To establish the health care management experiences of people who had sustained a mild traumatic brain injury (mTBI) in the United Kingdom. Interviews with people who had recently sustained a mTBI in the United Kingdom were conducted online using the platform Microsoft Teams and simultaneously digitally recorded and auto transcribed. Transcripts were cleaned and checked for accuracy before being subjected to inductive thematic analysis following the 6 phases outlined by Braun and Clarke. Seventeen people with experience of mTBI and one carer participated in this study (n = 18 interviews). Three broad themes with 9 subthemes were generated. Themes mapped to the mTBI patient's health care journey accessing (prehospital), traversing (in-hospital) and exiting health care services (posthospital). Prehospital experiences were characterized by "Decisional Difficulty" (Theme 1); notably, there were challenges deciding whether symptoms were the result of an mTBI or preexisting disease, whether the mTBI was severe enough to warrant medical review, and which service was most appropriate to present to. In-hospital care was described as "Lacking Holism" (Theme 2) and participants voiced that there was a focus on the injury, not the person. Care was experienced as fragmented and discharge information and follow-up were frequently described as an afterthought. The posthospital recovery landscape was depicted as "Uncertainty Central" (Theme 3); uncertainties arose in part from the lack of information on recovery trajectories provided at discharge. Participants also described a desire for reassurance to help them navigate these uncertainties, and the need for work and home spaces that are sensitized to recovery. The label mTBI has long been recognized as a misnomer given the significant debilitating impacts it can have in both the short and long term. This research describes patients' experiences of mTBI from a health care management perspective. It illuminates the suboptimal care pathways and management processes experienced by many. While there was staunch sympathy for health care providers and acknowledgement of the significant pressures they face, there is nevertheless a need for significant changes across primary, secondary, and tertiary care to ensure that the informational and care needs of people with mTBI are met. Greater public awareness in mTBI is also required, so that family members and other significant parties realize the scope of the impact. Finally, employment policies need to change to ensure that people with mTBI are supported in their recovery.
Background/Study Motivation: Sex work, an occupation or trade involving exchange of sexual services for economic compensation, is a highly gendered profession, with 60% to 80% of sex workers identifying as women. The rate of traumatic brain injury (TBI) among persons who experience intimate partner violence (IPV) in the sex worker population is significantly high. According to global estimates, 80% of female sex workers have experienced IPV, with an estimated 95% reporting TBIs, sustained either by being hit in the head with objects and/or having their heads slammed into objects while on the job. Conversely, only 10% of IPV survivors in general populations report TBIs. Despite the high "occupational risk" of TBI in the sex worker population, research on the intersection of IPV-TBI in this population has been scant, heavily focused on sexually transmitted diseases and law enforcement, rather than the occupational hazard of IPV-induced TBI that these women face on a daily basis. Literature on HIV/AIDS specifically in sex workers is very well represented, but there is a research gap on the risk of TBI in female sex workers, leaving one of the most vulnerable groups to TBI underrepresented in research and intervention. Objectives, Methods, and Design: In this commentary, we discuss the intersection of sex work and TBI using a "globalization" lens. Drawing from the literature, clinical, observational, and epidemiological cases from Africa (Kenya), Asia (Vietnam), North America (the US), and Oceania (New Zealand), we explore the evolving definitions of sex work; discuss the occupational hazards of the profession with an emphasis on TBI; advocate for ways forward through using harm reduction as a framework; and implore the TBI research community to identify women and girls who participate in sex work as a TBI high-risk group, so they can receive appropriate care and attention. After all, sex work is the "World's Oldest Profession."
In this retrospective essay celebrating the 40th anniversary of the Journal of Head Trauma and Rehabilitation, Dr. Joseph J. Fins traces the evolution of the neuroethics of disorders of consciousness through autobiographical reflections over the past four decades. His memoir highlights his origins as a medical student on the Cornell Neurology Service headed by Dr. Fred Plum, the co-originator of the Persistent Vegetative State with Dr. Bryan Jennett and culminates with his collaboration with Dr. Nicholas Schiff and the clinical and ethical importance of Cognitive Motor Dissociation in clinical care. During this period Fins describes the therapeutic nihilism that followed in the wake of landmark end-of-life cases like Quinlan, Cruzan and Schiavo and how scientific advance and an emerging nosology has begun to envision therapeutic possibility informed by an expanded nosology and neuroimaging. Fins asserts that the disability rights of people with disorders of consciousness need to be accommodated in tandem with access to technological advance in order to more fully integrate these individuals into the nexus of their families and communities. Fins argues that the developments of the past 40 years are a harbinger of further progress but cautions that this will not occur without sustained government support from the National Institutes of Health.
Significant progress has been achieved in understanding recovery from severe brain injury and resulting disorders of consciousness (DoC) since the inaugural issue of the Journal of Head Trauma Rehabilitation in 1986. Research across all biomedical sciences has sharpened diagnostic distinctions and increased prognostic accuracy and has led to the development of improved assessment strategies, pharmacologic and nonpharmacologic treatments. This article highlights achievements in these domains since the last update was provided 20 years ago. Unparalleled translation into clinical practice has been achieved in DoC compared to many areas in rehabilitation. International collaboration among scientists, clinicians, and professional organizations has resulted in critical partnerships that have helped to move evidence into practice. Specifically, evidence-based guidelines and position statements, funded and/or endorsed by interdisciplinary organizations, have helped to guide the field toward implementation. Further, public initiatives such as the Curing Coma Campaign initiated by the Neurocritical Care Society and the Model Systems Knowledge Translation Center funded by the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) have created international engagement using traditional and online media with expansive reach. The cumulative evidence and clinical guidance endorsed by multiple professional organizations have informed the development of quality-of-care standards for DoC rehabilitation that will be published in the CARF Medical Rehabilitation Standards Manual, which goes into effect July 1, 2026. Quality of care initiatives to improve implementation of DoC evidence-based care are creatively pursued by researchers via traditional funding agencies such as NIDILRR, the Department of Defense, and professional organizations and are highlighted as exemplars. Lastly, milestones for the next 20 years highlighting acceleration in research, discovery, and innovation in DoC are described.
To examine sex- and age-related differences in patterns of post-concussive symptoms (PCS), across cognitive, somatic, emotional, and behavioral domains, and their recovery within the first 6 months after mild traumatic brain injury (mTBI), and their relation to participation. Data were collected from patients visiting the emergency departments of 14 hospitals in the Netherlands. Two hundred 8 to 17-year-old children with mTBI and their caregivers, and 186 adults with mTBI. Data were collected in 2 prospective cohort studies, with assessments at 2 weeks and 6 months post-injury. Data were analyzed using Multivariate Latent Class Growth Analysis to detect latent PCS patterns (classes), multivariate logistic regressions to assess age and sex differences between classes, and Kruskal-Wallis tests to investigate class differences in participation. PCS were assessed with the Health and Behavior Inventory (children) and the Rivermead Post-Concussion Symptoms Questionnaire (adults). Participation (being involved in daily life situations) was assessed with the Child and Adolescent Scale of Participation (children) and the Utrecht Scale for Evaluation and Rehabilitation-Participation (adults). Three distinct classes with unique PCS recovery trajectories were found across samples (children/caregiver, adults). In child-reported PCS, sex differences were found, driven by higher levels of somatic and emotional PCS in females. No sex differences were found in caregiver reports or in adult reports. Age differences were found in the caregiver report for the child sample, with higher ages found in the class showing decreasing somatic symptoms over time, and in the adult sample, where younger individuals were more often in the class with recovered PCS. Classes differed in their levels of participation in all samples. Findings highlight the heterogeneity of PCS across the lifespan as well as the variation of discrepancies in sex- and age-related findings. Taking age and sex differences into account increases our understanding of recovery patterns after mTBI and allow identification of at-risk individuals and better-tailored interventions.
Mild traumatic brain injury (mTBI) is common in military veterans, with most symptoms fully resolving within weeks but some persisting for months or years after injury. Chronic symptoms are often attributed to aftereffects of the physiological injury, but veterans are also exposed to higher rates of psychological trauma which take place before, during, and after their military service careers. The present study sought to investigate the relationship between psychological trauma across the lifespan and persistence of mTBI symptoms and postinjury quality of life in US military veterans. A total of 463 veterans with a history of mTBI (88.1% male, age 18-92 years [mean age 45.7 years]) were recruited from a VA outpatient TBI clinic. In this observational study, participants completed the Neurobehavioral Symptom Inventory (NSI) and Quality of Life after Brain Injury Questionnaire (QOLIBRI) as primary outcome measures. The history of mTBI was extracted from existing VA records, and veterans provided accounts of their cumulative lifetime trauma exposure, including trauma measures from their childhood, deployment, and postdeployment periods. After controlling for demographic and mTBI characteristics, each trauma measure was significantly positively associated with NSI symptom severity (all partial η2 > .033, all P < .004) and significantly negatively associated with QOLIBRI life satisfaction (all partial η2 > .035, all P < .002). There were no significant associations between outcomes and mTBI characteristics after correcting for multiple comparisons. The associations between psychological trauma and mTBI outcomes were observed across most NSI and QOLIBRI symptom domains, including those more often attributed to physiological explanations (eg, NSI somatic, NSI vestibular, and QOLIBRI physical problem scales). These findings support the inclusion of comprehensive lifetime trauma assessment in chronic mTBI rehabilitation conceptualizations and underscore the potentially prominent role that psychological stressors play in the persistence of mTBI sequelae.
Post-concussion syndrome is a challenging condition to assess and triage rehabilitation secondary to the heterogeneity of patients' presentations. The aim of the present study was to examine the effectiveness of a subgroup-informed customized rehabilitation (CR) program in adults with persistent concussion symptoms as compared to the current symptom-based treatment approach. Rehabilitation hospital in Toronto, Ontario, Canada. 40 adults (mean age ± SD, 39.1 ± 13.6 years) with persistent post-concussion symptoms (mean symptom duration ± SD, 5 ± 3.1 months) were recruited from various head injury clinics around the greater Toronto area. Participants underwent a comprehensive standardized clinical exam to subgroup the ostensible symptom generators into autonomic, cervical, or vestibulo-ocular. In a crossover design, participants were randomized to undertake either a CR program for 6 weeks followed by standard care (SC) for 6 weeks (Group A) or SC followed by CR (Group B). The CR program was tailored to the individual based on the findings of the exam. The SC program was reflective of symptom-based rehabilitative recommendations. The primary outcome measure was the Rivermead Post-Concussion Questionnaire (RPQ-3 and RPQ-13). Secondary outcome measures included the Neck Disability Index, the Patient Health Questionnaire-9 and exercise tolerance as assessed via the Buffalo Concussion Treadmill Test. Participants in Group A made a clinically meaningful and statistically significant change to the primary and secondary outcome measures at the 6-week follow-up. These changes were maintained at the 12-week follow-up. Only following the CR program did Group B demonstrate significant and clinically meaningful changes in RPQ scores, as well as significant improvements in the secondary outcome measures. A shift away from symptom-based management to subgroup-informed customized rehabilitation may be key to advancing patient care and improving clinical outcomes for this population.
To (1) retrospectively apply the updated American Congress of Rehabilitation Medicine (ACRM) mild traumatic brain injury (mTBI) criteria to a cohort of high school athletes previously diagnosed with sport-related concussion (SRC) using prior clinical definitions, and (2) compare demographics, medical history, and recovery outcomes between those who met the full mTBI criteria versus those classified as suspected mTBI. Outpatient Specialty Concussion Clinic. In total, 181 concussed athletes aged 14 to 18 years were presented to clinic within 72 hours of injury. All were diagnosed with SRC by a certified athletic trainer or physician using the Concussion in Sport Group definition, which defines SRC as any traumatic blow to the head/body causing neurologic symptoms. Retrospective cohort study. Participants were classified as having a full or suspected mTBI based on the ACRM 2023 criteria. Full mTBIs required: (1) a plausible mechanism and either (2a) a clinical sign (eg, amnesia, loss of consciousness), or (2b) at least 2 symptoms plus a clinical examination finding. Suspected mTBIs had a plausible mechanism and at least 2 symptoms or at least 2 examination findings. Groups were compared across demographics, medical history, and recovery metrics (return-to-learn, symptom resolution, return-to-play). Of the 181 patients (mean age 16.3 ± 1.3 years; 35.9% female), 114 (63.0%) met the definition for a full mTBI, whereas 67 (37.0%) had a suspected mTBI. Significant differences included higher rates of family migraine history (24.8% vs 7.7%, P = .019) and on-field evaluations (50.4% vs 38.5%, P < .001) in the full group. No significant differences in return-to-learn (median [Mdn]: 4.0 vs 3.0), symptom resolution (Mdn: 11.0 vs 12.5), or return-to-play (Mdn: 15.0 vs 14.5) were noted (P > .05). Among high school athletes with SRC, most met the updated full ACRM mTBI criteria, with the rest meeting the suspected mTBI criteria. Results suggest high sensitivity for the ACRM definition for diverse concussion presentations.
To evaluate the feasibility and acceptability (eg, user experience) of 2 methods for home-based estimation of circadian timing among veterans with insomnia and a history of traumatic brain injury (TBI). An outpatient setting at a Department of Veterans Affairs medical center. Veterans between the ages of 18 and 64 years with current insomnia and a history of mild-to-severe TBI. A prospective observational study evaluating the feasibility of 2 home-based methods for estimating circadian timing, that is, dim light melatonin onset (DLMO): (1) indirect prediction of DLMO using activity and light-exposure data collected through actigraphy (ie, pDLMO); and (2) estimation of DLMO via direct measurement of melatonin in self-collected salivary samples (ie, salivary DLMO). Participants wore an actigraphy device and completed sleep diaries for one week. They then spent one evening self-collecting 7 saliva samples under dim light conditions. Finally, participants completed a brief qualitative interview on their experiences. Primary outcomes were the success rates for estimation of each home-based DLMO method. Feasibility was set as 70% successful estimation for a given measure, for those who completed the respective procedures. pDLMO could be estimated for 27 of 29 participants (93.1%) who completed actigraphy data collection, meeting the feasibility goal. Salivary DLMO could only be estimated for 7 of 28 participants (25%) who completed saliva collection. Participants broadly expressed acceptance of both home-based DLMO methods and a willingness to use them again. Several barriers related to each method were identified that can inform future implementation efforts with this patient population. pDLMO is feasible and acceptable for estimating circadian timing in veterans with insomnia and past TBI. Using pDLMO could help identify circadian-sleep misalignment after TBI, helping personalize insomnia treatments based on patient-specific needs and interrupting the bidirectional cycle of insomnia and circadian dysregulation.
First, to summarize the design of novel decision aid prototypes aimed at facilitating shared decision-making for Veterans with co-morbid mild traumatic brain injury (mTBI) and sleep disorders (insomnia, obstructive sleep apnea [OSA]) in the Veterans Health Administration (VHA) Polytrauma/TBI System of Care (PSC). Second, to elicit feedback regarding usability, acceptability, and feasibility of prototypes to inform future implementation. Nationwide VHA PSC sites. Clinicians included VHA providers involved in the management of mTBI and/or sleep disorders in the VHA PSC (n = 7). Veterans included those with a clinician-confirmed mTBI who received care for insomnia disorder and OSA within the past year (n = 5). Convergent parallel mixed methods. Semi-structured interview guides; System Usability Scale; Ottawa Decision Aid Acceptability Scale. Participants found the decision aid prototypes easy to use, highlighting its accessibility and features enabling an easy comparison of treatments. However, participants recommended changes to simplify and improve the design. Decision aids were seen as acceptable, providing essential information for Veterans with mTBI and facilitating shared decision-making among providers, Veterans, and other decision partners (eg, spouse). Removal of non-essential content was recommended to increase acceptability. Decision aids were considered feasible to implement, though extending the decision-making process beyond the initial encounter and accounting for time constraints were recommended. Findings highlight that the decision aids are easy-to-use, feasible to implement, and capable of improving Veteran-centered management of sleep disorders among those with mTBI. Nonetheless, clinicians and Veterans offered recommendations for changes that can improve the utility of the decision aids and facilitate their seamless integration into routine care for Veterans with co-morbid mTBI and sleep disorders. Findings lay the foundation for efforts aimed at implementing the decision aids into routine care for sleep disorders in the VHA PSC, aligning care decisions with Veteran preferences and improving outcomes.
Describe the development and initial psychometric evaluation of the Boston Assessment of Traumatic Brain Injury (TBI) Lifetime, Second Edition (BATL-2). The Translational Research Center for TBI and Stress Disorders (TRACTS) located at two large VA medical centers. Random selection of 100 US post-9/11 military Veterans enrolled at TRACTS Boston primary site and 20 Veterans enrolled at TRACTS Houston secondary site. Secondary analysis of a prospective longitudinal cohort study. Boston Assessment of TBI-Lifetime (BAT-L), BATL-2, Ohio State University Traumatic Brain Injury Identification Method (OSU-TBI-ID). BATL-2 instrument development included National Institute of Neurological Disorders and Stroke (NINDS) and American Congress of Rehabilitation Medicine (ACRM) field updates to TBI diagnostics, iterative review and feedback from stakeholders, and data-driven revisions. The BATL-2 demonstrated excellent diagnostic agreement with TBI diagnosis from the OSU-TBI-ID (κ = 0.94; sensitivity 100%; specificity 87.0%-92.5%). Internal consistency and diagnostic agreement between BATL-2 and the first edition BAT-L were high (Cronbach's α = 0.83; κ = 0.94). BATL-2 demonstrated convergent validity with neurobehavioral symptoms ( r = .260, p = .012) and discriminant validity with measures of depression ( r = .004, p = .966) and tobacco use ( r = .086 to .307, p > .553). Replication in a secondary sample showed robust diagnostic agreement (κ = 0.97). Results indicate that the BATL-2 is a valid and reliable measure of retrospective TBI diagnosis. Importantly, BATL-2 provides continuity of evidence-based assessment of TBI, including forward compatibility with updated field TBI diagnostic criteria while maintaining backward compatibility with BAT-L and previous TBI guidelines. The BATL-2 improves retrospective brain injury characterization by reducing administration time burden, assessing repetitive head impacts (RHI) and military occupational blast exposures (MOBE), and incorporating updated field standards.
Examine whether self-reported cognitive symptoms, an indicator of need, were associated with the likelihood that Veterans with moderate-severe traumatic brain injury (msTBI) received a cognitive rehabilitation referral. We also explored whether non-clinical factors modified the relationship between cognitive symptoms and receipt of a referral. Veterans Health Administration (VHA). Veterans with msTBI, determined using Comprehensive Traumatic Brain Injury Evaluation data from 2013-2023 (n = 10 790). Cross-sectional study of VHA medical record data. Modified Poisson regression modelled the likelihood of cognitive rehabilitation referral based on cognitive symptom severity and non-clinical predisposing (eg, race/ethnicity) and enabling (eg, drive time) factors. Models were specified to explain referral to occupational therapy (OT), speech-language pathology (SLP), and neuropsychology. Statistical interactions determined whether non-clinical factors modified the relationship between cognitive symptoms and referral. Cognitive rehabilitation referrals, identified using a validated algorithm detecting key phrases in unstructured consult data. Self-reported cognitive symptom severity measuring using the Neurobehavioral Symptom Inventory. Only 35% received a cognitive rehabilitation referral, with SLP services being the most common discipline (25%). Veterans with more severe self-reported cognitive symptoms were more likely to receive a referral (relative risk [RR], 1.06; 99% confidence interval [CI], 1.05-1.08), and this relationship was stable in discipline-specific models. However, many Veterans without a referral reported disabling cognitive challenges, indicating unmet need. Non-clinical factors-including drive time (RR, 0.86; 95% CI, 0.77-0.97) and rurality (RR, 0.92; 95% CI, 0.85-0.99)-were associated with receipt of a referral, though these relationships varied across discipline-specific models. Interactions did not provide support for non-clinical factors modifying the relationship between cognitive symptoms and receipt of a referral. While cognitive rehabilitation services tend to be allocated to those in need, results revealed gaps in access. Findings can guide development of strategies expanding access to cognitive rehabilitation among Veterans with msTBI, enhancing clinical outcomes.
Those who served on active duty after September 11, 2001 (Post-9/11) are screened for deployment-related mild traumatic brain injury (mTBI) when initiating Veterans Health Administration (VHA) clinical services. Positive screeners are offered a referral to a Comprehensive TBI Evaluation (CTBIE) by a TBI specialist to further determine deployment-related mTBI history and access interdisciplinary care if indicated. This study examined whether Post-9/11 veterans who screened positive and also participated in a prospective longitudinal study (PLS) differed in characteristics and outcomes depending on their clinical VHA CTBIE completion status and mTBI positive (+) or negative (-) determinations (CTBIE = mTBI+, CTBIE = mTBI-, No CTBIE). Veterans Health Administration (VHA) clinical and research settings. 658 Post-9/11 veterans. Secondary analysis of the PLS using a retrospective cohort design. Primary outcomes were associations of VHA CTBIE completion/determination with competitive employment and service-connected disability ratings obtained at time of PLS completion. Secondary outcomes included a range of PLS demographic, military, potential concussive event, health, functional, and quality-of-life measures. Based on their PLS research data, relative to the No CTBIE group, the CTBIE = mTBI+ group had lower adjusted odds ratios (aOR) of competitive employment (aOR = .51, 95% confidence interval [CI] = 0.31-0.83, P = .008) and higher odds of having a ≥50% service-connected disability rating (aOR = 2.02, 95% CI = 0.31-0.83, P = .01). The CTBIE = mTBI+ group also reported higher neurobehavioral and posttraumatic stress disorder symptom severity, and poorer outcomes on quality-of-life measures than the No CTBIE group. Generally, few differences were detected between the CTBIE = mTBI- and either of the CTBIE = mTBI+ and No CTBIE groups. This study leveraged the unique ability to combine VHA clinical and comprehensive research data to examine outcomes not routinely collected as part of standard VHA clinical care. These research data can inform VHA TBI leadership about long-term health and functional status of veterans who screen positive for TBI.
In North America, concussions are a common injury in the pediatric population. Much of the research to date has focused on biological aspects of concussion. Consideration of psychological, social and ecological factors, specifically the social determinants of health (SDH), relevant to concussion is essential to advancing the field of pediatric concussion. Using the WHO Conceptual Framework for Action on the Social Determinants of Health, we performed a scoping review to (1) identify and describe the research areas studied in the literature on SDH and pediatric concussion, and (2) summarize the reported findings of the included studies. A comprehensive search for peer-reviewed articles published between 2005 and 2025, was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses - Scoping Review (PRISMA-ScR) guidelines. Selected studies were reviewed for descriptive analysis by two independent reviewers. In total, 26 studies were included in this scoping review and the topics of study were grouped into 3 main categories: (1) identification; (2) service access and utilization; and (3) outcomes. Lower socioeconomic status (SES), limited English proficiency, and housing instability were linked to a higher incidence of concussions. Non-White pediatric patients, those with public insurance, and rural residents were more likely to use emergency departments instead of specialized concussion services. Non-White participants often had shorter recovery times, while the connections between socioeconomic status, public school attendance, and recovery duration were inconsistent. The findings illustrate current gaps in the literature and opportunities for actions to address SDH among children and adolescents to improve representation in concussion research, understand differences in concussion reporting and tracking and learn about and mitigate disparities in access to concussion care and treatment outcomes.
To update the status of physical activity research after moderate-to-severe traumatic brain injury (msTBI) by systematically reviewing empirical studies across health-related fields with the behavioral epidemiological framework to identify evidence-based interventions and inform future recommendations. The last review of physical activity research after msTBI, including studies between 2000 and 2012, found the field was in early stages of maturation. Articles published between January 2012 and December 2024 were retrieved from PubMed, Embase, Ovid Medline, Scopus, Web of Science, Rehabilitation & Sports Medicine Source, and Google Scholar using keywords related to traumatic brain injury, physical activity, and health promotion. Two authors independently screened titles, abstracts, and full texts for peer-reviewed research about physical activity behavior for adults with msTBI. Data were abstracted from included studies by study authors and then categorized into to the framework's 5 unique stages of development. A total of 958 references were imported, 129 duplicates were removed, 829 were screened with title and abstract, 165 articles underwent full-text review, and 100 final articles met the inclusion criteria. Consensus was achieved across different stages of the review through critical discussion. 40% were categorized in Phase 1 (establishing connections between behavior and health); 6% in Phase 2 (developing methods for measuring behaviors); 44% in Phase 3 (examining factors that influence behavior); 10% in Phase 4 (evaluating behavior change interventions); and 0% in Phase 5 (dissemination of health promotion programs). Many excluded full-text studies (n = 39/60) did not separate results by condition/injury severity (i.e., stroke/mild TBI). The greater number of studies in Phases 3 and 4 suggest the field has evolved in 12 years. The lack of progress in Phase 5 provides opportunity for implementation science efforts. Recommendations for physical activity behavior research after msTBI are discussed.
To determine the characteristics of subconcussive blast exposure associated with differences in brain structure and brain function. Veterans Affairs Health Care System. Combat-exposed veterans (n = 107) without history of blast-related traumatic brain injury (TBI) or military TBI volunteered to participate. Observational study. Connectome metrics describing the functional brain connectome, the unique brain network present at rest for individuals, were measured using magnetoencephalography. Regional brain volumes were calculated from anatomical magnetic resonance imaging using FreeSurfer. The Salisbury Blast Interview evaluated lifetime blast exposure. Several blast characteristics were associated with the functional connectome. The average severity of exposures was related to slowing of oscillatory communication (average pressure, parameter estimate = -4.41, P < .05 corrected). By contrast, the frequency of exposures was associated with topological differences including the number of active brain regions (number of blast exposures, parameter estimate = 0.01, P < .05 corrected) and the composition of core subnetworks (number of close-range blast exposures, parameter estimate = 0.0005, P < .05 corrected). Subconcussive blast exposure was unrelated to brain volumes. These results demonstrate that cumulative burden of subconcussive blast exposures is associated with long-term brain function. Independent relationships with the functional connectome were observed for both the average severity and the frequency of subconcussive blast exposures. This contrasts with previous work combining concussive and subconcussive blast demonstrating the highest severity across all exposures was most relevant to long-term brain function. A critical implication of these results is that long-term brain function may be associated with blast exposure, even in the absence of acute clinical effects or noticeable symptoms. This renders subconcussive blast exposure an invisible neurological insult with potential long-term implications for brain function. As military occupational blast exposure (MOBE) is primarily subconcussive in nature, this has direct implications for its conceptualization, regulation, and monitoring.
No previously published repeatability and reliability data for The Sports Concussion Assessment Tool-6 (SCAT6) exists. We aimed to evaluate inter/intra-tester reliability of the off-field SCAT6 in a non-concussed adult population. Inter-rater and Intra-rater reliability study design. Single university site. Twenty active adults (mean age: 27.55 ± 5.59 years) with no recent history of concussion (Concussive injury within past year). Participants completed 3 SCAT6 tests on the same day, with 3 testers (Inter-rater testing). The same participants returned at 2 further time points to complete the remaining 2 SCAT6 tests with 1 tester (Intra-rater testing). Participants complete a total of 5 SCAT6 assessments in total across testers and time. Rater Background: Those completing the SCAT6 testing, our study rater team, comprised of 1 senior physiotherapist and PhD candidate, and 2 MSc Physiotherapy students. All raters were from Scotland, and had significant training in completing SCAT6 assessments. Off-field SCAT6 Domain scores. ICCs were used to establish inter and intra-rater reliability for continuous, ration and ordinal data components of the SCAT6. For nominal data sets, Fleiss's kappa was calculated. Kendall's W was used for non-parametric data. Percentage error scores were calculated for SCAT6 domains. Inter-tester: Symptom number, severity, and dual-task scoring demonstrated excellent reliability (ICC = 0.981; 0.984; 0.913, respectively). Total concentration score was found to have good reliability (0.827). Dual-task errors (0.398), Total mBESS (0.199), and Month recall all returned poor scores (k = 0.191). Intra-tester: Dual tasking was the only domain to report excellent reliability (ICC = 0.943). Symptom number (0.868), severity (0.831), total concentration (0.787), total mBESS (0.813), and time tandem gait (0.834) yielded good reliability scores. Dual-task error testing returned poor reliability scores (Kendall's W = 0.001). All remaining domains yielded moderate reliability. Percentage error rates ranges from 3% to 100%, demonstrating the variability between scores yielded for non-concussed individuals completing the same SCAT6 domain tests. SCAT6 ICC results reported good-excellent reliability for 4 and 6 domains, out of 13 domains, for inter-tester and intra-tester reliability, respectively. Notably, the domains which relied on tester error scoring yielded poor reliability results. Percentage error highlighted the failure of the SCAT6 to provide consistent domain score results in this population.
This Special Communication reflects on progress in understanding the outcomes of pediatric traumatic brain injury (TBI) since the Journal of Head Trauma Rehabilitation special issue (volume 1, issue 4) on "head injury" in children appeared in 1986. We highlight the critical role that prospective, longitudinal cohort studies have played in advancing knowledge about both mild and moderate-severe pediatric TBI. We describe conceptual and methodological innovations that the past 40 years of research has spurred and summarize remaining challenges. These include the need for comparative effectiveness and randomized controlled trials to determine what interventions are effective, singly or in combination, as well as for implementation science to translate research into clinical practice, with the goal being to provide better care and improve outcomes for children with TBI and their families.
Traumatic brain injury (TBI) is recognized as a chronic health condition. The primary objective was to investigate the association between TBI and cardiovascular disease (CVD). Ovid MEDLINE, Ovid MEDLINE Epub Ahead of Print and In-Process, In-Data-Review and Other Non-Indexed Citations, Ovid Embase, Ovid APA PsycInfo, and the Cochrane Library were systematically searched until June 5, 2025. Observational studies that compared diagnoses of CVD, including atherosclerosis, coronary artery disease (CAD), heart failure, cardiomyopathy, arrhythmias, myocardial infarction, hypertension, hyperlipidemia, and cardiac death, between adults with and without TBI were included. Studies that focused on preinjury CVD and conditions, case reports, case series, letters, editorials, conference abstracts, reviews, and interventional studies were excluded. Study quality was evaluated using the National Institutes of Health quality assessment tool. DerSimonian-Laird random-effects meta-analyses were performed. The outcomes of interest were presence of any CVD, including atherosclerosis, CAD, heart failure, cardiomyopathy, arrhythmias, myocardial infarction, hypertension, hyperlipidemia, and cardiac death. This systematic review included 21 studies, with 18 studies involving 3,954,962 participants included in the meta-analysis. Two studies were rated as poor quality, with the rest fair to good. Individuals with TBI had higher odds of any CVD (odds ratio [OR] 1.78, 95% confidence interval [CI] 1.39-2.29), CAD (OR 1.40, 95% CI 1.20-1.63), arrhythmia (OR 1.42, 95% CI 1.12-1.80), cardiac death (risk ratio [RR] 3.07, 95% CI 2.17-3.98), hypertension (OR 1.42, 95% CI 1.07-1.90), and hyperlipidemia (OR 1.86, 95% CI 1.25-2.77) in unadjusted analysis. No association was found with heart failure (OR 1.16, 95% CI 0.96-1.39). The adjusted analysis was consistent with unadjusted findings for CAD, cardiac death, hypertension, and heart failure. Individuals with TBI have higher odds of CVD, hypertension, hyperlipidemia, CAD, arrhythmia, and cardiovascular death than the general population, highlighting the need for clinical screening, prevention, and management strategies after TBI.
To examine sex differences in exposure to military sexual trauma (MST), intimate partner violence (IPV), and traumatic brain injury (TBI) and their associations with new-onset mental health conditions in United States (U.S.) veterans. Retrospective analysis using Defense Health Agency (DHA) and Veterans Health Administration (VHA) data. U.S. service members and veterans (SMVs) who 1) served after September 1, 2001, (2) received DHA health care in ≥3 years between 1999 and 2019, (3) received VHA health care in ≥2 years between 2000 and 2019, and (4) completed MST screening. Participants were excluded if (1) TBI status was unclear, (2) had penetrating head injury, (3) age ≤17 years at the simulated TBI index date, or (4) TBI index date occurred before medical record availability. Retrospective cohort study. Exposure to MST, IPV, TBI, and mental health conditions (eg, post-traumatic stress disorder) were obtained from health records. Index date was TBI diagnosis date or simulated based on age. Sex differences in MST, IPV, and TBI, and their associations with mental health diagnoses after index date were examined. Of 2 530 847 SMVs in the Long-term Impact of Military-relevant Brain Injury Consortium Phenotype study, 1 249 848 (18.2% female) were included. TBI was more prevalent among men (P < .0001), while MST and IPV were more prevalent among women (P < .0001). Veterans with TBI, MST, or IPV had higher risk of developing a new-onset mental health condition after the index TBI, with highest risk among veterans with cumulative trauma exposures (eg, TBI + MST + IPV). Female veterans demonstrated the highest prevalence of MST/IPV exposures, but veterans with cumulative trauma exposures had higher risk of developing a mental health condition following index TBI. Thus, screening for both TBI and interpersonal trauma history would help identify veterans who may benefit from additional services and are at greatest risk for deleterious long-term mental health consequences.