Brain trauma 'signature' injury of wars in Afghanistan, Iraq

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In past wars, it may have been labeled "shell shock" or "battlefield fatigue." Or it may not have been diagnosed at all.

But what doctors now call "traumatic brain injury," or TBI, has emerged as the leading injury for U.S. forces in Iraq and Afghanistan, affecting up to 20 percent of all group troops.

"In the past, if you got a brain injury they might just tell you that you got your bell rung and to shake it off. But we take it much more seriously now," said Col. Jonathan Jaffin, acting commander of the Army Medical Research and Material Command at Fort Detrick in Maryland.

Military commanders today are more likely to pull troops suspected of TBI from combat because they pose a risk to themselves and others.

"Someone suffering from even mild TBI can have their cognitive reasoning impaired," Col. Jaffin said.

On Capitol Hill, lawmakers in both houses this year have proposed legislation to treat TBI, which is defined as a blow or jolt to the head or a penetrating head injury that disrupts normal brain function. The severity of such an injury ranges from "mild," a temporary change in mental status or consciousness, to "severe," an extended period of unconsciousness or amnesia after the injury, and can result in short-term or permanent problems.

More than 15,000 U.S. military personnel have been injured by explosive blasts in Iraq and Afghanistan since 2001 -- more than all other causes of combat injuries combined and the most common cause of brain injuries, the Department of Defense says.

"The nature of current warfare, with the improvised explosive devices, is exposing more people to a mechanism that can cause brain injury," said Dr. Barbara Sigford, national director for physical medicine and rehabilitation for the Department of Veterans Affairs.

Rep. Michael H. Michaud, Maine Democrat, who has sponsored legislation to increase treatment and research of TBI, says it is the "signature wound of this war" for veterans and says there is little understanding of its long-term consequences.

The House passed Mr. Michaud's bill Wednesday by a vote of 421-0. The legislation authorized new TBI research centers and mandate a comprehensive program for treating TBI at VA medical facilities. It also would require all veterans to be screened for TBI.

In the Senate, Veterans Affairs Committee Chairman Daniel K. Akaka, Hawaii Democrat, last month introduced similar legislation.

"As the needs of our wounded war veterans change, VA medical care must change to respond to those needs," said Mr. Akaka said, adding that the "VA has not fully adapted to meet the needs of those with this injury."

Better and quicker access to battlefield medical care, and improvements in protective gear, such as Kevlar vests, are helping keep down mortality rates. In Vietnam, about 20 percent of U.S. forces who were shot or hit with shrapnel died. In the current conflicts in Iraq and Afghanistan, the rate has fallen to 8.5 percent, according to the Army.

But with fewer combat deaths comes more living wounded. And because even the best helmet can't protect brain tissue from strong jolts, brain injuries increasingly are becoming a combat concern.

"Battlefield medicine has changed so that we are more successful at saving people" now, Dr. Sigford said. "It's kind of a mixed picture."

At the Defense and Veterans Brain Injury Center, a joint venture between the departments of defense and veterans affairs based at Walter Reed Army Medical Center in Washington, 2,130 military personnel who served in Iraq and Afghanistan were treated for TBI between January 2003 and March 2007. About 70 percent were classified as mild TBI.

But overall, accurate statistics on TBI among military personnel are difficult if not impossible to ascertain because many mild cases go undetected, experts say.

There is also no single standardized test to detect TBI, so mild TBI sometimes goes undiagnosed.

"In some of the individuals I've seen after they've left the military, they may describe an incident [involving TBI], but they don't even think that they were injured because they weren't bleeding or nothing was broken," Dr. Sigford said. "It's a very hard population to get your arms around," she said.