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VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI, 2009. Traumatic Brain Injury - Concussion in the Military May 25, 2010 The views.

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Presentation on theme: "VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI, 2009. Traumatic Brain Injury - Concussion in the Military May 25, 2010 The views."— Presentation transcript:

1 VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI, 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.

2  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  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 Source: Proponency Office for Rehabilitation & Reintegration

5  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  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  (non-MMTF, such as Veteran’s Affairs Medical Center and community partner facilities)  Level VIII: Lifetime care

7  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

8 DoD Deployment Health Clinical Center at Walter Reed Army Medical Center, Washington, D.C, May 2010


10 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 Trend for Total Army NUMBER OF ARMY SOLDIERS WITH IDENTIFIED TBI 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. Calendar Year in which Injury Occurred

11  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)

12  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) 12

13 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  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

15  PTSD, Depression, anxiety, stress,  Pre-existing disorder, dysfunction, or limitation  Expectation of the SM / denial  Limited cognitive reserve  Somatoform disorder  Sleep disorder  Malingering

16 Headaches 59% Blurred vision 45% Anxiety 58% Dizziness 52% Fatigue 64% Light sensitivity 40% Poor concentration 78% Trouble thinking 57% Memory Problems 59% Irritability 66% Depression 63% Rohling 2003

17 Audiologist Case manager Neurologist Neuropsychologist Occupational therapist Ophthalmologist / Optometrist Physical therapist Primary Care Manager Social Worker/ Counselor/ Psychologist Speech-Language Pathologist

18 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 % 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  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 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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