[Senate Hearing 118-681]
[From the U.S. Government Publishing Office]
S. Hrg. 118-681
TRAUMATIC BRAIN INJURY AND
BLAST EXPOSURE CARE
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HEARING
BEFORE THE
SUBCOMMITTEE ON PERSONNEL
OF THE
COMMITTEE ON ARMED SERVICES
UNITED STATES SENATE
ONE HUNDRED EIGHTEENTH CONGRESS
SECOND SESSION
__________
FEBRUARY 28, 2024
__________
Printed for the use of the Committee on Armed Services
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Available via http: //www.govinfo.gov
__________
U.S. GOVERNMENT PUBLISHING OFFICE
60-824 PDF WASHINGTON : 2025
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JACK REED, Rhode Island, Chairman
JEANNE SHAHEEN, New Hampshire ROGER F. WICKER, Mississippi
KIRSTEN E. GILLIBRAND, New York DEB FISCHER, Nebraska
RICHARD BLUMENTHAL, Connecticut TOM COTTON, Arkansas
MAZIE K. HIRONO, Hawaii MIKE ROUNDS, South Dakota
TIM KAINE, Virginia JONI ERNST, Iowa
ANGUS S. KING, Jr., Maine DAN SULLIVAN, Alaska
ELIZABETH WARREN, Massachusetts KEVIN CRAMER, North Dakota
GARY C. PETERS, Michigan RICK SCOTT, Florida
JOE MANCHIN III, West Virginia TOMMY TUBERVILLE, Alabama
TAMMY DUCKWORTH, Illinois MARKWAYNE MULLIN, Oklahoma
JACKY ROSEN, Nevada TED BUDD, North Carolina
MARK KELLY, Arizona ERIC SCHMITT, Missouri
Elizabeth L. King, Staff Director
John P. Keast, Minority Staff Director
_________________________________________________________________
Subcommittee on Personnel
ELIZABETH WARREN, Massachusetts,
Chairman
RICHARD BLUMENTHAL, Connecticut RICK SCOTT, Florida
MAZIE K. HIRONO, Hawaii MIKE ROUNDS, South Dakota
TIM KAINE, Virginia DAN SULLIVAN, Alaska
TAMMY DUCKWORTH, Illinois TED BUDD, North Carolina
(ii)
C O N T E N T S
_________________________________________________________________
February 28, 2024
Page
Traumatic Brain Injury and Blast Exposure Care................... 1
Member Statements
Statement of Senator Elizabeth Warren............................ 1
Statement of Senator Rick Scott.................................. 3
Witness Statements
McBirney, Samantha, Professor of Policy Analysis, Pardee Rand 5
Graduate School.
Zafonte, Ross D., Chief of Traumatic Brain Injury and Health & 14
Wellness Programs, Home Base.
Larkin, Frank J., Chief Operating Officer, Troops First 23
Foundation, Lead of National Warrior Call Day Initiative.
Martinez-Lopez, Hon. Lester, Assistant Secretary of Defense for 44
Health Affairs, Department of Defense; Kathy M. Lee, Director,
Warfighter Brain Health Policy, Department of Defense; and
Captain Carlos D. Williams, USN, Director, National Intrepid
Center of Excellence.
Questions for the Record......................................... 62
(iii)
TRAUMATIC BRAIN INJURY
AND BLAST EXPOSURE CARE
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WEDNESDAY FEBRUARY 28, 2024
United States Senate,
Subcommittee on Personnel,
Committee on Armed Services,
Washington, DC.
The Subcommittee met, pursuant to notice, at 2:59 p.m., in
room 222, Russell Senate Office Building, Senator Elizabeth
Warren (Chairman of the Subcommittee) presiding.
Subcommittee Members present: Senators Warren, Blumenthal,
Hirono, Kaine, Ernst, Sullivan, Scott, and Budd.
OPENING STATEMENT OF SENATOR ELIZABETH WARREN
Senator Warren.
[Technical problems.] This hearing will come to order. I am
pleased to welcome you all to today's hearing to receive
testimony on the Department of Defense's efforts to protect
servicemembers from blast overpressure.
Servicemembers put their lives and their health on the line
when they are--[technical problems]. In return, we have a
profound responsibility to make sure the Nation is doing all we
can to keep them safe, to prevent battlefield and training
casualties--oops, thank you.
[Technical problems.]
Senator Warren. That could be trouble. All right. Good. Did
we get the other on the record? Just so, I got started here.
Servicemembers put their lives and their health on the line
when they put on their uniforms.
In return, we have a profound responsibility to make sure
that the Nation is doing all that it can to keep them safe, to
prevent battlefield and training casualties, and to provide the
best possible care for those who are injured. We are holding
this hearing----
[Technical problems.]
Senator Warren. We are there? Good. We are holding this
hearing because DOD is not meeting its responsibilities when it
comes to traumatic brain injuries (TBI) and other injuries that
result from firing weapons.
Injuries from blast overpressure, the pressure that is
caused by a shock wave that exceeds normal atmospheric values,
have been the signature wounds of the wars in Iraq and
Afghanistan.
But there are also injuries incurred in training here at
home. They are invisible, but they affect thousands of
servicemembers, causing headaches, seizures, hallucinations,
and ultimately significantly increased risks of depression and
suicide.
Over the course of just 3 months in 2023, DOD provided TBI
treatment to servicemembers nearly 50,000 times. The more we
learn, the more we come to understand that blast exposure is an
ongoing threat to the health of individual servicemembers, and
to the well-being, the morale, and the readiness of our entire
force.
I appreciate the support I have had on this issue from
Ranking Member Scott, from Senator Ernst, from Senator Tillis,
and from other Members of this Committee. I secured a long term
study of blast overpressure injuries in the 2018 National
Defense Authorization Act, and I have worked with Senator Ernst
to introduce legislation on blast overpressure and to secure
additional requirements to track blast overpressure injuries in
the Fiscal Year 2020 NDAA.
DOD is working to implement this legislation, but we still
have significant problems. Last year, The New York Times
reported on heightened brain injury risks for United States
troops in Syria fighting ISIS. Four artillery batteries
assigned to the region fired more weapons than any military
American artillery since the Vietnam War.
The result was that each of these units had members with
serious blast overpressure injuries, and each had at least one
member that committed suicide. These deaths are a tragedy.
Ryan, a Navy SEAL deployed to Iraq and Afghanistan, was subject
to significant blasts from his own weapons over the course of
his career and later died by suicide.
His father, Mr. Frank Larkin, is here today to discuss the
harm that blast overpressure has caused to servicemembers and
to their families. The Times also revealed that even when DOD
had made policy changes to address risks, those changes were
not evident on the ground. Weapons known to deliver shock waves
well above safety thresholds were still widely used. Training
did not involve basic safety measures, and special operations
forces were not issued blast exposure gauges, the gauges that
are needed to track the threats they faced.
So, DOD and Congress both have a lot to do. Here is my
agenda to address this problem. First, we need to establish
mitigation strategies specific to the servicemember roles that
are most at risk for blast overpressure.
Second, we must require DOD to create blast exposure and
traumatic brain injury logs for all servicemembers and to
integrate these logs into their VA and DOD health care records.
Third, the Department of Defense should partner with
innovative, evidence based programs like Home Base to help
servicemembers get the care they need. And I am going to have
to brag here for just a minute.
Home Base is a nonprofit organization founded by
Massachusetts General Hospital and the Boston Red Sox to take
care of the invisible wounds of veterans, servicemembers,
military families, and families of the fallen. Home Base has
clinics in Massachusetts and in Florida, Ranking Member Scott's
State.
Home Base has a comprehensive brain health and trauma
program specifically designed for special operations veterans
and servicemembers, where it has been leading innovative
treatments for veterans with co-occurring substance abuse and
mental health conditions.
As we work through this year's NDAA, I want to support this
program's work, and I appreciate Dr. Zafonte from Home Base
joining us today. One more item.
We need to make sure that DOD sets a threshold on the
maximum number of rounds that is safe--that servicemembers can
safely fire, and that this includes consideration of exposure
limits over an extended period of time. DOD must do its part
and Congress must do our part.
So, to our witnesses, welcome and thank you for appearing.
We are going to have two panels today. The first panel will
consist of outside witnesses to provide their perspective on
where DOD and the services are falling short on protecting
servicemembers from blast overpressure.
Dr. Samantha McBirney Professor of Policy Analysis at the
Pardee RAND Graduate School, Dr. Ross Zafonte, Chief of
Traumatic Brain Injury and Health and Wellness Programs at Home
Base, and Frank Larkin, Chief Operating Officer of Troops First
Foundation and lead of the National Warrior Call Day
Initiative.
The second panel will consist of officials from the
Department of Defense and Walter Reed to hear how DOD is
tackling this issue. We will have Dr. Lester Martinez Lopez,
Assistant Secretary of Defense for Health Affairs, Kathy Lee,
Director of Warfighter Brain Health Policy at DOD, and Captain
Carlos Williams, Director of the National Intrepid Center of
Excellence at Walter Reed National Military Medical Center.
I will now turn to Ranking Member Scott for his comments to
open this hearing.
STATEMENT OF SENATOR RICK SCOTT
Senator Scott. First, I want to thank Senator Warren, the
Chairwoman of this Committee and--our Subcommittee and thank
her for caring about this issue and for taking this job so
seriously. Chairwoman Warren, I want to thank you for holding
this hearing on such an important topic.
Traumatic brain injury, or TBI, is one of the most common
injuries sustained by American servicemembers. In 2022, more
than 20,000 military personnel were diagnosed with TBI. Stop
and think about that for a second. Just in 2022, there are more
than 20,000, 20,000 members of military that were diagnosed
with a traumatic brain injury.
That is pretty bad. The vast majority, over 84 percent,
were classified as mild, which is more commonly known as a
concussion. But if any of us have--when you have raised kids
and they have a concussion, it scares the living daylights out
of you.
Missing from this data are servicemembers who are
frequently exposed to low level blasts that do not typically
result in a clinically diagnosable concussion. This is
concerning because repeated exposure to low level blast may
cause similar symptoms as more severe cases of TBI.
We know that low level blast exposure from fire and heavy
weapons systems or explosives may cause a variety of symptoms
including concentration, memory problems, irritability,
headaches, and decreased hand-eye coordination. Each of these
issues alone can be very serious and disrupt somebodies life.
Unfortunately, there remains a great deal about exposure to
these blasts that we yet do not know. More research and better
data are required so that military and health care providers
can mitigate the frequency of blast exposure where possible and
treat those exposed to blast where necessary.
We have actually taken action to do that. In the 2018
National Defense Authorization Act, Congress required the
Department of Defense to conduct a medical study on blast
pressure exposure.
Two months ago, the Committee received the Department's
final report on this study. This hearing presents an
opportunity to assess the quality of the Department's work. The
legislation required the study, which followed specific
individuals over an extended period of time, to include three
specific elements.
First, the Department was to ``monitor, record, and analyze
data on blast pressure exposure'' for any servicemember
``likely to be exposed to a blast in training or combat.''
Second, the study was to assess the feasibility and
advisability of including blast exposure history into a
servicemember's medical record.
Last, the Department was to review the safety precautions
of heavy weapons training in light of emerging research on
blast exposure. In reviewing the final report submitted this
past December, it is clear the Department still has more work
to do, particularly in its ability to monitor and record blast
exposures for military personnel.
Only a few hundred soldiers and marines were fitted with
wearable devices that unfortunately seem to suffer from quality
control issues. And while the Department's report does say that
it may be feasible to record blast exposure information in a
servicemember's medical record, a business case analysis is
required to determine the way forward in this area. In this
hearing, I would like to learn more about how the Department
plans to conduct this business case analysis.
This is an important issue. I believe the Department is
committed to getting this right and I believe the TBI Center of
Excellence and Warfighter Brain Health Initiatives are
excellent initiatives that I hope will provide the military
with the information needed to better understand the effects of
repetitive blast exposure.
We all must remember the exposure to low level blast will
continue to be a necessary risk for many of our frontline
combat troops. But if we can do better--if we can better
quantify the type and number of blasts that have the potential
to cause significant, perhaps permanent injuries, then we can
use that information to make better decisions about how best to
accomplish a particular mission.
I would like to hear from the witnesses what Congress can
do to ensure the Department of Defense has the resources it
needs to conduct its planned work and where we can help. Only
this is about the well-being of the individuals that are
willing to put on the uniform, who are closest to the front
line of combat, and every servicemember that is diagnosed with
TBI.
We owe it to them to ensure--and their families to ensure
that when they go into harm's way, they are well-trained, have
the right protective equipment, and are utilized in a manner
that achieves the objective with an understanding of the risk
involved.
I want to thank you to all the witnesses for being here
today. I look forward to your testimony. And again, I want to
thank Senator Warren for putting this together.
Senator Warren. Thank you.
[Technical problems.]
STATEMENT OF SAMANTHA MCBIRNEY, PROFESSOR OF POLICY ANALYSIS,
PARDEE RAND GRADUATE SCHOOL
Dr. McBirney. Chairwoman Warren, Ranking Member Scott, and
Members of the Committee, good afternoon, and thank you for the
opportunity to testify today. My name is Dr. Samantha McBirney,
and I am a Biomedical Engineer at the nonprofit, nonpartisan
RAND Corporation.
My research for the last 15 years, not only at RAND, but
also at the University of California, Berkeley and the
University of Southern California, has focused on traumatic
brain injury, or TBI, both as the result of blunt impact and
blast overpressure.
Today, I would like to speak with you about repeated
exposure to low level military occupational blasts, which are
low level blast exposures experienced while fulfilling military
occupational duties.
Evidence suggests that servicemembers are exposed to these
blasts in the form of blast overpressure, or the pressure wave
that emanates from the source of an explosion. This pressure
wave can cause sub-concussive injuries which are not
immediately detectable and would not qualify as a TBI.
Exposure to blast overpressure can occur both in combat and
in training, as has already been mentioned. During training,
exposure can be due to breaching exercises and the firing of
increasingly powerful weapon systems, such as the Carl Gustaf
recoilless rifle and the AT4.
To provide some perspective on the level of exposure some
servicemembers have, one study found that up to 32 percent of
blasts experienced by breaching instructors exceeded the
recommended exposure limit.
Studies have shown that the cumulative effect of repeated
low level blast exposure can cause symptoms similar to TBI.
While a variety of effects have been linked to low level blast
exposure, as Senator Warren and Senator Scott have already
mentioned, there remains a lack of scientific evidence linking
repeated exposure to injury. One reason for this is the
difficulty of diagnosis.
The very nature of low level blast exposure, and the fact
that it is not one single event that causes an issue, but
rather the cumulative effect of repeated exposure over time
complicates injury recognition.
Symptoms typically do not manifest immediately, which makes
it unlikely that repeated exposure to low level blast is
identified as the cause. Additionally, injury is vastly
underreported among servicemembers, only obfuscating the issue
of proper diagnosis further.
There is also a lack of research about the military
occupational specialties at greatest risk of exposure to low
level blast. While there is no doubt that certain occupational
specialties are more frequently exposed than others, there is
little research to support these hypotheses.
So, there remains a lack of understanding of the direct
impact that repeated exposure to low level blast has on the
health of servicemembers in different occupational specialties.
If the preventive intervention is perfectly effective but
cannot be delivered in time, it is not useful.
This quote from a 2019 RAND report perfectly describes the
current State and the reason many of us are here today, ``as a
research community, we clearly see that additional research
needs to be done. However, there are steps the DOD can take now
to better protect servicemembers against blast induced
injury.''
I highlight four recommendations in my written testimony,
and I would like to bring your attention to one of them here,
the creation and maintenance of blast exposure records. These
records should include number of exposures, the context of each
exposure, and any physical, mental, or emotional effects
resulting from that exposure.
This would allow the DOD to better track exposure
frequency, assess the occurrence among high risk occupational
specialties, determine the connection between exposure and
health outcomes, and develop strategies to mitigate exposure in
training environments.
Ultimately, these records could be used to develop an index
score to gauge an individual's combat readiness and potential
health risks. As our weapon systems continue to become more
advanced and increasingly powerful, low level military
occupational blasts will remain an enduring challenge for
servicemembers.
Addressing the issue of repeated exposure to these blasts
necessitates action and collaboration between the DOD and the
research community. By implementing the recommendations as
outlined in my written testimony, alongside continued research
efforts to close substantial knowledge gaps, the DOD can take
significant strides toward better protecting the health and
well-being of our servicemembers.
Thank you, and I look forward to your questions.
[The prepared statement of Dr. McBirney follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Senator Warren. Thank you.
STATEMENT OF ROSS D. ZAFONTE, CHIEF OF TRAUMATIC BRAIN INJURY
AND HEALTH & WELLNESS PROGRAMS, HOME BASE
[Technical problems.]
Dr. Zafonte. Good afternoon, Chairwoman Warren, Ranking
Member Scott, Members of the Subcommittee. My name is Dr. Ross
Zafonte. I am honored to provide testimony today on traumatic
brain injury care and blast exposure. My career is centered
around improving the lives of people with traumatic brain
injury.
I currently serve as President of Spalding, Chair of the
Physical Medicine Rehabilitation Department at Harvard Medical
School, Chief of the Department of Physical Medicine
Rehabilitation at Mass General Hospital and Brigham and Women's
Hospital, and for the past 15 years, I have served at the Home
Base Program, directing its Brain Injury Program. I actually
see the patients, as well as do the research.
Blast overpressure, as we just heard, is a sudden onset of
a pressure wave from explosions occurring with shoulder carried
artillery in training or deployment, in breaching buildings,
and from improvised explosive devices. Generally, the bigger
the explosion, the more damaging the pressure width.
TBI can have a wide range of physical and physiologic
effects. Some signs appear immediately, others take days or
weeks to occur, and they may result in physical, sensory,
cognitive, behavioral, or mental impacts.
According to the Department of Defense, since 2000, over
400,000 U.S. servicemembers experienced at least one brain
injury and 40 percent of those later screened positive for co-
morbid psychological health conditions.
Our own research has noted an elevated 10 year risk of
hypertension, cardiac disease, endocrine or hormonal
dysfunction, and behavioral concerns such as depression even
among the youngest of patients.
Home Base is located in Charlestown, Massachusetts, with, I
am proud to say, as a native Floridian, satellite locations in
Florida and Arizona, and operates one of the oldest and most
impactful private sector programs in the Nation.
For 15 years, we have served as an incubator for innovative
clinical care models and research, and the program is nested
within Mass General Hospital, allowing us to leverage the
faculty in Mass General Brigham Health System. Home Base
bridges the gap between research and clinical care.
Now, in 2018, Home Base was approached by the Navy Special
Warfare with a complex set of problems facing Navy SEALs. We
quickly developed a comprehensive brain injury and polytrauma
program. This program is named COMBAT, or the Comprehensive
Brain Health and Treatment Program.
It is modeled after existing programs that we developed for
elite athletes and provides integrated, multi-disciplinary,
specialist treatments, evaluation and care coordination for
veteran and Active Duty operators. Home Base has treated nearly
1,000 special operators through our intensive programs, 71.9
percent of combat participants are Active Duty and the
overwhelming majority return to duty, so we are keeping the
fighting force active. We currently have 178 Active Duty
special operators waiting to be screened and scheduled for
COMBAT Program, and COMBAT has cared for operators in 47
States, the District of Columbia, Guam, Puerto Rico, including
53 patients from Massachusetts, 60 from Florida, 6 from
Connecticut, 22 from Hawaii, 278 from Virginia, 4 from
Illinois, 1 from Alaska, and 54 from North Carolina.
The COMBAT program is highly efficient, agile, and
compressed into a 5-day model of care. Patients see a minimum
of nine providers, and this may expand grossly related to
pertinent diagnostic imaging or other studies.
So, in summary, we are very grateful for the support of
Congress, especially Chairwoman Warren, has shown this program,
and for the partnership and financial support provided by
SOCOM.
The program is successful and the demand for care is
growing at a steady pace. Based on my experience in this field
and treating patients at Home Base, I would recommend the
Department of Defense consider the following options. Invest in
and develop tools to measure----
[Technical problems.]
Dr. Zafonte. Increase funding for partnerships with
academic medical centers. Ensure all servicemembers with
traumatic brain injury can easily access care. And as has been
said, that data needs to be linked to blast exposure.
Develop novel methods to define and understand the impacts
of declining health spans and develop treatment interventions.
I also recommend that DOD partner with Home Base to develop a
long term, longitudinal health span study on the multi-system
injury of blast and traumatic brain injury.
And invest in research that evaluates and treats the long
term sequalae of repeated brain injuries of blast exposure.
Thank you for the opportunity to testify on this very important
topic, and for your commitment to supporting members of the
military. I am happy to answer questions the Committee may
have.
[The prepared statement of Dr. Ross D. Zafonte follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Senator Warren. Thank you, Dr. Zafonte. Mr. Larkin, would
you like to make an opening statement?
STATEMENT OF FRANK J. LARKIN, CHIEF OPERATING OFFICER, TROOPS
FIRST FOUNDATION, LEAD OF NATIONAL WARRIOR CALL DAY INITIATIVE
Mr. Larkin. Thank you to the Committee for the opportunity
to speak. My formal testimony is submitted for the record.
As a former Navy SEAL, I am here today to be a voice for
all those that have worn our Nation's uniform and are currently
struggling everyday with both visible and invisible wounds.
Wounds that transcend mental, physical, and spiritual domains.
Wounds that transcend--I am sorry, wounds that have influenced
an epidemic level of suicides amongst our Active Duty force and
veteran populations.
My intent today is not to pounce on the Department of
Defense or the Veterans Administration, but to help them
succeed. I would not be here if it was not for my son Ryan,
U.S. Navy SEAL Special Operator 1st Class Ryan F. Larkin. My
son would be 36 years old today if he had not taken his life on
the morning of April 23d, 2017.
He had been suffering from what we have come to
characterize as invisible wounds, a complex rubric of post-
traumatic stress disorder, moral injury, and substance use
disorder that was complicated by undiagnosed traumatic brain
injury from blast exposure, the signature injury of the past 20
plus years fighting the global War on Terror.
Ryan was a highly decorated and accomplished Navy SEAL,
trained as a special operations medic, sniper, and explosives
breacher. He loved being a SEAL, furthered by the love and
loyalty for his teammates that was cemented on the battlefield.
Following four heavy combat tours in Iraq and Afghanistan,
Ryan, like many others who have worn the uniform of our Nation
in combat, began experiencing uncharacteristic changes that
manifested in difficulty sleeping, nightmares, anxiety,
hypervigilance, loss of memory and declining cognitive
functions. He stopped smiling. He sought help, but the help
that was offered was not aligned with what he needed.
When his condition became more complicated, and their
proposed solutions didn't work, the system weaponized his pleas
for help against him and pushed him out of the SEAL team and
out of the Navy.
This abrupt separation created another deep weeping wound.
He felt that he had let his teammates down, abandoning them.
The system he trusted hung labels on him to justify their
assessments and their actions. A year after he honorably
separated from the Navy, Ryan ended his life. Ryan repeatedly
said, something is wrong with my head, nobody is listening,
they keep telling me I'm crazy.
This was reinforced by the endless stream of medications
prescribed by both defense health and VA clinicians to address
his behavioral symptoms, not the root cause of his challenges.
Everything defaulted to psychiatric and mental health illness,
with very little mention of TBI, despite his operational
profile and repeated exposures to blast overpressures from our
weapons systems and enemy IEDs.
Over the course of 2 years between defense health and the
VA, he was prescribed over 40 different medications, everything
from potions, lotions, and creams to high end psychotropic and
mood stabilizing drugs. He never received a clinical diagnosis.
He was a walking experiment.
One night prior to his death, he said that he wasn't going
to live very long, that he was broken up inside. He made me
promise that if anything ever happened to him, that he wanted
his body donated for TBI-Breacher's Syndrome research. Then he
turned to me and said, you know dad, it is going to take guys
killing themselves before the system wakes up to the fact that
it has a problem.
The guys are hurt. Ryan's brain was donated to a DOD
research effort at Walter Reed National Military Medical
Center. Two months later, we learned that Ryan had a severe
case of undiagnosed microscopic brain injury uniquely related
to repeated blast exposure. Ryan was hurt, not crazy.
He was right all along. Unfortunately, our medical
enterprises could not and still cannot see this level of
microscopic injury in a living warfighter or veteran. My son
died from his injuries suffered both in training for combat and
combat operations.
He just didn't die right away. These warriors with
invisible wounds, they are hurt. They are not broken. They
break when they are cut away from their teammates, their
tribes, and are betrayed by the institutions where they have
given their all. It has been 23 years since 9/11. DOD has spent
almost $3 billion in mental--on mental health, substance abuse,
suicide prevention, PTSD, TBI, and other warfighter assistance
programs.
I give them a D plus, C minus at best, for the lack of
measurable impact for those who need answers. Those are the
deck plate, dirt level warfighters we promised to take care of
and not leave behind.
Blast exposure is a key threat to warrior brain health and
potentially represents a significant national security threat
to our force, readiness, and resiliency. However, whatever
solutions we come up with, it can't impact our operational
effectiveness or lethality on the battlefield.
We need to do this smarter and by down the risk on the
front end. Thank you for the opportunity to be the voice for
others like Ryan. Subject to your questions.
[The prepared statement of Mr. Frank J. Larkin follows:]
Prepared Statement by Mr. Frank J. Larkin
introduction & background
. . . We know that losing someone with traumatic brain injury
(TBI) to suicide isn't the worst part. There are 500,000 other Ryan's
currently out there with TBI trying to stay alive, despite being four
times as likely to attempt suicide. Military TBI and suicide scientist
Dr. Jayna Moceri-Brooks' husband, a career Armor officer with TBI, is
just one of them. We know the worst parts are when you get the call
about another. And another. And another.
We know no one is immune, not even colleagues like Dr. Kate
Rocklein, whose husband Michael Froede was Special Operations (SOF),
had TBI, and died shortly after Ryan as she was conducting research on
factors inducing suicide in SOF. Always canaries in the coal mine, we
know Special Operations' projected incidence of TBI exceeds 52 percent,
three times that of other combatant commands, with corresponding
suicides in these elite units outpacing the larger military at
estimated rates of 2.5 to 1.
Ryan, Michael, nearly half of Michael's chalk from the Special
Forces Q course, and countless others have died from TBI while
inspectors general found last year the entire US Central Command failed
to assess and treat brain injuries in its combat troops. Or DOD
assigning no oversight authority for TBI initiatives force wide. Or DOD
spending three billion taxpayer dollars on quote-unquote the best
neurological care possible, like $3.7 million reading Greek classics to
soldiers, or $2.7 million producing a Sesame Street vignette about
death.
Or DOD spending $76 million annually for Preservation of the Force
and Family, an unsuccessful non-clinical fitness program posing as
brain and mental healthcare for Special Operators still
disproportionately dying from TBI-related suicide. Unfortunately, that
human performance program is the foundation of the Warfighter Brain
Health Initiative.
Without this Committee exercising the considerable power endowed by
its mandate to ensure our common defense, holding leadership
accountable for treating TBI and preventing related suicides will
remain aspirational, to the horror of families imagining more survivors
bearing the costs of these wars, and to a generation of potential
recruits again witnessing our military abandon the very troops it has
unsuccessfully enticed them to become.
We are elevating these threats to servicemembers (SM) lives to
congressional levels based on alarms raised by impartial clinicians and
scientists analyzing 20+ years of DOD's TBI initiatives. We are
elevating these threats because DOD's reports to Congress now globally
exclude mention of TBI and, on their face, are overtly disingenuous and
have over-capitalized Congress' patience and goodwill.
We know DOD hyperfocus on capturing blast overpressure data is a
ruse because DOD has had exposure thresholds for a decade. Warfighter
Brain is a 5-year-long exercise in regurgitative rebranding of
previously ignored recommendations made by myself and others years ago.
We know experts predict Warfighter Brain is more likely to induce TBI-
related suicides than prevent them.
We know the Longitudinal Blast Overpressure Study was neither
longitudinal nor an actual research study. Despite unfettered access to
DOD-created and approved sensors, investigators used untested, faulty
sensors while exposing SMs to dangerous ex-urban blast overpressures
without informed consent or right to refuse. Were it legitimate
research, it never would have passed review by a qualified ethics
board. And if it had produced any tangible results, those data would be
dismissed as biased, problematic, and unacceptable.
We know that pillars of Warfighter Brain have no basis in medical
evidence, nor can such human performance programs treat brain trauma in
any way advised by clinical medicine. We've known since 2006 that
athletic training cannot improve TBI cellular pathologies. We know
DOD's current plan is to treat TBI primarily by accelerating SMs'
cognitive processing speeds--an infinitesimally small aspect of TBI--
but not by providing cutting-edge TBI assessment and treatment
available to civilian citizens.
In the words of one Operator with TBI, ``HPO just means we're in
the best shape of our lives when we kill ourselves.''
We know DOD has weaponized science to avoid acting decisively on
TBI: they will again try to convince you that nothing can be done
without snipe hunting for more data. We know TBI from blasts with
pressures as low as 30psi--about the force of a bicycle tire exploding-
scrambles DNA signaling, causing hosts of chronic clinical syndromes
and neurological disorders, from Parkinson's to mood disorders to
suicide. Yet in November 2022, ASD guidance was that overpressures of
4psi were plenty dangerous enough. Again: we know that DOD knows the
overpressures and thresholds.
We know that SOF's superior fitness and resilience does not repair
anatomical damage from blast exposures and treating TBI with human
performance optimization is like prescribing CrossFit for Alzheimer's.
We know the past 10 years of DOD pushing athletic wellness programs for
neurological injuries has done much to gaslight SMs with TBI into
believing they could heal if they weren't so weak, further incenting
their suicides.
We know DOD is publicly moving toward force wide assessment of
cognitive processing deficits from TBI to remove injured SMs and their
families from career military service with immediacy--``med-boarding''
them is far more economically appealing than expenditures toward
healing and retaining our Nations' most experienced and sophisticated
SMs during a time when we can recruit neither into our armed forces.
We know from Dr. Moceri-Brooks' pioneering work that receiving the
Purple Heart for brain injuries would reduce suicides, one of precious
few tangible solutions available to us. We also know that without
consent of Congress, DOD adjusted criteria for the Purple Heart and
TBI. Awards branches now misapply regulations in denying multitudes of
eligible SMs Purple Hearts for combat related TBI: officially denying
this injury's existence and further incenting their suicides.
We know from Dr. Rocklein's influential work that Special Operators
have been stripped of tabs and tridents and separated from their teams
en masse for exhibiting uncontrollable symptoms of TBI and suicidal
behaviors. We know such institutional betrayals precede suicide in
Special Operations more often than not. And tomorrow these unsanctioned
practices can be easily reversed--with the stroke of a pen--at no cost
to taxpayers.
We know Warfighter Brain is another slick, opaque strategy full of
battlefield buzzwords without clear paths to success. Since we also
know DOD is only selling tickets to another circus, my second
recommendation is to transfer TBI care to vetted, agile private
industry and academic health sciences partnerships equipped to
immediately assess and initiate approved emerging treatments with basis
in evidence and efficacy.
Last, and especially poignant given my presence here because of
Ryan's death, and Dr. Rocklein's discoveries because of Michael's
death: we know comprehensive reforms are the only viable path forward.
Therefore, I recommend immediately implementing the Froede-Larkin
Reform Act, also submitted prior to testifying, into this year's NDAA.
It is evidence-based and signals sincere course correction to
disenfranchised SMs with TBI, and their families suffering with them,
reverses nearly 20 years of TBI mismanagement and confusion, and
ensures upcoming generations of SMs never again experience such
cruelties of bureaucratic inertia toward their health, welfare, and
survivability.
Acknowledgments: Testimony prepared collaboratively with Dr. Kate
Rocklein and Dr. Jayna Moceri-Brooks.
references
1. Shively SB, Perl DP. Traumatic brain injury, shell shock, and
posttraumatic stress disorder in the military--past, present, and
future. J Head Trauma Rehabil. 2012 May-Jun;27(3):234-9. doi: 10.1097/
HTR.0b013e318250e9dd. PMID: 22573042.; Traumatic Brain Injury Center of
Excellence (TBICoE), DOD TBI Worldwide Numbers.
2. Rocklein, Katharine J. No Sky Too High, No Sea Too Rough:
Resilience and Suicide in Special Operations Forces. New York, NY:
Amazon. 2024; Davidson, Peter. Human Performance Optimization in
Canadian Special Operations Forces Command (CANSOFCOM) and the Canadian
Armed Forces (CAF). Department of National Defence: Ottawa, ON. 2022;
Deuster, Patricia, et al. A Shift From Resilience to Human Performance
Optimization in Special Operations Training: Advancements in Theory and
Practice. J Spec Ops Medicine, 2017.
3. Coordinating Authority Needed for Psychological Health and
Traumatic Brain Injury Activities. GAO-12-154, Jan 25, 2012; GAO report
to House Armed Services, Biomedical Research: Observations on DOD's
Management of congressionally Directed Medical Research Programs,
January 31, 2022.
4. Evaluation of Traumatic Brain Injuries in the U.S. Central
Command Area of Responsibility. DODIG-2022-006, Nov 1, 2021; Evaluation
of the DOD's Management of Traumatic Brain Injury, DODIG-2023-059,
March 28, 2023.
5. Lee, Katherine M., Khatri, Trisha L., Fudge, Elizabeth R. U.S.
Department of Defense Warfighter Brain Health Initiative: Maximizing
performance on and off the battlefield. Journal of the American
Association of Nurse Practitioners 32(11):p 720-728, November 2020;
Department of Defense Warfighter Brain Health Initiative (WBHI):
Strategy and Action Plan, June 8, 2022.
6. New Poll Spells Trouble for U.S. Military Recruitment Woes.
Newsweek, Feb 9, 2024.
7. Suicide Prevention: DOD Should Enhance Oversight, Staffing,
Guidance, and Training Affecting Certain Remote Installations, GAO-22-
105108, Apr 28, 2022
8. Statement of Michael J. Roark, Deputy Inspector General,
Department of Defense, for a Hearing on Suicide Prevention and Related
Behavioral Health Interventions Before the Subcommittee on Personnel,
Senate Armed Services Committee, U.S. Senate, April 6, 2022
9. Inspector General, Department of Defense. Memorandum for Under
Secretary of Defense for Personnel and Readiness, Announcement of
Research on the Data Associated with the Department of Defense,
Surveillance of Suicide Related Events (Project No D2019-DEV000-
0160.000). May 13, 2019
10. Assistant Secretary of Defense. Memorandum for Assistant
Secretary of the Army, et al. Interim Guidance for Managing Brain
Health Risk from Blast Overpressure. Nov 4, 2022
11. Larkin, Frank. Previous testimoneys to Congress, 2017-present.
12. Rocklein, Katharine J, Moceri-Brooks, Jayna, Larkin, Frank.
Critical Review of the Warfighter Brain Health Initiative (WBHI) and
Longitudinal Medical Study on Blast Pressure Exposure of Members of the
Armed Forces. Froede-Larkin Military Suicide and Traumatic Brain Injury
Reform Initiative, January 2024.
13. Explosive Breaching Injury and Suicide Prevention, Tactical
Explosive Breaching Operations (NJ-002-RECV): Urban Detonation Subject-
Matter Expert (SME) Review, Oct 30, 2023; Longitudinal Medical Study on
Blast Pressure Exposure of Members of the Armed Forces, Dec 19, 2023;
Turner, Stephanie M., et al. Surveying the Landscape: A Review of
Longitudinal Traumatic Brain Injury Studies in Service Member and
Veteran Populations. J Neurotrauma 40.11-12 (2023): 1060-1074.
14. Misistia, Anthony, et al. ``Sensor orientation and other
factors which increase the blast overpressure reporting errors.'' PLoS
One 15.10 (2020): e0240262; Wiri, Suthee, et al. ``Development of a
fast-running algorithm to approximate incident blast parameters using
body-mounted sensor measurements.'' Military medicine 187.11-12 (2022):
e1354-e1362; L. A. Beardslee et al., ``Blast Capsule: An Embedded
Pressure Sensing System for Internal Blast Pressure Measurement,'' in
IEEE Sensors Letters, vol. 5, no. 11, pp. 1-4, Nov. 2021, Art no.
5501204, doi: 10.1109/LSENS. 2021.3117890; Belding, Jennifer N., et al.
``Getting on the same page: consolidating terminology to facilitate
cross-disciplinary health-related blast research.'' Frontiers in
neurology 12 (2021): 695496.
15. Rocklein Kemplin, Kate, and F. Young Bowling. ``Liberating the
Oppressed: Research Knowledge Differentials and Ethical Investigation
in Special Operations Forces Clinical Science.'' Journal of Special
Operations Medicine 17.1 (2017): xii-xv
16. Townsend, Michelle L., et al. ``Ethical issues when conducting
health research with military personnel: a scoping review protocol.''
JBI Evidence Synthesis (2023): 10-11124.
17. National Academies of Sciences, Engineering, and Medicine;
Health and Medicine Division; Board on Health Care Services; Board on
Health Sciences Policy; Committee on Accelerating Progress in Traumatic
Brain Injury Research and Care. Traumatic Brain Injury: A Roadmap for
Accelerating Progress. Matney C, Bowman K, Berwick D, editors.
Washington (DC): National Academies Press (US); 2022 Feb 1. PMID:
35533242; Silverberg, Noah D., et al. ``Management of concussion and
mild traumatic brain injury: a synthesis of practice guidelines.''
Archives of Physical Medicine and Rehabilitation 101.2 (2020): 382-393.
18. Rocklein Kemplin K, Paun O, Sons N, Brandon JW. The Myth of
Hyperresilience: Evolutionary Concept Analysis of Resilience in Special
Operations Forces. J Spec Oper Med. 2018 Spring;18(1):54-60. doi:
10.55460/1VKO-UVDZ. PMID: 29533434; Paun, O., D. C. Godbee, and J. W.
Brandon. ``Resilience and Suicide in Special Operations Forces: State
of the Science via Integrative Review.'' J Spec Oper Med. 19.2 (2019):
57-66.
19. Moceri-Brooks, Jayna, et al. ``The Purple Heart and suicide
risk in post-9/11 US Army combat veterans with a traumatic brain
injury: a mixed methods study.'' Military psychology(2023): 1-13.;
Moceri-Brooks, Jayna, et al. ``Exploring the use of the Interpersonal
Needs Questionnaire to examine suicidal thoughts and behaviors among
Post-9/11 US Combat Veterans: An integrative review.'' Military
Psychology (2023): 1-13.
20. As reported to Senate legislative liaison by Human Resources
Command, February 2024
21. Froede-Larkin Military Suicide and Traumatic Brain Injury
Reform Act (Internal Use Draft), January 31, 2024.
Senator Warren. Thank you, Mr. Larkin. I appreciate your
being here and sharing this story. I am sorry for your loss,
and I am sorry for the treatment your son Ryan received. I
think you said it right, traumatic brain injuries are
considered ``the signature wound'' of our wars in Iraq and
Afghanistan.
While improvised explosive devices, IEDs, may have caused
some of these medical injuries, a military medical research
study found that for troops with mild traumatic brain injury,
``the most important cause of brain injury was the long term
exposure to explosive weapons.''
In 2011, the Defense Advanced Research Projects Agency
determined that 75 percent of the troops' blast exposure in
Afghanistan was coming from their own weapons. The effects of
blast overpressure are terrible, including memory loss,
increased risk of dementia, and substance abuse problems.
But despite the severity of these impacts on
servicemembers' health, when these problems are diagnosed,
blast exposure is rarely identified as a potential cause. Dr.
McBirney, you have studied this issue for 15 years now. Why is
it so difficult to detect when blast overpressure is causing
the types of symptoms that we are talking about here in our
servicemembers?
Dr. McBirney. That is a great question, Senator Warren, and
a question that so many people within the research community
are committed to answering. It really comes back to the nature
of the injury itself.
We are not looking at an injury that is caused by one
isolated event. The fact that it is caused by repeated exposure
to very low level blasts that perhaps might happen throughout
the course of an entire military career really complicates
injury recognition.
Add to that the fact that symptoms typically don't manifest
immediately, as was mentioned, and it becomes increasingly
difficult to link symptoms to repeated exposure.
Senator Warren. So, yes, I just want to say, I want to pick
up on this, because I think this is a really important point
about the challenge in trying to diagnose because of the very
nature of what the injury looks like. It is not a single moment
in time where this happens. And so, I just want to pick up and
let's see if we can take this forward.
We need to know how often, I take it from your testimony--
we need to know how often a servicemember has been exposed to
blast overpressure, to give medical personnel the information
that they need to identify and treat the underlying cause of
their symptoms. Now, so far, the DOD only has blast exposure
data for a total of 500 servicemembers.
We are missing data, obviously, for a whole lot more.
Tracking this information through blast exposure and traumatic
brain injury logs for all servicemembers would be a good start,
but we also need to pay special attention to servicemembers
that are at especially high risk for blast exposure.
Some military occupational specialties, MOSs, such as
training instructors, are significantly more likely to be
exposed to blast during training or operations. The Marine
Corps found that the artillery community is also at
particularly high risk and that high rates of exposure could
lead them, ``to suffering injuries faster than combat
replacements can be trained to replace them.''
So, Dr. McBirney, I wanted to give you another chance in
this is we are trying to push this forward, does DOD currently
have the strategies it needs to mitigate the risks from blast
overpressure that are specific to each of the military
occupational specialties that are most likely to be exposed?
Dr. McBirney. I can't say I am aware of any of those
strategies. And in addition to that, a lot of the folks with
whom I interact on a very regular basis with boots on the
ground in these communities that are at risk of significant
exposure are additionally unaware of such strategies.
Senator Warren. Okay. So, anything more do you want to say
about what DOD should be doing in this space? I want to make
sure I have given you a chance here.
Dr. McBirney. No. Thank you, Senator. I think really Mr.
Larkin and I were discussing prior to this. I think if my--if I
could choose the key takeaway for today, it would be to not let
perfection interfere with progress. I think everyone here is
looking for the right solution. And what we really want to be
sure of is that we don't wait too long to implement what we
think is a perfect solution.
There is a lot of research that still needs to be done.
Coming from the research community, I am always a supporter of
more research. That being said, we can also be looking to
implement solutions, study said solutions, while they are being
implemented at the same time.
Senator Warren. So, let's focus on that for just a second,
just a little bit more, about the idea of collecting the data
as we go along, so at least it is a first step in getting the
information that we need.
I understand this is a gap that DOD needs to fill, and I
understand that it is more challenging to limit servicemember
blast exposure during combat, but there is no excuse for DOD to
continue to expose servicemembers to unnecessary levels of
blast overpressure during training. This is obviously an area
where we could make change, and it is clear that there is a lot
we need to do to protect our servicemembers from blast
exposure.
But DOD, it goes to your point Dr. McBirney, DOD constantly
says we need more research, we need more research. And I am a
data nerd. I always want more research, but I am very concerned
about the idea that we are going to put off treatment.
So, let me put the question more specifically to you, and
that is, do you think we know enough now about the risks of
blast overpressure to servicemembers' health to start taking
action now?
Dr. McBirney. In short, absolutely. Yes.
Senator Warren. All right. So, we do know enough. So, there
are number of steps DOD could take to help us get more data so
that we can understand this over time, but more importantly, a
number of steps they could take right now in terms of
treatment.
I have talked long enough so I will come back to you later
on this, Dr. Zafonte and Mr. Larkin. Senator Scott.
Senator Scott. Yes. Well, first, Mr. Larkin, I can't
imagine--having kids and grandkids, I can't imagine lose one.
So, thank you for your service, your son service and just hope
as a result, you know, something good happens out of it.
Somebody--it prevents something else from happening.
Dr. Zafonte, can you explain what the--the blast, what does
it do to the brain like this? Like let's say, you know, I go
shoot a shotgun or doing this stuff, what does it do--each one
of them, how does it impact my brain?
Dr. Zafonte. Well, I think, to my colleagues' good point,
perfection is the enemy of the good. You can criticize all of
the models, but we know that these sub-concussive injuries do a
number of different things.
They probably disproportionately impact areas of the brain
at gray matter, white matter interfaces. They probably have a
vascular effect. More likely long term, there is possibly a
premature aging effect to the brain itself with multiple
repetitive blast exposures or certainly with traumatic brain
injury.
So, lifelong exposure, getting that quantification that
Senator Warren talked about is critically important because we
need to know one thing. We need to know in who, how much, what
were they doing, and then what was the actual phenotype or what
actually happened to the symptoms of the person, and track that
very carefully.
Senator Scott. So, right now, you can get a glucose monitor
and put all your data in there, and pretty fast you can get a
correlation, right? So have you had any opportunity to take--
because we know, if you joined the service, we know what blast
you are going to have in boot camp if you are enlisting--you
know, enlisted. Is there anybody that is doing anything to just
say that when you just put all this data on something and then
just look at the model over a period of time?
Dr. Zafonte. I think there are a number of groups,
including our own, looking at blood based biomarkers for
people, neuroimaging. All of those are critical as we
understand the exposure and the diagnosis.
But we also want to know how those things and specific
lifelong exposures impact the symptoms of the person. Because
there is not a 1 to 1 relationship. There's a relative
relationship.
Senator Scott. If every servicemember, if you had the data
of--you know, just start today. Just anybody new that joins
boot camp and starts going through infantry training. If you
just have the data and you had that in front of you, then over
time you could do predictive analysis of, you know, where the
problems are, right?
Dr. Zafonte. Right, and I think that--but to the point that
was just raised, I think there are action steps now and that we
have--we are compelled very much so to make this a living
learning environment and continue to collect data and perhaps
change policy, change programs, change how we treat people as
we understand more over time.
Senator Scott. So, you don't have enough information today
exactly what happens as all these blasts happen. What you have
is, you know, you see the result. You see over a period of time
that this is what happens. That is what you have so far, right?
Dr. Zafonte. I think that is right. I think, Senator, what
we have, and thank you for the excellent question, is a series
of smaller studies that show changes in your imaging, changes
in blood based biomarkers, representative of injury of the
brain. But how it is going to behave in a large population of
people is one thing. How it is going to behave in Bobby or Sue
is a very different thing.
Senator Scott. Right. Okay, and how--so, Dr. McBirney, how
hard it would be to just put up a program? It wouldn't be that
hard, would it?
Dr. McBirney. That is a great question. Unfortunately, one
that I find myself unqualified to answer.
Senator Scott. But we do it in a whole bunch of other
stuff. We do it like with glucose monitors, right. And if you
gave servicemembers just--you know, just say, here--they all
have cell phones, right? You just had an app that said, okay,
so every time you have exposure okay, you put this in. You put
in exactly what you did and what you shot.
Some people are not going to do it well, just like no one
follows their health--you know, they didn't take their
medicine. But that wouldn't be that hard to do, right? I mean,
we have all this stuff from sugar levels.
Why don't we do--I mean, why don't we--why wouldn't that be
the simplest thing to start doing and then you could start
seeing that, like--if you could--if you had all that data, you
could pretty quickly do a predictive analysis of even short
term problems. Not, you know, it take a long time to say what
is my 20 year problem, right.
Dr. Zafonte. Yes, I think following people over decade will
be valuable. I think we will see certain markers and certain
things change early on, but we have to remember that it is not
an uncomplicated story.
Even the blood based biomarkers or other entities such as
imaging have a lot of variation within. You know, the brain, I
think my colleagues would support me, is an incredible
structure, but it is also a bit of a black box still within
science, and understanding how different networks
relationships, how these nodes connect, and an injury in one
space affects an injury another, that is a challenge.
Senator Scott. But you would actually know the result. I
mean, you even though you don't know exactly why, you could
over time predict what is going to happen.
Dr. Zafonte. If you are looking for symptomatic, senator,
prediction I think with a large enough data set, you certainly
could draw some strong relationships.
Senator Scott. Right, and then very quickly come back and
say, okay, we know this. We know that if you have this much,
you know--the, you know, the odds are like you can go get a
blood test for cancer now and it is very predictive of whether
you are going to end up with cancer. Is it perfect? No. I mean
it depends on the cancer. So, it seems like this would be
pretty easy to do and it shouldn't be that hard.
Dr. Zafonte. So, Senator, I would agree with you, but I
would bring up the issue that we are all individual and
different people, and these types of injuries affect
individuals in a different way.
So, a series of years? worth of exposure is affected by who
you were beforehand, the kinds of exposures, and then the
treatment you had afterwards. That produces this result, and
the fact that it is not so easy to put in a box.
Senator Scott. Right. Okay. Senator Hirono.
[Technical problems.]
Senator Hirono. I call myself for 5 minutes--[technical
problems]. There are a lot of our servicemembers who were
exposed to IEDs during the tenure in Afghanistan and Iraq. So,
are you tracking these servicemembers? Most of them probably
are in veteran status. Are you tracking them for exposure to
blasts and what is happening to them? Anybody?
Mr. Larkin. So, I used to be a senior leader within the
Department of Defense running the Joint IED Field Organization,
JIEDO. I can tell you that it was a concern as far back as
2008, 2009, that these blast exposures were creating a unique
health risk to our warriors.
We had gotten to the point where we had up armored and
created new armored vehicles that were surviving the blast, but
what got in that vehicle and what came out of that vehicle were
two different states, and it alerted us to the fact that there
were things--that blast effect was having an effect on the
human body that needed to be studied and researched.
So, as far as you know, having a handle on--unless there
was a catastrophic injury and usually one that was visible, at
the time, if they--a lot of these folks came out of these
vehicles, and they looked fairly normal.
Senator Hirono. Yes.
Mr. Larkin. It wasn't until time evolved that we started to
see the behavioral changes, cognitive dysfunction, and so
forth. I have no knowledge of whether anybody attempted to
formally collect on that data and do anything with it.
Senator Hirono. I think that is an important kind of
followup as we try to understand what the impact of these
blasts are long term. Also, I would think that--I mean, it is
bad enough that there is traumatic brain injury that needs to
be followed up on, but I would think that a lot of them may
develop conditions such as ringing in the ears. Yes, so, Dr.
Zafonte.
Mr. Larkin. Thank you very much, Senator, for the excellent
point. I think we have long term sequelae for people such as
tinnitus or ringing in the ear, chronic headaches.
Senator Hirono. Yes.
Dr. Zafonte. Pain is a big driver that drives not only a
headache or one's immediate perception, but it also invades
behavior. People who are in pain don't behave the same way, and
they don't cognitively perform the same way.
So, what I am saying is that blast has a multi-system
effect. Of course, the brain is our principal and driving
concern, but it has effects in things that are linked to the
brain, linked to the behavior that we need to know more about.
Senator Hirono. Well, for example, tinnitus--that doesn't
cause pain, but it is severely annoying. It can be
debilitating. I don't know whether you are--it sounds as though
you are also tracking the incidence of these kinds of issues,
and it is something I am very familiar with, and there seems to
be no cure for these conditions.
I am very interested to know what kind of breakthroughs
there are in treatment--I know that tinnitus is the disease,
and tinnitus is a ringing that's not related to any problem
with the ears. So, is that something that you all are also
studying, tracking?
Mr. Larkin. Senator, all I can tell you is that I have it
from the use of explosives and weapons.
Senator Hirono. You have it?
Mr. Larkin. It doesn't go away.
Senator Hirono. I know.
Mr. Larkin. It is just--I have to live with it.
Senator Hirono. Me too. It is very annoying. Sometimes it
is so loud that it interferes with sleeping. So that is--I
think that there are a lot more of our servicemembers who have
endured or are enduring those conditions that we have to pay
attention to. One more question.
A 2023 RAND report noted that there is a critical gap in
effective PPE in that most models represent the average human
male. So is that--and this is for Dr. McBirney. It is certainly
important that we protect--provide protective equipment to all
of our servicemembers.
So how can we make sure that this kind of protective
equipment is also--is appropriate for women. Is that happening?
Dr. McBirney. That is a great question, a very important
topic, and it is happening. So those findings were from the
last State of the science meeting that we had on blast induced
injury, and we were happy to learn that there is quite a bit of
research being done in the community to make sure that the
average male, and specifically in many instances the average
Caucasian male, is not the only subject that is being used to
test equipment.
Senator Hirono. Yes. That is very important. Thank you.
Thank you, Madam Chair.
Senator Warren. Thank you. Senator Ernst.
Senator Ernst. Thank you very much, and good afternoon. I
would like to thank you, Chairwoman, for the invitation to
participate in this Subcommittee today. It is a very important
discussion that we are having about the impact on our
servicemembers and their families.
Traumatic brain injuries can arise not only from the combat
deployments, but also from those routine training exercises
that our men and women go through every single day. Even when
they are adhering to safety standards and established safety
guidelines, the act of firing heavy weapons, just as you
stated, Mr. Larkin, can create those long term effects.
Other types of training sessions in preparation for combat
deployments, many of these things can potentially lead to
cognitive impairments affecting our function. Mr. Larkin, I
understand that you shared the story about your son, Ryan.
I want to thank you so much for your service as a Navy SEAL
and your son's service as a Navy SEAL. It was through Mr.
Larkin, through Frank sharing his son's story with me many
years ago that I finally understood the need to be involved
with traumatic brain injuries.
So, thank you so much for sharing what is a very difficult
story to tell, but one that is incredibly important for every
young man and woman that puts on the uniform of our Nation. So,
thank you for that. Mr. Larkin, did you share with the
Subcommittee then how it was discovered that your son Ryan had
traumatic brain injury?
Mr. Larkin. Thank you for the question, Senator, and thank
you for your comments. Ryan had expressed his desire that if
anything ever happened to him, he wanted his body and his brain
donated for traumatic brain injury breacher syndrome research.
That subsequently was done, and his brain was donated to an
activity at Bethesda, Walter Reed that postmortem analysis
revealed that he had an undiagnosed microscopic level of brain
injury that was uniquely aligned with blast exposure. They only
see this pattern of injury with blast exposure.
If we had not gotten that finding, the narrative that the
Navy had built around Ryan and his struggle, and his subsequent
passing would have continued on--would continue to have damaged
his reputation. But this finding was indisputable that he was
injured. He was not, in his terms, crazy.
Senator Ernst. Exactly, Mr. Larkin, and I just want
everyone to understand that so many of these injuries go
undetected through CAT scans, through MRI's, PET scans.
As a followup to that then, and I am very grateful that
Ryan had chosen to do that because you would not have known
about those injuries otherwise, but then for you, and Dr.
Zafonte--is that right?
I want to make sure I get it correct, Dr. Zafonte, is the
automated neuropsychological assessment metrics, the ANAM test
that is used by the DOD, an accurate method of detecting those
changes in cognition that can lead to a TBI diagnosis?
Dr. Zafonte. Senator, thank you for the excellent question.
I think we are searching for a gold standard. A number of these
measures, including the ANAM, have significant flaws in them.
Everything from the way they are administered, to
challenges on their consistency and internal behavior within an
individual and external to other individuals. So, while it is
an interesting screening tool, it is far from perfect.
Senator Ernst. Yes, and that is why I hope we continue to
work toward alternatives or ways that we find that gold
standard. That is something that this Subcommittee is working
on. You have spoken a little bit about wearable devices as well
that might be able to diagnose a TBI or blast exposure.
All of these things require research, development,
recommendations. Are you confident that we can get to a point
where you are able to make recommendations to Congress, to DOD,
that will provide us a path forward in protecting these men and
women. Any thoughts--yes, Dr. Zafonte.
Dr. Zafonte. Thank you, Senator, for your excellent
question. I would say, and I think my good colleague said this
before, perfection is the enemy of the good. There are things
we know to do now, and as we learn more, we should do better.
I think if we act and think our responsibilities to make
this a dynamic, learning, positive environment for our
servicemembers, we can do things now while evaluating data and
really making positive change in the future.
I think we are going to learn that there is a lot more of
that microscopic injury than we had ever believed, and then in
certain people, that is going to have some significant sequelae
over time.
Senator Ernst. Thank you, Dr. Zafonte, and I believe you
are absolutely correct. I think there are a lot more
servicemembers out there that have sustained various micro
tears or injuries to their brain. I was reminded of this quote
not too long ago, and it's an old one, so forgive me, but if
the human brain were so simple, we could understand it, we
would be so simple we couldn't.
Just let that sink in, because I think we are always going
to be striving to find the answer that we need when it comes to
traumatic brain injury. We may never reach that 100 percent
solution just because of the dynamics of this incredible organ,
but it doesn't mean we should just let it go. There are
absolute, disruptions to families, just as we have heard from
Mr. Larkin.
It is incredibly important that we pursue not only ways to
prevent traumatic brain injury, but that we also find ways if
it does occur and we won't be able to prevent it in 100 percent
of cases, but if it is to occur, we need to find ways to treat
it and mitigate the impact to our families.
So, thank you again, Chairwoman. I really appreciate the
opportunity to be here today.
Senator Warren. So, I just want to say a very special thank
you to you. Senator Ernst, Senator Ernst is not on this
Subcommittee.
Like many in the Senate, she has an absolutely packed
schedule, but she has been engaged for years now on the issues
around traumatic brain injury and working toward changes in the
law, both for the documentation that will lead us to better
diagnoses and also for the resources to begin treatment now for
those who need it.
She wanted to be here with us today, and I appreciate your
coming and doing this. Thank you. Thank you, Senator Kaine.
Senator Kaine. Thank you, Chair Warren, and to the
Subcommittee for having this hearing. It is really important,
and I am just going to ask the same question of both panels.
So, I just have one question and I would love to get your take,
and I will ask the same question to the second panel.
We are not the only country that employs weapons that can
have these effects on servicemembers' brain health. So, what
have we learned or what can we learn from the experience of
other nations and their militaries, either about strategies to
prevent or strategies to treat?
Mr. Larkin. Senator, again, in my role as a senior leader
of the Joint IED Defeat Organization at DOD, back during the
height of Iraq and Afghanistan, this was not a United States
only problem.
You know, we were very much in the trenches with our NATO
allies, Five Eyes partners, who were all experiencing the same
challenges with maneuvering on the battlefield because the IED
had paralyzed our movement and the IED was the weapon system
the enemy used against us that literally brought home all the
casualties and fatalities of those two conflicts and Africa.
If we don't bridge communications with those countries as
we try to solve this problem, we are missing a big part of it.
They have a great data. They are as concerned about what we are
talking about as we are.
I think that really we need unsolicited--we need a gyro
like task force to bring together the Government, industry,
academia, and our foreign partners for a unity of effort to
match the data, the intellectual capability, and our technology
to solve this.
We can solve it. It is just that we have different ad hoc
efforts going on right now. They are not coordinated. We are
handicapped by a lack of data sharing, and like I said, we got
to get everybody on--in the same----
Senator Kaine. Even within our own family. I know this
panel too has DOD, but not VA. I mean, I am I know in the
Richmond, VA, this is a very high priority. So, sharing within
our family certainly, but with our allies who have the same
experience is really important. Dr. McBirney or Dr. Zafonte, do
you want to add to that at all?
Dr. McBirney. Sure. No, thank you for the question,
Senator, and it is an excellent one. One consideration that I
know some of our allies are considering at this time, and it
was published in a report in 2018 by the Center for a New
American Security, is reviewing and updating firing limits for
a lot of these weapon systems.
Those firing limits haven't necessarily been revisited in
some time. In my written testimony, there is a direct quotation
from that CNS report in 2018 that details exactly what
information to revisit in these weapon systems manuals, and
perhaps consider updating to really get at mitigating exposure
that our servicemembers experience in training in particular.
Senator Kaine. Dr. Zafonte.
Dr. Zafonte. Senator, thank you for the great question, and
I agree with the comments of my esteemed colleagues. I would
add just one other thing, you are completely right. There is
power in numbers. There is power in togetherness. There is
power in the opportunity to discover and serve our allies
throughout the world.
I would advocate for common data elements, common data sets
that go across our allies as we think about these kinds of
exposures and the kind of long term sequelae, both immediate,
what does somebody feel now, and then what do they experience
years later. Those kinds of things would be incredibly
important and doable in many other health systems.
Senator Kaine. Thank you very much. I yield back.
Senator Warren. Thank you. Very important. Senator
Sullivan.
Senator Sullivan. Thank you, Madam Chair, and thank you and
Senator Scott for holding this hearing. I think it is a really
important one, and I want to thank the witnesses for their
attention to these really important issues for our military.
So, I got here a little bit late, so if this has already
been discussed, bear with me, but I want to dig into this New
York Times article from November 2023 entitled, A Secret
Strange--Secret War, Strange New Wounds, and Silence from the
Pentagon. This was about the marines in Syria deployed in Syria
in 2016 and 2017.
They returned and really struggled with PTSD issues and
health issues, and it wasn't from direct combat. I mean, they
were in combat, but it was primarily from there, it appears,
really significant amount of firing howitzer rounds.
Kind of to Senator Kaine's point, we have had military
members in different wars, Vietnam, Korea, WWII, of course,
fire thousands and thousands of howitzer rounds. But so, we
have seen this before, but these marines seem to really have
struggled. Have you--either of you read this report or this
story? Okay.
Senators Warren, and Ernst, and Tillis on January 18th,
letter to Secretary Austin asked him a lot of specific
questions relating to this and other issues that relate to TBI.
But this is a kind of a different TBI.
So, sometimes I worry, you know, I just retired from the
Marine Corps myself, and I love the Marine Corps. But, you
know, like all big organizations, they can be bureaucratic, and
I am not sure these marines are treated very well. I am
wondering, from your experience, maybe we will start with you,
Dr. Zafonte, what is your assessment of that report? Was well
done reporting, in my view, from the New York Times.
What do you think the next steps should be? Obviously, we
will ask the Government witnesses in the next panel on this
topic but would just like to get your assessment from this
particular episode. A lot of my constituents in Alaska wrote--
read this article and were quite disturbed by it.
We don't even have a big Marine Corps presence in my State,
but big Army and Air Force presence. So, can--I would like all
of you to just comment on what your thoughts were and then what
we can do--you know, if the marines haven't seen this, you can
see how they could overlook it, but we--I think this needs a
much deeper dive than the military has given it.
To the Chairman's credit and some other senators are
already pressing Secretary Austin on it. So, what are your
thoughts on it?
Dr. Zafonte. Senator, thank you for the excellent point and
question. From my perspective, I think that the piece brought
up a series of issues. It really took the cover off of some
things and made them more public in some ways.
It talked about many of the long term sequelae, near term
and long term, that are being seen clinically in this
population of people. Now, these are extreme individuals, many
of them. They are the 1 percent of the 1 percent. They are the
fittest, the swiftest, and yet they are seeing clinically
apparent problems. There are also, in many ways, the most
resilient. They are selected many times.
So that raises for me some real concerns. It may be related
to the density of the exposure. It may be related to the
lifelong exposure, and it may be related to a global elements
of the life in that kind of stress for a significant period of
time.
So, I think we need to learn a lot more about the long term
issues here and the short term ones, and I think part of the
way we do that is better quantifying the exposure and the
person over time.
Senator Sullivan. Great. Doctor McBirney, do you have a
view on this?
Dr. McBirney. Absolutely. No, and thank you for raising
this. I thought that New York Times article was very well
written and well investigated and reported. I think----
Senator Sullivan. By the way, just for the record, I don't
believe everything at the New York Times writes.
[Laughter.]
Dr. McBirney. Certainly.
Senator Sullivan. So, Senator Warren might--no, I am just
kidding. But so, I am sure the marines had some points in there
that probably weren't reported, or I am not saying it was a
perfect piece, but it raised an important issue. These young
men, to Dr. Zafonte's point, these are, my view, the best of
what we have in America. We certainly, you know, we need to
take care of them.
Dr. McBirney. Absolutely, agreed. I think the one of the
main takeaways for me when I read that article was the fact
that there is a culture that is pervasive across the DOD,
unfortunately, that really contributes to this underreporting
that we see of injuries. I think the way that these men were
treated is indicative of this culture and the fear that a lot
of servicemembers have when it comes to reporting injuries.
There have been many studies done on the underreporting of
traumatic brain injury. There are a variety of reasons that
servicemembers don't report injuries. But fear of negative
repercussions on their military career is certainly a huge one.
So, I think when I read that New York Times article in the
series of articles, that is really what came to my mind, is a
culture that needs changing if we hope to improve this.
Senator Sullivan. Yes, and, Mr. Larkin, real quick. Sorry,
Madam Chair. You know, there--and I don't know if you have a
view on this, but we have had many wars with many thousands and
thousands of artillery rounds fired. I had an 81 millimeter
mortar platoon for 2 years on Active Duty, my marines.
We fired, you know, all kinds of 81 millimeter mortar. That
is not as big as these howitzers, but it is a big mortar, and,
you know, you feel it when you are firing those, and your ears
hurt when you don't have your ear protection on because it is
so loud.
But what is your sense on how we need to look at this, that
article, but compare it to other wars where we have shot
thousands and thousands and thousands of rounds.
Mr. Larkin. So, you know, if I am going to put my money, it
is going to be on the preventative end as much as we can to by
down these injuries. But I completely agree with Dr. McBirney,
the issue here is about trust.
You know, you are not going to get in reporting unless
there is trust that is built between that operator or that
warrior and the system. We have collected blast data on--in a
variety of different efforts----
Senator Sullivan. On artillery too?
Mr. Larkin. Just in, you know, a variety of different
settings where blast gauges and so forth have been worn by our
warriors. We have no idea where that data has gone. So again,
it never comes back to the warfighter like a dosimeter would
for radiation.
So, they say, well, you know, we wear these things, but we
don't hear anything back. One of the things, and it might be a
novel idea I offer, is, you know, when we procure and acquire
weapons systems and munitions, why don't we ask those
manufacturers to provide us with blast overpressure data
according to strict criteria that they all have to follow, that
ultimately will allow us to craft training protocols and
potentially surveillance programs for the more high risk
occupation.
But again, we have been calling this by a different name
coming off the battlefield since WWI, and it all has rested in
psychiatric mental health diagnosis, and we are now starting to
realize this is a biological injury caused by blast
overpressure.
Senator Sullivan. Thank you. Thank you, Madam Chair.
Senator Warren. Thank you. I have another round of
questions that I want to do. I know Senator Scott does. If
anyone else does, we are glad to do it. But I want to pick up
on what Mr. Larkin was just talking about, and that is trust.
That servicemembers who have been affected by blast
overpressure aren't getting the help they need.
The question is, why not? I will go back to The New York
Times article because it does give us some on the ground
anecdotes that people are experiencing. So, a Marine Corps
officer who is leading an artillery unit was quoted in this
story saying that he was experiencing severe headaches and
small seizures but, ``was worried that his injuries would not
be acknowledged because there was no documentation that he was
exposed to anything serious.''
Now, we have talked some about the importance of record
keeping and how that could fundamentally change what happens in
this area, but I want to talk about where we are right now and
the consequences of the failure to diagnose early and what that
means. Mr. Larkin, you are the one who has focused on this more
than anyone.
I think you said in your written testimony that you
estimate that about 80 percent of your son's exposure occurred
during training. Is that right? That is what I understood.
Mr. Larkin. Yes, Senator. If you talk to other veterans
that have trained for combat, been in combat, they will pretty
much confirm that the majority of their exposures is in the
training environment, an environment that we can control.
Senator Warren. So, if I can ask you, we know about what
happened to Ryan because he donated his brain postmortem, and
they were able to do an analysis. But can you speak to what
happened when Ryan was still alive, and whether you and your
family got the appropriate support that Ryan needed, as he
clearly demonstrated that he was in increasing trouble?
Mr. Larkin. So, one thing I didn't share about Ryan is that
after he passed, what we found on his computer were--he
downloaded numerous studies on blast exposure and TBI and also
was researching the medications that he got. So, he was locked
on this. I didn't like what he did. I didn't support what he
did. But I have grown to understand why he did it. It was for
his teammates. He was going to prove that something was wrong.
Now, when he went to get help, he did it more for his teammates
than himself.
But again, you know, we didn't know what we didn't know. I
think a lot of people were trying to do their best for him, the
best that they could, but maybe all the wrong way, and because
we lacked the science, we lacked the knowledge. TBI was not
mentioned--I mean, very little. It was not taken seriously
because they couldn't see it.
We still can't see this level of injury in a living
operator or living warfighter, which is--again within the
medical enterprise, if you don't have a blood marker that
alerts you, you know, just like a, you know, heart attack, we
look at heart, you know, enzymes and so forth, that alert us
that, hey, there is muscle damage and we see an EKG that tells
us that, you know, things are going wrong.
But then when the heart--we don't have that right now, and
it handicaps our ability to triage these folks early on in the
evolution, to your point. The opportunity here, and I don't
know if my colleagues would agree with me, but the opportunity
that we have here is to get it at this early, not wait till it
gets to a catastrophic, you know, point, you know, this disease
process, the injury process where things have gone too far.
Senator Warren. So let me just pick up on this. I
understand that this is hard to diagnose and that it is--we
collect data that will be one way to make it easier to
diagnose. I understand we would like to start as early in the
process as we can. But there is another feature of this that we
have some control over right now, that when someone has any
concern, who is the advocate to make sure they get the help
they need?
My sense of this is it is just a patchwork. You go here,
you get sent there, then you end up someplace else, and the
patient is put in the position of having to advocate for a
diagnosis, that it is not the patient's responsibility or
expertise to have to make. I am grateful that Ryan did what he
did in order to help his teammates. But ultimately, we have a
bigger responsibility here.
So, I just want to know if you can speak just a little bit
to the notion that starting now, before we have perfect
information, that we need a single way for people to go into
this system, to be able to raise a hand, say, I have problems
like the Marine that is quoted in The New York Times piece. I
have problems and know there will be one person there who will
advocate and at least get them to the best possible treatment
that we can. Can you speak to that, Mr. Larkin?
Mr. Larkin. Yes, and I think the No. 1 word that I would
pick out is listen. The system needs to listen to these folks
as they step forward.
You know, and we need to understand this is a leadership
problem, and we need to educate leadership as to what is going
on here so that they can properly usher these folks down the
right paths, so that we can stop their injury process and that
we can start a level of treatment that one size fits one, not
one size fits all, you know, which is precision medicine. I
think as the science develops, as our medical capabilities
develop, we are going to get better and better at doing that.
But again, Ryan became disenfranchised. He became, you
know, adversarial because the system turned on him, a system
that he depended on, a system I depended on. This was my
community, too, and so, this is why I am here today, and I
realize this isn't in a perfect world, but you know, the
ultimate grader of what we do or not do are the veterans, the
warfighters, and their families. Are we doing the right thing
for them?
Senator Warren. Yes. Yes. I very much appreciate that and
appreciate your comments here. If I can, I want to go to the
treatment part of this. Dr. Zafonte, you work at Home Base, and
Home Base tries to be the one place that brings people in and
gives a response.
That is on the side of our servicemember, not hostile to
our servicemember. You are on the front lines. You see people
with TBI every day. Can you talk just a little bit about how
Home Base has organized itself, and what you are seeing, and
what kind of needs you have?
Dr. Zafonte. Well, Senator, thank you for the excellent
question. I think we see ourselves as a partner with DOD, and
that we are auxiliary in an important and differential way.
That we take a look at the whole person, and what we try to
understand is that, you know, I think Mr. Larkin captured it
brilliantly, somebody is not just a psychological illness, but
we bring multiple specialists to bear on this person for a very
intense evaluation that might take, as I said, months or years
in a standard environment, and try to emerge them in a team
based behavior where we listen to the patients and we develop a
programmatic plan to treat.
If we can't treat the microscopic injury right away, let's
treat their symptoms and get them relatively well.
Senator Warren. I am so proud of the work that Home Base
does, and I really want to underscore the importance--there is
help. There are things we can do, and I take it, if I can just
have you underscore it again, Dr. Zafonte, you actually return
people to Active Duty military service. Can you say just a
little more about that?
Dr. Zafonte. I am happy to. Thank you, Senator. I think one
of the most extraordinary things, especially for our special
operators, is the very high degree of return to duty, return to
the force, return to fighting. Because if you think about it as
a person, that is what they want to do.
They want to be well and go back to their teammates and
contribute at a very high level, and indeed, that is the goal.
The goal is being able to give people agency over their own
health again, and that is what we do.
Very high rates of return. Large numbers of people still
waiting for service, which we hope to provide. I think that we
see this as a means of enhancing programmatic excellence and
serving as that bridge for mid-career, early career people who
really need a bolus of help.
Senator Warren. Early and accurate intervention, which I
think is the point you make as well, Mr. Larkin and Dr
McBirney. I appreciate the work you do. Thank you. Senator
Scott.
Senator Scott. Thank you, Chairwoman. Dr. Zafonte, NFL
players are wearing--some of them are wearing the Q collar.
Dr. Zafonte. Yes, sir.
Senator Scott. Okay, can you tell me how it works and what
you think of it?
Dr. Zafonte. Thank you very much, Senator, for that
excellent question. It is an area of debate that is certainly
of interest in the field of traumatic brain injury. The theory
behind the Q collar is that a compression here at the neck,
slight compression, would result in less force shaking within
the brain.
Its role in blast related injury, I believe, unless Dr.
McBirney has more data, is unclear. In sport related injury, it
has received preliminary approval, although the enthusiasm in
many investigators is modest.
Senator Scott. Okay. All right. Knowing what you all know
now, knowing the service is the service--so if you had a child
or grandchild that was 18 years old, wants to be a warfighter,
enlist in the, whatever, what would your advice be to him? You
want to start, Dr. McBirney?
Dr. McBirney. Is not enlisting an option? I mean that as a
serious question. Traumatic brain injury is such--there is such
a huge risk of getting this injury. As we have heard today,
detection of this injury, treatment of this injury is not
guaranteed.
I would--in sitting here, I now have a 14 month old
daughter, so this question is very relevant. I would strongly
urge her to reconsider her decision. Unfortunately, that is a
decision that I know many veterans that I personally know have
asked their children to reconsider as well.
Senator Scott. Mr. Larkin.
Mr. Larkin. So, Ryan is with me here today in spirit, and
much of what I am saying is actually him talking through me. He
would tell you he loved being a SEAL and he wouldn't trade
anything. It is just that we got to do it better.
I will say that my own Naval Special Warfare community, the
SEAL community, Ryan's story has deeply affected them, and they
have moved aggressively to try to make a difference, along with
the parent Command, USSOCOM, right up to the Commanding
General. They are leading the way, in my opinion, within the
Department of Defense.
Very often, you know, what Special Operations does, the
conventional forces follow. So, thanks, Ryan.
Senator Scott. Dr. Zafonte.
Dr. Zafonte. Certainly, I think this is a point of great
debate. But I guess what I would say, and we see this in
contact sport, we see it in the military. The first we can do
is know what we know to do now, which is eliminate unnecessary
exposure. Rules changes in sports have made a big difference.
I believe we can eliminate unnecessary exposure in this
population of people where there isn't a lot of return on
investment, either to their training or for their long term
health, or for their team members. That would be an awfully
good place to start in enhancing force health.
Senator Scott. Thank all of you. I mean, I don't think--if
we care about our freedoms, we actually don't have a choice. We
don't have a choice. We have to thank God every day somebody is
willing to put on the uniform, because if we get to a point
where people say there is too much risk, then say goodbye to
all of our liberties.
So, I hope we get to the point where, you know, nobody
would say you shouldn't go in because of the risk. So, thank
you.
Senator Warren. Senator King.
Senator King. Just a closing comment on that question,
Senator Scott, you know, thinking about what you would say to
your kid. One of my three kids is a Marine who was an 8-year
infantry commander, now a Marine reservist, and keep thinking
about him and how he might answer that question.
But as I think about the question, let me just recount an
amazing story that I heard not long ago from Doug Wilder, who
is the former Governor of Virginia, first African American
elected Governor.
He was drafted into the military in the Korean War, and the
military, like society at that time, was still dealing with an
awful lot of racial prejudice. He was in a unit where there
were many African Americans, many Caucasians, and others. And
Doug is a guy who is going to stand up for himself.
He had a commanding officer that said, I want everybody
here to be treated fairly, and he believed, as did others in
his unit, in the middle of some really difficult battle
circumstances--the African Americans in the unit were not being
treated well and they all agreed they were going to talk to
their CO and pass that on. When they all stood up to do it,
they all just said to Doug, okay, now you do it, and so, he
laid out his concerns about the way they were being treated.
His commanding officer said, you have done what I asked you
to do. Now you all go back to work and let me do what I need to
do, and things didn't change for about 3 or 4 weeks, and then
all of a sudden 1 day everything changed because he did what he
was supposed to do. He stood up and he said, this isn't right,
and we are a unit, and if we make some changes, things can be
better.
I would hope that people grappling with the decision, maybe
your daughter might be in this position 17.5 years from now,
but people grappling with the decision will realize things
don't just get better, you know, by themselves. Things don't
just change by osmosis. It takes people at all levels from the,
you know, private first class all the way up to a four star
standing up and saying, we will be better if we make these
changes.
I think an awful lot of our young people, or people at all
ages, but I think a lot of our young people have a lot of
wisdom to offer. I would hope that they might still say, yes, I
am doing this, and I am also going to be committed to speaking
up if I see areas where we can be better. Thank you.
Senator Warren. Thank you, Senator Kaine. I will be calling
on you, as we are doing the NDAA, both to tighten up the rules
on reporting and get more resources into treatment. That surely
has to come out of a hearing like this.
So, thank you. Thank you all for being with us today. I
would like to call up the second panel. Thank you. All right,
are we ready? Secretary Martinez Lopez, if you can give us an
opening statement, please.
JOINT STATEMENT OF HON. LESTER MARTINEZ-LOPEZ, ASSISTANT
SECRETARY OF DEFENSE FOR HEALTH AFFAIRS, DEPARTMENT OF DEFENSE;
KATHY M. LEE, DIRECTOR, WARFIGHTER BRAIN HEALTH POLICY,
DEPARTMENT OF DEFENSE; AND CAPTAIN CARLOS D. WILLIAMS, USN,
DIRECTOR, NATIONAL INTREPID CENTER OF EXCELLENCE
Dr. Martinez Lopez. Chairwoman Warren, Ranking Member
Scott, distinguished Members of the Senate Armed Services
Committee, we are pleased to represent the Office of the
Secretary of Defense to discuss the Department of Defense's
commitment to address warfighter brain health issues and
initiatives.
We are honored to represent the dedicated military and
civilian medical professionals and the military health system
providing support to our combatant commanders and delivering or
arranging health care for our 9.6 million beneficiaries.
We will inform the Committee about the Department's
initiatives to understand the causes and impact of brain
injuries and blast exposures, support ongoing training of
medical professionals, inform the development of treatment
protocols, and improve the cognitive and physical performance
of our servicemembers.
The Department of Defense's primary mission is to defend
the Nation. Fulfilling this mission means warfighters need the
ability to make expedient and effective decisions on the
battlefield.
Promoting brain health enables our effectiveness as a
fighting force operationally, and mitigating the impact of
traumatic brain injury in all its form is a top priority of DOD
as we focus on near and long term health care of our
servicemembers.
In support of these priorities, the DOD established a joint
effort between the operational and medical forces called the
Warfighter Brain Health Initiative. This initiative was
finalized in 2022 to codify a policy and direction in support
of unified efforts across the military to address TBI and blast
overpressure.
The Warfighter Brain Health Initiative focuses on cognitive
and physical performance, identification of known and emerging
brain threats in military environments, and methods to
immediately detect and treat brain injury. The WBHI Initiative
is an important organizing function for our Department wide
efforts to address brain injury and related diagnosis, such as
PTSD and suicide.
Between 2000 and 2023, 485,553 servicemembers were
diagnosed with TBI. The annual members of TBI grew from just
above 10,000 per year in 2000, to a peak of 33,000 per year in
2011. The DOD responded to this increasing rate of TBI in
combat during Operation Iraqi Freedom and Operation Enduring
Freedom through rapid expansion of TBI clinical care and
research to support military forces around the globe.
We recognize, however, that more research and insight is
needed in both the care and research dimensions to better
understand the risk, how to protect the warfighters, and how to
treat brain injuries more effectively.
Our strategic approach to this issue is an iterative one
involving policy to coordinate clinical changes and gab driven
research investment. When policies work, we look at how to
refine for broader effectiveness. When they do not work as
expected, we review why and modify them to invest in research
to advance alternative solutions.
With that overarching policy mindset, we hope to discuss
that we see as pivotal actions, research findings and their
impact on our current approach as implemented within the WBHI.
We communicate these insights not because we believe they are
foolproof solution. Rather, enable collective action through
shared knowledge.
We know there is still much to learn about the brain and
not everybody responds in the same way to similar exposures or
injuries. We seek to integrate solutions for the future as we
provide recommendations to inform and affect change to safety,
doctrine, and policy. This mission is more both personal and
professional.
As providers, researchers, and military leaders, we are
committed to mitigating the risk of and improving the treatment
for BOP exposures and TBI. We appreciate your continued support
of military medicine, and for inviting us to be here with you
today to discuss the important issues surrounding the brain
health of our warfighters.
We thank Senator Warren, Senator Scott, and the members of
the Subcommittee for leading continued congressional attention
on blast exposures and brain injuries, and we look forward to
your questions.
[The prepared joint statement of Dr. Martinez Lopez, Ms.
Lee, and Mr. Williams follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Senator Warren. Thank you very much. I appreciate it, Dr.
Martinez. So, I appreciate that DOD has begun to take steps
toward mitigating the risks associated with traumatic brain
injury.
Starting this year, new troops will be given regular
cognitive assessments to help monitor potential impacts from
blast exposure on their brain health. This will help medical
providers recognize brain injuries and changes in cognitive
function more quickly, and it will help servicemembers get the
clinical help that they need. I am glad that DOD is taking this
critical step, but it is important that we do this right.
Captain Williams, your organization, the National Intrepid
Center of Excellence, works with servicemembers with TBIs and
other invisible wounds of war. As you know, one of the--and we
have discussed here repeatedly today, one of the most
significant ways that troops are exposed to blast overpressure
is through training.
To ensure that we are accurately monitoring the impact of
blast exposure on servicemembers' brain health, would it be
helpful to give a cognitive test before the servicemember
begins training and firing weapons?
Captain Williams. Thanks, Senator, for the question, and
thank you for the opportunity to talk about this important
issue. Absolutely, yes. Let me start out by saying yes, it is
critically important.
Baselining is something that we utilize in all aspects of
medicine for surveillance. We utilize it prior to treatment,
utilize prior to modals that we know cause risk. So, we have
moved to now--this year, we hope to move to, all members, once
they join the military and before they start the initial
military training, they get cognitive testing.
They get cognitive testing, because we know that the
highest risk of TBIs in the military are in the training
environment, and so, it would be valuable. We wanted to use the
same precision medicine we have been using in the past for
other modalities, that we do with TBI.
Senator Warren. Okay. So, if the baseline assessment is not
starting until after training, that is not an accurate measure
of the servicemember's brain health changes over time. We are
going to miss the front end of this, and as we have talked
about the importance of isolating the problem early is
absolutely critical.
So, to make sure that we are able to detect signs of
cognitive decline due to blast exposure, we have got to do this
assessment before the training starts. Second thing, we also
need to do regular tests of servicemembers' cognitive health
after the baseline assessment. While Special Operations Command
will conduct these tests every 3 years, DOD is currently
planning to retest troops only every 5 years.
Dr. Martinez, you are responsible for assessing the effects
of and improving how DOD tracks blast pressure exposure. Would
annual cognitive testing for servicemembers help increase the
chance that we detect changes in cognitive function and detect
them earlier when intervention would be more effective?
Dr. Martinez Lopez. Ma'am, the--as the Department, we are
looking into this. I think if there is value into doing it
every year, we don't know. So, maybe 3 years, maybe 5 years.
There is more data and more science that we need to look into.
I am not looking at 10 year research.
I am looking at short term research to figure out what
would be the best frequency of doing the test. Not only that,
but what kind of other testing we should add to the battery to
assess the condition of the soldiers--the servicemembers.
Senator Warren. So, I just want to say I feel a little bit
frustrated here that Special Operations Command already clearly
says 5 years is not enough. They are at three. Frankly, until
we have better data, I don't know why we wouldn't be saying,
let's do an annual test and see what we can detect.
If the data show us that 3 years is often enough interval
to be able to detect changes, that is fine. But it seems to me,
given what else we know, and given how catastrophic the
implications of untreated TBI can be, that we ought to be
erring on the side at least of collecting these data annually.
So, I really want to push on this, waiting 5 years to test is
just not often enough.
Another way that DOD needs to show that it is serious about
protecting servicemembers from blast overpressure is by
establishing effective weapon use safety limits. We had some
conversation about this earlier. In 2022, DOD directed the
services to establish a maximum allowable number of rounds for
servicemembers to fire to mitigate blast overpressure injury
risk.
Now good start, but I see two problems with this. First,
the limits don't include brain injury risk. Blast pressure
experts have raised concerns that this means that our current
safety thresholds are built on things like whether or not it is
likely to cause your eardrum to burst. They are very old
guidelines, and they are not about traumatic brain injury.
Ms. Lee, you are in charge of overseeing DOD's warfighter
brain health policy. Why is it important that DOD establish a
maximum allowable number of rounds for servicemembers to fire
that takes into account brain injury as well as injury just to
the ears?
Ms. Lee. Senator Warren, thank you so much for the
question, and thanks for having us here today to be able to
talk about warfighter brain health, blast overpressure, and
traumatic brain injury.
This is an excellent question. We absolutely--it is
imperative that we have allowable number of rounds for all the
weapon systems that are commonly used so that we can avoid
unnecessary blast exposure in our servicemembers. We believe
that this also gives us an opportunity to be able to ensure the
usage is correct, the position, crew position, proximity, and
all those pieces can come together.
Our policies are moving in that direction to be able to
look at the brain. As you mentioned, historically, it has been
through ear and lung. However, we are looking at what the brain
effects are, and we will follow suit with our policies as such.
Senator Warren. So again, I want to say I feel a little bit
of frustration here. I appreciate that you are working on
establishing these limits, but we are going to get this off the
ground now.
We know enough to start moving in the right direction. My
office has heard stories of servicemembers having to take their
own initiative in setting limitations for their troops. We have
got training instructors who just say, I have decided that is
enough, and that is not enough to get this job done.
So again, I urge you better to make your best estimate and
get started on forcing these weapons manufacturers to start
collecting these data so that they will be able to give us
limits on how they can be used.
One more concern here. It is how we measure these weapons
use safety limits. DOD's own studies found that it took 70 to
96 hours to resolve servicemembers cognitive deficits after
firing heavy weapons. So that is about how long it appears
before people are back to their original steady State. But DOD
guidelines say they are only going to test for the first 24
hours.
Ms. Lee, could servicemembers benefit from establishing
weapons use safety limits for longer periods of time, like 72
hours?
Ms. Lee. Yes, ma'am. We are looking to expand that
timeframe so that we allow for those differences that are
coming up with blast overpressure. So that is again where our
policies, the direction that our policies are headed so that we
can cover that time period. We are firmly committed to early
detection, provides the opportunity to treat, and that
maximizes our outcome.
Senator Warren. Well, I hope you do this soon. The
Department of Defense's Inspector General has raised concerns
that military health system providers are not consistently
providing a 72 hour followup appointment for patients with mild
TBIs, so clearly, a longer timeframe is something that DOD
itself recognizes is important and that we need to get done.
Look, I get it, this is hard, and I am grateful that you
are doing the work you are doing. I want to be a partner, but a
partner that urges you to move faster and deliver more for our
servicemembers as quickly as possible. We need to do better for
our troops, and we need to do it right now. Senator Scott.
Senator Scott. Thank you, Chair. So, I will ask you the
same question, what would you tell your son or daughter who was
going to go in and be a warfighter, 18 years old, go enlist--
what would you tell them today, based on what you know?
Dr. Martinez-Lopez. Sir, I have three boys. Two of them
served in the military. One is still in the reserves. So, I am
very proud of their service just like, you know, and I will
tell my grandkids, I have eight of them--so, that there is a
great opportunity in the services.
I think there is some value as a human being that we
develop, that service to country is very important. Even if you
do it for a short time, it makes a big difference as you as a
person.
I don't care how you--where you serve or how you serve, is
it critical now? They need to understand that this is a risky
business, and what--so they need to come out with their eyes
wide open, right.
So, my kids knew that .I very, very--I made it very clear
and--but I am still very proud. I will tell my grandkids, if
they really think about, there is something that triggers them
to serve, go fetch.
Senator Scott. Captain.
Captain Williams. Thank you for the question, sir. I have
no children at this point, but I have many--nephews, nieces,
and friends of the family who I have encouraged to join the
military. This has been the greatest honor in my lifetime to
serve in uniform.
I wouldn't change that requirement for anyone or request to
anyone. I would tell them to follow their heart, and I would
encourage them to know that there are inherent risks to the
job, and our job is to make sure that the people who you are
entrusting your life to, they have a responsibility--a
responsibility to care for you. So, no different, and the
reason why I am here today is saying we want to make sure that
our men and women in uniform know that we are caring for them
in every possible way.
Senator Scott. Thank you. Ms. Lee.
Ms. Lee. Yes. So, I have five children and one grandchild,
and I would absolutely say to support and defend our homeland,
to join the military and join the armed services. One of them
is a Marine.
Through that service, it is about the trust, and I have
seen working in this environment for the last 20 years,
especially around the traumatic brain injury realm, that you
really do need to be credible and have integrity based on that
trust and ensuring that we are going to do right by you.
We are a family, and we are going to take care of you. Mr.
Larkin is part of our team. We are all in this together with
the same mission to take care of our people and take care of
servicemembers that make the sacrifice.
Senator Scott. Thanks. Secretary Martinez, the Department's
report to Congress on the longitudinal blast study says the
Department plans to conduct a business case analysis and review
lessons learned to inform its way forward with blast
monitoring.
So, who is conducting the business case analysis? When do
you expect the analysis to be completed? What factors is the
Department including in its analysis?
Dr. Martinez-Lopez. Sir, do you mind if I defer to Ms. Lee.
Ms. Lee. So, the business case analysis kickoff meeting was
the 14th of February. It is being conducted by a contract
service. We are expecting the results in September 2024. We
looked at--we are looking--we have extensively involved
military departments in this so that the outcome that comes,
the outcome and recommendations will be able to be implemented
by the military departments.
Both the service communities and the operational
communities are heavily invested in this business case analysis
so that we can review the necessary resources, the--and look at
how to establish a standardized monitoring program throughout
the force.
Senator Scott. When do you think you will be completed?
Ms. Lee. The business case analysis will be completed in
September.
Senator Scott. September? Okay. Right. The 2023, the Fiscal
Year 2023 NDAA also authorized but didn't require the Director
of the Defense Health Agency to conduct a pilot program to
monitor blast exposure to the use of commercially available,
off the shelf wearable sensors. Do you all plan to do it, and
do you have any sensors in mind that you think are working?
Ms. Lee. So, yes, sir. So, we are awaiting the BCA results,
the business case analysis results in September, to make a
decision on whether or not that pilot that could be the segue
from our Section 734 work into a full blown standard monitoring
blast program throughout the Department.
So, again, those decisions, we will probably make in the in
the September 2024 time period. In terms of blast sensors, we
have various communities to include the Special Operations
Command that have been looking at the--right now, the three
available, commercially available products.
Those decisions are, right now, living in the acquisition
world as they are doing suitability and fielding exercises, and
based on the requirements of each individual community.
Senator Scott. Good. Also, the Fiscal Year 2023 NDAA
required a report describing the strategy and implementation
plan for the Warfighter Brain Health Initiative. I guess this
was due at the end of last year or so. Is that different than
the others?
Ms. Lee. That is the strategy and action plan that has five
lines of effort. I believe that is headed over your way right
now.
Senator Scott. Oh, okay. All right. Thank you.
Senator Warren. So can I just ask one more question. It is
7 months before the business case analysis. What are you going
to do over the next 7 months?
Ms. Lee. So, in the original memo that was produced before
we had finished Section 734, the Assistant Secretary of Defense
for Readiness put out this interim guidance memo. Before we had
completed all of the information, all the data, we felt it was
imperative to try to get brain health guidance out at that
time.
So, we sent the memo out. Included in that four PSA memo
are six actions to try to avoid unnecessary blast exposures.
So, what we are doing in the meantime is updating that memo
with more data that we have from our research studies and from
the blast community of researchers, so that we can provide more
direction and guidance to the military departments on how they
can have safer actions out in the operational environment, in
the training environment.
Senator Warren. Okay. I appreciate that, and how are you
going to make sure that it makes it all the way down to the
ground level? There are anecdotes that suggest that we make
policy changes, we all talk to each other up here in the
abstract, and then down at the ground nothing has changed. Dr.
Martinez.
Dr. Martinez-Lopez. Ma'am, the first issue is this is a
joint effort between the operational forces and we in the
medical sector. So, it is the medical leadership and the
operational leadership.
If we don't work it together, this is not going to pan out.
So, the way we exercise that at DOD is through a safety
oversight council. So, we are meeting with all the services and
laid out the guidance, and we rely on the services then to push
it down. It is an issue of policy internal to the services.
It is an issue of training in the services. It is an issue
of equipping in the services. We will give them the medical
guidance, you know, the best knowledge we have, but the
implementation itself, how are you going to fire your weapon,
where, and those kind of things have to be exercised by the
line.
Now, I went over to Fort Campbell, and I talked to the CG
of Fort Campbell. He was--and I told him, it is simple. Less is
better, and less often and better. So really look at--pay
attention to that.
Senator Warren. Right. Right. Captain Williams, did you
want to add anything on that? Okay, good. Senator Scott.
Senator Scott. So, have you guys ever had a glucose
monitor? Do you know how they work? Okay, so I can put on
glucose monitor, I can put in my exercise, I can put in my
food, and I can just do it myself. I can sort of track to see,
you know, how I feel when my glucose goes up. So, why don't we
have something just simple that people can do on their own?
Because if I knew, gosh, I get headaches or I get, you
know--I have sleeping problems or I have any of these issues,
then I would say, I mean, I can't do this anymore. I mean, why
don't we do something--I mean, the technology is so simple,
right.
I mean, it is basically you just go you go to--there is two
companies that do the glucose one now that I know of. Why don't
we just go there and say, will you give us the technology and
we can implement this and just give it to everybody and let
them monitor it themselves?
[Technical problems.]
Dr. Martinez-Lopez. I am going to State the first steps--
[technical problems]. The problem with glucose is I know
exactly where the thresholds are. So, I know that like at 126
it is abnormal blood sugars, so anything above that or below
that, and I can monitor it. On this issue, I don't know what
the threshold is. So, we haven't determined that threshold yet,
and even worse----
Senator Scott. No, I will decide for myself. I will decide
that--the way I would look at it is, I will put the information
in there and then I would say, hey, here is what I noticed. If
I do this number of blasts, I get a headache. I do this number
of blast, I can't sleep.
Then I start saying to myself, and I say, well, okay, I am
not going to do that. I am not doing that to myself anymore
because--you know what, this has happened to me so I am not an
expert on this, but you would think, I mean, you know, we are
all--we are all going to be better if we self-monitor
ourselves, right? I mean, rather than some top down program
that tries to tell us everything, and even glucose--I mean,
your body is going to be different than my body.
So, what my high level should be is going to be different
than yours, right. So, I am just saying, put the information in
there. It is a real simple mode. Give it to everybody. Let them
start following it on their own, and then they can easy--you
know, like on those--anybody can connect.
You can say, oh, I am going to allow this person to
connect. There is a company out there that allows people to do
that now that--it is call levels and they are doing they are
doing--I think they have 50,000 people or so on a study, where
they are doing it on their own as a private sector, just with
everybody voluntarily putting their data in there.
Captain Williams. Sir, if I may, one of the most important
things--and what you are speaking about is really and truly
precision medicine and targeted therapy to the individual. It
is very variable for each individual who has had a TBI, the
symptoms that they have.
One of the things that the past NDAA said was that the DOD
needed to partner with private industry and private
organizations to improve research and to improve treatment.
That is one of the things that we want to look at, is look at
what type of modalities are out there, or that can be developed
to allow patient to focus on their individual symptoms.
But we have to know what that baseline is first for that
individual. Biofeedback is something that we do in the Defense
Intrepid network, at NICO, we help patients understand how to
control their own individual symptoms.
But if each person is different, then that is going to be a
challenging, should I say, monitoring to create, but it is
possible. As we continue to do research, I think we can come--
we can get there soon.
Senator Scott. So, to me, I just gave you my answer, that
is a big government answer. Okay, just my--you might be
absolutely right. Just, I am not saying you are wrong. I am
just--I just actually do believe that I will do a better job of
monitoring my health than anybody else will ever do my health.
I don't care what the study is, I will do a better job.
I think--if I started--I can just say personally, if I eat
something and I don't feel good, I am never touching it again,
all right, period. I assume--I mean, it is smart--these are
smart kids going in the service.
I mean, just look at these sports. All these people are
getting smarter about this and saying, I am not doing this to
my brain. I just think we ought to do exactly all the things
you are doing, but it is pretty simple to set up a program to
give and, you know--let the person monitor themselves because
their body is going to be totally different than everybody
else's. Like your blood glucose level is different than mine, I
guarantee you.
Captain Williams. So, I totally agree with you, sir, and as
an internist and a pediatrician, I always listen to the
patient. I always listen to the parents, right. It is very
important.
[Technical problems.]
Captain Williams. But I do want to say, though, I agree
with you. I think as a medical professional though, and even as
a researcher, we want to come up with a pathway forward for the
patients to monitor their own.
That means we need to come up with baselines, with normals,
which we just don't have at this point in time for TBI in
general. When we move toward blood biomarkers, when we move
toward much more concrete evidence, I think we can come up with
the tool that you are talking about, that can allow a patient
to monitor themselves.
Senator Scott. Thank you.
Senator Warren. Good. So, I want to thank you all for being
here--absolutely.
Senator Budd. Thank you all for being here. So, North
Carolina universities, including East Carolina University, ECU,
UNC Chapel Hill, and health care providers like Atrium Health
have prioritized research, care, and support for servicemembers
and veterans diagnosed with TBIs.
I was able to see that when I was in the State last week.
So again, I appreciate this hearing. Further understanding the
cause of TBI will significantly improve that care that they
offer, and I look forward to supporting their ongoing efforts.
Dr. Martinez, in the longitudinal study on blast pressure
exposure of members of the armed services that you published in
December, one of the key findings is a greater likelihood of
TBI--can you explain what you mean by a greater likelihood and
quantify the increased likelihood of TBI? So, what percentage
of people were exposed to what level blaster, likely to develop
TBI?
Dr. Martinez-Lopez. Senator, I will defer to me Ms. Lee for
the answer.
Senator Budd. Certainly. Thank you.
Ms. Lee. So, the Section 734 longitudinal study that you
are referencing, where we looked at monitoring and documenting
blast exposure and then also offerings a review of weapon
systems, which we codified as 15 weapon systems that were most
commonly used, and we went deep to figure out what all the
safety regulations were about those.
Under the safety rubric as well, we looked at what the
health and performance effects are, the brain health effects
from all this blast overpressure stuff. In the report, we were
able to--we reviewed 40 studies, 26 of those studies were
funded by the Department of Defense.
We looked at what type of effects happen when you are doing
blast overpressure, and then where do you have concerns about
traumatic brain injury. Most of the areas that we found
correlations were in the neurocognitive and thinking areas.
Also, in some health care utilization areas. We looked at
blood biomarkers and proteins to try to see if there was any
correlations, and we believe that that will bear fruit, but
right now there is no clear trends in that regard.
So, we are relying on the symptom reporting as being the
most indicative of someone that would have had a traumatic
brain injury, and again, early detection of that through
evaluation of multiple domains like their balance and their eye
movements, and their thinking skills, and their symptom
reporting.
Senator Budd. Thank you for that. Dr. Williams, what
recommendations would you make to improve the Department's
ability to diagnose and treat military personnel who are
repeatedly exposed to low level blast?
Captain Williams. Thank you for the question, Senator. As
we spoke earlier in terms of baselining early. So, it has been
stated several times, and when you know better, you do better.
One of the most important things we can do is baseline our
members from the moment they come into the military.
That means before they start the military training, and
that allows us to follow them over time. I admit we have to
find the right baselining tool. Right now, we use ANAM. ANAM
focuses on cognition and that is an appropriate component, but
we can do more. We can do better, and our goal is to, again,
start early so we can continue to monitor.
Senator Budd. Thank you. North Carolina is the proud home
of the Kennedy Special Warfare Center and School at Fort
Liberty, and research suggests that Special Operations forces
experience higher rates of blast exposure in training and
combat than other military personnel, and thus are at an
elevated risk for repeated blast exposure related brain injury.
So, does that track with your research?
Ms. Lee. Absolutely.
Senator Budd. All three of you?
Captain Williams. Yes.
Senator Budd. Thank you. While we certainly need to conduct
more research, we have to also do a better job protecting our
servicemembers with what we know today. That lines up with Dr.
Williams, with what you were just sharing.
So, I am concerned that the Department is not moving
quickly enough to address these TBI risks. So, there is tested,
FDA approved devices that can limit TBIs, including some like
neck collars that are currently being used by Special Operators
and just like you see in the NFL.
Now, I am hearing, however, that there is still years of
DOD testing that need to take place before they can be fielded
for the broader force.
So, for the panel, for each of you, why aren't we expanding
the fielding, FDA approved wearable devices now to keep our
warfighters safer from TBI inducing head trauma and
overpressure protection, rather than waiting for duplicative
testing to be completed within Department? How can we expedite
those devices, the use of those devices?
Captain Williams. You know, I would start with a simple
answer, our goal is to do no harm. Right now we need more
information for some of these devices to determine if they
would do harm in the operational setting.
Senator Budd. Even, doctor, if they are already FDA
approved devices?
Captain Williams. I totally understand. FDA approval,
oftentimes, is not tested in our population, and that is a
different story. So, we realize now that a lot of times this
research is being done and is not inclusive of operators,
especially high level operators that we are caring for. I think
our goal is to make sure we do no harm to that general
population.
Senator Budd. Thank you. Secretary.
Dr. Martinez-Lopez. We may have to look at the data and we
look at the size, if it is sound. Even in our study, we will
adopt it. If it is really going to make a difference, we will.
But we will put them through our internal processes, and that
is true for every intervention we do have with our patients.
Senator Budd. Ms. Lee?
Ms. Lee. Senator, the jugular vein compression devices that
you are speaking about had mainly been studied in head impact
in the sports community. So, pivoting to blast overpressure,
which has a different mechanism of injury, is worth a look--
definitely worth more than a look--to do more research to make
sure that it is safe and effective in both the military
population, as well as blast overpressure as the mechanism.
Senator Budd. Understood. Thank you all. I yield.
Senator Warren. Thank you, Senator Budd. I want to thank
you all, all of our witnesses for being here today. I want to
thank you for the work you do every day. My takeaways from this
are that the Department of Defense needs to do better.
We need to identify those who were most at risk for TBI
because of the particular work they do. We need to collect
better data, and we need to do all of this on a much faster
timetable.
Congress also needs to do better. We need to make sure that
you have the resources to do your work, and we also need to
make sure that those who are treating TBI like Home Base have
the resources they need.
It is shameful that there are Active Duty military who have
what appears to be TBI and they cannot be treated because the
resources simply are not there. A waiting list at a place like
Home Base is our failure.
We need those resources, and we need that capacity to be
able to treat those who have suffered brain injuries because of
their service to our Nation. We owe that to our servicemembers.
So, again, thank you all for being here. I want to thank the
senators who have been here.
I want to thank my partner, Senator Scott, in this, and
this will be an issue we will take up during the next round of
NDAA negotiations. Thank you.
[Whereupon, at 5:02 p.m., the Committee adjourned.]
[Questions for the record with answers supplied follow:]
Questions Submitted by Senator Mazie K. Hirono
tbi treatment at military treatment facilities
1. Senator Hirono. Dr. Zafonte, I applaud your dedication and
efforts as a principal investigator on DOD clinical trials evaluating
novel treatments for TBI and PTSD. Do you think there is enough
training for military medical professionals at treatment facilities,
such as Tripler Army Medical Center, to identify and treat TBI and the
accompanying symptoms?
Dr. Zafonte. As a non-profit academic medical center, outside DOD,
I do not have personal knowledge of the extent of the TBI training
programs at military medical centers.
2. Senator Hirono. Dr. Zafonte, which novel treatments in your
trials seem the most promising?
Dr. Zafonte. Home Base is proud of our TBI space's history of
innovation. Nestled within the world-renowned Massachusetts General
Hospital (MGH), Home Base's National Center of Excellence utilizes the
extensive resources and faculty of MGH, Harvard Medical School,
Spaulding Rehabilitation Hospital, the Massachusetts Eye & Ear
Hospital, and other components of the Mass General Brigham integrated
healthcare system to provide evidence-based care. Furthermore, this
incredible ecosystem within which we operate provides us with insight
into the latest research and clinical care opportunities, as well as
daily access to world-leading researchers and clinicians who work at
the forefront of mental health and brain injury care. This guarantees
the synchronization, not the siloing, of our efforts to treat these
invisible wounds.
Science is just beginning to understand the long-term impacts of
mild and moderate TBIs. Home Base is actively investigating the short-
term and long-term effects of these injuries, which encompass a
spectrum of physical and psychological ailments ranging from
neurodegenerative diseases to behavioral health disorders and even
cancer. A critical issue is understanding the specific biopsychosocial
injury patterns associated with repeated blasts. Through my research
and collaboration with specialists, we are uncovering critical insights
that continue to inform evidence-based interventions and elevate
clinical care standards.
tbi and mental health
3. Senator Hirono. Secretary Martinez-Lopez, Dr. McBirney, and Dr.
Zafonte, traumatic brain injuries can range from mild to severe, and
studies have shown notable correlations between TBI and mental health
conditions such as anxiety, PTSD, depression, and suicidality among
current and former servicemembers. Can you speak to this correlation
and what steps are being taken to address treatment with this
relationship in mind?
Secretary Martinez-Lopez. DOD Response (Secretary Martinez-Lopez):
Yes, DOD funded research has elucidated relationships between traumatic
brain injury (TBI) and mental health conditions. During the acute
evaluation of mild TBI using the Military Acute Concussion Evaluation
(MACE) 2 screening tool, there are questions about a history of
depression, anxiety, or other behavioral health concerns so that we can
offer additional assistance and followup for servicemembers who report
these concerns.
The MACE 2 also approaches concussion from a symptom cluster
perspective. Anxiety is covered under the concussion symptom clusters
and we manage each symptom cluster uniquely, recognizing that the
combination of symptoms changes recovery trajectory. We know
Servicemembers may take longer to recover (similar to other combined
injuries) and may require more followup medical encounters to
facilitate recovery if a history of a mental health condition (or other
non-mental health concussion symptomatology) is present.
In addition, other DOD guidelines and tools incorporate
psychological interventions as part of the multi-disciplinary approach
to TBI treatment. There are standardized concussion tools, such as the
Progressive Return to Activity (PRA) protocol, that outline state-of-
the-art treatments as well as how to return Servicemembers to duty and
full function. The PRA is meant to incorporate a range of symptoms
post-concussion and direct an individualized recovery plan. The DOD
also has specialty clinical and comprehensive interdisciplinary centers
of excellence called the Defense Intrepid Network (DIN) for TBI and
Brain Health. These programs have been developed to deliver a holistic
patient centered interdisciplinary TBI model of care. Behavioral health
services can include psychiatry, psychology, and social work.
Additional services may include neurology, sleep medicine, pain
management, and rehabilitation services, such as balance and vision
therapy. These centers of excellence also offer innovative treatments
such as creative arts therapies, animal-assisted therapies, and mind-
body wellness services.
Dr. McBirney. My research has remained focused on traumatic brain
injury (TBI) and subconcussive injuries, so, while I do know that there
is a correlation between TBI and some mental health conditions, such as
anxiety, posttraumatic stress disorder (PTSD), depression, and
suicidality,\1\ I do not feel qualified to speak to the correlation and
any subsequent treatment efforts.
---------------------------------------------------------------------------
\1\ Jennifer N. Belding, Claire A. Kolaja, Rudolph P. Rull, and
Daniel W. Trone, ``Single and Repeated High-Level Blast, Low-Level
Blast, and New-Onset Self-Reported Health Conditions in the U.S.
Millennium Cohort Study: An Exploratory Investigation,'' Frontiers in
Neurology, Vol. 14, March 2023; Michelle R. Dickerson, Susan F. Murphy,
Michael J. Urban, Zakar White, and Pamela J. VandeVord, ``Chronic
Anxiety-and Depression-Like Behaviors Are Associated with Glial-Driven
Pathology Following Repeated Blast Induced Neurotrauma,'' Frontiers in
Behavioral Neuroscience, Vol. 15, December 2021; Yueh-Chien Lu, Ming-
Kung Wu, Li Zhang, Cong-Liang Zhang, Ying-Yi Lu, and Chieh-Hsin Wu,
``Association Between Suicide Risk and Traumatic Brain Injury in
Adults: A Population Based Cohort Study,'' Postgraduate Medical
Journal, Vol. 96, No. 1142, December 2020; Trine Madsen, Annette
Erlangsen, Sonja Orlovska, Ramy Mofaddy, Merete Nordentoft, and Michael
E. Benros, ``Association Between Traumatic Brain Injury and Risk of
Suicide,'' JAMA, Vol. 320, No. 6, 2018; Sarah L. Martindale, Anna S.
Ord, Lakeysha G. Rule, and Jared A. Rowland, ``Effects of Blast
Exposure on Psychiatric and Health Symptoms in Combat Veterans,''
Journal of Psychiatric Research, Vol. 143, November 2021.
---------------------------------------------------------------------------
Dr. Zafonte.
The Need
My research with TBI has noted an elevated 10-year risk of
behavioral concerns such as depression, anxiety, and even bipolar
disorder. TBI can have wide-ranging psychological effects. Some signs
or symptoms may appear immediately after the traumatic event, while
others may appear days or weeks later. According to the Department of
Defense, since 2000, over 413,000 US (United States) servicemembers
have experienced at least one TBI, and 40 percent of those with in-
theater TBIs later screened positive for comorbid psychological health
conditions, including post-traumatic stress disorder (PTSD),
depression, and anxiety.
Innovative Treatment Models
In 2015, Home Base launched a 2-week intensive clinical program
(ICP) for veterans, servicemembers, and their families impacted by the
invisible wounds, including a TBI-specific track. The ICP combines
evidence-based therapy with complementary and alternative medicine.
What sets the ICP apart from other programs is that it is staffed not
only by Massachusetts General Hospital clinicians and fitness and
nutrition experts--all trained in military culture and specializing in
treating invisible wounds--but also by veterans, servicemembers, and
military family members who are subject-matter experts and are able to
provide high-level peer support through their shared life experiences.
Veterans and servicemembers work with their treatment team to determine
an individualized treatment plan. Our clinicians are experienced in
delivering the most effective and innovative treatments to help heal
the invisible wounds of war. We encourage family members and support
people to participate in our program offerings as they are integral
parts of the healing process. We also provide them with their own
education and support options.
Home Base recognizes that TBI treatment cannot exist in isolation.
The overwhelming majority of the patients who we treat in our ICP for
TBI also receive treatment for co-occurring mental and behavioral
health concerns through individual and group therapy, emotional
regulation training, mindfulness, and wellness classes. The TBI
patients receive supplementary services to treat their TBI concerns,
including daily cognitive rehab, physical medicine, and rehabilitation
(PM&R), and physical therapy.
holistic treatment for tbi
4. Senator Hirono. Secretary Martinez-Lopez, Dr. McBirney, and Dr.
Zafonte, if current medical approaches to treating TBI and related
outcomes in American servicemembers are lacking or require additional
resources, what alternative pathways are being explored to treating TBI
from a holistic perspective?
Secretary Martinez-Lopez. The Department has a multipronged
approach to care, allowing for each element to be enhanced as needed.
The core elements are standardized assessment tools and protocols;
specialty clinical sites networked for information sharing; and
standardized policy to optimize documentation, screening, and care. The
Defense Health Agency (DHA) established the Acute Concussion Care (ACC)
Pathway as part of the Fiscal Year 2021 Quadruple Aim Performance Plan
to standardize acute concussion assessment and care across the Military
Health System (MHS). The goal of the ACC Pathway is to improve recovery
times and outcomes by utilizing a multi-modal assessment tool at the
time of injury (MACE 2) and to ensure timely access to repeat
evaluations with personalized treatment protocols in alignment with a
progressive return to activity process.
Supporting the goal of the ACC Pathway, the DHA Procedural
Instruction 6490.04, ``Required Clinical Tools and Procedures for
Assessment and Clinical Management of Mild Traumatic Brain Injury/
Concussion in Non-Deployed Setting,'' April 26, 2021, established the
required clinical tools and procedures for management of mild TBI, or
concussion, in a non-deployed setting. Specifically, the use of the
MACE 2 and the PRA are the main tools used for the assessment,
management, and rehabilitation of all patients with a mild TBI. Our
current focus is on enhanced use of the existing mechanisms as well as
documentation to enable continued refinement.
The Defense Intrepid Network (DIN) for TBI and Brain Health, which
includes the National Intrepid Center of Excellence (NICoE),
collaborates with civilian healthcare facilities to enhance care for
servicemembers with TBIs and psychological health (PH) conditions. The
DIN provides state-of-the-art clinical care, best practices,
translational research, and education and training for the DOD and U.S.
Government. The DIN delivers a comprehensive, holistic,
interdisciplinary care model for the continuum of brain injuries and
associated behavior heath conditions. This interdisciplinary care model
is noted to be the most successful treatment for cases that have not
responded to traditional care. The DIN's model is the foundation on
which the majority of other TBI programs across the country are based.
The network includes 13 sites (located across the United States and one
in Germany). NICoE serves as the DIN's headquarters and is home to some
of the most advanced TBI and brain health research in the Nation. The
DINs interdisciplinary care model combines traditional medicine
services such as behavioral health, neurologic, and rehabilitative
care, with a host of complementary services such as acupuncture,
chiropractic, and meditation, along with integrative health services
such as art, music, and dance movement therapies. NICoE has a broad
armamentarium of technologies and techniques to diagnose, treat and
rehabilitate servicemembers. The model is rooted in a wellness mindset.
The DIN consistently shares its model of integrating care and research
with civilian facilities and leverages civilian expertise and
assistance through the referral service.
Dr. McBirney. Given my lack of clinical experience, particularly
compared with others on the panel, I do not consider myself to be well
positioned to answer this question. I will defer to my colleagues.
Dr. Zafonte. Home Base views all our patient care issues, from PTSD
to TBI, through a holistic lens. At Home Base, our approach to holistic
treatment for warriors is centered on addressing the complex interplay
of biopsychosocial issues that they often face. Our comprehensive and
integrative model focuses on treating the whole person, recognizing
that mental, physical, and social health are deeply interconnected.
Here is an outline of our approach:
Mindfulness and Mental Health
Mindfulness Practices: We incorporate mindfulness-based
stress reduction (MBSR) techniques to help warriors manage stress,
anxiety, and depression. Practices such as meditation, deep breathing
exercises, and guided imagery are taught to enhance emotional
regulation and promote a sense of calm.
Cognitive Behavioral Therapy (CBT): CBT is employed to
address negative thought patterns and behaviors, helping warriors
develop healthier coping mechanisms.
Trauma-Informed Care: Recognizing the impact of trauma on
mental health, we provide therapies specifically designed to address
PTSD and other trauma-related conditions. This includes Eye Movement
Desensitization and Reprocessing (EMDR) and trauma-focused CBT.
Addressing Physical Dysfunction and Pain Management
Comprehensive Physical Therapy: We offer personalized
physical therapy programs to address musculoskeletal issues, improve
mobility, and reduce pain. These programs often include exercises
tailored to individual needs, manual therapy, and strength training.
Pain Management Strategies: Our approach to pain
management is multifaceted, incorporating both traditional and
complementary methods. This includes pharmacological treatments,
acupuncture, chiropractic care, and massage therapy.
Functional Movement Training: We focus on improving
functional movement patterns to prevent injury and enhance physical
performance. This includes education on proper biomechanics and
posture.
Facilitating Safe and Vigorous Evaluation of Novel Holistic Therapies
Research and Evidence-Based Practice: We are committed to
staying at the forefront of medical research to ensure our treatments
are grounded in the latest scientific evidence. We conduct and
participate in clinical trials to evaluate the efficacy and safety of
novel holistic therapies.
Integrative Medicine: Our integrative medicine approach
combines conventional medical treatments with complementary therapies.
This might include nutrition counseling, herbal medicine, and mind-body
practices such as yoga and tai chi.
Patient-Centered Care: Each warrior receives a
personalized treatment plan based on their unique needs and
preferences. We involve patients in the decisionmaking process,
ensuring that their values and goals are respected.
Social Support and Community Integration
Family and Community Support Programs: Recognizing the
importance of social connections, we offer support programs for
families and facilitate community engagement activities. This helps
warriors build a strong support network.
Peer Support Groups: Peer support is a vital component of
our approach. We provide opportunities for warriors to connect with
others who have had similar experiences, fostering a sense of
camaraderie and mutual support.
Holistic Wellness Programs: Our holistic treatment
approach at Homebase aims to empower warriors by addressing the full
spectrum of their health needs, promoting resilience, and enhancing
their quality of life.
Nutrition and Lifestyle Counseling: Proper nutrition and
a healthy lifestyle are crucial for overall well-being. We offer
guidance on diet, exercise, and sleep hygiene to support warriors'
holistic health.
Recreational and Creative Therapies: Engaging in
recreational activities and creative arts can be therapeutic. We
provide opportunities for warriors to participate in art therapy, music
therapy, and recreational sports.
__________
Questions Submitted by Senator Elizabeth Warren
weapons training and brain health
5. Senator Warren. Secretary Martinez-Lopez, there is currently no
uniform chart or scale for safe levels of blast exposures for the
weapons that servicemembers routinely train on. When and what steps
will DOD take to implement safety standards and guidance to
servicemembers and military leaders that use, fire, and/or train on
these weapon systems?
Secretary Martinez-Lopez. DOD Response (Secretary Martinez-Lopez):
The DOD is focused on safety and mitigation to avoid unnecessary blast
exposures and will continue to issue weapon specific guidance in
accordance with research developments. We have learned that each combat
or training scenario modifies blast overpressure (BOP) in unique ways,
which presents challenges in developing uniform guidance. Accordingly,
while we continue to develop solutions to characterize BOP threats, the
Department has implemented an `as low reasonably achievable (ALARA)'
policy approach to maximize safety.
In parallel to this policy guidance, the Department is reviewing
and generating new data concerning blast exposures in training and
combat to update safety protocols for the prevention of TBI. In
November 2022, the Assistant Secretary of Defense for Readiness issued
``Interim Guidance for Managing Brain Health Risk from Blast
Overpressure.'' This interim guidance provides that DOD Components will
manage the risk of BOP exposures exceeding 4 pounds-force per square
inch (psi) as a part of training, planning, and execution. This policy
is currently being updated to expand on risk management actions based
on the outcome of research and studies.
6. Senator Warren. Secretary Martinez-Lopez, in order to get an
accurate measure of servicemembers' brain health over time, we must
have a starting point or baseline to serve as a point of reference and
comparison through force-wide cognitive testing. Previously, DOD
responded to a congressional inquiry that ``DOD will start with the 15
initial military training (IMT) sites. Each Military Service has
different lengths of IMT from 7 to 13 weeks. Cognitive baseline testing
will occur during IMT and varies as to the actual week during IMT that
this will occur based on current training cycles and new recruit
throughput. DOD's regular cognitive testing program will cover all
personnel in a phased approach, beginning with the Active Duty
component and then the Reserve Component. At minimum, cognitive testing
will be repeated every 5 years.'' How many IMT sites does this leave
out and what actions will be taken at those remaining IMT locations?
Secretary Martinez-Lopez. There are a total of 15 IMT sites across
the Department that encompasses enlisted and officer servicemembers in
both the Active Duty and Reserve components. Therefore, there are no
IMT sites that are left out. All newly accessioned servicemembers will
be tested at one of the 15 IMT sites. The Cognitive Monitoring Program
baseline collection is anticipated to begin June 2024 and IMT sites
will be phased in throughout the rest of calendar year (CY) 2024.
7. Senator Warren. Secretary Martinez-Lopez, what cognitive test
will you use for the baseline and periodic testing and will you
implement it at Military Entry Processing Stations (MEPS)?
Secretary Martinez-Lopez. The DOD currently uses the Automated
Neuropsychological Assessment Metrics (ANAM) for baseline and periodic
testing pursuant to DOD Instruction (DODI) 6490.13, ``Comprehensive
Policy on Traumatic Brain Injury-Related Neurocognitive Assessments by
the Military Services,'' September 11, 2015, as amended. DODI 6490.13
states ``The [ANAM] is the DOD-designated neurocognitive assessment
tool until such time as evolving science and medical best practices
inform a change in policy.'' The DOD has approved testing to begin at
various points at each IMT site (not at the Military Entry Processing
Stations). The Cognitive Monitoring Program baseline collection is
anticipated to begin June 2024 and installations will be phased in
throughout the rest of calendar year 2024.
8. Senator Warren. Secretary Martinez-Lopez, what is the
Department's plan to rapidly expand testing capabilities and sites that
can do them?
Secretary Martinez-Lopez. In September 2023, the Executive Council
on Recruit and Basic Training (CORBT) supported the establishment of a
DOD CORBT Cognitive Monitoring Working Group for the implementation of
cognitive assessments at the IMT sites. The cognitive monitoring
office, in coordination with the CORBT, has identified 15 IMT sites to
establish baseline testing. As discussed in question 6, baseline
collection is anticipated to begin June 2024 and IMT sites will be
phased in throughout the rest of calendar year 2024.
9. Senator Warren. Secretary Martinez-Lopez, do you have an
estimate of how much it would cost to expand testing capabilities and
sites to all IMT locations?
Secretary Martinez-Lopez. The Department has conducted a cost
analysis plan (CAP) and, as a result, the Department has programmed
resources for implementation of baseline testing at IMT. The current
estimated cost is 4 million dollars to conduct initial assessments at
all 15 IMT sites.
10. Senator Warren. Secretary Martinez-Lopez, what support and
resources will the Services need from DHA to meet increased demand for
assessments?
Secretary Martinez-Lopez. The DHA, in coordination with the Army,
has evaluated the resources needed to conduct the Cognitive Monitoring
Program, which involves obtaining baseline cognitive assessments and
then repeating, at minimum, every 5 years. The Department has
programmed resources for implementation of the Cognitive Monitoring
Program, which includes the estimates to conduct cognitive monitoring
at the IMT's.
11. Senator Warren. Secretary Martinez-Lopez, what are the 15 sites
where the DOD will implement cognitive testing during IMT?
Secretary Martinez-Lopez. The 15 sites are below.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
12. Senator Warren. Secretary Martinez-Lopez, when will cognitive
testing be available and required for all IMTs within DOD?
Secretary Martinez-Lopez. Cognitive baseline testing will begin at
select IMT sites in June 2024 and will be phased in throughout the rest
of calendar year 2024 until testing is available at all 15 IMT sites.
All newly accessioned servicemembers will go to one of the 15 IMT sites
and receive cognitive testing.
13. Senator Warren. Secretary Martinez-Lopez, what process do each
of the service branches follow to screen Active Duty servicemembers for
symptoms of blast overpressure and when do they conduct these
screenings?
Secretary Martinez-Lopez. All Services follow the same approach to
screen for symptoms associated with BOP, as outlined in standardized
clinical tools.
Historically, the focus in medical assessments after deployment has
been exposures to potentially concussive events, including blast
related exposures, and symptom based, with the latter typically driving
the need for further assessments or treatment. Standardized medical
assessments occur twice after deployment and are facilitated through
the Post Deployment Health Assessment Form DD 2796 and the Post
Deployment Health Re-Assessment Form DD 2900. All military medical
treatment facilities (MTFs) have providers trained in TBI screening
with the ability to refer patients to one of the TBI Specialty Care
clinics or the Defense Intrepid Network for TBI and Brain Health for
more comprehensive care. As a part of the continuum of care,
servicemembers receive ongoing evaluation and treatment by a primary
care provider during the annual Periodic Health Assessment, and those
individuals reporting a history of TBI (or circumstances suggestive of
the possibility) are further assessed for their Service or treatment
needs.
14. Senator Warren. Secretary Martinez-Lopez, what steps are each
of the service branches taking to support servicemembers who are
experiencing TBI and blast overpressure symptoms due to exposure during
training?
Secretary Martinez-Lopez. The Military Departments support
servicemembers who are experiencing TBI and BOP through clinical
treatments for symptoms, and by enhancing awareness, education, and
training to enable early recognition and treatment. The DHA provides a
robust compliment of evaluation and treatment services to address those
servicemembers who present with symptoms secondary to exposure to BOP
and TBIs. To help bring servicemembers into the healthcare system, in
December 2023, the DHA established the new Warfighter Brian Health
(WBH) hub (https://health.mil/Military-Health-Topics/Warfighter-Brain-
Health) that provides a unified approach toward optimizing
servicemember brain health. In addition, the WBH Strategy and Action
Plan, Objective 3d, ``Optimize Medical Care to Return Warfighters to
Full Duty Following TBI,'' aims to identify, develop, and deploy
evidence-based assessment, diagnostic, treatment, and rehabilitation
strategies for TBIs. In support, the DHA developed the July 2023,
Provider Fact Sheet, that informs providers about low-level blast
exposure and steps to take to ensure patient education, documentation,
and treatment.
15. Senator Warren. Secretary Martinez-Lopez, when will DOD start
to conduct routine cognitive testing for servicemembers who are already
in the service (not initial entry servicemembers)?
Secretary Martinez-Lopez. The Department plans to begin conducting
routine cognitive testing for servicemembers who are already in the
Service in December 2025; 18 months after the start of cognitive
testing in accessioned servicemembers at the IMTs.
tools for measuring brain health
16. Senator Warren. Ms. Lee, what tools would the department need
to equitably and accurately assess soldier brain health and the
diagnosis and prevention of brain injuries in soldier fitness tests and
operational performance?
Ms. Lee. As discussed in question 7, the DOD uses the ANAM for
baseline and periodic testing for brain health and as appropriate for
diagnosed TBIs with cognitive deficits. The ANAM is a cognitive
assessment tool designed to detect the speed and accuracy of attention,
memory, and thinking ability. ANAM is useful as a complimentary tool to
determine if there are cognitive changes in a servicemember. For this
reason, ANAM testing is conducted prior to deployment and can be used
to identify and monitor changes in function before and after an injury.
The DOD also continues to explore other tools that can be used to
assess WBH through conducting research analysis through in progress
reviews and sending out requests for information from industry and
academic communities. For concussions, injuries that are part of the
spectrum of brain injuries, the DOD continues to use the MACE 2 and PRA
tools in conjunction with networked specialty care.
17. Senator Warren. Secretary Martinez-Lopez, what partnerships or
collaborations does the Department of Defense have with private sector
companies or universities and are these partnerships advancing
solutions for traumatic brain injury prevention and recovery?
Secretary Martinez-Lopez. The DOD collaborates with multiple
universities and industry partners, such as the National Collegiate
Athletic Association, University of California San Francisco through
the Transforming Research and Clinical Knowledge in Traumatic Brain
Injury (TRACK TBI) initiative, Abbott, and the National Academy of
Science, Engineering, and Medicine, just to name a few.
Yes, these partnerships are advancing solutions for prevention,
diagnostics, treatments and recovery following TBI.
protecting most at-risk service members
18. Senator Warren. Dr. McBirney, what would be the benefits of
establishing strategies specific to the Military Occupational
Specialties (MOS) most at risk for blast overpressure?
Dr. McBirney. Establishing strategies specific to the MOSs most at
risk would allow for targeted prevention and mitigation efforts, which
would offer several benefits. One is improved occupational safety. MOS-
specific strategies would enhance the overall safety and well-being of
the servicemembers and reduce the likelihood of brain injury among
personnel who are regularly exposed to blasts. Additionally, by
safeguarding the health and well-being of servicemembers in roles with
known blast exposure risk, the military can maintain higher levels of
mission readiness and effectiveness. Moreover, MOS-specific strategies
would better support post-service transition and veteran care for
veterans who may have been exposed to blast overpressure during their
military service. Lastly, establishing MOS-specific strategies would
allow for limited resources to be focused where they are needed most.
19. Senator Warren. Ms. Lee, when will DOD establish strategies
specific to the Military Occupational Specialties most at risk for
blast overpressure?
Ms. Lee. Please see information provided in response to question 5.
In addition, the Department has identified MOS's that are most
vulnerable to BOP exposures and is implementing risk mitigation
activities aimed at those high risk MOS's and the utilization of Tier 1
weapon systems and munitions.
20. Senator Warren. Secretary Martinez-Lopez, although DOD has
identified the most at risk MOSs, it has grouped some broader groups
together. For example, putting all combat arms in the high risk group
combines heavy weapons troops with light infantry, which may risk
missing subpopulations such as mortar soldiers who may be at higher
risk than light infantry soldiers. Does DOD have plans to break down
these subpopulations to ensure that they are not missing out on
critical groups?
Secretary Martinez-Lopez. The Department is in the process of re-
evaluating munitions-related training and associated MOS's that put
servicemembers at risk of BOP exposure. As discussed above, recently
the Services have identified specific MOS's for the Department's WBH
Initiative to focus blast exposure efforts, to include mitigation of
activities and enhanced screening for servicemembers.
21. Senator Warren. Secretary Martinez-Lopez, the New York Times
reported at least one suicide in each of the artillery units they
investigated that experienced significant effects of blast overpressure
from fighting ISIS in Iraq and Syria in 2016 and 2017. Please provide a
breakdown of the rates of deaths by suicide among artillery units sent
to Syria and Iraq to fight against ISIS.
Secretary Martinez-Lopez. Currently, the DOD does not have a means
to longitudinally track each servicemember by MOS and their disposition
based on possible BOP exposure. The DOD is working closely with the
research community to develop a BOP dose response curve to update the
occupational exposure tracking system, which would allow for tracking
of those exposed to BOP.
tracking blast overpressure data
22. Senator Warren. Secretary Martinez-Lopez, what is DOD's plan
for a wide scale rollout for integrating blast overpressure data into
servicemember's individual longitudinal exposure record (ILER)
following the pilot study with 500 servicemembers?
Secretary Martinez-Lopez. The next steps include the finalization
of the common data elements to be captured for each servicemember
exposure event. Long term storage capability is also important so that
blast exposure data will be available for ongoing evaluation and
research purposes.
23. Senator Warren. Secretary Martinez-Lopez, when will DOD be able
to stand up this program and how much funding is needed to establish a
permanent module?
Secretary Martinez-Lopez. The Department is conducting a business
case analysis (BCA) to inform the development of a standardized
monitoring program for blast exposures. The BCA will evaluate the
resources necessary to monitor, record, and analyze BOP exposures. The
BCA is projected to be completed by December.
24. Senator Warren. Secretary Martinez-Lopez, will the information
on blast
exposure data added to the ILER records include retrospective data for
servicemembers?
Secretary Martinez-Lopez. All data in the ILER is retrospective and
is inclusive of environmental data that could impact servicemember
health. As blast exposure data becomes available, it will be evaluated
for the optimal way to include it in ILER.
25. Senator Warren. Secretary Martinez-Lopez, while the Defense
Department is tracking servicemembers who have had traumatic brain
injury, this misses out on important data regarding those who are
impacted by blast overpressure in other ways, such as sleep problems,
headaches, behavior health issues, irregular heartbeats, and vestibular
injuries. What steps is DOD taking to track a broader swath of
servicemembers impacted by blast overpressure and blast exposure,
beyond just TBI?
Secretary Martinez-Lopez. The Department's focus is connecting
servicemember level exposure to the ILER, with the Electronic Health
Record (EHR) being the primary means to link blast exposure and health
effects. The first priority is to encourage servicemembers to seek
treatment and to make them aware of the reasons they may want to seek
treatment for possible BOP related symptoms. Policy, standardized
screenings, and education all help enable that objective. Once in the
system, the DOD is seeking to track BOP as an exposure in the health
records if a servicemember presents for related symptoms. Currently if
a servicemember was experiencing adverse health effects from BOP in the
garrison environment, then they would seek care within the MHS. In the
deployed setting, all servicemembers who are within 50 meters of a
blast event are required to undergo a mandatory medical screening and
evaluation. The documentation of servicemember blast exposure is
critical.
To achieve this in the EHR, the DOD, in partnership with the
Department of Veterans Affairs (VA), developed a specific blast medical
diagnosis code in the International Classification of Diseases, Tenth
Revision (ICD-10) for primary blast injury to the brain. The Department
is developing guidance to ensure clear instructions for use of this new
blast medical record code to help provide additional insights to inform
clinical or operational decisions. This effort is expected to be
completed this year to enable better medical surveillance for BOP
exposure and injury.
26. Senator Warren. Secretary Martinez-Lopez, what updates does DOD
provide to servicemembers after they participate in studies monitoring
blast overpressure? Please provide a breakdown of the rates of deaths
by suicide among artillery units sent to Syria and Iraq to fight
against ISIS.
Secretary Martinez-Lopez. The DOD does not routinely provide
updates or information to servicemembers after they consent to be in a
research study. For most of the studies, the data collected by
individual servicemembers are aggregated and de-identified for purposes
of data analysis. There are plans to provide the results from the
anonymized studies that are summarized and made available on the WBH
Portal.
For the second part of this question, please refer to response to
question 21.
27. Senator Warren. Dr. McBirney, and Dr. Zafonte, what are the
benefits of establishing blast exposure and traumatic brain injury logs
for servicemembers?
Dr. McBirney. These logs would allow the Department of Defense
(DOD) to better track the frequency of low-level blast exposure, assess
the occurrence among high-risk occupational specialties, determine the
connection between exposure and health outcomes, and develop strategies
to mitigate low-level blast exposure in training environments.
Ultimately, in-depth exposure records could be used to develop an index
score to gauge an individual's combat readiness and potential health
risks. \2\
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\2\ Charles C. Engel, Emily Hoch, and Molly M. Simmons, The
Neurological Effects of Repeated Exposure to Military Occupational
Blast: Implications for Prevention and Health: Proceedings, Findings,
and Expert Recommendations from the Seventh Annual Department of
Defense State-of-the-Science Meeting, RAND Corporation, CF-380/1-A,
2019, https://www.rand.org/pubs/conf--proceedings/CF380z1.html; Lauren
Fish and Paul Scharre, Protecting Warfighters from Blast Injury, Center
for a New American Security, May 2018.
---------------------------------------------------------------------------
Dr. Zafonte. Logs would create a method by which patients could
bring more data to bear in their evaluations for TBI and allow for more
uniformity. Data would also give servicemembers greater control over
their healthcare, as they could make informed choices when seeking
treatment.
addressing cultural barriers
28. Senator Warren. Secretary Martinez-Lopez, what efforts is DOD
and all the services undertaking to inform, educate, and build a
culture of safety in units to follow appropriate safety measures to
protect from blast exposure, such as accurately wear personal
protective equipment (PPE) or blast gauges, pausing the use of weapons
once an unsafe threshold has been reached?
Secretary Martinez-Lopez. The November 2022 the interim guidance
memorandum, ``Managing Brain Health Risk from Blast Overpressure,''
(discussed above) stated that until the relationship between BOP and
brain health effects are more fully understood, DOD Components will
manage the risk of exposures from weapon systems exceeding 4 pounds per
square inch as part of training, planning, and execution. This
memorandum specified risk management requirements for DOD Components,
including minimizing the number of personnel in the vicinity of BOP
events, increasing standoff distances from weapons; minimizing the
duration of live-fire events; establishing a maximum allowable number
of rounds fired during each training event; ensuring application of
personal protective equipment; and training and educating on BOP
hazards and risk management actions. This policy is currently being
updated to expand on risk management actions based on the outcome of
research and studies.
The DHA, with all three Military Departments and the Assistant
Secretary of Defense for Health Affairs, developed the ``DOD Service
Member Fact Sheet, Information on Low-Level Blast Exposure,'' July
2023, found at: https://www.health.mil/Military-Health-Topics/Centers-
of-Excellence/Traumatic-Brain-Injury-Center-of-Excellence/Low-Level-
Blast-Exposure. The fact sheet was designed for servicemembers, where
their occupational specialties may involve working with or exposure to
blasts generated from firing heavy weapon systems or explosives in
combat or training environments. The last page gives examples of MOS's
that can be exposed to low level blast.
29. Senator Warren. Secretary Martinez-Lopez, what training is DOD
and the services providing to unit leaders on protecting their units
from the blast overpressure and blast exposure?
Secretary Martinez-Lopez. As specified within the interim guidance
memorandum, ``Managing Brain Health Risk from Blast Overpressure,''
(mentioned above) DOD Components are required to train and educate on
BOP hazards and risk mitigation actions. Additionally, Commanders are
to implement actions to further reduce risk by training and educating
personnel on BOP hazards and risk management actions. The Military
Departments and unit commanders are responsible to determine how often
and in what manner training is conducted and tracked to ensure
proficiency while training safely in compliance with current safety and
range regulations.
30. Senator Warren. Secretary Martinez-Lopez, what steps is DOD and
each of the services taking to destigmatize servicemembers who come
forward with blast overpressure and TBI symptoms, both for those who
have and have not engaged in direct combat?
Secretary Martinez-Lopez. Our first priority is the health of our
servicemembers which is why we make every effort to encourage anyone
who has experienced symptoms related to blast overpressure (BOP)
exposure or traumatic brain injury (TBI) to seek diagnosis and
treatment. Policy, standardized screenings, and education all help
enable that objective--and to ensure that servicemembers throughout the
Department do not perceive any potential stigmatizing barriers to care.
The Military Departments support servicemembers who are experiencing
symptoms related to TBI or BOP exposure through clinical treatments for
related symptoms, and by enhancing awareness, education, and training
to enable early recognition and treatment.
Currently, if a servicemember is experiencing adverse health
effects from BOP exposure in the garrison environment, then they would
seek care within the Military Health System (MHS) as outlined in the
July 2023, Service Member Fact Sheet (Information on Low-Level Blast
Exposure: Service Member Fact Sheet (health.mil)). In the deployed
setting, all servicemembers who are within 50 meters of a blast event
are required to undergo a mandatory medical screening and evaluation.
Required screenings and evaluation further build awareness of possible
risks and normalizes use of the MHS to receive care for these types of
experiences, thus further reducing any possible stigma associated with
seeking care. Incident based protocols do not require the servicemember
to self-identify the need for a medical evaluation; it is mandatory
based on the potentially concussive event (i.e., blast event).
Furthermore, servicemembers receive training and education on how to
recognize BOP symptoms, requirements to report exposures to their
command, and seeking an evaluation from their medical provider if
experiencing symptoms.
Military medical training institutions emphasize TBI prevention,
diagnosis, and treatment through both enlisted and officer courses as
part of our efforts to encourage accessing care and, whenever
applicable, reduce and eliminate any potential stigma associated with
receiving help. Additionally, the Military Services require
servicemembers to take the Joint Knowledge Online course US 1114
``Concussion Training for servicemembers,'' which describes actions and
responsibilities to protect warfighter brain health. Topics covered
include the definition and causes of concussion, signs and symptoms of
concussion, its impact on physical performance and mission readiness,
and the roles and responsibilities of servicemembers and leaders as
they pertain to concussion.
31. Senator Warren. Secretary Martinez-Lopez, what steps is DOD and
each of the services taking to ensure that servicemembers who come
forward due to traumatic brain injury or blast overpressure effects do
not face retaliation for doing so?
Secretary Martinez-Lopez. Our first priority is the health of our
servicemembers which is why we make every effort to encourage anyone
who has experience symptoms related to BOP exposure or TBI to seek
diagnosis and treatment. Taking care of our people, which includes
protecting them from retaliation or reprisal in any form at any level,
is important for our servicemembers' wellness and the overall readiness
of our force. The Military Departments support servicemembers who are
experiencing symptoms related to TBI or BOP exposure through clinical
treatments for related symptoms and education and training on early
recognition and treatment, the Department is implementing policy to
ensure they are afforded every opportunity to protect their ability to
serve along the way.
32. Senator Warren. Secretary Martinez-Lopez, the New York Times
reporting revealed that there are many cases where policies are not
being implemented on the ground, i.e. troops were not actually
following safety measures on the ground. What steps are you taking to
work with the services to ensure that policy changes are being
implemented on the ground?
Secretary Martinez-Lopez. The DOD's Deputy's Safety Oversight
Committee (DSOC) governance structure has been and will continue to
support oversight and compliance activities to ensure policy changes
are being implemented on the ground.
33. Senator Warren. Dr. McBirney, and Dr. Zofante, are you aware of
cases where servicemembers were retaliated against for coming forward
about their injuries from blast overpressure and exposure?
Dr. McBirney. I am not aware of any specific cases in which
servicemembers were retaliated against for coming forward about their
injuries from blast overpressure and exposure. However, there is ample
research on the underreporting of injuries among servicemembers \3\--
specifically, the underreporting of TBIs--and the reasons
servicemembers underreport, one of them frequently being concerns that
reporting could have negative consequences. A 2020 study assessing
unreported and untreated TBI among more than 5,000 soldiers concluded
that, of those who reported a concussion, only 52 percent sought
medical care. Of those who did not seek care, 18 percent were concerned
that reporting might have negative repercussions on their careers.
Additionally, 28 percent of soldiers who experienced a mild TBI (and 11
percent of soldiers who did not) reported that there is a stigma
associated with mild TBI. \4\ This stigma goes beyond TBI and speaks to
the culture across DOD--one in which there is stigma associated with
seeking medical services and/or mental health treatment. \5\
---------------------------------------------------------------------------
\3\ Laurel Smith, Richard Westrick, Sarah Sauers, Adam Cooper,
Dennis Scofield, Pedro Claro, and Bradley Warr, ``Underreporting of
Musculoskeletal Injuries in the US Army: Findings from an Infantry
Brigade Combat Team Survey Study,'' Sports Health, Vol. 8, No. 6,
November/December 2016.
\4\ Sandra M. Escolas, Margie Luton, Hamid Ferdosi, Bianca D.
Chavez, and Scot D. Engel, ``Traumatic Brain Injuries: Unreported and
Untreated in an Army Population,'' Military Medicine, Vol. 185, Supp.
1, January-February 2020.
\5\ Kyong Hyatt, Linda L. Davis, and Julie Barroso, ``Chasing the
Care: Soldiers Experience Following Combat-Related Mild Traumatic Brain
Injury,'' Military Medicine, Vol. 179, No. 8, August 2014.
---------------------------------------------------------------------------
Dr. Zafonte. I am not personally aware of any retaliation.
34. Senator Warren. Dr. McBirney, and Dr. Zofante, what steps
should DOD and the services take to encourage servicemembers to seek
treatment and help both during and after their career?
Dr. McBirney. Research shows that two common reasons servicemembers
do not seek treatment for TBIs relate to stigma and the belief that
their injury did not require care, \6\ the latter of which stems from a
lack of education and awareness. Additional barriers to seeking
treatment include logistical barriers and structural factors related to
the military medical system (as detailed in Question 7). \7\ Therefore,
there are several options that DOD has to encourage servicemembers to
seek treatment. These include destigmatizing [mental] health care,
enhancing the accessibility of services, implementing routine mental
health screenings, training servicemembers and leadership on the signs
of [mental] health issues and potential brain injury, establishing
clear, confidential channels for servicemembers to provide feedback on
care received and any barriers they encountered, and developing further
peer support programs. \8\
---------------------------------------------------------------------------
\6\ Joie D. Acosta, Wenjing Huang, Maria Orlando Edelen, Jennifer
L. Cerully, Sarah Soliman, and Anita Chandra, Measuring Barriers to
Mental Health Care in the Military: The RAND Barriers and Facilitators
to Care Item Banks, RAND Corporation, RR-1762-OSD, 2018, https://
www.rand.org/pubs/research--reports/RR1762.html; Escolas et al., 2020;
Hyatt, Davis, and Barroso, 2014; Marie-Louise Sharp, Nicola T. Fear,
Roberto J. Rona, Simon Wessely, Neil Greenberg, Norman Jones, and Laura
Goodwin, ``Stigma as a Barrier to Seeking Health Care Among Military
Personnel with Mental Health Problems,'' Epidemiologic Reviews, Vol.
37, January 2015; Terri Tanielian, Mahlet Woldetsadik, Lisa Jaycox,
Caroline Batka, Shaela Moen, Carrie Farmer, and Charles C. Engel,
``Barriers to Engaging Service Members in Mental Health Care Within the
U.S. Military Health System,'' Psychiatric Services, Vol. 67, No. 7,
July 2016.
\7\ Acosta et al., 2018; Tanielian et al., 2016.
\8\ Donald Berwick, Katherine Bowman, and Chanel Matney, eds.,
``Traumatic Brain Injury Prevention and Awareness,'' in Traumatic Brain
Injury: A Roadmap for Accelerating Progress, The National Academies
Press, 2022; Kathryn E. Bouskill, Carrie M. Farmer, Irineo Cabreros,
Jonathan H. Cantor, Natalie C. Ernecoff, Lynn Hu, Shira H. Fischer,
Aaron Kofner, Lisa S. Meredith, Matthew L. Mizel, Aneesa Motala,
Tepring Piquado, Zachary Predmore, and Rajeev Ramchand, Improving Care
for Veterans with Traumatic Brain Injury Across the Lifespan, RAND
Corporation, RR-A1205-1, 2022, https://www.rand.org/pubs/research--
reports/RRA1205-1.html; Escolas et al., 2020; Michael S. Jaffee,
``Traumatic Brain Injury and the Military Health System,'' in David
Butler, Jessica Buono, Frederick Erdtmann, and Proctor Reid, eds.,
Systems Engineering to Improve Traumatic Brain Injury Care in the
Military Health System: Workshop Summary, The National Academies Press,
2009; School of Education and Human Development, Texas A&M University,
``Support for Family Caregivers After Military Traumatic Brain
Injuries,'' November 27, 2018.
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Dr. Zafonte. As a non-profit academic medical center, outside the
system, I do not have sufficient personal knowledge of the internal
barriers servicemembers face to seeking TBI treatment to respond to
this question in detail.
35. Senator Warren. Dr. McBirney, and Dr. Zofante, what steps
should DOD and the services take to encourage servicemembers to follow
safety measures to protect themselves from blast overpressure?
Dr. McBirney. Perhaps the most effective way to encourage
servicemembers to follow safety measures is through education and
awareness. Servicemembers and leadership need authoritative information
about the dangers of blast overpressure, including its sources and the
potential short-and long-term health consequences. Regular training and
awareness campaigns can help personnel understand why protective
measures are necessary and how they can effectively mitigate risks. \9\
Additionally, the dissemination of safety equipment that is both
validated and functional will encourage safety members to protect
themselves from blast overpressure.
---------------------------------------------------------------------------
\9\ Berwick, Bowman, and Matney, 2022.
---------------------------------------------------------------------------
Dr. Zafonte. As a non-profit academic medical center, outside the
system, I do not have sufficient personal knowledge on the internal
incentives or barriers to servicemembers following safety measures.
providing service members care
36. Senator Warren. Dr. Zofante and Captain Williams, how many
servicemembers do you have on your waitlist and what is the average
wait period for them to start your respective programs?
Dr. Zafonte. Currently, there are 236 Special Operations personnel
in the screening and review process. We have scheduled 241 Special
Operations personnel for an upcoming cohort. From the start of the
first engagement with a potential participant, the average wait time is
12-15 months.
Captain Williams. The National Intrepid Center of Excellence
(NICoE) and the larger Defense Intrepid Network (DIN), 13 facilities
total, have two outpatient program types, the traditional outpatient
traumatic brain injury (TBI) clinic model and the interdisciplinary
intensive outpatient program (IOP). The Defense Health Agency access to
care standard for a specialty care program is 28 calendar days from
date of referral. Servicemembers referred to the traditional outpatient
clinic model consistently meet the access to care standard.
Nine of the 13 DIN sites have the IOP, and the waitlist for these
locations is approximately 640 servicemembers. Each site proactively
schedules patients into the program as openings become available, with
servicemembers typically booked within three to 6 months.
It should be noted that, in pursuit of career goals, there are
periods in the training and deployment rotation of servicemembers where
they are more willing to commit to the 4-week IOP program. Many of
these patients are still functioning at a high capacity (but not at
their full potential). Therefore, time from referral to engagement in
the IOP is not always considered to be an ``as soon as possible''
appointment by the servicemembers.
37. Senator Warren. Dr. Zofante and Captain Williams, how much
additional funding would you need to address the servicemembers on your
wait list for your respective programs?
Dr. Zafonte. Home Base is funded almost entirely through
philanthropy with some supplemental State and Federal appropriations.
Every dollar that we bring in makes an impact on how many patients we
can treat, the programs we can support, and the innovation that we can
pilot. The primary obstacle to reducing the waitlist is the absence of
adequate physical space for treatment and the need to expand our pool
of qualified healthcare providers. Home Base launched a capitol
campaign and was successful in raising funds to build a new floor for
our headquarters in Charleston, MA. When we complete that space in mid-
2024, we will have the capacity to see twice as many patients weekly as
part of the ComBHaT program. Increased Federal support for Home Base
would allow the organization to continue building out a world-class
provider team, ensure continued investment in innovative treatment
models and technology, and allow us to remain the gold standard for
treating TBI and invisible wounds of war.
Captain Williams. The additional resources necessary to address the
wait list are associated with increased specialized clinical personnel
and an exemption from standard healthcare productivity practices.
Staffing models for practice guidelines of interdisciplinary care,
including outpatient and IOP programs, are currently being established
for further determination of manning requirements.
38. Senator Warren. Dr. Zofante and Captain Williams, how much
advance notice do servicemembers get before they are able to enter your
program?
Dr. Zafonte. Entering the ComBHaT program is a multi-step process.
Prospective participants reach out over the phone, via email, or
through an online ``connect to care'' platform. Once an interest form
is submitted, a team member from Home Base reaches out to the
prospective patient and begins the screening and intake process. That
process is multi-faceted and may include a medical clearance process
before the Special Operations personnel can participate. Once cleared
for admission, the team works with the participant to find a time that
can work with the up-tempo schedule of Active Duty Special Operations
personnel. The entire process can take 12 to 18 months. Home Base also
maintains a standby list of people who are interested in filling the
spot for a last-minute cancellation.
Captain Williams. Each DIN site varies on the advance notice
provided to servicemembers. Typically, servicemembers often prefer
dates that are optimal for their training and deployment rotations and
can have upwards of 3 months' notice. However, due to the potential for
quickly changing circumstances with each individual patient, positions
in the IOP cohorts may open due to cancelations, sometimes with only
days or a few weeks' notice. Unscheduled members on the waitlist are
immediately offered the opportunity to attend if they are agreeable and
available.
See comment on question 36 above for additional clarification.
39. Senator Warren. Dr. Zofante and Captain Williams, what onsite
childcare options do you have for servicemembers when they attend your
program?
Dr. Zafonte. Home Base does not currently offer onsite childcare
for our participants.
Captain Williams. There are currently no onsite dedicated childcare
services across the network. Some installations have Child Development
Centers or Child and Youth Services that may be able to provide hourly
care for those registered with each individual program.
40. Senator Warren. Dr. Zofante and Captain Williams, what is the
average number of servicemembers whose families are able to attend your
respective programs as well?
Dr. Zafonte. We invite all ComBHaT participants to bring family
support. Approximately 50 to 60 percent of ComBHaT patients bring a
family support member with them for the 5-day evaluation program.
Captain Williams. The numbers of spouses/families that choose to
participate varies across locations in the DIN, ranging from 5 to 25
percent of spouses/families.
41. Senator Warren. Dr. Zofante and Captain Williams, at what point
in their career do most servicemembers attend your respective programs?
Dr. Zafonte. We have a diverse range of participants in ComBHaT,
from early careers to veterans. While we do not actively track our
participants' career stages in our data set, anecdotally, the majority
are in their final few years of service. Home Base has recently seen an
uptick in senior leaders (E-8/E-9 and O-5 through O-9) participating in
the ComBHaT program.
Captain Williams. Most members attending the DIN intensive
outpatient programs have greater than 15 years' time in service.
This percentage is slightly impacted by the military occupation
and/or community, severity of TBI and Service affiliation. It is common
for servicemembers with TBI symptoms and associated conditions to not
to seek care until they are nearing the end of their careers due to
fears of stigma, non-deployability, or duty limiting profiles.
Therefore, comprehensive medical and psychological evaluations near the
end of their career, including diagnoses and treatment for TBI
symptoms, continues to be highly sought after. Specific DIN locations
reported the following:
A. ISC Fort Liberty (Army Special Operations) reported that about
75 percent are within 2 years of retirement with the other 25 percent
at mid-career (10-12 year).
B. ISC Camp Lejeune (Marine Special Operations) reported that the
majority of IOP patients are at 815 to 18 years of service; the
outpatient program varies from first acute concussions event to pending
retirement (e.g., 18+ years).
C. ISC Eglin (Airforce Special Operations) reports for both IOP
and OP the average is 16 years' time in service with an average patient
age of 37 years old.
D. ISC Camp Pendleton (1st Marine Expeditionary Force) reported a
majority of servicemembers have ten or more years of service.
E. ISC Ft. Cavazos reported there has been a diverse
representation of mid and late career enlisted and officer
participation at both levels of care (outpatient and IOP) over the last
decade. In the last 2 years, there has been a spike in early career or
junior soldiers who have not deployed but sustained concussions in
while in garrison.
42. Senator Warren. Dr. McBirney, and Dr. Zofante, what are the
biggest gaps in information getting to servicemembers and their
families about blast overpressure risks and symptoms, as well as
options for treatment?
Dr. McBirney. My research has not focused on this, so I will defer
to my colleagues to answer this question.
Dr. Zafonte. As a non-profit academic medical center outside the
DOD system, I do not have sufficient personal knowledge on how DOD
shares information with servicemembers and their families. However, to
my knowledge, most servicemembers who come to Home Base learn about the
program from their peers and self-refer to the program. I recommend
that DOD ensure that high-quality evidence-based programs in the
private sector are easily accessible to servicemembers and their
families.
43. Senator Warren. Dr. McBirney, and Dr. Zofante, what are the
biggest barriers to servicemembers seeking and obtaining treatment for
blast overpressure and exposure?
Dr. McBirney. While there is little to no research on the barriers
that prevent servicemembers from seeking and/or obtaining treatment
specifically for blast overpressure and exposure, there is some
research on barriers that prevent servicemembers from seeking treatment
for TBI and further research on barriers related to the treatment of
mental health and other health issues. Barriers include those that are
purely logistical (e.g., difficulty scheduling an appointment \10\);
structural factors associated with the military medical system (e.g.,
limited capacity of the system, limited number of providers available
to address needs); \11\ a lack of knowledge of the risks of exposure to
lower-level blasts; \12\ and institutional attitudes and cultural
issues, also known as public stigma \13\ (e.g., perceived attitudes
held by leadership, \14\ concerns that seeking care could have negative
career repercussions \15\).
---------------------------------------------------------------------------
\10\ Acosta et al., 2018.
\11\ Tanielian et al., 2016.
\12\ Escolas et al., 2020.
\13\ Tanielian et al., 2016.
\14\ Acosta et al., 2018; Sharp et al., 2015; Tanielian et al.,
2016.
\15\ Escolas et al., 2020; Hyatt, Davis, and Barroso, 2014;
Tanielian et al., 2016.
---------------------------------------------------------------------------
Dr. Zafonte. Servicemembers often avoid seeking care for blast-
related injuries due to several interrelated reasons:
1. Stigma: There is a pervasive stigma associated with seeking
medical or psychological help, often viewed as a sign of weakness. Many
servicemembers fear that admitting to an injury, especially one
involving mental health, could negatively impact their careers and how
peers and superiors perceive them.
2. Desire to Stay in the Fight: The strong sense of duty and
commitment to their mission drives many servicemembers to downplay or
ignore their injuries. They may fear being sidelined or removed from
Active Duty, which could prevent them from fulfilling their
responsibilities and supporting their comrades.
3. Concern for Team Members: Servicemembers often prioritize the
well-being of their team over their own health. They worry that seeking
treatment could leave their team shorthanded, increasing the risk for
their fellow soldiers and potentially compromising the mission.
4. Lack of Recognition of Subtle Symptoms: Blast-related injuries,
particularly traumatic brain injuries (TBI), can have subtle and
delayed symptoms that are not immediately recognized. Servicemembers
may attribute these symptoms to stress, fatigue, or other benign
causes, leading to a delay in seeking appropriate care.
Addressing these barriers requires a cultural shift within military
organizations to normalize seeking help and recognize the importance of
early intervention for blast-related injuries.
__________
Questions Submitted by Senator Tammy Duckworth
blood tests for tbi screening
44. Senator Duckworth. Secretary Martinez-Lopez and Ms. Lee, the
Department of Defense (DOD) has recognized the need for an accurate
blood test to assess concussions and screen military personnel for
traumatic brain injuries. Due to DOD's leadership in this space and
working with industry to bring such a test to market, there now exists
an FDA-cleared blood test available to servicemembers and civilians
alike. However, more research and clinical trials are needed to make
this test available from the battlefield to the sports field, and to
truly operationalize the point-of-care ability of a TBI test. How is
DOD continuing to work with the stakeholder community to drive this
research forward?
Secretary Martinez-Lopez and Ms. Lee. The Department published the
WBH Research Strategy in January 2024 which provides guidance for DOD
medical and operational research and development (R&D) activities to
coordinate, optimize, and advance WBH science. Specifically, focus area
2.6 of the WBH Research Strategy, ``Assessing and Diagnosing Warfighter
Brain Injuries,'' recognizes blood biomarkers as a priority. Select
medical units within the DOD have fielded blood biomarker kits in their
medical equipment sets. The WBH Vision outlines R&D efforts focused on
brain health hazards, threats, and operational requirements, with the
goal of rapidly transitioning products and practices to optimize WBH
and performance. The Department also collaborates with multiple
stakeholders to include industry partners, academic institutions, and
other Federal agencies within the context of the National Academies of
Science, Engineering and Medicine (NASEM) TBI Forum, specifically in
the area of biomarkers for TBI. In April, the Director of the WBH
Office presented at a National Academies of Science, Engineering, and
Medicine (NASEM) workshop on `Innovation Trends in Technology for the
Prevention, Treatment, and Management of TBI' to outline the DOD's
challenges and barriers to using TBI FDA cleared devices as part of
ongoing efforts to maximize implementation and to and drive research
and innovation in this space.
45. Senator Duckworth. Secretary Martinez-Lopez and Ms. Lee, are
there other opportunities to work with Federal partners like VA, CDC,
BARDA, and NIH to research, update, and disseminate best practices and
evidence-based diagnosis for TBI?
Secretary Martinez-Lopez and Ms. Lee. Yes, there are many
opportunities to partner. The Department has a long history of
successful partnerships with other Federal agencies and organizations
in advancing clinical practice, conducting research, developing
educational and prevention and awareness products and exploring
technology solutions. For example, the DOD partnered with the VA to
publish the ``VA/DOD Clinical Practice Guideline for the Management and
Rehabilitation of Post Acute Mild Traumatic Brain Injury,'' in June
2021. In 2023, the Department has partnered with the Department of
Health and Human Services, the VA, and the Department of Transportation
to lead and support recently published recommendations from the NASEM
report, ``Traumatic Brain Injury: A Roadmap for Accelerating
Progress.''
__________
Questions Submitted by Senator Joni Ernst
early detection
46. Senator Ernst. Dr. Zafonte and Captain Williams, what methods
are there to diagnose TBI where the wounds are undetectable on MRI and
PET scans?
Dr. Zafonte. For servicemembers with negative standard anatomic MRI
scans, more sophisticated diagnostic tools are essential to detect
subtle or cumulative injuries that might not be visible on conventional
imaging. Multimodality scanning, which employs advanced MRI paradigms
potentially linked to PET-based markers, offers a more comprehensive
assessment of brain function and structure. These advanced imaging
techniques can reveal microstructural damage, metabolic changes, and
other subtle abnormalities indicative of traumatic brain injury (TBI).
Additionally, blood-based biomarkers, as well as physiological and
reaction markers, hold promise for enhancing our understanding of both
short-and long-term exposure effects. These biomarkers can provide
critical information about the biological processes underlying injury
and recovery, thereby supporting clinical diagnosis and monitoring.
It is crucial to link these sub-markers and tools to clinical
symptoms, resilience factors, and long-term maladaptation. This linkage
ensures that diagnostic findings are relevant and actionable within a
clinical context. By correlating biomarkers and advanced imaging
results with clinical presentations and patient outcomes, we can
develop more targeted and effective treatment plans. This holistic
approach enhances our ability to identify those at risk, monitor their
recovery, and ultimately improve the long-term health and resilience of
our servicemembers.
Captain Williams. The most reliable method to diagnosis continues
to be history and physical examination of the patient. Blood based
biomarkers are an important emerging tool in TBI diagnosis. Advanced
technologies to further characterize TBI, including
magnetoencephalography (MEG) and quantitative EEG methods that look at
neural network disruptions, remain under research investigation.
The most reliable mechanism for assessing the invisible wounds of
war is still a sound medical history and neurological/
neuropsychological and behavioral health evaluations. Interdisciplinary
approaches leverage the expertise of each provider and enhances the
understanding of the multifaceted disease State. Not only do
neurological and behavioral health providers shed light on brain health
and functioning, but assessments by internal medicine (endocrinological
disturbances, nutritional deficiencies), physiatry, and rehabilitation
providers identify important medical conditions that impact cognitive
bandwidth, level of performance, and emotional regulation.
Each interdisciplinary team member has objective and subjective
screening tools and outcome measures. These approaches include not only
diagnosis of TBI but treatment of symptoms and sequelae. Some examples
include a servicemember's neurocognitive testing helps to understand
disruption of cognitive domains, levels of functioning, and emotional
regulation. Assessment of sleep disturbances is also a critical
component in the assessment and treatment of TBI, sub concussive
events, blast exposure, and psychological health conditions. In
addition, utilization of the creative arts therapies has been
advantageous in the externalization of otherwise compartmentalized and
untreated symptoms for servicemembers.
47. Senator Ernst. Dr. Zafonte, are there other alternatives
available Automated Neuropsychological Assessment Metrics (A-NAM) test
that is used by the DOD an accurate method of detecting changes in
cognition that can lead to a TBI diagnosis?
Dr. Zafonte. ANAM is used to assess for cognitive deficits acutely,
usually within the first week, following a traumatic brain injury. It
is typically used in the first few days following a mild traumatic
brain injury. There has been a large amount of research published over
the past 15 years relating to using ANAM and other neuropsychological
test batteries for this purpose. Each battery carries known limitations
and strengths. To address this question adequately, a working group
would need to review the State of the science on this topic.
48. Senator Ernst. Dr. Zafonte, would wearable devices assist in
the diagnosis of these types of TBI? If so, what kind?
Dr. Zafonte. Implementing wearable technology to detect blast
exposure represents a significant advancement in identifying
servicemembers at cumulative risk and refining exposure thresholds.
These devices can continuously monitor environmental factors and
physical responses, providing real-time data on blast intensity and
frequency. This information is crucial in recognizing those who might
be at increased risk due to repeated low-level exposures that could
cumulatively result in significant harm.
While wearable technology offers valuable insights, it is important
to understand that it does not diagnose traumatic brain injuries (TBI)
on its own. Instead, these devices serve as an early warning system,
raising suspicion of potential injuries based on exposure patterns.
They provide additional evidence that clinicians can use to make more
informed decisions about further evaluation and potential intervention.
By integrating data from wearable technology with clinical
assessments, we can enhance our ability to identify at-risk individuals
early, potentially before significant symptoms manifest. This proactive
approach supports better outcomes by enabling timely and targeted care,
ultimately improving the health and readiness of our servicemembers.
49. Senator Ernst. Secretary Martinez-Lopez and Captain Williams,
earlier, we heard from Mr. Larkin, whose son Ryan had microscopic tears
on his brain that were not detectable on MRI and PET scans. What
methods are there to diagnose TBIs like this?
Secretary Martinez-Lopez and Captain Williams. There is no approved
technology to radiographically diagnose microscopic tears. These
injuries can be below the resolution of conventional and advanced
imagery; therefore, a variety of assessment and treatment approaches
are utilized to identify neurological network disruptions. This makes
the interdisciplinary model critical for targeting treatment and
recovery, as well as deploying investigatory technology such as MEG and
Quantitative Electroencephalography (QEEG).
See comment on question 46 above for additional information.
50. Senator Ernst. Secretary Martinez-Lopez, when will the DOD
transition from the pre-deployment neurocognitive testing to the
broader screening program?
Secretary Martinez-Lopez. The Department plans to expand the
current cognitive assessment testing beginning June 2024 at 15 initial
military training sites.
51. Senator Ernst. Secretary Martinez-Lopez, what neurocognitive
test are you using and why is this best suited for our servicemembers?
Secretary Martinez-Lopez. For several years, the DOD has used the
ANAM as the primary neurocognitive test to meet the requirements
outlined in DOD Instruction 6490.13, ``Comprehensive Policy on
Traumatic Brain Injury-Related Neurocognitive Assessments by the
Military Services,'' September 11, 2015, as amended. The Army has been
the lead agent in executing the Department's neurocognitive program and
has collected over 3.7 million baseline tests (approximately 93-95
percent are pre-deployment). A sample size of the data within the
repository supported the publication of the ``Long-Term Test--Retest
Stability of ANAM in a Large Military Sample \1\.'' The study results
indicate that the use of the ANAM baseline for comparison can be done
up to 5 years, thus the baseline results are stable. To date the
Department continues to use the ANAM as the primary neurocognitive test
as there has been no data to demonstrate superiority of another
assessment tool, despite head-to-head comparison studies of
computerized neurocognitive tests \2\.
---------------------------------------------------------------------------
\1\ Meyers J. (2019). Long-Term Test-Retest of ANAM in a Large
Military Sample. Archives of Clinical Neuropsychology 35 (2020) 70-74.
\2\ Wesley C. (2017). A Comparison of Four Computerized
Neurocognitive Assessment Tools to a Traditional Neuropsychological
Test Battery in servicemembers with and without Mild Traumatic Brain
Injury. Archives of Clinical Neuropsychology 33 (2018) 102-119.
52. Senator Ernst. Ms. Lee, what information are you providing to
servicemembers and their families about the Warfighter Brain Health
Initiative?
Ms. Lee. In additional to information provided to servicemembers
seen in TBI clinics, we have education and awareness efforts tailored
for military and family members. The WBH Hub, established in December
2023 (at health.mil/brain), serves as the single source of information
on brain health topics. Our goal is to make the latest brain health
information easy to access for our servicemembers, providers, families,
and the public and provide a bridge from our clinical community to the
operational environment.
53. Senator Ernst. Ms. Lee, what positive impacts has the
Warfighter Brain Health Initiative made on the servicemembers and their
families?
Ms. Lee. The outreach activities that support the WBH Initiative
(WBHI) have positively impacted the overall awareness of the importance
of optimizing brain health. Due to multiple educational efforts,
especially throughout March, which is Brain Injury Awareness Month,
servicemembers and their families have increased knowledge and
resources available to them. The WBHI offers extensive support in areas
crucial to military relevance, including cognitive performance, brain
health, BOP exposures, TBI evaluations, treatments, care, and long term
or late effects of brain exposures and injuries. This broad scope
provides numerous opportunities for positively impacting the readiness
of the Force and enhancing the quality of life for servicemembers and
their families.
54. Senator Ernst. Secretary Martinez-Lopez and Ms. Lee, how is the
Department screening servicemembers who may have developed TBI in a
deployed location?
Secretary Martinez-Lopez and Ms. Lee. DODI 6490.11, ``DOD Policy
Guidance for Management of Mild Traumatic Brain Injury/Concussion in
the Deployed Setting,'' September 18, 2012, as amended, directs a
medical screening and evaluation of a servicemember that has been
involved in a potentially concussive event, such as being 50 meters or
closer to a blast incident. DOD policy dictates that the MACE 2
screening tool and PRA are used nearest to time of injury and drive
clinical decisionmaking for immediate care. Upon redeployment there are
standardized medical assessments which occur twice and are facilitated
through the Post Deployment Health Assessment Form DD 2796 and the Post
Deployment Health Re Assessment Form DD 2900. All military health care
facilities have providers trained in TBI screening with the ability to
refer patients to one of the TBI clinics or to the Defense Intrepid
Network for TBI and Brain Health for more comprehensive care. As a part
of the continuum of care, servicemembers receive ongoing evaluation and
treatment by a primary care provider during the annual Periodic Health
Assessment, and those individuals reporting a history of TBI (or
circumstances suggestive of the possibility) are further assessed for
their Service or treatment needs.
55. Senator Ernst. Secretary Martinez-Lopez and Ms. Lee, what can
the DOD do to expedite developing a system to monitor blast exposure
among servicemembers?
Secretary Martinez-Lopez and Ms. Lee. The DOD has multiple efforts
underway, the first major step was the Assistant Secretary of Defense
for Readiness memorandum (discussed above), published November 4, 2022,
``Interim Guidance for Managing Brain Health Risk from Blast
Overpressure.'' This memorandum provided guidance to implement the
following mitigation strategies: (1) minimizing the number of personnel
in the vicinity of BOP events; (2) increasing standoff distances from
weapons; (3) minimizing the duration of live fire events; (4)
establishing a maximum allowable number of rounds that may be fired
during each event or time period; (5) ensuring application and
appropriate use of personal protective gear and equipment (e.g.,
hearing protection); and (6) training and educating on blast
overpressure hazards and risk management actions.
The Assistant Secretary of Defense for Health Affairs is working
with the Military Departments the Assistant Secretary of Defense for
Readiness, and DOD's Public Health and occupational health subject
matter experts to develop a dose response curve for BOP (currently this
does not exist in either the military or the civilian sector). In
parallel, we are seeking supplementary data sources and ammunition
distribution logs that might provide blast exposure by weapon system or
round with both timing and unit level information. Last, the DHA is
leading a BCA on BOP monitoring, with a projected completion of
December 2024. The BCA will evaluate various methods for monitoring and
documenting BOP exposures, such as recording shot counts, using MOS's
as proxies for blast exposure, surveys and questionnaires through self-
reporting, and wearable blast sensors.
56. Senator Ernst. Secretary Martinez-Lopez, Ms. Lee, and Captain
Williams, can you detail the current State of brain-computer interface
(BCI) technology and how it's being utilized within the Department of
Defense (DOD) to detect, measure, or assist in recovery from traumatic
brain injuries (TBIs) among servicemembers?''
Secretary Martinez-Lopez, Ms. Lee, and Captain Williams. The DIN
uses Bio and Neurofeedback (NFB) as a form of BCI. BCI represents a
body of science focused on the acquisition of brain signals, signal
analysis and translation into commands that control an external device
to replace or restore useful function to people with neurological/
neuromuscular disorders.
In the DIN, utilization of BCI focuses on techniques designed to
improve internal brain-body performance by acquiring brain wave
information and augmenting brain wave band power through NFB. NFB
converts neural signals into visual, auditory, and tactile information,
and the subject can selectively enhance or inhibit certain components
to promote learning and regulate brain function through real-time NFB
training. Studies in the DIN network and in the academic community have
demonstrated the ability to enhance performance in memory,
concentration, and limb movement. A similar process is used in
biofeedback to regulate internal brain-heart coherence, sweat response,
respiration rate and skin temperature to modulate the bodies autonomic
nervous system. Additionally, NICoE is leveraging MEG technology in
research protocols to characterize the complex waveform harmonics of
the brain in understanding distortion and patterns in posttraumatic
stress disorder. These precision real-time characterizations may
provide future strategies for improving treatment of posttraumatic
stress and other behavioral health disorders in the setting of
traumatic brain injury.
57. Senator Ernst. Secretary Martinez-Lopez, Ms. Lee, and Captain
Williams, how is BCI technology being planned for and/or transitioned
from various innovation and R&D portfolios across the Department and
services to be integrated into operational routines to potentially
monitor and measure overall brain health and TBI indicators from the
time of entry into service until completion of service for our
servicemembers?
Secretary Martinez-Lopez, Ms. Lee, and Captain Williams. The DOD,
to include the DIN, does not currently utilize BCI technology for
monitoring of overall brain health and TBI indicators during service.
We will continue to evaluate findings from our research investments for
possible integration where appropriate.
See comment on question 56 above for more information.
58. Senator Ernst. Secretary Martinez-Lopez, Ms. Lee, and Captain
Williams, what are the projected priorities, investments, and key
developments in the field of BCI technology over the current FYDP and
future needs for the Department, specifically as it relates to improved
monitoring, data, and improved detection to improve outcomes for
servicemembers with TBI?
Secretary Martinez-Lopez, Ms. Lee, and Captain Williams. There are
currently no set clinical priorities for BCI technology.
See comment on question 56 above for more information.
59. Senator Ernst. Secretary Martinez-Lopez, Ms. Lee, and Captain
Williams, what is the current protocol, cadence, and process for a
servicemember to be identified as being at risk for TBI, evaluated, and
subsequent followup? Please include associated timelines, general cost
per servicemember, and confidence/accuracy of reliable TBI detection at
scale.
Secretary Martinez-Lopez, Ms. Lee, and Captain Williams.
Comprehensive screening protocols to identify servicemembers being at
risk for TBI include assessing for potential risk factors such as
history of head injuries, behavioral health conditions, and combat
exposure. Cadence of screenings varies depending on factors such as
deployment cycles, mission requirements and changes in individual
health status. Deployment cycle evaluations include the pre deployment
health assessment, the post deployment health assessment and the post
deployment health reassessment, which are all opportunities for
servicemembers to be identified as being at risk for TBI and evaluated.
Throughout all these standardized processes, if a servicemember is
identified as being at risk for TBI, then they are referred for further
evaluation. There is no monetary cost to the servicemember.
60. Senator Ernst. Secretary Martinez-Lopez, Ms. Lee, and Captain
Williams, what congressional support and guidance needs to be provided
in order for the Department of Defense to have the necessary
authorities and resources to ensure that the personnel and healthcare
leadership across each service are able to develop and employ programs
that would use BCI technology to monitor, track and mitigate risks such
as TBI, costly fatigue/focus mishaps, or other relevant brain health
categories?
Secretary Martinez-Lopez, Ms. Lee, and Captain Williams. The
Department has the necessary authorities to employ BCI technology to
monitor, track, and mitigate risks such as TBI, which would require a
prospective longitudinally monitored program to establish a normative
data set with neurocognitive testing, blood biomarkers, cerebral
vasomotor reactivity measurements and quantitative
electroencephalography matched against time in service, and the
tracking of various Military Occupational Specialties with different
levels of exposure to different weapons systems (including Explosive
Ordinance Disposal, Special Warfare Combatant Crewmen personnel, and
paratroopers).
See comment on question 56, 57 and 58 above for more information.
treatment approaches
61. Senator Ernst. Ms. Lee, during your tenure at the Warfighter
Brain Health Policy Initiative, what non-conventional treatments have
been seen to be effective in treating TBI?
Ms. Lee. The Defense Intrepid Network for TBI and Brain Health
utilizes many innovative and non-conventional treatments to help
relieve symptoms and to optimize functioning and well-being. Many of
these treatments are undergoing empirical validation of their
effectiveness. Some examples of these treatments include biofeedback
and mindfulness training, acupuncture, therapeutic arts, such as music,
writing, art, dance and movement, and animal engagement, such as canine
and equine therapy.
62. Senator Ernst. Captain Williams, Intrepid Centers offer
specialized treatments focused on treating TBI that are not widely
available at other military treatment facilities. Can you describe some
of these treatments and their effectiveness in treating TBI?
Captain Williams. Repetitive TBI operational stressors can result
in an overall disruption of brain health characterized by a wide
variety of symptoms and conditions. The key to treatment is the
establishment of a patient-centric interdisciplinary holistic program,
to address the injuries of mind, body, brain, and spirit, to enhance
return to duty, and improve interpersonal relationships, and overall
functioning.
The DIN uses an interdisciplinary model of care, where the
treatment team specialties to treat TBI and associated psychological
health conditions are co-located within one facility. The NICoE program
leverages the co-localization of 18 disciplines and treatment
modalities combine conventional neurological, behavioral health and
rehabilitation therapies with integrative medicine interventions and
educational modules to promote a culture of healing, self-efficacy, and
self-advocacy. This includes creative arts therapies (art therapy,
dance movement therapy and music therapy) that provide an essential
integrated behavioral health approach, in conjunction with mind-body
wellness services, biofeedback, and psychological health services.
Integration of this ``high touch'' to the ``high tech'' paradigm,
includes neuroimaging, neuro-optometry, audiology, vestibular testing,
and augmented reality/virtual reality assessment and treatment. NICoE
and other DIN sites also teach detailed cognitive strategy and
assistive technology training, including the Brain Fitness Center,
which uses personal cognitive training programs.
The interdisciplinary team approach expedites diagnostic evaluation
and helps achieve a collaborative comprehensive care plan. Studies have
shown significant improvement using this model of care in recovery
across multiple neurological and behavioral health domains. Since the
onset, there are now 13 centers that use this interdisciplinary model
for both intensive outpatient programs and extended outpatient
programs.
The NICoE intensive outpatient program includes the scheduling of
105-130 separate encounters (varies with individual need) across 4
weeks with the assessment and treatment across 18 disciplines. The
clinical program is informed by research conducted at the NICoE and
with academic and industry partners. Our research has demonstrated
statistically significant and clinically meaningful recovery across
seven major domains of functioning.
63. Senator Ernst. Captain Williams, how do we make these
treatments more accessible to servicemembers with TBIs?
Captain Williams. The formalization of the DIN will accelerate the
standardization of TBI specialty care across the DHA and increase
programs that provide the same high-quality care for our beneficiaries.
Our best practices can be utilized by all TBI providers across the
military health system.
The establishment of the DIN supports local and regional patient
populations, as well as local and regional referring entities. It will
allow expansion of services and sharing of resources within the DIN
sites via telehealth services. The primary focus will be Active Duty
servicemembers who have experienced a TBI, are at greatest risk of TBI
injury and blast exposure, or those who may experience sub-concussive
events. Formalization of the DIN will also allow for retirees and
beneficiaries to access services. The DIN also strives to partner with
other Centers of Excellence to continue expansion and accessibility of
care.
In addition, the Continuum of Caring, Healing and Thriving
Initiative (the Continuum) is intended to facilitate a seamless
transition of care by sharing resources for mental health treatment and
peer networks at the Department of Veterans Affairs and non-
governmental organizations, creating great opportunities for public-
private partnerships and to work closer with operational units to
prevent, educate and build resilience in the warfighter (aligning with
lines of effort of the Warfighter Brain Health Initiative). The
Continuum will allow the DIN the opportunity to support servicemembers
in their journey long after they have completed treatment, with peer
support and case management, and assist them as they transition into
civilian life.
64. Senator Ernst. Secretary Martinez-Lopez and Dr. Williams: The
legislation responsible for the creation of the National Intrepid
Center of Excellence is 15-years old, yet I understand that your
program is not a ``program of record'' for the Department of Defense.
Is that accurate, and if so, why is that the case? What are the
implications of not being a program of record?
Secretary Martinez-Lopez, and Captain Williams. Yes, the DIN, which
includes the NICoE, is not a program of record. As the TBI facilities
have become a network with centralized governance, establishing the DIN
as a program of record is the next step.
Activities that are not a program of record do not have a separate
allocation of funds for that activity. That means the activity is
included in the overall medical facility funding and must compete with
other personnel and resource funding priorities. The impact to care can
be more consequential at DIN sites where there is a model of care
utilizing unique staffing patterns and there may be little capability
in the private sector. Presently, the NICoE, and associated DIN TBI
clinics are funded from Defense Health Program dollars for their
respective military medical treatment facilities.
65. Senator Ernst. Captain Williams, what recommendations would you
make to improve the Department's ability to treat military personnel
who, as part of the job, are repeatedly exposed to low-level blasts?
Captain Williams. Start conducting baseline identification upon
entering the military and/or engaging in high-risk Military
Occupational Specialties, including neurocognitive testing, and
monitoring over time and/or change in functioning. It is also crucial
to support early career training on sleep hygiene, dietary/nutritional
assessment, exercises that promote autonomic control, and emotional
regulation. Behavioral health assessments and treatment following
deployment are also important to introduce behavioral health as self-
care and teach team member monitoring as part of the culture of peak
combat performance. This will help minimize the stigma of prevention
and increase resilience.
warfighter brain health initiative
66. Senator Ernst. Secretary Martinez-Lopez and Ms. Lee, in order
to assess the operation needs of the Services with regard to the
Warfighter Brain Health Initiative, how does the DOD/DHA maintain
awareness of the needs and concerns of the operational communities that
they support?
Secretary Martinez-Lopez and Ms. Lee. DOD governance structures are
the primary means by which we maintain awareness of the needs and
concerns of the operational community. I, as the Assistant Secretary of
Defense for Health Affairs, coordinate through the Under Secretary of
Defense for Personnel and Readiness, with the Assistant Secretary of
Defense for Readiness and other senior officials within the Office of
the Secretary of Defense, to execute requirements related to
operational communities. To maintain awareness, DOD leverages the
current MHS governance structure, which includes representatives from
the Military Departments, and executes operational needs and
requirements through the Joint Staff processes and initiatives.
67. Senator Ernst. Secretary Martinez-Lopez and Ms. Lee, how are
the military department's priorities communicated to the DHA Commander
and staff and likewise, what is the mechanism for DHA to engage with
senior operational leaders providing updates on the evolving science
impacting the Military Department's personnel health and readiness?
Secretary Martinez-Lopez and Ms. Lee. Refer to question 66 above
for the same mechanism to communicate the Departments priorities.
68. Senator Ernst. Secretary Martinez-Lopez and Ms. Lee, who in DHA
has the responsibility for drafting the requirement/Capabilities
Development Document for the blast dosimeter program? Has this process
already started? What is the status of the program?
Secretary Martinez-Lopez and Ms. Lee. A blast dosimeter program has
not been developed. The DHA J5 (Strategy, Plans and Policy) is
responsible for drafting requirements documents. Currently the MHS has
published Initial Capabilities Documents addressing research solutions
for WBH, combat casualty care and military operational medicine, which
will support the development of Capabilities Development Documents for
a blast dosimeter program.
__________
Questions Submitted by Senator Dan Sullivan
marine artillerymen tbis in syria
69. Senator Sullivan. Secretary Martinez-Lopez and Ms. Lee, in
large scale combat operations against a peer adversary, artillerymen
are going to fire thousands of rounds. Can you tell me what the DOD is
doing to ensure the experience of the marines who were deployed to
Syria in 2016 and 2017, as reported in the New York Times article from
November 5, 2023 titled ``A Secret War, Strange New Wounds, and Silence
from the Pentagon,'' is not repeated?
Secretary Martinez-Lopez and Ms. Lee. In response to recent
casualty events in Syria, the Department reviewed its procedures in
place for the reporting of potentially concussive events (PCE) and its
management of TBI. It is important to acknowledge that our
understanding and focus on brain injury and pivot to WBH is evolving.
Before WBH our medical and policy practices included exposures to PCEs
but remained focused on TBI by traditional definitions. In the standing
up of the WBH program we are acknowledging the relationship between
``sub-concussive'' BOP and symptoms and seeking to expand our
screening, treatment, and followup. Accordingly, the DOD's review
included an in-depth look at TBI related documentation, screening,
diagnosis, treatment, follow-on care, and reporting as prescribed in
DOD policy. The review also provided insight into the mild TBI (mTBI)
rates resultant from a drone attack on a forward operating base, which
represents an emerging threat to the Joint Force. Early detection and
treatment for mTBI remains essential to maximizing patient outcomes and
ensuring the prompt and safe return of our warfighters to duty. The
Department will continue to review our processes and procedures as part
of policy oversight and compliance functions.
tbi prevention & treatment
70. Senator Sullivan. Secretary Martinez-Lopez and Ms. Lee, how is
the DOD's approach to TBI prevention changing as new data is gathered?
Secretary Martinez-Lopez and Ms. Lee. The biggest shift is one from
a TBI centric approach to a more holistic approach to WBH. As insights
grew from research investments and the experiences of military
providers caring for servicemembers with TBI in combat and the home
front, the DOD developed novel treatment paradigms and policy to
maximize utilization across the force. By 2018, military leaders began
to explore the hypothesis that BOP exposures could result in brain
health changes similar to those seen with diagnosed concussions. Also
in 2018, the Deputy Secretary of Defense directed the development of a
comprehensive strategy and action plan to promote brain health and
counter TBI. The DOD's WBHI is a joint effort between operational and
medical forces. The focus is to optimize WBH, specifically cognitive
and physical performance, identify known and emerging brain threats in
military environments, and detect brain injury immediately when it
occurs to combat its effects on warfighters, their families, first line
leaders/commanders, and their communities at large. As part of our
responsibility to our Nation and the troops defending it, DOD wants to
reduce the risks of exposure to known and emerging brain threats, such
as BOP, head impact, and directed energy. Our commitment is to
understand, prevent, accurately diagnose, and promptly treat BOP and
effects in all its forms in all operating environments. This means that
we are committed to understanding, through our research investments and
field experiences, the role that BOP exposures plays in sustaining
TBI's. In support of these policy initiatives, we continue to focus on
how to disseminate best practices, new research findings and resources
about WBH. The WBH Hub, established in December 2023, at health.mil/
brain, serves as the single source of information on brain health
topics. Our goal is to make the latest brain health information easy to
access for our servicemembers, providers, families, and the public and
service as a bridge from our clinical community to the operational
environment. These linkages are critical for TBI prevention efforts.
71. Senator Sullivan. Secretary Martinez-Lopez and Ms. Lee, how is
the DOD's approach to TBI treatment changing as new data is gathered?
Secretary Martinez-Lopez and Ms. Lee. Through the DHA's Acute
Concussion Care Pathway, the Department has been able to direct the
usage of State of the science tools that are improved and updated as
new data is gathered. This care pathway, tailored to each
servicemember, was established with the goal of improving recovery
times and outcomes by utilizing the MACE 2 to ensure brain health
deficits were identified even if only detectable in a subset of
clinical domains. These tools also help ensure timely access to repeat
evaluations with personalized treatment protocols that are demonstrated
to accelerate injury recovery through individualized progressive return
to activity processes. This pathway resulted in the clinical screening
of approximately 20,000 first time TBI diagnosed servicemembers across
the Military Services in fiscal year 2023.
As discussed above, the MACE 2 is an acute assessment tool for all
medically trained personnel who treat servicemembers involved in a
potentially concussive event. This tool incorporates current state-of-
the-science TBI assessment, including balance, eye movements and
cognitive screening. This clinical advance was driven by the DOD, first
though research to clarify what was needed, and then through early
adoption. The DOD is currently preparing a shortened version of the
MACE 2 based on feedback from medical staff utilization in combat that
will enable more rapid screening. As noted, the MACE 2 supports the PRA
protocol that has demonstrated accelerated recovery through
individualized treatment. The tool was updated in January 2023 with new
data that had been gathered. Additionally, the DHA also coordinates
with our research community through formal review and analysis meetings
to evaluate research findings that can be translated into practices and
tools to help improve treatment options available to those with TBI.
72. Senator Sullivan. Secretary Martinez-Lopez and Ms. Lee, are DOD
medical personnel appropriately trained and equipped to identify and
diagnose TBIs?
Secretary Martinez-Lopez and Ms. Lee. Yes, DOD medical personnel
are trained to identify and diagnose TBIs. Training content and
platforms are evolving as clinical translation opportunities arise from
research findings. Additionally, the Department continues to provide
opportunities for awareness and training for providers, most recently
through the release of the WBH hub at www.health.mil/brain. Military
Services issue TBI diagnostic equipment based on roles of care and
individual Service mission requirements.
73. Senator Sullivan. Secretary Martinez-Lopez and Ms. Lee, can you
describe the various echelons of care under which a servicemember is
initially exposed to a blast (say like the many recently injured by
drove and rocket attacks in Syria and Iraq), assessed, diagnosed with a
TBI, and then treated?
Secretary Martinez-Lopez and Ms. Lee. The military's medical system
is organized into several echelons of care, often referred to as
``Roles of Care.'' These roles outline the different levels of medical
support available to military personnel depending on their location,
the severity of their injuries, and the resources available. While
specific terminology and organization may vary between different
Military Departments, a typical framework includes the following:
Role 1 (Unit-Level Medical Care) medical personnel
provide primary health care, tactical combat casualty care, triage,
resuscitation, walking blood bank, and stabilization. Initial
management of TBI care begins at point of injury, where medical
personnel are trained in evaluation, treatment, management, and
evacuation of patients diagnosed with mild, moderate, to severe TBIs.
Role 2 (Forward Trauma Management and Emergency Medical
Treatment). Role 2 medical personnel provide reassessments of TBI
patients further trauma management and emergency medical treatment,
including continuation of resuscitation started in Role 1.
Role 3 (Theater Hospitalization). In Role 3, the patient
is treated in a MTF staffed and equipped to provide care to all
categories of patients, to include resuscitation, initial wound
surgery, and postoperative treatment. TBI patients receive
comprehensive care including advanced diagnostics, surgical
interventions, critical care, medication management, and early
rehabilitation services ensuring thorough treatment and stabilization.
These facilities provide both immediate and ongoing medical support to
manage brain injuries and associated complications.
Role 4 Care (Definitive Care). Role 4 medical care is
found in US-based hospitals and robust overseas MTFs. Role 4 represents
the highest level of definitive medical care available within the MHS
or the United States. These facilities provide specialized treatment
for servicemembers who suffered a TBI, including advanced medical and
surgical care, intensive rehabilitation services (physical,
occupational, and speech therapy) long-term neurological and
psychological support, and continuous monitoring to facilitate recovery
and reintegration.
The events in Syria triggered a medical screening for concussion
using the MACE 2. Providers are trained to conduct this assessment at
all Roles of care, although, based on operational requirements, this
may be deferred to a higher role of care.
As discussed above, the MACE 2 is multimodal in that it captures
assessment information from many health care areas such as balance, eye
movements, cognition, report of symptoms and key past medical history
that can prolong the recovery from a concussion. Acute TBI care is
provided throughout the Roles of care with checkups to ensure recovery.
There are standardized tools, such as the PRA protocol, that outline
state-of-the-art treatments as well as how to return servicemembers to
duty and full function. The PRA specifically allows clinicians to
follow recovery of symptoms identified in the MACE 2 and offer
treatment tailored to a servicemember's specific deficits (e.g.,
symptoms). There are also programs in place to screen for mild TBI and
offer followup care during redeployment.
If recovery does not occur as expected, the DOD has a wide
range of clinical services to assist with more in-depth care.
DOD has specialty clinical and comprehensive interdisciplinary
centers of excellence for TBI and brain health. These programs
have been developed to deliver a holistic patient centered
interdisciplinary TBI model of care. Behavioral health services
can include psychiatry, psychology, and social work. Additional
services may include neurology, sleep medicine, pain
management, and rehabilitation services such as balance and
vision therapy. These centers of excellence also offer
innovative treatments such as creative arts therapies, animal-
assisted therapies, and mind-body wellness services.
74. Senator Sullivan. Secretary Martinez-Lopez, are there
standardized TBI screenings that are part of pre and post-deployment
medical examinations?
Secretary Martinez-Lopez. Yes. As a part of the continuum of care,
servicemembers receive ongoing TBI screenings and evaluation by a
primary care provider during the annual Periodic Health Assessment, and
those individuals reporting a history of TBI (or circumstances
suggestive of the possibility) are further assessed for treatment
needs. Historically, the focus in medical assessments after deployment
has been exposures, including blast related exposures, and symptom
based, with the latter typically driving the need for further
assessments or treatment. Standardized medical assessments occur twice
after deployment and are facilitated through the Post Deployment Health
Assessment Form DD 2796 and the Post Deployment Health Re Assessment
Form DD 2900. All MTFs have providers trained in TBI screening with the
ability to refer patients to one of the TBI clinics or the Defense
Intrepid Network for TBI and Brain Health for more comprehensive care.
75. Senator Sullivan. Secretary Martinez-Lopez and Captain
Williams, since TBI injuries can present differently and at various
times post-injury, at what time intervals post-deployment/post-exercise
do servicemembers undergo TBI screening?
Secretary Martinez-Lopez, and Captain Williams. Post deployment
health assessments occur twice; 30 days before or after redeployment
and then 90 to 180 days after redeployment. TBI screening occurs during
those times.
76. Senator Sullivan. Secretary Martinez-Lopez, Ms. Lee, and
Captain Williams, has DOD compiled blast data from its inventory of
weapon systems to determine TBI risk based on system and duration of
exposure?
Secretary Martinez-Lopez, Captain Williams and Ms. Lee. The Office
of the Under Secretary of Defense for Acquisition and Sustainment
(OUSD(A&S)) is responsible for the acquisition policies. DOD Components
are responsible to evaluate environment, safety and occupational health
risks in the weapons systems acquisition processes in accordance with
the guidance contained in Military Standard (MIL STD) 882E \3\.
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\3\ Department of Defense Standard Practice, System Safety, MIL-
STD-882E, September 27, 2023
77. Senator Sullivan. Secretary Martinez-Lopez, Ms. Lee, and
Captain Williams, which office in the DOD is responsible for assessing
TBI risk from individual weapon system operation?
Secretary Martinez-Lopez, Captain Williams and Ms. Lee. The Office
of the Under Secretary of Defense for Acquisition and Sustainment
(OUSD(A&S)) is responsible for the acquisition policies. DOD Components
are responsible to evaluate environment, safety and occupational health
risks in the weapons systems acquisition processes in accordance with
the guidance contained in Military Standard (MIL STD) 882E3.
78. Senator Sullivan. Secretary Martinez-Lopez, Ms. Lee, and
Captain Williams, are weapon manufacturers required to provide blast
overpressure data to the DOD?
Secretary Martinez-Lopez, Captain Williams and Ms. Lee. My office
is not aware of any manufacturer requirements to provide BOP data to
the Component capability developer or program managers (PMs) nor of any
refusal to provide requested environmental, safety, or occupational
health (ESOH) data.
79. Senator Sullivan. Secretary Martinez-Lopez, Ms. Lee, and
Captain Williams, have any weapon manufacturers been asked to provide
blast overpressure data to the DOD and refused?
Secretary Martinez-Lopez, Captain Williams and Ms. Lee. My office
is not aware of any manufacturer requirements to provide BOP data to
the Component capability developer or program mangers, nor of any
refusal to provide requested ESOH data.
tbi injury tracking & data bases
80. Senator Sullivan. Secretary Martinez-Lopez and Ms. Lee, do
tracking mechanisms or medical data bases exist for TBI baselines and
injury assessments, much like they do for hearing audiograms, which
stay with servicemembers their full career and get transferred to the
VA once they exit the military?
Secretary Martinez-Lopez and Ms. Lee. Currently there is no tool
used to establish a traumatic brain injury baseline and the current
tracking mechanisms that exist for TBI baselines and injury assessments
are not similar to hearing audiograms. However, there is a data
repository for baseline neurocognitive assessments. Currently, the
baseline neurocognitive assessments do not get automatically
transferred to the VA when a military member separates or retires. The
VA does have access to the neurocognitive assessments upon initiation
by a VA clinician to request the results.
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