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DHA Centers of Excellence collaborate to improve TBI care

Medical personnel holding a model of the inner ear Elizabeth Kirkpatrick, the physical therapist for the Fort Drum Traumatic Brain Injury Clinic at Fort Drum, New York, uses a model of the inner ear to show how a concussion can lead to dizziness and other problems. (Photo by Warren Wright Jr., Fort Drum MEDDAC.)

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When a rocket-propelled grenade struck her helicopter in Afghanistan in 2011, Army Staff Sgt. Beth King sustained a traumatic brain injury and was later diagnosed with post-traumatic stress disorder. Following the event, she experienced headaches, difficulty concentrating, and problems moving around.

King’s story in the A Head for the Future video series shares how she overcame balance issues and learned to pedal a recumbent bicycle and went on to win a gold medal in cycling at the 2019 Warrior Games.

King’s story illustrates the critical role collaboration plays among the Defense Health Agency’s centers of excellence in improving recovery from a traumatic brain injury (TBI).

“Patients often have comorbid conditions such as headache, vertigo, dizziness, and visual disturbances. The joint efforts of the TBI, Psychological Health, Vision, and Hearing Centers of Excellence allow us to cover all aspects of care and management with these unique cases,” said Gary McKinney, chief of clinical practice and clinical recommendations at the Traumatic Brain Injury Center of Excellence (TBICoE) in Silver Spring, Maryland. The centers of excellence are divisions of the Defense Health Agency Research and Development Directorate.

Military soldier looking through a pair of colored glasses
A TBI patient at the Intrepid Spirit Center on Fort Bragg, North Carolina, uses colored glasses as part of vision rehabilitation, Dec. 15, 2017. (Photo by Army Sgt. Paige Behringer.)

Dizziness, for example, touches the work being done at several DHA centers of excellence, as damage to different parts of the brain or vestibular system in the inner ear can affect balance, vision and hearing.

According to one study, vestibular complaints were reported by half of TBI patients five years after injury. In 2018, TBICoE revised its clinical screening tool, now called the Military Acute Concussion Evaluation 2, to aid in assessing balance. Recently, TBICoE began revising its 2012 recommendation on dizziness, in collaboration with both the vision and hearing centers. The earlier recommendation was also a collaborative endeavor, based on the results of a 2011 conference consensus.

Vision problems related to TBI also provide opportunities to collaborate.

“It has been estimated that between 43% and 75% of people experiencing TBI events will also experience some form of vision dysfunction, which is why it is beneficial to have eye care professionals assess vision in patients who are involved in a TBI event,” said Dr. Michael Pattison, an optometrist and program manager at the Vision Center of Excellence (VCE). TBICoE participated in developing VCE’s clinical recommendations for treating vision dysfunction in TBI patients. TBICoE staff, including Division Chief Navy Capt. (Dr.) Scott Pyne, served on VCE’s working group, along with vision specialists and other subject matter experts.

TBICoE also worked closely with DHA’s Psychological Health Center of Excellence (PHCoE) to address TBI and PTSD for military health care providers. TBICoE produced a research review on these often co-occurring conditions.

Pattison also pointed out how collaboration contributed to DHA’s mission of satisfied patients and mission readiness.

“With these centers of excellence working together, we can utilize our biggest strengths, the variety of perspectives and experiences we all possess, to provide those that we are entrusted to take care of with the best possible solutions for assisting them to return to full duty and their highest quality of life,” he added. “It has to be a collaborative team approach to meet that mission.”

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March is Brain Injury Awareness Month. Be TBI Ready. A traumatic brain injury—or TBI—is a blow or jolt to the head that disrupts the normal function of the brain. The severity of the TBI is determined at the time of the injury and may be classified as: mild, moderate, severe, or penetrating.

During Brain Injury Awareness Month, TBICoE and the MHS will promote the theme “Be TBI Ready” — recognizing that health care providers and others in the military community need to be aware of the latest educational trainings, research, fact sheets, and other available resources to prevent, diagnose, and treat TBI.

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Returning to Duty After Concussion

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What's the best way to recover from a concussion? Returning to duty too soon after a concussion can lead to prolonged symptoms, decreased readiness, poor marksmanship, accidents and falls, and increased risk of more concussions. Progressively increasing activity in a step-wise manner can help you resolve your symptoms and return to duty safely. Ask your primary health care provider about TBICoE's Progressive Return to Activity to help you return to duty as quickly and safely as possible. Visit health.mil/TBICoE.

This TBICoE infographic gives an overview of the risks of returning to duty too soon after a concussion and explains how a progressive increase in activity can help get you back to duty safely. Returning to duty too soon after concussion can lead to prolonged symptoms, poor marksmanship, decreased readiness, accidents and falls, and increased risk of more concussions.

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"Sleep After Concussion" is intended for patients and caregivers of those who have sustained a TBI. The infographic reviews general information of sleep-related concerns and points towards additional educational resources.

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Diagnoses of Traumatic Brain Injury Not Clearly Associated with Deployment, Active Component, U.S. Armed Forces, 2001 – 2016

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Traumatic Brain Injury (TBI) is structural alteration of the brain or physiological disruption of brain function caused by an external force.  TBI, particularly mild TBI or concussion, is the most common traumatic injury in the U.S. military. This analysis provides the estimated rates of incident TBIs among service members before their first-ever deployment as well as separately among service members during deployments/ after deployments. It also mentions factors that may explain why the TBI incidence rates among the previously deployed were higher than those of the never-deployed group. Moreover, it describes the demographic and military traits of service members diagnosed as TBI cases (before/after deployment). Categorization of person time during surveillance period included four categories: Group 1 (Never deployed/TBI before first-ever deployment), Group 2 (Currently deployed or within 30 days of return), Group 3 (previously deployed but not currently deployed nor within 30 days of return) and Censored after Diagnosis of TBI. From 2001-2016, 276,858 active component service members received first-time diagnoses of TBI. The crude overall incidence rate of TBI among deployed service members was 1.5 times that of service members assigned to Group 1 and 1.2 times that of service members in Group 3 during the surveillance period.  Total TBI cases by group were Group 1 42.8%, Group 2 13.2% and Group 3 44.0%. Incidence rates by group (per 100,000 person-years) were Group 1 1,141.3, Group 2 1,690.5, and Group 3 1,451.2. Learn more at www.Health.mil/MSMR and see fact sheets at www.Health.mil/AFHSB

Traumatic Brain Injury (TBI) is structural alteration of the brain or physiological disruption of brain function caused by an external force. TBI, particularly mild TBI or concussion, is the most common traumatic injury in the U.S. military. This analysis provides the estimated rates of incident TBIs among service members before their first-ever deployment as well as separately among service members during deployments/ after deployments. It also mentions factors that may explain why the TBI incidence rates among the previously deployed were higher than those of the never-deployed group. Moreover, it describes the demographic and military traits of service members diagnosed as TBI cases (before/after deployment).

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