A Decade of mTBI Experience: What Have We Learned? A Summary of Proceedings From a NATO Lecture Series on Military mTBI.

Mild traumatic brain injury (mTBI, also known as a concussion) as a consequence of battlefield blast exposure or blunt force trauma has been of increasing concern to militaries during recent conflicts. This concern is due to the frequency of exposure to improvised explosive devices for forces engaged in operations both in Iraq and Afghanistan coupled with the recognition that mTBI may go unreported or undetected. Blasts can lead to mTBI through a variety of mechanisms. Debate continues as to whether exposure to a primary blast wave alone is sufficient to create brain injury in humans, and if so, exactly how this occurs with an intact skull. Resources dedicated to research in this area have also varied substantially among contributing NATO countries. Most of the research has been conducted in the US, focused on addressing uncertainties in management practices. Development of objective diagnostic tests should be a top priority to facilitate both diagnosis and prognosis, thereby improving management. It is expected that blast exposure and blunt force trauma to the head will continue to be a potential source of injury during future conflicts. An improved understanding of the effects of blast exposure will better enable military medical providers to manage mTBI cases and develop optimal protective measures. Without the immediate pressures that come with a high operational tempo, the time is right to look back at lessons learned, make full use of available data, and modify mitigation strategies with both available evidence and new evidence as it comes to light. Toward that end, leveraging our cooperation with the civilian medical community is critical because the military experience over the past 10 years has led to a renewed interest in many similar issues pertaining to mTBI in the civilian world. Such cross-fertilization of knowledge will undoubtedly benefit all. This paper highlights similarities and differences in approach to mTBI patient care in NATO and partner countries and provides a summary of and lessons learned from a NATO lecture series on the topic of mTBI, demonstrating utility of having patients present their experiences to a medical audience, linking practical clinical care to policy approaches.

The Stanford Hall consensus statement for post-COVID-19 rehabilitation.

The highly infectious and pathogenic novel coronavirus (CoV), severe acute respiratory syndrome (SARS)-CoV-2, has emerged causing a global pandemic. Although COVID-19 predominantly affects the respiratory system, evidence indicates a multisystem disease which is frequently severe and often results in death. Long-term sequelae of COVID-19 are unknown, but evidence from previous CoV outbreaks demonstrates impaired pulmonary and physical function, reduced quality of life and emotional distress. Many COVID-19 survivors who require critical care may develop psychological, physical and cognitive impairments. There is a clear need for guidance on the rehabilitation of COVID-19 survivors. This consensus statement was developed by an expert panel in the fields of rehabilitation, sport and exercise medicine (SEM), rheumatology, psychiatry, general practice, psychology and specialist pain, working at the Defence Medical Rehabilitation Centre, Stanford Hall, UK. Seven teams appraised evidence for the following domains relating to COVID-19 rehabilitation requirements: pulmonary, cardiac, SEM, psychological, musculoskeletal, neurorehabilitation and general medical. A chair combined recommendations generated within teams. A writing committee prepared the consensus statement in accordance with the appraisal of guidelines research and evaluation criteria, grading all recommendations with levels of evidence. Authors scored their level of agreement with each recommendation on a scale of 0-10. Substantial agreement (range 7.5-10) was reached for 36 recommendations following a chaired agreement meeting that was attended by all authors. This consensus statement provides an overarching framework assimilating evidence and likely requirements of multidisciplinary rehabilitation post COVID-19 illness, for a target population of active individuals, including military personnel and athletes.

Direct Skeletal Fixation in bilateral above knee amputees following blast: 2 year follow up results from the initial cohort of UK service personnel.

AIMS: The aim of the study is to evaluate the clinical outcome and complications from the initial cohort of blast injured bilateral lower limb, above knee amputees who underwent Direct Skeletal Fixation (DSF). PATIENTS AND METHODS: We undertook a retrospective analysis of a prospective data base identifying patients who had undergone implantation with the Australian Osseointegration Group of Australia-Osseointegration Prosthetic Limb (OGAP-OPL) prosthesis, with minimum 24 months follow up. Patient demographics, injury profile, and polymicrobial colonisation status were recorded. Physical functional performance measures recorded were the 6 minute Walk Test (6-MWT) and patient reported outcome measures were the Short Form Health Survey-36 (SF-36). Post operatively, complications including infection, re-operation, and fracture were recorded. RESULTS: 7 patients (14 femora) were identified (mean age 29.8yrs), all injured by dismounted blast. Mean follow up was 46 months. All were polytrauma patients and all had previous polymicrobial colonisation. Following surgery, all patients mobilised with significant improvement in 6-minute walk time, with a mean improvement of 154 m (248 m vs 402 m, p = 0.018). The physical component score for the SF-36 demonstrated a statistically significant improvement from 34.65 to 54.5 (p = 0.018) and the mental component score demonstrated a similar improvement (41.55-58.19 p = 0.018). At follow up, no patient required explantation of the implant. Each had been prescribed a minimum of 1 course of antibiotics with no evidence of deep infection. CONCLUSION: DSF is an option for amputees who, due to the nature of their injuries, may not be able to tolerate traditional suspension socket prostheses and have exhausted all other treatment options. At a minimum of 2 year follow up, the absence of significant infective complications suggests DSF may be utilised in the blast injured despite chronic polymicrobial colonisation. Longer term surveillance of these patients is required to assess the long-term suitability of this technique in this cohort of patients.

Adjusting to persistent post-concussive symptoms following mild traumatic brain injury and subsequent psycho-educational intervention: a qualitative analysis in military personnel.

OBJECTIVE: Best practice guidelines outline ways in which mild traumatic brain injury (mTBI) and persistent post-concussive symptoms (PPCS) should be managed. In line with the existing evidence base, DMRC Headley Court established a treatment programme for UK servicemen and women with mTBI. This study explored the experiences of a sample of UK military personnel living with PPCS, who also received psycho-educational intervention (Phase 2) at this unit. SETTING: DMRC Headley Court, Southeast England. PARTICIPANTS: Sixteen service personnel who had completed the intervention within 24 months prior to interview. DESIGN: Semi-structured qualitative interview study, with purposive sampling and thematic analysis. RESULTS: Participants described their mTBI in terms of: (1) onset; (2) subsequent symptom experience; (3) recovery; and (4) acceptance. All participants reported a significant degree of confusion and chaos in the aftermath of their traumatic event. These themes highlighted how, following enrolment onto the Phase 2 intervention at DMRC Headley Court, participants reported being (largely) able to manage PPCS. Further, many reported acceptance of their condition and described how they had managed to re-establish a sense of order. CONCLUSIONS: Following a flexible and tailored intervention for PPCS, patients report feeling empowered and describe having a renewed sense of stability.

Pituitary dysfunction after blast traumatic brain injury: The UK BIOSAP study.

OBJECTIVE: Pituitary dysfunction is a recognized consequence of traumatic brain injury (TBI) that causes cognitive, psychological, and metabolic impairment. Hormone replacement offers a therapeutic opportunity. Blast TBI (bTBI) from improvised explosive devices is commonly seen in soldiers returning from recent conflicts. We investigated: (1) the prevalence and consequences of pituitary dysfunction following moderate to severe bTBI and (2) whether it is associated with particular patterns of brain injury. METHODS: Nineteen male soldiers with moderate to severe bTBI (median age = 28.3 years) and 39 male controls with moderate to severe nonblast TBI (nbTBI; median age = 32.3 years) underwent full dynamic endocrine assessment between 2 and 48 months after injury. In addition, soldiers had structural brain magnetic resonance imaging, including diffusion tensor imaging (DTI), and cognitive assessment. RESULTS: Six of 19 (32.0%) soldiers with bTBI, but only 1 of 39 (2.6%) nbTBI controls, had anterior pituitary dysfunction (p = 0.004). Two soldiers had hyperprolactinemia, 2 had growth hormone (GH) deficiency, 1 had adrenocorticotropic hormone (ACTH) deficiency, and 1 had combined GH/ACTH/gonadotrophin deficiency. DTI measures of white matter structure showed greater traumatic axonal injury in the cerebellum and corpus callosum in those soldiers with pituitary dysfunction than in those without. Soldiers with pituitary dysfunction after bTBI also had a higher prevalence of skull/facial fractures and worse cognitive function. Four soldiers (21.1%) commenced hormone replacement(s) for hypopituitarism. INTERPRETATION: We reveal a high prevalence of anterior pituitary dysfunction in soldiers suffering moderate to severe bTBI, which was more frequent than in a matched group of civilian moderate to severe nbTBI subjects. We recommend that all patients with moderate to severe bTBI should routinely have comprehensive assessment of endocrine function.

The outcome of British combat amputees in relation to military service.

BACKGROUND: The study aim was to determine the outcome, in relation to military service in UK military combat amputees. PATIENTS AND METHODS: Casualties were assessed at mean 2.4 years after injury and graded by a Functional Activity Assessment (FAA) ranging from 1 (fully fit) to 5 (unfit all duties) to score vocational functional outcome. ISS were calculated and the patients were categorised as having unilateral or multiple amputations. The Short Form-36 Health Survey (SF-36) was completed. RESULTS: Of the 52, 8 patients had left the forces by medical discharge, with 44 continuing to serve. 33 of the 44 had returned to work. 50 patients had FAA grades and were at least 7.6 months post-injury. No patients were graded as FAA1, 8 as FAA2, 18 as FAA3, 19 as FAA4 and 5 as FAA5. There was a trend for the FAA score to increase with injury severity, as measured by ISS i.e. vocational functional outcome was worse with more severe injuries, although this did not reach statistical significance (p=0.095). Multiple amputee patients had significantly higher FAA grades (p<0.001) and were all FAA 4 or 5. Of the 33 patients who had returned to work, 8 were FAA2, 12 FAA3 and 12 FAA4. The mean SF-36 scores for Physical Component Summary (PCS) increased significantly from 36.4 to 43.4 (p=0.001) with rehabilitation, while Mental Component Summary (MCS) was 53.0 and remained similar at 53.6 (p=0.987). MCS scores were similar in these patients to the normal population, 50 (SD 10). CONCLUSIONS: This study is the first to report the outcomes, with regards to return to work, of the UK military amputees injured in Afghanistan and Iraq Soldiers are surviving more severe and complex injuries than before and the majority are able to return successfully to military work. SF-36 PCS scores improve significantly with rehabilitation, and while MCS scores remain constant, the initial assessments are comparable with a normal population.

Comparison of development of heterotopic ossification in injured US and UK Armed Services personnel with combat-related amputations: preliminary findings and hypotheses regarding causality.

BACKGROUND: Recent reports have documented the rate of heterotopic ossification (HO) formation in the residual limbs of combat-related amputees from the US Armed Forces injured in Operations Iraqi and Enduring Freedom. Final amputation level within the zone of injury and blast as the mechanism of injury were identified as possible risk factors for the occurrence and grade of HO. There has been no previous description of HO in combat-related amputees from the UK service personnel. The purpose of this study was to examine potential differences in the prevalence of HO between UK and US Allied Forces, with particular attention to these risk factors, patient exposures, and any treatment differences between these two groups. METHODS: We reviewed the medical records and radiographs of 35 combat-related amputations from the UK and contrasted them with 213 previously reported amputations in US military personnel. We evaluated prevalence and severity of residual limb HO, Injury Severity Score (ISS), the mechanism and zone of injury, type and level of amputation, number of debridements, method of wound irrigation, presence of severe head injury and/or burns injury, use of topical negative pressure therapy and pulse lavage, number of days until wound closure, type of closure, and subsequent infections. All patients had a minimum of 2-month posthospital discharge radiographic follow-up. Comparisons were made using Fisher's exact, one-way analysis of variance, and chi2 analyses. RESULTS: There was no significant difference in either the overall prevalence of HO or the prevalence of moderate to severe HO in the two populations. Twenty of 35 (57.1%) limbs in the UK amputations developed HO compared with 134 of 213 (63%) in the US amputations (p > 0.05). The UK amputations had 12 cases (34.3%) of moderate to severe HO compared with 72 cases (33.8%) in the US amputations (p > 0.05). However, there was a significant difference in the number of UK amputations 0 of 20 (0%) versus the number of US amputations 25 of 134 (12%; p = 0.04), which required excision of symptomatic lesions. There was a significant association in the development of HO in UK personnel with the use of topical negative pressure treatment (p = 0.05) and increasing ISS scores (p = 0.04) and in the development of moderate to severe HO with increasing ISS (p = 0.006) and severe HI (p = 0.04). Unlike in the previous report, no significant association was found in UK personnel between any of the remaining hypothesized risk factors and either the presence or grade of HO. CONCLUSIONS: Although no difference was identified in the overall prevalence of HO, there are inconsistencies in the possible underlying causes of HO between the two cohorts. Further research is required in an ongoing effort to determine a causal relationship between treatment and subsequent HO formation.