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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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The PRA is an evidence-based, easy-to-use approach to help providers return service members with mild TBIs back to duty safely. TBICoE researchers have found that, if medical providers completed a two-hour, in-person training on the use of the PRA, their patients saw an overall reduction in symptoms after one week, one month, and three months, when compared to patients treated by providers who had not received the training.

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Brain Injury Awareness Month "Be TBI Ready" Infographic

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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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Progressive Return to Activity Following Acute Concussion/Mild TBI Provider Training

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The TBICoE revised the Progressive Return to Activity Following Acute Concussion/Mild Traumatic Brain Injury Clinical Recommendation (PRA) and this updated provider training slide deck. The trainings objectives will help providers to identify the key changes to the updated 2021 PRA; explain the rationale for using a PRA protocol for service members post-concussion; understand the criteria for progression following a concussion or mild traumatic brain injury; identify appropriate activities at each stage of progression; understand how to apply primary care management strategies and specialty referral considerations to treat concussed service members who are not progressing as expected; utilize the Tri-Service Workflow mild TBI Alternate Input Method Form to document the PRA in the Armed Forces Health Longitudinal Application.

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Progressive Return to Activity Following Acute Concussion/Mild TBI

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The 2021 Progressive Return to Activity (PRA) Following Acute Concussion/Mild Traumatic Brain Injury Clinical Recommendation is an evidence-based return to activity protocol for primary care managers and concussion/traumatic brain injury (TBI) clinic providers. The PRA is a six-step approach that begins after the provider performs the Military Acute Concussion Evaluation 2 (MACE 2) and diagnoses the patient with a concussion/TBI. The PRA stages start with relative rest and allow service members to gradually increase activities until they receive clearance for return to full duty or activity. In each stage, it offers general and military specific activities and options to help providers manage their patients’ primary symptom clusters. The PRA also offers recommendations on specialty referrals and handouts are available for providers to give patients and leadership.

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March 2021 Toolkit

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March is nationally recognized as Brain Injury Awareness Month, with the goal of increasing traumatic brain injury (TBI) awareness and improve health care providers’ ability to identify, care for, and treat all those who are affected by TBI. A TBI is a blow or jolt to the head that disrupts the normal function of the brain. According to the Defense Health Agency Traumatic Brain Injury Center of Excellence, 430,720 service members have been diagnosed with a first-time TBI since 2000. The toolkit also contains information on patient Safety Awareness Week, National Nutrition Month and many other graphics and messages you can use for holidays and observances during March.

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VCE examines low vision with detection and care

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Dr. David Eliason, of the Vision Center of Excellence, says low vision awareness is about prevention, detection, and continuing treatment.

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Sleep After Concussion

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Sleep After Concussion. Service members with TBI report 3 times more sleep problems. TBIs can happen anywhere, only 16.9 percent of TBIs happen while deployed. Visit health.mil/TBIFactSheets to learn more about sleep problems and how to improve them

"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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Sleep and TBI

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Sleep disturbances are common for service members and veterans following a mild TBI, also known as concussion.

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Caregivers share their stories of support for TBI recovery

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The Network leveraged their geographic distribution to help each other quickly adapt to changing times.

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Sleep After mTBI

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"Sleep After mTBI" is intended for providers to show the importance of screening and treating service members affected by sleep issues following mTBI.

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TBI Champions Roxana Delgado & Victor Medina

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While he was deployed, retired Army Sgt. 1st Class Victor Medina was in a vehicle that was hit by an explosive device. He sustained a traumatic brain injury (TBI) that severely impaired some of his physical functions and ability to speak. Medina’s wife, Roxana Delgado, continued her pursuit of a Ph.D. in health sciences and became his caregiver. As they adjusted to a life neither one of them had imagined, their marriage became a new kind of partnership.

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TBI Champion Gary Moran

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TBI Champion Micah Norgard

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After 12 years as an infantryman, Norgard's biggest battle was recognizing the cumulative effects of multiple TBIs.

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