55

Complications of Mild Traumatic Brain Injury in Veterans

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APPENDIX A. SEARCH STRATEGIES

Database: Ovid MEDLINE(R) and Ovid OLDMEDLINE(R) <1946 to September Week 3 2012>, 

Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations <October 02, 2012>

Search Strategy:

--------------------------------------------------------------------------------

1 exp Brain edema/ (11605)

2 exp cerebrovascular trauma/ (4960)

3 exp craniocerebral trauma/ (113847)

4 exp coma/ (17150)

5 exp glasgow outcome scale/ (1042)

6 exp glasgow coma scale/ (6068)

7 ((brain* or capitis or cerebr* or crani* or hemispher* or inter-crani* or intra-crani* or 

skull*) adj4 (contusion* or damag* or fractur* or injur* or trauma* or wound*)).ab,ti. 

(77042)

8 ((brain or crani* or cerebr* or head or inter-cran* or intra-cran*) adj4 (bleed* or 

haematoma* or haemorrhag* or hematoma* or hemorrhag* or pressure)).ti,ab. (23995)

9 (Glasgow adj (coma or outcome) adj (scale* or score*)).ab,ti. (7439)

10 ‘Rancho Los Amigos Scale’.ti,ab. (31)

11 diffuse axonal injur*.ti,ab. (755)

12 ((brain or cerebral or intracranial) adj3 (edema or oedema or swell*)).ab,ti. (11389)

13 ((coma* or concuss* or unconscious* or ‘persistent vegetative state’) adj2 (damag* or 

fractur* or injur* or trauma* or wound*)).ti,ab. (1686)

14 (mtbi or “mild trauma* injur*”).tw. or “minor trauma* injur*”.mp. (639)

15 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 (209513)

16 exp cohort studies/ (1212058)

17 exp prognosis/ (967036)

18 exp morbidity/ (328065)

19 exp mortality/ (255922)

20 exp survival analysis/ (158174)

21 exp models, statistical/ (230839)

22 prognos*.tw. (324957)

23 course*.tw. (428896)

24 diagnosed.tw. (303319)

25 cohort*.tw. (221535)

26 death.tw. (417341)

27 predict*.tw. (808663)

28 16 or 17 or 18 or 19 or 20 or 21 or 22 or 23 or 24 or 25 or 26 or 27 (3743025)

29 diagnosed.tw. (303319)

30 cohort:.mp. (281196)

31 (predictor: or death).tw. (578864)

32 exp models, statistical/ (230839)

33 prognosis/ (327999)
56

Complications of Mild Traumatic Brain Injury in Veterans

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34 29 or 30 or 31 or 32 or 33 (1494750)

35 28 or 34 (3743144)

36 15 and 35 (67135)

37 exp rehabilitation, vocational/ (8852)

38 exp employment/ (49891)

39 exp work/ (12406)

40 sick leave/ (3365)

41 absenteeism/ (6861)

42 exp occupational health/ (23070)

43 exp occupational medicine/ (21574)

44 exp disabled persons/ (43220)

45 “recovery of function”/ (25824)

46 exp human activities/ (291441)

47 exp self care/ (36358)

48 activities of daily living.tw. (13206)

49 (dressing or feeding or eating or toilet$ or bathing or mobil$ or driving or public 

transport$).tw. (409253)

50 ((daily or domestic or house or home) adj5 (activit$ or task$ or skill$ or chore$)).tw. 

(34321)

51 (“work status” or “work capacity”).tw. (4948)

52 (unemployment or re-employment or underemployment or “job retention”).ti,ab. (6217)

53 (return* adj2 school).tw. (428)

54 37 or 38 or 39 or 40 or 41 or 42 or 43 or 44 or 45 or 46 or 47 or 48 or 49 or 50 or 51 or 52 

or 53 (884984)

55 15 and 54 (12268)

56 exp dementia/ (109281)

57 Delirium/ or exp Delirium, Dementia, Amnestic, Cognitive Disorders/ (165121)

58 dement*.mp. or alzheimer*.tw. (137451)

59 exp Parkinsonian Disorders/ (53442)

60 parkinson*.tw. (67897)

61 56 or 57 or 58 or 59 or 60 (263117)

62 15 and 61 (10666)

63 36 or 55 or 62 (80547)

64 animals/ not (humans/ and animals/) (3693774)

65 63 not 64 (72473)

66 limit 65 to (danish or english or french or norwegian or spanish or swedish) (62699)

67 limit 66 to yr=”2001 -Current” (36478)

68 exp “Outcome Assessment (Health Care)”/ (605282)

69 (intervention* adj3 stud*).tw. (23915)

70 68 or 69 (626005)

71 15 and 70 (12781)

72 71 not 64 (12055)

73 limit 72 to (yr=”2001 -Current” and (danish or english or french or norwegian or swedish)) 

(8537)

74 67 or 73 (36658)
57

Complications of Mild Traumatic Brain Injury in Veterans

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75 randomized controlled trial.pt. (337763)

76 Randomized controlled trial/ (337763)

77 Randomized Controlled Trials as Topic/ (83241)

78 Double-Blind Method/ (117191)

79 clinical trial.pt. (474276)

80 “double blind:”.mp. (143695)

81 placebos/ (31353)

82 placebo:.mp. (158293)

83 random:.mp. (788646)

84 75 or 76 or 77 or 78 or 79 or 80 or 81 or 82 or 83 (1069355)

85 15 and 84 (10248)

86 review/ (1739065)

87 (medline or medlars or pubmed or grateful med or CINAHL or scisearch or psychinfo 

or psycinfo or psychlit or psyclit or handsearch* or hand search* or manual* search* or 

electronic database* or bibliographic database* or embase or lilacs or scopus or web of 

science).mp. (74569)

88 86 and 87 (48085)

89 meta-analysis.mp. (59484)

90 meta-analysis as topic/ (12450)

91 meta-analysis/ (36480)

92 systematic review*.tw. (38103)

93 cochrane database*.jn. (9039)

94 88 or 89 or 90 or 91 or 92 or 93 (112607)

95 15 and 94 (1435)

96 exp brain neoplasms/ (111650)

97 (cancer* or neoplasm* or tumor* or malign*).mp. and brain.tw. (75605)

98 exp Glioma/ (55756)

99 96 or 97 or 98 (164154)

100 15 and 99 (9656)

101 exp pain/ (283152)

102 exp chronic disease/ (210066)

103 101 and 102 (20005)

104 (chronic* adj3 pain*).mp. (32890)

105 103 or 104 (40897)

106 15 and 105 (366)

107 exp sports/ (100542)

108 exp recreation/ (116143)

109 (return* adj3 play*).tw. (803)

110 107 or 108 or 109 (116607)

111 15 and 110 (3782)

112 exp mental disorders/ (880032)

113 15 and 112 (15929)

114 exp disability evaluation/ (35932)

115 exp “Outcome Assessment (Health Care)”/ (605282)

116 disab:.tw. (119042)
58

Complications of Mild Traumatic Brain Injury in Veterans

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117 114 or 115 or 116 (728782)

118 15 and 117 (17459)

119 74 or 85 or 95 or 100 or 106 or 111 or 113 or 118 (68980)

120 limit 119 to (english language and yr=”2001 -Current” and (danish or english or french or 

norwegian or swedish)) (43016)

121 animals/ not (humans/ and animals/) (3693774)

122 120 not 121 (39793)

123 exp “United States Department of Veterans Affairs”/ or exp Veterans Health/ or exp 

Hospitals, Veterans/ or exp Veterans Disability Claims/ or exp Veterans/ (15311)

124 veteran.mp. (2331)

125 veterans.mp. (23349)

126 VA.mp. (16805)

127 VA.in. (58986)

128 VAMC.mp. (285)

129 VAMC.in. (2086)

130 exp Military Medicine/ or exp “United States Department of Defense”/ or exp Naval 

Medicine/ (30814)

131 exp Hospitals, Military/ (3861)

132 exp Military Facilities/ (3901)

133 (army or navy or air force or marines or coast guard).mp. [mp=title, abstract, original title, 

name of substance word, subject heading word, protocol supplementary concept, rare 

disease supplementary concept, unique identifier] (15842)

134 military.mp. or exp Military Personnel/ (22947)

135 soldier.mp. (1480)

136 soldiers.mp. (5245)

137 123 or 124 or 125 or 126 or 127 or 128 or 129 or 130 or 131 or 132 or 133 or 134 or 135 or 

136 (151164)

138 122 and 137 (1170)

139 traumatic brain injury.mp. or exp Brain Injuries/ (48119)

140 tbi.mp. (10831)

141 139 or 140 (51178)

142 137 and 141 (1468)

143 138 or 142 (1977)

144 from 143 keep 1-1977 (1977)

***************************

The above search strategy was applied to two additional databases on Oct. 3, 2012, with the 

following yield:

PsycINFO=961

Cochrane Register of Controlled Trials (OVID)=46
59

Complications of Mild Traumatic Brain Injury in Veterans

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APPENDIX B. STUDY SELECTION FORM 

1. Language: Is the full text of the article in English?

Yes........................................................................................................Proceed to #2

No.....................................................................................................Code X1. STOP

2. Population: Is the population adult, human participants who are Veterans or members of 

the military from any country? Studies that do not differentiate between adult and child 

populations, or between Veteran/military and civilian populations, will be excluded.

Yes........................................................................................................Proceed to #3

No..................Code X2. Add code B if retaining for background/discussion. STOP

3. Publication type: Does the article present original study data, or is it a systematic-review or 

meta-analysis? Narrative or non-systematic reviews, letters, editorials, and commentaries will 

be excluded.

Yes........................................................................................................Proceed to #4

No..................Code X3. Add code B if retaining for background/discussion. STOP

4. Case definition: Does the article stratify/examine mTBI separately from moderate to severe 

TBI cases? Participants can consist of a mixed group of TBI severity (mild, moderate or 

severe) only if the results are stratified by severity and the mTBI subjects can be clearly 

identified. Studies that include mixed groups of TBI severity and do not differentiate between 

mild, moderate and severe TBI in their analysis will be excluded. Patients must be clearly 

described as having mTBI, Post-Concussive Syndrome, or concussion; if none of these terms 

are used, patients must be clearly defined as falling within the definition of mTBI from the 

VA/DoD Clinical Practice Guideline for Management of Concussion/Mild Traumatic Brain 

Injury (2009) listed below.

Yes........................................................................................................Proceed to #5

No..................Code X4. Add code B if retaining for background/discussion. STOP

5. Systematic review: Is the article a systematic review or meta-analysis of primary studies? 

Yes................................................................Code ISR (systematic review). STOP

No.........................................................................................................Proceed to #6

6. Sample size: Is the article a primary study with a sample size of at least 30 mTBI cases?

Yes...............................................................................Proceed to #7

No .............Code X6. Add code B if retaining for background/discussion. STOP

7. Applicability: Does the study report outcomes addressed in our Key Questions (e.g., health, 

cognitive, etc. for KQ1; or factors associated with outcomes in KQ1; or cost/utilization)?

Yes........................................................................................................Proceed to #8

No..................Code X7. Add code B if retaining for background/discussion. STOP

8. Intervention studies: Is the study an intervention study?

Yes........................................................................................................Proceed to #9

No.......................................................................................................Proceed to #10
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Complications of Mild Traumatic Brain Injury in Veterans

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9. Intervention outcomes: Does the intervention study report outcomes not influenced by 

intervention participation (e.g., baseline and/or control group outcome data)?

Yes......................................................................................................Proceed to #10

No..................Code X8. Add code B if retaining for background/discussion. STOP

10. VA/DoD mTBI definition: Does the study define mTBI participants as meeting the VA/

DoD Clinical Practice Guideline for Management of Concussion/Mild Traumatic Brain 

Injury (2009) definition of mTBI (listed below) with the exception of including/excluding/

not reporting positive imaging results? Studies may use a different mTBI definition, but all 

criteria with the exception of positive imaging must fall within the VA/DoD definition.

Yes......................................................................Code IPS (primary study). STOP

No................Code X10. Add code B if retaining for background/discussion. STOP
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Complications of Mild Traumatic Brain Injury in Veterans

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APPENDIX C. Definition of mTBI from the VA/DoD 

Clinical Practice Guideline for Management of

Concussion/Mild Traumatic Brain Injury (2009) 

1.1 Definition of Traumatic Brain Injury 

A traumatically induced structural injury and/or physiological disruption of brain function as 

a result of an external force that is indicated by new onset or worsening of at least one of the 

following clinical signs, immediately following the event:

•	 Any period of loss of or a decreased level of consciousness (LOC) 

•	 Any loss of memory for events immediately before or after the injury (post-traumatic 

amnesia6

) 

•	 Any alteration in mental state at the time of the injury (confusion, disorientation, slowed 

thinking, etc.) (Alteration of consciousness/mental state5)

•	 Neurological deficits (weakness, loss of balance, change in vision, praxis, paresis/plegia, 

sensory loss, aphasia, etc.) that may or may not be transient

•	 Intracranial lesion 

External forces may include any of the following events: the head being struck by an object, the 

head striking an object, the brain undergoing an acceleration/deceleration movement without 

direct external trauma to the head, a foreign body penetrating the brain, forces generated from 

events such as a blast or explosion, or other forces yet to be defined. 

The above criteria define the event of a TBI. Not all individuals exposed to an external force will 

sustain a TBI, but any person who has a history of such an event with immediate manifestation 

of any of the above signs and symptoms can be said to have had a TBI. 

1.2 Severity of Brain Injury Stratification 

TBI is further categorized as to severity into mild, moderate, or severe based on the length of 

LOC, AOC, or PTA (see Table A-1). Acute injury severity is determined at the time of the injury.

•	 The patient is classified as mild/moderate/severe if s/he meets any of the criteria in 

Table A-1 within a particular severity level. If a patient meets criteria in more than one 

category of severity, the higher severity level is assigned. 

•	 If it is not clinically possible to determine the brain injury level of severity because 

of medical complications (e.g., medically induced coma), other severity markers are 

required to make a determination of the severity of the brain injury. 

•	 Abnormal structural imaging (e.g., Magnetic Resonance Imaging or Computed 

Tomography Scanning) attributed to the injury will result in the individual being 

considered clinically to have greater than mild injury. 

In addition to traditional imaging studies, other imaging techniques such as functional magnetic 

resonance imaging, diffusion tensor imaging, positron emission tomography scanning; 

electrophysiological testing such as electroencephalography; and neuropsychological or other 

standardized testing of function have been used in the evaluation of persons with TBIs, but are 
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Complications of Mild Traumatic Brain Injury in Veterans

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not considered in the currently accepted criteria for measuring severity at the time of the acute 

injury outlined in Table A -1.

The severity level has prognostic value, but does not necessarily predict the patient’s ultimate 

level of functioning. There is substantial evidence that the epidemiology, pathophysiology, 

natural history, and prognosis for concussion/mTBI are different than for moderate and severe 

TBI. For example, moderate and severe TBI are often associated with objective evidence of 

brain injury on brain scan or neurological examination (e.g., neurological deficits) and objective 

deficits on neuropsychological testing, whereas these evaluations are frequently not definitive in 

persons with concussion/mTBI. The natural history and prognosis of moderate and severe TBI 

are much more directly related to the nature and severity of the injury in moderate and severe 

TBI, whereas factors unrelated to the injury (such as co-existing mental disorders) have been 

shown to be the strong predictors of symptom persistence after a concussion/mTBI. 

Table A-1. Classification of TBI Severity

Criteria Mild Moderate Severe 

Structural imaging Normal Normal or abnormal Normal or abnormal 

Loss of Consciousness 

(LOC) 

0–30 min > 30 min and < 24 

hrs 

> 24 hrs 

Alteration of consciousness/

mental state (AOC) 

a moment up to 24 

hrs

> 24 hours. Severity based on other criteria

Post-traumatic amnesia 

(PTA) 

0-1 day > 1 and < 7 days > 7 days 

Glasgow Coma Scale (best 

available score in first 24 

hours) 

13-15 9-12 < 9 
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Complications of Mild Traumatic Brain Injury in Veterans

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APPENDIX D. Excluded studies that did not meet

mTBI definition criteria

Author, Year Definition

Patients 

with 

Abnormal 

Imaging

Citation How 

Assessed

Adams, Larson, 

Corrigan, et al., 

20121

Length of LOC classified as < 1 minute, 

1-20 minutes, or > 20 minutes. Used the 

Health Related Behaviors Among Active 

Duty Military Personnel Survey response 

categories: “The HRB Survey symptom 

response groups permit recoding LOC 

as up to 20 minutes and greater than 

20 minutes. This provides insufficient 

information to code LOC using the 

American Congress of Rehabilitation 

Medicine’s definition of mild TBI.”

NR Kay, Harrington, 

Adams, et al., 1993

Self-report 

survey

Arbisi, Polusny, 

Erbes, et al., 20112

Adapted from the Defense and Veterans 

Brain Injury Center screening tool: yes 

to last item “dazed, confused, see stars, 

get knocked out or lose consciousness” 

classified as mTBI. No participants 

reported “receiving treatment while in 

Iraq for a TBI or were removed from 

assigned duties as a result of exposure to 

blast or other form of head trauma.”

NR Schwab et al., 2007 Self-report 

mailed questionnaire

Armistead-Jehle, 

20103

“Screened positive on the VHA TBI 

screens” for “possible mTBI.” “All 

patients suffered at most a mild TBI..., 

as none reported loss of consciousness of 

more than 30 minutes or posttraumatic 

amnesia of 24 hours or more.”

NR US Department of 

Veterans Affairs, 

2007

Self-report

Bazarian, 

Donnelly, Peterson, 

et al., 20124

“Mild TBI diagnosis was determined 

by in-person interview using a 22-item 

questionnaire developed to establish 

the nature, probability, and severity of 

deployment-related TBI among OEF/OIF 

veterans. The interview followed previously 

published TBI diagnostic criteria, which 

include confirmation of a possible 

TBI event, confirmation of alteration 

of consciousness, and confirmation of 

postconcussion symptoms. On the basis 

of the standardized clinical interview, 

interviewers rated the likelihood of mild 

TBI according to a 6-point scale: “not at 

all likely,” “very unlikely,” “somewhat 

unlikely,” “somewhat likely,” “very likely,” 

and “almost certainly.” These likelihood 

categories were used in all analyses. 

However, for descriptive purposes, 

subjects were defined as having mild TBI 

if interviewers rated them “very likely” or 

“almost certainly.””

NR Lew, Poole, & 

Vanderploeg, 2007

Clinical 

interview
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Complications of Mild Traumatic Brain Injury in Veterans

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Author, Year Definition

Patients 

with 

Abnormal 

Imaging

Citation How 

Assessed

Booth-Kewley, 

Highfill-McRoy, 

Larson, et al., 

20125

“Mild TBI symptoms were assessed using 

a set of questions that asked participants 

whether they had received an injury to the 

head during their most recent deployment 

that involved ‘being dazed, confused, or 

‘seeing stars’’ or ‘not remembering the 

injury, or losing consciousness (knocked 

out).’ A participant was classified as having 

a positive TBI screen if any of the three 

questions elicited a positive response.”

NR Centers for Disease 

Control and 

Prevention & World 

Health Organization 

definitions adapted 

by the Defense and 

Veterans Brain Injury 

Center working group 

for military use

Self-report 

survey

Brenner, Terrio, 

Homaifar, et al., 

20106

Warrior Administered Retrospective 

Casualty Assessment Tool (WARCAT) and 

Brief Trauma Brain Injury Screen. “All 45 

participants whose test scores were included 

in analyses had a history of blast exposure 

with alteration of or loss of consciousness 

(LOC).” “The nature of the most serious 

mTBIs reported were: n = 30, altered 

consciousness only; n = 12, up to 1-min 

LOC; and n = 3, one to 20-min LOC.”

NR Soldier Readiness 

Process, 2007; 

Schwab et al., 2007

Chart 

review, 

self-report 

survey, and 

clinical 

interview

Brenner, Ivins, 

Schwab, Warden, 

Nelson, Jaffee, & 

Terrio, 20107

As described in Terrio et al., 2009: Warrior 

Administered Retrospective Casualty 

Assessment Tool (WARCAT) and Brief 

Trauma Brain Injury Screen

NR Soldier Readiness 

Process, 2007; 

Schwab et al., 2007

Chart 

review, 

self-report 

survey, and 

clinical 

interview

Cameron, 

Marshall, 

Sturdivant, & 

Lincoln, 20118

“Incident cases of mTBI were operationally 

defined according to the administrative 

case definition proposed by the Centers 

for Disease Control and Prevention (CDC) 

for research purposes... and include ICD9-CM codes for skull fracture (800.00, 

800.5, 801.0, 801.5, 803.0, 803.5, 804.0, 

and 804.5), concussion (850.0, 850.1, 

850.5, and 850.9), intracranial injury of 

unspecified nature (854.0), and head injury 

unspecified (959.01). In addition to the four 

digit codes listed, all subordinate five-digit 

codes were also included.”

NR Centers for Disease 

Control and 

Prevention, 2003

Chart review

Carlson, Kehle, 

Meis, et al., 20119

“Included studies must have assessed 

participants for a “probable” TBI (identified 

using self-report screening instruments) or 

diagnosed TBI history.”

NR NR NA

Clement & 

Kennedy, 200310

LOC<60 minutes with no neurological 

findings

Excluded NR Chart review
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Complications of Mild Traumatic Brain Injury in Veterans

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Author, Year Definition

Patients 

with 

Abnormal 

Imaging

Citation How 

Assessed

Dougherty, 

MacGregor, Han, 

et al., 201111

International Classification of Diseases, 9th

Revision (ICD-9) codes 800.0-801.9, 803.0-

804.9, 850.0-854.1. “The Abbreviated 

Injury Scale (AIS) was used to describe 

the severity of brain injury... Due to a 

small number of TBI observations with 

scores of 4 (severe injury) and 5 (critical 

injury) in the present study, TBI severity 

was classified as follows: 0 = No TBI, 1 = 

minor, 2 = moderate and 3-5 = serious to 

critical. Service members with AIS scores 

of 6 were not eligible for inclusion in the 

study.”

NR Gennarelli & Wodzin, 

2005

Chart review

Drake, Gray, 

Yoder, et al., 200012

“Subjects were consecutive MTBI 

patients... meeting specific inclusion 

criteria... a documented TBI classified by 

accepted criteria as a mild TBI.” No specific 

mTBI definition noted.

NR NR Self-report 

and chart 

review

Eskridge, 201113 “Clinical diagnosis codes from the 

International Classification of Diseases, 9th

Revision (ICD-9) were assigned to each 

injury... In addition to the assigning of 

diagnosis codes, severity of each injury is 

accessed with two different standardized 

measures of injury severity; the Abbreviated 

Injury Scale (AIS) and the Injury Severity 

Scale (ISS)... The ISS for each blast 

episode was documented and categorized 

into one of four severity levels; mild (ISS 

1-3), moderate (ISS 4-8), serious (ISS 9-15) 

and severe (ISS 16 and higher).”

NR NR Chart review

Fear, Jones, 

Groom, et al., 

200914

“Criteria for identification include 

confusion or disorientation, loss of 

consciousness lasting less than 30 min or 

post-traumatic amnesia lasting less than 

24 h.” However, description of population 

studied only states, “we have examined 

the prevalence of symptoms thought to 

be a consequence of mTBI,” with unclear 

description of how mTBI was determined.

NR Holm, et al., 2005 Chart review

Ferrier-Auerbach, 

Erbes, Polusny, et 

al., 200915

“Three items adapted from the Defense 

and Veterans Brain Injury Center (DVBIC) 

Blast Exposure Screening Questionnaire... 

(1) Were you ever so close to a blast that 

you could feel the blast wave (such as 

heat or pressure) or afterward had trouble 

hearing or problems with attention or 

memory?... (2) Did you have any injuries 

from a blast, vehicle crash, bullet/shrapnel 

or fall?... (3) Did any injury cause you to 

be dazed/confused, ‘see stars,’ get knocked 

out, or lose consciousness?”

NR Schwab et al., 2007 Self-report 

survey
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Complications of Mild Traumatic Brain Injury in Veterans

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Author, Year Definition

Patients 

with 

Abnormal 

Imaging

Citation How 

Assessed

French, Lange, 

Iverson, Ivins, et 

al., 201216

LOC < 15 mins; PTA < 24 hours; absence 

of intracranial abnormality on computed 

tomography or magnetic resonance imaging 

scan

Excluded Used VA/DoD 

criteria, but data 

limited to LOC < 15 

minute categories.

Chart review

Gottshall, Gray, 

Drake, et al., 

200717

Definition: GCS 13-15. One patient 

identified as having an open head injury. 

LOC categorized as 31-60 (1 patient), and 

> 60 minutes (one patient), and up to 20 

minutes (all remaining patients).

NR American Academy 

of Neurology, 1997

Clinical 

presentation 

(to ED or 

Battalion Aid 

Station)

Helfer, Jordan, 

Lee, et al., 201118

ICD-9CM codes 850.0, 850.11, 850.12, 

850.2, 850.3, 850.4, 850.5, 850.9, 959.01, 

V15.52

NR US Dept of Health 

and Human Services, 

2008

Chart review

Heltemes, 

Dougherty, 

MacGregor, & 

Galarneau, 201119

International Classification of Diseases, 

9th Revision, Clinical Modification (ICD9-CM) codes 800.0-801.9, 803.0-804.9, 

850.0-854.1.

NR Centers for Disease 

Control and 

Prevention, 2003

Chart review

Hoffer, Balaban, 

Gottshall, et al., 

201020

“Definitive diagnosis of mild traumatic 

brain as defined by the 2007 Joint Service 

Surgeon General’s Definition”

NR Assistant Secretary 

of Defense: 

Memorandum on 

Traumatic Brain 

Injury: Definition and 

Reporting. Available 

at http://www.

pdhealth.mil/TBI.asp

In theater 

clinical 

evaluation

Hoffer, Donaldson, 

Gottshall, et al., 

200921

No specific mTBI definition listed. NR NR Clinical 

interview

Hoge, McGurk, 

Thomas, et al., 

200822

Positive response to three questions: LOC, 

being dazed and confused, seeing stars or 

not remembering the injury. However, “four 

Soldiers reported LOC lasting longer than 

30 minutes. Although technically they were 

considered to have a moderate TBI they 

were not excluded because the number was 

low and it was not possible to verify the 

self-report data on any of the subjects”.

NR DVBIC, 2006; CDC, 

2003

Self-report

Ivins, Schwab, 

Baker, & Warden, 

200323

“Head injury for which any LOC or any 

alteration of mental state without LOC 

was reported.” Reports rates of concussion 

grades separately, though the categories are 

divided by LOC < 20 minutes and LOC 

between 20-59 minutes.

NR Kay et al., 1993 Chart review

Ivins, Schwab, 

Baker, & Warden, 

200624

ICD-9CM codes 800.00-801.99, 803.00-

804.99, and 850.0-854.19 and AIS severity 

codes of minor or moderate.

NR Kay et al., 1993; 

Thurman & Guerrero, 

1999

Chart review
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Complications of Mild Traumatic Brain Injury in Veterans

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Author, Year Definition

Patients 

with 

Abnormal 

Imaging

Citation How 

Assessed

Ivins, Kane, & 

Schwab, 200925

Brief Traumatic Brain Injury Screen 

(BTBIS); LOC criteria < 20 mins. 

Additional computerized survey 

administered; however, it appears that 

only those with LOC < 20 minutes were 

included in the further assessment.

Brief Traumatic Brain Injury Screen 

(BTBIS); Patients who screened positive 

for TBI and had LOC< = 20 minutes and/or 

possible PTA< = 24 hours were identified 

as having MTBI with LOC or possible PTA

NR Kay et al., 1993; 

Thurman & Guerrero, 

1999

Chart review

Ivins, 201026 Mapped ICD-9 CM diagnoses to the 

Abbreviated Injury Scale (AIS): ICD-9CM 

codes 800.00-801.99, 803.00-804.99, and 

850.0-854.19 and AIS severity codes of 

minor or moderate. Combines mild and 

moderate into one category.

NR Kay et al., 1993; 

Thurman & Guerrero, 

1999

Chart review

Lange, Pancholi, 

Bhagwat, et al., 

201227

“PTA < 24 hours and LOC < 15 minutes.” 

“It was our preference to use a LOC 

criterion of < 30 minutes, consistent with 

commonly used diagnostic criteria... 

However, the available information 

regarding LOC was limited to categorical 

data that did not allow us to differentiate 

between LOC greater or lower than 30 

min.”

Included Carroll et al., 2004; 

Management of 

Concussion/mTBI 

Working Group, 

2009; ACRM, 1993

Chart review

Lange, Pancholi, 

Brickell, et al., 

201228

LOC < 15 mins; PTA < 24 hours Included Used VA/DoD 

criteria, but data 

limited to LOC < 15 

minute categories.

Chart review 

and clinical 

interview

Lange, Brickell, 

French, et al., 

201229

Uncomplicated: PTA<24 hours, LOC < 

15 mins, negative imaging; complicated: 

positive imaging. “It was our preference to 

use an LOC criterion of 30 min to classify 

MTBI consistent with commonly used 

military and civilian diagnostic criteria. 

However, the available information 

regarding LOC was limited to categorical 

data that did not allow us to differentiate 

between LOC greater or less than 30 min 

(i.e., available data = LOC < 15 min and 

LOC 16–60 min).”

Excluded Used VA/DoD 

criteria, but data 

limited to LOC < 15 

minute categories.

Routine 

comprehensive clinical 

evaluation

Lew, Garvert, 

Pogoda, et al., 

200930

Mild TBI was defined as an initial GCS 

score of 13 to 15, PTA duration of <1 day, 

or LOC duration of <1 hour

NR NR Chart review 

and clinical 

evaluation
68

Complications of Mild Traumatic Brain Injury in Veterans

and Military Personnel: A Systematic Review Evidence-based Synthesis Program

Author, Year Definition

Patients 

with 

Abnormal 

Imaging

Citation How 

Assessed

Luis, Venderploeg, 

& Curtiss, 200331

“During the interview, participants were 

asked, among many others, the following 

three questions: 1) since your discharge 

from active duty, have you been injured in a 

MVA? 2) Since your discharge from active 

duty have you injured your head (HI)? and 

(3) Did you lose consciousness as a result 

of the head injury?”

Analysis by LOC group but time of LOC 

not specified.

NR NR Self-report

MacGregor, 200732 “An ICD-9 code in the following ranges 

was defined as a TBI (n = 124): 800.0- 

801.9 (fractures of the vault or base of the 

skull); 803.0-804.9 (other and unqualified 

and multiple fractures of the skull); and 

850.0-854.1 (intracranial injury, including 

concussion, contusion, laceration, and 

hemorrhage)... Severity of TBI was 

indicated with the Abbreviated Injury Scale 

(AIS). The AIS ranges from 1 (relatively 

minor) to 6 (currently untreatable), 

and is determined separately for each 

different body region. Severity of TBI was 

determined by maximum AIS score for the 

head region – head AIS 1-2 indicated mild 

TBI, head AIS 3-5 indicated moderatesevere TBI. A majority of TBI identified via 

CHAMPS did not have a head AIS score 

present; in this case the TBI was assumed 

to be of mild severity due to a closed head 

injury.”

NR ICD-9-CM, 2005 Chart review

MacGregor, 

Dougherty, & 

Galarneau, 201133

International Classification of Diseases, 9th

Revision (ICD-9) codes 800.0-801.9, 803.0-

804.9, 850.0-854.1. “The AIS was used to 

describe the severity of these injuries and 

the injuries were scored according to the 

following scale: 0, no injury; 1 minor; 2, 

moderate; 3, serious; 4, severe; 5, critical; 6, 

fatal injury. As per previous literature, each 

participant was categorized by the severity 

of their highest (or maximum) AIS Head 

score as mild (AIS score = 1-2), moderate 

(AIS score = 3), or severe (AIS score = 

4-6).

NR Ommaya, Ommaya, 

Dannenberg, et al., 

1996

Chart review

MacGregor, 

Dougherty, 

Morrison, et al., 

201134

“A concussion was defined by the ICD9-CM code of 850.0-850.9. Severity of 

concussion was defined using the AIS.”

NR NR Chart review 

MacGregor, 

Shaffer, Dougherty, 

et al. 201035

ICD-9 codes 800-801.9, 803-804.9, and 

850-854.1; Abbreviated Injury Scale (AIS) 

score 1-2 = “mild,” 3-5 = “moderate to 

severe”

NR Ommaya et al., 1996 Chart review
69

Complications of Mild Traumatic Brain Injury in Veterans

and Military Personnel: A Systematic Review Evidence-based Synthesis Program

Author, Year Definition

Patients 

with 

Abnormal 

Imaging

Citation How 

Assessed

McGuire, 

Marsh, Sowin, & 

Robinson, 201236

“LOC less than 30 min or amnesia less than 

60 min”

NR Annegers et al., 1998 NR

Mora, Ritenour, 

Wade, et al., 200937

“Consciousness status to determine mTBI 

was queried using both codes from ICD and 

Abbreviated Injury Scale for indications of 

trauma to the head, concussive injuries, and 

indications of consciousness at the time of 

injury. A loss of consciousness served as the 

definition for mTBI.

NR NR Chart review

Morgan, 

Lockwood, 

Steinke, et al., 

201238

No clear mTBI definition. NR NR Self-report 

screening 

and clinical 

interview

Nelson, Weiser, 

Giford, et al., 

201139

“The Brief Traumatic Brain Injury Screen 

was used to identify cases (probable mTBl) 

and controls (no mTBI). Individuals were 

placed in the “probable mTBl” group if 

they endorsed an injury (reported at least 

one injury on the BTBIS) and indicated that 

they had lost consciousness for a defined 

period of time (ranging from less than 1 

minute to longer than 20 minutes) following 

the injury.

Those who did not report an injury or a loss 

of consciousness (LOC) for any amount of 

time following an injury acted as the control 

group.”

NR Defense and Veterans 

Brain Injury Center 

(DVBIC)

Chart review

Olson-Madden, 

Forster, Huggins, 

& Schneider, 

201240

“Injury severity data were coded as either 

mild (alteration in consciousness or loss 

of consciousness </ = 30 minutes) or 

moderate/severe (loss of consciousness > 

30 minutes).”

NR Kay et al., 1993 Clinical 

interview

Ommaya, 

Ommaya, 

Dannenberg, et al., 

199641

“Head-injury-related discharge diagnosis 

(800.00-801.99, 803.00-804.99, and 

850.0-854.19).” Injury Severity Scale and 

Abbreviated Injury Scale were calculated.

NR NR Chart review

Ommaya, Salazar, 

Dannenberg, et al., 

199642

“Records with a head-injury hospitalrelated discharge diagnosis (800.00-801.99, 

803.00-804.99, and 850.0-854.19) were 

identified as described in a previous study.”

“Maximum Abbreviated Injury Score (AIS) 

head and Injury Severity Score (ISS) were 

computed using the ICD-9 map. Mild TBI 

was defined as maximum AIS head equal 

to 1 or 2”

NR NR Clinical 

records

Pietrzak, Johnson, 

Goldstein, Malley, 

Southwick 

200943

“Positive mTBI screen” based on 

endorsement of all 4 items on the DVBIC 

questionnaire

NR GAO, 2008 & 

DVBIC, 2006

Self-report 

survey
70

Complications of Mild Traumatic Brain Injury in Veterans

and Military Personnel: A Systematic Review Evidence-based Synthesis Program

Author, Year Definition

Patients 

with 

Abnormal 

Imaging

Citation How 

Assessed

Plassman, Havlik, 

Steffens, et al., 

200044

“1) mild injury = loss of consciousness 

or posttraumatic amnesia for less than 

30 minutes, with no skull fracture; 2) 

moderate injury = loss of consciousness or 

post-traumatic amnesia for more than 30 

minutes but less than 24 hours, and/or a 

skull fracture; and 3) severe injury = loss of 

consciousness or post-traumatic amnesia for 

more than 24 hours.”

NR Frankowski, 

Annengers, & 

Whitman, 1985

Chart review

Polusny, Kehle, 

Nelson, Erbes, 

Arbisi, Thuras, 

201145

Injury with altered mental status or LOC 

(items 1-3 on DVBIC screen)

NR Schwab et al., 2007 Self-report 

in theater, 1 

month prior 

to return 

home

Roebuck-Spencer, 

Vincent, Twille, et 

al., 201246

“Although data on recency and severity of 

injury were not available in this dataset, 

TBIs reported in this study are presumed 

to be mild in nature given that Service 

Members were still on active duty. Mild 

TBI was defined as such when individuals 

reported an injury event accompanied 

by an alteration of consciousness. This 

included endorsement of at least one of 

the following: feeling dazed or confused, 

experiencing loss of consciousness (LOC), 

or experiencing loss of memory for the 

injury or posttraumatic amnesia (PTA) for 

the event.”

NR NR Self-report 

screening 

tool

Romesser, Shen, 

Reblin, Kircher, 

Allen, Roberts, & 

Marchand, 201147

“History of military-related concussion 

during a VHA TBI secondary evaluation.” 

Excluded if “self-report suggested a history 

of a moderate or severe TBI (i.e., if they 

endorsed loss of consciousness more than 

30 minutes).”

NR NR Clinical 

interview

Rona, Jones, Fear, 

et al., 201248

“Possible mTBI was assessed using a 

modified version of the BTBIS... A second 

item asked about possible symptoms 

associated with the injury. These were 

losing consciousness; being dazed or 

confused; not remembering the injury; 

concussion (e.g., headache, dizziness); head 

injury, and none of these. Participants were 

asked to tick all that applied. Self-report of 

the duration of any loss of consciousness 

was also obtained, we eliminated one 

participant from the analysis who reported 

prolonged loss of consciousness... 

Participants who endorsed at least one of 

these symptoms were classified as having 

mTBI.”

NR Iverson, Langlois, 

McCrea, & Kelly, 

2009

Self-report 

questionnaire
71

Complications of Mild Traumatic Brain Injury in Veterans

and Military Personnel: A Systematic Review Evidence-based Synthesis Program

Author, Year Definition

Patients 

with 

Abnormal 

Imaging

Citation How 

Assessed

Rona, Jones, Fear, 

et al., 201249

“Possible mTBI was assessed using a 

modified version of the BTBIS, which 

included an item exploring possible causes 

of injury (blast, shrapnel fragments, bullet, 

fall, and vehicle accident and other). 

Participants could state that they had not 

suffered an injury during deployment. 

A second item asked about possible 

symptoms associated with the injury. These 

were losing consciousness; being dazed 

or confused; not remembering the injury; 

concussion (e.g., headache, dizziness); head 

injury; and none of these. Participants were 

asked to tick all that applied. Self-report of 

the duration of any loss of consciousness 

was also obtained, we eliminated 1 

participant from the analysis who reported 

prolonged loss of consciousness (which 

would be classified traumatic brain injury, 

not mTBI). Participants who endorsed at 

least one of these symptoms were classified 

as having mTBI.”

NR Iverson, Langlois, 

McCrea, & Kelly, 

2009

Self-report 

questionnaire

Schneiderman, 

Braver & Kang, 

200850

Three-item Brief Traumatic Brain Injury 

Screen

NR Defense and Veterans 

Brain Injury Center

Self-report 

survey

Skopp, 

Trofimovich, 

Grimes, et al., 

201251

mild TBI (subset of all TBI codes): 

310.2, 800.00-800.02, 800.06, 800.09, 

800.50, 800.52, 801.00, 801.01,801.02, 

801.06, 801.09, 801.50, 801.51, 801.52, 

803.00-803.02, 803.06, 803.09, 803.50, 

803.51, 803.52, 804.00, 804.01, 804.02, 

804.06, 804.09, 804.50, 804.51, 804.52, 

850.0, 805.1, 850.11, 850.9, 959.01, 

V15.52, V15.5_7, V15.5_C, V15.52_2, 

V15.52_2,V15.52_7, V15.52_C

NR DoD standard TBI 

surveillance case 

definition to ascertain 

TBI status and 

severity

Chart review
72

Complications of Mild Traumatic Brain Injury in Veterans

and Military Personnel: A Systematic Review Evidence-based Synthesis Program

Author, Year Definition

Patients 

with 

Abnormal 

Imaging

Citation How 

Assessed

Theeler, Flynn, & 

Erickson, 201052

“2-question screen followed by a 

10-question screen... The first question 

asks if, while deployed, the soldier was 

exposed to or near a blast, improvised 

explosive device (IED) explosion, car 

bomb, suicide explosion, or exposed to 

any other combat event or resulted in 

a blow or jolt to the head. The second 

question asks if the soldier was involved 

in a motor vehicle accident, a fall, a sports 

accident, or any other event that caused 

a blow to the head or resulted in a neck 

whiplash. If the soldier answers yes to 

either question 1 or 2, 10 more questions 

asking about loss of consciousness, dazed 

sensation after the event, and neurologic or 

behavioral sequelae following the event are 

administered. This questionnaire is scored 

in a standardized manner from 0 to 39.The 

case definition for concussion constituted 

a score of 5 or greater on the 2-plus-10 

questionnaire.”

NR NR Self-report 

survey

Theeler, Flynn, & 

Erickson, 201253

No specific criteria: 2-question followed by 

a 10-question screen if the soldier answers 

yes to either of the first 2 questions. This 

questionnaire is scored in a standardized 

manner from 0 to 39; the score from the 

2-plus-10 questionnaire will herein be 

called the TBI Score

NR Theeler, Flynn, & 

Erickson, 2010

Self-report 

survey

Vanderploeg, 

Belanger, & 

Curtiss, 200954

“Have you injured your head?... Did you 

lose consciousness as a result of the head 

injury?” “those individuals who required 

hospitalization after their head injury (n 

= 40) were excluded.” “head injury with 

altered consciousness” were classified as 

mild TBI.

NR NR Clinical 

interview

Vanderploeg, 

Curtiss & 

Belanger, 200555

“During the interview, participants were 

asked, among many others, the following 

three questions: 1) Since your discharge 

from active duty, have you been injured in a 

MVA? 2) Since your discharge from active 

duty have you injured your head (HI)? and 

3) Did you lose consciousness as a result of 

the head injury?”

NR NR Self-report

Vanderploeg, 

Curtiss, Duchnick, 

Luis, 200356

Positive responses to following questions: 

“Since discharge from active duty, have you 

been injured in a MVA?”; “Since discharge 

from active duty, have you injured your 

head (from any cause)?”; and “Did you 

lose consciousness as a result of the head 

injury?”

NR NR Self-report 

survey
73

Complications of Mild Traumatic Brain Injury in Veterans

and Military Personnel: A Systematic Review Evidence-based Synthesis Program

Author, Year Definition

Patients 

with 

Abnormal 

Imaging

Citation How 

Assessed

Vasterling, Brailey, 

Proctor, et al., 

201257

“Congruent with reports showing stronger 

associations between clinical outcomes 

and TBI following loss of consciousness 

v. altered consciousness, only those pre- to 

post-deployment interval injuries resulting 

in loss of consciousness were queried.”

NR NR Self-report 

survey

Wilk, Herrell, 

Wynn, Riviere, & 

Hoge, 201258

“Injury resulted in being dazed, confused, 

or seeing stars, not remembering the injury, 

or losing consciousness (knocked out).”

NR DoD/VA Brain 

Injury Center Brief 

Traumatic Brain 

Injury Screen

Self-report 

survey

Wilk, Thomas, 

McGurk, et al., 

201059

“Injury resulted in being dazed, confused, 

or seeing stars, not remembering the injury, 

or losing consciousness (knocked out).”

NR DoD/VA Brain 

Injury Center Brief 

Traumatic Brain 

Injury Screen

Self-report 

survey

Yurkiewicz, 

Lappan, Neely, et 

al., 201260

“Defense and Veterans Brain Injury Center 

(DVBIC) assesses TBI severity after a 

blast event or motor vehicle accident, 

answers questions about evacuation and 

in-theater clinical care and medication, and 

provides recommendations on headache 

management and vision, hearing, vestibular, 

and neurologic issues. Successes of the 

program include a stratified headache 

protocol for primary care providers and 

an early management protocol for mild 

TBI and posttraumatic headache stratified 

headache protocol.” 

“We reviewed consults sent to the 

neurology group from October 2006 to 

December 2010 and consults sent to the 

TBI group from March 2008 to December 

2010. Microsoft Excel spreadsheets were 

constructed to organize and analyze data 

regarding number of consultations, response 

times, location of origin, branch of service, 

clinical images transmitted, anatomic 

location of complaint, type of injury, 

workup recommended, and treatment and 

evacuation recommendations.”

NR DVBIC Brief 

Traumatic Brain 

Injury Screen

Chart review

Note. None of the studies reported information on assessor blinding of study hypotheses when assessing mTBI.
74

Complications of Mild Traumatic Brain Injury in Veterans

and Military Personnel: A Systematic Review Evidence-based Synthesis Program

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postdeployment outcomes in national guard soldiers deployed to Iraq. Arch Gen Psychiatry. 

Jan 2011;68(1):79-89.

46. Roebuck-Spencer TM, Vincent AS, Twillie DA, et al. Cognitive change associated with selfreported mild traumatic brain injury sustained during the OEF/OIF conflicts. The Clinical 

Neuropsychologist. Apr 2012;26(3):473-489.

47. Romesser J, Shen S, Reblin M, et al. A preliminary study of the effect of a diagnosis of 

concussion on PTSD symptoms and other psychiatric variables at the time of treatment 

seeking among veterans. Mil Med. Mar 2011;176(3):246-252.

48. Rona RJ, Jones M, Fear NT, et al. Mild traumatic brain injury in UK military personnel 

returning from Afghanistan and Iraq: cohort and cross-sectional analyses. J Head Trauma 

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49. Rona RJ, Jones M, Fear NT, Sundin J, Hull L, Wessely S. Frequency of mild traumatic brain 

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Complications of Mild Traumatic Brain Injury in Veterans

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79

c Brain Injury in Veterans and Military Personnel: A Systematic Review Evidence-based Synthesis Program

esults of included studies

nd general fund of verbal knowledge measures in studies of U.S. Veterans and members of the U.S. military with mild TBI

mparison group description Outcome measure Subscale or test component mTBI group Mean (SD) Comparison group Mean (SD) p value for comparison Magnitude of effect

xis I disorder WTAR scaled score --- 106.7 (10.1) 105.4 (5.7) “NS” NR

WAIS-III Information scaled score 12.8 (1.7) 11.8 (2.1) “NS” NR

ensic context WAIS-III Information scaled score 11.97 (1.92) 11.58 (1.82) “NS” NR

ast exposed RBANS Language 97.43 (12.42) 92.81 (14.10) p = 0.187 NR

C and/or PTA Shipley Institute of Living 

Scale

Vocabulary Subtest 49.15 (7.50) 49.15 (6.20) NR NR

 Health Diagnosis 

her than PTSD

WTAR --- 96.8 (10.8) 101.7 (12.3) NR NR

SD Diagnosis WTAR --- 96.8 (10.8) 99.0 (11.2) NR NR

 population with 

erate/severe TBI

WTAR Estimated Full Scale IQ 

(FSIQ)

98.3 (9.3) 97.6 (9.1) p = .67 NR

 population with 

erate/severe TBI

WTAR Estimated Full Scale IQ 

(FSIQ)

98.1 (14.6) 96.1 (12.8) p = .35 NR

opulation without 

mTBI

RBANS Language 92.90 (15.586) 93.66 (11.873) p = 0.732 NR

opulation without 

 none with poor 

effort

WAIS-III Information scaled score 12.21 (2.01) 12.26 (2.25) “NS” d = .22

opulation without 

 none have Axis I

WAIS-III Information scaled score 12.8 (1.7) 11.9 (2.6) “NS” NR

WTAR scaled score 106.7 (10.1) 106.0 (9.2) “NS” NR
80

c Brain Injury in Veterans and Military Personnel: A Systematic Review Evidence-based Synthesis Program

n in studies of U.S. Veterans and members of the U.S. military with mild TBI

mparison group 

description Outcome measure Subscale or test component mTBI group Mean (SD) Comparison group Mean (SD) p value for comparison Magnitude of effect

NA RCFT Figure Copy 33.6 (2.9) NA NA NA

Figure Orientation 3.6 (1.7) NA NA NA

Time to Copy 158.7 (63.5) NA NA NA

opulation without 

mTBI

RBANS Visuospatial/ 

Constructional

104.06 (13.382) 109.29 (10.47) p = 0.007 NR

opulation without 

 none have Axis I

RCFT Figure Copy 31.3 (3.2) 32.0 (2.1) “NS” NR

WAIS-III Block Design scaled score 12.2 (2.6) 13.0 (2.9) “NS” NR

xis I disorder RCFT Figure Copy 31.3 (3.2) 31.5 (3.0) “NS” NR

WAIS-III Block Design scaled score 12.2 (2.6) 12.2 (3.1) “NS” NR

ast exposed RBANS Visuospatial/ Constructional 112.11 (9.70) 108.09 (11.80) p = 0.159 NR

ADS Anxiety Visual Organization/ 

Processing Factor

--- NR NR p > .05 r = -.12

DS Depression Visual Organization/ 

Processing Factor

--- NR NR p < .001 r = -.25

C and/or PTA Visual Organization/ 

Processing Factor

--- 49.08 (9.98) 50.46 (10.12) p = .30 NR

RCFT Figure Copy 33.72 (2.64) 33.78 (2.38) NR NR

Organization 3.64 (1.74) 3.99 (1.81) NR NR

Time to Copy 170.51 (63.07) 166.17 (74.91) NR NR

 Health Diagnosis 

her than PTSD

RCFT Figure Copy 32.6 (4.9) 32.7 (4.7) NR NR

CL-M score Visual Organization/ 

Processing Factor

--- NR NR p < .05 r = -.18

SD Diagnosis RCFT Figure Copy 32.6 (4.9) 32.1 (6.0) NR NR

eported slowed 

ng/organization

RCFT Figure Copy NR NR “NS” r = -.13

Figure Orientation NR NR “NS” r = -.02

Time to Copy NR NR “NS” r = -.14

vice connected Visual Organization/ 

Processing Factor

--- NR NR p = .57 NR
81

c Brain Injury in Veterans and Military Personnel: A Systematic Review Evidence-based Synthesis Program

 in studies of U.S. Veterans and members of the U.S. military with mild TBI

mparison group description Outcome measure Subscale or test component mTBI group Mean (SD) or Median (IQR) Comparison group Mean (SD) or Median (IQR) p value for comparison Magnitude of effect

xis I disorder CVLT-II Long Delay Free Recall 

z-score

0.5 (0.9) -0.1 (1.1) “Significant” NR

Trials 1-5 z-score 0.6 (0.9) 0.1 (1.0) “NS” NR

RCFT Delayed Recall z-score -0.1 (1.3) -0.5 (.98) “NS” NR

ast exposure BVMT-R Delayed Recall t score 48.6 (12.8) 50.7 (10.7) “NS” NR

Total Recall t score 45.2 (12.3) 50.1 (10.1) “NS” NR

CVLT-II Long Delay Free Recall 

t-score

48.3 (9.1) 50.5 (11.4) p = .38 NR

Total Trials 1-5 t-score 52.8 (10.5) 54.0 (8.1) p = .38 NR

ast exposure RBANS Immediate Memory 91.70 (11.0) 91.81 (15.67) P = 0.994 NR Delayed Memory 96.96 (16.59) 95.12 (16.04) P = 0.664 NR

ensic context CVLT-II Long Delay Free Recall 

z-score

0.03 (0.99) -0.73 (1.12) “NS” NR

Trials 1-5 t-score 52.82 (8.61) 46.33 (9.23) “NS” NR

ADS Anxiety Memory Factor --- NR NR p < .001 r = -.29

DS Depression Memory Factor --- NR NR p > .05 r = -.15

C and/or PTA Memory Factor --- 49.22 (9.89) 49.61 (10.36) NR NR

RBANS Story Memory Immediate 

Recall

44.99 (10.19) 48.10 (10.36) NR NR

Story Memory Delayed 

Recall

45.41 (10.49) 44.98 (10.71) NR NR

RCFT Immediate Recall 44.43 (12.72) 44.50 (13.65) NR NR

 Health Diagnosis 

her than PTSD

CVLT-II Long Delay Free Recall 8.9 (3.7) 8.9 (3.9) NR NR

Short Delay Free Recall 8.3 (3.5) 8.6 (3.9) NR NR

CVLT-II Total Trials 1-5 43.7 (12.0) 44.6 (13.7) NR NR

RCFT Immediate Recall 16.4 (7.7) 17.4 (7.2) NR NR

Delayed Recall 16.0 (7.9) 17.4 (7.2) NR NR
82

c Brain Injury in Veterans and Military Personnel: A Systematic Review Evidence-based Synthesis Program

mparison group description Outcome measure Subscale or test component mTBI group Mean (SD) or Median (IQR) Comparison group Mean (SD) or Median (IQR) p value for comparison Magnitude of effect

mparison group RBANS Story Memory Immediate 

Recall

17.2 (3.4) NA NA NA

Story Memory Delayed 

Recall

8.4 (2.3) NA NA NA

RCFT Immediate Recall 19.9 (6.2) NA NA NA

MSP subtest Baseline: 51 (43-53) 

≤ 72 hours: 44 (38.5-

51)

Baseline: 50 (45-55)

≤ 72 hours: 50 (44-

56)

Baseline: p = .57

≤ 72 hours: p 

<.001

NR

CL-M score Memory Factor --- NR NR p < .05 r = -.34

SD Diagnosis CVLT-II Long Delay Free Recall 8.9 (3.7) 7.6 (3.2) NR NR

Short Delay Free Recall 8.3 (3.5) 7.0 (3.4) NR NR

Total Trials 1-5 43.7 (12.0) 38.7 (11.1) NR NR

RCFT Immediate Recall 16.4 (7.7) 15.7 (8.5) NR NR

Delayed Recall 16.0 (7.9) 16.1 (7.1) NR NR

e population of 

 participants, none 

th poor effort

CVLT-II Long Delay Free Recall 

z-score

0.27 (0.91) 0.45 (0.81) “NS” d = 0.21

Trials 1-5 t-score 54.43 (8.95) 57.16 (8.04) “NS” d = 0.32

 population with 

rate/ severe TBI

BVMT-R Delayed Recall NR NR “NS” NRBVMT-R Total Recall NR NR “NS” NR

CVLT-II Long Delay Free Recall NR NR p < .05 NR

Total Trials 1-5 NR NR p < .01 NR

 population with 

rate/ severe TBI

Memory Composite 

Score

--- 9.0 (2.4) 7.7 (2.8) p = .04 NR

opulation without 

th minor traumatic 

 not involving the 

 and noninjured 

teers from same 

population

ANAM CDD subtest Baseline: 

42.5 (36.5-50)

5+ days: 

49.5 (40-56)

10+ days: 

49.5 (40.1-53.1)

Baseline:

44 (37-52)

5+ days: 

50.3 (44.1-57.8)

10+ days: 

50.3 (44.1-57.8)

Baseline: 

p = 0.47

5+ days: p = 0.07

10+ days: 

p = 0.17

NR

MSP subtest Baseline: 

51 (43-53)

5+ days: 

50.5 (44-58)

10+ days: 

51.8 (43.5-57.9)

Baseline: 

52 (44.5-57.8)

5+ days: 

51.5 (44.5-57.6)

10+ days: 

51.5 (44.5- 57.6)

Baseline: 

p = 0.29

5+ days: p = 0.47

10+ days: 

p = 0.77

NR

opulation without 

TBI

RBANS Immediate Memory 95.14 (14.181) 96.49 (14.445) p = .589 NR
83

c Brain Injury in Veterans and Military Personnel: A Systematic Review Evidence-based Synthesis Program

mparison group description Outcome measure Subscale or test component mTBI group Mean (SD) or Median (IQR) Comparison group Mean (SD) or Median (IQR) p value for comparison Magnitude of effect

opulation without 

th minor traumatic 

 not involving the 

 and noninjured 

teers from same 

population

ANAM CDD subtest Baseline: 

42.5 (35-50) 

≤ 72 hours: 

42 (35-49.5)

Baseline: 

45 (38-52) 

≤ 72 hours: 

44.75 (39-51)

Baseline: 

p = .20

≤ 72 hours: 

p = .04

NR

opulation without 

 none have Axis I

CVLT-II Long Delay Free Recall 

z-score

0.5 (0.9) 0.6 (0.8) “NS” NR

Trials 1-5 z-score 0.6 (0.9) 0.8 (0.8) “NS” NR

RCFT Delayed Recall z-score -0.1 (1.3) -0.3 (1.3) “NS” NR

Delayed Memory 96.48 (12.998) 100.42 (12.854) p = 0.072 NR

eported memory 

deficits

RBANS Story Memory Immediate 

Recall

NR NR “NS” r = -.05

Story Memory Delayed 

Recall

NR NR p < .05 r = -.20

RCFT Immediate Recall NR NR “NS” r = .08

vice connected Memory Factor --- NR NR p = .17 NR
84

c Brain Injury in Veterans and Military Personnel: A Systematic Review Evidence-based Synthesis Program

ion measures in studies of U.S. Veterans and members of the U.S. military with mTBI

mparison group description Outcome measure Subscale or test component mTBI group Mean (SD) or Median (IQR) Comparison group Mean (SD) or Median (IQR) p value for comparison Magnitude of effect

xis I disorder WAIS-III Digit Span scaled score 9.9 (2.8) 9.9 (2.1) “NS” NR

ensic context WAIS-III Digit Span scaled score 9.61 (2.55) 8.42 (2.77) “NS” NR

ast exposure RBANS Attention 98.89 (16.64) 94.78 (14.51) p = 0.311 NA

ADS Anxiety Verbal Attention Factor --- NR NR p < .05 r = -.24

Visual Attention Factor --- NR NR p > .05 r = -.12

DS Depression Verbal Attention Factor --- NR NR p < .05 r = -.24

Visual Attention Factor --- NR NR p > .05 r = -.13

C and/or PTA Verbal Attention Factor --- 49.69 (10.91) 49.87 (9.69) p = .91 NR

Visual Attention Factor --- 50.67 (9.61) 49.61 (10.36) p = .50 NR

C and/or PTA WAIS-IV Digit Sequencing 9.30 (2.76) 9.41 (2.27) NR NR

Digit Span Backward 9.23 (2.54) 8.92 (2.18) NR NR

Digits Forward 8.39 (2.63) 8.64 (2.70) NR NR

mparison group WAIS-IV Digit Sequencing 8.0 (1.9) NA NA NA

Digits Backward 7.8 (2.1) NA NA NA

Digits Forward 9.6 (2.1) NA NA NA

CL-M score Verbal Attention Factor --- NR NR p < .05 r = -.21

Visual Attention Factor --- NR NR p < .05 r = -.20

Digit Span scaled score 9.9 (2.8) 10.9 (2.4) “NS” NR

opulation without 

BI; with minor 

matic injuries not 

ng the head and 

jured volunteers 

same population

ANAM Mathematical Processing 

(MTH) subtest

Baseline: 

51 (42-57.3)

5+ days: 

50.5 (43-56)

10+ days: 

50.8 (46.3-55.8)

Baseline: 

50 (42-55)

5+ days: 

52 (44-59.8)

10+ days: 

52 (44-59.8)

Baseline: 

p = 0.71

5+ days: 

p = 0.29

10+ days: 

p = 0.51

NR

opulation without 

mTBI

RBANS Attention 84.06 (15.013) 89.74 (14.898) p = 0.026 NR
85

c Brain Injury in Veterans and Military Personnel: A Systematic Review Evidence-based Synthesis Program

mparison group description Outcome measure Subscale or test component mTBI group Mean (SD) or Median (IQR) Comparison group Mean (SD) or Median (IQR) p value for comparison Magnitude of effect

opulation without 

BI; with minor 

matic injuries not 

ng the head and 

jured volunteers 

same population

ANAM Mathematical Processing 

(MTH) subtest

Baseline: 

47 (42-57) 

≤ 72 hours: 

46.7 (40.5-52.5)

Baseline: 

52 (42-55) 

≤ 72 hours: 

50 (44-56.6)

Baseline: 

p = .57

≤ 72 hours: 

p = .03

NR

opulation without 

 none with poor 

effort

WAIS-III Digit Span scaled score 10.50 (2.29) 10.65 (2.37) “NS” d = .06

ported attention 

deficits

WAIS-IV Digit Sequencing NR NR “NS” r = -.15

Digits Backward NR NR “NS” r = -.11

Digits Forward NR NR “NS” r = -.15

Digit Sequencing NR NR “NS” r = .00

Digits Backward NR NR “NS” r = -.14

vice connected Verbal Attention Factor --- NR NR p = .42 NR

Visual Attention Factor --- NR NR p = .17 NR

 speed in studies of U.S. Veterans and members of the U.S. military with mild TBI

roup 

n Outcome measure Subscale or test component mTBI group Mean (SD) or Median (IQR) Comparison group Mean (SD) or Median (IQR) p value for comparison Magnitude of effect

er Stroop Color and 

Word Test

Color t-score 49.5 (6.9) 45.8 (7.8) “NS” NR

Word t-score 49.4 (9.8) 46.2 (8.6) “NS” NR

Trail Making Test Part A t-score 50.0 (11.7) 50.5 (9.7) “NS” NR

WAIS-III Digit Symbol Coding 

scaled score

10.9 (2.0) 9.8 (2.4) “NS” NR

re Trail Making Test Part A t-score 45.8 (14.8) 46.2 (11.6) all p values > .10 NR

WAIS-III Digit Symbol Coding 

scaled score

8.3 (2.7) 8.9 (2.5) all p values > .10 NR
86

c Brain Injury in Veterans and Military Personnel: A Systematic Review Evidence-based Synthesis Program

roup 

n Outcome measure Subscale or test component mTBI group Mean (SD) or Median (IQR) Comparison group Mean (SD) or Median (IQR) p value for comparison Magnitude of effect

ext Stroop Color and 

Word Test

Color t-score 45.29 (8.60) 40.04 (7.00) “NS” NR

Word t-score 45.47 (9.01) 39.12 (7.54) “NS” NR

Trail Making Test Part A t-score 48.71 (10.44) 39.96 (9.78) “Significant” NR

WAIS-III Digit Symbol Coding 

scaled score

9.92 (2.53) 7.12 (2.53) “Significant” NR

PTA Trail Making Test Part A 48.93 (10.83) 47.99 (11.04) NR NR

agnosis 

TSD

Stroop Color & 

Word Test

Color 58.8 (12.1) 54.1 (11.2) NR NR

Word 76.2 (16.5) 77.0 (17.7) NR NR

Trail Making Test Part A 41.8 (15.8) 41.9 (19.1) NR NR

group Trail Making Test Part A 29.6 (13.1) NA NA NA

Procedural Reaction 

Time (PRT) subtest

Baseline: 52 (43-53) 

≤ 72 hours: 46 (34.5-54.5)

Baseline: 50 (47-58) 

≤ 72 hours: 52.5 (46.5-59)

Baseline: p = .60

≤ 72 hours: p < .001

NR

Simple Reaction Time 

(SRT) subtest

Baseline: 53 (48-55)

≤ 72 hours: 44.5 (34.5-52)

Baseline: 52 (47-55)

≤ 72 hours: 52 (47-55.5)

Baseline: p = .24

≤ 72 hours: p < .001

NR

sis Stroop Color & 

Word Test

Color 58.8 (12.1) 60.8 (15.3) NR NR

Word 76.2 (16.5) 79.6 (18.2) NR NR

Trail Making Test Part A 41.8 (15.8) 40.1 (15.0) NR NR

tion 

with 

njuries 

the 

jured 

 same 

n

ANAM Code Substitution (CDS) 

subtest

Baseline: 46 (39.5-48.5)

5+ days: 52.5 (46.5-58)

10+ days: 53 (47-60)

Baseline: 48 (43-55)

5+ days: 57 (50-63)

10+ days: 57 (50-63)

Baseline: p = 0.04

5+ days: p = 0.03

10+ days: p = 0.14

NR

Procedural Reaction 

Time (PRT) subtest

Baseline: 52 (43-57)

5+ days: 52 (44.5-58.5)

10+ days: 48.8 (42-62.1)

Baseline: 52 (47-58)

5+ days: 54 (47-62.5)

10+ days: 54 (47-62.5)

Baseline: p = 0.77

5+ days: p = 0.13

10+ days: p = 0.20

NR

Simple Reaction Time 

(SRT) subtest

Baseline: 53 (52-55)

5+ days: 54 (48-56.5)

10+ days: 54.5 (46.6-57.6)

Baseline: 52 (47-58)

5+ days: 53.5 (48.8-56.5)

10+ days: 53.5 (48.8-56.5)

Baseline: p = .23

5+ days: p = .97

10+ days: p = .71

NR

tion 

with 

njuries 

the 

jured 

 same 

n

ANAM Code Substitution (CDS) 

subtest

Baseline: 44 (37-50) 

≤ 72 hours: 44 (38.5-51)

Baseline: 48 (43-55) 

≤ 72 hours: 52 (45-57)

Baseline: p = .02

≤ 72 hours: p < .001

NR
87

c Brain Injury in Veterans and Military Personnel: A Systematic Review Evidence-based Synthesis Program

roup 

n Outcome measure Subscale or test component mTBI group Mean (SD) or Median (IQR) Comparison group Mean (SD) or Median (IQR) p value for comparison Magnitude of effect

tion 

none 

ort

Stroop Color and 

Word Test

Color t-score 46.00 (8.88) 47.26 (6.90) “NS” d = 0.16

Word t-score 46.29 (9.10) 48.58 (8.64) “NS” d = 0.26

Trail Making Test Part A t-score 48.89 (9.89) 49.61 (11.66) “NS” d = 0.10

WAIS-III Digit Symbol Coding 

scaled score

10.46 (2.52) 10.35 (2.47) “NS” d = 0.04

tion 

none 

Stroop Color and 

Word Test

Color t-score 49.5 (6.9) 48.9 (6.7) “NS” NR

tion 

BI; 

 PTSD

Reaction time on a 

Go/NoGo task

--- NR NR p > .7 NR

n with 

re TBI

Trail Making Test Part A NR NR all p values > .10 NR

WAIS-III Digit Symbol Coding NR NR all p values > .10 NR

Word t-score 49.4 (9.8) 48.3 (6.6) “NS” NR

Trail Making Test Part A t-score 50.0 (11.7) 51.8 (12.1) “NS” NR

WAIS-III Digit Symbol Coding 

scaled score

10.9 (2.0) 11.1 (2.7) “NS” NR

ention 

Trail Making Test Part A NR NR “NS” r = -.03

owed 

zation

Trail Making Test Part A NR NR “NS” r = -.09
88

c Brain Injury in Veterans and Military Personnel: A Systematic Review Evidence-based Synthesis Program

g in studies of U.S. Veterans and members of the U.S. military with mild TBI

mparison group description Outcome measure Subscale or test component mTBI group Mean (SD) Comparison group Mean (SD) p value for comparison Magnitude of effect

ast exposure Trail Making Test Part B t-score 49.1 (15.0) 45.6 (9.4) all p values > .10 NR

 population with 

erate/severe TBI

Trail Making Test Part B NR NR all p values > .10 NR

C and/or PTA Trail Making Test Part B t-score 49.96 (8.35) 48.80 (8.65) NR NR

 Health Diagnosis 

her than PTSD

Stroop Color & Word Test Color Word 32.9 (7.9) 30.3 (9.0) NR NR

Trail Making Test Part B 93.0 (38.8) 106.1 (73.2) NR NR

SD Diagnosis Stroop Color & Word Test Color Word 32.9 (7.9) 30.5 (8.5) NR NR

Trail Making Test Part B 93.0 (38.8) 95.2 (34.5) NR NR

xis I disorder COWA t-score --- 46.4 (11.0) 42.7 (9.5) “NS” NR

Stroop Color and Word Test Color-Word t-score 51.1 (9.5) 48.3 (9.5) “NS” NR

Trail Making Test Part B t-score 51.0 (12.1) 48.4 (10.8) “NS” NR

opulation without 

 none have Axis I

COWA t-score --- 46.4 (11.0) 48.9 (9.7) “NS” NR

Stroop Color and Word Test Color-Word t-score 51.1 (9.5) 52.6 (7.0) “NS” NR

Trail Making Test Part B t-score 51.0 (12.1) 53.6 (7.5) “NS” NR

ensic context COWA t-score --- 44.79 (10.43) 42.83 (8.52) “NS” NR

Stroop Color and Word Test Color-Word t-score 46.95 (9.09) 43.78 (8.10) “NS” NR

Trail Making Test Part B t-score 51.45 (10.25) 44.71 (10.22) “NS” NR

opulation without 

ne with poor effort

COWA t-score 47.04 (8.94) 46.97 (9.69) “NS” d = 0.01

Stroop Color and Word Test Color-Word t-score 48.86 (9.35) 50.52 (9.22) “NS” d = 0.18

Trail Making Test Part B t-score 52.21 (10.20) 52.77 (5.83) NS d = 0.07

 population with 

erate/severe TBI

Executive Function 

Composite Score

--- 10.4 (2.2) 9.5 (3.0) p = .13 NR

None Trail Making Test Part B 72.8 (34.8) NA NA NA

ported attention 

deficits

Trail Making Test Part B NR NR “NS” r = -.01

eported slowed 

ng/organization

Trail Making Test Part B NR NR “NS” r = -.01
89

c Brain Injury in Veterans and Military Personnel: A Systematic Review Evidence-based Synthesis Program

n measures in a study of U.S. Veterans with mild TBI evaluated in a research versus forensic context

come measure Portion or subscale Research context Mean (SD) Forensic context Mean (SD) p value for comparison Magnitude of effect

CVLT-II Forced Choice 15.87 (0.41) 15.50 (1.18) “NS” NR

Failures raw score --- 0.32 (0.58) 1.17 (0.87) “Significant” NR

Rey FIT Combination 28.84 (2.06) 26.13 (3.72) “Significant” NR

VSVT Easy Items 23.90 (0.31) 22.92 (2.00) “Significant” NR

Difficult Items 22.11 (2.87) 15.63 (6.25) “Significant” NR

Total Items 46.00 (3.08) 38.54 (7.43) “Significant” NR

WAIS-III Reliable Digit Span 9.63 (1.98) 8.38 (1.71) “NS” NR
90

c Brain Injury in Veterans and Military Personnel: A Systematic Review Evidence-based Synthesis Program

ain composite scores in studies of U.S. Veterans and members of the U.S. military with mild TBI

mparison group description Outcome measure Subscale or test component mTBI group Mean (SD) Comparison group Mean (SD) p value for comparison Magnitude of effect

ast exposure RBANS Total Score 98.61 (9.33) 94.88 (12.92) p = 0.211 NR

opulation without 

mTBI

RBANS Total Score 92.16 (11.932) 96.71 (11.672) p = 0.023 NR

opulation without 

ne with poor effort

Overall Test Battery Mean 

z-score

--- 0.00 (0.55) 0.11 (0.42) “NS” d = 0.22

opulation without 

 none have Axis I

Overall Test Battery Mean 

z-score

--- 0.14 (0.69) 0.26 (0.38) “NS” d = .23

 population with 

erate/severe TBI

Attention/Processing Speed 

Composite Score

--- 9.8 (1.9) 8.5 (2.0) p < .01 NR

xis I disorder Overall Test Battery Mean 

z-score

--- 0.14 (0.69) -.14 (.45) “NS” NR

ensic context Overall Test Battery Mean 

z-score

--- -0.15 (0.55) -0.75 (0.52) “Significant” NR

che intervention 

ng sleep hygiene, 

in, headache and 

ucation, and group 

therapy

MOCA --- 24.50 (.49) 28.60 (.59) p < .001 NR

LOC MOCA --- 28.9 (.32) 25.1 (.18) p < .001 NR

 Health Diagnosis 

her than PTSD

WAIS-III (73 participants 

administered);

WAIS-IV (9 participants 

administered)

WAIS-III Vocabulary, 

Information, Matrix 

Reasoning, Block Design 

Subscales; 

WAIS-IV: all subtests 

97.4 (11.0) 100.2 (15.4) NR NR

 neurological and/

uropsychological 

findings

Number of blast exposures 

associated with LOC or AOC

--- 2.65 (.18) 4.42 (.23) p < .001 NR

Number of blast exposures 

associated with LOC only

--- 1.46 (.09) 3.91 (.20) p < .001 NR

SD Diagnosis WAIS-III (73 participants 

administered);

WAIS-IV: (9 participants 

administered)

WAIS-III Vocabulary, 

Information, Matrix 

Reasoning, Block Design 

Subscales;

WAIS-IV: all subtests

97.4 (11.0) 95.6 (13.3) NR NR
91

c Brain Injury in Veterans and Military Personnel: A Systematic Review Evidence-based Synthesis Program

ve deficits in studies of U.S. Veterans and members of the U.S. military with mild TBI

mparison group description Outcome measure Subscale or test component mTBI group Mean (SD) Comparison group Mean (SD) p value for comparison Magnitude of effect

one additional AIS 

code

NSI Cognitive Cluster 10.01 (4.90) 6.88 (5.25) p < 0.001 NR

Concentration 2.16 (1.17) 1.40 (1.32) p < 0.001 NR

Decision-Making 1.74 (1.22) 1.04 (1.15) p < 0.001 NR

Memory 2.36 (1.16) 1.81 (1.34) p < 0.001 NR

Slowed Thinking/

Organization

1.89 (1.18) 1.11 (1.21) p < 0.001 NR

xis I disorder Memory --- 1 (5.6) 4 (11.8) “NS” NR

ast exposure NSI Decision-Making NR NR p > .002 NR

Memory NR NR p > .002 NR

Slowed Thinking/

Organization

NR NR p > .002 NR

ADS Anxiety NSI Concentration NR NR p < .001 r = .56

Decision-Making NR NR p < .001 r = .52

Memory NR NR p < .001 r = .49

Slowed Thinking/

Organization

NR NR p < .001 r = .58

DS Depression NSI Concentration NR NR p < .001 r = .55

Decision-Making NR NR p < .001 r = .57

Memory NR NR p < .001 r = .51

Slowed Thinking/

Organization

NR NR p < .001 r = .62

C and/or PTA NSI Concentration 2.08 (1.21) 2.71 (1.12) NR NR

Decision-Making 1.59 (1.365) 2.05 (1.36) NR NR

Memory 2.17 (1.16) 2.86 (1.18) NR NR

Slowed Thinking/

Organization

1.80 (1.32) 2.38 (1.29) NR NR

NA NSI Concentration 2.31 (1.08) NA NA NA

Decision-Making 1.72 (1.12) NA NA NA

Memory 2.50 (1.04) NA NA NA

Slowed Thinking/

Organization

1.96 (1.18) NA NA NA
92

c Brain Injury in Veterans and Military Personnel: A Systematic Review Evidence-based Synthesis Program

mparison group description Outcome measure Subscale or test component mTBI group Mean (SD) Comparison group Mean (SD) p value for comparison Magnitude of effect

CL score > 50 NSI Decision-Making NR NR p < .002 NR

Memory NR NR p < .002 NR

Slowed Thinking/

Organization

NR NR p < .002 NR

≥60 (controls had 

PCL-C ≤30)

NSI Cognitive Cluster 3.04 (3.40) 13.32 (3.90) p < .0001 NR

Concentration 0.47 (0.79) 2.87 (0.88) p < .0001 NR

Decision-Making 0.33 (0.73) 2.28 (1.13) p < .0001 NR

Memory 0.95 (1.14) 3.00 (0.91) p < .0001 NR

Slowed Thinking/

Organization

0.42 (0.81) 2.57 (0.98) p < .0001 NR

CL-M score NSI Concentration NR NR p < .001 r = .59

Decision-Making NR NR p < .001 r = .63

Memory NR NR p < .001 r = .53

Slowed Thinking/

Organization

NR NR p < .001 r = .68

 population with 

erate/severe TBI

FrSBe Subjective Executive 

Dysfunction pre- to postinjury change

10.8 (14.2) 21.6 (18.3) p = .01 NR

vice connected NSI Concentration NR NR p < .05 NR

Decision-Making NR NR p < .05 NR

Memory NR NR p < .001 NR

Slowed Thinking/

Organization

NR NR p < .05 NR
93

c Brain Injury in Veterans and Military Personnel: A Systematic Review Evidence-based Synthesis Program

s

in studies of U.S. Veterans and members of the U.S. military with mild TBI

ison group description Outcome measure

mTBI group

Mean (SD) or 

% of subjects

Comparison 

group

Mean (SD) or 

% of subjects

p value for 

comparison

Magnitude of 

effect

one additional AIS code NSI: Headaches 2.71 (1.10) 1.45 (1.30) p < 0.001 NR

Axis I disorder Headache 6 (33.3) 12 (35.3) “NS” NR

Blast exposure NSI: Headaches NR NR p < .002 NRBlast exposure HIT-6 54.32 (9.44) 56.03 (9.54) p = 0.489 NR

e intervention involving 

p hygiene, Prazosin, 

he and pain education, 

nd group therapy

Headache frequency (number per month) 12.40 (.94) 4.77 (.19) p < .001 NR

Headache pain level (scale 0-10) 7.28 (.27) 4.08 (.19) p < .001 NR

NA NSI: Headaches 2.29 (1.04) NA NA NANA Neurology referral for headaches 82/246 = 33.3% NA NA NA

Neurology referral for headaches, Chronic daily type 11/246 = 4.47% NA NA NA

Neurology referral for headaches, Cluster type 1/246 = 0.41% NA NA NA

Neurology referral for headaches, Migraine type 25/246 = 10.16% NA NA NA

Neurology referral for headaches, Mixed type 8/246 = 3.25% NA NA NA

Neurology referral for headaches, Other type 1/246 = 0.41% NA NA NA

Neurology referral for headaches, Post-traumatic type 4/246 = 1.63% NA NA NA

Neurology referral for headaches, Tension type 6/246 = 2.44% NA NA NA

NA Headaches started < 1 week after trauma 12/33 = 36% NA NA NA

Headaches started > 1 month after trauma 3/33 = 9% NA NA NA

Headaches started 1 week to 1 month after trauma 1/33 = 3% NA NA NA

Unspecified onset of headache after trauma 5/33 = 15% NA NA NA

Worsening of pre-existing headaches 12/33 = 36% NA NA NA

PCL score > 50 NSI: Headaches NR NR p < .002 NR

60 (controls had PCL-C 

≤30)

NSI: Headaches 1.01 (1.15) 2.79 (1.18) p < .0001 NR
94

c Brain Injury in Veterans and Military Personnel: A Systematic Review Evidence-based Synthesis Program

ison group description Outcome measure

mTBI group

Mean (SD) or 

% of subjects

Comparison 

group

Mean (SD) or 

% of subjects

p value for 

comparison

Magnitude of 

effect

e neurological and/or 

psychological findings

Headache frequency: > 10 per month 0/0 = 0% 31/74 = 42% p < .001 NR

Headache frequency: > 4 per month 2/6 = 33% 71/74 = 96% p < .001 NR

Headache frequency: Daily 0/0 = 0% 10/14 = 14% p < .001 NR

Headache pain level (scale 0-10) 4.33 (.27) 7.28 (.27) p < .001 NR

Headache: Migraine type 0/0 = 0% 14/74 = 19% p < .001 NR

Headache: Mixed type 0/0 = 0% 30/74 = 41% p < .001 NR

Headache: Tension type 6/6 = 100% 30/74 = 41% p < .001 NR

 to Neurology clinic for 

headaches

NSI: Headache 1.97 (0.91) 2.87 (0.80) p < .01 NR

opulation without mTBI Headache days per month after deployment 

(days/month)

11.9 (10.0) 10.3 (8.0) NR NR

Headache days per month during deployment 

(days/month)

14.5 (11.7) 9.4 (9.4) NR NR

Headache duration (hours) 8.8 (7.3) 7.5 (5.2) NR NR

Headache NOS 7/33 = 21% 7/48 = 14% NR NR

Headache severity (0-10 scale) 7.1 (1.5) 7.1 (1.2) NR NR

Medication overuse headache 4/33 = 12% 0/48 = 0% NR NR

MIDAS 30.8 (44.3) 26.8 (27.5) NR NR

Migraine with aura 8/33 = 24% 3/48 = 6% NR NR

Migraine without aura 15/33 = 45% 30/48 = 62% NR NR

Multiple headache types 10/33 = 30% 16/48 = 33% NR NR

Occipital headache 5/33 = 15% 3/48 = 6% NR NR

Probable migraine 3/33 = 9% 5/48 = 10% NR NR

Tension-type headache 5/33 = 15% 13/48 = 27% NR NR
95

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dies of U.S. Veterans and members of the U.S. military with mild TBI

mparison group description Outcome measure mTBI group Comparison group p value for comparison Magnitude of effect

me population 

ithout mTBI

Pain (On a scale of 0 to 10, with 0 as no 

pain and 10 as the worst pain possible, how 

would you rate your current pain?)

Median = 3.5 Median = 2.0 p = .18 Cohen’s d = .30

 population with 

erate/severe TBI

Pain in the past 30-days 112/125 = 90% 6/6 = 100% p = .53 NR

in studies of U.S. Veterans and members of the U.S. military with mild TBI

mparison group description Outcome measure mTBI group Mean (SD) Comparison group Mean (SD) p value for comparison Magnitude of effect

Blast exposure NSI: Feeling Dizzy NR NR p > .002 NR

NSI: Loss of Balance NR NR p > .002 NR

NSI: Poor Coordination NR NR p > .002 NR

PCL score > 50 NSI: Feeling Dizzy NR NR p < .002 NR

NSI: Loss of Balance NR NR p < .002 NR

NSI: Poor Coordination NR NR p < .002 NR

NA NSI: Feeling Dizzy 1.47 (.86) NA NA NA

NSI: Loss of Balance 1.32 (.92) NA NA NA

NSI: Poor Coordination 1.32 (.93) NA NA NA

 ≥60 (controls had PCL-C ≤30) NSI: Feeling Dizzy 0.52 (0.81) 1.88 (1.13) p < .0001 NR

NSI: Loss of Balance 0.45 (0.66) 1.89 (1.04) p < .0001 NR

NSI: Poor Coordination 0.30 (0.55) 1.98 (1.04) p < .0001 NR

 volunteer subjects without TBI. 

plicitly stated whether controls 

m the same population as cases, 

 controls were evaluated at the 

same time and place.

DHI NR NR p < .01 for weeks 1, 2, 

3, & 4 following injury

NR

 volunteer subjects without TBI. 

plicitly stated whether controls 

m the same population as cases, 

 controls were evaluated at the 

same time and place.

DVAT NR NR p < .01 for week 1

p > .01 for week 4

NR

east one additional AIS code NSI: Feeling Dizzy 1.44 (1.09) 0.94 (1.05) p < 0.001 NR

NSI: Loss of Balance 1.30 (1.08) 0.92 (0.98) p = 0.002 NR

NSI: Poor Coordination 1.71 (1.05) 0.92 (1.03) p < 0.001 NR

Axis I disorder Disorientation 7 (38.9) 13 (38.2) “NS” NR

Dizziness 5 (27.8) 8 (23.5) “NS” NR

Imbalance 2 (11.1) 4 (11.8) “NS” NR
96

c Brain Injury in Veterans and Military Personnel: A Systematic Review Evidence-based Synthesis Program

tudies of U.S. Veterans and members of the U.S. military with mild TBI

Comparison group description Outcome measure mTBI group Comparison group p value for comparison Magnitude of effect

At least one additional AIS code NSI: Sensitivity to Light 1.56 (1.26) 0.85 (1.22) p < 0.001 NR

NSI: Vision Problems 1.18 (1.16) 0.86 (1.16) p = 0.022 NR

Axis I disorder Photophobia 4 (22.2) 6 (17.6) “NS” NR

Blast exposure NSI: Sensitivity to Light NR NR p > .002 NR

NSI: Vision Problems NR NR p > .002 NR

NA NSI: Sensitivity to Light 1.72 (1.17) NA NA NA

NSI: Vision Problems 1.51 (1.07) NA NA NA

PCL score > 50 NSI: Sensitivity to Light NR NR p < .002 NR

NSI: Vision Problems NR NR p < .002 NR

PCL-C ≥60 (controls had PCL-C 

≤30)

NSI: Sensitivity to Light 0.65 (0.99) 2.06 (1.44) p < .0001 NR

NSI: Vision Problems 0.51 (0.99) 1.68 (1.23) p < .0001 NR

 studies of U.S. Veterans and members of the U.S. military with mild TBI

Comparison group description Outcome measure mTBI group Mean (SD) Comparison group Mean (SD) p value for comparison Magnitude of effect

Blast exposure NSI Hearing Difficulty NR NR p < .002 NR

Sensitivity to Noise NR NR p > .002 NR

PCL score > 50 NSI Hearing Difficulty NR NR p < .002 NR

Sensitivity to Noise NR NR p < .002 NR

NA NSI Hearing Difficulty 1.88 (1.06) NA NA NA

Sensitivity to Noise 1.85 (1.11) NA NA NA

PCL-C ≥60 (controls had PCL-C 

≤30)

NSI Sensitivity to Noise 0.48 (0.87) 2.50 (1.09) p < .0001 NR

Hearing Difficulty 0.70 (1.02) 2.06 (1.11) p < .0001 NR

At least one additional AIS code NSI Sensitivity to Noise 1.86 (1.17) 1.29 (1.41) p < 0.001 NR

Hearing Difficulty 1.46 (1.12) 1.39 (1.28) p = 0.620 NR

Axis I disorder Tinnitus 8 (44.4) 13 (38.2) “NS” NR

Phonophobia 4 (22.2) 4 (11.8) “NS” NR
97

c Brain Injury in Veterans and Military Personnel: A Systematic Review Evidence-based Synthesis Program

es in studies of U.S. Veterans and members of the U.S. military with mild TBI

Comparison group description Outcome measure mTBI group Mean (SD) or % of subjects Comparison group Mean (SD) or % of subjects p value for comparison Magnitude of effect

At least one additional 

AIS code

NSI: Numbness or Tingling 1.02 (1.08) 1.22 (1.32) p = 0.157 NR

 

Blast exposure NSI: Numbness or Tingling NR NR p > .002 NR

LOC Neurological deficits based on 

examination

0/16 = 0% 65/125 = 52% p < .001 NR

NA NSI: Numbness or Tingling 1.61 (1.19) NA NA NA

 

PCL score > 50 NSI: Numbness or Tingling NR NR p < .002 NR

PCL-C ≥60 (controls had 

PCL-C ≤30)

NSI: Numbness or Tingling 0.76 (0.96) 1.83 (1.26) p < .0001 NR

omes in studies of U.S. Veterans and members of the U.S. military with mild TBI

Comparison group description Outcome measure mTBI group Mean (SD) Comparison group Mean (SD) p value for comparison Magnitude of effect

 

Blast exposure NSI Change in Taste or Smell NR NR p > .002 NR

Loss of Appetite NR NR p > .002 NR

Nausea NR NR p > .002 NR

PCL score > 50 NSI Change in Taste or Smell NR NR p < .002 NR

Loss of Appetite NR NR p < .002 NR

Nausea NR NR p < .002 NR

NA NSI Change in Taste or Smell 0.82 (1.03) NA NA NA

Loss of Appetite 1.53 (1.13) NA NA NA

Nausea 1.13 (1.01) NA NA NA

PCL-C ≥60 (controls had 

PCL-C ≤30)

NSI Change in Taste or Smell 0.15 (0.60) 1.14 (1.14) p < .0001 NR

Loss of Appetite 0.50 (0.84) 2.05 (1.10) p < .0001 NR

Nausea 0.31 (0.70) 1.57 (1.12) p < .0001 NR

At least one additional 

AIS code

NSI Change in Taste or Smell 0.54 (0.92) 0.49 (0.90) p = 0.681 NR

Loss of Appetite 1.44 (1.11) 1.13 (1.16) p = 0.026 NR

Nausea 1.12 (1.07) 0.60 (0.94) p < 0.001 NR

Axis I disorder Nausea 3 (16.7) 4 (11.8) “NS” NR
98

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tudies of U.S. Veterans and members of the U.S. military with mild TBI

Comparison group description Outcome measure mTBI group Mean (SD) Comparison group Mean (SD) p value for comparison Magnitude of effect

1025 At least one additional AIS code PCL-C Arousal With Reminder 3.02 (1.39) 2.17 (1.36) p < 0.001 NR

Avoid Activities 2.50 (1.39) 2.03 (1.28) p = 0.004 NR

Avoid Thoughts 2.92 (1.42) 2.31 (1.36) p < 0.001 NR

Avoidance Cluster 17.72 (7.54) 13.93 (6.61) p < 0.001 NR

Disturbing Dreams 3.10 (1.42) 2.74 (1.47) p = 0.042 NR

Disturbing Memories 3.32 (1.32) 3.03 (1.43) p = 0.086 NR

Feeling Distant 2.97 (1.43) 2.10 (1.22) p < 0.001 NR

Feeling Numb 2.31 (1.41) 1.85 (1.19) p = 0.004 NR

Future Cut Short 2.29 (1.40) 1.85 (1.24) p = 0.006 NR

Hyper-Arousal Cluster 17.47 (4.91) 13.65 (5.58) p < 0.001 NR

Irritability 3.18 (1.32) 2.51 (1.40) p < 0.001 NR

Jumpy, Easily Startled 3.34 (1.30) 2.72 (1.41) p < 0.001 NR

Loss of Interest 2.55 (1.41) 2.01 (1.19) p = 0.001 NR

Poor Sleep 4.11 (1.16) 3.36 (1.48) p < 0.001 NR

Re-experiencing Cluster 14.95 (5.74) 12.07 (5.92) p < 0.001 NR

Reliving Experience 2.54 (1.29) 1.99 (1.26) p < 0.001 NR

Super-Alert, Watchful 3.44 (1.28) 2.67 (1.39) p < 0.001 NR

Total Score 50.14 (16.66) 39.64 (16.72) p < 0.001 NR

Trouble Concentrating 3.41 (1.26) 2.46 (1.39) p < 0.001 NR

Trouble Remembering 2.48 (1.42) 2.05 (1.32) p = 0.009 NR

Upset When Reminded 2.98 (1.34) 2.42 (1.36) p = 0.001 NR

229 Axis I disorder CAPS 9.8 (12.1) 54.2 (52.5) “Significant” NR

SCID-I: PTSD 0 (0.0) 24 (70.6) “NS” NR

t al., 

Blast exposure PCL 37.3 (17.6) 41.5 (17.4) p = .047 NR

201216 Blast exposure PCL-M 36.29 (14.72) 37.88 (16.42) p = .696 NR
99

c Brain Injury in Veterans and Military Personnel: A Systematic Review Evidence-based Synthesis Program

Comparison group description Outcome measure mTBI group Mean (SD) Comparison group Mean (SD) p value for comparison Magnitude of effect

26 Blast exposure PCL-C Avoidance All: 15.6 (7.0)

AOC: 14.8 (6.9)

LOC: 16.1 (7.1)

All: 15.8 (7.4)

AOC: 14.9 (7.1)

LOC: 16.3 (7.5)

All: p = .826

AOC: “NS”

LOC: “NS”

NR

Hyper-Arousal All: 14.5 (5.7)

AOC: 14.0 (5.6)

LOC: 14.8 (5.8)

All: 15.2 (5.6)

AOC: 14.6 (5.4)

LOC: 15.6 (5.7)

All: p = .202

AOC: “NS”

LOC: “NS”

NR

Re-experiencing All: 12.0 (5.7)

AOC: 11.8 (5.8)

LOC: 12.2 (5.8)

All: 13.3 (5.9)

AOC: 12.6 (5.7)

LOC: 13.7 (5.9)

All: p = .020

AOC: “NS”

LOC: “NS”

NR

Total Score All: 42.7 (16.9)

AOC: 40.6 (17.0)

LOC: 43.1 (17.0)

All: 44.3 (17.6)

AOC: 42.0 (16.8)

LOC: 45.7 (17.9)

All: p = .198

AOC: “NS”

LOC: “NS”

NR

201028 Blast exposure PCL: Civilian and Military versions 49.75 (15.11) 54.45 (14.98) p = .005 NR

20 HADS Anxiety PCL-M NR NR p < .001 r = .76

HADS Depression PCL-M NR NR p < .001 r = .76

32 LOC PTSD diagnosis (based on PCL-M as 

well as clinical interview)

1/16 = 6.25% 83/125 = 66% p < .001 NR

20 LOC and/or PTA PCL-M 50.61 (16.24) 56.74 (14.61) p < .05 NR

913 NA PCL-C: Total Score 53.5 (15.6) NA NA NA

NA PCL-M 52.4 (15.0) NA NA NA

Positive neurological and/or 

neuropsychological findings

PTSD diagnosis: (PCL score > 50 and 

meeting DSM-IV criteria)

11/46 = 24% 72/80 = 90% p < .001 NR

131 Referral to neurology clinic for 

headaches

PTSD (clinician confirmed or selfreported symptoms) 116/164 = 70.7% 66/82 = 80.5% p = .10 NR

ench, 

Same population with moderate/

severe TBI

PCL 35.4 (16.8) 23.5 (13.7) p < .0001 NR

ett, & 

Same population with moderate/

severe TBI

PCL 45.5 (17.2) 30.1 (15.5) p < .0001 NR

owles, 

Same population with moderate/

severe TBI

PCL-M 42 (1) 37 (3) NR NR

Same population with moderate/

severe TBI

PTSD diagnosis 91/125 = 73% 5/6 = 83% p = .49 NR

owles, 

Same population without mTBI PCL-M 42 (1) 31 (4) NR NRSame population without mTBI PCL-M: Score </= 44 14/31 = 45% 10/45 = 22% p = .0345 NRSame population without mTBI PCL-C 34.6 (13.3) 36.0 (14.0) NR NR
100

c Brain Injury in Veterans and Military Personnel: A Systematic Review Evidence-based Synthesis Program

Comparison group description Outcome measure mTBI group Mean (SD) Comparison group Mean (SD) p value for comparison Magnitude of effect

Same population without mTBI CAPS: B – Re-experiencing Subscale 20.02 (7.03) 17.53 (6.06) p = .08 Cohen’s d = 

0.38

CAPS: Total Score 74.02 (16.21) 67.20 (13.21) p = .03 Cohen’s d = 

0.46

PCL-S 61.86 (11.04) 58.19 (12.89) p = .17 Cohen’s d = 

0.30

owles, 

Same population, neurologic 

patients (tumor, stroke, electrical, 

subarachnoid hemorrhage, anoxia, 

encephalitis, Parkinson’s disease, 

fronto-temporal dementia)

PCL-M 42 (1) 35 (5) NR NR

Self-reported attention deficits PCL-M NR NR p < .001 r = .60

Self-reported memory deficits PCL-M NR NR p < .001 r = .48

Self-reported slowed thinking/

organization

PCL-M NR NR p < .001 r = .54
101

c Brain Injury in Veterans and Military Personnel: A Systematic Review Evidence-based Synthesis Program

in studies of U.S. Veterans and members of the U.S. military with mild TBI

Comparison group description Outcome measure mTBI group Mean (SD) Comparison group Mean (SD) p value for comparison Magnitude of effect

Blast exposure NSI: Feeling Anxious NR NR “NS” NR

PCL score > 50 NSI: Feeling Anxious NR NR p < .002 NR

NA NSI: Feeling Anxious 2.58 (1.08) NA NA NA

PCL-C ≥60 (controls had 

PCL-C ≤30)

NSI: Feeling Anxious 0.48 (0.82) 2.96 (0.91) p < .0001 NR

LOC and/or PTA HADS: Anxiety 11.56 (4.06) 13.16 (3.92) p < .05 NR

HADS Depression HADS: Anxiety NR NR p < .001 r = .56

At least one additional 

AIS code

NSI: Feeling Anxious 1.99 (1.24) 1.49 (1.34) p = 0.001 NR

NA HADS: Anxiety 11.9 (4.5) NA NA NA

Self-reported slowed 

thinking/organization

HADS: Anxiety NR NR p < .001 r = .39

Self-reported attention 

deficits

HADS: Anxiety NR NR p < .001 r = .48

Self-reported memory 

deficits

HADS: Anxiety NR NR p < .001 r = .33
102

c Brain Injury in Veterans and Military Personnel: A Systematic Review Evidence-based Synthesis Program

on in studies of U.S. Veterans and members of the U.S. military with mild TBI

mparison group description Outcome measure Subscale or test component mTBI group Mean (SD) or % of subjects Comparison group Mean (SD) or % of subjects p value for comparison Magnitude of effect

t one additional AIS 

code

NSI Feeling Depressed or Sad 1.16 (1.26) 1.08 (1.19) p = 0.566 NR

last exposure NSI Feeling Depressed or Sad NR NR “NS” NR

OC and/or PTA HADS Depression 7.95 (4.61) 10.34 (4.013) p < .001 NR

NA NSI Feeling Depressed or Sad 2.09 (1.20) NA NA NANA HADS Depression 8.7 (4.3) NA NA NA

CL score > 50 NSI Feeling Depressed or Sad NR NR p < .002 NR

0 (controls had PCL-C 

≤30)

NSI Depression 0.30 (0.64) 2.44 (1.19) p < .0001 NR

population without 

all participants had 

PTSD.

BDI-II --- 20.0 (12.3) 20.8 (9.2) NR NR

population without 

mTBI

BDI-II --- 31.56 (11.06) 29.17 (10.53) p = .29 Cohen’s d = 0.23

Hopelessness (Who or what 

gives you strength and 

hope?)

--- 6/46 = 13% 6/46 = 13% NR NR

SCID-I Major Depressive Disorder 25/46 = 54% 18/46 = 39% p = .14 φ = .15

eported attention 

deficits

HADS Depression NR NR p < .001 r = .45

rted memory deficits HADS Depression NR NR p < .001 r = .36

reported slowed 

king/organization

HADS Depression NR NR p < .001 r = .52

orders in studies of U.S. Veterans and members of the U.S. military with mild TBI

mparison group description Outcome measure Subscale or test component mTBI group % of subjects Comparison group % of subjects p value for comparison Magnitude of effect

xis I disorder SCID-I Alcohol Abuse/Dependence 5/18 = 27.8% 12/34 = 35.3% “Significant” NR

opulation without 

 none have Axis I

Alcohol Abuse/Dependence 5/18 = 27.8% 5/28 = 17.9% “NS” NR

opulation without 

mTBI

SCID-I Alcohol Problem 13/46 = 28% 17/46 = 37% p = .37 φ = .09

Drug Problem 4/46 = 9% 7/46 = 15% p = .34 φ = .10
103

c Brain Injury in Veterans and Military Personnel: A Systematic Review Evidence-based Synthesis Program

mes in studies of U.S. Veterans and members of the U.S. military with mild TBI

Comparison group description Outcome measure mTBI group % of subjects Comparison group % of subjects p value for comparison Magnitude of effect

Same population without 

mTBI

Suicidal ideation (Have 

you had thoughts about 

death or about killing 

yourself?)

11/44 = 25% 5/44 = 11% p = .10 φ = .18

Suicidal Intent (Have you 

ever intended to commit 

suicide?)

3/46 = 7% 1/46 = 2% NR NR

Past Suicide Attempts 

(Have you ever attempted 

suicide?)

2/46 = 4% 2/46 = 4% NR NR

outcomes in studies of U.S. Veterans and members of the U.S. military with mild TBI

mparison group description Outcome measure Subscale or test component mTBI group Comparison group p value for comparison Magnitude of effect

one additional AIS 

code

NSI Affective Cluster 7.21 (4.21) 5.43 (4.54) p < 0.001 NR

Frustration 1.86 (1.22) 1.24 (1.29) p < 0.001 NR

Irritability 2.19 (1.23) 1.62 (1.32) p < 0.001 NR

ast exposure NSI Frustration NR NR “NS” NR

NA NSI Frustration 2.41 (1.17) NA NA NA

Irritability 2.76 (1.06) NA NA NA

CL score > 50 NSI Frustration NR NR p < .002 NR

≥60 (controls had 

PCL-C ≤30)

NSI Affective Cluster 2.97 (2.93) 14.64 (3.48) p < .0001 NR

Frustration 0.31 (0.68) 2.82 (0.95) p < .0001 NR

Irritability 0.63 (0.89) 2.95 (0.90) p < .0001 NR

 population with 

erate/severe TBI

FrSBe Apathy, pre- to post-injury 

change

14.7 (17.2) 27.8 (16.8) p < .01 NR

Behavioral Disinhibition, 

pre- to post-injury change

5.3 (7.8) 5.5 (11.2) p = .98 NR

opulation without 

mTBI

SCID-I Any Co-Morbid Axis I 

Disorder

34/46 = 78% 29/46 = 63% p = .14 φ = .12

opulation without 

mTBI

Psychiatric Diagnosis --- 25 (50.0%) 26 (22.2%) p = 0.001 NR
104

c Brain Injury in Veterans and Military Personnel: A Systematic Review Evidence-based Synthesis Program

mes

es in studies of U.S. Veterans and members of the U.S. military with mild TBI

mparison group description Outcome measure

mTBI group

% of subjects or

OR (95% CI) compared to 

non-mTBI control

Comparison group

% of subjects or

OR (95% CI) compared to 

non-mTBI control

p value for 

comparison

Magnitude of 

effect

opulation without 

mTBI

Unemployment 

(% who responded ‘No’ to ‘Are you 

employed?’)

9/45 = 20% 14/45 = 31% p = .23 φ = .13

LOC Missed work: ≥2 missed workdays 

in the past month

1.8 (95% CI 0.9-3.5) 1.4 (95% CI 0.5-3.6) NR NR

Occupational Impairment, Heavy 

Load: 

Difficulty carrying a heavy load in 

past month

2.2 (95% CI 1.3-3.5) 3.0 (95% CI 1.5-5.7) NR NR

Occupational Impairment, Physical 

Training: 

Difficulty performing physical 

training (PT) in past month

1.9 (95% CI 1.2-2.9) 1.6 (95% CI 0.8-3.0) NR NR
105

c Brain Injury in Veterans and Military Personnel: A Systematic Review Evidence-based Synthesis Program

udies of U.S. Veterans and members of the U.S. military with mild TBI

son group description Outcome measure Subscale or test component

mTBI group

Mean (SD),

Median (IQR), or

% of subjects

Comparison group

Mean (SD), 

Median (IQR), or

% of subjects

p value for 

comparison

Magnitude of 

effect

st one additional AIS 

code

NSI Fatigue 1.85 (1.11) 1.51 (1.14) p = 0.009 NR

Sleep 2.73 (1.10) 2.15 (1.33) p < 0.001 NR

Blast exposure NSI Fatigue NR NR p < .002 NR

dache intervention 

ving sleep hygiene, 

n, headache and pain 

on, and group therapy

ESS --- 16.10 (0.28) 7.28 (0.34) p < .001 NR

NA NSI Fatigue 2.10 (1.11) NA NA NA

Sleep 2.72 (1.17) NA NA NA

population without 

with minor traumatic 

not involving the head 

oninjured volunteers 

m same population

Sleep hours per night < 4 6/47 = 13% 7/108 = 7% p = 0.21 for sleep 

hours overall

NR

hours per night ≥4 40/47 = 87% 99/108 = 93% p = 0.21 for sleep 

hours overall

NR

Sleep Change < 2 hour loss 10/47 = 23% 4/108 = 6% p = 0.02 for sleep 

change overall

NR

> 2 hour loss 33/47 = 77% 62/108 = 94% p = 0.02 for sleep 

change overall

NR

population without 

with minor traumatic 

not involving the head 

oninjured volunteers 

m same population

Sleep hours per night Median = 6 (5-7) Median = 6 (5-7) p = .22 NR

Sleep Change (negative 

value = hours lost)

--- Median = 0 (-2.5-0) Median = 0 (0-0) p < 0.001 NR

PCL score > 50 NSI Fatigue NR NR p < .002 NR

60 (controls had PCL-C 

≤30)

NSI Fatigue 0.86 (0.91) 2.60 (1.04) p < .0001 NR

Sleep 1.24 (1.17) 3.45 (0.70) p < .0001 NR

e neurological and/or 

sychological findings

NSI Sleep 5/46 = 11% 66/80 = 82.5% p < .001 NR

to Neurology clinic for 

headaches

NSI Sleep 2.53 (1.17) 2.78 (1.12) p = .11 NR

e population with 

derate/severe TBI

Sleep disturbance in 

the past 30 days

--- 2.72 (1.24) 3.17 (.75) p = .38 NR
106

c Brain Injury in Veterans and Military Personnel: A Systematic Review Evidence-based Synthesis Program

udies of U.S. Veterans and members of the U.S. military with mild TBI

mparison group description Outcome measure mTBI group % of subjects Comparison group % of subjects p value for comparison Magnitude of effect

opulation without 

mTBI

Lack of emotional support 

(% who responded ‘No’ to 

‘Do you have an emotional 

support system?’)

9/35 = 26% 6/35 = 17% p = .38 φ = .10

Marital status (Are you 

married?)

NR NR p = .72 φ = .04

comes in studies of U.S. Veterans and members of the U.S. military with mild TBI

omparison group description Outcome Measure

mTBI group

OR (95% CI) compared to 

non-mTBI control, 

% of subjects, or 

Mean (SD)

Comparison group

OR (95% CI) compared to 

non-mTBI control, 

% of subjects, or 

Mean (SD)

p value for 

comparison

Magnitude 

of effect

LOC Medical utilization: ≥2 “sick 

call” visits in past month

2.0 (95% CI 1.3-3.1) 1.9 (95% CI 1.04-3.6) NR NR

me population without mTBI; 

th minor traumatic injuries not 

olving the head and noninjured 

unteers from same population

Current Counseling 2/47 = 4% 4/108 = 4% p >0.99 NR

Current Mental Health 

Medication

2/47 = 4% 9/108 = 9% p = 0.50 NR

me population without mTBI; 

th minor traumatic injuries not 

olving the head and noninjured 

unteers from same population

Current Counseling 4/66 = 6% 5/146 = 3% p = .46 NR

Current Mental Health 

Medication

3/66 = 5% 8/146 = 6% p = .99 NR

me population with moderate/

severe TBI

Currently taking pain 

medications

24/44 = 55% 37/64 = 57% p = .44 NR

ame population without mTBI Length of Hospital Stay (days) PTSD: 13.6 (9.8) 

No PTSD: 19.0 (20.9)

PTSD: 16.0 (26.6) 

No PTSD: 14.1 (22.2)

NR NR

Length of Intensive Care Unit 

Stay (days)

PTSD: 2.0 (6.7) 

No PTSD: 12.1 (12.1)

PTSD: 1.6 (3.9) 

No PTSD: 2.8 (8.9)

NR NR

me population without mTBI; all 

participants had PTSD.

Number of medications 18 5 NR NR

ame population without mTBI Pain Medication (Narcotic) 32 (64.0%) 85 (72.6%) p = 0.264 NR
107

Complications of Mild Traumatic Brain Injury in Veterans

and Military Personnel: A Systematic Review Evidence-based Synthesis Program

APPENDIX F. LIST OF EXCLUDED STUDIES GROUPED BY 

REASON FOR EXCLUSION

Population does not meet criteria for adult, human subjects who are Veterans or members of 

the military from any country

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R REVIEW COMMENTS AND RESPONSES

Comment Response

 scope, and methods for this review clearly described?

Noted.

n the background of Executive Summary more rationale (e.g., 

standing OEF/OIF cohort vis-à-vis mTBI for planning etc). 

We have made this addition.

ing the criteria that were used for inclusion/exclusion at the 

document.

Due to space limitations, we have left reference to inclusion/exclusion criteria in the body of the report and appendices; however, this information will be presented earlier in the planned article publication of the results.

ore specific when mentioning comparison to controls (e.g., on 

y injured controls, postdeployed controls?)

We have included this information in the data abstraction tables.

Noted.

 review are clearly described. 

 review is clearly described. 

Noted.

k detail. Expectations for reporting methodological detail have 

ally over the past few years, and although this would expand the 

, I highly recommend that this be done. 

Noted. We have expanded this discussion.

ommend that the report follow the most recent PRISMA 

porting systematic reviews. I recognize that this is not primarily 

ument. However, adherence to the PRISMA guidelines would 

dibility of the review.

Noted. We have expanded our reporting to be in line with PRISMA guidelines as you suggest.

no online protocol was published, but if so, that should be 

We have updated this information in the report.

ria: The study designs included were mentioned. I have a few 

control studies are not listed in the inclusion criteria. Were case 

xcluded from the search? I assume that case series and case 

luded, but this is not explicit. Under the criteria “Timing: No 

 on timing” – my question – timing of what? Please clarify

Noted. Case control studies were not excluded. Timing has been updated to reflect time since injury. The inclusion criteria have been updated accordingly.

ources: This is well covered. However, if study authors were 

ditional information, this information should be included. If they 

ed, it is fine to leave the section as it is.

Correct – no authors were contacted for additional information about studies included in this review.
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Comment Response

ectronic search is included in appendix A. This is very good. Also, 

andard practice to clarify that the search was developed by a 

xperienced in database searches of this sort. It has also recently 

ended practice for a search strategy to be peer reviewed by a 

 Was this done? What measures were taken to ensure that the 

prehensive?

We have added this description of procedures.

n: This section is nicely detailed. Including the study selection 

ul. Other information to consider adding: What procedures were 

PI and the other reviewer disagreed on relevance at the point 

ning? What procedures were undertaken where the reviewers 

evance at the point of full article screening? A detailed definition 

d in Appendix C. This requires a Mild TBI to have normal CT/MRI. 

d in the methods section (or someplace else in the document) 

universally agreed upon criteria – many definitions of MTBI 

malities on imaging, differentiating these by classifying them as 

ncomplicated mild TBI. Of course it is important to adhere to the 

but it is a possible point of discrepancy from other criteria that 

tly noted.

Thank you. We have included this additional information in the updated report.

on: Good tables. It would be useful to have details about the data 

ess. It has become the standard to have at least two independent 

– was this done? Who did the data abstraction? How was this 

where data were missing or ambiguous in the report, were 

d? It would also be helpful to include study design in the tables.

We have updated the report with this additional information. We chose not to include study design in the tables because the designs were often inaccurately reported in the published studies and because all studies were observational in nature. Specific study design criteria related to quality/potential for bias were abstracted in the tables (e.g., sample selection, comparison group, etc.)

ment: In this section, you state that case control and case series 

uded. This should be consistent with the statement of study 

criteria. More details should be provided. Who did the quality 

 standard practice to have two independent quality assessments 

nd to report the procedures undertaken when there is no 

ality. How (specifically) was the assessment of quality used in 

s process? How specifically was this linked to rating the body of 

performed this linkage?

This discrepancy has been corrected. We have added this information.

have provided a reasonable way of grouping the studies and no 

s conducted – I see this decision as appropriate. However, details 

nthesis was conducted would be very good to add. This includes who 

nthesis, was this discussed in a larger group, were the conclusions 

working group, and what processes were used to reach agreement.

We have added this information.
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c Brain Injury in Veterans and Military Personnel: A Systematic Review Evidence-based Synthesis Program

Comment Response

 literature flow chart. This is very good. Noted.

well-formulated summary statements, and in your detailed 

you link findings to your citations. But it might also be useful to 

he particular studies in your summary statements as well. This is 

esent it as worth considering.

Due to the lengthiness of the report, we decided not to link findings to particular studies in the summary section. However, we linked findings in the results section to the citations of included studies should readers be interested in these specifics.

nkage between particular studies and their study quality 

more importantly, their assessed risk of bias. This does not 

y the need for an overall score, and the use of an overall additive 

widely criticized. But the reader should be able to see which 

 of which biases. There is some reference to overall study 

tions reporting summary of findings, but most recent standards 

 this be reported in a more study-specific way. When you say 

what specifically do you mean? I also wonder whether studies 

bias in their methodological quality can usefully contribute to our 

I in the military?

We have updated our description of study quality and risk of bias to specifically describe each study as being of low quality due to the high risk of bias. We have also provided additional cautionary, interpretive statements in the summary section related to the strength of evidence from a body of low quality studies.

ectional studies included in sections related to risk or prognostic 

no information provided about the restriction of study designs 

estions. Obviously, cross-sectional studies are appropriate for 

prevalence of symptoms, but not for making causal inferences 

ptoms. Could this be clarified in the report?

We have clarified the inclusion of various types of study designs, highlighted findings from the only prospective study, and noted limitations of interpretation based solely on cross sectional studies reporting association rather than causal inferences.

have done a good job in discussing limitations of the literature 

t section. Would it be useful to be even more specific about 

itations and Recommendations section? E.g., providing concrete 

ll bias; of incidence-prevalence bias (where it might exist), etc.

We have added additional discussion of these points.

Noted.

Noted.

ection of the Executive Summary is missing important 

ut inclusion/exclusion criteria and how quality and strength of 

. This latter point is particularly important as it makes it very 

eader to understand why the authors consider the strength of the 

ow. 

We have added this information to the executive summary section of the report.

r when the authors state that no clear pattern of risk and 

s emerge whether the studies were designed to look at risk and s.

We have noted this in the discussion.
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Comment Response

ve Summary Conclusions section (and elsewhere in the report) 

 to “objective results” (p.4). It would be helpful if they discussed 

re “objective” and what is meant by “objective”.

We have updated this section to describe results not based on self-report.

o me why the authors are including the headache intervention 

rticipating in a headache intervention a protective factor? What 

 protective factor? Do the authors mean that the sample referred 

ervention was different than those not referred? Why is that 

Qs? In general, the information presented on this particular study 

ughout the report and relevance is not clear.

We have clarified references to this intervention throughout the report.

o me why studies focused on biomarkers are included. I do not 

kers are “impairments” (KQ 1) according to any definition of 

 not see how biomarkers address either KQ2A (pre-injury factors) 

y factors) if they not include a focus on outcomes, given the way 

d. How does this study meet criteria for the outcomes listed on 

We agree and have moved information from this section to the discussion rather than including it in the evidence synthesis.

the mTBI definition column confusing. What do the authors mean 

at do the authors mean when they list “LOC, AOC and PTA” given 

 requires DOD/VA/ACRM definition of mTBI? A note to the table 

We have clarified this column label.

g tables summarizing strength of evidence per study. This 

rticularly important given the conclusions. It would also make it 

der to refer to specific studies when reviewing the report. In the 

nformation, it is difficult to interpret statements like, “Strength of 

s low because of ....”. If I missed something that was included in 

ogize.

We have clarified this information in the text of the report. All included studies were rated as low quality due to high risk of bias, without exception.

would have liked to see the pertinent studies referenced rather 

n addition to the number of studies listed in parentheses. 

 be as important as quality, in my opinion. Question based on 

dies find that mean scores for processing speed were within 

h possible exceptions of those getting C&Ps and <10 days since 

s is what the Table suggests, unless I am not reading it correctly.

We have referenced individual citations in the text, and due to the low quality rating of all included studies, have not identified individual studies or study quality in the table for reasons of space. You are correct in your interpretation of the presented information in the table.
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c Brain Injury in Veterans and Military Personnel: A Systematic Review Evidence-based Synthesis Program

Comment Response

hors make statements like “most research reported no significant 

 factors,” it would be helpful to know the number/percent of 

king at risk/protective factors.

We have noted this information in the discussion as an overall commentary on the body of literature given that only one included study was prospective in nature, and the rest were not designed to assess risk/protective factors. We have also clarified these sentences in the report to reflect studies of association rather than implying that studies were designed to assess risk/protective factors.

that readers who are not neuropsychologists will understand 

 are distinguishing between cognitive and physical health 

ample, it may not be clear why visuospatial abilities falls in the 

n but vision is in the physical health results section. It is not clear 

review “effort and motivation” at all. It is not clear why studies 

 are in the functional/social outcomes section. I suggest that the 

 describe the rationale for their groupings.

We have provided additional description of these decisions in the report.

tive Summary Limitation section, the authors state that the 

in the review relied on well-validated assessment tools. Are they 

SI as well-validated? Perhaps this statement can be more precise. 

We have made this statement more accurate and non-specific to individual tools. We refer to well-validated assessment tools being a strength of the overall body of literature, and report specific tools in the data abstraction. However, we did not to an individual literature search or other method of assessment to determine validation of each tool used in the included studies. We do also note limitations of some of the tools (e.g., the NSI) used to assess single-item, self-report outcomes.

ation and Costs: For this section, it does not make sense to 

cross Veteran and active duty samples given differences in the 

ms. I recommend that the authors clearly state which findings are 

ns using VA and which are specific to active duty.

We have added a clarifying statement noting that all included studies investigated Veterans.

Noted.

Noted.

ention cognitive “disability” as an outcome, but based on the 

ed in the literature, cognitive “deficits” may be a better term. The 

ng mental health outcomes could also be clarified. The objectives 

oms” but the operational definition is later given as diagnoses. 

ation of the measures in the studies included suggests that 

uld be the more accurate term.

We have changed the wording to “deficits.”

Noted.
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c Brain Injury in Veterans and Military Personnel: A Systematic Review Evidence-based Synthesis Program

Comment Response

escribed. Noted.

Noted.

ectives clearly described, but missing some information. 

cussion of how common features of mTBI, e.g. the presence of 

d multiple TBIs, were handled in inclusion criteria. 

We have clarified these criteria in the report.

” was a major factor in exclusion (p.14) but no further 

ided on how this criterion was applied.

Study relevance simply implies that the study must provide information included in the KQs and meet inclusion/exclusion criteria. No additional relevance criteria were applied.

s in discussion of physical and neuroimaging outcomes. The 

 by the key questions does not include imaging or biomarkers 

s not clear whether these topics were adequately searched 

search strategy presented. However, I am not familiar with the 

d formatting used to detail the search strategy, so this was a bit 

n explanation or reference would be helpful.

We agree and have moved the imaging/biomarker information to the discussion section and removed it from the results/evidence synthesis.

ment, scope is very large and each element (e.g. cognitive 

 the subject of a report.

Noted.

Noted.

es and methodology are sound. Noted.

Noted.

ing to: Key Question # 1:

vice Members who suffer a mTBI and develop acute and or 

e of mTBI symptoms what is the prevalence of health conditions 

ches, insomnia, vertigo, or seizure disorder), functional 

return to work/duty, marital status/family dynamics), cognitive 

 attention, concentration or memory) and or associated mental 

s ( e.g. PTSD, depression or anxiety disorder ). Key Question # 

ffect outcomes for Veterans/service members with mTBI? Key 

r Veteran/military populations, are there pre-injury (premorbid) 

 pre-injury mental health factors, genetic factors, or prior 

protective factors ??) that affect outcomes for mTBI? Key 

 Veteran/military populations, are there post-injury risk factors 

ession or anxiety) or protective factors that affect outcomes for 

We have changed the wording of the key questions slightly.Noted.
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c Brain Injury in Veterans and Military Personnel: A Systematic Review Evidence-based Synthesis Program

Comment Response

as in our synthesis of the evidence?

Noted.

Noted.

dication of bias, although it is always useful to discuss possible 

and how this might impact on the synthesis. However, a synthesis 

biased studies can bias a synthesis. Where studies were highly 

ty), can it be estimated what direction those methodological 

e biased the study’s findings? (toward or away from the null, for 

ay impact on the interpretation of study findings.

Noted. We have added these points to the discussion.

Noted.

Noted.

tes that TBI is THE leading cause of morbidity and disability in 

 believe that this is accurate. More important, one needs to 

een TBI history and TBI-related disability. The prevalence of 

ility is unknown and some evidence suggests that persistent 

y individuals who suffered TBI in OEF/OIF result from mental 

ties

Noted. We have changed the introductory paragraphs to better reflect these distinctions.

ummary Conclusions section, the authors state that “It is likely 

nce....is largely influenced by factors other than deployment 

g uniquely associated with mTBI.” They do NOT however describe 

is conclusion. This reviewer suggests that the authors clearly 

s based on the literature reviewed otherwise the sentence 

nion. The statement in the Executive Summary Conclusions 

e most likely exceptions are...evaluation linked with potential 

s particularly troubling as it seems to be based on the one study 

mpensation effects (#34). In the Executive Summary Limitation 

ors state “...self-reported deficits are more likely to persist for 

mTBI particularly when associated with compensation (p.40.” 

ment seems too strong if only one study (#34) reviewed looked at 

ffects unless that study was of very high quality

These conclusions are based on consistent findings across Veteran/military and civilian literature, though we agree that the conclusions could have been interpreted as basing conclusions on solely the Veteran/military literature, which would not have been warranted. These concluding statements have been tempered and clarified to more accurately reflect the results available from the body of literature.
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c Brain Injury in Veterans and Military Personnel: A Systematic Review Evidence-based Synthesis Program

Comment Response

ry and Discussion section the authors conclude, “The body 

gest that many health consequences resolve within the first 

wing injury, if not sooner” (p.49). I am not clear about what 

e using the draw that conclusion given the design of the studies 

ch specific studies/findings are the authors referring when they 

 cognitive impairment most often resolves within a few weeks 

 I suggest that authors be very clear about the findings and 

using to make that claim. That claim also seems to be in direct 

eir statement in the Background section that “TBI is the leading 

ty and disability...” It also contradicts the statement in the 

n/Costs that “The long-term resource needs of recent Iraq and 

 Veterans who sustained mTBI are likely substantial”. (p.52). Why 

e case?

We have clarified the studies on which these conclusions are based, as sometimes the quotes were in direct reference to the Carroll et al, 2004 review findings that we were summarizing. We have also tempered the introductory statements relating to the potential effects of TBI.

so state in Summary and Discussion, “This report documents that 

uation for compensation as being a risk factor...(p.49)” Is this the 

 one study referred to in multiple sections of this report (#34) or 

tudies? The basis for this statement was not clear to me.

This statement was in reference to findings from the Carroll et al, 2004 review, and this citation has been clarified.

Noted.

o with studies included versus excluded. Your criteria are clear 

e bottom of page 9, of which the DoD/VA criteria are one 

ition of those criteria. 

Noted.

nuscript includes studies that don’t meet that criteria because 

Noted.

rates and “unclassified” severity patients [Morrisette, Woodward, 

 201175, Schiehser, Delis, Filoteo, et al., 201135] or, 

Thank you for catching this error. Though this paper reports findings for the mTBI only group separately from those with moderate or unclassified TBI, the specific finding we reported in our review was a combined group finding; therefore, this study has been excluded.

e where TBI was not verified (“probably TBI) [Ruff, Riechers, 

232], or 

Though this paper reports some findings for a combined TBI group, the findings that we reported in this review are reported separately for the mTBI only group.

rently written in the tables, state criteria at variance to the DoD/

h as the GCS > 13 was used or GCS = 13 (when it should be > 13) 

per, Mercado, et al., 200821, Cooper, Mercado-Couch, Richfield, et 

You are correct that this was inaccurately stated in the table. It should be > 13, as reported in the article, and therefore these studies remain included.
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c Brain Injury in Veterans and Military Personnel: A Systematic Review Evidence-based Synthesis Program

Comment Response

ded, that in my view meet the DoD/VA criteria at least as well, 

n some of the included studies. Of course I am biased, but I’m 

tudies:

Noted. We have reviewed all the suggested studies and agree that they provide useful information; however, we have scoped the review to include a specific subset of papers meeting VA/DoD mTBI criteria, and the papers you suggest do not fit within those pre-specified criteria and are therefore not included in the review.

loeg RD, Curtiss G. Predictors of postconcussion symptom 

ommunity dwelling male veterans. J Int Neuropsychol Soc. Nov 

01-1015.

Reviewed, not included due to not meeting inclusion criteria.

 Belanger HG, Curtiss G. Mild traumatic brain injury and 

c stress disorder and their associations with health symptoms. 

ed Rehabil. Jul 2009;90(7):1084-1093.

Reviewed, not included due to not meeting inclusion criteria.

 Curtiss G, Belanger HG. Long-term neuropsychological 

lowing mild traumatic brain injury. J Int Neuropsychol Soc. May 

28-236.

Reviewed, not included due to not meeting inclusion criteria.

 Curtiss G, Duchnick JJ, Luis CA. Demographic, medical, and 

ctors in work and marital status after mild head injury. J Head 

abil. Mar-Apr 2003;18(2):148-163.

Reviewed, not included due to not meeting inclusion criteria.

OC is not reliable because individuals do not know if they actually 

mply a memory gap (i.e., PTA). Our studies used alteration of 

efined as “loss consciousness or ‘black out’”. That is, either a 

C or a self-reported Alteration of consciousness. It is possible, 

y, that my studies included a few folks who had moderate injuries. 

 the data was collected in the 1970s at which time those with 

han a mild TBI would be hospitalized overnight at least, and no 

italized. In addition, the bias come in because other studies were 

d moderate or “unclassified” TBI severity subjects. 

See above comments; we have re-reviewed all noted studies and the inclusion/exclusion criteria have been appropriately applied. Thank you for noting the possible discrepancies as one of the studies was inappropriately included in the first draft of the report and has now been excluded (Morrisette).

ld change findings, but my studies do address things the 

 have not been addressed – frequencies of different medical 

oms and psychosocial outcomes, as well as frequencies of 

cal impairments, in addition to comparison with an injury control 

ost other studies do not have) and controlling for comorbid or 

cal and mental health conditions.

See above response re: included studies.
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c Brain Injury in Veterans and Military Personnel: A Systematic Review Evidence-based Synthesis Program

Comment Response

findings of these studies have been replicated in a new sample 

t you would likely agree does meet the DoD/VA criteria for mild 

so not included, is:

D., Belanger, H.G., Horner, R.D., Spehar, A.M., Powell-Cope, 

cott, S.G., (2012). Health Outcomes Associated With Military 

d Traumatic Brain Injury, Blast, Trauma, and Combat Associations 

tional Guard. Archives of Physical Medicine and Rehabilitation, 

We have reviewed this study and it does not quite meet VA/DoD criteria, and therefore is not included in the review.

Noted.

studies is straightforward, but given the large number excluded, 

ul to summarize in the table of excluded studies, the specific 

sion. Without knowing how close these studies came to being 

ion in the paper, it’s difficult to assess whether the eligibility 

es may have incidentally introduced a bias. For example, are war

ore likely to be excluded than veteran samples due to contextual 

somehow limited the information gathered? I’m not suggesting 

bility criteria, but instead suggesting assessing potential 

” (for inclusion in the review) based on the possible identification 

istently associated with failure to use the DoD/VA definition.

We had similar concerns, and this was the rationale for including a table of studies meeting all inclusion criteria except for VA/DoD mTBI definition so that we were transparent about exclusions and readers could examine the list for possible bias in the included/excluded studies. We have also added a table of all the full-text study citations and exclusion codes. 

Noted.

bsent of bias, and was appropriately critical of the lack of 

ology, TBI severity description, and appropriate controls that 

 throughout the literature on TBI in U.S. service members and 

Noted.

Noted.

 introduced biases that should be discussed. Use of VA/DoD 

could time-limit the literature to after 2007; indeed, all included 

m within the last 3 years. These criteria may also limit to military 

 researchers and to US researchers. It is possible that exclusion of 

 reporting of LOC and PTA led to unnecessary loss of data, as the 

ese is usually based on self-report and is unreliable. 

We agree that any scoping decisions, this one included, introduce potential for bias. This decision was agreed upon by stakeholders for this review in order to obtain the most accurate description of a specific population of interest: Members of the US military/Veterans with mTBI meeting VA/DoD criteria. Therefore, though the report is limited in these ways, the stakeholders agreed that other, broader reports (e.g., the Carroll et al, 2004 WHO mTBI report) could address broader/different questions. In response to your comment, we have broadened the discussion of this point in the discussion.
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c Brain Injury in Veterans and Military Personnel: A Systematic Review Evidence-based Synthesis Program

Comment Response

 for an mTBI sample size of at least 30 will bias the type of 

es that are used. Because of expense and other limitations, few 

udies will fulfill this requirement. Large studies can be limited in 

form in-depth testing, and so the report may be biased toward 

estionnaire data and easier-to-administer testing protocols (e.g. 

ning measure designed for dementia). Large studies also may 

resentation of individual results, which as you note, can be 

 objective evaluations of physical outcomes (e.g. audiology) were 

severely limits interpretation of this domain.

We agree, and have moved the neuroimaging information to the discussion section because of the likelihood that it is not comprehensive since we did not design the search to focus on these outcomes. We have also now added a table of excluded studies so that authors can review studies that were excluded based on sample size to gather additional information as needed.

ved as sources across outcome domains (e.g. Nelson et al., 

 potentially perpetuate any biases or limitations present in the 

ss domains (e.g. recruitment setting, inadequate power).

We agree and have noted this limitation in the discussion.

Noted.Noted.Noted.

npublished studies that we may have overlooked?

Noted.

ck, & Yan, 2012 (published in Work) This study does not meet our inclusion criteria because of 

unclearly reported definition of mTBI and because results are not reported separately for those with mTBI versus moderate/severe TBI.

Noted.

nk of. Noted.

Noted.

nalysis of US Veterans Health Administration comprehensive 

raumatic brain injury in Operation Enduring Freedom and 

reedom Veterans. Brain Inj 2012

We have reviewed this study and it does not meet inclusion criteria due to the mTBI definition used to define the cohort of participants.

Noted.

s reviewed the CBO report: The Veterans Health Administration’s 

SD and Traumatic Brain Injury Among Recent Combat Veterans?

We have reviewed this report and agree that though it provides important information and guidance, it does not meet our criteria for inclusion in this review.

Noted.
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c Brain Injury in Veterans and Military Personnel: A Systematic Review Evidence-based Synthesis Program

Comment Response

D., Belanger, H.G., Horner, R.D., Spehar, A.M., Powell-Cope, 

cott, S.G., (2012). Health Outcomes Associated With Military 

d Traumatic Brain Injury, Blast, Trauma, and Combat Associations 

tional Guard. Archives of Physical Medicine and Rehabilitation, 

We have reviewed this study and agree that though it provides important information, it does not meet VA/DoD mTBI definitional criteria and is therefore not included in this review.

Noted.

e, the report captures all of the military/military veteran studies. 

discussion of meta-analytic studies from the civilian literature, it 

ant to balance the discussion with the Pertab et al., meta-analysis 

data from previous meta-analytic studies and reveals a potential 

rior findings.

This review has been added to the report.

Noted.

y come out with a TBI sensory and communications disorders 

ssue 7, 2012). Even though this journal is published after Oct. 3, 

les cover deployment-related experiences (e.g., blast, TBI), and 

 the following senses, conditions, and patterns: vestibular, visual, 

TSD, and referrals. This compendium fits well with the focus of 

Thank you for this suggestion. We have reviewed all studies from this special issue none meet criteria for inclusion in this report.

studies that were not included, though would be excluded for 

BI criteria, are:

., Hendricks, A., Kimerling, R., Krengel, M., Meterko, M., Stolzmann, 

Pogoda, T.K., Vasterling, J., & Lew, H.L. (2011). Psychiatric diagnoses 

havioral symptom severity among OEF/OIF VA patients with 

related TBI. Women’s Health Issues, 2(4S), S210-S217.

We have reviewed this study and agree that though it provides important information, it does not meet VA/DoD criteria and is therefore not included in this review.

aft, M., Pogoda, T.K., Amick, M.M., Woods, P., & Cifu, D.X. (2011). 

nd Characteristics of Driving Difficulties in Operation Enduring 

eration Iraqi Freedom Combat Returnees. JRRD, 48(8), 913-926. 

We have reviewed this study and agree that though it provides important information, it does not meet VA/DoD criteria and is therefore not included in this review.

goda, T.K., Baker, E., Meterko, M., Stolzmann, K.L., Cifu, D.X., 

& Hendricks, A.M. (2011). Prevalence of dual sensory impairment 

iation with traumatic brain injury and blast exposure in OEF/OIF 

urnal of Head Trauma & Rehabilitation, 26(6):489-96.

We have reviewed this study and agree that though it provides important information, it does not meet VA/DoD criteria and is therefore not included in this review.

M, Amara J, Baker E, Charns MP, Gardner JA, Iverson KM, et al. 

eening for mild traumatic brain injury in OEF-OIF deployed US 

empirical assessment of VHA’s experience. Brain Injury

We were not able to obtain a copy of this study for review.

Noted.
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c Brain Injury in Veterans and Military Personnel: A Systematic Review Evidence-based Synthesis Program

Comment Response

010. Comparison of Concussive Symptoms, Cognitive 

d Psychological Symptoms Between Acute Blast-Versus 

d Mild Traumatic Brain Injury. Journal of the International 

cal Society (2011), 17, 36–45.

We reviewed this study and it did not meet inclusion criteria.

9 Traumatic Brain Injury Screening: Preliminary Findings in a US 

mbat Team. J Head Trauma Rehabil Vol. 24, No. 1, pp. 14–23.

We reviewed this study and it did not meet inclusion criteria.

0 The Structure of Postconcussive Symptoms in 3 US Military 

Trauma Rehabil Vol. 25, No. 6, pp. 447–458.

We reviewed this study and it did not meet inclusion criteria.

9. Eye and visual function in traumatic brain injury. J Rehab 

ume 46, Number 6, 2009 Pages 811–818.

We reviewed this study and it did not meet inclusion criteria.

ne, 2011. Head Injury and Blast Exposure: Vestibular 

Otolaryngol Clin N Am 44 (2011) 323–334.

We reviewed this study and it did not meet inclusion criteria.

12. Multisensory Impairment Reported by Veterans with and 

tic Brain Injury History. J Rehab Research Dev Volume 49, Number 

.

This study has been included in the report. Thank you for the suggestion.

2012. Neuropsychological outcomes of mild traumatic brain 

matic stress disorder and depression in Iraq-deployed US Army 

hiatry 201, 186-192

We reviewed this study and it did not meet inclusion criteria.

2012 Altered brain activation in military personnel with one 

tic brain injuries following blast. J Int Neuropsychol Soc. 2012 

We have moved the discussion of imaging and biomarkers to the discussion section of the report since it falls outside the scope of our key questions.

2 Effects of chronic mild traumatic brain injury on white matter 

nd Afghanistan war veterans. Hum Brain Mapp. 2012 Jun 15

We have moved the discussion of imaging and biomarkers to the discussion section of the report since it falls outside the scope of our key questions.

t al.,2011. Neuroimaging Correlates of Traumatic Brain Injury and 

r J Head Trauma Rehabil Vol. 26, No. 4, pp. 276–289

We reviewed this study and it did not meet inclusion criteria.

 Evidence of disrupted functional connectivity in the brain after 

blast injury. NeuroImage 54 (2011) S21–S29

We have moved the discussion of imaging and biomarkers to the discussion section of the report since it falls outside the scope of our key questions.

11. Cerebrocerebellar hypometabolism associated with repetitive 

ild traumatic brain injury in 12 Iraq war Veterans with persistent 

symptoms. NeuroImage 54 (2011) S76–S82.

We reviewed this study and it did not meet inclusion criteria.

y that have been excluded that meet criteria for inclusion. Please 

ing Vision data.

Noted.Noted.
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c Brain Injury in Veterans and Military Personnel: A Systematic Review Evidence-based Synthesis Program

Comment Response

Relationship between mechanism of injury and neurocognitive 

EF/OIF service members with mild traumatic brain injuries. Mil 

77(10):1157-60.

This study has been included in the report. Thank you for the suggestion.

 Analysis of US Veterans Health Administration comprehensive 

raumatic brain injury in Operation Enduring Freedom and 

reedom Veterans. Brain Inj. 2012;26(10):1177-84. 

We have reviewed this study and it does not meet inclusion criteria due to the mTBI definition used to define the cohort of participants.

oss of Consciousness, Depression, Posttraumatic Stress Disorder, 

Among Deployed Military Personnel With Mild Traumatic Brain 

uma Rehabil. 2012 Oct 16. 

This study has been added to the included studies for this report. Thank you for the suggestion.Noted.

 call you had mentioned that another group (I believe IOM) was 

ew of mTBI literature. It would be helpful to note this since non

were not included in the literature review and could have been 

 the comparison to the Veteran based studies.

Agreed. The WHO group lead by Dr. Linda Carroll is updating the 2004 mTBI prognosis review, and we have included this information in our report for reader reference.

gestions or comments below. If applicable, please indicate the page and line numbers from the draft report.

se define “old learning.” More specificity in general would be 

ample, for ‘memory studies’, were delayed recall, trial-by-trial 

tion all examined? On page 48 in the summary of results, to what 

roups were mTBI compared? On page 53, suggest adding the 

s as a future area for investigation. On page 54, suggest being 

e use of the word “persistent” since it is unclear if symptoms 

gitudinal sense.

We have changed “old learning” to be “language abilities and general fund of verbal knowledge.” We have included additional information on specific tests and on comparison groups in the appendix tables. We have added a statement in the discussion relating to future research of the number of TBIs. We have clarified and limited use of the term persistent throughout the report.

other reviews are cited, it would be useful to explicitly indicate 

were published, since early systematic reviews might simply be 

udy citation is included, of course, but inclusion of the year of 

e body of this section would highlight that point.

We have included the year in text in this section.

ent evidence review. Noted. Thank you.

hasized for all domains that major shortcomings in the literature 

on-mTBI comparison groups and lack of adequate pre-mTBI 

.

Agreed, and we have added this point to the discussion.

ntal disorders, some controlled civilian studies do show higher 

isorders after mTBI compared with non-TBI controls (e.g., 

Gen Psychiatry 2004). Presence of prior psychiatric conditions 

ctor. Data from this same cohort showed higher health care 

g those with mTBI compared with non-TBI controls (Rockhill et al, 

012).

We have clarified that some civilian literature indicates higher rates of mental disorders after mTBI, as noted in the Carroll et al 2004 review.
139

c Brain Injury in Veterans and Military Personnel: A Systematic Review Evidence-based Synthesis Program

Comment Response

pecific comments about organization and note some areas 

 used where not clear to me. Please disregard if not helpful in 

 the report.

Thank you for the suggestions. Some will be included in this report, though some will be included in the planned article publication rather than in this full report.

the authors orient the reader at the beginning to their overall 

marizing the findings. It took this reviewer a few reads to 

the authors were presenting the material. It was a bit confusing 

e summary before the sections describing findings per domain 

 cognitive functioning in general before description in each 

n). Sometimes the summaries seem completely unnecessary 

e study is reviewed. In general, there was considerable repetition 

ructure of this report, which made the report difficult to read. 

eads to know what is new information versus a restating of what 

 summarized. 

Because some parts of this report are purposely repetitive (e.g., the executive summary), we plan to make the suggested change for the published article.

suggests the authors state reason time since injury is important 

ming the reader already has this information. 

Noted, and this has been added.

ader understand the “cognitive function” section, I suggest the 

eader that x# studies are based on neuropsychological testing 

n. It would be helpful to have an appendix in which the function 

es is described – otherwise, I am not sure how helpful it is to list 

yms in Appendix E. I did not find it useful to have the names of 

 the text – in fact, I think it makes the narrative harder to read. 

We have made some of these changes, including shortening the acronyms listed in the results section of the report.

ry of Findings for Cognitive Function Results the author state 

ed scores are scores associated with impairment below a certain 

t quite right and I do not think the sentence expresses what they 

We have corrected this sentence.

when the authors state that risk factors include “LOC and PTA” 

 that they are using the DoD/VA/ACRM definition of mTBI. As 

?

We have clarified that LOC and PTA were compared to just alteration of consciousness.

ore accurate on p.39 to state that the PCL scores suggest clinically 

oms rather than “impairment” as stated in the report

We have chosen to use the term impairment across measures to use similar terminology describing scores above a clinically significant cutoff.

 sequelae” as used here is confusing. For example, on p. 28 

 that one study reported “...based on mTBI with LOC and PTA 

se with mTBI who did not have these immediate sequelae.” What 

If these individuals did not have these “sequelae”, how was mTBI 

s is probably a matter of simple clarification.

We have changed this sentence to clarify.
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c Brain Injury in Veterans and Military Personnel: A Systematic Review Evidence-based Synthesis Program

Comment Response

Conclusions: This section is largely devoted to discussion of the 

. The subsection on Physical Health Outcomes (p.49) does not 

Veteran/military studies. I suggest switching the focus so that the 

y discuss the literature they reviewed for this report.

Noted. We have updated the physical health section to focus the discussion on a comparison.

e that references are used inconsistently. Why are there no 

e summaries? Why are the “one study” referred to on p. 26 and 

es” on .34 not referenced What are the “some studies” (p.30 

r cognitive function for those not evaluated in forensic settings? I 

as just one study that examined this issue (#34). In some sections, 

 to identify which studies are forming the basis of the authors’ 

Noted. We have made the suggested corrections to text. The format for this report is such that summaries do not contain citations; however, citations will be used consistently throughout the published article.

SD is an AXIS I disorder (p.35). I do not understand the statement, 

many individual studies...general association between specific 

tcomes with other mental health diagnoses and symptoms”.

We have clarified that some studies looked at only PTSD, some examined “any Axis I disorder” which would include PTSD. We have clarified the confusing sentence.

 made without any supporting reference, that I do not believe the 

ports. 

 the leading cause of morbidity and disability among OEF/OIF 

ers.” I’m not sure about “morbidity” (but I think chronic pain and 

 are higher), but I’m quite sure there is no evidence to support 

” claim. This statement is repeated several times throughout the 

This has been corrected throughout the manuscript.

 (and elsewhere) “One or more studies have found . . . [problems 

riencing loss or alteration of consciousness at the time of the 

ms to me that everyone included in every study meets this criteria 

s the criteria for TBI. So, that statement it seems problematic. If 

 all subjects with an immediate event-related “loss or alteration 

ess” how can “loss or alteration of consciousness at the time of 

nique factor?

We have clarified that this refers only to patients who have PTA but not LOC or AOC, as described by the primary study authors.

ewhere): If you include my studies (or the one you inadvertently 

use it was recently published), the statement “Similar to objective 

lts, prevalence of self-reported cognitive deficits was not 

e included studies” would be inaccurate.

We have updated all summary statements to reflect the final list of articles meeting inclusion criteria.
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c Brain Injury in Veterans and Military Personnel: A Systematic Review Evidence-based Synthesis Program

Comment Response

atement “. . . self-reported deficits are more likely to persist for 

th mTBI” is inaccurate. There is a difference between “persistence 

 and “symptoms reported in the chronic phase” which may come

-and-wane. Studies have not demonstrated persistence. What 

monstrated is problems/symptoms reported in the post-acute 

ase. The studies do not document that these began at the time 

nd persisted over time to the time of assessment. Other civilian 

rly documents that symptoms and problems are not persistent, 

t they come-and-go or wax-and-wane, but are generally higher in 

mild TBI subjects. We don’t know if they were also higher prior to 

ut we do know that they are not persistent. 

We have made this change throughout the report.

guage and Old Learning” is a term no one uses, and as a result 

nitially I thought you were referring to “Verbal Learning and 

ould suggest using the term “Language Abilities and General Fund 

wledge” or something like that. 

Thank you for this suggestion. We have made this change.

e review you refer to “statistical significance” or lack thereof. 

ct size would seem to better capture the important issue. If 

re somewhat small (or there are is lot of variability across 

 moderate effect size could be non-significant, but a moderate 

uld be clinically important. 

We agree entirely. We report effect sizes in the tables whenever available; however, authors frequently did not report effect sizes or data with which effect sizes could be calculated.

 to that above, is that studies may compare a mild TBI group 

TBI control group and find differences (as some studies did). 

se two groups may differ on other important factors as well that 

group differences (e.g., education, race, age, degree of comorbid 

 or medical health conditions). It seems to me that you would 

ss this issue if you can for those studies that reported group 

n example of this is on the bottom of page 26. 

Agreed. We highlighted any statistical adjustment or other adjustment for variation across groups in the text and tables; unfortunately, most studies did not provide this information, and this lack of adjustment for potential confounders is a contributing factor to the low study quality ratings for this body of literature.

erm “associated with mTBI” is used in talking about mental 

ers and symptoms. This implies some actual association, when it 

that they are simply comorbid factors both due to deployment

-related) experiences that are risk factors for both mTBI and 

ntal health conditions.

st using the term “comorbid” rather than “associated”.

We have made this change to the paper.
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c Brain Injury in Veterans and Military Personnel: A Systematic Review Evidence-based Synthesis Program

Comment Response

g mean cognitive performance scores are criticized within 

se they cannot provide prevalence estimates of impairment. 

plication that report of percentage of participants scoring 

ment cut-off or below a certain standard score would yield a 

 estimate of cognitive impairment does not take into account 

ognitive abilities of participants. Clinically relevant cognitive 

pically thought of as an intra-individual decline. Scores normally 

ow average may not indicate acquired impairment but instead 

e potential of the individuals; similarly, above average scores 

ognitive decline (i.e., impairment) in an individual with superior 

al. Thus, the suggestion in the report does not go far enough. To 

e prevalence of cognitive impairment following a TBI, prospective, 

surement would be necessary. This is typically not feasible, 

ould nevertheless avoid implications that use of normative 

ard to the individual’s baseline potential would yield accurate 

ates of cognitive decline. The paper states this in the Summary 

ection, but it is also important to mention it earlier when 

rment cut-offs based on standardized scores.

Noted. We have included this discussion both within the section on cognitive outcomes, and within the discussion section.

ts: The synthesis was very well written and took a comprehensive 

mining the extant literature on mTBI in U.S. service members 

 synthesis was inconsistent with respect to its use of citations 

ts repetition of acronyms and abbreviations. Other editorial and 

ments (line numbers not included in reviewed drafts):

Noted. Thank you.

 OEF/OIF should be defined. Also, what about OND? This change has been made. No studies reported outcomes 

for OND Veterans and the information we describe in the background is specific to OEF/OIF Veterans.

efine WHO This change has been made.

 PTA This change has been made.

uction of NSI – Neurobehavioral Symptoms (no S) Inventory This change has been made.

ast paragraph, two instances of “reported that” – delete one This change has been made.

ast paragraph – “mTBI).” ß no reference to an open parentheses, 

This change has been made.

MRI This change has been made.
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c Brain Injury in Veterans and Military Personnel: A Systematic Review Evidence-based Synthesis Program

Comment Response

ph: the recommendation to include imaging results is noted; 

recommendation is not feasible in terms of equipment, 

cipant willingness to participate (might lead to biased self

g, and costs. This recommendation also needs to be reconciled 

 Clinical Practice Guidelines (see excerpt below). Though, the 

at if imaging studies, especially functional fMRI or DTI, were 

 frequently, then perhaps there would be notable distinctions 

l” and “mild TBI” states.

. 16)

Noted, and we have changed this recommendation slightly to be more consistent with this comment.

ditional imaging studies, other imaging techniques such 

gnetic resonance imaging, diffusion tensor imaging, 

n tomography scanning; electrophysiological testing such as 

ography; and neuropsychological or other standardized testing 

been used in the evaluation of persons with TBIs, but are not 

e currently accepted criteria for measuring severity at the time of 

outlined in Table A -1

Noted, and the criteria presented are consistent with the VA/DoD criteria.

ble: There were some abbreviations throughout the text that 

ly” defined before their first use, so these are included along 

AOC = Alteration of consciousness/mental state 5 (based on 

es) p.5; (b) BAMC (last row) = Brooke Army Medical Center, 

Compensation & Pension , p. 21; (d) CTE = Chronic Traumatic 

 p. 10; (e) EFP = Explosively formed penetrator (?) – used on p. 17 

AS – “symptoms” misspelled, p. 6; (g) NSI = I = Inventory, p. 6; (h) 

estigator, p. 9 (or just say “Principal Investigator on p. 9); (i) VHA = 

Administration (like on p. 8), p. 7; (j) For SCID, indicate Axis I, not 

efine/include VACO and PM&R, as introduced on p. 8; (l) define 

entioned on p. 8)

These changes have been made.

dies from which the “12 to 23 percent” are derived. Also 

endricks et al. (in press, Brain Injuries), who examined VA 

TBI evaluation (CTBIE) data and found: “In the study population, 

positive for potential TBI and 54.6% of these had an electronic 

. Of those with CTBIE records, evaluators confirmed TBI in 57.7%, 

stimate that 6.8% of all those screened were confirmed to have 

This citation has been added.

agraph: “fame” should be “frame” This change has been made.
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Comment Response

agraph: “factors unique to combat deployments.” I would take out 

e replace with “military,” but not sure if that’s necessary), since 

ted conditions (e.g., noise in the general military environment), 

mbat, may uniquely account for experiencing post-concussive 

since women are restricted from some combat roles, the use of 

may minimize what women potentially experience.

This change has been made.

semi-colon in second paragraph, This change has been made.

Veterans Health Administration” as VHA; This change has been made.

R and VACO This change has been made.

gy – can now call it “mTBI” This change has been made.

ph – why not include “post-traumatic amnesia” along with AOC, 

This change has been made.

aph, discussion about “severity of sequelae” gets a little 

se TBI sequelae can be defined as either AOC, LOC, or PTA (which 

 be primed for, since there was just discussion about these in 

tence), or TBI residual symptoms (e.g., headache, vestibular, 

sual, etc. impairment). I don’t know if “the Severity of sequelae” 

o be here, but I understand that it makes the point that very 

re used to categorize TBI severity, and it’s important to note that 

ental/physical symptoms following a TBI event are not used to 

I would replace “sequelae” with “symptoms,” and then provide a 

toms to orient the reader. It might also be helpful to briefly state 

 on the duration of LOC, AOC, or PTA. You can then list the criteria 

in), or refer to the reader to a more detailed description, as you 

This change has been made.

D in first paragraph This change has been made.

TE in “Outcomes” paragraph This change has been made.

ullet points in the last box to the right would help the criteria 

We left out bullet points for space reasons.

rnes et al., spell out “medical” We have corrected this mistake.

Mercado-Couch, et al. – BAMC should be defined earlier (e.g., 

al. citation above it in the table); Should American “College” be 

s not clear about 10 participants excluded due to PTA suggesting 

BI... Is it that the duration of PTA was longer than the criteria for 

d by ACRM?

This change has been made.
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Comment Response

define “C and P,” also, in mTBI definition, why not just call it 

This change has been made.

al., American College or Congress?; defined “EFP,” as previously 

This change has been made.

l., Time since Injury – define unit of time. This change has been made.

eal et al., last column, just say MVA instead of spelling it out This change has been made.

 et al., use “TBI” consistently – sometimes it’s spelled out (see 

mns)

This is a quote so it is spelled out as in the original text.

et al., spell “through,” not “thru.” This change has been made.

l., reference 34: define what “forensic” context is. This change has been made.

Based on “VA”/DoD Consensus definition (reversed as written). This change has been made.

rs et al., “Department of CVAMC” needs editing; also, in 

hree groups of Veterans, for the first two indicate “deployment

ot sure what “combat Veterans without “LOC” means – is this a 

did they have AOC or PTA?; In the mTBI definition column, not 

finition is referring to – did Veterans have to have LOC or AOC 

, PLUS PTA?

These changes have been made.

t al., mTBI definition column – delete © This change has been made.

al., C&P needs to be defined earlier This change has been made.

 Combat Veterans diagnosed, not “diagnoses” This change has been made.

l., mTBI definition column – use DVBIC acronym This change has been made.

ast paragraph – can abbreviate LOC and AOC – make clear, if this 

participants demonstrated better overall cognitive functioning 

on?”

This change has been made.

ar in 2nd to last paragraph – second line: Should this be “NOT” 

uld “NOT” be deleted?

We have clarified this sentence.

 speed row, Key Question #1 column, not sure why “possible” 

re – delete that word?

This change has been made.

aph – could you cite the 7 studies here? We are providing summary paragraphs without citations for 

each section, which are followed by the cited results sections by key question. This will be consolidated for the published article version of the report.
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c Brain Injury in Veterans and Military Personnel: A Systematic Review Evidence-based Synthesis Program

Comment Response

aph, 2nd line, instead of “with” TBI, replace “with” with 

 indicate “with mTBI history.” Also make this correction in Key 

graph, first line.

This change has been made.

al abilities, first sentence, cite the 5 studies here. We are providing summary paragraphs without citations for 

each section, which are followed by the cited results sections by key question. This will be consolidated for the published article version of the report.

agraph: Just give the abbreviations/acronyms, no need to spell 

ychological test names.

This change has been made.

aph, 3rd line: instead of saying “significant correlations,” indicate 

ce it seems like visuospatail abilities and MH conditions would be 

ated.

This change has been made.

ory” paragraph, mid-way through, again report direction of 

This change has been made.

on 1 paragraph: just report abbreviations This change has been made.

on 1 paragraph, 5th from last row, use “longer” instead of “much 

This change has been made.

ast row, use (C&P) for compensation and pension, since this 

 introduced previously.

This change has been made.

ph, second from last row: Use LOC and PTA instead of spelling 

This change has been made.

Concentration paragraph, cite the 7 studies after mentioning 

We are providing summary paragraphs without citations for each section, which are followed by the cited results sections by key question. This will be consolidated for the published article version of the report.

Concentration paragraph, last line can read “....OR PTSD was not 

ciated with outcomes.”

This change has been made.

on 1 paragraph, do not spell out neuropsychological test names. This change has been made.

aph, “forensic” mentioned a couple of times – define what exactly 

This change has been made.

aph, indicate direction of associations; do not spell out LOC, PTA This change has been made.

on 1 paragraph (here the 9 studies are cited, very helpful!); , do 

ropsychological test names.

This change has been made.
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c Brain Injury in Veterans and Military Personnel: A Systematic Review Evidence-based Synthesis Program

Comment Response

estion 2 paragraphs for each page, can say C&P instead of spelling 

no need to define what a C&P evaluation is here, define it when 

This change has been made.

vation paragraph – regarding “with mTBI,” see comment #41 This change has been made.

on 2 paragraph, see comments #56, 58 This change has been made.

on 1 paragraph, do not spell out neuropsychological test names. This change has been made.

on 1 paragraph: There is discussion about “non-mTBI” 

e these participants who never experienced a TBI (non-mTBI 

o not currently have mTBI (symptoms resolved?)

This has been clarified

on 2 paragraph: compensation and pension evaluation can be 

This change has been made.

ed Cognitive Problems paragraph. I’m wondering if “service 

uld be considered a “risk factor,” as it’s really a proxy for a 

hat was sustained or aggravated during military service. The point 

vice connection” is a short-hand for the latter, so this might be a 

tics.

Agreed, and this is how it is described in the primary study.

– instead of saying “control,” say “control group.” This change has been made.

of Physical health results first paragraph – it would be helpful to 

es here.

We are providing summary paragraphs without citations for each section, which are followed by the cited results sections by key question. This will be consolidated for the published article version of the report.

of Physical health results first paragraph – to be consistent, 

rom time-since-injury.

This change has been made.

om last paragraph, no need to spell out NSI – already introduced. This change has been made.

first row, similar to comment 63, “referral to neurology clinic 

s listed as a risk factor, but is likely a proxy for headache 

cy. Again, this might just be a matter of semantics and readers 

he implication. Without reviewing the article, not sure if any 

ven for why a patient might be referred to a neurology clinic, so I 

this might be the only unit of measurement.

Agreed—and this is how it was described in the primary study.

ome articles from JRRD 49(7) would be relevant here (if you 

e frame of your search)

We have added these articles.

graph – when describing the pain level scale, please provide 

ain at all?) to 10 (very severe pain?) scale.

This change has been made.
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c Brain Injury in Veterans and Military Personnel: A Systematic Review Evidence-based Synthesis Program

Comment Response

raph for “Headaches,” last line about referral to neurology clinic 

ee comment #68.

Noted.

tion 1 paragraph – here, the 9 studies being alluded to are 

od!).

“NSI” here, no need to spell it out.

This change has been made.

tion 2 paragraph: Provide more detail in the first sentence – 

ps being compared

This change has been made.

tion 2 paragraph, last sentence – see comment #68. Noted.

aragraph: cite the one study being discussed We are providing summary paragraphs without citations for 

each section, which are followed by the cited results sections by key question. This will be consolidated for the published article version of the report.

Appetite” first paragraph - cite the specific studies you highlight, 

y describing mild to moderate effects of mTBI population, PTSD 

sults study

We are providing summary paragraphs without citations for each section, which are followed by the cited results sections by key question. This will be consolidated for the published article version of the report.

mary of Mental Health Results section – cite the studies where you 

es, two studies, PTSD, alcohol abuse, etc.

We are providing summary paragraphs without citations for each section, which are followed by the cited results sections by key question. This will be consolidated for the published article version of the report.

e comment #68 Noted.

tions, 17 studies are alluded to in the first paragraph, and then 

n the Key Question paragraph, and then cited. Just make sure 

ncy between the sections throughout the report in terms of when 

Noted.

estion 2, could you add specifics? For example, for study #27, 

ociation between the PCL re-experiencing cluster and blast

This change has been made.

nxiety paragraph, cite the studies that are being alluded to. We are providing summary paragraphs without citations for 

each section, which are followed by the cited results sections by key question. This will be consolidated for the published article version of the report.

tion 1 – just say “NSI” This change has been made.

tion 1 – abbreviations This change has been made.
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c Brain Injury in Veterans and Military Personnel: A Systematic Review Evidence-based Synthesis Program

Comment Response

e Use disorders first paragraph – cite studies alluded to We are providing summary paragraphs without citations for 

each section, which are followed by the cited results sections by key question. This will be consolidated for the published article version of the report.

st paragraph - cite studies alluded to We are providing summary paragraphs without citations for 

each section, which are followed by the cited results sections by key question. This will be consolidated for the published article version of the report.

ntal Health Outcomes first paragraph – cite studies alluded to We are providing summary paragraphs without citations for 

each section, which are followed by the cited results sections by key question. This will be consolidated for the published article version of the report.

ntal Health Outcomes first paragraph – aren’t “frustration” and 

e NSI affective cluster (e.g., Meterko et al., 2012, Journal of Head 

ation, 27(1), 55-62 Psychometric assessment of the Neurobehavioral 

ry-22: the structure of persistent postconcussive symptoms 

ment-related mild traumatic brain injury among veterans.)

Yes, and we would consider these part of the mental health related outcomes section for this report.

on 1 – abbreviations This change has been made.

on 1, second to last sentence – period before 12,20 citations. This change has been made.

 of functional/social outcome results: cite studies alluded to We are providing summary paragraphs without citations for 

each section, which are followed by the cited results sections by key question. This will be consolidated for the published article version of the report.

 of functional/social outcome results – make clear throughout 

hether patients with mTBI, patients without mTBI, or results 

both groups are being discussed.

This change has been made.

oduction paragraph – what are “positive neurological findings?” This change has been made.

 Question 1 – abbreviations This change has been made.

sults” paragraph: Throughout the paragraph, the word 

ed several times. I think a better word here would be “exhibiting.”

This section has been removed and edited.

on 1: Abbreviations This section has been removed and edited.

on 1: I found the first sentence difficult to follow – please add 

punctuation and clarifying language.

This section has been removed and edited.

tion 2: the tense was different in this paragraph than in others. 

tead of “obtain.”

This section has been removed and edited.
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c Brain Injury in Veterans and Military Personnel: A Systematic Review Evidence-based Synthesis Program

Comment Response

 of service utilization/costs results: Please cite studies alluded to. We are providing summary paragraphs without citations for 

each section, which are followed by the cited results sections by key question. This will be consolidated for the published article version of the report.

tion 1: Table X = Table 7? This change has been made.

al health outcomes, it’s acknowledged that PTSD is a focus for 

I’m wondering if this section could be rounded out by also 

other mental health conditions that are typically of interest: 

PTSD anxiety, and substance use disorders? As a starting point, 

lister has published on mild TBI in civilian populations and its 

, cognitive, mental health conditions; Silver JM, McAllister TW, 

epression and cognitive complaints following mild traumatic brain 

hiatry. 2009; 166: 653-61.)

Agreed, and due to space limitations, we provided an expanded discussion of PTSD at the request of our stakeholders, but have not provided an expanded discussion of other outcomes, instead referring readers to other reviews and studies.

raph of the MH Outcomes section: instead of “causal factors,” 

erm “event-related?”

This change has been made.

ot Surprisingly” paragraph, cite the “aforementioned” literature 

 last sentence of this paragraph, it might be more clear to say, 

BI versus other factors, such as those that are deployment

clear.”

This change has been made.

al paragraph at top, “When individuals experience the mTBI as 

der replacing “experience” with “perceive,” since, by definition, 

f mTBI is traumatic, at least physiologically/functionally.

This sentence has been clarified.

agraph, starting with “The results,” I think more detail could be 

h as citations, especially when you cite specific figures. Consider 

st sentence as:

high prevalence estimates may differ from results observed in 

ns, as they may be related to unique deployment-related factors, 

rather than, specifically, to the presence of mTBI. 

This change has been made.

biomarkers paragraph: cite the one study here. We are providing summary paragraphs without citations for 

each section, which are followed by the cited results sections by key question. This will be consolidated for the published article version of the report.

 biomarkers” sentence: Do you mean “as prognostic tools among 

vere” TBI or with “moderate to severe” TBI? (not sure if severe 

s a category, or if this was meant as “not mild.”

This change has been made.
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c Brain Injury in Veterans and Military Personnel: A Systematic Review Evidence-based Synthesis Program

Comment Response

 biomarkers” paragraph: after introducing chronic traumatic 

 put “(CTE)”

This change has been made.

ph, 2nd sentence, put “imaging” after “functional”; 5th sentence, 

d of spelling it out; instead of “demonstrated” throughout this 

observed;” Cite

This change has been made.

raph, 2nd sentence; add “patients with” mTBI. This change has been made.

raph, 6th sentence, should be an “in” between “decreases 

This change has been made.

aph, 9th sentence, reword: differences between “individuals with 

iduals without mTBI” or “individuals in the control group.” 

This change has been made.

aph, 9th sentence – reword, such as “fMRI studies found 

nces between individuals with mTBI and individuals in the 

ring cognitive and behavioral tasks consistent with....”

This change has been made.

ragraph, first sentence, reverse last two words so that it reads: 

ng; cite which studies found increased vs. decreased FA; instead 

 “control participants.”

This change has been made.

raph, first sentence, say “universal” limitation (instead of across 

This has been re-worded.

raph, what is the evidence that participants aren’t blinded to 

s? It’s my sense that patients are told that the purpose of the 

ine differences,” “observe,” etc., and aren’t informed about 

al hypotheses until after study completion, if at all.

No studies reported that patients were blinded, and therefore we cannot assume that any were blinded.

ragraph, 3rd-4th sentences; “wide variety of tools used to assess 

 interest.”

This change has been made.

ns, 2nd sentence, I would say, “The literature reviewed here,” This change has been made.

ns, 4th sentence, instead of saying “negative outcomes,” 

gh a significant portion of individuals who have experienced an 

-term mental and physical health symptoms” .....”not significantly 

dividuals who “did not experience mTBI” or “served as controls.”

This section has been re-worded.

s, 7th sentence, I would stay away from “outcomes,” and say 

mptoms,” because we don’t know whether symptoms/conditions 

n “outcome”) by the mTBI.

This change has been made.

ns, 8th sentence from last – instead of “do not have mTBI,” I 

have not experienced mTBI” or “who do not have mTBI history”

This change has been made.
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c Brain Injury in Veterans and Military Personnel: A Systematic Review Evidence-based Synthesis Program

Comment Response

ns, 7th sentence from last, “instead of saying “is largely influenced 

can be accounted for” by other factors that are deployment

an....”

This change has been made.

et al., “five-difit”, should be “five-digit” This change has been made.

., “seeking starts” should be “seeing stars” This change has been made.

“loose” should be “lose” This change has been made.

n et al. – why aren’t the p-values listed? We have listed results according to what was reported in the 

primary studies and have put labels used by study authors in quotes to indicate a direct quote in our tables.

mitation of non-reporting of impaired subgroups is emphasized. Noted. Thank you.

t repetitive and disorganized with regards to reporting of the 

hed. For example, conclusions are reported on p.13 within a 

erature Flow. 

We have re-ordered the presentation of findings.

esults needs revision. Tables contain a great deal of text and no 

rs are occasionally presented without units (e.g. p.18 Gordon et 

ury: 20.1 (weeks?)). Table 1 should include each study’s outcome 

eferably study hypothesis. It was good to see that effect sizes 

he tables in the appendices, but effect sizes are missing for most 

ported, these can be calculated). Also, in cases where significance 

n corrected for multiple comparisons (e.g. Table 5), this should 

We have made these corrections to the table. For space reasons, we have presented some information in appendix tables rather than in text. We report the data as reported in the studies without calculating effect sizes when the authors did not provide this information; however, we are considering providing this calculated information in the article version of the report.

aging and biomarkers, p.51: it is mentioned twice that functional 

have “failed” to show differences in performance along with 

ain function, and this point would benefit from clarification. One 

ported by activation patterns, is that mTBI patients are able 

milar test performance to uninjured controls through greater 

eural resources. (e.g. McAllister, 2001, Neuroimage. 2001 

12.Differential working memory load effects after mild traumatic 

We have moved all discussion of imaging results to the discussion due to searching limitations and refer readers to more comprehensive reviews of this literature.

tle “Verbal and Old Learning” inappropriate as the tests 

section measure vocabulary and knowledge, not learning 

arning and memory).

We have changed this title.

5: “...without mTBI on the RBANS Visuospatial/Constructional 

entence does not match information presented in table 1b for 

We have made sure these results are correct and consistent with the table.
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c Brain Injury in Veterans and Military Personnel: A Systematic Review Evidence-based Synthesis Program

Comment Response

 E, some information in the “comparison group description 

t appear to describe a comparison group, but rather a covariate 

Yes, this indicates continuous variables rather than comparison groups, and as such, correlation results are presented for these studies.

ments: Noted as below.

“...and its associated post-concussion symptoms is...” should be 

Refers to mTBI, not the symptoms, therefore left as “is.”

 “...a TBI while deployed).” The parenthesis does not have a 

This change has been made.

and p.8 paragraph 2: “...balance problems) beyond this time 

e “frame” 

This change has been made.

 “...often require the attention from a range of health care 

should remove “the”

This change has been made.

“lengthly” should be “lengthy” This change has been made.

 “...Veteran/military participants without mTBI).” The parenthesis 

partner.

This change has been made.

 “disruption of brain function (e.g. altered of consciousness...)” 

tion”

This change has been made.

4: “six studies reporting...” Should be “reported” This change has been made.

3: “Axis 1” should be “Axis I” This change has been made.

3: “...we excluded many studies which proported to study mTBI” 

orted”

This change has been made.

Cockerham and Goodrich might be beneficial in the section 

dresses occult visual deficits in this patient population. This 

flated with self-reported complaints, as previously established 

ssessment were deemed not sensitive in detecting these 

dditionally, as this data is prospectively collected at all Polytrauma 

data be incorporated in the analyses.

We have reviewed this literature and though it provides important information related to vision outcomes, we did not find studies meeting our inclusion criteria for this report due to the populations examined.

mmend additional references regarding TBI incidence—pg #8 

e point could be substantiated by and WHO data or CDC Data.

We have re-worked the introduction for the report.
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c Brain Injury in Veterans and Military Personnel: A Systematic Review Evidence-based Synthesis Program

Comment Response

umber of veterans and service members who have incurred a 

t related mTBI have lead to persistent or chronic post-concussion 

Multiple studies have reported PCS-like symptoms among 

ears after mTBI. Agree that published studies to date has been 

y all the potential risk factors and a major causative role other 

0 and DSM-4 criteria have been established for diagnosing PCS 

what. There continues to be a lack of consensus regarding PCS, 

s limit the symptoms to within 4 weeks of injury, while DSM-4 

symptom onset shortly after injury, but persistence at least 3 

these diagnostic guidelines, evidence suggests that symptoms 

ediately, or weeks to months after the initial injury (Ryan et 

ent studies have reported PCS-like symptoms among Veterans 

 mTBI. ( Scholten et al.2012). While these persistent symptoms 

mplicate return to work/duty and negatively affect quality of life, 

 and time courses are not understood and diagnosis remains 

relies mostly on self-report of complex symptomatology rather 

uantitative or biological measures. The reasons why people 

r fail to recover fully from mTBIs is not known and there are no 

logies for diagnosis or prognosis of PCS. Identifying the cognitive, 

m biomarkers that accurately diagnose veterans or service 

ersistent symptoms is critical to our understanding of long-term 

 patient population and needs to explored further.

We have expanded the discussion section to include some of these ideas.

nging area with limited available published studies. I would 

ating in the early overview section that there are no prospective 

.

We have stated this in the executive summary and the body of the report.

o seems somewhat contradictory when you report that imaging 

w strength of evidence yet your recommendations indicate that 

es should be designed to report imaging findings.

We have rearranged and clarified the imaging findings and recommendations.

mplementation Questions

formance measures, programs, quality improvement measures, patient care services, or conferences that will be directly 

lease provide detail.

 new information here. Conclusions are consistent with 

owever, making this available to national Polytrauma calls or 

 Mental Health/PTSD calls and conferences would help reinforce 

Noted. We plan to make the report findings available in a variety of formats, including VA intranet, a published article, presentation at a national neuropsychology conference, and through a VA cyber-seminar. We will consider how to expand the audience as you recommend.
155

c Brain Injury in Veterans and Military Personnel: A Systematic Review Evidence-based Synthesis Program

Comment Response

aise the question of the context in which mTBI may be best 

A. The results also have implications for compensation and 

s regarding mTBI.

Noted, though we caution our readers not to make strong inferences based on the low quality literature available for synthesis in this report. Relying on these report findings in conjunction with related research on civilian populations with mTBI will provide the strongest available foundation for such weighty decisions.

nce injury” was cited throughout the document as being related 

ut also noted to be missing in many studies, I think it would 

nt to capture this variable in national VA databases, such as the 

TBI Evaluation database. If this information is available in any DoD 

efense Manpower Data Center (DMDC), then a data exchange 

d VA would benefit studies by having these data located in one 

hus reducing the risk of error through patient self-report.

We have added this to the discussion.

d nature and low quality of literature, it is not possible to reach 

 There is nothing to be implemented at this time.

Noted, and we encourage readers of this report to consider the results in conjunction with findings from civilian literature in order to make conclusions based on the best available evidence.

in the Inpatient/Polytrauma Units might be affected. Noted.

 TBI System of Care. Noted.

em of Care, can be disseminated on one of the national calls and 

rs with link to report

Noted.

endations on how this report can be revised to more directly address or assist implementation needs.

er adding review of any studies that looked at multiple mTBI’s. It 

mplication” 

’d suggest clearly delineating the difference between cognitive 

d symptom complaints. While it’s true that the literature 

te cognitive performance recovery by 3 months (or even 7 days 

re), there is a difference between performance and symptoms. 

e civilian literature suggests that PCS symptoms in fact do 

e Meares et al) and such the use of the term ‘persist’ may be 

nce” may be more accurate.

We have made these changes throughout the report.

What” section. However, one could potentially make the 

ince outcomes do not differ following mTBI, that all the DoD/VHA 

d attention devoted to this matter may be a less than ideal use 

 example: Do we really need to continue to screen for mTBI? Are 

mprehensive TBI Evaluations following a positive TBI screen, really 

od use of resources?

Noted, and we have expanded our discussion of these points in the report.
156

c Brain Injury in Veterans and Military Personnel: A Systematic Review Evidence-based Synthesis Program

Comment Response

ways to meet the needs of those symptomatic returning service 

terans than focusing on mTBI, when mTBI does not appear to be 

ning the symptoms and problems?

Noted, and we have expanded our discussion of this point in the report.

tions. This is a thorough report with well-reasoned conclusions. Noted. Thank you.

ates that many of the mTBI studies performed with service 

terans are methodologically limited and provide low strength 

se implementation should be based on strong evidence, it doesn’t 

report should make any health services related recommendations 

on, but should recommend that VA leaders prioritize 

 to ensure high quality research, and develop mechanisms 

standard communications between DoD and VA) that assist 

btaining reliable data.

We agree that ideally, recommendations should be made based on strong evidence. However, in the absence of strong evidence, then the best available evidence should be the basis on which treatment and policy decisions are made. We have made cautious recommendations consistent with the best available evidence for treatment and policy as well as making strong recommendations for further high quality research as you suggest.

ypographical errors should be addressed. Presentation of results 

d. Consider other data presentation modes in addition to tables. 

markers could possibly be removed and examined in a separate 

tion criteria that are more appropriate for these kinds of studies. 

Noted, and we have incorporated your suggested edits.

 in the TBI clinics is the CHRONIC effects of mTBI 3-10 years post 

ed sequale of the initial injury which does not completely follow 

ern of the civilian mTBI population. In the civilian population the 

nsient and self-limiting, with apparent full recovery occurring 

everal weeks following injury (Levin et al., 1997) which is distinct 

/service member population who have persistent symptoms and/

ations (Iverson et al., 2006; Ruff et al., 1996). There needs to be 

on into the etiology and treatment of these chronic/persistent PCS 

We agree and have expanded our discussion of treatment implications.

act details of any additional individuals/stakeholders who should be made aware of this report.

A? Noted.

mmendations other than VA polytrauma staff. Noted.

R&D leaders responsible for prioritizing funding, inclusive of and 

D

D

D

, MPT

ma Clinic Directors

Noted.
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c Brain Injury in Veterans and Military Personnel: A Systematic Review Evidence-based Synthesis Program

Comment Response

ck, Deputy Director, Defense and Veterans Brain Injury Center

k@tma.osd.mil

Noted.

keholders should made aware of this report: VHA Polytrauma 

which include Polytrauma Rehabilitation Centers (PRC),Polytrauma 

bilitation Programs (PTRP), Polytrauma Network Site (PNS), 

ort Clinic Team (PSCT), and Polytrauma Point of Contact (PPOC). 

Military Heath System’s TBI clinics, Defense and Veterans Brain 

VBIC) and National Intrepid Center of Excellence (NICoE) satellite 

Noted.