Hidden Wounds

Nearly four years into the war in Iraq and six years into the war in Afghanistan, Americans are discovering that the most telling injuries from these conflicts are not always visible. Medical personnel at the Defense and Veterans Brain Injury Center at Walter Reed Army Medical Center in Washington have found that troops in both battle zones are suffering traumatic brain injuries at a rate double that of previous conflicts. What's more, 88 percent of patients who sustained traumatic brain injuries did not have penetrating head wounds, meaning their injuries were not always apparent to others or even to themselves.

"The point is, [troops] may not appear to have [traumatic brain injury] yet their emotions, their thinking, their very sense of themselves may be different. And there's no external way to see that," says Dr. Deborah Warden, national director of the center. "That's an important issue for society to understand."

Traumatic brain injury, a medical term used to describe any head injury that disrupts brain function, occurs in 28 percent to 31 percent of troops evacuated to Walter Reed after being wounded in combat in Iraq and Afghanistan, Warden says. While data from previous conflicts is not completely comparable, officials generally believe the rate was 14 percent to 20 percent. About half the cases doctors are seeing at Walter Reed are considered mild, Warden says, and most such patients eventually will recover completely. But half are deemed moderate to severe, and medical personnel are grappling with the best ways to treat them.

Patients with traumatic brain injury sometimes also have post-traumatic stress disorder, a psychiatric condition that can result from combat. "They are two different things, but they can co-occur in the same individual. We're working to learn more about that. From the [scientific literature on PTSD] we know people who have any physical injury are more likely to develop PTSD than those who are in some terribly frightening event and do not sustain physical injury. That's one of the things we want to understand," says Warden.

What medical personnel do know from civilian sports studies is that once an individual sustains a brain injury, even a mild one, he or she is at higher risk for a repeat concussion. "That's why it's so important to identify [traumatic brain injury]," says Warden. It's critical that troops who've experienced even mild brain injuries rest long enough to give the brain time to heal and to minimize the chance of subsequent concussion.

The Defense and Veterans Brain Injury Center has worked to create an assessment tool for detecting traumatic brain injury, but post-deployment screening is not yet comprehensive, and troops don't always realize they've suffered an injury. In July, the Army issued an alert to units throughout the Army advising commanders to be aware of such injuries and recommending they seek medical evaluation for soldiers who might have sustained such injuries, even unawares.

"Certainly in a war zone a commander needs to evaluate the situation, and the exigencies of the war zone may dictate they'll be required to perform fully for the next few hours. But where that's not required because of the operational requirements, we want commanders to know that one, their troop is not going to be performing at 100 percent in this immediate post-concussive period, and that two, they will be better able to retain their fighting force if that person can rest," Warden says.

Troops who suffered moderate to severe traumatic brain injury in Iraq and Afghanistan and then received care from VA facilities had similar outcomes to brain-injured civilians treated in the private sector, a July 2006 study by VA's Office of Inspector General found. "Given that our patients have more severe injuries than the average patient, and given that it takes longer for them to begin rehabilitation because of the complexity of their wounds and because of the distance they must travel from the theater of war to begin treatment for those wounds, the fact that our patients do as well as those in the private sector demonstrates that we are doing an outstanding job in supporting their recovery," says Dr. Gerald Cross, acting principal deputy undersecretary for health at the Veterans Affairs Department.

The study, "Health Care Inspection: Health Status of and Services for Operation Enduring Freedom/Operation Iraqi Freedom Veterans After Traumatic Brain Injury Rehabilitation" (05-01818-165), found that most patients reported significant behavior changes and families need more support than they are receiving. Anger was a particular problem, creating family turmoil and interfering with therapy. One wife told interviewers she was fearful of taking her husband out in public because he becomes agitated and uses racial slurs; family and friends have stopped visiting, and they are isolated. Several patients reported feeling alienated and emotionally fragile and said they avoid social contact.

Severely injured troops, including those with brain injuries, typically receive care at one of four multi-disciplinary VA rehabilitation centers nationwide, which are co-located with traumatic brain injury lead centers, facilities that were established in 1992 to improve management of patients under what is now the Defense and Veterans Brain Injury Center. In conducting the study, analysts interviewed 52 troops with moderate to severe traumatic brain injury one year after being discharged from a polytrauma center between March 1 and Sept. 30, 2004. (Seventy-four patients meeting the criteria were discharged from the facilities during this period, but 11 had returned to active duty overseas and could not be reached, six refused to be interviewed, four could not be located and one had died.) Of those interviewed, 33 had been discharged from the military and 19 remained on active duty.

The lead centers all are certified by the Commission on Accreditation of Rehabilitation Facilities and all have been cited for exemplary performance by the organization, according to the inspector general. But the IG also noted that case management at the facilities was inconsistent, ranging from poor to outstanding.

Defense and Veterans Affairs officials have worked to correct problems with how cases are managed between the two agencies, but the difficulties are likely to grow as the caseload expands. In addition, funding for the Defense and Veterans Brain Injury Center is uncertain. The center's budget has grown from $8.7 million in 2004, to more than $13 million last year. But the Bush administration requested only $4.9 million for the center in 2007. Congress in recent years has increased the center's budget over administration requests but has not yet done so for 2007.

A study published last year by Linda Bilmes at Harvard University and Joseph E. Stiglitz at Columbia University estimated that the treatment of brain-injured veterans would cost at least $14 billion over the next 20 years, if U.S. troops are withdrawn from Iraq by 2010.