Brain Imaging and Behavior DOI 10.1007/s11682-015-9399-z
MILITARY/VETERAN TBI
Traumatic brain injury in the US military: epidemiology and key clinical and research programs Katherine M. Helmick 1 & Cynthia A. Spells 1 & Saafan Z. Malik 1 & Cathleen A. Davies 1 & Donald W. Marion 1 & Sidney R. Hinds 1
# Springer Science+Business Media New York (outside the USA) 2015
Abstract Traumatic brain injury (TBI), and particularly concussion, is a major concern for the U.S. Military because of the associated short term disability, long term cognitive and pain symptoms suffered by some, and risk of prolonged or permanent neurologic injury if the Service member incurs a second TBI before full recovery from the first. Concussions were seen more often during the recent conflicts in Afghanistan and Iraq than in prior conflicts, such as the Vietnam War, because of the use of improvised explosive devices that typically caused nonpenetrating closed head injury. Since 2000 more than 300,000 Service members were diagnosed with TBI, of which more than 80 % were concussions. Improved TBI screening tools also have identified a higher than expected incidence of concussions occurring in garrison. In this review we summarize current epidemiologic data for TBI in the Military, and describe contemporary Military procedures and strategies for TBI prevention, identification, evaluation, and acute and chronic care. Key TBI clinical research priorities and programs are described, and innovative organizational plans to address future TBI needs are summarized.
Keywords Traumatic brain injury . Military . Department of Defense . Concussion . Surveillance . Clinical recommendations
* Katherine M. Helmick [email protected] Donald W. Marion [email protected] 1
DVBIC/DCoE Headquarters, 1335 East West Hwy, Suite 605, Silver Spring, MD 20910, USA
Scope of the problem Traumatic brain injury (TBI), and especially mild TBI or concussion, is the most common traumatic injury in the Military. Since 2000 more than 310,000 active duty service members, National Guard members and reservists have been diagnosed with TBI, most occurring in the garrison or the home station environment (DVBIC 2015a). The prevalence of these injuries has compelled Congress to invest in the development of policies and programs that support evidence-based care for the full continuum of TBI, from concussions to severe and penetrating brain injuries. Although the Department of Defense (DoD) has made great strides in the areas of TBI clinical care, education, and research, there remains an urgent need to leverage technology, research, and education to inform the most effective policies that will maximize care of service members and veterans. In the DoD, TBI care provided by the Army, Navy, and Air Force is enhanced, and in some respects coordinated, by the Defense and Veterans Brain Injury Center (DVBIC). DVBIC is a DoD agency originally created by Congress in 1992 as a research organization, and enlarged in the early 2000’s to include clinical and educational programs. In collaboration with the Armed Forces Health Surveillance Center (AFHSC) and the Joint Trauma Analysis and Prevention of Injury in Combat (JTAPIC) Directorate, DVBIC’s Surveillance office tracks incident cases of TBI in Service members worldwide (DVBIC 2015a). Since 2000, the vast majority (82.4 %) have been concussions (e.g., mild TBI), only approximately 1 % are severe injuries that render the Service member comatose for prolonged periods, and only 1.5 % are penetrating injuries. (See Fig. 1) This likely reflects the fact that the most common mechanism of injury during the Afghanistan and Iraq conflicts was improvised explosive devices, so blast injuries or blast combined with blunt injuries were more common than in
Brain Imaging and Behavior
DoD Numbers for Traumatic Brain Injury Worldwide - Totals 2000 -2014 Q2 Penetrating Severe Moderate Mild Not Classifiable Total - All Severities
4,538 3,088 25,370 253,350 20,937
6.8%
1.5% 1.0%
8.3%
82.4%
307,283
Fig. 1 Incidence of traumatic brain injury in the Department of Defense since 2000. Figure courtesy of DVBIC, data provided by the Armed Forces Health Surveillance Center
previous conflicts, and penetrating injuries far less common. Gunshot wounds in Afghanistan and Iraq were 19 % of all injuries, compared with 35 % in Vietnam and 27 % during World War II. Conversely, 81 % of injuries in Afghanistan and Iraq were explosion-related, compared with 65 % in Vietnam and 73 % in World War II (Owens et al. 2008). In 2007 extensive mandatory concussion screening programs were implemented throughout the DoD, including the creation and field utilization of the Military Acute Concussion Evaluation (MACE) (French et al. 2008; DVBIC 2012). This led to an abrupt increase in the reporting of TBI, though not necessarily in the actual incidence. (Fig. 2) The incidence of TBI does appear to be declining from a peak of more than 32, 000 cases per year in 2011. However, even with the end of combat operations in Afghanistan and Iraq there will likely be 20,000 or more cases per year in the DoD because the majority appear to occur in the non-deployed environment as a result of motor vehicle crashes (privately owned and military vehicles), falls, sports, and recreational activities, and military training (DVBIC 2015a). Although more than 80 % of TBIs are diagnosed before or after deployment, some of those injuries actually were deployment related injuries diagnosed weeks or months after return from deployment. Recent studies have found that the pre-deployment (e.g., garrison) incidence rate for TBI is 119.8/100,000, and highest in the Army (147.3/100,000) and the Marines (114.8/100,000) (Regasa et al. 2015). Immediately following deployment the risk of being diagnosed with TBI is as high as 8.4 times that of the risk before deployment. The risk decreases thereafter up to 40 weeks post deployment. Post-deployment screening programs, including the Post Deployment Health Assessment, Post Deployment Health Reassessment, and the Veterans Affairs (VA) TBI Screen (VA 2010) have been very effective in identifying previously deployed Service members who had a TBI during deployment. For example, from April of 2007 through September of 2010, nearly 300,000 Veterans of Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF)/Operation New Dawn (OND) were screened for possible deployment-related
concussion; 55,070 had positive screens, and approximately 55 % of those were confirmed to have had a concussion (Scholten et al. 2012). Thus, 30,267 veterans were not discovered to have had a deployment related concussion for weeks or months after their injury. In addition, just the experience of having been deployed can increase the long term risk for TBI in garrison by nearly 2 fold (Regasa et al. 2015). Because the majority of TBI in the Military occurs in garrison, there remains significant concern about TBI even though OEF/OIF/ OND have concluded. Since the majority of Service members are young adults, it is not surprising that a substantial proportion of the concussions that occur in garrison are sports-related concussions. The Institute of Medicine (IOM) Report: Sports-Related Concussions in Youth: Improving the Science, Changing the Culture 2013 reviewed the science of sports-related concussion in youth from elementary school through young adulthood, including military personnel and their dependents.(Institute of Medicine (IOM) and National Research Council (NRC) 2013) DVBIC supported and participated in the production of this Report, in part because there is a natural synergy between the examination of the occurrence of concussion in garrison and youth sports concussion. The culture of Bshake it off and get back in the game^ is as prevalent in combat as it is in sports. But without timely and appropriate concussion treatment there is an increased risk for less than optimal patient outcomes, the possibility of longterm neurologic damage, and an increased risk for subsequent injury. Part of the IOM Committee’s report examined sportsrelated concussions among military dependents as well as concussions in military personnel ages 18 to 21 that result from sports and physical training at military service academies or during recruit training. The report yielded six recommendations for federal agencies and the DoD to focus on in order to improve the surveillance and prevention of concussions in athletes: & &
&
&
…establish and oversee a national surveillance system to accurately determine the incidence of sports-related concussions, including those in youth ages 5–21… …research to establish objective, sensitive and specific metrics and markers of concussion diagnosis, prognosis and recovery…and to inform creation of age-specific evidence-based guidelines for the management of concussion sequelae… …conduct controlled, longitudinal studies to assess short and long-term cognitive, emotional, behavioral, neurobiological, and neuropathological consequences of concussions and repetitive head impacts… …undertake a rigorous scientific evaluation of the effectiveness of age-appropriate techniques, rules, and playing and practice standards in reducing sports-related concussions…
Brain Imaging and Behavior Annual TBI in DoD (2000 - 2014Q2) total: 307,283
# of TBI's Diagnosed
Fig. 2 The annual incidence of traumatic brain injury in the Department of Defense, since 2000. Data provided by the Armed Forces Health Surveillance Center and analyzed by DVBIC
*
2000 Total TBI's 10,958
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014Q2
11,619
12,407
12,815
14,468
15,529
17,037
23,217
28,464
28,880
29,199
32,668
30,615
27,324
12,083
* Only data of Jan - Jun 2014 areavailable.
& &
…research on age- and sex-related biomechanical determinants of injury risk for concussion in youth… …develop, implement and evaluate the effectiveness of large-scale efforts to increase knowledge about concussions and change in social norms, attitudes and behavior surrounding concussions…
In response to these recommendations, the DoD is aggressively pursuing research and educational programs to better understand how concussions are being tracked and managed at its training facilities, including the four service academies. For example, at the US Naval Academy a better understanding of post-concussive cognitive deficits in Midshipman is now possible as the result of an initiative to collect computerized neurocognitive baseline data for all 4800 Midshipmen at the Academy using the Automated Neuropsychological Assessment Metric (ANAM), accomplished over the course of 2 years (ANAM 2012). As a result, post-injury ANAM study results can now be compared with the individual Midshipman’s personal baseline study. In addition, an assessment of all Service academies’ sideline evaluations during organized sporting events are being evaluated to assure state of the science approaches for concussion evaluations.
Priority focus areas Prevention Prevention of TBI has become an increasingly important concern of the Military Health System (MHS) in view of the surveillance data that shows that most TBI in the Military occurs as a result of non-combat related activities such as motor vehicle crashes or sports injuries. DVBIC recognized the need for a comprehensive injury prevention program aimed at Service members and their families, and in 2014 launched BA Head for the Future^, a multi-year campaign aimed to increase prevention, awareness and education of
mild TBI for service members, veterans, and their beneficiaries through multimedia materials and strategic outreach events (A Head for the Future 2015). The initiative also has a dedicated website with links to the training sites for the services, the VA BMake the Connection^ website, and other federal partners including the Centers for Disease Control and Prevention (CDC) website as well as that of the Health Resources and Services Administration (HRSA). In addition, significant partnerships with the National Collegiate Athletic Associateion (NCAA), the National Football League (NFL), and several academic institutions have been established to increase awareness of the prevention and treatment of TBI. Identification/Evaluation The early detection and diagnosis of mild TBI and early treatment results in the best outcomes, and will help prevent a second concussion before recovery from the first. It is now clear that concussive injury initiates a complex cascade of pathophysiological changes that include hyper-acute ionic flux, indiscriminant excitatory neurotransmitter release, acute hyperglycolysis and sub-acute metabolic depression (MacFarlane and Glenn 2015). These metabolic changes can lead to impaired neurotransmission, alternate fuel usage and modifications in synaptic plasticity and protein expression, metabolic alterations that likely cause the transient and prolonged cognitive deficits that characterize concussion. Most importantly, if the Service member were to sustain a second concussion before full recovery of these metabolic abnormalities, there is a high risk for long term or permanent neurologic injury. As a result, the DoD through DVBIC has created tools and programs intended to facilitate the early identification of deployed Service members suspected of, or at risk for, a concussion. Some of the earliest TBI screening programs were implemented at Landstuhl Regional Medical Center in 2006. All Service members evacuated for medical reasons, regardless of combat, non-combat, or illness designation, received a standardized evaluation
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utilizing the Military Acute Concussion Evaluation (MACE). Since that time the MACE has undergone 4 revisions and is now a mandatory screening tool for use by combat medics and corpsmen evaluating any Service member suspected of having a concussion. DVBIC also has developed Concussion Management Algorithms with detailed instructions for providers at all skill levels to help assure consistent high quality concussion care throughout the DoD (CMA 2014). Since 2008 TBI assessment questions have been included in the PDHA and PDHRA forms which are health-status screening tools that all Service members are required to complete following each deployment (PDHA 2008; PDHRA 2008). This screening program requires a face-to-face evaluation with a clinician upon arrival to their home duty station. Most programs intended for early identification of concussion have been frustrated by a Military culture that has traditionally discouraged a Service member from admitting that he or she has been hurt, and promotes getting back to the fight. This concern was addressed in 2010 when the DoD implemented an incident-based system of reporting which required field commanders to remove from combat and report all Service members under their command who were exposed to a potentially concussive event. This new directive pertains to all deployed Service members who were within 50 m of a blast, were in a building or vehicle exposed to a blast, had a direct blow to the head or witnessed loss of consciousness, were exposed to more than one blast event, or were simply thought to require further evaluation by their commander (Incident – based reporting 2010). After reporting the incident, a medical evaluation is mandated before the Service member can return to duty. Quarterly data regarding exposure to concussive events and the proportion of those Service members actually diagnosed with a concussion is described in Fig. 3. During August, 2010 through June, 2014, there were 16,760 SMs who met one or more of these criteria. Among those, 16.3 % or 2734 were diagnosed with a concussion. In addition, a Department of Defense Instruction (DoDI) mandates a 24 h rest period for the first concussion and a 7 day rest period if there have been two diagnosed concussions within 12 months (DoDI 6490.11 2012). If 3 or more concussions have been documented within a 12 month period the Service member must undergo a comprehensive neurologic/cognitive evaluation prior to return to duty. In June of 2013 the Army implemented a similar incident-based policy for acute management of Soldiers who are involved in potentially concussive events while in the garrison environment. Therefore, between the theater and garrison policies the Army has one worldwide standard of care to educate Army personnel and to identify, treat and track Service members as close to the point of injury as possible. Additionally, these policies have increased awareness and decreased the stigma associated with mild TBI and should help to prevent or mitigate the possibility of long-term effects associated with concussion/mTBI.
Acute care The Military has made great strides in the acute care of TBI, and particularly concussion, during the last few years. Emphasis is on consistent high quality evidencebased acute care. In addition to rapid screening of potentially concussed Service members using the MACE, standardized Concussion Management Algorithms are used to assure the most appropriate acute care and triage of injured Service members (CMA 2014). They include detailed decision tree type algorithms for combat medics/ Corpsmen, initial providers, and for providers at facilities that provide definitive care. Guidance for evaluation and care of Service members with recurrent concussions also is provided. These tools were used with great success during the conflicts in Afghanistan and Iraq. They prescribe mandatory rest for a period of time after the injury to allow the brain to recover before putting the Service member at risk for a second concussion, and a graded or stepwise return to activity/duty to assure that increasing activity does not provoke symptoms. Post-concussive symptoms are treated with an emphasis on nonpharmacologic treatment where possible, and nonnarcotic pharmacologic pain management. In Afghanistan the Military capabilities for providing rest and structured programs for return to activity were greatly enhanced through the installation of regional Concussion Care Centers (CCCs) staffed by physical and/or occupational therapists. This innovative care delivery system allowed for the local physical and cognitive rehabilitation of Service members with concussions for up to 7–10 days, structured return to duty programs, and an appropriate environment for computerized neurocognitive reassessments. Detailed clinical recommendations for improving sleep, (DVBIC Sleep CR 2014) and for the optimal use of post-injury ANAM studies,(DVBIC PostInjury ANAM CR) were developed by DVBIC and provided to the CCCs. The deployment of the CCCs resulted in an estimated 95 % reduction in the need for triage out of country for concussed Service members (personal communication, theater neurologist, 2013) The Military also systematically evaluates cognitive deficits caused by concussions with the ANAM, a computerized neurocognitive assessment tool that can be administered via a laptop computer with a mouse. Since 2007 the DoD has mandated that all deploying Service members must have a pre-deployment baseline ANAM within 12 months of deployment and to date approximately 1,650,000 Service members have been tested (data provided by the Army Neurocognitive Assessment Branch, San Antonio TX, 2015). These pre-deployment assessments are available in theater for comparison with post-injury ANAM assessments to help identify post-
Brain Imaging and Behavior Fig. 3 Exposures to potentially concussive events and concussions resulting from exposures. Blast exposure and concussion incident report (BECIR) provided by the Joint Trauma Analysis and Prevention of Injury in Combat Office of the DoD
concussive cognitive deficits, and for helping to inform return-to-duty decision making. Imaging is not recommended for uncomplicated concussions in the Military, but CT scanning capabilities are available at most higher level facilities, and were available at those facilities in Afghanistan and Iraq. In 2011–12 MRI machines were briefly used in Afghanistan but were not considered useful for the general acute care and evaluation of Service members with TBI.
from the DoD to the VA for their health care needs (DoD/ VA Program Coordination 2013). A particular focus of this initiative is to integrate the electronic health records of each Department so that physicians at a VA hospital can seamlessly interrogate a Service members DoD medical record. The DoD National Center for Telehealth and Technology (T2 2015) together with the DVBIC are exploring new technology that will allow for tracking and interacting with Service members in remote areas of the country who could benefit from care and follow up for persistent post-concussion symptoms.
Long term care Education/Training The long term consequences of TBI are a major concern of the DoD. Post-concussive symptoms and the patient’s global appraisal of the effectiveness of care are core domains of concussion health care outcomes evaluation that are currently being promoted throughout the DoD. Providers at all MTFs are being encouraged to have their concussed patients complete the Neurobehavioral Symptom Inventory (NSI) and the Patient’s Global Impression of Change (PGIC) at each concussion-related follow up visit (Meterko et al. 2012; Hurst and Bolton 2004). The goal is to use this outcome data, linked with various concussion care treatment alternatives, to help inform Bbest-practices^ for concussion care in the DoD. Co-morbidities are common in those who suffer from persistent post-concussion symptoms, so TBI patients with protracted symptoms often need multispecialty care. Because of the geographically disperse network of 11 MTF’s and 5 VA Medical Centers at which DVBIC Recovery Support Coordinators are positioned, DVBIC is uniquely able to closely track concussed Service members, assure that they receive the care they need, and monitor their progress. Long term care of injured Service members also is enhanced through the improved collaboration of the VA and DoD healthcare systems coordinated through the VA/DoD Executive Council and the VA/ DoD Health Executive Committee, two interagency governing bodies that are charged with seamlessly integrating health care delivery to Service members as they transition
The DoD has comprehensive programs for educating service members, veterans, and family members about concussion. An extensive library of TBI resource materials is available at the DVBIC website, including state-of-the-art concussion education materials intended not only for the concussed Service member but also for their family members, and for providers (DVBIC 2015b). The DoD also recognizes that it is necessary to have well-trained professionals who not only are familiar with the signs and symptoms of concussions, but can manage them effectively. The DoD has implemented TBI provider training requirements via a variety of training programs, platforms, and training modalities, including computer-based, virtual, or face-to-face, all designed to best meet the needs of its busy practitioners. Technology has made it easier to reach a large number of learners across a geographically dispersed area. This includes a monthly TBI webinar series for DoD and VA providers as well as joint, face-to-face TBI training events for military providers each quarter. Part of the mission of DoD is to identify, develop, and disseminate quality state of the science clinical guidance for treatment of TBI in the MHS. DVBIC works closely with the military services to engage in ongoing needs assessment and response to the treatment challenges. The goal is to assure that clinical providers engaged in treating Service members, Veterans and their family members have access to timely clinical
Brain Imaging and Behavior Table 1
Clinical recommendations for evaluation and treatment of concussion
Name of CR
Date released
Web location
Indications and Conditions for In-Theater post-injury Neurocognitive Assessment Tool (NCAT) testing Indications and Conditions for Neuroendocrine Dysfunction Screening Post Mild TBI Assessment and Management of Dizziness Associated with Mild TBI Assessment Management of Visual Dysfunction Associated with Mild TBI Neuroimaging Following Mild TBI in the Non-Deployed Setting Progressive Return to Activity Following Acute Concussion/Mild TBI Management of Sleep Disturbances Following Concussion/Mild TBI
May, 2011
https://dvbic.dcoe.mil/material/indications-and-conditionstheater-post-injury-neurocognitive-assessment-tool-ncat-testing https://dvbic.dcoe.mil/material/indications-and-conditionsneuroendocrine-dysfunction-screening-post-mtbi-recommendations https://dvbic.dcoe.mil/material/assessment-and-management-dizzinessassociated-mtbi-clinical-recommendation https://dvbic.dcoe.mil/material/assessment-and-managementvisual-dysfunction-associated-mtbi-clinical-recommendation https://dvbic.dcoe.mil/material/neuroimaging-following-mtbinon-deployed-setting-clinical-recommendation https://dvbic.dcoe.mil/resources/progressive-return-to-activity
August, 2012 September, 2012 January, 2013 July, 2013 January, 2014 June, 2014
knowledge that will result in optimum treatment outcomes. Based on this interaction, DVBIC has evolved a system for the development of BClinical Recommendations (CRs)^ for the rapid translation of contemporary evidence-based treatment knowledge into clinical practice. These CRs are developed through an extensive literature review, discussions by a panel of national experts, and incorporation of feedback from each of the Services so that the final recommendations will not only reflect current evidence, but also will be practical. To date 7 different CRs have been developed through this process. (Table 1)
Current research priorities in the military Despite intensive prevention programs and sophisticated helmets and body armor, TBI, and particularly concussion, remains a common problem for the military. Concussion has been described as a silent injury because, unlike a traumatic limb amputation, the wound is often invisible and manifest as headaches, PTSD, depression, memory disturbances, or other disabling cognitive problems. A recent clinical study of Service members exposed to blasts showed signs of mental disability even if they were not diagnosed with brain injury (MacDonald et al. 2014). With potential long-term deleterious effects, and more than 3 million individuals in the US living with some type of disability related to the consequences of TBI, it has emerged as a chronic health condition and a high priority area of research for the DoD (Zaloshnja et al. 2008). Therefore, the DoD currently supports hundreds of basic science and clinical TBI research programs. DVBIC is directly involved with 60 of those studies, more than half of which focus on epidemiology. DVBIC supported studies also include projects related to TBI prevention, screening, treatment, rehabilitation, and reintegration. Among many critical
https://dvbic.dcoe.mil/material/management-sleep-disturbances/ clinical-recommendation
areas of need are early objective diagnostics, the potential for long term neurologic disability including chronic traumatic encephalopathy (CTE), and cognitive disability.
Objective diagnostics for concussion The definition of concussion is subjective, and to date there is no validated biomarker, physiologic test or other objective methods for establishing the diagnosis. In part this is because concussion is due to physiologic dysfunction or disruption, and not typically associated with anatomic injury such as might be visualized on a CT image. In 2010 an expert working group convened by DVBIC concluded that a combination of clinical tests would be most promising for the early diagnosis of concussion, and would optimally include tests of pupil reaction, postural stability and visual tracking, as well as serum biomarkers and EEG (Marion et al. 2011). However, subsequent studies have concluded that serum biomarkers may not appear in detectable amounts, or for longer than a few hours, following a concussion (Papa et al. 2015). Studies of eye tracking devices have found that some eye movement abnormalities are associated with concussion, but also with sleep deprivation, lack of concentration, and other confounds (Maruta and Ghajar 2014). There currently is increasing interest in testing physiologic systems most often affected by trauma, such as balance, reaction time, memory, and other relatively non-orthogonal physiologic systems, with the use of smartphone apps. The premise is that concussion typically disturbs one or more physiologic systems, but that the system or combination of systems affected varies among different individuals or among different severities of injury. However, if those systems can be objectively assessed, and the results of those assessments integrated, a highly sensitive and specific prediction of concussion could potentially be derived.
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Relationship of blast and multiple TBI with long term neurologic disability such as CTE The DoD’s Congressionally mandated 15 year longitudinal study on the effects of TBI from OEF/OIF started in 2011 and continues to provide information on the needs of service members and veterans with TBI of all severities, as well as information about the quality of life and impact of the TBI on caregivers of service members and veterans with TBI (DVBIC 2014). In addition to extensive neuropsychological testing at periodic intervals, the study also includes extensive MRI with sophisticated imaging techniques so that ultimately it will be possible to identify those most at risk for long term disability from TBI, and thereby identify preventive or therapeutic measures to reduce that risk. An interagency research action plan entitled the National Research Action Plan (NRAP) was developed in direct response to a Presidential Order to accelerate the discovery of the causes and mechanisms underlying TBI and other cooccurring conditions (NRAP 2012). One of the goals of the NRAP is to determine the chronic effects and long term outcomes following TBI, and to identify long-term health needs and resources required for the care for TBI patients. The DoD has also established vital partnerships with the NFL and NCAA on this topic to track athletes and Service members with TBI longitudinally. Through the Center for Neuroscience and Regenerative Medicine (CNRM) a brain tissue repository to study the long-term effects of TBI and differences between blast exposed and non-blast exposed brain tissues was developed (CNRM 2015). Together with the Department of Veterans Affairs, the DoD is sponsoring the chronic effects of neurotrauma consortium (CENC 2014). The CENC is a coordinated, multicenter collaboration linking basic science, translational, and clinical neuroscience researchers from the VA, military, and academia to effectively address the long-term effects of concussion and its diagnosis and treatment. The Consortium brings together a nationwide group of researchers who have extensive experience with internal and external collaborations, demonstrated productivity in knowledge translation and dissemination, and the proven ability to recruit and follow up with research subjects. The overarching goals of the CENC are to examine the critical issues related to the identification and characterization of the anatomic, molecular, and physiological mechanisms of chronic brain injury and potential neurodegeneration, to investigate the relationship of comorbidities of trauma and combat exposure to mild TBI and neurodegeneration, and to assess the efficacy of existing and novel treatment strategies for chronic TBI effects and neurodegeneration. Current studies in development include a longitudinal cohort study to identify and assess the long-term effects of concussion in active duty and Veteran service members with a history of OEF/OIF/OND deployment and combat exposure, and a basic-science animal
study to determine the effects of a concussion on the production of Tau protein. Cognitive dysfunction is the leading cause of disability following TBI (Rabinowitz and Levin 2014). Some of the most common deficits are loss or reduction of short term memory, difficulties forming or retaining new memories, confusion, or disorientation. Such cognitive deficits have led to profound functional disability in many Service members who remain symptomatic months or years after their injury. Dean and Sterr (2013) studied the long term effects of concussion on cognitive performance and found a correlation between cognitive performance and symptoms in concussed subjects with worse performance correlating with lower sleep quality, higher post-concussion symptoms, PTSD and anxiety. In 2010 Congress directed the Secretary of Defense to conduct a clinical trial to evaluate the efficacy of cognitive rehabilitation therapy for OEF/OIF service members who sustained a mild TBI and had persistent cognitive impairments. In compliance with this mandate a study of cognitive rehabilitation effectiveness after concussion (SCORE 2011) was initiated to evaluate the efficacy of cognitive rehabilitation therapy for Service members diagnosed with concussion while deployed in OEF/OIF, and who reported cognitive difficulties 3– 24 months after their injury. Study participants were assigned to 6 weeks of therapy in one of four treatment arms and evaluated at 3, 6, 12 and 18 weeks following initiation of the study. The 4 treatment paradigms were designed to include the best available cognitive rehabilitation treatment strategies. Study participants were assessed for improvement in cognitive functioning, post concussive symptoms, cognitive complaints, cognitive fatigue, quality of life, health care utilization and work status. The data is currently being analyzed and the study is intended to identify which, if any, of the 4 treatment arms are most effective.
Summary TBI, and especially concussion, remains a significant concern for Military medicine. The most common mechanism of injury in both the Afghanistan and Iraq conflicts was improvised explosive devices leading to blast, or blast plus blunt, head injuries, and the incidence of severe and penetrating injuries has been very low (French 2010). The DoD has made great strides in identifying concussion despite a military culture that traditionally fosters a Bget back to the fight^ attitude. This was facilitated with the widespread implementation of the MACE, an easy to use concussion evaluation system, and a new incident-based reporting system. Through these robust surveillance efforts it became apparent that non-deployment related TBIs are more common than combat related injuries. Therefore, the DoD has focused on garrison or home station injuries and youth sports concussions as well as injuries that
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occur in the deployed environment. Innovative, state-of-theart clinical and educational programs for TBI/concussion prevention, identification, evaluation, acute care, long term care and education and training have been implemented. Clinical and translational TBI research also is a priority for the DoD, with an emphasis on translating research findings into state of the science clinical recommendations. The Defense Department is committed to providing standardized, evidence-based medical care. This can best be accomplished through coordination of care across the continuum, beginning with prevention and ending with reintegration, by implementing TBI Bpathways of care^. The goal is to systematically monitor outcomes following a TBI and to modify treatment recommendations or strategies to conform to best practices, as identified by outcomes analyses. DVBIC is uniquely positioned to manage the development, refinement and implementation of TBI pathways of care through understanding the political and military drivers of medical care, visibility of proposed and ongoing TBI research, standardizing and evaluating TBI clinical care, and providing or ensuring a common platform for all DoD TBI education. The goal is to accomplish these objectives through close collaboration with the individual Services. Benefits of this centralized coordination are that disparate sources of TBI research, education, and clinical care can be evaluated for, and limited resources can be expended, in keeping with the needs of the patients, their providers and caregivers. Collaborations and partnerships with other public or private organizations which already have identified solutions to shortcomings in TBI care allow for adoption of those solutions at considerable cost savings. Ultimately the goal is to assure that the best and most effective TBI care is available in a timely fashion to all of those who have dedicated their lives to the service of our Military.
Challenges for the future Concussion is by far the most common type of TBI in the Military, and the Military Health System is focused on addressing several key concussion-related challenges. The definition of concussion currently used by the Military is subjective and heavily dependent on information provided by the concussed patient. This can lead to the significant over- or underdiagnosis which can have important implications for appropriate return-to-duty decision making. As a result, the DoD is focused on the development or identification of an objective test of the presence or absence of concussion, as well as the severity of the concussion. Such a test might include one or a combination of serum biomarkers, or tests for neurophysiologic dysfunction. Ideally this objective test for concussion will be administered via a highly mobile platform amenable for use in austere environments. An additional challenge is
that a large proportion of concussions occur in garrison, so safety and injury prevention measures must be pervasive, innovative and effective. The chronic effects of single and especially multiple blast and blunt concussions also are of concern, and both the DoD and VA are collaborating to support short and long term research programs intended to identify personal and environmental risk factors for long term cognitive or other neurologic dysfunction following TBI.
Disclaimer The views expressed in this publication are those of the authors and do not represent official views or policy of the Department of Defense, Department of Veterans Affairs, the Department of Health and Human Services, The United States Public Health Service, or the United States Government. Statement of Compliance with Ethical Standards None of the authors (Katherine M. Helmick, Cynthia A. Spells, Saafan Z. Malik, Cathleen A. Davies, and Donald W. Marion) have potential conflicts of interest with any of the material presented in this manuscript. This is a review of previously published studies, and is not new research involving human participants or animals. As a result, there is no requirement for informed consent.
References A Head for the Future (2015): http://dvbic.dcoe.mil/aheadforthefuture ANAM (2012): http://www.dcoe.mil/content/Navigation/Documents/ About%20ANAM.pdf CENC (2014): https://cenc.rti.org/ CMA (2014): https://dvbic.dcoe.mil/material/concussion-managementalgorithm-cma-pocket-cards CNRM (2015): http://www.usuhs.mil/cnrm/ Dean, P., & Sterr, A. (2013). Long term effects of mild TBI on cognitive performance. Frontiers in Human Neuroscience, 7, 30. DoD/VA Program Coordination (2013): http://www.tricare.mil/DVPCO/ joint-exe.cfm DoDI 6490.11 (2012): http://www.usaisr.amedd.army.mil/assets/cpgs/ DODI_6490.11_Policy_Guidance_for_Mgmt_of_Mild_ Traumatic_Brain_Injury_or_Concussion_in_the_Deployed_ Setting.pdf DVBIC (2012): https://www.jsomonline.org/TBI/MACE_Revised_ 2012.pdf DVBIC (2015a): http://dvbic.dcoe.mil/dod-worldwide-numbers-tbi DVBIC (2015b): http://dvbic.dcoe.mil/resources DVBIC Sleep CR (2014): https://dvbic.dcoe.mil/resources/managementsleep-disturbances French, L. M. (2010). Military traumatic brain injury: an examination of important differences. Annals of the New York Academy of Sciences, 1208, 38–45. doi:10.1111/j.1749-6632.2010.05696.x. French, L., McCrea, M., & Baggett, M. (2008). The military acute concussion evaluation. (MACE). Journal of Special Operations Medicine, 8(1), 68–77. Hurst, H., & Bolton, J. (2004). Assessing the clinical significance of change scores recorded on subjective outcome measures. Journal of Manipulative and Physiological Therapeutics, 27(1), 26–35. Incident –based reporting (2010): http://dvbic.dcoe.mil/sites/default/files/ uploads/Line%20Leader%20Fact%20Sheet%202012_V3_Final% 20.pdf
Brain Imaging and Behavior Institute of Medicine (IOM) and National Research Council (NRC). (2013). Sports-related concussion in youth: Improving the science, changing the culture. Washington: The National Academies Press. MacDonald, C., Johnson, A., Wierzerchowski, L., Kassner, E., Stewart, T., Nelson, E., Werner, N., Zonies, D., Oh, J., Fang, R., & Brody, D. (2014). Prospective assessed clinical outcomes in concussive blast vs nonblast traumatic brain injury among evecuated US military personnel. JAMA Neurology, 71(8), 994–1002. MacFarlane, M. P., & Glenn, T. C. (2015). Neurochemical cascade of concussion. Brain Injury, 29(2), 139–53. Marion, D. W., Curley, K. C., Schwab, K., Hicks, R. R., & mTBI Diagnostics Workgroup. (2011). Proceedings of the military mTBI Diagnostics Workshop, St. Pete Beach, August 2010. Journal of Neurotrauma, 28(4), 517–26. doi:10.1089/neu.2010.1638. Maruta, J., & Ghajar, J. (2014). Detecting eye movement abnormalities from concussion. Progress in Neurological Surgery, 28, 226–33. doi:10.1159/000358786. Meterko, M., Baker, E., Stolzmann, K. L., Hendricks, A. M., Cicerone, K. D., & Lew, H. L. (2012). Psychometric assessment of the neurobehavioral symptom inventory-22: the structure of persistent postconcussive symptoms following deployment-related mild traumatic brain injury among veterans. The Journal of Head Trauma Rehabilitation, 27(1), 55–62. doi:10.1097/HTR.0b013e318230fb17. NRAP 2012: The White House- National Research Action Plan (2012): http://www.whitehouse.gov/sites/default/files/uploads/nrap_for_ eo_on_mental_health_august_2013.pdf Owens, B. D., Kragh, J. F., Wenke, J. C., Macaitis, J., Wade, C. E., & Holcomb, J. B. (2008). Combat wounds in operation Iraqi freedom
and operation enduring freedom. The Journal of Trauma, 64, 295– 99. Papa L, Ramia MM, Edwards D, Johnson BD, Slobounov SM (2015) Systematic review of clinical studies examining biomarkers of brain injury in athletes after sports-related concussion. Journal of Neurotrauma, 32(10), 661–673. PDHA (2008): http://www.pdhealth.mil/dcs/dd_form_2796.asp PDHRA (2008): http://www.armyg1.army.mil/hr/pdhra/ Rabinowitz, A. R., & Levin, H. S. (2014). Cognitive sequelae of traumatic brain injury. The Psychiatric Clinics of North America, 37(1), 1– 11. doi:10.1016/j.psc.2013.11.004. Regasa LE, Thomas M, Gill R, Marion DW, Ivins BJ (2015) Military deployment may increase the risk for TBI following deployment. The Journal of Head Trauma Rehabilitation, in press. Scholten, J. D., Sayer, N. A., Vanderploeg, R. D., Bidelspach, D. E., & Cifu, D. X. (2012). Analysis of US veterans health administration comprehensive evaluations for traumatic brain injury in operation enduring freedom and operation Iraqi freedom veterans. Brain Injury, 26(10), 1177–84. SCORE (2011): https://clinicaltrials.gov/ct2/show/NCT01339806 T2 (2015): http://t2health.dcoe.mil/ VA (2010): http://www.va.gov/optometry/docs/vha_directive_2010012_screening_and_evaluation_of_possible_tbi_in_oef-oif_ veterans.pdf Zaloshnja, E., Miller, T., Langlois, J. A., & Selassie, A. W. (2008). Prevalence of long-term disability from traumatic brain injury in the civilian population of the United States, 2005. The Journal of Head Trauma Rehabilitation, 23(6), 394–400.
MILITARY/VETERAN TBI
Traumatic brain injury in the US military: epidemiology and key clinical and research programs Katherine M. Helmick 1 & Cynthia A. Spells 1 & Saafan Z. Malik 1 & Cathleen A. Davies 1 & Donald W. Marion 1 & Sidney R. Hinds 1
# Springer Science+Business Media New York (outside the USA) 2015
Abstract Traumatic brain injury (TBI), and particularly concussion, is a major concern for the U.S. Military because of the associated short term disability, long term cognitive and pain symptoms suffered by some, and risk of prolonged or permanent neurologic injury if the Service member incurs a second TBI before full recovery from the first. Concussions were seen more often during the recent conflicts in Afghanistan and Iraq than in prior conflicts, such as the Vietnam War, because of the use of improvised explosive devices that typically caused nonpenetrating closed head injury. Since 2000 more than 300,000 Service members were diagnosed with TBI, of which more than 80 % were concussions. Improved TBI screening tools also have identified a higher than expected incidence of concussions occurring in garrison. In this review we summarize current epidemiologic data for TBI in the Military, and describe contemporary Military procedures and strategies for TBI prevention, identification, evaluation, and acute and chronic care. Key TBI clinical research priorities and programs are described, and innovative organizational plans to address future TBI needs are summarized.
Keywords Traumatic brain injury . Military . Department of Defense . Concussion . Surveillance . Clinical recommendations
* Katherine M. Helmick [email protected] Donald W. Marion [email protected] 1
DVBIC/DCoE Headquarters, 1335 East West Hwy, Suite 605, Silver Spring, MD 20910, USA
Scope of the problem Traumatic brain injury (TBI), and especially mild TBI or concussion, is the most common traumatic injury in the Military. Since 2000 more than 310,000 active duty service members, National Guard members and reservists have been diagnosed with TBI, most occurring in the garrison or the home station environment (DVBIC 2015a). The prevalence of these injuries has compelled Congress to invest in the development of policies and programs that support evidence-based care for the full continuum of TBI, from concussions to severe and penetrating brain injuries. Although the Department of Defense (DoD) has made great strides in the areas of TBI clinical care, education, and research, there remains an urgent need to leverage technology, research, and education to inform the most effective policies that will maximize care of service members and veterans. In the DoD, TBI care provided by the Army, Navy, and Air Force is enhanced, and in some respects coordinated, by the Defense and Veterans Brain Injury Center (DVBIC). DVBIC is a DoD agency originally created by Congress in 1992 as a research organization, and enlarged in the early 2000’s to include clinical and educational programs. In collaboration with the Armed Forces Health Surveillance Center (AFHSC) and the Joint Trauma Analysis and Prevention of Injury in Combat (JTAPIC) Directorate, DVBIC’s Surveillance office tracks incident cases of TBI in Service members worldwide (DVBIC 2015a). Since 2000, the vast majority (82.4 %) have been concussions (e.g., mild TBI), only approximately 1 % are severe injuries that render the Service member comatose for prolonged periods, and only 1.5 % are penetrating injuries. (See Fig. 1) This likely reflects the fact that the most common mechanism of injury during the Afghanistan and Iraq conflicts was improvised explosive devices, so blast injuries or blast combined with blunt injuries were more common than in
Brain Imaging and Behavior
DoD Numbers for Traumatic Brain Injury Worldwide - Totals 2000 -2014 Q2 Penetrating Severe Moderate Mild Not Classifiable Total - All Severities
4,538 3,088 25,370 253,350 20,937
6.8%
1.5% 1.0%
8.3%
82.4%
307,283
Fig. 1 Incidence of traumatic brain injury in the Department of Defense since 2000. Figure courtesy of DVBIC, data provided by the Armed Forces Health Surveillance Center
previous conflicts, and penetrating injuries far less common. Gunshot wounds in Afghanistan and Iraq were 19 % of all injuries, compared with 35 % in Vietnam and 27 % during World War II. Conversely, 81 % of injuries in Afghanistan and Iraq were explosion-related, compared with 65 % in Vietnam and 73 % in World War II (Owens et al. 2008). In 2007 extensive mandatory concussion screening programs were implemented throughout the DoD, including the creation and field utilization of the Military Acute Concussion Evaluation (MACE) (French et al. 2008; DVBIC 2012). This led to an abrupt increase in the reporting of TBI, though not necessarily in the actual incidence. (Fig. 2) The incidence of TBI does appear to be declining from a peak of more than 32, 000 cases per year in 2011. However, even with the end of combat operations in Afghanistan and Iraq there will likely be 20,000 or more cases per year in the DoD because the majority appear to occur in the non-deployed environment as a result of motor vehicle crashes (privately owned and military vehicles), falls, sports, and recreational activities, and military training (DVBIC 2015a). Although more than 80 % of TBIs are diagnosed before or after deployment, some of those injuries actually were deployment related injuries diagnosed weeks or months after return from deployment. Recent studies have found that the pre-deployment (e.g., garrison) incidence rate for TBI is 119.8/100,000, and highest in the Army (147.3/100,000) and the Marines (114.8/100,000) (Regasa et al. 2015). Immediately following deployment the risk of being diagnosed with TBI is as high as 8.4 times that of the risk before deployment. The risk decreases thereafter up to 40 weeks post deployment. Post-deployment screening programs, including the Post Deployment Health Assessment, Post Deployment Health Reassessment, and the Veterans Affairs (VA) TBI Screen (VA 2010) have been very effective in identifying previously deployed Service members who had a TBI during deployment. For example, from April of 2007 through September of 2010, nearly 300,000 Veterans of Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF)/Operation New Dawn (OND) were screened for possible deployment-related
concussion; 55,070 had positive screens, and approximately 55 % of those were confirmed to have had a concussion (Scholten et al. 2012). Thus, 30,267 veterans were not discovered to have had a deployment related concussion for weeks or months after their injury. In addition, just the experience of having been deployed can increase the long term risk for TBI in garrison by nearly 2 fold (Regasa et al. 2015). Because the majority of TBI in the Military occurs in garrison, there remains significant concern about TBI even though OEF/OIF/ OND have concluded. Since the majority of Service members are young adults, it is not surprising that a substantial proportion of the concussions that occur in garrison are sports-related concussions. The Institute of Medicine (IOM) Report: Sports-Related Concussions in Youth: Improving the Science, Changing the Culture 2013 reviewed the science of sports-related concussion in youth from elementary school through young adulthood, including military personnel and their dependents.(Institute of Medicine (IOM) and National Research Council (NRC) 2013) DVBIC supported and participated in the production of this Report, in part because there is a natural synergy between the examination of the occurrence of concussion in garrison and youth sports concussion. The culture of Bshake it off and get back in the game^ is as prevalent in combat as it is in sports. But without timely and appropriate concussion treatment there is an increased risk for less than optimal patient outcomes, the possibility of longterm neurologic damage, and an increased risk for subsequent injury. Part of the IOM Committee’s report examined sportsrelated concussions among military dependents as well as concussions in military personnel ages 18 to 21 that result from sports and physical training at military service academies or during recruit training. The report yielded six recommendations for federal agencies and the DoD to focus on in order to improve the surveillance and prevention of concussions in athletes: & &
&
&
…establish and oversee a national surveillance system to accurately determine the incidence of sports-related concussions, including those in youth ages 5–21… …research to establish objective, sensitive and specific metrics and markers of concussion diagnosis, prognosis and recovery…and to inform creation of age-specific evidence-based guidelines for the management of concussion sequelae… …conduct controlled, longitudinal studies to assess short and long-term cognitive, emotional, behavioral, neurobiological, and neuropathological consequences of concussions and repetitive head impacts… …undertake a rigorous scientific evaluation of the effectiveness of age-appropriate techniques, rules, and playing and practice standards in reducing sports-related concussions…
Brain Imaging and Behavior Annual TBI in DoD (2000 - 2014Q2) total: 307,283
# of TBI's Diagnosed
Fig. 2 The annual incidence of traumatic brain injury in the Department of Defense, since 2000. Data provided by the Armed Forces Health Surveillance Center and analyzed by DVBIC
*
2000 Total TBI's 10,958
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014Q2
11,619
12,407
12,815
14,468
15,529
17,037
23,217
28,464
28,880
29,199
32,668
30,615
27,324
12,083
* Only data of Jan - Jun 2014 areavailable.
& &
…research on age- and sex-related biomechanical determinants of injury risk for concussion in youth… …develop, implement and evaluate the effectiveness of large-scale efforts to increase knowledge about concussions and change in social norms, attitudes and behavior surrounding concussions…
In response to these recommendations, the DoD is aggressively pursuing research and educational programs to better understand how concussions are being tracked and managed at its training facilities, including the four service academies. For example, at the US Naval Academy a better understanding of post-concussive cognitive deficits in Midshipman is now possible as the result of an initiative to collect computerized neurocognitive baseline data for all 4800 Midshipmen at the Academy using the Automated Neuropsychological Assessment Metric (ANAM), accomplished over the course of 2 years (ANAM 2012). As a result, post-injury ANAM study results can now be compared with the individual Midshipman’s personal baseline study. In addition, an assessment of all Service academies’ sideline evaluations during organized sporting events are being evaluated to assure state of the science approaches for concussion evaluations.
Priority focus areas Prevention Prevention of TBI has become an increasingly important concern of the Military Health System (MHS) in view of the surveillance data that shows that most TBI in the Military occurs as a result of non-combat related activities such as motor vehicle crashes or sports injuries. DVBIC recognized the need for a comprehensive injury prevention program aimed at Service members and their families, and in 2014 launched BA Head for the Future^, a multi-year campaign aimed to increase prevention, awareness and education of
mild TBI for service members, veterans, and their beneficiaries through multimedia materials and strategic outreach events (A Head for the Future 2015). The initiative also has a dedicated website with links to the training sites for the services, the VA BMake the Connection^ website, and other federal partners including the Centers for Disease Control and Prevention (CDC) website as well as that of the Health Resources and Services Administration (HRSA). In addition, significant partnerships with the National Collegiate Athletic Associateion (NCAA), the National Football League (NFL), and several academic institutions have been established to increase awareness of the prevention and treatment of TBI. Identification/Evaluation The early detection and diagnosis of mild TBI and early treatment results in the best outcomes, and will help prevent a second concussion before recovery from the first. It is now clear that concussive injury initiates a complex cascade of pathophysiological changes that include hyper-acute ionic flux, indiscriminant excitatory neurotransmitter release, acute hyperglycolysis and sub-acute metabolic depression (MacFarlane and Glenn 2015). These metabolic changes can lead to impaired neurotransmission, alternate fuel usage and modifications in synaptic plasticity and protein expression, metabolic alterations that likely cause the transient and prolonged cognitive deficits that characterize concussion. Most importantly, if the Service member were to sustain a second concussion before full recovery of these metabolic abnormalities, there is a high risk for long term or permanent neurologic injury. As a result, the DoD through DVBIC has created tools and programs intended to facilitate the early identification of deployed Service members suspected of, or at risk for, a concussion. Some of the earliest TBI screening programs were implemented at Landstuhl Regional Medical Center in 2006. All Service members evacuated for medical reasons, regardless of combat, non-combat, or illness designation, received a standardized evaluation
Brain Imaging and Behavior
utilizing the Military Acute Concussion Evaluation (MACE). Since that time the MACE has undergone 4 revisions and is now a mandatory screening tool for use by combat medics and corpsmen evaluating any Service member suspected of having a concussion. DVBIC also has developed Concussion Management Algorithms with detailed instructions for providers at all skill levels to help assure consistent high quality concussion care throughout the DoD (CMA 2014). Since 2008 TBI assessment questions have been included in the PDHA and PDHRA forms which are health-status screening tools that all Service members are required to complete following each deployment (PDHA 2008; PDHRA 2008). This screening program requires a face-to-face evaluation with a clinician upon arrival to their home duty station. Most programs intended for early identification of concussion have been frustrated by a Military culture that has traditionally discouraged a Service member from admitting that he or she has been hurt, and promotes getting back to the fight. This concern was addressed in 2010 when the DoD implemented an incident-based system of reporting which required field commanders to remove from combat and report all Service members under their command who were exposed to a potentially concussive event. This new directive pertains to all deployed Service members who were within 50 m of a blast, were in a building or vehicle exposed to a blast, had a direct blow to the head or witnessed loss of consciousness, were exposed to more than one blast event, or were simply thought to require further evaluation by their commander (Incident – based reporting 2010). After reporting the incident, a medical evaluation is mandated before the Service member can return to duty. Quarterly data regarding exposure to concussive events and the proportion of those Service members actually diagnosed with a concussion is described in Fig. 3. During August, 2010 through June, 2014, there were 16,760 SMs who met one or more of these criteria. Among those, 16.3 % or 2734 were diagnosed with a concussion. In addition, a Department of Defense Instruction (DoDI) mandates a 24 h rest period for the first concussion and a 7 day rest period if there have been two diagnosed concussions within 12 months (DoDI 6490.11 2012). If 3 or more concussions have been documented within a 12 month period the Service member must undergo a comprehensive neurologic/cognitive evaluation prior to return to duty. In June of 2013 the Army implemented a similar incident-based policy for acute management of Soldiers who are involved in potentially concussive events while in the garrison environment. Therefore, between the theater and garrison policies the Army has one worldwide standard of care to educate Army personnel and to identify, treat and track Service members as close to the point of injury as possible. Additionally, these policies have increased awareness and decreased the stigma associated with mild TBI and should help to prevent or mitigate the possibility of long-term effects associated with concussion/mTBI.
Acute care The Military has made great strides in the acute care of TBI, and particularly concussion, during the last few years. Emphasis is on consistent high quality evidencebased acute care. In addition to rapid screening of potentially concussed Service members using the MACE, standardized Concussion Management Algorithms are used to assure the most appropriate acute care and triage of injured Service members (CMA 2014). They include detailed decision tree type algorithms for combat medics/ Corpsmen, initial providers, and for providers at facilities that provide definitive care. Guidance for evaluation and care of Service members with recurrent concussions also is provided. These tools were used with great success during the conflicts in Afghanistan and Iraq. They prescribe mandatory rest for a period of time after the injury to allow the brain to recover before putting the Service member at risk for a second concussion, and a graded or stepwise return to activity/duty to assure that increasing activity does not provoke symptoms. Post-concussive symptoms are treated with an emphasis on nonpharmacologic treatment where possible, and nonnarcotic pharmacologic pain management. In Afghanistan the Military capabilities for providing rest and structured programs for return to activity were greatly enhanced through the installation of regional Concussion Care Centers (CCCs) staffed by physical and/or occupational therapists. This innovative care delivery system allowed for the local physical and cognitive rehabilitation of Service members with concussions for up to 7–10 days, structured return to duty programs, and an appropriate environment for computerized neurocognitive reassessments. Detailed clinical recommendations for improving sleep, (DVBIC Sleep CR 2014) and for the optimal use of post-injury ANAM studies,(DVBIC PostInjury ANAM CR) were developed by DVBIC and provided to the CCCs. The deployment of the CCCs resulted in an estimated 95 % reduction in the need for triage out of country for concussed Service members (personal communication, theater neurologist, 2013) The Military also systematically evaluates cognitive deficits caused by concussions with the ANAM, a computerized neurocognitive assessment tool that can be administered via a laptop computer with a mouse. Since 2007 the DoD has mandated that all deploying Service members must have a pre-deployment baseline ANAM within 12 months of deployment and to date approximately 1,650,000 Service members have been tested (data provided by the Army Neurocognitive Assessment Branch, San Antonio TX, 2015). These pre-deployment assessments are available in theater for comparison with post-injury ANAM assessments to help identify post-
Brain Imaging and Behavior Fig. 3 Exposures to potentially concussive events and concussions resulting from exposures. Blast exposure and concussion incident report (BECIR) provided by the Joint Trauma Analysis and Prevention of Injury in Combat Office of the DoD
concussive cognitive deficits, and for helping to inform return-to-duty decision making. Imaging is not recommended for uncomplicated concussions in the Military, but CT scanning capabilities are available at most higher level facilities, and were available at those facilities in Afghanistan and Iraq. In 2011–12 MRI machines were briefly used in Afghanistan but were not considered useful for the general acute care and evaluation of Service members with TBI.
from the DoD to the VA for their health care needs (DoD/ VA Program Coordination 2013). A particular focus of this initiative is to integrate the electronic health records of each Department so that physicians at a VA hospital can seamlessly interrogate a Service members DoD medical record. The DoD National Center for Telehealth and Technology (T2 2015) together with the DVBIC are exploring new technology that will allow for tracking and interacting with Service members in remote areas of the country who could benefit from care and follow up for persistent post-concussion symptoms.
Long term care Education/Training The long term consequences of TBI are a major concern of the DoD. Post-concussive symptoms and the patient’s global appraisal of the effectiveness of care are core domains of concussion health care outcomes evaluation that are currently being promoted throughout the DoD. Providers at all MTFs are being encouraged to have their concussed patients complete the Neurobehavioral Symptom Inventory (NSI) and the Patient’s Global Impression of Change (PGIC) at each concussion-related follow up visit (Meterko et al. 2012; Hurst and Bolton 2004). The goal is to use this outcome data, linked with various concussion care treatment alternatives, to help inform Bbest-practices^ for concussion care in the DoD. Co-morbidities are common in those who suffer from persistent post-concussion symptoms, so TBI patients with protracted symptoms often need multispecialty care. Because of the geographically disperse network of 11 MTF’s and 5 VA Medical Centers at which DVBIC Recovery Support Coordinators are positioned, DVBIC is uniquely able to closely track concussed Service members, assure that they receive the care they need, and monitor their progress. Long term care of injured Service members also is enhanced through the improved collaboration of the VA and DoD healthcare systems coordinated through the VA/DoD Executive Council and the VA/ DoD Health Executive Committee, two interagency governing bodies that are charged with seamlessly integrating health care delivery to Service members as they transition
The DoD has comprehensive programs for educating service members, veterans, and family members about concussion. An extensive library of TBI resource materials is available at the DVBIC website, including state-of-the-art concussion education materials intended not only for the concussed Service member but also for their family members, and for providers (DVBIC 2015b). The DoD also recognizes that it is necessary to have well-trained professionals who not only are familiar with the signs and symptoms of concussions, but can manage them effectively. The DoD has implemented TBI provider training requirements via a variety of training programs, platforms, and training modalities, including computer-based, virtual, or face-to-face, all designed to best meet the needs of its busy practitioners. Technology has made it easier to reach a large number of learners across a geographically dispersed area. This includes a monthly TBI webinar series for DoD and VA providers as well as joint, face-to-face TBI training events for military providers each quarter. Part of the mission of DoD is to identify, develop, and disseminate quality state of the science clinical guidance for treatment of TBI in the MHS. DVBIC works closely with the military services to engage in ongoing needs assessment and response to the treatment challenges. The goal is to assure that clinical providers engaged in treating Service members, Veterans and their family members have access to timely clinical
Brain Imaging and Behavior Table 1
Clinical recommendations for evaluation and treatment of concussion
Name of CR
Date released
Web location
Indications and Conditions for In-Theater post-injury Neurocognitive Assessment Tool (NCAT) testing Indications and Conditions for Neuroendocrine Dysfunction Screening Post Mild TBI Assessment and Management of Dizziness Associated with Mild TBI Assessment Management of Visual Dysfunction Associated with Mild TBI Neuroimaging Following Mild TBI in the Non-Deployed Setting Progressive Return to Activity Following Acute Concussion/Mild TBI Management of Sleep Disturbances Following Concussion/Mild TBI
May, 2011
https://dvbic.dcoe.mil/material/indications-and-conditionstheater-post-injury-neurocognitive-assessment-tool-ncat-testing https://dvbic.dcoe.mil/material/indications-and-conditionsneuroendocrine-dysfunction-screening-post-mtbi-recommendations https://dvbic.dcoe.mil/material/assessment-and-management-dizzinessassociated-mtbi-clinical-recommendation https://dvbic.dcoe.mil/material/assessment-and-managementvisual-dysfunction-associated-mtbi-clinical-recommendation https://dvbic.dcoe.mil/material/neuroimaging-following-mtbinon-deployed-setting-clinical-recommendation https://dvbic.dcoe.mil/resources/progressive-return-to-activity
August, 2012 September, 2012 January, 2013 July, 2013 January, 2014 June, 2014
knowledge that will result in optimum treatment outcomes. Based on this interaction, DVBIC has evolved a system for the development of BClinical Recommendations (CRs)^ for the rapid translation of contemporary evidence-based treatment knowledge into clinical practice. These CRs are developed through an extensive literature review, discussions by a panel of national experts, and incorporation of feedback from each of the Services so that the final recommendations will not only reflect current evidence, but also will be practical. To date 7 different CRs have been developed through this process. (Table 1)
Current research priorities in the military Despite intensive prevention programs and sophisticated helmets and body armor, TBI, and particularly concussion, remains a common problem for the military. Concussion has been described as a silent injury because, unlike a traumatic limb amputation, the wound is often invisible and manifest as headaches, PTSD, depression, memory disturbances, or other disabling cognitive problems. A recent clinical study of Service members exposed to blasts showed signs of mental disability even if they were not diagnosed with brain injury (MacDonald et al. 2014). With potential long-term deleterious effects, and more than 3 million individuals in the US living with some type of disability related to the consequences of TBI, it has emerged as a chronic health condition and a high priority area of research for the DoD (Zaloshnja et al. 2008). Therefore, the DoD currently supports hundreds of basic science and clinical TBI research programs. DVBIC is directly involved with 60 of those studies, more than half of which focus on epidemiology. DVBIC supported studies also include projects related to TBI prevention, screening, treatment, rehabilitation, and reintegration. Among many critical
https://dvbic.dcoe.mil/material/management-sleep-disturbances/ clinical-recommendation
areas of need are early objective diagnostics, the potential for long term neurologic disability including chronic traumatic encephalopathy (CTE), and cognitive disability.
Objective diagnostics for concussion The definition of concussion is subjective, and to date there is no validated biomarker, physiologic test or other objective methods for establishing the diagnosis. In part this is because concussion is due to physiologic dysfunction or disruption, and not typically associated with anatomic injury such as might be visualized on a CT image. In 2010 an expert working group convened by DVBIC concluded that a combination of clinical tests would be most promising for the early diagnosis of concussion, and would optimally include tests of pupil reaction, postural stability and visual tracking, as well as serum biomarkers and EEG (Marion et al. 2011). However, subsequent studies have concluded that serum biomarkers may not appear in detectable amounts, or for longer than a few hours, following a concussion (Papa et al. 2015). Studies of eye tracking devices have found that some eye movement abnormalities are associated with concussion, but also with sleep deprivation, lack of concentration, and other confounds (Maruta and Ghajar 2014). There currently is increasing interest in testing physiologic systems most often affected by trauma, such as balance, reaction time, memory, and other relatively non-orthogonal physiologic systems, with the use of smartphone apps. The premise is that concussion typically disturbs one or more physiologic systems, but that the system or combination of systems affected varies among different individuals or among different severities of injury. However, if those systems can be objectively assessed, and the results of those assessments integrated, a highly sensitive and specific prediction of concussion could potentially be derived.
Brain Imaging and Behavior
Relationship of blast and multiple TBI with long term neurologic disability such as CTE The DoD’s Congressionally mandated 15 year longitudinal study on the effects of TBI from OEF/OIF started in 2011 and continues to provide information on the needs of service members and veterans with TBI of all severities, as well as information about the quality of life and impact of the TBI on caregivers of service members and veterans with TBI (DVBIC 2014). In addition to extensive neuropsychological testing at periodic intervals, the study also includes extensive MRI with sophisticated imaging techniques so that ultimately it will be possible to identify those most at risk for long term disability from TBI, and thereby identify preventive or therapeutic measures to reduce that risk. An interagency research action plan entitled the National Research Action Plan (NRAP) was developed in direct response to a Presidential Order to accelerate the discovery of the causes and mechanisms underlying TBI and other cooccurring conditions (NRAP 2012). One of the goals of the NRAP is to determine the chronic effects and long term outcomes following TBI, and to identify long-term health needs and resources required for the care for TBI patients. The DoD has also established vital partnerships with the NFL and NCAA on this topic to track athletes and Service members with TBI longitudinally. Through the Center for Neuroscience and Regenerative Medicine (CNRM) a brain tissue repository to study the long-term effects of TBI and differences between blast exposed and non-blast exposed brain tissues was developed (CNRM 2015). Together with the Department of Veterans Affairs, the DoD is sponsoring the chronic effects of neurotrauma consortium (CENC 2014). The CENC is a coordinated, multicenter collaboration linking basic science, translational, and clinical neuroscience researchers from the VA, military, and academia to effectively address the long-term effects of concussion and its diagnosis and treatment. The Consortium brings together a nationwide group of researchers who have extensive experience with internal and external collaborations, demonstrated productivity in knowledge translation and dissemination, and the proven ability to recruit and follow up with research subjects. The overarching goals of the CENC are to examine the critical issues related to the identification and characterization of the anatomic, molecular, and physiological mechanisms of chronic brain injury and potential neurodegeneration, to investigate the relationship of comorbidities of trauma and combat exposure to mild TBI and neurodegeneration, and to assess the efficacy of existing and novel treatment strategies for chronic TBI effects and neurodegeneration. Current studies in development include a longitudinal cohort study to identify and assess the long-term effects of concussion in active duty and Veteran service members with a history of OEF/OIF/OND deployment and combat exposure, and a basic-science animal
study to determine the effects of a concussion on the production of Tau protein. Cognitive dysfunction is the leading cause of disability following TBI (Rabinowitz and Levin 2014). Some of the most common deficits are loss or reduction of short term memory, difficulties forming or retaining new memories, confusion, or disorientation. Such cognitive deficits have led to profound functional disability in many Service members who remain symptomatic months or years after their injury. Dean and Sterr (2013) studied the long term effects of concussion on cognitive performance and found a correlation between cognitive performance and symptoms in concussed subjects with worse performance correlating with lower sleep quality, higher post-concussion symptoms, PTSD and anxiety. In 2010 Congress directed the Secretary of Defense to conduct a clinical trial to evaluate the efficacy of cognitive rehabilitation therapy for OEF/OIF service members who sustained a mild TBI and had persistent cognitive impairments. In compliance with this mandate a study of cognitive rehabilitation effectiveness after concussion (SCORE 2011) was initiated to evaluate the efficacy of cognitive rehabilitation therapy for Service members diagnosed with concussion while deployed in OEF/OIF, and who reported cognitive difficulties 3– 24 months after their injury. Study participants were assigned to 6 weeks of therapy in one of four treatment arms and evaluated at 3, 6, 12 and 18 weeks following initiation of the study. The 4 treatment paradigms were designed to include the best available cognitive rehabilitation treatment strategies. Study participants were assessed for improvement in cognitive functioning, post concussive symptoms, cognitive complaints, cognitive fatigue, quality of life, health care utilization and work status. The data is currently being analyzed and the study is intended to identify which, if any, of the 4 treatment arms are most effective.
Summary TBI, and especially concussion, remains a significant concern for Military medicine. The most common mechanism of injury in both the Afghanistan and Iraq conflicts was improvised explosive devices leading to blast, or blast plus blunt, head injuries, and the incidence of severe and penetrating injuries has been very low (French 2010). The DoD has made great strides in identifying concussion despite a military culture that traditionally fosters a Bget back to the fight^ attitude. This was facilitated with the widespread implementation of the MACE, an easy to use concussion evaluation system, and a new incident-based reporting system. Through these robust surveillance efforts it became apparent that non-deployment related TBIs are more common than combat related injuries. Therefore, the DoD has focused on garrison or home station injuries and youth sports concussions as well as injuries that
Brain Imaging and Behavior
occur in the deployed environment. Innovative, state-of-theart clinical and educational programs for TBI/concussion prevention, identification, evaluation, acute care, long term care and education and training have been implemented. Clinical and translational TBI research also is a priority for the DoD, with an emphasis on translating research findings into state of the science clinical recommendations. The Defense Department is committed to providing standardized, evidence-based medical care. This can best be accomplished through coordination of care across the continuum, beginning with prevention and ending with reintegration, by implementing TBI Bpathways of care^. The goal is to systematically monitor outcomes following a TBI and to modify treatment recommendations or strategies to conform to best practices, as identified by outcomes analyses. DVBIC is uniquely positioned to manage the development, refinement and implementation of TBI pathways of care through understanding the political and military drivers of medical care, visibility of proposed and ongoing TBI research, standardizing and evaluating TBI clinical care, and providing or ensuring a common platform for all DoD TBI education. The goal is to accomplish these objectives through close collaboration with the individual Services. Benefits of this centralized coordination are that disparate sources of TBI research, education, and clinical care can be evaluated for, and limited resources can be expended, in keeping with the needs of the patients, their providers and caregivers. Collaborations and partnerships with other public or private organizations which already have identified solutions to shortcomings in TBI care allow for adoption of those solutions at considerable cost savings. Ultimately the goal is to assure that the best and most effective TBI care is available in a timely fashion to all of those who have dedicated their lives to the service of our Military.
Challenges for the future Concussion is by far the most common type of TBI in the Military, and the Military Health System is focused on addressing several key concussion-related challenges. The definition of concussion currently used by the Military is subjective and heavily dependent on information provided by the concussed patient. This can lead to the significant over- or underdiagnosis which can have important implications for appropriate return-to-duty decision making. As a result, the DoD is focused on the development or identification of an objective test of the presence or absence of concussion, as well as the severity of the concussion. Such a test might include one or a combination of serum biomarkers, or tests for neurophysiologic dysfunction. Ideally this objective test for concussion will be administered via a highly mobile platform amenable for use in austere environments. An additional challenge is
that a large proportion of concussions occur in garrison, so safety and injury prevention measures must be pervasive, innovative and effective. The chronic effects of single and especially multiple blast and blunt concussions also are of concern, and both the DoD and VA are collaborating to support short and long term research programs intended to identify personal and environmental risk factors for long term cognitive or other neurologic dysfunction following TBI.
Disclaimer The views expressed in this publication are those of the authors and do not represent official views or policy of the Department of Defense, Department of Veterans Affairs, the Department of Health and Human Services, The United States Public Health Service, or the United States Government. Statement of Compliance with Ethical Standards None of the authors (Katherine M. Helmick, Cynthia A. Spells, Saafan Z. Malik, Cathleen A. Davies, and Donald W. Marion) have potential conflicts of interest with any of the material presented in this manuscript. This is a review of previously published studies, and is not new research involving human participants or animals. As a result, there is no requirement for informed consent.
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