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Brain Injury Center Releases Care Guidance for Concussions

By Terri Moon Cronk
American Forces Press Service

SILVER SPRING, Md., Feb. 12, 2014 – While treatment for moderate to severe brain injuries has long been studied, mild cases, or concussions, have only recently been recognized as requiring standard care, officials at the Defense and Veterans Brain Injury Center here said.

After the center’s medical staff and numerous collaborators found that concussions and similar mild brain injuries call for rest and a gradual return to work and activities to avoid further injury to the brain, DVBIC recently issued recommendations for standard treatment, said Kathy Helmick, the center’s deputy director.

DVBIC compiled the new standards for treating concussions with input from academic experts, sports concussion clinicians and all-service military TBI experts, Helmick said.

While some people might think a jolt or a bump on the head isn’t treatment-worthy, determining whether someone has suffered a concussion and treating it are vital to the Defense Department, Helmick said, noting that unit readiness can be at risk when a service member with a concussion goes untreated.

“All those symptoms can affect marksmanship, whether or not you can read a map, your judgment, and whether or not you can go on patrol,” she explained.

The Defense Department has policies in place for early detection of brain injuries, and a widespread awareness campaign to recognize symptoms, both stateside and in combat, Helmick said. Because of that, DVBIC’s recommendations for the milder injuries center on events that could cause concussion.

“Mild [traumatic brain injury comprises] the largest population of brain trauma, and that’s why DOD put so much emphasis on this,” Helmick said, even though as recently as 2005, mild TBI had the least amount of literature available to health care providers.

“We learned a lot about severe brain injury in the ’90s,” she said, “and by 2005-06, when we became concerned about concussion during the war effort, there were only about 200 studies [available].”. We really want to instill the notion [of] having early detection, because that gives us an opportunity to treat early.”

The emphasis on concussion came from the services, after identifying them in concussion care centers in Afghanistan, Helmick said, and the need for rest and gradual return to duty were presented to DVBIC.

Helmick said the brain needs time to heal itself, and concussions can affect a person’s physical, cognitive and balance abilities. The new recommendations outline how much patients should spend in activities that involve any of those three functions of the body.

Often during training, combat or even off-duty recreation, a service member might not be aware of a concussion, DVBIC officials said. Helmick noted how important it is for a primary care doctor to find out what happened, whether consciousness was lost, or the patient felt dazed or confused, and what the patient recalls from the event.

She said the most common symptoms from a concussion are headache, memory or attention issues, dizziness and sleep disturbances.

Certain event triggers are in place to make sure a service member is evaluated, such when someone is subjected to blasts that are less than 50 meters -- or about 164 feet -- away, a vehicle accident, a blow or jolt to the head, or when a commander notices unusual behavior in a service member, Helmick said. The new recommendations strongly emphasize the need for a clinician to recommend a progressive amount of time for a patient with a concussion to return to normal activities, she added.

The clinical recommendations, Helmick said, include a how-to manual on how to return to the pre-injury activity in a “staged, stepwise approach [to] increase your activity so your body can handle the increase,” Helmick said. And this potentially keeps the patient from suffering a second concussion, she added.

The recommendations define what safe rest means for the brain and what to do and what to avoid at home, Helmick said, adding that 24 hours is the minimum for rest.

“We monitor blood pressure, heart rate and how difficult it is for somebody to exert themselves,” she said. “Our bodies give us a lot of signals on whether or not we’re ready to progress.”

And brain injuries can be accumulative emphasizing the need to give the brain a break.

“Because we have a better understanding of what your brain is doing from a chemical and neurochemical standpoint, we are much more conservative in our approach So the lengths of time are elongated as you have subsequent concussions.”

Patient education is a vital part of recovery so patients can discuss their progress with primary physicians or rehabilitative specialists if the primary doctor believes additional treatment is necessary, said Public Health Service Lt. Cmdr. Cathleen Shields, DVBIC’s acting education director.

Patients rate themselves on their progress and discuss it with their doctors, she explained, adding that the DVBIC website also features downloadable products for caregivers of those with mild TBIs.

Shields said that since 2000, more than 287,000 service members have suffered a TBI, with 83 percent of that number diagnosed with mild TBI. Interestingly, she added, “the large majority of that 83 percent are from nondeployment [injuries], which means they are not happening in the combat arena.”

Gradual return to duty is key, said Dr. Therese West of the center’s clinical practice and clinical recommendations division.

“Two years ago, no one defined what ‘graduated’ was, and there was no standardized approach,” to mTBI. But DVBIC identified that gap and began working with private- and public-sector experts to develop the guidance, she added.

“We also needed to be careful and mindful of our military partners and the requirements within DOD,” she noted. “We cross-walked every aspect of our products with DOD policy and each service to make sure [the guidance] did not contradict any policies, and that they each fit into the guidelines of each service.”

She called the new recommendations comprehensive and international in scope for standardized concussion care.

“We still don’t have all the answers, but this is the best we have available to us today, and we have many partners who have been waiting for the products to be available” West said. “People across the country and internationally have been waiting for someone to take this information and put it together comprehensively [as] a standardized process that will allow people to be treated in the same manner across [DOD’s} Military Health System.”

(Follow Terri Moon Cronk on Twitter @MoonCronkAFPS)


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Related Sites:
Clinical Recommendations for Primary Care Managers and Rehabilitation Providers
Defense and Veterans Brain Injury Center

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