The Madigan Army Medical Center TBI Program Lessons Learned in the Care of Our Wounded Warriors

1. Frederick G. Flynn, DO, FAAN Medical Director, TBI Program Chief, Neurobehavior Madigan Army Medical Center The Madigan Army Medical Center TBI ProgramLessons Learned in the Care of Our Wounded Warriors

2. 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

4. 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

5. 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

6. Common Post mTBI Symptoms SomaticCognitiveNeurobehavioral Headache Attention/Concentration Depression Sleep Disturbance Problems Anxiety Fatigue Memory Problems: Irritability Dizziness - Forgetfulness Impulsivity Nausea/Vomiting - Forgetting to remember Aggressiveness Tinnitus -Working memory problems Apathy Visual Disturbance Executive Dysfunction:Disinhibition Disequilibrium -Multitasking Photo/Phonophobia -Planning/Organizing Heightened alcohol -Problem Solving Sensitivity -Slowed mental processing Altered Sense Smell/ -Slowed reaction time Taste Transient Focal Neurological Symptoms

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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)

13. 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

14. 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

15. Persistent Post-Concussive Sxs Consider: Chronic pain Acute/chronic stress Undiagnosed medical condition PTSD Mood disorders Anxiety Substance abuse Medication misuse Job change/unemployment Financial problems Marital discord/family stressors Spiritual loss Impending combat deployment Secondary gain Somatoform disorder Personality disorder Unmasking a pre-morbid psychiatric condition

16. 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 required C - Avoidant / Numbing – 3/7 required D - Hyper-arousal – 2/5 required E - Duration > 1 month in B,C,D F - Functional significance • significant distress • impairment in social occupational functions • Chronic: > 3 mos • Delayed onset: 6 mos after event

17. 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)

18. 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)

19. 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)

20. 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)

21. 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)

22. 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)

25. 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

26. 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)

27. Post-Deployment Screening and Evaluation SRP PDHA 2+10 Screen TBI Program Referral from other clinics, in MAMC, AF, Navy CG, NG Neurologist/Behavioral Neurologist Neuropsychologist Psychologist IOP* PT/OT Sleep Medicine Speech Pathology Case Management Education Specialist Ombudsman (Ret CSM) Other Specialty Consultants, PRN 50 min Evaluation Hx, Neuro, Cog - By Physician / Neuropsychologist Symptomatic Objective Findings Headache Sleep PTSD Questionnaire VS by LPN No/mild Sxs Educational materials Return to Unit - Reassess in 3 mos Treatment Strategies Pharmacological Non-Pharmacological - sleep - memory classes/groups - headache Individual/Group therapy Couples Counseling Education/Military Counseling Case Management – Coordinated Care Family/Unit Leadership education Team Meetings Case Conferences Coordinated Treatment Strategies Liaison with other Madigan programs (eg. WTU), VA, Civilian rehab Specialty Sub-Specialty Assessment

28. Team Meetings Case Conferences Coordinated Treatment Strategies Liaison with other Madigan programs (eg. WTU), VA, Civilian rehab Return to Unit Restrictions / No Restrictions WTU MEB? F/U in TBI Program Cognitive / Behavorial Rehab Other Activities of the TBI Program Research Education of Military Leaders about TBI Educational Conferences Representation on Committees/ Panels of SMEs, DoD, DCoE, DVBIC, OTSG Tele-TBI Education + Consultation with WRMC (21 states) On-site support of other MTFs Local State National VIP Briefings

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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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