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.
Among Veterans with traumatic brain injury (TBI) who received a cognitive rehabilitation referral, we sought to describe rates of referral completion (ie, Veteran attends the initial encounter). Second, we examined nonclinical factors associated with referral completion. Veterans Health Administration (VHA). Veterans with 1) clinician-confirmed TBI determined using the Comprehensive TBI Evaluation database and 2) a cognitive rehabilitation referral, determined using a validated algorithm (n = 19,923 mild TBI [mTBI]; n = 3797 moderate-severe TBI). Retrospective cohort study of VHA medical record data. Modified Poisson regression was used to model the likelihood of completing a cognitive rehabilitation referral based on nonclinical predisposing (eg, age) and enabling (eg, homelessness) factors. All analyses were stratified by TBI severity (mTBI vs. moderate-severe TBI). Completed cognitive rehabilitation referrals (no/yes), identified in the VHA electronic medical record. Cognitive rehabilitation referrals are documented as "complete" when the Veteran attends an initial encounter with the provider who receives the referral. The proportion of Veterans who completed their cognitive rehabilitation referral was similar across severities, with 69% of Veterans with mTBI and 68% of Veterans with moderate-severe TBI completing the referral. Veterans with mTBI who were older, married, and those who identified as students/homemakers/volunteers or unemployed and not looking (vs. employed) were more likely to complete the referral. Among Veterans with moderate-severe TBI, history of homelessness was associated with a reduced likelihood of completing a cognitive rehabilitation referral. While most Veterans with TBI initiate cognitive rehabilitation after receipt of a referral, a notable portion do not, suggesting missed opportunities for beneficial services in this population. Furthermore, patient factors such as age, marital status, employment status, and history of homelessness were associated with referral completion. Findings lay the foundation for system-level strategies that facilitate engagement with cognitive rehabilitation among Veterans with TBI.
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 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.
To examine the association of select demographic, medical history, and injury-related factors to Concussion Clinical Profile Screening (CP Screen) scores and clinician-adjudicated profiles in patients following concussion. This study used an outpatient concussion specialty clinic setting. Of 5024 patients, 242 participants aged 9 to 51 years ( M = 15.66, SD  = 4.1) were selected who were diagnosed with a concussion at their initial visit within 30 days, had no moderate to severe traumatic brain injury, and had no neurological, substance use, vestibular, or ocular disorders. This is a retrospective cross-sectional study with masked intervention clinicians. The scores of 5 CP Screen profiles (anxiety/mood, cognitive/fatigue, posttraumatic migraine, vestibular, and ocular) and 2 modifiers (sleep and cervical) were correlated with masked clinician-adjudicated clinical profiles. Multiple backward stepwise linear regressions were used to predict scores on the CP Screen. Adjudicated clinical profiles were predicted using multiple backward stepwise logistic regressions (LR) with receiver operating curve analyses of the areas under the curve. CP Screen scores and adjudicated profiles were compared using point biserial correlations. Most risk factors were related to one or more CP Screen scores ( P < .05). Multiple LRs for clinician-adjudicated profiles revealed depression history (OR = 7.58), attention-deficit/hyperactivity disorder learning disabilities (ADHD/LD) history (OR = 2.67), and non-sport-related concussions (non-SRC; OR = 0.27) predicted anxiety/mood profile (area under the curve [AUC] = 0.74, P < .001). Motion sickness history (OR = 0.47) predicted posttraumatic migraine profile (AUC = 0.64, P = .01). ADHD/LD history (OR = 2.67) predicted cognitive/fatigue profile (AUC = 0.65, P = .01). All CP Screen scores correlated with the adjudicated anxiety/mood profile ( r = 0.20-0.47, P < .05) and most scores with vestibular profile ( r = 0.13-0.36, P < .05). Posttraumatic migraine ( r = -0.13 to 0.32, P < .05) and ocular ( r = 0.15-0.34, P < .05) profile scores correlated with most clinical profile adjudications. Numerous preinjury and injury-related factors are useful for identifying CP Screen scores. However, only few factors predicted respective clinician-adjudicated profiles also. These findings highlight the utility of these factors for concussion care and the injury's multifaceted nature.
Although the relationship between physical activity (PA) and clinical outcomes after traumatic brain injury (TBI) has been evaluated in the civilian TBI literature, few studies have examined these relationships in Veterans. We evaluated whether PA moderates the relationship between probable TBI and clinical outcomes in post-9/11 Veterans. This study used electronic health record data sourced from the VA's Corporate Data Warehouse through the VA Million Veteran Program (MVP) and MVP surveys. Participants included MVP-enrolled Veterans (n = 7217; 77.35% male) who were screened for possible deployment-related TBI through the TBI Screening and Evaluation Program. Observational, cross-sectional, retrospective design using secondary data analysis. The TBI Screen was used to classify Veterans into 2 groups: "TBI Screen-" (n = 4921) or "TBI Screen+" (n = 2296). PA was assessed using self-reported frequency of engagement in vigorous exercise on an MVP survey and categorized as None ("No-PA"; n = 1373), Below Recommended ("Below Recommended-PA"; n = 2118), or Meets/Exceeds Recommended ("Meets/Exceeds Recommended-PA"; n = 3726). Clinical outcomes included self-reported assessments of posttraumatic stress disorder symptoms, depression/anxiety symptoms, subjective cognition, and health-related quality of life. Linear regressions, adjusting for sociodemographics, evaluated interactions between TBI Screen status and PA on all outcomes. We observed significant main effects of TBI Screen (P's < .001) and PA (P's ≤ .001 to .003), and significant TBI Screen × PA interactions (P's = .001 to .016) on all outcomes except 1 health-related quality of life measure. Among both TBI Screen groups, a dose-response effect of PA frequency was observed, such that the "Meets/Exceeds Recommended-PA" group fared the best, followed by the "Below Recommended-PA" and then "No-PA" groups; however, this pattern was more pronounced among TBI Screen+ Veterans. Findings suggest a buffering effect of PA on clinical outcomes, particularly among Veterans with a probable TBI history. These results underscore the potential of PA as an accessible intervention for post-9/11 Veterans.
This study compared the effects of 3 different approaches to handling missing data (listwise deletion of participants with missing data, mean imputation, and full information maximum likelihood [FIML]) when predicting functional independence trajectories over 10 years in older adults after traumatic brain injury (TBI). Twenty-three TBI Model Systems (TBIMS) inpatient rehabilitation facilities in the United States. Adults who sustained a complicated mild, moderate, or severe TBI at age 60 years or older and needed inpatient rehabilitation. They had to meet all eligibility criteria and have one or more functional independence measure (FIM) scores at 1, 2, 5, or 10 years post-TBI from the TBIMS national database. Retrospective analysis of observational data using hierarchical linear models. FIM total scores at 1, 2, 5, and 10 years post-TBI. Different missing data approaches led to drastically different findings. Model comparisons supported a quadratic effect of time only in the listwise deletion model and found no other significant predictors. Linear trajectories were found in the mean imputation and FIML models. For both these models, older age, underrepresented minority status, unemployment at injury, longer posttraumatic amnesia duration, and pre-injury limitations all predicted lower overall FIM trajectories. However, when compared with the mean imputation model, the FIML-estimated b-weights were larger with smaller P-values. Years of education significantly predicted higher overall FIM trajectories in the mean imputation model but not the FIML model, likely because of the artificial shrinking of the estimated b-weight standard errors in mean imputation. History of mental health treatment predicted lower FIM trajectories only in the FIML model. These findings show that it is critical to use appropriate modern methods to handle missing data because the method can affect outcome trajectory shape and identification of relevant predictor variables. Using older methods for handling missing data, such as listwise deletion, greatly reduces predictive ability, resulting in less generalizability and imprecision in longitudinal rehabilitation research.
Social determinants of health (SDoH) affect health care access and outcomes. Screening for SDoH is needed to advance health care equity for persons with traumatic brain injury (TBI). The purpose of this scoping review was to examine whether the Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences (PRAPARE®), can be used successfully with persons with more severe TBI (ie, TBI of sufficient severity to require inpatient rehabilitation). We sought to determine whether the tool had been previously used with persons with TBI (or similar populations) and if any difficulties were encountered and/or if any accommodations were provided to foster completion. We also sought to determine whether findings were relevant to improving health care access for persons with TBI. We sought input from persons with TBI regarding difficulties or discomfort with responding to the questions. Community. Scoping review of the literature from 2014 through December 21, 2023, using 8 databases. During the last stage, we sought input from 17 persons living with TBI. PRAPARE®. After screening 140 articles, the scoping review identified 2 studies meeting the inclusion criteria. These studies included patients with glioma (n = 100) and with chronic conditions (n > 7000). No study specified inclusion of persons with TBI. The glioma study allowed for assistance by another person. While the participants in the glioma study were low risk, the study of persons with chronic conditions found that persons with a greater comorbidity burden were more likely to be from socioeconomically disadvantaged or racial/ethnic minoritized backgrounds and have transportation and childcare needs. Input from persons with TBI suggested items are generally well understood. Six items presenting with minor challenges may require accommodations during administration. PRAPARE® may be used with individuals with TBI to screen for social SDoH. Screening considerations include respect of privacy, an individual's choice and priorities, availability of resources, being trauma-informed, and clarifying items that are sensitive and/or difficult to understand.
To provide a comprehensive summary of the existing literature that describes treatment options for post-concussion sleep disturbances in children and adults. Studies have shown that 30%-70% of individuals who sustain a concussion develop a post-injury sleep disturbance. The presence of sleep disturbance contributes to prolonged recovery from concussion and poorer long-term outcomes. Thus, identifying effective treatments for post-concussion sleep disturbances is essential to reduce the burden of persisting post-concussion symptoms. Scoping review. A systematic literature search was conducted in MEDLINE, Embase, CINAHL, Web of Science, and ProQuest Dissertations & Theses Global. Two reviewers screened titles and abstracts, then full-text articles against the inclusion and exclusion criteria. Primary studies that investigated at least 1 treatment for post-concussion sleep disturbances were included. Of the 3660 articles yielded from the initial search, 19 were included in this review. The most commonly studied intervention was CBT (n = 3), followed by blue-light therapy (n = 2), photobiomodulation (n = 2), and melatonin (n = 2). Other treatments included an educational intervention, trauma-focused psychotherapy, 2 novel forms of psychotherapy, acoustic neuromodulation, multisensory integration therapy, gabapentin, hand self-shiatsu, interdisciplinary rehabilitation, and music therapy. The most common study design was a randomized controlled trial (n = 8, 42%). Over half of the studies (n = 13, 68%) used pre-existing validated scoring tools as subjective measures of sleep. Only 4 studies were conducted exclusively in children 18 years and younger. This review supports current guidelines that recommend CBT as a first-line therapy for post-concussion sleep disturbances. However, higher-quality evidence is needed before other interventions should be incorporated into routine practice, particularly for children. Future research should consider the impact of other post-concussion symptoms on adherence to sleep-promoting therapies.
Managing patients on oral anticoagulant therapy (OAC) who present with traumatic intracranial hemorrhage (ICH) poses a critical challenge in balancing the prevention of thromboembolic events and the risk of progression or recurrent ICH. The objective of this systematic review was to determine the optimal timing for resuming OAC in patients with traumatic ICH, and to assess the risk of hemorrhagic and thromboembolic events, and mortality in patients for whom anticoagulation was resumed. With a medical librarian, 4 databases and gray literature were searched without language or date restrictions. Eligible studies included patients with traumatic ICH undergoing OAC resumption and reporting on timing, ICH progression or recurrence, thromboembolic events, and/or mortality. Of 3384 identified studies, 12 cohort studies met inclusion criteria, involving 13,528 patients with varying severities of traumatic brain injury. Most patients were treated with vitamin K antagonists; only 3 studies included patients on direct oral anticoagulants. The median time to resume OAC ranged from 8 to 67 days. In studies limited to traumatic ICH, OAC resumption was not associated with increased recurrent ICH risk with reported RR 0.70 (95% CI, 0.52-0.95) and HR 0.45 (95% CI, 0.26-0.76). All but one study reported reduced thromboembolic events with OAC resumption. The studies also suggested that complete resolution of the initial ICH allowed for safe resumption of OAC. This systematic review suggests that resumption of OAC after traumatic ICH may be considered in selected patients, without a clear evidence of increase in the risk of recurrent ICH and with a potential reduction in thromboembolic events. However, we were unable to define a safe timeframe, and further studies are needed to establish recommendations to guide clinical practice. Level III, Systematic Review and Meta-Analysis.
To evaluate validity, reliability, and targeting of the Norwegian 7-item Fatigue Severity Scale (FSS-7) in adults with moderate-to-severe traumatic brain injury (TBI). Inpatient and outpatient acute care and postacute rehabilitation facilities. Ninety-four patients with intracranial injury, 20% women, with a mean age of 45.8 years (SD = 13.6), provided 185 complete FSS-7 responses at 6 months (n = 94) and 12 months (n = 91) post-TBI. Secondary analysis of data from a longitudinal observational study using the Rasch model and graphical log-linear Rasch models (GLLRM). The FSS-7 is a self-report fatigue measure derived from the original FSS by omitting items 1 and 2. Differential item functioning (DIF) was examined for sex, age, education, and sleep disturbances (Epworth sleepiness scale and insomnia severity index). The FSS-7 did not fit the Rasch model due to poor fit of item 4 and local dependence between items 5 and 6. A 6-item version (FSS-6), excluding item 4, provided good fit to a GLLRM accounting for the local dependence between items 5 and 6. No DIF or item parameter drift over time was detected. The FSS-6 demonstrated excellent reliability (r = 0.936), while targeting was less than optimal, as on average, only 57% of the maximum obtainable test information was reached. The FSS-6, excluding item 4, provides a valid measure of fatigue with excellent reliability for adults at 6 and 12 months post-TBI. The total raw score is invariant across sex, age, educational level, and sleep disturbances with no item parameter drift from 6 to 12 months postinjury. The FSS-6 may be useful for screening and monitoring fatigue in TBI rehabilitation and research, although a reassessment of targeting is recommended for future research on a larger and broader sample of patients.
First, to describe the development of a novel postconcussive symptom (PCS) code set for identifying symptoms via medical records. Second, to apply it to a population-based cohort of service members with a history of mild traumatic brain injury (mTBI) per Military Health System (MHS) records, to identify distinct subgroups based on patterns of risk for specific PCS. MHS. Population-based sample of service members with mTBI who served in the Army, Air Force, Navy, and Marine Corps and received a diagnosis within the MHS (n = 148 293). Retrospective cohort study using medical record data from the MHS spanning 2002 to 2021. In collaboration with clinical experts, we iteratively refined a novel PCS code set comprised of ICD-9/10 codes based on Neurobehavioral Symptom Inventory categories, when possible. We used latent class analysis (LCA) with a split-sample cross-validation procedure to identify subgroups of service members with mTBI based on probability of receiving each PCS diagnosis. The final PCS code set included 20 symptoms, spanning vestibular, sensory, cognitive, and mood/behavioral-related symptoms. The LCA supported 5 distinct subgroups, the most prevalent being the Minimal subgroup (59%), characterized by low probability of all PCS. The next most common class was the Headache class (16%), followed by the Mood-Behavioral (15%), Headache-Sleep (6%), and Headache-Mood-Sleep (5%) classes. Using a novel PCS code set leveraging routinely collected data, we identified 5 clinically meaningful and statistically distinct subgroups based on symptom patterns in a population-based cohort of service members with a history of mTBI. These subgroups provide a nuanced, person-centered understanding of symptoms among those with a history of TBI and can inform targeted interventions and policies aimed at meeting the needs of these service members. Further, findings establish a foundation for investigating risk factors and outcomes across subgroups, informing prognostication.
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.
To investigate impairment rates on the Brief Test of Adult Cognition by Telephone (BTACT) domains and subtests by race/ethnicity, education, and primary language for individuals with moderate-to-severe traumatic brain injury (TBI) in the Traumatic Brain Injury Model Systems (TBIMS) national database. Secondary analysis of the TBIMS national database. A total of 2,981 adults with complicated-mild-to-severe TBI who completed all BTACT subtests at 1-year follow-up (Mage = 41.0 years; 27.1% Female; Meducation = 13.6 years; 63.5% White). Cross-sectional observational study. Brief Test of Adult Cognition by Telephone domain and subtest scores were standardized using combined Midlife Development in the US norms. Cognitive impairment was defined as scores ≤ -1.5 below the normative means. Impairment rates were compared across race/ethnicity, language of administration (Spanish versus English), and education. Logistic regression models evaluated the contribution of race/ethnicity, education, and language to impairment after controlling for variables that the normative data are stratified on (age, education, sex). Participants who identified as Black, Hispanic, or multiracial were more likely to be classified as cognitively impaired on the BTACT domain scores and subtests. Individuals with ≤eighth grade education had higher impairment rates on recall and executive function measures. Spanish-language administration revealed increased odds of impairment on executive functioning tasks. Racial/ethnicity disparities in impairment persisted after adjustment for age, sex, and years of education. Findings indicate that BTACT normative data disproportionately classify those with lower education, racial/ethnic minority, and Spanish speakers as cognitively impaired. This can result in misinterpretation of disparities in cognitive outcomes and highlight the need for demographically representative normative data. Appropriate norms are critical for accurate assessment of cognitive outcomes and for the valid interpretation of the trajectories in diverse TBI populations.
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 compare head motion capacity during a prescribed in-laboratory task with head motion performance in free-living daily life in individuals with mild traumatic brain injury (mTBI) and healthy controls. A secondary objective was to assess whether in-laboratory peak head motion metrics were associated with near maximal (95th percentile) free-living movements. Research laboratory and participants' daily environments over 7 days of continuous monitoring. Twenty-three adults participated: 10 individuals with subacute, symptomatic mTBI (5F; age 30.3 (7.7) years; 35.2 (20.1) days postinjury) and 13 healthy controls (7F; age 31.9 (9.6) years). Participants were free of neurological, musculoskeletal, or balance-affecting conditions. Observational study combining a laboratory gait task with horizontal head turns and a 7-day free-living monitoring period using wearable inertial sensors on the head and lumbar spine. In-laboratory head turn amplitude and peak angular velocity (capacity); daily-life amplitude and angular velocity distributions (mean, median, 95th percentile), intra- and interday variability (performance); and associations with free-living measures. Individuals with mTBI demonstrated slower in-laboratory head turns than controls (223.53 (62.32) deg/s versus 302.01 (55.88) deg/s; P = 0.006), with no difference in amplitude. Daily-life amplitude and velocity did not differ between the groups. However, mTBI participants showed consistently smaller intra- and interday variability (P < 0.05), indicating more constrained daily movement patterns. Associations between in-laboratory peaks and free-living 95th percentile values were weak (r = -0.22 for amplitude; r = 0.10 for angular velocity). Although mTBI participants show reduced head motion capacity in laboratory tasks, their average daily-life kinematics are comparable to healthy adults. Reduced variability suggests constrained free-living movement strategies. These findings highlight the dissociation between capacity and performance and support integrating both laboratory assessments and continuous monitoring as complementary measures to fully characterize motor behavior following mTBI.
To conduct a systematic review and meta-analysis of studies examining the proportion of first responders (law enforcement and corrections officers, firefighters, and emergency medical services personnel) with traumatic brain injury (TBI). This review is reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and was a priori registered in PROSPERO. Eligible observational and interventional studies reporting the proportion of first responders with TBI (lifetime history; job/career-related; job/training-related; event-related) were identified and data were abstracted by 2 independent reviewers (with disagreements resolved by a third reviewer) from systematic searches in 5 databases (PubMed, Embase, Scopus, CINAHL [Cumulative Index to Nursing and Allied Health Literature], and Web of Science). Random-effects meta-analyses were performed when population-based denominators were available with between-study heterogeneity evaluated using I2. Risk of bias was assessed using an adapted Newcastle-Ottawa Scale. Twenty-three studies met inclusion criteria, with 5 contributing data to meta-analyses. Studies were heterogeneous in the method of TBI ascertainment, with some defining TBI from self-reported validated or unvalidated survey responses and others using medical or job-related administrative data to define TBI. Furthermore, definitions and language regarding the injury were heterogeneous between studies, with some studies referring to TBI (with or without loss of consciousness) and others referring to concussion or head injury/trauma. Among law enforcement and corrections officers, the pooled prevalence of lifetime TBI was 58.8% (95% confidence interval [CI]: 48.0%-69.6%; I2 = 91.5%), and the proportion with job/career-related TBI was 17.2% (95% CI: 5.8%-28.6%; I2 = 97.2%). Firefighters were found to have high self-reported lifetime TBI prevalence (62%-77%), although data were limited. Emergency medical service data were sparse and largely restricted to administrative or event-related reports. Traumatic brain injury is common among first responders, but studies are heterogeneous. Standardized TBI definition, surveillance, routine screening, and longitudinal occupational health monitoring are needed to address cumulative injury risk and inform prevention and policy.
To determine the incidence of benign paroxysmal positional vertigo (BPPV) among adults with traumatic brain injury (TBI) undergoing inpatient rehabilitation using routine vestibular screening independent of symptom report, and to describe clinical presentation, canal characteristics, and response to canalith repositioning maneuvers. Retrospective cohort study. Inpatient rehabilitation hospital. Consecutive adults admitted for inpatient rehabilitation after TBI. Medical records were retrospectively reviewed for all patients with traumatic brain injury admitted to inpatient rehabilitation who underwent standardized vestibular assessment as part of routine screening irrespective of dizziness complaints. BPPV was diagnosed based on documented positional nystagmus consistent with Bárány Society criteria. Incidence was defined as the proportion of patients diagnosed with BPPV among those who completed routine vestibular assessment during inpatient rehabilitation. Symptom status, canal involvement, and treatment outcomes were descriptively analyzed. Of 119 patients screened, 10 could not be reliably assessed and were excluded. Among 109 assessed patients, 49 were diagnosed with BPPV, yielding an incidence of 45.0% (95% CI: 35.4%-54.8%). Of the 49 patients with BPPV, 19 (38.8%) reported dizziness before vestibular assessment, 13 (26.5%) reported symptoms only during positional testing, 9 (18.4%) reported no subjective vertigo despite objective positional nystagmus, and 8 (16.3%) were unable to reliably report symptom status because of cognitive or communication impairment. Posterior canal involvement was most common (65.3%), followed by horizontal canal involvement (22.4%) and multiple-canal involvement (12.2%). Canalith repositioning maneuvers resulted in resolution in 95.9% of cases (95% CI: 86.0%-99.5%). Most patients (73.5%) resolved with a single session, 20.4% required 2 sessions, and 6.1% required 3 or more sessions (median 1 session; range 1-3). BPPV is a common complication of TBI during inpatient rehabilitation. Routine vestibular screening identified cases that would not have been detected through spontaneous symptom reporting alone, including individuals without subjective vertigo and those unable to reliably report symptoms.
To document and characterize headache and dizziness provocation during mental imagery of real-life symptom-provoking movements in patients with persistent postconcussive symptoms (PPCS). Outpatient rehabilitation department at Reuth Rehabilitation Hospital, Tel Aviv, Israel. Thirteen adults (7 females; mean age 34.3 ± 12.6 years) undergoing multidisciplinary rehabilitation for PPCS with functional decline after mild traumatic brain injury. All were ≥3 months postinjury, reported both headache and dizziness, and had a known real-life symptom trigger (eg, movements, activity). Patients with cognitive, linguistic, or psychiatric impairments were excluded. Case series. The primary outcome was the result of mental imagery testing of symptom-provoking movements for headache and dizziness, routinely performed as part of vestibular evaluation protocol at the facility. Secondary outcomes included demographics, medical history, clinical trajectory, imaging results, current medications, symptom questionnaires scores (Brief Pain Inventory, Dizziness Handicap Inventory), and vestibular bedside assessments findings. Headache was provoked in 9 out of 13 patients (69.2%), and dizziness in 11 out of 13 patients (84.6%) during mental imagery of real-life symptom-provoking movements. Five of the 13 patients (38.5%) had oculomotor and vestibular abnormalities (eg, benign paroxysmal positional vertigo, vestibular asymmetry, oculomotor deficits). Symptom reproduction occurred regardless of vestibular pathology in 3 out of 5 cases with oculomotor or vestibular abnormalities. All patients reported additional symptoms, such as musculoskeletal pain, fatigue, and sleep disturbances. This case series identifies a novel clinical phenomenon in patients with PPCS, where mental imagery of symptom-provoking movements provokes headache and dizziness. These findings suggest a potential link between mental imagery and symptom exacerbation, supporting the notion that PPCS may reflect functional rather than structural mechanisms. This perspective underscores the need for further research to elucidate underlying mechanisms and explore potential therapeutic interventions.
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.