Chrisanne Gordon, MDResurrecting Lives Foundation

December 3, 2013

TBI, PTS, Pain

National Council on Disability: March 2009

Established the HALLMARK pathologies of

OIF/OEF:• Operation Iraqi Freedom- OIF• Operation Enduring Freedom-OEF• TBI = Traumatic Brain Injury• PTS = Post Traumatic Stress

OIF/OEF - TBI, PTS, Pain

1. TBI + PTS = PDS-Post Deployment Syndrome

2. PAIN- HA, LBP, Shoulder, Knee

3. Amputations – multiple due to armor

4. Drugs:TBI –amphetamine, caffeine, cocaine

5. Drugs: PTS- SSRI, ETOH, marijuana,

6. Drugs: Pain-Oxycontin

Statistics of War

Physicians who Dx and Rx TBIOnly 10% of all physicians treat TBI

PM&R = Specialty trained – 12,000 in the USSports Medicine physicians-

NCAA/ProfessionalER Physicians – “treat and street”These specialties are sparse in the DOD/VA

and the community

20% - 25% TBI in War Theatre

BLAST INJURY – IED; RPG; Mortar

VEHICULAR ACCIDENTS –MRAP

FALLS- Terrain

Direct HITS, eg. during night drills

Assaults

Anoxic Injury – Drowning, Vascular Compromise, Choking

Is TBI a new injury in War?

This is not a new war injury, but this is first wartime that technology is available to detect the injury.

Previous wars included Shell Shock, Tremors, Parkinsonism

IF there are tremors, think TBI – Parkinson’s

NEJM landmark articles

HOGE- 2004 – TBI is signature wound HOGE- 2008 – PTSD is signature wound

But throughout history of war, soldiers have sustained brain injuries – most died in previous wars.

Helmets improve and technology changes – mild TBI vs. Death in previous wars

Cost of Treating TBI

Estimated costs of PTSD Rx. 1 year $3000 if no depression

$9000 if depression

Estimated costs for TBI Rx. 1 year $30,000 – requires TEAM approach

Moderate TBI - $260,000/case

Severe TBI - $400,000- $ 1.5 million/case

RAND July 2008

Discussion of BRAIN SYNDROME

TBI- result of blow, jolt, or penetrating wound to the head that results in disruption of brain function.

Concussion – injury due to shaking, spinning, or blow. More focal – Sports Injury

BLAST is hallmark – insult from external mechanical force.- No LOC required- Diffuse Axonal Injury -DAI

Effects are additive – CTE-Chronic Traumatic Encephalopathy

HALLMARKS of TBI – midbrain/frontal injuries

1. Sensory processing alterations

a) Photophobia- CN IV

b) Hyperacusis – CN VIII

c) Sensory overload – ie.Big Box Syndrome

2. Loss of Mapping skills.

3. Pituitary Dysfunction.

4. Chronic Headaches.

5. Memory Problems

Midbrain

Midbrain Over Drive

Co-morbidities of TBI

Substance Abuse – 90% ETOH abuse in 1 year; Marijuana second drug chosen. Self- Medication – SLOW IT DOWN!

Amphetamine – Speed it UP! (10-15%)

Incarceration – Loss of Executive Function – 60% felons in California.

SUICIDE – 7.7 X – STOP IT!- GSW, Drugs/Etoh, MVA; Death by Law Enforecement

NFL and TBI

Chronic Traumatic Encephalopathy

CTE- after Playing Field…Known

CTE- after Battle Field? 1st Case April 2012

Dr. Ann McKee – Boston University

TBI stats in civilian world:

1.7 million estimated on ER visits75% are considered mTBI – mild TBIMale: Female 2:1Direct and indirect costs - $100 billion/year in

civilian worldChildren (0-4) ; Adolescents (15-19) older

pop. (65+) High School legislation leading the nation for

TBI prevention – preventing second impact syndrome.

Diagnosis of TBI

Listen to the Patient: He is telling you the diagnosis.

Sir William Osler

TBI Diagnosed by HISTORY.

What do you say/hear with TBI?

1. “I used to know this stuff.”

2. “Why can’t I think?”

3. “What? When did you tell me,”

4. “No, I didn’t.”

5. “I don’t remember.”

6. “Keep it down!”

7. “Why don’t you/I understand?”

8. “GET OFF MY BACK!”

Pay attention to HOW it is said

1. Hypervigilant affect/Impatient

2. Hollow eyes/ Lights out/Flat affect

3. Slowness of speech

4. Word finding problems

5. Heightened irritability/emotion- sporadic

6. “Choice Language”

7. Distractable

Neuroimaging StudiesRadiologic Studies: Timing/Technique

1. CT/MRI – Notoriously Negative – VA standard

2. Diffusion Tensor Imaging – Gold Standard Lipton et al. Radiology Aug. 2009 (DAI)

3. PET- SPECT - Hovda UCLA -2007

4. fMRI –brain mapping

Most veterans tested 1-4 yrs. after last TBI by #1.

NEGATIVE MRI/CT is the norm in mild TBI

Laboratory Workup

Blood work – pituitary profile- GH; TSH; LH; ACTH;Testosterone CRP, Tox screen.

Do NOT miss Dx. of hypopituitarism which mimics depression.

Neuropsychological Testing May find equivocal results

Most with mild TBI won’t show memory deficits without a baseline

Lack of baseline pre-deployment

Helpful in more significant injuries

ImPACT, COGSTAT, ANAM, Headminder may be useful (Logan, 2009)

Increased Arousal (Sympathetic Nervous Activation)

Difficulty falling or staying asleep Irritability or outbursts of anger Difficulty concentrating Hypervigilance Exaggerated Startle Response

PTS? or TBI? Answer: BOTHSURVIVAL depends on Hypervigilance

Suicide 2nd leading cause of death in military – 154 in 155

Days.

Young, White, Unmarried Male Junior Enlisted Active Duty

Drugs/alcohol / Firearms

No psychiatric history (Washington Post, 2008, per CDP)

1.2% Army Post-Deployment survey had suicidal ideation (Miliken et al., 2007 per CDP)

Of completed suicides, most saw a healthcare provider within one month before suicide (USUHS, 2009)

19% of patients with PTSD will attempt suicide (CDP, 2009) and patients with TBI are at 7.7 X greater risk

HYPERVIGILANCE of PhysicianImportant to the Survival of the returning heroListen to the patient/Listen to the familyNote the signs of TBI – word searching, rhythm

of speech, depression, irritability, photophobiaAsk hero to explain what is happening so that

you may help his/her fellow soldiersThank them for their service and acknowledge

that they have already survived –Point out the VALUE they are to their comrades

Why People Die By Suicide 2005 Dr. Thomas Joiner

Capability Desirability Feeling of burdensomeness.

Remember the word SERVICE in Service personnel

“PDS” Syndrome

Symptoms more consistent with PTS

Flashbacks

Nightmares

Intrusive thoughts

Avoidance behaviors

Exaggerated startle response

PTS = Brain Injury – U of Rochester Report -June 2, 2012 – Dr. BazarianResults showed that 30 of the 52 New York

veterans suffered at least one mild traumatic brain injury,

The severity of veterans’ PTS symptoms correlated with the amount of axonal injury seen on the DTI scans.

“Based on our results, it looks like the only way to detect this injury is with DTI/MRI,”

BRAIN injury, not Mind Problem – reduced Stigma

Post Concussive Syndrome

PCS = constellation of symptoms with mild TBI that persist for three months or more following a “concussion”.

Primary symptoms are headache, photophobia, irritability, sleep disturbance, cognitive deficits.

This is a subset of TBI- Sympathetic Overdrive

MYTHS about PCS

Symptoms are exaggerated due to pre-existing medical/psychological conditions.

Litigation is often involved so symptoms are for secondary gain.

May be iatrogenic – physicians concern may lead to increased symptoms and disability.

TRUTHS about PCS

Different injury from the onset. PCS develops the MOMENT of the injury.

Research revealing HYPER state of brain at time of injury is crucial.

SPECT scan proof of decreased glucose utilization in the brain

REST / Decreased stimulation is key.

Treatment for PCS

MILD doses of antidepressants or stimulants – INDIVIDUALIZE RX.

Frequent visits with minor changes in medications is most important.

Have patient keep a journal.

Decrease stimulation in environment.

Mild exercise is key.

Alternative therapies- Reiki, Yoga, ARTS

TREATMENT options for TBI:

Amantadine, Methylpheniate, Dextroamphetamine - for processing

Propranolol, amitriptyline – for aggression/depression- (SSRI’s can be detrimental)

Electronic aides – Bushnell, GPS, PDA, iPHONE Setting modifications or organization Routine/schedule Memory strategies (chunking, acronyms, music) Pain management as needed- NO OXYCONTIN Exercise

Adjunctive Treatment Service Education (GI-Bill) Psychoeducation and support groups for self and

family Exercise and pleasurable activity scheduling De-toxification from caffeine, stimulants, and alcohol Solutions (action-oriented, specific goals) Family or marital treatments Advocate regarding employment or military

problems Stress management Adequate, restful sleep Nutrition Relaxation/Rest

TBI Team Primary care physician/specialist Nurse/nurse practitioner Psychiatrist Psychologist/Neuropsychologist Counselor Social Worker Physiatrist Speech-Language Pathologist Occupational Therapist Physical Therapist

Resurrectinglives.org

Mission Statement:THE MISSION.Our mission is narrow and deep. We will

assist the recovery/reintegration of our OIF/OEF Veterans with Traumatic Brain Injury (TBI) by defining the brain pathology and by developing the protocols for recovery. We will advocate for our returning heroes and their families while educating the public about the injuries and co-morbidities associated with a traumatic brain injury.

HOPE of Brain; Peace of Mind Cognitive Retraining is KEY Telemedicine Opportunities Self-taught computer programs Journaling Avoid Psychotropic Medications Exercise mind/body/soul Group education courses online – GOOGLE

PLUS

Think Different – 99% solution