Treating the Signature Injury

Abstract

You have accessThe ASHA LeaderFeature1 Jul 2012Treating the Signature Injury Carole R. RothPhD, CCC-SLP Carole R. Roth Google Scholar More articles by this author , PhD, CCC-SLP https://doi.org/10.1044/leader.FTR3.17082012.np SectionsAbout ToolsAdd to favorites ShareFacebookTwitterLinked In The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the U.S. government. Jason arrived by military transport to the Naval Medical Center in December. Jason, an explosive ordinance disposal specialist, sustained a concussion and injuries to his foot when he stepped on an IED while deployed to Afghanistan. He was blown off his feet and felt dazed and disoriented for a few seconds. After being medically stabilized and assessed for a concussion, he was transported to Landstuhl Regional Medical Center where he remained for four days before being transported to San Diego, one week after being injured. He was hospitalized for several weeks at the Naval Medical Center where he underwent multiple foot surgeries including amputation before being discharged from inpatient status to the Wounded Warrior Barracks, where he resided during his outpatient polytrauma rehabilitation. Jason was assigned a primary nurse case manager who tracked his discharge from Landstuhl and alerted the rehab team in San Diego to his medical needs. Following hospital discharge, Jason’s first outpatient appointment was an interview and evaluation by a primary care provider on the combat care rehabilitation team. The primary care provider submitted a consult to speech pathology for screening of cognitive communication abilities and to audiology and otolaryngology for post-deployment hearing evaluations. When seen for the initial intake by a speech-language pathologist, Jason was focused solely on moving forward with his amputation care. He admitted to experiencing slow thinking and memory difficulties, pain for which he was taking narcotics, disordered sleep, and post-traumatic stress. The day before he was injured, Jason saw a close friend get blown up and die from blood loss. Jason was a well-spoken, articulate young man who did well in high school and had specific goals to complete his undergraduate degree. As he was mourning the loss of his buddy, he was also able to think about and plan for his future. Jason commented to this clinician that he felt he owed it to his buddy to make something of his own life (see full case study below). As a civilian speech-language pathologist who works for the U.S. Navy, my workday begins with a walk across a cement bridge that brings me onto the Naval Medical Center San Diego (NMCSD). Even though I’m not boarding an actual ship, each day when I pass through the gate, I am greeted with, “Welcome aboard, Ma’am,” by a U.S. Navy security guard. In many ways, the NMCSD appears as a large naval vessel, with its many long ramps that serve as bridges from the parking areas to the hospital and clinic buildings. At 0755 each morning, employees and visitors are alerted by a single bugle, the “first call” to colors, and at 0800 the bugle alerts everyone to stop, face the flag pole, and salute as the colors (flag) are posted (raised) while the national anthem blares out across the Command. The Speech-Language Pathology Division of the Department of Otolaryngology consists of four clinicians who support military medicine by delivering care to service members and their spouses and children. Each day brings a full schedule with new challenges. The caseload ranges from evaluating the speech and resonance of a preschooler who has a repaired cleft lip and palate to conducting modified barium swallow studies and voice evaluations. Since 2009, however, the largest caseload has been wounded warriors, many of whom live on the Command in the Wounded Warrior Battalion (WWB) (barracks). Every day wounded service members are discharged from inpatient wards to the WWB to begin their outpatient rehabilitation. Others are admitted directly into the WWB after arriving by medical transport from the Middle East via Landstuhl Regional Medical Center. Signature Injury Since 2000, more than 233,425 service members deployed to Iraq and Afghanistan have sustained a traumatic brain injury (TBI), mostly resulting from blasts, making this the “signature injury” of the Middle East conflicts. Concussion or mild TBI—(m)TBI—is the most common brain injury sustained. The large increase in the incidence of (m)TBI among service members seen after 2005 can be explained by the increased science and understanding of these invisible injuries and the increased identification and tracking of the number of individuals sustaining TBI. Many service members were and are exposed to multiple explosions and repeat concussions. In recognition of this increasing incidence, in 2007 the Department of Defense (DoD) revised its approach to treating service members with (m)TBI. First, a definition of (m)TBI was formally adopted, consistent with definitions previously established by respected national and international organizations (see chart [PDF]). Mild TBI, or concussion, is defined as “a traumatic event that causes a disruption in brain function resulting in at least one of the following clinical signs immediately following the event: loss of or alteration of consciousness, which is measured by a Glasgow Coma Scale (GCS) score of 13–15; loss of memory for events immediately before or after the event, measured as post-traumatic amnesia (PTA); confusion, disorientation, or slowed thinking; other neurological deficits; or the presence of an intracranial lesion.” After these terms were defined, the DoD and Veterans Administration (VA) set out to identify service members and veterans who sustained TBI while deployed—the VA screened post-deployed veterans and the DoD aimed for early detection. Early detection was recognized as important for maintaining a more healthy and productive military force. In 2010, the DoD issued a directive stating that it was official policy to identify, track, and protect to the fullest extent possible service members exposed to potential concussive events, including blasts. This policy includes a medical evaluation in the combat zone for any service member exposed to such an event and directs the management of concussion treatment in theater with the use of approved clinical guidance [PDF]. The Continuum The Continuum of Care for mTBI as established by the Department of Defense’s Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury defines the current model of military care for troops deployed to the combat zones at risk of sustaining mTBI. The continuum begins with education and prevention of mTBI; at the opposite end of the continuum is the goal of reintegration into the military or civilian life for those who sustain brain injuries. The mission is to produce an educated force trained and prepared to provide early recognition, tracking, treatment, and documentation of TBI to protect the health of deployed service members (Helmick, 2011). Education involves training every service member to recognize the effects of TBI. Prevention is addressed through improvements in protective gear, including efforts to increase the protection of the helmets and still provide the greatest comfort. For example, researchers are examining the potential for embedding pressure monitors in the helmets to measure the extent of blast pressure sustained by the solder during an IED blast. Early detection involves mandatory screening for mTBI/concussion in theater, immediately following the injury event or as soon as operationally feasible. Even the most severely injured are screened for concussion (Defense and Veterans Brain Injury Center, 2006). The MACE tool (see sidebar below) allows medics/corpsmen and front line providers to identify co-morbid TBI quickly in the context of polytrauma and to ensure proper transportation to an appropriate facility (Defense Centers of Excellence, 2009). But MACE alone does not diagnose concussion/mTBI. Anyone who is evaluated must wait 24 hours and be re-evaluated prior to resuming duties. Any service member who loses consciousness during the event must undergo a neurological evaluation by a physician, physician assistant, or nurse practitioner. Tracking consists of a medical evaluation and a period of rest, which has been shown to be the best care for optimal recovery from a concussion (Mittenberg, Tremont, Zielinski, Fichera, & Rayls, 1996). The service member is tracked for recovery from symptoms and does not return to combat until symptoms have resolved. Anyone who sustains three or more mTBIs within 12 months is evacuated to the continental United States for a comprehensive neuropsychological evaluation. Treatment consists of a standardized educational component to help the service member understand the nature of his or her blast exposure relative to cognitive communication concerns, and to promote a message of positive prognosis and expectations for recovery. Research suggests that 90% of all individuals suffering a concussion resulting from mTBI see full resolution of symptoms within one week. Communicating this fact to an affected service member can greatly aid recovery. Promoting accurate symptom reporting and active management of persistent symptoms can lead to a quick and complete return to duty for affected personnel (Doria, 2012). As a result of these findings and increased understanding of mTBI, the DoD is emphasizing in-theater treatment and recovery when possible. Rehabilitation, recovery, and reintegration are the final stage of the continuum. In 2010, the first concussion rehabilitation care center (CRCC) was established in Afghanistan to provide evidence-based intervention to facilitate rest, recovery, and reintegration or return to the combat zone (Iverson, Brooks, Collins, & Lovell, 2006; McCrea et al., 2008; (Mittenberg, Canyock, Condit, & Patton, 2001). The goal of the CRCC is to treat service members with persisting post-concussive symptoms without polytrauma to get them back into the fight safely. Since Aug. 30, 2010, almost 1,800 wounded service members received treatment at the CRCC; 36 were returned to the United States for further evaluation and intervention. The average length of stay at the CRCC is 13 days before the service member is sent back to combat. Service members who sustain polytrauma, including mTBI (like Jason in the case study) are medically evacuated to the United States, some to the Naval Medical Center in San Diego, for more comprehensive medical and surgical care and multidisciplinary rehabilitation, including speech-language pathology and audiology services. NMCSD Model of Care When the Speech-Language Pathology Division at NMCSD receives consultations for active duty service members with combat-related mTBI, we initially screen each individual for cognitive-communication concerns, including concentration, memory, social communication, word-retrieval, planning, problem-solving, and reasoning, to determine if further evaluation is needed (Cherney et al., 2010). Screening for cognitive–communication concerns consists of: An interview reviewing the history of mTBI beginning with the most recent event, date/time post-onset, duration of alteration or loss of consciousness, onset and duration of symptoms; history of previous concussion or TBI, and any persisting symptoms; a history of learning difficulties and diagnoses; a detailed list of current concerns (listed from most to least) with specific examples of functional daily impact on quality of life. Cognitive-linguistic screen (this may be an informal assessment of concrete and abstract verbal reasoning and memory skills or a formal test, such as the Cognistat, Cognitive-Linguistic Quick Test, or Repeatable Battery for the Assessment of Neuropsychological Status). A self-assessment of cognitive communication concerns (adapted from Sohlberg et al., 2001). If the patient denies persistent concerns and screens negative, no further evaluation or intervention is recommended. If the patient denies persistent concerns and screens positive, further evaluation is completed if the patient is willing. When a patient is willing to return for further evaluation, and findings are positive, then a short-term treatment plan is defined to include diagnostic treatment. If the deficits are affecting the patient’s level of functioning, sessions are recommended to focus on facilitation and compensatory strategies to address any attention, memory, or organization inefficiencies. When the patient expresses concerns and screening is negative, a short term of treatment is offered—two to four sessions of education related to the complex nature of TBI sustained in combat, its co-morbidities, and their role in contributing to cognitive impairments. We acknowledge the patient’s concerns and reinforce the prognosis and expectation of recovery. We provide and train them to use assistive technology for facilitating and compensating for cognitive concerns. It is well accepted that early identification of deficits can lead to resolution of symptoms with education about brain injury and its consequences, counseling regarding the recovery process, and guidance about ways to monitor and adjust daily cognitive and communication demands to allow the brain to recover (Roth, 2008). We assist patients in understanding that, similar to the recovery process from major injury to other parts of the body, the brain requires rest and modified demands to allow it to recover. Therefore, we introduce compensatory and facilitation strategies (see full case study). When screening results in positive findings of impairment, we complete a formal evaluation to determine a treatment plan. This evaluation includes a broad cognitive assessment followed by domain-specific tests of attention, memory, information processing speed, etc. (Cornis-Pop et al., in press). The typical program of treatment is a combination of individual and group cognitive-communication therapy addressing one or more of the following domains: Attention/concentration Speed of information processing Memory Executive functions including organization, reasoning, insight, judgment, problem-solving. Self-awareness and self-regulation Social communication, including pragmatics and conversational fluency Therapy tasks focus on functional tasks as well as the use of assistive technology and apps that are available for use on patients’ smartphones, iPod Touches, iPads, and computers (Wild, 2012). Evidence-based practice is available for a number of these domains and further information can be found on the DoD website [e.g.,Cognitive Rehabilitation for Mild Traumatic Brain Injury–Consensus Conference–2009 [PDF], Helmick et al., 2010]. Cognitive rehabilitation combines individual and group therapy and includes interventions with occupational therapy and neuropsychology. The service member frequently has a comprehensive list oftherapeutic appointments including occupational and physical therapy, vestibular therapy, recreational therapy, wellness, nutrition services, and speech-language services. Each patient receives the same message from all health care providers: the expectation of recovery with sleep hygiene, good diet, exercise, and mental health services. Going Forward Jason’s self-confidence contributed to his successful rehabilitation. He was able to laugh at himself and was not afraid to display his impairments. He was encouraged to self-monitor for situations or contexts that triggered increased and decreased cognitive-communication performance. We instructed him to use strategies and technology to improve his functional performance across cognitive-linguistic and communication tasks, with the long-term goal of returning to college. He successfully enrolled in a class on the Command and reported to the clinician that he was pleased with his progress and planned to return to school in his hometown as soon as he was medically discharged. As a result of the conflicts in the Middle East and the number of injured, notably the number of mTBIs, rehabilitation care has advanced and is supported by clinical research and clinical practice across all the military branches.Clinical practice guidances now assist health care providers in evaluating and treating wounded warriors for (m)TBI, post-traumatic stress disorder, headaches, sleep disorders, dizziness, balance problems, etc. The NMCSD Speech-Language Pathology Clinic has screened and treated more than 600 service members with post-concussion symptoms since 2006 and contributed to increased understanding of (m)TBI through: Development of a position statement describing the role of the SLP and audiologist in working with post-combat injured service members (Cherney et al., 2010). Participation in a consensus conference to explore and define the process for providing cognitive rehabilitation for mTBI (Helmick et al., 2010). Development of clinical practice guidance for cognitive-communication rehabilitation for combat-related mTBI (Cornis-Pop et al., in press). Additionally, a multidisciplinary rehabilitation toolkit is in the review process (see sidebar below). With the recent establishment of the rehabilitation centers in the combat zone and the establishment of the continuum of care, more service members are able to stay in the fight and return home healthy. The focus is on successful reintegration back into their personal and professional lives. For those individuals with persisting deficits, a dedicated and trained rehabilitation team of specialists is addressing their cognitive communication symptoms and reassuring them that the odds of recovery are in their favor. They are young and their future can be bright. Statement by Carole R. Roth and Michael E. Hoffer: We are military service members (or employees of the U.S. Government). This work was prepared as part of our official duties. Title 17, USC, §105 provides that ‘Copyright protection under this title is not available for any work of the U.S. Government.’ Title 17, USC, §101 defines a U.S. Government work as a work prepared by a military service member or employee of the U.S. Government as part of that person’s official duties. Audiology and TBI by Michael E. Hoffer Mild traumatic brain injury (mTBI) secondary to blast exposure and/or blunt head injury is associated with a variety of hearing complaints. Work in our lab has demonstrated that as many as 49% of those with mTBI have some audiological symptoms. The most common audiological symptoms are tinnitus and hearing loss but both of these disorders have a variety of underlying pathophysiology. The most common disorders seen (roughly in the order of presentation) are: Tympanic membrane perforation with and without conductive hearing loss Tinnitus Sensorineural hearing loss Mixed hearing loss Central auditory processing disorder (CAPD) Our institution uses a comprehensive approach to these disorders. Patients are initially evaluated with an audiogram followed by a visit with a neurologist. Perforations and conductive hearing losses are watched for six months (as 80% will resolve spontaneously). Those whose difficulties do not resolve spontaneously will have surgery to repair the eardrum and/or the bones of hearing. Individuals with sensorineural hearing loss or mixed hearing loss with a significant sensorineural component will receive a trial hearing aid, if appropriate. Those who fail such a trial, have hearing loss too significant for a hearing aid, or have deafness in one or both ears are eligible for a variety of implantable ear devices. Naval Medical Center San Diego offers the most extensive collection of hearing implantable devices in the United States, from standard cochlear implants to novel middle ear devices. Those with CAPD are managed jointly by audiology and speech pathology. Finally, a new program of tinnitus retraining therapy is underway in our lab, combined with two new IRB-approved studies examining new management strategies for tinnitus. Balance disorders are the most frequent abnormality seen with mTBI injury secondary to blast exposure and/or blunt head injury. Ninety percent of service members with mTBI will have some form of balance disorder. The most common are: Blast-induced disequilibrium with or without vertigo Post-traumatic spatial disorientation Post-traumatic migraine-associated dizziness Exertionally induced dizziness Benign positional dizziness Superior semicircular canal dehiscence Meniere’s disease Our institution uses a comprehensive management strategy for these patients. After an initial audiogram, the patients see our neurotologist, who evaluates the patient and makes a referral to audiology for any of a number of special balance tests and to vestibular rehabilitation for an evaluation. This entire process is scheduled to be reduced to a single-initial-visit, multidisciplinary management protocol in August 2012. Management of these individuals varies depending on the diagnosis, but usually includes medications and vestibular rehabilitation therapy, and may require surgery. Two new protocols to examine the treatment of these individuals are beginning in the near future. It is critically important to understand the beneficial contributions afforded by attention and management of patients’ cognitive, hearing, and sleep disorders. Capt. Michael E. Hoffer, USN, MD, director of the Spatial Orientation Center at the Naval Medical Center, San Diego, is board-certified in otolaryngology and neurotology. His research has focused on the basic science, diagnosis, and treatment of vestibular disorders. He has studied inner ear drug delivery and basic human vestibular mechanisms, and most recently has examined the effect of head injury on vestibular and cognitive function. Contact him at [email protected]. Rehabilitation Toolkit A toolkit for the rehabilitation of patients with mTBI was developed by a group of VA/DoD rehabilitation specialists (occupational and physical therapists, speech-language pathologists, and optometrists) to address persisting post-concussive symptoms [PDF]. The toolkit was designed to be used as a therapeutic “go-by” for any type of health care provider, in combat theater as well as in the United States. (To date, the Mild Traumatic Brain Injury Rehabilitation Toolkit remains in review by the Department of Defense, although sections have been distributed to military health care providers.) A second version of this rehab toolkit that includes audiology and neuropsychology components and expands on other topics is in the proposal phase. A New Identification System Early identification and documentation of each episode of concussion sustained by the troops is critical for providing the appropriate level of care. As a result, the military recently implemented a systematic process for training all deployed military personnel to administer the Military Acute Concussion Evaluation (MACE) tool for identifying symptoms of mTBI/concussion. Following an explosive event in the combat zone that results in possible traumatic injuries to a service member, a medic or trained service member completes a MACE to screen for symptoms of concussion. MACE screens four cognitive domains—orientation, immediate memory, concentration, and memory recall—and includes a brief neurological examination and a symptom checklist. Cognitive screening scores of less than 25 indicate cognitive dysfunction and warrant further evaluation. A symptomatic individual is removed from combat to reduce the risk of additional head trauma and to provide recovery through rest and control of sensory stimulation until the symptoms resolve. If symptoms persist, the service member is evacuated out of the combat zone to a concussion rehabilitation care center or out of theater to the Landstuhl Regional Medical Center in Germany, where the individual is screened for mTBI again, away from the combat environment. Apps for mTBI Education about TBI: DoD mTBI Pocket Guide (CONUS) which includes: TBI Basics – Definition, VA/DoD Clinical Practice Guideline (CPG) for the Management of Concussion/Mild TBI, Cognitive Rehabilitation for Mild TBI Consensus Conference: Summary of Clinical Recommendations, Patient Education handoutm Clinical Tools and Resources, About mTBI. For memory: Brain Trainer, Nudge, Vault (for passwords) ADL Reminders and organizers: Grocery Lists, Corkulous, RxmindMe, Notes, Reminders, CoziCalendar Productivity: Evernote, Intuition, Peek, Dragon Dictation, PlainText, ToDo Academic: myHomework, iStudiezLite, iBooks, Military Ranks, Penultimate, Paper Port, GoodNotes Cognitive Games: Brain Box, Brain Reactor, Brain Challenge, Find the Difference, BeGEARedlite, Tap Tap, Where’s My Water, Sudoku, Pac-Man Finance: Pageonce, Mint, Calculator, moneyStrands PTSD/Mental Health: Tactical Breathing Trainer (T2TB), DailyBurn, T2Moodtracker, Breath2Relax Full Case Study: Jason Jason arrived by military transport to the Naval Medical Center in December. Jason, an explosive ordinance disposal specialist, sustained a concussion and injuries to his foot when he stepped on an IED while deployed to Afghanistan. He was blown off his feet and felt dazed and disoriented for a few seconds. After being medically stabilized and assessed for a concussion, he was transported to Landstuhl Regional Medical Center where he remained for four days before being transported to San Diego, one week after being injured. He was hospitalized for several weeks at the Naval Medical Center where he underwent multiple foot surgeries including amputation before being discharged from inpatient status to the Wounded Warrior Barracks, where he resided during his outpatient polytrauma rehabilitation. Jason was assigned a primary nurse case manager who tracked his discharge from Landstuhl and alerted the rehab team in San Diego to his medical needs. Following hospital discharge, Jason’s first outpatient appointment was an interview and evaluation by a primary care provider on the combat care rehabilitation team. The primary care provider submitted a consult to speech pathology for screening of cognitive communication abilities and to audiology and otolaryngology for post-deployment hearing evaluations. When seen for the initial intake by a speech-language pathologist, Jason was focused solely on moving forward with his amputation care. He admitted to experiencing slow thinking and memory difficulties, pain for which he was taking narcotics, disordered sleep, and post-traumatic stress. The day before he was injured, Jason saw a close friend get blown up and die from blood loss. Jason was a well-spoken, articulate young man who did well in high school and had specific goals to complete his undergraduate degree. As he was mourning the loss of his buddy, he was also able to think about and plan for his future. Jason commented to this clinician that he felt he owed it to his buddy to make something of his own life. Jason sustained polytrauma with blast-related concussion. His screening for symptoms of mTBI in theater was positive. At Landstuhl, he was screened again and continued to be symptomatic with findings of disorientation, attention, and memory impairments. He also presented with a dysfluent, stutter-like speech pattern. After receiving acute medical intervention, he was stabilized for the long medical evacuation flight back to the United States. During his inpatient hospitalization, Jason underwent several surgeries and received heavy doses of pain medication. Jason’s Rehabilitation Screening When discharged to t