Transcript The DX. And RX. Of TBI/PTSD in OIF/OEF Veterans

Chrisanne Gordon, MD
Resurrecting 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
1) Over 2 million have deployed
2) 350,000 cases PTS estimated-Post Traumatic
Stress
3) 450,000 cases of TBI estimated Traumatic
Brain injury
4) Many will have both= PDS-post deployment
5) Fewer than 30% receiving treatment
• RAND Report July 2008 / updated stats 2012
Physicians who Dx and Rx TBI
 Only 10% of all physicians treat TBI
 PM&R = Specialty trained – 12,000 in the US
 Sports Medicine physicians- NCAA/Professional
 ER Physicians – “treat and street”
 These specialties are sparse in the DOD/VA and the
community
20% - 25% TBI in War Theatre
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BLAST INJURY – IED; RPG; Mortar
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VEHICULAR ACCIDENTS –MRAP
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FALLS- Terrain
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Direct HITS, eg. during night drills
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Assaults
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Anoxic Injury – Drowning, Vascular Compromise,
Choking
Is TBI a new injury in War?
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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
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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
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$3000 if no depression
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$9000 if depression
 Estimated costs for TBI Rx. 1 year
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$30,000 – requires TEAM approach
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Moderate TBI - $260,000/case
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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
Sensory processing alterations
1.
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
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Substance Abuse – 90% ETOH abuse in 1 year;
Marijuana second drug chosen. Self- Medication –
SLOW IT DOWN!
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Amphetamine – Speed it UP! (10-15%)
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Incarceration – Loss of Executive Function – 60%
felons in California.
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SUICIDE – 7.7 X – STOP IT!- GSW, Drugs/Etoh,
MVA; Death by Law Enforecement
NFL and TBI
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Chronic Traumatic Encephalopathy
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CTE- after Playing Field…Known
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CTE- after Battle Field? 1st Case April 2012
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Dr. Ann McKee – Boston University
TBI stats in civilian world:
 1.7 million estimated on ER visits
 75% are considered mTBI – mild TBI
 Male: Female
2:1
 Direct and indirect costs - $100 billion/year in civilian
world
 Children (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 Studies
Radiologic 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
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May find equivocal results
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Most with mild TBI won’t show memory deficits
without a baseline
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Lack of baseline pre-deployment
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Helpful in more significant injuries
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ImPACT, COGSTAT, ANAM, Headminder may
be useful (Logan, 2009)
Increased Arousal
(Sympathetic Nervous Activation)
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Difficulty falling or staying asleep
Irritability or outbursts of anger
Difficulty concentrating
Hypervigilance
Exaggerated Startle Response
PTS? or TBI? Answer: BOTH
SURVIVAL depends on Hypervigilance
Suicide
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2nd leading cause of death in military – 154 in 155 Days.
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Young, White, Unmarried Male Junior Enlisted Active
Duty
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Drugs/alcohol / Firearms
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No psychiatric history (Washington Post, 2008, per
CDP)
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1.2% Army Post-Deployment survey had suicidal
ideation (Miliken et al., 2007 per CDP)
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Of completed suicides, most saw a healthcare provider
within one month before suicide (USUHS, 2009)
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19% of patients with PTSD will attempt suicide (CDP,
2009) and patients with TBI are at 7.7 X greater risk
HYPERVIGILANCE of Physician
 Important to the Survival of the returning hero
 Listen to the patient/Listen to the family
 Note the signs of TBI – word searching, rhythm of
speech, depression, irritability, photophobia
 Ask hero to explain what is happening so that you may
help his/her fellow soldiers
 Thank 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
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Capability
Desirability
Feeling of burdensomeness.
Remember the word SERVICE in Service
personnel
“PDS” Syndrome
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Hard to differentiate mild TBI from PTSD
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Sometimes both present
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Psychological factors may lead to
maintenance of TBI symptoms and medical
issues may lead to maintenance of
psychological factors
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Mind, Body, Spirit - Holistic
•
David Cifu, MD, VA Polytrauma 2011
Symptoms more consistent with PTS
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Flashbacks
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Nightmares
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Intrusive thoughts
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Avoidance behaviors
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Exaggerated startle response
PTS = Brain Injury – U of
Rochester Report  June 2, 2012 – Dr. Bazarian
 Results 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
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PCS = constellation of symptoms with mild
TBI that persist for three months or more
following a “concussion”.
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Primary symptoms are headache,
photophobia, irritability, sleep disturbance,
cognitive deficits.
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This is a subset of TBI- Sympathetic Overdrive
MYTHS about PCS
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Symptoms are exaggerated due to pre-existing
medical/psychological conditions.
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Litigation is often involved so symptoms are
for secondary gain.
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May be iatrogenic – physicians concern may
lead to increased symptoms and disability.
TRUTHS about PCS
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Different injury from the onset. PCS develops
the MOMENT of the injury.
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Research revealing HYPER state of brain at
time of injury is crucial.
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SPECT scan proof of decreased glucose
utilization in the brain
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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:
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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
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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
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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
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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