Out of Sync: The Effects of Traumatic Brain Injury and the Battle to Recovery

The blast was deafening and created a concussion that sucked the oxygen from the air. The roadside bomb lifted the armored Humvee off the ground tossed its occupants like rag dolls. All survived, but one had life-threatening injuries and was evacuated to a trauma center in Europe. The rest of the crew suffered scrapes, bruises, and a few broken bones, but felt well enough to return to duty shortly after the attack. Although their visible injuries had healed, the military is increasingly aware of the unseen physical wound known as traumatic brain injury (TBI).

TBI is caused by a blow or jolt to the head or a penetrating head injury that disrupts the normal function of the brain. Brain tissue can be damaged when bullets, shrapnel or other foreign objects pierce the skull or, in the case of a fall or blow to the head, the brain can impact the skull with enough force to bruise or tear the brain tissue. TBIs can range in severity from a mild concussion that may often heal without medical treatment to severe injuries that may require surgery and years of rehabilitation.

Closed head trauma — brain injury where the skull is not fractured — is the signature injury in our nation’s current military conflicts. One in five Iraq and Afghanistan veterans

have experienced a traumatic brain injury, according to a recent Rand study (April 2008). This is a marked increase from documented TBI cases in the Vietnam War and is attributed to more powerful munitions and improved body armor and protective gear. Service members are now surviving injuries that would have been fatal before the development of today’s force-protection materials and equipment.

Because of the growing incidence, the Departments of Defense (DoD) and Veterans’ Affairs (VA) are undertaking several initiatives to identify and assist TBI victims. Working in conjunction with private and governmental agencies, progress is being made in diagnosing, treating and rehabilitating those affected by TBI.

Severe versus Mild TBI

“On the clinical spectrum, traumatic brain injuries range from severe to mild; ‘severe’ meaning the patient is in a coma and ‘mild’ is classified as a concussion,” explains Dr. Jamshid Ghajar, president and founder of the Brain Trauma Foundation (BTF), a nonprofit organization dedicated to improving the outcome for TBI patients.

Severe brain injuries are relatively easy to identify, says Ghajar. “There’s a head wound; the patient is in a coma. It’s pretty obvious. And we’ve made remarkable strides in treating severe TBIs. The mortality rate was 55 percent 20 years ago, but thanks to the development of treatment protocols, the mortality rate has dropped to 20 percent. That’s dramatic.”

The effects of severe brain trauma can be devastating, with approximate 30 percent of survivors left with severe neurological disabilities or in a vegetative state. But nearly half of those who survive experience positive outcomes and are able to live independently.

This success, according to Ghajar, is directly related to the prompt and appropriate attention provided by front-line medical personnel who are well trained in best treatment practices. “DoD is doing a good job of handling severe TBI cases. Patients, who often have other life-threatening injuries in addition to TBI, are quickly transferred to trauma centers that also employ the latest technology and techniques to facilitate positive outcomes.”

Concussions account for about 90 percent of all TBIs, but the term “mild TBI” doesn’t mean the consequences aren’t serious. Seizures, slurred speech, loss of memory, headaches, dizziness, vision problems, lack of attention and personality changes can all result from a concussion and the symptoms can last for years.

“The concussions are difficult to deal with,” says Ghajar, “because they are hard to identify. The victims may look normal, be coherent, walking, talking, telling everyone they’re fine and ready to get back into the action, when in fact, they’ve experienced a traumatic brain injury.”

Symptoms of TBI, such as headache, fatigue and irritability, are not unique to brain injury and therefore are often overlooked. Symptoms aren’t always immediately visible and other physical injuries that are more apparent take precedence and delay a TBI diagnosis. Even when symptoms like slow speech, balance problems, difficulty in communicating or lack of attention are present, they are often mistaken for indicators of a stroke or Post Traumatic Stress Disorder (PTSD). Combined with the chaos and lack of diagnostic equipment on the battlefield, it’s not surprising that combat TBI often goes undiagnosed.

Diagnostic Technology

The impact of undiagnosed TBI can also be devastating. Delayed treatment time often results in prolonged recovery, which in turn can cause serious personal complications that can put the service member and his unit in harm’s way. “It’s important to identify and treat TBI victims as early as possible, particularly in a combat situation” explains Ghajar. “We’ve learned that TBI creates a lack of attention, which can put a soldier and the whole unit at risk. TBI often disrupts sleep patterns, another contributing factor in lack of attention, and can compound the problem. We want to limit any activity that would put the patient or his buddies at further risk.”

Research has also shown that the results of TBI are cumulative and, of those diagnosed with a concussion, many had previous brain injuries. A brain-injured soldier who is continually exposed to bombs, grenades, and other artillery is at higher risk for additional brain trauma, and as a result, combat veterans often take longer to recover from concussions. TBI symptoms can worsen over time if not treated, which can delay reintegration to their military unit or civilian community. And because of social stigma or simple lack of understanding about the dangers, it’s estimated that more than half of the 320,000 service members who’ve suffered TBIs in Iraq and Afghanistan have not sought diagnosis or treatment.

Technological advances are making the job of diagnosing TBI a little easier. Dr. Ghajar and the Brain Trauma Foundation have been studying concussions for the past eight years, and recognized a trend among TBI victims.

“Many said they ‘felt out of sync’ with the outside world,” recalls Ghajar. “We believe the brain is predictive; it anticipates what’s going to happen and then processes information accordingly. It’s like a tennis player who sees the ball coming at him. He anticipates where the ball will be a few seconds in the future and swings so that his racket will intersect that point at the appropriate instant. Our brains are about two-and-a-half seconds in the future. We make these types of predictions all the time in our daily lives and this timing allows us to anticipate and respond. It allows us to pay attention. If our timing is off, the brain can’t process information in a normal way.”

Ghajar has invented several neurosurgical devices that have been adopted worldwide, but his latest project is a quick and relatively simple diagnostic test that is yielding promising results. Patients are asked to watch a small dot of light as it travels in a predictable circular pattern while their eye movements are monitored. Patients with normal brain function can accurately predict the pattern and are able to track the dot with ease. The task is much more difficult for those with TBI.

“Patients with TBI don’t track the dot in a circle. Their eyes track in an erratic, wobbly pattern. The amount of ‘wobble’ is proportional to the severity of the injury; the more wobble in their tracking, the more difficulty they have in paying attention. We’ve been developing this technology over the past six years and have a desktop tracking device that requires manual analysis. Thanks to a $4.6 million grant from the Department of Defense, we’re working to create a fully automated system that is portable for use on the battlefield. We’re funded to have a goggle-style prototype by 2012, but we’re hoping to get accelerated funding so that we can have something in the field by next year. It’s a 30-second test that can provide immediate assessment, and can be used at sporting events, where players often suffer blows to the head, and also has great potential for future diagnostic uses, such as for patients with Attention Deficit Disorder [ADD] or diagnosing pre-dementia in aging patients. We believe this device could make a huge difference.”

Eye-tracking can be the first step in diagnosing brain injury, followed by advanced imaging tools. When there is a sheering of the brain, there is often tearing of the connections that help the regions of the brain communicate with one another. Microscopic tears to these connections, called axons, can disrupt brain function.

Traditional magnetic resonance images (MRI) don’t show damage to axons and, as a result, about 70 percent of TBIs aren’t visible on an MRI. New high-definition neuroimaging technology, like diffusion tensor imaging (DTI), allows doctors to assess the integrity of the brain’s axons. Magnetoencephalography (MEG), another advanced imaging technique, helps identify areas of the brain that have slower-than-normal brain waves.

“There’s no single diagnostic technique for identifying TBI,” says Ghajar, who is chief of neurosurgery at The Jamaica Hospital-Cornell Trauma Center and a clinical professor of neurological surgery at Weill Cornell Medical College. “We’re working to find ways to achieve a more specific diagnosis, and I believe it will require a combination of assessing behavior and other symptoms, eye-tracking, and advanced imaging techniques.”

Raising Awareness and Making Progress

In addition to diagnostic tools, progress is also being made in tracking and treating TBI patients. In an effort to identify military head trauma cases, Congress mandated that service members be evaluated for brain injury when they return from combat tours.

These tests are repeated periodically for those who suffer a concussion or head injury to more accurately gauge the long-term affects of brain trauma. And more than 100,000 service members have undergone neurocognitive tests prior to deployments, establishing a baseline that will make it easier to evaluate them for brain injury when they return from combat. Data collected from these studies will help DoD develop more effective force-protection equipment and techniques, and also assist military and civilian physicians as they refine treatment protocols.

In November 2007, DoD created the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE). In partnership with the Departments of Defense and Veterans’ Affairs and a national network of military and civilian resource agencies and clinical experts, DCoE is working to establish best practices and quality standards of treatment of TBI. Their work focuses on clinical care, education and training, prevention, research, and outreach efforts to ensure the medical needs of military personnel and their families are being met through a variety of channels.

“We have a community that really understands the needs of service members and their families,” explains Army Brig. Gen. Loree K. Sutton, special assistant to the assistant secretary of defense for health affairs and director of the DCoE. “DoD medicine has focused on saving lives for a long time, but we’re new to the rehabilitation piece. DCoE is part of a cultural transformation that’s very exciting.”

The DCoE website (www.dcoe.health.mil) offers a wealth of informationaimed at connecting service members, veterans and their familieswith the resources they need to recover and reintegrate, as well asassist them as they navigate thehealth care system. The DCoE also provides an Outreach Center that is an authoritative source of information and resources on TBI concerns. Military personnel, veterans, family members, health care providers, military and congressional leaders, researchers and educators are invited to contact the center 24/7 at 866-966-1020 or by e-mail at Resources@DCoEOutreach.org. Outreach is acritical component of the DCoE’s work, says Sutton. “We’re working to reach nearly half of the 18 million service members who are no longer wearing the uniform. Their health concerns don’t end when they separate from service. Even if the war ends tomorrow, we have decades of work to do to care for those with existing injuries.”

Sutton enthusiastically lists the high and low-tech mechanisms being developed to assist TBI patients. “Our AfterDeployment.org website offers a self-assessment tool and provides useful information about specific concerns, such as overcoming anger or sleep disruptions. The site is a work in progress, but we’re already getting 4,000 hits a month.

We’re using today’s social networking sites, like Twitter and Flicker, to help TBI victims connect with one another, and we’re developing virtual coaches and leveraging other technologies to make it less intimidating for service members to seek the help they need. We’re also very pleased with the progress on the National Intrepid Center of Excellence. This new facility is scheduled to open in 2010 and will offer holistic treatment and rehab services for psychological health and TBI patients just as the Center for the Intrepid is doing for amputees. From a less-technical perspective, we’re also exploring alternative medical treatments like yoga and acupuncture.”

The primary operational component of the DCoE is the Defense and Veterans Brain Injury Center (DVBIC), a collaborative research and training effort by DoD and VA. DVBIC’s efforts to define the treatment process from the point of injury to resolution include the development of a TBI registry. This registry allows DoD and VA to identify patients who’ve experienced brain trauma, track their medical and psychological history to ensure they receive needed treatment, facilitate communication among health care providers, and track their recovery over the long term.

Not Just a Military Issue

Traumatic brain injury is not limited to those serving on the battlefield. Auto accidents are the leading cause of TBI, but sporting injuries, accidental falls and a myriad of other accidents contribute to the high incidence of brain injury.

“TBI is a big problem because the incidence rate is so high,” explains Ghajar. “It’s the leading cause of death and disability in young people, and for every severe TBI, there are 10 concussions. There are approximately three to four million concussions each year.”

The cost of treating a mild TBI for a year is estimated at $32,000. Treating a severe brain injury can range from $268,000 to $408,000 per injury per year. These estimates include treatment costs, loss of income and the value of caregivers. “By implementing BTF treatment guidelines for severe TBI, we’ve been able to reduce the mortality rate by 50 percent, double positive outcomes and save an estimated $3.8 billion,” says Ghajar. “Getting a handle on preventing, diagnosing and treating TBI will save lives and money.”

Lauren Armstrong is the Contributing Editor and an LA FRA Member at Large. She can be reached at lauren@fra.org.