**Transcript of Cyberseminar**

**Timely Topics of Interest**

**TBI Theater Systems of Care**

**Presenters: Col. Jamie Grimes; Col. Beverly Scott**

**March 26, 2013**

**TBI Theater Systems of Care**

**March 26, 2013**

Moderator:And as we are at the top of the hour, at this time I would like to turn it over to Dr. Ralph DePalma to introduce our speakers.

Dr. Ralph DePalma:It is my great pleasure to introduce two fine DoD neurologists who served in Afghanistan. Colonel Jamie Grimes will discuss the DoD processes for TBI care in this deployed environment, and Colonel Beverly Scott will discuss her clinical experiences and diagnoses and treatment of TBI the field. Molly?

Moderator:Thank you very much. I do just want to make a quick note. Dr. Scott is unable to connect to the online forum, but we are thankful to have her on a telephone, so I will be advancing her slides for her. So we want to thank her for doing this low-tech solution for her presentation. And at this time, I would like to turn it over to Colonel Grimes.

Colonel Jamie Grimes:Thank you, Molly, and thank you, Dr. DePalma, for inviting myself and Colonel Scott to this wonderful opportunity to share our experience on the TBI landscape. My disclaimer is essentially I have nothing to disclaim and I am just representing myself and not official policy of the Army, DOD or the U.S. government.

Moderator:Can I ask you to put your slide show up into slide show mode? Down in the bottom right-hand corner, just click that one; it looks like a presentation. There you go.

Colonel Jamie Grimes:There we go.

Moderator:Perfect. Thank you.

Colonel Jamie Grimes:[Overlapping voice]. Already a faux pas to begin, but I will let you, Molly, take the folks through the poll question.

Moderator:Excellent. Thank you. For our attendees, we would like to get an idea of who is in our audience today, so on your screen now you will see a poll question. Please click the circle next to the answer that describes your primary role in VA. The choices are Student, Trainee or Fellow; Clinician; Researcher; Manager or Policy Maker; or Other. And we have already had two-thirds of the audience vote, so we will give people just a few more seconds to get in their answer. Thank you for replying. It does help our presenters to kind of gear their talks towards the correct audience. Okay, and it looks like the answers have stopped streaming in. We have had about 75 percent respond. So at this time I am going to close the poll and share the results. 

We have 4 percent Student, Trainee or Fellow. We have 37 percent Clinicians; 37 percent Researchers; 2 percent Managers or Policy Makers; and 20 percent identifying as Other. So I would like to thank those respondents. And we do have one more poll question for you before we get to Dr. Grimes’ content. This poll is, which best describes your experience – I am sorry. Dr. Grimes, is the correct one for you right now?

Colonel Jamie Grimes:Yes. This is the correct one.

Moderator:Which best – thank you. Which best describes your experience treating symptoms after concussions/MBTI and TBI: the first option, I have no experience; the second option, some experience with chronic persistent symptoms after mTBI; some experience with both acute and chronic symptoms after mild TBI; or have significant overall experience with mild TBI. And we have already had 70 percent of our audience vote and the responses have stopped streaming in, so at this point I am going to close the poll and share the responses. Looks like 39 percent have no experience treating symptoms after concussion or mild TBI; 22 percent have some experience with chronic persistent symptoms afterwards; 18 percent have some experience with both acute and chronic symptoms after mild TBI; and 20 percent have significant overall experience with mTBI. So that is excellent. Thank you again. And at this time ...

Colonel Jamie Grimes:Yes, thanks Molly.

Moderator:... I am going to ...

Colonel Jamie Grimes:I appreciate that. That is really great for me to know that we have a significant smorgasbord, so to speak, of folks with no experience to those, even 20 percent that have significant experience. 

Well, the Defense and Veterans Brain Injury Center, of which I am the national director, has 21 years of experience in traumatic brain injury. We were written into a Defense appropriation bill way back in 1991 and actually came into being with humans executing this mission in 1992. And the focus then from Congressional language was to track and evaluation head injury survivors. Appropriate treatments and rehab are in place. Study the treatment outcomes, treat-as-you-learn and learn-as-you-treat and counsel family members. 

Our mission continues serving active-duty military beneficiaries and Veterans with traumatic brain injury, and we do this through the state-of-the-art clinical care, innovative clinical research and education programs. And we support also four self-protection services. That mission actually came on board in 2008 both for surveillance and also tracking their cognitive assessments.

DVBIC actually has significant collaboration not just within the DoD but also specifically with the services. We work with their TBI reps of all services as well as we have close partnership with the VA. The civilian health partners are also a part of our team and local communities and families and individuals with TBI.

We are really endowed to optimize care of service members and Veterans, and we do this through our three pillars, which are research, clinical affairs and education. And that is really across our 18 network sites, which include military treatment facilities, VA polytrauma centers as well as in two community settings.

You can see here under research this is predominantly clinical investigations, not bench research, but really clinically-driven investigations. We have several congressionally-mandated studies to include head-to-head trials and to include a longitudinal study. We also have a long history of epidemiological research, and translation of that research into clinical practice, which is an interdigitation with our clinical affairs in that we commissioned to identify and share best practices, which include clinical guidelines and recommendations. 

As a matter of fact, four Clinical Recommendations will be launched this year with the first one for vision – a vision recommendation which was a huge partnership with the VA already launched in January. We also are in the Office of Responsibility for TBI Surveillance and include two under Clinical Neuro-Rehab/Reintegration Centers. And our Care Coordination platform is across our sites. 

And education, this is a major initiative of ours. And that is, as you can see, through tools and resource development, awareness and training of service members as well as educating within the civilian community in partnerships like with the Red Cross. We also do product distribution and dissemination. In 2011 there was over 1 million distributed pieces of information.

We also have the Family Caregiver program, which is really for moderate to severe TBIs. And just as we have for care clinical affairs, we have care coordinators; we have education coordinators for our education pillar.

As we look at where the 18 sites are, you can see them listed here, predominantly military treatment facilities as well as five VA and the two civilian rehabs. We have presence all the way in Germany to Alaska, and Alaska Elmendorf-- Richardson, Elmendorf, is our latest partner to the team.

I wanted to share some of the numbers. Sometimes it is important to say what or why do we care. You can here are the numbers that began to be tracked in 2000 and this includes all numbers up to the end of 2012, the calendar year 2012. You can see a cumulative total of over 260,000. And when you look at the number, approximately 80 percent of all these numbers are non-deployment-related and the same rubric goes for 80 percent are mild TBI or concussion.

When we look at severity here, it is just another depiction of what I just described, which is that mild TBI is the main severity that we address in the DoD. But also we have penetrating and severe and moderate. 

Non-classifiable has to do with improper coding. All of us on the line know how onerous coding is, but it really does help us be granular on what we are addressing and what we are trying to accomplish.

I did want to mention the policy. That has really been a game-changer for the military. That is the first directive-type memorandum that became a DoD LAR, a DoD instruction, just since September of last year. It actually is a commitment of line leaders with the medical community mandating that any potential concussive event will have a scripted, a mandated evaluation. You can see that the mandatory events are listed there, whether it is exposure to blast, a vehicle collision, a witnessed loss of consciousness or other head trauma.

It also mandates referrals to up-to-date protocols and has specific duty limitations and evaluations of requirements from recurrent concussion. You can see that it is really transition from having to raise your hand and saying that something is wrong with you to actually incident-driven. And that has actually been extremely powerful.

And the reporting requirements are not just for medical, but for the line, in tracking and following exposures. So we do get to have the whole denominator  of who, say, is exposed to a blast and then we can figure out how many of those actually do sustain a concussion. But really the bottom line is right at the bottom—mitigating the effects of potential concussive events not just on the service member’s health but also on readiness and ongoing operations.

These are these four mandatory events that require evaluation. 

· You can see it is in more detail what I just said about the involvement in a vehicle event, whether it is a collision or a rollover. 

· Within 50 meters of a blast whether inside or outside of a vehicle or a building. 

· A direct blow to the head or a witnessed loss of consciousness. 

· And then exposure to more than one blast. The commander can actually mandate a medical evaluation.

These are the in-theater tools that actually just got updated last year. Both are on their fourth version, both the Military Acute Concussion Evaluation (MACE) and the Concussion Management Algorithm. If I could poll you guys again, I would just to see how many of you are familiar with these because both of these tools, both as an algorithm as the MACE date back to 2006.

As we look at the Clinical Algorithms, there are four concussion management algorithms that focus on the combat medics first, then an initial provider, then a comprehensive concussion evaluation, and the last one being the recurrent concussion, which is defined as three or more TBIs in the past year.

You can see here that they were actually updated just last year, actually rolled out in-theater in July of 2012.

I wanted to give you just a little overbrief of the concussion care that exists in Afghanistan. Bev was the theater neurologist that preceded me. I got there in March of ’11 and she was there through the heady days just prior to that. We actually have expanded and contracted concussion sites, as many as 12 at one point and now at seven. So you can see that there is a theater neurologist that helps to manage the far and wide policy for implementation for resources and really for clinical advice and support.

But you can see that there are also the Concussion Specialty Care Centers. Those have neurologists at them. They have been on the east of Afghanistan, down to the south in Kandahar. You can see, too, that the Concussion Care Centers are really run by a part-time provider who has as the main caregivers the occupational therapist with an occupational therapy technician. 

There are currently six concussion care centers and the two concussion specialty care centers with the theater neurologists supporting the far and wide. We have a Concussion Restoration Care Center that is really run for the Marines down in the southwest of Afghanistan, and I would just let you know that Afghanistan is about the size of Texas, so it is a pretty large terrain. 

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And the status currently is in – 97 percent are recovered within two weeks with the concussion care that we have in theater currently, which I would argue would rival any concussion care in the United States, acute concussion care in the United States, for especially that large a geographic area.

Just going to walk the ground and try to stay on time here. Can use a prototype and use a 23-year-old reservist who is a specialist, an E-4, who was in an IED blast. He is the driver of that seven-ton. Had the mine-roller with it when the IED went off and the backdrop here is that no one had any TBI training beforehand, neither him nor his comrades nor medical personnel.

So what do we know about him? We know that due to other more grave injuries and dangerous events going on, he actually had his medical evaluation about four hours later. Confirmed that he was wearing his helmet, but he did not attach the chin strap but actually got knocked off, and he was not wearing a seatbelt. He hit his head on the window and he self-reports—he saw stars and felt dazed.

You can see the witness there, his battle buddy in the vehicle observed him when they had a sound-off of the folks in the vehicle and he was really kind of out of it. He was never knocked out. He was never completely unconscious, but he was out of it for at least 10 to 15 minutes.

He undergoes his Military Acute Concussion Evaluation, which I want to – if you are not familiar with that tool, it actually has the SAC embedded in it, but it has six different word lists and digits, a FAN list. But it also has a neurological examination, so we use the mnemonic CNS. So there is a cognitive score, which is that SAC portion within the MACE. There is a neurological exam, which includes eye tracking, motor and even balance and speech. And then there is a symptom score, too. We have a set of symptoms and you are screened for it.

Here is his score listed as 24 out of possible 30, normal neurological exam, so he is green there. And then B, which means – A means no symptoms and B means symptoms.

So he would potentially – if he was down at RC Southwest, he would potentially go to this Concussion Restoration Care Center. So these are two of my colleagues, both of which are researchers. One is a research psychologist embedded at the CRCC and the other is actually with the Navy as a research psychologist looking at the psychological health is with the TBI.

So what we know about him two days after his injury: he is continuing to have headaches. He is not getting better, but he is really not consistently using his NSAIDs – or the Tylenol. He has now also identified his neck and his hip hurt and cannot sleep and he really is just upset. 

So he is referred to one of the concussion care centers that I just described, where they go over emphatically what a TBI is, an expectation of recovery, and what the signs and symptoms are and how they are going to address them. He is also educated on good sleep hygiene and that you do not drink Rip It right before you go to bed, nor do you have massive stimuli like video games right before you go to bed.

Instituted regular use of anti-inflammatories and then actually did a much more thorough history to find out that this is his second concussion in the past year because he had a loss of consciousness in a motor vehicle crash earlier.

So what do we know now at the Concussion Care Center on Day 4? He rules in by our criteria for a concussion. This is his second concussion in the past year, so that will impact on his return to duty based on our concussion management algorithm. He is in a high-risk assignment, so he is with the DoD and so we now know he has had two and putting him back to duty in his mission will potentially expose him to a much higher rate than others. We know that he really was never educated before. 

And we also find out that he had a history of depression in the past, so that is something on our landscape, too. He has no symptoms at rest now, but any exertion brings it on; and he is still struggling with some sleep issues. And he is becoming more anxious and agitated in groups.

So if we stop and take a moment here just to take an inventory of what we do in Afghanistan, especially in a pretty thorough assessment, which includes those medical algorithms that include treatment recommendations. We have an acute tool in the MACE. But we really have learned over these last – really since 2010 when we have been really tracking, that sleep is a key intervention to ensure is intact. When sleep is not supported, there is no way to recover these folks.

We do know, too, that complementary alternative medicine is actually very helpful, but that this is a cocurring risk too for stress reaction; and partnering with our Combat Operational Stress Centers—that is what the COSC stands for—is really important, as well as the chaplain. Some have had a modicom of, is this also a mind injury in the carnage of war with life-threatening concussion and having colleagues, comrades injured? So we know the chaplains play a big role.

And the OTs at these concussion care centers have implemented several standardized assessments and we can see them there as well as some that were trying to look into validation. And they actually have a clinical recommendation that will come out on Validated Performance for Return to Duty. 

So these are really the questions that persist as we go forward. How do we assess the effectiveness of our clinical diagnosis, and how do we augment that with other objective measures and tests? We have really examined within the military; should we not do the same TBI care stateside, or what we call garrison, since it has been so successful; and especially when we know 80 percent of concussions are happening stateside and the Army actually is looking into a garrison mTBI plan that will mirror what the DoD-I mandates.

You can see here we also want to know are all individuals equal or those at greater risk, should they have a more in-depth evaluation? And we really did really heavily in the past on history and self-report, which we know can be flawed; and how do we better objectify this so that we can evaluate this more thoroughly?

So now we skip all the way to Day 14 because at Day 7 he just really was continuing to have more difficulties. So he was referred to the Concussion Specialty Care Center. And that was because his headaches actually rather than getting better started getting worse and his sleep became really problematic. You can see that he underwent an Acute Stress Reaction, which did support that there was increasing anxiety and stress. And I have to say at the Concussion Care Centers, they do an Entrance ASR so they are able to track.

So in two weeks total from his injury at the Concussion Specialty Care Center, he actually undergoes a multi-specialty evaluation. And I should say at the Concussion Specialty Care Center, both of them are what we call CSH, Combat Support Hospitals. This is the highest level of care and they actually have MRIs at them. There are only three CSHs in theater and the Concussion Restoration Care Center I mentioned is very close to the third one that I did not mention, which is Bastian. But these two actually have neurologists. They have imaging capability. They have a full complement of trauma specialists as well as medical docs embedded in the care there.

So at Day 14, he actually has had a third evaluation. He has had a change in his medication and he is actually plugged in with Combat Operational Stress to continue followup with him, and he is discharged back to his unit. And I would say that this is really not a unique, this is the majority that recover actually far forward from that Specialty Care Center. But when they get to the Specialty Care Center, it is augmented.

I just wanted to let you know—many of you may know that the Joint Theater Registry or the JTR  [*no speech from 00:24:42 to 00:24:45*] – I do not know what that was! but getting back to this, that we have clinical practice guidelines that are on the Joint Theater System either actually scope out how to use MRI, now that we have MRI in-theater. And they also scope out how to manage concussion in an algorithmic fashion. 

We have research underway and some of the preliminary of that is MRI is—and TBI—and more to come on that with Dr. Octavian Adam in collaboration with a civilian researcher as well.

So as we conclude here, these are really the questions that we have. What is predictive of true concussion and not concussion and how do we augment that clinical diagnosis now? How do we assess for effort and how do we look at comorbidity? And Dave Brody is actually the one that is helping Octavian Adam with the MRI study to help mirror his study that he did at launch school.

You can see here, too, that we want to also have predictive objectives, information for recovery and not recovery. What is a higher risk or co-occuring conditions? Is it something to look at early upfront and intervene, or do we need to – we know that recurrent and cumulative TBI is very, very important, but we do not know the response curve on that. We need more information about that, too.

So, then, as I conclude here, here is Specialist Jones. He is back home. He has actually completed his deployment. He returned to duty and now he has completed deployment and he has actually been back at home just shy of six months, but he is starting to have some symptoms that were very much like what happened to him when he was in theater. 

So that provider now, because it went into the electronic medical records, can actually look up his chart and can see that he actually had a concussion. They documented he also had a history of a concussion before that, but he actually resolved and had resolution of his symptoms. But now that he is having symptoms, now what we need to know is that a re-emergence or is that another diagnosis? And we need to know how to cognitively assess him, image, and involve him in therapy so that he can get better. But ultimately we need to make the right diagnosis to render the right treatment.

So that concludes my portion and I will turn this back over to you, Molly.

Moderator:For those of you that joined us after the top of the hour, to submit a question or a comment for either one of the presenters, please go to the GoToWebinar dashboard on the right-hand side of your screen and just type it into the question section and press send. We will get to it in the order that it is received. We do already have some pending questions. I am just going to jump right in with those. How long is it safe to use Ambien in trying to get warrior to sleep but trying to avoid complications of Ambien dependence? Similar question for how to avoid benzo or use of chronic opioid use from primary care providers.

Colonel Beverly Scott:I do not know. Jamie, do you want to answer that or do you have thoughts?

Colonel Jamie Grimes:I would say that we try to limit the Ambien and those sleep aids to a week, no more than two weeks and especially in the Concussion Care Centers, and maybe you can address this. The experience was that if they are not sleeping after a week and they are having persistent headaches, then we try a two-for, so we try to initiate maybe a low-dose of a tricyclic to try to address the sleeping and the headaches with that.

But I do know that when I was a theater neurologist that Ambien and those sleep medicines were like the number one prescribed treatment in theater. And it is ubiquitous that people do not sleep, do not have good sleep hygiene and are chronically sleep deprived. But we would support them anywhere from a week to two weeks. But if there were persistent symptoms after that, that was when less habit-forming medications were addressed.

And we tried very, very hard to avoid any narcotics, especially in the first week. And the only time that really became an issue is if they had other injuries, musculoskeletal injuries, where the pain was significant; and that is where clinical judgment really should rule and in most cases they needed the pain medication for musculoskeletal injury. And I would say that would be okay as long as your eyes were wide open and you understand the consequences and it could slow recovery from concussion.

Over to you, Bev.

Colonel Beverly Scott:Yeah. I mean that I would highlight ...

Moderator:Thanks.

Colonel Beverly Scott:... that amitriptyline was also very helpful for both the sleep and the headaches in that early post-concussion period. As to the issue about narcotics, I mean I think the clinicians in the group recognized that narcotics unfortunately make headaches, specifically migraine, much worse. And some of the cases that referred to me weeks, weeks after their concussion, were actually treated with narcotics for other issues and were not for their headaches and unfortunately had already developed the analgesic overuse component to their headaches. So as a rule we tried to avoid narcotics in theater. But as Jamie mentioned, sometimes it was unavoidable.

Colonel Jamie Grimes:And I can remember advising one clinician not to use Fiorinal and Fioricet either for these headaches after concussion just for the confounding effects they have. Over.

Moderator:Thank you both very much for those replies. And we will go ahead and move on to the next question. This one is a little bit long, so stay with me here. I am surprised about the role of physical therapy is to address pain issues. Physical therapists in other setting provide vestibular rehab for gaze, stability, dizziness, balance, spatial disorientation, and manual therapies and exercise therapies for headache and migraine-like symptoms, and exercise-tolerance programs to diminish/eradicate symptoms related to physical exertion. Who does this in the DoD deployed setting?

Colonel Beverly Scott:I mean the one thing I will emphasize on this is dizziness is not uncommon in that early post-concussion period that, as I alluded earlier, there is a big differential for the multiple types of issues that can cause dizziness after a concussion or blow to the head. And the one thing that I certainly strongly advocated is that anyone with complicated symptoms, again they really do need to be ideally evaluated by a neurologist. Or at least the providers throughout theater would contact a neurologist in theater to discuss cases and decide if they needed to be sent in to be evaluated.

But certainly, the physical therapist, I would clarify did more than just treat pain. I mean they were certainly an adjunct to me in just the overall evaluation of these service members and sometimes had some role in addressing some of these specific symptoms following concussion to include essentially dizziness. 

Colonel Jamie Grimes:This is Jamie. I would just emphasize that the physical therapists are scarce. We would need more. We definitely needed more of them. But also they are also very busy with musculoskeletal injuries. We have a tremendous amount of musculoskeletal injuries just from training and from wear and tear of daily activity, especially humping all their equipment. That was a major initiative. So especially at the CSH where physical therapists worked, they were just so busy with their primary mission of treating musculoskeletal conditions that although they were part of the team, the OTs did not have such a heavy load. That is why they were really quite keen on the Concussion Care Center teams because they had the ability to implement plans that were very standardized and very recovery based. So the way for the future for the military is it is not scripted just to OT, but that was the personage that we had. In other words, those were available providers. Where physical therapy definitely would have done it except for they were already overtasked. Over.

Moderator: Excellent. Thank you both for those responses. Moving on to the next question. What is the likelihood of the development of PTSD in service members with PCS? How does it compare to those without mild TBI?

Colonel Beverly Scott:Could you repeat – the question was not clear to me.

Moderator:No problem. What is the likelihood of the development of PTSD in service members with PCS? How does it compare to those without mild  TBI?

Colonel Beverly Scott:Is it service members who PCS? Or what is PCS—oh, Post Concussive Syndrome. I am sorry. Well again, I mean the statistics I am aware is that I think it is estimated that 19 percent of service members who redeploy have been diagnosed with PTSD historically and the number is even higher in individuals that have suffered significant injuries. But I think the question is how often are individuals with chronic post concussive problems, is there a higher incidence of PTSD in that group? 

Moderator:Yes, asking what is the likelihood of development of PTSD in that group compared to those without mTBI.

Colonel Beverly Scott:I am not sure I know specific numbers. I think it is a high-risk group, certainly. Again just having suffered an injury, but I do not know that I can speak to that further.

Colonel Jamie Grimes:I would say that Charles Hoag and Robert Ruff have done...  others, too, but those are two that I know have addressed this and have seen an increased risk for post-traumatic stress disorder, especially with loss of consciousness and concussion. And I know Hoag’s studies really look like a dose-response curve, too. The more they are deployed and engaged in activity and have a physical injury, and really concussion is a physical injury as well, the risk goes significantly up. I would say that if you look at the rate of post-traumatic stress disorder in military prior to 2003, so look at 2000, it is vastly lower than the national average. But then if you look at Charles Hoag’s studies, there is a significant increase with more exposure and again with physical injury. 

So I do not know if that really answers the question. And I cannot quote direct numbers except for Robert Ruff, which I think was an online version with the British Medical Journal. Charles Hoag [PH] has been in the New England Journal of Medicine. Both addressed some of those numbers. Over.

Moderator:Thank you both for those responses. The next question: do downrange service members receive educational handouts after positive mild TBI screens?

Colonel Jamie Grimes:I would say yes, they do. Actually, it is a validated education brochure that was updated and it is given to them whether they are far forward or if they are at the combat support hospital. And it is intended for the deployment setting and it is in the acute period an educational tool with that expectation of recovery.

Moderator:Thank you. The next person wrote in two different questions. We will tackle them one at a time.

Colonel Jamie Grimes:Molly, can I just interrupt this for a second to say that if you go to DVBIC.org, you can actually find these educational brochures. You can even go to the shopping cart and you will see where we have an educational brochure entitled, Acute Concussion. And that is actually where you can find that tool. Over.

Moderator:Great, thank you for that additional resource. So the first question is, mild TBI presentations and training often have a preponderance of information on epidemiology assessment, evaluation, diagnostic issues differentiating mild TBI from co-occurring conditions, and only a small portion on treatment of the TBI. What is the consensus treatment for post-acute mild TBI other than treating the co-occurring conditions?

Colonel Beverly Scott:Now I think the two key points that I would emphasize is education—I think that has been proven to facilitate recovery—and rest. I mean the main treatment for concussion is physical and mental rest, and certainly identification and symptomatic management of some of the symptoms that may follow concussion. But I think there is perhaps a bit of a misconception that there is a treatment for concussion. I mean the treatment is rest. And again, with an appropriate symptom management that we talked about. Jamie, do you have any additional thoughts?

Colonel Jamie Grimes:Yes. We look at the VA DoD Concussion Clinical Practice Guideline of 2009 and we know that when they have persistent symptoms that we address the symptoms specifically. And I tried to get kind of a standardized treatment plan across several MTS and what I come back with, including like a profile, is that really it is important to address the symptoms that they present with. It is not a global treatment plan that you give, but you individualize it with the symptoms that they present with. Whether it is headache or if it is dizziness or if it is visual complaints that you address specifically the symptoms that they present with. 

Or the question excluded behavioral health, but those would be addressed along with acute. So kind of a holistic approach. And I think the guidelines of ’09 are really very valuable to look at for some of those strategies. Over.

Colonel Beverly Scott:And this is Colonel Scott here. I mean although I would emphasize, though, as we suggested today that most folks recover fully and recover early. And those that have persistent or complicated symptoms, in my experience both in theater as well as back here in garrison and seeing a lot of these individuals chronically, there are clearly identifiable comorbid issues that may be unrelated to their remote concussion. 

And I certainly feel strongly that those individuals should be referred ideally to neurologist and behavior health specialists to really kind of sort through it. And it is complicated. Even though I think it is often suggested concussion care is best handled through a primary care model, I think when there are individuals who are complicated, and I think everybody can recognize and know who those individuals are, you have to be very careful not to attribute their chronic, persistent problems to that remote concussion. Because often there are comorbid issues. There are iatrogenic issues related to medication side effects. There are so many additional issues that actually we, as neurologists, can often sort through and get folks back on track. Over.

Moderator:Thank you both. We do just have two pending questions left. The next one: When mental health comorbidities are discussed, it is as if they exist independent of brain activity or have separate parallel courses and contributions to clinical presentation. Same for psychosocial stress and stress reactions like anger and irritability. An interaction model is less frequently discussed where these symptoms may present more severely when the injured brain cannot manage well enough the environmental demands placed on it. Do you have thoughts on this?

Colonel Jamie Grimes:I am just going to jump in—this is Jamie—because I am actually a psychiatrist and a neurologist. And I agree that sometimes we get pedantic and we say, it is a neurological condition or it is a behavioral health condition when it is the same brain manifesting different symptoms. And so I think that is also why we try to address the symptoms that they present with. It is important to make the right diagnosis and render the right care, but I do think that you have to treat the individual holistically. And by addressing individual symptoms, at least you can come up with different strategies to mitigate those symptoms and treat the person holistically.

Sometimes if we get too totalitarian on the diagnosis, we can miss that holistic approach, too. I have been impressed that sometimes it is just actually defining what symptoms they are having and how to mitigate them rather than in some ways treating them as if just because they are behavioral health they do not matter as much. They truly do matter. It is a huge quality of life issue. And that engagement, sort of that partnership of the provider with the patient is really key to focus on what they are presenting with, what is causing their difficulties. But I am definitely a believer of holistic approach. I will turn it over to you, Bev.

Colonel Beverly Scott:Again I would just highlight what was so fantastic about managing and caring for these service members in theater. It was actually a very small core group that dealt with these folks that tended to be more complicated. I know the psychologist and neuropsychologists were across the hall and the psychiatrist was down the hall. And we talked on a daily basis about these complicated folks and between the three or four of us could actually often work together to improve their care. And I think sometimes I feel we did a better job in theater than we do back home in that back home we do not have the psychologists and the psychiatrists working in our neurology areas, so the care becomes somewhat fragmented. And I think we can do better, and I really strongly advocate for a very targeted, individualized approach for each service member that only the individuals that need to be involved, depending on which symptoms and problems the patient is having. And again highlighting that a lot of the problems may not be directly the result of the concussion, in my opinion. Over.

Moderator: Thank you both for those responses. The final question we have: will yoga and other nontraditional approaches such as reiki and acupressure be helpful for treating post-traumatic headaches?

Colonel Beverly Scott:This is Colonel Scott and I treat a lot of headaches, and certainly there is a role for yoga and relaxation therapy, biofeedback, nonpharmacologic approaches, especially in individuals that have frequent or daily headaches. Because in those individuals, one of the biggest problems is overuse of medication, which then leads to development of a secondary headache disorder. We call it analgesic overuse headache. So absolutely, in the appropriate patients some of these other strategies can be extremely helpful.

Moderator:Thank you. Colonel Grimes, would you like to add to that?

Colonel Jamie Grimes:No, I think Bev has articulated it very well that that is a strategy that also can be very successful, and it is identifying those patients where that is also what they would like to pursue. Because at the end of the day, the patient has the decision to make. You are like the coach. You are trying to bring the best evidence to the table, but you need to be a partnership with that patient so that it is something that they want to pursue as well. Over.

Moderator:Thank you very much for both of your responses. That is the final _____ [00:48:03] question we have, so at this time I would like to give both of you the opportunity to make any final comments. We will go ahead and start with you, Colonel Grimes.

Colonel Jamie Grimes:Again, I just want to thank Molly and Bev and Dr. DePalma for inviting us to speak. I really appreciate this opportunity and I think we have made enormous advances on the battlefield for concussion care, just like we have for moderate and severe as well as in strategies in those more grave injuries. It is just that this is the preponderance of the brain injury that we are seeing and to have a standardized system of care has been really a game-changer, especially with this line-leader and medical teamwork that really has helped to foment great care. And I think that is mirrored also in the VA with senior leadership. Mr. Shinseki, the head of the VA, has really been a leader that has emphasized the importance of excellence in care in the VA, so in many ways I feel like this is all along a continuum. Over.

Moderator:Thank you. And Colonel Scott?

Colonel Beverly Scott:Yeah, again, I would like to thank Dr. DePalma and the organizers, and thank the audience for participating in this forum. And I would just like to encourage especially the primary care providers in the audience that if they are caring for some of these individuals with chronic, persistent, complicated symptoms, I really do strongly recommend that you find the right specialist to get involved to help you care for these service members, because they are complicated. 

And I think we can do better, but I think it does take a core group of folks and the right individuals involved to really again identify some of these comorbidities that might be contributing to these chronic presentations. And certainly if I can be of any help, I welcome it. I think my point of contact information I can make sure is available to you so that I certainly welcome phone calls for advice on patient care issues. So thank you.

Moderator:Excellent. Well, thank you both very much for lending your expertise to our audience. We appreciate your taking the time out of your busy schedules to do this. And I also want to thank our audience for joining us today. 

And to our audience members, as you exit today’s session, wait just a moment and a feedback survey will pop up on your screen. Please do complete that as your feedback is what guides what topics we present.

So thank you once again to our speakers and our audience and this does conclude today’s HSR&D Cyber Seminar.

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