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Complications of Mild Traumatic Brain Injury in Veterans
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Complications of Mild Traumatic Brain Injury in Veterans. and Military Personnel A Systematic Review Evidence based Synthesis Program. Quality Enhancement Research Initiative s QUERI Evidence based Synthesis Program. ESP was established to provide timely and accurate syntheses of targeted healthcare topics. of particular importance to Veterans Affairs VA managers and policymakers as they work to. improve the health and healthcare of Veterans The ESP disseminates these reports throughout. QUERI provides funding for four ESP Centers and each Center has an active VA affiliation The. ESP Centers generate evidence syntheses on important clinical practice topics and these reports. develop clinical policies informed by evidence, guide the implementation of effective services to improve patient outcomes. and to support VA clinical practice guidelines and performance measures. set the direction for future research to address gaps in clinical knowledge. In 2009 the ESP Coordinating Center was created to expand the capacity of QUERI Central. Office and the four ESP sites by developing and maintaining program processes In addition. the Center established a Steering Committee comprised of QUERI field based investigators. VA Patient Care Services Office of Quality and Performance and Veterans Integrated Service. Networks VISN Clinical Management Officers The Steering Committee provides program. oversight guides strategic planning coordinates dissemination activities and develops. collaborations with VA leadership to identify new ESP topics of importance to Veterans and the. VA healthcare system, Comments on this evidence report are welcome and can be sent to Nicole Floyd ESP. Coordinating Center Program Manager at nicole floyd va gov. Recommended citation O Neil ME Carlson KF Storzbach D Brenner LA Freeman M. Qui ones A Motu apuaka M Ensley M Kansagara D Complications of Mild Traumatic Brain. Injury in Veterans and Military Personnel A Systematic Review VA ESP Project 05 225 2012. This report is based on research conducted by the Evidence based Synthesis Program. ESP Center located at the Portland VA Medical Center Portland OR funded by the. Department of Veterans Affairs Veterans Health Administration Office of Research and. Development Quality Enhancement Research Initiative The findings and conclusions. in this document are those of the author s who are responsible for its contents the. findings and conclusions do not necessarily represent the views of the Department. of Veterans Affairs or the United States government Therefore no statement in this. article should be construed as an official position of the Department of Veterans Affairs. No investigators have any affiliations or financial involvement e g employment. consultancies honoraria stock ownership or options expert testimony grants or patents. received or pending or royalties that conflict with material presented in the report. Complications of Mild Traumatic Brain Injury in Veterans. and Military Personnel A Systematic Review Evidence based Synthesis Program. TABLE OF CONTENTS, Executive summary, Background 1. Limitations and Future Research 4, Abbreviations Table 5. Introduction 8, Topic Development 9, Search Strategy 9.
Study Selection 10, Data Abstraction 11, Quality Assessment 11. Data Synthesis 12, Rating the Body of Evidence 12, Peer Review 12. Methodologic Considerations 13, Literature Flow 13. Summary of Findings 23, Cognitive Functioning Results 23. Physical Health Results 30, Mental Health Results 34.
Functional Social Outcome Results 38, Service Utilization Costs Results 40. Summary And Discussion, Summary of Evidence 42, Limitations and Recommendations for Future Research 46. Conclusions 48, References 49, Table 1 Descriptive Characteristics of Studies of U S Veterans and Members of the U S. Military with mTBI 15, Table 2 Summary of Evidence for Cognitive Functioning Outcomes Associated with mTBI in. Veteran and Military Populations 24, Table 3 Summary of Evidence for Physical Health Outcomes Associated with mTBI in Veteran.
and Military Populations 31, Complications of Mild Traumatic Brain Injury in Veterans. and Military Personnel A Systematic Review Evidence based Synthesis Program. Table 4 Summary of Evidence for Mental Health Outcomes Associated with mTBI in Veteran. and Military Populations 35, Table 5 Summary of Evidence for Functional Social Outcomes Associated with mTBI in. Veteran and Military Populations 39, Table 6 Summary of Evidence for Service Utilization Costs Associated with mTBI in Veteran. and Military Populations 41, Figure 1 Literature Flow Diagram 14. Appendix A Search Strategies 55, Appendix B Study Selection Form 59.
Appendix C Definition of Mtbi from the VA DOD Clinical Practice Guideline. for Management of Concussion Mild Traumatic Brain Injury 2009 61. Appendix D Excluded Studies That Did Not Meet MTBI Definition Criteria 63. Appendix E Results of Included Studies 79, Cognitive Functioning. Table 1a Language abilities and general fund of verbal knowledge measures in studies of U S. Veterans and members of the U S military with mild TBI 79. Table 1b Visuospatial function in studies of U S Veterans and members of the U S military with. mild TBI 80, Table 1c Memory functioning in studies of U S Veterans and members of the U S military with. mild TBI 81, Table 1d Attention concentration measures in studies of U S Veterans and members of the U S. military with mTBI 84, Table 1e Cognitive processing speed in studies of U S Veterans and members of the U S military. with mild TBI 86, Table 1f Executive functioning in studies of U S Veterans and members of the U S military.
with mild TBI 88, Table 1g Effort and motivation measures in a study of U S Veterans with mild TBI evaluated in. a research versus forensic context 89, Table 1h Total and cross domain composite scores in studies of U S Veterans and members. of the U S military with mild TBI 90, Table 1i Self reported cognitive deficits in studies of U S Veterans and members of the U S. military with mild TBI 91, Physical Health Outcomes. Table 2a Headache outcomes in studies of U S Veterans and members of the U S military with. mild TBI 93, Table 2b Pain outcomes in studies of U S Veterans and members of the U S military with.
mild TBI 95, Table 2c Vestibular outcomes in studies of U S Veterans and members of the U S military with. mild TBI 95, Table 2d Vision outcomes in studies of U S Veterans and members of the U S military with. mild TBI 96, Complications of Mild Traumatic Brain Injury in Veterans. and Military Personnel A Systematic Review Evidence based Synthesis Program. Table 2e Hearing outcomes in studies of U S Veterans and members of the U S military with. mild TBI 96, Table 2f Neurological outcomes in studies of U S Veterans and members of the U S military. with mild TBI 97, Table 2g Nausea appetite outcomes in studies of U S Veterans and members of the U S military.
with mild TBI 97, Mental Health Outcomes, Table 3a PTSD outcomes in studies of U S Veterans and members of the U S military with. mild TBI 98, Table 3b Measures of anxiety in studies of U S Veterans and members of the U S military with. mild TBI 101, Table 3c Measures of depression in studies of U S Veterans and members of the U S military. with mild TBI 102, Table 3d Substance use disorders in studies of U S Veterans and members of the U S military. with mild TBI 102, Table 3e Suicide related outcomes in studies of U S Veterans and members of the U S military.
with mild TBI 103, Table 3f Other mental health outcomes in studies of U S Veterans and members of the U S. military with mild TBI 103, Functional Social Outcomes. Table 4a Employment outcomes in studies of U S Veterans and members of the U S military. with mild TBI 104, Table 4b Sleep outcomes in studies of U S Veterans and members of the U S military with mild TBI 105. Table 4c Social outcomes in studies of U S Veterans and members of the U S military with mild TBI 106. Service Utilization Costs, Table 5 Service utilization outcomes in studies of U S Veterans and members of the U S military. with mild TBI 106, Appendix F List of Excluded Studies Grouped by Reason for Exclusion 107.
Appendix G Peer Review Comments and Responses 125, Complications of Mild Traumatic Brain Injury in Veterans. and Military Personnel A Systematic Review Evidence based Synthesis Program. EXECUTIVE SUMMARY, BACKGROUND, Traumatic brain injury TBI is a common condition especially among military members. Twelve to 23 percent of service members returning from Operations Enduring Freedom Iraqi. Freedom and New Dawn OEF OIF OND experienced a TBI while deployed Although various. criteria are used to define TBI severity the majority of documented TBI events among OEF OIF. OND service members may be classified as mild in severity or mTBI according to the definition. used by the Veterans Health Administration and Department of Defense VA DoD. While some researchers suggest most individuals recover within three months of an mTBI. others estimate that 10 to 20 percent of individuals continue to experience post concussive. symptoms e g headaches dizziness balance problems beyond this time fame This estimate. may be higher among OEF OIF service members given the frequency of multiple TBI events. concomitant mental health conditions such as depression and posttraumatic stress disorder. PTSD and other factors unique to combat deployments As such deployment related mTBI is. a significant issue for the VA as patients who report ongoing mTBI symptoms may require the. attention from a range of health care professionals This evidence synthesis review will be used. by the VHA TBI Advisory Committee to develop strategies to identify those at risk for long term. mTBI effects inform clinical practice determine resource allocation and identify future research. priorities, The key questions were, Key Question 1 For Veteran military populations what is the prevalence of health problems. such as pain seizure disorders headaches migraines and vertigo cognitive deficits functional. limitations such as employment status changes in marital status family dynamics and mental. health symptoms such as PTSD and depression that develop or persist following mTBI. Key Question 2 What factors affect outcomes for Veteran military patients with mTBI Key. Question 2A For Veteran military populations are there pre injury premorbid risk protective. factors e g pre injury mental health factors genetic factors or prior concussions that affect. outcomes for mTBI Key Question 2B For Veteran military populations are there post injury. risk protective factors e g PTSD that affect outcomes for mTBI. Key Question 3 What is the resource utilization over time for Veteran military patients with. We searched Medline PsychINFO and Cochrane Register of Controlled Trials OVID from. database inception to October 3 2012 We adapted the search strategy developed by the World. Health Organization WHO Collaborating Centre for Neurotrauma Prevention Management. and Rehabilitation Task Force for a recent systematic review of prognosis after mTBI and we. included terms to identify articles specific to Veterans and military personnel We obtained. Return to Contents, Complications of Mild Traumatic Brain Injury in Veterans. and Military Personnel A Systematic Review Evidence based Synthesis Program. additional articles from systematic reviews reference lists of pertinent studies reviews. editorials and by consulting clinical and research experts in the area of mTBI. We included studies reporting outcomes in Veterans or military personnel who had suffered. an mTBI using a case definition consistent with definitions in the VA DoD Clinical Practice. Guideline for Management of Concussion Mild Traumatic Brain Injury Reviewers trained in. the critical analysis of literature assessed the titles and abstracts for relevance and retrieved. full text articles for further review We compiled a narrative synthesis of findings We assessed. individual study quality using criteria based on the Newcastle Ottawa quality assessment tools. for observational studies We assessed the overall strength of evidence for the body of included. literature according to criteria developed by the GRADE Working Group. A draft version of this report was reviewed by 11 technical experts as well as clinical leadership. Reviewer comments were addressed and our responses were incorporated in the final report. Appendix G, From 2 668 titles and abstracts we identified 354 articles for full text review Of these 31.
primary studies met inclusion criteria In general we found that though self reported cognitive. physical and mental health symptoms were common in the Veteran military population there. was little evidence that symptoms were more common in those with mTBI than those without. mTBI However the evidence base is weakened by inconsistent findings methodologic. shortcomings of many studies and variation in outcomes considered and outcome measurement. approaches The following sections detail findings by symptom category. Summary of Cognitive Functioning Results, We found 17 studies reporting cognitive outcomes for those with mTBI Overall few studies. found an association between mTBI and cognitive deficits The strength of evidence is low. overall because of poor and incomplete reporting of data and sampling procedures lack of time. Complications of Mild Traumatic Brain Injury in Veterans and Military Personnel A Systematic Review Evidence based Synthesis Program EXECUTIVE SUMMARY BACKGROUND Traumatic brain injury TBI is a common condition especially among military members Twelve to 23 percent of service members returning from Operations Enduring Freedom Iraqi Freedom and New Dawn OEF OIF OND experienced a TBI

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