TBI Outcomes: Focusing on the Effects of Head Trauma

TBI Outcomes: Focusing on the Effects of Head Trauma
About the Author

Don Vaughan is a freelance writer based in North Carolina. 

View the full featured article from our March 2016 issue.

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Like many veterans of the wars in Afghanistan and Iraq, Staff Sgt. Kevin Hopper, USA (Ret), experienced a multitude of potentially concussive events, including frequent enemy mortar attacks, during his yearlong stint providing logistical training and support to the Iraqi military between 2005-06. Understandably, these experiences took a heavy toll on Hopper, who, after 20 years of active duty service, retired from the Army in 2012 with a shoulder injury, memory problems, hearing loss, and a diagnosis of post-traumatic stress (PTS).

Now a psychology student at Virginia Commonwealth University (VCU) in Richmond, Va., where he also works in the school's Veterans Education Assistance Program, Hopper recently agreed to participate in a nationwide longitudinal study by the VA and several top universities to determine whether he also has an accompanying traumatic brain injury (TBI).

As a study participant, Hopper has filled out numerous questionnaires about his health and his time in the Army, answered still more questions while having his brain waves monitored, undergone CT and MRI scans, had his vision and hearing examined, and received psychological testing. “I'm hoping that they can figure out what's going [on] with my brain,” Hopper says of his decision to participate, “and also help the younger generation of soldiers.”

TBI is a signature condition of the wars in Afghanistan and Iraq, affecting more than 300,000 military personnel between 2000-13, according to DoD. The majority of cases were the result of exposure to explosive blasts such as enemy IEDs and the smaller-intensity charges used by military breachers (those tasked to set charges) to access buildings. A smaller number resulted from training accidents and other noncombat-related incidents.

A century of concern 

TBI dramatically can affect servicemembers' lives, researchers warn, affecting family and work and perhaps even placing them at greater risk of neurodegenerative conditions such as Alzheimer's disease later in life. There's still much to learn, but DoD and the VA are on the front lines, partnering with experts in academia to decipher this perplexing problem and develop new and better tools for diagnosis and treatment. 

TBI has garnered much attention in recent years, but it's a military concern that dates back nearly a century. One of the first medical reports on the subject appeared in the February 1915 issue of the British medical journal The Lancet, in an article about three British soldiers who complained of a variety of symptoms, including memory loss and visual impairment, after repeated exposure to exploding artillery shells. (The term “shell shock” was published for the first time in this article.) Initially, the condition was thought to be an emotional response to the extreme stresses of war; only much later did doctors conclusively link TBI to exposure to concussive events. 

Clinicians today divide TBI into three categories: mild (more commonly known as a concussion, and the most common form of TBI), moderate, and severe, reports Dr. Sandeep Vaishnavi, a neuropsychiatrist at the Duke University Medical Center in North Carolina, director of the Neuropsychiatric Clinic at Carolina Partners in Raleigh, N.C., and coauthor of The Traumatized Brain: A Family Guide to Understanding Mood, Memory, and Behavior after Brain Injury (Johns Hopkins Press, 2015). 

One of the biggest factors in determining the severity of a TBI, Vaishnavi says, is the patient's level of awareness, or dazing, following a concussive event. “With mild TBI, impaired awareness or loss of consciousness may be momentary or it may last up to 30 minutes,” he explains. “For a moderate injury, it would be 30 minutes to 24 hours. And for a severe injury, it would last more than 24 hours.” Additional indications of TBI over time might include dizziness, anxiety, mood swings, depression, severe headaches, and behavioral changes. 

An explosive blast can damage the brain in multiple ways, Vaishnavi notes. There might be an external force, such as being struck in the head by flying debris; a penetrating injury, such as when shrapnel pierces the skull; or a blast wave that causes pressure changes in the environment around the brain. 

Once it became evident roadside bombs would be a continuing menace in Afghanistan and Iraq, DoD raced to protect servicemembers. Vehicles were “up-armored,” and protective gear became mandatory. This saved lives by protecting the torso but, ironically, placed troops at higher risk of TBI by directing the brunt of an explosive blast upward toward the head, observes Vaishnavi.

Effects on the brain 

A blast wave can be especially damaging because it causes the brain to shake violently within the skull. When this occurs, the brain might rub against bony prominences near the frontal and temporal lobes, resulting in significant damage. Enemy IEDs can produce a blast wave strong enough to lift an armored vehicle off the ground, but smaller blasts, such as those produced by breachers, also can cause harm. 

In a 2008 study by the Marine Corps Weapons Training Battalion Dynamic Entry School that followed students and instructors over a two-week course, breachers reported severe headaches and painful muscle aches in the chest and back for days after exposure to an explosion. In addition, neurobehavioral tests conducted before and after the course showed indications of declining performance among instructors, who tend to be exposed to far more blasts than students. 

Indeed, TBI can result in a host of medical issues. Of growing concern to doctors is the association between TBI and PTS. Because TBI often results from being within close proximity of an explosion, it's understandable many servicemembers with TBI also develop PTS, notes Dr. Michael Weiner, a staff physician at the VA San Francisco medical center and creator of the Brain Health Registry (www.brainhealthregistry.org), a novel neuroscience project that collects data on brain health from volunteer participants. 

Treatment for patients with both TBI and PTS can be problematic because the conditions share similar symptoms, and symptoms typically guide treatment. “It can be very difficult for clinicians to parse out to what extent symptoms are PTS-related and to what extent they are TBI-related,” Weiner says. “Ultimately, symptoms must be appropriately treated with various types of rehabilitation and, in some cases, with medications. You can't treat these conditions separately - it requires an integrated treatment program.” 

An integrated, comprehensive approach to assessment and treatment is also key to Targeted Evaluation, Action, and Monitoring of Traumatic Brain Injury (TEAM TBI), funded by DoD and developed by the University of Pittsburgh Medical Center's Sports Medicine Concussion Program in collaboration with the departments of Orthopaedic Surgery, Psychology, and Neurosurgery. “TEAM TBI is a targeted evaluation assessment strategy and management approach to chronic brain injury, predominantly mild brain injury,” explains Anthony Kontos, Ph.D., the program's research director. “We have partnered with experts in neurosurgery, neuropsychology, brain imaging, and other disciplines to develop a comprehensive assessment of mild TBI in chronic cases. These are current and former military personnel who have had symptoms for six months to a year minimum who are not getting better with conventional approaches.” 

Patients enrolled in the program meet with an array of specialists to produce a clear, detailed picture of their injuries and deficits, which helps clinicians develop a targeted treatment regimen based on their clinical profiles and specific to their individual needs, Kontos notes. 

No Laughing Matter 

One of the unusual conditions associated with traumatic brain injury (TBI) is pseudobulbar affect (PBA) - characterized by episodes of involuntary crying or laughing. The condition affects about 2 million people, researchers report, including around 52 percent of TBI patients. PBA also might affect those with Alzheimer's disease, Lou Gehrig's disease, multiple sclerosis, Parkinson's disease, and stroke. 

PBA typically develops when disease or injury damages portions of the brain responsible for controlling emotional expression, Dr. Sandeep Vaishnavi reports. Episodes might last from a few seconds to several minutes. “This is an involuntary expression of emotion and can be difficult to separate from depression,” Vaishnavi adds. 

PBA can have a debilitating effect on patients' lives. Some become homebound, fearful of an inappropriate emotional outburst while out in public or visiting friends. The condition also can have a detrimental effect on personal relationships and work. 

In 2010, the FDA approved dextromethorphan and quinidine as a first-line treatment for PBA. Previously, doctors sometimes prescribed selective serotonin reuptake inhibitor antidepressants, which helped only a small percentage of PBA patients.

DVBIC leads the way

Within DoD, the Defense and Veterans Brain Injury Center (DVBIC), headquartered in Silver Spring, Md., has been leading the effort to better understand TBI for nearly 25 years. Established by Congress in 1992, DVBIC is the TBI operational component of the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury. “Our mission is to use the latest scientific information to better the lives of our servicemembers [and] veterans and their families through clinical care, education, and research,” notes National Director Army Col. Sidney Hinds, M.D., M.C.

Toward that goal, DVBIC has clinical researchers and education coordinators who augment services at 11 military treatment facilities and five VA medical centers across the nation. In addition, DVBIC provides recovery support specialists who assist case managers with the transition of wounded warriors. Education is another important component of DVBIC's mission, Hinds says. This includes literature and education regarding new approaches to treatment for health care providers and educational handouts and other support for TBI patients.

Education also extends to servicemembers who are about to deploy and includes training on TBI and the equipment available to help prevent it. “It's not dissimilar to riding a bike,” Hinds observes. “If a helmet is part of that gear, you should be using it to help reduce any effects that might occur from an accident. We encourage our servicemembers to use safety protection as required.”

One of DVBIC's biggest game changers was moving TBI identification from a symptoms-base to an incidence-base, meaning servicemembers are evaluated more on their exposure to a concussive event than any symptoms they might or might not report. “We also have made it a leadership issue,” Hinds says. “If a leader believes that a deployed servicemember may have experienced a concussion, he is encouraged to refer that member for medical evaluation.” DVBIC also created the Military Acute Concussion Evaluation form to help military medical personnel more rapidly assess servicemembers who have experienced a concussive event.

Back home, the Army has enacted a garrison policy of assessment and treatment that mirrors the deployment policy. This is important, Hinds says, because the majority of TBIs are diagnosed at home rather than in theater.

On the research front, DVBIC is conducting a 15-year longitudinal study, led by a team at Walter Reed National Military Medical Center in Bethesda, Md., to examine mild, moderate, and severe TBI. “The study is enrolling patients [through the continuum of severity] and taking a look at things like brain imaging, biomarkers, and neuropsychological testing and examining their impact over time on servicemembers and veterans,” Hinds reports.            

Focusing on the long term     

DVBIC's multiyear study is not the only ongoing research into TBI. The VA study that recruited Hopper is one of 12 funded by a $62.2 million federal grant to oversee a national consortium of researchers charged with investigating the effects of TBI among servicemembers and veterans. According to Chair and Herman J. Flax, M.D. Professor Dr. David Cifu, principal investigator in the Department of Physical Medicine and Rehabilitation at VCU, researchers hope to learn more about the long-term effects of mild TBI, including its pathophysiology and the long-suspected association between repeated concussions and neurodegenerative conditions such as Alzheimer's disease and chronic traumatic encephalopathy, a debilitating condition common among boxers, football players, and others who experience frequent concussions.

The good news, says Cifu, is most patients with mild TBI do well with treatment. “Up to 95 percent of people with this condition will have a complete resolution at one year with the right kind of care,” he reports. “Eighty-five percent will be well in three to six months.”

 

 

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