IntroductionThe Department of Defense is working to establish effective rehabilitative management options for individuals who have experienced Anomalous Health Incidents (AHI).MethodsThis retrospective, observational study conducted at Walter Reed National Military Medical Center describes the clinical presentation of forty patients (21 female and 19 male; mean [SD] age, 43.3 [9.2] years) with reported AHI. It also describes the application of a cognitive training intervention, its utilization, patient satisfaction, and changes in cognitive performance and symptoms over time. At baseline, the overall pattern of objective cognitive efficiency scores was within normal limits, though numerically below healthy norms. However, patients performed below normal limits on measures of processing speed. Patient self-report surveys found slightly elevated psychological symptoms, highly elevated neurobehavioral and headache symptoms, and severe impact on life.ResultsPatients used an at-home cognitive training program and provided generally positive feedback regarding the program. On an internal clinic survey, over 75% of the patients felt that participation helped in areas of memory, visuo-spatial skills, and attention. Some changes in objective cognitive testing were observed over time. Self-reported symptoms, which were not directly targeted in the intervention, did not change over time.DiscussionThis study demonstrates that the clinical integration of targeted cognitive training for individuals reporting cognitive symptoms following an AHI is feasible and acceptable, with patients demonstrating good engagement and a positive clinical trajectory in cognitive efficiency over time.

To examine the relationship between intimate partner (IP) caregiver strain with health and family outcomes in military couples with service members and veterans (SMV) experiencing chronic symptoms following traumatic brain injury (TBI). Participants included 202 military couples (N = 404) classified into two groups: [1] Caregiving (169 dyads) and [2] Non-Caregiving (33 dyads). The Caregiving group was further classified into [1a] High Caregiver Strain (61 dyads) and [1b] Low Caregiver Strain (86 dyads) groups; excluding 22 dyads to maximize group distinction. Dyads completed measures of physical, psychological, social, caregiving, neurobehavioral, and/or family outcomes. IPs in the High Caregiver Strain group reported significantly worse scores on health and family outcome measures compared to IPs in the Low Caregiver Strain and Non-Caregiving groups (p<.05, d=0.57-1.97). SMVs of IPs in the High Caregiver Strain Group reported worse scores on outcome measures compared to SMVs of IPs in the Low Caregiver Strain and Non-Caregiving Groups (p<.05, d=0.33-0.1.60). High caregiver strain was associated with assisting SMVs with greater difficulty performing activities (p<.05, d=0.44-0.75) and providing care more hours per day (p<.001, PR = 1.90), but not TBI severity (p=.272, PR = 1.66). A higher prevalence of dyads in the High Caregiver Strain group reported clinically elevated symptoms (≥ 60T) on the health and family outcome measures (11.5

Objective: The recently updated American Congress of Rehabilitation Medicine diagnostic criteria for mild traumatic brain injury (mTBI) removed retrograde amnesia (RA) as a main criterion for mTBI, recommending it be included as a substitute criterion only when posttraumatic amnesia (PTA) cannot be reliably assessed. This study aimed to investigate the evidence base for this recommendation. Setting: Military treatment facility. Participants: A total of 752 US military service members/veterans (mean age = 36.1 years, SD = 9.4 years) with a history of TBI prospectively enrolled in the Defense and Veterans Brain Injury Center-Traumatic Brain Injury Center of Excellence 15-Year Longitudinal TBI study who sustained a total of 1015 TBIs with substantiated RA and PTA. Most participants were male (93.6%), not of Hispanic Origin (84.7%), and White (84.5%). Evaluations were conducted on average 7.6 years (SD = 6.9 years) after injury. Design: Case series. Main Measures: Presence and duration of RA and PTA; and ratio of PTA and RA (PTA:RA). Results: There were no TBIs where RA was present but PTA was absent. Within the 1015 TBIs, 896 (88.3%) involved both RA and PTA, 65 (6.4%) involved PTA only, and 54 (5.3%) did not involve RA or PTA. For the 635 TBI events with substantiated recorded minutes of RA and PTA both >0, the mean ratio of PTA:RA was 31:1. In only one instance was the ratio of PTA:RA <1. Conclusion: There were no TBIs where RA was present without PTA. RA tended to be much shorter than PTA. Findings support the American Congress of Rehabilitation Medicine’s decision to remove RA as a main criterion for mTBI.

ObjectiveUsing a dyadic approach, this study examined health and family outcomes in military couples following service member and veteran (SMV) traumatic brain injury (TBI), within the context of relationship satisfaction.MethodsParticipants included 164 dyads (N = 328), composed of US SMVs (n = 164) and their intimate partners (IPs, n = 164). Dyads completed a measure of relationship satisfaction, as well as measures of psychological, social, caregiving, family, neurobehavioral, and/or PTSD outcomes. Dyads were classified into four relationship satisfaction groups: (1) SMV and IP satisfied (Both Satisfied, n = 72 dyads), (2) SMV satisfied and IP dissatisfied (SMVsat/IPdis, n = 25 dyads), (3) SMV dissatisfied and IP satisfied (SMVdis/IPsat, n = 21 dyads), and (4) SMV and IP dissatisfied (Both Dissatisfied, n = 46 dyads).ResultsWithin dyads, SMVs reported worse scores than their IPs, except in the SMVsat/IPdis group, where their dissatisfied IPs reported worse scores on four measures. Across groups, dissatisfied SMVs reported worse scores compared to satisfied SMVs, and dissatisfied IPs reported worse scores compared to satisfied IPs. Satisfied and dissatisfied SMVs and IPs in the mixed relationship satisfaction groups reported little to no differences across measures compared to their respective SMVs and IPs in the Both Satisfied and Both Dissatisfied groups, with the exception of the family measures for dissatisfied SMVs or IPs.ConclusionsRelationship dissatisfaction was related to worse health and family outcomes, even when the other members of the dyad reported satisfaction in their relationship. A dual-goal, dyadic approach to TBI treatment that focuses on how individual, couple, and family factors interact will likely maximize service member recovery and return to duty, as well as outcomes for military families.

Objective:To examine the relationship between family functioning and health-related quality of life (HRQOL) outcomes following traumatic brain injury (TBI) in service members and veterans (SMVs). Participants:Participants were 359 United States SMVs classified into three groups: non-injured controls (NIC, n = 62); uncomplicated mild TBI (MTBI; n = 189); and complicated mild, moderate, severe, and penetrating TBI (STBI; n = 108). Participants completed 10 HRQOL measures from the TBI-QOL and Neuro-QOL, and the Family Assessment Device-General Functioning subscale (FAD-GF) 2-or-more years post-injury. Using the FAD-GF, the NIC, MTBI, and STBI participants were divided into six subgroups: Group 1 = NIC Healthy Family Functioning (HFF) (n = 34); Group 2 = NIC Unhealthy Family Functioning (UnHFF) (n = 28); Group 3 = MTBI HFF (n = 88); Group 4 = MTBI UnHFF (n = 101); Group 5 = STBI HFF (n = 58); and Group 6 = STBI UnHFF (n = 50). Results:Participants with UnHFF had a significant and meaningfully higher number of clinically elevated HRQOL scores compared to those with HFF in the MTBI (p < 0.001, η p 2 =0.07) and STBI (p = 0.001, η p 2 =0.10) groups, but not in the NIC group (p = 0.107, η p 2 =0.04). There were no differences in the total number of clinically elevated HRQOL scores when comparing the MTBI and STBI HFF groups to controls (p = 0.074 to 0.841). The MTBI and STBI UnHFF groups had a significant and meaningfully higher number of clinically elevated HRQOL scores when compared to controls (p < 0.001 to p = 0.018; η p 2 =0.07 to.14). The MTBI UnHFF group was 10 to 28 times more likely to have poor HRQOL outcome compared to controls. The STBI UnHFF group was 6 to 17 times more likely to have poor HRQOL outcome compared to controls. Conclusion:UnHFF was strongly associated with poor long-term HRQOL. HFF was strongly associated with good long-term HRQOL outcome. Assessment and management of family distress may facilitate better TBI recovery and readiness in warfighters.

Objective: Using a dyadic approach with military couples, the current study examined family risk factors for chronic neurobehavioral symptoms in service members and veterans (SMVs) following a mild traumatic brain injury (MTBI). Setting : Military Treatment Facility. Participants : SMV ( n = 122) and intimate partner (IPs, n = 122) dyads ( N = 244). Design : Prospective cohort. Main Measures: SMVs completed seven neurobehavioral outcome measures. Their intimate partners completed 12 health-related quality of life (HRQOL) risk factor measures. Both members of the dyad completed three family relationships risk factor measures. Results: The number of neurobehavioral measures that were clinically elevated (≥60 T) were summed and used to classify SMVs into three outcome groups: (1) None/Few Symptoms [0–1 elevated scores]; (2) Several Symptoms [2–3 elevated scores]; and (3) Many Symptoms [4–7 elevated scores]. SMVs in the Many Symptoms group had significantly higher scores on nine family risk factor measures compared to the None/Few Symptoms group, and seven family risk factor measures compared to the Several Symptoms group. The Several Symptoms group had higher scores on one risk factor measure compared to the None/Few Symptoms group. The largest effect sizes were found for the SMV family relationships risk factor measures. SMVs were 4.2 to 13.0 times more likely to have poor neurobehavioral outcomes when they had negative versus positive family relationships. Conclusion: An important and unique addition to the literature was the finding that a range of risk factors in the SMV’s family environment were strongly associated with clinically elevated chronic neurobehavioral symptoms following an MTBI. The establishment of the Family Wellness Program within the Defense Intrepid Network will open the door for family wellness to have a long-term place in military TBI treatment programs as a holistic, family-centered interdisciplinary model of care for warfighter brain health and return to duty following a TBI, and healthy, resilient, and military ready families.

This report details a bench to bedside translation of behavioral and social science research into a clinical program as a result of a collaboration between two United States Defense Health Agency Centers of Excellence for warfighter traumatic brain injury (TBI) and brain health. Identifying a gap in health-related quality of life (HRQOL) measures, our team instigated a 7-year multisite effort to validate and develop generic and caregiver specific HRQOL domains for family members of warfighters and civilians with a TBI using state-of-the-science measurement development standards; the Traumatic Brain Injury Caregiver Quality of Life (TBI-CareQOL) measurement system. The TBI-CareQOL was integrated into the Defense and Veterans Brain Injury Center-Traumatic Brain Injury Center of Excellence 15-Year Longitudinal TBI Study designed to address four elements in a Congressional mandate (NDAA FY2007 Sec721 Public Law 109-364). Based on findings from the 15-Year Longitudinal TBI study and larger body of related literature demonstrating the bidirectional associations between warfighter neurobehavioral outcomes and family distress, relevant TBI-CareQOL measures were integrated into the Family Wellness Program (FWP) for intimate partner (IP) beneficiaries of warfighters with TBI in treatment for chronic neurobehavioral symptoms across the Defense Intrepid Network for Traumatic Brain Injury and Brain Health (DIN). The FWP screens IPs for clinically elevated HRQOL symptoms with clinical follow up offered in alignment with operations at each DIN treatment center and military base. In July 2024, the FWP was launched at the National Intrepid Center of Excellence at Walter Reed National Military Medical Center, and is currently expanding across the DIN.

The Blast Exposure Threshold Survey (BETS) is a recently developed measure of lifetime blast exposure. Although promising, it is considered a fundamental tenet to establish that the BETS (and other measures like it) have good psychometric properties before it can be recommended for clinical use. The purpose of this study was to examine the test-retest reliability of the BETS in a military sample. Participants were 83 United States service members and veterans prospectively recruited from three military medical treatment facilities and from the community. Participants were classified into two broad groups as part of a larger study: traumatic brain injury (TBI; n = 41; mild-severe TBI) and controls (n = 42; injured and non-injured controls). Participants completed the BETS, Neurobehavioral Symptom Inventory, and a brief structured interview to gather basic demographic, military, and injury-related information (e.g., age, education, deployments, etc.). In addition, participants completed the BETS on a second occasion (T2) 3 weeks following the first administration (T1). Using Spearman rho correlation analyses, the test-retest reliability of the BETS Generalized Blast Exposure Value (GBEV) was classified as "acceptable" (r = 0.76). However, when comparing individual responses across T1 and T2, 33% of the sample reported significant inconsistencies in the endorsement of the five weapons categories. The most problematic inconsistency (∼10% of the sample) related to the failure of some participants to consistently endorse, or not endorse, exposure to a weapons category at T1 and T2 (e.g., T1 = exposure present; T2 = exposure absent). Less problematic, but also of concern, was the failure of some participants (∼23%) to consistently report the same number of years in which they were exposed to a weapons category from T1 and T2 (e.g., T1 = 10 years; T2 = 5 years). Factors associated with inconsistent reporting from T1 to T2 included higher GBEV scores, older age, higher number of years in the military, higher number of deployments, and higher blast exposure. This is one of the first studies to comprehensively examine the test-retest reliability of the BETS GBEV. Overall, the test-retest reliability of the GBEV was considered statistically acceptable and provides support for the use of the GBEV in both clinical and research settings. Concerningly, however, substantial inconsistencies were found in the basic reporting of weapons exposure in 33% of the sample that need to be addressed. Future researchers should identify ways to improve the BETS to increase response consistency over time.

OBJECTIVE:To examine (a) change in chronic neurobehavioral symptoms in service members/veterans (SMVs) with an uncomplicated mild traumatic brain injury (MTBI) at two time points over 3 years and (b) the influence of intimate partner (IP) health-related quality of life (HRQOL) risk factors for chronic neurobehavioral symptoms. METHOD:IPs (N = 175) completed measures of SMV neurobehavioral adjustment symptoms and 13 IP HRQOL risk factors at Time 1 (T1) ≥ 12 months post-TBI and Time 2 (T2) 3 years later. Scores on the risk factor measures were classified into four IP HRQOL symptom trajectory categories based on clinically elevated (≥ 60 T) symptoms: (a) persistent (T1 + T2 ≥ 60T), (b) developed (T1 < 60T + T2 ≥ 60T), (c) improved (T1 ≥ 60T + T2 < 60T), and (4) asymptomatic (T1 + T2 < 60T). RESULTS:There was little change in mean SMV adjustment scores or the percentage of clinically elevated scores from T1 to T2. The percentage of clinically elevated adjustment scores was 30% at T1 and T2; 14.3% at T1 only; and 5.7% at T2 only. The IP HRQOL symptom trajectories had a stronger effect on mean SMV adjustment than within-group change in adjustment, which was largely driven by the persistent and asymptomatic IP HRQOL categories. The strongest effects were found for caregiving and social HRQOL risk factors, followed by psychological, and then physical HRQOL risk factors. CONCLUSION:A range of clinically elevated IP HRQOL constructs emerged as long-term risk factors for chronic neurobehavioral symptoms in SMVs post-MTBI. More attention to the role that family distress has on poor warfighter recovery and return to duty following an MTBI is required. (PsycInfo Database Record (c) 2026 APA, all rights reserved).

PURPOSE/OBJECTIVE:This study aimed to explore family risk factors for chronic neurobehavioral symptoms in service members and veterans (SMVs) with traumatic brain injury (TBI). RESEARCH METHOD/DESIGN:SMVs (n = 72) completed eight neurobehavioral outcome measures. Their family members (n = 72) completed 13 family risk factor measures assessing physical, psychological, and social health, and family functioning. The number of neurobehavioral measures that were clinically elevated (≥ 60T) were summed and used to classify SMVs into three outcome groups: (a) none/few symptoms (0-1 elevated scores), (b) several symptoms (2-3 elevated scores), and (c) many symptoms (4-8 elevated scores). RESULTS:SMVs in the many symptoms group had family members with significantly higher scores on nine family risk factor measures compared to family members of SMVs in the none/few symptoms group and two family risk factors compared to family members of SMVs in the several symptoms group. SMVs in the several symptoms group had family members with higher scores on three risk factor measures compared to family members of SMVs in the none/few symptoms group. Family member Anger was the most significant predictor of the total number of SMV elevated scores followed by family functioning, together accounting for 26.9% of the variance. CONCLUSIONS/IMPLICATIONS:An important and unique addition to the literature was the finding that a range of risk factors in the warfighter's family environment were strongly associated with clinically elevated chronic neurobehavioral symptoms following a TBI of any severity. More attention to the well-being of family members and their role in warfighter recovery and return to duty following a TBI are required. (PsycInfo Database Record (c) 2026 APA, all rights reserved).

The purpose of this study was to extend previous research by examining the relationship between lifetime blast exposure and neurobehavioral functioning after mild TBI (MTBI) by (a) using a comprehensive measure of lifetime blast exposure, and (b) controlling for the influence of post-traumatic stress disorder (PTSD). Participants were 103 United States service members and veterans (SMVs) with a medically documented diagnosis of MTBI, recruited from three military treatment facilities (74.8%) and community-based recruitment initiatives (25.2%, e.g., social media, flyers). Participants completed a battery of neurobehavioral measures 12 or more months post-injury (Neurobehavioral Symptom Inventory, PTSD-Checklist PCLC, TBI-Quality of Life), including the Blast Exposure Threshold Survey (BETS). The sample was classified into two lifetime blast exposure (LBE) groups: High (n=57) and Low (n=46) LBE. In addition, the sample was classified into four LBE/PTSD subgroups: High PTSD/High LBE (n=38); High PTSD/Low LBE (n=19); Low PTSD/High LBE (n=19); and Low PTSD/Low LBE (n=27). The High LBE group had consistently worse scores on all neurobehavioral measures compared with the Low LBE group. When controlling for the influence of PTSD (using ANCOVA), however, only a handful of group differences remained. When comparing measures across the four LBE/PTSD subgroups, in the absence of clinically meaningful PTSD symptoms (i.e., Low PTSD), participants with High LBE had worse scores on the majority of neurobehavioral measures (e.g., post-concussion symptoms, sleep, fatigue). When examining the total number of clinically elevated measures, the High LBE subgroup consistently had a greater number of clinically elevated scores compared with the Low LBE subgroup for the majority of comparisons (i.e., four to 15 or more elevated symptoms). In contrast, in the presence of clinically meaningful PTSD symptoms (i.e., High PTSD), there were no differences between High versus Low LBE subgroups for all measures. When examining the total number of clinically elevated measures, however, there were meaningful differences between High versus Low LBE subgroups for those comparisons that included a high number of clinically elevated scores (i.e., six to 10 or more), but not for a low number of clinically elevated scores (i.e., one to five or more). High LBE, as quantified using a more comprehensive measure than utilized in past research (i.e., BETS), was associated with worse overall neurobehavioral functioning after MTBI. This study extends existing literature showing that lifetime blast exposure, that is largely subconcussive, may negatively impact warfighter brain health and readiness beyond diagnosable brain injury.

IntroductionThe purpose of this study was to examine whether blood-based biomarkers associate with neurobehavioral functioning at three time points following traumatic brain injury (TBI).Materials and methodsParticipants were 328 United States service members and veterans (SMVs) prospectively enrolled in the Defense and Veterans Brain Injury Center-Traumatic Brain Injury Center of Excellence (DVBIC-TBICoE) 15-Year Longitudinal TBI Study, recruited into three groups: uncomplicated mild TBI (MTBI, n = 155); complicated mild, moderate, severe TBI combined (STBI, n = 97); non-injured controls (NIC, n = 76). Participants were further divided into three cohorts based on time since injury (≤12 months, 3–5 years, and 8–10 years). Participants completed the Minnesota Multiphasic Personality Inventory-2-Restructured Format (MMPI-2-RF) and underwent blood draw to measure serum concentrations of glial fibrillary acidic protein (GFAP), neurofilament light (NfL), and tau. A total of 11 MMPI-2-RF scales were examined (e.g., depression, anxiety, anger, somatic, cognitive symptoms). Stepwise hierarchical regression models were conducted within each group.ResultsSignificant associations were found between biomarkers and MMPI-2-RF scales (all p < 0.05; R2Δ > 0.10). GFAP was inversely related to (a) neurological complaints in the MTBI group at ≤12 months, (b) demoralization, anger proneness in the STBI group at ≤12 months, and (c) head pain complaints in the STBI group at 8–10 years. NfL was (a) related to low positive emotions in the NIC group; and inversely related to (b) demoralization, somatic complaints, neurological complaints, cognitive complaints in the MTBI group at ≤12 months, (c) demoralization in the STBI group at ≤12 months, and (d) demoralization, head pain complaints, stress/worry in the STBI group at 3–5 years. In the STBI group, there were meaningful findings (R2Δ > 0.10) for tau, NFL, and GFAP that did not reach statistical significance.DiscussionResults indicate worse scores on some MMPI-2-RF scales (e.g., depression, stress/worry, neurological and head pain complaints) were associated with lower concentrations of serum GFAP, NfL, and tau in the sub-acute and chronic phase of the recovery trajectory up to 5 years post-injury, with a reverse trend observed at 8–10 years. Longitudinal studies are needed to help elucidate any patterns of association between blood-based biomarkers and neurobehavioral outcome over the recovery trajectory following TBI.

Sub-concussive injuries have emerged as an important factor in the long-term brain health of athletes and military personnel. The objective of this study was to explore the relationship between service member and veterans (SMVs) lifetime blast exposure and recovery from a traumatic brain injury (TBI). A total of 558 SMVs with a history of TBI were examined. Lifetime blast exposure (LBE) was based on self-report (M = 79.4, standard deviation = 392.6; range = 0-7500) categorized into three groups: Blast Naive (n = 121), Low LBE (n = 223; LBE range 1-9), and High LBE (n = 214; LBE >10). Dependent variables were the Neurobehavioral Symptom Inventory (NSI) and Post-traumatic Stress Disorder Checklist-Civilian (PCL-C) and the Traumatic Brain Injury Quality of Life (TBI-QOL). Analyses controlled for demographic factors (age, gender, and race) as well as TBI factors (months since index TBI, index TBI severity, and total number lifetime TBIs). The Blast Naive group had significantly lower NSI and PCL-C scores compared with the Low LBE group and High LBE group, with small to medium effect sizes. On the TBI-QOL, the Blast Naive group had better quality life on 10 of the 14 scales examined. The Low LBE did not differ from the High LBE group on the PCL-C, NSI, or TBI-QOL. Blast exposure over an SMV's career was associated with increased neurobehavioral and post-traumatic stress symptoms following a TBI. The influence of psychological trauma associated with blasts may be an important factor influencing symptoms as well as the accuracy of self-reported estimates of LBE.

OBJECTIVE:To examine correlates of the discrepancy between subjective cognitive complaints and processing speed performance in a sample of military personnel with and without traumatic brain injury (TBI). METHOD:About 235 U.S. military service members (31 noninjured controls [NIC], 69 injured controls [IC], 70 uncomplicated mild TBI [mTBI], and 65 complicated mild/moderate/severe TBI [sTBI]) prospectively enrolled in a longitudinal TBI study completed neuropsychological testing, performance validity tests, and self-report measures of cognitive complaints and psychological symptoms. Service members were categorized as "Accurate Estimators," "Underestimators," and "Overestimators" based on discrepancies between their subjective cognition and processing speed performance. RESULTS:The NIC group was less likely to underestimate their cognitive abilities than the mTBI group (p < .05). Discrepancy groups significantly differed in processing speed scores (p < .001), with underestimators demonstrating the best objective cognitive performance. Spearman correlations revealed significant positive correlations between unadjusted discrepancy scores and psychological symptoms in the NIC, IC, and sTBI groups (ps < 0.05) but not the mTBI group (ps > 0.05). In contrast, discrepancy scores adjusted for premorbid intelligence were consistently and positively correlated with psychological symptoms across all injury groups (ps < 0.05). CONCLUSIONS:Findings suggest that mTBI injuries may increase the likelihood of a patient underestimating their cognitive performance. Further, premorbid cognitive functioning is an important factor in evaluating discrepancies in self-reported cognitive complaints and processing speed performance.

Purpose/Objective: To examine longitudinal change in health-related quality of life (HRQOL) in caregivers of service members/veterans with traumatic brain injury and factors associated with clinically elevated symptoms. Research Method/Design: Caregivers (N = 220) completed nine HRQOL outcome measures and 10 risk factor measures at a baseline evaluation and follow-up evaluation 3 years later. Caregiver's responses on the nine HRQOL outcome measures were classified into four clinical change categories based on the presence/absence of clinically elevated T-scores (>= 60 T) at baseline and follow-up: (a) Persistent (baseline >= 60T + follow-up >= 60 T), (b) Developed (baseline < 60 T + follow-up >= 60 T), (c) Improved (baseline >= 60 T + follow-up < 60 T), and (d) Asymptomatic (baseline < 60 T + follow-up < 60 T). A clinical change composite score was calculated by summing the number of Persistent or Developed HRQOL outcome measures and used to create three clinical change groups: (a) No Symptoms (n = 69, zero measures), (b) Some Symptoms (n = 88, one to three measures), and (c) Numerous Symptoms (n = 63, four to nine measures). Results: Of the nine HRQOL outcome measures, Bodily Pain, Perceived Stress, Sleep-Related Impairment, and Fatigue were most frequently classified as Persistent or Developed from baseline to follow-up in the entire sample. A linear relationship was found between the vast majority of risk factors across the three clinical change groups at baseline and follow-up (Numerous > Some > None). The risk factors were correlated with the number of elevated HRQOL symptoms at baseline and follow-up. Most Asymptomatic or Persistent caregivers did not have meaningful change (>= 1 SD) in HRQOL scores. A sizable proportion of Developed or Improved caregivers had either meaningful or no change in HRQOL scores. Conclusions/Implications: There is a need for ongoing clinical services for military caregivers.

Objective: To examine elevated symptoms on health-related quality of life (HRQOL) measures over 2 years in caregivers of service members with traumatic brain injury (TBI). To compare outcomes to caregivers of veterans. Method: Caregivers (N = 315) were classified into two groups: (a) service member caregiver group (n = 55) and (b) veteran caregiver group (n = 260). Caregivers completed 17 HRQOL measures at a baseline evaluation and follow-up evaluation 24 months later. Results: In the service member caregiver group, the highest frequency of clinically elevated T-scores (>= 60 T) at baseline and follow-up were found on physical and psychological HRQOL measures (16.4%-30.9%). A higher proportion of the veteran caregiver group had clinically elevated scores on nine measures at baseline and seven measures at follow-up. Examining the number of clinically elevated scores simultaneously across all 17 measures, the service member caregiver group had multiple elevated scores (e.g., 4 or more: baseline = 25.5%, follow-up = 27.3%). A higher proportion of the veteran caregiver group had multiple clinically elevated scores for 13 comparisons at baseline (h = .35-.82), but reduced to eight comparisons at follow-up (h = .36-.63). In the service member caregiver group, the proportion of caregivers with clinically elevated scores at baseline and follow-up was equally dispersed across persistent and newly developed symptoms, but higher for persistent symptoms compared to developed symptoms in the veteran caregiver group. Conclusions: Many caregivers of service members reported clinically elevated scores across HRQOL domains and the prevalence increased over 2 years. More services for caregivers in the Department of Defense may be helpful in reducing the trajectory of newly developed symptoms long term. Clinical Impact Statement An important and unique addition to the literature was the finding that many family members (predominantly intimate partners) of United States service members with a traumatic brain injury reported providing ongoing care and support for numerous years while the service member was still in the military. In addition, many family members reported clinically elevated (worse) scores across health-related quality of life domains, and the prevalence of these symptoms increased over 2 years. More services for family members providing care and support to warfighters in the Department of Defense may be helpful in reducing the trajectory of new onset symptoms long-term.

Women are more directly involved in combat operations today than ever before, currently making up 18.6% of officers and 16.8% of enlisted personnel in the United States military. However, women continue to be under-represented in military research. Studies that do consider gender differences in traumatic brain injury (TBI) outcomes have shown that women report significantly more post-concussive symptoms than men. Conclusions for true gender differences related to TBI are hard to make without controlling for non-TBI factors. The effects previously identified in the literature may be an artifact of how men and women differ in their response to injury, unrelated to the neurological recovery process associated with TBI. The objective of this study was to examine the effects of gender specifics on mild TBI (mTBI) sequelae on injured and uninjured control groups, and to investigate the role of post-traumatic stress disorder (PTSD) on symptom reporting. It should be noted that the terms "gender" and "men/women" are used in this article in place of "sex" or "males/females" given that we are not discussing biological attributes. A total of 966 United States military service members and veterans were included in the study. Of the total sample, 455 men and 46 women were in the mTBI group, 285 men and 31 women were in the injured controls group (IC), and 111 men and 38 women in the non-injured controls group (NIC). Post-concussive and quality of life symptoms were compared for men and women while controlling for combat exposure. MTBI and IC groups were also stratified by PTSD presentation. Measures used included the Neurobehavioral Symptom Inventory (NSI), PTSD Checklist (PCL-C), Traumatic Brain Injury Quality of Life (TBI-QOL), and Combat Exposure Scale. In the mTBI group, women had worse scores on NSI total, NSI Somatosensory and Affective clusters, and the TBI-QOL Anxiety, Fatigue, and Headache scales (n2 = 0.018-0.032, small to small-medium effect sizes). When PTSD was present, women had worse scores on the NSI Somatosensory cluster only (n2 = 0.029, small-medium effect size). In contrast, when PTSD was absent, women had worse scores than men on the NSI Somatosensory and Affective clusters, and the TBI-QOL Anxiety and Headache scales (n2 = 0.032-0.063, small to medium effect sizes). In the IC group, women had worse scores on the NSI Cognitive cluster and the TBI-QOL Fatigue and Pain Interference scales (n2 = 0.024-0.042, small to small-medium effect sizes). However, group differences were no longer found when stratified by PTSD sub-groups. In the NIC group, there were no significant group differences for any analyses. We were able to identify symptoms unique to women recovering from mTBI that were not present following other forms of physical injury or in healthy controls. However, the impact of PTSD exacerbates the symptom profile and its comorbidity with mTBI equates to most of the noted gender differences.

To examine [a] the association of caregiver health-related quality of life (HRQOL) and service member/veteran (SMV) neurobehavioral outcomes with caregiver resilience; [b] longitudinal change in resilience at the group and individual level; and [c] the magnitude of change at the individual level. Caregivers (N = 232) of SMVs with traumatic brain injury completed a resilience measure, and 18 caregiver HRQOL and SMV neurobehavioral outcome measures at a baseline evaluation and follow-up evaluation three years later. Caregivers were divided into two resilience groups at baseline and follow-up: [1] Low Resilience (≤ 45 T, baseline n = 99, follow-up n = 93) and [2] High Resilience (> 45 T, baseline n = 133, follow-up n = 139). At baseline and follow-up, significant effects were found between Low and High Resilience groups for the majority of outcome measures. There were no significant differences in resilience from baseline to follow-up at the group-mean level. At the individual level, caregivers were classified into four longitudinal resilience groups: [1] Persistently Low Resilience (Baseline + Follow-up = Low Resilience, n = 60), [2] Reduced Resilience (Baseline = High Resilience + Follow-up = Low Resilience, n = 33), [3] Improved Resilience (Baseline = Low Resilience + Follow-up = High Resilience, n = 39), and [4] Persistently High Resilience (Baseline + Follow-up = High Resilience, n = 100). From baseline to follow-up, approximately a third of the Reduced and Improved Resilience groups reported a meaningful change in resilience (≥ 10 T). Nearly all of the Persistently High and Persistently Low Resilience groups did not report meaningful change in resilience (< 10 T). Resilience was not a fixed state for all caregivers. Early intervention may stall the negative caregiving stress-health trajectory and improve caregiver resilience.

The Blast Exposure Threshold Survey (BETS) is a recently developed and promising new self-report measure of lifetime blast exposure (LBE). However, there are no studies that have examined the psychometric properties of the BETS, which currently limits its clinical utility. The purpose of this study was to examine the convergent and discriminant validity of the BETS by comparing the BETS Generalized Blast Exposure Value (GBEV) to six variables hypothesized to be associated with LBE (i.e., single-item LBE, combat exposure, years in the military, number of combat deployments, and military occupation specialty [MOS]) and three variables hypothesized not to be associated with LBE (i.e., age at the time of injury, estimated pre-morbid Full-Scale Intelligence Quotient [FSIQ], and resilience). Participants were 202 United States service members and veterans prospectively enrolled from three military medical treatment facilities (68.7%) and via community recruitment initiatives (31.3%). Participants completed the BETS, Combat Exposure Scale (CES), Deployment Risk and Resiliency Inventory-2 Combat Experiences (DRRI-2 CE), Traumatic Brain Injury-Quality of Life Resilience scale, and a brief structured interview. For some analyses, participants were classified into two blast risk MOS groups: high (n = 89) and low (n = 94). The BETS GBEV was not significantly correlated with all three non-blast related variables (rs = 0.01 to rs = -0.12). In contrast, GBEV was significantly (p < 0.001) associated with all blast-related variables; single-item LBE (rs = 0.76), CES (rs = 0.58), number of combat deployments (rs = 0.53), DRRI-2 CE (rs = 0.48), and high blast risk MOS (r = 0.36, medium effect size). However, a stronger relationship was found between the blast-related variables and three modified GBEV scores when excluding some small weapons categories; single-item LBE (rs = 0.80-0.82), CES (rs = 0.64-0.67), number of combat deployments (rs = 0.56), DRRI-2 CE (rs = 0.51-0.53), and high blast risk MOS (r = 0.42-0.49, medium-large effect size). This is the first study to examine the psychometric properties of the BETS. Overall, these results offer support for the convergent and discriminant validity of the BETS. In order to ensure that the BETS can be confidently used as a valid and reliable measure of LBE, more research is needed to further examine the psychometric properties of the test, particularly with regard to the establishment of test-retest reliability.

OBJECTIVE:Blood-based biomarkers have received considerable attention for their diagnostic and prognostic value in the acute and postacute period following traumatic brain injury (TBI). The purpose of this study was to examine whether blood-based biomarker concentrations within the first 12 months of TBI can predict neurobehavioral outcome in the chronic phase of the recovery trajectory.SETTING:Inpatient and outpatient wards from 3 military medical treatment facilities.PARTICIPANTS:A total of 161 service members and veterans classified into 3 groups: ( a ) uncomplicated mild TBI (MTBI; n = 37), ( b ) complicated mild, moderate, severe, penetrating TBI combined (STBI; n = 46), and ( c ) controls (CTRL; n = 78).DESIGN:Prospective longitudinal.MAIN MEASURES:Participants completed 6 scales from the Traumatic Brain Injury Quality of Life (ie, Anger, Anxiety, Depression, Fatigue, Headaches, and Cognitive Concerns) within 12 months (baseline) and at 2 or more years (follow-up) post-injury. Serum concentrations of tau, neurofilament light, glial fibrillary acidic protein, and UCHL-1 at baseline were measured using SIMOA.RESULTS:Baseline tau was associated with worse anger, anxiety, and depression in the STBI group at follow-up ( R2 = 0.101-0.127), and worse anxiety in the MTBI group ( R2 = 0.210). Baseline ubiquitin carboxyl-terminal hydrolase L1 (UCHL-1) was associated with worse anxiety and depression at follow-up in both the MTBI and STBI groups ( R2 Δ = 0.143-0.207), and worse cognitive concerns in the MTBI group ( R2 Δ = 0.223).CONCLUSIONS:A blood-based panel including these biomarkers could be a useful tool for identifying individuals at risk of poor outcome following TBI.