Current Neuropsychological Perspectives on Assessment and Treatment of TBI in Returning Veterans
TBI in Returning Veterans: DoD/VHA System of Care for ... · TBI in Returning Veterans: DoD/VHA...
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TBI in Returning Veterans: TBI in Returning Veterans: DoD/VHA System of Care for DoD/VHA System of Care for
Comprehensive TreatmentComprehensive Treatment
Rodney D. Vanderploeg, Ph.D., ABPPRodney D. Vanderploeg, Ph.D., ABPP--CNCNTampa VAMCTampa VAMC
Louis French, Psy.D.Louis French, Psy.D.WRAMCWRAMC
Key Iraq wound: Brain traumaBy Gregg Zoroya, USA TODAY A growing number of U.S. troops whose body armor helped them survive bomb and rocket attacks are suffering brain damage as a result of the blasts. It's a type of injury some military doctors say has become the signature wound of the Iraq war.
Shaun Radhay , a Marine, suffered brain damage and other injuries in a mortar blast.
By H. Darr Beiser, USA TODAY
American Congress of Rehabilitation American Congress of Rehabilitation Medicine Criteria for Mild TBIMedicine Criteria for Mild TBI
Traumatically induce physiologic disruption of brain Traumatically induce physiologic disruption of brain function, indicated by at least one of the following:function, indicated by at least one of the following:
Any period of loss of consciousnessAny period of loss of consciousnessAny loss of memory for events immediately before or Any loss of memory for events immediately before or after the accidentafter the accidentAny alteration in mental state at the time of the accidentAny alteration in mental state at the time of the accidentFocal neurologic deficits that may or may not be Focal neurologic deficits that may or may not be transient transient
Severity of the injury does not exceed: Severity of the injury does not exceed: Loss of consciousness of 30 minLoss of consciousness of 30 minGCS score of 13GCS score of 13--15 after 30 min15 after 30 minPosttraumatic amnesia of 24 hr Posttraumatic amnesia of 24 hr
Criteria for Severity of TBICriteria for Severity of TBI
PTA > 7daysPTA > 7daysPTA PTA << 7days7daysPTA PTA << 24hr24hr
GCS 3GCS 3--88GCS 9GCS 9--1212GCS 13GCS 13--1515
LOC > 6 hours LOC > 6 hours withwithabnormal CT abnormal CT &/or MRI&/or MRI
LOC LOC << 6 6 hours withhours withabnormal CT abnormal CT &/or MRI&/or MRI
LOC LOC << 30 min 30 min with with normal CT &/or normal CT &/or MRIMRI
SevereModerateMild
Severe Brain Injury Severe Brain Injury
Consequences of TBIConsequences of TBI
CognitiveCognitiveAttentionAttentionInformation processing Information processing (speed & efficiency)(speed & efficiency)
Memory and LearningMemory and LearningExecutive FunctionsExecutive Functions•• Problem solving, planning, Problem solving, planning,
insight/awareness, set shifting, sequencinginsight/awareness, set shifting, sequencing
Consequences of TBIConsequences of TBIBehavioralBehavioral--emotionalemotional
Affect Regulation: apathy, agitation, Affect Regulation: apathy, agitation, aggressionaggressionIrritabilityIrritabilityImpulsivityImpulsivityDepression, AnxietyDepression, AnxietySocial PragmaticsSocial Pragmatics
Cognitive and behavioral impairments Cognitive and behavioral impairments are the most disabling longare the most disabling long--term, more term, more so than physical injuriesso than physical injuries
Treatment ConsiderationsTreatment Considerations
Treatment varies based upon:Treatment varies based upon:Severity of injurySeverity of injuryTime since injuryTime since injuryConstellation of impairmentsConstellation of impairments
Wall of Air (Primary) Blast Wave (Primary)
Flying Debris(Secondary)
Displacement (Tertiary)
Collapse Building (Quaternary)
IEDIED’’s are theWeapon of Choice: s are theWeapon of Choice: OneOne Explosion/Blast has Explosion/Blast has
MultipleMultiple Mechanisms of InjuryMechanisms of Injury
TBI in Combat SettingsTBI in Combat Settings
New mechanism of injuryNew mechanism of injury
New constellation of injuriesNew constellation of injuries
New challenges for TBI rehabilitationNew challenges for TBI rehabilitation
Requires new expertise and new Requires new expertise and new model of caremodel of care
WRAMC Patients WRAMC Patients (1/2003 (1/2003 -- 4/2005)4/2005)
Patients with severe enough injuries Patients with severe enough injuries toto be evacuated be evacuated fromfrom the military the military theatertheaterBlastBlast--Related injury most common = Related injury most common = 68%68%Of all blast patients screened, Of all blast patients screened, 59%59% had head had head injuryinjury89% had closed head injury89% had closed head injury
Severity: Severity: 56.3%56.3% modmod--severe; severe; 43.7%43.7% mildmild
PainPain 95%95%BrainBrain 77%77%WoundsWounds 65%65%Ortho Ortho 46%46%Nerve Nerve 38%38%PsychiatricPsychiatric 35%35%VisualVisual 31%31%LungLung 31%31%IInfectionsnfections 27%27%HearingHearing 15%15%AmputeeAmputee 12%12%
War Injured Patients: War Injured Patients: Multiple Impairments (Tampa VAMC data)Multiple Impairments (Tampa VAMC data)
Average of Six Impairments
Level V MTFWRAMCNMMCBAMC
Level I – First AidLevel II ForwardSurgical team
Level III CSHLevel IV Landstuhl
Military EvacuationMilitary EvacuationInternational TrackingInternational Tracking
DoD Levels of CareDoD Levels of Care
Level ILevel I –– Basic Level of Care (First Aid; medic)Basic Level of Care (First Aid; medic)Level IILevel II –– At least one Emergency MedicineAt least one Emergency Medicine--trained physician and the basic equipment that trained physician and the basic equipment that allows the patients to be treated according to allows the patients to be treated according to standards of practice found in most CONUS standards of practice found in most CONUS Emergency Departments Emergency Departments Level IIILevel III –– That plus neuroimaging and specialty That plus neuroimaging and specialty evaluation (neurosurgery and neurology) evaluation (neurosurgery and neurology) Level IVLevel IV –– Major Medical Center with all trauma Major Medical Center with all trauma and specialty care LRMC (in this conflict)and specialty care LRMC (in this conflict)
VHA - Polytrauma System of Rehabilitation Care
VHA VHA -- Polytrauma System of Polytrauma System of Rehabilitation CareRehabilitation Care
A New Kind of Care in a New Era of Causalities
VHA Polytrauma: DefinitionVHA Polytrauma: Definition
Trauma to several body areas or Trauma to several body areas or organ systemsorgan systems
Occur at the same timeOccur at the same time
One or more is life threateningOne or more is life threatening
Polytrauma Centers (4)
Polytrauma Networks (22)
Polytrauma Support Clinics (76)
Polytrauma Case Management
Goal: Get HomeGoal: Get Home
Polytrauma Rehabilitation System of CarePolytrauma Rehabilitation System of Care(National Tracking)(National Tracking)
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Palo Alto
1919 2323
1818
1616
2020
77
99
1515
66
2121
1717
11
2222
88
441111
221212
1010 55
33
Tampa
Minneapolis
Richmond
Four Polytrauma Rehabilitation CentersMinneapolis
Richmond
Tampa
Pal AltoVISN Boundary
Network of CareEasternSouthernMidwestWestern
^ Lead Center
VISN BoundaryNetwork of Care
EasternSouthernMidwestWestern
^ Lead Center
VHA Polytrauma Rehabilitation Centers VHA Polytrauma Rehabilitation Centers (PRCs) Level I(PRCs) Level I
““Brain Injury PlusBrain Injury Plus””
Brain injury drives the care processBrain injury drives the care process
Integrate care for complex polytrauma in single Integrate care for complex polytrauma in single location location ---- simultaneous tx of multiple injuriessimultaneous tx of multiple injuries
Higher level of medical acuityHigher level of medical acuity
Sequence and integrate treatment to meet Sequence and integrate treatment to meet patient needpatient need
Coordinated team effort with expanded team of Coordinated team effort with expanded team of consultantsconsultants
Interdisciplinary Team and Interdisciplinary Team and Interdisciplinary Rehab ApproachInterdisciplinary Rehab Approach
Rehab Medicine physicianRehab Medicine physicianRehab nurses (primary nurse model)Rehab nurses (primary nurse model)Rehabilitation PsychologistsRehabilitation PsychologistsNeuropsychologistsNeuropsychologistsPhysical, Occupational, Recreational, and Physical, Occupational, Recreational, and Vocational TherapistsVocational TherapistsSpeech TherapistsSpeech TherapistsSocial WorkersSocial WorkersCase Managers (including longCase Managers (including long--term)term)
Extensive Team of ConsultantsExtensive Team of ConsultantsAnesthesiologyAnesthesiologyAudiologyAudiologyChaplin ServicesChaplin ServicesDentistryDentistryDriver RehabilitationDriver RehabilitationGastroenterologyGastroenterologyGeneral SurgeryGeneral SurgeryInfectious DiseaseInfectious DiseaseMedicineMedicineNeurologyNeurologyNeuroNeuro--ophthalmologyophthalmologyNeurosurgeryNeurosurgeryNutritionistNutritionist
OptometryOptometryOral and Maxillofacial Oral and Maxillofacial SurgerySurgeryOrthopedicsOrthopedicsOrthoticsOrthoticsOtolaryngologyOtolaryngologyPharmacyPharmacyPlastic SurgeryPlastic SurgeryProstheticsProstheticsPsychiatryPsychiatryPulmonologyPulmonologyRadiologyRadiologyUrologyUrologyVocational SpecialistVocational Specialist
Inpatient Acute RehabilitationInpatient Acute Rehabilitation
33--5 hours of therapies per day (OT, PT, 5 hours of therapies per day (OT, PT, SP, Recreational, Psychology)SP, Recreational, Psychology)Average length of stay 1Average length of stay 1--3 months3 monthsTherapies include community outings Therapies include community outings planned and organized by the TBI patients planned and organized by the TBI patients together with the therapiststogether with the therapistsCase management begins before patients Case management begins before patients arrive and includes contacting familiesarrive and includes contacting familiesCase management continues following Case management continues following discharge, may last for yearsdischarge, may last for years
Other Lead TBI Center ProgramsOther Lead TBI Center Programs
Emerging Consciousness ProgramEmerging Consciousness Program: : For those with acute coma, NOT longFor those with acute coma, NOT long--term coma or vegetative state careterm coma or vegetative state careShortShort--stay admissionsstay admissions for:for:
Evaluation and treatment planningEvaluation and treatment planningTreatment trialsTreatment trialsVocational evaluations Vocational evaluations
Respite CareRespite Care upon occasionupon occasion
Other Lead TBI Center Programs Other Lead TBI Center Programs (cont.)(cont.)
New ProgramNew Program beginning July/August 2007beginning July/August 2007
Transitional Residential ProgramsTransitional Residential Programs6 6 –– 12 month program12 month programResidentialResidentialCommunity reCommunity re--entry program / servicesentry program / servicesCompensated Work TherapyCompensated Work TherapyWork trialsWork trials
Polytrauma Network Sites: Level IIPolytrauma Network Sites: Level II(Outpatient)(Outpatient)
Screen every returning Iraq or Afghanistan Screen every returning Iraq or Afghanistan veteran who seeks care in the VA for TBIveteran who seeks care in the VA for TBIEvaluate and treat on an outpatient basis mild Evaluate and treat on an outpatient basis mild TBI (or postTBI (or post--acute moderate/severe TBI)acute moderate/severe TBI)Refer any appropriate patient to the nearest PRC Refer any appropriate patient to the nearest PRC for specialized care, if neededfor specialized care, if neededDevelop innovative outpatient programs (e.g., Develop innovative outpatient programs (e.g., Day Treatment programs, Community ReDay Treatment programs, Community Re--entry entry programs)programs)Work with PRCs to provide Community ReWork with PRCs to provide Community Re--entry entry services to veterans discharged from PRCs to services to veterans discharged from PRCs to their catchment areatheir catchment areaAssist with ongoing Case ManagementAssist with ongoing Case Management
Polytrauma Support Clinical Polytrauma Support Clinical Teams: Level III (Outpatient)Teams: Level III (Outpatient)
Screen every returning Iraq or Afghanistan Screen every returning Iraq or Afghanistan veteran who seeks care in the VA for TBIveteran who seeks care in the VA for TBIEvaluate and triage (treat) TBI patients to Evaluate and triage (treat) TBI patients to appropriate local programsappropriate local programsRefer any appropriate patient to the nearest Refer any appropriate patient to the nearest PNS or PRC for specialized care, if neededPNS or PRC for specialized care, if neededWork with PRCs and PNSs to facilitate Work with PRCs and PNSs to facilitate Community ReCommunity Re--entry to veterans in their entry to veterans in their catchment areacatchment areaServe as a local resource for ongoing TBI case Serve as a local resource for ongoing TBI case managementmanagement
Family SupportFamily SupportCase ManagementCase ManagementBenefits ManagementBenefits Management
Polytrauma Rehabilitation Polytrauma Rehabilitation Lifetime Continuum of CareLifetime Continuum of Care
---- Supported Supported LivingLiving
---- VocationalVocational---- EducationalEducational---- Day ActivitiesDay Activities---- Support Support
GroupsGroups---- Outpatient Outpatient
followfollow--upup
Transitional/Community Transitional/Community ReRe--entry entry -- ResidentialResidential
Transitional/CommunityTransitional/CommunityReRe--entry entry -- Day ProgramDay Program
OutpatientOutpatient
---- InpatientInpatientAcuteAcute
---- InpatientInpatientemerging emerging consciousness consciousness
---- Inpatient Inpatient SubacuteSubacute
SurgicalSurgical
MedicalMedical
Acute TraumaAcute Traumacarecare
AcuteAcuteRehabilitationRehabilitation
Post AcutePost AcuteRehabilitationRehabilitation
LifetimeLifetimeCommunityCommunity
CareCare
DoD VHA VHDoD VHA VHA VHAA VHA