{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,28]],"date-time":"2026-10-28T12:29:08Z","timestamp":1793190548437,"version":"4.5.0"},"reference-count":33,"publisher":"MDPI AG","issue":"24","license":[{"start":{"date-parts":[[2021,12,8]],"date-time":"2021-12-08T00:00:00Z","timestamp":1638921600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"U.S. Army Medical Research and Materiel Command","award":["Work Unit no. N1629"],"award-info":[{"award-number":["Work Unit no. N1629"]}],"id":[{"id":"https:\/\/ror.org\/03cd02q50","id-type":"ROR","asserted-by":"crossref"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["IJERPH"],"abstract":"<jats:p>Because traumatic brain injury (TBI)\u2014most often caused by exposure to high-level blast (HLB)\u2014is a leading cause of medical evacuations of deployed U.S. service members in recent conflicts, researchers seek to identify risk factors for TBI. Previous research using self-reported data has identified low-level blast (LLB) as one such risk factor and suggests an association with susceptibility to and symptoms associated with TBI. This article presents a population-based study of all branches of military service that examines the association between occupational risk for LLB and both clinically diagnosed TBIs\u2014from concussions to severe and penetrating TBIs\u2014and conditions commonly comorbid with concussion. Using archival medical and career records from &gt;2 million service members between 2005\u20132015, this work demonstrates that occupational risk of LLB is associated with any TBI, mild TBI, moderate TBI, cognitive problems, communication problems, hearing problems, headaches, any behavioral health condition, anxiety, drug abuse\/dependence, alcohol abuse\/dependence, delirium\/dementia, posttraumatic stress disorder, post-concussive syndrome, tinnitus, fatigue, and migraines. Understanding the full scope of the effects of LLB on service members will help ensure the health and readiness of service members and may influence both military policy and clinical practice guidelines for blast-induced injuries.<\/jats:p>","DOI":"10.3390\/ijerph182412925","type":"journal-article","created":{"date-parts":[[2021,12,10]],"date-time":"2021-12-10T02:07:18Z","timestamp":1639102038000},"page":"12925","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":46,"title":["Occupational Risk of Low-Level Blast Exposure and TBI-Related Medical Diagnoses: A Population-Based Epidemiological Investigation (2005\u20132015)"],"prefix":"10.3390","volume":"18","author":[{"given":"Jennifer N.","family":"Belding","sequence":"first","affiliation":[{"name":"Leidos, Inc., San Diego, CA 92106, USA"},{"name":"Naval Health Research Center, San Diego, CA 92106, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Robyn","family":"Englert","sequence":"additional","affiliation":[{"name":"Leidos, Inc., San Diego, CA 92106, USA"},{"name":"Naval Health Research Center, San Diego, CA 92106, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"James","family":"Bonkowski","sequence":"additional","affiliation":[{"name":"Leidos, Inc., San Diego, CA 92106, USA"},{"name":"Naval Health Research Center, San Diego, CA 92106, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Cynthia J.","family":"Thomsen","sequence":"additional","affiliation":[{"name":"Naval Health Research Center, San Diego, CA 92106, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2021,12,8]]},"reference":[{"key":"ref_1","unstructured":"Defense Manpower Data Center (2021, September 15). Defense Casualty Analysis System: Conflict Casualties. Available online: https:\/\/dcas.dmdc.osd.mil\/dcas\/pages\/casualties.xhtml."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"2043","DOI":"10.1056\/NEJMp058102","article-title":"Traumatic Brain injury in the war zone","volume":"352","author":"Okie","year":"2005","journal-title":"N. Engl. J. Med."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"398","DOI":"10.1097\/00001199-200609000-00004","article-title":"Military TBI during the Iraq and Afghanistan wars","volume":"21","author":"Warden","year":"2006","journal-title":"J. Head Trauma Rehabil."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"295","DOI":"10.1097\/TA.0b013e318163b875","article-title":"Combat Wounds in Operation Iraqi Freedom and Operation Enduring Freedom","volume":"64","author":"Owens","year":"2008","journal-title":"J. Trauma Acure Care Surg."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"1011","DOI":"10.3389\/fneur.2021.695496","article-title":"Getting on the same page: Consolidating terminology to facilitate cross-disciplinary health-related blast research","volume":"12","author":"Belding","year":"2021","journal-title":"Front. Neurol."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"950","DOI":"10.3171\/JNS\/2008\/108\/5\/0950","article-title":"Traumatic brain injury during Operation Iraqi Freedom: Findings from the United States Navy-Marine Corps Combat Trauma Registry","volume":"108","author":"Galarneau","year":"2008","journal-title":"J. Neurosurg."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"301","DOI":"10.1016\/S0140-6736(09)61797-9","article-title":"Diagnoses and factors associated with medical evacuation and return to duty for service members participating in Operation Iraqi Freedom or Operation Enduring Freedom: A prospective cohort study","volume":"375","author":"Cohen","year":"2010","journal-title":"Lancet"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"405","DOI":"10.1016\/S0140-6736(09)60257-9","article-title":"Blast injuries","volume":"374","author":"Wolf","year":"2009","journal-title":"Lancet"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"720","DOI":"10.1097\/JXX.0000000000000532","article-title":"US Department of Defense Warfighter Brain Health Initiative: Maximizing performance on and off the battlefield","volume":"32","author":"Lee","year":"2020","journal-title":"J. Am. Assoc. Nurse Pract."},{"key":"ref_10","doi-asserted-by":"crossref","unstructured":"Denny, J.W., Brown, R.J., Head, M.G., Batchelor, J., and Dickinson, A.S. (2020). Allocation of funding into blast injury-related research and blast traumatic brain injury between 2000 and 2019: Analysis of global investments from public and philanthropic funders. BMJ Mil. Health.","DOI":"10.2139\/ssrn.3688866"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"269","DOI":"10.3389\/fneur.2014.00269","article-title":"Effects of low-level blast exposure on the nervous system: Is there really a controversy?","volume":"5","author":"Elder","year":"2014","journal-title":"Front. Neurol."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"87","DOI":"10.55460\/3AC6-AX9I","article-title":"Low-level blast exposure in humans: A systematic review of acute and chronic effects","volume":"20","author":"Belanger","year":"2020","journal-title":"J. Spec. Oper. Med."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"274","DOI":"10.3389\/fneur.2021.628782","article-title":"Potential health and performance effects of high-level and low-level blast: A scoping review of two decades of research","volume":"12","author":"Belding","year":"2021","journal-title":"Front. Neurol."},{"key":"ref_14","doi-asserted-by":"crossref","unstructured":"Simmons, M.M., Engel, C.C., Hoch, E., Orr, P., Anderson, B., and Azhar, G.S. (2020). Neurological Effects of Repeated Exposure to Military Occupational Levels of Blast: A Review of Scientific Literature, RAND Corporation.","DOI":"10.7249\/RR2350"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"1620","DOI":"10.1089\/neu.2012.2683","article-title":"Serum brain biomarker level, neurocognitive performance, and self-reported symptom changes in soldiers repeatedly exposed to low-level blast: A breacher pilot study","volume":"30","author":"Tate","year":"2013","journal-title":"J. Neurotrauma"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"S472","DOI":"10.1097\/TA.0b013e318232e7da","article-title":"Controlled blast exposure during forced explosive entry training and mild traumatic brain injury","volume":"71","author":"Baker","year":"2011","journal-title":"J. Trauma Acute Care Surg."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"2691","DOI":"10.1007\/s00221-018-5328-x","article-title":"A jugular vein compression collar prevents alterations of endogenous electrocortical dynamics following blast exposure during special weapons and tactical (SWAT) breacher training","volume":"236","author":"Bonnette","year":"2018","journal-title":"Exp. Brain Res."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"273","DOI":"10.1682\/JRRD.2014.09.0204","article-title":"Effects of repetitive low-level blast exposure on visual system and ocular structures","volume":"52","author":"Jurek","year":"2015","journal-title":"J. Rehabil. Res. Dev."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"28","DOI":"10.7205\/MILMED-D-15-00137","article-title":"Repeated low-level blast exposure: A descriptive human subjects study","volume":"181","author":"Carr","year":"2016","journal-title":"Mil. Med."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"90","DOI":"10.1016\/j.bbi.2017.02.015","article-title":"Moderate blast exposure results in increased IL-6 and TNF\u03b1 in peripheral blood","volume":"65","author":"Gill","year":"2017","journal-title":"Brain Behav. Immun."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"227","DOI":"10.4103\/nah.NAH_58_16","article-title":"The effects of repeated low-level blast exposure on hearing in marines","volume":"19","author":"Kubli","year":"2017","journal-title":"Noise Health"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"71","DOI":"10.1089\/neu.2014.3824","article-title":"The vestibular effects of repeated low-level blasts","volume":"33","author":"Littlefield","year":"2015","journal-title":"J. Neurotrauma"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"E51","DOI":"10.1097\/HTR.0000000000000361","article-title":"Correspondence of the Boston Assessment of Traumatic Brain Injury-Lifetime and the VA Comprehensive TBI Evaluation","volume":"33","author":"Radigan","year":"2018","journal-title":"J. Head Trauma Rehabil."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"47","DOI":"10.1097\/HTR.0000000000000064","article-title":"Relation of repeated low-level blast exposure with symptomology similar to concussion","volume":"30","author":"Carr","year":"2015","journal-title":"J. Head Trauma Rehabil."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"2219","DOI":"10.1089\/neu.2020.6997","article-title":"Self-reported concussion symptomology during deployment: Differences as a function of injury mechanism and low-level blast exposure","volume":"37","author":"Belding","year":"2020","journal-title":"J. Neurotrauma"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"e538","DOI":"10.1093\/milmed\/usz289","article-title":"Blast exposure and risk of recurrent occupational overpressure exposure predict deployment TBIs","volume":"185","author":"Belding","year":"2020","journal-title":"Mil. Med."},{"key":"ref_27","doi-asserted-by":"crossref","unstructured":"Belding, J.N., Khokhar, B., Englert, R.M., Fitzmaurice, S., and Thomsen, C.J. (2021). The persistence of blast- versus impact-induced concussion symptomology following deployment. J. Head Trauma Rehabil.","DOI":"10.1097\/HTR.0000000000000715"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"619","DOI":"10.3389\/fneur.2020.00619","article-title":"Association of MOS-based blast exposure with medical outcomes","volume":"11","author":"Carr","year":"2020","journal-title":"Front. Neurol."},{"key":"ref_29","unstructured":"Department of Defense and Department of Veterans Affairs (2021, December 05). VA\/DoD Clinical Practice Guideline for the Management of Concussion-Mild Traumatic Brain Injury, Version 2.0. Available online: https:\/\/da7648.approby.com\/m\/9ab05e8918081d36.pdf."},{"key":"ref_30","unstructured":"Traumatic Brain Injury Center of Excellence (2021, September 15). DoD TBI Worldwide Numbers. Available online: https:\/\/health.mil\/About-MHS\/OASDHA\/Defense-Health-Agency\/Research-and-Development\/Traumatic-Brain-Injury-Center-of-Excellence\/DoD-TBI-Worldwide-Numbers."},{"key":"ref_31","first-page":"172","article-title":"Career History Archival Medical and Personnel System","volume":"170","author":"Gunderson","year":"2005","journal-title":"Mil. Med."},{"key":"ref_32","first-page":"11","article-title":"Understanding treatment of mild traumatic brain injury in the Military Health System","volume":"6","author":"Farmer","year":"2017","journal-title":"Rand Health Q."},{"key":"ref_33","unstructured":"St Onge, P., McIlwain, D.S., Hill, M.E., Walilko, T.J., and Bardolf, L.B. (2011). Marine Corps Breacher Training Study: Auditory and vestibular findings. US Army Med. Dep. J., 97\u2013107."}],"container-title":["International Journal of Environmental Research and Public Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1660-4601\/18\/24\/12925\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T07:43:01Z","timestamp":1760168581000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1660-4601\/18\/24\/12925"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,12,8]]},"references-count":33,"journal-issue":{"issue":"24","published-online":{"date-parts":[[2021,12]]}},"alternative-id":["ijerph182412925"],"URL":"https:\/\/doi.org\/10.3390\/ijerph182412925","relation":{},"ISSN":["1660-4601"],"issn-type":[{"value":"1660-4601","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,12,8]]}}}