POST-DEPLOYMENT SYNDROME (PDS)

•POST-TRAUMATIC STRESS DISORDER (PTSD)

•MILD TRAUMATIC BRAIN INJURY (MTBI)
•CHRONIC PAIN
•DEPRESSION
•GENERALIZED ANXIETY DISORDER (GAD)
OPERATION ENDURING FREEDOM (OEF) AND
OPERATION IRAQI FREEDOM (OIF)
•2.4 million military personnel deployed to Iraq and Afghanistan
•60% of injured OEF/OIF soldiers presented symptoms of TBI
•Signature injury of OEF/OIF service members
• Symptoms may take days/weeks to appear
• Often overlooked
•High co-prevalence of chronic pain and PTSD
POST-DEPLOYMENT SYNDROME A.K.A
•COMBAT STRESS
•BLAST INJURY
•POST-CONCUSSIVE SYNDROME (PCS)
•P3 OR P4 (POLYTRUMA, POST-TRAUMATIC STRESS
SYNDROME, PAIN, POLY-SUBSTANCE ABUSE)
•POST-DEPLOYMENT MULTI-SYMPTOM DISORDER (PMD)
POST-DEPLOYMENT SYNDROME (PDS)
•Nearly 1 in 5 OEF/OIF service members deployed to
Iraq or Afghanistan returned with s/sx of PDS
•Single most common complaint: Pain
•42% of sample reported concurrent PTSD, mTBI symptoms
•Less symptom improvement with tx
POST-DEPLOYMENT SYNDROME: S/SX
• SLEEP DISTURBANCE • MUSCULOSKELETAL DISORDERS
• IRRITABILITY AND LOW FRUSTRATION • AFFECTIVE DISTURBANCE
TOLERANCE • APATHY AND PERSONALITY CHANGE
• CONCENTRATION, ATTENTION AND • SUBSTANCE MISUSE
MEMORY PROBLEMS
• ACTIVITY AVOIDANCE
• FATIGUE • RELATIONSHIP CONFLICT
• HYPERVIGILANCE • EMPLOYMENT OR SCHOOL
• HEADACHES DIFFICULTIES
USUAL MEDICAL TREATMENT MODELS
DIAGNOSIS
• History of concussion
• Symptoms persisting greater than 30 or 60 days
MRI: UNREMARKABLE
• Test for hematomas
• Rule out head injury complications from more severe trauma
INFLAMMATORY MARKERS
• Lack specificity
• Not currently useful in identification of TBI or PDS
PROGNOSIS
•Traditional models of care have failed to meet clinical
need, improve quality of life
•Less symptom improvement after treatment
•Few resources on how to best manage PDS
POST-DEPLOYMENT REHABILITATION
EVALUATION PROGRAM (PREP) JAHVH
• Inpatient integrated mental health & rehabilitative treatment model
• Specializes in evaluation, treatment of complex multifactorial symptoms
associated with mTBI and post-deployment adjustment difficulties
• Designed to address unique behavioral health needs of OEF/OIF
returnees
• Provides coordinated services with specialty providers and treatment
programs not readily available in military or community settings
POST-DEPLOYMENT REHABILITATION
EVALUATION PROGRAM (PREP) JAHVH
PROGRAM REFERRALS
•Decrease functional disability
•Improve coping ability
•Reintegrate into community Return to Duty
GENERAL NUTRITION RECOMMENDATIONS
CHO Protein Fat Calories
Acceptable Macronutrient Distribution Range
General Population/ Sedentary Military 45-65% 10-35% 20-35%
50-55% <30%
Athlete/Active Military
4-8 g/kg 0.8-1.6 g/kg
Adequate Intake
General Population/ Sedentary Military 130 g 46-56 g 2000
Athlete/Active Military 5000
Tactical Performance/SOF Nutrition Recommendations
Performance Level Dependent 3-8 g/kg 0.8-2 g/kg 0.9-1 g/kg 45/kg FFM
 SUPPLEMENT USE IN MILITARY
Any MVI Any Vit C Vit E Ca Fe PRO PRO Creatine Sports Sports
Vit/ or AA Drinks Bars
Min

Elite Force 76% 37% 15% 9% 20% 20% 20% 39% 19%
Women 65% 40% 29% 15% 7% 14% 12% 25% 3%
Men 55% 32% 18% 15% 8% 9% 9% 22% 7%

Knapik J, Steelman R, Hoedebecke S, Farina E, Austin K, Lieberman H. A systematic review and meta-analysis on the prevalence of dietary supplement use by military personnel. BMC Comp Alt Med. 2014;14:143.
 NUTRITION MGMT POST-DEPLOYMENT
HUMAN PERFORMANCE INSTITUTES PERFORMANCE/SPORTS NUTRITION RD
•
Strategic nutrition planning
•
Food service integration
•
Day-to-day guidance

THOR3 TACTICAL HUMAN OPTIMIZATION, RAPID REHABILITATION RECONDITIONING

•SF human performance, exercise rehabilitation program, Fort Bragg, NC
•More resilient SOF peak physical shape for injury prevention, return to action
NUTRITION ASSESSMENT
ANTHROPOMETRICS
• Body compartment estimates
BIOCHEMICAL DATA
• Visceral protein and
hematological assessments
• Liver and kidney function
• Inflammation and hydration
• Body weight trends
• Indirect calorimetry
• Urine Urea Nitrogen
• Electrolyte and renal profile
• Vitamin and mineral status
NUTRITION ASSESSMENT
FOOD AND NUTRITION RELATED HISTORY
•Diet recall and supplement use
•Client History
NUTRITION FOCUSED PHYSICAL EXAM
•Eyes, skin, hair, nails and oral cavity
•Symptoms of gastrointestinal disturbance
NUTRITION INTERVENTION
NUTRITION EDUCATION, COUNSELING BASED ON ASSESSMENT FINDINGS
• Nutrition relationship to health/disease
• Reference standards for intake of specific nutrients
• Results interpretation
• Recommended modifications
NUTRITION COUNSELING STRATEGIES
• Self-monitoring and goal setting
• Collaboration with other providers
• Referral may be necessary
NUTRITION MONITORING AND EVALUATION
•Intake of energy and macronutrients
compared to recommendations
•Physical signs of micronutrient deficiency
and toxicity
GENERAL CASE INFORMATION: DT
AGE: 33 years
HEIGHT: 72 in [182.9 cm]
WEIGHT: 233.8 lbs [106.3 kg]
OCCUPATION: Active Duty Army Ranger
Platoon Sergeant
EDUCATION: BS Political Science
GOALS: MBA, Life Coach Gym
MARITAL STATUS: Married 7 years
CHILDREN: Son (4yrs) , Daughter (3 yrs)
HOME: Alabama
HOMETOWN: Arizona
HISTORY OF CONCUSSION
• Static line jump
• IED vehicle explosion
• 16 block C4 plastic explosives
• Combative training
• Marine, SOF Reconnaissance missions
• August 2016: 160-pound crate, LOC
• Develop stingers, paralysis of left arm
• February 2017: Deployment
• Paralysis near accident
• September 2017 Evaluation: Damage
from C5/6 to T1/2, MRI unremarkable
• C6/7 anterior cervical discectomy &
fusion with left iliac crest bone graft
• Stingers did not resolve
• Treatment at EXOS Human Performance
Facility
PRESENT ADMISSION
• January 16, 2018: DT screened and accepted to the PREP program
• Purpose: “improve clinical symptoms of TBI, headaches, dizziness/vertigo,
memory loss, insomnia, anxiety and improve overall ability to perform his job”
• Treating Physician: Staff Physiatrist Bryan Merritt, M.D.
• Primary Diagnosis: mTBI
• Secondary Diagnoses: chronic pain syndrome, tinnitus, hearing loss, inhalation
exposures, Attention Deficit Hyperactivity Disorder.
• Estimated Length of Stay: 2-4 weeks
TREATMENT PLAN CONSULTS
• Psychology
DAILY
• Rehabilitative nursing • Neuropsychology
• Psychiatry
• Physical Therapy • Speech pathology
• Occupational Therapy • Audiology
• Speech Therapy •
•
Polytrauma optometry
Recreational therapy
SUPPLEMENTAL • Physical therapy
• Social welfare • Occupational therapy
• Pain kinesiotherapy
• Recreation therapy • Respiratory therapy
WEEKLY medical team staff conference
• Electroencephalography
• Electrocardiogram
DIETITIAN CONSULT
• January 17, 2018 Dietitian consult: “32y/o Active Duty Ranger injured in 2015 by
being impaled on stake during a parachute jump. Surgeon removed seven feet of
large intestine and six to seven feet of small intestine. He has some very specific
dietary needs. Eats a larger than usual amount of protein and fresh vegetables;
minimal carbohydrates and fat. Please evaluate.”
• Duplicate consult: “Patient has history of colostomy with reversal in 2015 due to
being Impaled during training exercise. Would like high protein, low carbohydrate
diet with minimally processed foods; has frequent diarrhea approximately six times
per day. Also works out six times per week and would like double portions.”
DIETITIAN CONSULT
•Consult received by the Rehab Dietitian for diet change request
•Follow-Up Encounter by intern:
• DT dateailed impalement by six-foot stake during a parachute jump
• Transported to a local Korean teaching hospital
• Septic shock 2-3 weeks following surgery
• Congenital intestinal malrotation
NUTRITION ASSESSMENT
CH: 33 yo M Active Duty Army Ranger with hx mTBI, intestinal trauma, resection
FH: Restricts carbohydrate, fat consumption; avoids all processed foods, bread,
rice; eats plain vegetables with 8-10 oz meat; protein shakes between meals.
Purchases rotisserie chicken from grocery store (unable to consume foods provided
on diet ordered upon admission)
Estimated daily intake: 2600-3200 kcals; 250-300 g protein (or 1.5 g/lb ABW).
Estimate from 24 hour dietary recall: 3000 kcals; 311 g protein
Supplements: Creatine (20 g/ day), multivitamin, fish oil, probiotics
 NUTRITION ASSESSMENT
ANTHROPOMETRIC MEASUREMENTS
• UBW : 256 lbs Pre-Impalement
• 1 month: 201 lbs (21.5% decrease in body weight) Post-Impalement
• 2 months: 188 lbs
• UBW: 233 lbs BMI 31.8

BIOCHEMICAL DATA, MEDICAL TESTS/PROCEDURES

• Elevated: UUN (21 g N; ref range 10-20 g), ALT (47 U/L; ref range 11-44U/L)
• WNL: Cr, BUN, Glu, Na, K, Cl, Ca, Vit B12, D, folate, D, AST, anion gap, albumin,AlkPhos
• Low: platelets, neutrophils, lymphocytes, total WBC
NUTRITION ASSESSMENT
NUTRITION FOCUSED PHYSICAL FINDINGS
•BM: 6-8/day, 5-10 minutes after eating
•GI discomfort, fecal urgency with CHO and high fat consumption
•Undigested food particles, oil in stool, no hematochezia
•No nausea, vomiting or constipation
•No overt signs or symptoms of micronutrient deficiency
 NUTRITION ASSESSMENT
HAND GRIP: 82.5kg (8 SD above mean) BIOELECTRICAL IMPEDANCE ANALYSIS:
TRICEPS SKINFOLD: 5-10th percentile • RESISTANCE: 286.1
• REACTANCE: 44.1
MID ARM CIRCUMFERENCE: 90-95th • PHASE ANGLE: 8.8 degrees (w/in avg)
percentile • FAT% OF TOTAL WEIGHT: 8.0%
ARM MUSCLE AREA: >95th percentile • TOTAL BODY WATER: 72.4 L (Above avg
by 19.4L; Ref Range 37.9 - 53.0 L)
NUTRITION ASSESSMENT
NUTRITION PRESCRIPTION
Estimated Energy Needs: 3800-4200 kilocalories/day
• RMR (Indirect calorimetry): 2860 kilocalories/day
• Activity Factor 1.5 (conservative)
Estimated Protein Needs: 160 grams per day
• UUN: 21 grams
• Margin of Error: 4 grams
NUTRITION DIAGNOSES
1. Altered GI function RT colon/small intestine resection AEB Service Member reports
of frequent stools and reports of oily stool when consuming high fat foods.
2. Imbalance of nutrients RT consumption of high-dose nutrient supplements and food
faddism AEB diet recall estimating 40% of calories from protein (2.8 g/kg), 40%
from fat and 20% from carbohydrates with inadequate intake of potassium and fiber
3. Food- and Nutrition-Related Knowledge Deficit RT lack of prior nutrition-related
education AEB no prior education provided on how to apply food and nutrition
related information and reports of previous attempts to learn information.
NUTRITION INTERVENTION
HONORED REQUEST FOR HIGH CALORIE, HIGH PROTEIN DIET
NUTRITION EDUCATION
• Recommendations for Protein, CHO and fat intake
• Types of Fiber found in foods
• Results Interpretation: Body compositions analysis
• Adequate intake of vitamins and minerals through foods vs supplements
• Nutrition relationship to health and disease
• Goal setting (CHO, PRO intake goals not implemented during inpatient stay
d/t food preference, facility offerings)
NUTRITION MONITORING AND EVALUATION
INTAKE
Realistic Short Term Goals
•Increase CHO to 35% of total calories
•Decrease protein to 25% of total calories
Long term goals
•CHO 45-60% total calories
•Protein 1.6 grams per kg ABW
NUTRITION MONITORING AND EVALUATION
Vitamin B12
• Potential reduced absorptive capacity
• Recommended reduction in protein intake
Nitrogen balance
• ST: <20, positive
• LT: <6, positive
Weight/BMI trends
Additional monitors based on recommended fecal fat analysis, PT/INR,
and serum retinol tests
NUTRITION PROBLEM STATUS UPDATE

1. Altered GI function…………………………………………….….UNRESOLVED
2. Imbalance of nutrients…………………………………………..UNRESOLVED
3. Food- Nutrition-Related Knowledge Deficit…….IMPROVEMENT SHOWN
DISCUSSION OF OUTCOMES
•Eager to learn, asks questions
•RD referral for diet request not ‘met’ by the standard diet order
•Healthy Diet: 2150 calories, 80 grams of protein per day
•High Calorie High Protein Diet: 3000 kcals, 150 g protein/day
•Selection and food preferences may interfere with intake goals
•PRO supplementation limits variety
•Concern for adequate intake macro/micronutrients
FOLLOW UP NUTRITIONAL CARE
REMAINING BOWEL ANATOMY
• Gastrointestinal adaptation
• Tolerance of dietary recommendations
MALABSORPTION TESTS
• Qualitative fecal fat
• Serum retinol profile
• Prothrombin time/International normalized ratio (PT/INR)
REDUCED BIOSYNTHESIS
• Microbiome • Vitamin K • SCFA
SUMMARY
MEDICAL PROGNOSIS
•Phase I Evaluation and Treatment in the PREP program: Complete
•Phase II Treatment: LOA, return to duty
NUTRITIONAL PROGNOSIS
•Operations may limit adherence to dietary recommendations
•High protein consumption in caloric deficit to preserve LBM
•Muscle protein synthesis limited >1.5 g protein/kg body weight
•Continued education reinforcement with GI adaptation/tolerance
EFFECTIVENESS
•Education materials consider needs, barriers to learning
•Cognitive
•Visual
•Auditory
•Method of dietary assessment
•Program LOS
•Opportunities for evaluation
•Education reinforcements
OTHER CONSIDERATIONS
•High total body water from BIA
•Possible fluid overload status
•Low white blood cell counts
•Borderline low sodium, vitamin D levels
•Presence of inflammation
•Collaboration with Human Performance Dietitian
•Responsible administration of hospital resources
•Pre-deployment nutrition education
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