Journalism in the Public Interest

Military Still Struggling to Treat Troops With Brain Injuries

Defense Department leaders and lawmakers have taken steps to improve the diagnosis and treatment of traumatic brain injuries since ProPublica and NPR began a two-year investigation, but progress remains incremental.

(Spencer Platt/Getty Images)

This is part of our year-end series, looking at where things stand in each of our major investigations.

For the past two years, ProPublica and NPR have collaborated on an investigation that looks in-depth at the military's handling of traumatic brain injuries, a signature wound of the conflicts in Iraq and Afghanistan.

More than 115,000 soldiers have sustained mild traumatic brain injuries, also called concussions, in the wars when shock waves from bombs rippled through their brains. Most have recovered quickly, but some have suffered lasting cognitive problems, from headaches and dizziness to problems with memory and reasoning.

As a result of our work, Congress and government investigators have pressed the Defense Department to fix flaws that have prevented troops with TBIs from being properly diagnosed and treated.

In January, Sen. Claire McCaskill, D-Mo., questioned the Pentagon's decision to deny cognitive rehabilitation therapy to troops with brain injuries. Her inquiry came after a story we did about how the Pentagon based its decision not to pay for such care on a much-criticized report from the ECRI Institute. Following the story and McCaskill's inquiry, the Pentagon solicited the help of the Institute of Medicine, which released a report in October urging the Defense Department to do more research on the therapy before offering it more broadly.

Investigators at the U.S. Government Accountability Office have also scrutinized military programs developed to address brain injuries. In a February report, the GAO said that the Pentagon's Defense Centers of Excellence was plagued by weak leadership, uncertain priorities and flawed accounting. The DCOE, which was created after a 2007 Washington Post series exposed the poor living conditions of concussed troops at Walter Reed Army Medical Hospital, couldn't explain exactly how much taxpayer money it received or how it was spent, the GAO report said.

In March, the Army responded to a story we published last year about how soldiers had been denied Purple Hearts after suffering concussions on the battlefield. The Army issued new guidance, making it easier for brain-injured soldiers to get recognition.

Among the reasons the military has struggled to treat brain-injured troops, one of the most obdurate is a lack of neurologists, according to interviews and documents we obtained earlier this year. Policies issued in June 2010 requiring soldiers to receive a comprehensive evaluation when they suffer three or more mild traumatic brain injuries in one year have intensified the need for qualified doctors.

Plus, as we reported in May, more than half of all Iraq and Afghanistan veterans treated in Department of Veterans Affairs hospitals since 2002 have been diagnosed, at least preliminarily, with mental health problems.

One such veteran is Brock Savelkoul, a troubled young man who survived a blast in Iraq. Back home in North Dakota, he embarked on an equally harrowing journey that ended in an armed standoff with local law enforcement officers, who spent hours persuading him not to commit suicide.

Savelkoul, who we featured in a Kindle Single earlier this year, was one of about 300 troops examined in a study conducted by then-Lt. Col. Mike Russell, the Army's leading neuropsychologist. Russell presented his findings in November 2009 and concluded that a computer test being used to evaluate whether soldiers had suffered concussions was "only slightly better than a coin toss."

Russell was referring to the Automated Neuropsychological Assessment Metrics, or ANAM, which the military has given to 1 million troops since 2008 in response to an order from Congress.

Last month, we published a story about how the military came to spend $42 million on the ANAM program, despite the fact that the test was never scientifically proven to detect brain injuries. As part of our investigation, we released a withering report on the ANAM that Russell delivered to members of Congress, which was not previously available to the public. In his critique, Russell lambastes nearly every aspect of the program, saying that "the selection of ANAM was nepotistic, and the long delay in examining alternative instruments is baffling."

Following our story, McCaskill began an investigation into contracts surrounding the ANAM program. Rep. Bill Pascrell, D-N.J., co-chairman of the Congressional Brain Injury Task Force, proposed an amendment to the 2012 National Defense Authorization Act to help fix the beleaguered testing program, but it was pulled from the legislation. Pascrell is now pushing for a large increase in funding for the military's TBI services in this year's appropriations bill.

retrospective criticism always deserves close inspection.

the requirement for a mechanism to test for possible brain injury was immediate: a decision to use ANAM because it was immediately available, while a head to head analysis of it versus other potential tools to detect and quantify brain injury was done, does not seem unreasonable.

an attempt to do a prior head to head analysis, which would have taken some time, before rolling out a tool, any tool, would have been even more criticized.  besides, one of the reports quoted in the withering report to Congress as indicating that the ANAM would not be useful in evaluating brain injury says the same thing about the other evaluated assessment tools.  In other words, there was no scientifically proven tool available, and in the absence of one, a tool already owned by DoD that could be quickly deployed without the contracting process required to obtain a commercial tool, may not have been such a bad idea.

in this debate, there is no winning strategy, and sometimes, the exigencies of responding to Congress and other critics cause decision making that, especially in retrospect, can be seen as poor.  Or not.

Kathleen Roane

Dec. 28, 2011, 4:58 a.m.

There is no scientically valid test that will detect all brain injuries, The military could try adopting policies similar to that of the NHL or NFL in which if a player “has his bell rung” or suffers a blow to the head where he is dazed or altered, he is removed from the playing field or ice and cannot return for a specific period of time or until he passes neurological testing.
This, however, would mean taking a soldier out of the combat arena, which I’m sure, just won’t happen. The problem is successive concussions tend to have an additive effect. As with many illnesses or injuries, response is individual as is recovery. And many don’t display all symptoms/evidence of damage until years after injury.

This is the name i use on my computer.

the discussion confuses concussion with closed head traumatic brain injury. closed head TBI (i have a non-service related closed head TBI) is often caused by violent shaking of the head with no debilitating blow, and the symptoms develop over a period of weeks, generalized pain, nausea, dizziness, weakness, frequent migraine, memory loss, poor concentration, difficulty with math and spatial relationships, improper comments, sudden rage, social isolation, an inability to remember the names of things, violent nightmares and severely disturbed sleep. improvement is slow, especially the first three years, and uncertain. complex tasks become difficult or impossible, employment problematic, personal relationships strained to the limit. it is difficult to diagnose, i think most people still self diagnose because the majority of doctors and many neurologists don’t know it exists. try convincing an insurance company! that thousands of GIs have this injury is one of the saddest results of our decade of sad sack wars…

Angela Gardner

Dec. 30, 2011, 5 p.m.

There needs to be better tools used by the VA and the military to screen for TBI than a computer program. Why is it that in the civilian medical system and sports medicine there are effective ways to screen and diagnose concussions. The Pentagon is making this process way too complicated by creating a complex computer program to screen for concussions instead of looking into how other neurologist identify concussions in the civilian medical system.
Also I feel that the Pentagon is stalling on approving cognative rehabilitation therapy as a treatment for soldiers with TBI by doing another study. They don’t want to pay for the cost of the therapy that’s why they are denying it to our service men and women.
Look at the astonishing progress of Rep. Gabby Giffords which is mostly due to this type of therapy. It works.

To echo the points of others, there isn’t going to be a magic wand to instantly diagnose every brain injury.  It may well be impossible.  Imagine looking at a picture of a city (or being allowed to ask a civil servant three questions) and trying to figure out where the three smartest people in town live.  There may be some vague indicators, and sometimes the information is right on the surface, but certainty in all cases would be absurdly difficult.

To that end, ANAM sounds like a start.  It needs work, it needs to be applied properly, and (so people like us aren’t armchair quarterbacking and the first two goals can be accomplished) it needs to be published so we can see how it’s trying to work.

Where that’s not happening—where ANAM isn’t being improved or its results are being discarded to keep boots on the ground—the respect for our soldiers needs to be improved to the point where their lives are valued more than the government’s outdated image of infallibility.

This article is part of an ongoing investigation:
Brain Wars

Brain Wars: How the Military Is Failing Its Wounded

The military has failed to diagnose brain injuries in thousands of soldiers returning from overseas.

The Story So Far

Traumatic brain injury is considered the “signature wound” of soldiers fighting in Iraq and Afghanistan. Official military statistics show that more than 115,000 soldiers have suffered mild traumatic brain injuries since the wars began. Shock waves from roadside bombs can ripple through soldiers’ brains, causing damage that sometimes leaves no visible scars but may cause lasting mental and physical harm.

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