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Thursday, November 5, 2015

(Just Work) - The truth about veterans and concussion


“My TBI is getting worse … I can’t remember anything.”


I overheard a 30-something Army veteran tell this to another combat veteran during a short break in a group education class I was co-teaching for veterans struggling with attention and memory difficulties.


The wars in Iraq and Afghanistan have been going on for well over a decade now. Some 330,000 service members have sustained concussions while serving since 2000, sometimes related to IED or mortar blasts, other times during training activities, or most often while involved in activities such as recreational sports or motor-vehicle accidents. Of note, the Department of Defense reports that more than 80% of traumatic brain injuries are diagnosed in non-deployed settings, and the majority call in the “mild” classification, which we prefer to call concussion. Yet traumatic brain injury, or TBI, has been touted as the “signature injury” of our military involvement in the most recent conflicts in the Middle East. There are now federal mandates ordering the Department of Defense (DoD), Department of Veterans Affairs (VA) and the Centers for Disease Control and Prevention (CDC) to collaborate in collecting incidence and prevalence, disseminating the information, and improving upon diagnostic and treatment tools.


Statistically speaking, mild traumatic brain injury (mTBI), or concussion, has indeed been a problem for servicemembers, a problem which by all accounts is now being addressed. First of all, concussions are being evaluated for in the field. Second, service members who fail certain objective tests are being pulled out, given time to heal and reducing the risk of another head insult.


As a speech-language pathologist specializing in cognitive rehabilitation, my job is to assist people with attention, memory and executive functioning difficulties, often as a result of a TBI. I might teach a compensatory strategy, such as writing down information that would be important to remember. I often connect patients to assistive memory devices - such as a smartphone, tablet, or day planner - to help keep track of their appointments, medication, contacts, and tasks. I often teach what are called “metacognitive strategies,” which is a fancy way of talking about methods to think about thinking. Attention exercises have their role in rehabilitation, at times, but the research about the validity of brain training, for either the injured or the healthy brain, remains mixed.


My main job, however, is education. Early education about the signs and symptoms of concussion, and positive prognostic expectations, is a key treatment factor. Research demonstrates the strong correlation between early patient and family education and reduced likelihood of later somatic or cognitive complaints.


In my current position at the VA in a specialty clinic designed to treat veterans with traumatic brain injuries, I do in fact see a few people with the kind of polytraumatic blast-related injuries that you might expect from the news. Adam, for example, is now 23 and married to his high school sweetheart. By all accounts, he’s lucky to be alive. A former Army specialist, he stepped on an IED while serving in Afghanistan, just two weeks remaining in his tour. He lost both his legs, several fingers, broke numerous bones, and sustained a traumatic brain injury that left him in a coma for more than six months. Now, he relies almost entirely on his family and paid caregivers, and is at the VA near daily for various therapies and medical appointments.


The thing is, Adam is the exception to the rule. He is a perfect example of what most civilians think when I tell them what I do for a living. That I work in a “polytrauma clinic.” That I provide cognitive therapy for people with “traumatic brain injury.” As an individual patient, I truly love working with Adam. He’s got a great sense of humor, he is motivated to learn to read again, and he consistently participates in therapy activities both in my clinic and at home. He makes a great, heart-warming story about combat veterans and sacrifice, reminding us to honor those who have served. As we should. But the thing is, most of the people coming through my team’s TBI clinic, they look nothing like Adam. The majority of people on my caseload - those with “TBI” diagnoses, those earning service-connected funds for “traumatic brain disease” - they would better be described as having a “history of concussion.”


These veterans, their stories are complicated, but not necessarily by that one time they hit their head on the MRAP. They need our help and support, without a doubt, but not because they may or may not have lost consciousness for a few seconds many months or even a few years ago. Their attention, memory, and communication difficulties are what we like to call “multifactorial in nature.”


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The current scientific literature actually purports that the overall prognosis for patients who sustain a single mTBI or concussion is good. Most of these patients will recover within hours or days with no prolonged effects. It is estimated that 85-90% of individuals with concussion will recover from headaches, sleep disturbance, dizziness, reduced attention, or irritability within 30 days. We don’t yet know much about how and why the “miserable minority” experiences longer-lasting signs and symptoms of concussion. We do know that a complex mix of factors such as physical, genetic, and psychosocial may account for slower recovery. And we do know that a concussion doesn’t “get worse.”


Difficulty sleeping. Increased irritability. Reduced concentration. Headache. Anxiety and depression. Increased forgetting. These can all be symptoms of what current diagnostic measures call “post concussion syndrome.” But also, of PTSD. Of adjustment disorder. Of hormonal imbalances. Of medication effects. Of anxiety and depression.”


And there’s a difference between the civilian that sustains a concussion, and the service member who sustains a concussion while in combat. He or she is exposed to myriad additional factors, complicating both the diagnosis and treatment of common complaints following a concussion. There’s chronic pain, disordered sleep, medication effects, social factors such as homelessness and substance use or abuse, mental health factors from anxiety to depression to PTSD. Individually, each of these can impact our cognitive function, even in the best of scenarios. And then there’s the adjustment from military life to civilian life. Adjustment from the Middle East to the United States. Adjustment from a combat zone to a family home. Mix them all together and we have what I like to call a clusterfuck.

It’s not fair to call this “traumatic brain injury” and chalk it up to a single “signature injury,” concussion. It’s a disservice to the current scientific literature, and certainly to the veteran his/herself. It distills the very complicated picture into a simplistic one, encourages our veterans to identify as “having a brain injury,” and undermining their motivation and ability to incorporate back into being productive members of our civilian society.


With no intention to undermine the experiences of returning service men and women - those with and without a history of concussion, those with and without combat exposure, those with and without PTSD - we are in fact doing a disservice by pathologizing concussion, attributing all the vague but similar signs and symptoms to a brain injury. The pendulum has swung from “who cares about concussion” to “concussion is forever,” when in fact it should rest somewhere in the middle.


For this very specific population - these veterans who have indeed served in combat zones, who have been exposed to stressful or traumatic events, who may or may not have sustained a concussion whether combat-related or not, who are exposed to “moral injury,” who may have had pre-existing mental health issues, who are struggling to maintain regular sleep schedules, who are on multiple medications to address myriad of issues, who are experiencing chronic musculoskeletal discomfort and pain, who are transitioning from a highly routinized environment to one that provides little structure - let’s call this something different. Let’s allow language and thus space for these veterans to attribute their current difficulties to everything that they’ve experienced and are experiencing now, to give equal credence to the many environmental, social, emotional, spiritual, and physiological factors influencing them from every angle. Let’s call this “post-deployment syndrome,” or “OIF/OEF/OND disorder,” or “combat adjustment disorder,” or anything else other than just “TBI” or just “PTSD.” And then let’s create new treatment regimens, integrative approaches to treating not just the individual symptoms, but the whole person. What we are doing currently, it isn’t working. At least, not well enough.

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