Chapter 10 Traumatic Brain Injury (TBI) in the Military Facts About Traumatic Brain Injury (TBI) Majority caused by explosive devices (blast explosure). Signature wound of wars in Iraq and Afghanistan. Since 2000, over 195,000 service members screened for suspected TBI. Ranges from mild to severe; estimated 70% to 90% diagnosed as mild in severity. Moderate to severe detected early; mild more complex. Diagnostic Criteria Any period of loss of consciousness (LOC) Posttraumatic stress amnesia (PTA) Glasgow Coma Scale (GCS) rating Impact of Time Majority of symptoms resolve over time. Symptoms do not worsen over time. Following a mild to moderate brain injury, individuals begin to return to preinjury level of functioning over weeks to months. An exception to this rule is when there are other complications in functioning such as psychiatric illness, substance abuse, and/or chronic pain. Neuroimaging Neuroimaging can assist with assessing the severity of TBI and potential outcome. MRI and CT are commonly used. MRI (Magnetic Resonance Imaging) uses magnetic signals to generate images that create a structural map of the brain. CT (Computerized Tomography) generates computerized pictures of the brain that are produced from multiple X-ray images. An MRI of a Severe Traumatic Brain Injury (Top) Compared to an MRI of a Healthy Brain (Bottom) Acute Symptoms Following Moderate to Severe TBI In a combat setting, service members who sustain a mTBI/concussion following a blast exposure often present with a multitude of complex symptoms: severe headache with progressive worsening dizziness, pain, fatigue, sleep difficulties repeated vomiting or nausea convulsions or seizures the inability to wake up from sleep dilation of one or both pupils of the eyes problems speaking limb weakness or numbness loss of coordination, confusion, restlessness, and agitation. In the military, symptoms such as severe headache and vomiting are considered red flags and warrant immediate medical attention. Treatment and Recovery Following Moderate to Severe TBI Four stages: immediate, intermediate, rehabilitation, transitional treatment. The vast amount of cognitive recovery (e.g. attention, memory, and processing speed) occurs primarily during the first two years following the event. Recovering from multiple physical injuries may complicate TBI recovery. The damage to the brain resulting from a moderate to severe TBI may lead to lifelong disabilities, including a loss of physical or mental functioning. Activities of daily living are often more challenging, even in those who appear to have fully recovered. Physical and mental changes can affect the service member’s personal life, family relationships, career goals, and future It is crucial that the social work provider assist in offering early education, intervention, and continued support to both the patient and his or her family members. Mild TBI (mTBI) in the Military Symptoms in three domains: Physical headaches, nausea, vomiting, fatigue, blurred vision, sensitivity to light/noise, dizziness, balance problems, and sleep disturbance Cognitive changes in attention, concentration, short-term memory, speed of processing information, judgment, and executive functioning Behavioral/emotional irritability, agitation, depression, anxiety, impulsivity and aggression Postconcussion syndrome following mTBI Controversial Treatment and Recovery Following mTBI The expectation following mTBI is generally a full resolution of symptoms and recovery If sustained in theatre, frequently medically managed in theater. Period of rest (e.g., 24 hours behind the wire), reevaluated, and then returned to duty as soon as a symptomatic. Interventions vary: Early Psychoeducation on recovery is important. Group based interventions, including compensatory strategy training, have shown a decrease in symptoms of depression and cognitive dysfunction. With early education, and intervention, most mTBI patients recover successfully. Co-Occurring Recovery Considerations Discussion Questions A veteran comes into your office and tells you that during the weekend he was playing baseball and was struck in the head with a bat. He fell to the ground, blacked out for 20 seconds, and can't remember the hour prior to the baseball game. He tells you he is feeling "dizzy." What was the severity level of the concussion? You see a sailor in your clinic on a regular basis. During the last visit he told you that he was having dizziness, irritability, thinking difficulties, headaches, and depression. He has a recent history of concussion or mTBI and combat stress. Which of his symptoms could be related to combat stress? Which of his symptoms could be related to his concussion or mTBI? Which symptoms overlap? Discussion Questions You are completing a clinical interview with a Marine when she tells you she sustained a mild concussion, with 10 minutes of LOC, 1 hour of PTA, and minimal symptoms. While reading through her medical record, you discover that she was assaulted and has positive brain imaging findings. Her report of LOC and PTA is consistent with medical records. What is the severity level of her TBI? What conditions other than a TBI can affect a Glasgow Coma Scale? What are the possible implications of a second concussion before the first concussion has resolved?