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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 * * * * Hoge, C. W., McGurk, D., Thomas, J ... – PowerPoint PPT presentation

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


1
Mild Traumatic Brain Injury A Signature Injury
of the Iraq Conflict
Monica L. Jefferson, Ph.D. Neuropsychologist NJ
WRIISC
2
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

3
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.
4
OEF/OIF represent new challenges
  • Different Weaponry
  • Ambiguous Front Line
  • Advances in Amour and Protection

5
When an OEF/OIF Veteran returns
  • Healthy Adjustment?
  • Psychiatric Condition?
  • Mild TBI?

6
When an OEF/OIF Veteran returns
  • Healthy Adjustment?

7
Veterans may experience a range of NORMAL,
HEALTHY responses 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)

8
When an OEF/OIF Veteran returns
  • Unhealthy Adjustment?

9
ReactionsContinue long after event Interfere
with ability to function Cause significant
distress
  • Depression
  • Suicidal Thoughts
  • Self-blame, Guilt and Shame
  • Anger or Aggressive Behavior
  • Alcohol and/or Drug Abuse
  • Post Traumatic Stress Disorder

10
When an OEF/OIF Veteran returns
  • Post Traumatic Stress Disorder?

11
  • 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)

12
  • 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

13
When an OEF/OIF Veteran returns
  • Mild Traumatic Brain Injury?

14
There is no clear consensus on definition of
MTBI This
  • Complicates Diagnostic Efforts
  • Complicates Research Efforts
  • Increases need for INTERDISCIPLINARY APPROACH to
    assessment, treatment and rehabilitation

15
American Congress of Rehabilitation 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

16
TBI Epidemiology United 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)

17
TBI Epidemiology US 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

18
Blasts and MTBI
19
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

20
Mechanisms of Blast Injury
  • From When Things Go Boom Blast Injuries By
    Robert Nixon,
  • EMT-P, and Charles Stewart, MD. fireEMS, May 1,
    2004

21
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

22
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)

23
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)

24
MTBI Recovery
  • Immediate Symptoms
  • Loss of consciousness
  • Disorientation and/or Confusion
  • Memory Difficulties (e.g., amnesia)
  • Headache
  • Hearing difficulties
  • Visual difficulties
  • etc

25
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

26
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

27
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???

28
  • MTBI Civilians and Athletes
  • But some do not fully recover

29
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

30
  • MTBI and Returning Veterans
  • Can we apply our current knowledge?

31
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

32
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)

33
MTBI Recovery
Factors to consider with returning Veterans
34
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

35
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/

36
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