Whether on the sport field or the battlefield, the Defense Health Agency is the global leader in research on the effects of concussion—known as mild traumatic brain injury—in the military. Its research has fueled the development of protocols to help providers assess and treat concussion from initial injury to acute and post-acute medical settings, rehabilitation, and, ultimately, a return to family, community, work, continued duty, or recreation.
Over the past 22 years, more than 468,000 U.S. service members have sustained a TBI, with the majority of events occurring in training maneuvers, such as breaching structures, anti-tank weapon use, parachute jumping, and blast exposure, according to the DHA’s Traumatic Brain Injury Center of Excellence.
Only 16.9% of TBIs occur in the deployed setting, with others related to sports, recreational activities, and motor vehicle collisions, TBICoE stated, adding nearly 83% of TBIs were diagnosed as mild.
Concussions on the Field, Return to Play, Return to Learn
The U.S. Naval Academy records more than 250 concussions per academic year out of 4,500 total midshipmen, said U.S. Navy Cmdr. (Dr.) Kevin Bernstein, team physician for Navy football and a sports medicine specialist. “It's probably one of the higher concentrations of a TBI-type of scenario” because of the number of sports teams and the fact the academy is a Division I National Collegiate Athletic Association school, he added.
While many concussions come from sports such as football, rugby, soccer, lacrosse, and hockey, they also come from the academy’s required physical education activities such as boxing and combat ground fighting, Bernstein explained.
Naval Academy athletic trainers and physicians use the standardized Sports Concussion Assessment Tool 5 (SCAT5) for immediate on-field diagnosis of concussion, Bernstein said. The diagnosis of a concussion is a clinical judgment, the protocol states. It was developed by the worldwide Concussion in Sport Group.
The U.S. Air Force Academy records more than 300 concussions annually and diagnoses concussion based on two main components: mechanism of injury and ensuing signs and symptoms, academy sport medicine and concussion researchers said. It also uses the SCAT5, which is followed up by referring a cadet to the Cadet Concussion Clinic, which performs a full neurological examination including:
Both academies have similar five-phase return to play protocols, developed in part with DHA and the NCAA, with a minimum of five days off from sports or PE activities.
Since 2014, the Department of Defense has collaborated with the NCAA to advance studies of TBI in contact sports, club sports, and service academy training exercises in the most comprehensive research of its kind through the Concussion Assessment, Research, and Evaluation Consortium.
Because the academies are learning institutions, they also follow return-to-learn protocols after concussion.
The Air Force Academy’s phased system has been in place since 2018 and includes:
- Cognitive and physical rest that allows the brain to heal more quickly and typically begins the day of injury; this usually lasts for two to three days.
- Light cognitive tasks such as homework and computer work for up to 60 minutes
- Return to partial classes with maximum modifications
- Return to full class with minimum modifications
- Full class attendance with no modifications
“We try to get them back into class, even if they're just sitting there not actively learning or engaged,” Bernstein said. “We find that getting them back into a classroom with their friends and social peers is really helpful.”
According to the Air Force Cadet Concussion Clinic, “the identification of risky training activities has led to a 75% decrease in concussions during basic cadet training and during military training throughout the year.”
Through these protocols, the academy is able to identify the true incidence of concussion. This allows for appropriate care and leads to an earlier return to duty, a former Air Force academy researcher said.
Active-Duty Concussion
DHA and academic research collaborations have led to the development of many tools, resources, and guides over the last two decades, and there is still much more to learn about brain health. Resources and tools include the:
Blast Overpressure
The January 2020 attack on American service members at the Al Asad Airbase in Iraq demonstrated the impact of targeted missiles on brain health, specifically concussive waves known as blast overpressure, said U.S. Navy Capt. Scott Cota, TBICoE division chief. The air strikes resulted in 110 service members diagnosed with TBIs.
The concern about blast overpressure is global: Last November, DHA hosted a blast overpressure conference with members of the North Atlantic Treaty Organization to discuss current research and future initiatives and protective methods.
Later in 2023, a report will go to Congress detailing the use of certain weapons and their blast overpressure effects on warfighters. DOD issued interim guidance on this topic on in 2022.
The fiscal year 2018 National Defense Authorization Act study “Low Level Blast Pressure Exposure in Service Members” and the recent NATO conference are linked to the department’s Warfighter Brain Health Initiative. This joint strategy and action plan addresses long-term or late effects of TBl, from blast exposures, with the goal of optimizing brain health and countering TBI.
What Comes Next for a Holistic System
“The research effort between the DOD and the NCAA is to improve our understanding of brain injury, in particular how to better diagnose and treat those with acute concussion to maximize their recovery and optimize their return to military duty and sports,” said Dr. Paul Pasquina, chair of the Uniformed Service University’s Department of Physical Medicine and Rehabilitation.
In addition, “we would also like to provide athletes, service members, military leaders, and sports coaches better tools to help predict recovery time and the long-term prognosis after concussion or repetitive head impact exposure,” Pasquina said.
“There remain many unanswered questions regarding the long-term outcomes of individuals with a history of concussion, blast exposure, or repetitive head impact exposure,” he said. “If there any unique determining factors that may identify a person as being more susceptible for long-term problems after concussion, or if there are any early markers to help identify those that might be at risk of developing long-term problems, we owe it to our service members and athletes to try and find them.”
Pasquina was a co-leader of the concussion consortium’s second phase from 2018 to 2021. That phase looked at the effects of sport, military training, and concussion over the course of a collegiate career and outcomes up to five years after graduation. The first phase (2014-2018) focused on six-month outcomes following concussion. On March 23, 2023, DOD announced a third, five-year phase, that will allow further examination beyond five years from injury.
The consortium data are available to “those involved in caring for individuals with concussion or brain injury, so they are much more aware of the signs and symptoms, the type of recovery that takes place, of how to better educate their patients, their patients’ families, as well as the various stakeholders, whether they be health care providers, military leaders or policy makers,” Pasquina added.
The findings of the CARE study have already penetrated the clinical practice of caring for individuals with concussion and “will translate beyond varsity athletes and military service members to help the greater population,” Pasquina said.
“The general idea is to maintain the human weapon system, which is the most critical element of any warfighting structure,” Cota said. “The earliest we can get to some of these performance measures and identify the impact on performance and how to mitigate and … accelerate return to duty and recovery, the better. All of those things are within reach.”