Role of Department of Defense Policies in Identifying Traumatic Brain Injuries Among Deployed US Service Members, 2001-2016.

OBJECTIVES: To examine the role of Department of Defense policies in identifying theater-sustained traumatic brain injuries (TBIs). METHODS: We conducted a retrospective study of 48 172 US military service members who sustained their first lifetime TBIs between 2001 and 2016 while deployed to Afghanistan or Iraq. We used multivariable negative binomial models to examine the changes in TBI incidence rates following the introduction of Department of Defense policies. RESULTS: Two Army policies encouraging TBI reporting were associated with an increase of 251% and 97% in TBIs identified following their implementation, respectively. Among airmen, the introduction of TBI-specific screening questions to the Post-Deployment Health Assessment was associated with a 78% increase in reported TBIs. The 2010 Department of Defense Directive Type Memorandum 09-033 was associated with another increase of 80% in the likelihood of being identified with a TBI among soldiers, a 51% increase among sailors, and a 124% increase among Marines. CONCLUSIONS: Department of Defense and service-specific policies introduced between 2006 and 2013 significantly increased the number of battlefield TBIs identified, successfully improving the longstanding problem of underreporting of TBIs.

Continuum of the United States military's traumatic brain injury care: adjusting to the changing battlefield.

Over the past 8 years, advances in the US Military Health System (MHS) have led to extensive changes in the way combat casualty care is provided to deployed service members with a traumatic brain injury (TBI). Changes include the application of cutting-edge Clinical Practice Guidelines, use of pioneering technologies, and advances in evacuation procedures. Compared with previous engagements, current operations occur on a much smaller scale, and more frequently in austere environments, such that effective medical support is increasingly challenging. In this paper, the authors describe key aspects of the current continuum of TBI care in the US military, from the point of injury through rehabilitation, with an emphasis on how emerging technologies and evidence-based Clinical Practice Guidelines assist MHS clinicians with providing the best clinical care possible in the changing battlefield.

Health services and rehabilitation for active duty service members and veterans with mild TBI.

OBJECTIVE: We review health services and reintegration practices that contribute to the rehabilitation of US active duty service members (ADSMs) and Veterans who experienced traumatic brain injury (TBI), especially mild TBI (mTBI), as discussed at the 2015 Department of Veterans Affairs (VA) TBI State-of-the-Art (SOTA) Conference. METHODOLOGY: We reviewed the state-of-the-art at the time of the previous 2008 TBI SOTA Conference, advances in the field since then, and future directions to address gaps in knowledge. MAIN RESULTS: We reviewed: (1) mTBI and its comorbid conditions documented in ADSMs and Veterans, and recognized the need for additional healthcare utilization, health cost and quality of care studies; (2) VA vocational rehabilitation programmes and the effectiveness of supported employment for helping those with workplace difficulties; (3) the application of technology to assist in TBI rehabilitation, including mobile device applications for self-management, videoconferencing with providers, and virtual reality to help with behavioural and cognitive challenges, and (4) Department of Defense (DoD)-VA partnerships on identification, evaluation and dissemination of TBI best practices. CONCLUSIONS: There have been significant advances in TBI rehabilitation, but multiple areas across the DoD and VA care continuum need further exploration and development to meet the needs of ADSMs and Veterans.

Traumatic brain injury screening: preliminary findings in a US Army Brigade Combat Team.

OBJECTIVES: The objective of this article is to report the proportion of soldiers in a Brigade Combat Team (BCT) with at least 1 clinician-confirmed deployment-acquired traumatic brain injury (TBI) and to describe the nature of sequelae associated with such injuries. PARTICIPANTS: Members of an Army unit (n = 3973) that served in Iraq were screened for history of TBI. Those reporting an injury (n = 1292) were further evaluated regarding sequelae. Of the injuries suffered, 907 were TBIs and 385 were other types of injury. The majority of TBIs sustained were mild. METHODS: Postdeployment, responses to the Warrior Administered Retrospective Casualty Assessment Tool (WARCAT) facilitated clinical interviews regarding injury history and associated somatic (ie, headache, dizziness, balance) and neuropsychiatric symptoms (ie, irritability, memory). Traumatic brain injury diagnosis was based on the American Congress of Rehabilitation Medicine mild TBI criteria, which requires an injury event followed by an alteration in consciousness. RESULTS: A total of 22.8% of soldiers in a BCT returning from Iraq had clinician-confirmed TBI. Those with TBI were significantly more likely to recall somatic and/or neuropsychiatric symptoms immediately postinjury and endorse symptoms at follow-up than were soldiers without a history of deployment-related TBI. A total of 33.4% of soldiers with TBI reported 3 or more symptoms immediately postinjury compared with 7.5% at postdeployment. For soldiers injured without TBI, rates of 3 or more symptoms postinjury and postdeployment were 2.9% and 2.3%, respectively. In those with TBI, headache and dizziness were most frequently reported postinjury, with irritability and memory problems persisting and presenting over time. CONCLUSION: Following deployment to Iraq, a clinician-confirmed TBI history was identified in 22.8% of soldiers from a BCT. Those with TBI were significantly more likely to report postinjury and postdeployment somatic and/or neuropsychiatric symptoms than those without this injury history. Overall, symptom endorsement decreased over time.

Traumatic brain injuries sustained in the Afghanistan and Iraq wars.

OVERVIEW: When traumatic brain injury (TBI) occurs simultaneously with more obviously life-threatening wounds, it may go unrecognized. Civilians and military personnel working in or near combat zones are at risk for this injury. Blast-related and closed-head injuries, rather than penetrating injuries, constitute the majority of TBIs in this population. The authors describe the experiences of the Defense and Veterans Brain Injury Center team at Walter Reed Army Medical Center in Washington, DC, and present a composite case to illustrate the nurse's role in the assessment and care of the TBI patient.

Traumatic brain injury in the US military: epidemiology and key clinical and research programs.

Traumatic brain injury (TBI), and particularly concussion, is a major concern for the U.S. Military because of the associated short term disability, long term cognitive and pain symptoms suffered by some, and risk of prolonged or permanent neurologic injury if the Service member incurs a second TBI before full recovery from the first. Concussions were seen more often during the recent conflicts in Afghanistan and Iraq than in prior conflicts, such as the Vietnam War, because of the use of improvised explosive devices that typically caused non-penetrating closed head injury. Since 2000 more than 300,000 Service members were diagnosed with TBI, of which more than 80 % were concussions. Improved TBI screening tools also have identified a higher than expected incidence of concussions occurring in garrison. In this review we summarize current epidemiologic data for TBI in the Military, and describe contemporary Military procedures and strategies for TBI prevention, identification, evaluation, and acute and chronic care. Key TBI clinical research priorities and programs are described, and innovative organizational plans to address future TBI needs are summarized.

Day of injury cognitive performance on the Military Acute Concussion Evaluation (MACE) by U.S. military service members in OEF/OIF.

OBJECTIVES: The study investigated the clinical validity of the cognitive screening component of the Military Acute Concussion Evaluation (MACE) for the evaluation of acute mild traumatic brain injury (mTBI) in a military operational setting. METHODS: This was a retrospective data study involving analysis of MACE data on Operation Enduring Freedom/Operation Iraqi Freedom deployed service members with mTBI. In total, 179 cases were included in analyses based on ICD-9 diagnostic codes and characteristics of mTBI, and availability of MACE data on day of injury. MACE data from the mTBI group was compared to a military sample without mTBI administered the MACE as part of a normative data project. RESULTS: On day of injury, the mTBI group performed worse than controls on the MACE cognitive test (d = 0.90), with significant impairments in all cognitive domains assessed. MACE cognitive score was strongly associated with established indicators of acute injury severity. Lower MACE cognitive performance on day of injury was predictive of lengthier postinjury recovery time and time until return to duty after mTBI. CONCLUSIONS: Findings from the current study support the use of the MACE as a valid screening tool to assess for cognitive dysfunction in military service members during the acute phase after mTBI.

Cognitive rehabilitation for military personnel with mild traumatic brain injury and chronic post-concussional disorder: Results of April 2009 consensus conference.

A consensus conference on cognitive rehabilitation for mild traumatic brain injury was conducted by the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury and the Defense and Veterans Brain Injury Center. Fifty military and civilian subject matter experts from a broad range of clinical and scientific disciplines developed clinical guidance for the care of Service Members with persistent post-concussion cognitive symptoms three or more months post injury. "Cognitive rehabilitation" was identified to be a broad group of diverse services. Specific services within this rubric were identified as effective or not, and were evaluated both as single-services and as combined integrated cognitive rehabilitation programs. Co-morbidities were acknowledged and addressed, but the conference and ensuing guidance focused primarily upon treatment of cognitive impairment. Guidance regarding effective services addressed the areas of assessment, intervention, outcome measurement, and treatment program implementation.

Neuropsychological test performance in soldiers with blast-related mild TBI.

This exploratory study was conducted to increase understanding of neuropsychological test performance in those with blast-related mild traumatic brain injury (mTBI). The two variables of interest for their impact on test performance were presence of mTBI symptoms and history of posttraumatic stress disorder (PTSD). Forty-five soldiers postblast mTBI, 27 with enduring mTBI symptoms and 18 without, completed a series of neuropsychological tests. Seventeen of the 45 met criteria for PTSD. The Paced Auditory Serial Addition Test (Frencham, Fox, & Mayberry, 2005; Spreen & Strauss, 1998) was the primary outcome measure. Two-sided, 2-sample t tests were used to compare scores between groups of interest. Presence of mTBI symptoms did not impact test performance. In addition, no significant differences between soldiers with and without PTSD were identified. Standard neuropsychological assessment may not increase understanding about impairment associated with mTBI symptoms. Further research in this area is indicated.

Traumatic brain injuries sustained in the Afghanistan and Iraq wars.

UNLABELLED: Because these injuries can go unrecognized, nurses stateside need to know how to recognize possible cases and how to help. OVERVIEW: When traumatic brain injury (TBI) occurs simultaneously with more obviously life-threatening wounds, it may go unrecognized. Civilians and military personnel working in or near combat zones are at risk for this injury. Blast-related and closed-head injuries, rather than penetrating injuries, constitute the majority of TBIs in this population. The authors describe the experiences of the Defense and Veterans Brain Injury Center team at Walter Reed Army Medical Center in Washington, DC, and present a composite case to illustrate the nurse's role in the assessment and care of the TBI patient.