By Lt. Ana Soper, MSC, neuropsychologist, Naval Hospital Beaufort
The wars in Iraq and Afghanistan have had a significant impact in advancing the science on traumatic brain injury (TBI). The research on military-related TBI is far from over, however; we are just beginning to gain a greater understanding of topics such as blast-related TBI or schedule of return to activity after TBI.
The best way for us to improve our assessment and treatments for individuals with deployment-related TBI is for further research to take place. If we as a society can continue to ask questions and engage the debate about TBI recovery, we will keep the search for answers alive through continued support for TBI research.
There has been great interest in understanding blast-related TBI on deployment resulting from Improvised Explosive Device attacks. While the current science suggests that not every blast wave exposure results in TBI, some do result in TBI.
According to the DoD definition, TBI diagnosis is based primarily on the characteristics of injury immediately following the event. TBI is defined as any period of loss or decreased level of consciousness, loss of memory for events immediately before or after the injury, alteration in mental state at the time of injury such as confusion or disorientation, or lesion due to TBI shown on a brain scan. One question chiefly under study is whether blast-related TBI results in different outcomes (such as rate of healing) than TBI due to other causes.
There is also much discussion around rate of return to activity or duty after concussion or mild TBI. Currently, rest is prescribed after TBI in theater to help facilitate the brain’s recovery. What types of activities after mild TBI constitute “rest” for the brain, and for how long should this rest take place?
When have the maximum benefits of rest been achieved for individuals whose symptoms have persisted? The Defense and Veterans Brain Injury Center has recently published guidelines which providers are recommended to consider when making decisions about rest after concussion (“Progressive Return to Activity Following Acute Concussion/Mild TBI: Guidance for the Rehabilitation Provider in Deployed and Non-Deployed Settings” available at http://dvbic.dcoe.mil/). There continues to be much debate about this in the broader research literature.
Mild TBI (also known as concussion) has a time-limited and predictable course, leading to complete healing, in most cases. However, there is much debate about whether lasting symptoms seen after mild TBI in a minority of cases are due to the TBI itself or other factors, such as depression or posttraumatic stress. Symptoms after TBI can occur frequently in individuals with other conditions who have not experienced TBI. For example, one can see attention problems or irritability in people with posttraumatic stress disorder alone or in TBI alone, sometimes making it difficult at times for professionals to determine the cause of symptoms in people with both conditions.
How to assess for changes in thinking abilities (such as memory loss) in the deployed setting after TBI is also under study. When assessment of memory and other thinking abilities is warranted post-TBI on deployment, the DoD mandates the use of a computer-based tool to assess thinking abilities, using prescribed tests. The name of this measure is the Automated Neuropsychological Assessment Metric (ANAM). While there is debate around this metric, it is helpful in providing a good basis of comparison since everyone requiring more in-depth cognitive testing takes this very same test in theater. Service members are also required to take this identical test in the U.S. before deploying to serve as a baseline.
When I was deployed to Afghanistan, some non-English speaking coalition forces were also suspected to have experienced mild TBI. However, our standardized assessment tools for looking at thinking abilities such as memory were limited to the English language, and use of a translator was not feasible. The potential for misinterpretation of results would be high if a provider were to use a test designed for native English speakers with an individual whose English vocabulary is limited to several words only, so we were unable to use these tests. While a brief neurologic exam and a basic symptom report was conducted, it will be important to think about how coalition forces fluent in languages other than English can have greater access to these assessment methods.
It is important for the public to be aware of the ongoing issues faced in the clinic post-TBI. The need for further research and the public health significance is clear. As a recently deployed service member myself, it is my hope that the public will continue to believe in the importance of continued TBI research to support our service members as part of mission readiness.