Risa Nakase-Richardson

Objective: To assess the relationship between rehabilitation needs and mental health symptoms in Veterans and Service Members with polytrauma, including history of mild traumatic brain injury (TBI). Setting: Five Veterans Affairs (VA) Intensive Evaluation and Treatment Programs. Participants: Veterans and Service Members enrolled in the VA TBI Model Systems study who completed a follow-up greater than 6 months postprogram. Design: Cohort study. Main Measures: Primary regression analyses included rehabilitation needs (Rehabilitation Needs Survey) and post-traumatic stress symptoms (PTSD Checklist-Civilian version). Age, sex, months from rehabilitation to follow-up interview, preinjury mental health, disability level (Glasgow Outcome Scale–Extended), and number of comorbidities were included as covariates. Secondary analyses applied the same model structure to assess the relationship between rehabilitation needs and anxiety (Generalized Anxiety Disorder-7) and depression (Patient Health Questionnaire-9) symptoms. Results: Most Veterans and Service Members with polytrauma, including mild TBI, reported a current need for services to control physical symptoms (55%) and greater than one-third endorsed a current need for services to improve memory (46%), manage emotions (45%), improve health (44%), manage daily stress (42%), and solve daily problems (38%). Adjusted regression analyses revealed that rehabilitation needs were significantly and positively associated with post-traumatic stress, anxiety, and depression self-report symptoms. These relationships were maintained when analyses were repeated with mental health–related items removed from the Rehabilitation Needs Survey, suggesting the finding was not solely because of mental health needs. Higher comorbidity burden and disability were also independently associated with higher rehabilitation needs. Conclusions: Veterans and Service Members with polytrauma, especially those with elevated post-traumatic stress, anxiety, and/or depressive symptoms in the context of mild TBI, could benefit from ongoing access to evidence-based psychotherapies and other specialty care, rehabilitation, and support services to manage long-term care and rehabilitation needs in the chronic phase of injury.

Background: People with traumatic brain injury (TBI) morbidity (impaired cognition and behavioral regulation) and polytrauma comorbidity (depression, posttraumatic stress disorder [PTSD], chronic pain, and sleep disorders) experience health care inequities. Among Veterans and Service Members (V/SMs), TBI morbidity or polytrauma comorbidity may impact access and meaningful engagement in the high-quality health care needed to reduce poor health care outcomes. The National Academy of Science, Engineering, and Medicine Report on Accelerating Progress in TBI highlights a dearth of implementation science research in TBI that may help overcome health care access challenges. Implementation science uses a mixed methods approach to understand, implement, and examine outcomes associated with using evidence-based care in practice. Objective: The I-HEAL (Improving Health Care Access and Engagement for Veterans and Service Members with TBI Morbidity) protocol includes 4 synergistic projects with the goal of addressing key knowledge gaps that will improve access and engagement in high-quality, evidence-based health care services for V/SMs with TBI morbidity. Collectively, the 4 projects propose to: (1) adapt existing interventions to promote access and engagement in health care; (2) engage stakeholder communities to maximize uptake and translation; (3) promote research translation that informs policy and practice through knowledge translation products and deliverables targeting key partners (clinicians, V/SMs, caregivers, policymakers, and researchers); (4) facilitate research and implementation to enhance access to high-quality health care for V/SMs with TBI-related morbidity; and (5) foster the development of early/mid-career researchers in advancing implementation science research on access to care for V/SMs with TBI. Methods: Project 1 will involve the development of a nudge intervention (electronic health care reminder) for providers to engage health care proxies when interacting with cognitive disability at risk for poor health care engagement. Project 2 will involve the development of a provider toolkit of adaptations of guideline-endorsed behavioral health interventions for common polytrauma comorbidities to meet the needs of cognitively impaired individuals. Project 3 will involve the adaptation and dissemination of evidence-based team interventions for managing maladaptive behaviors after TBI. Project 4 will involve evaluation and recommendations for policy for virtual health modalities among persons with TBI and polytrauma comorbidity. Results: I-HEAL has been funded as an implementation science Focused Program Award by Congressionally Directed Medical Research Programs, and start-up activities began in October 2023. All 4 projects are currently underway with funding through September 2027. Project 1 has enrolled 48 participants, and project 3 has enrolled 34 participants through September 2025. Conclusions: TBI is associated with increased health care utilization, comorbid health conditions, and premature mortality. This study has proposed to utilize strategies from the implementation science field to help overcome barriers to physical and psychological health care in order to reduce health care disparities associated with TBI disability.

Objective: We sought to examine changes in mild-to-moderate TBI-related symptoms among service members and veterans (SM/Vs) following participation in a 5-site inpatient rehabilitation program with the US Department of Veterans Affairs between 7/1/2022 and 5/30/2024. Methods: Neurobehavioral outcomes, posttraumatic stress disorder (PTSD) symptoms, pain interference, and lifestyle behaviors related to brain injury were assessed at baseline, discharge, and a 6-month follow-up. Mixed effects linear regression models, adjusting for key patient characteristics, were estimated to determine changes in TBI-related outcomes across the 3 time points. Results: Mean participant age, for those with complete data (n = 127), was 41.64 years (SD = 5.57), with a mean of 7.45 deployments (SD = 3.12) and 16.32 concussive events (SD = 7.21). Participants were predominantly White (73.23%) Special Operations personnel (82.68%). TBI-related outcomes, including neurobehavioral symptoms, pain interference, PTSD, and brain injury adaptability, decreased significantly from baseline to discharge (b = −14.36, SE = 1.03; b = −3.79, SE = 0.49; b = −11.14, SE = 1.27; b = −2.41, SE = 0.41), with Cohen’s d effect sizes of 1.14, 0.71, 0.69, and 0.56, respectively. Six-month follow-up, TBI-related outcomes remained statistically and practically below baseline levels in all measures except adaptability. Conclusions and Relevance: Findings illustrate an interdisciplinary, inpatient rehabilitation program for mild-to-moderate TBI yields significant improvements in TBI-related symptoms that are common among SM/Vs and are sustained at 6 months postdischarge.

UNSTRUCTURED People with traumatic brain injury (TBI)-related morbidity (impaired cognition, behavioral regulation) and polytrauma comorbidity (depression, posttraumatic stress disorder (PTSD), chronic pain, sleep disorders) experience healthcare inequities leading to poor health outcomes. Our work has highlighted that Veterans and Service Members (V/SMs) with TBI have high rates of rehospitalization, unique healthcare needs, and distinct causes of early mortality (self-inflicted deaths and preventable injuries). Any TBI morbidity or polytrauma comorbidity may impact access and meaningful engagement in the high-quality healthcare needed to reduce poor healthcare outcomes. The National Academy of Science, Engineering, and Medicine Report on Accelerating Progress in TBI recognizes and calls for action to improve healthcare access for persons with TBI and highlights a dearth of implementation science research in TBI that may help overcome healthcare access challenges. Implementation science uses a mixed methods approach to understand, implement, and examine outcomes associated with using evidence-based care in practice. It also uses evidence-based practice for adaptations or innovations in how care is delivered (to retain technical quality, fidelity) across healthcare systems (e.g., Veterans Affairs, Department Of Defense, civilian settings) and populations (e.g., disabled vs healthy cohorts) to achieve healthcare equity. The I-HEAL protocol includes four synergistic projects with the goal to address key knowledge gaps that will improve access and engagement in high-quality, evidence-based healthcare services for V/SM with TBI morbidity. Specific foci include the following: Project 1) development of a nudge intervention (electronic healthcare reminder) for providers to engage healthcare proxies when interacting with cognitive disability at risk for poor healthcare engagement; Project 2) development of a provider toolkit of adaptations of guideline-endorsed behavioral health interventions for common polytrauma comorbidities (sleep, PTSD, depression, chronic pain) to meet the needs of cognitively impaired individuals; Project 3) adaptation and dissemination of evidence-based team interventions for managing maladaptive behaviors after TBI; and Project 4) evaluation and recommendations for policy for virtual health modalities for persons with TBI and polytrauma comorbidity. Collectively the four projects propose to accomplish the following overarching objectives: 1) adapt existing interventions to promote access and engagement in healthcare; 2) engage stakeholder communities to maximize uptake and translation; 3) promote research translation that informs policy and practice through knowledge translation products and deliverables targeting key partners (clinicians, Veterans, Service Members, caregivers, policymakers, and other researchers); 4) facilitate research and implementation to enhance access to high-quality healthcare for V/SM with TBI-related morbidity; and 5) foster development of early/mid-career researchers in advancing implementation science research on access to care for V/SM with TBI. TBI is associated with increased healthcare utilization, comorbid health conditions, and premature mortality. This study proposed to utilize strategies from the implementation science field to help overcome barriers to physical and psychological healthcare to reduce healthcare disparities associated with TBI disability.

Few studies have examined long-term mortality following traumatic brain injury (TBI) in a military population. This is a secondary analysis of a prospective, longitudinal study that examines long-term mortality (up to 10 years) post-TBI, including analyses of life expectancy, causes of death and risk factors for death in service members and veterans (SM/V) who survived the acute TBI and inpatient rehabilitation. Among 922 participants in the study, the mortality rate was 8.3% following discharge from inpatient rehabilitation. The mean age of death was 54.5 years, with death occurring on average 3.2 years after injury, and with an average 7-year life expectancy reduction. SM/V with TBI were nearly 4 times more likely to die compared with the US general population. Leading causes of death were external causes of injury, circulatory disease, and respiratory disorders. Also notable were deaths due to late effects of TBI itself and suicide. Falls were a significant mechanism of injury for those who died. Those who died were also more likely to be older at injury, unemployed, non-active duty status, not currently married, and had longer post-traumatic amnesia, longer rehabilitation stays, worse independence and disability scores at rehabilitation discharge, and a history of mental health issues prior to injury. These findings indicate that higher disability and less social supportive infrastructure are associated with higher mortality. Our investigation into the vulnerabilities underlying premature mortality and into the major causes of death may help target future prevention, surveillance, and monitoring interventions.

Objective: To describe the self-reported needs of family caregivers of service members and veterans (SMVs) with traumatic brain injury (TBI) at 10 to 15 years post-injury and to identify unique predictors of unmet family needs. Setting: Five Department of Veterans Affairs Polytrauma Rehabilitation Centers. Participants: A total of 209 family caregivers of SMVs with TBI from the VA TBI Model Systems national database who completed a 10- or 15-year follow-up assessment. Design: Observational study. Main Outcome Measure: Family Needs Questionnaire-Revised (FNQ-R). Results: Item-, domain-, and total score-level descriptive analyses of FNQ-R responses were conducted. On average, 56.3% of the FNQ-R family caregiver needs were reported as met. Health information and involvement in care needs were the most often met, and emotional support and instrumental support needs were the least often met. Adjusted multivariable regression models demonstrated that urban-dwelling SMVs (compared to suburban) and spouses/significant others (compared to parents) were associated with more unmet family needs. Distinct associations were identified between the 6 FNQ-R domains and SMV environmental factors (ie, urbanicity, rurality, and being active duty at follow-up), SMV comorbidities (ie, receiving mental health treatment in the year prior to the follow-up), and caregiver factors (ie, spouses/significant others). Conclusion: Family caregivers of SMVs with TBI reported multiple unmet needs at 10 to 15 years post-injury, emphasizing the importance of ongoing caregiver support after TBI. Policy and programming to support military caregivers should consider the current findings to direct resources to address the identified unmet needs.

Objective: Obstructive sleep apnea (OSA) has been associated with structural and functional brain changes and cognitive impairment in sleep clinic samples. Persons with traumatic brain injury (TBI) are at increased risk of OSA compared to community samples, and many experience chronic cognitive disability. However, the impact of OSA on cognitive outcome after TBI is unknown. The purpose of this study was to examine the relationship between polysomnographic sleep parameters on neuropsychological performance 2 years following TBI. We hypothesized that oxygen desaturation, sleep fragmentation, and sleep depth would predict neuropsychological performance. Method: Participants (N = 123) were persons with moderate-to-severe TBI who underwent Type 1 Polysomnography during acute neurorehabilitation. At 2 years post-TBI, participants completed telephone-based neuropsychological testing (the Brief Test of Adult Cognition by Telephone). General linear models were fit to investigate the relationship between sleep parameters and neuropsychological performance, controlling for demographics and posttraumatic amnesia. Results: When controlling for demographics, injury characteristics, and other sleep parameters, greater percent of Stage 1 sleep time predicted poorer cognitive performance (Overall BTACT composite, p = 0.0078, η_p2 = 6.6%; Verbal Memory composite, p = 0.0407, η_p2 = 3.9%; Executive Function composite, p = 0.0215, η_p2 = 4.9%). Oxygen desaturation, cortical arousals, Stage 3 sleep, and the obstructive apnea-hypopnea index were not significantly associated with cognitive outcome. Conclusions: Reduced sleep depth was associated with cognitive outcome in persons with TBI; these findings require replication. Future research should examine whether improving sleep (e.g. increasing deep sleep) during acute recovery can improve cognitive recovery following TBI.

Objective: To examine, among persons discharged from inpatient rehabilitation for traumatic brain injury (TBI), the degree to which pre-TBI factors were associated with post-TBI hospitalization for psychiatric reasons. The authors hypothesized that pre-TBI psychiatric hospitalization and other pre-TBI mental health treatment would predict post-TBI psychiatric hospitalization following rehabilitation discharge, up to 5 years post-TBI. Setting: Five Veterans Affairs Polytrauma Rehabilitation Centers. Participants: Participants with nonmissing rehospitalization status and reason, who were followed at 1 year (N = 1006), 2 years (N = 985), and 5 years (N = 772) post-TBI. Design: A secondary analysis of the Veterans Affairs TBI Model Systems, a multicenter, longitudinal study of veterans and active-duty service members with a history of mild, moderate, or severe TBI previously admitted to comprehensive inpatient medical rehabilitation. This study examined participants cross-sectionally at 3 follow-up timepoints. Main Measures: Psychiatric Rehospitalization was classified according to Healthcare Cost and Utilization Project multilevel Clinical Classifications diagnosis terminology (Category 5). Results: Rates of post-TBI psychiatric hospitalization at years 1, 2, and 5 were 4.3%, 4.7%, and 4.1%, respectively. While bivariate comparisons identified pre-TBI psychiatric hospitalization and pre-TBI mental health treatment as factors associated with psychiatric rehospitalization after TBI across all postinjury timepoints, these factors were statistically nonsignificant when examined in a multivariate model across all timepoints. In the multivariable analysis, pre-TBI psychiatric hospitalization was significantly associated with increased odds of post-TBI psychiatric hospitalization only at 1-year post-TBI (adjusted odds ratio = 2.65; 95% confidence interval, 1.07-6.55, P = .04). Posttraumatic amnesia duration was unrelated to psychiatric rehospitalization. Conclusions: Study findings suggest the limited utility of age, education, and pre-TBI substance use and mental health utilization in predicting post-TBI psychiatric hospitalization. Temporally closer social and behavior factors, particularly those that are potentially modifiable, should be considered in future research.

Background: The responsibility of care for Veterans and Service Members (V/SMs) with traumatic brain injury (TBI) often defaults to informal family caregivers. Caregiving demands considerable knowledge, skill, and support to facilitate the health and well-being of V/SMs and themselves. Persistent and common TBI caregiver issues include strain, depression, and anxiety. While evidence-based, brief interventions have been developed and implemented for family caregivers in Veteran neurodegenerative populations, few interventions have been developed, adapted, or tested to support the unique needs of caregivers of V/SMs with TBI. Objective: This study will adapt and test an evidence-based, personalized, 6-session telehealth caregiver intervention, “Resources for Enhancing All Caregivers’ Health” (REACH), to meet the unique needs of caregivers of V/SMs with TBI. If successful, a community-based participatory research team will develop an implementation plan to roll out REACH TBI across the national Veterans Affairs Polytrauma System of Care. Methods: This mixed methods, crossover waitlist control clinical trial will use a Type 1 Hybrid Effectiveness-Implementation approach to adapt and then test the effects of REACH TBI on key TBI caregiver outcomes. Results: This study was funded by the Department of Defense in September 2023. Participant enrollment and data collection will begin in 2024. Conclusions: If effective, REACH TBI will be the first evidence-based intervention for caregivers of V/SMs with TBI that can be scaled to implement across the Veterans Affairs Polytrauma System of Care and fill a notable gap in clinical services. International Registered Report Identifier (IRRID): PRR1-10.2196/57692