Understanding the Effects of Concussion, Blast, and Brain Injuries: A Guide for Families, Veterans, and Caregivers

Introduction

Why this guide was written

This guide has been written to help the families of service members who have sustained traumatic brain injuries. It is also intended for the caregivers, clinicians and therapists who work with them over the various stages of their treatment and recovery. Traumatic brain injury has become known as the signature wound of the war in Iraq and conflicts in Afghanistan. While helmets, protective body gear and armored vehicles help protect troops during combat and on patrol, they still are exposed to possible injury or death each day that they are in a war zone. The sophisticated battlefield medicine and rapid air transport that are provided when a service member is injured have resulted in extraordinarily high rates of survival among the troops who have been injured. Unfortunately, some have not survived and their deaths are tragic losses for their families and this country.

Service members with traumatic brain injuries

The global war on terror is resulting in new types of traumatic injuries. In previous conflicts, troops fought on the front lines of combat. There is no "front line" in Iraq and Afghanistan. The war is being fought in local neighborhoods, open markets, cafes and routine traffic stops. Sniper fire, explosions and ambushes are part of daily life for support, transport and combat troops. This lack of a safety zone creates additional stresses and risks for troops who must be on alert 24 hours a day, 7 days a week. Extended and multiple deployments add to the emotional stress and physical risks. Shock waves and blasts from improvised explosive devices (IEDs), land mines and rocket propelled grenades can cause terrible damage to the human body. Many service members have had injuries to multiple body areas – called polytrauma in medical terms. They are returning to the US with missing limbs, the scars of painful burns, and loss of vision or hearing. The brain is especially vulnerable in an explosion, collision or fall as it is the most complex organ in the body – and it controls how we think, act, move, feel, and communicate.

Just the words "traumatic brain injury" raises all sorts of questions and images. No two brain injuries are alike. Consequently, the recovery of each individual with a brain injury is unique. A mild brain injury (often called a concussion) may have temporary effects that last for only several hours, days or weeks. However, multiple concussions can have more serious effects over time. Moderate to severe brain injuries can result in more serious damage and increase the likelihood that a service member will become disabled. A traumatic brain injury can result in visible physical changes. Some individuals literally have to learn how to walk, talk, communicate, and do the basics of daily life all over again.

Consequences of traumatic brain injury

It is the changes in a person’s thinking, reasoning, behavior, and personality after a brain injury that are usually harder for others to understand. These are the less visible but major consequences of a traumatic brain injury that can have life long effects on an individual’s life and the family. A brain injury can change how a service member thinks, remembers, reasons, organizes, plans and problem solves – the very abilities that are essential for independent and active lives. There are also psychological and social changes that can alter the personality so that the individual literally seems like a different person. Impulsive, explosive and unpredictable behaviors and actions can be the direct result of damage to certain areas of the brain. It is these changes in thinking, emotions and behavior that become the most challenging over time for families and caregivers as service members return to their homes and communities.

This guide will help the service members, their families and caregivers understand the immediate and long-term consequences of traumatic brain injury. Ironically, if a silver lining can be found, it is that today’s veterans with brain injuries have the good fortune of timing. The medical treatment and rehabilitation of adults with traumatic brain injury has made many gains over the past 30 years. Brain injury medicine and rehabilitation has made amazing advances in care and treatment since the Vietnam War. That expertise is helping our service members injured in the Global War on Terror. We are now learning about the new types of brain injuries caused by blast injuries and shock waves and are using state of the art medicine. We also know from the struggles of previous veterans that post traumatic stress disorder (PTSD) can have serious consequences if unidentified and untreated. We have learned from the past. The advances in brain injury treatment are helping our service members who are being treated in the polytrauma centers under the Department of Defense, the Veterans Administration Hospitals and Clinics, and within the private civilian sector.

Coming home

The next big challenge for many service members comes when they return home. Surviving a brain injury is one thing; living with a brain injury is another. The transition from living in a war zone to coming home is not always a smooth nor easy one. Life has changed. Children have been born and grown, couples have grown together or split apart, roles and responsibilities have shifted, jobs have changed, homes have moved. This transition will be even more stressful and complicated for the family with a service member who is coming home with a traumatic brain injury. Programs and services in local communities for survivors of traumatic brain injuries and their families have not grown at the same pace as medical and rehabilitation services. Just sorting out the disability and health benefits and coverage under the various programs for active duty military, veterans and reservists is a challenge. The community of individuals and families living with brain injury stretches far and wide. Unfortunately, it continues to grow. While each person and each family are unique, the experience of having one’s life changed by an injury to the brain unites them.

How to use this guide

This guide will help readers understand the many dimensions of traumatic brain injury. It provides tips and strategies for coping and moving forward as service members and their families resume and rebuild their lives. It gives an overview of the many dimensions of brain injury with more in-depth detail on specific topics. Many of he articles were originally published by Lash and Associates Publishing/Training Inc. as "Tip Cards" on specific aspects of brain injury and were written by experts in the field of traumatic brain injury. This tip card format was chosen because families and caregivers said they needed information they could quickly read and absorb that was written in clear language with practical suggestions or tips on what to look for, what to do and strategies to use. This format and style has been used again for this guide because it provides a quick summary with action steps without all the jargon. We have chosen all the tip cards that are relevant for service members, their families and caregivers. They have been revised and made into a collection of articles for this guide.

Not all the articles will apply to all individuals, their families or caregivers. Readers are encouraged to pick and choose the sections and articles that fit your situation. As the person progresses and recovers, topics of interest and needs for information will change. That is why we have put all the information together in this guide. It is a resource that you can go back to repeatedly over time as new questions, challenges and needs emerge. There is literally something for everyone in this guide.

Section 1 – Articles on Helping Families

Just as life changed for you when your family member went to war, it has changed again with the diagnosis of a brain injury. Families have many worries, fears, questions and uncertainties as they face the future after a loved one has been injured. Once the immediate danger of whether the person will survive has passed, the question becomes, "What will she be like? Will he be different now? How will our family manage?" Whether it is your son or daughter, brother or sister, husband or wife, cousin, aunt or uncle – the entire family is affected by a brain injury.

This section has articles to help families cope during the initial days, weeks or months of hospital care and rehabilitation. It discusses changes in the relationship between spouses or partners after the service member comes home as responsibilities change and daily life is reorganized. Suggestions for talking to children when a parent has a brain injury are given with considerations for the child’s age and understanding.

The power of emotions and methods for coping are discussed as families come to realize that life may never be the same again. Warning signs of stress and depression among caregivers as well as the individual with a brain injury are described. As roles and responsibilities shift and family members become caregivers, balancing the needs of everyone while holding the family together can feel like a juggling act with no breather. Suggestions are given to avoid caregiver stress and burnout and methods for becoming efficient coordinators for services and care.

Section 2 - Articles on Concussion and Trauma

The severity of a brain injury can range from mild to severe. Even a mild brain injury or a concussion can have consequences. For those with more severe brain injuries, the period of coma can be frightening and stressful. This section contains two articles on coma and concussion to help families recognize symptoms and monitor recovery.

Post traumatic headache and post traumatic stress disorder can slow and complicate a service member’s recovery and make it harder to function at home, back at work, and in the community. They may affect the service member’s ability to return to duty. They are described in detail with suggestions on how and when to seek help.

Section 3 - Articles on Medications

This section goes into detail about the use of medications after brain injury and how they work. It is a useful resource for families to use to discuss concerns and questions about medications with physicians who may be prescribing drugs and monitoring their effects.

Section 4 - Articles on Behavior and Cognition (thinking)

Changes in a service member’s behavior, thinking, learning, personality, communication, social skills, memory, and self awareness can be the most difficult changes for family members. The brain does not heal like a broken bone. It is commonly said that, "War changes a person." So does a brain injury. The combination of being in combat and having a brain injury is powerful. It can affect a service member in more ways than physical injuries. Many families report that their loved one seems like a new person – and this makes it hard to know what to expect and how to respond. This section explains why a person may act and think differently after a brain injury and gives many practical tips for families and caregivers on how to help.

Section 5 - Articles on Life in the Community

Recovery from a moderate or severe brain injury can be a long journey. As service members who have survived a brain injury try to pick up their lives at home and in the community, families often worry about how much help, support or assistance is needed. This section provides a checklist for families and caregivers to guide them as they consider what is needed for the person’s safety, independence and supervision.

The use of alcohol poses special risks for anyone who has had a brain injury. These risks are explained with suggestions for finding treatment programs and getting help for substance abuse.

There is even an article about concerns for aging after a person has a brain injury. While many of our military are now young, we all grow older each year. For other service members now in mid life, these concerns may be more pressing.

Section 6 - Articles on College and Working

Life after military service involves decisions about college, vocational training, and employment. An individual with a brain injury may need accommodations on the job or may need retraining or schooling to find a new job. This section gives information about vocational resources and programs in the states as well as federal laws that protect workers with a disability from discrimination.

Section 7 - Resources

Developing this section was difficult because the military and civilian sectors are very different.

Just navigating the complex system of health care and benefits for various branches of the service and national guard is a challenge. This can be even more stressful when a family is dealing with the effects of a traumatic brain injury and the uncertainties of the future.

While many programs and agencies dedicated to supporting service members discussed post deployment adjustment, it was difficult to identify resources that addressed this for the service member who had had a traumatic brain injury. On the other hand, there are many programs and services in the civilian sector with expertise in traumatic brain injury, but they may have little knowledge of, or experience with, service members. There is also the challenge of figuring out eligibility under the Veterans Administration, TRICARE, Social Security, private insurance and state services. The resources described in this section provide a starting point for understanding this complex system.