Chances are you have seen the signs in your own neighborhood – “Support Our Troops.” This message takes on new meaning as waves of our soldiers make their journey home. While communities welcome home their troops, thankful for their safe return, many families will face the life-long challenge of living with their loved one’s traumatic brain injury (TBI).
TBI is one of the leading casualties of warfare, due largely to the inherent high risk involved in military duty. The current Global War on Terror is the first wartime situation where the cases of TBI are being looked at carefully.
The Defense and Veterans Brain Injury Center (DVBIC) has been addressing the issue of brain injury in the military for the past twelve years. The Center serves active duty military, their dependents and veterans with TBI.
DVBIC is a collaborative effort between the Department of Defense (DOD) and the Department of Veterans’ Affairs (VA) serving both active duty soldiers and veterans.
The core focus of DVBIC is to deliver state-of-the-art clinical care, clinical research, and education and outreach. “With the war,” Dr. Rose Collins, neurophysiologist for the Minneapolis VA said, “the clinical care component has taken priority.”
One huge benefit to the program is the ability to keep patients longer and offering more extensive rehabilitation opportunities “Whereas in the private sector,” said Collins, “once the person is ambulatory, they are often discharged.”
Tackling the Numbers
During peacetime, there are approximately 7,000 annual TBI admissions to military and veterans hospitals. During war, the military estimates that approximately 20 percent of the surviving soldiers sustain a TBI. But the numbers are problematic for several reasons. Due to combat conditions, the military can not always accurately track the percentage of deaths that are related to TBI.
The most recent study of TBI prevalence at Walter Reed Army Medical Center places the number of TBI cases higher. However, explained Collins “The number has the potential of being misleading. Of the injured soldiers who are being seen at Walter Reed, 60 to 67 percent of those have also sustained a TBI. It’s really too early to tell if that number is characteristic of the active duty military overall,” said Collins.
Regardless of the overall numbers, it is clear that TBI cases in the military are on the rise.
Better Protection, Higher Rate of TBI
Since past wars, improvements have been made to the body armor and the Kevlar helmets that soldiers wear during combat, as well as improvements to emergency medical care, resulting in more lives saved. The Kevlar helmets in particular have reduced the number and the severity of penetrating head injuries, the sort of injury that often lead to fatalities in past wars. Ironically, while these helmets have saved lives, they have likely increased the number of mild to moderate brain injuries due to the concussive force of blasts.
“The type of warfare is having an impact. As you move further into war, the other side is going to figure out where your vulnerabilities are. The warfare of choice in terms of Iraq and Afghanistan is the rocket propelled grenade and the Improvised Explosive Devices (IED),” said Collins. IEDs are packed with dirt, glass, rock, nails, anything available, and when they explode, the shrapnel can have devastating effects. “Now we’re seeing patients with single or multiple amputations, and they may also be blind. So a challenge for a rehabilitation therapist is developing and adapting our standard TBI rehabilitation approaches for these individuals with multiple injuries,” said Collins.
The DVBIC program at the Minneapolis VA collaborates with the amputee and blind rehab programs. Collins said that whenever possible, patients are sent to TBI rehab first, so that therapists can develop a plan of action that will enable the other rehab programs better understand potential cognitive deficits that may affect traditional approaches to blind or amputee therapy. “We are certainly positioned to respond to the demand and the challenges that are posed by the global war on terror,” she added.
PTSD and Mild TBI
The similarities of mild TBI and Post-Traumatic Stress Disorder (PTSD) present another challenge in identifying cases of TBI that may have been missed during a tour of duty. There are overlaps in symptoms including sleep disturbances, irritability, physical restlessness, difficulty concentrating and some memory disturbances.
While there are similarities, there are also significant differences in what Collins calls the profile or “constellation” of cognitive impairments. “In PTSD, memory disturbances are typically involved with aspects of the trauma. In TBI, the patient has preserved older memories, but has difficulty retaining new memories and new learning. We’ll see more problems with executive functioning, planning, organization, problem solving, insight and awareness, difficulties with attention and information processing in TBI.” Coming from a combat situation, some patients can experience both PTSD and TBI, making diagnosis and treatment even more challenging. “It’s critical to have thorough evaluations so that we can treat each appropriately,” Collins said.
When TBI is Missed
Despite ongoing efforts to monitor TBI in the military, some cases are still missed due to the sheer volume of injuries, the limitations of combat medicine, and limited awareness among military personnel about brain injury or the DVBIC program. “Typically what happens in an acute medical situation is that you focus on the obvious. So there’s focus on the blindness and/or the loss of limb, but these people may have sustained a mild TBI too,” said Collins.
There are potentially devastating consequences for soldiers with TBI who return home without a diagnosis, including difficulties retaining employment, failing relationships, alcohol and substance abuse and potential homelessness. Tom Gode, Executive Director for the Brain Injury Association of Minnesota, explains “Soldiers who are not diagnosed may ultimately be misdiagnosed at a later date when their behaviors resemble mental illness, and yet without a brain injury diagnosis any mental health treatment and recovery strategies will have limited affect.”
The Wilder Research Center is currently conducting a study examining the issue of veterans and homelessness in Minnesota. Preliminary results show that 65 percent of homeless veterans had experienced a serious blow to the head that resulted in seeing stars or loss of consciousness. Of the veterans who had sustained a blow to the head, 46 percent reported problems with headaches, concentration or memory, understanding, excessive worry, sleeping or getting along with others – indicating a brain injury.
“With a diagnosis they can begin to understand the changes in their lives, with connections to services and resources they can begin to develop the compensatory strategies to assist them to return to a civilian life better able to cope with their challenges,” said Gode.
Education and Outreach
Education and outreach are key factors in addressing TBI in the military, and play an important role in catching cases of mild TBI.
The Veteran’s Health Initiative just produced a web-based TBI Education program for primary care providers, to educate them about TBI, and about services for patients with TBI in the VA system. The program is free for service providers and CEU credits are available.
The Brain Injury Association of Minnesota is also poised to offer assistance for Minnesota soldiers with TBI when they return to their communities. “The Association is prepared to provide soldiers who have sustained brain injury and/or their families the resources and support to better cope with the residual effects of the brain injury. The Association can provide information and resources on a one time basis or support an individual over two years with Resource Facilitation,” said Gode. Resource Facilitation offers regular telephone contact to assist with problem solving, coping strategies and support.
To request services for active duty military or veterans who were injured while on active duty, call DVBIC Headquarters at 1-800-870-9244 between 9:00 a.m. and 5:00 p.m. EST. For more information about VA care, contact Gretchen C. Stephens, DVA National TBI Coordinator at (804) 675-5597. For more information on the Minneapolis VA TBI Program contact Stacy Tepper, LCSW, at (612) 467-3235.
Further information about DVBIC can be found at www.dvbic.org.
The Veterans Health Initiative course on Traumatic Brain Injury is available online at http://www.ees-learning.net/dod to all VA, DOD and other interested persons. CME and CE credit is available for physicians, nurses, social workers, psychologists, speech-language pathologists, and audiologists through June 2005 at no cost. The program is available in pdf format on the web at http://www1.va.gov/vhi/docs/TBIfinal_www.pdf
Minnesota veterans are eligible to participate in the Resource Facilitation program. For more information, a Resource Facilitator may be contacted by calling 612-378-2742, or 1-800-669-6442. Individuals who reside outside of Minnesota can access resources through their local Brain Injury Associations. Contact information can be obtained by visiting http://www.biausa.org/Pages/state_contacts.html