Treatment of traumatic brain injury: better, but still flawed
During his 2008 run for president, Barack Obama vowed to improve treatment of traumatic brain injuries.
In the context of the U.S. military, they are brain injuries caused by exposure to an explosion or other blows to the head. The term can refer to anything from a mild concussion to a fractured skull. Studies on the effects of traumatic brain injury on troops suggest links to depression, dementia, seizures and post-traumatic stress disorder.
Conflicts in Iraq and Afghanistan in the past decade have resulted in a new surge of service members returning home with traumatic brain injuries -- and at higher rates than in past wars.
"Due to numerous deployments and the nature of enemy tactics, troops are at risk for sustaining more than one mild brain injury or concussion in a short timeframe,” said a 2009 report by the military and U.S. Department of Veterans Affairs. Mild traumatic brain injury -- the most common type -- can be especially difficult to detect, the authors noted.
Blast-induced head trauma is the "signature wound” of the war in Iraq because of the prevalence and sophistication in new explosive devices combined with advances in medical response, aerial evacuation and the widespread use of body armor. Today's troops survive explosions at higher rates.
A bipartisan report commissioned under President George W. Bush in 2007 raised concerns about the treatment of traumatic brain injury within the military and Veterans Affairs, which apparently prompted Obama's 2008 promise.
Candidate Obama's pledge focused on three topics:
- standards of care for traumatic brain injury treatment;
- screenings for brain injury before and after deployment and;
- improved case management
In all three instances, changes were already underway before Obama became president, but his administration made improvements, too.
"These things have all been getting better,” said Adrian Atizado, who works on federal policy issues for Disabled American Veterans.
"I would argue that, by and large, the administration has kept its promises or at least tried to keep its promises,” said Susan Connors, president of the Brain Injury Association of America.
Treatment for traumatic brain injury: What has changed?
We'll look at each element of Obama's promise separately.
Standards of care: The Defense Department established standards of care in 2006 for the evaluation, acute and chronic care of all service members with traumatic brain injury. Those standards have been updated in the past four years and are "much easier to use and understand, particularly for the corpsman or combat medic in theater,” said Lauren Sucher, a spokeswoman for the Defense and Veterans Brain Injury Center, a health research division within the Defense Department.
Also, a directive from the Defense Department in 2010 now requires any service member within 50 meters of a blast, or within a building or vehicle affected by a blast, to rest for one day and receive a concussion evaluation before returning to duty.
Standards of care have improved in the past four years, but evaluating and treating combat-related traumatic brain injury remains a relatively new medical field, according to Atizado, of the Disabled American Veterans. He said doctors are still learning how trauma caused by explosions affect the brain differently from better understood types of head traumas, such as concussions in sports.
The current standards of care don't go far enough, according to Gregory O'Shanick, medical director emeritus for the Brain Injury Association of America. Connors, the association's president, did credit the Defense and Veterans Brain Injury Center with creating detailed, science-based how-to guidelines for treating traumatic brain injury on the battlefield (which predate Obama). Connors said the military and Veterans Affairs need to establish similar clinical practice guidelines for long-term treatment and rehabilitation once a service member leaves a combat environment.
Deployment screenings: Before 2008, "there was no consistent requirement for pre-deployment neuropsychological testing,” Sucher said.
The 2008 National Defense Authorization Act required that service members must get screened within 12 months before deployment. After their deployment, they must get health assessments, which can trigger an evaluation for traumatic brain injury. Finally, any service member that checks into a Veterans Health Administration hospital must undergo a brain injury screening.
Case management: In 2007 the Defense Department established a network of regional care coordinators for traumatic brain injury.
Sucher explained that regional care coordinators now fill a void in monitoring the condition of service members who return to duty or transition to Veterans Affairs. In July, the program increased the frequency of follow-up interviews to three, six, nine, 12, 18 and 24 months, so long as they continue to show symptoms.
In our interviews, advocates of veterans health were most critical of case management and coordination of care, particularly during the transition out of active duty.
"Ongoing and appropriate care is often a struggle for these guys,” said Meredith Beck, who works as a consultant for the Wounded Warrior Project.
Beck complained about a fragmented case management system, with different case managers for service members' and veterans' different injuries and needs. Roughly at the same time that Obama was campaigning on traumatic brain injury, the Defense Department and Veterans Affairs were creating separate case management and care coordination programs, which remain distinct today.
A March 2012 report by the Government Accountability Office documented problems that arose from this two-headed response: "inadequate information exchange and poor coordination between these programs have resulted in not only duplication of effort, but confusion and frustration for (veteran) enrollees, particularly when case managers and care coordinators duplicate or contradict one another's efforts.”
Obama promised to improve the treatment of traumatic brain injury among current and former military service members. We found evidence of gains in standards of care, deployment screenings and case management, though the system remains far from perfect. We rate this a Compromise.
Email interview with Lauren Sucher, communications manager for the Defense and Veterans Brain Injury Center, Dec. 11, 2012
Interview with Ralph Ibson, national policy director for the Wounded Warrior Project, Dec. 12, 2012
Interview with Adrian Atizado, assistant national legislative director for Disabled American Veterans, Dec. 13, 2012
Interview with Meredith Beck, former national policy director and current consultant for the Wounded Warrior Project, Dec. 13, 2012
Interview with Susan Connors, president of the Brain Injury Association of America, Dec. 13, 2012
Interview with Gregory O'Shanick, medical director emeritus for the Brain Injury Association of America, Dec. 14, 2012
Institute of Medicine of the National Academies, Board on Population Health and Public Health Practice, Committee on Gulf War and Health: Brain Injury in Veterans and Long-Term Health Outcomes, Gulf War and health: Long-Term Consequences of Traumatic Brain Injury, 2008
Government Accountability Office, Government Efficiency and Effectiveness: Opportunities for Improvement and Considerations for Restructuring, March 21, 2012
Brain Trauma Foundation, Defense and Veterans Brain Injury Center, Guidelines for field management of combat-related head trauma, November 2005
PolitiFact, Veterans claims backlog grew under Obama, Nov. 2, 2012
Departments of Veterans Affairs, Department of Defense, The Management of Concussion/mTBI Working Group, April 2009
Brain Injury Association of America, Fact Sheets: Mild Traumatic Brain Injury (accessed on Dec. 14, 2012)
Progress, but not yet a standard of care
In his campaign, Barack Obama promised to "establish standards of care for TBI (traumatic brain injury) treatment, require pre- and post-deployment screenings and improve case management so that service members get the best possible care."
Since January 2008, a year before Obama became president, the newest version of the Post-Deployment Health Reassessment Program has included pre- and post-deployment screenings for Traumatic Brain Injury.
In April 2009, after President Obama took office, the Department of Veterans Affairs and the Department of Defense issued a joint "clinical practice guideline" which "provide[s] evidence-based recommendations to assist providers and their patients in the decision-making process related to the patient health care problems." In it are recommendations for diagnosing and treating mild TBI, which often goes undiagnosed, and, even when diagnosed, is more difficult to treat.
Although evidence-based reccomendations are given, the guideline is very specific that it should not be used to "define a standard of care". But Obama was very clear that he wanted a standard of care. So for now, we'll just rate this one In the Works.
VA/DOD, "Management of Concussion/mild Traumatic Brain Injury" April, 2009.
Deployment Health Clinical Center, "Post-Deployment Health Reassessment Program" Accessed Jan. 12, 2010