va/dod clinical practice guideline for management of concussion/mtbi, 2009. traumatic brain injury -...
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VA/DoD Clinical Practice Guideline For Management of Concussion/mTBI, 2009.
Traumatic Brain Injury - Concussion
in the Military
May 25, 2010
The views expressed in this presentation are those of the authors and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the U.S. Government.
Background Definition of TBI Army TBI Trends Epidemiology Natural history and course of Army TBI Therapy Outcomes & Common Symptoms Management and Treatment
SLP- LT Joann Shen & Ms. Carla Chase OT- CDR Laura M. Grogan PT- CDR Henry McMillan & LCDR Alicia Souvignier
ASR: Acute stress reaction CONUS: Continental US DoD: Department of Defense IED: improvised explosive devices mTBI: mild Traumatic Brain Injury, concussion MVA: motor vehicle accident OEF: Operation Enduring Freedom OIF: Operation Iraqi Freedom PTSD: Post-traumatic stress disorder SM: Service Member- active duty, Reservists, National
Guard, and Veterans
Source: Proponency Office for Rehabilitation & Reintegration www.armymedicine.army.mil.prr
Early identification, evaluation, management, treatment, documentation, and coding
Neurocognitive testing Tele-health assets Education and training for SM, leaders, patients, MHS
providers, community health care providers, Family members, and others
Strategic communications and marketing Research TBI Program Validation
Source: Proponency Office for Rehabilitation & Reintegration www.armymedicine.army.mil.prr
Level I: Buddy Aid to Battalion Aid Station (BAS) Level II: Forward Support Medical Company/Forward Surgical
Team Level III: Combat Support Hospital (CSH) and Combat Stress Unit Level IV: Evacuation Center (Landstuhl Regional Medical Center
[LRMAC]) Level V: Military medical treatment facility (MMTF) - Inpatient and
Outpatient Level VI: Inpatient Rehabilitation (non-MMTF, such as Veteran’s Affairs Medical Center and
community partner facilities) Level VII: Outpatient rehabilitation (non-MMTF, such as Veteran’s Affairs Medical Center and
community partner facilities) Level VIII: Lifetime care
Significant incident in theatre results in Medivac to Germany and then to CONUS to start clinical care
Upon return from deployment, all SM’s are provided a Post Deployment Health Assessment and screening
SM with possible symptoms of concussion, are then referred to the TBI clinic for additional evaluation and possible treatment and care
DoD Deployment Health Clinical Center at Walter Reed Army Medical Center, Washington, D.C , May 2010
This slide depicts TBI of varying severity based on data from the Defense Medical Surveillance System (DMSS), 31 December 2009. TBI numbers reflect all Army Soldiers Diagnosed with Traumatic Brain Injury, irrespective of their Deployment history (Soldiers who have deployed and those who never deployed). Data is updated Quarterly and First Qtr 2010 data is currently incomplete.
Source: Office of the Surgeon General Last updated: 6 April 2010
Trend for Total ArmyN
UM
BE
R O
F A
RM
Y S
OL
DIE
RS
WIT
H I
DE
NT
IFIE
D T
BI
Increase in the number of mild TBI cases between CY05 and CY08 is largely due to Post Deployment Screenings and aggressive identification of incident and symptoms.
Calendar Year in which Injury Occurred
Estimated 12% of the 1.6 million SM’s deployed in OEF/OIF may have sustained a mTBI (Schneiderman, Braver, & Kang, 2008, data up to Oct 07)
Head & neck injuries reported in one-quarter of servicemen evacuated from theater. A possible 10-15% mTBI in all deployed SM’s (Hoge et al, 2008)
High incidence of TBI attributed to the consequences of blasts or explosions caused by IED’s
Other sources: Bullets, fragments, MVA’s, assaults (DVBIC) Males 1.5 x’s higher risk than females (DVBIC)
Primary – Overpressure of “blast wave”
Secondary – Flying Debris
Tertiary – Body Displacement, Victim thrown into stationary objects
Quaternary – Any injury or disease not due to other mechanisms (burns,
toxic inhalation, crush
injuries, radiation exposure)
12
Symptoms:
- Transient- Rapid or gradual resolution within days or weeks- Highly nonspecific: headache, blurred vision, dizziness,
sleep problems, cognitive changes (attention/concentration/memory)
- Prognosis after mTBI: Good- Recovery occurs for most within 3-12 months with or
without intervention, very small percentage of cases have symptoms persisting beyond 3 months
- Persisting symptoms attributable to other factors: demographic , psychosocial, medical, situational
McCrea 2008
Optimistic expectation for full recovery > 90% of individuals with sports concussion are
recovered and return to play by 30 days (Collins, 2006) Majority of non-sports related concussions resolve by 3
months Between 8%(Binder, 1997) and 33%(Guskiewicz,
2007) (of what type) have continued symptoms past 3 months
Therapists incorporate assessment of the Service Members goals and priorities along with TBI related symptoms to develop a plan of care with expected improvement
PTSD, Depression, anxiety, stress, Pre-existing disorder, dysfunction, or limitation Expectation of the SM / denial Limited cognitive reserve Somatoform disorder Sleep disorder Malingering
Headaches 59%Blurred vision 45%Anxiety 58%Dizziness 52%Fatigue 64%Light sensitivity 40%Poor concentration 78%Trouble thinking 57%Memory Problems 59% Irritability 66%Depression 63%
Rohling 2003
AudiologistCase managerNeurologistNeuropsychologistOccupational therapistOphthalmologist / OptometristPhysical therapistPrimary Care ManagerSocial Worker/ Counselor/ PsychologistSpeech-Language Pathologist
Blast injuries are unique, injuries can be invisible or latentMost severe symptoms evident within minutes of injuryDelayed symptom onset relatively rareCombination of physical and cognitive symptoms most
commonMeasurable improvement seen within hours of injuryGradual symptom recovery occurs over 7-10 days in 80-
90% of casesHeadache tends to linger the longest.Good prognosis for recoveryWhile mTBI is difficult to diagnose, as therapists, we treat
the functional impairments regardless of underlying diagnosis
Defense & Veterans Brain Injury Center: www.dvbic.org Brainline (DVBIC-sponsored): www.brainline.org Defense Centers of Excellence for Psychological Health
and Traumatic Brain Injury: www.dcoe.health.mil Deployment Health Clinical Center: www.pdhealth.mil Defense Centers of Excellence for Psychological Health
& Traumatic Brain Injury: www.health.mil/dcoe.aspx Department of Veterans Affairs (VA): www.va.gov DoD Disabled Veterans: www.dodvets.com Polytrauma Sites: www.polytrauma.va.gov Traumatic Brain Injury National Resource Center:
www.nrc.pmr.vcu.edu Brain Injury Association of America: www.biausa.org
LT Joann Shen, M.S. CCC-SLP Ms. Carla Chase, M.S. CCC-SLPTripler Army Medical Center Schofield Barracks Health ClinicPhone: 808-433-4362 Phone: [email protected]
CDR Laura M. Grogan, OTR/LEvans Army Community Hospital
Phone: [email protected]
LCDR Alicia Souvignier, CDR Henry McMillanEvans Army Community Hospital Womack Army Medical CenterPhone: 719-526-3704 Phone: [email protected] [email protected]