A New Paradigm of Rehabilitation for a New Generation of Veterans
Micaela Cornis-Pop, Ph.D.Rehabilitation Services, VACO
Outline A new generation of veterans accesses VA
care VA System of Care for polytrauma and TBI
rehabilitation Meeting the TBI rehabilitation needs of the
new generation of veterans Clinical and research data from the
experience of the VA Polytrauma/TBI System of Care
Who Do We Serve: The President’s Commission
Number of deployments 2,200,000 Service members deployed 1,500,000 Air evacuated 37,851 Wounded in action 28,000 Returned to duty within 72 hours 23,270 Time in combat greater than any other time in
military history The new veterans represent 3% of all
veterans who used VA health services in FY2006
OEF/OIF Veterans Utilizing VA Health Care (=205,097 Sept 2001 to March 2007)
87%
13%
3%
53%
23%
21%
67%
12%
11%
10%
49%
51%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Male
Female
Under Age 20
Age 20-29
Age 30-39
Over Age 40
Army
Air Force
Marine
Navy
Active
Reserve/NG
Severely Wounded: The President’s Commission
Seriously injured (TSGLI recipients) 3,082
Traumatic Brain Injuries 2,726
Amputations 644 Serious burns 598 Polytrauma 391 Spinal cord injuries 94 Blind 48
Prevalence of TBI in OEF/OIF
88% due to IED/mortar attack- 33% about the head (Murray & Reynolds, 2005)
97% explosions (65% IED’s, 32% mines)- 53.5% head or neck (Gondusky &Reiter, 2005)
Walter Reed at-risk group, 59% had TBI (Okie, 2005)
At least 20% of wounded had some degree of brain injury (Okie, 2005)
Ft. Carson TBI screening -10-20% positive screens for a one year deployment (DVBIC, 2007)
Multi-Dimensional InjuriesPolytrauma and TBI
Most injuries are from blasts Most blasts are from IEDs
Overpressure/barotrauma
Fragmentation injuries
Blunt trauma
Crush injuries
Thermal/inhalation
Shock wave and brain injury
Biomechanical – Coupled fluid-structures interaction during compression wave propagation in brain parenchyma, inertial shear/deformation of brain tissue, damage to axons, glia, blood-brain barrier (BBB)
Hemodynamic – Blood and pressure distribution in brain, local hemorrhage, edema, hematoma, BBB integrity disruption, increased ICP
Neurobiological – DAI, rise intracellular Ca++, apoptosis
Metabolic – inflammatory response, hypoxia, ischemia
Source: Defense Veterans Brain Injury Center
AGENT OF INJURY SEVERITY OF INJURY
April 30, 2007
Mild Mod Severe Penetrating
Unk
Blast 1,552 162 141 40 60
Bullet 45 18 9 22 3
Fall 191 18 4 1 15
Fragment 121 23 20 42 19
Other/Unk 55 9 8 0 6
Vehicle 158 57 32 0 8
Total 2,122 287 214 105 111
Agent and Severity of TBI (DVBIC data)
Rebuilding wounded lives – A new generation of veterans
A new generation of veteransSpc. Mariela Mason spent the night at her parents' home in Livermore last weekend for the first time since December 2004, when she was hit by a car in Kuwait during her second tour of duty in Iraq. Mason is married and has a 3-year-old daughter, Jaela. She has goals. "The top is to be able to walk again," Mason said. "And to stop stuttering. It used to be bad."
Oakland Tribune, July 31, 2007, by Jennifer Gokhman
A new generation of veterans
Retired Army Sgt. Edward Wade, 27, served in Afghanistan and Iraq
February 14, 2004, IED detonated beside his Humvee
Severe brain injury and loss of right arm. Coma=2 mos.
Inpatient rehabilitation for 8 months Lives with wife, Sarah, in N. Carolina Receives outpatient care, including
cognitive rehabilitation, life-skills coaching, and training for use of the R arm prosthesis.
Ted and Sarah advocate for services for other wounded warriors and family members
Cornis-Pop, M. The ASHA Leader, July 11, 2006
Nine months ago, Marine Lt. Col. Tim Maxwell could barely speak. His right side didn't work - none of it from his vision down to his foot. Thoughts got jumbled in his brain. His left arm was almost useless.
But Maxwell isn't the kind of guy who gives up easily.
It's probably why Maxwell, 40, is where he is today - a Marine still on active duty looking for ways to improve himself and the Marine Corps.
Devil Dog Marines Blog, March 2006
A new generation of veterans
Wounded in theater – combat environment
High arousal Sleep deprivation “Fog of war” - “deficits observed
greater than…alcohol intoxication or treatment with sedating drugs” Lieberman et al., 2005
Cumulative effect of repeated exposures to blasts
Wounded in theater – care environment
Stabilization in the combat environment
Far from family Adjusting to non-combat
environment while healing and separated from unit
Survivor guilt
Wounded in theater – life stage changes
Drastic change in career path Trained in combat skills Cognitive deficits, seizures lead to
inability to perform combat tasks Often also unable to translate these
skills to civilian employment (Police, FBI, etc)
Loss of identity (within unit, branch of service)
Wounded in theater – physical disfigurement
Due to use of explosive devices, shrapnel and burn injuries to face are more common
Also, early surgical interventions which are potentially life saving leave significant bony defects
VA System of Care for Polytrauma and Brain Injury Rehabilitation
February 05: Four Polytrauma Rehabilitation Centers
December 05: 21 Polytrauma Network Sites
VA TBI and Polytrauma System of Care implementation
March 07 75 Polytrauma Support Clinic Teams, 54 Polytrauma Points of Contact
1992: VA DVBIC TBI Lead Centers Selected
July 06: Polytrauma Telehealth Network
April 07: TBI Screening
New paradigm of rehabilitation care
Integrated system of care with 100 specialized rehabilitation sites distributed across the country
Services provided by specialized interdisciplinary rehabilitation teams
Emphasis on care coordination and care management
Support caregivers and military identity Provide life-long care and access to a continuum
of services Polytrauma Telehealth Network Advanced rehabilitation practices and equipment
with the goal to achieve community re-integration
Integrated Rehabilitation Care
Polytrauma Rehabilitation Center
Brain Injury Program
PainManagement
PTSDProgram
RehabilitationAnd
OrthopedicPrograms
Audiology Program
AmputeeProgram
Head Injuries
Pain
Emotional Shock
Soft Tissue Trauma
Amputations
Hearing Loss
Blind Rehabilitation
Program
Vision Loss
Spinal Cord InjuryProgram
Cord injury
23
Responding to the needs of the OIF/OEF veterans Endurance, strength, and fitness impact
rehab potential and expectations for rehabilitation
Responding to the needs of the OIF/OEF veterans
Lifestyle changes may be necessary Military career may not be an option Role within the family needs to be redefined Need to incorporate healthcare concerns into
lifelong plans
Responding to the needs of the OIF/OEF veterans
Focus on becoming independent is important, but may be hindered by injuries Voc Rehab / Independent Living Family Involvement
Young veterans are dealing with issues of loss that are not typical of this age group
Level of maturity and experience is uneven
Clinical and Research Data
TBI inpatient rehabilitation –The Palo Alto experience
138 patients seen at the Polytrauma Rehabilitation Center
Standardized assessments at admission, and 1 and 2 years post admission
Supported by Defense and Veterans Brain Injury Center grant
Lew HL, et al. Persistent problems after TBI, JRRD, April 2006
Traumatic Brain Injury
Attention/ConcentrationProcessing speed
Memory disturbanceExecutive dysfunction
Safety JudgmentDepression
AnxietyPTSD
IrritabilityDisinhibition
Self-careMoney management
EmploymentRecreational activities
Community accessPain
Motor weaknessGait abnormalitiesDizziness/Vertigo
Seizures
CognitiveDisturbanc
e
Community Integration
Issues
EmotionalDisturbance
PhysicalDisturbance
Post-InjuryPsychosocial
Factors
Pre-InjuryFactors
Neurobehavioral sequelae of TBI
TBI sequelae at one and two years post injury
Initial evaluation: 90% or more had at least 1 problem in each category
2 yrs after discharge: more than 75% continued to have multiple problems
Combat vs. non-combat TBI sequelae
Evaluation of 66 consecutive TBI patients since the onset of OEF/OIF
All completed tours of duty in Iraq or Afghanistan
38 sustained TBI in combat (majority: blast injury)
28 sustained TBI in non-combat situations (majority: MVA outside war-zone)
13-item inventory of post-concussive symptoms
Symptom frequency: higher in combat-injured TBI
Problems reported by outpatients with suspected TBI1
Symptoms % patients N=166)
Sleep Disturbances 84%
Irritability 84%
Attention/Concentration 79%
Mood swings 76%
Memory problems 76%
Anxiety 74%
Headaches 71%
Light/noise sensitivity 69%
Depression 66%
Visual disturbances 66%
Tinnitus 58%
Excessive fatigue 58%
Balance problems 42%
Dizziness 40%
Lew HL, et al. Defining Characteristics of Returning Military in a VA PNS, JRRD (in press)
Conclusions
A new paradigm of rehabilitation care is necessary to address the complexities of blast related and combat related TBI
Combat environment leads to different spectrum of behavioral manifestations of TBI
Need for evidence based guidelines for treating combat TBI and associated trauma
Identify factors of resilience Monitor the effects of aging on TBI sequelae