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Traumatic Brain Injury (TBI)

Learn more about traumatic brain injury (TBI), which has been called the new signature wound of Iraq and Afghanistan.

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Matt "Bodi" Beaudoin, from the documentary Where Soldiers Come From, suffers from what has been called the new signature wound of Iraq and Afghanistan, traumatic brain injury (TBI), the long-term effects of which can range from headaches, dizziness and vertigo to problems with memory and reasoning.
(Photo credit: Heather Courtney)

Background


What is Traumatic Brain Injury (TBI)?

Traumatic brain injury (TBI) is a blow or jolt to the head or a penetrating head injury that disrupts the function of the brain. It is not currently known how neurological trauma resulting in TBI exactly interferes with the emergence of PTSD, but like PTSD, traumatic brain injury is difficult to recognize, diagnose and treat. While the creation of mine-resistant ambush-protected armored vehicles has saved many lives, TBIs suffered through these blasts have become known as the new silent signature war wounds of the war in Afghanistan. Because these explosions were at one time deadly, it is unclear what the full effects are of surviving the kind of trauma associated with uncovering IEDs.

While severe TBI can leave a person almost incapacitated, even mild TBI (mTBI) — also known as concussion — can lead to symptoms, including headaches, balance problems, hearing problems, lack of self-control, mood changes, ringing in the ears, problems sleeping and memory loss. Recovery can take years.

The Role of Multiple Deployments

Aftermath of an IED attack in Ninawa, Iraq

Aftermath of an IED attack in Ninawa, Iraq
(Photo: Flickr user rodneykeen,
Creative Commons license BY-SA 2.0)

Situations in Afghanistan and Iraq, where troops are likely to face multiple deployments and repeated ambushes by roadside bombs or improvised explosive devices (IEDs), are especially conducive to mild TBI. Out of 2 million troops who have served in Iraq and Afghanistan, more than 800,000 have had multiple deployments, many five or more. According to BrainLine.org (a multimedia project funded by the Defense and Veterans Brain Injury Center), approximately 80 percent of TBI diagnoses in the military are associated with closed head injuries incurred as a result of blasting or other activities not directly combat-related. A 2009 study published by the American Journal of Public Health documents that troops who face multiple deployments are at a 300 percent increased risk of several mental health outcomes.

How Many Troops Are Affected by TBI?

Just how many troops are affected is hard to know. Sections of the government have released numbers ranging from 50,000 (Department of Defense) to 115,000 (the Pentagon), while the Brain Injury Association of America estimates the number at 360,000 and RAND corporation has suggested it could be as high as 400,000.

Contributing to the uncertainty are the facts that TBI is difficult to diagnose, and that some soldiers may be reluctant to be diagnosed. The Pentagon found that 60 percent of the soldiers who suffered from TBI symptoms refused help because they worried unit leaders would treat them differently, or that the condition would prevent them from getting jobs as police officers and firefighters after they got out of the service.

Diagnosing TBI

The military uses two in-the-field methods to discern damage: the Military Acute Concussion Evaluation, or MACE (a brief clinical exam taken immediately after an incident), and the Automated Neuropsychological Assessment Metrics, or ANAM. Many soldiers have learned how to "trick" the first by memorizing the words they're supposed to recite back to the medics, in order to avoid the stigma of being injured or being separated from their platoons; reliability of results from the ANAM is no better than a "coin flip," according to recent Congressional testimony by Lieutenant General Eric Schoomaker, the U.S. Army's top medical official. ANAM is a computer-based tool designed to detect speed and accuracy of attention, memory, and thinking ability.

PET image of the brain

Researchers are using tools such as
positron emission tomography (PET) to
study the consequences of TBI.
(Photo: Robert W. Van Boven and others,
Journal of Rehabilitation Research and Development
46(6) pp.717-756, Department of Veteran Affairs)

Even sophisticated CAT and MRI scans rarely show damage, though a new study at Washington University in St. Louis that used a new scanning technique did show that about one third of American troops who have suffered brain injuries from bomb blasts show immediate evidence of stretched and damaged nerve fibers at both the front and the back of the brain. Brain scans show that for days and even weeks after a traumatic brain injury, the brain's metabolism slows down, leaving some cells starved for energy.

David Hovda, who directs the Brain Injury Research Center at the University of California, Los Angeles says, "During the time when this metabolism is altered, the brain not only is dysfunctional, but it's also extremely vulnerable, so that if it's exposed to another mild injury, which normally you'd be able to tolerate really well, now there can be long-term devastating consequences." Bodi suffered repeated concussions, about 10 in all, before he was kept from going on missions.

Treating TBI

According to NPR, brain injury experts are trying to apply lessons from the football field to the battlefield. Brain injury experts say mandatory rest and evaluation are even more important in combat because of new discoveries about the way energy from an explosion appears to reach the brain and cause damage. When somebody is involved in a blast, he or she experiences impact plus blast, which makes a blast injury different from other impact injuries, such as car accident injuries and sports injuries.

An Army Master Sgt. with moderate TBI receives therapy at the Carl R. Darnall Army Medical Center in Fort Hood, Texas.

An Army Master Sgt. with moderate
TBI receives therapy at the
Carl R. Darnall Army Medical Center
in Fort Hood, Texas.
(Photo: Patricia Deal /
CRDAMC Public Affairs / U.S. Army)

Efforts have increased to stop military personnel from suffering multiple concussions. The Pentagon recently released a new policy for the treatment of TBI, which includes a mandatory 24-hour rest period after a blast and a complete neurological assessment for anyone who's had three or more concussions. The United States Congress has mandated that military and veterans' hospitals screen all service members returning from combat assignments. Yet even when TBI is properly diagnosed, it is difficult to treat properly. Often a soldier does not realize he or she has suffered a concussion — symptoms may first surface months or years later. Those who go untreated may find their symptoms worsening over time, with some patients at risk for depression, substance abuse, severe anxiety, obsessive-compulsive disorders, Alzheimer's and suicide. In 2010, almost as many soldiers committed suicide as died in battle.

Experts polled by NPR unanimously agreed that in cases of lasting or severe damage, cognitive rehabilitation therapy (CRT), which retrains patients for tasks such as counting, cooking and memory, is an effective and helpful treatment. CRT takes time, however, and can cost $15,000 to $50,000 per patient. Many patients are treated only with weekly therapy or with medication. According to the U.S. Department of Defense, the majority of those with moderate to severe brain injuries never completely recover prior functioning.

New Recognition for TBI

Due to a recent change to the military's recognition of TBI, troops who have suffered a traumatic brain injury are now eligible for the Purple Heart, traditionally awarded to those wounded or killed by enemy action.

 

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Traumatic Brain Injury Lesson Plan

Video still from CEMM TBI website video

Part of this lesson involves viewing video from
The Center for Excellence in Medical Multimedia's
Traumatic Brain Injury website

In this POV lesson plan, The Impact of Traumatic Brain Injury on Veterans and Their Families, students will investigate traumatic brain injury (TBI), which has become the signature injury of military service in Iraq and Afghanistan. Students will watch video clips that illustrate issues related to TBI, research additional information and create fact sheets to educate soldiers and their families about TBI and direct them to organizations that can provide support.

Go to POV's lesson plan page: The Impact of Traumatic Brain Injury on Veterans and Their Families »

 

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Traumatic Brain Injury (TBI) Links

American Veterans with Brain Injuries
This group provides a peer chat room and forum for American service members and veterans, as well as for family members and caregivers. Both the forum and chat room are interactive and designed for participants to ask questions, get information and share personal experiences with others.

Brain Injury Association of America (BIAA)
The Brain Injury Association of America was founded in 1980. Its mission is "creating a better future through brain injury prevention, research, education and advocacy." The organization's website offers extensive resources and links to related websites.

BrainLine.org
BrainLine.org is a national multimedia project offering information and resources for preventing, treating and living with TBI. BrainLine.org is a service of WETA, the public television and radio station in Washington, D.C., and is funded by the Defense and Veterans Brain Injury Center through a contract with the Henry M. Jackson Foundation.

Brain Trauma Foundation
The Brain Trauma Foundation is dedicated to improving the outcomes for traumatic brain injury patients worldwide by developing best practices guidelines, conducting clinical research and educating medical professionals and consumers. Its efforts also focus on public education aimed at increasing awareness and understanding of the symptoms of a concussion. The group's goal is to better educate coaches, nurses, athletes, parents and all citizens about the importance of recognizing concussions and taking the appropriate steps to ensure people receive appropriate care.

DVBIC-Charlottesville Rehabilitation Programs
DVBIC-Charlottesville Rehabilitation Programs, in Charlottesville, Virginia, provides a community integrated brain injury rehabilitation program, comprehensive evaluation, outpatient therapy clinic, vocational training and innovative community re-entry services for military and civilians with brain injury. DVBIC-Charlottesville is a national leader in developing treatment modules for community reintegration and evolving use of technology aids. Its experienced rehabilitation team and scientific agenda promote optimal treatment.

DVBIC-Johnstown
DVBIC-Johnstown is the combination of multiple sites in Johnstown, Pennsylvania. These sites include a community re-entry program and an outpatient clinic. DVBIC-Johnstown is committed to improving the lives of military personnel and veterans with traumatic brain injuries by maximizing independence and facilitating re-entry into family and community life. Treatment programs are client-centered and family-centered, transdisciplinary and innovative.

The Journey Home
The Journey Home website, administered by the Center of Excellence for Medical Multimedia, provides an informative and sensitive exploration of TBI, including information for patients, family members and caregivers. Topics include types and symptoms of brain injury, TBI treatment and recovery and helpful insights about the potential long-term effects of brain injury. Animation is used to help patients clearly understand the brain and the results of injuries to different parts of the brain. Survivors and their caregivers share courageous stories about their own experiences, providing down-to-earth facts along with inspiration and hope.

National Association of State Head Injury Administrators (NASHIA)
The National Association of State Head Injury Administrators (NASHIA) is a nonprofit organization created by state government employees administering public programs for individuals with traumatic brain injury and their families. NASHIA assists state governments in promoting partnerships and building systems to meet the needs of individuals with brain injury. NASHIA provides information on state contacts, public programs and resources within states; hosts a website containing materials and information; sponsors an annual national conference; provides training through webcasts and radiocasts; monitors state and federal public policies and legislation; and advocates for public policies and funding to assist states in better meeting the needs of individuals with traumatic brain injury and their families.

National Center for Injury Prevention and Control (NCICP)
National Center for Injury Prevention and Control (NCICP), at the Centers for Disease Control and Prevention, supports data collection and follow-up studies in more than 15 states to track and monitor TBI in the United States, link people with TBI to information about services and find ways to prevent TBI-related disabilities. The center's website offers fact sheets about traumatic brain injury, including information on the problem, consequences, causes, cost, groups at risk, collaborating organizations and references.

National Institute of Neurological Disorders and Stroke
Created in 1950, the National Institute of Neurological Disorders and Stroke aims to reduce the burden of neurological disease — found in every age group, every segment of society and all over the world. The group's TBI information page includes extensive resources and links to related websites.

Swords to Plowshares
War causes wounds and suffering that last beyond the battlefield. Swords to Plowshares' mission is to heal those wounds, restore dignity, hope and self-sufficiency to all veterans in need and significantly reduce homelessness and poverty among veterans.

POV: Where Soldiers Come From: Links & Books
POV's website for the documentary Where Soldiers Come From has an extensive list of resources spanning traumatic brain injury (TBI), health care and other support for veterans.

 

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Recent Research


Those with access to academic journals can analyze recent research findings about traumatic brain injury (TBI), compiled in November 2011.

A clinical primer for physicians, which includes a historical review. The paper describes how World War I British physicians reported cases of "shell shock," which today would be described in terms of TBI.
Burgess, P. Sullivent, E. E., Sasser, S. M., Wald, M. M., Ossmann, E. & Kapil, V. (2010). Managing traumatic brain injury secondary to explosions. Journal of Emergencies, Trauma, and Shock, 3(2), 164-172.

This research associates TBI with a range of psychiatric disorders, including depression and aggressive behavior.
Hesdorffer, D. C., Rauch, S. L. Tamminga, C. A. (2009). Long-term Psychiatric Outcomes Following Traumatic Brain Injury: A Review of the Literature.  J Head Trauma Rehabil, 24(6), 452-459.

This research found that veterans of wars in Iraq and Afghanistan who screen positive for TBI have high rates of PTSD.
Hill, J. J., III, Mobo, B. P. & Cullen, M. R. (2009). Separating Deployment-Related Traumatic Brain Injury and Posttraumatic Stress Disorder in Veterans: Preliminary Findings from the Veterans Affairs Traumatic Brain Injury Screening Program. Am. J. of Physical Medicine & Rehabilitation, 88(8), 605-614.

An analysis of a survey of U.S. Army soldiers who participated in combat in Iraq found that mild TBI (i.e., concussion) is strongly associated with PTSD and physical health problems three to four months after the soldiers return home.
Hoge, C. W., McGurk, D., Thomas, J. L., Cox, A. L., Engel, C. C. & Castro, C. C. (2008). Mild Traumatic Brain Injury in U.S. Soldiers Returning from Iraq. New England Journal of Medicine, 358(5), 453-463.

Researchers used diffusion tensor imaging, a form of MRI, to conclude that mild TBI can involve axonal injury in many regions of the brain.
Mac Donald, C. L., Johnson, A. M., Cooper, D., Nelson, E. C., Werner, N. J., Shimony, J. S., Snyder, A. Z., Raichle, M. E., Witherow, J. R., Fang, R. Flaherty, S. F. & Brody, D. L. (2001). Detection of Blast-Related Traumatic Brain Injury in U.S. Military Personnel. New England Journal of Medicine, 364(22), 2091-2100.

Research indicates that TBI can have negative effects on employment, including the amount of time it takes to return to work as well as the stability of employment.
Machammer, J. Temkin, N., Fraser, R., Doctor, J. N. & Dikmen, S. (2005). Stability of employment after traumatic brain injury. Journal of the International Neuropsychological Society, 11, 807-816.

TBI
Severity

Loss of
consciousness
duration

Posttraumatic
amnesia
duration

Mild

<1 hour

<24 hours

Moderate

1 to 24 hours

24 hours to 7 days

Severe

24 hours+

7 days+

This paper presents a framework for determining the severity of TBI, ranging from "mild" (a brief loss of consciousness) to "severe" (extensive unconsciousness or amnesia after the injury). The severity is measured by a number of factors, including (but not limited to) the duration of unconsciousness and amnesia.
Martin, E. M., Lu, W. C., Helmick, K., French, L. & Warden, D. L. (2008). Traumatic Brain Injuries Sustained in the Afghanistan and Iraq Wars American Journal of Nursing, 108(4), 40-47.

Researchers examine the relationship between TBI and PTSD, shared symptoms and its high co-occurance among soldiers.
Stein, M. B. & McAllister, T. W. (2009). Exploring the Convergence of Posttraumatic Stress Disorder and Mild Traumatic Brain Injury. The American Journal of Psychiatry, 166, 768-776.

Researchers at the RAND Corporation estimated the cost of TBI treatment to be between $148,573 to $222,000 per case over a single year (2005).
Tanielian, T. & Jaycox, L. H. (Eds.). (2008). Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery. Santa Monica, CA: RAND Corporation.

 

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Sources


Links to references used to create this resource page.

» American Psychological Association
» Berglass, Nancy. "America's Duty: The Imperative of a New Approach to Warrior and Veteran Care." Center for a New American Security, November 2010.
» BrainLine.org
» Brown, David. "Study of Troops with Traumatic Brain Injury Hints at Specific Sites of Damage." The Washington Post, June 1, 2011.
» Defense and Veterans Brain Injury Center
» DeGrandpre, Andrew, and Richard Sandza. "Mild Brain Injury Could Soon Rate Purple Heart." Marine Times, March 15, 2011.
» Freeman, David W. "Traumatic Brain Injury Seen in 'Healthy' Soldiers, Thanks to High-Tech Scans." CBS News, June 2, 2011.
» FRONTLINE. "FAQs —Traumatic Brain Injury."
» Hale, Roland. "Review of Purple Heart Award Policy Allows Fort Riley Officer to Receive Purple Heart for TBI." www.army.mil, April 29, 2011
» Hallinan, Conn. "The Traumatic Brain Injury Epidemic." Counterpunch, June 21, 2011.
» Hamilton, Jon. "Football's Brain Injury Lessons Head to Battlefield." NPR, October 12, 2010
» Kiland, Taylor. "What the NFL and the Military Are Teaching Each Other About Mild Concussions." Veterans Examiner, March 17, 2010
» Kim, Paul Y. Paul Y. Kim, Jeffrey L. Thomas, Joshua E. Wilk, Carl A. Castro and Charles W. Hoge. "Stigma, Barriers to Care and Use of Mental Health Services Among Active Duty and National Guard Soldiers After Combat." Clinical Manual of Psychosomatic Medicine. (2010).
» Matson, John. "Legacy of Mental Health Problems from Iraq and Afghanistan Wars Will be Long-lived." Scientific American, June 27, 2011.
» Miller, T. Christian, and Daniel Zwerdling. "With Traumatic Brain Injuries, Soldiers Face Battle for Care." NPR, June 9, 2010.
» Mulhall, Erin with Vanessa Williamson. "Red Tape: Veterans Fight New Battles for Care and Benefits." Iraq and Afghanistan Veterans of America, February 2010.
» RAND Corporation. "One in Five Iraq and Afghanistan Veterans Suffer from PTSD or Major Depression."
» United States Department of Veterans Affairs.
» U.S. Army Medical Department. "Neurocognitive Assessment Branch."
» Veterans Health Initiative. "Traumatic Brain Injury."
» Williamson, Vanessa and Erin Mulhall. "Invisible Wounds: Psychological and Neurological Injuries Confront a New Generation of Veterans." Iraq and Afghanistan Veterans of America, January 2009.





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