4 not, emotional and cognitive symptoms persist after mTBI and are maintained by dysfunctional thought processes and emotional impairment. Early research suggests addressing these emotional issues in the initial stages of treatment, sim- ultaneously with the neurologic injury has been helpful in preventing postconcussion sequelae [21]. Tiersky and colleagues [22] noted that with a combina- tion of cognitive remediation and CBT, participants reported less emotional distress and increased cognitive functioning after treatment. Additionally, the emotional improvements continued to increase at the 1-month and 3-month followups posttreatment. The cognitive remediation portion of the treatment focused on attention, information processing, and memory. The focus of CBT was to provide increased coping behaviors, teach skills to prevent relapse, and cope with the feelings of loss related to their decreased functioning. Although the treatment was not purely CBT, it provides addi- tional evidence that CBT can be eﬀective with patients who have sustained both mild and moderate TBIs. A more recent study of an individualized treatment of CBT was also found eﬀective in reducing emotional distress in patients with a TBI [23]. In this research, CBT was modi- ﬁed from its standard form to include repetition of impor- tant concepts and frequent breaks. Because cognitive assess- ments were completed prior to the study, the intervention was individualized to each patient based on their ability to learn and retain information and their cognitive processing speed. The intervention was delivered in both a group format and over the telephone. Those in the treatment groups had statistically signiﬁcant less emotional distress following the study and at the 1-month followup. This suggests that pa- tients who have sustained a TBI can beneﬁt from CBT, even though some alterations may need to be made to the basic CBT concepts. Insomnia is also commonly associated with mTBI and often prolongs the recovery process. Ouellet and Morin [24] conducted a case study of a man who sustained a brain injury and had failed pharmacotherapy for insomnia. Following eight weeks of treatment focusing on stimulus control, sleep restriction, cognitive therapy, and sleep hygiene education, the participant’s sleep had improved. At the 3-month follow- up, the positive eﬀects were still apparent. This case study showed that the use of CBT is promising for post-TBI insom- nia. In 2007, Ouellet and Morin [25] expanded on their work. With a small group of participants (n = 11) who had sus- tained a TBI, they provided the same treatment as above and added a fatigue management component. Sleep eﬃciency had improved for each participant in the study at the end of treatment and the positive eﬀects remained at the 3-month followup. This appears to be an eﬀective way of managing insomnia in individuals with a TBI, however, more research with larger sample sizes continues to be needed in the ﬁeld. 7. The Impact of Multiple Concussions While some studies have shown little to no impact of 2 concussions [26], other research has shown that multiple concussions and subconcussive blows may lead to chronic Rehabilitation Research and Practice traumatic encephalopathy (CTE) [27]. Chronic traumatic encephalopathy has been found on autopsy in boxers, football players, and hockey players who suﬀered multiple concussions, and many more subconcussive blows, eventu- ally exhibiting early dementia and depression. Histologically, CTE is characterized by the expression of high concentra- tions of tau protein (neuroﬁbrillary tangles) and Beta Amyl- oid plaques. These ﬁndings appear to be relevant to the military due to the high risk of multiple blast injuries. This oﬀers further support for the importance of new guidelines for concussion identiﬁcation, management, and long-term follow-up. 8. Conclusion Almost four decades ago, mild head injury in clinical pop- ulations began to gain attention from the medical and neu- ropsychological communities. Much of the initial controlled data on mTBI and concussions was gleaned from athletes who were at high risk for mild head trauma. With the mul- tiple combat tours and the nature of warfare in Iraq and Afghanistan that are putting service members at risk for multiple concussive injuries, the lessons learned from the sports concussion literature are being applied to the military. While there are diﬀerences in the mechanism of injury and additional challenges when TBIs occur in the combat setting, there are also similarities. Due to these similarities and the need for a graduated return to duty (or play), the military is now implementing clinical practice guidelines similar to the Zurich recommendations used in many civilian sports. Following a TBI, military personnel and veterans have ser- vices available to them though military medical treatment facilities and the Department of Veterans Aﬀairs for contin- ued treatment of symptoms. There is continuing research on the impact of multiple concussions and subconcussive blows in boxing, football, soccer, and hockey that have led to a better understanding of the possible links to CTE. There are, however, no longitu- dinal bodies of data currently available from which to draw conclusions regarding the impact of multiple concussions during combat. Continued study of combat related blast concussions is important to our eﬀorts to quickly and safely return service members to duty, treat persistent concussion symptoms, and avoid long-term sequel and CTE. 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