Isaac Darko, MD Cincinnati VAMC TBI/Polytrauma Program Director University of Cincinnati Assistant Professor, PM&R Division 3/18/2016

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1 Isaac Darko, MD Cincinnati VAMC TBI/Polytrauma Program Director University of Cincinnati Assistant Professor, PM&R Division 3/18/2016

2 Objectives Current state of the science: where are we now with TBI? How do Veterans receive TBI services? Overview of the VA Polytrauma System of Care Identification of the TBI Interdisciplinary Team: a comprehensive approach to care PTSD vs. TBI: what s the difference and do we care?

3 Current state of the science: Where are we now with TBI? Diagnosis Diagnostics: Imaging/Biomarkers Treatment

4 DOD/DVA Consensus-Based Classification of Closed TBI Severity LOC=Loss of consciousness GCS= Glasgow coma scale AOC=Altered level of Consciousness PTA=Post traumatic Amnesia

TBI Severity: Military Years 2000-2014 Defense and Veterans Brain Injury Center

Penetrating, 1% Unclassified, 7% Mild, 83% The overwhelming majority of TBI

5 TBI Severity: Military Years Defense and Veterans Brain Injury Center (DVBIC) report: 313,816 TBIs in military years Moderate, 8% Severe, 1% Penetrating, 1% Unclassified, 7% Mild, 83% The overwhelming majority of TBI Patients we see at Cincinnati VAMC have mild TBI, most of them due to blast exposure.

6 Blast TBI TBI was identified as the signature injury of the War on Terror and was caused by the majority of blast injuries. Blast injuries accounted for 81% of all Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) injuries (Sayer et al. 2008, Owens et al. 2009). Higher than those of previous wars: of all injuries sustained, blast injuries accounted for 73% in WWII, 69% in Korea, and 65% in Vietnam. Advances in Kevlar body armor, helmet technology and other protective equipment, as well as improved acute trauma care allow personnel to survive injuries that would likely have proven fatal in prior conflicts (Okie S, 2005).

7 Percentage of Injuries due to Blast by Eras 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% WWII Korean War Vietnam War OEF/OIF Figure 1: Percentage of injuries related to blasts

8 Mechanisms of Blast Brain Injury Primary: overpressurization shock wave Secondary: flying debris Tertiary: body displacement Quaternary : Crush injuries from structure collapse and burns

9 Diagnostics/Technology Several technologies are being investigated They are showing significant promise in better diagnosing and characterizing mtbi Diagnostics and technology are anticipated to help in understanding recovery and prognosis in moderate and severe TBI 3 of these technologies include: Protein/Serum Biomarkers Advanced Neuroimaging Quantitative Electroencephalography

10 Treatment of TBI Multidisciplinary/Interdisciplinary Team Approach

Extensive media reports and coverage on sports related concussions.

11 Sports vs. Military Concussion 2012 Concensus Statement on Concussion in Sports Extensive media reports and coverage on sports related concussions. There are not as many military concussion media stories when compared to sports, however there are specific VA/DOD Clinical Guidelines for practitioners.

12 Veteran Resources for TBI

13 Yes, there is an app for that! Concussion Coach

14 Veteran Access to TBI Care 50% of returning active duty service members enroll in VA s healthcare system for treatment of their difficulties, including service-related conditions. Primary Care and Other Providers (Neurology, Neuropsychology, Psychiatry, etc) OEF/OIF Clinic Veteran Access to TBI Care at Cincinnati VAMC Self-Referral Therapists (SLP/PT/OT) and Other Services (Audiology, Optometry, Case Management/SW)

15 Challenges The number of Veterans with TBI are likely underestimated because: About 46% of Veterans eligible for VA care do not elect to get care within the VA healthcare system (Taylor et al, 2014) Even though the VA put a screening program in place in April 2007, this retrospective approach may have led to underestimated numbers (Belanger et al. 2012) Mild TBI is difficult to diagnose because overt signs are not always present

16 VA-DOD Combined Effort VA and DoD created an integrated continuum of care to provide optimal health care services, known as the Polytrauma System of Care (PSC). The PSC s mission is to enhance, preserve and restore the quality of life of Veterans and Servicemembers with polytrauma and TBI through the use of rehabilitation services (VHA Handbook, 2015).

level Polytrauma Network Sites 87 facility

17 Polytrauma System of Care Four tier integrated system of TBI and Polytrauma Rehabilitation Programs 5 Polytrauma Transitional Rehabilitation Centers 23 VISN level Polytrauma Network Sites 87 facility based Polytrauma Support Clinic Teams 39 Polytrauma Points of Contact

Yes to any of the four questions generates a referral to the Polytrauma Clinic for a complete TBI

19 VA TBI Screen Service members transitioning to VA will be screened for TBI using the TBI Clinical Reminder, which is a 4 question screen. Yes to any of the four questions generates a referral to the Polytrauma Clinic for a complete TBI (CTBIE), Level II/Second Level evaluation. Positive screening initiates additional work up (Level II) and care through designated TBI Clinics within VA s Polytrauma System of Care.

20 Interdisciplinary Team Approach Prevalence of ear injury of 31% (Dougherty et al,2013) Visual disturbance: 75% of the mtbi diagnosed veterans from the OIF/IEF conflict. (Lew et al 2007, Stelmack et al 2009) Dual sensory impairment: Visual + Audiotory dysfunction (Lew et al. 2011) Multisensory impairment (MSI): Auditory+Visual+Vestibular (Pogoda et al. 2012) Injury to one or more musculoskeletal system in 67% of individuals 88% of individuals with blast-related polytrauma reported persistent pain post-deployment (Sayer et al. 2007) Headache (Majority Migrainous): In 74% of confirmed mtbi within 1month, with 1/3 progressed to persistent headache symptoms (Patil et al. 2011)

21 Services offered by the Cincinnati TBI/Polytrauma Team Outpatient Services Provider evaluation and short-term management (minimal MSK issues addressed as needed) Case Management Psychosocial evaluation and management Rehab Therapies by OT/PT/Speech, including cognitive rehabilitation Neuropsychological evaluations Audiology and Optometry evaluations Interdisciplinary approach to patient care Telehealth Services TBI Support Group for Veterans and family members

22 Cincinnati VAMC Polytrauma/TBI Support Clinic Team: Isaac Darko, TBI Medical Director Lora Clore, TBI Social Worker Kaya Harper, Neuropsychologist Laura Klug, Speech-Language Pathologist Lindsay Riegler, Speech-Language Pathologist Stephanie Christman, Physical Therapist Mary Kelly Bone, Audiologist Occupational Therapy

23 Lora Clore, LISW-S x5972

25 PTSD and TBI In recent years, concern about combat-associated TBI and PTSD has been at the forefront of clinical care and research pathways PTSD: military>civilian (likely due to greater general stress and trauma exposure in the military) Even when accounting for predeployment symptoms, prior TBI, and combat intensity, TBI during the most recent deployment is the strongest predictor of postdeployment PTSD symptoms (Hoge et al. 2014) Whether TBI is a risk factor for PTSD has been difficult to determine because of overlapping symptoms

26 Overlap of PTSD and TBI Symptoms

27 We do Care! The relationship between TBI and PTSD is complicated by a number of factors including severity of brain injury Deployment-related TBI significantly increased the likelihood of post-deployment PTSD (Yurgil et al. 2014) Given the overlap of post-concussive symptoms, PTSD, and other mental health disorders (i.e. depression, anxiety), collaborative care is highly recommended. (Report of VA Consensus Conference: Practice Recommendations for Treatment of Veterans with Comorbid TBI, Pain, and PTSD )

28 Post-TBI: Addressing Family Concerns Many rehabilitation models of care emphasize family inclusion and it is known that the patient is not the only person affected by traumatic injuries, including TBI. Comprehensive care models include family members and caregivers as part of the team. Even though families are aware that a veteran has sustained TBI, it may take time (up to 2 years) for families to realize the full extent of the injury (Port et al. 2002). Family members in VA rehabilitation settings report that their greatest need is for health information. Helping family members cope with the relationship changes that accompany Polytrauma and TBI improves outcomes for the patient and their support system (Wilder et al. 2013).

29 References Sayer NA, Cifu DX, McNAmee C et al: Rehabilitation needs of combat-injured service members admitted to VA polytrauma rehabilitation centers: The role of PM&R care of wounded warriors. Phys Med Rehabil 2009;1:23-8. PMID: Owens BR, Kragh JF, Wenke JC et al: Combat Wounds in Operation Iraqi Freedom and Operation Enduring Freedom. J Trauma 2008; 64: PMID: Okie S. Traumatic Brain Injury in the War Zone. New England Journal of Medicine 2005; 352(20): PMID: Belanger HG, Vanderploeg RD, Soble JR, Richardson M et al: Validity of the Veterans Health Administration s Traumatic Brain Injury Screen. Arch Phys Med Rehabil 2012;93: PMID: Taylor, BC. Fiscal Year 2012 VA Utilization Report for Iraq and Afghanistan War Veterans Diagnosed with TBI, sponsored by Veteran Affairs Quality Enhancement Research Initiative (VAQUERI) for Polytrauma/Blast-Related Injuries. Published February PDF available for download at: Annengers JF, Grabow JD, Kurland LT, Laws ER Jr. The incidence, causes, and secular trends of head trauma in Olmstead County, Minnesota, Neurology 1980;30(9): PMID: Omalu BI, DeKosky ST, Minster RL, Kamboh MI, Hamilton RL, Wecht CH. Chronic traumatic encephalopathy in a National Football League player. Neurosurgery Jul;57(1):128-34; discussion PubMed PMID: Dougherty AL, MacGregor AJ, Han PP, Viirre E, Heltemes KJ, Galarneau MR. Blast-related ear injuries among U.S. military personnel. J Rehabil Res Dev. 2013;50(6): PubMed PMID:

30 References 45 Lew HL, Pogoda TK, Baker E, Stolzmann KL, Meterko M, Cifu DX, Amara J, Hendricks AM. Prevalence of dual sensory impairment and its association with traumatic brain injury and blast exposure in OEF/OIF veterans. J Head Trauma Rehabil Nov-Dec;26(6): doi: /HTR.0b013e318204e54b. PubMed PMID: Pogoda TK, Hendricks AM, Iverson KM, Stolzmann KL, Krengel MH, Baker E, Meterko M, Lew HL. Multisensory impairment reported by veterans with and without mild traumatic brain injury history. J Rehabil Res Dev. 2012;49(7): PubMed PMID: Sayer NA, Chiros CE, Sigford B, Scott S, Clothier B, Pickett T, Lew HL. Characteristics and rehabilitation outcomes among patients with blast and other injuries sustained during the Global War on Terror. Arch Phys Med Rehabil Jan;89(1): doi: /j.apmr PubMed PMID: Patil VK, St Andre JR, Crisan E, Smith BM, Evans CT, Steiner ML, Pape TL. Prevalence and treatment of headaches in veterans with mild traumatic brain injury. Headache Jul-Aug;51(7): doi: /j x. PubMed PMID: Carlson KF, Nelson D, Orazem RJ, Nugent S, Cifu DX, Sayer NA. Psychiatric diagnoses among Iraq and Afghanistan war veterans screened for deployment-related traumatic brain injury. J Trauma Stress Feb;23(1): PMID: Weeks DL, Greer CL, Bray BS, Schwartz CR, White JR Jr. Association of antidepressant medication therapy with inpatient rehabilitation outcomes for stroke, traumatic brain injury, or traumatic spinal cord injury.arch Phys Med Rehabil May;92(5): PMID: Yurgil KA, Barkauskas DA, Vasterling JJ, Nievergelt CM, Larson GE, Schork NJ, Litz BT, Nash WP, Baker DG; Marine Resiliency Study Team. Association between traumatic brain injury and risk of posttraumatic stress disorder in active-duty Marines. JAMA Psychiatry Feb;71(2): PMID: Port, A., Willmott, C., & Charlton, J. (2002). Self-awareness following traumatic brain injury and implications for rehabilitation. Brain Injury, 16(4), PMID: Wilder Schaaf, K; Kreutzer, Jeffrey S.; Danish, Steven J.; Pickett, Treven C.; Rybarczyk, Bruce D.; Nichols, Michelle G. Evaluating the needs of military and veterans' families in a polytrauma setting. Rehabilitation Psychology, Vol 58(1), Feb 2013, VHA Handbook updated on 3/20/13 detailing the VA Polytrauma System of Care accessed 2/28/15: Hoge CW, Castro CA. Treatment of generalized war-related health concerns: Placing TBI and PTSD in context. Jama. Oct ;312(16): Report of (VA) Consensus Conference: Practice Recommendations for Treatment of Veterans with Comorbid TBI, Pain, and PTSD

31 References Caporro M1, Haneef Z, Yeh HJ, Lenartowicz A, Buttinelli C, Parvizi J, Stern JM. Functional MRI of sleep spindles and K-complexes. Clin Neurophysiol Feb;123(2): doi: /j.clinph Epub 2011 Jul 19. McQuillen JB, McQuillen EN, Morrow P. Trauma, sport, and malignant cerebral edema. Am J Forensic Med Pathol Mar;9(1):12-5. PubMed PMID: Cantu RC. Second-impact syndrome. Clin Sports Med Jan;17(1): Review. PubMed PMID: Cyrus Eierud a, b, R. Cameron Craddock c, d, Sean Fletcher e, Manek Aulakh e, Brooks King-Casas a, f, Damon Kuehl g, Stephen M. LaConte a, Neuroimaging after mild traumatic brain injury: Review and meta-analysis. NeuroImage: Clinical. Volume 4, 2014, Pages Lew HL, Poole JH, Vanderploeg RD, Goodrich GL, Dekelboum S, Guillory SB, Sigford B, Cifu DX. Program development and defining characteristics of returning military in a VA Polytrauma Network Site. J Rehabil Res Dev. 2007;44(7): PubMed PMID: Stelmack JA, Frith T, Van Koevering D, Rinne S, Stelmack TR. Visual function in patients followed at a Veterans Affairs polytrauma network site: an electronic medical record review. Optometry Aug;80(8): doi: /j.optm PubMed PMID:

33 Ty York, Veteran TBI Survivor Jeri York, Caregiver

The Veterans Health Administration TBI/Polytrauma Program

The Veterans Health Administration TBI/Polytrauma Program Joel Scholten, MD Special Projects Director, Physical Medicine and Rehab Program Office September 10, 2012 Physical Medicine & Rehabilitation National