Office of Research & Development

VA research on

Traumatic Brain Injury (TBI)


Introduction

Traumatic brain injury (TBI) 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 car accident.

In a brain injury, the person 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.

The Department of Defense (DoD) estimates that 22 percent of all combat casualties from Iraq and Afghanistan are brain injuries. 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.

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.

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, and because some of the symptoms are similar to symptoms from other problems that also follow combat trauma, such as posttraumatic stress disorder (PTSD).

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

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

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Selected Major Accomplishments

  • 2008: Established a Brain Bank to collect and study post-mortem human brain and spinal cord tissue to better understand the effects of trauma on the human nervous system
  • 2012: Discovered chronic traumatic encephalopathy, a degenerative disease linked to repeated head traumas such as concussion, in the brains of four Veterans after their deaths
  • 2013
    • Funded, along with the Department of Defense (DoD), two consortia to improve treatment for PTSD and mild TBI as part of the National Research Action Plan
    • Showed that, in mice, an artificial communication link inserted in the brain can restore functions lost as a result of TBI
  • 2016: Identified the cerebellum as particularly vulnerable to repeated blast exposures

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New, Ongoing, and Published Research

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 ways 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 PTSD. These studies will lead to more understanding and better treatment options for returning Veterans with both conditions.

The department's Brain Rehabilitation Resource Center, at the Malcolm Randall VA Medical Center in Gainesville, Florida, develops and tests treatments to improve or restore motor, cognitive, and emotional impairments 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.

VA's War Related Illness and Injury Study Center, located at the VA medical centers in Palo Alto, California; Washington, D.C.; and East Orange, New Jersey, 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.) Much of VA's clinical TBI research takes place at the department's five polytrauma rehabilitation centers.

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.

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➤ The National Research Action Plan

In 2013, VA, DoD, and the departments of Health and Human Services and Education developed a wide-reaching plan to improve access to mental health services for Veterans, service members, and military families.

The National Research Action Plan is improving scientific understanding of TBI, PTSD, various conditions 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 (CENC), led by Virginia Commonwealth University.

Among the projects currently underway at CENC are an effort to develop standards that will calibrate magnetic resonance imaging (MRI) scanners to the same reference values, so that researchers can pool and share MRI data. CENC researchers are also working to identify and characterize the anatomic molecular, and physiological mechanisms of TBI; evaluating how comorbidities are associated with and exacerbated by neurotrauma; and helping to develop appropriate treatment and rehabilitative strategies.

All four federal agencies are collaborating with colleges and universities. They are standardizing, integrating, and sharing data as appropriate; building new tools and technologies; and maximizing the impact of existing research.

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

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➤ 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.

Brain aging—A 2015 study led by researchers from TRACTS found that Veterans who were near bomb blasts in Iraq and Afghanistan appear to experience faster brain aging.

The team studied 195 Veterans who had been exposed to bomb blasts within 100 feet, and 56 who had not. Study participants were an average age of 33 years. The team learned that even in blasts that do not necessarily lead to concussion, those exposed to bomb blasts showed aging in brain images designed to detect the "leakiness" and fraying of the white matter in the brain.

Consequences of this potentially premature brain aging could be increased rehabilitation time and an earlier need for health care for issues such as dementia.

Problems with daily living—Another 2015 TRACTS study found that Veterans with a combination of depression, PTSD, and military-related TBI had the greatest difficulties of all Iraq and Afghanistan Veterans in getting around, communicating and getting along with others, handling self-care, and accomplishing other daily tasks.

According to the research team, many Iraq and Afghanistan Veterans require highly integrative treatment approaches, and their health problems need to be dealt with in a comprehensive and coordinated manner.

Cerebellum issues—A 2016 study by researchers with the VA Puget Sound Health Care System and the University of Washington identified the cerebellum as particularly vulnerable to repeated blast exposures. The cerebellum, an area of the brain, coordinates and regulates muscle activity.

The investigators looked at brain scans from Veterans who had experienced an average of 21 mild TBIs each as a result of explosions. The more blasts they were exposed to, the more likely they were to show lower levels of glucose metabolism in the cerebellum. Glucose metabolism is a marker of brain activity.

The research team also created "shock tubes" to test similar blast effects in mice—and found that repeated explosions ruptured part of the blood-brain barrier and led to the loss of neurons in the cerebellum. They also revealed the buildup of proteins associated with dementia and Alzheimer's disease.

CTE and TBI—In 2012, an international team including researchers from the Boston VA Healthcare System 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 are 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.

VA, along with Boston University and the Concussion Legacy Foundation, established a Brain Bank in 2008 to collect and study post-mortem human brain and spinal cord tissue to better understand the effects of trauma on the human nervous system.

In 2016, VA hosted "Brain Trust: Pathways to InnoVAtion", a two-day public-private partner event that brought together many important leaders in the area of brain health to identify and advance solutions together for mild TBI and PTSD. Among those present were representatives from DoD, the sports industry, other federal and private agencies, Veterans Service Organizations, and community partners. At the event, Secretary of Veterans Affairs Robert A. McDonald pledged to donate his brain to the brain bank upon his death.

Brain damage in Veterans without TBI symptoms—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 2015 study by researchers at VA's Mid-Atlantic Mental Illness Research Education and Clinical Center (MIRECC) in Durham, North Carolina, 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, and that TBI symptoms such as headache, dizziness, nausea, memory problems, and irritability may eventually develop in blast-exposed Veterans who appear not to have had even a mild TBI as a result of their exposure.

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➤ Other body changes in TBI

Sensory issues—Sensory problems are common among Veterans who have had TBI In 2012, VA researchers reported on a study of 21,000 Veterans evaluated for TBI in VA outpatient clinics. They found that 9.9 percent of them reported vision problems, 31.3 percent reported hearing impairments, and 34.6 percent reported both vision and hearing issues.

Hearing support—A 2015 study by VA's National Center for Rehabilitative Auditory Research (NCRAR) looked at 99 Veterans who were exposed to blasts in Iraq or Afghanistan. All 99 had clinically normal hearing, but all reported problems hearing in difficult listening situations.

The research team asked study participants to participate in 10 performance-based tests that have been shown to uncover problems people may have in processing hearing signals. They found that many of the participants had difficulty in one or more of the tests, compared with non-blast-exposed Veterans, although they may have performed well in other tests.

The team concluded that auditory processing symptoms may vary among is Veterans exposed to blasts, but that blast injuries can and do result in damage to the central auditory system.

In a 2014 study, NCRAR and Tampa VA researchers showed that frequency modulation (FM) may help Veterans with mild TBI who have normal hearing but problems understanding speech.

The researchers tested an FM system, which uses radio waves to transmit signals directly from a microphone to an earpiece to make a speaker's voice more clear. They also tested a "brain training" computerized auditory training program that has users follow instructions or interpret sound.

They divided 99 Veterans into four groups; those who received only informational counseling (the control group); those who received the FM system alone; those who received the auditory training alone; and those who received both the FM system and the auditory training.

Preliminary analyses have shown that both the FM system alone and the FM and auditory training groups have significantly better subjective outcomes than either the control group or the auditory training alone group.

RNA molecule deficiencies—In 2015, researchers at the James J. Peters VA Medical Center in the Bronx and VA's War-Related Illness and Injury Study Center in East Orange, New Jersey, learned that four specific RNA molecules, known by the designations ACA48, U35, U55 and U83A, were found at lower-than-normal levels in Veterans who had TBIs along with PTSD.

RNA, or ribonucleic acid, is a nucleic acid present in all living cells. Its main role is to act as a messenger carrying instructions from DNA for controlling the synthesis of proteins.

The researchers tested blood samples from 58 Iraq and Afghanistan Veterans. Some of the Veterans had a combination of TBI and PTSD, some had only one of the conditions, and others had neither.

Veterans with only PTSD had significantly lower levels of only the U55 RNA molecule, and Veterans who only had a TBI and not PTSD had normal levels of all four molecules.

The team hopes that their study will eventually result in a simple blood test to help diagnose the two issues in Veterans.

TBI predicts PTSD—The Marine Resiliency Study, based in San Diego, involves some 2,600 Marines. VA and DoD researchers are probing dozens of risk factors, from biological to behavioral, that may affect the abilities of service members to withstand emotional stress.

In 2014, Marine Resiliency Study researchers learned that TBI during a deployment was by far the strongest predictor of post-deployment PTSD symptoms in service members and Veterans. It was far more significant than prior TBIs or the intensity of combat they experienced. Researchers are continuing to analyze the data.

TBI and other mental health problems—In a 2015 study, researchers from the Hunter Holmes McGuire Veterans Affairs Medical Center in Richmond, Virginia, the Defense and Veterans Brain Injury Center, and Virginia Commonwealth University found that mild TBI, by itself, may not lead to mental health problems such as PTSD or mood anxiety disorders.

The researchers conducted structured interviews with 107 Iraq and Afghanistan Veterans. More than half had at least one mental health condition. But the researchers found that the number of blast exposures Veterans underwent had no effect on the rates of mood or anxiety diagnoses, or of PTSD. It also made no difference whether or not the Veterans had incurred a mild TBI as the result of a blast, or suffered amnesia when the blast occurred. There was a link between more severe brain injuries and mental health disorders, however.

According to the team, more research is needed to sort out the complex interrelationships among blast exposures, TBI, and mental health problems.

TBI and epilepsy—In 2015, researchers at the VA South Texas Health Care System and the University of Texas reported that Iraq and Afghanistan Veterans with mild TBIs were about 28 percent more likely to have developed epilepsy than those without TBIs.

The researchers also showed that Veterans who suffered penetrating or severe TBIs had the highest risk of developing epilepsy. The study looked at 256,284 Iraq and Afghanistan Veterans who received either inpatient or outpatient care at VA in fiscal years 2009 and 2010.

Previous studies of Veterans from World War II and the Korean War have shown a link between combat-related head injury and epilepsy. The research team concluded that because war-related epilepsy in Vietnam Veterans continued 35 years after the war, a detailed, prospective study is needed to understand the long-term relationship between epilepsy and TBI severity in Iraq and Afghanistan Veterans.

TBI and stroke—A 2013 study by researchers at the VA Ann Arbor Healthcare System 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.

TBI and Alzheimer's disease—In a 2014 study, researchers from the San Francisco VA Health Care System and the University of California looked at the records of more than 188,000 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 diagnosis of a TBI had a 60 percent greater risk of developing dementia over a nine-year period. The researchers hypothesized that TBI in older Veterans may predispose them toward development of symptomatic dementia. They raised concern about the potential long-term consequences of TBI in younger Veterans and civilians.

TBI and suicide—In 2011, researchers from the VA Eastern Colorado Health Care System established that 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.

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➤ Diagnosing TBI

Value of TBI screening questionnaire—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, researchers from the VA Boston Healthcare System published a study documenting that this TBI screening process helps clinicians refer 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.

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➤ Investigating 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.

Hyperbaric oxygen therapy—In 2014, a VA-DoD team of researchers published results from a study on hyperbaric oxygen therapy for mild TBI, and found no evidence that the therapy was useful. 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.

Value of antidepressants—Brain scans of Veterans with PTSD have led researchers to an area of the prefrontal cortex that appears to be a good predictor of how well Veterans who receive treatment with SSRIs (a class of antidepressants) will respond to that treatment.

The prefrontal cortex is responsible for emotions and mood regulation. The SSRIs paroxetine (Paxil) and sertraline (Zoloft) are currently the only drugs approved by the Food and Drug Administration to treat PTSD. Fluoxetine, sold as Prozac, is another SSRI, but it has not yet been approved to treat PTSD.

The 2016 study, led by investigators from the Jesse Brown VA Medical Center and the University of Illinois at Chicago, showed that patients who showed the most improvement from receiving SSRIs were those who showed the least activation of a brain area called the right ventrolateral prefrontal cortex before their treatment—even though that area of the brain was not the exact area that appeared to be affected by the treatment.

Headaches and rTMS—A 2015 study involving Veterans with headaches related to mild TBI found positive results from a treatment called repetitive transcranial magnetic stimulation (rTMS).

The treatment involves taking an electromagnet (a wire wrapped around a solid coil), charging it with electricity, and applying it to specific points on the skull to target the underlying brain area. The result is a very powerful magnetic field that can affect brain cells.

Researchers at the VA San Diego Healthcare System looked at 24 Veterans who had persistent daily headaches as the result of head trauma. Each Veteran received either three real or sham treatments within a week. In assessments one week later, about 58 percent of the real-treatment group had at least a 50 percent reduction in headache intensity, versus only 17 percent in the shame group. After four weeks, the real-treatment group still showed greater improvements than the sham group.

The Food and Drug Administration approved this kind of treatment for refractory (treatment-resistant) depression in 2008.

Neural prosthesis for brain damage—In 2013, 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, about 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. That said, researchers need to overcome several challenges with the technology before it can be translated into clinical use. One for example, is improving the long-term durability of the implants. Another is figuring out how to avoid the need for frequent recalibration.

Proteins to treat TBI—Two 2013 studies indicated 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 that helps protect cells from stress.) Researchers at the San Francisco VA Health Care System found that mice that produced Hsp70 had smaller brain lesions, less bleeding in the brain, and fewer TBI symptoms.

The second study, also by VA researchers in San Francisco, 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.

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➤ Coping strategies for Veterans and their families

Value of multi-family group treatment—For Veterans with mild TBI, adjusting to life back home can be difficult. The process can be stressful for their families as well. In 2010 and 2011, VA researchers in Durham, N.C., involved Veterans and family members in groups to help them learn about mild TBI, solve problems, and establish life goals. The participants were surveyed about their problems, and explored their common struggles and relationships together.

Veterans and family members found the multifamily groups "highly acceptable"—possibly because of the presence of other Veterans in the group. The group therapy, of a sort, 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.

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➤ CogSMART program

Researchers at the VA San Diego Healthcare System and the University of California 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. It helps Veterans with problems remembering to do things like take their medication and buy cards for their spouse's birthday.

In a 2014 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.

REACH VA—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. The program is now being modified to help caregivers of Veterans with TBI and spinal cord injury.

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.

Caregiver health—A 2015 study by researchers at the Edward Hines, Jr. VA Hospital in Hines, Ill., and the Loyola University Chicago Marcella Niehoff School of Nursing found that the blame and anger associated with the grief of caring for a loved one with a TBI may be related to inflammation and certain chronic diseases, including heart disease, cancer, and diabetes. The study examined grief and its association with inflammation in 40 wives or partners of Veterans with TBIs.

Study participants completed written measures of grief, perceived stress, and symptoms of depression. They also provided morning saliva samples to measure TNF-alpha, a substance associated with inflammation and chronic disease.

The caregivers collectively reported levels of grief comparable to that of individuals who have lost a loved one. That grief was not associated with TNF-alpha or inflammation in general. However, higher levels of TNF-alpha were found in those caregivers who reported high levels of blame and anger associated with their grief.

High levels of TNF-alpha are related to a variety of inflammatory-related health issues, and may be an important indicator of which caregivers may be at risk for developing chronic health problems such as heart disease.

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➤ Ongoing large-scale 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, begun in 2009 by VA's Office of Public Health (OPH), is providing military and civilian researchers with data on a large number of well-documented cases of TBI from the wars in Iraq and Afghanistan. The registry helps evaluate and compare different therapeutic options and outcomes; compares war-related TBI with TBI in civilian patients; and examines the association of TBI with other medical conditions, including PTSD, depression, memory loss, sensory loss, and seizure. As of September 2013 the registry contained data on more than 200,000 Veterans.

VA's National Health Study for a New Generation of U.S. Veterans is another OPH project. Over 10 years, investigators will 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. Researchers are analyzing health information from Veterans who have symptoms of TBI or PTSD and a comparison group of Veterans. They will use what they've learned to build objective and consistent diagnostic criteria for both conditions.

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More on Our Website

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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. VHA's 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.

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.

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.

Complex comorbidity clusters in OEF/OIF Veterans: the polytrauma clinical triad and beyond.Elizondo B, Pugh JA, Pugh MJ, Finley EP, Copeland LA, Wang CP, Noel PH, Amuan ME, Parsons HM, Wells M. A discussion of the kinds of chronic conditions that often exist simultaneously in patients with TBI, PTSD, and pain. Med Care. 2014 Feb;52(2):172-81.

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.

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 percent increase in the risk of developing dementia over nine years after accounting for competing risks and potential confounders. Neurology. 2014 Jul 22;83(4):312-9

Select small nucleolar RNAs in blood components as novel biomarkers for improved identification of comorbid traumatic brain injury and post-traumatic stress disorder in veterans of the conflicts in Afghanistan and Iraq. Ho L, Lange G, Zhao W, Wang J, Rooney R, Patel DH, Fobler MM, Helmer DA, Elder G, Shaughess MC, Ahlers ST, Russo SJ, Pasinetti GM. Biological interactions between TBI and PTSD may contribute to the clinical features of Veterans with comorbid mild TBI and PTSD. Am J Neurodegener Dis, 2014 Dec 5;3(3):170-81.

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. 2015 Jan-Feb;30(1):E15-25.

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. 2015 Jan-Feb;30(1):E15-25.

Deployment-related psychiatric and behavioral conditions and their association with functional disability in OEF/OIF/OND Veterans. Lippa SM, Fonda JR, Fortier CB, Amick MA, Kenna A, Milberg WP, McGlinchey RE. Depression, PTSD, and a history of military mild TBI may comprise an especially harmful combination associated with high risk for substantial disability. J Trauma Stress. 2015 Feb;28(1):25-33.

Structured interview for mild traumatic brain injury after military blast: interrater agreement and development of diagnostic algorithm. Walker WC, Cifu DX, Hudak AM, Goldberg G, Kunz RD, Sima AP. The research team developed a fully structured interview algorithm that may serve to enhance diagnostic standardization for clinical research in Veterans who may have mild TBIs. J Neurotrauma. 2015 Apr 1;32(7):464-73.

Prevalence of mental health conditions after military blast exposure, their co-occurrence, and their relation to mild traumatic brain injury. Walker WC, Franke LM, McDonald SD, Sima AP, Keyser-Marcus L. No clear association was found between mild TBI history and post-deployment mental health conditions. Brain Inj. 2015:29(13-14):1581-8.

Repetitive blast exposure in mice and combat Veterans causes persistent cerebellar dysfunction. Meabon JS, Huber BR, Cross DJ, Richards TL, Minoshima S, Pagulayan KF, Li G, Meeker KD, Kraemer BC, Petrie EC, Raskind MA, Peskind ER, Cook DG. The cerebellum is vulnerable to repetitive mild TBI in both mice and humans. SCI Transl Med. 2016 Jan 13;8(321):321.

The man I once knew: grief and inflammation in female partners of Veterans with traumatic brain injury. Saban KL, Mathews HL Collins EG, Hogan NS, Tell D, Bryant FB, Pape TL, Griffin JM, Janusek LW. Blame and anger associated with grief in partners of Veterans with TBIs may be related to elevations in a proinflammatory cytokine, tumor necrosis factor α. Biol Res Nurs. 2016 Jan;18(1):50-9.

Repetitive transcranial magnetic stimulation in managing mild traumatic brain injury-related headaches. Leung A, Shukla S, Fallah A, Song D, Lin L, Golshan S, Tsai A, Jak A, Polston G, Lee R. Repetitive transcranial magnetic stimulation appears to be a clinically feasible and effective treatment option in managing mild traumatic brain injury-related headache. Neuromodulation, 2016 Feb;19(2):133-41.

Combat-related mild traumatic brain injury: association between baseline diffusion-tensor imaging findings and long-term outcomes. Ware JB, Biester RC, Whipple E, Robinson KM, Ross RJ, Nucifora PG. Differences in white matter microstructure may partially account for the variance in functional outcomes among Veterans who sustained combat-related mild TBI. Radiology 2016 Mar 29:151013. (Epub ahead of print.)

Cognitive improvement after mild traumatic brain injury measured with functional neuroimaging during the acute period. Wylie GR, Freeman K, Thomas A, Shpaner M, OKeefe M, Watts R, Naylor MR. Subjects with persistent cognitive symptoms after a mild TBI had an increased requirement for posterior cingulate activation to complete memory tasks at one week following a brain injury. PLoS One. 2015 May 11: 10(5):e0126110.

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Traumatic Brain Injury Fact Sheet


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