The Army can do a better job at identifying and treating traumatic brain injury (TBI) in returning soldiers, according to a new report by a task force created by the Army Surgeon General and chaired by Brig. Gen. Donald Bradshaw, commander of the Army's Southeast Regional Medical Command.
The Traumatic Brain Injury task force, which includes representatives from all the military services, and the Department of Veterans Affairs, found inconsistencies throughout the country in Army resources for TBI.
Among the problems, the report noted that the Army lacks a standardized system to identify and document TBI and that communication breakdowns among systems of care forced family members to assume the role of case manager. In addition, the task force reported inconsistencies in specialty staffing; for example, some hospitals lack a neurologist with expertise in TBI, and acute TBI rehabilitation is not available at all care sites.
A TBI screening of over 35,000 redeploying soldiers conducted by the Defense and Veterans Brain Injury Center found a 10- to 20-percent rate of mild TBI. The Army defines a mild traumatic brain injury as a non-penetrating injury that may or may not be followed by a loss of consciousness of up to 30 minutes and with post-traumatic amnesia that resolves within 24 hours. They also use the score 13–15 on the Glasgow Coma Score to define mild TBI. The 15-point scale assesses brain injury outcomes and measures motor, verbal, and eye-opening responses; higher numbers indicate a less severe injury and better outcome.
Since the report was completed last May but not released to the public until Jan. 17, some of the report's 47 recommendations are already being implemented, the Army has stated.
For example, as recommended, all soldiers are being given neuropsychological tests to screen for possible effects of a mild traumatic injury. On April 1, the Army started screening all soldiers who have served in Afghanistan and Iraq for brain injuries. The Veterans Affairs Administration is also having all soldiers take a baseline neuropsychological evaluation before deployment.
In October, the Army released a set of standardized screening and treatment guidelines for all of its hospitals and centers. The Army is also working to establish primary care, social work, case management, and behavioral health programs at each of its TBI facilities.
The report recommended that the Army establish a TBI Center of Excellence that would make the Defense and Veterans Brain Injury Center, located in Washington, DC, a main unit within a network of treatment centers.
Because of these initiatives, “I can honestly say we're very proud of the fact that we've done a pretty good job at capturing all the soldiers who need care,” said Frederick G. Flynn, DO, Col. (retired), and medical director of the Madigan Traumatic Brain Injury Center in Tacoma, WA.
Dr. Flynn said that all returning soldiers are screened for a history of TBI and for whether they continue to be symptomatic. Those who are identified as having had a probable TBI are referred to a specialized center such as Madigan. Soldiers who show no signs of TBI on a neurological and cognitive assessment are given education materials and contacts and told to follow up with their primary care provider.
For those who have persistent symptoms of mild TBI, such as headaches, dizziness, problems with sleep, memory, or concentration, a more detailed neuropsychological assessment is given.
Mild TBI is the most common form of brain injury in returning soldiers, he said. “Usually, if a soldier is felt to be healthy enough to return to duty with their unit, their injury is usually a mild TBI. Moderate to severe injuries will be acutely cared for in-theater, with many requiring neurosurgical intervention.” These patients are subsequently transferred for more intensive care at the American military hospital in Landstuhl, Germany, and then to Walter Reed in Bethesda, MD, he added.
IMPLICATIONS FOR CIVILIANS
Douglas I. Katz, MD, associate professor of neurology at Boston University School of Medicine and medical director of Brain Injury Programs at Braintree Rehabilitation Hospital in MA, said the Army is addressing the same problems that occur in treating civilians with concussion. These include the need for a more organized system of identifying mild brain injuries, and assuring appropriate follow-up treatment for those who need it, particularly after patients are seen in the emergency room.
“The problem with civilians is that once the emergency room is done in making sure that it's not something that needs urgent intervention, there's the instruction to the patient about what warning signs to watch out for, but they are then vaguely told to ‘get follow-up,’” Dr. Katz said. He emphasized that follow-up care is variable since not everyone seeks it from physicians who are trained to recognize and treat symptoms of concussion.
Kathleen Bell, MD, medical director of the Brain Injury Rehabilitation Program at the University of Washington, agreed. “I think some of the gaps they describe are real holes in our broad knowledge of brain injury,” she said. “One of the most salient issues is the definition of mild TBI and how that's operationally carried out in the civilian population. There's been tremendous controversy over mild TBI and post-concussion syndrome: Is it a real thing? Is it all psychiatric in nature?”
One problem for the military to address, she said, is figuring out whether soldiers who have been home for a few years but are just being seen now experienced a brain injury during deployment.
“I'm glad that the military is paying attention to this because we suspect that in previous wars, particularly in the Vietnam War, there were indeed people who sustained TBI who weren't diagnosed and went through many miserable years getting a bad rap from the public and the powers that be,” she said. “It's a good thing that this is starting to get sorted out by the military.”