1. 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

2. 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

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

4. 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

5. 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

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

7. 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

8. 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

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

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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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 =
Moderate TBI
= 9 – 12
Severe TBI
= 3 - 8

17. 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

18. 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

19. Ongoing Cognitive Problems3
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

20. 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; yrs; >75 yrs

22. 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

23. 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

24. 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

25. 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/ /06)
85% closed head injury

26. 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

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

28. 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

29. 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

30. 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

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

32. 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

33. 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

36. Mild TBI Interventions3
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

37. Leve l Mild TBI Moderate TBI Severe TBI3
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

38. Ongoing Cognitive Problems3
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

39. Vocational Rehabilitation and/or Ongoing Case Management3
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