TBI victims are dazed, confused, and changed

How traumatic brain injuries turn military personnel and their families’ worlds upside down

By Caroline Fernandez

Turn. Boom. Crash. G.I. Jim was sitting in his patrol Humvee on a sunny afternoon in Iraq when, in an instant, his life was literally and figuratively turned upside down.

A roadside bomb exploded and turned his upside down. His head and spine were violently compressed, resulting in a traumatic brain injury and leading him and his family down a long and tedious road to recovery.

Jim’s case is not unusual. In fact, it’s more normal than one would think. Pain, memory loss, a lack of learning capabilities and more can carry on for years and even decades after such an injury and they are often misdiagnosed.


A traumatic brain injury (TBI) is a brain dysfunction caused by an outside force, usually a violent blow to the head. According to the Defense and Veterans Brain Injury Center more than 12,000 cases of traumatic brain injury ranging from mild to severe were reported in men and women in the military in 2014.

Stephen Folger, program director at Elon University’s department of physical therapy said TBIs can be classified as mild (the most common amongst those injured in the military), moderate or severe.

Folger said that while a lot of work is now being done in the field there is room for improvement in post-TBI treatment, especially in cases of military personnel, who are often asked to go back into the field after such an injury. “Even though a single incidence might not have any great symptoms, multiple traumas over time become more problematic,” he explained.


Blast waves multiply damage, actually causing four types of damage

Most military TBIs occur due to blast injuries — the result of an intense pressure wave generated by an explosion. The four main types are classified as primary, secondary, tertiary and quaternary.

A “primary” blast injury is the impact explosion itself. “Secondary” injuries are caused by impacts by objects associated with the blast such as shrapnel, or energized fragments flying through the air. These fragments emitted from a bomb, shell or another object sometimes enter the skull, causing a penetrating brain injury.

A tertiary blast injury occurs due to the impact of a person thrown by an explosion when he or she is thrown into the ground or an object. A quaternary blast injury is the severe trauma that comes from significant blood loss.

Folger said the human brain is bathed in spinal fluid, cushioned in a state of suspension inside the skull. Even people implementing advanced protective gear and helmet technology such as the Gentex Advanced Combat Helmet used by the U.S. military the brain will still be shaken and impacted.

“The brain is suspended within the skull and when you suffer a blast injury or a direct impact to the head, the brain moves against the skull and bony surfaces within, it can essentially bruise itself,” Folger said.

“White matter can be seen as tracks that go from one end of the brain to the other,” he continued. “They are like roads and with a traumatic brain injury those roads can fracture and shear. And that means that the cells they are associated with are still there and alive but they can no longer communicate with one another because that road has been blocked and cut off.”


They can be insidious: Traumatic brain injuries often go undiagnosed for years

The most-severe TBIs generally appear as a large hematoma, a big blood clot, or herniation from movement of the brain when it shifted from one side to another on scans.

White matter doesn’t usually show up well in medical diagnostic scanning, making subtle and mild TBIs difficult to detect. Thus the most common injuries military men and women suffer are often not found when they receive treatment after the trauma.

“Sometimes there’s nothing discernible that looks wrong with the brain,” Folger said.

U.S. Department of Defense figures on TBIs globally from 2000 to 2012.

This contributes to misdiagnoses or even the absence of the diagnosis of a TBI, which can lead to military men and women returning to combat roles and suffering repeated injuries that can cause more permanent damage.

These overlooked injuries can come to haunt these men and women and their families, significantly diminishing their quality of life.

“Some military people return from duty with no knowledge of their injuries,” Folger said. “They may never have been diagnosed. They may function pretty well in certain conditions but it’s only when other conditions are present, for instance when they have to multitask, that a possible injury becomes apparent.”


Therapy and rehabilitation aim toward retraining the brain to function well

Memory loss from TBI can often present itself in different stages and variations, requiring a victim to go through phases of therapy and rehabilitation. Patients go through one, some or all of three major types of therapy: speech, occupational and physical.

Amy Overman, an associate professor of psychology at Elon University, said TBIs are high-impact because everything people learn and do requires the firing of neurons along the paths described by Folger.

“When you’re learning something new, neurons fire to represent the concepts you’re learning and the more they’re active together, the stronger the concepts become,” she explained. “You link together concepts by sets of neurons linking.”

Victims of TBI go to therapy sessions to work to encourage disconnected parts of the brain to get on track. Therapies can be outpatient or inpatient. Sometimes patients live at a therapy facility while they and their families learn how to acclimate back to independent living.

Learning Services is brain treatment and rehabilitation organization with locations in six states, including North Carolina.

While some military men and women with traumatic brain injuries receive treatment at Veterans Affairs (VA) locations in North Carolina such as the Durham VA Medical Center, Asheville VA Medical Center, Fayetteville VA Medical Center and W.G. Hefner Medical Center in Salisbury, many others are referred to and seek therapy at Learning Services locations throughout the state.

Susan Snow, director of admissions for Learning Services, said the facility serves individuals who are currently on active duty and others through contract work with large military programs.

In the 2013–2014 fiscal year, 13.75 percent of all Learning Services patients were military veterans, while military men and women in the North Carolina locations made up 16.42 percent of the population served.

Rehab programs and techniques are sometimes altered for the needs of those who have served in the military, Snow said. “We work with the VA for special service programs like post-traumatic stress disorder and alcohol rehabilitation,” she said.


Those living with the injury sometimes receive compensation from the VA

Every year in Alamance County, the Alamance County Veteran Services, according to the center’s director Brenda Perry, serves about 12–15 military veterans with traumatic brain injuries.

While there isn’t a large treatment facility in Alamance County, Perry said many military veterans live in the area. “It is common for them to return back to their home of record where they have lived all of their lives,” Perry said.

The Burlington VA assists TBI veterans by working with claims and benefits for compensation. Perry said that the amount of money veterans receive depends on the severity of their injuries and whether or not they have a spouse.

If an injury is mild to moderate it is likely a veteran will be awarded 30–40 percent compensation, while a severe injury can receive up to a full 100 percent compensation.

Perry said an unmarried veteran who is awarded 100 percent compensation for a traumatic brain injury will receive $2,906.83 per month; the compensation increases to $3,068.90 a month if the veteran has a spouse.


Stephen Folger, program director for Elon University’s Department of Physical Therapy explains military TBIs. VIdeo by Caroline Fernandez

Moving toward advancements in
post-injury treatment and assistance

Veterans suffering from TBI sometimes try to self-medicate with alcohol and some become dependent on drugs. Their families and friends can help by seeking assistance for them not only in dealing with the brain injury but in dealing with the additional stresses TBIs can cause.

Experiments are continuing in various research projects investigating potential new TBI tests and therapies including light therapy and antioxidant therapy.

Looking ahead, neuroscience and therapy professionals like Folger is hopeful that more awareness and a widening conversation regarding TBIs in the military and in other fields such as children’s and professional sports will lead to progress.

“Up to recently in the military environment no one wanted to expose weaknesses,” he said. “A good number of undiagnosed people could benefit from rehab and support. More and more people are becoming sensitive to this problem, and there’s more and more recognition.”

About this multimedia journalist:

Caroline Fernandez is a sophomore Journalism major. In addition to the work she has done with Reporting for the Public Good, she dedicates a lot of her time to her role as the News Editor for Elon University’s newspaper The Pendulum. She enjoys telling people’s different perspectives through writing and photography.