Traumatic brain injury (TBI) has been described as the “signature injury” of recent military conflicts Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF).

• According to the US Department of Defense (DOD), over 63,000 service members were diagnosed with TBI between January 2003 and September 2009.

• Some researchers suggest that an additional 10%-20% of military personnel serving in Operation Iraqi Freedom and Operation Enduring Freedom may have sustained a mild TBI.

• Blast-related injury is the main cause of TBI in Operation Iraqi Freedom and Operation Enduring Freedom.

Mechanisms of Injuries

Mechanisms of injury also seen in civilian TBI

• Blunt trauma to the head (i.e., when individual is struck on the head)
• Penetrating trauma to the head/brain (i.e., when something pierces the skull, as in a gunshot wound)
• Acceleration-deceleration injury (e.g., associated with whiplash)
• Scraping of the brain against the bony base of the skull
• Can occur with blunt trauma, acceleration-deceleration injuries

Blast-related injuries

Blast-related injuries in service members involved in OEF and OIF can be caused by:

• improvised explosive devices (IEDs; aka roadside bombs)
• mortar rounds
• rocket-propelled grenades
• land mine explosions
• explosively-formed penetrators or projectiles

Explosions can result in TBI due to multiple mechanisms:

• Primary mechanism is brain over-pressurization
• This has been shown to cause structural and biochemical changes in animal models.
• Effects on persons are less well understood.

• Secondary mechanism
• Being struck on the head by debris and shrapnel.

• Tertiary mechanism
• Striking one’s head when thrown by the pressure of the blast into a stationary object.

• Quarternary mechanism
• Burns, crush injuries, inhalation of toxic fumes/smoke/etc.

Blast-related injury is the main cause of TBI in Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF)

Mild TBI and Postconcussional Disorder

General Definition of Mild TBI

• Also sometimes referred to as a concussion, this is a head injury with characteristics that can include:
• Brief loss of consciousness <or> disorientation <or> post-traumatic amnesia
• Glasgow Coma Scale score ranging from 13-15

Defense and Veterans Brain Injury Center (DVBIC) Definition of Mild TBI¹

• An injury to the brain from an external force and/or acceleration/deceleration mechanism
• Mechanisms include blast, fall, direct impact, or motor vehicle accident

• The injury causes an alteration in mental status, typically resulting in the temporally-related onset of symptoms including:
• Headache
• Nausea
• Vomiting
• Dizziness/balance problems
• Fatigue
• Trouble sleeping/sleep disturbances
• Drowsiness
• Sensitivity to light/noise
• Blurred vision
• Difficulty remembering
• Difficulty concentrating

Postconcussional Disorder

• History of head trauma that has caused a concussion or mild TBI
• Evidence of cognitive difficulties
• Memory disturbance
• Problems concentrating
• Difficulties shifting attention and/or multi-tasking

• Physiological and psychological symptoms lasting at least 3 months, including:
• Increased fatigue
• Sleep difficulties
• Headache
• Vertigo, dizziness
• Irritability
• Anxiety, depression, emotional lability
• Personality changes (e.g., social inappropriateness)
• Apathy
• Evidence that symptoms have a negative effect on social, occupational, daily functioning

Approximately 5-10% of individuals who have sustained a mild TBI may experience persisting difficulties considered to reflect Postconcussional Syndrome.

Although the exact causes are not yet known, both biological and psychological factors may play a role in the development of Postconcussional Syndrome.

Posttraumatic Stress Disorder (PTSD) and Traumatic Brain Injury

Symptoms of PTSD²

• Exposure to an event that was threatening to the individual and/or others, and that was responded to with intense fear, helplessness or horror.
• Re-experiencing of trauma, via intrusive memories, recurrent nightmares, a feeling of reliving the trauma, and emotional distress and/or physiological reactions (e.g., increased heart rate) when exposed to reminders of the traumatic event.
• Persistent avoidance of things associated with the trauma (e.g., conversations about the event, places associated with the event) and general numbing (e.g., decreased interest in activities, feelings of detachment from others, reduced range of emotions).
• Increased arousal (e.g., problems falling asleep, irritability, hypervigilence, increased startle response).

Among military personnel sustaining a mild TBI in OIF conflict, over 1/3 may have symptoms of PTSD and/or depression.³

Overlap of Symptoms in PTSD and TBI

• Anxiety-related symptoms that can result from mild TBI are also seen in PTSD, such as:
• General anxiety/uneasiness
• Feelings of fearfulness
• Social withdrawal
• Interpersonal conflict
• Dreams with anxious themes/content
• Difficulties concentrating

• The overlap in symptoms can make it difficult to distinguish whether symptoms are due to mild TBI and/or to PTSD.
• Mild TBI appears to be a risk factor for developing PTSD.
• Mild TBI may negatively affect long-term recovery from PTSD.

US Department of Defense Efforts to Address TBI Needs

Prevention

• Developments in personal protective equipment are ongoing, and are intended to reduce the occurrence of TBI.

Early Detection

• Baseline pre-deployment cognitive testing started in May 2008 to assist with early detection and to inform return-to-duty determinations following possible TBI.

Treatment

• Clinical practice guidelines have been revised and updated for the management of mild to severe TBI.
• Care coordination, managed by the Defense and Veterans Brain Injury Center (DVBIC), is available for those diagnosed with TBI.
• Over 55 TBI programs as of June 2009 across the US and in international locations (e.g., Germany, Japan)
• The National Intrepid Center of Excellence at the National Naval Medical Center in Bethesda, MD, a facility dedicated to serving military personnel with TBI and complex psychological health issues, was opened in June 2010.

Support for Families

• Congress mandated the development of a Family Caregiver Curriculum, an initiative that has been coordinated by the Defense and Veterans Brain Injury Center (DVBIC). http://www.traumaticbraininjuryatoz.org/Caregivers-Journey.aspx
• Also a social networking initiative by DVBIC to connect family members whose loved one sustained a TBI.
• http://www.traumaticbraininjuryatoz.org/

Research

• DVBIC is currently overseeing a 15 year longitudinal study of TBI in military personnel.
• Research documenting the effects of blast injuries is ongoing.
• Research on interventions for chronic TBI (e.g., hyperbaric oxygen) is ongoing.

Military Resources for Non-Military Professionals

Defense and Veterans Brain Injury Center
http://www.dvbic.org/
http://www.dvbic.org/Providers/TBI-Clinical-Tools-(1).aspx

Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury
http://www.dcoe.health.mil/DCoEv2/ForHealthPros/TipsforTreatingTBI_PTSD.aspx

Learn about Military Culture⁴

Resources for Treating Veterans with Chronic Mild TBI Symptoms and PTSD⁴