Care of Our Homecoming Warriors Mild Traumatic Brain Injury Mild Traumatic Brain Injury Operation Iraqi Freedom Operation Enduring Freedom Carol Burgess

Care of Our Homecoming Care of Our Homecoming WarriorsWarriors

Mild Traumatic Brain Mild Traumatic Brain InjuryInjury

Operation Iraqi FreedomOperation Iraqi FreedomOperation Enduring FreedomOperation Enduring Freedom

Carol Burgess MDCarol Burgess MD

Battlefield TBI: Sources of Battlefield TBI: Sources of trauma trauma

Types of TraumaTypes of Trauma• Direct trauma (MVA and falls), shrapnel, bullet Direct trauma (MVA and falls), shrapnel, bullet

woundswounds• Improvised explosive devicesImprovised explosive devices• Rocket-propelled grenadesRocket-propelled grenades

– Hoge, McGurk, Thomas et al. Mild traumatic brain injury in U.S. Soldiers Hoge, McGurk, Thomas et al. Mild traumatic brain injury in U.S. Soldiers returning from Iraq. returning from Iraq. N Engl J MedN Engl J Med 2008: 358:453 2008: 358:453

Protective GearProtective Gear• Interceptor Body ArmorInterceptor Body Armor protects the torso from kinetic protects the torso from kinetic

energy of blast (fewer body-related casualties)energy of blast (fewer body-related casualties)

• Modular Integrated Communications Helmet (MICHModular Integrated Communications Helmet (MICH)) worn by Rangers, Special Forces, Navy SEALS, Air Force worn by Rangers, Special Forces, Navy SEALS, Air Force Special Operations, Marine reconnaissance, FBI Hostage, Special Operations, Marine reconnaissance, FBI Hostage, one brigade of 82one brigade of 82ndnd Airborne only. Offers increased impact Airborne only. Offers increased impact protection. protection. – Standard helmet is Standard helmet is KevlarKevlar

TBI or Traumatic Brain TBI or Traumatic Brain InjuryInjury

ImmediateImmediate:: vacant stare, vacant stare, delayed verbal expression,delayed verbal expression, inability to focus attention,inability to focus attention, disorientation, disorientation, slurred or incoherent speech, slurred or incoherent speech, incoordination or disequilibrium, incoordination or disequilibrium,

Potential ComplicationsPotential Complications:: Coma,Coma, ischemia/edema and mass effect, ischemia/edema and mass effect, seizure, seizure, intracranial hemorrhageintracranial hemorrhage

Traumatic Brain InjuryTraumatic Brain Injury

• Signs and symptoms of dangerSigns and symptoms of danger:: prolonged unconsciousness, prolonged unconsciousness, skull fracture (esp. open or depressed), skull fracture (esp. open or depressed), CSF leak,CSF leak, hematotympanum, hematotympanum, raccoon eyes or Battle’s sign, raccoon eyes or Battle’s sign, greater than two episodes vomiting, greater than two episodes vomiting, incontinence, incontinence, older than 65, older than 65, persistent mental status alterations, persistent mental status alterations, amnesia before impact of greater than 30 minutes,amnesia before impact of greater than 30 minutes, dangerous mechanism (fall greater than 3 feet or greater dangerous mechanism (fall greater than 3 feet or greater

than 5 stairs, or pedestrian struck by MV) than 5 stairs, or pedestrian struck by MV) abnormalities on neurologic exam. abnormalities on neurologic exam.

• Kelly, Rosenberg. Diagnosis and management of concussion Kelly, Rosenberg. Diagnosis and management of concussion in sports. in sports. NeurologyNeurology 1997:48:575 1997:48:575

Incidence of TBI Incidence of TBI 1.4 million reported incidents of TBI annually in US, most- 1.4 million reported incidents of TBI annually in US, most- 75% to 75% to

95% are mild.95% are mild.Division of Injury and Disability OutcomesDivision of Injury and Disability Outcomeshttp://www.cdc.gov/ncipc/pub-res/TBI_in_US_04/TBI_ED.htmhttp://www.cdc.gov/ncipc/pub-res/TBI_in_US_04/TBI_ED.htm

1.6 million military deployed to the Iraq and Afghanistan conflicts.1.6 million military deployed to the Iraq and Afghanistan conflicts. 62% of those requiring 62% of those requiring medical evacuationmedical evacuation from from

the Iraq and the Iraq and Afghanistan conflict have TBI Afghanistan conflict have TBI 16% of returning military have had a reported 16% of returning military have had a reported

alteration in alteration in consciousness or LOCconsciousness or LOC 13%-17% reported incidence of PTSD13%-17% reported incidence of PTSD

Am J EpidemiolAm J Epidemiol 2008:167:1446-1452 2008:167:1446-1452

Some estimates of incidence of TBI including Blast injury as well Some estimates of incidence of TBI including Blast injury as well as direct concussion and trauma: as high as 25% among as direct concussion and trauma: as high as 25% among returning militaryreturning military

Monetary Costs of TBIMonetary Costs of TBI

• Direct and indirect costs may exceed $60 Direct and indirect costs may exceed $60 billion per year in the USbillion per year in the US

• Costs of inpatient rehabilitation often Costs of inpatient rehabilitation often exceed $100,000/patientexceed $100,000/patient

• Outpatient cognitive rehabilitation Outpatient cognitive rehabilitation approximately $20,000 to $30,000/patientapproximately $20,000 to $30,000/patient

• Employment drops from 69% to 31% by Employment drops from 69% to 31% by end of 1end of 1stst year of injury for civilian TBI year of injury for civilian TBI

• US civilian TBI result in $642 million in lost US civilian TBI result in $642 million in lost wages yearly, $96 million in lost taxes wages yearly, $96 million in lost taxes yearly, and $353 million in increased public yearly, and $353 million in increased public assistance expenditures.assistance expenditures.

• Archives of Phys Med &Rehab Archives of Phys Med &Rehab Vol 84, Feb 03, page 238-241Vol 84, Feb 03, page 238-241

Acute symptoms of Mild Brain Injury:Acute symptoms of Mild Brain Injury:Definition of Definition of Mild Traumatic Brain Mild Traumatic Brain InjuryInjury According to the American According to the American

Congress of Rehabilitation MedicineCongress of Rehabilitation Medicine• 1. Any period of loss of consciousness:1. Any period of loss of consciousness:• 2. Any loss of memory for events immediately 2. Any loss of memory for events immediately

before or after the accidentbefore or after the accident• 3. Any alteration in mental state at the time of the 3. Any alteration in mental state at the time of the

accident (e.g. feeling dazed, disoriented, or accident (e.g. feeling dazed, disoriented, or confused), andconfused), and

• 4. Focal neurological deficit(s) that may or may 4. Focal neurological deficit(s) that may or may not be transient; but where the severity of the not be transient; but where the severity of the injury does not exceed the following:injury does not exceed the following:– Post-traumatic amnesia not greater than 24 hoursPost-traumatic amnesia not greater than 24 hours– After 30 minuets, an initial Glasgow Coma Scale score of After 30 minuets, an initial Glasgow Coma Scale score of

13-1513-15– LOC of 30 minutes or lessLOC of 30 minutes or less

Mild Traumatic Brian Injury Committee of the Head Injury Mild Traumatic Brian Injury Committee of the Head Injury Interdisciplinary Special Interest Group of the American Congress of Interdisciplinary Special Interest Group of the American Congress of Rehabilitation Medicine. The definition of traumatic brain injury. Rehabilitation Medicine. The definition of traumatic brain injury. J Head Trauma J Head Trauma Rehabil.Rehabil. 1993;8(3):86-87 1993;8(3):86-87

Mild TBI/PCS (post concussive Mild TBI/PCS (post concussive syndrome)syndrome)

May not be a true history of LOCMay not be a true history of LOC Hallmark manifestations of Hallmark manifestations of

concussion: concussion: confusion and amnesiaconfusion and amnesia 80% of those with mild TBI will 80% of those with mild TBI will

experience some symptoms of post-experience some symptoms of post-concussive syndromeconcussive syndrome

Risk of PCS does not correlate well Risk of PCS does not correlate well with severity of injurywith severity of injury

Common clinical usage of both Common clinical usage of both terms, PCS is a subset of mild TBIterms, PCS is a subset of mild TBI

Mild TBI mechanisms and Mild TBI mechanisms and pathologypathology

Coup and Contra-coup injuriesCoup and Contra-coup injuries-Goodman. Pathologic changes in mild head injury. -Goodman. Pathologic changes in mild head injury. Semin NeurolSemin Neurol 1994:14:191994:14:19

Mild axonal injuries and ruptureMild axonal injuries and rupture

Potential for vessel oscillations to transmit force of a Potential for vessel oscillations to transmit force of a blastblast to the Brain with subsequent axonal to the Brain with subsequent axonal neurofilament disruption and damage (leading to axonal neurofilament disruption and damage (leading to axonal swelling, Wallerian degeneration, and transection). swelling, Wallerian degeneration, and transection). Postulated involvement of the Hippocampus, Brainstem, Postulated involvement of the Hippocampus, Brainstem, and Cortex. and Cortex.

--Bhattacharjee,Y Shell shock revisited: solving the puzzle of blast trauma. Bhattacharjee,Y Shell shock revisited: solving the puzzle of blast trauma. ScienceScience 2008:319:4062008:319:406

--Povlishock, Katz. Update of neuropathology and neurological recovery after traumatic Povlishock, Katz. Update of neuropathology and neurological recovery after traumatic brain injury. brain injury. J Head Trauma RehabilJ Head Trauma Rehabil 2005: 20:76 2005: 20:76

Possible acceleration of the pathophysiology of aging, Possible acceleration of the pathophysiology of aging, buildup of neurofilament proteins. Note possible buildup of neurofilament proteins. Note possible vulnerability of individuals with ApoE allele.vulnerability of individuals with ApoE allele.

--Jordan, Relkin, Ravdin, et al. Apolipoprotein E epsilon4 associated with chronic Jordan, Relkin, Ravdin, et al. Apolipoprotein E epsilon4 associated with chronic traumatic brain injury in boxing. traumatic brain injury in boxing. JAMAJAMA 1997; 278:136 1997; 278:136

Comparison of normal CNS tissue to Comparison of normal CNS tissue to posthumous CNS tissue from NFL posthumous CNS tissue from NFL

player sufferingplayer suffering Chronic Traumatic Encephalopathy Chronic Traumatic Encephalopathy

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/2009/HEALTH/01/26/athlete.brains/index.html

Normal Brain Tissue

Brain Tissue from NFL athlete suffering CTE - greater than 100 head traumas

Note tangles in superficial rather than deep neocortex

Occurs without neuritic plaques

Evaluation of the Patient Evaluation of the Patient with TBIwith TBI

• History and Physical ( Neurologic exam) History and Physical ( Neurologic exam) with appropriate laboratory and EKG.with appropriate laboratory and EKG.

• Radiologic evaluationRadiologic evaluation– CT, MRI/MRA, possible role of functional MRICT, MRI/MRA, possible role of functional MRI

• EEGEEG• Acoustic, Visual, Vestibular evaluationAcoustic, Visual, Vestibular evaluation• Neuropsychological evaluation/Cognitive Neuropsychological evaluation/Cognitive

testingtesting• Sleep evaluationSleep evaluation• Appropriate system evaluation (Cardiac, GI, Appropriate system evaluation (Cardiac, GI,

Urology, Pulmonary, Endocrine)Urology, Pulmonary, Endocrine)• Substance use evaluation and treatmentSubstance use evaluation and treatment

Symptoms of Post Concussive Symptoms of Post Concussive SyndromeSyndrome

Symptoms:Symptoms: Fatigue Fatigue (91%)(91%) Personality change Personality change (50%)(50%) Headaches Headaches ( 78%)( 78%) Chronic PainChronic Pain (75%) (75%) Dizziness Dizziness (59%)(59%) InsomniaInsomnia (70%) (70%) Sensory sensitivitySensory sensitivity (46%) (46%) Neuropsychiatric Symptoms (note commonality to some Neuropsychiatric Symptoms (note commonality to some

symptoms of PTSD)symptoms of PTSD)• IrritabilityIrritability (62%) (62%)• Anxiety Anxiety (63%)(63%)• Psychiatric illnessPsychiatric illness (20%) (20%)

Cognitive Impairment:Cognitive Impairment: attention, working attention, working memory(73%), processing speed, reaction time, and memory(73%), processing speed, reaction time, and “executive function”“executive function”

Paniak, Reynolds, Phillips, et al. Patient complaints within 1 month of mild Paniak, Reynolds, Phillips, et al. Patient complaints within 1 month of mild traumatic brain injury: a controlled study. traumatic brain injury: a controlled study. Arch Clin NeuropsycholArch Clin Neuropsychol 2002; 2002; 17:31917:319Dikmen, Mclean, Tmkin. .Neuropsychological and psychosocial Dikmen, Mclean, Tmkin. .Neuropsychological and psychosocial consequences of minor head injury. consequences of minor head injury. J Neurol Neurosurg PsychiatryJ Neurol Neurosurg Psychiatry 1986: 1986: 49:122749:1227

Mental Health Sequelae for Mental Health Sequelae for military returning from military returning from

Iraq/Afghanistan Iraq/Afghanistan 17% from Iraq showing signs of PTSD, major 17% from Iraq showing signs of PTSD, major

depression or severe anxiety (90% involved in direct depression or severe anxiety (90% involved in direct combat)combat)

11% from Afghanistan showing signs of PTSD, major 11% from Afghanistan showing signs of PTSD, major depression or severe anxiety (31% were involved in depression or severe anxiety (31% were involved in direct combat )direct combat )

Some reports of returning military units with 80% Some reports of returning military units with 80% incidence of significant mental health issue and 85% incidence of significant mental health issue and 85% incidence of divorceincidence of divorce

PTSD in Vets May Present as Substance Abuse. PTSD in Vets May Present as Substance Abuse. www.internalmedicinewww.internalmedicine news.com news.com Dec 15,2008Dec 15,2008

Emerging suicide issuesEmerging suicide issues Increased incidence of criminal arrests (reported as Increased incidence of criminal arrests (reported as

high as 20-30%) among returning military from high as 20-30%) among returning military from Iraq/AfghanistanIraq/Afghanistan

Assessment of validity ofAssessment of validity of Post Concussive SyndromePost Concussive Syndrome

• Risk factors for Post concussive syndrome and Risk factors for Post concussive syndrome and protracted recoveryprotracted recovery– Female genderFemale gender– Increasing ageIncreasing age– MVA /Assault, rather than sport related injuryMVA /Assault, rather than sport related injury– Pre-morbid depression or other psychiatric illnessPre-morbid depression or other psychiatric illness– Co-existent PTSDCo-existent PTSD– Decreased social supportsDecreased social supports– Issue of concerns for role of litigationIssue of concerns for role of litigation– Issue of coexistence of chronic pain complaintsIssue of coexistence of chronic pain complaintsIssues:Issues:--patients with psychiatric illness may be more prone to injurypatients with psychiatric illness may be more prone to injury-patients with psychiatric illness may be more prone to -patients with psychiatric illness may be more prone to

develop PCS after injurydevelop PCS after injury-head injury may precipitate psychiatric disease in -head injury may precipitate psychiatric disease in

susceptible individualssusceptible individuals

Comparison of PTSD to TBIComparison of PTSD to TBI• DSM IV criteria PTSDDSM IV criteria PTSD

• A. Exposed to traumatic eventA. Exposed to traumatic event-1-1.Experienced .Experienced or witnessedor witnessed-2.Response of helplessness or horror-2.Response of helplessness or horror

B. Traumatic event persistently re-experiencedB. Traumatic event persistently re-experienced-1. recurrent intrusive recollections-1. recurrent intrusive recollections--2.recurrent distressing dreams2.recurrent distressing dreams- 3.acting or feeling like event is recurring- 3.acting or feeling like event is recurring--4.intense emotional distress4.intense emotional distress at exposure to events resembling the event at exposure to events resembling the event--5.physiological reactivity5.physiological reactivity on exposure to cues resembling the event on exposure to cues resembling the event

C .Persistent avoidance of stimuli associated with the traumaC .Persistent avoidance of stimuli associated with the trauma-1. Efforts to avoid thoughts, feelings and conversations associated with the -1. Efforts to avoid thoughts, feelings and conversations associated with the

traumatrauma- - 2.Efforts to avoid activities, places and people2.Efforts to avoid activities, places and people that arouse recollection of the that arouse recollection of the

eventevent--3.Inability to recall an important aspect of the trauma3.Inability to recall an important aspect of the trauma-4.diminished interest or participation in significant activities-4.diminished interest or participation in significant activities-5. feeling of detachment or estrangement from others-5. feeling of detachment or estrangement from others-6. restricted range of affect (unable to feel love)-6. restricted range of affect (unable to feel love)-7. sense of foreshortened future (-7. sense of foreshortened future (different than limited expectations due to different than limited expectations due to

impairment)impairment)D. Persistent symptoms of increased arousal indicated by 2 of the following:D. Persistent symptoms of increased arousal indicated by 2 of the following:

--1. difficulty with sleep1. difficulty with sleep-2.irritability or outbursts of anger-2.irritability or outbursts of anger-3.difficulty concentrating-3.difficulty concentrating-4.hypervigilance-4.hypervigilance-5.exaggerated startle response (-5.exaggerated startle response (different than hyperacusis or photophobia)different than hyperacusis or photophobia)

E. Duration is 1 month (acute if less than 3 months – chronic if greater than 3 months.E. Duration is 1 month (acute if less than 3 months – chronic if greater than 3 months.F. The disturbance causes clinically significant distress or impairment of occupational function.F. The disturbance causes clinically significant distress or impairment of occupational function.

C Burgess MDC Burgess MD

TBI

Traumatic Event to CNS

Fatigue andCognitive fatigue “veil of cement”InsomniaAnxiety / DepressionSensory sensitivityAutonomic/Adrenergic dysfunctionOverwhelmed with copingAmnesia from traumaReduced socializationReduced capacitiesCognitive limitations

InsomniaDizzinessIrritability/OutburstsPoor emotional controlHeadacheConcentration limitationsOccupational changePersonality change







RadiologyRadiology• CT scanCT scan

– 10% CT abnormal in mild TBI (demonstrating contusions, 10% CT abnormal in mild TBI (demonstrating contusions, subdural hemorrhage, or subarachnoid hemorrhage ) subdural hemorrhage, or subarachnoid hemorrhage )

• MRI scanMRI scan – (MRI abnormalities present in 30% or the cases of mild TBI with (MRI abnormalities present in 30% or the cases of mild TBI with

reported normal CT – many of these findings consistent with axonal reported normal CT – many of these findings consistent with axonal injury but not specific to TBI or TBI outcome)injury but not specific to TBI or TBI outcome)

• Mittl, Grossman, Hiehle, et al. Prevalence of MR evidence of diffuse axonal injury in Mittl, Grossman, Hiehle, et al. Prevalence of MR evidence of diffuse axonal injury in patients with mild head injury and normal head CT findings. patients with mild head injury and normal head CT findings. Am J NeuroradiolAm J Neuroradiol 1994; 1994; 15:158315:1583

• SPECT, PET and functional MRISPECT, PET and functional MRI more likely to more likely to demonstrate abnormalities, supporting a role for demonstrate abnormalities, supporting a role for diffuse structural and/or physiologic abnormality diffuse structural and/or physiologic abnormality in mild TBI.in mild TBI.

Primarily a research tool.Primarily a research tool.– Similar abnormalities may be noted on functional Similar abnormalities may be noted on functional

imaging studies in migraine and depression.imaging studies in migraine and depression.

Metting, Rodiger, De Keyser, van der. Structural and functional neuroimaging Metting, Rodiger, De Keyser, van der. Structural and functional neuroimaging in mild-to-moderate head injury. in mild-to-moderate head injury. Lancet NeurolLancet Neurol 2007; 6:699 2007; 6:699

SPECT Brain Perfusion SPECT Brain Perfusion after mild TBIafter mild TBI







Seizures post TBISeizures post TBI• Post –traumatic seizures occur in less than 5% of mild or Post –traumatic seizures occur in less than 5% of mild or

moderate TBI.moderate TBI. – Increased frequency with more severe trauma.Increased frequency with more severe trauma. – 50% occur within the first 24 hours of injury. 50% occur within the first 24 hours of injury. – 25% occur within first hour of injury.25% occur within first hour of injury.

• After the first hour, majority are simple partial (motor) or After the first hour, majority are simple partial (motor) or focal with secondary generalization.focal with secondary generalization.

• Early seizures increase the risk of post- traumatic epilepsy Early seizures increase the risk of post- traumatic epilepsy by 4Xby 4X

• Anticonvulsants are not useful in prevention of post Anticonvulsants are not useful in prevention of post traumatic epilepsy, but may be used to in treatment of traumatic epilepsy, but may be used to in treatment of early seizures.early seizures.

Treatment of Treatment of mild TBImild TBI

Longitudinal Continuity of Care with Longitudinal Continuity of Care with Primary PhysicianPrimary Physician

Symptomatic TreatmentSymptomatic Treatment• Frequent visits (Frequent visits (often every 2 weeks)often every 2 weeks)

– Address suicidal thoughts and psychotic ideation Address suicidal thoughts and psychotic ideation earlyearly

• Only Only one one or two or two “projects”“projects” per visit per visit• Provide a Notebook: Provide a Notebook: “Back-pocket Memory”“Back-pocket Memory”

(VA may provide a PDA)(VA may provide a PDA)• OrchestrateOrchestrate care and care and network patientsnetwork patients• Set reasonable expectations: Set reasonable expectations: Adaptation Adaptation

(LIMIT grief)(LIMIT grief)• Provide emotional support and Provide emotional support and

attitudinal course correctionsattitudinal course corrections• Provide necessary family and community Provide necessary family and community

EducationEducation (with consent… (with consent… call them,call them, if not if not with patient at visit)with patient at visit)

• Celebrate success !Celebrate success !C Burgess MDC Burgess MD

Suggested Sequence of Suggested Sequence of Symptomatic Treatment Symptomatic Treatment

and Rehabilitation for mild and Rehabilitation for mild TBITBI

1)1) First Priority: First Priority: SLEEPSLEEP2)2) Pain and HeadachePain and Headache3)3) Emotional Concerns: Anxiety and Depression…Emotional Concerns: Anxiety and Depression…

PTSD. PTSD. 4)4) Sensory Disturbance: Visual, Acoustic, EquilibriumSensory Disturbance: Visual, Acoustic, Equilibrium5)5) FatigueFatigue6)6) Education: Family and EmployerEducation: Family and Employer7)7) Visual and Vestibular RehabVisual and Vestibular Rehab8)8) Cognitive RehabCognitive Rehab

C Burgess MDC Burgess MD

TBI: Management TBI: Management post- traumatic Headachepost- traumatic Headache

Use Low Dose pharmacologic therapyUse Low Dose pharmacologic therapy!! Often worse after mild TBI : occur in 25% to Often worse after mild TBI : occur in 25% to

78% of patients with mild TBI78% of patients with mild TBI Use localized therapy or treatment when Use localized therapy or treatment when

possible (lidocaine patch, NSAID patch, possible (lidocaine patch, NSAID patch, cortisone injection, or physical therapy)cortisone injection, or physical therapy)

Types of Headache:Types of Headache: o mixed, mixed, o tension (75%), tension (75%), o migraine, migraine, o occipital and trigeminal neuralgia, occipital and trigeminal neuralgia, o TMJ, TMJ, o positional, positional, o analgesic overuse, analgesic overuse, o low CSF pressure, low CSF pressure, o cluster, cluster, o hemicrania continuahemicrania continua

Pharmacologic Pharmacologic management of headache management of headache

associated with TBIassociated with TBI• Pharmacologic Management:Pharmacologic Management:

ProphylacticProphylactic**Tricyclic antidepressants:Tricyclic antidepressants: Amitriptyline and Amitriptyline and

Nortriptyline (Amitriptyline 10mg-250mg qd)Nortriptyline (Amitriptyline 10mg-250mg qd)**Calcium channel BlockersCalcium channel Blockers: Verapamil (initiate : Verapamil (initiate

Verrapamil SR 120mg qd.)Verrapamil SR 120mg qd.)**B blockers:B blockers: Nadolol (20mg qd – 40mg bid), Nadolol (20mg qd – 40mg bid),

Propanolol SR (80mg-160mg qd)Propanolol SR (80mg-160mg qd) also Timolol, metoprolol, and also Timolol, metoprolol, and

atenololatenolol- Valproate (125mg bid increasing to 250mg bidValproate (125mg bid increasing to 250mg bid- Gabapentin (900 to 1200 mg daily)Gabapentin (900 to 1200 mg daily)- Topamirimate (25 mg to 125 mg daily)Topamirimate (25 mg to 125 mg daily)- Naproxen (250 mg to 500 mg bid)Naproxen (250 mg to 500 mg bid)- Tizanidine (1-2mg po qhs, may increase to 8 mg Tizanidine (1-2mg po qhs, may increase to 8 mg

qhs)qhs)

Management of TBI Management of TBI Headache (Continued)Headache (Continued)

– PropanololPropanolol or or amitriptylineamitriptyline in combination or in combination or alone have a response rate of up to 70%alone have a response rate of up to 70%

– Dihydroergotamine Dihydroergotamine and and metaclopramidemetaclopramide IV IV in repetitive dosing in an inpatient setting in repetitive dosing in an inpatient setting may be effectivemay be effective

– Triptans Triptans may be used for acute Migraine may be used for acute Migraine – Indomethacin Indomethacin may be used for paroxysmal may be used for paroxysmal

hemicrania and hemicrania continua; (25 mg hemicrania and hemicrania continua; (25 mg tid increase to 50 mg tid)tid increase to 50 mg tid)

– Occipital nerve blockOccipital nerve block with local anesthetic with local anesthetic and corticosteroid for occipital headache is and corticosteroid for occipital headache is highly effective for greater occipital highly effective for greater occipital neuralgia.neuralgia.

– Analgesic overuse headache is common.Analgesic overuse headache is common.

Management of Management of Sensory Disturbance post Sensory Disturbance post

TBITBI• Avoidance of “overstimulation” prior to Avoidance of “overstimulation” prior to

or during performance of tasksor during performance of tasks• PhotophobiaPhotophobia: :

– Use of dark and transitional glasses. Use of dark and transitional glasses. – Careful lighting (fluorescent an issue) Careful lighting (fluorescent an issue) – Referral: “Behavioral optometrist”Referral: “Behavioral optometrist”

• DiplopiaDiplopia may result from injuries to CN III, IV, may result from injuries to CN III, IV, and VI.and VI.

• Anosmia and HyposmiaAnosmia and Hyposmia: impaired taste and : impaired taste and smell due to injury to olfactory filaments at the smell due to injury to olfactory filaments at the cribiform plate. In 2/3 of patients is a permanent cribiform plate. In 2/3 of patients is a permanent injury (usually permanent if still present at 1 year). injury (usually permanent if still present at 1 year). Attention needed to avoid weight alterations and Attention needed to avoid weight alterations and gastric irritation. Avoidance of gas appliances.gastric irritation. Avoidance of gas appliances.

Management of Sensory Management of Sensory Disturbance (continued)Disturbance (continued)

• HyperacusisHyperacusis:: Use of specialty ear plugs in noisy Use of specialty ear plugs in noisy environment. Referral: Audiologistenvironment. Referral: Audiologist– Example of available: Example of available: Westone ES 49 earpiece protection Westone ES 49 earpiece protection

for musiciansfor musicians

• Disequilibrium and VertigoDisequilibrium and Vertigo: : – Vestibular rehabilitationVestibular rehabilitation. Referral: ENT and specially . Referral: ENT and specially

trained physical therapist. trained physical therapist. – Consider pharmacologic use of Consider pharmacologic use of MeclizineMeclizine or or ClonazepamClonazepam

(disadvantage is sedation and suppression of adaptive (disadvantage is sedation and suppression of adaptive learning).learning).

– Encourage Encourage regular coordinated movementregular coordinated movement (dance, tai-chi, (dance, tai-chi, etc.). Avoid sports prone to new injuries! etc.). Avoid sports prone to new injuries!

– Driving can be an issueDriving can be an issue: rehabilitation facilities often have : rehabilitation facilities often have driving assessment services and retraining.driving assessment services and retraining.

• NO ETOH!NO ETOH!

Post Traumatic Post Traumatic Vertigo/DizzinessVertigo/Dizziness

• Mechanisms of Vertigo:Mechanisms of Vertigo:– Direct injuryDirect injury cochlea cochlea or vestibular structure esp. with sensorineural or vestibular structure esp. with sensorineural

hearing loss or fracture of temporal bonehearing loss or fracture of temporal bone– Labyrinthine concussionLabyrinthine concussion (vertigo plus ataxia) maximal at onset and (vertigo plus ataxia) maximal at onset and

abating within weeksabating within weeks– BPPVBPPV (benign paroxysmal positional vertigo) due to shearing (benign paroxysmal positional vertigo) due to shearing and and

displacement of otoconia. Can be a hiatus of weeks or months between displacement of otoconia. Can be a hiatus of weeks or months between TBI and development.TBI and development.

– Perilymphatic fistulaPerilymphatic fistula due to rupture of oval or round window. due to rupture of oval or round window. Unilateral SN hearing loss with persistent vertigo and ataxia Unilateral SN hearing loss with persistent vertigo and ataxia characteristiccharacteristic

– OtherOther: post-traumatic Meniere’s, brainstem ischemia with vertebral : post-traumatic Meniere’s, brainstem ischemia with vertebral artery dissection, epileptic vertigo, and migraine related vertigo.artery dissection, epileptic vertigo, and migraine related vertigo.

• Mechanisms of Mechanisms of non-vertiginous dizzinessnon-vertiginous dizziness is often is often cervical:cervical:- Aberrant afferent input from positional proprioceptors in C- spineAberrant afferent input from positional proprioceptors in C- spine- Overstimulation of cervical sympathetic nervesOverstimulation of cervical sympathetic nerves- Compromised vertebral arterial flowCompromised vertebral arterial flow

Management of Fatigue and Management of Fatigue and lack of Concentrationlack of Concentration

• Appropriate Appropriate sleep, diet and limited exercisesleep, diet and limited exercise. . Respect for biorhythmsRespect for biorhythms

• Frequent Frequent rest periodsrest periods • Avoidance of excessive environmental Avoidance of excessive environmental

stimulationstimulation• Pharmacologic managementPharmacologic management

– Wellbutrin SR/XLWellbutrin SR/XL ( (Budeprion)Budeprion)100mg q am – 300mg 100mg q am – 300mg q amq am

– Provigil Provigil ((modinafilmodinafil) 100mg q am - 200 mg q am and ) 100mg q am - 200 mg q am and afternoon afternoon

– Occasional use Occasional use adderal, concerta, dexedrine, adderal, concerta, dexedrine, ritalin…ritalin…• May exacerbate irritability, anger, and sleep issuesMay exacerbate irritability, anger, and sleep issues

FavoriteFavorite pharmacologic pharmacologic choices for mild TBI choices for mild TBI C J Burgess, C J Burgess,

MDMDNortriptylineNortriptyline 10-25 mg qhs 10-25 mg qhs for headache, sleep, pain and for headache, sleep, pain and

potentially anxietypotentially anxietyPlus Plus zolpediemzolpediem (Ambien) 5-10 mg, or (Ambien) 5-10 mg, or ramelteonramelteon

(Rozerem)(Rozerem) 88 mg mg if needed for sleepif needed for sleep

CitalopramCitalopram (Celexa) 10-20mg, (Celexa) 10-20mg, escitalopramescitalopram (Lexapro) 5-10mg, or (Lexapro) 5-10mg, or VanlafaxineVanlafaxine (Effexor XR) (Effexor XR) 37.5-75 mg for 37.5-75 mg for anxiety and depression, agitation, emotional anxiety and depression, agitation, emotional lability and to improve sense of “well being”.lability and to improve sense of “well being”.

ModinafilModinafil (Provigil) 100-200 mg or (Provigil) 100-200 mg or Budeprion SRBudeprion SR (Wellbutrin) 100-150 mg qam (Wellbutrin) 100-150 mg qam for alertness and reduced for alertness and reduced fatigue.fatigue.

ClonazepamClonazepam (Klonopin) .25 - .5mg up to tid (Klonopin) .25 - .5mg up to tid for for equilibrium issues and vertigo if meclizine fails. Use short term as a equilibrium issues and vertigo if meclizine fails. Use short term as a “bridge to vestibular rehab”.“bridge to vestibular rehab”.

Donepezil Donepezil (Aricept) 10mg qd(Aricept) 10mg qd if memory issues are if memory issues are profound and persistent.profound and persistent.

Topamax Topamax 25mg to 100mg qd25mg to 100mg qd if headaches remain if headaches remain intractable.intractable.

Cognitive RehabilitationCognitive Rehabilitation

Continuing Continuing controversycontroversy regarding short-term and regarding short-term and long term benefits to outcome of early long term benefits to outcome of early intervention with cognitive and behavioral intervention with cognitive and behavioral therapy.therapy.

Differences in study designDifferences in study design including patient including patient selection, nature of intervention, and measures of selection, nature of intervention, and measures of performance have hindered assessment of performance have hindered assessment of cognitive interventions. cognitive interventions.

InterventionsInterventions often delivered in an individual often delivered in an individual setting based on deficits identified with Neuro-setting based on deficits identified with Neuro-psych testing (full evaluation often involves 4 -6 psych testing (full evaluation often involves 4 -6 days of testing).days of testing).

Cognitive Evaluation of Cognitive Evaluation of mild TBImild TBI

Neuropsychological TestingNeuropsychological Testing Vulnerable domains to TBIVulnerable domains to TBI

• AttentionAttention• Working memoryWorking memory• Processing speedProcessing speed• Reaction timeReaction time

Not associated with gross deficits of intelligence Not associated with gross deficits of intelligence and memoryand memory

Findings can be confused with those of pain Findings can be confused with those of pain syndromes and medication effects as well as syndromes and medication effects as well as psychological illnesspsychological illness

May be helpful in differentiating TBI from May be helpful in differentiating TBI from alternative diagnosis.alternative diagnosis.

Schretlen, Shapiro. A quantitative review of the effects of Schretlen, Shapiro. A quantitative review of the effects of traumatic brain injury on cognitive functioning. traumatic brain injury on cognitive functioning. Int Rev Int Rev PsychiatryPsychiatry 2003; 15:341 2003; 15:341

ExpectationsExpectations

Expectations after Mild Expectations after Mild TBITBI

• 10-15% of mild TBI cases have 10-15% of mild TBI cases have persistent symptoms beyond one yearpersistent symptoms beyond one year

– Iverson. Outcome from mild traumatic brain injury. Iverson. Outcome from mild traumatic brain injury. Curr Curr Opin PsychiatryOpin Psychiatry 2005; 18:301 2005; 18:301

• 80% of those with post traumatic 80% of those with post traumatic headache improve significantly during headache improve significantly during the first year.the first year.

• 15%-31% of those with post traumatic 15%-31% of those with post traumatic headaches persist for greater than 3 headaches persist for greater than 3 years and are likely permanent.years and are likely permanent.

– Packard RC. Post-traumatic Headache: permanency and Packard RC. Post-traumatic Headache: permanency and relationship to legal settlement. relationship to legal settlement. HeadacheHeadache. 1992;32:496-500. 1992;32:496-500

Expectations after mild Expectations after mild TBITBI

• Pre-morbid personality and educational Pre-morbid personality and educational characteristicscharacteristics may play a role in recovery from mild may play a role in recovery from mild TBI. Pre-morbid physical limitations, prior head TBI. Pre-morbid physical limitations, prior head injury, psychiatric illness, and older age may limit injury, psychiatric illness, and older age may limit recovery.recovery.

• Most improvements occur in the first one to two Most improvements occur in the first one to two yearsyears after injury, but patients may continue to after injury, but patients may continue to report progress (improvement in cognition and report progress (improvement in cognition and memory as well as a decline in physical symptoms) memory as well as a decline in physical symptoms) as late as five years post injury. as late as five years post injury.

• Prompt diagnosisPrompt diagnosis, appropriate post-injury , appropriate post-injury expectationsexpectations, and continued , and continued support of support of familyfamily, employer and community lead to , employer and community lead to better long term outcomes after injury. better long term outcomes after injury.

Instructions for Employers Instructions for Employers and Familiesand Families

• Frequent rest periodsFrequent rest periods• Variable schedulingVariable scheduling• Careful sequencing (prioritize)Careful sequencing (prioritize)• Avoidance of unnecessary stimulationAvoidance of unnecessary stimulation::

– Noise, multiple sources of soundNoise, multiple sources of sound– Harsh Light (fluorescent lights potentially problematic)Harsh Light (fluorescent lights potentially problematic)– Hectic motion-filled environmentHectic motion-filled environment– Fumes (issue with Migraine)Fumes (issue with Migraine)– Emotional circumstancesEmotional circumstances

• Calm environmentCalm environment• Redirection and rest if actions/verbalization are Redirection and rest if actions/verbalization are

inappropriateinappropriate• Early identification of problem areas for treating Early identification of problem areas for treating

MD/rehab team/transition coach. Use the MD/rehab team/transition coach. Use the notebook or back-pocket memory.notebook or back-pocket memory.

• Strong feedback on successStrong feedback on success

Lessons learned from mild Lessons learned from mild TBI patientsTBI patients

• Family physicians have pleotropic effects.Family physicians have pleotropic effects.• Physician and patient Physician and patient expectationsexpectations are critical to are critical to

recovery. Set an obtainable expectation at each recovery. Set an obtainable expectation at each and and every visitevery visit. First steps first.. First steps first.

• Don’t allow a mild or moderate TBI to become Don’t allow a mild or moderate TBI to become the the defining moment of the patients existence. defining moment of the patients existence. So So what?what? Is a critical concept to a successful Is a critical concept to a successful ““reboot”reboot” by a patient with TBI. by a patient with TBI.

• The human brain is “plastic”.The human brain is “plastic”.• HumorHumor has amazing therapeutic value. So does has amazing therapeutic value. So does

expression of Art, Poetry, Music, and movement. expression of Art, Poetry, Music, and movement. • Allow patients to Allow patients to share share their successes and their successes and

experiences with other similar patients of the experiences with other similar patients of the practice if support groups are not plentiful. Don’t practice if support groups are not plentiful. Don’t be intimidated by HIPPA.be intimidated by HIPPA.

Lessons learned, Lessons learned, continuedcontinued

• Recruit helpRecruit help from any available source including from any available source including family and children, libraries, literary volunteers, family and children, libraries, literary volunteers, community centers, etc. Elementary educational community centers, etc. Elementary educational materials may be a critical tool for those not eligible materials may be a critical tool for those not eligible for cognitive rehab. Office staff are often an for cognitive rehab. Office staff are often an amazing resource. Patients have a hard time asking amazing resource. Patients have a hard time asking for help for themselves.for help for themselves.

• Support with enthusiasm any potentially achievable Support with enthusiasm any potentially achievable educational or recreational objective or project that educational or recreational objective or project that interests the patient. The interests the patient. The process of participationprocess of participation, , effort and study will help effort and study will help heal the patientheal the patient often often creating “detours” for injuries sustained. Have the creating “detours” for injuries sustained. Have the patient “volunteer” if they are not employable.patient “volunteer” if they are not employable.

• Prevent second injuries.Prevent second injuries.

Call for Immediate Action Call for Immediate Action

• Availability of appropriate primary MD Availability of appropriate primary MD evaluation and evaluation and longitudinal care for our longitudinal care for our homecoming military.homecoming military.

• Availability and Availability and timely referraltimely referral for appropriate for appropriate diagnostic diagnostic testing (?universal application for testing (?universal application for those with known trauma or blast exposure) those with known trauma or blast exposure)

• Availability of Availability of outpatient rehabilitation programsoutpatient rehabilitation programs, , group and individualgroup and individual

• Availability of psychological support and Availability of psychological support and treatmenttreatment

• Availability of support for transition to peacetime Availability of support for transition to peacetime civilitycivility

• No adverse sequela to seeking treatmentNo adverse sequela to seeking treatment:: Avoidance of long term military career Avoidance of long term military career

impedanceimpedance• Availability of special care by the Judicial system Availability of special care by the Judicial system

BrainstormingBrainstorming• Establish community and base military Establish community and base military TBI support groups and TBI support groups and

group rehabilitation programs group rehabilitation programs. (Establish location and . (Establish location and leader) Potential for formal group psychotherapy. Funding for leader) Potential for formal group psychotherapy. Funding for educational programs.educational programs.

• Establish community and base “Establish community and base “intervention teams”intervention teams” for for potential evolving crisis circumstance. A need for “time out” short potential evolving crisis circumstance. A need for “time out” short term residences (not the hospital, the local bar, or a jail cell)term residences (not the hospital, the local bar, or a jail cell)

• Special legal channelingSpecial legal channeling within the court system for those within the court system for those with military transition problems.with military transition problems.

• Evolution of “Evolution of “transition teams” and coachingtransition teams” and coaching: to promote : to promote successful transition from battlefield to family and employment. successful transition from battlefield to family and employment. Programs for individuals remaining in active military careers as Programs for individuals remaining in active military careers as well as those transitioning to community. May vary by region and well as those transitioning to community. May vary by region and service.service.

• Adequate Adequate formulary and device supportformulary and device support for treatment. for treatment.

• Encourage local bars to offer a few tasty “brain drinks” (not a Encourage local bars to offer a few tasty “brain drinks” (not a “shirley temple”).“shirley temple”).

Resources Resources • Defense and Veterans Brain Injury CenterDefense and Veterans Brain Injury Center• Available: Available: Heads up: Brain Injury in your Practice Tool kitHeads up: Brain Injury in your Practice Tool kit• National Educational Resources DatabaseNational Educational Resources Database• www.DVBIC.orgwww.DVBIC.org

– Group of 7 TBI programs in DoD and Dept of VA hospitals and a civilian TBI Group of 7 TBI programs in DoD and Dept of VA hospitals and a civilian TBI programprogram

– Available: comprehensive outpatient assessments: psychological, audiologic, Available: comprehensive outpatient assessments: psychological, audiologic, neurological, neuropsychological and laboratory testingneurological, neuropsychological and laboratory testing

– Inpatient evaluations include additional: neuro-opthalmology, dental, ENT, Inpatient evaluations include additional: neuro-opthalmology, dental, ENT, vestibular, psychiatry, etc.vestibular, psychiatry, etc.

– Access to clinical trialsAccess to clinical trials

Sites:Sites:Military Treatment Facilities (MTF)Military Treatment Facilities (MTF)

Walter Reed Army Medical Center, Washington DCWalter Reed Army Medical Center, Washington DCWilford Hall Medical Center, Lackland Air Force Base, TXWilford Hall Medical Center, Lackland Air Force Base, TXNaval Medical Center San Diego, San Diego, CANaval Medical Center San Diego, San Diego, CA

Veterans Affairs (VA) Sites:Veterans Affairs (VA) Sites:Hunter McGuire VA Medical Center, Richmond, VAHunter McGuire VA Medical Center, Richmond, VAJames A Haley VA Hospital, Tampa, FLJames A Haley VA Hospital, Tampa, FLVeterans Affairs Medical Center, Minneapolis, MNVeterans Affairs Medical Center, Minneapolis, MNVA Palo Alto Health Care System, Palo Alto, CAVA Palo Alto Health Care System, Palo Alto, CA

Civilian Partner Site:Civilian Partner Site:Virginia NeuroCare, Charlottesville, VAVirginia NeuroCare, Charlottesville, VA

Eligible: persons with TBI who are eligible for TRICARE or VA benefitsEligible: persons with TBI who are eligible for TRICARE or VA benefitsReferral: 1-800-870-9244 or Referral: 1-800-870-9244 or [email protected]@dvbic.org

Resources, continuedResources, continued New York State Brain Injury AssociationNew York State Brain Injury Association

– 1-800-228-8201 1-800-228-8201 http://http://www.bianys.orgwww.bianys.org– Albany women’s support group: Robin CohnAlbany women’s support group: Robin Cohn

• [email protected]@nycap.rr.com CDC National Center for Injury Prevention CDC National Center for Injury Prevention

and Control: TBI resourcesand Control: TBI resourceshttp://www.cdc.gov/ncipc/factsheets/tbi.htmhttp://www.cdc.gov/ncipc/factsheets/tbi.htm

Traumatic Brain Injury Resource GuideTraumatic Brain Injury Resource Guidehttp://www.neuroskills.com/http://www.neuroskills.com/

National Resource Center on Traumatic National Resource Center on Traumatic Brain InjuryBrain Injury

http://www.neuro.pmr.vcu.edu/http://www.neuro.pmr.vcu.edu/ Traumatic Brain Injury National Data Traumatic Brain Injury National Data

CenterCenterhttp://www.tbindc.org/http://www.tbindc.org/

Appendix 1:Appendix 1:Acute evaluation and disposition of patients Acute evaluation and disposition of patients

with mild TBI with mild TBI

Data from: Vos, PE. Eur J Neurol 2002; 9:207 and Borg, J. J Rehabil Med 2004; S43:61.

Appendix 2: Standardized assessment of Appendix 2: Standardized assessment of

concussion: SACconcussion: SAC

Documents

Care of Our Homecoming Warriors Mild Traumatic Brain Injury Mild Traumatic Brain Injury Operation Iraqi Freedom Operation Enduring Freedom Carol Burgess