Department Makes ‘Great Strides’ in Brain-injury Care

WASHINGTON — The Defense Depart­ment is mak­ing great strides in the field of trau­mat­ic brain injury that will ben­e­fit not only the depart­ment, but also its glob­al and civil­ian part­ners, a TBI expert said today.
“The depart­ment is com­mit­ted to fast-track­ing promis­ing research and to improv­ing the diag­no­sis and treat­ment of TBI to ben­e­fit ser­vice mem­bers, vet­er­ans and their fam­i­lies,” Kathy Helmick, deputy direc­tor for TBI for the Defense Cen­ters of Excel­lence for Psy­cho­log­i­cal Health and Trau­mat­ic Brain Injury, said dur­ing a tele­con­fer­ence host­ed by the Defense Cen­ters of Excel­lence.

Helmick was one of sev­er­al offi­cials from across the Defense and Vet­er­ans Affairs depart­ments who out­lined new and upcom­ing pro­grams and ini­tia­tives designed to assist ser­vice mem­bers and vet­er­ans diag­nosed with trau­mat­ic brain injuries. They also pre­viewed the lat­est in TBI diag­no­sis, eval­u­a­tion and research. 

More than 19,000 ser­vice mem­bers were diag­nosed with a mild TBI, or con­cus­sion, last year, accord­ing to the Defense Cen­ters of Excel­lence website. 

The Defense Depart­ment has made sig­nif­i­cant advance­ments in TBI man­age­ment dur­ing the last sev­er­al years, and is con­tin­u­ing to learn as it treats, Helmick noted. 

“Nav­i­gat­ing the clin­i­cal chal­lenges providers face in the field is crit­i­cal to ensur­ing that we’re employ­ing state-of-the-art care for all lev­els of TBI sever­i­ty, from con­cus­sions to severe and pen­e­trat­ing brain injuries,” she said. 

Helmick out­lined three areas of focus for the depart­ment regard­ing TBI: cog­ni­tive reha­bil­i­ta­tion, co-occur­ring dis­or­ders and guidance. 

The depart­ment is study­ing the effects of cog­ni­tive reha­bil­i­ta­tion for mild TBI, she said. Fol­low­ing a TBI, peo­ple may expe­ri­ence symp­toms of func­tion­al lim­i­ta­tions, she explained, includ­ing atten­tion issues, mem­o­ry prob­lems and issues with social, emo­tion­al and exec­u­tive func­tion­ing, such as plan­ning and judgment. 

Cog­ni­tive reha­bil­i­ta­tion ther­a­py is now per­formed at 13 mil­i­tary treat­ment facil­i­ties, she noted. 

Addi­tion­al­ly, the Defense Cen­ters of Excel­lence has released a co-occur­ring con­di­tions toolk­it for mild TBI and psy­cho­log­i­cal health, Helmick said, which can help pri­ma­ry care providers with assess­ing and man­ag­ing brain injuries. The toolk­it address­es depres­sion, chron­ic pain, headache and sub­stance abuse disorder. 

The depart­ment also is aggres­sive­ly work­ing diag­no­sis and treat­ment of TBI in the com­bat the­ater through a direc­tive-type mem­o­ran­dum, Helmick explained, which estab­lish­es guid­ance for the man­age­ment of con­cus­sions in deployed set­tings. The mem­o­ran­dum, which offi­cials signed into pol­i­cy June 21, includes manda­to­ry pro­to­cols for expo­sure, med­ical eval­u­a­tion and rest require­ments, and guide­lines for resump­tion of sports and oth­er activ­i­ties that involve a con­cus­sion risk. 

Com­man­ders and oth­er rep­re­sen­ta­tives are required to assess ser­vice mem­bers involved in poten­tial­ly con­cus­sive events, she added, includ­ing mem­bers with­out vis­i­ble injuries. 

Ser­vice mem­bers with mild TBI receive a stan­dard edu­ca­tion sheet, she con­tin­ued, and new pro­to­cols address mem­bers that have expe­ri­enced three or more TBIs in a 12-month period. 

“We’ve learned ear­ly diag­no­sis and treat­ment help to max­i­mize the pos­si­bil­i­ty that mem­bers will ful­ly recov­er from a TBI and return to duty,” Helmick said, not­ing that this applies to injuries suf­fered while deployed or at home. 

On aver­age, accord­ing the Defense Cen­ters of Excel­lence web­site, it takes peo­ple about one to three months to recov­er from a mild TBI

For U.S. Cen­tral Com­mand, the major TBI focus in the­ater has been on the imple­men­ta­tion of the June 21 pol­i­cy, not­ed Dr. Theodore Brown, pre­ven­tive med­i­cine physi­cian for Cent­com. It’s his job, he explained, to trans­late the pol­i­cy to the Cent­com the­ater of oper­a­tions and to work close­ly with med­ical per­son­nel on imple­men­ta­tion “to ensure not only a joint, but a cohe­sive, uni­fied” effort. 

One of the policy’s require­ments is to track and report all ser­vice mem­ber expo­sures to con­cus­sive events, he not­ed. That track­ing and report­ing was con­duct­ed man­u­al­ly in the past, but Cent­com since has devel­oped an auto­mat­ed Blast Expo­sure and Con­cus­sion Inci­dent Report, he explained, which is with­in the Com­bined Infor­ma­tion Data Net­work Exchange. This exchange is used through­out the­ater to report sig­nif­i­cant oper­a­tional events. 

Through the inci­dent report, the record of expo­sure auto­mat­i­cal­ly is linked to the sig­nif­i­cant event, he said, which allows a more com­pre­hen­sive cap­ture of expo­sures and, lat­er, analy­sis of the data. 

Brown also touched on a new, stan­dard­ized ini­tial eval­u­a­tion form. The pol­i­cy calls for all ser­vice mem­bers exposed to a con­cus­sive event to be med­ical­ly eval­u­at­ed and for the inci­dent to be doc­u­ment­ed in their elec­tron­ic record. Cent­com offi­cials worked with the ser­vices to cre­ate an ini­tial eval­u­a­tion tem­plate that will be avail­able through­out the the­ater in the Elec­tron­ic Med­ical Record Sys­tem, he said. 

“This is tru­ly a team effort, not just meet­ing intent of pol­i­cy, but with the greater intent of pro­tect­ing ser­vice mem­bers,” he said. 

In the area of research, sev­er­al large-scale, long-term TBI ini­tia­tives either are under way or in the plan­ning stages, Army Col. (Dr.) Jamie Grimes, nation­al direc­tor of the Defense and Vet­er­ans Brain Injury Cen­ter, said. 

Grimes first touched on a study — a joint effort by the Defense and Vet­er­ans Affairs depart­ments — that’s aimed at study­ing the effec­tive­ness of cog­ni­tive reha­bil­i­ta­tion to treat TBI. The study is slat­ed to begin in May and con­clude in Decem­ber 2012. 

Addi­tion­al­ly, the brain and injury cen­ter has been com­mis­sioned to do a lon­gi­tu­di­nal study of TBI, she not­ed, that will span 15 years and include ser­vice mem­bers and vet­er­ans of oper­a­tions Iraqi and Endur­ing Free­dom as well as their fam­i­ly mem­bers. The study will involve 1,200 peo­ple: 600 mild, mod­er­ate or severe TBI sur­vivors; 300 who have suf­fered some type of non-TBI trau­ma; and 300 who deployed with­out resul­tant injuries. 

And final­ly, the cen­ter will con­duct “head to head” stud­ies that will look at the var­i­ous neu­rocog­ni­tive assess­ment tools, includ­ing the stan­dard­ized TBI assess­ment tool used across the Defense Department. 

“There are many cog­ni­tive tests out there, but there’s not been a study to look at what is best,” Grimes said. 

The state­side study already has begun, she not­ed, involv­ing four neu­rocog­ni­tive assess­ment tools and 85 peo­ple. The aim is to enroll 400 peo­ple. In the com­bat the­ater, tests will involve five neu­rocog­ni­tive assess­ment tools, she explained, and will have 300 peo­ple enrolled. 

Experts from each ser­vice also touched on new pro­grams and ini­tia­tives their branch has estab­lished or will be rolling out soon. 

First up was Maj. Sarah Gold­man, Army TBI pro­gram man­ag­er, who high­light­ed the Army’s TBI pro­gram val­i­da­tion ini­tia­tive. The ini­tia­tive has three stages, she explained: ini­tial val­i­da­tion, full val­i­da­tion and fol­low-up inspec­tions as part of the Med­ical Command’s orga­ni­za­tion­al inspec­tion program. 

Gold­man said she’ll be trav­el­ing to two dif­fer­ent regions, span­ning 21 mil­i­tary treat­ment facil­i­ties, in the upcom­ing weeks for the inspec­tion. She and a team will look at bud­gets to ensure TBI funds are appro­pri­ate­ly used and that facil­i­ties have their needs addressed, will talk with staff mem­bers to address out­come mea­sures, and will look at patient satisfaction. 

“We’re look­ing to make sure every­one is fol­low­ing the lat­est guide­lines for TBI care,” Gold­man explained. “It’s anoth­er oppor­tu­ni­ty for us to make sure sol­diers are get­ting top qual­i­ty care accord­ing to the lat­est guidelines.” 

This ini­tia­tive is just one of many for the Army, she added. 

Navy Cmdr. Jack Tsao, direc­tor of TBI pro­grams for the U.S. Navy Bureau of Med­i­cine and Surgery, touched on the Navy’s train­ing and eval­u­a­tion efforts. 

The “bedrock” of the Navy’s TBI pro­gram, he not­ed, is the train­ing med­ical offi­cers and corps­men receive pri­or to deploy­ment. This four-hour pro­gram includes hands-on teach­ing on how to admin­is­ter and review assess­ment tools and infor­ma­tion on clin­i­cal prac­tice guidelines. 

The Navy also is devel­op­ing a hand­held neu­rocog­ni­tive device to help corps­men make deci­sions regard­ing con­cus­sions on the bat­tle­field. The project has been in the works for sev­er­al years and should move to test­ing in the next cou­ple of weeks, he said. 

Dr. Kei­th Mori­ta, chief of med­ical oper­a­tions for the Air Force Med­ical Sup­port Agency, high­light­ed the Air Force’s TBI clin­ic in Bal­ad, Iraq, as well as joint efforts state­side between Air Force and Army medics to ensure com­pre­hen­sive TBI care. 

Addi­tion­al­ly, the Air Force start­ed a TBI clin­ic in 2009 at Joint Base Elmen­dorf-Richard­son, Alas­ka, Mori­ta not­ed, to offer ser­vice mem­bers return­ing from deploy­ment “care in a sup­port­ive envi­ron­ment with loved ones.” 

Dr. David Taran­ti­no, direc­tor for clin­i­cal pro­grams at Head­quar­ters Marine Corps, said the Marine Corps offers a com­pre­hen­sive approach to brain injuries, from edu­ca­tion and train­ing to track­ing and surveillance. 

Lead­ers have placed an empha­sis on pre­ven­tion, Taran­ti­no not­ed, includ­ing the devel­op­ment of advanced armored vehi­cles, body armor and helmets. 

In the area of treat­ment, the Marine Corps has tak­en an inno­v­a­tive approach, he explained, by estab­lish­ing a con­cus­sion and restora­tion care cen­ter. The cen­ter offers a mul­ti­dis­ci­pli­nary and holis­tic approach to con­cus­sion man­age­ment, he said. 

Marine Corps lead­ers have made brain injuries a lead­er­ship pri­or­i­ty, Taran­ti­no said. They “rec­og­nize the crit­i­cal chal­lenge of TBI and con­cus­sion as sig­na­ture injuries of mod­ern com­bat, and the lead­ing com­bat injury we’re see­ing,” he added. 

Offi­cials also touched on efforts to edu­cate and sup­port fam­i­ly mem­bers. The Defense Depart­ment and indi­vid­ual ser­vices offer a vari­ety of resources and infor­ma­tion on brain injuries, they said, cov­er­ing every­thing from the signs and symp­toms to care and support. 

For more infor­ma­tion on help­ing resources, Helmick sug­gest­ed peo­ple vis­it the Defense Cen­ters of Excel­lence and Mil­i­tary Health Sys­tem websites. 

U.S. Depart­ment of Defense
Office of the Assis­tant Sec­re­tary of Defense (Pub­lic Affairs) 

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