Download The Epidemic of “Mild’ Traumatic Brain Injury in Young Americans: A Civilian and Military Perspective

8/15/2014
ETSU New Symbol
MSHA Symbol
The Epidemic of “Mild” Traumatic Brain Injury in America’s Young Adults: A Civilian and Military Team Perspective
Tyler Putnam, MD, FACS, FCCM
Medical Director, Trauma/Acute Care Surgery Services
Mountain States Health Alliance/Johnson City Medical Center
Colonel, United States Air Force (retired)
Objectives
• Traumatic Brain Injury Introduction • Military and Civilian Aspects of TBI– An American Medical Team Approach:
– Dissecting the Current Epidemic of Mild TBI
– Evaluation for Mild TBI
– Treatment for Mild Traumatic Brain Injury
– Prevention Strategies for Mild TBI
MILD TBI
A Very Current and Relevant Sports Medicine Challenge in our Community!
1
8/15/2014
Mild TBI ‐ A Very Relevant National Public Health Problem CDC, Morbidity and Mortality Weekly Report, July 12, 2014
– Traumatic brain injury ‐ #1 cause of death in ages 1‐45 yo
– 75% of brain injuries are concussions/mild TBI
– > 2.4 million ED visits, hospitalizations and deaths are due to TBI (latest CDC Data, 2009)
– ED visits for TBI increased 14.4% (2002‐2006)
– Hospitalizations for TBI increased 19.5% (same period)
What do These People Have In
Common?
• Ryan Church-New York Mets outfielder
• George Clooney- actor/director
• Ben Roethlisberger-Pittsburgh
Steelers quarterback
• Mike Wallace-journalist
• Tyler Putnam – Trauma Surgeon
Answer:
• They have all had one or more
mild traumatic brain injuries
(concussions)
• They received medical and
rehabilitation help and support
• They all returned to work
2
8/15/2014
Mild Traumatic Brain Injury is the most
common type of Brain Injury
among Civilians and US Service Members
• About 75-80% of all civilian traumatic brain
injuries are mild (CDC 2009)
– 1.6-3.8 million sports related concussions/year
• An estimated 11-20% of service members
sustained a mild TBI/concussion while
serving in OEF/OIF
(US Army Surgeon General 2008, Hoge, et. al. 2008, Taneilian and Jaycox 2008)
What is Traumatic Brain Injury?
“…..is caused by a blow to the head or a
penetrating head injury that disrupts the normal
function of the brain. Not all blows or jolts to the
head result in a TBI. The severity of a TBI may
range from “mild,” a brief change in mental status
or consciousness to “severe,” an extended period
of unconsciousness or amnesia after injury”
Centers for Disease Control & Prevention
Causes of TBI
• Civilians;
– Falls, Motor vehicle crashes, assaults, struck
by/against events (CDC 2009)
• Service Members (injured in combat);
– Blast exposure, gunshot wounds, falls and
motor vehicle accidents (Defense and Veterans Brain
Injury Center 2009)
3
8/15/2014
“Mild” Traumatic Brain Injury (Concussion)
•
•
•
•
•
A confused or disoriented state Lasts less than 24 hours; Loss of consciousness for up to 30 minutes;
Memory loss lasting less than 24 hours
Structural brain imaging (MRI or CT scan) yielding normal results.
Defense and Veterans Brain Injury Center (DVBIC)
Mild TBI Definition American Congress
of Rehabilitation Medicine “Traumatically induced disruption of brain function that results in loss of consciousness of less than 30 minutes’ duration or in an alteration of consciousness manifested by an incomplete memory of the event or being dazed and confused.”
McCallister 2005
Moderate TBI
• A confused or disoriented state which lasts more than 24 hours
• Loss of consciousness for more than 30 minutes, but less than 24 hours • Memory loss lasting greater than 24 hours but less than seven days
• Structural brain imaging yielding normal or abnormal results.
Defense and Veterans Brain Injury Center (DVBIC)
4
8/15/2014
Severe TBI
• A confused or disoriented state which lasts more than 24 hours
• Loss of consciousness for more than 24 hours
• Memory loss for more than seven days
• Structural brain imaging yielding normal or abnormal results.
Defense and Veterans Brain Injury Center (DVBIC)
Penetrating TBI or Open Head Injury
• A head injury in which the dura mater, the outer layer of the meninges, is penetrated.
• Penetrating injuries can be caused by high‐
velocity projectiles or objects of lower velocity such as knives, or bone fragments from a skull fracture that are driven into the brain.
Concussion = “Mild” Brain Injury
“To call this a ‘mild’ injury is very inappropriate” Dr. Brown, Boston Univ. Center for Study of Traumatic Encephalopathy:
– 20% of concussion symptoms last months or years
– Significant negative impact on performance at school and at work
5
8/15/2014
“Mild Traumatic Brain Injury (MTBI) in the United States: Steps to Prevent a Serious Public Health Problem” Report to Congress, September 2003
Report to Congress on Traumatic Brain Injury in the United States: Understanding the Public Health Problem among Current and Former Military Personnel DoD Report, 2013
United States Civilian Traumatic Brain Injury: Hospitalizations by Age Group
National Hospital Discharge Survey — United States, 2001–2010 (Hospitalizations
6
8/15/2014
Worldwide numbers represent medical diagnoses of TBI that occurred anywhere U.S. forces are located including the continental United States since 2000.
Evaluation of Mild TBI
Acute Concussion Evaluation (ACE)
Civilian (Forms Available – PDF)
Management of Mild TBI
CARE
PLAN
7
8/15/2014
Management of Mild TBI
CARE PLAN
(Adult)
US Military’s Emphasis on TBI
The “Signature” Wound of Iraq/Afghanistan Traumatic Brain Injury
A TRAUMA SURGEON’S PERSPECTIVE
In Johnson City
Initial Evaluation in the Trauma Bays
(Emergency Department)
8
8/15/2014
The Trauma Path Leads to East Tennessee!
Wilford Hall Medical Center, Texas
Level 1 Trauma Center
Misawa Air Base, Japan
University of Maryland
Shock Trauma Center
Traumatic Brain Injury
Pathophysiology
• Primary Brain Injury • Secondary Brain Injury
– Hypotension
– Hypoxia
– Anemia
26
The Primary Goal after Brain Injury
(Mild,Moderate or Severe)
• Prevent secondary brain injury
– Maintain adequate oxygenation (airway/breathing)
– Maintain adequate blood pressure and cerebral perfusion (circulation)
• Rapid evacuation of mass lesions/hematomas
– CT scan, rapid neurosurgical evaluation
9
8/15/2014
Maintaining Cerebral Perfusion After Injury Cerebral perfusion pressure
=
Mean arterial pressure
_
Intracranial pressure
• Preserve cerebral blood flow by keeping – Cerebral Perfusion Pressure > 70
– Mean Arterial Pressure > 90
– Intracranial Pressure < 20
28
Types of Head Injury
• Scalp
• Skull
• Intracranial
– Diffuse
• Concussion
• Diffuse Axonal Injury
– Focal
• Contusion
• Hematomas ‐ Epidural, Subdural, Intracerebral
29
After Initial TBI Evaluation and Diagnosis of Mild TBI
10
8/15/2014
•
•
•
•
•
Common Mild TBI/Postconcussive Symptoms
Poor concentration
Memory difficulty
Headache
Irritability
Fatigue
•
•
•
•
•
Depression
Anxiety
Dizziness
Light sensitivity
Sound sensitivity
Immediately post‐injury 80% to 100% describe one or more symptoms
Most individuals return to baseline functioning within a year
Ferguson et al. 1999, Carroll et al. 2004; Levin et al. 1987
Terrio, H., Brenner, L.A., Ivins, B., Cho, J.M., Helmick, K.,Schwab, K., Scally, K., Bretthauser, R., Warden, D. Traumatic Brain Injury Screening: Preliminary Findings Regarding Prevalence and Sequelae in a US Army Brigade Combat Team. Journal of Head Trauma Rehabilitation. 2009 Terrio, H., Brenner, L.A., Ivins, B., Cho, J.M., Helmick, K.,Schwab, K., Scally, K., Bretthauser, R., Warden, D. Traumatic Brain Injury Screening: Preliminary Findings Regarding Prevalence and Sequelae in a US Army Brigade Combat Team. Journal of Head Trauma Rehabilitation. 2009 11
8/15/2014
Mild TBI
Question:
Does a person always get
“knocked out” or loose
consciousness when they
have a brain injury?
Answer:
No!!
They may however experience
a period of feeling dazed, they
may look fine, but their brains
have been knocked “off line”
and are unable to lay down new
memories
For Example…..
12
8/15/2014
“That first morning, wow, I didn’t want
to move, I was thankful that nothing’s
broken, but my brain was all
scrambled”
Ryan Church, New York Times 3/10/08
“All he remembers from the collision
with Anderson is the aftermath, being
helped off the field by two people,
although he said he did not know who
they were until he saw a photograph
later” Ben Shpigel New York Times reporter
Signs of “Mild” Traumatic brain
Injury
Early Signs
• confusion
• blank staring
• decreased response time for directions
and/or answering questions
• dizziness/sensitivity to light and/or sound
• vomiting
• headache
• nausea
BIAA, Brain Injury Source Summer 2000, Vol.4, Issue 2, 30‐37
After mild TBI. for many, the
symptoms go away within hours
or days.
If they do not and/or an individual
gets another mild traumatic brain
injury they may experience
additional symptoms….
13
8/15/2014
Signs of Mild Traumatic Brain Injury
Late Signs
•
•
•
•
•
•
•
Persistent headache
Poor attention
Irritability/aggression
Hearing problems
Ringing in the ears
Restlessness
Depressed mood
•
•
•
•
Decreased memory
Sleep disturbances
Fatigue and anxiety
Blurry vision/visual
problems
• Lightheadedness
• Difficulty making
decisions
BIAA, Brain Injury Source Summer 2000, Vol.4, Issue 2, 30‐37
When to seek help after mild
TBI...
If things that have always come easily to
patient, are harder, take longer, especially if
their ability to multi-task is not what it was
prior to the incident
and/or
Their family, friends, fellow soldiers/players or
superiors/coaches comment negatively on
performance of duties, their responsiveness
to new situations and ability to communicate.
Per Military Behavioral Health,
individuals concerned about lingering
symptoms after mild TBI can...
• Speak to a chaplain
• Go to their installation Department of
Behavioral Health or Community or Division
Mental Health
(www.behavioralhealth.army.mil) as well as...
• Thoroughly respond to the questions asked
in the Post-Deployment Health Assessment
(PDHA). Several items screen for possible
traumatic brain injury
14
8/15/2014
Mild TBI
The Good News:
With treatment and time the
brain will usually heal and
allow a functional recovery!
After TBI:
Suggested services/strategies
may include...
• Consultation with a neurologist and or a
neuropsychologist
• Work with a speech, occupational, and or
physical therapist as recommended by
medical personnel
• Scheduling breaks/down time
• Minimize alcohol intake as it can depress
brain cell growth/regeneration after injury
• Follow recommendations for physical
exercise-it supports brain health
Mild Traumatic Brain Injury:
Clinical Practice Guidelines
for Acute and Chronic Management
in the DoD (CONUS)
 300,000 American TBIs in Recent Wars
 Largest number of well documented young adult mild TBI victims
 Extensive efforts to diagnose and manage TBI, especially mild TBI
15
8/15/2014
Definition
• Mild TBI/Concussion (DoD
definition)
–
–
–
–
LOC: 0-30 minutes
AOC: up to 24 hours
PTA: 0-24 hours
Structural Imaging (if done): normal
• All head injuries do not result in TBI
• Level of injury severity does not
equal level of functional impairment
46
Management Overview
• Clinical guidance based
upon time of presentation
– Acute = < 7 days
– Sub-acute/Chronic = > 7 days
• Acute management: Symptom
Management in Mild TBI - Health
Affairs Policy Memo (May 2008)
• Sub-acute/Chronic management:
VA/DoD Clinical Practice Guideline for
the Management of Concussion/mild
Traumatic Brain Injury (March 2009)
47
Mild TBI
Management Overview
• Identification of injury
• Evaluation for potential red
flags
• Symptom management
• Rest
• Prevention of further injury
• Education
48
16
8/15/2014
Mild TBI ‐ Asymptomatic
• Closely monitor for symptoms and
provide supportive education up to
30 days post injury
• Provide reassurance about recovery
• Advise about precautionary measures
to prevent future head injury
• Provide written contact information for
healthcare provider and instructions
to contact for follow-up for changes in
condition or development of
symptoms
• Document concussion in medical
record
49
Post Concussive Symptoms
Emotional
• Anxiety
• Depression
• Irritability
• Mood
lability
Physical
Cognitive
• Slowed
processing
Dizziness
• Decreased
Sleep Disturbances
attention
• Poor
Balance problems
Concentration
Nausea/Vomiting Fatigue
• Memory Problems
Visual disturbances
• Verbal dysfluency
• Word-finding
Sensitivity to light/
• Abstract reasoning
noise
• Headache
•
•
•
•
•
•
• Ringing in the ears
Mild TBI
Codependent Symptoms
mTBI Symptom
Interaction
Sleep
Headache
Cognitive
Irritability/
Mood
17
8/15/2014
Clinical Practice Guideline
Symptomatic mild TBI
Summary of Algorithm B: Management of Symptoms
Step One: History and Physical Exam
Confirm
diagnosis of mild TBI
Characterize initial injury and identify detailed information of the injury
event
Patient’s symptoms and health concerns
Are symptoms related to the event characterized as a mild TBI
Pre-morbid conditions, potential co-occurring conditions, other
psychosocial risk factors
Evaluate signs and symptoms indicating potential for
neurosurgical emergencies that require immediate referrals
Assess danger to self or others
Complete history
Physical Exam
Focused neurological examination
Focused vision examination
Focused musculoskeletal examination of head and neck
Lab Tests
Not necessary for mild TBI (may consider lab tests for evaluating other
non-TBI [52] causes of symptoms)
Imaging
Not recommended in patients who sustained mild TBI beyond
emergency phase (72 hours post-injury) unless condition deteriorates
or red flags noted
CT scan - modality of choice for acute mild TBI. Absence of abnormal
findings does not preclude presence of mild TBI
Clinical Practice Guideline ‐ Symptomatic mild TBI
Step Two: Clarify Symptoms
Duration
Frequency
Onset and triggers
Location
Previous episodes
Intensity or severity
Previous treatment and response
Patient perception
Impact on functioning
Assess exacerbating factors:
Prescribed and OTC medications
Caffeine, tobacco and other stimulants (energy drinks)
Sleep patterns & sleep hygiene
Co-existing illnesses
Step Three: Evaluate and Treat Co-Occurring Disorders
Mood disorders
Anxiety
Stress
Substance use disorders
Step Four: Determine Treatment Plan
Document summary of patient’s problems
Develop treatment plan that includes severity and urgency for treatment interventions
Emphasize good prognosis and empower patient for self-management
Step Five: Educate Patient and Family (written & verbal)
Review potential symptoms of mild TBI
Review expected outcomes and recovery
Educate about prevention of further injuries
Empower patient for self management
Techniques to manage stress
Step Six: Provide Early (Non-Pharmacologic) Interventions
Sleep hygiene education
Relaxation techniques
Limiting use of caffeine, tobacco, alcohol
Graded return to exercise with close monitoring
Monitored progressive return to normal duty, work or activity
Clinical Practice Guideline ‐ Symptomatic mild TBI
Step Seven: Consider Case Management
Consider case management if all symptoms not sufficiently resolved within days. Assign case manager to:
oFollow-up and coordinate (remind) future appointments
oReinforce early interventions and education
oAddress psychosocial issues (financial, family, housing or school/work)
oConnect to available resources
Step Eight: Initiate Symptom-Based Treatment
 See specific symptom tabs for symptom management
Step Nine: Follow Up and Reassess
Follow up and reassess in 4-6 weeks, sooner if clinically indicated
Encourage and reinforce positive expectation of recovery
Monitor for co-morbid conditions
Address:
oReturn to work, duty or activity
oCommunity participation
oFamily/social issues
Step Ten: If Symptoms Not Sufficiently
Resolved
Continue to Algorithm C Management of Persistent Concussion/mild TBI Symptoms
Re-assess symptom severity and functional status and complete psychosocial evaluation
Possible referrals to mental health, occupational therapy, vocational therapy
Continue case management
18
8/15/2014
Clinical Practice Guideline ‐ Symptomatic mild TBI
Management of Headaches
Post Traumatic Headaches
(Includes Tension and Migraine)
History



Characterize headaches
Pre-existing headache disorder
Assess sleep/wake cycles (lack of sleep is an exacerbating factor and mTBI is also associated with
impaired sleep)
Patient
Examination


Head and neck
Complete cranial nerve, fundoscopic and
pupil exam
Muscle strength and tone



Gait
Upper and lower extremity coordination
Medication
Review


Chronic daily use of non-steroidal anti-inflammatory drugs (NSAIDs) or acetaminophen (alone or
combined with caffeine) may lead to rebound headaches
Excessive use or rapid withdrawal of caffeine or tobacco can trigger headaches
Referral *

–
Emergency Department
Fever
–
Stiff neck
• Neurology
- Worsening headache
-Seizures
- Blackout
-Any abnormality found during neurological or
musculoskeletal exam






Patient
Education
Perform series of neck stretches
Review sleep posture and make adjustments to ensure neck and spine are in a neutral position
Awareness and avoidance of migraine triggers
Maintaining regular exercise, sleep and meal schedules
Recognize warning signs (aura)
Headache diary
Clinical Practice Guideline ‐ Symptomatic mild TBI
Management of Headaches (cont’d)
Tension
Migraine
Pharmacologic Treatment
**



NSAIDs
Acetaminophen
Prophylactic therapy



Non-Pharmacologic
Treatment

Relaxation training and biofeedback in combination
with medication
Physical therapy
Increased physical activity
Alternate ice and heat on neck and head 2-3 times per
day for about 20 minutes
Therapeutic massages to help with headaches
from neck tension
•Relaxation
•Biofeedback
•Visualization
•Extracranial pressure
•Cold compress
•Regular exercise
•Alternate ice and heat on neck and
head 2-3 times per day for about 20
minutes
•Therapeutic massages to help with
headaches from neck tension




Analgesic washout period
Limit to 3 treatments/week or less
Prophylactic therapy
Clinical Practice Guideline ‐ Symptomatic mild TBI
Management of Dizziness
Dizziness
Physical Assessment
Medication Review
(for medications that
exacerbate or
worsen symptom)
Referrals *
Pharmacologic
Treatment
Non-Pharmacologic
Treatment
Patient Education












–
–
–

Neurological examination
Vision
Auditory
Sensory
Motor
Coordination
Stimulants
Benzodiazepines
Tricyclics
Monoamine oxidase inhibitors
Tetracyclics
Neurology
Lateral abnormality
Nystagmus
Abnormal Romberg
Not shown to be effective in chronic
dizziness after mild TBI

Consider only if symptoms are severe
enough to significantly limit functional
activities

May be helpful during acute period
Vestibular and balance rehabilitation








Vestibular
Evaluation of functional and
balance activities
Turning






–
Neuroleptics
Anticonvulsants
Selective serotonin agonists
Beta blockers
Cholinesterase inhibitors
Emergency Department
CSF leak






Meclizine
Scopolamine
Dimenhydrinate
Lorazepam
Clonazepam
Diazepam
Perform neck stretches
Modify activity and change positions slowly
Change sleep position
Perform vestibular rehabilitation exercises
Talk with your healthcare provider if exercises do not help your dizziness
19
8/15/2014
Clinical Practice Guideline ‐ mild TBI: Fatigue and Sleep Disturbances
Fatigue
Sleep Disturbances
Management of Fatigue and Sleep Disturbances
History
Pre/post-injury level of physical activity,
cognitive function and mental health (identify
and
treat
underlying
medical
and
psychological disorders)
Physical Assessment
Multidimensional Assessment of Fatigue
(MAF)
Fatigue Impact Scale (FIS)
Fatigue Assessment Instrument (FAI)
Laboratory tests (CBC, Metabolic panel,
Vitamin B12 & folate, Thyroid function test,
Erythrocyte Sedimentation Rate (ESR))
If medication appears contributory, perform
Applied Behavioral Analysis (ABA) trial to
determine the association
Medication Review (for
medications that
exacerbate or worsen
symptom)
Referrals *
Sleep routine
Alcohol and substance abuse
Sleep activity
Nightmares
Frightened arousal
Epworth Sleepiness Scale
Consider Pittsburgh Sleep Quality Index (PSQI)
Neck size, airway, height, weight
Sleep study referral
Apnea ESS>12
Address modifiable factors prior
to initiating pharmacotherapy
Persistent symptoms (> 4 weeks) without
improvement with management of sleep,
pain, depression, lifestyle, may consider
neurostimulant:
Medication trial for at least 3 months
Well balanced meals
Sleep hygiene
Regular exercise
Cognitive behavioral therapy
Pharmacologic
Treatment **
NonPharmacologic
Treatment
Patient Education
BMI>30
Prazosin
Zolpidem
Trazodone (sleep maintenance)
Amitriptyline (headache benefit) *
Well balanced meals
Sleep hygiene
Regular exercise
Cognitive behavioral therapy
Sleep hygiene
Reduce stimulation before bedtime
No caffeine, heavy exercise, alcohol, nicotine or heavy meals 3
hours prior to bedtime
Avoid bright light exposure near bedtime
Keep regular bedtime and wakeup hours
Foster quiet, pleasant sleep environment
Stop work or TV viewing at least one hour before bedtime
Use bed only for sleep and sex
Clinical Practice Guideline ‐ Symptomatic mild TBI
Management
of Sensory Changes
Management
of Vision,
Hearing & Olfactory
Symptoms
Vision
Hearing
History
Pre-injury visual deficits

Pre-injury hearing deficits
(common)
Physical
Assessment




Otologic examination
Decreased auditory acuity
Sensitivity to noise
Referrals


Ophthalmologic examination
Extraocular movements
Pupils
Visual fields by confrontation
o
o
o
Optometry and
Ophthalmology

NonPharmacol
ogic
Treatment




Initial use of sunglasses
followed by formal weaning
program (decrease by 15
minutes every 2 hours)
Sunglasses
Intermittent patching for
double vision
Reassurance, pain
management, controlling
environmental light




Olfactory

Pre-injury causes of anosmia



Decreased appetite
Perform nasal and
oropharyngeal examination
Perform depression screen
Audiology (if no other cause is
found)
ENT * (Hemotympanum, FB, TM
perforation)

ENT (if needed)
Reassurance
Pain management
Controlling environmental
noise
White noise generators


Reassurance and monitoring
Increase spicing of foods (+/dietary referral)
Monitor weights

Clinical Practice Guideline ‐ Symptomatic mild TBI
Management of Irritability
History
Evaluate specific history and symptoms, physical fighting, alcohol intake,
relationship problems, suicidal, homicidal
Physical Assessment


Referrals
Psychiatry, psychology and social work

Outward violence

Excessive alcohol intake

Suicidal ideation

Homicidal ideation
Pharmacologic Treatment



Sertraline
Citalopram Allow 3-4 week therapeutic trial of each drug
Refer to psychiatry, psychology, social work for treatment failure of 2
medications
Patient Education

Understand that it is normal to have feelings of anxiety, depression,
agitation and feeling overwhelmed
Replace negative thoughts and actions with positive ones
Do not call yourself bad names or put yourself down
Talk to someone you love and trust about these concerns
Seek emergency care if you have thoughts or feelings of hurting yourself or
others
Seek psychological support if these feelings are causing you problems at
work or home





Administer PCL-M screening questionnaire
Consider PHQ-9 or other depression inventory
20
8/15/2014
Clinical Practice Guideline ‐ Symptomatic mild TBI
Management of Appetite Changes & Nausea
Appetite Changes
Nausea
History
Pre-injury causes of appetite issues
Define triggers and patterns
of nausea
Physical Assessment



Medication Review
Assess medication list for agents that can cause
olfactory or gustatory abnormalities (centrally
acting medications, in particular antiepileptics, some antibiotics)
Assess medication list for
agents that may cause or
worsen GI symptoms
Non-Pharmacologic
Treatment




Perform nasal and oropharyngeal examination
Review neurovegetative signs (assess for
depressed affect or clinical depression)
Reassurance and monitoring
Increase spicing of foods (+/- dietary referral)
Monitor weights

Perform oropharyngeal
examination
Reassurance and
monitoring
Encourage rapid
management of dizziness
and return to activity
Clinical Practice Guideline
Symptomatic mild TBI
When to Refer
Symptoms cannot be linked to a event
(suspicion of another diagnosis)
An atypical symptom pattern or course
is present
Findings indicate an acute neurologic
condition that requires urgent
intervention
Presence of other major co-morbid
conditions requiring special
evaluation
When to
Refer to
Specialists
62
Clinical Practice Guideline ‐ Symptomatic mild TBI
Return to Duty (Return to Play)
When to Return
to Activity




When to Apply
Duty
Restrictions




Period of rest for individuals with post-injury
symptoms
Encourage gradual return to normal activity as
clinically appropriate
Suggest exertional testing if a person’s normal
activity involves significant physical activity
If exertional testing results in a return of symptoms,
recommend additional rest until symptoms resolve
A duty specific task cannot be safely or competently
completed based on symptoms
The work/duty environment cannot be adapted to
the patient’s symptom- based limitation
The deficits cannot be accommodated
Symptoms reoccur
63
21
8/15/2014
mTBI and "Co‐occurring" Conditions
The polytrauma clinical triad:
Distribution of patients with
1. chronic pain,
2. posttraumatic stress disorder
(PTSD), and
3. persistent postconcussive
symptoms (PPCS)
in a sample of 340 Operation
Iraqi Freedom/Operation
Enduring Freedom (OIF/OEF)
veterans evaluated at
Department of Veterans Affairs
Boston Polytrauma Network Site
(PNS).
Lew et. al., Prevalence of chronic pain, posttraumatic
stress disorder and persistent postconcussive
symptoms in OIF/OEF veterans: Polytrauma
clinical triad. JRRD, 2009, 46(6), 697-702.
Clinical Practice Guideline Symptomatic
TBI
Recently Published
Clinical mild
Recommendations
• Co-occurring conditions toolkit
• Cognitive rehabilitation in mild TBI
• Driving assessments after TBI
65
Defense and Veterans Brain Injury Center
(DVBIC)
• Established in 1992,
• Unique collaboration between: – Department of Defense (DOD)
– Department of Veterans Affairs (DVA)
– Brain Injury Association of America (BIAA). • Goal of DVBIC: – To ensure that active duty military and veterans with brain injury receive the best evaluation, treatment, and follow‐
up.
22
8/15/2014
National TBI Evaluation and Care System
We need to Apply Lessons Learned from Military and Veterans Healthcare Systems
President Announces Concussion Prevention Partnership
May 29, 2014
WASHINGTON, May 29, 2014 – At a White House Summit today on youth sports safety and concussions, President Barack Obama announced that the Defense Department is partnering with the NCAA in an effort to better prevent, diagnose and treat brain injuries.
The NCAA and DOD have committed $30 million for concussion education and a study involving up to 37,000 college athletes ‐‐ the most comprehensive concussion study ever, Obama said.
“And our service academies ‐‐ Army, Navy, Air Force, and Coast Guard ‐‐ are all signed up to support this study in any way that they can,” he added.
“I’ve seen in my visits to wounded warriors [that] traumatic brain injury is one of the signature issues of the wars in Iraq and Afghanistan,” the president said.
But, Obama said, most mild traumatic brain injuries in the military don’t occur during deployments.
“So even though our wars are ending, addressing this issue will continue to be important to our armed forces,” he said.
“And as part of a new national action plan we announced last year, we’re directing more than $100 million in new research to find more effective ways to help prevent, diagnose and treat mental health conditions and traumatic brain injury ‐‐ because the more we can learn about the effects of brain injuries, the more we can do to help our courageous troops and veterans recover,” the president said.
There’s more work to do, Obama said. “We’ve got to have better research, better data, better safety equipment, better protocols,” he said.
And enacting deep and real social change is a critical part of developing better prevention and treatment options for brain injuries, the president said.
“We’ve got to have every parent and coach and teacher recognize the signs of concussions,” Obama said. “And we need more athletes to understand how important it is to do what we can to prevent injuries and to admit them when they do happen.
“We have to change a culture that says you ‘suck it up,’” he continued. “Identifying a concussion and being able to self‐
diagnose that this is something that [you] need to take care of doesn’t make you weak ‐‐ it means you’re strong.”
By Claudette Roulo, American Forces Press Service
Mild TBI ‐ Resources for Field Diagnosis/Early Management
CDC Concussion – Field Palm Card (1)
23
8/15/2014
CDC Concussion – Field Palm Card (2)
CDC Concussion – Field Palm Card (3)
CDC Concussion – Field Palm Card (4)
24
8/15/2014
Mild TBI and the Importance of Neuropsychology
1. MTBI, more than any other clinical entity, is a neuropsychological construct
2. The contribution by neuropsychologists to MTBI research is unmatched by any other discipline
3. Neuropsychologists are uniquely suited to evaluate and treat MTBI
4. Neuropsychologists should not limit their role in MTBI just to neuropsych testing
Mild TBI A Multi‐disciplinary Approach
Pre‐hospital to Rehabilitation
• EMS education
• ED consultation
• Acute TBI Clinic
• Multidisciplinary Approach
• Neuropsychology & PM/R
• Patient/family education
• Supportive follow‐up
• Outcome research
SUMMARY The Epidemic of Mild TBI in Young Adults
How Can WE Make an “Impact” • Avoidance – TRAUMA PREVENTION is THE CURE!
• TBI EDUCATION
• LONGER TERM FOLLOW UP WITH EVALUATION/TESTING
• CONCUSSION CLINIC (431‐2477) – Mountain State Medical Group Neurosurgery/Trauma Services
25
8/15/2014
Mild Traumatic Brain Injury
Conclusion
• No athlete (or soldier) diagnosed with a concussion should RTP/RTD on the same day or while symptomatic. The RTP/RTD decision is a medical one.
• Additional research is needed: –
–
–
–
to validate current assessment tools,
further delineate the role of NP and balance testing,
validate RTP/RTD guidelines Improve identification of those at risk for prolonged concussive symptoms or other short‐term or long‐
term complications.
Resources
• Defense and Veterans Brain Injury Center 1-800-8709244 www.dvbic.org. Check out video Survive, Thrive
& Alive on brain injury and treatment and recovery of
several injured service members.
• Brain Injury Association of America 703-236-6000,
www.biausa.org
• www.cdc.gov/concussion/headsup/pdf/Facts
• Brain Injury Association of Maryland 410-448-2924,
www.biamd.org
• Ohio Valley Center For Brain Injury Prevention and
Rehabilitation, 614-293-3802, www.ohiovalley.org.
• www.headinjury.com. Good resource for memory
aides and tips
Heads Up Facts for Physicians About Mild Traumatic Brain Injury (MTBI) U.S. www.cdc.gov/concussion/headsup/pdf/Facts
26
8/15/2014
SUMMARY
Trauma Care Excellence
National Outcomes Comparison
Johnson City Medical Center - Level I Trauma Center
Improved Survival, Improved Outcomes
- World Class Care for Traumatic Brain Injury
Variable
JCMC Mean
Comparison Group Mean
Age
50
51
Hospital LOS
5
5.5
ICU LOS
4.7
5.4
ISS
9.8
10.5
Vent days
5.9
6.5
% Deaths
3.13
4.25
Deaths ISS > 25
17.0
27.7
PLEASE CONTACT ME IF YOU HAVE ANY QUESTIONS OR WOULD LIKE “Toolkit Material” FOR MILD TBI (PDF)
Tyler Putnam, MD, FACS, FCCM
Medical Director, Trauma Services
Mountain States Health Alliance/Johnson City Medical Center
Phone – 423‐794‐7789
[email protected]
[email protected]
• Thank yOU
THANK YOU!
The Mountain States
Trauma Team
27