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Traumatic Brain Injury within the VHA and DoD Systems of Health Care

Traumatic Brain Injury within the VHA and DoD Systems of Health Care. Rodney D. Vanderploeg, Ph.D. Tampa VAMC VA Psychology Leadership Conference/APA April 2006. Objectives. Describe the DoD/VHA system of specialized TBI care for active duty and veterans

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Traumatic Brain Injury within the VHA and DoD Systems of Health Care

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  1. Traumatic Brain Injury within the VHA and DoD Systems of Health Care Rodney D. Vanderploeg, Ph.D. Tampa VAMC VA Psychology Leadership Conference/APA April 2006

  2. Objectives • Describe the DoD/VHA system of specialized TBI care for active duty and veterans • Briefly describe TBI, and its incidence, severity, time course of recovery, and treatment stages • Describe the role of psychology and neuropsychology in TBI evaluation and care

  3. Defense & Veterans Brain Injury Center Clinical Care Research Education Prevention Established in 1992

  4. Defense & Veterans Brain Injury Center • Multi-site Center • Collaboration of Department of Defense & Department of Veterans Affairs • Established in 1992 • Congressionally funded • Mission: Clinical Care, Clinical Research, and Education

  5. Center HQ Support Advisors Research Clinical Care Education Provider Registry VA Concussion VaNC DoD Rehabilitation Pharm/Neurobehavior Doctor/ Therapist Family/ Caregiver Patient Defense & Veterans Brain Injury Center (DVBIC) Director Deputy Dir Consumer Medic

  6. Defense & Veterans Brain Injury Center • 3 Military Sites • 4 VA Sites • 1 Civilian Partner Program

  7. Defense & Veterans Brain Injury Center • Military Sites • Walter Reed Army Medical Center (Head Quarters) • Naval Medical Center, San Diego • Wilford Hall US Air Force Med Ctr

  8. Defense & Veterans Brain Injury Center • VA Sites • Minneapolis VA Medical Center • Palo Alto Health Care System • Richmond VA Medical Center • Tampa VA Medical Center • Civilian Partner Program • Virginia NeuroCare, Charlottesville

  9. VHA TBI Network of Care • 4 Lead TBI Centers • 16 Network Sites • 7 Associate Network Sites

  10. * Minneapolis * * Richmond Palo Alto * Tampa VHA TBI Network of Care: Four Lead TBI Rehabilitation Sites

  11. Interdisciplinary Team and Interdisciplinary Rehab Approach • Rehab Medicine physician • Rehab nurses (primary nurse model) • Physical, Occupational, Recreational, and Vocational Therapists • Speech Therapists • Social Workers • Case Managers (including long-term) • Rehab or Counseling Psychologists • Neuropsychologists

  12. Inpatient Acute Rehabilitation • 3-5 hours of therapies per day (OT, PT, SP, Recreational, Psychology) • Average length of stay 1-3 months • Therapies include community outings planned and organized by the TBI patients together with the therapists • Case management begins before patients arrive and includes contacting families • Case management continues following discharge, may last for years

  13. Other Lead TBI Center Programs • Low level or coma program: Only for those with acute coma, NOT long-term coma or vegetative state care • Short-stay admissions for: • Evaluation and treatment planning • Treatment trials • Re-evaluation • Vocational evaluations • Respite Care upon occasion

  14. Traumatic Brain Injury • Insult to the brain caused by an external physical force • Produces a diminished or altered state of consciousness • Results in impairments in physical, cognitive, behavioral, and/or emotional functioning

  15. Coma 5 2 __1_ < 8 GCS Mild TBI = 13 - 15 Moderate TBI = 9 – 12 Severe TBI = 3 - 8

  16. Post-traumatic Amnesia • The time interval from when the person regains consciousness until he or she is able to form memories for ongoing events • The individual is not fully oriented, typically confused, and unable to remember information after a period of distraction

  17. Criteria for Severity of TBI

  18. Cogni t ive Leve l Preinjury Functioning Mild TBI Brief PTA Moderate TBI Ongoing Cognitive Problems Severe TBI INJURY Ongoing Cognitive Problems PTA PTA Coma 6 12 3 9 Retro- Grade Amnesia Months

  19. Traumatic Brain Injury • Types of TBI • Open vs. Closed • Etiology • Motor vehicle accidents • Falls, assaults, gun shots to the head • Explosive Blasts (Iraqi conflict) • Demographics • Males > Females • Peak ages of incidence: 1-5 yrs; 15-24 yrs; >75 yrs

  20. Civilian Incidence of TBI • General Population • 1.5 Million Americans per year • 91 per 100,000 • > Stroke, Spinal Cord Injury, MS • Prevalence: 5.3 million with TBI disability

  21. Military Incidence of TBI • Military and Veterans • 7,000 peacetime admissions annually • Active Duty males: 225 per 100,000 • Active Duty females: 150 per 100,000

  22. Blast Induced Brain Injury • Rats exposed to whole body blasts (overpressurization waves) & to focal blasts to torso while head protected had cognitive dysfunction (Cernak et al. 2001) • Clinical characteristics of blast TBI in humans not well described in literature

  23. War Injuries:Explosive Blasts • Most common cause of injury • 64% of war injuries caused by blasts • 41% of blast injured at WRAMC had TBI (01/05 - 02/06) • 85% closed head injury

  24. Key Iraq wound: Brain trauma By 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

  25. Consequences of TBI • Cognitive • Attention • Information processing (speed & efficiency) • Memory and Learning • Abstract Reasoning • Executive Functions • Problem solving, planning, insight/awareness, set shifting, sequencing

  26. Consequences of TBI • Behavioral-emotional • Irritability • Impulsivity • Affect Regulation: apathy, agitation, aggression • Depression, Anxiety • Social Pragmatics Cognitive and behavioral impairments are the most disabling long-term, more so than physical injuries

  27. Psychology-Related Assessment Issues • Determining original severity of injury • Identifying past and present treatment, and the success or lack thereof • Neuropsychological evaluation of current functioning • Psychological functioning: Axis I & II, and coping resources • Identifying and assessing family and systems issues

  28. Neuropsychological Assessment • Focus on Memory and Executive problems • Core (Brief) DVBIC Battery • WTAR (Wechsler Test of Adult Reading) • CVLT-II • Brief Visuospatial Learning Test – Revised • Letter-Number Sequencing (working memory) • D-KEFS Verbal Fluency (letters and semantic) • Design Fluency • Trails A and B • WCST-64 • Grooved Pegboard Test

  29. Treatment Considerations • Treatment varies based upon: • Severity of injury • Time since injury • Constellation of impairments

  30. Mild TBI: Overlapping Symptoms across Conditions • Postconcussion Syndrome (PCS) • Insomnia • Impaired memory • Poor concentration • Depression • Anxiety • Irritability • Headache • Dizziness • Fatigue • Noise/light intolerance • PTSD • Insomnia • Memory problems • Poor concentration • Depression • Anxiety • Irritability • Stress symptoms • Emotional numbing • Avoidance

  31. Predisposing Factors Causative Factors Perpetuating and Mitigating Factors Medical Iatrogenesis Psychiatric Conditions Psychiatric Conditions Litigation Iatrogenesis Personality Traits Personality Traits Medical Conditions Medical Conditions Self-Expectation Acute Symptoms Chronic Symptoms Intelligence Level Intelligence Level mTBI Demographic Characteristics Coping Abilities Social Support Coping Abilities

  32. Cogni t ive Leve l Preinjury Functioning Mild TBI Brief PTA Ongoing Cognitive Problems Moderate TBI INJURY Severe TBI PTA Ongoing Cognitive Problems PTA Coma Months 6 12 3 9 Retro- Grade Amnesia Mild TBI Interventions Psychological Support, Psychotherapy, Existential Issues, Family Issues

  33. Cogni t ive Leve l Preinjury Functioning Mild TBI Brief PTA Ongoing Cognitive Problems Moderate TBI INJURY Severe TBI PTA Ongoing Cognitive Problems PTA Coma Months 6 12 3 9 Retro- Grade Amnesia Psychological Support, Psychotherapy, Existential Issues, Family Issues Acute Specialized Brain Injury Rehabilitation For those with Moderate to Severe Injuries

  34. Cogni t ive Leve l Preinjury Functioning Mild TBI Brief PTA Ongoing Cognitive Problems Moderate TBI INJURY Severe TBI PTA Ongoing Cognitive Problems PTA Coma Months 6 12 3 9 Retro- Grade Amnesia Psychological Support, Psychotherapy, Existential Issues, Family Issues Subacute Rehab, Outpatient Therapies, Day Treatment, or Community Re-Entry Programs

  35. Cogni t ive Leve l Preinjury Functioning Mild TBI Brief PTA Ongoing Cognitive Problems Moderate TBI INJURY Severe TBI PTA Ongoing Cognitive Problems PTA Coma Months 6 12 3 9 Retro- Grade Amnesia Psychological Support, Psychotherapy, Existential Issues, Family Issues Vocational Rehabilitation and/or Ongoing Case Management

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