Army physicians are proceeding with a step-by-step introduction of a
computerized screening test they hope will pick up neurological deficits
resulting from traumatic brain injuries (TBIs) caused by roadside bombs in
Iraq and Afghanistan.
"As the war has changed, there are bigger blasts and thus bigger
exposure," said Col. Jonathon Jaffin, MC, acting commander of the U.S.
Army Medical Research and Materiel Command and a trauma surgeon. In fact, over
80 percent of wounds suffered in Iraq are caused by explosions. Many of the
injured have no open head wounds, but shock waves from blasts may cause a
brief loss of consciousness, ringing and bleeding in the ears, confusion, or
temporary hearing loss.
The Army also wants to alert civilian psychiatrists and other physicians
that they may see more former service members who have had blast injuries or
post-traumatic stress disorder (PTSD).
"Perhaps 70 percent of soldiers with TBI have mild injuries, and the
vast majority recover over time," Jaffin told a press conference at the
Army surgeon general's office in September. Some of the rest may have somatic
or behavioral symptoms that may seem minor to the soldier or even unconnected
to the event. Surveys of soldiers in combat units returning to Ft. Carson,
Colo., found that as many as 17 percent could have mild TBI, he said.
That percentage might not apply to all combat units, but such numbers
aren't available because there has been no comprehensive screening for
"We're pushing to do a lot more surveillance, but even so we know
it's a serious problem, and we have to make an effort now," said
The Army is starting to use the Automated Neuropsychological Assessment
Metric (ANAM), originally developed by military researchers to assess
cognitive side effects of chemical warfare antidotes and pretreatment agents.
It has since been adapted by the Defense and Veterans Brain Injury Center at
Walter Reed Army Medical Center as a screening tool for brain injury.
"The ANAM doesn't replace a clinical evaluation, but it's a great
screening tool," said Jaffin. The test collects standardized, objective
data on cognitive function and reaction time and alerts medical personnel to
changes that signal a need for further medical evaluation. It can then be used
to track a patient's recovery.
"Often, no evidence of neurological impairment shows up on X-rays or
MRIs, so the ANAM gives us a tool to convince officers that a soldier should
come off the line and get evaluated," he said. "Soldiers just want
to shrug off injuries."
That "suck-it-up" attitude can hinder efforts to diagnose and
treat both TBI and PTSD, said Jaffin. "We emphasize confidentiality and
encourage them to get help, but that's a cultural change and won't happen
In part to nudge that change along, the Army began a campaign last summer
to require everyone along the chain of command to learn, teach, and discuss
issues involving TBI and PTSD.
The ANAM is already being used to create a baseline cognitive measure of a
division scheduled to rotate back to Iraq shortly. Soldiers exposed to bomb
blasts or other head trauma will be screened using the same tool. Then the
entire division will go through the same test on their return home to measure
the effects of any mild brain trauma that may have been missed in the war
zone. The Army will evaluate the ANAM's sensitivity, specificity, and accuracy
during this process.
Other tests for TBI—such as quantitative EEG or tests for brain
enzymes released into the bloodstream—are still in the research stage,
While most troops returning from Iraq or Afghanistan will have access to
military or Veterans Affairs health systems, a large minority may go elsewhere
for care, said Col. Elspeth Ritchie, MC, psychiatric consultant to the Army
The stigma attached to PTSD and TBI still remaining among members of the
military may also induce service members who are worried that disclosure may
harm their careers to visit civilian doctors.
"Civilian doctors will see soldiers no longer on active duty and who
live far from VA facilities or are using student health insurance when they go
to college, or are back at work and covered by their employer's health
insurance," said Ritchie. "They should ask veterans—who may
be of almost any age—if they have been exposed to head trauma, blasts,
or other traumatic events," which could indicate a need for further
screening or monitoring.
Civilian physicians should also be ready to help families understand that
TBIs may cause behavioral symptoms such as anger or depression, symptoms that
may appear months or years after a soldier's return from war, said Ritchie.
Finally, pediatricians should be aware that behavioral changes in parents with
TBI or PTSD may affect relationships with their children.
Information about traumatic brain injury is posted at the Department
of Defense's Deployment Health Clinical Center at<www.pdhealth.mil/TBI.asp>.▪