Medicine

A Blow to the Head: No Impact, No Idea

Written by J Rawls

The media and public have grown accustomed to seeing news concerning veterans with Post Traumatic Stress (PTS). Yet little information is given about the often sidekick and sometimes reason – Traumatic Brain Injury (TBI). If the reader is not familiar with the term, think along the lines of a concussion. Troops have worn helmets for years to protect their head (and brain), but some injuries can slip through the cracks, especially ones from years ago; when records/policy was not so tight on the subject. So once they leave the military, who takes care of them then?

Everyone should be familiar with what a concussion is: some form of injury to the head by force. There are three different stages and several scales to rate the severity of this injury, which are also used for TBI, as they are the same thing. Concussions are the first stage of TBI; known as a Mild TBI. Some of the major immediate concerns are length of the subject being out (unconscious), penetration, internal swelling, and cognition upon waking (if knocked out). Luckily, most research shows that recovery can be short-term. Most, but not all.

Now, what if we thought of a military deployment like a season of college football? Well, research shows that white matter changes during just a single season trial with helmet impacts of varying degrees. In the article Persistent, Long-term Cerebral White Matter Changes after Sports-Related Repetitive Head Impacts by Bazarian, et al. in the April 2014 issue of PLoS ONE, Vol. 9 Issue 4, pages 1-12, we see that the data can be recorded and show results.

Compare the ages. Studies show evidence of white matter changes in athletes in college. This same age group, 18 to 21, is the driving force for the military. According to Statistic Brain Research Institute’s (2015) Demographics of Active Duty U.S. Military, 18 to 21 year-old’s make up 36.9 percent of the U.S. Marine Corps. The number in this age group is smaller for other branches but the next age group, 22-30, is the highest percentage group in each branch; this age group makes up 46 percent of the Marine Corps. The brain can reset pathways – basically repair itself to a certain degree – up to the age of 23. Some research even shows individuals capable of healing after a stroke, such as in Neuroscientist Investigates How the Brain Repairs Itself after a Stroke, by Michael Sutphin, published by Eureka Alert, March 2014, which is very promising. But what does that say for those over the age of 23?

Troops don’t hit with helmets, you say? Probably not in the normal sense, but kinetic force does play into the equation – IED’s, mortars, rockets, and so on. A good example to reference is “Spall Liner”. Inside many combat vehicles today, especially MRAP’s, the walls are lined with spall liner. What is it for? When a projectile hits armor, some are not made just to penetrate, but to also impact. The Spalling Effect comes from the internal armor peeling or splintering away as the impact hits the outside armor, creating shrapnel. The kinetic force is at play here, traveling in waves of energy. Whatever touches the armor, receives the energy. Though the force dissipates further from the impact site, if the impact can spall the armor, what can it do to the individuals inside? Primarily, what can it do to their brains?

Many military vehicles now come with seats that utilize suspension or shock absorbers (seen here). Step away from the vehicle and look at terrain/open combat. What if it isn’t a vehicle impact? What if the kinetic force comes from a mortar at close range? No visible signs of shrapnel in the targets, yet impacted none the less. Articles on the damage and similarities of direct impact and concussive force have been published as recent as 2014. In IOM Addresses Ongoing Effects of Blast Injury on Soldiers by Mike Mitka, published by The Journal of the American Medical Association March 2014, Vol 311, No. 11, it states, “Soldiers exposed to explosions during war are at increased risk of long-term adverse health outcomes, and better research is needed to understand how such blasts affect health and to learn how to treat veterans with blast exposure, conclude the authors of an Institute of Medicine (IOM) report.”

This reporting is not new but seems to be brushed aside. An article, Bombs’ hidden impact: The brain war, by Sharon Weinberger in Nature 477, pages 390 to 393 in Sept. 2011, shows that the facts have been around for a few years now. The article shows that research is trying to catch up, providing the Department of Defense continues programs. So while this is a good step, let’s ask the first question yet again… What about once troops leave active service? Who watches them then?

That furthers the question; what about the long-term? According to the Alzheimer’s Association, research has shown a connection between Moderate/Severe TBI to fostering a greater risk of producing Alzheimer’s disease or dementia, even years following the initial injury. What about Mild TBI? This is the gray area for some. Troops that fell through the cracks in the early years of the current war or past wars, pushing through and not being evaluated, by standards, should show no issues. What if they do? Many things can influence the initial injury: PTS, stress, depression, drug and alcohol abuse and so on. It doesn’t make it easy to identify. If the individual had a TBI and is diagnosed with PTS, where do you start when they come in years later? The individual may not even know what is going on with them.

Degradation in cognition over a prolonged time frame requires further research in connection to kinetic force variables, especially in multiple impact cases. The Department of Veterans Affairs will need to pick up where the Department of Defense leaves off. Unfortunately, this is not a simple hand receipt. Luckily, the VA is doing continued research in this field. There are multiple areas the VA currently looks at, stated on their site under Traumatic Brain Injury (TBI), Office of Research and Development. Stating:

“Mild TBI, also known as concussion, is usually more difficult to identify than severe TBI, because there may be no observable head injury—it may have occurred at the same time as other visible injuries or wounds—and because some of the symptoms are similar to symptoms from other problems that also follow combat trauma, such as PTSD.

While most people with mild TBI have symptoms that resolve themselves within hours, days, or weeks, a minority may experience persistent symptoms that last for several months or longer.”

They conduct studies at various locations, also stating, “….the VA Boston Healthcare System, conducts studies to understand the complex changes in the brain, thinking, and psychological well-being that result from TBI and posttraumatic stress disorder (PTSD). These studies will lead to more understanding and better treatment options for returning Veterans with TBI and PTSD.”

Now the real question: Will any of this research information actually get to the medical personnel seeing the individuals with trauma; concerning long-term evaluations and care? If current policy and standards persist, shown in how the VA has conducted itself for decades, then no. The answer is no. No impact, no idea.


References

Bazarian, J. J., Zhu, T., Zhong, J., Janigro, D., Rozen, E., Roberts, A., & … Blackman, E. G. (2014). Persistent, Long-term Cerebral White Matter Changes after Sports-Related Repetitive Head Impacts. Plos ONE, 9(4), 1-12. doi:10.1371/journal.pone.0094734

Demographics of Active Duty U.S. Military. Statistic Brain Research Institute, publishing as Statistic Brain, Web. (2014)

Mitka M. IOM Addresses Ongoing Effects of Blast Injury on Soldiers. JAMA. (2014);311(11):1098-1099. doi:10.1001/jama.2014.1993.

Sutphin M. Neuroscientist Investigates How the Brain Repairs Itself After a Stroke. Via Virginia Tech. Eureka Alert. The American Association for the Advancement of Science. (2014)

Traumatic Brain Injury. Alz.org. Alzheimer’s Association. Web. 2015

Traumatic Brain Injury (TBI). U.S. Department of Veterans Affairs. Office of Research and Development.

Weinberger S. Bombs’ hidden impact: The brain war. Nature. (2011)- 477: 390-393. doi:10.1038/477390a

About the author

J Rawls

Jeremy Rawls is a former active duty Marine with two combat tours in Iraq. He was part of the invasion in 2003 and later returned for the take down of Fallujah. After leaving the Corps, he worked as a contractor for the Department of Defense and the Department of Homeland Security with two contracts in Afghanistan. He is currently a freelance writer.

  • Peggy Tomko

    I’m currently surveying the scientific literature about how TBI relates to central auditory processing deficits so I can better understand the significant difficulties our Vets have hearing/understanding speech when their hearing sensitivity is within normal limits. I’ll be talking to Veteran college students next month at a veterans services fair.

    • @peggy_tomko:disqus
      I can vouch for that idea. My mid-range hearing is greatly affected due to hearing damage as well as tinnitus on both sides. For me, I can hear people talk normally when they are talking to me AND when they are talking at a slightly elevated level, but if they face away from me, it all sounds like a charlie brown phone conversation… There exists the possibility that having suffered an mTBI in the past could have aided in making the issue worse, or at least have been a contributing factor, because my actual auditory hearing exams say I’m fine – despite knowing for a fact that my hearing is damaged in some way. I seriously look forward to reading your survey results. 🙂