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)

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