Policy Aims to Better Identify, Treat Concussions

By Donna Miles

American Forces Press Service

WASHINGTON, April 1, 2011 – A memorandum that took effect throughout the Defense Department in June is expected to have a major impact on efforts to identify and treat traumatic brain injuries in the combat theater faster and more systematically, medical officials reported at the recent Armed Forces Public Health Conference in Hampton, Va.

The directive memo, which sets policy and management guidelines concerning TBI in deployed settings, relies for the first time on events, rather than personal reporting, to trigger a chain of institutional responses, Army Maj. Sarah Goldman, the Army’s TBI program manager, told an audience of health care professionals.

“This is an absolutely revolutionary policy,” Goldman said. “This is really the first time in traumatic brain injury care, and certainly in the Department of Defense traumatic brain injury care, that we have an event-driven protocol. What that means is that you don’t have to rely on service members to raise their hand and say, ‘I am having some problems’ after they have been involved in an event.”

Instead, the new policy lays out a response whenever a service member experiences something that could cause TBI.

“This is an event-driven policy,” Goldman said. “So, for example, if the service member hits their head or is somewhere near a blast, they have to get checked out, they have to get treated and they have to get reported. There also is mandatory downtime.”

DOD officials have long struggled to find ways to more quickly identify and treat what has become a signature -– and often invisible -- combat injury. TBIs often result from bullet blasts, vehicle accidents that cause a jolt to the head or exposure to a blast. The most common symptoms are loss of consciousness, memory loss, alteration of consciousness and other neurological problems.

Moderate and severe TBI is relatively easy to recognize, Navy Cmdr. (Dr.) David Tarantino, director for clinical programs at Headquarters Marine Corps, told the group. What’s far more challenging, he said, is recognizing the 80 percent of TBI patients whose conditions are mild –- meaning they have suffered a concussion.

“In layman’s terms, you feel dizzy, confused, see stars and have some alteration of consciousness,” Tarantino said. Other symptoms, he said, include disorientation, headache, balance difficulties, sleep disturbances, nausea and vomiting.

Not diagnosing a service member with mild TBI can have serious operational impact, Tarantino said.

“You have difficulty following instructions, poor marksmanship, slow reaction time and decreased concentration. All of those have an impact on the battlefield,” he said. “If someone has a concussion, you don’t want to give them a weapon and send them right back to the front lines. That can do a lot of harm.”

It’s the same principle the National Football League uses to protect its players, Tarantino said. “You don’t want to have your quarterback in on a final drive if he has been knocked loopy,” he said. “It’s a similar kind of thing.”

But as the NFL and military are learning together, there’s another reason to identify and treat mild TBI as quickly as possible. Not only is it the best way to ensure a full recovery; it’s also the best way to prevent more severe issues if the patient gets another concussion before the first one heals.

Studies on athletes show that a history of three concussions increases their risk of chronic problems three-fold, Tarantino said. “We are starting to see from NFL players what the cumulative, long-term effects are,” he said, including early Alzheimer’s disease and chronic traumatic encephalopathy, a progressive degenerative disease.

“This is an issue we are concerned about and trying to prevent” in U.S. service members, Tarantino said. “We have a lot of guys exposed [to blasts] many times. So the question is: ‘How do we make sure that they get the proper rest and care and treatment before they get exposed again?’”

Goldman called the new DOD memorandum a major step in the right direction. Developed by scientific experts from around the country, “it represents what we understand is the best science to date to manage concussion,” she said.

“As the science continues to evolve, we certainly will be updating this policy,” she said. The first policy update is expected later this year, when the memo becomes a permanent DOD instruction.

The new memo requires commanders to ensure all service members involved in potentially concussive events receive a medical evaluation, even if they have no apparent injuries. It also authorizes commanders to refer a soldier, sailor, airmen or Marine under their charge who appears to be showing symptoms for evaluation.

It also mandates that all cases of TBI be documented into an electronic medical record. This, Goldman said, will provide a registry for the Defense Department and a tool to inform commanders whose units are about to redeploy.

Air Force Maj. (Dr.) Laura Baugh, the Air Force TBI program manager, called this leadership responsibility a key part of the new policy. “It requires leaders to recognize service members who have been involved in an event that could cause a concussion and to ensure they get a medical evaluation, and requires them to track these service members in the electronic database,” she said.

“Not only does this ensure service members get the follow-on care they need down the road,” she said. “It also helps [DOD] understand the true incidence of this problem in the theater.”

The policy establishes new protocols for service members with recurrent TBIs.

“If there is a service member who has sustained three or more concussions within a 12-month period, they are getting a four-hour neuropsychological battery,” Baugh said, including vestibular and functional testing.

“They get the entire ‘works,’” Goldman said.

“Don’t get me wrong. Certainly the ones who experienced just one event also are getting checked out,” Goldman continued. “But I will tell you, it is a much more intensive evaluation for service members involved in the recurrent concussion protocol.”

The memo revises the military acute concussion evaluation screening test, introducing a three-part score that includes patient history and results of cognitive screening and a neurological screening exam, she said.

In terms of patient care, it mandates two of the best-known treatments for mild TBI: rest and education.

Troops suffering mild TBI require at least 24 hours of rest before returning to duty, and often more as they receive their medical evaluations, Tarantino said. Ideally, that rest is offered in a “reduced-stimulus environment” –- a place that’s cool, quiet and comfortable and allows patients to rest and catch up on lost sleep, he said.

Often service members need to be moved to find these conditions, he recognized. “It’s pretty hard at a forward operating base getting shelled or [under] mortar fire, or where there’s no air conditioning or it’s noisy or loud of uncomfortable,” he said. “That, in itself, might be a reason to move the patient back to get rest.”

Tarantino cited the Marines’ Concussion Restoration Care Center at Camp Leatherneck, Afghanistan, as a new approach to providing this respite in the combat theater. It offers comprehensive, interdisciplinary concussion care that includes sports medicine, occupational therapy, physical therapy and even acupuncture that he said “has proven very popular with the Marines and, at least anecdotally, very effective.”

The center tends to treat some of the more severe concussions, offering care that typically lasts about 14 days. However, 95 percent of its patients return to full duty, Tarantino reported.

As the military works to improve the way it diagnoses and treats mild TBI, it’s also focusing more heavily on educating service members about TBI. The education effort begins during the pre-deployment cycle and continues in the combat theater and on redeployment home. “The best treatment is education, providing information, counseling and instructions about common symptoms and expected outcomes,” Tarantino said.

Goldman said she’s enthusiastic about the potential of the new policy to help the military better identify and treat mild TBI and to ensure service members have the best chance of a full recovery.

“I just can’t overemphasize just how revolutionary this policy is,” she said. “We are really looking forward to the long-term results to see how this impacts long-term outcomes.”