Traumatic Brain Injury - Concussion in the Military May 25, 2010

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 Source: Proponency Office for Rehabilitation & Reintegration www.armymedicine.army.mil.prr

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 www.armymedicine.army.mil.prr

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 • (non-MMTF, such as Veteran’s Affairs Medical Center and community partner facilities) • 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

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

9. Severity Scales of Closed TBI

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 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 2009. 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)

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)

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

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

16. Most Common Symptoms of mTBI • 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. TBI Team Members • Audiologist • Case manager • Neurologist • Neuropsychologist • Occupational therapist • Ophthalmologist / Optometrist • Physical therapist • Primary Care Manager • Social Worker/ Counselor/ Psychologist • Speech-Language Pathologist

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: www.dvbic.org • Brainline (DVBIC-sponsored): www.brainline.org • Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury: www.dcoe.health.mil • Deployment Health Clinical Center: www.pdhealth.mil • Defense Centers of Excellence for Psychological Health & Traumatic Brain Injury: www.health.mil/dcoe.aspx • Department of Veterans Affairs (VA): www.va.gov • DoD Disabled Veterans: www.dodvets.com • Polytrauma Sites: www.polytrauma.va.gov • Traumatic Brain Injury National Resource Center: www.nrc.pmr.vcu.edu • Brain Injury Association of America: www.biausa.org

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: 808-433-4362 Phone: 808-433-8323 Joann.Shen@us.army.milCarla.Chase1@amedd.army.mil CDR Laura M. Grogan, OTR/L Evans Army Community Hospital Phone: 719-526-3704 Laura.Grogan@amedd.army.mil LCDR Alicia Souvignier, CDR Henry McMillan Evans Army Community Hospital Womack Army Medical Center Phone: 719-526-3704 Phone: 910-907-7911 Alicia.Souvignier@amedd.army.milHenry.mcmillan@us.army.mi