The Corpus Callosum

Bad Science at the Pentagon

Traumatic Brain Injury href="http://scienceblogs.com/neurophilosophy/2007/08/traumatic_brain_injury_on_the.php">has
been called the “signature injury” of the Iraq War, due to the
reported high prevalence of the injury there.  This is in contrast
to previous wars.  It’s not that head injury is necessarily more
common; what is more common is for soldiers to sustain such injuries
and survive. 

The Pentagon has recognized this, and ( href="http://scienceblogs.com/effectmeasure/2007/05/signing_a_check_for_iraqs_sign.php">reportedly)
is addressing it.  But now, a paper published in NEJM indicates
that they might not be doing a very good job.  The paper is not
open-access, but there is an article about the article that is open:

href="http://pn.psychiatryonline.org/cgi/content/full/44/10/30">Health
Officials Criticize Pentagon’s TBI Criteria

Lack of a case definition for mild traumatic brain injury hampers
diagnosis of U.S. troops exposed to explosive blasts.

Aaron Levin
Psychiatr News May 15, 2009
Volume 44, Number 10, page 30
© 2009 American Psychiatric Association

U.S. military health officials are using an ambiguous and
unvalidated method of identifying mild traumatic brain injuries among
troops returning from service in Iraq and Afghanistan, according to
three Army medical researchers.

The Department of Defense now uses a brief checklist after the troops
return from the war zones to screen for medical consequences of
deployment. Only one question on the Post Deployment Health Assessment
(PDHA) form asks about possible traumatic brain injury (TBI).

The resulting information does not amount to a case definition because
it lacks three essential criteria for use months after injury:
symptoms, time course, and impairment, wrote Col. Charles Hoge, Col.
Carl Castro, and Herb Goldberg in the April 16 New England Journal of
Medicine.

While there is no doubt that there have been numerous cases of brain
injury in the Iraq War, the study indicates that the data collection
has not been very good.  This leaves us not knowing the true
extent of the problem:

“Positive responses to this single, unvalidated question
have accounted for two-thirds of all reported cases of concussion/mild
TBI,” they wrote. The current system may be inflating the number of
cases.

href="http://www.rand.org/publications/randreview/issues/summer2008/wounds1.html">Prior
estimates for the number of cases were as high as 320,000.  So
even if two-thirds are not really cases, that still would leave over
100,000 young people with significant brain injury.  Poor data
collection practices complicate matters greatly.  The authors have
raised this problem within the Department of Defense (DoD):

In response to the perspective in the New England Journal
of Medicine, the Pentagon unit charged with researching TBI
acknowledged that there was no clear standard of care for it in the
early years of the two current wars, but it has been collecting data to
improve screening and clinical practice, said Michael Kilpatrick, M.D.,
director of strategic communications for the Military Health Service.

“Today DoD [Department of Defense] continues to analyze the data that
have been collected to make the best scientific changes to processes to
optimally identify, document, and treat mild TBI/concussion,” said
Kilpatrick in a prepared statement. “The Hoge paper is the expression
of an opinion supporting this scientific process.”

Another article about the NEJM paper clarifies some points:

href="http://www.navytimes.com/news/2009/04/military_mild_TBI_041709w/">TBI
screens need to get specific, report says

By William H. McMichael – Staff writer
Navy Times
Posted : Monday Apr 20, 2009 5:21:31 EDT

…”It is a problem,” said Allen Brown, a physician who studies the
measure of impairment following traumatic brain injury at the Mayo
Clinic in Rochester, Minn. “Really, there isn’t a lot of agreement
about this. What I mean about ‘concussion’ is very different from what,
say, a neurosurgeon would mean, or an internist; … there’s just not
any unifying, agreed-upon medical terminology that is useful.”…

…Hoge said their conclusions are not an effort to bring about a
reduction, for whatever reason, in the number of mild TBI cases.

“This article should not be interpreted as suggesting that concussion
is not an important problem,” he said. “Concussion is an important
problem, and we’ve shown, and others have shown, that soldiers who have
experienced concussions on the battlefield, where they lost
consciousness in particular, are at higher risk for a variety of health
concerns when they come home, to include post-traumatic stress disorder
and depression and a variety of physical health problems…

Part of the challenge, in the task of developing a validated case
definition, is that the validation has to be specific to the intended
purpose of the definition.  If the definition is to be used to
determine treatment, it needs to be validated, in that context, as
being clinically useful.  If it is to be used to determine
disability benefits, it is possible that a different definition would
be more appropriate. 

The articles indicate that the DoD is taking this seriously, and is
revising their procedures.  However, the Navy Times warns:

Paul Sullivan of the Washington, D.C.-based advocacy group
Veterans for Common Sense said he’s pleased that the military continues
to study TBI but expressed concerns about too much reliance on better
early screening, noting anecdotal reports of troops exposed to roadside
bomb blasts who did not develop symptoms of TBI until much later.

Sullivan also warned that the Pentagon and the Department of Veterans
Affairs have a history of downplaying serious medical problems, such as
Gulf War Syndrome, and called for outside organizations to perform
independent studies.

Perhaps we will see how well they take up this cause.  Obama is href="http://multimedia.boston.com/m/video/22024759/obama-says-veterans-issues-will-be-properly-funded.htm?q=%22traumatic+brain+injury%22">saying
the right things, but he is only a part of the bureaucracy. 

Comments

  1. #1 Eamon
    May 21, 2009

    I would think there’s be a lot of information from Northern Ireland that would be pertinent to a case definition. Lots of bombs, urban areas, armoured vehicles – 30 years of data.

  2. #2 Pierce R. Butler
    May 21, 2009

    This generation of veterans is going to suffer worse stigmatization than even the (purportedly) drug-addicted, lawless, crazed grunts who came back from Vietnam.

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    May 26, 2009

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