Veterans with Traumatic
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
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
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
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
Determine the most effective means to facilitate
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
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.
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
Affects can be minimized or amplified due to their expectations of
the injury, poor coping styles, or adverse reaction to an emotional
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
Consultation across the Polytrauma System of Care
PSC Initiative Case Management and Care
Case Management/Care Coordination – Customized approach to
managing care which is adheres to the Intensity Based Model of
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
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.
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),
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-
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/