Brain Injury Professional, vol. 4 issue 1 by Nikolai Alexeev

BRAIN INJURY professional vol. 4 issue 1

The official publication of the North American Brain Injury Society

Special Issue on blast injury and TBI Selected Biomechanical Issues of Brain Injury Caused by Blasts A Brief History of the Defense and Veterans Brain Injury Center (DVBIC) New Ways to Diagnose and Assess Attentional and Cognitive Deficits Following Blast Injury Reintegrating Military Personnel after Traumatic Brain Injury (TBI): A Community Integrated Rehabilitation Model in Practice Current Trends in Post Traumatic Stress Disorder and Traumatic Brain Injury Among Military Personnel

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contents

BRAIN INJURY professional vol. 4 issue 1, 2007

The official publication of the North American Brain Injury Society

north american brain injury society

departments 4 Executive Vice President’s Message 6 Guest Editor’s Message 8 Message From Bill Pascrell 20 Professional Appointments 32 Non-Profit News 34 Conferences BRAIN INJURY professional

chairman Robert D. Voogt, PhD treasurer Bruce H. Stern, Esq. family liason Julian MacQueen executive vice president Ronald C. Savage, EdD executive director/administration Margaret J. Roberts executive director/operations J. Charles Haynes, JD marketing manager Joyce Parker graphic designer Nikolai Alexeev administrative assistant Benjamin Morgan administrative assistant Bonnie Haynes

brain injury professional publisher Charles W. Haynes publisher J. Charles Haynes, JD Editor in Chief Ronald C. Savage, EdD founding editor Donald G. Stein, PhD design and layout Nikolai Alexeev advertising sales Joyce Parker

vol. 4 issue 1

The official publication of the North American Brain Injury Society

features 10 Selected Biomechanical Issues of Brain Injury Caused by Blasts by Mariusz Ziejewski, PhD, Inz, Ghodrat Karami, PhD, and Iskander Akhatov, PhD 16 A Brief History of the Defense and Veterans Brain Injury Center

(DVBIC) by George Zitnay, PhD 18 New Ways to Diagnose and Assess Attentional and Cognitive Deficits

Following Blast Injury by Minah Suh, PhD, Ranjeeta Sarkar, Rachel Kolster, Pamela Drexel, Jamshid Ghajar, MD, PhD 22 Reintegrating Military Personnel after Traumatic Brain Injury (TBI):

EDITORIAL ADVISORY BOARD Michael Collins, PhD Walter Harrell, PhD Chas Haynes, JD Cindy Ivanhoe, MD Ronald Savage, EdD Elisabeth Sherwin, PhD Donald Stein, PhD Sherrod Taylor, Esq. Tina Trudel, PhD Robert Voogt, PhD Mariusz Ziejewski, PhD

editorial inquiries Managing Editor Brain Injury Professional PO Box 131401 Houston, TX 77219-1401 Tel 713.526.6900 Fax 713.526.7787 Website: www.nabis.org Email: contact@nabis.org

advertising inquiries Joyce Parker Brain Injury Professional HDI Publishers PO Box 131401 Houston, TX 77219-1401 Tel 713.526.6900 Fax 713.526.7787

A Community Integrated Rehabilitation Model in Practice by Tina M. Trudel, PhD, John DaVanzo, MS, MEd, CCC-SLP, Erin O. Mattingly, MA, CCC-SLP, F. Don Nidiffer, PhD, Jeffrey T. Barth, PhD, ABPP 26 Current Trends in Post Traumatic Stress Disorder and Traumatic Brain

Injury Among Military Personnel BY F. Don Nidiffer, PhD, Austin Errico, PhD, Tina M. Trudel, PhD, Jeffrey T. Barth, PhD, ABPP

national office

North American Brain Injury Society PO Box 1804 Alexandria, VA 22313 Tel 703.960.6500 Fax 703.960.6603 Website: www.nabis.org Brain Injury Professional is a quarterly publication published jointly by the North American Brain Injury Society and HDI Publishers. © 2007 NABIS/HDI Publishers. All rights reserved. No part of this publication may be reproduced in whole or in part in any way without the written permission from the publisher. For reprint requests, please contact, Managing Editor, Brain Injury Professional, PO Box 131401, Houston, TX 77219-1400, Tel 713.526.6900, Fax 713.526.7787, e-mail mail@hdipub.com

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executive vice president’s message

Every war or major military conflict produces a characteristic injury or wound that eventually becomes that conflict’s “signature wound”. World War Two was associated with an increase in radiation-induced cancer from atomic bombs while the Vietnam war led to a better

words, the Iraq war could produce a generation of veterans with life changing brain injury, affecting thousands of service men and women from all walks of life across the country. During the Vietnam War and the Persian Gulf War, 76 percent of American troops survived combat wounds. But

As professionals in the field know, the “walking wounded” do not disappear. And many more will be seen and heard in this decade. Thanks to improvements in protective gear and swift medical treatment, more of America’s wounded are surviving - and returning home with serious, permanent injuries. How will these veterans fare in the routines of daily life? Will they be able to maintain employment? How will their injuries impact their families, friends, coworkers, and communities? Ronald Savage, EdD understanding and increase in occurrence of Post Traumatic Stress Disorder (PTSD) and the physical effects of exposure to Agent Orange.(US Veteran Brain Injury News). The war in Iraq will be no different in producing a “signature wound”, only this time the wound is in the brains of those affected. Medical experts are witnessing an emerging and significant increase in Traumatic Brain Injury (TBI). In other

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in this century, the U.S. military’s surgical teams “have saved the lives of an unprecedented 90 percent of the soldiers wounded in battle…” (New England Journal of Medicine, December, 2006). Furthermore, Walter Reed Army Medical Center reported that nearly 30% of all patients with combat-related injuries seen at Walter Reed from 2003 to 2005 sustained a TBI and that blast injuries are a significant cause of TBIs (www. neurotodayonline.com). In addition, they reported that TBI is often associ-

ated with severe multiple trauma, post traumatic stress disorder (PTSD) or undiagnosed concussions. Thus, screening soldiers who are at risk for a TBI is important in order to ensure that TBIs are identified and appropriately treated. Diagnosis can be difficult even when TBI is apparent or the patient is able to describe a concussive head injury to their doctors. The more common mild brain injury often has more than mild consequences and can cause depression, reduced cognitive functioning, nausea, sleep disturbance, erratic behavior, and mood swings. These impairments are exacerbated by misdiagnosis, lack of treatment and the public’s misperceptions about brain injury and mental illness. For veterans with brain injuries, the lack of physical signs and the diffuse nature of symptoms may be met with skepticism, considered to be psychological, or worse, malingering. NABIS especially wants to give deep appreciation and thanks to Representative Bill Pascrell, co-chair of the Congressional Brain Injury Task Force. Congressman Pascrell has been a champion of traumatic brain injury in Washington for many years. NABIS also wants to thank Dr. Tina Trudel for her extraordinary work in the field of TBI, commitment to our military personnel with brain injuries and their families and for serving as Guest Editor of this import issue of Brain Injury Professional. Ronald Savage, EdD

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guest editorâ&#x20AC;&#x2122;s message I am both pleased and honored to have the opportunity to serve as Guest Editor for this special issue of the Brain Injury Professional addressing blast injury and Traumatic Brain Injury (TBI) in the military. My professional focus on this unique population within the brain injury community has been brief in comparison with many of the esteemed con-

fer thousands of brain injuries from motor vehicle accidents, falls and other causes, by virtue of training activities and the nature of military occupations, as well as the same factors that contribute to brain injury in the general population. In both war and in peace time, brain injury remains a key military issue. Thus, the DVBIC is of paramount value as the premier brain injury center for the development and coordination of military TBI treatment, training, research and education activities. In assembling this issue, the diverse group of contributors and topics addressed represents a series of snapshots from different perspectives in the unfolding story of TBI in the military. It would take a far grander scale to capture what we currently know and are actively learning, about the assessment and treatment of blast and military related TBI. The contributions are rich and generous, and I hope you enjoy reading them. It is my goal to have something of value for everyone interested in this topic. The introduction to this special issue is written by Representative Bill Pascrell, cochair of the Congressional Brain Injury Task Force. Congressman Pascrell is a long-time, Tina M. Trudel, PhD passionate advocate for individuals with brain injury, especially our troops. My sincere tributors to this issue. Since becoming in- thanks to Representative Pascrell, for his time volved with the Defense and Veterans Brain and effort participating in this issue, and his Injury Center (DVBIC), I have been struck continued support, sensitivity and commitby the dedication and talent of the military ment to the brain injury community. colleagues with whom I have the pleasure of Dr. Mariusz Ziejewski and colleagues collaborating, the many professionals from from the Department of Biomechanical Enthe civilian sector whose research and treat- gineering at North Dakota State University ment initiatives seek to assist military person- lead off this collection of articles by providnel with TBI, and most importantly, I have ing a detailed review of effects of blast, eshad the privilege of experiencing first hand pecially the biomechanics of brain injury the pride and perseverance of our men and under models of blast loading, as well as the women in uniform and their families, whose phenomenon of cavitation. Dr. Ziejewski lives have been affected by brain injury. has conducted research and consulted in the While the media reminds us daily of the biomechanics of head and neck injury and diverse opinions regarding the war in Iraq, helmet design. working with the DVBIC and on this special Dr. George Zitnay, one of the founders of issue has confirmed unequivocally, that there the Defense and Veterans Brain Injury Cenis a strong and unified opinion among Amer- ter, provides an article detailing the history of icans of all walks of life, affirming our collec- DVBIC, its contributions to the field and the tive commitment to members of the armed evolution of the program since its inception services, especially those who have suffered in 1991 as the Defense and Veterans Head disabling injuries. TBI due to blast is the sig- Injury Program. Additionally, Dr. Zitnay nature injury of the current war. However, concludes by discussing some of the future even in peace time, military personnel suf- goals of DVBIC in areas of basic research,

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clinical innovation and treatment outcome. An article submitted by Dr. Minah Suh and colleagues from the Cognitive and Neurobiological Research Consortium in Traumatic Brain Injury follows, providing an overview of concussion assessment tools applicable in military environments, and current innovations under investigation. Implementation of web-based and computerized screenings are discussed, as well as their development of visual based screening utilizing oculomotor testing. The issue concludes with contributions prepared by staff and colleagues of the DVBIC Virginia NeuroCare community program and the University of Virginia Medical School. Their first article reviews the literature on community integrated rehabilitation, addressing the various models and published outcome studies. The article also reviews their innovative program elements, utilization of current advanced technology and development of standardized core treatment manuals to facilitate research, replication and dissemination for both military and potential civilian applications. Their second article provides an overview of post-traumatic stress disorder and brain injury, addressing the research literature, symptom overlap, assessment challenges and treatment implications of this complex set of symptoms. I would like to formally thank the distinguished contributors to this issue, and the many clinicians and researchers across the country at the various DVBIC sites, working under the leadership of Dr. Deborah Warden, who have devoted their careers to advancing the field and improving outcomes for military personnel, as well as civilians, with TBI. Lastly, I wish to thank the men and women of our armed forces. So few of us truly appreciate your sacrifices on our behalf. We owe all of you our deepest gratitude for your service.

Tina M. Trudel, PhD

Principal Investigator, Defense and Veterans Brain Injury Center at Virgininia NeuroCare Assistant Professor of Clinical Psychiatry and Neurobehavioral Sciences, University of Virginia Medical School President/COO, Lakeview Healthcare Systems, Inc.

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message from rep. bill pascrell The brave American military men and women who are engaged in combat operations overseas have seen a dramatic increase in cases of Traumatic Brain Injury (TBI). The measurable rise in this dangerous affliction has pushed military doctors to name TBI as the signature wound of the wars in Iraq and Afghanistan.

Force is fortunate to enjoy a strong partnership with the Defense and Veterans Brain Injury Center (DVBIC). Established in 1992 after Operation Desert Storm, DVBIC provides brain injury specific care and rehabilitation within the Department of Defense (DoD) and Veterans Administration (VA). Before 1992, no such provider existed to specifically service the basic needs of American combat veterans. The results of this egregious neglect are as evident as they are unfortunate. Vietnam veterans for example, were never properly diagnosed or treated for brain injuries. As a result many ended up in mental hospitals or prison. An en-

The success of the Congressional Brain Injury Task Force and DVBIC is immeasurably vital to America

Rep. Bill Pascrell In my role as the founder and cochairman of the Congressional Brain Injury Task Force, I am committed to leading Congress in acting urgently and responsibly so that our soldiers have access to adequate diagnostic, treatment, and rehabilitative services. TBI has gone undiagnosed and unrecognized for too long. It is morally incumbent upon this Congress to provide our military and health experts with the resources necessary to fully address the increase in brain injuries. We must exercise this most meaningful way to honor the courage of Americaâ&#x20AC;&#x2122;s brave military heroes. The Congressional Brain Injury Task

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tire generation of veterans suffered unusually high divorce and suicide rates. As the nature of warfare changes, so must the provision of specialized medical care. Unlike any time in our military history, experts estimate that fifty percent of all combat injuries result from explosive blasts. I was proud to be a part of a Congressional effort to authorize the Blast Injury Prevention, Mitigation and Treatment Initiative. The initiative which passed Congress this summer would create guidelines for the assessment and follow-up care after a blast-related TBI within the military environment. Specifically it would fund combat medicine and blast injury prevention, mitigation and treatment research. The initiative would provide funding for clinical diagnosis and care of victims of blast injury, including TBI.

The Blast Injury Prevention, Mitigation and Treatment Initiative is an important indication of Congressional commitment to finally service our veterans most common combat wounds. As the Bush Administration considers sending more troops into Iraq where they will face blast threats in a hostile urban environment ravaged by sectarian violence, it is a commitment that we are obligated to continue to pursue and build upon. I look forward to beginning the 110th Session of Congress and building even greater membership on the Congressional Brain Injury Task Force. The threat of TBI which is already so prevalent in everyday civilian life, has become an absolute scourge amongst our military personnel. The membership of my colleagues on our Task Force is more important than ever before. With broad bipartisan support, DVBICâ&#x20AC;&#x2122;s congressionally-directed mission to coordinate clinical care, execute research, and educate military and civilian communities will have the potential to thrive. The success of the Congressional Brain Injury Task Force and DVBIC is immeasurably vital to America, as our troops remain engaged in an increasingly complex global challenge. Congressman Pascrell is a founder and co-chair of the Congressional Brain Injury Task Force. The Congressional Brain Injury Task Force works to further awareness of brain injury, its prevalence, prevention and treatment. It also supports funding for basic and applied research on brain injury rehabilitation and development of a cure. The Task Force has been successful in securing additional funding for the only federal programs focused on assisting individuals with TBI: the Traumatic Brain Injury Act and the Defense and Veterans Brain Injury Center.

san antonio conference C

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Selected Biomechanical Issues of Brain Injury Caused by Blasts

Mariusz Ziejewski, PhD, Inz, Ghodrat Karami, PhD, and Iskander Akhatov, PhD This paper will introduce the importance of the biomechanics analysis of brain injury under blast loading. It will demonstrate the implementation procedures of a mechanized, and a multiscale model for head, brain tissues and brain cells in an effort to address the level of brain injury under blast loading. In such a modeling scheme, the objective will be to conduct the analysis and characterization procedures in a multi-step process so that the brain injury can be detected at different levels and under different blasts with various severities. The Finite Elements computational algorithms will be used for the analysis needed throughout. Also, cavitation, a microscale phenomenon, which happens as a result of the movements of the elements of brain under impact loading, will be dealt with using the small-scaled fluid dynamics phenomena. Introduction With an increasing use of improvised explosive devices (IEDs) in terrorist and insurgent activities, exposure to blasts is becoming more frequent. Research into diagnosing cases of Traumatic Brain Injury (TBI), caused by these kinds of blasts, is a critical component in treating the injuries and in preventing the onset of serious physical consequences and impairments that can result from them. Although tremendous new developments in neuroimaging have become available in diagnosing and assessing TBIs, two challenges remain: 1) identifying all distinguishable evidence; and 2) linking that evidence to the trauma. Blast injuries can be multiple and complex and can of10 BRAIN INJURY PROFESSIONAL

ten not be assessed in the same manner that other brain injuries might be examined. A better approach to take in evaluating a brain injury caused by a blast may, therefore, be to conduct the evaluation based on the mechanism (cause) of the injury [1]. Mathematical modeling and computer simulation due to the speed, versatility and mechanized nature of such methods, facilitate closely-approximated solutions for biomechanical diagnosis of resulted injuries. Primary blast injuries occur as a result of blast wave-induced changes in atmospheric pressure and affect organs (i.e., brain); secondary blast injuries occur from objects put in motion by the blast hitting people; tertiary blast injuries occur by people being forcefully put in motion by the blast; and quaternary blast injuries occur from burns, or inhalation of gases [2]. Secondary and tertiary blast injuries have been studied for many years by biomechanical researchers. The primary blast injury category, which results in traumatic brain injury (TBI), however, is the main subject of this article. The researchers from the Impact Biomechanics laboratory at North Dakota State University have been involved in analysis of brain injury mechanisms employing biomechanical modeling under impact loading including impacts due to blasts and explosions. The group has devised the scientific analysis of TBI caused by a blast into several steps as shown in Figure 1. Steps one and two involve blast simulation using LS Dyna Finite Elements Model (FEM) coupled with human dynamic model of Articulated Total Body (ATB) [3]. The outcome of

figure 1

Flow chart of blast injury analysis

figure 2

(a) Variation of pressure with distance, (b) Blast wave pressure-time history [8]

figure 3

The energy change after a blast

figure 4

Types of acceleration

steps one and two include a profile of pressure distribution and head acceleration. Step three involves FEM of brain tissue using brain images from MRIs, etc [4]. The outcome of step three is to analyze the stress/strain characteristics of the brain tissue. Step four is multiscale cellular analysis [5], with the outcome being the effect of blast originated impulse on cellular damage, which is the solid mechanics approach. Step five involves cavitation, cellular modeling of the solid/liquid and cell matrix interaction. The outcome of this step is the effect of blast originated impulse on micro damage due to cavitation inception in micro/nanoscale structure based on a fluid dynamics approach [6,7]. Physics of Blast Blasts mostly happen with the presence of an explosive material such as TNT. The threat of explosive materials is defined by two equally important elements: 1) the explosive charge weight, which is normally measured using the equivalent amount of TNT; and 2) the standoff distance between the blast source and the target. With the detonation of a mass of TNT at, or near, the ground surface, the peak blast pressures resulting from this hemispherical explosion decay as a function of the distance from the origin (see Figure 2a). The pressures can, however, be amplified by a reflection factor as the shock wave encounters an object, or structure, in its path. The reflected pressure is at least twice that of the incident shock wave. It is also proportional to the strength of the incident shock, which is proportional to the charge weight. The blast pressure decays exponentially and eventually becomes negative as shown in Figure 2b. For mathematical modeling and simulation purposes, the human head should be subjected to the incoming wave from an explosion. The explosion can be assumed to happen in an open space, as well as within a contained space. The fluid/solid interaction (air and the object) will determine the impact on the confronting object. The energy of the blast will quickly change into other forms of destructive energy. In Figure 3, the results of the change of blast energy within a contained block are shown as a result of an explosion. As seen, the total energy can be transferred to kinetic, as well as internal energy, as time goes by after the explosion. Modeling of Injury Studying the biomechanics (application of engineering in the study of living organisms such as the human body) is a method of analyzing the mechanism of the injury. Biomechanics determines forces acting on the human body and the effect of those forces. Biomechanical engineering analysis is a tool that, if used properly, can incorporate common-sense experience in understanding the nature and severity of injury to the human brain as a result of trauma, and in this case, a blast. Factored into the biomechanical analysis is the study of the environmental and human body dynamics and the human tolerance limits. Nowadays, there are two main approaches to biomechanical analysis: 1) experimental evaluation which is the most valuable, but not always practical; 2) detailed computer simulations using mathematically and numerically-based biomechanical formulae. Only computer simulation approaches allow inclusion of all necessary parameters in evaluation of specific scenarios. Brain injury can result from the sudden change in velocity due to trauma such as head impact, or inertia loading of the head. An important influence on engineering parameters is the BRAIN INJURY PROFESSIONAL

acceleration, representing the change in the velocity as a function of time. In the biomechanics field, the head acceleration, therefore, has been used in characterization of the severity of an insult to the brain. For a more detailed discussion of the above concepts, see Ziejewski, 2004 [9]. The complete global representation of the head motion, in terms of acceleration, can only be achieved, if the complex input of linear and angular acceleration is known. This includes three components for linear acceleration and three for angular acceleration, see Figure 4. The head acceleration data can be used directly to assess the probability of TBI by extracting the resultant maximum values and the rate of change of acceleration, or by calculation of head injury assessment functions such as the Head Injury Criteria (HIC) (NHTSA 49), Head Impact Power (HIP), Power Index (PI) and others [10]. Additional parameters that deal with local brain deformation have also been developed. They are an extension of the evaluation based on head acceleration. It has been suggested that brain surface contusions, Diffuse Axonal Injury (DAI), and acute sub dural hematoma can be predicted using, among other things, brain motion, [11,12,13, 14,15,16, 17], sudden change in the inter cranial pressure, which is largely due to the linear acceleration [18], sheer strain, stress/strain concentration [19,20], and the product of stress and strain rate [21]. In order to gain better understanding of the head injury mechanisms, both clinical as well as laboratory studies have been conducted for decades. Among the biomechanical simulations, sophisticated 3D finite element analysis and rigid body bio dynamics methods have been used to study impact injury events and the response of the human head. In general, TBI develops when the internal mechanical responses exceed tissue tolerance levels, a process referred to as load-injury scheme. Simulation of Primary Blast Injury The brain is clearly vulnerable to both secondary and tertiary blast injuries. The issue of whether, or not, primary blast forces directly injure the brain, however, is still unresolved. The vulnerability of the brain to a primary blast is supported by recent animal studies [22]. One of the outcomes has been identified as the formation of gas emboli, leading to infarction [2]. A more in-depth understanding of that outcome, including the location, size and geometry of the damage site, would be of assistance to physicians in properly interpreting neuro diagnostic results. In an approach to be demonstrated briefly, the macro/ micro scale solid mechanics modeling of brain tissues, cells, and head will be used in conjunction with the micro/nano scale fluid mechanics modeling of cavitation created under sudden movement of the elements of brain constituents. Macro and Micro Scale Solid Mechanics Modeling The finite element modeling (FEM) will be conducted at macroscale for head and brain tissues and at microscale for brain cells. LSDyna as a powerful finite element software and tool for the analysis under impact loading has the capacity to determine the motion of the brain elements, due to blast. Part of the input data to the LSDyna program can be determined using Articulated Total Body (ATB) [3]. ATB is a rigid-body dynamic simulation program that is especially suited to measure head and neck motion parameters when the body is exposed to attacking waves of explosion. The program will be used to mea12 BRAIN INJURY PROFESSIONAL

figure 5

The right-half model of the brain, CSF and skull bone

sure accelerations (linear or angular) at different points of the head. The output will be forwarded to FEM for detailed stress and deformation of the skull and brain tissue analysis. The macroscale global FEM brain analysis takes into account the detailed structure of the human head anatomy, including the brain, falx and tentorium, CSF, dura mater, pia mater, skull bone and scalp. The brain, CSF and skull bone will be modeled as first-order brick elements with eight-node [4,23,24,25]. The falx, tentorium, dura, pia and scalp will be modeled as four-node membrane or shell elements with uniform thickness. Figure 5 shows the 3D finite element model of these components [4]. In an effort to examine the injury in a multiscaled approach, i.e., from cellular to the global head, the multi-scale modeling of the brain and its components will be advanced. The verifications are done through MRIs which can create a link between the mechanism of brain injury at the cellular level and the mechanism of mechanical loading on the head at the macroscopic level. The work will focus on: • • • • • •

blasts and creation of destructive wave; determination of TBI at various scales; accurate modeling of brain material; damage and tolerance at cellular level; correlation of damage at different levels; material characterization of the brain and its components; and • data for a systematic design of injury protection devices The cellular analysis is an important issue in injury analysis. The cell, as a basic unit of life, is a biologically complex system. The understanding of cells’ behavior requires a combination of various disciplines and approaches including biomechanics. Cells must use genetic information, perform synthesis, sort, store, and transport biomolecules; convert different forms of energy; transduce signals; maintain internal structures; and respond to external environments [5,26,27]. Many of these processes involve mechanisms that should be dealt with using the principles of mechanics. Micro and Nano Scale Fluid Mechanics Modeling (Cavitation) An additional effect of primary blast injuries is based on the pressure differences that cause micro/nanoscale cavitation making a component of overall injury evaluation. The effect of such an impact on the brain has been investigated theoreti-

figure 6

Computational fluid dynamics modeling in nanoscopic environments

cally and experimentally with certain idealizations [28,29,30, 31,32,33,34,35,36,37,38,39]. In these studies, an experimental and numerical analysis of a simple model of the human brain under impact was used. Namely, a water-filled cylinder was struck by a free-flying mass. Rigid-body acceleration time histories and the pressure at the fluid-cylinder interface were monitored during impact. Comparisons between the experimental results and the results of a computational model were made. As a conclusion of this work, the following view of head impact was developed: when the head receives a blow and a positive pressure develops under the point of impact, a small cavity, opposite the impact, can form between the skull and the dura. This cavity is created due to negative pressure (tension) developed between the dura and the skull. Its subsequent collapse could be a mechanism of injury. The study also indicated that under complex loading conditions, cavitation could occur in the brain material, not just at the boundary. It was found that if the head underwent pre-impact acceleration, immediately before the head strike, internal cavitation was likely. Internal cavitation implies potential cellular tissue damage. It was admitted, therefore, that if the impact is severe enough, it may produce cavitation in the brain, and the associated violent cavity collapse could be a supplementary mechanism of brain injury. The complexity of the problem is mainly due to the fact that liquid in the brain is confined between membranes and cells at very different scales from 1cm to 0.1 μm. When a blast occurs, it creates pressure waves. There are several different phases of the waves beginning with a positive phase, moving into a negative phase, moving into a smaller positive phase, and then moving into a smaller negative phase, etc., until it passes. It is the negative phases that result in cavitation. Our research shows that 1) in macro scale confinement (ventricles and subarachnoid space) a brain injury may be caused by cavitation bubble collapse; 2) in micro and nano scale confinement (neurons) cavitation inception may be a possible cause for a brain injury (see Figure 6). As can be seen in Figure 6, pressure induced by cavitation inception may cause significant positive pressure on the brain tissue in micro and/or nano scale channel, filled by bio-fluid. These types of channels can be found deep in the structure of the central nervous system. Fluid dynamics and cavitation inception in tight confinements will have a great impact on the integrity of neurons in general, and on axonal transport, or axoplasmic flow, in particular.

Developing theoretical approaches and experimental methods that allow an adequate prediction of liquid micro and nano film dynamics and cavitation in the brain are crucial for improving early diagnoses and interpretations of TBI. Physical concepts and mathematical tools for the dynamics of liquid micro and/or nano films confined between two solid or elastic surfaces, or membranes, need to be developed. Conclusion Recent world events related to terrorism and the increased use of IEDs, has led to a need for better understanding of the mechanism of blast injuries and early diagnoses and interpretations of TBI caused by blasts. The identification of all distinguishable evidence of blast injuries, however, continues to be a challenge for medical professionals working with the injured military personnel. The application of biomechanics for studying blast injuries provides a valuable tool to view the injury and its mechanism. Increased knowledge of cellular level damage, including cavitation, has the potential to be a field of research that could have tremendous impact on how those injured by blasts are diagnosed, treated and rehabilitated. About the Authors

Mariusz Ziejewski, PhD, Inz, is an Associate Professor in the Department of Mechanical Engineering and Applied Mechanics at North Dakota State University, where he serves as Director of the Impact Biomechanics Laboratory and the Automotive Systems Laboratory. Dr. Ziejewski is also an adjunct Associate Professor in the Department of Neurosciences at the University of North Dakota School of Medicine. His research interests include short duration impact phenomena in the area of biomechanics, and the effect of such events on the human body, especially the head and neck. Ghodrat Karami, PhD, is an Associate Professor in the Department of Mechanical Engineering and Applied Mechanics at North Dakota State University. Previously he was a visiting professor at the University of Wyoming and at Washington State University. He is currently researching multiscale modeling for noncomposite materials and has authored over 100 papers in the field of engineering. Iskander Akhatov, PhD, is an Associate Professor in the Department of Mechanical Engineering and Applied Mechanics at North Dakota State University. He previously was a visiting researcher at Rensselear Polytechnic Institute, Boston University and the University of Gottingen. Dr. Akhatov also served as the Director of the Institute of Mechanics at the Ufa Branch of the Russian Academy of Sciences.

References

1. Scott S, Belanger H, Vanderploeg R, Massengale J, Scholten J. Mechanism-of-injury approach to evaluating patients with blast-related polytrauma. Jnl Amer Osteopathic Assoc 2006;106(5):265270. 2. Taber, K, Warden D, Hurley R. Blast-Related Traumatic Brain Injury: What is Known? Jnl Neuropsychiatry Clin Neurosci 2006;18(2):141-145. 3. Ziejewski M, Song J. Assessment of brain injury potential in design process of children’s helmet using rigid body dynamics and finite element analysis. ATB Users’ Group Conference sponsored by US Air Force, Armstrong Laboratory, Dayton OH, 1998. 4. Li D, Ziejewski M, and Karami G. Parametric studies of brain materials in the analysis of head impact. IMECE-2006-15596 paper, ASME Congress, Chicago, 2006. 5. Abolfathi, N , Karami G and Ziejewski M, Biomechanical cell modeling under impact loading, International Journal of Modeling and Simulation, 2006 (in press). 6. Gavrilyuk S, Akhatov I. Model of a liquid nanofilm on a solid substrate based on the van der Waals concept of capillarity. Phys Rev E 2006;73:021604. 7. Nagrath S, Jansen K, Lahey RT Jr, Akhatov I. Hydrodynamic simulation of air bubble implosion using a level set approach. Jnl Computational Physics 2006;215(1):98-132. 8. Mendis T, Ngo T. Vulnerability assessment of concrete tall buildings subjected to extreme loading conditions. Australian Conference, 2002. 9. Ziejewski M. The biomechanical assessment of traumatic brain injury. Brain Injury Professional, The Official Publication of the North American Brain Injury Society 2004;1(1):26-30. 10. Newman J, Shewchenko N, Welbourne E. A proposed new biomechanical head injury assessment function – the maximum power index. 44th Stapp Car Crash Conference, Atlanta, GA, 2000. BRAIN INJURY PROFESSIONAL

11. Meaney DF. The biomechanics of acute subdural hematoma in the subhuman primate and man. Ph.D. Dissertation, University of Pennsylvania, Philadelphia, PA, 1991. 12. Genarelli TA, Thibault LE. Biomechanics of acute subdural hematoma. Jnl Trauma 1982;22:680-686. 13. Abel JM, Gennarelli TA, Segawa H. Incidence and severity of cerebra concussion in the rhesus monkey following sagittal plane angular acceleration. Proc. 22nd Stapp Car Crash Conference, SAE Paper No. 780886. Society of Automotive Engineers, Warrendale, PA, 1978. 14. Edbert S, Rieker J, Angrist A. Study of impact pressure and acceleration in plastic skull models. Laboratory Investigation 1963;12:1305-1311. 15. Gurdjian ES, Hodgson VR, Thomas LM. High speed techniques in head injury research. Med Sci 1967;18(11):45-56. 16. Unterharnscheidt F, Higgins LS. Traumatic lesions of brain and spinal cord due to non-deforming angular acceleration of the head. Texas Rep on Bio and Med 1969;27:127-166. 17. Pudenz RH, Sheldon CH. The lucite calvarium- a method for direct observation of the brain; cranial trauma and brain movement. Jnl Neurosurg 1946;3:487-505. 18. Zhang L, Yang KH, King AI. Biomechanics of neurotrauma. Neurological Res 2001;23:144156. 19. Ross DT, Meany, DF, Sabol MK, Smith DH, Genneralli, TA. Distribution of forebrain diffuse axonal injury following inertial closed head injury in miniature swine. Exp Neurol 1994;126:291-299. 20. Holbourne AHS. Mechanics of head injuries. Lancet 1943;438-441. 21. Viano DC, Lovsund P. Biomechanics of brain and spinal cord injury: Analysis of neurophysiological experiments. Crash Prevention and Injury Control 1999;1:35-43. 22. Kaur C, Singh J, Lim MK, et al: The response of neurons and microglia to blast injury in the rat brain. Neuropath and App Neurobio 1995;21:369-377. 23. Kleiven S, von Holst H. Review and Evaluation of Head Injury Criteria. Proc. RTO Specialist Meeting, the NATO’s Research and Technology Organization (RTO), Koblenz, Germany 19-23, 2003 24. Ruan JS. Impact biomechanics of head injury by mathematical modeling. PhD. Dissertation, Wayne State University, 1994. 25. Willinger R, Kang, HS, Diaw B. Three-dimensional human head finite element model validation against two experimental impacts. Annals Biomed Eng 1999;27:403. 26. Fabry B, Maksym G, Butler J, Glogauer M, Navajas D, Freedberg J. Scaling the microrheology of living cells. Phys Rev Letters 2001;87(14):1-4. 27. Guilak F, Jones WR, Ting-Beall HP, Lee GM. The deformation behavior and mechanical properties of chondrocytes in articular cartilage. Osteoarthritis Cart 1999;7:59-70. 28. Benedict JV, Harris EH, van Rosenberg DV. An analytical investigation of the cavitations hypothesis of brain damage. Biomechanics and Human Factors Conference. ASME No. 70, BHF-3, 1970. 29. Luback P, Goldsmith W. Experimental cavitation studies in a model head-neck system. Jnl Biomech 1988;13:1041. 30. Genarelli TA. Animate models of human head injury. Jnl Neurotrauma 1994;11:357. 31. McLean AJ. Brain injury without head impact. Traumatic Brain Injury Bioscience and Mechanics. Ed and Mary Liebert, Inc. New York: Larchmont 45-49, 1996. 32. Mertz HJ, Nusholtz GS. Head injury risk assessment for forebrain impacts. Society of Automotive Engineers, Inc. SAE # 960099, 1996. 33. Nusholtz GS, Lux P, Kaiker PS, and Janicki MA. Head impact response-skull deformation and angular acceleration. Proc. 28th Stapp Crash Conf. Paper #841657, 41, 1984. 34. Nusholtz, GS, Kaiker, PS, Lehman, RJ. Critical limitations on significant factors in head injury research, Proc. 30th Stapp Car Crash Conf. Paper # 861890, 237,1986. 35. Nusholtz GS, Ward CC. Comparison of epidural pressure in live anesthetized and postmortem primates. Aviation Space Env Med Jnl 1987;88:9. 36. Nusholtz GS, Kaiker PS, Wylie EB, and Glascoe LG. The effects of the skull/ dura interface and foramen magnum on the pressure response during head impact. 14th ESV Conference, Munich, Paper # 94 S1 0 26, 1994. 37. Nusholtz GS, Wylie, E.B., and Glascoe, LG. Cavitation/boundary effects in a simple head impact model, Aviation Space Env Med Jnl 1995;66(7):661. 38. Nusholtz GS, Wylie EB, and Glascoe LG. Internal cavitation in simple head impact model. Jnl Neurotrauma 1995;12(4):707. 39. Nusholtz, GS, Glascoe, LG, Wylie, EB. Cavitation during head impact. Society of Automotive Engineers, Inc, SAE # 970390, 1997.

Additional References

LeSar R.. Modeling and simulation of biomaterials. Annu Rev Mater Res 2004;34:279–314. Lim CT, Zhou EH, Quek ST. Mechanical model for living cell – a review. Jnl Biomechanics 2006;39:195-216. National Highway Traffic Safety Administration. 49 CFR Parts 553,571,585,595 (Dock NHTSA 00-7013), May 2000. Nishimoto T, Murakami S. Relation between diffuse axonal injury and internal head structures on blunt impact. Jnl Biomech Eng 1998;120:140-147. Peeters A, Oomensa E, Boutena, CVC, Baderb DL, Baaijens FPT. Mechanical and failure properties of single attached cells under compression. Jnl Biomech 2005;38:1685-1693. Sacks, M. and Sun, W. Multiaxial mechanical behavior of biological material. Annu Rev Biomed Eng 2003;5:251–284. Ziejewski, M.. A biomechanical examination of brain dynamics as a result of minor impacts, 6th Congress of the European Federation of Neurological Societies, Vienna, Austria., 2002. Ziejewski, M. State-of-the-art biomechanical issues in relation to mild traumatic brain injury, North American Brain Injury Society Conference, Amelia Island, FL, 2004.

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A Brief History of the Defense and Veterans Brain Injury Center (DVBIC)

George Zitnay, PhD The Defense and Veterans Brain Injury Center was founded in 1991 by Andres Salazar, M.D. and George A. Zitnay, Ph.D. as a response to the pending war in the Middle East. As Operation Desert Shield (later named Operation Desert Storm) was about to begin, Dr. Salazar and Dr. Zitnay went to the Pentagon and Congress to express concern regarding the planning for care of injured soldiers with head injuries. This concern stemmed from the work that Dr. Salazar and his colleagues had been conducting in their follow-up study of soldiers who had sustained head injuries in the war in Vietnam. The Vietnam Head Injury study suggested that without proper planning and follow-up services, soldiers sustaining head injuries would be undiagnosed, under served and under treated resulting in many servicemen and women with head injuries being misplaced in inappropriate settings or not served at all. When first established, the Defense and Veterans Brain Injury Center was called the Defense and Veterans Head Injury Program (DVHIP) and the objective was to create an overall systems program for providing TBI specific care and rehabilitation within the Department of Defense (DOD) and Veterans Health Administration (VHA). The DVHIP was thus created by the DOD Office of Health Affairs first and foremost as an interagency clinical program oriented to treatment, rehabilita16 BRAIN INJURY PROFESSIONAL

tion, and care management. However, an integrated programmatic clinical research mission was included in the initial charter. The program was envisioned as a collaborative effort with the DOD, Department of Veterans Affairs (DVA), the Brain Injury Association (BIA) and the International Brain Injury Association (IBIA). At the time the DVHIP was established Dr. Zitnay was serving as the President and CEO of the BIA and was President of IBIA. One of the early specific goals of the DVHIP was to ensure that military personnel and veterans with brain injury receive TBI-specific evaluation, treatment and follow-up, while at the same time, addressing the readiness mission of the military and helping to define optimal rehabilitation for persons with TBI nationwide. The DVHIP began by serving the 7,000 peacetime admissions to DOD and DVA hospitals each year, and providing the guidance, direction and follow-up treatment for all those servicemen and women who had sustained a brain injury in Operation Desert Storm. As the DVHIP grew, the goals and scope of the program enlarged to encompass new needs and to remain on the cutting edge. The goals then began to address questions relating to all military TBI including acute care and the combat casualty care process as well as the effects of mild TBI on combat perfor-

mance. The DVHIP maintains an important combat Head Injury Registry that is used for research follow-up and long term management of TBI resulting from battlefield operations. Today the Defense and Veterans Head Injury Program has evolved into a nationally recognized center of excellence in brain injury rehabilitation with an embedded research program. The Defense and Veterans brain Injury Center (DVBIC) is headquartered at Water Reed Army Medical Center in Washington, D.C., and is directed by Deborah Warden, M.D. The DVBIC mission is to ensure optimal care for military personnel and veterans with TBI, conduct military relevant clinical research and to provide education about TBI causes, consequences, treatment and prevention for military, veterans and their families. The DVBIC is comprised of nine core sites located at Walter Reed Army Medical Center; Naval Medical Center, San Diego; Wilford Hall in Texas, and at Veterans Hospital locations in Richmond, Tampa, Palo Alto and Minneapolis. In addition, there are two community re-entry sites, Virginia NeuroCare in Charlottesville, VA, and Laurel Highlands Neurorehabilitation Center in Johnstown, Pennsylvania. The DVBIC Military sites primarily focus on mild TBI, provide comprehensive evaluation services, education, “fitness” for return to active duty, information for medical boards, case management, coordination with VA sites and follow-up services. The VA sites of the DVBIC primarily focus on moderate to severe brain injuries and provide comprehensive evaluation, a full range of medical and rehabilitation services, including cognitive rehabilitation, education and driver training. These VA sites also provide case management, care coordination, transition from military to veteran status and follow-up service. Extensive research protocols and advances in diagnosis and treatment are emerging through the work of the DVBIC Military sites. The two community re-entry locations primary focus is on the full spectrum of TBI in the context of post acute rehabilitation. Comprehensive community re-entry services are provided in residential transitional living that includes life skills training in community programs, vocational rehabilitation, a full range of therapy services, comprehensive evaluation, education, “fitness” to return to active duty, case management, follow-up services and coordination with VA sites and home services. Specialized community re-entry services include university affiliated neuropsychological and computerized driver evaluation/simulation, enhanced environmental enrichment programs and development of treatment manuals for standardization, research and replication. All of the core sites participate in an embedded military relevant research program aimed at improving outcomes and returning soldiers with TBI to active duty. The war in Iraq and Afghanistan has focused more resources on clinical care and treatment as well as on training. DVBIC sites have seen over 1,300 patients with TBI. Of those patients treated, a little more than half have moderate to severe injuries and the remainder have a mild TBI. Blast injury is the most common cause of TBI. Additionally, DVBIC has provided training for medics in theater, developed concussion guidelines for assessment in the field and has led the effort at post development screening of troops upon their return from theater.

Research to better understand the pathophysiological and relevant neurologic injury of blast injury is being undertaken especially with mild TBI, to minimize risk of over estimation from screening information and from self-reported information. Careful construction of a validated screening tool is underway. DVBIC is collecting data and has developed disposition assessment guidelines regarding when and if a service member who had sustained a TBI event should return to active duty. Finally, a comprehensive data collection system on TBI and blast events is being developed for formulation of future research questions, for planning and to better inform senior leadership. Education, case management and follow-up along with family support is an integral part of DVBIC programs and centers. Future directions for DVBIC include: 1. Characterization of soldiers with TBI from OIF/OEF with outcomes 2. Conduct blast related research with regards to neuropsychological, neuro-imaging, biochemical, genetic and epidemiological domains 3. Study TBI/co-morbidity interactions including PTSD, substance abuse, amputation and burns 4. Develop new treatments for TBI including pharmacological, telemedicine, tele-rehabilitation, neuroprotection, clinical management guidelines development, new care and case coordination methodology, new family and professional educational programs, manualized post-acute rehabilitation modules and new prevention efforts and material development 5. Develop more specific and sensitive measure of treatment effects and outcomes in TBI Conclusion

The Defense and Veterans Brain Injury Center, a congressionally mandated program established in 1991, has evolved into a specific disease management system that integrates TBI clinical care, TBI education, prevention and case management follow-up program with an embedded military relevant research program. The DVBIC has demonstrated the value of a coordinated care system for TBI between the DOD and VHA with community partners. About the Author

George Zitnay, PhD, is the founder of the Laurel Highlands Neurorehabilitation Center, a DVBIC program in Johnstown, PA. Dr. Zitnay has over 45 years in the field of neurotrauma and rehabilitation and has served as Chairman of the Advisory Committee for the National Medical Rehabilitation Center at NIH and as the Chairman of the Neurotrauma Committee of the WHO. He was the founder of the National Brain Injury Research, Treatment and Training Foundation, Co-founder of the Defense and Veterans Head Injury Program and past President of both the Brain Injury Association of America and the International Brain Injury Association.

References

Salazar A, Zitnay G, Warden D, Schwab KA. Defense and Veterans Head Injury Program: Background and overview. J Head Trauma Rehabilitation 2000;15(5):1081-1091. Ommaya A, Salazar A, Schwab KA. Defense and Veterans Head Injury Program: A model injury registry. Military Medicine 1999;164(8 Suppl):1-21. Schwab KA, Baker G, Ivins BJ, Sluss-Tiller M, Lux W, Warden D. The Brief Traumatic Brain Injury Screen (BTBIS): Investigating the validity of a self-report instrument for detecting traumatic brain injury (TBI) in troops returning from deployment. Neurology 2006;66(suppl 2):A235.

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New Ways to Diagnose and Assess Attentional and Cognitive Deficits Following Blast Injury Minah Suh, PhD, Ranjeeta Sarkar, Rachel Kolster, Pamela Drexel, Jamshid Ghajar, MD, PhD Blast Prevalence

Explosive devices directed against both civilian and military targets are often employed in acts of terrorism throughout the world, with the incidence of blast injuries on the rise [1]. In war zones, it is estimated that as many as 47% of all blast injuries affect the head [2]. Increased prevalence underscores the need for researching innovative assessment methods in detecting blast-related brain injury, since many brain injuries may have no external marker of injury. Blast injuries often produce symptoms similar to those found in classical traumatic brain injury (TBI) [3], thereby making detection, diagnosis, and treatment exceedingly complex and variable [4]. Relationship between Blast Injury and TBI

TBI can be mild, moderate, or severe, depending on the extent of damage to the brain and a patient’s subsequent level of wakefulness. The damage sustained can be confined to one area of the brain, making it focal, or it can involve more than one area of the brain, thereby making it diffuse [5]. Blast related TBI shares these features, but can also include additional considerations, such as blast impact, propulsion of the patient due to the force of the blast, possible burns, and inhalation of toxic substances [1]. Approximately twenty percent of mild TBI patients develop a number of persistent symptoms post-injury. These symptoms are collectively labeled post concussive syndrome (PCS). Such behavioral, cognitive, and psychological symptoms vary greatly in both severity and onset, and are also evident in patients who have suffered blast related TBI [6]. Many patients experience 18 BRAIN INJURY PROFESSIONAL

cognitive deficits including problems with concentration and attention, as well as difficulties with higher level executive functions, such as planning, organization, and decision making. Critical life outcomes such as vocational success, community reintegration and social autonomy have been linked with executive functioning following brain injury [7]. Web-based Neuropsychological Measures

Several studies have examined the efficacy of web-based support for both patients and family members. Wade, et al [8] suggest that a computer-based pediatric intervention may be utilized in an effort to improve children’s emotional and cognitive outcomes following TBI, as well as ameliorate injury-related burden, psychiatric symptoms, and depression in parents of children with TBI. A similar study in adults used a website to provide in-home adjunctive and supportive services to TBI patients and their families [9], with family caregivers using webbased interventions for social support and guidance following the return home of family members who had suffered a TBI. Web-based neuropsychological measures are aimed at offering a more accessible alternative to traditional paper-based cognitive batteries. Such tools include the online version of the Glasgow Coma Scale, as well as the Orientation Log [10], a measure of one’s awareness and orientation similar to the popular paper-based Galveston Orientation and Amnesia Test (GOAT), along with the Rancho Los Amigos Scale, an outcome assessment form delineating ten descriptive levels of cognitive function that range from “modified independent” to “total assistance” [11]. Websites such as the one from the Center for

Outcome Measurement in Brain Injury (COMBI), are geared toward current researchers, and offer detailed explanations of scales, along with specific administration protocols for researchers to employ (www.tbims.org/combi). Although not identical, the sports model of rapid, effective cognitive assessment could be applied to blast related TBI in an effort to provide an index of a patientâ&#x20AC;&#x2122;s cognitive functioning post-injury. For instance, the Concussion Resolution Index (CRI), based largely on the well-known Reliable Change Index (RCI) has been developed as an online assessment tool that, following sports-related concussion, tracks the resolution of symptoms in patients [12], and is largely geared toward determining if an athlete is well enough to return to competitive play. Similarly, the CSI, or Cognitive Stability Index, is a web-based system that attempts routine monitoring of cognitive function in TBI patients [12]. The variable nature of existing neuropsychological evaluations of TBI make results hard to interpret and codify, highlighting the need for a sensitive, straightforward assessment of post-injury cognitive function. Existing neuropsychological measures used to examine the cognitive implications of brain injury are numerous. Some of the most widely used measures include the California Verbal Learning Test (CVLT), a standardized measure of working memory [13], and the Wechsler Abbreviated Scale of Intelligence (WASI), a measure of both verbal and quantitative abilities [14], the Center for Epidemiological Studies Depression Scale (CES-D), a commonly used metric of depression/anxiety [15], and the Glasgow Outcome Scale (GOS), an interview addressing gross physical and mental functionality post-injury [16]. However, some of these tests depend on lengthy testing sessions, making the assessment of brain injury inefficient for researchers, clinicians, and patients alike. Eyetracking Advantages and Sensitivity

Since neural pathways in eye movements and higher cognitive functions [17] are similar, it has been suggested that oculomotor testing may be a promising and sensitive marker for attentional deficits in TBI patients. The utilization of oculomotor testing with high temporal resolution (500Hz) enables researchers to collect hundreds of data points in a short amount of time. Previous studies [18, 19] have shown that mild TBI patients showed reduced target anticipation, increased oculomotor error, and increased variability of oculomotor error during predictive target tracking, and these deficits were correlated with deficits in the California Verbal Learning Test (CVLT-II) measures related to working memory, learning, and executive attention [13]. Furthermore, when the target is temporarily extinguished during predictive target tracking, the smooth pursuit system relies on cortical input in order to extrapolate the virtual trajectory [17, 20], necessitating the need of anticipatory eye movement. Such paradigms may be an especially sensitive indicator of the integrity of cerebellar-cortical pathways after mild TBI [19]. With greater sensitivity than traditional neuropsychological tests, eyetracking has the potential to be an effective tool for the precise and rapid diagnosis of deficits in cognitive functioning following blast injury. Furthermore, eyetracking equipment can be developed to be portable, so that it could be brought to the injury site, thereby allowing for a rapid, effective assay of cognitive abilities post-injury.

About The Author

Minah Suh, PhD, is Assistant Professor of Neuroscience in the Department of Neurological Surgery at Cornell University Medical College, where she has been actively conducting various clinically oriented neuroscience projects, such as optical imaging of epilepsy & synchronization in the olivo-cerebellar system and cognitive deficits in traumatic brain injury (TBI). Ranjeeta Sarker graduated from Barnard College in 2004 with a BA in Neuroscience, and has been a research assistant at the Brain Trauma Foundation for three years. She is currently working on longitudinal studies of cognitive deficits and their relationship to white matter tract integrity in mild TBI patients. Rachel Kolster graduated from Columbia University in 2004 with a BA in Neuroscience, and has been a research assistant at the Sackler Institute of Cornell Medical College and the Brain Trauma Foundation for two years. She is currently working on studies of the relationship between eye movement deficits and white matter tract integrity in mild TBI patients. Pamela Drexel trained as a clinical psychologist, and she has served as Executive Director of the Brain Trauma Foundation since 2001. Jamshid Ghajar, MD, PhD, is Chief of Neurosurgery at NewYorkâ&#x20AC;&#x2122;s Jamaica Hospital-Cornell Trauma Center and is a practicing neurosurgeon at New York Presbyterian Hospital. He is currently President of the Brain Trauma Foundation, whose mission is to improve the outcome of patients with traumatic brain injury.

REFERENCES

1. Davis TE, Lee CY. An introduction to asymmetric war (terrorism) and the epidemiology of blast trauma [Greater New York Hospital Association Emergency Preparedness Resource Center Web site]. October 17, 2005. 2. Taber KH, Warden DL, Hurley RA. Blast-related traumatic brain injury: what is known? J Neuropsychiatry Clin Neurosci. 2006; 18(2):141-5. 3. Henigsberg N, Lagerkvist B, Matek Z, Kostovic, I. War victims in need of physical rehabilitation in Croatia. Scandinavian Journal of Social Medicine, 25(3), 202-206. 4. Wightman JM, Gladish SL. Explosions and blast injuries. Annals of Emergency Medicine; June 2001; 37(6): 664-p678. 5. Povlishock JT, Katz DI. Update of neuropathology and neurological recovery after traumatic brain injury. J Head Trauma Rehabil. 2005; 20: 75-94. 6. Cernak I, Savic J, Ignjatovic D, Jevtik M. Blast injury from explosive munitions. J Trauma 1999 Jul; 47(1): 96-103. 7. Stuss, DT, Knight, RT. Principles of Frontal Lobe Function, Oxford University Press, 2002. 8. Wade SL, Wolfe C, Brown TM, Pestian JP. Putting the pieces together: preliminary efficacy of a web-based family intervention for children with traumatic brain injury. J Pediatr Psychol. 2005 Jul-Aug;30(5):437-42. 9. Rotondi AJ, Sinkule J, Spring M. An interactive Web-based intervention for persons with TBI and their families: use and evaluation by female significant others. J Head Trauma Rehabil. 2005 Mar-Apr;20(2):173-85. 10. Jackson WT, Novack TA, Dowler RN. Effective serial measurement of cognitive orientation in rehabilitation: the Orientation Log. Arch Phys Med Rehabil. 1998; 79(6): 718-20. 11. Malkmus D, Booth BJ, Kodimer C. Rehabilitation of the head-injured adult: comprehensive management, Professional Staff Association of Rancho Los Amigos Hospital, Inc., Downey (CA) 1979. 12. Erlanger D, Feldman D, Kutner K, Kaushik T, Kroger H, et al. Development and validation of a web-based neuropsychological test protocol for sports-related return-to-play decision-making. Arch Clin Neuropsychol 2003 Apr;18(3):293-316. 13. Delis DC, Kramer JH, Kaplan E, Ober BA. California Verbal Learning Test Manual, Adult Version, Second edition, The Psychological Corporation, 2000. 14. Ryan JJ, Carruthers CA, Miller LJ, Souheaver GT, Gontkovsky ST, Sehr MD. The WASI matrix reasoning subtest: performance in traumatic brain injury, stroke, and dementia. Int J Neurosci. 2005 Jan; 115(1):129-36. 15. Rapoport, MJ, McCullagh, S, Shammi, P, Feinstein A. Cognitive impairment associated with major depression following mild and moderate traumatic brain injury. J Neuropsychiatry Clin Neurosci 2005; 17: 61-65. 16. Hudak AM, Caesar RR, Frol AB, Krueger K, Harper CR, Temkin NR, Dikmen SS, Carlile M, Madden C, Diaz-Arrastia R. Functional outcome scales in traumatic brain injury: a comparison of the Glasgow Outcome Scale (Extended) and the Functional Status Examination. J Neurotrauma. 2005 Nov;22(11):1319-26. 17. Nagel M, Sprenger A, Zapf S, Erdmann C, Kompf D, Heide W, Binkofski F, Lencer R, Parametric modulation of cortical activation during smooth pursuit with and without target blanking: An fMRI study. Neuroimage, 2006; 29(4): 1319-1325. 18. Suh M, Kolster R, Sarkar R, McCandliss B, Ghajar J. Deficits in predictive smooth pursuit after mild traumatic brain injury. J Neurosci Lett. 2006 Jun 19;401(1-2):108-13. 19. Suh M, Basu S, Kolster R, Sarkar R, McCandliss BD, Ghajar J. Increased oculomotor deficits during target blanking as an indicator of mild traumatic brain injury. J Neurosci Lett. 2006; 410(3): 203-7. 20. Becker W, Fuchs AF. Prediction in the oculomotor system: smooth pursuit during transient disappearance of a visual target. Exp Brain Res, 1985; 57: 562-75. BRAIN INJURY PROFESSIONAL

professional appointments RN PATIENT CARE DIRECTOR for three Rehabilitation nursing units including brain injury, spinal cord injury , stroke and pain management. Touro Rehabilitation, New Orleans, LA. Minimum 5 years experience. MSN required. Apply online at www.touro.com. PT, OT, ST for Per-diem positions, Night Nurse Manager- P/T, REGISTERED NURSES openings at Craig Hospital. For information go to www.craighospital.org. Career Opportunities, or send resume to Susi Szaltzer, RN, BSN, MS, Healthcare Recruiter, Human Resources, Craig Hospital, 3425 South Clarkson Street, Englewood, CO 80113. Phone: (303) 789-8463, Fax: (303) 7898684 or Sszaltzer@craighospital.org. RNs Touro Rehabilitation Center is seeking RNs full time, part time, and flex for their 27 bed Physical Rehab Unit for Stroke and SCI patients who need bedside rehab nursing caregivers. Prefer Certified Rehabilitation Registered Nurses, 8 and 12 hour shifts, with weekendonly options available. Competitive salary. Contact Susan Greco at GrecoS@Touro.com or phone (504) 897-8082 to apply. RNs needed for brain injury rehab at Centre for Neuro Skills, a post-acute brain injury rehab clinic which offers intensive residential and out-pt rehab for clients recovering from all types of acquired brain injury. The CNS community based approach focuses on helping clients regain a normal rhythm of living. Irving, TX clinic has openings for Licensed Nurses, M-F, holidays off, exc. benefits. Rehab experience is preferred. Resumes to hrtx@neuroskills.com or call (972) 580-8500. OCCUPATIONAL THERAPIST - Opportunity to make a difference with clients who have sustained or acquired brain injuries. This individual will work with a team of skilled professionals. Related degree and license to practice is required. Contact Cynthia Calhoun, PHR, Director Human Resources at Transitional Learning Center, 1528 Postoffice Street, Galveston, TX 77550, (800) TLC-GROW or (409) 797-1445. Fax (409) 797-1480 or email: ccalhoun@tlcgalveston.org. www.tlcrehab.org. OCCUPATIONAL THERAPIST Peace Rehabilitation Center, located in downtown Greenville, SC, specializes in community reintegration and provides unique opportunities for treatment. The Greenville Hospital System University Medical Center is one of the largest hospital systems in South Carolina and a leader in research, medical education and critical care. We are seeking SC License or SC License eligible candidates for a full-time Occupational Therapist position. Experience preferred. CARF accredited Outpatient brain injury program. We offer competitive pay, excellent benefits package, relocation assistance, 90 day COBRA Reimbursement and interview expenses. $5000 Sign on Bonus. Visit our website at www.ghs.org to learn more and submit an online application for immediate consideration. Contact Reneeâ&#x20AC;&#x2122; Bacon, Senior Employment Specialist, for more information at (864)455-8452. To list your professional appointments on this page, please contact Joyce Parker, (713) 526-6900, or by e-mail: jparker@hdipub.com.

20 BRAIN INJURY PROFESSIONAL

REHABILITATION CENTER A HISTORY OF SHARED SUCCESS For a free professional assessment and excellent treatment you can count on, call us. • Fully accredited for Brain Injury, Spinal Cord Injury, Chronic Pain, and Stroke • Full spectrum of in- and outpatient services • Return of patient to highest level of function Call 897-8565 for a confidential professional consultation free of charge. 1401 Foucher Street • New Orleans, LA 70115 www.touro.com

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Reintegrating Military Personnel after Traumatic Brain Injury (TBI): A Community Integrated Rehabilitation Model in Practice Tina M. Trudel, Phd, John DaVanzo, MS, MEd, CCC-SLP, Erin O. Mattingly, MA, CCC-SLP, F. Don Nidiffer, Phd, Jeffrey T. Barth, Phd, ABPP INTRODUCTION Traumatic Brain Injury is a major health problem in civilian and military populations, where even in peace time, injuries number in the thousands. Individuals experiencing moderate to severe brain injuries require a continuum of care involving acute hospitalization and post-acute rehabilitation, including community reintegration and hopefully a return home as a productive member of the community and family life. In the military, the goal is to help individuals with TBI return to active duty or make an optimal return to civilian life if the extent of their injuries necessitates a â&#x20AC;&#x153;medical boardâ&#x20AC;? discharge. Whether civilian or military, individuals with TBI who move beyond the need to live in a medical or supervised setting require supports and services in order to successfully reintegrate back into the community. This article discusses community integrated rehabilitation, and describes the Defense and Veterans Brain Injury Center at Virginia Neurocare, a program designed to provide community reintegration and rehabilitation for military personnel with TBI. Brain injury has become a leading public health problem for civilians and the military. In the United States civilian population, 1.4 million individuals sustain traumatic brain injury (TBI) annually resulting in 235,000 hospital admissions and 50,000 deaths[1]. Economically, the total impact of direct and indirect medical and other costs in 1995 dollars is reported to exceed $56 billion[2]. The Centers for Disease Control and Prevention estimate that long-term disability as a result of brain injuries (defined as needing assistance with activities of daily living) affects 5.3 million Americans, with thousands of new individuals affected every year [3]. Brain injury is an ever present risk of military duty. The experience of brain injury in the military and the need to develop 22 BRAIN INJURY PROFESSIONAL

new medical, safety and rehabilitative technologies to address the efficiency of evolving warfare has been instrumental in driving research and advancement of clinical care [4]. Recognition of the unique challenges of TBI in the military and the need to provide innovative treatment approaches contributed to the development of the Defense and Veterans Brain Injury Center (DVBIC), which was established in 1991 (formerly known as the Defense and Veterans Head Injury Program) and is discussed in depth in this special issue (Zitnay, page 16). The DVBIC provides an integrated program to enhance clinical quality, research and education across the military brain injury treatment continuum, including community integrated brain injury rehabilitation through its civilian partner, Virginia NeuroCare (VANC). The professional and public interest in military TBI has dramatically increased with the occurrence of such injuries in Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF - includes Afghanistan). With regard to OIF, the Office of the Surgeon General of the Army notes that 64% of wounded in action injuries have occurred as a result of blast from improvised explosive devices (IED), rocket propelled grenades, land mines and mortar/artillery shells [5]. Given improvements in helmet design and body armor and the resultant reductions in penetrating injuries including penetrating head trauma, blast related closed head injuries have become the signature injury of these military operations. Many armed service members who sustain TBI are treated in theater and return to active duty, productive work, social roles, family responsibilities and their pre-morbid status. However, some military TBI survivors live with residual disability, are unable to return to active duty, have complex care needs, and/or are initially unsuccessful in re-entering home,

vocational and community life. Those TBI survivors at risk for unsatisfactory outcomes or with continued rehabilitation needs are candidates for community integrated rehabilitation. Community Integrated Rehabilitation (CIR) is a broad term encompassing various approaches and contexts for treatment, with an evolving body of supporting scientific evidence. Military personnel receiving CIR services through programs such as VANC have provided, and will continue to provide, critical data for the empirical development of this level of post-acute care [6]. APPROACHES TO COMMUNITY INTEGRATED REHABILITATION Community integrated rehabilitation is also referred to as post-acute brain injury rehabilitation and includes diverse approaches that allow for individuals with TBI to benefit from further rehabilitation after medical stability is established and initial acute (in-hospital) rehabilitation is completed. Typically, CIR does not include sub-acute brain injury rehabilitation programs that specialize in coma management or the treatment of behaviors that actively pose a risk of serious endangerment [7]. These clinical scenarios are more often addressed in skilled nursing settings and intensive neurobehavioral programs, respectively. The most common delineation of CIR programs has followed the framework proposed by Malec and Basford (1996), including neurobehavioral programs, residential programs, comprehensive holistic (day treatment) programs and more recently, home-based programs [6, 8]. Neurobehavioral CIR programs have historically focused on treatment of mood, behavior and executive function, while ensuring supervision and safety in 24-hour, non-hospital setting. Such programs focus on psychosocial outcomes with emphasis on application of behavioral principles, development of functional skills and pharmacological management as needed. Neurobehavioral CIR programs typically have inter- or transdisciplinary treatment teams, utilize direct support personnel as therapeutic extenders, and often involve neuropsychologists, behavior analysts and/or psychiatrists [9]. Residential CIR programs were initially developed to meet the needs of individuals who required extended comprehensive TBI rehabilitation, 24-hour supervision and/or did not have access to adequate outpatient/day services. The home-like, enriched environment and staff support in such programs facilitate development of skills needed to negotiate everyday life, maximizing opportunities for practice and learning while easing generalization across community environments [9]. Comprehensive holistic day treatment CIR programs provide a milieu-oriented, multimodal approach, often with a neuropsychological focus. Interventions target awareness, cognitive functions, social skills and vocational goals through individual, group and family-mediated interventions delivered through an inter- or transdisciplinary team [11]. These programs have the greatest research foundation in the field of CIR, and while treatment guidelines are often site specific, such resources are invaluable, allowing discourse, analysis, replication, theory dvelopment and dissemination of techniques [7, 11-13]. Home-based CIR involves a highly variable array of services and supports for the individual with TBI able to reside in a home environment, and is often based on the available home service providers or professionals in a particular com-

munity. Most often, individuals receiving home-based CIR do not require 24-hour supports or supervision. Home-based CIR includes a spectrum of outpatient services commonly accessed through individual treatment providers or clinics. There is usually not an identified ‘treatment team’, although collaboration may occur across a number of health and social service systems. Behavioral approaches using self-monitoring, environmental support and cueing may be employed, as well as models wherein family members or in-home paraprofessionals serve as therapeutic agents. Additionally, some examples of home-based CIR are primarily educational, supportive and/ or emphasize use of telephonic, web-based, and technological aides [6, 8]. Reviews of the effectiveness of various forms of CIR are available in the literature, with studies ranging from observational accounts to randomized control trials. While the evidence supporting the benefits of CIR has been slow to develop, recent studies demonstrate significant gains in social participation, vocational outcomes, self/family ratings of functioning, physical status, cognitive abilities and psychological well-being related to participation in CIR after TBI [14, 15, 16]. Support for the benefits of CIR exist across the continuum from mild to severe TBI [9, 17, 18] and for individuals from a year to many years post-injury [12, 19] Implementation of a Residential Brain Injury CIR for Military Personnel The valuable clinical research characteristics identified early in DVBIC’s history (homogeneity, available records, infrastructure, multi-site, outcomes measurement, tracking) [4] provide an optimal foundation for CIR research through the DVBIC VANC program with a long history of CIR focus and expertise. VANC’s CIR Pilot Clinical Research Project is engaged in the development, implementation and analysis of educational and treatment interventions with VANC program participants from the military who have suffered mild, moderate, and severe TBI primarily from combat IED blast forces and motor vehicle accidents. These military personnel with TBI have benefited from acute medical intervention and sub-acute rehabilitation hospitalization at other DVBIC facilities, and they have progressed to the stage where they benefit from the VANC residential and day treatment program aimed at community re-entry. The military program participants at VANC are typically several months post injury and have made substantial recovery, yet they still suffer mild to moderate neurological and behavioral challenges, typically associated with frontal and temporal lobe dysfunction and executive dyscontrol. These service men and women are still in the active stages of recovery, but no longer require acute medical intervention. Complex brain injury sequelae may persist including balance problems, ataxia, incoordination, impaired activities of daily living, memory difficulties, attentional problems, fatigue, problematic initiation and motivation, irritability, frustration, depression, sleep disturbance, poor judgment, impulsiveness, anosognosia, organizational problems, speech difficulties, anger management and socialization skill problems, general cognitive dysfunction, and family or work stress. There VANC program offers individualized interventions based on a common core of neurorehabilitation tools. Services BRAIN INJURY PROFESSIONAL

provided include both individual and small group treatment, and rehabilitation tools utilizing a virtual reality type of drivand therapeutic activities in office, home, work and community ing simulator. settings. Each soldier who participates in the community reAfter demonstrating the ability to be independent with entry program at VANC stays in an eight bed residential living basic Activities of Daily Living (ADLs), a military program facility that is housed in a Victorian-style house in Charlottes- participant may be able to move into an independent living ville, Virginia, or as clinically indicated, in community-based arrangement. VANC provides apartment environments dediapartments with support. Designed to replicate a home rather cated to independent living. The independent living aspect than a hospital, the residential house provides 24 hour supervi- of the program features modified independent living in a less sion by trained staff members who administer medications, fa- intensely supervised setting. The soldier is responsible for all cilitate meals and activities, collect data, and provide necessary aspects of his/her own care from household management to bill extended therapeutic support for soldiers with brain injury. payment. It affords service men and women the opportunity The VANC program provides an intensive rehabilitation day and assistance necessary to take the final step towards reintegraprogram, offering a unique experience of research and theoreti- tion in the community or return to duty. cally based therapies facilitated by occupational and physical Participation in the apartment and independent living phastherapists, psychologists, vocational specialists, and speech-lan- es requires successful engagement in the intensive rehabilitation guage pathologists. The program addresses cognitive-behav- day program. Military program participants are responsible for ioral, neuromotor, personal and community activities of daily their own community transportation, meal preparation, launliving, and social skills in real-world settings while participat- dry, household management, medication management, finaning in functional, community-based cial management, and recreational activities. Military program partici- The goal is discharge to the least restrictive, most participation. Soldiers spend the pants work with therapists on cogniintegrated environment possible, ranging from day outside the house, involved in tive and behavioral coping abilities, an independent to supervised living situation, or either school, volunteer, or work and to improve skills necessary for activities. military re-entry to supported employment. reintegration in the community, reReturn to work is a common turn to work, or return to active duty in the military. goal of survivors of brain injury. The vocational program has The program features therapeutic educational modules that numerous work and volunteer contracts with local businesses, are being transformed into manualized treatment tools ad- in order to provide situational assessment, job-site assessment, dressing: brain injury education, wellness, empowerment, time on-the-job training, work adjustment training, cognitive trainmanagement, attention/memory, and social skills. The mod- ing and supervised work experience. Active duty military proules are designed to address difficulties with coping and living gram participants often serve at the Judge Advocate General successfully with an acquired brain injury. Emphasis is placed (JAG) Training School at the University of Virginia where they on enhancing self-awareness/self-appraisal skills throughout demonstrate their ability to maintain a competitive work situeach therapeutic endeavor. Some or all of the following skills ation while in a military environment. The goal is discharge are developed and implemented in the home and commu- to the least restrictive, most integrated environment possible, nity: meal planning and preparation, grocery shopping, use ranging from an independent to supervised living situation, or of public transportation, increased volunteerism, clubhouse military re-entry to supported employment. membership, supported work experiences, community navigaDischarge is considered when the soldier has developed and tion, laundry skills, social and communication skills, money demonstrated competence in independent living, physical fitmanagement, and medication management. If necessary, pros- ness, cognitive ability, emotional control and vocational ability. thetics and adaptive equipment are utilized all with the goal Active duty military program participants must be able to demof developing modified independent living skills. Working onstrate that they are fit for duty to be able to be considered toward returning to the workplace and fostering a sense of pro- for return to duty. After completion of the program, active ductivity, clients begin by seeking out a volunteer work experi- duty military program participants follow a set of procedures ence. In conjunction with a therapist, the soldierâ&#x20AC;&#x2122;s volunteer for disposition back into formal active duty. By tracking effecexperience builds confidence and demonstrates competence. A tive approaches to treating service men and women who have wide variety of volunteer opportunities are available, including experienced brain injuries in the course of their duties, VANC the VANC operated used bookstore on the downtown mall of hopes to delineate the most cost-effective strategies that can Charlottesville. be utilized in other programs, both military and civilian. Such The VANC program is increasingly using advanced and programs are critically needed as the number of brain injuries everyday technology in order to maximize the potential of pro- continue to escalate from war and non-war events. gram participants. Current clinical projects for 2007 include use of global positioning satellite technology to facilitate orientation, community navigation skills and functional indepen- About the Authors dence. Assistive technology such as personal data assistant and Tina M. Trudel, PhD is the Principal Investigator of the Virginia Neuroprogrammable watches are also implemented. Along with the Care DVBIC program, and the President/COO of Lakeview Healthcare Systems, Inc., a national provider of rehabilitation and neurobehavioral functional implementation of technological aides, ratings are services. She is an Assistant Professor of Clinical Psychiatric Medicine in gathered regarding the person-technology interface to assess the Department of Psychiatry and Neurobehavioral Sciences at the Unithe best fit, as high acceptance of a technological aide is associ- versity of Virginia School of Medicine and has published and presented ated with greater likelihood of on-going use. Lastly, VANC extensively in the field of brain injury. is commencing collaboration with the University of Virginia John DaVanzo, MS, MEd, CCC-SLP is the Clinical Coordinator of the Neurocognitive Assessment Lab to develop both assessment DVBIC program at Laurel Highlands. He is a speech-language patholo24 BRAIN INJURY PROFESSIONAL

gist and the former Clinical Director of the DVBIC program at Virginia NeuroCare. He is presently completing his doctorate at the University of Virginia and is conducting research on the assessment of quality of life after brain injury. Erin O. Mattingly, MA, CCC-SLP is the Clinical Coordinator and a speech-language pathologist for the DVBIC program at Virginia Neurocare. She is presently involved in research developing community integrated rehabilitation manualized treatment and assessment models. F. Don Nidiffer, PhD, is the Co-Principal Investigator of the Virginia NeuroCare DVBIC program and Executive Director of Lakeview Virginia NeuroCare. Dr. Nidiffer is a clinical psychologist with 23 years of experience in the University of Virginia Health System, providing rehabilitation and behavior therapy services across all ages. He completed his post-doctoral fellowship in Behavioral Pediatrics from Johns Hopkins School of Medicine. Jeffrey T. Barth, PhD, ABPP holds the John Edward Fowler Endowed Professorship in Clinical Neuropsychology at the University of Virginia School of Medicine. He is Chief of the Neurobehavioral Study Section and Director of the UVA Brain Injury and Sports Concussion Institute. He also maintains a Senior Scientist position with Lakeview Healthcare Systems and Virginia Neurocare, and has published and presented internationally on topics including neuropsychology, brain injury and rehabilitation.

5. Defense and Veterans Brain Injury Center: Providing care for soldiers with traumatic brain injury. The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., 2006, http://www.hjf.org/research/featureDVBIC.html. 6. Warden DL, Salazar AM, Martin EM, et al. A home program of rehabilitation for moderately severe traumatic brain injury patients. J Head Trauma Rehabil 2000;15(5):1092-1102. 7. Malec JF, Basford J. Postacute brain injury rehabilitation. Arch Phys Med Rehabil 1996;77:1996. 8. Willer B, Button J, Rempal R. Residential and home-based postacute rehabilitation of individuals with traumatic brain injury: a case control study. Arch Phys Med Rehabil 1999;80:399406. 9. Wood R, McCrea J, Wood L, Merriman R. Clinical and cost effectiveness of post-acute neu•NeuroRehabilitation robehavioral rehabilitation. Brain Inj 1999;13(2):69-88. •NeuroBehavioral 10. Glenn MB, Rotman M,Rehabilitation Goldstein R, Selleck EA. Characteristics of residential community integration programs for adults with brain injury. J Head Trauma Rehabil 2005;20(5):393•Adolescent Integration 401. •Supported Living Programs 11. Ben-Yishay Y, Silver SM, Paisetsky E, Rattock J. Relationship between employability and vocational outcome after intensive holistic cognitive rehabilitation. J Head Trauma Rehabil •Outpatient Services 1987;2:35-48. •DayJF.Treatment / Outpatientday treatment on societal participation for persons with 12. Malec Impact of comprehensive acquired brain injury. Arch •Respite Services Phys Med Rehabil 2001;82(July):885-895. 13. Prigatano GP: Principles of neuropsychological rehabilitation. New York: Oxford University Support Press,•Vocational 1999. 14. •Community-Based Turner-Stokes L, Disler PB, Mair A, Wade DT. Multidisciplinary rehabilitation for acResidential Services quired brain injury in adults of working age (review). The Cochrane Database of Systematic Reviews, 2005:1-29. Part15.ofTrudel a National Network of JT. Local Providers TM, Nidiffer FD, Barth Community integrated brain injury rehabilitation: clinical research with civilian and in military populations. Unpublished manuscript MENTOR Advancing ABI offers Brain Injury Services these locations in review. References Heslin J, Greenwood Brain R. Community based rehabilitation after severe traumatic 1. Langlois JA, Rutland-Brown W, Thomas KE. Traumatic brain injuryCCS-Carbondale, in the United States: IL16. Powell J,REM-Minnesota Injury Services brain injury: A randomized control trial. J Neurol Neurosurg Psych 2002;72:193-202. Emergency department visits, hospitalizations, and deaths. Atlanta, GA: Centers for Disease CCS-Florida REM-Iowa Brain Injury Services Control and Prevention, National Center for Injury Prevention and Control, 2004. 17. Cicerone KD, Mott T, Azulay J, Friel JC. Community integration and satisfaction with CCS-Kentucky REM-Health functioning after intensive cognitive rehabilitation for traumatic brain injury. Arch Phys Med 2. Thurman D. The epidemiology and economics of head trauma. In: Miller L, Hayes R, eds. CCS-New England REM-Colorado Brain Injury Services Rehabil 2004;85:943-950. Head Trauma Therapeutics: Basic, Preclinical and Clinical Aspects. New York (NY): Wiley and Sons, 2001. CCS-Tennessee Jersey-MENTOR 18. SarajuuriNew JM, Kaipio ML, Koskinen SK, Niemala MR, Servo AR, Vilkki, JS. Outcome of a comprehensive neurorehabilitation program for patients with traumatic brain injury. Arch Phys 3. Thurman D, Alverson C, Dunn K, Guerrero J, Sniezek J. Traumatic brain injury in the REM-Wisconsin CareMeridian Med Rehabil 2005;86:2296-2303. United States: A public health perspective. J Head Trauma Rehabil 1999;14(6): 602-615. Brain Injury Services For more contact 19. High WM, Roebuck-Spencer T, Sander AM, information Struchen MA, Sherer M. Early versus later ad4. Salazar AM, Zitnay GA, Warden DL, Schwab KA, DVHIP Study Group. Defense and Vetermission to postacute rehabilitation:Toll impact on functional outcome after traumatic brain injury. ans Head Injury Program: Background and overview. J Head Traumawww.mentorabi.com Rehabil 2000;15(5):1081Free: 800.203.5394 Arch Phys Med Rehabil 2006;87:334-342. 1091.

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Current Trends in Post Traumatic Stress Disorder and Traumatic Brain Injury Among Military Personnel

F. Don Nidiffer, PhD, Austin Errico, PhD, Tina M. Trudel, PhD, Jeffrey T. Barth, PhD, ABPP Introduction Individual reactions to being exposed to trauma vary greatly. Factors that influence such reactions include age, gender, history of previous exposure, personality predispositions, and nature of the trauma [1]. For most people, being exposed to trauma on any given day is fortunately of low probability. For others, such as those in military combat, trauma is a part of daily life. The experience of trauma in daily life is more frequent than one may think. Children and spouses who are frequently exposed to violence at home know what it’s like to live in an unsafe situation, and can develop “stress disorders” that can include mood disorders, anxiety disorders and somatoform disorders [2]. Military personnel who are exposed to severe training conditions in readiness for deployment to active duty are also familiar with living under extremely stressful circumstances. Stress related disorders often result in physiological distress and concomitant cognitive and behavioral problems. Traumatic events that are capable of causing a brain injury also may cause stress reactions and/or can further complicate pre-existing anxiety disorders. A stress related disorder can interfere with and significantly impede the treatment and recovery from traumatic brain injury (TBI). Stress and Post traumatic Stress Disorder (PTSD) Evolution requires that a species adapt or become extinct. One basic adaptation is known as the “fight or flight” response. Whether choosing to fight or escape from danger, autonomic changes are rapid and intense. Changes include blood pressure 26 BRAIN INJURY PROFESSIONAL

elevation, increased cardiac output, increased bronchial dilation, increase in blood glucose, elevation in basal metabolic rate and increased central nervous system excitability. By the same token, physiological systems that are not needed to address an acute threat are spared. These include decreased immune response, decrease in blood flow to the digestive systems, etc. Essentially, attention to the threat and assessment of the immediate surroundings become the primary focus. Such responses place a strain on many organ systems, including the heart, lung, and endocrine system, etc. All of these biological responses are adaptive and increase the possibility of survival by increasing the readiness of the organism to effectively cope with the impending threat. When the threat disappears, for most people, so do the physiological responses that prepared them to survive. However, when the threat occurs for longer periods of time or the possibility exists that the threat may return, the result is an inability to relax and return to a homeostatic physiological state. Unfortunately, no physiological difference may exist between actual or anticipated threat when it comes to wear and tear on the body. Continued exposure to threat, whether actual or perceived, can over time, damage, the same organ systems that prepared the person for survival. The Diagnostic and Statistical Manual used by professionals in mental health has an explicit definition of PTSD noted in Table 1. As indicated in the table, characteristics this anxiety disorder include four major criteria and three basic symptom clusters. In evaluating someone for the first time, it is impor-

DSM-IV Criteria for Posttraumatic Stress Disorder

Table 1

A. The person has been exposed to a traumatic event in which both of the following have been present:

1. the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others 2. the person’s response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated behavior.

B. The traumatic event is persistently reexperienced in one (or more) of the following ways:

1. recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed. 2. recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable content. 3. acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur upon awakening or when intoxicated). Note: In young children, trauma-specific reenactment may occur. 4. intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event. 5. physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.

C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following:

1. efforts to avoid thoughts, feelings, or conversations associated with the trauma 2. efforts to avoid activities, places, or people that arouse recollections of the trauma 3. inability to recall an important aspect of the trauma 4. markedly diminished interest or participation in significant activities 5. feeling of detachment or estrangement from others 6. restricted range of affect (e.g., unable to have loving feelings) 7. sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)

D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:

1. 2. 3. 4. 5.

difficulty falling or staying asleep irritability or outbursts of anger difficulty concentrating hypervigilance exaggerated startle response

E. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than one month. F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Specify if: Acute: if duration of symptoms is less than 3 months . Chronic: if duration of symptoms is 3 months or more Specify if: With Delayed Onset: if onset of symptoms is at least 6 months after the stressor

tant to note duration of symptoms, as should symptoms persist for more than one month, the early diagnosis of Acute Stress Disorder becomes PTSD, a more chronic and persistent anxiety condition. Prevalence of PTSD in the general civilian population ranges from 2% to 20%. An estimated 5% of men will develop PTSD at some point in their lifetime. Estimates for women are 10% [3]. In addition, women are four times more likely to develop PTSD than men who are exposed to the same trauma. Events that are perceived as unpredictable or uncontrollable, by definition, are experienced by the organism as stressful. These events, when severe, are capable of precipitating the development of PTSD. Examples of such traumatic events include physical and emotional abuse, motor vehicle accidents, gunshot wounds, burns, witnessing abuse of others, natural disasters and continuous exposure to life-threatening conditions such as combat. This article will focus on the co-occurrence of PTSD and TBI in the military population. Predictors of PTSD Development When someone is exposed to a traumatic event, he/she is at risk for developing PTSD. Whether PTSD develops or not depends upon a number of factors [1, 4]. People who are already depressed, anxious, or have a history of PTSD are more likely to develop PTSD symptoms following a traumatic event [5]. Other risk factors include use of an avoidant coping style [6], history of chronic pain; history of substance abuse and/or an inordinate fear of death. Moreover, persons who externalize blame for their problems or experience a loss of

control during a traumatic event are more likely to present with symptoms. In a military population, combat exposure can result in the development of PTSD [7,8]. Hoge and colleagues (2004) studied military personnel who had been deployed to Iraq. They reported that the incidence of PTSD increased as a function of the number of firefights a person experienced during deployment. PTSD was found in 4.5% of the Iraq deployed military personnel who had no exposure to firefights, 9.3% for one to two firefights, 12.7% for three to five firefights, and 19.3% for more than five firefights. In addition, criteria were met for major depression, generalized anxiety or PTSD in 15.6% to 17.1% of the military personnel after duty in Iraq and 11.2% after duty in Afghanistan. Interestingly, 9.3% of the military personnel in the same study were found to have one of these diagnoses prior to deployment, however rates of PTSD increased more than any other condition from pre- to post-deployment periods. Rona et al., (2005) discussed the problems associated with screening for psychological conditions in the military. Acceptability of this approach, confidentiality, stigma associated with reporting problems, validity of screening instruments, and the evaluation of treatments were identified as obstacles in attempting to screen military personnel for mental health problems. The authors suggested that the focus should be upon a conservative approach to screening, improving support systems and improving recognition and management of health problems while maintaining confidentiality [9]. Neurophysiological Studies of PTSD Brain imaging studies on individuals diagnosed with PTSD (e.g., Bremner, 2002) have largely focused on the hippocampal region of the brain. Such studies have found that veterans with PTSD have a smaller hippocampus than veterans without PTSD[10]. Moreover, the hippocampal size was specific to the effects of PTSD versus anxiety in general. This finding has been replicated with survivors of childhood abuse, demonstrating an inverse relationship between the level of abuse and the size of the hippocampus. PET scans of these individuals revealed low activity levels (glucose uptake) in the hippocampal region as well [11]. Hippocampal functioning is critical in the consolidation of new learning for long term memory, a cognitive function commonly affected after TBI. The Hypothalamic –Pituitary –Adrenal (HPA) Axis plays a central role in the physiological preparation of an organism to address an acute stressor. In brief, corticotrophin releasing factor (CRF) is produced and released by the hypothalamus during times of stress. CRF travels down the hypophyseal stalk on route to its target organ, the pituitary gland. The pituitary gland, in response to CRF, produces a hormone call Adrenocorticotropic Hormone (ACTH). ACTH, in turns, travels through the bloodstream toward its target organ, the adrenal cortex. The adrenal cortex, in response to ACTH, produces the glucocorticoid, cortisol. Elevated levels of cortisol serve to decrease the secretion of CRF, resulting in feedback inhibition of ACTH production. CRF production is also inhibited through neuronal pathways between the hypothalamus and the hippocampus. Cortisol has a number of adaptive functions in response to acute stress including the increase in blood glucose through the process of gluconoegenesis and the increase in blood pressure. BRAIN INJURY PROFESSIONAL

As stated above, the HPA axis provides an adaptive function to the organism during times of acute stress. Maladaptive effects can arise, however, when the HPA axis is stimulated for long periods of time in response to chronic stressors [12]. In these incidences, cortisol can cause destruction to the immune system, a decrease in muscle mass, thinning of the skin and damage to cells in the hippocampus Recall that the hippocampus has an inhibitory effect on the release of CRF. Therefore, a reduction in hippocampal neurons would result in greater amounts of CRF being available, and this has been noted in cerebrospinal fluid [10]. Recall that high cortisol levels secondary to chronic stress are associated with damage to hippocampal neurons, especially in the CA3 region. Cortisol disrupts cellular metabolism and increases vulnerability of hippocampal neurons to glutamate, an excitatory amino acid. While the hippocampus is capable of regenerating neurons, chronic stress inhibits this process. Both the hippocampus and prefrontal cortex (PFC) have demonstrated decreased activation (PET scans) upon provocation of PTSD symptoms in veterans and women abused as children [10]. Animal studies have supported the finding that glucocorticoid-mediated elevation occurs with PTSD and results in PFC impairment affecting aspects of memory and amygdala restraint [13]. The prefrontal cortex modulates emotional responsiveness and conditioned fear responses through inhibition of amygdala. Through this mechanism, the prefrontal cortex is theorized to underlie pathological emotional responses in PTSD. This PFC is also one of the regions most vulnerable to the effects of traumatic brain injury. Traumatic Brain Injury and Post traumatic Stress Disorder Estimates of the co-occurrence of PTSD and TBI vary from one study to another. Studies estimate that PTSD symptoms from a brain injury can occur anywhere from 3% to 33% of the time, depending upon the nature of the trauma and the study participants. In a large sample study of persons with TBI from motor vehicle crashes, 48% at three months and 33% at one year presented with PTSD [14]. However, when comparing individuals with TBI to those suffering non-TBI related traumatic injuries, some studies have found lower rates of PTSD among the TBI group [15]. Such studies have led to the belief that the amnesia that commonly occurs with brain injuries may actually serve a protective function in the development of PTSD symptoms. While such amnesia may not completely eliminate the possibility of PTSD development, support exists that post-TBI amnesia may serve to lessen the probability and severity of PTSD, although the evidence is not well established [16,17,18]. Klein et al. (2003) found that when traumatized individuals with brain injuries did recall at least part of the traumatic event, they were five times more likely to develop PTSD. In one of the largest studies in this area involving 993 Cambodian refugees, individuals with TBI had among the highest rates of depression and PTSD of all refugees, second only to those who were victims of torture [19]. When TBI and PTSD do co-exist, the effects are often synergistic. Similar brain regions and functions are frequently impacted. For instance, both TBI and PTSD can impair executive functioning, aspects of memory and emotional regulation. Additionally, memory and attention are impaired both through 28 BRAIN INJURY PROFESSIONAL

the primary effects of tissue damage from the physical injury and by the emotional response and obsessive thinking from the psychological disorder. A similar pattern can emerge regarding emotional changes. For instance, during times of war, military personnel may undergo prolonged periods of stress that can exacerbate the stress that is frequently accompanied by TBI. In short, just as PTSD can exacerbate the cognitive impairments that are caused by a TBI, TBI can exacerbate the psychological impairments that are caused by PTSD. Treatment of TBI and PTSD The presence of either TBI or PTSD can be devastating, particularly if either is severe. The combination of these two conditions frequently has debilitating effects even on simple tasks of daily living. As such, both conditions are best treated simultaneously. For example, nightmares from PTSD can limit restful sleep and, if frequent, may cause a fear of falling asleep. This, combined with the common fatigue from brain injury, can significantly impede participation in rehabilitation and routine cognitive functions. Treatment approaches that address fatigue with this knowledge are likely to be more successful than those that target the cause as arising exclusively from one condition or another. Similarly, mood instability from TBI can exacerbate the hyper vigilance often experienced by individuals with PTSD. Inattention and distractibility can arise from either TBI or PTSD with the effects being cumulative in creating functional impairments in daily life. TBI and PTSD also have depression as a shared major feature. Agitation from TBI and emotional overreactivity from PTSD can further impair daily functioning. All of these problems are better addressed when the rehabilitation team can be sensitive to the multiple etiologies that underlie the targeted symptom. Treatment approaches include individual, group and family psychotherapy; education on brain injury and psychological syndromes; and pharmacological interventions. Most studies have examined the use of only one of these approaches. Future research should consider the additive benefit from a multiprong approach, particularly including all of the aforementioned elements. Practice Guidelines from the International Society for Traumatic Stress Studies have strongly endorsed Cognitive Behavior Therapy (CBT) as the treatment of choice for treating PTSD [20,21]. This approach addresses conditioned fear and cognitive distortions associated with conditioning. CBT effectively treats misperceptions that have occurred from prolonged exposure to trauma by challenging the belief that the world is an inordinately dangerous place and that one is powerless to change their fate. CBT also helps to overcome emotions such as guilt and shame that arise from an inaccurate sense of responsibility attached to the traumatic experiences. Other CBT techniques attempt to extinguish anxiety based responses to situations by having the individual systematically experience presumably threatening circumstances in visualizations or in vivo (often with relaxation therapy) until the anxiety subsides. By doing so, the avoidant responses that arose from unrealistic fear and sustained anxiety will disappear or be better managed[22]. Likewise, psychotherapeutic interventions for survivors of TBI include a gamut of approaches that are often symptom specific or skill based. CBT is again a recommended approach.

Problems addressed in psychotherapy can include commonly displayed social skills difficulties arising from impairments in executive functions, such as poor judgment, egocentricity, impulsivity, and lack of reciprocity in interpersonal relationships. Behavioral strategies can focus upon difficulties with initiation or inhibition. Education and support-focused groups for soldiers with brain injury and PTSD and their families can help to address misperceptions about alterations in behavior. Greater understanding and broad personal/family coping skills can be developed while focused treatment attempts to target symptoms. Support group models related to TBI and PTSD are common and usually cover the general issues and needs of these disorders. However, areas of importance for education that are at times neglected include the implications of system and symptom overlap between these two conditions, recovery of function versus use of compensatory strategies, maximization of environmental adaptations, a focus on wellness and the need for pacing. From a psychotropic-pharmacological standpoint, Selective Serotonin Reuptake Inhibitors (SSRIs) are usually the first line of treatment for PTSD. Sertraline and paroxetine have been shown to address the three basic clusters of PTSD symptomsâ&#x20AC;&#x201D;re-experiencing of the trauma, avoidance/numbing in association with traumatic events, and hyperarousal and hypervigilance to maintain a constant state of readiness. Other medications, such as antiadrenergic agents and anticonvulsants may eventually prove to be even more effective [22]. According to the American Psychiatric Association (see Practice Guidelines for the Treatment of Patients with Acute Stress Disorder and Posttraumatic Stress Disorder, 2004), benzodiazepines have not been found to be useful for PTSD, and this class of medications is minimally used post-TBI due to suppression of neural growth factor which helps recovery after TBI [23]. In general, medication following traumatic brain injury is largely dependent upon the specific symptom that is problematic. For example, Ritalin or other stimulants may be given to help address problems of inattention/concentration that commonly occur following a brain injury. Antidepressants, such as SSRIs, are frequently used for treatment of brain injuries and can be beneficial for PTSD as mentioned previously. Newer types of anticonvulsants that are used in treatment of PTSD (lamotrigine) may already be in place for TBI related seizure management or prevention and may also facilitate mood stabilization. Summary The military must maintain a constant state of readiness in order to fulfill their primary purpose of defending the country. In times of combat, prolonged periods of stress can result in physiological changes that may impair cognitive, emotional and behavioral functioning. Traumatic Brain Injury is also common in wartime, and it too results in cognitive, emotional, and behavioral dysfunction. While returning home can be challenging without an injury, the combination of a TBI and PTSD requires even greater effort. The occurrence of TBI and PTSD produces significant challenges for service men and women, their families, and the rehabilitation team. Professionals who recognize the potential synergistic effects of these two conditions are better able to provide education and design treatment approaches that are sensitive to the multiple etiologies that underlie many of the complex symptoms shared by both conditions.

About The Author

F. Don Nidiffer, PhD, is the Co-Principal Investigator of the Virginia NeuroCare DVBIC program and Executive Director of Lakeview Virginia NeuroCare, Dr. Nidiffer is a clinical psychologist with 23 years of experience in the University of Virginia Health System, providing rehabilitation and behavior therapy services across all ages. He completed his post-doctoral fellowship in Behavioral Pediatrics from Johns Hopkins School of Medicine. Austin Errico, PhD, is the Clinical Director of Lakeview NeuroRehabilitation Center in Effingham Falls, NH, where he previously served as neuropsychologist and Director of the APPIC accredited psychology internship program. Dr. Errico received his doctorate in biological psychology from the University of Oklahoma, completed his training in clinical neuropsychology at the University of Virginia and has served as a neuropsychologist in rehabilitation hospital, residential treatment and community integrated settings. Tina M. Trudel, PhD, is the Principal Investigator of the Virginia NeuroCare DVBIC program, and the President/COO of Lakeview Healthcare Systems, Inc., a national provider of rehabilitation and neurobehavioral services. She is an Assistant Professor of Clinical Psychiatry and Neurobehavioral Sciences at the University of Virginia School of Medicine and has published and presented extensively in the field of brain injury. Jeffrey T. Barth, PhD, ABPP holds the John Edward Fowler Endowed Professorship in Clinical Neuropsychology at the University of Virginia School of Medicine. He is Chief of the Neurobehavioral Study Section and Director of the UVA Brain Injury and Sports Concussion Institute. He also maintains a Senior Scientist position with Lakeview Healthcare Systems and Virginia Neurocare, and has published and presented internationally on topics including neuropsychology, brain injury and rehabilitation.

References

1. Vasterling JJ, Brewin CR. Neuropsychology of PTSD. New York, NY: Guilford; 2005. 2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-Text Revision (DSM-IV-TR). Arlington, VA: American Psychiatric Association; 2000. 3. McMillan TM, Williams WH, Bryant R. Post-traumatic stress disorder and traumatic brain injury: A review of causal mechanisms, assessment, and treatment. Neuropsych Rehab. 2003; 13:149-164. 4. Hickling EJ, Gillen R, Blanchard EB, Buckley T, Taylor, A. Traumatic brain injury and posttraumatic stress disorder: A preliminary investigation of neuropsychological test results in PTSD secondary to motor vehicle accidents. Brain Inj. 1998; 12:265-274. 5. Levin HS, Brown SA, Song JX, McCauley SR, Boake C, Contant CF, Goodman H, Kotria KJ. Depression and posttraumatic stress disorder at three months after mild to moderate traumatic brain injury. Jnl Clin Exp Neuropsych. 2001; 23:754-769. 6. Harvey AG, Bryant RA. Predictors of acute stress following mild traumatic brain injury. Brain Inj. 1998; 12:147-154. 7. Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. New Eng Jnl Med. 2004; 351:13-22. 8. Friedman MJ. Posttraumatic stress disorder among military returnees from Afghanistan and Iraq. Am Jnl Psych. 2006; 163:586-593. 9. Rona RJ, Hyams KC, Wessely S. Screening for psychological illness in military personnel. JAMA. 2005; 293:1257-1260. 10. Bremner JD. The lasting effects of psychological trauma on memory and the hippocampus. Cyberounds. 2002; www.lawandpsychiatry.com/html/hippocampus.htm. 11. DeBellis MD, Hooper SR, Sapia JL. Early trauma exposure and the brain. In: Vasterling JJ, Brewin CR. Neuropsychology of PTSD. New York, NY: Guilford; 2005:153-177. 12. Sapolsky RM. Glucocorticoids and hippocampal atrophy in neuropsychiatric disorders. Arch Gen Psych. 2000;57:925-935. 13. Friedman MJ. Pharmacological approaches to cognitive deficits associated with PTSD. In: Vasterling JJ, Brewin CR. Neuropsychology of PTSD. New York, NY: Guilford; 2005:292-326. 14. Mayou RA, Black J, Bryant B. Unconsciousness, amnesia and psychiatric symptoms following road traffic accident injury. Brit Jnl Psych. 2000; 177:540-545. 15. Bryant RA, Harvey AG. The influence of traumatic brain injury on acute stress disorder and posttraumatic stress disorder following motor vehicle accidents. Brain Inj. 1999; 12:15-22. 16. Ellenberg J, Levin H, Saydjari C. Posttraumatic amnesia as a predictor of outcome after severe closed head injury. Arch Neurol. 1996; 53:782-791. 17. Turnbull SJ, Campbell EA, Swann IJ. Post-traumatic stress disorder symptoms following a head injury: Does amnesia for the event influence the development of symptoms? Brain Inj. 2001; 15:775-785. 18. Klein E, Caspi Y, Gil S. The relation between memory of the traumatic event and PTSD: Evidence from studies of traumatic brain injury. Can Jnl Psych. 2003; 48:28-33. 19. Mollica RG, Henderson DC, Tor S. Psychiatric effects of traumatic brain injury events in Cambodian survivors of mass violence. Brit Jnl Psych. 2002; 181:339-347. 20. Rothbaum BO, Meadows EZ, Resick P, Foy DW. Cognitive-behavioral therapy. In Effective Treatments for PTSD: Practice Guidelines from the International Society for Traumatic Stress Studies. New York,NY: Guilford; 2000:60-83. 21. Foa EB, Rothbaum BO. Treating the trauma of rape: Cognitive Behavioral Therapy for PTSD. New York, NY: Guilford; 1998. 22. Friedman MJ. Future pharmacotherapy for post-traumatic stress disorder: Prevention and treatment. Psych Clin North Am. 2002; 25:427-441. 23. American Psychiatric Association. Practice guidelines for the treatment of patients with acute stress disorder and posttraumatic stress disorder. Am Jnl Psych. 2004; 161:Nov. Supplement.

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non-profit news Brain Injury Association of America The Brain Injury Association of America has enjoyed a busy but very productive first quarter. We are pleased to announce our partnership with ABC journalist Bob Woodruff. As honorary spokespersons for BIAA, Bob, his wife Lee, and other members of the Woodruff Family will help increase awareness of brain injury and work to support, protect and heal individuals with brain injury. BIAA is administering the newly formed Bob Woodruff Family Fund for TBI to make grants to community-based organizations providing direct assistance to servicemen and women with blast brain injuries. BIAA worked closely with Woodruff, ABC News producers, state BIAs in Illinois and New York, and StarrConstand Communications in filing reports for World News, Good Morning America and Nightline to air during March and on ABC websites. The reports cover various aspects of brain injury and include some of the individuals featured in our awareness month campaign, “Living with Brain Injury: As Diverse as We Are.” BIAA is grateful to the Centers for Disease Control and Prevention for its sponsorship of this year’s campaign and to the Medtronic Foundation and the Defense and Veterans Brain Injury Center for supplemental support. Awareness kits are available from www.biausa.org. The Feb 19 issue of People Magazine carried a full-page public service announcement from our Safe World Campaign. We are pleased to recognize the creative geniuses at BVK/McDonald for the art design and to thank to Drew Nagel from BIA of Pennsylvania for securing the pro bono ad space. Last, but certainly not least, on Jan 8, the Wall Street Journal published “Cognitive Dissonance: Why Some Patients Get No Help After Brain Injury.” Portions of the article were drawn from the Association’s position statement, “Cognitive Rehabilitation: The Evidence, Funding and Case for Advocacy in Brain Injury,” which is available from BIAA’s website. Now more than ever, BIAA needs the financial support and personal involvement of professionals in our field. Please visit our website at www.biausa.org to learn more about our public awareness and public policy activities, to sign up for educational meetings and conferences, browse in our bookstore, or make an on-line donation. Large or small, every contribution helps create a better future in brain injury.

BRAIN TRAUMA FOUNDATION Research has always been a major component of the Brain Trauma Foundation’s activities and it serves as both a means to report on the findings of our various projects and as a stimulus to the implementation of evidence-based practice. Using data from our Quality Improvement Program in New York State, we conducted a multi-center study to explore the impact of prehospital management decisions and on early mortality after severe TBI. This study, published in the June 2006 issue of the Journal of Trauma, provides Class II evidence demonstrating a 50% increase in mortality associated with indirect transfer of TBI patients. Through a multi-year grant from the Department of Transportation’s National Highway Safety Administration, BTF has supported a number of studies to test the effectiveness of its prehospital TBI training and to initiate research projects suggested in its Guidelines 32 BRAIN INJURY PROFESSIONAL

for Prehospital Management of Traumatic Brain Injury. Papers submitted by all three of our Centers of Excellence -- Harborview Medical Center in Seattle, Washington, Inova Fairfax Hospital in Virginia, and the University of Alabama at Birmingham – have been published in Prehospital Emergency Care, the Journal of Trauma, and other peerreviewed journals. Supported by a grant to BTF from the McDonnell Foundation, with lead investigators from Weill Cornell Medical College, UC San Francisco, and UC Berkeley, our Cognitive and Neurobiological Research Consortium in Traumatic Brain Injury has had several papers recently accepted. Published in Biological Cybernetics, “A quantitative synchronization model for smooth pursuit target tracking” proposes a mathematical model for human eye tracking that accounts for smooth pursuit and quantitatively reproduces characteristic patterns of eye dynamics. The model embodies synchronization of a complex biological system with perceived sensory signals. Additionally, two papers elucidating eyetracking in TBI participants have been published in Neuroscience Letters. The first, entitled “Deficits in Predictive Smooth Pursuit after Mild Traumatic Brain Injury”, describes the impact of mild TBI on predictive eye movements, as well as the correlation between eye movement deficits and impairments in attention. The study shows that mild TBI patients are characterized by increased performance variability, a rapidly growing field of interest in cognitive neuroscience. The second publication, entitled “Increased oculomotor deficits during target blanking as an indicator of mild traumatic brain injury”, suggests that, compared to a typical target-tracking eye paradigm without blanking, or gaps in the trajectory a participant must follow, this paradigm stimulates the generation of predictive eye movements which are subserved by brain regions involved in cognitive processing. In addition, California Verbal Learning Test (CVLT-II) scores related to working memory, learning, and executive function were more highly correlated with oculomotor variability during target blanking than during target tracking. Both studies suggest that eye movement testing may be a sensitive metric for mild TBI and an improvement over traditional testing methods.

International Brain Injury Association IBIA has announced that it’s next World Congress will be held in Lisbon, Portugal. The meeting will be held April 9-12th and include a one day symposium, co-sponsored with the World Federation of Neurological Rehabilitation (WFNR) on “Advances and Controversies in Mild Traumatic Brain Injury.” Several new awards will be announced at the 2008 meeting, including the Henry H. Stonnington award for best review article for the IBIA endorsed scientific journal, “Brain Injury,” and two other international achievement awards, yet to be announced, one for clinical/scientific contributions to the field of TBI and the other for historical advocacy efforts in the field of brain injury. The international scientific planning committee has been formed and includes the following individuals: • •

Michael Barnes, MD Lucia Braga, PhD

• • • • • •

Jose Leon Carrion, PhD Jorge Lains, MD Mario Rui Silva, MD Donald Stein, PhD Klaus Von Wild, MD Nathan Zasler, MD

Currently, IBIA has recently received formal endorsements for the meeting from the following organizations: • • • • • • • • •

International Society of Physical Medicine and Rehabilitation Portuguese National Institute of Emergency Medicine Portuguese Neuroscience Society Portuguese Society of Physical Medicine and Rehabilitation Portuguese Society of Neurology Portuguese Society of Neurosurgery Portuguese Society of Psychiatry Portuguese Society of Neuropsychology World Federation of Neurological Rehabilitation

On separate note, the NeuroTrauma Letter continues to be published quarterly, edited by IBIA chairperson, Nathan D. Zasler, M.D. If you are interested in receiving this publication, please note that it is one of the many benefits of IBIA membership. Demos Publications has also made available a discount to IBIA members on Dr. Zasler’s new publication, Brain Injury Medicine Principles and Practice, a core, comprehensive textbook dealing with full continuum issues from acute care to community re-entry following traumatic brain injury. For more information on the Congress and IBIA activities, visit www.internationalbrain.org.

National Association of State Head Injury Administrators The President’s proposed FY 08 budget once again has eliminated funding for the Health Resources and Services Administration (HRSA) Federal TBI Program. The Federal TBI Program awards grants to States, Territories and the District of Columbia to develop and expand access to service delivery and to state Protection & Advocacy (P&A) Systems to expand advocacy services to individuals with traumatic brain injury and their families. The National Association of State Head Injury Administrators (NASHIA) is committed to work with Congress to include funding for FY 08. Since 2003 when the Federal TBI Program was funded at $9.5 million, the spending amount for the HRSA Federal TBI Program has been reduced each year through a series of rescissions imposed on Federal programs. At the same time the number of States and Territories participating in the State Grant Program has increased. Therefore, we are asking for an increase in funding to $21 million for the HRSA Federal TBI Program to provide funding for States ($15 million) and Protection & Advocacy Systems ($6 million); and $9 million for the Centers for Disease Control and Prevention TBI Program. In addition to securing FY 08 appropriations, we will also be seeking to reauthorize the TBI Act in the upcoming year. The TBI

Act authorizes funding to HRSA for the Federal TBI Program as described above; the Centers for Disease Control and Prevention (CDC) to conduct surveillance, prevention and public education programs; and the National Institutes of Health (NIH) to conduct basic and applied research in brain injury. Your assistance will be needed to convince Congress of the importance of these Programs. Be sure to check out the NASHIA website (www.nashia.org) to obtain the latest information on Congressional activities and state systems development to meet the needs of individuals with brain injury and their families.

North american Brain Injury society NABIS is hard at work planning our Fifth Annual Conference on Brain Injury set for September 27 through 29, 2007 at the Westin Riverwalk Hotel in San Antonio, Texas. Individual topic track chairs have been selected and the following individuals have been appointed to the Program Committee: Randy Evans, PhD Simon Forgette, Esq. Chas Haynes, JD Harvey Jacobs, PhD Kenneth Kolpan, Esq. Brent Masel, MD Margaret Roberts Ronald Savage, EdD David Seaton Bruce Stern, Esq Robert Voogt, PhD Mariusz Ziejewski, PhD Our abstract submission system for the Conference is now operational. Submissions will be considered for oral or poster presentations. NABIS values sessions that present current and best practices, including information that compliments the Conference’s topic tracks (Life-Long Living, Medical/Clinical Best Practices, Research and Legal Issues) as well as innovative approaches to brain injury assessment, treatment, intervention and rehabilitation. Awards will be given to the top scoring abstracts. Those interested in submitting papers are encouraged to visit www.nabis.org for more information. The submission deadline is June 11th, 2007. Planning is also well underway for the Legal Issues in Brain Injury Conference that will be held concurrently with the Medical Conference in San Antonio. Highlights this year include a presentation by recognized attorney Howard Nations, and a three-hour workshop by David Ball covering damages in the TBI case. The preliminary program will be posed on www.nabis.org by the end of March, 2007. NABIS Chairman of the Board Robert Voogt, PhD, is pleased to announce new members of the NABIS Board of Directors: Brent Masel, MD, Tina Trudel, PhD, Barry Willer, PhD, and Debra Braunling-McMorrow, PhD. NABIS is also pleased to note that its Executive Vice President, Dr. Ronald Savage, was recently named to the Board of Directors of the Society for Cognitive Rehabilitation as the NABIS liaison. BRAIN INJURY PROFESSIONAL

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Serving the community for two decades, Beechwood has expanded its TBI offering to encompass broad neurological services as well as new Behavioral Remediation and Late Adolescent programs.

FEBRUARY 15-17 – Pacific Coast Brain Injury Conference in partnership with the Brain Injury Association of Canada presents Canada’s National Brain Injury Conference. Hyatt Regency, Vancouver, BC, Canada. Contact: (604) 949-0716, www.pcbic.org.

In addition to TBI, we serve individuals with brain damage due to:

MARCH 9-11 – International Congress on Neurology and Rehabilitation (ICNR), New Delhi, India. Contact: icnr2007@gmail.com, web: www.iamst.com.

• Anoxia/Hypoxia due to drowning, heart attack, drug overdose, alcohol poisoning, anesthesia errors, etc.

• Electric shock/lightning strike • Degenerative diseases • Infectious diseases • Early stage moderate dementias • Tumors • Brain surgeries • Many neurological disorders

• Stroke For information and admissions, call 1-800-782-3299. Our facilities are adapted to accommodate all levels of accessibility.

APRIL 9-27 – Certificate Course in Neurological Rehabilitation, Newcastle upon Tyne, UK. Contact: traceymole@wfnr.co.uk. MAY 2-5 - Brain Injury Association of Florida, Inc., in partnership with Contemporary Forums presents Brain Injuries. Disney’s Coronado Springs Resort, Orlando, Florida. Contact: Cindy Hess (954) 786-2402, www.biaf.org. 24-26 – 2nd Biennial International Conference on Vocational Outcomes in Traumatic Brain Injury. Vancouver, BC Canada. Contact: (604) 875.1775, www.tbicvancouver.com, sljproductions@telus.net

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JUNE 10-14 – 4th World Congress of the International So 10-14 – 4th World Congress of the International Society of Physical Medicine and Rehabilitation, Seoul, Korea. Contact: isprm2007@ intercom.co.kr, www.isprm2007.org. 16-19 – Advances in Neurorehabilitation: Part of The Festival of International Conferences on Caregiving, Disability, Aging and Technology (FICCDAT), Toronto, Canada. Contact: catherine@smartmove.ca, www.ficdat.ca. 16-20 – 17th Meeting of the European Neurological Society, Rhodes, Greece. Contact: www.ensinfo.com. 18-20 – 2nd Neurorehabilitation Panamerican Congress. Buenos Aires, Argentina. Contact: dfelder@ineba.net, web: www. ineba.net. 22-24 – Joint Meeting of WFNR and EMN, Fiuggi, Italy. Contact: fservade@ausl-cesena.emr.it, www.emn.cc AUGUST 25-28 – 11th Congress of the European Federation of Neurological Societies, Brussels, Belgium. Contact: headoffice@ efns.org, web: www.efns.org/efns2007. SEPTEMBER 24-27 – 5th World Congress for NeuroRehabilitation, 24-27 – 5th World Congress for NeuroRehabilitation, Rio de Janeiro, Brazil. Contact: traceymole@wfnr.co.uk. 27-29 – North American Brain Injury Society’s Fifth Annual Conference on Brain Injury, Westin Riverwalk, San Antonio, Texas. Contact: conference@nabis.org, www.nabis.org. 27-29 – 20th Annual Conference on Legal Issues in Brain Injury, Westin Riverwalk, San Antonio, Texas. Contact: conference@nabis.org, www.nabis.org.

2008 APRIL 9-12 The International Brain Injury Association’s 7th World Congress on Brain Injury, Pestana Palace Hotel, Lison, Portugal. Contact: mjroberts@aol.com, or call +703 960-6500. SEPTEMBER 18-21 7th Mediterranean Congress of Physical Medicine & Rehabilitation Medicine, Potorose, Slovenia. Contact: marincek. crt@mail.ir-rs.si. 24-27 5th World Congress for NeuroRehabilitation, Rio de Janeiro, Brazil. Contact: traceymole@wfnr.co.uk.

34 BRAIN INJURY PROFESSIONAL

A Continuum of Care for Adults & Children with Brain Injuries.

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Brain Injury

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Rainbow’s unique “Continuum of Care” approach to brain injury rehabilitation offers a variety of programs providing residential, day treatment and outpatient services for individuals of all ages. Our professional staff, specially trained in brain injury treatment, consistently provides understanding, supportive and progressive rehabilitation at every stage of the recovery process. To receive a free copy of Rainbow’s Brain Injury Rehabilitation “Continuum of Care” brochure call...

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