For veterans with mild traumatic brain injury, improved posttraumatic stress disorder severity and sleep correlated with symptomatic improvement.

This was an observational study of a cohort of 63 Operation Iraqi Freedom/Operation Enduring Freedom veterans with mild traumatic brain injury (mTBI) associated with an explosion. They had headaches, residual neurological deficits (NDs) on neurological examination, and posttraumatic stress disorder (PTSD) and were seen on average 2.5 years after their last mTBI. We treated them with sleep hygiene counseling and oral prazosin. We monitored headache severity, daytime sleepiness using the Epworth Sleepiness Scale, cognitive performance using the Montreal Cognitive Assessment test, and the presence of NDs. We quantitatively measured olfaction and assessed PTSD severity using the PTSD Checklist-Military Version. Nine weeks after starting sleep counseling and bedtime prazosin, the veterans' headache severity decreased, cognitive function as assayed with a brief screening tool improved, and daytime sleepiness diminished. Six months after completing treatment, the veterans demonstrated additional improvement in headache severity and daytime sleepiness and their improvements in cognitive function persisted. There were no changes in the prevalence of NDs or olfaction scores. Clinical improvements correlated with reduced PTSD severity and daytime sleepiness. The data suggested that reduced clinical manifestations following mTBI correlated with PTSD severity and improvement in sleep, but not the presence of NDs or olfaction impairment.

Relationships between mild traumatic brain injury sustained in combat and post-traumatic stress disorder.

The setting of the trauma is a distinguishing feature between mild traumatic brain injury (mTBI; also called concussion) that occurs in civilian settings compared with that occurring in combat. Combat mTBI is frequently associated with a prolonged stress reaction, post-traumatic stress disorder (PTSD). Individuals with mTBI and PTSD from combat in Operations Iraqi Freedom and Enduring Freedom often develop prolonged post-concussion symptoms (PCSs) such as headache. Both mTBI and PTSD may contribute to PCSs. PTSD may worsen and prolong the PCSs following mTBI by disrupting sleep. It is not known how mTBI predisposes an individual to develop PTSD.

Improving sleep: initial headache treatment in OIF/OEF veterans with blast-induced mild traumatic brain injury.

This was an observational study of a cohort of 126 veterans with mild traumatic brain injury caused by an explosion during deployment in Operation Iraqi Freedom or Operation Enduring Freedom (OIF/OEF); 74 of the 126 veterans had comorbidities including frequent, severe headaches and residual deficits on neurological examination, neuropsychological testing, or both. Of these veterans, 71 had posttraumatic stress disorder and only 5 had restful sleep. We examined whether treatment with sleep hygiene counseling and oral prazosin would improve sleep, headaches, and cognitive performance. Nine weeks after providing sleep counseling and initiating an increasing dosage schedule of prazosin at bedtime, 65 veterans reported restful sleep. Peak headache pain (0-10 scale) decreased from 7.28 +/- 0.27 to 4.08 +/- 0.19 (values presented as mean +/- standard deviation). The number of headaches per month decreased from 12.40 +/- 0.94 to 4.77 +/- 0.34. Montreal Cognitive Assessment scores improved from 24.50 +/- 0.49 to 28.60 +/- 0.59. We found these gains maintained 6 months later. This pilot study suggests that addressing sleep is a good first step in treating posttraumatic headaches in OIF/OEF veterans.

Headaches among Operation Iraqi Freedom/Operation Enduring Freedom veterans with mild traumatic brain injury associated with exposures to explosions.

Traumatic brain injury (TBI) is a common injury type among Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) veterans, and headaches are a frequent consequence of TBI. We examined the hypothesis that among veterans who reported mild TBI caused by exposure to an explosion during deployment in OIF/OEF, those with residual neurocognitive deficits would have a higher frequency of headaches and more severe headaches. We evaluated 155 consecutive veterans with neurological examination and neuropsychological testing. We excluded 29 veterans because they did not have mild TBI or they did not complete the evaluation. We analyzed headache pattern, intensity, and frequency. Among the 126 veterans studied, 80 had impairments on neurological examination or neuropsychological testing that were best attributed to TBI. Veterans with impairments had been exposed to more explosions and were more likely to have headache, features of migraine, more severe pain, more frequent headaches, posttraumatic stress disorder, and impaired sleep with nightmares.

Directed rehabilitation reduces pain and depression while increasing independence and satisfaction with life for patients with paraplegia due to epidural metastatic spinal cord compression.

We determined whether directed rehabilitation affected survival, pain, depression, independence, and satisfaction with life for veterans who were nonambulatory after spinal epidural metastasis (SEM) treatment. We compared 12 consecutive paraplegic veterans who received 2 weeks of directed rehabilitation with a historical control group of 30 paraplegic veterans who did not receive rehabilitation. The rehabilitation program emphasized transfers, bowel and bladder care, incentive spirometry, nutrition, and skin care. The outcome measures were survival, independence, pain levels, depression, and satisfaction with life. Patients receiving rehabilitation had longer median survivals, fewer deaths from myelopathic complications, less pain 2 weeks after SEM treatment, lower depression scores, and higher satisfaction with life scores. In addition, among the patients who received rehabilitation, eight became independent for transfers (vs zero controls) and nine returned home (vs six controls). We conclude that directed rehabilitation reduced patients' pain levels and increased their mobility, survival, and life satisfaction.

Persistent benefits of rehabilitation on pain and life quality for nonambulatory patients with spinal epidural metastasis.

We determined whether the benefits of directed rehabilitation for pain, depression, and satisfaction with life persisted for veterans who were nonambulatory after spinal epidural metastasis (SEM) treatment. Twelve consecutive veterans (paraplegic after SEM treatment) who received 2 weeks of directed rehabilitation were compared with a historical control group of thirty paraplegic veterans who did not receive rehabilitation. Subjects were followed until death. Pain levels, depression, satisfaction with life, and consumption of pain medication were measured. Subjects who received rehabilitation had less pain, consumed less pain medication, were less depressed, and had higher satisfaction with life. The benefits to the rehabilitated subjects persisted until their deaths. We conclude that spinal cord injury rehabilitation for nonambulatory subjects with SEM produces persistent benefits for pain, depression, and satisfaction with life.