Once a Warrior, Always a Warrior

Charles W. Hoge, MD, Lyons Press
Once a Warrior, Always a Warrior

Chapter 2: Combat Mild Traumatic Brain Injury (mTBI/Concussion)

The wars in Iraq and Afghanistan have led to increased awareness of the impact of traumatic brain injury (TBI) on troops. The availability of modern protective equipment and advances in battlefield medicine have resulted in many warriors surviving injuries from IEDs (improvised explosive devices), RPGs (rocket-propelled grenades), rockets, mortars, EFPs (explosively formed projectiles), and other munitions that would have been fatal in prior wars. Some of these injured warriors have experienced serious brain injuries resulting in long-term impairment in physical, cognitive, and behavioral functioning.

Unfortunately, there has been very poor education about the distinction between mild traumatic brain injury (mTBI), also known as “concussion,” and moderate or severe TBI, where damage to the brain is usually apparent on clinical evaluation and brain scans (CTs and MRIs). All TBIs (concussions/mild, moderate, and severe) have been grouped together by medical professionals and in educational materials given to warriors and their families. In 2008, investigators from the RAND Corporation reported that 20 percent of all Iraq and Afghanistan war veterans (more than 300,000) experienced a “probable traumatic brain injury” while deployed, without clarifying that over 99 percent of these cases were concussions and that their study was based on an inadequately validated survey administered months or years after the warriors had returned from deployment. Concussions/mTBIs have also become entangled and confused with PTSD, and these two conditions have been described as “silent” wounds, affecting hundreds of thousands of OIF and OEF warriors.

When a warrior experiences a moderate or severe TBI on the Iraq or Afghanistan battlefields, this almost always results in rapid air transportation to one of the large military hospitals in Germany or the United States for neurosurgical, neurological, and rehabilitation services. Some of these warriors experience severe disability and require long-term treatment.

In contrast, when a warrior experiences a concussion/mTBI on the battlefield, which may involve being briefly knocked out, or getting their “bell rung” from a blast or other injury, this almost never results in evacuation from the combat theater. Concussions/mTBIs are very common in the military (as in nonmilitary settings) from sports injuries, motor vehicle accidents, hand-to-hand combatives training, and combat. Although concussions can occasionally lead to long-term health effects — such as headaches, irritability, sleep disturbance, memory problems, or fatigue — most warriors who experience concussions recover quickly. Concussions/mTBIs are clearly not the same as moderate and severe TBIs, but in the minds of many warriors, family members, the public, and even medical professionals, they have become the same condition, requiring an equivalent level of concern.

After every war, warriors have experienced high rates of physical, cognitive, emotional, or behavioral health concerns, including memory and concentration problems, anger, headaches, sleep disturbance, high blood pressure, rapid heart rate, pain, fatigue, dizziness, and other difficulties. These problems are associated with neurological, endocrine, cardiovascular, and immune system changes likely related to physiological effects of extreme stress on the body, extended sleep deprivation, environmental exposures, and other factors.

The reactions that warriors experience after coming back from war have been given different labels through the generations, including “Nostalgia” (Napoleonic Wars); “Da Costa Syndrome,” “Irritable Heart” (U.S. Civil War); “Effort Syndrome,” “Shell Shock” (World War I); “Battle Fatigue” (World War II); “Acute Combat Stress Reaction” (Korean War); “Agent Orange Syndrome,” “Substance Abuse,” “PTSD” (Vietnam); and “Gulf War Syndrome” (Gulf War 1). Some of these problems have been associated with serious environmental exposures (e.g., Agent Orange, Gulf War Syndrome).

After every war, the same mistakes are made. Rather than recognize that going to war can change the body’s physiology in a number of ways and identify the best treatments for the full range of health problems that warriors experience, postwar symptoms are attributed to causes that are highly influenced by prevailing politics. After every war, veterans are told that their war-related symptoms are “stress-related” or “psychological” (which understandably infuriates them), and the medical community becomes embroiled in divisive debates as to whether the causes of war-related symptoms are predominantly “psychological” or “physical” (or environmental) in origin. While medical professionals and policy-makers get caught up in debating the definition and nature of the problems (influenced by poor-quality scientific data and “turf” battles regarding allocation of resources), veterans feel that their problems are not taken seriously. Health professionals and policy-makers responsible for establishing initiatives to address the problems are well intentioned, but often become overly dependent on the advice of “experts,” and myopic to any scientific evidence that doesn’t support their positions. Ironically, the need to be perceived as expediently doing everything possible in the interest of veterans leads to the rapid implementation of interventions that are not necessarily beneficial, and may even prove harmful.

For the current OIF and OEF wars, the same problems have emerged. Intense debate is now going on in the medical community (and involving veterans organizations, politicians, and reporters), regarding whether or not certain war-related reactions—such as cognitive problems, rage, sleep disturbance, fatigue, headaches, and other symptoms—are best explained by a “psychological” cause (PTSD) or a “physical” cause (mTBI). Both have been labeled the “signature injuries” of these wars. There has been intense speculation, generated by a large gap in scientific knowledge, that exposure to primary pressure waves from explosions in Iraq and Afghanistan has caused “silent” mTBI injuries in hundreds of thousands of otherwise uninjured warriors that may predispose them to long-term problems. Advocates for the mTBI position, typically experts in neurology, rehabilitative medicine, or neuropsychology, have suggested that blast-related mTBI represents a new form of brain injury, and have even proposed that PTSD may be caused by the mTBIs themselves (ignoring the context in which these injuries occur).

Advocates for the PTSD position, who are often mental health professionals, frequently cite articles that our team at the Walter Reed Army Institute of Research had published in theNew England Journal of Medicine in 2008 and 2009. These showed that concentration and memory problems, anger, sleep disturbance, fatigue, dizziness, balance problems, headaches, and other difficulties reported by soldiers returning from Iraq were much more likely to be associated with PTSD than with concussion/mTBI, and that concussion/mTBI alone was only very weakly associated with any of these problems. Several other studies have also confirmed our findings. Advocates for both positions, however, have misunderstood the most important evidence from these research studies, having to do with the optimal treatment of interrelated health concerns through collaborative care approaches.

So what is the truth about concussion/mTBI and its relationship to PTSD? What are the most important things for you to understand about any problem you may be experiencing, and treatments that are available? The remainder of this chapter summarizes the answers from a number of different studies.

Concussion/mTBI: The Facts

Concussion/mTBI is not the same thing as moderate and severe TBI. Moderate and severe TBI are very serious medical conditions that require comprehensive treatment by neurologists, neurosurgeons, rehabilitation medicine professionals, mental health professionals, and other specialists working together. Moderate and severe TBIs are usually seen clearly on brain scans and result in health problems that can be detected on physical, neurological, and neuropsychological examinations. There have been remarkable advances in the treatment of moderate and severe TBI, and even after severe injuries, there is hope for recovery to high levels of functioning. However, recovery can be slow, and the warrior may not be able to get back to full functioning even after long-term treatment. This is very different than concussion/mTBI, and only concussion/mTBI is addressed in this book.

The term concussion is preferred over the term mTBI (mild traumatic brain injury) to clearly distinguish this from moderate and severe TBIs. Concussion/mTBI is defined as a blow or jolt to the head that briefly knocks you out (loss of consciousness); causes a temporary gap in your memory; or makes you confused, disoriented, or “see stars” (change in consciousness). This is also known as getting your “bell rung.” Most warriors who experience a concussion during hand-to-hand combatives training, during sports, as a result of a motor vehicle accident, or after blast explosions on the battlefield are only temporarily confused or disoriented. If they experience memory gaps or are knocked out, this usually lasts for a few seconds or minutes. When brain scans are performed, they are usually normal. Injury to some nerves in the brain may be able to be seen with newer brain-imaging technologies, but these are very subtle, difficult to detect, and these technologies are not useful yet in directing treatment.

Concussions can result in headaches, irritability, dizziness, balance difficulties, fatigue, sleep disturbance, ringing in the ears, blurred vision, cognitive problems (including concentration or memory difficulties), as well as other symptoms. These almost always clear up soon after the injury, but in some warriors may persist for a longer period; there is poor understanding of why they persist in some individuals. The newer brain-imaging methods often show healing of damaged areas, but they don’t always match with resolution of symptoms. When symptoms persist after concussion in combat, they are indistinguishable from symptoms warriors experience as a result of other injuries, or physiological effects of working in the war environment.

If you experienced one or more concussions during deployment or during your military service, and you’re experiencing any of the above symptoms now, they may or may not be related. These types of symptoms are common after combat. Their presence likely does not mean that something is persistently wrong with your brain, as implied by the term brain injury. While they might be related to concussions that you had during your service, this is only one of many possible causes.

The best time to make a diagnosis of concussion/mTBI is at the time of injury, and it becomes progressively more difficult to diagnose the more time has passed. The treatment prescribed at the time of injury is to rest until symptoms resolve, which generally occurs in a few hours to a few days. Once weeks or months have passed since the injury, there is no way for a doctor to accurately determine the exact cause of your symptoms, no matter how well trained they are. There is no blood test, brain scan, or neuropsychological test that can determine with certainty whether physical, cognitive, or behavioral symptoms and reactions that persist after combat — such as headaches, concentration/memory problems, anger, or sleep problems — are due to physiological changes from combat, the physiological effects of PTSD, the effects of exposure to chemicals or environmental factors, lingering effects of concussions or other injuries, the result of chronic sleep deprivation in combat, or various other potential causes. Also, knowing the likely cause doesn’t help very much with treatment, since treatment for these problems is exactly the same whether or not concussion is responsible. There are a variety of treatments that your doctor can prescribe to help with specific symptoms, such as persistent headaches.

Full recovery is expected even if you’ve had more than one concussion during deployment. The brain has a remarkable ability to heal itself through growing new connections between nerves, a process called “plasticity” that goes on continuously in the brain. Areas of the brain that are damaged can be replaced or reconnected through growth of other neurons. Things that help with healing include good sleep and avoidance of alcohol or drugs (both of which will be addressed in chapter 4). The brain is a living organ that can show remarkable healing capability even after very serious injuries, and certainly after concussions or mTBIs from any cause.

Although concerns about the health effects of blast waves are legitimate and are being actively researched, most injuries that warriors experience from explosions in Iraq and Afghanistan are due to fragments, shrapnel, or being thrown against something. It’s very unlikely to have effects on the brain from the primary pressure wave of an explosion without other serious injuries. Fragment dispersion in explosions usually extends out much farther than the pressure wave, particularly if the explosion goes off in an open space. If an explosion penetrates a vehicle or building, the primary pressure wave can get amplified inside the space, causing greater damage, but this is usually accompanied by very severe injuries that are not “silent.” This is an area that requires further research, but it’s not beneficial for you to worry excessively about possible long-term brain effects because you were injured from or close to one or more explosions while deployed. Worry itself has been tied to physiological changes in the body that can contribute to symptoms or hinder healing. Even if there were some lingering effects from the blasts you were exposed to that the medical community hasn’t fully identified, there’s no reason to think that the brain can’t heal itself as effectively after blast-related concussions as after concussions from sports, motor vehicle accidents, or combatives training.

Concussion/mTBI is not the same thing as PTSD, and having an either/or perspective isn’t helpful. Concussion is the injury event itself. PTSD, as explained in the last chapter, refers to a specific set of reactions or symptoms after trauma (that may or may not have included physical injury) persisting for at least one month, and usually much longer. Although persistent symptoms after concussion can overlap with those of PTSD, they can also overlap with hundreds of other medical conditions, and it’s not helpful to focus only on these two conditions. If you experienced a concussion during deployment, you may be at higher risk for PTSD because of the context in which the concussion occurred. If you were knocked out or temporarily disoriented from a blast on the battlefield, this was a very close call on your life, and you may also have had buddies who were injured from the same explosions. It’s understandable to experience PTSD symptoms after these types of experiences.

Screening for concussion/mTBI is now routine for veterans returning from OIF and OEF. However, this is leading to concussion/mTBI being underdiagnosed, overdiagnosed, and misdiagnosed because of the lack of any definitive way to make the diagnosis so many months or years after injury. Many warriors who had concussions during deployment have not been evaluated or treated. More important, many warriors with serious postwar symptoms, such as headaches, rage, memory problems, and sleep disturbance, have been mistakenly told that their symptoms are due to the lingering effects of a brain injury, when they’re actually due to other reasons. Widespread screening for concussion/mTBI may actually be causing warriors who are not brain-injured to believe that they are.

Some health professionals (and warriors) consider that it’s better to be diagnosed with a brain injury than with a mental disorder (PTSD), and the mTBI label is sometimes being used instead of PTSD. This is problematic, since the treatments are completely different. Many warriors are undergoing complex neuropsychological evaluations of memory, concentration, attention, and other cognitive abilities. However, these tests are often inconclusive, even when baseline measures have been obtained for comparison. Neuropsychological tests cannot distinguish concussion from other potential causes of cognitive complaints, such as sleep disturbance, coexisting medical problems, fatigue, anxiety, depression, or PTSD. The physiological effects of PTSD have been shown in several studies to be a much more likely cause of long-term concentration, attention, and memory problems after combat than concussion. Making an incorrect diagnosis can lead to the use of potentially harmful treatments or medicines that have side effects.

Here are the key things you should know about treatment:

Treatment for Concussion/mTBI

  • The one treatment proven to be effective for concussion/mTBI is rest immediately after the injury combined with education on what to expect. Once weeks or months have passed after the injury, treatment becomes focused on alleviating specific symptoms, such as sleep difficulties, headaches, or cognitive problems.
  • Many postwar symptoms, including those related to concussion/mTBI, are interconnected. Problems with anger, sleep disturbance, cognitive problems, being revved up physiologically, pain, and other symptoms go hand in hand. For example, if you’re experiencing memory or concentration problems, the most important initial treatment may be to ensure that there is good sleep and control of physiological symptoms related to being revved up, irritable, or angry. However, if headaches, nightmares, or pain are partially responsible for the sleep disturbance and irritability, these problems may need to be addressed first.
  • Although treatment is available for your postwar health concerns, including those related to concussion, there are some caveats that you should be aware of. Many war-related health problems, including persistent ones after concussion, are probably best addressed initially by your primary care provider, who has the most experience in treating a wide range of health concerns. That being said, sometimes primary care providers don’t have enough time during brief appointments to address all concerns, and may be inclined to refer you to a specialist for further evaluation or treatment. Some debilitating problems — like fatigue, cognitive problems, and pain — can be very difficult to treat, and are best addressed through collaborative approaches involving several professionals coordinated through primary care. However, evaluation by specialists can be a double-edged sword. Although specialists are skilled in the latest modalities of evaluation and treatment for their particular area of expertise (which can be of benefit to you), they often have little or no knowledge of effective treatments from other fields of medicine that may be relevant for the types of problems that you have. When the diagnosis is uncertain or involves multiple potential causes, specialists are more inclined than primary care professionals to attribute them to a disorder that they have the most expertise in, which may not be the right answer. Many specialists in concussion/mTBI have ignored evidence on effective collaborative treatments based on lessons learned from past wars and from studies conducted in primary care of how best to treat overlapping conditions when symptoms have more than one possible cause.
  • Being referred to specialists for war-related symptoms can sometimes feel like being thrown around like a Ping-Pong ball, which can contribute to high distress, frustration, and worsening health problems. When you visit multiple specialists, there is a higher likelihood of being given several medicines that may not interact well with each other. If you’re on several medicines, you could be at risk for complications unless your primary care provider is coordinating the care, monitoring the potential interactions, and isn’t reluctant to change medications recommended by specialists. This may be difficult for your primary care provider to accomplish in the time allotted for your care. Visiting different specialists can also consume a lot of your time, which may affect your work or other aspects of your life.
  • Sometimes the key to successful recovery is actually to do less. There are no easy answers. This is a product of the system that we operate in, and the only thing you can do is be aware that this is going on and ask questions about your care at each step along the way.
  • There is no distinction between “psychological,” “stress-related,” and “physical” symptoms related to war. All symptoms have a physical and physiological basis involving neurological, endocrine, and other systems in the body. They need to be addressed if they are causing functional impairment sufficient to interfere with your life. All have to be addressed simultaneously, which is why multidisciplinary and collaborative care approaches involving primary care professionals is so critical. There is no split between the body and mind. Medical professionals need to learn how to communicate this better so that warriors don’t feel like their debilitating symptoms are being dismissed as “stress” or “psychological” problems. In turn, warriors can help by gently reminding the medical community to stop splitting up symptoms into convenient groups and labels, stop arguing about their causes, and focus on finding the best treatment approaches for the full range of overlapping symptoms, regardless of their causes.
  • Chapter 4 will present more discussion on the physiological processes associated with war. Many of the exercises and skills in the remainder of this book can be beneficial to your overall physical and cognitive health by reducing the degree to which your body may be physiologically revved up as a result of your wartime service.
  • The VA has established regulations for disability concerning problems associated with concussion/mTBI that do not appear to be based on validated medical criteria. However, this is not necessarily bad for warriors. Because there is no definitive way to prove that postwar cognitive problems or other symptoms (e.g., irritability, sleep disturbance, fatigue, dizziness, headaches, etc.) are not due to concussion/mTBI, it would seem difficult to deny a disability claim under the current regulations as long as there’s a history of concussion/mTBI during military service and a medical provider who makes a determination that your current symptoms might be related to this. However, don’t consider yourself “brain-injured” if you apply for a concussion/mTBI disability. Just because you had a mild brain injury on the battlefield doesn’t mean that you’re brain-injured now. What you’re likely experiencing are the expected physical, cognitive, or behavioral symptoms that warriors have experienced after every war; concussion may have contributed, but is probably not the only factor. The brain can heal even after very serious injuries, and there are many things that can be done to alleviate these concerns. It’s important for your health to have a good understanding of these issues and to have a positive outlook. Positive expectations actually improve the physical health of the body.


In summary, don’t get caught up in the mTBI versus PTSD debate. Recognize that combat in itself, as well as combat-related injuries of all types, can lead to a variety of physical, behavioral, and cognitive reactions, and these are closely connected to each other. There is no mind-body split, and all postwar health concerns need to be addressed together. Have confidence that there are many things that can be done to alleviate these reactions to promote a healthy and fulfilling life despite injuries or other traumas that you may have experienced during your service in the war zone. You deserve to receive the very best care available.

Posted on BrainLine June 13, 2011.

Excerpted from Once a Warrior, Always a Warrior by Charles W. Hoge, MD, Colonel, U.S. Army (Ret.). Reprinted with the permission of Lyons Press, ©2010 by Charles W. Hoge. www.globepequot.com.