Title: A New Paradigm of Rehabilitation for a New Generation of Veterans Micaela CornisPop, Ph.D. Rehabilit
1A New Paradigm of Rehabilitation for a New
Generation of Veterans Micaela Cornis-Pop,
Ph.D.Rehabilitation Services, VACO
2Outline
- 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
3Who Do We Serve The Presidents 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
4OEF/OIF Veterans Utilizing VA Health Care
(205,097 Sept 2001 to March 2007)
5Severely Wounded The Presidents 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
6Prevalence of TBI in OEF/OIF
- 88 due to IED/mortar attack- 33 about the head
(Murray Reynolds, 2005) - 97 explosions (65 IEDs, 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)
7Multi-Dimensional InjuriesPolytrauma and TBI
- Most injuries are from blasts
- Most blasts are from IEDs
- Overpressure/barotrauma
- Fragmentation injuries
- Blunt trauma
- Crush injuries
- Thermal/inhalation
8Shock 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
9Agent and Severity of TBI (DVBIC data)
AGENT OF INJURY
SEVERITY OF INJURY
April 30, 2007
Source Defense Veterans Brain Injury Center
10Rebuilding wounded lives A new generation of
veterans
11A 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
12A 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. Coma2
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
14Wounded in theater combat environment
- High arousal
- Sleep deprivation
- Fog of war - deficits observed greater
thanalcohol intoxication or treatment with
sedating drugs Lieberman et al., 2005 - Cumulative effect of repeated exposures to blasts
15Wounded 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
16Wounded 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)
17Wounded 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(No Transcript)
19VA System of Care for Polytrauma and Brain Injury
Rehabilitation
20VA 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
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22New 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
23Integrated Rehabilitation Care
Brain Injury Program
Audiology Program
Polytrauma Rehabilitation Center
Hearing Loss
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
24Responding to the needs of the OIF/OEF veterans
- Endurance, strength, and fitness impact rehab
potential and expectations for rehabilitation
25Responding 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
26Responding 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
27Clinical and Research Data
28TBI 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
29Neurobehavioral sequelae of TBI
Attention/Concentration Processing speed Memory
disturbance Executive dysfunction Safety
Judgment Depression Anxiety PTSD Irritability Disi
nhibition 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
30TBI 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
31Combat 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
32Symptom frequency higher in combat-injured TBI
33Problems reported by outpatients with suspected
TBI1
Lew HL, et al. Defining Characteristics of
Returning Military in a VA PNS, JRRD (in press)
34Conclusions
- 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