title: Outcome Trends after US Military Concussive Traumatic Brain Injury.
abstract: Care for US military personnel with combat-related concussive traumatic brain injury (TBI) has substantially changed in recent years, yet trends in clinical outcomes remain largely unknown. Our prospective longitudinal studies of US military personnel with concussive TBI from 2008-2013 at Landstuhl Regional Medical Center in Germany and twp sites in Afghanistan provided an opportunity to assess for changes in outcomes over time and analyze correlates of overall disability. We enrolled 321 active-duty US military personnel who sustained concussive TBI in theater and 254 military controls. We prospectively assessed clinical outcomes 6-12 months later in 199 with concussive TBI and 148 controls. Global disability, neurobehavioral impairment, depression severity, and post-traumatic stress disorder (PTSD) severity were worse in concussive TBI groups in comparison with controls in all cohorts. Global disability primarily reflected a combination of work-related and nonwork-related disability. There was a modest but statistically significant trend toward less PTSD in later cohorts. Specifically, there was a decrease of 5.9 points of 136 possible on the Clinician Administered PTSD Scale (-4.3%) per year (95% confidence interval, 2.8-9.0 points, p = 0.0037 linear regression, p = 0.03 including covariates in generalized linear model). No other significant trends in outcomes were found. Global disability was more common in those with TBI, those evacuated from theater, and those with more severe depression and PTSD. Disability was not significantly related to neuropsychological performance, age, education, self-reported sleep deprivation, injury mechanism, or date of enrollment. Thus, across multiple cohorts of US military personnel with combat-related concussion, 6-12 month outcomes have improved only modestly and are often poor. Future focus on early depression and PTSD after concussive TBI appears warranted. Adverse outcomes are incompletely explained, however, and additional studies with prospective collection of data on acute injury severity and polytrauma, as well as reduced attrition before follow-up will be required to fully address the root causes of persistent disability after wartime injury.
authors.affiliation: 1 Washington University School of Medicine , St. Louis, Missouri.|2 Department of Neurological Surgery, University of Washington , Seattle, Washington.
authors.forename: Christine L
authors.initials: CL
authors.lastname: Mac Donald
authors.affiliation: 1 Washington University School of Medicine , St. Louis, Missouri.
authors.forename: Ann M
authors.initials: AM
authors.lastname: Johnson
authors.affiliation: 3 Landstuhl Regional Medical Center , Landstuhl, Germany .
authors.forename: Linda
authors.initials: L
authors.lastname: Wierzechowski
authors.affiliation: 3 Landstuhl Regional Medical Center , Landstuhl, Germany .
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Kassner
authors.affiliation: 3 Landstuhl Regional Medical Center , Landstuhl, Germany .
authors.forename: Theresa
authors.initials: T
authors.lastname: Stewart
authors.affiliation: 1 Washington University School of Medicine , St. Louis, Missouri.
authors.forename: Elliot C
authors.initials: EC
authors.lastname: Nelson
authors.affiliation: 1 Washington University School of Medicine , St. Louis, Missouri.
authors.forename: Nicole J
authors.initials: NJ
authors.lastname: Werner
authors.affiliation: 4 Naval Medical Center Portsmouth , Portsmouth, Virginia.|5 Department of Neurology, Berkshire Medical Center , Pittsfield, Massachusetts.
authors.forename: Octavian R
authors.initials: OR
authors.lastname: Adam
authors.affiliation: 4 Naval Medical Center Portsmouth , Portsmouth, Virginia.|6 Department of Neurosurgery, Virginia Commonwealth University , Richmond, Virginia.
authors.forename: Dennis J
authors.initials: DJ
authors.lastname: Rivet
authors.affiliation: 3 Landstuhl Regional Medical Center , Landstuhl, Germany .|7 Acute Surgical Care Specialists , El Paso, Texas.
authors.forename: Stephen F
authors.initials: SF
authors.lastname: Flaherty
authors.affiliation: 3 Landstuhl Regional Medical Center , Landstuhl, Germany .|8 Trauma, Critical Care, and Acute Care Surgery, Walter Reed National Military Medical Center , Bethesda, Maryland.
authors.forename: John S
authors.initials: JS
authors.lastname: Oh
authors.affiliation: 3 Landstuhl Regional Medical Center , Landstuhl, Germany .|9 Trauma and Critical Care, Oregon Health and Sciences University , Portland, Oregon.
authors.forename: David
authors.initials: D
authors.lastname: Zonies
authors.affiliation: 3 Landstuhl Regional Medical Center , Landstuhl, Germany .|10 US Air Force Center for Sustainment of Trauma & Readiness Skills, R. Adams Cowley Shock Trauma Center, University of Maryland , Baltimore, Maryland.
authors.forename: Raymond
authors.initials: R
authors.lastname: Fang
authors.affiliation: 1 Washington University School of Medicine , St. Louis, Missouri.
authors.forename: David L
authors.initials: DL
authors.lastname: Brody
mesh_terms: D000328:Adult; D001753:Blast Injuries / Q000150:complications / Q000453:epidemiology / Q000503:physiopathology*; D001924:Brain Concussion / Q000150:complications / Q000453:epidemiology / Q000503:physiopathology*; D060825:Cognitive Dysfunction / Q000453:epidemiology / Q000209:etiology / Q000503:physiopathology*; D003863:Depression / Q000453:epidemiology / Q000503:physiopathology*; D005260:Female; D005500:Follow-Up Studies; D023261:Glasgow Outcome Scale / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D008889:Military Personnel / Q000706:statistics & numerical data*; D012720:Severity of Illness Index; D013313:Stress Disorders, Post-Traumatic / Q000453:epidemiology / Q000503:physiopathology*; D014481:United States / Q000453:epidemiology; D055815:Young Adult
keywords: PTSD; blast TBI; clinical outcomes; concussive TBI