Biomedical Challenge to Warfighter, Veteran and Civilian: Diagnosing and Treating

Traumatic Brain Injury and PTSD

Wesley R. Cole, Ph.D. Senior Clinical Research Director

Defense and Veterans Brain Injury Center Womack Army Medical Center, Fort Bragg, NC

“Medically Ready Force…Ready Medical Force” 1

Disclosures

Contractor with General Dynamics Information Technology

I have no relevant financial relationships to disclose

The views expressed herein are those of the presenter and do not reflect the official policy of the Department of the

Army, Department of Defense, or the U.S. Government

“Medically Ready Force…Ready Medical Force” 2

TBI: Scope of the Problem

“Medically Ready Force…Ready Medical Force” 3

Since 2000, in Service Members: • 344,000+ documented TBIs1

• ~82% are concussions • 8-23% of Service Members affected2

1. Defense Medical Surveillance System (DMSS), Theater Medical Data

Store (TMDS). 2000-2015 as of March 30, 2016

2.(Terrio et al., 2009; Vasterling et al., 2006)

“Medically Ready Force…Ready Medical Force” 4

Common Causes of TBI in the Warfighter

• Blasts • Bullets • Fragments • Training

• Airborne operations • Combatives

• Falls • Motor vehicle crashes • Sports • Assaults

Image Source: www.dvidshub.net

Where Do Injuries Occur?

“Medically Ready Force…Ready Medical Force” 5

What is DVBIC?

“Medically Ready Force…Ready Medical Force” 6

• Educational Tools & Resource Development

• TBI Awareness & Training

• Product Distribution & Dissemination

• Family Caregiver Program

• Regional Education Coordination

DVBIC’s Mission

“Medically Ready Force…Ready Medical Force”

Research

• Clinical Investigations

• Congressionally Mandated Studies

• Epidemiological Research

• Statistical Analysis

• Translation of Research

• Program Evaluation

Clinical Affairs

• Care & Consultation

• Identification

& Sharing Best

Practices

• Clinical Guidelines

& Recommendations

• TBI Surveillance

• Regional Care

Coordination

• TBI Health Outcomes

Education

DVBIC Locations

“Medically Ready Force…Ready Medical Force” 8

DVBIC Clinical Recommendations

• Management of Headache

• Management of Sleep Disturbances

• Progressive Return to Activity: For Primary Care Managers

• Progressive Return to Activity: For Rehabilitation Providers

• Neuroimaging in the Non-Deployed Setting

• Assessment and Management of Visual Dysfunction

• Assessment and Management of Dizziness

• Neuroendocrine Dysfunction Screening Post Mild TBI

website: dvbic.dcoe.mil/resources/clinical-tools

“Medically Ready Force…Ready Medical Force” 9

DVBIC Other Resources

• Fact Sheets for Patients and Providers

• E.g. Concussion Signs and Symptoms, Mild TBI and PTSD, Symptom Management (Headaches, Dizziness, Memory, Healthy Sleep, etc.)

• Free Monthly Webinars

• June 9: Cognitive Rehabilitation in Mild TBI: Applications in Military Service Members and Veterans

• July 14: Performance Triad: Sleep, Nutrition, and Exercise

• Annual DCoE Summit: September 13-15, 2016

“Medically Ready Force…Ready Medical Force” 10

Fort Bragg Research at a Glance

• Over a dozen wide-ranging studies

• Evaluating computerized neurocognitive assessments as post-TBI screening tools

• Evaluation of Progressive Return to Activity clinical guidelines • Multi-site with Naval Medical Center San Diego and Camp Pendleton

• Investigation of post-traumatic headache • Epidemiology; Treatment with Botox (Dr. Alan Finkel)

• Nutrition based intervention (in collaboration with UNC, Walter Reed)

• Evaluation of visual function as an objective biomarker • Pupillary Light Reflex, Visual Tracking, Convergence

• Neuro-Opththalmic Device (NODe)

• Database of over 17,000 paratroopers • Over a dozen publications and counting

“Medically Ready Force…Ready Medical Force” 11

Image Source: Capo-Aponte, 2014

Challenge of Co-occurring Symptoms

“Medically Ready Force…Ready Medical Force” 12

Predictors of Persistent Symptoms

“Medically Ready Force…Ready Medical Force” 13

No Yes

• Loss of consciousness • Retrograde amnesia • Post-traumatic amnesia • Dizziness • Abnormal MRI • History of concussion

• High symptom reporting • Acute emotional distress • History of anxiety • History of depression • Pain • Negative expectations

(Carroll et al., 2004; Iverson, Dec. 2012; Luoto et al., Nov. 2012; Meares et al., 2011)

NICoE Intrepid Spirit

“Medically Ready Force…Ready Medical Force” 14

• National Intrepid Center of Excellence Satellite Site

• Bragg is 1 of 9 Sites located in DoD • Expand clinical, research, education

and training • “One Stop Shop” for TBI, PTSD, Pain • 25,000 sq ft/ Up to 60 staff members • Benefits

• Expanded work spaces • Enhanced access to care • Standardized treatments

• Operations at Bragg began 4 Jan 2016 Image Source: McMillan, 2016

Intrepid Spirit at a Glance

“Medically Ready Force…Ready Medical Force” 15

• Acute injury Walk-in Clinic (less than 7 days)

• Primary care (PA, NP, LPN, Neurologists) oversees treatment

• Multi-Disciplinary Evaluations include:

• Physical Therapy/Vestibular Evaluation

• Neuro-optometry Evaluation

• Neuropsychological Evaluation

• Behavioral Health Evaluation

• Development of individualized treatment plan

• Intensive Outpatient Program for some patients

• Case reviews every four weeks through discharge

• Performance Assessment of Recovery (PAR) Program

Image Source: McMillan, 2016

Websites

“Medically Ready Force…Ready Medical Force” 16

www.dvbic.dcoe.mil www.dcoe.mil

www.health.mil/dha