Mild Traumatic Brain Injury: A Signature Injury of the Iraq Conflict

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Mild Traumatic Brain Injury A Signature Injury
of the Iraq Conflict
Monica L. Jefferson, Ph.D. Neuropsychologist NJ
WRIISC
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LEARNING OBJECTIVES

• Review mental health concerns of returning
  Veterans
• Discuss current understandings of mild traumatic
  brain injury (MTBI)
• Discuss effects of blast exposure
• Identify injury and recovery factors unique to
  returning Veterans

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OEF/OIF A New Type of War

• Key Iraq wound Brain trauma
• by Gregg Zoroya
• USA TODAY
• March 2005

A growing number of U.S. troops whose body armor
helped them survive bomb and rocket attacks are
suffering brain damage as a result of the blasts.
It's a type of injury some military doctors say
has become the signature wound of the Iraq war.
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OEF/OIF represent new challenges

• Different Weaponry
• Ambiguous Front Line
• Advances in Amour and Protection

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When an OEF/OIF Veteran returns

• Healthy Adjustment?
• Psychiatric Condition?
• Mild TBI?

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When an OEF/OIF Veteran returns

• Healthy Adjustment?

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Veterans may experience a range of NORMAL,
HEALTHYresponses to their return home

• Excitement
• Relief
• Stress
• Tension
• Concern
• Combat Stress reactions
• (See National Center for PTSD http//www.ncptsd.va
  .gov/ncmain/index.jsp)

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When an OEF/OIF Veteran returns

• Unhealthy Adjustment?

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ReactionsContinue long after event Interfere
with ability to functionCause significant
distress

• Depression
• Suicidal Thoughts
• Self-blame, Guilt and Shame
• Anger or Aggressive Behavior
• Alcohol and/or Drug Abuse
• Post Traumatic Stress Disorder

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When an OEF/OIF Veteran returns

• Post Traumatic Stress Disorder?

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• Exposure to a traumatic event in which both are
  present
• Experienced, witnessed, or confronted with
  event(s) that involved actual or threatened death
  or serious injury to self or others
• Responded with intense fear, helplessness, or
  horror
• 3 Symptom Clusters
• Re-experiencing (e.g., recurrent intrusive
  images/thoughts)
• Avoidance Emotional numbing (e.g., markedly
  diminished participation in significant
  activities feeling emotionally detached from
  others)
• Arousal (e.g., difficulty sleeping irritability
  difficulty concentrating)

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• Symptoms present for more than 1 month
• Symptoms cause clinically significant distress or
  impairment in social, occupational or other
  important areas of functioning
• Symptoms can VARY in terms of Intensity and
  Duration

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When an OEF/OIF Veteran returns

• Mild Traumatic Brain Injury?

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There is no clear consensus on definition of
MTBIThis

• Complicates Diagnostic Efforts
• Complicates Research Efforts
• Increases need for INTERDISCIPLINARY APPROACH to
  assessment, treatment and rehabilitation

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American Congress ofRehabilitation Medicine
Definition of MTBI (1993)

• Traumatically induced physiologic disruption of
  brain
• function as manifested by at least one of the
  following
• 1. Any loss of consciousness
• 2. Any loss of memory for events immediately
  before or after the accident
• 3. Any alteration in mental state at the time of
  the accident
• 4. Focal neurologic deficit(s) that may or may
  not be transient
• Severity of the injury does not exceed
• Loss of consciousness of 30 min
• GCS score of 13-15 after 30 min
• Posttraumatic amnesia of 24 hr

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TBI EpidemiologyUnited States Overview (CDC)

• TBI is a leading cause of death and disability
• 1.4 million people sustain a TBI each year
• 5.3 million have long-term or life-long
  disability
• 75 of TBIs that occur each year are MTBI or
  concussions
• Causes
• Falls (28)
• Motor vehicle-traffic crashes (20)
• Struck by/against events (19)
• Assaults (11)

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TBI EpidemiologyUS Military

• Even in peacetime, military personnel have a
  higher rate of TBI than civilians.
• During war, this incidence increases
• Rand Report Invisible Wounds of War, 2008
• Since 2001, 320, 000 (19.5) sustained a TBI
• Probable TBI Only 12.2
• PTSD and Probable TBI 1.1
• Depression and Probable TBI 0.7
• PTSD/Depression/Probable TBI 5.5

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Blasts and MTBI
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Mechanisms of Blast Injury

• Primary results from impact of the
  overpressurization wave with body surfaces
• Secondary results from flying debris and bomb
  fragments
• Tertiary results form individual being thrown by
  the blast
• Quaternary all other explosion related injuries,
  illness or diseases not due to above

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Mechanisms of Blast Injury

• From When Things Go Boom Blast Injuries By
  Robert Nixon,
• EMT-P, and Charles Stewart, MD. fireEMS, May 1,
  2004

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Blasts and MTBI

• Are blast related MTBIs different than other
  MTBIs?
• Can we apply current models to blasts?
• Limited studies on effects of primary blast waves
  
• on human brain
• Pathophysiology of primary blast injuries may
  differ from other mechanisms
• Current evidence does not suggest difference in
  clinical outcomes

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MTBI What we know...MTBI and Civilians

• Symptoms are temporary
• Full recovery expected within weeks of initial
  injury
• Persistent symptoms may be attributable to
  non-injury factors
• (See Carroll et al. 2004 J Rehabil Med)

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MTBI What we know...Concussions and Athletes

• Concussion symptoms resolve within days to one
  month
• Professional football players appear to recover
  more quickly than collegiate and high school
  athletes
• Multiple concussions (3) are a risk factor for
  poorer recovery course
• (See Moser et al. 2007 Archives of Clin
  Neuropsych)

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MTBI Recovery

• Immediate Symptoms
• Loss of consciousness
• Disorientation and/or Confusion
• Memory Difficulties (e.g., amnesia)
• Headache
• Hearing difficulties
• Visual difficulties
• etc

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MTBI Recovery

• Initial Days or Weeks
• Physical Symptoms
• e.g., Headache Dizziness Balance difficulties
  Fatigue Light/Noise sensitivity
• Cognitive Symptoms
• e.g., Slowed information processing Difficulties
  with attention/concentration
• and/or Short-term memory
• Emotional and Behavioral Symptoms
• e.g., Irritability Depressed mood Anxiety
  Mood lability

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MTBI Recovery

• Initial Days or Weeks
• Initially, an individual may not develop many
  symptoms
• Most show at least some symptoms during the first
  several weeks after onset of injury
• NORMAL RECOVERY PROCESS

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MTBI Recovery

• One to Six Monthsand beyond
• Majority of individuals experience a rapid and
  complete recovery within 3 months
• (e.g., Belanger et al., 2005 Binder et
  al.,1997 Schrelten Shapiro, 2003)
• Prevalence of persistent symptoms varies from
  7-33 (e.g., Alexander, 1995 Binder et al.,
  1997 Iverson, 2005 Rimel et al., 1981)
• Post Concussion Syndrome???

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• MTBI Civilians and Athletes
• But some do not fully recover

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MTBI Recovery

• RISK FACTORS FOR POORER RECOVERY
• Severity of Injury (GCS LOC PTA complicated
  MTBI)
• Age gt 40 (55)
• Lower SES
• Medico-legal Involvement
• Pain
• Comorbid Medical or Psychiatric Condition
• Compromised Premorbid Functioning
• History of multiple TBIs

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• MTBI and Returning Veterans
• Can we apply our current knowledge?

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MTBI What we know...MTBI and Returning Veterans

• MTBI is strongly associated with PTSD and
  physical health problems
• PTSD and depression appear to be mediators of the
  relationship between MTBI and physical health
  problems (e.g., Hoge et al., 2008)
• Blast-injured personnel may experience greater
  symptoms of PTSD

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MTBI What we know...MTBI and Returning Veterans

• No strong evidence that sequelae of blast-related
  MTBI are different from other MTBI (e.g.,
  Belanger et al., 2009)
• Post Concussive symptoms are NOT specific to
  concussion (e.g., Fear et al., 2009)

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MTBI Recovery
Factors to consider with returning Veterans
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Injury and Recovery Factors

• unique to our returning Veterans
• Deployment
• Vulnerable/Compromised Pre-injury State
• Post-injury Recovery Variables
• Blasts and Multisystem Trauma
• Effects of additional Exposures
• UNKNOWNS

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Additional Resources

• National Center for PTSD (NCPTSD)
• http//www.ncptsd.va.gov
• Download Assessment Tools
• Defense and Veterans Brain Injury Center (DVBIC)
• http//www.dvbic.org/
• Download TBI Clinical Tools
• CDC Explosions and Blast Injuries A Primer for
  Clinicians
• http//www.cdc.gov/masstrauma/preparedness/primer.
  pdf
• For Veterans Returning Service Members -
  OEF/OIF
• http//www.oefoif.va.gov/
• Vet Centers
• http//www.vetcenter.va.gov/

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