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
Group (IRG)
Commission on Care
for America’s
Returning Wounded
Warriors
DoDIG Review of
DoD/VA Interagency
Care Transition
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
<24 hrs
>24hrs
<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
Number of TBI Cases
30000
25000
20000
15000
10000
5000
0
2000
Data Source: www.DVBIC.org
2002
2004
2006
2008
*2009 data does not include Oct - Dec
9
TBI Tracking: Severity Data
90
Percentage
80
70
Severe/Penetrating
60
50
Moderate
40
Mild
30
20
Not Classified
10
0
2000
2002
Data Source: www.DVBIC.org
2004
2006
2008
*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
800.5
804.0
800.6
804.1
851.9
800.7
804.2
852.0
800.8
804.3
852.1
800.9
804.4
852.2
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
801.5
850.0
801.6
850.1
854.1
801.7
850.2
950.1
801.8
850.3
950.2
801.9
850.4
950.3
850.5
959.01
Other and unspecified injury to head face and neck
803.1
850.9
995.55
Shaken baby syndrome
803.2
851.0
V15.5+Ext
GWOT TBI codes
803.3
851.1
801.0
803.0
Fracture of the base of the skull
Other closed skull fracture w/o
mention of intracranial injury
Closed fractures involving the skull or face with other
bones w/o mention of intracranial injury
851.8
Subarachnoid hemorrhage following injury w/o mention
of open intracranial wound
853.1
Concussion w/ no loss of consciousness
Cortex (cerebral) contusion w/o mention of open
intracranial wound
854.0
Injury to optic chiasm
11
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:
http://www.sciencedaily.com/releases/20
07/09/070905224343.htm
Image courtesy of Sports Legacy Institute
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
problems
• Irritability
• Poor Concentration
• Mood lability
• Memory Problems
• Nausea/Vomiting
• Fatigue
• Visual disturbances
• Verbal dysfluency
• Word-finding
• Abstract reasoning
• Sensitivity to
light/noise
• Ringing in the ears
21
Possible Effects of mTBI
• Acute
– Poor marksmanship
– Slower reaction time
– Decreased concentration
• Chronic
–
–
–
–
Reduced work quality
Behavioral problems
Emotional problems
“Unexplained“ symptoms
TBI-related impairments increase vulnerability to subsequent
injury until full recovery occurs
22
DoD Wide Initiatives
•
•
•
•
TBI Screening
(PDHA/PDHRA)
TBI Surveillance
NCAT (Neuro Cognitive
Assessment Tool) pre
deployment program
Clinical guidance packages
–
–
–
–
Cog rehab
Driving assessments after TBI
mTBI/PTSD
mTBI and co occurring conditions
• 4th Annual TBI military
training conference ( 30-31
Aug 10)
• TBI Family Caregiver
Guide
• TBI Care Coordination
• CDMRP bolus of research
funds
23
TBI Management Continuum
GOAL: A cultural change in fighter
management after concussive events:
identification and treatment close to point
of injury, documentation of the incident,
and expectation of recovery with early
treatment.
VISION: Every Warrior trained to:
– Recognize the signs/symptoms
– Reduce the effects
And in the event of an injury –
– Treat early to minimize the impact and
maximize recovery from TBI.
MISSION: Produce an educated force
trained and prepared to provide early
recognition, treatment, tracking &
documentation of TBI in order to protect
Warrior health.
Education &
Prevention
Rehabilitation,
Recovery,
Reintegration
& Research
Early
Detection
Treatment
& Tracking
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 ReAssessment (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
any of the following events? (Mark all that
apply)
(1) Blast or explosion (IED, RPG, land mine, grenade,
etc.)
(2) Vehicular accident/crash (any vehicle, including
aircraft)
(3) Fragment wound or bullet wound above your
shoulders
(4) Fall
(5) Other event (for example, a sports injury to your
head). Describe:
9.b. Did any of the following happen to you, or
were you told happened to you,
IMMEDIATELY after any of the event(s) you
just noted in question 9.a.? (Mark all that
apply)
(1)
Lost consciousness or got “knocked out”
(2)
Felt dazed, confused, or “saw stars”
(3)
Didn’t remember the event
(4)
Had a concussion
(5)
Had a head injury
9.c. Did any of the following problems begin or get
worse after the event(s) you noted in
question 9.a.? (Mark all that apply)
(1)
Memory problems or lapses
(2)
Balance problems or dizziness
(3)
Ringing in the ears
(4)
Sensitivity to bright light
(5)
Irritability
(6)
Headaches
(7)
Sleep problems
9.d. In the past week, have you had any of the
symptoms you indicated in 9.c.? (Mark all
that apply)
(1)
Memory problems or lapses
(2)
Balance problems or dizziness
(3)
Ringing in the ears
(4)
Sensitivity to bright light
(5)
Irritability
(6)
Headaches
(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
Slide 30 of 25
30
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
• Primary Care
• Referral to TBI specialist after
initial management failure
• Core TBI interventions (if
required) may include:
–
–
–
–
–
–
–
–
–
Cognitive rehabilitation
Vestibular/balance therapy
Medication management
Vision therapy
Driving rehabilitation
Assistive technology
Tinnitus management
Headache Management
Complementary and alternative medicine
interventions
MODERATE / SEVERE /
PENETRATING
• In-theater Acute Field
Management
• First Responder actions
(Combat Lifesaver)
• Neurosurgical theater presence
• Continuing evolution of air
transport capabilities
• DoD TBI centers, VA
Polytrauma Rehabilitation
Centers, Civilian Rehabilitation
Programs
34
Treatment: Headache
Chronic Daily Headache
Episodic Headache
•> 15 HA days per month
•Analgesic rebound
•Prophylaxis is key
•Characterize type
•Abortive therapy
•Maximum 6 doses/week
Avoid Narcotics
& Benzodiazipines
Prophylaxis
Abortive
NSAIDs
•GI side effects
Ibuprofen
Naproxen Sodium
Acetaminophen
Aspirin
Triptans
•Contraindicated in
patients with CAD
Onset of action ~ 4 wks
Combination
Medications
Alternatives
Promethazine
Metoclopramide
•Cognitive side effects Prochloroperazine
•Risk of W/D
Tizanidine
Non-medication
Fioricet
Trigger point injection
Fiorinal
Occipital nerve block
Midrin
Physical therapy
Anti-depressants Anti-epileptics Beta-blockers
•May improve mood
•Improves sleep
Nortriptylline
Amitryptilline
Paroxetine
Fluoxetine
•Neuropathic pain
gabapentin
•Mood lability
valproic acid
topirimate
•Non-selective may
have benefit on
autonomic effects of
PTSD
Propranolol
35
Treatment: Cognitive Deficits
DVBIC/DCoE MAR08
Cognition
Memory loss or
lapse
Forgetfulness
Poor concentration
Decreased
attention
Slowed thinking
Executive
dysfunction
Concussion Management Grid
Administer: MACE if injury within
24 hours,
Other neurocognitive testing as
available (eg ANAM or other
neuropsychological testing)
Gather: Collateral information from
family, command and others
Table 1
Normalize sleep & nutrition
Pain control
Refer: Speech/language
pathology
Occupational therapy
Neuropsychology
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
Chronic
Pain
N=277
81.5%
16.5%
10.3%
2.9%
PTSD
N=232
68.2%
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
–
Risk of recurrent concussion during the
healing period
Normal
High Activity
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-aroundtheleague/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
Draft53
DVBIC Virtual TBI Clinic
•
TBI screening, assessment,
consultation & care to:
–
–
•
•
•
Direct specialty care via VTC
Local PCPs provide on-site
testing and therapy
Multiple specialties
–
•
Patients at remote military medical centers
Troop intensive sites where demand fluctuates
with mass mobilizations
Neurology, neuropsychology, pain
management, rehabilitation
Contact DVBIC if interested in
establishing dedicated
connection to Tele-TBI Clinic
–
800.870.9244
54
Research & Development
Treatment & Clinical
Improvement
(e.g. Hyperbaric
Oxygen Therapy,
Cognitive Rehab)
Blast Physics/
Blast Dosimetry
Rehabilitation &
Reintegration:
Long Term
Effects of TBI
Complementary
Alternative
Medicine
Neuroprotection
& Repair
Strategies:
Brain Injury
Prevention
Field
Epidemiological
Studies (mTBI)
Force Protection
Testing & Fielding
Concussion:
Rapid field
Assessment
(e.g., Biomarkers/
Eye Tracking
55
Research & Development
CDMRP Funded Studies
Funded TBI Investigators
TBI Drugs
TBI Other Interventions
PI Funded
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