FROM USA TODAY ARCHIVE: Army task forces finds gaps in brain-injury care
Symptoms blamed on TBI after troops return home likely are due to depression, post-traumatic stress disorder (PTSD) or substance abuse, Hoge and Castro say, and the overemphasis on mild TBI keeps troops with those conditions from being properly treated.
Their article, published Thursday in The New England Journal of Medicine, says the Pentagon and VA are relying on flawed science to identify what the Pentagon estimates may be up 360,000 cases of brain injury suffered by veterans of the wars in Iraq and Afghanistan. Hoge and Castro have conducted some of the military's early and influential research on conditions such as PTSD.
Their arguments have convinced the Army's surgeon general, Gen. Eric Schoomaker, that the screening should be changed, says Schoomaker's spokeswoman, Cynthia Vaughan. But they also drew criticism from government and private brain-injury researchers who disagree with their findings and recommendations, which they say could leave injured troops without proper care.
It's too early to say that most troops recover from mild TBI as Hoge and Castro assert, says John Corrigan, an Ohio State University psychiatrist and researcher who advised the VA on its screening process. Without screening, troops with mild TBI risk may wind up like former professional football players who developed long-term neurological problems after suffering too many concussions, says David Hovda, director of the Brain Injury Research Center at UCLA.
With the advent of body armor and armor-plated vehicles, troops survive roadside bomb blasts in Iraq and Afghanistan, but return home with issues ranging from headaches to problem-solving difficulties. From 2005 forward, a rising chorus of experts, such as the Defense and Veterans Brain Injury Center, urged that troops be screened for brain injuries and if diagnosed, funneled into specialized care.
The Pentagon initially resisted. Last year USA TODAY reported that the delay was the result of fears that veterans would blame vague ailments on the little-understood wound caused by exposure to bomb blasts.
With nearly a $1 billion in funding from Congress for brain-injury treatment and research in 2007-08, the Pentagon began screening all troops returning from war zones last year.
This screening, Hoge and Castro write, causes troops needless worry and may prompt them to wrongly blame symptoms such as headaches on brain injury. Instead, they write, those symptoms may have a simple cause, such as sleep deprivation.
Michael Kilpatrick, a Pentagon health affairs official, said the department identifies and treats TBI based on consensus from the "best scientists … inside and outside the military." Katie Roberts, VA press secretary, says its policy reflects widely accepted scientific standards.
Terry Jones, a spokesman for the Pentagon's health affairs office, says Hoge and Castro's recommendations are being reviewed.
Rep. Bill Pascrell, D-N.J., chairman of the Congressional Brain Injury Task Force, urged caution proceeding with "efforts that might restrict the Department of Defense's ability to identify affected individuals and provide them with the proper care and compensation they deserve. … The evidence is that we have been under diagnosing this problem."
Ibolja Cernak, a brain-injury scientist at Johns Hopkins University Applied Physics Laboratory, dismissed The New England Journal article as offering a "narrow-minded and biased perspective."
At the heart of the debate is how explosions, especially roadside-bomb attacks on U.S. troops in Iraq and Afghanistan, affect the brain. Hoge and Castro say these effects are either devastating brain injuries or mild concussions from which a servicemember recovers quickly.
Hoge and Castro dispute the belief that all brain injury is the same disease with different levels that range from mild to severe. They argue that such injuries are distinct medical conditions.
Others, such as Corrigan, say these conclusions are not supported by the latest research on blast-induced brain injury. Recent findings by the Defense Advanced Research Projects Agency (DARPA), reported by USA TODAY last week, suggest that a blast causes a sliding scale of damage from mild to severe, all part of the same disease. "We now have a good body of evidence to define the continuum of the disease, all the way from none to severe," says Army Col. Geoffrey Ling, a DARPA scientist.
The difficulty comes in identifying whether a soldier has a mild brain injury, since damage is so microscopic that it does not show up on most medical scanning devices. The best practice, Hoge and others agree, is to examine someone soon after they suffer a potential head wound.
Military medical guidelines require that troops exposed to a blast be immediately examined. Army research shows that in most cases — especially in the heat of combat — troops shake off the effects and keep fighting.
Soldiers who suffered more than one mild brain injury in combat were nearly twice as likely to have problems such as dizziness and headaches in the months after coming home, than those who had one brain injury. The findings were released this week in a videoconference to brain experts across the country by Army Col. Heidi Terrio, director of deployment health at Fort Carson, Colo.
"It's not perfect," Corrigan says of the screening process, "but it's very responsible. The alternative is to essentially ignore (the possibility of a lingering mild brain injury)."
Hoge and Castro recommend changing the screening question the Pentagon uses for troops returning from the war. The new format would focus more on identifying and treating symptoms, rather than uncovering potential cases of mild TBI.