Blast traumatic brain injuries and sub-concussive blast injuries in the military
I am grateful that an issue I have both presented on and observed was yesterday given national media recognition via ABC news coverage
As I have shared on this website, I am a returned servicewoman myself. Even though my military service was a few formative years, one legacy is my desire to provide the very best of assessment and treatment I can to currently serving and ex-service men and women. There is a saying: when you join the military you write a ‘blank cheque’ to the country, which includes anything up to giving your life. Some make the ultimate sacrifice. Heartbreakingly a number are lost in the aftermath of what they were asked to do, what they did, what they saw, and what they heard. Mental health conditions are experienced, lived with and endured. Physical injuries happen and accumulate. Pain gives you so many less resources to deal with each day. Attempts to cope can involve substances, just so you can try and keep yourself going. Marriages are strained and fail (there are at least two different military sayings about marriage failure being the norm that I know of). Injuries to brains happen either directly via trauma or substance abuse.
For years now, there have been research papers indicating exposure to blasts can cause permanent and observable changes in brain tissue, resulting in cognitive changes. The severity of this can be categorised as mild, moderate, or severe. Blasts can be IED’s (improvised explosive devices or home-made bombs), artillery or anything with an explosive change. Explosive charges are routinely used in training and in particular, the use of explosives in gaining entry to buildings (“breacher training”) is routine training for some military and police branches. I’m so glad that what hit the media yesterday was what is called sub-concussive blast injury, another form of Mild Traumatic Brain Injury (mTBI for short). Sub-concussive means in isolation, one blast isn’t enough to cause a concussion. But with each blast, cumulatively, overtime, it adds up and can have a deleterious affect on the brain. Now don’t forget the brain controls everything so the symptoms can be seemingly widespread including personality changes, changes with emotional regulation and mental health issues, and cognitive changes such as attentional difficulties (Martindale, Ord & Rowland, 2020), reduced speed of information process, working memory, executive functioning and memory difficulties (Grande et al, 2018).
There was an article published in the prestigious journal Lancet Neurology in 2013 by Emeritus Professor Jeffrey Rosenfeld and colleagues. 11 years ago they published an article titled “Blast Related Traumatic Brain Injury” in which they outline 16 different mechanisms by which brain tissue could be damaged by a blast exposure based upon animal research. I will point out that this research was to do with bigger IED explosions not sub-concussive blasts. And yes, we do have other research outlining the potential effect of repetitive exposure to low-level sub-concussive blasts, particularly in relation to “Breacher” training where explosive charges are used to gain rapid access to buildings (Bonnette et al, 2018; Carr et al, 2016; Thiel, Dretsch & Ahroon, 2015).
By this stage I hope we all agree that current and ex-serving members need neuropsychological assessments as part of their healthcare so we can:
- adequately characterise cognitive strengths and weaknesses,
- inform ongoing support needs,
- modify therapeutic approaches to maximise treatment effectiveness
- assist in return to work suitability/planning
- identify whether and remediation and/or compensatory strategies need to be used.
- even assess for capacity in the event of cognitive impairments significant enough to impact a persons ability to make personal decisions for themselves (guardianship), their finances (administration), or ability to instruct a lawyer for example.
Okay, if you are still reading you are totally onboard with this idea (hopefully). The great news is currently serving members can be referred via the Garrison Health system and there is a choice of providers in metropolitan Perth. DVA does have funding for Clinical Neuropsychologists who have specially registered with DVA to provide assessments. I’m happy to walk with you.
References (look I can still do APA style!)
Bonnette, S., Diekfuss, J.A., Kiefer, A.W., Riley, M.A., Barber Foss, K.D., Thomas, S., et al. (2018). A jugular vein compression collar prevents alterations of endogenous electrocortical dynamics following blast exposure during special weapons and tactical breacher training. Experimental Brain Research, 236, 2691-2701.
Carr, W., Stone, J.R., Waliko, T., Young, L.A., Snook, T.L., Paggi, M.E., et al. (2016). Repeated low-level blast exposure: A descriptive human subjects study. Military Medicine, 181, 28-39.
Grande, L.J., Robinson, M.E., Radigan, L.J., Levin, L.K., Fortier, C.B., Milberg, W.P., et al. (2018). Verbal memory deficits in OEF/OIF/OND veterans exposed to blasts at close range. Journal of the International Neuropsychological Society, 24, 466-475.
Martindale, S.L., Ord, A.S., & Rowland, J.A. (2020). Influence of blast exposure on cognitive functioning in combat veterans. Neuropsychology, 34(7), 735-743.
Rosenfeld, J.V., McFarlane, A.C., Bragge, P., Armonda, R.A., Grimes, J.B. & Ling, G.S. (2013). Blast-related traumatic brain injury. The Lancet Neurology, 12, 882-893.
Thiel, K.J., Dretsch, M.N., & Ahroon, W.A. (2016). The effects of low-level repetitive blasts on neuropsychological functioning (USAARL Report No. 2016-06). Retrieved from https://www.usaarl.army.mil/TechReports/2016-06.