Running head: OEF/OIF TBI INTEGRATIVE REVIEW

Operation Enduring Freedom and Operation Iraqi Freedom

Combat Related Traumatic Brain Injury Integrative Review
Nicole Bayer
Bon Secours Memorial College of Nursing

OEF/OIF TBI INTEGRATIVE REVIEW

Abstract
A common injury sustained during Operation Enduring Freedom and Operation Iraqi Freedom
(OEF/OIF) is a combat related traumatic brain injury (TBI). The purpose of this integrative
review is to review literature on OEF/OIF combat Veterans with a TBI and how they are
screened for TBI, what the screening criteria is, and the treatment methods available to help these
service members reintegrate into the community after deployment. A series of articles were
evaluated and five were chosen as they are related to the purpose of this review. The results of
the integrative review of the five studies suggested the importance of screening for TBI upon
returning to the United States so no service member goes undiagnosed due to a lack of screening,
that there are many unique needs and concerns of combat Veterans with TBI, and that the
therapies studied, Prolonged Exposure (PE) therapy and Cognitive Symptom Management and
Rehabilitation Therapy (CogSMART), are effective in providing interventions that decrease
postconcussive symptoms, provide relief from the symptoms, and help Veterans to reintegrate
into the community post-deployment. Combat TBI is a complex injury that requires appropriate
screenings to diagnose and specific treatments aimed at providing management of a relief of
postconcussive symptoms.

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OEF/OIF Combat Related TBI Integrative Review

Traumatic brain injury (TBI) is a common injury that occurs in combat as a result of
blasts and improvised explosive devices (IED). Up until a few years ago, there has not been
much research regarding TBI amongst combat Veterans. As a result of a database search, five
articles about combat related TBI have been reviewed. These studies are recent, within the past
five years, studying combat Veterans from both OEF and OIF that received a TBI in Iraq and/or
Afghanistan.
The first article, Routine TBI screening following combat deployments (2010), by authors
A.I. Drake, K.S. Meyer, L.M. Cessante, C.R. Cheung, M.A. Cullen. E.C. McDonald, and M.C.
Holland is a descriptive study of 7,909 military Veterans from the First Marine Expeditionary
Force 2004-2006 to determine whether screening using the Brief Traumatic Brain Injury Screen
(BTBIS) was beneficial in identifying service members who have a potential TBI that would
otherwise go unrecognized. By screening personnel for one injury mechanism and a positive
change in mental status, many military service members returning from deployment were
followed up due to the large number of positive TBI screens from the BTBIS. Through clear and
concise language the authors suggested that screening all service members returning from
deployment helped to identify those with a TBI that would have gone undiagnosed and
unrecognized otherwise.
The second article, Epidemiologic Aspects of Traumatic Brain Injury in Acute Combat
Casualties at a Major Military Medical Center: A Cohort Study (2012), written by M.S.
Xydakis, G.S.F. Ling, L.P. Mulligan, C.H. Olsen, and W.C. Dorlac is a cohort study in which the
objective was to determine the effectiveness of using loss of consciousness (LOC) as a
diagnostic for TBI in combat Veterans. It was determined in the clear and concise article without

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medical jargon that LOC should not be used as the principle diagnostic criteria for LOC, because
LOC may not be reflective of an actual brain injury, rather a reaction to physical distress and
trauma.
Needs and Concerns of Male Combat Veterans with Mild Traumatic Brain Injury (2013)
written by V.S. Daggett, T. Bakas, J. Buelow, B. Habermann, and L.L. Murray is a qualitative
descriptive study to determine the needs and concerns of combat Veterans with mild TBI. The
article contained professional and unbiased information without medical jargon and determines
that the findings supported the use of a context-specific conceptual model that can help Veterans
to identify areas where interventions can be applied in order to enhance community reintegration.
The article reviewed, A Preliminary Examination of Prolonged Exposure Therapy With
Iraq and Afghanistan Veterans With a Diagnosis of Posttraumatic Stress Disorder and Mild to
Moderate Traumatic Brain Injury (2012), written by G.K. Wolf, T.Q. Strom, S.M. Kehle, and A.
Eftekhari is a quasi-experimental study in which there objective was to preliminarily determine if
PE therapy was effective in treating OEF/OIF Veterans with TBI for their posttraumatic stress
disorder (PTSD). The authors used clear and concise language without mention of medical
jargon and suggest that PE is safe and effective in treating Veterans with PTSD, TBI and
cognitive impairment.
The last article reviewed, Cognitive Symptom Management and Rehabilitation Therapy
(CogSMART) for Veterans with Traumatic Brain Injury: Pilot Randomized Control Trial (2014)
written by authors E.W. Twamley, A.J. Jak, D.C. Delis, M.W. Bondi, and J.B. Lohr is a
randomized control trial with the intention to determine whether or not CogSMART, which is a
cognitive training intervention, would help Veterans with TBI obtain employment. The authors
used clear and concise language without medical jargon and said the results suggested that

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adding CogSMART to supported employment is successful in improving postconcussive

symptoms and prospective memory which allowed Veterans to achieve employment. The therapy
was rated highly by the Veterans that used it.
Background
Traumatic brain injury related to combat is a large problem that occurs in many of the
OEF/OIF combat Veterans returning from deployments in Iraq and Afghanistan. There has been
little research until recently regarding TBI related to combat. There is substantial information
regarding TBI related to the typical head injury patient seen stateside in the United States. The
mechanism that causes combat related TBI is different and needs to be further studied in order to
provide the best, quality care to the service members of the United States military.
Combat TBI is most commonly received due to a closed head injury, but may also be
received due to an open head injury. A closed head injury in combat is caused by a blast or
explosive mechanism a majority of the time such as fragmentation (shrapnel), bodily
displacement, thermal burns, and over pressure as well as blunt biomechanical trauma. An open
head injury is caused by a penetrating intracranial brain injury from a firearm or blast. It has been
found that all combat Veterans who received an open head injury will have a TBI whereas 54.3%
of blast (explosive) injured Veterans and 56.6% of blunt biomechanical injured Veterans will
have a TBI as a result of their injury (Xydakis, Ling, Mulligan, Olsen, & Dorlac, 2012, p. 675).
It is often difficult to determine which Veterans have sustained a TBI. There are few
screening tools that are used and there are a significant number of Veterans returning stateside
who have a TBI, but it has been missed. In order to screen effectively for TBI there needs to be
strict criteria and a screening tool that is proven effective in identifying Veterans with TBI who
may require further follow up.

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Once a combat Veteran is diagnosed with a TBI and returns to the United States it is often
difficult to readjust and reintegrate into the community. Not only do they have cognitive
impairments, but they often have difficulties with emotional and psychological aspects of their
life. This is where there is research needed regarding the interventions that can be taken to
improve the Veterans quality of life and to help him or her readjust to live in a non-combat zone
while seeking, obtaining, and keeping employment. There are many aspects of combat related
TBI in Veterans from OEF/OIF that need to be studied and evaluated.
The purpose of this integrative review is to answer the following PICO question: How are
OEF/OIF combat Veterans screened for TBI, what is the screening criteria, and what are the
treatments available based on their needs and concerns to help these service members reintegrate
into life in the community after deployment?
Design and Search Methods
The purpose of this integrative literature review is to examine how TBI in combat
Veterans is screened for, the criteria used when screening for TBI, and the various treatments
available to help combat Veterans from the Iraq and Afghanistan wars reintegrate into the
community after deployment and a TBI. All five of the articles reviewed in this integrative
review were found on PubMed. There were many search terms used in order to find these articles
including: brain injuries, combat disorders/etiology, military medicine, war, military
personnel, veterans, young adult, Afghan campaign, Iraq War, postconcussive
symptoms, cognitive rehabilitation, hospitals, military, young adult, and cognitive
therapy. See table 1 for detailed search terms used to find each study. The terms were entered
into the MeSH search engine within the PubMed database. The titles, abstracts and then the body
of the article was reviewed for relevance to the PICO question. Articles that were older than 5

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years were excluded as well as articles that did not include a primary study. The inclusion criteria
for the literature review included articles about TBI resulting from a combat injury, Veterans, and
TBI from OEF/OIF or the Iraq and Afghanistan wars. There were many research articles and
studies available, but the five selected were the most closely related to the overall goal and
purpose of this integrative review.
Findings and Results
The first step when dealing with combat Veterans is determining if they have a potential
TBI. This is done by screening military service members after they return stateside after a
deployment. In a study by Drake, et al., 7909 Marines completed a BTBIS that screens for TBI.
Of this group 1799 (23%) screened positive for an injury related to combat (multiple
mechanisms/causes, blast, vehicle, fall, fragment, and bullet) and 709 (39.0%) of those that
screened positive for an injury also experienced a change in mental status. Of those 709 service
members that had a positive TBI screening, 500 (70.5%) had been identified for the first time as
having a TBI because of the use of the screening tool (BTBIS). Meanwhile, 209 (29.5%) of those
had already been diagnosed with a TBI by routine medical screenings prior to the use of the
BTBIS (Drake, et al., 2010, p. 185-86). This study suggests that all military personnel returning
from deployment should receive a routine TBI screening to detect TBI. This study shows the
significance of a TBI screening, because a majority of the combat Veterans would have gone
undiagnosed if it was not for the BTBIS TBI screen.
Another thing to consider when screening combat Veterans with TBI is the criteria used
to determine whether or not the Veteran received a legitimate TBI. In a study by Xydakis, et al.,
563 service members were admitted to Walter Reed Army Medical Center as a trauma admission.
Of these trauma admissions 365 (64.8%) sustained an injury as a result of a blast/explosive, 102

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(18.1%) were injured due to a blunt mechanical mechanism, 15 (2.7%) were injured due to
penetrating intracranial brain mechanism either by firearm or blast, and 81 (14.4%) were injured
as a result of a penetrating extracranial mechanism by firearm/gunshot wound. Of those that
experienced a blast/explosive 198 (54.3%) tested positive for a TBI, 58 tested positive of those
that received an injury due to a blunt biomechanical mechanism, 15 (100%) of those that
received a penetrating intracranial brain injury (open head trauma) tested positive for TBI. To
diagnose TBI in a closed head injury, the authors examined the use of structural neuroimaging,
loss of consciousness, alteration in consciousness (dazed or confused), post-traumatic antegrade
amnesia, and the Glasgow coma scale. As a result of this study it was determined that just
screening using LOC as the primary diagnostic criteria did not yield a correct diagnosis of TBI.
An LOC can be caused by a neurophysiologic response to trauma (often severe trauma and/or
pain medications/sedation) or it may be a potential indicator for a possible neurologic injury
(Xydakis, et al., 2012, p. 675-79). When screening combat Veterans for TBI, LOC should not be
the only indicator required for a TBI diagnosis. Medical personnel and TBI screeners should also
take into effect neuroimaging, the type of injury and whether LOC is a consequence of the bodily
injury, like in a hemorrhaging patient in hypovolemic shock), LOC, amnesia, how long LOC
occurred, and the Glasgow Coma Scale score received. Screening for TBI is a complex process
that is necessary, but should not be based on a single criteria.
Combat Veterans diagnosed with TBI often have difficulty readjusting and reintegrating
to life in the community. The study by Daggett, Bakas, Buelow, Habermann, & Murray (2013)
discusses the needs and concerns of male combat Veterans as they return stateside after
deployment and receiving a TBI. The result of a telephone interview with 8 combat Veterans
determined that the things combat Veterans had difficulty with when returning to the U.S. was

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the cognitive impairments sustained from the TBI injury, the physical symptoms related to the
TBI and their other injuries, emotional and behavioral difficulties, instrumental activities of daily
living (IADLs), interpersonal interactions, and community reintegration (Daggett, et al., 2013).
Because of this study there have been treatments used for combat Veterans with TBI that address
these specific needs and concerns.
There are various treatments available for combat Veterans with TBI. One of the
available methods is PE therapy. In this study by Wolf, et al., ten male OEF/OIF male combat
Veterans with PTSD and current cognitive deficits received PE therapy from doctoral level
therapists. As a result, Veterans experienced a significant decrease in PTSD symptom severity
(90% experienced clinically significant change and no longer met criteria for PTSD treatment)
and experienced significant decrease in depression symptom severity (40% demonstrated
clinically significant reduction in depression). Of the ten Veterans, 100% [] demonstrated
reliable reduction in depression from pre- to posttreatment while 90% demonstrated a reliable
reduction in depression from pre- to post treatment (Wolf, Strom, Kehle, & Eftekhari, 2012, p.
29). This study shows the significance of PE treatment and symptom management in combat
Veterans with TBI. By reducing the negative symptoms of TBI, Veterans will be able to
reintegrate into the community more successfully.
Another treatment available for TBI is CogSMART. In a study completed by Twamley, et
al., 34 Veterans participated in this study. A total of 16 Veterans received supported employment
and CogSMART, while the other 18 Veterans received enhanced supported employment only.
Those that received CogSMART over 12 weeks had improved postconcussive symptoms (e.g.
sleep disturbance, fatigue, headaches, and tension) and [improved] cognition in [] prospective
memory, attention, learning and memory, and executive functioning (Twamley, Jak, Delis,

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Bondi, & Lohr, 2014, p. 69-70). Veterans considered the intervention very helpful and helped
them to obtain and keep employment due to the improved postconcussive symptoms and
prospective memory. Using CogSMART seems to help combat Veterans reintegrate into life in
the community and to decrease the TBI symptoms so that they are able to function normally.
CogSMART appears to be a very effective therapy for OEF/OIF Veterans with TBI.
Discussion and Implications
Research shows that identifying TBI in combat Veterans is important and often
overlooked. It is also crucial not to identify TBI based off of one particular criteria, LOC being
the main criteria discussed. LOC is not necessarily conclusive or diagnostic of a TBI. A Veteran
may have LOC for a variety of reasons including a physiologic response to severe bodily trauma
or medication administration, such as sedatives or pain medications with amnesic effects. Some
Veterans with LOC may indeed have a TBI, so LOC is still an important criteria to examine, but
it should not be the only criteria used to diagnose TBI. As far as combat related TBI, there are no
methods, from what has been suggested from the studies that are better at treating Veterans with
TBI. The best treatments for combat related TBI are those that help to alleviate the symptoms in
order to help the Veteran reintegrate into society. There are a variety of concerns that Veterans
with TBI express concern about, but treatments aimed at relieving the difficulty these concerns
cause. PE therapy and Cognitive therapy are intervention therapies that help Veterans maintain
and find relief from their TBI symptoms. The results of this integrative review are consistent
with other literature reviews. TBI is complex and there is still research that needs to be done
regarding combat related TBI, in particular, the reintegration of and effective treatment for
military personnel who have sustained a TBI as a result of combat.

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The implications for future TBI research are limitless. Most of the studies reviewed with
the exception of Routine TBI Screening Following Combat Deployments and Epidemiologic
Aspects of Traumatic Brain Injury in Acute Combat Casualties at a Major Military Medical
Center: A Cohort Study featured a small number of combat Veterans in the studies. In order to
have a more reliable result, the studies should be repeated with a larger number of Veterans.
There are few studies that have been reviewed in this integrative review that study both male and
female combat Veterans. These studies should be replicated with females in order to determine
the effectiveness of TBI treatment with female combat Veterans. Female Veterans may have
concerns that differ from their male counterparts concerns. The most common implication
written about in the articles is that the studies should be replicated in a larger trial.
Conclusion and Limitations
As a result of this literature review the importance and complexity of TBI among
OEF/OIF combat Veterans is not to be underestimated. TBI is complex and requires screenings
for all combat Veterans returning from deployment. Without screenings, TBI may go
undiagnosed in a majority of Veterans that otherwise would be diagnosed with TBI. The
screening criteria is very important for the diagnosis of TBI. Veterans who have sustained a
combat related TBI have many concerns regarding reintegration into the community, but there
are various intervention therapies such as PE therapy and CogSMART that have been proven
beneficial and highly regarded by the Veterans who have used them. The intervention therapies
are aimed at treating the symptoms in order to improve the daily lives of the OEF/OIF Veterans
with a TBI. Combat Veterans with TBI require complex screening and treatments in order to
return to a level where they are able to function and reintegrate into the community.

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There were several limitations to this literature review. More studies could have been
used in order to find more support for a particular screening tool or treatment. Studies with a
larger sample of Veterans would have been useful for this integrative review. Also including
female Veterans in the studies and including a variety of institutions versus 2 VA Medical
Centers in the Midwest would have created more diversity. This integrative review could have
benefitted by using more studies that were quantitative by design. There is room for
improvement, and there should be more research and review of the uniqueness of combat related
TBI, the screenings for TBI, the criteria for screening, and the treatments available for OEF/OIF
combat Veterans as the wars in Iraq and Afghanistan continue.

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References:
Daggett, V. S., Bakas, T., Buelow, J., Habermann, B., & Murray, L. L. (2013). Needs and
concerns of male combat veterans with mild traumatic brain injury. Journal of
Rehabilitation Research and Development. 50(3), 32740.
DOI: 10.1682/JRRD.2011.09.0168
Drake, A., Meyer, K., Cessante, L., Cheung, C., Cullen, M., McDonald, E., & Holland, M.
(2010). Routine tbi screening following combat deployments. Neuro
Rehabilitation, 26(1), 183-189. DOI: 10.3233/NRE-2010-0554
Twamley, E., Jak, A., Delis, D., Bondi, M., & Lohr, J. (2014). Cognitive symptom management
and rehabilitation therapy (cogsmart) for veterans with traumatic brain injury: Pilot
randomized control trial. Journal of Rehabilitation Research and Development, 51(1), 5970. DOI: 10.1682/JRRD.2013.01.0020
Wardlaw, J. (2010). Advice on how to write a systematic review. Retrieved from
http://www.bric.ed.ac.uk/documents/advice on how to write a systematic review.pdf
Wolf, G. K., Strom, T. Q., Kehle, S. M., & Eftekhari, A. (2012). A preliminary examination of
prolonged exposure therapy with iraq and afghanistan veterans with a diagnosis of
posttraumatic stress disorder and mild to moderate traumatic brain injury. The Journal of
Head Trauma Rehabilitation. 27(1), 2632.
DOI: 10.1097/HTR.0b013e31823cd01f
Xydakis, M., Ling, G., Mulligan, L., Olsen, C., & Dorlac, W. (2012). Epidemiologic aspects of
traumatic brain injury in acute combat casualties at a major military medical center: A
cohort study. Annals of Neurology, 72(5), 673-681. DOI: 10.1002/ana.23757