Mild TBI Remains Little Understood and Hard to Diagnose

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BETHESDA, MD — With all of the attention given traumatic brain injury in recent years, it can be easy to forget that this is still a nascent area of medical science. It took six years of fighting in Afghanistan and Iraq for the military leaders to realize the impact TBI — especially the cumulative effects of multiple mild TBI — was having on servicemembers.

“This really is a new field,” explained Kathy Helmick, MS, RN, deputy director of the Defense Centers of Excellence (DCoE), at the 4th Annual Trauma Spectrum Conference held on the campuses of NIH. “We’re still exploring this realm in the medical literature, and there’s still a paucity of research.”

Her message to the conference was that, while physicians know far less about the mechanics of TBI than they would like, military researchers have been given the order to move as fast as safely possible with translating research into practice in order to help injured troops and veterans.

Less Than a Decade of Research

There have been 220,430 diagnosed cases of TBI in servicemembers since 2000. In 2000, prior to the current wars, there were 11,000 cases of TBI in the military, even without battlefield conditions.

The vast majority — between 60% and 80% — have been mild TBI (mTBI) — the type scientists understand least.

Research into TBIs did not take off until the 1990s, and most of that decade was spent studying severe and penetrating brain injuries, Helmick said. Little was known about the long-term effects of concussion.

“At the beginning of the war, the thinking in the military was that it happened, and there was nothing to be done about it,” Helmick said. If a servicemember was involved in a blast-related incident, he or she had to come forward and request a medical evaluation. Servicemembers were unlikely to do that if, as Helmick said, “they ‘just saw stars’ for a moment.”

It was not until 2007 that the evidence of cumulative cerebral effects from mTBIs began to come to light. It was not until 2009 that line commanders were approached with evidence of how those effects were impacting a servicemember’s functional abilities.

“This was what spoke to line leadership — when they see that the impact of concussion can have an impact on the soldier’s [effectiveness],” Helmick said. “It spoke to the essence of how a concussion can impact a war fighter, and that it was something that needed to be addressed.”

With evidence that mTBI could result in poor marksmanship, slower reaction time and decreased concentration, the model of sending soldiers back into combat without being evaluated began to be replaced with something different.

Changing the Diagnosis Paradigm

Airmen test their memory skills during a portion of the Automated Neuropsychological Assessment Metrics test Nov. 5, 2009, at Moody Air Force Base, Ga. An Army team visited Moody AFB to help conduct a mass ANAM testing for more than 800 Airmen. The test, which establishes a baseline for an individual’s brain activity, is mandatory prior to deploying. (U.S. Air Force photo/Airman 1st Class Joshua Green)

In June 2010, DoD issued a directive-type memorandum that ordered all servicemembers involved in a blast-related incident or who were within 50 meters of a blast to automatically be evaluated for TBI.

“We moved from a paradigm of, ‘Hi, I’ve got a headache, [so] I need to be seen,’ to ‘If you’re near a blast, you need to go see medical,’” Helmick said. “This was really important because it signified a change in how we did business: mandatory event-driven, rather than symptom-based reporting.”

Prior to this directive, servicemembers were sometimes evaluated as much as five weeks after the event. By then, symptoms of TBI could be even harder to diagnose.

“They were medically evacuated to Landstuhl, and then line commanders were wondering if they were ever coming back to finish their tour,” Helmick explained. “Now it’s a line effort, not a medical effort. Our goal is to get you diagnosed, treated and back to your unit ASAP. Evacuations to Landstuhl have dropped sharply.”

Not only does immediate treatment help curtail long-term effects, it also helps with future diagnoses involving the patient. If that patient shows up to a VA hospital, years after the blast-incident, complaining of some of the many symptoms shared by PTSD, TBI, depression and substance-abuse disorder, TBI can be ruled out, at least from that specific incident.

 The effectiveness of the system is hampered, however, by communication issues between DoD and VA. At the conference, one VA provider told Helmick that she had patients who came in talking about a battlefield “TBI clinic” where TBI was or wasn’t ruled out after a blast incident. However, data from that clinic was nowhere in the patient’s record.

“The data is starting to all come together,” Helmick said. “The sources are there, and we’re trying to push it through these different IT systems so clinicians can have them. We haven’t forgotten about VA.”

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