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Wednesday, March 12, 2008

Atlanta's Shepherd Center Picks Up Where TRICARE Leaves Off to Improve TBI Care of OEF/OIF Troops

Up to 20% of soldiers serving in Iraq and Afghanistan get TBI according to an Army report [pdf] released in January.

In addition to the 1-in-5 figure, some returning soldiers with the milder form of TBI (aka concussions) don't even know they have the injury most associated with IED attacks. The military had been flat-footed in the opening years of the war when it came to treating TBI; their limitations in care are still apparent. Fortunately, some private health care providers are providing relief to military families trying to recover from the more devastating of TBI injuries.

Sunday's CBS Evening News interviewed Brig. Gen. Donald Bradshaw, who heads up the military's TBI Task Force, on these issues.

In educational interest, article(s) quoted from extensively.

From BusinessWire:

Humana Military Healthcare Services (HMHS) and the Shepherd Center, an Atlanta-based hospital specializing in the medical care and rehabilitation of people with spinal cord and brain injuries, announced a partnership with Home Depot co-founder Bernie Marcus. This partnership will assist military service members wounded during their service in Operation Iraqi Freedom and Operation Enduring Freedom, as well as their families, in obtaining additional care that will aid in their recovery from combat related injuries.

The SHARE Initiative, began in January 2008, and will primarily focus on wounded service members in the Southeast, subsequently expanding to encompass a larger population. SHARE'S vision is to enrich the hope and recovery for wounded men and women of the military. The partnership with Shepherd Center (one of the nation's leading rehabilitation hospitals) will complement the healthcare that may not be covered by TRICARE or other health insurance. Services may include specialized rehabilitation and community reintegration for spinal cord or traumatic brain injuries (TBI) survivors who sustained injuries while serving in Iraq and Afghanistan.

"Humana Military is pleased to be a part of this initiative," said Dave Baker, president and CEO of HMHS. "The courageous men and women of the military deserve the finest of care when they return home with injuries. I am happy that HMHS is partnering with Mr. Marcus and the Shepherd Center to complement the quality care they are already receiving."

Marcus will sponsor wounded warriors needing assistance in paying for essential medical rehabilitation, post-acute rehabilitation, as well as community and family support services at the center that may not be covered under TRICARE or other health insurance.

The types of services that Marcus will take financial responsibility for could include: neuropsychological evaluation to assess for TBI and post-traumatic stress disorder (PTSD), cognitive therapy, counseling, activity- and community-based rehabilitation, residential services and respite care for family members, and housing while services are being delivered. Services also could include assistive technology devices, cognitive prosthetics, and home health care equipment, such as bathroom equipment and canes.

For more information, please contact Susan Johnson at the Shepherd Center, 404-352-2020.

Coverage on the Army's TBI report released in January, first from AP:

Up to 20 percent of U.S. troops returning from Iraq and Afghanistan may have suffered mild concussions but were unaware of them and did not get treatment...Concussions, which the military calls traumatic brain injuries (TBIs), are among the most common injuries troops suffer during combat tours. But the Army has a hard time identifying and treating affected troops because the soldiers and Marines don't recognize the symptoms and don't report them.

"The Army is challenged to understand, diagnose and treat military personnel who suffer with mild TBI," said Brig. Gen. Donald Bradshaw, who leads the Army's TBI task force. Traumatic brain injuries are caused by powerful blasts, such as ones created by improvised explosive devices, or other severe trauma that shakes the brain inside the skull. The result can be bruising of the brain or greater damage.

The Army began looking at the TBI issue and care in January 2007 by talking to soldiers, family members and caregivers to find out how such injuries were identified and treated, Army officials said. The Army now checks soldiers before and after deployment to identify and treat as many TBI-affected troops as possible.

Less than half who suffered from a mild traumatic brain injury in combat have persistent symptoms associated with it, Col. Robert Labutta, a neurosurgeon with the Army surgeon general's, office told The Associated Press. But symptoms from the injury such as irritability affect a soldier's interaction with family and fellow soldiers, said Col. Jonathan Jaffin, deputy commander of the U.S. Army Medical Research and Materiel Command.

"By identifying them, giving them a diagnosis so they don't think they're just going crazy ... we think that helps them deal with it," Jaffin told the AP.

From Armed Forces Press Service:

The report contains some 47 recommendations to help the Army better prevent, screen, diagnose, treat and research traumatic brain injury, said Brig. Gen. Donald Bradshaw, who led the task force charged with investigating TBI. Bradshaw is commander of Southeast Regional Medical Command and Eisenhower Regional Medical Center, at Fort Gordon, Ga.

"Our report indicates that, like our civilian counterparts, the Army has done well in the identifying and treatment of severe or penetrating traumatic brain injury, but is challenged to understand, diagnose and treat personnel who have suffered short-term or persistent symptoms of mild TBI," he said. "The task force identified opportunities for improvement as well as best-practice guidelines." ...

Today, eight of the recommendations made by the task force have already been implemented, said Col. Judith Ruiz, deputy director for rehabilitation and reintegration with the Office of the Surgeon General. "We have made significant progress to take care of soldiers and to standardize practices across the Army medical department," she said.

Some of the recommendations that have already been implemented include:

-- Working with interagency and civilian groups to better define TBI;

-- Implementing in-theater TBI screening and documentation for all soldiers exposed to brain injury-inducing trauma;

-- Adding TBI-specific questions to deployment-related health assessments;

-- Developing a proposal on the appropriate functions of a "TBI center of excellence";

-- Proposing the Defense and Veterans Brain Injury Center as the core of the new center of excellence;

-- Optimizing the positioning of clinical, educational and research activities;

-- Centralizing the evaluation of the scientific merit, clinical utility, and priority of new treatment strategies, devices or interventions; and

-- Adapting the Military Acute Concussion Evaluation overprint as an approved Department of the Army form to document mild TBI closest to the point of injury.

Ruiz said 31 additional recommendations are in progress, four are planned, and four are in the process of being transferred to other agencies. ...

The Army launched the post-traumatic stress disorder/mild traumatic brain injury chain teaching program in 2007 to help soldiers better identify signs and symptoms of these conditions and to reinforce the collective responsibility to take care of each other.

The Army is also working to educate the civilian medical community about mild TBI so that soldiers in the reserve components, who may not have full-time access to military medical care, also can be identified, said Col. (Dr.) Jonathan Jaffin, deputy commander of the U.S. Army Medical Research and Material Command.

"One of the things we are concerned with and … one of the points behind the whole chain teaching was trying to get the message out to the country, not just the active-duty force, Guard and reserve," he said. "(We wanted) the country, including providers throughout the country, to be aware of mild TBI and concussions and the long-term symptoms that some people may be having."

Bradshaw said Army leaders at all levels are committed to the good health and well-being of all soldiers and are proactively addressing the issue of TBI. "Continued research in this area can only help us more clearly understand the medical impacts of the war and the best ways to prevent, recognize and treat soldiers with TBI," he said.

Report details from U.S. Army Medical Command:

The Army has aggressively sought to prevent, diagnose and treat traumatic brain injuries (TBI), but much remains to be done to understand and respond to these injuries commonly associated with the conflicts in Iraq and Afghanistan.

So concluded the Traumatic Brain Injury Task Force, a group of experts chartered by the Army Surgeon General to analyze and make recommendations to improve the clinical, administrative and research processes involved with providing medical care and services to Soldiers and other service members.

The group was chaired by Brig. Gen. Donald Bradshaw, commander of the Army's Southeast Regional Medical Command, and included representatives from all the military services and the Department of Veterans Affairs (DVA). They studied the issue from January to May last year, and their report now has been released. ...

"We wanted to bring together the best practices, policies and resources to treat and manage Soldiers and Marines diagnosed with TBI," Brig. Gen. Bradshaw said. "We also want to identify any gaps in their medical care as they reintegrate back to their civilian lives or continue their military careers. Furthermore, we wanted to make recommendations for areas of additional research. The task force completed its work in May 2007 and since that time DoD and DVA have made vast improvements in the identification, treatment, screening and education for TBI as well as establishing research processes and priorities. The task force findings are one contribution to this ongoing improvement in care."

The task force visited military, DVA and civilian facilities caring for injured service members; interviewed Soldiers, Family members, caregivers and subject matter experts; and reviewed documents.

TBI is classified as mild, moderate, severe or penetrating, depending on the severity and nature of the injury. Mild TBI, commonly known as a concussion, may affect 10 to 20 percent of Soldiers and Marines redeploying from combat in Iraq and Afghanistan. It is not the same as Post Traumatic Stress Disorder, although the two conditions may produce similar symptoms, such as sleep problems, memory problems, confusion and irritability. Other mild TBI symptoms include headache, dizziness, nausea and light-sensitivity. More than 80 percent of patients treated for mild TBI recover completely.

"Our findings demonstrate that, like our civilian counterparts, the Army has a good handle on treatment of moderate to severe TBI but is challenged to understand, diagnose and treat military personnel who suffer with mild TBI. The task force identified opportunities for improvement as well as best practices and areas for additional research," Brig. Gen. Bradshaw said. ...

Some of the challenges identified included coordination and policy; recording of incident data; inconsistent treatment and documentation; and education for Soldiers, units, leaders, Families, providers and communities. From the provider perspective, the task force found inconsistent specialty staffing. They also found that the Army Physical Disability Evaluation system contained no specific standards for the use of neuropsychological testing and that the complexity of dysfunction after TBI is not easily captured by the Veterans Administration Schedule for Rating Disabilities.

Many best practices however, were also identified by the task force.

"Fort Carson, Colo., Soldier Readiness Processing is a model that is being emulated across the Army. All redeploying Soldiers are surveyed by a health-care provider for symptoms of possible mild TBI. Fort Carson providers noted that survey responses indicate approximately 17 percent of redeploying Soldiers could have TBI. Their careful screening methods and prompt, multi-disciplinary treatment are a "best practice" of early and appropriate treatment," Brig. Gen. Bradshaw said.

"Walter Reed Army Medical Center had a 100 percent screening of all patients from theater (now all military treatment facilities and the DVA do the same) and a multi-disciplinary approach to treatment and education of patients and families," he added. Brig. Gen. Bradshaw said he wants Soldiers and their Families to know that traumatic brain injury is a treatable condition with marked improvement in most cases—especially in concussion—and that Army leadership is proactively addressing the issue.

"We are committed to continued research in this area to help us more clearly understand the medical impacts of the war and the best ways to prevent, recognize and treat Soldiers with TBI," he said.

Read the report in full [pdf].

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