Living in a tense world, we just have to follow through with the dream

Traumatic brain injury (TBI) and mild traumatic brain injury (mTBI), also documented as a concussion, impact service persons in the armed forces. TBI is considered a signature injury of current military operations, with lasting unknown effects to the service person.

The epidemiology, research, prevention, mitigation, treatment and long term policies around TBI must improve. Success in the best prevention, mitigation and complete TBI restoration post-injury, through a coordinated global TBI network, is achievable.

The responsibilities that result from living in a tense world often fall on the individual tasked with protection through deployment or defensive service. Disregarding TBI innovation possibilities is disrespectful, harmful and reckless. Each health entity can help shoulder responsibility, with every aspect of TBI science and healthcare delivery reviewed for one’s best contribution match.

Civilian culture often practices intermittent gratitude or seconds of charitable praise on the service person. This culture carries into individual health institutions on all levels and, at times, glosses over military and veteran considerations as issues to be handled away from civilian silo. Compartmentalization is outdated and unacceptable. Integrated healthcare, with sincere attention to service person health equity, is the way forward.

It is the global medical community’s responsibility to care for any brain trauma that occurs to active duty and veteran populations. Living in a tense world, sometimes we just have to say that it’s time to follow through.

Public summary:

1. Recognize the severity and urgency of TBI and mTBI to global health, to the armed forces and to the numerous organizations involved.

2.Take lots of chances. Create opportunity for active duty and veteran TBI improvement by creating opportunity in global TBI healthcare.

3. Figure out the right work and align the right people, associations and groups. Structure international brain science efforts and strategically align TBI science.

4. Best the best for active duty and veteran TBI science. Let the quality of our work do the talking as we address military TBI surveillance and management gaps, set expectations of research quality to the TBI civilian-military research portfolio, improve TBI rehabilitation science, emphasize pharmacological and nutrition science, coordinate TBI biomarker science, improve animal and non-animal TBI models, welcome sports TBI science into civilian-military partnership and bond public responsibility to service person quality of life post-injury.

5. Start the global TBI science days with a positive attitude.

Executive detail, with expectation of executive attention:

1. Recognize TBI. Recognize the global work in brain science and recognize the global need for coordinated TBI networks. With alliance to global TBI innovation, we are afforded more options.

*Respect the severity and urgency of TBI impact to our service persons worldwide. A specific TBI incidence and prevalence remains unclear, and statistics vary by country. Some literature reviews estimate between 11-23% of US service personnel have been injured with TBI, and random sampling of service persons found that 17.3% of deployed were affected [1]. Other literature estimates between 8–20% of U.S. service members may have experienced a TBI in recent decades. Of these 8-20%, 84% have been diagnosed with mTBI [2]. Between 2001-2011, 85% of TBIs were attributed to non-deployment related injuries (traffic accidents, falls, sports, training accidents, etc.) [2] Some literature notes that 20% of UK service persons in the UK Joint Theatre Trauma Registry are affected by TBI[3], and recent work has identified that mTBI affects UK and Candian military service persons at a much lower prevalence (3.2%-5.2%) than US service persons. The exact numbers of affected service persons worldwide are unknown, and there is no screening standard. The U.S. Department of Defense (DoD) tracks formal counts of TBI [4] , it is unclear how many other militaries track TBI numbers, and methods of TBI tracking vary by military. NATO acknowledges the discrepancies between armed forces by country, and has cross-compared the screening in the Netherlands, medical encounter reliance in the US and UK, and unclear data methodology from Sweden and France [5]

*Recognize the known consequences of TBI. Impacts of a TBI may include cognitive, motor and behavioral changes. A mTBI causes headaches, fatigue, depression, anxiety and irritability, collectively referred to as post-concussion syndrome, and a significant number of people affected by mTBI will have impairment in cognition long after injury. These impairments can affect attention, learning, memory, executive function, processing speed and language function, regardless of child or adult age[6]. Even a single mTBI may produce long-term gray and white matter atrophy, age-related neurodegeneration, and increase the risk of motor neuron disease such as Alzherimer’s or Parkinson’s. Repetitive mTBI, a particular risk for deployed populations, may initiate long term neurological, behavioral and other health effects as well. Repetitive TBI is chronic traumatic encephalopathy (CTE), which irreversibly causes atrophy of the frontal and temporal lobes, thalamus, and hypothalamus, septal abnormalities, as well as abnormal deposits of hyperphosphorylated tau throughout the brain. Clinically, CTE impacts executive function, memory loss, behavioral changes, and cognitive impairments that may progress over time[7]. Moderate and severe TBI may cause permanent changes to thinking, behavior, cognitive function and sensation[8], and TBI can cause epilepsy[9]. A severe TBI can be fatal. Respect the urgency of need for professionalism and transparency in armed services accounting of TBI.

*Recognize the global burden of TBI, with respect to civilians. Globally, the incidence and prevalence of TBI is estimated, not known. A recent study reliant on Institute for Health Metrics and Evaluation (IHME) data found that 69 million new cases of TBI will occur worldwide yearly, most of them due to falls and motor vehicle accidents. IMHE data noted the highest incidences are in the US, Canada and Europe and the greatest overall burden is in the Southeast Asia and Western Pacific WHO regions [10] . Another study, reliant on Global Burden of Diseases, Injuries, and Risk Factors (GBD), noted that the prevalence of TBI has increased 8.4% from 1990-2016 for the world’s total population. The highest incidence rates of TBI were noted in central Europe, eastern Europe, and central Asia, with falls and motor vehicle accidents again as the main causes [11]. Limitations with data and estimation calculations are notable for both incidence/prevalence as well as with costs of care analyses. It is known that TBI care is economically costly, rehabilitation programs can lower costs, and the true economic metrics remain unknown [12], [13].

*Recognize the global expertise effort to address TBI. Neuroscience and the medical community continue to prioritize TBI science in care. Professional societies, including the American Association of Neurological Surgeons (AANS) and Society for Neuroscience (SfN), develop neurosurgical and neurology expertise on behalf of global TBI improvement [14], [15]. Prioritization at the U.S. national level includes the DoD Traumatic Brain Injury Center of Excellence (TBICoE) [16], the VA TBI research portfolio [17] , the Center for Neuroscience and Regenerative Medicine [18], academic medicine and private partnerships, Thinkfirst [19] , the CDC’s Heads UP [20] , National Science Foundation awards [21] and, very recently, new committees assigned by the National Academies[22]. Regional and international coordination continues to evolve for TBI work, including the Latin American Brain Injury Consortium [23] , the American Congress of Rehabilitation Medicine[24], the EU’s Center for TBI [25] and the U.S. Brain Initiative[26]. International TBI research collaboratives, such as the International Brain Research Organisation [27] , International Brain Initiative [28] and ENIGMA[29] continue to cross borders on behalf of brain science.

*Recognize the public’s effort in TBI care. Organizations that support patient care are found in many countries, and often have crossover work internationally. Many organizations, such as the Brain Trauma Foundation [30], Brain Injury Association of America [31], American Brain Coalition [32], National Association of State Head Injury Administrators [33], the UK’s Headway [34], the UK’s Brain Charity[35], and the Indian Head Injury Foundation[36], support patients with TBI. Military service persons are provided resources through general TBI patient care organizations as well as specialized services or resource direction through DAV[37], Brainline[38], the DoD TBICoE[16], the VA, Veterans Families United [39] and other organizations. Many TBI deliverables are through charity. The services available, care coordination, intensity of resource navigation, economics and other patient care organization characteristics vary widely.

2.Take lots of chances. Create opportunity for active duty and veteran TBI improvement by creating opportunity in global TBI healthcare. It’s hard work, and we musn’t slow down.

*Improve the global surveillance of TBI, and include service persons in the metrics. Problematic data continues to dilute research. A recent review of TBI deaths in China noted that the data repository was missing the nature of the injury (TBI or other) up to 46% of the time. Comparatively, the US was noted to be at .6% discrepancy. Countries participating in world health cooperatives should be responsible to quality in epidemiology and the global expectation should be clear [40]. An international TBI surveillance registry has been recommended and could be implemented with respect to privacy and national security. Epidemiological investment for every country should be initiated. Improvements to GBD data limitations and methodology should also be priority [10], [11].

*Support tracking, surveillance and fund research opportunities in LMIC. Develop a neurosurgical research agenda that is inclusive of LMIC[41] and LMIC clinicians. Build from major regional studies, such as the Pan-Asian Outcomes Study [42] , by establishing statisticians, researchers, clinicians and TBI guidelines for sustained improvement. In the aforementioned study, Singapore, Pakistan, India, South Korea, China, Malaysia and Vietnam could all standardize TBI classification, management and care coordination. Determine the single TBI project partnerships are active, such as UK and Myanmar partnerships[43], and support greater global neurological alignment opportunities.

*Require global commitment to preventative policy. It has been recommended that ministries of health, medical systems, and social support infrastructure focus on development and improvement of injury-prevention strategies, as well as maintenance of short-term and long-term care pathways to mitigate health loss and improve outcomes among patients with TBI[11]. Traffic safety, helmet laws, fall and stroke prevention, violence prevention and initial penetrating head injury emergent care guidance could be compared and contrasted in global policy review. There are many global and national injury prevention groups that hold expertise in these policies.

*Require TBI and mTBI designation in WHO brain health and trauma literature [44] [45]. If TBI is not included in distinction, global health is ignoring a population.

*Invest in TBI healthcare infrastructure. While research into TBI treatment, rehabilitation teams and care coordination are ongoing, healthcare operations can compare and uplift resources now. Staffing, supportive therapeutics, durable medical equipment, rehabilitation access, training and development should be inventoried, streamlined and improved, worldwide. Coordination of TBI healthcare infrastructure should be a global priority, and service person consideration should be included in national access and quality reviews. TBI clinician staffing requirements are unclear and team dynamics are formed without standards. Guidelines for clinician teams, allied health professionals, labor, education and credentials should be established. These guidelines can and should have formulas for LMIC tailoring. Physiotherapy, speech and language therapy, and neuropsychology resources should be determined from literature [46], with frequency and intensity understood. Global health should take care to emphasize staffing ratios by TBI incidence and prevalence per country, as well as understand military staffing ratios. Availability of neurologists and neurosurgeons, education needs by country, credentialing requirements and scope of mid-level practice in neurology could all be streamlined in guidance. Associations such as the American Neurological Association and World Federation of Neurology could assist [47], [48] in developing and enforcing these. Formalizing neurology and neurosurgeon credentials, and TBI team dynamics, secures our world as an advanced one. Invest.

3. Figure out the right work and align the right people, associations and groups.

*Structure the global movement of brain research. Brain research initiatives have become an international consideration, with basic, cellular and translational levels all at the forefront. This international collaboration energy is a tremendous opportunity for TBI science. Ask for specifics on governance and ask for strategic plans from international efforts, such as the IBI and IBRO. Identify how collaboratives like Enigma and the US BRAIN Initiative work together in basic and cellular brain insight. Determine comparable countries without initiative reach and consider partnership. Identify strategic planning considerations for mapping, neuron data aggregation and grey areas of big data for international brain collaborations, and identify how these projects will work tandem with the BRAIN Initiative. Identify global brain research evaluation structures: how brain science goals will be established, measured and reported. Goals in data sharing, research quality accreditation, cellular data collaborative, research operations centers, publication quality and long-term funding should be established. Goals in actual brain science insight should not require popular public tangible requests yet should require metrics of evaluation in progress, even if progress means that no statistical significance is found or that no successful animal model has been identified. Goals in global policy coordination should see global governance at the table. Require annual updates from these organizations. Harmonize the plans and be strategic with legacy. As personnel come and go, the plans should not revolve around the bureaucracy. Encourage long-term national funding security, as opposed to every 1,2 or 5 year approvals. Create evaluatory structure. Have secondary plans for budgets, plans not reliant on politics. There needs to be structure to international collaboration, with priority to evaluation.

*Structure the global movement in TBI research as a component to global brain science. NAM/NAS, DoD, NATO, Center-TBI, the Uniformed Services University’s CNRM and other TBI commitments should be accountable to specific research agenda that maximizes the global brain science share. Specify influence to national and international TBI research from these organizations, and value responsibilities accordingly. Value these organizations and their commitment to TBI by providing collaborative partnership opportunities, supporting professional development opportunities, funding data sharing options and funding efficient research operations quality improvements. Support national security efforts in brain research by asking for military TBI research inclusion in every major TBI initiative, and support security by implementing expertise in data sharing policy. Structure laboratory, animal and biotechnology science inclusion. Allowing for undisturbed BRAIN initiative focus, mTBI and TBI should be a separate seat, with scientific interpretation and research routing considerative of real-time BRAIN, IBI and IBRO findings.

*Require responsibility to standards in TBI and mTBI medical care; anything less is no longer acceptable. These responsibilities should be assured through hospital and healthcare reimbursement, quality accreditation and professional clinician development. Separate military and veteran systems, such as the MHS, should be held to the same standards. Any additional healthcare guidance necessary to assure veteran TBI care should be reimbursed for private healthcare and accounted for in national metrics. International systems, such as the NHS, should be able to cross compare metrics with mTBI and TBI healthcare delivery.

*Be accountable to literature. Literature reviews and meta-analyses that build from brain science need to be catalogued and built away from political reach.

*Welcome laboratory science, and laboratory professional involvement, to the international TBI research and delivery agenda [49].

*Align accountability in neuroethics. As brain science global coordination aligns, neuroethics must as well. Align policies on privacy, consent and biobanking[50]–[52]. Align policies on animal science[53], and include enforcement as well. Not only is poor animal science harmful to the animal, it is wasteful to the research dollar.

4. Be the best. Rather than try to convince service persons that we are the best ones to take care of their TBI/mTBI, let the quality of our work do the talking.

We can be the best with TBI science by dedicating national and international attention to:

Address military TBI surveillance and management gaps

Set expectations of research quality to the TBI civilian-military research portfolio

Improve TBI rehabilitation science

Emphasize pharmacological and nutrition science

Coordinate TBI biomarker science

Improve animal and non-animal TBI models

Welcome sports TBI science into civilian-military partnership

Bond public responsibility to service person quality of life post-injury

Address military TBI surveillance and management gaps as a coordinated effort.

Military departments cannot manage the complexities of TBI science alone, and we can help find the answers for them.

*Require consensus on standards and set timelines for resolution. The definition of concussion and mTBI, the definition of blast-related mTBI, TBI treatment initiation specifics, neurosurgical considerations, medical management guidelines and algorithms, repatriation from theatre, mandatory minimum rest, and role assignments should be resolved, and non-military expertise should be at the table [54]. Set expectations for eventual consensus on assessments and tools such as history, physical and neurological examination, symptom screening, the Military Acute Concussion Evaluation (MACE), the Neurobehavioral Symptom Inventory (NSI), Automated Neuropsychological Assessment Metrics (ANAM), Immediate Post-concussion Assessment and Cognitive Testing (ImPACT) and the Glasgow Coma Scale (GCS). Frequency, intensity, timing and details of use are necessary to clarify and standardize both for delivery of care and for research. It would be efficient to identify and plan for culturally appropriate modifications at the same time[5].

*Standardize the deployment-related mTBI investigation and remove reliance on service person self-reports. The differences in post-deployment screening and in theatre screening, noted in NATO reports[5], are unacceptable and the variance is irresponsible.

*Design a strategic plan to address TBI knowledge gaps as an international alliance. This plan should address the need for mTBI diagnostic tests, including advanced neuroimaging techniques, MRI diffusion tensor imaging, PET-CT, high-resolution fiber tracking and blood biomarkers. The plan should also address the need for electrophysiologic markers, including quantitative EEG and event-related potentials, measures of cerebral blood flow and intracranial pressure, neurocognitive assessments and sensory assessment tools.

*Determine TBI healthcare delivery quality indicators in military health. Include staffing, access to care by specialty and team-based care coordination. Respective of, yet beyond, country healthcare payer systems, initiate improvement reports. Hold expectations in quality reports alongside civilian and contracted care. Neurological, psychological and allied health care related to military TBI, mTBI and blast-related TBI are not government secrets. Quality to the delivery of care can improve in every military with positive peer support. Care coordination should be improved and measured between military and civilian institutions. Quality of care should be defined, measured and reimbursed accordingly.

*Define and place value on high quality care. RAND has initiated high quality definitions for service persons with a definition that this care should be evidence based, with treatment gains sustained throughout life. An examination of TBI impact alongside PTSD revealed 11 proposed high quality of care metrics. These should be incorporated into MHS, VA and private healthcare, attached to reimbursement [55]. Similar long term impacts of TBI/ mTBI could be analyzed, reported and metrics assigned. International adoption, or current international use of high quality care, should be compared.

*Be accountable to delayed diagnosis. Delayed diagnosis in deployment-related TBI has been noted, with diagnosis up to 76 weeks later. Disparities, operations, poor assessment methodology and other components should be tracked and analyzed continuously. When evidence of ongoing problems presents, TBI quality indicators should sharpen. Reimbursement and operational accountability should be required of all involved[56].

*Improve the coding in military healthcare operations, with consideration to veteran health operations as well. Administrative data and clinical records can be utilized for many data analytics, and reimbursement can be efficient, with better coding. DoD restrictions on TBI coding should be reflective of the injury, not just the symptom.

*Require follow up to national recommendations and international military reviews. Hard work and serious efforts should be responded to, and they should be shared in global alliance [2].

Set expectations of research quality in the TBI civilian-military research portfolio.

Militaries cannot improve research quality without the greater industry and civilian research commitment. We will help find the answers for them.

We need to know if we are doing the right thing or the wrong thing. Let’s stay ahead of the curve with knowledge advantage. Extra attention should be placed on TBI statistical methodology, definitions, tools, assessment methodology, unpublished data, design limitations, knowledge gaps, systematic review quality concerns, recommendation follow-up, policy and pragmatic design, and adherence to standards in PRISMA. Extra attention should also be placed on standardizing the evidence-based grading systems for TBI. The attention that we place on research quality should be matched by funding.

*Improve and standardize TBI statistics. How incidence and prevalence are counted matters. A systematic review of TBI epidemiology in Europe found that studies are widely variant. Crude incidence rates were reported and ranged from 47.3 per 100,000, to 694 per 100,000 population per year (country-level studies) and 83.3 per 100,000, to 849 per 100,000 population per year (regional-level studies). Mortality rates ranged from 9 to 28.10 per 100,000 population per year (country-level studies) and 3.3 to 24.4 per 100,000 population per year (regional-level studies) [57] . These variances are unacceptable. Improve the statistical standards.

*Obtain global consensus on TBI definitions. Definitions of TBI by stage, or type, matters. Many departments, including the DoD, assign one of five classifications to TBI: mild, moderate, severe, penetrating and unknown[58]. Much of the research reflects mild, moderate and severe categorization. Overall, the use and preference in definitions is unclear. The lack of consensus on mTBI and concussion definitions limits data and conclusions. A recent European systematic review found that journals measure TBI severity widely, including by use of GCS, AISHead and non-standardized clinical definitions such as duration of lost consciousness[57]. Improve, standardize and set expectations for the standards to be reflected accurately in the literature.

*Clarify cognition definitions, facets, dimensions, assessment tools and methodology. A publicly available table or organized data site could reflect TBI and cognitive impacts, as well as list the tools and methods utilized. When researchers introduce tools to military members, such as use of the Automated Neuropsychological Assessment Metric software, there should be understanding of where and how this tool has already been applied. Rapid reviewers could also consider tools for inclusion or exclusion to future work.

*Set the expectation for blast-related mTBI in research publication. There is no excuse for TBI expertise to ignore this stratification in analysis, and blast-related mTBI needs to be a component of the global brain research agenda. Both short and long term sequale analyses should address blast-related mTBI[5].

*Address and partner for military knowledge gaps, including research of mTBI and military healthcare delivery patterns and predictors, variations in diagnosis and care, and cohorts to assess persistent mTBI-related problems [2].

*Commit to measuring TBI health costs, utilization data, global burden in life years and quality of life metrics with epidemiological consensus. Formulas to calculate years of life lost due to TBI [59] should be adopted or redesigned with global consensus. These formulas could be duplicated and expanded to include overall TBI burden, with consideration to health quality of life. Civilian methodology applied to servicemembers should also warrant review and streamlining. The use of the South Carolina Traumatic Brain Injury and Follow-up Registry (SCTBIFR) model to determine service member disability, for example, should be examined. The SCTBIFR was developed with hospitalized civilians. If the methodology is found valid and reliable to military members, the methodology could be applied to a host of research. Notably, TBI patients identified at theater level 4 and 5 MTFs had an average long-term disability rate of 56.9% and 61.1%, respectively, and the methodology estimated that 25.2% of all service members hospitalized with TBI will develop long-term disability [60].

*Identify, verify and translate the risk factors associated with TBI trajectories. Be specific in active duty and veteran epidemiology. With proper research, possibilities to prevent non-deployment related TBI could shape interventions. Identification of risk factors for predictive behavior in traffic safety, as well as military training safety, could determine level of attention for TBI prevention. Equally, with transparency to data, identification of military operations that contributed to deployment-related TBI could assist in training and operational improvements. Risk factors for longer term mTBI impact should also continue to be analyzed.

*Identify, verify and translate external risk factors associated with TBI trajectories. One study found that neither the duration of loss of consciousness or posttraumatic amnesia, nor evidence of brain injury on CT scan or hospitalization, were associated with PTSD or major depressive disorder (MDD) risk after mTBI. What was associated with increased risk of PTSD and MDD after mTBI was having less education, being black and having a previous mental disorder. An injury resulting from assault or other violence increased the TBI patient’s PTSD risk as well [6]. In another example, one study found that socioeconomic status preinjury affects post-injury cognition for TBI affected individuals [61] . Another study found that SES did not affect post-injury cognitive, emotional or daily function, yet both pre-injury leisure as well as intellectual abilities did affect post-injury [62]. Healthcare access and quality should also be assessed in TBI epidemiology, as understanding rural and suboptimal care access, including ambulance time, is important to the insight [40]. Stronger research could map environmental and external factors for tailored care to optimize TBI recovery and health equity.

*Organize the fields of TBI research gaps as major categories. Including diagnostics, the gaps in research are intense. Epidemiology of TBI, demographics of patients, prevention, management, therapeutics, rehabilitation and chronic care should steer research portfolios. Gaps in research, such as differences between mTBI in civilians and service persons, and gaps in post-mTBI interval as it correlates to cognitive function have been noted [6]. Rehabilitation and occupational therapy gaps persist. Additionally, there is a major knowledge gap in the sustainability of social services, such as workplace interventions and vocational science [63]. There is also a need for key insights to design therapies that limit the chronic deficits associated with repeated mTBI, including therapies to stabilize and improve metabolic status for neuron and glia protection[64]. There has been an identified need for high quality research on TBI occupational therapy effectiveness and efficacy[65]. Another area of knowledge gap lies in interventions for TBI caregivers, families and relationships and communication interventions [66]. High quality research has also been requested for the acute and critical monitoring during severe TBI[67]. The organization of knowledge gaps should be accompanied by agreements in methodology. For example, the use of Newcastle-Ottawa Scale in non-invasive techniques for multimodal monitoring and TBI [68] may or may not be a standard in military science. Having predetermined agreements, under organized categories, maximizes evidence for expedited change.

*Assess the current coordination of major TBI collaboratives that already have established military connection. Determine how the VA National Research Action Plan (NRAP) operates alongside TBI and brain initiatives[69]. Determine how the Long Term Impact of Military-Relevant Brain Injury Consortium-Chronic Effects of Neurotrauma Consortium (LIMBIC-CENC) operates alongside DVBIC, TBICoE and brain initiatives. Determine how ENIGMA and its 43 country reach coordinates TBI and sports injury data science[29], [70]–[72].

*Shape blast-related TBI considerations in research.While one study found that blast and non-blast TBI groups had similar rates of depression, sleep disorders, alcohol misuse, vision loss, vestibular dysfunction, and functional status[73], inconsistencies and limitations have been noted. Blast-related TBI research should have consistency to outcome measures, blast injury mechanism descriptors and assessment methods[73].

*Partner for robust analyses, as opposed to designing for condensed resources. Research with veterans cites limitations of lag time between TBI patient participation and testing. Research also limits military-related TBI participation when assessing cognitive and executive function, and researchers exclude those with limb loss or in pharmaceutical therapies. Instead, robust research teams could allow for stronger analytics, broaden outcome assessments and secure inclusion of all TBI participants, understanding the outcomes as they apply to our current world [58], while also offering brain insight through stratification.

*Organize tools for TBI research. There are many, many TBI research tools used for various assessments. A global crosswalk should be available for all behavioral, cognitive, emotional, motor function, TBI self-reported experience and other assessment tools. Standardization and potential for standardization should be noted. ADaptability, such as with the Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) for cognitive impairment, should be noted. Once examined and created for adaptability, such as with the recent Tanzania Tanzania[74], military adoption within the same borders should also be considered.

*Organize tools for screening and assessment of TBI. Tailored tools for active duty and vetern populations should be a part of this comprehensive list and available to medicine. Screening and assessment studies that involve VA/VHA veterans [75] should warrant non-VA provider education. How primary or internal medicine care account for adaptable screening is important to note, including how proper assessments are conducted for the service person population affected who receive care outside the VA. On the other hand, civilian tool development should be reviewed for military inclusion. When it was a new tool introduced to assess quality of life after traumatic brain injury, QOLIBRI [76] could have been either streamlined or replaced.

*Determine the noted limitations that create low quality research and fund better designs. Small sample size, clinical outcome correlations, operational differences and other limitations to quality of acute care research impact the ability to shape evidence[67]. Even genetic work on APOE ε4 that indicated an association between long-term function and TBI was limited based on lack of large cohorting[77]. Funding should not be awarded to research networks that refuse to design for participation, limited bias, consistency in care and avoidance of limitations.

*Require research improvements once research recommendations are noted. As an example, mTBI research outcomes vary depending on which diagnostic criteria are employed, which assessment tools utilized and whether symptomatic groups are considered [78] . After a decade, the limitations listed for mTBI should already warrant better design. In another example, a recent review of clinical TBI outcome assessments for adult randomized controlled trials found a total of 126 separate outcomes identified in 58 studies. This limited comparisons, did not speak to robust patient reported outcomes, and did not always include the Glascow Outcome Scale/Extended. Consistency across studies was recommended, with use of common data elements for TBI outcomes and CONSORT guideline adherence recommended[79]. However, no consistency to outcomes has yet been created. These recommendations should be acknowledged and worked into future funded study.

*Be specific with quality in publication criteria for systematic and meta-analyses of TBI [6]

*Support open access. Funding should support open access with TBI publications. Our brains are our very identity. Use of data for health and science should respect this intimacy, including the extra voluntarism of service persons, and reflect the respect by sharing the data with the public.

*Require military inclusion at all clinical practice guideline tables. There is limited literature comparing and evaluating the strengths and weaknesses of all available CPGs for the treatment of acute TBI. A recent review of 24 CPGs involving 23 countries found that half of the guidelines were established by professional organizations, 4 by nonprofits, 3 with international committees, 3 with national governments, 1 by academic and 1 was of unclear origin[80]. The fact that no military involvement was discussed, despite the pervasive incidence and prevalence of TBI to military populations, is unfortunate. There should be no borders between TBI science and militaries. Researchers, publishers and professionals should be held to standards that require the discussion of active duty and veteran TBI in research and clinical practice guideline development. Further, findings that do not involve militaries should require civilian-military TBI review for consistency to care.

*Assess the current state of TBI evidence-based practice (EBP) in healthcare delivery. Assessments that could include surveys of provider practice, operational use, policies or protocols and national quality requirements to TBI EBP could be obtained. Results that indicate a mismatch between clinical care and EBP should be responded to with improvements, changes and high quality study if necessary.

*Request civilian-military engagement to address EBP gaps. The EBP methods for ranking and adoption of clinical guidelines should be determined[81]–[83]. The production and adoption of EBP, as well as meta-anlyses and systematic reviews produced by civilian healthcare, should be compared alongside military practice. In one example, occupation-based outcome measures and interventions for motor function recovery were discussed. Recommendations that motor function become an essential and standardized TBI occupational therapy component were made [65]. This recommendation should warrant active duty and veteran health care review alongside civilian healthcare, and the practice guidelines should be addressed together. In another example, researchers continue to analyze hypothermia in meta-analyses[84], [85], even though the continued discrepancy could be better addressed with global coordination and military leadership. Despite the ongoing TBI science leadership in military agenda, ongoing silo research speaks to the lack of civilian-military crossover. Request civilian-military engagement in EBP.

*Harmonize approaches in TBI outcome predictions. Consider IMPACT and CRASH calculators[86], as well as other identified formulas, and prepare for replicability of study design after diagnostic innovation.

*Identify policy and pragmatic design potential in TBI work. Studies that demonstrate significant motor vehicle and pedestrian TBI mortality have potential to influence policy[40].

*Establish a literature repository for the public and for researchers. Military TBI research that includes peer review reliance and manual search for references could have already warranted a better repository system. Public summaries or graded tiers of quality assigned, would benefit both the public and the science

*Coordinate neuroplasticity research. Neuroplasticity has the potential to recover lost functions [87], yet it needs translation from biology to bedside to reimbursement. Neurostimulation[88], pharmaceutical effects on neuroplasticity[89] and neurogenesis research should be coordinated. Data sharing, translational design and ethics policies should be a part of this global coordination. Provider and patient participation in research, including for protein synthesis at time of surgery, should be a component to global coordination[90]. As some research indicates that daily changes to routine, such as addition of acrobatic exercise, can impact brain plasticity [91], participation should be maximized. This work could be accomplished in tandem between private industry, civilian academic medicine and militaries across the globe.

Improve TBI rehabilitation science.

Not everyone’s situation is the same, yet we can improve the whole of TBI rehabilitation simultaneously for civilians and service persons.

*Establish consensus. Rehabilitation definitions, standards, center certification and healthcare accreditation should be standard across countries and across borders wherever possible. At the time of building construction, established guidelines should drive building requirements. As international work broadens care, particularly in LMIC and across high income networks, rehabilitation for TBI and mTBI should be consistent and comparable. Military health should be required to follow these standards, at minimum, and should be required to designate essential criteria for blast-related and military related TBI healthcare. Technological and other rehabilitation innovation should be backed in evidence and reimbursed accordingly[92], [93]. Sports related rehabilitation work should be at the greater table, with ongoing analytics[46].

*Implement practice guidance and audit criteria for TBI rehabilitation. Much of the evidence and parameters around rehabilitation and TBI are unknown due to low quality research or lacking data[94]. Create a robust analytics system, conduct research review and create clinical practice guidance that allows for continued evaluation. Establish team member responsibilities [95]. Require active duty and veteran status to be documented. Require blast-related TBI as a specific, separate code. Rehabilitation programs under hospital and large campus umbrellas are often affiliated with VA and veteran care; sharper attention to research and EBP is quite feasible.

*Establish cognitive rehabilitation as a sustained healthcare deliverable for individuals with TBI. Cognitive rehabilitation should follow tiered evidence and be available in the patient’s preferred environment. Implement standardized assessments, collaborate on policies and include cognitive domains in patient compliance considerations[96]. Employment and other aspects to quality of life should be secured as best as possible. Metrics should be required for TBI diagnosis maintenance that speak to cognitive rehabilitation and quality of life, and these metrics should follow best coding systems regardless of military or civilian health facility. Policies on cognitive rehabilitation requirements should address employment and other quality of life assessments, as well as funding for supportive employer and community environments.

*Require point persons or liaisons to assure best coordination for military-related TBI care. Analyses of rehabilitation research should address military training, blast-related and other non-stroke related TBI, and funding should fill the gaps. Evidence-based knowledge gaps between rehabilitation and military-related TBI can be best identified in this operation as well.

*Be accountable to cost-effective care and utilization data. Analytics should be conducted as a comprehensive component to TBI rehabilitation, with standards in definitions, codes and mathematical formulas. Reimburse accordingly.

Emphasize pharmacological and nutrition science.

Militaries cannot improve pharmaceutical and nutrition science without the greater industry and civilian research commitment. We will help find the answers for them.

*Compare pharmaceutical management in TBI clinical practice for civilian and military healthcare, and identify major discrepancies. Identify knowledge gaps and research needs.

*Require consistency to demographics and outcome metrics. Most TBI pharmaceutical research does not specify type of TBI, nor military-related status of the volunteers. Much of the literature also does not discuss cognitive ability as this relates to medication compliance or research participation compliance[97]. TBI pharmaceutical research often does not report adverse effects or safety information of the drug[98], [99]. Consistency in approach should be tied to funding.

*Coordinate high quality TBI pharmaceutical research with international networks. Many pharmaceutical reviews involving TBI identify serious research limitations. Literature may or may not include unpublished data[98]. The recommendations asking for well-powered, randomized controlled trials (RCT) with larger sample sizes and longer follow-ups should not go unheard[100] [101] [102]. Literature asking for data beyond RCT also needs follow up[103]. Have consensus with unpublished data and other bias avoidance. Fund accordingly.

*Determine priorities in pharmaceutical research. In example, the low efficacy of antidepressants in TBI affected populations[89], [100], [101], as well as consideration of antidepressants in neuroplasticity, should warrant immediate global coordination in study. Determine the priorities with consideration to the best models for specific TBI pharmaceutical research. As an example, the potential in ethanol and TBI recovery[104] should be assessed alongside available design models, such as animal models, and advanced only if warranted. Research dollars should be maximized for efficiency and potential.

*Be consistent with evidence ranking. Involve pharmacist and clinical chemist expertise in clinical practice guidelines and in large research cohort design. Require consideration of the service person population to the evidence. A review of studies involving hypertonic saline and intracranial pressure for TBI found that the type of TBI was not often categorized and concentration of fluids was not specified, nor were studies comprised of large, multi-site trials, prospectively registered, reported in accordance with current best practice [105]. While many of these specifics could be accounted for with better design, the evidence as-is also requires action to be taken.

*Require TBI pharmaceutical research leadership to be at the brain science table as data on basic and cellular science and the blood-brain barrier aggregate[106]. Opportunities for partnerships in research should not go unmet.

*Be accountable to military pharmaceutical research. It has been noted that veterans with moderate to severe TBI have a significantly increased risk of receiving opioid therapy. In one study, veterans reporting the most severe TBI sequelae (eg, loss of consciousness >30 minutes) were significantly more likely to receive short-term and long-term opioid therapy than those with less severe or no TBI sequelae[107]. The patient safety operations, continuous quality improvement, pain specialty clinical guidance development and involvement of civilian healthcare sector should be initiated.

*Determine rapid review pathways for clinical adoption. When TBI pharmacological intervention data is structured toward civilian populations and the non-deployed, such as with mTBI and anticoagulation[108], is there a network that could examine the research for applicability in TBI differentials? Is there a network that examines stroke information for differential uses with blast-related TBI care? And, if departments are to rely on specific clinical guideline task forces, how does the public know that the task forces are addressing these studies? Conversely, when evidence exists that determines a therapeutic is ineffective[109], how does the accumulation of greater data, review and practice change occur?

*Require nutritional consideration to pharmacology. The investigation of nutritional interventions, with the objective of altering neurophysiological outcomes following TBI, are of recent interest. While studies have measured various nutrients and amino acid supplementals for TBI patients, such as BCAA levels[110], there have not been large nutritional intervention studies involving humans. Across 43 studies using 2,897 animals, anti-oxidants, branched chain amino acids, and ω-3 polyunsaturated fatty acids have shown the most promising pre-clinical results for altering neurophysiological outcomes following TBI[111]. Serious attention to design, methodology and pre-clinical strategies should drive nutrition research for the TBI population.

*Welcome sports medicine to be at the TBI nutrition science table.

*Require clinical practice guidance review and research agenda review that addresses the gut microbiome. The gut microbiome has been noted to change with TBI[112]. Understanding involvement of biological and pharmacological processes, related clinical care and therapeutic interventions to the microbiome can establish a foundation on which pharmaceutical and nutritional analytics have footing.

*Require policy review for civilian and military leadership. Policies related to food supplementation assistance, nutrition in the workplace, financial assistance and access interventions should all be at the service person table, in time. Nutrition pre-deployment and during deployment, as well as with sports, should also be discussed.

Coordinate TBI biomarker science.

*Assess the biotechnology research portfolio as it currently stands regarding biomarkers and TBI science, worldwide. Determine the technologies in development to assess CSF/serum albumin ratio, S100B, tight junction proteins, plasma soluable prion protein, decrease in cerebral autoregulatory capacity that disturbs CBF, axonal injury, neuroimaging, Tau protein, UCHL1, NSE, GFAP, MPB, Neurofilaments, Spectirn breakdown products, NGAL, APOE, BDNF and the neuroinflammatory biomarkers interleukin, inflammatory proteins, such as IL-6, IL-8, and IL-10, in the CSF, and marinobufagenin [113]. Determine the technologies to assess biofluid biomarkers for downstream effects including metabolic changes, vascular pathologies, and inflammation during the secondary injury phase involved with progressive neuronal and glial damage. Determine the technologies that can assess the body’s ability to clear molecules after injury, including within the blood–brain barrier (BBB), interstitial fluid (ISF) bulk flow, and cerebrospinal fluid (CSF) absorption into the circulatory and peripheral lymphatic systems[114]. Assess research partnerships, intellectual property requirements, trade policies and data sharing of this science between industry, government and military work. Assess where the sports industry is currently involved.

*Create a strategic TBI biomarker agenda that coordinates with international brain science initiatives. Be specific, involve industry, be clear on funding needs. Create consensus to tiered, ranked potential. Include the ability to measure the effect of pressure gradients on the movement of proteins and protein fragments from the CSF into the peripheral circulation [114] . Include prioritization to sports and concussion biomarker science, including S100B, tau, neuron-specific enolase (NSE), and glial fibrillary acidic protein (GFAP) [115].

*Involve partnered TBI research where possible, and standardize methods. In the case of prognostic research involving TBI calculations, such as IMPACT and CRASH, specifics biomarkers have been identified for potential inclusion. Neuron-specific enolase (NSE), glial fibrillary acid protein (GFAP), S-100β protein, tumour necrosis factor-alpha (TNF-α), interleukin-6 (IL-6), myelin basic protein (MBP), cleaved tau protein (C-tau), spectrin breakdown products (SBDPs), and ubiquitin C-terminal hydrolase-L1 (UCH-L1), and sex hormone biomarker science could involve partnerships in funding, with robust research built in [86].

Improve animal and non-animal TBI models.

Even a college freshman animal rights activist would prioritize human TBI prevention and recovery. Even a research industry with multiple priorities can prioritize non-animal and humane improvements to TBI scientific discovery. And even a robust biotechnology industry can prioritize the scientific needs of active duty and veteran populations impacted by TBI.

*Structure animal science. Animal models and non-animal models for TBI research need global oversight under a strategic gameplan. Inefficiencies, high costs, inability to translate the science to human brains and poor quality to research are serious limitations with these models. Pain, suffering and cruelty are also serious. There is no coordination, nor graded research evidence, to steer operational decisions around the models. These animal models, including the fluid percussion injury (FPI) model, the controlled cortical impact (CCI) model, the impact acceleration model, the weight-drop model, the freeze lesion model, the penetrating injury model and the blast injury model each come with limitations[116]–[118]. When new models present, such as CHIMERA [119], there is no global review. Additionally, there is no structure to behavior or cognitive assessments of animal models and TBI[120]. Structure the science worldwide.

*Define animal model terminology and classifications. Despite decades of scientific use, the classification of animal model TBI injuries do not match global human TBI classifications, and there is no standard. The classification of scientific production does not account for cellular or molecular changes[121]. Further, the classification of injury after the TBI induction in the animal model remains debated [122]. The sheer lack of coordination in animal model research should warrant immediate TBI funding review. Global strategic planning for TBI and animal models should include consensus on definitions. This will reduce poor research, minimize harm and maximize international coordination toward best methods[116] [117].

*Structure methodology and interpretation analytics. Determine injury context and injury consequence measures for animal models[118]. Clarify human and animal anatomy and physiology differences, including aging processes and behavior processes, and how these major barriers affect animal data translation[116], [123]. Differences that include cerebral blood supply processes, biochemical and molecular data of the animals [116] also exist. Interpretation of animal models should be a component to a global, publicly available guide.

*Determine methodology and data analytics around secondary injury progression. The physiological and hemodynamic responses to TBI injury, including release of pro-inflammatory cytokines, chemokines, free radicals, mitochondria dysfunction, and oxidative stress that contribute to cell death, axonal degeneration, tissue necrosis and functional impairment[120], warrant global consensus on animal model use and interpretation. These responses also warrant biotechnology industry priorities toward better model development.

*Determine ethical guidance around repeated mTBI and animal use[124].

*Hold animal science publications to quality metrics. One metric should be that of classification of neurological syndrome, neurological event and neurological disease (concussion, TBI and CTE respectively). Publication quality matters [118].

*Advance non-animal models wherever possible, with similar global strategic structure. Computational modeling that studies head impact and initial head loading should be reviewed and advanced under guidelines[125].

Welcome sports TBI science into civilian-military partnership.

TBI science for athletes can and should advance alongside civilian-military partnership.

*Define TBI and mTBI with inclusion of sports considerations. Require consistency to sports injury definition for sports related concussions (SRC) and chronic traumatic encephalopathy (CTE). Require this of research publications, of clinical care and of public messaging. Consider coding consistency that aligns with comprehensive considerations, such as with the International Classification of Headache Disorders (ICHD)[126], [127].

*Determine research and clinical practice knowledge gaps. mTBI/SRC rest and treatment, CTE and other areas currently under research should be coordinated for maximum, focused data. Tier priorities as well. For example, literature recommends that science identify objective real-time markers for SRC. Helmet-based systems should be supported with better objective markers[127]. This should be tiered under the research umbrella. The prioritization of objective metrics for real-time sports analytics should be determined and private industry coordinated. Evidence availability should also determine priorities. For example, conflicting evidence on aerobic exercise and return to function should be examined for research prioritization. The limited evidence that collaborative care, including cognitive behavioral therapy, psychopharmacological consultation and care management, reduces symptoms [126] should also warrant review for further data needs.

*Emphasize quality to research. Systematic reviews and meta-analyses should be held to strong methodological rigor. Use of Downs and Black checklists[126], for example, should either be routine or replaced.

*Structure global coordination to clinical practice guideline adoption. If it is found that cervical and vestibular physiotherapy is more effective than typical rest for SRC[126], the intensity, duration and frequency of care should be determined. The reimbursement pattern in clinical care should also be determined.

*Require utilization analytics for sports-related TBI. If there is no evidence to minimal evidence that medical treatments are of benefit to concussion recovery[126], how the medical world accounts for current practice is important. In a world where CTE risk remains under study, how the medical world accounts for medical visits with other symptoms, or under other diagnoses, is critical. mTBI and repetitive SRC that result in short term physical dysfunction, mild cognitive impairment, impaired sport-related functions, prolong reaction times, memory impairment, visual-motor speed or later life depression [128] require utilization analytics. These analytics also serve to address healthcare access for athletes and former athletes, and these analytics remove barriers in private team ownership health transparency.

*Require consensus to the amount and type of tests, tools and methods undertaken by players. Catalogue and crosswalk the tools and methods used to assess mTBI, SRC, acute and chronic symptoms. Have evidence-based movement toward streamlined standards. One literature review found that most player tests were self-administered, without clinician consistency to administration. Additionally, the concussion themselves were self-reported, as opposed to a database with professional tracking and surveillance of occupational health[129]. These limitations greatly impact research. The limitations may also speak to clinical care quality.

*Require consensus to tools and methodology for assessment, including mandatory versus voluntary involvement[129], and include school health with occupational health operations. Cross-compare with greater healthcare and military work, particularly in the areas of mTBI screening and self-assessment.

*Coordinate global expertise and agenda. CTE research indicates that mTBI is the only consistent risk factor found,that there is no relationship between CTE and age of death, that there is no relationship between CTE and abnormal ApoE genetics, and that neither suicide nor premorbid dementia is strongly associated with CTE. A global research agenda could tease the findings apart. Coordinated expertise could determine where stronger evidence is required, and thus where collaborative funding could be allocated.

*Have sports science at the international brain science table. Neuropathological and clinical findings related to CTE overlap with many common neurodegenerative diseases[130], and mTBI/SRC science continues to evolve.

*Require professionalism to global health involvement mTBI and SRC. Almost 20 years later, WHO mTBI and concussion task force literature remains without direction[131]. The analytics involving a three-phase system do not appear replicated in today’s scientific community. Additionally, inclusion of public and patient interest remains absent. WHO priorities on pre-injury personality data may not be a priority to the injured population. mTBI and sport science requires an interested, involved global public health community. This community should be one that pulls up a military chair to the table.

*Coordinate public messaging nationally and global. Task national public health and nonprofits to be consistent. Basic information should include scientific findings thus far[132].

*Assess the occupational health inclusion of athletes and sports in occupational health science and policy.

*Determine best path forward for primary prevention and policy, including with helmet laws[133], worldwide.

Bond public responsibility to service person quality of life post-injury.

Just as it is important to cover obligations, it is equally important to assure health and quality of life equity for active duty and veteran service persons affected by TBI.

*Commit to ongoing medical needs assessments for the TBI population. Scheduled military-civilian leadership reviews should assure labor and facility resources. Access, staffing ratios, specialist availability, contracts and pertinent DVBIC training should be a part of this discussion[134]. Social service needs and satisfaction metrics should be included.

*Be consistent with health equity in healthcare quality of life. When military research identifies that service persons with TBI demonstrate diminished performance on tasks requiring attention and concentration; procedural computation; working memory; and neural processing speed/efficiency [58], interventions should be documented, with a focus on quality of life equity.

*Ask for publicly available social service clinical guidelines that address service persons and TBI from CNRM or other task forces[135].

*Measure, evaluate and be responsible for quality in social service deliverables around relations, family dynamics, caregivers[136], [137], resilience [138] and other support structure.

*Coordinate cognitive training. Cognitive training in rehabilitation continues with standards [139] and there should be consensus on active duty and veteran centric methods, formulas and interventions based on injury severity, timing of post-acute phase and intervention intensity/duration. Social services should partner in this leadership.

*Assess and improve the navigation of active duty and veteran TBI resources and services, and include DAV[37]. Set metrics to these, include metrics on durable medical equipment quality, and enforce responsibilities.

*Create consistency to DVBIC and DoD TBI resource use[140]. If navigation is intended for clinicians, members of the public and service persons, how are these resources being used? Measure the effectiveness and be accountable to efficiency in navigation.

*Target employment as a component to active duty and veteran TBI health and rehabilitation reimbursement. Increased unemployment rates, work limitations, and productivity loss have been noted in individuals after a mild TBI. Interventions should be a component to clinical practice guidelines[141].

*Include quality of life considerations and service person satisfaction data with any research collaborations seeking policy direction, including for post-TBI and driving[142]

*Be accountable to health equity and socioeconomic (SES) correlations with TBI affected service persons. Research that would assist service member routines pre-deployment, or offer protective assistance in any form, should be amplified, verified and translated to funded intervention. Examining this data for validity and generalizability, as well as improving major risk factor research, could drive clinical guidance. Within and away from the context of MHS access, SES as a predictor of prognosis, indicator for early intervention, indicator for prevention intervention and lifelong evaluation metrics should remain a consideration. If SES does impact brain anatomy and physiology[143], and some literature indicates it does from an early age[144], [145], what protective interventions have we placed in military operations during pre-deployment and deployment? What protective interventions have we placed in sustained social services post-injury, through the service person’s life?

*Strengthen satisfaction and customer service assessments, responses and interventions for active duty and veteran populations affected by TBI. Proactive ask, anticipatory communication and anticipatory service should be incorporated at every level of healthcare for this population. Reduce the stress and inefficient energy required of customers when poor customer service prevails. Ask the service persons affected by TBI what they want, and respond accordingly.

5. Start the global TBI science days with a positive attitude.

The days ahead remain infused with TBI brain science enthusiasm, compassionate medicine, passionate expertise, involved governments, and a supportive public. The days ahead can be wonderful days for active duty and veteran populations affected by TBI.

It is feasible to coordinate world health teams to collect and publicly disseminate TBI tools, methods, standards and research networks. It is feasible to align brain science research collaborations in global TBI strategic agenda. It is also feasible to train critical eyes to review and shepherd the TBI research agenda toward high quality. It is feasible to improve TBI care delivery, as well as sustained social service for service person health equity, worldwide. This is not a difficult movement to initiate nor maintain, and we can remain positive knowing that success is achievable.

Find the areas that your healthcare or medical care can contribute in leadership, and take the initiative for long-term transformation of active duty and veteran TBI care.

TBI research and healthcare delivery improvement for active duty and veteran populations, as well as for the greater public, is a responsibility we can each be a part of. We have found our world can be a watchful guardian of active duty and veteran healthcare; now that we have found one another, we can keep one another.

It’s our choice. This is what we are going to do.

Traveling with the refs:

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[4] “US Department of Defense Worldwide Numbers for TBI,” 2020, [Online]. Available: https://dvbic.dcoe.mil/dod-worldwide-numbers-tbi .

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[7] A. C. McKee and M. E. Robinson, “Military-related traumatic brain injury and neurodegeneration,” Alzheimers. Dement., vol. 10, no. 3 Suppl, pp. S242–53, Jun. 2014.

[8] “Severe TBI,” Centers for Disease Control and Prevention, 2020. https://www.cdc.gov/traumaticbraininjury/severe.html (accessed Feb. 01, 2021).

[9] H. M. Bramlett and W. D. Dietrich, “Long-Term Consequences of Traumatic Brain Injury: Current Status of Potential Mechanisms of Injury and Neurological Outcomes,” J. Neurotrauma, vol. 32, no. 23, pp. 1834–1848, Dec. 2015.

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