TBI In the Military Cynthia L. Boyer, Ph.D. © 2011 Bancroft | All rights reserved

2 By 2014 our distinct ability to deliver high quality individualized services in modern living, learning and working environments will exceed stakeholder expectations and secure Bancroft as the region’s elite provider of services to people with intellectual and developmental disabilities and brain injuries. Our Core Value Bancroft’s mission is to ensure that every person is given opportunities for lifelong learning and fulfillment. We do this by altering perceptions, and by supporting those with intellectual and developmental challenges and acquired brain injuries in achieving their life goals as valued and respected members of our world. Respect is our clearly defined core value that helps unify the organization and provide a framework for services, decision-making and working together. Our Vision Our Mission © 2011 Bancroft | All rights reserved

Copyright – 2012, Boyer, Bancroft Brain Injury Services 3 TBI is a “signature injury” of the conflicts in Iraq and Afghanistan © 2011 Bancroft | All rights reserved

Copyright – 2012, Boyer, Bancroft Brain Injury Services 4 DoD TBI Definition (Oct 07) Traumatically induced structural injury or physiological disruption of brain function as a result of external force to the head © 2011 Bancroft | All rights reserved

Copyright – 2012, Boyer, Bancroft Brain Injury Services 5 DoD TBI Definition (Oct 07) New or worsening of at least one of the following clinical signs Loss of consciousness or decreased consciousness Loss of memory immediately before or after injury Alteration in mental status (confused, disoriented, slow thinking) Neurological deficits Intracranial lesion DoD definition parallels standard medical definition CDC, WHO, AAN, ACRM © 2011 Bancroft | All rights reserved

Copyright – 2012, Boyer, Bancroft Brain Injury Services 6 Blast Injury Predominant cause of TBI in OIF/OEF A significant number of soldiers returning from the conflicts in Iraq and Afghanistan have this injury and will suffer long-term consequences © 2011 Bancroft | All rights reserved

Copyright – 2012, Boyer, Bancroft Brain Injury Services 7 Blast Injuries Primary-Explosion Blast wave strikes and compresses body Most serious damage sustained by air and fluid filled organs Causes brain injury without visible damage to the head/skull Causes significant damage to eyes, ears, lungs © 2011 Bancroft | All rights reserved

Copyright – 2012, Boyer, Bancroft Brain Injury Services 8 Blast Injuries Secondary Environmental material energized by explosion strikes the body/brain Tertiary Energy from explosion propels the body into stationery objects © 2011 Bancroft | All rights reserved

Copyright – 2012, Boyer, Bancroft Brain Injury Services 9 Multiple Neurological Injuries Skin breakdown Penetrating Injury Blast/concussive injury Skull base injury Facial fractures Vasospasm* Pseudoaneuryms* Sagital sinus injuries © 2011 Bancroft | All rights reserved

Copyright – 2012, Boyer, Bancroft Brain Injury Services 10 Blast Injuries Are Different Treated quickly and aggressively Occur under extreme stress Long term course is unknown © 2011 Bancroft | All rights reserved

Copyright – 2012, Boyer, Bancroft Brain Injury Services 11 DoD Initiatives Prevention Surveillance Screening Diagnosis Case Management Treatment Rehabilitation Reintegration © 2011 Bancroft | All rights reserved

Copyright – 2012, Boyer, Bancroft Brain Injury Services 12 © 2011 Bancroft | All rights reserved

Copyright – 2012, Boyer, Bancroft Brain Injury Services 13 Baseline Testing Pre-Deployment Neurocognitive Assessment Tool (ANAM)/Automated Neuropsychological Assessment Matrics (May 09) Computerized 20 min © 2011 Bancroft | All rights reserved

Copyright – 2012, Boyer, Bancroft Brain Injury Services 14 Screening Military Acute Concussion Exam (MACE) (Aug 06) TBI screening for all medically evacuated at Landstahl Regional Medical Center (May 06) PostDeployment HealthScreening (Jan 08) VA TBI Screening © 2011 Bancroft | All rights reserved

Copyright – 2012, Boyer, Bancroft Brain Injury Services 15 MACE: Military Acute Concussion Evaluation Developed by DVBIC and released in Aug 2006 Performed by medical personnel 3-Part Screening Tool – “CNS” Cognition Neurological Exam Symptoms © 2011 Bancroft | All rights reserved

Copyright – 2012, Boyer, Bancroft Brain Injury Services 16 MACE: Military Acute Concussion Evaluation Alternate versions available Upcoming revision will include recurrent concussion questions Can be used during exertional testing to ensure that cognitive function remains intact © 2011 Bancroft | All rights reserved

17 Post-Deployment Health Assessment/ Reassessment (January 08) © 2011 Bancroft | All rights reserved

Copyright – 2012, Boyer, Bancroft Brain Injury Services 18 Diagnosis Potential Objective Indicators Pupillary response/visual tracking Biomarkers Imaging (DTI) © 2011 Bancroft | All rights reserved

Copyright – 2012, Boyer, Bancroft Brain Injury Services 19 Mild TBI/Concussion More difficult to identify Symptoms not unique to TBI © 2011 Bancroft | All rights reserved

Copyright – 2012, Boyer, Bancroft Brain Injury Services 20 Possible Effects of TBI Acute Poor marksmanship Slower reaction time Decreased concentration © 2011 Bancroft | All rights reserved

Copyright – 2012, Boyer, Bancroft Brain Injury Services 21 Possible Effects of TBI Chronic Reduced work quality Behavioral Problems Emotional Problems “Unexplained” Problems © 2011 Bancroft | All rights reserved

Copyright – 2012, Boyer, Bancroft Brain Injury Services 22 Treatment Standardized Educational Information New Protocol for 3 or more TBIs within 12 months © 2011 Bancroft | All rights reserved

Copyright – 2012, Boyer, Bancroft Brain Injury Services 23 National Intrepid Center of Excellence (NICoE) Located on Navy campus in Bethesda, MD Dedicated 24 June 2010 Serves Service Members (and their families) with complex TBI Primarily evaluative in nature © 2011 Bancroft | All rights reserved

Copyright – 2012, Boyer, Bancroft Brain Injury Services 24 National Intrepid Center of Excellence (NICoE) Generally to be used by those who have refractory or difficult- to-diagnose/manage conditions Provides case management and referral capabilities to leading experts in the field Full Operating Capability: Oct 2011 © 2011 Bancroft | All rights reserved

Copyright – 2012, Boyer, Bancroft Brain Injury Services 25 Toolkit and Pocket Guide © 2011 Bancroft | All rights reserved

Copyright – 2012, Boyer, Bancroft Brain Injury Services 26 Treatment Co-Morbid Conditions Sleep Disorders Substance Abuse Psychiatric Illness Vestibular Disorders Visual Disorders Cognitive Disorders © 2011 Bancroft | All rights reserved

Copyright – 2012, Boyer, Bancroft Brain Injury Services 27 Co-Morbidities Associated with mTBI PTSD N= % 2.9% 16.5% 42.1% 6.8% 5.3 % 10.3% 12.6% TBI N= % Chronic Pain N= % Sleep disorders Substance abuse Psychiatric illness Vestibular disorders Visual disorders Cognitive disorders Lew, et al: “Prevalence of Chronic Pain, Posttraumatic Stress Disorder, and Persistent Postconcussive Symptoms in OIF/OEF Veterans: Polytrauma Clinical Triad”, Dept. of Veterans Affairs, Journal of Rehabilitative Research and Development, Vol. 46, No. 6, 2009, pp , Fig. 1 © 2011 Bancroft | All rights reserved

Copyright – 2012, Boyer, Bancroft Brain Injury Services 28 Treatment Research Clinical Trials Cognitive Rehabilitation Neuroprotective Medications Longitudinal Study © 2011 Bancroft | All rights reserved

Copyright – 2012, Boyer, Bancroft Brain Injury Services 29 Blast Physics/ Blast Dosimetry Force Protection Testing & Fielding Complementary Alternative Medicine Field Epidemiological Studies (mTBI) Rehabilitation & Reintegration: Long Term Effects of TBI Neuroprotection & Repair Strategies: Brain Injury Prevention Concussion: Rapid field Assessment Treatment & Clinical Improvement © 2011 Bancroft | All rights reserved

Copyright – 2012, Boyer, Bancroft Brain Injury Services 30 Challenges Undetected MTBI Force readiness/cultural barriers Improved Collaboration Effective Treatment © 2011 Bancroft | All rights reserved

Copyright – 2012, Boyer, Bancroft Brain Injury Services 31 Resources TBI Family Caregiver Guide © 2011 Bancroft | All rights reserved

Copyright – 2012, Boyer, Bancroft Brain Injury Services 32 Resources DCoE Facebook, Twitter, YouTube, Multiple Mobile Smartphone Applications DCoE Blog Yellow Ribbon Presentations © 2011 Bancroft | All rights reserved

Copyright – 2012, Boyer, Bancroft Brain Injury Services 33 Questions? © 2011 Bancroft | All rights reserved

Copyright – 2012, Boyer, Bancroft Brain Injury Services 34 Thank you for attending! © 2011 Bancroft | All rights reserved