Combat Related Mild Traumatic Brain Injury A Multispecialty ...

The Madigan Army Medical Center

TBI Program

Lessons Learned in the Care of Our Wounded Warriors

Frederick G. Flynn, DO, FAANMedical Director, TBI ProgramChief, NeurobehaviorMadigan Army Medical Center

The views expressed in this article are those of the

author and do not reflect the official policy or

position of the United States Army, Department of Defense or the United

States Government

Blast Injuries – Types of Injury

Primary ─ Direct result of blast wave and change in

atmospheric pressure ─ Injury severity and deflected waves─ Injury due to electromagnetic pulse

Secondary─ Objects projected by the blast

Tertiary─ Individual is put in motion and strikes

head Quarternary

─ Toxic gas, embolus, hypoxia, ischemia, hemorrhage

Mild TBI (Concussion)

Altered or LOC < 30 min

PTA < 24 hrs.

GCS = 13-15

Normal CT &/or MRI

Neurological findings may be present but are

transient

Common Post mTBI Symptoms

Somatic Cognitive Neurobehavioral

Headache Attention/Concentration DepressionSleep Disturbance Problems AnxietyFatigue Memory Problems: IrritabilityDizziness - Forgetfulness ImpulsivityNausea/Vomiting - Forgetting to remember AggressivenessTinnitus -Working memory problems ApathyVisual Disturbance Executive Dysfunction: DisinhibitionDisequilibrium -MultitaskingPhoto/Phonophobia -Planning/OrganizingHeightened alcohol -Problem Solving Sensitivity -Slowed mental processingAltered Sense Smell/ -Slowed reaction time TasteTransient Focal Neurological Symptoms

Acute Management of mTBI

Identifying the injured – new DOD directive Assessing early – use of MACE Identification of red flags and appropriate

consultations Appropriate duty restrictions Early education and discussion of recovery Symptom management Rest, hydration, sleep Reassessment and exertional testing Gradual return to full duty

VA/DOD Symptom Mgt

Individualized – risk-benefit analysis Headache most common sx Medication for cognitive sxs not recommended Medication for one sx may ameliorate other sxs Medication given for somatic or

neuropsychiatric sxs may cause sedation which may impact cognitive and motor performance

Consider other factors when post-concussive sxs persist beyond months-years

Practical GuidelinesThings to Avoid

Risking another brain injury (skiing, contact sports, motorcycles, etc.)

Alcohol and illicit drugs Caffeine or “energy enhancers” Cough, cold, allergy meds containing

pseudoephedrine Over the counter sleeping aids Returning too soon to a high risk

zone in a combat theater

Typical Course of Symptom Recovery in Concussion

Symptoms most severe immediately following the injury

Recovery begins within hours after the mTBI

Pattern of symptom recovery gradually continues over days to weeks

Important Issues Regarding Recovery

If delayed onset of symptoms Consider other co-morbidities

Return to apparent asymptomatic baseline May still be neurologically vulnerable

Return to combat too soon May result in susceptibility to repeat

concussion May put the Soldier and fellow Soldiers at risk

Important Issues Regarding Recovery (cont)

More protracted course: History of multiple concussions Co-morbid acute and/or chronic PTS Chronic pain Other medical, psychological, and

psychosocial stressors

Multiple concussions may lead to permanent cognitive compromise Higher risk for early onset Alzheimer Disease Chronic Traumatic Encephalopathy (CTE)

VA/DOD Clinical Practice Guidelines for Management Concussion/mTBI

Key Points When Symptoms Persist Beyond a Week after Injury

Promote recovery – avoid harm Patient centered approach to care Diagnosis based on nature of event

and sequelae immediately after the event

Majority improve with rest & time Do not require specific medical

treatment

VA/DOD Clinical Practice Guidelines for Management Concussion/mTBI

Key Points When Symptoms Persist Beyond a Week after Injury

Short and long term neurological deficits may be caused by blast exposure without a direct blow to the head

Post-concussive sxs may be found in patients or healthy individuals who have never sustained a TBI

Persistent Post-Concussive Sxs

Consider:Chronic pain Acute/chronic stressUndiagnosed medical condition PTSDMood disorders AnxietySubstance abuse Medication misuseJob change/unemployment Financial problemsMarital discord/family stressors Spiritual lossImpending combat deployment Secondary

gainSomatoform disorder Personality disorderUnmasking a pre-morbid psychiatric condition

PTSD Criteria (DSM IV – TR)A - Stressor – both required:• event – actual or threatened death/serious injury• response of intense fear, helplessness, or horror

B - Intrusive recollections – 1/5 requiredC - Avoidant / Numbing – 3/7 requiredD - Hyper-arousal – 2/5 requiredE - Duration > 1 month in B,C,DF - Functional significance• significant distress• impairment in social occupational functions

Chronic: > 3 mos Delayed onset: 6 mos after event

PTSD in Military

Prevalence among deployed – 14%(Golding et al 2009)

Post-deployment screening – 5-12% increase in rate after 6 mos – Delayed onset (Milliken et al 2007)

Mental health problems & deployments 1st – 12% 2nd – 19% 3rd – 27% (MHAT 2008)

19% post-deployment SMs – PTSD/depression

(Tanielian et al 2008)

Risk for PTSD

Any physical injury associated with traumatic event (Grieger et al 2006; Hoge et al 2004)

Depression / PTSD delayed onset (Grieger et al 2006)

Pre-exposure lower cognitive ability (Kremen et al 2007)

Memory of traumatic event (Caspi et al 2005)

Risk for PTSD (cont)

Poor coping skills (Halbauer et al 2009)

mTBI at time of traumatic event 27% with alteration in consciousness

PTSD 44% with LOC PTSD (Hoge et al 2008)

Acute stress reaction (Kennedy et al 2007)

Combat related trauma > non-combat (Kennedy et al 2007)

mTBI/PTSD Comorbidities Greater risk for persistent post-concussive

sxs (Brenner et al 2009)

PTSD most potent contributor to development of persistent PCS

(Vanderploeg et al 2009)

VHA – 42% with HX of mTBI PTSD (Lew et al 2007)

mTBI and acute stress reaction – six fold increase risk for PTSD (Kennedy 2007)

mTBI/PTSD Comorbidities (cont)

Increase risk for: Depression Substance abuse Suicide

(Stein & McAllister 2009)

Poor general health, unmet medical and psychological needs, psychosocial difficulties, perceived barriers to mental health (Pietrzak 2009)

mTBI/PTSD Comorbidities (cont)

mTBI increases risk of PTSD

mTBI in someone with PTSD – greater disability (Brenner et al 2009)

Neurobiological overlap- Neurochemical/morphological changes- Prefrontal neural circuits, amygdala,

hippocampus, cigulate gyrus (Bryant 2008)

Post-Deployment Screening

PDHA and other screening tools

Self-report of event occurring months before

Symptoms are non-specific to TBI

Attribution/misattribution of sxs

Referral to TBI Program

Madigan TBI Program Staff

Program Director/Behavioral-Neurologist TBI Program Administrative Officer Primary Care Providers (4) Neurologists (2) Neuropsychologists (2) Neuropsychometrist (1) Clinical Psychologists (2) Clinic LPN OT/PT/Speech Pathologists (1 each) TBI Case Managers ( 2 RNs) Education Specialist Director and RN Educators

(2) Ombudsman Admin Medical Assistants (4) Tele-TBI Team (PM, Technical Specialist, RN)

Post-Deployment Screening and EvaluationSRP

PDHA2+10

Screen

HeadacheSleep PTSD

Questionnaire

VS by LPN

Specialty Sub-

Specialty Assessmen

t

TBI Program

50 min EvaluationHx, Neuro, Cog - By

Physician /Neuropsychologist

No/mild Sxs

Educational materialsReturn to Unit - Reassess in

3 mos

Treatment StrategiesPharmacologicalNon-Pharmacological - sleep - memory classes/groups - headacheIndividual/Group therapyCouples CounselingEducation/Military CounselingCase Management – Coordinated CareFamily/Unit Leadership education

Referral from other clinics, in MAMC, AF,

Navy CG, NG

Neurologist/Behavioral NeurologistNeuropsychologistPsychologistIOP*PT/OTSleep MedicineSpeech PathologyCase ManagementEducation SpecialistOmbudsman (Ret CSM)Other Specialty Consultants, PRN

Team MeetingsCase ConferencesCoordinated Treatment StrategiesLiaison with other Madigan programs (eg. WTU), VA, Civilian rehab

Symptomatic

ObjectiveFindings

Return to Unit Restrictions / No RestrictionsWTUMEB?F/U in TBI ProgramCognitive / Behavorial Rehab

Other Activities of the TBI Program

Tele-TBIEducation + Consultation with WRMC (21 states)

Educational

ConferencesLocal

StateNational

Education of Military Leaders

about TBI

VIP Briefings

On-site support of other MTFs

Representation on

Committees/ Panels of

SMEs, DoD, DCoE, DVBIC,

OTSG

Team MeetingsCase ConferencesCoordinated Treatment StrategiesLiaison with other Madigan programs (eg. WTU), VA, Civilian rehab

Research

Ruff, R. J Head Trauma Rehab. 2005: 20:1

Lessons Learned

All TBIs are not alike – there may be striking differences in the nature of the injury and the degree of impairment

Impairment does not equal disability

Concussion due to blast may have a different pathophysiology and recovery course than that due to sports concussion

Lessons Learned

The athlete has a strong incentive to recover and get back in the game

A blast encountered in combat is associated with the reality and acute stress that someone wants to kill you

The Soldier may experience acute stress by witnessing the death and maiming of fellow Soldiers or innocent victims

Lessons Learned

A self-report of a history of mTBI is not confirmation that one actually occurred

The failure to report an event or seek medical help does not mean that a mTBI did not occur

When symptom onset is delayed by days to weeks after a mTBI the symptoms are most likely due to other causes than the mTBI

Unlike TBI, the symptoms associated with PTS are often delayed in onset

Lessons Learned

When patients present with typical post-concussive sxs, months after a documented mTBI , it does not mean that the sxs are due to the mTBI

The combination of mTBI and PTSD is not a benign condition. Protracted disability may be a consequence

Psychosocial stressors are often more severe after return from deployment

Lessons Learned

Even after return to functional baseline and normal neuropsychological function, a physical or emotional stressor may cause re-emergence of symptoms

Patients require a holistic approach to care – they are not defined by their TBI or PTSD

It is imperative to involve spouses, significant others, and in some cases their children, in the educational process and care of the patient

Lessons Learned

Patients require the time to tell their story and receive the comprehensive evaluation that they deserve – they can’t get this in a busy troop clinic

Sometimes providers who are trying to help, do more harm by the treatment they prescribe

Lessons Learned

Resources for treating TBI patients with severe social-behavioral problems are inadequate.

Support for developing skilled rehab facilities for this treatment is necessary

Financial support is necessary for family care givers who cannot work outside of the home in order to provide full time care for their loved one with TBI

Lessons Learned in the Madigan TBI Program

A multispecialty TBI program provides time for the Soldier, detailed evaluation, on the spot consultation with a variety of specialists, coordination of care, case management, education, continuity of care, selection of patients who would best benefit from referral for rehab, and communication with other providers, unit leadership, and administration