that would closely emulate the civilian Traumatic Brain Injury (TBI) Model Systems Centers Program established in 1987. Objective:To describe the development of a TBI Model Systems program within the Department of Veterans Affairs Polytrauma System of Care. Methods:Enrollment criteria and data collection/data quality efforts for the newly established Department of Veterans Affairs sites are reviewed. Results:Significant progress has been made in the establishment of a Model Systems program for the Polytrauma System of Care. Data collection has moved forward and program-specific modifications have been implemented. Conclusion:The Veterans Affairs TBI Model System program is established and growing, with many projects underway and a strong working relationship with the civilian TBI Model System programs.

Participation After Multidisciplinary Rehabilitation for Moderate to Severe Traumatic Brain Injury in Adults: A Systematic Review

OBJECTIVE To determine the effectiveness and comparative effectiveness of multidisciplinary rehabilitation programs for moderate to severe traumatic brain injury (TBI) in improving participation-related outcomes in adults. This article presents results of select key questions from a recent Agency for Healthcare Quality and Research comparative effectiveness review. DATA SOURCES MEDLINE, Cochrane Central Register of Controlled Trials, and PsycINFO; hand searches of previous relevant reviews. STUDY SELECTION We included prospective controlled studies that evaluated the effectiveness or comparative effectiveness of multidisciplinary rehabilitation programs delivered to adults with moderate to severe TBI on their participation in life and community. DATA EXTRACTION We extracted data, assessed risk of bias, and evaluated strength of evidence. Participation was selected as our primary outcome and included measures of productivity (eg, return to employment or military service) and select scales measuring community integration. Only data from studies with a low or moderate risk of bias were synthesized. DATA SYNTHESIS Twelve studies met our inclusion criteria; of these, 8 were of low or moderate risk of bias (4 randomized controlled trials of 680 patients and 4 cohort studies of 190 patients, sample size 36-366). Heterogeneous populations, interventions, and outcomes precluded pooled analysis. Evidence was insufficient to draw conclusions about effectiveness. Evidence on comparative effectiveness often demonstrated that improvements were not different between groups; however, this evidence was low strength and may have limited generalizability. CONCLUSIONS Our review used a rigorous systematic review methodology and focused on participation after multidisciplinary rehabilitation programs for impairments from moderate to severe TBI. The available evidence did not demonstrate the superiority of one approach over another. This conclusion is consistent with previous reviews that examined other patient-centered outcomes. While these findings will have little clinical impact, they do point out the limited evidence available to assess effectiveness and comparative effectiveness while highlighting important issues to consider in future comparative effectiveness research on this topic.

Community Reintegration Problems Among Veterans and Active Duty Service Members With Traumatic Brain Injury.

Objectives: To examine community reintegration problems among Veterans and military service members with mild or moderate/severe traumatic brain injury (TBI) at 1 year postinjury and to identify unique predictors that may contribute to these difficulties. Setting: VA Polytrauma Rehabilitation Centers. Participants: Participants were 154 inpatients enrolled in the VA TBI Model Systems Program with available injury severity data (mild = 28.6%; moderate/severe = 71.4%) and 1-year postinjury outcome data. Design: Prospective, longitudinal cohort. Main Measures: Community reintegration outcomes included independent driving, employability, and general community participation. Additional measures assessed depression, posttraumatic stress, and cognitive and motor functioning. Results: In the mild TBI (mTBI) group, posttraumatic stress disorder and depressive symptoms were associated with lower levels of various community reintegration outcomes. In the moderate/severe TBI group, cognition and motor skills were significantly associated with lower levels of community participation, independent driving, and employability. Conclusion: Community reintegration is problematic for Veterans and active duty service members with a history of TBI. Unique comorbidities across injury severity groups inhibit full reintegration into the community. These findings highlight the ongoing rehabilitation needs of persons with TBI, specifically evidence-based mental healthcare, in comprehensive rehabilitation programs consistent with a chronic disease management model.

Effects and Outcomes in Civilian and Military Traumatic Brain Injury: Similarities, Differences, and Forensic Implications

Traumatic brain injury (TBI) is a prominent public health problem in both civilian and military settings. This article discusses similarities and differences in the assessment and treatment of TBI and the attendant forensic implications. Acute care and management of moderate/severe TBI tend to be similar across environments, as is the recognition of disability status in affected individuals. By contrast, an increased focus on mild TBI in recent years has resulted in a reliance on self-report and screening measures to validate the occurrence of events leading to injury. This has complicated assessment, treatment and subsequent medicolegal proceedings. The neuropsychological literature has provided significant guidance on these difficult issues, although the complexity of disability adjudication for active duty members of the military and veterans continues to pose challenges for clinicians in evaluative and treatment contexts.

PTSD confounds detection of compromised cerebral white matter integrity in military veterans reporting a history of mild traumatic brain injury.

Abstract Primary objective: Based on high comorbidity between mild traumatic brain injury (mTBI) and post-traumatic stress disorder (PTSD) among deployed military service members, this study tested the hypothesis that the presence of PTSD disrupts the association between mTBI and lower white matter integrity identified in non-military samples. Research design/Methods and procedures: In a sample of 124 recent veterans with a range of mTBI and PTSD history, diffusion tensor imaging (DTI) metrics of white matter integrity in 20 regions were compared using multiple mTBI and PTSD contrasts. Main outcomes and results: Civilian mTBI was associated with lower global anisotropy, higher global diffusivity and higher diffusivity in 17 of 20 regions. No main effects of deployment mTBI were observed, but an interaction between deployment mTBI and lifetime PTSD on FA was observed globally and in 10 regions. Impact and blast mTBI demonstrated similar but weaker effects to those of civilian and deployment mTBI, respectively, demonstrating the context of mTBI is more relevant to white matter integrity than mechanism of injury. Conclusions: Overall, a main effect of civilian mTBI indicates long-term disruptions to white matter are likely present, while the interaction between deployment mTBI and PTSD indicates that a history of PTSD alters this relationship.

Utility of the Neurobehavioral Symptom Inventory As an Outcome Measure: A VA TBI Model Systems Study.

Objective: To examine the utility of the Neurobehavioral Symptom Inventory (NSI)—a measure of postconcussion symptoms used within the Veterans Health Administration—as an index of rehabilitation outcome. Setting: Veterans Administration Polytrauma Rehabilitation Centers Traumatic Brain Injury (TBI) Model Systems program. Participants: A total of 159 Veterans (14% with mild TBI; 86% with moderate-severe TBI). Main Measures: Disability Rating Scale; Functional Independence Measure; Glasgow Outcome Scale–Extended; NSI; Participation Assessment with Recombined Tools–Objective; Posttraumatic Stress Disorder Checklist–Civilian Version; Satisfaction With Life Scale; Supervision Rating Scale. Analyses: Correlations and exploratory factor analyses examined the interrelations among outcome measures. Hierarchical regression analyses were utilized to determine if the NSI predicted rehabilitation outcome measures after controlling for demographic variables, TBI severity, and time since injury. NSI reliable changes from pretreatment to 1-year follow-up were examined. Receiver operating characteristics curve analyses were conducted to evaluate the ability of changes in the NSI to predict meaningful change in functioning and employment status. Results: The NSI correlated with psychological distress measures. The NSI administered prior to brain injury rehabilitation had limited predictive utility beyond satisfaction with life. A minority of patients (32%) demonstrated reliable changes on the NSI from baseline to 1-year follow-up. Changes on the NSI were not predictive of meaningful change in employment or functioning. Conclusion: The NSI was not useful for assessing meaningful change in a sample of mixed severity TBI patients.

Specialty Competencies in Clinical Neuropsychology

In this volume, Drs. Lamberty and Nelson provide a comprehensive overview of the foundational and functional competencies related to the broad field of clinical neuropsychology. The authors distill not only the most important dimensions of the current science and practice, but also delineate important future directions and challenges. Anyone interested in obtaining an extensive survey of the extant literature related to this specialty, as well as insider knowledge on important professional issues, will find this volume to be an invaluable resource.

Comparison of the VA and NIDILRR TBI model system cohorts

Objective:Within the same time frame, compare the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) and VA Traumatic Brain Injury Model System (TBIMS) data sets to inform future research and generalizability of findings across cohorts. Setting:Inpatient comprehensive interdisciplinary rehabilitation facilities. Participants:Civilians, Veterans, and active duty service members in the VA (n = 550) and NIDILRR civilian settings (n = 5270) who were enrolled in TBIMS between August 2009 and July 2015. Design:Prospective, longitudinal, multisite study. Main Measures:Demographics, Injury Characteristics, Functional Independence Measures, Disability Rating Scale. Results:VA and NIDILRR TBIMS participants differed on 76% of comparisons (18 Important, 8 Minor), with unique differences shown across traumatic brain injury etiology subgroups. The VA cohort was more educated, more likely to be employed at the time of injury, utilized mental health services premorbidly, and experienced greater traumatic brain injury severity. As expected, acute and rehabilitation lengths of stay were longer in the VA with no differences in death rate found between cohorts. Conclusions:Substantial baseline differences between the NIDILRR and VA TBIMS participants warrant caution when comparing rehabilitation outcomes. A substantive number of NIDILRR enrollees had a history of military service (>13%) warranting further focused study. The TBIMS participant data collected across cohorts can be used to help evidence-informed policy for the civilian and military-related healthcare systems.

Transcendental meditation for veterans with post-traumatic stress disorder.

Objective: Transcendental Meditation (TM) is a mental technique using a mantra to facilitate meditation. TM has a potential for treating symptoms of posttraumatic stress disorder (PTSD), but its clinical efficacy remains to be clarified. This pilot study evaluated the acceptability, preliminary effectiveness, and neurophysiology of TM for veterans with PTSD. Method: Twenty-nine veterans (20.7% female) were recruited from a major medical center and enrolled in the study. TM instruction was provided by certified TM teachers from the Maharishi Foundation and consisted of 8 weeks of individual and group-based meditation instruction and practice. Outcomes were assessed at baseline, during treatment, posttreatment, and at 2-month follow-up, and included clinical interviews, self-report questionnaires, and electroencephalography (EEG) recorded during resting and meditation states. Results: From baseline to posttreatment, participants reported reductions in PTSD symptoms, experiential avoidance, and depressive and somatic symptoms, as well as increases on measures of mindfulness and quality of life. Gains were either maintained or continued to improve through the 2-month follow-up. Compared to baseline, EEG spectral power increased in low-frequency bands (1–7 Hz) at posttreatment and follow-up and only during meditation states suggesting TM-specific changes in brain state associated with the intervention. Conclusions: TM appears to be an acceptable and effective treatment for veterans with PTSD that warrants further study regarding specific outcomes and beneficial changes in brain function.