Policy Aims to Better Identify, Treat Concussions

WASHINGTON, April 1, 2011 — A mem­o­ran­dum that took effect through­out the Defense Depart­ment in June is expect­ed to have a major impact on efforts to iden­ti­fy and treat trau­mat­ic brain injuries in the com­bat the­ater faster and more sys­tem­at­i­cal­ly, med­ical offi­cials report­ed at the recent Armed Forces Pub­lic Health Con­fer­ence in Hamp­ton, Va.
The direc­tive memo, which sets pol­i­cy and man­age­ment guide­lines con­cern­ing TBI in deployed set­tings, relies for the first time on events, rather than per­son­al report­ing, to trig­ger a chain of insti­tu­tion­al respons­es, Army Maj. Sarah Gold­man, the Army’s TBI pro­gram man­ag­er, told an audi­ence of health care pro­fes­sion­als.

“This is an absolute­ly rev­o­lu­tion­ary pol­i­cy,” Gold­man said. “This is real­ly the first time in trau­mat­ic brain injury care, and cer­tain­ly in the Depart­ment of Defense trau­mat­ic brain injury care, that we have an event-dri­ven pro­to­col. What that means is that you don’t have to rely on ser­vice mem­bers to raise their hand and say, ‘I am hav­ing some prob­lems’ after they have been involved in an event.” 

Instead, the new pol­i­cy lays out a response when­ev­er a ser­vice mem­ber expe­ri­ences some­thing that could cause TBI. “This is an event-dri­ven pol­i­cy,” Gold­man said. “So, for exam­ple, if the ser­vice mem­ber hits their head or is some­where near a blast, they have to get checked out, they have to get treat­ed and they have to get report­ed. There also is manda­to­ry downtime.” 

DOD offi­cials have long strug­gled to find ways to more quick­ly iden­ti­fy and treat what has become a sig­na­ture -– and often invis­i­ble — com­bat injury. TBIs often result from bul­let blasts, vehi­cle acci­dents that cause a jolt to the head or expo­sure to a blast. The most com­mon symp­toms are loss of con­scious­ness, mem­o­ry loss, alter­ation of con­scious­ness and oth­er neu­ro­log­i­cal problems. 

Mod­er­ate and severe TBI is rel­a­tive­ly easy to rec­og­nize, Navy Cmdr. (Dr.) David Taran­ti­no, direc­tor for clin­i­cal pro­grams at Head­quar­ters Marine Corps, told the group. What’s far more chal­leng­ing, he said, is rec­og­niz­ing the 80 per­cent of TBI patients whose con­di­tions are mild –- mean­ing they have suf­fered a con­cus­sion. “In layman’s terms, you feel dizzy, con­fused, see stars and have some alter­ation of con­scious­ness,” Taran­ti­no said. Oth­er symp­toms, he said, include dis­ori­en­ta­tion, headache, bal­ance dif­fi­cul­ties, sleep dis­tur­bances, nau­sea and vomiting. 

Not diag­nos­ing a ser­vice mem­ber with mild TBI can have seri­ous oper­a­tional impact, Taran­ti­no said. “You have dif­fi­cul­ty fol­low­ing instruc­tions, poor marks­man­ship, slow reac­tion time and decreased con­cen­tra­tion. All of those have an impact on the bat­tle­field,” he said. “If some­one has a con­cus­sion, you don’t want to give them a weapon and send them right back to the front lines. That can do a lot of harm.” 

It’s the same prin­ci­ple the Nation­al Foot­ball League uses to pro­tect its play­ers, Taran­ti­no said. “You don’t want to have your quar­ter­back in on a final dri­ve if he has been knocked loopy,” he said. “It’s a sim­i­lar kind of thing.” But as the NFL and mil­i­tary are learn­ing togeth­er, there’s anoth­er rea­son to iden­ti­fy and treat mild TBI as quick­ly as pos­si­ble. Not only is it the best way to ensure a full recov­ery; it’s also the best way to pre­vent more severe issues if the patient gets anoth­er con­cus­sion before the first one heals. 

Stud­ies on ath­letes show that a his­to­ry of three con­cus­sions increas­es their risk of chron­ic prob­lems three-fold, Taran­ti­no said. “We are start­ing to see from NFL play­ers what the cumu­la­tive, long-term effects are,” he said, includ­ing ear­ly Alzheimer’s dis­ease and chron­ic trau­mat­ic encephalopa­thy, a pro­gres­sive degen­er­a­tive disease. 

“This is an issue we are con­cerned about and try­ing to pre­vent” in U.S. ser­vice mem­bers, Taran­ti­no said. “We have a lot of guys exposed [to blasts] many times. So the ques­tion is: ‘How do we make sure that they get the prop­er rest and care and treat­ment before they get exposed again?’ ” 

Gold­man called the new DOD mem­o­ran­dum a major step in the right direc­tion. Devel­oped by sci­en­tif­ic experts from around the coun­try, “it rep­re­sents what we under­stand is the best sci­ence to date to man­age con­cus­sion,” she said. 

“As the sci­ence con­tin­ues to evolve, we cer­tain­ly will be updat­ing this pol­i­cy,” she said. The first pol­i­cy update is expect­ed lat­er this year, when the memo becomes a per­ma­nent DOD instruction. 

The new memo requires com­man­ders to ensure all ser­vice mem­bers involved in poten­tial­ly con­cus­sive events receive a med­ical eval­u­a­tion, even if they have no appar­ent injuries. It also autho­rizes com­man­ders to refer a sol­dier, sailor, air­men or Marine under their charge who appears to be show­ing symp­toms for eval­u­a­tion. It also man­dates that all cas­es of TBI be doc­u­ment­ed into an elec­tron­ic med­ical record. This, Gold­man said, will pro­vide a reg­istry for the Defense Depart­ment and a tool to inform com­man­ders whose units are about to redeploy. 

Air Force Maj. (Dr.) Lau­ra Baugh, the Air Force TBI pro­gram man­ag­er, called this lead­er­ship respon­si­bil­i­ty a key part of the new pol­i­cy. “It requires lead­ers to rec­og­nize ser­vice mem­bers who have been involved in an event that could cause a con­cus­sion and to ensure they get a med­ical eval­u­a­tion, and requires them to track these ser­vice mem­bers in the elec­tron­ic data­base,” she said. 

“Not only does this ensure ser­vice mem­bers get the fol­low-on care they need down the road,” she said. “It also helps [DOD] under­stand the true inci­dence of this prob­lem in the theater.” 

The pol­i­cy estab­lish­es new pro­to­cols for ser­vice mem­bers with recur­rent TBIs. “If there is a ser­vice mem­ber who has sus­tained three or more con­cus­sions with­in a 12-month peri­od, they are get­ting a four-hour neu­ropsy­cho­log­i­cal bat­tery,” Baugh said, includ­ing vestibu­lar and func­tion­al test­ing. “They get the entire ‘works,’ ” Gold­man said. 

“Don’t get me wrong. Cer­tain­ly the ones who expe­ri­enced just one event also are get­ting checked out,” Gold­man con­tin­ued. “But I will tell you, it is a much more inten­sive eval­u­a­tion for ser­vice mem­bers involved in the recur­rent con­cus­sion protocol.” 

The memo revis­es the mil­i­tary acute con­cus­sion eval­u­a­tion screen­ing test, intro­duc­ing a three-part score that includes patient his­to­ry and results of cog­ni­tive screen­ing and a neu­ro­log­i­cal screen­ing exam, she said. 

In terms of patient care, it man­dates two of the best-known treat­ments for mild TBI: rest and education. 

Troops suf­fer­ing mild TBI require at least 24 hours of rest before return­ing to duty, and often more as they receive their med­ical eval­u­a­tions, Taran­ti­no said. Ide­al­ly, that rest is offered in a “reduced-stim­u­lus envi­ron­ment” –- a place that’s cool, qui­et and com­fort­able and allows patients to rest and catch up on lost sleep, he said. 

Often ser­vice mem­bers need to be moved to find these con­di­tions, he rec­og­nized. “It’s pret­ty hard at a for­ward oper­at­ing base get­ting shelled or [under] mor­tar fire, or where there’s no air con­di­tion­ing or it’s noisy or loud of uncom­fort­able,” he said. “That, in itself, might be a rea­son to move the patient back to get rest.” 

Taran­ti­no cit­ed the Marines’ Con­cus­sion Restora­tion Care Cen­ter at Camp Leath­er­neck, Afghanistan, as a new approach to pro­vid­ing this respite in the com­bat the­ater. It offers com­pre­hen­sive, inter­dis­ci­pli­nary con­cus­sion care that includes sports med­i­cine, occu­pa­tion­al ther­a­py, phys­i­cal ther­a­py and even acupunc­ture that he said “has proven very pop­u­lar with the Marines and, at least anec­do­tal­ly, very effective.” 

The cen­ter tends to treat some of the more severe con­cus­sions, offer­ing care that typ­i­cal­ly lasts about 14 days. How­ev­er, 95 per­cent of its patients return to full duty, Taran­ti­no reported. 

As the mil­i­tary works to improve the way it diag­noses and treats mild TBI, it’s also focus­ing more heav­i­ly on edu­cat­ing ser­vice mem­bers about TBI. The edu­ca­tion effort begins dur­ing the pre-deploy­ment cycle and con­tin­ues in the com­bat the­ater and on rede­ploy­ment home. “The best treat­ment is edu­ca­tion, pro­vid­ing infor­ma­tion, coun­sel­ing and instruc­tions about com­mon symp­toms and expect­ed out­comes,” Taran­ti­no said. 

Gold­man said she’s enthu­si­as­tic about the poten­tial of the new pol­i­cy to help the mil­i­tary bet­ter iden­ti­fy and treat mild TBI and to ensure ser­vice mem­bers have the best chance of a full recovery. 

“I just can’t overem­pha­size just how rev­o­lu­tion­ary this pol­i­cy is,” she said. “We are real­ly look­ing for­ward to the long-term results to see how this impacts long-term outcomes.” 

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

Face­book and/or on Twit­ter

Team GlobDef

Seit 2001 ist GlobalDefence.net im Internet unterwegs, um mit eigenen Analysen, interessanten Kooperationen und umfassenden Informationen für einen spannenden Überblick der Weltlage zu sorgen. GlobalDefence.net war dabei die erste deutschsprachige Internetseite, die mit dem Schwerpunkt Sicherheitspolitik außerhalb von Hochschulen oder Instituten aufgetreten ist.

Alle Beiträge ansehen von Team GlobDef →