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Traumatic Brain Injury (TBI) has been termed the "signature injury" of the recent Middle East conflicts. However, the defining condition of combat-exposed
service members and Veterans is better captured by the term "polytrauma," which is defined as two or more injuries to organ systems or parts of the body
that create potentially life-threatening injuries and/or disruption to physical, mental, and psychological functioning.
Studies have identified TBI, post-traumatic stress disorder (PTSD), and pain as the major comorbid elements most frequently seen in polytrauma injury. 1 Investigators have noted that, among Operations Enduring Freedom (OEF: Afghanistan through August 2010), Iraqi Freedom (OIF: Iraq through August 2010),
and New Dawn (OND: Afghanistan, Iraq, and surrounding regions since September 2010) service members treated at an
inpatient VA polytrauma rehabilitation unit, 80 to 93 percent were diagnosed with TBI, 81 to 96 percent with pain, and 44 to 52.6 percent with a mental health
disorder.2 And OEF/OIF/OND Service members and Veterans treated for combat-related injuries in VA outpatient
polytrauma programs were diagnosed with three or more post-concussive symptoms 67 to 97 percent of the time, complained of persistent pain 82 to 97 percent
of the time, and were diagnosed with PTSD 68 to 71 percent of the time. A number of other potentially disabling concomitant conditions—including depression
and substance abuse—can also accompany TBI and add to the complexity of diagnosis and management. Approximately half of all returning OEF/OIF/OND Veterans
who sought care from VA presented with one or more of these diagnoses; interestingly, more than 90 percent of those with confirmed TBI also have PTSD,
pain, or both diagnoses.3
As with any health condition that has several sources of pathology, layers of physiologic and psychologic underpinnings, and a complex symptomatology, the
key to successful understanding and management involves a uniform, interdisciplinary, comprehensive team approach. This approach is well exemplified by the
integrated post-deployment care that characterizes VA's Post-Deployment Integrated Care Initiative (PDICI)—an initiative grounded in the basic tenets of
the PACT (Patient Aligned Care Team) model. Drs. Hunt and Burgo-Black eloquently outline the evolution of these approaches in their commentary "A
Transformation in VA Post-Deployment Care."
While it is important to recognize that individuals with significant persistent polytrauma symptoms (or "post-deployment syndrome") may continue to
experience difficulties even in the best of circumstances, they are likely to benefit from the integrated services of the PDICI/PACT approach. Often, there
is no simple or quick solution to the complex conditions that may be seen with polytrauma, let alone the magnification and uniqueness of the symptoms and
functional deficits that Veterans may experience with two or more conditions. An established team of dedicated professionals with both primary care and
specialty care expertise is the most effective approach. Such a team understands the subtleties of diagnoses and care for post-deployment syndrome and can
develop a long-term relationship with Veterans. VA's highly developed mental health services, polytrauma system of care, and pain management services
provide the specialty expertise required for particularly challenging or atypical cases.
Ongoing research may provide some insights into: (1) the specifics of the initial injury or exposure (e.g., blast) on treatment selection or outcome; (2)
technological advances that will enhance diagnostic accuracy; (3) smart or designer pharmaceuticals that can target specific sites in the brain, spinal
cord, or peripheral nervous system to provide symptom relief or enhance recovery; and (4) the relative advantages of specific therapies (e.g., exercise,
cognitive, behavioral) for variants of polytrauma. For the time being, we are fortunate to have an established system of care in the Veterans Health
Administration (VHA) that addresses the difficulties of Veterans who have returned from combat with complex physical, cognitive, and behavioral dysfunction
in a comprehensive and compassionate way. In addition, the intense research focus by the military, VA, the sports world, and academia on the chronic
effects of TBI and the potential for neurodegenerative decline many years after single or multiple TBIs may yield specific diagnostic or management
More likely than not, any advances in research will reaffirm the value of the PDICI/PACT model of care as outlined in Hunt and Burgo-Black's commentary,
which describes strategies that Veteran-centric teams can use to complement their existing assessment and management tools. The increasing adoption of this
interdisciplinary model of health care to diagnose and manage complex conditions is pivotal to VHA's ongoing success in the 21st century.
Lew, H.L. et al. "Prevalence of Chronic Pain, Posttraumatic Stress Disorder, and Persistent Postconcussive Symptoms in OIF/OEF Veterans: Polytrauma
Clinical Triad," Journal of Rehabilitation Research and Development 2009; 46(6):697-702.
- Sayer, N.A. et al. "Rehabilitation Needs of Combat-Injured Service Members Admitted to the VA Polytrauma Rehabilitation Centers: The Role of PM&R in
the Care of the Wounded Warrior,"
PM&R 2009; 1(1):23-8.
Cifu, D.X. et al. "TBI, PTSD and Pain Diagnoses in Iraq and Afghanistan Conflict Veterans,"
Journal of Rehabilitation Research and Development, 2013 (in press).