On a visit recently to the Neurosurgery Clinic at the Medical College of Georgia in Augusta, I found on every table in the waiting room stacks of a magazine called NeurologyNow – Your Trusted Resource for Brain Health (August/September 2015 NeurologyNow.com). [View article online.] The target audience for this publication is the patient and family members who come to the doctor’s office with neurological/neurosurgical problems. After reading through this edition of NeurologyNow, I thought it should be mandatory reading for parents before their children participate in various athletic activities. The article of interest to me was titled “Heads First” and the person headlined (no pun intended) was Candy Parlow Cone who was known as one of the world’s best “headers” during her career in women’s soccer. She participated as part of the US 1999 World Cup team and in three Olympic Games. She sustained numerous so-called mild brain injuries and developed a chronic post-concussion syndrome. From her own experience, Ms. Cone stated, “We need to protect our youngest, most vulnerable kids. Each child has only one brain, and the effects of concussion, particularly repeated concussions, can last a lifetime.” [Watch an interview with Cone on HBO’s Real Sports.]
In this clear and comprehensive article a brain injury expert, Jeffrey Kutcher, MD, director of the Michigan NeuroSport Program and Associate Professor at the University of Michigan Medical School, states:
“We’ve come to appreciate that blows to the head can be more serious and require more lengthy recovery than anyone recognized even five years ago….We also know that concussion can occur without a direct hit to the head, for instance when the head moves quickly in response to a blow to the body. There’s a greater understanding not only of the potential long-term effects of these injuries, but also of the complexities of evaluating, diagnosing, and managing injuries in real time.”
This vital information is based on reliable published medical research that has been building our knowledge over the last 70 years. Now, in the last 15 years there has been a revolution in neurology and neurosurgery in regard to study of brain injury. The severity of injuries to the head and brain were documented in the Edwin Smith Surgical Papyrus from in the seventeenth century B.C. But serious consideration of the neuropathology of concussion started during and after World War II. A neurosurgeon buy the name of A. Earl Walker published the first land mark study in the Journal of Neurosurgery in March 1944, entitled The Physiological Basis of Concussion. [View article online.] Such studies were primitive compared to the data now available, in the era of CT and MRI scans of the brain and discoveries in neurochemistry. The definition of concussion is now in question, since we know significant brain pathology can be present even when there is no loss of consciousness and no neurological signs or symptoms.
As noted in previous posts to this blog (see Riding the White Dragon) on August 13th, long term neurodegenerative impairment can follow so-called minor injuries, particularly with repeated injuries. This occurs not just in children and adolescents, but also in adults, such as professional athletes; and, of course in members of the United States military. Remember, the force effect on the brain of a soldier who is exposed to a blast injury from an IED or road-side bomb is exponentially greater than the effect of a blow to the head in football, lacrosse, hockey or soccer.
The alarm has been sounded about brain injuries and slowly the public is beginning to listen. However, as our history tells us, the response to preventive public health initiatives has always been extremely slow; witness the worldwide deafness to the hazards of tobacco use, or the continued ongoing resistance to the use of vaccines; to say nothing about the use of cannabis preparations, which cause severe degenerative changes to the brain. It is possible the stories of professional football players with early dementia (chronic traumatic encephalopathy or CTE) will filter down to college, high school and Pop Warner football, but don’t hold your breath. Continued failure to deal with this epidemic is like—well, hiding our heads in the sand.
I will burden the reader with additional sources supporting this thesis – that there is no minor brain injury – studies published within the last month. JAMA Neurology published online August 3, 2015 a study entitled Peripheral Total Tau in Military Personnel Who Sustain Traumatic Brain Injuries During Deployment. [View article online.] The principal investigator, Anlys Olivera, PhD and a team of co- investigators reported the following:
“Approximately one-third of military personnel who deploy for combat operations sustain 1 or more traumatic brain injuries (TBIs), which increases the risk for chronic symptoms of post concussive disorder, posttraumatic stress disorder, and depression and for the development of chronic traumatic encephalopathy. Elevated concentrations of tau are observed shortly following TBI.”
Please note, that the figure of approximately one-third of deployed military personnel sustain TBI is a very gross under estimation because TBI can occur with blast exposure without the person knowing they have sustained trauma. Still, the conclusion of the study is the “military personnel who report multiple TBIs have long-term elevations in total tau concentrations. The total tau concentrations relates to symptoms of post-concussive disorder.” In face of this information, it is fair to ask the Department of Defense and Veterans Administration what are they doing to prevent these injuries and to prevent the development of the long term chronic effects of “mild TBI” – as they describe it.
Lest the significance of this information is lost, it should cause profound consternation to learn the actual numbers of reported medical diagnoses of TBI as reported by the DOD or specifically the Defense and Veterans Brain Injury Center. This website, in their own words, “provides numbers for service members diagnosed with TBI since 2000, listed in total and identified by service and injury severity.” It should be remembered that this information is collected from medical records and does not include the military personnel who were traumatized but were told, “Take a knee and then move on.” I strongly recommend you sit down to read the following figures. The total number of DOD TBI worldwide for the years 2000 through 2014 is documented by the DOD to be 313,816. That is correct: three hundred and thirteen thousand eight hundred and sixteen cases recorded in medical records. That does not include the military personnel who were exposed but did not report an injury or did not realize they sustained an injury. The highest number of TBIs was in 2011 with 32,668. Only the first three quarters of 2014 were reported with 18,564. [View data online.] This information begs the question: is the VA prepared to handle the tsunami of traumatic encephalopathy that is rolling toward its halls in the years to come?
If this is not enough to hold your head in astonishment about how the DOD deals with medical information, let me share, in light of current knowledge provided in editions of this blog, how the DOD rationalized these astounding numbers. Remember, I am quoting from a DOD public document available to all readers. “Every service member who was diagnosed with a TBI has still and/or is still receiving appropriate care.” This is a preposterous statement and prompts the question: 313,816 soldiers have actually been involved in appropriate care? It strains credulity even more when the same document stated the following: “The vast majority of TBIs sustained by members of the U.S. armed forces is still mild, also known as concussion, and of those service members who sustain an mTBI, most recover and return to duty within seven to 10 days.” The truth is, in light of current knowledge, there is no such thing as a mild brain injury. Most soldiers exposed to the massive effects of blast injuries are not adequately evaluated, and even then they return to duty to be re-exposed, often many times, and still do not get treatment. There is no indication the DOD, or at least the medical command of the Army recognizes the gravity of this situation. Soldiers and their families will be paying the price of these so-called “minor brain injuries” for years to come. Meanwhile the Surgeon General of the Army and her subordinates continue to ignore the most profound medical issues determining the health of the American soldiers. [See a future post to this blog entitled, The Shameful Performance Triad of the United Stated Army.]
There is another recent publication supporting the above concerns about so called mild brain injuries in the Journal of Neurosurgery, on line, August 21, 2015. It is basic research entitled Structural and biochemical abnormalities in the absence of acute deficits in mild primary blast induced head trauma. [View article online.] Michael Walls and colleagues summarize their findings in the following:
“Blast induced neurotrauma (BINT), if not fatal, is nonetheless potentially crippling. It can produce a wide array of acute symptoms in moderate-to-severe exposures, but mild BINT is characterized by the distinct absence of acute clinical abnormalities. The lack of observable indications for mBINT is particularly alarming, as these injuries have been linked to severe long-term psychiatric and degenerative neurological dysfunction.”
Thus, the evidence about this future neurological endemic continues to build, but in the Department of Defense and the Veterans Administration there is remarkably no appropriate action, reaction or planning.
For those interested in exploring the history of research on concussion and mild traumatic brain injury, the Journal of Neurosurgery (JNS) published a collection of articles on this topic in June 2012; the articles date from 1944 to 2012. [View online.] There is also an associated list of 184 reference articles on concussion and mild brain injury.