Transcript Mild Traumatic brain injury

Traumatic Brain
Injury - Concussion
in the Military
May 25, 2010
Clinical
For policy or position of the Department of the Army, Department
The views expressed in this presentation are VA/DoD
those of the
authors Practice
and do notGuideline
reflect the official
or the U.S. Government.
Management of Defense,
Concussion/mTBI,
2009.
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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
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
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Source: Proponency Office for Rehabilitation & Reintegration www.armymedicine.army.mil.prr
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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
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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
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Significant incident in theatre results in Medivac to
Germany and then to CONUS to start clinical care
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Upon return from deployment, all SM’s are provided a
Post Deployment Health Assessment and screening
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SM with possible symptoms of concussion, are then
referred to the TBI clinic for additional evaluation and
possible treatment and care
DoD Deployment Health Clinical Center at Walter Reed Army Medical Center, Washington, D.C , May 2010
NUMBER OF ARMY SOLDIERS WITH IDENTIFIED TBI
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.
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
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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)
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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)
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High incidence of TBI attributed
to the consequences of blasts or
explosions caused by IED’s
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Other sources: Bullets, fragments,
MVA’s, assaults (DVBIC)
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Males 1.5 x’s higher risk than
females (DVBIC)
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Primary – Overpressure of “blast wave”
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Secondary – Flying Debris
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Tertiary – Body Displacement, Victim thrown into
stationary objects
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Quaternary – Any injury or disease not due to other
mechanisms (burns,
toxic inhalation, crush
injuries, radiation exposure)
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Symptoms:
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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
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Optimistic expectation for full recovery
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> 90% of individuals with sports concussion are
recovered and return to play by 30 days (Collins, 2006)
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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
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Therapists incorporate assessment of the Service
Members goals and priorities along with TBI related
symptoms to develop a plan of care with expected
improvement
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PTSD, Depression, anxiety, stress,
Pre-existing disorder, dysfunction, or limitation
Expectation of the SM / denial
Limited cognitive reserve
Somatoform disorder
Sleep disorder
Malingering
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Headaches
Blurred vision
Anxiety
Dizziness
Fatigue
Light sensitivity
Poor concentration
Trouble thinking
Memory Problems
Irritability
Depression
59%
45%
58%
52%
64%
40%
78%
57%
59%
66%
63%
Rohling 2003
Audiologist
 Case manager
 Neurologist
 Neuropsychologist
 Occupational therapist
 Ophthalmologist / Optometrist
 Physical therapist
 Primary Care Manager
 Social Worker/ Counselor/ Psychologist
 Speech-Language Pathologist
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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 8090% 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
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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
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LT Joann Shen, M.S. CCC-SLP
Tripler Army Medical Center
Phone: 808-433-4362
[email protected]
Ms. Carla Chase, M.S. CCC-SLP
Schofield Barracks Health Clinic
Phone: 808-433-8323
[email protected]
CDR Laura M. Grogan, OTR/L
Evans Army Community Hospital
Phone: 719-526-3704
[email protected]
LCDR Alicia Souvignier,
Evans Army Community Hospital
Phone: 719-526-3704
[email protected]
CDR Henry McMillan
Womack Army Medical Center
Phone: 910-907-7911
[email protected]