Traumatic brain injury (TBI), in particular mild TBI (mTBI), is a relatively common injury experienced by service members across both deployed and nondeployed environments. Although many of the principles and practices used by civilian health care providers for identifying and treating this injury apply to military settings, there are unique factors that impact mTBI-related care in service members and Veterans. This article reviews several of these factors, including the epidemiology of TBI in the military/Veteran population, the influence of military culture on this condition, and identification and treatment of mTBI in the war zone.
Key points
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Traumatic brain injury (TBI), in particular mild TBI, is a relatively common injury experienced by service members across both deployed and nondeployed environments.
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Several unique aspects of the military environment render the identification and treatment of service members and Veterans who experience a TBI dissimilar from their civilian counterparts.
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The Departments of Defense and Veterans Affairs have developed specific protocols and systems of care for addressing TBI-related care in deployed and nondeployed environments.
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Comorbidities are a frequent occurrence with service members and Veterans with history of TBI that represent for care and must be considered in treatment planning.
Introduction/epidemiology of traumatic brain injury in the military
Prompted by the protracted nature of the conflicts in Afghanistan and Iraq and by enemy combatants’ frequent use of explosive devices, traumatic brain injuries (TBI) have become the focus of notable clinical and research attention in the military and Veteran health care environments. Although many of the medical principles and treatment protocols used in the civilian sector to evaluate and treat TBI are applicable to care in the military, there are several unique factors specific to this injury in military and Veteran populations. These factors, which include sustainment of injuries within combat zones, distinct mechanisms of TBI, psychiatric comorbidities, and influences of the military culture on health care utilization, are the focus of this review.
According to the Defense and Veterans Brain Injury Center, between 2000 and the first quarter of 2016, there have been approximately 348,000 active duty military service members (SMs) who have experienced a TBI. These injuries increased from 10,958 in 2000 to a peak of 32,907 in 2011. The annual number of SMs diagnosed with a TBI then steadily declined to 22,594 in 2015. The vast majority of these injuries (82%) have been categorized as mild in severity, and as such, mild traumatic brain injury (mTBI) is the primary focus of this review. As SMs separate from active duty status, their treatment transitions to the Veterans Health Administration (VHA), which also tracks epidemiologic data. In fiscal year 2014, 7% of Iraq and Afghanistan War Veterans seen in the VHA system carried a diagnosis of TBI. According to Taylor and colleagues, in 2014 the average cost of health care services in those with a diagnosis of TBI (mean = $15,161 [SD = $33,460]) was consistently higher than those without such a diagnosis (mean = $5058 [SD = $12,368]); this difference represents a moderate effect size (Cohen’s d = .40). Moreover, in 2014, 6% of Veterans were service connected for TBIs.
Despite the attention given to injuries sustained in the combat theater, most recorded concussions occur in garrison (nondeployed) environments. Outside of deployment to a combat zone, SMs routinely engage in operational and training activities that are physically demanding and can increase the risk for TBIs. Furthermore, as most SMs are men between 18 and 24 years of age, there is a higher demographic risk for concussion via events like motor vehicle crashes and sporting and recreational activities. Consequently, even with the relatively recent reduction of SMs deployed in support of direct combat operations, TBI will continue to be a condition of interest in the military and Veteran populations. Several factors reviewed in later discussion are unique to the military and Veteran populations and should be considered in evaluating and treating TBI within these populations.
Introduction/epidemiology of traumatic brain injury in the military
Prompted by the protracted nature of the conflicts in Afghanistan and Iraq and by enemy combatants’ frequent use of explosive devices, traumatic brain injuries (TBI) have become the focus of notable clinical and research attention in the military and Veteran health care environments. Although many of the medical principles and treatment protocols used in the civilian sector to evaluate and treat TBI are applicable to care in the military, there are several unique factors specific to this injury in military and Veteran populations. These factors, which include sustainment of injuries within combat zones, distinct mechanisms of TBI, psychiatric comorbidities, and influences of the military culture on health care utilization, are the focus of this review.
According to the Defense and Veterans Brain Injury Center, between 2000 and the first quarter of 2016, there have been approximately 348,000 active duty military service members (SMs) who have experienced a TBI. These injuries increased from 10,958 in 2000 to a peak of 32,907 in 2011. The annual number of SMs diagnosed with a TBI then steadily declined to 22,594 in 2015. The vast majority of these injuries (82%) have been categorized as mild in severity, and as such, mild traumatic brain injury (mTBI) is the primary focus of this review. As SMs separate from active duty status, their treatment transitions to the Veterans Health Administration (VHA), which also tracks epidemiologic data. In fiscal year 2014, 7% of Iraq and Afghanistan War Veterans seen in the VHA system carried a diagnosis of TBI. According to Taylor and colleagues, in 2014 the average cost of health care services in those with a diagnosis of TBI (mean = $15,161 [SD = $33,460]) was consistently higher than those without such a diagnosis (mean = $5058 [SD = $12,368]); this difference represents a moderate effect size (Cohen’s d = .40). Moreover, in 2014, 6% of Veterans were service connected for TBIs.
Despite the attention given to injuries sustained in the combat theater, most recorded concussions occur in garrison (nondeployed) environments. Outside of deployment to a combat zone, SMs routinely engage in operational and training activities that are physically demanding and can increase the risk for TBIs. Furthermore, as most SMs are men between 18 and 24 years of age, there is a higher demographic risk for concussion via events like motor vehicle crashes and sporting and recreational activities. Consequently, even with the relatively recent reduction of SMs deployed in support of direct combat operations, TBI will continue to be a condition of interest in the military and Veteran populations. Several factors reviewed in later discussion are unique to the military and Veteran populations and should be considered in evaluating and treating TBI within these populations.
Military culture
Over the past 25 years, there has been a growing appreciation that individual factors, such as one’s cultural identification, can influence medical treatment, development of a therapeutic alliance, and health care outcomes. Although cultural competence in modern health care has frequently focused on the influence of various ethnic and religious backgrounds, individuals who have served in the US military identify with a military culture that has its own set of unique values, traditions, language, and customs. Military values such as selfless service, mission focus, and decreased focus on personal needs over the good of the group are entrenched through military service and training. High levels of acculturation often remain following the end of a military career, as can be exemplified by the clothing and hats worn by Veterans in the community. Although some military personnel and Veterans receive their care in the Military Healthcare System and Veterans Healthcare System, nearly 66% of Veterans access their health care entirely in civilian settings. Accordingly, health care providers treating individuals with TBI need to have an understanding of and sensitivity to military culture to optimize health care outcomes.
For clinicians working with SMs and Veterans with TBI, military cultural competence is important in optimizing communication and developing skills to promote a strong therapeutic alliance and provide effective clinical care. Core values of military service that may serve as motivation and inspiration during the course of rehabilitation include (1) personal courage, (2) not accepting failure, (3) self-sacrificing, and (4) a commitment to the mission. The physical and psychological strength required to accomplish a mission can be recruited to persevere through challenges and reach treatment goals. Group-based treatment within a rehabilitation milieu can be adapted to align with military values of teamwork and comradery. Inclusion of family members, where applicable, can enhance compliance in Veterans and SMs.
In addition to fostering those military values that may enhance rehabilitation treatment, it is important to be sensitive to cultural issues that can represent a barrier to treatment or compliance with treatment recommendations. As discussed in other sections of this article, psychological comorbidities occur at a higher rate in those with deployment-related TBI than in the civilian population. In addition, there remains a stigma attached to behavioral health treatment for many individuals who served in the military, related to a perceived negative impact on one’s military career, self-sacrifice as a core military value, and the belief that accessing mental health care may indicate failure. For those who served in battle, exposure to life-threatening danger and death may alter life perspectives and expectations. Wounds may be not only physical or mental, but also moral, from participating in or witnessing traumatic events. Particularly in the context of moral injuries, clinicians need to be sensitive to the role of spirituality as it relates to resilience, healing, and recovery from the patient’s perspective. Fostering resilience through social supports, such as family and spirituality, as well as integration of behavioral health treatment into TBI care can help enhance this process and protect the individual from feeling alienated or becoming noncompliant with treatment recommendations.
In a recent RAND report on capacity to provide culturally competent care to military personnel and their families, cultural competence was operationalized through 3 general areas: (1) familiarity and awareness of military and Veteran culture; (2) comfort level in working with military/Veterans and their families; and (3) skills/training in serving this population. General principles to enhance cultural competence in one’s practice should include asking about military experience (including family members) when taking a clinical history, clarifying unfamiliar acronyms or military language, and considering military cultural factors when developing treatment plans and recommendations. Although there is a growing movement to integrate formal training about military culture into medical school curricula on a more systematic basis, many tools/training resources are currently available to enhance military/Veteran cultural competence in serving individuals with TBI and their families. For example, Ross and colleagues provide a listing of specific resources reproduced in Table 1 .
| Topic | Instruction Focus | Teaching Methods | Teaching Resources (Ref.) |
|---|---|---|---|
| VHA utilization | Share patterns of Veteran usage of VHA health care facilities | Focus didactics/lecture Self-paced learning | |
| Military cultural competence/consciousness | Provide trainees with an overview of the structure of the US military and military conflicts, and demographic background of US Veterans, as well as military socialization processes, traditions, values, and behavioral norms | Focus didactics/lecture Self-paced learning | |
| Military health history | Demonstrate how to obtain a focused military history, elicit service-related health concerns, and assess life stressors | Vignettes/trigger tapes Medical encounter videos | |
| Health care disparities | Identify causes of health disparities for US Veterans, highlighting the social determinants of health and the ways in which social location creates challenges in optimal health care | Problem-based learning cases Individual care-based discussion | |
| Empathetic communication | Instruct trainees to provide care that is concordant with the patient’s values and preferences that promotes active participation in decision making regarding their health and health care | Faculty role models/mentors Medical encounter video | |
| Common diagnoses in Veterans | Summarize conditions particularly prevalent in Veterans (eg, PTSD, TBI, anxiety, depression) and instruct trainees on how to identify these conditions within this population | Individual case-based discussion Workshops Problem-based learning cases | |
Identifying and treating concussion in the war zone
The theater of combat provides unique challenges to the identification and treatment of concussion that are distinct from injuries sustained in civilian settings. Historically, SMs in a combat zone have been unlikely to come forward with or be recognized for injuries that are not easily visible. That is, for injuries involving external indications of damage (eg, compound fractures, external bleeding, inability to breathe, extended loss of consciousness), the need for medical care is accepted. However, for injuries that are not readily evidenced by external signs, many SMs will seek to avoid medical care in an effort to continue mission engagements with their units. mTBI is such an injury whereby the pursuit of subsequent medical care has been limited, particularly within the first several years of the conflicts in Iraq and Afghanistan. Beyond the point of injury, when SMs return from deployment, there are mandated postdeployment screening measures that include evaluation for concussion-related symptoms. However, once injuries are reported, medically related appointments can be scheduled and delay the SM’s postdeployment leave and family reunification. Consequently, injuries and symptoms may be minimized at this time, which could conceivably forestall treatment and potentially complicate care. As the effects of mTBI on the war fighter have become better understood, policy has been instituted to more effectively identify and manage these injuries. Clinical and educational efforts have been aimed at improving early identification of mTBI as well as standardizing guidelines for return to duty.
In regards to clinical care in the deployed environment, a concussion management algorithm was established by the Department of Defense (DoD). This policy, instituted in 2012 and in effect through 2022, mandates use of the most recent DoD clinical practice guidelines and management algorithms in the deployed environment. At present, this states that SMs involved in a potentially concussive event are required to have at least 24 hours of rest and symptom resolution before returning to duty. If an SM experiences 2 concussions in a 12-month period, he or she is mandated an additional 7 days of rest following symptom resolution. With 3 diagnosed concussions within the past 12 months, a recurrent concussion evaluation is to be engaged. This comprehensive evaluation includes neurologic, neuropsychological, and functional assessments, with appropriate neuroimaging as indicated. In addition, all concussion evaluations require the administration of the Military Acute Concussion Evaluation (MACE). This mTBI screening and mental status evaluation have standardized the examination of acute and subacute concussion care across DoD medical providers and paraprofessionals. Next, since 2007, the DoD has mandated that each deploying SM complete baseline neurocognitive testing within 12 months of scheduled deployment. The Automated Neuropsychological Assessment Metrics (ANAM) was chosen as the neurocognitive assessment tool for the vast majority of SMs across the DoD. This measure can also be administered postinjury in theater, so that providers can use comparison scores to assist in return to duty decisions. These policies and related clinical tools have positively impacted TBI-related care in the combat theater. In Afghanistan, regional Concussion Care Centers (CCCs) staffed by specialty providers with expertise in concussion and rehabilitation were established so that SMs could obtain necessary services in theater. The CCCs allowed for 7 to 10 days of structured return to duty programs that reduce the need to medically evacuate SMs from the war zone. Of note, given the high incidence of concussion in nondeployed environments, the Army mandated nearly identical management algorithms for Soldiers experiencing an mTBI in garrison.
In regards to education, the DoD has implemented mandatory training sessions for all personnel that address the nature of mTBI, the mandated requirements for care, and the likely short-term impacts on unit readiness. The overarching message of such training is that SMs who experience an mTBI are expected to return to duty in a relatively short period of time; however, management of symptoms in the acute and subacute phases of recovery are essential to ensure optimal outcomes. Training is also required for all credentialed health care providers regardless of specialty, including primary care providers (PCP), medics, and non-PCPs. Given that most acute or subacute mTBIs can be successfully managed in primary care, the most intense of these trainings is for the PCP. Of note, as most of mTBIs occur in nondeployed settings, concussion-related training is mandated not only for those SMs that deploy but also for all civilian and active duty providers in garrison.
Mechanism of Injury
Mechanism of injury, and more specifically, high rates of blast-related injuries, further differentiates military TBI from TBI in the civilian sector. Briefly, blast-related injuries can be primary (ie, injury due to rapid atmospheric pressure changes), secondary (ie, impact injury resulting from propelled debris), tertiary (ie, injury from being thrown by the blast), or quaternary (eg, burns, toxic exposure following the blast). Moreover, the frequent occurrence of blast exposure in combat has resulted in a significant population of military personnel who sustained injuries to multiple body regions and/or systems (eg, amputations, visual damage, burns) in addition to TBI, which is classified as a “polytrauma injury” within the DoD and VHA systems of care (discussed later). Despite the complex medical and mental health comorbidities often associated with blast-related polytrauma, to date, studies have generally revealed few differences between blast- and non-blast-related TBIs for postconcussion symptom endorsement, neuropsychological test performance, or psychological symptoms, suggesting that the mechanism of injury may not be as critical as the actual TBI with regard to these functional outcomes.
Veterans health administration and department of defense systems of care for identification and treatment of traumatic brain injury after deployment
Traumatic Brain Injury Screening
Because of the increase in polytrauma injuries and concomitant increase in TBI seen in returning active duty personnel, the VHA and DoD developed a comprehensive and integrated system of care to treat TBI, particularly those with associated physical and emotional comorbidities. Because mTBI is so common in those injured, and because it is not always an obvious or visible injury, a system was needed to identify these patients and triage them accordingly. The DoD instituted Post-Deployment Health Assessment (PDHA) and Reassessment (PDHRA) programs. The PDHA is scheduled with trained health care providers within 30 days from deployment return. The purpose is to review each service member’s current health, mental health, psychosocial issues commonly associated with deployments, possible deployment-related occupational and environmental exposures (including TBI), and to discuss deployment-related health concerns. Positive responses require supplemental assessment and/or referrals for medical consultation. Similarly, the PDHRA, which is completed within 3 to 6 months after return from deployment, is designed to identify and address health concerns, with specific emphasis on mental health, that have emerged over time since deployment.
Similarly, VHA implemented a series of Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn clinical reminders (ie, mandated clinical questions to ask the Veteran, prompted by the electronic medical record), including a TBI clinical reminder protocol. Clinical reminders are completed by any provider within the VHA system of care who first encounters that patient following deployment. In addition to first asking about deployment location, the TBI screen asks the Veteran whether they have already been diagnosed with TBI related to deployment. Those who confirm deployment and report no prior TBI diagnosis are asked additional questions about: (1) injury event, (2) immediate loss or alteration of consciousness, (3) immediate/acute postconcussive symptoms, and (4) current (past week) postconcussive symptoms. A positive response to all 4 sections constitutes a positive screen. The screen is to be repeated if a Veteran is redeployed. Positive screens automatically generate a consult to a TBI specialist or specialty clinic if the Veteran agrees to further assessment or care. This mandated follow-up evaluation, called the Comprehensive TBI Evaluation, consists of further evaluation of blast exposures and TBI events, targeted review of systems, and a physical examination. The purposes of the follow-up evaluation are to (1) confirm the diagnosis of TBI, even if the present symptoms are thought to be secondary to other factors such as posttraumatic stress disorder (PTSD), stress, depression, or chronic pain; and (2) institute an appropriate plan for follow-up care (eg, other evaluations or diagnosis-based or symptom-based treatment). A VA/DoD evidence-based mild TBI treatment guideline was developed ( http://www.healthquality.va.gov/management_of_concussion_mtbi.asp ) to help the clinician develop a plan of care and treat the symptom complex identified through the comprehensive evaluation. So, for instance, if concentration problems are endorsed, a review of sleep hygiene is one of many recommended assessments, along with possible treatments.
Traumatic Brain Injury Rehabilitation
Stateside, the rehabilitation process for those returning from combat theater begins at acute medical settings, such as Military Treatment Facilities with the initiation of individual physical, occupational, and speech therapy. Collaboration via video teleconferences has allowed earlier physiatric input into the care of these complex patients and helped to coordinate a smooth transition from acute care facilities to rehabilitation units.
In response to the complexity inherent in those returning from war for rehabilitation, VHA set up a Polytrauma System of Care housed at its existing TBI Centers. This entire system of care is described in detail elsewhere. Briefly, the Polytrauma System of Care has the 4 following components:
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Polytrauma Rehabilitation Centers (located in Tampa, FL; Minneapolis, MN; Palo Alto, CA; Richmond, VA; San Antonio, TX) provide acute medical and rehabilitation care, research, and education related to polytrauma/TBI within the context of accreditation by the Commission on Accreditation of Rehabilitation Facilities for both acute TBI and Comprehensive Rehabilitation.
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Polytrauma Network Sites (located within each of VHA’s regional Veterans Integrated Service Networks) provide postacute rehabilitation care for individuals with polytrauma/TBI, including inpatient and outpatient rehabilitation and vocational rehabilitation programs. They are responsible for coordinating access to services to meet the needs of patients recovering from polytrauma.
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Polytrauma Support Clinic Teams are geographically distributed across VHA to facilitate access to specialized rehabilitation services close to the Veterans’ and active duty SM’s home communities. These interdisciplinary teams of rehabilitation specialists are responsible for managing the care of patients by providing treatment plans, regular follow-up, and any care needs as they arise.
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Polytrauma Points of Contact in remaining facilities are responsible for managing consultations for patients with polytrauma and referring these patients to appropriate programs.
Disability Process
Patients who participate in rehabilitation frequently are involved in disability proceedings. When SMs develop a medical condition that may render them unable to continue their military service, they are entered into the Integrated Disability Evaluation System (IDES), which combines the DoD Disability Process with the Veterans Affairs (VA) Disability Process. The first half of the IDES is known as the Medical Evaluation board (MEB) process. Eventually, a VA disability claim is filed and a Compensation and Pension evaluation is scheduled. The purpose of these processes is to ascertain the history and severity of the SM’s medical conditions and their impact on his/her ability to perform job duties. As noted above, disability for mTBI is not uncommon with an estimated 6% of Veterans carrying a service connection for mTBI. Of note, within the context of mTBI, validity of data obtained in various evaluations must be considered. For example, in cognitive testing of mTBI patients in Veteran settings, questionable validity is obtained in 29% to 59% of cases. In active duty patients, the rate varies from 38% to 59%, depending on which performance validity measure is used and whether the sample exclusively consisted of those involved in an MEB. In military samples with a history of mild TBI, performance validity test results account for the most variance in cognitive test scores, above demographic, concussion history, symptom validity, and psychological distress variables. Although much of the research on validity testing uses professional or paraprofessional administered instruments specific to cognition, a few self-report measures designed to assess respondent validity and possible overreporting have been developed. The mild Traumatic Brain Injury Atypical Symptoms scale and Validity-10 of the Neurobehavioral Symptom Inventory (NSI) can be administered across a variety of medical disciplines, to include primary care and physiatry. Although these measures are not as sensitive to invalid test performance and symptom exaggeration as traditional neuropsychological measures of performance and symptom validity, they can serve to alert the evaluating provider of gross levels symptom exaggeration.
Related posts:
Management of Medical Complications During the Rehabilitation of Moderate-Severe Traumatic Brain Injury
Diagnosis and Management of Acute Concussion
Rehabilitation of Persistent Symptoms After Concussion
Educational and Vocational Issues in Traumatic Brain Injury
Research Frontiers in Traumatic Brain Injury
Toward a Postmodern Pragmatic Discourse Semioethics for Brain Injury Care
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