TBI Theater Systems of Care

COL Jamie Grimes, MC USA

National Director, Defense and Veterans Brain 

Injury Center

26 MARCH 2013
Disclaimer

The views expressed in this presentation 

are those of myself and do not reflect the 

official policy of the Department of the 

Army, DoD, or U.S. Government.

 No financial/commercial disclaimers, no 

off label discussion
Poll Question #1

• What is your primary role in VA?

– student, trainee, or fellow

– clinician

– researcher 

– manager or policy-maker 

– other 
Poll Question #2

• Which best describes your experience treating 

symptoms after concussion/mTBI? 

– have no experience

– some experience with chronic persistent sx’s after 

mTBI 

– some experience with both acute and chronic sx’s 

after mTBI 

– have significant overall experience with mTBI 
Defense and Veterans Brain 

Injury Center (DVBIC)

Established as a Department of Defense organization by a Defense Appropriation 

Bill in 1991, DVBIC was directed to track and evaluate head injury survivors; ensure 

appropriate treatment and rehabilitation; study treatment outcomes; and counsel 

family members. 

DVBIC’s mission is to serve active duty military, their beneficiaries, and veterans 

with traumatic brain injuries (TBIs) through state-of-the-art clinical care, innovative 

clinical research initiatives and educational programs, and support for force health 

protection services. DVBIC fulfills this mission through ongoing collaboration with 

the DoD, military services, Department of Veterans Affairs, civilian health partners, 

local communities, families and individuals with TBI.

DVBIC assists the DoD and VA in optimizing care of 

service members and veterans who have sustained 

a TBI, in deployed and non-deployed settings through 

DVBIC’s three divisions: Research, Clinical Affairs, 

and Education. 
Serving Those Who Have Served

Clinical Affairs

• Care & Consultation

• Identification & 

Sharing Best Practices

• Clinical Guidelines & 

Recommendations

• TBI Surveillance

• Neurorehabilitation 

& Community 

Reintegration Centers

• Regional Care 

Coordination

Education

• Educational Tools & 

Resource 

Development 

• TBI Awareness & 

Training

• Product Distribution 

& Dissemination

• Family Caregiver 

Program

• Regional Education 

Coordination

Research

• Clinical 

Investigations

• Congressionally 

Mandated Studies

• Epidemiological 

Research

• Statistical Analysis

• Translation of 

Research 

These three pillars illustrate the many ways DVBIC supports service members, 

veterans, families and providers at our 18 network sites, which can be military 

treatment facilities, VA medical centers, or in community settings.
Defense and Veterans Brain Injury Center

Network Sites and Catchment Areas

www.DVBIC.org or email: info@DVBIC.org September 2012
Annual Defense Department TBI Diagnoses 

(All Severities) 

2000 - 2012 (Q3)

Year Number

2000 10,958

2001 11,580

2002 12,408

2003 12,815

2004 14,469

2005 15,531

2006 17,037

2007 23,217

2008 28,462

2009 28,875

2010 29,181

2011 32,609

2012 29,668

Total 266,810

Source: www.dvbic.org. 

Current as of March 2013

80% of all TBIs are 

mild / concussion

80% of all TBIs are 

non-deployment 

related 

Department of Defense TBI Incidences
DoD TBI Incidence by Severity

Source: www.dvbic.org

Classification

Penetrating (1.6%)

Severe (1%)

Moderate (8.2%)

Mild (82.4%)

Not Classifiable (6.8%)

Total 262,065

18,188

21,779

219,921

4,213

2,709

2000 - 2012

Traumatic Brain Injury Diagnoses in All Services 

As of March 5, 2013
Policy Guidance for the Management

of Concussion/mTBI in the Deployed Setting

• Department of Defense Instruction (DoDI) 6490.11

• Issued 18 September 2012, cancelling Directive Type Memorandum (DTM) 09-033 

which was issued 21 June 2010

• Involves commitment of line commanders and medical community

• Describes mandatory processes for identifying those service members involved in 

potentially concussive events

• Exposed to blast, vehicle collision, witnessed loss of consciousness, other head 

trauma

• Specific protocols for management of concussed Service members and those with 

recurrent concussion

• Transition from symptom driven reporting to incident driven

• Reporting requirements to track those involved in potentially concussive events

DESIRED END STATE: the mitigation of the effects of potential concussive 

events on both Service member health, readiness and ongoing operations
Mandatory Events Requiring Evaluation

Exposure to the following mandates prompt command and medical 

concussion evaluation, event reporting and a 24-hour rest period:

 

•Involvement in a vehicle blast event, collision, or rollover

•Presence within 50 meter of a blast (inside or out)

•A direct blow to the head or witnessed loss of consciousness

•Exposure to more than one blast event (the service member’s 

Commander shall direct a medical evaluation)
Military Acute Concussion 

Evaluation (MACE)

Concussion Management 

Algorithm 

In-Theater Tools
Clinical Algorithms

•Department of Defense (DoD) 

policy includes four 

concussion management 

clinical algorithms

- Combat Medic/Corpsman

- Initial Provider

- Comprehensive Concussion

- Recurrent Concussion

•Clinical algorithms were

updated in 2012; current

version is 4.0

Version 4.0 - 2012
RC-EAST RC-SOUTH THEATER RC-SOUTHWEST

Concussion Specialty Care NEUROLOGIST CSCC CRCC (Primary Care Model) Center (CSCC) •Neurologist Supporting Entire • Sports Medicine Physician • Neurologist •Psychologist CJOA-A • 2 Primary Care Physicians • Neuropsychologist •Physical Therapist • Psychologist • Primary Care Provider •Occupational Therapist

Nurse • Occupational Therapist •OT Technician •

• OT Technician • Occupational Therapist 2 CCC’s • Physical Therapist 4 CCCs Part-time Provider • Research Psychologist

• Part-time Provider •Occupational Therapist • Navy Corpsman

• Occupational Therapist •OT Technician

FOCUS: CAM, pain intervention, • OT Technician Warrior Recovery Care, tracking, 

cohesion of CCC/CSCC in Theater 

CCC: Concussion Care Center CRCC: Concussion TBI System of Care. Restoration Care Center

CSCCs: 2

Bagram Air Field

Kandahar Air Field

CCCs: 4 CRCC: 1

FOB Salerno Camp Leatherneck

FOB Shank

FOB Sharana

FOB Pasab

Concussion Care in Afghanistan
Walk the Ground: 

Combat Concussion Care Case

Situation

• 23-year-old activated reservist 

male, Specialist Jones, in 

improvised explosive device 

(IED) blast

• Driving up-armored 7T pushing 

mine roller; IED went off under 

front of truck

• No TBI training/education for 

him or unit, including both 

medical and personnel 

Photo by Lance Cpl. Bruno J. Bego
Combat Concussion Care: Evaluation

Specialist Jones:

•Medic evaluation four hours later: had his protective gear including helmet, 

but chin strap loose and no seatbelt

•Hit head on window; saw stars, felt dazed

•Witness: confused, slow responses, “out of it” for 10-15 minutes but no loss 

of consciousness

•MACE CNS 24/green normal Neuro/B (has symptoms). DoD score reporting 

includes input on Cog score, Neuro exam and presence/absence of 

symptoms
CRCC

Courtesy photo by Col. Jamie Grimes
Specialist Jones: Post-Injury 

Two days post injury:

• Daily HAs, in a.m.

• No improvement with 

inconsistent use of Motrin 

and Tylenol

• Neck and hip pain

• Not sleeping

• Difficulty concentrating

• Easily irritated

CCC enrollment D#3

• Review sleep hygiene

• TBI education program

• Start Ambien 10 mg/day

• Regular use of NSAID

• Provider and physical 

therapist evaluation

• Past TBI history: MVC with 

brief LOC 11 mo. HA, 

cognitive issues x 2 mo. 

then resolved 
Specialist Jones: D#4 at CCC

•“Ruled-In” by MACE screen 

for concussion

• History of second concussion 

in past year

• High risk assignment

• No pre-deployment training

• History of depression in past

• No fractures

• Now he has no sx’s at 

rest/walking but + running

• +Chronic sleep issues; 

sleeping now with Rx and 

sleep hygiene

• Improving hip pain with 

physical therapy but + neck 

pain

• Anxious and agitated in 

groups at CCC
Post-Injury Assessment & Rx in Afghanistan

Assessment/Dx/Rx 

•TBI Med Algo’s for Rx

•MACE acute tool

•Provider Clinical Exam

•Sleep is KEY Rx*

•Medication & CAM Rx*

•ASR and COSC*

•Chaplain counsel

•Effort and Cog testing

•CT and MRI

OT Tools

• BESS

• Graded Symptom Checklist 

• Sleep Measure Index

• Performance Assess

• --------------------------------

• OT Neurovisual screen

• Gait Speed Test

• Post-injury ANAM

• Military validated performance
TBI Ongoing Questions

• Metrics to assess effectiveness of assessment?

• Updates with ongoing research to incorporate advances in 

objective measures/tests/studies?

• Except for logistics of transfers, should CPG in theater differ 

from garrison TBI care? Train as you fight...line and medical...

• Different/additional studies, assessments for high risk like 

EOD/route clearance/bomb squads? Pre-deployment? Postdeployment?

• Co-occurring conditions predicting outcome: literature on 

persistent symptoms and increased self-reported “incidence”

of mTBI over time: conundrum of history/self report 
Specialist Jones: Day 14

ISSUES at Entry/Day 7

•Transferred to concussion specialty 

care center on day 7 because of 

increased c/o’s: HA, worsened sleep, 

vision, cognitive c/o’s are worse

•Neck pain worse

•ASR suggests anxiety and stress 

reaction* 

D#14 Rx & Response Recovery

 Normal full eye exam

 NP evaluation improved* 

 COSC evaluation and care 

established with f/u*

 He reports better sleep, 

thinking, normal vision, 

controllable mild neck and 

head pain after CAM

 Discharge to follow up at unit
What else could we offer Specialist Jones? MRI!

• Battlefield JTS CPG #14: DoD 

Policy Guidance for 

Management of mTBI in 

Deployed Setting

• Battlefield JTS CPG #37: Use 

of MRI in Management of 

mTBI/Concussion in 

Deployed Setting

 

• Research underway

• Three MRIs in theater

Col Julie Stola, USFOR-A Surgeon, KAF MRI suite. 

Courtesy photo by Col. Jamie Grimes
Research Relevance: 

Screen, Dx, Rx, Px

Predictive of True Concussion and Not Concussion

• Clinical Hx and Exam

• POI/Point of Injury and Return to Duty evals

• DTI? Brody 2011: Clinical screen greater

• Biomarkers? Timing

• Cognitive assessment? Effort output, comorbidity
Research Relevance: 

Screen, Dx, Rx, Px

Predictive of Recovery and Non-Recovery:

• Clinical symptoms

• Age and pre-morbidity

• Recurrent/cumulative TBI

• Cognitive baseline?

• Simple reaction time?

• Diagnostic tools?

• Co-occurring conditions?

• Mind injury?
Continuum of Care: TBI Recovery and Reset 

for Specialist Jones

• Jones at home less than six months 

later, +recurrence of symptoms on f/u 

with provider.

• Review of acute injury and treatment: 

recovered from concussion. Now 

new/recurring sx’s. 

• Further evaluation: diagnostic tests, 

cognitive assessments, clinical 

assessments, imaging, treatment 

trials. 

• What is Dx & Rx? 
Questions?

COL Jamie Grimes, National Director

www.DVBIC.org 

info@DVBIC.org