A New Paradigm of Rehabilitation for a New Generation of Veterans Micaela CornisPop, Ph.D. Rehabilit - PowerPoint PPT Presentation

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A New Paradigm of Rehabilitation for a New Generation of Veterans Micaela CornisPop, Ph.D. Rehabilit

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Serious burns 598. Polytrauma 391. Spinal cord injuries 94. Blind 48. Prevalence of TBI in ... Retired Army Sgt. Edward Wade, 27, served in Afghanistan and Iraq ... – PowerPoint PPT presentation

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Title: A New Paradigm of Rehabilitation for a New Generation of Veterans Micaela CornisPop, Ph.D. Rehabilit


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 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

4
OEF/OIF Veterans Utilizing VA Health Care
(205,097 Sept 2001 to March 2007)
5
Severely 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

6
Prevalence 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)

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. 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
14
Wounded 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

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
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19
VA System of Care for Polytrauma and Brain Injury
Rehabilitation
20
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
21
(No Transcript)
22
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

23
Integrated 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
24
Responding to the needs of the OIF/OEF veterans
  • Endurance, strength, and fitness impact rehab
    potential and expectations for rehabilitation

25
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

26
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

27
Clinical and Research Data
28
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

29
Neurobehavioral 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
30
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

31
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

32
Symptom frequency higher in combat-injured TBI
33
Problems reported by outpatients with suspected
TBI1
Lew HL, et al. Defining Characteristics of
Returning Military in a VA PNS, JRRD (in press)
34
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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