Presentation on theme: "Traumatic Brain Injury - Concussion in the Military"— Presentation transcript:
1 Traumatic Brain Injury - Concussion in the Military May 25, 2010The 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 TBITherapy Outcomes & Common SymptomsManagement and TreatmentSLP- LT Joann Shen & Ms. Carla ChaseOT- CDR Laura M. GroganPT- CDR Henry McMillan & LCDR Alicia Souvignier
3 Common Terminology ASR: Acute stress reaction CONUS: Continental US DoD: Department of DefenseIED: improvised explosive devicesmTBI: mild Traumatic Brain Injury, concussionMVA: motor vehicle accidentOEF: Operation Enduring FreedomOIF: Operation Iraqi FreedomPTSD: Post-traumatic stress disorderSM: 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 levelGeneral 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 codingNeurocognitive testingTele-health assetsEducation and training for SM, leaders, patients, MHS providers, community health care providers, Family members, and othersStrategic communications and marketingResearchTBI Program ValidationSource: 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 TeamLevel III: Combat Support Hospital (CSH) and Combat Stress UnitLevel IV: Evacuation Center (Landstuhl Regional Medical Center [LRMAC])Level V: Military medical treatment facility (MMTF) - Inpatient and OutpatientLevel VI: Inpatient Rehabilitation(non-MMTF, such as Veteran’s Affairs Medical Center and community partner facilities)Level VII: Outpatient rehabilitationLevel VIII: Lifetime care
7 Identification & Referral Significant incident in theatre results in Medivac to Germany and then to CONUS to start clinical careUpon return from deployment, all SM’s are provided a Post Deployment Health Assessment and screeningSM with possible symptoms of concussion, are then referred to the TBI clinic for additional evaluation and possible treatment and careComplex & 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 TBIDoD Deployment Health Clinical Center at Walter Reed Army Medical Center, Washington, D.C , May 2010Traumatic 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 definedOther 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 ArmyIncrease 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 TBIData is updated quarterly.Army Total CY 00-CY09Severe or Penetrating 3%; Moderate 16 %; Mild 75%; Not Classifiable 6%Calendar Year in which Injury OccurredThis 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 attributedto the consequences of blasts orexplosions caused by IED’sOther sources: Bullets, fragments,MVA’s, assaults (DVBIC)Males 1.5 x’s higher risk thanfemales (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 2006Principle cause of combat-related TBI is IEDs.DVBIC.org
12 Blast Injuries are Caused by Four Different Effects Primary – Overpressure of “blast wave”Secondary – Flying DebrisTertiary – Body Displacement, Victim thrown into stationary objectsQuaternary – Any injury or disease not due to other mechanisms (burns,toxic inhalation, crushinjuries, 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:TransientRapid or gradual resolution within days or weeksHighly nonspecific: headache, blurred vision, dizziness, sleep problems, cognitive changes (attention/concentration/memory)Prognosis after mTBI: GoodRecovery occurs for most within 3-12 months with or without intervention, very small percentage of cases have symptoms persisting beyond 3 monthsPersisting symptoms attributable to other factors: demographic , psychosocial, medical, situationalMcCrea 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 monthsBetween 8%(Binder, 1997) and 33%(Guskiewicz, 2007) (of what type) have continued symptoms past 3 monthsTherapists incorporate assessment of the Service Members goals and priorities along with TBI related symptoms to develop a plan of care with expected improvementMcCrea
15 Reasons for Persisting Symptoms PTSD, Depression, anxiety, stress,Pre-existing disorder, dysfunction, or limitationExpectation of the SM / denialLimited cognitive reserveSomatoform disorderSleep disorderMalingeringKashluba 2008Polytrauma 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 2003Rohling 2003 data, %’s not accurate however symptoms represent the most common reported
17 TBI Team Members Audiologist Case manager Neurologist NeuropsychologistOccupational therapistOphthalmologist / OptometristPhysical therapistPrimary Care ManagerSocial Worker/ Counselor/ PsychologistSpeech-Language PathologistIn addition to outside referral sources: BH, Acupuncture, Pain Mgmt.,Ideally family members, TBI educators (DVBIC), and perhaps possible command leaders
18 Take Home PointsBlast injuries are unique, injuries can be invisible or latentMost severe symptoms evident within minutes of injuryDelayed symptom onset relatively rareCombination of physical and cognitive symptoms most commonMeasurable improvement seen within hours of injuryGradual symptom recovery occurs over 7-10 days in 80-90% of casesHeadache tends to linger the longest.Good prognosis for recoveryWhile mTBI is difficult to diagnose, as therapists, we treat the functional impairments regardless of underlying diagnosis
19 Resources & WebsitesDefense & 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 InformationLT Joann Shen, M.S. CCC-SLP Ms. Carla Chase, M.S. CCC-SLPTripler Army Medical Center Schofield Barracks Health ClinicPhone: Phone:CDR Laura M. Grogan, OTR/LEvans Army Community HospitalPhone:LCDR Alicia Souvignier, CDR Henry McMillanEvans Army Community Hospital Womack Army Medical CenterPhone: Phone: