Traumatic Brain Injury
-By Timothy Lyons
On September 11th 2001, I was driving my car north on the 5 Freeway in Southern California. That morning on my way to an appointment, I noticed something was wrong. On the busiest freeway in the world there was no traffic. I looked around and asked my co-worker to call someone to find out what was going on. When he called his wife I will never forget the loud noise he made when he looked at me in shock and said that the world trade center was gone.
So many people remember what happened that day. Yet, there are those that do not. There are countless men and women who are no longer with us after nearly sixteen years of war against this enemy. Then there are those brave souls that are still with us but no longer have the capacity to remember. Traumatic Brain Injury (Traumatic Brain Injury) is also an unseen enemy. It has robbed so many of our valiant men and women soldiers of everything from moments of consciousness and brain damage to far more severe consequences such as, the inability to speak, neurological deficits, seizures, headaches, PTSD and Depression and the ability to remember events like the attacks on the World Trade Center. (Menon, Schwab, Wright, & Maas, 2010) (Guilmette & Paglia, 2004). At times the men and women who suffer from Traumatic Brain Injury can seem outwardly normal while suffering on the inside.
According to the Congressional Research Service (Fischer, 2015) between 2000 and 2015 in the theatres of Operation Freedom’s Sentinel, Operation Inherent Resolve, Operation New Dawn, Operation Iraqi Freedom, and Operation Enduring Freedom there have been more than 6855 deaths of our troops both off and on the battlefield. There are those veterans who live on as the legacy of these conflicts and who suffer from the lasting effects of Traumatic Brain Injury. These men and women are a major concern when it comes to treatment and rehabilitation for our troops. As of the first quarter of 2015 there have been more than 327,299 recorded incidents of Traumatic Brain Injury. The Department of Defense categorizes Traumatic Brain Injury cases as mild, moderate, severe, or penetrating. The vast majority (more than 90%) of Traumatic Brain Injury cases sustained on and off the battlefield are considered mild Traumatic Brain Injury or mTBI.
A special article form the journal Physical Medicine and Rehabilitation (Menon, Scwab, Wright, & Maas, 2010) gives a concise definition of Traumatic Brain Injury as …”an alteration in brain function, or other evidence of brain pathology, caused by an external force. “This definition is just the beginning. The article goes on to show just how varied the symptoms are that can eventually accompany this form of trauma. One of the hurdles encountered with Traumatic Brain Injury is a lack of understanding the injury and a perpetuation of myths about these injuries even among persons who are well educated. This is cited as problematic even at the level of health care in the very areas where most veterans are treated, the VA. (Guilmette & Paglia, 2004) Although through these studies we can see a negative correlation between the rise of education and knowledge attainment, the fact that myths about Traumatic Brain Injury still exist is troubling. With injuries so complex that they can cause a plethora of cognitive deficits, it is more important than ever to have staff educated in the areas surrounding the myths about Traumatic Brain Injury in order to provide access to proper care for our service members who struggle.
In the case of mild Traumatic Brain Injury the myths engender stereotypes and doubts about actual physical problems. In a fact sheet produced by the US Dept. of Veterans Affairs Quality Enhancement Research Initiative (QUERI, 2014) these post injury consequences are considered “invisible”. The etymology of Traumatic Brain Injury from blasts are commonly produced from artillery and mortar shells, mines, improvised explosive devices, bombs and booby traps among other devices. They are considered Polytrauma because they have an effect on multiple levels within the human body. Because of advancements in protection to the body and a high level of immediate acute trauma care on the battlefield there are more service men and women survivors moving past the acute and post-acute phases of injuries. These survivors suffer from multiple injuries one of which is the most prevalent, Traumatic Brain Injury. This has happened so much so that it is often referred to as the signature injury of this era. (QUERI, 2014)
In the case of invisible wounds and with the mindset that sufferers of mild Traumatic Brain Injury seem more functional, a case can be made that it is more important than ever to screen Traumatic Brain Injury cases at the outset and recognize the possible problems that a service member injured in this way may encounter. QUERI (2014) shows the prevalence rates of testing for Traumatic Brain Injury related injuries is high and about 1 in 5 of those tested have a positive screen for Traumatic Brain Injury. Once a veteran is screened positive for Traumatic Brain Injury they are referred for comprehensive Traumatic Brain Injury evaluation. It is interesting to note that this injury and its subsequent diagnosis show a rise in cost that is nearly doubled for those veterans injured who do not test positive. Many of the veterans were not knowledgeable about Traumatic Brain Injury but educational handouts were shown to increase awareness and understanding of Traumatic Brain Injury although did not change recovery outcomes. Those who tested positive were highly symptomatic. Although Women were shown to test positive less than men, their symptoms were higher when compared with the males. It is believed that mental health issues that may occur as a result of the Traumatic Brain Injury were a contributing factor in the exhibition of symptoms. Upon analysis of the data produced by the evaluations, researchers began grouping symptoms in the dimensions of cognitive (thinking), Affective (emotions) somatosensory (touch or tactile perception) and vestibular (balance and space). Although these groupings may not be meaningful they are being studied. (QUERI, 2014)
In two studies and one Wikipedia article (Van Reekum, Cohen, & Wong, 2000) (Hook et al., 2015) (Cathepsin B, 2016) we can see the idea of what happens when the injury occurs, what some of the correlated psychiatric problems are that are aftereffects of the Traumatic Brain Injury and a theoretical medical treatment involving medication that might be useful in helping to ameliorate the damage that is done by the initial blow that causes the concussion. There are studies that are geared toward proving a hypothesis of causality between Traumatic Brain Injury and psychiatric disorders. (Hook, Jacobsen, Grabstein, Kindy, & Hook, 2015) The belief is that establishing this relationship to show sequelae of Traumatic Brain Injury is important to our understanding and hopefully in treating the comorbid occurrences of psychiatric issues that follow this type of injury.
First we will look at some of the psychiatric and physiological problems that occur at a much higher rate in Traumatic Brain Injury patients. These are problems that are examined in a meta-analysis that are theoretically positively correlated with Traumatic Brain Injury. In (Van Reekum, Cohen, & Wong, 2000) the following psychiatric problems have shown to be higher in populations that have received Traumatic Brain Injuries.
Major Depression was shown to be greater in those persons who had suffered Traumatic Brain Injury. It was thought that although there may be a component of the depression that is linked with the psychological aspects of the injury it was more closely associated with lesions on the brain or actual physical damage. There is a caution that there is not enough known about this to show causality but that the numbers are higher and any theorizing about cause is cautioned.
Bipolar Affective Disorder is another psychiatric problem that follows from Traumatic Brain Injury at a greater rate than normal. It is also important to note that in one study that 50% of the Traumatic Brain Injuries resulted in seizures. Although this is a physiological phenomenon it is a statistically significant number and is of note in the study. It was posited that there was a relationship with brain lesions from the Traumatic Brain Injury and mania. The occurrence of Bipolar Affective Disorder was much greater in male population sufferers of Traumatic Brain Injury.
Anxiety disorder was a third psychiatric condition that was seen as being evident in greater numbers after injury. Van Reekum, Cohen, and Wong (2000, p. 324) states that “There is compelling evidence of causation for major depression, bipolar affective disorder, and the anxiety disorders after Traumatic Brain Injury.”
Posttraumatic Stress Disorder (PTSD) was positively correlated to memories of the incident. The incident was far higher in women who had been injured rather than men but could not be conclusively linked with the actual incident. It was nevertheless a byproduct of the injury event. This PTSD was as a result of terrible memories and horror of the accidents that caused the Traumatic Brain Injury. Some of the subjects developed the avoidance and arousal criteria of PTSD.
In the journal article (Mosconi, Pupa, & De Leon, 2008) it appears that from both Mild and moderate Traumatic Brain Injury, scans showed lesions in several areas of the brain when patients were given MRI’s. These lesions were shown to involve the frontal and temporal regions of the brain. PET scans of Traumatic Brain Injuries showed a decrease in glucose in areas of the brain post-injury in (Van Reekum et al., 2000). In the earlier mentioned study of Alzheimer’s patients in (Mosconi et al., 2008) it was shown that whole brain glucose hypometabolism or a lack of glucose is associated with early stage or early onset Alzheimer’s patients. There may also be a correlation between Traumatic Brain Injury and Alzheimer’s. In (Silvanandam & Thakur, 2012) it supports that fact that Traumatic Brain Injury causes the brain to swell, there is damage to the brain due to lack of oxygen, the function of the blood brain barrier is interrupted which increases inflammation of the brain, causes major stress and the damage leads to cognitive impairment. Studies done on persons who die and who have Traumatic Brain Injuries show the same plaques that appear in Alzheimer’s patients. Thus, Traumatic Brain Injury damage is a risk factor for Alzheimer’s.
As I mentioned earlier there are some types of treatments that may yield some positive results in helping to lessen the effects of Traumatic Brain Injury. Although there is no drug treatment for Traumatic Brain Injury, one of the many medicines that is currently being tested on animals is a type of protease inhibitor. (Hook, Jacobsen, Grabstein, Kindy, & Hook, 2015) You may have heard of this term in regards to treatment for HIV. One of the manners in which the brain is damaged during a Traumatic Brain Injury is with the release of a protein enzyme from the Protease family. It is called Cathepsin B. It is thought to be released from its place inside a cell that most likely breaks open when it is damaged. During the initial stages of the damage there is an upsurge in this enzyme in the brain. This enzyme, when released, has the power to destroy other cells within the brain through reduced oxygen, necrosis and natural cell destruction normally regulated by the body. The purpose of the protease inhibitor would then be to stop the Cathepsin B from doing damage. There have been trials in mice that have proven effective. When Traumatic Brain Injury was induced in these animals and an inhibitor known as E64d is introduced into the bloodstream of the animal it has demonstrated a clear reduction in not only the deficits caused by Traumatic Brain Injury but has also has been shown to assist with “related injuries including ischemia, cerebral bleeding, cerebral aneurysm, edema, pain, infection, rheumatoid arthritis, epilepsy, Huntington’s disease, multiple sclerosis, and Alzheimer’s “ (Hook, Jacobsen, Grabstein, Kindy, & Hook, 2015, p. 178) The promising area with the use of this drug is that it has been used orally and has been effective. It has also had safe use in humans. It is one of the drugs that needs more testing to be used in this manner but is an excellent candidate. Perhaps this would be a good treatment once it is finally determined safe.
There are so many medications that are in use today for Traumatic Brain Injury. To date those that have shown to be promising in reduction of damage have not yet been approved for use in humans and may still be in the trial stage. Many of the other medicines that are in use are primarily for the treatment of the symptoms that are seen after the Traumatic Brain Injury. These include medications indicated for the treatment of anxiety, depression, aggression, PTSD, cognition problems, mania and headaches. This list is not exhaustive and the number of post-acute injury treatments is beyond the scope of this article but you can find valuable information on this subject by doing an internet search for Traumatic Brain Injury medications.
Let’s look at just what happens from the injury on out. From the article (Wilson, 2014) we can see that the military has spent countless money and hours working out strategies to advance medical access to the battlefield wounded. For decades the US has had a network of trauma centers to deal with the immediacy of Traumatic Brain Injury but did not have the ability to deliver the wounded into the system quickly. One main change that the military used is to place medical staff and neurosurgeons as feasibly close as possible to the battle in order to facilitate ease of access. The surgeons can now contact the wounded in a very effective manner.
The Walter Reed Medical Center (Walter Reed Bethesda National Medical Military Center – Wounded Warrior Care Center,) and (Traumatic Brain Injury – Walter Reed National Military Medical Center,) elaborates this process. On the forefront of Medical assistance is the Walter Reed Medical Center in Bethesda Maryland. This leading service provider of Traumatic Brain Injury medical care is one of the world’s leaders in Traumatic Brain Injury treatment. They have incorporated both the Defense and Veterans Brain Injury Center (DVBIC) and the Wounded Warrior Care Center into a comprehensive and multi-disciplinary team of individuals.
The injured military service member is flown by Med Vac to Joint Base Andrews and the Critical Care Air Transport Team (CCATT) gives critical care and provides for stabilization of the wounded soldier. The training that is given to these fine care providers was unthinkable just a few decades ago. It has advanced to the point where our wounded immediate health care is unsurpassed in the world. They are brought into a health care system that is integrated and has an environment that helps both inpatients and outpatients with a holistic approach combining physical, psychological and spiritual care. The medical center is at the forefront with cutting edge technology, top notch referral services and the use of evidenced based practices.
This has aided in saving the lives of countless soldiers. Soldiers with Traumatic Brain Injury can now be dealt with immediately. This reduces cognitive impairment, gives higher survival rates and aids in neurological treatment immediacy. Once the service member who has been injured is placed into the system the VA has designed a system of treatment that involves the care and treatment of the whole person. The service member’s injury is categorized as one of three severities and as they become recovered they are downgraded and moved into the next level through a case management liaison. (Wilson, 2014)
From (Olson-Madden, Brenner, Matarazzo, & Signoracci, 2013) it is clear that there are physical, cognitive and psychological impairments as a result of Traumatic Brain Injury. The Department of Veteran’s Affairs has several internet based toolkits that give substantial information about casework referral and treatment of Traumatic Brain Injury. It is prepared for the treatment providers to bring them up to the educational level that is needed for treatment and to promote evidence based and best case practices. From the website (Veterans Administration, n.d.) there is a vast amount of data, therapeutic tools and resources that can be assimilated by community mental health centers and behavioral health organizations. These are the places that would need guidance and support in obtaining the specialized knowledge to help the Traumatic Brain Injury sufferer.
There are many services through Walter Reed that address the deficits that are induced by Traumatic Brain Injury. The occupational therapy services has a specific division that is just for Traumatic Brain Injury sufferers. They have a Traumatic Brain Injury clinic, provide speech and physical therapy, utilize case management services and have some of the best research and education services for Traumatic Brain Injury. The DVBIC consults with, evaluates for, and assesses adults with Traumatic Brain Injury. They use this knowledge for clinicians in their treatment and for further advancement and research. This division of Walter Reed receives world-wide referrals in their care and services their patients with a multidisciplinary rehabilitation team. DVBIC works with other VA hospitals as well as civilian medical services. They utilize the most up to date medicines for the wellness and recovery of the troops that deserve only the best.
Traumatic Brain Injury is the signature problem facing our military today. Because of the great efforts of the highly skilled medical staff that the military has obtained and maintains, the injuries that would have killed out troops just a couple decades ago are now being circumvented. The problem with that survival is that it comes at the cost of the hidden enemy Traumatic Brain Injury. Even the first time that one of our soldiers get Traumatic Brain Injury at even a mild severity, the possibility for physiological and psychological problems increase. The many different problems and needs of Traumatic Brain Injury sufferers are elaborated in (Lehr, 2016). There have been problems with movement, coordination, hearing, sight, eating and drinking, even sleep. The number of problems outweighs the number of solutions which are limited by time and money.
In an article from (Brain Injury Association of America, 2009), the BIAI has worked to get funding at the military level for Traumatic Brain Injury. They argue that it will help troops and civilians both. In 2014 the Congress acted to pass the Traumatic Brain Injury Reauthorization act s.2539 which paves the way for continued funding. The act will be funded through 2019 and helps with prevention and registry of Traumatic Brain Injury. The bill was designed with an eye toward looking for opportunities in research as well. The Traumatic Brain Injury Act funds programs for individuals with brain injury and agencies like the Centers for Disease Control, the National Institute for Health and the Health Resources Administration. This does not fix all of the problems that the system has, but it shows us that congress, private organizations and grass roots campaigning will not forget that the Traumatic Brain Injury needs for our service men and women who risked their lives to make our world better will continue to be addressed.
The brave men and women of our nation deserve to be treated for the injuries that they sustain. If this takes a lifetime and they never recover, this country should do everything in it’s’ power to help these people. The needs are many. The people are many. This great nation can continue to be a leader in this field. We will benefit all of the world by ensuring that military service members who have been injured in the field of battle will not be forgotten. That they will not be left behind. And that we as a country care for our soldiers.
References
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