Physical and Occupational. Treating Mild Traumatic. Injured Too. DoD Post Doctoral Research Team National Model Robyn Bolgla MSPT, CTRS

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1 Physical and Occupational Therapy Guidance to Treating Mild Traumatic Brain Injury Women Get Injured Too DoD Post Doctoral Research Team National Model Robyn Bolgla MSPT, CTRS MAJ, USAR, SP Army Professional Management Command Department of Veteran Affairs

2 Mild traumatic brain injury (MTBI) is the signature wound of Operation Enduring Freedom /Operation Iraqi Freedom/(OEF/OIF)

3 OCCUPATIONAL AND PHYSICAL THERAPY FOR MTBI: *adaptive and remedial interventions ti *address impairments *activity limitations *social participation issues associated with MTBI

4 OT and PT have played an essential role to the mission of the US Military and Veteran Affairs for the more than seventy five years. Medical Specialist Corps in the US Army, mission : to apply Corps unique skills to maximize the health and enhance the readiness of Warriors across the full spectrum of operational missions and environments (retrieved December 9, 2007 from Army Medical Specialist Corps)

5 OT/PT MISSION IN THE VA: provide the most advanced d rehab services to our nation s veterans to ensure maximum level of functioning and quality of life. HONOR OUR VETERANS.

6 WOMEN GET INJURED TOO *maintain troop levels *return to duty *ensure best possible recovery and rehab for those who are unable to return rn to duty CONSERVE FIGHTING STRENGTH

7 WHY DEVELOP A TEAM TO ESTABLISH PT/OT GUIDANCE FOR MILD TBI? NEUROLOGICAL IMPAIRMENTS COMPARED TO TRADITIONAL MUSCULOSKELETAL ORTHOPEDIC MILITARY INJURIES RETURNING SOLDIERS ARE THEY FIT FOR DUTY? PROPER DIAGNOSIS TBI? PTSD? DOD MILITARY DISABILITY RATING SYSTEM VS. DEPARTMENT OF VETERAN AFFAIRS DISABILITY SERVICE CONNECTION IED BLAST INJURIES, POLYTRAUMA, MULTIPLE DEPLOYMENTS, RESERVE VS. ACTIVE DUTY, WOMEN IN THE MILITARY

8 WOUNDED WARRIORS COMMISSION PRESIDENT ORDERS TASK FORCE TO DETERMINE BEST PRACTICE DONNA SHALALA PRESIDENT OF UNIVERSITY OF MIAMI, FORMER SECRETARY OF HEALTH FOR PRESIDENT CLINTON BOB DOLE FORMER SENATOR, PRESIDENTIAL CANDIDATE AND WWII DISABLED VETERAN 35 RECOMENDATIONS

9 United States Military Casualty Statistics: Operation Iraqi Freedom and Operation Enduring Freedom and Operation Enduring Freedom Hannah Fischer Information Research Specialist March 25, 2009

10 United States Military Casualty Statistics: Operation Iraqi Freedom and Operation Enduring Freedom Hannah Fischer Information Research Specialist March 25, 2009 Congressional Research Service RS22452 United States Military Casualty Statistics Congressional Research Service Summary U.S. military casualties in OIF and OEF can be found at the DOD s website, at In addition, CRS Report RS21578, OIF OEF Gender Distribution of Deaths Male 4,143 Female 102 Total Wounded in Action 31, Source: Department of Defense, pdf

11 As of March 20, 2009: Rates of Amputation September January 12, ,286 amputations in OIF, OEF CPT James Watt, OT Source: DOD, Operation Iraqi Freedom Military Deaths, at mil/personnel/ CASUALTY/oif-deaths-total.

12 Traumatic Brain Injuries: 43,779 TBI during

13 Blast injuries number one cause of injury or death in Iraq 69.4% of Wounded In Action caused by Blast or Explosion 62% of Blast Injuries result in Traumatic Brain Injury (TBI) 85% of TBI s are closed Head Injuries This means only 15% have visible wounds The symptoms closely l resemble those of PTSD and can be easily overlooked by medical staff not well versed in recognizing and diagnosing brain injury. Tuli, August 2007

14 Self-Inflicted Wounds \ DoD Casualty Website 177 died self- inflicted wounds in OIF 29 died of self-inflicted wounds serving in OEF Suicides in the Army reached a historic high in 2008 at 20.2 per 100,000 service members Department of Defense Personnel and Procurement Statistics, Statistical Information and Analysis Department, OIF at and OEF at dmdc mil/personnel/ CASUALTY/WOTSUM.pdf. Anne Scott Tyson, Military Investigates West Point Suicides, Washington Post, wpdyn/content/article/2009/01/29/ar html.

15 DEPARTMENT OF THE ARMY RESEARCH GRANT: 2007 POST DOCTORAL TEAM TO ESTABLISH PT/OT CLINICAL MANAGEMENT PROTOCOLS FOR MILD TRAUMATIC BRAIN INJURIES

16 September 2007, The Proponency Office for Rehab and Reintegration (Office of the Surgeon General) charged a team of 2 OT s and 3 PT s (2 military / 3 civilians) to develop OT/PT clinical management protocols for mild traumatic brain injury. The team was tasked to develop state of the art assessment/treatment guidelines for MTBI for military and VA 8 levels of care.

17 EIGHT LEVELS OF CARE US MILITARY & VA SYSTEM I Buddy Aid to Battalion Aid Station II Forward Support Medical Company/Forward Surgical Team III Combat Support Hospital IV Evacuation Center (Landstuhl Regional Medical Center - Germany) V Military Medical Treatment Facility (MMTF) Inpatient and Outpatient VI Inpatient Rehabilitation Non-MMTF VII Outpatient Rehabilitation Facility (Non-MMFT) VIII Lifetime Care

18 Convene a MTBI Rehab Care Summit: OT and PT subject matter experts from DOD, VA and the civilian sector developed consensus OT/PT clinical i l management mtbi treatment recommendations

19 METHODS The document development process consisted of 4 phases

20 STRESS AND STRAIN

21 POSSIBLY TO THE BRAIN?

22 LOOKS NORMAL?

23 BUT NOT QUITE RIGHT

24 LET US ALL TAKE A DEEPER LOOK

25 Rare view from patient with large occipital meningioma i and accented midline shift

26 PHYSICAL and OCCUPATIONAL THERAPY DOWN RANGE LEVEL I, II, III IRAQ and AFGHANISTAN

27 THE TRUE COST OF WAR.

28 AFTER BLAST IS THE SERVICE MEMBER FIT FOR DUTY???

29 PT/OT MTBI EVALUATION COMBAT READINESS CHECK RETURN TO DUTY DOWN RANGE OR EVACUATE CONUS

30 Military Acute Concussion Evaluation (MACE)

31 Defense and Veterans Brain Injury Center: MACE The purpose of the MACE is to evaluate a person in whom a concussion is suspected. The MACE is used to confirm the diagnosis and assess the current clinical status. The MACE has been extensively reviewed by leading civilian and military experts in the field of concussion assessment and management. While the MACE is not, yet, a validated tool, the examination section is derived from the Standardized Assessment of Concussion (SAC) (McCrea, M., Kelly, J. & Randolph, C. (2000). Standardized Assessment of Concussion ( y p ( ) (SAC): Manual for Administration, Scoring, and Interpretation. (2nd ed.) Waukesa,WI: Authors.) which is a validated, widely used tool in sports medicine.

32 MACE: Determine whether and length of time of self reported loss of consciousness (LOC). Orientation: Assess patients awareness of the accurate time Ask: WHAT MONTH IS THIS? WHAT IS THE DATE OR DAY OF THE MONTH? WHAT DAY OF THE WEEK IS IT? WHAT YEAR IS IT? WHAT TIME DO YOU THINK IT IS?

33 FIT FOR DUTY AFTER MTBI

34 EMERGING EVIDENCE SUGGESTS; Significant damage to cingulate gyrus often not seen on traditional MRI, however, with functional MRI used to measure brain injury supported electrographic and behavioral studies. Damage lit up like a Christmas tree. An inconsistent response is one of the most striking results produced by a lesion of the cerebral cortex Head, H (1926) Aphasia and kindled disorders of speech, Cambridge, Cambridge University Press, pp Concussion begets concussion 2/3 higher rate after initial concussion will get second concussion. 7 days to heal (recommended in guidance document) now 30 days mtbi Power Point Presentation, 20 June, 2008, Joseph Bleiberg, PhD National Rehabilitation Hospital (NRH),Fort Bragg Studies, Ft. Rucker Study.

35 BLAST STUDIES EMERGING EVIDENCE BLAST WAVE IMPACTS THE BRAIN HELMETS PROBABLY HAVE LITTLE EFFECT ON PRESSURE OF BLAST WAVE NEUROLOGICAL SYSTEM DEGRADES 30% OF SERVICE MEMBERS WITH BLAST INJURY WILL DEGRADE CAN WALK AND TALK BUT ONE YEAR LATER SIGNFICANT COGNITIVE, SPEECH AND MOTOR SKILL FAILURE HOW TO TREAT? R&R REST (30 DAYS) ANTIOXIDANTS TO ENHANCE NEUROLOGICAL FUNCTION AT A PHYSIOLOGICAL LEVEL MUST PERFORM CRC, DUAL TASKS (walk, talk, chew gum) EVALUATION FUNCTION AFTER PHYSICALLY STRESSED (under conditions of hypoxia Bleiberg) 4 th Annual Blast Conference, James A Haley Veterans Hospital, DVBIC Cernak, Ibolja MD, PhD, MS, Medical Director/Senior Professional Staff John Hopkins University Applied Physics Laboratory

36 IMPROVISED EXPLOSIVE DEVICE (IED) BLAST INJURY

37 RADIOGRAPHS TAKEN DOWN RANGE

38 POST OP IMAGING PRIOR TO DUST OFF

39 IED BLAST SURGERY DOWN RANGE IN IRAQ

40 AMPUTATIONS AND ORIF PERFORMED DOWN RANGE (IN IRAQ)

41 HAND LACERATION IRAQ

42 MAJ WELLS COL QUICK

43 DUST OFF

44 AIR EVACUATION FROM DOWN RANGE TO LANDSTUHL REGIONAL LEVEL IV

45 PATIENT TRANSFERRED ON LITTER AMBULANCE BUS Gary Sinise

46

47 NATURAL HISTORY OF MTBI LEVEL IV LANDSTUHL Symptomatic at time of incident or days or weeks after: *HA, dizziness, nausea and vomiting, sleep disturbances, sensitivity to noise and light, slowed thinking and reaction time, memory problems, irritability, depression and visual changes (Carroll et al.,2004) Majority of cases symptoms resolve within 3 months (Ruff,2005). However, 15-25% of those with MTBI, problems persist and impact normal function The miserable minority who present with persistent problems after 3 months may have post-concussive syndrome (PCS) (Mittenberg & Strauman,2001;Ruff,2005)

48

49 Sgt. Charlie McCall, a patient a Landstuhl Regional Medical Center, receives physical therapy from Navy Lt. Cmdr. Mitchel Ideue. (U.S. Army Photo/Michelle Barrera)

50 EVACUATION TO CONUS LEVEL V MILITARY TREATMENT FACILITIES (MTF) INPATIENT REHAB & OUTPATIENT REHAB WALTER REED ARMY MEDICAL CENTER/ BETHESDA NAVAL HOSPITAL, BROOK ARMY MEDICAL CENTER CENTER FOR THE ENTREPID

51 LEVEL V CENTER FOR THE INTREPID BROOK ARMY MEDICAL CENTER, FT. SAM HOUSTON TX REHABILITATION PT/OT INTERVENTIONS

52 CENTER FOR INTREPID REHAB INDOOR RUNNING TRACK

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59 Dr. Rebecca Hooper, program manager for the Center for the Intrepid, explains how the Computer Assisted Rehabilitation Environment simulator, works to the Chief of Staff of the Army, GEN. George W. Casey Jr., at the Center for the Intrepid,Ft. Sam Houston, TX, on Nov. 17, Army photo by D. Myles Cullen (released)

60 DRIVER SIMULATION NAVY PHYSICAL THERAPISTS

61 EIGHT LEVELS OF CARE US MILITARY & VA SYSTEM I Buddy Aid to Battalion Aid Stationti II Forward Support Medical Company/Forward Surgical Team III Combat Support Hospital IV Evacuation Center (Landstuhl Regional Medical Center - Germany) V Military Medical Treatment Facility (MMTF) Inpatient and Outpatient SERVICE MEMBER ARRIVES IN THE VA VI Inpatient Rehabilitation Non-MMTF TAMPA, PALO ALTO, RICHMOND, MINNIEAPOLIS VII Outpatient Rehabilitation Facility (Non-MMFT) VIII Lifetime Care

62 EXECUTIVE SUMMARY (recommendations related to PT and OT assessment and intervention ti associated with mtbi) Combat Readiness Check (performed by OT or PT in theatre) Activity intolerance Patient education Vestibular dysfunction Vision dysfunction HA and TMJ Cognitive dysfunction Performance of self-maintenance roles Self-awareness Community Re-entry Participation in exercise Outcomes measurement (at the Participation level)

63 O'Neal's status casts large shadow on Game 7 By Michael Cunningham South Florida Sun-Sentinel Sentinel May 3, 2009Miami - Pick an angle for Heat-Hawks Game 7. Effects from a concussion may limit it Jermaine O Neal s effectiveness the best perspective might come from the injury report.

64 Doctors warned Heat center Jermaine O Neal not to rush back from a concussion...with O Neal the matter is more serious. O Neal finished Game 5 and sat out Game 6 after trying to convince the Heat Medical staff he could play. But O'Neal expressed caution after talking with doctors on Saturday. if I don t play, it s because I physically can t play for the well being of not only my career, but my health (and) for my family,

65 O Neal said he first knew the injury could be serious when the Heat s flight landed in Miami and he was sensitive to the aircraft s cabin lights. He said his other symptoms included severe headaches and trouble sleeping. O Neal planned to rest as much as possible until game time with the help of medication that makes him sleepy. The symptoms have gotten a lot better over the last two days, he said.

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67 OT and PT have pivotal contributions to the recovery, rehabilitation, and reintegration of service members with MTBI POLYTRAUMA MEN AND WOMEN Research is needed in every area of practice presenting opportunities to advance outcomes for service members and civilians alike.

68 MILITARY WOMEN WITH MTBI WHAT ARE THE NUMBERS? POSSIBLY 300,000, % WOMEN? SPECIAL CONCERNS PREGNANCY PARENTING AMENORRHEA EFFECTS ON BONE LOSS SUBSTANCE ABUSE CHRONIC PAIN FORCE LOADS DOMESTIC VIOLENCE RETURN TO DUTY / CIVILIAN EMPLOYMENT LIFETIME CARE FITNESS WELLNESS

69 REFER RETURNING VETERANS TO OEF OIF PT/OT POST DEPLOYMENT CLINIC Initiate a consult : Mild Traumatic Brain Injury Pain Unspecified strain/sprain Activity intolerance Patient education Vestibular dysfunction (BPPV) Vision dysfunction Gait and functional balance training HA and TMJ Cognitive dysfunction Performance of self-maintenance roles Self-awareness Community Re-entry Participation in exercise (wellness, exercise, fitness prescription)

70 FORCE LOADS, MULTIPLE DEPLOYMENTS, STRESS AND STRAIN, POLYTRAUMA

71 KO2 = KO KO = KNOCK OUT, SERVICE KNOCK MEMBERS OUT LOOK TO US FOR HELP

72

73 WE DID IT, WE CAN STILL DO IT, LET OUR VOICES BE HEARD!!!

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