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PowerPoint Presentation - Washington State Traumatic Brain Injury

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					     TBI Programs and Resources in the US Military
                      30 April 2010
           Kathy Helmick MS, CRNP, CNRN
         Interim Senior Executive Director, TBI
                    27 October 2009
Defense Centers of Excellence for Psychological Health and
                 Traumatic Brain Injury

                          Version 1.0
    Agenda



•    DoD definition of TBI
•    Severity of injury
•    Mechanisms of injury
•    Recent research findings
•    DoD enterprise wide initiatives
•    TBI management continuum
•    Resources – patient, family, provider
•    Research
•    The way ahead




                                             2
High-level Attention

                           Task Force on
                         Returning Global
                        War on Terror Heroes
   Independent Review                        DoDIG Review of
      Group (IRG)                           DoD/VA Interagency
                                              Care Transition

 Commission on Care
    for America’s
 Returning Wounded
      Warriors                             Mental Health Task
                                                 Force
                   Veterans Disability
                  Benefits Commission
                 (www.vetscommission.org
                            )
                                                                 3
What is DCoE?
 – DCoE is a DoD organization that, in close partnership with the
   Department of Veterans Affairs, leads a national and international
   collaborative network of other governmental organizations, military and
   civilian agencies, community leaders, advocacy groups, clinical experts
   and academic institutions in helping service members with
   psychological health and traumatic brain injury issues.

 – DCoE’s work focuses on assessing, validating, overseeing and
   facilitating programs which aid service members with resilience,
   recovery and reintegration for psychological health and traumatic brain
   injury issues.

Our core messages
 – You are not alone
 – Treatment works. The earlier the intervention, the better
 – Reaching out is an act of courage and strength

                                                                             4
Who We Support

• Service members
    – Guard and Reserve
•   Veterans
•   Families
•   Military leaders
•   Healthcare providers
•   Researchers
•   Employers
•   Caregivers
•   Chaplains

                           5
       DoD TBI Definition (Oct 07)


• Traumatically induced structural injury or physiological disruption
  of brain function as a result of external force to the head
• New or worsening of at least one of the following clinical signs
   –   Loss of consciousness or decreased consciousness
   –   Loss of memory immediately before or after injury
   –   Alteration in mental status (confused, disoriented, slow thinking)
   –   Neurological deficits
   –   Intracranial lesion
• DoD definition parallels standard medical definition
   – CDC, WHO, AAN, ACRM




                                                                            6
   Severity Rating for TBI

                                 Traumatic Brain Injury Description
Severity                       GCS             AOC            LOC       PTA



Mild                           13-15          ≤24 hrs       0-30 min   ≤24 hrs


Moderate                        9-12          >24 hrs        >30min    >24hrs
                                                             <24 hrs   <7 days

Severe                           3-8          >24hrs         ≥24 hrs   ≥7 days

       GCS- Glasgow Coma Score
       AOC- Alteration in consciousness
       LOC -Loss of consciousness
       PTA- Post-traumatic amnesia                                            7
TBI Clinical Standards: Severity, Stages,
Environment
Types of TBI   TBI Post-Injury Stages   Levels of TBI Care

 Mild             Acute                   In-theater

 Moderate         Sub-Acute               CONUS

 Severe           Chronic                 In-patient

 Penetrating                              Outpatient
                                          Community




                                                             8
                      Tracking: DoD Totals
                      30000

                      25000
Number of TBI Cases




                      20000

                      15000

                      10000

                       5000

                          0
                              2000   2002   2004   2006         2008
Data Source: www.DVBIC.org                            *2009 data does not include Oct - Dec
                                                                                      9
                  TBI Tracking: Severity Data
             90
             80
             70
                                                            Severe/Penetrating
             60
Percentage




             50                                             Moderate

             40                                             Mild
             30                                             Not Classified
             20
             10
             0
                  2000   2002    2004   2006   2008

    Data Source: www.DVBIC.org                        *2009 data does not include Oct - Dec

                                                                                       10
            Tracking: TBI ICD 9 Code Surveillance
310.2   Post concussion syndrome             803.4                                                             851.2


800.0   Fracture of the vault of the skull   803.5                                                             851.3
800.1                                        803.6                                                             851.4
800.2                                        803.7                                                             851.5
800.3                                        803.8                                                             851.6
800.4                                        803.9                                                             851.7

                                                     Closed fractures involving the skull or face with other
800.5                                        804.0   bones w/o mention of intracranial injury                  851.8
800.6                                        804.1                                                             851.9

                                                                                                                           Subarachnoid hemorrhage following injury w/o mention
800.7                                        804.2                                                             852.0       of open intracranial wound
800.8                                        804.3                                                             852.1
800.9                                        804.4                                                             852.2


801.0   Fracture of the base of the skull    804.5                                                             852.3
801.1                                        804.6                                                             852.4
801.2                                        804.7                                                             852.5
801.3                                        804.8                                                             853.0
801.4                                        804.9                                                             853.1
801.5                                        850.0   Concussion w/ no loss of consciousness                    854.0
801.6                                        850.1                                                             854.1
801.7                                        850.2                                                             950.1       Injury to optic chiasm
801.8                                        850.3                                                             950.2
801.9                                        850.4                                                             950.3


        Other closed skull fracture w/o
803.0   mention of intracranial injury       850.5                                                             959.01      Other and unspecified injury to head face and neck
803.1                                        850.9                                                             995.55      Shaken baby syndrome

                                                     Cortex (cerebral) contusion w/o mention of open
803.2                                        851.0   intracranial wound                                        V15.5+Ext   GWOT TBI codes
                                                                                                                                                                       11
803.3                                        851.1
Mechanisms of Injury
• Acceleration-deceleration
   – Combination due to rapid velocity changes of the brain




                                                              12
Blast Injury




  Primary: Direct exposure to
  over pressurization wave      13
Impact Vice Blast Vice Blast “plus”


• Understanding differences in mechanism of
  injury
• Differences in DTI between blast and impact TBI
• Inflammatory markers in animal studies
• Computer modeling of blast injury
• Physiological, Histological, and/or behavioral
  differences between blast and non-blast in shock
  tubes with rodents



                                                     14
       Cause for Concern
CONCUSSIVE EFFECTS/TBI
• A study commissioned by the
NFL reports that Alzheimer’s -
like memory- related diseases
appear to have been
diagnosed in the league’s
former players vastly more
often than in the national
population – including a rate of
19 times the normal rate for
men ages 30 through 49.

- Study conducted by University of
Michigan’s Institute for Social
Research


                                     15
Chronic Traumatic Encephalopathy (CTE)
Center for the Study of Traumatic Encephalopathy (CSTE) at BU School of Medicine




      • “a distinct disease with a distinct cause,
        namely repetitive head trauma” (Ann McKee, MD,
          CSTE co-director and neuropathologist)
      • CTE diagnosed in 6 former NFL players since
        2002, including:
           – Pittsburgh Steelers - Mike Webster, Terry Long and Justin Strzelczyk
           – Tampa Bay Buccaneer Tom McHale, died at age 45
      • Youngest case to date: 18-year-old boy who
        suffered multiple concussions in high school
        football



                                                                                    16
   Sports Legacy Project
    Christopher Nowinski and the Sports Legacy Institute



Top: Slide detailing x600 magnification of
immunostained neocortex in a non-CTE
damaged brain.




Chris Benoit, Professional Wrestler

Bottom: Slide detailing x600 magnification of
Chris Benoit's tau-immunostained neocortex
showing neurofibrillary tangles, neuritic
threads, and several ghost tangles indicating
CTE.

Source:                                         Image courtesy of Sports Legacy Institute
http://www.sciencedaily.com/releases/20
07/09/070905224343.htm                                                                      17
Progressive Tauopathy in an athlete with
Chronic Traumatic Encephalopathy
Tau-immunoreactive neurofibrillary tangles in the superficial cortical layers of the frontal, subcallosal, insular,
temporal, and parietal cortices and the medial temporal lobe; marked accumulation of tau-immunoreactive astrocytes




                                                                   Accumulation of abnormal Tau protein in the form of NFTs and NTs in
                                                                   the brain has been confirmed to cause neurodegeneration, cognitive
                                                                   impairment and dementia.



  Coronal sections immunostained for tau with monoclonal antibody AT8 and counterstained with cresyl violet
  McKee AC, Cantu RC, Nowinski CJ, et al, J Neuropathol Exp Neurol Volume 68, Number 7, July 2009
                                                                                                                                 18
Clinical Sequelae of Chronic Traumatic
Encephalopatby



Symptoms can Include;
   –   Memory disturbances
   –   Behavioral changes
   –   Personality changes
   –   Parkinsonism
   –   Speech abnormalities
   –   Gait abnormalities




                                         19
  Cultural Change

Emerging science supports acute management
 to include concerns of safety to encourage
 acute management and evaluation to prevent
 recurrent concussions before full recovery
 from prior injury

State Laws:
  Washington – First state legislation
  Oregon, Texas
  Under consideration: ME, CA, MA, NJ, NY


                                              20
  Post Concussive Symptoms
  Physical                Emotional        Cognitive
• Headache              • Anxiety         • Slowed processing
• Dizziness             • Depression      • Decreased attention
• Balance               • Irritability    • Poor Concentration
  problems
                        • Mood lability   • Memory Problems
• Nausea/Vomiting
                                          • Verbal dysfluency
• Fatigue
                                          • Word-finding
• Visual disturbances
                                          • Abstract reasoning
• Sensitivity to
  light/noise
• Ringing in the ears



                                                                  21
 Possible Effects of mTBI


 • Acute                         • Chronic
     – Poor marksmanship           –   Reduced work quality
     – Slower reaction time        –   Behavioral problems
     – Decreased concentration     –   Emotional problems
                                   –   “Unexplained“ symptoms




TBI-related impairments increase vulnerability to subsequent
               injury until full recovery occurs


                                                                22
    DoD Wide Initiatives


•   TBI Screening                          • 4th Annual TBI military
    (PDHA/PDHRA)                             training conference ( 30-31
•   TBI Surveillance                         Aug 10)
•   NCAT (Neuro Cognitive                  • TBI Family Caregiver
    Assessment Tool) pre                     Guide
    deployment program
                                           • TBI Care Coordination
•   Clinical guidance packages
    –   Cog rehab                          • CDMRP bolus of research
    –   Driving assessments after TBI        funds
    –   mTBI/PTSD
    –   mTBI and co occurring conditions




                                                                           23
         TBI Management Continuum
GOAL: A cultural change in fighter
management after concussive events:
identification and treatment close to point              Education &
of injury, documentation of the incident,                 Prevention
and expectation of recovery with early
treatment.
VISION: Every Warrior trained to:             Rehabilitation,
 – Recognize the signs/symptoms                 Recovery,               Early
 – Reduce the effects                         Reintegration            Detection
 And in the event of an injury –
                                               & Research
 – Treat early to minimize the impact and
   maximize recovery from TBI.
MISSION: Produce an educated force                        Treatment
trained and prepared to provide early                     & Tracking
recognition, treatment, tracking &
documentation of TBI in order to protect
Warrior health.                               Educate – Train – Treat – Track


                                                                              24
Education & Prevention




                         25
          Early Detection: Why Screen for TBI?
  Studies suggest TBI is a common injury in OEF/OIF

  • 16% of returning Army Soldiers screened positive1

  • 15% of returning Army Soldiers screened positive2

  • 19% of OIF/OEF Veterans screened positive3

  • 23% of returning Army Soldiers screened positive4

  • 18.5% of Veterans at VA medical centers screened positive5

1.Schwab KA, Ivins B, Cramer G, Johnson W, Sluss-Tiller M, Kiley K, Lux W, Warden B. Screening for traumatic brain injury in troops
  returning from deployment in Afghanistan and Iraq: Initial investigation of the usefulness of a short screening tool for traumatic brain injury.
  J Head Trauma Rehabil 2007; 22(6): 377-389.
2.Hoge CW, McGuirk D, Thomas JL, Cox AL, Engel CC, Castro CA. Mild traumatic brain injury in US soldiers returning from Iraq. N Engl J
  Med 2008; 358(5): 453-463.
3.Schell TL, Marshall GN. Chapter 4, Survey of individuals previously deployed for OIF/OEF. In Tanielian T and Jaycox LH (eds.) Invisible
  Wounds: Mental Health and Cognitive Care Needs of America’s Returning Veterans. Santa Monica, CA: The RAND Corporation; 2008.
4.Terrio H, Brenner LA, Ivins BJ, Cho JM. Helmick K, Schwab K, Scally K, Bretthauer R, Warden D. Traumatic brain injury screening:
  Preliminary findings in a US Army brigade combat team. J Head Trauma Rehabil 2009; 24, 14-23.
5.Unpublished data. UNCLASSIFIED
                                                                                                                                             26
 Early Detection: Why Screen for TBI? (cont’d)

Most TBIs are mild (mTBI)

 76% of current military TBIs are mTBI1 (recent surveillance program trying to
  better define “scope of the problem”)

 75% of civilian TBIs are mTBI2

MTBI is often untreated and undocumented

 As many as 25% of those with mTBI do not seek medical attention3

 Many individuals with mTBI who receive medical attention do not have a TBI
  diagnosis recorded, especially those with multiple trauma4

1.DVBIC, unpublished data. UNCLASSIFIED
2.National Center for Injury Prevention and Control. Report to Congress on Mild Traumatic Brain Injury in the United States: Steps to
  Prevent a Serious Public Health Problem. Atlanta, GA: Centers for Disease Control and Prevention; 2003.
3.Sosin DM, Sniezek JE, Thurman DJ. The incidence of mild and moderate brain injury in the United States, 1991. Brain Inj 1996; 10:
  47-54.
4.Moss NEG, Wade DT. Admission after head injury: How many occur and how many
  are recorded. Inj 1996; 27: 159-161.
                                                                                                                                        27
  Locations Where TBI Screening Occurs

• In-theater

• Landstuhl Regional Medical
  Center (LRMC)

• CONUS, during Post
  Deployment Health
  Assessment (PDHA) and
  Post Deployment Health Re-
  Assessment (PDHRA)

• VA Medical Centers

Numerous screening safety nets to ensure capture of Service members requiring intervention


                Diagnosis is confirmed through clinical interview

                                                                                         28
Post-Deployment Health Assessment/
Reassessment
9.a. During this deployment, did you experience         9.b. Did any of the following happen to you, or
     any of the following events? (Mark all that               were you told happened to you,
     apply)                                                    IMMEDIATELY after any of the event(s) you
(1) Blast or explosion (IED, RPG, land mine, grenade,          just noted in question 9.a.? (Mark all that
     etc.)                                                     apply)
(2) Vehicular accident/crash (any vehicle, including    (1)    Lost consciousness or got “knocked out”
     aircraft)
(3) Fragment wound or bullet wound above your           (2)    Felt dazed, confused, or “saw stars”
     shoulders                                          (3)    Didn’t remember the event
(4) Fall                                                (4)    Had a concussion
(5) Other event (for example, a sports injury to your   (5)    Had a head injury
     head). Describe:

9.c. Did any of the following problems begin or get     9.d. In the past week, have you had any of the
       worse after the event(s) you noted in                   symptoms you indicated in 9.c.? (Mark all
       question 9.a.? (Mark all that apply)                    that apply)
(1)    Memory problems or lapses                        (1)    Memory problems or lapses
(2)    Balance problems or dizziness                    (2)    Balance problems or dizziness
(3)    Ringing in the ears                              (3)    Ringing in the ears
(4)    Sensitivity to bright light                      (4)    Sensitivity to bright light
(5)    Irritability                                     (5)    Irritability
(6)    Headaches                                        (6)    Headaches
(7)    Sleep problems                                   (7)    Sleep problems


 Positive screen = concurrence to all four questions
       Positive screen ≠ concussion diagnosis
 Need clinician confirmation to diagnose concussion
                                                                                                             29
  Warrior mTBI Management




Goal: A cultural change that focuses on leadership, service member and medical
   personnel mutual responsibilities after concussive events


Vision: Every Warrior treated appropriately to minimize concussive injury and
   maximize recovery


Mission: Produce an educated force trained and prepared to provide early
   recognition, treatment & tracking of concussive injuries in order to protect
   Warrior health.    Educate - Train - Treat - Track
                                                                           As of: 27 October 2009

                                                                                           30
                                                                Slide 30 of 25
Early Detection
In-theater Clinical Practice Guidelines
    SCENARIOS REQUIRING MANDATORY MEDICAL
                   SCREENING

• Mounted: All personnel in any damaged vehicle (e.g.
  blast, accident, rollover, etc)
• Dismounted: All within 50m of a blast; All within a
  structure hit by an explosive device
• Anyone who sustains a direct blow to the head or loss
  of consciousness
• Command Directed
   – NOT limited to repeated exposures


Currently Being Codified in Directive Type Memorandum (DTM)

                                                          31
Early Detection
In-theater Clinical Practice Guidelines
  MEDICAL SCREENING REQUIREMENTS

• ALL RECEIVE
  –   Medic/corpsman evaluation (MACE)
  –   Minimum 24 hrs downtime
  –   Medical re-evaluation pre-RTD
  –   Event capture/tracking
• mTBI/concussive event
  – Medical evaluation above with physician, PA or NP oversight
• Witnessed loss of consciousness
  – Neurological evaluation by physician, PA or nurse practitioner
  – Loss of consciousness greater than 5 minutes requires evacuation
    to Level III facility


                                                                       32
MACE: Military Acute Concussion Evaluation

                    •   Developed by DVBIC and
                        released in Aug 2006
                    •   Performed by medical
                        personnel
                    •   3-Part Screening Tool –
                        “CNS”
                         –   Cognition
                         –   Neurological Exam
                         –   Symptoms
                    •   Alternate versions available
                    •   Upcoming revision will
                        include recurrent concussion
                        questions
                    •   Can be used during exertional
                        testing to ensure that
                        cognitive function remains
                        intact


                                                        33
        Treatment
              MILD TBI                             MODERATE / SEVERE /
• Primary Care                                        PENETRATING
• Referral to TBI specialist after              • In-theater Acute Field
  initial management failure                      Management
• Core TBI interventions (if                    • First Responder actions
  required) may include:                          (Combat Lifesaver)
   –   Cognitive rehabilitation
   –   Vestibular/balance therapy               • Neurosurgical theater presence
   –   Medication management
   –   Vision therapy
                                                • Continuing evolution of air
   –   Driving rehabilitation                     transport capabilities
   –   Assistive technology
                                                • DoD TBI centers, VA
   –   Tinnitus management
   –   Headache Management                        Polytrauma Rehabilitation
   –   Complementary and alternative medicine     Centers, Civilian Rehabilitation
       interventions
                                                  Programs



                                                                                34
          Treatment: Headache


             Episodic Headache                                                                     Chronic Daily Headache
             •Characterize type                                                                    •> 15 HA days per month
             •Abortive therapy                                                                     •Analgesic rebound
                   •Maximum 6 doses/week                                                           •Prophylaxis is key

                                                            Avoid Narcotics
                                                           & Benzodiazipines
                                                                                                                Prophylaxis
                     Abortive                                                                               Onset of action ~ 4 wks




NSAIDs                                   Combination              Alternatives             Anti-depressants Anti-epileptics Beta-blockers
                   Triptans                                      Promethazine              •May improve mood                           •Non-selective may
•GI side effects   •Contraindicated in   Medications             Metoclopramide            •Improves sleep
                                         •Cognitive side effects Prochloroperazine                                                      have benefit on
                    patients with CAD                                                                              •Neuropathic pain    autonomic effects of
                                         •Risk of W/D            Tizanidine                Nortriptylline
Ibuprofen                                                                                                           gabapentin          PTSD
                                                                 Non-medication            Amitryptilline
Naproxen Sodium                          Fioricet                Trigger point injection   Paroxetine              •Mood lability
Acetaminophen                            Fiorinal                                                                   valproic acid      Propranolol
                                                                 Occipital nerve block     Fluoxetine
Aspirin                                  Midrin                  Physical therapy                                   topirimate
                                                                                                                                                     35
      Treatment: Cognitive Deficits



                                               Concussion Management Grid         Table 1
   DVBIC/DCoE MAR08
Cognition   Memory loss or       Administer: MACE if injury within          Normalize sleep & nutrition
            lapse                24 hours,                                  Pain control
            Forgetfulness        Other neurocognitive testing as            Refer: Speech/language
            Poor concentration   available (eg ANAM or other                pathology
            Decreased            neuropsychological testing)                Occupational therapy
            attention            Gather: Collateral information from        Neuropsychology
            Slowed thinking      family, command and others
            Executive
            dysfunction




                                                                                                     36
Treatment: Cognitive Rehabilitation in mTBI

 • Accelerating but still small body of scientific
   literature supporting cognitive rehabilitation in
   mTBI
 • DoD Programs (inventory of current programs)
 • Outsourced care vs MTF provided
 • DCoE/DVBIC Consensus Conference – April 2009
    –   2-day; 50 members
    –   DoD (Quad Service)/DVA representation
    –   SOCOM/Reserve Affairs representation
    –   Civilian Subject Matter Experts




                                                       37
Treatment: Cognitive Rehabilitation (cont’d)

 • Cognitive domains affected after TBI
    – Attention
       • Foundation for other cognitive functions/goal-directed behavior
       • Efficacy of attention training established
    – Memory
       • True memory impairment vs poor memory performance from
          inattention
       • Evidence to support development of memory strategies and
          training in use of assistive devices (‘memory prosthetics’)
    – Social/Emotional
       • Evidence to support group sessions in conjunction with
          individual goal setting
    – Executive Function
       • Evidence to support training use of multiple step strategies,
          strategic thinking and/or multitasking

 • Compensatory vs restorative therapy

                                                                           38
TBI and Co-occurring Conditions


•   PTSD
•   Pain
•   Substance Use Disorders
•   Dual Sensory Impairments
•   Depression
•   Anxiety
•   Suicide


                                  39
                                       39
  Prevalence of PTSD, mTBI and Pain
                                                                 PTSD
       Chronic                                                   N=232
       Pain                            16.5%                     68.2%
                                                     2.9%
       N=277            10.3%
       81.5%
                                     42.1%
                            12.6%                 6.8%



                                         5.3%



                                    TBI
                                    N=227
                                    66.8%
340 OEF/OIF Veterans evaluated at VA Boston Polytrauma site, Lew et al, In press

                                                                                   40
Toolkit Development




                      41
Toolkit Development
 •   Layout
     – Importance of assessment
         • Understanding the potential diagnoses behind the symptoms
     – First appointment tips
         • Requested by primary care
     – Primary symptoms
         • Sleep
         • Mood
         • Attention
         • Chronic Pain
     – Medication Appendix
         • Cross-walk table
         • Reference list of medications
     – Patient Resources
     – Provider Resources
         • Websites
         • Outcome measures and recommended assessment/re-assessment tools

                                                                             42
Functional Imaging
                                                            Concussion       Severe TBI

• Assessment of
  Neuronal/Metabolic Function


• Informing DoD policy --
  Undiagnosed concussion can
  result in:
   –   Symptoms affecting operational readiness                     Normal    High Activity
   –   Risk of recurrent concussion during the
       healing period




                                                                                  Low Activity
                Bergsneider et al., J Neurotrauma 17:2000
                                                                                                 43
       Imaging: mTBI and Depression
       An fMRI Study of Male Athletes


    • Athletes with symptoms of depression with onset after
      concussion showed reduced activation in the dorsolateral
      prefrontal cortex and striatum, and attenuated deactivation
      in medial frontal and temporal regions.
    • The severity of symptoms of depression correlated with
      neural responses in brain areas that are implicated in major
      depression.
    • Voxel-based morphometry confirmed gray matter loss in
      these areas.
    • Conclusion: Depressed mood following a concussion may
      reflect an underlying pathophysiology consistent with a
      limbic-frontal model of depression.




Neural substrates of symptoms of depression following concussion in male athletes with persisting postconcussion
symptoms. Chen JK, et al. Arch Gen Psychiatry. 2008 Jan;65(1):81-9.
                                                                                                                   44
   TBI Research: Novel/Innovative Areas of
   Inquiry

• Illustrative Examples:
  – Omega-3 fatty acids
  – Progesterone
  – Transcranial laser therapy
  – Transcranial magnetic stimulation
  – Neurofeedback (EEG
    biofeedback/neurotherapy)
  – Hyperbaric oxygen




                                             45
Treatment: Return to Duty Determination
                   • Objective: better inform return to
                     duty determinations in the field
                     following TBI beyond exertional
                     testing and MACE

                   • NCAT
                      – Over 500K baselines
                      – Army ANAM Ops


                   • Vestibular Balance Plate Testing
                      – Under development


                   • Nystagmus Detection
                      – Under development


                                                      46
Neurocognitive Assessment Tool (NCAT)/Automated
Neuropsychological Assessment Metrics (ANAM)

  • Computerized neurocognitive assessment tool
  • Purpose:
     – Establish an accurate assessment of pre-injury cognitive performance for
       comparison in post-injury return to duty (RTD) decisions
         • One piece of clinical picture
         • Selective use for those with more clinically challenging cases
  • Takes 20 minutes to complete
  • Current policy (May 08):
     – All pre-deployers receive baseline cognitive testing with ANAM within one year of
       deployment
  • Other tools being studied head-to-head
  • Better assessment if injured SM is compared to their baseline
    scores as opposed to a normative databank



                                                                                           47
                                                                                                47
Patient, Family and Caregiver Education




  Office of the Surgeon
 General/Army Medical
       Department
Health Policy & Services
 Proponency Office for
    Rehabilitation &
      Reintegration
     Curriculum for
 Traumatic Brain Injury



                                          48
Family Caregiver Curricula
 • 4 Modules:
    –   Module 1: Introduction to TBI
        (learning about the brain, acute care
        issues, complications)
    –   Module 2: Understanding Effects of
        T BI and What You Can do to Help
        (physical , cognitive,
        communication, behavioral,
        emotional)
    –   Module 3: Becoming a Family
        Caregiver for a Service
        Member/Veteran with TBI (starting
        the journey, caring for SM and
        yourself, finding meaning in
        caregiving)
    –   Module 4: Navigating the system
        (recovery care, eligibility for
        compensation and benefits)

 • Due to be released by
   Summer 2010
                                                49
                                                     49
Provider Resources


• DCoE : www.dcoe.health.mil
  – Outreach Center: 866.966.1020
  – Monthly video teleconferences

• DVBIC: www.dvbic.org
  – Annual TBI Military Training Conference
  – Education coordinators
  – TBI.consult: tbi.consult@us.army.mil

• VA/DoD mTBI/Concussion CPG Fact Sheet
• ICD-9 DoD TBI Coding Fact Sheet
• Service TBI POC



                                              50
Public Service Announcements


• NFL: Take Head Injuries out of Play
 http://www.nfl.com/videos/nfl-network-around-
 theleague/09000d5d814d2543/Concussion-safety


• DoD: Protect your most valuable
  weapon – your head!
 http://www.facebook.com/video/video.php?v=104
 824466213664


                                                 51
Regional Care Coordination Program
launched Nov 2007

  • Provide 100% follow-up to identified Service Members with
    Traumatic Brain Injury (mild, moderate, severe and penetrating)
    from 13 regional catchment areas across the US
  • Monitor the care continuum for traumatic brain injury to include
    potential rehabilitation needs, education, advocacy and support
    to Service Members with TBI and their families from injury to
    return to duty and/or re-entry into the community
  • Identify and connect Service Members to available TBI
    resources within DoD, VA and civilian communities
  • Provide education and support-serving as a TBI subject matter
    expert to all involved in the care and support of the Service
    Member and family.
  • Identify barriers and/or gaps in service delivery for TBI Service
    Members as they transition between systems and settings
  • Functional outcomes picture to look at quality of life issues
    related to home, work and social environments

                                                                        52
Rehabilitation, Recovery, Reintegration
DoD TBI Programs




                                              53
                                          Draft
DVBIC Virtual TBI Clinic
•   TBI screening, assessment,
    consultation & care to:
     –   Patients at remote military medical centers
     –   Troop intensive sites where demand fluctuates
         with mass mobilizations
•   Direct specialty care via VTC
•   Local PCPs provide on-site
    testing and therapy
•   Multiple specialties
     –   Neurology, neuropsychology, pain
         management, rehabilitation
•   Contact DVBIC if interested in
    establishing dedicated
    connection to Tele-TBI Clinic
     –   800.870.9244




                                                         54
Research & Development
                         Blast Physics/
                                             Neuroprotection
Treatment & Clinical    Blast Dosimetry
                                                & Repair
    Improvement                                Strategies:
  (e.g. Hyperbaric                             Brain Injury
 Oxygen Therapy,                               Prevention
 Cognitive Rehab)


 Rehabilitation &                                     Field
  Reintegration:                                 Epidemiological
   Long Term                                     Studies (mTBI)
  Effects of TBI


                                               Concussion:
  Complementary                                 Rapid field
    Alternative                                Assessment
     Medicine           Force Protection    (e.g., Biomarkers/
                       Testing & Fielding      Eye Tracking
                                                                   55
  Research & Development
  CDMRP Funded Studies
                                                                   TBI Drugs
  Funded TBI Investigators




  PI Funded                                                    TBI Other Interventions
  in Hawaii



Awards range from $150K over 18 months to $4M over 4 years
201 Proposals selected from a pool of 2110 applicants
                           TBI Research Gaps
                           Treatment and Clinical Management
                           Neuroprotection and Repair
                           Rehabilitation/Reintegration
                           Field Epidemiology
                           Physics of Blast



                                                                                         56
Way Forward


• Fast tracking of medical research projects to translate
  findings to Service members in the field
• TBI & Co-occurring disorders
    –   PTSD
    –   Dual Sensory Impairments: Visual and Auditory
    –   CPG’s addressing these
• Directive-type memorandum (DTM)
    –   Early detection and Early treatment
• In theater based care
    –   Role II centers
• Ongoing efforts to promote the linkage of blast tracking
  with medical data/science
• Training and Education efforts




                                                             57
Questions?




             58

				
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