Defense and Veterans Brain Injury Center: Program Overview and Research Initiatives

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1 MILITARY MEDICINE, 175, 7:37, 2010 Defense and Veterans Brain Injury Center: Program Overview and Research Initiatives COL Michael Jaffee, USAF MC ; Elisabeth Moy Martin, RN-BC, MA ABSTRACT For more than 16 years, the Defense and Veterans Brain Injury Center (at one time known as the Defense and Veterans Head Injury Program) has served to develop and disseminate clinical guidelines and undertake innovative clinical research initiatives and educational programs to serve active duty personnel, their dependents, and veterans with traumatic brain injury (TBI). Through educational initiatives and collaboration with civilian institutions, the center is ensuring that critical discoveries surrounding TBI prevention, screening, and treatment are made available to preserve and improve the health of those within and outside the military health system. INTRODUCTION Advances in battlefield care, transport and protective equipment have increased the likelihood of those injured in Afghanistan and Iraq surviving their wounds. Advances in personal protective equipment allowing survivability of thoracic and abdominal injuries and a robust screening and detection system have enhanced and increased detection of traumatic brain injury (TBI). The heightened incidence of TBI among this population has prompted an increase in the military medical system s efforts surrounding TBI education, screening, and treatment. In addition, the Centers for Disease Control have estimated 5.3 million Americans currently live with TBI-related disabilities. 1 The Defense and Veterans Head Injury Program (DVHIP) was established in February 1992 at the direction of Congress and represented a unique collaboration among the Department of Defense (DoD) and Department of Veterans Affairs (DVA). A primary mission was to ensure that military and veterans with TBIs receive TBI-specific evaluation, treatment, and followup, while addressing the readiness mission of the military and defining optimal care for TBI patients nationwide. 2 A motto of this program from its inception has been learn as we treat. Now known as the Defense and Veterans Brain Injury Center (DVBIC), the organization has a trifold mission from Congress to provide clinical care and standards, clinical research and education in the field of TBI for both military and veteran communities. In addition, recently added missions from the Office of the Secretary of Defense include DoD surveillance and triservice coordination of predeployment cognitive testing. DEFENSE AND VETERANS BRAIN INJURY CENTER The DVBIC is composed of a network of 19 sites, with each site involved in direct care for combat wounded. As of March 2009, cumulatively, DVBIC sites have seen more than 9,600 patients with TBI. Over 90% of combat-related TBIs are Defense and Veterans Brain Injury Center, Walter Reed Army Medical Center, P.O. Box 59181, Washington, DC The basis for this manuscript was from a presentation for the First Annual USU/HJF Symposium in Bethesda, MD on June 30, closed head injuries, with most service members sustaining a mild TBI (mtbi)/concussion. 3 The center s network includes 12 military troop facilities (Walter Reed Army Medical Center, Brooke Army Medical Center, Wilford Hall Medical Center, Naval Medical Center San Diego, Landstuhl Regional Medical Center [Germany], Fort Bragg, Fort Carson, Camp Pendleton, Camp Lejeune, Fort Hood, Fort Campbell, National Naval Medical Center Bethesda), five Veterans Affairs centers, the first four, which are recognized as the VA poly-trauma centers (Tampa, Minneapolis, Palo Alto, Richmond, and Boston) and two civilian partners (Lakeview Virginia Neurocare in Charlottesville, VA and DVBIC-Johnstown in Johnstown, Pennsylvania). This network provides the entire spectrum of care from the battlefield through the acute care in the military acute care treatment facilities and when needed, rehabilitation at a VA center and/or at transitional re-entry facilities (see Figure 1 : chart of the DVBIC network). DVBIC personnel provide direct patient care at all sites. In December 2007 the DVBIC was selected as the primary operational TBI component for the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE). Through partnerships, DVBIC is able to cover the entire spectrum of prevention, protection, outreach, and education as well as clinical care. Through clinical and research efforts, best practices for TBI are continually modified, enhancing the entire spectrum of care provided to service members, veterans, and their dependants. TBI is a broad spectrum and consists of multidisciplinary contributions for optimal patient care. The injury varies from very mild/concussion, to severe and penetrating injuries. Challenges and clinical demands occur at all levels (from battlefield, military treatment centers, VA centers, transitional community re-entry programs to return to duty) that may be quite different from one level of care to another. Because of this, a program to address all of these needs must be comprehensive. In addition, as patients move from theater to another level they rely on the air evacuation system and the skills of the critical care air transportation team. This has significantly contributed to the remarkable survival rate 98% survival MILITARY MEDICINE, Vol. 175, July Supplement

2 FIGURE 1. DVBIC network from the theater hospital to Germany 4 in this current era of warfare. Ongoing research initiatives continue to look at how best to facilitate and enhance care during transport, for example, the brain acoustic monitoring utilizing sound technology noninvasively to understand and determine brain function and wellbeing in the critical care context. 5,6 The Military Acute Concussion Evaluation tool (MACE) developed by DVBIC with civilian experts and released in August 2006 is now the primary instrument used to screen those who have been in a potential TBI in theater with ease of use allowing the medic or corpsman to decide on the need for further TBI evaluation at level II or III. The MACE has three components: a directed history and symptom check, a screening neurologic exam, and a cognitive screening score, which is an adaption of the Standardized Assessment of Concussion (SAC). DVBIC is in the second stage of a validation study regarding the screening for mtbi. The MACE is incorporated into the current concept of deployed clinical practice guidelines for the management of concussion/mtbi ( org/pdfs/dvbic_documentation_sheet.pdf ). EDUCATION Recent highlights of the DVBIC educational efforts include the Annual TBI Military Training Conference, September 2007 and 2008, in which over 800 providers each year attended receiving didactic information provided by military and civilian experts. DVBIC has also cosponsored scientific meetings with agencies such as the National Institutes of Health (NIH)/National Institute of Neurological Disorders and Stroke, the International Brain Injury Association, and the Congressional Brain Injury Task Force. More than 90 educational products for patients and families are available and compiled through the DVBIC. These products were developed by leading experts in positive expectation of recovery; additionally, the products recently received praise from the Rand Corporation 7 for their quality and their value in risk communication. Coordination has occurred with Triservice collaboration for service-specific clinical practice. In 2007, 2,500 copies of the DVD Survive, Thrive and Alive were distributed. The educational DVD focuses on the services for those with TBI within the DoD community and contains an introduction by General Colin Powell. In 2008, 3,200 copies were distributed with a user guide. The piece also was broadcast on the Pentagon Channel (cable TV and Website). Another 1,800 copies (DVD and user guide) were distributed to the National Guard and Reserve components at the end of 2008 and early Furthermore, a congressionally mandated family caregiver curriculum is being facilitated by DVBIC. This project is aimed at identifying the needs of the family members/ significant others who are taking care of some of the longterm needs of severely injured service members. The curriculum will provide them with the appropriate education, skills set, and insight needed for dealing with TBI patients. DVBIC is involved with Brainline.org, an on-line resource providing information on preventing, treating, and living with TBI. DVBIC funds WETA (the local public television and radio station) to develop and maintain this site. Its target audience is the general public, a small percentage of the Website material is military relevant. 38 MILITARY MEDICINE, Vol. 175, July Supplement 2010

3 DVBIC NETWORK OF RESEARCH The DVBIC network allows for single-site pilot studies as well as multisite studies. Multiple collaborations exist with various federal agencies such as the Armed Forces Institutes of Pathology (AFIP), DVA, CDC, Armed Forces Research Lab (AFRL), NIH, Defense Advanced Research Program Agency (DARPA), National Institution on Disability in Rehabilitation Research (NIDRR), as well as academic institutions such as Massachusetts Institute of Technology (MIT), Uniformed Services University of the Health Sciences (USUHS), UVA, UPMC, Ohio State and Industry (Raytheon). Such a collaborative research network allows for involvement in research along the complete continuum of care from primary to tertiary prevention of TBI. The framework for a research program diagram (see Figure 2 ) is borrowed from colleagues at the Army Medical Research and Material Command and illustrates the different aspects of a clinical research paradigm. This paradigm ensures projects look at protective and preventative measures as well as assessment of injury, diagnosis, and management once a diagnosis is made for a comprehensive review. DVBIC EPIDEMIOLOGY RESEARCH INITIATIVES Initiatives include the head to head study of five computerized cognitive assessment tools, which will assist the DoD in selecting a tool(s) from an evidence base that may be the most appropriate to use in the evaluation of the wounded warrior in the field. Congress has also designated DVBIC as the office of responsibility for a 15-year follow-up study of returning service members with combat TBI. Additionally, beginning in 2009 at two network sites, a focus of the epidemiology of mtbi in Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) returning warriors will be the overlap of mtbi and post-traumatic stress disorder (PTSD) and other behavioral issues. The overlap and commonality of symptoms in PTSD and TBI can result in a complicated clinical presentation. Clinicians must consider both diagnoses as an explanation of a patient s physical symptoms. For example, TBI may result in headaches and dizziness while PTSD-related behavioral symptoms may exacerbate these more somatic symptoms. 11 In DVBIC sponsored research on data from survivors from the Oklahoma City bombing, those who have had a TBI as part of their injury pattern may be more susceptible to PTSD than those who have been injured without a comorbid head injury. 10 Efforts should be made toward evaluating and treating the entire patient rather than utilizing an either or clinical paradigm. Related to protection and prevention are efforts to merge the technology that has been made in athletic and sports medicine surrounding concussion protection with helmet padding, examining ways to capitalize on technology, and merging current known components to further ballistic and impact head protection. TREATMENT-RELATED RESEARCH DVBIC proudly conducted the first ever randomized controlled trial (RCT) in the rehabilitation arena in the mid FIGURE 2. Framework for a research program. MILITARY MEDICINE, Vol. 175, July Supplement

4 1990s, at a time when it was felt that RCTs of rehabilitation modalities could not be done. Study results were published in JAMA8. The ability to complete this study has paved the way for further RCTs and has advanced the entire field of rehabilitation medicine. The DVBIC network was able to conduct the largest sample ( n = 360) in a RTC of TBI, comparing cognitive didactic and functional experiential approaches. Results of this study were published in December 2008 in the Archives of Physical Medicine and Rehabilitation. 9 An upcoming collaboration is the RCT at the four VA polytrauma centers of methylphenidate (MP), or ritalin, in severely injured TBI patients to establish efficacy of MP. This drug has been used clinically for many years but has not been tested in a scientific manner using the gold standard design of an RCT. Furthermore, DVBIC was able to conduct the first institutional review board (IRB)-approved prospective study in a combat zone. One aspect of this study looked at the feasibility for using computerized neurocognitive assessment tools in theater. The regulatory system developed to support this study is now used to support research in a variety of medical disciplines. BLAST INJURY RESEARCH Understanding the effect of primary blast injury on the brain has been challenging. It is a truism to say that it is easier to study animals where it is more possible to control external factors including blast. It is more difficult to understand primary blast as a mechanism of brain injury in humans as most of the injuries in our service members are not solely a result of a blast. To capture two concepts, we use the term blast plus. Often there may be a blast plus a rollover of the Humvee, flying shrapnel, and the forces that may displace someone against the surrounding objects such as a wall. It is somewhat unusual to see paraclinical evidence of the effects of blast alone. DVBIC clinicians have been able to observe one case of probable primary blast where diffusion tensor imaging did indicate dysfunction that improved over approximately a 6-month period. Recent analyses in the case-controlled study of blast in returning service members with mtbi who had diffuse tensor imaging (DTI) indicated persistent CNS damages appeared to occur with both blast-associated and impact mtbi but with greater severity and differing spatial extent in blast-associated mtbi patients. 12 Collaborations have been very important in advancing our knowledge and understanding of blast. Partnership with MIT has led to the development of whole brain-head computerized models, which will enable scientists to obtain a better understanding of the effects of blast waves on the brain together with enhancement of threat mitigation. In addition, collaboration between DVBIC and the Defense Advanced Research Projects Administration (DARPA) with the evaluation of marine breachers has been instrumental in establishing knowledge of blast thresholds and effects on service members. TRANSLATIONAL RESEARCH In 2008, DVBIC partnered with the AFIP to open a research center that allows investigators to perform advanced studies. On site, there are both a 7 Tesla 20-cm horizontal bore magnetic resonance (MR) spectrometer and a 9.4 Tesla 6-cm vertical-bore spectrometer. In addition, a Coherent AntiStokes Raman Scattering (CARS) microscopy will allow scientists to evaluate the effects of blasts on living tissues, rather than pathological specimens. The technique allows analysis of axonal and myelin structure as well as cellular level changes associated with TBI such as detection of water and ion distribution and detection of diffuse axonal injury. CONCLUSION For more than 16 years, DVHIP/DVBIC has served to develop and disseminate clinical guidelines and undertake innovative clinical research initiatives and educational programs to serve active duty personnel, their dependents, and veterans with TBI. Through educational initiatives and collaboration with civilian institutions, the center is ensuring that critical discoveries surrounding TBI prevention, screening, and treatment are made available to preserve and improve the health of those within and outside the military health system. DVBIC s success in responding effectively in both peacetime and war is largely due to its programmatic uniqueness. The DoD/VA collaboration and the Triservice participation from the outset have been integral to achieving its combined operational, clinical, and research missions. More than 100 peer-reviewed publications have been produced from this collaboration. An external review of TBI care in the United States was published by Cope et al. in in the Journal of Head Trauma Rehabilitation. DVBIC was named as the network with the most fully developed system of care in brain injury. Furthermore, DVBIC was given recognition from U.S. Defense Secretary Robert M. Gates in a public speech in June The military now has more thorough reporting mechanisms, requiring that anyone affected by a blast or blunt trauma in theatre go through an evaluation and screening. We have a single TBI registry and a single point of responsibility the Defense and Veterans Brain Injury Center to consolidate all TBI-related incidents and information. 14 DVBIC is a success story for USUHS and the Henry M. Jackson Foundation. DVBIC has evolved over time from an organization whose initial emphasis was on research to one that also advances education and public awareness and makes invaluable operational contributions. Looking forward, additional resources will allow for expanding epidemiology, imaging, and wet labs married with the entire spectrum of clinical care. The future challenge for DVBIC will be evolving from DoD consultant to executing newer responsibilities as a DoD office of responsibility for certain programs as well as serving as the operational TBI core of DCoE, both of which will require expanding and integrating programs across the DoD. 40 MILITARY MEDICINE, Vol. 175, July Supplement 2010

5 ACKNOWLEDGMENTS The authors extend acknowledgment to Dr. David Moore (Defense and Veterans Brain Injury Center) for his contributions on reviewing, commenting on, and editing the manuscript. REFERENCES 1. National Center for Injury Prevention and Control : Centers for Disease Control and Prevention : Traumatic Brain Injury. Available at cdc.gov/ncipc/factsheets/tbi.htm; accessed October 8, Salazar A, Zitnay G, Warden D, Schwab K; the DVHIP Study Group: Defense and Veterans Head Injury Program: background and overview. J Head Trauma Rehabil 2000 ; 15 (5) : Defense and Veterans Brain Injury Center : Fact Sheet, March Hall K : Standardizing war trauma surgery- Battlefield Docs converge in Iraq. May 31, 2007 ; Available at: asp?id= ; accessed October 10, Kennedy K : Testing Breakthrough for Mild TBI. Army News Feb 24, 2008 ; Available at braintrauma_w ; accessed October 8, Dutton R, VanDerHeijden M, Aarabi B, et al : Screening TBI patients with the brain acoustic monitor: association with CT scan findings and neurological status at hospital discharge. Clin Intensive Care 2005 ; 16 (2) : Tanielian T, Jaycox L (editors): Invisible Wounds of War : Psychological and Cognitive Injuries, their Consequences, and Service to Assist Recovery. Santa Monica, CA, Rand Center for Military Health Policy, Salazar A, Warden D, Schwab K, et al : Cognitive rehabilitation for traumatic brain injury: a randomized trial. JAMA 2000 ; 283 (23) : Vanderploeg R, Schwab K, Walker W, et al : Rehabilitation of Traumatic Brain Injury in Active Duty Military Personnel and Veterans: Defense and Veterans Brain Injury Center Randomized Controlled Trial of Two Rehabilitation Approaches. Arch Phys Med Rehabil 2008 ; 89: Walilko T, North C, Young LA, et al : Head Injury as a PTSD Predictor among Oklahoma City Bombing Survivors. J Trauma 2009 ; 67: Kennedy J, Jaffee M, Leskin G, et al : Posttraumatic stress disorder and post traumatic stress disorder-like symptoms and mild traumatic brain injury. J Rehabil Res Dev 2007 ; 44: Moore D, Riedy G, Fargus J et al : Diffusion Tensor Imaging and mtbi : A Case-Controlled Study of Blast (+) in Returning Service Members Following OIF and OEF. Abstract presentation and presentation for late breaking news plenary at the American Academy of Neurology, May Cope D, Mayer N, Cervelli L : Development of systems of care for person with traumatic brain injury. J Head Trauma Rehabil 2005 ; 20 (2) : Robert M. Gates : Speech delivered by Secretary of Defense Robert M. Gates, at the National Intrepid Center of Excellence Dedication, Bethesda, MD, June 5, Available at speeches/speech.aspx?speechid=1255 ; accessed October 29, MILITARY MEDICINE, Vol. 175, July Supplement

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