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Understanding Brain Injury

Understanding Brain Injury. Warrior Salute Veterans Conference Judith I. Avner, Esq., Executive Director Brain Injury Association of New York State October 2, 2013. Today’s Presentation. Traumatic brain injury - background, epidemiology, perspectives

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Understanding Brain Injury

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  1. UnderstandingBrain Injury Warrior Salute Veterans Conference Judith I. Avner, Esq., Executive Director Brain Injury Association of New York State October 2, 2013

  2. Today’s Presentation • Traumatic brain injury - background, epidemiology, perspectives • Understanding traumatic brain injury, post traumatic stress disorder, and challenges for veterans

  3. Comparative Incidence Brain Injury Association of America, 2005

  4. The “Silent Epidemic” Brain Injury in the Civilian Population • An estimated 10 million Americans are affected by stroke and TBI combined. • Every 18.5 seconds, one person in the United States sustains a traumatic brain injury. • 1.7 million Americans sustain a traumatic brain injury each year. • Fifty-two thousand people die every year as a result of traumatic brain injury. www.cdc.gov

  5. Brain Injury and the Military: Understanding the Scope of the Problem Early reports: • Over 30% of all combat related injuries (n=155) seen at Walter Reed Army Medical Center from 2003-2005 included a traumatic brain injury. • About half of the soldiers reported exposure to a blast. • 60% of these blast victims sustained a TBI.

  6. “The Signature Injury” A brief timeline*: • March 2005: military doctors begin referring to traumatic brain injury as the signature injury of the Iraq and Afghanistan conflicts. • January 2006: ABC news anchor Bob Woodruff sustained a TBI in Iraq. February 2007; he highlights the difficulties that veterans with brain injury face in “To Iraq and Back.” • April 2007: Presidential Task Force Recommendations include implementing TBI screening for service members and veterans who visit a VA facility. *http://www.npr.org/templates/story/story.php?storyId=127541772

  7. January 2008: Dr. Charles Hoge, an army psychiatrist publishes article in NEJM casting doubt on “mild TBI” as a cause for physical symptoms other than headaches. Suggests calling it a “concussion” instead of mild TBI to build an “expectation of rapid recovery.”* • April 2008: “Invisible Wounds of War” - Landmark study on TBI and PTSD published by Rand research organization. Reported 1 in 5 veterans have experienced a traumatic brain injury.** • June 2010: an investigation by NPR and ProPublica found the military medical system is still failing to diagnose brain injuries in troops, many of whom receive little or no treatment for lingering health problems.*** * N Engl J Med 360;16, NEJM April 16, 2009, pp. 1588-1591 **The Invisible Wounds of War, Rand Center for Military Health Policy Research, 2008 ***http://www.npr.org/templates/story/story.php?storyId=127402993

  8. RAND Center for Military Health Policy Research 2008 Report* *The Invisible Wounds of War, Rand Center for Military Health Policy Research, 2008

  9. Current Cause for Concern… • 3/24/12 Navy Times Survey of wounded OIF/OEF vets • 2,300 wounded warrior members responded • 80% reported having symptoms of a combat-related mental health condition and ½ said they had a TBI • 62% have current depression (8x rate of general population & 4x figures in 2008 Rand report)* Deepest concerns remain TBI and mental health care *http://www.armytimes.com/news/2012/03/military-80-percent-of-wounded-vets-have-mental-health-trouble-032412w/

  10. “New” Veteran Population • Prior to the most recent conflicts, age of vets typically age of 60-80 years old • New OEF/OIF vets typically 20-30 years old

  11. The Walking Wounded: A Story of Survival • Nature of warfare (blasts) • Better body armor • Shorter rescue time • Advanced medical treatment Many veterans will experience long-term or life-long effects of their injuries. 1Army Task Force Report, May 2008

  12. The Tip of the Iceberg The Incidence Of “Mild” TBI May Be Underestimated • Easier to capture the incidence of moderate to severe TBI • The effects of concussion from a blast injury are not always immediately apparent • Not everyone has a “diagnosis” • Reluctance to seek treatment

  13. “Where do I go to get my brain back?”

  14. Acquired Brain Injury Includes: • Aneurysm • Stroke • Encephalitis • Anoxia • Traumatic brain injury- Gunshot wound- Concussion blast injuries - Head hitting windshield- Severe whiplash- Shaken Baby Syndrome • Toxic exposure (CO, lead paint, neurotoxins, inhaled vapors)

  15. What is Traumatic Brain Injury? Traumatic brain injury is a specific type of damage to the brain that results when the head: • Is penetrated (e.g., a gunshot wound) • Is hit (e.g., by assault or by impact from debris) • Is violently shaken by an external force (e.g., • concussion blast injuries, severe whiplash) • Hits a stationary object (e.g., a windshield in a car crash, a gun mount in a humvee)

  16. How Brain Damage Occurs • The brain is a complicated organ, with millions of cells and connections. • While specific areas of the brain may be related to specific functions, in reality each function (walking, lifting an arm, speaking, etc.) involves many areas of the brain communicating and interacting with each other.

  17. Damage to the brain may vary in extent, area and type of damage depending upon: • Nature of the injury • Severity of the injury • How the injury occurred • Quickness of medical response

  18. Some time after the injury the following may affect the brain: • Hematoma (Blood Vessel Damage) • Brain Swelling • Increased Intracranial Pressure • Intracranial Infection • Seizures

  19. Types of Injury to the Brain Focal Damage Skull Fracture Contusion or bruises under the location of a particular area of impact Fronto-Temporal Contusions/Lacerations Bruising of brain or tearing of blood vessels in the frontal and temporal lobes of the brain caused by brain hitting or rotating across ridges inside skull Diffuse Axonal Injury Shifting and rotation of brain inside skull results in tearing and shearing injuries to the brain’s long connecting nerve fibers or axons Blast Injury Results from the complex pressure wave generated by an explosion.

  20. FOCAL DAMAGE Diffuse Axonal Injury Frontotemporal Regions

  21. Concussions • A concussion is a brain injury. • In most cases, a person with a concussion does not lose consciousness. • A history of 3 previous concussions increases risk of repeated concussions 3-fold. • Athletes with history of 3+ concussions report significantly more symptoms and have lower memory scores at baseline. • Symptoms following repeat concussions may be more serious and resolve at a slower rate.

  22. Blasts • Are the leading cause of TBI for active duty military personnel* • 88% of combat-related TBIs involved exposure to explosions** *The Defense and Veterans Brain Injury Center, http:// dvbic.org/blastinjury.html ** PTSD Quarterly, VOLUME 21/NO. 1, ISSN: 1050-1835, WINTER 2010, http://www.dtic.mil/cgi-bin/GetTRDoc?AD=ADA487081&Location=U2&doc=GetTRDoc.pdf

  23. Blasts and TBI Blast injuries result from the complex pressure wave generated by an explosion, which causes an instantaneous rise in pressure over atmospheric pressure followed immediately by a rapid decrease in pressure. Fluid-filled and air-filled organs like our ears, lungs, GI tract, brain and spine are susceptible to injury as a result of the blast wave, causing primary blast injury. Blast-Induced Neurotrauma (BINT)

  24. Blast Wave Simulation Blast arrival + .23ms + .38ms + .55ms + .65ms Each color represents a different pressure measurement: Black is the lowest pressure (1.0 atmosphere, or 14.7 pounds per square inch), and green, yellow, and red are higher pressures. Red is 3.5 atmospheres, or 51.4 pounds per square inch.  NRL *The Physics of Explosives and Blast Helmets Published: Tuesday, November 25, 2008 - 11:28 in Health & Medicine

  25. Blasts can cause brain injury in other ways: http://www.cdc.gov/masstrauma/preparedness/primer.pdf

  26. Every Person with Brain Injury is Different • Every person with a brain injury adjusts differently to the changes that result from brain injury • Therefore, every person with brain injury needs differing types and levels of support

  27. Common Problems after Brain Injury Can be categorized into the following broad functional areas: • PHYSICAL • COGNITIVE • EXECUTIVE FUNCTIONING • AFFECTIVE/BEHAVIORAL • PSYCHOSOCIAL

  28. Cognitive Short Term/Working Memory Attention Concentration Distractibility Decreased Verbal Fluency/Comprehension Information Processing System Arousal Problem Solving Changed Intellectual Functioning Abstraction and Conceptualization Slowed Reaction Time • Affective/Behavioral • Impulsivity • Emotional Lability • Irritability • Decrease Frustration Tolerance • Impaired Judgment • Tension/Anxiety • Depression • Aggressive Behaviors • Disinhibition • Changed Sexual Drive • Changed Personality Physical Loss of Smell and Taste Hearing Loss Visual Difficulties Balance Difficulties Dysarthria Motor Control and Coordination Fatigue Seizures Decreased Tolerance for Drugs and Alcohol Headaches Sleep Disturbances Chronic Pain Executive Functioning Goal Setting Self-Monitoring Planning Initiating Organizing Directing Creating Evaluating Modifying Bringing to Completion Ability to engage in meaningful activity Psychosocial Vocational Problems Educational Problems Family Issues

  29. Other Difficulties • Sensitivity to lights and loud noises • Chronic headaches • Behavioral and/or cognitive impulsivity • Behavioral inflexibility / cognitive rigidity • Easily overloaded or distracted • Changes in self-awareness / self-perception

  30. Long Term Effects of Mild TBI • Many individuals with mild traumatic brain injury, or concussion, will have no long-term effects. • A small group may have some longer lasting, or even permanent, symptoms. • Irritability, anxiety and depression are the most common lasting problems. • Challenges relating to movement, balance, attention span, concentration, judgment and reaction time can also be found in some patients.

  31. PTSD and TBI • The symptoms of PTSD could also be indicative of TBI. • It is not unusual for people to experience both diagnoses concomitantly. • The differences are often subtle.

  32. Posttraumatic Stress Disorder • PTSD is an anxiety disorder that can occur after experiencing or witnessing a traumatic event. • The person experienced, witnessed or was confronted by an event or events that involved actual or threatened death or serious injury or threat to physical integrity of self or others. • The person’s response involved intense fear, helplessness, or horror.

  33. Many symptoms of TBI overlap with the common reactions to trauma. • Sometimes difficult to tell what the underlying problem is. • Important to be assessed because: • People with TBI should not use some medications • No matter how mild or severe the injury itself was, the effects could be serious www.ptsd.va.gov/public/pages/traumatic_brain_injury_and_ptsd.asp

  34. Mild TBI and PTSD: Overlapping Symptoms Across Conditions • MTBI • Insomnia • Impaired memory • Poor concentration • Depression • Anxiety • Irritability • Headache • Dizziness • Fatigue • Noise/light intolerance • PTSD • Insomnia • Memory problems • Poor concentration • Depression • Anxiety • Irritability • Stress symptoms • Emotional numbing • Avoidance

  35. Challenges for Veterans • Social and emotional isolation • Readjustment, acculturation, and identity issues • Awareness and understanding of cognitive problems • Complicating physical & emotional conditions • Knowledge of support systems and available resources • Post-injury abilities are very different from pre-injury abilities

  36. Need to teach the vet how to advocate for self

  37. WHAT YOU NEED TO KNOW • Each person with a TBI will have different needs and levels of support • Each person with a TBI may have different benefits, assets, entitlements which may affect their ability to receive services • Consider the needs of family…

  38. THE FAMILY HAS SUDDENLY BEEN CHANGED FOREVER… …with no idea what the future holds

  39. CONFUSION HOPE FEAR ANXIETY the injury… GUILT BEWILDERED SHOCK ISOLATION ANGER PAIN DENIAL

  40. What Might Families Say? • What is going on? • We can’t help because no one knows what is wrong… • My loved one doesn’t feel like themselves anymore, feels like he/she is going crazy… • The therapy isn’t working… • Medications aren’t working… • These symptoms seemed to come from nowhere… • I don’t know who to talk to… • It’s been a fight to get healthcare…

  41. A Sampling of Treatment Providers Psychiatrist Neurologist Polytrauma Case Worker Orthopedic Surgeon Support group Kinesiotherapist Physiatrist Waiver Providers Community -based Providers Job coach Speech Therapist Pharmacist Pain Mgmt Specialist In-patient program Neuropsychologist Orthotist-Prosthetist Clergy Psychologist Cognitive therapist Urologist Physical Therapist Chiropractor Substance Abuse Counselor Nurses Occupational Therapist Confusion….

  42. THE FALLOUT… • What impact does the injury have on the family dynamic? • How committed was the family to their roles? • What happens to the role of the children? • Has one member become the “caregiver” • Who brings the children to school, takes care of the home? • Who navigates the healthcare system? • How is the family supported financially? • What if there is no family? • FAMILIES ARE EXHAUSTED!

  43. Steps Forward… • Continued interest and research prompt IMPROVEMENT: • Improveddiagnosis of TBIs and PTSD • VA San Diego research (published in 2011)* • Improvedcare andquality of programs through examination of effective components • RAND study (published in 2012)** *Rogers, Rick, North County Times-The Californian, “ VA Studies Prompt Better Diagnosis of TBIs, PTSD,” 5/6/11. **Weinick, Robin M., et al, “Programs Addressing Psychological Health and TBI Among U.S. Military Servicemembers and Their Families,” RAND Health Quarterly, Winter 2012, Article 8.

  44. Community Resources NYS Waiver Programs • Department of Health • Office for People with Developmental Disabilities (OPWDD) Community Based Rehabilitation Services • County Mental Health Departments • Local Rehabilitation Centers - located in private hospitals, university medical centers, private practice physicians/therapists/counselors • Community Based Day Programs Return to Work Vocational Planning • Volunteer Opportunities in Community • ACCES-VR http://www.acces.nysed.gov/vr/ • New York State Department of Labor http://www.labor.ny.gov/home/ Independent Living Centers • See www.bianys.org for NYS ILC listing Support Groups • See www.bianys.org for support group listing Drug and Alcohol Abuse • Substance Abuse Programs (at local VA Medical Centers)

  45. Resources (continued) www.dcoe.health.mil The Defense and Veterans Brain Injury Center www.dvbic.org http://www.bianys.org/ http://veterans.ny.gov/

  46. Some BIANYS Public Awareness/ Advocacy Tools

  47. The statewide non-profit membership organization that advocates on behalf of individuals with brain injury and their families.

  48. Brain Injury Training and Services Project • Family Advocacy, Counseling & Training Services Program (FACTS) • Support groups • Caregiver support • Statewide resources • Information and training about TBI • Certified Brain Injury Specialist training • Annual conferences and symposia • Family Help Line (800) 444-6443 • Project LEARN in the classroom (LEARNet)

  49. Family Advocacy, Counseling, and Training Services Program (FACTS) • A family support program operated by BIANYS and funded by NYS OPWDD. • Program participants must have sustained an injury prior to age 22 and be a NYS resident. College students may be eligible for services. • Sixteen FACTS coordinators located throughout NYS provide support and advocacy services to participants and their families.

  50. Brain Injury Training and Services Project • A collaboration between the Brain Injury Association of New York State & the NYS Department of Health • The project provides information about TBI, support for military personnel returning to NYS from Iraq and Afghanistan and their families, and training for providers about TBI Support is provided in part by project H21MC06742 from the Maternal Child Health Bureau (Title V, Social Security Act), Health Resources and Services Administration, Department of Health and Human Services

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