In My Opinion: Doing More
to Protect the Brain
by Kenneth W. Kizer, ’72, MD, MPH, Former Undersecretary for Health, U.S. Department of Veterans Affairs
On the back cover of a recent issue of Marine, the official magazine of the U.S. Marine Corps, there is a full page advertisement showing four marines in martial arts garb with a caption reading “Minds make the best weapons.”
If the Marines and other armed services believe that a well-functioning brain is the best weapon, why isn’t more being done to protect this critical asset? Why isn’t the military doing at least as much as many high schools and colleges do for their athletes?
Traumatic brain injury (TBI) from roadside bombs and other improvised explosive devices (IEDs) has been labeled the signature injury of the current wars in Iraq and Afghanistan.
According to Department of Defense (DOD) statistics, approximately 7,000 military personnel have suffered TBI in these conflicts, but official figures are widely viewed as underestimating the true incidence of TBI because of the military’s reliance on self-reporting and limited use of neuropsychological testing. Independent sources estimate the occurrence of mild TBI (for example, concussion) to be as high as 20 percent of those deployed to these areas, or more than 300,000 personnel to date. DOD officials have labeled such estimates “plausible.”
Traumatic injury to the brain may be caused in three ways: by penetrating trauma (such as from a bullet or shrapnel), by blunt force to the head (for example, head against windshield in a motor vehicle accident or helmet-to-helmet impact in football), or by pressure waves from bomb blasts (as with IEDs).
Penetrating trauma and blunt trauma are generally easy to detect. However, in bomb blast injuries, the explosive pressure waves move through the tissues and spaces of the head at different speeds due to the tissues’ different densities, damaging brain cells without leaving any outward sign of trauma. Symptoms of the injury are highly variable, nonspecific, and may appear to be psychological. Because mild TBI may display no obvious symptoms, the affected service member, his or her buddies, and field medics may not recognize that TBI has occurred.
The diagnostic challenge is made more difficult because service members are expected to self-report. However, even if the soldier is aware that something doesn’t feel right, like many athletes, he or she may be reluctant to admit that concern because of peer pressure or a desire to stay in the fray to support one’s teammates. Such dedication to duty is often encouraged by both coaches and military superiors.
Although scientific data about the long-term consequences of mild TBI are woefully inadequate, it is now understood that a variety of long-term health problems may result, including depression, dementia, Parkinson’s disease-like symptoms, and other emotional or psychological problems.
Once the brain has been injured, even mildly, it is more vulnerable to subsequent injury in the days or weeks after the first injury. This phenomenon, known as second impact syndrome, is well known in sports, where it has been linked with serious disability and death.
A greater understanding of second impact syndrome and its significance has created an imperative to test athletes after any significant head injury. An aggressive testing program aimed at preventing this problem now exists in many amateur and most professional teams engaged in contact sports. Athletes who show signs of mild TBI are not allowed to return to competition until their brain injury has healed, as demonstrated by both the resolution of symptoms and normalization of the neuropsychological test.
Mild TBI is not only a concern for the affected person. It also exposes the victim’s fellow troops to an increased risk of injury and death, especially in combat situations, because of decreased alertness, slowed reaction times, and other subtle effects of impaired mental function.
When mild TBI is suspected, a reliable neuropsychological screening test should be used to determine whether the person has sustained actual injury. Quick questionnaire survey tools such as those used by the military in Iraq and Afghanistan are often not sensitive enough to detect injury and are vulnerable to gaming.
Validated neuropsychological screening tests for mild TBI, like ImPACT (Immediate Post-Concussion and Cognitive Testing), widely used by sports teams with good result, have been available for some time. They are inexpensive and can be completed in about 15 minutes.
TBI screening tools generate a score that, when compared to population-based normal scores, can provide objective evidence of brain injury that can be tracked over time. The test’s reliability is substantially enhanced if it can be compared to a baseline test from the same person.
Recently, the DOD has decided to use another such test—the Automated Neuropsychological Assessment Metrics (ANAM)—for soldiers being deployed to combat zones. Although a step in the right direction, it is not enough to test just those going to combat.
Given the nature of military duty, there are myriad situations other than combat that put a service member at risk for TBI. It is highly likely that mild TBI occurs much more often among military personnel than generally recognized.
The military’s continued reliance on self-reporting of mild TBI and limited use of appropriate screening tests expose patients to more serious injury, and their comrades to unnecessary risk. The DOD should require every service member to complete a baseline neuropsychological screening test such as the ANAM or Im- PACT upon entry into the service, and whenever brain injury is suspected.
When members of the armed forces are asked to stand in harm’s way in foreign lands, protection of their brains deserves at least the same level of attention that high school and college athletes receive at home.
Kenneth W. Kizer, is chairman of the board at Medsphere Systems Corporation, and was founding president and CEO of the National Quality Forum, a Washington, D.C.-based organization committed to improving American health care through national voluntary consensus standards for measuring and reporting health care quality.