FALLS CHURCH, Va. -- In a combat zone, a single weapon discharge can unleash a force powerful enough to rattle the brain - without leaving a single visible mark. These invisible blast overpressure injuries, along with more severe traumatic brain injuries, are at the center of a growing Department of Defense campaign to protect cognitive performance, a significant component of medical readiness for America’s warfighters.
Launched in 2018 and codified through the Warfighter Brain Health Act of 2022, the initiative aims to preserve warfighter cognitive, psychological, and physical function through improved standards, training, and monitoring. The Air Force Medical Service, in partnership with joint agencies and research centers, is embedding this new approach across safety protocols, training standards, and clinical care systems.
“Warfighter brain health traverses multiple communities of interest across the Department of Defense,” said Katherine Lee, DoD Director of Warfighter Brain Health Policy. “The goal is to create an environment where optimal cognitive performance is built into our definition of readiness.”
Understanding the threat: BOP and TBI
At the heart of this initiative is a commitment to protect service members from the cumulative effects of air blast exposure and the consequences of brain injury. While sometimes referred to interchangeably, BOP and TBI are not the same. BOP refers to the physical shockwave generated by rapid pressure changes - such as from a rifle discharge or explosion. TBI, by contrast, is a medical diagnosis that can result from a range of causes, including but not limited to BOP exposure.
Symptoms of brain injury often present across physical, cognitive, and behavioral domains- ranging from headaches and dizziness to memory issues, mood shifts, and comorbid post-traumatic stress disorder.
“Blast overpressure is an external force with an impact not just on the brain but on the body,” said Lt. Col. Thomas Bayuk, neurologist and traumatic brain injury consultant to the Air Force Surgeon General. “We take this as a serious traumatic brain injury and want to do everything we can to provide appropriate clinical support and management of those patients from a medical standpoint.”
To help prevent and manage BOP and TBI, the Department of the Air Force is leveraging the Warfighter Brain Health Hub, a centralized DoD resource developed in partnership with the Traumatic Brain Injury Center of Excellence. The hub includes the latest guidance, educational materials, and a mobile app that allows clinicians to quickly assess symptoms potentially linked to BOP-related injury.
“We are supporting those joint entities and doing everything we can to be in alignment with the emerging science,” said Lt. Col. Keith Sanders, Chief of Occupational Health Programs at AFMS. “There’s the Blast Injury Research Coordinating Office, there’s the Centers of Excellence. Everything that we do is informed by the knowledge that comes out of those centers.”
“Blast is being treated as an emerging hazard in the same way we address hazardous noise or radiation. The key principle we follow is ALARA, ‘as low as reasonably achievable,’ which focuses on limiting personnel’s proximity to blast zones and encouraging the use of protective gear.”
– U.S. Air Force Lt. Col. Keith Sanders, Chief of Occupational Health Programs
From policy to practice: How AFMS Is taking action
AFMS has taken a dual-pronged approach, reducing BOP exposure risk and improving the detection and treatment of brain injuries. By treating blast exposure as an occupational hazard - on par with hazardous noise or radiation - FMS has implemented new thresholds, safety guidelines, and digital tools to safeguard Airmen and Guardians.
“We have longstanding processes in place for how to assess, document, and implement control actions,” said Sanders. “Blast is being treated as an emerging hazard in the same way we address hazardous noise or radiation. The key principle we follow is ALARA, ‘as low as reasonably achievable,’ which focuses on limiting personnel’s proximity to blast zones and encouraging the use of protective gear.”
To support teams in the field, AFMS expanded the Environmental Safety and Occupational Health Service Center, a centralized hub that now includes frequently updated BOP mitigation resources.
Sanders noted, “It’s available to all personnel doing occupational health in the field, and it includes technical guides and risk assessment tools that are continually updated.”
A new checklist system enables Department of the Air Force unit leaders to document exposures, track compliance, and elevate concerns for command-level review, mirroring practices in place for other industrial hazards.
“What we've done is taken all of the requirements that line leaders have for BOP and turned it into essentially a checklist for them to run at the local level so that they can read it, see what the requirements are, document if they're meeting those requirements, and then submit that to their commander for approval. It's the same process we follow for other hazards,” Sanders shared.
AFMS is also modernizing data collection and exposure documentation. Medical professionals are using new data analytics tools in conjunction with the Defense Occupational and Environmental Health Readiness System to track service wide BOP exposures and risk assessments. The data from risk assessments flow into the service member’s Individual Longitudinal Exposure Record which integrates directly with MHS GENESIS, ensuring exposure data is accessible to clinicians and, eventually, individual service members.
To help identify subtle cognitive impacts, especially following BOP exposure, the Department of the Air Force is expanding the use of baseline neurocognitive assessments. These assessments help determine whether a warfighter is operating at peak performance before and after potential exposure.
A 2024 memo from the Deputy Secretary of Defense mandates baseline cognitive assessments for high-risk personnel across all components by the end of fiscal year 2025. The Department of the Air Force is fully aligned with this requirement and is implementing it across the force.
Innovating at the edge: New tools for the future
AFMS is also helping lead the next generation of brain health solutions. In partnership with the Brain Trauma Foundation, the Department of the Air Force is co-developing a real-time screening tool to evaluate warfighter fitness in the aftermath of a blast.
“The goal is to create a screening tool that assesses readiness, particularly for blast-related injury, and integrates it into clinical practice,” said Bayuk, who is co-lead on the project.
The tool detects symptoms across physical (e.g., dizziness, tinnitus), cognitive (e.g., memory fog, slowed thinking), and behavioral (e.g., irritability, PTSD) domains, bringing greater speed and accuracy to both treatment and return-to-duty decisions.
Securing the mind behind the mission
Whether protecting against BOP or treating TBI, AFMS is working to secure the brain health of every Airman and Guardian. Through updated standards, advanced diagnostics, and a focus on prevention, the Department of the Air Force is redefining what it means to be medically and mentally ready.
With every protocol refined and every Airman and Guardian protected, AFMS ensures that cognitive resilience remains a cornerstone of the Air Force and Space Force mission - today and for the battles to come.