New Toolkit Advises Providers on Care of mTBI Patients With Additional Conditions Such as PTSD, Pain

by U.S. Medicine

May 20, 2011

Use short, simple sentences. Summarize key points throughout the appointment.

These are among the tips that a recently released toolkit recommends to providers treating military personnel with mTBI who are also suffering from co-occurring health conditions.

The care of mTBI patients can be significantly complicated when they also have PTSD, chronic pain or other conditions. While there are Clinical Practice Guidelines (CPGs) specific to treating and managing concussions, PTSD and chronic pain are all separate issues.

How are providers supposed to cross reference three clinical practice guidelines at the same time?” asked Miguel Roberts, PhD, clinical guidelines chief for DCoE’s Psychological Health Clinical Standards of Care directorate. “That is a significant challenge for providers to hold those three very large documents in their head simultaneously.”

A June 2009 consensus conference held by VA on concussion, PTSD and pain suggested that there was a need to develop clinical support tools to bring the three guidelines together in a way that clinicians could actually use.

As a result the toolkit, Co-occurring Conditions Toolkit: Mild Traumatic Brain Injury and Psychological Health, was developed by DCoE and other entities to help primary-care providers with the challenge of managing servicemembers and veterans with co-occurring conditions.

Geared to primary-are providers, the toolkit addresses the CPGs for the co-occurring conditions of concussion, PTSD, depression, chronic opioid therapy and substance use disorder. The toolkit notes that it serves as a guide to address areas of conflict that can arise among these CPGs when treating a patient presenting with multiple conditions.

“Our idea was that we would develop a guide or a toolkit for primary care providers to initiate the appropriate symptom management of these co-occurring complex patients,” said Roberts. “Our goal is to get patients started on the right steps of treatment.”

Comorbid Conditions

Roberts spoke on the toolkit during a webinar held by DCoE on mTBI and co-occurring conditions. His colleague, Alison Cernich, PhD, acting senior VA liaison for TBI at DCoE’s Traumatic Brain Injury Clinical Standards of Care directorate, said the challenge for providers is that most military patients personnel do not present with mTBI alone.

In one 2009 study she cited, 81.5% of the veterans presenting to a polytrauma network site had more than one diagnosis, and 42.1% had three co-occurring diagnosis, including pain, PTSD and post-concussion syndromes.

“As we start to really understand the literature and know that this is not necessarily a single occurring diagnosis in our returning veterans, there is definitely a need to consider how we are approaching that servicemember or veteran with a traumatic brain injury, how to really consider and evaluate some of the co-occurring psychological health difficulties that veteran may present with. And then to move forward to appropriate evaluation and treatment,” she said.

For example, research has shown that those with mTBI also often have PTSD, she said. Recent studies of individuals who have persistent symptoms following an mTBI also suggest that the presence of PTSD may prolong the duration of mTBI symptoms and make the symptoms worse.

“So if you are talking about looking at treatment, it would be best to consider these in a co-occurring fashion and understand that one of them may make the other one worse and vice versa,” she said.

“With a co-occurring treatment, if we can try to improve those simultaneously, we may have better treatment outcomes.”

The toolkit states that given the prevalence of co-occurring conditions, a holistic approach to care should be used. It also recommends that because this patient population is at high risk for polypharmacy, which may lead to significant drug-drug interactions, using non-pharmacological approaches is critical, where indicated and appropriate.

The toolkit is not intended to be used a diagnostic tool, it states, but rather to assist in decision-making.

No One Size Fits All

Frederick Flynn, MD, medical director of the Traumatic Brain Injury Program at Madigan Army Medical Center, gave an overview of the TBI program at MAMC. He said the new toolkit for providers is an outstanding resource for care for mTBI patients with co-occurring disorders but even with the toolkit, it is important to remember that there is no “one size fits all approach” to treatment and management to patients.

The TBI program at MAMC includes 26 staff members with multiple specialties. The first step in caring for mTBI patients, Flynn said, is to validate the injury they have suffered. “We reiterate that mild TBI is a clinical definition and not a judgment of the distress that soldier is experiencing,” he said. “We also emphasize that, although we validate their history of mild TBI, many of the symptoms they may be experiencing may be due to a different etiology. We do try to instill an expectation of recovery and also emphasize the soldier’s role in their own recovery.”

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