This document discusses traumatic brain injury (TBI) in veterans and active duty soldiers. It notes that TBI is the "signature wound" of recent wars. Mild TBI is difficult to identify but can still cause long-term symptoms. Soldiers are at risk of TBI from blast injuries from IEDs and other explosions. TBI often occurs with other injuries and can cause physical, cognitive, and behavioral issues. However, the long-term symptoms reported by many soldiers may be due to multiple factors beyond just the TBI, such as PTSD, depression, and the ongoing traumatic environment of combat. Early identification and treatment as well as education about recovery can help facilitate reintegration.

1. Traumatic Brain Injury:
From combat to reintegration
Wisconsin Women Veterans Conference
September 20, 2009
Presented by:
Jennifer C. Imig, Ph.D.
Copyright 09/20/2009

2. Overview
• Traumatic Brain Injury in returning veterans and active duty
soldiers
• Traumatic brain injury (TBI) is the “signature wound” of
soldiers and returning veterans.
• Identification of mild TBI is receiving great clinical attention in
the VA and DOD, as this injury may be “hidden.”

3. Incidence of TBI
• Due to improvements in body armor and field
trauma care, more individuals are surviving
beyond the acute phase of these injuries.
• The nature of intense, unpredictable, and
repeated blasts may lead to a significant number
of soldiers with traumatic brain injuries ranging in
severity from mild to severe.

4. How close does a soldier have to be to
a blast to cause an injury?

5. The answer is that we don’t know……

6. • Traumatic Brain Injury
….the hallmark injury faced by
veterans of Iraq and Afghanistan.
• Even those who were not obviously wounded
in explosions or accidents may have sustained
a brain injury.

7. Sources of TBI During Combat
• Blast Injuries—Limited or no physical signs
– Improvised Explosive Devices (IED), Rocket
Propelled Grenades (RPG) , Mortars
• Impact Injuries-Physical injuries noted
– MVC, Bullets, Falls/Accidents
• Each incident can potentially cause multiple
system injuries.

8. Mechanism of blast injury
• PRIMARY:
– effects of overpressure shock wave, affecting air-filled
organs (ear, lung, GI), organs surrounded by fluid-filled
cavities (brain, spinal cord)
• SECONDARY:
– flying debris/fragments --penetrating injuries
• TERTIARY:
– body displacement/blast wind, blunt/crush trauma,
fractures, amputation
• QUARTENARY:
– burns, respiratory injuries, septic syndromes

9. POLYTRAUMA and TBI Injuries
• Multi-Dimensional Injuries, unique in this
population
• TBI frequently occurs in polytrauma in
combination with other disabling conditions
such as amputation, auditory, and visual
impairments, SCI, PTSD and other mental
health conditions.

10. TBI Severity
• A mild TBI (which is usually not associated with visible
abnormalities on brain imaging) is one that causes loss of
consciousness lasting less than 1 hour or amnesia lasting less
than 24 hours.
• A moderate TBI produces loss of consciousness lasting
between 1 and 24 hours or post-traumatic amnesia for one to
seven days.
• A severe TBI causes loss of consciousness for more than 24
hours or post-traumatic amnesia for more than a week are
considered severe.

11. TBI Severity
• A mild TBI (which is usually not associated with visible
abnormalities on brain imaging) is one that causes loss of
consciousness lasting less than 1 hour or amnesia lasting less
than 24 hours.
• A moderate TBI produces loss of consciousness lasting
between 1 and 24 hours or post-traumatic amnesia for one to
seven days.
• A severe TBI causes loss of consciousness for more than 24
hours or post-traumatic amnesia for more than a week are
considered severe.

12. Mild TBI defined by the Head Injury Interdisciplinary Special
Interest Group of the American Congress of
Rehabilitation Medicine
"a traumatically induced physiologic disruption of brain function, as manifested
by one of the following:
Any period of loss of consciousness (LOC),
Any loss of memory for events immediately before or after the accident,
Any alteration in mental state at the time of the accident,
Focal neurologic deficits, which may or may not be transient."
The other criteria for defining mild TBI include the following:
GCS score greater than 12
No abnormalities on CT scan
No operative lesions
Length of hospital stay less than 48 hours

13. mTBI Evaluation
• DIAGNOSIS: mild TBI = Concussion
– Incidence of a change in mental status
• Loss of consciousness
• Seeing stars
• Dazed and confused
– Sometimes there is also loss of memory after the
event, called post traumatic amnesia
– Sometimes, but rarely, there is loss of memory for
before the event, called retrograde amnesia

14. Mild TBI may or may not
be associated with post-concussive symptoms.

15. Post-Concussive Syndrome: Management
• Post-TBI symptoms seen in PCS are present in 15 (DSM-IV) to 50%
(ICD-10) of persons with mTBI.
• Symptoms rapidly resolve by 2-4 weeks
post-mTBI in >90% individuals.
McCrea: JAMA 2003;290:2556-2563
• <5% may have persistent difficulties
by 12 months.
Iverson: Brain Injury Medicine 2007;373-405
• Early intervention improves short-and
long-term outcomes.
Ponsford: J Neurol Neurosurg Psych 2001;73:330-2
Wade: J Neurol Neurosrg Psysch 1998;65:177-183
David X. Cifu, M.D.
The Herman J. Flax, M.D. Professor and Chairman
Department of Physical Medicine and Rehabilitation
Virginia Commonwealth University

16. Even though the research suggests that the
symptoms of post concussive symptoms
should be transient in most cases…
…what do the soldiers report?

17. Common mTBI Complaints
• Problems with:
• Money management
• Employment
• School
• Recreational activities
• Family/ Significant Other
• Social interaction

18. Physical Problems
• Pain
• Motor weakness
• Sensory deficits
• Upper Motor Neuron/CNS findings
• Balance/Gait abnormality
• Dizziness/vestibular symptoms
• Headaches
• Fatigue
• Hearing loss/tinnitus/sensitivity to noise
• Visual changes
• Decreased psychomotor activity, tremor

19. Cognitive Deficits
• Deficits in:
• Attention/concentration
• Processing speed
• Memory
• Problem-solving
• Executive organization
• Safety judgment

20. Emotional/Behavioral Issues
• Depressed mood
• Anxiety
• PTSD
• Suicidal ideation
• Irritability/anger control
• Disinhibition
• Sleep disturbance

21. Why is there a discrepancy…. In what we expect and
what is reported?
The majority of the TBI research came from sport-
related research
Are these two sources of injuries
comparable?

22. TBI in Sports TBI in Combat
Head & Brain injury Brain injury without
head injury common
Isolated/discrete event Multiple events
Immediate medical care Often not immediate medical
evaluation
Player is safe after incident Soldier is not safe after incident
Pre and post changes are Difficult to detect pre and post
identifiable changes

23. Are these two types of injuries comparable?
Most likely they are not…
Due to the environment in which the TBI
occurred and the on-going trauma in the theatre
Therefore what contributes to sustained residuals
noted in soldiers with combat-related TBI?

24. What causes the prolonged symptoms reported
by many soldiers
– Current symptoms may be due to multiple
sources
• Due to mTBI only
• Due to mTBI and adjustment stress
• Due to mTBI and PTSD or depression
• Due to premorbid difficulities
–Started prior to military; possibly
exacerbated by the combat duty

25. Sources of Sustained Residuals
• Severity, multiple incidence, and mechanism of TBI
• PTSD
• Prior history of psychiatric distress (depression/anxiety)
• Military onset of psychiatric distress
• Drug use (especially cocaine and marijuana)
• Alcohol abuse
• Previous brain/head injury
• Previous childhood learning conditions (LD, AD/HD)
• Chronic and/or acute pain

26. PTSD
Re-experiencing
Avoidance
Arousal
Social withdrawal
Sensitive to noise
Memory gaps
Concentration
Apathy
Insomnia
Mild Difficulty with decisions
Irritability
Mental slowness
TBI Concentration
Residual Headaches
Dizzy
Appetite changes
Fatigue
Sadness
Depression
David X. Cifu, M.D.
The Herman J. Flax, M.D. Professor and Chairman
Department of Physical Medicine and Rehabilitation
Virginia Commonwealth University

27. So what can be done to ameliorate symptoms and
encourage successful reintegration in soldiers
Early Identification & Intervention
Education of Expected Recovery
Proactive Reintegration Efforts

28. Early Identification
• DOD
– Field Evaluations
– Camp TMCs
– Landstuhl, Germany
– Walter Reed, AMC
• DOD and VA Liasons
• VA
– TBI four level screening
– Polytrauma/TBI system of care
• Private Sector Collaborations

29. Early Intervention
• Value of Early Intervention
– Improves short and long term outcomes
– Education/positive reassurance
– Symptoms treatment: analgesics, antidepressants,
sleeping aid, psychological intervention
– Cognitive remediation/compensatory strategies
– Care coordination/Case management
– Close follow-up/monitor progress: symptoms,
life/job performance

30. Education of Expected Recovery
• Post Traumatic Growth:
– “… emphasizing the potential for FULL RECOVERY
minimize the unnecessary attribution of common
stress reactions to pathology and facilitate
resilience after mild TBI.”
– Richard A. Bryant, PhD
PTSD specialist, University of New South Wales, Australia
---Tom Valeo, Neurology Today, March 20, 2008

31. Proactive Reintegration Efforts
• Community Reintegration:
• Vocational Rehab
• Work Hardening program
• Recreation/Exercise, Recreation Therapist
• Driving safety
• Psychosocial/Family support and resources
• Adaptive equipments: PDAs, recorders, etc.
• Active duty/reserve:
• Redeployment/return to combat

32. TBI Recovery Resources
• Female focused treatment in women’s clinic
• OEF/OIF Outreach Groups
• Family Support Group
– Kids focused groups and materials
– Spouse focused materials
• Collaboration between VA, DOD and
private sector

33. Restoration of Premilitary Adjustment
Pre-military life Post-military life trajectory
trajectory Barriers are overcome
Barriers to Healthy
Adjustment
TBI
Military
PTSD
Depression
Substance Abuse

34. Website resources
• www.biausa.org (Brain Injury Assoc. of America)
• www.neuro.pmr.vcu.edu (National resource Center
for Traumatic Brain Injury)
• www.pdhealth.mil/TBI.asp (Deployment Health
Clinical Center (TBI)
• www.va.gov/health_benefits (VA Benefits)
• www.vetsuccess.gov (Voc Rehab and
Independent Living Services)
• www.militaryonesource.com

35. Questions
I am honored to serve those
who have served and their
families.
Thank you!
Jennifer
Jennifer.Imig@PsychologySpecialists.com
Jennifer.Imig@comcast.net