mild traumatic brain injury: the military experience and ... · pdf filemild traumatic brain...

Jay Pyo, D.O.Jay Pyo, D.O. Cynthia Boyd, Ph.D.Cynthia Boyd, Ph.D.MAJ, MC, USAMAJ, MC, USA CoCo--Senior Scientific DirectorSenior Scientific Director

Physical Medicine and Rehabilitation Physical Medicine and Rehabilitation Defense & Veterans Brain Injury CenterDefense & Veterans Brain Injury Center

Comprehensive Combat and Complex Casualty Care ProgramComprehensive Combat and Complex Casualty Care Program

Naval Medical Center San DiegoNaval Medical Center San Diego

Mild Traumatic Brain Injury:

The Military Experience and Applications for Managementin the Community

DisclaimerDisclaimer

�� I am a military service member (or employee I am a military service member (or employee of the U.S. Government). This work was of the U.S. Government). This work was prepared as part of my official duties. Title prepared as part of my official duties. Title 17, USC, 17, USC, §§105 provides that 105 provides that ‘‘Copyright Copyright protection under this title is not available for protection under this title is not available for any work of the any work of the U.S.GovernmentU.S.Government..’’ Title 17, Title 17, USC, USC, §§101 defines a 101 defines a U.S.GovernmentU.S.Government work as work as a work prepared by a military service a work prepared by a military service member or employee of the U.S. Government member or employee of the U.S. Government as part of the personas part of the person’’s official duties.s official duties.

MildMild Traumatic Brain Injury:Traumatic Brain Injury:The Military Experience and Applications The Military Experience and Applications

for Management in the Community.for Management in the Community.

Jay Pyo, D.O.Jay Pyo, D.O.

MAJ, MC, USAMAJ, MC, USA

Physical Medicine and RehabilitationPhysical Medicine and Rehabilitation

Comprehensive Combat and Complex Casualty Care ProgramComprehensive Combat and Complex Casualty Care Program

Naval Medical Center San DiegoNaval Medical Center San Diego

TBI TBI ““In the NewsIn the News””

�� September 11September 11thth, 2001, 2001

�� IraqIraq

�� AfghanistanAfghanistan

�� NFLNFL

�� NHLNHL

�� Congresswoman Congresswoman GiffordsGiffords

�� Other media outletsOther media outlets

*Signature Injury**Signature Injury*

Goals and ObjectivesGoals and Objectives

�� HistoryHistory

�� DefinitionDefinition

�� EpidemiologyEpidemiology

�� PathophysiologyPathophysiology

OverviewOverview

�� Assessing cognitive changesAssessing cognitive changes

�� Understanding behavioral changesUnderstanding behavioral changes

�� CoCo--morbid factors that interfere with morbid factors that interfere with

recoveryrecovery

History of TBI RehabilitationHistory of TBI Rehabilitation

�� PrePre--19001900

�� Penetrating head injury = 70% mortalityPenetrating head injury = 70% mortality

�� WWIWWI--WWII (Germany and Austria)WWII (Germany and Austria)

�� Advent of Advent of ““TBI rehabilitationTBI rehabilitation””

�� Recognition of neuropsychological impairmentsRecognition of neuropsychological impairments

�� Teaching strategies of preserved skills to Teaching strategies of preserved skills to

compensate for impairmentscompensate for impairments

�� Employment and vocation as outcome measure.Employment and vocation as outcome measure.


�� Post WWII (United Kingdom, Russia, Post WWII (United Kingdom, Russia, United States)United States)�� ResearchResearch

�� Compensatory training (motor planning, visual Compensatory training (motor planning, visual perception, executive functioning)perception, executive functioning)

�� Functional Prognosis (PTA)Functional Prognosis (PTA)

�� Medical Complications (seizures)Medical Complications (seizures)

�� Multidisciplinary approachMultidisciplinary approach

�� Standardized testingStandardized testing


�� Professional Development to meet Professional Development to meet

veteranveteran’’s needs.s needs.

�� SLPSLP

�� PTPT

�� OTOT

�� VocationalVocational

�� Mental HealthMental Health

�� Physical Medicine and Physical Medicine and Rehabilitation Rehabilitation ((PhysiatryPhysiatry))

�� Dedicated Dedicated

rehabilitation centersrehabilitation centers

�� SCISCI

�� TBITBI

�� StrokeStroke

�� Ortho (amputations)Ortho (amputations)

THENTHEN……

�� ……and NOWand NOW

http://blog.americanhistory.si.edu/osaycanyousee/2011/07/reflections-on-the-closing-of-a-hospital.html

http://www.caller.com/photos/2010/aug/14/85558/

http://www.usatoday.com/news/military/2011-07-27-walter-reed-closing_n.htm

File photo NMCD

http://www.frontpagenews.us/2009_04_01_archive.html

File photo NMCSD

http://ihm.nlm.nih.gov/luna/servlet/detail/NLMNLM~1~1~101442559~142364:Walter-Reed-Army-Medical-Center--Li?printerFriendly=1

http://www.army.mil/article/32595/

Traumatic brain injury (TBI) Traumatic brain injury (TBI)

�� NondegenerativeNondegenerative, , noncongenitalnoncongenital insult to the braininsult to the brain

�� External mechanical forceExternal mechanical force

�� Leading to permanent or temporary impairments of Leading to permanent or temporary impairments of

functionfunction

�� CognitiveCognitive

�� PhysicalPhysical

�� PsychosocialPsychosocial

�� Associated diminished or altered state of consciousness.Associated diminished or altered state of consciousness.

Defining the problemDefining the problem

�� Head Injury Interdisciplinary Special Interest Head Injury Interdisciplinary Special Interest

Group of the American Congress of Group of the American Congress of

Rehabilitation MedicineRehabilitation Medicine

�� Traumatically induced physiologic disruption of Traumatically induced physiologic disruption of

brain functionbrain function

�� LOCLOC

�� Immediate Retrograde/postImmediate Retrograde/post--traumatic amnesiatraumatic amnesia

�� Alteration of mental state (stars, dazed, Alteration of mental state (stars, dazed, ““bell rungbell rung””))

�� Focal neurologic deficitsFocal neurologic deficits

GradingGrading

�� MildMild

�� ModerateModerate

�� SevereSevere

Mild TBIMild TBI

�� Does not exceedDoes not exceed

�� LOC<30minLOC<30min

�� PTA <24hrPTA <24hr

�� GCS 13GCS 13--1515

�� No imaging findingsNo imaging findings

�� mTBImTBI=Concussion?=Concussion?

�� It depends on who you talk toIt depends on who you talk to……

ModerateModerate

�� LOC: 30minLOC: 30min--24hrs24hrs

�� PTA: 24hrPTA: 24hr--1 week1 week

�� GCS 9GCS 9--1212

�� NeuroimagingNeuroimaging evidence of intracranial traumaevidence of intracranial trauma

SevereSevere

�� LOC: >24hrsLOC: >24hrs

�� PTA: > 1 weekPTA: > 1 week

�� GCS <8GCS <8

�� NeuroimagingNeuroimaging evidence of intracranial traumaevidence of intracranial trauma

�� Penetrating/depressed/displaced scull fracturePenetrating/depressed/displaced scull fracture

Epidemiology: GWOTEpidemiology: GWOT

�� 1212--35%, 1.6 million Service Members deployed 35%, 1.6 million Service Members deployed

in last 11 years.in last 11 years.

�� 80% Blast related (IED, RPG, EFP, etc.)80% Blast related (IED, RPG, EFP, etc.)

EpidemiologyEpidemiology

�� CDCCDC

�� 20022002--20062006

�� Incidence 1.7 million Incidence 1.7 million

per year per year

(?underestimated?)(?underestimated?)

EpidemiologyEpidemiology

�� PitfallsPitfalls

�� Inconsistent definitionInconsistent definition

�� Inadequate reportingInadequate reporting

�� Inadequate imagingInadequate imaging

MOIMOI

Groups at RiskGroups at Risk

�� 59% male59% male

�� 00--4, 154, 15--19, >65 19, >65 yoayoa

�� 18 % TBI ER visits 018 % TBI ER visits 0--4 4 yoayoa

�� 22% hospitalization >75 22% hospitalization >75 yoayoa

�� Highest rate of hospitalization and deathHighest rate of hospitalization and death

Risk FactorsRisk Factors

�� AlcoholAlcohol

�� Substance AbuseSubstance Abuse

�� CrimeCrime

�� Societal factorsSocietal factors

Trends 1979Trends 1979--19921992

�� TBI deaths down 22%TBI deaths down 22%

�� GSW deaths (up 9%)GSW deaths (up 9%)

�� #1 cause of TBI deaths#1 cause of TBI deaths

�� Decreased MVA deaths (down 42%)Decreased MVA deaths (down 42%)

�� 30% associated with all injury related 30% associated with all injury related

death.death.

ImportanceImportance

�� 5.3 million Americans5.3 million Americans——2% of the U.S. 2% of the U.S. populationpopulation——currently live with disabilities currently live with disabilities resulting from brain injury.resulting from brain injury.

�� $76.5 billion total direct/indirect medical $76.5 billion total direct/indirect medical cost and lost productivitycost and lost productivity (2000)(2000)

�� LBP ~ $100 billionLBP ~ $100 billion

ImportanceImportance

��75% of 75% of TBIsTBIs that occur that occur

each year are mild TBI.each year are mild TBI.

Prevention and EducationPrevention and Education

�� AirbagsAirbags

�� Safety beltsSafety belts

�� HelmetsHelmets

�� Violence prevention programsViolence prevention programs

�� Falls prevention programsFalls prevention programs

�� Proper sports equipmentProper sports equipment

�� Combat protective equipmentCombat protective equipment

Goff, et. Al.Goff, et. Al.

�� Combat gear.Combat gear.

http://en.wikipedia.org/wiki/MRAP

http://defensetech.org/2007/08/30/amazing-mrap-survival-photos/

PathophysiologyPathophysiology

�� Self limitingSelf limiting

�� Short livedShort lived

�� Spontaneous resolutionSpontaneous resolution

�� Transient disturbancesTransient disturbances

�� ObservationObservation

�� Underreported and underestimatedUnderreported and underestimated


�� ““mildmild””=absence of cranial lesion=absence of cranial lesion

�� ““mildmild””=describes mechanism of injury=describes mechanism of injury

�� ““mildmild”” =/= 100% normal outcome or =/= 100% normal outcome or

predict prognosispredict prognosis

�� Typical resolution in 1Typical resolution in 1--12wks12wks

�� 15% remain symptomatic15% remain symptomatic


�� Diffuse Axonal InjuryDiffuse Axonal Injury

�� Spectrum of severitySpectrum of severity

http://www.braininjury.com/injured.shtmlhttp://www.uihealthcare.com/topics/medicaldepartments/neurosurgery/braininjury/03whattypesbraininjuries.html


�� Neurochemical/NeurometabolicNeurochemical/Neurometabolic eventsevents

�� Release of excitatory amino acids (EAA)Release of excitatory amino acids (EAA)

�� GlutamateGlutamate

�� Activation of NMDA receptorsActivation of NMDA receptors

�� Influx of calciumInflux of calcium

�� Impairment of mitochondrial activityImpairment of mitochondrial activity



�� Imbalance of ATP consumption/productionImbalance of ATP consumption/production

�� Compromises synaptic plasticityCompromises synaptic plasticity

�� Focal neurologic and other cognitive/behavioral Focal neurologic and other cognitive/behavioral

deficitsdeficits

�� NN--acetylasperateacetylasperate (NAA)(NAA)

�� Brain specific metaboliteBrain specific metabolite

�� Low levels suggest neuronal injuryLow levels suggest neuronal injury

�� Stroke, MS, dementiaStroke, MS, dementia




�� Brain specific metabolite (neuronal mitochondria)Brain specific metabolite (neuronal mitochondria)

�� High energy costHigh energy cost

�� Low levels suggest neuronal injuryLow levels suggest neuronal injury

�� Stroke, MS, dementiaStroke, MS, dementia

�� Hypoxic/ischemic/toxicHypoxic/ischemic/toxic

�� Proton magnetic resonance spectroscopy (1HProton magnetic resonance spectroscopy (1H--

MRS)MRS)




�� Animal modelsAnimal models

�� Correlated with severityCorrelated with severity

�� Mild TBI vs. sham head injuryMild TBI vs. sham head injury

�� Brain vulnerability vs. Second Impact SyndromeBrain vulnerability vs. Second Impact Syndrome

�� SIS is FATAL and rare (cerebral edema)SIS is FATAL and rare (cerebral edema)

�� Changes in ATP/NAA in repeated Changes in ATP/NAA in repeated mTBImTBI modelsmodels

�� Resolution over time?Resolution over time?

�� ~30days~30days


�� Genetic expressionGenetic expression

�� Increased ASPA gene expressionIncreased ASPA gene expression

�� Decreased NAA production (depressed Decreased NAA production (depressed

mitochondrial function)mitochondrial function)


�� Clinical/Research applicationsClinical/Research applications

�� Monitor NAA levelsMonitor NAA levels

�� Determine window of clearanceDetermine window of clearance

�� Treatment targeting mitochondrial functionTreatment targeting mitochondrial function

Modern State of TBI Modern State of TBI

SurveillanceSurveillance

�� DVBIC (DVHIP) DVBIC (DVHIP) –– 1992 (GW)1992 (GW)

�� TBI Act of 1996TBI Act of 1996

�� CDCCDC

�� DVBIC 2008 (GWOT)DVBIC 2008 (GWOT)

�� ““Signature InjurySignature Injury””

The The DoDDoD ApproachApproach

�� Office of Office of NeurotraumaNeurotrauma, Navy Medicine , Navy Medicine

West West SoCalSoCal

�� Naval Medical Center San DiegoNaval Medical Center San Diego

�� Naval Hospital Camp PendletonNaval Hospital Camp Pendleton

�� Naval Hospital Naval Hospital TwentynineTwentynine PalmsPalms

The NMCSD TEAMThe NMCSD TEAM

�� DVBICDVBIC�� Multicenter networkMulticenter network�� Collaboration between Collaboration between DoDDoD and VA entitiesand VA entities�� DCoEDCoE PH/TBIPH/TBI

�� Comprehensive Combat and Complex Casualty Care Comprehensive Combat and Complex Casualty Care (C(C--5) Program5) Program�� Case Management and Primary Care model with a Case Management and Primary Care model with a rehabilitation focus.rehabilitation focus.

�� Management of all overseas/deployed service member Management of all overseas/deployed service member who medically evacuated or transported to NMCSD.who medically evacuated or transported to NMCSD.

�� PolytraumaPolytrauma RehabilitationRehabilitation

The ApproachThe Approach

�� VAVA--DoDDoD CPGCPG�� Primary Care ModelPrimary Care Model

�� SATEPSSATEPS�� ScreeningScreening

�� AssessmentAssessment

�� TreatmentTreatment

�� EducationEducation

�� Patient FollowPatient Follow--upup

�� SurveillanceSurveillance

VA/VA/DoDDoD CPGCPG

�� Adult injuryAdult injury

�� Apply to all medical providersApply to all medical providers

�� Does not address acute management or Does not address acute management or

mod/mod/sevsev TBI.TBI.

VA/VA/DoDDoD CPGCPG

�� Establish accurate diagnosisEstablish accurate diagnosis

�� Evidence based management and Evidence based management and

treatmenttreatment

�� Early interventionEarly intervention

�� Multidisciplinary approachMultidisciplinary approach

VA/VA/DoDDoD CPGCPG

�� Adult injuryAdult injury

�� Apply to all medical providersApply to all medical providers

�� Does not address acute management or Does not address acute management or

mod/mod/sevsev TBI.TBI.

VA/VA/DoDDoD CPGCPG

�� Patient screeningPatient screening

�� Patient educationPatient education

�� Early interventionEarly intervention

�� Symptom managementSymptom management�� SomaticSomatic

�� psychiatricpsychiatric

�� RTD ASAPRTD ASAP�� PsychoPsycho--social support for refractory social support for refractory sypmtomssypmtoms

�� Secondary gain?Secondary gain?

�� Continuity and Follow up.Continuity and Follow up.

Core ComponentsCore Components

�� Screening: Screening:

�� DVBIC TBI Screening Tool, TBI Severity ScoreDVBIC TBI Screening Tool, TBI Severity Score

�� Assessment: Assessment:

�� Medical ExamMedical Exam

�� Treatment: Treatment:

�� 20 week care plan, VA 20 week care plan, VA DoDDoD CPG, CPG,

Interdisciplinary TeamInterdisciplinary Team

Core ComponentsCore Components

�� Education:Education:

�� Face to face with provider, DVBICFace to face with provider, DVBIC

�� Patient FollowPatient Follow--up: up:

�� Interdisciplinary TeamInterdisciplinary Team

�� Surveillance: Surveillance:

�� Demographics, Tracking, MetricsDemographics, Tracking, Metrics

Military DemographicsMilitary Demographics

�� Navy Medicine WestNavy Medicine West

638

739

298

188

106 110

0

100

200

300

400

500

600

700

800

FY10 FY11 (3Q)

NHCP

NMCSD

NHTP

TBI Patients IdentifiedTBI Patients Identifiedn=2079n=2079

TBI DemographicsTBI Demographicsn=492n=492

TBI in the CommunityTBI in the Community

�� MVAMVA

�� FallsFalls

�� ViolenceViolence

�� SportsSports

�� Amateur AthleteAmateur Athlete

�� Baby BoomersBaby Boomers

�� GenGen--XersXers

�� MillennialsMillennials

AlcoholAlcohol

ScreeningScreening

�� Neurosurgery/Neurology/PM&RNeurosurgery/Neurology/PM&R

�� SLPSLP

�� OTOT

�� VTVT

�� OptometryOptometry

�� DentalDental

�� Mental HealthMental Health

�� ENT/AudiologyENT/Audiology

�� Neuropsych (>3Neuropsych (>3--4 months)4 months)

Common SymptomsCommon Symptoms

�� Post Concussive Syndrome (Post Concussive Syndrome (1111--64%):64%):

�� HeadacheHeadache

�� Dizziness, Dizziness,

�� InsomniaInsomnia

�� AnergiaAnergia

�� Irritability, Irritability,

�� Anxiety Anxiety

�� Dysphoria Dysphoria

�� ApathyApathy

ManagementManagement

�� Also commonly seen in:Also commonly seen in:�� chronic painchronic pain

�� anxiety/depressionanxiety/depression

�� Service Member without body or brain injury Service Member without body or brain injury �� headaches 8%headaches 8%

�� sleep disturbance 24%, sleep disturbance 24%,

�� fatigue 25%, fatigue 25%,

�� memory difficulty 7% memory difficulty 7%

�� irritability 24%irritability 24%

Symptoms of PTSD & TBISymptoms of PTSD & TBI

CognitiveCognitive DeficitsDeficits

DepressionDepression

Flashbacks

Re-experiencing

phenomenon AnxietyAnxiety

PTSD

Headache

Nausea

vomiting

Dizziness

TBI

Avoidance

Hypervigilance

Nightmares

FatigueFatigue

IrritabilityIrritability

InsomniaInsomnia

Vision Problems

Sensitivity to light or

noise

TreatmentTreatment

�� NO MAGIC CURE FOR NO MAGIC CURE FOR

CONCUSSIONCONCUSSION……except time except time

�� Manage the symptomsManage the symptoms

�� Develop compensatory strategiesDevelop compensatory strategies

TreatmentTreatment

�� TBI education (TEAM)TBI education (TEAM)

�� Empower patient and hold them accountable for recoveryEmpower patient and hold them accountable for recovery

�� Support improvements in functionSupport improvements in function

�� Rehabilitation planRehabilitation plan

�� Return to work/school plan.Return to work/school plan.

�� Resist conveying that all difficulties are psychiatrically Resist conveying that all difficulties are psychiatrically

drivendriven

�� Offer reasonable explanation for cognitive complaintsOffer reasonable explanation for cognitive complaints

�� Be weary of secondary gain (36% MEB nonBe weary of secondary gain (36% MEB non--credible credible

cognitive findings)cognitive findings)

ConclusionConclusion

�� MUST HAVE COORDINATED EFFORTS:MUST HAVE COORDINATED EFFORTS:

�� Improve symptomsImprove symptoms

�� Maximize functionMaximize function

�� Return to workReturn to work

�� Improve quality of lifeImprove quality of life

�� MultiMulti--disciplinary effortsdisciplinary efforts

ReferencesReferences�� http://www.cdc.gov/traumaticbraininjury/statistics.htmlhttp://www.cdc.gov/traumaticbraininjury/statistics.html

�� Faul M, Xu L, Wald MM, Coronado VG. Traumatic brain injury in thFaul M, Xu L, Wald MM, Coronado VG. Traumatic brain injury in the United States: emergency department visits, hospitalizations, e United States: emergency department visits, hospitalizations, and and deaths. Atlanta (GA): Centers for Disease Control and Preventiondeaths. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2010., National Center for Injury Prevention and Control; 2010.

�� Centers for Disease Control and Prevention (CDC), National CenteCenters for Disease Control and Prevention (CDC), National Center for Injury Prevention and Control. Report to Congress on mild r for Injury Prevention and Control. Report to Congress on mild traumatic brain injury in the United States: steps to prevent a traumatic brain injury in the United States: steps to prevent a serious public health problem. Atlanta (GA): Centers for Diseaseserious public health problem. Atlanta (GA): Centers for Disease Control Control and Prevention; 2003.and Prevention; 2003.

�� AMERICAN COLLEGE OF SPORTS MEDICINE. Concussion (mild traumaticbAMERICAN COLLEGE OF SPORTS MEDICINE. Concussion (mild traumaticbrain injury) and the team physician: a consensus statement. rain injury) and the team physician: a consensus statement. Med. Sci. SportsExerc. 43:2412Med. Sci. SportsExerc. 43:2412--2422, 2011.2422, 2011.

�� AMERICAN COLLEGE OF SPORTS MEDICINE. Sideline preparedness for tAMERICAN COLLEGE OF SPORTS MEDICINE. Sideline preparedness for the team physician: a consensus statement. Med. Sci. Sports he team physician: a consensus statement. Med. Sci. Sports Exerc. 33:846Exerc. 33:846––849, 2001.849, 2001.

�� AMERICAN COLLEGE OF SPORTS MEDICINE. The team physician and retuAMERICAN COLLEGE OF SPORTS MEDICINE. The team physician and returnrn--toto--play issues: a consensus statement. Med. Sci. Sports play issues: a consensus statement. Med. Sci. Sports Exerc. 34:1212Exerc. 34:1212––1214, 2002.1214, 2002.

�� Laker, Scott R. Epidemiology of Concussion and Mild Traumatic BLaker, Scott R. Epidemiology of Concussion and Mild Traumatic Brain Injury. PM&R Journal. 3:S354rain Injury. PM&R Journal. 3:S354--358, 2011.358, 2011.

�� Rigg, J.L., Mooney, S.R. Concussions and the Military: Issues SRigg, J.L., Mooney, S.R. Concussions and the Military: Issues Specific to Sevice Members. PM&R Journal. 3:S380pecific to Sevice Members. PM&R Journal. 3:S380--386, 2011.386, 2011.

�� Chang, V.H., Lombard, L.A., Greher, M.R. Mild Traumatic Brain IChang, V.H., Lombard, L.A., Greher, M.R. Mild Traumatic Brain Injury in the Occupational Setting. PM&R Journal. 3:S387njury in the Occupational Setting. PM&R Journal. 3:S387--395, 2011.395, 2011.

�� Signoretti, S., Lazzarino, G., Tavazzi, B., Vagnozzi, R. The PaSignoretti, S., Lazzarino, G., Tavazzi, B., Vagnozzi, R. The Pathophysiology of Concussion. PM&R Journal. 3:S359thophysiology of Concussion. PM&R Journal. 3:S359--368, 2011.368, 2011.

�� Department of Defense [DOD] Task Force on Mental Health, 2007, pDepartment of Defense [DOD] Task Force on Mental Health, 2007, p. ES. ES--II

�� Crow W., Willis D. Crow W., Willis D. ““Estimating Cost of Care for Patients with Acute Low Back Pain: AEstimating Cost of Care for Patients with Acute Low Back Pain: A Retrospective Review of Patient Records.Retrospective Review of Patient Records.”” J Am J Am Osteopath Assoc. 2009:109:229Osteopath Assoc. 2009:109:229--233. 233.

�� Braddom (2006). Physical Medicine and Rehabilitation. WB SaunderBraddom (2006). Physical Medicine and Rehabilitation. WB Saunders .s .�� Cicerone e al. EvidenceCicerone e al. Evidence--Based Cognitive Rehabilitation: Updated Review of the LiteratureBased Cognitive Rehabilitation: Updated Review of the Literature From 1998 Through 2002. Arch Phys Med From 1998 Through 2002. Arch Phys Med

Rehabil Vol 86, August 2005Rehabil Vol 86, August 2005�� Crooks et al. Physical Medicine and Rehabilitation clinics of NoCrooks et al. Physical Medicine and Rehabilitation clinics of North America. Traumatic Brain Injury: A review of practice managerth America. Traumatic Brain Injury: A review of practice management and ment and

recent advances. 18(2007) 681recent advances. 18(2007) 681--710.710.�� Cuccurullo (2004). Physical Medicine and Rehabilitation Board ReCuccurullo (2004). Physical Medicine and Rehabilitation Board Review. Demos Publishing.view. Demos Publishing.�� Boake C, Diller L (2005).Boake C, Diller L (2005). "History of rehabilitation for traumatic brain injury""History of rehabilitation for traumatic brain injury". In High WM, Sander AM, Struchen MA, Hart . In High WM, Sander AM, Struchen MA, Hart

KA.KA. Rehabilitation for Traumatic Brain InjuryRehabilitation for Traumatic Brain Injury. Oxford [Oxfordshire]: Oxford University Press. Oxford [Oxfordshire]: Oxford University Press�� www.Dvbic.orgwww.Dvbic.org

Cognitive Symptoms reported following Cognitive Symptoms reported following

concussion/mTBIconcussion/mTBI

�� Impaired memory Impaired memory

�� Trouble concentratingTrouble concentrating

�� Difficulty finding wordsDifficulty finding words

�� Slowed overall processingSlowed overall processing

�� Impaired organizational and Impaired organizational and problem solving skillsproblem solving skills

Neuropsychological EvaluationNeuropsychological Evaluation

Context of referralContext of referral

�� SelfSelf--referredreferred

�� Provider referredProvider referred

�� Medical BoardMedical Board

PrePre--morbid Functioningmorbid Functioning

�� RankRank

�� ASVAB scoresASVAB scores

�� EducationEducation

Credible vs. NonCredible vs. Non--credible Clinical credible Clinical

PresentationPresentation

�� Undocumented or questionable mild Undocumented or questionable mild

head injuryhead injury

�� Marked discrepancy between the Marked discrepancy between the

individualindividual’’s claimed injury and the s claimed injury and the

objective test findingsobjective test findings

�� Implausible test results when compared Implausible test results when compared

to the medical historyto the medical history



�� Excessive inconsistencies in test dataExcessive inconsistencies in test data

�� Poor performance on obvious, but not less Poor performance on obvious, but not less

obvious tasks of same functionobvious tasks of same function

�� Symptom validity testsSymptom validity tests

�� Valid vs. invalid test performancesValid vs. invalid test performances

�� Will see terms: Will see terms: ““inconsistent,inconsistent,”” ““invalid,invalid,””

““results cannot be interpretedresults cannot be interpreted””

�� Effort vs. malingering Effort vs. malingering



�� Evaluate symptom complaints within the Evaluate symptom complaints within the

context of historical data, behavioral context of historical data, behavioral

observations, and current observations, and current ““real worldreal world””

functioningfunctioning

�� Be wary of a delayed onset of symptomsBe wary of a delayed onset of symptoms

�� Assess for secondary gainAssess for secondary gain

�� LitigationLitigation

�� Medical boardMedical board

Neuropsychological Test Neuropsychological Test

Performance in Soldiers w/ BlastPerformance in Soldiers w/ Blast--

Related Mild TBI (Related Mild TBI (Brenner, et al., 2010)Brenner, et al., 2010)

�� Exploratory study to examine whether persistent mTBIExploratory study to examine whether persistent mTBI--related symptoms or PTSD negatively impacted test related symptoms or PTSD negatively impacted test performanceperformance

�� Compared 27 SMCompared 27 SM’’s w/enduring mTBI symptoms to 18 SMs w/enduring mTBI symptoms to 18 SM’’s s w/o symptomsw/o symptoms

�� Results:Results:�� Presence of mTBI symptoms did not impact test Presence of mTBI symptoms did not impact test performanceperformance

�� No significant differences between soldiers with and w/o No significant differences between soldiers with and w/o PTSD were identifiedPTSD were identified

““Symptom validity test performance in U.S. veterans Symptom validity test performance in U.S. veterans

referred for evaluation of mild TBIreferred for evaluation of mild TBI””

ArmisteadArmistead--Jehle (2010)Jehle (2010)

Medical Symptom Validity Test (MSVT)Medical Symptom Validity Test (MSVT)

58% scored below the cut scores on subtests 58% scored below the cut scores on subtests

more sensitive to more sensitive to efforteffort than neurological insultthan neurological insult

Those with service connection failed at a higher Those with service connection failed at a higher

raterate

Maybe it is not secondary gain?Maybe it is not secondary gain?

�� ““Good Old DaysGood Old Days”” Bias Following Mild Bias Following Mild

Traumatic Brain InjuryTraumatic Brain Injury

�� Iverson, et al., (2010)Iverson, et al., (2010)

�� The Clinical NeuropsychologistThe Clinical Neuropsychologist

Research suggests that people who sustain an Research suggests that people who sustain an

injury often underestimate past problems (injury often underestimate past problems (““good good

old daysold days””))

““Good Old DaysGood Old Days”” Bias Following Mild Bias Following Mild

Traumatic Brain InjuryTraumatic Brain Injury”” Iverson, et al.(2010)Iverson, et al.(2010)

�� Sample: 90 temporarily fully disabled Sample: 90 temporarily fully disabled

individuals from a mTBI receiving Workerindividuals from a mTBI receiving Worker’’s s

CompensationCompensation

�� Patients provided postPatients provided post--injury & preinjury & pre--injury injury

retrospective ratings on the British retrospective ratings on the British

Columbia PostColumbia Post--concussion Symptom concussion Symptom

Inventory Inventory

�� Compared ratings with 177 healthy controls Compared ratings with 177 healthy controls

““Good Old DaysGood Old Days”” Bias Following Mild Traumatic Bias Following Mild Traumatic

Brain InjuryBrain Injury”” Iverson, et al.(2010)Iverson, et al.(2010)

�� mTBI patients endorsed fewer premTBI patients endorsed fewer pre--injury injury

symptoms compared to the controlssymptoms compared to the controls

�� Those who failed effort testing, reported Those who failed effort testing, reported

fewer symptoms prefewer symptoms pre--injury compared to injury compared to

those who passed effort testingthose who passed effort testing

�� Many mTBI patients reported their preMany mTBI patients reported their pre--injury injury

functioning as better than the average functioning as better than the average

person person

Important FactsImportant Facts

�� Look for documentationLook for documentation

�� Be wary of delayed symptoms or worsening of Be wary of delayed symptoms or worsening of

symptomssymptoms

�� Are the symptoms in line with the medical history?Are the symptoms in line with the medical history?

�� Cognitive/psychiatric evaluations should contain Cognitive/psychiatric evaluations should contain

formal SVTformal SVT’’s and embedded measuress and embedded measures

�� Avoid a Avoid a ““kneeknee--jerkjerk”” assumption of secondary gainassumption of secondary gain

�� Consider the unknowns of blastConsider the unknowns of blast--related TBIrelated TBI

�� Never base conclusions on one test scoreNever base conclusions on one test score

�� Assess Assess ““real worldreal world”” functioningfunctioning

Event Symptoms

SymptomsSymptoms

Symptoms

TBI PTSD

Chronic

Pain

Medication

Substance

Alcohol

Abuse

CoCo--morbid Complicationsmorbid Complications

Veterans in State & Federal Prison 2004Veterans in State & Federal Prison 2004U.S. Department of Justice (May 2007)U.S. Department of Justice (May 2007)

�� In 2004: male veterans had lower In 2004: male veterans had lower incarceration rates than nonveterans; incarceration rates than nonveterans; due in part to age differencesdue in part to age differences

�� 65% of male veterans in 2004 were at 65% of male veterans in 2004 were at least 55 years oldleast 55 years old

�� More than half of veterans in state More than half of veterans in state prisons were serving for a violent prisons were serving for a violent offenseoffense

�� More likely to have had recent mental More likely to have had recent mental health problemshealth problems

Violence as a Consequence of TBIViolence as a Consequence of TBI

�� Not all brainNot all brain--injured individuals are violent injured individuals are violent

or aggressiveor aggressive

�� Age of injury plays a roleAge of injury plays a role

�� History of aggression History of aggression

�� Use of alcohol or drugs increases Use of alcohol or drugs increases

likelihood of aggressive actslikelihood of aggressive acts

�� Presence of a mental disorder increase Presence of a mental disorder increase

likelihood of aggressionlikelihood of aggression

Behavioral Aspects of TBIBehavioral Aspects of TBI

Source: American Health Assistance Foundation. Anatomy of the Brain Webpage. http://www.ahaf.org/alzheimers/about/understanding/anatomy-of-the-brain.html

The AmygdalaThe Amygdala

�� Linked to the frontal lobeLinked to the frontal lobe

�� Primary role is in the acquisition Primary role is in the acquisition and and the the

physiological expression of conditioned fearsphysiological expression of conditioned fears

�� It processes and stores memories of It processes and stores memories of

emotional eventsemotional events

�� Stores feelings and physiologic responses Stores feelings and physiologic responses

associated with the event (fear with increased HR)associated with the event (fear with increased HR)

�� The stored memory can later be triggeredThe stored memory can later be triggeredPhelps, 2004Phelps, 2004

The AmygdalaThe Amygdala

�� Flight and fear responses (Flight and fear responses (““freezingfreezing””))

�� Has a distinct difference from a Has a distinct difference from a consciousconsciousfeeling of fearfeeling of fear

�� Defensive or aggressive reactionsDefensive or aggressive reactions

�� Has a sensory input system Has a sensory input system

Aggression and ViolenceAggression and Violence

Interaction: PTSD & TBIInteraction: PTSD & TBI

Increased Violence PotentialIncreased Violence Potential

ReferencesReferences

�� ArmisteadArmistead--Jehle, P. (2010). Symptom validity test performance in U.S. vetJehle, P. (2010). Symptom validity test performance in U.S. veterans erans

referred for evaluation of mild TBI. referred for evaluation of mild TBI. Applied Neuropsychology,Applied Neuropsychology,17: 5217: 52--59.59.

�� Brenner, L.A., Homaifar, B. Y., Gutierrez, P.M., Harwood, J. E. Brenner, L.A., Homaifar, B. Y., Gutierrez, P.M., Harwood, J. E. F., Adler, L.E, Terrio, F., Adler, L.E, Terrio,

H., Staves, P.J., Reeves, D., Ivins, B.J., Helmick, K., & WardenH., Staves, P.J., Reeves, D., Ivins, B.J., Helmick, K., & Warden, D. (2010). , D. (2010).

Neuropsychological test performance in soldiers with blastNeuropsychological test performance in soldiers with blast--related mild TBI. related mild TBI.

Neuropsychology,Neuropsychology, Vol. 24 No. 2, 160Vol. 24 No. 2, 160--167.167.

�� Iverson, G. L., Lange, R. T., Brooks, B.L., & Rennison, L. A. (2Iverson, G. L., Lange, R. T., Brooks, B.L., & Rennison, L. A. (2010). 010). ““Good old daysGood old days””

bias following mild traumatic brain injury. bias following mild traumatic brain injury. The Clinical Neuropsychologist,The Clinical Neuropsychologist, 24: 1724: 17--37.37.

�� Phelps, E.A., (2004). Human emotion and memory: interactions of Phelps, E.A., (2004). Human emotion and memory: interactions of the amygdala and the amygdala and

hippocampal complex. hippocampal complex. Current Opinion in Neurobiology, 14:198Current Opinion in Neurobiology, 14:198--202.202.

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