Transcript Document

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
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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
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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)
Reserve/NG
Active
51%
49%
Navy
10%
Marine
11%
Air Force
12%
Army
67%
Over Age 40
21%
Age 30-39
Age 20-29
23%
53%
Under Age 20
3%
Female
13%
Male
87%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Severely Wounded:
The President’s Commission
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Seriously injured (TSGLI recipients)
Traumatic Brain Injuries
Amputations
Serious burns
Polytrauma
Spinal cord injuries
Blind
3,082
2,726
644
598
391
94
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Prevalence of TBI in OEF/OIF
 88% due to IED/mortar attack- 33% about the
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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 Injuries
Polytrauma and TBI
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Most injuries are from blasts
Most blasts are from IEDs
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Overpressure/barotrauma
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Fragmentation injuries
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Blunt trauma
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Crush injuries
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Thermal/inhalation
Shock wave and brain injury
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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
Agent and Severity of TBI (DVBIC data)
AGENT OF INJURY
Mild
Blast
SEVERITY OF INJURY
Mod
Severe
Penetrating
Unk
1,552
162
141
40
60
45
18
9
22
3
Fall
191
18
4
1
15
Fragment
121
23
20
42
19
Other/Unk
55
9
8
0
6
158
57
32
0
8
2,122
287
214
105
111
Bullet
Vehicle
Total
April 30, 2007
Source: Defense Veterans Brain Injury Center
Rebuilding wounded lives –
A new generation of veterans
A new generation of veterans
Spc. 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
A new generation of veterans
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
Wounded in theater –
combat environment
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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
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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
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Drastic change in career path
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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
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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
VA TBI and Polytrauma System
of Care implementation
April 07: TBI Screening
March 07 75 Polytrauma Support
Clinic Teams, 54 Polytrauma Points
of Contact
July 06: Polytrauma Telehealth Network
December 05: 21 Polytrauma Network Sites
February 05: Four Polytrauma Rehabilitation Centers
1992: VA DVBIC TBI Lead Centers Selected
New paradigm of rehabilitation care
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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
Audiology
Program
Spinal Cord Injury
Program
Hearing
Loss
Cord
injury
Polytrauma
Rehabilitation Center
Head
Injuries
Brain Injury
Program
Pain
Amputations
Soft
Tissue
Trauma
Vision
Loss
Emotional
Shock
Pain
Management
Amputee
Program
Rehabilitation
And
Orthopedic
Programs
Blind
Rehabilitation
Program
PTSD
Program
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Responding to the needs of the
OIF/OEF veterans
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Endurance, strength, and fitness impact rehab
potential and expectations for rehabilitation
Responding to the needs of
the OIF/OEF veterans
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Lifestyle changes may be necessary
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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
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Focus on becoming independent is
important, but may be hindered by injuries
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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
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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
Neurobehavioral sequelae of TBI
Pre-Injury
Factors
Cognitive
Disturbanc
e
Emotional
Disturbance
Traumatic
Brain Injury
Post-Injury
Psychosocial
Factors
Community
Integration
Issues
Physical
Disturbance
Attention/Concentration
Processing speed
Memory disturbance
Executive dysfunction
Safety Judgment
Depression
Anxiety
PTSD
Irritability
Disinhibition
Self-care
Money management
Employment
Recreational activities
Community access
Pain
Motor weakness
Gait abnormalities
Dizziness/Vertigo
Seizures
TBI sequelae at one and two
years post injury
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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
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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
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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