TBI
on the Rise in the Military
by Sharon
Rolenc
Brain Injury Association of Minnesota
Chances are you have seen
the signs in your own neighborhood – “Support
Our Troops.” This message takes on new meaning as waves of
our soldiers make their journey home. While communities welcome home
their troops, thankful for their safe return, many families will
face the life-long challenge of living with their loved one’s
traumatic brain injury (TBI).
TBI is one of the leading casualties of warfare, due largely to
the inherent high risk involved in military duty. The current Global
War on Terror is the first wartime situation where the cases of TBI
are being looked at carefully.
The Defense and Veterans Brain Injury Center (DVBIC) has been addressing
the issue of brain injury in the military for the past twelve years.
The Center serves active duty military, their dependents and veterans
with TBI.
DVBIC is a collaborative
effort between the Department of Defense (DOD) and the Department
of Veterans’ Affairs (VA) serving
both active duty soldiers and veterans.
The core focus of DVBIC
is to deliver state-of-the-art clinical care, clinical research,
and education and outreach. “With
the war,” Dr. Rose Collins, neurophysiologist for the Minneapolis
VA said, “the clinical care component has taken priority.”
One huge benefit to the
program is the ability to keep patients longer and offering more
extensive rehabilitation opportunities “Whereas
in the private sector,” said Collins, “once the person
is ambulatory, they are often discharged.”
Tackling the Numbers
During peacetime, there are approximately 7,000 annual TBI admissions
to military and veterans hospitals. During war, the military estimates
that approximately 20 percent of the surviving soldiers sustain a
TBI. But the numbers are problematic for several reasons. Due to
combat conditions, the military can not always accurately track the
percentage of deaths that are related to TBI.
The most recent study
of TBI prevalence at Walter Reed Army Medical Center places the
number of TBI cases higher. However, explained Collins “The number has the potential of being misleading.
Of the injured soldiers who are being seen at Walter Reed, 60 to
67 percent of those have also sustained a TBI. It’s really
too early to tell if that number is characteristic of the active
duty military overall,” said Collins.
Regardless of the overall numbers, it is clear that TBI cases in
the military are on the rise.
Better Protection, Higher Rate of TBI
Since past wars, improvements have been made to the body armor and
the Kevlar helmets that soldiers wear during combat, as well as improvements
to emergency medical care, resulting in more lives saved. The Kevlar
helmets in particular have reduced the number and the severity of
penetrating head injuries, the sort of injury that often lead to
fatalities in past wars. Ironically, while these helmets have saved
lives, they have likely increased the number of mild to moderate
brain injuries due to the concussive force of blasts.
“The type of warfare is having an impact. As you move further
into war, the other side is going to figure out where your vulnerabilities
are. The warfare of choice in terms of Iraq and Afghanistan is the
rocket propelled grenade and the Improvised Explosive Devices (IED),” said
Collins. IEDs are packed with dirt, glass, rock, nails, anything
available, and when they explode, the shrapnel can have devastating
effects. “Now we’re seeing patients with single or multiple
amputations, and they may also be blind. So a challenge for a rehabilitation
therapist is developing and adapting our standard TBI rehabilitation
approaches for these individuals with multiple injuries,” said
Collins.
The DVBIC program at the
Minneapolis VA collaborates with the amputee and blind rehab programs.
Collins said that whenever possible, patients are sent to TBI rehab
first, so that therapists can develop a plan of action that will
enable the other rehab programs better understand potential cognitive
deficits that may affect traditional approaches to blind or amputee
therapy. “We are certainly positioned to
respond to the demand and the challenges that are posed by the global
war on terror,” she added.
PTSD and
Mild TBI
The similarities of mild TBI and Post-Traumatic Stress Disorder
(PTSD) present another challenge in identifying cases of TBI that
may have been missed during a tour of duty. There are overlaps in
symptoms including sleep disturbances, irritability, physical restlessness,
difficulty concentrating and some memory disturbances.
While there are similarities,
there are also significant differences in what Collins calls the
profile or “constellation” of
cognitive impairments. “In PTSD, memory disturbances are typically
involved with aspects of the trauma. In TBI, the patient has preserved
older memories, but has difficulty retaining new memories and new
learning. We’ll see more problems with executive functioning,
planning, organization, problem solving, insight and awareness, difficulties
with attention and information processing in TBI.” Coming from
a combat situation, some patients can experience both PTSD and TBI,
making diagnosis and treatment even more challenging. “It’s
critical to have thorough evaluations so that we can treat each appropriately,” Collins
said.
When TBI is Missed
Despite ongoing efforts
to monitor TBI in the military, some cases are still missed due
to the sheer volume of injuries, the limitations of combat medicine,
and limited awareness among military personnel about brain injury
or the DVBIC program. “Typically what happens
in an acute medical situation is that you focus on the obvious. So
there’s focus on the blindness and/or the loss of limb, but
these people may have sustained a mild TBI too,” said Collins.
There are potentially
devastating consequences for soldiers with TBI who return home
without a diagnosis, including difficulties retaining employment,
failing relationships, alcohol and substance abuse and potential
homelessness. Tom Gode, Executive Director for the Brain Injury
Association of Minnesota, explains “Soldiers who are
not diagnosed may ultimately be misdiagnosed at a later date when
their behaviors resemble mental illness, and yet without a brain
injury diagnosis any mental health treatment and recovery strategies
will have limited affect.”
The Wilder Research Center is currently conducting a study examining
the issue of veterans and homelessness in Minnesota. Preliminary
results show that 65 percent of homeless veterans had experienced
a serious blow to the head that resulted in seeing stars or loss
of consciousness. Of the veterans who had sustained a blow to the
head, 46 percent reported problems with headaches, concentration
or memory, understanding, excessive worry, sleeping or getting along
with others - indicating a brain injury.
“With a diagnosis they can begin to understand the changes
in their lives, with connections to services and resources they can
begin to develop the compensatory strategies to assist them to return
to a civilian life better able to cope with their challenges,” said
Gode.
Education and Outreach
Education and outreach are key factors in addressing TBI in the
military, and play an important role in catching cases of mild TBI.
The Veteran’s Health
Initiative just produced a web-based TBI Education program for
primary care providers, to educate them about TBI, and about services
for patients with TBI in the VA system. The program is free for
service providers and CEU credits are available.
The Brain Injury Association
of Minnesota is also poised to offer assistance for Minnesota soldiers
with TBI when they return to their communities. “The Association is prepared to provide soldiers
who have sustained brain injury and/or their families the resources
and support to better cope with the residual effects of the brain
injury. The Association can provide information and resources on
a one time basis or support an individual over two years with Resource
Facilitation,” said Gode. Resource Facilitation offers regular
telephone contact to assist with problem solving, coping strategies
and support.
Further Resources
To request services for active duty military or veterans who were
injured while on active duty, call DVBIC Headquarters at 1-800-870-9244
between 9:00 a.m. and 5:00 p.m. EST. For more information about VA
care, contact Gretchen C. Stephens, DVA National TBI Coordinator
at (804) 675-5597. For more information on the Minneapolis VA TBI
Program contact Stacy Tepper, LCSW, at (612) 467-3235.
Further information about DVBIC can be found at www.dvbic.org.
The Veterans Health Initiative
course on Traumatic Brain Injury is available online at http://www.ees-learning.net/dod to
all VA, DOD and other interested persons. CME and CE credit is available
for physicians, nurses, social workers, psychologists, speech-language
pathologists, and audiologists through June 2005 at no cost. The
program is available in pdf format on the web at http://www1.va.gov/vhi/docs/TBIfinal_www.pdf
Minnesota veterans are
eligible to participate in the Resource Facilitation program. For
more information, a Resource Facilitator may be contacted by calling
612-378-2742, or 1-800-669-6442. Individuals who reside outside
of Minnesota can access resources through their local Brain Injury
Associations. Contact information can be obtained by visiting
http://www.biausa.org/Pages/state_contacts.html
