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Jack Sisson's TBI Blog

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New York Times, May 31, 2007 --
The rate of diagnosed clinical depression among retired National Football League players is strongly correlated with the number of concussions they sustained, according to a study to be published today.

The study was conducted by the University of North Carolina’s Center for the Study of Retired Athletes and based on a general health survey of 2,552 retired N.F.L. players. It corroborates other findings regarding brain trauma and later-life depression in other subsets of the general population, but runs counter to longtime assertions by the N.F.L. that concussions in football have no long-term effects.

Later in the article:
While consistently defending its teams’ treatment of concussions and denying any relationship between players’ brain trauma and later neurocognitive decline, the N.F.L. has subsequently announced several related initiatives. The league and its players union recently created a fund to help pay the medical expenses of players suffering from Alzheimer’s disease or similar dementia. Last week, N.F.L. Commissioner Roger Goodell announced wide-ranging league guidelines regarding concussions, from obligatory neuropsychological testing for all players to what he called a “whistle-blower system” where players and doctors can anonymously report any coach’s attempt to override the wishes of concussed players or medical personnel.

Mr. Goodell said last week that the league’s concussion committee had just begun its own study “to determine if there are any long-term effects of concussions on retired N.F.L. players.”

Dr. Casson, the committee’s co-chair, said that players who retired from 1986 through 1996 would be randomly approached to undergo “a comprehensive neurological examination, and a comprehensive neurologic history, including a detailed concussion history,” using player recollection cross-referenced with old team injury reports. He said that the study would take two to three years to be completed and another year to be published.
Read the complete article here.

Also, don't miss this site for more information about head injuries and football (from youth ball to the NFL).

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Rene Magritte, 'Le-Paysage-de-Baucis' (1966), etching on woven paperMuch of the content here on the TBI blog -- especially lately -- focuses on attention devoted by the media to traumatic brain injuries suffered on the modern battlefield. But veterans' hospitals and medical tents are far from the most likely places where you'll encounter someone suffering from TBI. Indeed, you may have to look no further than the next cubicle, desk, assembly-line station.

That's part of the message of a brief publication put out by the Job Accommodation Network (JAN) at West Virginia University. (124KB PDF version also available.)

Never heard of JAN? From their "About" page (emphasis added):
The Job Accommodation Network is a service of the Office of Disability Employment Policy (ODEP) of the U.S. Department of Labor... JAN's mission is to facilitate the employment and retention of workers with disabilities by providing employers, employment providers, people with disabilities, their family members and other interested parties with information on job accommodations, self-employment and small business opportunities and related subjects. JAN's efforts are in support of the employment, including self-employment and small business ownership, of people with disabilities. JAN represents the most comprehensive resource for job accommodations available. JAN's work has greatly enhanced the job opportunities of people with disabilities by providing information on job accommodations since 1984. In 1991 JAN expanded to provide information on the Americans with Disabilities Act.
Yeah: since 1984. Twenty-three years of something very like invisibility, and darn those big-government bureaucracies anyway. [Sarcasm off.]

The invisibility of JAN parallels the invisibility, for the most part, of brain-injured workers. Someone who's been in an automobile accident or suffered a football or boxing injury may or may not evidence physical symptoms, like scars, broken limbs, and other alterations in their appearance. But there's nothing intrinsically visible about a TBI. From the JAN site:
...There are several different types of TBI (TBI Recovery Center, 2006):

Concussion: A concussion is the most minor and common type of TBI. A concussion is caused when the brain receives a somewhat minor trauma from an impact, such as a hit to the head by an object or person or from a sudden change in momentum, such as a fall. It may or may not result in a short loss of consciousness (not exceeding 20 minutes) and can be diagnosed by observing common symptoms such as headache, confusion, and vomiting. Difficulty with thinking skills (e.g., difficulty "thinking straight," memory problems, poor judgment, poor attention span, a slowed thought processing speed) (Brain Injury Association of America, 2006a; TBI Recovery Center, 2006).

Skull Fracture: A skull fracture occurs when the skull cracks or breaks. A depressed skull fracture occurs when pieces of broken skull press into the tissue of the brain. A penetrating skull fracture occurs when something pierces the skull and injures the brain (Brain Injury Association of America, 2006a; TBI Recovery Center, 2006).

Contusion: A contusion is bruising or bleeding of the brain (Brain Injury Association of America, 2006a; TBI Recovery Center, 2006).

Hematoma: A hematoma is a collection of blood inside the body (Brain Injury Association of America, 2006a; TBI Recovery Center, 2006).
With the possible exception of a skull fracture, in other words, everything going "wrong" with a TBI victim is going wrong inside:
...Symptoms of mild TBI include headache; confusion; lightheadedness; dizziness; blurred vision or tired eyes; ringing in the ears; bad taste in the mouth; fatigue; a change in sleep patterns; mood changes; and trouble with memory, concentration, attention, or thinking. The injury may or may not result in a brief period of unconsciousness.

...Symptoms of moderate to severe TBI may be similar to symptoms of mild TBI, but they may also include a headache that gets worse or does not go away, repeated vomiting or nausea, convulsions or seizures, inability to awaken from sleep, dilation of one or both pupils of the eyes, slurred speech, weakness or numbness in the arms or legs, loss of coordination, increased confusion, restlessness, or agitation.
Even those TBI symptoms which are observable can be easily dismissed as symptoms of something else: not enough sleep, drunkenness or hangover, a bad chunk of pork in the lunchtime takeout.

Furthermore, the above list scarcely addresses the most potentially debilitating conditions resulting from a TBI:
  • Depression about not being able to get help with your problem.
  • Depression, for that matter, about not being able to describe your problem adequately so help can be obtained in the first place.
  • The misery of knowing that you know something critical to your job function but can't quite put your finger on it, and the guilt and embarrassment that may go along with that failure.
  • Isolation from your co-workers who have no notion of what you're experiencing.
The JAN site's page on TBI-disabled workers is meant to assist supervisors in making accommodations for these employees. That said, it's worth a visit by anyone with an interest in TBI. It's brief, but eye-opening. And -- not to put too fine a point on it -- you won't be able to see anything at all as long as your eyes are closed.

Labels: , , , , , ,, 05/24/2007 - As many as 20% of service members returning from duty in Iraq and Afghanistan will have some level of traumatic brain injury.

This spring the Department of Defense acknowledged traumatic brain injury as a "significant health concern" and vowed to identify it among active duty troops. But many new cases are likely to emerge as troops transition to civilian life as veterans.

Military records show that 60% of the 25,000 war injuries to date resulted from explosive blasts like IED's or roadside bombs. And nearly 3,000 of the wounded are currently being treated for severe traumatic brain injury or TBI.

Fresno V.A. Hospital emergency room doctor James Lindsay says injuries in this war are different from other wars when bullets did the majority of the damage.

Dr. Lindsay, Fresno V.A. E.R. physician, says "there's less ballistic wounding from actual gunfire and more blast injuries and blast injuries typically produce traumatic brain injuries." And those blasts can leave an injury without ever breaking the skin.

Read the article here.

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News about brain injuries in Iraq doesn't stop:
Frontline combat troops in the Iraq war have at least a one in five chance of coming home with a brain injury, according to Chris Elia, a Veterans Affairs psychologist who spoke Friday about traumatic brain injuries in veterans at the second annual Black Hills Brain Injury Conference in Rapid City.

“And I suspect it’s a much higher chance than that,” Elia said, presenting an array of statistics about what has become the “signature wound” of the wars in Iraq and Afghanistan.

Of the 23,000 U.S. soldiers, marines and other military personnel who have been wounded in Iraq and Afghanistan since 2002, more than 6,500 have been diagnosed with traumatic brain injury, according to military figures. Elia said those numbers are probably low, given what today’s war is still teaching medical experts about blast injuries.
What a shame that it's literally taken a war to bring TBI front and center. Hardly a day goes by now that TBI is not in the news, and word of advances in TBI research hits the media with unusual frequency. Advocates for brain injury research have wanted this for a long time, but who could have forseen that a war would be necessary to accomplish it? The universe does indeed work in mysterious ways, but I can't imagine anyone who'd have chosen this route to brain-injury awareness.

Read the complete article here.

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Child Health News Wednesday, May 16, 2007 -- Traumatic brain injury is the leading cause of abusive death in children and is especially common in abused children under the age of 4. Fifteen hundred children a year in U.S. are killed because of traumatic brain injury and those who survive are often devastated.

It is impossible to do randomized controlled studies of abusive head trauma but researchers need to develop improved tools to correctly identify and ultimately prevent this abuse according to Dr. Laskey.

"We have to understand abusive head trauma. Research in the field is in its infancy compared to what we know about other pediatric conditions. We need to increase both the volume and the quality of what we know. We need to know more and we can't until we have pediatricians and pathologists, the doctors who see these children, speaking the same language," said Dr. Laskey.

Here's the complete article.

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'Red Tree Sky,' photo by Greg Olsen, copyright 2007
No matter your politics, I hope you'd agree that it's a strange world in which wars are said, dispassionately, to have "signature injuries." For the American Civil War, maybe this was battlefield amputations; for World War I, trench mouth or gas-attack symptoms; for Vietnam, I guess, post-traumatic stress; and for the original Gulf War, various Agent Orange-related afflictions.

Here at, we've noted before (recently, for example, here) that traumatic brain injury is widely regarded as the signature wound of the current war in Iraq. This sad state of affairs has at last received Federal attention, in the form of a Congressional ruling that soldiers must be tested for TBI before and after their Iraq deployments. This news came at the end of last week, in a report from USA Today. This comes roughly concurrently with a report from the Defense Department itself, per the Associated Press.

From USA Today:
The Pentagon must use computers to screen troops before and after they go to Iraq or Afghanistan to better determine whether they suffered traumatic brain damage in combat, according to a plan by a congressional brain-injury task force...

Congress has authorized a record $450 million for brain-injury treatment and research in the Iraq spending bill being negotiated by Congress and the White House. Legislators say the Pentagon acted slowly on this issue.

"The military was blindsided by the number of blast injury victims in Iraq and Afghanistan, and it is clear that the proper resources were never in place to care for them," says Rep. Bill Pascrell, D-N.J., co-chairman and founder of the 112-member Congressional Brain Injury Task Force.

And from the Associated Press:
Issuing an urgent warning, the Defense Department's Task Force on Mental Health chaired by Navy Surgeon General Donald Arthur said more than one-third of troops and veterans currently suffer from problems such as traumatic brain injury and post-traumatic stress disorder.

With an escalating Iraq war, those numbers are expected to worsen, and current staffing and money for military health care won't be able to meet the need, the group said in a preliminary report released Thursday.

"The system of care for psychological health that has evolved in recent decades is not sufficient to meet the needs of today's forces and their beneficiaries, and will not be sufficient to meet the needs in the future," the 14-member group says.
There have also been a couple of other recent news items on this issue:

As increasingly elaborate body armour protects the torso, and even the limbs, the brain is still vulnerable to shock waves that helmets cannot deter... And these "closed-head" injuries are harder to treat than even those commonly suffered by motorcyclists.
  • From the San Antonio Express-News, "Troops living with brain injury":
    ...untold thousands of U.S. troops [are] returning from the Middle East with a brain injury, the signature wound of the war in Iraq and a rising challenge stateside for everyone from doctors to lawmakers.

    Overtaxed military medical facilities have farmed out many cases [...] to private rehabilitation centers at an unprecedented pace, raising questions about oversight and quality of care and forcing the military to rethink preventing and screening for such injuries, many of which are hidden...

    In Iraq, modern body armor protects troops from bullets and shrapnel. Not even a padded helmet can keep a riveting blast from pounding the brain against the ridges inside the skull, causing bruising or swelling or stretching its nerve fibers. The injuries often aren't seen on CT scans or MRIs.

    But they can cause a loss of balance, memory or cognitive skills that might not appear until a year after deployment. Even civilians who don't live by the tough-and-ready ethos of the military are hesitant to seek help.

  • From Army Times, "Soldier says he was deployed with head injury":
An MRI later showed that Thurman had lesions on the right parietal lobe of his brain, a condition that led to a “don’t deploy” order — which the Army violated, according to Thurman. Worse, rather than providing compassionate understanding of the symptoms associated with traumatic brain injury, he said leaders at Fort Carson, Colo., have harassed him, refused him medication and pushed for an Article 15.

Thurman stepped forward Friday as one of the 18 soldiers whose cases were cited by six senators in a letter to the Government Accountability Office requesting a review of alleged improper handling of traumatic brain injuries, post-traumatic stress disorder and ungrounded personality disorder discharges.

The letter was sent after an Army surgeon general investigation into the cases said the soldiers were handled properly — but the soldiers involved said no one from the surgeon general’s office ever talked to them in the course of that investigation.
As an aside, if you -- like I -- were previously unfamiliar with the term "Article 15": It refers to a section of the Universal Code of Military Justice, or UCMJ. Generally, it's one of the UCMJ's "punitive articles." According to Rod Powers,'s "Guide to the US Military," Article 15 is one of several procedures
whereby the commanding officer or officer in charge may:
  • Make inquiry into the facts surrounding minor offenses allegedly committed by a member of his command;
  • afford the accused a hearing as to such offenses; and
  • dispose of such charges by dismissing the charges, imposing punishment under the provisions of Art. 15, UCMJ, or referring the case to a court-martial.
To initiate Article 15 action, a commander must have reason to believe that a member of his/her command committed an offense under the UCMJ. Article 15 gives a commanding officer power to punish individuals for minor offenses... The term "minor offense" ordinarily does not include misconduct which, if tried by general court-martial, could be punished by a dishonorable discharge or confinement for more than one year. The military services, however, have taken the position that the final determination as to whether an offense is "minor" is within the sound discretion of the commanding officer.
Note that the soldier whose case is covered in the Army Times piece claims about his post-TBI treatment that his superiors have "pushed for an Article 15." I understand that the military code of justice must be different than the civilian. But if this claim is at all true, I hope the military at least stops to reflect on ways in which Article 15 can be abused -- if not outright criminalizes the abuse.

[Updated 2007-05-09 7:56 pm]

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