Marc A. Silva

Incidence of Postconcussion Symptoms in Psychiatric Diagnostic Groups, Mild Traumatic Brain Injury, and Comorbid Conditions

The constellation of physical, cognitive, and emotional symptoms, collectively known as postconcussion syndrome (PCS), is not uniquely associated with concussion, making the etiology of chronic postconcussion symptoms controversial. The current study compared percentages of individuals meeting symptom-based criteria for PCS in a population-based sample of veterans composed of subgroups with various psychiatric diagnoses, a history of mild traumatic brain injury (MTBI), and healthy controls. Participants were identified from 4462 randomly sampled male U.S. Army veterans who served during the Vietnam era. Only 32% of veterans with a history of MTBI met DSM-IV symptom criteria for PCS as compared to 40% of those diagnosed with post-traumatic stress disorder (PTSD), 50% with generalized anxiety disorder (GAD), 57% with major depressive disorder (MDD), and 91% with somatization disorder. Results were consistent with existing literature showing that the PCS symptoms are not unique to concussion, and also provide important base-rate information for neuropsychologists practicing in both clinical and personal injury forensic settings.

Normative Data for the Neurobehavioral Symptom Inventory (NSI) and Post-Concussion Symptom Profiles Among TBI, PTSD, and Nonclinical Samples

The Neurobehavioral Symptom Inventory (NSI) is a self-report measure of symptoms commonly associated with Post-Concussion Syndrome (PCS) that may emerge after mild traumatic brain injury (mTBI). Despite frequent clinical use, no NSI norms have been developed. Thus, the main objective of this study was to establish NSI normative data using the four NSI factors (i.e., vestibular, somatic, cognitive, and affective) identified by Vanderploeg, Silva, et al. (2014) among nonclinical epidemiological samples of deployed and non-deployed Florida National Guard members as well as a reference sample of Guard members with combat-related mTBI. In addition, NSI subscale profile patterns were compared across four distinct subgroups (i.e., non-deployed-nonclinical, deployed-nonclinical, deployed-mTBI, and deployed-PTSD). The deployed-nonclinical group endorsed greater PCS symptom severity than the non-deployed group, and the mTBI group uniformly endorsed more symptoms than both nonclinical groups. However, the PTSD group endorsed higher symptom severity relative to the other three subgroups. As such, this highlights the non-specificity of PCS symptoms and suggests that PTSD is associated with higher symptom endorsement than mTBI.

The structure of postconcussion symptoms on the Neurobehavioral Symptom Inventory: a comparison of alternative models.

Objective:To evaluate and compare the existing Neurobehavioral Symptom Inventory factor structure models to determine which model provides the best overall fit for postconcussion symptoms and determine which model is useful across different samples (eg, with and without mild traumatic brain injury [TBI] history). Setting:N/A. Participants:A Florida National Guard sample (N = 3098) and a national Department of Veterans Affairs sample (N = 48 175). Design:Retrospective structural equation modeling was used to compare 16 alternative factor structure models. First, these 16 possible models were examined separately in both samples. Then, to determine whether the same factor structures applied across subsamples within these samples, the models were compared for those deployed and those not deployed in the Florida National Guard sample and between those with TBI confirmed on clinical evaluation and those who were determined not to have sustained a TBI within the Department of Veterans Affairs sample. Main Measures:Neurobehavioral Symptom Inventory. Results:A 4-factor model—vestibular, somatic, cognitive, and affective—had the best overall fit, after elimination of 2 items (ie, hearing problems and appetite disturbance), and was most applicable across samples. Conclusions:These findings extend the findings of Meterko et al to other samples. Because findings were consistent across sample and subsamples, the current findings are applicable to both Department of Veteran Affairs and Department of Defense postdeployment medical evaluation settings.

Concordance of Actigraphy With Polysomnography in Traumatic Brain Injury Neurorehabilitation Admissions

Objective:To examine concordance of accelerometer-based actigraphy (ACG) with polysomnography (PSG) in the determination of sleep states in inpatients with traumatic brain injury (TBI), and examine the impact of injury severity and comorbid conditions (spasticity, apnea) on concordance. Participants:This was a convenience sample of 50 participants with primarily severe TBI. Design:This was a retrospective chart review of concurrent administration of PSG with ACG in nonconsecutive rehabilitation admissions with TBI. Main Measures:Total sleep time and sleep efficiency were measured by PSG and ACG. Results:Moderate to strong correlations between ACG and PSG were observed for total sleep time (r = 0.78, P < .01) and sleep efficiency (r = 0.66, P < .01). PSG and ACG estimates of total sleep time (316 minutes vs 325 minutes, respectively) and sleep efficiency (78% vs 77%, respectively) were statistically indistinguishable. Conclusions:Actigraphy is a valid proxy for monitoring of sleep in this population across injury severity and common comorbidity groups. However, further research with larger sample sizes to examine concordance in patients with TBI with disorder of consciousness and spasticity is recommended.

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.

Subjective sleep quality and postconcussion symptoms following mild traumatic brain injury

Abstract Primary objective: The goal of this investigation is to examine the prevalence of poor subjective sleep in patients with a history of mild traumatic brain injury (mTBI) and examine the relationship between subjective sleep quality and postconcussive symptoms (PCS), above and beyond the typical demographic and psychological distress variables. Research design: Individuals with a history of mTBI completed online questionnaires. Regression analysis was utilized to determine if subjective sleep quality would predict PCS severity, above and beyond demographic variables and psychological distress. Methods and procedures: Individuals with a history of mTBI (n = 158) completed surveys online. Sleep quality was assessed with the Pittsburgh Sleep Quality Index (PSQI) and PCS with the Neurobehavioral Symptom Inventory (NSI). Demographic information was collected and psychological distress was measured using the Brief Symptom Inventory-18 (BSI-18). Main outcomes and results: In this sample, 92% of patients with mTBI reported poor sleep. Sleep quality significantly accounted for the variance in PCS, above and beyond demographics, time since injury and psychological distress (p < 0.001), although only a small amount of the variance in PCS was explained. Conclusions: Results indicate that poor subjective sleep quality is a significant problem in those with mTBI. While sleep is associated with PCS severity, psychological distress is a more potent predictor.

Postdoctoral Recruitment in Neuropsychology: A Review and Call for Inter-Organizational Action

The history of centralized matches for postgraduate selection is briefly discussed with a focus on the match instituted by the Association of Postdoctoral Programs in Clinical Neuropsychology (APPCN) in 2001] Survey data, conducted both by APPCN and independently, are summarized. In general, despite incomplete participation and an estimated 30% rate of “exploding offers”, applicants are somewhat satisfied with the match according to recent surveys (although satisfaction varies depending on whether an applicant matched). Given the high rate of withdrawal, the history of other specialties with suboptimal participation, and the concerns most commonly expressed by participants about this issue in survey data, there is cause for concern. We assert that incomplete participation in the match hurts applicants and programs. We propose that focused efforts are needed involving multiple organizations to enhance the match, including the Clinical Neuropsychology Synarchy (CNS) as our specialty council and the multiple organizations represented on the CNS.

Web-based psychoeducational intervention for postconcussion symptoms: a randomized trial

The objective of this study was to investigate the effectiveness of a web-based educational intervention for reducing postconcussion symptoms. 158 participants with self-reported symptomatic mild traumatic brain injury were randomized to intervention versus control. There was no effect of intervention on symptom severity or attributions. Subgroup analyses suggested benefit of the web-based intervention in those receiving concurrent mental health treatment and in those participants with the greatest time since injury (>1 year after mild traumatic brain injury). Web-based educational intervention was not effective overall in this sample. However, there is some suggestion of promise in those receiving concurrent mental health treatment and with more chronic symptoms. Findings also suggest potential benefit of interventions targeting self-efficacy.

Abnormal Neurological Exam Findings in Individuals with Mild Traumatic Brain Injury (mTBI) Versus Psychiatric and Healthy Controls

In those with a history of mild traumatic brain injury (mTBI), cognitive and emotional disturbances are often misattributed to that preexisting injury. However, causal determinations of current symptoms cannot be conclusively determined because symptoms are often nonspecific to etiology and offer virtually no differential diagnostic value in postacute or chronic phases. This population-based study examined whether the presence of abnormalities during neurological examination would distinguish between mTBI (in the chronic phase), healthy controls, and selected psychiatric conditions. Retrospective analysis of data from 4462 community-dwelling Army veterans was conducted. Diagnostically unique groups were compared on examination of cranial nerve function and other neurological signs. Results demonstrated that individuals with mTBI were no more likely than those with a major depressive disorder, generalized anxiety disorder, posttraumatic stress disorder, or somatoform disorder to show any abnormality. Thus, like self-reported cognitive and emotional symptoms, the presence of cranial nerve or other neurological abnormalities offers no differential diagnostic value. Clinical implications and study limitations are presented.

Implementation of Actigraphy in Acute Traumatic Brain Injury (TBI) Neurorehabilitation Admissions: A Veterans Administration TBI Model Systems Feasibility Study.

Sleep problems and disorders are prevalent in patients with traumatic brain injury (TBI) and are associated with negative outcomes. Incidence varies because of challenges including differences in assessment methods, particularly in the acute stages of recovery when patients are cognitively impaired and unable to complete traditional self‐report methods. Actigraphy (ACG) recently has been validated in the acute TBI rehabilitation setting and may serve as a superior method of assessing sleep‐wake patterns at this stage of recovery. Although a few studies with small sample sizes have described the use of ACG, none have described feasibility and implementation protocols.