RESEARCH PRIORITY-SETTING EFFORTS

The diversity of the TBI research landscape mirrors the diversity of populations impacted by TBI, from military personnel (Veterans, active duty military personnel, cadets and military trainees), to athletes (professional, collegiate, student, youth), to patients across the entire lifespan. The Department of Defense (DoD) and the Department of Veterans Affairs (VA) are heavily involved in the TBI research and care landscape across the gamut from funding to implementation. From enlistment, to active duty, to Veteran status, many military personnel are impacted by TBI throughout their career and beyond. Military personnel and Veterans also make up a large and unique population that can be studied to better understand long-term impacts of TBI. Athletes face a heightened risk of TBI, and their lives and livelihoods are impacted by TBI in unique ways. The National Football League (NFL), the National Collegiate Athletic Association (NCAA), and other athletic institutions have supported athlete-focused research to explore the effects of TBI on athletes during and after their athletic careers.

Because of the complexity and breadth of TBI, the research needed to diagnose, treat, and improve outcomes can vary according to the setting in which TBI occurs, the individual, the setting where TBI is being diagnosed or treated, and numerous other factors. Thus, funders and organizing bodies that support and advocate for TBI research often have needs that are connected to specific populations and settings. Other TBI initiatives address crosscutting issues and include all or more than one of these population groups. For instance, the needs of athletes and their coaches to assess potential TBI in high-pressure scenarios share some similarities with the needs of military medical staff assessing potential TBI in combat; the challenges of mild TBI are of similar significance in civilian and military settings; the study of TBI among aging Veterans may offer insights into the impacts of TBI among aging civilians; and novel advances in classification and measurement could improve the sensitivity of all TBI research, while efforts to promote data interoperability similarly affect all research settings.

ENABLING RESEARCH INFRASTRUCTURE

Several efforts have focused on developing standards for research data and establishing systems for collecting TBI-related data to inform future research (see Table A-1).

TABLE A-1

TBI Research Infrastructure.

Common Data Elements (CDE)³ standards were first published in 2010 through efforts funded by NIH and the Department of Health and Human Services (HHS). CDE Version 2 was published in 2012, and the guidelines have been continually updated since. CDE established data standards for TBI clinical research that are relevant to patients of all ages in all populations, along with common definitions and metadata protocols to ensure that data are captured and recorded consistently in studies throughout the TBI landscape. Pediatric Common Data Elements (PED-CDE)⁴ was first established in 2013, with the goal of enhancing the ability to conduct multicenter research and provide evidence-based care across Canada to assist in the diagnosis and treatment of pediatric mild TBI.

In 2011, the Federal Interagency TBI Research (FITBIR) informatics system⁵ was created through joint funding from DoD, the VA, and NIH. FITBIR offers a secure, centralized database for TBI clinical research and serves as a data repository, allowing for comparison of new and existing data. FITBIR includes data collected from more than 80,000 individuals from both military and civilian populations. Federal grants for TBI research typically stipulate that research data be shared via FITBIR.

In 2018, the National Concussion Surveillance System (NCSS)⁶ was created by CDC, with the aim of measuring the number and causes of concussions, the prevalence of brain injury, and the impacts of prevention measures. NCSS deals with civilian population data, with a focus on youth sports.

RESEARCH NETWORKS, CONSORTIA, AND STUDIES

As a diverse and interdisciplinary field, TBI research is often conducted through collaboration. The establishment of TBI research networks has aided collaboration and connected experts throughout the field (see Table A-2). A number of TBI networks have been formed, with an emphasis on improving patient outcomes; consolidating data and biological samples; accelerating research in specific areas, such as concussions research; and connecting clinicians to improve clinical standards of care.

TABLE A-2

TBI Consortia and Networks.

COllaborative Neuropathology NEtwork Characterizing OuTcomes of TBI (CONNECT-TBI)⁷ was established in 2020 among more than 10 universities in the United States, the United Kingdom, and Canada (Smith et al., 2021a). CONNECT-TBI is a network of brain banks and research institutions that share tissues and clinical datasets to support TBI research, investigate the pathologies of TBI, and explore the connections between TBI and neurodegenerative disease. CONNECT-TBI includes datasets from military, civilian, and athlete populations.

The Strategies to Innovate Emergency Clinical Care Trials Network (SIREN)⁸ was established in 2016 by NIH in collaboration with clinical centers at U.S. academic institutions. SIREN supports clinical trials with the aim of improving the outcomes of patients with neurologic, cardiac, respiratory, and hematologic emergencies by identifying effective treatments that can be provided in the earlier stages of TBI care. SIREN is associated with three noteworthy clinical studies:

• ProTECT (Progesterone for the Treatment of TBI III)⁹—failed clinical progesterone trial for moderate to severe TBI
• BOOST3 (Brain Oxygen Optimization in Severe TBI, Phase 3)¹⁰—study for severely injured intensive care unit (ICU) patients over the age of 14
• HOBIT (Hyberbaric Oxygen Brain Injury Treatment Trial)¹¹—study for adults aged 16–65 years with severe TBI

The Big Ten-Ivy League Concussion Taskforce¹² is a network and database established in 2012 to improve understanding of sport-related concussion and TBI. Studies conducted within the network are aimed at informing biomedical and behavioral sciences, enhancing clinical practice, and benefiting civilian and military populations through innovative TBI research (Putukian et al., 2019). The network’s efforts are focused on student athlete TBI cases.

The Collaborative European NeuroTrauma Effectiveness Research in TBI (CENTER-TBI)¹³ project arose from a workshop held to promote international TBI research. The CENTER-TBI prospective longitudinal observational study included 4,500 patients with 6-month patient follow-up, and the CENTER-TBI registry includes observational data from more than 15,000 patients. CENTER-TBI’s aims are to better characterize TBI as a disease; to identify effective interventions; to develop an open-source database that is compatible with FITBIR; to validate CDE for international settings; and to translate research outputs into practical information and guidelines for patients, clinicians, and policy makers.

Linking Investigations in Trauma and Emergency Services (LITES)¹⁴ was established in 2018 through collaboration between DoD and the University of Pittsburgh. The project created a network of medical professionals, prehospital providers, and emergency medical services providers to provide injury care and conduct outcomes research. The project’s goal is to inform clinical practice guidelines and update existing standards of care for traumatic injuries. The network is focused on adults with TBI who have hemorrhagic shock (SWAT [Shock, Whole Blood and Assessment of TBI] Trial)¹⁵ or need platelet transfusion (CriSP [Cold Stored Platelet Early Intervention in TBI] Trial).¹⁶

The DoD TBI Center of Excellence (TBICoE)¹⁷ (originally called the Defense and Veterans Brain Injury Center) was established in 1992 to support a network of military treatment facilities and VA medical centers with TBI education and research initiatives (Jaffee and Martin, 2010).

The International Initiative for Traumatic Brain Injury Research (InTBIR)¹⁸ coalition, supported by the European Commission, NIH’s National Institute of Neurological Disorders and Stroke, the Canadian Institutes of Health Research, One Mind, DoD, and the Ontario Brain Institute, coordinates and leverages clinical research activities on TBI research to improve care and lessen the global burden of TBI. InTBIR is focused on investigating the causal relationship between TBI treatments and clinical outcomes. InTBIR investigates TBI among civilian, military, athlete, and pediatric populations.

TBI Model Systems (TBIMS)¹⁹ was first established in 1987 as a demonstration project and expanded by HHS through the Administration for Community Living (Dijkers et al., 2010). A network of 16 TBIMS sites distributed throughout the United States focus on rehabilitation research and knowledge translation. The TBIMS National Database is currently the largest multisite longitudinal TBI study with information from preinjury through acute care and long-term outcomes among patients who received inpatient rehabilitation (Tso et al., 2021). In 2008, the VA and the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) collaborated to establish a VA TBIMS among the five Polytrauma Rehabilitation Centers that address TBI rehabilitation in Veterans.

TBI research is also driven by individual studies and the efforts of dedicated clinicians and researchers working day by day to generate evidence and improve TBI patient outcomes. Many studies have been conducted and consortia created, efforts that often are conducted in parallel with other initiatives, such as the creation of guidelines or the development of a new database.

The Injury and Traumatic Stress Clinical Consortium (INTRuST)²⁰ was established in 2016 through DoD funding. The consortium aims to combine research efforts by PTSD and TBI experts to develop innovative treatments. INTRuST maintains an imaging data repository, which includes only data from military patients with TBI severe enough to have required inpatient rehabilitation.

Operation Brain Trauma Therapy (OBTT) is a multicenter, preclinical drug and biomarker screening consortium that began in 2010 (Kochanek et al., 2018). Its aim is to define therapies that show efficacy and have promise for randomized controlled trials (RCTs), including TBI protein biomarker responses. OBTT has evaluated 10 therapeutics and assessed several blood biomarkers.

Warfighter Brain Health (WBH)²¹ was chartered in 2011 by the U.S. Army Medical Research and Development Command to lead the development and acquisition of material products to warfighters suffering from brain injuries and psychological health issues. The project aims to advance knowledge, technology prototypes, training, tools, and practice guidelines for TBI assessment. Notably, the project has resulted in the development of a blood test to detect brain injury.

Approaches and Decisions in Acute Pediatric TBI Trial (ADAPT)²² was conducted between 2014 and 2018 (final results not yet published). This international trial, supported by NIH and the University of Pittsburgh, was designed to evaluate the impact of interventions on severe TBI in children.

Army Study to Assess Risk and Resilience in Service members (ARMY STARRS) was a “multicomponent epidemiological and neurobiological study designed to generate actionable evidence-based recommendations to reduce army suicides and increase knowledge about risk and resilience factors for suicidality and its psychopathological correlates” (Ursano et al., 2014, p. 107). The study included a pre/post deployment component and a longitudinal study component.

Chronic Effects of Neurotrauma Consortium (CENC)²³ was conducted between 2013 and 2019. The largest study of TBI among Veterans, it aimed to address the long-term effects of mild TBI (mTBI) among military service personnel and Veterans. In 2019, CENC was succeeded by Long-term Impact of Military-relevant Brain Injury Consortium (LIMBIC),²⁴ which extended the research and has often been called LIMBIC-CENC to acknowledge those connections. LIMBIC aims to fill the gaps in basic science knowledge about mTBI and determine the effects on late-life outcomes and neurodegeneration. It also aims to identify service members most susceptible to the effects of mTBI and the most effective treatment strategies for these individuals. LIMBIC is funded by DoD and the VA in partnership with universities, research institutes, and health care organizations.

The Concussion Assessment, Research and Education Consortium (CARE)²⁵ began in 2014 with support from the NCAA and DoD. The largest mTBI study to date, it focuses on understanding the neurobiopsychosocial nature of concussive injury and recovery among student athletes and cadets in order to enhance the safety and health of youth athletes, service members, and civilian populations. Phase I is complete, and Phase II is ongoing.

Evaluation of Biomarkers of Traumatic Brain Injury (ALERT-TBI)²⁶ was conducted between 2012 and 2017 with funding from Banyan Biomarkers and DoD. It aimed to evaluate the utility of the Banyan UCH-L1/GFAP (ubiquitin carboxy-terminal hydrolase-L1/glial fibrillary acidic protein) Detection Assay as an aid in the evaluation of suspected TBI.

The NCAA concussion study was conducted between 1999 and 2001 (Guskiewicz et al., 2003). The seminal prospective cohort study evaluated 2,905 college football players to explore how common concussions are among college football players, average recovery time, and whether concussions occur more frequently among players who have previously experienced concussion.

Predicting and Preventing Post-concussive Problems in Pediatrics (5P)²⁷ was conducted between 2013 and 2015 by the Children’s Hospital of Eastern Ontario (CHEO) research institute in Canada (Zemek et al., 2013). This prospective, multicenter cohort study aimed to derive and validate easy-to-use prognosticators that would enable clinicians to identify children and youth at risk of persistent postconcussive symptoms. The study focused on pediatric patients aged 5–18 years who were evaluated within the first 48 hours after a TBI.

Transforming Research and Clinical Knowledge in TBI (TRACK-TBI),²⁸ which began in 2009, is the largest, most comprehensive civilian TBI initiative. The study is funded by NIH, DoD, and industry and philanthropic partners. Its aim is to collect and analyze detailed clinical data on subjects across the TBI spectrum, including computed tomography (CT) and magnetic resonance imaging (MRI) data, blood biospecimens, and detailed clinical outcomes. The study also aims to identify TBI subgroups based on imaging and blood biomarkers in order to develop precision medicine for TBI.

The TBI Endpoint Development (TED) Initiative²⁹ began in 2014 with the aim of identifying and validating measures of brain injury and recovery for use in clinical trials to enable the development of precision TBI treatment. TED is supported by DoD; the Food and Drug Administration (FDA); and various public–private partnerships involving academia, industry, philanthropy, and patient advocacy organizations. One impetus for TED was to develop an improved classification system for TBI.

EDUCATION AND AWARENESS-RAISING INITIATIVES

CDC’s HEADS UP initiative (see Table A-3) provides information and resources for parents, health care and school professionals, coaches, and athletes aimed at “raising awareness and informing action to improve prevention, recognition, and response to concussion and other serious brain injuries.”³⁰ The program has reportedly “distributed more than 6 million copies of [the] HEADS UP materials and trained over 3 million coaches” (Baldwin et al., 2016).

TABLE A-3

Selected TBI Educational Efforts.

Since 1986, the nonprofit ThinkFirst National Injury Prevention Foundation has focused on reducing youth and geriatric neurotrauma by developing and providing educational programs on injury prevention education and awareness for children, young adults, parents, and older adults (Youngers et al., 2017).

An effort by DoD’s TBICoE (formerly the Defense and Veterans Brain Injury Center [DVBIC]), “A Head for the Future” provides fact sheets on TBI and stories and videos from service members and Veterans.³¹

A number of awareness-raising and educational programs are undertaken each March for Brain Injury Awareness Month, led by the Brain Injury Association of America.

In addition, trauma-focused educational efforts may have relevance to TBI. For example, “Stop the Bleed,” founded by the American College of Surgeons, is a call-to-action awareness campaign that trains and empowers individuals to respond aptly in a bleeding emergency before professional help arrives. The course is taught by qualified instructors who focus on identification and treatment, as well as the basics of bleeding control through wound packing and pressure dressings.³²

CARE GUIDELINES

To achieve the best possible outcomes and reduce TBI-related morbidity and mortality, up-to-date, evidence-based guidelines, clinical best practices, and care recommendations are essential (see Table A-4). Much of the current TBI research is focused on addressing the need for such guidelines, and as TBI research advances, guidelines must be continually assessed and revised. Brain Trauma Foundation TBI Guidelines committees³³ have been creating TBI guidelines since 1995. The committees include representatives of various professional societies and academic institutions, including the American Association of Neurological Surgeons (AANS), Congress of Neurological Surgeons (CNS), Army Contracting Command, Aberdeen Proving Ground, Natick Contracting Division, Stanford University, and the Brain Trauma Foundation. The committees create evidence-based guidelines for treating TBI that aim to advance high-quality care and lower TBI-related morbidity and mortality. Since the initial guideline publication in 1995, updated guidelines have been published in 2000, 2007, and 2016.

TABLE A-4

Selected TBI Clinical Guidance Development Efforts.

DoD has established protocols for TBI assessment and return to duty³⁴ and continues to explore metrics for assessing readiness to return (Scherer et al., 2013). These guidelines are used primarily in military settings to manage mTBI among military personnel.

The International Forum on Consensus in Sport Concussion³⁵ first established guidelines in 2001, and its sixth conference is scheduled for 2022. Every 4 years, the forum conducts a systematic review of concussion evidence to inform a series of evidence-based statements. The most recent consensus statement was released in 2017 following the fifth international conference (McCrory et al., 2017).

In 2018, the American Academy of Neurology (ANN), American Congress of Rehabilitation Medicine (ACRM), and NIDILRR created new guidelines for disorders of consciousness (Giacino et al., 2018). These guidelines provided updated care recommendations for patients with prolonged disorders of consciousness, such as vegetative states, unresponsive wakefulness syndrome, and minimally conscious states.

CDC’s pediatric mTBI guidelines were first published in 2018 (Lumba-Brown et al., 2018).³⁶ They address diagnosis, prognosis, management, and treatment for pediatric mTBI.

As part of its HEADS UP initiative, a toolkit for healthcare professionals was first developed by CDC in 2003 and rereleased in 2007 (CDC, 2013). The website now includes online training courses for health care providers and youth sports coaches, among other resources.³⁷

FEDERAL INVESTMENTS IN TBI RESEARCH

Significant resources have been devoted to TBI over the past decade, including through federal and philanthropic research investments that have supported long-term clinical studies. According to available information, federal agencies invested approximately $330 million in fiscal year 2019 and approximately $2 billion over the 5-year period 2014 to 2019.

Information on support for TBI in the Federal RePORTER database for 2014 to 2019 shows 5,041 projects with $2,111,385,035 funding involving NIH; the CDMRP; the National Science Foundation; the NIDILRR; the Center for Neuroscience and Regenerative Medicine (based at the Uniformed Services University of the Health Sciences), CDC, the Combat Casualty Care Research Program, the Agency for Healthcare Research and Quality, and the National Institute of Food and Agriculture. TBI projects were also supported at the VA and DVBIC, although this funding was not reported in the available total.³⁸ NIH estimates of funding for TBI has increased from $87 million in 2014 to $134 million in 2019.³⁹ Recent annual funding among participating agencies of the NRAP has included funding from DoD ($141 million); VA Office of Research and Development ($41.9 million); NIH ($134 million); NIDILRR ($16 million); and CDC ($3 million), totaling approximately $335.9 million. The most recent request for proposals issued by the CDMRP in Traumatic Brain Injury and Psychological Health, released in August 2021, indicated that $175 million had been allocated to the program.⁴⁰

REFERENCES

• Baldwin G, Breiding M, Sleet D. Using the public health model to address unintentional injuries and TBI: A perspective from the Centers for Disease Control and Prevention (CDC). NeuroRehabilitation. 2016;39(3):345–349. [PubMed: 27497467]
• Brain Trauma Blueprint. Press release. 2021. [July 31, 2021]. Traumatic brain injury: A new roadmap outlining opportunities, barriers, and recommendations for advancing treatment solutions. https://www​.braintraumablueprint​.org/tbi-new-roadmap-advancing-treatment .
• CDC (Centers for Disease Control and Prevention). HEADS UP in 10 years: The anniversary viewbook of CDC’s HEADS UP. 2013. [September 24, 2021]. https://www​.cdc.gov/headsup​/pdfs/HeadsUp_10YrViewBook-a.pdf .
• Veterans Bioscience Cohen. Proceedings of the Second Annual Brain Trauma Blueprint State of the Science Summit. Jun 5–6, 2019. 2019. [July 31, 2021]. Pathways to effective treatments for traumatic brain injuries. https://www​.braintraumablueprint​.org/wp-content​/uploads/2020​/11/braintraumablueprint-tbisummit2019-proceedings.pdf .
• Dijkers M, Harrison-Felix C, Marwitz J. The Traumatic Brain Injury Model Systems history and contributions to clinical service and research. Journal of Head Trauma Rehabilitation. 2010;25(2):81–91. [PubMed: 20134334]
• DoD (Department of Defense), VA (Department of Veterans Affairs), HHS (Department of Health and Human Services), and ED (Department of Education). National research action plan: Responding to the Executive Order Improving Access to Mental Health Services for Veterans, Service Members, and Military Families. Aug 31, 2013. 2012. [July 31, 2021]. https:​//obamawhitehouse​.archives.gov/sites​/default/files/uploads​/nrap_for_eo_on_mental​_health_august_2013.pdf .
• Giacino JT, Katz DI, Schiff ND, Whyte J, Ashman EJ, Ashwal S, Barbano R, Hammond FM, Laureys S, Ling GSF, Nakase-Richardson R, Seel RT, Yablon S, Getchius TSD, Gronseth GS, Armstrong MJ. Practice guideline update recommendations summary: Disorders of consciousness: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology; the American Congress of Rehabilitation Medicine; and the National Institute on Disability, Independent Living, and Rehabilitation Research. Neurology. 2018;91(10):450–460. [PMC free article: PMC6139814] [PubMed: 30089618]
• Guskiewicz KM, McCrea M, Marshall SW, Cantu RC, Randolph C, Barr W, Onate JA, Kelly JP. Cumulative effects associated with recurrent concussion in collegiate football players: The NCAA Concussion Study. Journal of the American Medical Association. 2003;290(19):2549–2555. [PubMed: 14625331]
• Haarbauer-Krupa J, Pugh MJ, Prager EM, Harmon N, Wolfe J, Yaffe KC. Epidemiology of chronic effects of traumatic brain injury. Journal of Neurotrauma. 2021;38(23):3235–3247. https://doi​.org/10.1089/neu.2021.0062 . [PMC free article: PMC9122127] [PubMed: 33947273]
• Jaffee M, Martin EM. Defense and Veterans Brain Injury Center: Program overview and research initiatives. Military Medicine. 2010;175(7)(Suppl):37–41. [PubMed: 23634477]
• Kochanek PM, Dixon CE, Mondello S, Wang K, Lafrenaye A, Bramlett HM, Dietrich W, Hayes RL, Shear DA, Gilsdorf JS, Catania M, Poloyac SM, Empey PE, Jackson TC, Povlishock JT. MultiCenter pre-clinical consortia to enhance translation of therapies and biomarkers for traumatic brain injury: Operation brain trauma therapy and beyond. Frontiers in Neurology. 2018;9:640. [PMC free article: PMC6090020] [PubMed: 30131759]
• Lumba-Brown A, Yeates KO, Sarmiento K, Breiding M, Haegerich T, Gioia G, Turner M. Centers for Disease Control and Prevention guideline on the diagnosis and management of mild traumatic brain injury among children. JAMA Pediatrics. 2018;172(11):e182853. [PMC free article: PMC7006878] [PubMed: 30193284]
• Lumba-Brown A, Prager E, Harmon N, McCrea M, Bell M, J Ghajar, Pyne S, Cifu D. A review of implementation concepts and strategies surrounding traumatic brain injury clinical care guidelines. Journal of Neurotrauma. 2021;38(23) https://doi​.org/10.1089/neu.2021.0067 . [PubMed: 34714147]
• Manley GT, Mac Donald C, Markowitz A, Stephenson D, Robbins A, Gardner R, Winkler E, Bodien Y, Taylor S, Yue J, Kannan L, Kumar A, McCrea M, Wang K., TED Investigators. The Traumatic Brain Injury Endpoints Development (TED) Initiative: Progress on a public-private regulatory collaboration to accelerate diagnosis and treatment of traumatic brain injury. Journal of Neurotrauma. 2017;34(19):2721–2730. [PMC free article: PMC5647488] [PubMed: 28363253]
• McCrory P, Meeuwisse W, Dvořák J, Aubry M, Bailes J, Broglio S, Cantu R. Consensus statement on concussion in sport-the 5th international conference on concussion in sport held in Berlin, October 2016. British Journal of Sports Medicine. 2017;51(11):838–847. [PubMed: 28446457]
• Pugh MJ, Kennedy E, Prager E, Humpherys J, Dams-O’Connor K, Hack D, McCafferty MK, Wolfe J, Yaffe K, McCrea M, Ferguson A, Lancashire L, Ghajar J, Lumba-Brown A. Phenotyping the spectrum of traumatic brain injury: A review and pathway to standardization. Journal of Neurotrauma. 2021;38(23) https://doi​.org/10.1089/neu.2021.0059 . [PMC free article: PMC8917880] [PubMed: 33858210]
• Putukian M, D’Alonzo B, Campbell-McGovern C, Wiebe D. The Ivy League-Big Ten Epidemiology of Concussion Study: A report on methods and first findings. American Journal of Sports Medicine. 2019;47(5):1236–1247. [PubMed: 30943078]
• Scherer M, Weightman M, Radomski M, Davidson L, McCulloch K. Returning service members to duty following mild traumatic brain injury: exploring the use of dual-task and multitask assessment methods. Physical Therapy. 2013;93(9):1254–1267. [PubMed: 23766395]
• Smith D, Dollé J-P, Ameen-Ali KE, Bretzin A, Cortes E, Crary J, Dams-O’Connor K, Diaz-Arrastia R, Edlow B, Folkerth R, Hazrati L-N, Hinds S, Iacono D, Johnson V, Keene CD, Kofler J, Kovacs G, Lee E, Manley G, Meaney D, Montine T, Okonkwo D, Perl D, Trjanowski J, Wiebe D, Yaffe K, McCabe T, Stewart W. Collaborative Neuropatholoy Network Characterizing ouTcomes of TBI (CONNECT-TBI). Acta Neuropathologica Communications. 2021a;9:32. https://doi​.org/10.1186​/s40478-021-01122-9 . [PMC free article: PMC7919306] [PubMed: 33648593]
• Smith DH, Kochanek P, Rosi S, Meyer R, Ferland-Beckham C, Prager E, Ahlers S, Crawford F. Journal of Neurotrauma. 2021b. Roadmap for advancing pre-clinical science in traumatic brain injury. https://doi​.org/10.1089/neu.2021.0094 . [PMC free article: PMC8820284] [PubMed: 34210174]
• Tso S, Saha A, Cusimano MD. The Traumatic Brain Injury Model Systems National Database: A review of published research. Neurotrauma Reports. 2021;2(1):149–164. [PMC free article: PMC8240866] [PubMed: 34223550]
• Ursano RJ, Colpe LJ, Heeringa SG, Kessler RC, Schoenbaum M, Stein MB, Collaborators AS. The Army study to assess risk and resilience in servicemembers (Army STARRS). Psychiatry: Interpersonal and Biological Processes. 2014;77(2):107–119. [PMC free article: PMC4075436] [PubMed: 24865195]
• House White. Executive Order 13625 of August 31, 2012. 2012. [July 31, 2021]. Improving access to mental health services for Veterans, service members, and military families. https:​//obamawhitehouse​.archives.gov/the-press-office​/2012/08​/31/executive-order-improving-access-mental-health-services-veterans-service .
• Youngers EH, Zundel K, Gerhardstein D, Martínez M, Bertrán C, Proctor M, Spatola M, Neuwelt E. Comprehensive review of the ThinkFirst injury prevention programs: A 30-year success story for organized neurosurgery. Neurosurgery. 2017;81(3):416–421. [PubMed: 28368495]
• Zemek R, Osmond M, Barrowan N., and on behalf of the Pediatric Emergency Research Canada (PERC) Concussion Team. Predicting and Preventing Postconcussive Problems in Paediatrics (5P) study: Protocol for a prospective multientre clinical prediction rule derivation study in children with concussion. BMJ Open. 2013;3(8):e003550. https://doi​.org/10.1136​/bmjopen-2013-003550 . [PMC free article: PMC3733307] [PubMed: 23906960]