Increased Awareness Will Improve
WASHINGTON, March 5, 2007 - Traumatic brain injury, the signature wound of a conflict punctuated by daily bomb attacks on coalition forces and Iraqi civilians, is receiving increased emphasis from Defense Department leaders and the military medical community.
DoD has made great strides in treating severe traumatic brain injuries -- those with obvious symptoms like open head trauma or loss of consciousness -- but the challenge lies in better identifying and treating mild brain injury, two top officials in the DoD health care community said.
These mild injuries, which can be caused by repeated concussions or indirect exposure to a bomb blast, are hard to diagnose because soldiers may not recognize their own symptoms, and screening tests can't always capture the full range of possible symptoms.
Treatment of traumatic brain injury is an emerging field, because the use of improvised explosive devices is greater in this conflict than it has been in any other, said Dr. William Winkenwerder Jr., assistant secretary of defense for health affairs.
In late 2006, DoD implemented a thorough screening process, based on one used for professional athletes, for soldiers and Marines who suffer head injuries. The post-deployment health assessment all servicemembers must go through also includes questions about mental and psychological symptoms, Winkenwerder said. Even with these processes in place, not all servicemembers who suffer from mild traumatic brain injury are identified, he acknowledged.
"Everyone's antenna are raised at this point about the need to look for the subtle cases -- those who might not have been right immediately in a blast zone, but could have been near, or that they might have experienced this kind of event two or three times," Winkenwerder said. "In those cases, they need to be looked at very carefully."
Many cases of mild traumatic brain injury don't get reported because servicemembers don't recognize the symptoms or are too embarrassed to admit to problems with memory or other mental functions, said Navy Vice Adm. Donald C. Arthur, surgeon general of the Navy.
Arthur said he himself suffered a traumatic brain injury a year and a half ago and was initially embarrassed to talk about the problems he was having as a result. After he underwent basic cognitive tests, he said, medical personnel thought he was fine because they didn't have a baseline of his mental functioning before his injury to compare.
DoD needs to develop tests that will measure servicemembers' cognitive functions to establish a baseline for comparison when injuries occur, Arthur said. DoD also is refining its screening processes to better identify mild symptoms that are hard to spot, he said, but awareness needs to be increased to help soldiers recognize their own problems.
"We will try to identify all of them that we can using objective tests," he said. "But we need to be very open to servicemembers coming to us telling us that they perceive that they have an issue and treating them as if we had diagnosed them, because they may be more sensitive in their knowledge of themselves than we could be with objective tests."
Another thing that can complicate the diagnosis of traumatic brain injuries is the residual effect of injuries that occurred at the same time as the brain trauma or medication that servicemembers may be taking, Arthur said. Post-traumatic stress disorder also can affect mental functioning and may be confused for traumatic brain injury, he said.
"It's important for us to go back and look at what are the components of the brain injury that are left, after the medications, after the combat stress, and after the other injuries are cared for," he said.
Recent increased attention on traumatic brain injury is positive, Winkenwerder said, because it teaches servicemembers, commanders and medical personnel that subtle brain trauma is something that needs to be taken seriously and treated. DoD, in partnership with the Department of Veterans Affairs, is a leader in traumatic brain injury research, spending about $14 million so far in the area, he said. DoD is looking at enhancing that research effort in hopes of learning as much as possible quickly and applying that knowledge in the field, he said.
"We're never satisfied," he said. "We do not believe at any one point in time that we've reached the best. It's a continual striving, and as we learn and deal with new situations, new circumstances, ... it's our obligation to respond and to learn and to get better."