Clear strategies for treating traumatic brain injury are elusive, panel finds

There might be really good ways to restore brain-damaged people — especially the young wounded of the Iraq and Afghanistan wars — to a healthy, if not entirely normal, state. But it’s difficult to say with certainty what those techniques are.

That’s the conclusion of a scientific review of “cognitive rehabilitation therapy” performed by the Institute of Medicine at the request of the Defense Department.

This less-than-satisfying message from a 250-page report prepared by 14 experts is a testament to how difficult it is to study treatments for problems such as clouded thinking, inarticulate speech, poor planning, bad moods, unemployability and family conflict. It’s not as simple as determining whether a drug for hypertension reduces blood pressure.

“It doesn’t mean beneficial therapies don’t exist. It just means that at this point in time it’s hard to ascertain them,” said Ira Shoulson, a neurologist at Georgetown University who headed the Institute of Medicine panel.

“There are certainly deficiencies in the evidence about what works,” he added. “But there are also some glimpses of benefit. I’m fairly upbeat about this.”

Nevertheless, the report, which was released Tuesday, is unlikely to answer questions that patients and medical practitioners have about optimal treatment of blast injuries suffered on the battlefield.

As of late last year, 196,000 men and women in the military had been diagnosed with traumatic brain injury (TBI) since 2000. Early in the current wars, about 65 percent of cases were mild, which the military calls concussions. The rest were in the “moderate to severe” category, characterized by loss of consciousness for more than 30 minutes and mental confusion or memory loss lasting more than a day.

While the number of combat brain injuries rose steadily over the past decade (peaking at 29,000 in 2009), their severity has fallen. Today, about 80 percent are mild, with full recovery expected in most cases.

Although the wars, and to a lesser extent football injuries, have put traumatic brain injury on the public agenda, the problem isn’t new. Each year about 1.7 million Americans suffer a brain injury requiring medical treatment. About 52,000 die, and about 125,000 have long-term impairments.

Those disabilities include problems paying attention, following conversation, communicating clearly, reading, remembering, feeling oriented in space, tracking objects with the eyes, and planning and solving problems. Mood disorders, family problems and difficulties holding a job are common.

Brain-injury rehabilitation is a murky subject, and evaluating what works is an unusually hard task.

That’s because patients vary in their pre-wounded intelligence and emotional state, as well as the severity of their injuries. Further, rehabilitation consists of many activities, including speech therapy, occupational therapy, physical therapy, psychological counseling and social work. There are also many ways of measuring success, from neuropsychological tests to asking the patient whether things are better.