Veterans with Traumatic Brain Injury

1. Veterans with Traumatic Brain Injury Utah State University Vocational Assessment for Persons with Disabilities K. Auten, L. Bailey, B. Edwards, E. Martin, J. Trant & A. Yatskis

2. A traumatic brain injury (TBI) is defined as, “a blow or jolt to the head or a penetrating head injury that disrupts the function of the brain.” What is a Traumatic Brain Injury? (Source: Deployment Health Clinical Center, 2011)

3. Method(s) for Diagnosing TBI • A detailed neurological examination is important and will bring out evidence of brain injury. • Brain imaging with CAT scan, MRI, SPECT and PET scan may be useful. • Cognitive evaluation by a Neuropsychologist with formal neuropsychological testing. • Evaluations by physical, occupational and speech therapists help clarify the specific deficits of an individual.

4. Types of TBI • Penetrating Injuries: In these injuries, a foreign object (e.g., a bullet) enters the brain and causes damage to specific brain parts. This focal, or localized, damage occurs along the route the object has traveled in the brain. Symptoms vary depending on the part of the brain that is damaged. • Closed Head Injuries: Closed head injuries result from a blow to the head as occurs, for example, in a car accident when the head strikes the windshield or dashboard. These injuries cause two types of brain damage: • Primary Brain Damage - damage that is complete at the time of impact. • Secondary Brain Damage - damage that evolves over time after the trauma.

5. Symptoms of TBI • TBI’s impact individuals in a variety of ways, such as physically, emotionally, behaviorally and cognitively. • Variables that impact the outcome include, but are not limited to: the type of injury; the severity of the injury; age; time since injury; co-morbid conditions; and pre-morbid characteristics.

6. Common Cognitive Symptoms of TBI • Attention Problems: Difficulty completing tasks; distractedness or poor concentration; decreased ability to shift from task to task; and difficulty responding to two tasks simultaneously. • Memory Difficulty: Difficulty in learning new information, retaining the information, and then retrieving the information. Difficulty following directions, passing on messages, remembering to go to appointments, etc. • Executive Dysfunction: Loss of initiative or drive, difficulty moving from task to task, diminished awareness of deficits, inability to monitor performance properly, difficulty planning and organizing, poor reasoning, problem-solving and conceptualizing. • Communication Problems: Following a TBI individuals often have difficulty communicating effectively due to problems with organization and integrating language in order to comprehend and express concepts, difficulty with finding words in conversation, problems understanding abstract language and figures of speech, and poor adherence to rules of social communication.

7. Assessment of TBI The goal of assessment is to determine: • If there is a cognitive problem; • Establish the nature of the problem; • Evaluate the implications; • Estimate the capacity to participate in rehabilitation; • Determine the most effective means to facilitate learning; • Plan rehabilitation interventions; and • Measure recovery and treatment progress.

8. Data Collection & Synthesis in the Assessment & Treatment Planning Process • When an individual is initially screened for a TBI, an in-depth review of their history is usually the initial start for determining their treatment. • Provides critical insight to fully evaluate the trauma. • The initial severity of the TBI has been shown to correlate with short and long term functional and rational outcomes. An importance piece in the review of the patient’s history is an understanding of the condition and the nature for which the injury occurred.

9. Treatment Interventions There are two types of treatment interventions for cognitive problems after a TBI: • Cognitive Rehabilitation – The most common include modeling, guided practice, distributed practice, error less learning, direct instruction with feedback, paper-and-pencil tasks, communication skills, computer-assisted retraining programs, and the use of memory aids. • Pharmacological Interventions – Medications to help improve cognitive functioning after TBI should be tried only after medical and behavior factors have been mitigated. The efficacy of medication to improve cognition has been limited. However, evidence exists to support the use of stimulating agents to enhance arousal and attention after brain injury. These can include true stimulants, antidepressants, and dopaminergic agents. There is little evidence to support the use of memory enhancing agents.

10. Veterans with Traumatic Brain Injury According to the Department of Defence (DOD), the rate of combat-related brain injuries in service members returning from the current conflicts in Iraq and Afghanistan is higher than in previous conflicts. • “65 percent of the veterans who served in Iraq and Afghanistan treated at Walter Reed Hospital were diagnosed with TBI.” (U.S. House of Representatives, 2007)

11. Challenges to Diagnosing and Treating TBI with Veterans Due to the nature of a TBI, barriers to appropriate course of treatment can occur especially with the Veteran population. • Affects can be minimized or amplified due to their expectations of the injury, poor coping styles, or adverse reaction to an emotional occurrence. • The VA system often does not screen until several months or ever a year after deployment ends.

12. TBI Health Initiative • Through an agreement between the Department of Defense (DOD) and the U.S. Department of Veterans Affairs (VA) provides for transfer of active duty Service Members who have incurred a brain injury to VA medical centers for care. • The VA has implemented an integrated nationwide system of care for both Veterans and active duty Service Members recovering from TBI’s and polytrauma. • Network of more the 100 VA Medical Centers, each offering specialized rehabilitation care by an interdisciplinary team through the polytrauma system of care (PSC).

13. Polytrauma System of Care • The hallmark of the PSC if collaboration of specialists and the development of dedicated interdisciplinary teams who participate in the assessment, planning and implementation of the plan of care for each patient. • There are four Polytrauma Rehabilitation Centers (PRC’s) located in the United States: Minnesota, California, Virginia and Florida. • PRC Scope of Services: • Comprehensive Interdisciplinary Inpatient Evaluations • Acute Comprehensive Interdisciplinary Inpatient Rehabilitation • Emerging Consciousness Program • Polytrauma/TBI Assistive Technology Labs (AT Labs) • Polytrauma Transitional Rehabilitation Program (PTRP) • Post-acute Comprehensive Interdisciplinary Inpatient Rehabilitation • Comprehensive Interdisciplinary Outpatient Evaluation • Outpatient Interdisciplinary Rehabilitation • Individualized Rehabiliation and Community Reintegration Care Plan • Follow-up • Consultation across the Polytrauma System of Care

14. PSC Initiative Case Management and Care Coordination • Case Management/Care Coordination – Customized approach to managing care which is adheres to the Intensity Based Model of Care: • Intensive Case Management (Daily/Weekly) • Progressive Case Management (Monthly) • Supportive Case Management (Quarterly) • Screening and Evaluation– Commencing in April 2007, the initiative provides TBI screening that identifies exposure to 1.) High risk TBI event; 2.) Signs of symptoms associated with alteration in consciousness at the time of the event; 3.) Symptoms immediately following the event; and, 4.) Current symptoms.

15. Interview with Rebecca Quinn, TBI Resource Coordinator

16. Conclusions • The VA Health Initiative (VHI) was an independent study of Traumatic Brain Injury (TBI) issues that Primary Care Practitioners may encounter when providing care to Veterans and Active Duty military personnel. One of the main purposes was to improve comprehensive services, treatment of health problems related to TBI and providers extensive education to provides so that the most effective care to patients with TBI can be delivered. • The cognitive, emotional, and physical changes in survivors of TBI can be quite significant. As such, living with a family member who has sustained a TBI can be stressful and overwhelming for the family system as a whole. This initiative not only outlines and coordinates services for the family members living with a Veteran with a TBI, but also significantly addresses common family concerns regarding recovery and prognosis. • Regular screenings and re-evaluations are an integral part of providing a comprehensive continuum of care for TBI’s.

17. References Burke, H.S., Olney, M.F., Degeneffe, C.E. (2009). A new disability for rehabilitation counselors: Iraq war veterans with traumatic brain injury and post-traumatic stress disorder. Journal of Rehabilitation, 75 (3), 5-14. Carlson, K.F., Nelson, D., Orazem, R.J., Nugent, S., Cifu, D.X., Sayer, N.A. (2010). Psychiatric diagnoses among Iraq and Afghanistan war veterans screened for deployment-related traumatic brain injury. Journal of Traumatic Stress, 23(1), 17-24. Clinical Guidance for Evaluation and Management of Concussion/mTBI-Acute/Subacute (CONUS), (2011, May 8). Retrieved from http://www.dvbic.org/images/pdfs/Clinical-Tools/E--Clinical-Guidance-Evaluation.aspx Day, K., personal communication, November 8, 2011 Deployment Health Clinical Center. Retrieved from http://www.pdhealth.mil/TBI.asp Quinn, R., personal communication, November 3, 2011 U.S. House of Representatives Veterans’ Affairs Committee. Press Release issued July 18, 2007. Veterans Health Initiative, (2011, July 6). Retrieved from http://www.publichealth.va.gov/vethealthinitiative/