Mild Traumatic Brain Injury in Military ServicePersonnel; Key Issues and Considerations

Rehabilitation and long term outcomes: A ReviewSilviya P. Doneva, PhD1, 2

1The Centre for Veterans Health, King Edward VII’s Hospital,2The Medical Advisory Committee

1. Introduction• Mild traumatic brain injury (mTBI) has been defined as ‘a traumatic-ally induced physiological disruption of brain function’ [1], accompan-ied by an array of symptoms which differ per case.• If unresolved within 3 months of injury, these evolve into what isknown as persistent postconcussive symptoms (i.e., PCS; Table 1).• MTBI is the most common form of TBI, resulting in between 800000 and 900 000 cases being registered in UK emergency departmentsevery year [1].• Described as a ‘service-related mental disorder’ and a ‘signature warinjury’ for those returning from Iraq and Afghanistan.• The present review considers mTBI related to blunt head trauma in UKService Personnel.

Table1. Postconcussive symptoms reported following mTBI.

2. Aims and Objectives• To present an objective, evidence-based review of the topic, incor-porating as many of the different perspectives as possible.• To discuss some of the serious long-term conditions that can followfrom mTBI, as well as a number of approaches to managing the con-dition.• The full report also provides information on the definition, classific-ation, prevalence rates and markers of mTBI, as well on its comorbiditywith other disorders.

3. MethodInformation has been drawn from:• The most current reports (at the time of writing), published by theUK Ministry of Defence (MoD);• Reports by The World Health Organization (WHO) CollaboratingCentre Task Force on Mild Traumatic Brain Injury;• High-impact academic research in the field, mainly making use ofUK and US military data.This report was written under the supervision of Dr Anne Braidwood,Senior Medical Adviser to Service Personnel, MoD.

4. Long-Term EffectsIn a minority of cases mTBI can lead to a number of neuropathological,neurophysiological, and neurocognitive changes.

Table2. Possible Long-Term Effects following mTBI.

5. Treatment and Management

Table3. Current Practices in Approaching and Managing mTBI.

6. ConclusionStill no agreement on the classification and the aetiology of the disorder:• reflected in the array of reported PCS;• the volatility in the course of the condition (i.e., while some recoverwithin weeks, others develop long-term symptoms);• the variety of approaches to the management and treatment of mTBI.Future work should focus on identifying the predictors of the seriouslong-term conditions mTBI can evolve into and on bridging the gaps inthe management and treatment of the condition;

7. References[1] Kolias AG, Guilfoyle MR, Helmy A, Allanson J, Hutchinson PJ. Traumatic brain injury inadults. Pract Neurol. 2013 Aug;13(4):228–35.[2] McKee AC, Stein TD, Nowinski CJ, Stern RA, Daneshvar DH, Alvarez VE, et al. The spec-trum of disease in chronic traumatic encephalopathy. Brain. 2013 Jan 1;136(1):43–64.[3] Niogi SN, Mukherjee P, Ghajar J, Johnson CE, Kolster R, Lee H, et al. Structural dissociationof attentional control and memory in adults with and without mild traumatic brain injury. Brain.2008 Dec 1;131(12):3209–21.[4] Tremblay S, De Beaumont L, Henry LC, Boulanger Y, Evans AC, Bourgouin P, et al. SportsConcussions and Aging: A Neuroimaging Investigation. Cereb Cortex. 2013 May 1;23(5):1159–66.[5] Borg J, Holm L, Peloso P, Cassidy JD, Carroll L, von Holst H, et al. Non-surgical interventionand cost for mild traumatic brain injury: results of the who collaborating centre task force onmild traumatic brain injury. J Rehabil Med. 2004 Feb 1;36(0):76–83.[6] Mittenberg W, Tremont G, Zielinski RE, Fichera S, Rayls KR. Cognitive-behavioral preven-tion of postconcussion syndrome. Arch Clin Neuropsychol. 1996;11(2):139–45.[7] Wheaton P, Mathias JL, Vink R. Impact of pharmacological treatments on outcome in adult ro-dents after traumatic brain injury: a meta-analysis. J Psychopharmacol (Oxf). 2011;25(12):1581–99.[8] Hoffer ME, Balaban C, Slade MD, Tsao JW, Hoffer B. Amelioration of Acute Sequelae ofBlast Induced Mild Traumatic Brain Injury by N-Acetyl Cysteine: A Double-Blind, Placebo Con-trolled Study. Fehlings M, editor. PLoS ONE. 2013 Jan 23;8(1):e54163.

8. Contact

Dr Silviya P. Doneva,SilviyaDoneva@kingedwardvii.co.uk

9. AcknowledgementsWe would like to thank Dr Anne Braidwood, Senior Medical Adviser toService Personnel, MoD for all her very valuable guidance, commentsand suggestions while writing this report.