Army Traumatic Brain Injury Program

1. Army Traumatic Brain Injury Program Prepared for Brain Injury Awareness Month Proponency Office for Rehabilitation and Reintegration Health Policy and Services Office of The Surgeon General

2. Slide 2 of 20 Agenda Traumatic Brain Injury (TBI) Overview Army TBI Program Conclusion

3. Slide 3 of 20 What is TBI? Traumatic brain injury (TBI) is a disruption of function in the brain resulting from a blow or jolt to the head or penetrating head injury. Not all blows to the head result in injury TBI can be caused by: Falls Motor vehicle and motorcycle crashes Assaults Explosions Sports injuries Slide self-explanatory Slide self-explanatory

4. Slide 4 of 20 Severity of TBI The severity of injury may range from �mild� (a brief change in mental status or consciousness) to �severe� (an extended period of unconsciousness or amnesia after the injury). TBIs can also be penetrating. The severity of TBI is graded as mild, moderate or severe and a small percentage of TBI are penetrating, meaning the lining of the brain (dura) is penetrated. Each type and severity of TBI has it�s own natural history. Moderate, severe and open TBIs are much less common. These types of injuries are more easily recognized at the time of the injury and require immediate medical treatment. The recovery for moderate, severe and open TBI is typically more prolonged. The severity of TBI is graded as mild, moderate or severe and a small percentage of TBI are penetrating, meaning the lining of the brain (dura) is penetrated. Each type and severity of TBI has it�s own natural history. Moderate, severe and open TBIs are much less common. These types of injuries are more easily recognized at the time of the injury and require immediate medical treatment. The recovery for moderate, severe and open TBI is typically more prolonged.

5. Slide 5 of 20 Concussion Concussion, also known as Mild TBI A clinical diagnosis with no singular objective test to confirm diagnosis Diagnosis based upon a definition Requires an injury event AND an alteration of mental status Definition in HA policy 1 OCT 07 IAW major medical academic definitions Requires clinical judgment May require self-report Symptoms are not definitional - symptoms such as headache, dizziness, irritability, fatigue or poor concentration, when identified soon after injury, can be used to support the diagnosis of mild TBI, but CANNOT be used to make the diagnosis Most important thing to do is allow enough time to heal Recovery is usually quick, but the time greatly depends on the individual and the nature of the injury Important to let a provider decide when it�s time to return to duty Concussion is the most common type of TBI. According to the Defense and Veterans Brain Injury Center, over 90% of TBI in the military is concussion. Symptoms that may occur immediately after a concussion include Headaches, Dizziness, Excessive fatigue (tiredness), Concentration problems , Forgetting things (memory problems), Irritability, Sleep problems, Balance problems, Ringing in the ears, and Vision changes. Usually these symptoms are temporary. Most people with concussion recover in a few hours to days. This type of injury is often unreported. Often after a concussion service members think they�re OK, yet they�ve actually had an injury that needs attention. You should seek medical treatment from the nearest aid station as soon as possible after any injury where there may be a chance of a concussion. Your provider will evaluate you and will determine when it�s safe for you to return to duty. It�s important that your provider decides this because if you get another concussion before healing from the first one, you�re likely to be at greater risk for a more serious injury. Awareness of mild TBI is increasing in the DoD and VA and leading to transformation of healthcare systems. Concussion is the most common type of TBI. According to the Defense and Veterans Brain Injury Center, over 90% of TBI in the military is concussion. Symptoms that may occur immediately after a concussion include Headaches, Dizziness, Excessive fatigue (tiredness), Concentration problems , Forgetting things (memory problems), Irritability, Sleep problems, Balance problems, Ringing in the ears, and Vision changes. Usually these symptoms are temporary. Most people with concussion recover in a few hours to days. This type of injury is often unreported. Often after a concussion service members think they�re OK, yet they�ve actually had an injury that needs attention. You should seek medical treatment from the nearest aid station as soon as possible after any injury where there may be a chance of a concussion. Your provider will evaluate you and will determine when it�s safe for you to return to duty. It�s important that your provider decides this because if you get another concussion before healing from the first one, you�re likely to be at greater risk for a more serious injury. Awareness of mild TBI is increasing in the DoD and VA and leading to transformation of healthcare systems.

6. Slide 6 of 20 This is data from the Centers for Disease Control-Oct 2004. 1.4 Million TBIs occur in the US each year. 50,00 deaths are attributed to TBI, 235,000 hospitalizations, 1.2million ER visits. There is an unknown number of TBIs that go unreported or for which medical care is not sought. An estimated $56 billion is spent in direct and indirect costs as a result of all TBIs. This is data from the Centers for Disease Control-Oct 2004. 1.4 Million TBIs occur in the US each year. 50,00 deaths are attributed to TBI, 235,000 hospitalizations, 1.2million ER visits. There is an unknown number of TBIs that go unreported or for which medical care is not sought. An estimated $56 billion is spent in direct and indirect costs as a result of all TBIs.

7. Slide 7 of 20 TBI in the MilitaryDVBIC Sites Only This data comes from the Defense and Veterans Brain Injury Center. There are 11 reporting sites, so this is only a piece of the overall DoD/VA TBI numbers. The key information is 1) that the vast majority of TBIs at the DVBIC sites are Mild TBI and 2) that the percentages of mild, moderate, severe, and penetrating injuries has been steady over the past several years. This data comes from the Defense and Veterans Brain Injury Center. There are 11 reporting sites, so this is only a piece of the overall DoD/VA TBI numbers. The key information is 1) that the vast majority of TBIs at the DVBIC sites are Mild TBI and 2) that the percentages of mild, moderate, severe, and penetrating injuries has been steady over the past several years.

8. This data comes form the Decision Support Cell at the Office of the Surgeon General and reflects the number of cases patients with TBI in the direct care (non-deployed military treatment facilities) and in purchased care (civilian health care) sites. This data includes Active Duty, Reserve, and Guard members identified by at least one medical encounter with a TBI diagnosis. This data includes both patients who had deployment related injuries and those with non-deployment related injuries. The blue columns represent the new cases identified each year. The maroon columns represent new cases plus cases that carried over from the previous year. This gives a better understanding of the impact of TBI care on the military health care system (compared to the previous DVBIC site slide), but is not completely reliable because it relies on correct diagnosis coding. This data comes form the Decision Support Cell at the Office of the Surgeon General and reflects the number of cases patients with TBI in the direct care (non-deployed military treatment facilities) and in purchased care (civilian health care) sites. This data includes Active Duty, Reserve, and Guard members identified by at least one medical encounter with a TBI diagnosis. This data includes both patients who had deployment related injuries and those with non-deployment related injuries. The blue columns represent the new cases identified each year. The maroon columns represent new cases plus cases that carried over from the previous year. This gives a better understanding of the impact of TBI care on the military health care system (compared to the previous DVBIC site slide), but is not completely reliable because it relies on correct diagnosis coding.

9. Slide 9 of 20 Army TBI Program Purpose: To establish a standardized, comprehensive program that provides a continuum of integrated care and services for Soldiers and patients with TBI from point-of-injury to return to duty or transition from active duty and/or return to highest functional level. Desired End State: State-of-the-art, continuously improving care for Soldiers, beneficiaries, and their Families with TBI within Army MTFs, according to their TBI program capability level, in order to optimize functional outcomes and return to duty. Every medical facility is validated to provide TBI care congruent with the level of care provided at the facility. When necessary, this care is provided in conjunction with Department of Veteran�s Affairs (DVA) and TRICARE partners. The Army TBI program started in 2007 to fulfill the 47 recommendations of the Army TBI Task Force. An OPORD was published in April 2008 and programs are expected to be fully operational in Sep 2010. The Army TBI program started in 2007 to fulfill the 47 recommendations of the Army TBI Task Force. An OPORD was published in April 2008 and programs are expected to be fully operational in Sep 2010.

10. Slide 10 of 20 Partners The Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE) serves as an open front door for warriors, veterans and families living with brain injury and is a source of information, understanding, help and strength in dealing with TBI DCoE Outreach Center available 24 hours a day, seven days a week at 1-866-966-1020, by email at resources@dcoeoutreach.org. The Defense and Veterans Brain Injury Center is the DoD point of evaluation, treatment and clinical research on TBI. It provides treatment and follow-up TBI care to active duty service members, Veterans and their family members. The Army partners closely with the Defense Center of Excellence for Psychological Health and TBI and with the Defense and Veteran Brain Injury Center. The DCoE Outreach center hotline opened in Jan 09 to answer any questions on TBI and on behavioral health. This hotline is linked in with Military One Source and is staffed 24/7 with healthcare providers. The Army partners closely with the Defense Center of Excellence for Psychological Health and TBI and with the Defense and Veteran Brain Injury Center. The DCoE Outreach center hotline opened in Jan 09 to answer any questions on TBI and on behavioral health. This hotline is linked in with Military One Source and is staffed 24/7 with healthcare providers.

11. Slide 11 of 20 Accomplishments DoD definition for TBI Improved detection, documentation, screening and treatment TBI Program Validation Education initiatives Marketing and Communication Research initiatives The following slides describe some of the accomplishments related to TBI and the Army TBI program. The following slides describe some of the accomplishments related to TBI and the Army TBI program.

12. Slide 12 of 20 DoD Definition for TBI Traumatic brain injury (TBI) is a traumatically-induced structural injury and/or physiological disruption of brain function as a result of an external force that is indicated by new onset or worsening of at least one of the following clinical signs, immediately following the event: (1) Any period of loss, or a decreased level, of consciousness. (2) Any loss of memory for events immediately before or after the injury. (3) Any alteration in mental state at the time of the injury (confusion, disorientation, slowed thinking, etc.). (4) Neurological deficits (weakness, loss of balance, change in vision, praxis, paresis/plegia, sensory loss, aphasia, etc.) that may or may not be transient. (5) Intracranial lesion. External forces may include any of the following events: the head being struck by an object, the head striking an object, the brain undergoing an acceleration/deceleration movement without direct external trauma to the head, a foreign body penetrating the brain, forces generated from events such as a blast or explosion, or other force yet to be defined. Although many academic definitions of TBI exist, a consensus definition for use by all of DoD was published in October 2007. This is pretty clinical, but it is the standard used now across DoD and by VA as well.Although many academic definitions of TBI exist, a consensus definition for use by all of DoD was published in October 2007. This is pretty clinical, but it is the standard used now across DoD and by VA as well.

13. Slide 13 of 20 Clinical Management Guidance In Theater Guidelines Non-deployed Acute Non-deployed Sub-acute Clinical Practice Guideline in development Multiple clinical guidelines have been produce by Subject Matter Experts. Guidelines are tailored to in theater management and non-deployed setting management. The non-deployed setting management is broken down into acute (7 days or less since injury) and sub acute (greater than 7 days since injury) management. The non-deployed guideline for mild TBI care has recently been enhanced and will be published soon as a DoD/VA Clinical Practice Guideline. This evidence based guideline incorporates the highest levels of evidence available, such as research reports. Multiple clinical guidelines have been produce by Subject Matter Experts. Guidelines are tailored to in theater management and non-deployed setting management. The non-deployed setting management is broken down into acute (7 days or less since injury) and sub acute (greater than 7 days since injury) management. The non-deployed guideline for mild TBI care has recently been enhanced and will be published soon as a DoD/VA Clinical Practice Guideline. This evidence based guideline incorporates the highest levels of evidence available, such as research reports.

14. Slide 14 of 20 Four categories of PR&R TBI Programs: Providing inpatient and outpatient care for the full spectrum of traumatic brain injury severity (mild, moderate, and severe). Providing inpatient and outpatient care for mild and moderate traumatic brain injuries. Providing outpatient medical and rehabilitative care for Soldiers with mild and mild-moderate TBI. Providing outpatient medical care for Soldiers with mild TBI and refer for additional services as needed. Validation: The validation criteria are divided by functional program areas: management, assessment, treatment, education, and metrics. The program management requirements are divided into two phases. Initial validation - awarded upon submission and verification of completion of phase 1 requirements Full validation awarded upon submission and verification of the implementation of the full program Every medical facility has a designated TBI Program Manager Army MTF TBI Program Validation The Proponency Office for Rehabilitation and Reintegration (PR&R), a component of the Health Policy and Services Directorate of the Office of The Surgeon General, in collaboration with the Defense and Veterans Brain Injury Center (DVBIC) established a validation program for all Army Medical Department Medical Treatment Facilities (MTFs) that provide care to Soldier and other beneficiaries with TBI. This program was designed to established standards of care and to ensure that services, physical facilities, and staffing levels were consistent across the Army MTFs based on the level of care provided at the facility. There are 4 categories of programs-category 1 having the greatest capabilities for TBI care. Programs are validated after review by a team of subject matter experts. To date, 6 sites have received initial validation (Brooke Army Medical Center, Darnell Army Medical Center, Tripler Army Medical Center, US Army Health Clinic Schofield Barracks, Madigan Army Medical Center, and Walter Reed Army Medical Center. Review of all CONUS sites is scheduled between Feb and Jun 2009 with a goal of having every site achieve initial validation. The Proponency Office for Rehabilitation and Reintegration (PR&R), a component of the Health Policy and Services Directorate of the Office of The Surgeon General, in collaboration with the Defense and Veterans Brain Injury Center (DVBIC) established a validation program for all Army Medical Department Medical Treatment Facilities (MTFs) that provide care to Soldier and other beneficiaries with TBI. This program was designed to established standards of care and to ensure that services, physical facilities, and staffing levels were consistent across the Army MTFs based on the level of care provided at the facility. There are 4 categories of programs-category 1 having the greatest capabilities for TBI care. Programs are validated after review by a team of subject matter experts. To date, 6 sites have received initial validation (Brooke Army Medical Center, Darnell Army Medical Center, Tripler Army Medical Center, US Army Health Clinic Schofield Barracks, Madigan Army Medical Center, and Walter Reed Army Medical Center. Review of all CONUS sites is scheduled between Feb and Jun 2009 with a goal of having every site achieve initial validation.

15. Thi map depicts the medial treatment facilities and the category of their TBI PorgramThi map depicts the medial treatment facilities and the category of their TBI Porgram

16. Slide 16 of 20 Education Initiatives The most important tool for rehabilitation is education. The Proponency Office for Rehabilitation and Reintegration (PR&R) has worked closely with subject matter experts in the area of traumatic brain injury to produce several patient education tools. Much of the content was originally developed by the staff at Womack Army Medical Center, located in Ft. Bragg, NC, and has been reviewed by clinicians and various healthcare personnel to ensure the most accurate and beneficial information is provided to our Soldiers. 5 Patient handout s are currently available: 10 Ways to Improve Your Memory, TBI and Mood Changes, Rehabilitation for Healthy Sleep, Headache and Neck Pain, Head Injury and Dizziness. These education tools cover exercises and techniques that patients can use to assist with their rehabilitation from injuries associated with TBI. In addition to instructions for patients to aid in their recovery, there are also supporting visual images. These tools are only to be used under the guidance of a health care provider. They are available on line at http://www.armymedicine.army.mil/prr/edtraining.html. In addition to patient handouts, education tools for providers, leaders and patients are in development. Staff also regularly present at professional conferences. The most important tool for rehabilitation is education. The Proponency Office for Rehabilitation and Reintegration (PR&R) has worked closely with subject matter experts in the area of traumatic brain injury to produce several patient education tools. Much of the content was originally developed by the staff at Womack Army Medical Center, located in Ft. Bragg, NC, and has been reviewed by clinicians and various healthcare personnel to ensure the most accurate and beneficial information is provided to our Soldiers. 5 Patient handout s are currently available: 10 Ways to Improve Your Memory, TBI and Mood Changes, Rehabilitation for Healthy Sleep, Headache and Neck Pain, Head Injury and Dizziness. These education tools cover exercises and techniques that patients can use to assist with their rehabilitation from injuries associated with TBI. In addition to instructions for patients to aid in their recovery, there are also supporting visual images. These tools are only to be used under the guidance of a health care provider. They are available on line at http://www.armymedicine.army.mil/prr/edtraining.html. In addition to patient handouts, education tools for providers, leaders and patients are in development. Staff also regularly present at professional conferences.

17. Slide 17 of 20 Communications Plan Comprehensive Proactive The Proponency Office for Rehabilitation and Reintegration (PR&R) is the Army�s lead organization for policy, direction, and oversight of rehabilitation and reintegration. PR&R�s vision is to optimize the quality of life of Soldiers and their Families by establishing the world class model of military rehabilitation and reintegration services. PR&R was established to institute Army-wide standards of care for all rehabilitation and transition of injured Soldiers, with diagnoses to include traumatic brain injury (TBI), amputations, polytrauma, vision and hearing impairments, burns, chronic and acute musculoskeletal injuries, and functional limitations related to combat stress. An important element of our program is spreading our message. The PR&R has exhibited at 14 conferences since January 2008. The number of questions answered and materials distributed in in the thousands. The Proponency Office for Rehabilitation and Reintegration (PR&R) is the Army�s lead organization for policy, direction, and oversight of rehabilitation and reintegration. PR&R�s vision is to optimize the quality of life of Soldiers and their Families by establishing the world class model of military rehabilitation and reintegration services. PR&R was established to institute Army-wide standards of care for all rehabilitation and transition of injured Soldiers, with diagnoses to include traumatic brain injury (TBI), amputations, polytrauma, vision and hearing impairments, burns, chronic and acute musculoskeletal injuries, and functional limitations related to combat stress. An important element of our program is spreading our message. The PR&R has exhibited at 14 conferences since January 2008. The number of questions answered and materials distributed in in the thousands.

18. Slide 18 of 20 Intramural funding/fast track DOD and VA Within Congressional intent and target investment Target investment strategy not to exceed 25% Centers of Excellence � 15% Extramural/Intramural � 60% Six award mechanisms Research Initiatives Research regarding TBI, especially concussion (mild TBI) is vitally important to the development, expansion, and modification of Army programs. The DOD Congressionally Directed Medical Research Programs, a component of US Army Medical Research and Materiel Command is the lead for DoD TBI research activities. This program offers a variety of award mechanisms designed to bring investigators together, promotes new collaborations and partnerships, allows for international funding in order to increase the pool of researchers around the world, funds innovative research that can leapfrog advancements, and supports future innovators and leaders. The program received $150 M dollars of funding in FY 07 dedicated to TBI initiatives. Research regarding TBI, especially concussion (mild TBI) is vitally important to the development, expansion, and modification of Army programs. The DOD Congressionally Directed Medical Research Programs, a component of US Army Medical Research and Materiel Command is the lead for DoD TBI research activities. This program offers a variety of award mechanisms designed to bring investigators together, promotes new collaborations and partnerships, allows for international funding in order to increase the pool of researchers around the world, funds innovative research that can leapfrog advancements, and supports future innovators and leaders. The program received $150 M dollars of funding in FY 07 dedicated to TBI initiatives.

19. Slide 19 of 20 Slide self explanatorySlide self explanatory

20. Slide 20 of 20 Proponency Office for Rehabilitation & ReintegrationHealth Policy & ServicesOffice of The Surgeon General