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Study Says Military Over Diagnosing Mild Brain Injuries

Posted on: Thursday, 16 April 2009, 06:17 CDT

Army officials say the military is over diagnosing mild brain injuries because it is failing to use hard medical evidence and instead relying on soft criteria.

Mild brain injuries were once considered an under-recognized problem in returning military troops, but an Army doctor and two other officials are taking aim at Department of Veterans Affairs' rule for treating such veterans and determining disability pay.

The study is published in Thursday's New England Journal of Medicine.

The authors say many mild cases are actually "concussions" rather than "brain injuries."

"I think it's fair to say there's over diagnosis of concussions going on," said Dr. Charles Hoge, a top Army psychiatrist and one of the three authors.

Veterans groups support efforts to improve diagnose of traumatic brain injuries, but they believe it’s more likely the military has been undertreating the problem.

"It stretches credulity to believe that all the people who have suffered traumatic brain injuries in Iraq and Afghanistan are getting the treatment they need. That's a laughable notion," said Jason Forrester, director of policy at Veterans for America, an advocacy group.

The military defines a concussion as a blow or jolt to the head that caused loss of consciousness, altered consciousness, or amnesia. Many are attributed to pressure waves that affect troops near bomb blasts.

According to a 2008 Rand Corp. study, more than 300,000 U.S. veterans of the wars in Afghanistan and Iraq have suffered head injuries, many of them have gone untreated.

The rough estimate numbers are pulled from a questionnaire given to service members as they finish their deployment. However, that could mean several months after a blow or jolt occurred, and service members can't always get a thorough medical assessment on the battlefield, according to Hoge.

The authors highlight the problem with the questionnaire. It asks whether the person became dazed or confused at the time of an injury or blast, and it attributes such symptoms to concussion.

But researchers note that in fact a soldier can become dazed from several factors including stress, lack of sleep, the confusion of war, or other causes.

Last year, Hoge published a study in the New England journal showing that many brain injury symptoms were actually due to post-traumatic stress syndrome, or PTSD.

Trained doctors should be able to sort out the cause of symptoms, but researchers argue that a concussion diagnosis can still occur, because of both subjectivity and a loose concussion definition.

"The problem is we're attempting to measure concussion many months after injury," said Hoge, director of psychiatry and neuroscience at the Walter Reed Army Institute of Research in Silver Spring, Md.

Hoge wrote the article with Herb Goldberg, a communications specialist at Walter Reed, and Carl Castro, a psychologist at the U.S. Army Medical Research and Materiel Command at Fort Detrick, Md.

The three suggest that the questionnaire should be revised and questions should be asked closer to the time of the incident.

The study also notes that the military should refine its definition of concussion. They feel "concussion" better reflects the mild nature of the injury and promotes an expectation of recovery.

"It's a very, very, very mild physical injury" that often doesn't need medical treatment, Castro said.

In 2008, the VA started a disability category for residual effects of traumatic brain injury that was based on subjective, poorly defined symptoms, Castro and his colleagues argued.

The authors wrote that more scientific diagnosis criteria are needed "to ensure that disability regulations do not generate disability."

The Rand report said that treatment of mild traumatic brain injuries can cost up to $32,000 per case, but if the diagnosis is wrong, patients are exposed to drug side effects and other risks.

VA officials issued a statement this week saying they are proud of their efforts to treat traumatic brain injuries.

Forrester, the veterans advocate, said estimates of concussions are probably low because some soldiers fear their military career would be affected if they were diagnosed with a neurological or psychological problem.

Better assessment is needed for complicated problems, he added. "These are the most difficult, thorny wounds of war," he said.

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On the Net:

• New England Journal of Medicine
• US Army
• Veterans for America
• Walter Reed Army Institute of Research

Source: redOrbit Staff & Wire Reports

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