Fifty-one thousand American troops have come home from Iraq or Afghanistan diagnosed with brain injury. What's become of them?

Many have worked with military or VA specialists to learn to overcome or compensate for deficits in memory, speech, organizational skills, reading, finger dexterity -- everyday skills we take for granted. Tens of thousands of other Iraq and Afghanistan combat veterans were never diagnosed with Traumatic Brain Injury (TBI) and may be struggling without knowing why. The VA's shortage of therapists and difficulty reaching rural veterans means even those diagnosed may not get all the help they need.

But even those who were diagnosed and treated find that at some point, therapy has done all it can do. More sessions won't necessarily help. "If you've gone through physical and occupational therapy, you reach a plateau," said Adam Anicich, who was injured by an exploding mortar shell in Iraq in 2006. "You don't get better."

From that point on, veterans say, their lives become a matter of coping: working harder to get and keep a job, to sustain and repair relationships, confronting small daily challenges. Many feel slow to pick the right words, slow to put names to faces, have difficulty remembering where they parked or whether they turned off the coffee pot. Some find it harder than before to master their anger at a boss or coworker.

In a sense, they become unseen. Out of uniform and not visibly wounded, many avoid social situations because they feel they can't keep up. Or they don't want to talk about painful war experiences. And while some credit the VA with caring and effective treatment, once they're finished it's not clear what more the VA can do, even if it had the resources. Little is known about the lingering effects of brain injury once veterans finish therapy and are out on their own.

Some, like Brian McPherson, adjust and adapt. After a bomb blast, he found his memory of childhood was gone. But he taught himself how to ride a bike again, went back to college where he found ways to focus and organize, and has become a champion athlete.

Many aren't as successful, especially in civilian employment. The job attrition rate for brain-injured veterans "is very high in the first year," said a veterans employment counselor. The office environment can be dauntingly different from the military culture with its strict lines of authority, its honor code and self-discipline. Some veterans struggle in civilian jobs to distinguish suggestions from orders, to understand unclear directions by trying to read body language and voice tone, and to remember complicated work procedures.

Anicich, like many others, wasn't initially diagnosed with TBI. It took several years after he was wounded in 2006 for him to work up the courage to ask to be tested. He was getting help with his physical injuries, but his increasingly severe headaches and memory loss "scared me," he said. Eventually, he got himself to the VA "and they welcomed me with open arms."

He improved with therapy, but eventually reached a plateau, and he's had to figure out ways to manage. "Not slurring my words is very challenging," he told me. "I practice that a lot, understanding what others are saying and responding appropriately. Picking the word I want to say and articulating it. That takes a lot of effort. It's mentally fatiguing." After a long day, he often goes home and sits in silence.

But he's not exactly giving up. In addition to working at a government health agency, he's found time and energy to advocate for brain-injured veterans. He serves on the VA's PolyTrauma and Blast-related Injury Executive Committee and the pain research steering committee, shaping policy and programs to help identify, diagnose and treat veterans with brain injuries.

Jason Gladney also is finding ways to live past his injury. An infantry platoon leader in Iraq, Gladney was staggered by an IED blast in 2003. Like many others, he shrugged it off. It wasn't yet military policy to pull injured soldiers off duty and test them for TBI. But finally, Gladney's headaches and the ringing in his ears got so bad he couldn't function and he was sent back to the U.S. There, puzzled doctors declared his condition "non-determinate." The Army said he couldn't go back to war and finally he was, in his words, "chaptered out."

But he was selected for a wounded warrior program that enabled him to teach military history at the Army's Command and General Staff College, at Fort Leavenworth, Kan., and to earn a masters degree at the University of Kansas. He's now back home in Mississippi, where he teaches high school history in Hattiesburg.

Gladney, who is 41, praises therapists at the VA who helped him develop coping skills. Coaching him to slow down, to take his time, has paid off. "No one defines when you're better -- there's no litmus test for that," he said over the phone from Hattiesburg, on a break between classes. "But in many ways I feel I'm much better than before the IED. I take more time to do things right. You're not as cocky as before, when you felt invincible. It's like, maybe I should stop and ask directions."
Gladney loved his military life and regrets that he was unable to continue. Despite the violence and the loss of friends in battle, he felt value and pride in his service. But he's moving on. "I wanted to get away from Jason Gladney the wounded warrior, because I think it's a self-fulfilling prophecy." The risk, he said, is that "you stay a wounded warrior."

Of the blast that injured his brain, he said only this: "If you walk in the sand you leave footprints. That was a footprint in my life."