Mild Traumatic Brain Injury in Military Veterans: Clinical Implications for Assessment &

Treatment

Karen Gallagher, Ph.D., CCC-SLP

High Cognitive Demands of CollegeToday’s discussion will largely focus on this growing group of military veterans

2.6 million deployed to Iraq and Afghanistan over the past 17+ years 1

1.7 million have left military service and another quarter of a million more per year will do so over the next few years 1

The majority enter college after separation from service 2

1. Chairman’s Office on Reintegration Report, 2014; 2. Steele, J.L., Salcedo, N., & Coley, J. (November, 2010)

The number of military affiliated students at ASU are rising

Number of student veterans has increased drastically on a national level

In 2009 there were approximately 500,000 and in 2013 there were over 1 million

National Center for Education Statistics, 2016

Who are Student Veterans?

• Mostly male• Females are over represented• Older• Almost half have children• Almost half are married• Over 60% are first in their families to go to college

There are unique challenges in this population

ASU State Press, 2015

There is disagreement about academic success in military veteran college students

Student Veterans of America: 72% academic success among veterans (2017)

Only 51% of veterans graduate vs. 59% of non-veterans (National Center for Education Statistics, 2013)

There is an 88% attenuation rate (Briggs, 2012)

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1) Defense and Brain Injury Center, 2015; 2) U.S. Department of Veterans Affairs; Dolan et al., 2012; 3) National Alliance on Mental Illness; 4) Lew et al., 2010; 5) CDC; 6) U.S. Department of Veterans Affairs; 7) Anxiety and Depression Association of America; 8) Lew et al., 2010

Civilians~8% (adult) 5

6.8% 6

6.7% 7

18% yearly 7

Veterans20 - 33% 1

14 - 44% 2

14% 3

??

TBI (mTBI)PTSDepressionAnxiety Disorders

PTS within mTBI ??33 – 39%8

Service-Related Conditions

Results from Azuma & Gallagher presented at ICCDC, 2017

Condition Veterans (N=138)

Civilians (N=213)

Group Differences

Depression 24.3% 15.0% χ2=4.38, p=.036*PTSD 11.6% 1.4% χ2=17.00,

p<.001**mTBI (Diagnosed or Suspected)

25.4% 24.9% χ2<1

mTBI Group Only N=35 N=53mTBI + Depression 31.4% 9.4% χ2=6.86, p=.009**mTBI + PTSD 28.6% 0.0% χ2=17.08,

p<.001**

Table 1. Self-Reported Rates of Depression, PTSD, and mTBI in the Veteran and Civilian Groups

Challenges in Assessment and Treatment of Cognitive Symptoms Related to mTBI in Military Veterans

Military Culture

Injury Environment

TransitionOther

Conditions

What is Military Culture?

Military Culture

Defined by a unique vocabulary, rules, and belief systems (Reger et al., 2007)

Attitude that seeking healthcare services is an indication of weakness

Barrier to care

Military Culture

Injury Environment

Combat

Training

• Loss of life and limb• Delay the mission• Delay discharge/return home

• “Recycled”• Failure

Injury Environment

Barrier to care

Transition

Transition

Military-to-Civilian Transition can create stress and anxiety

Mobbs, M.C., Bonanno, G.A., (2018). Behond war and PTSD: The crucial role of transition stress in the lives of military veterans. Clinical Psychology Review, 59, 137-144.

Identity

Moral Injury

Civilian-military divide

Stereotypes

Barrier to care

Other Conditions

Commonly Reported Overlapping Symptoms

mTBI

PTS

Depression

Anxiety Disorders

Memory

Attention

Sleep

Anxiety

Overlapping symptoms of depression, anxiety and PTS and the frequent concomitance with mTBI, provides one of the largest hurdles in assessment of unremitting mTBI symptoms (Karr et al., 2014; Lange et al., 2012)

Other Conditions

Barrier to care

Military Culture

Injury Environment

TransitionOther

Conditions

Delay in Reporting

Absence of Reporting

Misdiagnosis

Questions&

Discussion

Military Culture

Injury Environment

TransitionOther

Conditions

Long-term Cognitive Symptoms related to mTBI in Military Veterans

• Memory• Attention• Executive Function• Speed of Processing

Symptoms present more than a year after injury

“…in contrast to the prevailing view that most symptoms of concussion are resolved within 3 months post injury, approximately half of individuals with a single mTBI demonstrate long-term cognitive impairment.”

Mcinnes, K., Friesen, C.L., MacKenzie, D.E., Westwood, D.A., and Boe, S.G. (2017). Mild Traumatic Brain Injury (mTBI) and chronic cognitive impairment: A scoping review. PLoS OnE 12(4).

Assessment of Unremitting mTBI Symptoms

Concomitant PTSD or Depression account for the deficits (Lang et al., 2012; Seal, 2016; Verfaellie et al., 2014)

No long-term neuropsychological deficits associated with mTBI (Storzbach et al., 2015)

Based on commonly used clinical neuropsychological assessments

Symptom report related to mTBI is often dismissed due to lack of neuropsychological test evidence (Spencer et al., 2010; Verfaellie et al., 2014)

Despite subjective reports of long-term symptoms related to mTBI in military veterans… (Hartikainen et al., 2010; Schneiderman et al., 2008)

Why don’t standardized assessments consistently capture subtle deficits related to chronic mTBI?

• Tests were not designed to measure chronic cognitive deficits related to mTBI

• Standardized to elicit the best possible performance

• Do not reflect real-world demands that may exacerbate “subtle” deficits

• Performance may only be affected when the task is challenging and placing more demands on the cognitive system (Cicerone, 2009)

Measuring MemoryDigit Span

• Forward• Backward

Word Lists• AVLT• Paired Associates

For the most part, these are decontextualized rote memory tasks that don’t reflect real-world demands

Our studies have included traditional clinical tasks, experimental tasks and self-report of symptoms

• Rote memory• Episodic memory tasks• Working memory• Executive function• Decision making• Attention

• Completed at home• 107 questions• Demographic information• Military, Medical, and Educational Background

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Online Questionnaire

VETERANS WITH mTBI: Utilizing Self-Report Information

Krug & Turkstra (2015)

Comprehensive survey as part of the assessment

Circumstances

Situational Checklist

Self-assessment and ratingMemoryAttentionAnxiety

VETERANS WITH mTBI: Asking the Right Questions

Military Service

• Beck Depression Inventory• Beck Anxiety Inventory • Informal Memory and Attention Ratings

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Self-Assessment and Rating

“Compared to other people my age, my OVERALL memory is:5 = much better4 = slightly better3 = the same2 = slightly worse1 = far worse”

History of Military Service

• Enlistment length

• Military Occupation

• Deployment

This information can lead to more specific questions and can direct your assessment and referral decisions

Diagnosed and Suspected Head InjuriesDescription of Circumstances

Who diagnosed the injury?

What caused the injury?

Where did the injury happen?

Suspected TBI?Symptoms

Immediately experienced

Still experiencing Mayo Classification System for Traumatic Brain Injury Severity (Malec et al., 2008)

In-Person Testing

At ASU

• Approximately 2 to 2 ½ hours

• Mostly computerized tasks

Commonly Used Neuropsychological Tasks

• Digit Span• Trail Making

Performance on these tasks were not related to mTBI or PTSD

Did provide evidence of effort

Reliable Digit Span Score (RDS): combining the highest span set where both trials were accurately recalled in both the forward and backward condition1

1) Heinely et al., 2005; Loring, Goldstein, Chen, Drane, Lah, Zhao, & Larrabee, 20162) Schroeder, Twumasi-Ankrah, Baade, & Marshall, 2012

Digit Span as a Measure of Effort

An RDS of <7 is considered evidence of lack of effort2

In my study no participant earned an RDS below 10

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Documenting Reported Deficits

We need ecologically valid, complex tasks that:

• Shift from simple memory tasks• Tasks should mirror real-world demands• Tasks should tap higher-order cognitive processes

Memory in Real Life

• Stories • Lectures• Conversations• Events

This type of memory is complex, requiring sequencing and recall of semantic information

Narrative Recall Tasks

Logical Memory I (Immediate)Participants were told two stories.After each story, the participant was asked to retell the story “in as much detail and using as many of the same words as possible.”

Logical Memory II (Delayed) After a 20-30 minute delay, the participant was asked to retell each story.

WMS-IV (Wechsler, 2009)

Gallagher, K., & Azuma, T. (2018). Analysis of story recall in military veterans with and without mild traumatic brain injury: Preliminary results. American Journal of Speech-Language Pathology, 27(1S), 485-494.

Control Group(N=42)

mTBI Group(N=22)

Females 13 (31%) 2 (9%)

Mean Age (yrs) 31.7 (6.5) 32.9 (7.3)

PTSD 5 (12%) 9 (41%)

Depression 11 (26%) 7 (32%)

Anxiety 24 (57%) 16 (73%)

Study Participants

Results

A Mixed-factor Analysis of Covariance (ANCOVA) was conducted on the data.

Delay (Immediate vs. Delayed): Within-subjects variable

Group (mTBI vs. Control): Between-subjects variablePTS, Depression: Covariates

This interaction was significant even when PTS and Depression were included as covariates.

PTS: F (1, 60) = 2.57, p = .114Depression: F (1, 60) = 2.70, p = .106

Significant main effect of Delay (F(1,60) = 44.49, p < .001, ηp

2 = .43) Significant Delay X Group interaction

(F(1,60) = 5.8, p = .019, ηp2 =.088)

Significant Findings

LM 1: Immediate Condition

Mea

n Sc

ores

No group difference

(t<1)

10

15

20

25

30

35

Control mTBI

t (62) = 1.97, p =.043

Mea

n Sc

ores

LM 2: Delayed Condition

10

15

20

25

30

35

Control mTBI

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• Widely used in both clinical and healthy populations (Lezak et al., 2012)

• Measure higher-order cognitive skills (Bagneux et al., 2013; Cui et al., 2015)

• Shown to be sensitive to deficits associated TBI (Bechara, 2007)

including risk-taking

Computerized using PEBL version 0.14 (Meuller & Piper, 2014)

Decision Making: The Iowa Gambling Task Bechara et al., 1994

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Significant: mTBIβ = -.264, t = -2.05, p = .045

The regression model was significant (F (1,56) = 4.50, p = .045)

Multiple Regression AnalysisDependent Variable: Advantageous Deck Score (Low Risk decks) – (High Risk decks)Predictor Variable: mTBI

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Trials were divided into blocks of 201

1. Based on conventional scoring methods for the IGT, (Bechara, 2007; Bagneux et al., 2013; Cotrena et al., 2014; Brenner et al., 2015)

2 (Group: Control vs. mTBI) X 4 (Block Advantageous Deck Selection Score for Blocks 2, 3, 4, 5) mixed-factor Analysis of Variance (ANOVA)

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-1

0

1

2

3

4

5

6

7

8

9

10

11

Block 2 Block 3 Block 4 Block 5

ControlmTBI

Mea

n Ad

vant

ageo

us D

eck

Scor

e

* Denotes significantly different from Block 2 (p<.008)

There was a significant main effect of Block (F(3, 165)=7.34 p<.001, partial ɳ2=.118)

No significant effect of Group (F(1,55)=2.29, p=.136, partial ɳ2=.04)

Marginally significant Block X Group interaction (F(3,165)=3.91, p=.053 partial ɳ2=.066)

Healthy control group, there was a significant effect of Block (F(3,105)=12.33, p<.001)mTBI group no effect of Block (F<1)

*

**

050403070908WRONG!

Visual Serial Addition

Longer task

Stress inducing

Time pressure (4 seconds)

Aversive feedbackWRONG!TOO SLOW!

Requires Updating and Inhibition (Executive Function Skills)

Results

Group (Control vs. mTBI): Between-subjects variable

Quartile (1, 2, 3, 4): Within-subjects variable

PTS: Covariate

A Mixed-factor Analysis of Covariance (ANCOVA)

The trials were divided into quartiles (25 trials per quartile).

Accuracy

Significant effect of Quartile (F(3, 150)=4.86, p=.003, ɳp2=.089)

No significant effect of Group (F(1,50)=1.68, p=.201, ɳp2 =.033)

Significant Quartile X Group interaction (F(3,150)=3.08, p=.029, ɳp2 =.058)

0.6

0.65

0.7

0.75

0.8

0.85

0.9

1st Quartile 2nd Quartile 3rd Quartile 4th Quartile

Mea

n Ac

cura

cy

ControlmTBI

**

Control : No effect of Quartile (F<1)mTBI: Significant effect of Quartile (F(3,54)=5.18, p=.003, ɳ2

p =.224)

* Compared to 2nd quartile, p<.008

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Valid and reliable working memory measures (Unsworth et al., 2005; Conway et al., 2005)

Measure higher-level skills (Unsworth & Engle, 2007)

Operation Span Task (Turner & Engle, 1989)

Experimental Measure of Complex Verbal Memory Span

( 3 * 4) – 4 = ?

Set sizes 4-6Possible Score range = 0-30Total Score = Total Correct

Computerized using E-Prime 2.0 software (Psychology Software Tools, Pittsburgh, PA)52

FK6

True False

Recall the letters in the order you saw them

Operation Span Task, Turner & Engle, 1989

Computerized Operation Span Task

Data presented by Gallagher, Azuma, Bacon, and Ingram at INS Conference 2019, New York City

Correlational analyses were used to examine the relationship between commonly reported service-related conditions/self-ratings (mTBI, PTS, Memory Rating, BDI) and Operation Span Score

When evaluating cognitive skills in military veterans with mTBI it is important to:

Consider the unique nature of military cultureHow it impacts report of injury

Consider the environmentHow it may delay diagnosisWhy the mTBI may be more traumatic

Consider possible service-related concomitant disorders Overlapping symptoms complicate assessmentReferrals may be needed

Overview

Consider the impact of transition Which support systems can be activated

There is emerging research that provides support for the validity of veterans’ self-assessments (Krug & Turkstra, 2015)

We can’t dismiss their symptom reports based on simple memory tests.

Researchers and clinicians are responsible for finding the right tests.

If we fail to document existing memory impairments, veterans don’t get needed services

Treatment & Treatment Resources

mTBI

PTS

Depression

Anxiety Disorders

Memory

Attention

Sleep

Anxiety

Transdisciplinary care is necessary

At ASU:

Grant-funded Veteran Specialty Clinic in the Speech and Hearing Clinic

Collaboration with the Pat Tillman Veteran Center

Specialized training given to the Disability Resource Center

Collaboration with the Counseling Center

Teammates vs. Expert-Patient Relationship

• Cognitive Coaching• Motivational Interviewing• Respects military values • Considers the transition experience• Vocationally/Academically relevant

Kennedy, M.R.T. (2017). Coaching College Students with Executive Function Problems. New York, NY: Guilford Press.

Veteran Specialty Clinic

Veterans self-select for intervention regardless of diagnosis

They complete 7-10 one-hour sessions with a graduate clinician supervised by me

During the initial session Veterans: Identified executive skills strengths and

weaknesses using the adult version of the Executive Skills Checklist1

Provided course information, work schedules, samples of notes, and descriptions of organization and studying strategies

Dawson, Peg, & Guare, Richard. (2012). Coaching Students with Executive Skills Deficits. Practical Intervention in the Schools Series (Vol. 20). Guilford Press. 72 Spring Street, New York, NY 10012.

During weekly sessions Veterans: Identified goals related to academic success, steps

to achieving goals, and barriers to achieving goals Identified memory, attention, and organization

strategies to be used during the week and defined the academic areas where those strategies would be applied

Reviewed strategy use and effectiveness and identified reasons for success or lack of success

Revised strategy use

During weekly sessions, Clinicians: Established a teammate rapport (vs. expert –

patient) Offered evidence-based organization, memory,

attention, and active studying strategy options for application on existing courses

Used motivational interviewing techniques to facilitate participant exploration and self-discovery of barrier behaviors and attitudes

Working Group to Develop a Clinician’s Guide to Cognitive Rehabilitation in mTBI: Application for Military Service Members and Veterans. (2016). Clinician’s guide to cognitive rehabilitation in mild traumatic brain injury: Application for military service members and veterans. Rockville, MD: American Speech-Language-Hearing Association. Available from http://www.asha.org/uploadedFiles/ASHA/Practice_Portal/Clinical_Topics/Traumatic_Brain_Injury_in_Adults /Clinicians-Guide-to-Cognitive-Rehabilitation-in-Mild-Traumatic-Brain-Injury.pdf

Clinician’s Guide to Cognitive Rehabilitation in Mild Traumatic Brain Injury: Application for Military Service Members and Veterans

Questions&

Discussion

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Karen Gallagher

Karen.Gallagher@asu.edu