TBI screens need to get specific, report says - Marine Corps News | News from Afghanistan & Iraq - Marine Corps Times

TBI screens need to get specific, report says

Inexact post-deployment questions about service members’ health are leading to incorrect diagnoses of mild traumatic brain injury, resulting in troops sometimes receiving the wrong medications and inappropriate treatment while other maladies go untreated, two leading Army TBI researchers conclude in a paper published April 16 in the New England Journal of Medicine.

Moreover, the doctors say in “Care of War Veterans with Mild Traumatic Brain Injury — Flawed Perspectives,” mistaken diagnoses carry negative connotations that can convince a service member who does not have mild TBI that he in fact does suffer from a concussion — the term the researchers prefer over “mild TBI” — creating a self-fulfilling prophecy.

In the paper, the authors, who include Col. Charles Hoge, director of the division of psychiatry and neuroscience at Walter Reed Institute of Research, and Col. Carl Castro, director of the military operational medicine research program at Fort Detrick, Md., note that alterations of consciousness in combat also can result from normal responses to injury, acute stress, dissociation, sleep deprivation or the confusion of war.

In an interview, the two doctors acknowledged that some might find their conclusions controversial — especially those who served with one of the advisory groups that have collectively developed policies and practices on how the military defines and diagnoses TBI.

“I think it’s safe to say that people who were on these expert consensus panels are not as happy with the recommendations,” Castro said. “Because there is a lack of good, rigorous, scientific evidence in this area — particularly as it pertains to concussions.”

“It is a problem,” said Allen Brown, a physician who studies the measure of impairment following traumatic brain injury at the Mayo Clinic in Rochester, Minn. “Really, there isn’t a lot of agreement about this. What I mean about ‘concussion’ is very different from what, say, a neurosurgeon would mean, or an internist; ... there’s just not any unifying, agreed-upon medical terminology that is useful.”

Paul Sullivan of the Washington, D.C.-based advocacy group Veterans for Common Sense said he’s pleased that the military continues to study TBI but expressed concerns about too much reliance on better early screening, noting anecdotal reports of troops exposed to roadside bomb blasts who did not develop symptoms of TBI until much later.

Sullivan also warned that the Pentagon and the Department of Veterans Affairs have a history of downplaying serious medical problems, such as Gulf War Syndrome, and called for outside organizations to perform independent studies.

Hoge said their conclusions are not an effort to bring about a reduction, for whatever reason, in the number of mild TBI cases.

“This article should not be interpreted as suggesting that concussion is not an important problem,” he said. “Concussion is an important problem, and we’ve shown, and others have shown, that soldiers who have experienced concussions on the battlefield, where they lost consciousness in particular, are at higher risk for a variety of health concerns when they come home, to include post-traumatic stress disorder and depression and a variety of physical health problems.

“This is all about identifying the best treatment strategies to take care of the range of war-related symptoms, which include symptoms that could be related to concussion,” Hoge said.

Hoge said their conclusions and recommendations attracted “discussion and debate” within the government, as well, and that the potential for controversy prompted the vetting of their findings through the peer-review process prior to publication in the prestigious journal. “So I think that this has scientific merit, and is going to lead to changes,” he said.

TBI diagnosis difficult

TBI is damage caused by sudden trauma, such as proximity to an explosion, according to the National Institutes of Heath. Thousands of U.S. troops in Iraq and Afghanistan have been exposed to blasts, particularly from roadside bombs, a signature weapon of the terrorist insurgency. TBI can result from such exposure, yet can do so without a visible wound, making it difficult to diagnose.

Yet the Pentagon and VA, Hoge and Castro said, have no agreed-upon set of validated diagnostic criteria for mild TBI, which hinders that objective.

That creates problems during standard post-deployment screenings, when returning veterans are asked what the authors called “nonspecific” questions, such as whether they were “dazed” or “confused” at the time of an injury or blast “experience.”

“There’s a lot of reasons for being dazed and confused on the battlefield in that kind of circumstance,” Hoge explained. “Being dazed or confused at the time of any injury is ... a common occurrence. And it’s so non-specific that it’s not a good screening question for traumatic brain injury — especially when it’s applied months or even years after service members come home.”

The question is far more useful when asked at the time of injury, Hoge said.

The authors recommend a new approach that comes up with a solid definition of mild TBI that, as Castro put it, “links the event to immediate reaction, to symptoms, to impairment, to time course, ... and a good screening program would have all of those elements in it.” Plans are in the works for the Defense Health Board to come up with a better definition, Hoge said.

The authors also say the TBI screen should ask more specific questions about all battlefield injuries, particularly those involving loss of consciousness and loss of memory of the event. Those recommendations have been endorsed by the Army surgeon general, Hoge said.

Troops’ responses to current post-deployment heath questions formed the basis of a 2008 Rand Corp. finding that more than 300,000 U.S. service members had suffered traumatic brain injuries during the wars in Iraq and Afghanistan.

But the authors concluded, Hoge said, that it’s “really impossible to say” how many incidents have taken place given the reliance on the imprecise questions being asked. About a third of those 300,000 cases involved a report of lost consciousness, but most of the occurrences were very brief, Hoge said.

In addition, Hoge said, the answers collected during the post-deployment screening process are “leading to many of these service members associating their symptoms with a traumatic brain injury ... when there really isn’t clinical evidence — when we really can’t be sure that that’s the case.”