Transcription:
The Long-Term Impacts of Concussions on Our Military Personnel

Alyne Ellis (Host): So many of us know someone or care for someone who has served in the military and has suffered a traumatic brain injury. Maybe you’re a vet struggling with the ravages of TBI. Here, perhaps, is some hope. The U.S. Departments of Defense and Veterans Affairs has just given Virginia Commonwealth University a $50 million grant to oversee a national research consortium. The group will study the long-term impacts of mild traumatic brain injuries on service members and veterans. This research project is called LIMBIC, the Long-term Impact of Military-relevant Brain Injury Consortium. I'm Alyne Ellis. This is Healthy with VCU Health. This is not the first grant VCU has received to study TBI. Here to tell us more is Dr. David Cifu, the principle investigator on both of VCU’s national studies. Dr. Cifu, let’s start with what VCU has already learned from a $62 million grant called CENC. 

David Cifu, MD (Guest):  CENC stands for the Chronic Effects of Neurotrauma Consortium. In 2013, we began evaluating this exact concept, which is to look at what were the both the short and the longer term – or chronic effects – of what were called combat associated concussions, which means a mild traumatic brain injury—or what we commonly call a concussion—that occurred in a military setting. So in this case in Iraq and Afghanistan. Then, looking at the effects of one, two, three or many, many more of these concussions – how they impact the soldiers and veterans in the short term—let’s say in the first three months, a year—to how they impact long term, let’s say five years, 20 years or even longer. So the concept is we’re trying to look at how folks recover after these events. If there is recovery, are there long-term problems that are perhaps not seen at first? Or if they don’t get all well, if they continue to have some difficulties, what does their course look like over time? So that was the overall setting that we were looking at.

Host:  What have you found out so far from the CENC study?

Dr. Cifu:  So far, to date, we’ve recruited 1,700 individuals who were in Afghanistan and Iraq and sustained injuries, as well as just were in that combat setting because that’s an important distinction from civilians or from athletes which we can talk about as well. So we follow 1,700 folks. Some of them had their injuries as many as 20 years ago at the beginning of the war. Others have had it more recently. On average, they're about nine years from their last injury. Most folks had more than one injury, more than one concussion. They also had issues with… some have PTSD, some have chronic pain, depression etcetera. So we’re seeing a complex group of individuals. So these are not just a high-level athlete who had one bump to the head and then returned to the field. These are folks that have been in a dangerous situation for a long period of time, have had often multiple concussions. 

What we’ve seen is that number one, the vast majority of people do extremely well. More than two-thirds of our 1,700 folks are high-performing nine years’ post-injury. They're working. They have families. They're going about their lives. They're active, they have hobbies, those kinds of things. They may have some residual difficulties – the most common being things like headaches, as well as some high-level thinking problems. Perhaps their attention isn’t as erect as it was before, but they're fully functional – hopefully as anybody who’s listening to this podcast. 

Unfortunately, a little less than a third of folks are having significant enough symptoms that they really can't fully function. They may be employed, they may be married, they may have lives outside of their injuries, but they feel so weighed down by their symptoms that they really aren’t at a level of performance as they were before they went to war. So there's a third of folks that really have a high dose of difficulties.  Fortunately, we’re finding that those individuals are accessing healthcare in a good way, predominately in the VA but also outside the VA. They are following up with their physicians and their other healthcare workers fairly closely. They aren’t being over treated or overmedicated, let’s say, for their back pain or their headaches. We find that no higher opioid use than in folks that weren’t in the war. We are finding that they are linked in with appropriate mental health professionals to take care of their post-traumatic stress disorder or depression. We do find that they have primary care physicians that are helping them to deal with their day-to-day symptoms.

So overall we are seeing that these are folks that have paid a significant price to preserve our freedom are having difficulties but are being managed. We’re not seeing any evidence of dementia in these folks. Again, up to 19 or 20 years out. On average, nine. We have seen no suicides in our group of more than 1,700—let’s knock on wood together. We’ve seen no issues with that. Again, we are seeing a lot of difficulties, but they're being managed. I think that’s the most important and uplifting thing is that this is not a death sentence. This is not a sentence of guaranteed dementia, what we may see on television and movies or in books. We’re actually just seeing folks that have difficulties but are in the right care settings. 

Host:  Now is it correct though to say that the third that you're talking about does have traumatic brain injury as opposed to concussion?

Dr. Cifu:  Well actually a concussion, which is sort of a lay term, is the exact same thing as a mild traumatic brain injury. Traumatic brain injuries can be of three types: Mild, which means you may have had an alteration of consciousness, meaning you were confused/dazed, or even a brief loss of consciousness for up to 30 minutes. Once that period of time is over, you pretty much get back to knowing what’s going on, figuring things out and being able to function. Typically, within minutes if not hours after the injury, but you may have some residual difficulties as I'm talking about. That’s the most common type of injury that everybody gets in the world. Again, a concussion or a mild brain injury. It’s also the most common injury seen in war. Over 90% of all brain injuries are of this mild type or concussion. The other two types are called moderate or severe. They're the ones where you typically are hospitalized, may need surgery, close monitoring. Weeks sometimes of care. Whereas a concussion is the same thing as a mild traumatic brain injury.

Host:  So now with this new grant that springs off the CENC grant, tell me what you're looking at involving the links between TBI and dementia.

Dr. Cifu:  We’ve transitioned or pivoted from this initial grant, the CENC grant, which brought together 30 universities, 15 VAs, 12 military treatment facilities who all were working together under VCU’s lead to kind of bring together this group of individuals with concussion and other injuries following war. So now we’re pivoting to a more focused project, whereas in the first study we actually had 11 different studies going on. Now for this second one we have two major studies going on. The first study is going to look at between 3,000 and 5,000 service members and veterans, 80% of whom have had at least one or more concussion, and we’re going to continue following them on and on for life. So we’ve already talked about we’ve already recruited 1,700 of these folks. We’re now going to add to that between 1,500 and 3,000 additional ones to really get a good number of veterans and service members so we can generalize what we find to a much larger population. 

I did mention that only 80% had brain injury. We have what's called a control group of 20%—so one out of five—were in military theater, were exposed to combat but didn’t have concussion. That way we can see is it just being a service member in a combat setting that causes difficulties or is it the added burden of a traumatic brain injury as well? So these are folks that we’re going to be following for long-term. We are going to look to see if we do see evidence of decline in function. Specifically, things like Parkinson’s disease, as well as dementia as you mentioned. 

The other major study, which is a continuation from earlier as well, is that we’ve put together a group of two million veterans and service members who have all been taken care of in either the military or [DS1] the VA health system. We have all of their medical records, all of their administrative records, all of their military records all together in one massive database or big data collection. We’re using that [DS2] big data of over two million unique veterans and service members to look at trends. To look at things like do they have a higher incidence of dementia. Do they have a higher incidence of suicide risk, of opioid use, of Parkinson’s, of depression? We have early analysis of the information which has demonstrated that in fact, yes. When you look at massive groups of individuals, there is a trend towards higher rates of suicide risk, opioid use, chronic pain, Parkinson’s disease, depression, PTSD and dementia. But it takes that many individuals in a research study to look for it. 

So now we’re going to try to apply what we found in this massive database to this smaller but still large prospective ongoing study of a little over 3,000 to 5,000 individuals. In the next five years, our goal is to see are we starting to see this specific population we’re getting back to the lab at least every five years and phone calling them at least every year to see how are you functioning? Are you still working? Are you still living alone, with family, etcetera? So now we’re going to be able to see in the real world. Forget about databases and electronic records. But in the real world and in human beings[DS3] , are we starting to see these problems? Obviously we hope not. 

One of the things that we’re going to be adding over the next five years are what are called clinical trials. So we’re going to be using unique interventions on those 3,000 to 5,000 to try to not only treat their active symptoms but prevent the future ones. So those are the two major areas. This large group – 3,000 to 5,000 veterans and service members all with combat exposure and about 80% with brain injury of the mild type called concussion. Then this massive database of 2 million folks that we have all their medical, healthcare, administrative and military records to try to track them electronically.

Host:  Tell me a little bit more. I'm intrigued by the part you said that isn’t[DS4]  just the[DS5]  data but is also the part[DS6]  about preventing or trying to prevent symptoms from progressing. Can you talk about that a little bit? Particularly the medical side of it?

Dr. Cifu:  Often we academicians kind of get fixated with we[DS7]  want to study[DS8]  things and we want to report things and write papers and all that. That’s important to move knowledge ahead. But, what’s more important to veterans and service members and their family and everybody listening on this podcast are well, what if I have a concussion or multiple concussions? What if I have concussions plus headaches? Concussions plus stress or PTSD? What's going to happen to me? What can we do to prevent that or reduce the risk? So we’ve already started work on five separate intervention trials, which are specific research studies where we’re going to be actively doing something to this high-risk group of 3,000 to 5,000 folks to try to diminish their active symptoms now—let’s say headaches, which is one trial we’re looking at or PTSD, which is another trial that we’re looking at—using innovative techniques that people are not currently using but which are showing evidence of early efficacy. Or it’s working in smaller studies of people or in some animal models that folks have published and are pushing forward. 

So we’re going to take the theoretical and what we’re seeing just in the very beginning of what are called pilot studies. We’re going to apply that to a large group of hundreds, if not thousands of individuals all with these difficulties to really see, is it actually going to work? Is it going to help the average Joe on the street or service member or veteran to relieve their dementia risk? To take care of their headache pain, to help them to sleep better. So these are things that we’re going to be applying in the next five years so that we’ll actually have takeaways, things that the average person can use. Hopefully what we can find is that the risk isn’t as high as people have always feared to begin with. Even if it is, here’s a way to make it a little bit less. Here’s a way to ameliorate your headaches, make you feel better. Here’s a way to help you sleep. Again, at the very least, reduce some of the risk for dementia, Parkinson’s and things of that sort. 

So we’re very excited about that phase as well because even we academicians don’t just want to write papers and give lectures. We actually want to have people that we’re working with in our clinics and that we’re providing care for or supporting – we want them to get well and to have a better feeling that they're going to have a good long-term outcome.

Host:  Is it too late for a veteran to get involved in the study? 

Dr. Cifu:  No. As we’ve been talking about, the studies are active and ongoing. Both this longitudinal or large gathering of 3,000 to 5,000, but also these intervention trials are just starting to be formulated and rolled out and initiated. So absolutely not. There’ll be information linked with this podcast on how to get into this study, but you can also go to www.cencstudy.org to go to our website where there’s some of this information I've been talking about in our knowledge translation area where you can hear about at a basic and understandable way the things I've been talking about. Also we’re talking about what are the study sites. We have 16 collection sites with 11 evaluation sites across the country. You can learn about how to sign up and be part of the CENC/LIMBIC program.

Host:  CENC is spelled C-E-N-C.

Dr. Cifu:  Yes. It’s cencstudy.org. So put the www before that. www.cencstudy.org. 

Host:  Finally, this can also relate to other general public problems like sports-related concussions. Some of the findings will help kids and other people who have sports-related football players and things like that.

Dr. Cifu: So here at VCU and in our department of PM&R, we’ve been providing brain injury rehabilitation care for all types of folks for more than 40 years. We’ve been doing research in the space. Most recently we’re turning now towards war combatants and veterans, but we also have similar programs and clinical care programs for civilians who have car accidents or fall off a ladder or sports. Whether it’s a juvenile sport in elementary school, high school, or whether it’s college or professional. We anticipate that things that we’re finding are going to apply directly to all civilians. Certainly being in war and having as many as 10 or 20 concussions within a year period is going to be significantly worse than most athletes or civilians, but certainly we see that in athletes. Also we’re seeing civilians with just one or two. So it’s very comparable. We anticipate anything we find is[DS9]  going to rapidly apply to everybody. This just gives us the unique advantage of a collective of folks that are well characterized that we can easily continue to follow over time, but it’s going to be applicable to just about anybody with a concussion or anybody that’s suffering from some of the longer term difficulties after a brain injury of any type. 

Host:  Well, thank you very much. Is there anything else you’d like to add?

Dr. Cifu:  The only final thing is I just want to make sure I'm acknowledging both all of the folks that I'm working with across the country who are the most amazing research team, but also most importantly to America’s service members and veterans who are there every day on the frontlines in a range of ways preserving our freedom and, at times, giving their final measure despite the risk. They're doing it willing and voluntarily. I just want to thank them for being part of our terrific research. 

Host:  Thank you very much for talking to us. Dr. David Cifu is the chair of the Department of Physical Medicine and Rehabilitation in the VCU School of Medicine and the senior TBI specialist for the U.S. Department of Veteran’s Affairs. I'm Alyne Ellis. To listen to other podcasts from VCU Health, visit vcuhealth.org/podcast.