Combat-related Traumatic Brain Injury Research Articles

Nurses' Knowledge of Pain Management for Patients with Combat-Related Traumatic Brain Injuries on Rehabilitation Units

The purpose of this project was to survey nurses' knowledge of pain management for patients with combat-related traumatic brain injuries (TBI). A survey was used to collect data regarding nurses' knowledge of pain assessment and management for patients with combat-related TBI. Nurses were invited to participate in the study via email and provided with a link to the electronic survey. Twenty-five surveys were returned (52% response rate). A total of 76% of nurse respondents perceived that TBI patients over report pain intensity. Only 40% of nurses were able to correctly identify the appropriate medication to treat migraine-type headache pain in TBI patients. This study identified gaps in knowledge regarding pain management for patients with combat related TBIs. Nurses need additional education regarding common pain syndromes, available treatments, and a better understanding of addiction in order to provide optimal care to these patients.

Trends in the Epidemiology of Disability Related to Traumatic Brain Injury in the US Army and Marine Corps

Traumatic brain injury (TBI) has been recognized as a major public health issue for several decades. Despite technological advancements in protective equipment and medical care available during recent military conflicts, TBI is the most common neurological condition among Soldiers and Marines evaluated for discharge from service. This study describes the demographic, service-related, and disability characteristics of Soldiers and Marines referred for combat-related TBI disability evaluation. Cross-sectional analysis of Soldiers and Marines evaluated for combat-related disability between October 1, 2004 and September 30, 2010 was performed. Traumatic brain injury cases were identified using the Veterans Affairs Schedule for Rating Disabilities code for TBI and compared with other combat-related disabilities. Combat-related TBI disability rates have significantly increased in both the Army and the Marine Corps since 2005. Significantly more unfitting conditions are present on average in combat-related TBI cases than in other combat-related disability cases. Combat-related TBI disability cases are more likely to be medically retired than other types of combat-related disability. Because veterans with combat-related TBI disabilities are likely to require chronic care for TBI-associated medical conditions, disability evaluation policy and programs must ensure that combat-related TBI disabilities are accurately identified and compensated, and the potential long-term care needs are addressed.

When Addiction Co-Occurs With Traumatic Brain Injury

When Addiction Co-Occurs With Traumatic Brain Injury

Combat-Related Headache and Traumatic Brain Injury

Post-traumatic headache is a commonly described complication of traumatic brain injury. Recent studies highlight differences between headache features of combat veterans who suffered traumatic brain injury compared to civilians. Not surprisingly, there is a higher rate of associated PTSD and sleep disturbances among veterans. Factors of lower socioeconomic status, rank, and multiple head injuries appear to have a similar effect on post-traumatic headache in combat-related traumatic brain injury. Areas of discordance in the literature include the effect of prolonged loss of consciousness and the prevalence of specific headache phenotypes following head trauma. To date, there have been no randomized trials of treatment for post-traumatic headache. This may be related to the variability of headache features and uncertainty of pathophysiologic mechanisms. Given this lack of data, many practitioners follow treatment guidelines for primary headaches. Additionally, because of mounting data linking PTSD to post-traumatic headache in combat veterans, it may be crucial to choose multimodal agents and take a multidisciplinary approach to combat-related headache.

Sleep Disturbances Among Soldiers With Combat-Related Traumatic Brain Injury

Sleep complaints are common among patients with traumatic brain injury. Evaluation of this population is confounded by polypharmacy and comorbid disease, with few studies addressing combat-related injuries. The aim of this study was to assess the prevalence of sleep disorders among soldiers who sustained combat-related traumatic brain injury. The study design was a retrospective review of soldiers returning from combat with mild to moderate traumatic brain injury. All underwent comprehensive sleep evaluations. We determined the prevalence of sleep complaints and disorders in this population and assessed demographics, mechanism of injury, medication use, comorbid psychiatric disease, and polysomnographic findings to identify variables that correlated with the development of specific sleep disorders. Of 116 consecutive patients, 96.6% were men (mean age, 31.1 ± 9.8 years; mean BMI, 27.8 ± 4.1 kg/m²), and 29.5% and 70.5% sustained blunt and blast injuries, respectively. Nearly all (97.4%) reported sleep complaints. Hypersomnia and sleep fragmentation were reported in 85.2% and 54.3%, respectively. Obstructive sleep apnea syndrome (OSAS) was found in 34.5%, and 55.2% had insomnia. Patients with blast injuries developed more anxiety (50.6% vs 20.0%, P = .002) and insomnia (63% vs 40%, P = .02), whereas patients with blunt trauma had significantly more OSAS (54.3% vs 25.9%, P = .003). In multivariate analysis, blunt trauma was a significant predictor of OSAS (OR, 3.09; 95% CI, 1.02-9.38; P = .047). Sleep disruption is common following traumatic brain injury, and the majority of patients develop a chronic sleep disorder. It appears that sleep disturbances may be influenced by the mechanism of injury in those with combat-related traumatic brain injury, with blunt injury potentially predicting the development of OSAS.

Mild Traumatic Brain Injury Screening, Diagnosis, and Treatment

The majority of combat-related traumatic brain injury (TBI) within the U.S. Armed Forces is mild TBI (mTBI). This article focuses specifically on the screening, diagnosis, and treatment aspects of mTBI within the military community. Aggressive screening measures were instituted in 2006 to ensure that the mTBI population is identified and treated. Screenings occur in-theater, outside the contiguous United States, and in-garrison. We discuss specific screening procedures at each screening setting. Current diagnosis of mTBI is based upon self-report or through witnesses to the event. TBI severity is determined by specific Department of Defense criteria. Abundant clinician resources are available for mTBI in the military health care setting. Education resources for both the patient and the clinician are discussed in detail. An evidence-based clinical practice guideline for the care of mTBI was created through collaborative efforts of the DoD and the U.S. Department of Veterans Affairs. Although symptoms following mTBI generally resolve with time, active treatment is centered on symptom management, supervised rest, recovery, and patient education. Medical specialty care, ancillary services, and other therapeutic services may be required.

Prevalence and Costs of Co-occurring Traumatic Brain Injury With and Without Psychiatric Disturbance and Pain Among Afghanistan and Iraq War Veteran VA Users

Traumatic brain injury (TBI) is the "signature injury" in the Afghanistan and Iraq wars [Operation Enduring Freedom in Afghanistan (OEF)/Operation Iraqi Freedom (OIF)]. Patients with combat-related TBI also have high rates of psychiatric disturbances and pain. To determine the prevalence of TBI alone and TBI with other conditions and the average cost of medical care for veterans with these diagnoses. Observational study using national inpatient, outpatient, and pharmacy data from Veterans Health Administration (VHA) datasets. Costs are estimated from utilization related to care within the VHA system. Participants were all OEF/OIF VHA users in 2009. Among 327,388 OEF/OIF veterans using VHA services in 2009, 6.7% were diagnosed with TBI. Among those with TBI diagnoses, 89% were diagnosed with a psychiatric diagnosis [the most frequent being posttraumatic stress disorder (PTSD) at 73%], and 70% had a diagnosis of head, back, or neck pain. The rate of comorbid PTSD and pain among those with and without TBI was 54% and 11%, respectively. The median annual cost per patient was nearly 4-times higher for TBI-diagnosed veterans as compared with those without TBI ($5831 vs. $1547). Within the TBI group, cost increased as diagnostic complexity increased, such that those with TBI, pain, and PTSD demonstrated the highest median cost per patient ($7974). The vast majority of VHA patients diagnosed with TBI also have a diagnosed mental disorder and more than half have both PTSD and pain. Patients with these comorbidities incur substantial medical costs and represent a target population for future research aimed at improving health care efficiency.

Mild Traumatic Brain Injury: Lessons Learned from Clinical, Sports, and Combat Concussions

Over the past forty years, a tremendous amount of information has been gained on the mechanisms and consequences of mild traumatic brain injuries. Using sports as a laboratory to study this phenomenon, a natural recovery curve emerged, along with standards for managing concussions and returning athletes back to play. Although advances have been made in this area, investigation into recovery and return to play continues. With the increase in combat-related traumatic brain injuries in the military setting, lessons learned from sports concussion research are being applied by the Department of Defense to the assessment of blast concussions and return to duty decision making. Concussion management and treatment for military personnel can be complicated by additional combat related stressors not present in the civilian environment. Cognitive behavioral therapy is one of the interventions that has been successful in treating symptoms of postconcussion syndrome. While we are beginning to have an understanding of the impact of multiple concussions and subconcussive blows in the sports world, much is still unknown about the impact of multiple blast injuries.

Traumatisme crânien léger et syndrome post-commotionnel : un questionnement ré-émergent

Traumatisme crânien léger et syndrome post-commotionnel : un questionnement ré-émergent

Injury-Specific Correlates of Combat-Related Traumatic Brain Injury in Operation Iraqi Freedom

The prevalence of traumatic brain injury (TBI) has increased during the wars in Iraq and Afghanistan compared with 20th century military conflicts. The aim of this study was to elucidate injury-specific correlates of combat-related TBI that have yet to be clearly defined. Predominately Marine US service members who sustained brain injuries in Iraq between March 2004 and April 2008 identified from clinical records completed in the theater of combat operations (n = 2074). Severity of TBI was classified as mild, moderate, or severe. Injury-specific factors, such as injury mechanism and type, were abstracted from the clinical records and were compared with severity of TBI. Of all TBIs observed in the sample, 89% were mild. Higher severity of TBI was associated with an increased likelihood of sustaining the injury by gunshot and a lower likelihood of helmet use. Improvised explosive devices were associated with a preponderance of mild TBIs, and frequency of injuries in locations in addition to the head was highest among those with moderate and severe TBIs. Concomitant injuries to the spine/back were associated with blast injury mechanisms. Most incidents of TBI occurring during Operation Iraqi Freedom are mild in severity and a result of blast mechanisms. Multiple injuries were common, particularly as severity of TBI increased. Further research is needed to determine effects of combat-related TBI on rehabilitative and adverse health outcomes.

Inpatient Hospitalizations of U.S. Military Personnel Medically Evacuated From Iraq and Afghanistan With Combat-Related Traumatic Brain Injury

Traumatic brain injury (TBI) has been called the signature wound of Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF). The aim of the present study was to describe and assess the incidence of inpatient hospitalizations of U.S. military personnel who were medically evacuated from OIF and OEF with combat-related TBI. Inpatient medical records from 2003 to 2008 were used to determine incident episodes of TBI requiring hospitalization in Landstuhl or CONUS Regional Medical Centers. Denominator data for calculating incidence rates were available from the Defense Manpower Data Center. During the study period, 1,213 U.S. military personnel from OIF and OEF were hospitalized with combat-related TBI. Of these, the largest proportion (40.9%) occurred in 2007. The rate of inpatient hospitalization with TBI was 10.4 per 10,000 troop strength (95% confidence interval: 9.9, 10.9). Future research should examine the incidence of TBI in-theater and include an analysis by injury severity.

The Role of the Met66 Brain-Derived Neurotrophic Factor Allele in the Recovery of Executive Functioning after Combat-Related Traumatic Brain Injury

Brain-derived neurotrophic factor (BDNF), a member of the neurotrophin family, promotes survival and synaptic plasticity in the human brain. The Val66Met polymorphism of the BDNF gene interferes with intracellular trafficking, packaging, and regulated secretion of this neurotrophin. The human prefrontal cortex (PFC) shows lifelong neuroplastic adaption implicating the Val66Met BDNF polymorphism in the recovery of higher-order executive functions after traumatic brain injury (TBI). In this study, we examined the effect of this BDNF polymorphism on the recovery of executive functioning after TBI. We genotyped a sample of male Vietnam combat veterans consisting of a frontal lobe lesion group with focal penetrating head injuries and a non-head-injured control group for the Val66Met BDNF polymorphism. The Delis-Kaplan Executive Function System as a standardized psychometric battery was administrated to examine key domains of executive functions. The results revealed that the Met allele but not the hypothesized Val allele promotes recovery of executive functioning. Overall, the Met66 carriers in the lesion group performed as well as the Met66 carriers in the control group. The Met66 allele accounted for 6.2% of variance for executive functioning independently of other significant predictors including preinjury intelligence, left hemisphere volume loss, and dorsolateral PFC volume loss. The findings point to different mechanisms of the Val66Met BDNF gene in complex phenotypes under normal and pathological conditions. A better understanding of these mechanisms could be instrumental in the development and application of effective therapeutic strategies to facilitate recovery from TBI.

Using Telehealth to Treat Combat-Related Traumatic Brain Injury

Using Telehealth to Treat Combat-Related Traumatic Brain Injury

Routine TBI screening following combat deployments

A precise estimate of the rates of traumatic brain injury (TBI) in returning combat troops is difficult to establish given the challenges of screening large numbers of military personnel returning from combat deployments. The Brief Traumatic Brain Injury Screen (BTBIS) was implemented in the First Marine Expeditionary Force between 2004 and 2006. Nine percent of the 7909 marines who completed the BTBIS were considered having a positive screen; that is, they endorsed at least one injury mechanism and indicated a change in mental status at the time of injury. The majority of combat-related TBI's were due to multiple injury agents with the next largest group related to blast exposure only. Most importantly, of those who screened positive for TBI 70.5% (n=500) were first identified by the screen. Service members who endorsed items on the BTBIS were contacted for follow-up assessment of persistent symptoms related to TBI and clinical referrals were made as needed. Given the rate of positive TBI screens in this non-referred sample of military personnel returning from a combat deployment, routine TBI screening appears valuable in screening individuals who might not be identified otherwise. Furthermore, this study appears to refute the contention that routine TBI screening will result in an over-identification of TBI in this population.

A pilot study examining effects of group-based Cognitive Strategy Training treatment on self-reported cognitive problems, psychiatric symptoms, functioning, and compensatory strategy use in OIF/OEF combat veterans with persistent mild cognitive disorder and history of traumatic brain injury

We aimed to determine whether group-based Cognitive Strategy Training (CST) for combat veterans with mild cognitive disorder and a history of traumatic brain injury (TBI) has significant posttreatment effects on self-reported compensatory strategy usage, functioning, and psychiatric symptoms. Participants included 21 veterans returning from conflicts in Iraq or Afghanistan with a diagnosis of Cognitive Disorder, Not Otherwise Specified and a history of combat-related TBI. Participants attended 6- to 8-week structured CST groups designed to provide them training in and practice with a variety of compensatory cognitive strategies, including day planner usage. Of the participants, 16 completed pre- and posttreatment assessment measures. Following CST, participants reported significantly increased use of compensatory cognitive strategies and day planners; an increased perception that these strategies were useful to them; increased life satisfaction; and decreased depressive, memory, and cognitive symptom severity. Group-based CST is a promising intervention for veterans with mild cognitive disorder, and randomized controlled trials are required to further evaluate its efficacy.

Symptom complaints following combat-related traumatic brain injury: Relationship to traumatic brain injury severity and posttraumatic stress disorder

Patients with a history of mild (n = 134) or moderate-to-severe (n = 91) TBI were asked to complete the Neurobehavioral Symptom Inventory (NSI) and the Posttraumatic Stress Disorder Checklist. Consistent with prior research, significantly more postconcussion symptoms were endorsed by the mild group. After controlling for age, time since injury, and mechanism of injury, TBI severity continued to be significantly related to postconcussion complaints on the NSI. However, after controlling for these same variables, along with posttraumatic stress disorder symptom severity, there no longer were differences between the TBI severity groups. That is, patients with mild TBI did not endorse significantly more complaints (adjusted mean = 22.4) than the moderate-to-severe group (adjusted mean = 21.8). These findings suggest that much of the symptom complaints in mildly injured patients may be due to emotional distress.

PTSD and Combat-Related Injuries: Functional Neuroanatomy

PTSD and Combat-Related Injuries: Functional Neuroanatomy

Acute clinical care and care coordination for traumatic brain injury within Department of Defense

The nature of current combat situations that U.S. military forces encounter and the use of unconventional weaponry have dramatically increased service personnel's risks of sustaining a traumatic brain injury (TBI). Although the true incidence and prevalence of combat-related TBI are unknown, service personnel returning from deployment have reported rates of concussion between 10% and 20%. The Department of Defense has recently released statistics on TBI dating back to before the wars in Iraq and Afghanistan to better elucidate the impact and burden of TBI on America's warriors and veterans. Patients with severe TBI move through a well-established trauma system of care, beginning with triage of initial injury by first-responders in the war zone to acute care to rehabilitation and then returning home and to the community. Mild and moderate TBIs may pose different clinical challenges, especially when initially undetected or if treatment is delayed because more serious injuries are present. To ensure identification and prompt treatment of mild and moderate TBI, the U.S. Congress has mandated that military and Department of Veterans Affairs hospitals screen all service personnel returning from combat. Military health professionals must evaluate them for concussion and then treat the physical, emotional, and cognitive problems that may surface. A new approach to health management and care coordination is needed that will allow medical transitions between networks of care to become more centralized and allow for optimal recovery at all severity levels. This article summarizes the care systems available for the acute management of TBI from point of injury to stateside military treatment facilities. We describe TBI assessment, treatment, and overall coordination of care, including innovative clinical initiatives now used.

Total Intravenous Anesthesia Including Ketamine versus Volatile Gas Anesthesia for Combat-related Operative Traumatic Brain Injury

Traumatic brain injury is a leading cause of death and severe neurologic disability. The effect of anesthesia techniques on neurologic outcomes in traumatic brain injury and potential benefits of total intravenous anesthesia (TIVA) compared with volatile gas anesthesia (VGA), although proposed, has not been well evaluated. The purpose of this study was to compare TIVA versus VGA in patients with combat-related traumatic brain injury. The authors retrospectively reviewed 252 patients who had traumatic brain injury and underwent operative neurosurgical intervention. Statistical analyses, including propensity score and matched analyses, were performed to assess differences between treatment groups (TIVA vs. VGA) and good neurologic outcome. Two hundred fourteen patients met inclusion criteria and were analyzed; 120 received VGA and 94 received TIVA. Good neurologic outcome (Glasgow Outcome Score 4-5) and decreased mortality were associated with TIVA compared with VGA (75% vs. 54%; P = 0.002 and 5% vs. 16%; P = 0.02, respectively). Multivariate logistic regression found admission Glasgow Coma Scale score of 8 or greater (odds ratio, 13.3; P < 0.001) and TIVA use (odds ratio, 2.3; P = 0.05) to be associated with good neurologic outcomes. After controlling for confounding factors using propensity analysis and repeated one-to-one matching of patients receiving TIVA with those receiving VGA with regard to Injury Severity Score, Glasgow Coma Scale score, base deficit, Head Abbreviated Injury Score, and craniectomy or craniotomy, the authors could not find an association between treatment and neurologic outcome. Total intravenous anesthesia often including ketamine was not associated with improved neurologic outcome compared with VGA. Multiple confounders limit conclusions that can be drawn from this retrospective study.

Traumatic Axonal Injury: Atlas of Major Pathways

Traumatic Axonal Injury: Atlas of Major Pathways