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Mild Traumatic Brain Injury: A Signature Injury of the Iraq Conflict. Monica L. Jefferson, Ph.D. Neuropsychologist NJ WRIISC. LEARNING OBJECTIVES:. Review mental health concerns of returning Veterans Discuss current understandings of mild traumatic brain injury (MTBI) - PowerPoint PPT Presentation
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Mild Traumatic Brain Injury: Mild Traumatic Brain Injury: A Signature Injury of the A Signature Injury of the
Iraq ConflictIraq Conflict
Monica L. Jefferson, Ph.D.Neuropsychologist
NJ WRIISC
LEARNING OBJECTIVES:LEARNING OBJECTIVES:
1. Review mental health concerns of returning Veterans
2. Discuss current understandings of mild traumatic brain injury (MTBI)
3. Discuss effects of blast exposure
4. Identify injury and recovery factors unique to returning Veterans
OEF/OIF: A New Type of OEF/OIF: A New Type of WarWar
“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.”
Key Iraq wound: Brain trauma
by Gregg ZoroyaUSA TODAYMarch 2005
OEF/OIF represent new OEF/OIF represent new challenges…challenges…
Different Weaponry Different Weaponry
Ambiguous Front LineAmbiguous Front Line
Advances in Amour and ProtectionAdvances in Amour and Protection
When an OEF/OIF Veteran When an OEF/OIF Veteran returns…returns…
Healthy Adjustment?Healthy Adjustment?
Psychiatric Condition? Psychiatric Condition?
Mild TBI?Mild TBI?
When an OEF/OIF Veteran When an OEF/OIF Veteran returns…returns…
Healthy Adjustment?
Veterans may experience a range of Veterans may experience a range of NORMAL, HEALTHYNORMAL, HEALTHY
responses to their return homeresponses 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)
When an OEF/OIF Veteran When an OEF/OIF Veteran returns…returns…
Unhealthy Adjustment?
Reactions…Continue long after event Reactions…Continue long after event Interfere with ability to functionInterfere with ability to function
Cause significant distressCause significant distress
Depression Suicidal Thoughts Self-blame, Guilt and Shame Anger or Aggressive Behavior Alcohol and/or Drug Abuse Post Traumatic Stress Disorder
When an OEF/OIF Veteran When an OEF/OIF Veteran returns…returns…
Post Traumatic Stress Disorder?
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)
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
When an OEF/OIF Veteran When an OEF/OIF Veteran returns…returns…
Mild Traumatic Brain Injury?
There is no clear consensus on There is no clear consensus on definition of MTBIdefinition of MTBI
This…This…
Complicates Diagnostic Efforts
Complicates Research Efforts
Increases need for INTERDISCIPLINARY APPROACH to assessment, treatment and rehabilitation
American Congress ofAmerican Congress ofRehabilitation Medicine Rehabilitation Medicine Definition of MTBI (1993)Definition of MTBI (1993)
Traumatically induced physiologic disruption of brain function as manifested by at least one of the following:
1. Any loss of consciousness2. Any loss of memory for events immediately before or after the
accident3. Any alteration in mental state at the time of the accident4. Focal neurologic deficit(s) that may or may not be transientSeverity 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
TBI: EpidemiologyTBI: EpidemiologyUnited States Overview (CDC)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%)
Even in peacetime, military personnel have a higher rate of TBI than civilians.
During war, this incidence increases
Rand Report: Invisible Wounds of War, 2008Since 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%
TBI: EpidemiologyTBI: EpidemiologyUS MilitaryUS Military
Blasts and MTBIBlasts and MTBI
Mechanisms of Blast InjuryMechanisms of Blast Injury
Primary Primary results from impact of the overpressurization results from impact of the overpressurization wave with body surfaceswave with body surfaces
Secondary Secondary results from flying debris and bomb results from flying debris and bomb fragmentsfragments
Tertiary Tertiary results form individual being thrown by the blastresults form individual being thrown by the blast
Quaternary Quaternary all other explosion related injuries, illness or all other explosion related injuries, illness or diseases not due to abovediseases not due to above
Mechanisms of Blast InjuryMechanisms of Blast InjuryFrom: When Things Go Boom: Blast Injuries By Robert Nixon,
EMT-P, and Charles Stewart, MD. fireEMS, May 1, 2004
Blasts and MTBIBlasts 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
MTBI: What we know...MTBI: What we know...MTBI and CiviliansMTBI 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)
MTBI: What we know...MTBI: What we know...Concussions and AthletesConcussions 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)
MTBI: RecoveryMTBI: Recovery
Immediate Symptoms
Loss of consciousness Disorientation and/or Confusion Memory Difficulties (e.g., amnesia) Headache Hearing difficulties Visual difficulties
etc…
MTBI: RecoveryMTBI: Recovery
Initial Days or Weeks
Physical Symptomse.g., Headache; Dizziness; Balance difficulties; Fatigue; Light/Noise sensitivity
Cognitive Symptomse.g., Slowed information processing; Difficulties with attention/concentration and/or Short-term memory
Emotional and Behavioral Symptomse.g., Irritability; Depressed mood; Anxiety; Mood lability
MTBI: RecoveryMTBI: 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
MTBI: RecoveryMTBI: Recovery
One to Six Months…and 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???
MTBI: Civilians and Athletes
…But some do not fully recover
MTBI: RecoveryMTBI: Recovery
RISK FACTORS FOR POORER RECOVERY
Severity of Injury (GCS; LOC; PTA; “complicated” MTBI)
Age > 40 (55) Lower SES Medico-legal Involvement Pain Comorbid Medical or Psychiatric Condition Compromised Premorbid Functioning History of multiple TBIs
MTBI and Returning Veterans
Can we apply our current knowledge?
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
MTBI: What we know...MTBI: What we know...MTBI and Returning VeteransMTBI 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)
MTBI: What we know...MTBI: What we know...MTBI and Returning VeteransMTBI and Returning Veterans
MTBI: RecoveryMTBI: RecoveryFactors to consider with returning Veterans
Injury and Recovery FactorsInjury 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
Additional ResourcesAdditional 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/