TRAUMATIC BRAIN INJURY (TBI) ASSESSMENT AND CARE:

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Presentation transcript:

TRAUMATIC BRAIN INJURY (TBI) ASSESSMENT AND CARE: The Defense and Veterans Brain Injury Center (DVBIC) Model at MacDill AFB & James A. Haley Veterans Hospital Tamara McKenzie-Hartman, PsyD

Disclaimer The views expressed in this presentation are those of the author and do not reflect the official policy of the Department of Defense or U.S. Government. There are no relevant financial relationships or conflicts of interest to disclose.

Agenda DVBIC Structure and Mission DVBIC at MacDill AFB Care Coordination with Tampa VA Health Care System Basic Information About TBI

Defense and Veterans Brain Injury Center (DVBIC) Also, if you ever need it, we have lots of concussion resources for you.

Department of Defense Hierarchy Department of Defense (DoD) Office of the Secretary of Defense (OSD) (Chuck Hagel) Assistant Secretary of Defense for Health Affairs (OSD/HA) Military Health System (MHS) The Service Surgeons General (OTSG) Army, Navy, Air Force, Coast Guard MHS Offices and Programs Force Health Protection and Readiness Hearing CoE DCoE for Psychological Health and TBI Defense Veterans Brain Injury Center Deployment Health Clinical Center National Center for Telehealth and Technology Office of the Chief Information Officer Tricare Uniform Service University Vision CoE Congressional Mandate 1991 Defense Appropriations Bill Established as a Department of Defense organization by a Defense Appropriation Bill in 1991, DVBIC was directed to track and evaluate head injury survivors; ensure appropriate treatment and rehabilitation; study treatment outcomes; and counsel family members. DVBIC’s mission is to serve active duty military, their beneficiaries, and veterans with traumatic brain injuries (TBIs) through state-of-the-art clinical care, innovative clinical research initiatives and educational programs, and support for force health protection services. DVBIC fulfills this mission through ongoing collaboration with the DoD, military services, Department of Veterans Affairs, civilian health partners, local communities, families and individuals with TBI. DVBIC assists the DoD and VA in optimizing care of service members and veterans who have sustained a TBI, in deployed and non-deployed settings through DVBIC’s three divisions: Research, Clinical Affairs, and Education.

Defense Centers of Excellence (DCoE)

About DCoE Serves as the principal integrator and authority on psychological health and traumatic brain injury (TBI) knowledge and standards for the Defense Department An integral part of the Military Health System (MHS) Programs and resources help promote resilience, rehabilitation and reintegration for our nation’s warriors, families and veterans DCoE Director serves as special assistant to the Assistant Secretary of Defense for Health Affairs

About Defense and Veterans Brain Injury Center Established as a DoD organization by a Defense Appropriation Bill in 1991, DVBIC was directed to track and evaluate head injury survivors; ensure appropriate treatment and rehabilitation; study treatment outcomes; and counsel family members. Our mission today remains to serve active-duty military and veterans with traumatic brain injury (TBI) and their family members through state-of-the-art medical care, innovative clinical research initiatives and educational products and programs. DVBIC assists the DoD and VA in optimizing care of service members and veterans who have sustained a traumatic brain injury (TBI), in deployed and non-deployed settings, through DVBIC’s three divisions: Research, Clinical Affairs, and Education.

Meeting the DVBIC Mission With a TBI focus and through the oversight and direction of three divisions, DVBIC provides services at 16 DoD and VA network sites in support of service members, veterans, families and providers. Clinical Affairs Clinical Care & Consultation Identifying & Sharing Best Practices Developing TBI Clinical Recommendations & Guidelines Clinical Care Surge Support TBI Surveillance Regional Care Coordination Education Educational Tools & Resource Development TBI Awareness & Training Product Dissemination & Distribution Family Caregiver Program Regional Education Coordination Research Clinical Investigations Congressionally Mandated Studies Epidemiological Research Statistical Analysis Translation of Research

DVBIC Sites and Catchment Regions DVBIC is a nationwide network, and also in Germany.

DVBIC TBI Clinic at MacDill AFB

Services at MacDill AFB TBI Clinic housed within the Mental Health Clinic Neuropsychologist Dr. McKenzie-Hartman TBI evaluations in Clinic and via VTC NP assessment TBI Recovery Support Specialist (RSS) Tina Barton, LCSW Initial TBI screening evaluations Follow-up care Coordination of further specialized care via Tampa VA Photo: accessed 14 JAN 2013 at www.jber.af.mil

Coordination of care via Tampa VA Staff cases seen at MacDill or via VTC and coordinate plans for care. Higher levels of care are referred to the Tampa VA TBI Clinic Seen by a TBI Physiatrist Outpatient TBI Services Inpatient: Post-Deployment Rehabilitation & Evaluation Program (PREP) *Chronic Pain Program, MH, also available Photo: accessed 14 JAN 2013 at www.jber.af.mil

TBI Recovery Support Program The DVBIC TBI Recovery Support program offers TBI expertise, resources and support to the military and veterans’ communities and facilitates connections across the entire continuum of recovery and spectrum of care. Eligibility: Service members (including National Guard and Reservists) or veterans who have sustained a TBI, their family members or caregivers. DVBIC’s TBI Recovery Support Program, formerly known as the Regional Care Coordination Program, provides services and resources to service members, National Guard and Reservists, and veterans who have sustained a TBI, as well as their family members and caregivers, as they negotiate complex systems of care. The program’s Recovery Support Specialists (RSSs) are assigned to 12 regions throughout the United States in order to provide a nationwide network for coordination of care. When a client enters the program, a RSS will talk with the client about issues s/he is having in treatment, other medical or mental health conditions and other relevant issues. The RSS assists in finding and accessing TBI and psychological health clinical care, supportive services and information. The RSS provides follow-up services for up to 24 months, offering support and tracking TBI symptoms and recovery. In addition, the TBI RSP provides information about TBI resources, trainings and research to TBI case managers and providers as they meet the clinical needs of TBI clients. A nationwide network of recovery support specialists assists clients as they negotiate through complex systems of care, return to duty or transition to civilian life. For referrals and more information: http://dvbic.dcoe.mil/tbi-recovery-support-program

TBI Recovery Support Program The Recovery Support Program provides: Support, education, advocacy, and advice Tracking of symptoms and monitoring of treatment compliance and outcomes Connection to TBI and psychological health services Up to 24 months of follow-up care For providers, information and access to TBI research, training and educational resources DVBIC’s TBI Recovery Support Program, formerly known as the Regional Care Coordination Program, provides services and resources to service members, National Guard and Reservists, and veterans who have sustained a TBI, as well as their family members and caregivers, as they negotiate complex systems of care. The program’s Recovery Support Specialists (RSSs) are assigned to 12 regions throughout the United States in order to provide a nationwide network for coordination of care. When a client enters the program, a RSS will talk with the client about issues s/he is having in treatment, other medical or mental health conditions and other relevant issues. The RSS assists in finding and accessing TBI and psychological health clinical care, supportive services and information. The RSS provides follow-up services for up to 24 months, offering support and tracking TBI symptoms and recovery. In addition, the TBI RSP provides information about TBI resources, trainings and research to TBI case managers and providers as they meet the clinical needs of TBI clients. A nationwide network of recovery support specialists assists clients as they negotiate through complex systems of care, return to duty or transition to civilian life.

Why Is TBI Evaluation & Care So important?

Definition of TBI Any traumatically induced structural injury and/or physiological disruption of brain function as a result of an external force that is indicated by new onset or worsening of at least one of the following clinical signs, immediately following the event: Any period of loss of consciousness (LOC) Any loss of memory for events immediately before or after the injury (PTA) Any alteration in consciousness (AOC) at the time of the injury (i.e., confusion, disorientation, slowed thinking) Neurological deficits (i.e., weakness, balance disturbance, praxis, paresis/plegia, visual changes, other sensory alterations, aphasia) that may or may not be transient. Intracranial lesion *The above criteria defines the historical event, not a condition, disorder, or syndrome *If a person meets these criteria, then they should be diagnosed as having sustained a TBI. plegia: Suffix meaning paralysis or a stroke. As in cardioplegia (paralysis of the heart), hemiplegia (paralysis of one side of the body), paraplegia (paralysis of the legs), and quadriplegia (paralysis of all four extremities). From the Greek plege meaning a blow or stroke. "Praxis" may also refer to the act of engaging, applying, exercising, realizing, or practicing ideas. Photo courtesy: jber.af.mil

External Force Forces causing brain injury include: head being struck by an object head striking an object brain undergoing an acceleration/deceleration mvmt. without direct external trauma to the head foreign body penetrating the brain forces generated from events such as blast or explosion, or other force yet to be defined Photo courtesy: jber.af.mil

Causes of TBI In the civilian sector, the most common cause of TBI is falls. The second most common cause is vehicle (i.e., car. bicycle, pedestrian, rec vehicles) related accidents. Firearm use is the leading cause of death related to TBI. Baltimore Sun file photo/Brendan Cavanaugh

Causes of TBI In the military, the most common causes of TBI in both the deployed and non-deployed settings include: Blasts Motor vehicle crashes - Falls - Sports and recreational activities - Blows to the head (i.e. military training) - Assaults Leading cause of TBI in the deployed setting is the involvement in a vehicle blast or rollover

VHA/ DoD TBI Severity Mild TBI/ Concussion Moderate TBI Severe TBI Neuroimaging Normal structural imaging Normal or abnormal structural imaging GCS 13-15 9-12 <9 LOC 0-30 min >30 min and <24hrs >24 hrs AOC A moment up to 24 hrs AOC >24hrs (use other criteria) PTA 0-1 day >1 day and <7 days >7 days GCS = Glasgow Coma Scale AOC = Alteration of Consciousness LOC = Loss of Consciousness PTA = Post Traumatic Amnesia

Mild TBI/ Concussion Approx. 75% of those who sustain a TBI have a mTBI. Mild TBI is believed to result when a traumatic force to the brain triggers a pathologic neurochemical cascade, but is insufficient to produce widespread neuronal dysfunction or the axonal disruption that characterizes more severe brain injuries.

Complicated mTBI When neuroimaging findings or positive signs on an acute neurological exam are present , following what would otherwise be classified as a mild TBI, the classification changes to “complicated mild TBI.” Recovery trajectory is more similar to the moderate TBI 6-month outcome.

Cumulative Concussions Sport literature suggests a possible cumulative effect from multiple concussions. However, any threshold for adverse events regarding frequency and severity of concussions has yet to be established. Yet there is concern that a second concussion prior to complete recovery from the first concussion may pose increased risk.

TBI SYMPTOMS AND IMPACT Photo courtesy: cdc.gov

Cognitive Recovery by TBI Severity 3 Cognitive Level Pre-injury Functioning INJURY Months since injury 6 9 12 Mild TBI Moderate TBI Severe TBI Recovery   Most individuals who suffer a mild TBI or concussion experience few post-injury problems and make a rapid recovery, often returning to normal within hours or days after their injury. The symptoms of concussion or mild TBI are very similar to symptoms of everyday stress. Such symptoms are part of the normal recovery process and are not signs of permanent brain damage or medical complications. Just like scratches or wounds itch while they heal, these symptoms are expected as your brain heals. They are not a cause for concern or worry. It is important to remember that people get better after head injury, not worse.

Common Signs and Symptoms (mTBI) Physical Symptoms Cognitive Behavioral / Emotional Sleep Headaches Visual problems Feeling dizzy Loss of balance Hearing difficulty Tinnitus Sensitivity to light and/or noise Nausea Attention Memory problems Poor concentration Delayed processing speed Difficulty finding words Impaired judgment Anxiety Depression Agitation Irritability Impulsivity Aggression Fatigue, loss of energy, getting tired easily Difficulty falling or staying asleep

Impact of Multiple TBIs Symptoms may be more severe with each additional TBI May take longer to improve or resolve Persistent symptoms may lead to: Reduced work performance Behavioral or emotional problems Relationship problems REVIEW TEXT CLICK TO ADVANCE TO NEXT SLIDE Photo: accessed 2 DEC 2013 at www.jber.af.mil

TBI and Co-Occurring Conditions PTSD Chronic Pain & Headaches Substance Use/Abuse Depression Anxiety Suicidality Daily Stress Photo courtesy: cdc.gov

Overlapping Symptoms Posttraumatic Stress Disorder (PTSD) is an anxiety disorder that can develop after experiencing a traumatic event. While only a portion of people go on to develop the disorder, many people initially exhibit a few signs after experiencing a traumatic event. These signs can include intrusive thoughts about the event or inability to stop thinking about it, avoiding situations that remind you of the event, feeling numb or detached from others, or feeling tense or keyed up. There is significant overlap in symptoms that one can experience following a mild TBI event and those experienced as part of PTSD. Many of these symptoms also overlap with other post-deployment conditions such as chronic pain and physical injuries, mood disorders (such as depression), other anxiety disorders, the effects of substance use/abuse, and medication side effects. These include: Sleep disruption Difficulty paying attention Difficulty concentrating Increased forgetfulness Feeling easily overwhelmed Sad or depressed mood Increased irritability Fatigue It can be nearly impossible to tease apart the relative contribution of different conditions or situations to this symptom cluster. The goal of treatment is not to determine which symptoms are caused by what, but to manage the symptoms in order to reengage in life activities and improve quality of life.

Want to Learn More About TBI?

MacDill AFB TBI Lunch & Learn If you are at MacDill… Attend our TBI LUNCH & LEARN SERIES 2ND TUESDAY OF EACH MONTH NOON-1PM TOPICS INCLUDING: 6/11/15: Introduction to TBI 7/9/15: Sleep and TBI 8/13/15: Headaches in TBI 9/10/15: Vestibular & Balance Issues in TBI 10/8/15: Vocational Rehabilitation for TBI 11/12/15: Recreation Therapy for TBI 12/10/15: Tampa VA’s Inpatient TBI (PREP) Program

Continuing Education

TBI Clinical Support Tools Mild Traumatic Brain Injury Pocket Guide (CONUS) and Mobile Application Quick reference resource on treatment and management of mTBI including: Evidence-based recommendations ICD-9 coding guidance Clinical recommendations for cognitive rehabilitation Clinical recommendations on assessing ability to drive safely Patient education materials Clinical tools and resources

TBI Clinical Support Tools PROVIDER TOOLS: Patient Education Fact Sheets

TBI Clinical Support Tools Management of Sleep Disturbances Following Concussion/Mild Traumatic Brain Injury Clinical recommendation and companion support tool Training guide Fact sheet Guides primary care managers in the assessment and management of common sleep disorders: insomnia, circadian rhythm sleep-wake disorder and obstructive sleep apnea Available to order at http://dvbic.dcoe.mil

TBI Clinical Support Tools Additional Clinical Recommendations available at http://dvbic.dcoe.mil: Neuroimaging Assessment of Dizziness Visual Dysfunction Next Clinical Recommendation due out 2015: Post-traumatic Headaches

Progressive Return to Activity Following Mild TBI Clinical Recommendation Released January 2014 by DVBIC Gives providers and patients a practical “how to” manual for concussion recovery Guidance for primary care managers in deployed and non-deployed settings for progressive return to activity following a concussion/mild TBI Offers a standardized approach for service members who remain symptomatic after sustaining a concussion/mTBI Identifies recommended criteria for referral to the rehabilitation provider for daily monitored return to activity process The first clinical tool to define “rest” Available to order at http://dvbic.dcoe.mil

TBI Case Management Resources Telehealth and Technology Web Resource Locator Website Compiled information from government and community resources Psychological health and TBI In support of service members, veterans and their families http://ttwrl.dcoe.mil Military TBI Case Management Quarterly Newsletter Information and resources for those caring for service members with TBI and their families Identifies and shares best practices across the military community

TBI Products for Service Members, Families “Back to School: Guide to Academic Success After Traumatic Brain Injury” Family Needs line of educational brochures Addressing Family Needs Talking with Children about Moderate or Severe TBI Taking Care of Yourself while Taking Care of Others Download and order all resources at http://dvbic.dcoe.mil Family Caregiver Curriculum Moderate to severe TBI Download and order at https://dvbic.dcoe.mil/material/traumatic-brain-injury-guide-caregivers-service-members-and-veterans Available to download at http://dvbic.dcoe.mil

DVBIC Online Provider Education Online TBI education for both civilian and military providers Webinars and online courses All are free of charge Some offer CE or CME credits https://dvbic.dcoe.mil/online-education

Websites http://dvbic.dcoe.mil http://dcoe.mil http://afterdeployment.org Here are some websites for you to jot down. PAUSE CLICK TO ADVANCE TO NEXT SLIDE

Other Helpful Websites TraumaticBrainInjuryAtoZ.org Brainline.org Brainlinemilitary.org VeteransCrisisLine.net cdc.gov/TraumaticBrainInjury/ Photo courtesy: cdc.gov

Questions? Photo: accessed 16 DEC 2013 at www.MilitaryOneSource.mil