Care of Our Homecoming Warriors

1. Care of Our Homecoming Warriors Mild Traumatic Brain Injury Operation Iraqi Freedom Operation Enduring Freedom Carol Burgess MD

2. Battlefield TBI: Sources of trauma Types of Trauma • Direct trauma (MVA and falls), shrapnel, bullet wounds • Improvised explosive devices • Rocket-propelled grenades • Hoge, McGurk, Thomas et al. Mild traumatic brain injury in U.S. Soldiers returning from Iraq. N Engl J Med 2008: 358:453 Protective Gear • Interceptor Body Armor protects the torso from kinetic energy of blast (fewer body-related casualties) • Modular Integrated Communications Helmet (MICH) worn by Rangers, Special Forces, Navy SEALS, Air Force Special Operations, Marine reconnaissance, FBI Hostage, one brigade of 82nd Airborne only. Offers increased impact protection. • Standard helmet is Kevlar

4. TBI or Traumatic Brain Injury • Immediate: • vacant stare, • delayed verbal expression, • inability to focus attention, • disorientation, • slurred or incoherent speech, • incoordination or disequilibrium, • Potential Complications: • Coma, • ischemia/edema and mass effect, • seizure, • intracranial hemorrhage

5. Traumatic Brain Injury • Signs and symptoms of danger: • prolonged unconsciousness, • skull fracture (esp. open or depressed), • CSF leak, • hematotympanum, • raccoon eyes or Battle’s sign, • greater than two episodes vomiting, • incontinence, • older than 65, • persistent mental status alterations, • amnesia before impact of greater than 30 minutes, • dangerous mechanism (fall greater than 3 feet or greater than 5 stairs, or pedestrian struck by MV) • abnormalities on neurologic exam. • Kelly, Rosenberg. Diagnosis and management of concussion in sports. Neurology 1997:48:575

7. Incidence of TBI 1.4 million reported incidents of TBI annually in US, most- 75% to 95% are mild. Division of Injury and Disability Outcomes http://www.cdc.gov/ncipc/pub-res/TBI_in_US_04/TBI_ED.htm 1.6 million military deployed to the Iraq and Afghanistan conflicts. • 62% of those requiring medical evacuation from the Iraq and Afghanistan conflict have TBI • 16% of returning military have had a reported alteration in consciousness or LOC • 13%-17% reported incidence of PTSD Am J Epidemiol 2008:167:1446-1452 Some estimates of incidence of TBI including Blast injury as well as direct concussion and trauma: as high as 25% among returning military

8. Monetary Costs of TBI • Direct and indirect costs may exceed $60 billion per year in the US • Costs of inpatient rehabilitation often exceed $100,000/patient • Outpatient cognitive rehabilitation approximately $20,000 to $30,000/patient • Employment drops from 69% to 31% by end of 1st year of injury for civilian TBI • US civilian TBI result in $642 million in lost wages yearly, $96 million in lost taxes yearly, and $353 million in increased public assistance expenditures. • Archives of Phys Med &Rehab Vol 84, Feb 03, page 238-241

9. Acute symptoms of Mild Brain Injury:Definition of Mild Traumatic Brain Injury According to the American Congress of Rehabilitation Medicine • 1. Any period of loss of consciousness: • 2. Any loss of memory for events immediately before or after the accident • 3. Any alteration in mental state at the time of the accident (e.g. feeling dazed, disoriented, or confused), and • 4. Focal neurological deficit(s) that may or may not be transient; but where the severity of the injury does not exceed the following: • Post-traumatic amnesia not greater than 24 hours • After 30 minuets, an initial Glasgow Coma Scale score of 13-15 • LOC of 30 minutes or less Mild Traumatic Brian Injury Committee of the Head Injury Interdisciplinary Special Interest Group of the American Congress of Rehabilitation Medicine. The definition of traumatic brain injury. J Head Trauma Rehabil. 1993;8(3):86-87

10. Mild TBI/PCS (post concussive syndrome) • May not be a true history of LOC • Hallmark manifestations of concussion: confusion and amnesia • 80% of those with mild TBI will experience some symptoms of post-concussive syndrome • Risk of PCS does not correlate well with severity of injury • Common clinical usage of both terms, PCS is a subset of mild TBI

11. Mild TBI mechanisms and pathology • Coup and Contra-coup injuries -Goodman. Pathologic changes in mild head injury. Semin Neurol 1994:14:19 • Mild axonal injuries and rupture • Potential for vessel oscillations to transmit force of a blast to the Brain with subsequent axonal neurofilament disruption and damage (leading to axonal swelling, Wallerian degeneration, and transection). Postulated involvement of the Hippocampus, Brainstem, and Cortex. -Bhattacharjee,Y Shell shock revisited: solving the puzzle of blast trauma. Science 2008:319:406 -Povlishock, Katz. Update of neuropathology and neurological recovery after traumatic brain injury. J Head Trauma Rehabil 2005: 20:76 • Possible acceleration of the pathophysiology of aging, buildup of neurofilament proteins. Note possible vulnerability of individuals with ApoE allele. -Jordan, Relkin, Ravdin, et al. Apolipoprotein E epsilon4 associated with chronic traumatic brain injury in boxing. JAMA 1997; 278:136

12. Comparison of normal CNS tissue to posthumous CNS tissue from NFL player suffering Chronic Traumatic Encephalopathy Note tangles in superficial rather than deep neocortex Occurs without neuritic plaques Brain Tissue from NFL athlete suffering CTE - greater than 100 head traumas Normal Brain Tissue • Note the absence of “brown” protein tangles in the Normal Brain, and the significant accumulation of protein tangles in the brain of a former NFL athlete with CTE. Pathologic findings similar to those of Alzheimer's dementia. Presented by the Center for the Study of Traumatic Encephalopathy at the Boston University School of Medicine • http://www.cnn.com/2009/HEALTH/01/26/athlete.brains/index.html

13. Evaluation of the Patient with TBI • History and Physical ( Neurologic exam) with appropriate laboratory and EKG. • Radiologic evaluation • CT, MRI/MRA, possible role of functional MRI • EEG • Acoustic, Visual, Vestibular evaluation • Neuropsychological evaluation/Cognitive testing • Sleep evaluation • Appropriate system evaluation (Cardiac, GI, Urology, Pulmonary, Endocrine) • Substance use evaluation and treatment

14. Symptoms of Post Concussive Syndrome • Symptoms: • Fatigue (91%) • Personality change (50%) • Headaches ( 78%) • Chronic Pain (75%) • Dizziness (59%) • Insomnia (70%) • Sensory sensitivity (46%) • Neuropsychiatric Symptoms (note commonality to some symptoms of PTSD) • Irritability (62%) • Anxiety (63%) • Psychiatric illness (20%) • Cognitive Impairment: attention, working memory(73%), processing speed, reaction time, and “executive function” Paniak, Reynolds, Phillips, et al. Patient complaints within 1 month of mild traumatic brain injury: a controlled study. Arch Clin Neuropsychol 2002; 17:319 Dikmen, Mclean, Tmkin. .Neuropsychological and psychosocial consequences of minor head injury. J Neurol Neurosurg Psychiatry 1986: 49:1227

15. Mental Health Sequelae for military returning from Iraq/Afghanistan • 17% from Iraq showing signs of PTSD, major depression or severe anxiety (90% involved in direct combat) • 11% from Afghanistan showing signs of PTSD, major depression or severe anxiety (31% were involved in direct combat ) • Some reports of returning military units with 80% incidence of significant mental health issue and 85% incidence of divorce PTSD in Vets May Present as Substance Abuse. www.internalmedicine news.com Dec 15,2008 • Emerging suicide issues • Increased incidence of criminal arrests (reported as high as 20-30%) among returning military from Iraq/Afghanistan

16. Assessment of validity ofPost Concussive Syndrome • Risk factors for Post concussive syndrome and protracted recovery • Female gender • Increasing age • MVA /Assault, rather than sport related injury • Pre-morbid depression or other psychiatric illness • Co-existent PTSD • Decreased social supports • Issue of concerns for role of litigation • Issue of coexistence of chronic pain complaints Issues: -patients with psychiatric illness may be more prone to injury -patients with psychiatric illness may be more prone to develop PCS after injury -head injury may precipitate psychiatric disease in susceptible individuals

17. DSM IV criteria PTSD A. Exposed to traumatic event -1.Experienced or witnessed -2.Response of helplessness or horror B. Traumatic event persistently re-experienced -1. recurrent intrusive recollections -2.recurrent distressing dreams - 3.acting or feeling like event is recurring -4.intense emotional distress at exposure to events resembling the event -5.physiological reactivity on exposure to cues resembling the event C .Persistent avoidance of stimuli associated with the trauma -1. Efforts to avoid thoughts, feelings and conversations associated with the trauma - 2.Efforts to avoid activities, places and people that arouse recollection of the event -3.Inability to recall an important aspect of the trauma -4.diminished interest or participation in significant activities -5. feeling of detachment or estrangement from others -6. restricted range of affect (unable to feel love) -7. sense of foreshortened future (different than limited expectations due to impairment) D. Persistent symptoms of increased arousal indicated by 2 of the following: -1. difficulty with sleep -2.irritability or outbursts of anger -3.difficulty concentrating -4.hypervigilance -5.exaggerated startle response (different than hyperacusis or photophobia) E. Duration is 1 month (acute if less than 3 months – chronic if greater than 3 months. F. The disturbance causes clinically significant distress or impairment of occupational function. C Burgess MD Comparison of PTSD to TBI TBI Traumatic Event to CNS Fatigue and Cognitive fatigue “veil of cement” Insomnia Anxiety / Depression Sensory sensitivity Autonomic/Adrenergic dysfunction Overwhelmed with coping Amnesia from trauma Reduced socialization Reduced capacities Cognitive limitations Insomnia Dizziness Irritability/Outbursts Poor emotional control Headache Concentration limitations Occupational change Personality change

18. Evaluation of the Patient with TBI • History and Physical ( Neurologic exam) with appropriate laboratory and EKG. • Radiologic evaluation • CT, MRI/MRA, possible role of functional MRI • EEG • Acoustic, Visual, Vestibular evaluation • Neuropsychological evaluation/Cognitive testing • Sleep evaluation • Appropriate system evaluation (Cardiac, GI, Urology, Pulmonary, Endocrine) • Substance use evaluation and treatment

19. Radiology • CT scan • 10% CT abnormal in mild TBI (demonstrating contusions, subdural hemorrhage, or subarachnoid hemorrhage ) • MRI scan • (MRI abnormalities present in 30% or the cases of mild TBI with reported normal CT – many of these findings consistent with axonal injury but not specific to TBI or TBI outcome) • Mittl, Grossman, Hiehle, et al. Prevalence of MR evidence of diffuse axonal injury in patients with mild head injury and normal head CT findings. Am J Neuroradiol 1994; 15:1583 • SPECT, PET and functional MRI more likely to demonstrate abnormalities, supporting a role for diffuse structural and/or physiologic abnormality in mild TBI. Primarily a research tool. • Similar abnormalities may be noted on functional imaging studies in migraine and depression. Metting, Rodiger, De Keyser, van der. Structural and functional neuroimaging in mild-to-moderate head injury. Lancet Neurol 2007; 6:699

20. SPECT Brain Perfusion after mild TBI

21. Evaluation of the Patient with TBI • History and Physical ( Neurologic exam) with appropriate laboratory and EKG. • Radiologic evaluation • CT, MRI/MRA, possible role of functional MRI • EEG • Acoustic, Visual, Vestibular evaluation • Neuropsychological evaluation/Cognitive testing • Sleep evaluation • Appropriate system evaluation (Cardiac, GI, Urology, Pulmonary, Endocrine) • Substance use evaluation and treatment

22. Seizures post TBI • Post –traumatic seizures occur in less than 5% of mild or moderate TBI. • Increased frequency with more severe trauma. • 50% occur within the first 24 hours of injury. • 25% occur within first hour of injury. • After the first hour, majority are simple partial (motor) or focal with secondary generalization. • Early seizures increase the risk of post- traumatic epilepsy by 4X • Anticonvulsants are not useful in prevention of post traumatic epilepsy, but may be used to in treatment of early seizures.

23. Treatment of mild TBI

24. Longitudinal Continuity of Care with Primary PhysicianSymptomatic Treatment • Frequent visits (often every 2 weeks) • Address suicidal thoughts and psychotic ideation early • Only one or two “projects” per visit • Provide a Notebook: “Back-pocket Memory” (VA may provide a PDA) • Orchestrate care and network patients • Set reasonable expectations: Adaptation (LIMIT grief) • Provide emotional support and attitudinal course corrections • Provide necessary family and community Education (with consent… call them, if not with patient at visit) • Celebrate success ! C Burgess MD

25. Suggested Sequence of Symptomatic Treatment and Rehabilitation for mild TBI • First Priority: SLEEP • Pain and Headache • Emotional Concerns: Anxiety and Depression…PTSD. • Sensory Disturbance: Visual, Acoustic, Equilibrium • Fatigue • Education: Family and Employer • Visual and Vestibular Rehab • Cognitive Rehab C Burgess MD

26. TBI: Management post- traumatic Headache • Use Low Dose pharmacologic therapy! • Often worse after mild TBI : occur in 25% to 78% of patients with mild TBI • Use localized therapy or treatment when possible (lidocaine patch, NSAID patch, cortisone injection, or physical therapy) • Types of Headache: • mixed, • tension (75%), • migraine, • occipital and trigeminal neuralgia, • TMJ, • positional, • analgesic overuse, • low CSF pressure, • cluster, • hemicrania continua

27. Pharmacologic management of headache associated with TBI • Pharmacologic Management: Prophylactic *Tricyclic antidepressants: Amitriptyline and Nortriptyline (Amitriptyline 10mg-250mg qd) *Calcium channel Blockers: Verapamil (initiate Verrapamil SR 120mg qd.) *B blockers: Nadolol (20mg qd – 40mg bid), Propanolol SR (80mg-160mg qd) also Timolol, metoprolol, and atenolol • Valproate (125mg bid increasing to 250mg bid • Gabapentin (900 to 1200 mg daily) • Topamirimate (25 mg to 125 mg daily) • Naproxen (250 mg to 500 mg bid) • Tizanidine (1-2mg po qhs, may increase to 8 mg qhs)

28. Management of TBI Headache (Continued) • Propanolol or amitriptyline in combination or alone have a response rate of up to 70% • Dihydroergotamine and metaclopramide IV in repetitive dosing in an inpatient setting may be effective • Triptans may be used for acute Migraine • Indomethacin may be used for paroxysmal hemicrania and hemicrania continua; (25 mg tid increase to 50 mg tid) • Occipital nerve block with local anesthetic and corticosteroid for occipital headache is highly effective for greater occipital neuralgia. • Analgesic overuse headache is common.

29. Management of Sensory Disturbance post TBI • Avoidance of “overstimulation” prior to or during performance of tasks • Photophobia: • Use of dark and transitional glasses. • Careful lighting (fluorescent an issue) • Referral: “Behavioral optometrist” • Diplopia may result from injuries to CN III, IV, and VI. • Anosmia and Hyposmia: impaired taste and smell due to injury to olfactory filaments at the cribiform plate. In 2/3 of patients is a permanent injury (usually permanent if still present at 1 year). Attention needed to avoid weight alterations and gastric irritation. Avoidance of gas appliances.

30. Management of Sensory Disturbance (continued) • Hyperacusis: Use of specialty ear plugs in noisy environment. Referral: Audiologist • Example of available: Westone ES 49 earpiece protection for musicians • Disequilibrium and Vertigo: • Vestibular rehabilitation. Referral: ENT and specially trained physical therapist. • Consider pharmacologic use of Meclizine or Clonazepam (disadvantage is sedation and suppression of adaptive learning). • Encourage regular coordinated movement (dance, tai-chi, etc.). Avoid sports prone to new injuries! • Driving can be an issue: rehabilitation facilities often have driving assessment services and retraining. • NO ETOH!

31. Post Traumatic Vertigo/Dizziness • Mechanisms of Vertigo: • Direct injury cochlea or vestibular structure esp. with sensorineural hearing loss or fracture of temporal bone • Labyrinthine concussion (vertigo plus ataxia) maximal at onset and abating within weeks • BPPV(benign paroxysmal positional vertigo) due to shearing and displacement of otoconia. Can be a hiatus of weeks or months between TBI and development. • Perilymphatic fistula due to rupture of oval or round window. Unilateral SN hearing loss with persistent vertigo and ataxia characteristic • Other: post-traumatic Meniere’s, brainstem ischemia with vertebral artery dissection, epileptic vertigo, and migraine related vertigo. • Mechanisms of non-vertiginous dizziness is often cervical: • Aberrant afferent input from positional proprioceptors in C- spine • Overstimulation of cervical sympathetic nerves • Compromised vertebral arterial flow

32. Management of Fatigue and lack of Concentration • Appropriate sleep, diet and limited exercise. Respect for biorhythms • Frequent rest periods • Avoidance of excessive environmental stimulation • Pharmacologic management • Wellbutrin SR/XL (Budeprion)100mg q am – 300mg q am • Provigil (modinafil) 100mg q am - 200 mg q am and afternoon • Occasional use adderal, concerta, dexedrine, ritalin… • May exacerbate irritability, anger, and sleep issues

33. Favorite pharmacologic choices for mild TBI C J Burgess, MD • Nortriptyline 10-25 mg qhs for headache, sleep, pain and potentially anxiety • Plus zolpediem (Ambien) 5-10 mg, or ramelteon (Rozerem)8 mg if needed for sleep • Citalopram (Celexa) 10-20mg, escitalopram (Lexapro) 5-10mg, or Vanlafaxine (Effexor XR) 37.5-75 mg for anxiety and depression, agitation, emotional lability and to improve sense of “well being”. • Modinafil (Provigil) 100-200 mg or Budeprion SR (Wellbutrin) 100-150 mg qam for alertness and reduced fatigue. • Clonazepam (Klonopin) .25 - .5mg up to tidfor equilibrium issues and vertigo if meclizine fails. Use short term as a “bridge to vestibular rehab”. • Donepezil (Aricept) 10mg qdif memory issues are profound and persistent. • Topamax 25mg to 100mg qdif headaches remain intractable.

34. Cognitive Rehabilitation • Continuing controversy regarding short-term and long term benefits to outcome of early intervention with cognitive and behavioral therapy. • Differences in study design including patient selection, nature of intervention, and measures of performance have hindered assessment of cognitive interventions. • Interventions often delivered in an individual setting based on deficits identified with Neuro-psych testing (full evaluation often involves 4 -6 days of testing).

35. Cognitive Evaluation of mild TBI • Neuropsychological Testing • Vulnerable domains to TBI • Attention • Working memory • Processing speed • Reaction time • Not associated with gross deficits of intelligence and memory • Findings can be confused with those of pain syndromes and medication effects as well as psychological illness • May be helpful in differentiating TBI from alternative diagnosis. Schretlen, Shapiro. A quantitative review of the effects of traumatic brain injury on cognitive functioning. Int Rev Psychiatry 2003; 15:341

36. Expectations

37. Expectations after Mild TBI • 10-15% of mild TBI cases have persistent symptoms beyond one year • Iverson. Outcome from mild traumatic brain injury. Curr Opin Psychiatry 2005; 18:301 • 80% of those with post traumatic headache improve significantly during the first year. • 15%-31% of those with post traumatic headaches persist for greater than 3 years and are likely permanent. • Packard RC. Post-traumatic Headache: permanency and relationship to legal settlement. Headache. 1992;32:496-500

38. Expectations after mild TBI • Pre-morbid personality and educational characteristics may play a role in recovery from mild TBI. Pre-morbid physical limitations, prior head injury, psychiatric illness, and older age may limit recovery. • Most improvements occur in the first one to two years after injury, but patients may continue to report progress (improvement in cognition and memory as well as a decline in physical symptoms) as late as five years post injury. • Prompt diagnosis, appropriate post-injury expectations, and continued support of family, employer and community lead to better long term outcomes after injury.

39. Instructions for Employers and Families • Frequent rest periods • Variable scheduling • Careful sequencing (prioritize) • Avoidance of unnecessary stimulation: • Noise, multiple sources of sound • Harsh Light (fluorescent lights potentially problematic) • Hectic motion-filled environment • Fumes (issue with Migraine) • Emotional circumstances • Calm environment • Redirection and rest if actions/verbalization are inappropriate • Early identification of problem areas for treating MD/rehab team/transition coach. Use the notebook or back-pocket memory. • Strong feedback on success

40. Lessons learned from mild TBI patients • Family physicians have pleotropic effects. • Physician and patient expectations are critical to recovery. Set an obtainable expectation at each and every visit. First steps first. • Don’t allow a mild or moderate TBI to become the defining moment of the patients existence. So what? Is a critical concept to a successful “reboot” by a patient with TBI. • The human brain is “plastic”. • Humor has amazing therapeutic value. So does expression of Art, Poetry, Music, and movement. • Allow patients to share their successes and experiences with other similar patients of the practice if support groups are not plentiful. Don’t be intimidated by HIPPA.

41. Lessons learned, continued • Recruit help from any available source including family and children, libraries, literary volunteers, community centers, etc. Elementary educational materials may be a critical tool for those not eligible for cognitive rehab. Office staff are often an amazing resource. Patients have a hard time asking for help for themselves. • Support with enthusiasm any potentially achievable educational or recreational objective or project that interests the patient. The process of participation, effort and study will help heal the patient often creating “detours” for injuries sustained. Have the patient “volunteer” if they are not employable. • Prevent second injuries.

42. Call for Immediate Action • Availability of appropriate primary MD evaluation and longitudinal care for our homecoming military. • Availability and timely referral for appropriate diagnostic testing (?universal application for those with known trauma or blast exposure) • Availability of outpatient rehabilitation programs, group and individual • Availability of psychological support and treatment • Availability of support for transition to peacetime civility • No adverse sequela to seeking treatment: Avoidance of long term military career impedance • Availability of special care by the Judicial system

43. Brainstorming • Establish community and base military TBI support groups and group rehabilitation programs. (Establish location and leader) Potential for formal group psychotherapy. Funding for educational programs. • Establish community and base “intervention teams” for potential evolving crisis circumstance. A need for “time out” short term residences (not the hospital, the local bar, or a jail cell) • Special legal channeling within the court system for those with military transition problems. • Evolution of “transition teams” and coaching: to promote successful transition from battlefield to family and employment. Programs for individuals remaining in active military careers as well as those transitioning to community. May vary by region and service. • Adequate formulary and device support for treatment. • Encourage local bars to offer a few tasty “brain drinks” (not a “shirley temple”).

44. Resources • Defense and Veterans Brain Injury Center • Available: Heads up: Brain Injury in your Practice Tool kit • National Educational Resources Database • www.DVBIC.org • Group of 7 TBI programs in DoD and Dept of VA hospitals and a civilian TBI program • Available: comprehensive outpatient assessments: psychological, audiologic, neurological, neuropsychological and laboratory testing • Inpatient evaluations include additional: neuro-opthalmology, dental, ENT, vestibular, psychiatry, etc. • Access to clinical trials Sites: Military Treatment Facilities (MTF) Walter Reed Army Medical Center, Washington DC Wilford Hall Medical Center, Lackland Air Force Base, TX Naval Medical Center San Diego, San Diego, CA Veterans Affairs (VA) Sites: Hunter McGuire VA Medical Center, Richmond, VA James A Haley VA Hospital, Tampa, FL Veterans Affairs Medical Center, Minneapolis, MN VA Palo Alto Health Care System, Palo Alto, CA Civilian Partner Site: Virginia NeuroCare, Charlottesville, VA Eligible: persons with TBI who are eligible for TRICARE or VA benefits Referral: 1-800-870-9244 or info@dvbic.org

45. Resources, continued • New York State Brain Injury Association • 1-800-228-8201 http://www.bianys.org • Albany women’s support group: Robin Cohn • rcohn18@nycap.rr.com • CDC National Center for Injury Prevention and Control: TBI resources http://www.cdc.gov/ncipc/factsheets/tbi.htm • Traumatic Brain Injury Resource Guide http://www.neuroskills.com/ • National Resource Center on Traumatic Brain Injury http://www.neuro.pmr.vcu.edu/ • Traumatic Brain Injury National Data Center http://www.tbindc.org/

46. Appendix 1:Acute evaluation and disposition of patients with mild TBI Data from: Vos, PE. Eur J Neurol 2002; 9:207 and Borg, J. J Rehabil Med 2004; S43:61.

47. Appendix 2: Standardized assessment of concussion: SAC