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The U.S. Service members returning from war zones in Iraq and Afghanistan include many who have experienced concussive events on and off the battlefield. Since these conflicts began, we have learned much about the signature war wound of traumatic brain injury (TBI). Widespread military screening for TBI, and in particular mild TBI (mTBI), began in 2006. This screening has increased the awareness and identification of mTBI, also known as concussion. This is important because mTBI does not produce external signs.
Between 2000 and 2012, 244,217 head injuries were recorded by the Armed Forces Health Surveillance Center.1 Seventy-six percent of these were mild head injuries, 16% were moderate head injuries, and 1% to 2% were severe and penetrating head injuries.1
The ability to identify and treat service members at the time of injury has evolved to the point that concussion care clinics are operating in Afghanistan. Unfortunately, many service members were injured in prior deployments and still experience symptoms. Some have never been evaluated or treated.
Identification Challenges
Several issues can delay the identification and treatment of head injury. Service members may be deployed multiple times, sometimes with only brief intervals between deployments.2 Service members may have a permanent change of station to a new unit soon after they complete deployment, interrupting the potential for continuity of care. This change of station may include moving family and re-establishing home, school and work responsibilities. Such relocations can curtail time for appointments and delay diagnosis and treatment.
Some soldiers deny or minimize symptoms during the postdeployment screening process.3 To help identify deployment-related injuries, screening for concussive events is now a routine part of the reintegration process. However, service members are aware that a report of medical issues may delay their ability to have time with their families. When they do acknowledge symptoms, soldiers may minimize them to bypass lengthy evaluations and return home quicker.3
The core values of service members may also come into play.3 The mindset of the typical service member is one of discipline and self-sacrifice. This mentality may negatively affect his or her ability to acknowledge injury and receive care.3
Stressors to Consider
The nature of our recent military conflicts adds to stress levels experienced by service members. Today's soldiers contend with improvised explosive devices, roadside bombs, suicide bombers, the handling of human remains, the killing of an enemy, seeing fellow soldiers and friends dead or injured, and the helplessness of being unable to stop violent situations.4 Upon returning home, the service member may cope with these past stressors by using alcohol and or drugs,5 which can further impair sleep disturbances, cognitive function and mood issues. In addition, the service member may have a persistent heightened level of awareness (fight or flight) even after leaving the war front. This combat stress reaction is a normal response to an abnormal environment and is necessary while in a war zone. However, persistent combat stress can lead to post-traumatic stress disorder (PTSD).6
Common Symptoms
The most common postconcussive symptoms in service members are headaches (tension and migraine), sleep disturbances, memory difficulties and mood difficulties.7,8 These symptoms are not unique to a postconcussive event. They are commonly reported in patients without a history of a head injury,9 in patients with anxiety or depression9 and in patients with chronic pain.11
The incidence of PTSD may be as high as 26% in returning troops.12 Service members who sustain combat-related trauma often develop an overlap of postconcussive symptoms with post-traumatic stress disorder.13 This overlap makes it difficult to discern whether the symptoms are from the concussion or the co-occurring PTSD.13,14
Cognition issues such as short-term recall and poor concentration are common in concussion but are not exclusive to it. Poor sleep, chronic pain and emotional or mood issues (including depression, anxiety and PTSD) can all increase cognitive complaints.15 Identifying and treating the underlying symptom may reduce cognitive complaints. Additional symptoms of chronic pain (often back or headache) increase the likelihood of persistent symptoms.14 Poor sleep due to nightmares may be responsible for prolonged postconcussive symptoms.16 Sleep impairment can increase headaches and light sensitivity, decrease cognition and increase emotional issues.15
Guidelines
The Department of Veterans Affairs and the Department of Defense (VA/DoD) developed a clinical practice guideline for the management of concussion in service members.15 Berrigan et al compared this document with 23 other concussion guidelines and concluded that it was one of just three to be strongly recommended.17 The VA/DoD guideline is the only one to include multiple recommendations about concussion patients who had persistent symptoms.17 This document was developed specifically for the military population and should be utilized by providers who treat veterans who have experienced combat-related injuries.
According to the VA/DoD clinical practice guideline, if the service member has had exposure to a known concussive event in the past 
and has never been evaluated or treated, the initial work-up should be the same as the work-up recommended for a patient with a recent concussion. This includes evaluating for onset and duration of symptoms, impact of the symptoms on ability to function, treatments attempted, physical examination, education about expected recovery and symptom management, addressing psychosocial issues, and assigning a case manager, if needed. If the patient does not experience symptom improvement after 6 weeks, the guideline recommends the strategies discussed in the sections below.
Nonspecific Complaints
When a patient's symptoms seem nonspecific and subjective, the treating provider should not try to attribute the symptoms to a past event.15 Even after careful review of the possible differential diagnoses, attributing cause to an event is a great challenge. The work-up and treatment should focus on the current symptoms and a return to the highest possible level of functioning. If the symptoms develop more than 30 days after the concussion, the work-up should be focused on those symptoms only. It is not likely that the symptoms are a result of the concussion. Improving the identified problem should be the focus of the intervention.
Influencing Factors
Several factors can adversely influence the healing process after concussion. These include age 40 or older,18 psychiatric conditions, chronic pain, substance overuse or abuse, secondary gain, unemployment and lack of social support systems.15
Population
Estimates of the percentage of people with ongoing postconcussive symptoms vary depending on the population and the study, but it falls somewhere between 5% and 30%.19,20 Treatment approaches to persistent postconcussive symptoms depend on the type and number of symptoms.
Headache
If a patient is experiencing a single symptom, such as post-traumatic headaches, referral to a specialist is not necessary if the primary care provider is comfortable treating the symptom. Post-traumatic headaches occur in up to 90% of patients who experience concussion.21
A review of multiple studies found that chronic post-traumatic headaches occur in 58% of patients who sustain concussion and can last for years.22 Treatment of these headaches depends on physical examination findings and characteristics of the headache. In general, after the initial concussive event, headaches should be treated according to their presentation. An article by Theeler and Erickson presents a helpful guide.23
Cognitive Complaints
According to the VA/DoD guideline, if the patient's complaint involves cognitive dysfunction, a neuropsychological assessment conducted by a trained evaluator with reliable and standardized tools can assist in clarifying treatment options. Neuropsychological/neurocognitive testing is the most reliable way to document and quantify cognitive impairments after head injury. Referral for cognitive rehabilitation may be beneficial.
Behavioral Symptoms
Referrals to behavioral health specialists should be considered for the patient who experiences persistent behavioral symptoms, increased severity of pre-existing psychiatric disorders, decreased functioning, increased stress, PTSD, or inadequate coping skills.15
Assessments
Certain assessments are recommended for service members who do not improve within 4 to 6 weeks of treatment initiation (Table 1). These assessments should examine functioning at home, work and/or school as well as functioning in family relationships.15
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Concussions do not occur in isolation. The service member may have been coping with current life stressors, but the head injury itself has caused increased stress. In addition, head injury may cause difficulties in the ability of the service member to cope with life situations.
It is also important to assess for risk factors that may contribute to prolonged symptoms. These risk factors include those that are pre-existing, those that occur at the time of the injury, and those that occur afterward. Preexisting conditions include older age, low socioeconomic status, less education, and pre-existing neurologic or mental health disorders. Risk factors that may be pre-existing, or that occur at the time of injury or afterward, include substance abuse, lack of support and legal compensation.15 Reassessing the patient's personal habits - sleep hygiene, dietary intake, exercise habits and use of medication, caffeine, alcohol and tobacco - can be valuable. The reassessment of personal habits is helpful in directing strategies the patient can incorporate to help himself or herself.15
Screening Tools
Several screening tools may assist primary care providers (Table 2).
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Neuroendocrine Dysfunction
Radiologic studies such as magnetic resonance imaging or single-photon emission computed tomography may be considered on a case-by-case basis; details are beyond the scope of this article. For primary care providers, additional laboratory tests may be helpful in determining underlying issues complicating the resolution of symptoms.
New guidelines on neuroendocrine dysfunction (NED) were released in August 2012 by the Defense Centers of Excellence. NED can occur as a result of trauma to the underlying structures in the brain. The anterior pituitary gland is the most susceptible area. The disorder can mimic symptoms of mTBI or PTSD, producing sleep disturbances, fatigue, memory and concentration issues, and emotional or mood disturbances.
If a patient experiences the above symptoms for more than 3 months or has a new onset of these symptoms up to 36 months after a concussion, he or she would benefit from NED screening (Table 3). This screening consists of blood work focused on gonadotropin, adrenocorticotropic and thyroid deficiencies. If deficiencies are identified, a referral to endocrinology is appropriate.24 NED screening can lead to prompt treatment, which can improve recovery and rehabilitation efforts.
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Multiple Symptoms
A patient who experiences multiple symptoms and does not show any improvement 4 to 6 weeks after the concussion, or seems to be getting worse, requires a more intense evaluation by a specialist or specialty clinic.14 This is also necessary for a patient with an atypical symptom pattern or anyone who has difficulty returning to pre-injury activities or readjusting to home or social life.
Appropriate specialists include providers in neurology, occupational therapy, recreational therapy, social work, optometry or ophthalmology, audiology, behavioral health, and nursing case management. Case management is essential if the patient is to be evaluated and treated by multiple specialists. The patient will most likely have numerous appointments and may have trouble keeping track. Even after referral, the primary care provider should stay involved throughout the rehabilitation process.
Postconcussion Syndrome
When trying to accurately code a patient's symptom, it can be tempting to put everything under one code, such as postconcussion syndrome. Providers have to be careful in making sure the postconcussive patient actually fits the criteria for postconcussion syndrome. A patient may have a combination of symptoms that seem to fit this syndrome, but the symptoms may be caused by another diagnosis.
To meet diagnostic criteria for postconcussion syndrome, the patient must have ongoing memory issues confirmed by neurobehavioral testing. The patient must also exhibit cognitive deficits lasting 3 months or longer, and at least three additional symptoms that began or were worsened by the concussive event.25
Clearing the Confusion
The postconcussive patient can be confusing at first glance. Often a provider must spend extra time interviewing, using an approach similar to peeling back the layers of an onion. Open-ended questions are most effective. When developing a treatment plan, address the most disabling symptoms first. The overall goal is to improve or return the patient to his or her previous functional ability.
References
1. Defense and Veterans Brain Injury Center. DoD Worldwide Numbers for TBI. http://www.dvbic.org/dod-worldwide-numbers-tbi
2. Hosek J, et al. How deployments affect service members. Santa Monica, CA: Rand Corp, MG-432-RC; 2006. http://www.rand/org/pubs/monographs/MG432/
3. Rigg JL, Mooney SR. Concussions and the military: issues specific to service members. PM R. 2011;3(10 Suppl 2):S380-S386.
4. Engel AG, Aquilino CA. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med. 2004;351(17):1798-1800.
5. Armstrong K, et al. Reactions to war. In: Courage After Fire. Coping Strategies for Troops Returning from Iraq and Afghanistan and Their Families. Berkeley CA: Ulysses Press; 2006: 25-26.
6. U.S. Department of Veterans Affairs. What is posttraumatic stress disorder? http://www.ptsd.va.gov/public/pages/what-is-ptsd.asp
7. Hoge CW, et al. Mild traumatic brain injury in the U.S. soldiers returning from Iraq. N Engl J Med. 2008;358(5):453-463.
8. Brenner LA, et al. Traumatic brain injury, posttraumatic stress disorder, and post concussive symptom reporting among troops returning from Iraq. J Head Trauma Rehabil. 2010;25(5):307-312.
9. Iverson GI, Lang RT. Examination of "postconcussion-like" symptoms in a healthy sample. Appl Neuropsychol. 2003;10(3):137-144.
10. Trahan DE, et al. Relationships among postconcussional-type symptoms, depression, and anxiety in neurologically normal young adults and victims of mild traumatic Brian injury. Arch Clin Neuropsychol. 2001;16(5):435-445.
11. Lange RT, et al. Comparability of neuropsychological test profile in patients with chronic substance abuse and mild traumatic brain injury. Clin Neuropsychol. 2008;22(2):209-227.
12. Tanielian T, Jaycox LH, eds. Invisible Wounds of War: Psychological and Cognitive injuries, Their Consequences, and Services to Assist Recovery. Santa Monica, CA: RAND Center for Military Health Policy Research: 3.
13. Ruff R, et al. Relationships between mild traumatic brain injury sustained in combat and post-traumatic stress disorder. F1000 Medicine Reports. 2010;2:64.
14. Lew HL, et al. Prevalence of chronic pain, posttraumatic stress disorder, and persistent postconcussive symptoms in OIF/OEF veterans: polytrauma clinical triad. J Rehabil Res Devel. 2009;46(6):697-702.
15. Management of Concussion/mTBI Working Group. VA/DoD clinical practice guideline for management of concussion/mild traumatic brain injury (mTBI). J Rehabil Res Dev. 2009;46(6):CP1-CP68.
16. Ruff RL, et al. Improving sleep: initial headache treatment in OIF/OEF veterans with blast-induced mild TBI. J Rehabil Res Dev. 2009;46(9):1071-1084.
17. Berrigan L, et al. Quality of clinical practice guidelines for persons who have sustained mild traumatic brain injury. Brain Inj. 2011;25(7-8):742-751.
18. McCrea MA. Acute symptoms and symptom recovery. In: Mild Traumatic Brain Injury and Post Concussion Syndrome: The New Evidence Base for Diagnosis and Treatment. New York: Oxford University Publishing Press; 2007: 86.
19. Lannsjo M, et al. Prevalence and structure of symptoms at 3 months after mild traumatic brain injury in a national cohort. Brain Inj. 2009;23(3):213-219.
20. Lundin A, et al. Symptoms and disability until 3 months after mild TBI. Brain Inj. 2006;20(8):799-806.
21. Lew HL, et al. Characteristics and treatment of headache after traumatic brain injury: a focused review. Am J Phys Med Rehabil. 2006;85(7):619-627.
22. Nampiaparampil DE. Prevalence of chronic pain after traumatic brain injury: a systemic review. JAMA. 2008;300(6):711-719.
23. Theeler BJ, Erickson JC. Posttraumatic headache in military personnel and veterans of the Iraq and Afghanistan conflicts. Curr Treat Options Neurol. 2012;14(1):36-49..
24. DCoE Clinical Recommendation August 2012: Indications and Conditions for Neuroendocrine Dysfunction Screening Post Mild Traumatic Brain Injury. http://www.dcoe.health.mil/Content/Navigation/Documents/DCoE_TBI_NED_Clinical_Recommendations.pdf
25. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). 4th ed. Washington, DC: American Psychiatric Association; 2000.
Karen Williams is a nurse practitioner at Landstuhl Regional Medical Center in Landstuhl, Germany, where she specializes in the treatment of traumatic brain injury. The views expressed in this article are those of the author and do not reflect the official policy or position of the Department of the Army, Department of Defense or the U.S. Government.