A Consideration of Voting Accessibility for

Injured OIF/OEF Service Members: Needs

Assessment

July 2012

Contract E4064914

2010 Voting Technology and Accessibility Research – Military Heroes Initiative 

CFDA #90.403

PREPARED FOR:

Election Assistance Commission 

1201 New York Avenue, N.W. 

Suite 300

Washington, D.C. 20005

PREPARED BY:

Human Systems Integration Division 

Electronic Systems Laboratory 

Georgia Tech Research Institute 

Georgia Institute of Technology 

Atlanta, Georgia 30332
Annotated Literature Review Results

Traumatic Brain Injuries

Brahm, K. D., Wilgenburg, H. M., Kirby, J., Ingalla, S., Chang, C., & Goodrich, G. L. (2009). Visual 

impairment and dysfunction in combat-injured service members with traumatic brain injury. Optometry 

and Vision Science, 86,(7), 817-825.

This study determined the frequencies of visual impairments among military personnel who had 

been treated at the the Polytrauma Network Site (PNS, outpatient facility) and the Polytrauma 

Rehabilitation Center (PRC, inpatient facility). A vision screening assessment of showed that 90% 

of PNS-outpatients and 84% of PRC-inpatients had TBIs associated with a blast event. Visual 

dysfunctions, including lens accommodation and oculomotor problems, were common in both 

populations. Poor visual acuity (20/100 or worse) was much less common. The findings suggest 

that military personnel who suffer from blast-induced TBI are at risk for visual dysfunction; in 

particular, they may often face difficulties with changing focal distance (i.e., accommodation) 

and with eye movements (i.e., convergence, smooth pursuit, and saccades).

Cifu, D. X., Cohen, S. I. Lew, H. L., Jaffee, M., & Sigford, B. (2010). The history and evolution of traumatic 

brain injury rehabilitation in military service members and veterans. American Journal of Physical 

Medicine & Rehabilitation, 89,(8), 688-694.

The incidence of TBI has recently increased, perhaps due to changes in weaponry and increase 

survival rates. This paper gives a historical account of the medical community’s adaptation to 

combat-related injuries over the years. The Department of Veterans Affairs and the Defense and 

Veterans Brain Injury Center have made a great impact how soldiers with traumatic brain injury 

are evaluated and treated. Several facilities and many clinical teams have recently been created 

to specifically focus on treating soldiers with polytrauma and traumatic brain injury.

Cockerham, G. C., Goodrich, G. L., Weichel, E. D., Orcutt, J. C., Rizzo, J. F., Bower, K. S., & Schuchard, R. A. 

(2009). Eye and visual function in traumatic brain injury. Journal of Rehabilitation Research & 

Development, 46(6), 811-818.

Traumatic brain injury in the civilian sector is often associated with visual dysfunctions, which 

include difficulty changing focal distance and moving the eyes. Often, no reduction in visual 

acuity occurs. Civilian TBI is often caused by blunt force trauma (e.g., automobile accidents) 

whereas combat-related TBI is often caused by blasts. Relative to the civilian sector, little is 

known about the visual effects of military (blast-induced) TBI. Blasts sometimes directly cause 

eye injury, which can be quickly detected and treated. When the eyes are not directly damaged, 

the treatment of visual dysfunctions caused by TBI might often be delayed. To rectify this, the 

authors suggest many lines of the research that should be pursued, such as the development of 

assessment tools, comparison of treatment methods (e.g., surgical interventions and

pharmacological therapies), and a systematized method of documenting the success of 

rehabilitation.
Colantonio, A., Ratcliff, G., Chase, S., Kelsey, S., Escobar, M., & Vernich, L. (2004). Long term outcomes 

after moderate to severe traumatic brain injury. Disability and Rehabilitation, 26(5), 253-261.

This study addressed long-term quality of life issues (e.g., self-rated health, employment, and 

activity limitations) for veterans who had suffered TBI at least 15 years prior to the study. The 

greatest challenges faced by respondents (N = 306) were related to driving, shopping, and 

managing finances. Many veterans with TBI may need long term assistance with these activities 

of daily living despite rehabilitation efforts.

Davis, C., Nelson, J., Hirsch, M. A., Hammond, F. M., Karlawish, J., Schur, L, Kruse, D., & Ball, A. (2010). An 

exploratory examination of political empowerment and voting among individuals with TBI. Brain Injury, 

24(3), 208.

This study used a community-based participatory research approach to assess the voting 

experience of individuals with TBI (along with their caregivers and family members) during the 

November 2007 and May 2007 General Election and the November 2008 Presidential Election in 

North Carolina. Interviews were conducted with 55 individuals with TBI, and with 27 spouses, 

caregivers, and healthcare and community providers of people with TBI. Participants were 

shadowed and observed as they voted at the polls. The study found that people with TBI can 

require extra resources (time, effort, transportation) to vote, and that people with TBI have 

challenges with remembering to vote, preparing to vote, researching candidates, and arranging 

transportation to the polls. Some people with TBI also note challenges navigating the polls and 

the ballot, and difficulty remembering who to vote for.

Doarn, C. R., McVeigh, F., & Poropatich, R. (2010). Innovative new technologies to identify and treat 

traumatic brain injuries: Crossover technologies and approaches between military and civilian 

applications. Telemedicine and e-Health, 16(3), 373-381.

The ubiquitous use of improvised explosive devices in Iraq and Afghanistan has contributed to 

the recent increase of TBI seen in the military. Higher rates of survival are also responsible. 

Although there has been a reduction in severe TBI, perhaps due to improved armor, mild and 

moderate TBI have increased. Because the physical and mental effects of TBI are often 

misdiagnosed, the U.S. Army is pursuing methods for early TBI detection and treatment. To 

pursue this subjective, the U.S. Army's Telemedicine and Advanced Technology Research Center 

collaborated with a civilian organization –the American Telemedicine Association – to hold a 

research symposium on the diagnosis and treatment of TBI. This paper documents the session 

topics at the symposium and gives general summaries of some of the presentations. This may be 

a good resource for finding current researchers in the field.
Doarn, C. R. (2009). Symposium report: Innovative new technologies to identify and treat traumatic 

brain injuries: Crossover technologies and approaches between military and civilian applications, Indian 

Wells, CA.

These symposium presentations are focused on current activities in diagnosis and treatment of 

TBI using various technologies from subject matter experts. One focus of discussion is the use of 

telemedicine in the diagnosis and treatment of TBI. The use of tele-rehabilitation for TBI 

patients is also discussed.

Dobscha, S. K., Clark, M. E., Morasco, B. J., Freeman, M., Campbell, R., & Helfand, M. (2009). Systematic 

review of the literature on pain in patients with poly-trauma including traumatic brain injury. Pain 

Medicine, 10(7), 1200-1217.

This literature review addressed pain assessment and management in patients with 

polytraumatic injuries, including blast-related headache and TBI. It covered studies published 

from 1950 to 2008. Most studies found in the literature search did not include a control group, 

but instead included observational and qualitative studies. The search criteria yielded one 

review paper, 93 observational studies, and one qualitative study. Surprisingly, the search did 

not yield any studies that evaluated the quality of pain-intensity measures or pain-related 

functional limitations among patients with TBI. There were also no studies that compared blastrelated headache with other types of headache, or that evaluated treatment options for blastrelated chronic headaches. Symptoms associated with TBI varied widely across studies; variables 

included pain severity and location, insomnia, fatigue, post-traumatic stress disorder, and 

depression. The authors advocated further research to guide pain assessment and management 

for individuals suffering from polytrauma.

DuBose, J. J., Barmparas, G., Inaba, K., Stein, D. M., Scalea, T., Cancio, L. C., Cole, J., Eastridge, B., 

Blackbourne, L. (2011). Isolated severe traumatic brain injuries sustained during combat operations: 

Demographics, mortality outcomes, and lessons to be learned from contrasts to civilian counterparts. 

Journal of Trauma, 70,(1), 11-18.

The epidemiology of severe TBI from the civilian and military (Joint Trauma Theatre Registry) 

sectors was compared. Patient demographics, treatments, and outcomes were reviewed. 

Military personnel were significantly more likely than their civilian counterparts to receive 

intracranial pressure monitoring and neurosurgery. Mortality was lower among military 

personnel overall, especially in cases of penetrating brain injury. It is suggested that the 

pressure monitoring and surgical interventions received by military personnel are partially 

responsible for their higher rates of survival. However, many other factors might play a role.
French, L. M., & Parkinson, G. W. (2008). Assessing and treating veterans with traumatic brain injury.

Journal of Clinical Psychology: In Session, 64(8), 1004-1013.

This article discusses comorbid injuries and the environmental context in which TBI is sustained 

by military personnel in recent conflicts. Comorbid injuries in the environmental stressors

greatly complicate clinical approaches. The influences of these factors are illustrated with case 

vignettes.

Hoge, C. W., McGurk, D., Thomas, J. L., Cox, A. L., Engel, C. C., & Castro, C. A. (2008). Mild traumatic 

brain injury in U.S. soldiers returning from Iraq. New England Journal of Medicine, 358(5), 453-463.

The authors surveyed 2525 U.S. Army infantry soldiers 3 to 4 months after their return from 

deployment. The purpose of the survey was to determine rates of TBI comorbidity with PTSD 

and major depression, and their combined effects on physical health. The survey consisted of 

validated measures of TBI, depression, and PTSD. Questions also addressed physical health. 

Fifteen percent of respondents reported symptoms that were indicative of mild TBI.

Of those who reported loss of consciousness, 43.9% reported symptoms indicative of PTSD. 

Among other groups who did not report a loss of consciousness, PTSD symptoms were reported 

much less frequently. Those with mild TBI, particularly those who had lost consciousness, were 

significantly more likely to report poor health outcomes. However, after a statistical adjustment 

for PTSD and depression, mild TBI was not significantly associated with physical health 

outcomes. The results suggest that the relationship between mild TBI and physical health 

problems is mediated by depression and PTSD; that is, those individuals who suffer from TBI but 

not depression or PTSD are less likely to suffer from physical health problems.

Iverson, G. I. (2010). Clinical and methodological challenges with assessing mild traumatic brain injury in 

the military. Journal of head Trauma Rehabilitation, 25(5), 313-319.

This article reviews a screening program designed to detect residual symptoms of mild TBI. The 

authors provide a critical review the current screening program, discuss its challenges, and make 

recommendations for its improvement. One problem with the current screening program is its 

inability to determine when a TBI may have been sustained for individuals who have served 

multiple tours of duty. Another limitation is that TBI may be sufficient but not necessary to 

generate some of the symptoms that are targeted by screening questions. Most critically, this 

screening program has a limited ability to dissociate TBI from PTSD and depression. Careful 

documentation and further research are needed to improve the program.

Lew, H. L., Garvert, D. W., Pogoda, T. K., Hsu, P. T., Devine, J. M., White, D. K., . . . Goodrich, G. L. (2009). 

Auditory and visual impairments in patients with blast-related traumatic brain injury: Effect of dual 

sensory impairment on Functional Independence Measure. Journal of Rehabilitation Research & 

Development, 46(6), 819-826.
In this study of 175 patients with blast-related traumatic brain injury (TBI), it was found that 

19%, 34%, and 32% of the patients showed clinical signs of hearing impairment, vision 

impairment, and dual sensory impairment (hearing and vision), respectively. A measure of 

functional independence was also administered; it comprised a motor subscale and a cognitive 

subscale. Statistical analysis showed a sensory-group difference for the motor functional 

independence scores at the time at discharge from a clinical care facility. Regarding

improvement over time, the dual sensory impairment group showed significantly less 

improvement in motor functional independence.

Lew, H. L., Weihing, J., Myers, P. J., Pogoda, T. K., & Goodrich, G. L. (2010). Dual sensory impairment 

(DSI) in traumatic brain injury (TBI): An emerging interdisciplinary challenge. NeuroRehabilitation, 26, 

213-222.

Dual sensory impairment (DSI), which often accompanies TBI, is marked by auditory and visual 

deficits that are either peripherally or centrally based. This review covers unimodal deficits as 

well as DSI in the military population. The heterogeneous nature of TBI injuries creates a 

challenge for clinicians to dissociate, for diagnostic and rehabilitative efforts, the effects of 

multiple sensory deficits from cognitive deficits. Current treatments for DSI include training 

exercises and sensory aids.

McCarthy, M. L., Dikmen, S. S., Langlois, J. A., Selassie, A. W., Gu, J. K., & Horner, M. D. (2006). Selfreported psychosocial health among adults with traumatic brain injury. Archives of Physical Medicine 

and Rehabilitation, 87, 953-961.

Symptoms associated with TBI are not limited to cognitive deficits, but also include physical and 

psychosocial problems, such as depression, anxiety, and social withdrawal. This study reports 

subjective measures of psychosocial health of 7612 civilians one year after their discharge from 

clinics. Twenty-nine percent reported poor psychosocial health. The following factors were 

positively associated with poor psychosocial health: female sex, younger age, Medicaid 

coverage, lack of health insurance, poor social support, cognitive deficits, and substance abuse. 

Of those who reported poor psychosocial health, only 36% reported receiving mental health 

care. To improve TBI rehabilitation, clinicians should attend to patients’ psychosocial health 

needs in the period following acute treatment.

Mount Sinai Medical Center (2008). What Impact Will Moderate or Severe TBI Have on a Person's Life? 

Retrieved from http://www.brainline.org/content/2008/07/what-impact-will-moderate-or-severe-tbihave-persons-life.html.

This article discusses the long-term functional deficits of TBI. A wide variety of bodily functions 

controlled by the brain may be affected. Given the fact that TBI produces heterogeneous 

symptoms, individuals may experience only one, several, or most of the possible effects. 

Furthermore, rehabilitative improvements (or lack thereof) vary greatly across individuals. 

Moderate-to-severe TBI often causes deficits in basic cognitive skills, such as the ability to 

sustain attention, remember newly learned material, think creatively, adapt to changes in 

routine, and make decisions based on many constraints. Personality traits, such as neuroticism, 
motivation, and social inhibition may also be altered. The social problems are compounded 

when patients deny (or are unaware of) the effects of their injuries. This denial can also impede 

rehabilitation. Other problems include sensory deficits, paralysis, chronic pain, and hormonal 

imbalances. Given the diversity of symptoms, it follows that the success of rehabilitation varies

greatly among individuals. Some individuals will completely recover after several years, whereas 

others will improve but never fully recover.

Pagulayan, K. F., Hoffman, J. M., Temkin, N. R., Machamer, J. E., & Dikmen, S. S. (2008). Functional 

limitations and depression after traumatic brain injury: Examination of the temporal relationship. 

Archives of Physical Medicine and Rehabilitation, 89, 1887-1892.

A longitudinal study was conducted to determine the temporal relationship between functional 

limitations and depression caused by TBI. Functional limitations were measured by the Sickness 

Impact Profile (SIP), which assesses quality of life issues and functional abilities such as sleep and 

rest, body care, home management, and social relationships. Evaluations were taken at three 

time points. Results showed that depressive symptoms were more highly correlated with high 

SIP scores at later time points than earlier time points. Statistical analyses showed that 

increased SIP scores usually preceded increased depression, which may imply a causal effect. 

That is, quality of life issues and functional abilities may influence emotional well-being, but 

depression may not strongly affect the perception of quality of life and functional abilities. The 

results have implications for the treatment of TBI related depression.

Schneiderman, A. I., Braver, E. R., Kang, H. K. (2008). Understanding sequelae of injury during the 

conflicts in Iraq and Afghanistan: persistent postconcussive symptoms and Posttraumatic stress 

disorder. American Journal of Epidemiology, 167(12), 1446-1452.

Associations among PTSD and post-concussive symptoms of TBI were investigated by a survey. 

Immediate neurologic symptoms that were reported after injuries were used to identify mild 

TBI. About 12% of 2,235 respondents reported symptoms that were indicative of mild TBI, and 

11% reported symptoms consistent with PTSD. Other than TBI, PTSD was the strongest factor 

associated with post-concussive symptoms.

Silver, J. M., McAllister, T. W., & Arciniegas, D. B. (2009). Depression and cognitive complaints following 

mild traumatic brain injury. American Journal of Psychiatry, 166(6), 653-661.

Problems with cognition, emotion, and behavior often accompany TBI. Although many patients 

improve significantly during the first several months after sustaining mild TBI, many other 

patients develop long-term functional problems. Some of the most common symptoms are 

cognitive impairment and depression. The symptoms sometimes are responsive to a 

combination of pharmacologic and rehabilitative treatments. This paper offers 

recommendations for clinical diagnosis and treatment of individuals suffering from depression 

and cognitive deficits following TBI.

Spencer, R. J., Drag, L. L., Walker, S. J., & Bieliauskas, L. A. (2010). Self-reported cognitive symptoms 

following mild traumatic brain injury are poorly associated with neuropsychological performance in 
OIF/OEF veterans. Journal of Rehabilitation Research & Development, 47(6), 521-530.

Screening for TBI is often accomplished by self-report measures, yet the accuracy of such 

measures is questionable. Self-report in general can be unreliable, and they may be particularly 

unreliable in this population who are often unaware (or in denial) of their symptoms. The study 

compared objective clinical assessments with self-reports in 105 service members who recently 

sustained mild TBI. Self-report measures of cognitive functioning were not significantly 

correlated with objective clinical measures. Clinicians who were surveyed tended to 

overestimate the association between clinical measures and self-report measures.

Taber, K. H., Warden, D. L., & Hurley, R. A. (2006). Blast-related traumatic brain injury: What is known?

The Journal of Neuropsychiatry and Clinical Neurosciences, 18(2), 141-145.

Causes of TBI can be placed in the following three categories: blast wave-induced changes in 

atmospheric pressure, impact of objects that are thrown by the blast, and impact of people as 

they are thrown by the blast. This paper discusses the medical complications associated with 

each of these types of TBI.

Temkin, N. R., Corrigan, J. D., Dikmen, S. S., & Machamer, J. (2009). Social functioning after traumatic 

brain injury. Journal of Head Trauma Rehabilitation, 24(6), 460-467.

A review of published literature was conducted to determine the relationship between TBI and 

various social functions, including employment, relationships, functional independence, and 

recreation. Results indicated that unemployment was associated with moderate and severe TBI 

but not mild TBI. Recreation, quality of social relationships, and functional independence were 

also adversely affected by TBI, regardless of severity. However, injury severity did affect the 

severity of social problems.

Tun, C., Hogan, A., & Fitzharris, K. (2009). Hearing and vestibular dysfunction caused by blast injuries and 

traumatic brain injuries. The Hearing Journal, 62(11), 24-26.

Blasts that induce TBI often also induce damage to the auditory and vestibular systems. This 

paper describes the symptoms associated with damage to the auditory and vestibular systems, 

as well as the frequency of these injuries at the Boston VA medical clinic.

Wounded Warrier injury fact sheet on traumatic brain injury (TBI). Retrieved from

http://wtc.army.mil/aw2/index.html.

The Wounded Warrior website has some informative fact sheets on some of the injuries and 

disabilities that occur in combat. This fact sheet on TBI includes data on prevalence, as well as 

information about treatment and recovery.