DOD VIDEO: TRAUMATIC BRAIN INJURY

FROM:  U.S. DEFENSE DEPARTMENT

FDA SAYS DIETARY SUPPLEMENTS WON'T TREAT CONCUSSIONS

FROM:  FOOD AND DRUG ADMINISTRATION 

Can a Dietary Supplement Treat a Concussion? No.

Exploiting the public's rising concern about concussions, some companies are offering untested, unproven and possibly dangerous products that claim to prevent, treat or cure concussions and other traumatic brain injuries (TBIs).
The Food and Drug Administration (FDA) is monitoring the marketplace and taking enforcement actions where appropriate, issuing warning letters to firms—the usual first step for dealing with claims that products labeled as dietary supplements are intended for use in the cure, mitigation, treatment, or prevention of disease. The agency is also warning consumers to avoid purported dietary supplements marketed with claims to prevent, treat, or cure concussions and other TBIs because the claims are not backed with scientific evidence that the products are safe or effective for such purposes. These products are sold on the Internet and at various retail outlets, and marketed to consumers using social media, including Facebook and Twitter.

One common claim: Using a particular dietary supplement promotes faster healing times after a concussion or other TBI.

Even if a particular supplement contains no harmful ingredients, that claim alone can be dangerous, says Gary Coody, FDA's National Health Fraud Coordinator.

"We're very concerned that false assurances of faster recovery will convince athletes of all ages, coaches and even parents that someone suffering from a concussion is ready to resume activities before they are really ready," says Coody. "Also, watch for claims that these products can prevent or lessen the severity of concussions or TBIs."

A concussion is a brain injury caused by a blow to the head, or by a violent shaking of the head and upper body. Concussions and other TBIs are serious medical conditions that require proper diagnosis, treatment, and monitoring by a health care professional. The long-term impact of concussions on professional athletes and children who play contact sports has recently been the subject of highly publicized discussions.

A growing body of scientific evidence indicates that if concussion victims resume strenuous activities—such as football, soccer or hockey—too soon, they risk a greater chance of having a subsequent concussion. Moreover, repeat concussions can have a cumulative effect on the brain, with devastating consequences that can include brain swelling, permanent brain damage, long-term disability and death.

"As amazing as the marketing claims here are, the science doesn't support the use of any dietary supplements for the prevention of concussions or the reduction of post-concussion symptoms that would enable one to return to playing a sport faster," says Daniel Fabricant, Ph.D., director of FDA's Division of Dietary Supplement Programs.

back to top

The Claims
One of the first alarms raised about dietary supplements being promoted to treat TBI came from the U.S. Department of Defense.
"We first learned from the military about a product being marketed to treat TBI, obviously a concern with wounded veterans. We were taken aback that anyone would make a claim that a supplement could treat TBI, a hot-button issue," says Jason Humbert, a senior regulatory manager with FDA's Office of Regulatory Affairs. "That sparked our surveillance."

FDA routinely monitors the marketplace. However, with more than 85,000 dietary supplements on the market and no product registration, products making false claims can slip through, at least for a time.

Typically, products promising relief from TBIs tout the benefits of ingredients such as turmeric and high levels of omega-3 fatty acids derived from fish oil. Turmeric is an Indian spice in the ginger family. For Omega-3, FDA has recommended a maximum daily level of 3 grams per day from all sources due to possible problems with increased risk of bleeding, increases in cholesterol and problems with controlling blood sugar levels.

In its initial surveillance, FDA identified two companies selling multiple products claiming to prevent and treat concussions and other TBIs. One company claimed to have "the world's first supplement formulated specifically to assist concussion recovery," saying "it has the dynamic ability to minimize long-term effects and decrease recovery time." A National Football League player testified to its "proven results in my own recovery" from a concussion, and an unnamed "licensed trainer" said he had incorporated it into his "concussion management protocol."

Similar claims were made by the other company, which was selling four products claiming to protect against and help heal TBIs. FDA sent letters in 2012 warning both companies that their products were not generally recognized as safe and effective for treating TBIs, that the products were misbranded (a legal term meaning, in this case, that the labeling of the products did not have adequate directions for use), and that unless various violations cited in the letters were promptly corrected, the violations could result in legal action taken without further notice, such as seizure or injunction.

Both companies changed their websites and labeling.

In December 2013, FDA issued a warning letter to Star Scientific, Inc., for marketing its product Anatabloc with claims to treat TBIs. FDA continues to monitor the marketplace for products with similar fraudulent claims, and will take appropriate regulatory action to protect the public health.

"As we continue to work on this problem, we can't guarantee you won't see a claim about TBIs. But we can promise you this: There is no dietary supplement that has been shown to prevent or treat them," says Coody. "If someone tells you otherwise, walk away."

This article appears on FDA's Consumer Updates page, which features the latest on all FDA-regulated products.

Dec. 31, 2013

FIRST INTREPID SPIRIT CENTER OPENS FOR TREATMENT OF TBI AND PTS

FROM:  U.S. DEFENSE DEPARTMENT
First of 9 'Intrepid Spirit' Centers Opens at Fort Belvoir
By J.D. Leipold
Army News Service

FORT BELVOIR, Va., Sept. 12, 2013 - Since the 9/11 terrorist attacks 12 years ago, more than 2.5 million U.S. troops have deployed to Iraq and Afghanistan, and over that same period, more than 260,000 service members have been diagnosed with the invisible wounds of traumatic brain injury and post-traumatic stress as a result of combat-related injuries and accidents
To treat and care for those service members suffering from the most severe forms of traumatic brain injury, known as TBI, and post-traumatic stress, or PTS, the first of nine Intrepid Spirit Centers planned nationwide officially opened its doors here yesterday in a dedication ceremony sponsored by the Intrepid Fallen Heroes Fund, a $100-million campaign funded entirely with donations from public and private sources.
The center has actually been operating for two months and has treated some 80 patients thus far, said Martin Edelman, a trustee with the fund, who acted as master of ceremonies.

Edelman added that the ribbon-cutting ceremony also signified the transfer of the $11 million, 25,000-square-foot center to the Defense Department. A second satellite center will open at Camp Lejeune, N.C., in October, and a third at Fort Campbell, Ky., in mid-2014, he said.

David Winters, president of the nonprofit fund, said there are plans to build and equip satellite centers at Fort Bragg, N.C.; Fort Hood, Texas; Fort Carson, Colo.; and Fort Bliss, Texas; as well as at Marine Corps Base Camp Pendleton, Calif., and Joint Base Lewis-McChord, Wash. All will be built and equipped from donations, Winters said.

All Intrepid Spirit centers will be located at military bases and medical centers around the country to provide medical care for service members meaning they will not have to leave their units and families for extended treatment. The centers are designed to enhance rehabilitation, officials said.

The design and mission of the satellite centers was based on the original National Intrepid Center of Excellence, or NICoE, which opened at Walter Reed National Military Medical Center in Bethesda, Md., in 2010. It's the most advanced facility of its kind in the country and serves as the center of the military's efforts in researching, diagnosing and treating TBI, PTS and related injuries.

Speakers at yesterday's ceremony included Arnold Fisher, honorary chairman of the Intrepid Fallen Heroes Fund; Army Col. Charles Callahan, commander of Fort Belvoir Community Hospital; Dr. Heechin Chae, director of the Fort Belvoir Intrepid Spirit Center, and Intrepid Spirit patient Army Sgt. Maj. Robert Haemmerle, who told the story of his recovery from the extreme, invisible signature wounds he received in Iraq and Afghanistan.

Capping the event and speaking on behalf of senior leadership across all the services, Army Vice Chief of Staff Gen. John F. Campbell reminded the audience that there are still 50,000-plus soldiers, sailors, airmen, Marines, Coast Guardsmen and civilians who continue to be in harm's way in Afghanistan, and many will need the type of help the Intrepid Spirit Centers offer.

"In this short month of September, the Army has already faced close to 50 wounded and in the months of June and July, it was in the hundreds for wounded and that will continue and we seem to forget that," he said. "What makes this event here extra special is to have the opportunity to honor our warriors who have sacrificed so much on Patriot Day, a day of service and a day of remembrance 12 years [after the 9/11 attacks].

"We are succeeding in recruiting America's finest to serve in all of our military, and that is a direct result of our commitment to programs like this that care for injured soldiers and their families. If we lose that commitment, if we waiver in that commitment, we lose," Campbell said. "We thank all of you for enabling the loyal and experienced warriors and their families who want to continue to serve."

First Lady Michelle Obama later toured the Intrepid Spirit Center and nearby USO and visited with wounded warriors and their families.

'INVISIBLE WOUNDS' TREATMENT

FROM:  U.S. DEFENSE DEPARTMENT 
Director Discusses Innovations in 'Invisible Wounds' Treatment
By Terri Moon Cronk
American Forces Press Service

WASHINGTON, Sept. 13, 2013 - The Military Health System acknowledges that U.S. troops in previous conflicts haven't been subjected to the circumstances that surround 12 years of war in Iraq and Afghanistan, a senior Defense Department physician said here yesterday during a panel discussion at a warrior-family symposium.

Dr. James Kelly, director of the Defense Department's National Intrepid Center of Excellence, talked about his center's advancements in post-traumatic stress disorder and traumatic brain injury – signature wounds from the wars - in a panel discussion titled, "Innovative Mental Health Solutions – Today and Tomorrow."

The annual symposium is sponsored by the Military Officers Association of America and the National Defense Industrial Association.

Kelly cited problems that stem from the pattern of repeated deployments and training between deployments, combined with an all-volunteer force composed of members put themselves in harm's way time and time again. "It is not the pattern we've previously had in our military," he said.

The idea that the younger generation is somehow softer or in some ways more vulnerable doesn't hold water, Kelly said. "These people are tough as nails," he said to a round of applause from hundreds of audience members.

"What we need to do is innovate, look more in depth, and understand them as people and individuals that have been engaged in ways [for which] we simply have no good track record to point to and say, 'Here's what this is about, and here's what to do about it,'" he said.

Kelly said he and his staff learn as they go at the center, conducting research and treating service members in an intensive four-week program.

In a previous interview with American Forces Press Service, Kelly explained that when service members with severe traumatic brain injury do not respond to conventional medical treatment, they can be referred to the National Intrepid Center of Excellence, but they must also have a co-existing psychological health issue, such as post-traumatic stress disorder, depression or anxiety.

Kelly became NICoE's director five years ago. The center got underway when Defense Department officials invited him -- a former neurology consultant for the Chicago Bears football team -- to join a group of doctors to examine how to treat service members who were exposed to blast injuries and other head trauma.

He and the other doctors were "willing volunteers" drawn to military health care and working with service members coming back from both wars because of blast-related injuries and a variety of other causes of concussions, Kelly said.

The need for innovation in research and in treating service members led to a concept of using "virtual reality war," with service members are immersed in a setting with a vision of what happens when they're inside a Humvee going down a road. The seat begins to vibrate as a bomb goes off, and the smell of burning rubber wafts into the vehicle. The hope, Kelly explained, is that while the service members are in a safe clinic setting, the experience can help them get past the traumatic events they brought back from deployments.

This use of virtual reality shows quantifiable metabolic changes deep inside the brain when it's dealing with stress, Kelly said.

"That's just one of the examples of the kinds of things that we're engaged in that is really novel, innovative," he added. "[It] bridges into areas of the mind ... in ways that traditional medicine -- certainly traditional neurology -- hadn't previously."

MULTI-INSTITUTIONAL CONSORTIA ESTABLISHED TO RESEARCH PTSD AND TBI

FROM:  U.S. DEPARTMENT OF DEFENSE 

DoD, VA Establish Two Multi-Institutional Consortia to Research PTSD and TBI

           In response to President Obama's Executive Order, the Departments of Defense (DoD) and Veterans Affairs (VA) highlighted today the establishment of two joint research consortia, at a combined investment of $107 million to research the diagnosis and treatment of post-traumatic stress disorder (PTSD) and mild traumatic brain injury (mTBI) over a five-year period.

           "VA is proud to join with its partners in the federal government and the academic community to support the President's vision and invest in research that could lead to innovative, new treatments for TBI and PTSD," said Secretary of Veterans Affairs Eric K. Shinseki. "We must do all we can to deliver the high-quality care our Service members and Veterans have earned and deserve."

           The Consortium to Alleviate PTSD (CAP), a collaborative effort between the University of Texas Health Science Center – San Antonio, San Antonio Military Medical Center, and the Boston VA Medical Center will attempt to develop the most effective diagnostic, prognostic, novel treatment, and rehabilitative strategies to treat acute PTSD and prevent chronic PTSD.

           The Chronic Effects of Neurotrauma Consortium (CENC), a collaborative effort between Virginia Commonwealth University, the Uniformed Services University of the Health Sciences, and the Richmond VA Medical Center will examine the factors which influence the chronic effects of mTBI and common comorbidities in order to improve diagnostic and treatment options.  A key point will be to further the understanding of the relationship between mTBI and neurodegenerative disease.

           Since Sep. 11, 2001, more than 2.5 million American service members have been deployed to Iraq and Afghanistan. Military service exposes service members to a variety of stressors, including risk to life, exposure to death, injury, sustained threat of injury, and the day-to-day family stress inherent in all phases of the military life cycle.

           To improve prevention, diagnosis, and treatment of mental health conditions, the President released an Executive Order directing the Federal agencies to develop a coordinated National Research Action Plan. The Department of Defense (DoD), Department of Veterans Affairs (VA), the Department of Health and Human Services (HHS), and the Department of Education (ED) came forward with a wide-reaching plan to improve scientific understanding, effective treatment,  and reduce occurrences of Post-Traumatic Stress Disorder (PTSD), Traumatic Brain Injury (TBI), co-occurring conditions, and suicide.

U.S. ARMY'S TBI, PTSD AWARENESS EFFORT

 

Army Brig. Gen. (Dr.) John M. Cho, Army Medical Command deputy chief of staff for operations, addresses the issues of post-traumatic stress disorder and traumatic brain injury during an awareness event on Capitol Hill in Washington, D.C., June 22, 2013. U.S. Army photo by David Vergun

FROM: U.S. DEPARTMENT OF DEFENSE

Army Initiates Collaborative Effort on TBI, PTSD

By David Vergun
Army News Service
 WASHINGTON, June 24, 2013 - Over the last 12 years, many soldiers have returned from Iraq and Afghanistan with wounds, some visible and some not, a leader in Army Medicine said here June 22.


"The invisible wounds -- post-traumatic stress disorder and traumatic brain injury -- are just as damaging as the visible ones. They impact the families as well as the soldiers," said Brig. Gen. (Dr.) John M. Cho, deputy chief of staff for operations with Army Medical Command.

An Iraq War veteran himself, Cho spoke outside the U.S. Capitol as part of National Post-Traumatic Stress Disorder Day. This year's theme was "Visible Honor for Invisible Wounds."

Post-traumatic stress disorder, known as PTSD, and traumatic brain injury, or TBI, are not just military-specific issues, Cho said. "They deserve a national discussion."

A big part of that discussion, he said, needs to focus on reducing the stigma associated with mental health issues.

Besides a national discussion, Cho said, agencies both inside and outside the military need to come together to learn more about identifying and treating PTSD and TBI, as well as preventing it in the first place.

Cho said a PTSD diagnosis is particularly challenging, as "you can't simply get a lab test or take an X-ray to find it."

As part of its collaborative effort, the Army is participating in a $60 million research study for TBI, sponsored by the National Football League, General Electric and athletic apparel manufacturer Under Armour, he said.

Also, $700 million has been allocated toward both PTSD and TBI as the result of a White House executive order for a renewed effort in collaboration with the Veterans Affairs Department and other organizations.

Additionally, the Army has set up seven "restorative centers" in Afghanistan, where TBI can be identified and treated, often allowing soldiers to stay in theater as they improve, he said.

The general explained that PTSD often, but not always, occurs with TBI, and that relationship, too, is being researched. "We're nowhere near where we want to be, however, when it comes to researching PTSD and TBI," he acknowledged. "A lot more needs to be done."

Cho said PTSD affected him personally when his brother, who also is a U.S. Military Academy graduate, returned from Afghanistan suffering from PTSD. He sought treatment and is better now, he said, adding that his brother is telling his story to other soldiers in an effort to get them to seek care.

"We know treatment helps," Cho said. "We can help them get better, and they can continue to serve in our Army with honor and distinction."

As a result of his brother's experience, Cho said, he's a big believer in group therapy, particularly cognitive processing psychotherapy.

Army Chief of Staff Gen. Ray Odierno, unable to attend the day's event, wrote in a letter for the attendees: "PTSD is a combat injury. Veterans suffering from PTSD deserve the same dignity and respect as our fellow wounded warriors.

"With the continued support and encouragement of organizations like Honor for ALL, the Army and this nation have made enormous strides in treating this injury, removing the stigma and instilling dignity in our recovering veterans," Odierno's letter continued. "But more work must be done!"

Honor for ALL, a nonprofit organization sponsoring the event, is dedicated to eliminating the stigma of PTSD and supports research into finding the causes and treatment of the disorder.

 

DOD TOUTS NICoE PROGRAM FOR TREATING SERVICE MEMBERS WITH SEVERE TBI

FROM: U.S. DEPARTMENT OF DEFENSE
Traumatic Brain Injury Treatment, Research Pay Off
By Terri Moon Cronk
American Forces Press Service

BETHESDA, Md., March 26, 2013 - Service members who have suffered severe traumatic brain injuries and psychological ills can benefit from an intensive four-week program at the National Intrepid Center of Excellence here.

Dr. James Kelly, the center's director, said that when service members with severe TBI fail to respond to conventional medical treatment, they often are referred to NICoE's program, which finds the best methods to treat their conditions on an individual basis. The patients must also have a co-existing psychological health issue, such as post-traumatic stress disorder, depression or anxiety, Kelly said.

"If you add together all of those things in a person, that's a very complex human condition," he said. "It is our job to characterize that complex condition ... and its effects on the brain, and look at what works to help them."

The only center of its kind, the Defense Department's NICoE offers a wealth of medical and alternative approaches for such service members, with medical professionals such as neurologists, therapists and counselors working in an interdisciplinary team approach, Kelly explained.

Because the team members are located in the same facility, he added, an occupational therapist and a speech therapist, for example, could see a patient together, discuss different approaches, and learn from each other. And because the teams comprise a variety of specialists, "every day we can ask, 'Did we hit the mark?' and if not, we say "Let's try something different tomorrow,'" Kelly said.

"Whatever patients need, they get," the director said, adding that NICoE does not operate in an assembly-line format, but rather as a "compact, intensive care" outpatient program that treats different patients with individualized forms of care that fit their particular needs.

"There's a whole menu of things we have available to them," Kelly said. "Not everybody gets the same 'dose' of sleep therapy, counseling or acupuncture, [because] everybody's individual needs are addressed."

Another key ingredient in treating service members with TBI is having their family members immersed in the treatment plan whenever possible, the doctor said. "We do our best to encourage [families to come to NICoE] because they are affected as well," he noted.

When service members finish the NICoE program, they are equipped with a thorough discharge summary of their diagnostic evaluations, treatment plans, counseling and rehabilitation work to take home to their doctors, Kelly said.

"We think highly of the existing system and the health care providers," he added. "Even though we have a unique opportunity that doesn't exist anywhere else, it's an unfair comparison to [put NICoE up against] anything else. I fully recognize our colleagues are doing good work."

Stood up two and a half years ago, NICoE is considered the DOD hub of TBI research, Kelly said. The center also is designed to influence TBI and PTSD treatment in the military health system with its cutting-edge approach.

Located on the campus of Walter Reed National Military Medical Center, NICoE partners in TBI research with other organizations, including the nearby Uniformed Services University of the Health Sciences and the National Institutes of Health, among others in academia, Kelly said.

The concept for NICoE began when DOD invited Kelly, a former neurology consultant for the Chicago Bears football team, to join a group of doctors to examine how to treat service members who were exposed to blast injuries and other head trauma, Kelly said.

NICoE was privately funded by the Intrepid Fallen Heroes Fund, which also oversaw the construction and equipment of the $65 million 72,000-square-foot center. NICoE's research, education and patient care have proven so successful, Kelly said, satellite clinics around the country now are in the works.

"We're being seen as a model to export, rather than just consult, on cases, so the project has led to satellite clinics because of the success of [our] concept," Kelly said.

Like NICoE, the clinics will be built with $100 million in philanthropic donations through the work of the Intrepid Fallen Heroes Fund. The clinics will be built at Fort Bragg, N.C.; Forts Bliss and Fort Hood in Texas; Fort Carson, Colo.; Fort Campbell, Ky.; Fort Belvoir, Va.; and Camp Lejeune, N.C.

NICoE officials estimate each of those clinics will see about 1,200 patients with TBI and PTSD per year. The most severe combat-related cases will still be cared for at the NICoE here.

The clinics also will benefit from NICoE's advanced research practices. Service members fill out questionnaires before and after their stay, Kelly said. "We compare the differences" he added,, "and they are striking."

The staff also observes service members' actions and records vital signs to show changes, he said. Relief from headaches, sleep disturbances, balance issues and vision concerns improves the quality of their lives are noted, Kelly said. Patient data is compiled and used in NICoE's research work to determine which treatments seem to help service members the most.

Another measure of success in the program is when former patients visit NICoE to advise the staff of how much their lives have changed for the better since their treatment, the director said.

Kelly said he sees the future of TBI research as "very specific" to characterize TBI on anatomical, physiological and emotional levels. Researchers also will look at the best forms of intervention that help to relieve symptoms and treat basic issues.

"We need to know what a person's concussion looks like, compared to another's," he said. "Why do some people recover more quickly than others, and what can we do to help them?"

So far, the NICoE staff knows that certain approaches produce success, such as the patients' complete immersion into the intensive care program and the interdisciplinary team approach, Kelly said. And when service members realize they have a TBI diagnosis and accompanying psychological issues that are real and treatable, they feel relieved and appreciate knowing there's something to work on, Kelly said. "They're validated by that," he added.

The center's director emphasized again that his staff's ability to help patients doesn't mean they weren't getting good care before they were referred for the NICoE program.

"Our successes with patients who have been through [another] system should not be seen as a reflection of inadequate care," he said. "Our job is to try something new, and that's what we've done."

CDC DISCUSSES TRAUMATIC BRAIN INJURY

Credit:  Wikimedia Commons.

FROM: CENTERS FOR DISEASE CONTROL
TBI: What You Should Know

Traumatic brain injury (TBI) is a serious public health issue for Americans. Each year, TBI contributes to a substantial number of deaths and permanent disability. A TBI is caused by a bump, blow or jolt to the head or a penetrating head injury that disrupts the normal function of the brain. The severity of a TBI may range from "mild" to "severe".

According to research from CDC, approximately 3.5 million persons have a TBI in the United States. Of these individuals:
2.1 million received care in emergency departments,
300,000 were hospitalized,
84,000 were seen in outpatient departments,
1.1 million received care from office-based physicians, and
53,000 died.
Previously referred to as the "Silent Epidemic," individuals with this injury may not have any visible scars, and symptoms may not show up or be noticed until hours or days later. Still, a TBI can cause short or long-term problems se¬riously affecting thinking, learning, memory, and/or emotions. A TBI can affect all aspects of an individual’s life, as well as that of their loved ones. This may include relationships with family and friends, as well as their ability to work or be employed, do household tasks, or drive a car.

The most common causes of TBI are from falls and car crashes. While there is no one-size-fits all solution, there are many ways to reduce the chances of a TBI, including:
Wearing a seat belt every time you drive or ride in a motor vehicle.
Never driving while under the influence of alcohol or drugs.
Avoiding activities that can distract you while you drive, such as using a cell phone, texting, and eating.
Wearing a helmet and making sure your children wear helmets while riding a bike.
Helping prevent falls by:
Encouraging older adults to improve their balance and coordination by exercising.
Using safety gates at the top and bottom of stairs to prevent young children from falling.
This March, in recognition of Brain Injury Awareness Month, CDC encourages you to learn more about TBI prevention.

ARMY VICE CHIEF GEN. AUSTIN III TOURS TBI, PTSD TREATMENT CENTER

FROM: U.S. DEPARTMENT OF DEFENSE

Army Vice Chief Tours TBI, PTSD Treatment Center

By Terri Moon Cronk
American Forces Press Service

WASHINGTON, Dec. 20, 2012 - Army Vice Chief of Staff Gen. Lloyd J. Austin III toured the National Intrepid Center of Excellence here Dec. 19 to gain perspective on treatment for service members who have traumatic brain injuries and post-traumatic stress disorder.

Austin also visited wounded warriors at Walter Reed National Military Medical Center here, a trip officials said he makes on a regular basis. Austin and his wife, Charlene, have taken a particular interest in treatments for TBI and PTSD, two signature wounds of the wars in Iraq and Afghanistan, officials said.

Dr. James Kelly, NICoE director, led Austin's tour of the two-year old center. During the visit, chiefs of major specialties briefed the general on their treatment approaches.

Austin learned how those approaches are effective in treating service members by using such modalities as art and music therapy, relaxation, a sleep lab and counseling, all in a team setting over the course of four weeks. He viewed magnetic resonance imaging -- also known as MRI -- and saw MRI films showing the occurrence of TBI and PTSD in the brain.

Two golden retrievers and their handlers from Warrior Canine Connection also greeted Austin at NICoE. The Warrior Canine Connection is a nonprofit organization that works with NICoE service members while they are undergoing treatment. In an optional program, service members can learn to train the retrievers as service dogs that are paired with veterans who are mobility impaired, the dog handlers said.

Austin also was briefed on the satellite NICoE clinics being developed around the country at Army posts and Marine Corps bases. The sites include Fort Bragg, N.C.; Forts Bliss and Hood, Texas; Fort Carson, Colo.; Fort Campbell, Ky.; Fort Belvoir, Va.; the Marine Corps' Camp Lejeune, N.C., and a yet-to-be determined base in Southern California.

NICoE officials estimate each of those clinics will see about 1,200 patients with TBI and PTSD per year, while the most severe cases of the disorders are usually referred to the NICoE here.

"I'm very much encouraged and excited about the satellite clinics," Austin told Kelly about the NICoE concept. "They will be beneficial to [service members]."

"It's not every day NICoE gets a visit from the Army vice chief of staff," Kelly said, adding that Austin asked him about the progress on the Fort Belvoir satellite clinic, which is now under construction.

"His main concern today was how what we learn here influences the system [for treating TBI and PTSD]," Kelly said.

"His dedication to our service members in these circumstances is unquestioned," he added.

ADDITIONAL INFORMATION FROM WALTER REED NATIONAL MILITARY MEDICAL CENTER

The National Intrepid Center of Excellence (NICoE) is a DoD institute dedicated to providing cutting-edge evaluation, treatment planning, research and education for service members and their families dealing with the complex interactions of mild traumatic brain injury and psychological health conditions.

The NICoE was created to focus the collected wisdom and knowledge of our military, federal, academic and private industry partners to define the pattern of the disease state, identify definitive diagnostic criteria, advance novel treatments and share that knowledge with each other. Ultimately, together we can return our wounded, ill and injured service members back to productive lives.

The NICoE aims to be a leader in advancing traumatic brain injury and psychological health treatment, research and education. With its dedicated staff, the NICoE seeks to be an instrument of hope, healing, discovery, and learning for service members recovering from TBI and PH conditions.

THE U.S. ARMY AND CONCUSSION SUFFERED BY MILITARY PERSONNEL

FROM:  AMERICAN FORCES PRESS SERVICES

Army Refines Medical Management of Concussion

By Cheryl Pellerin

WASHINGTON, April 18, 2012 - Over the past 20 months, the Army has been working to refine the way it tracks and treats the most common form of battlefield brain injuries -- concussion, also called mild traumatic brain injury, or mTBI.

The job isn't easy, because even in the United States, where civilians experience traumatic brain injuries at the rate of 1.7 million a year, according to the Centers for Disease Control and Prevention, no single diagnostic standard exists for TBI.

In the words of experts at the 2nd Annual Traumatic Brain Injury Conference last month in Washington, treatment of TBI and especially acute, or rapid-onset, TBI is still "a major unmet medical need" worldwide.

"This is why we have our program," Army Col. (Dr.) Dallas Hack, director of the Army's Combat Casualty Care Research Program, told American Forces Press Service.

"This is why Congress in 2007 issued a special appropriation of $300 million to start funding traumatic brain injury and psychological health research for our troops," he added, "and has continued to [add] significant amounts of funding," up to $633 million today.

In the research program, scientists try to find ways to look into the brain noninvasively to measure the effects of brain trauma, using brain scans, electroencephalograms for measuring brain electrical activity, eye-tracking systems that offer a window into the brain, and more.

Objective measurements are critical for mild brain trauma, which is called an invisible injury because effects on the brain of falls or explosions or vehicle accidents aren't always obvious.

Today, while processes and devices sensitive enough to measure mild brain trauma are in development, on the battlefield and at home mild TBI tends to be assessed in large part using the best tools available -- questionnaire-type assessments.

During a recent briefing at the Pentagon, Army specialists in behavioral health and in rehabilitation discussed the evolving behavioral health system of care for TBI.

A hallmark of the Army's standard of behavioral health care is a screening process administered to soldiers before they deploy, while they are in theater, as they prepare to return home, and while they are in garrison, said the behavioral health specialist.

The assessment process includes the following questionnaires:

-- Predeployment: All incoming service members are screened with the neurocognitive assessment tool, called NCAT, which is used as a baseline for future concussion or mTBI injuries.

-- In theater: Immediately after injury, the Military Acute Concussion Evaluation, called MACE, is used to quickly measure orientation, immediate memory, concentration, and memory recall. Combined with clinical information, a MACE score can guide recommendations, including evacuation to a higher care level.

-- Postdeployment: Because mTBI is not always recognized in the combat setting, active duty service members receive postdeployment health assessments. Four questions adapted from the Brief Traumatic Brain Injury Survey are asked during the assessments. Positive responses on all four prompt an interview with a doctor for an mTBI evaluation.

-- Veterans: Vets are screened for mTBI when they enter the Veterans Health Administration system. A TBI clinical reminder tracking system identifies all who were deployed to Iraq or Afghanistan. Those who report such deployment and don't have a prior mTBI diagnosis are screened using four sets of questions based on the Brief Traumatic Brain Injury Survey. Those who screen positive for mTBI are offered further evaluation.

"Part of what they do is complete those questionnaires," the rehabilitation specialist said. "The other part of any of those screenings is a face-to-face interview with a primary care provider. If there's something the primary care provider or the screening instrument identify as indicating some kind of psychological distress, then the soldier will also see a behavioral health provider face to face.

"The other part of our system of care includes something we call embedded behavioral health that we're rolling out across the Army right now," the behavioral health specialist said.

This involves putting behavioral health specialists in the physical location of brigade combat teams, she said. In such a setting, she explained, "[care] providers develop a habitual relationship with the commanders so they feel trust about communicating appropriate information about the soldier's health."

The Army is reaching out, she added, "trying to connect with soldiers at the various touch points, in their unit areas and also in primary care clinics, so they have every opportunity to access behavioral health care at any point in their health care and in their daily lives."

The current protocol for the traumatic brain injury system of care in theater, said the rehabilitation specialist, comes from a 2010 Defense Department directive-type memorandum that makes screening mandatory for soldiers who are involved in four kinds of events, even if they don't appear to be hurt.

Those who must be screened have been near a blast, sustained a blow to the head, are involved in a vehicle accident, or have commanders who are concerned about them and want to enter them in the protocol.

Anyone involved in a mandatory event receives the MACE evaluation, a medical evaluation and at least 24 hours of rest. And they must be cleared by a medical provider before returning to duty, the rehab specialist said.

Slightly different guidelines cover those who have had multiple concussions.

For somebody who has suffered a second concussion in theater, she added, the minimal 24-hour down time is extended to a minimum of seven days.

Those who have a third diagnosed concussion in theater receive seven days of down time and a comprehensive concussion assessment that consists of consultations with specialty care providers and a functional assessment -- for example, one that assesses their ability to keep their balance.

Also in theater are 11 concussion care centers with specialty providers and a restful environment.

In Afghanistan, for moderate or severe TBI, three neurologists staff Role 3 advanced hospitals, along with a neurology consultant who oversees the TBI neurology specialists.

Telemedicine -- the remote diagnosis and treatment of patients using telecommunications technology -- is also used to treat TBI, and those visits doubled from fiscal 2011 to 2012, the behavioral health specialist said.

The Army has invested more than $530 million to improve access to care, quality of care and research, and TBI screening and surveillance. But the best clinical treatment for service members and civilians with mild TBI may be months and years in the future.

Hack says it's the state of the science.

The Defense Department's protocol "is as good as we have," he said. "I am completely supportive of it. I'm trying to do better," he added.
 

MILLIONS OF NURSES TO BE TRAINED FOR PTSD AND TBI HEALTH CARE

FROM:  DEPARTMENT OF DEFENSE
Three Million Nurses to Receive PTSD, TBI Training
 April 11, 2012 by Alex Horton
One of the challenges of diagnosing and treating complex injuries like post-traumatic stress and traumatic brain injury is the sheer amount of qualified medical personnel who can recognize the often subtle signs of trauma.Joining Forces (which celebrated its one year anniversary today) is looking to solve part of that issue by training a corps of nurses in the coming years.

Over three million nurses will be trained on how to recognize and respond to PTSD and TBI, which will immediately impact the care of Veterans.
From Stars & Stripes:

Amy Garcia, chief nursing officer of the American Nurses Association, said the new initiative should have a more immediate impact on veterans care, because officials can introduce the lessons into professional development courses, medical journals and other nursing resources in a matter of weeks, not years.
…
“Our goal is to raise awareness of these issues, teach nurses to recognize the signs and symptoms, and help reduce the stigma of seeking care,” she said.

VA nurses are well trained in identifying PTSD and TBI, so this will mostly impact private care facilities that haven’t trained in these areas. But if a nurse at a private hospital comes to work at VA, it’ll be a big boost to have prior knowledge of two of the most pressing medical issues we work to address.