A reason for optimism in diagnosing, treating TBI
By SETH ROBBINS | STARS AND STRIPES Published: August 13, 2010
LANDSTUHL, Germany — Late one night at Joint Base Balad, Iraq, Sgt. 1st Class Eric Espinoza was watching TV when he noticed a spot describing the symptoms of mild traumatic brain injuries: dizziness, headaches, forgetfulness.
Espinoza, who had been in several explosions downrange dating to 2005, recognized them immediately.
“It was like being in church when you have not been doing right, and it feels like the preacher is talking to you,” he said, “It was like the TV was talking directly to me.”
Espinoza sought treatment at the base clinic, and last month, doctors at Landstuhl Regional Medical Center in Germany confirmed what the soldier first recognized — that he was suffering a mild traumatic brain injury, or mild TBI.
Espinoza’s self-diagnosis highlights how difficult it is for the military to catch this complicated and subtle injury. Since no clear test exists, doctors must rely on servicemembers to report symptoms, or on cognitive screening exams that are not always reliable.
But scientists and physicians are looking for a better way, examining how blasts affect the brain and the unique damage they cause. This new research could lead to definitive tests that could be used downrange in the next three years, said Ibolja Cernak, a scientist who has studied the effect of blasts on the body for more than a decade.
“I’m optimistic,” she said, “if we all put our efforts together in a synchronized way, we could do it very fast.”
Blasts and the brain
Experts say blasts produce a unique type of brain damage, one that differs from the damage caused by a typical blow to the head.
“It’s a much higher complexity of injury,” Cernak said.
Studies using new brain-imaging technology have shown that blasts produce a more diffuse pattern of damage, and that brain cells stay inflamed longer after a blast-related concussion than a normal one.
Blasts involve “many more energized events” than a typical blow to the head said Dr. (Col.) Jamie Grimes, the national director for the Defense and Veterans Brain Injury Center.
“With blasts,” she said, “it’s more a rotational force than a backward-and-forwards motion.”
A variation of MRI that tracks water molecules in the brain has shown that blasts produce a “more intense” pattern of damage to the neural connections between cells, said Dr. David Moore, a neurologist and National Scientific Advisor with the brain injury center. Moore and his colleagues at Walter Reed Army Medical Center compared brain scans of servicemembers in blasts with impact-only mild TBI patients and healthy troops.
The scans showed “a pepper-spray pattern” of damage, which looked similar to a shotgun blast, in the brains of servicemembers who had been close to an explosion, he said.
“It was more intense, and there was more of it in the blasts,” he said.
The brains of those in blasts also displayed lingering inflammation.
“Something else is going on there,” Moore said.
His findings, which need to be replicated, are important because this unique pattern of inflammation may be a signature of blast-related concussions, a finding that could lead to better diagnostic tools — and eventually more targeted treatments.
Besides brain imaging, researchers are also searching for biomarkers in blood and spinal fluids that would be telltale signs of mild TBI, said Kathy Helmick, the head of traumatic brain injuries at the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury.
“We’re faced with the severe challenge of finding that Holy Grail,” Helmick said.
Some never heal
Up to 20 percent of troops have suffered at least one concussion downrange, Helmick said. Though most naturally recover, about 135,000 have been diagnosed with mild TBI. Chronic symptoms include memory loss, severe headaches, dizziness and fatigue.
Even when there is no outward sign of trauma, a series of blasts can eventually damage the brain.
A veteran of three tours to Iraq, Espinoza said his injury stems from a 2005 tour, where he led two teams of combat engineers, responsible for clearing roadside bombs from the refuse-filled streets of Ramadi.
During the single tour, his unit removed 275 improvised explosive devices, of which 80 detonated. He was knocked unconscious twice, but most of the time the bombs left him with only a headache, some dizziness and a ringing in the ears — nothing serious, he thought.
He never saw a doctor, nor did his fellow engineers, he said, except for a driver whose ears bled after an attack.
“Back then,” he said, “we didn’t know.”
How it happens
The question of exactly how blasts are injuring servicemembers is still unsettled among neuroscientists; some researchers have hypothesized that electromagnetic waves or toxic fumes are what cause troops to suffer brain damage after a blast.
Others say it’s the shockwaves, violent waves of air called overpressures that travel at more than 1,600 miles per hour after an explosion. These are followed by rushes of displaced air flooding back, also under high pressure.
Cernak — a medical director at the Johns Hopkins University Applied Physics Laboratory in Laurel, Md., who has studied the effects of blast waves using animals — theorizes that these shockwaves send pulses of energy rippling through the body’s vascular system, like a tsunami.
The pulses eventually reach the brain, where they squeeze and stretch the cells, damaging their protective outer membranes and allowing electrolytes, such as calcium and others, to leak in. The electrolytes then trigger a number of destructive chemical and molecular changes.
“These cells start to die a slow death,” Cernak said.
No matter how blasts injure the brain, any definitive test for mild TBI would need to catch subtle changes to the brain chemistry and structure, something current MRIs and CT scans cannot do, Cernak said. The testing of early symptoms — such as problems with balance, speech and memory — would also need to become much more precise.
“Definitely we need more sensitive diagnostic methods,” Cernak said.
Lacking a surefire test and definitive treatment, the DOD is addressing the immediate effects of blasts on soldiers downrange.
In June, the DOD issued guidelines requiring that anyone involved in a blast, or who was near one, be screened by a medic or corpsman, Helmick said in an e-mail this week.
“The new policy will shift responsibility of self-reporting from service members who often didn’t want to admit concussion symptoms — many fearing the possibility of being pulled from duty,” Helmick said.
The new guidelines also mandate that troops who were near blasts rest for 24 hours. The rest period gives their brains a chance to heal before potentially being exposed to another blast.
In addition, all troops evacuated to Landstuhl are asked about their proximity to explosions. After their tours are finished, troops undergo various exams depending on their service and unit; all troops who have had three concussions must complete a neurological exam.
Finding the invisible injury
Espinoza is now contacting his fellow engineers on Facebook, telling them to get examined for mild TBI.
He knows — all too well — how difficult it can be to ask for help. Two years ago, he started forgetting routine tasks and appointments, including formation.
To compensate, he set alarms on his watch and cell phone as reminders. He jotted notes and left them on his truck’s dashboard, or at home.
Even after he recognized his problem, Espinoza kept it to himself for weeks because he was embarrassed. Only when he stumbled while returning from the mess hall did he seek medical care.
“You are expected to perform at a certain level as a sergeant first class,” he said, “and when you notice you are not, you start covering your tracks.”
Getting examined, even if you sustained concussions years ago, is the best step toward getting help.
“It is an invisible trauma,” saud nurse Karen Williams, who managed Espinoza’s care at Landstuhl’s Neurology and TBI center. “But that doesn’t mean we can’t take care of it.
Current and future treatments
The military is funding dozens of studies looking at new drugs and therapies to treat mild TBI, such as hyperbaric-oxygen therapy, in which servicemembers breathe oxygen under atmospheric pressure.
Other options include anti-inflammatory medications and drugs that have been shown in animal studies to stop brain cells from triggering the deadly cascade of chemicals that results in brain damage, Cernak said.
But the ability to reverse long-term brain damage with drugs is still far away.
“The trouble is we don’t even have proven therapies and treatment consensus for civilian mild TBI,” Cernak said.
For now, specialists rehabilitate patients using a number of psychological and physical therapies. Some are high-tech, such as virtual reality software, including driving simulators to test reaction times. Others simply teach patients workarounds for memory loss — writing in diaries or keeping a digital organizer.
Bill Campbell, a former National Guardsman who was diagnosed with a traumatic brain injury more than five years ago, spoke bluntly about current methods of treatment.
“You are basically stuck, and you have to live with it,” the 48-year-old said.
Campbell, who was in several explosions during his yearlong deployment in 2005, knows he will never return to work as a biologist for the state of Washington. His wife, Domenica, had to quit her job as a corrections officer to take care of him.
“Two or thee times a day,” she said, “he will ask me, ‘What day is it?’”
For Campbell, the best therapy has been a yellow Labrador retriever trained to help people with disabilities. The dog has helped him concentrate his thoughts.
“My attention is directed toward him,” Campbell said, “and taking care of him.”
The Labrador’s name is Pax, Latin for “peace.”
Scientists theorize that blasts affect the brain differently than blows to the head. This composite image was created by comparing brain scans of healthy troops with several troops who suffered a concussion from blasts. The "pepper spray" pattern of damage, shown in red, might be a signature of blast-related concussions.
Photo courtesy of Dr. David Moore