the differential pattern of post- concussive symptoms among female compared to male oef/oif veterans...
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The Differential Pattern of Post-Concussive Symptoms Among Female Compared to Male OEF/OIF Veterans with Deployment-Related TBI
Errol Baker, Ph.D.
Katherine M. Iverson, Ph.D.
Mark Meterko, Ph.D.
Kelly L. Stolzmann, MS and
Ann Hendricks, Ph.D.
This work is supported by VA HSR&D Grant: SDR 08-405 (PI: Ann Hendricks)
Traumatic Brain Injury (TBI)
• High risk of TBI during OEF/OIF deployments Blow to the head that disrupts brain functioning Prevalence: 12-20%1-4 Most cases are mild in severity5
• Associated with: Persistent postconcussive symptoms6
Commonly co-occurs with posttraumatic stress disorder (PTSD) in VA patients (64%-67%)7,8
TBI and Women Veterans
• The impact of deployment-related TBI on women’s health is largely unknown Women comprise 13% of U.S. personnel who have
served in OEF/OIF
• 10.5% of women using VA services after OEF/OIF deployments screen positive for TBI1
• Persistent postconcussive symptoms may be worse for women than for men9,10
Study Aims
1) To examine gender differences in postconcussive symptom severity among OEF/OIF Veterans judged to have deployment-related TBI
2) To examine gender differences as a function of etiology and PTSD comorbidity
Data Source: Comprehensive TBI Evaluation
• Protocol to assist in making a clinical judgment about whether a TBI occurred
• Etiology of injury (self-report) Blast exposure Non-blast related head injuries
o e.g., vehicular accidents, bullet above the shoulders, falls, etc.
• Neurobehavioral Symptom Inventory (NSI-22)11
• PTSD comorbidity
Study Population
• Veterans who…
Completed a Comprehensive TBI Evaluation between FY 2008 and FY 2009
Been judged to have deployment-related TBI
Did not report TBI prior to or following deployment
• Random sample of 5,941 Veterans for analysis
Design
• Dependent Variable Severity of postconcussive symptoms (NSI-22)
• Independent Variables: Participants were stratified by:
o Etiology: Blast only, Blast + non-Blast, non-Blast only Gender PTSD comorbidity: Yes, No
• Three-way MANOVA and follow-up Univariate ANCOVAs
Sample Characteristics (N = 5,941)
• 306 women comprised 5.2% of study population
• Blast exposure 60% of the women 85% of men
• PTSD comorbidity 69% of women 76% of men
Affective Somatosensory Cognitive Vestibular0
0.5
1
1.5
2
2.5
3
3.5
4
Postconcussive Symptoms on NSI-22Stratified by Gender (N = 5,941)
Mean +/- 95% CIFemale Male
Mea
n S
ever
ity
Rat
ing
*
*
*
*
Very Severe
Note. The four symptom domains were determined in a previous factor analysis of the NSI-22 12 *p<.001
None
Blast Only Blast + Non-Blast
Non-Blast Only
0
0.5
1
1.5
2
2.5
3
MalesMean +/- 95% CIPTSD non-PTSD
Etiology of Injury
Mea
n S
ever
ity
Rat
ing
Blast Only Blast + Non-Blast
Non-Blast Only
0
0.5
1
1.5
2
2.5
3
FemalesMean +/- 95% CI
PTSD non-PTSD
Etiology of Injury
Affective Severity Stratified by PTSD Comorbidity & Etiology
Blast Only Blast + Non-Blast
Non-Blast Only
0
0.5
1
1.5
2
2.5
3
MalesMean +/- 95% CI
PTSD non-PTSD
Etiology of Injury
Mea
n S
ever
ity
Rat
ing
Blast
Onl
y
Blast
+ N
on-..
.
Non-B
last
...
0
0.5
1
1.5
2
2.5
3
FemalesMean +/- 95% CI
PTSD non-PTSD
Etiology of Injury
Somatosensory Severity Stratified by PTSD Status & Etiology
Summary
1) 60% of women reported blast exposure
2) Women report more severe postconcussive symptoms than men, especially related to blast
3) PTSD comorbidity was consistently associated with higher symptoms severity regardless of etiology for men, but this was not always the case for women
4) Women's affective and cognitive symptoms are impacted by a complex interaction of both etiology and PTSD comorbidity
Limitations and Future Research Directions
• Analyses are hypothesis-generating in that they only describe gender differences
• May have been gender-related biases in the reporting of symptoms or in the judgment of TBI
• Need to identify contributing factors for gender differences in postconcussive symptoms
Implications
• Attention to postconcussive symptoms of women Veterans Management of specific symptoms Collaboration and coordination of care Interdisciplinary teams
• Educate health care providers, Veterans and the public Increase detection Tailor treatment to women’s specific needs Increased VA service
• Polytrauma and Blast-Related Injuries (PT/BRI) QUERI
• Expert Advisory Panel
Drs. N. Sayer, D. Cifu, R. Vanderploeg, S. Fitzgerald, M. Jaffee, A. Nelson, C. Tun, and E. Bass
• My contact information: Katherine.Iverson@va.gov
• First author’s contact information: Errol.Baker@va.gov
• HSR&D PI’s contact information: Ann.Hendricks@va.gov
Acknowledgements and Contact Information
References
1. Hendricks, A., Amara, J., Baker, E., Charns, M., Gardner, J. A., Iverson, K. M., Kimerling, R., Krengel, M., Meterko, M., Pogoda, T. K., Stolzmann, K. L., Wolfsfeld, L., & Lew, H. L. (2010). Screening for mild Traumatic brain injury in OEF-OIF deployed military: An empirical assessment of the VA Experience. Unpublished manuscript.
2. Hoge, C. W., McGurk, D., Thomas, J. L., Cox, A. L., Engel, C. C., & Castro, C. A. (2008). Mild traumatic brain injury in U.S. soldiers returning from Iraq. New England Journal of Medicine, 358, 453-463.
3. Schneiderman, A. I., Braver, E. R., & Kang, H. K. (2008). Understanding sequelae of injury mechanisms and mild traumatic brain injury incurred during the conflicts of Iraq and Afghanistan: Persistent postconcussive symptoms and posttraumatic stress disorder. American Journal of Epidemiology, 167, 1446-1452.
4. Tanielian, T., & Jaycox, L. H. (2008). Invisible wounds of war: Psychological and cognitive injuries, their consequences, and services to assist recovery. Santa Monica, CA: RAND Corp.
5. Hoge, C. W., Goldberg, H. M., & Castro, C. A. (2009). Care of war Veterans with mild traumatic brain injury—Flawed Perspectives. New England Journal of Medicine, 360, 1588-1591.
6. Sayer, N. A., Rettmann, N. A., Carlson, K. F., Bernardy, N., Sigford, B. J., Hamblen, J. L., Friedman, M. J. (2009). Veterans with history of mild traumatic brain injury and posttraumatic stress disorder: Challenges from provider perspective. Journal of Rehabilitation Research & Development, 46, 703-716.
7. Carlson, K. F., Nelson, D., Orazem, R. J., Nugent, S., Cifu, D. X., & Sayer, N. A. (2010). Psychiatric diagnoses among Iraq and Afghanistan war veterans screened for deployment-related traumatic brain injury. Journal of Traumatic Stress, 23, 17-24.
8. Iverson, K. M., Hendricks, A., Kimerling, R., Krengle, M., Meterko, M., Stolzmann, K., Baker, E., Pogoda, T., Vasterling, J., & Lew, H. (under review). Psychiatric diagnoses and neurobehavioral symptom severity among OEF/OIF VA patients with deployment-related TBI.
9. Colvin, A. C., Mullen, J., Lovell, M. R., West, R. V., Collins, M. W., & Groh, M. (2009). The role of concussive history and gender in recovery from soccer-related concussion. The American Journal of Sports Medicine, 37, 1699-1704.
10. Farace, E., & Alves, W. M. (2000). Do women fare worse? A metaanalysis of gender differences in outcome after traumatic brain injury. Neurosurgery Focus, 8, 1-8.
11. Cicerone, K. D., & Kalmar, K. (1995). Persistent postconcussion syndrome: The structure of subjective complaints after mild traumatic brain injury. Journal of Head Trauma Rehabilitation, 10, 1–17.
12. Meterko, M., Baker, E., Stolzmann, K. L., Cicerone, K. D., Hendricks, K. M., & Lew, H. L. (2010). Psychometric assessment of the NSI-22. Unpublished manuscript.
Neurobehavioral Symptom Inventory (NSI-22) + Pain Item: Factor Structure12
Scale k α Scale Content
Affective 6 .88• Low frustration tolerance• Irritability• Anxiety/tension
• Fatigue • Difficulties sleeping• Depressed or sad
Somatosensory 8 .81
• Light sensitivity• Noise sensitivity• Vision problems• Headaches
• Nausea• Numbness/tingling • Change in taste/smell• Pain
Cognitive 4 .89
• Difficulties getting organized/can’t finish things • Poor concentration • Forgetfulness • Difficulties making decisions
Vestibular 3 .82• Loss of balance• Feeling dizzy• Poor coordination/clumsy
Unassigned 2 NA• Loss or increase in appetite • Hearing difficulty
Blast
Onl
y
Blast
+ N
on-B
last
Non-B
last
Onl
y0
0.5
1
1.5
2
2.5
3
MalesMean +/- 95% CI
PTSD non-PTSD
Etiology of Injury
Mea
n S
ever
ity
Rat
ing
Blast
Onl
y
Blast
+ N
on-B
last
Non-B
last
Onl
y0
0.5
1
1.5
2
2.5
3
FemalesMean +/- 95% CI
PTSD non-PTSD
Etiology of Injury
Cognitive Severity Stratified by PTSD Status & Etiology
Blast
Onl
y
Blast
+ N
on-B
last
Non-B
last
Onl
y0
0.5
1
1.5
2
2.5
3
MalesMean +/- 95% CI
PTSD non-PTSD
Etiology of Injury
Mea
n S
ever
ity
Rat
ing
Blast
Onl
y
Blast
+ N
on-..
.
Non-B
last
...
0
0.5
1
1.5
2
2.5
3
FemalesMean +/- 95% CI
PTSD non-PTSD
Etiology of Injury
Vestibular Severity Stratified by PTSD Status & Etiology
Gender Etiology Total
Blast Only
Blast + Non-Blast
Non-Blast Only
Count % Count % Count % Count %
Female 79 25.8 104 34.0 123 40.2 306 100
Male 2,064 36.6 2,732 48.5 839 14.9 5,635 100
Total 2,143 36.1 2,836 47.7 962 16.2 5,941 100
Sample Characteristics: Gender and Injury Etiology (N = 5,941)
Sample Characteristics:Gender and PSTD Comorbidity (N = 5,941)
Gender PSTD Comorbidity Total
Present Absent
Count % Count % Count %
Female 210 68.6 96 31.4 306 100
Male 4,281 76.0 1,354 24.0 5,635 100
Total 4,491 75.6 1,450 24.4 5,941 100
Sample Characteristics:Gender, PTSD Comorbidity, Injury Etiology
Gender PTSD Etiology Total
Blast OnlyBlast +
Non-BlastNon-Blast
Only
n % n % n % n %
Female No 17 17.7 20 20.8 59 61.5 96 100
Yes 62 29.5 84 40.0 64 30.5 210 100
Male No 448 33.1 535 39.5 371 27.4 1354 100
Yes 1616 37.7 2197 51.3 468 10.9 4281 100
Total 2143 36.1 2836 47.7 962 16.2 5941 100
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