Traumatic Brain Injury:From combat to reintegration

Wisconsin Women Veterans Conference

September 20, 2009

Presented by:

Jennifer C. Imig, Ph.D.

Copyright 09/20/2009

Overview

• Traumatic Brain Injury in returning veterans and active duty soldiers

• Traumatic brain injury (TBI) is the “signature wound” of soldiers and returning veterans.

• Identification of mild TBI is receiving great clinical attention in the VA and DOD, as this injury may be “hidden.”

Incidence of TBI

• Due to improvements in body armor and field trauma care, more individuals are surviving beyond the acute phase of these injuries.

• The nature of intense, unpredictable, and repeated blasts may lead to a significant number of soldiers with traumatic brain injuries ranging in severity from mild to severe.

How close does a soldier have to be to a blast to cause an injury?

The answer is that we don’t know……

• Traumatic Brain Injury….the hallmark injury faced by veterans of Iraq and Afghanistan.

• Even those who were not obviously woundedin explosions or accidents may have sustained a brain injury.

Sources of TBI During Combat

• Blast Injuries—Limited or no physical signs

– Improvised Explosive Devices (IED), Rocket Propelled Grenades (RPG) , Mortars

• Impact Injuries-Physical injuries noted

– MVC, Bullets, Falls/Accidents

• Each incident can potentially cause multiple system injuries.

Mechanism of blast injury• PRIMARY:

– effects of overpressure shock wave, affecting air-filled organs (ear, lung, GI), organs surrounded by fluid-filled cavities (brain, spinal cord)

• SECONDARY:– flying debris/fragments --penetrating injuries

• TERTIARY: – body displacement/blast wind, blunt/crush trauma,

fractures, amputation

• QUARTENARY: – burns, respiratory injuries, septic syndromes

POLYTRAUMA and TBI Injuries• Multi-Dimensional Injuries, unique in this

population

• TBI frequently occurs in polytrauma in combination with other disabling conditions such as amputation, auditory, and visual impairments, SCI, PTSD and other mental health conditions.

TBI Severity

• A mild TBI (which is usually not associated with visible abnormalities on brain imaging) is one that causes loss of consciousness lasting less than 1 hour or amnesia lasting less than 24 hours.

• A moderate TBI produces loss of consciousness lasting between 1 and 24 hours or post-traumaticamnesia for one to seven days.

• A severe TBI causes loss of consciousness for more than 24 hours or post-traumatic amnesia for more than a week are considered severe.

TBI Severity

• A mild TBI (which is usually not associated with visible abnormalities on brain imaging) is one that causes loss of consciousness lasting less than 1 hour or amnesia lasting less than 24 hours.

• A moderate TBI produces loss of consciousness lasting between 1 and 24 hours or post-traumaticamnesia for one to seven days.

• A severe TBI causes loss of consciousness for more than 24 hours or post-traumatic amnesia for more than a week are considered severe.

Mild TBI defined by the Head Injury Interdisciplinary Special Interest Group of the American Congress of

Rehabilitation Medicine

"a traumatically induced physiologic disruption of brain function, as manifested

by one of the following:

Any period of loss of consciousness (LOC),

Any loss of memory for events immediately before or after the accident,

Any alteration in mental state at the time of the accident,

Focal neurologic deficits, which may or may not be transient."

The other criteria for defining mild TBI include the following:

GCS score greater than 12

No abnormalities on CT scan

No operative lesions

Length of hospital stay less than 48 hours

mTBI Evaluation• DIAGNOSIS: mild TBI = Concussion

– Incidence of a change in mental status• Loss of consciousness

• Seeing stars

• Dazed and confused

– Sometimes there is also loss of memory after the event, called post traumatic amnesia

– Sometimes, but rarely, there is loss of memory for before the event, called retrograde amnesia

Mild TBI may or may not

be associated with post-concussive symptoms.

Post-Concussive Syndrome: Management

• Post-TBI symptoms seen in PCS are present in 15 (DSM-IV) to 50% (ICD-10) of persons with mTBI.

• Symptoms rapidly resolve by 2-4 weeks post-mTBI in >90% individuals.

McCrea: JAMA 2003;290:2556-2563

• <5% may have persistent difficulties by 12 months.

Iverson: Brain Injury Medicine 2007;373-405

• Early intervention improves short-and long-term outcomes.

Ponsford: J Neurol Neurosurg Psych 2001;73:330-2

Wade: J Neurol Neurosrg Psysch 1998;65:177-183

David X. Cifu, M.D.

The Herman J. Flax, M.D. Professor and Chairman

Department of Physical Medicine and Rehabilitation

Virginia Commonwealth University

Even though the research suggests that the

symptoms of post concussive symptoms

should be transient in most cases…

…what do the soldiers report?

Common mTBI Complaints

• Problems with:

• Money management

• Employment

• School

• Recreational activities

• Family/ Significant Other

• Social interaction

Physical Problems• Pain

• Motor weakness

• Sensory deficits

• Upper Motor Neuron/CNS findings

• Balance/Gait abnormality

• Dizziness/vestibular symptoms

• Headaches

• Fatigue

• Hearing loss/tinnitus/sensitivity to noise

• Visual changes

• Decreased psychomotor activity, tremor

Cognitive Deficits

• Deficits in:• Attention/concentration

• Processing speed

• Memory

• Problem-solving

• Executive organization

• Safety judgment

Emotional/Behavioral Issues

• Depressed mood

• Anxiety

• PTSD

• Suicidal ideation

• Irritability/anger control

• Disinhibition

• Sleep disturbance

Why is there a discrepancy…. In what we expect and what is reported?

The majority of the TBI research came from sport-related research

Are these two sources of injuries comparable?

TBI in Sports TBI in Combat

Head & Brain injury Brain injury without head injury common

Isolated/discrete event Multiple events

Immediate medical care Often not immediate medical evaluation

Player is safe after incident Soldier is not safe after incident

Pre and post changes are Difficult to detect pre and post identifiable changes

Are these two types of injuries comparable?

Most likely they are not…

Due to the environment in which the TBI occurred and the on-going trauma in the theatre

Therefore what contributes to sustained residuals noted in soldiers with combat-related TBI?

What causes the prolonged symptoms reported by many soldiers

–Current symptoms may be due to multiple sources

• Due to mTBI only

• Due to mTBI and adjustment stress

• Due to mTBI and PTSD or depression

• Due to premorbid difficulities

–Started prior to military; possibly exacerbated by the combat duty

Sources of Sustained Residuals• Severity, multiple incidence, and mechanism of TBI

• PTSD

• Prior history of psychiatric distress (depression/anxiety)

• Military onset of psychiatric distress

• Drug use (especially cocaine and marijuana)

• Alcohol abuse

• Previous brain/head injury

• Previous childhood learning conditions (LD, AD/HD)

• Chronic and/or acute pain

PTSDRe-experiencing

Avoidance

Social withdrawal

Memory gaps

Apathy

MildTBI

Residual

Difficulty with decisions

Mental slowness

Concentration

Headaches

Dizzy

Appetite changes

Fatigue

Sadness

Arousal

Sensitive to noise

Concentration

Insomnia

Irritability

DepressionDavid X. Cifu, M.D.

The Herman J. Flax, M.D. Professor and Chairman

Department of Physical Medicine and Rehabilitation

Virginia Commonwealth University

So what can be done to ameliorate symptoms and encourage successful reintegration in soldiers

Early Identification & Intervention Education of Expected RecoveryProactive Reintegration Efforts

Early Identification

• DOD– Field Evaluations– Camp TMCs– Landstuhl, Germany– Walter Reed, AMC

• DOD and VA Liasons• VA

– TBI four level screening– Polytrauma/TBI system of care

• Private Sector Collaborations

Early Intervention

• Value of Early Intervention– Improves short and long term outcomes– Education/positive reassurance – Symptoms treatment: analgesics, antidepressants,

sleeping aid, psychological intervention– Cognitive remediation/compensatory strategies– Care coordination/Case management– Close follow-up/monitor progress: symptoms,

life/job performance

Education of Expected Recovery

• Post Traumatic Growth:

– “… emphasizing the potential for FULL RECOVERY minimize the unnecessary attribution of common stress reactions to pathology and facilitate resilience after mild TBI.”

– Richard A. Bryant, PhD

PTSD specialist, University of New South Wales, Australia

---Tom Valeo, Neurology Today, March 20, 2008

Proactive Reintegration Efforts

• Community Reintegration: • Vocational Rehab

• Work Hardening program

• Recreation/Exercise, Recreation Therapist

• Driving safety

• Psychosocial/Family support and resources

• Adaptive equipments: PDAs, recorders, etc.

• Active duty/reserve:• Redeployment/return to combat

TBI Recovery Resources

• Female focused treatment in women’s clinic

• OEF/OIF Outreach Groups

• Family Support Group

– Kids focused groups and materials

– Spouse focused materials

• Collaboration between VA, DOD and private sector

Restoration of Premilitary Adjustment

Pre-military life trajectory

Military

Barriers to Healthy Adjustment

TBIPTSDDepressionSubstance Abuse

Post-military life trajectoryBarriers are overcome

Website resources

• www.biausa.org (Brain Injury Assoc. of America)

• www.neuro.pmr.vcu.edu (National resource Center for Traumatic Brain Injury)

• www.pdhealth.mil/TBI.asp (Deployment Health Clinical Center (TBI)

• www.va.gov/health_benefits (VA Benefits)

• www.vetsuccess.gov (Voc Rehab and Independent Living Services)

• www.militaryonesource.com

QuestionsI am honored to serve those

who have served and their families.

Thank you!

Jennifer

Jennifer.Imig@PsychologySpecialists.com

Jennifer.Imig@comcast.net