By Annette M. Boyle
WASHINGTON – Warriors who served in Iraq and Afghanistan combat operations might experience lingering physical and psychological consequences of exposure to blasts. Because blasts affect multiple body systems — and because the full ramifications of injuries to the brain, in particular, might not appear for months or longer — pinpointing the causal relationships remains tricky.
Understanding the adverse health outcomes of blast exposure is further complicated by a dearth of research. The recent Institute of Medicine report, “Gulf War and Health, Volume 9: Long-Term Effects of Blast Exposures,” found some notable gaps in the evidence base.
“A fundamental feature of exposure to blast is that it can result in complex, multisystem injuries. Attention to those complexities has often been lacking in research studies,” the authors wrote. The committee also noted that most studies rely on patient reports of blast exposure but that an understanding the mechanisms of injury and development of effective prevention or treatment methods require far more detail on blast components and environment, as well as the individual’s exposure and physiological status.
For the VA, filling in the gaps and getting a better understanding of the long-term consequences of blast injuries is critically important. Researchers at the Integrated Disability Evaluation System (IDES), a joint DoD/VA program, estimate that the number of blast-related traumatic brain injuries (TBIs) experienced by servicemembers deployed to Iraq and Afghanistan could be as high as 320,000.
The VA “is very focused on the long-term health effects of exposure to blasts on Gulf War veterans and is a leader in state-of-the-art, evidenced-based therapies and research for traumatic brain injury,” David Cifu, MD, VA national director for physical medicine and rehabilitation, and Stuart Hoffman, PhD, scientific program manager for VA’s traumatic brain injury research, noted in an email to U.S. Medicine. As a result, the VA asked the IoM to assess the relevant scientific information available and draw conclusions regarding the strength of the evidence of an association between exposure to blast and health effects.The VA also requested that the IoM recommend future research on the topic.
The IoM committee determined that blast exposure was clearly associated with several long-term complications of TBI, including endocrine dysfunction, post-concussive symptoms and persistent headache. The committee found sufficient evidence of an association between posttraumatic stress disorder (PTSD) and direct and indirect blast exposure, “such as witnessing the aftermath of a blast or being part of a community affected by a blast.”
Severe or moderate TBI, not blast-related, was associated with permanent neurologic disability, including cognitive dysfunction, unprovoked seizures and headache. Because these associations also are known outcomes in TBI studies that combined blast and nonblast causes of TBI, the committee determined it was plausible that moderate or severe TBI from blasts had similar neurological consequences.
The report authors also found sufficient evidence to support a causal relationship between blast exposure and loss of vision from penetrating eye injuries and long-term effects on the genitourinary system (hypogonadism, infertility, voiding dysfunction or erectile dysfunction) and an association with cutaneous granulomas.
“Research based on recommendations in this report will inform decisions on how to diagnose blast injuries effectively for veterans, and how to manage, treat, and rehabilitate victims of battlefield traumas both in the aftermath of a blast and in the long term,” Cifu and Hoffman said.
In response to a previous IoM report, the VA initiated a research program in 2011 to investigate the chronic effects of central nervous system injury and, with the DoD, has created a consortium to study the chronic effects of brain injuries. The “consortium is now funded and is standing up research projects that meet the recommendations of this report,” report authors added.
The results of those research projects will not be available for several years. In the meantime, however, both VA and civilian primary-care providers will see an increasing number of former servicemembers who may have continuing effects from blast exposures and TBI.
Because of the number of former servicemembers at risk, healthcare providers should have a low threshold for screening for TBI. “Many will have been exposed to blasts or have hit their head,” said David Twillie, MD, chief of soldier readiness for DoD IDES. A simple screen may be all that’s necessary, he said: “Have you had a TBI or head injury with loss of consciousness?”
For veterans who present with headache, nausea, blurred vision, sensitivity to light and noise, tinnitus, dizziness, drowsiness or sleep issues, the index of suspicion for lingering effects of TBI should be high. Likewise, for those who say “they’re in a fog, have slowed thinking or trouble concentrating or remembering,” Twillie told U.S. Medicine.
While TBI is a likely diagnosis in these cases, it isn’t a simple one, because while these symptoms may indicate TBI, they also are associated with two commonly occurring comorbidities, PTSD and major depressive disorder.
According to the IoM report, “there is sufficient evidence of a substantial overlap in the symptoms of mild TBI and PTSD to exposure to blast, and there is limited/suggestive evidence that most of the shared symptoms are accounted for by PTSD and not a direct result of TBI alone.” The association between PTSD and major depressive disorder is well-established, the authors added.
“In the first year after a mild TBI, there’s a 34% comorbidity for any psychiatric illness,” said Judith Regan, MD, MBA, JD, a provider with IDES. If a patient continues to experience symptoms six months or more after the injurious event, “look for some kind of psychological disorder. Post-concussion syndrome could develop with depression or PTSD,” she told U.S. Medicine.
To tease out whether a patient continues to suffer from TBI, providers should “take a thorough history, conduct a physical and psychological exam, test muscle strength, perform a sensory exam and test coordination,” recommended Vickie Patton-Currie, PA-C, MPAS, a provider with IDES. “It’s also important to evaluate the mental state, to tell if there is any cognitive impairment.”
A provider could generally expect most symptoms of mild TBI to resolve in three months. “In three to six months, you should certainly see improvement, but some studies show that symptoms may persist up to a year,” noted Lee Solis, PA-C, MPAS, chief of the VA IDES clinic.
In their article, “Mild Traumatic Brain Injury and the Primary Care Provider; Aftermath of Iraq and Afghanistan,” the IDES team recommends symptomatic treatment for post-concussion syndrome, including migraine medication, analgesics, counseling and other medications. Specialty consultation with psychiatrists and neurologists and referrals to occupational, physical and speech therapists may also be indicated.