practice guidelines are developed. Those at the Department of Defense are the only ones in position to make policy judgments for the Military Health System. After extensive deliberation, the committee determined it was beyond its charge to interpret its assessment of the evidence with respect to policy recommendations or clinical practice guidelines.

In addition to reviewing the literature, the committee heard from experts in the fields of cognitive rehabilitation research and practice, investigators of major research studies of traumatic brain injury in military and civilian settings, and advocates for the role of families and communities in providing ongoing support to injured members of the military and veterans. The committee also received statements from stakeholders from various organizations and members of the public. Over the course of the study, the committee met six times, engaged the public through two workshops, and participated in a number of ongoing activities organized by working groups. The committee did not complete an independent assessment of the treatment of TBI by cognitive rehabilitation within the MHS (Subtask 5). This exclusion was due to constrained resources, including a lack of access to available data and time limitations.


In broad terms, a TBI is an injury to the head or brain caused by externally inflicted trauma. DoD defines TBI as a “traumatically induced structural injury and/or physiological disruption of brain functions as a result of an external force.” TBI may be caused by a bump, blow, or jolt to the head, by acceleration or deceleration forces without impact, or by penetration to the head that disrupts the normal function of the brain (CDC 2011b; Katz 1997; VA/DoD 2009a). The events that lead to TBI vary by population. Among civilians, motor vehicle accidents are the leading cause of TBI-related deaths; among young children and older adults, falls are a major cause of TBI (CDC 2010); and among soldiers and veterans, the most common source of TBI is a blast (i.e., BINT), followed by falls, motor vehicle accidents, and lastly, assault (DVBIC 2009). Chapter 2 provides a more complete description of TBI, including mechanisms of injury and classification schemes, which may aid in short- and long-term prognosis.

Across time, incidence of TBI has risen among the military population as an all-volunteer force has been engaged in the longest war (OEF) in U.S. history, and service members are exposed to longer and more frequent deployments. While in-theater, service members are increasingly attacked by more explosive weaponry. Approximately 22 percent of wounded soldiers from OEF/OIF theaters experienced wounds to the head, face, or neck (Okie 2005). From 2000 to 2010, the number of military service members diagnosed with TBI has nearly tripled (DVBIC 2011). Mild TBI, also called

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