mild traumatic brain injury: a signature injury of the iraq conflict

Mild Traumatic Brain Injury: Mild Traumatic Brain Injury: A Signature Injury of the A Signature Injury of the

Iraq ConflictIraq Conflict

Monica L. Jefferson, Ph.D.Neuropsychologist

NJ WRIISC

LEARNING OBJECTIVES:LEARNING OBJECTIVES:

1. Review mental health concerns of returning Veterans

2. Discuss current understandings of mild traumatic brain injury (MTBI)

3. Discuss effects of blast exposure

4. Identify injury and recovery factors unique to returning Veterans

OEF/OIF: A New Type of OEF/OIF: A New Type of WarWar

“A growing number of U.S. troops whose body armor helped them survive bomb and rocket attacks are suffering brain damage as a result of the blasts. It's a type of injury some military doctors say has become the signature wound of the Iraq war.”

Key Iraq wound: Brain trauma

by Gregg ZoroyaUSA TODAYMarch 2005

OEF/OIF represent new OEF/OIF represent new challenges…challenges…

Different Weaponry Different Weaponry

Ambiguous Front LineAmbiguous Front Line

Advances in Amour and ProtectionAdvances in Amour and Protection

When an OEF/OIF Veteran When an OEF/OIF Veteran returns…returns…

Healthy Adjustment?Healthy Adjustment?

Psychiatric Condition? Psychiatric Condition?

Mild TBI?Mild TBI?


Healthy Adjustment?

Veterans may experience a range of Veterans may experience a range of NORMAL, HEALTHYNORMAL, HEALTHY

responses to their return homeresponses to their return home

Excitement Relief Stress Tension Concern Combat Stress reactions

(See National Center for PTSD http://www.ncptsd.va.gov/ncmain/index.jsp)


Unhealthy Adjustment?

Reactions…Continue long after event Reactions…Continue long after event Interfere with ability to functionInterfere with ability to function

Cause significant distressCause significant distress

Depression Suicidal Thoughts Self-blame, Guilt and Shame Anger or Aggressive Behavior Alcohol and/or Drug Abuse Post Traumatic Stress Disorder


Post Traumatic Stress Disorder?

Exposure to a traumatic event in which both are present Experienced, witnessed, or confronted with event(s) that

involved actual or threatened death or serious injury to self or others

Responded with intense fear, helplessness, or horror

3 Symptom Clusters Re-experiencing (e.g., recurrent intrusive images/thoughts) Avoidance & Emotional numbing (e.g., markedly diminished

participation in significant activities; feeling emotionally detached from others)

Arousal (e.g., difficulty sleeping; irritability; difficulty concentrating)

Symptoms present for more than 1 month

Symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning

Symptoms can VARY in terms of Intensity and Duration


Mild Traumatic Brain Injury?

There is no clear consensus on There is no clear consensus on definition of MTBIdefinition of MTBI

This…This…

Complicates Diagnostic Efforts

Complicates Research Efforts

Increases need for INTERDISCIPLINARY APPROACH to assessment, treatment and rehabilitation

American Congress ofAmerican Congress ofRehabilitation Medicine Rehabilitation Medicine Definition of MTBI (1993)Definition of MTBI (1993)

Traumatically induced physiologic disruption of brain function as manifested by at least one of the following:

1. Any loss of consciousness2. Any loss of memory for events immediately before or after the

accident3. Any alteration in mental state at the time of the accident4. Focal neurologic deficit(s) that may or may not be transientSeverity of the injury does not exceed:

Loss of consciousness of 30 min GCS score of 13-15 after 30 min Posttraumatic amnesia of 24 hr

TBI: EpidemiologyTBI: EpidemiologyUnited States Overview (CDC)United States Overview (CDC)

TBI is a leading cause of death and disability ~ 1.4 million people sustain a TBI each year ≥ 5.3 million have long-term or life-long disability ~ 75% of TBIs that occur each year are MTBI or

concussions Causes:

Falls (28%) Motor vehicle-traffic crashes (20%) Struck by/against events (19%) Assaults (11%)

Even in peacetime, military personnel have a higher rate of TBI than civilians.

During war, this incidence increases

Rand Report: Invisible Wounds of War, 2008Since 2001, ~ 320, 000 (19.5%) sustained a TBI Probable TBI Only: 12.2% PTSD and Probable TBI: 1.1% Depression and Probable TBI: 0.7% PTSD/Depression/Probable TBI: 5.5%

TBI: EpidemiologyTBI: EpidemiologyUS MilitaryUS Military

Blasts and MTBIBlasts and MTBI

Mechanisms of Blast InjuryMechanisms of Blast Injury

Primary Primary results from impact of the overpressurization results from impact of the overpressurization wave with body surfaceswave with body surfaces

Secondary Secondary results from flying debris and bomb results from flying debris and bomb fragmentsfragments

Tertiary Tertiary results form individual being thrown by the blastresults form individual being thrown by the blast

Quaternary Quaternary all other explosion related injuries, illness or all other explosion related injuries, illness or diseases not due to abovediseases not due to above

Mechanisms of Blast InjuryMechanisms of Blast InjuryFrom: When Things Go Boom: Blast Injuries By Robert Nixon,

EMT-P, and Charles Stewart, MD. fireEMS, May 1, 2004

Blasts and MTBIBlasts and MTBI

Are blast related MTBIs different than other MTBIs?Can we apply current models to blasts?

Limited studies on effects of primary blast waves on human brain

Pathophysiology of primary blast injuries may differ from other mechanisms

Current evidence does not suggest difference in clinical outcomes

MTBI: What we know...MTBI: What we know...MTBI and CiviliansMTBI and Civilians

Symptoms are temporary

Full recovery expected within weeks of initial injury

Persistent symptoms may be attributable to non-injury factors

(See Carroll et al. 2004 J Rehabil Med)

MTBI: What we know...MTBI: What we know...Concussions and AthletesConcussions and Athletes

Concussion symptoms resolve within days to one month

Professional football players appear to recover more quickly than collegiate and high school athletes

Multiple concussions (3+) are a risk factor for poorer recovery course

(See Moser et al. 2007 Archives of Clin Neuropsych)

MTBI: RecoveryMTBI: Recovery

Immediate Symptoms

Loss of consciousness Disorientation and/or Confusion Memory Difficulties (e.g., amnesia) Headache Hearing difficulties Visual difficulties

etc…


Initial Days or Weeks

Physical Symptomse.g., Headache; Dizziness; Balance difficulties; Fatigue; Light/Noise sensitivity

Cognitive Symptomse.g., Slowed information processing; Difficulties with attention/concentration and/or Short-term memory

Emotional and Behavioral Symptomse.g., Irritability; Depressed mood; Anxiety; Mood lability


Initial Days or Weeks

Initially, an individual may not develop many symptoms

Most show at least some symptoms during the first several weeks after onset of injury =

NORMAL RECOVERY PROCESS


One to Six Months…and beyond

Majority of individuals experience a rapid and complete recovery within 3 months (e.g., Belanger et al., 2005; Binder et al.,1997; Schrelten & Shapiro, 2003)

Prevalence of persistent symptoms varies from 7-33% (e.g., Alexander, 1995; Binder et al., 1997; Iverson, 2005; Rimel et al., 1981)

Post Concussion Syndrome???

MTBI: Civilians and Athletes

…But some do not fully recover


RISK FACTORS FOR POORER RECOVERY

Severity of Injury (GCS; LOC; PTA; “complicated” MTBI)

Age > 40 (55) Lower SES Medico-legal Involvement Pain Comorbid Medical or Psychiatric Condition Compromised Premorbid Functioning History of multiple TBIs

MTBI and Returning Veterans

Can we apply our current knowledge?

MTBI is strongly associated with PTSD and physical health problems

PTSD and depression appear to be mediators of the relationship between MTBI and physical health problems (e.g., Hoge et al., 2008)

Blast-injured personnel may experience greater symptoms of PTSD

MTBI: What we know...MTBI: What we know...MTBI and Returning VeteransMTBI and Returning Veterans

No strong evidence that sequelae of blast-related MTBI are different from other MTBI (e.g., Belanger et al., 2009)

“Post Concussive” symptoms are NOT specific to concussion (e.g., Fear et al., 2009)

MTBI: What we know...MTBI: What we know...MTBI and Returning VeteransMTBI and Returning Veterans

MTBI: RecoveryMTBI: RecoveryFactors to consider with returning Veterans

Injury and Recovery FactorsInjury and Recovery Factors…unique to our returning Veterans

Deployment

Vulnerable/Compromised Pre-injury State

Post-injury Recovery Variables

Blasts and Multisystem Trauma

Effects of additional Exposures

UNKNOWNS

Additional ResourcesAdditional Resources

National Center for PTSD (NCPTSD) http://www.ncptsd.va.gov Download Assessment Tools

Defense and Veterans Brain Injury Center (DVBIC) http://www.dvbic.org/ Download TBI Clinical Tools

CDC Explosions and Blast Injuries: A Primer for Clinicians http://www.cdc.gov/masstrauma/preparedness/primer.pdf

For Veterans & Returning Service Members - OEF/OIF http://www.oefoif.va.gov/

Vet Centers http://www.vetcenter.va.gov/

mild traumatic brain injury: a signature injury of the iraq conflict

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