Defense and Veterans Brain Injury Center: The First 25 Years

Treating the Signature Injury

Using Telehealth to Treat Combat-Related Traumatic Brain Injury

Social Determinants of Health and Traumatic Brain Injury: Implications for Rehabilitation Service Delivery and Outcomes.

PTSD and Combat-Related Injuries: Functional Neuroanatomy

Invited Symposium 1: Traumatic Brain Injury: Highlighting the Contributions of Dr. Harvey S. Levin Ph.D., ABPP-CN, FACSM 1946 - 2022

With advances in body armor technology and acute trauma care, many military service members are now surviving injuries that would have been fatal in previous wars [1]. However, the brain remains susceptible to non-penetrating injuries from high-impact collisions and explosive blasts [2]. As eloquently stated by a Department of Veterans Affairs (VA) physician even before Operation Iraqi Freedom and Operation Enduring Freedom (OIF/ OEF) began, "It is necessary to discard the magical notion that wearing a helmet on the head is sufficient to protect against impact brain damage" [3]. Because of its high prevalence, traumatic brain injury (TBI) has been labeled the "signature wound" of modern warfare [4]. While the dramatic details of severe TBI have captured the attention of the media [5], one cannot ignore the clinical significance and potentially high prevalence of mild TBI in OEF/OIF returnees [6]. Much that has been learned about mild TBI in the past decade has been acquired through studies of sports-related concussions [7], but blast-related concussions may operate through a different mechanism [8]. In April 2007, the VA Central Office issued a directive implementing a mandatory procedure for the screening of symptomatic TBI, or postconcussive syndrome, among all OIF/OEF veterans [9]. The procedure includes four questions that sequentially delineate (1) a history of injury events that may increase the risk for TBI, (2) symptoms related to alteration of consciousness immediately after the traumatic event, (3) new or worsening TBI symptoms in the aftermath of the traumatic event, and (4) persistence of these symptoms into the present. Affirmative answers to all four questions constitute a positive TBI screen, which results in a referral for further clinical evaluation and then treatment. Like any test with significant clinical implications, this test has the inherent problem of false positives and false negatives. Thus, the screening procedure's sensitivity [10], specificity, predictive validity [11], and reliability [12] need to be determined. At the same time, despite the ongoing debate about the "gold standard" for diagnosing mild TBI, we need to develop a mechanism for following those who have positive manifestations of TBI but are not seeking evaluation or treatment. Clinicians often remark that "no two TBIs are alike." Because of the complex and typically violent nature of their injuries [13], patients with TBI almost always have multiple acute comorbidities that are often unrelated to their preexisting health conditions. By definition, comorbidity describes the effect of all other ailments a patient might have, other than the primary injury or illness. Along with life-threatening complications and physical impairments, mental health comorbidities are of prime importance in the rehabilitative process of TBI. For the general public, focusing on the cognitive deficits related to TBI is intuitive. However, a recent study revealed that TBI patients with more emotional problems were less likely to return for follow-up appointments [2], with the potential for adverse effects on care coordination and functional outcome. Another study showed that patients with TBI plus acute comorbidities tended to have longer hospital stays [14]. Based on the coexistence of medical and psychological issues in TBI and considering the resources required to care for these patients, we need to develop a unified TBI database across representative VA and Department of Defense (DOD) healthcare service locations. With this database established, clinicians and researchers will be able to (1) quantify and track the severity of TBI and its comorbidities, (2) study how these variables interact with TBI patients' healthcare utilization, and (3) conduct state-of-the-art (SOTA) TBI research, according to the special strengths of each of the participating VA/DOD healthcare facilities. A key concept is the need for a coordinated team of professionals to properly diagnose and rehabilitate patients with TBI and its comorbidities. …

Identify associations between self-reported history of military and nonmilitary traumatic brain injury (TBI) on hearing loss and hearing difficulty from the Noise Outcomes in Servicemembers Epidemiology (NOISE) study. Cross-sectional. Multi-institutional tertiary referral centers. Four hundred seventy-three Active-Duty Service members (ADSM) and 502 veterans. Self-reported history of no TBI, military TBI only, nonmilitary TBI only, both military and nonmilitary TBI. Pure-tone hearing thresholds, Speech Recognition In Noise Test (SPRINT), Hearing Handicap Inventory for Adults (HHIA), and Speech, Spatial and Qualities of Hearing Scale (SSQ)-12. 25% (120/473) of ADSM and 41% (204/502) of veterans self-reported a TBI. Military TBI was associated with poorer hearing thresholds in all frequency ranges in veterans (adjusted mean difference, 1.8 dB; 95% confidence interval [CI], 0.5-3.0; 3.3, 0.8-5.8; 5.1; 1.7-8.5, respectively), and in the high frequency range in ADSM (mean difference, 3.2 dB; 95% CI, 0.1-6.3). Veterans with military TBI only and nonmilitary TBI only had lower odds of correctly identifying speech in noise than veterans with no TBI (odds ratio [OR], 0.78; 95% CI, 0.72-0.83; 0.90; 0.84-0.98). ADSM with a military TBI (OR, 5.7; 95% CI, 2.6-12.5) and veterans with any TBI history (OR, 2.5; 95% CI, 1.5-4.3; OR, 2.2; 95% CI, 1.3-3.8; OR, 4.5; 95% CI, 2.1-9.8) were more likely to report hearing difficulty on HHIA. SSQ-12 results corroborated HHIA findings. Military TBI was associated with poorer hearing thresholds in veterans and ADSM, and poorer SPRINT scores in veterans. Military TBI was associated with poorer self-perceived hearing ability in ADSM. All types of TBI were associated with poorer self-perceived hearing ability in veterans, although the strength of this association was greatest for military TBI.

OBJECTIVES/GOALS: The purpose of this small survey-based study was to characterize the current role of neurocritical care physicians in traumatic brain injury (TBI) systems of care and research. In doing so, we aim to highlight potential roles of neurology providers in the medical management and enhancement of translational science in the field of TBI. METHODS/STUDY POPULATION: Between April and June 2021, a web-based survey was disseminated by email to members of the Neurocritical Care Society. The survey was open to all physician providers. A total of 36 surveys were completed. The survey consisted of 18 questions with pre-defined answer choices. Survey questions aimed to determine areas of practice, primary clinical specialty, hospital practice setting, provider involvement in TBI care, provider involvement in TBI research, and current research roles. RESULTS/ANTICIPATED RESULTS: 92% of survey respondents were in the United States (n=33), representing all national regions. 75% of the physicians were neurocritical care trained (n=27). 69% of providers were practicing in academic institutions while 78% were at sites designated as Level I trauma centers. All respondents managed acute TBI, but 50% served as consultants rather than being the primary service provider. At their sites of practice, 31% of patients were on non-neuroscience services, especially those with non-neurologic traumatic injury. Only 36% reported that TBI protocols were written and adhered to at their site. Only 44% reported that TBI research was performed at their site, while 50% had interest in participating in TBI research. TBI was the primary area of research for 17% of physicians. DISCUSSION/SIGNIFICANCE: This small physician survey highlights heterogeneity in TBI systems-based practice and research roles. Areas of potential improvement include greater involvement of neurocritical care physicians in TBI management, protocol-building and implementation, and TBI research. Reasons for current barriers are multifactorial and will be discussed.

Are Brain-Injured Vets Getting Adequate Care?

An Evaluation of the Veterans Affairs Traumatic Brain Injury Screening Process Among Operation Enduring Freedom and/or Operation Iraqi Freedom Veterans

Management of traumatic brain injury in China versus Europe

Joel Kupersmith, MD; Alex K. Ommaya, ScD; Michael E. Selzer, MD, PhD, FRCP; Robert L. Ruff, MD, PhD; Henry L. Lew, MD, PhD The Department of Veterans Affairs (VA), treating more than 5.5 million veterans annually [1], manages the largest integrated healthcare system in the nation and is committed to providing veterans with the highest quality healthcare. Conflicts in Iraq and Afghanistan (Operation Iraqi Freedom/Operation Enduring Freedom [OIF/OEF]) have resulted in an influx of new veterans to the VA health system. From 2002 to 2008, 945,423 OIF/OEF veterans left active duty, with 42 percent (400,304) obtaining VA healthcare [2]. The challenge that this trend presents to the maintenance of the VA’s high standard of care is compounded by the fact that many are returning home with complex injuries, such as traumatic brain injury (TBI), frequently referred to as the signature injury of modern warfare. Many knowledge gaps exist regarding TBI. Accordingly, in late April 2008, the VA’s Office of Research and Development (ORD) sponsored a state-of-theart (SOTA) conference to advance the knowledge base in TBI. This SOTA conference identified what we know and what we need to know about TBI, from the basic science to diagnosis, evidence-based treatment, acute management, and long-term rehabilitation for TBI. The goal was to recommend for all stakeholders further research on the development of clinical practice guidelines, policies, or processes that would improve quality and outcomes of TBI care. ORD assembled a prestigious planning committee. The planning committee developed the objectives for the SOTA conference and commissioned background articles to stimulate discussions among the 100 invited experts at the conference. Subject matter experts wrote the background articles and submitted them for peer review. Of those articles, 17 passed the rigorous review process and are published here in this special issue of Journal Rehabilitation Research and Development (JRRD). The articles cover various aspects of TBI and its comorbidities. Topics include— 1. Acute clinical care for TBI: Continuation of care from the battlefield to the Department of Defense (DOD) and the VA. 2. Pathology of blast-related brain injury. 3. Infectious complications in OIF/OEF veterans with TBI. 4. Posttraumatic epilepsy. 5. Prevalence of chronic pain, posttraumatic stress disorder (PTSD), and persistent postconcussive symptoms in OIF/OEF veterans: The polytrauma clinical triad. 6. Treating veterans with comorbid mild TBI (mTBI) and PTSD. 7. Advances in neuroimaging of TBI and PTSD. 8. Approaches to war-related mild to moderate TBI.

When Addiction Co-Occurs With Traumatic Brain Injury

Although traumatic brain injury (TBI) is known to cause many visual problems, the correlation between the extent of severe visual acuity loss (SVAL) and severity of TBI has not been widely explored. In this retrospective analysis, combined information from Department of Defense (DoD)/Veterans Affairs ocular injury and TBI repositories were used to evaluate the relationship between chronic SVAL, TBI, ocular injuries, and associated ocular sequelae for U.S. service members serving between 2001 and 2015. The Defense and Veterans Eye Injury and Vision Registry (DVEIVR) is an initiative led by the DoD and Veterans Affairs that consists of clinical and related data for service members serving in theater since 2001. The Defense and Veterans Brain Injury Center (DVBIC) is the DoD's office for tracking TBI data in the military and maintains data on active-duty service members with a TBI diagnosis since 2000. Longitudinal data from these 2 resources for encounters between February 2001 and October 2015 were analyzed to understand the relation between SVAL, and TBI while adjusting for ocular covariates such as open globe injury (OGI), disorders of the anterior segment and disorders of the posterior segment in a logistic regression model. TBI cases in DVEIVR were identified using DVBIC data and classified according to International Statistical Classification of Diseases criteria established by DVBIC. Head trauma and other open head wounds (OOHW) were also included. SVAL cases in DVEIVR were identified using both International Statistical Classification of Diseases criteria for blindness and low vision as well as visual acuity test data recorded in DVEIVR. Data for a total of 25,193 unique patients with 88,996 encounters were recorded in DVEIVR from February, 2001 to November, 2015. Of these, 7,217 TBI and 1,367 low vision cases were identified, with 638 patients experiencing both. In a full logistic model, neither UTBI nor differentiated TBI (DTBI, ie, mild, moderate, severe, penetrating, or unclassified) were significant risk factors for SVAL although ocular injuries (disorders of the anterior segment, disorders of the posterior segment, and OGI) and OOHW were significant. Any direct injury to the eye or head risks SVAL but the location and severity will modify that risk. After adjusting for OGIs, OOHW and their sequelae, TBI was found to not be a significant risk factor for SVAL in patients recorded in DVEIVR. Further research is needed to explore whether TBI is associated with more moderate levels of vision acuity loss.

Over 514,000 active duty Service Members (SMs) have sustained traumatic brain injuries (TBIs) since 2000, with mild TBI (mTBI) emerging as the signature injury of recent wars. Although many recover fully, some experience chronic mTBI with persistent symptoms such as headaches, memory issues, post-traumatic stress disorder (PTSD), chronic pain, depression, and cognitive impairment. The 2021 Department of Veterans Affairs (VA)/Department of Defense (DOD) clinical practice guidelines (CPGs) recommend symptom-focused treatment, addressing comorbid conditions, and supporting reintegration. Congress mandated specialized centers to provide comprehensive care, research, and rehabilitation for combat-injured Veterans and SMs (V/SMs) leading to the development of Intensive Evaluation and Treatment Programs (IETPs) at 5 VA Polytrauma Rehabilitation Centers offering interdisciplinary, individualized inpatient care. The IETPs integrate rehabilitation and specialty services for V/SMs with chronic mTBI and associated health issues. The study aimed to describe the IETPs and the participants it serves with chronic, multiple mTBI and comorbidities. Participants were V/SMs enrolled in the VA TBI Model Systems study and admitted to 1 of the 5 IETPs between 2009 and 2023. Inclusion criteria included TBI diagnosis, age ≥16, and consent for study participation. Data included demographics, military service characteristics, TBI history, and comorbidities. Injury data represented the index TBI qualifying participants for the study, although many had multiple TBIs. Measures included Functional Independence Measure, Disability Rating Scale, PTSD Checklist, and Neurobehavioral Symptom Inventory, among others. There have been 821 IETP participants from the program start through 2023. Participants averaged 35.3 years at admission, were predominantly White, non-Hispanic, married men, and included active duty SMs, many from Special Operations Forces (74.2%). Our findings show the prevalence of participants with comorbidities at IETP admission. The 2021 VA/DOD CPGs caution against over-involvement of specialty care for mTBI but acknowledge that patients with persistent symptoms and comorbidities may benefit from specialized programs like IETPs. Chronic pain, sleep apnea, musculoskeletal issues, and hypertension were common among IETP participants, highlighting the need for intensive inpatient care to address dynamic and interactive symptoms. IETPs provide integrated treatment, removing external demands and offering opportunities for medication trials, interventions, and evidence-based therapies.