Major advances occurring in traumatic brain injury care for veterans
New developments in traumatic brain injury prevention, diagnosis and treatment are certain to improve patient health among Soldiers, as well as improve Army readiness, said Tracie Lattimore, director of the Army's Traumatic Brain Injury program within the Office of the Army Surgeon General.
Lattimore said that new tests for assessing TBI are available this year. One such test allows providers to determine if a patient's eyes are tracking properly, and helps patients indicate if they are experiencing double vision or an increase of other symptoms. The test can determine whether or not "oculomotor dysfunction" is present, Lattimore said.
Oculomotor dysfunction, which involves the eye's inability to locate and fixate on objects in the field of vision, occurs in 40 to 60 percent of TBI cases, Lattimore said.
Also of benefit to providers and their patients are two new FDA-approved devices, including one called "BrainScope" and another called "InfraScan," Lattimore said.
BrainScope measures and analyzes the brain's electrical activity to aid in the evaluation of patients who are being considered for a head CT scan (to detect bleeding in a closed head injury). The BrainScope device is portable and rugged, and can be used in a variety of militarily-relevant scenarios. Lattimore said she is hopeful the devices can be distributed more broadly in the near future.
InfraScan uses near-infrared spectroscopy to detect potential brain bleeds, and is also meant for use in patients who are being considered for a head CT scan.
Lattimore said a study of concussions among college athletes, including some at military academies, is gathering interesting data on TBI prevention.
The study, which is still producing information, indicates that someone who experienced TBI often had one or more sub-concussive hits in the hours or days leading up to the hit that resulted in concussion, Lattimore said. This indicates that those smaller hits had a cumulative effect.
The study is an effort between the National Collegiate Athletic Association and the Department of Defense Grand Alliance.
Another interesting finding from the study was that in 2002, concussed players were returned to play after a few days, and then experienced a more severe concussion just 5.2 days after the first concussion, Lattimore said.
Now, the NCAA keeps players out of the game until they are symptom-free -- on average, 12 to 14 days after the first concussion.
With this increased recovery time after concussion, the average athlete did not experience a second concussion until 72 days after the first, and it was much less severe than the second concussion experienced by athletes in the 2002 study.
"This study validates the DOD's hallmark policy for concussion management in deployed settings, which beginning in 2010 removed Soldiers who sustained a concussion from duty until symptom-free," Lattimore said.
Lattimore said the study demonstrates that if a Soldier is removed from training or the war fight for an adequate recovery time, it results in an optimized capability when he or she is returned, while likely reducing the frequency and severity of additional injuries.
"That message needs to be communicated, not just to medical personnel, but to every Army leader," Lattimore said.
The standard concussion treatment, from 2008 to 2016, had been informally called "cocooning," Lattimore said. The treatment required patients to not exert themselves physically or mentally, to not watch TV, to not exercise, and to get plenty of sleep until they recovered.
Medical professionals now understand that cocooning is the wrong approach, Lattimore said.
After reviewing literature and patient experiences over the last four-to-five years, it was found that the only activities that must be limited are those that exacerbate symptoms, she said.
The DOD started moving in this direction with the release of the progressive return to activity guideline for concussed patients, Lattimore said. However, the evidence has grown even stronger for this model since its release.
After 24 to 48 hours of rest, Lattimore said, patients should be encouraged to be active, as long as the specific activity does not put them at risk for another head injury or provoke their symptoms.
"This is an enormous paradigm shift from the 'cocoon care' model," she said.
With oculomotor dysfunction, it's now understood that rest will not resolve symptoms. Instead, effective treatment for oculomotor dysfunction often involves practicing muscle memory under the guidance of a physical or occupational therapist, Lattimore said.
If the patient fails the pen test, for instance, he or she might respond to another sensory input, such as an acoustic clicker attached to the end of a pen.
Many of the advances in TBI prevention, diagnosis and treatment, Lattimore said, are so new that the Army is just now finishing up the process of evaluating how best to incorporate them into assessment protocols.
Many Army medical personnel are not yet aware of the developments, she said. However by the end of this year, she said that updated tools and training will be available to push the information out across the Army.