Department Makes ‘Great Strides’ in Brain-injury Care

By Elaine Wilson

American Forces Press Service

WASHINGTON, March 11, 2011 – 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.