The Corpus Callosum

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.

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:

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 saying the right things, but he is only a part of the bureaucracy.