Team approach to diagnosis and management of traumatic brain injury and its comorbidities. (2007)

With advances in body armor technology and acute trauma care, many military service members are now surviving injuries that would have been fatal in previous wars [1]. However, the brain remains susceptible to non-penetrating injuries from high-impact collisions and explosive blasts [2]. As eloquently stated by a Department of Veterans Affairs (VA) physician even before Operation Iraqi Freedom and Operation Enduring Freedom (OIF/ OEF) began, It is necessary to discard the magical notion that wearing a helmet on the head is sufficient to protect against impact brain damage [3]. Because of its high prevalence, traumatic brain injury (TBI) has been labeled the signature wound of modern warfare [4]. While the dramatic details of severe TBI have captured the attention of the media [5], one cannot ignore the clinical significance and potentially high prevalence of mild TBI in OEF/OIF returnees [6]. Much that has been learned about mild TBI in the past decade has been acquired through studies of sports-related concussions [7], but blast-related concussions may operate through a different mechanism [8]. In April 2007, the VA Central Office issued a directive implementing a mandatory procedure for the screening of symptomatic TBI, or postconcussive syndrome, among all OIF/OEF veterans [9]. The procedure includes four questions that sequentially delineate (1) a history of injury events that may increase the risk for TBI, (2) symptoms related to alteration of consciousness immediately after the traumatic event, (3) new or worsening TBI symptoms in the aftermath of the traumatic event, and (4) persistence of these symptoms into the present. Affirmative answers to all four questions constitute a positive TBI screen, which results in a referral for further clinical evaluation and then treatment. Like any test with significant clinical implications, this test has the inherent problem of false positives and false negatives. Thus, the screening procedure's sensitivity [10], specificity, predictive validity [11], and reliability [12] need to be determined. At the same time, despite the ongoing debate about the gold standard for diagnosing mild TBI, we need to develop a mechanism for following those who have positive manifestations of TBI but are not seeking evaluation or treatment. Clinicians often remark that no two TBIs are alike. Because of the complex and typically violent nature of their injuries [13], patients with TBI almost always have multiple acute comorbidities that are often unrelated to their preexisting health conditions. By definition, comorbidity describes the effect of all other ailments a patient might have, other than the primary injury or illness. Along with life-threatening complications and physical impairments, mental health comorbidities are of prime importance in the rehabilitative process of TBI. For the general public, focusing on the cognitive deficits related to TBI is intuitive. However, a recent study revealed that TBI patients with more emotional problems were less likely to return for follow-up appointments [2], with the potential for adverse effects on care coordination and functional outcome. Another study showed that patients with TBI plus acute comorbidities tended to have longer hospital stays [14]. Based on the coexistence of medical and psychological issues in TBI and considering the resources required to care for these patients, we need to develop a unified TBI database across representative VA and Department of Defense (DOD) healthcare service locations. With this database established, clinicians and researchers will be able to (1) quantify and track the severity of TBI and its comorbidities, (2) study how these variables interact with TBI patients' healthcare utilization, and (3) conduct state-of-the-art (SOTA) TBI research, according to the special strengths of each of the participating VA/DOD healthcare facilities. A key concept is the need for a coordinated team of professionals to properly diagnose and rehabilitate patients with TBI and its comorbidities. …