1. DoD Medical Research Program for the Prevention, Mitigation and Treatment of Blast Injuries UNCLASSIFIED 17-20 Nov 2008 1 of 8 DoD Medical Research Program for the Prevention, Mitigation and Treatment of Blast Injuries Blast-Related Traumatic Brain Injury Research Gaps Biomedical Science and Engineering Conference Oak Ridge National Laboratory 18-19 March 2009 Blast-Related Traumatic Brain Injury Research Gaps Biomedical Science and Engineering Conference Oak Ridge National Laboratory 18-19 March 2009 Michael J. Leggieri, Jr. Director DoD Blast Injury Research Program Coordinating Office U.S. Army Medical Research and Materiel Command The views expressed in this presentation are those of the author(s) and do not reflect official policy or position of the Department of the Army, Department of Defense or the U.S. Government. Michael J. Leggieri, Jr. Director DoD Blast Injury Research Program Coordinating Office U.S. Army Medical Research and Materiel Command The views expressed in this presentation are those of the author(s) and do not reflect official policy or position of the Department of the Army, Department of Defense or the U.S. Government. UNCLASSIFIED

2. DoD Medical Research Program for the Prevention, Mitigation and Treatment of Blast Injuries UNCLASSIFIED 18 March 2009 2 of 11  FY06 NDAA, Section 256, 6 Jan 06—directed SECDEF to establish a coordinated Medical Research Program for the Prevention, Mitigation and Treatment of Blast Injuries  DoDD 6025.21E—Medical Research for Prevention, Mitigation, and Treatment of Blast Injuries, 5 Jul 06  Designated SECARMY as Executive Agent (EA)  Assigns the Assistant Secretary of Defense for Health Affairs (ASD(HA)) as the approving authority for Military Health System prevention and treatment standards developed and proposed by the DoD EA.  SECARMY delegated authority and assigned responsibility to execute EA responsibilities to ASA(ALT), 4 Jan 2007  ASA(ALT) delegated authority and assigned program responsibility to Cdr, USAMEDCOM, 16 Jan 2007  Cdr, USAMEDCOM approved charter for Blast Program Coordinating Office at USAMRMC on 5 Jun 2007 Program History

3. DoD Medical Research Program for the Prevention, Mitigation and Treatment of Blast Injuries UNCLASSIFIED 18 March 2009 3 of 11 Defining “Blast Injuries” (DoDD 6025.21E) Defining “Blast Injuries” (DoDD 6025.21E) PRIMARY SECONDARY TERTIARY QUATERNARY QUINARY Blast lung Eardrum rupture and middle ear damage Abdominal hemorrhage and perforation Eye rupture Concussion (TBI without physical signs of head injury)? Penetrating ballistic (fragmentation) or blunt injuries Eye penetration Fracture and traumatic amputation Closed and open brain injury Blunt injuries Crush injuries Burns Injury or incapacitation from inhaled toxic fire gases Illnesses, injuries, or diseases caused by chemical, biological, or radiological substances (e.g., "dirty bombs") * Psychological trauma (including PTSD) *Added based on latest research suggesting a high risk of developing PTSD following a concussion

4. DoD Medical Research Program for the Prevention, Mitigation and Treatment of Blast Injuries UNCLASSIFIED 18 March 2009 4 of 11 Key Blast Injury Research Topics Injury Prevention Blast Loading CFD Simulation Observed Pathology FEM Simulation Test ConditionsBlast Loading CFD Simulation Observed Pathology FEM Simulation Test Conditions Link between primary blast and mTBI? Drugs to prevent and treat blast-related hearing loss Analysis of combat injuries and PPE performance (JTAPIC) Multi-effect blast injury models to improve protective equipment Resilience enhancement and prevention of PTSD Hair Cell Antioxida nt Defenses Tissue engineering and prosthetics Return-to-duty Standards Recovery of function Reset Before After Diagnostics and neuroprotectant drugs for TBI Hemorrhage control & blood products Treatment of psychological trauma Damage control orthopedics Pain management Acute Treatment

5. DoD Medical Research Program for the Prevention, Mitigation and Treatment of Blast Injuries UNCLASSIFIED 18 March 2009 5 of 11 Current DoD Investment in TBI Research  Field Epidemiology (TBI and Psychological Health)  Diagnostics (biomarkers and imaging)  Treatment (neuroprotectant drugs, tissue engineering, & other)  Rehabilitation/Reintegration Strategies (return-to-duty standards, telemedicine, & other technologies)  “Physics of Blast” (tissue-level injury mechanisms and computational modeling)  Effects of Repeated Blast Exposures  Treatment of Related Illnesses (e.g., heterotopic ossification)

6. DoD Medical Research Program for the Prevention, Mitigation and Treatment of Blast Injuries UNCLASSIFIED 18 March 2009 6 of 11 TBI Research Gaps mTBI Biomarkers Effects of Repeated Occupational BOP Exposures Epidemiology of mTBI and PTSD Advanced Neuroimaging to Detect mTBI Existence and Mechanism of BOP-Induced TBI TBI Therapeutics— Clinical Trials Novel Approaches to Facilitate TBI Rehab Field-Portable mTBI Diagnostic Devices TBI Rehab/Augmentation Programs or Devices

7. DoD Medical Research Program for the Prevention, Mitigation and Treatment of Blast Injuries UNCLASSIFIED 18 March 2009 7 of 11 Non-Impact, Blast-Induced Mild Traumatic Brain Injury (mTBI) The Problem  Warfighters are exposed to blast events  Major research gap is whether blast exposure causes a unique non-impact (primary) mTBI (concussion)  Two critical questions: Does non-impact, blast- induced mTBI exist? If so, what is the mechanism of injury? Oleg Nikishin/Getty Images

8. DoD Medical Research Program for the Prevention, Mitigation and Treatment of Blast Injuries UNCLASSIFIED 18 March 2009 8 of 11 Non-Impact, Blast-Induced Mild Traumatic Brain Injury (mTBI) Proposed Injury Mechanisms  Head acceleration  Micro-flexure of skull  Vascular surge  Air emboli  Biochemical  Electromagnetic pulse (EMP)

9. DoD Medical Research Program for the Prevention, Mitigation and Treatment of Blast Injuries UNCLASSIFIED 18 March 2009 9 of 11 Non-Impact, Blast-Induced Mild Traumatic Brain Injury (mTBI) Current Research Investment  More than 40 research projects at military and federal laboratories, universities, industry partners  Ongoing research in Sweden & Singapore  Research topics include: Computational modeling of brain injury Effects of blast loading on brain tissues Blast wave transmission through brain Effects of repeated blast exposure

10. DoD Medical Research Program for the Prevention, Mitigation and Treatment of Blast Injuries UNCLASSIFIED 18 March 2009 10 of 11 Non-Impact, Blast-Induced Mild Traumatic Brain Injury (mTBI) Way Ahead Organize and host International State of-Science Conference in May 2009, Nat’l Capital Region International, military, industry, and academic researchers & clinicians Examine research about relationship between blast exposure and non-impact mTBI Review mechanisms of non- impact, blast-induced mTBI Document outcome in peer- reviewed publication

11. DoD Medical Research Program for the Prevention, Mitigation and Treatment of Blast Injuries UNCLASSIFIED 18 March 2009 11 of 11 Points of Contact Mr. Michael Leggieri Director DoD Blast Injury Research Program Coordinating Office U.S. Army Medical Research and Materiel Command Fort Detrick, MD 21702 301-619-7376michael.leggieri@us.army.mil LTC Kelly Halverson Army Program Coordinator JTAPIC Program Manager DoD Blast Injury Research Program Coordinating Office U.S. Army Medical Research and Materiel Command Fort Detrick, MD 21702 301-619-9838kelly.halverson@us.army.mil Col (sel) Marla De Jong Air Force Program Coordinator DoD Blast Injury Research Program Coordinating Office U.S. Army Medical Research and Materiel Command Fort Detrick, MD 21702 301-619-9830marla.dejong@us.army.mil