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Traumatic Brain Injury Care for Veterans

Severe head trauma from sudden impact or penetrating injuries can affect brain function—a condition called traumatic brain injury (TBI). While TBI can affect anyone, certain groups face elevated risks, notably adolescents aged 15-19, older adults, and military personnel.

In the military context, TBI has become prevalent. The Defense and Veterans Brain Injury Center data shows over 400,000 service members in one decade received a TBI diagnosis. Combat-related blast exposure from grenades, bombs, or firearms accounts for the majority of cases. These injuries occur through direct physical impact from debris or blast-induced pressure waves. Falls and accidents during training or routine activities also contribute to TBI incidence among service members.

Immediate symptoms of TBI often manifest in unconsciousness, confusion, and memory loss, sometimes accompanied by concussion. In the long term, service members may struggle with routine activities such as walking or having problems sleeping, paying attention, and maintaining balance. Mental health conditions like PTSD and dementia frequently co-occur, further complicating veterans' reintegration into civilian life. In social settings, individuals may struggle with interactions due to hearing problems and other factors; some may have suicide ideations. Severe TBI can also cause brain cancer.

Veteran physicians employ a multifaceted approach to diagnose TBI. Advanced neuroimaging techniques reveal internal brain damage, such as bleeding or swelling. Clinicians also assess the length of unconscious or confusion, memory problems, and post-injury responsiveness. While most TBIs are mild, these cases can have significant long-term cognitive repercussions. Symptoms for mild TBI resolve within days or weeks, but some individuals may experience persistent effects for months or longer.

Treatment strategies for veterans with TBI vary based on severity. While mild cases don't require major intervention other than rest, over-the-counter medications, and symptom monitoring, severe TBIs may necessitate surgery to minimize brain tissue damage, remove blood clots and any debris inside the skull, alleviate pressure from swelling, and repair fractures. Post-surgery care may include pain relievers, drugs to manage seizure/lotting, and stimulants for increased alertness.

Rehabilitation is critical to recovery for injured veterans. Programs often target psychological support, physical conditioning, speech therapy, and other domains. Therapeutic activities may include hobby engagement, cognitive challenges, vocational skill development, and speech exercises. Behavioral interventions, e.g., cognitive-behavioral therapy (CBT), help veterans manage TBI-associated conditions and promote overall wellness through positive habit formation, such as mindfulness practices, sleep hygiene, regular physical activity, and balanced nutrition.

Experts in veteran healthcare propose several strategies to enhance care. Implementing comprehensive support systems is crucial for managing TBI's long-term effects. Long-term plans and support structures benefit veterans and caregivers by clarifying expectations for care as aging impacts abilities. Policy efforts focusing on expanding access to ongoing medical care for veterans dealing with TBI-related issues are key. Increasing the number of specialized facilities, hiring more healthcare providers for integrated care, and offering telehealth services to reach more veterans can also significantly improve the quality of care.

Given the knowledge gap about TBI and its unique impacts on veterans, ongoing research is necessary. Integrating military and medical records over time would enable comprehensive studies of symptoms, treatments, and outcomes. Long-term cohort studies could reveal disparities in care and needs across veteran groups, informing targeted treatment approaches.

Several ongoing research projects are making strides in this field. The Veterans Association's TBI Veterans Health Registry collects extensive clinical data to compare therapeutic outcomes for war-related cases. Further, a separate genetics study within an extensive military healthcare program explores how genetic and biological factors influence post-injury cognitive and mental health. Sustained investment in applied and basic research initiatives remains critical for advancing TBI care for veterans.

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Veterans Who Experience TBI Show Indicators for Alzheimers

According to the Alzheimer's Association, veterans who have experienced traumatic brain injury (TBI) have a higher risk of developing Alzheimer's and other memory loss diseases. A March 2024 article published in the American Academy of Neurology's (AAN) Neurology reported findings from a study that support this research. However, the study found that veterans predisposed to develop Alzheimer's also exhibited indicators.

TBI occurs after an individual experiences a bump, blow, or trauma to the head. Typically, this happens through falls, accidents, or assaults. In the case of service members, this trauma occurs because of involvement in an engagement involving a blast that results in an impact injury.

The study's researchers enlisted the help of 51 participants, all veterans who experienced a concussion in one war zone or blast and impact injuries. Concussions are mild forms of TBI involving the person losing consciousness from a few moments to 30 minutes. Researchers then compared the 51 participants with 85 veterans and civilians who never experienced TBI. All the study's participants were male except one female, and 35 was the average age. Data showed that the concussion group experienced 20 concussions resulting from a blast and an average of two concussions resulting from impact injuries.

Researchers assessed all participants' thinking and memory. They also collected cerebrospinal fluid from lumbar punctures. Researchers measured the amount of amyl-beta (AB42 and AB40) and tau in the fluid, both biomarkers indicating early signs of Alzheimer's.

The study's data shed light on the connection between TBI and Alzheimer's. Before this study, other research demonstrated that lower levels of AB42 and AB40 revealed an accumulation of amyloid in the brain, a precursor to Alzheimer's. In the study, researchers saw these levels decrease around age 45, 20 years earlier than the general population.

In addition, the data showed that participants who had experienced blasts from concussion blasts had lower levels of AB42 than the participant group who had not experienced a concussion as they increased with age. By 50 years old, both AB42 and AB40 levels in concussion blast participants became lower than those who had not experienced a concussion blast. No difference became apparent in the tau levels between both groups, and the results remained unchanged when the APOE-e4 allele, a gene predisposing people to Alzheimer's, presented itself.

Moreover, the study connected lower levels of amyloid with poor performance on thinking and memory tests at older ages. The participants took a trail-making test involving connecting a series of dots as quickly as possible. At 50, participants who experienced concussions took 34 seconds longer to finish the assessment than the group who had not experienced a concussion. They also took another assessment measuring verbal memory that required participants to recall words after a 20-minute delay.

Participants who had experienced concussions scored 8.8 points, while those who had not scored 13.1 points. Those in the concussion group scored 4.2 points lower, on average than those in the group who had not experienced a concussion.

The study's limitations include that many participants were young, with only a small number being older than 45. This age is important because the processes leading to Alzheimer's do not emerge until much later in life. Furthermore, other limitations were related to the overall sample size and study duration. Other studies have found that researchers must include amyloid level measurements in the brain.

Elaine Peskin, MD, senior study author of the Northwest Mental Illness Research, Education, and Clinical Center at the VA Puget Sound Healthcare System and the University of Washington School of Medicine, stated that the study does not fully address whether veterans who experience injuries of this type will develop Alzheimer's. Still, it does suggest that TBI might lead to dementia.

The Department of Veterans Affairs and the University of Washington supported this study.

The study had one limitation: Researchers only focused on veterans who served post-911. They could not make a general statement covering all other veteran groups, such as older service members who served in previous wars.

The Department of Defense supported this study, published in the American Academy of Neurology's (AAN) Neurology. The AAN is the largest association of neurologists and neuroscience professionals worldwide.

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Role of a Neurologic Consultant

A specialist branch of medicine, neurology delves into the intricacies of the human nervous system. Neurologists are the physicians who diagnose and treat the nervous system disorders. Consultant neurologists diagnose, treat, and consult on the most complicated neurological diseases and conditions.

Neurologic consultants study and qualify like any other doctor. However, they undertake further training, typically lasting 5-7 years, before they are eligible as consultants. In addition, practicing as a neurologic consultant requires continuous learning to ensure one is updated on the latest breakthroughs and developments in the field of neurology.

Neurologists specialize in treating conditions such as Parkinson's disease, epilepsy, stroke, multiple sclerosis (MS), motor neuron disease (MND), dementia, and brain tumors. Other conditions include muscle disorders, headaches, and blackouts. In their consulting role, neurologists diagnose and treat a nervous system disorder. After that, advise the primary healthcare provider on managing the patient’s overall health.

Because the nervous system is very complex, many neurologists specialize in treating people with specific neurology conditions or certain populations such as children, adults, or veterans. A neurologist, for example, may consult on conditions such as headache, concussion, or stroke.

Military conflicts in different parts of the world that involve the US, such as in Iraq and Afghanistan, have significantly increased the number of service members returning home with neurological disorders. These include traumatic brain injuries, polytraumatic injuries, and spinal cord injuries. The Department of Veterans Affairs (VA) and Department of Defense (DoD) have established a rehabilitation program to care for the nation’s war heroes. Veterans can access this service through hospitals and designated regional offices.

A consultant neurologist consults individuals with suspected neurological conditions or diseases. This entails discussing symptoms, ordering appropriate scans and tests, and reviewing the results. The duties include informing affected persons of their conditions and advising on the next steps, such as treatments, surgeries, and how to manage or improve the quality of life.

Although they can recommend surgical treatment, they don’t perform surgery. When this is the best treatment option, a neurosurgeon performs the surgery in consultation with the neurologist and other specialists in surgical treatments of the nervous system or brain. The neurologist monitors the treated patients and also supervises the continuing treatment regime.

Neurologic consultants sometimes evaluate people who have had surgery in hospitals or those experiencing new challenges such as decreased alertness or seizures. While they typically spend some time consulting and assessing new patients, neurologists may hold outpatient clinics. They may also evaluate recovering neurological patients or those living with degenerative conditions like Parkinson's, brain tumors, multiple sclerosis, motor neuron disease, or those recovering from surgery for a neurological condition.

Consultants often lead the decision-making process for treatment options for nervous system disease and disorder. This may, for example, involve referring patients to neurosurgeons for necessary surgical procedures. Consultants may also sign off on other medicines and treatments that might help manage neurological symptoms or conditions.

Besides consulting on treatments, neurologic consultants may help train junior doctors and shadow doctors in preparation for becoming consultants. Part of this might include supervising junior doctors on hospital ward rounds and giving formal training or mentoring. As senior and expert physicians, neurologic consultants may spend time working with universities and researchers to study neurological treatment and management further.

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Treating and Preventing Traumatic Brain Injury

An injury sustained by the brain as the result of an outside force may be categorized as a traumatic brain injury (TBI). A TBI is usually caused by a blow to the head, an event that violently shakes a person’s head, or an object that pierces the skull and enters the brain, though these types of injuries do not always lead to TBI. The symptoms and severity of TBI can vary dramatically, from minor, short-term problems to lifelong issues that make it difficult to communicate or complete daily activities. The nature of a specific TBI also determines a medical team’s options for treatment.

Individuals who experience a head injury should immediately seek medical attention. In some cases, a TBI will demand emergency medical services, such as an accident that results in the victim slipping into a coma, which may last days or weeks. Other times, TBI symptoms may be less noticeable. For instance, a person in a minimally conscious state may appear awake and capable of responding to basic questions, but they still require medical support before the condition worsens.

A person who feels they do not need medical attention immediately following a brain injury. Otherwise, they risk a series of secondary damages. Secondary damage is damage that occurs in the hours or days following TBI. Examples range from the hemorrhagic progression of contusion, which can create new, larger lesions on the brain, to a breakdown of the barrier between blood and the brain, which can lead to brain swelling and additional life-threatening symptoms. The importance of immediate medical care cannot be overstated, as the majority of TBI damage can be attributed to secondary damage.

As doctors treat the primary and secondary issues caused by a brain injury, they will begin to formulate a comprehensive treatment plan. Their plan will be influenced by factors such as the location and size of the injury. Initial care should be rendered in an emergency room or certified trauma center, while subsequent treatments may occur at various medical centers, including hospitals and outpatient facilities.

Mild TBI that results in a concussion may require no treatment other than medical oversight to ensure symptoms do not worsen. Certain genetic factors, as well as a person’s age and history of head injuries, can play a significant role in how well a person recovers from a brain injury. Individuals with mild TBI may benefit from over-the-counter or prescribed pain medication, drugs to prevent seizures, and anticoagulants that prevent blood clotting. Individuals who develop clinical depression following a head injury should discuss antidepressants and anti-anxiety medication with their care providers.

Individuals can take specific preventive measures against TBI. Falls are the most common cause of TBI; any person at an elevated risk for slip and fall injuries, such as seniors, should organize their home and make any necessary lifestyle changes to reduce their chances of tripping and falling. Examples include removing rugs and general clutter, using nonslip mats in bathrooms and showers, and installing handrails on stairways.

Treatment for severe TBI is more complex and initially revolves around preventing death and, if possible, permanent disability. Surgery is sometimes necessary to alleviate brain pressure or remove foreign objects. A multidisciplinary team of health professionals then develops a therapeutic plan to address the most urgent issues, including cognitive, physical, occupational, and emotional challenges.

Car accidents are another leading cause. Motorists should observe all road laws, while cyclists and pedestrians should exercise caution while near traffic. Wearing a seatbelt or cycling helmet can also minimize the risk of TBI. Driving under the influence is another controllable risk factor that can lead to TBI.

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AAN and AHA Introduce Ralph L. Sacco Scholarships for Brain Health

The American Academy of Neurology (AAN) is the largest neurological and neuroscience professional society in the world. Committed to achieving the highest possible quality of patient care, AAN provides more than 40,000 members with access to professional development, educational, and scholarship opportunities. The organization's awards and scholarships include the Wayne A. Hening Sleep Medicine Investigator Award and the Resident Scholarship to the Annual Meeting. AAN unveiled its latest award program in 2024, the Ralph L. Sacco Scholarships for Brain Health.

AAN created the program in association with the American Heart Association (AHA). The award was announced alongside the first two winners, researchers Patrick Devlin, PhD, of Houston, Texas, and New Haven, Connecticut's Cyprien Rivier, MD, MSc. The prize includes a two-year, $150,000 scholarship to be used for ongoing scientific research in areas of brain health.

The scholarship program was made possible thanks to a gift from the late Ralph L. Sacco, MD, MS, FAAN, FAHA, who maintains the unique distinction of being the only neurologist to serve as the president of both AAN and AHA. He spent more than two decades with the latter, during which time he spearheaded AHA's reevaluation of the importance of brain health. AHA chief executive officer Nancy Brown credited Dr. Sacco with developing and effectively implementing numerous initiatives that saved lives and improved quality of life for all Americans, to say nothing of Dr. Sacco's work mentoring younger scientists.

Meanwhile, AAN president Carlayne E. Jackson, MD, FAAN, highlighted Dr. Sacco's unyielding advocacy for continued brain health research. In this spirit, the two organizations have awarded the inaugural scholarships to scientists performing vital research with the potential to transform brain health in America.

Devlin, a postdoctoral research fellow with the University of Texas Health Science Center's Ritzel Lab, received recognition for his work on brain health following a stroke, with a focus on how stroke can cause the brain to age more rapidly and a potential link to dementia. Rivier, a Department of Neurology postdoctoral research fellow at Yale University's Falcone Lab, is advancing research involving the connection between brain health and biological age, as opposed to chronological age. A clearer understanding of biological age and its impact on brain health can help medical professionals lower the general population's risk for major health conditions.

Both Devlin and Rivier began their two-year research projects in July 2024. AHA chief clinical officer and former president Mitchell S. V. Elkind, MD, MS, FAAN, FAHA, stated that their work will build upon decades of work from Dr. Sacco, particularly in regards to improving the lives of individuals with stroke and advancing research about the connection between vascular disease and cognitive decline. Former American Academy of Neurology president Orly Avitzur, MD, MBA, FAAN, echoed these thoughts, adding that the scholarship program will support a new community of brain health researchers to carry on Dr. Sacco's work.

Together, Devlin and Rivier hold the honor of being the first AAN and AHA Sacco Scholars. Additional AAN scholarship and award opportunities include the Sleep Science Award, the Mitchell B. Max Award for Neuropathic Pain, the Neurology Practice Award, and many more. Information about applying for an award or scholarship can be found at aan.com.

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How Traumatic Brain Injuries Effect Vision

Traumatic brain injury (TBI) encompasses any brain damage caused by impacts. The most well-known kind of TBI is a concussion, a less severe degree of TBI. Due to the brain's role in processing visual information, both physical and cognitive symptoms can occur, including vision changes. While some symptoms seem mild, delaying diagnosis and treatment can exacerbate vision problems and lead to complications like retinal detachment, vitreous hemorrhage, bleeding in the eye, and optic nerve damage.

Post-trauma vision syndrome describes the collection of TBI symptoms that harm patients’ vision. These symptoms can inhibit tasks like reading, concentration, and driving. Blurred or double vision stems from convergence insufficiency, the eyes struggling to focus on nearby objects, and manifests through symptoms like dizziness and poor balance. Partial vision loss can occur due to damaged blood vessels in the eye, optic nerve injuries, or brain damage. Vertical heterophoria, an eye misalignment where one eye appears higher than the other, can worsen after head trauma.

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Neurological Conditions Impacting Military Veterans in America

According to the Pew Research Center, more than 18 million military veterans live in the United States, or roughly 6 percent of the adult population. A report from the Centers for Disease Control and Prevention estimates that 30 percent of veterans from the ages of 25 to 64 live with multiple chronic conditions, nearly double the rate of non-veterans. These chronic ailments include numerous neurological conditions.

Veterans Affairs (VA) has diagnosed more than 185,000 veterans with traumatic brain injury (TBI). Military members are at an elevated risk for TBI, as they are frequently exposed to gunfire, shrapnel, explosions, and various sources of blunt force trauma. Most TBI diagnoses are mild, but more severe symptoms can make it difficult for individuals to communicate, think, and control their behavior. Secondary TBI symptoms range from depression to insomnia.

Migraines may sound minor compared to TBI, but the condition can be disabling. Veterans can experience several migraine symptoms, including pain so severe individuals cannot complete basic daily activities. A National Institutes of Health study found that 10 percent of veterans have received a migraine diagnosis, including nearly one out of three female veterans. Migraines are more common among certain veteran groups. For example, a study focusing on the war in Iraq found that 36 percent of Iraqi War veterans had received migraine diagnoses.

These are only a few of the neurological conditions impacting America’s military veterans. Additional conditions include peripheral neuropathy, epilepsy, paralysis, and multiple sclerosis. Veterans living with a neurological disorder can file a claim with their local VA.

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Neurological Conditions That Impact Vision

Neurological conditions impact the brain, spinal cord, and nerve clusters throughout the body. These conditions can impact the body in many different ways. Neuro-visual disorders, for example, are neurological conditions that create visual distortions and similar symptoms.

Any damage to the optic nerves can result in optic neuropathy, a condition defined by pain and problems with vision. The issues are typically relegated to one eye. Pain may be constant or occur only when the eye moves. Similarly, a person can experience total vision loss or loss only in the center of their field of vision, a condition known as scotoma.

Optic neuritis, meanwhile, is a neurological condition caused by an infection, such as chickenpox or influenza. They may also develop alongside lupus and other disorders of the immune system. Individuals can treat optic neuritis pain and vision problems with corticosteroids, though in some cases the condition will resolve on its own. However, patients should discuss multiple sclerosis (MS) with their doctors, as roughly half of the people who experience optic neuritis will develop MS within the next 15 years.

Other neurological conditions impacting vision include giant cell arteritis and chiasm disorders. Some neurological disorders only impact how the eye moves, while others are associated with temporary vision problems, including migraines and headaches.

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A Comprehensive Approach Aids in Assessing the Neurological Patient

Assessing a patient with neurological symptoms involves a systematic approach known as the neurologic method. This method includes identifying the anatomical location of the lesion causing symptoms, understanding the pathophysiology, generating a differential diagnosis, and selecting appropriate tests.

The neurologic examination is crucial for pinpointing the likely site of neurological dysfunction. Key considerations include whether symptoms are due to a single or multiple lesions and whether the central or peripheral nervous system is involved. The neurologic history is vital and involves asking detailed questions about symptom quality, intensity, duration, and factors affecting symptoms. The patient's medical, family, and social history provide additional context, especially in inherited or systemic conditions.

Physical examination focuses on the nervous system, assessing mental status, cranial nerves, motor system, muscle strength, gait, sensation, reflexes, and the autonomic nervous system. Diagnostic tests confirm diagnoses or rule out other disorders, ensuring a thorough and accurate evaluation of neurological patients.

Pathophysiologic causes can be primary to the nervous system or secondary, originating elsewhere in the body. Common categories include vascular, infectious, neoplastic, degenerative, traumatic, toxic-metabolic, congenital, and immune-mediated causes. A methodical approach helps avoid errors and misdiagnoses, such as confusing stroke symptoms with those of a brain tumor.

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The Importance of Board Certification for Physicians

Board certification signifies a physician's ongoing commitment to expanding their knowledge and expertise beyond the basic state licensing requirements. To maintain board certification, physicians must continue their education and take an exam every ten years to stay current with medical advancements throughout their careers.

The American Board of Medical Specialties (ABMS) sets the gold standard for medical specialty certification in the United States. Its 24-member boards certify doctors in 40 specialties and 89 subspecialties according to rigorous standards for training and assessment. ABMS board certification provides doctors with a credential that demonstrates their ability to provide safe and effective care in a specific area of medicine.

Board-certified physicians are skilled, knowledgeable, and experts in their specialties. It is a mark of excellence that patients can rely upon when selecting a doctor for their needs. Furthermore, ABMS board certification encourages doctors to continue learning, fosters research and innovation in healthcare, and improves medical practices.