The Operation Iraqi Freedom and Operation Enduring Freedom (OIF/OEF) conflicts have resulted in increased numbers of veterans who have experienced Traumatic Brain Injuries (TBI) during their military service. The Veteran’s Brain Injury Center estimates that approximately 22% of all combat casualties from these conflicts are brain injuries, compared to a rate of 12% for Vietnam War veterans. 60-80% of soldiers who have other blast injuries may also have TBI.
Many veterans and medical professionals are of the opinion that the terms mild, moderate, and severe TBI refer to the severity of symptoms associated with the injury. The fact is these terms refer to the nature of the injury itself. Here are the definitions recognized by the U.S. Department of Veterans Affairs (VA):
- Mild traumatic brain injury is defined as a loss or alteration of consciousness < 30 minutes, post-traumatic amnesia < 24 hours, focal neurologic deficits that may or may not be transient, and/or Glasgow Coma Score of 13-15.
- Moderate traumatic brain injuries entail loss of consciousness > 30 minutes, post-traumatic amnesia > 24 hours, and an initial Glasgow Coma Score 9-12.
- Severe brain injuries entail all of the moderate criteria listed above, but with a Glasgow Coma Score < 9.
1. Mild TBI
The vast majority of TBI cases in the civilian population are mild traumatic brain injuries. The primary causes of TBI in the civilian population are falls, car accidents, being struck by an object, and assaults. Immediately following the event, 80-100% of veterans with mild TBI will experience one or more symptoms associated with their injury, such as headaches, dizziness, insomnia, impaired memory and/or a lower tolerance for light and loud noises. In most mild TBI cases the veteran returns to their previous level of functionality within three to six months. However, some 10-15% of veterans may go on to develop chronic post-concussive symptoms. These symptoms have been classified into three categories: Somatic (such as headaches, tinnitus, and insomnia), Cognitive (such as memory and concentration difficulties), and Behavioral/Emotional (such as irritability, depression, anxiety, and a lack of behavioral control). Veterans who have experienced mild TBI are also at an elevated risk for psychiatric disorders compared to their civilian counterparts, including depression and Post-Traumatic Stress Disorder.
The primary causes of TBI in OIF/OEF veterans are blasts, blasts plus motor vehicle accidents, motor vehicle accidents alone, and gunshot wounds. Exposure to blasts is unlike other causes of mild TBI and may produce different symptoms. For example, veterans with TBI seem to experience post-concussive symptoms longer than civilians and some studies conclude that most veterans will still experience residual symptoms 18-24 months following the injury. Added to this, many veterans have multiple medical problems. The combination of Post-Traumatic Stress Disorder, a history of mild TBI, chronic pain, and substance abuse is common and may complicate recovery from any one diagnosis. Given these special considerations, it is especially important to be supportive and reassure the veteran that their symptoms are, with appropriate treatment and healthy habits, likely to improve.
2. Moderate to Severe TBI
Veterans with moderate to severe brain injuries often suffer from focal deficits and sometimes profound brain damage. It should be observed, however, that the severity of the initial injury does not always directly match up with the severity of the brain damage, and that some of these veterans can make extraordinary recoveries. It is likely, though, that these veterans will require regular cognitive and vocational rehabilitation, case management, and prescriptions to return to their normal level of functioning.
The diagnosis of TBI presents unique challenges for medical professionals. Today’s technologies do not allow for completely accurate diagnoses; the standard regularly relied upon remains an interview by a skilled clinician. VA’s screening tool is intended more to start the evaluation process than to arrive at a definitive diagnosis.
Details of the original injury can also prove elusive. Veterans with moderate to severe TBI often, though not always, have a clear link between their symptoms and their injury. Veterans who have experienced mild TBI can be more difficult to diagnose, however. The speed of the event(s) behind the TBI may cause the injury to go unnoticed and the veteran may exhibit symptoms a while after the original injury. By this time, unfortunately, details can be hazy. Another factor is that these injuries can occur in chaotic circumstances, such as combat, and are likely to be ignored in the heat of the moment. VA medical professionals may be left with only vague concerns and few details about the original injury; whenever possible, VA medical professionals and veterans should attempt to obtain supportive documentation. At minimum, medical professionals should elicit as detailed an injury history as possible.
Once the history of the injury has been established in as complete a manner as possible, the veteran’s course of recovery and remaining post-concussive symptoms should be carefully documented. Because of the inherent overlap between post-concussive symptoms and symptoms of many psychiatric and neurologic disorders (such as Post-Traumatic Stress Disorder), this process can be challenging. Medical professionals at VA should be open to consulting any available expertise when making these complex diagnoses.
Veterans with TBI often meet criteria for Post-Traumatic Stress Disorder on screening instruments for TBI and vice versa. Some of these positive screens may represent false positives, but many OIF/OEF veterans have experience a mild traumatic brain injury and will also have Post-Traumatic Stress Disorder stemming from their combat experience.
To manage TBI, VA has initiated the Polytrauma System of Care, which treats veterans with TBI who have also experienced musculoskeletal, neurologic and psychological trauma. Many of the most severely injured Polytrauma veterans are already receiving treatment at one of the four Polytrauma Rehabilitation Centers or one of the 21 Polytrauma Network Sites. Veterans with milder injuries may present themselves for treatment at other locales, including their local Veterans Health Administration facility. Regardless of where a veteran engages in treatment, there is no wrong answer for care and VA is actively working to lower barriers to easy access to treatment.
Trials have demonstrated that early education for the veteran and their family over the course of recovery can significantly improve outcomes in veterans with TBI and help to prevent the development of other psychological issues. It is unfortunate, but for a variety of reasons (including those outlined above) many veterans and their families do not receive education early in the course of the illness and may require intervention after symptoms have become cemented. Currently, VA is making attempts to fix this by issuing recovery messages following the prognosis and involving family members in treatment planning.
Treatments for mild TBI should be symptom-focused. For example, evidence suggests that the treatments that have worked well in veterans with Post-Traumatic Stress Disorder alone (such as cognitive processing therapy) can also work well for veterans who suffer from mild TBI. Memory aids can also be useful in this population. Veterans can also benefit from occupational rehabilitation and case management, depending on the severity of their injuries. Veterans should be referred to consultants, such as neurologists, neuropsychologists, and substance abuse or other specialized treatment options as their situation requires.
Given the complexity of treatment plans for these veterans, careful cooperation and coordination of treatment between all providers is a critical element of effective treatment. VA is exploring ways to enhance this collaboration, particularly in more community-based outpatient clinics and isolated rural environments.
If you or someone you care about has had their PTSD, MST, TBI, anxiety, bipolar disorder, schizophrenia or depression disability claim denied or underrated by VA, call Dr. Bruce toll-free at 1-866-436-2407 or write us using our contact form for a FREE consultation. The Law office of Jonathan Bruce represents clients before the Board of Veterans’ Appeals and the U.S. Court of Appeals for Veterans Claims in Washington, D.C. You should contact Dr. Bruce as soon as possible to ensure you give yourself enough space for a timely appeal. All information will be held in the strictest confidence and all messages will be answered within 24 hours. Dr. Bruce habla con fluidez español.