Lisa H Lu’s research while affiliated with Brooke Army Medical Center and other places

Purpose The aim of this study was to describe the development of and pilot feasibility outcomes for a strategy-based, brief, intensive cognitive rehabilitation intervention delivered to U.S. service members and veterans with mild traumatic brain injury in a recently completed 3-year pragmatic clinical trial: Symptom-Targeted Approach to Rehabilitation for Concussion (STAR-C). Method To develop STAR-C, we used the Rehabilitation Treatment Specification System to identify core elements and principles from a previous randomized clinical trial of cognitive rehabilitation, and incorporated principles of neuroplasticity (e.g., high-dose spaced practice of personally meaningful tasks), best clinical practices (e.g., client-centered goal setting), health psychology (e.g., a focus on self-efficacy and motivation), and community-based participation research (e.g., the protocol was co-designed by clinicians and researchers). Treatment was based on a resource-allocation theory of everyday cognitive challenges, which predicted that automatic strategy use would reduce cognitive demands of everyday activities and therefore reduce cognitive symptoms. Treatment was delivered by speech-language pathologists (SLPs) and occupational therapists (OTs), using a protocol that included a problem-focused intake questionnaire, manualized treatment, and clinician resources. Therapy was delivered individually in six to 10 virtual or in-person sessions over 3–4 weeks. Therapy focused on desired changes in function, scaled using Goal Attainment Scaling. Results Trained SLPs and OTs delivered STAR-C to 53 U.S. service members and veterans, with treatment fidelity > 95%. Participants and clinicians rated STAR-C as acceptable, feasible, and appropriate, and most participants attained and maintained targets. Conclusion STAR-C appears to be a feasible method for improving everyday cognitive performance and efficacy should be tested in a controlled study. Supplemental Material https://doi.org/10.23641/asha.28222613

Introduction Headache is the most overwhelmingly reported symptom following mild traumatic brain injury (mTBI). The upper cervical spine has been implicated in headache etiology, and cervical dysfunction may result in neck pain that influences the experience of headache. Sleep problem is the second most reported symptom following mTBI. We explored the contribution of neck pain (as a potential proxy for cervical dysfunction) on headache burden along with the contribution of sleep quantity following mTBI. Materials and Methods Retrospective data from a repository consisting of service members recruited from primary care, with (N = 493) and without a history of mTBI (N = 63), was used for analysis. Portions of the Neurobehavioral Symptom Inventory, Pittsburgh Sleep Quality Index, and Orebro Musculoskeletal Pain Questionnaire were used for headache, sleep, and neck pain measures. Results Demographic and military characteristics that differed between groups were treated as covariates in analyses. Group comparisons revealed significant differences in the expected direction on all measures: mTBI > controls on headache and neck pain; controls > mTBI on sleep quantity. Regression revealed that neck pain accounted for the most variance in headache score, followed by group membership and sleep quantity. When analyzing groups separately, no difference in the pattern of results was revealed in the mTBI group. In the control group, variance in headache score was only significantly related to neck pain. Conclusions Amongst service members who sought service from primary care, neck pain explains more variance in headache burden than mTBI history or sleep quantity, supporting that cervical dysfunction may be a salient factor associated with headache. Neck functioning may be a potential area of intervention in the management of headaches.

Objective Research on the Minnesota Multiphasic Personality Inventory, 3 (MMPI-3) Somatic/Cognitive scales is limited, but primarily focused on their relationships with symptom and performance validity tests. This study expands prior literature by providing extensive Somatic/Cognitive Scale correlates with symptom validity tests and neurocognitive measures in a sample of active-duty personnel and veterans. Method The study included Active-duty Service Members (n = 22) and Veterans (n = 31). Various measures of cognitive abilities and symptom validity were examined as a function of the Cognitive Complaints (COG) scale. Results Moderate to large differences were observed between COG groups across all MMPI-3 overreporting scales and all somatic/cognitive scales, save the NUC scale (g = 0.66–1.31 [excluding NUC]). Groups differed on three Memory Complaints Inventory memory scales: General (g = 0.89), Visuo-spatial (g = 0.62), and Verbal (g = 0.97). No significant differences were observed across cognitive tests (e.g., WAIS, CVLT). COG was moderately associated with all MMPI-3 overreporting and most somatic/cognitive scales (r = 0.30–0.72). Small to moderate correlations were observed between COG and most external validity and neurocognitive measures (r = 0.05–0.60). Conclusions Results suggest the COG scale primarily captures subjective distress rather than objective neurocognitive performance, consistent with prior work (Gervais et al., 2009). These patterns are especially pronounced in emotional, social, and somatic symptom domains. Additionally, COG scores were associated with MMPI-3 overreporting scores, but COG had weaker associations with external neurocognitive and symptom validity measures. These results suggest that COG has weak convergent validity with other self-report measures of cognition (e.g., Neurobehavioral Symptom Inventory).

Objective: Persistent symptoms post-mild traumatic brain injury (mTBI) includes autonomic dysregulation (AD). The composite autonomic symptoms score, (COMPASS-31), was developed to quantify AD symptom severity in the last year, which limits clinical utility. The primary aim was to determine validity of a modified-COMPASS-31 measuring symptoms in the last month compared to the original, secondarily to compare both original and modified versions to the Neurobehavioral Symptom Inventory (NSI), and tertiarily to detect change post-treatment of the modified-COMPASS-31 compared to NSI and headache intensity (HI). Participants: Thirty-three military personnel with persistent headache post-mTBI. Main outcome measures: Total and domain scores for COMPASS-31 (original vs. modified) NSI and HI at baseline. Change in modified-COMPASS-31. NSI, and HI. Results: Baseline COMPASS-31 versions were comparable and highly correlated (r = 0.72, p < 0.001), they were moderately correlated at best to the NSI (r < 0.6), which may suggest differences in measurement metrics. The mean change in modified-COMPASS-31 scores (15.4/100, effect size 0.8) was mild to moderately correlated to the change in HI (r = 0.39) score, but not to NSI (r = 0.28). Conclusion: The modified-COMPASS-31 appears to be valid, can measure change of AD symptom severity, and is recommended as an outcome measure.

The present study evaluated whether Grooved Pegboard (GPB), when used as a performance validity test (PVT), can incrementally predict psychiatric symptom report elevations beyond memory-apparent PVTs. Participants (N = 111) were military personnel and were predominantly White (84%), male (76%), with a mean age of 43 (SD = 12) and having on average 16 years of education (SD = 2). Individuals with disorders potentially compromising motor dexterity were excluded. Participants were administered GPB, three memory-apparent PVTs (Medical Symptom Validity Test, Non-Verbal Medical Symptom Validity Test, Reliable Digit Span), and a symptom validity test (Personality Assessment Inventory Negative Impression Management [NIM]). Results from the three memory-apparent PVTs were entered into a model for predicting NIM, where failure of two or more PVTs was categorized as evidence of non-credible responding. Hierarchical regression revealed that non-dominant hand GPB T-score incrementally predicted NIM beyond memory-apparent PVTs (F(2,108) = 16.30, p < .001; R2 change = .05, β = -0.24, p < .01). In a second hierarchical regression, GPB performance was dichotomized into pass or fail, using T-score cutoffs (≤29 for either hand, ≤31 for both). Non-dominant hand GPB again predicted NIM beyond memory-apparent PVTs (F(2,108) = 18.75, p <.001; R2 change = .08, β = -0.28, p < .001). Results indicated that noncredible/failing GPB performance adds incremental value over memory-apparent PVTs in predicting psychiatric symptom report.

Objective: To determine correspondence between the statistically derived 8-point reliable change index for the Neurobehavioral Symptom Inventory (NSI) against clinically significant item-level change in symptom severity from intake to discharge for mild traumatic brain injury (mTBI). Setting: Brain Injury Rehabilitation Service at Brooke Army Medical Center, Fort Sam Houston, San Antonio, Texas. Patients: In total, 655 active-duty service members with a diagnosis of mTBI who received treatment and completed self-report measures between 2007 and 2020. Design: Observational retrospective analysis of outpatient clinical outcomes data. Main measures: NSI total score change was used to divide patients into responder and nonresponders based on whether they met an 8-point decrease between intake and discharge. In addition, patients who had at least one NSI item that changed from a rating of 3 (severe) or 4 (very severe) at intake to a rating of 0 (none) or 1 (mild) at discharge were coded as an individual with significant item-level change. Results: Forty-five percent of the sample had significant item-level change and were classified as responders according to the reliable change method. Eight percent of the sample had significant item-level change but did not meet the 8-point reliable change threshold. Fifteen percent of the sample did not experience significant item-level change but were classified as responders according to reliable change. Thirty-one percent did not meet either method's criterion for change. Classification agreement between the reliable change and item-level change methods was 76%, which was statistically significant (= 181.32, P < .001). Conclusion: There is good correspondence between reliable change and item-level change on the NSI in this population. Reliable change is easily calculated and thus much more accessible than the item-level change method. There may be some situations where calculating item-level change may be helpful.

Research Objectives Current gold standard for medical fitness to drive is on-road driving test conducted by a certified driving rehabilitation specialist (CDRS). Due to scarcity of CDRS, we evaluated whether driving simulator yields objective data that can inform decisions on medical fitness to drive. Design Prospective observational design. A single CDRS evaluated on-road driving and videos of simulated driving. The CDRS was “blinded” to participant status on videos of simulated driving. Setting Brain Injury Rehabilitation Service at Brooke Army Medical Center, Fort Sam Houston, San Antonio, TX. Participants 12 brain injury patients (5 with on-road driving test), 30 controls. Interventions None. Main Outcome Measures On-road driving safety. Safety based on simulated driving. Team decision based on sensory, cognitive, motor, and medical evaluations. Results The correspondence between safety from on-road driving and simulated driving was only 60%. It was more difficult to pass simulated driving than on-road driving. The correspondence between safety from on-road driving and team decision (based on sensory, cognitive, motor, medical evaluations) was only 60%. The correspondence between simulated driving and team decision (controls were presumed to be safe) was a dismal 40%. Conclusions Logistic and technical barriers precluded usefulness of objective simulator data. Nevertheless, important clinical lessons learned include: Simulated driving that includes opportunities to demonstrate handling of hazards appeared to be more difficult to pass than on-road driving tests. Controls enjoy a privilege of presumed driving safety while brain injury patients under medical scrutiny do not have this privilege. Each of three components considered (on-road driving; simulated driving; and team input of sensory, cognitive, motor and medical findings) contribute unique data that are valuable to determination of medical fitness to drive. Author(s) Disclosures Disclaimer: The views expressed in this abstract are those of the authors and do not necessarily represent the official policy or position of the Defense Health Agency, Department of Defense, or any other U.S. government agency. For more information, please contact [email protected] UNCLASSIFIED.

Objectives To compare sub-occipital muscle pressure sub pain thresholds (PPTs) in individuals with persistent-post-traumatic-headache (PPTH) in relation to the presence or not of cranial nerve and/or autonomic symptoms reported during sustained neck rotation (SNR). Background Previously 81% of military service members with PPTH demonstrated symptoms with SNR up to 60 seconds. Of these, 54% reported symptoms in one (Uni-Symp) and 46% in both directions of rotation (Bi-Symp). Sub-occipital PPTs, in relation to SNR direction, were of interest. Methods Retrospective review of records of 77 individuals, with PPTH with both SNR and PPTs. Average suboccipital and scalene PPTs were compared between Asymptomatic (n = 13), upon SNR testing, or Symptomatic (Uni-Symp, n = 32, Bi-Symp, n = 32), groups. Results The Bi-Symp group had significantly reduced sub-occipital PPTs relative to the Asymptomatic group on both sides [p < 0.009] with no side-to-side differences in either group. The Uni-Symp group had significantly lower sub-occipital PPTs on the symptomatic SNR test direction compared to the asymptomatic side [t(31) = 3.37, p = 0.002]. There were no differences within or between groups in the scalene PPTs(p’s > 0.08). Conclusions An upper cervical mechanical trigger of symptoms during SNR tests in some individuals with PPTH is possible. The direction of symptomatic SNR tests may indicate direction of guarded hypermobile dysfunction and direct treatment.

Introduction Many service members (SMs) have been diagnosed with traumatic brain injury. Currently, military treatment facilities do not have access to established normative tables which can assist clinicians in gauging and comparing patient-reported symptoms. The aim of this study is to provide average scores for both the Neurobehavioral Symptom Inventory (NSI) and Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5) for active duty SMs based upon varying demographic groups. Methods Average scores were calculated for both the NSI and PCL-5 surveys from SMs who attended a military outpatient traumatic brain injury clinic. For this analysis, only the initial surveys for each SM were considered. The identifying demographics included age group, gender, grade, and race. Results Four normative tables were created to show the average scores of both the NSI and PCL-5 surveys grouped by demographics. The tables are grouped by Age Group/Gender/Race and Grade/Gender/Race. Conclusion Clinicians and healthcare administrators can use the scores reported in this study to determine where SM NSI or PCL-5 scores fall within the average for their demographic group.

Objectives: To examine and categorize symptoms occurring within 60 s of vertebrobasilar-insufficiency (VBI) testing (left- and right-neck rotation) in individuals with persistent post-traumatic headache. Background: As part of routine clinical cervical screening in our patients, we found extended VBI testing often triggered additional symptoms. Therefore, we aimed to document the prevalence and precise symptoms occurring during each movement direction of this test and determine any demographic or baseline signs or symptoms associated with a positive test. Methods: A retrospective medical record review on military personnel receiving treatment for persistent post-traumatic headache was performed. Participants were grouped according to presence of non-headache related symptoms triggered during the tests. Frequency, onset, and symptom characteristics reported were categorized as potentially vascular and/or possible autonomic or cranial nerve in nature. Results: At least one symptom was reported by 81.3% of 123 patients. Of these, 54% reported symptoms in one and 46% in both directions of rotation, yielding 146 abnormal tests. Most reported symptoms were tear disruption (41%), altered ocular-motor-control (25%), and blepharospasm (16%). Enlisted individuals and those with altered baseline facial sensation were more likely to have a positive test. Conclusions: The majority reported symptoms not typical of VBI within 60 seconds of sustained neck rotation. Further study is needed to better understand the mechanisms and clinical relevance.