Computerized cognitive testing with software programs such as the Automated Neuropsychological Assessment Metrics (ANAM) have long been used to assess cognition in military samples. This study describes demographic influences on computerized testing performance in a large active duty military sample (n = 2366). Performance differences between men and women were minimal on most ANAM subtests, but there was a clear speed/accuracy trade-off, with men favoring speed and women favoring accuracy on the Continuous Performance Test (CPT) subtest. As expected, reaction time increased with age on most subtests, with the exception of Mathematical Processing Test (MTH). Higher education resulted in significant but minimal performance increases on Code Substitution (CDS), Matching to Sample (MSP), and Memory Search (STN) subtests. In contrast, substantial performance differences were seen between education groups on the MTH subtest. These data reveal that it is important to consider demographic factors, particularly age, when using ANAM to draw conclusions about military samples. These results also point to the importance of exploring demographic influences for all reaction time-based computerized assessment batteries.

Objective : To ascertain the value of relatively simple quantitative radiologic measurements after head injury. Despite major advances in neuroradiology, analysis and reporting of imaging studies is based primarily on individual subjective and local experience, rather than on reproducible, standardized parameters; reliance on newer technologies can improve care, but also raises diagnostic costs. Design : Blinded, retrospective, quantitative assessment of computerized tomography studies done some 14 years post-injury. Outcome measures : Frontal horn width (FHW); septum-caudate distance (SCD); temporal horn width (THW); interuncal distance (IUD); third ventricle width (3VW); ventricular score (VS); sulcal width (SW); gray-white matter discriminability (GWMD) and subjective assessment of atrophy (SAOA). Results : Diffuse and frontal damage was noted in both closed (CHI) and penetrating (PHI) head injury groups. Enlargement of frontal lobe parameters (septum caudate distance and frontal horn width suggest frontal injury in both closed and penetrating traumatic brain injury (TBI). Temporal horn width and inter-uncal distance were related to VS, 3VW and FHW in closed, but not in penetrating head injury. Conclusions : Simple linear CSF space measurements are correlated with volumetric and parenchymal measures, and can represent valuable and reliable low-cost quantitative measures of long term brain damage after TBI.

Context : Functional outcome in relation to CT findings in traumatic brain injured (TBI) patients is not well established in relation to cognitive and vocational outcome. Objective : To investigate the possible correlation between relatively simple quantitative radiological measurements and cognitive and vocational outcome. Design : Retrospective analysis of quantitative assessment of CT studies in relation to post-injury cognitive changes and vocational outcome. Setting : US Army Medical Centre. Patients : 74 penetrating head injured (PHI) and 37 closed head injured (CHI) Vietnam war veterans. Outcome measures : The Armed Forces Qualification Test (AFQT); Disability score; Return to work. Results : Total brain volume loss, third ventricle width (3VW), ventricular score (VS), and septumcaudate distance (SCD) were significantly related to cognitive change and return to work in PHI patients. Volume loss and 3VW were the most valuable radiologic predictors of outcome in multivariate linear and logistic regression models for both CHI and PHI. Conclusion : 3VW on late CT scans following traumatic brain injury is a powerful predictor of overall long-term cognitive outcomes and potential for return to work.

Confirmatory factor analysis was used to investigate the nature of memory distinctions underlying the performance of two samples: a sample of male Vietnam War veterans who had not received head injuries, and a second sample of male Vietnam War veterans who had suffered penetrating head injuries resulting in relatively small lesions (< 10 cc volume loss). For these two groups, comparisons were made of the fit of seven theory-based memory models, comprising from one to four factors. The four-component model with a verbal-episodic component, a visual-episodic component, a semantic component, and a short-term memory component provided a significantly better account of memory performance than the others. The implications of these findings and some advantages of this approach as a supplement to a purely experimental approach to memory are discussed.

CONTEXT:Traumatic brain injury (TBI) is a principal cause of death and disability in young adults. Rehabilitation for TBI has not received the same level of scientific scrutiny for efficacy and cost-efficiency that is expected in other medical fields.OBJECTIVE:To evaluate the efficacy of inpatient cognitive rehabilitation for patients with TBI.DESIGN AND SETTING:Single-center, parallel-group, randomized trial conducted from January 1992 through February 1997 at a US military medical referral center.PATIENTS:One hundred twenty active-duty military personnel who had sustained a moderate-to-severe closed head injury, manifested by a Glasgow Coma Scale score of 13 or less, or posttraumatic amnesia lasting at least 24 hours, or focal cerebral contusion or hemorrhage on computed tomography or magnetic resonance imaging.INTERVENTIONS:Patients were randomly assigned to an intensive, standardized, 8-week, in-hospital cognitive rehabilitation program (n=67) or a limited home rehabilitation program with weekly telephone support from a psychiatric nurse (n=53).MAIN OUTCOME MEASURES:Return to gainful employment and fitness for military duty at 1-year follow-up, compared by intervention group.RESULTS:At 1-year follow-up, there was no significant difference between patients who had received the intensive in-hospital cognitive rehabilitation program vs the limited home rehabilitation program in return to employment (90% vs 94%, respectively; P=.51; difference, 4% [95% confidence interval ¿CI¿, -5% to 14%]) or fitness for duty (73% vs 66%, respectively; P=. 43; difference, 7% [95% CI, -10% to 24%]). There also were no significant differences in cognitive, behavioral, or quality-of-life measures. In a post-hoc subset analysis of patients who were unconscious for more than 1 hour (n = 75) following TBI, the in-hospital group had a greater return-to-duty rate (80% vs 58%; P=. 05).CONCLUSIONS:In this study, the overall benefit of in-hospital cognitive rehabilitation for patients with moderate-to-severe TBI was similar to that of home rehabilitation. These findings emphasize the importance of conducting randomized trials to evaluate TBI rehabilitation interventions. JAMA. 2000;283:3075-3081

Context Traumatic brain injury (TBI) is a principal cause of death and disability in young adults. Rehabilitation for TBI has not received the same level of scientific scrutiny for efficacy and cost-efficiency that is expected in other medical fields.Objective To evaluate the efficacy of inpatient cognitive rehabilitation for patients with TBI.Design and Setting Single-center, parallel-group, randomized trial conducted from January 1992 through February 1997 at a US military medical referral center.Patients One hundred twenty active-duty military personnel who had sustained a moderate-to-severe closed head injury, manifested by a Glasgow Coma Scale score of 13 or less, or posttraumatic amnesia lasting at least 24 hours, or focal cerebral contusion or hemorrhage on computed tomography or magnetic resonance imaging.Interventions Patients were randomly assigned to an intensive, standardized, 8-week, in-hospital cognitive rehabilitation program (n=67) or a limited home rehabilitation program with weekly telephone support from a psychiatric nurse (n=53).Main Outcome Measures Return to gainful employment and fitness for military duty at 1-year follow-up, compared by intervention group.Results At 1-year follow-up, there was no significant difference between patients who had received the intensive in-hospital cognitive rehabilitation program vs the limited home rehabilitation program in return to employment (90% vs 94%, respectively; P=.51; difference, 4% [95% confidence interval {CI}, -5% to 14%]) or fitness for duty (73% vs 66%,respectively; P=.43; difference, 7% [95% CI, -10% to 24%]). There also were no significant differences in cognitive, behavioral, or quality-of-life measures. In a post-hoc subset analysis of patients who were unconscious for more than 1 hour (n=75) following TBI, the in-hospital group had a greater return-to-duty rate (80% vs 58%; P=.05).Conclusions In this study, the overall benefit of in-hospital cognitive rehabilitation for patients with moderate-to-severe TBI was similar to that of home rehabilitation. These findings emphasize the importance of conducting randomized trials to evaluate TBI rehabilitation interventions.

Section II. Military Traumatic Brain (Head) Injury Data 7-8 7-7. Magnitude ofthe Traumatic Brain (Head) Injury Problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 7-8 7-8. Incidence ofTraumatic Brain (Head) Injuries 7-10 7-9. Severity ofTraumatic Brain (Head) Injuries 7-12 7-10. Causes ofTraumatic Brain (Head) Injuries and Relative Risks of Important Causes 7-16 7-11. Costs ofTraumatic Brain (Head) Injuries 7-20

A Likert scale questionnaire was developed to assess motivation for postacute rehabilitation by traumatic brain injury patients. Items were designed to reflect head-injured individuals' statements about their attitudes toward head injury rehabilitation. Factors such as denial of illness, anger, compliance with treatment, and medical information seeking behavior were used to assess unfavorable and favorable components of motivation. Reliability was assessed using Cronbach's Alpha, which was found to be 0.91 for the total scale. Four factor analysis derived subscales were identified: Lack of Denial, Interest in Rehabilitation, Lack of Anger, and Reliance on Professional Help. Correlation and multiple regression analyses demonstrated moderate relationships between MOT-Q and several MMPI-2 variables largely related to indicators of somatic distress, depression and capacity for self-sufficiency. Lack of Denial subscale showed the strongest relationship to MMPI-2 of all MOT-Q variables, while Interest in Rehabilitation showed the best correlation to the MOT-Q total.

The WF Caveness Vietnam Head Injury Study includes over a thousand men who survived penetrating head injuries during the Vietnam War and on whom detailed medical and follow-up data are available. This population offers unique opportunities for the study of recovery from brain injury and of brain structure-function relationships. The authors briefly review long-term outcome in this cohort with respect to traumatic unconsciousness, post-traumatic epilepsy, and elements of psychologic and psychosocial function, including returning to work.

We investigated the relationship of neurologic, neuropsychological, and social interaction impairments to the work status of a large sample of penetrating head-injured patients wounded some 15 years earlier during combat in Vietnam. Extensive standardized testing of neurologic, neuropsychological, and social functioning was done at follow-up on each head-injured patient (N = 520), as well as on a sample of uninjured controls (N = 85). Fifty-six percent of the head-injured patients were working at follow-up compared with 82% of the uninjured controls. Seven systematically defined impairments proved to be most correlated with work status. These were post-traumatic epilepsy, paresis, visual field loss, verbal memory loss, visual memory loss, psychological problems, and violent behavior. These disabilities had a cumulative and nearly equipotent effect upon the likelihood of work. We suggest that a simple summed score of the number of these seven disabilities can yield a residual "disability score" which may prove to be a practical tool for assessing the likelihood of return to work for patients in this population and perhaps in other brain-injured populations. These findings may also help to focus rehabilitation efforts on those disabilities most likely to affect return to work.