VA ANNOUNCES EXPANDED BENEFITS FOR TBI

FROM:  U.S. VETERANS ADMINISTRATION 
VA to Expand Benefits for Traumatic Brain Injury
Adds Five Illnesses Related to Service-Connected TBI
WASHINGTON – Some Veterans with traumatic brain injury (TBI) who are diagnosed with any of five other ailments will have an easier path to receive additional disability pay under new regulations developed by the Department of Veterans Affairs.

The new regulation, which takes effect 30 days from today, impacts some Veterans living with TBI who also have Parkinson’s disease, certain types of dementia, depression, unprovoked seizures or certain diseases of the hypothalamus and pituitary glands.

“We decide Veterans’ disability claims based on the best science available,” said Secretary of Veterans Affairs Eric K. Shinseki. “As scientific knowledge advances, VA will expand its programs to ensure Veterans receive the care and benefits they’ve earned and deserve.”

This regulation stems from a report of the National Academy of Sciences, Institute of Medicine (IOM) regarding the association between TBI and the five diagnosable illnesses.  The IOM report, Gulf War and Health, Volume 7:  Long-Term Consequences of Traumatic Brain Injury, found “sufficient evidence” to link moderate or severe levels of TBI with the five ailments.

The new regulations, printed in the Federal Register, say that if certain Veterans with service-connected TBI also have one of the five illnesses, then the second illness will also be considered as service connected for the calculation of VA disability compensation.

Eligibility for expanded benefits will depend upon the severity of the TBI and the time between the injury causing the TBI and the onset of the second illness.  However, Veterans can still file a claim to establish direct service-connection for these ailments even if they do not meet the time and severity standards in the new regulation.

Veterans who have questions or who wish to file new disability claims may use the eBenefits website, available at www.eBenefits.va.gov/ebenefits.

Servicemembers who are within 180 days of discharge may also file a pre-discharge claim for TBI online through the VA-DoD eBenefits portal at www.eBenefits.va.gov/ebenefits.

The published final rule will be available Dec. 17 at http://www.regulations.gov.

HIGH-TECH ACCESS AVAILABLE FOR THOSE WHO SUFFER POST-TRAUMATIC STRESS

FROM: U.S. DEPARTMENT OF DEFENSE

Outreach Center Broadens Mental Health Resources
By Amaani Lyle
American Forces Press Service

ARLINGTON, Va., June 12, 2013 - Service members or anyone who bears the invisible scars of post-traumatic stress now have high-tech access to online resources to fight stress, depression and other psychological health concerns, a Defense Department official said here yesterday.


The Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury Outreach Center is a 24-hour phone, chat and email portal open to everyone and provides access to resources and information related to psychological health and traumatic brain injury issues, said George Lamb, outreach chief for the centers.

"Anybody can call if they need information on psychological health or traumatic brain injury," Lamb said. "We've received chats from downrange, where a service member has gone in [and] spoken with the doctor, and we were able to provide them the information they needed."

The National Center for Telehealth and Technology is a DOD agency that has developed Web, mobile and virtual reality tools to target post-traumatic stress disorder and mild traumatic brain injuries and to contribute to suicide prevention in the military community and beyond, he added.

Apps include the T2 MoodTracker, which identifies triggers and improves the mood, and Breath2Relax, a portable stress management tool that uses breathing techniques to reduce stress, Lamb explained.

In 2007, a mental health task force discovered a lack of mental health resources available to service members and others afflicted with psychological health problems, Lamb added.
Family members, friends, veterans or service members themselves can use the resources.
"It's free, and it's information that has been vetted by DOD," Lamb said. "We're not just doing Google searches and adding information to it."

Lamb said callers in crisis can connect to coaches who work with suicide prevention teams or local authorities and maintain contact with the caller until help arrives. The Outreach Center also is available to clinical staff members who can in turn provide the resources and information to service members.

"Even if the war was to end today, our service members still have the injuries that they've incurred in combat, and their family members are still going to have questions for years to come," Lamb said. "It's going to be enduring."

DOD SAYS IT WILL CONTINUE WORK ON TRAUMATIC BRAIN INJURY

FROM: U.S. DEPARTMENT OF DEFENSE
DOD Continues TBI Research, Education, Treatment
By Terri Moon Cronk
American Forces Press Service

WASHINGTON, May 8, 2013 - The Defense Department is committed to providing the best medical care and recovery for service members with traumatic brain injury, DOD's top doctor said in a statement issued yesterday.

Following a 60 Minutes segment on the treatment of traumatic brain injury that aired May 6, Dr. Jonathan Woodson, assistant secretary of defense for health affairs, said all service members will receive specialized care for any type of TBI, from mild concussions to severe head injuries that require "extensive specialized care at one of our research facilities for the rare instances."

Woodson said DOD is grateful to military and private sector leaders who understand TBI's impact on service members, help identify appropriate treatment, and help the military obtain the resources "to build and sustain additional world-class medical treatment and research facilities."

Woodson also said the department appreciates "the relationships we have cultivated with members of academia, philanthropic efforts and within our Military Health System, which have ensured that DOD's National Intrepid Center of Excellence is an additional highlight to our long line of exceptional medical research facilities."

NICoE was constructed with philanthropic donations and is staffed by DOD personnel, which represents an "important new model in public-private partnership," Woodson said.

Located on the Walter Reed National Military Medical Center campus in Bethesda, Md., NICoE brings in leading academic and military researchers to collaborate on the "nexus of TBI and psychological health conditions" that affect military readiness and public health, Woodson said.

Coming initiatives will further broaden TBI research, treatment and education as facilities and programs come online, he said.

These initiatives include:

-- NICoE is expanding with nine satellite clinics situated on military installations. They are Camp Lejeune, S.C.; Camp Pendleton, Calif.; Fort Campbell, Ky.; Fort Belvoir, Va.; Joint Base Lewis-McChord, Wash.; Fort Bragg, N.C.; Fort Carson, Colo.; and Fort Hood and Fort Bliss, Texas.

-- DOD will work aggressively with colleagues in the Veterans Affairs Department, National Institutes of Health, and the civilian medical community. Woodson said such collaborations help the military "better understand how to prevent, mitigate, detect and treat our people who suffer from TBI."

-- Research findings will be rapidly translated into clinical policy to ensure service members receive the most up-to-date, evidence-based medical care following a concussion.

-- Another goal is to reduce the stigma of TBI through partnerships, such as the formalized agreement made in August 2012 between the Army and NFL Commissioner Roger Goodell. The agreement pledges work on both sides to improve awareness of brain injuries, reduce the stigma of TBI, and change the culture surrounding such injuries on the battlefield and in the locker room.

-- The first brain tissue repository has been created to address the underlying mechanisms that cause brain injury and disabilities in service members with TBI. The repository is kept at the Uniformed Services University of the Health Sciences, also on the Walter Reed campus.

"Although our work has been underway for years, we are still in the early stages of beginning to unlock the mysteries of how the brain responds to traumatic events," Woodson said.

U.S. DEFENSE DEPARTMENT: THE COMPLICATION OF NEUROENDOCRINE DYSFUNCTION POST TBI

FROM: U.S. DEFENSE CENTERS OF EXCELLENCE

Neuroendocrine Dysfunction: Hidden Complication Following TBI

Posted by Diana Moon, DCoE Public Affairs on March 27, 2013
Health care providers understand that making the correct diagnosis is key to effective treatment and recovery. If you’re a provider, did you know that for your patients with traumatic brain injury (TBI), there’s a fair chance you could overlook a diagnosis of
neuroendocrine dysfunction (NED) post TBI? NED is a condition that can be tricky to diagnose because it has many symptoms in common with other conditions that co-occur with TBI, such as sleep disorders, depression, substance abuse disorder and posttraumatic stress disorder. Health care providers should be aware that because screening for NED is not performed routinely in the acute post-injury period, the dysfunction is under-diagnosed, under-treated and may affect the patient’s rate of recovery.

According to Therese West, subject matter expert with Defense and Veterans Brain Injury Center clinical affairs division, research has noted that an estimated 15 percent of patients with mild TBI experience persistent symptoms, and the incidence of NED in those mild TBI patients ranges from an estimated 16 to 40 percent. Simply put, NED refers to a variety of conditions caused by imbalances in the body's hormone production. There are two areas of the brain responsible for regulating the production of hormones, the hypothalamus and the pituitary gland; both are potentially vulnerable to traumatic brain injury.

Medical guidance to evaluate and treat NED is available to providers in the Neuroendocrine Dysfunction Screening Post Mild Traumatic Brain Injury Clinical Recommendation and Reference Card developed by Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE). The tools clarify the indications for post-injury neuroendocrine screening and provide a reference point for screening following traumatic brain injury.

Hard copies of the clinical support tools are available for order through DCoE. To download electronic versions of these tools and other TBI clinical resources, visit the Resources section of the DCoE website. If your patient has symptoms that suggest NED and they don’t resolve after three months, you should consider referring your patient to an endocrinologist.

THE EXPERIENCES AND RECOVERIES OF WOUNDED WARRIORS

FROM: U.S. DEPARTMENT OF DEFENSE

By Lisa Daniel
American Forces Press Service

WASHINGTON, Sept. 13, 2012 – Caregivers, National Guard, reserve support and sports for the wounded are the top Defense Department priorities for wounded warriors and their families, the deputy assistant secretary of defense for warrior care said today, as wounded warriors discussed their experiences with recovery.

John R. Campbell made the comments after listening to panelists at the annual Warrior-Family Symposium, sponsored by the Military Officers Association of America. The panel included four wounded warriors who spoke about their transitions to a new life after being wounded in battle.

Retired Marine Corps Master Sgt. William "Spanky" Gibson moderated the panel, along with Retired Marine Corps Col. Derek Donovan, vice president of the Fisher House Foundation. Gibson was a 35-year-old gunnery sergeant in Iraq in 2006 when he was shot through the knee. His left leg was amputated above the knee, but he started competing in triathlons while recuperating at Brooke Army Medical Center in San Antonio and has competed in more than a dozen races. In 2008, he went back to Iraq as the first above-the-knee amputee to return to a ground combat area of operations.

Gibson’s determination showed up early in his recovery, when he proved he could get himself to the second floor of a Fisher House room – the only one available – rather than stay in the hospital. "I went up and down those stairs for two hours, sweating profusely, just to prove I could do it," he said.

Another panelist, retired Navy Petty Officer Benjamin Host, was with the Seabees in Iraq in 2004 when he suffered severe traumatic brain injury and post-traumatic stress disorder after being in a Humvee convoy accident. Host said he received "exquisite" military medical care that included three brain surgeries and repairing his fractured skull. But, he said, "it’s the in-between area where we get a drop-off" meaning a lack of oversight in the recovery process.

Although it took a legal battle, Host said, he was medically retired from the Navy earlier this year.

Campbell and the audience also heard from Dr. Tara Dixon, a trauma and critical-care surgeon who deployed to Iraq as an Army reservist with a forward-deployed unit in 2008 and 2010. Dixon recalled the stress of "routine bombings" on her camp, of treating "the guy I had breakfast with that morning" for critical injuries, and of having to make split-second decisions about whether to amputate a limb or risk transporting a soldier hours away to a Baghdad hospital.

Then there were the abused Iraqi children brought in as decoys for insurgent attacks on the unit and the surprising number of female soldiers who needed treatment for sexual assaults – crimes she was legally bound not to report at the victims’ request, she said.

"It messes with your mind a bit," Dixon said of her time in Iraq. She described through tears the toll her service took, which culminated in a suicide attempt six months after her redeployment.

Among the many problems, Dixon said, was returning to a city without a military base and no means of support. "I was very much an outcast, and I felt very much alone," she said.

The panel also included retired Air Force Tech. Sgt. Matthew Slaydon and his wife, Annette. Slaydon was an ordnance disposal technician on his third deployment in Iraq in October 2007 when a roadside bomb exploded in his face. Like Host, Slaydon said he received excellent medical treatment, but struggled after returning home from the hospital. Family members didn’t understand the symptoms of post-traumatic stress, he said, and some relationships, including with his mother, ended.

Slaydon, who lost his arm and was blinded by the bomb, said his symptoms worsened after he received a medical retirement from the service. He became paranoid, he said, at noises in his house and would spend his days terrified and sitting with his guns.

Slaydon said he has had a wonderful caregiver in his wife, an Air Force recovery care coordinator. Still, the ongoing stress of recovery and caregiving weighed on the couple, and they separated even though Slaydon said he still loved her, but that he needed to recover on his own.

"There’s no handbook that says when you should pull back as a caregiver and give them more independence," Annette Slaydon said. "There is no instruction booklet about how to move forward on this."

Turning to Campbell, and with the preface of an apology, Mrs. Slaydon said, "There are some really big holes that need to be filled either by the government or the private sector or both to give our families a chance."

"It’s OK, I need to hear this," Campbell replied.

Campbell, a former bank executive who started MyVetwork, said he started the online social network to add meaning to his work. In doing so, he said, "I heard the voice of my mother," who was his caretaker after he was injured twice as a platoon commander in the Vietnam War.

"I’ve been worried and concerned for a while about caregivers," he said, adding that his office will host a conference early next year about how to help them.

On the Guard and reserves, he said, "They don’t have a base, they don’t have the community. They’re alone and they need our help."

Campbell said he wants to continue to explore the issues that most affect wounded warriors and their families and get them the help they need.

He said he believes in public-private-nonprofit partnerships. "There’s this mindset that [the government] can do it all, but it can’t," he said.

TRAUMATIC BRAIN INJURY AND THE ARMY-NFL TEAM

FROM: U.S. DEPARTMENT OF DEFENSE, , NFL, FIGHTING BRAIN INJURY

Army, NFL Team Up to Fight Brain Injuries
By David Vergun
Army News Service

WEST POINT, N.Y., Aug. 31, 2012 - The Army and the National Football League are working together to improve awareness of traumatic brain injury and increase research into its causes, prevention and treatment.

The top leaders of both organizations -- Army Chief of Staff Gen. Ray Odierno and NFL Commissioner Roger Goodell -- met at the U.S. Military Academy Aug. 30 to discuss the issue and sign a letter of agreement to continue sharing resources to combat TBI.

They were joined by a panel of soldiers and retired NFL players who have had concussions while serving on the battlefield and the playing field. About 200 cadets also attended, as well as representatives from Army medicine.

Odierno explained how some of the best traits in soldiers can sometimes prevent them from seeking help following concussions.

"Mental and physical toughness, discipline, team over self and stressing the importance of resilience are fundamental to the cultures of both the NFL and the Army," Odierno said. "We have the Warrior Ethos, reinforced by the Soldier's Creed."

These selfless traits, he said, make it "particularly difficult for individuals to come forward and identify physical and mental issues, especially mental.".

"We are seeking to educate both players and soldiers about TBI, to empower them to seek treatment both on the battlefield and playing field," Odierno said.

The Army and NFL are continuing their dialogue and sharing of research on TBI, said Odierno, citing examples of joint efforts at monitoring TBI, including placing special sensors in the helmets of soldiers and NFL players that can detect a possible concussion following trauma to the head.

NFL players and soldiers are now coordinating strategies and using special types of tests to determine if a concussion has occurred, added Dr. Richard Ellenbogen, chair, Department of Neurological Surgery, University of Washington. He expects research to continue to reduce TBI.

The NFL commissioner then addressed the cadets. "You are the future leaders of Army," Goodell said. "Together, we can make a big difference, sharing medical research, and helping players and fighters and bringing a greater awareness to society as well. I believe we can change our cultures, with athletes and soldiers sharing their experiences."

The cultural shift to which Goodell referred is the reluctance of many football players and soldiers to ask for help after receiving concussions.

"A frank conversation needs to take place at the lowest levels, with the people most powerful in soldiers' lives -- not me, but their platoon sergeants and first sergeants," Odierno said. "Soldiers must be made to realize that there will not be retribution of any kind for asking for help."

"Sometimes the NCOs must make the decision for the soldiers and not penalize them," said Army Staff Sgt. Shawn Hibbard, addressing the reluctance of many soldiers to seek help on their own. "When I got blown up I felt like, 'Hey, I'm mentally still in the fight.' That NCO must check those injured and remove them from the fight so they can get better." Hibbard said he suffered concussions himself during recent combat operations, but was reluctant to seek help.

Maj. Christopher Molino, who also suffered a concussion during recent combat operations, agreed that small unit leaders must step in and take charge. "Removing yourself is counterintuitive to soldiers' instincts. That's why good leadership is important."

Former NFL player Troy Vincent said he had a concussion on the football field so severe, that he was unconscious and didn't recall the event. No one got him to seek help, he explained. "They protected me with some play calls and didn't expose my weakness at the time," he said.

"The coach told me that 70 percent of you is better than 100 percent of the second string [players]," meaning that despite losing 30 percent of his ability to play due to concussion, he was still better than many of the uninjured players. Vincent was a cornerback for the Miami Dolphins, Philadelphia Eagles, Buffalo Bills and Washington Redskins.

Bart Oates, who also suffered a concussion on the playing field, agreed that the mindset is hard to change. He played center for the New York Giants and San Francisco 49ers.

Goodell said that old school mentality of not asking for help will no longer be tolerated. He stressed the importance of accountability. "Myself, the coaches and other members of this organization have a responsibility to make the lives of players better, both on and off the field," he said, adding that he hopes those in other sports -- especially young athletes -- get the message and provide proper leadership and supervision.

"We need to learn to rely on the players to do the right thing; to raise their hand if they need help or ask others to seek assistance," he said. "Someone needs to say 'Hey, you're not feeling too well,' and allow medical personnel to make the call whether to stay in the game. The coaches or players should not make that call. You can play smart as well as tough. Seeking help is playing smart."

The commissioner said he's not satisfied that enough progress has been made. "We're not going to stop; we're going to continue, we're going to make a difference."

Odierno agreed that more has to be done, despite recent policies and directives designed to protect the health of soldiers.

Army Directive-Type Memorandum 09-033, for instance, stipulates that soldiers have a minimum of 24 hours of downtime and get a medical clearance before returning to duty following a blast or vehicle incident.

Maj. Sarah Goldman, program director of Army Traumatic Brain Injury at the Office of the Surgeon General, Rehabilitation and Reintegration Division, emphasized that seeking help more often than not does not take a soldier "out of the fight." She said more than 13,000 service members sustained some form of concussion since 2010 and 95 percent were returned to duty.

Odierno, who played high school football, admitted that he likely would not have sought medical attention for a concussion. "I wouldn't have taken myself out. Someone else would have had to." He added that kind of thinking is wrong.

"I worry about our leaders more than anyone else. They're the ones who feel the burden of leadership and responsibility. They're the ones who won't take themselves out of the fight. I'm asking that leaders look after leaders," he implored. "First sergeants looking after NCOs, sergeants major looking after commanders, senior commanders looking out for junior commanders. We've got to have a bond to take care of each other."

The Army and the NFL have had a close working relationship over the last few years. "It was my honor to visit soldiers in Iraq and Afghanistan," said Goodell. "Our cultures are similar in so many ways. We owe it to our players and soldiers [to remove the stigma of seeking help]."

"Having played football and been the senior commander in Iraq for almost five years, I've personally seen the impact of traumatic brain injury," Odierno said. "Roger and I got together on several occasions. He's passionate about taking care of his players. Our organizations make a really good match. I'm excited."

Odierno said he hopes the initiative helps both soldiers and football players.

TRAUMATIC BRAIN INJURY AND MEDICAL DECISION MAKING

FROM:   HHS HealthBeat (May 30, 2012) 
Medical decision-making after a traumatic brain injury

People who’ve had traumatic brain injury might not be thinking straight but still may have to make crucial medical decisions.

Researchers at the University of Alabama at Birmingham tested 86 TBI patients’ ability to understand medical options, decide on treatments, and appreciate consequences of their choices.

One month after injury, patients with moderate or severe TBI – and some with mild TBI – still had impaired decision making skills.  

Researcher Daniel Marson:
"Even patients with mild injuries really depend to some degree on family members assisting them and guiding them, even if the patients still are able to make the decisions themselves."
The study in the journal Neurology was supported by the National Institutes of Health.

TOOLKIT HELPS TREAT PATIENTS WITH CO-OCCURRING CONDITIONS

The following excerpt is from the Defense Centers of Excellence website:
Treating patients with mild traumatic brain injury (TBI) can be challenging because TBI symptoms can sometimes resemble a number of psychological health conditions. Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE) developed Co-occurring Conditions Toolkit: Mild Traumatic Brain Injury and Psychological Health to provide guidance on the assessment and management of patients with the co-occurring conditions of concussion, post-traumatic stress disorder, pain, depression and substance use disorder.

The tool kit is a user-friendly, comprehensive clinical guidance tool for primary care providers, featuring evidence-based clinical practice guidelines and recommendations from the Departments of Defense and Veterans Affairs. It provides tips for an effective first appointment; guidance on clinical assessment; treatment recommendations; medication information; and patient education websites.

In January, we wrote about a free mobile application where you can access the tool kit from your iPhone, iPad or Android device. National Center for Telehealth and Technology (T2), a DCoE center, developed the Co-occurring Conditions Toolkit mobile app to give providers immediate access to critical and up-to-date information. Providers can use the app to identify appropriate interventions and timing of services to more effectively meet the needs and improve outcomes for patients who sustained a brain injury. Additional benefits of the app include increased use of evidence-based treatment recommendations, enhanced provider-patient interactions and more appropriate specialty referrals.
Visit the T2 website to see more military mobile apps.

Additionally, DCoE partnered with the U.S. Army to develop the Co-occurring Conditions Toolkit training video to provide an overview and offer instructions on how to apply the tool kit to clinical practice. The video is intended to be an on-the-job training reference and includes characteristics and descriptions of psychological health conditions; step-by-step instructions on using the tool kit; and real patient scenarios.