27 October 2009

TBI Programs and Resources in the US MilitaryTBI Programs and Resources in the US Military30 April 201030 April 2010

Kathy Helmick MS, CRNP, CNRNKathy Helmick MS, CRNP, CNRNInterim Senior Executive Director, TBIInterim Senior Executive Director, TBI

Defense Centers of Excellence for Psychological Health and Defense Centers of Excellence for Psychological Health and Traumatic Brain InjuryTraumatic Brain Injury

Version 1.0

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Agenda

• DoD definition of TBI• Severity of injury• Mechanisms of injury• Recent research findings• DoD enterprise wide initiatives• TBI management continuum• Resources – patient, family, provider• Research• The way ahead

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Mental Health Task Force

High-level Attention

Independent Review Group (IRG)

Task Force on Returning Global

War on Terror Heroes

DoDIG Review of DoD/VA Interagency

Care Transition

Veterans Disability Benefits Commission

(www.vetscommission.org)

Commission on Care for America’s

Returning Wounded Warriors

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What is DCoE?

– DCoE is a DoD organization that, in close partnership with the Department of Veterans Affairs, leads a national and international collaborative network of other governmental organizations, military and civilian agencies, community leaders, advocacy groups, clinical experts and academic institutions in helping service members with psychological health and traumatic brain injury issues.

– DCoE’s work focuses on assessing, validating, overseeing and facilitating programs which aid service members with resilience, recovery and reintegration for psychological health and traumatic brain injury issues.

Our core messages– You are not alone

– Treatment works. The earlier the intervention, the better

– Reaching out is an act of courage and strength

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• Service members– Guard and Reserve

• Veterans• Families• Military leaders• Healthcare providers• Researchers• Employers• Caregivers • Chaplains

Who We Support

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DoD TBI Definition (Oct 07)

• Traumatically induced structural injury or physiological disruption of brain function as a result of external force to the head

• New or worsening of at least one of the following clinical signs– Loss of consciousness or decreased consciousness

– Loss of memory immediately before or after injury

– Alteration in mental status (confused, disoriented, slow thinking)

– Neurological deficits

– Intracranial lesion

• DoD definition parallels standard medical definition– CDC, WHO, AAN, ACRM

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Severity Rating for TBI

Traumatic Brain Injury Description

Severity GCS AOC LOC PTA

Mild 13-15 ≤24 hrs 0-30 min ≤24 hrs

Moderate 9-12 >24 hrs >30min

<24 hrs

>24hrs

<7 days

Severe 3-8 >24hrs ≥24 hrs ≥7 days

GCS- Glasgow Coma Score

AOC- Alteration in consciousness

LOC -Loss of consciousness

PTA- Post-traumatic amnesia

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TBI Clinical Standards: Severity, Stages, Environment

Mild

Moderate

Severe

Penetrating

Acute

Sub-Acute

Chronic

In-theater

CONUS

In-patient

Outpatient

Community

Types of TBI TBI Post-Injury Stages Levels of TBI Care

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Tracking: DoD Totals

0

5000

10000

15000

20000

25000

30000

2000 2002 2004 2006 2008

Data Source: www.DVBIC.org *2009 data does not include Oct - Dec

Num

ber

of T

BI

Cas

es

10

0

10

20

30

40

50

60

70

80

90

2000 2002 2004 2006 2008

Severe/Penetrating

Moderate

Mild

Not Classified

TBI Tracking: Severity Data

Data Source: www.DVBIC.org *2009 data does not include Oct - Dec

Pe

rce

nta

ge

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Tracking: TBI ICD 9 Code Surveillance

310.2 Post concussion syndrome 803.4 851.2

800.0 Fracture of the vault of the skull 803.5 851.3

800.1 803.6 851.4

800.2 803.7 851.5

800.3 803.8 851.6

800.4 803.9 851.7

800.5 804.0Closed fractures involving the skull or face with other bones w/o mention of intracranial injury 851.8

800.6 804.1 851.9

800.7 804.2 852.0Subarachnoid hemorrhage following injury w/o mention of open intracranial wound

800.8 804.3 852.1

800.9 804.4 852.2

801.0 Fracture of the base of the skull 804.5 852.3

801.1 804.6 852.4

801.2 804.7 852.5

801.3 804.8 853.0

801.4 804.9 853.1

801.5 850.0 Concussion w/ no loss of consciousness 854.0

801.6 850.1 854.1

801.7 850.2 950.1 Injury to optic chiasm

801.8 850.3 950.2

801.9 850.4 950.3

803.0Other closed skull fracture w/o mention of intracranial injury 850.5 959.01 Other and unspecified injury to head face and neck

803.1 850.9 995.55 Shaken baby syndrome

803.2 851.0Cortex (cerebral) contusion w/o mention of open intracranial wound V15.5+Ext GWOT TBI codes

803.3 851.1

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Mechanisms of Injury

• Acceleration-deceleration– Combination due to rapid velocity changes of the brain

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Primary: Direct exposure to over pressurization wave

Blast Injury

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Impact Vice Blast Vice Blast “plus”

• Understanding differences in mechanism of injury

• Differences in DTI between blast and impact TBI• Inflammatory markers in animal studies• Computer modeling of blast injury• Physiological, Histological, and/or behavioral

differences between blast and non-blast in shock tubes with rodents

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• A study commissioned by the NFL reports that Alzheimer’s -like memory- related diseases appear to have been diagnosed in the league’s former players vastly more often than in the national population – including a rate of 19 times the normal rate for men ages 30 through 49.

- Study conducted by University of Michigan’s Institute for Social Research

CONCUSSIVE EFFECTS/TBI

Cause for Concern

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Chronic Traumatic Encephalopathy (CTE) Center for the Study of Traumatic Encephalopathy (CSTE) at BU School of Medicine

• “a distinct disease with a distinct cause, namely repetitive head trauma” (Ann McKee, MD, CSTE co-director and neuropathologist)

• CTE diagnosed in 6 former NFL players since 2002, including:– Pittsburgh Steelers - Mike Webster, Terry Long and Justin Strzelczyk– Tampa Bay Buccaneer Tom McHale, died at age 45

• Youngest case to date: 18-year-old boy who suffered multiple concussions in high school football

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Sports Legacy Project Christopher Nowinski and the Sports Legacy Institute

Top: Slide detailing x600 magnification of immunostained neocortex in a non-CTE damaged brain.

Bottom: Slide detailing x600 magnification of Chris Benoit's tau-immunostained neocortex showing neurofibrillary tangles, neuritic threads, and several ghost tangles indicating CTE.

Source: http://www.sciencedaily.com/releases/2007/09/070905224343.htm

Chris Benoit, Professional Wrestler

Image courtesy of Sports Legacy Institute

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Progressive Tauopathy in an athlete withChronic Traumatic EncephalopathyTau-immunoreactive neurofibrillary tangles in the superficial cortical layers of the frontal, subcallosal, insular, temporal, and parietal cortices and the medial temporal lobe; marked accumulation of tau-immunoreactive astrocytes

Coronal sections immunostained for tau with monoclonal antibody AT8 and counterstained with cresyl violetMcKee AC, Cantu RC, Nowinski CJ, et al, J Neuropathol Exp Neurol Volume 68, Number 7, July 2009

Accumulation of abnormal Tau protein in the form of NFTs and NTs in the brain has been confirmed to cause neurodegeneration, cognitive impairment and dementia.

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Clinical Sequelae of Chronic Traumatic Encephalopatby

Symptoms can Include;– Memory disturbances

– Behavioral changes

– Personality changes

– Parkinsonism

– Speech abnormalities

– Gait abnormalities

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Cultural Change

Emerging science supports acute management to include concerns of safety to encourage acute management and evaluation to prevent recurrent concussions before full recovery from prior injury

State Laws:Washington – First state legislation

Oregon, Texas Under consideration: ME, CA, MA, NJ, NY

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Post Concussive Symptoms

Cognitive• Slowed processing

• Decreased attention

• Poor Concentration

• Memory Problems

• Verbal dysfluency

• Word-finding

• Abstract reasoning

Emotional• Anxiety

• Depression

• Irritability

• Mood lability

Physical• Headache

• Dizziness

• Balance problems

• Nausea/Vomiting

• Fatigue

• Visual disturbances

• Sensitivity to light/noise

• Ringing in the ears

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Possible Effects of mTBI

• Acute– Poor marksmanship– Slower reaction time– Decreased concentration

• Chronic– Reduced work quality– Behavioral problems– Emotional problems– “Unexplained“ symptoms

TBI-related impairments increase vulnerability to subsequent injury until full recovery occurs

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DoD Wide Initiatives

• TBI Screening (PDHA/PDHRA)

• TBI Surveillance

• NCAT (Neuro Cognitive Assessment Tool) pre deployment program

• Clinical guidance packages– Cog rehab

– Driving assessments after TBI

– mTBI/PTSD

– mTBI and co occurring conditions

• 4th Annual TBI military training conference ( 30-31 Aug 10)

• TBI Family Caregiver Guide

• TBI Care Coordination• CDMRP bolus of research

funds

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GOAL: A cultural change in fighter management after concussive events: identification and treatment close to point of injury, documentation of the incident, and expectation of recovery with early treatment.

VISION: Every Warrior trained to:

– Recognize the signs/symptoms– Reduce the effects

And in the event of an injury –– Treat early to minimize the impact and

maximize recovery from TBI.

MISSION: Produce an educated force trained and prepared to provide early recognition, treatment, tracking & documentation of TBI in order to protect Warrior health.

Education & Prevention

Early Detection

Treatment& Tracking

Rehabilitation, Recovery,

Reintegration & Research

TBI Management Continuum

Educate – Train – Treat – Track

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Education & Prevention

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Early Detection: Why Screen for TBI?

Studies suggest TBI is a common injury in OEF/OIF

• 16% of returning Army Soldiers screened positive1

• 15% of returning Army Soldiers screened positive2

• 19% of OIF/OEF Veterans screened positive3

• 23% of returning Army Soldiers screened positive4

• 18.5% of Veterans at VA medical centers screened positive5

1.Schwab KA, Ivins B, Cramer G, Johnson W, Sluss-Tiller M, Kiley K, Lux W, Warden B. Screening for traumatic brain injury in troops returning from deployment in Afghanistan and Iraq: Initial investigation of the usefulness of a short screening tool for traumatic brain injury. J Head Trauma Rehabil 2007; 22(6): 377-389.

2.Hoge CW, McGuirk D, Thomas JL, Cox AL, Engel CC, Castro CA. Mild traumatic brain injury in US soldiers returning from Iraq. N Engl J Med 2008; 358(5): 453-463.

3.Schell TL, Marshall GN. Chapter 4, Survey of individuals previously deployed for OIF/OEF. In Tanielian T and Jaycox LH (eds.) Invisible Wounds: Mental Health and Cognitive Care Needs of America’s Returning Veterans. Santa Monica, CA: The RAND Corporation; 2008.

4.Terrio H, Brenner LA, Ivins BJ, Cho JM. Helmick K, Schwab K, Scally K, Bretthauer R, Warden D. Traumatic brain injury screening: Preliminary findings in a US Army brigade combat team. J Head Trauma Rehabil 2009; 24, 14-23.

5.Unpublished data. UNCLASSIFIED

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Early Detection: Why Screen for TBI? (cont’d)

Most TBIs are mild (mTBI)

76% of current military TBIs are mTBI1 (recent surveillance program trying to better define “scope of the problem”)

75% of civilian TBIs are mTBI2

MTBI is often untreated and undocumented

As many as 25% of those with mTBI do not seek medical attention3

Many individuals with mTBI who receive medical attention do not have a TBI diagnosis recorded, especially those with multiple trauma4

1.DVBIC, unpublished data. UNCLASSIFIED2.National Center for Injury Prevention and Control. Report to Congress on Mild Traumatic Brain Injury in the United States: Steps to

Prevent a Serious Public Health Problem. Atlanta, GA: Centers for Disease Control and Prevention; 2003.3.Sosin DM, Sniezek JE, Thurman DJ. The incidence of mild and moderate brain injury in the United States, 1991. Brain Inj 1996; 10:

47-54.4.Moss NEG, Wade DT. Admission after head injury: How many occur and how many

are recorded. Inj 1996; 27: 159-161.

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Locations Where TBI Screening Occurs

• In-theater

• Landstuhl Regional Medical Center (LRMC)

• CONUS, during Post Deployment Health Assessment (PDHA) and Post Deployment Health Re-Assessment (PDHRA)

• VA Medical Centers

Diagnosis is confirmed through clinical interview

Numerous screening safety nets to ensure capture of Service members requiring intervention

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9.a. During this deployment, did you experience any of the following events? (Mark all that apply)

(1) Blast or explosion (IED, RPG, land mine, grenade, etc.)

(2) Vehicular accident/crash (any vehicle, including aircraft)

(3) Fragment wound or bullet wound above your shoulders

(4) Fall(5) Other event (for example, a sports injury to your

head). Describe:

9.b. Did any of the following happen to you, or were you told happened to you, IMMEDIATELY after any of the event(s) you just noted in question 9.a.? (Mark all that apply)

(1) Lost consciousness or got “knocked out”(2) Felt dazed, confused, or “saw stars”(3) Didn’t remember the event(4) Had a concussion(5) Had a head injury

9.c. Did any of the following problems begin or get worse after the event(s) you noted in question 9.a.? (Mark all that apply)

(1) Memory problems or lapses(2) Balance problems or dizziness(3) Ringing in the ears(4) Sensitivity to bright light(5) Irritability(6) Headaches(7) Sleep problems

9.d. In the past week, have you had any of the symptoms you indicated in 9.c.? (Mark all that apply)

(1) Memory problems or lapses(2) Balance problems or dizziness(3) Ringing in the ears(4) Sensitivity to bright light(5) Irritability(6) Headaches(7) Sleep problems

Positive screen = concurrence to all four questions

Positive screen ≠ concussion diagnosis

Need clinician confirmation to diagnose concussion

Post-Deployment Health Assessment/ Reassessment

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Goal: A cultural change that focuses on leadership, service member and medical personnel mutual responsibilities after concussive events

Vision: Every Warrior treated appropriately to minimize concussive injury and maximize recovery

Mission: Produce an educated force trained and prepared to provide early recognition, treatment & tracking of concussive injuries in order to protect Warrior health. Educate - Train - Treat - Track

Warrior mTBI Management

As of: 27 October 2009

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Early Detection In-theater Clinical Practice Guidelines

SCENARIOS REQUIRING MANDATORY MEDICAL SCENARIOS REQUIRING MANDATORY MEDICAL SCREENINGSCREENING

• Mounted: All personnel in any damaged vehicle (e.g. blast, accident, rollover, etc)

• Dismounted: All within 50m of a blast; All within a structure hit by an explosive device

• Anyone who sustains a direct blow to the head or loss of consciousness

• Command Directed– NOT limited to repeated exposures

Currently Being Codified in Directive Type Memorandum (DTM)

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Early Detection In-theater Clinical Practice Guidelines

MEDICAL SCREENING REQUIREMENTSMEDICAL SCREENING REQUIREMENTS

• ALL RECEIVE– Medic/corpsman evaluation (MACE)– Minimum 24 hrs downtime– Medical re-evaluation pre-RTD– Event capture/tracking

• mTBI/concussive event– Medical evaluation above with physician, PA or NP oversight

• Witnessed loss of consciousness– Neurological evaluation by physician, PA or nurse practitioner – Loss of consciousness greater than 5 minutes requires evacuation

to Level III facility

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MACE: Military Acute Concussion Evaluation

• Developed by DVBIC and released in Aug 2006

• Performed by medical personnel

• 3-Part Screening Tool – “CNS”

– Cognition– Neurological Exam– Symptoms

• Alternate versions available• Upcoming revision will

include recurrent concussion questions

• Can be used during exertional testing to ensure that cognitive function remains intact

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MILD TBI• Primary Care• Referral to TBI specialist after

initial management failure• Core TBI interventions (if

required) may include:– Cognitive rehabilitation– Vestibular/balance therapy– Medication management– Vision therapy– Driving rehabilitation– Assistive technology– Tinnitus management– Headache Management– Complementary and alternative medicine

interventions

Treatment

MODERATE / SEVERE / PENETRATING

• In-theater Acute Field Management

• First Responder actions (Combat Lifesaver)

• Neurosurgical theater presence• Continuing evolution of air

transport capabilities• DoD TBI centers, VA

Polytrauma Rehabilitation Centers, Civilian Rehabilitation Programs

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Treatment: Headache

Episodic Headache•Characterize type•Abortive therapy

•Maximum 6 doses/week

Chronic Daily Headache•> 15 HA days per month•Analgesic rebound•Prophylaxis is key

Abortive

NSAIDs•GI side effects

IbuprofenNaproxen SodiumAcetaminophenAspirin

Triptans•Contraindicated in patients with CAD

CombinationMedications•Cognitive side effects•Risk of W/D

FioricetFiorinalMidrin

ProphylaxisOnset of action ~ 4 wks

Beta-blockers•Non-selective may have benefit on autonomic effects of PTSD

Propranolol

Anti-depressants•May improve mood•Improves sleep

NortriptyllineAmitryptillineParoxetineFluoxetine

Anti-epileptics

•Neuropathic pain

gabapentin•Mood lability valproic acid topirimate

AlternativesPromethazineMetoclopramideProchloroperazineTizanidineNon-medicationTrigger point injectionOccipital nerve blockPhysical therapy

Avoid Narcotics& Benzodiazipines

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Cognition Memory loss or lapse

Forgetfulness

Poor concentration

Decreased attention

Slowed thinking

Executive dysfunction

Administer: MACE if injury within 24 hours,

Other neurocognitive testing as available (eg ANAM or other neuropsychological testing)

Gather: Collateral information from family, command and others

Normalize sleep & nutrition

Pain control

Refer: Speech/language pathology

Occupational therapy

Neuropsychology

Table 1DVBIC/DCoE MAR08 Concussion Management Grid

Treatment: Cognitive Deficits

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Treatment: Cognitive Rehabilitation in mTBI

• Accelerating but still small body of scientific literature supporting cognitive rehabilitation in mTBI

• DoD Programs (inventory of current programs)• Outsourced care vs MTF provided• DCoE/DVBIC Consensus Conference – April 2009

– 2-day; 50 members– DoD (Quad Service)/DVA representation– SOCOM/Reserve Affairs representation– Civilian Subject Matter Experts

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Treatment: Cognitive Rehabilitation (cont’d)

• Cognitive domains affected after TBI– Attention

• Foundation for other cognitive functions/goal-directed behavior• Efficacy of attention training established

– Memory• True memory impairment vs poor memory performance from

inattention• Evidence to support development of memory strategies and

training in use of assistive devices (‘memory prosthetics’)– Social/Emotional

• Evidence to support group sessions in conjunction with individual goal setting

– Executive Function• Evidence to support training use of multiple step strategies,

strategic thinking and/or multitasking

• Compensatory vs restorative therapy

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TBI and Co-occurring Conditions

• PTSD• Pain• Substance Use Disorders• Dual Sensory Impairments• Depression• Anxiety• Suicide

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Prevalence of PTSD, mTBI and Pain

PTSD N=23268.2%

2.9%16.5%

42.1%

6.8%

5.3%

10.3%

12.6%

TBI N=22766.8%

Chronic Pain N=27781.5%

340 OEF/OIF Veterans evaluated at VA Boston Polytrauma site, Lew et al, In press

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Toolkit Development

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Toolkit Development• Layout

– Importance of assessment • Understanding the potential diagnoses behind the symptoms

– First appointment tips• Requested by primary care

– Primary symptoms• Sleep• Mood• Attention• Chronic Pain

– Medication Appendix• Cross-walk table• Reference list of medications

– Patient Resources– Provider Resources

• Websites• Outcome measures and recommended assessment/re-assessment tools

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Functional Imaging

• Assessment of Neuronal/Metabolic Function

• Informing DoD policy --Undiagnosed concussion can result in:

– Symptoms affecting operational readiness

– Risk of recurrent concussion during the healing period

High Activity

Low Activity

Concussion Severe TBI

Normal

Bergsneider et al., J Neurotrauma 17:2000

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Imaging: mTBI and DepressionAn fMRI Study of Male Athletes

• Athletes with symptoms of depression with onset after concussion showed reduced activation in the dorsolateral prefrontal cortex and striatum, and attenuated deactivation in medial frontal and temporal regions.

• The severity of symptoms of depression correlated with neural responses in brain areas that are implicated in major depression.

• Voxel-based morphometry confirmed gray matter loss in these areas.

• Conclusion: Depressed mood following a concussion may reflect an underlying pathophysiology consistent with a limbic-frontal model of depression.

Neural substrates of symptoms of depression following concussion in male athletes with persisting postconcussion symptoms. Chen JK, et al. Arch Gen Psychiatry. 2008 Jan;65(1):81-9.

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TBI Research: Novel/Innovative Areas of Inquiry

• Illustrative Examples:– Omega-3 fatty acids

– Progesterone

– Transcranial laser therapy

– Transcranial magnetic stimulation

– Neurofeedback (EEG biofeedback/neurotherapy)

– Hyperbaric oxygen

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• Objective: better inform return to duty determinations in the field following TBI beyond exertional testing and MACE

• NCAT– Over 500K baselines– Army ANAM Ops

• Vestibular Balance Plate Testing

– Under development

• Nystagmus Detection – Under development

Treatment: Return to Duty Determination

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Neurocognitive Assessment Tool (NCAT)/Automated Neuropsychological Assessment Metrics (ANAM)

• Computerized neurocognitive assessment tool• Purpose:

– Establish an accurate assessment of pre-injury cognitive performance for comparison in post-injury return to duty (RTD) decisions

• One piece of clinical picture• Selective use for those with more clinically challenging cases

• Takes 20 minutes to complete• Current policy (May 08):

– All pre-deployers receive baseline cognitive testing with ANAM within one year of deployment

• Other tools being studied head-to-head• Better assessment if injured SM is compared to their baseline

scores as opposed to a normative databank

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Patient, Family and Caregiver Education

Office of the Surgeon General/Army Medical

Department Health Policy & Services

Proponency Office for Rehabilitation &

ReintegrationCurriculum for

Traumatic Brain Injury

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Family Caregiver Curricula

• 4 Modules:– Module 1: Introduction to TBI

(learning about the brain, acute care issues, complications)

– Module 2: Understanding Effects of T BI and What You Can do to Help (physical , cognitive, communication, behavioral, emotional)

– Module 3: Becoming a Family Caregiver for a Service Member/Veteran with TBI (starting the journey, caring for SM and yourself, finding meaning in caregiving)

– Module 4: Navigating the system (recovery care, eligibility for compensation and benefits)

• Due to be released by Summer 2010

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Provider Resources

• DCoE : www.dcoe.health.mil– Outreach Center: 866.966.1020– Monthly video teleconferences

• DVBIC: www.dvbic.org– Annual TBI Military Training Conference– Education coordinators– TBI.consult: tbi.consult@us.army.mil

• VA/DoD mTBI/Concussion CPG Fact Sheet• ICD-9 DoD TBI Coding Fact Sheet• Service TBI POC

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Public Service Announcements

• NFL: Take Head Injuries out of Play http://www.nfl.com/videos/nfl-network-around-theleague/09000d5d814d2543/Concussion-safety

• DoD: Protect your most valuable weapon – your head! http://www.facebook.com/video/video.php?v=104824466213664

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Regional Care Coordination Program launched Nov 2007

• Provide 100% follow-up to identified Service Members with Traumatic Brain Injury (mild, moderate, severe and penetrating) from 13 regional catchment areas across the US

• Monitor the care continuum for traumatic brain injury to include potential rehabilitation needs, education, advocacy and support to Service Members with TBI and their families from injury to return to duty and/or re-entry into the community

• Identify and connect Service Members to available TBI resources within DoD, VA and civilian communities

• Provide education and support-serving as a TBI subject matter expert to all involved in the care and support of the Service Member and family.

• Identify barriers and/or gaps in service delivery for TBI Service Members as they transition between systems and settings

• Functional outcomes picture to look at quality of life issues related to home, work and social environments

53Draft

Rehabilitation, Recovery, Reintegration DoD TBI Programs

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DVBIC Virtual TBI Clinic

• TBI screening, assessment, consultation & care to:

– Patients at remote military medical centers– Troop intensive sites where demand fluctuates

with mass mobilizations

• Direct specialty care via VTC • Local PCPs provide on-site

testing and therapy• Multiple specialties

– Neurology, neuropsychology, pain management, rehabilitation

• Contact DVBIC if interested in establishing dedicated connection to Tele-TBI Clinic

– 800.870.9244

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Research & Development

Blast Physics/Blast Dosimetry

Force Protection Testing & Fielding

Complementary Alternative Medicine

Field Epidemiological Studies (mTBI)

Rehabilitation & Reintegration:

Long Term Effects of TBI

Neuroprotection & Repair

Strategies: Brain Injury Prevention

Concussion: Rapid field

Assessment (e.g., Biomarkers/

Eye Tracking

Treatment & Clinical Improvement (e.g. Hyperbaric

Oxygen Therapy, Cognitive Rehab)

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Research & DevelopmentCDMRP Funded Studies

TBI Drugs

TBI Other InterventionsPI Funded in Hawaii

Funded TBI Investigators

Awards range from $150K over 18 months to $4M over 4 years

201 Proposals selected from a pool of 2110 applicants

PH Research GapsTreatment and Intervention Prevention Measures in Screening/

Detection/Diagnosis Epidemiological Studies Families/CaregiversNeurobiology/Genetics

TBI Research GapsTreatment and Clinical Management Neuroprotection and Repair Rehabilitation/Reintegration Field Epidemiology Physics of Blast

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Way Forward

• Fast tracking of medical research projects to translate findings to Service members in the field

• TBI & Co-occurring disorders– PTSD– Dual Sensory Impairments: Visual and Auditory– CPG’s addressing these

• Directive-type memorandum (DTM)– Early detection and Early treatment

• In theater based care– Role II centers

• Ongoing efforts to promote the linkage of blast tracking with medical data/science

• Training and Education efforts

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Questions?