Exercise for patients with chronic kidney disease: from cells to systems to function.

Chronic kidney disease (CKD) is among the leading causes of death and disability, affecting an estimated 800 million adults globally. The underlying pathophysiology of CKD is complex creating challenges to its management. Primary risk factors for the development and progression of CKD include diabetes mellitus, hypertension, age, obesity, diet, inflammation, and physical inactivity. The high prevalence of diabetes and hypertension in patients with CKD increases the risk for secondary consequences such as cardiovascular disease and peripheral neuropathy. Moreover, the increased prevalence of obesity and chronic levels of systemic inflammation in CKD have downstream effects on critical cellular functions regulating homeostasis. The combination of these factors results in the deterioration of health and functional capacity in those living with CKD. Exercise offers protective benefits for the maintenance of health and function with age, even in the presence of CKD. Despite accumulating data supporting the implementation of exercise for the promotion of health and function in patients with CKD, a thorough description of the responses and adaptations to exercise at the cellular, system, and whole body levels is currently lacking. Therefore, the purpose of this review is to provide an up-to-date comprehensive review of the effects of exercise training on vascular endothelial progenitor cells at the cellular level; cardiovascular, musculoskeletal, and neural factors at the system level; and physical function, frailty, and fatigability at the whole body level in patients with CKD.

Changes in opioid prescribing in veterans with headache during the COVID-19 pandemic: A regression discontinuity in time analysis.

OBJECTIVE: To determine changes in opioid prescribing among veterans with headaches during the coronavirus disease of 2019 (COVID-19) pandemic by comparing the stay-at-home phase (March 15 to May 30, 2020) and the reopening phase (May 31 to December 31, 2020). BACKGROUND: Opioid prescribing for chronic pain has declined substantially since 2016; however, changes in opioid prescribing during the COVID-19 pandemic among veterans with headaches remain unknown. METHODS: This retrospective cohort study utilized regression discontinuity in time and difference-in-differences design to analyze veterans aged ≥18 years with a previous diagnosis of headache disorders and an outpatient visit to the Veterans Health Administration (VHA) during the study period. We measured the weekly number of opioid prescriptions, the number of days supplied, the daily dose in morphine milligram equivalents (MMEs), and the number of prescriptions with ≥50 morphine equivalent daily doses (MEDD). RESULTS: A total of 81,376 veterans were analyzed with 589,950 opioid prescriptions. The mean (SD) age was 51.6 (13.5) years, 57,242 (70.3%) were male, and 53,464 (65.7%) were White. During the pre-pandemic period, 323.6 opioid prescriptions (interquartile range 292.1-325.8) were dispensed weekly, with an median (IQR) of 24.1 (24.0-24.4) days supplied and 31.8 (31.2-32.5) MMEs. Transition to stay-at-home was associated with a 7.7% decrease in the number of prescriptions (incidence rate ratio [IRR] 1.077, 95% confidence interval [CI] 0.866-0.984) and a 9.8% increase in days supplied (IRR 1.098, 95% CI 1.078-1.119). Similar trends were observed during the reopening period. Subgroup analysis among veterans on long-term opioid therapy also revealed 1.7% and 1.4% increases in days supplied during the stay-at-home (IRR 1.017, 95% CI 1.009-1.025) and reopening phase (IRR 1.014, 95% CI 1.007-1.021); however, changes in the total number of prescriptions, MME/day, or the number of prescriptions >50 MEDD were insignificant. CONCLUSION: Prescription opioid access was maintained for veterans within VHA during the pandemic. The de-escalation of opioid prescribing observed prior to the pandemic was not seen in our study.

Characteristics and Gender Differences of Headache in the Veterans Health Administration: A National Cohort Study, Fiscal Year 2008-2019.

BACKGROUND AND OBJECTIVES: - To determine gender differences in headache types diagnosed, sociodemographic characteristics, military campaign and exposures, and healthcare utilization among United States (U.S.) Veterans in the Veterans Health Administration (VHA). METHODS: - This study employed a retrospective cohort design to examine VHA Electronic Health Record (EHR) data. This cohort includes Veterans who had at least one visit for any headache between fiscal years 2008 and 2019. Headache diagnoses were classified into eight categories using International Classification of Disease, Clinical Modification codes. Demographics, military-related exposures, comorbidities, and type of provider(s) consulted were extracted from the EHR, and compared by gender. Age-adjusted incidence and prevalence rates of medically diagnosed headache disorders were calculated separately for each type of headache. RESULTS: - Of the 1,524,960 Veterans with headache diagnoses included in the cohort, 82.8% were men. Compared with women, men were more often white (70.4% vs 56.7%), older (52.0±16.8 vs 41.9±13.0 years), with higher rates of traumatic brain injury (2.9% vs 1.1%) and post-traumatic stress disorder (23.7% vs 21.7%), and lower rates of military sexual trauma (3.2% vs 33.7%; p<0.001 for all). Age adjusted incidence rate of headache of any type was higher among women. Migraine and trigeminal autonomic cephalalgias rates were most stable over time. Men were more likely than women to be diagnosed with headache not-otherwise-specified (77.4% vs 67.7%) and have higher incidence rates of headaches related to trauma (3.4% vs 1.9% [post-traumatic]; 5.5% vs 5.1% [post-whiplash]; p <0.001 for all). Men also had fewer headache types diagnosed (mean ± standard deviation; 1.3 ± 0.6 vs 1.5 ± 0.7), had fewer encounters for headache/year (0.8 ± 1.2 vs 1.2 ± 1.6) and fewer visits to headache specialists (20.8% vs 27.4% p <0.001 for all), compared to women. Emergency Department utilization for headache care was high for both genders and higher for women compared to men (20.3% vs 22.9%; p<0.001). DISCUSSION: - Among Veterans with headache diagnoses, important gender differences exist for men and women Veterans receiving headache care within VHA regarding sociodemographic characteristics, headache diagnoses, military exposure, and headache healthcare utilization. The findings have potential implications for providers and the healthcare system caring for Veterans living with headache.

Psychometric Properties and Sex Differences on the Mayo-Portland Adaptability Inventory Participation Subscale (M2PI) in Veterans With Traumatic Brain Injury.

OBJECTIVE: To evaluate the structural validity of the Mayo-Portland Adaptability Inventory Participation Index (M2PI) in a sample of veterans and to assess whether the tool functioned similarly for male and female veterans. DESIGN: Rasch analysis of M2PI records from the National Veterans Traumatic Brain Injury Health Registry database from 2012-2018. SETTING: National VA Polytrauma System of Care outpatient settings. PARTICIPANTS: Veterans with a clinically confirmed history of traumatic brain injury (TBI) (N=6065; 94% male). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: M2PI, a 5-point Likert-type scale with 8 items. For this analysis, the 2 employment items were treated individually for a total of 9 items. RESULTS: The employment items misfit the Rasch Measurement model (paid employment mean square [MnSq]=1.40; other employment MnSq=1.34) and were removed from subsequent iterations. The final model had eigenvalue 1.87 on the first contrast, suggesting unidimensionality of the remaining 7 items. Item order from least to most participation restriction was transportation, self-care, residence management, financial management, initiation, leisure, and social contact. Wright's person separation reliability for nonnormal distributions was 0.93, indicating appropriateness of M2PI for making individual-level treatment decisions. Mean person measure was -0.92±1.34 logits, suggesting that participants did not report restrictions on most items (item mean=0 logits). A total of 3.8% of the sample had the minimum score (no impairment on all items), and 0.2% had the maximum score. Four items had different item calibrations (≥0.25 logits) for female compared with male veterans, but the hierarchy of items was unchanged when the female sample was examined separately. CONCLUSIONS: These findings suggest that, although employment is a poor indicator of participation restrictions among veterans with TBI, the M2PI is unidimensional. Because of subtle differences in scale function between male and female participants, M2PI should be part of a more thorough clinical interview about participation strengths and restrictions.

Physical Activity, Exercise, Whole Health, and Integrative Health Coaching.

Physical activity and exercise play a significant role in the management and prevention of chronic disease. Therefore, patient-center approaches offered within medical settings are essential for the promotion of health and well-being. The Whole Health model of care incorporates all aspects of care, including prevention, treatment, conventional, and complementary approaches resulting in care for the whole person. Integrative health coaching is a tool for clinicians seeking to achieve behavior changes for improved health, particularly in the areas of physical activity and exercise. The Whole Health model of care complements the rehabilitative process, using a combination of complementary and integrative medicine for health promotion. In addition to incorporating Whole Health tools into clinical care, rehabilitative specialists may partner with integrative health coaches to achieve challenging behavior changes in the areas of physical activity, exercise, and other areas of self-care.

Ten-Year Outcomes of a Systems-Based Approach to Longitudinal Amputation Care in the US Department of Veteran Affairs.

BACKGROUND: The goal of the US Department of Veterans Affairs (VA) Amputation System of Care (ASoC) is to enhance the quality and consistency of amputation rehabilitation care for veterans with limb loss. OBJECTIVE: The ASoC provides specialized expertise in amputation rehabilitation incorporating the latest practices in medical management, rehabilitation, and artificial limbs in order to minimize disability and to enable the highest level of social, vocational, and recreational success for veterans with amputation. DISCUSSION: The ASoC serves veterans with limb amputation from any etiology. Between 2009 and 2019, the VA experienced a 34% increase in the number of veterans with amputation who received care. During the same 10-year period, the percentage of veterans with major limb amputation seen in an outpatient amputation specialty clinic each year increased from 4.8 to 26%. This article highlights how the mission of the ASoC has been accomplished over the past decade through prioritization and implementation of key strategic initiatives in learning organization creation, trust in VA care, modernization, and development of a high-performance network with enhanced access and customer service. CONCLUSIONS: This synopsis of the VA amputation care program serves as a model of amputation care that can be utilized outside the federal sector and has the potential to serve as a systems-based example for providing longitudinal care to other populations within the VA.

Self-reported Participation Restrictions Among Male and Female Veterans With Traumatic Brain Injury in Veterans Health Administration Outpatient Polytrauma Programs.

OBJECTIVES: To identify areas of most restricted self-reported participation among veterans with traumatic brain injury (TBI), explore associations among participation restriction and clinical characteristics, and examine differences in participation restrictions by sex. DESIGN: Retrospective cross-sectional design. SETTING: National VA Polytrauma System of Care outpatient settings. PARTICIPANTS: Veterans with a confirmed TBI event (N=6065). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE(S): Mayo-Portland Participation Index (M2PI), a 5-point Likert-type scale with 8 items. Total score was converted to standardized T score for analysis. RESULTS: The sample consisted of 5679 male and 386 female veterans with ≥1 clinically confirmed TBI events (69% white; 74% with blast exposure). The M2PI items with greatest perceived restrictions were social contact, leisure, and initiation. There were no significant differences between men and women on M2PI standardized T scores. Wilcoxon rank-sum analyses showed significant differences by sex on 4 items: leisure, residence, employment, and financial management (all P<.01). In multinomial logistic regression on each item controlling for demographics, injury characteristics, and comorbidities, female veterans had significantly greater relative risk for part-time work and unemployment on the employment item and significantly less risk for impairment on the residence and financial management item. CONCLUSIONS: There was no significant difference between men and women. Veterans on M2PI standardized T scores, which masks differences in response patterns to individual items. Clinical teams should be encouraged to discuss perceived restrictions with patients and target these areas in treatment planning. Future work is needed to investigate the psychometric properties of the M2PI by biological sex.

Preliminary Study of the Effects of Eccentric-Overload Resistance Exercise on Physical Function and Torque Capacity in Chronic Kidney Disease.

The purpose of this preliminary study was to describe changes in physical function and torque capacity in adults with chronic kidney disease (CKD) in response to a novel progressive eccentric-overload resistance exercise (ERE) regime. Participants included men (n = 4) diagnosed with CKD according to estimated glomerular filtration rate (eGFR) between 59 and 15 mL/kg/1.73 m2 and not requiring dialysis. Physical function was determined by the Short Physical Performance Battery (SPPB), five repetitions of a sit-to-stand (STS) task, and timed-up and go (TUG). Knee extensor strength was assessed using both isometric and isokinetic contractions and performance fatigability indexes were calculated during a 30-s maximal isometric test and a 30-contraction isokinetic test at 180°/second. None of the patients exhibited significant worsening in their health status after training. Participants demonstrated improvements in several measures of physical function and torque capacity following 24 sessions of ERE. Following training, performance fatigability remained relatively stable despite the increases in torque capacity, indicating the potential for greater fatigue resistance. These findings provide initial evidence for ERE as a potential treatment option to combat declines in physical function and neuromuscular impairments in people with CKD. Future research is required to determine optimal progression strategies for maximizing specific neuromuscular and functional outcomes when using ERE in this patient population.

Gender Differences in Outcomes after Traumatic Brain Injury among Service Members and Veterans.

This scoping study describes the range of outcomes in traumatic brain injury (TBI) studies of military service members and veterans addressing gender differences. A secondary purpose is to identify differences in outcomes between male and female participants in such studies. We searched PubMed, CiNAHL, and PsycInfo databases for relevant articles. Two reviewers independently screened results. Of 822 unique titles and abstracts screened for eligibility, 55 full articles were reviewed, with 29 studies meeting full inclusion criteria. Twenty of the 29 included studies used retrospective designs and all but two used data collected from Veterans Affairs or Department of Defense health care settings. TBI was diagnosed by self-report, screening, and evaluation procedures, and medical record documentation. Ten different outcome categories were identified among the included studies. In general, female service members and veterans have not been well represented in TBI outcomes research. Evidence suggests that female veterans with mild TBI (mTBI) report more neurobehavioral symptoms and use more outpatient services than male veterans. Studies also indicate that female veterans with TBI are more frequently diagnosed with depression. Additional research is essential to support precision treatment recommendations for female veterans with TBI, as women represent a growing proportion of the patients served by the Veterans Health Administration. LEVEL OF EVIDENCE: IV.

Social rehabilitation for military veterans with traumatic brain injury, psychological trauma, and chronic neuropsychiatric symptoms: Intervention development and initial outcomes.

OBJECTIVE: A subset of military veterans who have experienced both traumatic brain injury and psychological trauma present with chronic neuropsychiatric symptoms and experience persistent obstacles to social reintegration. This project aimed to develop a novel treatment targeting the unmet social rehabilitation needs of these veterans. Initial intervention development, feasibility, and outcome data are explored. METHOD: Four treatment groups were conducted (n = 20). A treatment workbook was developed during Groups 1 and 2 (n = 10) and research data were collected from Groups 3 and 4 (n = 10). RESULTS: There was a 0% attrition rate across all groups with unanimous requests for additional sessions. T test effect sizes were analyzed with bias-corrected Hedges' g. Improvements were observed on measures of depression (p = .026, g = 0.73), empathic perspective taking (p = .007, g = 0.94), social cognition (p = .002-.678, g = 0.27-1.30 across multiple measures), social relationships (p = .007, g = 1.50), traumatic brain injury-related quality of life (social: p = .014, g = 0.68, emotional: p = .009, g = 1.28) and nonsocial executive functioning (p = .006, g = 0.54). CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Preliminary evidence from this exploratory study suggests that targeting multiple layers of social competence using a combined psychotherapy and cognitive rehabilitation approach holds promise. Larger, controlled studies are needed to further evaluate the feasibility and efficacy of this intervention. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Health Care Utilization and Costs of Veterans Evaluated for Traumatic Brain Injury Through Telehealth.

Background: Mild traumatic brain injury (TBI) is prevalent among Afghanistan (Operation Enduring Freedom [OEF]) and Iraq (Operation Iraqi Freedom [OIF]) Veterans. With clinical video telehealth (CVT), Veterans screening positive for potential deployment-related TBI can receive comprehensive TBI evaluations by providers at specialized centers through interactive video communication.Introduction: We examined health care utilization and costs for Veterans during the 12 months before and after being evaluated through CVT versus in-person.Materials and Methods: We examined OEF/OIF Veterans receiving comprehensive evaluations at specialized Veterans Affairs facilities from October 2012 to September 2014. Veterans evaluated through CVT and in-person at the same facilities were included. We used a difference-in-difference analysis with propensity score weighted regression models to examine health care utilization and costs between TBI evaluation groups.Results: There were 554 Veterans with comprehensive evaluations through CVT (380 with and 174 without confirmed TBI) and 7,159 with in-person evaluations (4,899 with and 2,260 without confirmed TBI). Veterans in the in-person group with confirmed TBI had similar increases in outpatient, inpatient, and total health care costs as Veterans who had TBI confirmed through CVT. However, Veterans with a confirmed TBI evaluated in-person had greater increases in rehabilitation and other specialty costs.Discussion: When visits are in-person, Veterans may have opportunities to discuss more issues and concerns, whether TBI-related or not. Thus, providers might make more referrals to rehabilitation and specialty care after in-person visits.Conclusion: Veterans receiving in-person evaluations who were diagnosed with TBI had similar increases in health care costs as Veterans with TBI confirmed through evaluations through CVT.

Department of Veterans Affairs Polytrauma Telerehabilitation: Twenty-First Century Care.

The use of telehealth for the management of the polytrauma patient provides a unique opportunity to leverage technology to enhance care for a complex patient cohort, to assist in clinical care, and to enhance support for community reintegration for veteran patients. Telehealth connects experts to patients in remote or underserved areas, thereby decreasing a health care disparity. This is especially important when the rehabilitation team is multidisciplinary. The future of telerehabilitation is unknown and implementing virtual care into rehabilitation providers' standard practice will be impeded until state licensure and payment issues are resolved.

Comparative Study of Two Systems for the Assessment of Static Balance in Veterans with Mild Traumatic Brain Injury.

BACKGROUND: Traditionally, the diagnosis of postural instability relies on the clinical examination of static balance. In recent years, computerized technologies have provided a new approach for the accurate detection of positional changes during functional balance. AIM: The aim of this study was to investigate the similarities and differences between two electronic systems, NeuroCom and BioSensics, and their application in the clinical assessment of impaired balance in American veterans. MATERIALS AND METHODS: We examined the sway around the center of mass during static balance conditions in 25 veterans with mild traumatic brain injury, using the two electronic systems. These patients met the inclusion criteria and were assessed for their impaired balance at the District of Columbia Veterans Affair Medical Center, Washington, DC, USA. RESULTS: There were six static balance tests conducted on either NeuroCom or BioSensics system in triplicate. Of the data for 36 sets of statistical data analyses, there were significant correlations among those for eight data sets (22.2%) between the two systems. The strongest positive correlation between the data from the two systems was found during the baseline test, when inputs from visual, vestibular and sensorymotor sources were uninterrupted. The data from the remaining experimental conditions did not correlate significantly with one another. CONCLUSIONS: Both NeuroCom and BioSensics provided comparable data in eight out of 36 experimental conditions in the assessment of static balance in patients with mild traumatic brain injury. The findings clarified the ambiguities in the application of NeuroCom versus BioSensics, provided new knowledge for the field of physical medicine and rehabilitation, and improved the clinical assessment of static balance in patients with mTBI.

The Role of Dual Tasking in the Assessment of Gait, Cognition and Community Reintegration of Veterans with Mild Traumatic Brain Injury.

BACKGROUND: This study focussed on the effect of dual versus single tasking on balance, gait and cognition in veterans with mild traumatic brain injury (mTBI). We examined the correlation between these parameters, with responses to questions on community reintegration activities. METHOD: 22 male and female veterans (aged 19-65) walked along a narrow and 6.1-meter long path, both at their self-selected and fastest but safe pace under single and dual tasking conditions. For dual tasking, participants were required to recall and vocalize a 5-digit number at the end of the path. The outcome measures were the accuracy, velocity, cadence, stride length, and number of steps off the path. We calculated the reliability and correlation coefficient values for the walking time compared with the stride length, velocity, and percentage of swing and stance. RESULTS: Under dual task, the participants demonstrated slower gait, recalled shorter digit span and stepped off the path 12.6% more often than under single task. The stride length decreased by about 20% and the stride velocity increased by over 2% in dual compared with single tasking. CONCLUSIONS: Dual tasking slows down the gait and reduces the attention span in patients with mTBI, which can negatively impact their community reintegration, at least early after their hospital discharge, hence the need for exercising caution with their community reintegration activities. Dual tasking may have the potential to improve balance, gait and attention span of the patients in the long-term, thus leading to safer community integration, if incorporated in the rehabilitation plans.

Traumatic brain injury clinical practice guidelines and best practices from the VA state of the art conference.

Management of symptoms following traumatic brain injury (TBI) can be complex and remains a high priority for Department of Defense (DoD) and Department of Veteran Affairs (VA). Concurrently, awareness of TBI in the public has increased. VA convened a State of the Art (SOTA) Conference to identify priorities for future research and promote best practices for TBI care. Scientific evidence of effective management of symptoms following TBI is expanding, and this evidence has been synthesized into Clinical Practice Guidelines (CPGs) and Clinical Practice Recommendations (CPRs). Knowledge gaps still exist and research efforts to address these gaps should include leveraging large administrative data sets and existing registries to determine effective treatments, investigate compliance of existing clinical care with CPGs and study limitations to determine modifiable vs. non-modifiable core tenants of the evidence-based treatments.

Three Year Trends in Veterans Health Administration Utilization and Costs after Traumatic Brain Injury Screening among Veterans with Mild Traumatic Brain Injury.

Examination of trends in Veterans Health Administration (VHA) healthcare utilization and costs among veterans with mild traumatic brain injury (mTBI) is needed to inform policy, resource allocation, and treatment planning. The objective of this study was to assess the patterns of VHA healthcare utilization and costs in the 3 years following TBI screening among veterans with mTBI, compared with veterans without TBI. A retrospective cohort study of veterans who underwent TBI screening in fiscal year 2010 was conducted. We used VHA healthcare utilization and associated costs by categories of care to compare veterans diagnosed with mTBI (n = 7318) with those who screened negative (n = 75,294) and those who screened positive but had TBI ruled out (n = 3324). Utilization and costs were greatest in year 1, dropped in year 2, and then leveled off. mTBI diagnosis was associated with high rates of utilization. Each year, healthcare costs for those with mTBI were two to three times higher than for those who screened negative, and 20-25% higher than for those who screened positive but had TBI ruled out. A significant proportion of healthcare use and costs for veterans with mTBI were associated with mental health service utilization. The relatively high rate of VHA utilization and costs associated with mTBI over time demonstrates the importance of long-term planning to meet these veterans' needs. Identifying and engaging patients with mTBI in effective mental health treatments should be considered a critical component of treatment planning.

Perspectives of veterans with mild traumatic brain injury on community reintegration: Making sense of unplanned separation from service.

For veterans separated from the military as a result of acquired mild traumatic brain injury (mTBI), the transition from a military identity to a civilian one is complicated by health, cognitive, and psychosocial factors. We conducted in-depth interviews with 8 veterans with mTBI to understand how they perceived the experience of departure from the military, rehabilitation services provided at a Department of Veterans Affairs (VA) Polytrauma Network Site, and reentry into civilian life. Two distinct patterns of thinking about community reintegration emerged. The first pattern was characterized by the perception of a need to fade one's military identity. The second pattern, conversely, advanced the perception of a need to maintain the integrity of one's military identity though living in a civilian world. These perceptions may be linked to individuals' roles while in the military and whether violent acts were committed in carrying out the mission of service, acts not consonant with positive self-appraisal in the civilian world. The crisis of unplanned, involuntary separation from the military was universally perceived as a crisis equal to that of the precipitating injury itself. The perception that civilians lacked understanding of veterans' military past and their current transition set up expectations for interactions with health care providers, as well as greatly impacting relationships with friend and family. Our veterans' shared perceptions support existing mandates for greater dissemination of military culture training to health care providers serving veterans both at VA and military facilities as well as in the civilian community at large. (PsycINFO Database Record

Does Co-Occurring Traumatic Brain Injury Affect VHA Outpatient Health Service Utilization and Associated Costs Among Veterans With Posttraumatic Stress Disorder? An Examination Based on VHA Administrative Data.

OBJECTIVE: To examine whether a traumatic brain injury (TBI) diagnosis was associated with increased outpatient service utilization and associated costs among Iraq and Afghanistan (Operation Enduring Freedom [OEF]/Operation Iraqi Freedom [OIF]/Operation New Dawn [OND]) War veterans with posttraumatic stress disorder (PTSD) who used Veterans Health Affairs (VHA) care in a 1-year period. SETTING: N/A. PARTICIPANTS: OEF/OIF/OND veterans with a diagnosis of PTSD and/or TBI who utilized VHA services during fiscal year 2012 (N = 164 644). DESIGN: Observational study using VHA administrative data. MAIN MEASURES: Outpatient VHA utilization (total and by category of care) and associated costs (total and by VA Health Economic Resource Center cost category). RESULTS: Veterans in the comorbid PTSD/TBI group had significantly more total outpatient appointment than veterans with PTSD but no TBI. This pattern held for all categories of care except orthopedics. The comorbid TBI/PTSD group ($5769) incurred greater median outpatient healthcare costs than the PTSD ($3168) or TBI-alone ($2815) group. CONCLUSIONS: Co-occurring TBI increases the already high level of healthcare utilization by veterans with PTSD, suggesting that OEF/OIF/OND veterans with comorbid PTSD/TBI have complex and wide-ranging healthcare needs.

Affective and Cognitive Conditions are Stronger Predictors of Success with Community Reintegration than Gait and Balance Performance in Veterans with Mild Traumatic Brain Injury.

INTRODUCTION: Optimal community reintegration is an integral part of the clinical management of patients with mild traumatic brain injury. BACKGROUND/OBJECTIVE: We sought the contribution and inter-relation of such variables as balance, executive function, and affective regulation to the community reintegration of veterans with mTBI. METHODS: We examined the statistical relationship among the above variables by conducting a series of objective evaluations to assess the balance, gait, executive function, affective regulation, and scores representing the patients' issues with community reintegration. The data were statistically analyzed for correlation and regression. RESULTS: High correlation was found among scores for balance and gait, executive function and affective regulation. The first and second best predictors of success with patient's community reintegration were data representing affective regulation and cognitive impairments, respectively. However, the data for dynamic balance correlated weakly and insignificantly with scores for the three subsets of community reintegration. CONCLUSIONS: We revealed varying degrees of correlation among balance, executive function and affective regulation, and as they related to the community reintegration success of patients with mTBI. The strongest, intermediate and weakest predictors for these patients' success with community reintegration represented those for affective regulation, executive function, and dynamic balance and gait performance, respectively.