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TBI Epidemic Out of Your Mind or Out of Your Brain?

TBI Epidemic Out of Your Mind or Out of Your Brain?. Chrisanne Gordon, MD Resurrecting Lives Foundation December 3, 2013. TBI, PTS, Pain. National Council on Disability: March 2009 Established the HALLMARK pathologies of OIF/OEF: Operation Iraqi Freedom- OIF

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TBI Epidemic Out of Your Mind or Out of Your Brain?

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  1. TBI EpidemicOut of Your Mind or Out of Your Brain? Chrisanne Gordon, MD Resurrecting Lives Foundation December 3, 2013

  2. TBI, PTS, Pain National Council on Disability: March 2009 Established the HALLMARK pathologies of OIF/OEF: • Operation Iraqi Freedom- OIF • Operation Enduring Freedom-OEF • TBI = Traumatic Brain Injury • PTS = Post Traumatic Stress

  3. OIF/OEF - TBI, PTS, Pain • TBI + PTS = PDS-Post Deployment Syndrome • PAIN- HA, LBP, Shoulder, Knee • Amputations – multiple due to armor • Drugs:TBI –amphetamine, caffeine, cocaine • Drugs: PTS- SSRI, ETOH, marijuana, • Drugs: Pain-Oxycontin

  4. Statistics of War • Over 2 million have deployed • 350,000 cases PTS estimated-Post Traumatic Stress • 450,000 cases of TBI estimated Traumatic Brain injury • Many will have both= PDS-post deployment • Fewer than 30% receiving treatment • RAND Report July 2008 / updated stats 2012

  5. Physicians who Dx and Rx TBI • Only 10% of all physicians treat TBI • PM&R = Specialty trained – 12,000 in the US • Sports Medicine physicians- NCAA/Professional • ER Physicians – “treat and street” • These specialties are sparse in the DOD/VA and the community

  6. 20% - 25% TBI in War Theatre • BLAST INJURY – IED; RPG; Mortar • VEHICULAR ACCIDENTS –MRAP • FALLS- Terrain • Direct HITS, eg. during night drills • Assaults • Anoxic Injury – Drowning, Vascular Compromise, Choking

  7. Is TBI a new injury in War? • This is not a new war injury, but this is first wartime that technology is available to detect the injury. • Previous wars included Shell Shock, Tremors, Parkinsonism • IF there are tremors, think TBI – Parkinson’s

  8. NEJM landmark articles • HOGE- 2004 – TBI is signature wound • HOGE- 2008 – PTSD is signature wound • But throughout history of war, soldiers have sustained brain injuries – most died in previous wars. • Helmets improve and technology changes – mild TBI vs. Death in previous wars

  9. Cost of Treating TBI • Estimated costs of PTSD Rx. 1 year • $3000 if no depression • $9000 if depression • Estimated costs for TBI Rx. 1 year • $30,000 – requires TEAM approach • Moderate TBI - $260,000/case • Severe TBI - $400,000- $ 1.5 million/case RAND July 2008

  10. Discussion of BRAIN SYNDROME • TBI- result of blow, jolt, or penetrating wound to the head that results in disruption of brain function. • Concussion – injury due to shaking, spinning, or blow. More focal – Sports Injury • BLAST is hallmark – insult from external mechanical force.- No LOC required- Diffuse Axonal Injury -DAI • Effects are additive – CTE-Chronic Traumatic Encephalopathy

  11. HALLMARKS of TBI – midbrain/frontal injuries • Sensory processing alterations • Photophobia- CN IV • Hyperacusis – CN VIII • Sensory overload – ie.Big Box Syndrome • Loss of Mapping skills. • Pituitary Dysfunction. • Chronic Headaches. • Memory Problems

  12. Midbrain

  13. Midbrain Over Drive

  14. Co-morbidities of TBI • Substance Abuse – 90% ETOH abuse in 1 year; Marijuana second drug chosen. Self- Medication – SLOW IT DOWN! • Amphetamine – Speed it UP! (10-15%) • Incarceration – Loss of Executive Function – 60% felons in California. • SUICIDE – 7.7 X – STOP IT!- GSW, Drugs/Etoh, MVA; Death by Law Enforecement

  15. NFL and TBI • Chronic Traumatic Encephalopathy • CTE- after Playing Field…Known • CTE- after Battle Field? 1st Case April 2012 • Dr. Ann McKee – Boston University

  16. TBI stats in civilian world: • 1.7 million estimated on ER visits • 75% are considered mTBI – mild TBI • Male: Female 2:1 • Direct and indirect costs - $100 billion/year in civilian world • Children (0-4) ; Adolescents (15-19) older pop. (65+) • High School legislation leading the nation for TBI prevention – preventing second impact syndrome.

  17. Diagnosis of TBI • Listen to the Patient: He is telling you the diagnosis. Sir William Osler • TBI Diagnosed by HISTORY.

  18. What do you say/hear with TBI? • “I used to know this stuff.” • “Why can’t I think?” • “What? When did you tell me,” • “No, I didn’t.” • “I don’t remember.” • “Keep it down!” • “Why don’t you/I understand?” • “GET OFF MY BACK!”

  19. Pay attention to HOW it is said • Hypervigilant affect/Impatient • Hollow eyes/ Lights out/Flat affect • Slowness of speech • Word finding problems • Heightened irritability/emotion- sporadic • “Choice Language” • Distractable

  20. Neuroimaging Studies Radiologic Studies: Timing/Technique • CT/MRI – Notoriously Negative – VA standard • Diffusion Tensor Imaging – Gold Standard Lipton et al. Radiology Aug. 2009 (DAI) • PET- SPECT - Hovda UCLA -2007 • fMRI –brain mapping Most veterans tested 1-4 yrs. after last TBI by #1. NEGATIVE MRI/CT is the norm in mild TBI

  21. Laboratory Workup Blood work – pituitary profile- GH; TSH; LH; ACTH;Testosterone CRP, Tox screen. Do NOT miss Dx. of hypopituitarism which mimics depression.

  22. Neuropsychological Testing • May find equivocal results • Most with mild TBI won’t show memory deficits without a baseline • Lack of baseline pre-deployment • Helpful in more significant injuries • ImPACT, COGSTAT, ANAM, Headminder may be useful (Logan, 2009)

  23. Increased Arousal (Sympathetic Nervous Activation) • Difficulty falling or staying asleep • Irritability or outbursts of anger • Difficulty concentrating • Hypervigilance • Exaggerated Startle Response PTS? or TBI? Answer: BOTH SURVIVAL depends on Hypervigilance

  24. Suicide • 2nd leading cause of death in military – 154 in 155 Days. • Young, White, Unmarried Male Junior Enlisted Active Duty • Drugs/alcohol / Firearms • No psychiatric history (Washington Post, 2008, per CDP) • 1.2% Army Post-Deployment survey had suicidal ideation (Miliken et al., 2007 per CDP) • Of completed suicides, most saw a healthcare provider within one month before suicide (USUHS, 2009) • 19% of patients with PTSD will attempt suicide (CDP, 2009) and patients with TBI are at 7.7 X greater risk

  25. HYPERVIGILANCE of Physician • Important to the Survival of the returning hero • Listen to the patient/Listen to the family • Note the signs of TBI – word searching, rhythm of speech, depression, irritability, photophobia • Ask hero to explain what is happening so that you may help his/her fellow soldiers • Thank them for their service and acknowledge that they have already survived – • Point out the VALUE they are to their comrades

  26. Why People Die By Suicide 2005Dr. Thomas Joiner Capability Desirability Feeling of burdensomeness. Remember the word SERVICE in Service personnel

  27. “PDS” Syndrome • Hard to differentiate mild TBI from PTSD • Sometimes both present • Psychological factors may lead to maintenance of TBI symptoms and medical issues may lead to maintenance of psychological factors • Mind, Body, Spirit - Holistic • David Cifu, MD, VA Polytrauma 2011

  28. Symptoms more consistent with PTS • Flashbacks • Nightmares • Intrusive thoughts • Avoidance behaviors • Exaggerated startle response

  29. PTS = Brain Injury – U of Rochester Report - • June 2, 2012 – Dr. Bazarian • Results showed that 30 of the 52 New York veterans suffered at least one mild traumatic brain injury, • The severity of veterans’ PTS symptoms correlated with the amount of axonal injury seen on the DTI scans. • “Based on our results, it looks like the only way to detect this injury is with DTI/MRI,” • BRAIN injury, not Mind Problem – reduced Stigma

  30. Post Concussive Syndrome • PCS = constellation of symptoms with mild TBI that persist for three months or more following a “concussion”. • Primary symptoms are headache, photophobia, irritability, sleep disturbance, cognitive deficits. • This is a subset of TBI- Sympathetic Overdrive

  31. MYTHS about PCS • Symptoms are exaggerated due to pre-existing medical/psychological conditions. • Litigation is often involved so symptoms are for secondary gain. • May be iatrogenic – physicians concern may lead to increased symptoms and disability.

  32. TRUTHS about PCS • Different injury from the onset. PCS develops the MOMENT of the injury. • Research revealing HYPER state of brain at time of injury is crucial. • SPECT scan proof of decreased glucose utilization in the brain • REST / Decreased stimulation is key.

  33. Treatment for PCS • MILD doses of antidepressants or stimulants – INDIVIDUALIZE RX. • Frequent visits with minor changes in medications is most important. • Have patient keep a journal. • Decrease stimulation in environment. • Mild exercise is key. • Alternative therapies- Reiki, Yoga, ARTS

  34. TREATMENT options for TBI: Amantadine, Methylpheniate, Dextroamphetamine - for processing Propranolol, amitriptyline – for aggression/depression- (SSRI’s can be detrimental) Electronic aides – Bushnell, GPS, PDA, iPHONE Setting modifications or organization Routine/schedule Memory strategies (chunking, acronyms, music) Pain management as needed- NO OXYCONTIN Exercise

  35. Adjunctive Treatment • Service • Education (GI-Bill) • Psychoeducation and support groups for self and family • Exercise and pleasurable activity scheduling • De-toxification from caffeine, stimulants, and alcohol • Solutions (action-oriented, specific goals) • Family or marital treatments • Advocate regarding employment or military problems • Stress management • Adequate, restful sleep • Nutrition • Relaxation/Rest

  36. TBI Team • Primary care physician/specialist • Nurse/nurse practitioner • Psychiatrist • Psychologist/Neuropsychologist • Counselor • Social Worker • Physiatrist • Speech-Language Pathologist • Occupational Therapist • Physical Therapist

  37. Resurrectinglives.org

  38. Mission Statement: • THE MISSION. • Our mission is narrow and deep. We will assist the recovery/reintegration of our OIF/OEF Veterans with Traumatic Brain Injury (TBI) by defining the brain pathology and by developing the protocols for recovery. We will advocate for our returning heroes and their families while educating the public about the injuries and co-morbidities associated with a traumatic brain injury.

  39. HOPE of Brain; Peace of Mind • Cognitive Retraining is KEY • Telemedicine Opportunities • Self-taught computer programs • Journaling • Avoid Psychotropic Medications • Exercise mind/body/soul • Group education courses online – GOOGLE PLUS

  40. Think Different – 99% solution

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