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TRANSITIONAL PROGRAMMING FOR TBI AND POLYTRAUMA OVERVIEW

VIEWS: 8 PAGES: 15

									     TRANSITIONAL
PROGRAMMING FOR TBI AND
     POLYTRAUMA
         Jamie Kaplan, CTRS/CBIS
         James A Haley VA Hospital
              Tampa, Florida




                 OVERVIEW

Brain and its functions
Definition of Traumatic Brain Injury
Overview of Traumatic Brain Injury:
Domestic versus Military
Overview of DVBIC and Polytrauma
Treatment centers
Overview of Polytrauma Transitional Care
Overview of Transitional Programming




                      Brain
It is through our brains that we experience ourselves and
our environment.
Scientists think of the brain as the organ of reason,
language, complex social relations, and morality.
The brain can be thought of as the most complex computer
on the planet.
Much like a computer, the brain can be thought of as a
sensory processor. Our experience of ourselves and our
environment is dependent upon the brain’s ability to
receive, process, store, retrieve and transmit sensory
information.




                                                            1
               Brain Structures
Frontal Lobe: Most anterior, right under the
forehead
     Functions:     Initiation                        Mental Flexibility
                    Problem Solving              Speaking (Expressive Lang)
                    Judgment
                    Inhibition of Behavior
                    Planning/Anticipation
                    Self-
                    Self-Monitoring
                    Motor Planning
                    Personality/Emotions
                    Awareness of Abilities or Limitations
                    Organization
                    Attention/Concentration




               Brain Structures
Frontal Lobe continued
     Injuries can manifest:
              Loss of simple movement of various body parts
              Inability to plan a sequence of complex purposeful
              movements
              Loss of spontaneity in interacting with others
              Loss of flexibility in thinking
              Persistence of a single thought
              Inability to focus on a task
              Mood Changes
              Changes in social behavior
              Changes in personality
              Difficulty with problem solving
              Inability to express language




               Brain Structures
Parietal Lobe: Near the back and top of the head
     Functions: Location for visual attention
                   Location for touch perception
                   Goal directed voluntary movements
                   Manipulation of objects
                   Integration of different senses that allows for
                   understanding a single concept

            Injuries can manifest:
                   Inability to attend to more than one object at a time
                   Inability to name an object
                   Inability to locate words for writing
                   Problems with reading
                   Difficulty with left and right
                   Inability to focus visual attention
                   difficulty with hand eye coordination




                                                                              2
             Brain Structures
Occipital Lobes: Most posterior at the back
of the head
      – Function: Vision
      – Problems: Visual deficits
                                                         environment
                   Difficulty in locating objects in the environment
                   Difficulty in identifying colors
                   Production of Hallucinations
                                                           objects
                   Visual illusions: inaccurately seeing objects
                                                             written
                   Word blindness: inability to recognize written
                   words
                   Difficulties with reading and writing




             Brain Structures
Temporal Lobes: Side of the head above the ears
      – Function: Hearing ability
                  Memory acquisition
                  Some visual perceptions
                  Categorization of objects

       Problems: Difficulty in recognizing faces
                 Difficulty in understanding spoken words
                 Disturbance with selective attention
                 Short term memory loss
                 Interference with long term memory
                 Increased or decreased sexual behaviors
                 Inability to categorize objects
                 Increased aggressive behavior




             Brain Structures
Cerebellum: Located at the base of the
skull
      – Function: Coordination of voluntary movement
                  Balance and Equilibrium
                  Some memory for reflex motor acts

      Problems: Loss of fine motor coordination
                Loss of ability to walk
                Tremors
                Dizziness
                Slurred speech
                Inability to make rapid movements




                                                                       3
             Brain Structures
Brain Stem: Deep in the brain leads to the spinal
cord
      – Function: Breathing                  Heart Rate
                  Swallowing                 Reflexes to seeing
                                              (BP,temp,digestion)
                  Controls regulatory Systems (BP,temp,digestion)
                  Affects level of alertness
                  Ability to sleep
                  Sense of Balance

      Problems: Decreased breath capacity
                Swallow problems
                Difficulty with organization and perception of movement
                Problems with balance and movement
                Dizziness and Nausea
                Sleep Disturbances




 TRAUMATIC BRAIN INJURY
Defined: TBI is an insult to the brain, not of a
degenerative or congenital nature but caused by
an external force, that may produce a diminished
or altered state of consciousness, which results in
an impairment of cognitive abilities and/or physical
functioning. It can also result in the disturbance of
behavioral or emotional functioning
These impairments may be either temporary or
permanent and cause partial or total functional
disability or psychosocial maladjustment.




CAUSES OF TBI: DOMESTIC
The primary causes of traumatic brain injury
to civilian personnel include:
     Motor Vehicle Crashes
     Falls
     Gunshot Wounds
     Sports Injuries
     Abuse (Shaken Baby,Child Abuse, Domestic
     Violence)
   *Currently 5.3 million Americans suffer from TBI per
     CDC




                                                                          4
  CAUSES OF TBI:MILITARY
64% of soldiers recently wounded in action
in OIF sustained brain injuries.
The primary causes of traumatic brain injury
in active duty military personnel include:
     Bullets, fragments, blasts
     Falls
            vehicle-
     Motor vehicle-traffic crashes
     Assaults




      CAUSES CONTINUED
Blasts are the leading cause of TBI for military
personnel in war zones.
The majority of blast related injuries come from
IEDs (Improvised Explosive Devices)
Blast injuries also come from RPGs (Rocket
Propelled Grenades), Mortars, Hand Grenades,
etc.
Unlike in domestic TBIs most military personnel do
not seek or receive medical treatment until they
return to their base or more often they return to the
states.




     SEVERITY OF INJURY
Severity of injury can be classified as:
     Mild: 80% of injuries
                                     0-
          -Loss of consciousness for 0-30 minutes
                                   13-
          -Glasgow Coma Scale of 13-15
           Post-
          -Post-traumatic amnesia less than 24 hours
          -Temporary or permanently altered mental or
            neurological state
          -Post concussion symptoms




                                                        5
        SEVERITY OF INJURY
  Severity of injury can be classified as:
                 10-
       Moderate: 10-30% of injuries
            -Coma more than 30 minutes but less than 24 hours
            -Glasgow Coma Scale of 9-129-
            -Possible skull fractures with bleeding and bruising
            -Signs on EEG, CAT, or MRI scans
            -Some long term problems in one or more areas of life




        SEVERITY OF INJURY
  Severity of injury can be classified as:
               5-
       Severe: 5-25% of injuries
               -Coma lasting longer than 24 hours often lasting
                 days or weeks
                -Glasgow Coma Scale of 3-8 3-
                -Bruising, bleeding in the brain
                -signs on the EEG, CAT or MRI scans
                -Long term impairments in one or more areas of life




     GLASGOW COMA SCALE
Eye Opening:
4   Spontaneous
3 Eye opening to verbal command
2 Eye opening to pain
1 No eye opening

Verbal Response:
5 Oriented to person, place, month, and year
4 Confused
3 Inappropriate words
2 Sounds, but words not understandable
1 No verbal response




                                                                      6
     GLASGOW COMA SCALE
Motor Response
6 Obeys Commands
5 Localizes Pain
4 Withdraws to pain
3 Abnormal flexion to pain
2 Abnormal extension to pain
1 No motor response

Scores are cumulative, with the higher the score being the
    more alert the patient is.




                        DVBIC
  THE DEFENSE AND VETERANS BRAIN
  INJURY CENTER (DVBIC)

  DVBIC is headquartered at Walter Reed
  Army Medical Hospital and operates at
  seven military and VA sites and two civilian
  treatment sites




                   DVBIC Sites
  Military Treatment Facilities
        Walter Reed Army Medical, Washington, DC
        Wilford Hall USAFMC Lackland AFB, TX
        Brooke Army Medical Center Ft. Sam Houston, TX
        Naval Medical Center San Diego, San Diego, CA




                                                             7
             MTF Continued
What they do:
Primary focus on trauma care, acute care stabilization and
prevention of secondary complications
Perform comprehensive evaluations
Provide education
Determine “fitness” to return to duty
Provide information for medical review boards
Provide case coordination
Coordinate with VA sites
Follow-
Follow-up




                DVBIC Sites
Concussion Clinics
– Fort Bragg, North Carolina
– Camp Pendleton, California

What they do:
-Screen for mild TBI
-Treat Symptoms
-Provide Care Coordination




                DVBIC Sites
Veterans Health Administration (VHA)
– James A Haley VA Hospital Tampa, Fl
– Hunter Mcguire VAMC Richmond, Virginia
– VAMC Minneapolis, Minnesota
– VA Palo Alto Health Care System Palo Alto, CA




                                                             8
              VHA Continued
What They Do:
-Primary focus on moderate to severe injuries
-Provide comprehensive evaluation
-Programs are CARF accredited
-Provide a full range of medical and rehab
  services, therapies, cog rehab and education.
-Provide case management/Care coordination
-Help transition from military to veteran status




                 DVBIC Sites
Civilian Partner sites:
– Lakeview Virginia Neurocare, Charlottesville,
  Virginia
                   Neuro-
– Laurel Highlands Neuro-Rehabilitation Center
  Johnstown, Pennsylvania




       Partner Sites Continued
What they do:
–   Primary focus on mild TBI and post acute care
–   Help with residential transitional living
–   Provide life skills training
–   Provide vocational rehabilitation
–   Provide comprehensive evaluation
–   Provide education
–   Provide care coordination
–   Coordinate with VA sites
–           follow-
    Provide follow-up




                                                    9
           DVBIC Continued
DVBIC is leading the initiative to provide
evidence based guidelines for assessment
     follow-
and follow-up care after blast related TBI
within the military environment




       TAMPA POLYTRAUMA
          PROGRAMS
Level I: Acute Inpatient Rehab
Level IIa: Independent Outpatient
      – Focused diagnoses or symptoms requiring an interdisciplinary
        approach
      – Patients are local with transportation and are able to attend
                                                                  disciplines
        multiple appointments on an outpatient basis across all disciplines
                                                                  candidates
        within a reasonable time frame or patients who are not candidates
        for levels III/IV/V who were PRC patients
      – Functional or treatment goals are feasibly attainable on an
        outpatient basis as determined by the PNS team and therapy
        appointments
      – Limited need for intensive or emergency diagnostics
      – Varying levels of case management and mental health needs
        which can be met on an independent outpatient basis




       TAMPA POLYTRAUMA
          PROGRAMS
Level IIb: Intensive Diagnostic Evaluation (PNS
and PRC)
      – Multiple symptoms, more complex diagnoses, in functional
                                                                   distances
        individuals or patients who would otherwise travel great distances
        for multiple appointments
                         2-
      – Comprehensive 2-3 week intensive assessment with development
        of treatment goals followed by goal directed interdisciplinary
        treatment by the PNS staff
      – Therapy provided 5x/wk
                                                                treatment
      – May return to a geographically appropriate facility for treatment
        after completion of program or advance to level III/IV/V
      – Services provided by PRC and PNS teams
      – Lodging may be provided through outside sources, PRC inpatient
        beds, or open transitional beds




                                                                                10
        TAMPA POLYTRAUMA
           PROGRAMS
Level III: Day Program
                                                                        benefit
       – Multiple symptoms, fair to poor functional status that would benefit from
                                                                      through
         daily intensive interdisciplinary programming not available through the
                                                                    community
         PNS. Services are directed at transition/reintegration to community
                                                                      daily,
       – Clients are local with transportation and are able to attend daily, all day,
         group and community based therapy appointments in addition to
                                                                         either in-
         individually directed discipline specific therapy as needed in either in-house
         or community settings.
                                                                      modified
       – Clients are typically living in modified independent or with modified with
                                                                         functional
         minimal supervision/assistance but continue to demonstrate functional
         impairments preventing successful return to independent living, return to
                                                                    relationships.
         school, or return to work or with struggling interpersonal relationships.
       – 4-52 weeks of programming
       – Multiple comprehensive treatment tracks (TBI, Polytrauma, PTSD,
         Neurobehavioral, Vocational services)
       – Menu Based services provided by the treatment team
       – Includes development of an ILS plan to assist with Ind living




      Polytrauma Transitional
       Rehabilitation Program
                   Overview
The polytrauma transitional rehabilitation program at the
The polytrauma transitional rehabilitation program at the
James A Haley Veterans’ Hospital is a comprehensive
rehabilitative treatment program designed to maximize
functional skills of post acute participants with a clearly
defined disability limiting community independence.
Program components include a comprehensive Residential
Program and an Outpatient Day treatment program as well
as follow up clinics and counseling services.
 Program participants undergo comprehensive evaluations
and treatment planning from an interdisciplinary treatment
team to determine current levels of functioning, physical
and cognitive strengths and deficits as well as
psychosocial needs.




      Polytrauma Transitional
      Rehabilitation Program
             Overview
Individual and group programming, specific to the needs of
the person served, are determined and implemented
through a variety of treatment services. Those services
include: Medical Care, Case Management, Psychological
and Family Counseling (including behavior management,
drug and alcohol relapse prevention and PTSD
management), Therapies such as Physical Therapy,
Occupational Therapy, Recreation Therapy, Speech
Therapy, Community Reentry activities, Social Work,
Vocational Rehab, Compensated Work Therapy and
continued follow up care.




                                                                                          11
      TAMPA POLYTRAUMA
         PROGRAMS
Scope of Services:
    Cognitive Rehabilitation
     –   Attention
     –   Language
     –   Memory
     –   Executive Functioning

     Examples: Community Outings, Money Management Groups,
      Transition Groups, Goals Group, Board Games, Video
      Games, Speech Groups, etc.




      TAMPA POLYTRAUMA
         PROGRAMS
Scope of Services:
    Health and Wellness
     –   Physical Fitness
     –   Nutrition
     –   Stress Management
     –   Leisure Skills and Education

         Examples: Yoga Group, Fitness Group, Cardio Group,
         Partnership with the YMCA, Weight Training, Therapeutic
         Kayaking, Adaptive Golf Program, Sports Coordinators, etc.




      TAMPA POLYTRAUMA
         PROGRAMS
Scope of Services:
    Psychosocial
     –   Individual and Group Therapies
     –   Couples Counseling
     –   Family Counseling
     –   Social Skills

     Examples: Healthy Lifestyles group, Transitional living group,
      ADATP Group, PTSD group, Family Group, etc.




                                                                      12
       TAMPA POLYTRAUMA
          PROGRAMS
Scope of Services
– Emotional/Neurobehavioral
      – Caregiver Communication Strategies
      – Behavioral Assessment and Therapies

      Examples: Family Support Groups, Cognitive Programs and
       Groups, etc.




       TAMPA POLYTRAUMA
          PROGRAMS
Scope of Services
– Medical and Psychiatric Services
    General Medical/Rehab Medicine
    Vision & Hearing
    Pain Management
    Mental Health Disorders
    PTSD
    Substance Abuse

   Ex: Pain Program, PTSD Program, ADATP Program, AA
    Programs/NA Programs




       TAMPA POLYTRAUMA
          PROGRAMS
Scope of Services
– Living Skills
    House Maintenance
    Kitchen Management
    Money Management
    Parenting
    Time Management
    Routine Management




                                                                13
        TAMPA POLYTRAUMA
           PROGRAMS
 Scope of Services:
      Community Integration
        –   Volunteering
        –   Return to School
        –   Return to Driving
        –   Public Transportation training
        –   Leisure Education and Skills Training
        –   Community Social Skills Training

        Examples: Community Trips and Outings, Continuing
         Education Programs, Bus Training, etc.




        TAMPA POLYTRAUMA
           PROGRAMS
 Scope of Services
      Vocational Rehab
        –   Return to Paid Employment
        –   Return to School
        –   Functional Capacity/Work Hardening
        –   Work Adjustment Counseling
        –   Coordination of Supported Employment
        –   Job Structuring and Supports

        Ex: Compensated Work Therapies (CWT), Job Coaching,
         Volunteer Resources, etc.




        Resources/Web Sites
 Brain Injury Information:
                               Center-
      Defense and Brain Injury Center-www.dvbic.org
                                  Center-
      Deployment Health Clinical Center-www.pdhealth.mil
                             America-
      Brain Injury Assoc. of America-www.biusa.org


Veteran Services Information:
                              Affairs-
      Department of Veteran’s Affairs-www.va.gov
                    Veterans-
      DoD Disabled Veterans-www.dodvets.com




                                                              14
      Resources/Web Sites
Vocational and Reemployment Services Info
    Operation Warfighter
    www.militaryhomefront.dod.mil/operationwarfighter

    Vocational Rehab and Employment
    www.vetsuccess.gov

   Vocational Rehab Information
   www.vba.va.gov/OPA/fact/index.htm




                                                        15

								
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