Traumatic Brain Injury and the Defense and Veterans Brain Injury Center
Traumatic brain injury has gained increasing
significance in the conflicts in Iraq and
Afghanistan as survival from previously
life-threatening injuries has improved.
Traumatic brain injury (TBI) has gained increasing significance in the conflicts in Iraq and Afghanistan as survival from previously life-threatening injuries has improved. Along those lines, more exposure to blasts and explosions along with effective personal protective equipment have resulted in higher numbers of servicemembers suffering mild, moderate or even severe traumatic brain injuries, often in conjunction with other injuries.
The Defense and Veterans Brain Injury Center (DVBIC) serves active-duty military members, as well as the Reserve component and National Guard, their dependents and veterans who have TBI. DVBIC does so through state-of-the-art clinical care, innovative clinical research initiatives and educational programs at several military, civilian and Department of Veterans Affairs (VA) sites across the country. Congressionally mandated and funded by the Department of Defense, this is a unique collaborative effort between DoD and VA that provides TBI-specific evaluation, treatment and follow-up care.
Over the last 16 years, DVBIC has made significant contributions to our knowledge of TBI; its members serve as the department’s primary subject matter experts. They have had a robust research program including the first-ever randomized controlled study of rehabilitation therapies and the first-ever institutional review board (IRB) approved study in a combat zone. They have a comprehensive network of clinical sites throughout DoD and VA. They have also created clinical practice guidelines for management and treatment of brain injured patients in theater, developed evidence-based guidelines for comprehensive care for severe injuries and conduct surveillance of TBI in Operation Iraqi Freedom and Operation Enduring Freedom servicemembers.
Established in 1992 as the Defense and Veterans Head Injury Program, “DVBIC synthesizes and develops clinical standards and provides clinical care while conducting research and education that has come to define optimal care for survivors of TBI,” according to DVBIC director, Air Force Colonel (Selectee) Michael Jaffee. Clinical care and research currently takes place at 10 military sites representing all four branches of service, four VA sites and two civilian treatment sites. This includes a network of 14 TBI regional care coordinators and 14 TBI regional education coordinators throughout the country. This network allows for coverage of the complete spectrum of care from acute injury to rehabilitation and transitional re-entry.
Data from DVBIC documents 5,926 servicemembers with TBI within the DVBIC network as of 29 February 2008. Of these, 55 percent are associated with a blast, 2 percent with a bullet, 6 percent from a fall, 1 percent from a fragment associated with a blast, and 7 percent from a vehicular accident. Two percent were not otherwise specified, and 27 percent were associated with more than one mechanism of injury. Of the total, 86 percent were mild TBI, 7 percent moderate, 6 percent severe or penetrating, and 1 percent unknown. DVBIC has been named by the Office of the Secretary of Defense as the office of responsibility for TBI surveillance for all the services.
A request from Congress for a comprehensive plan to address TBI within DoD led to Deputy Assistant Secretary of Defense for Force Health Protection and Readiness, Ellen P. Embrey, forming a special task force to examine TBI and psychological health issues. This cell of subject matter experts and service/agency representatives held an initial meeting in April of 2007 with service surgeons general and service representatives within Manpower and Reserve Affairs offices. Senior officials from the VA and the principal supporting DoD organizations such as the U.S. Army Medical Research and Materiel Command (MRMC), and DVBIC were also key participants.
Through intensive collaboration over the ensuing six months, a comprehensive program was developed to define an effective process from point of injury to resolution across the continuum of care for TBI and psychological health. In conjunction with efforts within the VA, this included: attention to baseline assessment; field evaluation and treatment; screenings post-deployment and in the periodic health assessment; education for military and family members; and research into protection, mitigation for primary prevention, and post-incident treatment and rehabilitation techniques to maximize recovery.
That led to the stand-up of the Defense Center of Excellence for Psychological Health and Traumatic Brain Injury (DCoE). DCoE is leading a collaborative effort toward optimizing psychological health and TBI treatment for DoD. DCoE establishes quality standards for: clinical care; education and training; prevention; patient, family and community outreach; and program excellence.
DCoE is part of DoD’s Military Health System which provides a “continuum of care,” from initial accession to separation and discharge, for all its servicemembers. “DVBIC brings its multi-site mission and capabilities to the DCoE as a key aspect to the center’s foundation, collaborating with the VA health care system and civilian partners,” Jaffee said. In addition to DVBIC, key components of DCoE’s network include the Center for Deployment Psychology, the Deployment Health Clinical Center, the Center for the Study of Traumatic Stress, and the National Intrepid Center of Excellence, which will be the facility where much of the clinical operations for DCoE will take place.
DVBIC develops the most modern TBI-specific evaluation, treatment and follow-up care for all military personnel, their dependents and veterans with brain injury. It continues to develop and deliver educational materials for prevention, treatment of TBI and management of its long-term effects.
The cost of evaluation and treatment of servicemembers who have TBI is not well understood, since assessment tools were only recently implemented and system-wide protocols for treatment and followup have not been developed.
TBI is a blow or jolt to the head, or a penetrating head injury that disrupts brain function. Traumatic brain injuries can range from mild (also known as concussion) to moderate and severe and penetrating. Because initial medical care usually addresses visible injuries, mild injuries may not be recognized or addressed until late in the evacuation chain. In the case of those who suffered no additional injury, mild TBI/concussion may not be recognized at all, until the servicemember complains of headache, dizziness, memory problems, or other symptoms that may accompany a mild TBI. This may be compounded by a “gung-ho” mentality of servicemembers, who, like football players stunned on the field, may want to stay with the unit and remain on duty rather than be thought a shirker with no visible injury.
The three degrees or severities mentioned above are based on medical criteria that use length of time for loss of consciousness or post-traumatic amnesia or initial Glasgow Coma Scale score. Mild TBI, to emphasize, is similar to a concussion in football or hockey, and can range from mild enough that a person can go back into the game after a short rest, to being out for the rest of the game or even season. Severe TBI usually results from a significant closed head injury, as in an automobile accident, or most open or penetrating injuries, which renders the patient in a coma and where there may be considerable residual deficits of brain function.
The role of blast overpressure in TBI is not well understood. Research is being conducted in the tri-service Blast Executive Agency at MRMC to better understand and diagnose overpressure injuries to the body. Of the overall severely wounded individuals, less than half have had brain injury.
DVBIC research consists of clinical trials of rehabilitation modalities and medications as well as epidemiology studies and studies utilizing advanced neuro-imaging and diagnostic techniques. There are many federal and academic collaborations that have led to initiatives involving proteomics, genomics and nanotechnology.
As the main hub for medically evacuated servicemembers out of theater, an important DVBIC site is located at Landstuhl Regional Medical Center in Germany. Servicemembers who are transported to Landstuhl Regional Medical Center for care due to wounds or injuries suffered in theater are also evaluated for mental health needs and possible TBI, as well as for nutrition, physical therapy or other potential needs. Those identified with a co-morbid TBI are transported to medical treatment facilities capable of managing this condition in addition to the other injuries.
Based on the demonstrated efficacy of supplemental post-deployment screening done by several DVBIC sites, DoD recently initiated systematic screening for concussion as part of the Post-Deployment Health Assessment. DoD has also adapted an in-theater tool called the MACE (Military Acute Concussion Evaluation) developed by DVBIC to assist in the identification of any TBI that occurs at the time of injury or shortly thereafter. DVBIC has also developed a clinical practice guideline for further medical evaluation and care required before return to duty, or for evaluation at higher levels of care both in deployed settings and in CONUS. There have also been practice guidelines developed by DVBIC in partnership with the Brain Trauma Foundation for first-responder medics in the field for moderate and severe injuries.
DVBIC has been a primary source for DoD TBI education for patients, caregivers, family members and commanders, as well as health care providers. DVBIC has been charged with developing the Congressionally-mandated family caregiver curriculum. In addition to providing pre-deployment and in-theater training to military medical personnel, they have provided TBI education at 14 bases and this past year trained over 700 DoD providers at the first tri-service DoD training course.
Improved design and materiel for protective gear, better training and equipment for first responders, and improved en route care capability have all contributed to improved survival. Advances in materials for body armor and helmets now better protect servicemembers from small arms and fragments. In previous conflicts, casualties with severe head injuries often died from other injuries. Treatable, isolated head injuries are seen more often in surviving personnel. Better medical equipment, quicker evacuation, and forward stationing of specialty care medical personnel (e.g. neurosurgeons) may also contribute to surviving severe TBI.
With mild TBI patients, full recovery can be from within minutes to hours for the mildest but may require up to three months or more for post concussive symptoms to resolve. A small percentage (5-15 percent) of patients have symptoms that may persist beyond three months. Casualties with severe TBI may never return to normal, though this can be difficult to predict.
As the United States faces crises both at home and abroad, DVBIC continues its commitment to the effort to prevent, treat, and provide education on TBI for servicemembers currently on active duty, National Guard and Reservists recently injured in the line of duty, their dependents and retired military personnel.
DoD is committed to providing the world’s best medical care for all servicemembers. The productive collaboration exemplified by DVBIC supports the major objective to develop the best practice to evaluate and treat every servicemember involved in an event that may result in brain injury. ♦