Article regarding TBI in veterans and services recieved.

1. SPECIAL REPORT ON BRAIN INJURY
WAR
ON THE
BRAIN
PHOTO CREDIT GOES HERE
Soldiers coming home from Iraq must battle an invisible enemy
emblematic of modern warfare: traumatic brain injury
BY LINDA CARROLL
M
argaret Benoit sits quietly damage occurs when soft, delicate tissue slams up
watching her son learn to against the solid inside wall of the skull.
walk for a second time. This kind of brain damage is so common among
The improvised bomb soldiers coming home from Iraq that many experts
that blew through the bot- are calling traumatic brain injury (TBI) the signature
tom of Sgt. James Benoit’s wound of the war. While TBI was not unheard-of
Humvee over a year ago in previous conflicts, a far greater proportion of the
left him missing much of soldiers returning from Iraq and Afghanistan have
the muscle on his lower left side and with unseen suffered significant injuries to their brains.
injuries to his brain that, for a time, made him seem The rise in the incidence of traumatic brain
like a stranger to those who knew him best. “Each injuries results partly from the widespread use of
day he becomes more and more his old self,” says improvised explosive devices, or IEDs, by insur-
his mother. “But it’s taken a year to get there.” gents. And ironically it results partly from innova-
Benoit had always been an easygoing guy back tions in protective gear and emergency medicine.
home in Wharton, N.J. But after the blast in Iraq, Soldiers who might have died in earlier conflicts
he became very particular. Little things jangled his are surviving because high-tech helmets and body
nerves. And it wasn’t just the 24-year-old soldier’s armor protect the head and torso from penetrat-
personality that had changed. His thinking had ing wounds. Advances in first aid and quicker trips
slowed and his memory dulled. He now had trouble to sophisticated medical centers are saving soldiers
keeping track of the simplest details of daily life. who might have died on the battlefield. But many
The changes were all signs that Benoit had sus- are surviving with badly wounded brains.
tained a brain injury in the blast—even though And those survivors with the worst brain inju-
he had no external wound to his head. Although ries must learn to live with lifelong disabilities. “TBI
doctors don’t fully understand what happens to the looms large in terms of chronic consequences,” says
brain in an explosion, they suspect much of the neurologist Warren Lux, M.D., acting director of
12 NEUROLOGY NOW • SEPTEMBER/OCTOBER 2006 PHOTOGRAPHS BY CHRIS HARTLOVE

2. REFLECTING BACK
Sgt. Brian Radke
looks to rediscover
what he’s lost.
NEUROLOGY NOW • SEPTEMBER/OCTOBER 2006 13

3. SPECIAL REPORT ON BRAIN INJURY
A missing leg is
obvious to anyone,
but even a severe
injury to the brain
can be invisible.
the Defense and Veterans Brain Injury Center.
“Brain injuries, like amputations, are for life.”
More than 20,000 U.S. military personnel
have been wounded in the war through mid-
September, according to the Defense Depart-
ment. But nobody knows exactly how many
of them have suffered traumatic brain injuries.
That’s because it’s possible to have a TBI with-
out any external wounds. And no one checks
each and every soldier for signs of a brain in-
jury after a blast.
The impact of a missing leg or arm is clear
to anyone meeting an amputee. But changes in
the brain that result from a soldier being thrown
around in a bomb blast aren’t always immedi-
ately obvious, even to the soldier. When the
wound is invisible, it can be easy to dismiss.
BASIC TRAINING
Sgt. James Benoit
“And a lot of guys don’t want to leave their
works at therapy buddies after they’ve been injured,” Dr. Lux
for body and brain. says. “They try to tough it out.”
At Walter Reed Army Medical Center in
Washington, D.C., where many of the most
severely injured soldiers are treated upon re-
turning to the U.S., everyone gets checked for
TBI. Doctors there found that about 60 percent of the soldiers
screened have suffered TBI, with more than half of those inju-
Defining TBI ries diagnosed as moderate or severe.
“Soldiers aren’t being routinely screened for brain injury,
A traumatic brain injury (TBI) is a blow or jolt to the and they should be,” says Wayne A. Gordon, Ph.D., associate
head that disrupts brain function. TBI can occur without director of the department of rehabilitation medicine at the
a penetrating wound or even a blow to the head, such Mount Sinai School of Medicine in New York City. “Without
as whiplash from a car crash. TBI can compromise routine screening, soldiers with traumatic brain injury may be
ability to function independently, sometimes for life. slipping through the cracks.”
J
Symptoms, which may show up right away
or appear days after the injury, include: ames Benoit may have trouble recalling aspects of day-
to-day life, but he remembers every detail of the day
® Confusion ® Trouble concentrating he drove down a road in Baghdad and a bomb ripped
and thinking through the bottom of his heavily armored vehicle.
® Headache “I was the driver,” Benoit says impassively as he takes
® Poor judgment
® Nausea and vomiting and impulsivity
a break from his physical therapy, propping himself up
against the rail of the parallel bars he’s been using to practice
® Dizziness and
balance problems
® Depression and anxiety walking. “I just heard this sound and looked around at the
guys to ask what had happened and, suddenly, I had this numb
® Seizures
® Memory problems feeling in my backside. And then my vision went black.”
® Change in sleep patterns Though temporarily blinded, Benoit was conscious as his
® Lack of coordination comrades pulled him from the damaged Humvee. He remem-
bers the long, slow ride back to the base and being loaded up
14 NEUROLOGY NOW • SEPTEMBER/OCTOBER 2006

4. ON THE
HOME
onto a helicopter. After that, there is nothing FRONT with chewed-up insulation starts to crackle
until the moment he woke up at Walter Reed and buzz, the information carried by nerve
with a multitude of doctors milling around
and his mother standing by his side.
5.3 MILLION fibers with damaged myelin can be slowed,
disrupted, or distorted.
Americans
She’d flown down to Washington while are currently “If the information isn’t being transmitted
he was still being stabilized in Germany. The as quickly,” Dr. Cicerone says, “mental con-
doctors initially weren’t optimistic. “They
disabled by nections are not made and processing speed
thought I’d be flying to Germany next,” she traumatic becomes very slow. There are tremendous re-
recalls. “At that point, they put his chances of brain injury percussions, including memory problems.
living at 5 percent.” “Think of it in terms of a kitchen sink that’s
The injuries to Benoit’s left side were seri-
ous—and easy to see. The wounds to his brain
1.5 MILLION partially clogged. If there’s only a little water
flowing into the sink, it works fine. But if you
Americans suffer
couldn’t be detected—even with the help of a a traumatic brain turn up the flow of water—or add more infor-
brain scan. mation, in the case of the injured brain—then
That’s because much of the damage in a TBI
injury each year it starts to back up. If there’s a lot of water
is to individual cells, experts say. And such
fine structure doesn’t show up on any type of 80,000 flowing into the sink, it doesn’t work at all.”
People with TBI can get overwhelmed and
scanning device currently available. Americans sus- completely shut down if there’s too much hap-
While experts don’t fully understand what tain long-term pening at the same time. Often, when there
happens to the brain when a soldier like Ben- disability from are multiple conversations going on, it may
oit gets hurled around in a bomb blast or gets TBI each year be impossible to focus on any one. Patients
hit by its shockwave, they suspect that the become fatigued by routine mental activities.
damage is comparable to that suffered by peo-
ple in a car wreck or infants with shaken-baby
EVERY 21 They can’t get as much done during the day as
they did before the injury.
syndrome. SECONDS, And, because the specific parts of the brain
Delicate brain structures smash up against someone in damaged in a TBI—the frontal lobes—are
the corrugated inside walls of the skull. There’s the U.S. suffers needed for higher-level thought processes,
bruising and sometimes outright death of a traumatic just about everything, from behavior to prob-
brain cells, explains Douglas H. Smith, M.D., brain injury lem solving, is affected. “The frontal lobes are
director of the Center for Brain Injury and Re- involved in what is called executive function:
pair at the University of Pennsylvania. Beyond the ability to reason, to initiate, to plan, and
this, nerve fibers can be torn by the sudden stretching. “The to organize,” says Mel Glenn, M.D, director of outpatient and
brain is like Silly Putty,” Dr. Smith says. “It can stretch under community brain injury rehabilitation at Spaulding Rehabili-
normal conditions. But there is damage when the brain un- tation Hospital in Boston. “This part of the brain also is what
dergoes rapid accelerations and decelerations.” allows you to look at yourself from an outsider’s point of view,
Small rips in nerve fibers can eventually lead to cell death and to monitor yourself.”
days after the original injury, experts say. The cells that don’t
I
die may permanently be impaired. n the vast physical therapy room at Walter Reed, James
Nerve cell fibers, which act like phone wires to carry infor- Benoit moves from the parallel bars to a stationary bike
mation from the body’s extremities to the brain and also be- while a fellow soldier tosses a ball back to his therapist
tween various brain structures, have an outer covering called and another soldier is having his ankle flexed on a bed.
myelin which keeps the signaling quick and crisp. When the Later, Benoit will go for a different kind of therapy, one
nerve fibers are twisted and stretched in a blast, “the protective designed to help rewire brain connections that were
covering gets stripped away,” explains Keith Cicerone, Ph.D., shorted out by the blast—and to develop strategies for coping
director of neuropsychology at the JFK-Johnson Rehabilita- with damage that can’t be repaired.
tion Institute in Edison, N.J. Brain connections formed over a lifetime are severed when
Just as words become unintelligible when a phone line neurons die after a TBI, experts say. Some of these circuits can
NEUROLOGY NOW • SEPTEMBER/OCTOBER 2006 15

5. SPECIAL REPORT ON BRAIN INJURY
Causes of TBI
transportation falls
accidents 28%
be rewired with the right kinds of 44% ity again so they do things a little
therapy; some cannot. And even safer. We’re getting them to pay
when new connections are made, attention, to listen and not get
the substitute circuitry rarely distracted. We’re getting them to
works as well as the original wir- respect other people.”
ing did. That’s because the brain others assaults Often the therapy involves get-
has to wire around the damage, or and ting patients to stop and to think
unknown firearms
using cells that weren’t necessarily out loud about things that were
9% 19%
designed to do the job. once almost reflex. “We try to get
“It’s a teaching process,” Dr. them to say things in their own
Glenn says. “Just as an amputee words—why something might not
might learn to walk in a different way using a prosthesis, you be safe, for example,” Alexis says. “We try to get them to self-censor.
can teach people to do things again by force of habit. Some- The difference here, of course, is that they have to learn not only
times they end up doing it in a different way and sometimes society’s norms, but also military standards. Yes, in society we can
it’s in a similar way.” do X, Y, and Z, but that’s not permissible in the military.”
Some of this mental rewiring is accomplished through rep- And, while it might at first seem that having to learn yet an-
etition, Dr. Cicerone says. This allows you to recruit neurons other set of social rules would complicate a soldier’s rehabili-
that aren’t damaged. tation, it probably makes the journey a bit easier, Alexis says.
For friends and family, the hardest adjustment can be to That’s because the Army provides much-needed structure and
changes in personality and behavior. When the frontal lobes because therapists can use soldiers’ ranks to help them recon-
are damaged, social skills learned over a lifetime are lost. TBI nect with the identity they had before the injury.
patients often don’t see subtle facial cues or pick up on body “Think about how structured the military is,” Alexis says.
language. They sometimes will blurt out any thought that “It’s repetitive, controlled. Everything is based on your rank. I
comes to mind. had a soldier who said to me one day, ‘Don’t call me sir. I’m a
The process of getting these mental abilities back is almost Specialist, not a sir.’ As profoundly injured as he was, he said,
like growing up all over again, experts say. “I often tell fami- ‘I am a Specialist.’ Because of that, I could say, ‘Specialist, stand
lies it’s sort of like having an adolescent,” says Carla Alexis, up straight,’ and he would. As much of a fog as they can be
a therapist who works with brain-injured patients at Walter in, I can say ‘Specialist’ or ‘Corporal’ or ‘Sergeant’ and then tell
Reed. “We’re trying to get them to understand their mortal- them what I need them to do. And those ingrained patterns
will pull them along.”
Ultimately, both the family and the TBI patient need to rec-
TRAUMATIC STATISTICS ognize that there might be some permanent changes.
Therapy can only bring people back so far, Dr. Cicerone
Number of people diagnosed annually with: says. “We’re not looking to make you who you were—but
TRAUMATIC BRAIN INJURIES 1,500,000 who you are now, the person you’ve already become.”
For some soldiers, that may be enough.
Heart attacks 1,200,000 As a result of the bomb blast, James Benoit’s life has changed
Stroke 700,000 in ways nobody could have predicted. When his mother
Alzheimer’s disease 377,000 learned he was injured, she contacted all of his hometown
Breast cancer 176,000 friends, including a woman who started visiting Benoit regu-
larly at Walter Reed. The two grew close. In the fall, the couple
Parkinson’s disease 60,000 will be getting married. “It’s kind of odd,” Benoit says. “In the
AIDS 43,000 end, a lot of good came out of it.” NN
Spinal cord injuries 11,000
Multiple sclerosis 10,000 Linda Carroll is a medical and science writer whose
work has appeared in The New York Times and
Health magazine as well as on msnbc.com.
16 NEUROLOGY NOW • SEPTEMBER/OCTOBER 2006