Caring for Those Who Serve: Rehab Innovations for Military Service Members

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Caring for Those Who ServeRehab Innovations for
Military Service Members

• Jessica Kovacevich, MOT, OTR/L
• Hillari Olson, DPT
• Colleen Schreffler, MEd,CTRS
• Minneapolis Veterans Affairs Medical Center
• Minneapolis, Minnesota

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Objectives

• Understand the Veterans Health Administration
  (VHA) Polytrauma System of Care
• Understand the incidence of brain injury in
  Operation Enduring Freedom (OEF) and Operation
  Iraqi Freedom (OIF)
• Identify interdisciplinary approaches to
  polytrauma rehabilitation
• Develop an awareness of the rehabilitation
  innovations utilized within the Minneapolis
  Veterans Affairs Medical Center (MVAMC)
• Follow a case study through the VHA polytrauma
  continuum of care

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What is Polytrauma?1

• Trauma to two or more body areas or organ systems
• Occur simultaneously
• One or more is life threatening
• Can include PTSD/psychological stress

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Potential Polytrauma Injuries

• Amputation
• Brain injury
• Burns
• Auditory/vestibular
• Fractures
• Cardiac and vascular
• Crush injuries
• Dental
• Endocrine

• Eye/orbit/face
• Gastrointestinal
• Infections
• Peripheral nerve injuries
• Psychological/PTSD
• Respiratory
• Renal
• Spinal Cord Injury
• Wounds

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What is Blast Injury?

• Trauma or damage as a result of violent explosion
  or the wave of pressure from such an explosion2
• -Primary
• -Secondary
• -Tertiary
• -Quaternary

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IED Explosion
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Mortar Blast
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Ground Mortar Blast
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History of TBI in Returning Service Members

• TBI occurs in approximately 10-20 of those
  injured in OEF/OIF
• Majority are mild TBI
• May be initially missed or missed altogether
• Multiple blast exposures

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From the Battlefield to the VHA
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VHA Polytrauma System of Care

• Polytrauma Rehabilitation Centers (PRCs)
• Polytrauma Network Sites (PNS)
• Polytrauma Support Clinic Teams (PSCT)
• Polytrauma Point of Contact (PPOC)

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Polytrauma Rehabilitation Centers
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PRC Mission

• To provide comprehensive inpatient rehabilitation
  services for individuals with complex physical,
  cognitive, and mental health sequalae of severe
  and disabling trauma while providing support to
  patients and their families.1

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Inpatient and Outpatient Demographics Minneapolis

• Spring 2003 to December 31st, 2007
• Inpatient (i.e. PRC)
• N115
• Outpatient (i.e PNS)
• N202

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Minneapolis PRC Demographics
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Minneapolis PRC Inpatient OEF/OIF
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Minneapolis PRC Length of Stay
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Interdisciplinary Team

• Patient
• Patients family
• Physiatrist
• Nurse Case Manager
• Social Work Case Manager
• Nurse Practitioner
• Rehabilitation Nursing
• Occupational Therapist
• Speech Pathologist

• Physical Therapist
• Recreation Therapist
• Blind Rehabilitation Specialist
• Military Liaison
• Psychologist
• Neuropsychologist
• Dietician
• Pharmacist
• Vocational Rehab Specialist

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Rehab Innovations

• Functional Mobility
• Cognitive Rehabilitation
• Community Integration
• Behavioral/Emotional

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Rehab Innovations

• Functional Mobility
• NeuroCom SMART Equitest
• Lokomat
• Gait Rite analysis system
• Solo Step harness system
• RTI 300 electrical stimulation bike

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Rehab Innovations Mobility

• NeuroCom SMART Equitest3
• Computerized Dynamic Posturography (CDP)
• SOT, MCT and ADT comprise the core battery of
  tests
• Considered the highest standard available for
  diagnosing the functional impairments underlying
  balance disorders
• http//www.onbalance.com/

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Rehab Innovations Mobility

• Lokomat4
• Worlds first driven gait orthosis that automates
  locomotion therapy on a treadmill  
• Improves the efficiency of treadmill training

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Rehab Innovations Mobility

• Gait Rite5
• Gait analysis system that captures electronic
  footprints instantly
• Measures cadence, step length, velocity and other
  gait parameters

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Rehab Innovations Mobility

• Solo Step6

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Rehab Innovations Mobility

• RTI 3007 electrical stimulation bike

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Rehab Innovations

• Cognitive Rehabilitation
• Memory compensation
• Palm pilots
• Digital watches
• Voice Recorders
• Computer software

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Rehab Innovations Cognitive

• Memory compensation

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Rehab Innovations Cognitive

• Computer software
• Quicken
• Problem solving games
• Brain Train8
• Microsoft Office
• PowerPoint
• Word

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Rehab Innovations

• Community Integration
• Driving
• Community and Recreational Programs
• Leisure

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Rehab Innovations Community

• Driving
• GPS
• Driving Simulator

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Rehab Innovations Community

• Community and Recreational Programs
• Hippotherapy Program
• Rowing Program
• Exposure Based Therapy
• Transportation Training
• School, Volunteer, and Vocational Integration
• Geocaching and Community Path Finding
• AFB, Community Fitness/Sport Programs
• Social and Recreation Community Outings

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When Toys Become Tools

• Wii, XBOX, Guitar Hero
• Music, Movies, IPOD, Musical Instruments
• GPS Devices (Garmin/Tom-Tom)
• Palm Pilots
• Computer Programs and Internet
• Two Way Radios, Cell Phones
• Voice Recorders and Digital Watches
• Video Cameras and Digital Cameras

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Leisure Interests of Polytrauma Patients
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Rehab Innovations

• Behavioral/Emotional
• Biofeedback
• Heartmath9
• Video cameras
• Military influence
• Psychologists in the community (PTSD)

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Polytrauma Case Study
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PFC T

• Demographics
• 20 y/o male
• Army, Private First Class, enlisted since age 18
• Married, no children
• Dates in theatre 02/8/07-06/09/07, Operation
  Iraqi Freedom
• MOS-Infantry, 11 Bravo

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PFC T

• Mechanism of injury IED blast while on patrol
• Date of injury June 10th, 2007
• Initial GCS 3
• Admit date 7/31/07
• Discharge date 02/07/08
• LOS 141 days

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PFC T

• Injuries
• Traumatic brain injury
• Subdural hematoma
• Fragment wound to neck with hypopharynx injury
• Scalp laceration
• Highly comminuted distal humerus and proximal
  radius fracture
• Right chest hematoma
• Multiple penetrating shrapnel wounds

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PFC T

• Surgeries
• Right craniectomy
• Right neck exploration
• Direct laryngoscopy
• Esophagoscopy
• Tracheostomy
• Repair of scalp laceration
• ID of distal humerus and proximal radius
  fractures with external fixator placement

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PFC T
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PFC T Initial Presentation

• Bilateral ankle plantar flexion contractures
• Bilateral lower extremity spasticity/tone
• Bilateral ulcers on heels and dorsal feet
• Left field cut
• Tracheostomy
• Right upper extremity fixator

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PFC T Initial Presentation

• Rancho Level III-IV
• Functional mobility
• ADLs
• Cognitive status
• Communication
• Behavior

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Interdisciplinary Goals Months 1-2

• Pt will sit at the edge of the bed with moderate
  assistance for 10 min consistently.
• Pt will respond to yes/no questions with 60
  accuracy.
• Pt will tolerate tilt table at 50 deg 2x/week.

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Interdisciplinary Goals Month 3

• Pt will be consistently oriented using external
  devices.
• Pt will complete laundry task with moderate
  assistance.
• Pt will use appropriate social pragmatics when on
  outing with moderate verbal cueing.

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Interdisciplinary Goals Month 4

• Pt will stand and bowl with no more than three
  losses of balance.
• Pt will help develop and participate in reward
  program to optimize participation in therapies.
• Pt will perform shoveling task with moderate
  assistance.

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Interdisciplinary Goals Month 5

• Pt will participate in divided attention task
  during physical activity with minimal cueing.
• Pt will ambulate to all therapies with close
  supervision using FWW and KAFO.
• Pt will review schedule in palm pilot at the end
  of each therapy session with minimal cueing.

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Interdisciplinary Goals Month 6

• Pt will complete 3/5 prospective memory tasks
  using external device.
• Pt will path find to unfamiliar locations in the
  hospital with no more than minimal cueing.
• Pt will locate 3 items in the gift shop with
  moderate cueing.

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Rehab Innovations PFC T

• Rock Band
• Karaoke Machine
• NeuroCom SMART Equitest
• Lokomat
• Computer games
• Driving Simulator

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PFC Ts Next Step of Care
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Challenges

• Lifelong care
• Education
• Long Term Placement/Supported Living
• Mental health
• Psycho-social
• Military Politics and Civilian Transition
• Geographical Location

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How Does This Affect You?

• Health care providers in the community
• Fee basis services
• Continuum of care
• Holistic approach
• PTSD vs mTBI

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Questions?

• Thank you!

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Contact Information

• Jessica Kovacevich jessica.kovacevich_at_va.gov
• Hillari Olson hillari.olson_at_va.gov
• Colleen Schreffler colleen.schreffler_at_va.gov

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References

• www.polytrauma.va.gov/
• www.dvbic.org
• http//www.onbalance.com/
• http//www.hocoma.ch/web/en/products/prd_lokomat
• http//www.gaitrite.com/
• http//solostep.datawareservices.com/default.html
• http//www.restorative-therapies.com
• www.braintrain.com
• www.heartmath.com