ARTICLE IN BRIEF
Within the medical establishment, there is disagreement about whether mild traumatic brain injury is the appropriate diagnosis for many returning vets, but most military physicians agree that they need to treat the symptoms.
Many soldiers arrive home from active duty in the Persian Gulf with a laundry list of neurological symptoms — from headache to memory loss. Now, military experts are arguing behind the scenes whether or not their symptoms result from an initial blast injury that caused concussive or mild traumatic brain injury (TBI) or whether it is caused by post-traumatic stress disorder (PTSD) or other psychiatric conditions.
The debate is not just about semantics. For Col. Charles W. Hoge, MD, director of the division of psychiatry and neuroscience at the Walter Reed Army Institute of Research, labeling soldiers with a diagnosis like mild TBI can set them down a life path without the proper treatment.
Dr. Hoge contends that wholesale diagnosis of mild TBI can send patients into specialty services for treatments that reinforce a diagnosis of mild TBI. “Treatments that are offered in the specialty services may not be what is necessarily best for these patients,” Dr. Hoge told Neurology Today. “We may be doing these soldiers more harm than good.”
“There is a tendency to attribute symptoms to concussive or mild traumatic brain injury,” said Dr. Hoge, who outlined his perspective in the April 16 issue of the New England Journal of Medicine. “We don't have the tools to determine the cause of these symptoms,” he added. “The symptoms could be related to post-traumatic stress injury, anxiety, or depression.”
Dr. Hoge and colleagues wrote that doctors “have no validated diagnostic criteria,” and that “substantial evidence demonstrates the difficulty of attributing symptoms to mild TBI, suggesting that clinical interviews will result in erroneous conclusions.” They argue that psychological factors, compensation, legal action, and expectations can contribute to the persistence of symptoms.
The problem with the military medical system, Dr. Hoge continued, is that soldiers come home months or years after the initial blast injury and they are screened to rule in concussive or mild TBI. The formula requires exposure to a blast and also a brief period (under 30 minutes) of unconsciousness or a feeling of being dazed. When they show up post-deployment with headache, irritability, memory, and sleep problems, the clinicians taking a history have to piece together the blast history to make a diagnosis long after the initial event.
He added that these conditions are not being over-diagnosed but misdiagnosed, and that clinicians would be better off working to treat the symptoms rather than trying to figure out what happened on the battlefield.
“The bottom line is that their symptoms need to be addressed,” Dr. Hoge said. “We need to revise our screening tools. Otherwise, the risks can be substantial.”
CONTRIBUTING FACTORS, SYMPTOMS
But Frederick G. Flynn, DO, FAAN, medical director of the Traumatic Brain Injury program at Madigan Army Medical Center in Tacoma, WA, does not think the issue is that easily addressed. “It is not that simple, as Dr. Hoge suggests, that most of the symptoms are due to psychological stress,” Dr. Flynn said. He added that military studies are now underway to determine whether stress on the heels of a mild TBI can lead to new symptoms or make lingering symptoms worse. “There are so many factors that contribute to what is going on in our soldiers returning home with symptoms,” Dr. Flynn said.
“We all agree that nothing beats having witnessed the event or having proof of what happened at the time of the blast, but in many cases when vets come back we are taking a history and relying on them to explain what happened at the time of the blast,” Dr. Flynn said.
He pointed out that not enough is known about the long-term symptoms following a blast or multiple blast exposures to know for sure whether the present-day symptoms can be directly attributed to the blast. “It is important to listen to the soldier's story,” said Dr. Flynn. “If it sounds as if they were knocked unconscious I feel more confident that the soldier had a concussion or mild traumatic brain injury.”
Dr. Flynn believes that the symptoms vets experience relate to a combination of physical and psychological factors. Chronic stress can result in changes in brain chemistry and thereby compound the biological consequences of a mild TBI, he said, and mild TBI in turn may increase the susceptibility to post-traumatic stress symptoms. “A soldier with a history of multiple mild TBIs due to exposure to multiple blasts, who also has chronic stress, may continue to have physical, cognitive, and psychological symptoms that persist for months or years,” he said.
Treatment should be targeted at the symptoms and not necessarily the diagnosis, he added. For instance, many soldiers complain of sleep problems that can then lead to headaches and memory problems. “We address the sum total of the patient's complaints,” he said.
‘The Signature Wound’
Traumatic brain injury is “the signature wound of the conflicts in Iraq and Afghanistan, and headache is the signature complication,” said headache specialist Teshamae Monteith, MD, a neurologist and clinical fellow at the Jefferson Headache Center of Jefferson Medical College in Philadelphia. Dr. Monteith noted that according to the Armed Forces Health Surveillance Center, there has been a nearly 60 percent increase in migraine incidence rates from 2002 to 2007.
The post-concussive syndrome has been controversial for over a century, and will continue until more objective testing becomes commonplace, she added, but in the meanwhile, returning soldiers are “largely left with acquired migraines and post-traumatic headaches and few treatment options.”
Dr. Monteith is now advocating for headache Centers of Excellence and clinical programs in the Veteran's Administration and Department of Defense.
“TBI, psychiatric disorders, and headache represent a clinical triad of the combat experience. The fear is that with high rates of depression, stressful events, and head trauma, returning veterans are at a higher risk for daily headaches,” Dr. Monteith added.
Robert Ruff, MD, PhD, national director of neurology for the Veteran's Administration, believes that head trauma from blast exposure can lead to prolonged symptoms of post-traumatic stress disorder and the resulting nightmares can worsen symptoms like headache. He has argued for better diagnosis. “These people are having problems getting back to work. The focus should be on treatment.”
Stephen Silberstein, MD, professor of neurology at Jefferson Medical College and director of the Jefferson Headache Center, stressed that more research on modern-day wartime symptoms is needed. He added that soldiers with chronic headache problems may not be able to get the appropriate treatment because comprehensive headache programs in military medical centers are rare.
Dr. Flynn disagreed. “Most of these soldiers with headache can be treated effectively with common medications used for migraine, including triptans and non-steroidal anti-inflammatory drugs,” he said. “At Madigan we offer comprehensive headache classes for education and non-pharmacological treatments to supplement medication. There are also many excellent neurologists and other medical specialists in military medical centers who treat headaches very effectively on a daily basis.”
For more data on new research on mild TBI and other neurological complications for returning vets, see “Unique Clinical, Imaging Findings Seen Among Veterans With Mild TBI” on page 18 in this issue.