The Impact of Stress on the Warfighter

The health and wellbeing of our service members and their families is the top priority for the department of defense, whether it is CONUS or OCONUS, pre or post deployment, service members deserve optimal care for military healthcare professionals, improved screenings, battlefield treatment, rehabilitation, and mental and behavioral care have had a significant impact on the reintegration of America’s troops. Joining us for this discussion is Dr. Denes Agoston, Associate Professor at the Uniform Services University of Health Sciences. @DefenseInsider Chris Archer Tell us a little bit more about you and your experience in this area? Denes Agoston I have been working on Traumatic Brain Injury - TBI - especially blast-induced TBI for the last four to five years. I also teach at Uniform Services University of Health Sciences which is affiliated with National Naval Medical Center and Walter Reed Hospital in Bethesda, near Washington DC. I am an MD/PhD and I have attended neurosurgery grand rounds and I have seen soldiers and marines suffering from TBI. These experiences have inspired me to focus my research on neurotrauma. I want to make a difference in the TBI field so patients can recover better and live a quality life. [eventPDF] My background is in neuroscience, have started studying the brain while in Medical School, quite a long time ago and have worked on many different aspects of brain research. In addition to the experience in the hospitals I spoke above, TBI has attracted me intellectually because it is one of the most challenging and complex diseases. I believe I can significantly contribute to make a real difference in the TBI field. I think if basic scientists from different fields of neuroscience and clinicians combine their expertise, we will be able to effectively treat people suffering from TBI. Chris Archer Can you explain ‘repeated mild blast induced TBI’ as it applies to service members. How common is it? What are the usual side effects of the symptoms? Denes Agoston As most of you probably have known, repeated mild blast-induced TBI (mbTBI) is the most common form of military head injury during the current conflict and that improvised explosive devices (IEDs) are the choice of weapon for insurgents. They are easy to assemble and they are very effective. The good news is that fatalities during the last conflicts are very low compared to previous conflicts and to the frequency of IED exposures. This is the result of intensive research in acute trauma care, improved protection, body armor, new design of vehicles, etc. A critical component is – as always – is the human factor. The dedication, bravery and knowledge of first responders, trauma surgeons and intensive care specialists have been making tremendous job. The bad news is that there are a large and increasing number of individuals suffering from what you Chris just described as mbTBI. mbTBI is a very challenging condition. Typically, exposure to a single low level of blast does not cause any acute symptoms, there is no loss of consciousness or very, very short-lasting, and no immediate neurobehavioral symptoms. After being evaluated by the best currently available test that are not accurate and not objective I might add, these soldiers and marines are going back to the field after a short rest period. So as they are deployed over an extended period of time and many of them are deployed multiple times, the chances that the same individual is exposed to several low levels of blasts are increasing. Consequently we are dealing with a fairly significant number of individuals who are exposed many-many times. mbTBI is very difficult to define and diagnose in the absence of immediate symptoms and due to lack of objective tests such as biomarkers. The problem is that multiple exposures to low level of blast can have a cumulative effect over time. These can develop weeks and months later. So we are sort of dealing with a time bomb if you like; large number of individuals, we do not know exactly how many that at some point will develop neurobehavioral symptoms. These can be severe enough to impair their ability to serve and later the neurobehavioral symptoms can make their reintegration into civilian life difficult. The symptoms we see are memory impairment, mood disorders, increased aggression, headache, sleep disturbances, etc. Because of the numbers of individuals affected, combined with the apparent delayed onset of the symptoms, this is a very significant military health issue. Chris Archer Based on the latest laboratory research being conducted, what can you tell us about the effective stress on a person with TBI? Denes Agoston Chris, this is a great question and it is a very significant issue. One of the difficulties of diagnosing mbTBI is that the neurobehavioral symptoms are overlapping with a condition which we call PTSD, post-traumatic stress disorder. PTSD by definition is caused by a single major or repeated psychological stress. As you can imagine, under battlefield conditions an explosion can be a stressor alone but also can cause injury. To make things even more complicated, stress can worsen the outcome of TBI, so it is a bad combination. Chris Archer Can you identify for us the various strategies towards an effective path to recovery for a person with TBI and maybe also forecast what you believe the next phase in researching the effect and treatment of somebody with TBI or mTBI? Denes Agoston As I said before, one of the key issues is to develop objective tests that can provide information about the severity of the injury and will be the basis for evidence-based treatment. This is very critical because in the absence of these objective measures, we it is difficult to distinguish between PTSD and mbTBI yet, they may require very different therapeutic strategies. So the next phase is to develop and validate markers. This will require close coordination and collaboration between researchers and clinicians. People involved must share precious biomaterials, serum or CSF samples and also information. There is a significant gap between animal/experimental data and clinical data. It is essential we close or narrow these gaps and that experimental research will be driven by real clinical needs and data. Current treatments mostly address the acute conditions, little is known about the long-term effect of these early interventions. We have not done a good job in improving functional recovery and rehabilitation. Current treatments mostly reflect the traditional therapy based on research and clinical experience in civilian TBI. We have to develop real, evidence-based therapies for the various forms of military TBIs, blast induced, and mbTBI. Chris Archer What is the next phase in your research for effectively treating TBI or MTBI patients? Denes Agoston So, our own research focuses on three aspects of TBI. One is to identify and validate objective serum based protein biomarkers. The goal is to supply the biological content for hand-held devices, a smart-phone type of device which can be used on the field and using a blood sample can provide the initial therapeutic guidance for the first responders. Two, these markers help us to understand the pathobiology, specifically the role of neuroinflammation in the TBI process. This is very important because as our recent study - under publication – shows, we can use existing drugs to prevent the development of cognitive deficits after TBI. This leads to number three, the development of evidence-based therapies that include rehabilitation strategies. We have very promising results using environmental enrichment therapies. We have shown that we can restore memory functions after blast induced TBI with these environmental therapies. As you may have sensed, our goal is to identify therapeutic strategies that can be practically immediately implemented in the clinic so we can help improving the quality of life of individuals suffering from TBI now. Time is the essence.

The Impact of Stress on the Warfighter

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