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Lingering Questions about Mild Traumatic Brain Injury: A Medical Research Priority

Posted Jun 09 2010 8:30pm

photo-by-peretzup-via-flickrFor anyone who missed it, I highly recommend the eye opening series NPR has been running this week, reported by T. Christian Miller and Daniel Zwerdling , on the military’s failure to diagnose and treat soldiers with mild traumatic brain injury, defined by the Department of Defense as a blow or jolt to the head that results in a brief change in mental status or consciousness.

As Miller and Zwerdling explain, “[b]etter armor and battlefield medicine mean troops survive explosions that would have killed an earlier generation. But blast waves from roadside bombs, insurgents’ most common weapon, can still damage the brain.  The shockwaves can pass through helmets, skulls and through the brain, damaging its cells and circuits in ways that are still not fully understood. Then, secondary trauma can follow, such as sending a soldier tumbling inside a vehicle or hurling into a wall, shaking the brain against the skull.”  While most sufferers of mild traumatic brain injury make a full recovery, some termed the “miserable minority” experience a devastating array of chronic, disabling symptoms, including balance issues, dizziness, headaches, memory and reasoning deficits, and vertigo.  Among Miller and Zwerdling’s findings are that “[w]ithout diagnosis and official documentation [a distinct possibility given the weaknesses of the diagnostic tests used and the fact that handheld recordkeeping devices fail and paper records are burned] soldiers with head wounds have had to battle for appropriate treatment.”

Complicating matters is a lingering controversy over what the appropriate treatment is for mild traumatic brain injury.  In a 2009 opinion piece in the New England Journal of Medicine, Charles Hoge a retired Army psychiatrist whom Miller and Zwerdling note is a high-level advisor to Lt. Gen. Eric Schoomaker, the Army’s most senior medical officer argued that (1) there are no validated diagnostic criteria for clinicians to use in diagnosing mild traumatic brain injury, (2) the physical, neurocognitive, and behavioral symptoms believed to be associated with mild traumatic brain injury are more strongly associated with post-traumatic stress disorder and depression, and (3) that misattributing “postwar health conditions that have been described for centuries” to mild traumatic brain injury could result in “a failure to address underlying conditions (e.g., depression, PTSD, or substance abuse), the use of unproven rehabilitation procedures, and the prescribing of medications for nonapproved indications (e.g., an atypical antipsychotic for sleep).”  On the other hand, Miller and Zwerdling report that “[a]n increasing number of brain-injury specialists say the best way to treat patients with lasting symptoms is to get them into cognitive rehabilitation therapy as soon as possible. That was the consensus recommendation of 50 civilian and military experts gathered by the Pentagon in 2009 to discuss how to treat soldiers.”

Given the high number of veterans of the wars in Iraq and Afghanistan who are affected, resolving the debate over the diagnosis and treatment of mild traumatic brain injury is a medical research priority of the highest order.  Miller and Zwerdling quote Congressman Bill Pascrell (D-NJ) as follows: “We are not doing service to our bravest.  There needs to be a sense of urgency on this issue.”

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