Neurobehavioral Symptom Inventory Research Articles

What Is the Prevalence of Intimate Partner Violence and Traumatic Brain Injury in Fracture Clinic Patients?

Individuals in violent intimate relationships are at a high risk of sustaining both orthopaedic fractures and traumatic brain injury (TBI), and the fracture clinic may be the first place that concurrent intimate partner violence (IPV) and TBI are recognized. Both IPV and TBI can affect all aspects of fracture management, but prevalence of TBI and comorbid TBI and IPV is unknown. (1) What are the previous-year and lifetime prevalence of IPV and TBI in women presenting to an outpatient orthopaedic fracture clinic? (2) What are the conditional probabilities of TBI in the presence of IPV and the reverse, to explore whether screening for one condition could effectively identify patients with the other? (3) Do patients with TBI, IPV, or both have worse neurobehavioral symptoms than patients without TBI and IPV? The study was completed in the fracture clinic at a community Level 1 trauma center in Southern Ontario from July 2018 to March 2019 and included patients seen by three orthopaedic surgeons. Inclusion criteria were self-identification as a woman, age 18 years or older, and the ability to complete forms in English without assistance from the person who brought them to the clinic (for participant safety and privacy). We invited 263 women to participate: 22 were ineligible (for example, they were patients of a surgeon who was not on the study protocol), 87 declined before hearing the topic of the study, and data from eight were excluded because the data were incomplete or lost. Complete data were obtained from 146 participants. Participants' mean age was 52 ± 16 years, and the most common diagnosis was upper or lower limb fracture. Prevalence of IPV was calculated as the number of women who answered "sometimes" or "often" to direct questions from the Woman Abuse Screening Tool, which asks about physical, emotional, and sexual abuse in the past year or person's lifetime. The prevalence of TBI was calculated as the number of women who reported at least one head or neck injury that resulted in feeling dazed or confused or in loss of consciousness lasting 30 minutes or less on the Ohio State University Traumatic Brain Injury Identification Method, a standardized procedure for eliciting lifetime history of TBI through a 3- to 5-minute structured interview. Conditional probabilities were calculated using a Bayesian analysis. Neurobehavioral symptoms were characterized using the Neurobehavioral Symptom Inventory, a standard self-report measure of everyday emotional, somatic, and cognitive complaints after TBI, with total scores compared across groups using a one-way ANOVA. Previous-year prevalence of physical IPV was 7% (10 of 146), and lifetime prevalence was 28% (41 of 146). Previous-year prevalence of TBI was 8% (12 of 146), and lifetime prevalence was 49% (72 of 146). The probability of TBI in the presence of IPV was 0.77, and probability of IPV in the presence of TBI was 0.36. Thus, screening for IPV identified proportionately more patients with TBI than screening for TBI, but the reverse was not true. Neurobehavioral Symptom Inventory scores were higher (more symptoms) in patients with TBI only (23 ± 16) than those with fractures only (12 ± 11, mean difference 11 [95% CI 8 to 18]; p < 0.001), in those with IPV only (17 ± 11) versus fractures only (mean difference 5 [95% CI -1 to -11]; p < 0.05), and in those with both TBI and IPV (25 ± 14) than with fractures only (mean difference 13 [95% CI 8 to 18]; p < 0.001) or those with IPV alone (17 ± 11, mean difference 8 [95% CI -1 to 16]; p < 0.05). Using a brief screening interview, we identified a high self-reported prevalence of TBI and IPV alone, consistent with previous studies, and a novel finding of high comorbidity of IPV and TBI. Given that the fracture clinic may be the first healthcare contact for women with IPV and TBI, especially mild TBI associated with IPV, we recommend educating frontline staff on how to identify IPV and TBI as well as implementing brief screening and referral and universal design modifications that support effective, efficient, and accurate communication patients with TBI-related cognitive and communication challenges. Level II, prognostic study.

Psychiatric symptoms influence social support in VA Million Veteran Program enrollees screening positive for traumatic brain injury

ObjectiveTo examine measures of social support and associations with neurobehavioral, psychiatric, and cognitive symptoms in Veterans who underwent the Veterans Health Administration's Traumatic Brain Injury (TBI) Screening and Evaluation Program. SettingNationally representative sample of U.S. Veterans enrolled in the Veterans Affairs Million Veteran Program. ParticipantsVeterans (N = 9,837) were classified into the following three diagnostic groups based on results from the TBI Screening and Evaluation Program: (1) negative TBI screen (Screen–; n = 6,523), (2) positive TBI screen but no TBI diagnosis (Screen+/TBI-; n = 1,308), or (3) positive TBI screen and TBI diagnosis (Screen+/TBI+; n = 2,006). DesignEpidemiological cross-sectional study. Main measuresMedical Outcomes Study Social Support Survey Instrument (MOS-SSSI), with subscales representing emotional, tangible, and affectionate support and positive social interaction; Neurobehavioral Symptom Inventory (NSI); PTSD Checklist (PCL); Patient Health Questionnaire-4 (PHQ-4); and Medical Outcomes Study Cognitive Functioning-Revised Scale (MOS-Cog-R). ResultsANCOVAs showed significant associations between diagnostic group and all aspects of social support. Pairwise comparisons revealed that Veterans in the two Screen+ groups (Screen+/TBI+ and Screen+/TBI-) reported comparable levels of social support, but that both Screen+ groups reported significantly lower levels of social support compared to the Screen– group. Among the Screen+ groups, adjusted linear regression models controlling for age, sex, and race/ethnicity showed significant associations between social support indices and all symptom measures, such that lower levels of social support were associated with more severe neurobehavioral and psychiatric symptoms and worse cognitive functioning. Finally, mediation analyses showed that psychiatric symptoms mediated the association between TBI screen group and social support. ConclusionsOur results are clinically informative and suggest (1) that the relationship between TBI screen status and social support is influenced by psychiatric symptoms and (2) that implementing distress reduction techniques before social support interventions may be most beneficial for Veterans screening positive for TBI.

Oculomotor, vestibular, reaction time, and cognitive tests as objective measures of neural deficits in patients post COVID-19 infection.

ObjectiveAn alarming proportion (>30%) of patients affected by SARS-CoV-2 (COVID-19) continue to experience neurological symptoms, including headache, dizziness, smell and/or taste abnormalities, and impaired consciousness (brain fog), after recovery from the acute infection. These symptoms are self-reported and vary from patient to patient, making it difficult to accurately diagnose and initiate a proper treatment course. Objective measures to identify and quantify neural deficits underlying the symptom profiles are lacking. This study tested the hypothesis that oculomotor, vestibular, reaction time, and cognitive (OVRT-C) testing using eye-tracking can objectively identify and measure functional neural deficits post COVID-19 infection.MethodsSubjects diagnosed with COVID-19 (n = 77) were tested post-infection with a battery of 20 OVRT-C tests delivered on a portable eye-tracking device (Neurolign Dx100). Data from 14 tests were compared to previously collected normative data from subjects with similar demographics. Post-COVID subjects were also administered the Neurobehavioral Symptom Inventory (NSI) for symptom evaluation.ResultsA significant percentage of post COVID-19 patients (up to 86%) scored outside the norms in 12 out of 14 tests, with smooth pursuit and optokinetic responses being most severely affected. A multivariate model constructed using stepwise logistic regression identified 6 metrics as significant indicators of post-COVID patients. The area under the receiver operating characteristic curve (AUC) was 0.89, the estimated specificity was 98% (with cutoff value of 0.5) and the sensitivity was 88%. There were moderate but significant correlations between NSI domain key variables and OVRT-C tests.ConclusionsThis study demonstrates the feasibility of OVRT-C testing to provide objective measures of neural deficits in people recovering from COVID-19 infection. Such testing may serve as an efficient tool for identifying hidden neurological deficits post COVID-19, screening patients at risk of developing long COVID, and may help guide rehabilitation and treatment strategies.

A-31 Examining Interactions between Concussion Population and Biological Sex on Post-Concussive Symptom Reporting in FITBIR

Abstract Purpose: The purpose of this study was to examine interactions between population (sport/civilian vs. military) and biological sex (females vs. males) on post-concussive symptom reporting using Federal Interagency Traumatic Brain Injury Research (FITBIR) data. Methods: Data were obtained from the national FITBIR informatics system. Studies released as of 04/07/21 that included both males and females with a history of concussion were included. In total, 6 studies with 9957 participants (8918 sport/civilian, 1039 military; 3209 females, 6748 males) were evaluated. Symptom measures included the Sport Concussion Assessment Tool-3rd Edition, Neurobehavioral Symptom Inventory, and Rivermead Post Concussion Symptoms Questionnaire. These measures were harmonized to generate an overall composite score and three symptom domains (somatic, affective, and cognitive). Data were analyzed using linear mixed-effects models. Symptom scores were regressed onto population, sex, and the population-by-sex interaction. Results: We found significant main effects of population (military&amp;gt;sport/civilian; beta(β) = 0.30, p = 0.003) and sex (females&amp;gt;males; β = 0.06, p &amp;lt; 0.001) on the overall composite, as well as a significant population-by-sex interaction such that female service members/veterans endorsed the highest rates of symptoms (β = 0.27, p &amp;lt; 0.001). Similar patterns of significance and effect sizes were observed for the somatic and affective composites. Cognitive symptom composites showed a similar pattern, but with smaller effect sizes overall. Conclusions: Findings increase our understanding of population and sex-specific experiences following concussion, suggesting a need for individually-tailored treatments and interventions for these groups. Future studies are planned using FITBIR data to further explore the population-by-sex interaction on post-injury outcomes.

NSI and PCL-5 Normative Tables for Active Duty Service Members Affected by Traumatic Brain Injury.

Many service members (SMs) have been diagnosed with traumatic brain injury. Currently, military treatment facilities do not have access to established normative tables which can assist clinicians in gauging and comparing patient-reported symptoms. The aim of this study is to provide average scores for both the Neurobehavioral Symptom Inventory (NSI) and Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5) for active duty SMs based upon varying demographic groups. Average scores were calculated for both the NSI and PCL-5 surveys from SMs who attended a military outpatient traumatic brain injury clinic. For this analysis, only the initial surveys for each SM were considered. The identifying demographics included age group, gender, grade, and race. Four normative tables were created to show the average scores of both the NSI and PCL-5 surveys grouped by demographics. The tables are grouped by Age Group/Gender/Race and Grade/Gender/Race. Clinicians and healthcare administrators can use the scores reported in this study to determine where SM NSI or PCL-5 scores fall within the average for their demographic group.

Efficacy of two-step resilience-oriented intervention for veterans with a remote traumatic brain injury

Researchers argue that rehabilitation interventions which cultivate resilience maypotentiate the effect of standard treatment and promote the readaptation of veterans withtraumatic brain injury. At the same there is a lack of such interventions. The objective of thearticle was to investigate the efficacy of two-step resilience-oriented intervention for veteranswith traumatic brain injury in remote period. We hypothesized that, compared with patientswho received standardized treatment and rehabilitation in inpatient setting, those whoreceived standardized treatment plus TROI would report increase in resilience effectivenessand positive outcomes, as well as reduced clinical symptoms. A total of 146 veterans withtraumatic brain injury were enrolled into a randomized controlled trial either intointervention group, which received two-step resilience-oriented intervention and standardtreatment and rehabilitation or to control group, which received only standard treatment andrehabilitation. Psychometric measures were administered at baseline, post-treatment, and 3months follow-up. Connor-Davidson Resilience Scale (CD-RISC), Neurobehavioral SymptomInventory (NSI), Montreal Cognitive Assessment Scale (MoCA), Hospital Anxiety andDepression Scale (HADS), Positive and Negative Affect Scale (PANAS), Posttraumatic StressDisorder Checklist 5 (PCL-5), Chaban Quality of Life Scale (CQLS) were used to assess thetreatment effectiveness. A linear mixed effect modelling was used to model each outcome.Improvements in all outcomes at post-treatment were observed in both intervention and TAUgroups. After adjusting for the baseline cognitive performance, gender, brain injury clinicaltype and time since last trauma, the intervention group demonstrated more favorable score onCD-RISC, MoCA, PCL-5, PANAS while demonstrating no clinically significant improvementin NSI, HADS and CQLS at both post-treatment and follow-up. Difference between groups inresilience-related outcomes like positive affect and quality of life only increased throughouttime, making a good follow-up prognosis. In summary, targeting cognitive and emotionalfactors in a single psychological intervention improves the resilience in veterans withtraumatic brain injury, making veterans more adaptable and more effective in managing both&#x0D; persistent clinical symptoms and comorbid post-traumatic stress. Adding such resilience-oriented program to the standard inpatient treatment and rehabilitation providesimprovement in clinical outcomes and better prognoses than just following usual treatmentstrategies.

Do sensorimotor control properties mediate sway in people with chronic balance complaints following mTBI?

BackgroundUp to 40% of mild traumatic brain injuries (mTBI) can result in chronic unresolved symptoms, such as balance impairment, that persist beyond three months. Sensorimotor control, the collective coordination and regulation of both sensory and motor components of the postural control system, may underlie balance deficits in chronic mTBI. The aim of this study was to determine if the relationship between severity of impairment in chronic (> 3 months) mTBI and poorer balance performance was mediated by sensorimotor integration measures. MethodsData were collected from 61 healthy controls and 58 mTBI participants suffering persistent balance problems. Participants completed questionnaires (Dizziness Handicap Inventory (DHI), Neurobehavioral Symptom Inventory (NSI), and Sports Concussion Assessment Tool Symptom Questionnaire (SCAT2)) and performed instrumented postural sway assessments and a test of Central Sensory Motor Integration (CSMI). Exploratory Factor Analysis was used to reduce the variables used within the mediation models to constructs of impairment (Impairment Severity – based on questionnaires), balance (Sway Dispersion – based on instrumented postural sway measures), and sensorimotor control (Sensory Weighting, Motor Activation and Time Delay – based on parameters from CSMI tests). Mediation analyses used path analysis to estimate the direct effect (between impairment and balance) and indirect (mediating) effects (from sensorimotor control). ResultsTwo out of three sensorimotor integration factors (Motor Activation and Time Delay) mediated the relationship between Impairment Severity and Sway Dispersion, however, there was no mediating effect of Sensory Weighting. SignificanceThese findings have clinical implications since rehabilitation of balance commonly focuses on sensory cues. Our findings indicate the importance of Motor Activation and Time Delay, and thus a focus on strategies to improve factors related to these constructs throughout the rehabilitative process (i.e., level of muscular contractions to control joint torques; response time to stimuli/perturbations) may improve a patient’s balance control.

Photosensitivity Is Associated with Chronic Pain following Traumatic Brain Injury.

Individuals with a history of traumatic brain injury (TBI) report increased rates of chronic pain. Photosensitivity is also a common chronic symptom following TBI and is prevalent among other types of chronic pain. The aim of this study was to better understand the relationship between chronic pain, pain-related disability, and photosensitivity in a TBI population. We quantified participants' visual photosensitivity thresholds (VPT) using an Ocular Photosensitivity Analyzer and measured pressure-pain sensitivity using pressure algometry. Participants also completed a battery of self-report measures related to chronic pain, TBI history, and mental health. A total of 395 participants completed testing, with 233 reporting a history of TBI. The TBI group was divided into 120 symptomatic TBI participants (s-TBI), and 113 asymptomatic TBI participants (a-TBI) based on their Neurobehavioral Symptom Inventory (NSI) scores. Participants in the s-TBI group scored significantly higher on self-reported chronic pain measures compared with a-TBI and no-TBI participants, including the Symptom Impact Questionnaire Revised (SIQR; p < 0.001) and the Michigan Body Map (MBM; p < 0.001). Despite differences in chronic pain complaints, groups displayed similar pressure-pain thresholds (p = 0.270). Additionally, s-TBI participants were more sensitive to light (lower VPT, p < 0.001), and VPT was correlated with SIQR scores across all participants (R = -0.452, p < 0.001). These data demonstrate that photosensitivity is associated with self-reported chronic pain and disability in individuals with chronic TBI symptomatology. Photosensitivity could therefore serve as a simple, more highly quantitative marker of high-impact chronic pain after TBI.

The Relation of Subjective and Objective Assessment of Sleep quality with Post Concussive Symptoms in Veterans

Sleep complaints are a significant and persistent health problem reported by military Veterans. Veterans with traumatic brain injury (TBI) experience a higher incidence of sleep disturbances, with mild TBI (mTBI) resulting in chronic sleep disruption post injury. However, the relation between sleep and mTBI history is still poorly understood.PurposeThe purpose of this study is to assess sleep using subjective (Pittsburgh Quality Sleep index; PSQI) and objective (actigraphy) measurements in Veterans with a history of mTBI using remote assessments.MethodsSeven Veterans (7 Males; age: 54±7yrs, body mass index (BMI): 31±7 kg/m2 mean±SD) completed a telemedicine VA clinical evaluation and enrolled in the study. Participants completed web‐based versions of the PSQI to assess subjective sleep quality (range 0‐21) and the Neurobehavioral Symptom Inventory (NSI) to assess post concussive syndrome (PCS) symptoms (range 0‐88). Participants wore a wrist‐worn actigraph (wGT3X‐BT) over a 7‐day baseline period to measure total sleep time and sleep variability (standard deviation) from home. Data were analyzed using Pearson’s correlations.ResultsNSI scores are significantly correlated with global PSQI (R2=0.81, P=0.02) where higher NSI scores are associated with a greater PSQI total score. There is no relation between NSI score and sleep time (R2=0.22, P=0.34). There are trending relations between sleep time variability (R2=0.50, P=0.07) and sleep disturbances (R2=0.5, P=0.10; ex. Feeling too hot or too cold, having bad dreams) and NSI, such that those with higher NSI scores have greater sleep variability and sleep disturbances.ConclusionHome‐based assessments offer a promising means of monitoring sleep in Veterans. Our preliminary data suggests that subjective measurement of sleep relate to PCS symptoms, however trending results suggest that specific features of sleep quality may be affected by mTBI history. Remote evaluations are critical to understand sleep quality of Veterans to aid improvements in PCS symptoms following mTBI.

Presence of Psychiatric Assistance Dogs and Relation to Post-Traumatic Stress Disorder Treatment Outcomes: A Nonrandomized, Observational Study in a Military Sample

The purpose of this study was to examine differences between military veterans and service members with and without a psychiatric assistance dog (PAD) who were receiving cognitive behavioral therapy (CBT) for post-traumatic stress disorder (PTSD). Six hundred eighty-two military veterans presented at a 2-week intensive, outpatient CBT program for PTSD from February 2016 to February 2020. Self-reports of symptoms and rates of treatment completion by PAD ownership were assessed. Patients with PADs ( n = 93) reported higher scores on the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) ( P = .04; Cohen's d = 0.23) and Neurobehavioral Symptom Inventory ( P &lt; .01; Cohen's d = 0.34) at baseline. PTSD symptom change was comparable between participants with and without PADs ( P &gt; .05). Dropout was higher among owners of PADs, but this difference was not significant ( P = .11). Among military populations, those with PADs may experience more severe PTSD and neuro-cognitive symptoms, but having a PAD was not associated with treatment outcome in intensive CBT. [ Psychiatr Ann . 2022;52(5):191–198.]

Participation Mediates the Relationship Between Postconcussive Symptoms and Suicidal Ideation Among Veterans.

Veterans with mild traumatic brain injury (mTBI) and associated symptoms are at risk for suicide. Postconcussive symptoms (PCS) may heighten risk for suicidal thoughts by limiting veterans' participation. To investigate whether participation mediates the relationship between PCS and suicidal ideation. Cross-sectional, exploratory design. Structural equation models were used to investigate whether participation mediated the relationship between PCS and suicidal ideation. Community. Veterans with mTBI (N = 145). The Ohio State University TBI Identification Method was used to establish mTBI diagnosis. We identified latent variables for PCS and participation using the Neurobehavioral Symptom Inventory and select domains of the Medical Outcomes Study Short Form-36, respectively. We used the Beck Scale for Suicide Ideation to measure the presence of suicidal ideation. Participation mediated the relationship between PCS and the presence of suicidal ideation (odds ratio [OR] = 1.09, p = .011). More severe PCS were associated with lesser participation (β = -.86, p < .001); greater participation was associated with lower odds of suicidal ideation (OR = 0.92, p = .007). PCS may heighten risk for suicidal thoughts among veterans by limiting successful participation, a primary target of occupational therapy intervention. Thus, the results suggest that occupational therapy practitioners can play a substantial role in suicide prevention services for veterans with mTBI. Preventive services could mitigate suicide risk among veterans with mTBI by enabling sustained engagement in meaningful and health-promoting activity (e.g., reasons for living) and targeting PCS. What This Article Adds: Researchers have proposed that occupational therapy practitioners can help prevent veteran suicide by supporting their engagement in meaningful, health-promoting activity and by targeting suicide risk factors within their scope of practice. To the best of our knowledge, this is the first study to offer empirical support for such proposed suicide prevention efforts. Although additional research is needed, these results are promising and highlight a distinct role for occupational therapy in suicide prevention.

History of Mild Traumatic Brain Injury Affects Static Balance under Complex Multisensory Manipulations.

A recent study in active-duty military in the Coast Guard suggested that lifetime experience with mild traumatic brain injury (mTBI) was associated with subtle deficits in postural control when exposed to multi-sensory discordance (i.e., rotating visual stimulation). The present study extended postural assessments to veterans recruited from the community. Service veterans completed the Defense Veteran Brain Injury Center TBI Screening Tool, Post-Traumatic Stress Disorder (PTSD) Checklist (PCL-5), and Neurobehavioral Symptom Inventory (NSI). Postural control was assessed using a custom-designed, virtual-reality-based device, which assessed center of pressure sway in response to six conditions designed to test sensory integration by systematically combining three visual conditions (eyes open, eyes closed, and rotating scene) with two somatosensory conditions (firm or foam surface). Veterans screening positive for lifetime experience of mTBI (mTBI+) displayed similar postural sway to veterans without a lifetime experience of mTBI (mTBI-) on basic assessment of eyes open or closed on a firm and foam surface. mTBI+ veterans displayed greater sway than mTBI- veterans in response to rotating visual stimuli while on a foam surface. Similar to previous research, degree of sway was affected by the number of lifetime experiences of mTBI. Increased postural sway was not related to PTSD, NSI, or balance-specific symptom expression. In summary, veterans who experienced mTBI over their lifetime exhibited dysfunction in balance control as revealed by challenging conditions with multi-sensory discordance. These balance-related signs were independent of self-reported balance-related symptoms or other symptom domains measured by the NSI, which can provide a method for exposing otherwise covert dysfunction long after the experience of mTBI.

Mild Traumatic Brain Injury and Integrated Healthcare: A Pilot Study

Research Objectives This pilot study aims to investigate post-concussive symptoms for individuals who received care from a specialized integrated concussion clinic compared to those who received standard care. Due to existing literature on use of integrated healthcare for treatment of various mental health diagnoses, as well as recommendations from professional organizations specializing in TBI, it was hypothesized that individuals who attended the clinic would have a reduction in post-concussive symptoms as compared to those who did not attend. Design Participants were referred to attend the concussion clinic for follow-up care after their hospital or outpatient visit. Participants were provided with the Multidisciplinary Examination of Neurotrauma Disorders (M.E.N.D.) at their visit or shortly after their missed appointment. Follow up on the M.E.N.D. was given approximately 6 months post injury. Setting The Concussion Clinic at Zuckerberg San Francisco General Hospital is a once-a-month outpatient clinic. Participants Participants (N= 38) included in this study were adults who were referred to attend the concussion clinic for follow-up care after their hospital or outpatient visit. Interventions Participants received the M.E.N.D. self-report questionnaire at time of visit at the concussion clinic, or shortly after their missed appointment, and approximately 6 months after the date of injury. Main Outcome Measures The M.E.N.D. is composed of the Neurobehavioral Symptom Inventory (NSI), and a TBI symptom questionnaire that is composed of the Patient Health Questionnaire-2 (PHQ-2), a two-item PTSD screener, and the 3-item Alcohol Use Disorders Identification Test Consumption (AUDIT-C). Results Consistent with our hypothesis, individuals who attended the clinic reported lower levels of post-concussive symptoms than those who did not attend the clinic. Specifically, the scores for the group that attended the concussion clinic decreased from an average score of 28.90 to 12.60 whereas scores from the "no show" group only slightly decreased from 31.13 to 30.25. Conclusions Findings suggest that use of a specialized integrated concussion clinic for treatment of mTBI may be helpful for those experiencing post-concussive symptoms; however, more research in this area is needed to substantiate these findings. Author(s) Disclosures None. This pilot study aims to investigate post-concussive symptoms for individuals who received care from a specialized integrated concussion clinic compared to those who received standard care. Due to existing literature on use of integrated healthcare for treatment of various mental health diagnoses, as well as recommendations from professional organizations specializing in TBI, it was hypothesized that individuals who attended the clinic would have a reduction in post-concussive symptoms as compared to those who did not attend. Participants were referred to attend the concussion clinic for follow-up care after their hospital or outpatient visit. Participants were provided with the Multidisciplinary Examination of Neurotrauma Disorders (M.E.N.D.) at their visit or shortly after their missed appointment. Follow up on the M.E.N.D. was given approximately 6 months post injury. The Concussion Clinic at Zuckerberg San Francisco General Hospital is a once-a-month outpatient clinic. Participants (N= 38) included in this study were adults who were referred to attend the concussion clinic for follow-up care after their hospital or outpatient visit. Participants received the M.E.N.D. self-report questionnaire at time of visit at the concussion clinic, or shortly after their missed appointment, and approximately 6 months after the date of injury. The M.E.N.D. is composed of the Neurobehavioral Symptom Inventory (NSI), and a TBI symptom questionnaire that is composed of the Patient Health Questionnaire-2 (PHQ-2), a two-item PTSD screener, and the 3-item Alcohol Use Disorders Identification Test Consumption (AUDIT-C). Consistent with our hypothesis, individuals who attended the clinic reported lower levels of post-concussive symptoms than those who did not attend the clinic. Specifically, the scores for the group that attended the concussion clinic decreased from an average score of 28.90 to 12.60 whereas scores from the "no show" group only slightly decreased from 31.13 to 30.25. Findings suggest that use of a specialized integrated concussion clinic for treatment of mTBI may be helpful for those experiencing post-concussive symptoms; however, more research in this area is needed to substantiate these findings.

Low resilience following traumatic brain injury is strongly associated with poor neurobehavioral functioning in U.S. military service members and veterans

ABSTRACT Objective The purpose of this study was to examine the relationship between resilience and self-reported neurobehavioral functioning following traumatic brain injury (TBI) in U.S. military service members and veterans (SMVs). A secondary objective was to examine the interaction between resilience and posttraumatic stress disorder (PTSD) on neurobehavioral functioning. Method Participants included 795 SMVs classified into four groups: Uncomplicated Mild TBI (MTBI; n=300); Complicated Mild, Moderate, Severe, or Penetrating TBI (STBI, n 162); Injured Controls (IC, n=185); and Non-injured Controls (NIC, n=148). Two independent cohorts were evaluated – those assessed within 1-year of injury and those assessed 10-years post-injury. SMVs completed self-report measures including the PTSD Checklist-Civilian version, Neurobehavioral Symptom Inventory, and TBI-Quality of Life. Results Results showed that (1) lower resilience was strongly associated with poorer neurobehavioral functioning across all groups at 1-year and 10-years post-injury, and (2) PTSD and resilience had a robust influence on neurobehavioral functioning at both time periods post-injury, such that SMVs with PTSD and low resilience displayed the poorest neurobehavioral functioning. Conclusion Results suggest that regardless of injury group and time since injury, resilience and PTSD strongly influence neurobehavioral functioning following TBI among SMVs. Future research evaluating interventions designed to enhance resilience in this population is indicated.

Perceptions About Writing by Adults With Moderate or Severe Traumatic Brain Injury.

Writing challenges can cause ongoing distress and limit resumption of pre-injury activities following traumatic brain injury (TBI); however, little TBI research or clinical practice addresses written communication. Understanding the writing perceptions and experiences of adults engaged in intensive, inpatient rehabilitation following hospital discharge for TBI is an initial step in addressing this situation. Transcendental phenomenology served to structure this qualitative research. Six adults between 2 and 6 months post-TBI participated in a common experience of writing about a personal memorable event. Standardized test scores and symptom ratings provided descriptive information about participants. Additionally, participants completed the Neurobehavioral Symptom Inventory and NASA Task Load Index and engaged in semistructured interviews to describe writing perceptions and experiences. Data analysis revealed themes and subthemes about writing perceptions, challenges, and support strategies. Participants varied in their perceptions of post-injury writing changes. Test results revealed areas of challenge for all participants, but only half reported awareness of writing changes. Those aware of changes differed from other participants regarding word retrieval, memory, and concentration as well as overall effort expended, frustration, and performance quality. Although all participants relied on writing supports, only one had adjusted multiple writing strategies following injury. Some adults with TBI are aware of writing changes while receiving posthospital, inpatient rehabilitation services, but others deny such changes. This differs from reports concerning later recovery stages, perhaps because few functional writing opportunities arise during rehabilitation. Application of compensatory strategies specific to post-injury writing challenges is unlikely while awareness remains limited.

Clinical utility of PTSD, resilience, sleep, and blast as risk factors to predict poor neurobehavioral functioning following traumatic brain injury: A longitudinal study in U.S. military service members.

This study examined the clinical utility of post-traumatic stress disorder (PTSD), low resilience, poor sleep, and lifetime blast exposure as risk factors for predicting future neurobehavioral outcome following traumatic brain injury (TBI). Participants were 591 U.S. military service members and veterans who had sustained a TBI (n = 419) or orthopedic injury without TBI (n = 172). Participants completed the Neurobehavioral Symptom Inventory, PTSD Checklist, and the TBI-Quality of Life (TBI-QOL) scale at baseline and follow-up. Using the four risk factors at baseline, 15 risk factor combinations were examined by calculating odds ratios to predict poor neurobehavioral outcome at follow-up (i.e., number of abnormal scores across five TBI-QOL scales [e.g., Fatigue, Depression]). The vast majority of risk factor combinations resulted in odds ratios that were considered to be clinically meaningful (i.e., ≥ 2.5) for predicting poor outcome. The risk factor combinations with the highest odds ratios included PTSD singularly, or in combination with poor sleep and/or low resilience (odds ratios = 4.3-72.4). However, poor sleep and low resilience were also strong predictors in the absence of PTSD (odds ratios = 3.1-29.8). PTSD, poor sleep, and low resilience, singularly or in combination, may be valuable risk factors that can be used clinically for targeted early interventions.

Correlations Between the Neurobehavioral Symptom Inventory and Other Commonly Used Questionnaires for Traumatic Brain Injury.

To evaluate the correlations between the Neurobehavioral Symptom Inventory (NSI) and other questionnaires commonly administered within military traumatic brain injury clinics. Military outpatient traumatic brain injury clinics. In total, 15,428 active duty service members who completed 24,162 NSI questionnaires between March 2009 and May 2020. Observational retrospective analysis of questionnaires collected as part of standard clinical care. NSI, Post-Traumatic Stress Disorder Checklist for DSM-5 and Military Version, Patient Health Questionnaire (PHQ), Generalized Anxiety Disorder, Headache Impact Test (HIT-6), Insomnia Severity Index (ISI), Epworth Sleepiness Scale (ESS), Activities-Specific Balance Confidence Scale (ABC), Dizziness Handicap Inventory (DHI), Alcohol Use Disorders Identification Test (AUDIT), and the World Health Organization Quality of Life Instrument-Abbreviated Version. Only questionnaires completed on the same date as the NSI were examined. The total NSI score was moderately to strongly correlated with all questionnaires except for the AUDIT. The strongest correlation was between the NSI Affective Score and the PHQ9 (r = 0.86). The NSI Vestibular Score was moderately correlated with the ABC (r = -0.55) and strongly correlated with the DHI (r = 0.77). At the item level, the HIT-6 showed strong correlation with NSI headache (r = 0.80), the ISI was strongly correlated with NSI difficulty sleeping (r = 0.63), and the ESS was moderately correlated with NSI fatigue (r = 0.39). Clinicians and healthcare administrators can use the correlations reported in this study to determine if questionnaires add incremental value for their clinic as well as to make more informed decisions regarding which questionnaires to administer.

Prevalence and Perception of Intimate Partner Violence-Related Traumatic Brain Injury.

Traumatic brain injury (TBI) is a serious and often undiagnosed consequence of intimate partner violence (IPV). Data on prevalence of TBI among IPV survivors are emerging, but prevalence of IPV among patients presenting to TBI clinics is unknown. Identification of IPV is important to ensure patients with TBI receive appropriate intervention and referrals. To determine the proportion of women 18 years and older presenting to an acquired brain injury (ABI) clinic with confirmed or suspected concussion who reported experiencing IPV in the last 12 months or their lifetime. Single-center cross-sectional cohort study. Proportion of IPV-related TBI or head, neck, or facial) injuries were determined using a modified HELPS Brain Injury Screening Tool and the Neurobehavioral Symptom Inventory. Of the 97 women approached, 50 were enrolled in the study. The average age was 46.1 years and 32 women (64.0%) reported a relationship history with a violent partner; 12-month prevalence of IPV was 26.5% and lifetime prevalence was 44.0%. Within their lifetime, all (44.0%) who reported an IPV history reported emotional abuse, 24.0% reported physical abuse, and 18.0% sexual abuse. HELPS responses indicated a high potential of lifetime IPV-related TBI for 29.2%, most commonly from being hit in the face or head (20.8%). Implementation of IPV screening in community-based ABI clinics is a pivotal step toward understanding the potential scope of TBI and addressing the wide range of somatic, cognitive, and affective symptoms experienced by IPV survivors. IPV screening also will lead to timely referral and follow-up and increase patient safety after discharge from rehabilitation.

Mixed Method Examination of the Brain Health of Former NCAA Division I Football Players and Former NFL Players

Young American athletes, at risk of sport-related concussion (SRC), represent many races; however, it is unknown how race influences the experience and outcome of SRC. Our objective was to compare White and Black athletes' recovery and subjective experiences after SRC. NA. A retrospective study was performed using the Vanderbilt Sport Concussion registry. Self-reported White (n = 211) and Black (n = 36) athletes (ages 12-23) treated for SRC between 2012 and 15 were included. Athletes with learning disabilities or psychiatric conditions were excluded. Data was collected by EMR review and phone calls to athletes and parents/guardians. The primary outcomes were: (1) days to symptom resolution (SR), (2) days to return-to-school, (3) changes in any daily activity (binary), (4) and sport behavior (binary). Secondary outcomes were changes in specific activities such as sleep, schoolwork, television time, as well as equipment (binary), playing style (more reckless, unchanged, less reckless) and whether the athlete retired from sport. Descriptive analyses, multivariable Cox proportional hazards and logistic regression were performed. A retrospective study was performed using the Vanderbilt Sport Concussion registry. Self-reported White (n = 211) and Black (n = 36) athletes (ages 12-23) treated for SRC between 2012 and 15 were included. Athletes with learning disabilities or psychiatric conditions were excluded. Data was collected by EMR review and phone calls to athletes and parents/guardians. The primary outcomes were: (1) days to symptom resolution (SR), (2) days to return-to-school, (3) changes in any daily activity (binary), (4) and sport behavior (binary). Secondary outcomes were changes in specific activities such as sleep, schoolwork, television time, as well as equipment (binary), playing style (more reckless, unchanged, less reckless) and whether the athlete retired from sport. Descriptive analyses, multivariable Cox proportional hazards and logistic regression were performed. Racial differences appear to exist in the outcomes and experience of SRC for young athletes, as Black athletes reached symptom resolution and return-to-school sooner than White athletes. Race should be considered as an important social determinant in SRC treatment.

Characterization of Million Veteran Program (MVP) enrollees with Comprehensive Traumatic Brain Injury Evaluation (CTBIE) data: An analysis of neurobehavioral symptoms

The purpose of this study was to examine neurobehavioral symptom reporting in a large sample of military veterans (N = 12,144) who completed the Comprehensive Traumatic Brain Injury Evaluation (CTBIE) and enrolled in the VA's Million Veteran Program (MVP). The CTBIE is a clinician-administered interview that assesses for historical, deployment-related traumatic brain injury (TBI) and evaluates symptoms using the Neurobehavioral Symptom Inventory (NSI). Clinicians completing the CTBIE made clinical determinations about participants' (1) TBI diagnostic status (i.e., CTBIE+ or CTBIE-) and (2) current symptom etiology (i.e., Symptom Resolution, TBI, Behavioral Health, Comorbid TBI + Behavioral Health [Comorbid], or Other). We evaluated the association of TBI diagnostic status and symptom etiology group with neurobehavioral symptoms. Results showed a significant association between TBI diagnostic status and all NSI variables, with CTBIE+ veterans endorsing greater symptoms than CTBIE- veterans. There was also a significant association between symptom etiology group and all NSI variables; specifically, the Comorbid and Behavioral Health groups generally endorsed significantly greater symptoms compared to the other groups. Follow-up analyses showed that relative to the Symptom Resolution group, the Comorbid and Behavioral Health groups had increased odds of severe/very severe cognitive and affective symptoms, whereas the TBI and Other groups did not. Finally, presence of psychiatric symptoms, pain, post-traumatic amnesia, loss of consciousness, and blast exposure significantly predicted Comorbid symptom etiology group membership. Findings from this large epidemiologic MVP study have relevant clinical implications and further highlight the importance of prioritizing integrated behavioral health interventions for this vulnerable population.