1. DAVID X. CIFU, M.D. ACTING NATIONAL DIRECTORCHIEF, PM&R SERVICES PM&R - VHARICHMOND VAMC HERMAN J. FLAX, M.D. PROFESSOR AND CHAIRMAN DEPARTMENT OF PHYSICAL MEDICINE AND REHABILITATION VIRGINIA COMMONWEALTH UNIVERSITY DAVID.CIFU@VA.GOV Rehabilitation Research in P3

2. A Complex Condition Mild TBI Combat- related Stress Pain Systemic Factors P3

3. Research Questions Epidemiology Descriptive explanatory models Intervention Trials – Individual diagnoses – Overlap Core Data set Systems Factors Research Dissemination

4. Epidemiology Multiple studies of civilian, Veteran and military populations. Findings variable related to time post-insult, differing definitions, and populations. Several ongoing PT/BRI-QUERI supported projects focused on screening and assessments. Potential impact on resource allocation.

5. Epidemiology PT/BRI QUERI portfolio includes  3 studies exploring psychometric properties of TBI screening tool.  5 studies assessing TBI evaluation process, including sources of variation.  2 studies focused on pain assessment in TBI/PT.  4 studies focused on sensory impairment (vision/hearing) in TBI/PT.  5 studies on morbidities and disability in TBI/PT  4 studies on reintegration and productivity

6. Epidemiology: P3 at the PRC’s Consecutive admissions to PRC (n=188) – 93% TBI – 81% Pain – 53% Mental Health Dx Sayer : PMR 2009;1(1):23–28 Consecutive admissions to PRC (n=50) – 80% TBI – 96% Pain – 44% PTSD Clark: J Rehabil Res Dev 2007;44(2):179

7. Epidemiology: P3 at the PNS’s Consecutive admissions to PNS (n=62) – 97% TBI/PPCS – 97% Pain – 71% PTSD Lew: J Rehabil Res Dev 2007;44(7):1027-34 Consecutive admissions to PNS (n=340) – 67% TBI/PPCS – 82% Pain – 68% PTSD Lew: J Rehabil Res Dev 2009;46(6):in press

8. Epidemiology: Mild TBI and Headache n.b.: 50% had confirmed 2 nd level eval for TBI 87.5% had pain >30 days N = 40,172 (+ TBI screen)

9. Epidemiology: Overlap of P3 10.3% 5.3% 2.9% 16.5% 6.8% 42.1% 12.6% PTSD 68.2% PPCS 66.8% Pain 81.5% Lew: J Rehabil Res Dev 2009;46(6):in press

10. Explanatory Modeling Post-combat Dysfunction Pain Combat stress Brain Injury

11. Explanatory Models 30+ years of basic science research in pain and TBI individually has begun to yield basic understanding. The complexity of the individual injuries and processes have challenged researchers. Dual diagnoses (or more) are unlikely be readily amenable to animal modeling. Animal models have been limited in complexity.

12. Explanatory Models Many researchers and clinicians seem unable (or unwilling) to accept the anything except a clear-cut model of the impact of various factors. Computer-based modeling may offer insights into complex interactions. No PT/BRI QUERI research projects in this arena.

13. Intervention Trials Limited clinical trials exist for complex interventions used for “isolated” pain and TBI care. Overlapping diagnoses will complicate already complex process Research limited by common definitions (diagnoses, interventions). Research limited by definitions and clinical relevance of outcome measures

14. Intervention Trials PT/BRI QUERI conducted needs assessment and then systematic review of assessment and treatment of TBI/PTSD. PT-QUERI supported projects include; 2 in Sleep interventions with TBI 4 to improve TBI/PT outcomes Planned in Pain, PTSD, and TBI

15. Core Data Set Common Data Elements process begun in Spring 2009 for TBI, PTSD, and Pain. Data elements include; - severity indicators - clinical descriptors. - outcome measures

16. Core Data Set VHA system facilitates acceptance of core data sets. Core data sets will facilitate multi-center clinical research protocols. Large subject size may help to account for large variability in clinical presentations and complexity of treatment interventions.

17. System Factors System factors:  Local – Clinician availability/quality  VISN – Second level evaluations  National – DoD, CPEP, TBI screening, Pain screening Likely to impact outcomes Efforts to impact system factors unlikely to be effective without research evidence

18. System Factors PT/BRI-QUERI supported projects include;  5 projects to improve care to reduce disparities and variations.  Partnership to promote CPG’s

19. Dissemination Extensive network of VHA lead dissemination Need for greater quality control on what is disseminated Face-to-face knowledge transmission is becoming increasingly more difficult. CPG process of unclear value

20. Summary Complete and disseminate epidemiologic data. Focus on Core Data development and training. Utilize core dataset to support intervention trials. Use core dataset to distinguish overlapping conditions. Disseminate promising or effective strategies through CPGs.