NYTimes- Symptoms of Traumatic Brain Injury Can Persist for Years

Symptoms of Traumatic Brain Injury Can Persist for Years
By JAMES DAO
Doctors have long thought that if you ding your head playing sports or in an automobile accident, the concussive effects — headaches, dizziness, memory problems — would fade away with a little rest.

But a new study out of the University of Oklahoma suggests that the symptoms of combat-related traumatic brain injury can last for years without decreasing in intensity.

The study, which was presented at the annual meeting of the American Headache Society last month, looked at 500 veterans of the wars in Iraq and Afghanistan who, between June 2008 and April 2011, had screened positive for traumatic brain injury during deployment. The veterans were being treated at a special traumatic brain injury clinic at the Oklahoma City Veterans Affairs Medical Center.

A second level of screening administered to those 500 veterans tried to gauge the persistence and severity of head injury symptoms, including headaches, dizziness, poor coordination, depression, and problems with judgment or memory. Grouped together, those symptoms are known as post-concussion syndrome.

The researchers organized the data based on whether the veterans had experienced a traumatic brain injury within the previous four years, or five to eight years before the screening.

What they found was dispiriting: none of the symptoms of post-concussion syndrome seemed to improve over the eight years.

Nearly half of the veterans who had traumatic brain injury within the previous four years reported that they were still having mild-to-moderate headaches. Nearly as many, about 46 percent, said they were experiencing severe headaches.

Those numbers were almost the same for veterans who had experienced traumatic brain injuries five to eight years before, with about 45 percent reporting mild headaches and 51 percent saying they had severe headaches.

The same pattern occurred in the data for five other symptoms of post-concussion syndrome: dizziness, balance, coordination, decision making and depression. The majority of veterans in the study screened positive for all of those symptoms except depression.

“What this says is we’re not seeing recovery in veterans with these head injuries,” said Dr. James R. Couch, a professor of neurology at the University of Oklahoma medical school and the lead author. “In fact, there is a tendency that things are getting just a little worse.”

Dr. Couch said the closed-head injuries could be particularly insidious because the veterans look normal but are experiencing pain or cognitive problems that can completely disrupt their lives.

He said that the symptoms worsened more for veterans who had had more than one traumatic brain injury, suggesting a cumulative impact of head injuries. Previous research has also pointed in that direction.

Most of the 500 veterans had received their brain injuries from explosions. But Dr. Couch said the data did not seem to vary significantly with veterans who had brain injuries from other sources, like vehicle accidents.

The persistence of a range of symptoms underscores the complexity of treating traumatic brain injuries, he said, since some are psychiatric and others physical, with different medications and therapies prescribed for each. Veterans with post-concussion syndrome might also need services to find employment or salvage marriages, he noted.

“We have to recognize that people who may have head injuries may look the same, but they often are not going to act the same,” Dr. Couch said. “You’ve got to stabilize the patient’s interaction with family and try to create the best milieu for the patient to be able to return to employment, stay with the family and return to self-respect.”

Dr. Couch said that the researchers considered the possibility that some veterans reported persistent symptoms so that they could continue receiving disability compensation.

He called that hypothetical phenomenon “compensation neurosis,” and said its existence has been debated since at least the 1880s when a German researcher found that the number of people who reported being injured in railway accidents skyrocketed after the government started paying compensation for such injuries.

But Dr. Couch said that there is also ample evidence that people generally do not report physical ailments based on whether compensation is involved.

One of the shortcomings of the study, which was partly financed by the Department of Veterans Affairs, is that it was retrospective and did not include follow-up with the veterans, Dr. Couch said. Consequently, events after a deployment, including problems with alcohol or drug abuse, or new injuries, were not considered.

Future research should focus on following a group of veterans with post-concussion syndrome over many years, not only to determine which symptoms persist but also which therapies are most effective.

That research should also look at whether veterans with head injuries tend to develop chronic traumatic encephalopathy, a serious brain disease that was once mainly associated with contact sports but has recently been discovered in young combat veterans.

“Early recognition, early treatment, is a big issue here,” he said. “If we treat these people early, we get a much better result.”