Ebook: Coping with Blast-Related Traumatic Brain Injury in Returning Troops
It has been shown that those who have served in both combat missions and peacekeeping operations are at increased risk for Traumatic Brain Injury (TBI). Research suggests that this may result from their “wounds of war”. Some wounds may be “invisible”, such as depression, stress, and chronic pain, while others, such as physical disabilities, are more obvious. In February 2011, 35 scientists and representatives from NATO and Partner countries met in Vienna, Austria for a three-day NATO Advanced Research Workshop entitled “Wounds of War: Coping with Blast-Related Traumatic Brain Injury in Returning Troops”. The aim of this publication, which presents papers from that workshop, is to critically assess the existing knowledge and to identify directions for future actions. The book addresses four key questions: 1. Characterization of TBI: Which characteristics make up and help to classify TBI? 2. Diagnosis and Assessment Issues Surrounding TBI: Which methods are used to diagnose and assess TBI? 3. Treatment of TBI: What are the latest treatment and therapy opportunities for soldiers after they have been diagnosed with TBI? 4. Quality of Life: How are the lives of TBI patients affected and in what ways can their quality of life be increased?
“Wounds of War III: Coping with Blast-related Traumatic Brain Injury in Returning Troops”
On behalf of the Austrian Peacekeepers and the Austrian Ministry of Defense, I want to welcome each of you and extend a special welcome to our distinguished guests who we look forward to hearing from today.
Austria first engaged in peacekeeping operations in the Congo in 1960. In the last 50 years more than 90,000 Austrian soldiers have taken part in peacekeeping operations, amongst them also a large portion of reserve soldiers. In 1995 a veteran organisation of military and civilian peacekeepers was founded. As President of this association I have been involved with the problems of traumatic injuries quite recently. The Austrian Peacekeepers organize the Blue Helmet Forum Austria every year. In 2010 the topic of the Forum was “Stress Management and Peacesoldiering.” On this occasion I had the pleasure to meet some of you. I must say I was extremely impressed by the high professional standard of the presentations and the lively discussions. I admit that as an ordinary soldier I sometimes felt that I had difficulties following the subject matter, but I realized the enormous importance of your expertise for the operational effectiveness of our troops and for the personal wellbeing of our soldiers.
By coincidence, the NATO sponsored Advanced Research Workshop held in Austria last year dealt also with Posttraumatic Stress Disorder. This time you will be discussing the effects of Traumatic Brain Injury and ongoing efforts to address the devastating impact of these injuries. Thanks to the sponsors of the workshop and to organizers Professor Brenda Wiederhold and Professor Walter Mauritz it has been possible to gather again a group of distinguished experts.
I believe these workshops are important because it is imperative that we continue to work together towards better and more effective strategies to both prevent and treat Traumatic Brain Injury. In the kind of asymmetric warfare we now have to face we must recognize the fact that Traumatic Brain Injuries will be a growing reality.
Dr. Norman Vincent Peale, an American minister and forefather of the power of positive thinking, once said, “When every physical and mental resource is focused, one's power to solve a problem multiplies tremendously.” I could not agree more with Dr. Peale and I also believe that working collaboratively, we can share insights, accelerate discoveries, and more effectively prevent and treat Traumatic Brain Injuries. We have incredible resources here with us over the next three days, and I encourage each of you to recognize the potential outcomes of your interactions, lectures, and discussions. Your ideas, intelligence, commitment and devotion to solving these complex problems may directly save lives of our military service men and women and will help to offer hope for their families and friends.
I am sure we can discover the right answers and our efforts should be, and I believe will be, focused on finding them … together.
Today, blast injuries are the most common injury treated in the Iraq and Afghanistan theaters. In 2006, almost 22% of all injuries treated were Traumatic Brain Injuries. At the time, that number was an estimate and many injuries from blasts were not categorized as Traumatic Brain Injuries but instead considered mere headaches, mood disorders or other “head and neck wounds.” What is clear today is that these numbers were vastly underestimated. Why?
We know now there was a lack of ability to promptly and accurately diagnose such injuries. If someone is missing a limb, we know immediately it is serious and the treatment that must be followed is known. A brain injury is not as apparent. We have seen many cases in which a team of soldiers riding in a Humvee encounters a roadside bomb. These soldiers, after being slammed against the heavy armor of the vehicle, appear mostly unscathed and seemingly capable of returning to duty.
We know now that many of these soldiers who lack any outward sign may very well have suffered a Traumatic Brain Injury. It is likely that tens of thousands of our combat men and women are misdiagnosed, ignored, or dismissed completely.
We need, therefore, to pay more attention to education. Not long ago leaders in the field did not know of the effects of Traumatic Brain Injury and were wholly ill equipped to make such judgments. They did not know what to look for, how to detect Traumatic Brain Injury and most importantly, how to prevent and treat it. But times are changing and through education and vigilance, field commanders, doctors, and other staff can no longer ignore the effects of such injuries. These are injuries that MUST not go undiagnosed. We owe that to these brave men and women who put their lives on the line each and every day.
We must also address the fact that there is a stigma associated with brain injuries. Our military officials and policy writers cannot remain skeptical about the effects of Traumatic Brain Injury and how it endangers the members of our military families. We must insist that facts, on-going research, and the input of these injured personnel continue to show that Traumatic Brain Injury is real, dangerous, and a reality that must be understood and addressed.
The challenges are great. Properly diagnosing and treating these injuries in light of doubtful leadership may be the least of our worries. A recent study showed that even some military tests are failing to diagnose 40% of concussions. And we know that mild Traumatic Brain Injuries are harder to detect due to the damage and breakdown that can occur at the cellular levels, blocking important chemical processes.
We also know that even when there is a correct diagnosis, the documentation of the injuries might not even reach the soldier's permanent medical record. Often this is not the fault of the physicians in the field, but due to other circumstances. Regardless of how or why, it is clear that without that information on file, appropriate treatment will not be provided.
Today, it is estimated that 59% of all blast injuries involve Traumatic Brain Injuries. Reflect on that number … 59% is nearly six out of ten. These figures are daunting but there is hope. More and more combat and medical personnel are recognizing that once a blast occurs, Traumatic Brain Injury is something that must be properly assessed and that it is something that requires immediate attention. While we still have far to go in regards to policies surrounding Traumatic Brain Injury, great strides have been made. The ability to immediately diagnose these injuries in the field and promptly evacuate the injured to proper treatment facilities has resulted in survival rates of almost 96%.
The good news is that those who have suffered from a mild Traumatic Brain Injury usually enjoy total recovery after a year. Again, the key is that we MUST not fail to diagnose. If we do fail, these injuries will likely become severe and will alter the lives of the wounded soldiers. Those injuries that are more severe can lead to depression and Posttraumatic Stress Disorder. Those injuries follow soldiers back from the field to their homes and families and have far reaching consequences as they are linked to future medical and socioeconomic realities.
The benefits from your work today will save and improve lives. I am convinced of that, and your work extends beyond the battlefield and finds application in other fields of battle, including sports. Only two weeks ago Austrians watched live on television the skiing race in Kitzbühel, the so called Streif downhill, where an Austrian downhill racer encountered a severe Traumatic Brain Injury after he did not land the famous Mausefalle jump and bumped his head heavily on the ground. While Traumatic Brain Injury is one of the signature wounds from the current conflicts in Iraq and Afghanistan, it is also a wound that affects thousands around the world in civilian life.
As many of you may know, I am a retired General with the Austrian Military and I have been commanding international operations in four different peacekeeping missions for more than 13 years. I have seen firsthand how Posttraumatic Stress and Traumatic Brain Injuries can affect our troops. When I was a young officer I do not remember anybody talking about Posttraumatic Stress or Traumatic Brain Injuries. We simply did not know. Now we know, but our challenges are still immense.
To speak with Dr. Peale, it is imperative that we remain focused on what we are about here – finding means, methods, protocols, ideas, and applications that will address the needs that face our brave war fighters who confront Traumatic Brain Injury.
Over the next three days you will work together to ensure these brave men and women have the best quality of life available to them. I wish you a productive meeting and a great stay in our beautiful city of Vienna.
General Günther Greindl (ret)
President, Austrian Peacekeepers
A valid definition of a symptom-based injury requires five components – an event, a reaction, unique symptoms, impairment, and a time course. In the case of mild traumatic brain injury (mTBI) or concussion, existing clinical definitions lack one or several of these components, thus hindering proper clinical diagnosis and research into the mechanisms, cause and treatment of mTBI/concussion. Recommendations for addressing this lack of definition validation are discussed.
In order to evaluate the occurrence of Mild Traumatic Brain Injury (mTBI) in participants of military operations outside of Poland suffering from combat-related stress disorders, treatment records of veterans of Polish Military Contingents (PMC) hospitalized in the Department of Psychiatry and Combat Stress (DP&CS) of the Military Institute of Medicine in Warsaw were reviewed. During the period of 2006-2010, a total of 144 PMC veterans were hospitalized. Firstly, we excluded from this group: those with confirmed examination and observation of evident brain damage; those whose mental condition made it impossible to obtain a credible anamnesis; those who were serving at posts without direct contact with combat operations during deployment, and those who had received a head injury prior to the deployment or after deployment. Basing on the above-presented criteria, 18 patients have been eliminated from further examinations. Medical records of the remaining 126 were analyzed by means of Brief Traumatic Brain Injury Screen (BTBIS). The analysis conducted showed that 53 (42.1%) out of 126 patients evaluated had, at the deployment, one or more injuries caused by an external force directly related to combat operations. Patients with a positive result of BTBIS (mTBI) made up 20 out of 53 (37.7%) injured veterans.
It was stated that mTBI veterans – compared to non-TBI veterans – were diagnosed with Posttraumatic Stress Disorder (PTSD) more often (60% vs 34.9%), with prevailing symptoms of increased arousal (30% vs. 4.7%), disorder was persistent, rehospitalization was necessary, (30.0% vs 4.7%) and usage of selective serotonin reuptake inhibitor (SSRI) (75% vs 56%) mood stabilizers was required (40.0% vs 27.4%).
Objective: We aimed to analyze the penetrating war head injuries in sieged Sarajevo during the first part of Bosnian war and to present our operative strategies in treatment of patients. Method and patients: We conducted a retrospective study of injured patients in sieged Sarajevo during the first two years of the Bosnian war (April 1992-July 1994) using a review of the hospital data. Our typical surgical strategy was craniectomy with reduced debridement of the brain injury without search and removal of the deep intracranial foreign fragments. In 34% of cases, operation was performed based only on clinical examination due to lack of electricity in the sieged city. Results: A total of 1,728 neurosurgical injured patients were admitted to our department from the region of central Sarajevo (361,179 inhabitants) with an almost equal divide of civilians and military personnel. Eighty-four percent of patients were admitted within 3 hours of injury and operated without any delay. Diagnosis was largely dependent on clinical examination (35% of cases) and plain radiography (47%). Computed tomography scan was only used 18% of the time due to lack of availability. The majority of neurosurgical injuries were head injuries (80%). Spine injuries comprised only 6% patients and peripheral nerve injuries 14%. Over 80% of head-injured patients had a penetrating injury. The patients with head injuries were operated on in 70% of the cases. Mortality of patients that were operated on with head injuries was 13.3%. The number of severely brain-injured patients with Glascow Coma Scale (GCS) 3 and GCS 4 who died were 143 (35%) and 122 (30%) respectively, giving a total of 265. The GCS 4 patients were operated on only in the case that compressive intracranial haematomas had been detected. A total mortality of the patients with head injury was 30%. Over 60% of injured patients who died were under 50 years old. The most common cause of death were excessive penetrating brain injury (85%) caused by high velocity missiles. Metal grenade fragments were the cause of injury in 73% of cases. Good outcome without any focal neurological deficit was found in 42.6% of all patients with head injuries. Conclusion: Our noninvasive early neurosurgical operative approach in the form of intracranial haematomas evacuation and reduced brain debridment without search for deep intracranial foreign bodies resulted in an acceptable treatment outcome during the Bosnian war.
Traumatic Brain Injury (TBI) is extremely prevalent in the soldiers returning from Iraq and Afghanistan. Although some soldiers in the United States are currently being screened for TBI both before and after they are deployed, there are many factors that limit the validity of these screenings. For example, many soldiers are reluctant to “step up” because they are concerned that a positive screen will delay their return home. Additionally, many of the symptoms of mild TBI may not emerge until the soldiers have returned home and picked up the fabric of their former life. This paper will review an approach to screening for TBI, the Brain Injury Screening Questionnaire (BISQ). Additionally, the development, validity and research on the BISQ, as well as its potential diverse clinical applications, will be reviewed.
Traumatic Brain Injury (TBI) is a common occurrence of modern warfare. It can be accompanied by multiple co-morbidities including Posttraumatic Stress Disorder (PTSD) and chronic pain. Most brain injuries are mild with complete recovery. However, residual symptoms may remain in some cases, making post-injury adjustment challenging. A thorough understanding of the physics of injury mechanisms, knowledge of neuroanatomy and pathways, and available assessment tools is necessary for optimal clinical management of a brain-injured patient. Clinical treatment guidelines and consensus findings are now available to assist the clinician in caring for these complex patients.
There is little doubt as to the existence of persistent post concussive symptoms (PPCSx) more than three months post concussion. However, much controversy exists as to the cause of such persistent symptoms, with some claiming that they are not directly due to concussion per se, but instead from psychological disorders such as Posttraumatic Stress Disorder (PTSD) and depression. Data from 12,000 recently deployed service members reveal that the strongest predictor of PPCSx is indeed PTSD and depression. However, a subset of service members complaining of PPCSx cannot be explained by psychological variables. Additional research revealed that post-deployment service members with PTSD who also suffered from concussion have greater autonomic dysregulation than those with PTSD alone. Together, this research suggests that it is preliminary to discount the possibility that a subset of those complaining of PPCSx have persistent problems due exclusively to PTSD and depression.
Among the most common and debilitating cognitive impairments after Traumatic Brain Injury (TBI) is disruption of executive functions and related emotional and behavioral dysregulation. Executive dysfunction after TBI represents one of the most significant barriers to recovery, community reintegration, and return to duty in military personnel with TBI. Investigators at the Brain Injury Research Center of Mount Sinai (BIRC-MS) have developed two theoretically- and empirically-based intensive group cognitive rehabilitation interventions that combine three distinct types of training (attention, emotional regulation and problem solving): Executive Plus and Short Term Executive Plus (STEP). A federally funded randomized controlled trial (RCT) to examine the effectiveness of Executive Plus was recently completed and an RCT of STEP is currently under way at the BIRC-MS. The proposed presentation will describe the methodology of these two RCTs. Preliminary findings from the Executive Plus study will be presented that treatment resulted in lasting benefits in the domains of self-efficacy, problem solving, attention, and quality of life even after treatment was withdrawn. In addition, MIL-STEP, a proposed adaptation of the model for treatment of veterans of OEF/OIF with TBI will be described.
We present the case of a soldier evacuated from Iraq because of traumatic stress symptoms with accompanying somatic syndromes. The symptoms occurred after explosion of a rocket that exploded approximately 40 meters away from him. Immediately after evacuation back to Poland, upon admission to the Clinic of Psychiatry and Combat Stress in Warsaw, he reported continuous internal anxiety, as well as many somatic symptoms. Psychological examination showed symptoms suggesting developing Posttraumatic Stress Disorder (PTSD) without any other irregularities including disorders connected with micro-damage of the central nervous system. During a prolonged stay in the clinic, despite medication and applied psychotherapy, the PTSD symptoms remained. With further observation it was found out that the patient suffers from a hearing disorder dissimulated by him by means of lip reading. The examination showed a significant double hearing loss, as well as a deformed nasal septum, and a longitudinal hypodensic area of a scar, located at the base of the left frontal lobe. The case presented shows that there may be comorbidity of PTSD symptoms and mild organic brain damage (mTBI), and disorders of some of the receptors (in this case, hearing).
Landmine explosions cause most of the war injuries on the battlefield and pose a substantial public health risk. Although the lower limbs are usually affected, head injuries may also occur. The aim of this study is to describe the types of head injuries caused by the explosion of landmines, along with the management of the victims. Twenty patients who sustained a head injury due to a landmine explosion were treated in the Department of Neurosurgery between 2000 and 2010. The average age of the patients was 23.5 (range between 20 and 33). Shrapnel, stone and earth were the wounding agents. Six patients underwent neurosurgical treatment and 14 had simple scalp closure and conservative treatment. Twelwe patients had associated lesions in the other parts of the body including thorax, upper and lower limbs, and the abdomen. Three patients died due to massive brain damage. Infection was observed among 6 patients. Five patients were treated by the psychiatry department for memory and cognitive problems. Landmines occasionally cause traumatic brain injury. Surgical intervention is seldom required and survival is likely unless the patient is in a deep coma. Multidisciplinary approaches are required for these patients.
Traumatic Brain Injury (TBI) is a frequent head injury, one of the leading causes of disability worldwide and a global health issue. TBI is defined as a direct physical impact to the head, and it elicits physical, cognitive, psychological, psychosocial and functional impairments. TBI can be associated with a fatal outcome. In addition, TBI is related to high healthcare costs, long term rehabilitations, prolonged sick-leaves, and social and functional disability. The conflicts around the globe have facilitated the development of complications after TBI, especially in combat veterans, but also in civilians affected by conflicts and combat situations. The severity of TBI might vary from mild to moderate and severe forms of TBI. The complications of TBI include cognitive dysfunctions, posttraumatic epilepsy, headaches and other motor and sensory neurological impairments. There are two phases of TBI: primary (a head injury) and secondary (a biological response to primary TBI). The understanding of the pathophysiology of the secondary TBI is still unclear. Biological processes that develop after TBI are the result of the organism response to the primary TBI, and they include activation of the inflammatory mediators and secretion of neurotransmitters, the development of apoptosis or necrosis, regenerative processes and altered synaptic plasticity. The main goal in TBI research is to improve the understanding of the underlying molecular mechanisms leading to the secondary TBI, to develop biomarkers that would be used to monitor the severity of injury, to find new targets (new molecules) for treatment and to have biomarkers that would follow the treatment response to reduce mortality and physical, cognitive, psychological, psychosocial and functional impairments after TBI, and to improve the clinical outcome.
Between September 2000 and September 2004, 72 casualties of terror attacks were treated in the rehabilitation department in Jerusalem; among them 17 suffered from Traumatic Brain Injury (TBI). As a control, we evaluated the rehabilitation process and outcome of 39 non-terror TBI patients treated in the same department at the same period. All patients were assessed upon admission and discharged from the rehabilitation department and at the end of their stay in rehabilitation day-care. Clinical data include demographic data, injury severity according to the Injury Severity Scale (ISS), length of stay, imaging results, surgical interventions, and complications. ADL was measured using the Functional Independence Measurement (FIM); cognitive and memory functions were measured using specific evaluation batteries. Terror TBI patients were significantly younger than the non-terror group (29 ± 9.5 versus 39.5 ±21, p=0.05). ISS score was significantly higher among terror victims and they had a higher rate of intracerebral hemorrhage, brain surgery and penetrating brain injuries with foreign bodies. The mean total length of stay of terror TBI patients in rehabilitation was 201± 88 days as opposed to 167± 148 days of non-terror victims (not significant). There was no difference in the mean FIM values of terror and non-terror TBI patients and both groups improved similarly reaching a mean FIM score of 119 upon discharge. In both groups, cognitive and memory tests improved significantly during rehabilitation without differences between the groups. Terror victims suffered from a higher percentage of posttraumatic epilepsy (35% versus 10% p=0.05). The rate of PTSD was similar in both groups as well as the rate of return to previous occupation. Although TBI terror victims had more severe injuries, they gained backmost ADL functions and their rehabilitation outcomes were similar to non-terror TBI patients.
Mild Traumatic Brain Injury (mTBI) is a common injury from combat. Detecting persistent symptoms is important in the care for returning service members. Retrospective self-reports were collected in a sample of 63 U.S. Navy Sailors who served a tour in Iraq while engaged in a high-risk mission for blast exposure. The sample fell into three injury exposure categories: no-injury (n = 17), blast only (n = 40), and blast plus blow-to-the-head (n = 6). Consistent with expectations, blast plus blow exposure resulted in greater symptom prevalence within category.
After suffering from a severe disease like spinal cord injury or stroke, patients are often unable to interact or even communicate with their environment anymore, especially at the beginning of rehabilitation. Brain-computer interfaces (BCIs) can substitute these temporarily lost communication channels. They also might support rehabilitation by providing an alternative way to control a computer: by thoughts without any muscle activity. This enables the patient to communicate by writing letters on the screen, and stay in social contact with friends or people outside of the rehabilitation facility by participating in games like Second Life© where they may appear as healthy people. Another application is to control items in their room that are connected to the BCI system, like the lights, which can be turned on and off (as can be done in a virtual smart home without leaving the bed). In this paper, the technology of such BCIs and the mentioned applications are described utilizing the P300 approach. A generic BCI interface is presented which allows concurrent control of the different applications and the ability to switch transparently among them. The results of a recent study show that a BCI can be used by patients suffering from cervical spinal cord injury almost as well as by healthy people. This encourages us to think that by enabling the user to socially interact and communicate easily, these applications may assist in rehabilitation and slow down the progress of late syndromes.
Traumatic Brain Injury (TBI) has been called the “signature wound” of the Iraq and Afghanistan wars. Helmets help, but don't completely protect against the pressure shifts caused by explosives. Flying objects from explosives have caused other head injuries. More allied soldiers are battling TBI now than in any other war. Better protective equipment and emergency care has saved more lives. Of those surviving a blast, 59% have suffered TBI. TBI is often followed by Posttraumatic Stress Disorder (PTSD). It is well recognized that the application of cooling directly to the head and neck region can potentially have a profound favorable effect on the recovery of the patient. A successful pilot study by Dr. Huan Wang, Dr. William Olivero, and William Elkins was conducted in 2001. Significant reduction in brain temperature in excess of 2°C (3.9°F) was achieved within 15 minutes of the application of the head cooling device. Core temperature was maintained at ≈+2°C over brain temperature. No device related complications were noted. Hypothermia is by far the most potent therapeutic neuro-protectant in laboratory studies. Although systemic (whole-body) hypothermia has demonstrated to provide significant neurological benefits in patients with pre-hospital cardiac arrests, its application in head trauma and stroke patients remains controversial. Systemic hypothermia has potentially severe complications that include arrhythmia, coagulopathy and infection. To minimize such systemic side effects induced by whole-body hypothermia, we have focused on techniques that could selectively cool the brain while maintaining the core body temperature in a safe range. Using National Aeronautics and Space (NASA) spin-off technology, we have developed a specialized integrated head-neck cooling and restraint system that allows optimal contact with the cranium and neck regions. In our pilot study involving severe head trauma and stroke patients, this device demonstrated both rapid and selective brain cooling. To maximize the therapeutic potential of selective cerebral hypothermia, ultra-early initiation of brain cooling in the field is necessary. This project is a prospective, controlled feasibility and safety study of applying a cooling head-neck liner integrated with head-neck stabilization and initiating selective cerebral hypothermia in brain injury patients in the field. This is an extension of a pilot study that we conducted in a clinical setting. The results we obtained from our clinical study demonstrated that we could rapidly lower the intracranial temperature to a hypothermic state while maintaining the body core temperature within a safe range. Our pilot study demonstrated that the cooling head cover was effective in rapidly achieving brain cooling and establishing a favorable brain-to-body temperature gradient. Our overall goal is to significantly improve the outcome of brain injured military personnel by rapidly inducing moderate cerebral (28-32°C) hypothermia but mild systemic (32-35°C) hypothermia to maximize the neuro-protective potentials yet minimize the systemic hypothermia induced complications.
Traumatic Brain Injury (TBI) is often comorbid with psychiatric disturbances that impede patients' recovery and everyday functioning. We present two case studies of patients who exhibited psychiatric disorders after TBI. Both patients were included in psychiatric treatment for approximately one year without improvement in anxiety, depressive symptoms, and quality of life in everyday functioning, before we decided to apply biofeedback/neurofeedback (BFB/NFB) treatment as add-on therapy. Protocols of BFB/NFB treatment are described in the paper. BFB/NFB treatment showed clinical improvement in anxiety, depressive symptoms, and overall functioning, which was confirmed by psychophysiological measures and clinical scales, as well as by patients' subjective reports.
Introduction: Troops deployed to Iraq and Afghanistan are at high risk for exposure to combat events. The occurrence of Posttraumatic Stress Disorder (PTSD) and Traumatic Brain Injuries (TBI) or concussion related to these events is of interest. In the last two decades much interest has been given to the prevalence of PTSD in returning soldiers. The Dutch deployment in Uruzgan was also characterized by the frequent occurrence of blasts caused by improvised explosive devices (IEDs). A timely and proper assessment of the impact of an IED blast is necessary for the health and sustainability of military personnel during missions. OBJECTIVE: We designed and implemented a protocol for the assessment of comorbid PTSD or depression and long term follow-up of soldiers who were exposed to blast of IED. Method: From November 2009 to August 2010 all Dutch soldiers who were exposed (during deployment in Afghanistan) to a blast from IED or grenades within 25 meters were assessed with the Military Acute Concussion Evaluation (MACE, McCrea, 2001)). This was performed within 24 hours (T1) in theatre, by a specially trained nurse or doctor. Three to six months after their return (T2) home this group of non-injured soldiers (n=106) was invited to be reassessed by a series of self-report and clinical instruments. After the test a clinical interview was performed with a clinical neuropsychologist to assess PTSD or depression. Concurrent treatment in hospital or in the outpatient department was not influenced and if necessary, the patient was referred to the psychiatrist for PTSD, rehabilitation center or other specialist for medical problems. RESULTS: In the acute phase, MACE was helpful to structure the assessment. Immediate in-theatre assessment will prevent retrospective bias when asked about event-related aspects later. Preliminary results of all MACE assessment on T1 (n=98), as well as the detailed follow-up assessment (T2) in the first cohort of 56 Dutch soldiers show few cases of PTSD (n=2), and no cases of mTBI on clinical assessment. Fatigue and subjective concentration problems were found in respectively, 12 and 21%. Impact of the event was reported as mild in most cases. Conclusions: These first results show mild effects on subjective symptom reporting after blast exposure, except for fatigue and subjective concentration. Extensive neuropsychological assessment indicated a reduced ability to store new information and an impairment of the long-term memory in a significant group. A limitation for the interpretation of these data is the absence of a control group, yet, the performance is remarkable and will need to be followed up. Careful recording of effects of blast exposure through targeted screening and structured assessment is essential to evaluate symptom onset, and long-term effects.
This study examined 12-month outcome following polytrauma and mild Traumatic Brain Injury (MTBI) in injured service members who were evaluated at the Walter Reed Army Medical Center following injuries sustained in combat theater during Operations Iraqi Freedom or Enduring Freedom (OIF/OEF). Patients (N=48) completed the Neurobehavioral Symptom Inventory within 2 months of injury (M=15.9 days, SD=13.6) and a telephone interview at 12 months post injury (M=13.1, SD=0.8). More than half of the sample met DSM-IV criteria for Postconcussional Disorder within 2 months (54.2%) and 12 months post injury (55.6%). Over time, 20.8% showed an improvement of symptoms, 16.7% worsened, and 33.3% had persistent symptoms. At 12 months, most were on active duty (79.2%), reported that they were satisfied with life (81.3%), and indicated that their health status was either “excellent,” “very good,” or “good” (66.7%). However, a substantial percentage reported that they continued to take medications (81.3%), experienced bodily pain (72.9%), needed help with daily activities (29.2%), and were currently in treatment with a mental health professional (39.6%). A small percentage reported that they had recently had suicidal or homicidal thoughts (10.4%). Extended follow-up is recommended for service members who sustain an MTBI in the context of polytrauma.
A brain undergoing Traumatic Brain Injury (TBI) suffers damage to almost all areas, and the pattern of lesions reflects the forces on the skull at the moment of the trauma; different symptoms result after every single trauma. The common problem for those afflicted by TBI is how to overcome the sudden change in emotions and how to accept their new situation with memories in the body still corresponding to the time before the accident. Members of the Austrian Association of TBI suffering from TBI were questioned concerning their situation after TBI. The change in life affects personal capacities, family and work relationships, ability to work, and financial/social situation and results in a change in relationships with key people in their life. The burden of change is more important if the person was previously a strong, body-oriented person who had to define himself through a hierarchic system, e.g. military organisation. The TBI patient may feel a resulting emptiness in their life, inside and out, and has to reorient himself with a reduced brain capacity. Most people, the injured and families alike, feel a sense of loneliness after TBI. Caregivers and case managers are not skilled enough to deal with emptiness, reorientation, the mourning process and the issue of responsibilities resulting from medical, therapeutic and social consequences after TBI. Reorientation Syndrome is a considerable condition after each TBI that has to be respected to understand how to help TBI patients and their families successfully reintegrate into a functional life after TBI.