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