Care for Military Service Members with Mild Traumatic Brain Injury

Traumatic brain injury (TBI) continues to be an important medical issue for the military. Between 2000 and the second quarter of 2022, a total of 463,392 service members were diagnosed with TBI; ≈82% of cases were mild TBI (mTBI)¹ (Figure 1). Recent updates in management of acute and chronic TBI have been made on the basis of information collected by the TBI Center of Excellence—the principal organization of the Department of Defense (DoD) for supporting TBI care—as well as the vast Military Health System and Department of Veterans Affairs (VA), leveraging hundreds of stateside and overseas medical providers and clinics to provide the best TBI care possible. In this review, we focus primarily on the care of people with mTBI.

Acute mTBI Care

The Military Health System facilitates acute mTBI evaluation and care through multiple structured policies and guidelines. This evaluation ideally starts at or near the point of injury, with combat medics and corpsmen trained in administering the Neurobehavioral Symptom Inventory and Military Acute Concussion Evaluation, Version 2 (MACE2), released in March 2021 as a more comprehensive version of its predecessor. The MACE2 is intended to be completed after a direct blow or trauma to the head or a potentially concussive event. A potentially concussive event is defined as one of four potential events: 1) motor vehicle accidents or rollovers, 2) a blast within 50 meters, 3) involvement in a vehicle blast event, or 4) a witnessed loss of consciousness. In comparison with the initial version of MACE, the MACE2 expands historical evaluation to include red flags and observable signs and symptoms and includes a more thorough neurologic evaluation, including further speech and balance testing in addition to vestibular and ocular-motor screening.

Once mTBI has been diagnosed, a service member proceeds through a progressive return to activity, a stepwise progression of increased aerobic activity through 6 stages culminating in a return to full duty with unrestricted activity. This process is nuanced by the number of mTBIs experienced within a 12-month period, with service members experiencing three or more events during this period requiring specialist evaluation prior to advancing to a return to full duty. If a service member demonstrates difficulties proceeding through the progressive return to activity, a symptom-guided treatment approach is mandated with an end goal of intensive activity entailing preinjury exercise routine and training activities prior to return to full duty.

Chronic or Persistent Symptoms of mTBI

VA/DoD Clinical Practice Guidelines for the Management and Rehabilitation of Postacute mTBI

In June 2021, the latest update of the VA/DoD clinical practice guidelines for the care of mTBI was released.^2,3 These guidelines offer a systematic evidence review of clinical and epidemiologic information aimed at providing the most up-to-date recommendations regarding mTBI care following the acute phase (>7 days postinjury). The VA/DoD clinical practice guidelines for the care of mTBI include recommendations on setting of care, diagnosis and assessment, neurocognitive decline, mechanism of injury, and symptom-based treatments; a review of interventions with insufficient evidence; and algorithms to support efficient clinical decision-making regarding symptoms related to mTBI.

Posttraumatic Headache

A common chronic sequala of mTBI managed by military healthcare providers is acute or persistent posttraumatic headache. The management of service members often does not differ substantially from that of their civilian counterparts, with some key nuances. A traumatic mechanism of injury and associated behavioral disturbances have substantial effects on the persistence of symptoms related to mTBI, including posttraumatic headache.^4,5 In addition, long-term therapies, particularly preventive ones, may not be compatible with active duty service, because many limitations apply to fitness for duty (eg, refrigerated medications, such as the large-molecule calcitonin gene-related peptide antagonists, are often excellent preventive therapies for service members with persistent posttraumatic headache of a migraine phenotype, but their use may limit a service member’s ability to deploy).

TBI and PTSD in the Military

Unsurprisingly, mTBI and posttraumatic stress disorder (PTSD) represent substantial health concerns for service members, and when co-occurring, present considerable challenges to medical providers in terms of diagnosis and management. In both civilian and military populations, PTSD occurs at a higher rate when associated with mTBI. Within military populations, there is a 2- to 4-fold increase in risk of PTSD occurring when mTBI is present and approximately double the risk compared with civilian populations.^6,7

Evidence suggests that comorbid PTSD may lead to prolonged recovery from mTBI.⁸ Furthermore, there is substantial overlap in the symptomatology associated with mTBI and PTSD, which may lead to incorrect symptom attribution and delay of appropriate care. The increased risk of co-occurrence, prolonged recovery, and overlapping symptomatology necessitate accurate diagnosis of mTBI comorbid behavioral health disorders, particularly PTSD, using validated diagnostic tools in the appropriate clinical setting.

Interdisciplinary Care and the Intrepid Spirit Network

The Military Health System recommends a symptom-based approach to mTBI, typically in a primary care setting. A minority of people with mTBI will have symptoms that persist despite conventional interventions and may benefit from a holistic and interdisciplinary approach to care in a TBI-centered clinic.^9,10 The recently developed Defense Intrepid Network for TBI and Brain Health applies an interdisciplinary approach to care that incorporates not only medical, rehabilitation, and behavioral health care, but also complementary and integrative health services in a patient-centered model of care.¹¹ The Defense Intrepid Network comprises the National Intrepid Center of Excellence, 10 Intrepid Spirit Centers, and 2 TBI clinics located at various military treatment facilities across the US and overseas. Each Intrepid Spirit Center provides interdisciplinary TBI care to service members either through conventional outpatient services or intensive outpatient programs, which typically take place over 2 to 4 weeks and focus on service members who may not have access to an Intrepid Spirit Center at their location or have limited time to participate in conventional outpatient services.

Blast-Related mTBI

Blast injury is a unique and understudied cause of mTBI, gaining increased attention since the early 2000s because of the prevalence of blast-related TBI in deployed service members. As an example, one study reported that out of 43,852 people screened for TBI between 2006 and 2011, 70% of TBIs were a result of blast-related injuries. The framework of blast injury is subdivided into 5 separate categories ranging from primary to quinary, characterized by the different physical exposures related to a blast, such as blast overpressure or postdetonation environmental contaminants.¹² Given the prominent effect of deployment-related TBI, commonly as a result of blast injury, on the readiness of the US military as well as the financial impact, estimated at between $96.6 and $144.4 million in 2007,¹³ blast-related TBI will continue to be a prominent focus of research for years to come in the military domain.

Future of Military TBI

In 2018, the DoD began development of what is now known as the Warfighter Brain Health Initiative, with the overarching purpose of maintaining service members’ optimized brain health through a series of solutions and activities expected to be accomplished over the next several years. In addition to developing and refining interventions for TBI, the Warfighter Brain Health Initiative creates a framework for prevention, education, and training, as well robust research activities (Figure 2). The Warfighter Brain Health Initiative extends beyond TBI to include new and emerging threats to service members and ensures a comprehensive approach to brain health.¹⁴

Conclusion

Providing the best medical care for service members with TBI is a priority for the Military Health System. Standardizing approaches to acute mTBI care, developing and refining an interdisciplinary approach for persistent symptoms related to mTBI, and optimizing brain health through the Warfighter Brain Health Initiative are some of the critical components in the evolution of TBI care in the military.