1. Impact of Post-Deployment Brain Injury on NSI-Symptom Domains Maxine H. Krengel, Ph.D. Errol Baker, Ph.D. Mark Meterko Ph.D. Kelly Stolzmann, MS Katherine Iverson, Ph.D. Terri Pogoda, Ph.D. Ann Hendricks, Ph.D. VA Boston Healthcare System June 14, 2011 This material is based upon work supported by HSR&D Grant: SDR 08-405

2. Presentation Outline OEF/OIF deployment-related TBI Review of multiple concussive injury Methods Research findings Conclusions Future directions

3. VA TBI Screening Process VA screens for TBI in all OEF/OIF returnees Positive screen comprehensive TBI evaluation (CTE) CTE consists of NSI-22 symptom severity, medical history, and physical exam CTE also includes events pre and post-deployment Treatment plan and referrals for care

4. Important Factors regarding Multiple Concussive Injury More than 75% or of deployment related injuries are due to blast Research on VA patients have found that rates of mTBI and PTSD are up to 60% No current data on multiple concussive injury in the OEF/OIF population

5. Sports Concussion Literature A history of more than 2 concussive events is associated with long term changes in neurophysiology Preliminary evidence suggests that athletes with multiple concussions show evidence of poorer short-term memory, raising awareness of cumulative effects Long-term effects of other types of post- concussive symptoms are less well known in sports concussive injury

6. Research Questions 1. What is the relative impact of multiple concussive events in a population- based cohort of individuals who have completed a VA CTE. 2. Is there an additive effect of type of deployment-related event (blast versus non-blast) and post-deployment concussive event on symptoms. 3. What is the impact of PTSD on questions 1 and 2.

7. Methods Data: Administrative centralized database of all VA CTEs performed between October 2007 and July 2009 (N = 36,401). Inclusion criteria: only one deployment-related event OR one deployment-related event plus a post- deployment concussive event (N = 3545). Participants were stratified by number of events during deployment, by etiology of deployment-related event (Blast or Non-blast) and by presence or absence of PTSD. Excluded participants with: 1) more than one deployment-related event, 2) no deployment-related event and 3) a pre-deployment event

8. Distribution of Study Population by PTSD, Injury Etiology and Number of Events 1 Event2 Events PTSD*PTSDPTSD*PTSDTOTAL BLAST1,53854772192,176 NO BLAST 71556056381,369 TOTAL2,2531,107128573,545

9. Data Analysis Statistics – Unweighted average scores for each of the NSI-22 domains – Cognitive – Affective – Somatosensory – Vestibular 3-way between groups multivariate analysis of variance (MANOVA) Follow-up univariate ANOVAs examining the effects of: – Number of events (1 vs. 2) – Type of event (blast vs. non-blast) – PTSD – All interactions

10. Affective Symptom Severity as a Function of Number Concussive Events No PTSD PTSD

11. Somatosensory Symptom Severity as a Function of Number Concussive Events No PTSD PTSD

12. Cognitive Symptom Severity as a Function of Number Concussive Events No PTSDPTSD

13. Vestibular Symtom Severity as a Function of Number Concussive Events No PTSDPTSD

14. Results 1. Multiple events: For blast-related events only, we found significant differences in severity of cognitive, affective, and somatosensory symptoms when there was an additional post- deployment concussive event. 2. There was an additive effect such that individuals without PTSD diagnosis who had a post-deployment concussive injury showed the largest increase in cognitive, affective and somatosensory symptoms.

15. Limitations Symptom severity is self-report Severity of initial injury is unknown Number of events, etiology of events or severity of post-deployment event is unknown Limited number of individuals with second event Descriptive information cannot draw conclusions about causality

16. Conclusions and Clinical Implications 1. Clinicians should pay careful attention to the number and type of events given the interaction between these two variables in symptom report. 2. Psychoeducation about the potential impact of multiple events should be provided to patients to reduce the risk of further cognitive, affective, somatic and vestibular compromise. 3. Treatments designed for OEF/OIF Veterans should take into account the interaction between etiology of injury and PTSD and include methods to reduce cognitive, somatic, and vestibular symptoms in addition to affective symptoms.