Chapter 2: Combat Mild Traumatic Brain Injury (mTBI/Concussion)

The wars in Iraq and Afghanistan have led to increased awareness of the impact of traumatic brain injury (TBI) on troops. The availability of modern protective equipment and advances in battlefield medicine have resulted in many warriors surviving injuries from IEDs (improvised explosive devices), RPGs (rocket-propelled grenades), rockets, mortars, EFPs (explosively formed projectiles), and other munitions that would have been fatal in prior wars. Some of these injured warriors have experienced serious brain injuries resulting in long-term impairment in physical, cognitive, and behavioral functioning.

Unfortunately, there has been very poor education about the distinction between mild traumatic brain injury (mTBI), also known as “concussion,” and moderate or severe TBI, where damage to the brain is usually apparent on clinical evaluation and brain scans (CTs and MRIs). All TBIs (concussions/mild, moderate, and severe) have been grouped together by medical professionals and in educational materials given to warriors and their families. In 2008, investigators from the RAND Corporation reported that 20 percent of all Iraq and Afghanistan war veterans (more than 300,000) experienced a “probable traumatic brain injury” while deployed, without clarifying that over 99 percent of these cases were concussions and that their study was based on an inadequately validated survey administered months or years after the warriors had returned from deployment. Concussions/mTBIs have also become entangled and confused with PTSD, and these two conditions have been described as “silent” wounds, affecting hundreds of thousands of OIF and OEF warriors.

When a warrior experiences a moderate or severe TBI on the Iraq or Afghanistan battlefields, this almost always results in rapid air transportation to one of the large military hospitals in Germany or the United States for neurosurgical, neurological, and rehabilitation services. Some of these warriors experience severe disability and require long-term treatment.

In contrast, when a warrior experiences a concussion/mTBI on the battlefield, which may involve being briefly knocked out, or getting their “bell rung” from a blast or other injury, this almost never results in evacuation from the combat theater. Concussions/mTBIs are very common in the military (as in nonmilitary settings) from sports injuries, motor vehicle accidents, hand-to-hand combatives training, and combat. Although concussions can occasionally lead to long-term health effects — such as headaches, irritability, sleep disturbance, memory problems, or fatigue — most warriors who experience concussions recover quickly. Concussions/mTBIs are clearly not the same as moderate and severe TBIs, but in the minds of many warriors, family members, the public, and even medical professionals, they have become the same condition, requiring an equivalent level of concern.

After every war, warriors have experienced high rates of physical, cognitive, emotional, or behavioral health concerns, including memory and concentration problems, anger, headaches, sleep disturbance, high blood pressure, rapid heart rate, pain, fatigue, dizziness, and other difficulties. These problems are associated with neurological, endocrine, cardiovascular, and immune system changes likely related to physiological effects of extreme stress on the body, extended sleep deprivation, environmental exposures, and other factors.

The reactions that warriors experience after coming back from war have been given different labels through the generations, including “Nostalgia” (Napoleonic Wars); “Da Costa Syndrome,” “Irritable Heart” (U.S. Civil War); “Effort Syndrome,” “Shell Shock” (World War I); “Battle Fatigue” (World War II); “Acute Combat Stress Reaction” (Korean War); “Agent Orange Syndrome,” “Substance Abuse,” “PTSD” (Vietnam); and “Gulf War Syndrome” (Gulf War 1). Some of these problems have been associated with serious environmental exposures (e.g., Agent Orange, Gulf War Syndrome).

After every war, the same mistakes are made. Rather than recognize that going to war can change the body’s physiology in a number of ways and identify the best treatments for the full range of health problems that warriors experience, postwar symptoms are attributed to causes that are highly influenced by prevailing politics. After every war, veterans are told that their war-related symptoms are “stress-related” or “psychological” (which understandably infuriates them), and the medical community becomes embroiled in divisive debates as to whether the causes of war-related symptoms are predominantly “psychological” or “physical” (or environmental) in origin. While medical professionals and policy-makers get caught up in debating the definition and nature of the problems (influenced by poor-quality scientific data and “turf” battles regarding allocation of resources), veterans feel that their problems are not taken seriously. Health professionals and policy-makers responsible for establishing initiatives to address the problems are well intentioned, but often become overly dependent on the advice of “experts,” and myopic to any scientific evidence that doesn’t support their positions. Ironically, the need to be perceived as expediently doing everything possible in the interest of veterans leads to the rapid implementation of interventions that are not necessarily beneficial, and may even prove harmful.