1. Mild Traumatic Brain Injury: Issues Related to Evaluation and Diagnosis

2. Traumatic Brain Injury Insult to the brain caused by an external physical force Produces a diminished or altered state of consciousness ▫Dazed and confused ▫Loss of consciousness Post traumatic amnesia (PTA) may be present

3. Severity of TBI Mild/Concuss ion ModerateSevere LOC less then 30 minutes with normal imagining LOC greater the 30 minutes, less then six hours with abnormal imaging LOC greater then 6 hours with abnormal imaging GCS 13-15GCS 9-12GCS<9 PTA less then 24 hours PTA less then 7 days PTA greater then 7days

4. TBI Prognosis Injury severity is the strongest predictor of recovery Recovery after moderate and severe TBI may not be as complete as recovery from mild TBI Pre and post injury medical and MH issues place people at risk for poorer outcome

5. Acute Phase The development of post concussive symptomology (PCS) is normal and expected Initial symptom development is related to organic and neuropathological processes Symptoms develop within minutes to hours to days after the injury ▫Delayed symptom development is rare Alves et al., 1986) McCrea, 2008

6. Post Concussive Symptomology (PCS) ▫Physical: Headache, dizziness, fatigue, noise/light intolerance, insomnia, sleep disturbances, tinnitus, balance and visual problems ▫Cognitive: Memory complaints, poor concentration ▫Emotional: Depression, anxiety, irritability, mood lability

7. Acute Phase Research suggests a period of metabolic dysfunction within hours to days of injury Metabolic disarray explains resulting cognitive impairment and post concussive symptomology mTBI subjects show an abnormal profile of cerebral activation in response to cognitive demands fMRI shows decreased activation of select neuronal circuits in the frontal lobes Effect is most evident in mTBI subjects with LOC McCrea, et al., 2002

8. Acute Phase Cognitive and physical symptoms are most common Emotional symptoms are difficult to link to concussion verses other stressors in the combat zone Anxiety, depression, combat stress, PTSD, grief

9. Recovery Recovery following mTBI/concussion is normal and expected Research has repeatedly demonstrated that in the civilian population, the vast majority of individuals who sustain a concussion completely recover in a matter of days to weeks. ▫80-90% recover in 7-10 days ▫3% experience persistent symptoms beyond one to three months Belanger et al., 2005; McCrea, 2008; Ivins et al., 2009

10. Cognitive Recovery After mTBI McCrea et al., 2003

11. Symptom Recovery After mTBI McCrea et al., 2003

12. Recovery Return to normal metabolic function is expected within several days fMRI studies show no cerebral activation deficits in the injured subjects after a few weeks McCrea, et al., 2002

13. Recovery Recovery follows a progressive course ▫Symptomology usually improves as time goes on; symptoms usually do not get worse over time ▫If they do, secondary etiologies should be considered Delayed symptom onset is rare Headache is the symptom that tends to linger the longest and to be most problematic in terms for clinical management

14. “Complicated” verses Uncomplicated “The unfortunate few”-approximately 3% mTBI with structure damage on imaging may have a more complicated recovery course ▫Outcome may be more consistent with moderate TBI Individuals with multiple mTBIs within a short period of time are also at risk for more persistent problems Guskiewicz et al., 2003

15. Persistent symptoms Symptoms persisting beyond the expected recovery course after mTBI are highly non- specific to MTBI and are often attributable to non-injury related factors PCS-like symptoms are common in “normal” people Mittenberg, 1996; McCrea, 2008

16. Post Concussive Symptoms SymptomMTBI/PCSGeneral Population Poor Concentration71%14% Irritability66%16% Fatigue64%13% Depression63%20% Memory Problems59%20% Headaches59%13% Anxiety58%24% Dizziness52%7% Blurry vision45%8% Light sensitivity40%14% Mittenberg, 1996

17. Effect Size of mTBI on Neuropsychological Functioning Iverson, 2005

18. Effect Size of mTBI on Memory Functioning Iverson, 2005

19. Diagnosis Issues Two questions: ▫Did the person have a concussion? ▫Are their current symptoms related to their history of concussion or better explained by other etiologies? Just because a person has a history of concussion does not mean that they have current brain injury.

20. Question 1: Did the patient experience a concussion? ▫This is the easy question ▫Assess injury event ▫Change in consciousness  Alteration in consciousness is different from a post- traumatic stress reaction ▫Development of post concussive symptomology

21. Question 2 Are their current symptoms related to their history of concussion or better explained by other etiologies? ▫This is the hard question ▫Emphasis must be on the temporal proximity of symptom development ▫Must assess other co-morbid medical and MH issues that may explain their current symptomology

22. VA/DOD Guidelines Training from central office has stressed the importance of assessing the temporal proximity of symptom development to the injury event ▫In order for the symptoms to be related to the concussion, they must have developed within hours to days after the injury ▫Symptoms that develop months to years later are most likely related to other causes

23. mTBI Evaluation Consider other in-theater factors that might explain symptom development ▫Combat stress, PTSD, sleep deprivation, dehydration Assess symptoms present prior to the concussion ▫Complete resolution would not be expected and ongoing problems may not be attributed to concussion ▫Patient will return to their baseline which is not the same as being symptom free  Patients with headaches before their concussion, will likely continue to experience headaches after

24. mTBI evaluation No symptom checklist can diagnose brain injury No physical or neurological test can diagnose brain injury Differential diagnosis relies on an in-depth clinical interview focusing on the temporal development of symptoms ▫Knowledge and assessment of other conditions that may be contributing is necessary

25. PTSD Re-experiencing Avoidance Social withdrawal Memory gaps Apathy mTBI Sequela Difficulty with decisions Mental slowness Concentration Headaches Dizzy Appetite changes Fatigue Sadness Arousal Sensitive to noise Concentration Insomnia Irritability Depression

26. PTSD Depression Substance Abuse Mild TBI Sequela Pain Medications Medical Issues

27. Post Traumatic Headaches Trauma event and headache start must correlate in time ▫How much time? International Headache Society (IHS) ▫Headache must develop within 7 days of the injury Other standards have been applied ▫Up to 30 days post injury

28. Summary History of concussion does not mean a current diagnosis of brain injury Most people completely recovery following a concussion Of the estimated 3% of remain symptomatic a portion of those are symptomatic for reasons other then brain injury

29. Summary Other etiologies of their current difficulties must be considered (i.e., PTSD, depression, medical issues, pain, medications, etc.) The timeline of symptom development is very important Secondary etiologies should be considered symptoms that develop much later

30. Additional Training Material VA Polytrauma training ▫Video with Dr. David Cifu mTBI research overview ▫Video with Dr. Michael McCrea Readings ▫Mild Traumatic Brain Injury and Post Concussive Syndrome-Michael McCrea

31. References Alves WM, Cohohan AR, O'Leary TJ, Rimel, RW and Jane JA. Understanding post-concussice symptoms after minor head injury. Journal of Head Injury Trauma Rehabilitation,1986; 1: 1-12. Belenger HG, Curtiss G, Demery, JA, Lebowski BK and Vanderploeg RD. Factors moderating neuropsychological outcomes following mild traumatic brain injury: A meta-analysis. Journal of the International Neuropsychological Society; 2005; 11, 215-227. Guskiewicz KM, McCrea M, Marshall SW et al. Cumulative effects associated with recurrent concussion in collegiate football players: the NCAA Concussion Study, JAMA, 2003; 290: 2549-55. Iverson GL. Outcome from mild brain injury. Curr Opin Psychiatry, 2005; 18: 301-7.

32. References continued Ivins BJ, Kane R and Schwab KA. Performance on the automated neuropsychological assessment metrics in a non-clinical sample of soldiers screened for mild TBI after returning from Iraq and Afghanistan: A descriptive analysis. Journal of Head Trauma Rehabilitation; 2009: 24(1) 24-31. McCrea, M. Mild Traumatic Brain Injury and Postconcussion Syndrome: The New Evidence Base for Diagnosis and Treatment. New York: Oxford University Press, 2008. McCrea M, Kelly JP, Randolph C, Cisler R, Berger L. Immediate neurocognitive effects of concussion. Neurosurgery 2002; 50: 1032- 42. McCrea M, Guskiewicz KMm Marshall SW, et al. Acute effects and recovery time following concussion in collegiate football players: the NCAA concussion study. JAMA, 2003; 290:2556-63. Mittenberg W, Tremont G, Zielinski R, Fichera S, Rayls, K. Cognitive behavioral prevention of post concussion syndrome. Archive of Clinical Neuropsychology; 1996; 11:139-145.