Veterans with Traumatic Brain Injury

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					Veterans with Traumatic
Brain Injury

                                   Utah State University
            Vocational Assessment for Persons with Disabilities

 K. Auten, L. Bailey, B. Edwards, E. Martin, J. Trant & A. Yatskis
What is a Traumatic Brain Injury?

A traumatic brain injury
  (TBI) is defined as, “a
  blow or jolt to the head
  or a penetrating head
  injury that disrupts the
  function of the brain.”



                             (Source: Deployment Health Clinical Center, 2011)
Method(s) for Diagnosing TBI

   A detailed neurological examination is important and
    will bring out evidence of brain injury.

   Brain imaging with CAT scan, MRI, SPECT and PET
    scan may be useful.

   Cognitive evaluation by a Neuropsychologist with
    formal neuropsychological testing.

   Evaluations by physical, occupational and speech
    therapists help clarify the specific deficits of an
    individual.
Types of TBI

   Penetrating Injuries: In these injuries, a foreign object (e.g., a
    bullet) enters the brain and causes damage to specific brain parts.
    This focal, or localized, damage occurs along the route the object
    has traveled in the brain. Symptoms vary depending on the part of
    the brain that is damaged.

   Closed Head Injuries: Closed head injuries result from a blow to
    the head as occurs, for example, in a car accident when the head
    strikes the windshield or dashboard. These injuries cause two types
    of brain damage:
       Primary Brain Damage - damage that is complete at the time of impact.

       Secondary Brain Damage - damage that evolves over time after the trauma.
Symptoms of TBI

   TBI’s impact individuals in a variety of ways,
    such as physically, emotionally, behaviorally
    and cognitively.

   Variables that impact the outcome include,
    but are not limited to: the type of injury; the
    severity of the injury; age; time since injury;
    co-morbid conditions; and pre-morbid
    characteristics.
Common Cognitive Symptoms of TBI
   Attention Problems: Difficulty completing tasks; distractedness or poor
    concentration; decreased ability to shift from task to task; and difficulty responding to
    two tasks simultaneously.

   Memory Difficulty: Difficulty in learning new information, retaining the information,
    and then retrieving the information. Difficulty following directions, passing on
    messages, remembering to go to appointments, etc.

   Executive Dysfunction: Loss of initiative or drive, difficulty moving from task to task,
    diminished awareness of deficits, inability to monitor performance properly, difficulty
    planning and organizing, poor reasoning, problem-solving and conceptualizing.

   Communication Problems: Following a TBI individuals often have difficulty
    communicating effectively due to problems with organization and integrating
    language in order to comprehend and express concepts, difficulty with finding words
    in conversation, problems understanding abstract language and figures of speech,
    and poor adherence to rules of social communication.
Assessment of TBI

The goal of assessment is to determine:
    If there is a cognitive problem;
    Establish the nature of the problem;
    Evaluate the implications;
    Estimate the capacity to participate in
     rehabilitation;
    Determine the most effective means to facilitate
     learning;
    Plan rehabilitation interventions; and
    Measure recovery and treatment progress.
Data Collection & Synthesis in the
Assessment & Treatment Planning Process
   When an individual is initially screened for a TBI, an in-depth review
    of their history is usually the initial start for determining their
    treatment.
       Provides critical insight to fully evaluate the trauma.


   The initial severity of the TBI has been shown to correlate with short
    and long term functional and rational outcomes. An importance
    piece in the review of the patient’s history is an understanding of the
    condition and the nature for which the injury occurred.
Treatment Interventions
There are two types of treatment interventions for cognitive
  problems after a TBI:

     Cognitive Rehabilitation – The most common include modeling, guided
      practice, distributed practice, error less learning, direct instruction with
      feedback, paper-and-pencil tasks, communication skills, computer-
      assisted retraining programs, and the use of memory aids.

     Pharmacological Interventions – Medications to help improve
      cognitive functioning after TBI should be tried only after medical and
      behavior factors have been mitigated. The efficacy of medication to
      improve cognition has been limited. However, evidence exists to support
      the use of stimulating agents to enhance arousal and attention after
      brain injury. These can include true stimulants, antidepressants, and
      dopaminergic agents. There is little evidence to support the use of
      memory enhancing agents.
Veterans with Traumatic Brain Injury

According to the Department of Defence
 (DOD), the rate of combat-related brain
 injuries in service members returning from
 the current conflicts in Iraq and Afghanistan is
 higher than in previous conflicts.

     “65 percent of the veterans who served in Iraq
      and Afghanistan treated at Walter Reed Hospital
      were diagnosed with TBI.” (U.S. House of Representatives, 2007)
Challenges to Diagnosing and Treating
TBI with Veterans
Due to the nature of a TBI, barriers to appropriate course of
  treatment can occur especially with the Veteran
  population.

     Affects can be minimized or amplified due to their expectations of
      the injury, poor coping styles, or adverse reaction to an emotional
      occurrence.

     The VA system often does not screen until several months or
      ever a year after deployment ends.
TBI Health Initiative
   Through an agreement between the Department of Defense
    (DOD) and the U.S. Department of Veterans Affairs (VA)
    provides for transfer of active duty Service Members who have
    incurred a brain injury to VA medical centers for care.

   The VA has implemented an integrated nationwide system of
    care for both Veterans and active duty Service Members
    recovering from TBI’s and polytrauma.
     Network of more the 100 VA Medical Centers, each offering
       specialized rehabilitation care by an interdisciplinary team
       through the polytrauma system of care (PSC).
Polytrauma System of Care
   The hallmark of the PSC if collaboration of specialists and the development of dedicated
    interdisciplinary teams who participate in the assessment, planning and implementation of the
    plan of care for each patient.

   There are four Polytrauma Rehabilitation Centers (PRC’s) located in the United States:
    Minnesota, California, Virginia and Florida.

   PRC Scope of Services:
      Comprehensive Interdisciplinary Inpatient Evaluations
      Acute Comprehensive Interdisciplinary Inpatient Rehabilitation
      Emerging Consciousness Program
      Polytrauma/TBI Assistive Technology Labs (AT Labs)
      Polytrauma Transitional Rehabilitation Program (PTRP)
      Post-acute Comprehensive Interdisciplinary Inpatient Rehabilitation
      Comprehensive Interdisciplinary Outpatient Evaluation
      Outpatient Interdisciplinary Rehabilitation
      Individualized Rehabiliation and Community Reintegration Care Plan
      Follow-up
      Consultation across the Polytrauma System of Care
PSC Initiative Case Management and Care
Coordination
   Case Management/Care Coordination – Customized approach to
    managing care which is adheres to the Intensity Based Model of
    Care:
       Intensive Case Management (Daily/Weekly)
       Progressive Case Management (Monthly)
       Supportive Case Management (Quarterly)

   Screening and Evaluation – Commencing in April 2007, the
    initiative provides TBI screening that identifies exposure to 1.) High
    risk TBI event; 2.) Signs of symptoms associated with alteration in
    consciousness at the time of the event; 3.) Symptoms immediately
    following the event; and, 4.) Current symptoms.
Interview with Rebecca Quinn, TBI
Resource Coordinator
Conclusions
   The VA Health Initiative (VHI) was an independent study of Traumatic Brain
    Injury (TBI) issues that Primary Care Practitioners may encounter when
    providing care to Veterans and Active Duty military personnel. One of the
    main purposes was to improve comprehensive services, treatment of health
    problems related to TBI and providers extensive education to provides so
    that the most effective care to patients with TBI can be delivered.

   The cognitive, emotional, and physical changes in survivors of TBI can be
    quite significant. As such, living with a family member who has sustained a
    TBI can be stressful and overwhelming for the family system as a whole.
    This initiative not only outlines and coordinates services for the family
    members living with a Veteran with a TBI, but also significantly addresses
    common family concerns regarding recovery and prognosis.

   Regular screenings and re-evaluations are an integral part of providing a
    comprehensive continuum of care for TBI’s.
References
Burke, H.S., Olney, M.F., Degeneffe, C.E. (2009). A new disability for rehabilitation counselors: Iraq war
    veterans with traumatic brain injury and post-traumatic stress disorder. Journal of Rehabilitation, 75 (3),
    5-14.

Carlson, K.F., Nelson, D., Orazem, R.J., Nugent, S., Cifu, D.X., Sayer, N.A. (2010). Psychiatric diagnoses
    among Iraq and Afghanistan war veterans screened for deployment-related traumatic brain injury.
    Journal of Traumatic Stress, 23(1), 17-24.

Clinical Guidance for Evaluation and Management of Concussion/mTBI-Acute/Subacute (CONUS), (2011,
     May 8). Retrieved from http://www.dvbic.org/images/pdfs/Clinical-Tools/E--Clinical-Guidance-
     Evaluation.aspx

Day, K., personal communication, November 8, 2011

Deployment Health Clinical Center. Retrieved from http://www.pdhealth.mil/TBI.asp

Quinn, R., personal communication, November 3, 2011

U.S. House of Representatives Veterans’ Affairs Committee. Press Release issued July 18, 2007.

Veterans Health Initiative, (2011, July 6). Retrieved from http://www.publichealth.va.gov/vethealthinitiative/

				
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