For centuries it has been recognised that alongside risking their lives for their country, service personnel are exposed to the psychological consequences of traumatic events on the battlefield and physical damage to the brain. In the US, this has been underlined through the sheer numbers participating in active combat; since 11 September 2001, more than 2.5 million American service members have been deployed to Iraq and Afghanistan.
Recognising the need to improve scientific understanding, develop effective treatment, and reduce the occurrences of the conditions and associated suicides, in August 2012 President Obama issued an Executive Order for a coordinated National Research Action Plan. In response, the Departments of Defence (DoD), Veterans Affairs (VA), Health and Human Services, and Education came forward with a wide-reaching plan to study these conditions in more depth in collaboration with academic institutes.
The Consortium to Alleviate PTSD (CAP) will attempt to develop diagnostic and prognostic methods, and novel treatments and rehabilitative strategies to treat acute PTSD and prevent chronic PTSD; and the Chronic Effects of Neurotrauma Consortium (CENC) will examine the factors which influence the chronic effects of mild TBI (mTBI) and associated conditions in order to improve diagnostic and treatment options.
For Dr. Robert Jaeger, director of deployment health research in the Veterans' Affairs Office of Research and Development, the collaborative nature of the research is essential to its success.
"This represents an unprecedented cooperation between the VA and the DoD," he says. "Using TBI as an example, the DoD has research programmes into what happens right after the blast, which the VA can't engage in. On the other hand, the VA is concerned with the long-term effect of and the chronic effects of multiple concussions, because we care for these veterans."
Dr David Cifu, chairman of the Department of Physical Medicine and Rehabilitation (PM&R) at the Virginia Commonwealth University (VCU), part of the CENC consortium, says: "The effects of brain injuries have been described in every conflict America's ever been in. I think it's wonderful the government realises we need to take it to the next level so veterans and service members will get more answers."
Traumatic brain injury - cause and effect
According to Cifu, the number one cause of TBI is concussive events, typically from blasts, such as improvised explosive devices, rocket propelled grenades or any other explosion.
"When you have the force of a wall of air pressure coming at you, or you're thrown to the ground and you hit your head, your brain is moved very rapidly forward and backward," he says. "This can cause the brain to have a concussion or a mild brain injury."
The effects of mTBI can be wide-ranging and vary over time.
"When it first happens, the classic symptoms are what is known as an alteration in consciousness," says Cifu. "In plain terms, you had your bell rung, you saw stars, and you heard birds. You feel a little woozy, you're disorientated, you're not exactly sure of what's going on. Within the next five to 60 minutes, we'll see problems with headache and dizziness. Sometime after that, maybe 30 minutes to a couple of hours, we can see some nausea, even vomiting, with persistence of headache and dizziness. Then we start to have memory difficulties, which start at the scene but add up over the course of hours to weeks."
"The last thing that is more chronic is behavioural changes, which can occur days to weeks afterwards, with irritability, poor frustration tolerance, difficulty in interpersonal skills and social skills," Cifu concludes.
Jaeger adds: "There's a variety of exposures in terms of severity, so consequently there's a variety of reactions. In PTSD typically if people observe something distressing they might have difficulty sleeping or aggressive outbursts, and these vary highly between people. Sometimes people with different degrees of TBI people have trouble paying attention, and in both conditions some will experience depression. As you can imagine with a spectrum of levels of severity, there's also a spectrum of treatments."
Biomarkers for diagnosis and treatment
Because of the wide variety of symptoms these conditions present and the timescales over which they manifest themselves, Jaeger would like the identification of specific indicators known as biomarkers to be a be goal of the research.
"For example, the blood sugar level is an accepted measurement technique for diabetes, and if you break your arm, you can have an X-ray to confirm it to the clinician," he says. "In terms of a biomarker for TBI, some blood test, neuroimaging, or other measurement could do a better job of indicating whether a TBI is present and how severe it is. That biomarker could also be used to indicate if the condition is getting better or worse when a treatment is being introduced."
Cifu would like the research to investigate how mTBI develops over time in a military population.
"Very few people have done longitudinal ongoing research into concussion or mild brain injury, particularly in the military population, as almost all the research has been done in sports conditions like NFL players," he says.
Jaeger believes there is a significant overlap with the NFL research. We're partnering with a site in Boston that collects the brains of NFL players that die to understand why football players have a greater propensity to commit suicide or have issues," he explains. "Brain injuries are brain injuries whoever they occur in. but there are differences between athletes and service members, so let's explore those and maybe that can give us some answers."
Cifu also wants to look into innovative interventions that expand on traditional methods where clinicians educate the patient and treat their symptoms. These could include computer of smartphone app tools, and using alternative and complementary medicine, medications or to push recovery forward. He also wants to investigate secondary brain injuries.
"Once you've had one brain injury, you have up to 10 times the risk rate of getting another due to a range of factors," he says. "We want to see how we can prevent that second injury with protective gear, with information and lifestyle changes."
The five years over which these consortia are funded is a short time in research circles, but the investigators have clear ideas about the results they'd like to see by the end of this period, and Cifu and Jaeger agree that amalgamating the finings is crucial.
"If you asked 10 concussion experts about recovery and outcomes, you'd probably get 12 different answers," Cifu says. "People can do amazingly well or badly with similar factors because you didn't take into consideration their epigenetics, or their substance use or other comorbidities. So we're going to try and put it on a single grid for a standardised patient, but recognise the factors that influence how they'll do."
Jaeger agrees that being better able to better analyse the data could help improve outcomes. "In clinical studies you need a large sample size. With the spectrum of severity in these conditions, seeing what works in a mild case might not work in a severe one and vice versa. Better analysis of our existing clinical data and trying to share data between the VA and DoD could conceivably help in that. The more information you have about a patient, the better."
It could be years before the research by the CAP and CENC consortia results in new clinical treatments, but de-stigmatisation of these conditions is as important as recognising the need for the studies.
"When an individual goes out and serves their country and loses an arm in battle, that's a very powerful symbol, says Jaeger. "When you talk about a TBI or PTSD, these are not visible; the person looks the same, but their brain is impaired due to the physical injury or the traumatic event they were exposed to. But since the beginning of the current conflict, my personal observation has been there's been a great increase in awareness."
With research and recognition working hand in hand, the outcome for TBI and PTSD sufferers could be much improved over the decades to come.