Page 65 - Journal of Special Operations Medicine - Summer 2015

posttraumatic stress disorder [PTSD]), dehydration, sleep charges or flash bangs within the confines of a closed
deprivation, or poor nutritional state. 5–8 The majority of building in a single day while conducting close quarters
combat-related TBI is blast related, and although sports combat training. It is also not uncommon to be exposed
concussion literature suggests that most blunt-trauma multiple times throughout a given year to the overpres-
closed head injuries recover days to weeks after injury, sure of antitank/antiarmor weapons and crew-served in-
recovery from blast-related mTBI is less predictable due direct fire weapons. This can be compounded by many
to increased presence of comorbidities and, therefore, is years of service in combat soldiery. Many times, Sol-
less understood. 9–12 Furthermore, while in garrison, the diers return home from training with sensory instabil-
majority of head injuries (80%) occur during noncombat ity, disorientation, complaints of a headache, or feeling
time, such as training or off-duty activity. Prevalence is “fuzzy” or fatigued mentally. These are common symp-
higher than in the civilian population—so high, in fact, toms of concussion or mTBI, along with deleterious
women in the military have prevalence rates on par with effects on vision and visual sensory cognitive process-
their civilian male counterparts. Given the morbidity ing. 10,17,21–30 With so many subclinical insults over a long
and persistent sequelae associated with mTBI sustained period of time, many of our Soldiers may not be able to
in theater and the high rate of injury in noncombat set- function optimally but still be relatively asymptomatic
tings, this is likely to remain a serious, persistent, and and function in a seemingly normal manner. When opti-
challenging military health problem for some time. 3,8,12 mum performance is required, subclinical abnormalities
may cause the individual to perform suboptimally. 4,31–34
Further complicating the issue is that some subpopu-
lation groups, particularly Special Operations Forces Current Guidelines and Lines of Effort in Research
(SOF), are routinely exposed to hundreds of subclinical
blast overpressures and direct impacts to the head during The US Government and the Department of Defense
training. These can result from door charges, concussive (DoD) have a vested interest in maximizing perfor-
grenades, large-caliber-weapon muzzle overpressure, mance to allow improved function and quality of life,
mortar training, antitank weaponry, artillery, and com- and to return Soldiers to active duty. From a financial
batives training. Soldiers may complain of chronic symp- standpoint, there is a strong desire to minimize the
toms consistent with mTBI. This begs the question, is long-term healthcare costs associated with combat- and
subclinical exposure truly subclinical? This combination training-related injuries. In response to the enormity of
of combat- and training-related exposures puts troops this problem, on 31 August 2012, President Obama en-
at risk for sustaining more than one mTBI in a short acted Executive Order 13625, Improving Health Care
time. 5,13,14 Although some studies have reported that sin- for Veterans, Service Members, and Military Families
gle mTBIs often self-resolve in 7 days to 1 month with Affected by TBI. Under Section 5 of the Order (Im-
35
proper management, there is an increasing body of re- proved Research and Development), the DoD and the
search demonstrating the likelihood of serious long-term Departments of Veterans Affairs, Health and Human
sequelae associated with cumulative effects of multiple Services, and Education, in coordination with the Of-
mTBIs in athletes. 13–18 Though signs and symptoms of fice of Science and Technology Policy, are directed to
mild concussion usually resolve within a week if prop- establish a National Research Action Plan to improve
erly managed, neurocognitive processing may be affected the coordination of agency research of TBI, PTSD, and
for up to 1 month despite proper management. 19,20 other mental health conditions, to reduce the number
of affected men and women through better prevention,
Among people with mTBI, a proportion will experi- diagnosis, and treatment.
ence longer-term postconcussive symptoms. The longer
lasting the symptoms after insult and the more times The continuum of care for TBI determines the research
concussed, the more persistent the postconcussive symp- approach. Therefore, action plan research priorities are
toms. 13,14,16,18–20 Within the military, this scenario occurs enumerated as follows: (1) basic science and epidemi-
most often in the combat arms occupational specialties, ology; (2) TBI/concussion prevention, education, and
particularly in the SOF. training; (3) possible concussive event via impact or
blast; (4) TBI/concussion screening (DoD guidelines);
Of great concern within SOF is that not only have sig- (5) TBI/concussion assessment; (6) TBI/concussion treat-
nificant numbers of personnel been exposed to blast and ment; (7) TBI/concussion recovery; (8) return to duty
injury, there is a subpopulation that has been exposed (RTD); and (9) identify, monitor for, and treat chronic
to blast and impact injuries but has never reported for effects (Figure 1). 6
care who, at some level, remains impaired. Many SOF
personnel are exposed to repeated blast overpressure on Just as the development of Special Operations Human
mission and while conducting training. It is not uncom- Performance Programs are emulating the sports perfor-
mon for SOF to be exposed to 10 or more breaching mance/sports medical team model, sports concussion

Postconcussion Visual Sensory Screening, Diagnostics, and Training for SOF 55