Office of Research & Development

Traumatic Brain Injury (TBI)

Traumatic Brain Injury iconSpotlight on VA Research

Traumatic brain injury (TBI) can happen from a blow or jolt to the head, or from an object penetrating the brain.

When the brain is injured, the person who has been injured may experience a change in consciousness that can range from becoming disoriented and confused to slipping into a coma. The person may also have a loss of memory for the time immediately before or after the event that caused the injury. Not all injuries to the head result in a TBI, however.

It is estimated that at least 20 percent of U.S. troops who were wounded in our most recent conflicts have been affected by a TBI. TBI is also a significant cause of disability outside of military settings, most often as the result of assaults, falls, automobile accidents, or sports injuries.

TBI can involve symptoms ranging from headaches, irritability, and sleep disorders to memory problems, slower thinking, and depression. These symptoms often lead to long-term mental and physical health problems that hurt Veterans' employment and family relationships, and their reintegration into their communities.

VA research related to TBI is wide-ranging. Among the goals of VA researchers working in this field are to shed light on brain changes in TBI, improve screening methods and refine tools for diagnosing the condition, and develop drugs to treat brain injury or limit its severity when it first occurs.

Researchers are also designing improved methods to assess the effectiveness of treatments, and learning the best ways to help family members cope with the effects of TBI and support their loved ones.

VA's Translational Research Center for TBI and Stress Disorders, at the VA Boston Healthcare System, conducts studies to understand the complex changes in the brain, thinking, and psychological well-being that result from TBI and posttraumatic stress disorder (PTSD). These studies will lead to more understanding and better treatment options for returning Veterans with TBI and PTSD.

The department's Brain Rehabilitation Resource Center, at the Malcolm Randall VA Medical Center in Gainesville, Fla., develops and tests treatments to improve or restore motor, cognition, and emotional impairments that have been caused by brain disease or injury.

At the Michael E. DeBakey VA Medical Center in Houston, the department has established a Traumatic Brain Injury Center of Excellence focusing on mild TBI. A mild TBI involves brief loss of consciousness, or a feeling of being dazed or confused. In some cases, those who have had mild TBIs have difficulty remembering details about the injury.

VA's War Related Illness and Injury Study Center, located at the VA medical centers in Palo Alto, Calif.; Washington, D.C.; and East Orange, N.J., develops and provide post-deployment health expertise to Veterans and their health care providers through clinical programs, research, education, and risk communication. VA's Office of Public Health directs the center.

VA's Polytrauma System of Care is an integrated network of specialized rehabilitation programs dedicated to serving Veterans and service members with TBI and multiple complex, severe injuries, which is termed polytrauma. (Click here to see a map of sites within the VHA Polytrauma/TBI system of care.)

The Defense and Veterans Brain Injury Center (DVBIC) serves active-duty military, their beneficiaries, and Veterans with TBI through state of-the-art-clinical care, innovative clinical research initiatives and educational programs, and support for force health protection services. DVBIC is part of the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury.

Selected Major Accomplishments

  • Finding that older Veterans with past TBI are at greater risk of developing dementia
  • Validating the usefulness of VA's TBI screening questionnaire
  • Finding that in rats, a neural prosthesis can restore functions lost as a result of TBI (related work on the technology is ongoing at VA's Advanced Platform Technology Center)
  • Developing a 12-week program to help Veterans with mild TBI manage their fatigue, sleep problems, headaches, and stress

Selected Milestones and Major Events

Overview

TBI, a complex type of injury to the brain structure, is common among war Veterans. It has been called a "signature injury" of modern combat.

Most TBI injuries are considered mild, but even mild cases can involve serious long-term effects on areas such as thinking ability, memory, mood, and focus. Other symptoms may include headaches, vision, and hearing problems.

Mild TBI, also known as concussion, is usually more difficult to identify than severe TBI, because there may be no observable head injury—it may have occurred at the same time as other visible injuries or wounds—and because some of the symptoms are similar to symptoms from other problems that also follow combat trauma, such as PTSD.

While most people with mild TBI have symptoms that resolve themselves within hours, days, or weeks, a minority may experience persistent symptoms that last for several months or longer.

TBIs can occur from direct contact to the head, or when the brain is shaken within the skull, such as from a blast or whiplash during a care accident. The severity of the TBI is determined at the time of the injury and is based on the length of the loss of consciousness, the length of either memory loss or disorientation, and how responsive the individual was after the injury.

Treatment typically includes a mix of cognitive, physical, speech, and occupational therapy, along with medication to control specific symptoms such as headaches or anxiety.

According to DVBIC, more than 300,000 cases of TBI were recorded among service members from 2000 to March 2014. More than 80 percent of these were non-combat related.

VA research focuses on gaining a better understanding of the brain changes that occur in TBI, refining screening and diagnostic tools, developing and evaluating treatments, and identifying coping strategies for Veterans and their families.

VA works closely with DoD on both health care and research related to TBI. DoD research focuses on the development of battlefield screening tools, combat casualty care, and rehabilitation efforts aimed at returning service members to duty.

The National Research Action Plan

VA, DoD, and the Departments of Health and Human Services and Education recently made public a wide reaching plan to improve access to mental health services for Veterans, service members, and military families.

The National Research Action Plan will be used to improve scientific understanding of TBI, PTSD, various conditions that are related to both TBI and PTSD, and suicide. Other goals of the plan include providing effective treatments for these conditions, and reducing their occurrence.

Among the highlights of the plan is the establishment of two joint DoD/VA research consortia at a combined investment of $107 million. These include the Consortium to Alleviate PTSD, a collaboration led by the University of Texas Health Science Center-San Antonio, and the Chronic Effects of Neurotrauma Consortium, led by Virginia Commonwealth University.

All four federal agencies will continue collaborating with colleges and universities. They will also standardize, integrate, and share data as appropriate, build new tools and technologies, and maximize the impact of existing research.

The agencies will also work together to explore markers that may demonstrate an association between genetics and elevated risk for mental health conditions. They will also work to identify possible changes in brain circuitry, confirm potential biomarkers for TBI and PTSD, and establish new data-sharing agreements.

Brain changes in TBI

TBI can result in brain damage that is sometimes subtle. This damage can result in changes in memory, attention, thinking, personality and behavior that are difficult to diagnose and treat. VA researchers are refining ways to reliably diagnose TBI and to predict Veterans' outcomes and care needs.

In 2012, an international team including researchers from the Boston VA Medical Center discovered chronic traumatic encephalopathy (CTE) in the brains of four Veterans after their deaths, including three who had survived explosions from improvised explosive devices. The fourth had suffered multiple concussions in and out of service.

CTE is a degenerative disease linked to repeated head traumas such as concussions, and has been identified in the brains of football players who have committed suicide. It is possible that some of the symptoms of PTSD in Veterans were caused by CTE.

A follow-up study by the team analyzed brain tissue from 85 people with histories of repetitive mild TBI. They found evidence of CTE in 68 of them. Of the 85 people studied, 64 were athletes and 21 were Veterans, although 86 percent of the Veterans also were athletes.

Veterans exposed to blasts from bombs, grenades, and other devices may still have brain damage even if they have no symptoms of TBI,according to a study by researchers at VA's Mid-Atlantic Mental Illness Research Education and Clinical Center (MIRECC) in Durham, N.C., and Duke University. The results of the study suggested that a lack of symptoms of TBI after a blast may not indicate the extent of brain damage caused by the blast.

A study conducted by researchers at the Ann Arbor VA Medical Center found a slightly increased risk for stroke in TBI patients. This study included data on everyone who visited a California emergency department or was hospitalized in California for TBI or non-TBI trauma from 2005 to 2009—more than 1 million people, of whom 37 percent had TBI.

Over approximately 28 months, 1.1 percent of the TBI group had a stroke, compared with 0.9 percent of the non-TBI group. The researchers hypothesized that because TBI can cause bleeding in the brain, it may increase the risk for stroke.

In another recent study, a team of researchers from the San Francisco VA Medical Center and the University of California, San Francisco, looked at the records of 188,764 Veterans aged 55 years or older who had at least one inpatient or outpatient visit during both the years 2000-2003 and 2003-2012 and did not have a diagnosis of dementia on their first visit.

They found that older Veterans with a TBI diagnosis had a 60-percent greater risk of developing dementia over a nine-year period. The results suggest that TBI in older veterans may predispose them toward developing dementia and raise concern about the potential long-term consequences of TBI in younger veterans and civilians.

An ongoing study hopes to determine whether traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD) increase Alzheimer's risk as Veterans age. Nationwide, approximately 1,000 Vietnam veterans will participate in screening interviews and 500 will be interviewed by telephone.

The study, called DOD-ADNI, will be funded by the Department of Defense (DoD). Its lead investigator will be Dr. Michael Weiner, a VA investigator who heads the Alzheimer's Disease Neuroimaging Initiative (ADNI) at the San Francisco VA Medical Center.

Other VA researchers from the Denver VA Medical Center have established that traumatic brain injury (TBI) is a risk factor for suicide. Compared with Veterans with no history of TBI, those with such a history were 55 percent more likely to die by suicide. Within the TBI group, those who had suffered a concussion or skull fracture were the most likely to take their own lives.

TBI screening and diagnostic tools

Because individuals who have persistent symptoms after a mild TBI may need targeted intervention, VA established a system-wide screening and assessment procedure in 2007 to identify mild TBI in Veterans as quickly as possible.

The tool consists of questions VA health care professionals must ask all Iraq and Afghanistan Veterans when they come in for care. Veterans who screen positive are offered follow-up evaluations with specialists. VA researchers collaborated in the development of this screening tool.

In 2012, VA researchers published a study documenting findings that this TBI screening process is inclusive, and has value in referring patients with current symptoms to appropriate care. More than 90 percent of Veterans who were evaluated received further VA health care, and evaluations that confirmed a diagnosis of mild TBI were associated with significantly higher health care use.

In another study, VA researchers developed an overview of post-concussion symptoms reported by Veterans evaluated for TBI following a positive TBI screen. Of the 55,000 Veterans who received comprehensive TBI evaluations between October 2007 and June 2010, clinicians diagnosed TBI during deployment in 55 percent, with 38 percent not having developed TBI. Researchers could not determine whether or if TBI had occurred during deployment for 7 percent of the patients they studied.

Treatments for TBI

VA researchers are studying the effectiveness of various existing and potential treatments for TBI and symptoms such as headaches, anxiety, and mood swings.

The latest results from a series of federally funded studies on hyperbaric oxygen therapy for mild TBI found no evidence of efficacy. The results matched those from earlier work by the VA and DoD investigators. The latest trial, conducted at the Naval Air Station in Pensacola, Fla., and involving 61 Marines, was a randomized, double-blinded sham-controlled trial, funded mainly by the Defense Advanced Research Projects Agency.

Research at the VA Puget Sound Health Care System and the University of Washington has suggested that restoring levels of certain hormones, namely those made in the pituitary gland, could help address PTSD- and depression-related symptoms in Veterans with TBI.

Recently, a team of researchers from the University of Kansas, the Louis Stokes VA Medical Center in Cleveland, and Case Western University published a study in which they suggest that an artificial communication link inserted in the brain can restore functions lost as a result of TBI.

The team fitted a microdevice containing a chip into the brains of rats whose motor skills had been impaired as a result of TBI. The neural prosthesis allowed the rats to recover nearly all function. The animals were tested by their ability to reach through a narrow opening and seize a food pellet.

Rats equipped with the neural prosthesis were able to complete the task 70 percent of the time, or as well as normal rats. Without the device, the injured rats were able to reach the food only 25 percent of the time.

The findings may offer new hope not only for Veterans with TBI, but also for stroke patients, those who have had tumors removed, and others with brain damage or impairments.

Two additional studies, one of which also involved mice, indicate that two proteins may help treat or prevent TBI. The first study compared TBI effects in mice, some of which produced a protein called Hsp70 and some of which did not. (Hsp70 is a protein whose function is to help protect cells from stress.) Researchers at the San Francisco VA Medical Center found that mice that produced Hsp70 had smaller brain lesions, less bleeding in the brain, and fewer TBI symptoms.

The second study, also by researchers at the San Francisco VA Medical Center, found that a molecule called LM11A-31 protects TBI-damaged nerve cells and reverses impairments in spatial memory (memory for spatial information, such as the interior of your home, or a friend's home.) Both molecules may develop into treatments for TBI-related injuries and symptoms.

Coping strategies for Veterans with TBI and their families

For Veterans with mild TBI, adjusting to life back home can be difficult—not only for themselves, but for their families as well. In 2010 and 2011, VA researchers in Durham, N.C., treated Veterans and family members in a group to learn about mild TBI, to solve problems, and to establish life goals. The participants were surveyed about their problems, and explored their common struggles and relationships together.

Veterans and family members found this kind of multifamily group treatment for TBI to be highly acceptable—possibly because of the presence of other Veterans in the group. This kind of group therapy also showed both Veterans and their family members that they were not alone, and helped to integrate the family into the patient care process. Results of the study were published in 2013.

One of the most effective tools to manage mild TBI is a smartphone calendar app. It helps Veterans with problems remembering to do things like take their medication and buy cards for their spouse's birthday.

A team of researchers at the VA San Diego Healthcare System and the University of California, San Diego developed a 12-week program called Cognitive Symptom Management and Rehabilitation (CogSMART) to help Veterans with mild TBI to manage their fatigue, sleep problems, headaches, and stress. The program was also designed to improve attention, memory, and problem solving skills. One of the program's key tools is the use of a smartphone calendar.

In a recent study, the team found that CogSMART may improve post-concussive symptoms and memory performance (the ability to conduct an assigned task 24 hours after it was assigned.) The researchers have suggested that the program be studied in a larger trial.

VA's Resources for Enhancing Alzheimer's Caregiver Health (REACH VA) program provides much-needed support for caregivers of Veterans with Alzheimer's disease. It is based on the knowledge that about 80 percent of caregivers for those with dementia often lack the skills to manage troubling patient behaviors—and their own stress.

As part of the program, VA researchers worked with the National Institutes of Health and several universities to develop and test a six-month training program to educate and support caregivers of Veterans with Alzheimer's disease, and to help them develop better caregiving skills.

The material is tailored to family members based on assessments of where they need the most help. REACH VA is now being rolled out at VA medical centers throughout the nation. It is also being modified to help caregivers of Veterans with TBI and spinal cord injury.

Ongoing TBI research

VA researchers are continually working to better understand TBI and to improve therapies for the condition. Ongoing large-scale initiatives designed to improve the health of Veterans with TBI include the Traumatic Brain Injury Veterans Health Registry and the "New Generation" study.

The TBI Veterans Health Registry will provide military and civilian researchers with data on a large number of well-documented cases of TBI from the conflicts in Iraq and Afghanistan. The registry will help evaluate and compare different therapeutic options and outcomes; compare war-related TBI to TBI in civilian patients; and examine the association of TBI with other medical conditions, including PTSD, depression, memory loss, sensory loss, and seizure.

VA's National Health Study for a New Generation of U.S. Veterans is a 10-year project to assess 60,000 Veterans, half of whom were deployed to combat areas. Some members of that group will participate in the MIND (Markers for the Identification, Norming, and Differentiation of TBI and PTSD) study. In this research, health information from Veterans who have symptoms of TBI or PTSD and a comparison group of Veterans will be analyzed to help build objective and consistent diagnostic criteria for both conditions.

More on our Website

Seeking new coping tools for Veterans with TBI, VA Research Currents, April 14, 2014

Researchers building roadmap of OEF/OIF injuries, VA Research Currents, March 27, 2014

Bringing families into the fold, VA Research Currents, March 12, 2014

Lab study: Microdevice restores function in damaged brains, VA Research Currents, Feb. 12, 2014

Journal scan: Trial reveals hyperbaric oxygen has little effect on TBI symptoms, VA Research Currents, Nov. 15, 2013

Inexpensive generic drug shown effective for nightmares, other PTSD symptoms, VA Research Currents, Sept. 13, 2013

Hormone findings point to possible TBI therapy, VA Research Currents, Summer 2013

Study links combat injuries to changes in brain's cortex, VA Research Currents, Summer 2013

New DoD-funded study to track Alzheimer's in Veterans with head injuries, VA Research Currents, March-April 2013

Trial yields hope for blast-related auditory problems, VA Research Currents, February 2013

Media Roundtable: Traumatic Brain Injury (TBI)

VA Brochure Series: Traumatic Brain Injury

Video: Traumatic Brain Injury

Selected Scientific Articles by our Researchers

Suicide and traumatic brain injury among individuals seeking Veterans Health Administration services. Brenner LA, Ignacio RV, Blow FC. Among VHA users, those with a diagnosis of TBI were at greater risk for suicide than those without the diagnosis. J Head Trauma Rehabil, 2011 Jul-Aug;26(4):257-64.

Analysis of US Veterans Health Administration comprehensive evaluations for traumatic brain injury in Operation Enduring Freedom and Operation Iraqi Freedom Veterans. Scholten JD, Sayer NA, Vanderploeg RD, Bidelspach DE, Cifu DX. VHAs TBI screening and evaluation process is identifying individuals with ongoing neurobehavioral symptoms. Brain Inj. 2012;26(10):1177-84.

Chronic traumatic encephalopathy in blast-exposed military veterans and a blast neurotrauma mouse model. Goldstein LE et al. The contribution of blast wind to injurious head acceleration may be a primary injury mechanism leading to blast-related TBI and CTE. Sci Transl Med. 2012 May 16;4(134):134ra60.

Screening for mild traumatic brain injury in OEF-OIF deployed US military: an empirical assessment of VHA's experience. Hendricks AM, Amara J, Baker E, Chams MP, Gardner JA, Iverson KM, Kimerling R, Krangel M, Meterko M, Pogoda TK, Stolzmann KL, Lew HL. VHA's TBI screening process is inclusive and has utility in referring patients with current symptoms to appropriate care. Brain Inj. 2013;27(2):125-34.

The spectrum of disease in chronic traumatic encephalopathy. McKee AC, Stern RA, Nowinski CJ, Stein TD, Alvarez VA, Daneshvar DH, Lee HS, Wojtowicz SM, Hall G, Baugh CM, Riley DO, Kubilus CA, Cormier KA, Jacobs MA, Martin BR, Abraham CR, Ikezu T, Reichard RR, Wolozin BL, Budson AE, Goldstein LE, Kowall NW, Cantu RC. Post-mortem analysis of brains obtained from a cohort of 85 subjects with histories of repetitive mild traumatic brain injury found evidence of chronic traumatic encephalopathy in 68 subjects. Brain. 2013 Jan;136(Pt 1):43-64.

Multifamily group treatment for veterans with traumatic brain injury: what is the value to participants? Straits-Troster K, Glerisch JM, Strauss JL, Dyck DG, Dixon LB, Norell D, Perlick DA. The results supported the feasibility and acceptability of multifamily group treatment for TBI. Psychiatr Serv, 2013 Jun;64(6):541-6.

Traumatic brain injury may be an independent risk factor for stroke. Burke JF, Stulc JL, Skolarus LE, Sears ED, Zahuranec DB, Morgenstern LB. In a large cohort of more than 1.1 million trauma subjects, TBI is associated with ischemic stroke, independent of other major predictors. Neurology, 2013 Jul 2;81(1):33-9.

The 70 kDa heat shock protein protects against experimental traumatic brain injury. Kim JY, Kim N, Zheng Z, Lee JE, Yenari MA. Data demonstrates a new mechanism linking TBI-induced hemorrhage and neuronal injury to the suppression of matrix meltalloproteinases by Hsp70, and support the development of Hsp70 enhancing strategies for the treatment of TBI. Neurobiol Dis. 2013 Oct;58:289-95.

A small molecule p75(NTR) ligand protects neurogenesis after traumatic brain injury. Shi J, Longo FM, Massa SM. Modulation of p75 neurotrophin receptor actions, which regulate cell survival, using small molecules such as LM11A-31 may constitute a potent therapeutic strategy for TBI. Stem Cells. 2013 Nov;31(11):2561-74.

Restoration of function after brain damage using a neural prosthesis. Guggenmos DJ, Azin M, Barbay S, Mahnken JD, Dunham C, Mohseni P, Nudo RJ. This proof-of-concept study demonstrates that neural interface systems can be used effectively to bridge damaged neural pathways functionally and promote recovery after brain injury. Proc Natl Acad Sci USA. 2013 Dec 24;110(52):21177-82.

Association between traumatic brain injury and risk of posttraumatic stress disorder in active-duty Marines. Yurgil KA, Barkauskas DA, Vasterling JJ, Nievergelt CM, Larson GE, Schork NJ, Litz Bt, Nash WP, Baker DG; Marine Resiliency Study Team. Even when accounting for predeployment symptoms, prior TBI, and combat intensity, TBI during the most recent deployment is the strongest predictor of post deployment PTSD symptoms. JAMA Psychiatry. 2014 Feb 1;71(2);149-57.

White Matter Compromise in Veterans Exposed to Primary Blast Forces. Taber KH, Hurley RA, Haswell CC, Rowland JA, Jurt SD, Lamar CD, Morey RA. Lack of clear TBI symptoms following primary blast exposure may not accurately reflect the extent of brain injury. J Head Trauma Rehabil. 2014 Mar 4. (Epub ahead of print.)

The Prevalence of Epilepsy and Association With Traumatic Brain Injury in Veterans of the Afghanistan and Iraq Wars. Pugh MJ, Orman JA, Jaramillo CA, Salinsky MC, Eapen BC, Towne AR, Amuan ME, Roman G, McNamee SD, Kent TA, McMillan KK, Hamid H, Grafman JH. Among OEF/OIF Veterans, epilepsy was associated with previous TBI diagnosis, with penetrating TBI having the strongest association. J Head Trauma Rehabil. 2014 Apr 1. (Epub ahead of print.)

Cognitive Symptom Management and Rehabilitation Therapy (CogSMART) for Veterans with traumatic brain injury: pilot randomized controlled trial. Twamely EW, Jak AJ, Delis DC, Bondi MW, Lohr JB. Adding CogSMART to supported employment may improve postconcussive symptoms and prospective memory. J Rehabil Res Dev. 2014;51(1):59-70.

Effects of traumatic brain injury and posttraumatic stress disorder on Alzheimer's disease in veterans, using the Alzheimer's Disease Neuroimaging Initiative. Weiner MW, et al. Description of a study that aims to use imaging techniques and biomarker analysis to determine whether traumatic brain injury (TBI) and/or PTSD resulting from combat or other traumas increase the risk for AD and decrease cognitive reserve in Veteran subjects, after accounting for age. Alzheimers Dement. 2014 Jun;10(3 Suppl):S226-35.

Traumatic brain injury and risk of dementia in older veterans. Barnes DE, Kaup A, Kurby KA, Byers AL, Diaz-Arrastia R, Yaffe K. TBI in older veterans was associated with a 60% increase in the risk of developing dementia over 9 years after accounting for competing risks and potential confounders. Neurology. 2014 Jul 22;83(4):312-9

VA and Other U.S. Government Online Resources

VA Translational Research Center for TBI and Stress Disorders

War Related Illness and Injury Study Center, Department of Veterans Affairs

Brain Rehabilitation Resource Center, Department of Veterans Affairs

Polytrauma/TBI System of Care, Department of Veterans Affairs

Traumatic Brain Injury Center of Excellence, Department of Veterans Affairs

Understanding Traumatic Brain Injury, Department of Veterans Affairs

Health Study for a new generation of U.S. Veterans, Department of Veterans Affairs

VA Press release: DoD, VA establish two multi-institutional consortia to research PTSD and TBI, Department of Veterans Affairs, Aug. 10, 2013

Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury, U.S. Department of Defense

Defense and Veterans Brain Injury Center, U.S. Department of Defense

Traumatic Brain Injury, Department of Defense Special Report

NINDS Traumatic Brain Injury Information Page, National Institute of Neurological Disorders and Stroke, National Institutes of Health

Traumatic Brain Injury, Medline Plus, National Institutes of Health

Traumatic Brain Injury, Centers for Disease Control and Prevention