Chapter 10
Traumatic Brain Injury
(TBI) in the Military
Facts About Traumatic Brain Injury (TBI)
 Majority caused by explosive devices (blast explosure).
 Signature wound of wars in Iraq and Afghanistan.
 Since 2000, over 195,000 service members screened
for suspected TBI.
 Ranges from mild to severe; estimated 70% to 90%
diagnosed as mild in severity.
 Moderate to severe detected early; mild more complex.
Diagnostic Criteria
 Any period of loss of consciousness (LOC)
 Posttraumatic stress amnesia (PTA)
 Glasgow Coma Scale (GCS) rating
Impact of Time
 Majority of symptoms resolve over time.
 Symptoms do not worsen over time.
 Following a mild to moderate brain injury, individuals
begin to return to preinjury level of functioning over
weeks to months.
 An exception to this rule is when there are other complications in
functioning such as psychiatric illness, substance abuse, and/or
chronic pain.
 Neuroimaging can assist with assessing the severity of
TBI and potential outcome.
 MRI and CT are commonly used.
 MRI (Magnetic Resonance Imaging) uses magnetic
signals to generate images that create a structural map
of the brain.
 CT (Computerized Tomography) generates
computerized pictures of the brain that are produced
from multiple X-ray images.
An MRI of a Severe Traumatic Brain Injury
(Top) Compared to an MRI of a Healthy
Brain (Bottom)
Acute Symptoms Following Moderate to
Severe TBI
 In a combat setting, service members who sustain a
mTBI/concussion following a blast exposure often present with
a multitude of complex symptoms:
severe headache with progressive worsening
dizziness, pain, fatigue, sleep difficulties
repeated vomiting or nausea
convulsions or seizures
the inability to wake up from sleep
dilation of one or both pupils of the eyes
problems speaking
limb weakness or numbness
loss of coordination, confusion, restlessness, and agitation.
In the military, symptoms such as severe headache and vomiting
are considered red flags and warrant immediate medical
Treatment and Recovery Following
Moderate to Severe TBI
 Four stages: immediate, intermediate, rehabilitation, transitional
 The vast amount of cognitive recovery (e.g. attention, memory, and
processing speed) occurs primarily during the first two years following
the event.
 Recovering from multiple physical injuries may complicate TBI
 The damage to the brain resulting from a moderate to severe TBI may
lead to lifelong disabilities, including a loss of physical or mental
 Activities of daily living are often more challenging, even in those who
appear to have fully recovered. Physical and mental changes can
affect the service member’s personal life, family relationships, career
goals, and future
 It is crucial that the social work provider assist in offering early
education, intervention, and continued support to both the patient
and his or her family members.
Mild TBI (mTBI) in the Military
 Symptoms in three domains:
 Physical
 headaches, nausea, vomiting, fatigue, blurred vision, sensitivity to light/noise,
dizziness, balance problems, and sleep disturbance
 Cognitive
 changes in attention, concentration, short-term memory, speed of processing
information, judgment, and executive functioning
 Behavioral/emotional
 irritability, agitation, depression, anxiety, impulsivity and aggression
 Postconcussion syndrome following mTBI
 Controversial
Treatment and Recovery Following mTBI
 The expectation following mTBI is generally a full
resolution of symptoms and recovery
 If sustained in theatre, frequently medically managed in
 Period of rest (e.g., 24 hours behind the wire), reevaluated, and
then returned to duty as soon as a symptomatic.
 Interventions vary:
 Early Psychoeducation on recovery is important.
 Group based interventions, including compensatory strategy
training, have shown a decrease in symptoms of depression and
cognitive dysfunction.
 With early education, and intervention, most mTBI patients
recover successfully.
Co-Occurring Recovery Considerations
Discussion Questions
 A veteran comes into your office and tells you that during the
weekend he was playing baseball and was struck in the head
with a bat. He fell to the ground, blacked out for 20 seconds,
and can't remember the hour prior to the baseball
game. He tells you he is feeling "dizzy."
 What was the severity level of the concussion?
 You see a sailor in your clinic on a regular basis. During the
last visit he told you that he was having dizziness, irritability,
thinking difficulties, headaches, and depression. He has a
recent history of
concussion or mTBI and combat stress.
 Which of his symptoms could be related to combat
 Which of his symptoms could be related to his concussion
or mTBI?
 Which symptoms overlap?
Discussion Questions
 You are completing a clinical interview with a Marine
when she tells you she sustained a mild concussion,
with 10 minutes of LOC, 1 hour of PTA, and minimal
symptoms. While reading through her medical record,
you discover that she was assaulted and has positive
brain imaging findings. Her report of LOC and PTA is
consistent with medical records.
 What is the severity level of her TBI?
 What conditions other than a TBI can affect a Glasgow
Coma Scale?
 What are the possible implications of a second
concussion before the first concussion has resolved?

Traumatic Brain Injury (TBI)