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Cited by 142Traumatic Brain Injury ResearchTraumatic Brain Injury and Neurovascular DisturbancesAutomotive and Human Injury Biomechanics

Early clinical predictors of 5-year outcome after concussive blast traumatic brain injury

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Mac Donald, Christine L., Barber, Jason, Jordan, Mary, Johnson, Ann M., Dikmen, Sureyya, Fann, Jesse R., Temkin, Nancy·2017·JAMA Neurology
DOI 10.1001/jamaneurol.2017.0143PMC PMC5732492
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Abstract

Importance: The long-term clinical effects of wartime traumatic brain injuries (TBIs), most of which are mild, remain incompletely described. Current medical disability cost estimates from world conflicts continually surpass projections. Additional information regarding long-term functional trajectory is needed to reduce this extensive public health burden. Objectives: To examine 5-year clinical outcomes leveraging existing clinical data collected at 1 year after injury in the same patients and to identify early risk factors for long-term disability. Design, Setting, and Participants: This prospective, longitudinal study enrolled active-duty US military after concussive blast injury (n = 50) in the acute to subacute stage and combat-deployed control individuals (n = 44) in Afghanistan or after medical evacuation to Germany from November 1, 2008, through July 1, 2013. One- and 5-year clinical evaluations were completed in the United States. All concussive blast injuries met the Department of Defense definition of mild, uncomplicated TBI. In-person clinical evaluations included standardized evaluations for neurobehavior, neuropsychological performance, and mental health burden that were essentially identical to the evaluations completed at 1-year follow-up. Data were analyzed from October 1 through November 30, 2016. Main Outcomes and Measures: Changes in the in-person standardized evaluations for neurobehavior, neuropsychological performance, and mental health burden from the 1- to 5-year follow-up. Predictive modeling was used to identify early risk factors for long-term disability. Results: Among the 94 participants (87 men [93%] and 7 women [7%]; mean [SD] age, 34 [8] years), global disability, satisfaction with life, neurobehavioral symptom severity, psychiatric symptom severity, and sleep impairment were significantly worse in patients with concussive blast TBI compared with combat-deployed controls, whereas performance on cognitive measures was no different between groups at the 5-year evaluation. Logistic regression on the dichotomized Extended Glasgow Outcome Scale (GOS-E) at 5 years as a measure of overall disability identified brain injury diagnosis, preinjury intelligence, motor strength, verbal fluency, and neurobehavioral symptom severity at 1 year as risk factors for a poor outcome at 5 years, with an area under the curve of 0.92 indicating excellent prediction strength. Thirty-six of 50 patients with concussive blast TBI (72%) had a decline in the GOS-E from the 1- to 5-year evaluations, in contrast with only 5 of 44 combat-deployed controls (11%). Worsening of symptoms in concussive blast TBI was also observed on measures of posttraumatic stress disorder and depression. Service members with concussive blast TBI experienced evolution, not resolution, of symptoms from the 1- to 5-year outcomes. Conclusions and Relevance: Considerable decline was observed in military service members with concussive blast TBI when comparing 1- and 5-year clinical outcomes. These results advocate for new treatment strategies to combat the long-term and extremely costly effect of these wartime injuries.

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  • The severity of depressive symptoms following concussion is strongly correlated with global disability, rate of recovery, and quality of life.

    “The severity of depressive symptoms following concussion is strongly correlated with global disability, rate of recovery, and quality of life (4, 10, 11).”

    From Adaptive trial for the treatment of depressive symptoms associated with concussion using accelerated intermittent theta burst stimulation (ADEPT): rationale, design and methods (2025) · cites this paper as [4]

    The Results, under “Predictors of Poor Outcome” (page not provided), identify lower depression severity as a predictor of improvement in global outcome in a small subset. The “Global Outcome” and “Psychiatric Evaluation” sections report disability, quality of life, and depression separately; they do not establish a strong correlation between depression severity and all three outcomes, or quantify its relationship with rate of recovery. (LLM, conf=0.83)

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  • Current or former service members who have sustained one or more concussions during their service have significantly higher rates of persistent depressive symptoms and suicidality following injury compared to non-injured peers.

    “Military service members (SMs) and veterans who have sustained one or more concussions during their service have significantly higher rates of persistent depressive symptoms and suicidality compared to non-injured peers.”

    From Adaptive trial for the treatment of depressive symptoms associated with concussion using accelerated intermittent theta burst stimulation (ADEPT): rationale, design and methods (2025) · cites this paper as [4]

    The Results, Psychiatric Evaluation section reports significantly more severe depressive symptoms five years after concussive blast TBI than in combat-deployed controls, with moderate-to-severe depression in 40% versus 14%. The paper does not report higher suicidality, and its studied injury was specifically combat-related blast concussion rather than concussions generally. Page numbers are unavailable in our copy. (LLM, conf=0.88)

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  • Despite the common occurrence of chronic cognitive subjective symptomology after mTBI, extant research shows a lack of a consistent relationship with cognitive performance on formal neuropsychological examination, including in military samples.

    “Despite the common occurrence of chronic cognitive subjective symptomology after mTBI, extant research shows a lack of a consistent relationship with cognitive performance on formal neuropsychological examination, including samples of military personnel”

    From Can mild traumatic brain injury alter cognition chronically? A LIMBIC-CENC multicenter study. (2023) · cites this paper as Mac Donald et al., 2017

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Authors
Mac Donald, C. L., Barber, J., Jordan, M., Johnson, A. M., Dikmen, S., Fann, J. R., & Temkin, N.
Affiliations
  • Department of Neurological Surgery, University of Washington, Seattle
  • University of Washington (US)
  • Washington University in St. Louis (US)
ORCID
Venue
JAMA Neurology
Publisher
American Medical Association (AMA)
Published
2017-07-01
Volume
74
Issue
7
Pages
821
ISSN
2168-6149 (ISSN-L)
DOI
10.1001/jamaneurol.2017.0143
PMC
PMC5732492
OpenAlex
W2611287086
Cited by
142
References
70
Citations by year
2026: 8 · 2025: 11 · 2024: 12 · 2023: 10 · 2022: 14 · 2021: 18 · 2020: 21 · 2019: 21 · 2018: 19 · 2017: 7
FWCI
14.57
Type
journal article
Language
en
Open access
Locations
  • JAMA Neurology (publishedVersion)
  • PubMed (publishedVersion)
  • Europe PMC (PubMed Central) (acceptedVersion)
  • PubMed Central (acceptedVersion)
Funders
  • U.S. Department of Defense (W81XWH1320095, W81XWH, W81XWH-13-2-, W81XWH-13)
  • National Institutes of Health (W81XWH)
  • National Institute of Neurological Disorders and Stroke (R01NS091618)
Topics
  • Health Sciences › Medicine › Epidemiology › Traumatic Brain Injury Research
  • Health Sciences › Medicine › Neurology › Traumatic Brain Injury and Neurovascular Disturbances
  • Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Automotive and Human Injury Biomechanics
Keywords
mild traumatic brain injury, military personnel, long-term disability, risk factors, neurobehavioral symptoms, sleep disorders, psychiatric symptoms, life satisfaction, cognitive function, Glasgow Outcome Scale-Extended, functional outcome prediction, neuropsychological performance, motor strength, verbal fluency, war-related brain injury, Afghanistan deployment
MeSH terms
Adult, Behavioral Symptoms, Blast Injuries, Brain Concussion, Female, Humans, Longitudinal Studies, Male, Migraine Disorders, Military Personnel, Prognosis, Risk Factors, United States, Case-Control Studies, Outcome Assessment, Health Care, Glasgow Outcome Scale, Afghan Campaign 2001-, Cognitive Dysfunction

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