The terms "mild," "moderate" and "severe," used by doctors to categorize head injuries in roughly 2 million Americans each year, are outdated and imprecise, and treatments based on those terms are leading to increased medical costs and preventable deaths, a group of medical experts wrote in a report published Feb. 1.
At least 439,000 U.S. service members have been diagnosed with brain injuries since 2000, with more than 83% of those classified as "mild" and roughly 36,000 defined as "moderate" or "severe."
These common labels for defining a traumatic brain injury may obscure the severity of head injuries, however, leading to inadequate treatment and potential harm to the patient, according to a report published this week by the National Academies of Sciences, Engineering and Medicine.
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The authors said traumatic brain injury should not be treated as a single event, but as an evolving condition that may have long-term effects. And they recommended changes to ensure patients get more accurate diagnoses and treatment.
"In today's world of precision medicine, one could not imagine classifying cancer as 'mild, moderate, or severe' for its diagnosis, treatment, and prognosis," Dr. Donald Berwick, president emeritus of the Institute for Healthcare Improvement and panel chairman, said in a press release.
"Implementing improved approaches for classifying [traumatic brain injury] would allow for more personalized care for patients, better ongoing monitoring of their condition, and more successful translation of therapies from research to the clinic," Berwick added.
Traumatic brain injuries are considered to be a signature wound of the Iraq and Afghanistan wars, with thousands of troops receiving one or more concussions -- or worse -- as the result of roadside bomb blasts, shelling and weapons firing.
The Defense Department introduced a revamped protocol for treating concussions in 2015, a rest and gradual return-to-work program based on the findings of sports-related studies and understanding of head injuries drawn from the previous 14 years of war.
Still, the vast numbers of concussions and injuries have placed service members at risk for ongoing symptoms, such as headaches and brain fog. There's also research suggesting head trauma could be tied to developing illnesses like dementia, Parkinson's and Alzheimer's disease.
According to the report's authors, the associated lifetime costs for the 2 million brain injuries in the U.S. each year, including health care, loss of income and quality of life, may be as high as $750 billion.
Despite the potential risk to quality of life and employment, brain injuries -- particularly concussions, considered to be "mild" traumatic brain injuries -- often are downplayed, which can be detrimental to patients and their families.
Among U.S. service members, this was most notably reflected in 2020, when then-President Donald Trump described the head injuries of more than 100 U.S. troops from a rocket attack in Iraq as "not very serious," since they simply had "headaches and a couple of other things."
Seventeen of the injured service members were sent to Landstuhl Regional Medical Center in Germany for treatment, and at least 29 received the Purple Hearts tied to their injuries.
"The consequences of injuries classified as mild can prove, in some instances, to be insidious," wrote the report's authors, who included former Army surgeon general and now retired Lt. Gen. Eric Schoomaker and retired Army Col. Sidney Hinds, a brain injury expert now with Wounded Warrior Project.
Given these injuries' impact on the American health system, civilian and military patients and their families, the panel made several recommendations, to include eliminating the current descriptive nomenclature in favor of a numeric scoring system known as the Glasgow Coma Scale, which the authors felt would more accurately reflect the level of injury and damage and better steer treatments.
The scale is based on assessments of eye opening capability and motor and verbal responses, with a combined total range of 3 -- likely a lasting vegetative state -- to 15, which is considered normal.
The authors also recommended that patients receive quality multidisciplinary rehabilitation as soon as possible after injury and continue to be screened for risks or decline in health and function.
And more attention needs to be paid to concurrent medical conditions, such as mental health disorders and the patient's need for assistance with housing and employment, as well as to the 2.5 million family caregivers who support the injured, "especially after the first year following injury," the authors wrote.
The group also recommended that the Department of Health and Human Services improve data collection to better track traumatic brain injuries in the U.S. and long-term outcomes, and form a task force to improve the system of care.
"Traumatic brain injury has resulted in preventable deaths, societal costs, and lost human potential," Dr. Victor Dzau, president of the National Academy of Medicine, said in the press release. "Millions of people with TBI deserve this so they can achieve the care and quality of life that science can make possible for them."
Research and publication of the report was requested and funded by the Department of Defense.
Editor’s Note: This story has been updated to clarify the report's recommendations to the Department of Health and Human Services on traumatic brain injury data collection.
-- Patricia Kime can be reached at Patricia.Kime@Military.com. Follow her on Twitter @patriciakime.
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