military service and TBI Flashcards
service members returning from operation Iraqi freedom
22% TBI and concussion
8% persistent symptoms
56% of these are mTBI
44% mTBI + PTSD
TBI = signature injury in modern warfare
causes of TBI in modern warfare
explosions, gunshot wound, MVA, closed or open
issues for this population
- mechanism of injury
- co occurring issues of deployment
- military culture
peacetime related brain injuries
Motor vehicle accidents
Falls
Sports related
Training accidents
Working in closed spaces (e.g., tanks or submarines)
High risk behaviors after returning from duty
4 levels of blast related injury
1. primary injury
- primary injury - direct injury from over-pressure wave, compresses air filled organs, catapults body backward
body parts - impacting lungs, GI, middle ear
ex: blast lung, tympanic injury, abdominal hemorrhage
4 levels of blast related injury
2. secondary injury
- secondary injury - energized debris or explosive fragments (shrapnel) impacts head/ body
body parts - any part
ex: penetrating ballistics (eyes) or blunt injury
4 levels of blast related injury
3. tertiary injury
- tertiary injury - body impacts wall, ground, or object
body parts - any part
ex: open or closed brain injury or fractures
4 levels of blast related injury
4. quaternary injury
- quaternary injury - inhalation of toxic gasses/ substances - exacerbation of any existing conditions
body parts - any part
ex: burns, COPD, asthma, hypertension
TBI screening - tests used by medics to screen for need for additional care
Military Acute Concussion Evaluation (MACE) developed by DVBIC
Provides gross measures of cognitive domains: orientation, immediate memory, concentration and memory recall
Combined with other information including LOC and PTA
TBI diagnoses made whenever alteration in consciousness exists
military neuropsych testing pre deployment
Prior to deployment each service member completes a 20 minute computerized neuropsychological battery
Effects of concussion can be better determined by comparing pre- and post- injury performance
Compared if suspicion of head injury
Helps to determine return to duty (RTD)
military neuropsych test example
Neurobehavioral Symptom Inventory (NSI): can be used to assess the most common symptoms experienced following TBI
The State-Trait Anxiety Inventory (STAI) & the Automated Neuropsychological Assessment Metrics (ANAM): Mood and Sleep Scales, which provide focused assessment of mood and anxiety disturbance
The ANAM Simple Reaction Time and Continuous Performance subtests, which objectively measure cognitive performance
Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) measuring immediate memory, visuospatial/constructional, attention, language and delayed memory
initial tx considerations for concussion and mTBI
Symptom management: i.e. headaches, vision, cognition, sleep
Education: signs and symptoms, strategies, rest guidelines
Therapy
Implementation of duty restrictions: for mTBI similar to sports concussion guidelines
return to duty considerations for mTBI
Clinical Practice Guidelines provide recommendations for care
Rest and RTD considerations are very important
No one is returned until symptom free at rest and exertion
BUT - Mission responsibilities may take precedence over recuperation and final decision is made by the Commander
PTSD and mTBI
Individuals with TBI may have fear, anxiety, acute stress reaction and PTSD pre-injury or may follow TBI
44% of service members with concussion may meet diagnostic criteria for PTSD and mTBI
With overlap of symptoms, difficult to diagnose
Co-Occurring Disorders with mTBI
chronic pain, PTSD, depression, anxiety, substance misuse
These medical and psychological co-morbidities provide a diagnostic challenge given the overlap of symptoms
Physical, psychological and cognitive problems associated with TBI are also aggravated by other symptoms
Treatment focuses on symptom relief
Medical discharge process
goes through 2 boards
medical evaluation board
physical evaluation board
determine if plan is return to duty, temporary disabled separate from active duty medical discharge
medical evaluation board
part 1 of medical discharge evaluation
physician determines if service member is able to meet medical retention standards - informal process
physical evaluation board
part 2 of medical discharge evaluation
formal fitness for duty and disability determination and eligibility for disability compensation
uses scale 0-100%
medical treatment in war zone
initial stabilization and treatment
evacuate through Landstuhl Regional Medical Center (Germany)
transfer to Walter Reed Medical Center
from Landstuhl med. center in Germany to DC area
transfer for surgery and comprehensive TBI screen, initial rehab and surveillance for complications
after Walter Reed initial rehab -
transfer to
home VA for continued tx, acute rehab, or community integration
or
polytrauma center for moderate- severe TBI ; acute rehab or community integration
Returning home after TBI
after medical stability,
tx team determines medical POC that best meets recovery goals
acute management of TBI range from symptom management to aggressive management of intracranial pressure
logistics issues of family are addressed
transition is complicated by cognitive and physical and behavioral changes
VA polytrauma system of care
Continuum of care from 5 regional Polytrauma Centers (PRC) to 23 Polytrauma Network Sites (PNS) to Polytrauma Support Clinics (PSC) to Polytrauma Points of Contact (POC)
Goal is to recover enough to transfer closer to home
team works with Seamless Transition Social Worker
Defense and Veterans Brain Injury Center (DVBIC)
community reentry and rehab
DVBIC develops brain injury rehabilitation through civilian partnership programs for model community reintegration of service members with TBI
Those with unmet needs or with long term disability may be candidates for Community Integrated Rehabilitation (CIR)
- this is post acute not subacute
community integrated model - neurobehavioral
patients have severe behavioral disturbances; needs 24 hour supervision
intensive residential behavioral care
community integrated model -
residential community program
24 hr supervision / support
residential setting with community access
integrated comprehensive tx
community integrated model -
comprehensive holistic treatment
need for intensive tx and benefit from increased awareness training
day programs, multimodal rehab
community integrated model - home based program
able to reside at home and self direct care
may need outpatient support services
Research for why community integrated models are beneficial
Improved functional outcomes Reduced social dependency Increased participation Better vocational outcomes Improved self and family ratings
