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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