National prevalence of traumatic brain injury, posttraumatic stress disorder, and pain diagnoses in OIF/OEF/OND Veterans from 2009 to 2011.

Improvements in protective body armor technology in the past decade, combined with advances in emergency and intensive care medicine, have saved countless lives from battlefield injury [1-4]. Survivors of military conflicts often present with a constellation of injuries, recently described as "polytrauma" by the Veterans Health Administration (VHA) [5]. While traumatic brain injury (TBI) has been coined as the "signature injury" in this generation of combat returnees, other concomitant physical and psychological impairments also require long-term follow-up and care [6-8]. The 2009 study by Lew et al. systematically reviewed 340 Operation Iraqi Freedom (OIF)/Operation Enduring Freedom (OEF) Veterans seen at a VHA Polytrauma Network Site (PNS) from 2007 to 2008, and the data revealed that TBI, posttraumatic stress disorder (PTSD), and pain were reported in 66.8, 68.2, and 81.5 percent of Veterans, respectively [9]. Since these three conditions (TBI, PTSD, and pain) tend to occur in combination (42.1%), as opposed to existing in isolation (5.3%, 2.9%, and 10.3%, respectively), their co-occurrence has been referred as the "polytrauma clinical triad" [9]. Given its complexity, an interdisciplinary team approach to diagnosis and treatment has been recommended for patients with this clinical triad [9-10]. Note, however, that this previous study [9] involved only those OIF/OEF Veterans who had (1) sought care within the VHA healthcare system, (2) completed the TBI screening questionnaire at the VHA, (3) answered yes to all four screening questions, (4) agreed to undergo further evaluation, and (5) then completed a comprehensive evaluation at a local VHA PNS (Figure). This issue of the Journal of Rehabilitation Research and Development includes a landmark article that truly defines the national prevalence of TBI, PTSD, and pain in Veterans from the OIF/OEF/Operation New Dawn (OND) conflicts, encompassing data from 2009 to 2011. Specifically, Cifu et al. [11] conducted a comprehensive investigation that systematically collected and analyzed data from 613,391Veterans who received any healthcare in the VHA from the beginning of 2009 to the end of 2011. Utilizing data from the entire population of OIF/OEF/OND Veterans seen for this three year period, Cifu et al.'s study revealed the actual prevalence of TBI, PTSD, and pain in this new generation of Veterans. Data from 613,391Veterans were captured at the initial stage of entry into the system, when they sought care with the VHA as either outpatients or inpatients, and then at subsequent visits during that three year period. Pooled data from all three years (2009-2011) revealed that only 6.0 percent of this population had the full polytrauma triad expression (TBI, PTSD, and pain). This current percentage (6.0%) is low when compared with the 42.1 percent from Lew et al.'s previous study [9], which was from a more selective sample since it assessed the local prevalence of the polytrauma triad in Veterans who had not only sought care with the VHA but also completed the TBI screening questionnaire at the VHA, answered yes to all four screening questions, agreed to undergo further evaluation, and completed a comprehensive evaluation at a VHA PNS. Comparisons of the overall and isolated occurrence rates of TBI, PTSD, and pain between the two studies are summarized in Tables 1 and 2, respectively. The drastic contrast in the TBI rates between the two studies was likely because the sample evaluated in the former study had already screened positive for TBI but not for PTSD or pain. [FIGURE OMITTED] Moreover, Cifu et al.'s results also revealed that "Among those with a TBI diagnosis, the majority also had a mental health disorder, with approximately half having both PTSD and pain. While the absolute number of Veterans increased by over 40 percent from 2009 to 2011, the proportion of Veterans diagnosed with TBI and the high rate of comorbid PTSD and pain in this population has remained relatively stable" [11]. …