Defense and Veterans Brain Injury Center: The First 25 Years

Abstract

OVER its first 25 years, the Defense and Veterans Brain Injury Center (DVBIC) has conducted high-impact work, bringing knowledge and resources to the care of service members injured by traumatic brain injury (TBI) and Veterans who were often invisible in the past. In this special issue of Journal of Head Trauma Rehabilitation (JHTR), this article highlights major DVBIC contributions. In February 1992, Congressional legislation authorized the stand-up of a head injury program currently known as DVBIC, forming a unique collaboration between the Department of Defense (DoD), the Department of Veterans Affairs (VA), and the Brain Injury Association of America. DVBIC is the first program coordinating services between the DoD and VA for TBI patients. Initially named as the Defense and Veterans Head Injury Program, it started its functions at 3 military treatment facilities (MTFs) and 4 VA hospitals. In 2001, the program was renamed as the “Defense and Veterans Brain Injury Center.” DVBIC has since grown to 22 sites: 17 MTFs and 5 VA hospitals, anchored by its headquarters in Silver Spring, Maryland. By facilitating communication between healthcare providers, standardizing the definition of TBI severity within the DoD and VA, conducting more joint research projects and educational efforts, and developing new clinical practice recommendations, DVBIC has become a model for coordination of care between the DoD and VA. DVBIC has made substantial contributions to the evidence and treatment guidelines for TBI treatment, prognosis, and prevalence. It conducted the first randomized clinical trial (RCT) of TBI rehabilitation and followed up with a second rehabilitation trial of 2 treatment approaches to TBI in 4 VA centers. DVBIC has led large longitudinal studies to determine prognostic indicators of outcomes after TBI, developed screening tools for in-theater assessment of TBI, and tools for the TBI screening of soldiers returning from Afghanistan and Iraq. It has been in the forefront of developing clinical recommendations (CRs) and guidelines for the treatment of symptoms and problems after military TBI and has provided continual educational programs for clinicians through webinars, talks, and seminars at professional meetings and annual summits, bringing together providers and researchers to discuss updated tools and research findings. DVBIC along with 4 other federal agencies developed sets of standardized common data elements to permit researchers to better compare findings and more quickly advance evidence on TBI. It is recognized as the authoritative place to obtain information on the numbers of service members injured with TBI. DVBIC is designated as the office of responsibility for ensuring standardization of TBI care (eg, categories 1-4) across MTF TBI clinics in each of the service branches. DVBIC promotes standardization through educational efforts to disseminate best practices, site visits, program improvement initiatives, and collaboration with the services. In addition, DVBIC serves as the single point of contact for knowledge on TBI research for the military health system (MHS) by identifying clinical and translational research being done on TBI within or funded by the MHS. Moreover, DVBIC assists with MHS gap identification and analysis to encourage research in areas identified as critical to the military. Prior to DVBIC, military and civilian research on TBI, particularly concussion, was sparse.1 In the past few decades, TBI has received growing attention in both the military and civilian populations. During peacetime in the 1990s, Army researchers studying hospitalization rates found training and motor vehicle accidents accounted for many TBIs.2 Army hospitalization rates decreased over the decade as the efforts in prevention, safety, and education increased. Training and regulations most likely contributed to this decline. However, with the onset of Operation Enduring Freedom (OEF) and subsequently Operation Iraqi Freedom (OIF), administrative data from 2000 to 2006 indicate that in the active-duty Army population, the hospitalized TBI incident rate doubled. The rate for TBI attributed to weapons increased 60%.3 From the beginning, DVBIC conducted its operations adopting the guiding principle of “learn as we treat”4 and benefitted from its leadership's clinical and research experience with TBI patients. Colonel Andres Salazar, the first DVBIC director (1992-2001), led an intensive investigation of penetrating head injury incurred in Vietnam (subsequent to the death of the study's original investigator). The landmark Vietnam Head Injury Study (VHIS) identified the consequences of penetrating head injury and resulted in more than 100 publications. Early versions of DVBIC programs and projects led by the clinical and research staff (eg, care coordination, follow-up, and educational programs) were subsequently adopted and revised to meet the needs of wounded service members from OEF, OIF, and Operation New Dawn (OND). During OEF/OIF/OND, DVBIC national directors in uniform—Colonel Michael Jaffee (2007-2010), Colonel Jamie Grimes (2010-2013), and Colonel Sidney Hinds II (2013-2016)—contributed to the development of in-theater concussion clinics and guidance for in-theater TBI evaluation and care. In 2009, Admiral Michael Mullen, the Chairman of the Joint Chiefs of Staff, activated the “Grey Team.” The initial team included Colonel Jaffee and was the first military medical assessment team to evaluate and provide recommendations for in-theater TBI care. As part of the Grey Team in 2011, Colonel Grimes traveled to each of the major concussion care sites, deployed to the Afghanistan Theatre of Operation, and served on the Grey Team's tour at Baghram Air Force Base and other NATO (North Atlantic Treaty Organization) locations. Colonel Grimes and Colonel Hinds each served as the in-theater neurology consultant in Afghanistan, overseeing concussion care centers and 3 magnetic resonance imaging (MRI) machines. Colonel Hinds was the primary author for translating the Department of Defense Instruction (DoDI)/Directive Type Memorandum into theater-specific mild TBI and MRI standards, allowing for operationalization. Colonel Geoffrey Grammer (national director 2016-2017) served as medical director for the 785th Combat Stress Control Company and as a psychiatrist at the combat support hospital at Contingency Operating Base Speicher and in Baghram. DVBIC's international contributions in the field of TBI extend beyond deployed US forces as seen with its participation with NATO. In 2009, the NATO Science and Technology Organization formed Task Group 193 to describe and summarize current knowledge and existing clinical practices in managing mild traumatic brain injury (mTBI) occurring in a military operational setting. Members of the task group included representatives from the United States, the United Kingdom, Sweden, Canada, France, and the Netherlands. The US delegation included DVBIC members Colonel Grimes, Colonel Jaffee, Dr Karen Schwab, and Ms Katherine Helmick. The task group's final report was published in January 2015.5 In 2007, DVBIC became the TBI component center of the Defense Centers of Excellence (DCoE) for Psychological Health and Traumatic Brain Injury. In 2016, DCoE became a part of the Defense Health Agency. DVBIC continues to carry out its critical missions, mandated by Congress and the Secretary of Defense, to (1) conduct clinical research, (2) develop clinical standards, (3) provide TBI education, and (4) provide DoD TBI surveillance and tri-service coordination of predeployment cognitive testing.6 As part of its surveillance role, DVBIC consolidates quarterly reports on all DoD TBI-related incidences and prevalence data, capturing and classifying TBI severity data. These widely cited DoD Worldwide Numbers reports are posted on the DVBIC Web site (http://dvbic.dcoe.mil/dod-worldwide-numbers-tbi).7 The DoD designated DVBIC to oversee the TBI Pathway of Care for the military. DVBIC NETWORK Currently, the DVBIC network includes 22 sites located at Walter Reed National Military Medical Center (Maryland), San Antonio Military Medical Center (Texas), Naval Medical Center San Diego (California), Camp Lejeune (North Carolina), Camp Pendleton (California), Fort Belvoir (Virginia), Fort Bragg (North Carolina), Fort Carson (Colorado), Fort Hood (Texas), Joint Base Elmendorf-Richardson (Alaska), Landstuhl Regional Medical Center (Germany), Fort Gordon (Texas), Fort Drum (New York), Fort Bliss (Texas), Fort Campbell (Kentucky), Joint Base Lewis-McCord (Washington), and the US Special Operations Command, Florida; network sites located at 5 VA hospitals: Richmond (Virginia), Tampa (Florida), Minneapolis (Minnesota), Palo Alto (California), and San Antonio (Texas). SELECTED DVBIC RESEARCH FINDINGS An early “Lessons Learned” conference, jointly sponsored by DVBIC and the Uniformed Services University of the Health Sciences in 2004, revealed the need for clinical guidelines for the treatment of combat-related brain injury. This provided impetus for DVBIC leadership to develop guidelines for the treatment of military concussion and updates for penetrating TBIs. The 2006 publication, “Military TBI During the Iraq and Afghanistan Wars,” by Dr Deborah Warden, DVBIC's national director from 2001 to 2007, was a major milestone, setting the stage for conceptualizing and describing wartime TBIs and remains one of the most cited TBI publications.8,9 During its first 25 years, DVBIC produced more than 480 peer-reviewed publications (http://dvbic.dcoe.mil/research/browse/dvbic-publications)10 from more than 100 research studies. These studies built upon the legacy of the VHIS, thus making major contributions to the evidence base for military and veteran TBIs. Studies have and continue to address short- and long-term sequelae, treatments, comorbid diagnoses, implications for families, and productivity at work and school. DVBIC publications encompassed epidemiological research, clinical trials, measurement and instrument validation and reliability, systematic reviews, case studies, CRs, wartime TBIs (to include blast TBIs), and cognitive rehabilitation. DVBIC produced 2 of the 3 class I studies on comprehensive TBI rehabilitation cited in research reviews.11–13 DVBIC clinical research studies included the following. Cognitive rehabilitation for TBI A single-center RCT was conducted in January 1992 through February 1997 at the Walter Reed Army Medical Center, Washington, District of Columbia. The study by Salazar et al was pivotal for military TBI. In total, 120 active-duty patients with moderate to severe TBI were randomized to either “an intensive, standardized, 8-week in-hospital cognitive rehabilitation program or a limited home rehabilitation program with weekly telephonic support from a psychiatric nurse.”14(p3075) Results from the 12-month follow-up, the primary findings from this study, were published in JAMA in June 2000.14 Prior to this study, active-duty service members who sustained a moderate to severe TBI were medically boarded/discharged from the military. However, the study indicated that some of those TBI patients could successfully return to duty. Moreover, the study showed that RCTs to evaluate TBI rehabilitation interventions were possible to conduct. This study was the first of its kind study, addressing cognitive rehabilitation in a full TBI rehabilitation program. Another cognitive rehabilitation study was conducted at the 4 inpatient VA polytrauma sites. This VA RCT of 2 types of TBI rehabilitation enrolled 366 patients from 1996 to 2003 for 60 days of protocol treatment. One-year posttreatment follow-up was conducted. This study was “the first randomized clinical head-to-head comparison of 2 acute inpatient interdisciplinary rehabilitation approaches to treating moderate to severe TBI-cognitive didactic versus functional experimental.” A second goal was to determine treatment efficacy for different patient subpopulations. Primary findings were published in the Archives of Physical Medicine and Rehabilitation in December 2008, with results indicating “improved but similar long-term global functional outcome” when “comparing cognitive-didactic and functional experiential approaches to brain injury rehabilitation.” “Participants in the cognitive treatment arm achieved better short-term functional cognitive performance than patients in the functional treatment arm.”15 SCORE/iSCORE The Study of Cognitive Rehabilitation Effectiveness (SCORE) was completed in 2014 at Brooke Army Medical Center in San Antonio, Texas. Researchers evaluated the effectiveness of integrated cognitive rehabilitation treatments in OEF and OIF Veterans with a history of mTBI symptoms persisting for 3 to 24 months. The study goal was to determine the most effective therapies associated with better treatment outcomes for chronic mTBI symptoms, on whom, and why. Following an interim report to Congress including description of the study's preliminary findings, results were disseminated at scientific conferences and publications in 2015. Study manuals are posted on the DVBIC Web site (http://dvbic.dcoe.mil/study-manuals).16 The primary article describing this study was published in 2016 in the Journal of Head Trauma Rehabilitation, with results indicating “both therapist-directed cognitive rehabilitation (CR) and integrated CR with cognitive-behavioral psychotherapy reduced functional cognitive symptoms in service members after mTBI beyond psychoeducation and medical management alone.”17 An imaging component of the study, called iSCORE, seeks to understand the mechanisms involved in treatment effectiveness using noninvasive brain imaging (structural/anatomical and functional) indices in combination with behavioral measures that include treatment outcome data. iSCORE data aim to enhance the ability to predict treatment responsiveness focused on cognitive rehabilitation, using clinically relevant MRI data to drive diagnosis and treatment of mTBI. The study was designed to (1) determine the neural correlates of persistent symptoms 3 to 24 months following mTBI (thereby providing a window into what neural factors can predict outcomes) and (2) correlate measures of perceived effort (qualitative and quantitative) with imaging results and outcomes following cognitive rehabilitation. Primary and secondary outcome measures from SCORE and iSCORE will be placed in a series of general linear models to correlate with neuroimaging data. Results to date indicate significant differences in the shape of subcortical structures (ie, thalamus, caudate, nucleus accumbens) for TBI patients compared with posttraumatic stress disorder (PTSD) and orthopedic controls. These findings indicate potentially diagnostic aspects of TBI pathophysiology, which require further study. These findings have been published in the Journal of Neurology in 201618 and in Military Medicine in 2017.19 Head to Head Researchers at the DVBIC site at Fort Bragg, North Carolina, compared and evaluated the reliability and validity of 4 computerized neurocognitive assessment tools (NCATs) used to identify service members who sustained a TBI in the military environment. Enrollment was completed in 2014. There are 2 publications on reliability: in 2013, Archives of Clinical Neuropsychology,20 and in 2016, The Clinical Neuropsychologist. Results indicated that the test-retest reliability for each test was less than optimal.21 The validity article was published in 2016 by the Journal of Clinical and Experimental Neuropsychology. Results indicated that TBI did affect performance in all NCATs; however, the effect was small. Furthermore, correlations between NCAT scores and scores from a traditional paper-and-pencil neuropsychological test battery were small.22 A systematic literature review article was published in 2017 in Concussion.23 15-year studies Under the umbrella name of “the 15-year studies,” several projects/studies began in 2010 and are conducted in collaboration with the VA, the Center for Neuroscience and Regenerative Medicine, the University of Michigan, the National Institutes of Health, and other DVBIC sites. Walter Reed National Military Medical Center leads this 15-year longitudinal study. Goals of these projects include developing a data repository of clinical and health information and biospecimens collected from injured and noninjured service members, documenting long-term outcomes to improve understanding of TBI in a military cohort (OEF and OIF service members and Veterans), investigating the effect of caring for a service member injured by TBI on the caregiver's health and well-being, and examining the effect of the TBI on the health and behavior of service members' children. To date, the 15-year studies have led to 65 publications, 125 published abstracts, and 148 conference presentations produced from the study data. 2017 marked the seventh year of the 15-year studies, and a report to Congress was submitted. From this report, 6 conclusions and 9 recommendations emerged, highlighting the ongoing need for comprehensive, integrated healthcare and rehabilitation services to address changing needs throughout the continuum of recovery; the use of validity testing and development of objective measures to supplement clinical assessment of ongoing symptoms; additional research to explain clinical differences between men and women who have sustained a TBI; education, outreach, and novel methods of care delivery to ensure all patients receive care; and additional support and resources for caregivers and family members providing care to service members and Veterans injured by TBI. Additional reports to Congress will be provided in the 11th and 15th years. Warrior Strong This study conducted at Fort Bragg and Fort Carson with soldiers returning from OEF, OIF, and OND received funding from the Congressionally Directed Medical Research Programs. More than 20 000 returning troops were screened for mTBI, with potential participants randomly selected and with TBI-positive screened soldiers oversampled. In total, 1600 soldiers consented to participate in this longitudinal study. Researchers collected data at baseline and 3, 6, and 12 months postdeployment. Data included injury events during the deployment (with associated physical and mental health symptoms), lifetime incidence and characteristics of TBI, military service, demographics, cognitive health, psychological health, headache prevalence and descriptors, pain, functional outcomes, and on a subset of subjects: qualitative interviews and neurological assessments. Researchers seek to determine the trajectories of symptoms, problems, and outcomes associated with mTBI in this population. Several articles and conference presentations have been disseminated, including an article describing the study and the 3-month follow-up symptoms and outcomes was published in Neurology. Findings to date indicate that compared with controls, there is a high prevalence of severe self-reported symptoms associated with deployment mTBI at the 3-month follow-up.24 In addition, in other research studies, Vanderploeg et al25–29 examined verbal and visual learning and memory deficits in patients with moderate to severe TBI in 5 highly cited articles. These researchers also developed an embedded validity scale for the widely used Neurobehavioral Symptom Inventory.30 Walker et al31 examined headache (longitudinal patterns and descriptions) after moderate to severe TBI and found that early improvement stabilized by 6 months posthospitalization. This group was the first to use computerized posturography in a severe TBI sample and discovered continued impaired balance post–traditional rehabilitation.32 In collaboration with the INjury and TRaumatic STress (INTRuST) Clinical Consortium, DVBIC researchers found promising results for reducing psychological distress after deployment-sustained TBI using a telephone-based problem-solving therapy.33 Bailie et al34 analyzed multisite data on mTBI patients that classified patients into 4 groups based upon symptomatology. The study has direct implications for clinical treatment and has been described in several DoD and VA webinars.34 Recent analyses have examined anger and irritability, a little-studied sequela of mTBI. They found that certain individuals are at increased risk for clinically significant problems with anger expression and control.35 PATHWAY OF CARE DVBIC provides guidance to the MHS by serving as the manager of the DoD TBI Pathway of Care and chair of the TBI Advisory Committee (TAC). The pathway provides an evidence-based, clinically focused process for advancing high clinical standards and decreasing variance across the DoD through continuous performance improvement. The TAC, established in 2015, is a chartered group that addresses issues related to the pathway across the DoD. The TAC provides a collaborative and transparent forum supporting enterprise-wide coordination to define and disseminate proven practices, conduct implementation oversight, monitor outcomes, and develop translation strategy and implementation guidelines. New responsibilities are generated through the activities of partnerships and working groups. The pathway outlines the entire continuum of TBI management from identification, assessment, diagnosis, and care in deployed and nondeployed settings to rehabilitation and reintegration efforts in the community. The pathway ensures care quality, access, and safety and supports standardization of diagnosis and assessment, management of care for all severities of TBI, education, collection of outcome measurement data, and documentation in medical records throughout the MHS. Members of the TAC continually review best practices for TBI through clinical and evidence-based research and socialize them throughout the MHS via educational and training efforts including webinars, workshops, an annual summit, in-service trainings, and print materials. Members of the TAC not only coordinate policy development, execution, and adherence but also provide guidance for delivering TBI health services within the MHS. All TBI sites of care are under the direct control of their local MTFs (for personnel management and direct patient care) per DoD policy. However, as outlined, the pathway manager (ie, DVBIC) will: Conduct strategic and business planning; Standardize evidence-based clinical care across the pathway; Provide oversight for care pathway implementation; Standardize outcome measures and reporting; Monitor standard clinical practice adherence; Maintain visibility of all clinical and translational research in TBI; and Assess outcomes of research and help identify new research requirements. SELECTED CLINICAL AND EDUCATIONAL RESOURCES As an established organization with more than 2 decades of experience supporting service members, Veterans, family members, and providers, DVBIC has developed a broad portfolio of clinical and educational resources for use by various stakeholders. These include but are not limited to in-theater tools, clinical recommendations (CRs), clinical practice guidelines, research reviews, webinars, and podcasts. In addition, DVBIC regularly conducts in-person training events. In-theater tools In collaboration with civilian experts, DVBIC developed and released the Military Acute Concussion Evaluation (MACE) tool in 2006. Revised in 2012 and validated in 2014, the MACE is the primary tool used to screen service members suspected to have a TBI. In 2012, DVBIC developed the clinical management algorithm for management of concussion/mTBI in the deployed setting, which uses the MACE (https://dvbic.dcoe.mil/material/mace-military-acute-concussion-evaluation-pocket-card).36 In 2012, the DoD released Instruction (DoDI) 6490.11 describing mandatory processes, including reporting requirements, and line commanders and medical community must follow to identify service members involved in potentially concussive events. To support this requirement, DVBIC sites collaborated to develop the TBI screen in the Veterans Health Administration and the military postdeployment health assessment (PDHA).37 The initial PDHA did not include TBI injury events. However, adding additional items ensured capture of in-theater TBI and triage of treatment. Clinical recommendations DVBIC develops CRs in collaboration with other stakeholders. Most CRs outline steps for providers evaluating, managing, and/or appropriately referring patients for specialty care. The process of developing a CR involves a comprehensive literature review and convening an expert working group from academia, research, and clinical practice in civilian and governmental agencies. For example, headache experts participated in the development of the Headache CR, along with medical representatives from all the services (Army, Navy, Air Force, Marines, and Coast Guard) and other MHS stakeholders. The working group utilized the most recent evidence-based information on TBI-related headache and reached consensus leading to development of the CR. A “suite” of products usually includes the CR and training PowerPoint slide deck for providers and fact sheets and brochures for both patients and families. To date, DVBIC has released CRs for assessment and management of the most common postconcussive symptoms: headache, sleep disturbances, dizziness, and visual dysfunction (http://dvbic.dcoe.mil/clinical-tools-providers-mild-tbi).38 Additional DVBIC CRs include the following: Indications and conditions for neuroendocrine dysfunction screen following mTBI; Neuroimaging following mTBI in the nondeployed setting; Progressive return to activity following acute concussion/mTBI for both the primary care manager and the rehabilitation provider; and Indications and conditions for in-theater postinjury NCAT testing. Clinical practice guidelines In 2009, DVBIC published the VA/DoD Clinical Practice Guideline for the Management of Concussion/Mild Traumatic Brain Injury and updated it in 2015. This clinical tool provides information to assist clinicians to evaluate, treat, and manage patients with a history of mTBI. This guide includes the table used to classify TBI severity, as well as recommendations for the assessment and treatment of symptoms commonly seen following TBI.39 A congressionally mandated family caregiver curriculum guide for caregivers of patients who had had a moderate to severe TBI was developed in 2010. This backpack of information and resources is currently under revision by DVBIC's Education Division and will include information in multiple media formats for easier navigation. Research reviews DVBIC research reviews provide clarification on topics of interest related to TBI research by summarizing relevant scientific literature pertaining to specific issues. Recent topics include chronic traumatic encephalopathy, TBI and substance use and abuse, TBI and irritability and aggression, acute management of intracranial pressure in severe TBI, and mild TBI and PTSD. Webinars DVBIC hosts bimonthly webinars to provide information and facilitate discussion on a variety of topics related to TBI. While webinars are targeted to healthcare providers, attendance is open to the public. For applicable webinars, continuing education credits are available to those who meet eligibility requirements. Continuing education credits do not apply to archived presentations. Podcasts DVBIC currently offers 2 free, on-demand audio podcasts available through iTunes and other podcast platforms. Launched in November 2016, The TBI Family is a podcast for caregivers of service members and Veterans with TBI. Each episode offers information, resources, and tips for caregivers and shares caregiver stories. Launched in May 2017, Clinical Updates in Brain Injury Science Today, or CUBIST, is a podcast for healthcare providers treating service members and Veterans injured by TBI. Each episode offers a brief analysis of current research relevant to clinicians. GAPS AND PRIORITIES DVBIC clinicians and researchers continue to address gaps in TBI knowledge. More research on diagnosis, assessment, monitoring, and treatment of mTBI with reliable and validated tools is critically important in improving health management. A missed or delayed diagnosis could prevent active implementation of treatment and measures to protect against the risk of a repeated injury. Moreover, important patient education material on how to manage symptoms and return to activities may not be provided. A compelling need remains for novel diagnostic tools to clearly and quickly identify mTBI in military field environments and determine best treatment options. Ideally, portable, cost-effective tools and tests that deliver minimal discomfort to patients are sought. Serum biomarkers and imaging techniques (specifically MRI) may prove to be the best objective tools to diagnose mTBI and offer some predictive and prognostic markers of recovery. Currently, several DVBIC researchers are partnering with researchers at other agencies to address these issues. Understanding the continuum and impact and effects of TBI sequelae on patients, families, and friends, as well as the impact on military readiness, is leading to more precise interventions and care. More remains to be done: long-term effects of TBI—of all severities—are not fully known. DVBIC clinicians and researchers will continue to address effects of gender, preinjury, and co-occurring medical and psychological issues as they develop effective and efficient ways to prevent, diagnose, and treat TBI. Additional multisite pharmacological and nonpharmacological treatment trials are needed to investigate interventions to optimize patient and family outcomes. CONCLUSIONS Over its first 25 years, DVBIC has conducted high-impact work, bringing knowledge and resources to the care of service members and Veterans injured by TBI who were often invisible in the past. Knowledge gained by the treatment of wartime injuries has advanced care not only on the battlefield but also in peacetime and civilian settings. Recognition of blast injuries during the recent conflicts led to screening efforts to identify probable TBIs and TBIs in individuals with multiple traumas. DVBIC was one of the first organizations to recognize these needs and to execute a systematic program of research and treatment to improve outcomes of service members and Veterans injured by TBI. These efforts during OEF/OIF/OND led to more resources devoted to military TBI and collaborations thereafter with organized sports to address concerns about concussions. The early partnership of DVBIC and the VA established treatment centers of excellence that evolved into the polytrauma centers treating Veterans and service members from the OEF/OIF/OND conflicts. DVBIC studies conducted in partnership with a wide range of multidisciplinary clinicians and researchers have produced more than 480 publications, contributing to improved levels of evidence on issues critical to the identification, treatment, and education of TBI in military and veteran populations. DVBIC studies have paved the way by conducting high-quality studies (RTC, observational, epidemiological, retrospective, and longitudinal) to address gaps in knowledge about military and veteran TBIs. DVBIC's success in its first 25 years has resulted from active collaboration with providers and researchers within the DoD, other federal agencies, and academia. DVBIC continues to shape and guide TBI research efforts by participating on government steering committees, scientific advisory boards, and collegial work with academia, federal, and civilian agencies. The DVBIC mission of preventing TBIs and improving the lives of service members and Veterans injured by TBI continues. Twenty-five years of contributions and innovations have set a strong foundation for the next 25 years of DVBIC service and responsibility as leaders in TBI education, research, and care. —Elisabeth M. Moy Martin, MA, RN-BC Defense and Veterans Brain Injury Center (DVBIC) Silver Spring, Maryland —Karen A. Schwab, PhD DVBIC Silver Spring, Maryland Salient CRGT Fairfax, Virginia —Saafan Z. Malik, MD DVBIC Silver Spring, Maryland Guest Editors