Title: Mild Traumatic Brain Injury: A Signature Injury of the Iraq Conflict
1Mild Traumatic Brain Injury A Signature Injury
of the Iraq Conflict
Monica L. Jefferson, Ph.D. Neuropsychologist NJ
WRIISC
2LEARNING 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
3OEF/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.
4OEF/OIF represent new challenges
- Different Weaponry
- Ambiguous Front Line
- Advances in Amour and Protection
5When an OEF/OIF Veteran returns
- Healthy Adjustment?
- Psychiatric Condition?
- Mild TBI?
6When an OEF/OIF Veteran returns
7Veterans 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)
8When an OEF/OIF Veteran returns
9ReactionsContinue 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
10When 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
13When an OEF/OIF Veteran returns
- Mild Traumatic Brain Injury?
14There is no clear consensus on definition of
MTBIThis
- Complicates Diagnostic Efforts
- Complicates Research Efforts
- Increases need for INTERDISCIPLINARY APPROACH to
assessment, treatment and rehabilitation
15American 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
16TBI 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)
17TBI 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
18Blasts and MTBI
19Mechanisms 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
20Mechanisms of Blast Injury
- From When Things Go Boom Blast Injuries By
Robert Nixon, - EMT-P, and Charles Stewart, MD. fireEMS, May 1,
2004
21Blasts 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
22MTBI 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)
23MTBI 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)
24MTBI Recovery
- Immediate Symptoms
- Loss of consciousness
- Disorientation and/or Confusion
- Memory Difficulties (e.g., amnesia)
- Headache
- Hearing difficulties
- Visual difficulties
- etc
25MTBI 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
26MTBI 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
27MTBI 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
29MTBI 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?
31MTBI 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
32MTBI 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)
33MTBI Recovery
Factors to consider with returning Veterans
34Injury 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
35Additional 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/
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