Jay Pyo, D.O. Jay Pyo, D.O. Cynthia Boyd, Ph.D. Cynthia Boyd, Ph.D. MAJ, MC, USA MAJ, MC, USA Co Co - - Senior Scientific Director Senior Scientific Director Physical Medicine and Rehabilitation Physical Medicine and Rehabilitation Defense & Veterans Brain Injury Center Defense & Veterans Brain Injury Center Comprehensive Combat and Complex Casualty Care Program Comprehensive Combat and Complex Casualty Care Program Naval Medical Center San Diego Naval Medical Center San Diego Mild Traumatic Brain Injury: The Military Experience and Applications for Management in the Community
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Jay Pyo, D.O.Jay Pyo, D.O. Cynthia Boyd, Ph.D.Cynthia Boyd, Ph.D.MAJ, MC, USAMAJ, MC, USA CoCo--Senior Scientific DirectorSenior Scientific Director
Physical Medicine and Rehabilitation Physical Medicine and Rehabilitation Defense & Veterans Brain Injury CenterDefense & Veterans Brain Injury Center
Comprehensive Combat and Complex Casualty Care ProgramComprehensive Combat and Complex Casualty Care Program
Naval Medical Center San DiegoNaval Medical Center San Diego
Mild Traumatic Brain Injury:
The Military Experience and Applications for Managementin the Community
DisclaimerDisclaimer
�� I am a military service member (or employee I am a military service member (or employee of the U.S. Government). This work was of the U.S. Government). This work was prepared as part of my official duties. Title prepared as part of my official duties. Title 17, USC, 17, USC, §§105 provides that 105 provides that ‘‘Copyright Copyright protection under this title is not available for protection under this title is not available for any work of the any work of the U.S.GovernmentU.S.Government..’’ Title 17, Title 17, USC, USC, §§101 defines a 101 defines a U.S.GovernmentU.S.Government work as work as a work prepared by a military service a work prepared by a military service member or employee of the U.S. Government member or employee of the U.S. Government as part of the personas part of the person’’s official duties.s official duties.
MildMild Traumatic Brain Injury:Traumatic Brain Injury:The Military Experience and Applications The Military Experience and Applications
for Management in the Community.for Management in the Community.
Jay Pyo, D.O.Jay Pyo, D.O.
MAJ, MC, USAMAJ, MC, USA
Physical Medicine and RehabilitationPhysical Medicine and Rehabilitation
Comprehensive Combat and Complex Casualty Care ProgramComprehensive Combat and Complex Casualty Care Program
Naval Medical Center San DiegoNaval Medical Center San Diego
�� 30% associated with all injury related 30% associated with all injury related
death.death.
ImportanceImportance
�� 5.3 million Americans5.3 million Americans——2% of the U.S. 2% of the U.S. populationpopulation——currently live with disabilities currently live with disabilities resulting from brain injury.resulting from brain injury.
�� $76.5 billion total direct/indirect medical $76.5 billion total direct/indirect medical cost and lost productivitycost and lost productivity (2000)(2000)
�� DVBICDVBIC�� Multicenter networkMulticenter network�� Collaboration between Collaboration between DoDDoD and VA entitiesand VA entities�� DCoEDCoE PH/TBIPH/TBI
�� Comprehensive Combat and Complex Casualty Care Comprehensive Combat and Complex Casualty Care (C(C--5) Program5) Program�� Case Management and Primary Care model with a Case Management and Primary Care model with a rehabilitation focus.rehabilitation focus.
�� Management of all overseas/deployed service member Management of all overseas/deployed service member who medically evacuated or transported to NMCSD.who medically evacuated or transported to NMCSD.
�� Faul M, Xu L, Wald MM, Coronado VG. Traumatic brain injury in thFaul M, Xu L, Wald MM, Coronado VG. Traumatic brain injury in the United States: emergency department visits, hospitalizations, e United States: emergency department visits, hospitalizations, and and deaths. Atlanta (GA): Centers for Disease Control and Preventiondeaths. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2010., National Center for Injury Prevention and Control; 2010.
�� Centers for Disease Control and Prevention (CDC), National CenteCenters for Disease Control and Prevention (CDC), National Center for Injury Prevention and Control. Report to Congress on mild r for Injury Prevention and Control. Report to Congress on mild traumatic brain injury in the United States: steps to prevent a traumatic brain injury in the United States: steps to prevent a serious public health problem. Atlanta (GA): Centers for Diseaseserious public health problem. Atlanta (GA): Centers for Disease Control Control and Prevention; 2003.and Prevention; 2003.
�� AMERICAN COLLEGE OF SPORTS MEDICINE. Concussion (mild traumaticbAMERICAN COLLEGE OF SPORTS MEDICINE. Concussion (mild traumaticbrain injury) and the team physician: a consensus statement. rain injury) and the team physician: a consensus statement. Med. Sci. SportsExerc. 43:2412Med. Sci. SportsExerc. 43:2412--2422, 2011.2422, 2011.
�� AMERICAN COLLEGE OF SPORTS MEDICINE. Sideline preparedness for tAMERICAN COLLEGE OF SPORTS MEDICINE. Sideline preparedness for the team physician: a consensus statement. Med. Sci. Sports he team physician: a consensus statement. Med. Sci. Sports Exerc. 33:846Exerc. 33:846––849, 2001.849, 2001.
�� AMERICAN COLLEGE OF SPORTS MEDICINE. The team physician and retuAMERICAN COLLEGE OF SPORTS MEDICINE. The team physician and returnrn--toto--play issues: a consensus statement. Med. Sci. Sports play issues: a consensus statement. Med. Sci. Sports Exerc. 34:1212Exerc. 34:1212––1214, 2002.1214, 2002.
�� Laker, Scott R. Epidemiology of Concussion and Mild Traumatic BLaker, Scott R. Epidemiology of Concussion and Mild Traumatic Brain Injury. PM&R Journal. 3:S354rain Injury. PM&R Journal. 3:S354--358, 2011.358, 2011.
�� Rigg, J.L., Mooney, S.R. Concussions and the Military: Issues SRigg, J.L., Mooney, S.R. Concussions and the Military: Issues Specific to Sevice Members. PM&R Journal. 3:S380pecific to Sevice Members. PM&R Journal. 3:S380--386, 2011.386, 2011.
�� Chang, V.H., Lombard, L.A., Greher, M.R. Mild Traumatic Brain IChang, V.H., Lombard, L.A., Greher, M.R. Mild Traumatic Brain Injury in the Occupational Setting. PM&R Journal. 3:S387njury in the Occupational Setting. PM&R Journal. 3:S387--395, 2011.395, 2011.
�� Signoretti, S., Lazzarino, G., Tavazzi, B., Vagnozzi, R. The PaSignoretti, S., Lazzarino, G., Tavazzi, B., Vagnozzi, R. The Pathophysiology of Concussion. PM&R Journal. 3:S359thophysiology of Concussion. PM&R Journal. 3:S359--368, 2011.368, 2011.
�� Department of Defense [DOD] Task Force on Mental Health, 2007, pDepartment of Defense [DOD] Task Force on Mental Health, 2007, p. ES. ES--II
�� Crow W., Willis D. Crow W., Willis D. ““Estimating Cost of Care for Patients with Acute Low Back Pain: AEstimating Cost of Care for Patients with Acute Low Back Pain: A Retrospective Review of Patient Records.Retrospective Review of Patient Records.”” J Am J Am Osteopath Assoc. 2009:109:229Osteopath Assoc. 2009:109:229--233. 233.
�� Braddom (2006). Physical Medicine and Rehabilitation. WB SaunderBraddom (2006). Physical Medicine and Rehabilitation. WB Saunders .s .�� Cicerone e al. EvidenceCicerone e al. Evidence--Based Cognitive Rehabilitation: Updated Review of the LiteratureBased Cognitive Rehabilitation: Updated Review of the Literature From 1998 Through 2002. Arch Phys Med From 1998 Through 2002. Arch Phys Med
Rehabil Vol 86, August 2005Rehabil Vol 86, August 2005�� Crooks et al. Physical Medicine and Rehabilitation clinics of NoCrooks et al. Physical Medicine and Rehabilitation clinics of North America. Traumatic Brain Injury: A review of practice managerth America. Traumatic Brain Injury: A review of practice management and ment and
recent advances. 18(2007) 681recent advances. 18(2007) 681--710.710.�� Cuccurullo (2004). Physical Medicine and Rehabilitation Board ReCuccurullo (2004). Physical Medicine and Rehabilitation Board Review. Demos Publishing.view. Demos Publishing.�� Boake C, Diller L (2005).Boake C, Diller L (2005). "History of rehabilitation for traumatic brain injury""History of rehabilitation for traumatic brain injury". In High WM, Sander AM, Struchen MA, Hart . In High WM, Sander AM, Struchen MA, Hart
KA.KA. Rehabilitation for Traumatic Brain InjuryRehabilitation for Traumatic Brain Injury. Oxford [Oxfordshire]: Oxford University Press. Oxford [Oxfordshire]: Oxford University Press�� www.Dvbic.orgwww.Dvbic.org
Cognitive Symptoms reported following Cognitive Symptoms reported following
concussion/mTBIconcussion/mTBI
�� Impaired memory Impaired memory
�� Trouble concentratingTrouble concentrating
�� Difficulty finding wordsDifficulty finding words
Credible vs. NonCredible vs. Non--credible Clinical credible Clinical
PresentationPresentation
�� Undocumented or questionable mild Undocumented or questionable mild
head injuryhead injury
�� Marked discrepancy between the Marked discrepancy between the
individualindividual’’s claimed injury and the s claimed injury and the
objective test findingsobjective test findings
�� Implausible test results when compared Implausible test results when compared
to the medical historyto the medical history
Credible vs. NonCredible vs. Non--credible Clinical credible Clinical
PresentationPresentation
�� Excessive inconsistencies in test dataExcessive inconsistencies in test data
�� Poor performance on obvious, but not less Poor performance on obvious, but not less
obvious tasks of same functionobvious tasks of same function
�� Symptom validity testsSymptom validity tests
�� Valid vs. invalid test performancesValid vs. invalid test performances
�� Will see terms: Will see terms: ““inconsistent,inconsistent,”” ““invalid,invalid,””
““results cannot be interpretedresults cannot be interpreted””
�� Effort vs. malingering Effort vs. malingering
Credible vs. NonCredible vs. Non--credible Clinical credible Clinical
PresentationPresentation
�� Evaluate symptom complaints within the Evaluate symptom complaints within the
context of historical data, behavioral context of historical data, behavioral
observations, and current observations, and current ““real worldreal world””
functioningfunctioning
�� Be wary of a delayed onset of symptomsBe wary of a delayed onset of symptoms
�� Assess for secondary gainAssess for secondary gain
�� LitigationLitigation
�� Medical boardMedical board
Neuropsychological Test Neuropsychological Test
Performance in Soldiers w/ BlastPerformance in Soldiers w/ Blast--
Related Mild TBI (Related Mild TBI (Brenner, et al., 2010)Brenner, et al., 2010)
�� Exploratory study to examine whether persistent mTBIExploratory study to examine whether persistent mTBI--related symptoms or PTSD negatively impacted test related symptoms or PTSD negatively impacted test performanceperformance
�� Compared 27 SMCompared 27 SM’’s w/enduring mTBI symptoms to 18 SMs w/enduring mTBI symptoms to 18 SM’’s s w/o symptomsw/o symptoms
�� Results:Results:�� Presence of mTBI symptoms did not impact test Presence of mTBI symptoms did not impact test performanceperformance
�� No significant differences between soldiers with and w/o No significant differences between soldiers with and w/o PTSD were identifiedPTSD were identified
““Symptom validity test performance in U.S. veterans Symptom validity test performance in U.S. veterans
referred for evaluation of mild TBIreferred for evaluation of mild TBI””
ArmisteadArmistead--Jehle (2010)Jehle (2010)
Medical Symptom Validity Test (MSVT)Medical Symptom Validity Test (MSVT)
58% scored below the cut scores on subtests 58% scored below the cut scores on subtests
more sensitive to more sensitive to efforteffort than neurological insultthan neurological insult
Those with service connection failed at a higher Those with service connection failed at a higher
raterate
Maybe it is not secondary gain?Maybe it is not secondary gain?
�� ““Good Old DaysGood Old Days”” Bias Following Mild Bias Following Mild
Traumatic Brain InjuryTraumatic Brain Injury
�� Iverson, et al., (2010)Iverson, et al., (2010)
�� The Clinical NeuropsychologistThe Clinical Neuropsychologist
Research suggests that people who sustain an Research suggests that people who sustain an
injury often underestimate past problems (injury often underestimate past problems (““good good
old daysold days””))
““Good Old DaysGood Old Days”” Bias Following Mild Bias Following Mild
Traumatic Brain InjuryTraumatic Brain Injury”” Iverson, et al.(2010)Iverson, et al.(2010)
Veterans in State & Federal Prison 2004Veterans in State & Federal Prison 2004U.S. Department of Justice (May 2007)U.S. Department of Justice (May 2007)
�� In 2004: male veterans had lower In 2004: male veterans had lower incarceration rates than nonveterans; incarceration rates than nonveterans; due in part to age differencesdue in part to age differences
�� 65% of male veterans in 2004 were at 65% of male veterans in 2004 were at least 55 years oldleast 55 years old
�� More than half of veterans in state More than half of veterans in state prisons were serving for a violent prisons were serving for a violent offenseoffense
�� More likely to have had recent mental More likely to have had recent mental health problemshealth problems
Violence as a Consequence of TBIViolence as a Consequence of TBI
�� Not all brainNot all brain--injured individuals are violent injured individuals are violent
or aggressiveor aggressive
�� Age of injury plays a roleAge of injury plays a role
�� History of aggression History of aggression
�� Use of alcohol or drugs increases Use of alcohol or drugs increases
likelihood of aggressive actslikelihood of aggressive acts
�� Presence of a mental disorder increase Presence of a mental disorder increase
likelihood of aggressionlikelihood of aggression
Behavioral Aspects of TBIBehavioral Aspects of TBI
Source: American Health Assistance Foundation. Anatomy of the Brain Webpage. http://www.ahaf.org/alzheimers/about/understanding/anatomy-of-the-brain.html
The AmygdalaThe Amygdala
�� Linked to the frontal lobeLinked to the frontal lobe
�� Primary role is in the acquisition Primary role is in the acquisition and and the the
physiological expression of conditioned fearsphysiological expression of conditioned fears
�� It processes and stores memories of It processes and stores memories of
emotional eventsemotional events
�� Stores feelings and physiologic responses Stores feelings and physiologic responses
associated with the event (fear with increased HR)associated with the event (fear with increased HR)
�� The stored memory can later be triggeredThe stored memory can later be triggeredPhelps, 2004Phelps, 2004
The AmygdalaThe Amygdala
�� Flight and fear responses (Flight and fear responses (““freezingfreezing””))
�� Has a distinct difference from a Has a distinct difference from a consciousconsciousfeeling of fearfeeling of fear
�� Defensive or aggressive reactionsDefensive or aggressive reactions
�� Has a sensory input system Has a sensory input system
�� ArmisteadArmistead--Jehle, P. (2010). Symptom validity test performance in U.S. vetJehle, P. (2010). Symptom validity test performance in U.S. veterans erans
referred for evaluation of mild TBI. referred for evaluation of mild TBI. Applied Neuropsychology,Applied Neuropsychology,17: 5217: 52--59.59.
�� Brenner, L.A., Homaifar, B. Y., Gutierrez, P.M., Harwood, J. E. Brenner, L.A., Homaifar, B. Y., Gutierrez, P.M., Harwood, J. E. F., Adler, L.E, Terrio, F., Adler, L.E, Terrio,
H., Staves, P.J., Reeves, D., Ivins, B.J., Helmick, K., & WardenH., Staves, P.J., Reeves, D., Ivins, B.J., Helmick, K., & Warden, D. (2010). , D. (2010).
Neuropsychological test performance in soldiers with blastNeuropsychological test performance in soldiers with blast--related mild TBI. related mild TBI.
�� Iverson, G. L., Lange, R. T., Brooks, B.L., & Rennison, L. A. (2Iverson, G. L., Lange, R. T., Brooks, B.L., & Rennison, L. A. (2010). 010). ““Good old daysGood old days””
bias following mild traumatic brain injury. bias following mild traumatic brain injury. The Clinical Neuropsychologist,The Clinical Neuropsychologist, 24: 1724: 17--37.37.
�� Phelps, E.A., (2004). Human emotion and memory: interactions of Phelps, E.A., (2004). Human emotion and memory: interactions of the amygdala and the amygdala and
hippocampal complex. hippocampal complex. Current Opinion in Neurobiology, 14:198Current Opinion in Neurobiology, 14:198--202.202.