Combat head trauma figures suspect in Iraq, Afghanistan wars, study finds

A servicemember receives a Diffusion Tensor Imaging scan of his brain at Landstuhl Regional Medical Center in Germany.


By CARL PRINE | The Pittsburgh Tribune-Review | Published: May 19, 2014

Up to five times as many active-duty troops endured head trauma during the early stages of the Iraq and Afghanistan wars than was recorded by the Pentagon, according to a study by researchers at Johns Hopkins University.

The widespread lack of documentation of traumatic brain injuries, or TBI, could stymie former military members seeking medical care or disability payments from the Department of Veterans Affairs or the services, the study warns. Published last week in the Journal of Head Trauma Rehabilitation, the study authored by Dr. Remington Nevin and researcher Rachel P. Chase estimates that the Department of Defense failed to document an estimated 21,257 to 24,033 cases of battlefield brain injury from early 2003 to late 2006.

“Any policy that rests on a veteran being able to produce documentation of the TBI would therefore be inadequate,” Nevin said.

The authors told the Tribune-Review that their study likely undercounted the number of concussions among troops because it excluded National Guard and reserves who fought overseas.

They and active-duty combatants benefited from innovations in battlefield medicine and body and vehicular armor that increasingly save the lives of troops who would have died from blast injuries in past wars. Survivors with head injuries, however, face a higher risk of memory loss, cognitive difficulties, mood disorders, substance abuse, insomnia and lethal degenerative conditions such as chronic traumatic encephalopathy, an Alzheimer's-like malady plaguing some football players and boxers.

“The more time that passes without attending to the under-documentation of TBI, the more we miss opportunities to understand and tackle the issues affecting their everyday lives,” Chase said.

In March, the military introduced “A Head for the Future,” a program designed to promote awareness of brain injuries and the best ways to prevent them.

“The (Department of Defense) will continue to evaluate screening, assessment and care, update guidance based on evidence, and continue to raise awareness, especially with a focus on injuries that occur outside the combat theater,” said Kathy Helmick, deputy director of the federal Defense and Veterans Brain Injury Center.

Although the Pentagon got better at documenting head injuries as the wars wore on, that was not always the case before 2007. To determine the number of uncounted concussions, the Johns Hopkins researchers turned to a gruesome census that was never underreported: amputations. Because many amputations of limbs and brain injuries can be traced to roadside bombs, the rates of both should have roughly paralleled each other, the authors note. Before 2007, however, military data revealed relatively few traumatic brain injuries — a number that began to rise dramatically when new screening policies took effect in the services and officials began recording more concussions.

The annual toll of diagnosed brain injuries in the military increased from 23,217 in 2007 to 32,625 in 2011 because of better reporting, not more fighting, the Pentagon acknowledges. By early 2011, nearly every head injury was well-documented by the services. That's because the military now tests for trauma every GI within a half-football field distance from a detonation.

Anyone receiving a direct blow to the head, including those hurt in vehicle crashes or training, must report for examination before returning to duty. Once those injuries are documented, U.S.-based troops must get waivers to deploy to war.

Some initiatives must attempt to protect the GIs from themselves. A 2009 Pentagon fact-finding mission to study recovering soldiers at New York's Fort Drum, for example, revealed that the troops had “started memorizing answers” on parts of the Military Acute Concussion Evaluation screening in order “to stay in theatre” and fight.

VA officials told the Trib that to compensate for the lack of head injury records, the agency allows veterans to use private medical diagnoses, buddy statements and other battlefield documents to help establish a connection between today's symptoms of head trauma and prior service in Iraq and Afghanistan.

“We've always taken into consideration any evidence that's presented to us. In fact, we have a legal obligation to do so,” said VA spokesman Steve Westerfeld. “A veteran can come back in the future and claim new conditions or secondary conditions that they believe are connected to the original injury, too.”

Dallas-based attorney Christopher Attig, who specializes in VA benefits claims, said today's “service medical records often lack substantial documentation of incidents related to head trauma.” Battlefield medical files frequently got lost within the military or after being shipped to VA, he said, and although the agency allows “lighter burden” of proof for brain injuries if the troops directly fought the enemy, many veterans get turned away because they lack the paperwork to back up their symptoms.

The Johns Hopkins study indicated that those still in uniform with undocumented brain injuries probably paid a steep price, too. Thousands of service members likely redeployed to war without officials recording their previous trauma, raising the risk of long-term harm from repeat blasts or accidents. Chase and Nevin called for more research into the health and career outcomes of troops with undocumented concussions, a topic few investigators have tackled after more than a dozen years of war.

“I don't know why there has not been a demand for these numbers or, if there was plenty of demand, why it was not addressed previously in the scientific literature,” Chase said. “However, now that we've started this line of work, it's our job moving forward to use this data to inform our approach to addressing the needs of veterans and their families.”