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Traumatic Brain Injury - Concussion in the Military

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1 Traumatic Brain Injury - Concussion in the Military
May 25, 2010 The views expressed in this presentation are those of the authors and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the U.S. Government. VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI, 2009.

2 Objectives Background Definition of TBI Army TBI Trends Epidemiology
Natural history and course of Army TBI Therapy Outcomes & Common Symptoms Management and Treatment SLP- LT Joann Shen & Ms. Carla Chase OT- CDR Laura M. Grogan PT- CDR Henry McMillan & LCDR Alicia Souvignier

3 Common Terminology ASR: Acute stress reaction CONUS: Continental US
DoD: Department of Defense IED: improvised explosive devices mTBI: mild Traumatic Brain Injury, concussion MVA: motor vehicle accident OEF: Operation Enduring Freedom OIF: Operation Iraqi Freedom PTSD: Post-traumatic stress disorder SM: Service Member- active duty, Reservists, National Guard, and Veterans

4 Army TBI Program Purpose:
To establish a standardized, comprehensive program that provides a continuum of integrated care and services for Service Members and patients with TBI from point-of-injury to return to duty or transition from active duty and/or return to highest functional level General for OT, PT and SLP only. Each discipline can further define more if needed. Are we missing any? Source: Proponency Office for Rehabilitation & Reintegration

5 Army Program Components
Early identification, evaluation, management, treatment, documentation, and coding Neurocognitive testing Tele-health assets Education and training for SM, leaders, patients, MHS providers, community health care providers, Family members, and others Strategic communications and marketing Research TBI Program Validation Source: Proponency Office for Rehabilitation & Reintegration

6 DoD Levels of Care Level I: Buddy Aid to Battalion Aid Station (BAS)
Level II: Forward Support Medical Company/Forward Surgical Team Level III: Combat Support Hospital (CSH) and Combat Stress Unit Level IV: Evacuation Center (Landstuhl Regional Medical Center [LRMAC]) Level V: Military medical treatment facility (MMTF) - Inpatient and Outpatient Level VI: Inpatient Rehabilitation (non-MMTF, such as Veteran’s Affairs Medical Center and community partner facilities) Level VII: Outpatient rehabilitation Level VIII: Lifetime care

7 Identification & Referral
Significant incident in theatre results in Medivac to Germany and then to CONUS to start clinical care Upon return from deployment, all SM’s are provided a Post Deployment Health Assessment and screening SM with possible symptoms of concussion, are then referred to the TBI clinic for additional evaluation and possible treatment and care Complex & repeat injuries make screening difficult. Assessment and screening may differ base to base, as well as the “gate keeper” for TBI referrals. AT EACH we use the SRP. Other referral mechanisms exist and vary depending on the facility/clinic.

8 DoD Definition for TBI DoD Deployment Health Clinical Center at Walter Reed Army Medical Center, Washington, D.C , May 2010 Traumatic brain injury (TBI) is a traumatically-induced structural injury and/or physiological disruption of brain function as a result of an external force that is indicated by new onset or worsening of at least one of the following clinical signs, immediately following the event: (1) Any period of loss, or a decreased level, of consciousness. (2) Any loss of memory for events immediately before or after the injury. (3) Any alteration in mental state at the time of the injury (confusion, disorientation, slowed thinking, etc.). (4) Neurological deficits (weakness, loss of balance, change in vision, praxis, paresis/plegia, sensory loss, aphasia, etc.) that may or may not be transient. (5) Intracranial lesion. External forces may include any of the following events: the head being struck by an object, the head striking an object, the brain undergoing an acceleration/deceleration movement without direct external trauma to the head, a foreign body penetrating the brain, forces generated from events such as a blast or explosion, or other force yet to be defined Other referral mechanisms exist and vary depending in the facility/clinic. DoD Deployment Health Clinical Center at Walter Reed Army Medical Center, Washington, D.C , May 2010

9 Severity Scales of Closed TBI
301- Severity Rating review

10 Trend for Total Army Increase in the number of mild TBI cases between CY05 and CY08 is largely due to Post Deployment Screenings and aggressive identification of incident and symptoms. NUMBER OF ARMY SOLDIERS WITH IDENTIFIED TBI Data is updated quarterly. Army Total CY 00-CY09 Severe or Penetrating 3%; Moderate 16 %; Mild 75%; Not Classifiable 6% Calendar Year in which Injury Occurred This slide depicts TBI of varying severity based on data from the Defense Medical Surveillance System (DMSS), 31 December TBI numbers reflect all Army Soldiers Diagnosed with Traumatic Brain Injury, irrespective of their Deployment history (Soldiers who have deployed and those who never deployed). Data is updated Quarterly and First Qtr 2010 data is currently incomplete. Source: Office of the Surgeon General Last updated: 6 April 2010

11 Epidemiology of Army TBI
Estimated 12% of the 1.6 million SM’s deployed in OEF/OIF may have sustained a mTBI (Schneiderman, Braver, & Kang, 2008, data up to Oct 07) Head & neck injuries reported in one-quarter of servicemen evacuated from theater. A possible 10-15% mTBI in all deployed SM’s (Hoge et al, 2008) High incidence of TBI attributed to the consequences of blasts or explosions caused by IED’s Other sources: Bullets, fragments, MVA’s, assaults (DVBIC) Males 1.5 x’s higher risk than females (DVBIC) Precise figures not available with variable reports. No gold standard for identification or time limits for symptom reporting. 30% from DVBIC 2006Precise figures not available with variable reports. 30% from DVBIC 2006 Principle cause of combat-related TBI is IEDs.

12 Blast Injuries are Caused by Four Different Effects
Primary – Overpressure of “blast wave” Secondary – Flying Debris Tertiary – Body Displacement, Victim thrown into stationary objects Quaternary – Any injury or disease not due to other mechanisms (burns, toxic inhalation, crush injuries, radiation exposure) Blast injuries differ from a sports or MVA head injury due to the negative pressure forces and vibrations of the blast. A SM can be exposed to multiple blast injuries over a short or long period of time. Differences are still being studied since most TBI data is related to sports or MVA’s.

13 Natural History and Course of mTBI
Symptoms: Transient Rapid or gradual resolution within days or weeks Highly nonspecific: headache, blurred vision, dizziness, sleep problems, cognitive changes (attention/concentration/memory) Prognosis after mTBI: Good Recovery occurs for most within 3-12 months with or without intervention, very small percentage of cases have symptoms persisting beyond 3 months Persisting symptoms attributable to other factors: demographic , psychosocial, medical, situational McCrea 2008

14 Expected Therapy Outcomes
Optimistic expectation for full recovery > 90% of individuals with sports concussion are recovered and return to play by 30 days (Collins, 2006) Majority of non-sports related concussions resolve by 3 months Between 8%(Binder, 1997) and 33%(Guskiewicz, 2007) (of what type) have continued symptoms past 3 months Therapists incorporate assessment of the Service Members goals and priorities along with TBI related symptoms to develop a plan of care with expected improvement McCrea

15 Reasons for Persisting Symptoms
PTSD, Depression, anxiety, stress, Pre-existing disorder, dysfunction, or limitation Expectation of the SM / denial Limited cognitive reserve Somatoform disorder Sleep disorder Malingering Kashluba 2008 Polytrauma and cumulative concussions?

16 Most Common Symptoms of mTBI
Headaches % Blurred vision % Anxiety % Dizziness % Fatigue % Light sensitivity % Poor concentration % Trouble thinking % Memory Problems % Irritability % Depression % Rohling 2003 Rohling 2003 data, %’s not accurate however symptoms represent the most common reported

17 TBI Team Members Audiologist Case manager Neurologist
Neuropsychologist Occupational therapist Ophthalmologist / Optometrist Physical therapist Primary Care Manager Social Worker/ Counselor/ Psychologist Speech-Language Pathologist In addition to outside referral sources: BH, Acupuncture, Pain Mgmt., Ideally family members, TBI educators (DVBIC), and perhaps possible command leaders

18 Take Home Points Blast injuries are unique, injuries can be invisible or latent Most severe symptoms evident within minutes of injury Delayed symptom onset relatively rare Combination of physical and cognitive symptoms most common Measurable improvement seen within hours of injury Gradual symptom recovery occurs over 7-10 days in 80-90% of cases Headache tends to linger the longest. Good prognosis for recovery While mTBI is difficult to diagnose, as therapists, we treat the functional impairments regardless of underlying diagnosis

19 Resources & Websites Defense & Veterans Brain Injury Center: Brainline (DVBIC-sponsored): Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury: Deployment Health Clinical Center: Defense Centers of Excellence for Psychological Health & Traumatic Brain Injury: Department of Veterans Affairs (VA): DoD Disabled Veterans: Polytrauma Sites: Traumatic Brain Injury National Resource Center: Brain Injury Association of America:

20 Contact Information LT Joann Shen, M.S. CCC-SLP Ms. Carla Chase, M.S. CCC-SLP Tripler Army Medical Center Schofield Barracks Health Clinic Phone: Phone: CDR Laura M. Grogan, OTR/L Evans Army Community Hospital Phone: LCDR Alicia Souvignier, CDR Henry McMillan Evans Army Community Hospital Womack Army Medical Center Phone: Phone:

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