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.
 

ARMY DRIVES SCIENCE, SPENDS OVER $630 MILLION ON TRAUMATIC BRAIN INJURY RESEARCH

FROM:  AMERICAN FORCES PRESS SERVICE

Army Research Drives Brain Injury Science

By Cheryl Pellerin

WASHINGTON, April 18, 2012 - With $633 million and 472 active research projects on traumatic brain injury alone, the Army is driving the science behind this neglected public health problem that affects everyone from kids on the sports field to service members in Afghanistan.

TBI, and especially mild TBI, "is essentially a frontier of medicine," Army Col. (Dr.) Dallas Hack, director of the Army's Combat Casualty Care Research Program, said in a recent interview with American Forces Press Service.

From 2000 to 2011, just over 133,000 soldiers were diagnosed with TBI. For the Defense Department as a whole in that period, 220,000 service members were diagnosed, according to an Army behavioral health specialist.

Traumatic brain injuries range from severe to moderate to mild and can be caused by a bump, blow or jolt to the head or a penetrating head injury that disrupts normal brain function.

On the battlefield, Hack said, fewer than 25 percent of brain injuries are combat related. Most are caused by training injuries, vehicle accidents and a range of other activities.

Severe brain injuries are easy to diagnose, Hack said. Any kind of a computed tomography, or CT, scan can show the resulting physical defect.

CT scans combine a series of X-ray views taken from many different angles with computer processing to produce cross-sectional images of soft tissues inside the brain.

It's a little more difficult to diagnose moderate TBI, he said, "although some of the more advanced imaging, even [magnetic resonance imaging, or MRI] scans generally do a decent job."

MRI machines use powerful magnets and radio waves to create pictures of the internal brain.

"Where it is so difficult and where we as a culture and as a profession basically ignored it for all these years," Hack said, "is in the mild TBI area."

To improve the spectrum of diagnosis-to-treatment of mild TBI, he said, the research program pushes the science with partners like university researchers, and even organizations like the National Football League and the National Hockey League, sports whose players are at risk for concussion, also called mild TBI.

Research being funded includes a range of neuroimaging or brain scanning technologies; quantitative electroencephalography or brain mapping, blood tests for biomarkers of brain injury, and even drugs that may prevent injuries from mild brain trauma.

Brain imaging is "probably the current best we can do," Hack said, but scientists often don't have enough data to interpret mTBI scans.

"The fact is," he added, "that on the milder injuries you don't see physical defects but you can see functional issues."

Studies are ongoing with functional MRIs, which rather than showing brain structures show brain activity by tracking the uptake of glucose, the brain's source of energy.

Other imaging research targets a new kind of CT scan called single-photon emission computed tomography, or SPECT, which shows how blood flows through arteries and veins in the brain.

A technique called DTI, for diffusion tensor imaging, is a special version of MRI that measures the direction of water molecules in the brain, Hack said, so scientists can follow the physical path of nerve tracts in the brain.

Brain mapping, called quantitative EEG, can automatically detect and locate abnormal brain activity, he added, "or what we call silent seizures. We often see these soon after an injury and we have studies that are working on getting [Food and Drug Administration] approval" to use the technique in mTBI.

The program's biomarker studies are producing devices that can test the blood for proteins unique to brain cells and indicate whether brain cells are damaged.

"When brain cells die and break [apart]," Hack said, "they spill their contents into the brain fluid. Some of that gets across into the blood and we can measure it."

An application for FDA approval of the device will be submitted sometime in 2013, the physician said, "and hopefully we can have an approved test by the end of 2013."

Eye movements are another way to get a look inside the brain.

"Certain kinds of eye movements are affected by even mild brain injury," Hack said, "so we have some projects in that. We have others in sensory function. Balance, for instance, or vestibular function, is also quite sensitive to brain injury.

In such fledgling brain science studies, the researchers have to make sure they're diagnosing the right conditions.

"Confounders are other conditions that could cause the same problems," Hack said, "and we need to make sure in our studies that we're able to differentiate brain injury from other conditions that can cause functional impact," including Alzheimer's disease, for example, or even lack of sleep or poor nutrition.

The program's three-pronged approach to understanding mTBI, he said, is to determine whether there is brain cell damage, where the damage is and its functional impact.

"The science behind all of that is still very rudimentary, so we're spending a lot of effort in those areas," he said.

The program also funds drug trials, some of which examine existing drugs to see if they have a beneficial effect on brain inflammation, which can occur after a brain injury.

Atorvastatin, whose brand name is Lipitor, "is one of the drugs that has shown a benefit [on inflammation] in brain cells."

The program is working with the National Institutes of Health on a phase III clinical trial of the female hormone progesterone.

"Progesterone is essentially a steroid that also is a female hormone but it is called a neurosteroid as well," Hack said. "It has a positive benefit on brain inflammation."

He added, "We don't think there's any one drug that will [help those with mTBI]. This is a complex problem and it's going to take multiple approaches to solving it."

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.