TBI In the Military
Cynthia L. Boyer, Ph.D.
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Bancroft’s mission is to ensure that every person is given opportunities
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We do this by altering perceptions, and by supporting those with
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people with intellectual and developmental disabilities and brain injuries.
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TBI is a “signature injury” of the conflicts
in Iraq and Afghanistan
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DoD TBI Definition (Oct 07)
Traumatically induced structural injury or
physiological disruption of brain function as
a result of external force to the head
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DoD TBI Definition (Oct 07)
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
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Blast Injury
Predominant cause of
TBI in OIF/OEF
A significant number of
soldiers returning from the
conflicts in Iraq and
Afghanistan have this injury
and will suffer long-term
consequences
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Blast Injuries
Primary-Explosion
• Blast wave strikes and compresses body
• Most serious damage sustained by air and
fluid filled organs
• Causes brain injury without visible damage
to the head/skull
• Causes significant damage to eyes, ears,
lungs
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Blast Injuries
Secondary
• Environmental material energized by
explosion strikes the body/brain
Tertiary
• Energy from explosion propels the body
into stationery objects
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Multiple Neurological Injuries
•
•
•
•
•
•
•
•
Skin breakdown
Penetrating Injury
Blast/concussive injury
Skull base injury
Facial fractures
Vasospasm*
Pseudoaneuryms*
Sagital sinus injuries
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Blast Injuries Are Different
• Treated quickly and aggressively
• Occur under extreme stress
• Long term course is unknown
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DoD Initiatives
•
•
•
•
•
•
•
•
Prevention
Surveillance
Screening
Diagnosis
Case Management
Treatment
Rehabilitation
Reintegration
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Baseline Testing Pre-Deployment
Neurocognitive Assessment Tool
(ANAM)/Automated Neuropsychological
Assessment Matrics (May 09)
• Computerized
• 20 min
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Screening
• Military Acute Concussion Exam (MACE)
(Aug 06)
• TBI screening for all medically evacuated
at Landstahl Regional Medical Center
(May 06)
• PostDeployment HealthScreening (Jan 08)
• VA TBI Screening
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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
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MACE: Military Acute
Concussion Evaluation
• Alternate versions available
• Upcoming revision will include
recurrent concussion questions
• Can be used during exertional
testing to ensure that cognitive
function remains intact
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Post-Deployment Health Assessment/
Reassessment (January 08)
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Diagnosis
Potential Objective Indicators
• Pupillary response/visual tracking
• Biomarkers
• Imaging (DTI)
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Mild TBI/Concussion
• More difficult to identify
• Symptoms not unique to TBI
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Possible Effects of TBI Acute
• Poor marksmanship
• Slower reaction time
• Decreased concentration
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Possible Effects of TBI
Chronic
• Reduced work quality
• Behavioral Problems
• Emotional Problems
• “Unexplained” Problems
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Treatment
• Standardized Educational
Information
• New Protocol for 3 or more TBIs
within 12 months
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National Intrepid Center
of Excellence (NICoE)
• Located on Navy campus in
Bethesda, MD
• Dedicated 24 June 2010
• Serves Service Members (and
their families) with complex
TBI
• Primarily evaluative in nature
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National Intrepid Center
of Excellence (NICoE)
• Generally to be used by those
who have refractory or difficultto-diagnose/manage conditions
• Provides case management and
referral capabilities to leading
experts in the field
• Full Operating Capability: Oct
2011
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Toolkit and Pocket Guide
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Treatment
Co-Morbid Conditions
• Sleep Disorders
• Substance Abuse
• Psychiatric Illness
• Vestibular Disorders
• Visual Disorders
• Cognitive Disorders
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Co-Morbidities Associated with mTBI
Chronic
Pain
N=277
81.5%
Sleep disorders
16.5%
2.9%
10.3%
42.1%
12.6%
6.8%
5.3
%
TBI
N=227
66.8%
PTSD
N=232
68.2%
Substance abuse
Psychiatric illness
Vestibular disorders
Visual disorders
Cognitive disorders
Lew, et al: “Prevalence of Chronic Pain, Posttraumatic Stress Disorder, and Persistent Postconcussive Symptoms in OIF/OEF
Veterans: Polytrauma Clinical Triad”, Dept. of Veterans Affairs, Journal of Rehabilitative Research and Development, Vol. 46,
No. 6, 2009, pp. 697-702, Fig. 1
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Treatment Research
• Clinical Trials
• Cognitive Rehabilitation
• Neuroprotective Medications
• Longitudinal Study
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Blast Physics/
Blast Dosimetry
Treatment & Clinical Improvement
Rehabilitation &
Reintegration: Long Term
Effects of TBI
Field Epidemiological Studies
(mTBI)
Complementary Alternative
Medicine
Concussion: Rapid field
Assessment
Force Protection Testing & Fielding
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Neuroprotection & Repair
Strategies: Brain Injury
Prevention
Challenges
• Undetected MTBI
• Force readiness/cultural barriers
• Improved Collaboration
• Effective Treatment
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Resources
• www.brainline.org
• www.braintrauma.org
•
www.maketheconnection.net
• www.dcoe.health.mil
• www.dvbic.org
• TBI Family Caregiver Guide
• www.Afterdeployment.org
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Resources
• DCoE Facebook, Twitter, YouTube,
•
Multiple Mobile Smartphone Applications
• DCoE Blog
• Yellow Ribbon Presentations
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Questions?
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Thank you
for attending!
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