WASHINGTON — All traumatic brain injuries are not equal. Soldiers who experience blast-induced brain trauma manifest significantly greater emotional upheaval than do soldiers with brain injuries caused by car accidents, judging from preliminary data on soldiers wounded while deployed in Iraq.
In presenting the data at a meeting sponsored by the Institute of Medicine, Louis French, Psy.D., said, “At least one of the things that differentiates blast-induced brain injury from other types of mechanically induced brain injury is how emotionally traumatic the event is for these people. Perhaps blast as a mechanism is a more difficult way to get hurt emotionally.”
Dr. French presented some preliminary data from 144 soldiers who returned from Iraq with traumatic brain injury (TBI) who had completed the neurobehavioral symptom inventory prior to deployment. Most (141) were men, and the average age was 30.5 years. The symptoms included emotional, cognitive, and functional. The soldiers rated the symptoms as to how problematic they were.
A total of 130 patients had suffered closed head injuries, and 108 (75%) were injured from a blast. A total of 62 patients were classified as having mild TBI. In those 62 patients, the most common problems were sleep disturbances (94%–-of which 33% have reported very severe sleep disturbances), forgetfulness (89%), and irritability (81%). The soldiers were treated at Walter Reed Army Medical Center in Washington, where Dr. French is on the staff of the Defense and Veterans Brain Injury Center.
There may be something different about a blast injury that introduces a certain type of symptom, he said.
The people who have been injured from blast were endorsing higher levels of symptom severity than were people who were injured through other ways, he noted.
The three statistically significant symptoms that differentiated the blast injury patients were anxiety, depression, and frustration tolerance, all of which came out of the emotional cluster of symptoms.
Soldiers with TBI are dealing with more than neurologic impairment and emotional symptoms resulting from their TBI. They also are facing problems such as chronic pain, stress, ongoing physical rehabilitation, and dramatic lifestyle changes all brought on by the TBI, Dr. French said in an interview.
During his presentation, Dr. French also offered data to highlight the epidemiology of TBI in military personnel, along with some sample characteristics, symptoms, and tips for how community neurologists might evaluate and treat these patients once they leave intensive care facilities. “While there has been a lot of attention to brain injuries in the military, we need to be cautious about making a diagnosis based on symptoms without knowing the timing of an event,” he said.
For a patient's symptoms to be related to a TBI, he or she needs to experience a traumatic event—such as a car accident or a blast injury—that creates an external force to the head and causes an alteration in brain function, at least a brief feeling of being dazed and confused, or a complete loss of consciousness.
Although some symptoms may manifest much later than the TBI, there will be some symptoms that occur immediately at the time of the TBI, if that is the true cause of the symptoms, Dr. French explained.
Depression is a good example of a symptom experienced by many soldiers that may or may not be related to their TBI. “We know that depression is a fairly common symptom following TBI. However, the depression may be related to the blow to the head itself or to the fact that someone can't work for a while or can't return to fighting,” Dr. French said.
Explosion and blast-related injuries are a significant problem among military returning from the war in Iraq, accounting for 68% of injuries among 433 wounded soldiers treated at Walter Reed between January 2003 and April 2005, Dr. French said. Of these, 89% were closed head injuries; 43% of the patients suffered posttraumatic amnesia of less than 24 hours (J. Neurotrauma 2005;22:1178).
Complications among the TBI patients while they were treated at Walter Reed included skull fractures (25%), subdural hematoma (18.7%), shock (14%), and hypoxia (9.5%). In addition, 91% reported postconcussive symptoms including headache (47%), forgetfulness (46%), irritability (45%), and problems concentrating (41%). Overall, 43% had psychiatric symptoms, 27% of which were depression related.
Dr. French and his colleagues developed a blast injury protocol to evaluate the soldiers with follow-ups at various intervals. The protocol calls for not only basic medical care but also physical therapy and psychotherapy, as well as treatment for cognitive problems and chronic pain.
“It's important to remember [that soliders who have returned from Iraq with blast-induced TBI face] issues of chronic pain, ongoing physical rehab, ongoing stress symptoms, and a change in life roles,” Dr. French said, adding basic medical care, such as treating headaches and sleep problems, can go a long way toward making these patients more comfortable during a lengthy, ongoing recover.