Traumatic Brain Injury within the VHA and DoD Systems of Health Care Rodney D. Vanderploeg, Ph.D. Tampa VAMC VA Psychology Leadership Conference/APA April 2006

Objectives Describe the DoD/VHA system of specialized TBI care for active duty and veterans Briefly describe TBI, and its incidence, severity, time course of recovery, and treatment stages Describe the role of psychology and neuropsychology in TBI evaluation and care

Defense & Veterans Brain Injury Center Clinical Care Research Education Prevention Established in 1992

Defense & Veterans Brain Injury Center Multi-site Center Collaboration of Department of Defense & Department of Veterans Affairs Established in 1992 Congressionally funded Mission: Clinical Care, Clinical Research, and Education

Defense & Veterans Brain Injury Center (DVBIC) Director Deputy Dir Advisors Center HQ Support Research Clinical Care Education Provider Registry Rehabilitation Pharm/Neurobehavior Concussion VA VaNC DoD Consumer Doctor/ Therapist Medic Patient Family/ Caregiver

Defense & Veterans Brain Injury Center 3 Military Sites 4 VA Sites 1 Civilian Partner Program

Defense & Veterans Brain Injury Center Military Sites Walter Reed Army Medical Center (Head Quarters) Naval Medical Center, San Diego Wilford Hall US Air Force Med Ctr

Defense & Veterans Brain Injury Center VA Sites Minneapolis VA Medical Center Palo Alto Health Care System Richmond VA Medical Center Tampa VA Medical Center Civilian Partner Program Virginia NeuroCare, Charlottesville

VHA TBI Network of Care 4 Lead TBI Centers 16 Network Sites 7 Associate Network Sites

VHA TBI Network of Care: Four Lead TBI Rehabilitation Sites * Minneapolis Tampa Richmond Palo Alto

Interdisciplinary Team and Interdisciplinary Rehab Approach Rehab Medicine physician Rehab nurses (primary nurse model) Physical, Occupational, Recreational, and Vocational Therapists Speech Therapists Social Workers Case Managers (including long-term) Rehab or Counseling Psychologists Neuropsychologists

Inpatient Acute Rehabilitation 3-5 hours of therapies per day (OT, PT, SP, Recreational, Psychology) Average length of stay 1-3 months Therapies include community outings planned and organized by the TBI patients together with the therapists Case management begins before patients arrive and includes contacting families Case management continues following discharge, may last for years

Other Lead TBI Center Programs Low level or coma program: Only for those with acute coma, NOT long-term coma or vegetative state care Short-stay admissions for: Evaluation and treatment planning Treatment trials Re-evaluation Vocational evaluations Respite Care upon occasion

4 TBI Lead Centers Each Center has 8 to 10 beds that they allow for TBI patients CARF Accredited in Brain Injury Rehabilitation Established treatment teams with specialized skills in TBI rehabilitation Provide the full range of TBI specific rehabilitation services Accept admissions nationwide, including active duty Focus is on patients in the acute and early post-acute phase Subject matter experts and provide consultation 18 Network Centers Do not have beds set aside CARF Accredited in general rehabilitation Provide components of specialized care but do not maintain a TBI rehab TX team Assist TBI Lead Centers with care coordination Facilitate obtaining TBI specific care in the community Follow the patient long term 5 Associate Network Centers Assist with care coordination across the continuum through the TBI care coordinator Provide some TBI care on an outpatient basis Follow the patient in their catchment area

Traumatic Brain Injury Insult to the brain caused by an external physical force Produces a diminished or altered state of consciousness Results in impairments in physical, cognitive, behavioral, and/or emotional functioning

Coma GCS Mild TBI 5 = 13 - 15 Moderate TBI 2 = 9 – 12 __1_ Severe TBI Glasgow Coma Scale Motor Response Obeys commands Localizing responses to pain Generalized withdrawal to pain Flexor posturing to pain Extensor posturing to pain No motor response to pain 6 5 4 3 2 1 Verbal Response Oriented Confused conversation Inappropriate speech Incomprehensible speech No speech Eye Opening Response Spontaneous eye opening Eye opening to speech Eye opening to pain No eye opening Coma 5 2 __1_ < 8 GCS Mild TBI = 13 - 15 Moderate TBI = 9 – 12 Severe TBI = 3 - 8

Post-traumatic Amnesia The time interval from when the person regains consciousness until he or she is able to form memories for ongoing events The individual is not fully oriented, typically confused, and unable to remember information after a period of distraction

Criteria for Severity of TBI Mild Moderate Severe LOC < 30 min with normal CT &/or MRI LOC < 6 hours with abnormal CT &/or MRI LOC > 6 hours with GCS 13-15 GCS 9-12 GCS 3-8 PTA < 24hr PTA < 7days PTA > 7days

Ongoing Cognitive Problems 3 Cogni t ive Leve l Preinjury Functioning PTA Coma INJURY Retro- Grade Amnesia Months 6 9 12 Mild TBI Moderate TBI Severe TBI Ongoing Cognitive Problems Brief PTA

Traumatic Brain Injury Types of TBI Open vs. Closed Etiology Motor vehicle accidents Falls, assaults, gun shots to the head Explosive Blasts (Iraqi conflict) Demographics Males > Females Peak ages of incidence: 1-5 yrs; 15-24 yrs; >75 yrs

Civilian Incidence of TBI General Population 1.5 Million Americans per year 91 per 100,000 > Stroke, Spinal Cord Injury, MS Prevalence: 5.3 million with TBI disability

Military Incidence of TBI Military and Veterans 7,000 peacetime admissions annually Active Duty males: 225 per 100,000 Active Duty females: 150 per 100,000

Blast Induced Brain Injury Rats exposed to whole body blasts (overpressurization waves) & to focal blasts to torso while head protected had cognitive dysfunction (Cer nak et al. 2001) Clinical characteristics of blast TBI in humans not well described in literature

War Injuries: Explosive Blasts Most common cause of injury 64% of war injuries caused by blasts 41% of blast injured at WRAMC had TBI (01/05 - 02/06) 85% closed head injury

Key Iraq wound: Brain trauma By Gregg Zoroya, USA TODAY “A growing number of U.S. troops whose body armor helped them survive bomb and rocket attacks are suffering brain damage as a result of the blasts. It's a type of injury some military doctors say has become the signature wound of the Iraq war.” Shaun Radhay , a Marine, suffered brain damage and other injuries in a mortar blast. By H. Darr Beiser, USA TODAY

Consequences of TBI Cognitive Attention Information processing (speed & efficiency) Memory and Learning Abstract Reasoning Executive Functions Problem solving, planning, insight/awareness, set shifting, sequencing

Consequences of TBI Behavioral-emotional Irritability Impulsivity Affect Regulation: apathy, agitation, aggression Depression, Anxiety Social Pragmatics Cognitive and behavioral impairments are the most disabling long-term, more so than physical injuries

Psychology-Related Assessment Issues Determining original severity of injury Identifying past and present treatment, and the success or lack thereof Neuropsychological evaluation of current functioning Psychological functioning: Axis I & II, and coping resources Identifying and assessing family and systems issues

Neuropsychological Assessment Focus on Memory and Executive problems Core (Brief) DVBIC Battery WTAR (Wechsler Test of Adult Reading) CVLT-II Brief Visuospatial Learning Test – Revised Letter-Number Sequencing (working memory) D-KEFS Verbal Fluency (letters and semantic) Design Fluency Trails A and B WCST-64 Grooved Pegboard Test

Treatment Considerations Treatment varies based upon: Severity of injury Time since injury Constellation of impairments

Mild TBI: Overlapping Symptoms across Conditions Postconcussion Syndrome (PCS) Insomnia Impaired memory Poor concentration Depression Anxiety Irritability Headache Dizziness Fatigue Noise/light intolerance PTSD Insomnia Memory problems Poor concentration Depression Anxiety Irritability Stress symptoms Emotional numbing Avoidance

Predisposing Factors. Causative Factors Predisposing Factors Causative Factors Perpetuating and Mitigating Factors Self-Expectation mTBI Psychiatric Conditions Personality Traits Medical Conditions Intelligence Level Demographic Characteristics Medical Iatrogenesis Litigation Iatrogenesis Acute Symptoms Chronic Symptoms Coping Abilities Social Support

Mild TBI Interventions 3 Cogni t ive Leve l Preinjury Functioning PTA Coma INJURY Retro- Grade Amnesia Months 6 9 12 Mild TBI Moderate TBI Severe TBI Ongoing Cognitive Problems Brief PTA Mild TBI Interventions Psychological Support, Psychotherapy, Existential Issues, Family Issues

Leve l Mild TBI Moderate TBI Severe TBI 3 Cogni t ive Leve l Preinjury Functioning PTA Coma INJURY Retro- Grade Amnesia Months 6 9 12 Mild TBI Moderate TBI Severe TBI Ongoing Cognitive Problems Brief PTA Psychological Support, Psychotherapy, Existential Issues, Family Issues Acute Specialized Brain Injury Rehabilitation For those with Moderate to Severe Injuries

Ongoing Cognitive Problems 3 Cogni t ive Leve l Preinjury Functioning PTA Coma INJURY Retro- Grade Amnesia Months 6 9 12 Mild TBI Moderate TBI Severe TBI Ongoing Cognitive Problems Brief PTA Psychological Support, Psychotherapy, Existential Issues, Family Issues Subacute Rehab, Outpatient Therapies, Day Treatment, or Community Re-Entry Programs

Vocational Rehabilitation and/or Ongoing Case Management 3 Cogni t ive Leve l Preinjury Functioning PTA Coma INJURY Retro- Grade Amnesia Months 6 9 12 Mild TBI Moderate TBI Severe TBI Ongoing Cognitive Problems Brief PTA Psychological Support, Psychotherapy, Existential Issues, Family Issues Vocational Rehabilitation and/or Ongoing Case Management