ARMY AL&T CONTINUUM OF PATIENT CARE
DETERMINES RESEARCH APPROACH Education/Training Reinforcement and Assessment
1.
Prevention / Education & Training
¥Training ¥Risk Screen
2. Early
Screening/ Intervention
¥Stress/ Trauma Coping Skills
¥In-‐theater Debriefing
¥Screening
¥Skills-based Strategies
¥Stigma Reduction ¥Self/Other Identification
¥Epidemiological Vulnerabilities
3. Assessment 4. Treatment
MEDICAL CAPABILITY NEEDED acute, chronic
¥Standard Clinical
¥Decompression Assessments
¥Iden8fica8on & Referral
¥Imaging/ Biomarkers
¥Differen8al Diagnosis
¥Clinical Prac8ce Guidelines:
¥Effec8ve Medica8ons
¥Cogni8ve/ Behavioral
Interven8ons
¥Individual/ Group Format
¥Best Practices ¥Screening Assessment
RESEARCH SOLUTIONS ¥Clinical
Assessments
¥Imaging ¥Biomarkers ¥Validated Protocol
¥Cognitive & Behavioral medications
¥Novel Treatments ¥Alternative Modalities
¥Telemental Health
¥Medication/ Therapy
¥Stepped Care Models
¥Technology Assisted
¥Systems approaches
¥Evaluation/ Measurement
¥Refractory care protocols
¥Systems based- approaches
5. Recovery 6.
Long-term Care /
Follow-up
¥Recovery Protocols
¥Con8nuity of Care Models
¥RTD Standards
¥Follow-‐up Care Model
¥Periodic Rescreening
¥Chronic/ Refractory
Care
• Recovery—The ongoing Study of Cognitive Rehabilitation Effects seeks to determine, through randomized treatment of military patients who have mild TBI, the effectiveness of methods that ask them to exercise their brains, such as by calculating or remembering, and so to strengthen their cognitive abilities.
• Reset—The Army is developing objective, repeatable assessments that can help determine if a Soldier is ready to return to duty. These assess- ments look at weapon utilization, physiologic measures, balance, and other factors.
HIGHLIGHTED RESEARCH
6 studies Stigma
9 studies Cognitive Disclosure 38 studies
Differential Diagnosis Tool
MG James K. Gilman / MCMR-ZA (301-619-7613) (DSN 343-) /
James.Gilman@
us.army.mil 55 studies Virtual Reality UNCLASSIFIED 3 studies
Stepped Care Model
Slide of 31 30 Nov 2010
injury in the brain, a measure of TBI. Eye-tracking devices can measure eye movement as a subject tracks and predicts the movement of an object.
• Assessment—A program called Bio- marker Assessment for Neurotrauma Diagnosis and Improved Triage Sys- tem is exploring objective measures of cellular damage through blood testing of nerve cell proteins, much as cardiologists measure enzymes or proteins as one indicator of cardiac damage. Gilman called the blood test “very promising, because that has probably the earliest hope to get us to an actual objective measure of some exposure to traumatic brain injury.” Large-scale clinical trials are planned that hopefully will lead, three or more years from now, to U.S. Food and Drug Administration (FDA) approval of this diagnostic test, which could then be used in fixed medical facilities. The ultimate goal is to develop a hand-held device for use in the field.
• Treatment—For acute or more severe TBI, there is currently no effective pharmaceutical treatment, but
32 APRIL –JUNE 2011
multiple drugs have shown promise in pre-clinical tests, including NNZ- 2566 from Neuren Pharmaceuticals of New Zealand. It is a molecule that is part of a naturally occurring hor- mone in the brain with the potential to reduce the effects of a brain injury by preventing further damage.
“The FDA has agreed to an expedited approval process if studies show the positive benefit in humans that was seen in pre-clinical studies,” Gilman said. However, it may take up to five years to complete the studies.
For the treatment of milder and moderate TBI, research is focusing on treating chronic symptoms. One possibility is hyperbaric oxygen, the delivery of pure oxygen in a pressur- ized room. DOD has established a tri-service effort to evaluate hyperbar- ic oxygen therapy. The problem with treating chronic or mild TBI, Gilman said, is that “over time, the symptoms … tend to improve. And so, if you provide any treatment during the time when improvement is likely to occur, it looks like the treatment worked.”
There is evidence that repeated head injuries require special attention. One type of TBI is Chronic Traumatic Encephalopathy (CTE), a progressive degenerative disease found in patients who have been subjected to multiple concussions and other forms of head injury.
Dr. Ann McKee, a neural patholo- gist from the Center for the Study of Traumatic Encephalopathy at Boston University, told the audience at the PEO Soldier conference that the symptoms of CTE have a slow, insidious onset and tend to develop in midlife. Symptoms include memory loss, “irritability, agi- tation, and a short fuse.” McKee said CTE develops in military veterans and has been described in many different types of mild traumatic injury.
“It’s less important how you get the injury,” in her view. What’s important is the repetitive injury. “This is the challenge, I think, with any discussion about helmet and equipment: How do we protect the brain from the long- term damage we are seeing in these players [athletes] and Soldiers?”
PTSD Challenges One of the challenges of research into PTSD is that the same roadside IED that causes blast TBI can also cause PTSD, and both can produce the same
Return to Duty, MOS Change, Discharge
Combat/Trauma Exposure
Epidemiology / Basic Science / Neurobiological Mechanisms 63 studies
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