Muscle Injury Tutorial

Gulf War Syndrome/Illness

Gulf War Syndrome (GWS), also known as Gulf War Illness (GWI), refers to a set of chronic symptoms experienced by many veterans of the 1990–1991 Gulf War. Despite decades of research, the condition remains poorly understood and often contested. Estimates suggest that between 25% and 35% of the nearly 700,000 U.S. service members deployed to the Gulf may be affected. This article explores the history, symptoms, possible causes, and current understanding of Gulf War Syndrome, along with its implications for medical research and veteran care.

Veterans with Gulf War Syndrome typically report a combination of symptoms that affect multiple organ systems. Common complaints include:

• Chronic fatigue
• Cognitive dysfunction (“brain fog”)
• Joint and muscle pain
• Gastrointestinal disturbances (e.g., irritable bowel symptoms)
• Headaches and dizziness
• Mood disorders (anxiety, depression, irritability)
• Sleep disturbances
• Skin rashes and respiratory issues

These symptoms closely overlap with conditions such as Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) and fibromyalgia, leading to speculation about shared mechanisms of illness.

Agent Orange & Related Illnesses (including Diabetes)

Agent Orange is a chemical herbicide and defoliant, one of the tactical uses of Rainbow Herbicides. It was notably used by the U.S. military as part of its herbicidal warfare program, Operation Ranch Hand, during the Vietnam War from 1962 to 1971. The U.S. was strongly influenced by the British who used Agent Orange during the Malayan Emergency. Primarily a mixture of equal parts of two herbicides, 2,4,5-T and 2,4-D, contained trace amounts of 2,3,7,8-T, a dioxin compound established as a carcinogen and persistent organic pollutant. The name Agent Orange came from the orange stripe on the gallon drums. One of the chemicals in Agent Orange contained minute traces of the chemical TCDD or dioxin. 

Studies have suggested that this chemical may be related to a number of conditions and disorders. A registry for Vietnam veterans who were concerned about the possible health effects of exposure to Agent Orange was established. The components of the registry are described in the Agent Orange tutorial as well as body systems that are given particular attention during a health examination.

There are various types of cancer associated with Agent Orange, including chronic B-cell leukemia, Hodgkin's lymphoma, multiple myeloma, non-Hodgkin lymphoma, prostate cancer, respiratory cancer, lung cancer, and soft tissue sarcomas.

Health Effects from Chemical, Biological, and Radiological Weapons

The tutorials on "Health Effects of Chemical, Biological, and Radiological Weapons" focus on the most commonly encountered substances within each category, highlighting their health impacts and potential clinical manifestations that reviewers may observe when reviewing veterans' medical records and case histories. The content has been developed by integrating information from the Veterans Health Initiative (VHI) website and other relevant sources to offer reviewers a thorough understanding of the health effects associated with military service. This resource is intended to assist reviewers in conducting efficient and accurate evaluations of veterans' health concerns.

Chemical Weapons

Exposure to chemical agents can occur easily through environmental contact, personal use, or occupational settings. This tutorial on chemical weapons covers the classification of chemical agents and the three main types of agents most likely to be encountered in military operations and terrorist attacks. It also addresses the physiological processes that occur following exposure, as well as the acute and chronic effects that may result from such exposure.

Biological Weapons

The main categories of biological agents of concern to public health include those responsible for diseases such as anthrax, smallpox, plague, botulism, tularemia, and viral hemorrhagic fever. When utilized by malicious actors, anthrax and smallpox represent significant threats due to their ease of dissemination and transmission, their capacity to cause high mortality rates, and their potential to cause substantial social disruption.

Radiological Weapons

Historically, many veterans have been exposed to or contaminated by various forms of radiation during their military service. While the likelihood of terrorist use of nuclear weapons has decreased compared to the past, it remains a possibility due to the challenges associated with acquiring the essential components and technology needed to develop such devices. Conversely, radiological materials are more accessible and can be used to create simpler, more feasible weapons, thereby maintaining the risk of widespread radiological contamination.

Radiation Job Aid

Other Specific Environmental Hazards

Sulfur Fire

On June 24, 2003 roughly 42 million pounds of sulfur dioxide (SO2) per day as well as release of hydrogen sulfide (H2S) in Northern Iraq, and from late 2004 through February 2007 exposure to the Mishraq State Sulfur Mine Fire was reported.

• polycyclic aromatic hydrocarbons formed during the incomplete burning of coal, oil and gas, garbage, or other organic substances
• volatile organic compounds (VOCs) emitted as gases from certain solids or liquids, and
• toxic organic halogenated dioxins and furans to include those associated with tactical herbicide use in Vietnam.

Camp Lejeune, North Carolina- drinking water contaminated with VOCs. Contaminants included:

• tricholoroethylene (TCE)
• perchloroethylene (PCE)
• benzene
• vinyl chloride, and
• other VOCs.

Chromium VI in sodium dichromate is a lung carcinogen through inhalation and an acidic compound that can cause immediate irritation to the eyes, nose, sinuses, lungs, and skin. Particulate Matter is made up of a number of components to include:

• acids (such as nitrates and sulfates)
• organic chemicals
• metals, and
• soil or dust particles.

Shrapnel (Trauma) Wounds

In the evolving landscape of strategic operations in recent and ongoing conflicts, the increased deployment of improvised explosive devices (IEDs) and roadside bombs has heightened the risk of shrapnel-related injuries among military personnel. This tutorial examines the most common injury types, the physiological responses to such trauma, and the body systems most frequently affected by shrapnel penetration. Additionally, methods for assessing potential injury outcomes and the long-term consequences of these injuries are discussed.

POW Medical Issues

Former Prisoners of War (POWs) have been mistreated and killed since the beginning of recorded history. Studies indicated that life-long effects on health, social and vocational adjustment, and increased vulnerability to psychological stress results from endless fears faced by imprisoned American service members as a result of the physical hardships, and psychological abuse endured by POWs.

In addition, the length of captivity, the promptness of implementing treatment, and the duration of treatment may all have an impact on a former POWs ability to face additional obstacles once returned to their pre-war lives.

Infectious Diseases

Infectious diseases that afflicted the geographic areas of western Asia during the Gulf War pose the same risk of infecting military personnel in Iraq today. Prior experience with these various communicable diseases during the Gulf War has assisted in the implementation of greater countermeasure defenses against mass outbreaks within the military community in Iraq, thus decreasing the incapacitation of troops.

Regardless of preventive measures taken, such as vaccinations, a small percentage of veterans will return from overseas deployments with unusual illnesses. Some veterans will return from hazardous military deployments with serious symptoms difficult to diagnose. Historically, after every major military conflict some form of chronic symptoms have arisen.

Different types of infectious diseases to include those causing acute and chronic illnesses and those putting military personnel at risk in the Iraqi environment are included in this tutorial. Route of transmission and correlating diseases including symptomatology and complications are also discussed and links to additional resources are provided.

Heat Injuries

Heat-related illnesses happen when your body’s usual mechanisms for managing heat get overwhelmed. This can occur due to hot and humid weather, metabolic heat (heat your body makes) or both. As a result, your body can’t get rid of heat efficiently enough to keep your temperature at a normal level. Sometimes, your temperature stays normal, but you develop other, uncomfortable symptoms — like a rash or muscle cramping.

Normally, your body has safeguards in place to cool you down when you get too hot. For example, your sweat glands produce sweat that evaporates from your skin, lowering your body temperature before it can get to dangerous levels. But sometimes, the weather is so hot and humid, or your body produces so much internal heat (for example, from a vigorous workout) that your natural cooldown system gets overwhelmed.

Post-Viral Syndrome

Post-viral syndrome, often following infections like the flu or COVID-19, manifests as unexplained chronic fatigue and discomfort that can last for weeks to months. Understanding the root causes and self-care practices can help manage symptoms and support recovery over time. 

Nearly any viral infection can cause post-viral syndrome. Other conditions associated with post-viral fatigue syndrome include:1

• Common cold, flu, pneumonia
• Herpes viruses (e.g., HHV-6, Epstein-Barr, cytomegalovirus)
• Q-Fever
• Ross River Virus (RRV) 
• West Nile virus
• HIV
• Lyme disease

Post-Polio Syndrome

Post-polio syndrome (PPS, poliomyelitis sequelae) is a group of latent symptoms of poliomyelitis (polio), occurring in more than 80% of polio infections. The symptoms are caused by the damaging effects of the viral infection on the nervous system and typically occur 15 to 30 years after an initial acute paralytic attack. Symptoms include decreasing muscular function or acute weakness with pain and fatigue. The same may also occur years after a nonparalytic polio infection.

Because PPS can fatigue facial muscles, as well as cause dysphagia (difficulty swallowing), dysarthria (difficulty speaking) or aphonia (inability to produce speech), sufferers may become malnourished from difficulty eating. Compensatory routines can help relieve these symptoms, such as eating smaller portions at a time and sitting down whilst eating. PPS with respiratory involvement requires exceptional therapy management, such as breathing exercises and chest percussion to expel secretions (clearing of the lungs) on a periodic basis (monitored via stethoscope). Failure to properly assess PPS with respiratory involvement can increase the risk of overlooking an aspiration pneumonia (a life-threatening infection of the lower respiratory tract, especially so if not caught early on). Severe cases may require permanent ventilation or tracheostomy. Sleep apnoea may also occur. Other management strategies that show improvement include smoking cessation, treatment of other respiratory diseases, and vaccination against respiratory infections such as influenza.

Silicosis and other conditions secondary to harmful inhalants

Silicosis is a type of pulmonary fibrosis, a lung disease caused by breathing in tiny bits of silica, a common mineral found in sand, quartz and many other types of rock. Silicosis mainly affects workers exposed to silica dust in jobs such as construction and mining. You can’t cure or reverse silicosis. But healthcare providers can help you manage symptoms. Severe cases can affect your ability to do daily activities. It can also be fatal.

Silicosis is a work-related lung disease. You’re at greater risk of developing silicosis if you work in the following industries:

• Construction, building and demolition
• Foundry work
• Mining and quarrying
• Pottery, ceramics and glassmaking
• Sandblasting
• Stone work, including making stone countertops

                                                                                  PACT ACT

The Promise to Address Comprehensive Toxics (PACT) Act is a historic new law that will help VA provide care and benefits to millions of toxic-exposed Veterans and their Survivors. Since President Biden signed the PACT Act into law on August 10, 2022, the VA has been hard at work on implementing this landmark legislation—and Veterans have already begun to apply for the benefits they’ve earned and deserve.

The PACT Act bring these changes:

• Expands and extends eligibility for VA health care for Veterans with toxic exposures and Veterans of the Vietnam era, Gulf War era, and post-9/11 era

• Adds more than 20 new presumptive conditions for burn pits and other toxic exposures

• Adds more presumptive-exposure locations for Agent Orange and radiation

• Requires VA to provide a toxic exposure screening to every Veteran enrolled in VA health care

• Helps VA improve research, staff education, and treatment related to toxic exposures

PACT Act Information page link