Traumatic Brain Injury TBI Challenges in 21st Century Warfare

1. Traumatic Brain Injury (TBI) Challenges in 21st Century Warfare

3. Learning Objectives:After viewing this presentation the participant will be able to: Describe the work of DVBIC Discuss concussions/TBI that occur in theater especially those resulting from blasts List the effects of TBI Make appropriate referrals to the Defense and Veterans Brain Injury Center (DVBIC)

4. Session Overview Background on Defense and Veterans Brain Injury Center (DVBIC) Recent work with blast injury Patient interview video Referral to DVBIC

5. DVBIC Headquarters: Walter Reed Army Medical Center

6. Uniformed Services University of the Health Sciences

7. The Defense and Veterans Brain Injury Center (DVBIC) Originally the Defense and Veterans Head Injury Program (DVHIP) Congressionally directed program (f. 1991) Clinical Care Clinical Research Education For the Active Duty Soldier Military Beneficiary, and Veteran

8. Head Injury Initiative “This funding will be for [DoD to take the lead] in tracking and evaluating head injury survivors, ensuring that the survivor is getting appropriate treatment, studying the outcome of the treatment, and for counseling family members of the survivor.”

9. Defense and Veterans Brain Injury Center Components 3 Military Treatment Facilities (Tertiary Care); HQ 4 Veterans Affairs Medical Centers - geographically dispersed across continental US 1 Community Reentry – newly added civilian site to augment existing resources within the military and veterans health care systems

10. DVBIC Sites Walter Reed Army Medical Center- HQ San Diego Naval Medical Center Wilford Hall Air Force Medical Center Minneapolis VA Medical Center Tampa VA Medical Center Richmond VA Medical Center Palo Alto VA Health Care System Virginia NeuroCare, Inc.

11. The Past Decade 1992 - “Large Randomized Trials can’t be done in rehabilitation” 2000 – JAMA publication of WRAMC Randomized Controlled Trial (RCT) of Cognitive Therapy for moderate-severe TBI

12. Cognitive RehabilitationFor Traumatic Brain Injury: A Randomized Trial AM Salazar, MD; DL Warden, MD; K Schwab, PhD; J Spector, PhD; S Braverman, MD; J Walter, PA; R Cole, MD; MM Rosner, MA; EM Martin, RNC; J Ecklund, MD, RG Ellenbogen, MD for the Defense & Veterans Head Injury Program (DVHIP) study group JAMA. 2000; 283:3075-3081

13. The Efficacy of TBI Cognitive RehabilitationA Prospective, Controlled Randomized Trial Hypotheses In Moderate to Severe TBI Patients: 1) An institutional cognitive rehabilitation program will result in greater return to work/duty rates than a limited home program. 2) Institutional cognitive rehabilitation will result in better behavioral / cognitive recovery and quality of life than a limited home program

14. TBI Cognitive RehabilitationA Prospective Randomized Trial Methods: Patients (N=120) 1) Closed head injury: (GCS) =12, OR PTA = 24 hours, OR focal CT/MRI. 2) = 3 months from injury 3) Rancho level 7 (oriented, appropriate) 4) No Hx prior severe TBI or any other severe disability. 5) Active duty military member, not awaiting medical separation. 6) Volunteer informed consent signed. 7) Available home if randomized to home program

15. TBI Cognitive RehabilitationA Prospective Randomized Trial Methods: Treatments Group I: Hospital Program (8 Weeks) (N = 67) Housing on minimal care ward Cognitive, Coping Skills, Speech, & Milieu Therapy in AM Structured Job Placement in afternoon Group II: Home Program (8 Weeks) (N = 53) Educational literature and home cognitive exercises ad lib Weekly, 30-minute telephone call from psychiatric nurse Both Groups Evaluation, education & counseling in hospital (approx. 5 days) Trial of return to limited military duty, follow-up at 6, 12, 24 mos.

16. TBI Cognitive RehabilitationA Prospective Randomized Trial Treatment Group Characteristics Home Hospital Number 53 67_________________ Mean age 26 25 NS Education 45% 39% NS Mean days post injury 43 41 NS Traumatic LOC = 1 hour 76% 53% .01 PTA = 7 days 43% 42% NS MRI Hematoma / contusion 53% 51% NS Shear Injury on MR 91% 94% NS Headaches 57% 58% NS Violent Behavior 9% 7% NS Depression 28% 24% NS

17. TBI RehabilitationA Prospective Randomized Trial Return to Work/Duty One Year Post-Injury GROUP I GROUP II P value (Hospital) (Home) Number 66 53 Return to work 88% 93 % NS Fitness for duty 73% 66 % NS

18. TBI RehabilitationA Prospective Randomized Trial Quality of Life One Year Post-Injury GROUP I GROUP II P value (Hospital) (Home) Mean Katz Scores Belligerence 17.1 19.8 NS Social Irresponsibility 29.3 29.4 NS Antisocial Behavior 9.5 11.1 NS Social Withdrawal 9.8 10.8 NS Apathy 6.9 8.2 NS

19. TBI RehabilitationA Prospective Randomized Trial Patient Subset Analysis Percent Fit for Duty by Treatment Patient Subset N Hospital Home P value LOC = 1 hr. 75 80% 58% .04 LOC < 1 hr. 40 68% 85% .13

20. TBI RehabilitationA Prospective Randomized Trial Conclusions 1) Results question the value of institutional cognitive rehabilitation for the group of Active Duty moderate - severe TBI survivors with LOC < 1 hour. 2) Results suggest an advantage of institutional cognitive rehabilitation for those with LOC > 1 hour. 3) The potential therapeutic benefits of the home setting need further study.

21. Have we made a difference? 2002 American College of Rehabilitation Medicine and American Association of Neurorehabilitation Cited WRAMC study as 1 of only 3 studies in the literature linking severity of injury to a specific intervention. 2002 – NIDRR - Model Systems now doing RCTs 2002 – new NIH Clinical Trials Network for TBI at centers with emergency care through rehabilitation

22. Defense and Veterans Brain Injury Center How is DVBIC different from NIH and other brain injury research programs? Focus on those who put themselves in harms way for our country. Specialized focus on the unique needs of military and veteran beneficiaries- return to duty considerations, continuity of care with military and veterans hospitals and TRICARE No other program focuses clinical studies on the welfare of Active Duty military, including paratroopers Clinical Care, Clinical Research, Education

23. TBI Education in Military/VA Prevention: military health fairs; schools First responders: medics; military trainers -Concussion recognition Brief clinical evaluation including severity grading AAN guidelines on return to play/activity and referral for further medical evaluation Emergency department personnel Clinical guidelines for imaging Risk factors for persistent symptoms Improved patient education material

24. TBI Education in Military/VA Primary care providers Veterans Health Initiative to identify and treat Neurobehavioral consequences of TBI Case managers (direct care; contractor) Needs of individuals Available resources; difficulties locating resources, especially in rural areas Patients/caregivers Augment available resources Military/Veteran system specific materials Increase utilization of Web-based learning Sport Concussion Study at West Point: refine appropriate instrument for the evaluation of brain function following concussion; and to implement an incollegiate sports concussion protocol at West Point San Diego teaches TBI assessment to Navy and Marine independent duty corpsmen Wilford Hall is looking into the possibility of adding TBI evaluation into orientation for Military Training Instructors at Lackand AFB; gateway to the military for all AF enlisted personnelSport Concussion Study at West Point: refine appropriate instrument for the evaluation of brain function following concussion; and to implement an incollegiate sports concussion protocol at West Point San Diego teaches TBI assessment to Navy and Marine independent duty corpsmen Wilford Hall is looking into the possibility of adding TBI evaluation into orientation for Military Training Instructors at Lackand AFB; gateway to the military for all AF enlisted personnel

25. Congressional Brain Injury Taskforce October 2003 – Press Conference Capitol Hill Survivors of TBI –Afghanistan, Iraq, Pentagon Initial assessment, treatment including education, follow-up care and appropriate interventions

26. DVBIC Research Initiatives Rehabilitation VA Cognitive Rehab VA Methylphenidate Study Genetic Factors of Recovery TBI Pharmacology Trials Sertraline for acute Post Concussion Symptoms; Citalopram for Anxiety Valproate for agitation – Tampa VA Exelon® for chronic cognitive deficits (sponsored by Novartis Pharmaceuticals)

27. DVBIC Research Initiatives Military Research Acute concussion evaluation Telemedicine for remote concussion evaluation Enhanced helmet design for concussion protection Brain Injury Registry follow-up Evaluation and care of Blast Injury survivors

28. Fort Bragg Paratrooper Evaluation Study

30. Lifetime History of TBI

31. Symptom Reporting after Mild TBI These symptoms represent some of the symptoms respondents reported which disturbed them to a moderate or severe degree. All were significantly different for subjects with prior traumatic brain injury compared to subjects without prior brain injury.These symptoms represent some of the symptoms respondents reported which disturbed them to a moderate or severe degree. All were significantly different for subjects with prior traumatic brain injury compared to subjects without prior brain injury.

32. Postconcussion Symptoms (PCS) Headache Dizziness Irritability Decreased Concentration Memory Problems Fatigue Visual Disturbances Sensitivity to Noise Judgement Problems Anxiety Depression

33. USMA Concussion Study

34. Simple Reaction Time

35. Modern Warfare and TBI

36. Brain Injuries in War On Terrorism Bullet wound or penetrating head injury Dr. Warden will discuss in next session Blast injuries result of explosive munitions (e.g., bombs, grenades, land mines, missiles, and mortar/artillery shells)

37. Blast Injuries Multifactorial injury mechanism: Direct exposure to overpressurization air wave – velocity >/= 300m/sec (speed of sound in air) Impact from blast energized debris – penetrating and nonpenetrating Displacement of the person by the blast and impact Burns/Inhalation of gases Combination with MVA in war theater

38. Blast Injuries Biological Injury dependent upon: Peak overpressure Duration of the positive wave of the overpressure (above atmospheric pressure) Peak overpressure wave decays rapidly passing thru air Difficulty predicting forces due to multiple reflections of shock wave, including available venting

39. Blast Injuries Primary blast injury: interaction of the overpressurization wave and the body; differences occurring from one organ to system to another Air-filled organs such as the ear, lung, and gastrointestinal tract especially susceptible The brain is also vulnerable: direct injury, e.g. cerebral contusion; indirect injury, e.g. cerebral infarction secondary to air emboli

40. Blast Injuries and Modern Warfare Blast injuries are a common occurrence in modern warfare/conflicts both in civilian disasters (e.g., terrorist actions) and military operations. Suggested 50% of combat injuries result of explosive munitions (e.g., bombs, grenades, land mines, missiles, and mortar/artillery shells; Coupland & Meddings, 1999). Brain injury from blasts also common.

41. Blast Injury Induced Brain Injury

42. Blast Injury Induced Brain Injury

43. Observations in bomb blast fatalities in Northern Ireland 1969-77

44. The Beirut Terrorist Bombing 12 tons of TNT equivalent 167/ 234 immediate fatalities demonstrated evidence of head injury 70% fatality rate from head injury 59% rate of head injury (Higher than previous explosions except Northern Ireland, likely reflects large amount of TNT)

45. The Beirut Terrorist Bombing 112 Marines treated at Battalion Aid Station 86 Marines required further treatment 72 transferred to Iwo Jima nearby 14 referred directly to local Beirut hospital 28 patients with concussion (25% immediate survivors) 7/28 with post concussion syndrome 2/7 with disability retirements including PCS 13 with skull fracture: all concussion or scalp laceration

46. Desert Storm Injuries 1991 143 soldiers (140 males) received ballistic injury 17.3% had head wounds; 4.3% had neck wound; 90% had extremity wound; 6% chest; 9% abdomen. 136 (95%) had fragments; 7 (5%) were injured by bullets. Only 2 had a PBI – both from entry below the Kevlar helmet area frontally.

47. Blast Injuries Seen in Operation Iraqi Freedom/Operation Enduring Freedom High incidence of blast secondary to the use of explosive munitions. Increasing reports of head injury in soldiers in Iraq (Wagner, 2003). Blasts Survivability: Body armor, medical care

48. Recent Blast Injuries Seen at Walter Reed Army Medical Center 155 Patients from combat operations screened for TBI ( e.g., blasts, MVA’s, falls, GSW); most seen between August 2003 and 02 December 2003; 96 of the 155 ( 62%) were identified as having sustained a TBI 88 of the 155 (57%) patients screened were involved in blasts (e.g., Land mine, RPG, IED) 54 (61%) of the 88 blast cases were identified as having sustained a TBI

49. ACRM Mild Traumatic Brain Injury (MTBI) Definition A traumatically induced physiological disruption of brain function manifested by at least one of these symptoms: Loss of consciousness < 30 minutes Loss of memory for events immediately before (retrograde amnesia) or after the accident (Post Traumatic Amnesia <24 hours) Any alteration in mental state at the time of the injury (dazed, disoriented, confused) Presence of focal neurological deficits If given, GCS score > 13

50. DVBIC TBI Screening/Evaluation Those at risk based on mechanism of injury (blast, vehicle crash, bullet/shrapnel, fall, etc.) Any LOC, impaired memory for or after the event (ACRM criteria) Cognitive screening (i.e., RBANS) and/or full neuropsychological evaluation Neurologic, psychiatric (including PCS), psychosocial, audiologic evaluation; EEG; MRI as clinically indicated

51. Neurocognitive Changes Following TBI Reduced Information Processing Capacity Problems with attention/concentration, new learning Slowed speed of cognitive processing

52. Cognitive Screening Results to Date 52 RBANS Administered 24 out of 52 (46%) patients demonstrated impairment and required full neuropsychological evaluation 22 out of 52 (42%) patients’ results were within expected limits 6 out of 52 (12%) had borderline/equivocal results

53. Patient Education and Follow-up Education: PCS Expected Course Contact Information and Available Resources Follow-up: Telephone Re-evaluation

54. Referral to Defense and Veterans Brain Injury Center (DVBIC) Formal Informal Toll Free Referral and Information Line 1-800-870-9244 DSN 662-6345 Web Site: www.DVBIC.org   EXHIBIT Booth 205