Neurobehavioral Symptom Inventory Research Articles

B - 15 Symptom Presentation on the Neurobehavioral Symptom Inventory and Post Traumatic Stress Disorder Checklist for DSM-5 in a Cohort of Explosive Ordnance Disposal Veterans

Abstract Objective This preliminary research examined symptom differences on the Neurobehavioral Symptom Inventory (NSI) and Post Traumatic Stress Disorder Checklist DSM-5 (PCL-5) for Explosive Ordnance Disposal (EOD) and Non-EOD Veterans receiving care at the Washington DC-War Related Illness and Injury Study Center (DC-WRIISC) Veterans Administration Medical Center. EOD Veterans have extensive repetitive blast-exposure histories, exposure to environmental toxins, and operated under high-stress/allostatic load throughout their careers. Therefore, we aim to understand how these unique occupational exposures influence long-term health outcomes for EOD Veterans. Method Eligible participants (N = 39, Mage = 51 years (SD = 9.5 years); EOD, n = 21) completed comprehensive interdisciplinary evaluations, self-report questionnaires, were combat deployed, and experienced traumatic brain injury. Total and component scores for the NSI (affective, cognitive, somatic, vestibular, and validity-10) and PCL-5 (criterion B-E symptom clusters), and total score for the Holmes-Rahe Life Stress Inventory, (HRLSI) were included. Results Regression analysis revealed overall NSI severity was positively correlated to PCL-5 total scores for both groups (EOD: F(1,19) = 25.30, p < 0.001); (Non-EOD: F(1,16) = 25.48, p < 0.001). However, significant differences in symptom presentation were noted between groups. NSI Cognitive scores were positively correlated with PCL-5 component scores for Criterion B for EOD (F(3,17) = 8.40, p < 0.001) and Criterion E for Non-EOD (F(3,14) = 24.32, p < 0.001). Post-hoc analysis suggested stress/resiliency may further contribute to group differences (HRLSI; Non-EOD, F(2,12) = 33.96, p < 0.001). Conclusion DC-WRIISC Veterans often present with cognitive concerns and complex medical presentations. Our findings suggest the presence of unique symptom presentations that may improve diagnostic formulation, treatment planning, and engagement. These findings highlight the need for continued research examining the influence occupational exposures have on Veteran health.

A - 32 The Patient Global Impression of Change—a Powerful Complimentary Tool for Assessing Improvement in Concussion Patients

Abstract Objective The purpose of this study was to determine the extent to which patient’s perspective of symptom improvement, as indexed by the Patient Global Impression of Change (PGIC) survey, is associated with symptom improvement on common measures of neurobehavioral and mental health symptoms following concussion. Methods Data were from 474 US active duty service members in interdisciplinary treatment programs for TBI. PGIC rating (range = 1–7) was evaluated for compatibility in assessing improvement in or clinically-elevated neurobehavioral (using Neurobehavioral Symptom Inventory, NSI) and mental health (using Post-traumatic Stress Disorder Checklist, DSM-5, PCL-5 and Patient Health Questionnaire, PHQ-8) symptoms. Results Higher PGIC scores were related to a higher prevalence of a clinically-relevant decrease in NSI, PCL-5 or PHQ-8 scores. Participants with a PGIC rating of 3+ (vs. < 3) were about 2.2 (CI = 1.4–3.5), 1.6 (CI = 1.1–1.3), and 2.7 (CI = 1.4–5.1) times more likely to report a clinically-relevant decrease in NSI, PCL-5 and PHQ-8 symptoms, respectively. Conclusion PGIC may help providers incorporate patients’ perspectives on symptom improvement achieved during rehabilitation. An approach combining PGIC with surveys such as NSI, PCL-5 and PHQ-8 may provide a more comprehensive understanding of symptom improvement and realistic view of expectations for what would be deemed recovery to pre-injury symptom levels.

B - 42 Evaluating the MMPI-3 Somatic/Cognitive Scales in Service Members and Veterans with Mild Traumatic Brain Injury (mTBI)

Abstract Objective Research on the Minnesota Multiphasic Personality Inventory, 3 (MMPI-3) Somatic/Cognitive scales is limited, but primarily focused on their relationships with symptom and performance validity tests. This study expands prior literature by providing extensive Somatic/Cognitive Scale correlates with symptom validity tests and neurocognitive measures in a sample of active-duty personnel and veterans. Method The study included Active-duty Service Members (n = 22) and Veterans (n = 31). Various measures of cognitive abilities and symptom validity were examined as a function of the Cognitive Complaints (COG) scale. Results Moderate to large differences were observed between COG groups across all MMPI-3 overreporting scales and all somatic/cognitive scales, save the NUC scale (g = 0.66–1.31 [excluding NUC]). Groups differed on three Memory Complaints Inventory memory scales: General (g = 0.89), Visuo-spatial (g = 0.62), and Verbal (g = 0.97). No significant differences were observed across cognitive tests (e.g., WAIS, CVLT). COG was moderately associated with all MMPI-3 overreporting and most somatic/cognitive scales (r = 0.30–0.72). Small to moderate correlations were observed between COG and most external validity and neurocognitive measures (r = 0.05–0.60). Conclusions Results suggest the COG scale primarily captures subjective distress rather than objective neurocognitive performance, consistent with prior work (Gervais et al., 2009). These patterns are especially pronounced in emotional, social, and somatic symptom domains. Additionally, COG scores were associated with MMPI-3 overreporting scores, but COG had weaker associations with external neurocognitive and symptom validity measures. These results suggest that COG has weak convergent validity with other self-report measures of cognition (e.g., Neurobehavioral Symptom Inventory).

B - 110 Exploring the Relationship between Subjective Cognitive Complaints, Psychiatric Symptom Reporting, and Neurocognitive Test Performance in a Post-SARS-CoV-2 Clinical Sample

Abstract Objective This study evaluated the relationship between subjective cognitive complaints, objective cognitive performance, and psychological outcomes among clinical patients referred for persisting cognitive concerns following SARS-CoV-2 infection. Method The sample consisted of 49 patients (69.4% female; 38.8% Black, 36.7% White, 18.4% Hispanic, 6.0% Other; Mage = 45.27, SD = 12.08; Meducation = 15.49; SD = 3.0) referred for neuropsychological evaluation to assess for long-term post-SARS-CoV-2 cognitive changes. All patients were administered a uniform neuropsychological test battery that included measures of working memory, processing speed, and verbal learning/memory, as well as measures of anxiety, depression, and perceived stress. Degree of subjective cognitive concerns was established using the Neurobehavioral Symptom Inventory (NSI) cognitive subscale. Linear regression models were conducted between the NSI cognitive subscale and each cognitive and psychological outcome. Results NSI cognitive scale predicted all psychological (depression [F = 31.37, p < 0.001(R2 = 0.41)]; anxiety [F = 6.71, p = 0.01(R2 = 0.13); perceived stress [F = 4.40, p = 0.04(R2 = 0.10)]) variables. The NSI cognitive scale also significantly predicted working memory [F = 4.624, p = 0.04(R2 = 0.09)]; however, no individual scores fell below the low average range upon further analysis. Cognitive complaints did not significantly predict any other cognitive (processing speed [F = 0.002, p = 0.97(R2 = 0.00)], total learning [F = 0.14, p = 0.71(R2 = 0.00)], and delayed recall [F = 1.03, p = 0.32(R2 = 0.02)]) variable. Conclusions Subjective cognitive complaints significantly predicted self-reported psychological symptoms including depression, anxiety, and perceived stress, while working memory was the only cognitive performance with a similarly meaningful relationship. These preliminary findings suggest that the psychological effects of persistent symptoms following SARS-CoV-2 infection, rather than objective cognitive changes, may better explain subjective cognitive concerns reported by this population.

B - 30 Influence of Military Blast Exposure on Subjective Post-Concussion Symptom Reporting

Abstract Objective Repeated subconcussive blast exposure associated with explosive breaching, mortars, and shoulder-fired artillery weapons is commonly seen in the military/veteran population and has been found to contribute to adverse neurological outcomes; however, the extent is not fully understood. The aim of this study was to assess the effects of blast exposure during military or other training exercises on neurobehavioral symptom endorsement. Method Cross-sectional data from 48 nonclinical post-deployment Operation Enduring Freedom/Operation Iraqi Freedom veterans prospectively-recruited for a study examining posttraumatic stress and cognitive correlates at an urban VA Medical Center were examined (M age = 36.02; SD = 6.12; M years of education = 14.94; SD = 1.84). The sample was 96% male, 41% White, 39% Black, 4% Asian, and 16% Other. The Neurobehavioral Symptom Inventory (NSI) was used to assess self-reported vestibular, somatosensory, cognitive, and affective post-concussion symptoms, and the Boston Assessment of Traumatic Brain Injury-Lifetime semi-structured clinical interview assessed military-related blast exposure. Results There was a significant difference in neurobehavioral symptoms based on blast exposure, F(4,43) = 3.49, p = 0.015; Wilk’s Λ = 0.755, partial η2 = 0.25. Follow-up analyses showed that veterans with history of blast exposure endorsed significantly higher levels of somatosensory (F(1,47) = 7.69, p = 0.008, η2 = 0.143); affective (F(1,47) = 12.66, p < 0.001, η2 = 0.216); cognitive (F(1,47) = 5.97, p = 0.018, η2 = 0.115); and vestibular (F(1,47) = 7.21, p = 0.010, η2 = 0.136) post-concussive symptoms on the NSI compared to those without history of military blast exposure. Conclusion Veterans with blast exposure during military service reported significantly greater levels of post-concussion symptoms. This demonstrates the need to assess history of blast exposure, implement prevention measures through safeguards and decreased exposure when possible, and establish treatment modalities to improve outcomes.

B - 44 Examining Test–Retest Reliability and Mean Score Differences in Self-Reported Neuropsychological Symptoms in Active-Duty and Veterans with Mild Traumatic Brain Injury (Mtbi)

Abstract Objective Test–retest reliability is a foundational psychometric property of tests, providing a means through which tests may be assessed for time invariant interpretation. This study evaluated the test–retest reliability of several self-report instruments commonly employed in a veteran/military neurocognitive rehabilitation setting. Method Repeat administration of the Neurobehavioral Symptom Inventory (NSI), Key Behaviors Change Inventory (KBCI), Veterans RAND 12 Item Health Survey (VR12), C4 Inventory, Center for Epidemiologic Studies-Depression, Post-traumatic Checklist-DSM-5 (PCL-5), and the Epworth Sleepiness Scale (ESS) was collected across baseline, one, four, and twelve week timepoints. Interclass correlation coefficients and a two-way mixed ANOVA was conducted on 31 Veteran and 22 Active-duty participants (71.5% male). Results Most measures demonstrated a significant mean difference during follow-up, with reductions across the 1- and 4-week follow-ups. ICC ranged from good to excellent (0.76–0.93) across the measures. Correlations between time points on measures were high (e.g., PCL-5 Baseline/4wk r = 0.93), suggesting high reliability for measures despite changing scores after treatment completion. Conclusions This study found good test–retest reliability across the three follow-up timelines, supporting the use of the included measures in neurocognitive rehabilitation settings. Reliability and post-treatment changes in symptoms observed across these measures will be further discussed.

Emerging Indications for Hyperbaric Oxygen Treatment: Registry Cohort Study.

Hyperbaric oxygen (HBO2) treatment is used across a range of medical specialties for a variety of applications, particularly where hypoxia and inflammation are important contributors. Because of its hypoxia-relieving and anti-inflammatory effects HBO2 may be useful for new indications not currently approved by the Undersea and Hyperbaric Medical Society. Identifying these new applications for HBO2 is difficult because individual centers may only treat a few cases and not track the outcomes consistently. The web-based International Multicenter Registry for Hyperbaric Oxygen Therapy captures prospective outcome data for patients treated with HBO2 therapy. These data can then be used to identify new potential applications for HBO2, which has relevance for a range of medical specialties. Although hyperbaric medicine has established indications, new ones continue to emerge. One objective of this registry study was to identify cases where HBO2 has been used for conditions falling outside of current Undersea and Hyperbaric Medical Society-approved indications and present outcome data for them. This descriptive study used data from a web-based, multicenter, international registry of patients treated with HBO2. Participating centers agree to collect data on all patients treated using standard outcome measures, and individual centers send deidentified data to the central registry. HBO2 treatment programs in the United States, the United Kingdom, and Australia participate. Demographic, outcome, complication, and treatment data, including pre- and posttreatment quality of life questionnaires (EQ-5D-5L) were collected for individuals referred for HBO2 treatment. Out of 9726 patient entries, 378 (3.89%) individuals were treated for 45 emerging indications. Post-COVID-19 condition (PCC; also known as postacute sequelae of COVID-19; 149/378, 39.4%), ulcerative colitis (47/378, 12.4%), and Crohn disease (40/378, 10.6%) accounted for 62.4% (n=236) of the total cases. Calciphylaxis (20/378, 5.3%), frostbite (18/378, 4.8%), and peripheral vascular disease-related wounds (12/378, 3.2%) accounted for a further 13.2% (n=50). Patients with PCC reported significant improvement on the Neurobehavioral Symptom Inventory (NSI score: pretreatment=30.6; posttreatment=14.4; P<.001). Patients with Crohn disease reported significantly improved quality of life (EQ-5D score: pretreatment=53.8; posttreatment=68.8), and 5 (13%) reported closing a fistula. Patients with ulcerative colitis and complete pre- and post-HBO2 data reported improved quality of life and lower scores on a bowel questionnaire examining frequency, blood, pain, and urgency. A subset of patients with calciphylaxis and arterial ulcers also reported improvement. HBO2 is being used for a wide range of possible applications across various medical specialties for its hypoxia-relieving and anti-inflammatory effects. Results show statistically significant improvements in patient-reported outcomes for inflammatory bowel disease and PCC. HBO2 is also being used for frostbite, pyoderma gangrenosum, pterygium, hypospadias repair, and facial filler procedures. Other indications show evidence for improvement, and the case series for all indications is growing in the registry. RR2-10.2196/18857.

A Baseline Model of PTSD From the ACES Cohort.

Post-traumatic stress disorder (PTSD) is a primary military psychiatric condition with complex etiology including strong genetic and/or environmental influences. Environmental influences and demographics can play a role in supporting underlying genetic traits for clinical utility evaluation as risk modifying factors. We are undertaking an IRB approved study to evaluate polygenic scores of PTSD risk in the adverse childhood experience and serotonin (ACES) transporter cohort. Baseline demographic characteristics and statistical modeling of 291 active duty service members from ACES cohort were used and excluded individuals with traumatic brain injury-induced loss of consciousness, pre-deployment PTSD or anxiety disorder, and pre-deployment prescription of antidepressants or psychoactive medications. Summary of categorical and numerical variables were evaluated using chi-square and t-test, respectively. We model PTSD risk and associated scores using linear and logistic regressions. The ACES subset was 79.1% males, multi-ancestry, and mean age of 38.3 years. Most PTSD individuals received behavioral therapy (89.6%) and/or prescribed antidepressants (67%) had higher scores in ACES, combat exposure scales, PTSD checklist military version, neurobehavioral symptom inventory, Pittsburg sleep quality index, insomnia severity index, and composite autonomic symptom score surveys and were less likely to expect future deployment. A positive correlation between age, total months deployed, ACES, CES, PCL-M, and positive-PTSD diagnosis were consistent but not in older individuals, who were more likely and frequently deployed although increasing risk for combat exposure. Demographic characteristics of the ACES cohort fit a coherent model of risk for PTSD to evaluate polygenic scores. Additional research is merited to understand PTSD effects on these confounding factors.

Age of First Exposure to Contact Sports Is Not Associated With Worse Later-In-Life Brain Health in a Cohort of Community-Dwelling Older Men.

To evaluate whether early age of first exposure to contact sports (AFE-CS) is associated with worse long-term brain health outcomes. A cross-sectional, survey study of older men with a history of contact sport participation was completed. Tertiary care facility. A cohort of community-dwelling older men dichotomized by using AFE-CS (<12 years vs ≥12 years). Independent variables included a dichotomized group of AFE-CS (<12 years vs ≥12 years). Brain health outcomes measured by depression, anxiety, cognitive difficulties, and neurobehavioral symptoms. Endorsements of general health problems, motor symptoms, and psychiatric history were also collected. Age of first exposure groups was compared using t tests, χ2 tests, and multivariable linear regressions, which included the following covariates: age, number of prior concussions, and total years of contact sport. Of 69 men aged 70.5 ± 8.0 years, approximately one-third of the sample (34.8%) reported AFE-CS before age 12 years. That group had more years of contact sports (10.8 ± 9.2 years) compared with those with AFE-CS ≥12 (5.6 ± 4.5 years; P = 0.02). No differences were found after univariate testing between AFE-CS groups on all outcomes (P-values >0.05). Multivariable models suggest that AFE-CS is not a predictor of depression or anxiety. Those in the AFE-CS <12 group had fewer cognitive difficulties (P = 0.03) and fewer neurobehavioral symptoms (P = 0.03). Those with AFE-CS <12 to contact sports did not have worse long-term brain health outcomes compared with those with AFE-CS ≥12. Individuals with AFE-CS <12 had significantly lower British Columbia Cognitive Complaints Inventory and Neurobehavioral Symptom Inventory scores compared with those with AFE-CS ≥12. The benefits of earlier AFE-CS may outweigh the risks of head strikes and result in comparable long-term brain health outcomes.

A - 53 Age of First Exposure to Football and Later-Life Health Issues in Community-Dwelling Adults

Abstract Purpose This study assessed whether age of first exposure (AFE) to football was associated with later-life psychiatric and neurobehavioral symptoms, cognitive difficulties, and general health problems in a cohort of former amateur football players. Method A cross-sectional survey study of men with a history of amateur football exposure was conducted using the ResearchMatch online platform. Independent variables included demographics, number of lifetime concussions, AFE to football (dichotomized as AFE &amp;lt; 12 years vs. AFE ≥ 12 years), and total years of football participation. Main outcomes included current depressive (Patient Health Questionnaire-9), anxiety (Generalized Anxiety Disorders-7), cognitive (British Columbia Cognitive Complaints Inventory), and neurobehavioral symptoms (Neurobehavioral Symptom Inventory). T-tests (AFE &amp;lt; 12 vs. AFE ≥ 12) and multivariable regressions assessed for associations between AFE and outcome variables, adjusting for age, number of prior concussions, and years of football exposure. Results A total of 107 male participants (mean age = 60.6 ± 15.1 years) reported an average of 4.2 ± 2.7 years of exposure to amateur football, with 41 participants reporting AFE &amp;lt; 12 (38.3%). In multivariable analyses, AFE &amp;lt; 12 was not a significant predictor of depressive (B = 0.51, SE = 1.25, p = 0.682), anxiety (B = 0.09, SE = 0.95, p = 0.926), cognitive (B = -0.65, SE = 0.77, p = 0.403), or neurobehavioral symptom scores (B = -0.56, SE = 2.93, p = 0.850). However, having more prior concussions were associated with worse depressive (B = 0.44, SE = 0.10, p &amp;lt; 0.001), anxiety (B = 0.33, SE = 0.07, p &amp;lt; 0.001), cognitive (B = 0.26, SE = 0.06, p &amp;lt; 0.001), and neurobehavioral symptoms (B = 1.04, SE = 0.23, p &amp;lt; 0.001). Conclusions AFE to football was not associated with adverse psychiatric, cognitive, or neurobehavioral difficulties. However, these outcomes were associated with a greater number of lifetime concussions.

Sex differences in postconcussive symptom reporting in those with history of concussion: Findings from the federal interagency traumatic brain injury research (FITBIR) database

Objective: This study investigated influence of biological sex on postconcussive symptoms (PCS) following concussion using the Federal Interagency Traumatic Brain Injury Research (FITBIR) database. Method: All studies with publicly released data as of 4/7/21 that included both males and females, enough information to determine severity of injury consistent with concussion, a measure of PCS, and objective measures of neurocognitive functioning were used. This resulted in 6 studies with a total of 9890 participants (3206 females, 6684 males); 815 participants completed the Neurobehavioral Symptom Inventory (NSI), 471 completed the Rivermead Post-Concussion Symptoms Questionnaire (RPSQ), and 8604 completed the Sport Concussion Assessment Tool–3rd Edition (SCAT 3). Questionnaires were harmonized and the following symptom composite scores were computed: total score, somatic, cognitive, and affective. Data were analyzed using linear mixed-effects models. Results: Females endorsed higher total symptoms relative to males and that military personnel endorsed higher symptoms relative to civilians. Additionally, there was a small but significant interaction effect, such that female military personnel endorsed even higher symptoms than would be predicted by the main effects. Similar patterns were observed for somatic, cognitive, and affective symptom domains. Conclusions: Further understanding sex differences in PCS reporting is key to informing the most appropriate treatment options. Future work will need to examine whether sex differences in symptom reporting is due to sex differences in endorsement styles or genuine differences in symptom presentation, as well as the relationship between study population (e.g., military, civilian, sport) and sex on objective cognitive functioning and other functional outcomes.

The Patient Global Impression of Change as a complementary tool to account for neurobehavioral and mental health symptom improvement for patients with concussion

Purpose The purpose of this study was to determine the extent to which patient’s perspective of symptom improvement, as indexed by the Patient Global Impression of Change (PGIC) survey, is associated with symptom improvement on common measures of neurobehavioral and mental health symptoms following concussion. Materials and methods Data were from 449 US active duty service members receiving treatment in interdisciplinary programs for their concussion. PGIC rating (range = 1–7) was evaluated for compatibility in assessing improvement in or clinically-elevated neurobehavioral (using Neurobehavioral Symptom Inventory [NSI]) and mental health (using Post-traumatic Stress Disorder Checklist, DSM-5 [PCL-5] and Patient Health Questionnaire [PHQ-8]) symptoms. Results Higher PGIC scores were related to a higher prevalence of clinically-relevant decrease in NSI, PCL-5 or PHQ-8 scores. Participants with a PGIC rating of 3+ (vs.<3) were about 2.2 (CI = 1.4–3.5), 1.6 (CI = 1.1–1.3), and 2.7 (CI = 1.4–5.1) times more likely to report clinically-relevant decrease in NSI, PCL-5 and PHQ-8 symptoms, respectively. Conclusion PGIC may help providers incorporate patients’ perspectives on symptom improvement achieved during rehabilitation. An approach combining PGIC with surveys such as NSI, PCL-5 and PHQ-8 may provide a more comprehensive understanding of symptom improvement and realistic view of expectations for what would be deemed recovery to pre-injury symptom levels.

Validation of a modified-composite autonomic symptom score (COMPASS-31) as an outcome measure for persistent autonomic symptoms post-concussion: an observational pilot study

ABSTRACT Objective Persistent symptoms post-mild traumatic brain injury (mTBI) includes autonomic dysregulation (AD). The composite autonomic symptoms score, (COMPASS-31), was developed to quantify AD symptom severity in the last year, which limits clinical utility. The primary aim was to determine validity of a modified-COMPASS-31 measuring symptoms in the last month compared to the original, secondarily to compare both original and modified versions to the Neurobehavioral Symptom Inventory (NSI), and tertiarily to detect change post-treatment of the modified-COMPASS-31 compared to NSI and headache intensity (HI). Participants Thirty-three military personnel with persistent headache post-mTBI. Main outcome measures Total and domain scores for COMPASS-31 (original vs. modified) NSI and HI at baseline. Change in modified-COMPASS-31. NSI, and HI. Results Baseline COMPASS-31 versions were comparable and highly correlated (r = 0.72, p < 0.001), they were moderately correlated at best to the NSI (r < 0.6), which may suggest differences in measurement metrics. The mean change in modified-COMPASS-31 scores (15.4/100, effect size 0.8) was mild to moderately correlated to the change in HI (r = 0.39) score, but not to NSI (r = 0.28). Conclusion The modified-COMPASS-31 appears to be valid, can measure change of AD symptom severity, and is recommended as an outcome measure.

Gender Disparities in Neurobehavioral Symptoms and the Role of Post-Traumatic Symptoms in US Service Members Following Mild Traumatic Brain Injury.

Women are more directly involved in combat operations today than ever before, currently making up 18.6% of officers and 16.8% of enlisted personnel in the United States military. However, women continue to be under-represented in military research. Studies that do consider gender differences in traumatic brain injury (TBI) outcomes have shown that women report significantly more post-concussive symptoms than men. Conclusions for true gender differences related to TBI are hard to make without controlling for non-TBI factors. The effects previously identified in the literature may be an artifact of how men and women differ in their response to injury, unrelated to the neurological recovery process associated with TBI. The objective of this study was to examine the effects of gender specifics on mild TBI (mTBI) sequelae on injured and uninjured control groups, and to investigate the role of post-traumatic stress disorder (PTSD) on symptom reporting. It should be noted that the terms "gender" and "men/women" are used in this article in place of "sex" or "males/females" given that we are not discussing biological attributes. A total of 966 United States military service members and veterans were included in the study. Of the total sample, 455 men and 46 women were in the mTBI group, 285 men and 31 women were in the injured controls group (IC), and 111 men and 38 women in the non-injured controls group (NIC). Post-concussive and quality of life symptoms were compared for men and women while controlling for combat exposure. MTBI and IC groups were also stratified by PTSD presentation. Measures used included the Neurobehavioral Symptom Inventory (NSI), PTSD Checklist (PCL-C), Traumatic Brain Injury Quality of Life (TBI-QOL), and Combat Exposure Scale. In the mTBI group, women had worse scores on NSI total, NSI Somatosensory and Affective clusters, and the TBI-QOL Anxiety, Fatigue, and Headache scales (n2 = 0.018-0.032, small to small-medium effect sizes). When PTSD was present, women had worse scores on the NSI Somatosensory cluster only (n2 = 0.029, small-medium effect size). In contrast, when PTSD was absent, women had worse scores than men on the NSI Somatosensory and Affective clusters, and the TBI-QOL Anxiety and Headache scales (n2 = 0.032-0.063, small to medium effect sizes). In the IC group, women had worse scores on the NSI Cognitive cluster and the TBI-QOL Fatigue and Pain Interference scales (n2 = 0.024-0.042, small to small-medium effect sizes). However, group differences were no longer found when stratified by PTSD sub-groups. In the NIC group, there were no significant group differences for any analyses. We were able to identify symptoms unique to women recovering from mTBI that were not present following other forms of physical injury or in healthy controls. However, the impact of PTSD exacerbates the symptom profile and its comorbidity with mTBI equates to most of the noted gender differences.

Clinical relevance of subthreshold PTSD versus full criteria PTSD following traumatic brain injury in U.S. service members and veterans

BackgroundThe purpose of this cross-sectional study was to examine the influence of subthreshold posttraumatic stress disorder (PTSD) and full PTSD on quality of life following mild traumatic brain injury (mTBI). MethodsParticipants were 734 service members and veterans (SMV) classified into two injury groups: uncomplicated mild TBI (MTBI; n = 596) and injured controls (IC, n = 139). Participants completed a battery of neurobehavioral measures, 12-or-more months post-injury, that included the PTSD Checklist Civilian version, Neurobehavioral Symptom Inventory, and select scales from the TBI-QOL and MPAI. The MTBI group was divided into three PTSD subgroups: No-PTSD (n = 266), Subthreshold PTSD (n = 139), and Full-PTSD (n = 190). ResultsThere was a linear relationship between PTSD severity and neurobehavioral functioning/quality of life in the MTBI sample. As PTSD severity increased, significantly worse scores were found on 11 of the 12 measures (i.e., MTBI: Full-PTSD > Sub-PTSD > No-PTSD). When considering the number of clinically elevated scores, a linear relationship between PTSD severity and neurobehavioral functioning/quality of life was again observed in the MTBI sample (e.g., 3-or-more elevated scores: Full-PTSD = 92.1 %, Sub-PTSD = 61.9 %, No-PTSD = 19.9 %). LimitationsLimitations included the use of a self-report measure to determine diagnostic status that may under/overcount or mischaracterize individuals. ConclusionPTSD symptoms, whether at the level of diagnosable PTSD, or falling short of that because of the intensity or characterization of symptoms, have a significant negative impact on one's quality of life following MTBI. Clinicians' treatment targets should focus on the symptoms that are most troubling for an individual and the individual's perception of quality of life, regardless of the diagnosis itself.

Cumulative Blast Impulse Is Predictive for Changes in Chronic Neurobehavioral Symptoms Following Low Level Blast Exposure during Military Training.

Cumulative low-level blast exposure during military training may be a significant occupational hazard, increasing the risk of poor long-term outcomes in brain function. US Public Law 116-92 section717 mandates that US Department of Defense agencies document the blast exposure of each Service member to help inform later disability and health care decisions. However, which empirical measures of training blast exposure, such as the number of incidents, peak overpressure, or impulse, best inform changes in the neurobehavioral symptoms reflecting brain health have not been established. This study was approved by the US Army Special Operations Command, the University of North Carolina at Chapel Hill, and the VA Puget Sound Health Care System. Using methods easily deployable across different organizational structures, this study sought to identify and measure candidate risk factors related to career occupational blast exposure predictive of changes in neurobehavioral symptom burden. Blast dosimetry-symptom relationships were first evaluated in mice and then tested in a military training environment. In mice, the righting time neurobehavioral response was measured after exposure to a repetitive low-level blast paradigm modeled after Special Operations training. In the military training environment, 23 trainees enrolled in a 6-week explosive breaching training course, 13 instructors, and 10 Service member controls without blast exposure participated in the study (46 total). All participants provided weekly Neurobehavioral Symptom Inventory (NSI) surveys. Peak blast overpressure, impulse, total number of blasts, Time in Low-Level Blast Occupation, and Time in Service were analyzed by Bayesian analysis of regression modeling to determine their probability of influence on the post-training symptoms reported by participants. We tested the hypothesis that cumulative measures of low-level blast exposure were predictive of changes in neurobehavioral symptoms. In mice, repetitive blast resulted in reduced righting times correlated with cumulative blast impulse. In Service members, peak blast overpressure, impulse, total number of blasts, Time in Low-Level Blast Occupation, and Time in Service all showed strong evidence of influence on NSI scores after blast exposure. However, only models including baseline NSI scores and cumulative blast impulse provided significant predictive value following validation. These results indicate that measures of cumulative blast impulse may have utility in predicting changes in NSI scores. Such paired dosimetry-symptom measures are expected to be an important tool in safely guiding Service members' occupational exposure and optimizing force readiness and lethality.

The Neurobehavioral Symptom Inventory: Psychometric Properties and Symptom Comparisons in Women With and Without Brain Injuries Due to Intimate Partner Violence.

This study psychometrically evaluated the Neurobehavioral Symptom Inventory (NSI) among women survivors of intimate partner violence (IPV) and compared symptoms between women with no brain injury history (n = 93) and women with IPV-related brain injury history (n = 112). Women completed the NSI and questionnaires on traumatic brain injury (TBI), hypoxic-ischemic brain injury (HI-BI), and lifetime IPV history. A four-factor NSI model, including affective, somatosensory, cognitive, and vestibular factors, had the best fit (comparative fit index = 0.970, root mean square error of approximation = 0.064), with strong reliability for the total score (ω = .93) and subscale scores (ω range = .72-.89). In group comparisons, women with IPV-related brain injuries reported greater total, affective, and cognitive symptom severity after adjusting for age and education; however, no group differences were observed after adjusting for IPV severity. When examining lifetime number of brain injuries, HI-BI count was independently predictive of total, cognitive, and vestibular symptom severity after adjusting for age, education, and IPV severity; whereas TBI count did not independently predict any NSI scores after adjusting for these covariates. The NSI had acceptable psychometric properties for measuring neurobehavioral symptoms among women survivors of IPV. The association between HI-BI count and cognitive and vestibular symptoms may indicate the importance of studying repetitive nonfatal strangulation as an injury mechanism in this population.

Neurobehavioral Symptoms in Spanish-Speaking Individuals With Subconcussive Injuries.

To examine whether exposure to high-risk events causing injury to the head or neck has an effect on neurobehavioral symptoms in the absence of an alteration of consciousness in Spanish-speakers. Web-based survey. Seven hundred forty-eight individuals from Spain and Latin America, aged 18 to 65 years, with 10 years or more of education. Thirty-nine participants failed quality checks and were excluded. Seven hundred nine participants were included in the analyses. Cross-sectional study. Subconcussive exposure was defined as endorsing exposure to one or more high-risk scenarios in the absence of any alteration of consciousness. Three injury groups were derived: No Head Injury, Subconcussive Exposure, and traumatic brain injury (TBI). The Subconcussive Exposure group was further divided into Single and Multiple Exposures. Two analyses were conducted: the effect of lifetime exposure to injury (No Head Injury, Subconcussive Exposure, TBI) on neurobehavioral symptoms; the effect of Subconcussive Exposure Frequency (No Head Injury, Single Exposure, Multiple Exposures) on neurobehavioral symptoms. Spanish Ohio State University Traumatic Brain Injury Identification Method Self-Administered-Brief (OSU TBI-ID SAB); Neurobehavioral Symptom Inventory (NSI). There was a significant effect for Injury group on the NSI partial eta-squared (η p2 = 0.053) and a significant effect of Exposure Frequency group on the NSI (η p2 = 0.40). Individuals with subconcussive exposures reported significantly more neurobehavioral symptoms than those with no history of head injury and significantly less symptoms than those with TBI. Individuals with multiple subconcussive exposures reported significantly more neurobehavioral symptoms than those with single and no exposure. This research expands the utility of the OSU-TBI-ID SAB as a lifetime TBI history assessment tool to one capable of evaluating subconcussive exposure dosing effects in Spanish-speakers. Such an index may facilitate establishment of subconcussive exposure prevalence rates worldwide, leading to improved understanding of the chronic effects of high-risk exposures.

Addressing Participation in Adults With Postconcussive Symptoms Using Cognitive Strategy Training: A Feasibility Trial.

Some people experience persistent symptoms after a concussion that greatly affect occupational performance. To evaluate the feasibility and preliminary effect of metacognitive strategy training in a sample of adults with postconcussive symptoms. Single-group, prospective design. University research laboratory. Adults with persistent concussive symptoms affecting function (N = 14). Ten 45-min sessions of a metacognitive strategy training intervention, Cognitive Orientation to daily Occupational Performance (CO-OP). Assessed feasibility outcomes included recruitment, retention, and adherence rates, and intervention acceptability was evaluated with the Client Satisfaction Questionnaire-8. The preliminary effect was measured on occupational performance (Canadian Occupational Performance Measure), concussive symptoms (Neurobehavioral Symptom Inventory), sleep (Pittsburgh Sleep Quality Inventory), vision (College of Optometrists in Vision Development-Quality of Life Outcomes Assessment), and cognition outcomes (Dysexecutive Questionnaire, Weekly Calendar Planning Activity, and National Institutes of Health Toolbox Cognition Battery). Acceptable recruitment (32%), retention (93%), and adherence rates (100%) were observed, along with a high level of acceptability to participants. Large intervention effects were present for occupational performance, general concussive symptoms, and cognitive functioning. Findings suggest that the CO-OP is feasible to administer for adults with postconcussive symptoms and perceived as suitable for the needs of this population. Feasibility findings, coupled with improvements in occupational performance outcomes, provide the foundation for a future larger scale trial. Plain-Language Summary: The Cognitive Orientation to daily Occupational Performance intervention is practical to use to address the functional impact of persistent concussive symptoms in adults. Further research is needed to evaluate the efficacy of the CO-OP intervention with this population.

Cumulative Blast Exposure During a Military Career Negatively Impacts Recovery from Traumatic Brain Injury.

Sub-concussive injuries have emerged as an important factor in the long-term brain health of athletes and military personnel. The objective of this study was to explore the relationship between service member and veterans (SMVs) lifetime blast exposure and recovery from a traumatic brain injury (TBI). A total of 558 SMVs with a history of TBI were examined. Lifetime blast exposure (LBE) was based on self-report (M = 79.4, standard deviation = 392.6; range = 0-7500) categorized into three groups: Blast Naive (n = 121), Low LBE (n = 223; LBE range 1-9), and High LBE (n = 214; LBE >10). Dependent variables were the Neurobehavioral Symptom Inventory (NSI) and Post-traumatic Stress Disorder Checklist-Civilian (PCL-C) and the Traumatic Brain Injury Quality of Life (TBI-QOL). Analyses controlled for demographic factors (age, gender, and race) as well as TBI factors (months since index TBI, index TBI severity, and total number lifetime TBIs). The Blast Naive group had significantly lower NSI and PCL-C scores compared with the Low LBE group and High LBE group, with small to medium effect sizes. On the TBI-QOL, the Blast Naïve group had better quality life on 10 of the 14 scales examined. The Low LBE did not differ from the High LBE group on the PCL-C, NSI, or TBI-QOL. Blast exposure over an SMV's career was associated with increased neurobehavioral and post-traumatic stress symptoms following a TBI. The influence of psychological trauma associated with blasts may be an important factor influencing symptoms as well as the accuracy of self-reported estimates of LBE.