The VA's real surprise is the low number of diagnoses for traumatic brain injury (TBI), which has become one of the signature injuries in the Iraqi/Afghanistan conflict due to the large number of roadside bombs, mortars and rocket-propelled grenades.
Four years ago, the Rand Corp. interviewed 1,965 vets and projected in its controversial 2008 report that 18.5 percent of all returning service members would meet the criteria for either PTSD or depression (14 percent for each, but there's some overlap), and that another 19.5 percent would experience a probable TBI while overseas. Again after taking into account that overlap, it said 31 percent of all returning troops would suffer from one or all of those ailments.
The VA's actual treatment figures show 28.5 percent of the returning vets are seeking mental health care, which is right on track with the Rand Report. But while the Rand Report projected that some 320,000 American soldiers would need help for TBI, the VA says only 54,070 vets (a little over 4 percent of the returning vets) qualified for that diagnosis.
"That's absurd, preposterous, erroneous," snorts Mike Zacchea, a Marine Corps lieutenant colonel retired on a medical disability after service in Iraq, where he survived a bomb in a mess hall, almost daily sniper attacks, mortar attacks on his unit's convoy, and a rocket wound during intense combat in Fallujah. All of those took a huge physical and emotional toll on Zacchea.
As of last June, the VA had data on 544,481 vets whose brains might have been affected by battlefield explosions, according to Dr. David Cifu, national director of the VA's Physical Medicine & Rehabilitation program. Of that number, he says, "19.8 percent have screened positive for a mild TBI (concussion), that is were exposed to explosions that might have caused traumatic brain injury.
"When those 19.8 percent of veterans were evaluated by one of the 100 TBI specialty teams across the nation, approximately one third (or 7.8 percent of the original 544,481) tested positive for TBI with persistent symptoms," says Cifu. "Another approximately 2 percent were found to have a TBI that pre-dated their military service. Those two figures (the 7.8 percent plus the 2 percent) add up to 54,070 veterans."
The difference, says Cifu, is that the Rand Report used the total number of injuries as its TBI figure while the VA used only the number of vets still showing TBI symptoms a year after their injuries.
"The Rand Report was pretty accurate on the number of those who may have had injuries due to a blast, but didn't take into consideration that many of those may have injuries that will fairly quickly get better over time," says Cifu. "We know that up to 97 percent of those who experience concussions are normal without symptoms within a year. So we're tracking just the people who continue to have difficulties."
But Zacchea, a staunch member of Veterans for Common Sense, charges that the VA is trying hard to deny this disability. "Today's cutting edge neurology is that any symptoms that last longer than two weeks indicate traumatic brain injury," says Zacchea. "They're using the one-year time frame because that benefits them, but that's just medieval."
Zacchea says he was quickly diagnosed with post-traumatic stress disorder after returning from combat, but that he had to fight for his TBI diagnosis. "They wouldn't even let me see a neurologist," he says. So he took his case to the Yale Medical School, got a private diagnosis of TBI and challenged the VA to disprove it. After a number of verification tests, he was finally granted a TBI diagnosis by the VA in 2008.
His ongoing symptoms include migraine headaches, sensitivity to light and noise, and loss of fine motor skills. "My fingers are numb, and I'm always dropping things," he says. "I have difficulty tying my shoes so I usually wear slip-on shoes." He also has a distinct taste in his mouth. "I've lost most of my taste sensation," he explains, "so I put hot sauce on pretty much everything."
A new book, The Concussion Crisis, concludes that even minor concussions repeated regularly can be harmful, leading to impaired cognition and ultimately early-onset dementia among athletes such as boxers and football players, as well as among soldiers. In reviewing the book, Connie Goldsmith wrote: "There is no such thing as a minor concussion. Every concussion is a potentially devastating injury. These stories focus on concussions among athletes of all ages, as well as concussions among soldiers and victims of auto accidents. Some of the stories are heartbreaking: adolescents who suddenly die after what appear to be minor head injuries; boxers and football players with early-onset Alzheimer's disease and dementia; and returning veterans left to wander through the medical system seeking treatment for their unrecognized or misdiagnosed concussions."
Dr. Allen Brown, head of the Mayo Clinic's Brain Injury Unit, defines a TBI as an external mechanical force impacting a body and creating a brain injury. Thus, by definition, every concussion is a TBI and should be part of the medical record.
But in the civilian world, he says, only about 8 percent of brain injuries are severe enough to be labeled a "definite TBI," as opposed to a "probable TBI" which is milder or a "possible TBI" which is symptomatic. A "definite TBI" involves any of the following: loss of consciousness for more than 30 minutes, post-traumatic amnesia for more than 24 hours, significant loss of motor skills as measured on the Glasgow Coma Scale, or intracranial bruising or bleeding.
Brown agrees with Cifu that "an overwhelming majority" of brain injuries resolve themselves, although repeated injuries increase the risk of significant damage. "It's pretty clear to me that the cumulative effect of any injury increases the risk for secondary problems, including repeated TBIs that could lead to loss of cognition later in life," he told me. "It may not happen in every case, but the risk is whoppingly high."
And he calls the disparity between the Rand Report and the VA's definitions of TBI "one of the most argued-over controversies in medicine."