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Traumatic Brain Injury (TBI): Signature Wound of the War

Traumatic brain injury is nothing new. Called the "silent epidemic," TBI actually cries out in a chorus of mysterious and unwelcome voices - headaches, memory loss, poor concentration, mood swings, nausea, dizziness. And that's just a mild injury. The worst TBIs can cause radical personality changes, chronic pain, loss of senses, slurred speech, seizures or even paralysis.

Until Phineas Gage had an iron rod pass through his skull in 1848 and managed to survive the ordeal, we knew little about the relationship between brain and behavior. After his injury, the friendly, soft-spoken railroad worker turned rude and crude, barely recognizable to friends. "Gage was no longer Gage," they said. But his case proved that specific regions of the brain are responsible for specific functions and traits, and triggered thousands of discoveries in the field of neurology.

These discoveries can't, and won't, prevent people from conking their heads. About 1.5 million Americans sustain a TBI every year in falls, car accidents and assaults. As recently as the 1960s, 90 percent of these patients died. Computer-assisted imaging techniques such as CT scans and MRIs now offer them phenomenally better odds, helping doctors identify methods of treatment and rehabilitation.
Further advances can't come soon enough. As the signature wound of the Iraq war, traumatic brain injury is getting more attention than ever. TBI is described as the new PTSD - a handy acronym for a condition, usually explosion-related, affecting thousands of combat soldiers.

TBI can be a life-changing monster. Once-healthy young men are suddenly anxious, impulsive, sensitive to noise and light, unable to do simple problem-solving, prone to emotional outbursts. As they battle these demons, their parents and spouses are thrust into the difficult role of caregiver, mourning what sometimes feels like the loss of the person they once knew and loved.

Every war has had its share of TBI. Today, however, the condition has ascended to unprecedented levels of awareness because of blast trauma sustained in Iraq and Afghanistan, where improvised explosive devices and rocket-propelled grenades are the enemies' preferred weapons. And more TBI cases than ever are coming home alive. Due to advances in body armor and helmet technology, improved medic training and quick evac, the injury-to-death ratio is 16-to-1. But the price of surviving an explosion can be high. The pressure wave of an IED blast wreaks havoc with air-filled organs such as the ears, lungs and gastrointestinal tract, along with those surrounded by fluid-filled cavities, like the brain and spine.

Often accompanied by burns, organ damage, and blunt or penetrating injury, this is not the TBI of wars past.

The high number of Iraq and Afghanistan survivors has led to a rewiring of VA medical care at nearly every level. Everyone receiving VA care is now screened for TBI, and those who test positive are offered follow-up evaluations that include injury histories, physical exams targeted to the symptoms, and checklists to assess the presence and severity of symptoms associated with mild TBI. What VA still lacks, according to a recent Government Accountability Office study, is an objective diagnostic test that definitively identifies mild TBI, which shares symptoms with PTSD.

Last July, the President's Commission on Care for America's Returning Wounded Warriors, led by former U.S. Sen. Bob Dole and former Secretary of Health and Human Services Donna Shalala, called for aggressive prevention and treatment of TBI. The report called upon the Department of Defense to arrange a network of public and private-sector expertise in TBI, so that prevention, diagnosis and treatment will "stay current with the changing science base." Specifically, the commission recommended comprehensive training programs in TBI for military leaders, VA and DoD medical personnel, family members and caregivers. Where no TBI clinical practice guidelines exist, DoD and VA should work with other national experts to develop them, the commission recommended.

In testimony before the House and Senate Veterans Affairs committees last fall, American Legion National Commander Marty Conatser drew attention to the obstacles faced by combat TBI veterans and their families, including the absence of VA rehabilitative care in many communities. "They have sacrificed financially, have lost jobs that provided the sole income for the family, and have endured extended separations from children," he said.

That testimony is illustrative of how TBI, the signature wound of today's war, has caught the attention of veterans, the public, Congress, the administration, VA and DoD like never before. The attention is not only fueled by an interest America always takes in wartime sacrifices. Our nation's focus on TBI reaches even deeper than that, into the mysterious engine of human knowledge, toward what we know and don't know about our own brains.

Medical researchers break new ground every day, much of it connected to VA and some of it funded by The American Legion. The field of neurology stands at a threshold of discovery unseen since the days of Phineas Gage

In the accompanying articles, The American Legion Magazine offers just some of what we are learning from the trauma of wartime brain injury, which is advancing a field of study that one scientist describes as "a continuous integration" of discouragements and excitements. For scientists and sufferers alike, it is a journey whose destination remains unknown, and progress is measured in milliseconds, one synapse at a time

– Matt Grills

 

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