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Aftershock: The Ticking Time Bomb of Soldiers' Traumatic Brain Injuries

Soldiers returning from Iraq and Afghanistan are a generation of warriors whose fight has shifted from external combat zones to invisible internal battlefields.

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For each of the men, Russell entered two diagnoses in their electronic medical records:

1. Concussion
2. Post concussive syndrome

The New Epidemic

War has always fueled innovation, helpful and horrible. Better body armor and battlefield medicine have helped soldiers survive injuries in Iraq and Afghanistan that would have proven fatal in previous conflicts. But the advances that have saved soldiers' bodies cannot protect their minds from insurgents' primary weapon, the roadside bomb. Blast waves penetrate through Humvee doors, bulletproof vests and Kevlar helmets, rattling soldiers' brains and altering cells and circuitry. Most recover quickly, but some suffer lasting damage to their cognitive abilities. At the same time, the terrifying experience of surviving such blasts haunts them, seeping out in violent nightmares and emotional outbursts.

Given the number of troops deployed, tens of thousands of soldiers, Marines, sailors and airmen may be suffering from this pernicious combination of PTSD and lasting problems from mild traumatic brain injury. They become, quite literally, different men and women than they used to be, a generation of warriors whose fight has shifted from external combat zones to invisible internal battlefields.

The issue has ignited debate in scientific and military circles, where much of the basic science remains in dispute. Are the two conditions related? If so, how? Does having a mild traumatic brain injury increase the chance of developing post-traumatic stress disorder? Or does surviving a terrifying event somehow make it more difficult for the brain to recover from a concussion? Doctors also struggle to tell the two conditions apart. PTSD and traumatic brain injury can produce similar symptoms, such as problems with memory and concentration. Yet both conditions escape detection by medical imaging devices, hindering diagnosis. Other conditions further complicate the picture. Besides PTSD and cognitive problems stemming from brain injury, soldiers also face chronic pain, missing limbs, vision, hearing and other physical problems. "It's very complicated," said Jennifer Vasterling, who has studied the issue and treated soldiers as chief of psychology at the Boston Veteran's Administration Hospital. "There are no simple scenarios."

Until recently, concussions were not even seen as particularly serious. Boxers boasted of returning to the ring after being knocked out. Soldiers in combat shook off feeling dazed and unfocused. Symptoms of concussions can include headaches, dizziness, difficulty speaking, memory troubles and sometimes balance and visions problems. Most people recover within four to six weeks. But for some, the symptoms can persist for months or even years. Civilian studies have found that between 5 percent and 15 percent of concussion victims endure long-term problems -- a condition formally known as post-concussion syndrome. Recent studies of athletes in the NFL and other sports have shown that repeated concussions can result in chronic traumatic encephalopathy, a condition associated with dementia and other Alzheimer's-like disorders.

Some researchers believe that soldiers' concussions may pose an even more complex medical challenge. Soldiers sustain their injuries in settings dramatically different from those encountered by athletes or car accident victims. Civilian concussions are typically caused by a physical blow to the head. But nobody is sure exactly how the brain is damaged in a blast concussion. Do blast waves rupture miniature blood vessels inside the brain? Does the force sever connections between neurons? Does it damage individual brain cells? Or does it simply slam the helmet into the head hard enough to injure the brain?

After the blast, soldiers face a different environment than typical concussion victims. No fans applaud as they rise from the field. Medics often can't rush them to the safety of a hospital right away. Instead, they remain on a hostile battlefield, fighting for their lives, the violence and rush of combat filling their brain with abnormal levels of chemicals such as adrenaline. Those left dazed, but not unconscious, experience a fear so fierce that it may simultaneously trigger post-traumatic stress. Paradoxically, patients who suffer severe traumatic brain injuries are less likely to develop PTSD -- perhaps because, knocked unconscious, they do not actually experience the horror unfolding around them.

 
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