TRAUMATIC BRAIN INJURY

Original Article:  http://www.mayoclinic.com/health/traumatic-brain-injury/DS00552

Definition

Traumatic brain injury occurs when an external mechanical force causes brain dysfunction.

Traumatic brain injury usually results from a violent blow or jolt to the head or body. An object penetrating the skull, such as a bullet or shattered piece of skull, also can cause traumatic brain injury.

Mild traumatic brain injury may cause temporary dysfunction of brain cells. More serious traumatic brain injury can result in bruising, torn tissues, bleeding and other physical damage to the brain that can result in long-term complications or death.

Symptoms

Traumatic brain injury can have wide-ranging physical and psychological effects. Some signs or symptoms may appear immediately after the traumatic event, while others may appear days or weeks later.

Mild traumatic brain injury
The signs and symptoms of mild traumatic brain injury may include:

• Loss of consciousness for a few seconds to a few minutes
• No loss of consciousness, but a state of being dazed, confused or disoriented
• Memory or concentration problems
• Headache
• Dizziness or loss of balance
• Nausea or vomiting
• Sensory problems, such as blurred vision, ringing in the ears or a bad taste in the mouth
• Sensitivity to light or sound
• Mood changes or mood swings
• Feeling depressed or anxious
• Fatigue or drowsiness
• Difficulty sleeping
• Sleeping more than usual

Moderate to severe traumatic brain injuries
Moderate to severe traumatic brain injuries can include any of the signs and symptoms of mild injury, as well as the following symptoms that may appear within the first hours to days after a head injury:

• Loss of consciousness from several minutes to hours
• Profound confusion
• Agitation, combativeness or other unusual behavior
• Slurred speech
• Inability to awaken from sleep
• Weakness or numbness in fingers and toes
• Loss of coordination
• Persistent headache or headache that worsens
• Repeated vomiting or nausea
• Convulsions or seizures
• Dilation of one or both pupils of the eyes
• Clear fluids draining from the nose or ears

Children's symptoms
Infants and young children with brain injuries may lack the communication skills to report headaches, sensory problems, confusion and similar symptoms. In a child with traumatic brain injury, you may observe:

• Change in eating or nursing habits
• Persistent crying and inability to be consoled
• Unusual or easy irritability
• Change in ability to pay attention
• Change in sleep habits
• Sad or depressed mood
• Loss of interest in favorite toys or activities

When to see a doctor
Always see your doctor if you or your child has received a blow to the head or body that concerns you or causes behavioral changes. Seek emergency medical care if there are any signs or symptoms of traumatic brain injury following a recent blow or other traumatic injury to the head.

The terms "mild," "moderate" and "severe" are used to describe the effect of the injury on brain function. A mild injury to the brain is still a serious injury that requires prompt attention and an accurate diagnosis.

Causes

Traumatic brain injury is caused by a blow or other traumatic injury to the head or body. The degree of damage can depend on several factors, including the nature of the event and the force of impact. Injury may include one or more of the following factors:

• Damage to brain cells may be limited to the area directly below the point of impact on the skull.
• A severe blow or jolt can cause multiple points of damage because the brain may move back and forth in the skull.
• A severe rotational or spinning jolt can cause the tearing of cellular structures.
• A blast, as from an explosive device, can cause widespread damage.
• An object penetrating the skull can cause severe, irreparable damage to brain cells, blood vessels and protective tissues around the brain.
• Bleeding in or around the brain, swelling, and blood clots can disrupt the oxygen supply to the brain and cause wider damage.

Common causes
Common events causing traumatic brain injury include the following:

• Falls. Falling out of bed, slipping in the bath, falling down steps, falling from ladders and related falls are the most common cause of traumatic brain injury overall, particularly in older adults and young children.
• Vehicle-related collisions. Collisions involving cars, motorcycles or bicycles — and pedestrians involved in such accidents — are a common cause of traumatic brain injury.
• Violence. About 10 percent of traumatic brain injuries are caused by violence, such as gunshot wounds, domestic violence or child abuse. Shaken baby syndrome is traumatic brain injury caused by the violent shaking of an infant that damages brain cells.
• Sports injuries. Traumatic brain injuries may be caused by injuries from a number of sports, including soccer, boxing, football, baseball, lacrosse, skateboarding, hockey, and other high-impact or extreme sports.
• Explosive blasts and other combat injuries. Explosive blasts are a common cause of traumatic brain injury in active-duty military personnel. Although the mechanism of damage isn't well understood, many researchers believe that the pressure wave passing through the brain significantly disrupts brain function. Traumatic brain injury also results from penetrating wounds, severe blows to the head with shrapnel or debris, and falls or bodily collisions with objects following a blast.

Risk factors

The people most at risk of traumatic brain injury include:

• Children, especially newborns to 4-year-olds
• Young adults, especially those between ages 15 and 24
• Adults age 75 and older

Complications

Several complications can occur immediately or soon after a traumatic brain injury. Severe injuries increase the risk of a greater number of complications and more-severe complications.

Altered consciousness
Moderate to severe traumatic brain injury can result in prolonged or permanent changes in a person's state of consciousness, awareness or responsiveness. Different states of consciousness include:

• Coma. A person in a coma is unconscious, unaware of anything and unable to respond to any stimulus. This results from widespread damage to all parts of the brain. After a few days to a few weeks, a person may emerge from a coma or enter a vegetative state.
• Vegetative state. Widespread damage to the brain can result in a vegetative state. Although the person is unaware of his or her surroundings, he or she may open his or her eyes, make sounds, respond to reflexes, or move. It's possible that a vegetative state can become permanent, but often individuals progress to a minimally conscious state.
• Minimally conscious state. A minimally conscious state is a condition of severely altered consciousness but with some evidence of self-awareness or awareness of one's environment. It is often a transitional state from a coma or vegetative condition to greater recovery.
• Locked-in syndrome. A person in a locked-in state is aware of his or her surroundings and awake, but he or she isn't able to speak or move. The person may be able to communicate with eye movement or blinking. This state results from damage limited to the lower brain and brainstem. This rarely occurs after trauma.

Seizures
Some people with traumatic brain injury will have seizures within the first week. Some serious injuries may result in recurring seizures, called post-traumatic epilepsy.

Fluid buildup
Cerebrospinal fluid may build up in the spaces in the brain (cerebral ventricles) of some people who have had traumatic brain injuries, causing swelling and increased pressure in the brain.

Infections
Skull fractures or penetrating wounds can tear the layers of protective tissues (meninges) that surround the brain. This can enable bacteria to enter the brain and cause infections. An infection of the meninges (meningitis) could spread to the rest of the nervous system if not treated.

Blood vessel damage
Several small or large blood vessels in the brain may be damaged in a traumatic brain injury. This damage could lead to a stroke, blood clots or other problems.

Nerve damage
Injuries to the base of the skull can damage nerves that emerge directly from the brain (cranial nerves). Cranial nerve damage may result in:

• Paralysis of facial muscles
• Damage to the nerves responsible for eye movements, which can cause double vision
• Damage to the nerves that provide sense of smell
• Loss of vision
• Loss of facial sensation
• Swallowing problems

Cognitive problems
Most people who have had a significant brain injury will experience changes in their thinking (cognitive) skills. Traumatic brain injury can result in problems with many skills, including:

• Memory
• Learning
• Reasoning
• Problem solving
• Speed of mental processing
• Judgment
• Attention or concentration
• Multitasking
• Organization
• Decision making
• Beginning or completing tasks

Communication problems
Language and communications problems are common following traumatic brain injuries. These problems can cause frustration, conflict and misunderstanding for people with a traumatic brain injury, as well as family members, friends and care providers. Communication problems may include:

• Difficulty understanding speech or writing
• Difficulty speaking or writing
• Difficulty deciphering nonverbal signals
• Inability to organize thoughts and ideas
• Inability to use the muscles needed to form words (dysarthria)
• Problems with changes in tone, pitch or emphasis to express emotions, attitudes or subtle differences in meaning
• Trouble starting or stopping conversations
• Trouble with turn taking or topic selection
• Trouble reading cues from listeners
• Trouble following conversations

Behavioral changes
People who've experienced brain injury often experience changes in behaviors. These may include:

• Difficulty with self-control
• Lack of awareness of abilities
• Risky behavior
• Inaccurate self-image
• Difficulty in social situations
• Verbal or physical outbursts

Emotional changes
Emotional changes may include:

• Depression
• Anxiety
• Mood swings
• Irritability
• Lack of empathy for others
• Anger
• Insomnia
• Changes in self-esteem

Sensory problems
Problems involving senses may include:

• Persistent ringing in the ears
• Difficulty recognizing objects
• Impaired hand-eye coordination
• Blind spots or double vision
• A bitter taste or a bad smell
• Skin tingling, pain or itching
• Trouble with balance or dizziness

Degenerative brain diseases
A traumatic brain injury may increase the risk of diseases that result in the gradual degeneration of brain cells and gradual loss of brain functions. These include:

• Alzheimer's disease, which primarily causes the progressive loss of memory and other thinking skills
• Parkinson's disease, a progressive condition that causes movement problems, such as tremors, rigidity and slow movements
• Dementia pugilistica — most often associated with repetitive blows to the head in career boxing — which causes symptoms of dementia and movement problems

Tests and diagnosis

Because traumatic brain injuries are usually emergencies and because consequences can worsen swiftly without treatment, doctors usually need to assess the situation rapidly.

Glasgow Coma Scale
This 15-point test helps a doctor or other emergency medical personnel assess the initial severity of a brain injury by checking a person's ability to follow directions and move their eyes and limbs. The coherence of speech also provides important clues. Abilities are scored numerically. Higher scores mean milder injuries.

Information about the injury and symptoms
If you observed someone being injured or arrived immediately after an injury, you may be able to provide medical personnel with information that's useful in assessing the injured person's condition. Answers to the following questions may be beneficial in judging the severity of injury:

• How did the injury occur?
• Did the person lose consciousness?
• How long was the person unconscious?
• Did you observe any other changes in alertness, speaking, coordination or other signs of injury?
• Where was the head or other parts of the body struck?
• Can you provide any information about the force of the injury? For example, what hit the person's head, how far did he or she fall, or was the person thrown from a vehicle?
• Was the person's body whipped around or severely jarred?

Imaging tests

• Computerized tomography (CT). A CT scan uses a series of X-rays to create a detailed view of the brain. A CT scan can quickly visualize fractures and uncover evidence of bleeding in the brain (hemorrhage), blood clots (hematomas), bruised brain tissue (contusions) and brain tissue swelling.
• Magnetic resonance imaging (MRI). An MRI uses powerful radio waves and magnets to create a detailed view of the brain. Doctors don't often use MRIs during emergency assessments of traumatic brain injuries because the procedure takes too long. This test may be used after the person's condition has been stabilized.

Intracranial pressure monitor
Tissue swelling from a traumatic brain injury can increase pressure inside the skull and cause additional damage to the brain. Doctors may insert a probe through the skull to monitor this pressure.

Treatments and drugs

Mild injury
Mild traumatic brain injuries usually require no treatment other than rest and over-the-counter pain relievers to treat a headache. However, a person with a mild traumatic brain injury usually needs to be monitored closely at home for any persistent, worsening or new symptoms. He or she also may have follow-up doctor appointments.

The doctor will indicate when a return to work, school or recreational activities is appropriate. It's best to avoid physical or thinking (cognitive) activities until symptoms have stopped. Most people return to normal routines gradually.

Immediate emergency care
Emergency care for moderate to severe traumatic brain injuries focuses on making sure the person has an adequate oxygen and blood supply, maintaining blood pressure, and preventing any further injury to the head or neck. People with severe injuries may also have other injuries that need to be addressed.

Additional treatments in the emergency room or intensive care unit of a hospital will focus on minimizing secondary damage due to inflammation, bleeding or reduced oxygen supply to the brain.

Medications
Medications to limit secondary damage to the brain immediately after an injury may include:

• Diuretics. These drugs reduce the amount of fluid in tissues and increase urine output. Diuretics, given intravenously to people with traumatic brain injury, help reduce pressure inside the brain.
• Anti-seizure drugs. People who've had a moderate to severe traumatic brain injury are at risk of having seizures during the first week after their injury. An anti-seizure drug may be given during the first week to avoid any additional brain damage that might be caused by a seizure. Additional anti-seizure treatments are used only if seizures occur.
• Coma-inducing drugs. Doctors sometimes use drugs to put people into temporary comas because a comatose brain needs less oxygen to function. This is especially helpful if blood vessels, compressed by increased pressure in the brain, are unable to deliver the usual amount of nutrients and oxygen to brain cells.

Surgery
Emergency surgery may be needed to minimize additional damage to brain tissues. Surgery may be used to address the following problems:

• Removing clotted blood (hematomas). Bleeding outside or within the brain can result in a collection of clotted blood (hematoma) that puts pressure on the brain and damages brain tissue.
• Repairing skull fractures. Surgery may be needed to repair severe skull fractures or to remove pieces of skull in the brain.
• Opening a window in the skull. Surgery may be used to relieve pressure inside the skull by draining accumulated cerebral spinal fluid or creating a window in the skull that provides more room for swollen tissues.

Rehabilitation
Most people who have had a significant brain injury will require rehabilitation. They may need to relearn basic skills, such as walking or talking. The goal is to improve their abilities to perform daily activities.

Therapy usually begins in the hospital and continues at an inpatient rehabilitation unit, a residential treatment facility or through outpatient services. The type and duration of rehabilitation varies by individual, depending on the severity of the brain injury and what part of the brain was injured. Rehabilitation specialists may include:

• Physiatrist, a doctor trained in physical medicine and rehabilitation, who oversees the entire rehabilitation process
• Occupational therapist who helps the person learn, relearn or improve skills to perform everyday activities
• Physical therapist, who helps with mobility and relearning movement patterns, balance and walking
• Speech and language pathologist, who helps the person improve communication skills and use assistive communication devices if necessary
• Neuropsychologist or psychiatrist, who helps the person manage behaviors or learn coping strategies, provides talk therapy as needed for emotional and psychological well-being, and prescribes medication as needed
• Social worker or case manager, who facilitates access to service agencies, assists with care decisions and planning, and facilitates communication among various professionals, care providers and family members
• Rehabilitation nurse, who provides ongoing rehabilitation care and services and who helps with discharge planning from the hospital or rehabilitation facility
• Traumatic brain injury nurse specialist, who helps coordinate care and educates the family about the injury and recovery process
• Recreational therapist, who assists with leisure activities
• Vocational counselor, who assesses the ability to return to work and appropriate vocational opportunities, and provides resources for addressing common challenges in the workplace

Prevention

Follow these tips to reduce the risk of brain injury:

• Seat belts and airbags. Always wear a seat belt in a motor vehicle. Small children should always sit in the back seat of a car and be secured in child safety seats or booster seats that are appropriate for their size and weight.
• Alcohol and drug use. Don't drive under the influence of alcohol or drugs, including prescription medications that can impair the ability to drive.
• Helmets. Wear a helmet while riding a bicycle, skateboard, motorcycle, snowmobile or all-terrain vehicle. Also wear appropriate head protection when playing baseball or contact sports, skiing, skating, snowboarding or riding a horse.

Preventing falls
The following tips can help older adults avoid falls around the house:

• Install handrails in bathrooms
• Put a nonslip mat in the bathtub or shower
• Remove area rugs
• Install handrails on both sides of staircases
• Improve lighting in the home
• Keep stairs and floors clear of clutter
• Get regular vision checkups
• Get regular exercise

Preventing head injuries in children
The following tips can help children avoid head injuries:

• Install safety gates at the top of stairs
• Keep stairs clear of clutter
• Install window guards to prevent falls
• Put a nonslip mat in the bathtub or shower
• Use playgrounds that have shock-absorbing materials on the ground
• Make sure area rugs are secure
• Don't let children play on fire escapes or balconies

Coping and support

A number of strategies can help a person with traumatic brain injury cope with complications that affect everyday activities, communication and interpersonal relationships. Depending on the severity of injury, a family caregiver or friend may need to help implement the following approaches:

• Join a support group. Talk to your doctor or rehabilitation therapist about a support group that can help you talk about issues related to your injury, learn new coping strategies and get emotional support.
• Write things down. Keep a record of important events, people's names, tasks or other things that are difficult to remember.
• Follow a routine. Keep a consistent schedule, keep things in designated places to avoid confusion and take the same routes when going to frequently visited destinations.
• Take breaks. Make arrangements at work or school to take breaks as needed.
• Alter work expectations or tasks. Appropriate changes at work or school may include having instructions read to you, allowing more time to complete tasks or breaking down tasks into smaller steps.
• Avoid distractions. Minimize distractions such as loud background noise from a television or radio.
• Stay focused. Work on one task at a time.

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Traumatic Brain Injuries have been called the 'signature wounds' of the wars in Iraq and Afghanistan.

Brain Injuries Remain Undiagnosed in Thousands of Soldiers

by T. Christian Miller, ProPublica, and Daniel Zwerdling, NPR June 7, 2010, 10 p.m. 

WASHINGTON, D.C.--The military medical system is failing to diagnose brain injuries in troops who served in Iraq and Afghanistan, many of whom receive little or no treatment for lingering health problems, an investigation by ProPublica and NPR has found.

So-called mild traumatic brain injury has been called one of the wars' signature wounds. Shock waves from roadside bombs can ripple through soldiers' brains, causing damage that sometimes leaves no visible scars but may cause lasting mental and physical harm.

Officially, military figures say about 115,000 troops have suffered mild traumatic brain injuries since the wars began. But top Army officials acknowledged in interviews that those statistics likely understate the true toll. Tens of thousands of troops with such wounds have gone uncounted, according to unpublished military research obtained by ProPublica and NPR.

"When someone's missing a limb, you can see that," said Sgt. William Fraas, a Bronze Star recipient who survived several roadside blasts in Iraq. He can no longer drive, or remember simple lists of jobs to do around the house. "When someone has a brain injury, you can't see it, but it's still serious."

In 2007, under enormous public pressure, military leaders pledged to fix problems in diagnosing and treating brain injuries. Yet despite the hundreds of millions of dollars pumped into the effort since then, critical parts of this promise remain unfulfilled.

Over four months, we examined government records, previously undisclosed studies, and private correspondence between senior medical officials. We conducted interviews with scores of soldiers, experts and military leaders.

Among our findings:

• From the battlefield to the home front, the military's doctors and screening systems routinely miss brain trauma in soldiers. One of its tests fails to catch as many as 40 percent of concussions, a recent unpublished study concluded. A second exam, on which the Pentagon has spent millions, yields results that top medical officials call about as reliable as a coin flip.
• Even when military doctors diagnose head injuries, that information often doesn't make it into soldiers' permanent medical files. Handheld medical devices designed to transmit data have failed in the austere terrain of the war zones. Paper records from Iraq and Afghanistan have been lost, burned or abandoned in warehouses, officials say, when no one knew where to ship them.
• Without diagnosis and official documentation, soldiers with head wounds have had to battle for appropriate treatment. Some received psychotropic drugs instead of rehabilitative therapy that could help retrain their brains. Others say they have received no treatment at all, or have been branded as malingerers.

In the civilian world, there is growing consensus about the danger of ignoring head trauma: Athletes and car accident victims are routinely tested for brain injuries and are restricted from activities that could result in further blows to the head.

But the military continues to overlook similarly wounded soldiers, a reflection of ambivalence about these wounds at the highest levels, our reporting shows. Some senior Army medical officers remain skeptical that mild traumatic brain injuries are responsible for soldiers' troubles with memory, concentration and mental focus.

Civilian research shows that an estimated 5 percent to 15 percent of people with mild traumatic brain injury have persistent difficulty with such cognitive problems.

"It's obvious that we are significantly underestimating and underreporting the true burden of traumatic brain injury," said Maj. Remington Nevin, an Army epidemiologist who served in Afghanistan and has worked to improve documentation of TBIs and other brain injuries. "This is an issue which is causing real harm. And the senior levels of leadership that should be responsible for this issue either don't care, can't understand the problem due to lack of experience, or are so disengaged that they haven't fixed it."

When Lt. Gen. Eric Schoomaker, the Army's most senior medical officer, learned that NPR and ProPublica were asking questions about the military's handling of traumatic brain injuries, he initially instructed local medical commanders not to speak to us.

"We have some obvious vulnerabilities here as we have worked to better understand the nature of our soldiers' injuries and to manage them in a standardized fashion," he wrote in an e-mail sent to bases [1] across the country. "I do not want any more interviews at a local level."

When confronted with the findings later, however, he acknowledged shortcomings in the military's diagnosing and documenting of head traumas.

"We still have a big problem and I readily admit it," said Schoomaker, the Army's surgeon general. "That is a black hole of information that we need to have closed."

Brig. Gen. Loree Sutton, who oversees brain injury issues for the Pentagon, said the military had made great strides in improving attitudes towards the detection and treatment of traumatic brain injury.

The military is considering implementing a new policy to mandate the temporary removal from the battlefield of soldiers exposed to nearby blasts. Later this year, the Pentagon expects to open a cutting-edge center for brain and psychological injuries, which will treat about 500 soldiers annually.

"This journey of cultural transformation, it is a journey not for the faint of heart," Sutton said. "At the end of our journeys, at the end of our travels, what we must ensure is, we must ensure that we have consistent standards of excellence across the board. Are we there yet? Of course we're not there yet."

Soldiers like Michelle Dyarman wonder what's taking so long. Dyarman, a former major in the Army reserves, was involved in two roadside bomb attacks and a Humvee accident in Iraq in 2005.

Today, the former dean's list student struggles to read a newspaper article. She has pounding headaches. She has trouble remembering the address of the farmhouse where she grew up in the hills of central Pennsylvania.

For years, Dyarman fought with Army doctors who did not believe that she was suffering lasting effects from the blows to her head. Instead, they diagnosed her with an array of maladies from a headache syndrome to a mood disorder.

"One of the first things you learn as a soldier is that you never leave a man behind," said Dyarman, 45. "I was left behind."

In 2008, after Dyarman retired from the Army, Veterans Affairs doctors linked her cognitive problems to her head traumas.

Dyarman has returned to her civilian job inspecting radiological devices for the state, but colleagues say she turns in reports with lots of blanks; they cover for her.

Dyarman's 67-year-old father, John, looks after her at home, balancing her checkbook, reminding her to turn the oven on before cooking. The joyful, bright child he raised, the first in the family to attend college, is gone, forever gone.

"It hurts me, too," he said, growing upset as he spoke. "That's my daughter sitting there, all screwed up. She's not the kid she was."

Walkie Talkies

Better armor and battlefield medicine mean troops survive explosions that would have killed an earlier generation. But blast waves from roadside bombs, insurgents' most common weapon, can still damage the brain [2].

The shock waves can pass through helmets, skulls and through the brain, damaging its cells and circuits in ways that are still not fully understood. Secondary trauma can follow, such as sending a soldier tumbling inside a vehicle or hurling into a wall, shaking the brain against the skull.

Not all brain injuries are alike. Doctors classify them as moderate or severe if patients are knocked unconscious for more than 30 minutes. The signs of trauma are obvious in these cases and medical scanning devices, like MRIs, can detect internal damage.

[2]But the most common head injuries in Iraq and Afghanistan are so-called mild traumatic brain injuries. These are harder to detect. Scanning devices available on the battlefield typically don't show any damage. Recent studies suggest that breakdowns occur at the cellular level, with cell walls deteriorating and impeding normal chemical reactions.

Doctors debate how best to categorize and describe such injuries. Some say the term mild traumatic brain injury best describes what happens to the brain. Others prefer to use concussion, insisting the word carries less stigma than brain injury.

Whatever the description, most soldiers recover fully within weeks, military studies show. Headaches fade, mental fogs clear and they are back on the battlefield.

For a minority, however, mental and physical problems can persist for months or years. Nobody is sure how many soldiers who suffer mild traumatic brain injury will have long-term repercussions. Researchers call the 5 percent to 15 percent of civilians who endure persistent symptoms the "miserable minority."

A study published last year in the Journal of Head Trauma Rehabilitation found that, of the 900 soldiers in one battle-hardened Army brigade who suffered brain injuries, most of them mild, almost 40 percent reported having at least one symptom weeks or months later.

The long-term effects of mild traumatic brain injuries can be devastating, belying their name. Soldiers can endure a range of symptoms, from headaches, dizziness and vertigo to problems with memory and reasoning. Soldiers in the field may react more slowly. Once they go home, some commanders who led units across battlefields can no longer drive a car down the street. They can't understand a paragraph they have just read, or comprehend their children's homework. Fundamentally, they tell spouses and loved ones, they no longer think straight.

Such soldiers are sometimes called "walkie talkies" -- unlike comrades with missing limbs or severe head wounds, they can walk and talk. But the cognitive impairments they face can be severe.

"These are people who go on to live" with "a lifelong chronic disability," said Keith Cicerone, a leading researcher in the field. "It is going to be terrifically disruptive to their functioning."

An increasing number of brain-injury specialists say the best way to treat patients with lasting symptoms is to get them into cognitive rehabilitation therapy as soon as possible. That was the consensus recommendation of 50 civilian and military experts gathered by the Pentagon in 2009 to discuss how to treat soldiers.

Such therapy can retrain the brain to compensate for deficits in memory, decision-making and multitasking.

A soldier whose injuries are not diagnosed or documented misses out on the chance to get this level of care -- and the hope for recovery it offers, say veterans advocates, soldiers and their families.

"Talk is cheap. It is easy to say we honor our servicemen," said Cicerone, who has helped the military develop recommendations for appropriate treatments for soldiers with brain injuries. "I don't think the services that we are giving to those servicemen honors those servicemen."

Missing Records

The military's handling of traumatic brain injuries has drawn heated criticism before.

ABC News reporter Bob Woodruff chronicled the difficulties soldiers faced [3] in getting treatment for head traumas after recovering from one himself, suffered in a 2006 roadside bombing in Iraq. The following year, a Washington Post series [4] about substandard conditions at Walter Reed Army Medical Hospital described the plight of several soldiers with brain injuries.

Members of Congress responded by dedicating more than $1.7 billion to research and treatment of traumatic brain injury and post-traumatic stress, a psychological disorder common among soldiers returning from war. They passed a law requiring the military to test soldiers' cognitive functions before and after deployment so brain injuries wouldn't go undetected.

But leaders' zeal to improve care quickly encountered a host of obstacles. There was no agreement within the military on how to diagnose concussions, or even a standardized way to code such incidents on soldiers' medical records.

Good intentions banged up against the military's gung ho culture. To remain with comrades, soldiers often shake off blasts and ignore symptoms. Commanders sometimes ignore them, too, under pressure to keep soldiers in the field. Medics, overwhelmed with treating life-threatening injuries, may lack the time or training to recognize a concussion.

The NPR and ProPublica investigation, however, indicates that the military did little to overcome those battlefield hurdles. They waited for soldiers to seek medical attention, rather than actively seeking to evaluate those in blasts.

The military also has repeatedly bungled efforts to improve documentation of brain injuries, the investigation found.

Several senior medical officers said soldiers' paper records were often lost or destroyed, especially early in the wars. Some were archived in storage containers, then abandoned as medical units rotated out of the war zones.

Lt. Col. Mike Russell, the Army's senior neuropsychologist, said fellow medical officers told him stories of burning soldiers' records rather than leaving them in Iraq where anyone might find them.

"The reality is that for the first several years in Iraq everything was burned. If you were trying to dispose of something, you took it out and you put it in a burn pan and you burned it," said Russell, who served two tours in Iraq. "That's how things were done."

To improve recordkeeping, medics began using pricey handheld devices to track injuries electronically. But they often broke or were unable to connect with the military's stateside databases because of a lack of adequate Internet bandwidth, said Nevin, the Army epidemiologist.

"These systems simply were not designed for war the way we fight it," he said.

In 2007, Nevin began to warn higher-ups that information was being lost. His concerns were ignored, he said. While communications have improved in Iraq, Afghanistan remains a concern.

That same year, clinicians interviewed soldiers about whether they had suffered concussions for an unpublished Army analysis, which was reviewed by NPR and ProPublica. They found that the military files showed no record of concussions in more than 75 percent of soldiers who reported such injuries to the clinicians.

Nevin said that without documentation of wounds, soldiers could have trouble obtaining treatment, even when they report they can't think, or read, or comprehend instructions normally anymore.

Doctors might say, "there's no evidence you were in a blast," Nevin said. "I don't see it in your medical records. So stop complaining."

Problems documenting brain injuries continue.

Russell said that during a tour of Iraq last year, he examined five soldiers the day after they were injured in a January 2009 rocket attack. The medical staff had noted shrapnel injuries, but Russell said they failed to diagnose the soldiers' concussions.

The symptoms were "classic," Russell said. The soldiers had "dazed" expressions, and were slow to respond to questions.

"I found out several of them had significant gaps in their memory," Russell said. "It wasn't clear how long they were unconscious for, but the last thing they remember is they were playing video games. The next thing they remember, they are outside the trailer."

Another doctor told NPR and ProPublica of finding soldiers with undocumented mild traumatic brain injuries in Afghanistan as recently as February 2010.

"It's still happening, there's no doubt," said the military doctor, who did not want to be named for fear of retribution

Screened Out

After the Walter Reed scandal, the military instituted a series of screens to better identify service members with brain injuries. Soldiers take an exam before deploying to a war zone, another after a possible concussion in theater, and a third after returning home.

But each of these screens has proved to have critical flaws.

The military uses an exam called the Automated Neuropsychological Assessment Metrics [5], or ANAM, to establish a baseline for soldiers' cognitive abilities. The ANAM is composed of 29 separate tests that measure reaction times and reasoning capabilities. But the military, looking to streamline the process, decided to use only six of those tests.

Doubts immediately arose about the exam, which had never been scientifically validated. Schoomaker, the Army surgeon general, recently told Congress that the ANAM was "fraught with problems" and that "as a screening tool," it was "basically a coin flip."

Military clinicians have administered the exam to more than 580,000 soldiers, costing the military millions of dollars per year, but have accessed the results for diagnostic purposes only about 1,500 times.

Rep. Bill Pascrell Jr., D-N.J., who has led efforts to improve the treatment and study of brain injuries, accused the military of ignoring the Congressional directive.

"We are not doing service to our bravest," Pascrell said. "There needs to be a sense of urgency on this issue. We are not doing justice."

Once in theater, soldiers are supposed to take the Military Acute Concussion Evaluation [6], or MACE, to check for cognitive problems after blasts or other blows to the head.

But in interviews, soldiers said they frequently gamed the test, memorizing answers beforehand or getting tips from the medics who administer it.

Just last summer, Sgt. Victor Medina was leading a convoy in southern Iraq when a roadside bomb exploded. He was knocked unconscious for 20 minutes.

Afterwards, Medina had trouble following what other soldiers were saying. He began slurring his words. But he said the medic helped him to pass his MACE test, repeating questions until he answered them correctly.

"I wanted to be back with my soldiers," he said. "I didn't argue about it.".

Senior military officials said problems with the MACE were common knowledge.

"There's considerable evidence that people were being coached or just practicing," said Russell, the senior neuropsychologist. "They don't want to be sidelined for a concussion. They don't want to be taken out of play."

If cases of brain trauma get past the battlefield screen, a third test -- the post-deployment health assessment [7], or PDHA -- is supposed to catch them when soldiers return home.

But a recent study, as yet unpublished, shows this safety net may be failing, too.

When soldiers at Fort Carson, Colo., were given a more thorough exam bolstered by clinical interviews, researchers found that as many as 40 percent of them had mild traumatic brain injuries that the PDHA had missed.

In a 2007 e-mail, a senior military official bluntly acknowledged the shortcomings of PDHA exams, describing them as "coarse, high-level screening tools that are often applied in a suboptimal assembly line manner with little privacy" and "huge time constraints."

Col. Heidi Terrio, who carried out the Fort Carson study, said the military's screens must be improved.

"It's our belief that we need to document everyone who sustained a concussion," she said. "It's for the benefit of the Army and the benefit of the family and the soldier to get treatment right away."

Gen. Peter Chiarelli, the Army's second in command, acknowledged that the military has not made the progress it promised in diagnosing brain injuries.

"I have frustration about where we are on this particular problem," Chiarelli said.

Fundamentally, he said, soldiers, military officers and the public needed to take concussions seriously.

"We've got to change the culture of the Army. We've got to change the culture of society," he said, adding later, "We don't want to recognize things we can't see."

Skeptics

The shift Chiarelli envisions may be impossible without buy-in from senior military medical officials, some of whom are skeptical about the long-term harm caused by mild traumatic brain injuries.

One of Schoomaker's chief scientific advisors, retired Army psychiatrist Charles Hoge, has been openly critical of those who are predisposed to attribute symptoms like memory loss and concentration problems to mild traumatic brain injury.

In 2009, he wrote a opinion piece in the New England Journal of Medicine that said the "illusory demands of mild TBI" might wind up hobbling the military with high costs for unnecessary treatment. Recently, Hoge questioned the importance of even identifying mild traumatic brain injury accurately.

"What's the harm in missing the diagnosis of mTBI?" he wrote to a colleague in an April 2010 e-mail obtained by NPR and ProPublica [8]. He said doctors could treat patients' symptoms regardless of their underlying cause.

In an interview, Hoge said, "I've been concerned about the potential for misdiagnosis, that symptoms are being attributed to mild traumatic brain injury when in fact they're caused by other" conditions. He noted that a study he conducted, published in the New England Journal of Medicine, "found that PTSD really was the driver of symptoms. That doesn't mean that mTBI isn't important. It is important. It's very important."

Other experts called Hoge's posture toward mild TBI troubling.

To be sure, brain injuries and PTSD sometimes share common symptoms and co-exist in soldiers, brought on by the same terrifying events. But treatments for the conditions differ, they said. A typical PTSD program, for instance, doesn't provide cognitive rehabilitation therapy or treat balance issues. Sleep medication given to someone with nightmares associated with PTSD might leave a brain-injured patient overly sedated, without having a therapeutic effect.

"I'm always concerned about people trivializing and minimizing concussion," said James Kelly, a leading researcher who now heads a cutting-edge Pentagon treatment center for traumatic brain injury. "You still have to get the diagnosis right. It does matter. If we lump everything together, we're going to miss the opportunity to treat people properly."

***

At her family farm outside Hanover, Pa., Michelle Dyarman has a large box overflowing with medical charts, letters and manila envelopes. They are the record of her fight over the past five years to get diagnosis and treatment for her traumatic brain injury.

After her last roadside blast in Baghdad, which killed two colleagues, Dyarman wound up at Walter Reed for treatment of post-traumatic stress.

Over the course of two and a half years, she received drugs for depression and nightmares. She got physical therapy for injuries to her back and neck. A rehabilitation specialist gave her a computer program to help improve her memory.

But it wasn't until she began talking with fellow patients that she heard the term mild traumatic brain injury. As she began to research her symptoms, she asked a neurologist whether the blasts might have damaged her brain.

Records show the neurologist dismissed the notion that Dyarman's "minor head concussions" were the source of her troubles, and said her symptoms were "likely substantially attributable" to PTSD and migraine headaches.

"It was disappointing," she said. "It felt like nobody cared."

When she was later given a diagnosis of traumatic brain injury by Veterans Affairs doctors, she said she felt vindicated, yet cheated all at once.

"I always put the military first, even before my family and friends. Now looking back, I wonder if I did the right thing," she said. "I served my country. Now what's my country doing for me?"

http://www.propublica.org/article/brain-injuries-remain-undiagnosed-in-thousands-of-soldiers

Beyond the Invisible

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