Care of Our Homecoming Warriors

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Care of Our Homecoming Warriors

• Mild Traumatic Brain Injury
• Operation Iraqi Freedom
• Operation Enduring Freedom
• Carol Burgess MD

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Battlefield TBI Sources of trauma

• Types of Trauma
• Direct trauma (MVA and falls), shrapnel, bullet
  wounds
• Improvised explosive devices
• Rocket-propelled grenades
• Hoge, McGurk, Thomas et al. Mild traumatic brain
  injury in U.S. Soldiers returning from Iraq. N
  Engl J Med 2008 358453
• Protective Gear
• Interceptor Body Armor protects the torso from
  kinetic energy of blast (fewer body-related
  casualties)
• Modular Integrated Communications Helmet (MICH)
  worn by Rangers, Special Forces, Navy SEALS, Air
  Force Special Operations, Marine reconnaissance,
  FBI Hostage, one brigade of 82nd Airborne only.
  Offers increased impact protection.
• Standard helmet is Kevlar

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TBI or Traumatic Brain Injury

• Immediate
• vacant stare,
• delayed verbal expression,
• inability to focus attention,
• disorientation,
• slurred or incoherent speech,
• incoordination or disequilibrium,
• Potential Complications
• Coma,
• ischemia/edema and mass effect,
• seizure,
• intracranial hemorrhage

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Traumatic Brain Injury

• Signs and symptoms of danger
• prolonged unconsciousness,
• skull fracture (esp. open or depressed),
• CSF leak,
• hematotympanum,
• raccoon eyes or Battles sign,
• greater than two episodes vomiting,
• incontinence,
• older than 65,
• persistent mental status alterations,
• amnesia before impact of greater than 30 minutes,
• dangerous mechanism (fall greater than 3 feet or
  greater than 5 stairs, or pedestrian struck by
  MV)
• abnormalities on neurologic exam.
• Kelly, Rosenberg. Diagnosis and management of
  concussion in sports. Neurology 199748575

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Incidence of TBI

• 1.4 million reported incidents of TBI annually in
  US, most- 75 to 95 are mild.
• Division of Injury and Disability Outcomes
• http//www.cdc.gov/ncipc/pub-res/TBI_in_US_04/T
  BI_ED.htm
• 1.6 million military deployed to the Iraq and
  Afghanistan conflicts.
• 62 of those requiring medical evacuation from
  the Iraq and Afghanistan conflict have TBI
• 16 of returning military have had a reported
  alteration in consciousness or LOC
• 13-17 reported incidence of PTSD
• Am J Epidemiol 20081671446-1452
• Some estimates of incidence of TBI including
  Blast injury as well as direct concussion and
  trauma as high as 25 among returning military

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Monetary Costs of TBI

• Direct and indirect costs may exceed 60 billion
  per year in the US
• Costs of inpatient rehabilitation often exceed
  100,000/patient
• Outpatient cognitive rehabilitation approximately
  20,000 to 30,000/patient
• Employment drops from 69 to 31 by end of 1st
  year of injury for civilian TBI
• US civilian TBI result in 642 million in lost
  wages yearly, 96 million in lost taxes yearly,
  and 353 million in increased public assistance
  expenditures.
• Archives of Phys Med Rehab Vol 84, Feb 03, page
  238-241

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Acute symptoms of Mild Brain InjuryDefinition
of Mild Traumatic Brain Injury According to the
American Congress of Rehabilitation Medicine

• 1. Any period of 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 (e.g. feeling dazed, disoriented, or
  confused), and
• 4. Focal neurological deficit(s) that may or may
  not be transient but where the severity of the
  injury does not exceed the following
• Post-traumatic amnesia not greater than 24 hours
• After 30 minuets, an initial Glasgow Coma Scale
  score of 13-15
• LOC of 30 minutes or less
• Mild Traumatic Brian Injury Committee of the
  Head Injury Interdisciplinary Special Interest
  Group of the American Congress of Rehabilitation
  Medicine. The definition of traumatic brain
  injury. J Head Trauma Rehabil. 19938(3)86-87

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Mild TBI/PCS (post concussive syndrome)

• May not be a true history of LOC
• Hallmark manifestations of concussion confusion
  and amnesia
• 80 of those with mild TBI will experience some
  symptoms of post-concussive syndrome
• Risk of PCS does not correlate well with severity
  of injury
• Common clinical usage of both terms, PCS is a
  subset of mild TBI

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Mild TBI mechanisms and pathology

• Coup and Contra-coup injuries
• -Goodman. Pathologic changes in mild head
  injury. Semin Neurol 19941419
• Mild axonal injuries and rupture
• Potential for vessel oscillations to transmit
  force of a blast to the Brain with subsequent
  axonal neurofilament disruption and damage
  (leading to axonal swelling, Wallerian
  degeneration, and transection). Postulated
  involvement of the Hippocampus, Brainstem, and
  Cortex.
• -Bhattacharjee,Y Shell shock revisited solving
  the puzzle of blast trauma. Science 2008319406
• -Povlishock, Katz. Update of neuropathology
  and neurological recovery after traumatic brain
  injury. J Head Trauma Rehabil 2005 2076
• Possible acceleration of the pathophysiology of
  aging, buildup of neurofilament proteins. Note
  possible vulnerability of individuals with ApoE
  allele.
• -Jordan, Relkin, Ravdin, et al. Apolipoprotein E
  epsilon4 associated with chronic traumatic brain
  injury in boxing. JAMA 1997 278136

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Comparison of normal CNS tissue to posthumous CNS
tissue from NFL player suffering Chronic
Traumatic Encephalopathy
Note tangles in superficial rather than deep
neocortex Occurs without neuritic plaques
Brain Tissue from NFL athlete suffering CTE -
greater than 100 head traumas
Normal Brain Tissue
Note the absence of brown protein tangles in
the Normal Brain, and the significant
accumulation of protein tangles in the brain of a
former NFL athlete with CTE. Pathologic findings
similar to those of Alzheimer's dementia.
Presented by the Center for the Study of
Traumatic Encephalopathy at the Boston
University School of Medicine http//www.cnn.com/2
009/HEALTH/01/26/athlete.brains/index.html
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Evaluation of the Patient with TBI

• History and Physical ( Neurologic exam) with
  appropriate laboratory and EKG.
• Radiologic evaluation
• CT, MRI/MRA, possible role of functional MRI
• EEG
• Acoustic, Visual, Vestibular evaluation
• Neuropsychological evaluation/Cognitive testing
• Sleep evaluation
• Appropriate system evaluation (Cardiac, GI,
  Urology, Pulmonary, Endocrine)
• Substance use evaluation and treatment

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Symptoms of Post Concussive Syndrome

• Symptoms
• Fatigue (91)
• Personality change (50)
• Headaches ( 78)
• Chronic Pain (75)
• Dizziness (59)
• Insomnia (70)
• Sensory sensitivity (46)
• Neuropsychiatric Symptoms (note commonality to
  some symptoms of PTSD)
• Irritability (62)
• Anxiety (63)
• Psychiatric illness (20)
• Cognitive Impairment attention, working
  memory(73), processing speed, reaction time, and
  executive function
• Paniak, Reynolds, Phillips, et al. Patient
  complaints within 1 month of mild traumatic brain
  injury a controlled study. Arch Clin
  Neuropsychol 2002 17319
• Dikmen, Mclean, Tmkin. .Neuropsychological and
  psychosocial consequences of minor head injury. J
  Neurol Neurosurg Psychiatry 1986 491227

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Mental Health Sequelae for military returning
from Iraq/Afghanistan

• 17 from Iraq showing signs of PTSD, major
  depression or severe anxiety (90 involved in
  direct combat)
• 11 from Afghanistan showing signs of PTSD, major
  depression or severe anxiety (31 were involved
  in direct combat )
• Some reports of returning military units with
  80 incidence of significant mental health issue
  and 85 incidence of divorce
• PTSD in Vets May Present as Substance Abuse.
  www.internalmedicine news.com Dec 15,2008
• Emerging suicide issues
• Increased incidence of criminal arrests
  (reported as high as 20-30) among returning
  military from Iraq/Afghanistan

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Assessment of validity of Post Concussive
Syndrome

• Risk factors for Post concussive syndrome and
  protracted recovery
• Female gender
• Increasing age
• MVA /Assault, rather than sport related injury
• Pre-morbid depression or other psychiatric
  illness
• Co-existent PTSD
• Decreased social supports
• Issue of concerns for role of litigation
• Issue of coexistence of chronic pain complaints
• Issues
• -patients with psychiatric illness may be more
  prone to injury
• -patients with psychiatric illness may be more
  prone to develop PCS after injury
• -head injury may precipitate psychiatric disease
  in susceptible individuals

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Comparison of PTSD to TBI
TBI Traumatic Event to CNS Fatigue
and Cognitive fatigue veil of
cement Insomnia Anxiety / Depression Sensory
sensitivity Autonomic/Adrenergic
dysfunction Overwhelmed with
coping Amnesia from trauma Reduced
socialization Reduced capacities Cognitive
limitations Insomnia Dizziness Irritability/Outb
ursts Poor emotional control Headache Concentratio
n limitations Occupational
change Personality change

• DSM IV criteria PTSD
• A. Exposed to traumatic event
• -1.Experienced or witnessed
• -2.Response of helplessness or horror
• B. Traumatic event persistently re-experienced
• -1. recurrent intrusive recollections
• -2.recurrent distressing dreams
• - 3.acting or feeling like event is recurring
• -4.intense emotional distress at exposure to
  events resembling the event
• -5.physiological reactivity on exposure to cues
  resembling the event
• C .Persistent avoidance of stimuli associated
  with the trauma
• -1. Efforts to avoid thoughts, feelings and
  conversations associated with the trauma
• - 2.Efforts to avoid activities, places and
  people that arouse recollection of the event
• -3.Inability to recall an important aspect of
  the trauma
• -4.diminished interest or participation in
  significant activities
• -5. feeling of detachment or estrangement from
  others
• -6. restricted range of affect (unable to feel
  love)

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Evaluation of the Patient with TBI

• History and Physical ( Neurologic exam) with
  appropriate laboratory and EKG.
• Radiologic evaluation
• CT, MRI/MRA, possible role of functional MRI
• EEG
• Acoustic, Visual, Vestibular evaluation
• Neuropsychological evaluation/Cognitive testing
• Sleep evaluation
• Appropriate system evaluation (Cardiac, GI,
  Urology, Pulmonary, Endocrine)
• Substance use evaluation and treatment

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Radiology

• CT scan
• 10 CT abnormal in mild TBI (demonstrating
  contusions, subdural hemorrhage, or subarachnoid
  hemorrhage )
• MRI scan
• (MRI abnormalities present in 30 or the cases of
  mild TBI with reported normal CT many of these
  findings consistent with axonal injury but not
  specific to TBI or TBI outcome)
• Mittl, Grossman, Hiehle, et al. Prevalence of MR
  evidence of diffuse axonal injury in patients
  with mild head injury and normal head CT
  findings. Am J Neuroradiol 1994 151583
• SPECT, PET and functional MRI more likely to
  demonstrate abnormalities, supporting a role for
  diffuse structural and/or physiologic abnormality
  in mild TBI.
• Primarily a research tool.
• Similar abnormalities may be noted on functional
  imaging studies in migraine and depression.
• Metting, Rodiger, De Keyser, van der. Structural
  and functional neuroimaging in mild-to-moderate
  head injury. Lancet Neurol 2007 6699

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SPECT Brain Perfusion after mild TBI
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Evaluation of the Patient with TBI

• History and Physical ( Neurologic exam) with
  appropriate laboratory and EKG.
• Radiologic evaluation
• CT, MRI/MRA, possible role of functional MRI
• EEG
• Acoustic, Visual, Vestibular evaluation
• Neuropsychological evaluation/Cognitive testing
• Sleep evaluation
• Appropriate system evaluation (Cardiac, GI,
  Urology, Pulmonary, Endocrine)
• Substance use evaluation and treatment

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Seizures post TBI

• Post traumatic seizures occur in less than 5 of
  mild or moderate TBI.
• Increased frequency with more severe trauma.
• 50 occur within the first 24 hours of injury.
• 25 occur within first hour of injury.
• After the first hour, majority are simple partial
  (motor) or focal with secondary generalization.
• Early seizures increase the risk of post-
  traumatic epilepsy by 4X
• Anticonvulsants are not useful in prevention of
  post traumatic epilepsy, but may be used to in
  treatment of early seizures.

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Treatment of mild TBI
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Longitudinal Continuity of Care with Primary
PhysicianSymptomatic Treatment

• Frequent visits (often every 2 weeks)
• Address suicidal thoughts and psychotic ideation
  early
• Only one or two projects per visit
• Provide a Notebook Back-pocket Memory
• (VA may provide a PDA)
• Orchestrate care and network patients
• Set reasonable expectations Adaptation
• (LIMIT grief)
• Provide emotional support and
• attitudinal course corrections
• Provide necessary family and community Education
  (with consent call them, if not with patient at
  visit)
• Celebrate success !
• C Burgess MD

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Suggested Sequence of Symptomatic Treatment and
Rehabilitation for mild TBI

• First Priority SLEEP
• Pain and Headache
• Emotional Concerns Anxiety and DepressionPTSD.
  
• Sensory Disturbance Visual, Acoustic,
  Equilibrium
• Fatigue
• Education Family and Employer
• Visual and Vestibular Rehab
• Cognitive Rehab
• 
  C Burgess MD

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TBI Management post- traumatic Headache

• Use Low Dose pharmacologic therapy!
• Often worse after mild TBI occur in 25 to 78
  of patients with mild TBI
• Use localized therapy or treatment when possible
  (lidocaine patch, NSAID patch, cortisone
  injection, or physical therapy)
• Types of Headache
• mixed,
• tension (75),
• migraine,
• occipital and trigeminal neuralgia,
• TMJ,
• positional,
• analgesic overuse,
• low CSF pressure,
• cluster,
• hemicrania continua

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Pharmacologic management of headache associated
with TBI

• Pharmacologic Management
• Prophylactic
• Tricyclic antidepressants Amitriptyline and
  Nortriptyline (Amitriptyline 10mg-250mg qd)
• Calcium channel Blockers Verapamil (initiate
  Verrapamil SR 120mg qd.)
• B blockers Nadolol (20mg qd 40mg bid),
  Propanolol SR (80mg-160mg qd)
• also Timolol,
  metoprolol, and atenolol
• Valproate (125mg bid increasing to 250mg bid
• Gabapentin (900 to 1200 mg daily)
• Topamirimate (25 mg to 125 mg daily)
• Naproxen (250 mg to 500 mg bid)
• Tizanidine (1-2mg po qhs, may increase to 8 mg
  qhs)

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Management of TBI Headache (Continued)

• Propanolol or amitriptyline in combination or
  alone have a response rate of up to 70
• Dihydroergotamine and metaclopramide IV in
  repetitive dosing in an inpatient setting may be
  effective
• Triptans may be used for acute Migraine
• Indomethacin may be used for paroxysmal
  hemicrania and hemicrania continua (25 mg tid
  increase to 50 mg tid)
• Occipital nerve block with local anesthetic and
  corticosteroid for occipital headache is highly
  effective for greater occipital neuralgia.
• Analgesic overuse headache is common.

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Management of Sensory Disturbance post TBI

• Avoidance of overstimulation prior to or during
  performance of tasks
• Photophobia
• Use of dark and transitional glasses.
• Careful lighting (fluorescent an issue)
• Referral Behavioral optometrist
• Diplopia may result from injuries to CN III, IV,
  and VI.
• Anosmia and Hyposmia impaired taste and smell
  due to injury to olfactory filaments at the
  cribiform plate. In 2/3 of patients is a
  permanent injury (usually permanent if still
  present at 1 year). Attention needed to avoid
  weight alterations and gastric irritation.
  Avoidance of gas appliances.

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Management of Sensory Disturbance (continued)

• Hyperacusis Use of specialty ear plugs in noisy
  environment. Referral Audiologist
• Example of available Westone ES 49 earpiece
  protection for musicians
• Disequilibrium and Vertigo
• Vestibular rehabilitation. Referral ENT and
  specially trained physical therapist.
• Consider pharmacologic use of Meclizine or
  Clonazepam (disadvantage is sedation and
  suppression of adaptive learning).
• Encourage regular coordinated movement (dance,
  tai-chi, etc.). Avoid sports prone to new
  injuries!
• Driving can be an issue rehabilitation
  facilities often have driving assessment services
  and retraining.
• NO ETOH!

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Post Traumatic Vertigo/Dizziness

• Mechanisms of Vertigo
• Direct injury cochlea or vestibular structure
  esp. with sensorineural hearing loss or fracture
  of temporal bone
• Labyrinthine concussion (vertigo plus ataxia)
  maximal at onset and abating within weeks
• BPPV (benign paroxysmal positional vertigo) due
  to shearing and displacement of otoconia. Can
  be a hiatus of weeks or months between TBI and
  development.
• Perilymphatic fistula due to rupture of oval or
  round window. Unilateral SN hearing loss with
  persistent vertigo and ataxia characteristic
• Other post-traumatic Menieres, brainstem
  ischemia with vertebral artery dissection,
  epileptic vertigo, and migraine related vertigo.
• Mechanisms of non-vertiginous dizziness is often
  cervical
• Aberrant afferent input from positional
  proprioceptors in C- spine
• Overstimulation of cervical sympathetic nerves
• Compromised vertebral arterial flow

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Management of Fatigue and lack of Concentration

• Appropriate sleep, diet and limited exercise.
  Respect for biorhythms
• Frequent rest periods
• Avoidance of excessive environmental stimulation
• Pharmacologic management
• Wellbutrin SR/XL (Budeprion)100mg q am 300mg
  q am
• Provigil (modinafil) 100mg q am - 200 mg q am
  and afternoon
• Occasional use adderal, concerta, dexedrine,
  ritalin
• May exacerbate irritability, anger, and sleep
  issues

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Favorite pharmacologic choices for mild TBI C J
Burgess, MD

• Nortriptyline 10-25 mg qhs for headache, sleep,
  pain and potentially anxiety
• Plus zolpediem (Ambien) 5-10 mg, or ramelteon
  (Rozerem) 8 mg if needed for sleep
• Citalopram (Celexa) 10-20mg, escitalopram
  (Lexapro) 5-10mg, or Vanlafaxine (Effexor XR)
  37.5-75 mg for anxiety and depression, agitation,
  emotional lability and to improve sense of well
  being.
• Modinafil (Provigil) 100-200 mg or Budeprion SR
  (Wellbutrin) 100-150 mg qam for alertness and
  reduced fatigue.
• Clonazepam (Klonopin) .25 - .5mg up to tid for
  equilibrium issues and vertigo if meclizine
  fails. Use short term as a bridge to vestibular
  rehab.
• Donepezil (Aricept) 10mg qd if memory issues are
  profound and persistent.
• Topamax 25mg to 100mg qd if headaches remain
  intractable.

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Cognitive Rehabilitation

• Continuing controversy regarding short-term and
  long term benefits to outcome of early
  intervention with cognitive and behavioral
  therapy.
• Differences in study design including patient
  selection, nature of intervention, and measures
  of performance have hindered assessment of
  cognitive interventions.
• Interventions often delivered in an individual
  setting based on deficits identified with
  Neuro-psych testing (full evaluation often
  involves 4 -6 days of testing).

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Cognitive Evaluation of mild TBI

• Neuropsychological Testing
• Vulnerable domains to TBI
• Attention
• Working memory
• Processing speed
• Reaction time
• Not associated with gross deficits of
  intelligence and memory
• Findings can be confused with those of pain
  syndromes and medication effects as well as
  psychological illness
• May be helpful in differentiating TBI from
  alternative diagnosis.
• Schretlen, Shapiro. A quantitative review of the
  effects of traumatic brain injury on cognitive
  functioning. Int Rev Psychiatry 2003 15341

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Expectations
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Expectations after Mild TBI

• 10-15 of mild TBI cases have persistent symptoms
  beyond one year
• Iverson. Outcome from mild traumatic brain
  injury. Curr Opin Psychiatry 2005 18301
• 80 of those with post traumatic headache improve
  significantly during the first year.
• 15-31 of those with post traumatic headaches
  persist for greater than 3 years and are likely
  permanent.
• Packard RC. Post-traumatic Headache permanency
  and relationship to legal settlement. Headache.
  199232496-500

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Expectations after mild TBI

• Pre-morbid personality and educational
  characteristics may play a role in recovery from
  mild TBI. Pre-morbid physical limitations, prior
  head injury, psychiatric illness, and older age
  may limit recovery.
• Most improvements occur in the first one to two
  years after injury, but patients may continue to
  report progress (improvement in cognition and
  memory as well as a decline in physical symptoms)
  as late as five years post injury.
• Prompt diagnosis, appropriate post-injury
  expectations, and continued support of family,
  employer and community lead to better long term
  outcomes after injury.

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Instructions for Employers and Families

• Frequent rest periods
• Variable scheduling
• Careful sequencing (prioritize)
• Avoidance of unnecessary stimulation
• Noise, multiple sources of sound
• Harsh Light (fluorescent lights potentially
  problematic)
• Hectic motion-filled environment
• Fumes (issue with Migraine)
• Emotional circumstances
• Calm environment
• Redirection and rest if actions/verbalization are
  inappropriate
• Early identification of problem areas for
  treating MD/rehab team/transition coach. Use the
  notebook or back-pocket memory.
• Strong feedback on success

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Lessons learned from mild TBI patients

• Family physicians have pleotropic effects.
• Physician and patient expectations are critical
  to recovery. Set an obtainable expectation at
  each and every visit. First steps first.
• Dont allow a mild or moderate TBI to become the
  defining moment of the patients existence. So
  what? Is a critical concept to a successful
  reboot by a patient with TBI.
• The human brain is plastic.
• Humor has amazing therapeutic value. So does
  expression of Art, Poetry, Music, and movement.
• Allow patients to share their successes and
  experiences with other similar patients of the
  practice if support groups are not plentiful.
  Dont be intimidated by HIPPA.

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Lessons learned, continued

• Recruit help from any available source including
  family and children, libraries, literary
  volunteers, community centers, etc. Elementary
  educational materials may be a critical tool for
  those not eligible for cognitive rehab. Office
  staff are often an amazing resource. Patients
  have a hard time asking for help for themselves.
• Support with enthusiasm any potentially
  achievable educational or recreational objective
  or project that interests the patient. The
  process of participation, effort and study will
  help heal the patient often creating detours
  for injuries sustained. Have the patient
  volunteer if they are not employable.
• Prevent second injuries.

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Call for Immediate Action

• Availability of appropriate primary MD evaluation
  and longitudinal care for our homecoming
  military.
• Availability and timely referral for appropriate
  diagnostic testing (?universal application for
  those with known trauma or blast exposure)
• Availability of outpatient rehabilitation
  programs, group and individual
• Availability of psychological support and
  treatment
• Availability of support for transition to
  peacetime civility
• No adverse sequela to seeking treatment
  Avoidance of long term military career impedance
• Availability of special care by the Judicial
  system

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Brainstorming

• Establish community and base military TBI support
  groups and group rehabilitation programs.
  (Establish location and leader) Potential for
  formal group psychotherapy. Funding for
  educational programs.
• Establish community and base intervention teams
  for potential evolving crisis circumstance. A
  need for time out short term residences (not
  the hospital, the local bar, or a jail cell)
• Special legal channeling within the court system
  for those with military transition problems.
• Evolution of transition teams and coaching
  to promote successful transition from battlefield
  to family and employment. Programs for
  individuals remaining in active military careers
  as well as those transitioning to community. May
  vary by region and service.
• Adequate formulary and device support for
  treatment.
• Encourage local bars to offer a few tasty brain
  drinks (not a shirley temple).

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Resources

• Defense and Veterans Brain Injury Center
• Available Heads up Brain Injury in your
  Practice Tool kit
• National Educational Resources
  Database
• www.DVBIC.org
• Group of 7 TBI programs in DoD and Dept of VA
  hospitals and a civilian TBI program
• Available comprehensive outpatient assessments
  psychological, audiologic, neurological,
  neuropsychological and laboratory testing
• Inpatient evaluations include additional
  neuro-opthalmology, dental, ENT, vestibular,
  psychiatry, etc.
• Access to clinical trials
• Sites
• Military Treatment Facilities (MTF)
• Walter Reed Army Medical Center, Washington DC
• Wilford Hall Medical Center, Lackland Air Force
  Base, TX
• Naval Medical Center San Diego, San Diego, CA
• Veterans Affairs (VA) Sites
• Hunter McGuire VA Medical Center, Richmond, VA
• James A Haley VA Hospital, Tampa, FL
• Veterans Affairs Medical Center, Minneapolis, MN
• VA Palo Alto Health Care System, Palo Alto, CA

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Resources, continued

• New York State Brain Injury Association
• 1-800-228-8201 http//www.bianys.org
• Albany womens support group Robin Cohn
• rcohn18_at_nycap.rr.com
• CDC National Center for Injury Prevention and
  Control TBI resources
• http//www.cdc.gov/ncipc/factsheets/tbi.htm
• Traumatic Brain Injury Resource Guide
• http//www.neuroskills.com/
• National Resource Center on Traumatic Brain
  Injury
• http//www.neuro.pmr.vcu.edu/
• Traumatic Brain Injury National Data Center
• http//www.tbindc.org/

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Appendix 1Acute evaluation and disposition of
patients with mild TBI
Data from Vos, PE. Eur J Neurol 2002 9207 and
Borg, J. J Rehabil Med 2004 S4361.
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Appendix 2 Standardized assessment of
concussion SAC