Examining Traumatic Brain Injury as a Chronic Condition: Proceedings of a Workshop (2025)

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Examining Traumatic Brain Injury as a Chronic Condition Convened March 11–12, 2025 Olivia Yost, Ashley Bologna, and Katherine Bowman, Rapporteurs Forum on Traumatic Brain Injury Health and Medicine Division Proceedings of a Workshop PREPUBLICATION COPY—Uncorrected Proofs 

NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001 This activity was partially supported by a contract between the National Academy of Sciences and the Centers for Disease Control and Prevention (75D30121D11240, Task 75D30124F00046) and support from Cohen Veterans Bioscience. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project. International Standard Book Number-13: 978-0-309-XXXXX-X Digital Object Identifier: https://doi.org/10.17226/29230 This publication is available from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242; https://nap. nationalacademies.org. The manufacturer’s authorized representative in the European Union for product safety is Authorised Rep Compliance Ltd., Ground Floor, 71 Lower Baggot Street, Dublin D02 P593 Ireland; www.arccompliance.com. Copyright 2025 by the National Academy of Sciences. National Academies of Sciences, Engineering, and Medicine and National Academies Press and the graphical logos for each are all trademarks of the National Academy of Sciences. All rights reserved. Printed in the United States of America. Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2025. Examining traumatic brain injury as a chronic condition: Proceedings of a workshop. Washington, DC: National Academies Press. https://doi. org/10.17226/29230. PREPUBLICATION COPY—Uncorrected Proofs 

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WORKSHOP PLANNING COMMITTEE1 ODETTE HARRIS (Chair), Stanford University School of Medicine and VA Palo Alto Health Care System KRISTEN DAMS-O’CONNOR, Icahn School of Medicine at Mount Sinai RAMON DIAZ-ARRASTIA, University of Pennsylvania Perelman School of Medicine DEREK FALES, Maine Department of Health and Human Services FLORA HAMMOND, Indiana University School of Medicine JEANNE M. HOFFMAN, University of Wahington School of Medicine RISA NAKASE-RICHARDSON, James A. Haley Veterans’ Hospital and University of South Florida OWEN PERLMAN, Associates in Physical Medicine & Rehabilitation, PC STACY SUSKAUER, Kennedy Krieger Institute and Johns Hopkins University School of Medicine KELLI G. TALLEY, Virginia Commonwealth University AMY K. WAGNER, University of Pittsburgh Staff OLIVIA YOST, Workshop Director and Program Officer (until June 2025) ASHLEY BOLOGNA, Research Assistant KATHERINE BOWMAN, Director, Forum on Traumatic Brain Injury CLARE STROUD, Senior Director, Board on Health Sciences Policy James C. Puffer, M.D./American Board of Family Medicine Fellowship ALYSSA TILHOU, Boston University Consultants ANNA NICHOLSON, Founder and Lead Writer, Doxastic TAMARA HAAG, Science Writer, Doxastic ALI RIZVI, Video Producer 1 The National Academies of Sciences, Engineering, and Medicine’s planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for the published Proceedings of a Workshop rests with the workshop rap- porteurs and the institution. v PREPUBLICATION COPY—Uncorrected Proofs 

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FORUM ON TRAUMATIC BRAIN INJURY1 DONALD BERWICK (Cochair), Institute for Healthcare Improvement CORINNE PEEK-ASA (Cochair), University of California San Diego JOE BONNER, Eunice Kennedy Shriver National Institute of Child Health and Human Development JOE BRENNAN, Avalon Action Alliance JAVIER CÁRDENAS, West Virginia University and American Academy of Neurology JOHN CORRIGAN, Ohio State University and Brain Injury Association of America RAMON DIAZ-ARRASTIA, University of Pennsylvania Perelman School of Medicine LAGWYN DURDEN, National Collegiate Athletic Association COURTNEY EDWARDS, Emergency Nurses Association E. WESLEY ELY, Vanderbilt University Medical Center BRUCE EVANS, Upper Pine River Fire Protection District and National Association of Emergency Medical Technicians STEVEN FLANAGAN, New York University Grossman School of Medicine and American Academy of Physical Medicine and Rehabilitation DAVID GOLDSTEIN, George Washington University GENE GURKOFF, University of California, Davis, and National Neurotrauma Society MAGALI HAAS, Cohen Veterans Bioscience ODETTE HARRIS, Stanford University School of Medicine and VA Palo Alto Health Care System RICHARD HODES, National Institute on Aging STUART HOFFMAN, Department of Veterans Affairs FREDERICK KORLEY, University of Michigan WALTER KOROSHETZ, National Institute of Neurological Disorders and Stroke RACHEL LAZARUS, AARP KATHY LEE, Department of Defense JULIE MALLOY, American Occupational Therapy Association TARA JO MANAL, American Physical Therapy Association GEOFFREY MANLEY, University of California, San Francisco, and Zuckerberg San Francisco General Hospital LUCA MARINELLI, GE HealthCare Technology & Innovation Center 1 The National Academies of Sciences, Engineering, and Medicine’s forums and roundtables do not issue, review, or approve individual documents. The responsibility for the published Proceedings of a Workshop rests with the workshop rapporteurs and the institution. vii PREPUBLICATION COPY—Uncorrected Proofs 

CHRISTINA L. MASTER, University of Pennsylvania Perelman School of Medicine and Children’s Hospital of Philadelphia BETH MCQUISTON, Abbott Laboratories CATE MILLER, National Institute on Disability, Independent Living, and Rehabilitation Research CANDICE NASH, Toyota Motor North America CHRIS NOWINSKI, Concussion Legacy Foundation TESSIE OCTOBER, Eunice Kennedy Shriver National Institute of Child Health and Human Development DAVID OKONKWO, University of Pittsburgh School of Medicine TOLULOPE O. OYESANYA, Duke University School of Nursing MAYUR B. PATEL, Vanderbilt University Medical Center and American College of Surgeons Committee on Trauma LESLIE PRICHEP, BrainScope Company, Inc. TERRY RAUCH, Department of Defense JOEL SCHOLTEN, Department of Veterans Affairs SHELLY TIMMONS, Medical College of Wisconsin and American Association of Neurological Surgeons GAMUNU WIJETUNGE, National Highway Traffic Safety Administration REBECCAH WOLFKIEL, National Association of State Head Injury Administrators KRISTINE YAFFE, University of California, San Francisco Forum Staff KATHERINE BOWMAN, Forum Director ASHLEY BOLOGNA, Research Assistant CHRISTIE BELL, Finance Business Partner CLARE STROUD, Senior Director, Board on Health Sciences Policy James C. Puffer, M.D./American Board of Family Medicine Fellowship ANITA RAVI, PurpLE Health Foundation ALYSSA TILHOU, Boston University viii PREPUBLICATION COPY—Uncorrected Proofs 

Reviewers This proceedings of a workshop was reviewed in draft form by indi- viduals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical com- ments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published proceedings as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the charge. The review comments and draft manuscript remain confidential to protect the integrity of the process. We thank the following individuals for their review of this proceedings: ANASTASIA EDMONSTON, Maryland Department of Health STEVEN FLANAGAN, New York University LINDSAY NELSON, Medical College of Wisconsin Although the reviewers listed above provided many constructive com- ments and suggestions, they were not asked to endorse the content of the proceedings nor did they see the final draft before its release. The review of this proceedings was overseen by JENNIFER BOGNER, The Ohio State University. She was responsible for making certain that an indepen- dent examination of this proceedings was carried out in accordance with standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the rapporteurs and the National Academies. ix PREPUBLICATION COPY—Uncorrected Proofs 

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Contents 1 Introduction 1 BRAIN INJURY AS A CHRONIC HEALTH CONDITION, 4 REFERENCES, 7 2 Exploring the Evidence for Characterizing Traumatic Brain Injury as a Chronic Condition 9 EPIDEMIOLOGY OF TBI AS A CHRONIC CONDITION, 11 NEUROPATHOPHYSIOLOGICAL MECHANISMS UNDERLYING TBI AS A CHRONIC CONDITION, 21 EVIDENCE ON HEALTH OUTCOMES AND COMORBIDITIES, 28 REFERENCES, 44 3 Examining Rehabilitative Care and Specialized Services for People Living with Lasting Effects of TBI 53 CHRONIC TBI CARE FOR VETERANS, 56 POSTACUTE REHABILITATION SERVICES, 56 TBI TRANSITIONAL CARE, 58 NORTH DAKOTA BRAIN INJURY NETWORK, 60 MAINE DEPARTMENT OF HEALTH AND HUMAN SERVICES, 61 MOVING FROM FRAGMENTED TO PERSON-CENTERED TBI CARE SOLUTIONS, 62 DISCUSSION, 63 REFERENCES, 65 xi PREPUBLICATION COPY—Uncorrected Proofs 

xii CONTENTS 4 Considering Opportunities to Advance Research and Improve Care and Services 67 THE USE OF CHRONIC CARE MODELS FOR TBI, 69 NEAR-TERM OPPORTUNITIES TO IMPROVE CARE FOR TBI AS A CHRONIC CONDITION, 76 NEAR-TERM OPPORTUNITIES TO ADVANCE RESEARCH ON TBI AS A CHRONIC CONDITION, 81 FINAL REMARKS, 84 REFERENCES, 85 APPENDIXES A Statement of Task 87 B Workshop Agenda 89 C Planning Committee, Video Participant and Speaker Biographies 95 PREPUBLICATION COPY—Uncorrected Proofs 

Boxes and Figures BOXES 1-1 Perspectives of Individuals Living with Chronic TBI Symptoms, 3 2-1 Factors Affecting Outcomes in Chronic TBI, 16 2-2 Perspectives of Individuals Living with Chronic TBI Symptoms, 29 3-1 Perspectives of Individuals Living with Chronic TBI Symptoms, 55 4-1 Defining Chronic TBI, 70 FIGURES 1-1 Changes in Glasgow Outcome Scale-Extended (GOSE) scores over time in people diagnosed with moderate to severe TBI, 5 1-2 Changes in Glasgow Outcome Scale-Extended (GOSE) scores and self-reported function (interview-based) measures over time in peo- ple diagnosed with mild TBI, 5 xiii PREPUBLICATION COPY—Uncorrected Proofs 

xiv BOXES AND FIGURES 2-1 TBI is associated with 1.7 times the risk of any stroke (ischemic or hemorrhagic) in U.S. military veterans over a median of 5 years, along with elevated risks for ischemic stroke and for hemorrhagic stroke over time, 14 2-2 Prevalence of psychiatric disorders during the first 5 years after TBI, 30 2-3 Potential relationships connecting preinjury factors and brain injury to cognitive and cardiovascular dysfunction, including neu- robiological changes, comorbidities, and behavioral or lifestyle factors that may collectively contribute to increased risk, 38 3-1 Effectiveness of rehabilitation after cerebrovascular accident (CVA) and after TBI, showing percent improvement at discharge assessed using a variety of outcomes scales, 58 4-1 Effectiveness of care models in chronic disease management, 71 PREPUBLICATION COPY—Uncorrected Proofs