Frederick G. Flynn, DO, FAAN
Medical Director, TBI Program
Chief, Neurobehavior
Madigan Army Medical Center
The views expressed in this article
are those of the author and do
not reflect the official policy or
position of the United States
Army, Department of Defense or
the United States Government
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Primary
Direct result of blast wave and change in
atmospheric pressure
─ Injury severity and deflected waves
─ Injury due to electromagnetic pulse
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Secondary
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Tertiary
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Objects projected by the blast
Individual is put in motion and strikes head
Quarternary
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Toxic gas, embolus, hypoxia, ischemia,
hemorrhage
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Altered or LOC < 30 min
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PTA < 24 hrs.
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GCS = 13-15
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Normal CT &/or MRI
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Neurological findings may be present but are
transient
Somatic
Cognitive
Neurobehavioral
Headache
Sleep Disturbance
Fatigue
Dizziness
Nausea/Vomiting
Tinnitus
Visual Disturbance
Disequilibrium
Photo/Phonophobia
Heightened alcohol
Sensitivity
Altered Sense Smell/
Taste
Transient Focal
Neurological Symptoms
Attention/Concentration
Problems
Memory Problems:
- Forgetfulness
- Forgetting to remember
-Working memory problems
Executive Dysfunction:
-Multitasking
-Planning/Organizing
-Problem Solving
-Slowed mental processing
-Slowed reaction time
Depression
Anxiety
Irritability
Impulsivity
Aggressiveness
Apathy
Disinhibition
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Identifying the injured – new DOD directive
Assessing early – use of MACE
Identification of red flags and appropriate
consultations
Appropriate duty restrictions
Early education and discussion of recovery
Symptom management
Rest, hydration, sleep
Reassessment and exertional testing
Gradual return to full duty
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Individualized – risk-benefit analysis
Headache most common sx
Medication for cognitive sxs not recommended
Medication for one sx may ameliorate other sxs
Medication given for somatic or neuropsychiatric
sxs may cause sedation which may impact
cognitive and motor performance
Consider other factors when post-concussive sxs
persist beyond months-years
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Risking another brain injury (skiing, contact
sports, motorcycles, etc.)
Alcohol and illicit drugs
Caffeine or “energy enhancers”
Cough, cold, allergy meds containing
pseudoephedrine
Over the counter sleeping aids
Returning too soon to a high risk zone in a
combat theater
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Symptoms most severe immediately
following the injury
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Recovery begins within hours after the mTBI
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Pattern of symptom recovery gradually
continues over days to weeks
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If delayed onset of symptoms
 Consider other co-morbidities
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Return to apparent asymptomatic baseline
 May still be neurologically vulnerable
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Return to combat too soon
 May result in susceptibility to repeat concussion
 May put the Soldier and fellow Soldiers at risk
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More protracted course:
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History of multiple concussions
Co-morbid acute and/or chronic PTS
Chronic pain
Other medical, psychological, and psychosocial
stressors
Multiple concussions may lead to permanent
cognitive compromise
 Higher risk for early onset Alzheimer Disease
 Chronic Traumatic Encephalopathy (CTE)
Key Points When Symptoms Persist
Beyond a Week after Injury
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Promote recovery – avoid harm
Patient centered approach to care
Diagnosis based on nature of event and
sequelae immediately after the event
Majority improve with rest & time
 Do not require specific medical treatment
Key Points When Symptoms Persist
Beyond a Week after Injury
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Short and long term neurological deficits may
be caused by blast exposure without a direct
blow to the head
Post-concussive sxs may be found in patients
or healthy individuals who have never
sustained a TBI
Consider:
Chronic pain
Acute/chronic stress
Undiagnosed medical condition PTSD
Mood disorders
Anxiety
Substance abuse
Medication misuse
Job change/unemployment
Financial problems
Marital discord/family stressors
Spiritual loss
Impending combat deployment Secondary gain
Somatoform disorder
Personality disorder
Unmasking a pre-morbid psychiatric condition
A - Stressor – both required:
• event – actual or threatened death/serious injury
• response of intense fear, helplessness, or horror
B - Intrusive recollections – 1/5 required
C - Avoidant / Numbing – 3/7 required
D - Hyper-arousal – 2/5 required
E - Duration > 1 month in B,C,D
F - Functional significance
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• significant distress
• impairment in social occupational functions
Chronic: > 3 mos
Delayed onset: 6 mos after event
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Prevalence among deployed – 14%
(Golding et al 2009)
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Post-deployment screening – 5-12% increase in
rate after 6 mos – Delayed onset
(Milliken et al 2007)
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Mental health problems & deployments
1st – 12% 2nd – 19% 3rd – 27%
(MHAT 2008)
 19% post-deployment SMs – PTSD/depression
(Tanielian et al 2008)
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Any physical injury associated with traumatic
event (Grieger et al 2006; Hoge et al 2004)
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Depression / PTSD delayed onset (Grieger et al 2006)
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Pre-exposure lower cognitive ability (Kremen et al
2007)
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Memory of traumatic event (Caspi et al 2005)
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Poor coping skills (Halbauer et al 2009)
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mTBI at time of traumatic event
 27% with alteration in consciousness PTSD
 44% with LOC PTSD
(Hoge et al 2008)
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Acute stress reaction (Kennedy et al 2007)
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Combat related trauma > non-combat
(Kennedy et al 2007)
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Greater risk for persistent post-concussive sxs
(Brenner et al 2009)
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PTSD most potent contributor to
development of persistent PCS
(Vanderploeg et al 2009)
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VHA – 42% with HX of mTBI
PTSD
(Lew et al 2007)
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mTBI and acute stress reaction – six fold
increase risk for PTSD (Kennedy 2007)
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Increase risk for:
 Depression
 Substance abuse
 Suicide
(Stein & McAllister 2009)
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Poor general health, unmet medical and
psychological needs, psychosocial difficulties,
perceived barriers to mental health (Pietrzak 2009)
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mTBI increases risk of PTSD
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mTBI in someone with PTSD – greater
disability (Brenner et al 2009)
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Neurobiological overlap
- Neurochemical/morphological changes
- Prefrontal neural circuits, amygdala, hippocampus,
cigulate gyrus (Bryant 2008)
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PDHA and other screening tools
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Self-report of event occurring months before
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Symptoms are non-specific to TBI
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Attribution/misattribution of sxs
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Referral to TBI Program
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Program Director/Behavioral-Neurologist
TBI Program Administrative Officer
Primary Care Providers (4)
Neurologists (2)
Neuropsychologists (2) Neuropsychometrist (1)
Clinical Psychologists (2)
Clinic LPN
OT/PT/Speech Pathologists (1 each)
TBI Case Managers ( 2 RNs)
Education Specialist Director and RN Educators (2)
Ombudsman
Admin Medical Assistants (4)
Tele-TBI Team (PM, Technical Specialist, RN)
Post-Deployment Screening and Evaluation
SRP
PDHA
2+10 Screen
Headache
Sleep
PTSD
Questionnaire
VS by LPN
Referral from other clinics,
in MAMC, AF, Navy CG, NG
TBI Program
50 min Evaluation
Hx, Neuro, Cog - By Physician /
Neuropsychologist
Symptomatic
Objective
Findings
No/mild Sxs
Educational materials
Return to Unit - Reassess in 3 mos
Specialty
Sub-Specialty
Assessment
Treatment Strategies
Pharmacological
Non-Pharmacological
- sleep
- memory
classes/groups
- headache
Individual/Group therapy
Couples Counseling
Education/Military Counseling
Case Management – Coordinated Care
Family/Unit Leadership education
Neurologist/Behavioral Neurologist
Neuropsychologist
Psychologist
IOP*
PT/OT
Sleep Medicine
Speech Pathology
Case Management
Education Specialist
Ombudsman (Ret CSM)
Other Specialty Consultants, PRN
Team Meetings
Case Conferences
Coordinated Treatment Strategies
Liaison with other Madigan programs
(eg. WTU), VA, Civilian rehab
Team Meetings
Case Conferences
Coordinated Treatment Strategies
Liaison with other Madigan programs
(eg. WTU), VA, Civilian rehab
Return to Unit
Restrictions / No Restrictions
WTU
MEB?
F/U in TBI Program
Cognitive / Behavorial Rehab
Other Activities of the TBI Program
Tele-TBI
Education +
Consultation
with WRMC
(21 states)
Educational
Conferences
Local
State
National
Education of
Military
Leaders
about TBI
VIP Briefings
Research
On-site
support of
other MTFs
Representation
on Committees/
Panels of SMEs,
DoD, DCoE,
DVBIC, OTSG
Ruff, R. J Head Trauma Rehab. 2005: 20:1
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All TBIs are not alike – there may be striking
differences in the nature of the injury and the
degree of impairment
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Impairment does not equal disability
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Concussion due to blast may have a different
pathophysiology and recovery course than
that due to sports concussion
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The athlete has a strong incentive to recover
and get back in the game
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A blast encountered in combat is associated
with the reality and acute stress that
someone wants to kill you
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The Soldier may experience acute stress by
witnessing the death and maiming of fellow
Soldiers or innocent victims
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A self-report of a history of mTBI is not
confirmation that one actually occurred
The failure to report an event or seek medical
help does not mean that a mTBI did not occur
When symptom onset is delayed by days to
weeks after a mTBI the symptoms are most
likely due to other causes than the mTBI
Unlike TBI, the symptoms associated with
PTS are often delayed in onset
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When patients present with typical postconcussive sxs, months after a documented
mTBI , it does not mean that the sxs are due
to the mTBI
The combination of mTBI and PTSD is not a
benign condition. Protracted disability may
be a consequence
Psychosocial stressors are often more severe
after return from deployment
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Even after return to functional baseline and
normal neuropsychological function, a
physical or emotional stressor may cause reemergence of symptoms
Patients require a holistic approach to care –
they are not defined by their TBI or PTSD
It is imperative to involve spouses, significant
others, and in some cases their children, in
the educational process and care of the
patient
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Patients require the time to tell their story
and receive the comprehensive evaluation
that they deserve – they can’t get this in a
busy troop clinic
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Sometimes providers who are trying to help,
do more harm by the treatment they
prescribe
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Resources for treating TBI patients with
severe social-behavioral problems are
inadequate.
Support for developing skilled rehab facilities
for this treatment is necessary
Financial support is necessary for family care
givers who cannot work outside of the home
in order to provide full time care for their
loved one with TBI
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A multispecialty TBI program provides time
for the Soldier, detailed evaluation, on the
spot consultation with a variety of specialists,
coordination of care, case management,
education, continuity of care, selection of
patients who would best benefit from referral
for rehab, and communication with other
providers, unit leadership, and administration