Gulf War and Health Volume 7: Long-Term Consequences of Traumatic Brain Injury (2009) / Chapter Skim
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5 MAJOR COHORT STUDIES
5 MAJOR COHORT STUDIES
Pages 117-172
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From page 117... ...
Most major cohorts, once established, led to additional health outcome studies, which the committee refers to as derivative studies. Table 5.1, at the end of this chapter, provides information on each original cohort study, including the study design, the recruitment method, the eligible population, the study population, and the percentage of subjects who were enrolled.
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From page 118... ...
For each major cohort study, the methods for selecting the study population, the outcomes assessed, and the general findings are discussed. The committee was most interested in studies of long-term health outcomes related to TBI in military and veteran populations, so this group of studies is given primary consideration below.
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From page 119... ...
Head injuries were diagnosed on the basis of demonstration of immediate posttraumatic neurologic disturbance or evidence of a contusion, laceration, or compound wound injury of the scalp. Posttraumatic epilepsy was diagnosed on the basis of absence of preinjury seizures and the occurrence of seizures at some time after injury.
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From page 120... ...
Clinical examinations were conducted on 154 of those with epilepsy and 95 of those with encephalopathy. The authors found a statistically significantly lower survival rate in those with posttraumatic epilepsy.
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From page 121... ...
, 35 brain-injured veterans and 12 controls with arm or leg peripheral nerve injury were selected for assessment of performance on a modified Seguin-Goddard formboard task by area of brain injury. The brain-injured veterans
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From page 122... ...
Although sustaining a penetrating head injury alone did not shorten life expectancy, the risk of death increased when it was coupled with posttraumatic epilepsy. As of May 1, 1983, mortality was 3.6 times higher in veterans with brain injury and epilepsy than in veterans with peripheral nerve injury.
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Those with penetrating head injuries had a prevalence of seizures of 32%, those with blunt head injuries 8%, and those with blast wounds 2%. Caveness and colleagues (1962)
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assessed interictal personality traits in 238 veterans who had developed seizure disorders and compared them with personality traits in 229 veterans with penetrating head injuries but without seizures and 84 uninjured controls. Of the 238 with seizure disorders, 39 had simple partial seizures, 59 had complex partial seizures, 76 had partial seizures with secondary generalization, and 64 had generalized seizures.
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From page 125... ...
were associated with seizures. The authors found that the incidence of posttraumatic epilepsy was 86% in patients who had residual aphasia.
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. From the total eligible population, 4,462 veterans were randomly selected.
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From page 127... ...
By maintaining complete medical histories, the Rochester Epidemiology Project provides the capability to conduct population-based studies of disease risk factors and health outcomes and can be used to study long-term secular trends in disease incidence (Melton, 1996)
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The overall standardized incidence ratio (SIR) of seizures in patients with brain injury was 3.1 (95% CI, 2.5–3.8)
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From page 129... ...
Of those who sustained severe head injury, 56% died, and 50% of the survivors were disabled. The authors note that "head injuries induce long-lasting handicap in 9 per 100,000 habitants which is severe in 2 per 100,000." Canadian Study of Health and Aging The Canadian Study of Health and Aging (CSHA)
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Traumatic Brain Injury Model Systems The Traumatic Brain Injury Model Systems (TBIMS) program was established in 1987 by the National Institute on Disability and Rehabilitation Research of the US Department of Education.
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(2004) studied moderately to severely injured patients identified from the TBIMS database, which covered 15 TBI Model Systems Centers (TBIMSCs)
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(1991b) investigated the outcome of vegetative states and consciousness after severe closed head injuries.
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conducted a prospective cohort study to compare rates of acute stress disorder (ASD) and PTSD in MVA survivors who sustained a mild TBI with rates in MVA survivors who did not have a TBI.
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From page 134... ...
University of Washington Longitudinal Traumatic Brain Injury Studies A number of studies were based on a series of longitudinal investigations of health outcomes related to TBI conducted at the University of Washington by Dikmen and colleagues. The data from the studies have been formed into a repository and have been used to address questions about outcomes.
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From page 135... ...
The Patient Characteristics and Head Injury Outcome study did not exclude subjects on the basis of those conditions. The Dilantin Prophylaxis of Post-Traumatic Seizures and the Valproate Prophylaxis of Post-Traumatic Seizures studies enrolled patients who had more severe head injuries that posed an increased risk of seizures, such as intracranial hematoma, cortical contusion, and depressed skull fracture.
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From page 136... ...
The study participants were drawn from the three studies mentioned previously (45% from the Patient Characteristics and Head Injury Outcome Study, 33% from the Dilantin Prophylaxis of PostTraumatic Seizures Study, and 22% from the Behavioral Outcome of Head Injury Study)
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From page 137... ...
who sustained nonmissile head injuries and were admitted to the Radcliffe Infirmary in Oxford from November 1948 to February 1952. The cohort consisted of the first 1,000 cases of the Roberts (1979)
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From page 138... ...
examined early and late epilepsy by studying 381 patients who sustained blunt head injuries: 139 had early epilepsy, 282 late epilepsy, and 40 both early and late epilepsy. The population was drawn from the 46 patients with early epilepsy in the Oxford series, 93 patients with early epilepsy in Manchester and Cardiff, England, and patients at the Oxford Infirmary outside the study dates.
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From page 139... ...
. Posttraumatic epilepsy was assessed 10–24 years after injury in the consecutive series: 75 (26%)
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From page 140... ...
. STUDIES OF SPORTS-RELATED TRAUMATIC BRAIN INJURY Concussions are relatively common in people who participate in contact sports, so studies of such people afford a unique opportunity to assess the short-term and long-term consequences of head injury.
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From page 141... ...
Boxing Sports literature has been used to evaluate boxers and to assess the effects of repetitive head injury on long-term health outcomes, particularly neurologic and neurocognitive outcomes, such as dementia pugilistica and the relationship between the APOE e4 gene and chronic TBI. A number of the studies discussed below assess long-term health outcomes in brain-injured boxers, including two (Porter and Fricker, 1996; Porter, 2003)
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From page 142... ...
(2005) conducted studies of neurocognitive outcomes related to soccer-related head injuries.
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From page 143... ...
Enrolled Reference Purpose Study Design Eligible Located (Response Rate) Comments Weiss et al., Mortality Cohort 1,010 Bavarian men with head injuries from World War I; 1982 1,000 unwounded Bavarian World War I veterans; final numbers: 647 cases, 616 controls 143
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Enrolled Reference Purpose Study Design Eligible Located (Response Rate) Comments Walker and Posttraumatic symptoms, Cohort 313 men examined, questioned for relevant symptoms Erculei, 1969 including nervousness, headache, irritability, easy fatigability, impaired memory, dizziness, impaired mentation, lack of concentration, insomnia, intolerance to alcohol Walker and Neurologic deficit Cohort Neurologic deficit assessed with two subgroups of population: patients Erculei, 1969 with no neurologic deficit (n = 50)
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From page 145... ...
Enrolled Reference Purpose Study Design Eligible Located (Response Rate) Comments Achte et al., Psychiatric disturbances Prospective cohort In more inclusive sample, 10,000 men with mild, moderate, or severe No comparison 1991 open, closed head injuries were studied 50 years after injury group 145
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From page 146... ...
Comments Teuber and Spatial and motor function Case–control 35 veterans with penetrating brain injuries, 12 veterans with peripheral Weinstein, nerve injuries from the original series 1954 Weinstein Intelligence scores Case–control 62 veterans with penetrating brain injuries, 50 veterans with peripheral and Teuber, nerve injuries for whom preinjury Army General Classification Test 1957a score was available Weinstein Intelligence scores Case–control 62 veterans with penetrating brain injuries, 50 veterans with peripheral and Teuber, nerve injuries for whom preinjury Army General Classification Test 1957b score was available Weinstein et Sensorimotor discrimination Case–control 40 World War II, 3 Korean War veterans with penetrating head al., 1958 injuries, 20 controls with peripheral nerve injuries from original series Corkin et Life expectancy Case–control 190 World War II veterans with penetrating head injuries, 106 World al., 1984 War II veterans with peripheral nerve injuries who were in original series Corkin et Cognitive performance Case–control 57 men with penetrating head injuries, 27 with peripheral nerve injuries al., 1989 who were in original series
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From page 147... ...
Caveness Studies of Korean War Veterans Caveness, Military personnel of Prospective cohort 467 No reference 1963 Korean War who suffered group head injuries and were treated in either US Naval Hospital in Yokusaka or US Navy hospital ships off coast of Korea Population (Where Appropriate) Enrolled Reference Purpose Study Design Eligible Located (Response Rate)
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From page 148... ...
Enrolled Reference Purpose Study Design Eligible Located (Response Rate) Comments Weiss et al., Posttraumatic epilepsy Retrospective Participants from phase I, including 378 of 1,221 participants found to 1983 cohort have posttraumatic seizures Rish et al., Mortality, posttraumatic Prospective cohort Participants from phase I, including 1,127 male Vietnam veterans alive 1983 epilepsy 1 week after trauma
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From page 149... ...
Comments Salazar et al., Posttraumatic epilepsy Retrospective Participants from phase I, including 421 (of 1,131) head-injured men No reference 1985 cohort group; unclear whether had preinjury seizures Grafman et Face discrimination, Retrospective Participants from phase II, including 213 men with penetrating TBI, 49 Assessed al., 1986 memory cohort controls outcomes based on region of brain affected Salazar et al., Intelligence, reasoning, Retrospective Participants from phase II including 15 veterans who suffered unilateral Assessed 1986 attention; memory, verbal cohort penetrating missile wounds to basal forebrain, 49 uninjured controls, outcomes based free recall, nonverbal 113 patients with lesions elsewhere in brain on region of memory, language brain affected Kraft et al., Occupational, educational Retrospective Participants from phase II, including 520 men with penetrating head 1993 achievement cohort injury, 85 uninjured controls Schwab et al., Measured work status 15 Retrospective Participants from phase II, including 520 men with penetrating head Assessed work 1993 years after injury; cohort injury, 85 uninjured controls outcomes neurologic, neurophysiologic, social interaction impairments Grafman et Violence, aggression Retrospective Participants from phase II, including 279 male veterans, 57 healthy Assessed al., 1996 cohort controls outcomes based on region of brain affected Groswasser et Cognitive, vocational Retrospective Participants from phase II, including 74 with penetrating head injury, al., 2002 outcome cohort 37 with closed head injury Koenigs et al., PTSD Retrospective Participants from phase III, including 193 veterans with lesions 2007 cohort distributed throughout brain (as result of penetrating head injuries sustained during combat)
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From page 150... ...
Enrolled Reference Purpose Study Design Eligible Located (Response Rate) Comments Luis et al., PPCSC Cross-sectional 3,957 veterans of original population; 329 excluded because they did 2003 cohort sample not meet criteria for either ICD-10 or DSM-IV PPCSC, but not both; 55 excluded because of hospitalization; 121 excluded because of incomplete data Vanderploeg Psychiatric, neurologic, Cross-sectional 4,384 veterans of original population; 40 excluded because of et al., 2007 psychosocial outcomes cohort sample hospitalization after injury; 38 excluded because of incomplete data Vanderploeg Work, marital status Logistical regression 4,322 veterans of original population; 53 excluded because of et al., 2003 analysis hospitalization after injury; 87 excluded because of incomplete data Vanderploeg Neuropsychologic outcomes Cross-sectional 4,384 veterans of original population; 40 excluded because of et al., 2005 cohort sample hospitalization after injury; 38 excluded because of incomplete data Responded or Subgroup (n= Contacted or Enrolled Type of Study or Date(s)
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From page 151... ...
Comments Annegers et Cancer Double cohort All traumatic brain injuries in Olmstead County, MN, 1935–1974; al., 1979 patients must have survived initial trauma and had no known pre existing tumor; 2,953 patients followed for total of 29,859 person-years Annegers et Seizures Population-based 2,747 patients of Olmstead County, MN, with head injuries sustained al., 1980 retrospective cohort 1935–1974 Chandra et Alzheimer disease Population-based All incident cases of clinically diagnosed Alzheimer disease in al., 1989 retrospective cohort population of Rochester, MN, with onset 1965–1974 (n = 274) Williams et Dementia, parkinsonism, Population-based 821 Olmsted County residents with head trauma and presumed brain al., 1991 ALS, PD retrospective cohort injury occurring 1935–1974 Siva et al., Multiple sclerosis Population-based 225 incident cases of multiple sclerosis 1905–1991, 164 prevalence 1993 retrospective cohort cases (December 1, 1991)
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From page 152... ...
registered from death certificates, 8,190 hospital admissions observed during sampling periods in residents of Aquitaine Population (Where Appropriate) Enrolled Reference Purpose Study Design Eligible Located (Response Rate)
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From page 153... ...
Rate) Comments Traumatic Brain Injury Model Systems NDSC, Patients entered into any Prospective, 1987–present 2008 nationwide Traumatic Brain longitudinal Injury Model Systems multicenter Centers and meeting the following criteria: moderate to severe TBI (PTA > 24 h or LOC > 30 min or GCS in ED < 13 or intracranial neuroimaging abnor malities)
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From page 154... ...
Comments Harrison- Mortality Retrospective 2,178 patients in 15 TBI Model Systems Centers treated 1988– Felix et al., December 31, 2000 2004 Harrison- Mortality Retrospective 2,140 people surviving 1 year after injury in 15 TBI Model Systems Felix et al., Centers treated 1988–December 31, 2000 2006 Cifu et al., Rehospitalization Prospective 665 patients admitted to ED within 24 h of injury to four TBI Model 1999 Systems Centers 1989–1996; response rate for both 1 and 2 years after injury 53% of eligible patients, 3-year response rate 47% Marwitz et Rehospitalization Prospective 1,547 patients admitted within 24 h of injury to 17 TBI Model Systems al., 2001 Centers 1989–1999; 1-year followup 895 (58%) patients; 5-year followup 442 (55%)
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From page 155... ...
of Eligible Located (% (Response Reference Eligible Population Methods Enrollment Subjects) of Eligible)
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From page 156... ...
Rate) Comments University of Washington Longitudinal Traumatic Brain Injury Studies Behavioral Consecutively Prospective cohort 1980–1982 102 English-speaking Outcome in Head admitted adults to adults; enrolled Injury, McLean et Level I trauma center at time of injury al., 1993 at Harborview; and subjects met prospectively following criteria: followed to 1 any period of loss of year; of 102 consciousness, PTA enrolled and for at least 1 h, or examined at 1 other objective month, 97 evidence of head examined at 1 trauma; injury had to year require hospitalization; age range, 15–60 years; patients with pre existing conditions excluded; 102 friend controls included in study
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From page 157... ...
English-speaking Prophylaxis of admitted head injured adults; 137 of Post-Traumatic adults to Level I 170 (81%) Seizures, Temkin trauma center at followed to 1 et al., 1990; Harborview; subjects year after injury; Dikmen et al., met one or more of subjects with 1991 following criteria: pre-existing GCS score of 10 or conditions below, cortical excluded; contusion docu- subjects had to mented on CT, be at least 15 depressed skull years old fracture, subdural hematoma, epidural hematoma, traumatic intracerebral hema toma, penetrating head wound, or seizure within 24 h after injury 157
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From page 158... ...
1986 social outcomes of controls; subjects with pre-existing conditions excluded; subjects were mild head injured mild TBI from Behavioral Outcome in Head Injury study seen at 1 year; healthy friend controls may not control for general effects of trauma
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From page 159... ...
Comments Dikmen et al., Memory Prospective cohort 102 closed head-injured patients selected from Behavioral Outcome of 97 of 102 head1987 Head Injury study; 102 friend controls; no pre-existing conditions injured subjects evaluated 1 year after injury Fraser et al., 1988 Comparison of Prospective cohort 48 of 102 closed head-injured patients selected from Behavioral All 48 followed people with TBI who Outcome of Head Injury study who were working for more than 4 to 1 year after had returned to work h/day for at least 5 mo before injury; 102 friend controls; no pre- injury at 1 year and those existing conditions who had not returned in neuropsychologic, psychosocial functioning at 1 mo, 1 year after injury Dikmen et al., Neuropsychologic Prospective cohort 31 adults with moderate or severe head injury investigated over 2 Subgroup 1990 outcomes years (subgroup of sample of 102 consecutive head injured patients analyses based selected from Behavioral Outcome of Head Injury study) ; 102 on small samples noninjured friend controls 31 of 46 (67%)
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From page 160... ...
, 102 Behavioral noninjured friend controls Outcome of Head Injury study followed to 2 years after injury; no significant differences between 31 who completed 2-year followup and 15 who were lost on demographics or neurologic severity indexes McLean et al., Psychosocial Prospective cohort 102 consecutive head injured patients from Behavioral Outcome of Followed 97 of 1993 outcomes; Sickness Head Injury study, 102 noninjured friend controls 102 (95%) to 1 Impact Profile; year after injury; Head Injury Subgroup Symptom Checklist; analyses based Modified Function on small samples Status Index Dikmen et al., Time to return to Prospective cohort 366 head injured individuals from 3 prospective, longitudinal studies Head injured and 1994 work (Behavioral Outcome of Head Injury, Patient Characteristics and Head controls similar Injury Outcome, Dilantin Prophylaxis of Post-Traumatic Seizures)
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From page 161... ...
Comments Haaland et al., Motor skills Prospective cohort 40 patients selected from 102 consecutive head-injured patients 40 of 58 selected 1994 selected from Behavioral Outcome of Head Injury study who did not with no have peripheral upper body injuries, 88 healthy friend controls peripheral injuries, had complete data at 1 mo and 1 year after injury; 18 cases presumably excluded primarily because neurologically too impaired to be tested at 1 mo Dikmen et al., Preinjury drinking, Prospective cohort 197 head-injured patients from Patient Characteristics and Head Injury 179 of 197 (91%) 1995a blood alcohol level; Outcome study followed until 1 preinjury, postinjury year after injury; patterns of alcohol 89 also use participated in Dilantin Prophylaxis of Post-Traumatic Seizures study and told by study nurse that they should not drink alcohol Dikmen et al., Neuropsychologic Prospective cohort 436 adult head-injured patients recruited at time of injury in 3 Study subjects 1995b outcomes prospective, longitudinal studies (Behavioral Outcome in Head Injury, included 85% of Patient Characteristics and Head Injury Outcome, Dilantin 514 subjects Prophylaxis of Post-Traumatic Seizures)
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From page 162... ...
Comments Dikmen et al., Global outcome, Prospective cohort 466 subjects with TBI selected from 3 prospective, longitudinal 91% of 514 1995c independent living, studies (Behavioral Outcome in Head Injury, Patient Characteristics subjects followed employment, income, and Head Injury Outcome, and Dilantin Prophylaxis of Post- to 1 year after Sickness Impact Traumatic Seizures) injury Profile Results presented 124 trauma controls who had bodily injury other than to head as weighted averages to 88 friend controls, friends of TBI patients, with no pre-existing adjust for conditions differences in eligibility criteria between studies Doctor et al., 2005 Employment status Prospective cohort 418 TBI working before injury from 4 longitudinal investigations 374 of 418 (89%)
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From page 163... ...
Comments Roberts, Hypothalamic, pituitary Prospective 291 patients from consecutive series 1979 dysfunction Roberts, Positional vertigo, Prospective 291 patients from consecutive series 1979 headaches Roberts, Epilepsy Prospective 291 patients from consecutive series 1979 Lewin et al., Epilepsy, mortality Prospective, 291 patients from consecutive series, 75 patients in whom cause of 1979 retrospective death was determined Responded or Subgroup (n= Contacted or Enrolled Type of Study or Date(s) of Eligible Located (% (Response Reference Eligible Population Methods Enrollment Subjects)
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From page 164... ...
Comments Jennett, Epilepsy Prospective 189 patients from Oxford series, cases from Lewin; 150 patients from 1969 Glasgow series epileptic within 8 weeks after injury; 73 patients with missile injuries as comparison group; 333 patients 1 year after injury, 219 patients 4 years after injury with depressed fractures from Oxford and Glasgow series Jennett, Epilepsy Prospective 381 patients who had blunt head injuries followed by early epilepsy (n 1962 = 139) , late epilepsy (n = 282)
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From page 165... ...
Enrolled Reference Purpose Study Design Eligible Located (Response Rate) Comments Porter, 2003 Neuropsychologic Prospective, 20 male boxers from amateur boxing clubs in Ireland 16–25 years old; See comments impairment observational subjects had to complete a minimum of 40 bouts above 1 case and 2 controls lost to followup NOTE: ALS = amyotrophic lateral sclerosis, CHSA = Canadian Study of Health and Aging, CT = computed tomography, DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, 4th ed., ED = emergency department, GCS = Glasgow Coma Scale, GSW = gunshot wound, ICD-10 = International Statistical Classification of Diseases and Health Related Problems, 10th revision, LLI = lower-limb injury, LOC = loss of consciousness, MA = Massachusetts, MN = Minnesota, MS = multiple sclerosis, MTBI = mild traumatic brain injury, MVA = motor vehicle accident, PCS = postconcussion syndrome, PD = Parkinson disease, PPCSC = predictors of postconcussion symptom complex, PTA = posttraumatic amnesia, PTSD = posttraumatic stress disorder, TBI = traumatic brain injury, TCDB = Traumatic Coma Databank, UK = United Kingdom, US = United States, VA = Veterans Affairs, VHIS = Vietnam Head Injury Study, WA = Washington.
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From page 166... ...
1998. Relationship between acute stress disorder and posttraumatic stress disorder following mild traumatic brain injury.
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From page 167... ...
2003. Outcome 3 to 5 years after moderate to severe traumatic brain injury.
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From page 168... ...
Part II: Cognition and work after closed and penetrating head injury: A report of the Vietnam Head Injury Study. Brain Injury 16(8)
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2000. Two-year prospective evaluation of the relationship between acute stress disorder and posttraumatic stress disorder following mild traumatic brain injury.
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From page 170... ...
2008. Traumatic Brain Injury Model Systems.
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From page 171... ...
2001. Incidence of seizures after traumatic brain injury -- a 50-year population survey.
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From page 172... ...
2005. Long-term neuropsychological outcomes following mild traumatic brain injury.
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