1. + – Traumatic Brain Injury Clinic Martin Army Community Hospital Christopher R. Walsh, PA. Commander, USPHS MACH TBI Service

2. Educational Objectives 1. Define Military Mild Traumatic Brain Injury (mTBI) 2. List the causes and complications associated with mTBI including comorbid disorders. 3. Discuss various instruments to assess the severity of TBI and PTSD (MACE, PCL-M, PHQ9P, RBANS) CDR Walsh has no relevant financial relationships. The opinions and assertions contained in this presentation are the private views of CDR Walsh and do not necessarily reflect the official policies or positions of the Department of Defense or the Department of the Army.

3. TBI Services Primary Care Neurology Psychiatry Physiatry (Pain Management) Case Management Neuropsychology Team Consulting Occupational & Physical Therapy Administration

4. Epidemiology In US, 1.5 million cases seen in Emergency Departments 85% Diagnosed as mTBI Majority are motor vehicle accidents, falls and sports injuries. mTBI is called the “Silent Epidemic” Neurological findings typically within normal limits but the patient is functionally disabled.

5. Military mTBI 1.69 million U.S. Military personnel have been deployed more than 2.2 million times to OIF or OEF since the start of military operations in 2001. Head and neck injuries, including severe brain trauma, have been reported in 25% of SM who have been evacuated from Iraq and Afghanistan. mTBI, or concussion, characterized by brief LOC or altered mental status, as a result of deployment-related head injuries, particularly those resulting from proximity to blast explosions may be as high as 18% of returning SM. NEJM Hoge et. Al (2008)

6. Screening for TBI Anyone exposed to or involved in a: Blast Fall Vehicle crash Direct impact Who becomes dazed or confused even momentarily, should be further evaluated for brain injury. DVBIC CPG

7. A Concussion is a Brain Injury 1. When in doubt…sit ‘em out 2. When signs & symptoms of concussion are present: No physical activity Minimize cognitive activities to levels that are easily tolerated 3. When signs & symptoms of concussion are completely gone: Resume physical activity, gradually increasing intensity Gradually increase the intensity of cognitive activities 4. IF ANY SYMPTOMS REAPPEAR WHEN RESUMING ACTIVITIES, GO BACK TO STEP 1.

9. IED Explosion

10. TBI Related Disorders

11. Definition of Military mTBI An injury to the brain resulting from an external force and/or acceleration/deceleration mechanism which causes an alteration in mental status typically resulting in the temporally related onset of symptoms such as: headache, nausea, vomiting, dizziness/balance problems, fatigue, trouble sleeping/sleep disturbances, drowsiness, sensitivity to light/noise, blurred vision, difficulty remembering, and/or difficulty concentrating.

12. LOC of 30 minutes After 30 minutes, and initial GCS 0f 13-15; and PTA not greater than 24 hours ( Diffusion Spectrum Imaging tracks the movement of water molecules as they slide down axons. Red reflects right to left connections; green front to back and blue up and down including links to the spinal cord. )

13. Multiple Concussions A worst-case scenario is a rare complication called "second-impact syndrome” caused by sustaining a second concussion before the symptoms of the prior concussion have resolved. This condition can be fatal. There is conflicting data regarding the cumulative pathologic effects of multiple concussions. There is also no consensus on how many concussions are too many, in either the sports world or the Military.

14. Blast Injuries PRIMARY: Direct exposure to overpressurization wave – velocity >/= 300m/sec (speed of sound of air) SECONDARY: Impact of blast energized debris penetrating and non penetrating TERTIARY: Displacement of the person by the blast and impact QUARTERNARY: Inhalation of toxic fumes, smoke, chemicals

15. TBI Assessment Tools MACE (Military Acute Concussion Evaluation) PCL-M (PTSD Checklist-Military) PHQ9P CNS Vital Signs RBANS (Repeatable Battery for Assessment of Neuropsych Status

16. + Psychiatric Comorbidities mTBI (i.e., concussion) occurring among soldiers deployed in Iraq is strongly associated with PTSD and physical health problems 3 to 4 months after the soldiers return home. PTSD and depression are important mediators of the relationship between mild traumatic brain injury and physical health problems. NEJM Hoge et. Al (2008)

17. General Lee lies on its side after surviving a buried IED blast in 2007.

18. mTBI and PTSD Comorbid mTBI with Posttraumatic Stress Disorder (PTSD) is a common clinical presentation among troops returning from OEF and OIF. Soldiers with comorbid PTSD (+TBI/+PTSD) have greater executive dysfunction and poor processing speed than the mTBI-only group (+TBI/-PTSD). Journal of Head Trauma, Nelson et. al, (2009)

19. Glutamate Neurotoxicity Glutamate neurotoxicity is a mechanism that may explain the large overlap in symptoms and functional deficits in such seemingly diverse clinical entities as PTSD, depression, and mild traumatic brain injury. Nash et. Al (2009) Psychiatric Annals 39:8

20. Neurometabolic Cascade Following TBI 1. Nonspecific depolarization and initiation of action potentials. 2. Release of excitatory neurotransmitters. 3. Massive efflux of potassium. 4. Increased activity of membrane ionic pumps to restore homeostasis. 5. Hypergylcolysis to generate more adenosine triphosphate (ATP)

21. Neurometabolic Cascade (cont’d) 6. Lactate accumulation 7. Calcium influx & sequestration in mitochondria leading to impaired oxidative metabolism. 8. Decreased energy (ATP) production 9. Calpain activation and initiation of apoptosis a. Axolemmal disruption & calcium influx b. Neurofilament compaction via phosphorylation or sidearm cleavage c. Microtubule disassembly & accumulation of axonally transported organelles. d. Axonal swelling and eventual axotomy Giza & Hovda (2001)

22. Multiple Concussions Top: Slide detailing x600 magnification of immunostained neocortex in a non-CTE damaged brain. Bottom: Slide detailing x600 magnification of Chris Benoit's tau- immunostained neocortex showing neurofibrillary tangles, neuritic threads, and several ghost tangles indicating CTE. (Credit: Image courtesy of Sports Legacy Institute)

23. Multiple Concussions Involving Athletes Athletes with 3 or more concussive events had 20.2% rate of depression vs. 6.6% with no lifetime concussion diagnosis Center for the Study of CTE at Boston University Study- 12 brains of football players were found to be riddled with tau protein. Netherlands Study (Matser & Lezak) Soccer players with 2 or more concussions are 3 to 4 times more likely to show deficits in memory and planning skills.

24. HUMVEE Hit by IED

25. mTBI in U.S. Soldiers Returning from Iraq NEJM 2008; 358:453-63 Charles W. Hoge, M.D., Dennis McGurk, Ph.D., et al. 2525 U.S. Army soldiers 3 to 4 months after return from 1 yr. 124 (4.9%) +LOC; 260 (10.3%) altered mental status, & 435 (17.2%) other injuries during deployment + LOC = 43.9% met criteria for PTSD; AMS = 27.3%; other injuries = 16.2%; no injury = 9.1% mTBI associated with poor general health, missed workdays, medical visits, > somatic & PCS compared to SM with other injuries. After adjustment for PTSD & depression, mTBI no longer associated with poor physical health except headache

26. PTSD and TBI Overlay Sustaining any type of physical injury in theater is known to increase a service members risk for PTSD (Hoge, 2004) Symptoms found in both PTSD and mTBI: deficits in attention, and memory, irritability and sleep disturbance. Distinguishing symptoms such as headache, dizziness, balance problems and nausea/vomiting may help to differentiate TBI from ASR/PTSD.

27. Comprehensive Array of Tests Effort and compliance Premorbid intelligence Intelligence Arousal and attention Language ability Learning and memory Visuospatial skills Executive functions Motor Skills Emotion, behavior & personality

28. TBI Headaches, vision changes, light and sound sensitivity, dizziness, hearing changes PTSD Flashbacks, hallucinations, intrusive recollections, physiological reactivity, nightmares *Sleep disturbances *Personality changes: irritability, aggression *Loss of interest (anhedonia) *Memory problems

29. MACH TBI Services Primary Care Assessment Case Management Neurological Evaluation/Treatment Psychiatric Evaluation/Treatment Pain Evaluation/Management Neuropsychological Screening/Evaluation Individual & Group Psychotherapy Psychoeducation Cognitive Rehabilitation Biofeedback/Neurofeedback/Alpha-Stim Balance Assessment/Neurocom

30. Eslinger, P. J. Neuropsychological Interventions: Clinical Research and Practice, 2005 Eslinger, P. J. Neuropsychological Interventions: Clinical Research and Practice, 2005 Ponsford, J. Traumatic Brain Injury: Rehabilitation for Everyday Adaptive Living (REAL), 1995 Ponsford, J. Traumatic Brain Injury: Rehabilitation for Everyday Adaptive Living (REAL), 1995 Sohlberg, K. M. & Mateer, C. Attention Process Training APT-I, A Clinical Tool for Cognitive Remediation Sohlberg, K. M. & Mateer, C. Attention Process Training APT-I, A Clinical Tool for Cognitive Remediation Rohling, M. L., Faust, M. E., Beverly, B., & Demakis, G. Effectiveness of Cognitive Rehabilitation Following Acquired Brain Injury: A Meta-Analytic Re-Examination of Cicerone et al.’s (2000, 2005) Systematic Reviews, 2009 Rohling, M. L., Faust, M. E., Beverly, B., & Demakis, G. Effectiveness of Cognitive Rehabilitation Following Acquired Brain Injury: A Meta-Analytic Re-Examination of Cicerone et al.’s (2000, 2005) Systematic Reviews, 2009 Gillen, G. Cognitive and Perceptual Rehabilitation: Optimizing Function, 2009 Gillen, G. Cognitive and Perceptual Rehabilitation: Optimizing Function, 2009

31. Executive Function Memory Language Spatial- Visualization Attention

32. Constitutes the basis for cognitive processes. Basic memory functions are dependent on intact attention processes. Attention skills serve as a cognitive foundation. Attention is a prerequisite to engage in most if not all meaningful activities. Impairment in attention processes will result in observable difficulties in everyday life.

34. Interventions Area of cognitive impairment Empirically-supported interventions Attention Attention process training Working memory training Memory Various mnemonic techniques Visual imagery mnemonics Attention Memory notebook Memory External cuing Executive functioning

35. Interventions (cont’d) Area of cognitive impairment Empirically-supported interventions Executive functioning Social communication skills training groups Social pragmatics Attention Problem solving training Memory Error management training Executive functioning Emotional regulation training Social pragmatics Integrated use of individual and group interventions

36. Defense and Veterans Brain Injury Center TBI Service 706-544- 5102/5176 www.dvbic.org Gail Wolf, M.A. – Slide Designs MACH TBI Team LT. Donelle McKenna Acknowledgements Thanks to these resources: