Traumatic Brain Injury:
From combat to reintegration
 Wisconsin Women Veterans Conference
          September 20, 2009

  ...
Overview
• Traumatic Brain Injury in returning veterans and active duty
  soldiers

• Traumatic brain injury (TBI) is the ...
Incidence of TBI
• Due to improvements in body armor and field
  trauma care, more individuals are surviving
  beyond the ...
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 thos...
Sources of TBI During Combat
• Blast Injuries—Limited or no physical signs
  – Improvised Explosive Devices (IED), Rocket
...
Mechanism of blast injury
• PRIMARY:
  – effects of overpressure shock wave, affecting air-filled
    organs (ear, lung, G...
POLYTRAUMA and TBI Injuries
• Multi-Dimensional Injuries, unique in this
  population

• TBI frequently occurs in polytrau...
TBI Severity
•   A mild TBI (which is usually not associated with visible
    abnormalities on brain imaging) is one that ...
TBI Severity
•   A mild TBI (which is usually not associated with visible
    abnormalities on brain imaging) is one that ...
Mild TBI defined by the Head Injury Interdisciplinary Special
         Interest Group of the American Congress of
        ...
mTBI Evaluation
• DIAGNOSIS: mild TBI = Concussion
  – Incidence of a change in mental status
     • Loss of consciousness...
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%
         (I...
Even though the research suggests that the
symptoms of post concussive symptoms
should be transient in most cases…

      ...
Common mTBI Complaints
• Problems with:
    • Money management
    • Employment
    • School
    • Recreational activities...
Physical Problems
•   Pain
•   Motor weakness
•   Sensory deficits
•   Upper Motor Neuron/CNS findings
•   Balance/Gait ab...
Cognitive Deficits
• Deficits in:
     • Attention/concentration
     • Processing speed
     • Memory
     • Problem-solv...
Emotional/Behavioral Issues
•   Depressed mood
•   Anxiety
•   PTSD
•   Suicidal ideation
•   Irritability/anger control
•...
Why is there a discrepancy…. In what we expect and
what is reported?

The majority of the TBI research came from sport-
re...
TBI in Sports                   TBI in Combat
Head & Brain injury             Brain injury without
                       ...
Are these two types of injuries comparable?


     Most likely they are not…

     Due to the environment in which the TBI...
What causes the prolonged symptoms reported
              by many soldiers
 – Current symptoms may be due to multiple
   s...
Sources of Sustained Residuals
 •   Severity, multiple incidence, and mechanism of TBI
 •   PTSD
 •   Prior history of psy...
PTSD
                                                         Re-experiencing

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



Early Identification & In...
Early Identification
• DOD
  –   Field Evaluations
  –   Camp TMCs
  –   Landstuhl, Germany
  –   Walter Reed, AMC
• DOD a...
Early Intervention
• Value of Early Intervention
   – Improves short and long term outcomes
   – Education/positive reassu...
Education of Expected Recovery
• Post Traumatic Growth:
  – “… emphasizing the potential for FULL RECOVERY
    minimize th...
Proactive Reintegration Efforts
• Community Reintegration:
     •   Vocational Rehab
     •   Work Hardening program
     ...
TBI Recovery Resources
• Female focused treatment in women’s clinic

• OEF/OIF Outreach Groups

• Family Support Group
   ...
Restoration of Premilitary Adjustment
     Pre-military life        Post-military life trajectory
     trajectory         ...
Website resources
• www.biausa.org (Brain Injury Assoc. of America)
• www.neuro.pmr.vcu.edu (National resource Center
  fo...
Questions
I am honored to serve those
  who have served and their
          families.
        Thank you!
          Jennife...
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Military TBI Post ; Special Focus on Military Women

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Military TBI Post ; Special Focus on Military Women

  1. 1. 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
  2. 2. 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.”
  3. 3. 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.
  4. 4. How close does a soldier have to be to a blast to cause an injury?
  5. 5. The answer is that we don’t know……
  6. 6. • Traumatic Brain Injury ….the hallmark injury faced by veterans of Iraq and Afghanistan. • Even those who were not obviously wounded in explosions or accidents may have sustained a brain injury.
  7. 7. 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.
  8. 8. 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
  9. 9. 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.
  10. 10. 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-traumatic amnesia 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.
  11. 11. 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-traumatic amnesia 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.
  12. 12. 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
  13. 13. 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
  14. 14. Mild TBI may or may not be associated with post-concussive symptoms.
  15. 15. 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
  16. 16. Even though the research suggests that the symptoms of post concussive symptoms should be transient in most cases… …what do the soldiers report?
  17. 17. Common mTBI Complaints • Problems with: • Money management • Employment • School • Recreational activities • Family/ Significant Other • Social interaction
  18. 18. 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
  19. 19. Cognitive Deficits • Deficits in: • Attention/concentration • Processing speed • Memory • Problem-solving • Executive organization • Safety judgment
  20. 20. Emotional/Behavioral Issues • Depressed mood • Anxiety • PTSD • Suicidal ideation • Irritability/anger control • Disinhibition • Sleep disturbance
  21. 21. 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?
  22. 22. 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
  23. 23. 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?
  24. 24. 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
  25. 25. 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
  26. 26. PTSD Re-experiencing Avoidance Arousal Social withdrawal Sensitive to noise Memory gaps Concentration Apathy Insomnia Mild Difficulty with decisions Irritability Mental slowness TBI Concentration Residual Headaches Dizzy Appetite changes Fatigue Sadness Depression David X. Cifu, M.D. The Herman J. Flax, M.D. Professor and Chairman Department of Physical Medicine and Rehabilitation Virginia Commonwealth University
  27. 27. So what can be done to ameliorate symptoms and encourage successful reintegration in soldiers Early Identification & Intervention Education of Expected Recovery Proactive Reintegration Efforts
  28. 28. 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
  29. 29. 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
  30. 30. 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
  31. 31. 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
  32. 32. 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
  33. 33. Restoration of Premilitary Adjustment Pre-military life Post-military life trajectory trajectory Barriers are overcome Barriers to Healthy Adjustment TBI Military PTSD Depression Substance Abuse
  34. 34. 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
  35. 35. Questions I am honored to serve those who have served and their families. Thank you! Jennifer Jennifer.Imig@PsychologySpecialists.com Jennifer.Imig@comcast.net

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