Routine TBI screening following combat deployments

NeuroRehabilitation 26 (2010) 183 189 183 DOI 10.3233/NRE-2010-0554 IOS Press Routine TBI screening following combat deployments Angela I. Drake c,, Kimberly S. Meyer c, Lynne M. Cessante a, Catherine R. Cheung a, Maren A. Cullen a, Eric C. McDonald b and Martin C. Holland b a Defense and Veterans Brain Injury Center, Naval Medical Center, San Diego, San Diego, CA, USA b Naval Medical Center, San Diego, CA, USA c Defense and Veterans Brain Injury Center, Walter Reed Army Medical Center, Washington, DC, USA Abstract. A precise estimate of the rates of traumatic brain injury (TBI) in returning combat troops is difficult to establish given the challenges of screening large numbers of military personnel returning from combat deployments. The Brief Traumatic Brain Injury Screen (BTBIS) was implemented in the First Marine Expeditionary Force between 2004 and 2006. Nine percent of the 7909 marines who completed the BTBIS were considered having a positive screen; that is, they endorsed at least one injury mechanism and indicated a change in mental status at the time of injury. The majority of combat-related TBI s were due to multiple injury agents with the next largest group related to blast exposure only. Most importantly, of those who screened positive for TBI 70.5% (n = 500) were first identified by the screen. Service members who endorsed items on the BTBIS were contacted for follow-up assessment of persistent symptoms related to TBI and clinical referrals were made as needed. Given the rate of positive TBI screens in this non-referred sample of military personnel returning from a combat deployment, routine TBI screening appears valuable in screening individuals who might not be identified otherwise. Furthermore, this study appears to refute the contention that routine TBI screening will result in an over-identification of TBI in this population. Keywords: Blast, combat veteran, injury mechanism, Iraq, Afghanistan, Marines, military, post-deployment, prevalence, screening, traumatic brain injury Abbreviations: OIF = Operation Iraqi Freedom; OEF = Operation Enduring Freedom; TBI = traumatic brain injury; IED = improvised explosive device; DVBIC = Defense and Veterans Brain Injury Center; WRAMC = Walter Reed Army Medical Center; PDHA = Post Deployment Health Assessment; I MEF = First Marine Expeditionary Force; BTBIS = Brief Traumatic Brain Injury Screen; NMCSD = Naval Medical Center San Diego. 1. Introduction Estimates of the rate of non-combat related traumatic brain injury (TBI) in the military were established some years ago in an important paper by Ommaya and colleagues [12]. Examination of several military medical databases revealed that the active duty service mem- Address for correspondence: Angela I. Drake, PhD., Defense and Veterans Brain Injury Center, Building 1, Room B209, Walter Reed Army Medical Center, 6900 Georgia Avenue, NW, Washington, DC 20307-5001, USA. Tel.: +1 619 534 3359 (CA); +1 202 782 6345 (DC); Fax: +1 202 782 4400; E-mail: adrake@dvbic.org. bers were at increased risk for TBI even in peacetime. It was also apparent from this analysis that TBI was a costly medical issue for the military, both in terms of resources and lost manpower, with inpatient medical costs associated with TBI estimated conservatively at $43 million for 1992. The rate of TBI among military personnel deployed to Iraq and Afghanistan has garnered more interest in recent years because of the widespread use of explosive devices of various sorts in Iraq and Afghanistan [16]. Several well regarded papers addressing injuries in troops deployed to Iraq have reported a high number of traumatic brain injuries (TBI) associated with blasts [4, ISSN 1053-8135/10/$27.50 2010 IOS Press and the authors. All rights reserved

184 A.I. Drake et al. / Routine TBI screen after combat deployments 11,17]. Other reports have revealed that blast exposure with significant injury was the most common reason for medical evacuation from Afghanistan and Iraq [6,10] and reports of mortality rates from Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) revealed that blast exposure accounts for a high rate of reported combat deaths [2,7]. Initial reports addressing the rate of TBI were based on screening inpatients hospitalized at Walter Reed Army Medical Center for other severe blast related injuries (WRAMC) [17]. Although these screening efforts revealed that many of these severely wounded casualties did have a concomitant TBI, the rates reported were not necessarily applicable to those service members exposed to significant blast events but not medically evacuated to the U.S. While severe blast related TBI is quickly identified and treated in theatre, it is more challenging to diagnose mild TBI in theatre for a number of reasons [16]. One factor likely contributing to the under-identification of mild blast-related TBI is the notion that a concussion without more visible orthopedic trauma does not represent a serious injury [1]. Daily exposure to blasts in the war zone may result in a normalization of such events and decreased self-reporting of symptoms. This is particularly an issue in the context of the war zone where individuals are highly motivated to stay with their units and finish a deployment regardless of any medical limitations. At least one author [1] suggested that all troops exposed to significant blast events should undergo comprehensive screening evaluations for all potential injuries related to blast exposure, including TBI. A mild blast-related TBI may not be recognized acutely nor receive medical evaluation immediately because medical assets are unavailable or unreachable and because of the rigors of combat [14]. It was apparent that a significant number of service members deployed to Iraq have been involved in blasts [6] and that many mild blastrelated TBI s were not readily recognized, increasing the need for additional information on the rates of mild blast-related TBI in returning troops. A large clinical screening effort focused on all returning service members was needed to determine the incidence of mild blast-related TBI in this population. At least one effort had been made to determine the utility of routine TBI screening in US Army troops using the BTBIS [14]. The BTBIS is a standardized questionnaire developed to triage those who screen positive into further evaluations as opposed to using it to formally diagnose a TBI following a combat deployment. This screening effort was undertaken within the context of a large set of ongoing studies of TBI and was completed at a Defense and Veterans Brain Injury Evaluation Center at Fort Bragg, NC. The validity of the BT- BIS was evaluated using a convenience sample of US Army troops. The BTBIS was administered with several more extensive questionnaires designed to clinically diagnose TBI. In addition, for those who had a positive TBI screen on the BTBIS, a follow-up interview was conducted to further validate the sensitivity and specificity of this measure at detecting TBI. Of the sample of 596 soldiers, 16% (n = 94) were positive for a combat-related TBI on the BTBIS, using the American Congress of Rehabilitative Medicine (ACRM) and the Centers for Disease Control and Prevention (CDC) TBI criteria. In contrast, the in-depth clinical questionnaires resulted in more conservative estimates for the diagnosis of TBI (7% and 9%), while the clinical interview done on those who screened positive for TBI on the BTBIS revealed a positive predictive value (83%) [14]. It appears that the BTBIS has adequate sensitivity as a screening tool. Furthermore, it has been recommended as the primary tool for ongoing screening efforts in the military by the Institute of Medicine [8]. Because exposure to significant blast events among deployed troops is so common and may not result in an acute diagnosis of TBI or medical evacuation from the field, there was a directive to gather information on the rates of TBI in a non-medically evacuated sample of service members returning from a combat deployment. The notion of routine, standardized TBI screening for all returning troops has proven controversial. It has been suggested that widespread screening will result in an over-estimate of the rates of TBI in returning troops [5]. Some authors have asserted that the symptoms often associated with TBI are nonspecific and may be confused with those related to other common post-deployment conditions, such as posttraumatic stress syndrome [9], or that screening will promote the negative expectation for recovery [5]. However, from a purely clinical perspective, it was important to begin to efficiently identify those who would benefit from additional evaluation and treatment following a deployment. All service members returning from deployments are required to complete the Department of Defense Form 2796, Post Deployment Health Assessment (PDHA). The PDHA was instituted to provide routine screening of all returning troops for specific deployment-related health conditions and it is completed by unit medical providers. The medical personnel, either a General Medical Officer or a Medical Corpsman, review the forms for any potential health related issues. Positive

A.I. Drake et al. / Routine TBI screen after combat deployments 185 responses on the PDHA result in a review of deployment health records and appropriate referral for followup care as needed. Because of the early recognition of high rates of blast exposure in the returning service members and the high rates of TBI documented in medically evacuated samples of severely injured military personnel, the DVBIC and the I Marine Expeditionary Force (I MEF) Surgeon worked together to implement the BTBIS screening evaluation for all returning members of the I MEF beginning in 2004. This screening was completed by medical providers within the units who had often deployed with the troops. It was also administered either immediately before or immediately after returning to the US. The goal of the additional TBI questions was to identify service members who might need further assessment and treatment of persistent symptoms potentially related to a blast-related TBI or concussion. The PDHA was modified in 2007 and now has the TBI screening questions embedded within the assessment [3]. 2. Methods 2.1. Measure The BTBIS was initially developed as a brief screening tool to detect TBI following combat deployments [14]. The first item addressed potential injury causes, specifically if service members reported any of the following injuries during deployment: 1) fragment, 2) bullet, 3) vehicular (any type of vehicle, including airplane), 4) blast (IED, Rocket Propelled Grenade (RPG), Landmine, Grenade, etc.) or 5) other. The second item addressed the issue of mental status change associated with this injury; specifically if an injury received during deployment result in any of the following: 1) being dazed, confused, or seeing stars, 2) not remembering the injury, 3) losing consciousness (knocked out) for less than a minute, 4) losing consciousness for 1 20 minutes, 5) losing consciousness for longer than 20 minutes, 6) having symptoms of concussion afterward (such as headache, dizziness, irritability, etc.) or 7) head injury. Demographic and contact information was also gathered to facilitate clinical follow-up. 2.2. Procedures In April 2004, the DVBIC staff with the assistance of the First Marine Expeditionary Force (I MEF) Surgeon implemented the BTBIS. Screening forms were provided to unit medical personnel to administer to service members when the PDHA was administered, typically either immediately before or immediately after returning to the US. Because this was established as a clinical initiative, procedures varied regarding where and when the questionnaires were completed, but the majority of the BTBIS were completed by unit medical providers within the context of other routine post-deployment assessments. Completed forms were forwarded to DVBIC staff at NMCSD where questionnaires were reviewed by staff trained in identifying individuals at risk for concussion or TBI. The information from the questionnaires was entered into a comprehensive clinical database. A subset of individuals with positive screens was contacted by phone for further follow-up using a standardized phone interview. Referrals for additional medical care, such as an in-person intake with the DVBIC, were made based on these interviews. During the clinical interviews, it was determined if symptoms were likely attributable to TBI, psychological health or other medical conditions and referrals were made accordingly. Individuals were also provided with education on symptoms and recovery following TBI, including additional educational resources; upon request, education packets were mailed to service members. Education packets were sent to individuals who could not be contacted by phone. 3. Results The proposed analysis of clinical data was reviewed and approved by the full IRB at Naval Medical Center San Diego as a retrospective examination of clinical data prior to any data analysis. The data was analyzed using SPSS software and descriptive statistics were calculated to describe the sample. The data presented is based on a sample of 7906 military personnel with post-deployment screening completed by medical providers in the I MEF between April 2004 and March 2006. Demographic information regarding the entire sample is presented in Table 1. Twenty three percent of the service members who completed the TBI screen indicated they sustained a physical injury during the deployment on the BTBIS (n = 1799). Most of the injuries were due to the effects of a blast (27.9%, n = 395), with other causes of injury to include 21.9% (n = 310) from a fall, 11% (n = 155) from a vehicle, 4.4% (n = 62) from a fragment, 4% (n = 57) from a bullet. Fully 30.8% (n = 436) of the

186 A.I. Drake et al. / Routine TBI screen after combat deployments Table 1 Demographic information of I MEF military personnel, N = 7909 Mean (SD) Range n (%) Age 25.05 (5.79) 18 60 Male 7643 (97.0) Military Branch Marines 7208 (91.1) Navy 670 (8.5) Army 6 (0.1) Unknown 25 (0.3) Military Occupational Specialties (MOS) Infantry 2404 (30.4) Motor Transportation 692 (8.7) Navy Medical 665 (8.4) Command and Control Systems 661 (8.4) Field Artillery 554 (7.0) Supply, Admin and Operations 519 (6.6) Various (MOS) 2414 (30.5) group indicated that they had sustained some bodily injuries from more than one of the listed injury causes. Of those service members who indicated that they had experienced an injury during the deployment, 39.0% (n = 709) indicated that they had also experienced a change in mental status associated with the injury. These individuals were considered to have a positive TBI screen. These numbers represent approximately 9.0% of the entire sample screened. Of this group, blast once again represented the most common single cause of injury, with 30.8% (n = 245) from blast, 8.7% (n = 69) from vehicle, 7.3% (n = 58), from fall, 2.3% (n = 18) from fragment, 2.3% (n = 18) from a bullet. However, most marines reported that they had sustained injuries from more than one of the injury mechanisms (37.8%, n = 301), with the remainder of the sample indicating that they had received their injuries from other causes. See Fig. 1 for a complete list of injury mechanisms. Of the 709 service members who were considered to have a positive TBI screen on the BTBIS, the majority (70.5%, n = 500) were identified for the first time with the screener while 29.5% (n = 209) had already been identified by routine medical care prior to the BT- BIS/PDHA screening. Phone follow-up was attempted for those service members identified for the first time by the BTBIS since they would be less likely to have routine follow-up. The military personnel database was utilized to obtain accurate contact information whenever possible. One hundred sixty one (161, 32.2%) service members were successfully contacted. Attempts were made to contact the remaining service members (n = 339) with the following results: 34.6% (n = 173) were left messages but did not call back for follow-up, 29.6% (n = 149) were wrong numbers, did not answer Other Source 5% Multiple 39% No Cause 5% Bullet 2% Fall 7% Fragment 2% Fig. 1. TBI mechanism of injury, n = 796. Blast 31% Vehicle 9% or had no contact information, 2.6% (n = 13) represented multiple deployments from the same person(s), 0.8% (n = 4) were deployed and 0.2% (n = 1) was deceased. Eighty-three percent (n = 134) of those who were contacted via phone reported experiencing persistent symptoms at the time of the follow-up phone interview, while 15% (n = 24) denied any symptoms and 2% (3) were unknown. The time since injury ranged from 14.6 days to 17.5 months with a mean time of 10 months (SD = 4.25 months). Fifty seven (57,42.5%) service members reported experiencing 2 5 symptoms,

A.I. Drake et al. / Routine TBI screen after combat deployments 187 Table 2 Post-concussive symptoms reported by TBI/injury group, n = 134 Symptoms Reported Occurrence Percent Physical Symptoms Sleep Disturbances 73 54.5 Headaches 68 50.7 Hearing Loss 58 43.3 Sensitivity to Noise 47 35.1 Fatigue 45 33.6 Dizziness 30 22.4 Sensitivity to Light 28 20.9 Blurred Vision 24 17.9 Nausea 7 5.2 Vomiting 3 2.2 Cognitive Symptoms Memory Loss/Forgetfulness 70 52.2 Concentration Difficulties 45 33.6 Slowed Thinking 23 17.2 Confusion 16 11.9 Mood Symptoms Irritability 78 58.2 Increased Frustration 56 41.8 Mood Swings 43 32.1 Symptoms of Combat Stress 31 23.1 (6% (8) unknown) Depression 29 21.6 Loss of Interest in Activities 29 21.6 Changes in Personality 27 20.1 Anxiety 24 17.9 (17.3% (23) unknown) Decrease/Change in Motivation 23 17.2 Withdrawal 18 13.4 Decrease/Change in Daily Functioning 14 10.4 Total percentage is greater than 100% since multiple symptoms were reported. Table 3 Recommendations for further medical attention, n = 161 Recommendation Occurrence Percent Referred to DVBIC for intake 31 19.3 VA follow-up 17 10.6 Counseling follow-up 16 9.9 BAS follow-up 12 7.5 Total percentage is greater than 100% since multiple recommendations were made for some service members. 44 (32.8%) endorsed 6 10 symptoms, 22 (16.4%) reported greater than 11 symptoms and 11 (8.2%) endorsed only one symptom. See Table 2 for list of symptoms reported. As a result of the phone interviews, further medical attention was recommended for 36% (n = 58) of service members. See Table 3 for list of recommendations. The remaining 64% (n = 103) required phone screening and education only, either because they were already receiving appropriate care or they denied any current difficulties. 4. Discussion The highly efficient military medical evacuation system, combined with improved protective equipment, resulted in increased survival rates even after significant blast exposure [4,11]. Despite these advances, it is unclear if protective body armor or heavily armored vehicles can completely prevent blast-related TBI due to the effects associated with rapid changes in air pressure [6, 10]. These mild blast-related TBI may be overlooked in theatre for a variety of reasons, but the implementation of routine screening to identify these patients has been highly controversial. Critics have suggested that routine screening will result in an over-diagnosis of TBI and that the symptoms associated with mild TBI are non-specific and have a significant overlap with other potential co-morbid conditions, such as post-traumatic stress disorder. The BTBIS and other current screening methods may be subject to response bias. Anecdotally, several factors may influence TBI symptom reporting. Underreporting is thought to be related to the service member s strong desire to remain with his unit, concerns for delaying personal leave (vacation) due to required medical care, and less commonly, in response to commander request. Conversely, over-reporting is seen in those attempting to avoid further deployment, gain higher disability ratings, or account for other disciplinary problems. This screening process is designed to capture all service members who may be in need of medical care for TBI-related problems. Utilization of a validated response bias scale may be fruitful in the confirmatory clinical evaluation. TBI screening implemented within the I Marine Expeditionary Force at Camp Pendleton was completed on almost 8000 marines returning from combat deployments within a two year window of time. The screening differed from several previous reports in that the TBI screening was done by existing unit medical personnel at the same time routine post-deployment health assessment was completed. The majority of these medical personnel had actually deployed with these units and knew the combat history of these marines. A previous screening effort completed within the context of a larger study of TBI reported that 16.0% of those screened positive for TBI in a U.S. Army brigade; although it should be noted that these screenings were done at a TBI evaluation clinic by specially trained providers. The current analysis revealed that approximately 9.0% of returning combat veterans screened positive on the BTBIS when the screening was done with the PDHA.

188 A.I. Drake et al. / Routine TBI screen after combat deployments Hoge [5] has suggested that screening should be done as close as possible to the time of injury. Given the fact that many of these marines sustained significant blast exposures some months before their return to the U.S., the screening described in the current report is not optimal and better screening in theatre for mild TBI has been proposed and implemented by the USMC. Although the screened sample did not include one hundred percent of the deployed force of the I MEF, the data did appear to identify a percentage of marines not previously identified as having a TBI; that is, of those marines who screened as positive on the BTBIS, only 30 percent had already been identified as having some medical issues. Fully 70% of those positive screens were identified for the first time by this screening. This group is of concern as it potentially includes individuals who could have persistent symptoms or may require further follow-up and education about TBI. Some service members may be motivated to minimize symptoms rather than risk being removed from their unit due to injury. The finding that 9.0% of these combat veterans screened positive on a routine TBI screening measure underscores the importance of postdeployment TBI screening and also suggests that this type of screening will not over-identify TBI in this population. In fact, the rates of positive TBI screens was lower than that reported in an earlier report describing TBI screening within the context of a specialty TBI evaluation clinic. The current findings suggest that routine post-deployment screening for TBI can be completed by existing medical assets within the units. These issues are particular important to consider given the controversial nature of post-deployment TBI screening. Given the nature of combat deployments, where blasts are an everyday occurrence, these troops are at a greater risk for TBI. Routine screening for TBI done as part of the post-deployment health assessment process appears to represent an excellent method of identifying those individuals in a resource efficient manner. Hoge [5] has suggested that post-deployment screening is founded on the assumption that a causal connection has been established between concussion and persistent post-concussive symptoms, but the current analysis was focused on screening not definitive diagnosis. Other issues related to persistence of symptoms and medical utilization were also examined within this sample. Of those who screened positive for TBI and had not already been identified as having a TBI, phone followup was attempted, but only about one third of those individuals were able to be contacted by phone. This difficulty highlights the transient nature of these service members and the fact that many complete multiple deployments within relatively short periods of time. In the small sample of those who screened positive on the BTBIS who were contacted by phone, most had significant residual symptoms at the time of the followup. Most of those symptomatic marines were receiving appropriate medical care at the time of the phone follow-up. In fact, 49.0% of those marines followed up by phone were already under the care of specialty medical providers at the time of the phone follow-up. Those few marines who were still symptomatic and not already receiving medical care were referred for further services and provided education about TBI symptoms. The post-concussive symptoms observed in these service members ranged from physical complaints such as headache and dizziness, to cognitive difficulties including memory problems and impaired judgment, to mood symptoms such as irritability and impulsivity. These symptoms have the potential to negatively impact performance in the field. Early screening and follow-up for persistent symptoms is important since this is more likely to result in prompt and appropriate medical follow-up. This is especially relevant for service members in combat zones with undiagnosed TBI who may appear fit for duty but are unable to function reliably [15]. Furthermore, early intervention and education has been shown effective in reducing persistent symptoms [13]. The findings from this screening shed light on the incidence of mild TBI in this particular sample; however, the groups who completed the screening may not entirely represent the entire population. It is possible that certain units were more or less likely to participate in the screening initiative for a variety of reasons. Regardless, given the size of the sample and the consistency in rates of TBI compared to other reports, it is felt that the current results represent a very reasonable estimate of the incidence of combat-related TBI within the military. An additional limitation to the current analysis is that only one-third of those identified for further assessment were successfully contacted for follow-up. This certainly may have biased the followup symptom reports. It is possible that these particular marines were available because they were receiving medical care, placed on limited duty, or even being medical retired as opposed to those marines who already had redeployed, resulting in an over estimation of the rates of persistent symptoms. This highlights the inherent difficulty with follow-up in a population that tends to change duty stations and contact information, particularly after deployment.

A.I. Drake et al. / Routine TBI screen after combat deployments 189 The optimal way to identify the true prevalence of TBI following deployment is to screen every service member across all military branches in a systematic manner. The current form of the PDHA has been modified to contain TBI screening questions. This should result in non-biased sampling and better estimates of the rates of TBI among returning service members. It is important to ensure the most accurate identification of these individuals in order to provide follow-up care and referral for appropriate medical treatment. 5. Conclusion This article examines the utility of routine TBI screening among returning combat veterans from OIF/OEF. Post-deployment TBI screening in this sample revealed that blast-related TBI is common even among those service members who are not medically evacuated from theatre. The importance of identification is essential in ensuring appropriate medical care and follow-up. Improvement of TBI screening and follow-up medical care for these individuals would also enhance retention of highly trained service members experiencing persistent symptoms following combat deployments. Disclaimer This work was supported by the Defense and Veterans Brain Injury Center at WRAMC and NMCSD; resources and use of facilities were provided by the Naval Medical Center, San Diego. The views expressed in this article are those of the authors and do not reflect the official policy or position of the funding agency, the Department of the Navy, the United States Marine Corps, the United States Army, the Department of Defense, or the United States Government. Acknowledgements We wish to acknowledge the contributions of the First Marine Expeditionary Force medical providers, especially the Division Surgeon s Office at Camp Pendleton for assisting with the implementation of this screening effort. We would also like to thank the Defense and Veterans Brain Injury Center Headquarters at Naval Medical Center San Diego and Walter Reed Army Medical Center for their guidance and support of this project. Finally and most importantly, we would like to express our gratitude and deepest respect to all the Marines and Sailors who participated in this screening. References [1] H.G. Belanger, S.G. Scott, J. Scholten, G. Curtiss and R.D. Vanderploeg, Utility of mechanism-of-injury-based assessment and treatment: Blast Injury Program case illustration, J Rehabil Res Dev 42(4) (2005), 403 412. [2] H.R. Champion, J.B. Holcomb and L.A. Young, Injuries from explosions: physics, biophysics, pathology, and required research focus, J Trauma 66(5) (2009), 1468 1477. [3] Enhanced Post-Deployment Health Assessment (PDHA) Process (DD Form 2796). Deployment Health Clinical Center Web Site. http://www.pdhealth.mil/dcs/dd form 2796.asp. Accessed September 1, 2009. [4] J.S. Gondusky and M.P. 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