Cifu, David X. MD; Cohen, Sara I. MD; Lew, Henry L. MD, PhD; Jaffee, Michael MD; Sigford, Barbara MD, PhD
The essentials of rehabilitation therapies may be traced back nearly two millennium to the ancient Greeks and Romans, who used techniques such as massage, electrical currents, heat, and cold to relieve pain.1 Although deeply rooted in the past, the field of rehabilitation has experienced significant advancements in the past century due to injuries and disability resulting from large-scale wars and the concomitant advances in battlefield medicine that have dramatically increased survival rates. Traumatic brain injury (TBI) rehabilitation has historically lagged behind that of amputation and general orthopedic rehabilitation, but in the past decade, there has been a great expansion of TBI services provided to persons serving in the military.2,3 This literature review examines the influences of major wars on the development of TBI rehabilitation services over the past two centuries, from the Civil War to the present day conflicts in Iraq and Afghanistan, and provides a glimpse into the future of TBI rehabilitation.
Historical Evolution of TBI Rehabilitation in the Military
Before the 20th century, severe TBI was generally considered fatal.4,5 During the Civil War (1861–1865), gunshot wounds to the head were seen in large numbers, and although accurate statistics for mortality rates are not available for the 19th century, survival was known to be poor because of infection.4,6 However, despite the high mortality of TBI, a great deal was known about its pathophysiology. Epidural and subdural hematomas were well described, and a confederate surgeon named, John Chisolm, discussed the complexities of diffuse axonal injury.6
Because of the development of improved antiseptic techniques in the later 19th century and more effective neurosurgical techniques, the mortality of a head wound with dural penetration was 35% during World War I (1917–1918).4,5 Also contributing to the increased survival rate of soldiers with penetrating head wounds were the rifles themselves: muzzle velocity was faster, and bullets were smaller and more deformable.7 However, penetrating head wounds still occurred despite protection to the head afforded by the British “Brodie” helmet and the United States Marine Corps Doughboy helmet.7
The increased survival rate of individuals with TBI prompted the need for rehabilitation services. Some of the earliest TBI rehabilitation units were established in Germany, the best known of which were directed by Kurt Goldstein in Frankfurt and Walther Poppelreuter in Cologne.4 These rehabilitation units were based on providing coordinated services and community reentry in the form of vocational workshops.4 Early United States rehabilitation attempts were closely modeled after the German system. However, TBI rehabilitation in the United States lagged behind as a result of the country's late entry into World War I; the only hospital for TBI rehabilitation was the Hospital for Head Surgery in Cape May, NJ, which used three speech correction teachers and did significant work in aphasia.4 However, at that time, most patients with brain injury received, at best, custodial care.2
Unfortunately, by the start of World War II (1941–1945), most of these TBI rehabilitation centers, and general rehabilitation hospitals, had closed. Early in the course of World War II, TBI casualties received only physiotherapy for motor difficulties; patients with significant cognitive or behavioral impairments were sent to mental institutions.2 However, with the acute neurosurgical mortality from brain wounds having dropped to 10%–13%, there was once again a need for specialized TBI centers.8
In 1943, a speech disorder unit was established in affiliation with a neurosurgical center at Brooke General Hospital in Fort Sam Houston in San Antonio, TX, which included an interdisciplinary treatment regimen of physical therapy, physiotherapy, vocational therapy, and occupational therapy; there were 13 more such units by 1944–1945.4 A psychiatrist named, John Aita, established a postacute head injury rehabilitation program in a military general hospital that used the interdisciplinary system of care, in which patients were treated by a team of physical and occupational therapists, psychologists, vocational specialists, a social worker, a physician, and a case manager; the program also incorporated participation from relatives and therapeutic trials at home.9 Job therapy was established, which resulted in 60% of patients having enrolled in school or returned to work on follow-up. Once again, at the conclusion of the war, these rehabilitation programs were shut down.4
During the Korean War (1950–1953), the mortality from head injuries continued to decrease. Because of the efforts of Australian-born neurosurgeon Hugh Cairns, helmets had become mandatory.7 Furthermore, it was recognized that rapid relief of a hematoma was key to reducing mortality.10 Employment of mobile teams at the division level to evacuate hematomas resulted in a drop in the rate of meningiocerebral infections from 42% to <1% over the course of the Korean War.10 By the Vietnam War, it was established that 40% of combat fatalities were because of head and neck injuries, and 14% of those surviving had TBI.11,12 Moreover, survival of these soldiers was improved as a result of the establishment of air evacuation of the wounded.13 At the same time, an increased incidence of high-speed motor vehicle accidents propelled a more rapid development of rehabilitation for TBI in the private sector.14
Israel also made significant contributions in the area of TBI rehabilitation. It began providing continuity of treatment for brain injury following its 1967 and 1973 wars. Following the Lebanon War in 1982, it began reporting the advantages of early rehabilitation intervention for TBI.2 In the 1970s, acute head injury rehabilitation units such as the Loewenstein Rehabilitation Hospital near Tel Aviv and Rancho Los Amigos Hospital near Los Angeles were established in response to increased survival from motor vehicle accidents. The cognitive rehabilitation protocols at these facilities formed the basis of modern rehabilitation.4 It was between 1980 and 1990 that TBI rehabilitation was established as a subspecialty of rehabilitation medicine.15
During the Persian Gulf War (1991), brain injuries made up 17% of casualties.16 In 1992, there were many admissions for TBI in military medical centers.17 It was noted that the military population was at higher risk for TBI because of combat, with certain military occupations such as parachuting incurring an even greater risk.11 To address the need for TBI rehabilitation, in 1992 the Defense and Veterans Head Injury Program, later renamed the Defense and Veterans Brain Injury Center (DVBIC), was established as a collaboration between the Department of Defense (DOD), the Department of Veterans Affairs (VA), and civilian partners, with the goal to integrate specialized TBI care, research, and education across the military, veteran, and civilian medical care system.11,18
The DVBIC has established clinical standards and guidelines for TBI. The DVBIC's efforts have included the Military Acute Concussion Evaluation, an in-theater TBI screening tool, a toll-free TBI helpline, an integrated follow-up program, a standardized TBI core evaluation battery, and a standardized TBI screening instrument.18 The DVBIC also conducted the first large randomized trial of TBI rehabilitation.19 Over the past decade the DVBIC has had time to gain experience evaluating and treating various TBI populations and can now apply this knowledge to help the casualties of our current conflict.
A New Generation of Service Members with TBI and the Development of Innovative Rehabilitation Services
The War on Terror commenced in October of 2001 with Operation Enduring Freedom in Afghanistan followed by Operation Iraqi Freedom in May of 2003.20 Nearly two million military personnel have been deployed to Iraq or Afghanistan, and TBI has been labeled a “signature wound” of our current conflict (Fig. 1).21
The combat operations in Iraq and Afghanistan have resulted in a complex pattern of blast-related injuries from artillery, improvised explosive devices, mines, and rocket-propelled grenades.22 More than 60% of blast injuries result in a TBI.23 Injuries to the brain because of blasts can occur by primary blast wave-induced changes in atmospheric pressure, shrapnel or other fragments projected from the blast, or when the individual is thrown as a result of the explosion.24 There have been 2700 surviving casualties of these blasts with moderate to severe TBI, and it is estimated that up to 20% of deployed service members may have mild TBI from blast injury.22 For this reason, although initial rehabilitation treatment efforts were aimed at moderate to severe brain injury, the focus of rehabilitation efforts has shifted to include less severe cases with no radiologic evidence of brain injury as well.25 Blast-related mild TBI (mTBI) has been found to be associated with several common concurrent conditions, such as vestibular, auditory, visual, and communicative disorders, which have been an additional focus of research and novel treatment approaches.26,27
In response to the large number of returning service members presenting with TBI and complicated by multiple concomitant injuries, Congress allocated funding to provide state-of-the-art care and rehabilitation in the VA in 2005.28 Using this funding, the Polytrauma System of Care was developed. Polytrauma is defined as injury to two or more physical regions or organ systems that occur simultaneously, one or more being life threatening, and frequently includes TBI.29 The Polytrauma System of Care is designed to balance access with specialized expertise in TBI and comprises four components: Polytrauma Rehabilitation Centers; Polytrauma Network Sites; Polytrauma Support Clinic Teams; and Polytrauma Points of Contact. It incorporated the existing expertise of the preexisting VA Traumatic Brain Injury Lead Centers that had been providing brain injury rehabilitation services to veterans and the military since 1991.
The initial four Polytrauma Regional Centers were formally designated in February of 2005 at Veterans Administration Medical Centers in Minneapolis, MN; Palo Alto, CA; Richmond, VA; and Tampa, FL.29 A fifth polytrauma center is currently being established in San Antonio, TX.21 The Polytrauma Rehabilitation Centers are acute inpatient rehabilitation units CARF accredited for TBI care and specializing in the rehabilitation of the combat-injured patients with polytrauma and patients with TBI. They also provide residential community reentry services. The Polytrauma Network Sites were designated in December of 2005 to provide subacute inpatient rehabilitation and outpatient services for patients with polytrauma and TBI. They were designated to correspond with existing regional administrative units in VA, the Veterans Integrated Service Networks, and were given the additional responsibilities of serving organizational and developmental administrative responsibilities for their respective network. There are currently 22 Polytrauma Network Sites providing care to distinct geographical regions.29 The Polytrauma Support Clinic Teams are outpatient clinic teams dedicated to providing services to patients with polytrauma and TBI in their local catchment area. They provide the required follow-up care and case management as long as services are required, which may be for life. As demand grows, new Polytrauma Support Clinic Teams are developed, and there are currently ∼90. The Polytrauma Points of Contacts are individuals knowledgeable about polytrauma and TBI patient care and services who serve to direct the care of new referrals to the most appropriate source of care in the system. There is a Polytrauma Points of Contact at every Veterans Administration Medical Centers that does not serve as one of the other components.
In December 2006, the Veterans Health Administration (VHA) also developed a state-of-the-art Polytrauma Telehealth Network linking VA rehabilitation facilities, resulting in expedited access to care, improved clinical communication, and elimination of unnecessary travel for severely wounded veterans and their families.30
In addition to providing specialized rehabilitation care, the Polytrauma System of Care also developed a cadre of services aimed at easing the transitions from military to civilian life. Rehabilitation units were redesigned to promote recognition of the service member's active duty role and commitment, special active duty military liaisons were deployed to Veterans Administration Medical Centers where care was being provided, Veterans Administration Medical Centers Social Workers and Rehabilitation Nurses were assigned to the Military Treatment Facilities providing the initial trauma care, special Internet access was provided so that service members could stay in touch with their military comrades, housing for families was provided, and special attention to transitions for the injured service member and their families was made. Each Service Member was assigned a case manager. These supportive services were a new innovation unique to these conflicts. In addition, the development of an organized and integrated system of care allowed broad application of knowledge and best practices to individuals entering the system at any point of care.
As noted above, in addition to Service Members sustaining moderate to severe TBI, many were returning with mTBI. Some of these individuals were never diagnosed at the time of injury. VHA initiated mandatory screening of all OEF/OIF veterans for TBI in April 2007. If the veteran screened positive for a possible TBI and was still experiencing symptoms, that veteran was then required to be referred to the most appropriate clinical setting in the Polytrauma System of Care, if they consented. In this setting, the veteran receives a comprehensive TBI evaluation that includes a detailed history of the injury, a comprehensive physical assessment, and a 22-item postconcussive symptom questionnaire called the Neurobehavioral Symptom Inventory-22, which helps to direct the plan of care.31 The clinics follow the interdisciplinary model and include a physiatrist, a neuropsychologist, a social worker, an occupational therapist, a physical therapist, and a speech language pathologist.28 In this population of patients with polytrauma, treatment is aimed at common postconcussive symptoms, such as headache, cognitive problems, and sleep disturbances.25 A written interdisciplinary plan of care is required for all these veterans, and each is assigned a case manager. In addition, results of the TBI screen and comprehensive evaluation are entered into the medical record electronically via a specific template that allows standardized recording and later evaluation of additional needs, outcomes, and provision of services at both the individual and system level.
VHA has also funded numerous research initiatives to better understand care and treatment of polytrauma and TBI. Among these is a specialized funding stream named Quality Enhancement Research Initiative. Quality Enhancement Research Initiative programs are dedicated to implementing best practices across the VHA system. The VHA has funded a Polytrauma/Blast-Related Injuries Quality Enhancement Research Initiative reflecting the considerable dedication of VHA to understanding and providing effective care to this population of veterans.
Pain in the polytrauma population is currently an area of expanding research and development. Persistent pain has been identified in 42%–81% of the noninjured military personnel and is nearly universal in polytrauma patients.32 In patients with mTBI, pain was the second most commonly reported impairment after cognitive deficits.32 In a review of patients treated at the Tampa Polytrauma Rehabilitation Center, 96% of soldiers had at least one pain problem, 70% of those at more than one site.20 These pain issues have been addressed with medication, physical and occupational therapy, and to a lesser extent, by use of interventional procedures.20
Psychiatric disorders such as posttraumatic stress disorder are also often seen comorbidly with TBI in soldiers. In the RAND study of post-Iraqi military deployment, more than one-third of solders with mTBI were also diagnosed with posttraumatic stress disorder or depression.33 Hoge et al.34 reported a prevalence of 43.9% for posttraumatic stress disorder in soldiers with a history of loss of consciousness during deployment. Posttraumatic seizures are also seen in TBI, ranging in prevalence from 0.7% in patients with mTBI to 10% in severe TBI, prompting the recent creation of the VA Epilepsy Centers of Excellence.35 In response to the host of common issues including pain, epilepsy, and posttraumatic stress disorder that are unique to the polytrauma population, the VA is funding polytrauma fellowship programs with the objective to enhance the skills of clinicians who wish to serve this expanding population of veterans.22
Innovative Research and the Future of TBI
With ∼30,000 service members having sustained nonfatal injuries during Operation Iraqi Freedom and Operation Enduring Freedom as of July of 2007, the Department of Defense has provided $150 million in funding for research in TBI.21 The United States Congress has approved the Traumatic Brain Injury Reauthorization Bill that expands funding to research at the National Institute of Health, in addition to expanding a range of TBI rehabilitation programs.36 There are currently several ongoing research efforts that have potential to benefit veterans with new TBI.
One area of research is in biomarkers, which can be used to define the extent and type of injury and to direct therapy.37 The University of Florida has identified alpha-II spectrin and survivin as biomarkers of brain injury and are working to develop a palm-sized instrument using these biomarkers to detect axonal debris in the blood, which may be used in the field to determine the extent of brain injury only 2–4 hrs after the injury has occurred.25 Oh et al.38 identified the serum S100 biomarker, which was successfully used to identify patients with CT or MRI positive brain injury. The S100 biomarker and serum neuron-specific enolase and myelin protein concentrations have also been found to be biomarkers of TBI by Berger et al.39 Biomarkers have potential to serve as a prognostic indicator; in a recent trial by Darwish et al.,40 poor neurologic outcome has been associated with increased levels of nitrotyrosine in the cerebrospinal fluid.
Little is known about the exact neurological consequences of blast injury, which has sparked the need for innovative research aimed specifically at understanding the mechanism, sequelae, and treatments of blast injuries.11 Chen et al.41 has developed an in vitro TBI model that may be used to study the effects of a blast injury at the molecular and cellular level. Cernak et al.42 has examined the effects of blast-induced neurotrauma on memory deficits in rats and identified that rats with blast injuries had impaired performance on active avoidance tasks for 5 days after injury. Long et al.43 simulated blast injuries in rats to assess the effects of the resultant brain injury on acute cardiovascular homeostasis mechanisms and neurobehavioral functions and to evaluate the protection provided by the Kevlar vest.
The DVBIC is also sponsoring trials aimed at improving the pharmacological treatment of TBI. The most recent of these trials is a randomized study of methylphenidate and its effects of rehabilitation in patients with moderate-to-severe TBI.11 Other agents such as amphetamines and cholinesterase inhibitors have also shown promise as neurostimulants in TBI, but further studies are required.44 Research is also being conducted to assess rehabilitation interventions for patients with TBI. The loss of driving skills is associated with disability and is a major obstacle to rehabilitation; therefore, recent studies have used a modern driving simulator that approximates real-life activity.45 The driving simulator tests the visual-motor speed and accuracy, vigilance, sustained attention, safety, and judgment, and it can be used for both assessment and treatment of patients with driving deficits.
There is also research being done in hopes of improving the inpatient rehabilitation process. A recent study by DVBIC.46 conducted in four Veterans Administration acute inpatient TBI rehabilitation programs compared cognitive-didactic and functional-experimental treatments. Although there were no differences between the groups in the broad 1-yr outcome, the cognitive arm seemed to have greater benefit to younger patients, and the functional arm was more beneficial to the older patients. The results of studies examining various rehabilitation approaches may be used to better direct treatment of newly brain-injured patients.
Advances in the field of Physical Medicine and Rehabilitation have consistently been spurred by military activity. The development of brain injury services for veterans has evolved since the time of the Civil War to our present day conflict, in response to the needs of the casualties of war. Because of the circumstances that result in the war-related injuries such as blasts and violent trauma, patients with TBI often have comorbidities such as chronic pain, sensory deficits (auditory, vestibular, visual, and communicative), in addition to the more obvious cognitive impairments and emotional difficulties. Thus, they will require multidisciplinary, long-term follow-up and care, to ensure the best possible outcome.
The ultimate goal for TBI rehabilitation is community and vocational re-integration. To achieve this goal, there needs to be a concerted effort from clinicians and researchers, to provide evidence-based practice for this generation of veterans with TBI. The federal government is continuing to provide funding to improve clinical care and services for this new cohort of veterans. Important efforts have also begun in the VA, NIH, DVBIC, Department of Defense, and Congressionally Directed Medical Research Program to fund research projects in this area, with the hope that the results will inform clinicians and administrators in improving the diagnosis and functional outcome of patients with TBI and its comorbidities.
We acknowledge Dr. Tammy Crowder, Dr. Alex Ommaya, Dr. Sean Monion, Ms. Lisa Martin, and Dr. Terri Pogoda for their assistance.
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