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 woundof 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, 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)

8. When an OEF/OIF Veteran returns… Unhealthy Adjustment?

9. Reactions…Continue 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

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

15. 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

16. 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%)

17. 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%

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 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???

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 > 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/