MILITARY MEDICINE, 188, 3/4:e771, 2023

Repetitive Low-level Blast Exposure and Neurocognitive Effects

in Army Ranger Mortarmen
Julia L.A. Woodall, BS*; Jordyn A. Sak, BS*; Kyle R. Cowdrick, MSE*;
Brady M. Bove Muñoz, BS*; Jessica H. McElrath, BS*; Grace R. Trimpe, BS*; Yajun Mei, PhD†;
MAJ Remington L. Myhre, BS, USA‡; James K. Rains, PE*; MAJ Charles R. Hutchinson, DO, USA‡

ABSTRACT
Introduction:
Occupational exposure to repetitive, low-level blasts in military training and combat has been tied to subconcussive

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injury and poor health outcomes for service members. Most low-level blast studies to date have focused on explosive
breaching and firing heavy weapon systems; however, there is limited research on the repetitive blast exposure and
physiological effects that mortarmen experience when firing mortar weapon systems. Motivated by anecdotal symptoms
of mortarmen, the purpose of this paper is to characterize this exposure and its resulting neurocognitive effects in order
to provide preliminary findings and actionable recommendations to safeguard the health of mortarmen.

Materials and Methods:

In collaboration with the U.S. Army Rangers at Fort Benning, blast exposure, symptoms, and pupillary light reflex
were measured during 3 days of firing 81 mm and 120 mm mortars in training. Blast exposure analysis included the
examination of the blast overpressure (BOP) and cumulative exposure by mortarman position, as well as comparison
to the 4 psi safety threshold. Pupillary light reflex responses were analyzed with linear mixed effects modeling. All
neurocognitive results were compared between mortarmen (n = 11) and controls (n = 4) and cross-compared with blast
exposure and blast history.

Results:
Nearly 500 rounds were fired during the study, resulting in a high cumulative blast exposure for all mortarmen. While
two mortarmen had average BOPs exceeding the 4 psi safety limit (Fig. 2), there was a high prevalence of mTBI-
like symptoms among all mortarmen, with over 70% experiencing headaches, ringing in the ears, forgetfulness/poor
memory, and taking longer to think during the training week (n ≥ 8/11). Mortarmen also had smaller and slower pupillary
light reflex responses relative to controls, with significantly slower dilation velocity (P < 0.05) and constriction velocity
(P < 0.10).

Conclusion:
Mortarmen experienced high cumulative blast exposure coinciding with altered neurocognition that is suggestive of
blast-related subconcussive injury. These neurocognitive effects occurred even in mortarmen with average BOP below
the 4 psi safety threshold. While this study was limited by a small sample size, its results demonstrate a concerning
health risk for mortarmen that requires additional study and immediate action. Behavioral changes like ducking and
standing farther from the mortar when firing can generally help reduce mortarmen BOP exposure, but we recommend
the establishment of daily cumulative safety thresholds and daily firing limits in training to reduce cumulative blast
exposure, and ultimately, improve mortarmen’s quality of life and longevity in service.

INTRODUCTION
* Wallace H. Coulter Department of Biomedical Engineering, Georgia The adverse cognitive and neurological effects of blast expo-
Institute of Technology, Atlanta, GA 30332, USA sure have been a prominent focus in military medicine
† H. Milton Stewart School of Industrial and Systems Engineering,
since the introduction of improvised explosive devices and
Georgia Institute of Technology, Atlanta, GA 30332, USA
‡ 75th Ranger Regiment, Fort Benning, GA 31905, USA other forms of explosive warfare within armed conflicts
Previous presentation of work: (1) Southeast Regional Clinical & in Iraq and Afghanistan. From 2000 to 2020, there were
Translational Science Conference; Georgia CTSA; held virtually March 4-5, 434,618 service members in the U.S. Military diagnosed with
2021, (2) Georgia Institute of Technology Capstone Design Expo; Georgia some form of traumatic brain injury (TBI); the majority of
Tech; held virtually November 23, 2020, and (3) 75th Ranger Regiment
Academic Research Symposium; US Army 75th Ranger Regiment; held which were classified as mild TBI (mTBI) (82.4%).1 Addi-
virtually September 16, 2020. tionally, in a retrospective cohort study, 66% of TBIs in
The views expressed are solely those of the authors and do not reflect deployed settings were found to be caused by blasts.2 To
the official policy or position of the 75th Ranger Regiment, US Army, address this issue, traditional research has focused on char-
Department of Defense, or US Government.
doi:https://doi.org/10.1093/milmed/usab394
acterizing the pathophysiology of and establishing preventa-
© The Association of Military Surgeons of the United States 2021. tive measures for injury caused by single, high-level blasts
All rights reserved. For permissions, please e-mail: journals. like improvised explosive devices.3 However, a severely
[email protected]. understudied source of blast exposure that also results

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 Mortarmen and Blast Exposure

in negative health outcomes is repetitive, low-level blasts regional gray matter volume captured by structural magnetic
(LLBs).4 resonance imaging scans relative to controls.7,9 While these
LLBs are blasts with low pressure that typically originate results demonstrate the potential for objectively assessing the
from a service member’s own weapon system. Recent reports neurocognitive effects of LLB exposure, most studies still
suggest that occupational exposure to repetitive LLBs may rely on subjective, self-reported symptoms, highlighting the
cause subconcussive, neurological injury that cumulatively need for a standard, field-ready tool to objectively evaluate
impacts service member health and readiness.5 One source of blast-related neurocognitive effects in the military.19
LLB is the mortar weapon system. Mortars are traditionally The use of pupillometry to assess the function of the
used for indirect fire and are operated by a crew of three to four pupillary light reflex (PLR) has shown potential as a hand-
service members (i.e., mortarmen) depending on the specific held and sensitive neurological assessment tool in populations
mortar size. The mortar systems used in the U.S. Army are the with blast-related mTBI. Specifically, Capó-Aponte et al.
60 mm, the 81 mm, and the 120 mm. When a mortar round is observed significantly slower constriction and dilation veloc-

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fired, explosive charges ignite within the mortar tube, launch- ities and delayed constriction latency in blast-induced mTBI
ing the round to its target. This process exposes mortarmen to patients, and Truong and Ciuffreda observed smaller initial
an LLB every time a round is fired. Currently, there is lim- and end pupil diameters in mTBI patients, both relative to con-
ited research on the LLB exposure of mortarmen, and, to the trols.20,21 These may act as biomarkers for autonomic nervous
best of our knowledge, there are no publications to date on the system function but have yet to be assessed in populations
physiological effects of blast exposure within the mortarmen with subconcussive injury from LLB exposure.22
population. To address the limited literature on blast exposure and
Blast exposure from a variety of nonmortar LLB sources related neurocognitive effects from firing mortars, we aimed
has been studied, including explosive breaching, heavy to quantify the LLB exposure of mortarmen and explore
weapon systems, and rifles.6–13 The Carl Gustaf recoilless the associations of this exposure with positioning, symp-
rifle has particularly gained notoriety for its high blast over- toms, and PLR function. This study was conducted in col-
pressure (BOP), or maximum blast pressure, resulting in the laboration with the U.S. Army Rangers stationed at Fort
establishment of daily firing limits in training.10,14 Studies Benning during a week-long mortar training exercise and
with the Gustaf and explosive breaching have found that was motivated by multiple anecdotal reports of symptoms
both produce BOPs exceeding 4 pounds per square inch from current and former mortarmen. We hypothesized that
(psi).7,8,10,11 This is the incident pressure threshold at which mortarmen would experience blast exposure and symptoms
the unprotected human eardrum can rupture.15 While this similar to other military populations with repetitive LLB
threshold is not based on the risk of neurotrauma nor on the exposure.
cumulative exposure of repetitive blasts, it is relevant as it
is referenced in most LLB studies and is used by the U.S. MATERIALS AND METHODS
Army to calculate the minimum safe distance for explosive
breaching.16 Participants
A study from Kamimori et al. quantifying blast exposure This exploratory study was reviewed and cleared as a “process
from mortar systems found that the average BOP experienced improvement pilot study” by the U. S. Army Special Oper-
by the entire 120 mm mortarmen crew exceeded 4 psi.12 ations Command Review Board and jointly acknowledged
Mortarmen who were observed standing, rather than ducking by the Georgia Institute of Technology Institutional Review
below the opening of the mortar tube, experienced an individ- Board. All participants signed consent forms to participate
ual average BOP of 5-6 psi. While cumulative blast exposure and provided de-identified demographic information.
was not quantified in the study, Kamimori et al. hypothesized This study was conducted over a 6-day period at Fort Ben-
cumulative blast exposure to be high in the mortarmen pop- ning with the US Army Rangers (Table S1). Blast exposure,
ulation, as they have no firing limits and can fire hundreds neurocognitive symptoms, and pupillometry data were col-
of rounds a day. No other publicly available studies have lected from mortarmen (n = 11) during 3 days of live fire
been conducted concerning mortarmen blast exposure or their training on both 81 mm and 120 mm mortar systems. Firing
resulting cognitive or neurological effects. days alternated with nonfiring days, during which symptoms
Despite this lack of research, the cognitive and neurolog- and pupillometry data were collected from control subjects
ical effects of LLB exposure from explosive breaching have who were also rangers but not mortarmen. Six controls partici-
been studied and can provide insight into the mortarmen expe- pated in the study; however, two controls were retrospectively
rience. Explosive breaching has shown reports of increased excluded based on the criteria disallowing controls who were
incidence and severity in symptoms similar to those of mTBI, exposed to blasts during the study or diagnosed with any
including headaches, impaired working memory, and sleep severity of TBI within the year prior to the study. This resulted
disturbance.17,18 Recent studies have also shown evidence in the inclusion of only four controls (n = 4). Follow-up symp-
of slower procedural reaction time measured by the Defense tom and PLR measurements were collected 17 days after the
Automated Neurobehavioral Assessment (DANA) and less mortarmen’s last day of firing.

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FIGURE 1. Mortarmen positions. Two views of mortarmen firing the 120 mm mortar with positions labeled (AG = assistant gunner, G = gunner, SL = squad
leader, AB = ammunition bearer). Firing positions for the 81 mm mortar system are analogous, with the exception of no AB.

Blast Measurements post-concussion symptom questionnaire to rank each symp-

®
The Blast Gauge System (BlackBox Biometrics, Inc., tom from 0 (not experienced) to 4 (a severe problem)
Rochester, NY), Generation 7, was used to collect blast mea- (Fig. S1).24 The modifications included 16 additional blast-
surement data. These gauges measure both reflected and inci- related questions previously used in other LLB studies.18,25
dent pressure—capturing true environmental exposure—and Controls also self-reported symptoms at the same times of
have been used to measure LLB in numerous other stud- day as the mortarmen on nonfiring days to ensure con-
ies.7–12,23 Three gauges were used per mortarman, located at sistency in symptoms due to fatigue and other day-to-day
the head, shoulder, and chest. Gauges were preset to detect all factors.
blast pressures above 0.5 psi, their lowest detectable pressure. Questionnaire results were analyzed to identify the preva-
The mortarmen positions included an assistant gunner (AG), lence of symptoms among all subjects and test the hypothesis
gunner (G), and squad leader (SL) for each mortar, and an that mortarmen experience more symptoms than controls. The
ammo bearer (AB) for the 120 mm mortar (Fig. 1). There were most common symptoms were further analyzed by mortarmen
also four fire direction centers (FDCs) who oversaw firing of classifications: mortar crew and average BOP above or below
both weapon systems but were generally positioned farther 4 psi.
away and not involved in direct firing. All mortarmen wore
standard issue and fitted protective gear, including ear protec-
tion (PELTORTM earmuffs), helmets, and body armor with PLR Assessments
ballistic front and side plates. The PLR-3000 pupillometer (NeurOptics, Irvine, CA) was
Data from the Blast Gauge System was processed in MAT- used to collect PLR measurements during the study.26 After
LAB (MathWorks, Inc., Natick, MA). For an individual blast each subject finished their symptom questionnaire and had
event, the Blast Gauge with the highest BOP value from the adjusted to the ambient light—the natural light outside—for
set of three gauges was used for BOP analysis. Similarly, the at least 10 minutes, the device recorded static and dynamic
Blast Gauge with the highest positive impulse (psi-ms) in a set pupillary responses to a dim light pulse (10 µW) and a bright
of three was used for impulse calculations. Positive impulse light pulse (121 µW) for each pupil. These responses included
was calculated using the following equation, where Pn is the initial pupil diameter (mm), end pupil diameter (mm), con-
nth pressure recording above atmospheric pressure and ∆t is striction latency (s), constriction velocity (mm/s), maximum
the time between recordings. constriction velocity (mm/s), and dilation velocity (mm/s).
To determine differences between mortarmen and control
∑
M
pupillary responses, PLR results were analyzed with linear
Pn · ∆t
mixed effects models using RStudio (RStudio PBC, Boston,
n=1
MA). These models allowed for characterizing associations
Cumulative BOP and cumulative impulse were calculated between predictor variables and outcome responses when
as the sums of each mortarman’s BOP and impulse mea- analyzing repeated measure data by adjusting within-subject
surements, respectively, across all firing days. One-sample variances. Predictor variables included subject type (control
t-tests were performed to compare the average BOP of each or mortarman), pupil measured (left or right pupil), and night
mortarman to the 4 psi threshold. measured. Outcome responses are the pupillary responses
recorded with each PLR measurement. PLR measurements
Neurocognitive Symptom Questionnaire taken during the day were excluded from analysis, due to the
Mortarmen self-reported symptoms immediately before difference in outdoor ambient light between the day and night
and after firing each day using a modified Rivermead confounding pupillary responses.

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FIGURE 2. (A) Swarm scatter chart displaying all blast events for each mortarman on the 120 mm and 81 mm mortars (AG = assistant gunner, G = gunner,
SL = squad leader, AB = ammunition bearer). Overlaid with box plots for each. Subjects with means significantly greater than 4 psi are indicated with
***P < 0.001. (B) Blast overpressure (BOP) exposure values for all mortarmen, including FDCs (FDC = fire direction center).

Cross Comparison Analysis Blast Measurements

Pearson correlations were determined between baseline During the training week, mortarmen were exposed to a range
symptom severity and time served as a mortarman— of 191-268 total blast events on the 81 mm and 216-233 total
representing blast history. Baseline symptom results were blast events on the 120 mm. All but three rounds fired were
used for this analysis because they were not influenced by charge 2. The charge refers to the amount of explosive pro-
recent blast exposure. Pearson correlations were also cal- pellant used to fire each round and ranges from 0 to 4, with
culated to identify associations between pupillary responses 4 being the highest charge. The 120 mm G and AG both had
and two blast exposure measurements: average BOP and average BOPs exceeding 4 psi (Fig. 2A). The G had an aver-
cumulative impulse. age of 5.33 psi, with 74% (172 of 232) of blast events above 4
psi; the AG had an average of 5.84 psi, with 91% (211 of 233)
RESULTS of blast events above 4 psi (Fig. 2B). The 120 mm SL, 81 mm
AG, and two FDCs experienced some blast events above 4 psi
Demographics but still had average BOPs below 4 psi.
All subjects were male rangers with no diagnosed brain The average cumulative BOP for all 81 mm mortar-
trauma within the year prior to this study. Mortarmen and men was expectedly lower than the 120 mm mortarmen
controls did not have a significant difference in time spent as (448 ± 234.3 psi and 951 ± 423.1 psi, respectively). The
rangers, but they had a significant difference in age (P = 0.02), average cumulative impulse reflected this expectation as
with averages of 23.1 and 28.9 years, respectively (Table S2). well (560 ± 261.7 psi-ms and 788 ± 299.1 psi-ms, respec-
One control (n = 1/4) had prior experience as a mortarman, tively). Supplementary material lists all blast exposure cal-
but the effect of this history was not considered in the scope culations and results for all mortarmen, including FDCs
of this study. (Table S3).

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Neurocognitive Symptom Questionnaire TABLE I. Summary Statistics for Pupillary Light Reflex (PLR)
The most common symptoms experienced during the week Mortarmen
by mortarmen were headaches (91%, n = 10/11 mortarmen), (n = 11) Controls (n = 4)
ringing in the ears (82%, n = 9/11), forgetfulness/poor mem- Pupillary
ory (82%, n = 9/11), taking longer to think (73%, n = 8/11), response Mean ± SD Mean ± SD P
sleep disturbance (64%, n = 7/11), and being irritable or eas-
ily angered (64%, n = 7/11). The prevalence of these same Dim light pulse (10 µW)
Initial pupil 6.29 ± 0.66 6.82 ± 0.89 0.28
symptoms was generally lower among controls: headaches diameter (mm)
(25%, n = 1/4 controls), ringing in the ears (50%, n = 2/4), End pupil 3.76 ± 0.48 4.22 ± 0.79 0.25
forgetfulness/poor memory (0%, n = 0/4), taking longer to diameter (mm)
think (25%, n = 1/4), sleep disturbance (75%, n = 3/4), and Constriction 0.23 ± 0.03 0.23 ± 0.02 0.85
being irritable or easily angered (25%, n = 1/4). Further anal- latency (s)

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Constriction 3.15 ± 0.49 3.50 ± 0.35 0.09
ysis showed a high prevalence of symptoms in mortarmen velocity (mm/s)
regardless of having an average BOP above or below 4 psi. Max constriction 5.69 ± 2.29 6.05 ± 0.78 0.55
For mortarmen above 4 psi, n = 2/2 reported headaches, ring- velocity (mm/s)
ing in the ears, and forgetfulness, and n = 1/2 reported taking Dilation velocity 1.02 ± 0.28 1.33 ± 0.23 0.04*
longer to think, sleep disturbance, and being irritable or eas- (mm/s)
ily angered. For those below 4 psi, all six symptoms were Bright light pulse (121 µW)
Initial pupil 6.10 ± 0.68 6.71 ± 0.74 0.16
reported by at least n = 6/9 mortarmen. A similar high preva-
diameter (mm)
lence was identified when comparing 81 mm, 120 mm, and End pupil 3.33 ± 0.41 3.73 ± 0.66 0.23
FDC mortarmen and showed no preference toward a cer- diameter (mm)
tain position (Table S4). The prevalence and severity of all Constriction 0.22 ± 0.03 0.24 ± 0.05 0.85
questionnaire results are provided (Table S5). latency (s)
Constriction 3.20 ± 0.48 3.60 ± 0.41 0.06
velocity (mm/s)
PLR Assessments Max constriction 5.99 ± 2.54 6.26 ± 0.53 0.62
Mortarman had smaller pupil diameters and slower pupil- velocity (mm/s)
Dilation velocity 0.55 ± 0.29 0.87 ± 0.45 0.02*
lary responses than controls (Table I). Dilation velocity was (mm/s)
significantly slower in mortarmen than controls for both
Mean and standard deviation (SD) of pupillary responses measured at night
dim (P = 0.04) and bright (P = 0.02) light pulses. Constric-
from controls (n = 4) without blast exposure and from mortarmen (n = 11)
tion velocity was also significantly slower in mortarmen for immediately after mortar firing. Includes responses from both dim and bright
both dim (P = 0.09) and bright (P = 0.06) light pulses when light pulses. Significant values of P < 0.10 are in bold, and P < 0.05 is
increasing the significance threshold (α = 0.10). indicated with *.
Additionally, constriction velocity was significantly asso-
ciated (α = 0.05) with pupil measured for all subjects with
observed most prominently with forgetfulness/poor memory,
both dim (P = 0.005) and bright (P = 0.03) light pulses, indi-
being irritable or easily angered, and sleep disturbance. Con-
cating asymmetry in pupillary response between left and right
trols reported none of these baseline symptoms, except for
eyes. Further analysis of mortarmen and control data sepa-
n = 1/4 controls reporting sleep disturbance at a severity of
rately showed that this asymmetry was only significant with
1. Pupillary responses negatively trended with blast exposure,
mortarmen for the dim light pulse setting (P = 0.01). No
indicating lower pupil responsivity with increasing average
other significant main effects were found. These results were
BOP and increasing cumulative impulse. The initial pupil
determined using linear models and parameter estimations
diameter and end pupil diameter had fair correlations to both
summarized in the supplementary material (Tables S6-S8).
average BOP and cumulative impulse while dilation veloc-
ity had poor correlations. Graphs for all pupillary responses
Cross Comparison compared to average BOP, cumulative BOP, and cumulative
Analyses between symptom severity, time as a mortarmen, impulse show similar negative trends (Figure S2).
PLR measurements, and BOP exposure were performed
(Fig. 3). For symptom comparison only, the sample size DISCUSSION
for controls was n = 3 due to the exclusion of the control
who had experience as a mortarman, and the sample size Blast Exposure
for mortarmen was n = 12 due to the inclusion of an addi- Multiple mortarmen had blast exposure exceeding the 4 psi
tional mortarman who reported baseline symptoms but was incident pressure safety threshold. This included the AG, G,
not available for the rest of the study. A moderate positive and SL on the 120 mm mortar and the AG on the 81 mm mor-
correlation was identified when comparing baseline symp- tar. Furthermore, the AG and G on the 120 mm mortar, the
tom severity scores to time spent as a mortarman and was positions closest to the mortar when firing, had an average

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FIGURE 3. Cross comparison of symptoms, blast history, and blast exposure. Trendlines of mortarmen data, excluding controls from calculations. Pearson
correlation coefficients displayed as R. (A) Baseline symptom severity scores compared to time as a mortarmen (n = 3 controls, n = 12 mortarmen). (B)
Pupillary light reflex (PLR) measures compared to average blast overpressure (BOP) (B-C: n = 4 controls, n = 11 mortarmen). (C) PLR measures compared
to cumulative impulse.

BOP of 5.8 psi and 5.3 psi, respectively, significantly greater officer—an FDC in our study. All FDCs and SLs in our study
than 4 psi. ducked when near the mortar and experienced lower BOPs,
Field observations indicated mortarmen positioned farther suggesting that ducking may help decrease blast exposure.
from the mortar generally experienced less blast exposure. The cumulative blast exposure of the mortarmen in our
The only exception to this was with the AG and G; despite study was also very high. While there are no recommended
the Gs being the closest to the mortar, they experienced lower safety thresholds regarding cumulative blast exposure, the
BOPs than their respective AGs, who were slightly farther magnitude of exposure experienced by mortarmen can be
away. This is inconsistent with Kamimori et al.’s results, in compared to other sources of LLB. One study observing
which their Gs had slightly greater average BOPs.12 Addi- instructors of shoulder-mounted artillery (e.g., the Gustaf)
tionally, in their study, mortarmen who stood when in close found that the cumulative BOP experienced over 3 years
proximity to the mortar experienced higher BOPs than those ranged from 400 psi to 600 psi.27 The cumulative BOP of
who ducked. This occurred with their SLs and range safety most of the mortarmen in our study (n = 7/11) reached this

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range within just 3 days of training, with the highest cumu- typically relies on the identification of a single blast event
lative BOP at 1,361 psi—more than double the instructors’ contributing to the onset of symptoms.35 A diagnosis specific
cumulative exposure. Another study evaluating the cumu- to cases of repetitive LLB exposure would allow for early
lative impulse of U.S. Marines over six days of explosive intervention and treatment during the careers of mortarmen
breaching in training found the average cumulative impulse that could improve their long-term health.
to be 51 psi-ms for students and 43.3 psi-ms for instructors.6
The exposure of all mortarmen far exceeded these cumulative Pupillometry
impulses in just 3 days of mortar firing, with their cumulative Mortarmen exhibited significantly slower dilation and con-
impulses ranging from 115 psi-ms to 1,033 psi-ms. More- striction velocities relative to controls, which is typical of
over, these cumulative impulses are expected to increase with individuals with mTBI or other forms of depressed autonomic
the additional explosive propellant of charge 3 and 4 rounds neurological function.20–22 Although not significant, mortar-
commonly used in combat. men also had smaller pupil diameters on average. The older

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Another recently conducted breacher study evaluating age of controls could have contributed to this lack of signif-
blast exposure in conjunction with neurocognitive perfor- icance given pupil size decreases with age.36 These results
mance using the DANA Rapid found that breachers with a are suggestive of systemic neurological issues in mortarmen.
cumulative impulse greater than 25 psi-ms in 24 hours had The mortarmen also had significant asymmetry in the con-
slower reaction times in most DANA Rapid subtasks.7 In our striction velocity under the dim light pulse. This has not been
study, all mortarmen exceeded this 25 psi-ms threshold every observed in mTBI patients but could be a consequence of
day, with their daily cumulative impulses ranging from 34 pupil measurement order.37 Regardless, the observed PLR
psi-ms to 444 psi-ms. On average, the mortar crews reached differences between blast-exposed mortarmen and controls
this threshold after firing just 12 and 8 rounds on the 81 mm suggest pupillometry is a promising objective assessment tool
and 120 mm mortars, respectively. These are drastically lower for neurological abnormality following blast exposure.
than the respective averages of 89 and 78 rounds fired per
day during our study and even lower when compared to the Study Limitations
hundreds of rounds fired per day in other training events or The major limitation of this study was the small mortarmen
combat. and control sample sizes. To conduct our study without inter-
fering with the operational activities of the rangers, only two
Symptoms mortar crews with limited charge ranges could participate in
Headaches, ringing in the ears, forgetfulness/poor memory, the study. Controls were also limited to available rangers, pre-
taking longer to think, sleep disturbance, and being irritable or cluding selection of controls with demographics comparable
easily angered were reported by over 60% of mortarmen dur- to mortarmen.
ing the training week. This contrasted with the symptoms of The change in outdoor ambient light before and after firing
control subjects, who predominantly exhibited ringing in the presented another challenge by causing measurements to vary
ears and sleep disturbance. Ringing in the ears, i.e., tinnitus, is significantly between day and night, as observed elsewhere.38
common in military service members, and its high prevalence To be a viable neurological assessment tool in outdoors, field
in both mortarmen and controls was expected. The prevalence environments typical of military training and deployment,
of sleep disturbance in controls, while unexpected, could be we recommend future pupillometer designs better control for
attributed to the ranger lifestyle and altered sleep schedules measurements taken in varying ambient light settings.
during training. Another notable result was the high preva-
lence of symptoms in both mortar crews, even if their average Future Work and Recommendations
BOP remained below the 4 psi threshold. Future work to better understand the effect that blast expo-
The symptoms exhibited by mortarmen expectedly paral- sure has on mortarmen performance and health could include
leled symptoms experienced by breachers and aligned with conducting studies with a similar structure to our study—
some of the symptoms typical of post-concussive and mTBI quantifying blast exposure and objectively measuring neu-
patients.28,29 This supports the theory that repetitive LLB rocognitive effects—to verify our findings. Studies could also
can lead to subconcussive injuries, similar to repetitive head explore additional effects of blast exposure not considered
impact in sports.5,30 Increased symptom severity in those with in this study, such as longitudinally observing changes in
longer history as mortarmen suggests there is an accumu- symptomatology and neurocognition over the careers of mor-
lation of repetitive, subconcussive effects over mortarmen’s tarmen. Alternatively, a retrospective study evaluating the
careers, resulting in cumulative neurodegeneration presented long-term health outcomes of all service members that have
as delayed onset and increased severity of post-concussive been mortarmen could be considered.
symptoms.5,30–34 These delayed effects often go undiagnosed In addition to continued research, three areas of action
and untreated. Although symptoms exhibited by mortarmen can be considered to reduce mortarmen’s blast exposure and
align with mTBI symptoms, a blast-related mTBI diagnosis improve their long-term health outcomes: behavioral changes,

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engineering solutions, and safety regulations. Behaviorally, and daily firing limits be established for Army Ranger mortar-
mortarmen who stood farther away from the mortar and men and translated to other mortarmen populations following
ducked generally experienced lower blast exposure; however, additional study.
this is not a fix-all solution. While it may decrease exposure,
ducking mortarmen in this study still experienced high blast ACKNOWLEDGMENTS
exposure and altered neurocognition relative to controls. Dr. C.R. Hutchinson, the senior author, would like to acknowledge that the
Alternatively, blast exposure of mortarmen can be reduced authors Julia L.A. Woodall and Jordyn A. Sak contributed equally in all
through engineering solutions. Protective gear, for example, aspects to this publication. We would like to thank BlackBox Biometrics for
could be designed to reduce blast exposure but would still providing use of The Blast Gauge System, and NeurOptics for providing use
of a PLR-3000 pupillometer. We thank Dr. Walter Carr (Walter Reed Army
need to prevent the more immediate, life-threatening injuries
Institute of Research) for providing the symptom questionnaire and advising
caused by blunt force or penetrating objects. Another engi- our team. We also want to thank the National Security Innovation Network
neering solution is a blast attenuation device (BAD), which for supporting the early stages of this research, and the Georgia Tech BME

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extends from the opening of a mortar and reduces the aver- Capstone program for providing us this opportunity. We thank every individ-
age BOP of mortarmen. In this study, the 81 mm mortar had a ual that participated in an interview and provided their professional expertise
or personal experiences which informed and inspired this research. Last, we
BAD but the 120 mm mortar did not. Our results of high symp-
thank all the mortarmen and rangers who supported our study and welcomed
tom prevalence and decreased PLR function among the 81 mm our team during their training.
mortarmen suggest that the BAD by itself is not enough to
drastically improve health outcomes for mortarmen.
SUPPLEMENTARY MATERIAL
Last, safety regulations can be implemented such as pres-
Supplementary material is available at Military Medicine online.
sure safety thresholds and firing limits. Safety thresholds
based on cumulative blast exposure and true environmental
exposure—including both incident and reflected pressure— FUNDING
This research was supported by the Georgia Tech Capstone Design program
are needed for mortars and other repetitive LLB sources.
and the National Security Innovation Network.
Based on these thresholds, firing limits in training could be
established for mortars like they have been for other weapon
systems with repetitive LLBs.14 Setting daily firing limits in CONFLICT OF INTEREST STATEMENT
training based on a daily cumulative impulse threshold, like None declared.
that described in LaValle et al., would effectively decrease
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