When Joe Montanari left the Army in 2008 after a decade of service, he knew little about traumatic brain injury.
He’d deployed to Iraq and served abroad in Kosovo and elsewhere over the years. But no one told him what could happen inside his brain after one or more concussions.
“I believe it needs to be talked about more. When I got out, I didn’t even know I had mild TBI,” said Montanari, now 39. “I knew I hit my head a couple times but I didn’t have much knowledge.”
He learned more about combat concussions after joining ongoing research at Virginia Commonwealth University in Richmond. For instance, the injuries can cause headaches, nausea, speech problems, sleep issues, dizziness and more, weeks or even years down the line.
“Getting into this study really brought to light what it was and how to know signs and symptoms,” he said. It’s important “being able to identify when you do have one.”
Montanari is now both a participant and coordinator for the research at VCU, which was recently tapped by the federal Defense and Veterans Affairs departments to oversee a $50 million national project investigating the long-term impacts of combat concussions among military veterans and service members.
Researchers are following Montanari and thousands of others throughout their lifetimes to observe and test how the brain injuries affect their mental and physical health. Nearly three dozen so far come from the military-heavy Hampton Roads region, and more are being recruited.
“The military cares about what happens to its folks in combat, short term and long term, and the VA has to take care of these people,” said Dr. David Cifu, lead researcher and chair of the VCU School of Medicine’s Department of Physical Medicine and Rehabilitation. The goal is to find out how to treat people early and prevent progressive neurological disorders.
Cifu said the military started to really notice the issue about a decade ago, when they saw “that there were lots and lots of individuals who were coming back from the Iraq and Afghan wars with a lot of brain injuries.”
A national research action plan signed by President Barack Obama in 2012 called for further study of the topic and soon afterward, VCU received $62 million to lead a consortium of universities, VA hospitals and military treatment facilities. The group has created an electronic medical records database of more than 2 million veterans and service members that allows researchers to learn about the common traits between people and conclusions that would be hard to draw from a single study. Cifu said VCU stores a massive data set on a server in a locked room.
The new grant allows the research to continue and expand. In addition to the study that follows thousands of participants, smaller targeted projects use data gathered through it, such as DNA and biomarkers in blood.
An initial day and a half of testing at the Hunter Holmes McGuire VA Medical Center in Richmond includes a specialized MRI, computerized eye tracking, smell and balance testing, questioning and more. Researchers later check in with the participants periodically.
The service members and veterans are allowed to ask questions about their results, and are referred for available treatment when needed. If, say, a new treatment or clinical trial becomes available for a certain symptom, officials can also use the national registry to reach out to those who could benefit.
More than 380,000 service members have been diagnosed with a traumatic brain injury since 2000, according to numbers from the Department of Defense, about 60% of them in the Army and the rest evenly divided between the Marines, Navy and Air Force. The cause is almost always either blasts or vehicle collisions.
There’s a clear association between the injuries and the eventual development of dementia, Parkinson’s disease, opioid addiction, chronic pain and suicide risk, Cifu said.
“There’s something about brain injury that increases your lifetime risks of those problems,” he said. “Concussion is important because it alerts us that there’s something about this group of people that elevates their risk. It may be the door that opens us up to these people: ‘Your brain health is key, so let’s do things to nurture your brain, treat your mental health difficulties more aggressively.'”
Inside the brain, combat concussions are no different from those sustained in athletics or civilian life, Cifu said. A football player who collides with an opponent and a soldier hit by a roadside bomb experience similar impacts: a whiplash-like motion that moves the brain around in damaging ways.
“While there are unique aspects to being injured in combat … if you remove those elements and just look at the concussion itself, the brain has no way of knowing how it was injured,” he said. “It looks to the brain exactly the same as being beaten up in a fight.”
There is, however, a much higher rate of post-traumatic stress disorder that goes along with combat concussions. About 40% of those who sustain them develop PTSD, as opposed to about 5% in the general population. That’s not surprising considering many of those concussions are experienced alongside traumatic wartime events.
The brain injuries don’t cause PTSD, “but the same event is probably the seed that caused them,” Cifu said.
Because of the similarities between combat and civilian concussions, “what we learn in civilians we can apply to combat, and vice versa.”
As a result of the coalition’s research, he said, the military has changed its standard concussion care protocols in the battlefield.
“In the Green Zone there are actually concussion tents set up for service members who get injuries,” he said. In the early days of the Iraq and Afghanistan wars, some of these soldiers would be flown home or somewhere in Europe because there wasn’t the knowledge of how to handle it. Now “they’ve gotten well before either going back to battle or coming home. That’s a difference.”
The team has also found that women who have combat injuries report more challenges and symptoms as a result, something Cifu said held true among civilians and athletes.
There are about 1,700 current participants in the research — all service members and veterans with combat experience, some who’ve had concussions and a control group who have not. The research is planned to expand to more than 3,000.
“Many of us don’t miss the job or the hardships that came along with being in the military, but we miss those we served with,” said Kevin Sickinger, 56, a participant and research administrator who served 23 years in the Army and retired as a lieutenant colonel in 2010. “This is a way of staying connected. A way of helping those I served with.”
Project leaders need large numbers of participants to be able to draw conclusions in the data. Sickinger said they’ll be headed down to Hampton Roads soon to recruit more active duty members. Only about a fifth of the current subjects are in active service; a majority of them are veterans.
“There might not even be a cure, a quick fix or long term fix,” Sickinger said. “But to be able to participate in helping to find out anything that can help our future brothers and sisters in the military, is worthwhile.”
Anyone interested in participating in the study can visit www.cencstudy.org.
Katherine Hafner, 757-222-5208, katherine.hafner@pilotonline.com
