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A New Paradigm of Rehabilitation for a New Generation of Veterans Micaela Cornis-Pop, Ph.D. Rehabilitation Services, VA

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

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A New Paradigm of Rehabilitation for a New Generation of Veterans Micaela Cornis-Pop, Ph.D. Rehabilitation Services, VA

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  1. A New Paradigm of Rehabilitation for a New Generation of Veterans Micaela Cornis-Pop, Ph.D.Rehabilitation Services, VACO

  2. 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

  3. 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

  4. OEF/OIF Veterans Utilizing VA Health Care (=205,097 Sept 2001 to March 2007)

  5. 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

  6. 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)

  7. 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

  8. 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

  9. Agent and Severity of TBI (DVBIC data) AGENT OF INJURY SEVERITY OF INJURY April 30, 2007 Source: Defense Veterans Brain Injury Center

  10. Rebuilding wounded lives – A new generation of veterans

  11. 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

  12. 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

  13. 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

  14. 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

  15. 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

  16. 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)

  17. 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

  18. VA System of Care for Polytrauma and Brain Injury Rehabilitation

  19. 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

  20. 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

  21. Integrated Rehabilitation Care Brain Injury Program Audiology Program HearingLoss Polytrauma Rehabilitation Center Head Injuries Spinal Cord Injury Program Cord injury Pain Management Pain Amputations Soft Tissue Trauma Emotional Shock Vision Loss Amputee Program Rehabilitation And Orthopedic Programs PTSD Program Blind Rehabilitation Program 23

  22. Responding to the needs of the OIF/OEF veterans • Endurance, strength, and fitness impact rehab potential and expectations for rehabilitation

  23. 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

  24. 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

  25. Clinical and Research Data

  26. 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

  27. Neurobehavioral sequelae of TBI 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 Pre-Injury Factors Cognitive Disturbance Emotional Disturbance Traumatic Brain Injury Community Integration Issues Physical Disturbance Post-Injury Psychosocial Factors

  28. 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

  29. 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

  30. Symptom frequency: higher in combat-injured TBI

  31. Problems reported by outpatients with suspected TBI1 Lew HL, et al. Defining Characteristics of Returning Military in a VA PNS, JRRD (in press)

  32. 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

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