​​War is Hell


The conflicts in Iraq and Afghanistan have placed an increased awareness on TBI, in particular the 'mild' and 'subconcussive' forms. Various studies and publications have estimated the incidence of TBI for deployed service personnel. However, all have been based on extrapolations of data sets or subjective evaluations due to the current methods of diagnosing a TBI. Therefore, it has been difficult to get an accurate rate and severity of deployment related TBIs, or the incidence of multiple TBI's service members are experiencing.1.

As such, there is a critical need to develop a rapid objective method to diagnose TBI on the battlefield. 


As noted above, estimates are all that are available to researchers and clinicians at this time. 

RAND Corporation’s “InvisibleWounds of War” collected data in 2007/8 from 1,965 previously deployed personnel;

• 19.5% suffered “probable TBI”

• That equates to 320,000 of the 1.64 million deployed service members at that time

• However, by then end of 2008 only 197,000 (12%) cases of TBI were diagnosed (Armed Forces Health Surveillance Center)



image82

Due to the complexities of war and of TBI, it has been extremely difficult to measure the severity of TBIs or the incidence of multiple TBIs service members are actually experiencing. The major reason is the lack of a method to objectively determine if the brain has been injured. In 2006 the Military Acute Concussion Evaluation (MACE) was add to the list of tools to screen casualties.2. While the MACE has been well integrated into the military medical evaluation, it still relies on subjective recall of the events, may be affected by fatigue as with other neuropsychological tests and has shown low sensitivity when administered greater than 12 hrs post incident.3. Thus there remains a gap for the ability to objectively measure brain injury with a method that is not impacted by this and other factors such as extra-cranial injury (i.e., polytrauma), stress, fatigue, and/or battlefield conditions.


Diagnosis


The diagnosis of TBI, associated post-concussive symptoms and other comorbidities such as PTSD, presents unique challenges for diagnosticians. No screening instruments available can reliably make the diagnosis; the 'gold standard' remains an interview by a skilled clinician. The current VA screening tool is intended to initiate the evaluation process, not to definitively make a diagnosis.


Cost


​For the approximately 1.6 million troops who have deployed since 2001, it is estimated that PTSD-related and major depression–related costs could range from $4.0 to $6.2 billion over two years. Applying the costs per case for TBI to the total number of diagnosed TBI cases identified as of June 2007 (2,726), we estimate that total costs incurred within the first year after diagnosis could range from $591 million to $910 million.8.

image83

References

1. Kara E. Schmid,Frank C. Tortilla. The Diagnosis of Traumatic Brain Injury on the Battlefield. Front Neurol. 2012; 3: 90

2. Meyer K. S., Marion D. W., Coronel H., Jaffee M. S. (2010). Combat-related traumatic brain injury and its implications to military healthcare. Psychiatr. Clin. North Am. 33, 783–796

​3. Coldren R. L., Kelly M. P., Parish R. V., Dretsch M., Russell M. L. (2010). Evaluation of the military acute concussion evaluation for use in combat operations more than 12 hours after injury. Mil. Med. 175, 477–481